WO2017027512A1

WO2017027512A1 - Use of laquinimod to treat traumatic brain injury

Info

Publication number: WO2017027512A1
Application number: PCT/US2016/046169
Authority: WO
Inventors: Bruce Lamb; Atsuko KATSUMOTO
Original assignee: Teva Pharmaceutical Industries Ltd.
Priority date: 2015-08-13
Filing date: 2016-08-09
Publication date: 2017-02-16

Abstract

This application provides for a method of treating a subject suffering from traumatic brain injury, the method comprising periodically administering to the subject an amount of laquinimod or pharmaceutically acceptable salt thereof effective to treat the subject. This application also provides use of laquinimod in the manufacture of a medicament for treating a subject suffering from traumatic brain injury. This application also provides laquinimod for use in treating a subject suffering from traumatic brain injury. This application also provides use of laquinimod in treating a subject suffering from traumatic brain injury. This application also provides a pharmaceutical composition comprising laquinimod for use in treating a subject suffering from traumatic brain injury. This application also provides a pharmaceutical oral unit dosage form of laquinimod for use in treating a subject suffering from traumatic brain injury.

Description

USE OF LAQUINIMOD TO TREAT TRAUMATIC BRAIN INJURY

Throughout this application various publications are referenced. The disclosures of these publications in their entireties are hereby incorporated by reference into this application in order to more fully describe the state of the art to which this invention pertains .

Background

Traumatic Brain Injury

Traumatic brain injuries (TBI) are internal and external injuries to the brain as a direct or indirect result of mechanical insult. (Tran, 2014) . TBI is a devastating disorder associated with significant morbidity and mortality, and creates substantial costs to society. (Kumar, 2012) . Within the United States alone, nearly 2 million people sustain a TBI annually, contributing to one-third of all injury-related deaths. (Corps, 2015). Furthermore, TBI is suspected to contribute to a variety of chronic degenerative processes, including chronic traumatic encephalophathy, Alzheimer disease, and Parkinson disease. (Corps, 2015) . TBI may be focal or diffuse. (Mayer, 2013). Focal injuries occur in a specific location whereas diffuse injuries are associated with potentially widespread vascular damage and axonal dysfunction. (Mayer, 2013) .

TBI is caused by both primary and secondary mechanisms. (Kumar, 2012) . Primary injury mechanisms result from the mechanical damage that occurs at the time of trauma to neurons, axons, glia, and blood vessels as a result of shearing, tearing or stretching. (Kumar, 2012) . Collectively, these effects trigger secondary injury mechanisms which include a cascade of cellular and molecular processes such as ionic disturbance, excitotoxicity, mitochondrial dysfunction, oxidative stress, neuronal apoptosis, blood-brain barrier disruption, and cerebral edema. (Tran, 2014; Kumar, 2012) . An important secondary mechanism that contributes to ongoing-neurodegerenation and neurological impairment associated with TBI is neuroinflammation . (Kumar, 2012) . Neuroinflammation is characterized by glial cell activation, leukocyte recruitment, and upregulation of inflammatory mediators. (Kumar, 2012) .

Microglia are the primary source of pro- and anti-inflammatory cytokines and chemokines in the brain. (Kumar, 2012) . Microglia become activated in response to insult, infection, or injury. Activated microglia can assume either Ml or M2 phenotypes depending on stimuli in the local microenvironment . (Mayer, 2013) . The Ml phenotype produces high levels of pro-inflammatory cytokines and oxidative metabolites that are essential for host- defense and phagocytic activity, but that also cause damage to healthy cells and tissue. (Mayer, 2013). The M2 phenotype promotes angiogenesis, and thus CNS repair. (Mayer, 2013) . Following an insult or injury to the brain, it is likely that Ml and M2 microglial exist in a state of dynamic equilibrium within the lesion microenvironment. (Mayer, 2013). Chronic microglial activation may contribute to chronic neurodegeneration and relative neurological deficits following injury. (Kumar, 2012) .

Monocytes are also known to generally particulate in functions such as phagocytosis, cytokine or chemokine release, immune modulation, and tissue repair. (Corps, 2015) . The role of monocytes in TBI pathogenesis is currently unknown. However, it has been suggested that monocyte-derived macrophages play a pathogenic role in the chronic phase after TBI. (Corps, 2015).

Symptoms of TBI include confusion, dizziness, blurred vision, impaired hearing, sensitivity to light or sound, slurred speech, fatigue, headache, memory loss, sleep disturbances, nausea, vomiting, behavior or mood changes, loss of consciousness, loss of coordination, increased confusion, increased agitation, and/or convulsions or seizures. (Eunice Kennedy Shriver National Institute of Child Health and Human Development, 2012) . Treatment Options

TBI causes both acute and chronic neurodegeneration by inducing diverse, delayed biochemical changes. (Kumar, 2012). The pathogenesis of TBI is highly complex. Considerable research efforts have sought to elucidate secondary injury mechanism in order to develop treatments. (Kumar, 2012). However, even though some preclinical studies have suggested promising pharmacological treatments, all clinical trials to date have failed (Kabadi, 2014) . As a result, there is currently no FDA-approved neuroprotective treatment for TBI.

Nonetheless, a number of compounds are being investigated as potential neuroprotective agents for treating TBI, including progesterone, statins, cyclosporine A, diketopiperazines, substance P antagonists, cell cycle inhibitors, etc. (Kabadi, 2014).

In addition, it has been suggested that both pathophysiological changes and neurological impairment after experimental TBI can be attenuated by physical activity. (Kabadi, 2014) . The mechanisms underlying the therapeutic effects of exercise many include up- regulation of brain-derived neurotrophic factor (BDNF) , leading to neuron plasticity as well as anti-apoptotic and antiinflammatory effects. (Kabadi, 2014).

