WO2023084459A1 - Methods of treating sars-cov-2 - Google Patents

Abstract

This invention relates to methods of treating a method of treating a patient infected with SARS-CoV-2 comprising administering to the patient in need of such treatment a therapeutically effective amount of pexmetinib, or a pharmaceutically acceptable salt thereof. The patient infected with SARS-CoV-2 could be suffering from one or more of fever, dry cough, diarrhea, headache, lymphopenia, hypoxia, shortness of breath, transaminitis, pulmonary edema, acute hypoxemic respiratory failure, kidney failure, respiratory failure, pneumonia, macrophage activation syndrome (MAS or cytokine storm), severe acute respiratory syndrome (SARS), acute respiratory distress syndrome (ARDS), and cardiac failure. The invention also relates to methods of treating a patient infected with other viral infections as described, comprising administering to the patient in need of such treatment a therapeutically effective amount of pexmetinib, or a pharmaceutically acceptable salt thereof. The invention also relates to associated combination therapies, pharmaceutical compositions and pharmaceutical uses.

Description

METHODS OF TREATING SARS-COV-2

FIELD OF THE INVENTION

This invention relates to discovery of new methods for treating patients that are affected by viral infections, including those infected with SARS-CoV-2 and with coronavirus disease 2019 (COVID-19).

BACKGROUND OF THE INVENTION

Coronavirus disease 2019 (COVID- 19) is a viral disease caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), that can cause acute respiratory distress syndrome (ARDS). ARDS is an acute lung disease due to destruction of the alveolar epithelium (diffuse alveolar damage) that is a response to a variety of injurious stimuli including viral pathogens such as SARS-CoV-2. The destruction of the alveolar epithelial barrier leads to an exudation of interstitial fluid and inflammatory cells (neutrophils and macrophages) that ultimately compromises lung dynamics, ventilation, and oxygenation. Clinically, development of ARDS is characterized by bilateral pulmonary infiltrates, decreased pulmonary compliance, and progressive hypoxemia. The severity of COVID-19 can vary from asymptomatic illness to severe or fatal disease. Many patients may rapidly (within 1 - 2 weeks of infection) develop dyspnea and pneumonia and require hospitalization for respiratory support. Of these hospitalized patients, 20 - 30% have required admission to intensive care units (ICUs) for ventilatory support due to development of ARDS, with ventilatory failure being a major cause of overall mortality due to COVID- 19.

The genome sequence of SARS-CoV-2 was sequenced from isolates from nine patients in Wuhan, China and found to be of the genus betacoronavirus sharing about 79% homology with severe acute respiratory syndrome coronavirus (SARS-CoV), the causative agent of the SARS outbreak in 2002-2003. Nonclinical data from betacoronaviruses that are similar to SARS-CoV-2 suggest that the pathogenic characteristics of progressive disease are dominated by an intense inflammatory response. The ultimate result is progressive destruction of the alveolar epithelium leading to ARDS. Moreover, the exudative phase of ARDS is due, at least in part, to a pro-inflammatory response involving influx of innate immune cells (neutrophils and macrophages) and elevations of inflammatory cytokines such as interleukin (IL)-6, IL-8, and tumor necrosis factor (TNF)-a, with higher levels of both IL-6 and IL-8 levels being correlated with increased mortality. While innate immune signaling is likely important for the initial response to SARS-CoV-2 infection, once pneumonia has developed, immunomodulatory therapy may be beneficial in reducing the deleterious effects of lung inflammation and mitigating progressive lung injury.

Mitogen-activated protein kinases (MAPKs) including ERK, JNK and p38 are involved in cell death and are thought to play a role in coronavirus infection. Pre-clinical work has suggested that chloroquine mediates its anti-viral effect on viral replication by inhibiting p38 MAPK (Kono et al, 2008, Antiviral Research: 77, 150-152). Additional work has demonstrated that p38 MAPK controls gene expression induced upon infection with highly pathogenic avian influenza viruses (HPAIV). P38 MAPK regulates interferon synthesis and subsequent interferon signaling, and the inhibition of p38 MAPK protects mice from lethal cytokine expression; the authors concluded that p38 MAPK is crucial for the infection-induced hypercytokinemia (Borgeling et al, 2014, JBC 289: 13-27). This is further supported by the findings that innate immune cell recruitment and early innate cytokine and chemokine production in infected mice lungs are independent events regulated by pulmonary epithelium (Teijaro et al., 2011 , Cell 146: 980-991) and there is a direct link between IFN-1 signaling, immune activation, negative immune regulator expression, lymphoid tissue disorganization and virus persistence which can be controlled by blocking IFN-1 signaling (Teijaro et al., 2013, Science 340: 207-211).

Beyond coronavirus infection, p38 MAPK activity is thought to play a role in viral infection and replication. For example, inhibition of p38 MAPK has been reported to impair virus inducted primary and secondary host gene responses protecting mice from lethal H5N1 infection (Borgeling et al., 2013, J. Biol Chem 289(1): 13-27) and a novel p38 MAPK specific inhibitor has been reported to suppress respiratory syncytial virus and influenza A virus replication by inhibiting virus-induced p38 MAPK activation (Choi et al., 2016, Biochem and Biophys Res Comm 477: 311-316).

A quantitative mass spectrometry-based proteomics survey of the effects of SARS-CoV- 2 infection revealed activation of p38 MAPK and casein kinase II (CK2), production of diverse cytokines, and shutdown of mitotic kinases results in cell cycle arrest. Pharmacologic inhibition of p38 produced antiviral effects (Bouhaddou et al., 2020, Cell 182: 685-712).

Coronavirus is an enveloped, single-stranded positive sense RNA virus. Approximately two-thirds of the 5' genome encodes two overlapping polyproteins, pp1a and pplab, which are essential for viral replication and transcription. The 3' terminus encodes a set of four structural proteins for coronavirus: nucleocapsid (N), spike protein (S), membrane protein (M), and envelope protein (E), which are responsible for virion assembly and suppression of host immune response. In the life cycle of coronavirus infection, it mainly uses spike proteins to bind to their receptors for attachment onto the host cell membrane. Then, the coronavirus fuses with host cellular membrane and releases its genomic RNA. Subsequently, the two polyproteins are expressed through hijacking host ribosomes, which are further processed by two viral proteases, papain-like protease and main protease (Mpro), also termed 3CL protease, into 16 mature non-structural proteins (nsps). These nsps, including helicase, RNA-dependent RNA polymerase (RdRp), and methyltransferase, can then assemble into the replication: transcription complex and initiate viral RNA replication and translation (Thiel et al., 2003, J. Gen. Virol. 84(Pt.9): 2305-2315). The newly produced viral RNA and proteins are then packaged into mature progeny virions, which are subsequently released through exocytosis to infect other healthy cells.

Mpro, or 3CL protease, is a 33.8-kDa cysteine protease which mediates the maturation of functional polypeptides involved in the assembly of replication-transcription machinery (Wang et al., 2016, Virol. Sin. 31:24-30). Mpro digests the polyprotein at no less than 11 conserved sites, starting with the autolytic cleavage of this enzyme itself from pp1a and pplab. In addition, 3CL protease has no human homolog and is highly conserved among coronaviruses (Yang et al., 2006, Curr. Pharm. Des. 12: 4573-4590). These above features make it an attractive drug target.

There are several animal models which recapitulate disease and virus replication of SARS-CoV-2. For example, transgenic mice expressing the SARS-CoV-2 receptor, human ACE2 have been produced that support viral replication of SARS-CoV-2 (Bao et al, 2020, Nature: 583, 830-833; Sun et al, 2020, Cell Host & Microbe: 28, 124-133). However, with ectopic expression of ACE2 in these models, the virus appears to cause the death of animals due to inappropriately high-level expression of ACE2 in the brain, resulting in viral encephalitis (Jiang et al, 2020, Cell: 182, 50-58). Subsequently, a robust MA-SARS-CoV-2 model was developed by site directed mutations in spike gene and multiple passages; thus, allowing for evaluation of antiviral agents in vivo against SARS-CoV-2 (Dinnon et al, 2020, Nature: 586(7830), 560-566; Leist et al., 2020, Cell: 183, 1070-1085).

The airway epithelium is a major target tissue for respiratory infections. The epithelial anti-viral response is orchestrated by the interferon regulatory factor-3 (IRF3) which induces type I and type III interferon (IFN) signaling.

To date there are few treatments for CVOID-19. Paxlovid (nirmatrelvir, ritonavir) has been authorized by FDA in United States of America for emergency use under an Emergency Use Authorization for the treatment of mild-to-moderate COVD-19 in adults and pediatric patients with positive results of direct SARS-CoV-2 viral testing, and who are at high risk for progression to severe COVID-19, including hospitalization or death. Lagevrio (molnupiravir) has been authorized by FDA in United States of America for emergency use under an Emergency Use Authorization, for the treatment of mild-to-moderate COVID-19 in adults who are at risk for progression to severe COVID-19, including hospitalization or death, and for whom alternative COVID-19 treatment options authorize d by FDA are no accessible or clinically appropriate. Veklury (remdesivir) is approved in United States for the treatment of adults and pediatric patients for the treatment of COVID-19 requiring hospitalization. There remains a need for therapies for COVID-19, for example that are effective treatments for COVID-19 beyond the initial days of infection, or that prevent the progression of infection to severe disease and death, in particular among hospitalized patients with active pneumonia. Further there remains a need for therapies that have a direct effect on reducing viral replication, for example by inhibiting post-cell entry viral RNA synthesis. The present invention provides methods for treating SARS-CoV-2 patients for example by inhibiting the inflammatory pathways activated by COVID- 19 SARS-CoV-2 infection. There also remains a need for additional therapies that treat other viral infections, including respiratory viral infections.

