Methods and compositions for oral, sublingual or buccal administration of diadenosine tetraphosphate analogs

Abstract

This disclosure provides oral, sublingual or buccal use of P1,P4-diadenosine tetraphosphates as antithrombotic agents in vivo, and in particular as antiplatelet agents for prevention and / or treatment of diseases related to platelet activation and aggregation. The disclosure also provides formulations which enhance the oral, sublingual or buccal bioavailability of the P1,P4-diadenosine tetraphosphates.

Description

180817.46476 Methods and Compositions for Oral, Sublingual or Buccal Administration of Diadenosine Tetraphosphate Analogs FIELD

[0001] This disclosure provides oral, sublingual or buccal use of P1,P4- diadenosine tetraphosphates as antithrombotic agents in vivo, and in particular as antiplatelet agents for prevention and / or treatment of diseases related to platelet activation and aggregation. BACKGROUND

[0002] Antithrombotics are a class of drugs that reduce the blood’s ability to coagulate. Undesired in vivo blood clothing can result from surgical interventions, including Percutaneous Coronary Intervention (PCI), traumas, various vascular diseases, including coronary or brain artery diseases and various blood clothing abnormalities. Application of antithrombotics in these cases reduces the risk of intravascular blood clothing and ischemic events or death.

[0003] There are two major classes of antithrombotics: anticoagulants that inhibit plasma clothing system, and antiplatelets, that inhibit platelet activation and aggregation. Platelets or thrombocytes are anucleate cells that are present in a large number in the blood and play a critical role in blood homeostasis. They are activated by subendothelial blood tissue factors exposed during trauma, surgical intervention of vascular disease, such as sclerotic plaque rupture. They are also activated by high shear stress due to vascular stenosis or occlusion, which take pace in vascular diseases, such as arterial plaque formation. Activated platelets change their shape, and release various factors that further potentiate their activation, and recruit and activate other platelets. Activated platelets attach to the site of endothelial damage and to other activated platelets, resulting in a white thrombus formation. They also potentiate the plasma clotting cascade and bind fibrin which results in a stable thrombus formation. The resulted ischemic events that follow intravascular thrombus formation, such as myocardial infarction or stroke are the leading cause of death in the developed world. 166334706.1

[0004] There are various classes of antiplatelet drugs that target different parts of the platelet activation system, but the most widely used are those, targeting platelet P2Y12 receptor. Such are the class of the thienopyridines, that are converted in vivo to metabolites, which irreversibly inhibit P2Y12 receptor, such as clopidogrel (Plavix®), and the newer class of direct acting, reversible inhibitors of P2Y12, ticagrelor (Brilinta®) and cangrelor (Kengreal®).

[0005] The class of the thienopyridines, despite of their widespread use, suffer from significant disadvantages. Since they are irreversible inhibitors, their platelet inhibitory effect persists for the lifetime of the platelet, and therefore the effect of the drug cannot be quickly withdrawn if the patient develops bleeding complication or is in need of emergency surgery. Also, being prodrugs, they have to be metabolized in vivo by two separate cytochrome P450 enzymes in the liver in order to produce the active substance, that consequently causes a delay of action and necessitates “preloading” patients before a PCI procedure and also results in significant inter-patient activity variability due to variations in the P450 system and liver function. Limited response to clopidogrel, often referred to as “clopidogrel resistance,” occurs in up to 20% of patients. The requirement for liver metabolism also increases the potential for drug-drug interactions.

[0006] The use of ticagrelor and cangrelor is associated with enhanced risk of bleeding, and cangrelor has shown significant renal toxicity.

[0007] US patent 8,575,127 discloses compounds having structure I, and in particular compound with structure II as a new class of potent platelets aggregation inhibitors in vitro and ex vivo and antithrombotics in vivo that inhibit both P2Y1 and P2Y12 platelet receptors (Vaduganathan, M.; Bhatt, D. L. (2016) Simultaneous Platelet P2Y12 and P2Y1 ADP Receptor Blockade: Are Two Better Than One? Arterioscler. Thromb. Vasc. Biol., 36: 427-8). P2Y1 and P2Y12 are activated by a major paletelet’s releasate, ADP. P2Y1 initiate ADP induced platelet activation and platelet shape change, while P2Y12 plays major role in amplification and stabilization of the activation. There is a complex interplay between P2Y1 and P2Y12, and co-activation of both receptors is necessary for full platelet aggregation. (Hardy, A. R., et al. (2004) "Reciprocal cross-talk between P2Y1 and P2Y12 receptors at the level of calcium signaling in human 2 166334706.1platelets." Blood 104(6): 1745-1752). While P2Y12 is the target of the major antiplatelets (Angiolillo, D. J., et al. (2017) "International Expert Consensus on Switching Platelet P2Y12 Receptor-Inhibiting Therapies" Circulation 136(20): 1955-1975) therapeutic targeting of P2Y1 has not been achieved yet. Nyhlander et al. has shown that simultaneous inhibition of both P2Y1 and P2Y12 has a highly synergistic effect on platelet aggregation inhibition (Nylander, S. et al. (2004) Synergistic action between inhibition of P2Y12 / P2Y1 and P2Y12 / thrombin in ADP- and thrombin-induced human platelet activation, Br. J. Pharmacol., 142:1325-1331). The compound with structure II potently inhibits in vitro and ex vivo platelet activation (IC50 of 1.1 nM for GPIIb-IIIa and IC50 of 0.6 nM for P- selectin expression) and platelet aggregation (IC50 of 11.6 nM for 5 M ADP induced human platelets by optical aggregometry) (Gremmel, T. et al. Synergistic Inhibition of Both P2Y1 and P2Y12 Adenosine Diphosphate Receptors as Novel Approach to Rapidly Attenuate Platelet-Mediated Thrombosis. Arterioscler. Thromb. Vasc. Biol.2016, 36, 501-509). In vivo, in the canine model of recurred thrombosis mimicking unstable angina (Folts model), the compound of structure II significantly improved the injured and restricted coronary artery patency and the cyclic flow variation after IV infusion of doses as low as 1.08 g / kg / h without increasing of the peripheral bleeding time (Koganov, E. S., et al. (2018). "GLS- 409, an Antagonist of Both P2Y1 and P2Y12, Potently Inhibits Canine Coronary Artery Thrombosis and Reversibly Inhibits Human Platelet Activation." Scientific Reports 8(1): 14529).

[0008] Oral treatment is a preferred route for pharmacotherapy. Parenteral, and especially intravascular treatment may suffer from significant drawbacks, such as, risk for infections, high cost, need for qualified medical personal, less stable formulations, possibilities for vascular injuries, and may be impractical as a long-term treatment.

[0009] The applicability of the oral route of treatment is limited by the oral bioavailability of the therapeutic. Prerequisites for oral bioavailability of organic compounds have been studied extensively and are known to those skilled in the art (Alqahtani, M. S., et al. (2021). "Advances in Oral Drug Delivery." Front. Pharmacol.12: 618411). Also known to those skilled in the art is the so called “Lipinski Rule of Five”, which can be summarized as “A promising oral drug 166334706.1candidate has to be a relatively small, moderately hydrophobic molecule”. In particular, the molecular weight should be below 500 Da, the number of hydrogen bond donor atoms should be below 5, the number of hydrogen acceptor atoms should be below 10, the logarithm of the water-n-octanol partition coefficient (CLogP) should be between -0.4 and +5, and the molar refractivity (CMR) should be between 40 and 130. The compound of structure II is a large, highly hydrophilic molecule, with MW = 1081 Da (cutoff, 500 Da), 6 hydrogen bond donor atoms (cutoff, 5), 26 hydrogen bond acceptor atoms (cutoff, 10), CLogP = - 3 (cutoff -0.4 - +5), and CMA = 21 (cutoff, 30-140). Therefore, according to the widely accepted Lipinski Rule of Five, the compound with structure II is highly unlikely to be an orally bioavailable drug.

[0010] Subsequent works resulted in the development of two additional oral bioavailability molecular predictors: molecular flexibility, estimated by the number of rotatable bonds, and the molecular polar surface area (Veber, D. F., et al. (2002). "Molecular properties that influence the oral bioavailability of drug candidates." J Med Chem 45(12): 2615-2623). The cutoff limits for oral bioavailability for those two parameters in the rat model are: number of rotatable bonds equal or less than 10 and molecular polar surface area equal or less than140 . The compound with structure II has 26 rotatable bonds and polar surfacearea of 552 (calculated by the method in Ertl, P., et al. (2000). "Fast Calculationof Molecular Polar Surface Area as a Sum of Fragment-Based Contributions and Its Application to the Prediction of Drug Transport Properties." Journal of Medicinal Chemistry 43(20): 3714-3717). Based on this data, one skilled in the art of predicting of oral bioavailability of drug candidates may conclude that compounds with structure I and II are very unlikely to be orally bioavailable. Indeed, none of the nucleoside polyphosphate type drugs, Diquafosol (Diquas, Prolacria®, diuridine tetraphosphate), Cangrelor (Kengreal, Kengrexal®, ATP analog), Adeflavin (Flavitan, Flaziren, Wakadenin®, Flavin Adenine Dinucleotide, FAD), Adesinon®(Adenosine 5’-triphosphate, ATP) are orally bioavailable. Citicoline (CerAxon, Nicholin, Somazina®, cytidine 5'-diphosphocholine), a naturally occurring intermediate in the synthesis of phosphatidylcholine, is available in an oral form, and used as a supplement but is not truly orally bioavailable, since the drug is hydrolyzed in the intestines to choline and uridine, 166334706.1which are taken up into the blood circulation. Once in the cells, uridine is converted to UPT and re-combined, in part, with choline to cytidine 5'- diphosphocholine by Choline-phosphate cytidylyltransferase. From the class of nucleoside polyphosphate like drugs, ATP was studied most thoroughly for its oral bioavailability because of its use as a food and energy supplement. Yet, no increase of ATP level in plasma or erythrocytes was observed after oral treatment of laboratory animals or humans (Arts, I. C. W., et al. (2012). "Adenosine 5'- triphosphate (ATP) supplements are not orally bioavailable: a randomized, placebo-controlled cross-over trial in healthy humans." J. Int. Soc. Sports Nutr.9: 16).

