Methods of treating ophthalmic conditions in a defined patient population

Abstract

The present invention relates to methods for treating an ophthalmic condition in a defined patient in need of treatment thereof. The methods comprise inducing the activity of peroxisome proliferator–activated receptor gamma coactivator-1 alpha (PGC1α) in a defined patient that needs treatment of an ophthalmic condition. The defined patient in these methods has been previously identified as having reduced carboxylesterase 1 (CES1) activity, compared to normal activity levels of CES1.

Description

Attorney Docket No. ALMO-01.5001.W001METHODS OF TREATING OPHTHALMIC CONDITIONS IN A DEFINED PATIENT POPULATIONStatement Regarding Federally Sponsored Research or Development

[0001] N / AReference to Sequence Listing Submission via EFS-Web

[0002] N / ABackground of the InventionField of the Invention

[0003] The present invention relates to methods for treating an ophthalmic condition in a defined patient in need of treatment thereof. In particular, the methods of treatment comprise inducing the activity of peroxisome proliferator-activated receptor gamma coactivator-1 alpha (PGCla) in a defined patient, where the defined patient is a patient previously identified as having reduced carboxylesterase 1 (CES1) activity, compared to normal activity levels of CES1 activity.Background of the Invention

[0004] In industrialized countries, the average life span is over 80 years of age and continues to increase steadily. Age-related macular degeneration (AMD), the most prevalent form of macular degeneration, is associated with progressive loss of visual acuity in the central portion of the visual field, changes in color vision and abnormal dark adaptation and sensitivity. AMD is the leading cause of blindness worldwide, and the World Health Organization estimates that over 14 million people are blind or severely affected by AMD. Indeed, AMD is the major cause of severe visual loss in the United States for individuals over the age of 60. Moreover, AMD has a profound impact on the physical and mental health of elderly individuals and their families.

[0005] Two principal clinical manifestations of AMD have been described as "dry AMD," (dAMD) also known as the atrophic form, and "wet AMD", (wAMD), also known as the neovascular, or exudative, form.

[0006] The vast majority of AMD patients present with the dry form of AMD, and about 10-20% of these dAMD patients eventually progress to wAMD . Rarely, some patients may present with both wetAttorney Docket No. ALMO-01.5001.W001 and dry forms. Dry AMD can, and often does, progress to Geographic Atrophy, a severe form of dAMD with distinctive features, e.g., confluent areas, typically at least 175 pm, of RPE cell death accompanied by overlying photoreceptor atrophy. In dAMD, cellular debris (drusen) accumulate between the retina and the choroid, and the retina can become detached. The presence of drusen are typically the earliest clinical finding in AMD, and the existence, location, and number of drusen are used in classifying the disease into stages and for monitoring its progression

[0007] In wet, exudative, AMD, blood vessels grow from the choriocapillaris through defects in Bruch's membrane, and in some cases the underlying RPE. Organization of serous or hemorrhagic exudates escaping from these vessels results in fibrovascular scarring of the macular region with attendant degeneration of the neuroretina, detachment and tears of the retinal pigment epithelium, frank retinal detachment and vitreous hemorrhage, all of which contribute to permanent loss of central vision. The pathogenesis of new choroidal vessels is poorly understood, but such factors as inflammation, ischemia, and local production of angiogenic factors are thought to be important.

[0008] To date, there are no effective treatments for dAMD and treatments for wAMD are generally ineffective are directed to antiangiogenic modes of therapy. What is needed in the art, therefore, is an effective treatment for AMD.Summary of the Invention

[0009] The present invention relates to methods for treating an ophthalmic condition in a defined patient in need of treatment thereof. In particular, the methods of treatment comprise inducing the activity of peroxisome proliferator-activated receptor gamma coactivator-1 alpha (PGCla) in a defined patient, where the defined patient is a patient previously identified as having reduced carboxylesterase 1 (CES1) activity, compared to normal activity levels of CES1 activity.

[0010] The present invention also relates to methods of monitoring the effectiveness of a treatment of an ophthalmic condition in a defined patient in need of treatment thereof. The methods of monitoring comprise determining the activity levels of PGCla in the defined patient over time in response to the administration of the treatment of the ophthalmic condition. An increase in the levels of PGCla activity over time is indicative that the treatment is providing beneficial effects to the defined patient. The defined patient in these monitoring methods has been previously identified as having reduced CES1 activity, compared to normal activity levels of CES1.Attorney Docket No. ALMO-01.5001.W001Brief Description of the Drawings

[0011] FIGURE 1 depicts how the selection of Responders and Non-responders to fenofibrate (FF) allows the construction of Cybrid Retinal Pigment Epithelial (RPE) cell lines derived from an individual, selected patient

[0012] FIGURE 2 depicts the methodology used to create cybrid cells from the peripheral blood mononuclear cells (PBMCs) of selected patients by fusion with RPE cells depleted of mitochondria

