Methods for treating disorders of copper metabolism

Abstract

Described are combinations of copper(II) and elesclomol useful in treatment methods for conditions associated with copper dysregulation.

Description

METHODS FOR TREATING DISORDERS OF COPPER METABOLISM RELATED APPLICATIONS

[0001] This application claims priority of U.S. Provisional Patent Application No. 63 / 670,679, filed July 12, 2024, and U.S. Provisional Patent Application No. 63 / 691,969, filed September 6, 2024, the content of each of which is incorporated herein by reference.FIELD

[0002] This disclosure relates to treatment methods for conditions associated with copper dysregulation.BACKGROUND

[0003] Copper, an essential trace element, is an important cofactor for many enzymes such as those required for cellular respiration, iron oxidation, pigment formation, neurotransmitter biosynthesis, and antioxidant defense. Dietary copper is generally absorbed in the gastrointestinal tract. The major route of copper elimination is by biliary excretion and the liver plays a critical role in copper metabolism by regulating biliary copper excretion. The liver utilizes some copper for its metabolic needs, including synthesis and secretion of ceruloplasmin (a copper containing protein) which is involved in iron metabolism, and the excess of copper is excreted in bile in normal individuals.

[0004] Menkes disease is an X-linked copper deficiency disorder caused by mutations in the ATP7A gene resulting in death in early childhood. Affected boys have severe neurological problems, abnormal hair, connective tissue defects, and suffer from hypothermia due to the low activity of various copper (Cu)-dependent enzymes. Females may also have changes in hair and skin color, but typically do not exhibit significant medical problems.

[0005] Appropriate treatment of Menkes disease requires early diagnosis and treatment before irreversible brain damage occurs. Currently, there is no approved therapy for Menkes disease, but typical treatment includes injection of copper histidine into the body to avoid epithelial cell injury in the gastrointestinal tract. However, studies have shown that genetic abnormalities causing Menkes disease cannot be corrected merely by copper replacement injections.

[0006] There is a need for improved methods fortreatment of disorders of copper metabolism.SUMMARY

[0007] Provided herein is a method for treating a disorder of copper metabolism in a subject in need thereof, the method comprising: a first administration to the subject and a second administration to the subject, wherein:the first administration is oral administration of a therapeutically effective amount of a composition comprising elesclomol; and the second administration is subcutaneous administration of a therapeutically effective amount of a composition comprising copper.

[0008] Provided herein is the use of a combination for treating a disorder of copper metabolism, the combination comprising: a first component and a second component, wherein: the first component is an orally administrable composition comprising a therapeutically effective amount of elesclomol; and the second component is a subcutaneously administrable composition comprising a therapeutically effective amount of copper.BRIEF DESCRIPTION OF THE DRAWINGS

[0009] FIG. 1A depicts a comparison of probability of survival (Y axis) of Md,rmice treated with ES PO and Cu-His SC vs Cu-His SC alone.

[0010] FIG. IB depicts a comparison of probability of survival (Y axis) of / c mice treated with ES PO and Cu-BG SC vs Cu-BG SC alone.

[0011] FIG. 1C depicts a comparison of probability of survival (Y axis) of Mrmice treated with ES PO and Cu-GC SC vs Cu-GC SC alone.

[0012] FIG. ID depicts probability of survival (Y axis) in groups of Mdrmice treated with a single compound, i.e., ES PO Cu-His SC, Cu-BG SC, or Cu-GC SC.

[0013] FIG. 2A depicts body weight for Md>rmice treated with ES PO and Cu-His SC vs Cu- His SC alone.

[0014] FIG. 2B depicts body weight for Md" mice treated with ES PO and Cu-BG SC vs Cu-BG SC alone.

[0015] FIG. 2C depicts body weight for Mrmice treated with ES PO and Cu-GC SC vs Cu-GC SC alone.

[0016] FIG. 3A depicts a comparison of % spontaneous alternations in the Y maze at 7 weeks of age between Md}rmice treated with a combination of ES PO and a SC Cu source and WT mice treated with vehicle.

[0017] FIG. 3B depicts a comparison of total arm entries in the Y maze at 7 weeks of age between Afc^ mice treated with a combination of ES PO and a SC Cu source and WT mice treated with vehicle.

[0018] FIG. 4 depicts a comparison of average distance traveled (cm) in the open field assay at 7 weeks of age between Md,rmice treated with a combination of ES PO and a SC Cu source and WT mice treated with vehicle.

[0019] FIG. 5 depicts a comparison of grip strength at 7 weeks of age, normalized by bodyweight, between Afo*rmice treated with a combination of ES PO and a SC Cu source and WT mice treated with vehicle.

[0020] FIG. 6 depicts a timeline of a study design exemplified herein.

[0021] FIG. 7 depicts probability of survival (Y axis) in groups of Md’rmice treated with oral elesclomol alone, subcutaneous Cu-His alone, or a combination of oral elesclomol and subcutaneous Cu-His.

[0022] FIG. 8 depicts probability of survival (Y axis) in groups of Md}rmice treated with oral elesclomol alone, subcutaneous Cu-BG alone, or a combination of oral elesclomol and subcutaneous Cu-BG.

[0023] FIG. 9 depicts probability of survival (Y axis) in groups of Md,rmice treated with oral elesclomol alone, subcutaneous Cu-GC alone, or a combination of oral elesclomol and subcutaneous Cu-GC.

[0024] FIG. 10 depicts changes in bodyweight over time of Md,rmice treated with combinations of oral elesclomol and subcutaneous copper.

[0025] FIG. 11 depicts the number of arm entries in Y-maze performance of ft mice treated with combinations of oral elesclomol and subcutaneous copper as compared to wildtype mice treated with oral and subcutaneous vehicles.

[0026] FIG. 12 depicts the % alternations in Y-maze performance of Md,rmice treated with combinations of oral elesclomol and subcutaneous copper as compared to wildtype mice treated with oral and subcutaneous vehicles.

[0027] FIG. 13 depicts the grip strength of Md]rmice treated with combinations of oral elesclomol and subcutaneous copper as compared, on an age basis, to wildtype mice treated with oral and subcutaneous vehicles.

[0028] FIG. 14 depicts the grip strength of Md" mice treated with combinations of oral elesclomol and subcutaneous copper as compared, on an age basis and normalized by body weight, to wildtype mice treated with oral and subcutaneous vehicles.

[0029] FIG. 15 depicts latency to fall in a rotarod test of Md,rmice treated with combinations of oral elesclomol and subcutaneous copper as compared to wildtype mice treated with oral and subcutaneous vehicles.

[0030] FIG. 16 depicts vertical activity in an open field test of Mdrmice treated with combinations of oral elesclomol and subcutaneous copper as compared to wildtype mice treated with oral and subcutaneous vehicles.

[0031] FIG. 17 depicts distance travelled in an open field test of Mdjrmice treated with combinations of oral elesclomol and subcutaneous copper as compared to wildtype mice treated with oral and subcutaneous vehicles.

[0032] FIG. 18 depicts margin activity in an open field test of Md" mice treated with combinations of oral elesclomol and subcutaneous copper as compared to wildtype mice treated with oral and subcutaneous vehicles.