[0011] We hereby disclose that we unexpectedly discovered that compounds of structure I are bioavailable in therapeutically significant concentrations after oral, sublingual, or buccal treatment of mammal and that compounds of structure I can be used for oral, sublingual, or buccal treatment for in vivo modulation of platelet properties and for oral, sublingual or buccal treatment of mammal diseases in which platelets play a direct or indirect role. SUMMARY

[0012] This disclosure provides a method for modulation of platelet properties and function in vivo in a mammal, by oral, sublingual or buccal administration of compound with structure I or a formulation, containing compound of structure I, or a mixture of active substances, containing compound of structure IStructure I or a pharmaceutically acceptable salt, where: 166334706.1each M is independently or collectively selected from a monovalent cation, i.e. is a cation having one positive charge; one-half of a divalent cation, i.e. is a cation having two positive charges (alternatively, two M together comprise one divalent cation); one-third of a trivalent cation, i.e. a cation having 3 positive charges (alternatively, three M together comprise one trivalent cation); one-quarter of a tetravalent cation, i.e. a cation having 4 positive charges (alternatively, four M together comprise one tetravalent cation); n M form a part of a n-valent cation, i.e. is a cation having n positive charge, where n is a number from 5 to 100000, preferably from 5 to 10000; and wherein the cation or cations can be a metal cation, hydrogen cation, an organic cation, an organic polymer, or combination thereof; each R is independently selected from methyl, ethyl, propyl, isopropyl, Cl, Br and I; and wherein the phosphorous atoms 1 and 4 are both in RP configuration, or both in SP configuration, or one of them is in RP and the other is SP configuration, in which case the carbon atom between P2and P3is either in pseudo-r or pseudo-s configuration, or the compound of structure I is a mixture comprising any of those stereo-configurations in any ratio, including 0% of one or more of them, or is a racemic mixture of stereoisomers.

[0013] M in Structure I can be any metal or organic base that can form a cation or cations that form “pharmaceutically acceptable salts”. For example, pharmaceutically acceptable salts are described in: Berge et al., “Pharmaceutical salts”, J. Pharmaceutical Sciences 66:1-19, 1977 and in “Pharmaceutical Salts. Properties, Selection, and Use”, (Eds. P. H. Stahl and C. G. Wermuth), Wiley- VCH, 2008. Non-limiting examples of such metals are: sodium, lithium, potassium, calcium, magnesium, aluminum, titanium and the like. Examples of cations are ammonium cations (for example, NH4+, NH3R+’, NH2R’2+, HNR’3+or NR'4+, wherein each R' is independently alkyl, and particularly C1-6 alkyl, which may be branched or unbranched). Organic cations can be any organic base, preferably of limited toxicity or non-toxic, which can be protonated to a mono-, di-, tri, or polycation. Non-limiting examples of organic bases are: methylamine, 6 166334706.1dimethylamine, triethylamine, tetramethylammonium, monoethylamine, dimethylamine, triethylamine, tetramethylammonium, choline, morpholine, N- alkylmorpholines, piperidine, N-alkylpiperidines, pyrrolidine, N-alkylpyrrolidines, piperazine, N-alkylpiperazines, N,N’-dialkylpiperazines, mono-, di-, and triethanolamine,1,2-ethanediamine, 1,3-propanediamine, 1,4-butanediamine, spermidine, spermine, lysine, dilysine, oligolysine, polylysine, arginine, diarginine, oligoarginine, polyarginine, oligoethyleneimine, polyethyleneimine, chitosan, N- methylchitosan, Tat fragment 48-60, penetratin, cationic lipid such as DOTAP and DOTMA. Pharmaceutically acceptable cations are those salt-forming ions with a positive charge. References hereinafter to a compound according to this disclosure include compounds of the general formulae shown, as well as their pharmaceutically acceptable salts.

[0014] The compound of structure I can be administered as a formulation, which formulation may contain biologically active or biologically inert components, i.e. various excipients, and which formulation may be formed in a solid form, such as tablets, capsule, caplet, pill, beads, powders or granules, sachets, troches, SEC (soft elastic capsule or "caplet"), or hard gelatin capsule or in liquid form, or in a mixture of one or more liquid and solid or solids, such as emulsion or suspension, and the liquid or mixture may be contained in capsule, soft elastic gelatin capsule, hard gelatin capsule, caplet, aerosol, spray, bottle, or in other forms appropriate for oral, sublingual or buccal administration, and which formulation may have an effect on the compound stability, or the tablet rate of disintegration, or the compound rate of dissolution, may have an effect on the compound stability in the gastrointestinal tract, or modulates the resident time in the gastrointestinal tract, or modulates the rate of absorption in the gastrointestinal tract or by the lingual or buccal mucosa, modulates the effect of the compound on the gastrointestinal tract, or increase the oral, sublingual or buccal bioavailability of the compound, or enables for a fast tablet disintegration, and, or compound dissolution in the sublingual or buccal space, or prevents the contact of the compound with the stomach content, or enables slow release of the compound in the gastrointestinal track, or modulates the rate of release of the compound in the gastrointestinal tract, or provides for a variable rate of release of the compound in the gastrointestinal track. 166334706.1

[0015] The tablets may contain, without being limited to, excipients as diluents, binders, granulating agents, suspending or dispersing agents, glidants (flow aids) and lubricants, disintegrants, antiadherents, antioxidants, compression aids, emollients, emulsifiers, sorbents, preservatives, sweeteners, flavors, fragrances, pigments and printing inks and film forming and coating agents. Non- limiting examples of such excipients are: butylated hydroxytoluene (BHT), calcium carbonate, calcium phosphate (dibasic), calcium stearate, croscarmellose, crosslinked polyvinyl pyrrolidone, citric acid, cysteine, ethylcellulose, gelatin, hydroxypropyl cellulose, hydroxypropyl methylcellulose, lactose, magnesium stearate, maltitol, mannitol, methionine, methylcellulose, methyl paraben, microcrystalline cellulose, polyethylene glycol, polyvinyl pyrrolidone, povidone, pregelatinized starch, propyl paraben, retinyl palmitate, shellac, silicon dioxide, sodium carboxymethyl cellulose, sodium citrate, sodium starch glycolate, sorbitol, starch (corn), stearic acid, sucrose, talc, titanium dioxide, Vitamin A, vitamin E. Vitamin C, and Xylitol.

[0016] The compound with structure I can be formulated with, or co- administered with compounds, which enhance the rate of absorption or transport of the compound through the gastrointestinal or lingual or buccal epithelium, including compounds which enhance the permeability of the epithelium tight junction, or enhance the compound uptake or penetration of the apical side of the epithelial cells, and / or enhance the rate of diffusion through, or release through, or efflux through the basal side of the epithelial cells.

[0017] The compound with structure I can be formulated or packed in nano particles or other micro or nano structures, which particles or structures may, or may not contain other compounds or components that improve compounds packing, particles or structures stability, or enhance the uptake or the release of the particles by the epithelial cells.

[0018] Examples of biologically active compounds that can be co-formulated or co-administered with compound with structure I are vasodilators, for instance, nitroglycerin, isosorbide mononitrate, isosorbide dinitrate and pentaerythritol tetranitrate, anticoagulants, such as warfarin (Coumadin®), apixaban (Eliquis®), dabigatran (Pradaxa®), edoxaban (Lixiana®) and rivaroxaban (Xarelto®), or other antiplatelets, such as aspirin. 166334706.1

[0019] This disclosure provides a method for inhibiting of human platelet activation or aggregation in vivo by oral, sublingual or buccal administration of an amount of the compound with structure I sufficient to inhibit the activation or aggregation of the platelets of a human in need thereof. In certain embodiments, platelet aggregation is inhibited by at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90% or 100% compared to the platelet aggregation in the absence of the compound.

[0020] The disclosure also provides a method for treating or preventing of a human disease related to platelet activation or aggregation by oral, sublingual or buccal administration of the compound with structure I in a therapeutically effective amount to a human in need thereof. Such diseases may include, without being limited to, coronary or cerebral arterial thrombosis, including thrombosis associated with unstable angina, coronary angioplasty, acute myocardial infarction, myocardial infarction, ST-Elevated myocardial infarction, ST- Nonelevated myocardial infarction, unstable angina, arterial thrombosis due to atherosclerotic disease, venous thrombosis, thrombophlebitis, arterial embolism, stroke, transient ischemic event, pulmonary embolism, cerebral embolism, kidney embolism, thrombosis or thrombotic complications due to intervention for treatment of atherosclerotic disease, including stent placement, thrombosis or thrombotic complication due to surgical interventions, mechanical or trauma damage or inflammation, including vascular inflammation or due to fibrinolytic therapy or due to coronary artery disease, or peripheral artery disease, or platelet activation and adhesion due to extracorporeal circulation.

[0021] The term “treating” or “treatment” as used herein is understood to those skilled in the art to mean obtaining beneficial of desirable results, such as clinical or health results. Such beneficial and desirable results can include, without being limited to, remission (whether partial or total), whether detectable or undetectable of a disease, disorder or condition; diminishment of extent of disease, disorder, or condition; stabilization (i.e. not worsening) of the state of disease, disorder, or condition; delay or slowing the progress of the disease, disorder, or condition; amelioration or palliation of the disease, disorder, or condition; and alleviation or amelioration of one or more symptoms of a disease, disorder or conditions. These terms may also mean “palliating” of a disease, disorder, or condition, that 166334706.1is, lessening the extent of a disease, disorder or condition, lessening of the undesirable clinical manifestation of a disease, disorder or condition, or lessening of the symptoms, or shortening of the time-course, or slowing the progress or the extent of a disease, disorder or condition as compared to the extent, manifestation or time course in the absence of treatment with compound of structure I. These terms may also include prolongation of the survival time or survival rate or improvement of the quality of life as compared to the one in absence of the treatment.

[0022] The terms “treating” or “treatment” may also include prevention of one or more symptoms or manifestation or negative outcomes of a disease, disorder or condition. In this case the treatment is prophylactical, and can be initiated before the onset of a disease, disorder or condition, or can be initiated before or after an event precedes the onset of the disease, disorder or condition, non- limiting examples of such event being intervention, procedure, trauma or onset of pre-disposing morbidity. BRIEF DESCRIPTION OF THE FIGURES

[0023] Figure 1 shows a plot of the average plasma concentration after oral treatment of 3 rats with 36 mg / kg of the compound with structure II.

[0024] Figure 2 shows a plot of the average plasma concentration after oral treatment of groups of 3 fasted rats with 2 mg / kg and 10 mg / kg of the compound with structure II.

[0025] Figure 3 shows a plot of the average plasma concentration ( g / L) aftersublingual treatment of 3 rats with 10 mg / kg of the compound with structure II. DETAILED DISCRIPTION

[0026] The term “oral administration” used herein refers to a route of administration in which a substance or a formulation is taken by mouth and swallowed in order to reach the gastro-intestinal track, or directly administered to the gastro-intestinal tract.

[0027] The term “sublingual administration” used herein refers to a route of administration in which a substance or a formulation in placed under the tongue and kept there for a certain amount of time. 166334706.1

[0028] The term “buccal administration” used herein refers to a route of administration in which a substance or formulation is placed between the gums and the cheeks and kept there for a certain amount of time.

[0029] The term “bioavailability” used herein refers to the ability of a substance administered to a mammal to reach its intended biological destination in the mammal. In the case of an antithrombotic or antiplatelet drug, to reach the blood circulation.

[0030] The terms “oral bioavailability” or “buccal bioavailability” or “sublingual bioavailability” used herein refer to the ability of a substance or formulation, which is administered orally, or buccally, or sublingually to a mammal to reach its intended biological destination. In the case of an antithrombotic or antiplatelet drug, to reach the blood circulation.

[0031] The term “mammal” as used herein refers to a human or a vertebrate animal whose young are nourished with milk. Mammals include humans and domestic or wild mammal animals.