[0013] FIGURE 3 depicts the effect of fenofibrate treatment, which positively enhances mitochondrial activity in human acute macular degeneration (AMD) Cybrid Cells. The cybrid cells were constructed using mitochondria obtained from patients who had AMD. Peripheral blood mononuclear cells (PBMCs) were collected from these patients and were used to construct cybrids with ARPE19 cells, a cell line obtained from human RPE. The ARPE19 cells were fused with the patient cells had been depleted of mitochondria prior to fusion by ethidium bromide treatment. The control is shown versus the fenofibrate treated cells. The green fluorescence represents mitochondria, and the blue fluorescence represents a stain for nuclei. The fenofibrate treatment produced an increase in the green fluorescence signal, indicating proliferation of mitochondria resembling the proliferation in the control cells, demonstrating that fenofibrate treatment addresses mitochondrial death that is observed in RPE cells derived from AMD patients.

[0014] FIGURE 4 depicts AMD cybrids carrying different mtDNA haplogroups respond differentially To Fenofibrate Treatment, as evidenced by different assays of mitochondrial function. The JC-1 assay is excellent to measure the decrease of mitochondrial membrane potential, which is an early sign of cellular stress and apoptosis. The MTT assay measures the levels of metabolic activity by analyzing the NAD(P)H-dependent oxidoreductase enzymes.

[0015] FIGURE 5 depicts fenofibrate treatment (GREY BAR) upregulates protective genes in AMD cybrid cells (untreated - black bar).

[0016] FIGURE 6 depicts fenofibrate treatment (GREY BAR) improves mitochondrial function in AMD Cybrid Cells (untreated - black bar) using a variety of mitochondrial functional assays (as indicated).Detailed Description of the InventionAttorney Docket No. ALMO-01.5001.W001

[0017] The present invention relates to methods for treating an ophthalmic condition in a defined patient in need of treatment thereof. In particular, the methods of treatment comprise inducing the activity of peroxisome proliferator-activated receptor gamma coactivator-1 alpha (PGCla) in a defined patient, where the defined patient is a patient previously identified as having reduced carboxylesterase 1 (CES1) activity, compared to normal activity levels of CES1. The terms "subject" and "patient" are used interchangeably herein, unless noted in a specific embodiment.

[0018] As used herein the term "treat" or "treating" refers to providing an intervention of a condition, in this case an ophthalmic condition, that is intended to ameliorate, reverse or stop from occurring one or more symptoms, condition metrics or underlying causes of the condition. The term treat or treatment as used herein does not necessarily mean that the subject is "cured" such that all symptoms or underlying causes of the condition have been removed, halted or reversed completely. In certain embodiments, the effect of the interventional regimen may include but is not limited to reducing one or more symptoms of the ophthalmic condition, a reduction in the severity of the ophthalmic condition, the complete ablation of the ophthalmic condition or a delay in the onset or worsening of one or more symptoms of the ophthalmic condition. Provided that at least one of the subject's symptoms or condition metrics improves, as compared to the symptoms or condition metrics prior to the intervention, after the providing of the intervention, the methods described herein would have successfully treated the subject. Moreover, the improvement need not be permanent in that adjustments in the interventional regimen may be necessary, but not required.

[0019] In other aspects of the present invention, the therapeutic methods described herein may be used to reduce the likelihood of the onset of an ophthalmic condition or delay the onset of an ophthalmic condition. For example, the therapeutic methods described herein may be used for precluding, delaying, averting, obviating, forestalling, stopping or hindering the onset, incidence, severity or recurrence of the ophthalmic condition or one or more symptoms thereof. For example, the disclosed therapeutic methods may result in a reduction or delay in onset, incidence, severity, or recurrence of the ophthalmic condition or one or more symptoms or condition metrics thereof in a subject susceptible to the ophthalmic condition.

[0020] In one embodiment, the treatment methods require administering to the subject one or more compounds that induce the activity of peroxisome proliferator-activated receptor gamma coactivator-1 alpha (PGCla), also known as Ligand Effect Modulator 6 (LEM6). As used herein, and as is well-known inAttorney Docket No. ALMO-01.5001.W001 the art, PGCla is a transcription co-activator that interacts with other nuclear transcription factors to promote gene transcription. In particular, PGCla is a transcription co-activator that is well-known to control or contribute to mitochondrial biogenesis. For example, PGCla is highly expressed in tissue with high energy demands and with copious mitochondria, such as brown adipose tissue, brain, skeletal muscle and heart to name a few. Moreover, PGCla activity is reduced in patients with Alzheimer's Disease, Parkinson's Disease and Amyotrophic Lateral Sclerosis, to name a few. The wild-type amino acid sequence of human PGCla is found at UniProt Accession No. Q9UBK2, which is available on the worldwide web at uniport.org. UniProt Accession No. Q9UBK2 and the information therein is incorporated by reference herein in its entirety.