Laquinimod

Laquinimod is a novel synthetic compound with high oral bioavailability which has been suggested as an oral formulation for the treatment of Multiple Sclerosis (MS) (Polman, 2005; Sandberg-Wollheim, 2005) . Laquinimod and its sodium salt form are described, for example, in U.S. Patent No. 6,077,851. The mechanism of action of laquinimod is not fully understood. Laquinimod showed a favorable safety and tolerability profile in multiple sclerosis (MS) patients in two phase III trials (Results of Phase III BRAVO Trial Reinforce Unique Profile of Laquinimod for Multiple Sclerosis Treatment; Teva Pharma, Active Biotech Post Positive Laquinimod Phase 3 ALLEGRO Results) .

Laquinimod has not been disclosed to be effective in treating traumatic brain injury (TBI) .

Summary of the Invention

This invention provides a method of treating a subject suffering from traumatic brain injury, the method comprising periodically administering to the subject an amount of laquinimod or pharmaceutically acceptable salt thereof effective to treat the subject .

This invention provides use of laquinimod in the manufacture of a medicament for treating a subject suffering from traumatic brain injury.

This invention provides laquinimod for use in treating a subject suffering from traumatic brain injury.

This invention provides use of laquinimod in treating a subject suffering from traumatic brain injury.

This invention provides a pharmaceutical composition comprising laquinimod for use in treating a subject suffering from traumatic brain injury.

This invention provides a pharmaceutical oral unit dosage form of laquinimod for use in treating a subject suffering from traumatic brain injury.

Brief Description of the Drawings

Figure 1 Figure 1 is a graphical representation of the number of monocytes present post infliction of injury. Figure 1A shows the number of monocytes (on the y-axis) against the days after infliction of injury (on the x-axis) for TBI and sham groups. Figure IB shows the number of Ly6C high monocytes (on the y-axis) against the days after infliction of injury (on the x-axis) for TBI and sham groups. Figure 2 Figure 2 shows the ipsilateral-cortex at 1 day post-injury (DPI), 3 DPI, and 5 DPI, where green corresponds to microglia, and red corresponds to monocytes .

Figure 3: Figure 3A shows the presence of monocytes in the cortex in Sham-water group, Sham-LAQ group, TBI- water group, and TBI-LAQ group at 3 days post injury. Figure 3B shows the CCR2+ volume (mm³) (on the y-axis) in the Sham-water group, Sham-LAQ group, TBI-LAQ group, and TBI-water group (on the x-axis) . Figure 4: Figure 4 shows the number of Ly6C high monocytes and rate of infiltration of Ly6C high monocytes (on the y-axis) in the Sham-water, Sham-LAQ, TBI-water, and TBI-LAQ groups (on the x-axis) at 3 days post injury. Figure 5: Figure 5A shows microglial reaction in TBI in Sham- water group, Sham-LAQ group, TBI-water group, and TBI-LAQ group, at 3 days post injury. Figure 5B shows the volume of GFP+ area (mm³) (on the y-axis) in the Sham-water group, Sham-LAQ group, TBI-LAQ group, and TBI-water group (on the x-axis) .

Figure 6 : Figure 6A shows the microglial density (mm²) (on the y-axis) in the ipsilateral and contralateral side of injury (on the x-axis) in the cortex, CA1, CA3, and dentate gyrus of mice in the TBI-water and TBI- LAQ groups. Figure 6B shows the microglial density in the ipsilateral side of injury in the cortex, CA1, CA3, and dentate gyrus of mice in the TBI-LAQ and TBI-water groups at 3 days post injury.

Figure 7 shows the number of APP+ cells in the corpus callosum (on the y-axis) in the ipsilateral and contralateral side of injury of mice in the Sham-water, Sham-LAQ, TBI-water, and TBI-LAQ groups (on the x-axis) at 3 days post injury.

Figure 8 shows the number of APP+ cells in the hippocampus (on the y-axis) in the ipsilateral and contralateral side of injury of mice in the Sham- water, Sham-LAQ, TBI-water, and TBI-LAQ groups (on the x-axis) at 3 days post injury.

Figure 9 shows the number of doublecortin+ cells in the dentate gyrus (on the y-axis) in the ipsilateral and contralateral side of injury in the Sham-water, Sham-LAQ, TBI-water, and TBI-LAQ groups (on the x-axis) at 3 days post injury.

Figure 10 shows the volume (mm³) of the lateral ventricle and of the hippocampus (on the y-axis) in each group of mice studied, i.e. sham-water, sham- LAQ, TBI-water, and TBI-LAQ (on. the x-axis) at 120 days post injury.

Figure 11A is a graphical representation of the Rotarod test results. The graph shows the latency in seconds (on the y-axis) at different time points in for the Sham-water, Sham-LAQ, TBI-water, and TBI-LAQ groups (on the x-axis) . Figure 11B is a graphical representation of the Y-maze test results The graphs show the number of total entry and the percent alteration (on the y-axis) at different time points for the Sham-water, Sham-LAQ, TBI-water, and TBI-LAQ groups (on the x-axis) .

Figure 12: Figure 12 is a graphical representation of the

Water-maze test results for the TBI-water and TBI- LAQ groups. Figure 12A shows the latency to find platform in seconds (on the y-axis) at days 1, 2, 3, 4, and 5 (on the x-axis) . Figure 12B shows the velocity (cm/s) (on the y-axis) at days 1, 2, 3, 4, and 5 (on the x-axis) . Figure 12C shows the distance moved (cm) (on the y-axis) at days 1, 2, 3, 4, and 5 (on the x-axis) .

Figure 13: Figure 13 is a graphical representation of the

Water-maze test results for the Sham-water, Sham- LAQ, TBI-water, and TBI-LAQ groups. Figure 13A shows the latency to find platform in seconds (on the y-axis) at days 1, 2, 3, 4, and 5 (on the x- axis) . Figure 13B shows the velocity (cm/s) (on the y-axis) at days 1, 2, 3, 4, and 5 (on the x-axis) . Figure 13C shows the distance moved (cm) (on the y- axis) at days 1, 2, 3, 4, and 5 (on the x-axis) .