[0033] FIG. 19 depicts the impact of continued treatment (drug holiday) on physiology and behavior in Y-maze performance of ft mice treated with combinations of oral elesclomol and subcutaneous copper as compared to wildtype mice treated with oral and subcutaneous vehicles.

[0034] FIG. 20 depicts the impact of continued treatment (drug holiday) on physiology and behavior in grip strength performance of Mrmice treated with combinations of oral elesclomol and subcutaneous copper as compared to wildtype mice treated with oral and subcutaneous vehicles.

[0035] FIG. 21 depicts the impact of continued treatment (drug holiday) on physiology and behavior in latency to fall in the rotarod assay of Md>rmice treated with combinations of oral elesclomol and subcutaneous copper as compared to wildtype mice treated with oral and subcutaneous vehicles.

[0036] FIG. 22 depicts the impact of continued treatment (drug holiday) on physiology and behavior in an open field assay of Mrmice treated with combinations of oral elesclomol and subcutaneous copper as compared to wildtype mice treated with oral and subcutaneous vehicles.

[0037] FIG. 23 depicts the impact of copper source and duration of combination treatment (oral elesclomol and subcutaneous copper) on brain copper levels.

[0038] FIG. 24 depicts the impact of copper source and duration of combination treatment (oral elesclomol and subcutaneous copper) on intestinal copper levels.

[0039] FIG. 25 depicts the impact of copper source and duration of combination treatment (oral elesclomol and subcutaneous copper) on kidney copper levels.DETAILED DESCRIPTION

[0040] Elesclomol ("ES") (STA-4783, CAS No. 488832-69-5), disclosed in U.S. Patent No. 7,795,313 (incorporated herein by reference), is a compound represented by the formula shown below. Elesclomol as referred to herein may be as a free base (i.e. neutral form) or as apharmaceutically acceptable salt. In some embodiments, the elesclomol, when a salt, is not a copper salt.Elesclomol

[0041] Elesclomol, originally developed as an anticancer agent, may be referred to as N- malonyl-bis (N'-methyl-N'-thiobenzoylhydrazide), l-N',3-N'-bis(benzenecarbonothioyl)-l-N',3-N'- dimethylpropanedihydrazide or l,3-bis[2-Methyl-2-(phenylthioxomethyl)hydrazide]propanedioic acid.

[0042] Copper histidine ("Cu-his") is used as a subcutaneous injection for treatment of Menkes disease. Previous clinical trials exploring intravenous elesclomol as a treatment for certain cancers were halted for various reasons, including efficacy and safety. US 2021 / 0290571 (incorporated herein by reference) discloses treatment of Menkes disease with subcutaneous injections of elesclomol or copper. Subcutaneous injection of elesclomol complexed with copper has also been proposed for treatment of Menkes disease Front Cell Dev Biol. 2022; 10: 856300).

[0043] Elesclomol is rapidly eliminated from plasma with mean half-life values ranging from 0.79 to 1.06 hours, and the mean clearance of elesclomol ranges from 28.6 to 38.7 L / h / m2. This short half-life and rapid elimination make therapeutic use of elesclomol challenging.

[0044] It has been found that a combination of oral elesclomol and subcutaneous copper are useful in treatment of Menkes disease.

[0045] Also contemplated within the scope of embodiments presented herein is the use of the methods described herein for treatment of other human disorders characterized by dysregulation of copper metabolism. For example, mutations in the ATP7A gene cause occipital horn syndrome and X-linked distal hereditary motor neuropathy, both of which are associated with copper metabolism dysregulation. Amyotrophic lateral sclerosis or Lou Gehrig's disease is caused by mutation in Cu / Zn-superoxide dismutase (SOD1) and augmenting copper delivery to SOD1 by the methods described herein may be therapeutically beneficial. A feature of Alzheimer's disease is the accumulation of extracellular beta-amyloid (A|3) plaques in the brain. Copper delivery via diet or pharmacological means has been shown to reduce interstitial Ag and improve cognitive function in transgenic mouse models of Alzheimer's disease. Huppke-Brendel syndrome is caused by mutations in AT-1 gene that encodes the endoplasmic reticulum membrane acetyl CoA transporter, which is required for acetylation of one or more copper proteins. Mutations in AT-1 result in lower serum copper levels and neurological defects. The methods described herein can be beneficial in treating conditions associated with AT-1 mutations. Mental retardationenteropathy deafness neuropathy ichthyosis keratoderma (MEDNIK) syndrome is caused by mutation in AP1S1 gene and is characterized by perturbation of copper metabolism with reduced expression of cytochrome c oxidase and SOD1. The methods described herein may be useful in treating MEDNIK syndrome. Parkinson's disease, Leigh syndrome, Huntington's disease, mitochondrial phosphate carrier deficiency, Indian childhood cirrhosis, and cataracts are some additional disorders of copper metabolism which may be treated using the methods described herein. Abnormal copper balance may cause or aggravate additional diseases such as neurodegenerative diseases, anemia, metabolic syndrome, cardiovascular diseases, and / or cancer which may be treated using the methods described herein.Definitions

[0046] The terms "a," "an," "the," and similar referents used in the context of describing the disclosure (especially in the context of the following claims) are to be construed to cover both the singular and the plural, unless otherwise indicated herein or clearly contradicted by context. Recitation of ranges of values herein is merely intended to serve as a shorthand method of referring individually to each separate value falling within the range. Unless otherwise indicated herein, each individual value is incorporated into the specification as if it were individually recited herein. All methods described herein can be performed in any suitable order unless otherwise indicated herein or otherwise clearly contradicted by context. The use of any and all examples, or exemplary language (e.g., "such as") provided herein is intended merely to better illuminate the disclosure and does not pose a limitation on the scope of the disclosure otherwise claimed. No language in the specification should be construed as indicating any non-claimed element essential to the practice of the disclosure.

[0047] "Disorder of copper metabolism" refers to disorders characterized by dysregulation of copper metabolism. Such dysregulation includes abnormal copper balance, including deficiency, overload, or misdistribution, and / or any perturbation in homeostasis of copper.

[0048] "Substantially free of copper" means that the elesclomol contains an undetectable amount of copper. In some embodiments, substantially free of copper means that the elesclomol contains no more than 0.001%, 0.1%, 0.5%, 1%, 2%, 3%, 4%, or 5% of copper by weight.

[0049] "Copper" includes elemental copper, salts of copper, complexes of copper with organic molecules, or any combination thereof.

[0050] "Composition" as used herein is intended to encompass a product comprising the specified ingredients in the specified amounts, as well as any product, which results, directly or indirectly, from combination of the specified ingredients in the specified amounts.

[0051] "Pharmaceutically acceptable" means the carrier, diluent, or excipient must be compatible with the other ingredients of the formulation and not deleterious to the recipient thereof.

[0052] "Pharmaceutically acceptable excipient" includes without limitation any adjuvant, carrier, excipient, glidant, sweetening agent, diluent, preservative, dye / colorant, flavor enhancer, surfactant, wetting agent, dispersing agent, suspending agent, stabilizer, isotonic agent, solvent, or emulsifier which has been approved by the United States Food and Drug Administration as being acceptable for use in humans or domestic animals.