[0032] This disclosure provides a method for treatment or prevention of a disease, disorder or condition in a mammal, which disease, disorder or condition is associated with, or dependent of, or influenced by mammal’s platelet activation and / or aggregation, by oral, sublingual or buccal administration to that mammal of compound with structure I or a formulation, containing compound of structure I, or a mixture of active substances, containing compound of structure I. The term mammal as used herein includes human or domesticated animal.Structure I or a pharmaceutically acceptable salt, wherein: 166334706.1each M is independently or collectively selected from a monovalent cation, i.e. is a cation having one positive charge; one-half of a divalent cation, i.e. is a cation having two positive charges (alternatively, two M together comprise one divalent cation); one-third of a trivalent cation, i.e. a cation having 3 positive charges (alternatively, three M together comprise one trivalent cation); one-quarter of a tetravalent cation, i.e. a cation having 4 positive charges (alternatively, four M together comprise one tetravalent cation); n M form a part of an n-valent cation, i.e. a cation having n positive charge, where n is a number from 5 to 100000, preferably from 5 to 10000; and wherein the cation or cations can be a metal cation, hydrogen cation, an organic cation, an organic polymer, or combination thereof; and each R is independently selected from methyl, ethyl, propyl, isopropyl, Cl, Br and I.

[0033] A particular example of compound with structure I is the compound with structure IIStructure II

[0034] The compound for use in the methods and formulations provided herein also embodies all stereoisomers of the compound with structure I or II. The term “stereoisomers” as used herein means stereoisomers of the compound resulted from the two chiral phosphorus atoms at positions 1 and 4, and the carbon atom between phosphorus 2 and 3, which becomes pro-chiral when P1 and P2 are in opposite stereo configuration. In one embodiment, both P1 and P4 166334706.1are in RP configuration, in another embodiment they both are in the SP configuration. In yet another embodiment P1 is in the RP configuration and P4 is in the SP configuration and the pro-chiral carbon atom between P2 and P3 is in pseudo-r configuration, and in another embodiment the carbon atom is in pseudo-s configuration. The stereoisomers can be separated by methods described in Chang, H., et al. (2014) "Antiplatelet Activity, P2Y1 and P2Y12 Inhibition, and Metabolism in Plasma of Stereoisomers of Diadenosine 5',5'''- P1,P4-dithio-P2,P3-chloromethylenete-traphosphate." PLoS One 9(4): e94780, or in Yanachkov, I. B., et al. (2016). "New highly active antiplatelet agents with dual specificity for platelet P2Y1 and P2Y12 adenosine diphosphate receptors." Eur J Med Chem 107: 204-218, or by other methods for separation of stereoisomers, known to one skilled in the art.

[0035] The terms “stereoisomers”, “chiral phosphorus atom”, “stereo configuration”, “pro-chiral”, “RP”, “SP”, “pseudo-r” and “pseudo-s” are known to those skilled in the art and are described in literature. See, for example, G.P. Moss, Basic terminology of stereochemistry, Pure Appl. Chem.68 (1996).

[0036] Some non-limiting examples of compound with structure I are listed in Table 1.166334706.1

[0037] The compound with structure I can be used in a formulation with one or more pharmaceutically acceptable excipients.

[0038] In one embodiment, the compound with structure I can be formulated in solid form such as tablets, capsules, pills, granules, lozenges, pastilles, chewable implements, or in other dosage forms appropriate for oral, sublingual or buccal administration to human subjects or mammals. The methods for preparation of such solid forms are known to one skilled in the art of drugs formulation , as described for example in Yihong Qiu, Yisheng Chen, Geoff G.Z. Zhang, Lirong Liu, William Porter (Editors), “Developing Solid Oral Dosage Forms - Pharmaceutical Theory and Practice”, 2008, Elsevier and in the references cited therein, all of which are incorporated here by reference. Various formulating excipients may be used in the preparation of the solid forms, such as: binders, fillers, granulating agents, suspending or dispersing agents, diluents, glidants 166334706.1(flow aids) and lubricants, disintegrants, antiadherents, antioxidants, compression aids, emollients, emulsifiers, sorbents, preservatives and stabilizing agents, sweeteners, flavors, fragrances, pigments and printing inks, film forming and coating agents and chewable agents. Non-limiting examples of such excipients are: butylated hydroxytoluene (BHT), calcium carbonate, calcium phosphate (dibasic), calcium stearate, croscarmellose, crosslinked polyvinyl pyrrolidone, citric acid, cysteine, ethylcellulose, gelatin, hydroxypropyl cellulose, hydroxypropyl methylcellulose, lactose, magnesium stearate, maltitol, mannitol, methionine, methylcellulose, methyl paraben, microcrystalline cellulose, polyethylene glycol, polyvinyl pyrrolidone, povidone, pregelatinized starch, propyl paraben, retinyl palmitate, shellac, silicon dioxide, sodium carboxymethyl cellulose, sodium citrate, sodium starch glycolate, sorbitol, starch (corn), stearic acid, sucrose, talc, titanium dioxide, Vitamin A, vitamin E. Vitamin C, and Xylitol. Various processes, known in the art can be used in the preparation of the solid forms, such as milling, mixing and blending, drying, screening, granulation, pressing and compression, extrusion, coating and printing. Controlled release

[0039] In another embodiment, the compound with structure I is formulated in such a way as to provide controlled-release in the gastrointestinal tract or in the sublingual space, or in the buccal cavity of the compound with structure I. The term “controlled-release” as used herein means releasing of a specified amount of compound with structure I into the gastrointestinal tract, in the sublingual space, or in the buccal cavity, or in specified segment or segments of the gastrointestinal tract, over a specified period of time. The term “controlled- release” also encompasses such terms as extended release, modified release, long-acting, or long-acting release, prolonged release, sustained release, depot, or depot release, timed release, pulsed release, delayed release or immediate release, or combination of those terms, all of which describe or imply specific kinetics, or rate of release of the compound.

[0040] In one embodiment, a specified amount of the compound with structure I is released in the gastrointestinal tract after swallowing a tablet, pill, capsule or other form within specified amount of time. In another embodiment, this specified 166334706.1amount of released compound is from 50% to 95% from the total amount, and the specified amount of time is 1h, 2h, 3h, 4h, 5h, 6h, 7h, 8h, 10h, 12h, 14h, 16h, 18h, 20h, 22h, 24h, 36h, or 48h, as measured by a standard type 2 USP dissolution apparatus, filled with deionized water and set at 37oC±2oC at a paddle speed of 50 rpm. Preferably, the specified amount is from 70% to 90% and the specified time is from 2 to 6 h, and most preferably from 3 to 5 h. In another embodiment, the compound is released with constant rate, or by zero- order, or almost zero-order, or predominantly by zero-order kinetics. In yet another embodiment some amount of the compound is released initially by an enhanced rate (loading or burst rate) followed by release of the rest of the compound by slower zero-order kinetics. In a further embodiment, the compound is released after swallowing first by a first-order kinetics, followed by a zero-order kinetics.

[0041] In another embodiment, the compound is formulated to be quickly released in the sublingual space or in the oral cavity when applied sublingually or buccally. At least 80% of the compound may be released for at least 15 min, 10 min, 5 min, 3 min, 2 min, 1 min, 45 sec., 30 sec, or 15 sec.

[0042] In one embodiment, the controlled-release form is prepared using a diffusion-controlled system, in which the rate of release is restricted by a slow diffusion of the compound’s solution through a polymer or through a semi- permeable membrane or through a micro-porous membrane. In another version of this embodiment, the compound is dispersed in a solid form in a porous, semi- porous, or nano-porous polymer or material. Upon swallowing, gastrointestinal tract fluids diffuse through the polymer, dissolve the compound and the solution diffuses back to be released in the gastrointestinal track. In another version of this embodiment, the compound is not dispersed into the polymer, but is surrounded by a layer, or is encapsulated by a layer of material or membrane through which the GI tract fluids diffuse slowly to dissolve the compound and then the solution diffuses back to be released. In yet another embodiment, in order to control more precisely the rate of release, the compound is deposited as a layer around a solid inert core, and this layer of compound is surrounded or covered by a polymer or semi-permeable membrane through which a slow diffusion of the GI tract fluids and compound’s solution takes place. In another version of this 166334706.1embodiment, the inert core is surrounded by two or more interleaving layers of compound and diffusion polymer or membrane. Non-limiting examples of polymer or materials that can be used are: carbomers, carboxy methyl cellulose, chitosan, dextrin, ethyl cellulose (EC), gelatin, guar-gum, hydroxylethyl cellulose (HEC), hydroxylpropyl cellulose, hydroxypropyl methylcellulose (Hypromellose), maltodextrin, methyl cellulose, microcrystalline cellulose, polycarbophil, polydextrose, polyethylene glycol, povidone, tragacanth, sodium alginate, and xanthan gum. The rate of release can be controlled by the selection of the type of the polymer – some polymers, like carboxy methyl cellulose, swell more in aqueous environment and display faster diffusion kinetics, other polymers, like ethyl cellulose swell less, and are less permeable. A mixture of two or more polymers may be used for further control. The thickness and the number of polymer membranes is another way to control the release kinetics. Other parameters that can be optimized to obtain the desired release kinetics are the size of the compound crystals, the size of the internal inert core (if any), and the size of the formulation capsules.

[0043] Another embodiment provides a controlled-release of the compound from a polymer in which the compound is uniformly dispersed and which polymer is gradually dissolved, degraded, disintegrated or eroded in the GI tract. It should be understood that this process of controlled-release can take place in the diffusion-controlled systems describe above, if the diffusion-control polymer can be gradually degraded, dissolved or eroded in the GI tract. In this case the compound is release both by slow diffusion of compound solution out of the polymer and by direct release of the compound due to the polymer disintegration. Some examples of such polymer matrixes are: water-soluble natural gums of polysaccharides of natural origin, such as xantham gum, alginate, and locust bean gum; nonionic homopolymers of ethylene oxide, such as poly(ethylene oxide), [H(OCH2CH2)nOH] with a molecular weight range of 100,000 to 8,000,000 (e.g., Polyox WSR N-12K, WSR N-60K, WSR-301, WSR-coagulant, WSR-303, WSR-308); non-ionic soluble cellulose ethers, such as hydroxypropyl- methylcellulose (HPMC, e.g., Methocel K100 LV, K4 M, K15 M, K100 M; Benecel MP 843, MP 814, MP 844; Metolose® 100, 4000, 15000 and 100000 SR), hydroxypropylcellulose (HPC, e.g., Klucel GXF, MXF, HXF), 166334706.1hydroxyethylcellulose (HEC, e.g., Natrosol 250 HHX, HX, M, G) with varying degrees of substitutions and viscosity grades; or polyvinyl alcohol, albumins, sodium alginate, or various mixtures of the above polymers. The rate of release can be controlled by changing of the type or the polymer, or the composition of a mixture of polymers, by varying the size and the thickness of the capsules, and by the use of internal inert cores of various sizes.

[0044] In another embodiment, the compound is formulated in macro or micro capsules, which are encapsulated by polymer film which dissolves, disintegrates, or decomposes in the GI tract. Once the polymer disintegrates than whole amount of the drug is released. The time of release can be controlled by controlling the type of the polymer and its thickness. Uniform or close to uniform rate of release can be achieved by mixing capsules with different thickness of the encapsulating polymer.

