EA041458B1 - CHILDREN'S DOSAGE FORM CONTAINING AN APICAL SODIUM-DEPENDENT TRANSPORTER INHIBITOR - Google Patents

Description

This application claims priority under U.S. Provisional Application No. 61/553094, dated October 28, 2011, U.S. Provisional Application No. 61/607487, dated March 6, 2012, and U.S. Provisional Patent Application No. 61/607503, dated March 6, 2012. which are incorporated herein by reference in their entirety.

Background Art Information

Cholestatic liver diseases occur in a small proportion of children, but their therapy requires significant annual costs. Currently, many cholestatic liver diseases in children require invasive and expensive treatments such as liver transplantation and surgery. An effective and less invasive mass treatment of the pediatric population is unknown.

It is obvious and generally accepted that the requirements for therapy in children are significantly different from those for adults, which requires a special study of the effects of drugs on children. For example, for most adult patients, oral administration of a solid dosage form is painless and fairly simple, however, for children, swallowing a dosage form prepared in the same way as for adults can be problematic. In addition, drugs administered in solid dosage form often have an unpleasant taste. More importantly, oral administration of adult drugs in the treatment of cholestatic liver disease can lead to side effects such as diarrhea and intestinal discomfort. These issues pose threats to patient safety and affect compliance. Effective and acceptable forms of medication are needed for the treatment of cholestatic liver disease in children.

The essence of the invention

A pediatric dosage form is proposed to alleviate cholestatic liver disease in children, or childhood cholestasis.

A pediatric dosage form is proposed containing an apical sodium-dependent transporter inhibitor (ASBTI), which is

or a pharmaceutically acceptable salt thereof and a pharmaceutically acceptable excipient, wherein the dosage form is an oral liquid solution formulated to be released in the distal ileum and is suitable for the treatment of cholestatic liver disease in children, wherein cholestatic liver disease in children is is progressive familial intrahepatic cholestasis (PFIC), Alagille syndrome (ALGS), childhood primary sclerosing cholangitis (PSC), or biliary atresia (BA).

In some embodiments, the pediatric dosage form reduces serum bile acids or hepatic bile acids in a patient.

In some embodiments, the pediatric dosage form reduces serum bile acids or hepatic bile acids by at least 20% in a patient.

In some embodiments, the cholestatic liver disease in children is biliary atresia (BA).

In some embodiments, the cholestatic liver disease in children is progressive familial intrahepatic cholestasis (PFIC), type 1 PFIC, type 2 PFIC, or type 3 PFIC.

In some embodiments, the cholestatic liver disease in children is Alagille syndrome (ALGS).

In some embodiments, the cholestatic liver disease is childhood primary sclerosing cholangitis (PSC).

In some embodiments, the dose of ASBTI is from 1 μg/kg/day to 10 mg/kg/day. In some embodiments, the dose of ASBTI is from 5 μg/kg/day to 5 mg/kg/day. In some embodiments, the dose of ASBTI is from 0.4 to 1.5 mg/day. In some embodiments, the dose of ASBTI is administered twice daily. In some embodiments, less than 10% ASBTI is absorbed systemically.

In some embodiments, the pharmaceutically acceptable adjuvant is a diluent, a taste-masking agent, an antioxidant, an excipient, an acidifier, or combinations thereof.

In some embodiments, the volume of the dose is from 5 to 50 ml.

In some embodiments, pediatric dosage forms are provided comprising a pediatric dosage form of a non-systemically administered apical sodium dependent bile transporter inhibitor (ASBTI) or a pharmaceutically acceptable salt thereof. In some variants, children's

- 1 041458 dosage forms containing non-systemically taken ASBTI or its pharmaceutically acceptable salt. In some embodiments, pediatric dosage forms are provided that contain a non-systemically administered ASBTI, or a pharmaceutically acceptable salt thereof, and a second component described herein.

In some embodiments, the pediatric dosage form reduces the concentration of bile acids in serum or liver by at least 50%, 45%, 40%, 35%, 30%, 25%, 20%, 15%, or 10% compared to the concentration in control subjects. In some embodiments, the proposed methods reduce the concentration of bile acids in serum or liver by at least 30%. In some embodiments, the proposed methods reduce the concentration of bile acids in serum or liver by at least 25%. In some embodiments, the proposed methods reduce the concentration of bile acids in serum or liver by at least 20%. In some embodiments, the proposed methods reduce the concentration of bile acids in serum or liver by at least 15%.

In some embodiments, the use of the compounds provided herein reduces or inhibits the recycling of bile salts in the gastrointestinal tract. In some embodiments, the proposed methods reduce the ratio of bile acids/salts within enterocytes or reduce necrosis and/or damage to the intestinal or hepatocellular architecture.

In some embodiments, the disclosed methods assist in the treatment or amelioration of cholestatic liver disease in children by increasing the luminal concentration of bile acids/salts, which are then excreted in the feces, which reduces the total bile acid content in the serum or liver of the affected child. In some embodiments, increasing the concentration of bile acids in the lumen, according to the methods described here, provides protection and/or regulates the integrity of the liver and/or intestine, impaired as a result of cholestasis and/or cholestatic liver disease.

In some embodiments, the disclosed methods assist in the treatment or amelioration of pruritus by increasing the patient's luminal bile acid/salt concentrations and/or decreasing those serum or liver concentrations. In some embodiments, increasing the concentration of bile acids in the lumen, according to the methods described here, provides protection and/or regulates the integrity of the liver and/or intestine, impaired as a result of cholestatic liver disease.

In some embodiments, the methods described herein reduce serum or liver acid concentrations of bile acids by increasing the patient's intraluminal bile acid/salt concentration. In some embodiments, increasing the concentration of bile acids in the lumen, according to the methods described here, provides protection and/or regulates the integrity of the liver and/or intestine, impaired as a result of cholestatic liver disease.

In some embodiments, provided herein are ASBTIs or therapeutically acceptable salts thereof for the treatment of cholestatic liver disease in children, wherein the ASBTI is taken non-systemically or is included in a non-systemic absorption composition. In some embodiments, a pharmaceutical composition is provided for use in the treatment of cholestatic liver disease in children, which includes a pediatric dosage form of ASBTI and a pharmaceutically acceptable excipient, and ASBTI is used non-systemically or is included in the composition for non-systemic absorption. In some embodiments, such a composition is suitable for non-systemic administration to the distal ileum, colon, and/or rectum.

In some embodiments, an ASBTI or a therapeutically acceptable salt thereof is provided for the treatment of pruritus in a child suffering from cholestatic liver disease, wherein the ASBTI is applied non-systemically or is formulated for non-systemic absorption. In some embodiments, provided herein is a pharmaceutical composition for the treatment of pruritus, the composition comprising a pediatric dosage form of ASBTI and a pharmaceutically acceptable excipient, the ASBTI being applied non-systemically or included in the composition for non-systemic absorption. In some embodiments, the composition provided herein is suitable for non-systemic administration to the distal ileum, colon, and/or rectum.

In some embodiments, an ASBTI or a therapeutically acceptable salt thereof is provided for lowering serum or hepatic bile acids in a child suffering from cholestatic liver disease, wherein the ASBTI is used non-systemically or is in a non-systemic absorption formulation. In some embodiments, a pharmaceutical composition is provided for reducing serum or liver bile acid concentrations, the composition comprising a pediatric formulation of ASBTI and a pharmaceutically acceptable excipient, wherein the ASBTI is applied non-systemically or is included in the composition for non-systemic absorption. In some embodiments, the proposed composition is suitable for non-systemic administration to the distal ileum, colon and/or rectum.

In some embodiments, the provided ASBTI is minimally absorbed or formulated for minimal absorption. In some embodiments, the pediatric formulation of ASBTI is administered to the patient non-systemically in the distal ileum, colon, and/or rectum. In some embodiments, the ASBTI is administered to the patient non-systemically in the distal ileum, colon, and/or rectum. In some embodiments, less than 50% is systemically absorbed, less

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40%, less than 30%, less than 20%, less than 10%, less than 9%, less than 8%, less than 7%, less than 6%, less than 5%, less than 4%, less than 3%, less than 2% or less than 1% ASBTI. In a preferred embodiment, less than 10% ASBTI is absorbed systemically. In another preferred embodiment, less than 5% ASBTI is absorbed systemically. In another preferred embodiment, less than 1% ASBTI is absorbed systemically.

In some embodiments, the distal gastrointestinal tract is the small intestine, ileum, colon, or rectum. In some embodiments, the distal gastrointestinal tract is the ileum, colon, or rectum. In some embodiments, the distal gastrointestinal tract is the small intestine. In some embodiments, the distal gastrointestinal tract is the ileum.

In some embodiments, the cholestatic liver disease in children is progressive familial intrahepatic cholestasis (PFIC), PFIC type 1, PFIC type 2, PFIC type 3, Alagille syndrome, Dubin-Johnson syndrome, biliary atresia, Kazai biliary atresia, transplant biliary atresia liver disease, post-liver transplant cholestasis, liver disease associated with post-liver transplant condition, liver disease associated with bowel failure syndrome, liver injury from bile acids, childhood primary sclerosing cholangitis, MRP2 deficiency syndrome, neonatal sclerosing cholangitis, childhood obstructive cholestasis, childhood non-obstructive cholestasis, childhood extrahepatic cholestasis, childhood intrahepatic cholestasis, childhood primary intrahepatic cholestasis, childhood secondary intrahepatic cholestasis, benign recurrent intrahepatic cholestasis (BRIC), BRIP type 1, BRIC type 2, BRIC type 3, total cholestasis associated with parenteral nutrition, paraneoplastic cholestasis, Staufer's syndrome, drug-related cholestasis, cholestasis associated with infection or cholelithiasis. In some embodiments, cholestatic liver disease in children is a childhood form of the liver diseases described herein.

In some embodiments, cholestatic liver disease in children is characterized by one or more of biliary effusion, pruritus, cirrhosis, hypercholaemia, neonatal respiratory distress syndrome, pneumonia, elevated serum bile acids, elevated liver bile acids, elevated serum bilirubin , hepatocellular injury, liver scarring, liver failure, hepatomegaly, xanthoma, malabsorption, splenomegaly, diarrhea, pancreatitis, hepatocellular necrosis, giant cell formation, hepatocellular carcinoma, gastrointestinal bleeding, portal hypertension, hearing loss, fatigue, loss of appetite, anorexia, foul smell, dark urine, soft stools, steatorrhea, weight loss and/or kidney failure.

In some embodiments, the affected child is a newborn, preterm, pre-school child, school-age child, pre-pubertal child, post-pubertal child, adolescent, or teenager under eighteen years of age. In some embodiments, the affected child is a newborn, preterm, preschool, or school age child. In some embodiments, the child is a newborn, prematurely born, a child or a child of preschool age. In some embodiments, the child is a newborn, a premature baby, and a toddler. In some embodiments, the affected child is a newborn. In some embodiments, the affected child is a toddler. In some embodiments, the patient is a sick preschool child.

In some embodiments, the patient is a child less than 2 years of age. In some cases, any methods and/or compositions described apply to children aged 0-18 months. In some cases, any methods and/or compositions described apply to children 1-18 months of age. In some cases, any methods and/or compositions described apply to children aged 2-18 months. In some cases, any methods and/or compositions described apply to children aged 3-18 months. In some cases, any methods and/or compositions described apply to children aged 4-18 months. In some cases, any described methods and/or compositions apply to children aged 6-18 months. In some cases, any methods and/or compositions described apply to children aged 18-24 months. In some cases, any described methods and/or compositions apply to children aged 6-12 months. In some examples, any of the described methods and/or compositions apply to children aged 2-10 years. In some examples, the child is less than about 10 years of age. In some examples, the child is about 10-17 years of age.

In some instances, any of the described methods and/or compositions apply to children aged 6 months to 12 years.

In some embodiments, therapeutic methods and compositions are provided using compounds that inhibit the apical sodium-dependent bile transporter (ASBT), or a therapeutically acceptable salt thereof, or any recuperative bile salt transporter, for the treatment of cholestatic liver disease in children or pruritus or a decrease in the concentration of bile acids in

- 3 041458 serum. In some cases, the use of the proposed compounds reduces or inhibits the recycling of bile salts in the gastrointestinal tract. In some embodiments, the proposed methods reduce the ratio of bile acids/salts within the enterocyte and/or damage to the iliac or hepatocellular architecture as a result of cholestatic liver disease in children and/or promote the regeneration of the intestinal or liver mucosa. In some embodiments, bile transport inhibitors are non-systemic drugs. In other embodiments, the bile transport inhibitors are systemic drugs that are delivered non-systemically. In other embodiments, the bile transport inhibitors are systemic drugs. In some embodiments, the disclosed bile transport inhibitors increase the secretion of enteroendocrine peptides from intestinal L cells.

In some embodiments, pediatric dosage forms are provided, such as solution, syrup, suspension, elixir, powder for use as a suspension or solution, dispersible/effervescent tablet, chewable tablet, chewy candy, lollipop, popsicles, lozenges, absorbable sticks, absorbable tablets, soluble powders, soft gelatin capsules and capsules filled with powders or granules.

In some embodiments, the pediatric dosage form includes 0.5 mg ASBTI. In some embodiments, the pediatric dosage form contains 1 mg of ASBTI. In some embodiments, the pediatric dosage form contains 2.5 mg ASBTI. In some embodiments, the pediatric dosage form contains 5 mg ASBTI. In some embodiments, the pediatric dosage form contains 10 mg of ASBTI. In some embodiments, the pediatric dosage form contains 20 mg of ASBTI.

In some embodiments, the pediatric dose of ASBTI is administered once daily. In some embodiments, the pediatric dose of ASBTI is given daily. In some embodiments, the pediatric dose of ASBTI is administered once daily in the morning. In some embodiments, the pediatric dose of ASBTI is administered once at noon. In some embodiments, the pediatric dose of ASBTI is administered once daily in the evening or at night. In some embodiments, the pediatric dose of ASBTI is administered twice daily. In some embodiments, the pediatric dose of ASBTI is administered twice daily. In some embodiments, the pediatric dose of ASBTI is administered twice daily in the morning and afternoon. In some embodiments, the pediatric dose of ASBTI is administered twice daily in the morning and evening. In some embodiments, the pediatric dose of ASBTI is administered twice daily in the morning and at night. In some embodiments, the pediatric dose of ASBTI is given twice daily in the afternoon and evening. In some embodiments, the pediatric dose of ASBTI is administered twice a day, day and night. In some embodiments, the pediatric dose of ASBTI is administered three times a day. In some embodiments, the pediatric dose of ASBTI is administered three times a day. In some embodiments, the pediatric dose of ASBTI is administered four times a day. In some embodiments, the pediatric dose of ASBTI is administered four times a day. In some embodiments, the pediatric dose of ASBTI is administered every four hours. In some embodiments, the pediatric dose of ASBTI is administered every other day. In some embodiments, the pediatric dose of ASBTI is administered every other day. In some embodiments, the pediatric dose of ASBTI is administered three times a week. In some embodiments, the pediatric dose of ASBTI is administered three times a week.

In some embodiments, methods and dosage forms (e.g., oral or rectal doses) are provided for the treatment of cholestatic liver disease or pruritus in children, or for the reduction of serum bile acid concentrations, comprising a therapeutically effective amount of ASBTI or a therapeutically acceptable salt thereof, and a carrier. In some embodiments, a method of treating cholestasis and/or cholestatic liver disease is provided, comprising administering orally to a patient a therapeutically effective amount of a minimally absorbable ASBTI or a therapeutically acceptable salt thereof. In some embodiments, a method of treating cholestasis and/or cholestatic liver disease is provided, comprising administering orally to a patient a therapeutically effective amount of a minimally absorbable ASBTI or a therapeutically acceptable salt thereof. In some embodiments, the ASBTI or salt thereof is the minimally absorbable ASBTI. In specific embodiments, the dosage form is an enteric formulation, an ileal pH-dependent release formulation, a suppository, or other suitable form.

In some embodiments, the composition used in the treatment of cholestatic liver disease or pruritus in children or to reduce serum bile acid concentrations contains at least one lyophilizing agent or wetting agent. In some embodiments, the composition contains an absorption inhibitor. In some instances, the absorption inhibitor is a mucoadhesive component (eg, a mucoadhesive polymer). In some embodiments, the mucoadhesive component is selected from methylcellulose, polycarbophil, polyvinylpyrrolidone, sodium carboxymethylcellulose, and combinations thereof. In some embodiments, the enteroendocrine peptide secretion-enhancing component is covalently linked to an absorption inhibitor. In some embodiments, the pharmaceutical composition includes an enteric coating. In some embodiments, the composition described above for use in the treatment of cholestasis, cholestatic liver disease, or pruritus contains a carrier. In some embodiments, the carrier is suitable for rectal administration. In some embodiments, any pharmaceutical composition described above is in the form of a suppository, enema solution, rectal foam, or rectal gel. In some embodiments, any pharmaceutical composition described above contains a carrier suitable for oral administration.

In some embodiments, the ASBTI-containing pediatric dosage form is administered orally. IN

- 4 041458 In some embodiments, the ASBTI is administered as a pH dependent ileal release formulation that delivers the ASBTI to the patient's distal region, colon and/or rectum. In some embodiments, the ASBTI is administered as an enteric-coated formulation. In some embodiments, oral delivery as provided herein may include formulations well known to those skilled in the art that provide sustained or sustained delivery of the drug to the gastrointestinal tract by multiple mechanisms. These include, but are not limited to, pH-dependent release of the drug by changing the pH in the small intestine, slow disintegration of the tablet or capsule, retention in the stomach depending on the physical properties of the drug, bioadhesion of the dose to the intestinal mucosa, or release of the active drug by the action of enzymes. The expected effect is to increase the time during which active drug molecules are delivered to the site of action (ileum) by varying the dose. Thus, enteric-coated preparations and such controlled release preparations are within the scope of the present invention. Suitable enteric coatings include cellulose acetate phthalate, polyvinyl acetate phthalate, hydroxypropyl methylcellulose phthalate, and anionic polymers of methacrylic acid and methacrylic acid methyl ester.

In some embodiments, the proposed methods and compositions also include the introduction of a bile acid sequestrant or binder to reduce side effects in the gastrointestinal tract. In some embodiments, the methods include administering a labile bile acid sequestrant that has low affinity for at least one bile acid in the colon or rectum of the patient. In some embodiments, the labile bile acid sequestrant provided herein releases bile acid in the human colon or rectum. In some embodiments, the labile bile acid sequestrant provided herein does not cleave the bile acid and prevents it from being excreted in the faeces. In some embodiments, the labile bile acid sequestrant provided herein is a non-systemic labile bile acid sequestrant. In some embodiments, the non-systemic labile bile acid sequestrant is systemically absorbed by less than 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 25, 30, 35, 40, 45%. In some embodiments, the labile bile acid sequestrant is lignin or a modified lignin. In some embodiments, the labile bile acid sequestrant is a polycationic polymer or copolymer. In some embodiments, the labile bile acid sequestrant is a polymer or copolymer containing one or more K-alkenyl-K-alkylamino groups; one or more K,K,K-trialkyl-K-(K'alkenylamino)alkylazanium groups; one or more K,K,K-trialkyl-K-alkenylazine groups; cholestyramine, colestipol or cholesevelamor, or a combination thereof.

In some embodiments, the pediatric pharmaceutical form containing the ASBTI is administered before a meal. In some embodiments, the pediatric pharmaceutical form containing the ASBTI is administered with or after a meal.

Some options also include administering vitamin supplements to a child with cholestatic liver disease, pruritus, or elevated serum bile acid levels or concentrations to compensate for reduced vitamin intake, including fat-soluble vitamins. In some embodiments, the vitamin supplements include fat soluble vitamins. In some embodiments, fat-soluble vitamins include vitamins A, D, E, or K.

In some cases, any of the methods of administration of ASBTIs described above will reduce the content of bile acids/salts in enterocytes in a patient. In some embodiments, the described methods reduce the accumulation in the patient's ileum of fatty acids/salts in enterocytes. In some cases, any of the methods of administration of ASBTIs described above will inhibit the transport of fatty acids/salts from the patient's iliac lumen to enterocytes. In some cases, the methods of administration of ASBTIs described above increase the content of fatty acids/salts in the lumen of the ileum in a patient. In some instances, any of the methods of administration of ASBTIs described above reduce damage to the patient's intestinal (eg, iliac cells) or hepatocellular (eg, liver cells) architecture associated with childhood cholestatic liver disease or elevated liver bile acids. In some instances, any of the methods of administration of ASBTIs described above result in regeneration of the intestinal mucosa or liver cells damaged by cholestasis and/or cholestatic liver disease in a child suffering from cholestatic liver disease.

In some embodiments, the ASBTI is administered in combination with one or more selected from the group consisting of ursodiol, UDCA, ursodeoxycholic acid, chenodeoxycholic acid, cholic acid, taurocholic acid, ursocholic acid, glycocholic acid, glycodeoxycholic acid, taurodeoxycholic acid, taurocholate, glycochenodeoxycholic acid, tauroursodeoxycholic acid, cholestyramine resins, antihistamines (eg, hydroxyzine, diphenylhydramine), rifampin, nalaxone, phenobarbital, dronabinol (CB1 agonist), methotrexate, corticosteroids, cyclosporine, colchicine, vitamin E (TPGS), vitamins A, D, E or K optionally with polyethylene glycol, zinc, gum, or a sequestrant for absorption of bile acids.

In some embodiments, a kit is provided that includes any of the compositions described (on

- 5 041458 example, a pharmaceutical composition for rectal administration) and a device for localized delivery to the rectum or toast. In some embodiments, such a device is a syringe, a container, or a sealed container.

Brief description of the figures

Fig. 1. Oral administration to rats of various doses of 264W94 increases the content of fecal bile acids. The concentration of fecal bile acids increased by 6.5 times at an effective dose of ED ₅₀ 0.17 mg/kg compared with the introduction of the vehicle. The content of faecal non-esterified fatty acids also slightly increased in rats that were injected with 264W94. Plasma bile acid concentrations in 264W94-treated rats decreased in a dose-dependent manner.

Fig. Fig. 2. The level of bile acids in the plasma of ZDF rats after the introduction of increasing doses of SC435 and LUM002. Male ZDF rats (n = 4) were administered an inert drug, SC-435 (1.10 or 30 mg/kg) or LUM002 (0.3, 1, 3, 10 or 30 mg/kg) orally twice a day for 2 weeks . Plasma bile acid levels were determined at the end of the second week. Data are presented as means±SEM.

Fig. 3. Randomized, double-blind, placebo-controlled bile acid (SBA) analysis in healthy patients after oral administration of a multiply increasing dose of LUM001. The graph shows data for groups receiving doses of 0.5 (n=16), 1.0 (n=8), 2.5 (n=8), 5.0 (n=8) and 10 (n=8) mg. On the first day, blood was collected for baseline approximately 30 minutes before and after breakfast and 30 minutes after lunch and dinner. Samples received on day 14.

Fig. 4. Randomized, double-blind, placebo-controlled analysis of fecal bile acids in healthy patients after oral doses of LUM001. Fecal samples were collected from all groups except for the titration group of 2.5 (2) and 5 mg (2) from days 9 to 14 and from days 23 to 28.

Fig. 5. Serum bile acid levels measured on an empty stomach and after a meal in children under 12 years of age. LUM001 was administered once daily (QD) in the morning for fourteen days. In patients treated with placebo, the average fasting serum bile acid level was 8.6 µmol/L and the peak postprandial serum bile acid was 11.9 µmol/L. In patients treated with LUM001, these values are 6.5 µmol/L and 9.2, respectively, i.e. the decrease in the level was 24 and 23%.

Detailed description of the invention

Bile acids/salts play a critical role in the activation of digestive enzymes and the dissolution of fats and fat-soluble vitamins and diseases of the liver, bile ducts, and intestines. Bile acids are synthesized in the liver by a multi-step mechanism. Hydroxyl groups are attached to specific centers of the steroid structure, the double bond in the cholesterol B cycle is weakened and the hydrocarbon chain is shortened by three carbon atoms, which leads to the formation of a carboxyl group at the end of the chain. The most common bile acids are cholic acid and chenodeoxycholic acid (primary cholic acids). Before hepatocyte isolation and bile formation, bile acids combine with either glycine (to form glycocholic or glycochendeoxycholic acid) or taurine (to form taurocholic acid or taurochendeoxycholic acid). Conjugated bile acids are called bile salts and their amphipathic nature makes them more effective detergents than bile acids. Bile acids are not found in bile, but bile salts.

Bile acids are excreted by the hepatocycles into the tubules to form bile. The tubules drain into the right and left bile ducts, and the bile enters the gallbladder. Bile is secreted from the gallbladder and sent to the duodenum, where it contributes to the metabolism and breakdown of fats. Bile salts are reabsorbed in the terminal ileum and returned to the liver via the portal vein. Bile salts often make multiple enterohepatic circulations before they are excreted in the faeces. A small proportion of bile salts can be reabsorbed in the proximal intestine as a result of transport - either passive or with the help of a vehicle. Most of the bile salts are recovered in the distal ileum by a sodium-dependent, apically localized bile acid transporter called the apical sodium-dependent bile acid transporter (ASBT). On the basolateral surface of the enterocyte, the truncated portion of the ASBT is included in the vectorial transport of bile acids/salts in the portal circulation. The enterohepatic circulation is terminated at the basolateral surface of the hepatocyte by transport that initially involves the sodium-dependent bile acid transporter. Intestinal bile acid transport plays a key role in the enterohepatic circulation of bile salts. Molecular analysis of this process has recently led to major advances in understanding the biology, physiology, and pathophysiology of bile acid transport in the intestine.

The concentration of bile acids in the intestinal lumen varies depending on the amount of reabsorption in the distal intestine. Bile acids/salts influence the growth of bacterial flora in the intestine. Described here are specific compositions and methods that allow the regulation

- 6 041458 to control the concentration of bile acids in the intestinal lumen and thus regulate hepatocellular damage caused by the accumulation of bile acids in the liver.

In another aspect, the compositions and methods provided herein increase the concentration of bile acids in the intestine. Elevated bile acid/salt concentrations stimulate the subsequent secretion of factors that protect and regulate intestinal integrity that is damaged by childhood cholestasis and/or cholestatic liver disease (eg, pruritus-associated cholestatic liver disease or elevated concentration-associated cholestatic liver disease). bile acids in serum or in the liver.

In yet another aspect, the compositions and methods described herein are advantageous over systemically absorbable components. The compositions and methods described herein use ASBT inhibitors that are absorbed non-systemically. Thus, these compositions are effective when they do not leave the intestinal lumen, which reduces any toxicity and/or side effects associated with systemic absorption. The formulations for children described here have an advantage over existing pharmaceutical formulations for adults in terms of less dreadful side effects and easier adherence to the prescribed therapy regimen.

In a further aspect, the compositions and methods described herein stimulate the release of the enteroendocrine hormones GLP-2 and PYY. Increased secretion of GLP-2 or PYY allows the prevention or treatment of childhood cholestasis and/or cholestatic liver disease by regulating the adaptation process, attenuating intestinal damage, reducing bacterial translocation, inhibiting the release of free oxygen radicals, inhibiting the formation of pro-inflammatory cytokines, or any combination thereof.

Described here is the use of an ASBT inhibitor or any recuperative fatty acid salt transporter active in the gastrointestinal (GI) tract for the treatment or prevention of childhood cholestasis and/or cholestatic liver disease. In some embodiments, the use of an ASBT inhibitor or any recuperative fatty acid salt transporter active in the gastrointestinal (GI) tract is described for the treatment or prevention of pruritus in a patient. In some embodiments, the use of an ASBT inhibitor or any recuperative bile salt transporter active in the gastrointestinal (GI) tract is described herein to reduce serum or liver bile acid concentrations in a patient. In some embodiments, the methods include administering to a patient a therapeutically effective amount of an ASBT inhibitor. In some embodiments, such ASBT inhibitors are absorbed non-systemically. In certain such embodiments, such bile acid transport inhibitors include moieties or moieties that interfere with, reduce, or inhibit systemic absorption of the compound in vivo. In some embodiments, charged moieties or groups on compounds interfere with, reduce, or inhibit the release of compounds from the gastrointestinal tract and reduce the risk of side effects due to systemic absorption. In some other embodiments, such ASBT inhibitors are absorbed systemically. In some embodiments, the ASBTIs provided herein are formulated for non-systemic delivery to the distal iliac region. In some embodiments, ASBTI is minimally absorbed. In some embodiments, the ASBTI is administered non-systemically to the colon or rectum of a patient.

