Compositions and methods for treating rheumatic disease

Abstract

In the various aspects and embodiments, the present disclosure provides compositions and methods for treating rheumatic disease in a human subject in need thereof, including but not limited to arthritic disease and SLE. In accordance with this disclosure, the subject receives a regimen of larazotide or derivative thereof during a period of disease remission (e.g., to reduce the frequency and / or severity of disease relapse or flare) and / or during periods of relapse (e.g., to reduce the duration and / or severity of relapse, and achieve disease remission). In embodiments, the subject is not responsive or is only partially responsive to conventional disease modifying drugs.

Description

[0001] COMPOSITIONS AND METHODS FOR TREATING RHEUMATIC DISEASE

[0002] CROSS-REFERENCE TO RELATED APPLICATIONS

[0003] This application claims the benefit of U.S. Provisional Patent Application No. 63 / 665,930, filed June 28, 2024, the entire contents of which are hereby incorporated by reference in their entirety.

[0004] DESCRIPTION OF THE TEXT FILE SUBMITTED ELECTRONICALLY

[0005] This application contains a Sequence Listing in XML format submitted electronically herewith via Patent Center. The contents of the XML copy, created on June 30, 2025, is named “INT-064PC_137776-5064.xml” and is 5,971 bytes in size. The Sequence Listing is incorporated herein by reference in its entirety.

[0006] BACKGROUND

[0007] Rheumatic diseases are immune or inflammatory conditions affecting the musculoskeletal tissues such as the joints, tendons, muscle, ligaments, bones, and / or muscles. Common rheumatic diseases include various types of arthritis (e.g., rheumatoid arthritis) and Systemic Lupus Erythematosus (SLE). Many rheumatic diseases shift between periods of remission and disease flares (or relapse), in which the frequency of flares can drive disease progression. While disease modifying drugs can help control the disease (e.g., maintain remission or reduce the frequency of flares), many patients are not responsive or fully responsive to these agents. Accordingly, compositions and methods for controlling rheumatic diseases are needed.

[0008] DETAILED DESCRIPTION

[0009] In the various aspects and embodiments, the present disclosure provides compositions and methods for treating rheumatic disease in a human subject in need thereof, including but not limited to arthritic disease and SLE. In accordance with this disclosure, the subject receives a regimen of larazotide or derivative thereof during a period of disease remission (e.g., to reduce the frequency and / or severity of disease relapse or flare) and / or during periods of relapse (e.g., to reduce the duration and / or severity of relapse, and achieve disease remission). In embodiments, the subject is not responsive or is only partially responsive to conventional disease modifying drugs.

[0010] In an aspect, the disclosure provides a method for treating a subject (e.g., a human subject) having a rheumatic disease. The method comprises administering an oral dosage form of larazotide or a derivative thereof to said subject at an effective amount and schedule to reduce or prevent disease symptoms.

[0011] Larazotide has the amino acid sequence: Gly Gly Vai Leu Vai Gin Pro Gly (SEQ ID NO: 1). Derivatives of larazotide comprise from one to three amino acid modifications with respect to SEQ ID NO: 1, and the modifications may be independently selected from substitutions, deletions, insertions or additions with respect to SEQ ID NO: 1. In some embodiments, the larazotide derivative is a derivative having 1, 2, or 3 amino acid substitutions with respect to SEQ ID NO: 1. By way example, in some embodiments, the larazotide derivative is a derivative described in U.S. Pat. Nos. 8,785,374, 8,957,032, and 9,279,807, which are each hereby incorporated by reference in their entirety. In some embodiments, the derivative has one or more non-genetically encoded amino acids, or one or more (or all) (d)-amino acids. The term “larazotide” or “larazotide treatment” refers to treatment with larazotide or a derivative that promotes tight junction integrity, for example, in the small intestine. In some embodiments, the treatment is with (d)-larazotide, that is, where all non-glycine residues are in (d) form.

[0012] In embodiments, the rheumatic disease is an arthritic disease, such as an arthritic disease selected from rheumatoid arthritis (RA), osteoarthritis, psoriatic arthritis, spondyloarthritis, and juvenile idiopathic arthritis (JIA). In embodiments, the rheumatic disease is Systemic Lupus Erythematosus (SLE) (e.g., lupus nephritis). In still other embodiments, the rheumatic disease is selected from Polymyalgia Rheumatica, Giant Cell Arteritis, fibromyalgia, scleroderma, and Sjogren’s syndrome.

[0013] In some embodiments, the subject has an arthritic disease, such as rheumatoid arthritis (RA), osteoarthritis, psoriatic arthritis, spondyloarthritis, and juvenile idiopathic arthritis (JIA). The larazotide or derivative may be administered during times of remission and / or relapse (as described herein), and / or as an additional or alternative therapy to disease modifying small molecules or biologies (as described herein). In embodiments, the subject has rheumatoid arthritis (RA). RA is a type of arthritis where the immune system attacks the tissue lining the joints, and which generally occurs on both sides of the body. Affected joints frequently include small joints such as fingers, hands, wrists, feet, and toes; as well as larger joints such as shoulders, elbows, hips, knees and ankles. The uncontrolled inflammation damages cartilage, and over time may deform joints, erode bone, and / or result in fusion of joints. In addition to affecting joints, RA may affect other parts of the body, including skin, eyes, mouth, lungs, and heart. In most RA subjects, the disease manifests as periods of symptom flares, and periods with no or few symptoms (remission).

[0014] In embodiments, the subject’s RAis in remission, that is, the larazotide or derivative is administered at least during periods where the subject is experiencing no or few symptoms of RA (e.g., joint pain and inflammation). In accordance with such embodiments, the regimen of larazotide or derivative reduces the frequency and / or severity of flares (otherwise referred to as relapse), optionally in combination with other disease modifying agents as described herein. In embodiments, the subject’s drug regimen (without larazotide or derivative) is insufficient to maintain long periods of remission, or insufficient to achieve remission.

[0015] In embodiments, the subject’s RA is in relapse, or the subject has difficulty in achieving remission (e g., progressive RA). That is, larazotide or derivative is administered at least during periods where the subject is experiencing significant symptoms of RA (e.g., joint pain and inflammation). In accordance with such embodiments, the regimen of larazotide or derivative reduces the duration or severity of the relapse (e.g., flare), and / or helps the subject achieve remission, optionally in combination with other disease modifying agents as described herein. In embodiments, the subject’s drug regimen (without larazotide or derivative) is insufficient to achieve stable remission.