SUMMARY OF THE INVENTION

The present invention provides a method of treating a patient infected with SARS-CoV-2 comprising administering to the patient in need of such treatment a therapeutically effective amount of a p38 MAPK inhibitor, preferably pexmetinib (also known as “ARRY-614”) or a pharmaceutically acceptable salt thereof.

The invention provides a method of treating a patient infected with SARS-CoV-2 comprising administering to the patient in need of such treatment a therapeutically effective amount of pexmetinib, or a pharmaceutically acceptable salt thereof.

Preferably, the invention comprises administering a dose of 25-400 mg of pexmetinib, once per day, or an equivalent amount of pexmetinib in the form of a pharmaceutically acceptable salt thereof. More preferably, the dose is 25, 50, 100, 200, 250, 300, 350 or 400 mg of pexmetinib, once per day, or an equivalent amount of pexmetinib in the form of a pharmaceutically acceptable salt thereof. More preferably, the dose is 200 mg of pexmetinib, once per day, or an equivalent amount of pexmetinib in the form of a pharmaceutically acceptable salt thereof.

In an embodiment of the invention, one or more cytokines selected from the group consisting of interleukin-1 p (IL-1p), tumor necrosis factor a (TNFa), interleukin-6 (IL-6) or prostaglandin E2 (PGE2) is reduced in said patient following at least 14 daily doses of pexmetinib. Preferably, the cytokine is reduced by at least 25%.

In an embodiment of the invention, the expression of one or more cytokines selected from the group consisting of interleukin-1 (I L-1 P), tumor necrosis factor a (TNFa), interleukin-6 (IL-6) or prostaglandin E2 (PGE2) is reduced in said patient following at least 14 daily doses of pexmetinib. Preferably, the expression of the cytokine is reduced by at least 25%.

In an embodiment of the invention, the method further comprises administering a therapeutically effective amount of additional therapeutic agent that is an anti-viral agent, an anti-cytokine agent, a steroid, or an anti-inflammatory agent.

The invention also provides a method of treating a patient infected with SARS-CoV-2 comprising administering to the patient in need of such treatment a therapeutically effective amount of pexmetinib or a pharmaceutically acceptable salt thereof and a therapeutically effective amount of a 3CL protease inhibitor. Preferably, the 3CL protease inhibitor is PF- 07321332 or a pharmaceutically acceptable salt thereof. In other embodiments, the 3CL protease inhibitor is PF-07304814 or PF-00835231 or a pharmaceutically acceptable salt thereof.

In some embodiments, the patient is asymptomatic from the coronavirus infection. In some embodiments, the patient is symptomatic from the coronavirus infection. For example, the patient is symptomatic from the coronavirus infection with one or more symptoms selected from the group consisting of fever, dry cough, diarrhea, headache, lymphopenia, hypoxia, shortness of breath, transaminitis, pulmonary edema, acute hypoxemic respiratory failure, kidney failure, respiratory failure, pneumonia, macrophage activation syndrome (MAS), cytokine storm, severe acute respiratory syndrome (SARS), acute respiratory distress syndrome (ARDS), and cardiac failure.

The invention also provides a method for treating severe acute respiratory syndrome (SARS) or acute respiratory distress syndrome (ARDS) comprising administering to a patient in need thereof a therapeutically effective amount of pexmetinib or a pharmaceutically acceptable salt thereof. The invention also provides a method for treating severe acute respiratory syndrome (SARS) or acute respiratory distress syndrome (ARDS) in a patient in need thereof infected with SARS-CoV-2, comprising administering to the patient a therapeutically effective amount of pexmetinib or a pharmaceutically acceptable salt thereof.

The invention also provides a method for reducing a risk that the patient will develop severe acute respiratory syndrome (SARS) or acute respiratory distress syndrome (ARDS) comprising administering to a patient in need thereof a therapeutically effective amount of pexmetinib or a pharmaceutically acceptable salt thereof. The invention also provides a method for preventing a patient from developing severe acute respiratory syndrome (SARS) or acute respiratory distress syndrome (ARDS) comprising administering to a patient in need thereof a therapeutically effective amount of pexmetinib or a pharmaceutically acceptable salt thereof. In some embodiments, the patient has tested positive for infection by SARS-CoV-2. In some embodiments, the patient has one or more symptoms selected from the group consisting of fever, dry cough, diarrhea, headache, lymphopenia, hypoxia, shortness of breath, transaminitis, pulmonary edema, acute hypoxemic respiratory failure, kidney failure, respiratory failure, pneumonia, MAS or cytokine storm.

In some embodiments, the method further comprises administering a therapeutically effective amount of additional therapeutic agent that is an anti-viral agent, an anti-cytokine agent, a steroid, or an anti-inflammatory agent. Preferably, the additional therapeutic agent is a 3CL protease inhibitor. More preferably, the 3CL protease inhibitor is PF-07321332 or a pharmaceutically acceptable salt thereof. In other embodiments, the 3CL protease inhibitor is PF-07304814 or PF-00835231 or a pharmaceutically acceptable salt thereof.

In some embodiments, the anti-cytokine agent is selected from an anti-IL-6 agent, anti- IL-1 agent, and an anti-TNF agent.

The invention also provides a method of reducing viral load in a patient infected with SARS-CoV-2 comprising administering to a patient in need thereof a therapeutically effective amount of pexmetinib or a pharmaceutically acceptable salt thereof.

The invention also provides a method of reducing morbidity and mortality in a patient infected with SARS-CoV-2, wherein the patient has active pneumonia, comprising administering to a patient in need thereof a therapeutically effective amount of pexmetinib or a pharmaceutically acceptable salt thereof.

The invention also provides a method of mitigating lung injury leading to ARDS in a patient infected with SARS-CoV-2, comprising administering to a patient in need thereof a therapeutically effective amount of pexmetinib or a pharmaceutically acceptable salt thereof.

The present invention also provides a method of treating a lung inflammation in a patient infected with SARS-CoV-2 comprising administering to the patient in need of such treatment a therapeutically effective amount of a p38 MAPK inhibitor, preferably pexmetinib (ARRY-614) or a pharmaceutically acceptable salt thereof and whereby the lung inflammation is reduced in the subject.

In some embodiments, the lung inflammation comprises bronchial epithelial cells infected with SARS-CoV-2.

Definitions

As used herein, the singular form "a", "an", and "the" include plural references unless indicated otherwise. For example, "a" substituent includes one or more substituents.

The term “about” when used to modify a numerically defined parameter (e.g., the dose of a p38 MAPK inhibitor, the dose of pexmetinib and the like) means that the parameter may vary by as much as 10% above or below the stated numerical value for that parameter. For example a dose of about 5 mg/kg should be understood to mean that the dose may vary between 4.5 mg/kg and 5.5 mg. kg.

The term “BID,” as used herein means administration of drug twice a day to patients.

The term “QD,” as used herein means administration of drug once a day to patients.

The term “immune” or “immune system,” as used herein means the innate and adaptive immune systems.

The term “patient” or “subject,” as used herein, means a human being in need of the treatments or therapies as described herein. The term “treating” or “treatment” means an alleviation of symptoms associated with the relevant virus, for example with COVID-19 disease, or halt of further progression or worsening of those symptoms, including, where applicable, syndrome coronavirus 2, severe acute respiratory syndrome (SARS) and acute respiratory distress syndrome (ARDS). Depending on the condition of the patient, the term “treatment” as used herein may include one or more of curative, palliative and prophylactic treatment. Treatment can also include administering a pharmaceutical formulation of the present invention in combination with other therapies.

The term "therapeutically effective" indicates the capability of an agent to prevent or improve the severity of the underlying viral disease, for example COVID-19 disease, or halt of further progression or worsening of those symptoms, including, where applicable, syndrome coronavirus 2, severe acute respiratory syndrome (SARS) and acute respiratory distress syndrome (ARDS), while avoiding adverse side effects typically associated with alternative therapies. The phrase "therapeutically effective" is to be understood to be equivalent to the phrase "effective for the treatment, prevention, or amelioration", and both are intended to qualify the amount of each agent for use in a monotherapy or in a combination therapy which will achieve the goal of improvement in the severity of the disease, for example COVID-19 disease, or pain or other symptom thereof, and the frequency of incidence over treatment of each agent by itself, while avoiding adverse side effects typically associated with alternative therapies.

“Pharmaceutically acceptable” means suitable for use in a “patient” or “subject.”

“Ameliorating” means a lessening or improvement of one or more symptoms as compared to not administering a therapeutic agent of a method or regimen of the invention. “Ameliorating” also includes shortening or reduction in duration of a symptom.

As used herein, an “effective dosage” or “effective amount” of drug, compound or pharmaceutical composition is an amount sufficient to effect any one or more beneficial or desired, including biochemical, histological and I or behavioral symptoms, of the disease, its complications and intermediate pathological phenotypes presenting during development of the disease. For therapeutic use, a “therapeutically effective amount” refers to that amount of a compound being administered which will relieve to some extent one or more of the symptoms of the disorder being treated. An effective dosage can be administered in one or more administrations. For the purposes of this invention, an effective dosage of drug, compound, or pharmaceutical composition is an amount sufficient to accomplish prophylactic or therapeutic treatment either directly or indirectly. As is understood in the clinical context, an effective dosage of drug, compound or pharmaceutical composition may or may not be achieved in conjunction with another drug, compound or pharmaceutical composition.