In some embodiments, such ASBT inhibitors are absorbed non-systemically. In certain such embodiments, such bile salt transport inhibitors include a moiety or group that interferes with, reduces, or inhibits systemic absorption of the compound in vivo. In some embodiments, the charged moiety or group on the compounds interferes with, reduces, or inhibits the clearance of the compounds from the gastrointestinal tract and reduces the risk of side effects due to systemic absorption. In some other embodiments, such ASBT inhibitors are absorbed systemically. In some embodiments, ASBTIs are formulated for non-systemic delivery to the distal iliac region. In some embodiments, ASBTI is minimally absorbed. In some embodiments, the ASBTI is administered non-systemically to the colon or rectum of a patient.

In some embodiments, less than 50%, less than 40%, less than 30%, less than 20%, less than 10%, less than 9%, less than 8%, less than 7%, less than 6%, less than 5%, less than 4%, less than 3%, less than 2% or less than 1% ASBTI. In some embodiments, the ASBTIs described herein inhibit the uptake of bile salts by the recuperative bile salt transporter in the distal gastrointestinal tract (eg, distal ileum, colon and/or rectum).

In some examples, inhibition of bile salt recycling leads to elevated concentrations of bile salts in the lumen of the distal gastrointestinal tract or parts thereof (eg, in the distal small intestine and/or colon and/or rectum). As used herein, the term distal gastrointestinal tract includes the region from the distal ileum to the anus. In some embodiments, the compounds described herein reduce the content of bile acids/salts inside enterocytes or their accumulation. In some embodiments, the compounds described herein reduce damage to the hepatocellular or intestinal architecture associated with cholestasis and/or cholestatic liver disease.

Mammalian microbiome, bile acid stores and metabolic interactions.

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The integral metabolism of bile acid stores in the intestinal lumen leads to complex biochemical interactions between host cells of the intestinal microflora and symbionts.

Bile acids/salts are synthesized from cholesterol in the liver by a multi-enzyme coordinated process and are key to the absorption of nutritious fats and fat-soluble vitamins in the gut. Bile acids/salts play an important role in maintaining intestinal barrier function to prevent intestinal bacterial overgrowth and translocation, as well as invasion of intestinal bacteria into underlying tissues.

Under normal conditions (ie, when the child does not suffer from cholestasis and/or cholestatic liver disease), symbiotic gut microorganisms (microbial) interact closely with the host metabolism and are important indicators of health. Many bacteria in the gut are capable of modifying and metabolizing bile acids/salts, and the gut microflora influences systemic processes such as metabolism and inflammation.

Bile acids/salts have strong antimicrobial and antiviral effects - their deficiency leads to bacterial overgrowth and increased deconjugation, resulting in less resorption in the iliac region. In animals, the intake of conjugated bile acids with food stops the growth of bacteria, reduces the translocation of bacteria to the lymph nodes, and reduces endotoxemia.

Accordingly, the methods and compositions described herein allow for the replacement, elimination and/or redirection of bile acids/salts to various areas of the gastrointestinal tract that affects (e.g., inhibits or slows down) the growth of microorganisms that can cause infection-related cholestasis and/or cholestatic liver disease.

Types of cholestatic liver disease in children.

As used herein, the term cholestasis refers to a disease or symptom including impaired bile production and/or bile flow. As used herein, the term cholestatic liver disease refers to liver disease associated with cholestasis. Cholestatic liver disease is often associated with biliary effusion, fatigue, and itching. Biomarkers of cholestatic liver disease include elevated serum bile acids, elevated serum alkaline phosphatase (AP), elevated gamma-glutamyl transpeptidase, increased direct hyperbilirubinemia, and elevated serum cholesterol.

Cholestatic liver disease can be divided into two main clinicopathological categories - obstructive, often extrahepatic, cholestasis and non-obstructive, or intrahepatic cholestasis. In the first case, cholestasis occurs when the flow of bile is mechanically blocked, as in gallstones or tumors, or as extrahepatic biliary atresia.

The last group with non-obstructive intrahepatic cholestasis, in turn, can be divided into two main subgroups. In the first subgroup, cholestasis occurs when the processes of bile secretion and the modification or synthesis of bile components lead to such severe secondary hepatocellular damage that non-specific impairment of many functions, including those that serve to form bile, can be expected. In the second subgroup, the putative cause of hepatocellular damage cannot be identified. Cholestasis in such patients appears to occur when one of the stages of bile secretion or the modification or synthesis of bile components is constitutionally disturbed. Such cholestasis is considered primary.

Accordingly, methods and compositions are provided for promoting epithelial proliferation and/or regeneration of the intestinal mucosa and/or enhancing adaptive processes in the intestine in patients with cholestasis and/or cholestatic liver disease. In some such embodiments, the methods include increasing the concentration of bile acids and/or GLP-2 in the intestinal lumen.

Hypercholaemia and elevated levels of AP (alkaline phosphatase), LAP (leukocyte alkaline phosphatase), gamma GT (gamma-glutamyl transpeptidase), and 5'-nucleotidase are chemical signatures of cholestasis and cholestatic liver disease. Accordingly, methods and compositions are provided for promoting epithelial proliferation and/or regeneration of the intestinal mucosa and/or enhancing adaptive processes in the intestine in patients with hypercholaemia and elevated levels of AP (alkaline phosphatase), LAP (leukocyte alkaline phosphatase), gamma GT (gammaglutamyl transpeptidase or GGT). ) and/or 5'-nucleotidase. In some of these embodiments, the methods include increasing the concentration of bile acids in the intestinal lumen. Also provided are methods and compositions for reducing hypercholaemia and elevated levels of AP (alkaline phosphatase), LAP (leukocyte alkaline phosphatase), gamma GT (gamma-glutamyl transpeptidase), and/or 5'-nucleotidase, comprising reducing total bile acid content by excreting bile acid into feces.

Itching in children is often associated with cholestasis and cholestatic liver disease. It has been suggested that itching is due to bile salts acting on peripheral pain afferent nerves. The degree of itching varies from patient to patient (i.e. some patients are more sensitive to elevated bile acids/salts). In some patients, the administration of components that reduce serum bile acid concentrations has been shown to reduce pruritus. Corresponding

- 8 041458 venously proposed methods and compositions for stimulating epithelial proliferation and/or regeneration of the intestinal mucosa and/or enhancing adaptive processes in the intestine in patients with pruritus. In some embodiments, the methods include increasing the concentration of bile acids in the intestinal lumen. Also provided are methods and compositions for the treatment of pruritus, comprising reducing the total content of bile acids by excreting bile acid in the feces.

Another symptom of cholestasis and cholestatic liver disease in children is an increase in serum conjugated bilirubin. Elevated serum conjugated bilirubin leads to bilious spillage and dark urine. The degree of increase is not important diagnostically, because. An association between serum levels of conjugated bilirubin and the severity of cholestasis and cholestatic liver disease has not been established. The concentration of conjugated bilirubin rarely exceeds 30 mg/dL. Accordingly, methods and compositions are provided herein for promoting epithelial proliferation and/or regeneration of the intestinal mucosa and/or enhancing adaptive processes in the intestine in patients with elevated levels of conjugated bilirubin. In some embodiments, the methods include increasing the concentration of bile acids in the intestinal lumen. Also provided are methods and compositions for treating elevated serum conjugated bilirubin, comprising reducing total bile acid levels by excreting bile acids in faeces.

Elevated serum unconjugated bilirubin is also considered a diagnosis of cholestasis and cholestatic liver disease. Parts of serum bilirubin covalently bind to albumin (delta-bilirubin or biliprotein). This fraction may explain the marked proportionality between total bilirubin levels in patients and cholestatic biliary effusion. The presence of large amounts of delta-bilirubin indicates chronic cholestasis. Delta-bilirubin in cord or neonatal blood indicates childhood cholestasis/cholestatic liver disease before the baby is born. Accordingly, methods and compositions are provided herein for promoting epithelial proliferation and/or regeneration of the intestinal mucosa and/or enhancing adaptive processes in the intestine in patients with elevated serum levels of unbound bilirubin or delta-bilirubin. In some embodiments, the methods include increasing the concentration of bile acids in the intestinal lumen. Also provided are methods and compositions for treating elevated serum unconjugated bilirubin and delta-bilirubin levels, comprising reducing total bile acid content by excreting bile acids in the feces.

Childhood cholestasis and cholestatic liver disease lead to hypercholeemia. During metabolic cholestasis, hepatocytes retain bile salts. Bile salts are secreted back from the hepatocytes into the serum, resulting in an increase in the concentration of bile salts in the peripheral circulation. In addition, the absorption of bile salts entering the liver with the blood of the portal vein is not effective, because. leads to the involvement of bile salts in the peripheral circulation. Accordingly, compositions are provided herein for promoting epithelial proliferation and/or regeneration of the intestinal mucosa and/or enhancing adaptive processes in the intestine in hypercholemic patients. In some embodiments, the methods include increasing the concentration of bile acids in the intestinal lumen. Also provided are methods and compositions for the treatment of hypercholaemia, including reducing the total content of bile acids by excreting bile acids in the feces.

Some, but not all, cholestatic diseases are characterized by hyperlipidemia. In cholestasis, serum cholesterol levels are elevated due to decreased circulation of bile salts, which are involved in the metabolism and breakdown of cholesterol. Cholesterol retention is associated with an increase in membrane cholesterol and a decrease in membrane fluidity and membrane function. In addition, since bile salts are products of cholesterol metabolism, the weakening of cholesterol metabolism leads to a decrease in the synthesis of bile acids/salts. In children with cholestasis, serum cholesterol is in the range of about 1000-4000 mg/dL. Accordingly, methods and compositions are provided herein for promoting epithelial proliferation and/or regeneration of the intestinal mucosa and/or enhancing adaptive processes in the intestine in patients with hyperlipidemia. In some embodiments, the methods include increasing the concentration of bile acids in the intestinal lumen. Methods and compositions for the treatment of hyperlipidemia are also provided, including reducing the total content of bile acids by excreting bile acids in the feces.

Patients with childhood cholestasis and cholestatic liver disease develop xanthoma due to the deposition of excess circulating cholesterol in the skin. The development of xanthoma is more typical for obstructive cholestasis than for hepatocellular cholestasis. Flat xanthoma first appears around the eyes, then in the folds of the palms and soles, and then on the neck. Lumpy xanthomas are associated with chronic and prolonged cholestasis. Accordingly, methods and compositions are provided for promoting epithelial proliferation and/or regeneration of the intestinal mucosa and/or enhancing adaptive processes in the intestine in patients with xanthomas. In some embodiments, methods

- 9 041458 include an increase in the concentration of bile acids in the intestinal lumen. Also provided are methods and compositions for treating xanthoma, comprising reducing the total content of bile acids by excreting bile acids in the feces.

In children with chronic cholestasis, one of the main consequences of childhood cholestasis and cholestatic liver disease is a halt in the child's weight gain. The halt in weight gain is a consequence of reduced delivery of bile salts to the intestine, which causes inefficiency in nutrition and fat absorption, and reduced absorption of vitamins (vitamins E, D, K and A are not absorbed in cholestasis). In addition, the delivery of fat to the colon can lead to colonic secretion and diarrhea. Treatment for weight loss includes diet and administration of long chain triglycerides, medium chain triglycerides, and vitamins. Ursodeoxycholic acid, used to treat certain cholestatic disorders, does not form mixed micelles and does not interfere with fat absorption. Accordingly, methods and compositions are provided for promoting epithelial proliferation and/or regeneration of the intestinal mucosa and/or enhancing adaptive processes in the intestine in patients (eg, children) with weight gain arrest. In some embodiments, the methods include increasing the concentration of bile acids in the intestinal lumen. Also provided are methods and compositions for the treatment of weight gain arrest, comprising reducing the total content of bile acids by excreting bile acids in the feces.

Symptoms of childhood cholestasis and cholestatic liver disease have been treated with choleretic agents (eg, ursodiol), phenobarbitals, corticosteroids (eg, prednisone and budesonide), immunosuppressants (eg, azathioprine, cyclosporine A, methotrexate, chlorambucil, and mycophenolate), sulindac, bezafibrate, tamoxifen and lamivudine. Accordingly, in some embodiments, any methods disclosed herein also include administering an additional active agent selected from: choleretic agents (eg, ursodiol), phenobarbitals, corticosteroids (eg, prednisone and budestonide), immunosuppressants (eg, azathioprine, cyclosporine A, methotrexate, chlorambucil and mycophenolate), sulindac, bezafibrate, tamoxifen, lamivudine, and combinations thereof. In some embodiments, methods are used to treat patients who do not respond to treatment with choleretic agents (eg, ursodiol), phenobarbitals, corticosteroids (eg, prednisone and budestonide), immunosuppressants (eg, azathioprine, cyclosporine A, methotrexate, chlorambucil, and mycophenolate), sulindac, bezafibrate, tamoxifen, lamivudine, and combinations thereof. In some embodiments, methods are used to treat patients who do not respond to treatment with choleretic agents. In some embodiments, methods are used to treat patients who do not respond to treatment with ursodiol.

Progressive familial intrahepatic cholestasis (PFIC).

PFIC 1.

PFIC 1 (also known as Byler's disease or FIC1 deficiency) is associated with mutations in the ATP8B1 gene (also called FIC1). This gene, which encodes the P-type of ATPase, is located on human chromosome 18 and also mutates into a milder phenotype, benign secondary intrahepatic cholestasis type 1 (BRIC1) and Greenlandic familial cholestasis. The FIC1 protein is localized on the canalicular membrane of the hepatocyte, but inside the liver it is mainly expressed in cholangiocytes. The P-type of ATPase appears to be an aminophospholipid transporter responsible for maintaining the abundance of phosphatidylserine and phosphatidylethanolamine at the inner leaflet of the plasma membrane compared to the outer leaflet. The asymmetric distribution of lipids in the membrane bilayer performs the function of protecting against high concentrations of bile salts in the lumen of the tubules. Atypical protein function may indirectly interfere with biliary secretion of bile acids. Atypical secretion of bile acids/salts leads to an overload of hepatocytes with bile acids.

PFIC-1 is commonly seen in children (eg, 6-18 months of age). Children may have signs of itching, bile spillage, abdominal bloating, diarrhea, malnutrition, and short stature. Biochemically, PFIC-1 patients are characterized by elevated serum transaminase, elevated bilirubin, elevated serum bile acid levels, and low gamma-HT levels. Patients may also experience liver fibrosis. Patients with PFIC-1 usually do not have bile duct proliferation. Patients with PFIC-1 develop end-stage liver disease by the age of 10 years. No medical means have given a good result in the long-term treatment of PFIC-1. Medium-chain triglycerides and fat-soluble vitamins are often given to children to reduce extrahepatic symptoms (eg, malnutrition and weight loss). Ursodiol has been shown to be ineffective in patients with PFIC-1.

In some embodiments, disclosed herein are methods of treating PFIC-1 in patients, comprising non-systemic administration of a therapeutically effective amount of an apical sodium dependent bile acid transporter inhibitor (ASBTI), or a therapeutically acceptable salt thereof. In some embodiments, such ASBT inhibitors are absorbed non-systemically. In some embodiments, such bile salt transporter inhibitors include a moiety or moiety that interferes, reduces, or inhibits systemic absorption of the compound in vivo. In some embodiments, the charged moiety or group in the compounds interferes with, reduces, or inhibits the release of the compounds from the gastrointestinal tract.

- 10 041458 and reduce the risk of side effects due to systemic absorption. In some other embodiments, such ASBT inhibitors are absorbed systemically. In some embodiments, ASBTIs are formulated for non-systemic delivery to the ileum. In some embodiments, ASBTIs are minimally absorbed. In some embodiments, the ASBTI is administered non-systemically to the colon or rectum of a patient. In some embodiments, methods are also provided comprising administering a therapeutically effective amount of a secondary bile acid (e.g., ursodiol), a corticosteroid (e.g., prednisone and budestonide), an immunosuppressant (e.g., azathioprine, cyclosporine A, methotrexate, chlorambucil, and mycophenolate), sulindac, bezafibrate, tamoxifen, lamivudine, and any combination thereof. PFIC 2 PFIC 2 (also known as Byler syndrome or BSEP deficiency) is associated with mutations in the ABCB11 gene (also referred to as BSEP). The ABCB11 gene encodes the ATP-dependent canalicular bile salt export pump (BSEP) in the human liver and is localized on human chromosome 2. The BSEP protein, expressed on the hepatocyte canalicular membrane, is the main exporter of bile acids/salts that prevents extreme concentration gradients. Mutations in this protein are responsible for reduced secretion of biliary bile salts, leading to the reduced bile flow and accumulation of bile salts within the hepatocyte with subsequent severe hepatocellular damage described in patients.

PFIC-2 is commonly seen in children (eg, 6-18 months of age). Children may have signs of itching. Biochemically, patients with PFIC-2 are characterized by elevated serum transaminases, elevated bilirubin, elevated serum bile acids, and low gamma-HT. Patients may also have portal inflammation and congenital giant cell hepatitis. In addition, patients often develop hepatocellular carcinoma. No medical means have given a good result in the long-term treatment of PFIC-2. Medium-chain triglycerides and fat-soluble vitamins are often given to children to reduce extrahepatic symptoms (eg, malnutrition and weight gain). Ursodiol has been shown to be ineffective in patients with PFIC-2.

In some embodiments, disclosed herein are methods of treating PFIC-2 in patients, comprising non-systemic administration of a therapeutically effective amount of an apical sodium dependent bile acid transporter inhibitor (ASBTI), or a therapeutically acceptable salt thereof. In some embodiments, such ASBT inhibitors are absorbed non-systemically. In some embodiments, such bile salt transporter inhibitors include a moiety or moiety that interferes, reduces, or inhibits systemic absorption of the compound in vivo. In some embodiments, the charged moiety or group in the compounds interferes with, reduces, or inhibits the release of compounds from the gastrointestinal tract and reduces the risk of side effects due to systemic absorption. In some other embodiments, such ASBT inhibitors are absorbed systemically. In some embodiments, ASBTIs are formulated for non-systemic delivery to the ileum. In some embodiments, ASBTIs are minimally absorbed. In some embodiments, the ASBTI is administered non-systemically to the colon or rectum of a patient. In some embodiments, methods are also provided comprising administering a therapeutically effective amount of a secondary bile acid (e.g., ursodiol), a corticosteroid (e.g., prednisone and budestonide), an immunosuppressant (e.g., azathioprine, cyclosporine A, methotrexate, chlorambucil, and mycophenolate), sulindac, bezafibrate, tamoxifen, lamivudine, and any combination thereof. PFIC3 PFIC3 (also known as MDR3 deficiency) is caused by a genetic defect in the ABCB4 gene (also called MDR3) located on chromosome 7. Class III multidrug resistance (MDR3) P-glycoprotein (P-gp) is a phospholipid translocator involved in biliary phosolipid (phosphatidylcholine) excretion into the canalicular membrane of the hepatocyte. PFIC3 arises from bile toxicity, in which the bile salt detergent is not inactivated by phospholipids, leading to damage to the bile ducts and biliary epithelium.

PFIC-3 is also seen in early childhood. In contrast to PFIC-1 and PFIC-2, patients have elevated gamma-HT levels. Patients also have portal inflammation, fibrosis, cirrhosis, and massive proliferation of the bile ducts. Patients may also develop intrahepatic gallstone disease. Ursodiol has proven effective in treating or attenuating PFIC-3.

In some embodiments, disclosed herein are methods of treating PFIC-3 in patients, comprising non-systemic administration of a therapeutically effective amount of an apical sodium dependent bile acid transporter inhibitor (ASBTI), or a therapeutically acceptable salt thereof. In some embodiments, such ASBT inhibitors are absorbed non-systemically. In some embodiments, such bile salt transporter inhibitors include a moiety or moiety that interferes, reduces, or inhibits systemic absorption of the compound in vivo. In some embodiments, the charged moiety or group in the compounds interferes with, reduces, or inhibits the release of compounds from the gastrointestinal tract and reduces the risk of side effects due to systemic absorption. In some other embodiments, such ASBT inhibitors are absorbed systemically. In some embodiments, ASBTIs are formulated for non-systemic delivery to the ileum. In some embodiments, ASBTIs are minimally absorbed. In some embodiments, the ASBTI is administered non-systemically to the colon or rectum of a patient. In some embodiments, methods are also provided, comprising administering a therapeutically effective

- 11 041458 amount of secondary bile acid (eg ursodiol), corticosteroid (eg prednisone and budestonide), immunosuppressant (eg azathioprine, cyclosporine A, methotrexate, chlorambucil and mycophenolate), sulindac, bezafibrate, tamoxifen, lamivudine and any combinations thereof.

Benign secondary intrahepatic cholestasis (BRIC).

BRIC 1.

BRIC1 is caused by a genetic defect in the FIC1 protein in the canalicular membrane of hepatocytes. BRIC1 is commonly associated with normal serum cholesterol and γ-glutamyl transpeptidase levels, but elevated serum bile salts. Residual FIC1 expression and function is associated with BRIC1. Despite secondary attacks of cholestasis or cholestatic liver disease, chronic liver disease does not progress in most patients. During attacks, patients experience severe bile effusion, itching, steatorrhea, and weight loss. Some patients have gallstones, pancreatitis, and diabetes.

BRIC2.

BRIC2 is caused by mutations in ABCB11 that result in defective BSEP expression and/or function in the hepatocyte canalicular membrane.

BRIC3.

BRIC3 refers to defective expression and/or function of MDR3 in the canalicular membrane of hepatocytes. Patients with MDR3 deficiency typically have elevated serum γ-glutamyl transpeptidase levels along with normal or slightly elevated bile acid levels.

Dubin-Johnson Syndrome (DJS).

DJS syndrome is characterized by conjugated hyperbilirubinemia resulting from inherited MRP2 dysfunction. In sick patients, liver function is preserved. Several different mutations have been associated with this condition, resulting in either a complete absence of immunohistochemically detectable MRP2 in affected patients or reduced protein maturation and sorting.

Acquired cholestatic diseases.

Pediatric primary sclerosing cholangitis (PSC).

Childhood PSC is a chronic inflammatory liver disease that progresses slowly to end-stage liver failure in most affected patients. In pediatric PSC, inflammation, fibrosis, and obstruction of large and medium-sized intra- and extrahepatic tubules predominate.

Disease of the gallbladder.

Gallstone disease is one of the most common and costly digestive diseases and predominates in 17% of Caucasian women. Cholesterol-containing gallstones are the main form of gallstones, and therefore an oversaturation of bile with cholesterol is a prerequisite for the formation of gallstones. ABCB4 mutations may be involved in the pathogenesis of gallstone disease.

Medical cholestasis.

Inhibition of BSEP function by drugs is an important mechanism of drug-induced cholestasis, which leads to accumulation of bile salts in the liver and subsequent destruction of liver cells. Several drugs have been shown to be involved in BSEP inhibition. Most of these drugs, such as hypampicin, cyclosporine, glibenclamide, or troglitazone, directly cis-inhibit ATP-dependent competitive taurocholate transport, while estrogen and progesterone metabolites indirectly trans-inhibit Bsep after being secreted into the bile canaliculi by Mrp2. Alternatively, drug-induced stimulation of MRP2 may promote cholestasis or cholestatic liver disease due to changes in bile composition. TPNAC-associated cholestasis is one of the most serious clinical scenarios where cholestasis or cholestatic liver disease progresses rapidly and results in early death. Children, usually preterm, who have had a bowel resection depend on TPN for growth and often have cholestasis or cholestatic liver disease that progresses rapidly to fibrosis, cirrhosis, and portal hypertension, usually before six months of age. The degree of cholestasis or cholestatic liver disease and the chance of survival in these children is associated with the number of episodes of sepsis, which are probably initiated by secondary bacterial translocation along the intestinal mucosa. Although cholestatic effects from intravenous drugs are also present in these children, sepsis mediators are likely to have the strongest influence on changes in liver function.

Alagille syndrome.

Alagille syndrome is a genetic disorder that affects the liver and other organs. It often occurs in infancy (eg, 6–18 months of age) and early childhood (eg, 3–5 years of age) and may stabilize after 10 years of age. Symptoms may include chronic progressive cholestasis, ductopenia, biliary effusion, pruritus, xanthomas, congenital heart problems, bile duct insufficiency, poor linear growth, hormonal resistance, butt

- 12 041458 nii embryotoxon, Axenfeld's anomaly, retinitis pigmentosa, pupillary anomalies, heart murmur, atrial septal defect, ventricular septal defect, patent ductus arteriosus and tetralogy of Fallot. Patients diagnosed with Alagille syndrome were treated with ursodiol, hydroxyzine, cholestyramine, rifampicin, and phenobarbital. Because of the reduced ability to absorb fat-soluble vitamins, patients with Alagille syndrome are given large doses of multivitamins.

In some embodiments, methods for treating Alagille syndrome in patients are disclosed herein, comprising non-systemic administration of a therapeutically effective amount of ASBTI, or a therapeutically acceptable salt thereof. In some embodiments, such ASBT inhibitors are absorbed non-systemically.

In some embodiments, such bile salt transport inhibitors include a moiety or moiety that interferes, reduces, or inhibits systemic absorption of the compound in vivo. In some embodiments, the charged moiety or group in the compounds interferes with, reduces, or inhibits the release of compounds from the gastrointestinal tract and reduces the risk of side effects due to systemic absorption.

In some other embodiments, such ASBT inhibitors are absorbed systemically. In some embodiments, ASBTIs are formulated for non-systemic delivery to the ileum. In some embodiments, ASBTIs are minimally absorbed. In some embodiments, the ASBTI is administered non-systemically to the colon or rectum of a patient. In some embodiments, methods are also provided comprising administering a therapeutically effective amount of a secondary bile acid (e.g., ursodiol), a corticosteroid (e.g., prednisone and budestonide), an immunosuppressant (e.g., azathioprine, cyclosporine A, methotrexate, chlorambucil, and mycophenolate), sulindac, bezafibrate, tamoxifen, lamivudine, and any combination thereof.

Biliary atresia.

Biliary atresia is a life-threatening condition in children in which the bile ducts inside or outside the liver do not have normal openings. In biliary atresia, bile is trapped, held back, and destroys the liver. Destruction of the liver leads to scarring, shrinkage of liver tissue, and cirrhosis. Without treatment, the liver fails, and the child needs a liver transplant to stay alive. There are two types of biliary atresia - fetal and perinatal. Fetal biliary atresia appears while the baby is in the womb. Perinatal biliary atresia is much more common and may not be obvious until 2–4 weeks after birth. Biliary atresia - operation according to the Kasai method.

Biliary atresia is treated with a surgical procedure called a Kazai operation, or liver transplant. The Kazai method is usually the first treatment for biliary atresia. During Kazai's operation, a pediatric surgeon removes damaged bile ducts from a child and inserts a loop of intestine to replace them. Although Kazai surgery can repair the bile duct and correct many of the problems caused by biliary atresia, biliary atresia cannot be cured by surgery. If Kazai's surgery fails, the child usually needs a liver transplant within 1 to 2 years. Even after successful surgery, most children with biliary atresia slowly develop cirrhosis over a number of years and liver transplantation is necessary at a transitional age. Possible complications after Kazai surgery include ascites, bacterial cholangitis, portal hypertension, and pruritus. Biliary atresia after transplantation

With complete atresia, liver transplantation is the only viable option. Although liver transplantation in the treatment of biliary atresia is usually successful, liver transplantation leads to complications such as organ rejection. In addition, a donor liver may not be available. In addition, liver transplantation may not be successful in treating biliary atresia in some patients.

xanthoma.