[0053] "Therapeutically effective amount" or "effective amount" as used herein refers to an amount that is effective to elicit the desired biological or medical response, including the amount of a compound that, when administered to a subject for treating a disease, is sufficient to effect such treatment for the disease. The effective amount can vary depending on the compound, the disease and its severity, and the age, weight, etc., of the subject to be treated. The effective amount can include a range of amounts. As is understood in the art, an effective amount may be in one or more doses, i.e., a single dose or multiple doses may be required to achieve the desired treatment endpoint. An effective amount may be considered in the context of administering one or more therapeutic agents, and a single agent may be considered to be given in an effective amount if, in conjunction with one or more other agents, a desirable or beneficial result may be or is achieved.

[0054] "Subject" refers to animals such as mammals, including, but not limited to, primates (e.g., humans), cows, sheep, goats, horses, dogs, cats, rabbits, rats, mice, and the like. In certain embodiments, the subject is a human.

[0055] In one aspect provided herein is a method for treating a disorder of copper metabolism in a subject in need thereof, the method comprising administering elesdomol to the subject orally, wherein the elesclomol is not complexed to copper. In some embodiments, the elesclomol is administered orally in combination with, e.g., on the same day as, a subcutaneous injection of copper.

[0056] In another aspect, provided is a method for treating a disorder of copper metabolism in a subject in need thereof, the method comprising: a first administration to the subject and a second administration to the subject, wherein: the first administration is oral administration of a therapeutically effective amount of a first composition comprising elesclomol; and the second administration is subcutaneous administration of a therapeutically effective amount of a second composition comprising copper.

[0057] In another aspect, provided is a method for treating Menkes disease in a subject in need thereof, the method comprising: a first administration to the subject and a second administration to the subject, wherein: the first administration is oral administration of a therapeutically effective amount of a first composition comprising elesclomol; and the second administration is subcutaneous administration of a therapeutically effective amount of a second composition comprising copper.

[0058] In another aspect, provided is a method of improvement of weight gain in a subject having Menkes disease, the method comprising: a first administration to the subject and a second administration to the subject, wherein: the first administration is oral administration of a therapeutically effective amount of a first composition comprising elesclomol; and the second administration is subcutaneous administration of a therapeutically effective amount of a second composition comprising copper, wherein the improvement of weight gain is with respect to a subject, or a class of subjects, having Menkes disease and not receiving either the first administration or the first and second administration.

[0059] In another aspect, provided is a method of improvement of a neurological function in a subject having Menkes disease, the method comprising: a first administration to the subject and a second administration to the subject, wherein: the first administration is oral administration of a therapeutically effective amount of a first composition comprising elesclomol; and the second administration is subcutaneous administration of a therapeutically effective amount of a second composition comprising copper, wherein the improvement of the neurological function is with respect to a subject, or a class of subjects, having Menkes disease and not receiving either the first administration or the first and second administration.

[0060] In another aspect, provided is a method of improvement of physical mobility in a subject having Menkes disease, the method comprising: a first administration to the subject and a second administration to the subject, wherein: the first administration is oral administration of a therapeutically effective amount of a first composition comprising elesclomol; andthe second administration is subcutaneous administration of a therapeutically effective amount of a second composition comprising copper, wherein the improvement of the physical mobility is with respect to a subject, or a class of subjects, having Menkes disease and not receiving either the first administration or the first and second administration.

[0061] In another aspect, provided is a method of improvement of survival of a subject having Menkes disease, the method comprising: a first administration to the subject and a second administration to the subject, wherein: the first administration is oral administration of a therapeutically effective amount of a first composition comprising elesclomol; and the second administration is subcutaneous administration of a therapeutically effective amount of a second composition comprising copper, wherein the improvement of the survival of the subject is with respect to a subject, or a class of subjects, having Menkes disease and not receiving either the first administration or the first and second administration.

[0062] In yet another aspect, provided herein is a combination, comprising: a first composition, wherein the first composition is an oral dosage form comprising elesclomol; and a second composition, wherein the second is a subcutaneous dosage form comprising copper.

[0063] In some embodiments of the combinations or methods herein, the orally administered elesclomol is substantially free of copper. In some embodiments, the orally administered elesclomol is administered once a day. In some embodiments, the oral composition of elesclomol includes a capsule filled with powder which can be swallowed. In some embodiments, the oral composition of elesclomol includes a capsule filled with powder which can be broken and the powder is sprinkled on food or dispersed in a fluid prior to ingestion. In some embodiments, the oral composition of elesclomol includes a tablet or a granule or a capsule comprising granules.

[0064] In some embodiments of the combinations or methods herein, the orally administered elesclomol is administered three times per week, and the subcutaneously administered copper is administered three times per week. In some embodiments, the elesclomol and copper are administered on the same day. In some embodiments, the elesclomol and copper are administered from the subject's birth until the subject is an adolescent age (e.g., a human being about 10, 11, 12, 13, 14, 15, 16, 17, 18, or 19 years of age), the subject having Menkes disease,optionally wherein the subject no longer is administered the combination of elesclomol and copper after the adolescent age.

[0065] As used herein, a composition substantially free of copper may refer to a composition having less than 1 PPM of copper. Alternatively, a composition substantially free of copper may refer to a composition that includes a compound capable of complexing copper, and the composition comprises a ratio of the compound to copper of greater than 99: 1. Thus, in some embodiments, a composition comprising elesclomol may be substantially free of copper by having a ratio of elesclomol to copper of greater than 99:1.

[0066] In some embodiments of the combinations or methods herein, the disorder of copper metabolism is a copper deficiency or a copper misdistribution. In some embodiments, the disorder of copper metabolism is Menkes disease, occipital horn syndrome, X-linked distal hereditary motor neuropathy, amyotrophic lateral sclerosis, Huntington's disease, Parkinson's disease, Alzheimer's disease, Leigh syndrome, Huppke-Brendel syndrome, Mental retardation enteropathy deafness neuropathy ichthyosis keratoderma (MEDNIK) syndrome, mitochondrial phosphate carrier deficiency, Indian childhood cirrhosis, or cataracts. In some embodiments, the disorder of copper metabolism is Menkes disease.

[0067] In some embodiments of the combinations or methods herein, the copper is in the form of a complex, or salt form, with one or more additional compounds. In some embodiments, a copper complex comprises Cu (II) and the stoichiometry of the complex is 2: 1 for X:Cu(II) where X is any suitable compound that can form a complex with copper. In some embodiments, a copper complex comprises Cu(I) and the stoichiometry of the complex is 1:1 for X:Cu(I) where X is any suitable compound that can form a complex with copper. In some embodiments, a copper complex as used herein is selected from copper-histidine (e.g., copper bishistidinate), coppergluconic acid (e.g., copper bisgluconate), copper-glycine (e.g., copper bisglycinate), copper- elesclomol, copper-citric acid (e.g., biscopper citrate), copper-orotic acid (e.g., copper bisorotate), copper-acetylacetone (e.g., copper bisacetylacetonate), copper-methionine (e.g., copper bismethionine), copper-cysteine (e.g., copper biscycsteinate), copper-homocysteine (e.g., copper bishomocysteinate), copper-taurine (e.g., copper bistaurinate), or a combination thereof.