Figure 14: Figure 14A and 14B show the upregulated genes by

TBI in microglia and the processes associated therewith .

Figure 15: Figure 15A and 15B show the downregulated genes by

TBI in microglia and the processes associated therewith.

Figure 16 is a graphical representation of the gene expression changes in microglia by laquinimod (on the y-axis) against the gene upregulated by TBI (on the x-axis) .

Figure 17 shows hierarchical clustering analysis of microglia which shows that laquinimod treatment attenuated TBI-induced microglial gene expression closer to the sham group .

Detailed Description of the Invention

This invention provides a method of treating a subject afflicted with traumatic brain injury, the method comprising periodically administering to the subject an amount of laquinimod or pharmaceutically acceptable salt thereof effective to treat the subject.

In one embodiment, the amount of laquinimod is effective to improve recovery of the subject comparing to the recovery of a subject afflicted with TBI not treated with laquinimod.

In one embodiment, the recovery is evaluated using the Glasgow Outcome Scale (GOS) . In one embodiment, the amount of laquinimod is effective to increase the percentage of subjects with favorable outcome on the GOS by at least 10% comparing to that of subjects afflicted with TBI not treated with laquinimod. In another embodiment, the amount of laquinimod is effective to increase the percentage of subjects with favorable outcome on the GOS by at least 30% comparing to that of subjects afflicted with TBI not treated with laquinimod. In another embodiment, the amount of laquinimod is effective to increase the percentage of subjects with favorable outcome on the GOS by at least 50% comparing to that of subjects afflicted with TBI not treated with laquinimod.

In one embodiment, the subject is evaluated using the GOS at three months after the infliction of injury. In another embodiment, the subject is evaluated using the GOS at six months after the infliction of injury. In another embodiment, the subject is evaluated using the GOS at 12 months or more after the infliction of injury.

In one embodiment, the amount of laquinimod is effective to promote anti-inflammatory gene expression in microglia, downregulate inflammatory gene expression in microglia, and/or reduce apoptotic gene expression in microglia of the subject comparing to that in microglia of a subject afflicted with TBI not treated with laquinimod. In one embodiment, the amount of laquinimod is effective to promote anti-inflammatory gene expression in microglia of the subject comparing to that in microglia of a subject afflicted with TBI not treated with laquinimod. In another embodiment, the amount of laquinimod is effective to downregulate inflammatory gene expression in microglia of the subject comparing to that in microglia of a subject afflicted with TBI not treated with laquinimod. In another embodiment, the amount of laquinimod is effective to reduce apoptotic gene expression in microglia of the subject comparing to that in microglia of a subject afflicted with TBI not treated with laquinimod.

In one embodiment, the amount of laquinimod is effective to reduce monocyte infiltration in the subject comparing to that in a subject afflicted with TBI not treated with laquinimod. In one embodiment, monocyte infiltration is reduced by reducing the number of infiltrating monocytes. In another embodiment, monocyte infiltration is reduced by reducing the rate of infiltration of monocytes. In another embodiment, the monocytes are inflammatory monocytes . In one embodiment, the amount of laquinimod is effective to reduce axonal damage in the subject comparing to that in a subject afflicted with TBI not treated with laquinimod. In one embodiment, axonal damage is reduced in the corpus callosum. In another embodiment, axonal damage is reduced in the hippocampus. In one embodiment, the amount of laquinimod is effective to increase microglial density in the subject comparing to that in a subject afflicted with TBI not treated with laquinimod. In one embodiment, microglial density is increased in the cortex. In another embodiment, microglial density is increased in the hippocampus. In another embodiment, microglial density is increased in the CA1 region of the hippocampus. In another embodiment, microglial density is increased in the CA3 region of the hippocampus. In another embodiment, microglial density is increased in the dentate gyrus region of the hippocampus . In one embodiment, the amount of laquinimod is effective to promote tissue repair and/or neurogenesis in the subject comparing to that in a subject afflicted with TBI not treated with laquinimod. In one embodiment, tissue repair and/or neurogenesis is promoted in the dentate gyrus.

In one embodiment, the amount of laquinimod is effective to prevent enlargement of lateral ventricle volume in the subject comparing to that in a subject afflicted with TBI not treated with laquinimod. In one embodiment, the amount of laquinimod is effective to promote phagocytosis in the subject comparing to that in a subject afflicted with TBI not treated with laquinimod.

In one embodiment, the amount of laquinimod is effective to improve cognitive function in the subject comparing to that in a subject afflicted with TBI not treated with laquinimod. In one embodiment, the cognitive function is memory. In another embodiment, the memory is long-term memory. In another embodiment, the memory is spatial reference memory. In another embodiment, the cognitive function is learning. In another embodiment, the learning is spatial reference learning. In another embodiment, the cognitive function is spatial navigation.

In one embodiment, the amount of laquinimod is effective to reduce a symptom of TBI in the subject comparing to that in a subject afflicted with TBI not treated with laquinimod.

In one embodiment, the symptom of TBI is confusion, dizziness, disorientation, loss of coordination, memory loss, inability to form new memories, sleep disturbances, behavior or mood changes, increased agitation, depression, convulsions, and/or seizures.

In one embodiment, the amount of laquinimod reduces a symptom of TBI by at least 10%. In another embodiment, the amount of laquinimod reduces a symptom of TBI by at least 20%. In another embodiment, the amount of laquinimod reduces a symptom of TBI by at least 30%. In another embodiment, the amount of laquinimod reduces a symptom of TBI by at least 50%. In another embodiment, the amount of laquinimod reduces a symptom of TBI by at least 70%. In another embodiment, the amount of laquinimod reduces a symptom of TBI by more than 100%. In another embodiment, the amount of laquinimod reduces a symptom of TBI by more than 300%. In another embodiment, the amount of laquinimod reduces a symptom of TBI by more than 1000%. In one embodiment, the TBI was inflicted by concussion. In one embodiment, the TBI was inflicted by an open head injury. In another embodiment, the TBI was inflicted by a closed head injury. In one embodiment, the TBI was inflicted by a focal injury. In another embodiment, the TBI was inflicted by a diffuse injury.