Each of the embodiments of the present invention described below may be combined with one or more other embodiments of the present invention described herein which is not inconsistent with the embodiment(s) with which it is combined. In addition, each of the embodiments below describing the invention envisions within its scope the pharmaceutically acceptable salts, solvates, hydrates and complexes thereof, and to solvates, hydrates and complexes of salts thereof, including polymorphs, stereoisomers, and isotopically labelled versions thereof of the compounds of the invention. Accordingly, the phrase “or a pharmaceutically acceptable salt thereof” is implicit in the description of all compounds described herein.

BRIEF DESCRIPTION OF THE DRAWINGS

Figure 1 provides a graph showing the dose-dependent effect of pexmetinib (ARRY- 614) reducing viral titer in SARS-CoV-2 infected human airway epithelial (HAE) cells. Results are shown as percent (%) virus inhibition as compared to uninfected cells at day 3 and day 5 post-infection.

Figure 2 provides a graph showing the dose-dependent effect of remdesivir reducing viral titer in SARS-CoV-2 infected HAE cells. Results are shown as percent (%) virus inhibition as compared to uninfected cells at day 3 and day 5 post-infection.

DETAILED DESCRIPTION OF THE INVENTION

The present invention may be understood more readily by reference to the following detailed description of the embodiments of the invention and the Examples included herein. It is to be understood that the terminology used herein is for the purpose of describing specific embodiments only and is not intended to be limiting. It is further to be understood that unless specifically defined herein, the terminology used herein is to be given its traditional meaning as known in the relevant art.

There are three clinical phases associated with patients infected with SARS-CoV-2.

The first phase is characterized by robust virus replication that initiates the patient’s antiviral defense that includes: early IFN response; inflammatory monocyte-macrophage and neutrophil infiltration; and pro-inflammatory cytokines and chemokines. An effective endogenous response at this stage leads to, for example: minimal epithelial and endothelial cell apoptosis; reduced vascular leakage; optimal T cell and antibody responses; reduced virus replication and effective virus clearance. Reducing MEK dependent cytokines at this stage may not be desired but inhibiting MEK to reduce viral replication and viral titers as well as to enhance IFN response would be desired.

The second phase is associated with high fever, hypoxemia, and progression to pneumonia-like symptoms despite a progressive decline in virus titers towards the end of this phase. Anti-viral cytokines and chemokines at this stage lead to an overexuberant response including monocyte/macrophage and polymorphonuclear leukocytes (neutrophils, eosinophils, and basophils). Reducing pathologic levels of MEK dependent cytokines/chemokines may have benefit at this stage of disease.

The third phase, of which -20% of patients progress, is characterized by ARDS and often results in death. Due to the progressive decline in virus titers, this phase may result from overexpression of pro-inflammatory cytokines/chemokines. Reducing pathologic levels of MEK dependent cytokines/chemokines may have benefit at this stage of disease.

The present invention provides a method of treating a patient infected with SARS-CoV-2 comprising administering to the patient in need of such treatment a therapeutically effective amount of a p38 MAPK inhibitor, preferably, pexmetinib or a pharmaceutically acceptable salt thereof.

ARRY-614 is an orally bioavailable, small-molecule kinase inhibitor of p38 MAPK. The ARRY-614 compound, 1-(3-(terf-butyl)-1-(p-tolyl)-1/7-pyrazol-5-yl)-3-(5-fluoro-2-((1-(2- hydroxyethyl)-1 H-indazol-5-yl)oxy)benzyl)urea, has the structure:

It has been assigned the International Nonproprietary Name (INN) pexmetinib. It is an orally bioavailable, small molecule potent dual inhibitor of p38 MAPK and TEK tyrosine kinase, endothelial (Tie2).

Preparation of pexmetinib is described in International patent application PCT/US2007/002272, which published on 9^th August 2007 as WO 2007/089646, and US Patent Nos. 8,039,639 and 8,044,083, the contents of each of which are incorporated herein by reference in their entirety. Crystalline forms of pexmetinib, and formulations thereof are described in International patent application PCT/US2013/027979, which published on 6^th September 2013 as WO 2013/130573, and US Pat. No. 9,278,936, the contents of which is incorporated herein by reference in its entirety.

Inhibitors of MAPK p38 are known to have inhibitory activity with respect to inflammation and cytokine production (e.g., TNF, IL-6, etc.) (Scherle et al., 1998, J. Immunol. 161 : 5681- 5686; Van der Bruggen et al., 1999, Mancuso et al., 2002, Infect. Immun. Q7: 3824-3829; J. Immunol. 169: 1401-1409). In addition, inhibition of p38MAPK promotes anti-tumor immunity via a dendritic cell-driven anti-tumor T-cell response (Lu et al., 2014, Nat. Commun. 5: 4229, PMID 24957461). Published studies have shown that viral replication is p38 MAPK dependent and inhibition of p38 MAPK decreases viral titers in HSV (Su et al., 2017, Acta Pharmacologica Sinica, 38: 402-414). and mouse coronavirus infected cells (Banerjee et al., 2002, J. Virol. 76: 5937-5948). Thus, there are two mechanisms of action by which p38 inhibitors may have utility in the treatment of COVD-19, through dendritic cell priming and inhibition of inflammatory cytokines that may be assisting in alveolar cell viral entry, viral replication and subsequent tissue destruction.

In one embodiment, the present invention provides a method of treating a patient infected with SARS-CoV2 by administering pexmetinib such that cytokines, e.g., p38 MAPK- driven cytokines, are reduced, preferably, by at least 25%, more preferably 50%, or even more preferably 70-80% for a sustained period following multiple doses (e.g., 5, 7, 10, or 14 daily doses) or reduced for at least 2, 4 or 12 hours following a single dose.

In one embodiment, the present invention provides a method of treating a patient infected with SARS-CoV-2 by administering pexmetinib such that one or more cytokines selected from the group consisting of interleukin-1 p (IL-1P), tumor necrosis factor a (TNFa), interleukin-6 (IL-6) or prostaglandin E2 (PGE2) is reduced in said patient, preferably, by at least 25%, more preferably by at least 50%, or even more preferably by at least 70-80% for a sustained period following multiple doses (e.g., 5, 7, 10, or 14 daily doses) or reduced for at least 2, preferably 4 or more preferably 12 hours following a single dose. Preferably one or more cytokines selected from the group consisting of interleukin-1 (IL-1P), tumor necrosis factor a (TNFa), interleukin-6 (IL-6) or prostaglandin E2 (PGE2) is reduced in said patient following at least 14 daily doses of pexmetinib. Preferably, the one or more cytokines are reduced by at least 25%.

Following administration of single doses of pexmetinib to healthy subjects in a Phase 1, randomized, placebo controlled, double-blind, crossover single ascending dose and multiple ascending dose study to evaluate safety, pharmacokinetics and pharmacodynamics, a dose dependent inhibition of cytokine production (IL-1 p, TNFa, IL-6 and prostaglandin E2 (PGE2)) has been observed. The doses studied were 25, 50, 100, 200 and 400 mg pexmetinib administered once per day for the 14-day study period. The magnitude and duration of inhibition was dependent on the dose and the pharmacodynamic (PD) biomarker, with IL-ip and PGE-2 appearing to be the most sensitive to p38 MAPK inhibition. The degree of inhibition varied among biomarkers with maximal inhibition in the range of 70-80% (relative to placebo) observed at 2 to 4 hours post-dose following the 400 mg dose. Inhibition of greater than 50% was observed for at least 12 hours post-dose for the most sensitive biomarker, I L- 1 p. Following administration of multiple doses of pexmetinib to healthy subjects, inhibition of biomarker production was sustained over the 14-day dosing period and was statistically significant at all doses when compared to placebo.

The PD effect of pexmetinib was assessed by monitoring the ex vivo E. coli lipopolysaccharide (LPS)-stimulated production of cytokines, including IL-1 p, TNFa, IL-6, and PGE2. Release of these cytokines following LPS exposure was p38 MAPK dependent. Looking at all dose groups after a single PO dose of pexmetinib showed evidence of a dose response at all sampling time points with maximal inhibition at pexmetinib concentrations above 40 ng/ml for IL-1 p, above 50 ng/ml for TNF, above 80 ng/ml for IL-6, and above 30 ng/ml for PGE2. After repeated dosing of pexmetinib, maximal inhibition of IL-i and TNF were associated with plasma pexmetinib concentrations greater than 50 ng/ml. Maximal inhibition of IL-6 occurred at plasma concentrations above 100 ng/ml. For PGE2, inhibition appeared to reach a maximum at pexmetinib plasma concentrations greater than 40 ng/ml.

A study was performed to evaluate the effect of a single dose of pexmetinib on peak plasma cytokine concentrations following a systemic S. aureus enterotoxin A (SEA) or LPS challenge in male Swiss-Webster mice. Pexmetinib was highly active in both models. SEA- induced TN Fa, IL-6 and y-interferon plasma concentrations were significantly reduced in mice with apparent ED50 values of less that 30 mg/kg, less than 3 mg/kg, and less than 3 mg/kg, respectively. Pexmetinib significantly inhibited LPS-induced TNFa and IL-6 serum concentrations in mice with an ED50 of less than 3 mg/kg.