[0016] The subject’s RA and / or the clinical course of the RA can be determined by an attending physician. In embodiments, the subject has early RA (Stage 1 RA). In early stage RA, the tissue around some joints is inflamed, and the subject may experience pain and stiffness. There are no destructive changes evident in the bones. In embodiments, the subject has mild RA (Stage 2 RA) or moderate RA (Stage 3 RA). In Stage 2 RA, inflammation has started to damage the cartilage in the joints, and joint stiffness and a decreased range(s) of motion are evident. In Stage 3 RA, inflammation begins to damage bones, and physical changes may be evident. In embodiments, the subject has severe RA (Stage 4 RA), where there is severe pain, swelling, stiffness and loss of mobility.

[0017] In embodiments, the subject has spondylarthritis, which is characterized by inflammation in the spine and joints. In embodiments, the subject may have ankylosing spondylitis, axial spondyloarthritis, or enteropathic spondyloarthritis. Ankylosing spondylitis or axial spondyloarthritis can cause fusion of vertebrae over time, making the spine less flexible and resulting in a hunched posture. Ribs may also be affected, making it difficult to breathe. Enteropathic spondyloarthritis occurs in patients with inflammatory bowel diseases (IBDs) and other gastrointestinal diseases, such as Whipple's disease (WD), celiac disease (CD), or intestinal bypass surgery. It is difficult to achieve remission for spondyloarthritis. However, it is believed that the regimen of larazotide or derivative makes remission more possible, as well as the duration of remission. Accordingly, the subject may be administered the larazotide regimen during remission and / or during relapse of the spondyloarthritis. In embodiments, the spondyloarthritis is early spondyloarthritis. In embodiments the spondyloarthritis is progressive spondyloarthritis. In embodiments, the spondyloarthritis is late spondyloarthritis.

[0018] In embodiments, the subject has one or more comorbidities, that may exacerbate the subject’s arthritis or symptoms thereof, and / or make it difficult to achieve or maintain remission of the arthritic disease. In embodiments, the subject has a comorbidity selected from Inflammatory Bowel Syndrome (IBS), Inflammatory Bowel Disease (IBD) (such as ulcerative colitis or Crohn’s disease), celiac disease, psoriasis, Long COVID, SLE, inflammatory liver disease (e.g., NASH), kidney disease, pancreatitis, type 1 diabetes mellitus, and dysbiosis. In embodiments, the subject has one or more comorbidities that affect intestinal permeability or involve persistent gastrointestinal inflammation. In still other embodiments, the subject does not exhibit any obvious signs of gastrointestinal comorbidity (e.g., persistent gastrointestinal inflammation).

[0019] In embodiments, the subject has signs of intestinal dysbiosis. Dysbiosis refers to an imbalance in bacterial composition, changes in bacterial metabolic activities, or changes in bacterial distribution within the gut. These can include loss of beneficial bacteria, overgrowth of potentially pathogenic bacteria, and loss of bacterial diversity. The dysbiosis can be asymptomatic (or largely asymptomatic), or the dysbiosis may manifest in significant and persistent abdominal pain and bloating. Dysbiosis can be determined from symptoms, and / or by analysis of the microbiome of the subject’s stool sample or intestinal biopsy, as known in the art.

[0020] In embodiments, despite whether the subject exhibits any gastrointestinal symptoms, the subject may have an elevated zonulin level. In embodiments, the subject has a high serum zonulin level or a high fecal zonulin level. In embodiments, the subject’s zonulin range is at least 1.5 times a mean reference value for a healthy subject (e.g., with no inflammatory disease), or at least about 2-fold, or at least about 3-fold, or at least about 4-fold, or at least about 5-fold higher than the mean reference value for a healthy subject. For example, the reference value may be determined for a Laboratory Developed Test (LDT) and / or using any of the commercial zonulin detection kits. For example, in embodiments, zonulin levels are determined by ELISA. In embodiments, the subject has a serum zonulin level of greater than about 100 ng / mL, or greater than about 150 ng / mL, or greater than about 200 ng / mL, or greater than about 250 ng / mL, and the subject may or may not have signs of gastrointestinal comorbidity. Upon the treatment according to this disclosure, zonulin levels can decline and be maintained at lower levels, and in embodiments, can decline and be maintained below about 150 ng / mL or below about 100 ng / mL.

[0021] Alternatively or in addition, the subject may have an elevated rheumatoid factor (RF) level or an elevated level of C-reactive protein (CRP). RF is a blood test that measures the amount of the RF auto-antibody in the blood. An elevated level of RF is considered higher than 20 U / mL of blood. CRP is a measure of clinical inflammation. For example, a normal measurement is less than about 1.0 mg / L.

[0022] Alternatively or in addition, the subject has an elevated level of anti -cyclic citrullinated peptide (anti-CCP) in blood. A normal level of anti-CCP is less than about 20 U / mL.

[0023] In embodiments, the subject is receiving one or more disease modifying antirheumatic drugs (DMARD). Exemplary DMARDs (particularly for RA) include methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine. In embodiments, the subject is receiving methotrexate therapy. Methotrexate can be administered in times of RA remission as well as times of relapse to control disease (e.g., the drug can be administered continually in embodiments, including for several years). In embodiments, the subject receives oral methotrexate therapy, which may be administered once per week or in a plurality of sub-doses. In embodiments the subject receives oral methotrexate therapy of 10 mg or less as a weekly dose (e.g., about 7.5 mg or about 10 mg). Particularly if the subject cannot tolerate higher doses of methotrexate, the larazotide or derivative regimen can render these lower doses more effective, thus avoiding higher doses that are more likely to have adverse effects (including but not limited to gastrointestinal side effects). In embodiments, the subject receives from 10 to 20 mg of methotrexate per week (e g., in one dose or in a plurality of sub-doses). In still other embodiments, the subject receives injectable methotrexate therapy, e.g., about 25 mg by injection about once a week. Particularly where the methotrexate therapy is not effective to maintain remission, the regimen of larazotide or derivative can provide synergy to achieve and maintain this remission, where methotrexate alone cannot. That is, the subject in embodiments is only partially responsive to methotrexate therapy.