[0021] As used herein, "inducing the activity" with respect to PGCla means any mechanism by which the PGCla protein is more active than without or prior to the intervention. Such induction may include but is not limited to, increasing the transcription or translation of the gene or mRNA encoding the PGCla protein, increasing the stability of the PGCla protein, e.g., half-life, or mRNA encoding the PGCla protein, reducing or eliminating inhibitors of PGCla activity, reducing or eliminating inhibitors of transcription of the gene encoding PGCla, reducing or eliminating inhibitors of translation of the mRNA transcript encoding PGCla, increasing the availability of peroxisome proliferator-activated receptor gamma (PPARy) or other nuclear receptors with which PGCla is known to interact, increasing the affinity of PGCla to PPARy or other nuclear receptors with which PGCla is known to interact.

[0022] The methods disclosed herein comprise treating a defined patient or defined patient population. As used here, the "defined patient" is a patient previously identified as having reduced carboxylesterase 1 (CES1) activity, compared to normal activity levels of CES1. The CES1 protein, also known as liver carboxylesterase 1, is an enzyme that is well-known to metabolize certain drugs, pesticides and other compounds. In fact, CES1 is the most abundant drug-metabolizing enzyme in the liver and is responsible for metabolizing large classes of drugs, such as but not limited to, anticoagulants, angiotensinconverting enzyme inhibitors, antihyperlipidemic agents, antivirals, chemotherapeutics, immunosuppressants and even psychoactive drugs. In just one example, CES1 is the primary enzyme responsible for metabolizing fenofibrate. In the past, pharmaceutical companies and drug developers have taken advantage of the activity of CES1 by designing drugs where the metabolite of an administered compound is the active molecule that provides a therapeutic benefit, / .e., administering a pro-drug to patients. The canonical amino acid sequence of human CES1 is found at UniProt AccesssionAttorney Docket No. ALMO-01.5001.W001No. P23141, which is available on the worldwide web at uniport.org. UniProt Accession No. P23141 and the information therein is incorporated by reference herein in its entirety.

[0023] In contrast to the current state of the art, however, the methods provided herein comprise identifying patients in which the activity of CES1 is reduced, such that a compound administered to the patient is not metabolized by CES1 as rapidly as normal. For example, PCT Publication No. WO 2020 / 163493 discloses the concept of co-administering one of more inhibitors of CES1, e.g., kaempferol along with fenofibrate to prevent or reduce the metabolism of fenofibrate, such that fenofibrate can act directly upon PGCla. Indeed, identifying patients with reduced CES1 activity levels prior to therapeutic intervention provides new patient population for more optimal therapeutic intervention of abnormal conditions, such as one or more of the ophthalmic conditions listed herein.

[0024] It has been recognized that there are a number of polymorphisms of the CES1 gene. These polymorphisms may result in the reduction of CES1 activity. There are four major haplotypes of CES1 and various combinations of these four haplotypes give rise to three different diplotypes which have 2,3, or 4 copies of CES1. The four major haplotypes are designated as: CES1P1-CES1A1, CES1A2-CES1A1, CESIPl-CESlAlc and CES1A2-CES1A1C. Two of the haplotypes contain a CESl-related pseudogene (CES1P1). CES1 itself can be duplicated, and the duplicated CES1 variant is termed CES1A2, while the original CES1 copy is designated CES1A1. The promoter region, exon 1, and the first part of intron 1 in CES1A2 are homologous to CES1P1, but apart from these regions CES1A1 and CES1A2 are identical. In addition, there is a variant of CES1A1 designated CESlAlc (also known as CES1VAR) in which exon 1 with flanking sequences has been replaced by the corresponding sequences of CES1P1.

[0025] A large number of genetic variants of the CES1 gene itself are known. In fact, over 3500 genetic variants of CES1 are listed in the NIH database. Some variants could be associated with loss of expression of CES1 or more subtle effects. For example, as designated by their single nucleotide polymorphisms (SNPs), some SNPs of CES1 include but are not limited to, Rsl2443580, Rsl21912777, Rs2244614, Rs2307240, Rsl48947808 and Rs202121317.

[0026] Other variants are clearly associated with defects in drug metabolism. Some of the most common CES1 variants in the prior art which have been shown to effect drug metabolism are include but are not limited to: (1) G143E loss of function of CES1 (SNP Rs71647871), (2) G147C loss of function and reduced expression, (3) E220G loss of function, (4) L40T loss of function and expression, (5) R171C loss of function, (6) R199H loss of function and (7) T209M loss of function, which is present in allAttorney Docket No. ALMO-01.5001.W001 populations examined at the level of 0.01-0.03%. The nomenclature of the mutations used herein is well-understood by one of skill in the art. For example, a "G143E" mutation indicates that the glycine amino acid (G) at position 143 of the amino acid sequence of CES1 has been changed to glutamic acid (E). This G143E mutant results in loss of function of the CES1 protein. Each of the variants disclosed herein and in the prior art have known expression frequencies in various human populations.

