Combination therapy for orthopox infections

Abstract

The addition of a tyrosine kinase inhibitor, including but not limited to imatinib, in a dosage regimen in combination with tecovirimat provides superior results in the treatment of orthopox infections, including monkeypox infections or monkeypox disease. The unexpected results show that the combined administration of imatinib and tecovirimat provides synergistic reduction of monkeypox spread.

Description

[0001] COMBINATION THERAPY

[0002] FOR ORTHOPOX INFECTIONS CROSS REFERENCE TO RELATED APPLICATIONS

[0003] This application claims the benefit of U. S. Provisional Patent Application No.

[0004] 63 / 712,592, filed October 28, 2024.

[0005] FIELD OF THE INVENTION

[0006] Tills invention is in the area of improvement in treating orthopoxvirus infections and diseases thereof, including but not limited to monkeypox.

[0007] BACKGROUND OF THE INVENTION

[0008] Orthopoxviruses are emerging as a critical public health concern due to the potential for spread through a variety of means such as international travel. Orthopoxviruses that infect humans and which belong to the Poxviridae family include variola virus, vaccinia virus, monkeypox virus (MPXV), cowpox virus, Akhmeta virus, and Borealpox (Alaskapox) virus. Except for variola virus, orthopoxviruses are zoonotic infections that can be transmitted person-to-person and cause serious clinical illnesses in a subject. For example, illnesses associated with monkeypox (MPOX) include encephalitis, severe inflammatory response syndrome, respiratory failure, painful head, and neck lymph node swelling with or without associated airway and / or swallowing compromise, extensive dermal disruption during rash phase, and / or other septic syndromes. There are two main genetic clades of MPXV (Clade I and Clade II) which have been historically found in central and west Africa, respectively. An increased number of MPOX cases have recently been reported in the Democratic Republic of Congo (DRC), in which clade I MPXV has been confirmed among tested cases.

[0009] In 2022, a global MPOX (Clade lib ) outbreak led to reports of a multitude of human MPOX cases in countries without historical transmission or prior reports of MPOX. This outbreak highlighted the risk of MPXV spread and potential for sustained local transmission. As of February 2024, over 94,000 MPOX cases had been reported in 117 countries. Prior to tills outbreak, reported MPOX cases were limited in nonendemic areas. In the United States, there were over 32,000 cases were reported during the 2022 MPOX outbreak, while a low mortality rate was observed (<0.2%). Large vaccine campaigns have been utilized to contain the transmission of MPXV. Currently, there are two Food and Drug Administration (FDA)-approved vaccines for Orthopoxvirus infections, including ACAM2000 and Jynneos. ACAM2000 is a replication-competent, live vaccinia vaccine approved for smallpox for adults and children. Jynneos is a replication-deficient, Modified Vaccinia Ankara-Bavarian Nordic [MVA-BN] approved and commercially available for smallpox and MPOX in adults 18 years and older. It is important to note, however, that an effective vaccination of a subject must occur either before or soon after exposure to prevent or reduce disease caused by an Orthopoxvirus infection. Currently, there is no treatment approved by the FDA for MPOX infections.

[0010] Novel therapies for the treatment of orthopoxvirus infections are therefore urgently needed.

[0011] SUMMARY OF THE INVENTION

[0012] It has been surprisingly and unexpectedly discovered that the combination of a tyrosine kinase inhibitor, including but not limited to imatinib, or pharmaceutically acceptable salt thereof, and tecovirimat, or a pharmaceutically acceptable salt thereof, is particularly effective at preventing or treating an orthopoxvirus infection in a subject in need thereof. For example, and as described herein, increasing amounts of GLEEVEC® and tecovirimat resulted in a dosedependent decrease in plaque formation (see, e.g., FIG. 3 of Example 2) and comet formation (see, e.g., FIG. 4 of Example 2) in BHK cells infected with Clade 1 MPXV-761. Unexpectedly, imatinib in combination with tecovirimat synergistically inhibited MPOX viral spread in these MPXV-infected cells in vitro (see, e.g., FIGs. 6A-6B of Example 3). These findings have led to a randomized, placebo-controlled, 2 2 factorial, double-blind study to test GLEEVEC® monotherapy, TPOXX® monotherapy, or GLEEVEC® + TPOXX® combination therapy for the treatment of human adults and children with laboratory-confirmed MPOX disease (see, e.g., FIG. 2, Example 2).

[0013] Tills improvement provides a significant advance in the state of the art of pox viral treatments.

[0014] In one aspect, provided herein is a method for preventing or treating an orthopoxvirus infection in a subject in need thereof, comprising administering to the subject (a) a therapeutically effective amount of a tyrosine kinase (TK) inhibitor, and (b) a therapeutically effective amount of tecovirimat, or a pharmaceutically acceptable salt thereof. In some embodiments, the orthopoxvirus is selected from a variola virus, a vaccinia virus, a monkeypox virus (MPXV), a cowpox virus, an Akhmeta virus, or a Borealpox (Alaskapox) virus.

[0015] In some embodiments, the orthopoxvirus infection comprises a monkeypox (MPOX) infection. In some embodiments, the MPOX infection is caused by an MPXV strain selected from clade 1, clade 2, or clade 3.

[0016] In some embodiments, the TK inhibitor comprises a Src- and / or Abl-family TK inhibitor. In some embodiments, the TK inhibitor is selected from asciminib, bosutinib, dasatinib, imatinib, nilotinib, pazopanib, ponatinib, sunitinib, or a pharmaceutically acceptable salt thereof.

[0017] In some embodiments, the TK inhibitor is imatinib, or a pharmaceutically acceptable salt thereof. In some embodiments, the TK inhibitor is nilotinib, or a pharmaceutically acceptable salt thereof. In some embodiments, the nilotinib salt is nilotinib hydrochloride. In some embodiments, the TK inhibitor is dasatinib, or a pharmaceutically acceptable salt thereof.

[0018] In one aspect, provided herein is a method for preventing or treating an orthopoxvirus infection in a subject in need thereof, wherein the orthopoxvirus infection comprises an MPOX infection, comprising administering to the subject (a) a therapeutically effective amount of a TK inhibitor, wherein the TK inhibitor is imatinib, or a pharmaceutically acceptable salt thereof, and (b) a therapeutically effective amount of tecovirimat, or a pharmaceutically acceptable salt thereof.

[0019] In one aspect, provided herein is a pharmaceutical combination for use in preventing or treating an orthopoxvirus infection in a subject in need thereof, comprising: (a) a therapeutically effective amount of a tyrosine kinase (TK) inhibitor, (b) a therapeutically effective amount of tecovirimat, or a pharmaceutically acceptable salt thereof, and (c) one or more pharmaceutically acceptable carriers or excipients.

[0020] In one aspect, provided herein is a pharmaceutical combination for use in preventing or treating an orthopoxvirus infection in a subject in need thereof, comprising: (a) a therapeutically effective amount of imatinib, or a pharmaceutically acceptable salt thereof, (b) a therapeutically effective amount of tecovirimat, or a pharmaceutically acceptable salt thereof, and (c) one or more pharmaceutically acceptable carriers or excipients.

[0021] A summary of embodiments of the invention is described in further detail below. BRIEF DESCRIPTION OF THE FIGURES

[0022] The accompanying drawings, which are incorporated in and constitute a part of this specification, illustrate certain examples of the present disclosure and together with the description, serve to explain, without limitation, the principles of the disclosure. Like numbers represent the same elements throughout the figures.

[0023] FIG. 1 A shows a Poxvirus life cycle. Reproduced and modified from Reeves PM et al. Disabling poxvirus pathogenesis by inhibition ofAbl-family tyrosine kinases. Nature medicine 11.7:731-739(2005).

[0024] FIG. IB shows actin tails forming on MPXV-infected cell. 3'1'3 cells were infected with MPXV and stained with FITC-phalloidin to visualize actin, pY mAb, and DAPI to visualize DNA. Scale bar represents 5 um. Reproduced and modified from Reeves PM et al. Variola and monkeypox viruses utilize conserved mechanisms of virion motility and release that depend on abl and SRC family tyrosine kinases. Journal of virology 85.1:21-31(2011).

[0025] FIG. 1C shows “Comet” plaque assays show effects of Sprycel on MPXV cell-associated virions (CV) and extracellular virions (EVs), giving a small plaque phenotype and no comets, and GLEEVEC® on MPXV EVs, which prevents comets but does not reduce plaque size. Reproduced and modified from Reeves PM et al. Variola and monkeypox viruses utilize conserved mechanisms of virion motility and release that depend on abl and SRC family tyrosine kinases. Journal of virology 85.1:21-31(2011).

[0026] FIG. ID shows GLEEVEC® limits in vivo spread following IN infection with Luc-W. Reproduced and modified from Reeves PM et al. Variola and monkeypox viruses utilize conserved mechanisms of virion motility and release that depend on abl and SRC family tyrosine kinases. Journal of virology 85.1:21-31(2011).

[0027] FIG. 2 shows Study Design of the trial described in Example 2 herein.

[0028] FIG. 3 shows a Plaque formation assay of GLEEVEC® and Tecovirimat alone or in combination as described in Example 2.

[0029] FIG. 4 shows a Comet plaque assay of GLEEVEC® and Tecovirimat alone or in combination as described in Example 2.

[0030] FIG. 5A shows a Comet plaque assay of GLEEVEC® and Tecovirimat (TPOXX®) alone as described in Example 3.

[0031] FIG. 5B shows a Comet plaque assay of GLEEVEC® and Tecovirimat (TPOXX®) in combination as described in Example 3.

[0032] FIG. 6A shows a Comet plaque assay of Imatinib and Tecovirimat (TPOXX®) alone as described in Example 3. FIG. 6B shows a Comet plaque assay of Imatinib and Tecovirimat (TPOXX®) in combination as described in Example 3.

[0033] DETAILED DESCRIPTION

[0034] The following description of the disclosure is provided as an enabling teaching of the disclosure in its best, currently known embodiment(s). To this end, those skilled in the relevant ait will recognize and appreciate that many changes can be made to the various embodiments of the invention described herein, while still obtaining the beneficial results of the present disclosure. It will also be apparent that some of the desired benefits of the present disclosure can be obtained by selecting some of the features of the present disclosure without utilizing other features. Accordingly, those who work in the art will recognize that many modifications and adaptations to the present disclosure are possible and can even be desirable in certain circumstances and are a part of the present disclosure. Thus, the following description is provided as illustrative of the principles of the present disclosure and not in limitation thereof.