The present invention also provides a method of treating respiratory syncytial virus (RSV) infection in a patient, comprising administering to the patient in need of such treatment a therapeutically effective among of a p38 MAPK inhibitor, preferably pexmetinib or a pharmaceutically acceptable salt thereof.

As used herein, the term “respiratory syncytial virus infection” refers to a subject who is infected with the RSV virus and, therefore, may exhibit RSV-associated disorders or symptoms including, but not limited to, nasal congestion, nasal flaring, coughing, rapid breathing, breathing difficulty, fever, shortness of breath, wheezing and hypoxia. RSV infection may also result in respiratory complications such as pneumonia, bronchiolitis, bronchitis and croup. Methods of treatment of RSV infection include acute management and chronic management of the disease.

In some embodiments of the method of treating respiratory syncytial virus (RSV) infection, the method further comprises administering a therapeutically effective amount of additional therapeutic agent that is an anti-viral agent, an anti-cytokine agent such as an anti- TNF-alpha antibody, a bronchodilator drug, supplemental oxygen or a corticosteroid.

The present invention also provides a method of treating herpes simplex 1 infection in a patient, comprising administering to the patient in need of such treatment a therapeutically effective among of a p38 MAPK inhibitor, preferably pexmetinib or a pharmaceutically acceptable salt thereof.

As used herein, the term “herpes simplex 1 infection” refers to a subject who is infected with the herpes simplex 1 virus and, therefore, may exhibit herpes simplex 1 associated disorders or symptoms including, but not limited to, skin lesions such as sores or blisters and associated symptoms such as skin tingling, itching or burning sensation.

In some embodiments of the method of treating herpes simplex 1 infection, the method further comprises administering a therapeutically effective amount of additional therapeutic agent that is gamma interferon antibody, anti TNF-alpha agent, an antibody to IL-1 , or topical retinoid.

The present invention also provides a method of treating hepatitis C virus infection in a patient, comprising administering to the patient in need of such treatment a therapeutically effective among of a p38 MAPK inhibitor, preferably pexmetinib, or a pharmaceutically acceptable salt thereof.

As used herein, the term “hepatitis C virus infection” refers to a subject who is infected with hepatitis C virus infected with HCV genotype 1, 1a, 1b, 2, 3, 4, 5, or 6. In addition the subject may optionally be renal impaired, for example the subject may optionally have chronic kidney disease. Furthermore, the subject may optionally be without cirrhosis. Alternatively, the subject may optionally be with compensated cirrhosis.

In some embodiments of the method of treating hepatitis C virus infection, the method further comprises administering a therapeutically effective amount of additional therapeutic agent that is a protease inhibitor, a nucleoside or nucleotide polymerase inhibitor, a nonnucleoside polymerase inhibitor, a NS3B inhibitor, a NS4A inhibitor, a NS5A inhibitor, a NS5B inhibitor, or a cyclophilin inhibitor.

The present invention also provides a method of treating influenza A virus infection in a patient, comprising administering to the patient in need of such treatment a therapeutically effective among of a p38 MAPK inhibitor, preferably pexmetinib, or a pharmaceutically acceptable salt thereof.

In some embodiments of the method of treating influenza A virus infection, the method further comprises administering a therapeutically effective amount of additional therapeutic agent that is a additional antiviral agents, such as oseltamivir or zanamivir or an adamantane such as amantadine and rimantadine.

The present invention also provides a method of treating a human coronavirus infection in a patient, comprising administering to the patient in need of such treatment a therapeutically effective among of a p38 MAPK inhibitor, preferably pexmetinib, or a pharmaceutically acceptable salt thereof.

In one embodiment of the method of treating a human coronavirus infection, the human coronavirus infection is 229E (alpha coronavirus). In another embodiment of the method of treating a human coronavirus infection, the human coronavirus infection is NL63 (alpha coronavirus). In another embodiment of the method of treating a human coronavirus infection, the human coronavirus infection is OC43 (beta coronavirus). In another embodiment of the method of treating a human coronavirus infection, the human coronavirus infection is HKLI1 (beta coronavirus). In another embodiment of the method of treating a human coronavirus infection, the human coronavirus infection is MERS-CoV (beta coronavirus that causes Middle East Respiratory Syndrome or MERS). In another embodiment of the method of treating a human coronavirus infection, the human coronavirus infection is SARS-CoV (beta coronavirus that causes severe acute respiratory syndrome or SARS). p38 MAPK Inhibitors

As an alternative to pexmetinib, or a pharmaceutically acceptable salt thereof, other exemplary p38 MAPK inhibitors that can be used in the present invention include acumapimod (BCT-197), AKP-001, AMG-548, ARRY-371797, AVE-9940, SB203580, dilmapimod, doramapimod (BIRB 796), SB202190 (FHPI), ralimetinib dimesylate (LY2228820), LY-3007113, ML-3595, VX-702 (Selleck), PH-797804, neflamapimod (VX-745), TAK-715, pamapimod (R- 1503, RO4402257), SD 0006, SB-242235, SB-281832, SB239063, Skepinone-L (CBS3830), losmapimod (GW856553X, GW856553, GSK-AHAB), BMS-582949, BMS-751324, CHF-6297, EO-1606, FX-005, GeN1e-1124, GLS-1027, SK610677B, HEP689, IT139, KC-706, KVK-702, LEO-15520, NP-202, PUR-1800, R-1487, RO3201195, RWJ-67657, SC-80036, SCIO-323, SYD-003, TA-02, TOP-1288, TOP-1630, clomethiazole edisilate, deupirfenidone, fluorofenidone, hydronidone, pirfenidone, recilisib sodium, regorafenib, succinobucol, thioureidobutyronitrile hydrochloride, and PD169316, or pharmaceutically acceptable salts thereof.

In one embodiment, the p38 MAPK inhibitor is acumapimod, or a pharmaceutically acceptable salt thereof.

In one embodiment, the p38 MPAK inhibitor is dilmapimod, or a pharmaceutically acceptable salt thereof.

In one embodiment, the p38 MAPK inhibitor is dormapimod, or a pharmaceutically acceptable salt thereof.

In one embodiment, the p38 MAPK inhibitor is losmapimod, or a pharmaceutically acceptable salt thereof.

In one embodiment, the p38 MAPK inhibitor is neflamapimod, or a pharmaceutically acceptable salt thereof.

In one embodiment, the p38 MAPK inhibitor is pamapimod, or a pharmaceutically acceptable salt thereof.

In one embodiment, the p38 MAPK inhibitor is PH797804, or a pharmaceutically acceptable salt thereof.

In one embodiment, the p38 MAPK inhibitor is regorafenib, or a pharmaceutically acceptable salt thereof. In one embodiment, the p38 MAPK inhibitor is clomethiazole, or a pharmaceutically acceptable salt thereof.

In one embodiment, the p38 MAPK inhibitor is pirfenidone, or a pharmaceutically acceptable salt thereof.

Further Therapeutic Agents

As used herein, the term “combination therapy” refers to the administration of each therapeutic agent of the combination therapy of the invention, either alone or in a medicament, either sequentially, concurrently or simultaneously.

As used herein, the term “sequential” or “sequentially” refers to the administration of each therapeutic agent of the combination therapy of the invention, either alone or in a medicament, one after the other, wherein each therapeutic agent can be administered in any order. Sequential administration is particularly useful when the therapeutic agents in the combination therapy are in different dosage forms, for example, one agent is a tablet and another agent is a sterile liquid, and I or are administered according to different dosing schedules, for example, one agent is administered daily, and the second agent is administered less frequently such as weekly.

As used herein, the term “concurrently” refers to the administration of each therapeutic agent in the combination therapy of the invention, either alone or in separate medicaments, wherein the second therapeutic agent is administered immediately after the first therapeutic agent, but that the therapeutic agents can be administered in any order. In a preferred embodiment the therapeutic agents are administered concurrently.

As used herein, the term “simultaneous” refers to the administration of each therapeutic agent of the combination therapy of the invention in the same medicament.

The MAPK inhibitor, preferably pexmetinib, can be administered in combination with another agent or other agents, for example, another anti-viral therapeutic that targets SARS- CoV-2.

For example, numerous therapeutics have been reported to effectively inhibit SARS- CoV-2 replication since the outbreak of the pandemic in late 2019 (Tu et al., 2020, Int. J. Mol. Sci. 12: 2657). They mainly target the essential proteins in the life cycle of the virus. Remdesivir is a promising drug which interferes the viral genome replication by targeting RdRp (Warren et al., 2016, Nature 531 : 381-385). Remdesivir resembles the structure of adenosine, enabling it to incorporate into nascent viral RNA and result in premature termination of the viral RNA chain. Another recently reported potential drug is APN01 , which could inhibit SARS-CoV-2 replication in cellular and embryonic stem cell-derived organoids. It is a soluble recombinant human angiotensin-converting enzyme 2 (ACE2), and could prevent the activation of cellular ACE2, which is the host receptor for viral S protein (Monteil et al., 2020, Cell 181: 905-913). Numerous drug candidates which inhibit the 3CL protease activity and the maturation of nsps have been discovered, such as ebselen, disulfiram, carmofur, a-ketoamides, and peptidomimetic aldehydes 11a/11 b (Dai et al., 2020, Science 368: 1331-1335; Jin et al., 2020a, Nature 582: 289-293; Jin et al., 2020b, Nat. Struct. Mol. Biol. 27 529-532; Zhang et al., 2020, Science 368: 409-412). Although several existing antiviral drugs have shown good results in clinical trials, continued efforts to discover new drugs that efficiently treat COVID-19 are ongoing.