[0027] In certain embodiments, the therapeutic methods comprise providing an interventional regimen to a subject in which the haplotype of the CES1 gene in the subject results in a reduction of activity of the CES1 protein. In specific embodiments, the therapeutic methods comprise providing an interventional regimen to a subject comprising a CES1 genotype selected from the group consisting of (1) G143E loss of function of CES1 (SNP Rs71647871), (2) G147C loss of function and reduced expression, (3) E220G loss of function, (4) L40T loss of function and expression, (5) R171C loss of function, (6) R199H loss of function and (7) T209M loss of function. Once the genotype or haplotype of the subject is established to identify a subject having a genotype or haplotype correlated with reduced CES1 activity, the interventional methods of the present invention to induce the activity of PGCloc may be administered to the subject.

[0028] In one aspect of the present invention, the methods of inducing the activity of PGCloc comprise administering a drug or compound that would normally be metabolized by CES1 in subjects with normal CES1 activity, except that, in the present methods, the drug or compound is being administered to a subject in which the genotype or haplotype of the subject identifies the subject as having reduced activity of CES1, compared to normal levels of CES1 activity. In another aspect of the present invention, the methods of treatment comprise administering a drug or compound that would normally be metabolized by CES1 in subjects with normal CES1 activity and excludes the administration of a compound, drug or other therapeutic that inhibits the activity, function or expression of CES1. For example, one embodiment of the methods of treatment of the present invention excludes the administration of quercetin, kaempferol or another drug that inhibits the activity of CES1.

[0029] Examples of drugs that could be administered in the treatment methods of the present invention that induce the activity of PGCla in subjects identified as having reduced CES1 activity include but are not limited to fenofibrate, bezafibrate, ciprofibrate, etofibrate, clofibride, clinofibrate, gemfibrozil, nafenopin, ronifibrate, simfibrate or any the compounds of any of Formulas I, II, III, IV, V, VI, VII, VIII, IX, X, XI, XII, XIII, XIV, XV, XVI, XVII, XVIII, XIX XX, XXI, XXII or XXIII as shown below. In selectAttorney Docket No. ALMO-01.5001.W001 embodiments, the treatment methods comprise administering drugs to induce the activity of PGCla in subjects identified as having reduced CES1 activity include but are not limited to fenofibrate, gemfibrozil, the compound of any of Formulas I, II, III, IV, V, VI, VII, VIII, IX, X, XI, XII, XIII, XIV, XV, XVI, XVII, XVIII, XIX, XX, XXI, XXII or XXIII as shown below but exclude the administration of kaempferol or another drug that inhibits the activity of CES1.disclosed in Brown, P. J., et al.,Chemistry & Biology, 4(12), 909-918 (1997), incorporated by reference in its entirety;International J. Organic Chemistry, 12(2), 116 (2022), incorporated by reference in its entirety;Attorney Docket No. ALMO-01.5001.W001Medicinal Chemistry, 44(13), 2061-2064 (2001), incorporated by reference in its entirety;(IV), disclosed in DeH'Uomo, N., et al., Chemistry Enabling DrugDiscovery, 1(1), 49-53 (2006), incorporated by reference in its entirety;Medicinal Chemistry, 44(10), 3973-3980 (2009), incorporated by reference in its entirety;Attorney Docket No. ALMO-01.5001.W001(VIII), compounds VI-VII I being disclosed in U.S. Pat. No.5,985,886, incorporated by reference in its entirety,disclosed in U.S. Pat. No. 7,163,952, incorporated by reference in its entirety;Attorney Docket No. ALMO-01.5001.W001Attorney Docket No. ALMO-01.5001.W001(XV), with compound X-XV disclosed in U.S. Pat. No. 7,524,870, incorporated by reference in its entirety;compounds XVI-XVII disclosed in Sauerberg, P., et al., Bioorganic & Medicinal Chemistry Letters, 15(5), 1497-1500 (2005), incorporated by reference in its entirety;Attorney Docket No. ALMO-01.5001.W001compounds XVI I l-XIX disclosed in Sashidhara, K. V., et al., J. Medicinal Chemistry, 55(6), 2769-2779 (2012), incorporated by reference in its entirety;disclosed in Kasuga, J. I., et al., Bioorganic & MedicinalChemistry Letters, 18(3), 1110-1115 (2008), incorporated by reference in its entirety;Attorney Docket No. ALMO-01.5001.W001disclosed in Perrone, M. G., et al., European Journal of MedicinalChemistry, 40(2), 143-154 (2005) incorporated by reference in its entirety;, disclosed in PCT Publication No. WO 2002 / 015902A1, which is incorporated by reference in its entirety; andAttorney Docket No. ALMO-01.5001.W001disclosed in Sierra, M. L, et al. (2007). Substituted 2-[(4- aminomethyl) phenoxy]-2-methylpropionic acid PPARa agonists. 1. Discovery of a novel series of potent HDLc raising agents. Journal of Medicinal Chemistry, 50(4), 685-695 (2007), which is incorporated by reference in its entirety.