In one embodiment, the subject was clinically diagnosed to have a form of TBI prior to receiving administration of laquinimod. In one embodiment, the form of TBI is mild TBI. In another embodiment, the form of TBI is moderate TBI. In another embodiment, the form of TBI is severe TBI.

In one embodiment, the subject was clinically diagnosed to have a form of TBI using the Glasgow Coma Scale (GCS) prior to receiving administration of laquinimod. In one embodiment, the subject had a GCS score of 13 to 15. In another embodiment, the subject had a GCS score of 9-12. In another embodiment, the subject had a GCS score of 3-8.

In one embodiment, the subject is not afflicted with multiple sclerosis .

In one embodiment, the laquinimod is laquinimod sodium.

In one embodiment, laquinimod is administered via oral administration.

In one embodiment, the periodic administration is daily administration. In another embodiment, the periodic administration is more often than once daily. In another embodiment, the periodic administration is less often than once daily. In one embodiment, the amount laquinimod administered is less than 0.6 mg/day. In another embodiment, the amount laquinimod administered is 0.1-40.0 mg/day. In another embodiment, the amount laquinimod administered is 0.1-2.5 mg/day. In another embodiment, the amount laquinimod administered is 0.25-2.0 mg/day. In another embodiment, the amount laquinimod administered is 0.5-1.2 mg/day. In another embodiment, the amount laquinimod administered is 0.25 mg/day. In another embodiment, the amount laquinimod administered is 0.3 mg/day. In another embodiment, the amount laquinimod administered is 0.5 mg/day. In another embodiment, the amount laquinimod administered is 0.6 mg/day. In another embodiment, the amount laquinimod administered is 1.0 mg/day. In another embodiment, the amount laquinimod administered is 1.2 mg/day. In another embodiment, the amount laquinimod administered is 1.5 mg/day. In yet another embodiment, the amount laquinimod administered is 2.0 mg/day.

In one embodiment, the periodic administration of laquinimod continues for at least 3 days. In another embodiment, the periodic administration of laquinimod continues for more than 30 days. In another embodiment, the periodic administration of laquinimod continues for more than 42 days. In another embodiment, the periodic administration of laquinimod continues for 8 weeks or more. In another embodiment, the periodic administration of laquinimod continues for at least 12 weeks. In another embodiment, the periodic administration of laquinimod continues for at least 24 weeks. In another embodiment, the periodic administration of laquinimod continues for more than 24 weeks. In another embodiment, the periodic administration of laquinimod continues for 6 months or more. In one embodiment, the laquinimod is administered in combination with nonsteroidal anti-inflammatory drugs (NSAIDs) , salicylates, slow-acting drugs, gold compounds, hydroxychloroquine, sulfasalazine, combinations of slow-acting drugs, corticosteroids, cytotoxic drugs, immunosuppressive drugs and/or antibodies . In one embodiment, the subject is a human.

In one embodiment, the pharmaceutical oral unit dosage form comprises less than 0.6 mg laquinimod. In another embodiment, the pharmaceutical oral unit dosage form comprises 0.1-40.0 mg laquinimod. In another embodiment, the pharmaceutical oral unit dosage form comprises 0.1-2.5 mg laquinimod. In another embodiment, the pharmaceutical oral unit dosage form comprises 0.25-2.0 mg laquinimod. In another embodiment, the pharmaceutical oral unit dosage form comprises 0.5-1.2 mg laquinimod. In another embodiment, the pharmaceutical oral unit dosage form comprises 0.25 mg laquinimod. In another embodiment, the pharmaceutical oral unit dosage form comprises 0.3 mg laquinimod. In another embodiment, the pharmaceutical oral unit dosage form comprises 0.5 mg laquinimod. In another embodiment, the pharmaceutical oral unit dosage form comprises 0.6 mg laquinimod. In another embodiment, the pharmaceutical oral unit dosage form comprises 1.0 mg laquinimod. In another embodiment, the pharmaceutical oral unit dosage form comprises 1.2 mg laquinimod. In another embodiment, the pharmaceutical oral unit dosage form comprises 1.5 mg laquinimod. In another embodiment, the pharmaceutical oral unit dosage form comprises 2.0 mg laquinimod.

For the foregoing embodiments, each embodiment disclosed herein is contemplated as being applicable to each of the other disclosed embodiments. In addition, the elements recited in the method embodiments can be used in the use and pharmaceutical composition embodiments described herein and vice versa.

A pharmaceutically acceptable salt of laquinimod as used in this application includes lithium, sodium, potassium, magnesium, calcium, manganese, copper, zinc, aluminum and iron. Salt formulations of laquinimod and the process for preparing the same are described, e.g., in U.S. Patent Application Publication No. 2005/0192315 and PCT International Application Publication No. WO 2005/074899, each of which is hereby incorporated by reference into this application. A dosage unit may comprise a single compound or mixtures of compounds thereof. A dosage unit can be prepared for oral dosage forms, such as tablets, capsules, pills, powders, and granules.