Lopinavir and ritonavir were among the first drugs used in clinical trials to treat COVID- 19 targeting 3CL protease (Cao et al., 2020, N. Engl. J. Med. 382: 1787-1799). They are inhibitors to human immunodeficiency virus (HIV) aspartyl protease, which is encoded by the pol gene of HIV and cleaves the precursor polypeptides in HIV (Walmsley et al., 2002, N. Engl. J. Med. 346: 2039-2046). The combination of lopinavir and ritonavir are commonly used as a therapeutic regimen for patients with HIV infection (Cvetkovic and Goa, 2003, Drugs 63: 769- 802). Lopinavir was previously shown to inhibit 3CL protease of SARS-CoV in vitro (Wu et al., 2004, Proc. Natl. Acad. Sci. USA 101: 10012-10017), and further studies demonstrated promising antiviral capacity of lopinavir/ritonavir against SARS-CoV and MERS-CoV (Chan et al., 2003, Hong Kong Med. J. 9: 399-406; Chan et al., 2015, J. Infect. Dis. 212: 1904-1913).

N3 is a Michael acceptor-based peptidomimetic inhibitor (Yang et al., 2005, PLoS Biol. 3: e324) which exhibits inhibition of SARS-CoV-2 3CL protease (Jin et al., 2020a, supra). Also identified as potent inhibitors are disulfiram, carmofur, Ebselen, shikonin, tideglusib, PX-12, and TDZD-8 (Jin et al., 2020a, supra) as well as bocepravir, GC-376, and calpain inhibitors II and XII (Ma et al., 2020, Cell Res. 31: 678-692). Other molecules are disclosed in Rathnayake et al., 2020, Sci. Transl. Med. 12:eabc5332) and the review by Cui et al. (2020, Frontiers in Molecular Biosciences 7:Article 616341).

A preferred 3CL protease inhibitor for use in combination in the present invention is Paxlovid™, which comprises the 3CL protease inhibitor PF-07321332, (1R,2S,5S)-/V-{(1S)-1- Cyano-2-[(3S)-2-oxopyrrolidin-3-yl]ethyl}-6,6-dimethyl-3-[3-methyl-/\/-(trifluoroacetyl)-L-valyl]-3- azabicyclo[3.1.0]hexane-2-carboxamideor as nirmatrelvir, and which is of formula:

PF-07321332 Another preferred 3CL protease inhibitor for use in combination in the present invention is ((S)-3-((S)-2-(4-methoxy-1 H-indole-2-carboxamido)-4-methylpentanamido)-2-oxo-4-((S)-2- oxopyrrolidin-3-yl)butyl dihydrogen phosphate) also referred herein as PF-07304814, which is cleaved by alkaline phosphatase enzymes in tissue, releasing the active antiviral (N-((S)-1- (((S)-4-hydroxy-3-oxo-1-((S)-2-oxopyrrolidin-3-yl)butan-2-yl)amino)-4-methyl-1-oxopentan-2-yl)- 4-methoxy-1 H-indole-2-carboxamide) also referred herein as PF-00835231 (Boras et al., 2021, BioRxiv, doi: 10.1101/2020.09.12.293498), and which are of formula:

Additional 3CL protease inhibitors that can be used in combination in the present invention are disclosed, for example, in International Patent Applications PCT/IB2021/051768, PCT/IB2021/052738, and PCT/IB2021/052689, in US Patent Application Ser. Nos. 17/221,676 and 17/395,139, and in US Provisional Patent Application Ser. Nos. 63/073,982, 63/143,435, 63/170,158, 63/050,766, 63/167,714, and 63/170,801, US 63/194,241. All patent applications and provisional patent applications cited above are herein incorporated by reference.

Dosage Forms and Regimens

Each therapeutic agent of the methods of the present invention may be administered either alone, or in a medicament (also referred to herein as a pharmaceutical composition) which comprises the therapeutic agent and one or more pharmaceutically acceptable carriers, excipients, or diluents, according to pharmaceutical practice.

When using pexmetinib in each of the present methods described and claimed herein, the invention provides the method wherein said effective amount of pexmetinib is about 5 mg to about 500 mg QD, or free base eguivalent, preferably, e.g., 25 mg, 50 mg, 100 mg, 200 mg, 250 mg, 300 mg, 350 mg, or 400 mg QD, or free base eguivalent. Most preferably, the dose is 200 mg QD, or free base eguivalent.

In some embodiments the present invention provides a method comprising administering a therapeutically effective amount of PF-07321332 (nirmatrelvir), or a pharmaceutically acceptable salt thereof, wherein said effective amount of PF-07321332 (nirmatrelvir) is about 300 mg of PF-07321332 twice per day, or a lower dosage amount of 50 mg, 75 mg, 100 mg, 125 mg, 150 mg, 175 mg, 200 mg, 225 mg, 250 mg, 275 mg, twice per day or the free base equivalent amount of PF-07321332 (nirmaltrelvir) in the form of a pharmaceutically acceptable salt thereof.

In some embodiments the present invention provides a method comprising administering a therapeutically effective among of the 3CL protease inhibitor is PF-07321332, or a pharmaceutically acceptable salt thereof, and further comprises administering to the patient a therapeutically effective amount of ritonavir, or a pharmaceutically acceptable salt thereof, wherein said effective amount of ritonavir, or a pharmaceutically acceptable salt thereof, is about 150 mg of ritonavir twice per day, or a lower dosage amount of 25 mg, 50 mg, 75 mg, 100 mg, 125 mg, twice per day, or the free base equivalent amount of ritonavir in the form of a pharmaceutically acceptable salt thereof. When the present invention comprises administering a therapeutically effective amount of ritonavir, or a pharmaceutically acceptable salt thereof, said ritonavir, or a pharmaceutically acceptable salt thereof, is administered in combination with PF-07321332, or a pharmaceutically acceptable salt thereof.

Administration of compounds of the invention may be conducted by any method that enables delivery of the compounds to the site of action. These methods include oral routes, intraduodenal routes, parenteral injection (including intravenous, subcutaneous, intramuscular, intravascular or infusion), topical, and rectal administration.

Dosage regimens may be adjusted to provide the optimum desired response. For example, a therapeutic agent of the combination therapy of the present invention may be administered as a single bolus, as several divided doses administered over time, or the dose may be proportionally reduced or increased as indicated by the exigencies of the therapeutic situation. It may be particularly advantageous to formulate a therapeutic agent in a dosage unit form for ease of administration and uniformity of dosage. Dosage unit form, as used herein, refers to physically discrete units suited as unitary dosages for the mammalian subjects to be treated; each unit containing a predetermined quantity of active compound calculated to produce the desired therapeutic effect in association with the required pharmaceutical carrier. The specification for the dosage unit forms of the invention may be dictated by and directly dependent on (a) the unique characteristics of the chemotherapeutic agent and the particular therapeutic or prophylactic effect to be achieved, and (b) the limitations inherent in the art of compounding such an active compound for the treatment of sensitivity in individuals.

Thus, the skilled artisan would appreciate, based upon the disclosure provided herein, that the dose and dosing regimen is adjusted in accordance with methods well-known in the therapeutic arts. That is, the maximum tolerable dose may be readily established, and the effective amount providing a detectable therapeutic benefit to a subject may also be determined, as can the temporal requirements for administering each agent to provide a detectable therapeutic benefit to the subject. Accordingly, while certain dose and administration regimens are exemplified herein, these examples in no way limit the dose and administration regimen that may be provided to a subject in practicing the present invention.

It is to be noted that dosage values may vary with the type and severity of the condition to be alleviated and may include single or multiple doses. It is to be further understood that, for any particular subject, specific dosage regimens should be adjusted over time according to the individual need and the professional judgment of the person administering or supervising the administration of the compositions, taking into consideration factors such as the severity of the disorder or condition, the rate of administration, the disposition of the compound and the discretion of the prescribing physician. The dosage ranges set forth herein are exemplary only and are not intended to limit the scope or practice of the claimed composition. For example, doses may be adjusted based on pharmacokinetic or pharmacodynamic parameters, which may include clinical effects such as toxic effects and/or laboratory values. Thus, the present invention encompasses intra-patient dose-escalation as determined by the skilled artisan. Determining appropriate dosages and regimens for administration of the chemotherapeutic agent are well-known in the relevant art and would be understood to be encompassed by the skilled artisan once provided the teachings disclosed herein.

Pharmaceutical Compositions and Routes of Administration

A "pharmaceutical composition" refers to a mixture of one or more of the therapeutic agents described herein, or a pharmaceutically acceptable salt, solvate, hydrate or prodrug thereof as an active ingredient, and at least one pharmaceutically acceptable carrier or excipient. In some embodiments, the pharmaceutical composition comprises two or more pharmaceutically acceptable carriers and/or excipients.

As used herein, a "pharmaceutically acceptable carrier" refers to a carrier or diluent that does not cause significant irritation to an organism and does not abrogate the biological activity and properties of the active compound or therapeutic agent.

The pharmaceutical acceptable carrier may comprise any conventional pharmaceutical carrier or excipient. The choice of carrier and/or excipient will to a large extent depend on factors such as the particular mode of administration, the effect of the excipient on solubility and stability, and the nature of the dosage form.