[0024] In some embodiments, the subject cannot tolerate or is refractory to methotrexate therapy, and the subject receives the regimen of larazotide or derivative in the absence of methotrexate therapy.

[0025] In embodiments, the subject receives corticosteroid therapy, for example, during periods of relapse or progression, e.g., during periods of disease symptoms. In embodiments, the corticosteroid is prednisone, prednisolone, or dexamethasone for oral administration. Corticosteroids can provide benefit to patients with arthritic disease (e.g., RA), but can have significant side effects. In embodiments, the subject may receive a course of corticosteroid therapy along with the larazotide or larazotide derivative. For example, the corticosteroid may be given orally, at least once daily. For example, the corticosteroid may be administered in a tapered drug regimen, starting with a high dose and then tapering off (e.g., over the course of two to four weeks). In embodiments, the high dose may be continued for at least five days. In some embodiments, a low dose of the corticosteroid is administered (e.g., at least once daily) over a longer period of time. In embodiments, a low dose of corticosteroid can be administered continually, with the regimen of larazotide or derivative, even during periods of remission. In embodiments, the subject receives an injection of the corticosteroid, optionally to an affected joint. In embodiments, the therapy with larazotide or derivative may help achieve disease remission, or render low doses or corticosteroid more effective, thereby reducing side effects of the medication. For subjects that are not fully responsive to corticosteroid therapy, the regimen of this disclosure can improve the response.

[0026] In some embodiments, the subject cannot tolerate or is refractory to corticosteroid therapy, and the subject receives the regimen of larazotide or derivative in the absence of corticosteroid therapy.

[0027] Patients that retain at least a moderate level of disease activity, despite DMARD treatment (e.g., methotrexate therapy) and / or corticosteroid therapy in some embodiments, may be prescribed a biologic. For example, for RA, the subject may receive therapy with a biologic targeting (i.e., inhibiting) TNF , IL-6, IL-1, IL-17a, or other targets of inflammatory disease. For RA, a TNF-a inhibitor and IL-6 inhibitor is administered in some embodiments. For spondyloarthritis, TNF-a or IL-17a inhibitor is administered in some embodiments. In embodiments, the subject receives a biologic selected from etanercept, golimumab, infliximab, adalimumab, tocilizumab, sarilumab, secukinumab, ixekizumab, brodalumab, anakinra, rituximab, and abatacept. The subject may or may not also undergo therapy with methotrexate. In such embodiments, the subject may not be fully responsive to the biologic therapy, and the regimen of larazotide or derivative helps the subject achieve or maintain disease remission (or otherwise reduce severity of symptoms).

[0028] In some embodiments, the subject receives the regimen of larazotide or derivative thereof as an alternative to a biologic, thereby avoiding these costly drugs and / or their side effects (which can be substantial).

[0029] In embodiments, the larazotide or derivative acts as a Rho kinase (ROCK) inhibitor, thereby reducing synovial inflammation, cartilage damage, and even bone erosion (observed in Stage 2 or 3 RA, for example). See PCT / US2023 / 154770, which is hereby incorporated by reference. ROCK inhibition for RA could provide a dual action on inflammation and bone erosion. Rodriquez-Trillo A., ROCK inhibition with Y-27632 reduces joint inflammation and damage in serum-induced arthritis model and decreases in vitro osteoclastogenesis in patients with early arthritis. Front Immunol. 2022; 13: 858069.

[0030] In some embodiments, the subject is undergoing therapy with a non-steroidal antiinflammatory drug (NSAID) for the arthritic disease or a comorbidity. In embodiments, the NSAID is acetylsalicylate (aspirin), naproxen, ibuprofen, indomethacin, or etodolac. While these can provide some relief of moderate pain, these agents can damage the gastrointestinal tract and / or cause dysbiosis, which could exacerbate disease symptoms. In embodiments, the regimen of larazotide or derivative thereof can ameliorate or prevent these side effects, allowing for continued NSAID therapy if desired.

[0031] In some embodiments, the rheumatic disease is Systemic lupus erythematosus (SLE). SLE is an autoimmune disorder characterized by antibodies to nuclear and cytoplasmic antigens, multisystem inflammation, and a relapsing and remitting course. SLE symptoms include fever, malaise, arthralgias, myalgias, and headache. Nonspecific fatigue, fever, arthralgia, and weight changes are the most common symptoms in new cases or recurrent active SLE flares. In embodiments, the SLE is lupus nephritis.

[0032] In embodiments, the subject’s SLE is in remission, that is, the larazotide or derivative is administered at least during periods where the subject is experiencing no or few symptoms of SLE (e.g., not experiencing: fever or malaise; arthralgias or myalgias; blood in the urine or urine that foams because of too much protein; swelling such as in the legs, ankles or feet; high creatinine levels in the blood). In accordance with such embodiments, the regimen of larazotide or derivative reduces the frequency and / or severity of flares, optionally in combination with other disease modifying agents. In embodiments, the subject’s drug regimen (without larazotide or derivative) is insufficient to maintain long periods of remission, or insufficient to achieve remission.

[0033] In embodiments, the subject’s SLE is in relapse, or the subject has difficulty in achieving and / or maintaining remission. That is, larazotide or derivative is administered at least during periods where the subject is experiencing significant symptoms of SLE (e.g., as described). In accordance with such embodiments, the regimen of larazotide or derivative reduces the duration or severity of the relapse (e.g., flare), and / or helps the subject achieve remission, optionally in combination with other disease modifying agents as described herein. In embodiments, the subject’s drug regimen (without larazotide or derivative) is insufficient to achieve stable remission.

[0034] In embodiments, the SLE is Class I (e.g., Minimal mesangial lupus nephritis), which can involve inflammatory activity, including arthritis, nephritis, and rashes. In embodiments, the SLE is Class 2 SLE, which includes proliferative mesangial lupus nephritis, since mesangial proliferation is seen on light microscopy unlike Class 1. In embodiments, the SLE is Class III (e.g., Focal lupus nephritis), in which immune complex deposits may be visualized in the mesangial, subendothelial, and / or subepithelial space on immunofluorescence imaging. In embodiments, the SLE may be Class IV (Diffuse lupus nephritis), in which immune complex deposits may occur in the mesangial, subendothelial, and / or subepithelial space. Lesions may be segmental, involving less than 50% of the glomeruli, or global, which instead involves more than 50%.