[0068] In some embodiments of the combinations or methods herein, the copper is a copperhistidine (e.g., copper bishistidinate) complex. In some embodiments, the copper is a coppergluconic acid (e.g., copper bisgluconate) complex. In some embodiments, the copper is a copperglycine (e.g., copper bisglycinate) complex. In some embodiments, the copper is a copper- elesclomol complex.

[0069] In some embodiments of the combinations or methods herein, the elesclomol composition and the copper composition are administered sequentially in any order. In someembodiments, the elesclomol and the copper are administered together, e.g., at approximately the same time, e.g., within about 5 minutes of administration of one another.

[0070] In some embodiments of the combinations or methods herein, the oral composition comprises elesclomol, and further comprises polyethylene glycol, hydroxyethyl cellulose, betacyclodextrin derivatized with sulfoalkylether groups, or water, or any combination thereof. In some embodiments, the beta-cyclodextrin is derivatized with an average of 6.5 sulfobutylether groups per cyclodextrin molecule.

[0071] In some embodiments of the combinations or methods herein, an oral composition of elesclomol comprises about 20% w / w of Captisol®. In some embodiments, an oral composition of elesclomol comprises about 18% to about 25% w / w of Captisol®, about 12% to about 18% by weight of hydroxyethyl cellulose, about 18% to about 25% w / w of polyethylene glycol, about 0.1% to about 10% w / w of elesclomol, and water.

[0072] In some embodiments of the combinations or methods herein, the treatment methods described herein rescue defects of cells in a subject having deficiencies or mutations in at least one of SOD1, AT-1, AP1S1, COA6, SCO2, COX6B1, CTR1, ATOX1, CCS, GSX1, ATP7A, CLCNS, and CLCN.

[0073] In some embodiments of the combinations or methods herein, the first composition comprises a ratio of elesclomol to copper of greater than 99:1.

[0074] In some embodiments of the combinations or methods herein, the first composition has less than 1 ppm of copper.

[0075] In some embodiments of the combinations or methods herein, the first composition is orally administered 4-12 hours after the second composition is subcutaneously administered.

[0076] In some embodiments of the combinations or methods herein, the first composition is orally administered 0-4 hours after the second composition is subcutaneously administered.

[0077] In some embodiments of the combinations or methods herein, the first composition is orally administered 2-4 hours after the second composition is subcutaneously administered.

[0078] In some embodiments of the combinations or methods herein, the first composition and second composition are each administered at least once within the same 24-hour period.

[0079] In some embodiments of the combinations or methods herein, the first composition and second composition are each administered at least once within the same about 2-, 5-, or 10- minute period.

[0080] In some embodiments of the combinations or methods herein, the first composition comprises a ratio of elesclomol to copper of greater than 99: 1 or the first composition has lessthan 1 ppm of copper, and wherein the copper is a copper-histidine (e.g., copper bishistidinate) complex, a copper-gluconic acid (e.g., copper bisgluconate) complex, a copper-glycine (e.g., copper bisglycinate) complex, or a combination thereof.

[0081] In some embodiments of the combinations or methods herein, the combination is used for treating a disorder of copper metabolism, for example selected from Menkes disease, occipital horn syndrome, X-linked distal hereditary motor neuropathy, amyotrophic lateral sclerosis, Huntington's disease, Parkinson's disease, Alzheimer's disease, Leigh syndrome, Huppke-Brendel syndrome, Mental retardation enteropathy deafness neuropathy ichthyosis keratoderma (MEDNIK) syndrome, mitochondrial phosphate carrier deficiency, Indian childhood cirrhosis, or cataracts.

[0082] In some embodiments of the combinations or methods herein, provided herein is the use of a combination of active agents for treating a disorder of copper metabolism, the combination comprising: a first component and a second component, wherein: the first component is an orally administrable composition comprising a therapeutically effective amount of elesclomol; and the second component is a subcutaneously administrable composition comprising a therapeutically effective amount of copper.

[0083] In some embodiments of the combinations or methods herein, the elesclomol in the first component is substantially free of copper. In some embodiments, the copper in the second component is a copper complex as described herein. Thus, in some embodiments of the combinations herein, e.g., for use or in the methods herein, the first composition (oral component) comprises elesclomol (e.g., substantially free of copper, e.g., having less than 1 PPM copper), whether a salt or free base (i.e. neutral form), and the second composition (subcutaneous component) comprises a copper-histidine complex. In other embodiments of the combinations herein, e.g., for use or in the methods herein, the first composition (oral component) comprises elesclomol (e.g., substantially free of copper, e.g., having less than 1 PPM copper), whether a salt or free base (i.e. neutral form), and the second composition (subcutaneous component) comprises a copper-bisglycinate complex. In still other embodiments of the combinations herein, e.g., for use or in the methods herein, the first composition (oral component) comprises elesclomol (e.g., substantially free of copper, e.g., having less than 1 PPM copper), whether a salt or free base (i.e. neutral form), and the second composition (subcutaneous component) comprises a coppergluconate complex.

[0084] In some embodiments of the combinations or methods herein, the first composition (oral component) and the second composition (subcutaneous component) are administered withinthe same 24-hour period. In some embodiments the oral component is administered after and within 24 hours of administration of the subcutaneous component. In some embodiments the oral component is administered after and within 12 hours of administration of the subcutaneous component. In some embodiments the oral component is administered after and within 4 hours of administration of the subcutaneous component. In some embodiments the oral component is administered after and within 30 minutes of administration of the subcutaneous component. In some embodiments the oral component is administered after and within 5 minutes of administration of the subcutaneous component.Compositions

[0085] In some embodiments, the combinations herein may be provided or referred to as a composition.

[0086] Pharmaceutical compositions comprising elesclomol for oral administration can be administered in a variety of dosage forms such as, for example, tablets, powders, lozenges, syrups, or capsules.

[0087] Pharmaceutical compositions comprising copper (e.g., copper complexes as defined herein) may be formulated with pharmaceutically acceptable carriers, diluents or excipients and can be administered by parenteral route (e.g., subcutaneous, intramuscular, intrathecal, intravenous, or intradermal). It will be appreciated that the route can depend on the general condition and age of the subject to be treated, the nature of the condition to be treated, and the active ingredient chosen.

[0088] For oral or parenteral administration, elesclomol or copper compositions, respectively, may suitably be formulated using, for example methods described in Remington: The Science and Practice of Pharmacy, 23rdEdition, Elsevier.