[0035] Reference will now be made in detail to the embodiments of the invention, examples of which are illustrated in the drawings and the examples. This invention may, however, be embodied in many different forms and should not be construed as limited to the embodiments set forth herein.

[0036] Definitions

[0037] Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood to one of ordinary skill in the art to which this disclosure belongs. The term “comprising” and variations thereof as used herein is used synonymously with the term “including” and variations thereof and are open, non-limiting terms. Although the terms “comprising” and “including” have been used herein to describe various embodiments, the terms “consisting essentially of” and “consisting of’ can be used in place of “comprising” and “including” to provide for more specific embodiments and are also disclosed.

[0038] As used in the specification and claims, the singular form “a”, “an”, and “the” include plural references unless the context clearly dictates otherwise. For example, the term “an agent” includes a plurality of agents, including mixtures thereof.

[0039] The terms 'about” and "approximately" are defined as being “close to” as understood by one of ordinary skill in the art. Unless stated otherwise, the term “about” means within 10% (e.g., within 2% or 1 %) of the particular value modified by the term “about.” In a non-limiting embodiment, the terms are defined to be within 10%. In a non-limiting embodiment, the terms are defined to be within 5%. In a non-limiting embodiment, the terms are defined to be within 1%.

[0040] Notwithstanding that the numerical ranges and parameters seting forth the broad scope of the disclosure are approximations, the numerical values 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. Furthermore, when numerical ranges of varying scope are set forth herein, it is contemplated that any combination of these values inclusive of the recited values may be used. Further, ranges can be expressed herein as from “about” one particular value, and / or to “about” another particular value. When such a range is expressed, another aspect includes from the one particular value and / or to the other particular value. Similarly, when values are expressed as approximations, by use of the antecedent “about,” it will be understood that the particular value forms another aspect. It will be further understood that the endpoints of each of the ranges are significant both in relation to the other endpoint, and independently of the other endpoint.

[0041] “Administration" to a subject includes any route of introducing or delivering to a subject an agent. Administration can be carried out by any suitable route, including oral, topical, intravenous, subcutaneous, transcutaneous, transdermai, intramuscular, intra-joint, parenteral, intra-arteriole, intradermal, intraventricular, intracranial, intraperitoneal, intralesional, intranasal, rectal, vaginal, by inhalation, via an implanted reservoir, parenteral (e.g., subcutaneous, intravenous, intramuscular, intra- articular', intra-synovial, intrasternal, intrathecal, intraperitoneal, intrahepatic, intralesional, and intracranial injections or infusion techniques), and the like. "Concurrent administration", "administration in combination", "simultaneous administration" or "administered simultaneously" as used herein, means that the compounds are administered at the same point in time or essentially immediately following one another. In the latter case, the two compounds are administered at times sufficiently close that the results observed are indistinguishable from those achieved when the compounds are administered at the same point in time. "Systemic administration" refers to the introducing or delivering to a subject an agent via a route which introduces or delivers the agent to extensive areas of the subject's body (e.g. greater than 50% of the body), for example through entrance into the circulatory or lymph systems. By contrast, "local administration " refers to the introducing or delivery to a subject an agent via a route which introduces or delivers the agent to the area or area immediately adjacent to the point of administration and does not introduce the agent systemically in a therapeutically significant amount. For example, locally administered agents are easily detectable in the local vicinity of the point of administration but are undetectable or detectable at negligible amounts in distal parts of the subject's body. Administration includes self-administration and the administration by another.

[0042] As used herein, the terms "optionally," "may," and "may optionally" are used interchangeably and are meant to include cases in which the condition occurs as well as cases in which the condition does not occur. Thus, for example, the statement that a formulation "may include an excipient" is meant to include cases in which the formulation includes an excipient as well as cases in which the formulation does not include an excipient.

[0043] As used here, the terms “therapeutic agent,” “beneficial agent,” and “active agent” are used interchangeably herein to refer to a chemical compound or composition that has a beneficial biological effect. Beneficial biological effects include both therapeutic effects, i.e., treatment of a disorder or other undesirable physiological condition, and prophylactic effects, i.e., prevention of a disorder or other undesirable physiological condition. The terms also encompass pharmaceutically acceptable, pharmacologically active derivatives of beneficial agents specifically mentioned herein, including, but not limited to, salts, esters, amides, prodrugs, active metabolites, isomers, fragments, analogs, and the like. When the terms “beneficial agent” or “active agent” are used, then, or when a particular agent is specifically identified, it is to be understood that the term includes the agent per se as well as pharmaceutically acceptable, pharmacologically active salts, esters, amides, prodrugs, conjugates, active metabolites, isomers, fragments, analogs, etc.

[0044] As used herein, the term “preventing” a disorder or unwanted physiological event in a subject refers specifically to the prevention of the occurrence of symptoms and / or their underlying cause, wherein the subject may or may not exhibit heightened susceptibility to the disorder or event.

[0045] As used herein, the terms “treating” or “treatment” of a subject includes the administration of a drug to a subject with the purpose of curing, healing, alleviating, relieving, altering, remedying, ameliorating, improving, stabilizing or affecting a disease or disorder, or a symptom of a disease or disorder. The terms “treating” and “treatment” can also refer to reduction in severity and / or frequency of symptoms, elimination of symptoms and / or underlying cause, prevention of the occurrence of symptoms and / or their underlying cause, and improvement or remediation of damage.

[0046] By the term “effective amount” of a therapeutic agent is meant a nontoxic but sufficient amount of a beneficial agent to provide the desired effect. The amount of beneficial agent that is “effective” will vary from subject to subject, depending on the age and general condition of the subject, the particular beneficial agent or agents, and the like. Thus, it is not always possible to specify an exact “effective amount”. However, an appropriate “effective’ amount in any subject case may be determined by one of ordinary skill in the art using routine experimentation. Also, as used herein, and unless specifically stated otherwise, an “effective amount” of a beneficial can also refer to an amount covering both therapeutically effective amounts and prophylactically effective amounts.

[0047] An “effective amount” of a drug necessary to achieve a therapeutic effect may vary according to factors such as the age, sex, and weight of the subject. Dosage regimens can be adjusted to provide the optimum therapeutic response. For example, several divided doses may be administered daily or the dose may be proportionally reduced as indicated by the exigencies of the therapeutic situation.

[0048] As used herein, a “therapeutically effective amount” of a therapeutic agent refers to an amount that is effective to achieve a desired therapeutic result, and a “prophylactically effective amount” of a therapeutic agent refers to an amount that is effective to prevent an unwanted physiological condition. Therapeutically effective and prophylactically effective amounts of a given therapeutic agent will typically vary with respect to factors such as the type and severity of the disorder or disease being treated and the age, gender, and weight of the subject. The term “therapeutically effective amount" can also refer to an amount of a therapeutic agent, or a rate of delivery of a therapeutic agent (e.g., amount over time), effective to facilitate a desired therapeutic effect. The precise desired therapeutic effect will vary according to the condition to be treated, the tolerance of the subject, the drug and / or drug formulation to be administered (e.g., the potency of the therapeutic agent (drug), the concentration of drug in the formulation, and the like), and a variety of other factors that are appreciated by those of ordinary skill in the art.

[0049] As used herein, the term “pharmaceutically acceptable” component can refer to a component that is not biologically or otherwise undesirable, i.e., the component may be incorporated into a pharmaceutical formulation of the invention and administered to a subject as described herein without causing any significant undesirable biological effects or interacting in a deleterious manner with any of the other components of the formulation in which it is contained. When the term “pharmaceutically acceptable" is used to refer to an excipient, it is generally implied that the component has met the required standards of toxicological and manufacturing testing or that it is included on the Inactive Ingredient Guide prepared by the U. S. Food and Drug Administration.

[0050] "Pharmaceutically acceptable carrier" (sometimes referred to as a "carrier") means a carrier or excipient that is useful in preparing a pharmaceutical or therapeutic composition that is generally safe and non-toxic and includes a carrier that is acceptable for veterinary and / or human pharmaceutical or therapeutic use. 'The terms "carrier" or "pharmaceutically acceptable carrier" can include, but are not limited to, phosphate buffered saline solution, water, emulsions (such as an oil / water or water / oil emulsion) and / or various types of wetting agents. As used herein, the term "carrier" encompasses, but is not limited to, any excipient, diluent, filler, salt, buffer, stabilizer, solubilizer, lipid, stabilizer, or other material well known in the ait for use in pharmaceutical formulations and as described further herein.

[0051] As used herein, “pharmaceutically acceptable salt” is a derivative of the disclosed compound in which the parent compound is modified by making inorganic and organic, nontoxic, acid or base addition salts thereof. The salts of the present compounds can be synthesized from a parent compound that contains a basic or acidic moiety by conventional chemical methods. Generally, such salts can be prepared by reacting free acid forms of these compounds with a stoichiometric amount of the appropriate base (such as Na, Ca, Mg, or K hydroxide, carbonate, bicarbonate, or the like), or by reacting free base forms of these compounds with a stoichiometric amount of the appropriate acid. Such reactions are typically carried out in water or in an organic solvent, or in a mixture of the two. Generally, non-aqueous media like ether, ethyl acetate, ethanol, isopropanol, or acetonitrile are typical, where practicable. Salts of the present compounds further include solvates of the compounds and of the compound salts.

[0052] Examples of pharmaceutically acceptable salts include, but are not limited to, mineral or organic acid salts of basic residues such as amines; alkali or organic salts of acidic residues such as carboxylic acids; and the like. The pharmaceutically acceptable salts include die conventional non-toxic salts and the quaternary ammonium salts of the parent compound formed, for example, from non-toxic inorganic or organic acids. For example, conventional non-toxic acid salts include those derived from inorganic acids such as hydrochloric, hydrobromic, sulfuric, sulfamic, phosphoric, nitric and the like; and the salts prepared from organic acids such as acetic, propionic, succinic, glycolic, stearic, lactic, malic, tartaric, citric, ascorbic, palmoic, maleic, hydroxymaleic, phenylacetic, glutamic, benzoic, salicylic, mesylic, esylic, besylic, sulfanilic, 2-acetoxybenzoic, fumaric, toluenesulfonic, methanesulfonic, ethane disulfonic, oxalic, isethionic, H00C-(CH2)n- COOH where n is 0-4, and the like, or using a different acid that produces the same counterion. Lists of additional suitable salts may be found, e.g., in Remington's Pharmaceutical Sciences, 17th ed., Mack Publishing Company, Easton, Pa., p. 1418 (1985).