[0035] In embodiments, the subject has one or more comorbidities, that may exacerbate the subject’s SLE or symptoms thereof, and / or make it difficult to achieve or maintain remission. In embodiments, the subject has a comorbidity selected from Rheumatoid Arthritis, Inflammatory Bowel Syndrome (IBS), Inflammatory Bowel Disease (IBD) (such as ulcerative colitis or Crohn’s disease), Long COVID, inflammatory liver disease (e.g., NASH), kidney disease, pancreatitis, type 1 diabetes mellitus, and dysbiosis (as described). In embodiments, the subject has one or more comorbidities that affect intestinal permeability or involve persistent gastrointestinal inflammation. In still other embodiments, the subject does not exhibit any obvious signs of gastrointestinal comorbidity (e.g., persistent gastrointestinal inflammation). In embodiments, the subject has an elevated zonulin level (serum or fecal) as described.

[0036] In embodiments, the subject is receiving one or more disease modifying antirheumatic drugs (DMARD). Exemplary DMARDs (particularly for SLE) include hydroxychloroquine, methotrexate, leflunomide, and other immune suppressants (e.g., azathioprine, mycophenolate motetil, cyclophosphamide, and cyclosporine).

[0037] In embodiments, the subject is receiving hydroxychloroquine therapy, which can be administered in times of SLE remission as well as times of relapse to control disease (e.g., the drug can be administered continually in embodiments, including for several years). In embodiments, the subject receives oral hydroxychloroquine therapy, which may be administered once per week or in a plurality of sub-doses. In embodiments the subject receives oral hydroxychloroquine therapy of 6.5 mg / kg or less as a daily dose (e.g., from about 200 mg to about 400 mg daily). The larazotide or derivative regimen can render these doses more effective, thus avoiding higher doses that are more likely to have adverse effects (including but not limited to gastrointestinal side effects, where hydroxychloroquine can induce nausea, vomiting, upset stomach, cramps, or diarrhea). Particularly where the hydroxychloroquine therapy is not effective to maintain remission, the regimen of larazotide or derivative can provide synergy to achieve and maintain this remission, where hydroxychloroquine alone cannot. That is, the subject in embodiments is only partially responsive to hydroxychloroquine therapy.

[0038] In some embodiments, the subject cannot tolerate or is refractory to hydroxychloroquine therapy (or other immunosuppressant treatment), and the subject receives the regimen of larazotide or derivative in the absence of hydroxychloroquine therapy (or other immunosuppressant treatment).

[0039] In embodiments, the subject is receiving methotrexate therapy, optionally for arthritis (e.g., RA) comorbidity, and optionally according to a regimen as already described. In embodiments, the subject receives oral methotrexate therapy, which may be administered once per week or in a plurality of sub-doses. In embodiments the subject receives oral methotrexate therapy of 10 mg or less as a weekly dose (e.g., about 7.5 mg or about 10 mg). In embodiments, the subject receives from 10 to 20 mg of methotrexate per week (e.g., in one dose or in a plurality of sub-doses).

[0040] In embodiments, the subject receives corticosteroid therapy, for example, during periods of relapse or progression, e.g., during periods of disease symptoms. In embodiments, the corticosteroid is prednisone, prednisolone, or dexamethasone for oral administration. Corticosteroids can also provide benefit to patients with arthritic disease comorbidities (e.g., RA), but can have significant side effects. In embodiments, the subject may receive a course of corticosteroid therapy along with the larazotide or larazotide derivative. For example, the corticosteroid may be given orally, at least once daily. For example, the corticosteroid may be administered in a tapered drug regimen, starting with a high dose and then tapering off (e.g., over the course of two to four weeks). In embodiments, the high dose may be continued for at least five days. In some embodiments, a low dose of the corticosteroid is administered (e.g., at least once daily) over a longer period of time. In embodiments, a low dose of corticosteroid can be administered continually, with the regimen of larazotide or derivative, even during periods of remission. In embodiments, the therapy with larazotide or derivative may help achieve disease remission, or render low doses or corticosteroid more effective, thereby reducing side effects of the medication. For subjects that are not fully responsive to corticosteroid therapy, the regimen of this disclosure can improve the response.

[0041] Patients that retain at least a moderate level of disease activity, despite DMARD treatment (e.g., hydroxychloroquine therapy) and / or corticosteroid therapy in some embodiments, may be prescribed a biologic. For example, for SLE, the subject may receive therapy with a biologic targeting B cells (e.g., BLys or CD20), IL-17, or IL-1 (e.g., IL-1 B). In embodiments, the subject receives a biologic selected from belimumab and rituximab. In embodiments, the subject receives a biologic selected from secukinumab, ixekizumab, brodalumab, and anakinra. The subject may or may not also undergo therapy with hy doxy chloroquine. In such embodiments, the subject may not be fully responsive to the biologic therapy, and the regimen of larazotide or derivative helps the subject achieve or maintain disease remission (or otherwise reduce severity of symptoms).

[0042] In some embodiments, the subject receives the regimen of larazotide or derivative thereof as an alternative to a biologic, thereby avoiding these costly drugs and / or their side effects (which can be substantial). For example, treatment with larazotide can avoid the need for immunosuppressive biologies.

[0043] In embodiments, the larazotide or derivative acts as a ROCK inhibitor, thereby reducing immune activation by IL-17 and IL-2L See PCT / US2023 / 154770, which is hereby incorporated by reference. See also Isgro J. Enhanced ROCK Activation in Patients with Systemic Lupus Erythematosus. Arthritis Rheum. 2013 Jun; 65(6): 1592-1602.

[0044] In some embodiments, the subject is undergoing therapy with a non-steroidal antiinflammatory drug (NSAID) for SLE or a comorbidity (e.g., RA). In embodiments, the NSAID is acetylsalicylate (aspirin), naproxen, ibuprofen, or indomethacin. While these can provide some relief of moderate pain, these agents can damage the gastrointestinal tract and / or cause dysbiosis, which could exacerbate disease symptoms. In embodiments, the regimen of larazotide or derivative thereof can ameliorate or prevent these side effects, allowing for continued NS AID therapy if desired.