Laquinimod can be administered in admixture with suitable pharmaceutical diluents, extenders, excipients, or carriers (collectively referred to herein as a pharmaceutically acceptable carrier) suitably selected with respect to the intended form of administration and as consistent with conventional pharmaceutical practices. The unit will be in a form suitable for oral administration. Laquinimod can be administered alone but is generally mixed with a pharmaceutically acceptable carrier, and co-administered in the form of a tablet or capsule, liposome, or as an agglomerated powder. Examples of suitable solid carriers include lactose, sucrose, gelatin and agar. Capsule or tablets can be easily formulated and can be made easy to swallow or chew; other solid forms include granules, and bulk powders. Tablets may contain suitable binders, lubricants, diluents, disintegrating agents, coloring agents, flavoring agents flow-inducing agents, and melting agents . Specific examples of the techniques, pharmaceutically acceptable carriers and excipients that may be used to formulate oral dosage forms of the present invention are described, e.g., in U.S. Patent Application Publication No. 2005/0192315, PCT International Application Publication Nos . WO 2005/074899, WO 2007/047863, and WO/2007/146248, each of which is hereby incorporated by reference into this application.

General techniques and compositions for making dosage forms useful in the present invention are described-in the following references: 7 Modern Pharmaceutics, Chapters 9 and 10 (Banker & Rhodes, Editors, 1979); Pharmaceutical Dosage Forms: Tablets (Lieberman et al . , 1981); Ansel, Introduction to Pharmaceutical Dosage Forms 2nd Edition (1976); Remington's Pharmaceutical Sciences, 17th ed. (Mack Publishing Company, Easton, Pa., 1985); Advances in Pharmaceutical Sciences (David Ganderton, Trevor Jones, Eds., 1992); Advances in Pharmaceutical Sciences Vol 7. (David Ganderton, Trevor Jones, James McGinity, Eds., 1995); Aqueous Polymeric Coatings for Pharmaceutical Dosage Forms (Drugs and the Pharmaceutical Sciences, Series 36 (James McGinity, Ed., 1989); Pharmaceutical Particulate Carriers: Therapeutic Applications: Drugs and the Pharmaceutical Sciences, Vol 61 (Alain Rolland, Ed., 1993); Drug Delivery to the Gastrointestinal Tract (Ellis Horwood Books in the Biological Sciences. Series in Pharmaceutical Technology; J. G. Hardy, S. S. Davis, Clive G. Wilson, Eds.); Modern Pharmaceutics Drugs and the Pharmaceutical Sciences, Vol. 40 (Gilbert S. Banker, Christopher T. Rhodes, Eds.). These references in their entireties are hereby incorporated by reference into this application.

Tablets may contain suitable binders, lubricants, disintegrating agents, coloring agents, flavoring agents, flow-inducing agents, and melting agents. For instance, for oral administration in the dosage unit form of a tablet or capsule, the active drug component can be combined with an oral, non-toxic, pharmaceutically acceptable, inert carrier such as lactose, gelatin, agar, starch, sucrose, glucose, methyl cellulose, dicalcium phosphate, calcium sulfate, mannitol, sorbitol, microcrystalline cellulose and the like. Suitable binders include starch, gelatin, natural sugars such as glucose or beta-lactose, corn starch, natural and synthetic gums such as acacia, tragacanth, or sodium alginate, povidone, carboxymethylcellulose, polyethylene glycol, waxes, and the like. Lubricants used in these dosage forms include sodium oleate, sodium stearate, sodium benzoate, sodium acetate, sodium chloride, stearic acid, sodium stearyl fumarate, talc and the like. Disintegrators include, without limitation, starch, methyl cellulose, agar, bentonite, xanthan gum, croscarmellose sodium, sodium starch glycolate and the like.

The severity of the patient's TBI may be quantified by the Glasgow Coma Scale (GCS) . The GCS is the cumulative score of three areas of examination: Eye, Verbal and Motor function. For the Eye exam, the patient is graded from 1 to 4 as follows: 1-no eye opening to any stimulation, 2-eye opening only in response to pain, 3-eye opening to speech, and 4-eyes are open spontaneously. For the Verbal exam, the patient is graded from 1 to 5 as follows: 1-no verbal response, 2-incomprehensible sounds, 3- inappropriate words, 4-confused, and 5-oriented. For the Motor exam, the patient is graded from 1 to 6 as follows: 1-no motor response, 2-extension to pain, 3-abnormal flexion to pain, 4- withdrawal to pain, 5-localizes to pain, and 6-obeys commands. The GCS score is the sum of the three scores received for the Eye, Verbal and Motor responses. In general, head injury is classified as mild, moderate or severe based on the Glasgow Coma Scale as follows: Mild: GCS > 13, Moderate: GCS 9 - 12, and Severe: GCS < 8. (Jones, 1979). The level of recovery of TBI patients may be quantified by the Glasgow Outcome Scale (GOS) . The Glasgow Outcome Scale is a 5- level score: 1-dead, 2-vegetative state, 3-severely disabled, 4- moderately disabled, and 5-good recovery. The GOS is frequently divided into "favorable" outcomes (moderately disabled and good recovery) and "unfavorable" outcome (dead, vegetative state, and severely disabled) . (Narayan, 2000) .

Terms

As used herein, and unless stated otherwise, each of the following terms shall have the definition set forth below.

As used herein, "laquinimod" means laquinimod acid or a pharmaceutically acceptable salt thereof, as well as derivatives as laquinimod such as deuterium enriched laquinimod, and salts thereof .

A "salt" is salt of the instant compounds which have been modified by making acid or base salts of the compounds. The term "pharmaceutically acceptable salt" in this respect, refers to the relatively non-toxic, inorganic and organic acid or base addition salts of compounds of the present invention. A pharmaceutically acceptable salt of laquinimod as used in this application includes lithium, sodium, potassium, magnesium, calcium, manganese, copper, zinc, aluminum and iron. Salt formulations of laquinimod and the process for preparing the same are described, e.g., in U.S. Patent No. 7,589,208 and PCT International Application Publication No. WO 2005/074899, which are hereby incorporated by reference into this application . As used herein, "about" in the context of a numerical value or range means ±10% of the numerical value or range recited or claimed.