[0053] Also, as used herein, the term “pharmacologically active” (or simply “active”), as in a “pharmacologically active” derivative or analog, can refer to a derivative or analog (e.g., a salt, ester, amide, conjugate, metabolite, isomer, fragment, etc.) having the same type of pharmacological activity as the parent compound and approximately equivalent in degree.

[0054] As used herein, the term “subject” or “host” can refer to living organisms such as mammals, including, but not limited to humans, livestock, dogs, cats, and other mammals. Administration of the therapeutic agents can be carried out at dosages and for periods of time effective for treatment of a subject. In some embodiments, the subject is a human.

[0055] As used herein, the term “composition” 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. References in the specification and concluding claims to parts by weight of a particular element or component in a composition denotes the weight relationship between the element or component and any other elements or components in the composition or article for which a part by weight is expressed. Thus, in a mixture containing 2 parts by weight of component X and 5 parts by weight component Y, X and Y are present at a weight ratio of 2:5, and are present in such ratio regardless of whether additional components are contained in the mixture.

[0056] A weight percent (wt.%) of a component, unless specifically stated to the contrary, is based on the total weight of the formulation or composition in which the component is included.

[0057] The term “increased” or “increase” as used herein generally means an increase by a statically significant amount; for the avoidance of any doubt, “increased” means an increase of at least 10% as compared to a reference level, for example an increase of at least about 20%, or at least about 30%, or at least about 40%, or at least about 50%, or at least about 60%, or at least about 70%, or at least about 80%, or at least about 90% or up to and including a 100% increase or any increase between 10-100%’ as compared to a reference level, or at least about a 2-fold, or at least about a 3-fold, or at least about a 4-fold, or at least about a 5-fold or at least about a 10-fold increase, or any increase between 2-fold and 10-fold or greater as compared to a reference level.

[0058] The term “reduced”, “reduce”, “reduction”, or “decrease” as used herein generally means a decrease by a statistically significant amount. However, for avoidance of doubt, “reduced” means a decrease by at least 10% as compared to a reference level, for example a decrease by at least about 20%’, or at least about 30%, or at least about 40%, or at least about 50%, or at least about 60%, or at least about 70%, or at least about 80%, or at least about 90% or up to and including a 100% decrease (i.e. absent level as compared to a reference sample), or any decrease between 10-100% as compared to a reference level. As used herein, the terns “reduce”, “decrease”, “ablate”, and “eliminate” can be used interchangeably,

[0059] Non-ATP Competitive Tyrosine Kinase Inhibitors

[0060] Protein kinases can be categorized into those that phosphorylate tyrosine residues (tyrosine kinases), those that phosphorylate serine and threonine residues (serine / threomne kinases), and those that phosphorylate all three. In addition, a variety of subclasses of protein kinases are known. Many7tyrosine kinase (TK) families are currently recognized, including Abl, Fes / Fer, Syk / Zap70, Jak, Tec, Fak, Ack, Src, and Csk. Certain TK inhibitors, including the ATP -competitive TK inhibitor STI-571 (also called imatinib mesylate or GLEEVEC®), are useful in the treatment of bacterial and viral infections by binding to the ATP-binding sites of TKs.

[0061] Imatinib

[0062] Imatinib is a small molecule kinase inhibitor that inhibits the BCR-ABL tyrosine kinase, as well as receptor tyrosine kinases for platelet-derived growth factor (PDGF) and stem cell factor (SCF). Imatinib mesylate is designated chemically as 4-[(4-Methyl-1-piperazinyl)methyl]-N-[4-methyl-3-[[4-(3-pyridinyl)-2-pyrimidinyl]amino]-phenyl] benzamide methanesulfonate and its structural formula is:

[0063]

[0064] Imatinib mesylate is a white to off-white to brownish or yellowish tinged crystalline powder. Its molecular formula is C29H31N7O·CH4SO3and its molecular weight is 589,7 g / mol. Imatinib mesylate is soluble in aqueous buffers less than or equal to pH 5.5 but is very slightly soluble to insoluble in neutral / alkaline aqueous buffers. In non-aqueous solvents, the drug substance is freely soluble to very7slightly soluble in dimethyl sulfoxide, methanol, and ethanol, but is insoluble in n-octanol, acetone, and acetonitrile.

[0065] Nilotinib Nilotinib is a small molecule tyrosine kinase inhibitor that inhibits the BCR-ABL tyrosine kinase by binding to and stabilizing the inactive conformation of the kinase domain thereof. Nilotinib ding substance, in the form of monohydrochloride monohydrate, is a white to slightly yellowish to slightly greenish yellow powder with the molecular formula and weight, respectively, of C28H22F3N7O·HCl·H2O and 584 g / mol (the corresponding molecular formula and weight of nilotinib base, anhydrous are C28H22F3N7O and 529 g / mol, respectively). The chemical name of nilotinib monohydrochloride monohydrate is 4-methyl-N-|3-(4-methyl-lH-imidazol- 1 -yl)-5 -(trifhioromethyl)phenyl] -3-[[4-(3 -pyridinyl)-2-pyrimidinyl] amino] -benzamide, monohydrochloride, monohydrate. The structural formula of nilotinib is shown below:

[0066]

[0067] Nilotinib is marketed as TASIGNA® capsules for oral use containing 50 mg, 150 mg, or 200 mg of nilotinib base, anhydrous (equivalent to 55 mg, 166 mg, and 221 mg nilotinib monohydrochloride monohydrate, respectively). TASIGNA® capsules further comprise the inactive ingredients colloidal silicon dioxide, crospovidone, lactose monohydrate, magnesium stearate, and poloxamer 188.

[0068] Dasatinib

[0069] Dasatinib (N-(2 chloro-6-methylphenyl)-2-[[6-[4-(2 -hydroxyethyl)-! -piperazmyl]-2-methyl-4 pyrimidinyl]amino]-5-thiazolecarboxamide, monohydrate) (i.e., SPRYCEL®) is a small molecule tyrosine kinase inhibitor that inhibits several kinases, including BCR-ABL, SRC family kinases (SRC, LCK, YES, FYN). c-KIT, EPHA2, and PDGFRp. The molecular formula of dasatinib is C22H26CIN7O2S • H2O, which corresponds to a formula weight of 506.02 (monohydrate). The anhydrous free base has a molecular weight of 488.01. The structural formula of dasatinib is shown below:

[0070]

[0071] Tecovirimat

[0072] Tecovirimat (i.e., tecovirimat monohydrate, TPOXX®) is an inhibitor of the orthopoxvirus VP37 envelope wrapping protein. Inhibiting VP37 prevents the formation of egress-competent enveloped virions necessary for cell-to-cell and long-range dissemination of virus. The inhibitory activity of tecovirimat is from 600 to several thousand-fold that of cidofovir and similar drugs for treatment various orthopoxvirus species. Effective tecovirimat concentrations which resulted in 50% reduction in virus-induced cytopathic effect (EC50) in cell culture assays were 0.016-0.067pM, 0.014-0.039 pM, 0.015 pM, and 0.009 pM for variola, mpox, rabbitpox, and vaccinia viruses, respectively.

[0073] Tecovirimat is commonly available in both oral capsule and injection vial forms. Tecovirimat TPOXX® capsules for oral administration are immediate release capsules containing tecovirimat monohydrate equivalent to 200 mg of tecovirimat. TPOXX® capsules further comprise the inactive ingredients colloidal silicon dioxide, croscarmellose sodium, hydroxypropyl methyl cellulose, lactose monohydrate, magnesium stearate, microcrystalline cellulose, and sodium lauryl sulfate. All inactive ingredients / excipients are generally recognized as safe and are United States Pharmacopeia / National Formulary grade. In some embodiments, the recommended standard oral dosage of TPOXX® in healthy adults weighing less than 120 kg is 600 mg every 12 hours administered.

[0074] Tecovirimat TPOXX® solution for intravenous injection delivery is a sterile, colorless to pale yellow solution free of visible particles that is diluted prior to administration. Tecovirimat injection is available in a single-dose vial containing 200 mg / 20 mL (10 mg / mL) of tecovirimat and 8,000 mg (400 mg / mL) of Hydroxypropyl Betadex, NF (hydroxypropyl P-cyclodextrin) and Water for Injection, USP / NF. In some embodiments, tecovirimat injection (200 mg / 20 mL) single-dose vial contains tecovirimat monohydrate (unmicronized) equivalent to 200 mg tecovirimat and the excipient HP-P-CD 8000 mg. In some embodiments, tecovirimat injection is diluted with 2 parts 0.9% normal saline or 5% dextrose solution prior to infusion. In some embodiments, the recommended standard intravenous dosage of TPOXX® in healthy adults is 200 mg every 12 hours administered by IV infusion over 6 hours. Tecovirimat monohydrate is a white to off-white crystalline solid with the chemical name Benzamide, N-[(3aR,4R,4aR,5aS,6S,6aS)-3,3a,4,4a,5,5a,6,6a-octahydro-l,3-dioxo-4,6 ethenocycloprop[f]isoindol-2(lH)-yl]-4-(trifluorometbyl), rel -(monohydrate). The chemical formula is CigHisFsbbCh’HzO representing a molecular weight of 394.35 g / mol. The molecular structure of tecovirimat is shown below:

[0075]

[0076] Tecovirimat monohydrate is practically insoluble in water and across the pH range of 2.0-6.5 (< 0.1 mg / mL).

[0077] Pharmaceutical Compositions and Combinations

[0078] In one aspect, provided herein is a pharmaceutical combination for use in preventing or treating an orthopoxvirus infection in a subject in need thereof, comprising: (a) a therapeutically effective amount of a tyrosine kinase (TK) inhibitor, (b) a therapeutically effective amount of tecovirimat, or a pharmaceutically acceptable salt thereof, and (c) one or more pharmaceutically acceptable carriers or excipients.