[0089] A suitable dosage of elesclomol and / or any copper complex described herein can depend on the age and condition of the patient, the severity of the disease to be treated, and other factors well known to the practicing physician. The orally administered elesclomol composition and the parenterally (e.g., subcutaneously) administered copper composition may be administered according to different dosing schedules, e.g., daily or with intervals, such as weekly intervals. In general, a single dose will be in the range from 0.01 to 100 mg / kg body weight, preferably from about 0.05 to 75 mg / kg body weight, more preferably between 0.1 to 50 mg / kg body weight, and most preferably between 0.1 to 25 mg / kg body weight, e.g., a dosage (e.g., human dosage) of elesclomol of about 0.5-3 mg / kg or 20-40 mg / m2and a dosage (e.g., human dosage) of copper(II) (e.g., a copper(II) complex herein) of about 0.03-1 mg / kg or 1-3 mg / m2.

[0090] In some embodiments, elesclomol is administered orally once a day. In some embodiments, a copper complex (e.g., Cu-his, Cu GC, Cu BG) is subcutaneously injected at aboutthe same time as the elesclomol is administered orally. In other embodiments, the copper complex is subcutaneously administered after a time interval ranging from about 0.5 to about 48 hours after the elesclomol has been administered orally. In some embodiments, a copper complex is subcutaneously administered, and the elesclomol is administered orally at about the same time as the copper complex was injected subcutaneously. In other embodiments, the elesclomol is administered orally after a time interval ranging from about 0.5 to about 48 hours after a dose of the copper complex has been administered subcutaneously. In some embodiments, a copper complex (e.g., Cu-his, Cu GC, Cu BG) is subcutaneously injected once a week, twice a week, three times a week, four times a week, or five times a week. In some embodiments, a copper complex (e.g., Cu-his, Cu GC, Cu BG) is subcutaneously injected daily.

[0091] Provided herein is a kit comprising an oral composition comprising elesclomol (as described herein, e.g., as a salt, a free base, or as a complex) and an injectable (e.g., subcutaneously injectable) composition comprising copper (or a complex or salt thereof as described herein).EXAMPLES

[0092] The mottled brindled mouse mutant Mcr) is the closest currently available animal model for Menkes disease. Other mouse models, including tissue-specific knockouts of the high affinity copper uptake protein 1 (CTR1), are not considered to fully recapitulate Menkes disease. Heterozygous Md" female mice have normal viability. They have curly vibrissae, but the coat is not noticeably waved. Hemizygous (HEMI) males are almost devoid of pigment except in the eyes and ears. The vibrissae are strongly curled, and the coat is wavy. HEMI Md" males usually die by three weeks of age. They have behavioral abnormalities consisting of slight tremor, uncoordinated gait, and clasping of the hindfeet when held up by the tail.

[0093] Each mouse is weighed, and its body weight recorded. Syringes used for dosing are primed with compound by preloading once, then emptying. A primed syringe is loaded with the volume needed based on bodyweight. Each mouse is placed on a flat surface. The skin over the scruff between the shoulders or hips is injected using a primed syringe for subcutaneous administration. For oral administration, mice are administered a compound with an oral gavage needle with a ball size no bigger than 2-2.5 mm at a volume of 5 mL / kg.Example 1

[0094] The aim of this study was to compare oral routes of administration of elesclomol on plasma, urine, and tissue copper levels, and survival in brindled mice mutant (Afo*Q.

[0095] To generate mottled-brindled hemizygous males for enrolling in experimental groups, heterozygous females were mated with age-matched C57BL6 / J males, till at least three litters were born. Pups were genotyped by toe-clip between P0-P2 and phenotyped by P5 based on(silver) coat color. Experimental group enrollment was done on a rolling basis, and breeding was maintained until enrollment for all groups was complete.

[0096] Broadly, the study design (FIG. 6) is directed to administration of oral elesclomol in combination with administration of a copper source (e.g., copper-histidinate, copper-gluconate, or copper-bisglycinate). The copper source is administered via oral administration or via subcutaneous administration. All groups started dosing at P7 with oral elesclomol. In groups with oral (po) elesclomol (ES) and subcutaneous (sc) Cu(II) salts, the sc Cu-salt treatment initiated one day prior, on P6. The frequency of dosing is 3 times per week. The last dose and termination subgroups are: a— dosed P7-P42, and sacrificed at P42; b— dosed P7-P70, and sacrificed at P70; and c— dosed P7-P42, drug holiday, and sacrificed at P70. On dosing days, each mouse was weighed and dosed at a dose level of lOmg / kg for po ES and fixed dose volume of the Cu-salt. Survival of mice was assessed on a daily basis. Mice were weaned, together with littermates at P28. Surviving Mo-br mice were assessed behaviorally at 6 and 9 weeks of age (during the 7thand 10thweek). Tissues were collected at scheduled terminal necropsy timepoints of P42 and P70, or if animals respond poorly to the injection or its components, including significant loss of BW (> 20% peak weight) or lethargy, or failure to respond to stimuli, mice older than P8 were necropsied and included for analyses in the <P42 dataset.

[0097] Efficacy of dosing route of the combination therapy vs. oral elesclomol alone was assessed by varying the administration route of copper source— oral vs. subcutaneous. Efficacy of treatment was assessed by survival outcomes of Md” mice. Impact of treatment on growth, function, and copper levels in Afc mice was assessed by body weight, cognitive function, motor activity, and muscle strength. Impact of continued treatment was assessed by introduction of a drug holiday by cessation of dosing after P42. Impact of copper source on efficacy was assessed by using copper-histidinate, copper-gluconate, or copper-bisglycinate.

[0098] Y-maze: Mice were placed in the center of a Y-shaped maze with visual cues at the end of each arm. Mice had free access to all three arms for 8 minutes. The data were analyzed as a % of correct alternations, which is defined by a visit to each of the three arms before returning to any of the three arms. It is used as a measure of spatial and working memory.

[0099] Grip strength: Bioseb grip strength meter equipped with a grid for grasping suitable for mice was used for this assay. Mice were lowered towards the grid by their tails to allow for visual placing and for the mouse to grip the grid with their forepaws. Mice were firmly pulled horizontally, parallel to the bench and away from the grid for 3 consecutive trials with a brief rest period (~30 seconds) between trials. The average force in grams of the forepaw- and all-pawtrials were analyzed and presented normalized to bodyweight.

[0100] Rotarod: The Ugo-Basile accelerating rotarod model 47600 for mice was utilized. After acclimatization of the mice to the testing room, mice were placed on the rod starting at speed of 5 rpm (rotations per minute) then accelerated up to 40 rpm over the course of 300 seconds. Each mouse underwent 3 consecutive trials with a ~45 sec inter-trial interval. Latency to fall off the rotating rod was measured.

[0101] Open field: Activity was assessed with Versamax Open Field Arenas (40cm x 40cm x 40cm each, lighting consistent with housing room). 1 hour after habituation inside the testing room, mice were placed individually into the center of an arena where infrared beams record distance traveled (cm), vertical activity, and peri meter / center time. Mice were recorded for 1 hour and returned to their home cage after recording.

[0102] Terminal procedures and necropsy: Mice were humanely euthanized by CO2 narcosis. Whole blood was collected by cardiac puncture. Brain was divided into hemispheres and flash frozen on dry ice. Kidneys were dissected out and flash frozen individually. The intestines, from the stomach to the cecum were flushed with PBS and flash frozen.

[0103] Copper concentrations in tissues were determined using ICP-mass spectrometry at Charles River Laboratories.