"Administration" means the giving of, dispensing of, or application of medicines, drugs, or remedies to a subject to relieve or cure a pathological condition. Oral administration is one way of administering the instant compounds to the subject. An "amount" or "dose" of laquinimod as measured in milligrams refers to the milligrams of laquinimod acid present in a preparation, regardless of the form of the preparation. A "dose of 0.6 mg laquinimod" means the amount of laquinimod acid in a preparation is 0.6 mg, regardless of the form of the preparation. Thus, when in the form of a salt, e.g. a laquinimod sodium salt, the weight of the salt form necessary to provide a dose of 0.6 mg laquinimod would be greater than 0.6 mg (e.g., 0.64 mg) due to the presence of the additional salt ion.

As used herein, "combination" means an assemblage of reagents for use in therapy either by simultaneous or contemporaneous administration. Simultaneous administration refers to administration of an admixture (whether a true mixture, a suspension, an emulsion or other physical combination) of the reagents. In this case, the combination may be the admixture or separate containers of the reagents that are combined just prior to administration. Contemporaneous administration refers to the separate administration of the reagents at the same time, or at times sufficiently close together that a synergistic activity or an activity that is additive or more than additive relative to the activity of either reagents alone is observed.

As used herein, "effective" when referring to an amount of laquinimod refers to the quantity of a laquinimod that is sufficient to yield a desired therapeutic response without undue adverse side effects (such as toxicity, irritation, or allergic response) commensurate with a reasonable benefit/risk ratio when used in the manner of this invention.

As used herein, "treating" encompasses, e.g., inducing inhibition, regression, or stasis of the disorder. Specifically, treatment of a patient suffering from TBI includes, e.g., reducing a symptom of TBI in the subject, inducing clinical response, inhibiting disease progression, or inhibiting a disease complication in the subject. "Inhibition" of disease progression or disease complication in a subject means preventing or reducing the disease progression and/or disease complication in the subject.

A "symptom" associated with TBI includes any clinical or laboratory manifestation associated with TBI and is not limited to what the subject can feel or observe.

As used herein, "a subject afflicted with TBI" means a subject who was been clinically diagnosed to have a form of TBI.

As used herein, a "loading dose" refers to an initial higher dose of a drug that may be given at the beginning of a course of treatment before dropping down to a lower "intended dose" or "maintenance dose".

A "salt thereof" is a salt of the instant compounds which have been modified by making acid or base salts of the compounds. The term "pharmaceutically acceptable salt" in this respect, refers to the relatively non-toxic, inorganic and organic acid or base addition salts of compounds of the present invention. For example, one means of preparing such a salt is by treating a compound of the present invention with an inorganic base. As used herein, "pharmaceutically acceptable carrier" refers to a carrier or excipient that is suitable for use with humans and/or animals without undue adverse side effects (such as toxicity, irritation, and allergic response) commensurate with a reasonable benefit/risk ratio. It can be a pharmaceutically acceptable solvent, suspending agent or vehicle, for delivering the instant compounds to the subject.

A "concussion" is a clinical syndrome characterized by immediate and transient impairment of neural function such as alteration of consciousness, disturbance of vision, equilibrium, etc., due to mechanical force. A concussion may or may not result in external signs of head trauma. A "closed head injury" is a trauma in which the brain is injured as a result of a blow to the head, or a sudden, violent motion that causes the brain to knock against the skull. In a closed injury, no object actually penetrates the brain. Closed injuries can be diffuse or focal.

An "open head injury" is a trauma in which object penetrates the skull and enters the brain. Open head injuries are usually focal.

An injury is "focal" if the injury confined to one area of the brain. In most cases, the brain tissue is damaged at the site where the injury occurred.

An injury is "diffuse" if the area of damage is widespread.

A "favorable outcome" refers to the GOS outcome where the patient is evaluated to have a score of 4: moderately disabled, or a score of 5: good recovery at the relevant time of the patient's recovery.

An "unfavorable outcome" refers to the GOS outcome where the patient is evaluated to have a score of 1: dead, a score of 2: vegetative state, or a score of 3: severely disabled at the relevant time of the patient's recovery. It is understood that where a parameter range is provided, all integers within that range, and tenths and hundreds thereof, are also provided by the invention. For example, "0.2 - 2.0 mg/day" includes 0.2 mg/day, 0.25 mg/day, 0.3 mg/day, 0.4 mg/day, 0.5 mg/day, 0.6 mg/day etc. up to 2.0 mg/day. This invention will be better understood by reference to the Experimental Details which follow, but those skilled in the art will readily appreciate that the specific experiments detailed are only illustrative of the invention as described more fully in the claims which follow thereafter. Experimental Details

Example 1: Effects of Laquinimod on Microglia and Monocytes Following Traumatic Brain Injury

Introduction The aim of the performed study was to use a mice model of traumatic brain injury (TBI) to assess the effect of laquinimod on TBI-induced neuroinflammation including microglial activation and monocyte infiltration along with persistent inflammation and neurodegeneration, and to test the hypothesis that laquinimod differentially effects microglia and monocytes to alter inflammation following TBI.

Animals

2-month old CX3CR1GFP/+ CCR2RFP/+ mice were utilized for clear distinction of microglia and infiltrating monocytes. General Study Design

Traumatic brain injury was inflicted by fluid percussion injury device at 1 ATM of pressure.

Mice were administered laquinimod or vehicle by oral gavage before and after the TBI. Laquinimod was administered at 25 mg/kg once daily.

To assess the effect of TBI on microglia, the following comparison was conducted.

Table 1.

Naive, water TBI, water

Sham-ipsilateral, water TBI-ipsilateral, water

To assess the effect of laquinimod on TBI with respect microglia, the following comparison was conducted.

Table 2.

To assess the effect of laquinimod on TBI with respect to monocytes, the following comparison was conducted.

Table 3.

TBI-ipsilateral, wat TBI-ipsilateral, laquinimod

To assess the effect of laquinimod on behavior following TBI, mice were subjected to the Rotarod test, which assesses balance and coordination, at 1, 3, 6, 30, 60, and 90 days post-injury (DPI) .