[0030] The present invention also provides methods of treatment wherein the treatment comprises administering a compound that induces the activity of PGCla in subjects at doses that are less than the approved doses of the drug. For example, fenofibrate is approved for use in doses ranging from 48 mg daily to 160 mg daily, depending on the indication. All of these indications, however, are related to dyslipidemia and fenofibrate is administered for its lipid-lowering effects, and fenofibrate is administered in these indications as a prodrug in which first-pass metabolism is required for its therapeutic effects. In the present invention, however, fenofibrate is administered as the active moiety for its ability to treat ophthalmic conditions in subjects with compromised CES1 activity. Thus, fenofibrate may be administered in doses less than doses currently approved.

[0031] In specific embodiments of the present invention, fenofibrate is administered to the subject at daily doses of between about 10 mg and about 400 mg, between about 20 mg and about 380 mg, between about 30 mg and about 360 mg, between about 40 mg and about 340 mg, between about 50 mg and about 320 mg, between about 60 mg and about 300 mg, between about 70 mg and about 280 mg, between about 80 mg and about 260 mg, between about 90 mg and about 240 mg, between about 100 mg and about 220 mg, between about 110 mg and about 200 mg, between about 120 mg and about 180 mg or between about 140 mg and about 160 mg.Attorney Docket No. ALMO-01.5001.W001

[0032] In other specific embodiments of the present invention, gemfibrozil is administered to the subject at daily doses of between about 10 mg and about 1200 mg, between about 20 mg and about 1180 mg, between about 30 mg and about 1160 mg, between about 40 mg and about 1140 mg, between about 50 mg and about 1120 mg, between about 60 mg and about 1100 mg, between about 70 mg and about 1080 mg, between about 80 mg and about 1060 mg, between about 90 mg and about 1040 mg, between about 100 mg and about 1020 mg, between about 110 mg and about 1000 mg, between about 120 mg and about 980 mg, between about 140 mg and about 960 mg, between about 160 mg and about 940 mg, between about 180 mg and about 920 mg, between about 200 mg and about 900 mg, between about 220 mg and about 880 mg, between about 240 mg and about 860 mg, between about 260 mg and about 840 mg, between about 280 mg and about 820 mg, between about 300 mg and about 800 mg, between about 320 mg and about 780 mg, between about 340 mg and about 760 mg, between about 360 mg and about 740 mg, between about 380 mg and about 720 mg, between about 400 mg and about 700 mg, between about 420 mg and about 680 mg, between about 440 mg and about 660 mg, between about 460 mg and about 640 mg, between about 480 mg and about 620 mg and between about 500 mg and about 600 mg.

[0033] In other specific embodiments of the present invention, any one of bezafibrate, ciprofibrate, etofibrate, clofibride, clinofibrate, nafenopin, ronifibrate or simfibrate is administered to the subject at daily doses of between about 10 mg and about 1200 mg, between about 20 mg and about 1180 mg, between about 30 mg and about 1160 mg, between about 40 mg and about 1140 mg, between about 50 mg and about 1120 mg, between about 60 mg and about 1100 mg, between about 70 mg and about 1080 mg, between about 80 mg and about 1060 mg, between about 90 mg and about 1040 mg, between about 100 mg and about 1020 mg, between about 110 mg and about 1000 mg, between about 120 mg and about 980 mg, between about 140 mg and about 960 mg, between about 160 mg and about 940 mg, between about 180 mg and about 920 mg, between about 200 mg and about 900 mg, between about 220 mg and about 880 mg, between about 240 mg and about 860 mg, between about 260 mg and about 840 mg, between about 280 mg and about 820 mg, between about 300 mg and about 800 mg, between about 320 mg and about 780 mg, between about 340 mg and about 760 mg, between about 360 mg and about 740 mg, between about 380 mg and about 720 mg, between about 400 mg and about 700 mg, between about 420 mg and about 680 mg, between about 440 mg and about 660 mg, between about 460 mg and about 640 mg, between about 480 mg and about 620 mg and between about 500 mg and about 600 mg. .Attorney Docket No. ALMO-01.5001.W001

[0034] In other specific embodiments of the present invention, any one of the compounds of Formulae l-XXIII is administered to the subject at daily doses of between about 10 mg and about 1200 mg, between about 20 mg and about 1180 mg, between about 30 mg and about 1160 mg, between about 40 mg and about 1140 mg, between about 50 mg and about 1120 mg, between about 60 mg and about 1100 mg, between about 70 mg and about 1080 mg, between about 80 mg and about 1060 mg, between about 90 mg and about 1040 mg, between about 100 mg and about 1020 mg, between about 110 mg and about 1000 mg, between about 120 mg and about 980 mg, between about 140 mg and about 960 mg, between about 160 mg and about 940 mg, between about 180 mg and about 920 mg, between about 200 mg and about 900 mg, between about 220 mg and about 880 mg, between about 240 mg and about 860 mg, between about 260 mg and about 840 mg, between about 280 mg and about 820 mg, between about 300 mg and about 800 mg, between about 320 mg and about 780 mg, between about 340 mg and about 760 mg, between about 360 mg and about 740 mg, between about 380 mg and about 720 mg, between about 400 mg and about 700 mg, between about 420 mg and about 680 mg, between about 440 mg and about 660 mg, between about 460 mg and about 640 mg, between about 480 mg and about 620 mg and between about 500 mg and about 600 mg.