[0104] Statistical analyses: GraphPad Prism software (8.1.1) was used to graph and analyze all the data. Data were analyzed by ANOVA (one-way or two-way as stated), followed by multiple comparisons to test for significance. Data were considered significantly different at p<0.05.

[0105] All in-life procedures were done at Jackson Laboratories in accordance with IACUC policies.

[0106] Materials:

[0107] Preparation of oral elesclomol: To 80 mL of purified water in a flask equipped with a stir bar was added 250 mg of hydroxyethyl cellulose (HEC), and the mixture was gently stirred till dissolution. The stir bar was removed and water added to make a final volume of 100 mL of HEC solution.

[0108] 20 mL of PEG-400 was placed in a volumetric flask. 20 g of Captisol® was added to the flask. 60-70 mL of the HEC solution was added to the flask. The mixture was shaken on an orbital shaker till Captisol® dissolved. Additional HEC solution was added to make a final volume of 100 mL. The pH of the formulation was adjusted to 7.4 by using 0.1 N NaOH to provide the formulation vehicle.

[0109] 10 mg of elesclomol was placed in a 5 mL volumetric flask. The formulation vehicle was added to a volume of 5 mL. The dispersion was vortexed till a homogenous suspension wasobtained. If needed, the pH was adjusted to 7.4 by using 0.1 N NaOH. This 2 mg / mL mixture (corresponding to a dose of 10 mg / kg) was used for oral administration to / mice.

[0110] A similar procedure was used for preparation of a 2 mg / mL mixture (corresponding to a dose of 10 mg / kg) comprising elesclomol complexed to copper.

[0111] In an alternate procedure, to 5.52 mL 20% Captisol® 1 mg of elesclomol-copper complex was added. The slurry was sonicated for 5 minutes at 30°C followed by continuous mixing at room temperature for 3 hours to ensure complete dissolution, yielding a stock of 0.181 mg / mL. The pH was adjusted to 7.4 using 0.2 NaOH. The solution was sterile filtered (0.2 pM filter) and stored at 4°C for up to 30 days.

[0112] Preparation of Cu-histidine complex: 31 mg of pharmaceutical grade L-histidine (Sigma Aldrich) was added to 1.983 mL of 100 mM HEPES buffer pH 7.4. 17.05 mg CuCl2-2H2O (Sigma Aldrich) was added and the mixture was stirred at room temperature for three hours to complete a 2:1 stoichiometric complexation. Vigorous stirring was avoided to reduce introduction of oxygen. This is stock solution of copper histidinate.

[0113] 62.9 pL of stock solution (50 mM 2HIS-Cu2+) was added to 9.94 mL 20% Captisol®.When 100 pL of this solution is injected subcutaneously, it provides 11.68 pg 2HIS-Cu(II) (9.68 pg Histidine, 2 pg Cu2+) and 20 pg inert Captisol®. Assuming a mouse body weight of 0.02 kg, the mouse dosage is about 0.6 mg / kg.

[0114] Table 1 shows the experimental design. PO means oral, SC means subcutaneous, HEMI M means hemizygous male mice, and ES means elesclomol.

[0115] Treatment Protocol: Treatment began with sc copper source on postnatal day (P) 6, followed by combination treatment starting on P7, administered three times a week. Surviving animals were further divided into two subgroups: Subgroup (a) was sacrificed at ~P42 (or younger for unscheduled necropsies) while subgroup (b) continued receiving treatment and was sacrificed at ~P70.

[0116] In-life measures and tissue collection: Survival and bodyweight was measured throughout the study. Behavioral assessments were conducted at two time points during the seventh and ninth weeks of life. Brain, kidney, and small intestinal tissues were collected for copper analysis at the terminal time points around <P42 and P70.Table 1Table 1, continued

[0117] As used herein, the letter "P" followed by a number indicates the day from postnatal day (PO). For example, P7 means postnatal day 7.

[0118] On postnatal day (PO) the pups are genotyped. Dosing begins on P6 / 7. Table 2 shows percent survival data from the experiment. Mpk means mg / kg. Groups 1, 3, and 5 have a 61%, 70%, and 81% probability of survival to P42, respectively, which compares to 97% for wildtype group 8. By contrast, Groups 2, 4, 6, 7a, 7d, 7e, and 7f have a 0% probability of survival to P42. These data demonstrate a 61-81% probability of survival for mice treated with oral elesclomol in combination with subcutaneous copper, whereas no treatment, copper alone, or elesclomol alone provide a 0% probability of survival at P42. Combination treatment surprisingly enhances survival past P42 compared to monotherapy only.Table 2

[0119] The data in Table 2 shows that oral Cu-his followed by oral ES was not effective. However, a combination of oral ES with SC Cu-his improved survival.

[0120] Surprisingly, changing the copper complex from Cu-his to Cu-gluconate (Cu-GC) or Cu- bisglycinate (Cu-BG) provided further improved survival as shown in Table 2. With a combination of oral ES + Cu-his, 61% of the animals survived at P42. By contrast, with a combination of oral ES + Cu-BG, 70% of the animals survived at P42, and with a combination of oral ES + Cu-GC, 81% of the animals survived at P42.

[0121] Md>rmice on average die at about P16 without treatment. The data herein, including FIG. 7, FIG. 8, and FIG. 9, surprisingly show that oral elesclomol in combination with asubcutaneous, but not oral, source of copper enhances survival of Md}rmice, and in some instances demonstrates a survival probability beyond the simple sum of survival probabilities of MA mice administered oral elesclomol alone or subcutaneous copper alone.

[0122] Behavior testing— Rota rod test: This test evaluates neuromotor function including balance, endurance, grip strength, and motor coordination. It involves placing mice on a horizontally oriented rotating rod suspended over the cage floor and monitoring the time until they fall.

[0123] The lower number of total arm entries in the Y-maze by "rescued" Mcf>rmice indicates decreased general activity and movement. This aligns with the open field data described below. Despite lower general physical activity, cognition as measured in this assay is not impacted.

[0124] Behavior testing— Open field test: Mice are put in an open area (box). Automated systems are used to quantify the behavior of mice. General movement (distance travelled) is measured. The time spent in center vs. periphery (margin) gives an indication of anxiety-like behavior. Vertical activity (climbing, rearing) is also quantified.

[0125] FIGs. 1A-C show comparative data for a combination of oral ES and subcutaneous Cu compound vs Cu compound alone. Amice were treated with oral ES and subcutaneous source of copper starting at P7, 3 times a week until scheduled necropsy at P70. Untreated MA mice die, on average at P16 (data not shown). Only treating with subcutaneous copper (regardless of source / salt form) does not enhance survival.

[0126] Additionally, treating only with oral ES does not enhance survival (FIG. ID).

[0127] FIG. 1A provides a comparison of survival of MA mice treated with ES PO and Cu-His SC vs Cu-His SC alone. The combination of ES PO + Cu-His SC improves probability of survival. FIG. IB provides a comparison of probability of survival of MA mice treated with ES PO and Cu- BG SC vs Cu-BG SC alone. The combination of ES PO + Cu-BG SC improves probability of survival. FIG. 1C provides a comparison of probability of survival of M mice treated with ES PO and Cu- GC SC vs Cu-GC SC alone. The combination of ES PO + Cu-GC SC improves probability of survival.