[0079] In some embodiments, the orthopoxvirus is selected from a variola virus, a vaccinia virus, a monkeypox virus (MPXV), a cowpox virus, an Akhmeta virus, or a Borealpox (Alaskapox) virus.

[0080] In some embodiments, the orthopoxvirus infection comprises a monkeypox (MPOX) infection. In some embodiments, tire MPOX infection is caused by an MPXV strain selected from clade 1, clade 2, or clade 3.

[0081] In some embodiments, the TK inhibitor comprises a Src- and / or Abl-family TK inhibitor. In some embodiments, the TK inhibitor is selected from asciminib, bosutinib, dasatinib, imatinib, nilotinib, pazopanib, ponatinib, sunitinib, or a pharmaceutically acceptable salt thereof.

[0082] In some embodiments, the TK inhibitor is imatinib, or a pharmaceutically acceptable salt thereof. In some embodiments, the TK inhibitor is nilotinib, or a pharmaceutically acceptable salt thereof. In some embodiments, the nilotinib salt is nilotinib hydrochloride.

[0083] In some embodiments, the TK inhibitor is dasatinib, or a pharmaceutically acceptable salt thereof.

[0084] In one aspect, provided herein is a pharmaceutical combination for use in preventing or treating an orthopoxvirus infection in a subject in need thereof, comprising: (a) a therapeutically effective amount of imatinib, or a pharmaceutically acceptable salt thereof, (b) a therapeutically effective amount of tecovirimat, or a pharmaceutically acceptable salt thereof, and (c) one or more pharmaceutically acceptable carriers or excipients.

[0085] In some embodiments, the imatinib salt is imatinib mesylate.

[0086] In one aspect, provided herein is a pharmaceutical combination for use in preventing or treating an orthopoxvirus infection in a subject in need thereof, comprising: (a) a therapeutically effective amount of nilotinib, or a pharmaceutically acceptable salt thereof, (b) a therapeutically effective amount of tecovirimat, or a pharmaceutically acceptable salt thereof, and (c) one or more pharmaceutically acceptable carriers or excipients.

[0087] In some embodiments, the nilotinib salt is nilotinib monohydrochloride monohydrate. In one aspect, provided herein is a pharmaceutical combination for use in preventing or treating an orthopoxvirus infection in a subject in need thereof, comprising: (a) a therapeutically effective amount of dasatinib, or a pharmaceutically acceptable salt thereof, (b) a therapeutically effective amount of tecovirimat, or a pharmaceutically acceptable salt thereof, and (c) one or more pharmaceutically acceptable carriers or excipients.

[0088] In some embodiments, the pharmaceutically acceptable carriers or excipients comprise a liquid, solution, suspension, gel, cream, ointment, implant, explant, slab gel, or coated contact lens.

[0089] A "pharmaceutically acceptable" component can refer to a component that is not biologically or otherwise undesirable, i.e., the component may be incorporated into a pharmaceutical formulation of the invention and administered to a subject as described herein without causing significant undesirable biological effects or interacting in a deleterious manner with any of the other components of the formulation in which it is contained. When used in reference to administration to a human, the term generally implies the component has met the required standards of toxicological and manufacturing testing or that it is included on the Inactive Ingredient Guide prepared by the U. S. Food and Drug Administration.

[0090] As used herein, the term “earner” encompasses any excipient, diluent, filler, salt, buffer, stabilizer, solubilizer, lipid, stabilizer, or other material well known in the art for use in pharmaceutical formulations. The choice of a carrier for use in a composition will depend upon the intended route of administration for the composition. The preparation of pharmaceutically acceptable carriers and formulations containing these materials is described in, e.g., Remington's Pharmaceutical Sciences, 21 st Edition, ed. University of the Sciences in Philadelphia, Lippincott, Williams & Wilkins, Philadelphia, PA, 2005. Examples of physiologically acceptable carriers include saline, glycerol, DMSO, buffers such as phosphate buffers, citrate buffer, and buffers with other organic acids; antioxidants including ascorbic acid; low molecular weight (less than about 10 residues) polypeptides; proteins, such as serum albumin, gelatin, or immunoglobulins; hydrophilic polymers such as polyvinylpyrrolidone; amino acids such as glycine, glutamine, asparagine, arginine or lysine; monosaccharides, disaccharides, and other carbohydrates including glucose, mannose, or dextrins; chelating agents such as EDTA; sugar alcohols such as mannitol or sorbitol; salt-forming counterions such as sodium; and / or nonionic surfactants such as TWEEN™ (ICI, Inc.; Bridgewater, New Jersey), polyethylene glycol (PEG), and PLURONICS™ (BASF; Florham Park, NJ). To provide for the administration of such dosages for the desired therapeutic treatment, compositions disclosed herein can advantageously comprise between about 0.1% and 99% by weight of the total of one or more of the active compounds based on the weight of the total composition including carrier or diluent.

[0091] The composition of any preceding aspect may be administered in such amounts, time, and route deemed necessary in order to achieve the desired result. The exact amount of the composition of any preceding aspect will vary from subject to subject, depending on the species, age, and general condition of the subject, the severity of the cardiac and / or skeletal muscle disease, the particular composition, its mode of administration, its mode of activity, and the like.

[0092] The composition of any preceding aspect is preferably formulated in dosage unit form for ease of administration and uniformity of dosage. It will be understood, however, that the total daily usage of the composition of any preceding aspect will be decided by the attending physician within the scope of sound medical judgment. The specific therapeutically effective dose level for any particular subject will depend upon a variety of factors including the cardiac and / or skeletal muscle disease being treated and the severity of the symptoms; the activity of the composition employed; the specific composition employed; the age, body weight, general health, sex and diet of the patient; the time of administration, route of administration, and rate of excretion of tire specific composition employed; the duration of the treatment; drugs used in combination or coincidental with the specific composition employed; and like factors well known in the medical arts.

[0093] The composition of any preceding aspect may be administered by any route. In some embodiments, the composition of any preceding aspect is administered via a variety of routes, including oral, intravenous, intramuscular, intra-arterial, intramedullary, intrathecal, subcutaneous, intraventricular, transdermal, interdermal, rectal, intravaginal, intraperitoneal, topical (as by powders, ointments, creams, and / or drops), mucosal, nasal, buccal, enteral, sublingual; by intratracheal instillation, bronchial instillation, and / or inhalation; and / or as an oral spray, nasal spray, and / or aerosol. In general, the most appropriate route of administration will depend upon a variety of factors including the nature of the composition (e.g., its stability in the environment of the subject’s body), the condition of the subject (e.g., whether the subject is able to tolerate the chosen route of administration), etc.

[0094] The exact amount of the composition of any preceding aspect required to achieve a therapeutically effective amount will vary from subject to subject, depending on species, age, and general condition of a subject, severity of the side effects, identity of the particular compound(s), mode of administration, and the like. The amount to be administered to, for example, a child or an adolescent can be determined by a medical practitioner or person skilled in the art and can be lower or the same as that administered to an adult. In some embodiments, the composition of any preceding aspect is administered 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, or more times.

[0095] In some embodiments, the composition of any preceding aspect is administered every day, every 2 days, every 3 days, every 4 days, every 5 days, every 6 days, every 7 days, or more. In some embodiments, the composition of any preceding aspect is administered every week, every 2 weeks, every 3 weeks, every 4 weeks, or more. In some embodiments, the composition of any preceding aspect is administered every month, every 2 months, every 3 months, every 4 months, every 5 months, every 6 months, every 7 months, every 8 months, every 9 months, every 10 months, every 11 months, every 12 months, or more. In some embodiments, the composition of any preceding aspect is administered every year, every 2 years, every 3 years, every 4 years, every 5 years, or more.

[0096] In some embodiments, the composition of any preceding aspect is administered at least once daily. In some embodiments, the composition of any preceding aspect is administered at least twice daily. In some embodiments, the composition of any preceding aspect is administered daily, weekly, monthly, bimonthly, quarterly, semiannually, annually, or as needed for the subject. In some embodiments, the composition of any preceding aspect is administered every other day, five times per week, four times per week, three times per week, two times per week, once daily, twice daily, one to four times daily, continuously, or as frequently or infrequently as needed for the subject. In some embodiments, the composition of any preceding aspect is administered acutely or chronically.

[0097] Methods

[0098] In one aspect, provided herein is a method for preventing or treating an orthopoxvirus infection in a subject in need thereof, comprising administering to the subject (a) a therapeutically effective amount of a tyrosine kinase (TK) inhibitor, and (b) a therapeutically effective amount of tecovirimat, or a pharmaceutically acceptable salt thereof.

[0099] In some embodiments, the orthopoxvirus is selected from a variola virus, a vaccinia virus, a monkeypox virus (MPXV), a cowpox virus, an Akhmeta virus, or a Borealpox (Alaskapox) virus.

[0100] In some embodiments, the orthopoxvirus infection comprises a monkeypox (MPOX) infection. In some embodiments, the MPOX infection is caused by an MPXV strain selected from clade 1, clade 2, or clade 3.

[0101] In some embodiments, the TK inhibitor comprises a Src- and / or Abl-family TK inhibitor. In some embodiments, the TK inhibitor is selected from asciminib, bosutinib, dasatinib, imatinib, nilotinib, pazopanib, ponatinib, sunitinib, or a pharmaceutically acceptable salt thereof.

[0102] In some embodiments, the TK inhibitor is imatinib, or a pharmaceutically acceptable salt thereof.

[0103] In some embodiments, the TK inhibitor is dasatinib, or a pharmaceutically acceptable salt thereof.

[0104] In some embodiments, the TK inhibitor is nilotinib, or a pharmaceutically acceptable salt thereof. In some embodiments, the nilotinib salt is nilotinib hydrochloride.

[0105] In some embodiments, the TK inhibitor and tecovirimat are administered to the subject for 14 days or more.

[0106] In one aspect, provided herein is a method for preventing or treating an orthopoxvirus infection in a subject in need thereof, wherein the orthopoxvirus infection comprises an MPOX infection, comprising administering to the subject (a) a therapeutically effective amount of a TK inhibitor, wherein the TK inhibitor is imatinib, or a pharmaceutically acceptable salt thereof, and (b) a therapeutically effective amount of tecovirimat, or a pharmaceutically acceptable salt thereof.