To assess the effect of laquinimod on behavior following TBI, mice were subjected to the Y-maze test, which assesses spatial working memory, at 9, 30, 60, and 90 DPI.

To assess the effect of laquinimod on behavior following TBI, mice were subjected to the water maze test, which assesses spatial reference memory, at 120-126 DPI. Mice were sacrificed 3 days after the injury for gene expression analyses .

Microglia and monocytes were examined using nanostring analysis and gene chip which contains 445 microglial enriched genes and 17 inflammatory-related genes for the levels of immune gene mRNAs.

Samples were analyzed twice to reduce technical variability.

Results

Acute Phase (3 DPI)

Monocyte infiltration in the injured cortex reached a peak at 3 DPI. There was a downward trend of the number of infiltrating monocytes in the laquinimod treated group.

In monocytes, laquinimod up-regulated genes related to phagocytosis and down-regulated toll-like receptor (TLR) signaling and adhesion molecules. Notably, we also found a significant elevation of CD45+CCR2+Ly6Chigh inflammatory monocytes in the brain 3 days following TBI by flow cytometry, which was reduced by laquinimod treatment (p<0.05). There was no difference in microglial reaction between the TBI-water group and the TBI-LAQ group. Laquinimod treated mice showed less axonal damage and restored suppressed neurogenesis by TBI. Gene expression analyses demonstrated microglia up-regulate TLR-4 cascade and NFKB signaling and at the same time down-regulate inflammatory (IL-6 and IL-8) at 3 days following TBI. Laquinimod treatment promoted anti-inflammatory gene expression profile within microglia and hierarchical clustering showed that laquinimod treatment attenuated TBI-induced microglial gene expression closer to the sham group. In addition, immunohistochemistry showed that axonal damage was lessened following laquinimod treatment.

Chronic Phase (120 DPI) Laquinimod restored enlarged ventricles induced by TBI.

TBI-water group showed enlarged lateral ventricle, which was not seen in TBI-LAQ group.

There was no difference between all groups in Rotarod and Y-maze tests.

Laquinimod treated group, both Sham and TBI, showed better score than water control group in Water maze test.

Conclusions

The results suggest that laquinimod acts on both monocytes and microglia following TBI to attenuate inflammation by both reducing the recruitment of inflammatory monocytes as well as promoting a more sham-like microglial phenotype that leads to an amelioration of neuronal-based alterations induced by TBI.

References

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Claims

What is claimed is :

A method of treating a subject afflicted with traumatic brain injury (TBI) comprising periodically administering to the subject an amount of laquinimod or pharmaceutically acceptable salt thereof effective to treat the subject.

The method of claim 1, wherein the amount of laquinimod is effective to improve recovery of the subject comparing to that of a subject afflicted with TBI not treated with laquinimod.

The method of claim 2, wherein the recovery of the subject is evaluated using the Glasgow Outcome Scale (GOS) .

The method of claim 3, wherein the amount of laquinimod is effective to increase the percentage of subjects with favorable outcome on the GOS by at least 10% comparing to that of subjects afflicted with TBI not treated with laquinimod.

The method of claims 3 or 4, wherein the amount of laquinimod is effective to increase the percentage of patients with favorable outcome on the GOS by at least 30% comparing to that of subjects afflicted with TBI not treated with laquinimod.

The method of any one of claims 3-5, wherein the amount of laquinimod is effective to increase the percentage of patients with favorable outcome on the GOS by at least 50% comparing to that of subjects afflicted with TBI not treated with laquinimod.

The method of any one of claims 3-6, wherein the subject is evaluated using the GOS at three months after the infliction of injury.

The method of any one of claims 3-7, wherein the subject is evaluated using the GOS at six months after the infliction of injury.

9. The method of any one of claims 3-8, wherein the subject is evaluated using the GOS at 12 months or more after the infliction of injury.

10. The method of any one of claims 1-9, wherein the amount of laquinimod is effective to reduce inflammation by promoting anti-inflammatory gene expression, downregulating inflammatory gene expression, and/or reducing apoptotic gene expression in microglia of the subject comparing to that in microglia of a subject afflicted with TBI not treated with laquinimod.

11. The method of claim 10, wherein the amount of laquinimod is effective to promote anti-inflammatory gene expression in microglia of the subject comparing to that in microglia of a subject afflicted with TBI not treated with laquinimod. 12. The method of claim 10, wherein the amount of laquinimod is effective to downregulate inflammatory gene expression in microglia of the subject comparing to that in microglia of a subject afflicted with TBI not treated with laquinimod.

13. The method of any one of claims 1-12, wherein the amount of laquinimod is effective to reduce apoptotic gene expression in microglia of the subject comparing to that in microglia of a subject afflicted with TBI not treated with laquinimod.

14. The method of any one of claims 1-13, wherein the amount of laquinimod is effective to reduce monocyte infiltration in the subject comparing to that in a subject afflicted with TBI not treated with laquinimod.

15. The method of claims 14, wherein monocyte infiltration is reduced by reducing the number of infiltrating monocytes.

16. The method of claims 14 or 15, wherein monocyte infiltration is reduced by reducing the rate of infiltration of monocytes.

17. The method of any one of claims 14-16, wherein the monocytes are inflammatory monocytes.

18. The method of any one of claims 1-17, wherein the amount of laquinimod is effective to reduce axonal damage in the subject comparing to that in a subject afflicted with TBI not treated with laquinimod.

19. The method of any one of claims 1-18, wherein axonal damage is reduced in the corpus callosum.

20. The method of any one of claims 1-18, wherein axonal damage is reduced in the hippocampus .

21. The method of any one of claims 1-20, wherein the amount of laquinimod is effective to increase microglial density in the subject comparing to that in a subject afflicted with TBI not treated with laquinimod.