Xanthoma is a skin condition associated with cholestatic liver disease in which certain fats are trapped under the surface of the skin. Cholestasis leads to several disorders of fat metabolism leading to the formation of abnormal fat particles in the blood called lipoprotein X. Lipoprotein X is formed when liver fats are recycled back into the blood from the liver and does not bind LDL receptors to deliver cholesterol to cells throughout the body, unlike normal fats. LDL. Lipoprotein X increases the formation of cholesterol in the liver by five times and blocks the normal removal of lipoprotein particles from the blood by the liver.

A pediatric dosage form is proposed containing an apical sodium-dependent transporter inhibitor (ASBTI), which is

- 13 041458

or a pharmaceutically acceptable salt thereof and a pharmaceutically acceptable excipient, wherein the dosage form is an oral liquid solution formulated to be released in the distal ileum and is suitable for the treatment of cholestatic liver disease in children, wherein cholestatic liver disease in children is is progressive familial intrahepatic cholestasis (PFIC), Alagille syndrome (ALGS), childhood primary sclerosing cholangitis (PSC), or biliary atresia (BA).

In some embodiments, the pediatric dosage form reduces serum bile acids or hepatic bile acids in a patient.

In some embodiments, the pediatric dosage form reduces serum bile acids or hepatic bile acids by at least 20% in a patient.

In some embodiments, the cholestatic liver disease in children is biliary atresia (BA).

In some embodiments, the cholestatic liver disease in children is progressive familial intrahepatic cholestasis (PFIC), type 1 PFIC, type 2 PFIC, or type 3 PFIC.

In some embodiments, the cholestatic liver disease in children is Alagille syndrome (ALGS).

In some embodiments, the cholestatic liver disease is childhood primary sclerosing cholangitis (PSC).

In some embodiments, the dose of ASBTI is from 1 μg/kg/day to 10 mg/kg/day. In some embodiments, the dose of ASBTI is from 5 μg/kg/day to 5 mg/kg/day. In some embodiments, the dose of ASBTI is from 0.4 to 1.5 mg/day. In some embodiments, the dose of ASBTI is administered twice daily. In some embodiments, less than 10% ASBTI is absorbed systemically.

In some embodiments, the pharmaceutically acceptable adjuvant is a diluent, a taste-masking agent, an antioxidant, an excipient, an acidifier, or combinations thereof.

In some embodiments, the volume of the dose is from 5 to 50 ml.

The compound described here and other related compounds with various substituents are synthesized using the procedures and materials described here and as described, for example, in Fieser and Fieser's Reagents for Organic Synthesis, Volumes 1-17 (John Wiley and Sons, 1991); Rodd's Chemistry of Carbon Compounds, Volumes 1-5 and Supplemental (Elsevier Science Publishers, 1989); Organic Reactions, Volumes 1-40 (John Wiley and Sons, 1991), Larock's Comprehensive Organic Transformations (VCH Publishers Inc., 1989), March, Advanced Organic Chemistry 4 ^th Ed., (Wiley 1992); Carey and Sundberg, Advanced Organic Chemistry ^4th Ed., Vols. A and B (Plenum 2000, 2001), and Green and Wuts, Protective Groups in Organic Synthesis ^3rd Ed., (Wiley 1999) (which are all incorporated herein by reference). General methods for obtaining the compounds described here are modified by using the appropriate components and conditions for introducing various fragments presented in the proposed formulas. In this case, the following synthetic methods are used.

The formation of covalent bonds by the reaction of an electrophile with a nucleophile.

To introduce new functional groups or substituents, the compounds described herein are modified using various electrophiles and/or nucleophiles. In table. A, titled Examples of Covalent Bond Compounds and Their Precursors, provides selected non-limiting examples of covalent bond compounds and precursor functional groups that form covalent bonds. Tab. A is used as a guide to combining various electrophiles and nucleophiles capable of forming covalent bonds. The functional groups of the precursors are shown as electrophilic and nucleophilic groups.

- 14 041458

Table A. Examples of substances with covalent bonds and their precursors

Connection with forged links electrophile Nucleophile Carboxamides Activated Esters Amines/anilines Carboxamides Acylazides Amines/anilines Carboxamides Acyl halides Amines/anilines Esters Acyl halides Alcohols/phenols Esters Acylnitriles Alcohols/phenols Carboxamides Acylnitriles Amines/anilines Imines Aldehydes Amines/anilines Hydrazones Aldehydes or ketones Hydrazines oximes Aldehydes or ketones Hydroximines Alkylamines Alkyl halides Amines/anilines Esters Alkyl halides carboxylic acids Thioethers Alkyl halides Thiols Ethers Alkyl halides Alcohols/phenols Thioethers Alkylsulfonates Thiols Esters Alkylsulfonates carboxylic acids Ethers Alkylsulfonates Alcohols/phenols Esters Anhydrides Alcohols/phenols Carboxamides Anhydrides Amines/anilines Thiophenols Aryl halides Thiols Arylamines Aryl halides Amines Thioethers Azindines Thiols Boric esters Boronates Glycols Carboxamides carboxylic acids Amines/anilines Esters carboxylic acids Alcohols Hydrazines Hydrazides carboxylic acids N-acylureas or anhydrides Carbdiimides carboxylic acids Esters Diazoalkanes carboxylic acids Thioethers Epoxides Thiols Thioethers haloacetamides Thiols Ammotriazines Halogenthiazines Amines/anilines Triazine esters Halogenthiazines Alcohols/phenols Amidines Imidoesters Amines/anilines Urea Isocyanates Amines/anilines Urethanes Isocyanates Alcohols/phenols Thioureas Isothiocyanates Amines/anilines Thioethers Maleimides Thiols Esters of phosphorous acid Phosphoramidites Alcohols Silyl ethers Silyl halides Alcohols Alkylamines Esters of sulfonic acids Amines/anilines Thioethers Esters of sulfonic acids Thiols Esters Esters of sulfonic acids carboxylic acids Ethers Esters of sulfonic acids Alcohols Sulfonamides Sulfonyl halides Amines/anilines Esters of sulfonic acids Sulfonyl halides Phenols/alcohols

The use of protecting groups.

In the above reactions, it may be necessary to protect reactive functional groups, such as hydroxyl, amino, imino, thiol or carboxyl groups, which it is desirable to retain in the final product in order to avoid their undesirable participation in the reactions. Protecting groups are used to block some or all of the reactive moieties so as to prevent such groups from participating in chemical reactions until the protecting group is removed. In some embodiments, it is believed that each protecting group can be removed in different ways. Protective groups that cleave under conditions quite unsuitable for other groups meet the removal requirements in a variety of ways.

In some embodiments, the protecting groups are removed under acidic, basic, reducing conditions (such as, for example, hydrogenolysis) and/or oxidizing conditions. Groups such as trityl, dimethoxytrityl, acetal, and tert-butyldimethylsilyl are labile under acidic conditions and are used to protect carboxyl and hydroxyl reactive moieties in the presence of amino groups protected by carbobenzoxyl (Cbz), which is removed by hydrogenolysis, and 9fluorenylmethoxycarbonyl (Fmoc) groups, which are labile in the presence of bases. Reactive carboxylic acid fragments and hydroxyl groups are capped with basic labile groups such as (but not limited to) methyl, ethyl and acetyl groups in the presence of amines capped with acid labile groups such as tert-butylcarbamate or carbamate groups, which are stable in both acidic and basic media, but are removed by hydrolysis.

In some embodiments, reactive carboxyl and hydroxyl moieties are capped with hydrolyzable protecting groups such as the benzyl group, while amino groups capable of hydrogen bonding with acids are capped with basic labile groups such as Fmoc. Reactive fragments of carboxyl groups protecting

- 15 041458 are esterified, as shown here, converting them to alkyl ethers, or blocked with protective groups removed under oxidizing conditions, such as the 2,4-dimethoxybenzyl group, while the amino groups present are blocked with fluorine-labile silyl carbamates.

Allyl blocking groups are used in the presence of acidic and basic protecting groups, because the former are stable and are subsequently removed in the presence of metal or π-acid catalysts. For example, the protection of an allyl-blocked carboxylic acid is removed by a Pd ⁰ catalyzed reaction in the presence of protective groups, acid-labile tert-butyl carbamate or basic aminoacetate labile. Another type of protecting group is a resin containing an attached compound or intermediate. Since the residue is connected to the resin, the functional group is blocked and does not react. The resin-free functional group is available for reaction.

Typical blocking/protecting groups are selected from the following:

allyl ^Bn Cbz alloc Me

For other protecting groups and a detailed description of the techniques used to introduce and remove protecting groups, see Greene and Wuts, Protective Groups in Organic Synthesis, 3rd Ed., John Wiley & Sons, New York, NY, 1999, and Kocienski, Protective Groups , Thieme Verlag, New York, NY, 1994, which are incorporated here by reference.

In some embodiments, the ASBTI described herein is prepared as described, for example, in WO 96/05188, US Pat. Nos. 5,994,391; 7238684; 6906058; 6020330; and 6,114,322. In some embodiments, the ASBTI described herein is synthesized from commercially available starting compounds or prepared according to the procedures described herein. In some embodiments, the compounds described herein are prepared according to Scheme 1.

Scheme 1. @6^.

1-1

In some embodiments, the synthesis begins with the reaction of 1,4-diazabicyclo[2.2.2]octane with 4-iodo-1chlorobutane to form a compound of structure 1-I. Such compounds are obtained by any method, for example, as described in Tremont S.J. et. al., J. Med. Chem. 2005, 48, 5837-5852. The compounds of structure 1-I are then reacted with phenylethylamine to give a compound of structure 1-II. The compound of structure 1-II is then reacted with dicyandiamide to form a compound of formula I.

In some embodiments, the first compound of formula III is introduced into the subsequent reaction and the second compound of formula III is obtained, as shown in scheme 2.

- 16 041458

Scheme 2

The first compound of formula III (1-IA) is alkylated with methyl iodide to form the second compound of formula III (1-IB). Alkylation of compound 1-IB with a compound of structure 2-II leads to the following compound of formula III (IC). Alternatively, a first compound of formula III (1-IA) is alkylated with a compound of structure 2-I to form a second compound of formula III (1-IC).

In some embodiments, the compounds described herein are prepared by the method shown in Scheme 3.

- 17 041458

General definitions.

As used herein, the term bile acid includes steroid acids (and/or the corresponding carboxylate anion) and their salts from animal (e.g., human) bile, including but not limited to cholic acid, cholate, deoxycholic acid, deoxycholate, hyodeoxycholic acid, hyodeoxycholate, glycocholic acid. , glycocholate, taurocholic acid, taurocholate, chenodeoxycholic acid, ursodeoxycholic acid, ursodiol, tauroursodeoxycholic acid, glycoursodeoxycholic acid, 7-B-methylcholic acid, lithocholic acid methyl ester, chenodeoxycholate, lithocholic acid, lithocholate, and the like. Taurocholic acid and/or taurocholate is referred to here as TCA. Any reference to a bile acid used herein includes reference to one and only one bile acid, one or more bile acids, or at least one bile acid. Therefore, the terms bile acid, bile salt, bile acid/salt, bile acids, bile salts, and bile acids/salts, unless otherwise indicated, are used interchangeably. Any reference used herein to a bile acid includes a reference to a bile acid or salt thereof. In addition, pharmaceutically acceptable bile esters are optionally used as bile acids described herein, such as bile acids/salts associated with an amino acid (eg, glycine or taurine). Other bile esters include, for example, substituted or unsubstituted alkyl ester, substituted or unsubstituted heteroalkyl esters, substituted or unsubstituted aryl esters, substituted or unsubstituted heteroaryl esters, and the like. For example, the term bile acid includes cholic acid associated with glycine or taurine: glycocholate and taurocholate, respectively (and their salts). Any reference used herein to a bile acid includes a reference to an identical synthetic or natural compound. In addition, it should be understood that any single reference to a component (bile acid or otherwise) used herein includes reference to one and only one, one or more, or at least one of such components. Likewise, any multiple reference used herein includes reference to one and only one, one or more, or at least one of such components, unless otherwise noted. In addition, the bile acid/salt mimetics described herein are compounds that mimic the agonistic signaling properties of bile acid/salt, especially at TGR5 receptors (GPBAR1, BG37, Axor109). Examples include the description included herein in WO 2010/014836. In some embodiments, the bile acid mimetics include a triterpenoid such as oleanoic acid, urosolic acid, and the like.

The term subject, patient, or individual is used interchangeably herein and refers to mammals and non-mammals, such as those suffering from the diseases described herein. Examples of mammals include, but are not limited to, any member of the mammal class: humans, primates such as chimpanzees, other apes; farm animals such as cows, horses, sheep, goats, pigs; domestic animals such as rabbits, dogs and cats; laboratory animals, including rodents such as rats, mice and guinea pigs, and the like. Examples of non-mammals include, but are not limited to, birds, fish, and the like. In one embodiment of the methods and compositions provided herein, the mammal is a human.

Unless otherwise indicated, the following terms used in this application, including description and claims, are defined as follows in relation to a child or patient of childhood, including neonates (children aged 0-4 weeks), toddlers (children aged 4 weeks and older up to 2 years), children (age 2-5 years), children aged 6-11 years and adolescents (12-18 years).

As used herein, the term roughly includes any value within 10% of the stated value.

As used herein, the term between includes the lower and upper values of the interval.

As used herein, the term colon includes the caecum, ascending colon, hepatic flexure, splenic angle, and sigmoid colon.

The term composition as used herein includes the disclosure of both the composition and the composition administered by the method described here. In addition, in some embodiments, the composition according to this invention includes a drug, pharmaceutical oral or rectal form, as described here.

As used herein, the terms treat or cure and other grammatical equivalents include amelioration, inhibition or reduction of symptoms, reduction or inhibition of the severity of a condition, reduction in the incidence of a disease, reduction or inhibition of relapse, delay in the onset of a disease, delay in the recurrence of a disease, amelioration or amelioration of the symptoms of a disease or condition, amelioration root causes of symptoms, inhibition of the disease or condition, such as stopping the development of the disease or condition, ameliorating the symptoms of the disease or condition, causing regression of the disease or condition, ameliorating the condition caused by the disease or condition, or ending the symptoms of the disease or condition. The terms also include achieving a therapeutic effect. The therapeutic effect is understood as the elimination or amelioration of the underlying disease that is the object of treatment, and / or the elimination or mitigation of one or more physiological symptoms associated with the underlying disease, leading to an improvement

- 18 041458 to change the patient's condition.

As used herein, the terms prevent, prevent, or prevent, or other grammatical equivalents, include prevention of additional symptoms, prevention of underlying causes of symptoms, inhibition of a disease or condition, such as halting the development of a disease or condition, and also includes prevention. In addition, these terms reflect the achievement of a preventive effect. To achieve a prophylactic effect, the compositions are optionally administered to a patient at risk of developing a particular disease, when the patient exhibits one or more physiological symptoms of the disease, or administered to a patient at risk of recurrence of the disease.

In considering methods of treatment and prophylaxis with a combination, it is not intended that the components described herein be limited to the particular nature of the combination. For example, the components described here are optionally administered in combination as simple mixtures, as well as chemical hybrids. An example of the latter is the case where the component is covalently linked to the target carrier or active drug. Covalent bonding can be accomplished in many ways, such as, but not limited to, the use of commercially available cross-linking components. In addition, when treating with combinations, they are optionally administered separately or together.

As used herein, the terms pharmaceutical combination, administration of an additional therapy, administration of an additional therapeutic component, and the like. refers to pharmaceutical therapy, due to the mixing or combination of more than one active ingredient, which includes fixed and non-fixed combinations of active ingredients. The term fixed combination means that at least one of the components described here and at least one second component is administered to the patient simultaneously in the form of a single substance or dose. The term non-fixed combination means that at least one of the components described herein and at least one second component is administered to the patient in the form of separate portions simultaneously, in concert or sequentially at different times, and such administration provides an effective level of presence of two or more components in the patient's body . In some cases, the second component is administered once or for some time, after which the component is administered once or after some time. In other cases, the second component is administered after some time, after which both components, the first and the second, are administered. In the following embodiments, the component is administered once or after some time, after which the second component is administered once or after some time. Both components are applicable to cocktail therapy, for example by administering three or more active components.

As used herein, the terms co-administration, administered in combination with, and their grammatical equivalents mean the administration of selected therapeutic components to the same patient and includes administration regimens in which the components are administered in the same or different ways, as well as at the same time or at different times. In some embodiments, the components described herein are administered in conjunction with other components. These terms include the administration of two or more components to an animal so that both reagents and/or their metabolites are present in the animal at the same time. These include simultaneous administration in separate compositions, administration at different times in separate compositions, and/or administration in compositions in which both components are present. Thus, in some embodiments, the components described herein and other components are administered as a single composition. In some embodiments, the components described herein and other components are added to the composition.

As used herein, the terms effective amount or therapeutically effective amount refer to a sufficient amount of at least one administered component that produces the desired result, for example, reduces to some extent one or more symptoms of the disease or condition in need of treatment. In some cases, the result is a reduction and/or amelioration of the signs, symptoms, or course of a disease, or any other desired change in the biological system. In some cases, an effective amount for use in therapy is the amount of the composition containing the component specified here, which is necessary to achieve a clinically noticeable attenuation of the disease. The effective amount in each individual case is determined by any method, such as experiments with a gradual increase in dose.

As used herein, the terms enter, introduction, and the like. refer to methods for delivering components or compositions to the right place to effect a biological effect. These methods include, but are not limited to, oral administration, duodenal administration, parenteral injection (including intravenous, subcutaneous, intraperitoneal, intramuscular, intravascular or infusion), topical administration, and rectal administration. Methods of administration, which are optionally used for the components in the methods described here, can be found in sources such as, for example, Goodman and Gilman, The Pharmacological Basis of Therapeutics, current ed.; Pergamon; and Remington's, Pharmaceutical Sciences (current edition), Mack Publishing Co., Easton, Pa. In some embodiments, the components and compositions described herein are administered orally.

The term pharmaceutically acceptable as used herein refers to a substance that does not interfere with the biological activity or properties of the components described herein and is relatively non-current

- 19 041458 sichen (i.e. the toxicity of the substance does not significantly exceed its benefits). In some cases, a pharmaceutically acceptable substance can be administered to a patient without causing significant undesirable biological effects or significant undesirable interactions with any components of the composition in which it is contained.

As used herein, the term carrier refers to relatively non-toxic chemical components which, in some cases, facilitate the introduction of the component into cells or tissues.

The term non-systemic or minimally absorbable as used herein refers to low systemic bioavailability and/or absorption of an administered compound. In some examples, the non-systemic compound is a compound that is primarily absorbed non-systemically. In some embodiments, the ASBTI compositions described herein deliver the ASBTI to the distal ileum, colon, and/or rectum and are absorbed non-systemically (eg, a substantial portion of the ASBTI is absorbed non-systemically). In some embodiments, the non-systemic absorption of the non-systemic compound is <0.1%, <0.3%, <0.5%, <0.6%, <0.7%, <0.8%, <0.9%, <1%, <1.5%, <2%, < 3% or <5% of the administered dose (wt.% or mol.%). In some embodiments, non-systemic absorption of the non-systemic compound is <10% of the administered dose. In some embodiments, non-systemic absorption of the non-systemic compound is <15% of the administered dose. In some embodiments, non-systemic absorption of the non-systemic compound is <25% of the administered dose. In an alternative approach, a non-systemic ASBTI is a compound with lower systemic bioavailability compared to the systemic bioavailability of a systematic ASBTI (eg, compounds 100A, 100C). In some embodiments, the bioavailability of the non-systemic ASBTI described herein is <30%, <40%, <50%, <60%, or <70% of the bioavailability of a systemic ASBTI (eg, Compounds 100A, 100C).

In an alternative approach, the compositions described herein are formulated to deliver <10% of the administered dose of ASBTI systemically. In some embodiments, the compositions described herein are formulated to deliver <20% of the administered dose of ASBTI systemically. In some embodiments, the compositions described herein are formulated to deliver <30% of the administered dose of ASBTI systemically. In some embodiments, the compositions described herein are formulated to deliver <40% of the administered dose of ASBTI systemically. In some embodiments, the compositions described herein are formulated to deliver <50% of the administered dose of ASBTI systemically. In some embodiments, the compositions described herein are formulated to deliver <60% of the administered dose of ASBTI systemically. In some embodiments, the compositions described herein are formulated to deliver <70% of the administered dose of ASBTI systemically. In some embodiments, systemic absorption is determined by any method, including an estimate of the total amount of circulating substance, the amount of substance detected after administration, and the like.

The term ASBT inhibitor refers to a compound that inhibits apical sodium-dependent transport of bile or any recuperative transport of bile salts. The term apical sodium dependent transporter (ASBT) is used interchangeably with the term ileal bile acid transporter (IBAT).

The term increased secretion of enteroendocrine peptide refers to a sufficient increase in the level of enteroendocrine peptide, for example, in the treatment of any disease or disease described here. In some embodiments, increased secretion of the enteroendocrine peptide alters or alleviates the symptoms of cholestasis or cholestatic liver disease.

In various embodiments, the pharmaceutically acceptable salts described herein include, but are not limited to, nitrate, chloride, phosphate, sulfate, acetate, hexafluorophosphate, citrate, gluconate, benzoate, propionate, butyrate, sulfosalicylate, maleate, laurate, malate, fumarate, succinate, tartrate, amsonate , pamoate, p-toluenesulfonate, mesylate, and the like. In addition, pharmaceutically acceptable salts include, but are not limited to, alkaline earth metal salts (eg, calcium or magnesium), alkali metal salts (eg, sodium or potassium dependent), ammonium salts, and the like.

The term optionally substituted or substituted means that the group in question contains one or more additional groups. In some embodiments, one or more additional groups are individually and independently selected from amide, ester, alkyl, cycloalkyl, heteroalkyl, aryl, heteroaryl, heteroalicyclyl, hydroxy, alkoxy, aryloxy, alkylthio, arylthio, alkyl sulfoxide, arylsulfoxide, ester, alkyl sulfone, arylsulfone, cyano, halogen, alkoil, alkoyloxo, isocyanato, thiocyanato, isothiocyanato, nitro, haloalkyl, fluoroalkyl, amino, alkylamino, dialkylamino, amido.

An alkyl group refers to an aliphatic hydrocarbon group. Reference to an alkyl group includes saturated alkyl and/or unsaturated alkyl. A saturated or unsaturated alkyl group includes a branched, straight chain or cyclic group. By way of example, alkyl includes methyl, ethyl, propyl, isopropyl, n-butyl, isobutyl, sec-butyl, pentyl, isopentyl, neopentyl, and hexyl. In some embodiments, the alkyl group includes, but is not limited to, methyl, ethyl, propyl, isopropyl, butyl, isobutyl, t-butyl, pentyl, hexyl, ethenyl, propenyl, butenyl, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, and the like. Lower alkyl is C ₁ -C ₆ alkyl. In heteroal

- 20 041458 keel group, any one carbon atom of the alkyl group is replaced by a heteroatom with the appropriate number of attached hydrogen atoms (for example, a CH2 group is replaced by an NH or O group).

The term alkylene refers to a divalent alkyl radical. Any of the above monovalent alkyl groups can become alkylene by removing a second hydrogen atom from the alkyl. In one embodiment, the alkylene is C ₁ -C ₁₀ alkylene. In another embodiment, the alkylene is C _g C ₆ alkylene. Exemplary alkylene groups include, but are not limited to, -CH2-, -CH(CH3)-, -C(CH3)2-, -CH2CH2-, _-CH2CH (CH3)-, _-CH2C (CH3) ₂ -, -CH2CH2CH2-, -CH2CH2CH2CH2-, -CH2CH2CH2CH2CH2-, -CH ₂ CH ₂ CH ₂ CH ₂ CH ₂ CH ₂ - and the like.

An alkoxy group refers to an (alkyl)O-group, where alkyl is defined here.

The term alkylamine refers to the group -N(alkyl) _x H _y , where alkyl is defined here and x and y are selected from the group x=1, y=1 and x=2, y=0. If x=2, the alkyl groups, together with the nitrogen atom to which they are attached, optionally form a cyclic system.

The amide is a chemical moiety of the formula -C(O)NHR or -NHC(O)R, where R is selected from alkyl, cycloalkyl, aryl, heteroaryl (bonded to a carbon atom in the ring) heteroaleccyclyl (bonded to the carbon atom in the ring).

The term ester refers to a chemical moiety of the formula -C(=O)OR where R is selected from the group consisting of alkyl, cycloalkyl, aryl, heteroaryl and heteroalicyclic.

The term aryl as used herein refers to an aromatic ring, where each atom forming the ring is a carbon atom. The aryl rings described herein include those of five, six, seven, eight, nine or more carbon atoms. Aryl groups may optionally have substituents. Examples of aryl groups include, but are not limited to, phenyl naphthalenyl.

The term aromatic refers to a planar ring with a delocalized π-electron system containing 4n+2 π-electrons, where n is an integer. Aromatic rings may contain five, six, seven, eight, nine, ten or more atoms. Aromatic rings may optionally have substituents. The term aromatic includes both carbocylic aryl (aryl, eg phenyl) and heterocyclic aryl (or heteroaryl or heteroaromatic) groups, (eg pyridine).

The term includes a monocyclic or polycyclic group with fused rings (ie, rings in which adjacent pairs of carbon atoms are generalized).

The term cycloalkyl refers to a monocyclic or polycyclic non-aromatic radical, where each atom of the ring-forming atoms (ie, backbone atoms) is a carbon atom. In various embodiments, cycloalkyls are saturated or partially unsaturated. In some embodiments, cycloalkyls are fused to an aromatic ring. Cycloalkyl groups include groups with 3-10 atoms. Examples of cycloalkyl groups include, but are not limited to, the following moieties:

and so on. Monocyclic cycloalkyls include, but are not limited to, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, cycloheptyl, and cyclooctyl.

The term heterocyclo refers to heteroaromatic and heteroalicyclic groups containing from one to four heteroatoms, each selected from O, S and N. In some cases, each heterocyclic group contains 4-10 atoms in the cyclic system, provided that the cycle of the specified group does not contain two adjacent O or S atoms. Non-aromatic heterocyclic groups include groups with 3 atoms in the ring system, but aromatic heterocyclic groups must include at least 5 atoms in the ring system. Heterocyclic groups include benzo-fused ring systems An example of a 3-membered heterocyclic group is aziridinyl (derived from aziridine). An example of a 4-membered heterocyclic group is azetidinyl (derived from azetidine). An example of a 5-membered heterocyclic group is thiazolyl. An example of a 6-membered heterocyclic group is pyridyl, and an example of a 10-membered heterocyclic group is quinolyl. Examples of non-aromatic heterocyclic groups are pyrrolidinyl, tetrahydrofuranyl, dihydrofuranyl, tetrahydrothienyl, tetrahydropyranyl, dihydropyranyl, tetrahydrothiopyranyl, piperidinyl, morpholyl, thiomorpholyl, thiooxanyl, piperazinyl, aziridinyl, azetidinyl, oxetanyl, thietanyl, homopiperidinyl, oxepanyl, oxepanyl, thiepanyl

- 21 041458 nil, diazepinyl, thiazepinyl, 1,2,3,6-tetrahydropyridinyl, 2-pyrrolinyl, 3-pyrrolinyl, indolinyl, 2H-pyranyl, 4H-pyranyl, dioxanyl, 1,3-dioxolanyl, pyrazolinyl, dithianyl, dithiolanyl , dihydropyranyl, dihydrothienyl, dihydrofuranyl, pyrazolidinyl, imidazolinyl, imidazolidinyl, 3-azabicyclo[3.1.0]hexanyl, 3-azabicyclo[4.1.0]heptanyl, 3H-indolyl, and quinolisyl. Examples of aromatic heterocyclic groups are pyridinyl, imidazolyl, pyrimidinyl, pyrazolyl, triazolyl, pyrazinyl, tetrazolyl, furyl, thienyl, isoxazolyl, thiazolyl, oxazolyl, isothiazolyl, pyrrolyl, quinolinyl, isoquinolinyl, indolyl, benzimidazolyl, benzofuranyl, cinnolinyl, indazolyl, phthalazinyl , pyridazinyl, triazinyl, isoindolyl, pteridinyl, purinyl, oxadiazolyl, thiadiazolyl, furazanil, benzofurazanil, benzothiophenyl, benzothiazolyl, benzoxazolyl, quinazolinyl, quinoxalinyl, naphthyridinyl, and furopyridinyl.