[0107] In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered to the subject at a lower dose relative to a standard dose if the subject has access to a high fat diet. In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered to the subject at a standard dose if the subject does not have access to a high fat diet.

[0108] In one aspect, provided herein is a method for preventing or treating an orthopoxvirus infection in a subject in need thereof, wherein the orthopoxvirus infection comprises an MPOX infection, comprising administering to the subject: (a) a reduced amount relative to a standard dose of imatinib, or a pharmaceutically acceptable salt thereof, (b) a therapeutically effective amount of tecovirimat, or a pharmaceutically acceptable salt thereof, and (c) one or more pharmaceutically acceptable carriers or excipients; wherein the subject is maintained on a high fat diet during the method of prevention or treatment.

[0109] In some embodiments, the tecovirimat and / or combination of tecovirimat and TK inhibitor are administered within about 30 minutes before or after a full meal containing moderate or high fat, for example, within about 25 minutes, within about 20 minutes, within about 15 minutes, within about 10 minutes, within about 5 minutes, or less, after a full meal containing moderate or high fat. In some embodiments, the tecovirimat and / or combination of tecovirimat and TK inhibitor are administered within about 30 minutes after a full meal containing moderate or high fat.

[0110] In one aspect, provided herein is a method for preventing or treating an orthopoxvirus infection in a subject in need thereof, wherein the orthopoxvirus infection comprises an MPOX infection, comprising administering to the subject: (a) a standard dose of imatinib, or a pharmaceutically acceptable salt thereof, (b) a therapeutically effective amount of tecovirimat, or a pharmaceutically acceptable salt thereof, and (c) one or more pharmaceutically acceptable carriers or excipients; wherein the subject does not have access to a high fat diet during the method of prevention or treatment.

[0111] In some embodiments, the MPOX infection is caused by an MPXV strain selected from clade 1, clade 2, or clade 3.

[0112] In some embodiments, the imatinib, or a pharmaceutically acceptable salt thereof, is administered to the subject at a dose of between about 25 mg and about 1000 mg. In some embodiments, the imatinib, or a pharmaceutically acceptable salt thereof, is administered to the subject at a dose of between about 100 mg to about 750 mg, between about 250 mg to about 500 mg, between about 25 mg to about 500 mg, between about 50 mg to about 250 mg, between about 250 mg to about 1000 mg, or between about 500 mg to about 750 mg. In some embodiments, the imatinib, or a pharmaceutically acceptable salt thereof, is administered to the subject at a dose of between about 400 mg and about 600 mg. In some embodiments, the imatinib, or a pharmaceutically acceptable salt thereof, is administered to the subject at a dose of about 400 mg.

[0113] In some embodiments, the imatinib, or a pharmaceutically acceptable salt thereof, is administered to the subject at a dose of about 600 mg.

[0114] In some embodiments, the imatinib, or a pharmaceutically acceptable salt thereof, is administered to the subject at least once per day. In some embodiments, the imatinib, or a pharmaceutically acceptable salt thereof, is administered to the subject at least twice per day.

[0115] In some embodiments, the imatinib, or a pharmaceutically acceptable salt thereof, is administered to the subject orally.

[0116] In some embodiments, the imatinib salt is imatinib mesylate.

[0117] In one aspect, provided herein is a method for preventing or treating an orthopoxvirus infection in a subject in need thereof, wherein the orthopoxvirus infection comprises an MPOX infection, comprising administering to the subject (a) a therapeutically effective amount of a I’K inhibitor, wherein the TK inhibitor is nilotinib, or a pharmaceutically acceptable salt thereof, and (b) a therapeutically effective amount of tecovirimat, or a pharmaceutically acceptable salt thereof.

[0118] In some embodiments, the total daily dose of nilotinib, or pharmaceutically acceptable salt thereof, can be adjusted to the needs of the patients depending, in particular on the disease to be treated and the disease status of the patient under treatment, but will not exceed a total daily dose of 800 mg. In some embodiments, the nilotinib, or a pharmaceutically acceptable salt thereof, is administered to the subject at a dose of between about 25 mg and about 800 mg. In some embodiments, the imatinib, or a pharmaceutically acceptable salt thereof, is administered to the subject at a dose of between about 100 mg to about 750 mg, between about 250 mg to about 500 mg, between about 25 mg to about 500 mg, between about 50 mg to about 250 mg, between about 250 mg to about 800 mg, or between about 500 mg to about 800 mg. In some embodiments, the nilotinib, or a pharmaceutically acceptable salt thereof, is administered to the subject at a dose of between about 25 mg and about 250 mg. In some embodiments, the nilotinib, or a pharmaceutically acceptable salt thereof, is administered to the subject at a dose of about 50 mg, about 150 mg, or about 200 mg. In some embodiments, the nilotinib, or a pharmaceutically acceptable salt thereof, is administered to the subject at a dose of about 50 mg. In some embodiments, the nilotinib, or a pharmaceutically acceptable salt thereof, is administered to the subject at a dose of about 10 mg. In some embodiments, the nilotinib, or a pharmaceutically acceptable salt thereof, is administered to the subject at a dose of about 200 mg.

[0119] In one aspect, provided herein is a method for preventing or treating an orthopoxvirus infection in a subject in need thereof, wherein the orthopoxvirus infection comprises an MPOX infection, comprising administering to the subject: (a) a therapeutically effective amount of dasatinib, or a pharmaceutically acceptable salt thereof, (b) a therapeutically effective amount of tecovirimat, or a pharmaceutically acceptable salt thereof, and (c) one or more pharmaceutically acceptable carriers or excipients.

[0120] In some embodiments, the total daily dose of dasatinib, or pharmaceutically acceptable salt thereof, can be adjusted to the needs of the patients depending, in particular on the disease to be treated and the disease status of the patient under treatment, but will not exceed a total daily dose of 1000 mg. In some embodiments, the dasatinib, or a pharmaceutically acceptable salt thereof, is administered to the subject at a dose of between about 5 mg and about 1000 mg. In some embodiments, the imatinib, or a pharmaceutically acceptable salt thereof, is administered to the subject at a dose of between about 50 mg to about 600 mg, between about 100 mg to about 900 mg, between about 20 mg to about 150 mg, between about 50 mg to about 250 mg, between about 250 mg to about 1000 mg, or between about 500 mg to about 1000 mg. In some embodiments, the imatinib, or a pharmaceutically acceptable salt thereof, is administered to the subject at a dose of between about 20 mg and about 180 mg. In some embodiments, the imatinib, or a pharmaceutically acceptable salt thereof, is administered to the subject at a dose of about 20 mg, about 40 mg, about 50 mg, about 70 mg, about 80 mg, about 100 mg, about 140 mg, or about 180 mg. In some embodiments, the imatinib, or a pharmaceutically acceptable salt thereof, is administered to the subject at a dose of about 100 mg. In some embodiments, the imatinib, or a pharmaceutically acceptable salt thereof, is administered to the subject once daily at a dose of about 50 mg. In some embodiments, the imatinib, or a pharmaceutically acceptable salt thereof, is administered to the subject once daily at a dose of about 80 mg. In some embodiments, the imatinib, or a pharmaceutically acceptable salt thereof, is administered to the subject once daily at a dose of about 100 mg. In some embodiments, the imatinib, or a pharmaceutically acceptable salt thereof, is administered to the subject once daily at a dose of about 140 mg. In some embodiments, the imatinib, or a pharmaceutically acceptable salt thereof, is administered to the subject once daily at a dose of about 180 mg. In some embodiments, the imatinib, or a pharmaceutically acceptable salt thereof, is administered to the subject twice daily at a dose of about 50 mg. In some embodiments, the imatinib, or a pharmaceutically acceptable salt thereof, is administered to the subject twice daily at a dose of about 70 mg.

[0121] In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered at a dose of between about 25 mg to about 1000 mg. In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered to the subject at a dose of between about 100 mg to about 750 mg, between about 250 mg to about 500 mg, between about 25 mg to about 500 mg, between about 50 mg to about 250 mg, between about 250 mg to about 1000 mg, or between about 500 mg to about 750 mg. In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 600 mg, about 400 mg, about 300 mg, about 200 mg, or about 100 mg.

[0122] In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered to the subject at least once per day. In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered to the subject at least twice per day. In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered to the subject at least three times per day.

[0123] In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered to the subject orally or intravenously.

[0124] In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered to the subject orally. In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered to the subject orally at a dose of about 600 mg every 12 hours. In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered to the subject orally. In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered to the subject orally at a dose of about 600 mg every 8 hours. In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered to the subject orally. In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered to the subject orally at a dose of about 400 mg every 12 hours. In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered to the subject orally at a dose of about 300 mg every 12 hours. In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered to the subject orally. In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered to the subject orally at a dose of about 200 mg every 12 hours. In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered to the subject by intravenous infusion. In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered to the subject by intravenous infusion over about 6 hours at a dose of about 6 mg / kg every 12 hours. In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered to the subject by intravenous infusion over about 6 hours at a dose of about 200 mg every 12 hours. In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered to the subject by intravenous infusion over about 6 hours at a dose of about 300 mg every 12 hours.

[0125] In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, is administered to the subject for 14 days or more.

[0126] In some embodiments, the tecovirimat, or a pharmaceutically acceptable salt thereof, when administered in combination with a TK inhibitor as disclosed herein, is administered at a dose lower than the standard of care.

[0127] In some embodiments, the tecovirimat salt is tecovirimat monohydrate.

[0128] In some embodiments, the method reduces orthopoxvirus viral titer, increases or stimulates orthopoxvirus viral clearance, reduces or inhibits orthopoxvirus viral proliferation, reduces the amount of an orthopoxvirus viral protein or the amount of an orthopoxvirus viral nucleic acid, or reduces or inhibits synthesis of an orthopoxvirus viral protein or an orthopoxvirus viral nucleic acid, or a combination thereof.

[0129] In some embodiments, the method reduces one or more adverse physiological conditions, disorders, illness, diseases, symptoms or complications caused by or associated with orthopoxvirus infection or disease pathology.

[0130] In some embodiments, the method of any preceding aspect or embodiment described herein reduces or limits disfigurement and / or internal organ damage.