Suitable pharmaceutical carriers include inert diluents or fillers, water and various organic solvents (such as hydrates and solvates). The pharmaceutical compositions may, if desired, contain additional ingredients such as flavorings, binders, excipients and the like. Thus, for oral administration, tablets containing various excipients, such as citric acid may be employed together with various disintegrants such as starch, alginic acid and certain complex silicates and with binding agents such as sucrose, gelatin and acacia. Examples, without limitation, of excipients include calcium carbonate, calcium phosphate, various sugars and types of starch, cellulose derivatives, gelatin, vegetable oils and polyethylene glycols. Additionally, lubricating agents such as magnesium stearate, sodium lauryl sulfate and talc are often useful for tableting purposes. Solid compositions of a similar type may also be employed in soft and hard filled gelatin capsules. Non-limiting examples of materials, therefore, include lactose or milk sugar and high molecular weight polyethylene glycols. When aqueous suspensions or elixirs are desired for oral administration the active compound therein may be combined with various sweetening or flavoring agents, coloring matters or dyes and, if desired, emulsifying agents or suspending agents, together with diluents such as water, ethanol, propylene glycol, glycerin, or combinations thereof.

The pharmaceutical composition may, for example, be in a form suitable for oral administration as a tablet, capsule, pill, powder, sustained release formulation, solution or suspension, for parenteral injection as a sterile solution, suspension or emulsion, for topical administration as an ointment or cream, or for rectal administration as a suppository.

Exemplary parenteral administration forms include solutions or suspensions of an active compound in a sterile aqueous solution, for example, aqueous propylene glycol or dextrose solutions. Such dosage forms may be suitably buffered, if desired.

The pharmaceutical composition may be in unit dosage forms suitable for single administration of precise amounts.

Pharmaceutical compositions suitable for the delivery of the therapeutic agents of the combination therapies of the present invention, and methods for their preparation will be readily apparent to those skilled in the art. Such compositions and methods for their preparation may be found, for example, in ‘Remington’s Pharmaceutical Sciences’, 19th Edition (Mack Publishing Company, 1995), the disclosure of which is incorporated herein by reference in its entirety.

Therapeutic agents of the combination therapies of the invention may be administered orally. Oral administration may involve swallowing, so that the therapeutic agent enters the gastrointestinal tract, or buccal or sublingual administration may be employed by which the therapeutic agent enters the blood stream directly from the mouth.

Formulations suitable for oral administration include solid formulations such as tablets, capsules containing particulates, liquids, or powders, lozenges (including liquid-filled), chews, multi- and nano-particulates, gels, solid solution, liposome, films (including muco-adhesive), ovules, sprays and liquid formulations.

Liquid formulations include suspensions, solutions, syrups and elixirs. Such formulations may be used as fillers in soft or hard capsules and typically include a carrier, for example, water, ethanol, polyethylene glycol, propylene glycol, methylcellulose, or a suitable oil, and one or more emulsifying agents and/or suspending agents. Liquid formulations may also be prepared by the reconstitution of a solid, for example, from a sachet. Therapeutic agents of the combination therapies of the present invention may also be used in fast-dissolving, fast-disintegrating dosage forms such as those described by Liang and Chen (Expert Opinion in Therapeutic Patents, 2001, 11(6): 981-986), the disclosure of which is incorporated herein by reference in its entirety.

For tablet dosage forms, the therapeutic agent may make up from 1 wt% to 80 wt% of the dosage form, more typically from 5 wt% to 60 wt% of the dosage form. In addition to the active agent, tablets generally contain a disintegrant. Examples of disintegrants include sodium starch glycolate, sodium carboxymethyl cellulose, calcium carboxymethyl cellulose, croscarmellose sodium, crospovidone, polyvinylpyrrolidone, methyl cellulose, microcrystalline cellulose, lower alkyl-substituted hydroxypropyl cellulose, starch, pregelatinized starch and sodium alginate. Generally, the disintegrant may comprise from 1 wt% to 25 wt%, preferably from 5 wt% to 20 wt% of the dosage form.

Binders are generally used to impart cohesive qualities to a tablet formulation. Suitable binders include microcrystalline cellulose, gelatin, sugars, polyethylene glycol, natural and synthetic gums, polyvinylpyrrolidone, pregelatinized starch, hydroxypropyl cellulose and hydroxypropyl methylcellulose. Tablets may also contain diluents, such as lactose (monohydrate, spray-dried monohydrate, anhydrous and the like), mannitol, xylitol, dextrose, sucrose, sorbitol, microcrystalline cellulose, starch and dibasic calcium phosphate dihydrate.

Tablets may also optionally include surface active agents, such as sodium lauryl sulfate and polysorbate 80, and glidants such as silicon dioxide and talc. When present, surface active agents are typically in amounts of from 0.2 wt% to 5 wt% of the tablet, and glidants typically from 0.2 wt% to 1 wt% of the tablet.

Tablets also generally contain lubricants such as magnesium stearate, calcium stearate, zinc stearate, sodium stearyl fumarate, and mixtures of magnesium stearate with sodium lauryl sulphate. Lubricants generally are present in amounts from 0.25 wt% to 10 wt%, preferably from 0.5 wt% to 3 wt% of the tablet.

Other conventional ingredients include antioxidants, colorants, flavoring agents, preservatives and taste-masking agents.

Exemplary tablets may contain up to about 80 wt% active agent, from about 10 wt% to about 90 wt% binder, from about 0 wt% to about 85 wt% diluent, from about 2 wt% to about 10 wt% disintegrant, and from about 0.25 wt% to about 10 wt% lubricant.

Tablet blends may be compressed directly or by roller to form tablets. Tablet blends or portions of blends may alternatively be wet-, dry-, or melt-granulated, melt congealed, or extruded before tableting. The final formulation may include one or more layers and may be coated or uncoated; or encapsulated. The formulation of tablets is discussed in detail in “Pharmaceutical Dosage Forms: Tablets, Vol. 1”, by H. Lieberman and L. Lachman, Marcel Dekker, N.Y., N.Y., 1980 (ISBN 0- 8247-6918-X), the disclosure of which is incorporated herein by reference in its entirety.

Solid formulations for oral administration may be formulated to be immediate and/or modified release. Modified release formulations include delayed-, sustained-, pulsed-, controlled-, targeted and programmed release.

Suitable modified release formulations are described in U.S. Patent No. 6,106,864. Details of other suitable release technologies such as high energy dispersions and osmotic and coated particles may be found in Verma et al, 2001, Pharmaceutical Technology On-line, 25(2): 1-14. The use of chewing gum to achieve controlled release is described in WO 00/35298. The disclosures of these references are incorporated herein by reference in their entireties.

The compounds of the invention may be prepared by any method known in the art. In particular, the compounds of the invention can be prepared by the procedures described by reference to the prior art references in which they are disclosed.

Kits

The therapeutic agents of the combination therapies of the present invention may conveniently be combined in the form of a kit suitable for coadministration of the compositions.

In one aspect, the present invention relates to a kit which comprises a first container, a second container and a package insert, wherein the first container comprises at least one dose of a p38 MAPK inhibitor, or a pharmaceutically acceptable salt thereof, the second container comprises at least one dose of a further therapeutic agent, and the package insert comprises instructions for treating a subject.

In one embodiment, the kit of the present invention may comprise one or both of the active agents in the form of a pharmaceutical composition, which pharmaceutical composition comprises an active agent, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier. The kit may contain means for separately retaining said compositions, such as a container, divided bottle, or divided foil packet. An example of such a kit is the familiar blister pack used for the packaging of tablets, capsules and the like.

The kit may be particularly suitable for administering different dosage forms, for example, oral and parenteral, for administering the separate compositions at different dosage intervals, or for titrating the separate compositions against one another. To assist compliance, the kit typically includes directions for administration and may be provided with a memory aid. The kit may further comprise other materials that may be useful in administering the medicaments, such as diluents, filters, IV bags and lines, needles and syringes, and the like.

It is to be understood that all references, publications and patent applications cited herein are incorporated by reference in their entireties. EXAMPLES

Example 1 - Effect of pexmetinib to inhibit SARS-COV-2 virus in cell-based assay

Pexmetinib effects on SARS-CoV-2 virus inhibition was assessed in human airway epithelial cells and compared to remdesivir.

Test Compound: Prior to the assay, pexmetinib was dissolved in 100% DMSO at a concentration of 20 mg/ml and further diluted to the test dilutions in the MatTek (MatTek Corporation, Ashland, MD) culture medium (AIR-100-MM).

Cell Culture: Antiviral activity was evaluated in differentiated normal human bronchial epithelial (dNHBE) cells in a BSL-3 facility. The dNHBE cells (EpiAirway) were obtained from MatTek and were grown on trans-well inserts consisting of approximately 1.2 x 10⁶ cells in AIR- 100-MM added to the basolateral side, with the apical side exposed to a humidified 5% CO2 environment at 37 °C. On day 1, dNHBE cells were infected with SARS-CoV-2 strain USA- WA1/2020 at a MOI of approximately 0.0015 50% of the cell culture infectious dose (CCID50) per cell, and treatment was carried out by inclusion of drug dilutions in basolateral culture media.