The terms heteroaryl or alternatively heteroaromatic group refers to an aryl group that includes one or more ring heteroatoms selected from nitrogen, oxygen and sulfur. N-containing heteroaromatic or heteroaryl fragment refers to an aromatic group in which at least one of the atoms of the cyclic skeleton is a nitrogen atom. In some embodiments, the heteroaryl groups are monocyclic or polycyclic. Illustrative examples of heteroaryl groups include the following:

A heteroalicyclic group or a heterocyclo group refers to a cycloalkyl group in which at least one ring atom is a heteroatom selected from nitrogen, oxygen and sulfur. In various embodiments, the radicals also contain aryl or heteroaryl. Illustrative examples of heterocyclo groups, also referred to as non-aromatic heterocycles, include

and so on. The term heteroalicyclic also includes all cyclic forms of carbohydrates, including, but not limited to, monosaccharides, disaccharides, and oligosaccharides.

The term halo or alternatively halogen means fluorine, chlorine, bromine and iodine.

The terms haloalkyl and halooxy include alkyl and alkoxy structures that contain one or more halogen atoms. In some embodiments where more than one halogen is included in the group, the halogens are the same or different. The terms fluoroalkyl and fluoroalkoxy include haloalkyl and haloalkoxy groups, respectively, where halogen is fluorine.

The term heteroalkyl includes optionally substituted alkyl, alkenyl, and alkynyl radicals that include one or more ring atoms other than carbon, such as oxygen, nitrogen, sulfur, phosphorus, silicon, or combinations thereof. In some embodiments, the heteroatoms are located at any internal positions of the heteroalkyl group. Examples include, but are not limited to, CH2-O-CH3, -CH ₂ -CH ₂ -O-CH ₃ , -CH2-NH-CH3 , -CH ₂ -CH ₂ -NH-CH ₃ , -CH ₂ -N (CH ₃ )-CH ₃ , -CH2-CH2-NHCH3, -CH2-CH2-N(CH3)-CH3, -CH2-S-CH2-CH3, -CH2-CH2, -S(O)-CH3, - CH2-CH2-S(O)2-CH3, -CH=CH-O-CH3, -Si(CH ₃ ) ₃ , -CH ₂ -CH=N-OCH ₃ and -CH=CH-N(CH ₃ ) _-CH3 . In some embodiments, up to two heteroatoms are located in series, for example in -CH2-NH-OCH3 and -CH ₂ -O-Si(CH ₃ ) ₃ .

The cyano group refers to the -CN group.

The isocyanato group refers to the -NCO group.

The thiocyanato group belongs to the -CNS group.

Isothiocyanato belongs to the -NCS group.

- 22 041458

Alkoyloxy refers to the RC(=O)O- group.

Alkoyl belongs to RC(=O)-rpynne.

The term modulate, as used here, refers to something that affects (eg increases, raises, or maintains at a certain level).

The term optionally substituted or substituted means that the group in question may contain one or more additional groups independently selected from C1-C6 alkyl, _C3 - _C8 cycloalkyl, aryl, heteroaryl, C2-C6 heteroalicyclic, hydroxy, € _1- € ₆ alkoxy, aryloxy, arylalkoxy, aralkyloxy, arylalkyloxy, C ₁ -C ₆ alkylthio, arylthio, C ₁ -C ₆ alkyl sulfoxide, aryl sulfoxide, C ₁ -C ₆ alkyl sulfone, arylsulfone, cyano group, halogen, C 2 -C ₈ acyl, C 2 -C ₈ acyloxy, nitro groups, C ₁ -C ₆ haloalkyl, C ₁ -C ₆ fluoroalkyl and amino groups, including C ₁ -C ₆ alkylamino groups, and protected derivatives thereof. For example, an optional substituent may be L ^s R ^s , where each L ^s is independently selected from a bond, -O-, -C(=O)-, -S-, -S(=O)-, -S(=O) 2-, -NH-, -NHC(=O)-, -C(=O)NH-, S(=O)2NH-, -NHS(=O)2-, -OC(=O)NH-, -NHC(=O)O-, -(C1-C6 alkyl)-, or -(C2-C6 alkenyl)-; and each R ^s is independently selected from H, (C1-C4 alkyl), ( _C3 - _C8 cycloalkyl), heteroaryl, aryl, and C1-C6 heteroalkyl. Optionally substituted non-aromatic groups may contain one or more oxo groups (=O). The protecting groups that can form protected derivatives of these substituents are known to those skilled in the art and can be found in the references above, for example Greene and Wuts. In some embodiments, the alkyl groups described herein optionally contain an O substituent that is bonded to two adjacent carbon atoms (i.e., an epoxide is formed).

As used herein, the terms therapeutically effective amount or effective amount refer to a sufficient amount of a therapeutically active ingredient to provide the desired effect in a patient. In some embodiments, a therapeutically effective amount or effective amount of ASBTI refers to a sufficient amount of ASBTI to treat cholestasis or cholestatic liver disease in a patient.

L-cells.

Applicants have found that enteroendocrine L-cells play a large role in recovery. The epithelial barrier also plays a key role in immunity. The next splicing product of pre-proglucagon A, GLP-2, is secreted by enteroendocrine L cells in the distal small intestine and has been shown to improve intestinal wound healing with the participation of TGF-B (the anti-inflammatory cytokine TGF-B), to which the small intestine is more responsive. intestine than the large intestine. GLP-2 has also been shown to attenuate barrier dysfunction caused by experimental stress and food allergy. Also, L cells are activated by nutrients in the intestinal lumen, and the barrier disturbances seen in TPN may partly reflect hypersecretion in the absence of an enteric stimulus. In addition, GLP-2 is also at least partially responsible for the growth and adaptation seen in short gut models. Therefore, abnormal function of enteroendocrine cells (EEC) may predispose to inflammatory diseases of the gastrointestinal (GI) tract and the main effect of nutrient-EEC-vagal is directed to the damaged intestine, as suggested in the above options.

L-cells are distributed throughout the epithelium from the duodenum to the rectum, with the largest number of cells in the ileum, colon and rectum. They are characterized by an open cell morphology with apical microvilli opening into the lumen and with secretory vesicles adjacent to the basolateral membrane and therefore in direct contact with nutrients in the intestinal lumen. In addition, L-cells are located near neurons and the microvasculature of the intestine, as a result of which both neural and hormonal signals affect the L-cell. Like glucagon-like peptide 1 (GLP-1) and glucagon-like peptide 2 (GLP-2), L cells also secrete peptide YY (PYY) and glutamate. The cells are only one member of a much larger family of enteroendocrine cells that secrete a range of hormones, including ghrelin, GIP, cholecystokin, somatostatin, and secretin, which are involved in the local coordination of intestinal physiology and also play a broader role in regulating cytokine release and/or regulating adaptive processes, mitigating intestinal damage, reducing bacterial translocation, inhibiting the release of free oxygen radicals, or any combination thereof. L-cells are unevenly distributed in the gastrointestinal tract with higher concentrations in the distal region of the gastrointestinal tract (eg, in the distal ileum, colon and rectum).

Bile acids.

Bile contains water, electrolytes, and many organic molecules, including bile acids, cholesterol, phospholipids, and bilirubin. Bile is secreted by the liver and stored in the gallbladder, and as a result of the contraction of the gallbladder when eating fatty foods, it passes through the bile duct into the intestine. Bile acids/salts are critical for digestion and absorption of fats and fat-soluble vitamins in the small intestine. An adult excretes 400-800 ml of bile per day. The secretion of bile can be seen as a two-stage process. Hepatocytes first secrete

- 23 041458 bile into the tubules, from which it enters the bile ducts, and this hepatic bile contains large amounts of bile acids, cholesterol and other organic substances. Then, as the bile moves through the bile ducts, it is modified by the addition of an aqueous, bicarbonate-rich secret from the ductal epithelial cells. When in the gallbladder, bile thickens usually five times.

The lowest flow of bile is observed on an empty stomach, and most of it returns to the gallbladder, where it is concentrated. When the slurry from digested food enters the small intestine, acid, partially digested fats, and proteins stimulate the secretion of cholecystokinin and secretin, both of which are important for bile secretion and flow. Cholecystokinin (cholecysto = gallbladder and kinin = movement) is a hormone that stimulates contractions of the gallbladder and common bile duct, allowing bile to flow into the intestine. The strongest stimulus for cholecystokinin release is the presence of fat in the duodenum. Secretin is a hormone released in response to acid in the duodenum and stimulates the biliary cells of the bile duct to secrete bicarbonate and water, which expand the volume of bile and increase its flow to the intestine.

Bile acids/salts are derivatives of cholesterol. Introduced as part of food or synthesized in the liver, cholesterol is converted in hepatocytes into bile acids/salts. Examples of such bile acids/salts include cholic and chenodeoxycholic acids, which then react with an amino acid (such as glycine or taurine) to form a conjugated form that is actively secreted into the tubules. The most common human bile salts are cholates and deoxycholates, and they are usually conjugated with either glycine or taurine to form glycocholates or taurocholates, respectively.

Free cholesterol is insoluble in aqueous solutions, but becomes soluble in bile due to the presence of bile acids/salts and lipids. Hepatic synthesis of bile acids/salts accounts for most of the conversion of cholesterol in the human body. Approximately 500 mg of cholesterol is converted into bile acids/salts in the human body and excreted daily in the bile. Therefore, secretion into bile is the main mechanism for the elimination of cholesterol. Large amounts of bile acids/salts are secreted daily into the intestines, but only relatively small amounts are lost. This is because approximately 95% of the bile acids/salts entering the duodenum are reabsorbed back into the blood in the ileum by a mechanism known as enterohepatic recirculation.

Venous blood from the ileum enters directly into the portal vein and hence through the sinusoidal capillaries of the liver. Hepatocytes are very efficient at extracting bile acids/salts from sinusoidal blood, and a small proportion of them exit the healthy liver into the systemic circulation. The bile acids/salts are then transported through the hepatocytes and re-secreted into the tubules. The net effect of this enterohepatic recirculation is that each bile salt molecule is used approximately 20 times, often twice or twice, during one phase of digestion. Bile biosynthesis represents the main metabolic pathway for cholesterol, which corresponds to more than half of the approximately 800 mg/day cholesterol that a middle-aged person uses in metabolic processes. By comparison, steroid hormone synthesis absorbs only about 50 mg of cholesterol per day. More than 400 mg of bile salt must be secreted into the intestine per day, and this is achieved by recycling bile salts. Most of the bile salts secreted into the upper small intestine are absorbed along with dietary lipids, which are emulsified in the lower small intestine. They are separated from dietary lipids and returned to the liver for reuse. Thus, recycling contributes to the secretion of 20-30 g of bile salts into the small intestine per day.

Bile acids/salts are amphipathic, with the cholesterol derived portion containing both hydrophobic (fat soluble) and polar (hydrophilic) moieties, while the amino acid conjugate is typically polar and hydrophilic. The amphipathic nature provides bile acids/salts with two important functions: emulsification of lipid aggregates and dissolution and transport of lipids in the aquatic environment. Bile acids/salts act as detergents for dietary fat particles, causing fat globule breakdown or emulsification. Emulsification is important because it markedly increases the surface area of fat available for processing by lipases, which cannot penetrate into the lipid droplets. In addition, bile acids/salts are lipid carriers and are capable of dissolving many lipids to form micelles, which is critical for the transport and absorption of fat soluble vitamins.

Pharmaceutical compositions and methods for their use.

In some embodiments, the compositions described herein are administered to deliver components that increase the secretion of enteroendocrine peptides to a patient. In some embodiments, any of the compositions described herein are for delivery to the ileum, rectum, and/or colon. In more specific embodiments, the composition is intended for non-systemic or local delivery to the rectum and/or colon. As used herein, the term colon delivery is to be understood to include

- 24 041458 delivery to the sigmoid colon, transverse colon and/or ascending colon. In even more specific embodiments, the composition is for non-systemic or local delivery to the rectum and/or colon and is administered rectally. In other specific embodiments, the composition is for non-systemic or local delivery to the rectum and/or colon and is administered orally.

In some embodiments, a composition is provided comprising a component for increasing secretion of an enteroendocrine peptide and optionally a pharmaceutically acceptable carrier for alleviating symptoms of childhood cholestasis or cholestatic liver disease.

In some embodiments, such a composition includes a component to enhance secretion of an enteroendocrine peptide and an absorption inhibitor. In specific embodiments, the absorption inhibitor inhibits the absorption of (at least one) the specific secretion-enhancing component of the enteroendocrine peptide with which it is combined. In some embodiments, the composition includes a component to enhance secretion of an enteroendocrine peptide, an absorption inhibitor, and a carrier (eg, a carrier for oral administration or rectal administration, depending on the route of administration intended). In some embodiments, the composition includes an enteroendocrine peptide secretion enhancer, an absorption inhibitor and a carrier, and one or more cholesterol absorption inhibitors, an enteroendocrine peptide, a peptidase inhibitor, a lyophilizing agent, and a wetting agent.

In other embodiments, the composition described herein is administered orally for non-systemic delivery of the bile salt active ingredient to the rectum and/or colon, including the sigmoid colon, transverse colon, and/or ascending colon. In particular embodiments, compositions for oral administration are, for example, coated oral dosage forms, or oral forms such as tablets and/or capsules. It should be understood that the terms patient or individual are used interchangeably herein and include, for example, humans and patients in need of treatment.

absorption inhibitors.

In some embodiments, non-systemic ASBTI delivery compositions described herein also include an absorption inhibitor. As used herein, the term absorption inhibitor includes a component or group of components that inhibit the absorption of bile acids/salts.

Bile acid absorption inhibitors (also referred to herein as absorption inhibition components) include, but are not limited to, anion exchange matrices, polyamines, polymers containing quaternary amines, quaternary ammonium salts, polyallylamine polymers and copolymers, colesevelam hydrochloride, CholestaGel polymer (K,K,K- triethyl-6-(2-propenidamino)-1hexaneaminium chloride with (chloromethyl)oxirane, 2-propene-1-amine and K-2-propenyl-1-decanamine hydrochloride, cyclodextrins, chitosan, chitosan derivatives, carbohydrates that bind bile acids , lipids that bind bile acids, proteins, proteins that bind bile acids, and antibodies and albumins that bind bile acids. and hydroxypropyl-v-cyclodextrin.Useful proteins include those that bind bile acids/salts, such as, as a non-limiting For example, bovine serum albumin, ovalbumin, casein, α-1 acid glycoprotein, gelatin, soy, peanut, almond and wheat vegetable proteins.

In some embodiments, the absorption inhibitor is cholestyramine. In specific embodiments, cholestyramine is combined with bile acid. Cholestyramine is an ion exchange resin, is a styrene polymer containing quaternary ammonium groups cross-linked with divinylbenzene. In other embodiments, the absorption inhibitor is colestipol. In specific embodiments, colestipol is combined with a bile acid. Colestipol, an exchange resin, is a copolymer of diethylenetriamine and 1-chloro-2,3-epoxypropane.

In some embodiments of the described compositions and methods, the ASBTI is associated with an absorption inhibitor, while in other embodiments, the ASBTI and the absorption inhibitor are separate molecular forms. In specific embodiments, the model bile acid or modified bile acid is bound to a bile acid absorption inhibitor as described herein.

Cholesterol absorption inhibitors.

In some embodiments, the composition described herein optionally includes at least one cholesterol absorption inhibitor. Suitable cholesterol absorption inhibitors include, but are not limited to, ezetimibe (SCH 58235), ezetimibe analogs, ACT inhibitors, stigmastanil phosphorylcholine, stigmastanil phosphorylcholine analogs, β-lactam cholesterol absorption inhibitors, sulfate polysaccharides, neomycin, plant sponins, plant sterols, from phytostanol FM-VP4, sitostanol, β-sitosterol, acyl-CoA:cholesterol-Oacyltransferase (ACAT) inhibitors, avasimib, implitapid, steroidal glycosides, etc. Suitable analogs of enzetimibe include, but are not limited to, SCH 48461, SCH 58053, and the like. Suitable

ACT inhibitors include, but are not limited to, trimethoxyaliphatic acid anilides of type CI-976, 3-[decyldimethylsilyl]-N-[2-(4-methylphenyl)-1-phenylethyl]propanamide, melinamide, and the like. β-lactam-based cholesterol absorption inhibitors include, but are not limited to, (3R-4S)-1,4-bis-(4-methoxyphenyl)-3-(3-phenylpropyl)-2-azetidinone, and the like.

peptidase inhibitors.

In some embodiments, the compositions described herein optionally include at least one peptidase inhibitor. Such peptidase inhibitors include, but are not limited to, dipeptidyl peptidase-4 (DPP-4) inhibitors, neutral endopeptidase inhibitors, and enzyme conversion inhibitors. Suitable inhibitors of dipeptidyl peptidase-4 (DPP-4) include, as a non-limiting example, Vildagliptin-(2S)-1-{2-[(3-hydroxy-1-adamantyl)amino]acetyl}-pyrrolidine-2-carbonitrile, Sitagliptin-( 3R)-3-amino-1-[9-(trifluoromethyl)-1,4,7,8-tetrazabicyclo[4.3.0]nona-6,8-dien-4-yl]-4-(2,4, 5-trifluorophenyl)butan-1-one and Saxagliptin - (1S,3S,5S)-2-[(2S)-2-amino-2-(3hydroxy-1-adamantyl)acetyl]-2-azabicyclo[3.1.0 ]hexane-3-carbonitrile. Such neutral endopeptidase inhibitors include, but are not limited to, Candoxatrilate and Ecadotril.

Lyophilizers/wetting agents.

In some embodiments, the compositions described herein optionally include a lyophilizing component. In some embodiments, the lyophilizing component is used to improve the distribution of the composition in the colon and rectum. Suitable lyophilizers include, but are not limited to, hydroxyethyl cellulose, hydroxypropyl methylcellulose, polyethylene glycol, colloidal silicon dioxide, propylene glycol, cyclodextrins, microcrystalline cellulose, polyvinylpyrrolidone, polyoxyethylated glycerides, polycarbophil, di-octyl ethers, Cetiol™OE, aliphatic alcohol esters of polyalkylene glycol, Aethoxal™B ), 2ethylhexyl palmitate, Cegesoft™C 24) and isopropyl esters of fatty acids.

In some embodiments, the compositions described herein optionally include a wetting agent. In some embodiments, a wetting agent is used to improve the wettability of the composition in the colon and rectum. Suitable wetting agents include, but are not limited to, ionic or non-ionic surfactants. In some embodiments, surfactants are selected from, but are not limited to, SLS, poloxamers (e.g., poloxamer 188), polysorbates (e.g., 20 or 80), stearylheptanoate, caprylic/capric acid esters, C1 ₂ saturated aliphatic alcohol esters -C1 ₈ , isostearic acid isostearyl diglyceride, sodium dodecyl sulfate, isopropyl myristate, isopropyl palmitate and a mixture of isopropyl myristate/isopropyl stearate/isopropyl palmitate.

Vitamins.

In some embodiments, the methods provided herein also include the administration of one or more vitamins.

In some embodiments, the vitamin is vitamins A, B1, B2, B3, B5, B6, B7, B9, B12, C, D, E, K, folic acid, pantothenic acid, niacin, riboflavin, thiamine, retinol, beta carotene, pyridoxine, ascorbic acid, cholecalciferol, cyanocobalamin, tocopherols, phylloquinone, menaquinone.

In some embodiments, the vitamin is fat soluble, such as vitamins A, D, E, K, retinol, beta-carotene, cholecalciferol, tocopherols, phyloquinone. In preferred embodiments, the fat soluble vitamin is tocopherol polyethylene glycol succinate (TPGS).

Bile acid sequestrants/binders.

In some embodiments, the labile bile acid sequestrant is enzyme dependent. In some embodiments, the enzyme is bacterial. In some embodiments, the enzyme is a bacterial enzyme that is found at a high concentration in the human colon or rectum compared to the concentration in the small intestine. Examples of microflora activating systems include dosage forms containing pectin, galatomannan and/or Azo hydrogels and/or glycoside conjugates (eg D-galactoside, e-D-xylopyranoside, etc.) with an active ingredient. Examples of enzymes from the microflora of the gastrointestinal tract include bacterial glycosidases such as D-galactosidase, e-D-glucosidase, β-L-arabinofuranosidase, e-D-xylopyranosidase, or the like.

In some embodiments, the action of the labile bile acid sequestrant is time dependent. In some embodiments, the labile bile acid sequestrant releases bile acid or is destroyed after 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 seconds of sequestration. In some embodiments, the labile bile acid sequestrant releases bile acid or is destroyed after 15, 20, 25, 30, 35, 40, 45, 50, or 55 seconds of sequestration. In some embodiments, the labile bile acid sequestrant releases bile acid or is destroyed after 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 minutes of sequestration. In some embodiments, the labile bile acid sequestrant releases bile acid or is destroyed after about 15, 20, 25, 30, 35, 45, 50, or 55 minutes of sequestration. In some embodiments, the labile bile acid sequestrant releases bile acid or is degraded through

- 26 041458 approx. 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23 or 24 h sequestration. In some embodiments, the labile bile acid sequestrant releases bile acid or is destroyed after 1, 2, or 3 days of sequestration.

In some embodiments, the labile bile acid sequestrant has a low affinity for bile acid. In some embodiments, the labile bile acid sequestrant has a high affinity for the primary bile acid and a low affinity for the secondary bile acid.

In some embodiments, the action of the labile bile acid sequestrant is pH dependent. In some embodiments, the pH-dependent bile acid sequestrant has a high affinity for bile acid at pH 6 or lower and a low affinity for bile acid at a pH greater than 6. In some embodiments, the pH-dependent bile acid sequestrant has a high affinity for bile acid at pH 6.5 or lower, and low affinity for bile acid above pH 6.5. In some embodiments, the pH-dependent bile acid sequestrant has a high affinity for bile acid at pH 7 or lower and a low affinity for bile acid at a pH greater than 7. In some embodiments, the pH-dependent bile acid sequestrant has a high affinity for bile acid at pH 7.1 or lower and low affinity for bile acid above pH 7.1. In some embodiments, the pH-dependent bile acid sequestrant has a high affinity for bile acid at a pH of 7.2 or lower and a low affinity for bile acid at a pH above 7.2. In some embodiments, the pH-dependent bile acid sequestrant has a high affinity for bile acid at a pH of 7.3 or lower and a low affinity for bile acid at a pH above 7.3. In some embodiments, the pH dependent bile acid sequestrant has a high affinity for bile acid at a pH of 7.4 or lower and a low affinity for bile acid at a pH above 7.4. In some embodiments, the pH dependent bile acid sequestrant has a high affinity for bile acid at a pH of 7.5 or lower and a low affinity for bile acid at a pH above 7.5. In some embodiments, the pH dependent bile acid sequestrant has a high affinity for bile acid at a pH of 7.6 or lower and a low affinity for bile acid at a pH above 7.6. In some embodiments, the pH-dependent bile acid sequestrant has a high affinity for bile acid at or below 7.7 and a low affinity for bile acid at a pH above 7.7. In some embodiments, the pH dependent bile acid sequestrant has a high affinity for bile acid at a pH of 7.8 or lower and a low affinity for bile acid at a pH above 7.8. In some embodiments, the pH dependent bile acid sequestrant is degraded at a pH greater than 6. In some embodiments, the pH dependent bile acid sequestrant is degraded at a pH greater than 6.5. In some embodiments, the pH dependent bile acid sequestrant is degraded at a pH greater than 7. In some embodiments, the pH dependent bile acid sequestrant is degraded at a pH greater than 7.1. In some embodiments, the pH-dependent bile acid sequestrant is destroyed at a pH greater than 7.2. In some embodiments, the pH-dependent bile acid sequestrant is destroyed at a pH greater than 7.3. In some embodiments, the pH-dependent bile acid sequestrant is destroyed at a pH greater than 7.4. In some embodiments, the pH-dependent bile acid sequestrant is destroyed at a pH greater than 7.5. In some embodiments, the pH-dependent bile acid sequestrant is destroyed at a pH greater than 7.6. In some embodiments, the pH-dependent bile acid sequestrant is destroyed at a pH greater than 7.7. In some embodiments, the pH-dependent bile acid sequestrant is destroyed at a pH greater than 7.8. In some embodiments, the pH dependent bile acid sequestrant is degraded at a pH greater than 7.9.

In some embodiments, the labile bile acid sequestrant is lignin or a modified lignin. In some embodiments, the labile bile acid sequestrant is a polycationic polymer or copolymer. In some embodiments, the labile bile acid sequestrant is a polymer or copolymer comprising one or more N-alkenyl-K-alkylamino groups; one or more N,N,N-trialkyl-N-(N'-alkenylamino)alkylazane groups; one or more K,K,K-trialkyl-K-alkenylazine groups; one or more alkenylamine groups; or their combinations.

In some embodiments, the bile acid binder is cholestyramine and various compositions including cholestyramine, which are described, for example, in US patent No. 3383281; 3308020; 3769399; 3846541; 3974272; 4172120; 4252790; 4340585; 4814354; 4874744; 4895723; 5695749; and 6,066,336. In some embodiments, the bile acid binder is cholestipol or cholezevelam.

Ways.

In some embodiments, provided herein are methods for treating childhood cholestasis or cholestatic liver disease in children, comprising non-systemic administration of a therapeutically effective amount of ASBTI. In some embodiments, provided herein are methods of treating childhood cholestasis or cholestatic liver disease, comprising contacting the gastrointestinal tract from the ileum to the colon and/or rectum of an ASBTI patient. Also provided herein are methods for reducing the level of bile acids in enterocytes, reducing damage to the hepatocellular or intestinal architecture caused by cholestasis or cholestatic liver disease in a patient, comprising administering a therapeutically effective amount of ASBTI to the patient.

In some embodiments, provided herein are methods of treating childhood cholestasis or cholestatic liver disease, including delivery to the ileum or colon or rectum.

- 27 041458 the intestine of a patient with a therapeutically effective amount of any ASBTI described here. In some embodiments, provided herein are methods of reducing damage to hepatocellular or intestinal architecture or cells due to cholestasis or cholestatic liver disease, comprising administering a therapeutically effective amount of ASBTI. In some embodiments, provided herein are methods for reducing the level of bile acids/salts in enterocytes, comprising administering a therapeutically effective amount of ASBTI to a patient.

In some embodiments, provided herein are methods for inhibiting bile acid recycling by administering any of the compounds described herein to a patient. In some embodiments, the ASBTI described herein is systemically absorbed after administration. In some embodiments, the ASBTI described herein is absorbed non-systemically. In some embodiments, the ASBTI described herein is administered orally to a patient. In some embodiments, the ASBTI described herein is delivered and/or released in the patient's ileum.

In some cases, exposure of the child's ileum to an ASBTI (eg, any ASBTI described here) inhibits bile acid reuptake and increases the concentration of bile acids/salts near L-cells in the distal ileum and/or in the colon and/or rectum , which leads to a decrease in the content of bile acids in enterocytes, a decrease in the level of bile acids in the serum and liver, a decrease in the total content of bile acids and / or a decrease in damage to the architecture of the ileum caused by cholestasis or cholestatic liver disease. Without being limited by a particular theory, it can be argued that a decrease in the level of bile acids in the serum and/or liver attenuates cholestasis and/or cholestatic disease.