[0035] In one embodiment of the methods of treatment disclosed herein, the defined patient has also been diagnosed with an ophthalmic condition or is at higher than normal risk for developing an ophthalmic condition. In one particular embodiment, the defined patient has been diagnosed or is exhibiting symptoms of an ophthalmic condition. In another embodiment, the patient is not exhibiting any symptoms of an ophthalmic condition, but is at a higher than normal risk for developing an ophthalmic condition.

[0036] As used herein, the ophthalmic condition is a condition affecting the metabolic activity, normal function or "health" of cells involved in vision. In some embodiments, the cells are neural cells including but not limited to bipolar cells, retinal ganglion cells, horizontal cells, amacrine cells, glial cells or astrocytes. In specific embodiments, the cells are epithelial cells, such as but not limited to retinal pigment epithelial (RPE) cells that are present in the retina and provide critical support functions for the photoreceptors and other cells of the retina. In other embodiments, the cells are photoreceptor cells, microglia, astrocytes, Muller cells, rod cells and / or cone cells of the retina. In one embodiment of the present invention, the methods provide the inducing PGCloc activity in one or more cells comprising contacting the one or more cells with at least one of the compounds disclosed herein. In someAttorney Docket No. ALMO-01.5001.W001 embodiments, the contacting step is in vivo. In other embodiments, the induction of PGCla in the cells is PPARy-independent.

[0037] The ophthalmic condition may or may not be a degenerative disease. Examples of ophthalmic conditions include but are not limited to age-related macular degeneration (AMD), both wet (wAMD) and dry (dAMD) versions thereof, Best macular dystrophy, Sorsby fundus dystrophy, Mallatia Leventinese and Doyne honeycomb retinal dystrophy. In specific embodiments, the methods of the present invention provide for treating a defined patient for wAMD or dAMD, with the methods comprising inducing the activity of peroxisome proliferator-activated receptor gamma coactivator-1 alpha (PGCla) in the defined patient, wherein the defined patient in need of treatment of wAMD or dAMD has been previously identified as having reduced carboxylesterase 1 (CES1) activity, compared to normal activity levels of CES1, prior to the inducing of PGCla.

[0038] During the progression of either type of AMD, vision loss is associated with readily observable abnormalities of Bruch's membrane, the choroid, the neural retina and most notably the retinal pigment epithelium (RPE). The RPE layer is crucial for photoreceptor health. RPE cells recycle visual pigment (rhodopsin), phagocytose photoreceptor tips as part of rod and cone regeneration and transport fluid across the membrane to the choroid, which is believed to maintain attachment of the neural retina.

[0039] In another embodiment of the methods disclosed here, the methods comprise treating a defined patient for a macular degeneration related condition. As used herein, the term macular degeneration related condition refers to any disorder in which the macula of the patient's retina degenerates or loses functional activity. The degeneration or loss of function of the macula may arise, for example, from dysregulated cell death or apoptosis, cellular necrosis, decreased cell proliferation, loss or deterioration of normal function, loss or deterioration of cellular metabolism or any combination thereof. Macular degeneration can lead to and / or manifest as alterations in the structural integrity of the cells and / or extracellular matrix of the macula, alteration in normal cellular and / or extracellular matrix architecture, and / or the loss of function of macular cells. The cells can be any cell type normally present in or near the macula including RPE cells, photoreceptors, and / or capillary endothelial cells. Geographic Atrophy is an extreme form of dry AMD which is included as macular degeneration related condition.

[0040] In yet additional embodiments, the defined patient on which the methods of the present application are administered is a patient that does not have and is not suspected of having or sufferingAttorney Docket No. ALMO-01.5001.W001 from diabetic retinopathy. Diabetic retinopathy (DR) is sometimes confused with AMD, but the two conditions are quite distinct. For example, DR affects the blood vessels within the retina, whereas AMD involves drusen and blood vessels under the retina. In addition, DR is generally caused by chronically high blood glucose levels that damage the blood vessels of the retina. These damaged blood vessels can swell, leak and even undergo angiogenesis, i.e., proliferation of new blood vessels, all of which can interfere with vision and lead to vision impairment. Thus, treating the root cause of DR, e.g., diabetic and anti-angiogenesis treatments, would likely not have an effect on a degenerative condition affecting the cells of the macula such as AMD.

[0041] In specific embodiments of the methods disclosed herein, the subject has or has a higher than normal risk of developing AMD. The symptoms or condition metrics of wAMD or dAMD include but are not limited to, difficulty recognizing familiar faces, dark or blurry areas in the center of vision, trouble seeing in low light conditions, changes in color perception, blank spots in vision. In specific embodiments of the present invention, the subject with compromised CES1 activity levels has been diagnosed with wAMD and / or dAMD.