[0045] In another embodiment, the controlled-release of the compound is achieved by an osmotic pump formulation. In this formulation the compound is contained in a capsule or micro-capsule, which is surrounded by a semi- permeable membrane or layer, through which only water can diffuse, and which is not permeable by the solutes, including the compound in aqueous solution. As water diffuses through the membrane, it dissolves the compound resulting in development of osmotic pressure inside the capsule. This osmotic pressure causes the solution to leave the capsule through one or more micro-holes or orifices that are pre-made in the capsule. A number of natural, synthetic or semi- synthetic polymers can be used as a membrane, including, for example, partially acetylated cellulose. The micro-holes or orifices can be made by laser drilling. Alternatively, the acetylated cellulose or ethyl cellulose can be mixed with pore- forming materials, such as poly(ethylene glycol) or other water soluble material, which eliminates the need of laser drilling. After dissolution of the pore-forming material, the compound solute can leave the capsule through the formed micro- pores. In addition to the compound with structure I, a biologically inert, water- soluble compound can be added as a co-osmotic agent inside the capsules in order to further increase the osmotic pressure. The rate of release can be controlled by selecting the size of the capsules, the type of the membrane, its thickness and its properties, as for instance, the degree of acetylation of acetyl 166334706.1cellulose, or by varying the size and the number of orifices or macro-pores, and the presence, type and amount of co-osmotic agent. Other osmotic pump systems and designs are known, for example those disclosed by Almoshari, Y. in "Osmotic Pump Drug Delivery Systems-A Comprehensive Review." Pharmaceuticals (Basel) 15(11) (2022), and which one with average skill in the art can utilize to obtain a controlled delivery of compound with structure I in the GI tract.

[0046] In some embodiments, the coating or matrix providing for the controlled, or delayed release is acetate phthalate, propylene glycol, sorbitan monoleate, cellulose acetate phthalate (CAP), cellulose acetate trimellitate, hydroxypropyl methyl cellulose phthalate (HPMCP), methacrylates, chitosan, guar gum, polyethylene glycol (PEG), hydroxypropylmethylcellulose (HPMC), hydroxypropylethylcellulose, ethylcellulose or hydroxypropylmethylcellulose acetate succinate (HPMC-AS).

[0047] In an embodiment, the compound with structure I is attached or complexed to a weak or strong anion-exchange resin. The resin-drug complex when delivered orally to a subject provides for a controlled, gradual delivery of the compound in the GI tract by exchange with chloride or with other anions in the GI tract. The resin beads can be further modified as for example by coating with semi-permeable polymer to further modify the rate of delivery.

[0048] The scope of the present disclosure is not restricted to the disclosed embodiments for controlled release of compound with structure I. Numerous other methods for achieving of controlled release of drug substances are known, and can be used to prepare formulations for controlled release of the compound with structure I. Methods and means for preparation of controlled-release formulations of active pharmaceutical substances are disclosed by Adepu, S. and S. Ramakrishna (2021) in “Controlled Drug Delivery Systems: Current Status and Future Directions.” Molecules 26(19); or by Qiu, Y. in Chapter 20 – Rational Design of Oral Modified-Release Drug Delivery Systems, Developing Solid Oral Dosage Forms. Y. Qiu, Y. Chen, G. G. Z. Zhang, L. Liu and W. R. Porter (Editors), San Diego, Academic Press: 469-499 (2009); or by Kaur, G., et al. in Chapter 15 – Oral controlled and sustained drug delivery systems: Concepts, advances, preclinical, and clinical status, Drug Targeting and Stimuli Sensitive 166334706.1Drug Delivery Systems, A. M. Grumezescu (Editor hydroxypropyl methylcellulose), William Andrew Publishing: 567-626 (2018), all of which and the references cited therein are incorporated herein by reference. GI tract residential time increase

[0049] In another embodiment, the compound with structure I is formulated with, or is co-administered with a substance or substances that increase the residential time of the compound in the upper GI tract. Such substances, for instance, can be antispasmodic agents, such as propantheline, or a ciliostatic agent, which decreases the motility of the epithelial cilia, and reduces the rate of clearing of the GI tract mucus, which agents are known to increase the upper GI tract residential time. The ciliostatic agent may be selected from, e.g., benzalkonium chloride, EDTA, and bile salts. In another version of this embodiment, the compound is formulated with polymers that poses enhanced adhesion to the GI tract mucus - and thus increase the GI residential time. Many highly hydrophilic polymers upon hydration form so-called hydrogels, which hydrogels display enhanced affinity to the mucus gel covering GI tract epithelial surface. Examples of such polymers are polyacrylic acid (Carbopol, Carbomer), polyethylene glycol, alginate and pectin. Many other hydrophilic polymers, such as carboxyethyl cellulose, hydroxyethyl cellulose, hydroxypropyl cellulose hydroxypropyl methylcellulose, hydroxyethyl methacrylate, polyvinyl alcohol, polyvinylpyrrolidone, or polycarbophil also have enhanced affinity to the GI mucus and can be utilized to increase the GI residential tract of compound formulations. Entero-coating

[0050] In another embodiment, the compound with structure I is delivered orally with formulations or means that prevent the contact of the compound with the stomach content. Such means are used to protect oral drugs that are sensitive to the low pH or enzymatic activity of the stomach juice. In embodiments, the drug formulation is protected by coating with a barrier that is stable at the low pH of the stomach juice and disintegrates or swells and become permeable at the higher pH of the duodenum and the small intestines. Such a coatings, also known as enteric coatings, can be applied to whole tablets, to 166334706.1capsules, granules, pellets, microcapsules and micro- or nanoparticles. There are different materials which may be used for the for enteric coating, including, for example, polyacrylates or polymethacrylates and their derivatives. In the acidic stomach environment, the carboxylic functions of these polymers are in non- dissociated, COOH form. As a result, the polymers are poorly solvated and un- penetrable for the stomach juice. At the slightly alkaline duodenum and small intestine environment, the COOH functional groups are converted to carboxylate anions, which causes the polymer to form highly hydrated and permeable gel or to dissolve. Such polymers and coating technologies are commercially available. Other polymers that can be used for enteric coating are cellulose derivatives, such as cellulose acetate phtalate (CAP), cellulose acetate trimellitate (CAT), cellulose acetate succinate (CAS), hydroxypropyl methylcellulose phthalate (HPMCP) or hydroxypropyl methylcellulose acetate succinate (HPMCAS). Some polyvinyl derivatives, such as polyvinyl acetate phtalate (PVAP), also display pH dependence of their solubility and can be used as enteric coating agents, as disclosed by Nesbitt, R.U., Goodhart, F.W., Gordon, R.H., in “Evaluation of polyvinyl acetate phthalate as an enteric coating material”, Int J Pharm 26, 215- 226 (1985). Natural materials, such as shellac (esters of aleuritic acid), zein, amylose starch, starch derivatives and dextrins can be used for enteric coating in the preparation of oral forms containing compound I. In addition, different enteric coating materials can be mixed, or can be mixed with plasticizers, that impart flexible resiliency to the material for resisting fracturing, for example during tablet curing or aging, such as diethylphtalate, dibutylphtalate, dibutyl sebacate, triethyl citrate, and glycerol acetates, such as triacetin, and other agents that modulate and improve the properties of the coatings. The coating can be applied using known methods for coating of pharmaceutical solid oral forms, such as standard coating pan method, in which a solution of the coating material in volatile solvents is added to the tablets or to other coated formulations, which tumble, or are otherwise stirred, and through which a stream of air or nitrogen is passed. The heat for evaporation of the solvent is provided either by heating of the pan, the gas, or both. Alternatively, the process of fluidized bed coating can be used, which is especially preferable for coating of smaller size formulations, such as pallets, granules and microcapsules, or microparticles. In this process heated air or gas is passed through a layer of the formulations at such a speed, as to 166334706.1constantly mix and keep in levitation the formulation particles. A solution of the coating material is added to the fluidized bed for its uniform distribution on the surface of the particles and evaporation. Other processes that can be used and are known to one skilled in the art are hot melt coating, in which a melt of the coating material, instead of solution is used, or compaction or pressure coating, in which the coating material is pressed on the tablet surfaces, or electrostatic coating, in which the coated forms and the coating material are electrostatically charged with opposite charges. The coating material is sprayed either as powder or solution. This method provided for a highly uniform film formation with minimal losses. The film is cured (stabilized) either by sintering, melting or evaporation. Other coating methods that can be used in the formulations provided herein are 3D printing or microencapsulation. The provided means and methods for enteric coating do not restrict the scope of the disclosure. One skilled in the art can utilize other coating materials or coating methods, such as those disclosed by Maderuelo, C., et al. in "Enteric coating of oral solid dosage forms as a tool to improve drug bioavailability." Eur J Pharm Sci 138: 105019 (2019); or by Salawi, A. in "Pharmaceutical Coating and Its Different Approaches, a Review." Polymers (Basel) 14(16) (2022) and the references cited therein, all of which are incorporated herein by reference. GI uptake enhancers

[0051] In another embodiment, a bioavailability enhancing agent is used to improve the oral, sublingual, or buccal bioavailability of the compound with structure I or its formulations. This agent can be administered separately, or co- administered, or can be co-formulated with the compound with formula I. Various methods, means or agents can be used for improvement of the oral, sublingual of buccal bioavailability of compound with structure I, as for example those disclosed by Yewale, C., et al. in "Oral Absorption Promoters: Opportunities, Issues, and Challenges", Critical Reviews in Therapeutic Drug Carrier Systems 32(5): 363-387 (2015); or by Boegh, M., et al. in "Mucosal drug delivery: barriers, in vitro models and formulation strategies", Journal of Drug Delivery Science and Technology 23(4): 383-391 (2013); or by Dave, V. S., et al. in "Current and evolving approaches for improving the oral permeability of BCS Class III or analogous molecules", Drug Development and Industrial Pharmacy 43(2): 177- 166334706.1189 (2017), all of which and the references cited therein are incorporated herein by reference.

[0052] In one embodiment, the mammal or human receiving oral treatment with compound with formula I is also treated with an agent that improve the stability of the compound with formula I in the GI tract, as for example, agents for reduction of the stomach juice acidity, such as proton pump inhibitors (for example omeprazole, esomeprazole, lansoprazole, rabeprazole, pantoprazole or dexlansoprazole); or various neutralizing agents (magnesium oxide or hydroxide, sodium hydrogen carbonate, aluminum hydroxide, aluminum phosphate, calcium carbonate, etc.); or inhibitors of the enzymatic or chemical degradation of the compound in the GI tracts such as inhibitors of GI tract phosphatase of phosphodiesterase activity; or inhibitors, or antibacterial agents that protect the compound from degradation by the bacteria in the lower GI tract. The agents improving the stability, or inhibiting the degradation of compound with formula I can be co-administered, or can be administered separately, or can be co- formulated with the compound with formula I.