Experimental design: Each compound treatment (120 l) and virus treatment (120 pl) was applied to the apical side. At the same time, the compound treatment (1 ml) was applied to the basal side for a 2-hour incubation. As a virus control, some of the cells were treated with placebo (cell culture medium only). Following the 2-hour infection, the apical medium was removed, and the basal side was replaced with fresh compound or medium (1 ml). The cells were maintained at the air-liquid interface. On day 5, the medium was removed and discarded from the basal side. Virus released into the apical compartment of the dNHBE cells was harvested by the addition of 400 pl of culture medium that was pre-warmed at 37°C. The contents were incubated for 30 minutes, mixed well, collected, thoroughly vortexed and plated on Vero 76 cells for VYR titration. Duplicate wells were used for virus control and cell controls.

Determination of virus titers from each treated cell culture: At day 3 and day 5, virus released into the apical compartment was harvested by the addition of 0.4 ml culture media. The virus titer was then quantified by infecting Vero76 cells in a standard endpoint dilution assay and virus dose that was able to infect 50% of the cell cultures (CCID50 per ml) was calculated (Reed and Muench, 1938, Am J Hygiene 27: 493-497, doi:

10.1093/oxfordjournals.aje.a118408). To determine the EC50 and EC90 values, the CCIDso/ml values were normalized to that of no drug control as a percentage of inhibition and plotted against compound concentration in GraphPad Prism software by using four-parameter logistic regression. Untreated, uninfected cells were used as the cell controls.

Results - Dose-dependent viral inhibition was demonstrated for both pexmetinib (ARRY- 614) and remdesivir at day 3 and day 5 as shown in Figure 1 and Figure 2, respectively. Pexmetinib EC50 at day 3 and day 5 were 102.7 nM and 16.5 nM, respectively. In comparison, remdesivir EC50 at day 3 and day 5 were 12.2 nM and 2.4 nM, respectively.

Example 2 - Protocol

Background

Multifocal interstitial pneumonia represents the most common cause of admission in intensive care units and death in SARS-CoV-2 infections. In our hospital up to 25% of admitted patients with pneumonitis require mechanical ventilation or oro-tracheal intubation within 5-10 days.

Although information about pathological and pathophysiological features of alveolar- interstitial damage is very limited, available data, mostly collected on other coronavirus infections with similar clinical presentation (SARS1, MERS), seem to indicate as the primary pathogenic mechanism an intense cytokine storm with a consequent inflammatory infiltrate of the pulmonary interstitium, macrophage activation, giant cells formation and subsequent extended alveolar damage.

Preliminary evidence is accumulating about the efficacy of an aggressive treatment of coronavirus-induced inflammation, and case series have shown the effectiveness of anti-IL6 strategies in reducing the severity of multifocal interstitial pneumonia in patients affected by SARS-CoV-2, implying a major role of IL-6 in the pathogenesis of lung damage in these patients.

Based on the above rationale, we believe that inhibition of p38 MAPK will be clinically beneficial in down-regulating cytokine-driven, in particular, IL-6, TNF and IL-1, inflammation in patients with SARS-CoV-2 infection. The nonclinical data in models of viral disease may also to translate to beneficial anti-viral activity of p38 MAPK inhibition.

Aims

1) To decrease the virus-induced cytokine storm and prevent the developing of severe pulmonary function deterioration and multiple organ dysfunction, as monitored by the levels of key inflammatory cytokines (e.g., IL-6, IL-1 , TNF).

2) To reduce the rate of patients who need mechanical ventilation and/or oro-tracheal intubation (primary outcome).

3) To reduce infection-related mortality.

4) To obtain a preliminary assessment of anti-viral activity.

Study Design: Prospective, single cohort, open-label pilot study

It is expected that 25% of patients will require mechanical ventilation within 7-10 days after hospital admission for SARS-CoV-2 related pneumonitis. To test the hypothesis that early administration of pexmetinib will reduce this rate to <5%, 50 patients will be enrolled in the study (power 80%, alpha 0.05, excluded from analysis 5%). The planned study duration is 10 weeks. Inclusion Criteria

Able to provide written informed consent; patients under guardianship may participate with the consent of their legally authorized guardian if permitted by local regulations. Age 18-80 years. SARS-CoV-2 infection diagnosed by rt-PCR or suspected SARS-CoV-2 infection with results of SARS-CoV-2 assay not available may be enrolled with prior Sponsor approval. Radiographic scan-confirmed interstitial pneumonia. Hospital admission within the previous 24 hours.

Adequate bone marrow, organ function and laboratory parameters: Aspartate transaminase (AST) and alanine transaminase (ALT) < 2.5 x upper limit of normal (ULN); total bilirubin < 1.5 x ULN; serum creatinine < 1.5 x ULN or calculated creatinine clearance > 50 mL/min by Cockroft-Gault formula or estimated glomerular filtration rate > 50 mL/min/1.73 m² using the Modification of Diet in Renal Disease Study (MDRD) Equation; female patients must have negative serum or urine pregnancy test prior to enrollment; agreement to use effective contraception for 30 days for males and females (of childbearing potential) after last dose of study treatment.

Exclusion Criteria

Requirement for mechanical ventilation at time of admission; history of thromboembolic or cerebrovascular events < 12 weeks prior to the first dose of study treatment (e.g., transient ischemic attacks, cerebrovascular accidents, hemodynamically significant deep vein thrombosis or pulmonary emboli); pregnancy or breastfeeding; known history of retinal degenerative disease, retinal vein occlusion or uncontrolled glaucoma require careful consideration of the risk: benefit of pexmetinib treatment and prior investigator/sponsor approval.

Impaired cardiovascular function or clinically significant cardiovascular disease including, but not limited to, any of the following: history of acute coronary syndrome (ACS) within the last 6 months or active congestive heart failure (CHF) (i.e. New York Heart Association (NYHA) 3 or greater) or active uncontrolled hypertension (150/100 or greater) require a careful consideratiom of the risk: benefit and prior investigator/sponsor approval; LVEF < 50% as determined by multigated acquisition scan (MLIGA) or extracorporeal membrane oxygenation (ECHO); uncontrolled hypertension defined as persistent systolic blood pressure > 150 mmHg or diastolic blood pressure > 100 mmHg despite optimal therapy; history of or current serious arrhythmia (atrial fibrillation (AF) and paroxysmal supraventricular tachycardia (PSVT) are allowed if controlled); baseline QTc interval > 480 msec or a history of prolonged QT syndrome.

Outcome

Primary Outcomes: Rate of patients needing mechanical ventilation to maintain SO2 >92%; rate of patients needing admission to the intensive care unit for oro-tracheal intubation and/or evidence of multiple organ dysfunction. Secondary Outcomes: Rate of patients with evidence of pulmonary function deterioration, defined as worsening of SO2 > 3 percentage points (with stable FiO2) or decrease of PaO2 >10% or decrease of PaO2/FiO2 ratio >50%; duration of hospitalization, measured in days; duration and incidence of new non-invasive ventilation or high flow oxygen use; duration and incidence of new oxygen use; duration and incidence of new ventilator or ECMO use; number of non-invasive ventilation/high flow oxygen free days; number of oxygenation free days; subject 14-day mortality; date and cause of death (if applicable); subject 28-day mortality; date and cause of death (if applicable); ventilator/ECMO free days.

Outcome Assessments

Patients will be evaluated at baseline (time 0) and followed for 14 days or until discharge. At baseline and every 24 hours (unless otherwise indicated), the following will be assessed: hemodynamic and respiratory parameters; changes in hematology, chemistry or coagulation parameters (every other day); arterial blood gases; physical exam (including mental status); viral load.

At baseline and at day +7 and +14, 7 ml of serum will be stored to evaluate the serum levels of cytokines and other exploratory analyses. Patients who require mechanical ventilation or ICU transfer within 24 hours from hospital admission will be excluded from analysis.

Experimental Intervention

Patients will receive pexmetinib at doses of 100, 200, or 400 mg orally QD. Treatment will be started within 12 hours from admission and maintained for 14 days.

Concomitant Treatments

All patients should be treated with hydroxychloroquine (400-600 mg/day) and low molecular weight heparin subcutaneously as per local guidance. Other treatments such as antivirals, antibiotics, or other supportive therapies are permitted and may be administered as per local guidance.

Rescue Therapy

In patients who require mechanical ventilation, pexmetinib treatment can be stopped and rescue therapy started according to institutional standards.

Safety Evaluations

Patients will be evaluated for adverse events every day by clinical examination. Blood examinations will be performed every alternate day.

Any event will be recorded on patient’s documentation and case report form (CRF). All adverse events (AEs), serious and nonserious (including the exacerbation of a pre-existing condition) and regardless of causality to study drug, will be fully recorded on the appropriate eCRF. For each AE, the Investigator must provide its duration (start and end dates or ongoing), severity (intensity), assessment of causality and whether specific action or therapy was required and whether action was taken with regard to study drug treatment. Stopping Rule

Enrollment will be suspended for detailed case review if more than two serious treatment- related adverse events are reported.

Example 3 - In vivo assay to determine the effect of pexmetinib on SARS-CoV-2 in MA-SARS- CoV-2 mouse infection model

To determine the effect of ARRY-614 (pexmetinib) as an inhibitor of SARS-CoV-2 infection in the mouse adapted SARS-CoV-2 mouse infection model (as described in Leist et al., 2020, Cell’. 183, 1070-1085 and Owen et al., 2021, Science’. 374, 1586-1593 including the supplementary materials), a typical study will include the following groups for evaluation: 1) untreated, infected vehicle control, 2) pexmetinib at 1^st dose, for example 30mg/kg QD, 3) pexmetinib at 2^nd dose, for example 100mg/kg QD, and 3) optionally a positive control group, dosed with a treatment such as a 3CL protease inhibitor. Six animals per treatment dose will be orally administered daily during the duration of the study period. Six animals in the vehicle control group will receive vehicle only.