[0128] Table 2a summarizes data depicted in FIGs. 1A-D.Table 2a

[0129] FIGs. 2A-C show that combining subcutaneous copper with oral ES allows for weight gain in Md]rmice. FIG. 2A shows body weight for Mdjrmice treated with ES PO and Cu-His SC vs Cu-His SC alone. FIG. 2B shows body weight for Md* mice treated with ES PO and Cu-BG SC vs Cu-BG SC alone. FIG. 2C shows body weight for Mdrmice treated with ES PO and Cu-GC SC vsCu-GC SC alone. FIGs. 2A-C show that Afc ^ mice treated with oral ES and subcutaneous copper survive past the average age of death and gain body weight at a steady pace regardless of copper- source administered subcutaneously.

[0130] As can be seen from FIG. ID, administration of ES PO alone resulted in a 0% probability of survival by P17. As can be seen from FIG. 1A, administration of Cu-His SC alone resulted in a 0% probability of survival by P28. As can be seen from FIG. IB, administration of Cu-BG SC alone resulted in a 0% probability of survival by P34. As can be seen from FIG. 1C, administration of Cu-GC SC alone resulted in a 0% probability of survival by P16. Surprisingly, the combination of ES PO with Cu-His SC improved the probability of survival to about 83% survival at P70 (scheduled necropsy at P70), which is well beyond the mere sum of any survival probability from ES PO alone and Cu-His SC alone. Still more surprisingly, the combination of ES PO with Cu- BG SC or the combination of ES PO with Cu-GC SC further improved the probability of survival to 100% survival at P70 (scheduled necropsy). Put another way, it was unexpectedly found that oral elesclomol with subcutaneous administration of a Cu source improved the probability of survival of Md" mice from 0% at P34, when administered oral elesclomol alone or a subcutaneous Cu source alone, to about 83-100% at P70.

[0131] As can be seen from FIG. 10, and Table 3, surviving Mrmice treated with oral elesclomol and a subcutaneous copper source thrive and gain body weight steadily regardless of the form of the copper source. Combination treated mice that survive at each timepoint gain weight steadily, reaching about 70-80% of wildtype bodyweight by P42.Table 3

[0132] As can be seen from FIG. 11 and Fig. 12, Mrmice treated with oral elesclomol and a subcutaneous copper source display wildtype-levels of percent spontaneous alternations in the Y- maze at 7 weeks of age indicating normal cognitive function despite significantly lower total arm entries.

[0133] As can be seen from FIG. 13 and Fig. 14, Mrmice treated with oral elesclomol and a subcutaneous copper source display wildtype-levels of grip strength at 7 weeks of age when normalized by bodyweight, regardless of copper source. Combination treated Mrmice display lower average grip strength compared to age-matched wildtype mice.

[0134] As can be seen from FIG. 15, Md>rmice treated with oral elesclomol and a subcutaneous copper source display wildtype-levels of neuromotor behavior at 7 weeks of age as observed by latency to fall in the rotarod assay, regardless of copper source.

[0135] As can be seen from FIG. 16, FIG. 17, and FIG. 18, while Mrmice treated with oral elesclomol and a subcutaneous copper source display significantly lower general activity in the open field test at 7 weeks of age, which suggests motor impairments, rescued Mrmice spend similar time in margins as wildtype mice indicating no overt anxiety-like behavior, regardless of copper source.

[0136] As can be seen from Table 4, P42 surviving Mdrmice treated with oral elesclomol and a subcutaneous copper source have a 100% probability of survival to P70 regardless of whether treatment is continued and regardless of the subcutaneously injected copper source.Table 4

[0137] As can be seen from Table 5 and Table 5a, P42 survivingrmice treated with oral elesclomol and a subcutaneous copper source continue to gain weight steadily reaching about 86-92% of wildtype weight by P70 when treatment is continued beyond P42 through P70. Additionally, when given a drug holiday from P42 through P70, the previously treated mice continue to gain weight at a similar rate as wildtype over the 28-day period of P42 to P70. Md}rmice continued to gain weight at a similar rate as WTs at ~0.2g / day, which is greater than the rate of weight gain in WTs (!0.13g / day) from P42-P70, with no difference between groups receiving or not receiving continued treatment.Table 5Table 5a

[0138] As can be seen from FIG. 19, Mdrmice treated with oral elesclomol and a subcutaneous copper source display wildtype-levels of percent spontaneous alternations, with lower arm entries, in the Y-maze at 9 weeks of age indicating a drug holiday from P42-P70 does not negatively impact cognitive performance (alternations) or movement (total arm entries) in the Y-maze (group c).

[0139] As can be seen from FIG. 20, Mrmice treated with oral elesclomol and a subcutaneous copper source on average display wildtype-levels of grip strength (normalized by body weight) following a drug holiday from P42 to P70 at 9 weeks of age indicating a drug holiday from P42-P70 does not negatively impact grip strength (group c).

[0140] As can be seen from FIG. 21, Md” mice treated with oral elesclomol and a subcutaneous copper source on average display wildtype-levels of latency to fall in the rotarod assay following a drug holiday from P42 to P70 at 9 weeks of age indicating a drug holiday from P42-P70 does not negatively impact neuromotor coordination (group c).

[0141] As can be seen from FIG. 22, while Mrmice treated with oral elesclomol and a subcutaneous copper source display on average lower vertical activity and distance travelled in the open field test at 7 weeks of age, a drug holiday from P42 to P70 in rescued Mdrmice does not further the general motor deficit (group c).

[0142] Afc mice subject to a drug holiday from P42-P70, having already been rescued by the combination treatment of oral elesclomol and subcutaneous copper, continue to survive with 100% probability to at least P70, continue to thrive with steady weight gain reaching about 80- 90% of wildtype body weight, and maintain at 10 weeks: cognition (Y maze, spontaneous alternations), grip strength (in all paws, normalized by bodyweight), neuromotor coordination (rotarod), and reduced locomotor activity (open field).

[0143] The impact of copper source (e.g., Cu++) and duration of treatment on brain, intestinal, and kidney copper levels was also examined. When dosed with the combination up to P70 (b groups), up to about 55% of wildtype brain levels of copper was reached, and on average the source of copper did not significantly impact brain copper levels (see FIG. 23). Brain concentrations are 11-46% higher with 4 weeks of additional dosing past PND42 (group b vs. c).A drug holiday for a period of 28 days from P42 to P70 did not result in copper reduction in the brain (group a vs. c). As depicted in FIG. 24, higher levels of intestinal copper were observed in younger Afc mice (PND42 a-group vs. PND70 b- and c- groups). Continued treatment (b-groups) result in about 2-3-fold higher copper levels in intestinal tissue than wildtype at P70. Intestine concentrations of copper are about 36-80% higher with 4 weeks additional dosing past PND42 (groups b vs. c). A drug holiday of the combination from P42-P70 results in reduction in intestinal copper levels bringing them closer to wildtype levels (c-groups). As depicted in FIG. 25, Afc ^mice, whether young or older with treatment show kidney copper levels significantly higher than wildtype (groups a, b, and c). Continued treatment (group b) results in about 10-12x higher levels of copper in kidney tissue than wildtype. A drug holiday of the combination from P42-P70 results in lower or similar copper levels in kidney tissue on average (groups a vs. c). After being dosed until P42, and despite a drug holiday of 4 weeks, kidney copper levels are about 4-7x higher than wildtype (group c). A drug holiday of 4 weeks does not show reduction in brain copper levels, or cognition, neuromotor coordination, or muscle strength, but does reduce intestinal and kidney copper levels.