[0131] In some embodiments, the method improves one or more adverse physiological conditions, disorders, illness, diseases, symptoms, or complications caused by or associated with orthopoxvirus infection or disease pathology.

[0132] In some embodiments, the symptoms are selected from fever, chills, headache, body aches, swollen lymph nodes, exhaustion, rash, or a combination thereof.

[0133] In some embodiments, the TK inhibitor and tecovirimat are administered prior to, concurrently with, or following exposure of the subject to the orthopoxvirus or infection of the subject with the orthopoxvirus. In some embodiments, the TK inhibitor and tecovirimat are administered prior to exposure of the subject to orthopoxvirus or infection of the subject with orthopoxvirus.

[0134] In some embodiments, the TK inhibitor and tecovirimat are administered following exposure of the subject to orthopoxvirus or infection of the subject with orthopoxvirus.

[0135] In some embodiments, the orthopoxvirus is an MPXV.

[0136] In some embodiments, the TK inhibitor and tecovirimat are administered within 2-72 hours, 2-48 hours, 4-24 hours, 4-18 hours, or 6-12 hours following a symptom of orthopoxvirus infection or exposure develops.

[0137] In some embodiments, the subject has laboratory-confirmed MPOX disease. Methods of confirming MPOX infection and / or disease are known to those of skill in the art. For example, MPOX disease may be diagnosed by PCR obtained from blood oropharynx or a skin lesion that develops within 48 hours of screening.

[0138] In some embodiments, the MPOX infection is an early-stage infection.

[0139] In some embodiments, the subject is at risk for severe disease. In some embodiments, the subject at risk for severe disease comprises an HIV-positive (HIV+) subject.

[0140] In some embodiments, the method of any preceding aspect or embodiment described herein is used as a prophylactic to protect a subject at risk of exposure but cannot be vaccinated. In some embodiments, the unvaccinatable subject at risk of exposure comprises a subject ha ving eczema.

[0141] In some embodiments, the methods of any preceding aspects or embodiments are used for preventing, mitigating, or treating complications from prior vaccine treatments.

[0142] In some embodiments, the subject is a human. In some embodiments, the subject is a child. In some embodiments, the subject is an adult.

[0143] EXAMPLES

[0144] The following examples are set forth below to illustrate the compositions, devices, methods, and results according to the disclosed subject matter. These examples are not intended to be inclusive of all aspects of the subject matter disclosed herein, but rather to illustrate representative methods and results. These examples are not intended to exclude equivalents and variations of the present invention which are apparent to one skilled in the art.

[0145] Example 1. Imatinib and Tecovirimat Combinations for Treating Orthopoxvirus Infections Orthopoxviruses, including monkeypox (MPXV), variola (the cause of smallpox), and the vaccinating strain vaccinia (VV), spread between cells and through tissues. Poxviruses enter mammalian cells, replicate extra-nuclearly, produce intracellular' virions (TVs) that travel along microtubules to the cell surface where they acquire additional membranes upon fusion with the plasma membrane, called cell-associated virions (CVs) (FIG. 1A).

[0146] Once outside the cell, CVs egress towards apposing cells by stimulating formation of actin-filled membranous protrusions, called "tails," that mediate intercellular spread within tissues. It was previously shown that CVs utilize Abl- and Src-family tyrosine kinases (TKs) to phosphorylate viral and cellular factors that initiate actin polymerization. Notably, tail formation is blocked by Abl- and Src-family kinase inhibitors (e.g., Sprycel). Release of CVs to form extracellular virions (EVs) is thought to mediate longer range spread within or between tissues and requires Abl- but not Src-family TKs. EV release is blocked by GLEEVEC®, an Abl-family TK inhibitor used to treat chronic myelogenous leukemia (CML) in humans. Known TK targets include cellular proteins, as well as viral factors such as A36, which scaffolds TKs and signaling factors (Nek, N-WASP) that activate Arp2 / 3 to catalyze actin polymerization. A comprehensive understanding of the tyrosine phosphorylation networks that control CV tails or EV release remains incomplete. Although death of infected cells releases IV, these are readily recognized and cleared by immune cells, while CVs and EVs have limited antigenicity and thus mediate intercellular and inter-tissue spread to disseminate infection, a major contributor to poxvirus morbidity. Thus, dissemination is an important target for drug development.

[0147] GLEEVEC® reduced viral dissemination in a low-inoculum mouse model by five orders of magnitude, and promoted survival from an otherwise lethal infection, all without impacting acquisition of immunity. GLEEVEC® was less effective at controlling viral spread in models that utilize high inoculums and generate disseminated infection, including high inoculum i.n.-VV infections in mice and i.v.-MPXV infections in prairie dogs and primates (Sprycel was ineffective because it blocks essential T / B cell functions). Thus, while not wishing to be bound by any one theory, GLEEVEC® is capable of being used as a prophylactic or in treating early stage MPXV infections, or in treating complications associated with vaccination (e.g., eczema vaccinatum), but drugging additional targets to fully suppress viral dissemination may increase its utility against disseminated disease.

[0148] Signaling pathways mediating pox virus dissemination and identify novel therapeutic targets are systematically characterized as follows. Mapping TK tyrosine phosphorylation sites following VV and MPXV infections Agnostic mass spectroscopy (MS) techniques are utilized in conjunction with kinase-deficient cell lines and TK inhibitors to map the TK phosphorylation sites on cellular and viral proteins induced by infection with VV and MPXV.

[0149] Investigate Cellular- and Viral-Protein Mediated Dissemination of Viruses Based on tyrosine phosphoproteonie mapping, the involvement of identified cellular and viral proteins mediating dissemination is tested using viruses containing Y-to-F phosphorylation site mutations and drugs targeting newly identified cellular pathways.

[0150] The poxvirus problem:

[0151] The rise of human transmissible MPXV infections raises the possibility of a new endemic poxvirus in humans. MPXV is not as deadly as variola, except in the immune-compromised, the malnourished, and in fetuses; however, like variola it causes disfigurement. With variola, infection of the nasopharyngeal mucosa and lungs is followed by dissemination to lymph nodes, spleen, marrow and other lymph nodes, and finally systemic dissemination. Virions in sebaceous glands of the skin cause the characteristic "pox." Death results from disseminated intravascular coagulation, hypotension, and cardiovascular collapse. VV-based vaccines are not without issues; individuals with acquired or congenital immunocompromising conditions are at risk for complications including encephalitis, fetal VV, and eczema vaccinatum. DNA polymerase inhibitors such as Cidofovir and its derivatives don't work on MPXV and / or exhibit high renal toxicity.

[0152] Results suggest that anti-cancer diugs such as GLEEVEC®, which are FDA-approved for CML, limit spread in low inoculum infections, and may be effective as prophylactics or in early-stage infections or for complications from vaccines. Safe and more efficacious drugs that limit spread are therefore mandated.

[0153] Contribution of TKs, actin motility, and EV release to viral dissemination

[0154] Viral and cellular phosphoproteins that mediate C V actin motility and EV release are identified, and in so doing identify druggable targets that limit viral dissemination. It was shown that poxviruses including MPXV, variola, and VV use Src and Abl-family kinases for CV actin motility and Abl-family TKs only to release CVs and form EVs (FIG. IB). Accordingly, the Abl-family TK inhibitor GLEEVEC® prevents EV release, and the Src / Abl inhibitor Sprycel prevents actin motility. GLEEVEC® limits VV dissemination in vivo (e.g. FIG. ID), and prevents death from an otherwise lethal infection, without impacting acquisition of immunity. These data suggest a role for CV actin motility and EVs in pathogenesis in vivo. Accordingly, deletion (or mutation of Y phosphorylation sites) in A36, a Src and Abl target, abolishes actin motility in vitro, reduces EVs, and attenuates pathogenesis in vivo. Although less immunogenic than IVs, neutralizing a-EV pAbs do prevent death from an otherwise lethal infection. Thus, EV- (and likely CV)-mediated dissemination is critical for mortality in vivo. However, how CV actin motility and EVs contribute to dissemination and immune evasion is poorly understood. While not wishing to be bound by any one theory, and although results with GLEEVEC® have been extremely promising in low inoculum infections, it may be possible to target other molecules in the pathway to better limit dissemination, in a manner akin to tecovirimat (ST-246) though without the attendant toxicity.

[0155] The overall deliverable is to map phosphotyrosine signaling pathways perturbed by infection with VV and MPXV, and identify specific pathways mediating CV motility and EV release to identify additional targets for FDA approved drugs.

[0156] Mapping the phosphoproteome of poxvirus-infected, cells.

[0157] Methods:

[0158] Protein mass spectroscopy (MS) is used to identify host and viral substrates of TKs modified during poxvirus infection. VV and a clinical MPXV (Clade III) clinical isolate are used. MPXV infection experiments are done. VV WR or IHD-J strains are used to generate mutant viruses or carry out animal infections. MPXV is used only for initial phosphoproteome studies because CV and EV proteins are nearly identical in VV and MPXV, and these viruses behave identically in every CV / EV assay to date. Moreover, protracted manipulation of MPXV using high titre stocks (1011pfu / ml) poses an unacceptable risk, and it is unclear whether recombinant viruses with engineered mutations in MPXV are permissible.

[0159] (1) To assess the phosphoproteome associated with CVs or EVs in VV- or MPXV-infected cells, infected cells grown under several conditions at 6, 12 and 24 hours post infection are harvested, including:

[0160] (i) murine fibroblasts, which form both CVs and EVs;

[0161] (ii) murine fibroblasts lacking Src, Fyn and Yes, and treated with GLEEVEC® (10 pM), which form neither CVs nor EV s;

[0162] (iii) murine fibroblasts treated with Sprycel (10 pM), or ST-246 (10 pM) which, like (ii), form neither CVs nor EVs; (iv) murine fibroblasts lacking Abl-family kinases (Abl and Abl2 (Arg)), or (v) murine fibroblasts treated with GLEEVEC® [conditions (iv) and (v) form only CVs and not EVs];

[0163] (vi) To confirm that fibroblast results are recapitulated in human cells, human lung epithelia or human monocytes are infected with VV or MPXV ± Sprycel or + GLEEVEC® or ± ST-246. Primary human lung epithelial cultures are made available.