The compound described herein is administered by any suitable route, including, but not limited to, the following routes of administration: orally, intraperitoneally, parenterally (eg, intravenously, subcutaneously, intramuscularly), nasally, buccally, topically, rectally, or transdermally. Any compounds or compositions described herein are administered in the form of a formulation appropriate for the treatment of a neonate or toddler. When treating a neonate or toddler, any compounds or compositions described herein are administered as an oral formulation (eg, solid or liquid). In some embodiments, the pediatric dosage form is selected from solution, syrup, suspension, elixir, powder for reconstitution into a suspension or solution, lingual/effervescent tablet, chewable tablet, lozenge, lollipop, cold lozenges, lozenges, sticks, orally dispersible tablets , orally absorbable sticks and fine powder or small granules for oral administration.

In some embodiments, a compound or composition described herein is administered as a pediatric dosage form intended for the treatment of children. In some embodiments, a compound or composition for treating adolescents described herein is administered as a pediatric dosage form. In some embodiments, a compound or composition described herein is administered as a pediatric dosage form in the treatment of neonates or toddlers. In some embodiments, a compound or composition for treating neonates or infants described herein is administered as an oral formulation (eg, solid or liquid). In some embodiments, the described pediatric dosage form is administered before a meal, with a meal, or after a meal.

In some embodiments, a compound or composition comprising a compound described herein is administered for prophylaxis and/or therapeutic treatment. In therapeutic use, the compound is administered to a patient already suffering from a disease or condition in an amount sufficient to cure or at least partially alleviate the symptoms of the disease or condition. In different cases, the amount effective for such use depends on the severity and course of the disease or condition prior to therapy, health status, weight and response to drugs, as well as the opinion of the attending physician.

In prophylactic use, compounds or compositions comprising a compound as described herein are administered to a patient who is otherwise at risk for a particular disease, disorder, or condition. In some such applications, the precise amounts of compounds administered depend on the health condition, weight of the patient, and the like. In addition, in some instances of administration of a compound or composition described herein, effective amounts for such use will depend on the severity and course of the disease, disorder or condition prior to therapy, the health status of the patient, response to medications, and the judgment of the attending physician.

In some instances where the patient's condition does not improve following administration of a selected dose of a compound or composition described herein, administration of a compound or composition described herein to relieve, control, or limit the symptoms of a disorder, disease, or condition need not necessarily become chronic, i. applied over a long period of time, including life.

In some embodiments, the effective amount of a given component depends on one or more factors, such as the particular compound, the severity of the disease or condition, the characteristics of the patient (e.g., weight) in need of treatment, and is determined by the specific

- 28 041458 specific circumstances, including, for example, the specific component administered, the route of administration, the condition to be treated, and the patient being treated. In some embodiments, doses administered include doses up to the maximum tolerated dose. In some embodiments, doses administered include doses up to the maximum dose tolerated by the newborn or infant.

In some embodiments, the patient is administered about 0.001-5000 mg per day, about 0.001-1500 mg per day, about 0.001-100 mg/day, about 0.001-50 mg/day, or about 0.001-30 mg/day, or about 0.001-10 mg /day of the compound described here. In various embodiments, the desired dose is conveniently formulated as a single dose or as divided doses administered simultaneously (or over a short period of time) or at appropriate intervals, such as two, three, four or more small doses per day. In various embodiments, the unit dose is from about 0.001 mg/kg to about 500 mg/kg. In various embodiments, the unit dose is from about 0.001, 0.01, 0.1, 1, or 10 mg/kg to about 10, 50, 100, or 250 mg/kg. In various embodiments, a unit dose of ASBTI is from about 0.001 mg/kg to about 100 mg/kg. In various embodiments, a unit dose of ASBTI is from about 0.001 mg/kg to about 50 mg/kg. In various embodiments, a unit dose of ASBTI is from about 0.001 mg/kg to about 10 mg/kg. In various embodiments, a single dose of ASBTI is administered every 6 hours, every 12 hours, every 24 hours, every 48 hours, every 72 hours, every 96 hours, every 5 days, every 6 days, or once a week.

If the patient's condition improves, the ASBTI need not be given continuously after the physician's judgment; alternatively, the dose of the drug administered is temporarily reduced or temporarily stopped for a period of time (eg, drug holidays). The duration of the drug-free period does not necessarily vary between 2 days and 1 year, including, by way of example only, 2, 3, 4, 5, 6, 7, 10, 12, 15, 20, 28, 35, 50 , 70, 100, 120, 150, 180, 200, 250, 280, 300, 320, 350 or 365 days. Dose reduction during drug holidays is 10-100% including, by way of example only, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80 , 85, 90, 95 or 100%. In some embodiments, the total unit dose of ASBTI is in the above range.

After the patient's condition has improved, a maintenance dose is administered if necessary. The dose or frequency of administration, or both, is then reduced, depending on the symptoms, to a level that continues to improve the disease, disorder, or condition. In some embodiments, patients require interruptions in treatment for a long time before the onset of any symptoms of the disease.

In some cases, an individual treatment regimen depending on many variables and significant deviations from these recommended values are within the scope of the invention described here. The dosages herein do not necessarily vary depending on many variables such as, but not limited to, the activity of the compound used, the disease or condition to be treated, the route of administration, the wishes of the patient, the severity of the disease or condition, and the judgment of the attending physician.

The toxicity and therapeutic efficacy of such therapeutic regimens is optionally determined using pharmaceutical procedures in cell cultures or experimental animals, including, but not limited to, determination of LD ₅₀ (lethal dose for 50% of the population) and ED ₅₀ (therapeutically effective dose for 50% of the population) . The dose ratio between toxicity effects and therapeutic efficacy is the therapeutic index and can be expressed as the ratio of LD ₅₀ and ED ₅₀ . Compounds with high therapeutic indices are preferred. In some embodiments, data obtained from analysis of cell cultures and animals is used to select a dosage range in application to humans. In specific embodiments, the dose of the compounds described here lies in the range of concentrations that include the ED50 with minimal toxicity. The dose is optionally changed within this range depending on the dosage form used and the route of administration.

In some embodiments, systemic exposure to a therapeutically effective amount of a non-systemic ASBTI described herein (e.g., an ASBTI comprising an LK type non-systemic moiety or other groups described herein) is reduced compared to systemic exposure to a therapeutically effective amount of any systemically absorbed ASBTI (e.g., compounds 100A, 100C) . In some embodiments, the AUC of a therapeutically effective amount of a non-systemic ASBTI described herein (e.g., an ASBTI that includes an L-K type non-systemic moiety or other described groups) is reduced by at least 10%, at least 20%, at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, or at least 90% of the AUC of any systemically absorbed ASBTI ( e.g. compounds 100A, 100C).

In some embodiments, the C _max of a therapeutically effective amount of the non-systemic ASBTI described herein is reduced by at least 10%, at least 20%, at least 30%, at least 40%, at least 50%, at least at least 60%, at least 70%, at least 80%, or at least 90% of the _Cmax of any systemically absorbed ASBTI (eg, Compound 100A).

- 29 041458

In some embodiments, the pharmaceutical composition administered includes a therapeutically effective amount of a bile salt, a model bile salt, an absorption inhibitor, and a carrier (eg, an oral carrier or a rectal carrier, depending on the intended route of administration). In some embodiments, the pharmaceutical composition used or administered includes a therapeutically effective amount of a bile salt or model bile salt, an absorption inhibitor, a carrier, and one or more cholesterol absorption inhibitors, an enteroendocrine peptide, a peptidase inhibitor, a lyophilizing agent, and a wetting agent.

In a specific embodiment, the composition used to make a rectal dosage form includes a bile salt or model bile salt, a rectal carrier, an optional cholesterol absorption inhibitor, an optional enteroendocrine peptide, an optional peptidase inhibitor, an optional lyophilizing agent, and an optional wetting agent. In some embodiments, rectally administered compositions include an anorectal response. In specific embodiments, the anorectal response is an increase in the secretion of one or more types of enteroendocrine side cells (eg, L cells) in the colon and/or rectum (eg, in the epithelial layer of the colon and/or rectum). In some embodiments, the anorectal response is maintained for at least 1.2, 3, 4,5,6,7,8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 , 21, 22, 23, or 24 hours. In other embodiments, the anorectal response is maintained for 24-48 hours, while in other embodiments, the anorectal response is maintained for more than 48 hours.

In another specific embodiment, a pharmaceutical composition used to prepare an oral dosage form comprises a bile salt, a model bile acid or a model bile salt, an absorption inhibitor, an oral carrier, an optional cholesterol absorption inhibitor, an optional enteroendocrine peptide, an optional peptidase inhibitor. , an optional lyophilizing agent, and an optional wetting agent. In some embodiments, orally administered compositions elicit an anorectal response. In specific embodiments, the anorectal response is an increase in the secretion of one or more types of enteroendocrine side cells in the colon and/or rectum (eg, L-cells in the epithelial layer of the colon and/or rectum). In some embodiments, the anorectal response is maintained for at least 1, 2, 3, 4,5,6,7,8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 , 21, 22, 23, or 24 hours. In other embodiments, the anorectal response is maintained for 2448 hours, while in other embodiments, the anorectal response is maintained for more than 48 hours.

Routes of administration and doses.

In some embodiments, the compositions described herein and administered by the methods described herein are formulated to inhibit bile acid reuptake or lower serum or hepatic levels of bile acids. In some embodiments, the compositions described herein are formulated for rectal or oral administration. In some embodiments, such preparations are administered rectally or orally, respectively. In some embodiments, the compositions described herein are combined with a device for local delivery of the compositions to the rectum and/or colon (sigmoid colon, transverse colon, or ascending colon). In some embodiments, for rectal administration, the compositions described herein are formulated as enemas, rectal gels, rectal foams, rectal sprays, suppositories, jelly suppositories, or retention enemas. In some embodiments of oral administration, the compositions described herein are prepared for oral administration and intracolonic administration.

In some embodiments, the compositions or methods described herein are non-systemic. In some embodiments, the compositions described herein deliver ASBTI to the distal ileum, colon, and/or rectum non-systemically (eg, a significant portion of the enteroendocrine peptide secretion-enhancing component is absorbed non-systemically). In some embodiments, the oral compositions described herein deliver the ASBTI to the distal ileum, colon, and/or rectum non-systemically (eg, a significant portion of the enteroendocrine peptide secretion-enhancing component is absorbed non-systemically). In some embodiments, the rectal compositions described herein deliver ASBTI to the distal ileum, colon, and/or rectum non-systemically (eg, a significant portion of the enteroendocrine peptide secretion-enhancing component is absorbed non-systemically). In some embodiments, the non-systemic compositions described herein deliver systemically less than 90% w/w. ASBTI. In some embodiments, the non-systemic compositions described herein deliver systemically less than 80% w/w. ASBTI. In some embodiments, the non-systemic compositions described herein deliver systemically less than 70% w/w. ASBTI. Some non-systemic compositions described herein deliver systemically less than 60% w/w. ASBTI. Some of the non-systemic compositions described herein deliver systemically less than 50% w/w. ASBTI. In some embodiments, the non-systemic compositions described herein deliver systemically less than 40% w/w. ASBTI. In some embodiments, the non-systemic compositions described herein deliver systemic

- 30 041458 dark less than 30% wt./wt. ASBTI. In some embodiments, the non-systemic compositions described herein deliver systemically less than 25% w/w. ASBTI. In some embodiments, the non-systemic compositions described herein deliver systemically less than 20% w/w. ASBTI. In some embodiments, the non-systemic compositions described herein deliver systemically less than 15% w/w. ASBTI. In some embodiments, the non-systemic compositions described herein deliver systemically less than 10% w/w. ASBTI. In some embodiments, the non-systemic compositions described herein deliver systemically less than 5% w/w. ASBTI. In some embodiments, systemic absorption is determined by any method, including determining the total circulating amount, the amount observed after administration, and the like.

In some embodiments, the compositions and preparations described herein are administered at least once a day. In some embodiments, ASBTI-containing formulations are administered at least twice daily, while in other embodiments, ASBTI-containing formulations are administered at least three times daily. In some embodiments, formulations containing ASBTIs are administered at least five times per day. It should be understood that in some embodiments, the dosing regimen of the composition containing the ASBTI described herein is set after taking into account various factors such as the age of the patient, sex and nutrition.

The concentration of ASBTI administered in the formulations described herein ranges from about 1 mM to about 1 M. In some embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 1 mM to about 750 mM. In some embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 1 mM to about 500 mM. In some embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 5 mM to about 500 mM. In some embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 10 mM to about 500 mM. In some embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 25 mM to about 500 mM. In some embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 50 mM to about 500 mM. In some embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 100 mM to about 500 mM. In some embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 200 mM to about 500 mM.

In some embodiments, any composition described herein contains a therapeutically effective amount of ursodiol (eg, for the treatment of cholestasis or cholestatic liver disease). In some embodiments, the ursodiol may be substituted for any other therapeutic bile acid or salt thereof. In some embodiments, the compositions and methods described herein include administering from about 0.01 mg to about 10 g of ursodiol. In some embodiments, a composition or method described herein comprises administering from about 0.1 mg to about 500 mg of ursodiol. In some embodiments, a composition or method described herein comprises administering from about 0.1 mg to about 100 mg of ursodiol. In some embodiments, the compositions and methods described herein include administering from about 0.1 mg to about 50 mg of ursodiol. In some embodiments, the compositions and methods described herein include administering from about 0.1 mg to about 10 mg of ursodiol. In some embodiments, the compositions and methods described herein include administering from about 0.5 mg to about 10 mg of ursodiol. In some embodiments, the compositions and methods described herein include administering from about 0.1 mmol to about 1 mol of ursodiol. In some embodiments, the compositions and methods described herein include administering from about 0.01 mmol to about 500 mmol of ursodiol. In some embodiments, the compositions and methods described herein include administering from about 0.1 mmol to about 100 mmol of ursodiol. In some embodiments, the compositions and methods described herein include administering from about 0.5 mmol to about 30 mmol of ursodiol. In some embodiments, the compositions and methods described herein include administering from about 0.5 mmol to about 20 mmol of ursodiol. In some embodiments, the compositions and methods described herein include administering from about 1 mmol to about mmol of ursodiol. In some embodiments, the compositions and methods described herein include administering from about 0.01 mmol to about 5 mmol of ursodiol. In some embodiments, the compositions and methods described herein include administering from about 0.1 mmol to about 1 mmol of ursodiol. In various embodiments, some bile acids/salts have different capabilities, according to which the dose is not necessarily set. For example, when studying TGR5 transfected CHO cells of the TGR5 agonist, the potential of natural bile acids/salts shows the following potential ranking: lithocholic acid (LCA) > deoxycholic acid (DCA) > murocholic acid (Muro-CA) > lagodeoxycholic acid (lago-DCA) > chenodeoxycholic acid (CDCA) > cholic acid (CA) > hyodeoxycholic acid (HDCA > ursodeoxycholic acid (UDCA); and analyzes of TGR5-transfected CHO cells show that EC ₅₀ (in μM) for UDCA was 36.4, TauroCA (TCA) 4.95 and LCA 0.58 .

In some embodiments, when directed to the distal gastrointestinal tract (for example, the distal ileum, colon and/or rectum), the described

- 31 041458 compositions and methods are effective (for example, in reducing microbial growth and/or ameliorating the symptoms of cholestasis or cholestatic liver disease) at a reduced dose of enteroendocrine peptide (for example, compared with an oral dose that does not target the distal gastrointestinal tract ).

Preparations for rectal administration.

The pharmaceutical compositions described herein for non-systemic delivery of the described compound to the rectum and/or colon are prepared for rectal administration in the form of rectal enemas, rectal foams, rectal gels, and rectal suppositories. The components of such preparations are described here. It is to be understood that the pharmaceutical compositions used herein are or include the formulations described herein. In some embodiments, rectal preparations include rectal enemas, foams, gels, or suppositories.

In some embodiments, the described compositions and/or preparations include liquid carriers or additional solvents, including, as a non-limiting example, purified water, propylene glycol, PEG200, PEG300, PEG400, PEG600, polyethylene glycol, ethanol, 1-propanol, 2-propanol, 1- propen-3-ol (allyl alcohol), propylene glycol, glycerin, 2-methyl-2-propanol, formamide, methylformamide, dimethylformamide, ethylformamide, diethylformamide, acetamide, methylacetamide, dimethylacetamide, ethylacetamide, diethylacetamide, 2-pyrrolidone, N-methyl- 2-pyrrolidone, N-ethyl-2-pyrrolidone, tetramethylurea, 1,3-dimethyl-2-imidazolidinone, propylene carbonate, 1,2-butylene carbonate, 2,3-butylene carbonate, dimethyl sulfoxide, diethyl sulfoxide, hexamethylphosphoramide, pyruvic aldehyde, dimethyl acetal, dimethyl isosorbide, and combinations thereof .

In some embodiments, the stabilizers used in the compositions and/or formulations described herein include, but are not limited to, mono- and diglycerides of polyoxyethylene saturated aliphatic acids.

In some embodiments, surfactants/emulsifiers used in the compositions and/or preparations described herein include, as a non-limiting example, mixtures of cetostearyl alcohol and sorbitan esterified with polyoxyethylene aliphatic acids, polyoxyethylene aliphatic acids, polyoxyethylene aliphatic esters, aliphatic acids, sulfated aliphatic acids, phosphated bile acids, sulfosuccinates, amphoteric surfactants, non-ionic poloxamers, non-ionic meroxapols, petroleum derivatives, aliphatic amines, polyxyloxane derivatives, aliphatic esters of sorbitan, laureth-4, PEG-2 dilaurate, stearic acid, sodium laurate sulfate, dioctyl sodium sulfosuccinate, cocoamphipropionate, poloxamer 188, meroxapol 258, triethanolamine, dimethicone, polysorbate 60, sorbitan monostearate, pharmaceutically acceptable salts and combinations.

In some embodiments, non-ionic surfactants used in the compositions and/or formulations described herein include, but are not limited to: phospholipids, alkyl poly(ethylene oxide), poloxamers (e.g., poloxamer 188), polysorbates, sodium dioctylsulfosuccinate, Brij™-30 (Laureth -4), Brij™-58 (Ceteth-20) and Brij™-78 (Steareth-20), Brij™-721 (Steareth-21), Crillet-1 (Polysorbate 20), Crillet-2 (Polysorbate 40), Crillet-3 (Polysorbate 60), Crillet 45 (Polysorbate 80), Myrj-52 (PEG-40 Stearate), Myrj-53 (PEG-50 Stearate), Pluronic™ F77 (Poloxamer 217), Pluronic™ F87 (Poloxamer 237) , Pluronic™ F98 (Poloxamer 288), Pluronic™ L62 (Poloxamer 182), Pluronic™ L64 (Poloxamer 184), Pluronic™ F68 (Poloxamer 188), Pluronic™ L81 (Poloxamer 231), Pluronic™ L92 (Poloxamer 282), Pluronic ™ L101 (Poloxamer 331), Pluronic™ P103 (Poloxamer 333), Pluracare™ F 108 NF (Poloxamer 338) and Pluracare™ F 127 NF (Poloxamer 407) and combinations thereof. Pluronic™ polymers are available from BASF, USA and Germany.

In some embodiments, anionic surfactants used in the compositions and/or formulations described herein include, but are not limited to, sodium lauryl sulfate, sodium dodecyl sulfate (SDS), ammonium laurate sulfate, alkyl sulfate salts, alkyl benzene sulfonate, and combinations thereof.

In some embodiments, cationic surfactants used in the compositions and/or formulations described herein include, but are not limited to, benzalkonium chloride, benzethonium chloride, cetyltriethylammonium bromide, hexadecyltrimethylammonium bromide, other alkyltrimethylammonium salts, cetylpyridinium chloride, polyethoxylated fat, and combinations thereof.

In some embodiments, thickeners used in the compositions and/or formulations described herein include, but are not limited to, natural polysaccharides, semi-synthetic polymers, synthetic polymers, and combinations thereof. Natural polysaccharides include, but are not limited to, acacia, agar, alginates, carrageenan, guar, Arabica, gum tragacanth, pectins, dextran, gellan and xanthan gums. Polysynthetic polymers include, but are not limited to, cellulose esters, modified starches, modified celluloses, carboxymethylcellulose, methylcellulose, ethylcellulose, hydroxyethylcellulose, hydroxypropylcellulose, and hydroxypropylmethylcellulose. Synthetic polymers include

- 32 041458 as a non-limiting example, polyoxyalkylenes, polyvinyl alcohol, polyacrylamide, polyacrylates, carboxypolymethylethylene (carbomer), polyvinylpyrrolidone (povidones), polyvinyl acetate, polyethylene glycols and poloxamer. Other thickeners include, but are not limited to, polyoxyethylene glycol isostearate, cetyl alcohol, polyglycol 300 isocyanate, propylene glycol, collagen, gelatin, and aliphatic acids (e.g., lauric acid, myristic acid, palmitic acid, stearic acid, palmitoleic acid, linoleic acid, linoleic acid, oleic acid, etc.).

In some embodiments, chelating agents used in the compositions and/or formulations described herein include, but are not limited to, ethylenediaminetetraacetic acid (EDTA) or its salts, phosphates, and combinations thereof.

In some embodiments, the concentration of the chelating component or components used in the rectal preparations described herein is, for example, about 0.1, 0.15, 0.2, 0.25, 0.3, 0.4%, or 0.5% (w/v).

In some embodiments, preservatives used in the compositions and/or formulations described herein include, but are not limited to, parabens, ascorbyl palmitate, benzoic acid, butylated hydroxynisole, butylated hydroxytoluene, chlorobutanol, ethylenediamine, ethylparaben, methylparaben, butylparaben, propylparaben, monothioglycerol, phenol, phenylethyl Alcohol, Propylparaben, Sodium Benzoate, Sodium Propionate, Formaldehyde Sodium Sulfoxylate, Metabisulfite, Sorbic Acid, Sulfur Dioxide, Maleic Acid, Propyl Gallate, Benzalkonium Chloride, Benzethonium Chloride, Benzyl Alcohol, Chlohexidine Acetate, Chlorhexidine Gluconate, Sorbic Acid, Potassium Sorbitol, Chlorbutanol, Phenoxyethanol, Cetylpyridine chloride, phenylmercuric nitrate, trimerazole, and combinations thereof.

In some embodiments, the antioxidants used in the compositions and/or formulations described herein include, but are not limited to, ascorbic acid, ascorbyl palmitate, butylated hydroxynisole, butylated hydroxytoluene, hypophosphorous acid, monothioglycerol, propyl gallate, sodium ascorbate, sodium sulfite, sodium bisulfite, sodium sulfoxylate formaldehyde, potassium metabisulfite, sodium metabisulfite, oxygen, quinones, tert-butylhydroquinone, erythorbic acid, olive oil (olea eurpaea), pentasodium pentetate, pentetic acid, diethylenetriaminepentaacetic acid, tocopherol, tocopheryl acetate, and combinations thereof.

Pharmaceutically acceptable preservatives include quaternary ammonium salts such as benzalkonium chloride, alcohols such as benzyl alcohol, organic acids or salts and derivatives thereof such as benzoic acid, sodium benzoate, sorbic acid, potassium sorbate, propionic acid, sodium propionate, parabens such as methyl parahydroxybenzoate, propyl parahydroxybenzoate, ethyl parahydroxybenzoate or butyl parahydroxybenzoate, aqueous preservatives, chlorhexidine diacetate, digluconate. When planning the use of this composition, it is preferred that preservatives can be given to children. Preferred preservatives are parabens such as methyl parahydroxybenzoate, propyl parahydroxybenzoate, ethyl parahydroxybenzoate or butyl parahydroxybenzoate, in particular methyl parahydroxybenzoate or propyl parahydroxybenzoate. Preservatives are present in the composition in such a concentration as to provide sufficient antimicrobial activity in the original preparation or in the liquid composition after dilution. Preferably, the concentration of preservatives in the resulting diluted liquid composition is up to about 3% (w/w), more preferably up to about 2.5% (w/w), more preferably up to about 2% (w/w). depending on the specific preservative used.

The composition of the present invention may also include one or more antioxidants such as, for example, sodium metabisulphite, sodium bisulfite, sodium sulfite, sodium thiosulfate, ascorbic acid, BHA (butylhydroxynisole), BHT (butylhydroxytoluene), vitamin E, propyl gallate, ascorbyl palmitate, or complexing agents. components such as EDTA (ethylenediaminetetraacetic acid), citric acid, tartaric acid, sodium hexametaphosphate, and the like. When planning the use of this composition, it is preferred that preservatives can be given to children. Preferred antioxidants are BHA, BHT, vitamin E or propyl gallate. In some embodiments, the concentration of the antioxidant or antioxidants used in the rectal preparations described herein is sufficient to achieve the desired result, for example, about 0.1, 0.15, 0.2, 0.25, 0.3, 0.4, or 0.5% (w/v).

Lubricants used in the compositions and/or formulations described herein include, but are not limited to, natural or synthetic fat or oil (eg, triglycerides of aliphatic acids, etc.). Some lubricants include, but are not limited to, glycerin (also called glycerol, 1,2,3-propanetriol, and trihydroxypropane), polyethylene glycols (PEGs), propylene glycol, polyisobutene, polyethylene oxide, behenic acid, behenyl alcohol, sorbitol, mannitol, lactose, polydimethylsiloxane. and their combinations.

In some embodiments, mucoadhesive and/or bioadhesive polymers are used in the combinations and/or formulations described herein as absorption inhibitors of an enteroendocrine peptide secretion-enhancing component in the rectal or colonic mucosa. Bioadhesive

- 33 041458 or mucoadhesive polymers include, as a non-limiting example, hydroxypropylcellulose, polyethylene oxide homopolymers, polyvinyl ether-maleic acid copolymers, methylcellulose, ethylcellulose, propylcellulose, hydroxyethylcellulose, hydroxypropylcellulose, hydroxypropylmethylcellulose, carboxymethylcellulose, polycarbophil, polyvinylpyrrolidone, carbopol, polyurethane, propylene oxide copolymers, sodium carboxyethyl cellulose, polyethylene, polypropylene, lectins, xanthan gum, alginates, sodium alginate, polyacrylic acid, chitosan, hyaluronic acid and its ester derivatives, vinyl acetate homopolymer, calcium polycarbophil, gelatin, natural gums, karaya gum, tragacanth, algin, chitosan, starches, pectins and their combinations.

In some embodiments, the buffers/pH-setting agents used in the compositions and/or formulations described herein include, but are not limited to, phosphoric acid, sodium or potassium phosphate monobasic, triethanolamine (TRIS), BICINE, HEPES, Trizma, glycine, histidine, arginine , lysine, asparagine, aspartic acid, glutamine, glutamic acid, carbonate, bicarbonate, potassium metaphosphate, potassium phosphate, sodium acetate monobasic, acetic acid, acetates, citric acid, sodium citrate anhydrous, sodium citrate dihydrate, and combinations thereof. In some embodiments, an acid or base is added to adjust the desired pH. Suitable acids or bases include, but are not limited to, HCl, NaOH, and KOH.

In some embodiments, the concentration of buffer and buffers used in the rectal preparations described herein is sufficient to achieve or maintain a physiologically desirable pH value, for example, about 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.8, 0.9, or 1.0% (w/w .).

Tonicity modifiers used in the compositions and/or formulations described herein include, but are not limited to, sodium chloride, potassium chloride, sodium phosphate, mannitol, sorbitol, or glucose.

Children's dosage forms of preparations and compositions.

In some embodiments, a formulation or pediatric pharmaceutical composition is provided herein, comprising a therapeutically effective amount of any compound described herein. In some examples, the pharmaceutical composition contains an ASBT inhibitor (eg, any ASBTI described herein).