[0042] The present invention also relates to methods of monitoring the effectiveness of a treatment of an ophthalmic condition in a defined patient in need of treatment thereof. The methods of monitoring comprise tracking levels of PGCla activity over time in the subject. The tracking of PGCla activity may be a direct or indirect measurement its activity. For example, the methods of monitoring may include tracking the symptoms or clinical metrics of the ophthalmic condition such that an improvement in the subject's symptoms or clinical metrics over time indicates that methods of treatment have been effective.

[0043] Other methods of monitoring the activity of PGCla over time include measuring levels of the mRNA transcripts encoding the PGCla protein, measuring levels of the PGCla protein, measuring levels of the downstream targets of PGCla, such as any protein on which the PGCla protein acts as a transcription co-factor, measuring levels PGCla receptors, such as immunoprecipitation methods by precipitating PGCla with its binding partner / target, measuring amounts or activity levels of mitochondria, such as but not limited to measuring amount or activity of mitochondrial enzymes, e.g., citrate synthase, quantifying mitochondria, assessing oxygen consumption rates and the like. Any method of directly or indirectly assessing the activity of PGCla over time may be used in the methods ofAttorney Docket No. ALMO-01.5001.W001 the present invention. An increase in the activity levels of PGCla over time is indicative that the treatment is providing beneficial effects to the defined patient.

[0044] The methods of monitoring may or may not include establishing a baseline of clinical metrics in the subject prior to the subject exhibiting symptoms of the ophthalmic condition. For example, if the subject is determined to be at a higher risk than normal for developing an ophthalmic condition, the attending physician may establish baseline values of clinal metrics of the subject prior to the subject exhibiting symptoms.Examples

[0045] Example 1 -

[0046] As depicted in FIGURE 1, the selection of Responders and Non-responders to fenofibrate (FF) allows the construction of Cybrid Retinal Pigment Epithelial (RPE) cell lines derived from an individual, selected patient.

[0047] Example 2 -

[0048] As depicted in FIGURE 2, the invention provides methods of creating cybrid cells from the peripheral blood mononuclear cells (PBMCs) of selected patients by fusion with RPE cells depleted of mitochondria.

[0049] Example 3 -

[0050] As depicted in FIGURE 3, fenofibrate treatment positively enhances mitochondrial activity in human acute macular degeneration Cybrid Cells. The cybrid cells were constructed using mitochondria obtained from patients who had AMD. PBMCs were collected from these patients and were used to construct cybrids with ARPE19 cells, a cell line obtained from human RPE. The ARPE19 cells were fused with the patient cells had been depleted of mitochondria prior to fusion by ethidium bromide treatment. The control is shown versus the fenofibrate treated cells. Untreated (Con) and Fenofibrate (FFR)-treated AMD cybrids. The cybrids were stained with Cell Light mitochondrial GFP stain followed by confocal imaging of cells. Figure 3 (A) shows representative brightfield, DAPI, mtGFP, and overlay (DAPI + mtGFP) confocal images. Figure 3 (B) shows fenofibrate-treated AMD cybrids having a drastic increase in mtGFP fluorescence intensity compared to the untreated group (p<0.05, n=3). Data are presented asAttorney Docket No. ALMO-01.5001.W001 mean +SEM and normalized to untreated AMD cybrids, which were assigned a value of 1. Mann- Whitney test was used to measure statistical differences; *p<0.05.

[0051] Example 4 -

[0052] As depicted in FIGURE 4, AMD cybrids carrying different mtDNA haplogroups respond differentially to fenofibrate treatment, as evidenced by different assays of mitochondrial function. The numbers 1A -6A represent cybrids derived from individual patients 1A-6A. Two assays were used to measure function of the cybrids from those patients, the JC-1 assay and the MTT assay.

[0053] The JC-1 assay measures the decrease of mitochondrial membrane potential, which is an early sign of cellular stress and apoptosis. The JC-1 assay utilized a fluorescent dye called JC-1. JC-1 is a cationic dye that readily accumulates in the mitochondrial matrix due to the negative charge across the mitochondrial membrane, where it forms aggregates that emit red fluorescence. When the mitochondrial membrane potential is disrupted, JC-1 remains in the cytoplasm as monomers, emitting green fluorescence. A higher red / green ratio indicates a higher mitochondrial membrane potential and healthier mitochondria. Thus, as shown in FIGURE 4, fenofibrate treatment produced healthier mitochondria in the cybrid cells derived from patients.

[0054] The MTT (3-(4, 5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) assay is a colorimetric assay for measuring cellular growth, and it can also be used for toxicity assessment of toxicants. The water-soluble yellow dye MTT is a tetrazolium salt that is readily taken up by viable cells and reduced into purple color formazan by the action of mitochondrial succinate dehydrogenase in the mitochondria of living cells. Reduction of MTT occurs only in metabolically active cells, and the level of activity is a measure of the viability of the cells. As shown, fenofibrate treatment produced healthier mitochondria in the cybrid cells derived from patients.