[0045] Larazotide and its derivatives, among other things, promote tight junction integrity of epithelial and endothelial tissues, including of the intestinal epithelium. In accordance with certain embodiments, the present invention provides larazotide derivatives that confer, among other things, increased resistance to exopeptidase degradation, including aminopeptidase degradation. In various embodiments, the larazotide derivative comprises one or more amino acid substitutions, deletions, and / or insertions with respect to the peptide having the amino acid sequence of SEQ ID NO: 1. Exemplary modifications are described in US 8,785,374, US 8,957,032, US 9,279,807, PCT / US2019 / 19350, and PCT / US21 / 27410 (all of which are hereby incorporated by reference). In some embodiments, the peptide derivative of larazotide contains one or more (d) amino acids. For example, the larazotide derivative may contain 1, 2, 3, 4, or 5 (d) amino acids (that is, the D configuration as opposed to the L configuration). In some embodiments, the larazotide derivative has the amino acid sequence of Gly-Gly-Val-Leu-Val-Gln-(d)Pro-Gly (SEQ ID NO: 2). This peptide is referred to herein as “(d)-Pro” or (d)-Pro larazotide. In other embodiments, the larazotide derivative has the amino acid sequence of Gly-Gly-(d)Val-(d)Leu-(d)Val-(d)Gln-(d)Pro-Gly (SEQ ID NO: 3). This peptide is referred to herein as “(d)-larazotide”.

[0046] In embodiments, the pharmaceutical compositions for administration comprise larazotide or a derivative (i.e., or pharmaceutically acceptable salt thereof) at about 1.0 mg or less, or at about 0.75 mg or less, or at about 0.5 mg or less. In some embodiments, the pharmaceutical composition contains about 0.4 mg of the larazotide derivative or less, or about 0.3 mg of the larazotide derivative or less, or about 0.25 mg of the larazotide derivative of less, or about 0.2 mg of the larazotide derivative or less, or about 0.15 mg of the larazotide derivative or less, or about 0.1 mg of the larazotide derivative or less. In some embodiments, the pharmaceutical composition contains from about 100 pg to about 500 pg of a larazotide derivative (e.g., d-larazotide), or from about 100 pg to about 400 pg of the larazotide derivative (e.g., d-larazotide). In embodiments, the present invention contemplates a pharmaceutical composition that contains more than about 0.5 mg of a larazotide derivative (e.g., d-larazotide), and substantially avoids the inverse dose or “bell shape” response observed with larazotide. For example, in some embodiments, the pharmaceutical composition contains about 0.6 mg of the larazotide derivative or more, or about 0.75 mg of the larazotide derivative or more, or about 1.0 mg of the larazotide derivative or more, or about 1.25 mg of the larazotide derivative or more, or about 1.5 mg of the larazotide derivative or more, or about 2.0 mg of the larazotide derivative or more. In some embodiments, the larazotide derivative (e.g., (d)-larazotide or (d)-Pro), is administered at about 0.5 mg. In embodiments, larazotide is administered in oral doses of about 0.5 mg, which may be larazotide acetate.

[0047] In embodiments, the present invention provides methods and compositions for treating a condition associated with ROCK activity in the small intestine of a subject having a rheumatic disease, including a rheumatic disease as described.

[0048] The terms “subject” and “patient” are used interchangeably herein, and generally refer to mammalian subjects / patients. In various embodiments the subject is a human subject, but in embodiments may be a veterinary subject, such as a dog or horse.

[0049] In some embodiments, the peptide or pharmaceutical composition is administered to the gastrointestinal tract (GI) of a subject. Pharmaceutical compositions can be formulated for release in affected portions of the GI (e g., stomach, small intestine, and / or large intestine). Larazotide derivatives of the present invention may be administered in any suitable form, including as a salt. For example, peptides may be administered as an acetate salt. Alternative salts may be employed, including any pharmaceutically acceptable salt such as those listed in Journal of Pharmaceutical Science, 66, 2-19 (1977) and The Handbook of Pharmaceutical Salts; Properties, Selection, and Use. P. H. Stahl and C. G. Wermuth (eds.), Verlag, Zurich (Switzerland) 2002, which are hereby incorporated by reference in their entirety.

[0050] In embodiments, the compositions are administered to a subject by contacting the epithelial tissues or mucosal surfaces of the gastrointestinal tract. For example, the compositions may be formulated for delivery to one or more of the stomach, small intestine, and / and large intestine. Release of the peptide from the composition can be designed for affected region(s) (e.g. duodenum jejunum and ileum, colon transversum, colon descendens, colon ascendens, colon sigmoidenum and cecum). Targeted delivery of the peptide in the small or large intestine can be achieved by coating beads or particles with the peptide, along with a delayed-release coating that prevents release in the stomach and degrades at or near the targeted location(s). In some embodiments, the larazotide or larazotide derivative is administered in a sustained release or controlled release formulation that releases from about 0.5 to about 5 mg of larazotide or derivative in the intestine (or a dose as already described). In certain embodiments, the controlled release formulation contains at least 0.5 or 1 mg of larazotide or derivative. In some embodiments, the peptide (e.g., larazotide or larazotide derivative) is formulated for sustained or modified or controlled delivery in one or more locations of the GI. For example, this disclosure contemplates a sustained or controlled release formulation that may functionally release the peptide in the small and / or large intestine over the course of at least about 2 hours, or over the course of at least about 2.5 hours, or over the course of at least about 3 hours, or over the course of at least about 4 hours, or over the course of at least about 5 hours. In some embodiments, the sustained or controlled release composition begins to release peptide starting within about 10 to about 30 minutes of exposure to simulated intestinal fluid, with release of peptide continuing for at least about 180 minutes, or at least about 210 minutes, or at least about 240 minutes, or at least about 280 minutes of exposure to simulated intestinal fluid. Release profiles can be prepared, for example, using compositions with different enteric polymer coats and / or different thicknesses of the polymer coats.