In some embodiments, suitable dosage forms include, but are not limited to, aqueous or non-aqueous oral dispersions, liquids, gels, syrups, elixirs, suspensions, solutions, controlled release preparations, fusible preparations, effervescent preparations, lyophilized preparations, chewable tablets, confections. toffees, orally dispersible tablets, powders for reconstitution in suspension or solution form, loose powders or granules for oral administration, dragees, sustained release preparations, extended release preparations, pulsatile release preparations, multiparticulate preparation, immediate release preparation and controlled release. In some embodiments, a pharmaceutical composition is provided wherein the pediatric dosage form is selected from a solution, syrup, suspension, elixir, powder for reconstitution to a suspension or solution, lyophilized/effervescent tablet, chewable tablet, toffee, lozenge, ice lozenge, lozenge, thin narrow strips for oral administration, a disintegrating tablet in the mouth, a narrow stick disintegrating in the mouth, sachets and loose powder or granules for oral administration.

In another aspect, there is provided a pharmaceutical composition wherein at least one excipient is a flavor or sweetener. In some embodiments, a shell coating is provided. In some embodiments, a technique for taste masking is provided in which drug particles are coated with a neutral-tasting polymer by spray drying, wet granulation, fluidization, and microencapsulation; technology of coating with molten waxes from a mixture of molten waxes and other pharmaceutical adjuvants, capturing drug particles by complexation, flocculation or coagulation of an aqueous polymer dispersion; adsorbing the drug particles on the resin and inorganic carriers; and dispersing the solid, wherein the drug and one or more neutral-tasting compounds are melted and cooled or co-precipitated by evaporating the solvent. In some embodiments, formulations of drug particles or granules are provided with delayed or sustained release at a rate controlled by a polymer or matrix.

Suitable sweeteners include sucrose, glucose, fructose, or intense sweeteners, i. sweeter components compared to sucrose (eg, at least 10 times sweeter than sucrose). Suitable intense sweeteners include aspartame, sodium, potassium or calcium saccharin, acesulfame potassium, sucralose, alitame, xylitol, cyclamate, neomate, neohesperidin dihydrochalcone or mixtures thereof, thaumatin, palatinite, stevioside, rebaudioside, Magnasweet(R). The total concentration of sweeteners can be from zero to about 300 mg/ml, based on the liquid composition after dilution.

To improve the pleasant taste of the liquid composition after dilution in an aqueous medium, you can add

- 34 041458 incorporating one or more flavor components into the composition in order to mask the taste of the ASBT inhibitor. Such a component may be a sweetener, a flavoring agent, or a combination thereof. The taste-masking component is typically incorporated into the pharmaceutical composition in an amount up to about 0.1% or 5% by weight of the total pharmaceutical composition. In a preferred embodiment of the present invention, the composition contains both sweetener(s) and flavor(s).

A flavoring agent is a substance capable of improving the taste or smell of a composition. Suitable natural or synthetic flavors are selected from a standard reference such as Fenaroli's Handbook of Flavor Ingredients, 3rd edition (1995). Non-limiting examples of flavors and/or sweeteners used in the preparations described herein include, for example, acacia syrup, acesulfame K, elite, anise, apple, aspartame, banana, bavarian, cream, berries, blackcurrant, toffee, calcium citrate, camphor, caramel, cherry, cherry cream, chocolate, cinnamon, chewing gum, citrus, citrus punch, citrus cream, cotton candy, cocoa, cola, cherry flavor, citrus flavor, cyclamate, cilamate, dextrose, eucalyptus, eugenol, fructose, fruit punch, Ginger, Glycyrrhetinate, Glycyrrhiza, Licorice Syrup, Grape, Grapefruit, Honey, Isomalt, Lemon, Lime, Lemon Cream, Monoammonium Glyrrhizinate (MagnaSweet®), Maltol, Mannitol, Maple Syrup, Marshmallow, Menthol, Peppermint Cream, Mixed Berry, Neohesperidin DC, Neotame, Orange, Pear, Peach, Peppermint, Mint Cream, Prosweet® Powder, Raspberry, Root Beer, Rum, Saccharin, Safrole, Sorbitol, Peppermint, Peppermint Cream, Strawberry, Strawberry Cream, Stevia, Sucralose, Sucrose, Sodium saccharin, with acharin, aspartame, acesulfame potassium, mannitol, talin, silitol, sucralose, sorbitol, swiss cream, tagatose, tangerine, thaumatin, tutti frutti, vanillin, walnut, watermelon, wild cherry, wintergreen, xylitol, or any combination of these fragrant components, for example, anise-menthol, cherry-anise, cinnamon-orange, cherry-cinnamon, chocolate-mint, honey-lemon, lemon-lime, lemon-mint, menthol-eucalyptus, orange-cream, vanillin-mint, and mixtures thereof. Flavors can be used alone or in combination of two or more substances. In some embodiments, the aqueous liquid dispersion contains a sweetener or flavor at a concentration of from about 0.001% to about 5.0% by volume of the aqueous dispersion. In one embodiment, the aqueous liquid dispersion includes a sweetener or flavor at a concentration of from about 0.001% to about 1.0% by volume of the aqueous dispersion. In another embodiment, the aqueous liquid dispersion includes a sweetener or flavoring agent at a concentration of from about 0.005 vol.% to about 0.5 vol.% of the aqueous dispersion. In yet another embodiment, the aqueous liquid dispersion includes a sweetener or flavoring agent at a concentration of from about 0.01 vol.% to about 1.0 vol.% of the aqueous dispersion. In yet another embodiment, the aqueous liquid dispersion includes a sweetener or flavoring agent at a concentration of from about 0.01 vol.% to about 0.5 vol.% of the aqueous dispersion.

In some embodiments, the pharmaceutical compositions are conveniently prepared using one or more physiologically acceptable carriers, including, for example, excipients and additives that facilitate processing of the active compounds into formulations suitable for pharmaceutical use. In some embodiments, the type of drug depends on the selected route of administration. A summary of the pharmaceutical compositions described herein can be found, for example, in Remington: The Science and Practice of Pharmacy, Nineteenth Ed (Easton, Pa.: Mack Publishing Company, 1995); Hoover, John E., Remington's Pharmaceutical Sciences, Mack Publishing Co., Easton, Pennsylvania 1975; Liberman, H.A. and Lachman, L., Eds., Pharmaceutical Dosage Forms, Marcel Decker, New York, N.Y., 1980; and Pharmaceutical Dosage Forms and Drug Delivery Systems, Seventh Ed. (Lippincott Williams & Wilkins 1999).

As used herein, the term pharmaceutical composition refers to a mixture of compounds described herein, for example compounds of formulas I-VI, with other chemical components such as carriers, stabilizers, diluents, dispersing agents, suspending agents, thickeners and/or excipients. In some cases, the pharmaceutical composition facilitates the administration of the compound to a patient or to a particular cell. In some embodiments of the methods of treatment or use provided herein, a therapeutically effective amount of the compounds described herein is administered to a pharmaceutical composition for a patient suffering from the disease, disorder, or condition to be treated. In specific embodiments, the patient is a human. As shown here, the compounds described here are used alone or in combination with one or more additional therapeutic components.

In some embodiments, the pharmaceutical preparations described herein are administered to a patient by any route, such as, but not limited to, parenterally (eg, intravenously, subcutaneously, intramuscularly), nasally, buccally, topically, rectally, or transdermally.

In some embodiments, the pharmaceutical compositions described herein include one or more of the compounds described herein as the active ingredient without acid or base, or as a pharmaceutically acceptable salt. In some embodiments, the compounds described herein are used as the N-oxide in crystalline or amorphous form (ie, as a polymorph). In some situations, the compound described here exists as tautomers.

All tautomers are included within the scope of the compounds presented here. In some variants, the

The compound herein exists in an unsolvated or solvated form, the solvated forms including any pharmaceutically acceptable solvents such as water, ethanol, and the like. The solvated forms of the compounds presented here have been described above.

The carrier includes, in some embodiments, a pharmaceutically acceptable excipient and is selected based on compatibility with the compounds described herein, such as compounds of any formula I-VI, and the release rate of the desired dosage form. Examples of carriers include agents such as binders, suspending agents, solubilizers, stabilizers, lubricants, wetting agents, diluents, and the like. See, for example, Remington: The Science and Practice of Pharmacy, Nineteenth Ed (Easton, Pa.: Mack Publishing Company, 1995); Hoover, John E., Remington's Pharmaceutical Sciences, Mack Publishing Co., Easton, Pennsylvania 1975; Liberman, H.A. and Lachman, L, Eds., Pharmaceutical Dosage Forms, Marcel Decker, New York, N.Y., 1980; and Pharmaceutical Dosage Forms and Drug Delivery Systems, Seventh Ed. (Lippincott Williams & Wilkins 1999).

In addition, in some embodiments, the pharmaceutical compositions described herein are formulated into dosage forms. In some embodiments, a dosage form suitable for administration to a patient is provided herein, comprising a compound described herein. In some embodiments, suitable dosage forms include, but are not limited to, aqueous oral dispersions, liquids, gels, syrups, elixirs, suspensions, solid oral dosage forms, aerosols, controlled release preparations, fusible preparations, effervescent preparations, lyophilized preparations, tablets, powders, pills, dragees, capsules, delayed release preparations, extended release preparations, pulsatile release preparations, multiparticulate preparations, mixed immediate and controlled release preparations.

In some aspects, a composition or formulation comprising one or more of the compounds described herein is administered orally to deliver the ASBTI locally, or the compound described herein is administered to the colon and/or rectum. Unit dose forms of such compositions include a pill, tablet, or capsule formulated for delivery to the intestine in the colon. In some embodiments, such pills, tablets, or capsules contain the compositions described herein entrapped or embedded in microspheres. In some embodiments, the microspheres include, but are not limited to, HPMC capsules of chitosan microparticles, capsules, and cellulose acetate butyrate (CAB) microspheres. In some embodiments, oral dosage forms are prepared by conventional methods known to those skilled in the pharmaceutical arts. For example, in some embodiments, tablets are prepared using standard tablet processing procedures and equipment. Examples of a tableting process are direct compression of a powder, crystalline or granular composition containing the active ingredients themselves or in combination with one or more carriers, additives, and the like. In alternative embodiments, tablets are prepared by wet or dry granulation. In some embodiments, tablets are prepared by shaping rather than compressing a wet or other deformable substance.

In some embodiments, tablets for oral administration contain various excipients, including, but not limited to, binders, diluents, lubricants, disintegrators, fillers, stabilizers, surfactants, preservatives, colors, flavors, and the like. In some embodiments, binders are used to impart cohesive properties to the tablet so that the tablet remains intact after compression. Suitable binders include, but are not limited to, starch (including corn starch and pregelatinized starch), gelatin, sugars (including sucrose, glucose, dextrose, and lactose), polyethylene glycol, propylene glycol, waxes, and natural and synthetic gums, such as sodium acacia alginate, polyvinylpyrrolidone, cellulose polymers (including hydroxypropylcellulose, hydroxypropylmethylcellulose, methylcellulose, ethylcellulose, hydroxyethylcellulose, and the like), veegum, and combinations thereof. In some embodiments, diluents are used to expand the volume of the tablet to give it a substantially usable size. Suitable diluents include, but are not limited to, dicalcium phosphate, calcium sulfate, lactose, cellulose, kaolin, mannitol, sodium chloride, dry starch, powdered sugar, and combinations thereof. In some embodiments, lubricants are used to facilitate the manufacture of tablets; examples of suitable lubricants include, but are not limited to, vegetable oils such as peanut, cottonseed, sesame, olive, corn and cocoa butter, glycerin, magnesium stearate, calcium stearate, stearic acid, and combinations thereof. In some embodiments, disintegrators are used to facilitate tablet disintegration and include, but are not limited to, starches, clays, celluloses, algins, gums, cross-linked polymers, and combinations thereof. Fillers include, but are not limited to, silica, titanium dioxide, alumina, talc, kaolin, cellulose powder, and microcrystalline cellulose, as well as solubles such as mannitol, urea, sucrose, lactose, dextrose, sodium chloride, and sorbitol. In some embodiments, stabilizers are used to inhibit or slow down drug degradation reactions, such as oxidative reactions. In some embodiments, surfactants are anionic, cationic, amphoteric, or non-ionic surfactants.

- 36 041458 active components.

In some embodiments, the compounds described herein are administered orally with a carrier suitable for delivery to the distal gastrointestinal tract (eg, distal ileum, colon or rectum).

In some embodiments, the composition described herein includes ASBTI or other compounds described herein together with a matrix (eg, a matrix comprising hypermellose) that provides a controlled release of the active ingredient in the distal ileum and/or colon. In some embodiments, the composition includes a pH-sensitive polymer (eg, an MMX™ matrix from Cosmo Pharmaceuticals) that provides controlled release of the active ingredient in the distal ileum. Examples of such pH sensitive polymers suitable for controlled release include, but are limited to, polyacrylic polymers (e.g., anionic polymers of methacrylic acid and/or methacrylic acid esters, e.g., Carbopol® polymers) which contain acidic groups (e.g., -COOH , -SO3H) and swell in the gut at basic pH (eg, pH about 7 to about 8). In some embodiments, a composition suitable for controlled release in the distal ileum contains the active ingredient in the form of microparticles (eg, micron-sized particles). In some embodiments, an enzymatically degradable poly(dI-lactide-coglycolide) (PLGA) core serves to deliver an enteroendocrine peptide secretion enhancer (eg, bile acid) to the distal ileum. In some embodiments, a dosage form comprising an enteroendocrine peptide (e.g., bile acid) secretion-enhancing component is coated with an enteric polymer (e.g., Eudragit® S-100, cellulose acetate phthalate, polyvinyl acetate phthalate, hydroxypropyl methylcellulose phthalate, anionic polymers of methacrylic acid, methacrylic acid esters, etc. .p.) for delivery to a specific center of the ileum and/or colon. In some embodiments, the bacteria-activated systems serve to target delivery to the distal ileum. Examples of microflora-activated systems include formulations containing pectin, galactomannan and/or Azo hydrogels and/or glycoside conjugates of the active ingredient (eg, D-galactoside, e-D-xylopyranoside, etc.). Examples of enzymes from the gastrointestinal microflora include bacterial glycosidases such as, for example, D-galactosidase, e-D-glucosidase, α-Larabinofuranosidase, e-D-xylopyranosidase, or the like.

In some embodiments, the action of the labile bile acid sequestrant is time dependent. In some embodiments, the labile bile acid sequestrant releases bile acid or degrades after 1,2,3, 4, 5, 6, 7, 8, 9, or 10 seconds of sequestration. In some embodiments, the labile bile acid sequestrant releases bile acid or degrades after 15, 20, 25, 30, 35, 40, 45, 50, or 55 seconds of sequestration. In some embodiments, the labile bile acid sequestrant releases bile acid or degrades after 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 minutes of sequestration. In some embodiments, the labile bile acid sequestrant releases bile acid or degrades after about 15, 20, 25, 30, 35, 45, 50, or 55 minutes of sequestration. In some embodiments, the labile bile acid sequestrant releases bile acid or degrades in about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23 or 24 hours of sequestration. In some embodiments, the labile bile acid sequestrant releases bile acid or degrades after 1, 2, or 3 days of sequestration.

In some embodiments, the labile bile acid sequestrant has a low affinity for bile acid. In some embodiments, the labile bile acid sequestrant has a high affinity for the primary bile acid and a low affinity for the secondary bile acid.

In some embodiments, the action of the labile bile acid sequestrant is pH dependent. In some embodiments, the pH-dependent bile acid sequestrant has a high affinity for bile acid at pH 6 or lower and a low affinity for bile acid at a pH greater than 6. In some embodiments, the pH-dependent bile acid sequestrant has a high affinity for bile acid at pH 6.5 or lower, and low affinity for bile acid above pH 6.5. In some embodiments, the pH-dependent bile acid sequestrant has a high affinity for bile acid at a pH of 7.1 or lower and a low affinity for bile acid at a pH greater than 7. In some embodiments, the pH-dependent bile acid sequestrant has a high affinity for bile acid at a pH of 7.1 or lower and low affinity for bile acid above pH 7.1. In some embodiments, the pH dependent bile acid sequestrant has a high affinity for bile acid at a pH of 7.2 or lower and a low affinity for bile acid at a pH above 7.2. In some embodiments, the pH dependent bile acid sequestrant has a high affinity for bile acid at a pH of 7.3 or lower and a low affinity for bile acid at a pH above 7.3. In some embodiments, the pH dependent bile acid sequestrant has a high affinity for bile acid at a pH of 7.4 or lower and a low affinity for bile acid at a pH above 7.4. In some embodiments, the pH dependent bile acid sequestrant has a high affinity for bile acid at a pH of 7.5 or lower and a low affinity for bile acid at a pH above 7.5. In some variants, pH-dependent seque

The bile acid strant has a high affinity for bile acid at pH 7.6 or lower and a low affinity for bile acid at pH above 7.6. In some embodiments, the pH-dependent bile acid sequestrant has a high affinity for bile acid at or below 7.7 and a low affinity for bile acid at a pH above 7.7. In some embodiments, the pH dependent bile acid sequestrant has a high affinity for bile acid at a pH of 7.8 or lower and a low affinity for bile acid at a pH above 7.8. In some embodiments, the pH-dependent bile acid sequestrant is degraded at a pH greater than 6. In some embodiments, the pH-dependent bile acid sequestrant is degraded at a pH greater than 6.5. In some embodiments, the pH dependent bile acid sequestrant is degraded at a pH greater than 7. In some embodiments, the pH dependent bile acid sequestrant is degraded at a pH greater than 7.1. In some embodiments, the pH dependent bile acid sequestrant is degraded at a pH greater than 7.2. In some embodiments, the pH dependent bile acid sequestrant is degraded at a pH greater than 7.3. In some embodiments, the pH dependent bile acid sequestrant is degraded at a pH greater than 7.4. In some embodiments, the pH dependent bile acid sequestrant is degraded at a pH greater than 7.5. In some embodiments, the pH-dependent bile acid sequestrant is degraded at a pH above 7.6. In some embodiments, the pH dependent bile acid sequestrant is degraded at a pH greater than 7.7. In some embodiments, the pH dependent bile acid sequestrant is degraded at a pH greater than 7.8. In some embodiments, the pH-dependent bile acid sequestrant is degraded at a pH greater than 7.9.

In some embodiments, the labile bile acid sequestrant is lignin or a modified lignin. In some embodiments, the labile bile acid sequestrant is a polycationic polymer or copolymer. In some embodiments, the labile bile acid sequestrant is a polymer or copolymer comprising one or more N-alkenyl-K-alkylamine groups; one or more N,N,N-trialkyl-N-(N'-alkenylamino)alkylazanium groups; one or more K,K,K-trialkyl-K-alkenylazine groups; one or more alkenylamine groups; or their combinations.

In some embodiments, the bile acid binder is cholestyramine and various compositions including cholestyramine, which are described, for example, in US patent No. 3383281; 3308020; 3769399; 3846541; 3974272; 4172120; 4252790; 4340585; 4814354; 4874744; 4895723; 5695749; and 6,066,336. In some embodiments, the bile acid binder is cholestipol or cholezevelam.

Ways.

In some embodiments, provided herein are methods for treating childhood cholestasis or cholestatic liver disease, comprising non-systemic administration of a therapeutically effective amount of ASBTI. In some embodiments, provided herein are methods of treating childhood cholestasis or cholestatic liver disease, comprising contacting the gastrointestinal tract from the ileum to the colon and/or rectum with ASBTI in a patient in need of treatment. Also provided herein are methods for reducing the level of bile acids in enterocytes, reducing damage to hepatocellular or intestinal architecture caused by cholestasis or cholestatic liver disease in a patient, comprising administering to the patient a therapeutically effective amount of ASBTI.

In some cases, exposure of a child's ileum to an ASBTI (e.g., any ASBTI described herein) inhibits bile acid reuptake and increases the concentration of bile acids/salts near L-cells in the distal ileum and/or in the colon and/or rectum. , which leads to a decrease in the content of bile acids in intraenterocytes, a decrease in the level of bile acids in the serum and liver, a decrease in the total content of bile acids and / or a decrease in damage to the architecture of the ileum caused by cholestasis or cholestatic liver disease. Without being limited by a particular theory, it can be argued that a decrease in the level of bile acids in the serum and/or liver attenuates cholestasis and/or cholestatic disease.

The compound described herein is administered by any suitable route, including, but not limited to, the following routes of administration: orally, intraperitoneally, parenterally (eg, intravenously, subcutaneously, intramuscularly), nasally, buccally, topically, rectally, or transdermally. Any compounds or compositions described herein are administered in a formulation appropriate for the treatment of a neonate or toddler. Any of the compounds or compositions described herein are administered as an oral formulation (eg, solid or liquid) in the treatment of a neonate or toddler. In some embodiments, the pediatric dosage form is selected from a solution, a syrup, a suspension, an elixir, a reconstitution powder to form a suspension or solution, a lingual/effervescent tablet, a chewable tablet, a lozenge, a lollipop, ice lozenges, lozenges, thin lozenges that dissolve in tablets, orally absorbable sticks and coated granules for oral administration.

In some embodiments, a compound or composition described herein is administered as a pediatric dosage form intended for the treatment of children. In some embodiments, a compound or composition for treating adolescents described herein is administered as a pediatric dosage form. In some embodiments, a compound or composition described herein is administered as a pediatric dosage form.

- 38 041458 for the treatment of newborns or toddlers. In some embodiments, a compound or composition for treating neonates or toddlers described herein is administered in an oral formulation (eg, solid or liquid). In some embodiments, the described pediatric dosage form is administered before a meal, instead of with a meal, or after a meal.

In some embodiments, a compound or composition comprising a compound described herein is administered for prophylaxis and/or therapeutic treatment. In therapeutic use, the compounds are administered to a patient suffering from a disease or condition in an amount sufficient to cure or at least partially alleviate the symptoms of the disease or condition. In various cases, the amount effective for such use depends on the severity and course of the disease or condition, prior therapy, health status, weight and response to drugs, as well as the judgment of the attending physician.

In prophylactic use, compounds or compositions comprising a compound as described herein are administered to a patient who is otherwise at risk for a particular disease, disorder, or condition. In some such uses, the precise amounts of compounds administered depend on the patient's health status, weight, and the like. Furthermore, in some instances of administration of a compound or composition described herein, effective amounts for such use will depend upon the severity and course of the disease, disorder or condition, prior therapy, the patient's health status, drug response, and the judgment of the attending physician.

In some cases, if after administration of a selected dose of a compound or composition described herein, the patient's condition does not improve, then, at the discretion of the physician, the administration of the compound or composition described herein does not necessarily become chronic, i. over a long period of time, including life, to reduce, regulate or limit the symptoms of a disorder, disease or condition.

In some embodiments, the effective amount of a given component depends on one or more factors, such as the particular compound, the severity of the disease or condition, the individual characteristics of the patient (e.g., weight) in need of treatment, and is determined according to the particular circumstances, including, for example, the particular administered component, route of administration, condition to be treated, and characteristics of the patients being treated. In some embodiments, doses administered include doses up to the maximum tolerated dose. In some embodiments, doses administered include doses up to the maximum dose tolerated by the newborn or infant.

In some embodiments, the patient is administered about 0.001-5000 mg per day, about 0.001-1500 mg per day, about 0.001-100 mg/day, about 0.001-50 mg/day, or about 0.001-30 mg/day, or about 0.001-10 mg /day of the compound described here. In various embodiments, the desired dose is conveniently prepared as a single dose or as divided doses administered simultaneously (or over a short period of time) or at appropriate intervals, such as two, three, four or more small doses per day. In various embodiments, the unit dose is from about 0.001 mg/kg to about 500 mg/kg. In various embodiments, the unit dose is from about 0.001, 0.01, 0.1, 1, or 10 mg/kg to about 10, 50, 100, or 250 mg/kg. In various embodiments, a unit dose of ASBTI is from about 0.001 mg/kg to about 100 mg/kg. In various embodiments, a unit dose of ASBTI is from about 0.001 mg/kg to about 50 mg/kg. In various embodiments, a unit dose of ASBTI is from about 0.001 mg/kg to about 10 mg/kg. In various embodiments, a single dose of ASBTI is administered every 6 hours, every 12 hours, every 24 hours, every 48 hours, every 72 hours, every 96 hours, every 5 days, every 6 days, or once a week.

In the event that the patient's condition improves, the ASBTI is not necessarily given continuously after the physician's judgment; alternatively, the dose of medication administered is temporarily reduced or discontinued for a period of time (eg, medication holidays). The duration of a medicinal holiday does not necessarily vary between 2 days and 1 year, including by way of example only, 2, 3, 4, 5, 6, 7, 10, 12, 15, 20, 28, 35, 50, 70, 100, 120, 150, 180, 200, 250, 280, 300, 320, 350 or 365 days. Dose reduction during drug holidays includes 10-100%, including as an example only 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85 , 90, 95 or 100%. In some embodiments, the total unit dose of ASBTI is in the above range.

After the patient's condition has improved, a maintenance dose is administered if necessary. The dose or frequency of dosing, or both, is then reduced, depending on the symptoms, to a level that continues to improve the disease, disorder, or condition. In some embodiments, patients require long breaks in treatment if any of their symptoms recur.

In some cases, an individual treatment regimen depending on many variables and significant deviations from these recommended values are within the scope of the invention described here. The dosages given herein do not necessarily vary depending on many variables such as, by way of non-limiting example, the activity of the compound used, the disease or condition to be treated, the route of administration, the wishes of the patient, the severity of the disease or condition, and the judgment of the attending physician.

The toxicity and therapeutic efficacy of such therapeutic regimens is optionally determined using pharmaceutical procedures in cell cultures or experimental animals, including, but not limited to, determination of LD ₅₀ (lethal dose for 50% of the population) and ED ₅₀ (therapeutically effective dose for 50% of the population) . The dose ratio between toxicity effects and therapeutic efficacy is the therapeutic index and can be expressed as the ratio of LD ₅₀ and ED ₅₀ . Compounds with a high therapeutic index are preferred. In some embodiments, data obtained from cell culture and animal assays is used to tailor a dosage range for human application. In specific embodiments, the doses of the compounds described herein lie in the range of concentrations that include the ED ₅₀ with minimal toxicity. The dose is optionally changed within this range depending on the dosage form used and the route of administration.

In some embodiments, systemic exposure to a therapeutically effective amount of the non-systemic ASBTI described herein is reduced compared to systemic exposure to a therapeutically effective amount of any systemically absorbed ASBTI (eg, compounds 100A, 100C). In some embodiments, the AUC of a therapeutically effective amount of a non-systemic ASBTI described herein is reduced by at least 10%, at least 20%, at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, or at least 90% of the AUC of any systemically absorbed ASBTI (eg Compounds 100A, 100C).

In some embodiments, the C _max of a therapeutically effective amount of a non-systemic ASBTI described herein is reduced by at least 10%, at least 20%, at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, or at least 90% of the _Cmax of any systemically absorbed ASBTI (eg, Compound 100A).

In some embodiments, the pharmaceutical composition administered includes a therapeutically effective amount of a bile salt, a model bile salt, an absorption inhibitor, and a carrier (eg, an oral carrier or a rectal carrier, depending on the intended route of administration). In some embodiments, the pharmaceutical composition used or administered includes a therapeutically effective amount of a bile salt or model bile salt, an absorption inhibitor, a carrier, and one or more cholesterol absorption inhibitors, an enteroendocrine peptide, a peptidase inhibitor, a lyophilizing agent, and a wetting agent.