[0164] (2) Phosphopeptide mapping and analysis is carried out by digesting cell pellets with trypsin, labeling peptides derived from cells grown in each condition with a specific chemical group that is identifiable and quantifiable by MS / MS (enabling sample multiplexing), and then isolating phosphopeptides by immunoprecipitation with two a-PY antibodies (or with Fe-NTA affinity resin). Recovered p-Y (or p-S / T) peptides is analyzed by MS / MS.

[0165] To isolate the CV- and EV-specific tyrosine phosphoproteome, phosphorylation patterns in cells grown is compared under the above conditions. For example, for EV-specific phosphopeptides, the loss of Y phosphorylation on peptides is examined from cells lacking Abl-family kinases or from GLEEVEC®-treated cells.

[0166] Cellular kinase substrates identified by MS:

[0167] A variety of cellular Abl substrates have been identified including Abl-1, Crkll, Nek and N-WASP. All these proteins localize on the virion and so may be phosphorylated by Abl TKs (e.g. the c-Src substrate cortactin regulates actin dynamics, localizes in tails, and is phosphorylated upon infection).

[0168] Viral substrates: Pox proteins are to be isolated that, when mutated (Y to F), have defects in motility but not EEV release, defects in EEV release but not motility, defects in both motility and release, and defects in motility and release due to specific infectivity or replication defects, and those with no defects in motility or release. A33, A34, A56, FT3, Ell, F12, B5, and A36 all localize in the membrane surrounding the 1EV, CEV, or EEV. Preliminary data suggest that some of these (including A34, Fl 1, and A36) are phosphorylated by in vitro kinase assays with Abl or Src. A pilot MS / MS experiment identified several tyrosine phosphopeptides (pTyr / pY). One was from a viral phosphoprotein, FT3, a known EV component and target of ST-246. Data indicate F13 is indeed a target of Src and Abl-family TKs, because in vitro transcribed / translated Fl 3 was phosphorylatable in ex vivo TK assays, and a-PY western analysis of Fl 3 immunoprecipitated from VV-infected cells showed loss of Y phosphorylation with GLEEVEC®. By pathway analysis, targets of known drugs are identified, which can then be scored for small plaque phenotype, indicative of CV and EV block, or comet loss, indicative of EV block (as in FIG. 1C). Comparisons of global phosphorylation caused by VV and MPXV infections in primary epithelia vs. immune ceils show differences between viruses, and differences in CV / EV spread mechanisms between cell types.

[0169] Effects of viral phosphorylation site mutants on dissemina tion in vit ro.

[0170] Which identified viral proteins are TK targets that mediate spread in vitro are established. Using available antibodies against cellular and viral proteins, Y phosphorylation and sensitivity to drugs is assessed by western analysis. Next, a limited number of recombinant viruses containing Y-to-F mutants (< 5) is generated. Some are available (e.g., in A36R). Plaque and comet assays are carried out to detect effects on plaque size or comets. Alternatively, deletion strains are complemented with plasmids expressing WT or Y-to-F mutant proteins (KO strains are usually readily available by collaboration). Finally, the spread of WT (or mutant) VV strains is assessed using in vitro organ cultures of skin, gut or lung by time lapse microscopy in Incucyte. Cells expressing RFP actin (or recombinant viruses expressing RFP actin) and eGFP-labeled WT or mutant viruses, or ± GLEEVEC® (to block EVs), or ± Sprycel, or + ST-246 (to block CEV and EVs) are used, or other drugs identified in.

[0171] The pattern of dissemination of mutant strains in mice is established (e.g., viral dissemination to ovaries monitored using luciferase expressing virus), or with treatment with a limited number of new drugs (< 3), assessed daily for 12-14 days (e.g., viral load in ovaries), and compare to established data with IHD-J following intranasal inoculation with PFUs of 102to 105, wherein IP inoculation with virus in presence of a drug or combination thereof (e.g., imatinib, imatinib + tecovirimat) blocks transit of virus from peritoneal cavity to ovaries (see, e.g., Figure 6e of Reeves PM et al. Variola and monkeypox viruses utilize conserved mechanisms of virion motility and release that depend on abl and SRC family tyrosine kinases. J Virol. 2011 Jan;85(l ):21-31.' Figure 6b of Reeves PM et al. Disabling poxvirus pathogenesis by inhibition of Abl-family tyrosine kinases. Nat Med. 2005 Jul;ll(7):7 1-9. doi: 10.1038 / nm 12' 65. Epub 2005 Jun 26.). While not wishing to be bound by any one theory, the motility, release, and inoculum influence spread, but these processes may do so in different ways, with actin tails mediating intra-tissue spread and EEV mediating longer range inter-tissue spread in vivo, or by accelerating the rate of spread. A possible extension is to evaluate spread in vivo in the context of neutralizing B / T cells. Thus, how neutralizing T / B cells limit spread is tested: following adoptive transfer of GFP-tagged T and / or B cells derived from a previously vaccinated animal into a naive animal, IHD-J-Luc is infected at different inoculums and monitor viral dissemination (or breakthrough) by imaging GFP and Luciferase. An extension is to transfer T / B cells generated at different times after inoculation, and / or with specific neutralization capacity against IVs or CV / EVs, or, alternatively, neutralizing a-IV or a-CV / EV pAbs. Such experiments may facilitate design of novel vaccines without attendant shortcomings of live poxviruses.

[0172] Conclusion

[0173] Novel signaling pathways mediating viral spread in cultured cells are identified and tested for the involvement of these pathways in vivo. These data allow manipulation of the Y phosphorylation pathways via mutation of host or virus. A planned trial comprises testing whether combination of GLEEVEC® with tecovirimat (ST-246) for the treatment of viral infections. In some embodiments, the tecovirimat is administered at a low dose relative to the standard, recommended dose.

[0174] The detailed characterization of TK signaling pathways is expected to generate data on both the mechanisms by which poxviruses use host TK signaling to spread, but also to identify novel methods and pharmaceutical compositions / combinations for intervention. Poxvirus drugs are woefully inadequate, and the disease (and vaccines) are lethal and / or dangerous in immunocompromised and pregnant individuals.

[0175] A key motivation of this study is to use TK inhibitors for poxviruses and to identify new druggable pathways. Drugs such as GLEEVEC® are FDA approved and generally safe in immunocompromised people (though not pregnant women), and they may be directly testable in humans.

[0176] Example 2. Study to Evaluate the Efficacy of Imatinib mesylate (GLEEVEC®) and Tecovirimat (TPOXX®) in People infected with MPOX

[0177] Imatinib mesylate (GLEEVEC®) vs tecovirimat (TPOXX®) vs the combination for Treatment of MPOX

[0178] This is a randomized, placebo-controlled, 2 x 2 factorial, double-blind study to test GLEEVEC® monotherapy, TPOXX® monotherapy, or GLEEVEC® + TPOXX® combination therapy for the treatment of adults and children with laboratory-confirmed MPOX disease. Approximately 800 eligible and consented participants are randomized 1: 1: 1: 1 to receive either oral GLEEVEC® and placebo to TPOXX®, oral TPOXX® and placebo to GLEEVEC®, both oral GLEEVEC® and TPOXX®, or placebo to each medication (FIG. 2). Study medication is administered in the hospital with standard -of-care (SOC) treatment for 14 days. Participants are followed for 28 days with an optional visit at Day 59 for long-term assessment. Study Design is provided in FIG. 2.

[0179] Inclusion Criteria

[0180] • Laboratory-confirmed MPOX infection as determined by PCR obtained from blood oropharynx, or skin lesion within 48 hours of screening;

[0181] • MPOX illness of any duration provided that the patient has at least one active, not yet scabbed lesion;

[0182] • Weight >3 kg;

[0183] • Men and non-pregnant women of reproductive potential must agree to use effective means of contraception when engaging in sexual activities that can result in pregnancy from the time of enrollment through the end of study participation;

[0184] • Stated willingness to comply with all study procedures (including required inpatient stay) and availability for the duration of the study; and

[0185] • Ability to provide informed consent personally or by a legally or culturally acceptable representative if the patient is unable to do so.

[0186] Exclusion Criteria

[0187] • Current or planned use of a meglitinide (repaglinide, nateglinide);

[0188] • Current or planned use of use of strong C YP3A4 inducers (e.g„ dexamethasone, phenytoin, carbamazepine, rifampin 1 rifabutin, rifampacinl phenobarbital);

[0189] • Planned use of midazolam while on study drug;

[0190] • Severe anemia, defined as hemoglobin <7 g / dl;

[0191] • Current or planned use of another investigational drug at any point during study participation;

[0192] • Patients who, in the judgement of the investigator, are at significantly increased risk as a result of participation in the study; and

[0193] • Participants who are unable to safely swallow oral medications, such as those who are at risk of aspiration.

[0194] Outcome Measures

[0195] Primary: • Time to lesion resolution.

[0196] Key Secondary:

[0197] • Number of participants with negative blood PCR results;

[0198] • Number of participants with negative orophary ngeal swab PCR results;

[0199] • Number of participants with negative lesion swab PCR results;

[0200] • Mortality within the first 28 days post-randomization; and

[0201] • Frequency of solicited clinical symptoms.

[0202] Trial Design Questions

[0203] • How does known natural history inform us about the NIH endpoints and sample size? • Consider a sentinel cohort to evaluate safety (e.g. first 200 participants)

[0204] • Is a TPOXX®-only arm in the context of PALM 007 results needed (see NCT05559099)? • Eligibility criteria

[0205] o Was treatment in PALM 007 too late?

[0206] o Treatment of contacts? Ring trial?

[0207] o Stratify by JYNNEOS vaccination status? How is this accounted for in the sample size?

[0208] • Can data from PALM 007 be obtained for sample calculations?

[0209] Experimental Design

[0210] • BHK cells: Plated at 80% confluency;

[0211] • Infected with 200PFU of MPXV-761;

[0212] • Infection is allowed to be established for 24 hours;

[0213] • Change to media containing imatinib mesylate (GLEEVEC®) at either 0, 0.1, 1.0, 10 pM in DMSO and Tecovirimat (TPOXX®) at either 0, 0.1, 1.0, 10 nM;

[0214] • Return to the incubator and allow plaques and comets to for over 5 days.;

[0215] • % Plaque formation = (number of plaques in untreated / number of plaques in treatment group) x 100; and

[0216] • % comet formation = (number of plaques / number of comets) x 100.