[0053] In one embodiment, the mammal or human receiving oral treatment with compound with formula I is also treated with an agent that improves the rate of diffusion of the compound through mucus lining of the GI tract. Such an agent, for instance, can be hyaluronidase, which administration reduces the thickness of the GI tract mucosal layer and improves oral bioavailability as disclosed by Aoki, Y., et al. in “Regiondependent role of the mucous / glycocalyx layers in insulin permeation across rat small intestinal membrane”, Pharm. Res.2005, 22, 1854– 62.

[0054] In an embodiment, the compound with formula I is co-formulated with, or the mammal receiving oral, sublingual or buccal treatment with compound with formula I receives co-treatment with an agent that enhances the permeation of the compound with formula I through the buccal or GI tract epithelium. A compound that is enhancing the penetration of compound with formula I through the buccal or GI tract epithelium is referred to herein as a “penetrant”. Such penetrants can be, without being limited to, chelating agents and in particular, Ca2+ chelating agents; short-, medium- or long-chain fatty acids and their salts and glycerides, like caprylic acid (C8), capric acid (C10), lauric acid (C12), oleic 166334706.1acid (C18) and their salts and / or derivatives; lipoaminoacids, N-(8-(2- hydroxylbenzoyl)amino)caprylate (SNAC), 8-(N(2-hydroxy-5-chlorobenzoyl))- aminocaprylic acid (5-CNAC); fatty acids derivatives, e.g. palmitoylcarnitine; bileacids and their salts or derivatives, such as N -deoxycholyl-L-lysyl methyl ester;non-ionic, anionic and cationic surfactants or amphoteric of zwitterion sufactants; salicylates; cyclodextrins and their derivatives; various cationic polymers, including but not limited to polylysine, polyarginine, chitosan, N-trimetylchitosan, poly- and oligoimidazoles, penetration-enhancing peptides, or cell penetration peptides, such as Clostridium perfringens enterotoxin (CPE) and its C-terminus peptide (C-CPE), peptides, corresponding to the occludin extracellular loop, Vibrio cholerae Zonula occludens toxin (Zot) and its 12 kDa fragment delta G, zonulin, Tat and its 48-60 fragment and penetratin; protein kinases and protease inhibitors and azone. Some of the penetrants are cationic and polycationic and can form salts, i.e. to ion-pair with, or to play the role of M in the compound with structure I. Penetrants can also be various micro- or nano-structures or particles, which contain, or are bound to compound with structure I, such as micelles, liposomes, nano particles, which micro- or nano-structures can be pegylated or non-pegylated and cationic or neutral.

[0055] Without wishing to be bound by theory, the penetrant can cause epithelial tight junction reversible opening, or increased leakage, which can increase the paracellular rate of diffusion of compound with structure I through the epithelium, or can enhance the uptake of compound with structure I at the apical side of the epithelial cells, or enhance the compound release through the basolateral side of the epithelial cells, or would reduce the rate of pumping out of the compound through the apical part of the cell membrane in the lumen.

[0056] In some embodiments, the penetrant is selected from the group consisting of a fatty acid or pharmaceutically acceptable salt thereof, a fatty acid derivative or pharmaceutically acceptable salt thereof, a bile acid or pharmaceutically acceptable salt thereof, a bile acid derivative and / or pharmaceutically acceptable salt thereof, a chelating agent, a surfactant, a non- chelating non-surfactant agent, and a chitosan, methylchitosans, or derivative thereof. 166334706.1

[0057] Without wishing to be bound by theory, calcium ions play an important role in the maintenance of the tight junction integrity, and it is known that lowering of free Ca2+ concentration causes reversible permeabilization of the epithelial and endothelial tight junctions and modulation of the Ca2+ ions concentration can be used to enhance the transcellular penetration of the epithelium. In an embodiment, one or more calcium chelators such as, but not limited to, ethylenediaminetetraacetic acid, EDTA, and / or its salts, or diethylenetriamine- pentaacetic acid, and / or its salts, or citric acid, and / or its salts, or salicyclate, a N- acyl derivative of collagen, laureth-9, an N-amino acyl derivative of a beta- diketone or a mixture thereof are used as penetrants.

[0058] In one embodiment, the penetrant is caprylic acid (C8), capric acid (C10), lauric acid (C12), oleic acid (C18), N-(8-(2- hydroxylbenzoyl)amino)caprylate (SNAC), 8-(N(2-hydroxy-5-chlorobenzoyl))- aminocaprylic acid (5-CNAC), or pharmaceutically acceptable salt thereof, such as a sodium salt of the aforementioned fatty acid or derivative, or mixtures thereof.

[0059] In another embodiment, the penetrant is a fatty acid or pharmaceutically acceptable salt thereof, or ester thereof. Suitable fatty acids and their derivatives include C8-C20 saturated or unsaturated, linear, branched or cyclic carboxylic acids. For instance, the fatty acid can be arachidonic acid, oleic acid, lauric acid, caprylic acid, capric acid, myristic acid, palmitic acid, stearic acid, linoleic acid, linolenic acid, dicaprate, tricaprate, monoolein, dilaurin, glyceryl 1-monocaprate, 1-dodecylazacycloheptan-2-one, an acylcarnitine, an acylcholine; or a C1-10 alkyl ester of fatty acid, monoglyceride, or diglyceride ofone or more fatty acids, or a fatty acid derivative, such as choline ester, or N , orN amide with L-lysine, di-lysine, oligolysine, polylysine, arginine, diarginine,oligoarginine, polyarginine, ornithine, di-, oligo- or polyornitine, creatine, or an cationic peptide, or a pharmaceutically acceptable salt thereof (such as a sodium salt) or a mixture thereof.

[0060] In another embodiment, the penetrant is one or more compounds and / or mixtures selected from the group of sodium caprate, either alone or in conjunction with sodium caprylate and / or sodium laurate; N-(8-(2- hydroxylbenzoyl)amino)caprylate (SNAC), 8-(N(2-hydroxy-5-chlorobenzoyl))- 166334706.1aminocaprylic acid (5-CNAC) (an acetylated amino acid); sodium laurate; bile acids and / or their salts, fatty acids mixture (C10, C12, sodium ursodeoxycholate (UDCA); POE; lecithin; sodium-2-octyldodecanoate; PEG 3350; 1% Eudragit; Gantrex AN-169; 5% Gantrex AN-169 and 5% carbopol 974P; 5% Gantrex AN- 169; labrasol, cumulase; alkyl saccharide; lipids; EDTA; Ca2+chelator; Gantrez with bioadhesives; sodium phosphate tribasic and UDC.

[0061] In another embodiment, the penetrant is one or more surfactants, i.e. a compound comprising a hydrophobic moiety bonded to a hydrophilic moiety, and depending on the hydrophilic moiety the surfactant can be an anionic, or cationic, or nonionic surfactant. Nonionic surfactants include nonionic esters such as ethylene glycol esters, propylene glycol esters, glyceryl esters, polyglyceryl esters, sorbitan esters, sucrose esters, and ethoxylated esters. Nonionic alkanolamides and ethers such as fatty alcohol ethoxylates, propoxylated alcohols, and ethoxylated / propoxylated block polymers are also included in this class. The polyoxyethylene surfactants are the most popular members of the nonionic surfactant class. Some examples of non-ionic surfactants are polyoxyethylene-9-lauryl ether, polyoxyethylene-20-cetyl ether, sorbitan monostearate, lauryl glucoside, and tweens 20, 40, 60 or 80. If the polar moiety is an anion, then the surfactant is an anionic surfactant. Anionic surfactants can be fatty acid salts or carboxylates such as soaps, acyl lactylates, acyl amides of amino acids, esters of sulfuric acid such as alkyl sulfates and ethoxylated alkyl sulfates, sulfonates such as alkyl benzene sulfonates, acyl isethionates, acyl taurates and sulfosuccinates, and phosphates. The anionic surfactant class includes the alkyl sulfates and the soaps. Some examples are sodium stearate, lauryl sulfate and sodium dodecylsulfonate. If the polar moiety is a cation, then the surfactant is a cationic surfactant. Examples are ammonium salts, alkylammonium salts, quaternary ammonium salts and ethoxylated amines. The quaternary ammonium salts are representative members of this class. Some examples are cetylammonium chloride and benzalkonium chloride. If the polar moiety has both positive and negative charges, then the surfactant is zwitterionic or amphoteric. Amphoteric surfactants can be amino carboxylic acids with a hydrophobic moiety, amino sulfate esters, or amino sulfonic acids, N- alkylbetaines and phosphatides, like phosphatidylcholine. Some examples are 166334706.1CHAPS (3-[(3-cholamidopropyl)-dimethylammonio]-1-propanesulfonate) and phospholipids, like phosphatidylserine, phosphatidylethanolamine, phosphatidylcholine, and sphingomyelins. Other surfactants are described in, for example, Chemistry and Technology of Surfactants, by Richard J. Farn (Editor), Blackwell Publishing, 2006, ISBN-10: 1-4051-2696-5; Rieger, in “Pharmaceutical Dosage Forms,” Marcel Dekker, Inc., New York, N.Y., 1988.

[0062] In some embodiments, the penetrant is cell permeation peptide, examples of which are, without being limited to: GRKKRRQRRRPPQC (Tat fragment 48-60); RQIKIWFQNRRMKWKK (penetratin);ACYCRIPACIAGERRYGTCIYQGRLWAFCC ( -defensin);DHYNCVSSGGQCLYSACPIFTKIQGTCYRGKAKCCK ( -defensin);GALFLGWLGAAGSTMGAWSQPKKKRKV (signal sequence based peptide); LLIILRRRIRKQAHAHSK (PVEC); GWTLNSAGYLLKINLKALAALAKKIL (transportan); RRRRRRRRR (Arg9); KFFKFFKFFK (Bacterial cell wall permeating peptide); LLGDFFRKSKEKIGKEFKRIVQRIKDFLRNLVPRTES (LL- 37); SWLSKTAKKLENSAKKRISEGIAIAIQGGPR (cecropin P1); RKCRIVVIRVCR (bactenecin); KLALKLALKALKAALKLA (amphiphilic model peptide); RRRPRPPYLPRPRPPPFFPPRLPPRIPPGFPPRFPPRFPGKR-NH2 (PR-39); ILPWKWPWWPWRR-NH2 (indolicidin); AAVALLPAVLLALLAP (RFGF); and AALLPVLLAAP (RFGF analogue).

[0063] In another embodiment, the penetrant is bile acid, bile acid salt, or bile acid derivative. The bile acid can be cholic acid, deoxycholic acid, dehydrocholic acid, glucholic acid, glycholic acid, glycodeoxycholic acid, fusidic acid, glycodihydrofusidic acid, taurodihydrofusidic acid, taurocholic acid, taurodeoxycholic acid, chenodeoxycholic acid, ursodeoxycholic acid, tauro-24,25- dihydro-fusidic acid, or a or a pharmaceutically acceptable salt thereof (such as a sodium salt), or a derivative thereof, such as, but not limited to, ether, amide, or ester, such as polyoxyethylene ester, or a mixture thereof.