[0051] In some embodiments, the disclosure provides a composition comprising an effective amount of larazotide or derivative (or salt thereof), contained within a biodegradable or erodible polymer matrix, which further comprises an enteric coating. Formulations employing a biodegradable or erodible matrix are described in WO 2021 / 034629, which is hereby incorporated by reference in its entirety. Further, the erodible polymer matrix can comprise a polysaccharide matrix. In some embodiments, the matrix comprises one or more of cellulose, chitin, chitosan, alginate, amylose, pectin, callose, laminarin, chrysolaminarin, xylan, arabinoxylan, mannan, fucoidan, galactomannan, xanthan gum, dextran, welan gum, gellan gum, diutan gum, pullulan, hyaluronic acid, and derivatives thereof. In further embodiments, the matrix comprises microcrystalline cellulose. In these embodiments, the composition leverages the low effective dose of larazotide or a larazotide derivative (e.g., (d)-larazotide or (d)-Pro), while also minimizing any local accumulation of inactive fragments. Further, the formulation in these embodiments has the benefit of treating large surfaces of the GI with small doses of the peptide deposited continually during transit. In various embodiments, the pharmaceutical composition may be formulated to have a delayed- release profile, i.e. not immediately release the active ingredient(s) upon ingestion; rather, postponement of the release of the active ingredient(s) until the peptide passes the stomach and is lower in the gastrointestinal tract; for example, for release in the small intestine (e.g., one or more of duodenumjejunum, ileum) or the large intestine (e.g., one or more of cecum, ascending, transverse, descending or sigmoid portions of the colon).

[0052] In an embodiment, the pharmaceutical composition is formulated to have a delayed- release profile as described in, for example, U.S. Patent No. 8,168,594, the entire contents of which are hereby incorporated by reference. For example, the peptide may be administered to at least the duodenum of the patient, as an oral dosage, delayed-release composition that contains the peptide. In such embodiments, the composition comprises a first population of beads having a coating that is stable in gastric fluid (i.e., gastro-resistant coating) and unstable in intestinal fluid so as to degrade and substantially release the peptide in the duodenum. In embodiments, the gastro-resistant coating begins to release the larazotide or derivative within about 5 to about 60 minutes, or within about 5 minutes to about 30 minutes, of exposure to simulated intestinal fluid. The composition may further comprise a second population of beads with a pH-dependent coating to affect release of the peptide in the jejunum and / or ileum of the patient. For example, the second population of beads may release the peptide about 30 minutes or about 45 minutes after the beads releasing peptide in the duodenum. The oral dosage composition can be in the form of a capsule or tablet. The pH-dependent coating in some embodiments is a 1 : 1 co-polymer of methacrylic acid and ethyl acrylate, wherein the thickness of the layer determines the release profde of each bead. The beads may have one or more additional coatings such as a base coat, a separating layer, and an overcoat layer.

[0053] In an exemplary oral dosage composition, an effective amount of the peptide (e.g., as the acetate salt) is provided in first delayed-release particles that are capable of releasing the peptide in the duodenum of a patient, and second delayed release particles that are capable of releasing the peptide in the jejunum of a patient. Each particle has a core particle, a coat comprising the peptide over the core particle, and a delay ed-release coating (e.g., a 1 : 1 co-polymer of acrylate and methacrylate) outside the coat comprising the peptide. Whereas the first delayed-release particles release at least 70% of the peptide in the first delayed-release particles by about 60 minutes of exposure to simulated intestinal fluid having a pH of greater than 5; the second delayed-release particles release at least 70% of the peptide by about 30 and about 90 minutes of exposure to simulated intestinal fluid having a pH of greater than 5.

[0054] In some embodiments, the pharmaceutical composition involves a coated tablet, or coated beads or granules, having a delayed-release profile as described in, for example, U.S. Patent No. 8, 168,594, the entire contents of which are hereby incorporated by reference. An exemplary enteric coating comprises a co-polymer of acrylate and methacrylate, which is a 1 : 1 co-polymer in some embodiments. Other fillers, binder, and plasticizers, including for seal coats or topcoats, are described in US 8,168,594, which is hereby incorporated by reference.

[0055] In embodiments, the delayed-release coating may degrade as a function of time without regard to the pH and / or presence of enzymes. Such a coating may comprise, for example, a water insoluble polymer. Its solubility is therefore independent of the pH._The term “pH independent” as used herein means that the permeability of the polymer and its ability to release pharmaceutical ingredients is not a function of pH and / or is only very slightly dependent on pH. Such coatings may be used to prepare, for example, sustained release formulations. Suitable water insoluble polymers include, but are not limited to, cellulose ethers, cellulose esters, or cellulose ether-esters, i.e., a cellulose derivative in which some of the hydroxy groups on the cellulose skeleton are substituted with alkyl groups and some are modified with alkanoyl groups. Examples include ethyl cellulose, acetyl cellulose, nitrocellulose, and the like.

[0056] Polymers for constructing delayed release coatings include, but are not limited to, lacquer, and acrylic and / or methacrylic ester polymers, polymers or copolymers of acrylate or methacrylate having a low quaternary ammonium content, or mixture thereof and the like. Examples of insoluble polymers include EUDRAGIT RS®, EUDRAGIT RL®, and EUDRAGIT NE®. Insoluble polymers include, for example, polyvinyl esters, polyvinyl acetals, polyacrylic acid esters, butadiene styrene copolymers, and the like. Various types of enteric coatings for delayed yet substantial delivery of active agents to the GI tract are known.

[0057] In some embodiments, the sustained-release composition includes an enteric agent that is substantially stable in acidic environments and substantially unstable in near neutral to alkaline environments. In an embodiment, the sustained-release coating contains an enteric agent that is substantially stable in gastric fluid. The enteric agent can be selected from, for example, solutions or dispersions of methacrylic acid copolymers, cellulose acetate phthalate, hydroxypropylmethyl cellulose phthalate, polyvinyl acetate phthalate, carboxymethylethylcellulose, and EUDRAGIT®-type polymer (poly(methacrylic acid, methylmethacrylate), hydroxypropyl methylcellulose acetate succinate, cellulose acetate trimellitate, shellac or other suitable enteric coating polymers. The EUDRAGIT®- type polymer include, for example, EUDRAGIT® FS 30D, L 30 D-55, L 100-55, L 100, L 12,5, L 12,5 P, RL 30 D, RL PO, RL 100, RL 12,5, RS 30 D, RS PO, RS 100, RS 12,5, NE 30 D, NE 40 D, NM 30 D, S 100, S 12,5, and S 12,5 P. In some embodiments, one or more of EUDRAGIT® FS 30D, L 30 D-55, L 100-55, L 100, L 12,5, L 12,5 P RL 30 D, RL PO, RL 100, RL 12,5, RS 30 D, RS PO, RS 100, RS 12,5, NE 30 D, NE 40 D, NM 30 D, S 100, S 12,5 and S 12,5 P is used. The enteric agent may be a combination of the foregoing solutions or dispersions. In some embodiments, the enteric agent is EUDRAGIT F30D, which comprises a co-polymer of methyl acrylate, methyl methacrylate, and methacrylic acid. The co-polymer has a ratio of free carbonyl groups to ester groups of about 1 : 10.