In a particular embodiment, the composition used to formulate a rectal dosage form comprises a bile salt or model bile salt, a rectal carrier, an optional cholesterol absorption inhibitor, an optional enteroendocrine peptide, an optional peptidase inhibitor, an optional lyophilizing agent, and an optional wetting agent. In some embodiments, rectally administered compositions include an anorectal response. In specific embodiments, the anorectal response is an increase in the secretion of one or more types of enteroendocrine side cells (eg, L cells) in the colon and/or rectum (eg, in the epithelial layer of the colon and/or rectum). In some embodiments, the anorectal response persists for at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 , 21, 22, 23, or 24 hours. In other embodiments, the anorectal response persists for 24-48 hours, while in other embodiments, the anorectal response persists for more than 48 hours.

In another specific embodiment, a pharmaceutical composition used to prepare an oral dosage form comprises a bile salt or model bile salt, an absorption inhibitor, an oral carrier, an optional cholesterol absorption inhibitor, an optional enteroendocrine peptide, an optional peptidase inhibitor, an optional lyophilizing agent. and an optional wetting agent. In some embodiments, orally administered compositions elicit an anorectal response. In specific embodiments, the anorectal response is an increase in the secretion of one or more types of enteroendocrine side cells in the colon and/or rectum (eg, L-cells in the epithelial layer of the colon and/or rectum). In some embodiments, the anorectal response persists for at least 1, 2, 3, 4,5,6,7,8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 , 21, 22, 23, or 24 hours. In other embodiments, the anorectal response persists for 24-48 hours, while in other embodiments, the anorectal response persists for more than 48 hours.

Routes of administration and doses.

In some embodiments, the compositions described herein and administered by the methods described herein are formulated to inhibit bile acid reuptake or lower serum or hepatic bile acid levels. In some embodiments, the compositions described herein are for rectal or oral administration. In some embodiments, such preparations

- 40 041458 rats are administered rectally or orally, respectively. In some embodiments, the compositions described herein are combined with a device for local delivery of the compositions to the rectum and/or colon (sigmoid colon, transverse colon, or ascending colon). In some embodiments, for rectal administration, the compositions described herein are formulated as enemas, rectal gels, rectal foams, rectal sprays, suppositories, jelly suppositories, or retention enemas. In some embodiments of oral administration, the compositions described herein are formulated for oral and intestinal administration to the colon.

In some embodiments, the compositions or methods described herein are non-systemic. In some embodiments, the compositions described herein deliver ASBTI to the distal ileum, colon, and/or rectum and non-systemically (eg, a significant portion of the enteroendocrine peptide secretion-enhancing component is absorbed non-systemically). In some embodiments, the oral compositions described herein deliver the ASBTI to the distal ileum, colon, and/or rectum non-systemically (eg, a significant portion of the enteroendocrine peptide secretion-enhancing component is absorbed non-systemically). In some embodiments, the rectal compositions described herein deliver ASBTI to the distal ileum, colon, and/or rectum non-systemically (eg, a significant portion of the enteroendocrine peptide secretion-enhancing component is absorbed non-systemically). In some embodiments, the non-systemic compositions described herein deliver systemically less than 90% w/w. ASBTI. In some embodiments, the non-systemic compositions described herein deliver systemically less than 80% w/w. ASBTI. In some embodiments, the non-systemic compositions described herein deliver systemically less than 70% w/w. ASBTI. Some non-systemic compositions described herein deliver systemically less than 60% w/w. ASBTI. In some embodiments, the non-systemic compositions described herein deliver systemically less than 50% w/w. ASBTI. In some embodiments, the non-systemic compositions described herein deliver systemically less than 40% w/w. ASBTI. In some embodiments, the non-systemic compositions described herein deliver systemically less than 30% w/w. ASBTI. In some embodiments, the non-systemic compositions described herein deliver systemically less than 25% w/w. ASBTI. In some embodiments, the compositions of non-systemic action described here deliver systemic less than 20% wt./wt. ASBTI. In some embodiments, the non-systemic compositions described herein deliver systemically less than 15% w/w. ASBTI. In some embodiments, the non-systemic compositions described herein deliver systemically less than 10% w/w. ASBTI. In some embodiments, the non-systemic compositions described herein deliver systemically less than 5% w/w. ASBTI. In some embodiments, systemic absorption is determined by any method, including determining the total circulating amount, the amount observed after administration, and the like.

In some embodiments, the compositions and preparations described herein are administered at least once a day. In some embodiments, ASBTI-containing formulations are administered at least twice daily, while in other embodiments, ASBTI-containing formulations are administered at least three times daily. In some embodiments, ASBTI-containing formulations are administered at least five times per day. It should be understood that in some embodiments, the dosing regimen of the composition containing the ASBTI described herein is established after consideration of various factors such as the age of the patient, sex and nutrition.

The concentration of ASBTI administered in the formulations described herein ranges from about 1 mM to about 1 M. In some embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 1 mM to about 750 mM. In some embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 1 mM to about 500 mM. In some embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 5 mM to about 500 mM. In some embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 10 mM to about 500 mM. In some embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 25 mM to about 500 mM. In some embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 50 mM to about 500 mM. In some embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 100 mM to about 500 mM. In some embodiments, the concentration of ASBTI administered in the formulations described herein ranges from about 200 mM to about 500 mM.

In some embodiments, any composition described herein contains a therapeutically effective amount of ursodiol (eg, for the treatment of cholestasis or cholestatic liver disease). In some embodiments, the ursodiol may be substituted for any other therapeutic bile acid or salt thereof. In some embodiments, the compositions and methods described herein include administering from about 0.01 mg to about 10 g of ursodiol. In some embodiments, a composition or method described herein comprises administering from about 0.1 mg to about 500 mg of ursodiol. In some embodiments, a composition or method described herein comprises administering from about 0.1 mg to about 100 mg ur

- 41 041458 sodiol. In some embodiments, the compositions and methods described herein include administering from about 0.1 mg to about 50 mg of ursodiol. In some embodiments, the compositions and methods described herein include administering from about 0.1 mg to about 10 mg of ursodiol. In some embodiments, the compositions and methods described herein include administering from about 0.5 mg to about 10 mg of ursodiol. In some embodiments, the compositions and methods described herein include administering from about 0.1 mmol to about 1 mol of ursodiol. In some embodiments, the compositions and methods described herein include administering from about 0.01 mmol to about 500 mmol of ursodiol. In some embodiments, the compositions and methods described herein include administering from about 0.1 mmol to about 100 mmol of ursodiol. In some embodiments, the compositions and methods described herein include administering from about 0.5 mmol to about 30 mmol of ursodiol. In some embodiments, the compositions and methods described herein include administering from about 0.5 mmol to about 20 mmol of ursodiol. In some embodiments, the compositions and methods described herein include administering from about 1 mmol to about mmol of ursodiol. Some of the compositions and methods described herein include administering from about 0.01 mmol to about 5 mmol of ursodiol. In some embodiments, the compositions and methods described herein include administering from about 0.1 mmol to about 1 mmol of ursodiol. In various embodiments, some bile acids/salts have different capabilities, according to which the dose is not necessarily set. For example, a study of the agonist activity of TGR5 transfected TGR5 CHO cells of natural bile acids/salts showed that their activity decreases in the order: lithocholic acid (LCA) > deoxycholic acid (DCA) > murocholic acid (Muro-CA) > lagodeoxycholic acid (lago-DCA) > chenodeoxycholic acid (CDCA) > cholic acid (CA) > hyodeoxycholic acid (HDCA > ursodeoxycholic acid (UDCA); and analyzes of TGR5-transfected CHO cells show that EC ₅₀ (in µmol) for UDCA was 36.4, TauroCA (TCA) 4.95 and LCA 0.58.

In some embodiments, when targeted to the distal gastrointestinal tract (e.g., distal ileum, colon, and/or rectum), the described compositions and methods are effective (e.g., in reducing microbial growth and/or ameliorating the symptoms of cholestasis or cholestatic liver disease). ) at a reduced dose of the enteroendocrine peptide (eg compared to an oral dose that does not target the distal gastrointestinal tract).

Preparations for rectal administration.

The pharmaceutical compositions described herein for non-systemic delivery of the described compound to the rectum and/or colon are prepared for rectal administration in the form of rectal enemas, rectal foams, rectal gels, and rectal suppositories. The components of such preparations are described here. It is to be understood that the pharmaceutical compositions and formulations used herein are or include the formulations described herein. In some embodiments, rectal preparations include rectal enemas, foams, gels, or suppositories.

In some embodiments, liquid carriers or co-solvents in the compositions and/or formulations described herein include, but are not limited to, purified water, propylene glycol, PEG200, PEG300, PEG400, PEG600, polyethylene glycol, ethanol, 1-propanol, 2-propanol, 1-propene-3- ol (allyl alcohol), propylene glycol, glycerin, 2-methyl-2-propanol, formamide, methylformamide, dimethylformamide, ethylformamide, diethylformamide, acetamide, methylacetamide, dimethylacetamide, ethylacetamide, diethylacetamide, 2-pyrrolidone, K-methyl-2-pyrrolidone, K-ethyl-2-pyrrolidone, tetramethylurea, 1,3-dimethyl-2-imidazolidinone, propylene carbonate, 1,2-butylene carbonate, 2,3-butylene carbonate, dimethyl sulfoxide, diethyl sulfoxide, hexamethylphosphoramide, pyruvic aldehyde, dimethyl acetal, dimethyl isosorbide, and combinations thereof.

In some embodiments, the stabilizers used in the compositions and/or formulations described herein include, but are not limited to, mono- and diglycerides of polyoxyethylene saturated aliphatic acids.

In some embodiments, surfactants/emulsifiers used in the compositions and/or preparations described herein include, as a non-limiting example, mixtures of cetostearyl alcohol and sorbitan esterified with polyoxyethylene aliphatic acids, polyoxyethylene aliphatic acids, polyoxyethylene aliphatic esters, aliphatic acids, sulfonated aliphatic acids, phosphated bile acids, sulfosuccinates, amphoteric surfactants, nonionic poloxamers, nonionic meroxapols, petroleum derivatives, aliphatic amines, polyxyloxane derivatives, aliphatic esters of sorbitan, laureth-4, PEG-2 dilaurate, stearic acid, sodium laurate sulfate, dioctyl sodium sulfosuccinate, cocoamphopropionate, poloxamer 188, meroxapol 258, triethanolamine, dimethicone, polysorbate 60, sorbitan monostearate, pharmaceutically acceptable salts and combinations.

In some embodiments, nonionic surfactants used in the compositions and/or formulations described herein include, but are not limited to, phospholipids, alkyl poly(ethylene oxide), poloxamers (e.g., poloxamer 188), polysorbates, sodium dioctylsul

- 42 041458 Phosuccinate, Brij™-30 (Laureth-4), Brij™-58 (Ceteth-20) and Brij™-78 (Steareth-20), Brij™-721 (Steareth-21), Crillet-1 (Polysorbate 20), Crillet-2 (Polysorbate 40), Crillet-3 (Polysorbate 60), Crillet 45 (Polysorbate 80), Myrj-52 (PEG-40 Stearate), Myrj-53 (PEG-50 Stearate), Pluronic™ F77 ( Poloxamer 217), Pluronic™ F87 (Poloxamer 237), Pluronic™ F98 (Poloxamer 288), Pluronic™ L62 (Poloxamer 182), Pluronic™ L64 (Poloxamer 184), Pluronic™ F68 (Poloxamer 188), Pluronic™ L81 (Poloxamer 231) ), Pluronic™ L92 (Poloxamer 282), Pluronic™ L101 (Poloxamer 331), Pluronic™ P103 (Poloxamer 333), Pluracare™ F 108 NF (Poloxamer 338), and Pluracare™ F 127 NF (Poloxamer 407), and combinations thereof. Pluronic™ polymers are available from BASF, USA and Germany.

In some embodiments, anionic surfactants used in the compositions and/or formulations described herein include, but are not limited to, sodium lauryl sulfate, sodium dodecyl sulfate (SDS), ammonium laurate sulfate, alkyl sulfate salts, alkyl benzene sulfonate, and combinations thereof.

In some embodiments, cationic surfactants used in the compositions and/or formulations described herein include, but are not limited to, benzalkonium chloride, benzethonium chloride, cetyltriethylammonium bromide, hexadecyltrimethylammonium bromide, other alkyltrimethylammonium salts, cetylpyridinium chloride, polyethoxylated fat, and combinations thereof.

In some embodiments, thickeners used in the compositions and/or formulations described herein include, but are not limited to, natural polysaccharides, semi-synthetic polymers, synthetic polymers, and combinations thereof. Natural polysaccharides include, but are not limited to, acacia, agar-agar, alginates, carrageenan, guar, Arabica, gum tragacanth, pectins, dextran, gellan and xanthan gums. Semi-synthetic polymers include, but are not limited to, cellulose esters, modified starches, modified cellulose, carboxymethylcellulose, methylcellulose, ethylcellulose, hydroxyethylcellulose, hydroxypropylcellulose, and hydroxypropylmethylcellulose. Synthetic polymers include, but are not limited to, polyoxyalkylenes, polyvinyl alcohol, polyacrylamide, polyacrylates, carboxypolymethylethylene (carbomer), polyvinylpyrrolidone (povidones), polyvinyl acetate, polyethylene glycols, and poloxamer. Other thickeners include, but are not limited to, polyoxyethylene glycol isostearate, cetyl alcohol, polyglycol 300 isocyanate, propylene glycol, collagen, gelatin, and aliphatic acids (e.g., lauric acid, myristic acid, palmitic acid, stearic acid, palmitoleic acid, linoleic acid, linoleic acid, oleic acid, etc.).

In some embodiments, chelating agents used in the compositions and/or formulations described herein include, but are not limited to, ethylenediaminetetraacetic acid (EDTA) or its salts, phosphates, and combinations thereof.

In some embodiments, the concentration of the chelating component or components used in the rectal preparations described herein is, for example, about 0.1, 0.15, 0.2, 0.25, 0.3, 0.4, or 0.5% (w/v).

In some embodiments, the preservatives used in the compositions and/or formulations described herein include, but are not limited to, parabens, ascorbyl palmitate, benzoic acid, butylated hydroxynisole, butylated hydroxytoluene, chlorobutanol, ethylenediamine, ethylparaben, methylparaben, butylparaben, propylparaben, monothioglycerol, phenol, phenylethyl Alcohol, Propylparaben, Sodium Benzoate, Sodium Propionate, Formaldehyde Sodium Sulfoxylate, Metabisulfite, Sorbic Acid, Sulfur Dioxide, Maleic Acid, Propyl Gallate, Benzalkonium Chloride, Benzethonium Chloride, Benzyl Alcohol, Chlohexidine Acetate, Chlorhexidine Gluconate, Sorbic Acid, Potassium Sorbitol, Chlorbutanol, Phenoxyethanol , cetylpyridinium chloride, phenylmercury nitrate, trimerazole, and combinations thereof.

In some embodiments, the antioxidants used in the compositions and/or formulations described herein include, but are not limited to, ascorbic acid, ascorbyl palmitate, butylated hydroxynisole, butylated hydroxytoluene, hypophosphorous acid, monothioglycerol, propyl gallate, sodium ascorbate, sodium sulfite, sodium bisulfite, sodium sulfoxylate formaldehyde, potassium metabisulfite, sodium metabisulfite, oxygen, quinones, tert-butylhydroquinone, erythorbic acid, olive oil (olea eurpaea), pentasodium pentetate, pentetic acid, diethylenetriaminepentaacetic acid, tocopherol, tocopheryl acetate, and combinations thereof.

Pharmaceutically acceptable preservatives include quaternary ammonium salts such as benzalkonium chloride, alcohols such as benzyl alcohol, organic acids or their salts and derivatives such as benzoic acid, sodium benzoate, sorbic acid, potassium sorbate, propionic acid, sodium propionate, parabens such as methyl parahydroxybenzoate, propyl parahydroxybenzoate, ethyl parahydroxybenzoate or butyl parahydroxybenzoate, aqueous preservatives, chlorhexidine diacetate, digluconate. When planning the use of this composition, it is preferred that preservatives can be given to children. Preferred preservatives are parabens such as methyl parahydroxybenzoate, propyl parahydroxybenzoate, ethyl parahydroxybenzoate or butyl parahydroxybenzoate.

- 43 041458 sibenzoate, in particular methyl parahydroxybenzoate or propyl parahydroxybenzoate. Preservatives are present in the composition in such a concentration as to provide sufficient antimicrobial activity in the original composition or in the liquid composition after dilution. Preferably, the concentration of preservatives in the resulting diluted liquid composition is up to about 3% (w/w), more preferably up to about 2.5% (w/w), more preferably up to about 2% (w/w). depending on the specific preservative used.

The composition of the present invention may also include one or more antioxidants such as, for example, sodium metabisulphite, sodium bisulfite, sodium sulfite, sodium thiosulfate, ascorbic acid, BHA (butylhydroxynisole), BHT (butylhydroxytoluene), vitamin E, propyl gallate, ascorbyl palmitate, or complexing agents. components such as EDTA (ethylenediaminetetraacetic acid), citric acid, tartaric acid, sodium hexametaphosphate, and the like. When planning the use of this composition, it is preferred that the antioxidants can be given to children. Preferred antioxidants are BHA, BHT, vitamin E or propyl gallate. In some embodiments, the concentration of the antioxidant or antioxidants used in the rectal preparations described herein is sufficient to achieve the desired result, for example, about 0.1, 0.15, 0.2, 0.25, 0.3, 0.4, or 0.5% (w/v).

Lubricants used in the compositions and/or formulations described herein include, but are not limited to, natural or synthetic fat or oil (eg, triglycerides of aliphatic acids) and the like. In some embodiments, lubricants include, but are not limited to, glycerol (also called glycerol, 1,2,3-propanetriol, and trihydroxypropane), polyethylene glycols (PEGs), propylene glycol, polyisobutene, polyethylene oxide, behenic acid, behenyl alcohol, sorbitol, mannitol, lactose, polydimethylsiloxane, and their combinations.

In some embodiments, mucoadhesive and/or bioadhesive polymers are used in the combinations and/or formulations described herein as absorption inhibitors of the enteroendocrine peptide secretion-enhancing component in the rectal or colonic mucosa. Bioadhesive or mucoadhesive polymers include, but are not limited to, hydroxypropylcellulose, polyethylene oxide homopolymers, polyvinyl ester-maleic acid copolymers, methylcellulose, ethylcellulose, propylcellulose, hydroxyethylcellulose, hydroxypropylcellulose, hydroxypropyl methylcellulose, carboxymethylcellulose, polycarbophil, polyvinylpyrrolidone, carbopol, polyurethanes, polyethyleneoxide-polypropylene copolymers. polyethylene, polypropylene, lectins, xanthan gum, alginates, sodium alginate, polyacrylic acid, chitosan, hyaluronic acid and its ester derivatives, vinyl acetate homopolymer, calcium polycarbophil, gelatin, natural gums, karaya gum, tragacanth, algin, chitosan, starches, pectins and their combinations.

In some embodiments, the buffers/pH-setting agents used in the compositions and/or formulations described herein include, but are not limited to, phosphoric acid, sodium or potassium phosphate monobasic, triethanolamine (TRIS), BICINE, HEPES, Trizma, glycine, histidine, arginine , lysine, asparagine, aspartic acid, glutamine, glutamic acid, carbonate, bicarbonate, potassium metaphosphate, potassium phosphate, sodium acetate monobasic, acetic acid, acetate, citric acid, sodium citrate anhydrous, sodium citrate dihydrate, and combinations thereof. In some embodiments, an acid or base is added to adjust the desired pH. Suitable acids or bases include, but are not limited to, HCl, NaOH, and KOH.

In some embodiments, the concentration of the buffer and buffers used in the rectal preparations described here is sufficient to achieve or maintain a physiologically required pH value, for example, about 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.8, 0.9 or 1.0% (wt ./ wt.).

Tonicity modifiers used in the compositions and/or formulations described herein include, but are not limited to, sodium chloride, potassium chloride, sodium phosphate, mannitol, sorbitol, or glucose.

Children's doses of drugs and compositions.

In some embodiments, a pediatric formulation or composition is provided herein comprising a therapeutically effective amount of any compound described herein. In some examples, the pharmaceutical composition contains an ASBT inhibitor (eg, any ASBTI described herein).

In some embodiments, suitable dosage forms include, but are not limited to, aqueous or non-aqueous oral dispersions, liquids, gels, syrups, elixirs, suspensions, solutions, controlled release preparations, fusible preparations, effervescent preparations, lyophilized preparations, chewable tablets, confections. toffees, orally dispersible tablets, powders for reconstitution in suspension or solution form, loose powders or granules for oral administration, dragees, delayed-release preparations, extended-release preparations, pulsatile-release preparations, multiparticulate preparations, immediate-release preparations and controlled release. In some embodiments, provided herein is a pharmaceutical composition wherein a pediatric drug

- 44 041458 the form is selected from solution, syrup, suspension, elixir, powder for reconstitution to suspension or solution, lyophilized/effervescent tablet, chewable tablet, toffee, lozenge, cold lozenges, lozenges, thin narrow strips for oral administration, disintegrating into tablet, disintegrating narrow strip, sachet and free-flowing powder or granule for oral administration.

In another aspect, there is provided a pharmaceutical composition wherein at least one excipient is a flavor or sweetener. In some embodiments, sheathing is provided. In some embodiments, a taste-masking technology is provided that includes coating drug particles with a neutral-tasting polymer by spray drying, wet granulation, fluidization, and microencapsulation; coating with molten waxes from a mixture of molten waxes and other pharmaceutical adjuvants, capturing drug particles by complexation, flocculation or coagulation of an aqueous polymer dispersion; adsorbing drug particles on resin and inorganic carriers; and solid dispersion, in which the drug and one or more neutral-tasting compounds are melted and cooled or co-precipitated by evaporating the solvent. In some embodiments, delayed or sustained release formulations are provided, comprising drug particles or granules, at a polymer or matrix dependent rate.

Suitable sweeteners include sucrose, glucose, fructose, or intense sweeteners, i. components with increased sweetness compared to sucrose (for example, at least 10 times sweeter than sucrose). Suitable intense sweeteners include aspartame, saccharin, sodium potassium or calcium saccharin, acesulfame potassium, sucralose, alitame, xylitol, cyclamate, neomate, neohesperidin dihydrochalcone or mixtures thereof, thaumatin, palatinite, stevioside, rebaudioside, Magnasweet(R). The total concentration of sweeteners can vary from zero to about 300 mg/ml based on the liquid composition after dilution.

To enhance the palatability of a liquid composition after reconstitution in an aqueous medium, one or more flavoring agents may be added to the composition to mask the taste of the ASBT inhibitor. Such a component may be a sweetener, a flavoring agent, or a combination thereof. The taste-masking component is typically incorporated into the pharmaceutical composition in an amount up to about 0.1% or 5% by weight of the total pharmaceutical composition. In a preferred embodiment of the present invention, the composition contains both sweetener(s) and flavor(s).

A flavoring agent is a substance capable of improving the taste or smell of a composition. Suitable natural or synthetic flavors are selected from a standard reference such as Fenaroli's Handbook of Flavor Ingredients, 3rd edition (1995). Non-limiting examples of flavors and/or sweeteners used in the preparations described herein include, for example, acacia syrup, acesulfame K, alitame, anise, apple, aspartame, banana, Bavarian cream, berries, blackcurrant, toffee, calcium citrate, camphor, caramel , cherry, cherry cream, chocolate, cinnamon, chewing gum, citrus, citrus punch, citrus cream, cotton candy, cocoa, cola, cherry juice, citrus juice, cyclamate, cilamate, dextrose, eucalyptus, eugenol, fructose, fruit punch, ginger , Glycyrrhetinate, Glycyrrhiza, Licorice Syrup, Grape, Grapefruit, Honey, Isomalt, Lemon, Lime, Lemon Cream, Monoammonium Glyrrhizinate (MagnaSweet®), Maltol, Mannitol, Maple, Marshmallow, Menthol, Peppermint Cream, Blend Berry, Neohesperidin DC, Neotame, Orange, Pear, Peach, Peppermint, Mint Cream, Prosweet® Powder, Raspberry, Root Beer, Rum, Saccharin, Safrole, Sorbitol, Peppermint, Peppermint Cream, Strawberry, Strawberry Cream, Stevia, Sucralose, Sucrose, Sodium Saccharin, saccharin, aspartame, aces ulfam potassium, mannitol, talin, silitol, sucralose, sorbitol, swiss cream, tagatose, tangerine, thaumatin, tutti frutti, vanillin, walnut, watermelon, wild cherry, wintergreen, xylitol, or any combination of these flavorings, such as anise-menthol , cherry-anise, cinnamon-orange, cherry-cinnamon, chocolate mint, honey-lemon, lemon-lime, lemon-mint, menthol-eucalyptus, orange-cream, vanillin-mint, and mixtures thereof. Flavorings can be used alone or in combination of two or more substances. In some embodiments, the aqueous liquid dispersion contains a sweetener or flavor at a concentration of from about 0.001% to about 5.0% by volume of the aqueous dispersion. In one embodiment, the aqueous liquid dispersion includes a sweetener or flavor at a concentration of from about 0.001% to about 1.0% by volume of the aqueous dispersion. In another embodiment, the aqueous liquid dispersion includes a sweetener or flavoring agent at a concentration of from about 0.005 vol.% to about 0.5 vol.% of the aqueous dispersion. In yet another embodiment, the aqueous liquid dispersion includes a sweetener or flavoring agent at a concentration of from about 0.01 vol.% to about vol.% of the aqueous dispersion. In yet another embodiment, the aqueous liquid dispersion comprises a sweetener or flavoring agent at a concentration of from about 0.01% by volume to about 0.5% by volume of the aqueous dispersion.

In some embodiments, the pharmaceutical compositions are conveniently prepared using one or more physiologically acceptable carriers, including, for example, excipients and additives that facilitate processing of the active compounds into formulations suitable for pharmaceutical use. In some embodiments, the desired drug depends on the selected route of administration.

- 45 041458

A summary of the pharmaceutical compositions described herein can be found, for example, in Remington: The Science and Practice of Pharmacy, Nineteenth Ed (Easton, Pa.: Mack Publishing Company, 1995); Hoover, John E., Remington's Pharmaceutical Sciences, Mack Publishing Co., Easton, Pennsylvania 1975; Liberman, H.A. and Lachman, L., Eds., Pharmaceutical Dosage Forms, Marcel Decker, New York, N.Y., 1980; and Pharmaceutical Dosage Forms and Drug Delivery Systems, Seventh Ed. (Lippincott Williams & Wilkins 1999).

As used herein, the term pharmaceutical composition refers to a mixture of compounds described herein, for example compounds of formula I-VI, with other chemical components such as carriers, stabilizers, diluents, dispersing agents, suspending agents, thickeners and/or excipients. In some cases, the pharmaceutical composition facilitates the administration of the compound to the patient or to the target cell. In some embodiments, the practice of the methods of treatment or use proposed herein, a therapeutically effective amount of the compounds described herein is administered to a pharmaceutical composition for a patient suffering from the disease, disorder, or condition to be treated. In specific embodiments, the patient is a human. As shown here, the compounds described here are used either alone or in combination with one or more additional therapeutic components.

In some embodiments, the pharmaceutical preparations described herein are administered to a patient by any route, including, but not limited to, parenteral (eg, intravenous, subcutaneous, intramuscular), nasal, buccal, topical, rectal, or transdermal.

In some embodiments, the pharmaceutical compositions described herein include one or more of the compounds described herein as the active ingredient in acid- or base-free forms, or in the form of a pharmaceutically acceptable salt. In some embodiments, the compounds described herein are used in the form of an N-oxide or a crystalline or amorphous form (ie, a polymorph). In some situations, the compound described here exists as tautomers. All tautomers are included within the scope of the compounds presented here. In some embodiments, a compound described herein exists in an unsolvated or solvated form, the solvated forms including any pharmaceutically acceptable solvents, such as water, ethanol, and the like. The solvated forms of the compounds presented here have been described above.