[0064] In another embodiment, the penetrant is a polycationic compound, i.e. a compound having multiple positive charges, i.e. a compound with 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 20 or more positive charges. Examples of such compounds are natural or synthetic polyamines, branched or linear polyethyleneimines, di-, tri-, tetra-, oligo-, or polylysines; di-, tri-, tetra-, oligo-, or 166334706.1polyarginines, di-, tri-, tetra-, oligo-, or polyornitines, chitosan, N- methylchitosanes or chitosan derivatives.

[0065] In yet another embodiment, the penetrant is a polycationic compound, i.e. a compound having multiple positive charges and which forms a salt, or an ion-pair or a complex with the compound with structure I, i.e. the penetrant is M from structure I.

[0066] In one embodiment the penetrant is chitosan, or methylchitosan, or chitosan derivative.

[0067] In some embodiments, the penetrant is a particle, micro- or nanoparticle, micro-, or nanosphere, or other micro- or nano-formation, such as, without being limited to a micelle, a liposome, a nanoparticle, a polymer particle, a dendrimer, viral particle or viral capsid, nanotube, or protein or peptide assembly, such as lipoprotein or lipoprotein-like peptide assembly. The compound with structure I can be packed inside the micro-, or nano-formation, or particle, or can be attached to it, by absorption, ion-pairing, electrostatic interaction, or by chemical bond. Such carrier particles or formations can be, without being limited to, poly-amino acids, polyimines, DEAE-derivatized polyimines, polyacrylates, polyalkylacrylates, polyoxethanes, polyalkylcyanoacrylates, cationized gelatins, albumins, starches, polyethylene glycols, pollulans, celluloses, chitosan, poly-L-lysine, polyhistidine, polyornithine, polyspermines, protamine, polyvinylpyridine, polyaminostyrene, poly(methylcyanoacrylate), poly(ethylcyanoacrylate), poly(butylcyanoacrylate), poly(isobutylcyanoacrylate), poly(isohexylcyanoacrylate), DEAE-methacrylate, DEAE-ethyhexylacrylate, DEAE-acrylamide, DEAE-albumin, DEAE-dextran, polymethylacrylate, polyhexylacrylate, poly(D, L-lactic acid), poly(DL-lactic- coglycolic acid) (PLGA). In some embodiments, the carrier particles are cationic. In some embodiments, the carrier particles comprise a complex of poly-L-lysine and alginate, a complex of protamine and alginate, lysine, dilysine, trilysine, calcium, albumin, glucosamine, arginine, galactosamine, nicotinamide, creatine, lysine-ethyl ester or arginine ethyl-ester. In a preferred embodiment, the particles or the formations are cationic, and the compound with structure I is packed inside, or is attached to them by electrostatic interactions, or by salt formation, or by ion-paring formation, or by charge neutralization. 166334706.1

[0068] The particles or the formations can be formed by spray drying, lyophilization, evaporation, fluid bed drying, vacuum drying, or by combination thereof. They can also be produced by electrostatic spraying, electrospray, or by self-assembly or by spontaneous assembly, or by polymerization or polycondensation in block, in emulsion, or in solution.

[0069] In another embodiment, the penetrant is selected from: a) fatty acid or fatty acid derivative; b) fatty acid aggregate, such as a micelle; c) bile acid, bile acid salt or bile acid derivative; d) surfactant; e) surfactant aggregate, such as a micelle of lyposome; f) phospholipid; g) phospholipid aggregate, such as a micelle or lyposome; h) a chelating agent; i) cyclodextrin or beta-cyclodextrin; j) medium chain fatty acid, its salt or its derivative; k) an amino acid or amino acid derivative; l) a cationic oligomer or polymer; m) a cationic dendrimer; o) nano- particle; p) chitosan or chitosan derivative; q) any combination of the penetrant agents recited in a) to p).

[0070] In another embodiment, the penetrant is selected from: a) epithelial tight junction physiology modulating agent; b) an agent enhancing the transport of molecules through the apical or basolateral sides of the epithelial cell membrane; an apical or basolateral membrane transporter modulating agent; c) an apical side efflux pump inhibitor; d) an agent that decreases the thickness, or enhances the penetrability of the GI tract mucus; e) ciliostatic agent; f) degradative enzyme inhibitory agent; g) pH modulating agent; h) mucoadhesive agent; i) negative charge neutralizing agent.

[0071] The penetrant may be present from 0.01% to 50% of the weight of the oral, sublingual or buccal dose, in another embodiment it is from 0.1% to 10% of the dose, and in yet another embodiment it is from 0.5% to 5% from the dose. Dosing forms

[0072] In some embodiments, the compound with formula I is formulated to be delivered orally, sublingually or buccally in the form of a capsule, soft elastic gelatin capsule, hard gelatin capsule, caplet, aerosol, spray, powders or granules, suspensions or solutions in water or non-aqueous media, emulsions, syrups, or elixirs. 166334706.1

[0073] In some embodiments, the formulation is a solid formulation, in a solid form, such as a tablet, capsule, caplet, pill, beads, powders or granules, sachets, troches, SEC (soft elastic capsule or “caplet”), or hard gelatin capsule.

[0074] In some embodiments, the formulation is in a form of suspension, solution in water or non-aqueous media, an emulsion, aerosol, or spray.

[0075] In some embodiments, the formulation is a capsule, tablet, compression coated tablet, bilayer tablet, trilayer tablet, sachet, liquid-filled capsule or capsule comprising both liquid and solid components.

[0076] For sublingual or buccal delivery, the formulation is targeted to, or is applied to sublingual mucosa which includes the membrane of ventral surface of the tongue and the floor of the mouth or the buccal mucosa which constitutes the lining of the cheek. The administration to the sublingual space or the buccal cavity of a human can be done by tablets, prepared to disintegrate sublingually, or by spraying into the cavity, without inhalation, from a metered dose spray dispenser, pharmaceutical formulation as described above and a propellant. The formulation for oral and buccal application can also be formed in sachets, chewable tablets or capsules, chewable gums, soft elastic capsules, and thin films.

[0077] The formulation containing compound with formula I may also be administered to a mammal, including a human subject via oral tubing or oral gavage, using a cannular, tube, or gavage needle.

[0078] The formulation can contain various excipients, and auxiliary agents that may play a role in tablet formation, stabilization, disintegration among others. Such agents may serve as bulking agents, stabilizers, lubricants, preservatives, wetting agents, emulsifiers, osmotic pressure regulators, buffers, disintegrants, colorings, flavorings and / or aromatic substances and the like, and which excipients or auxiliary agents do not deleteriously interact with the compound with formula I. In addition, the formulation may contain one or more controlled-release agents, one or more enteric coating agents and one or more penetration enhancement agent (penetrants).

[0079] The formulation of compound I may include bulking agents or carriers. Suitable bulking agents are, without being limited to, polyethylene glycols, gelatin, 166334706.1mannitol, lactose and other sugars and sugar derivatives, amylose, magnesium stearate, talc, silicic acid, viscous paraffin, colloidal silicon dioxide, hydroxymethylcellulose, polyvinylpyrrolidone, water, salt solutions, alcohols, among others; lubricants, such as magnesium stearate, talc, silica, colloidal silicon dioxide, stearic acid, metallic stearates, hydrogenated vegetable oils, corn starch, polyethylene glycols, sodium benzoate, sodium acetate, etc.; disintegrants, such as starch, sodium starch glycolate, EXPLOTAB); and wetting agents, such as sodium lauryl sulphate or other surfactants; or buffering agents, such as salts of phosphoric acid.

[0080] The tablet forms are prepared by using standard processes, such as milling, screening, weighing, mixing, granulation, drying, pressing, coating and printing, which processes are performed using known equipment, such as weighing balances, milling machines, screening machines, blenders, granulators, driers, presses, coating machines and printers.

[0081] Standards capsule molding and cutting processes are used for capsules preparation.

[0082] Methods for preparation of different oral, sublingual and buccal formulation and dosing forms are known to those skilled in the art and are described for instance by Tovey, G. D. (Editor) in “Pharmaceutical Formulation: The Science and Technology of Dosage Forms”, RSC, London, 2018, ISBN 978- 1-84973-941-2, which and the references sited therein are included herein by reference. Application

[0083] The methods of the disclosure may be employed for the inhibition of platelet aggregation in vivo. Diseases and uses benefiting from the inhibition of platelet aggregation include thrombosis, such as coronary and cerebral arterial thrombosis (associated with unstable angina, coronary angioplasty, and acute myocardial infarction), unstable angina, myocardial infarction, stroke, transient ischemic event, cerebral embolism, kidney embolisms, pulmonary embolisms, primary arterial thrombotic complications of atherosclerotic disease (thrombotic stroke, peripheral vascular disease, and myocardial infarction without thrombolysis), thrombotic complications of interventions of atherosclerotic 166334706.1disease (associated with angioplasty, percutaneous coronary intervention, endarterectomy (e.g., of the carotid artery), stent placement (e.g., in the carotid artery), and coronary or other vascular graft surgery), thrombotic complications of surgical or mechanical damage (tissue salvage following surgical or accidental trauma, reconstructive surgery including skin flaps, and reductive surgery), mechanically-induced platelet activation (cardiopulmonary bypass resulting in microthromboembolism), shunt occlusion (renal dialysis or plasmapheresis), thrombosis secondary to vascular damage and inflammation (vasculitis, arteritis, glomerulonephritis, or organ graft rejection), indications with a diffuse thrombotic / platelet consumption component (disseminated intravascular coagulation, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, heparin-induced thrombocytopenia, or pre-eclampsia / eclampsia), pathological effects of atherosclerosis and arteriosclerosis (arteriosclerosis, acute myocardial infarction, chronic stable angina, unstable angina, transient ischemic attacks, strokes, peripheral vascular disease, arterial thrombosis, preeclampsia, embolism, restenosis or abrupt closure following angioplasty, carotid endarterectomy, or anastomosis of vascular grafts), chronic or acute states of hyper-aggregability (caused by DIC, septicemia, surgical or infectious shock, post-operative and post-partum trauma, cardiopulmonary bypass surgery, incompatible blood transfusion, abruptio placentae, thrombotic thrombocytopenic purpura, snake cenom or immune diseases), reocclusion of an artery or vein following fibrinolytic therapy, platelet adhesion associated with extracorporeal circulation, coronary artery disease, peripheral artery disease, and thrombotic complications associated with thrombolytic therapy, venous thrombosis (deep vein thrombosis, Veno-occlusive disease, and hematological conditions (thrombocythemia or polycythemia)), thrombophlebitis and arterial embolism.

[0084] In another embodiments, sublingual or buccal treatment with the compound with structure I is used as a first-in-line treatment for a subject presenting acute coronary syndrome symptoms. The treatment may be done with a formulation containing the compound alone, or with formulation containing a vasodilator, such as nitroglycerin, and / or additional antithrombotic, such as aspirin. 166334706.1

[0085] In another embodiment, the oral, sublingual or buccal treatment with the compound with formula I is used on patients, presenting with non-ST- elevation (NSTEMI) acute coronary syndromes, including NSTEMI myocardial infarction or unstable angina.