[0058] In some embodiments, the beads comprise an enteric coating that is substantially resistant to dissolution in simulated gastric fluid. The composition remains essentially intact, or may be essentially insoluble, in gastric fluid. The stability of a gastric-resistant coating can be pH dependent. For example, the enteric coating may prevent substantial release of the peptide in simulated gastric fluid as well as simulated intestinal fluid having a pH of about 5.5. In some embodiments, the matrix provides for the sustained release of the peptide in simulated intestinal fluid having a pH of about 6 or more, such as from about 6.5 to about 7.0. Thus, the enteric coating is stable in simulated gastric fluid but unstable in simulated intestinal fluid having a pH above about 6.0. The enteric coating in such embodiments does not substantially release peptide in the duodenum, but delays release until the composition enters the jejunum, and thereafter providing a sustained release in the jejunum and ileum.

[0059] In some embodiments, the composition is a capsule for oral delivery comprising a population of beads, the population of beads comprising an effective amount of the larazotide or derivative (e.g., (d)-larazotide or (d)-Pro or salt thereof) contained within an erodible polymer matrix, the beads further comprising an enteric coating, which may comprise a co-polymer of methyl acrylate, methyl methacrylate, and methacrylic acid. The ratio of free carbonyl groups to ester groups in the co-polymer may be about 1 : 10 (e.g., EUDRAGIT F30D). In such embodiments, the enteric coating may be from about 20% to about 30% of the total weight of the composition. In some embodiments, the erodible matrix comprises microcrystalline cellulose. In some embodiments, the composition provides for less than about 15% release of peptide after about 2 hours in simulated gastric fluid. Further, the composition provides for less than about 25% release of peptide after about 2 hours in simulated intestinal fluid having a pH of about 5.5. In various embodiments, the composition releases at least about 40% but no more than about 80% of peptide after about 2 hours in simulated intestinal fluid having a pH of about 7.0. In various embodiments, 100% release in simulated intestinal fluid having a pH of about 7 is not reached until at least three hours, or in some embodiments, at least about 3.5 or at least about four hours.

[0060] In accordance with certain embodiments, the present invention provides for the composition described herein to be administered one or more times daily. In embodiments, the oral dosage form is administered more than once daily, and may be administered at least two times daily or at least three times daily, or at least four times daily, or at least five times daily. In embodiments, the oral dosage form is administered three times daily.

[0061] As used herein, and unless the context required otherwise, the term “about” or “approximately” mean a range of ±10% of an associated value.

[0062] All publications, patents, patent applications, and / or other documents cited in this application are incorporated by reference in their entirety. LEFT BLANK UPON FILING (SEE RO 106)

Claims

CLAIMS:

1. A method for treating a human subject having a rheumatic disease, comprising: administering an oral dosage form of larazotide or a derivative thereof to said subject at an effective amount and schedule to reduce or prevent disease symptoms.

2. The method of claim 1, wherein the rheumatic disease is an arthritic disease.

3. The method of claim 2, wherein the arthritic disease is selected from rheumatoid arthritis (RA), osteoarthritis, psoriatic arthritis, spondyloarthritis, and juvenile idiopathic arthritis (JIA).

4. The method of claim 1, wherein the rheumatic disease is Systemic Lupus Erythematosus (SLE).

5. The method of claim 1, wherein the rheumatic disease is selected from Polymyalgia Rheumatica, Giant Cell Arteritis, scleroderma, and Sjogren’s syndrome.

6. The method of claim 3, wherein the subject has RA.

7. The method of claim 6, wherein the subject’s RA is in remission.

8. The method of claim 6, wherein the subject’s RA is in relapse.

9. The method of claim 6, wherein the subject has progressive RA.

10. The method of any one of claims 6 to 9, wherein the subject has early RA (Stage 1RA).

11. The method of any one of claims 6 to 9, wherein the subject has mild RA (Stage 2 RA) or moderate RA (Stage 3 RA).

12. The method of any one of claims 6 to 9, wherein the subject has severe RA (Stage 4 RA).

13. The method of any one of claims 6 to 12, wherein the subject has a comorbidity selected from Inflammatory Bowel Syndrome (IBS), Inflammatory Bowel Disease (IBD), celiac disease, psoriasis, Long COVID, SLE, and dysbiosis.

14. The method of any one of claims 6 to 13, wherein the subject has an elevated zonulin level.

15. The method of any one of claims 6 to 14, wherein the subject has an elevated rheumatoid factor (RF) level or and an elevated level of C-reactive protein (CRP).

16. The method of any one of claims 6 to 15, wherein the subject is receiving one or more of methotrexate and corticosteroid therapy.

17. The method of any one of claims 6 to 16, wherein the subject is refractory to methotrexate therapy or only partially responsive to methotrexate therapy, or is refractory to corticosteroid therapy or only partially responsive to corticosteroid therapy.

18. The method of claim 17, wherein the subject does not receive therapy with a biologic, which optionally targets TNF-a or IL-6, or which is selected from etanercept, golimumab, infliximab, adalimumab, anakinra, rituximab, and abatacept.

19. The method of any one of claims 6 to 17, wherein the subject receives therapy with a biologic, which optionally targets TNF-a or IL-6, or which is optionally selected from etanercept, golimumab, infliximab, adalimumab, anakinra, rituximab, and abatacept.

20. The method of claim 19, wherein the subject is not fully responsive to the biologic therapy.

21. The method of any one of claims 6 to 20, wherein the subject is undergoing therapy with a non-steroidal anti-inflammatory drug (NSAID) for the arthritic disease or a comorbidity.

22. The method of claim 3, wherein the arthritic disease is Ankylosing spondylitis, Axial spondyloarthritis, or Enteropathic spondyloarthritis.