[0144] In the brindled mouse mutant Mobr)la genetic model of Menkes disease, oral elesclomol together with subcutaneous copper substantially enhanced survival of mice to adulthood compared to treatment with copper alone, the mice displayed stable weight gain and were thriving, and the mice showed normalized physiological functions in multiple domains, displaying wild type (WT) levels of cognitive function, physical-strength, and gross motor function.

[0145] The data herein demonstrate that oral elesclomol together with subcutaneous copper can effectively deliver the copper to tissues including the brain, where copper is involved in essential neuronal processes, including energy production and cellular respiration, which can rescue neurodevelopmental processes and cognition, thereby meaningfully improving quality of life for patients.

[0146] Unless otherwise indicated, all numbers expressing quantities of ingredients, properties such as molecular weight, reaction conditions, and so forth used in the specification and claims are to be understood as being modified in all instances by the term "about." As used herein the terms "about" and "approximately" means within ±15% (e.g., ±10%, e.g., ±5%). Accordingly, unless indicated to the contrary, the numerical parameters set forth in the specification and attached claims are approximations that may vary depending upon the desired properties sought to be obtained by the present disclosure. At the very least, and not as an attempt to limit the application of the doctrine of equivalents to the scope of the claims, each numerical parameter should at least be construed in light of the number of reported significant digits and by applying ordinary rounding techniques. Notwithstanding that the numerical ranges and parameters setting forth the broad scope of the disclosure are approximations, the numericalvalues set forth in the specific examples are reported as precisely as possible. Any numerical value, however, inherently contains certain errors necessarily resulting from the standard deviation found in their respective testing measurements.

[0147] Groupings of alternative elements or embodiments of the disclosure herein are not to be construed as limitations. Each group member may be referred to and claimed individually or in any combination with other members of the group or other elements found herein. It is anticipated that one or more members of a group may be included in, or deleted from, a group for reasons of convenience and / or patentability. When any such inclusion or deletion occurs, the specification is deemed to contain the group as modified thus fulfilling the written description of all Markush groups used in the appended claims.

[0148] Specific embodiments disclosed herein may be further limited in the claims using consisting of or consisting essentially of language. Embodiments of the disclosure so claimed are inherently or expressly described and enabled herein.

[0149] Furthermore, where numerous references are made to patents and printed publications throughout this specification, each of the above-cited references and printed publications are individually incorporated herein by reference in their entirety.

[0150] In closing, it is to be understood that the embodiments of the disclosure herein are illustrative of the principles of the present disclosure. Other modifications that may be employed are within the scope of the disclosure. Thus, by way of example, but not of limitation, alternative configurations of the present disclosure may be utilized in accordance with the teachings herein. Accordingly, the present disclosure is not limited to that precisely as shown and described.

Claims

CLAIMSWe claim:

1. A combination, comprising: a first composition, wherein the first composition is an oral dosage form comprising elesclomol; and a second composition, wherein the second composition is a subcutaneous dosage form comprising copper(II).

2. The combination of claim 1, wherein the first composition comprises a ratio of elesclomol to copper of greater than 99:1 or the first composition has less than 1 ppm of copper, and wherein the copper(II) is a copper bisglycinate complex, a copper bisgluconate complex, a copper bishistidinate complex, or a combination thereof.

3. The combination of claim 1 for use in treating a disorder of copper metabolism selected from Menkes disease, occipital horn syndrome, X-linked distal hereditary motor neuropathy, amyotrophic lateral sclerosis, Huntington's disease, Parkinson's disease, Alzheimer's disease, Leigh syndrome, Huppke-Brendel syndrome, Mental retardation enteropathy deafness neuropathy ichthyosis keratoderma (MEDNIK) syndrome, mitochondrial phosphate carrier deficiency, Indian childhood cirrhosis, or cataracts.

4. A method of treating a disorder of copper metabolism in a subject in need thereof, the method comprising: oral administration of a first composition, wherein the first composition comprises elesclomol; and subcutaneous administration of a second composition, wherein the second composition comprises copper(II).

5. The method of claim 4, wherein the first composition is substantially free of copper.

6. The method of claim 4, wherein the disorder of copper metabolism is Menkes disease, occipital horn syndrome, X-linked distal hereditary motor neuropathy, amyotrophic lateral sclerosis, Huntington's disease, Parkinson's disease, Alzheimer's disease, Leigh syndrome,Huppke-Brendel syndrome, Mental retardation enteropathy deafness neuropathy ichthyosis keratoderma (MEDNIK) syndrome, mitochondrial phosphate carrier deficiency, Indian childhood cirrhosis, or cataracts.

7. The method of claim 4, wherein the disorder of copper metabolism is Menkes disease.

8. The method of claim 4, wherein the copper(II) includes a copper complex.

9. The method of claim 4, wherein the copper(II) is a copper bishistidinate complex.

10. The method of claim 4, wherein the copper(II) is a copper bisgluconate complex.

11. The method of claim 4, wherein the copper(II) is a copper bisglycinate complex.

12. The method of claim 4, wherein the copper(II) is a copper-elesclomol complex.

13. The method of claim 4, wherein the copper(II) is a copper salt.

14. The method of claim 4, wherein the first composition and the second composition are administered sequentially in any order, or are administered simultaneously.

15. The method of claim 4, wherein the first composition comprises elesclomol, and further comprises polyethylene glycol, hydroxyethyl cellulose, beta-cyclodextrin derivatized with at least one sulfoalkylether group, or water, or a combination thereof.

16. The method of claim 15, wherein the beta-cyclodextrin is derivatized with an average of 6.5 sulfobutylether groups per beta-cyclodextrin molecule.

17. The method of claim 4, wherein the treatment rescues defects of cells in a subject having deficiencies or mutations in at least one of SOD1, AT-1, AP1S1, COA6, SCO2, COX6B1, CTR.1, ATOX1, CCS, GSX1, ATP7A, CLCNS, or CLCN.

18. The method of claim 4, wherein the first composition comprises a ratio of elesclomol to copper(II) of greater than 99:1.

19. The method of claim 4, wherein the first composition has less than 1 ppm of copper.

20. The method of claim 4, wherein the first composition is orally administered 4-12 hours after the second composition is subcutaneously administered.

21. The method of claim 4, wherein the first composition is orally administered 0-4 hours after the second composition is subcutaneously administered.

22. The method of any one of claims 4-21, wherein the first composition and second composition are each administered at least once within the same 24-hour period.

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