[0217] Plaque formation in response to different concentrations of the combination of GLEEVEC® and TPOXX® is shown in FIG. 3. Comet formation in response to different concentrations of the combination of GLEEVEC® and TPOXX® is shown in FIG. 4. Increasing amounts of GLEEVEC® and tecovirimat resulted in a dose-dependent decrease in plaque formation (see, e.g., FIG. 3 of Example 2) and comet formation (see, e.g., FIG. 4 of Example 2).

[0218] Example 3. Combined administration of Imatinib mesylate (GLEEVEC®) and Tecovirimat (TPOXX®) effects on MPOX spread

[0219] It was analyzed whether combined administration of imatinib and tecovirimat could improve effects on MPOX spread.

[0220] Experimental Design:

[0221] BHK cells were infected with 2.00 PFU of Clade 1 MPXV-761 from 2022. Two (N=2) independent experiments were conducted, with 2-3 replicates / condition. Infection was established for 24 hours, and then imatinib mesylate (GLEEVEC®) was added at 0, 0.1, 1.0, or 10 mM or Tecovirimat (TPOXX®) at 0, 0.1, 1.0, or 10 nM, or combinations thereof. It is noted that mM doses of imatinib mesylate (GLEEVEC®) are necessary in vitro as approximately 95% of drug is bound to serum. Primary plaques and comets were enumerated after ~5 days. The calculation for percent comet formation was calculated as follows:

[0222] % Comet formation = [Number of plaques with comets / Number of plaques] x 100.

[0223] Results

[0224] Treatment with either imatinib mesylate (GLEEVEC®) at 0.1 pM or TPOXX® at 0.1 nM or 1 nM alone does not significantly decrease comet formation (FIG. 5A). Combination treatment with imatinib mesylate (GLEEVEC®) at 0.1 pM and TPOXX® at 0.1 nM or 1 nM does not demonstrate synergistic inhibition of comet formation (FIG. 5B).

[0225] Imatinib mesylate (GLEEVEC®) alone and in combination with TPOXX® demonstrates inhibition of mpox viral spread in vitro (FIG. 6A-6B). Administration of imatinib mesylate (GLEEVEC®) at 1 pM with either 0.1 nM or I nM TPOXX® demonstrated synergy (FIG. 6B).

Claims

CLAIMSWhat is claimed is:

1. A method for preventing or treating an orthopoxvirus infection in a subject in need thereof, comprising administering to the subject (a) a therapeutically effective amount of a tyrosine kinase (TK) inhibitor, and (b) a therapeutically effective amount of tecovirimat, or a pharmaceutically acceptable salt thereof.

2. The method of claim 1, wherein the orthopoxvirus is selected from a variola virus, a vaccinia virus, a monkeypox virus (MPXV), a cowpox virus, an Aklimeta virus, or a Borealpox (Alaskapox) virus.

3. The method of claim 1 or 2, wherein the orthopoxvirus infection comprises a monkeypox (MPOX) infection.

4. The method of claim 3, wherein the MPOX infection is caused by an MPXV strain selected from clade 1, clade 2, or clade 3.

5. The method of any one of claims 1-4, wherein the TK inhibitor comprises a Src- and / or Abl-family TK inhibitor.

6. The method of any one of claims 1-5, wherein the TK inhibitor is selected from asciminib, bosutinib, dasatinib, imatinib, nilotinib, pazopanib, ponatinib, sunitinib, or a pharmaceutically acceptable salt thereof.

7. The method of any one of claims 1-6, wherein the TK inhibitor is imatinib, or a pharmaceutically acceptable salt thereof.

8. The method of any one of claims 1-7, wherein the TK inhibitor and tecovirimat are administered to the subject for 14 days or more.

9. The method of claim 7 or 8, wherein the imatinib salt is imatinib mesylate.

10. The method of any one of claims 7-9, wherein the imatinib is administered to the subject at a dose of between about 25 mg and about 1000 mg.

11. The method of any one of claims 7-10, wherein the imatinib is administered to the subject at a dose of between about 400 mg and about 600 mg.

12. The method of any one of claims 7-11, wherein the imatinib is administered to the subject at a dose of about 400 mg.

13. The method of any one of claims 7-12, wherein the imatinib is administered to the subject at a dose of about 600 mg.

14. The method of any one of claims 7-13, wherein the imatinib is administered to the subject at least once per day.

15. The method of any one of claims 7-14, wherein the imatinib is administered to the subject at least twice per day.

16. The method of any one of claims 7-15, wherein the imatinib is administered to the subject orally.

17. The method of any one of claims 1-16, wherein the tecovirimat salt is tecovirimat monohydrate.

18. The method of any one of claims 1-17, wherein the tecovirimat is administered at a dose of between about 25 mg to about 1000 mg.

19. The method of any one of claims 1-18, wherein the tecovirimat is administered to the subject at least once per day.

20. The method of any one of claims 1-18, wherein the tecovirimat is administered to the subject at least twice per day.

21. The method of any one of claims 1-18, wherein the tecovirimat is administered to the subject at least three times per day.

22. The method of any one of claims 1-21, wherein the tecovirimat is administered to the subject orally or intravenously.

23. The method of any one of claims 1-21, wherein the tecovirimat is administered to the subject orally.

24. The method of any one of claims 1-23, wherein the tecovirimat is administered to the subject orally at a dose of about 600 mg every 12 hours.

25. The method of any one of claims 1-21, wherein the tecovirimat is administered to the subject by intravenous infusion.

26. The method of any one of claims 1-21 or 25, wherein the tecovirimat is administered to the subject by intravenous infusion over about 6 hours at a dose of about 200 mg every 12 hours.

27. The method of any one of claims 1-26, wherein the tecoviriniat is administered to the subject for 14 days or more.

28. A method for preventing or treating a monkeypox infection in a subject in need thereof, comprising administering to the subject (a) a therapeutically effective amount of imatinib, or a pharmaceutically acceptable salt thereof, and (b) a therapeutically effective amount of tecoviriniat, or a pharmaceutically acceptable salt thereof.

29. The method of claim 28 wherein the monkeypox infection is caused by an MPXV strain selected from clade 1, clade 2, or clade 3.

30. The method of claim 28 or 29, wherein the imatinib salt is imatinib mesylate.

31. The method of any one of claims 28-30, wherein the imatinib is administered to the subject at a dose of between about 25 mg and about 1000 mg.

32. The method of any one of claims 28-30, wherein the imatinib is administered to the subject at a dose of between about 400 mg and about 600 mg.

33. The method of any one of claims 28-30, wherein the imatinib is administered to the subject at a dose of about 400 mg.

34. The method of any one of claims 28-30, wherein the imatinib is administered to the subject at a dose of about 600 mg.

35. The method of any one of claims 28-34, wherein the imatinib is administered to the subject at least once per day.

36. The method of any one of claims 28-34, wherein the imatinib is administered to the subject at least twice per day.

37. The method of any one of claims 28-36, wherein the imatinib is administered to the subject orally.

38. The method of any one of claims 28-37, wherein the tecoviriniat salt is tecoviriniat monohydrate.

39. The method of any one of claims 28-38, wherein the tecoviriniat is administered at a dose of between about 25 mg to about 1000 mg.

40. The method of any one of claims 28-39, wherein the tecoviriniat is administered to the subject at least once per day.

41. The method of any one of claims 28-39, wherein the tecovirimat is administered to the subject at least twice per day.

42. The method of any one of claims 28-39, wherein the tecovirimat is administered to the subject at least three times per day.

43. The method of any one of claims 28-42, wherein the tecovirimat is administered to the subject orally or intravenously.

44. The method of any one of claims 28-42, wherein the tecovirimat is administered to the subject orally.

45. The method of any one of claims 28-44, wherein the tecovirimat is administered to the subject orally at a dose of about 600 mg every 12 hours.

46. The method of any one of claims 28-42, wherein the tecovirimat is administered to the subject by intravenous infusion.

47. The method of any one of claims 28-42 or 46, wherein the tecovirimat is administered to the subject by intravenous infusion over about 6 hours at a dose of about 200 mg every 12 hours.

48. The method of any one of claims 28-47, wherein the tecovirimat is administered to the subject for 14 days or more.

49. The method of any one of claims 1-48, wherein the method reduces orthopoxvirus viral titer, increases or stimulates orthopoxvirus viral clearance, reduces or inhibits orthopoxvirus viral proliferation, reduces the amount of an orthopoxvirus viral protein or the amount of an orthopoxvirus viral nucleic acid, or reduces or inhibits synthesis of an orthopoxvirus viral protein or an orthopoxvirus viral nucleic acid, or a combination thereof.

50. The method of any one of claims 1-49, wherein the method reduces one or more adverse physiological conditions, disorders, illness, diseases, symptoms or complications caused by or associated with orthopoxvirus infection or disease pathology.

51. The method of any one of claims 1-50, wherein the method improves one or more adverse physiological conditions, disorders, illness, diseases, symptoms, or complications caused by or associated with orthopoxvirus infection or disease pathology.

52. The method of claim 50 or 51, wherein the symptoms are selected from fever, chills, headache, body aches, swollen lymph nodes, exhaustion, rash, or a combination thereof.

53. The method of any one of claims 1-52, wherein the TK inhibitor and tecovirimat are administered prior to, concurrently with, or following exposure of the subject to the orthopoxvirus or infection of the subject with the orthopoxvirus.

54. The method of any one of claims 1-53, wherein the TK inhibitor and tecovirimat are administered prior to exposure of the subject to orthopoxvirus or infection of the subject with orthopoxvirus.

55. The method of any one of claims 1-53, wherein the TK inhibitor and tecovirimat are administered following exposure of the subject to orthopoxvirus or infection of the subject with orthopoxvirus.

56. The method of any one of claims 49-55, wherein the orthopoxvirus is a monkeypox virus.

57. The method of any one of claims 1-56, wherein the TK inhibitor and tecovirimat are administered within 2-72 hours, 2-48 hours, 4-24 hours, 4-18 hours, or 6-12 hours following a symptom of orthopoxvirus infection or exposure develops.

58. The method of any one of claims 1-57, wherein the subject is a human.

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