[0086] In yet another embodiment, the oral, sublingual or buccal treatment with the compound is used before, during and after percutaneous coronary intervention (PCI), including coronary stent placement, and including long term treatment after PCI.

[0087] In another embodiment, the compound with structure I is used for an IV treatment before, and / or during, and / or immediately after PCI, followed by transition from an IV to an oral treatment with an oral formulation of the compound after the PCI procedure and following with long term oral treatment after the PCI procedure with an oral formulation of the compound.

[0088] The dosage of the compound with structure I, and / or formulation comprising the compound, can vary depending on many factors, such as the severity and responsiveness of the disease state to be treated, the nature and extent of the symptoms, the course and the frequency of the treatment, and the type of concurrent treatment, if any; the mode of administration (oral, sublingual of buccal); and the age, health, and weight of the recipient. One of skill in the art can determine the appropriate dosage based on the above factors. Optimal dosing schedule can take into account the clearance rate of the compound from the circulation, and the accumulation of the compound in the body of the patient. In general, it can be estimated based on EC50s or EC70s found to be effective in in vivo animal models. The compounds with structure I may be administered initially in a dosage that is estimated from the data from the in vivo animal efficacy experiments, which dose may be later adjusted as required, depending on the clinical response. In general, satisfactory results may be obtained when the compound is administered to a human at a daily dosage of between 0.05 mg and 3000 mg (measured as the solid compound with formula I). A preferred dose range is between 0.05-500 mg / kg, more preferably between 0.5-50 mg / kg.

[0089] The compound with formula I can be used alone or in combination with other agents to treat, prevent, and / or reduce or delay the symptoms or course of 166334706.1the disease for which the treatment with the compound with formula I is beneficial. In combination treatments, the dosages of the compound with formula I and the co-administered compound or compounds may be reduced from standard dosages when administered alone.

[0090] The compound with formula I can be used prophylactically, i.e. to prevent, delay, or lower the probability of one or more symptoms or manifestation or negative outcomes of a disease, disorder or condition. In this case the treatment can be initiated before the onset of a disease, disorder or condition, or can be initiated before or after an event that precedes, or increases the likelihood of the onset of the disease, disorder or condition, non-limiting examples of such event being intervention, procedure, trauma or onset of pre-disposing morbidity, developing of pre-disposing conditions, or obtaining tests or information that increases the likelihood of onset of the disease. EXAMPLES

[0091] The following examples are included for the purposes of illustration of certain aspects of the embodiments of the disclosure and are not intended to limit the disclosure. Example 1

[0092] Oral treatment of rats with 36 mg / kg of compound with structure II results in oral bioavailability of the compound with plasma compartment concentration exceeding significantly the fully protective plasma concentration in an animal acute coronary syndrome (ACS) model.

[0093] Three male SD rats with catheterized Jugular vein were treated orally by gavage with aqueous solution of the compound with structure II (5 mg / ml, 7.2 mL / kg) at a dose of 36 mg / kg. Blood samples, 0.35 ml were taken from each rat at 20, 40, 60, 80, 100, 120 and 140 min post treatment from the JVC. The blood was chilled on ice and plasma was prepared by centrifugation. The plasma was frozen in dry ice for analysis. The analytical method utilized deuterium labeled analyte (6 deuterium atoms) as an internal standard and a solid phase extraction with weak anion-exchange resin for plasma samples purification. The final separation was done by reversed phase UHPLC chromatography. The detection and quantification were done by MS / MS using a triple quadrupole mass 166334706.1spectrometer with electrospray ionization in the negative ionization mode and multiple reaction monitoring fragmentation for the analyte detection and quantification. All 3 animals at all time points had detectable and quantifiable plasma levels of the compound with structure II. The average plasma concentration for the 3 animals at all time points is shown in Table 2 and plotted in Figure 1, where the vertical bars indicate the standard error of the mean for the three animals.

[0094] Figure 1 shows the average plasma concentration after oral treatment of 3 rats with 36 mg / kg of compound with structure II. The maximum plasma concentration was 52.1 g / L at 1.66 h post treatment. The minimal plasma concertation during the window 0.33 – 2.33 h post treatment was 32.6 g / L, and the average plasma concentration for the 0.33 – 2.33 h post treatment window was 42.1 g / L. The fully protective IV dose in the animal model of acute coronary syndrome (Folts model) was 10.8 g / kg*h IV infusion, and the partially protective dose in the same model was 1.08 g / kg*h IV infusion (as disclosed in "GLS-409, an Antagonist of Both P2Y1 and P2Y12, Potently Inhibits Canine Coronary Artery Thrombosis and Reversibly Inhibits Human Platelet Activation." Scientific Reports 8(1): 14529). These IV infusion doses correspond to steady state plasma concentrations of 9.1 g / L for the 10.8 g / kg*h infusion and 0.91 g / L for the 1.08 g / kg*h infusion dose (based on the IV infusion pharmacokinetics data for the compound with structure II in the rat). Based on these data, one may conclude that oral treatment of rat with 36 mg / kg of compound results in average plasma concentrations of the drug for the 0.33 – 2.33 h post treatment window, which are 4.6 times higher than the minimal fully protective plasma concentration, and 46 times higher than the partially protective plasma concentration in the animal ACS model. The minimal plasma concentration for the same post-treatment window is 3.6 times higher than the fully protective, and 36 times higher than the partially protective plasma concentration in the same animal model. 166334706.1Example 2

[0095] Oral treatment of fasted rats with 2 mg / kg and with 10 mg / kg of the compound with structure II results in an average plasma concentration of the compound which is between the minimal fully protective and the partially protective plasma concentration in the animal model of ACS.

[0096] In this example, the animals were treated with lower doses of the compound (2 and 10 mg / kg) and were fasted, which results in a lower residential time in the upper GI tract, which reduces the oral bioavailability.

[0097] Two groups of three fasted overnight male SD rats in each, with catheterized femoral vein were treated orally by gavage with aqueous solution of the compound with structure II. The first Group 1 received 2 mg / kg of 0.1% solution and the Group 2 received 10 mg / kg of 0.5% solution of the compound. Blood samples, 0.25 ml were taken from each rat at 20 min, 40 min, 1 h, 1 h and 20min, 1 h and 40 min, 2 h, 2.5 h, 3 h, 3.5 h, 4 h, 5 h and 7 h post dosing. After each sampling 0.25 ml saline was re-injected through the catheter for patency maintenance and fluid volume compensation. The blood was immediately chilled on ice and plasma was prepared by centrifugation. The plasma was frozen in dry ice for analysis. The analysis was performed by the method, described above, and the data is shown in Table 3 and plotted in Figure 2.

[0098] Figure 2 shows the average plasma concentration after oral treatment of groups of 3 fasted rats with 2 mg / kg and 10 mg / kg of compound with structure II. The maximum plasma concentration in Group 1 (2 mg / kg) is 4.58 g / L at 100 min post dosing, the minimum plasma concentration is 1.42 g / L and the average plasma concentration for the window 0.33 – 6 h post dosing is 3.63 g / L. The maximum plasma concentration in Group 2 (10 mg / kg) is 6.15 g / L at 120 min post dosing, the minimum plasma concentration is 2.26 g / L and the average plasma concentration for the window 0.33 – 6 h post dosing is 4.50 g / L. All 166334706.1plasma concentrations in both doses are above the partially protective plasma concentration in the animal model of ACS. The average plasma concentration for the 2 mg / kg group is 40%, and for the 10 mg / kg group is 50% from the minimal fully protective plasma concentration in the animal model of ACS. Example 3.

[0099] Sublingual treatment of rats with 10 mg / kg of the compound with formula II results in plasma concentration of the compound significantly higher that the fully protective plasma concentration in an animal ACS model.

[0100] Three male SD rats, with catheterized Jugular vein, and 300-320 g in weight, were anesthetized with isoflurane. While under anesthesia, the animals received a single sublingual 10 mg / kg, 0.075 mL / kg dose of 133 mg / mL aqueous solution of the compound with structure II. The administration was performed by a pipette and the solution was placed under the tongue in a way to avoid any damage to the tongue or the surface area of application that could cause abrasion / bleeding and trying to achieve the greatest surface of application possible while avoiding swallowing of the test material by the animal. Following dose administration, the animals were placed in dorsal recumbency (to allow the test material to absorb) and remained in this position until the completion of the experiment, except during blood collection. The animals remained anaesthetized during the experiment. Whole blood samples (~250 μL) were collected from the JVC at 10, 20, 30, and 40-minutes post-treatment, and terminal blood was collected by cardiac puncture at 60 min post treatment (±5%). Prior to sample collection, a frank blood sample, at least 0.10 mL, was collected and discarded ensuring the removal of locking solution / saline. The blood samples were collected in K2EDTA tubes, inverted well to mix with the anticoagulant and placed on wet ice. Following each sample collection, the catheter was flushed with sterile saline for injection. The blood samples were processed within 30 minutes of collection by cold centrifugation, at minimum 1000 g for 3 minutes and the plasma was extracted. The plasma samples were snap frozen and stored at - 70ºC until analyzed for compound with structure II concentration. The analysis was done using the method described in Example 1. The averaged plasma concentration for all animals is listed in Table 4, and graphed in Figure 3. 166334706.1

[0101] The plasma concentration of the compound did not reach a maximum within the study window. The maximum concentration within the study window was 60.8 g / mL which concentration is 6.7 times higher than the minimal fully protective plasma concentration in an animal ACS model. 166334706.1

Claims

CLAIMS 1. A method for modulation of platelets properties in vivo in a subject in need thereof, comprising oral, sublingual or buccal administration to the subject of a formulation comprising a compound with the structureor a pharmaceutically acceptable salt, wherein; a) each R is independently selected from methyl, ethyl, propyl, isopropyl, Cl, Br and I; and b) each M is independently or collectively selected from a monovalent cation, i.e. is a cation having one positive charge; one-half of a divalent cation, i.e. is a cation having two positive charges (alternatively, two M together comprise one divalent cation); one-third of a trivalent cation, i.e. a cation having 3 positive charges (alternatively, three M together comprise one trivalent cation); one-quarter of a tetravalent cation, i.e. a cation having 4 positive charges (alternatively, four M together comprise one tetravalent cation); or n M are part of a n-valent cation, i.e. are a part of a cation having n positive charges, where n is a number from 5 to 100000, preferably from 5 to 10000; and wherein the cation or cations can be a metal cation, such as Li, Na, K, Ca, Mg, Al, or Ti, or ammonium cation, or a hydrogen cation, or an organic cation, including an organic cation with two or more positive charges, or an organic polymer, or combination thereof, and wherein c) the phosphorous atoms 1 and 4 are both in RP configuration, or both in SP configuration, or one of them is in RP and the other is SP configuration, in which case the carbon atom between P2and P3is either in pseudo-r or pseudo-s configuration, or the compound of 166334706.1structure I is a mixture any of those stereo-configurations in any ratio, including 0% of one or more of them, or is a racemic mixture of stereoisomers.

2. The method of claim 1, wherein each R is methyl, each M is sodium and the stereoisomers resulted from P1, P4 and the carbon atom between P2 and P4 represent a racemic mixture.