[0055] Example 5 —

[0056] As depicted in FIGURE 5, fenofibrate treatment (GREY BAR) upregulated expression of protective genes in AMD cybrid cells (untreated - black bar). The genes shown are mitochondrial protective genes.

[0057] Example 6 -Attorney Docket No. ALMO-01.5001.W001

[0058] As depicted in FIGURE 6, fenofibrate treatment (GREY BAR) improved mitochondrial function in AMD Cybrid Cells (untreated - black bar) using a variety of mitochondrial functional assays (as indicated).

Claims

Attorney Docket No. ALMO-01.5001.W001What is Claimed is:

1. A method for treating an ophthalmic condition in a defined patient in need of treatment thereof, the method comprising inducing the activity of peroxisome proliferator-activated receptor gamma coactivator-1 alpha (PGCla) in the defined patient, wherein the defined patient in need of treatment of the ophthalmic condition has been previously identified as having reduced carboxylesterase 1 (CES1) activity, compared to normal activity levels of CES1, prior to the inducing of PGCla.

2. The method of claim 1, wherein the defined patient that has been previously identified as having reduced carboxylesterase 1 (CES1) activity comprises a genotype of the CES1 gene that is associated with reduced activity, compared to normal activity levels of CES1.

3. The method of claim 2, wherein the inducing of PGCla comprises the administration of a drug that is metabolized by CES1 in subjects with normal activity levels of CES1.

4. The method of claim 3, wherein the drug is a drug selected from the group consisting of fenofibrate, bezafibrate, ciprofibrate, etofibrate, clofibride, clinofibrate, gemfibrozil, nafenopin, ronifibrate and simfibrate.

5. The method of claim 3, wherein the ophthalmic condition is selected from the group consisting of wet age-related macular degeneration (wAMD), dry age-related macular degeneration (dAMD), Best macular dystrophy, Sorsby fundus dystrophy, Mallatia Leventinese and Doyne honeycomb retinal dystrophy.

6. The method of any of claims 1-5, wherein the methods exclude administration of an inhibitor of CES1 activity to the defined patient.

7. The method of any of claims 4-6, wherein the fenofibrate is administered to the defined patient at doses of less than 160 mg / day.

8. The method of any of claims 1-7 further comprising monitoring the activity levels of the PGCla in the defined patient over time in response to the administration of the treatment.Attorney Docket No. ALMO-01.5001.W0019. The method of claim 8, further comprising increasing the dose or frequency of the treatment in the defined patient when the activity levels of PGCla in the defined patient do not increase over time in response to the administration of the treatment of the ophthalmic condition.

10. The method of claim 8, further comprising decreasing the dose or frequency of the treatment in the defined patient when the activity levels of PGCla in the defined patient increase over time in response to the administration of the treatment of the ophthalmic condition.

11. A method of monitoring the effectiveness of a treatment of a ophthalmic condition in a defined patient in need of treatment thereof, the method of monitoring comprising determining the activity levels of peroxisome proliferator-activated receptor gamma coactivator-1 alpha (PGCla) in the defined patient over time in response to the administration of the treatment of the ophthalmic condition, wherein an increase in the levels of PGCla activity over time is indicative that the treatment is providing beneficial effects to the defined patient, and wherein the defined patient was previously identified as having reduced carboxylesterase 1 (CES1) activity, compared to normal activity levels of CES1, prior to the administration of the treatment.

12. The method of claim 11, wherein the defined patient that was previously identified as having reduced carboxylesterase 1 (CES1) activity comprises a genotype of the CES1 gene that is associated with reduced activity, compared to normal activity levels of CES1.

13. The method of claim 12, wherein the treatment comprises the administration of a drug that is metabolized by CES1 in subjects with normal activity levels of CES1.

14. The method of claim 13, wherein the drug is a drug selected from the group consisting of fenofibrate, bezafibrate, ciprofibrate, etofibrate, clofibride, clinofibrate, gemfibrozil, nafenopin, ronifibrate and simfibrate.

15. The method of claim 13, wherein the ophthalmic condition is selected from the group consisting of wet age-related macular degeneration (aAMD), dry age-related macular degeneration (dAMD), Best macular dystrophy, Sorsby fundus dystrophy, Mallatia Leventinese and Doyne honeycomb retinal dystrophy.Attorney Docket No. ALMO-01.5001.W00116. The method of any of claims 11-15 further comprising increasing the dose or frequency of the treatment in the defined patient when the activity levels of PGCloc in the defined patient do not increase over time in response to the administration of the treatment of the ophthalmic condition.

17. The method of any of claims 11-15 further comprising decreasing the dose or frequency of the treatment in the defined patient when the activity levels of PGCla in the defined patient increase over time in response to the administration of the treatment of the ophthalmic condition.

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