For virus challenge, mice will be anesthetized by intraperitoneal injection of ketamine/xylazine (50 mg/kg/5 mg/kg) prior to challenge by dosing intranasally with 1 x 10⁵ CCID50 of SARS-CoV-2-MA-10 (mouse adapted MA 10 virus), in a 90 pL inoculum volume. Animals will then be treated with the treatment dose or vehicle daily beginning four hours post infection by per oral administration of a 0.1 mL volume of drug, or vehicle, or optionally with a positive control dosed as needed. For oral administration drug will be solubilized in an appropriate vehicle such as 0.5% methylcellulose in water, containing 2% Tween80. Six animals per group will be euthanized on study day 4 by isoflurane inhalation and the right lung lobes will be fixed in 4% paraformaldehyde at 4°C for histopathology and the left lung lobes placed in 1 mL phosphate buffered saline (PBS) with sterile glass beads at -80°C to evaluate lung virus titers.

Virus lung titers will be determined using a standard CCID50 assay in Vero 76 cells. MA- SARS-CoV-2 lung titers will be quantified by homogenizing mouse lungs in 1 mL PBS using 1.0 mm glass beads and a Beadruptor. Endpoint dilution method will be used for virus titration as follows: Serial log dilutions of lung tissue homogenate will be plated in quadruplicate wells of 96-well microplates containing confluent monolayers of Vero 76 cells. The plates will be incubated at 37°C and 5% CO2 for 6 days. The plates will then be scored by visual observation under a light microscope for the presence of cytopathic effect using a light microscope. Virus titer for each sample will be calculated by linear regression using the Reed-Muench method (Reed & Muench, 1938, Epidemiol: 27, 493-497).

The fixed lung lobes will be shipped to an external histology laboratory for processing as follows: Group samples (n = 6) will be processed as one H&E-stained slide from each lung specimen. Blinded evaluation of each lung sample will be conducted by an experienced veterinary pathologist using a semi-quantitative analysis using four parameters: perivascular inflammation, bronchial or bronchiolar epithelial degeneration or necrosis, bronchial or bronchiolar inflammation, and alveolar inflammation. A 5-point scoring system for assessment of epithelial degeneration/necrosis and inflammation will be utilized (0-with normal limits; 1 -mild, scattered cell necrosis/vacuolation, few/scattered inflammatory cells; 2-moderate, multifocal vacuolation or sloughed/necrotic cells, thin layer of inflammatory cells; 3-marked, multifocal/segmental necrosis, epithelial loss/effacement, thick layer of inflammatory cells; 4- severe, coalescing areas of necrosis, parenchymal effacement, confluent areas of inflammation. A total pathology score will be calculated for each mouse by adding the individual histopathological scores.

Modifications may be made to the foregoing without departing from the basic aspects of the invention. Although the invention has been described in substantial detail with reference to one or more specific embodiments, those of ordinary skill in the art will recognize that changes may be made to the embodiments specifically disclosed in this application, and yet these modifications and improvements are within the scope and spirit of the invention.

Claims

28 Claims

1. A method of treating a patient infected with SARS-CoV-2 comprising administering to the patient in need of such treatment a therapeutically effective amount of pexmetinib, or a pharmaceutically acceptable salt thereof.

2. The method of claim 1 , comprising administering a dose of 25-400 mg of pexmetinib, once per day, or an equivalent amount of pexmetinib in the form of a pharmaceutically acceptable salt thereof.

3. The method of claim 2, wherein said dose is 25, 50, 100, 200, 250, 300, 350 or 400 mg of pexmetinib, once per day, or an equivalent amount of pexmetinib in the form of a pharmaceutically acceptable salt thereof.

4. The method of claim 3, wherein said dose is 200 mg of pexmetinib, once per day, or an equivalent amount of pexmetinib in the form of a pharmaceutically acceptable salt thereof.

5. The method of any of claims 1-4, wherein one or more cytokines selected from the group consisting of interleukin-1 p (I L-1 ), tumor necrosis factor a (TNFa), interleukin-6 (IL-6) or prostaglandin E2 (PGE2) is reduced in said patient following at least 14 daily doses of pexmetinib.

6. The method of claim 5, wherein said cytokine is reduced by at least 25%.

7. The method of any one of claims 1-6, wherein the method further comprises administering a therapeutically effective amount of additional therapeutic agent that is an antiviral agent, an anti-cytokine agent, a steroid, or an anti-inflammatory agent.

8. A method of treating a patient infected with SARS-CoV-2 comprising administering to the patient in need of such treatment a therapeutically effective amount of pexmetinib or a pharmaceutically acceptable salt thereof and a therapeutically effective amount of a 3CL protease inhibitor.

9. The method of claim 8, wherein the 3CL protease inhibitor is PF-07321332, or a pharmaceutically acceptable salt thereof.

10. The method of claim 9, comprising administering a dose of 300 mg of PF-07321332 twice per day, or an equivalent amount of PF-07321332 in the form of a pharmaceutically acceptable salt thereof.

11. The method of any of claims 9-10, further comprising administering to the patient a therapeutically effective amount of ritonavir, or a pharmaceutically acceptable salt thereof.

12. The method of claim 11, comprising administering a dose of 150 mg of ritonavir twice per day, or an equivalent amount of ritonavir in the form of a pharmaceutically acceptable salt thereof.

13. The method of any of claims 11-12, wherein the ritonavir, or a pharmaceutically acceptable salt thereof, is administered in combination with PF-07321332, or a pharmaceutically acceptable salt thereof.

14. The method of claim 8, wherein the 3CL protease inhibitor is PF-07304814 or PF- 00835231, or a pharmaceutically acceptable salt thereof.

15. The method of any one of claims 1 to 14, wherein the patient is asymptomatic from the coronavirus infection.

16. The method of any one of claims 1-14, wherein the patient is symptomatic from the coronavirus infection.

17. The method of claim 16, wherein the patient is symptomatic from the coronavirus infection with one or more symptom selected from the group consisting of fever, dry cough, diarrhea, headache, lymphopenia, hypoxia, shortness of breath, transaminitis, pulmonary edema, acute hypoxemic respiratory failure, kidney failure, respiratory failure, pneumonia, macrophage activation syndrome (MAS), cytokine storm, severe acute respiratory syndrome (SARS), acute respiratory distress syndrome (ARDS), and cardiac failure.

18. A method for treating severe acute respiratory syndrome (SARS) or acute respiratory distress syndrome (ARDS) comprising administering to a patient in need thereof a therapeutically effective amount of pexmetinib or a pharmaceutically acceptable salt thereof.

19. A method for reducing a risk that a patient will develop severe acute respiratory syndrome (SARS) or acute respiratory distress syndrome (ARDS) comprising administering to a patient in need thereof a therapeutically effective amount of pexmetinib, or a pharmaceutically acceptable salt thereof.

20. The method of claim 19, wherein the patient has tested positive for infection by SARS- CoV-2.

21. The method of any of claims 18-20, wherein the patient has one or more symptoms selected from the group consisting of fever, dry cough, diarrhea, headache, lymphopenia, hypoxia, shortness of breath, transaminitis, pulmonary edema, acute hypoxemic respiratory failure, kidney failure, respiratory failure, pneumonia, MAS or cytokine storm.

22. The method of any of claims 18-21, wherein the method further comprises administering a therapeutically effective amount of additional therapeutic agent that is an anti-viral agent, an anti-cytokine agent, a steroid, or an anti-inflammatory agent.

23. The method of claim 22, wherein the additional therapeutic agent is a 3CL protease inhibitor.

24. The method of claim 23, wherein the 3CL protease inhibitor is PF-07321332, or a pharmaceutically acceptable salt thereof.

25. The method of claim 24, comprising administering a dose of 300 mg of PF-07321332 twice per day, or an equivalent amount of PF-07321332 in the form of a pharmaceutically acceptable salt thereof.

26. The method of any of claims 23-24, further comprising administering to the patient a therapeutically effective amount of ritonavir, or a pharmaceutically acceptable salt thereof.

27. The method of claim 26, comprising administering a dose of 150mg of ritonavir twice per day, or an equivalent amount of ritonavir in the form of a pharmaceutically acceptable salt thereof.

28. The method of any of claims 26-27, wherein ritonavir, or a pharmaceutically acceptable salt thereof, is administered in combination with PF-07321332, or a pharmaceutically acceptable salt thereof.

29. The method of claim 23, wherein the 3CL protease inhibitor is PF-07304814 or PF- 00835231, or a pharmaceutically acceptable salt thereof.

30. The method of claim 22, wherein the anti-cytokine agent is selected from an anti-IL-6 agent, anti-IL-1 agent, and an anti-TNF agent.

31. A method of reducing viral load in a patient infected with SARS-CoV-2 comprising administering to a patient in need thereof a therapeutically effective amount of pexmetinib, or a pharmaceutically acceptable salt thereof.

32. A method of reducing morbidity and mortality in a patient infected with SARS-CoV-2, wherein the patient has active pneumonia, comprising administering to a patient in need thereof a therapeutically effective amount of pexmetinib, or a pharmaceutically acceptable salt thereof.

33. A method of mitigating lung injury leading to ARDS in a patient infected with SARS-CoV- 2, comprising administering to a patient in need thereof a therapeutically effective amount of pexmetinib, or a pharmaceutically acceptable salt thereof.