3. The method of claim 1 or claim 2, wherein the configuration of P1 and P4 is SP.

4. The method of any one of claims 1 to 3, wherein the compound of structure I is formulated to be released in a controlled manner in the gastro-intestinal tract.

5. The method of claim 4, wherein the time for the controlled release of the compound of structure I is equal or close to the time of residence of the formulation in the upper GI tract, and preferably the compound of structure I is released during that time in a constant rate or close to constant rate.

6. The method of claim 4 or 5, wherein the formulation releases from about 60% to about 90% of the total amount of the compound of structure I for about 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 h, and preferably for about 2, 3, 4, 5, 6, 7, 8 h, and most preferably for between 3 and 5 h in deionized water when tested in a standard USP type 2 dissolution apparatus set to 37oC±2 oC at a paddle speed of 50 rpm.

7. The method of any one of claims 1 to 3, wherein the formulation is administered to the subject sublingually or buccally and releases at least 80% of the compound within 15 min, 10 min, 5 min, 3 min, 2 min, 1 min, 30 sec or 15 sec from the time of administration, preferably at least 90% in at least 2 min, and most preferably in less than 1 min.

8. The method of any one of claims 1 to 3, wherein the formulation prevents the contact of the compound of structure I with the stomach content, but releases the compound of structure I to be dissolved in the duodenum or the small intestine’s fluids.

9. The method of any one of claims 1 to 3, wherein the formulation comprises one or more agents that increase the residential time of the compound of structure I in the upper GI tract. 166334706.

110. The method of claim 9, wherein the one or more agents comprise ciliostatic agents, which reduce the rate of mucus clearing and which ciliostatic agents may be selected from, e.g., benzalkonium chloride, EDTA, and bile salts; or antispasmodic agents, which reduce the GI tract peristaltic, such as propantheline, or agents that enhance the affinity of the formulation to the upper GI tract mucus, such as polyacrylic acid, polyethylene glycol, alginate, pectin, modified celluloses, hydroxyethyl methacrylate, polyvinyl alcohol, polyvinylpyrrolidone, or polycarbophil.

11. The method of any one of claims 1 to 6 or 8 to 10, wherein the formulation comprises one or more agents that increase the stability of the compound of structure I in the GI tract.

12. The method of claim 11, wherein the one or more stability enhancing agents are be selected from: agents for reduction of the stomach juice acidity, such as proton pump inhibitors such as omeprazole, esomeprazole, lansoprazole, rabeprazole, pantoprazole or dexlansoprazole; or neutralizing agents such as magnesium oxide or hydroxide, sodium hydrogen carbonate, aluminum hydroxide, aluminum phosphate, calcium carbonate; or inhibitors of the enzymatic or chemical degradation of the compound in the GI tracts such as inhibitors of GI tract phosphatase of phosphodiesterase activity; or inhibitors, or antibacterial agents that protect the compound from degradation by the bacteria in the lower GI tract.

13. The method of any one of claims 1 to 6 or 8 to 12, wherein the formulation comprises one or more uptake enhancing agents.

14. The method of claim 13, wherein the one or more uptake enhancing agents enhance the rate of diffusion through the GI tract mucus, or enhance the rate of uptake by, or the rate of penetration through the GI tract epithelium by the compound of structure I.

15. The method according to claim 13 or claim 14, wherein the one or more uptake enhancing agents are selected from: a. i) fatty acid or fatty acid derivative; ii) fatty acid aggregate, such as a micelle; iii) bile acid, bile acid salt or bile acid derivative; iv) surfactant; v) surfactant aggregate, such as a micelle of liposome; vi) phospholipid; vii) phospholipid aggregate, such as a micelle or 41 166334706.1liposome; viii) a chelating agent, preferably a Ca2+ chelating agent; ix) cyclodextrin or beta-cyclodextrin; x) medium chain fatty acid, its salt or its derivative, or a mixture of medium chain fatty acids, their salts and / or their derivatives; xi) an amino acid or amino acid derivative; xii) an cationic oligomer or polymer; xiii) a cationic dendrimer; xiv) nano-particle; xv) chitosan or chitosan derivative; xvi) GI tract mucus tinner, such as hyaluronidase; xvii) any combination of the uptake enhancing agents recited in i) to xv); b. Ca2+ chelating agent, such as ethylenediaminetetraacetic acid, and / or its salts, or diethylenetriaminepentaacetic acid, and / or its salts, or citric acid, and / or its salts, or salicyclate, a N-acyl derivative of collagen, an N-amino acyl derivative of a beta-diketone or a mixture thereof; c. a medium chain fatty acid, such as caprylic acid (C8), capric acid (C10), lauric acid (C12), oleic acid (C18), or medium chain fatty acid derivative, such as N-(8-(2-hydroxylbenzoyl)amino)caprylate (SNAC), 8-(N(2-hydroxy-5-chlorobenzoyl))-aminocaprylic acid (5- CNAC), or pharmaceutically acceptable salt thereof, such as a sodium salt, or a mixture thereof; d. a bile acid, bile acid salt, or bile acid derivative, such as cholic acid, deoxycholic acid, dehydrocholic acid, glucholic acid, glycholic acid, glycodeoxycholic acid, fusidic acid, glycodihydrofusidic acid, taurodihydrofusidic acid, taurocholic acid, taurodeoxycholic acid, chenodeoxycholic acid, ursodeoxycholic acid, tauro-24,25-dihydro- fusidic acid, or a or a pharmaceutically acceptable salt thereof (such as a sodium salt), or a derivative thereof, such as, but not limited to, ether, amide, or ester, such as polyoxyethylene ester, or a mixture thereof; e. one or more surfactants, such as nonionic surfactant, such as polyol esters or ethers, carbohydrate esters or ethers, oligo-, or polyoxyethylene esters or ethers of fatty acids, fatty alcohols, bile acids, sterols, or other hydrophobic carboxylic acids or alcohols, some examples being polyoxyethylene-9-lauryl ether, polyoxyethylene-20-cetyl ether, sorbitan monostearate, lauryl 42 166334706.1glucoside, and tweens 20, 40, 60 or 80; or an anionic surfactants, such as fatty acid salts, salts of sulfate esters or sulfonates of hydrophobic compounds, such as fatty acids, alcohols, or alkylated aromatic compounds, examples being sodium stearate, lauryl sulfate and sodium dodecylsulfonate; or cationic surfactants, compounds containing one or more quaternary ammonium groups, or protonated amino-groups attached to an hydrophobic moiety, examples being cetylammonium chloride and benzalkonium chloride; or amphoteric or zwitterionic surfactants, amino carboxylic acids with a hydrophobic moiety, amino sulfate esters, or amino sulfonic acids, N-alkylbetaines and phosphatides, like phosphatidylcholine, some examples being CHAPS (3-[(3- cholamidopropyl)dimethylammonio]-1-propanesulfonate) and phospholipids, like phosphatidylserine, phosphatidylethanolamine, phosphatidylcholine, and sphingomyelins; or mixtures thereof; f. or oligo- or polycationic compound, or cationic oligomer or polymer, such as natural or synthetic polyamines, branched or linear polyethyleneimines, di-, tri-, tetra-, oligo-, or polylysines; di-, tri-, tetra-, oligo-, or polyarginines, di-, tri-, tetra-, oligo-, or polyornitines, chitosan, N-methylchitosanes or chitosan derivatives, or cationic dendrimers; or mixtures thereof; g. or one or more agents selected from the group of a) epithelial tight junction physiology modulating agent; b) an agent enhancing the transport of molecules through the apical or basolateral sides of the epithelial cell membrane; an apical or basolateral membrane transporter modulating agent; c) an apical side efflux pump inhibitor; d) an agent that decreases the thickness, or enhances the penetrability of the GI tract mucus; e) ciliostatic agent; f) degradative enzyme inhibitory agent; g) pH modulating agent; h) mucoadhesive agent; i) negative charge neutralizing agent.

16. The method of any one of claims 13 to 15, wherein the uptake enhancing agent or agents are from 0.01% to 50% of the weight of the oral, sublingual or buccal dose, or from 0.1% to 10% of the dose; or are from 0.5% to 5% from the dose. 166334706.

117. The method of any one of claims 1 to 16, wherein the compound of structure I is loaded into, or attached to a particle, micro- or nanoparticle, micro-, or nanosphere, or other micro- or nano-formation, such as, without being limited to a micelle, a liposome, a nanoparticle, an polymer particle, a dendrimer, viral particle or viral capsid, nanotube, or protein or peptide assembly, such as lipoprotein or lipoprotein-like peptide assembly, and where the compound of structure I can be attached to the micro- or nanoparticle or form by absorption, ion-pairing, electrostatic interaction, or by chemical bond.

18. The method of any one of claims 1 to 17, wherein the formulation to be delivered orally, sublingually or buccally is the form of a capsule, soft elastic gelatin capsule, or caplet, hard gelatin capsule, caplet, sachets, troches, chewing tablet, chewing gum, aerosol, spray, powders or granules, suspension or solution in water or non-aqueous media, emulsions, syrup, elixir; and where the tablet may be compression coated tablet, bilayer tablet, trilayer tablet, and the capsule may be liquid-filled capsule or capsule comprising both liquid and solid components.

19. The method of any one of claims 1 to 18, wherein the modulation of platelet properties involves platelets activation and / or aggregation reduction or inhibition, and wherein the compound of structure I is administered orally, sublingually or buccally in a therapeutically effective amount to a mammal, including a human for treatment or prevention of one or more diseases that are related to platelet activation and aggregation, such as, but not limited to coronary or cerebral arterial thrombosis, including thrombosis associated with unstable angina, coronary angioplasty, acute myocardial infarction, myocardial infarction, ST-Elevated myocardial infarction, ST-Nonelevated myocardial infarction, unstable angina, arterial thrombosis due to atherosclerotic disease, venous thrombosis, thrombophlebitis, arterial embolism, stroke, transient ischemic event, pulmonary embolism, cerebral embolism, kidney embolism, thrombosis or thrombotic complications due to intervention for treatment of atherosclerotic disease, including stent placement, thrombosis or thrombotic complication due to surgical interventions, mechanical or trauma damage or inflammation, including vascular 44 166334706.1inflammation or due to fibrinolytic therapy or due to coronary artery disease, or peripheral artery disease, or platelet activation and adhesion due to extracorporeal circulation.

20. The method of any one of claims 1 to 19, wherein the formulation comprising the compound of structure I is applied sublingually or buccally as a first-in-line treatment of human presenting acute coronary syndrome symptoms.

21. The method of any one of claims 1 to 20, wherein the compound of structure I is co-formulated with a vasodilator, such as nitroglycerin, and / or with other antithrombotic agent, such as aspirin.

22. The method of any one of claims 1 to 21, where the formulation comprising the compound of structure I is administered orally, sublingually or buccally before, during and / or after percutaneous coronary intervention (PCI), including coronary stent placement, and including for a long-term treatment after PCI.

23. The method of any one of claims 1 to 22, where the formulation comprising the compound of structure I is administered to a mammal, including a human subject via oral tubing or oral gavage, using a cannular, tube, or gavage needle. 166334706.1

Images