22. The method of claim 21, wherein microglial density is increased in the cortex.

23. The method of claims 21 or 22, wherein microglial density is increased in the hippocampus .

24. The method of any one of claims 21-23, wherein microglial density is increased in the CA1 region of the hippocampus.

25. The method of any one of claims 21-23, microglial density is increased in the CA3 region of the hippocampus.

26. The method of any one of claims 21-23, wherein microglial density is increased in the dentate gyrus region of the hippocampus .

27. The method of any one of claims 1-26, wherein the amount of laquinimod is effective to promote tissue repair and/or neurogenesis in the subject comparing to that in a subject afflicted with TBI not treated with laquinimod.

28. The method of any one of claims 1-27, wherein tissue repair and/or neurogenesis is promoted in the dentate gyrus.

29. The method of any one of claims 1-28, wherein the amount of laquinimod is effective to prevent enlargement of lateral ventricle volume in the subject comparing to that in a subject afflicted with TBI not treated with laquinimod.

30. The method of any one of claims 1-29, wherein the amount of laquinimod is effective to promote phagocytosis in the subject comparing to that in a subject afflicted with TBI not treated with laquinimod.

31. The method of any one of claims 1-30, wherein the amount of laquinimod is effective to improve cognitive function in the subject comparing to that in a subject afflicted with TBI not treated with laquinimod.

32. The method of claim 31, wherein the cognitive function is memory.

33. The method of claim 32, wherein the memory is long-term memory.

34. The method of claims 32 or 33, wherein the memory is spatial reference memory.

35. The method of any one of claims 31-34, wherein the cognitive function is learning.

36. The method of claim 35, wherein the learning is spatial reference learning.

37. The method of any one of claims 31-36, wherein the cognitive function is spatial navigation.

38. The method of any one of claims 1-37, wherein the amount of laquinimod is effective to reduce a symptom of TBI in the subject comparing to that in a subject afflicted with TBI not treated with laquinimod. 39. The method of claim 38, wherein the symptom of TBI is confusion, dizziness, disorientation, loss of coordination, memory loss, inability to form new memories, sleep disturbances, behavior or mood changes, increased agitation, depression, convulsions, and/or seizures. 40. The method of claims 38 or 39, wherein the amount of laquinimod reduces a symptom of TBI by at least 10%, at least 20%, at least 30%, at least 50%, at least 70%, more than 100%, more than 300%, or more than 1000%. 41. The method of any one of claims 1-40, wherein the TBI was inflicted by concussion.

42. The method of any one of claims 1-41, wherein the TBI was inflicted by an open head injury.

43. The method of any one of claims 1-41, wherein the TBI was inflicted by a closed head injury.

44. The method of any one of claims 1-43, wherein the TBI was inflicted by a focal injury.

45. The method of any one of claims 1-43, wherein the TBI was inflicted by a diffuse injury. 46. The method of any one of claims 1-45, wherein the subject was clinically diagnosed to have a form of TBI prior to receiving administration of laquinimod.

47. The method of claim 46, wherein the form of TBI is mild TBI.

48. The method claim 46, wherein the form of TBI is moderate TBI.

49. The method of claim 46, wherein the form of TBI is severe TBI . 50. The method of any one of claims 1-49, wherein the subject was clinically diagnosed to have a form of TBI using the Glasgow Coma Scale (GCS) prior to receiving administration of laquinimod.

51. The method of claim 50, wherein the subject had a GCS score of 13 to 15.

52. The method of claim 50, wherein the subject had a GCS score of 9-12.

53. The method of claim 50, wherein the subject had a GCS score of 3-8.

54. The method of any one of claims 1-53, wherein the subject is not afflicted with multiple sclerosis.

55. The method of any one of claims 1-54, wherein the laquinimod is laquinimod sodium.

56. The method of any one of claims 1-55, wherein the laquinimod is administered via oral administration.

57. The method of any one of claims 1-56, wherein the periodic administration is daily administration.

58. The method of any one of claims 1-56, wherein the periodic administration is more often than once daily.

59. The method of any one of claims 1-56, wherein the periodic administration is less often than once daily.

60. The method of any one of claims 1-59, wherein the amount laquinimod administered is less than 0.6 mg/day.

61. The method of any one of claims 1-60, wherein the amount laquinimod administered is 0.1-40.0 mg/day.

62. The method of any one of claims 1-61, wherein the amount laquinimod administered is 0.1-2.5 mg/day.

63. The method of any one of claims 1-62, wherein the amount laquinimod administered is 0.25-2.0 mg/day.

64. The method of any one of claims 1-63, wherein the amount laquinimod administered is 0.5-1.2 mg/day.

65. The method of claim 61, wherein the amount laquinimod administered is 0.25 mg/day, 0.3 mg/day, 0.5 mg/day, 0.6 mg/day, 1.0 mg/day, 1.2 mg/day, 1.5 mg/day, or 2.0 mg/day.

66. The method of any one of claims 1-65, wherein the periodic administration of laquinimod continues for at least 3 days, for more than 30 days, for more than 42 days, for 8 weeks or more, for at least 12 weeks, for at least 24 weeks, or for 6 months or more.

67. The method of any one of claims 1-66, wherein the laquinimod is administered in combination with nonsteroidal antiinflammatory drugs (NSAIDs) , salicylates, slow-acting drugs, gold compounds, hydroxychloroquine, sulfasalazine, combinations of slow-acting drugs, corticosteroids, cytotoxic drugs, immunosuppressive drugs and/or antibodies.

68. The method of any one of claims 1-67, wherein the subject is a human.

69. Use of laquinimod in the manufacture of a medicament for treating a subject suffering from traumatic brain injury.

70. Laquinimod for use in treating a subject suffering from traumatic brain injury.

71. Use of laquinimod in treating a subject suffering from traumatic brain injury. 72. A pharmaceutical composition comprising laquinimod for use in treating a subject suffering from traumatic brain injury.

73. A pharmaceutical oral unit dosage form of laquinimod for use in treating a subject suffering from traumatic brain injury.