23. The method of claim 22, wherein the subject’s spondyloarthritis is in remission.

24. The method of claim 22, wherein the subject’s spondyloarthritis is in relapse.

25. The method of any one of claims 22 to 24, wherein the spondyloarthritis is early spondyloarthritis.

26. The method of any one of claims 22 to 24, wherein the spondyloarthritis is progressive spondyloarthritis.

27. The method of any one of claims 22 to 24, wherein the spondyloarthritis is late spondyloarthritis.

28. The method of any one of claims 22 to 27, wherein the subject has a comorbidity selected from Inflammatory Bowel Syndrome (IBS), Inflammatory Bowel Disease (IBD), celiac disease, psoriasis, Long COVID, SLE, and dysbiosis.

29. The method of any one of claims 22 to 28, wherein the subject has an elevated zonulin level.

30. The method of any one of claims 22 to 29, wherein the subject has an elevated level of calprotectin, or an elevated level of vasoactive endothelial growth factor (VEGF).

31. The method of any one of claims 22 to 30, wherein the subject does not receive therapy with a biologic, such as a TNF-alpha inhibitor or IL-17a inhibitor.

32. The method of any one of claims 22 to 30, wherein the subject receives therapy with a biologic, optionally selected from a TNF-alpha inhibitor or IL-17a inhibitor.

33. The method of claim 32, wherein the subject receives therapy with one or more of etanercept, golimumab, infliximab, adalimumab, secukinumab, ixekizumab, and brodalumab.

34. The method of claim 32 or 33, wherein the subject is not fully responsive to the biologic therapy.

35. The method of any one of claims 22 to 34, wherein the subject is undergoing therapy with an NSAID for spondyloarthritis or a comorbidity.

36. The method of claim 4, wherein the rheumatic disease is SLE, which is optionally lupus nephritis.

37. The method of claim 36, wherein the subject’s SLE is in remission.

38. The method of claim 36, wherein the subject’s SLE is in relapse.

39. The method of any one of claims 36 to 38, wherein the SLE is lupus nephritis and is Class I (Minimal mesangial lupus nephritis), Class II (Mesangial proliferative lupus nephritis), Class III (Focal lupus nephritis), or Class IV (Diffuse lupus nephritis).

40. The method of any one of claims 36 to 39, wherein the subject has a comorbidity selected from Rheumatoid Arthritis, Inflammatory Bowel Syndrome (IBS), Inflammatory Bowel Disease (IBD), Long COVID, and dysbiosis.

41. The method of any one of claims 36 to 40, wherein the subject has an elevated zonulin level.

42. The method of any one of claims 36 to 41, wherein the subject is receiving therapy with one or more of hydroxychloroquine and corticosteroid.

43. The method of any one of claims 36 to 42, wherein the subject is refractory to hydroxychloroquine therapy or only partially responsive to hydroxychloroquine therapy, and / or is refractory to corticosteroid therapy or only partially responsive to corticosteroid therapy.

44. The method of any one of claims 36 to 43, wherein the subject is receiving therapy with one or more immunosuppressant drugs, optionally selected from methotrexate, azathioprine, mycophenolate mofetil, and cyclophosphamide.

45. The method of any one of claims 36 to 44, wherein the subject does not receive therapy with a biologic, such as belimumab or rituximab.

46. The method of any one of claims 36 to 44, wherein the subject receives therapy with a biologic, optionally selected from belimumab or rituximab.

47. The method of claim 45 or 46, wherein the subject is not fully responsive to biologic therapy.

48. The method of any one of claims 36 to 47, wherein the subject is undergoing therapy with an NS AID for SLE or a comorbidity.

49. The method of any one of claims 1 to 48, wherein the oral dosage form comprises larazotide or a pharmaceutically acceptable salt thereof, which is optionally larazotide acetate.

50. The method of claim 49, wherein the oral dosage form comprises less than about 1 mg of larazotide or salt thereof.

51. The method of claim 50, wherein the oral dosage form comprises less than about 0.75 mg of larazotide or salt thereof, or less than about 0.5 mg of larazotide of salt thereof.

52. The method of claim 50, wherein the oral dosage form comprises about 0.5 mg of larazotide of salt thereof, and which is optionally larazotide acetate.

53. The method of any one of claims 1 to 48, wherein the oral dosage form comprises a larazotide derivative having one or more d-amino acids, and optionally where all amino acids other than glycine are in d-form.

54. The method of claim 53, wherein the oral dosage form comprises at least about 1 mg of the larazotide derivative, or at least about 1.5 mg of the larazotide derivative.

55. The method of claim 54, wherein the oral dosage form comprises about 1 mg of the larazotide derivative or less, or about 0.5 mg of the larazotide derivative or less.

56. The method of claim 55, wherein the oral dosage form comprises about 0.5 mg of the larazotide derivative.

57. The method of any one of claims 1 to 56, wherein the oral dosage form delivers the larazotide or derivative to the small intestine.

58. The method of claim 57, wherein the oral dosage form delivers the larazotide or derivative to one or more of the duodenumjejunum and ileum.

59. The method of claim 58, wherein the oral dosage form delivers the larazotide or derivative to at least the jejunum and ileum.

60. The method of any one of claims 1 to 59, wherein the oral dosage form comprises beads having a gastro-resistant coating.

61. The method of claim 60, wherein the oral dosage form comprises beads having at least two different types or amounts of gastro-resistant coating to release the larazotide or derivative at different times.

62. The method of claim 61, wherein the gastro-resistant coatings begins to release the larazotide or derivative within about 5 to about 60 minutes, or within about 5 minutes to about 30 minutes, of exposure to simulated intestinal fluid.

63. The method of any one of claims 57 to 62, wherein the oral dosage form comprises a biodegradable matrix providing a sustained release of the larazotide or derivative in the small intestine.

64. The method of any one of claims 57 to 63, wherein the oral dosage form releases larazotide or derivative over at least 90 minutes in simulated intestinal fluid, or over at least 120 minutes in simulated intestinal fluid, or over at least 210 minutes in simulated intestinal fluid.

65. The method of any one of claims 1 to 64, wherein the oral dosage form is administered more than once daily, and is optionally administered at least 2 times daily or at least 3 times daily, or at least four times daily, or at least five times daily.

66. The method of claim 65, wherein the oral dosage form is administered three times daily.