The carrier includes, in some embodiments, a pharmaceutically acceptable excipient and is selected based on compatibility with the compounds described herein, such as compounds of any formula I-VI, and the release rate of the desired dosage form. Examples of carriers include agents such as binders, suspending agents, solubilizers, stabilizers, lubricants, wetting agents, diluents, and the like. See, for example, Remington: The Science and Practice of Pharmacy, Nineteenth Ed (Easton, Pa.: Mack Publishing Company, 1995); Hoover, John E., Remington's Pharmaceutical Sciences, Mack Publishing Co., Easton, Pennsylvania 1975; Liberman, H.A. and Lachman, L, Eds., Pharmaceutical Dosage Forms, Marcel Decker, New York, N.Y., 1980; and Pharmaceutical Dosage Forms and Drug Delivery Systems, Seventh Ed. (Lippincott Williams & Wilkins 1999).

In addition, in some embodiments, the pharmaceutical compositions described herein are formulated into dosage forms. In some embodiments, there is provided a dosage form comprising a compound as described herein suitable for administration to a patient. In some embodiments, suitable dosage forms include, but are not limited to, aqueous oral dispersions, liquids, gels, syrups, elixirs, suspensions, solid oral dosage forms, aerosols, controlled release preparations, fusible preparations, effervescent preparations, lyophilized preparations, tablets, powders, pills, dragees, capsules, delayed release preparations, extended release preparations, pulsatile release preparations, multiparticulate preparations, mixed immediate release and controlled release preparations.

In some aspects, a composition or formulation comprising one or more of the compounds described herein is administered orally to deliver the ASBTI locally, or the compound described herein is administered to the colon and/or rectum. Unit dose forms of such compositions include a pill, tablet, or capsule formulated for delivery to the intestine in the colon. In some embodiments, such pills, tablets, or capsules contain the compositions described herein entrapped or embedded in microspheres. In some embodiments, microspheres include, but are not limited to, HPMC capsules of chitosan microparticles, capsules, and cellulose acetate butyrate (CAB) microspheres. In some embodiments, oral dosage forms are prepared by conventional methods known to those skilled in the pharmaceutical arts. For example, in some embodiments, tablets are prepared using standard tablet processing procedures and equipment. Examples of a tableting process are direct compression of a powder, crystalline or granular composition containing the active ingredients alone or in combination with one or more carriers, additives, and the like. In alternative embodiments, tablets are prepared by wet granulation or dry granulation. In some embodiments, tablets are prepared by shaping rather than compressing a wet or other deformable substance.

- 46 041458

In some embodiments, tablets formulated for oral administration contain various excipients, including, but not limited to, binders, diluents, lubricants, disintegrants, fillers, stabilizers, surfactants, preservatives, colors, flavors, and the like. In some embodiments, binders are used to impart cohesive properties to the tablet so that the tablet remains intact after compression. Suitable binders include, but are not limited to, starch (including corn starch and pregelatinized starch), gelatin, sugars (including sucrose, glucose, dextrose, and lactose), polyethylene glycol, propylene glycol, waxes, and natural and synthetic gums, such as sodium acacia alginate, polyvinylpyrrolidone, cellulose polymers (including hydroxypropylcellulose, hydroxypropylmethylcellulose, methylcellulose, ethylcellulose, hydroxyethylcellulose, and the like), veegum, and combinations thereof. In some embodiments, diluents are used to expand the tablet to a practical size. Suitable diluents include, but are not limited to, dicalcium phosphate, calcium sulfate, lactose, cellulose, kaolin, mannitol, sodium chloride, dry starch, powdered sugar, and combinations thereof. In some embodiments, lubricants are used to facilitate the manufacture of tablets; examples of suitable lubricants include, but are not limited to, vegetable oils such as peanut, cottonseed, sesame, olive, corn and cocoa butter, glycerin, magnesium stearate, calcium stearate, stearic acid, and combinations thereof. In some embodiments, disintegrants are used to facilitate tablet disintegration and include, but are not limited to, starches, clays, celluloses, algins, gums, cross-linked polymers, and combinations thereof. Fillers include, but are not limited to, silica, titanium dioxide, alumina, talc, kaolin, cellulose powder, and microcrystalline cellulose, as well as solubles such as mannitol, urea, sucrose, lactose, dextrose, sodium chloride, and sorbitol. In some embodiments, stabilizers are used to inhibit or slow down drug degradation reactions, such as oxidative reactions. In some embodiments, surfactants are anionic, cationic, amphoteric, or nonionic surfactants.

In some embodiments, the compounds described herein are administered orally with a carrier suitable for delivery to the distal region of the gastrointestinal tract (eg, distal ileum, colon or rectum).

In some embodiments, the composition described herein includes ASBTI or other compounds described herein together with a matrix (eg, a matrix comprising hypermellose) that provides a controlled release of the active ingredient in the distal ileum and/or colon. In some embodiments, the composition includes a pH-sensitive polymer (eg, an MMX™ matrix from Cosmo Pharmaceuticals) that provides controlled release of the active ingredient in the distal ileum. Examples of such pH sensitive polymers suitable for controlled release include, but are limited to, polyacrylic polymers (e.g., anionic polymers of methacrylic acid and/or methacrylic acid esters, e.g., Carbopol® polymers) which contain acidic groups (e.g., -COOH , -SO3H) and swell in the gut at basic pH (eg, pH about 7 to about 8). In some embodiments, a composition suitable for controlled release in the distal ileum contains the active ingredient in the form of microparticles (eg, micron-sized particles). In some embodiments, an enzymatically degradable poly(dI-lactide-coglycolide) (PLGA) core is suitable for delivering an enteroendocrine peptide (eg, bile acid) secretagogue to the distal ileum. In some embodiments, a dosage form comprising an enteroendocrine peptide secretion enhancer (e.g., bile acid) is coated with an enteric polymer (e.g., Eudragit® S-100, cellulose acetate phthalate, polyvinyl acetate phthalate, hydroxypropyl methylcellulose phthalate, anionic polymers of methacrylic acid, methacrylic acid esters and the like) for delivery to a specific site in the ileum and/or colon. In some embodiments, bacteria-activated systems are suitable for targeted delivery to the distal ileum. Examples of microflora-activated systems include formulations containing pectin, galactomannan and/or Azo hydrogels and/or glycoside conjugates of the active ingredient (eg, D-galactoside, e-D-xylopyranoside, etc.). Examples of enzymes from the gastrointestinal microflora include bacterial glycosidases such as, for example, D-galactosidase, βD-glucosidase, a-L-arabinofuranosidase, e-D-xylopyranosidase, or the like.

The pharmaceutical compositions described herein optionally include additional therapeutic compounds described herein and one or more pharmaceutically acceptable additives, such as a compatible carrier, binder, filler, suspending agent, flavoring agent, sweetener, disintegrant, dispersing agent, surfactant, lubricant, coloring agent. , thinner, solubilizer, wetting agent, plasticizer, stabilizer, penetration accelerator, wetting agent, defoamer, antioxidant, con

- 47 041458 sideboard or one or more combinations thereof. In some aspects, a film coating for a formulation is provided, such as that described in Remington's Pharmaceutical Sciences, 20th Edition (2000). In one embodiment, the compound described herein is in the form of particles, some or all of which are coated. In some embodiments, some or all of the particles of a compound described herein are encapsulated in microcapsules. In some embodiments, all particles of a compound described herein are not encapsulated or coated.

In further embodiments, a tablet or capsule comprising ASBI or other compounds described herein is coated for delivery to target sites in the gastrointestinal tract. Examples of film shells include, but are not limited to, hydroxypropylmethylcellulose, polyvinylpyrrolidone, hydroxypropylcellulose, polyethylene glycol 3350, 4500, 8000, methylethylcellulose, pseudoethylcellulose, amylopectin, and the like. Solid dosage forms for administration to children The solid dosage forms of the present invention for administration to children can be prepared by standard manufacturing methods. Non-limiting examples of oral pediatric solid pharmaceutical forms are described below.

Effervescent compositions.

The effervescent compositions of the invention may be prepared according to procedures well known to those skilled in the pharmaceutical arts.

Effervescent preparations contain vapors of basic and acid components, which easily form gas in the presence of water. In some embodiments, the main component may be, for example, an alkali or alkaline earth metal carbonate or bicarbonate. The acid component may contain, for example, an aliphatic carboxylic acid or a salt thereof, such as citric acid. Each basic and acidic component may comprise, for example, 25-55% (w/w) of the effervescent composition. The ratio of acidic and basic component can be from 1:2 to 2:1.

The effervescent compositions of this invention can be made using additional pharmaceutical carriers or excipients. For example, one or more flavor-hiding components may be used. You can also use a dye, because. children often prefer colored pharmaceutical combinations. The compositions may take the form of, for example, tablets, granules or powders placed in a bag.

Chewable tablets.

Chewable tablets according to the invention can be made according to methods well known to experts in the field of pharmaceuticals.

Chewable tablets are tablets intended to disintegrate in the mouth when chewed or sucked, and as a result the active ingredient has an increased ability to come into contact with bitter taste receptors on the tongue.

One way to get rid of this is to absorb the active ingredient onto a suitable substrate. This approach is described in US Pat. No. 4,647,459.

Another approach involves forming the active component in an aggregate along with a pre-swollen anhydrous hydrocolloid. The hydrocolloid absorbs saliva and acquires a slippery texture that can lubricate aggregate particles and mask the taste of the active ingredient. This approach is described in European patent application 0190826.

Another approach involves the use of a water insoluble hygroscopic excipient such as microcrystalline cellulose. This approach is described in US Pat. No. 5,275,823.

In addition to the above approaches, the chewable tablets of the present invention may also contain other excipients such as a disintegrant and a taste masking agent.

Lozenges.

The resorbable tablets of this invention can be prepared according to methods well known to those skilled in the pharmaceutical arts.

The mixture of excipients in lozenges according to the invention should be such that the rate of disintegration allows an extremely short buccal residence time and in particular is well below sixty seconds. In some embodiments, the mixture of excipients is characterized in that the active substance is in the form of microcrystals or microgranules, coated or uncoated. In some embodiments, the lozenge contains one or more disintegrants such as carboxymethyl cellulose or insoluble reticular PVP, one or more swelling agents, which may include carboxymethyl cellulose, starch, modified starch or microcrystalline cellulose, or optionally direct compression sugar.

Powders for recovery.

Powders for reconstitution of the pharmaceutical compositions of the invention may be prepared according to procedures well known to those skilled in the pharmaceutical arts.

In some embodiments, powders for restoring the compositions of the invention include an effective amount of at least one internal dehydrating component. An internal dehydrating component increases the stability of the powder. In some variants, internal

- 48 041458 ny dehydrating component is magnesium citrate or disodium carbonate. In some embodiments, the powder composition includes pharmaceutically acceptable diluents such as sucrose, dextrose, mannitol, xylitol, or lactose.

The powder compositions of the invention can be placed in bags or vials for simultaneous dissolution or short-term storage in liquid form (eg, 7 days).

Jelly Bean.

The gummies of this invention may be prepared according to procedures well known to those skilled in the pharmaceutical arts.

Traditional gummies are made from gelatin. Gelatin provides elasticity to the candy, the right chewy texture and a longer shelf life. In some embodiments, the pharmaceutical compositions of this invention in chewable candies include a binder, a sweetener, and an active ingredient.

In some embodiments, the binder is pectin gel, gelatin, food starch, or any combination thereof.

In some embodiments, the chewy candy includes sweeteners, a binder, natural and/or artificial flavors, and colors and preservatives. In some embodiments, the gummies contain glucose syrup, natural sugarcane juice, gelatin, citric acid, lactic acid, natural colors, natural flavors, fractionated coconut oil, and carnauba wax.

Liquid dosage forms.

Liquid dosage forms according to this invention can be manufactured according to methods well known to experts in the field of pharmaceuticals.

Solution refers to a liquid pharmaceutical preparation in which the active ingredient is dissolved in a liquid. Pharmaceutical solutions of this invention include syrups and elixirs. Suspension refers to a liquid pharmaceutical preparation in which the active ingredient is precipitated in a liquid.

It is desirable that the liquid dosage form has a specific pH and/or keeps it in a specific range. A suitable buffer system can be used to adjust the pH. In addition, the buffer system must maintain the pH value within the desired range. Examples of the buffer system used in the present invention include, but are not limited to, citrate buffers, phosphate buffers, or any other known suitable buffers. Preferably, the buffer system includes sodium citrate, potassium citrate, sodium bicarbonate, potassium bicarbonate, sodium dihydrogen phosphate and potassium dihydrogen phosphate, etc. The concentration of the buffer system in the final suspension will vary depending on factors such as the buffering capacity of the buffer system and the desired pH/pH range for the liquid dosage form. In one embodiment, the concentration in the final liquid dosage form ranged from 0.005 to 0.5% wt./about.

The pharmaceutical composition in the form of a liquid dosage form of the present invention may also include a suspending/stabilizing component to prevent precipitation of the active substance. Over time, precipitation can cause the active substance to stick to the inside walls of the package, making redispersion and accurate pouring of the active substance difficult. Suitable stabilizers include, but are not limited to, polysaccharides such as xanthan, guar, and tragacanth gum, as well as cellulose derivatives HPMC (hydroxypropyl methyl cellulose), methyl cellulose, and Avicel RC-591 (microcrystalline cellulose/sodium carboxymethyl cellulose). Alternatively, polyvinylpyrrolidone (PVP) can also be used as a stabilizer.

In addition to the above components, an ASBTI oral dosage form may also contain other excipients commonly found in pharmaceutical compositions, such as alternative diluents, taste-masking agents, antioxidants, excipients, acidifiers, enzyme inhibitors, and other components described in the Handbook of Pharmaceutical Excipients, Rowe et al. al., Eds., ^4th Edition, Pharmaceutical Press (2003), which is incorporated by reference.

The addition of an alternative solvent helps to increase the solubility of the active ingredient in the liquid dosage form and hence the absorption and bioavailability in the patient's body. Preferably, alternative solvents include methanol, ethanol or propylene glycol, etc.

In another aspect, the present invention provides a method for making a liquid dosage form. The method includes preparing a mixture of ASBTI or its pharmaceutically acceptable salts with components including glycerol or syrup or mixtures thereof, a preservative, a buffer system and a suspending/stabilizing component, etc. in a liquid environment. In general, a liquid dosage form is prepared by uniformly and intimately mixing these various components in a liquid medium. For example, components such as glycerol or syrup or mixtures thereof, preservative, buffer system and suspending/stabilizing component, etc. dissolved in water to form an aqueous solution, then the active ingredient is dispersed in an aqueous solution to form a suspension.

- 49 041458

In some embodiments, the liquid dosage form provided herein may be in a volume of 5-50 ml. In some embodiments, the liquid dosage form provided herein may be 5-40 ml. In some embodiments, the dosage form provided herein may be in a 5 ml volume. In some embodiments, the dosage form may be in a volume of 5-20 ml. In some embodiments, the liquid dosage form provided herein may be in a volume of 10-30 ml. In some embodiments, ASBTI may be present in an amount of about 0.001-90% of the total volume. In some embodiments, ASBTI may be present in an amount of about 0.01-80% of the total volume.

In some embodiments, ASBTI may be present in an amount of about 0.1-70% of the total volume.

In some embodiments, ASBTI may be present in an amount of about 1-60% of the total. In some embodiments, ASBTI may be present in an amount of about 1-50% of the total. In some embodiments, ASBTI may be present in an amount of about 1-40% of the total. In some embodiments, ASBTI may be present in an amount of about 1-30% of the total. In some embodiments, ASBTI may be present in an amount of about 1-20% of the total. In some embodiments, ASBTI may be present in an amount of about 1-10% of the total volume. In some embodiments, ASBTI may be present in an amount of about 5-70% of the total. In some embodiments, ASBTI may be present in an amount of about 5-60% of the total volume. In some embodiments, ASBTI may be present in an amount of about 5-50% of the total volume. In some embodiments, ASBTI may be present in an amount of about 5-40% of the total. In some embodiments, ASBTI may be present in an amount of about 5-30% of the total volume. In some embodiments, ASBTI may be present in an amount of about 5-20% of the total volume. In some embodiments, ASBTI may be present in an amount of about 5-10% of the total volume. In some embodiments, ASBTI may be present in an amount of about 10-50% of the total. In some embodiments, ASBTI may be present in an amount of about 10-40% of the total volume. In some embodiments, ASBTI may be present in an amount of about 10-30% of the total volume. In some embodiments, ASBTI may be present in an amount of about 10-20% of the total. In one embodiment, the resulting final liquid dosage form may be in a liquid volume

10-30 ml, preferably 20 ml, and the active ingredient may be present in an amount in the range of about 0.001-16 mg/ml or about 0.025-8 mg/ml or about 0.1-4 mg/ml or about 0.25 mg/ml or about 0.5 mg/ml or about 1 mg/ml or about 2 mg/ml or about 4 mg/ml or about 5 mg/ml or about 8 mg/ml or about 10 mg/ml or about 12 mg/ml or about 14 mg/ml ml or about 16 mg/ml.

Bile acid sequestrant.

In some embodiments, an oral preparation for use in any of the ways described herein is, for example, an ASBTI together with a labile bile acid sequestrant. A labile bile acid sequestrant is a labile bile acid sequestrant with a labile affinity for bile acids. In some embodiments, the labile bile acid sequestrant described herein is a component that sequesters (eg, absorbs or combines with) bile acid and/or salts thereof.

In specific embodiments, a labile bile acid sequestrant is a component that sequesters (e.g., absorbs or combines with it) bile acid and/or salts thereof and releases at least a portion of the absorbed bile acid and/or salts thereof in the distal gastrointestinal tract ( for example, colon, ascending colon, sigmoid colon, distal colon, rectum, or any combination thereof). In some embodiments, the labile bile acid sequestrant is an enzyme dependent bile acid sequestrant. In specific embodiments, the enzyme is bacterial. In some embodiments, the enzyme is bacterial, which is present in a high concentration in the human colon or rectum compared to the concentration in the small intestine. Examples of microflora-activated systems include formulations containing pectin, galactomannan and/or Azo hydrogels and/or glycoside conjugates of the active ingredient (eg, D-galactoside, β-D-xylopyranoside, etc.). Examples of enzymes from the microflora of the gastrointestinal tract include bacterial glycosidases such as, for example, D-galactosidase, e-D-glucosidase, a-L-arabinofuranosidase, e-D-xylopyranosidase, or the like. In some embodiments, the labile bile acid sequestrant is a slow release bile acid sequestrant (i.e., sequesters the bile acid and/or its salts and releases at least a portion of the bile acid and/or its salts over time). In some embodiments, the slow release bile acid sequestrant is a component that degrades over time in an aqueous environment. In some embodiments, the labile bile acid sequestrant described herein is a bile acid sequestrant that has a low affinity for bile acid and/or salts thereof, which allows the bile acid sequestrant to continue to sequester bile acid and/or salts thereof in an environment with a high concentration of bile acid and/or or its salts and release them in a place where the concentration of bile acid and/or salts thereof is relatively low. In some embodiments, a labile bile sequestrant

- 50 041458 slots has a high affinity for primary bile acid and a low affinity for secondary bile acid, which allows the bile acid sequestrant to sequester the primary bile acid or its salt and then release the secondary bile acid or its salt as the primary bile acid or its the salt is converted (eg, metabolized) to the secondary bile acid or its salts. In some embodiments, the labile bile acid sequestrant is a pH dependent bile acid sequestrant. In some embodiments, the pH-dependent bile acid sequestrant has a high affinity for bile acid at or below pH 6 and a low affinity for bile acid at a pH greater than 6. In some embodiments, the pH-dependent bile acid sequestrant degrades at a pH greater than 6.

In some embodiments, the labile bile acid sequestrant described herein includes any compounds, such as macrostructural compounds, that can sequester bile acids/salts and/or salts thereof by any suitable mechanism. For example, in some embodiments, the bile acid sequestrant sequesters bile acids/salts and/or salts thereof by ionic interactions, polar interactions, static interactions, hydrophobic interactions, lipophilic interactions, hydrophilic interactions, steric interactions, or the like. In some embodiments, macrostructural compounds sequester bile acids/salts and/or salts thereof by trapping bile acids/salts and/or salts thereof in the niches of the macrostructural compounds and optionally other interactions such as those described above. In some embodiments, bile acid sequestrants (e.g., a labile bile acid sequestrant) include, but are not limited to, lignin, modified lignin, polymers, polycationic polymers and copolymers, polymers and/or copolymers containing any one or more K-alkenyl-K-alkylamine groups. ; one or more K,K,K-trialkyl-K-(K'-alkenylamino)alkylazane groups; one or more N,N,Ntrialkyl-K-alkenylazine groups; one or more alkenylamine groups, or combinations thereof, or any combination.

Covalent bond of a drug to a carrier.

In some embodiments, the strategy employed for targeted delivery to the colon includes, but is not limited to, covalently linking ASBTI or other compounds described herein to a carrier, coating a pH-sensitive polymer dosage form for colonic delivery, using oxidation-sensitive recovery of polymers, the use of slow release drugs, the use of shells that are specifically degraded by colonic bacteria, the use of bioadhesive systems and osmotic drug delivery systems.

In some embodiments, such oral administration of compositions containing ASBTI or other compounds described herein, includes covalent attachment to the carrier, and after oral administration, the associated fragment remains unchanged in the stomach and small intestine. When it enters the colon, the covalent bond is broken as a result of pH changes, the action of enzymes and / or decomposition by the intestinal microflora. In some embodiments, covalent binding of the ASBTI to the carrier includes, but is not limited to, the formation of azo bonds, glucoside conjugates, glucuronide conjugates, cyclodextrin conjugates, dextran conjugates, and amino acid conjugates (amino acids with high hydrophilicity and long carrier chain).

Polymer shells: pH-sensitive polymers.

In some embodiments, the oral dosage forms described herein are enteric-coated to facilitate delivery of the ASBTI or other compounds described herein to the colon and/or rectum. In some embodiments, the enteric coating remains intact in the stomach at low pH, but readily dissolves when the optimum pH for dissolution of the particular coating is reached, which depends on the chemical composition of the enteric coating. The shell thickness depends on the solubility parameters of the shell substance. In some embodiments, the thickness of the shell used in the formulations described herein varies in the range of about 25,200 microns.

In some embodiments, the compositions or formulations described herein are coated such that the ASBTI or other compounds or formulations described herein are delivered to the colon and/or rectum without absorption in the upper intestine. In a particular embodiment, specific delivery to the colon and/or rectum is via a dosage form polymeric shell that degrades only at the pH in the colon. In alternative embodiments, the composition is coated with an enteric coating that dissolves at the pH of the intestine and an outer layer of a matrix that is slowly degraded in the intestine. In some such embodiments, the matrix is destroyed until only the core with the composition containing the enteroendocrine peptide secretion accelerator (and in some such embodiments, the absorption inhibitor of the component) remains, and the core is delivered to the colon and/or rectum.

Some embodiments of pH-dependent systems use a progressively increasing pH along the entire gastrointestinal tract (GIT) from the stomach (pH 1-2, which rises to 4 during

- 51 041458 digestion time), small intestine (pH 6-7) in the area of digestion and up to 7-8 in the ileum. In some embodiments, oral dosage forms of the compositions described herein are coated with pH-sensitive polymers to provide delayed release and protect enteroendocrine peptide secretion-enhancing components from gastric juices. In some embodiments, such polymers should withstand lower pH in the stomach and proximal small intestine, but disintegrate at neutral or slightly alkaline pH in the terminal ileum and/or at the ileocycal junction. Thus, in some embodiments, oral dosage forms are provided in a shell containing a pH-sensitive polymer. In some embodiments, colon and/or rectal targeting polymers include, but are not limited to, methacrylic acid copolymers, methacrylic acid-methyl methacrylate copolymers, Eudragit L100, Eudragit S100, Eudragit L-30D, Eudragit FS-30D, Eudragit L100-55, polyvinyl acetate phthalate, hydroxypropyl ethylcellulose phthalate, hydroxypropyl methylcellulose phthalate 50, hydroxypropyl methylcellulose phthalate 55, cellulose acetate trimelliate, cellulose acetate phthalate, and combinations thereof.

In some embodiments, oral dosage forms suitable for delivery to the colon and/or rectum have a shell containing a biodegradable and/or bacterially degradable polymer or polymers that are degraded by microflora (bacteria) in the colon. In such biodegradable systems, polymers include, but are not limited to, azopolymers, polyurethanes with linear segments containing azo groups, polygalactomannans, pectin, glutaraldehyde cross-linked dextran, polysaccharides, amylose, guar gum, pectin, chitosan, inulin, cyclodextrins, chondroitin sulfate, dextrans, locust bean gum, chondroitin sulfate, chitosan, poly(caprolactone), polylactic acid and poly(lactic glycolic acid).

In some embodiments of such oral administration of compositions containing one or more ASBTIs or other compounds described herein, the compositions are delivered to the colon without absorption in the upper intestine by coating dosage forms of redox-sensitive polymers that are biodegradable ( bacteria) in the large intestine. In such biodegradable systems, polymers include, but are not limited to, redox-sensitive polymers containing azo and/or disulfide bonds in their backbone.

In some embodiments, the compositions for delivery to the colon and/or rectum are designed to be slow release. In some embodiments, slow release formulations are stable in the acidic environment of the stomach, resulting in a delayed release of enteroendocrine peptide secretagogues until the drug reaches the colon and/or rectum.

In some embodiments, the slow release formulations described herein comprise a capsule (containing an enteroendocrine peptide secretion enhancer and optionally an absorption inhibitor) with a hydrogel stopper. In some embodiments, the capsule and hydrogel plug are coated with a water-soluble cap and the entire unit is coated with an enteric polymer. When the capsule enters the small intestine, the enteric coating dissolves, the hydrogel plug swells and after a while separates from the capsule, and the composition is released from the capsule. Apply such an amount of hydrogel, which allows you to set the desired time period for the release of the contents.

In some embodiments, multilayer coated oral dosage forms are provided that include different layers of polymers with different pH sensitivities. As the coated dosage form moves along the GIT, the different layers dissolve depending on the pH value. Useful polymers in such formulations include, but are not limited to, polymethacrylates with appropriate dissolution parameters at various pH levels, Eudragit® RL and Eudragit®RS (inner layer) and Eudragit® FS (outer layer). In other embodiments, the dosage form is an enteric-coated tablet wherein the outer layer is hydroxypropyl cellulose or hydroxypropyl methylcellulose acetate succinate (HPMCAS).

In some embodiments, oral dosage forms are provided that include a shell of cellulose butyrate phthalate, cellulose acid phthalate, cellulose propionate phthalate, polyvinyl acetate phthalate, cellulose acetate phthalate, cellulose acetate trimelliate, hydroxypropyl methyl cellulose phthalate, hydroxypropyl methyl cellulose acetate, dioxypropyl methyl cellulose succinate, carboxymethyl ethyl cellulose, acrylic acid succinate, hydroxypropyl methyl cellulose copolymers, methacrylic acid; and combinations thereof.

Combined therapy.

In some cases, combination compositions and/or methods of therapy are provided, including any compound described herein and an additional therapeutic component. In some embodiments, the additional therapeutic moiety is an L cell endocrine peptide enhancer. In some cases, the L cell endocrine peptide enhancer is GLP-2 uxi

- 52 041458 lit. In some embodiments, the GLP-2 enhancer is GLP-2, a GLP-2 secretion enhancer, a GLP-2 degradation inhibitor, and a combination thereof. In some cases, the increased concentration with GLP-2 provides regeneration of the intestinal mucosa and/or heals damage to gastrointestinal structures and/or reduces the induction of cytokines and/or enhances the adaptation process, reduces intestinal damage, reduces bacterial translocation, inhibits the formation of oxygen free radicals or any combination of processes.

In some cases, the L cell endocrine peptide enhancer is a PYY enhancer. In some cases, the L cell endocrine peptide enhancer is oxyntomodulin. In some cases, increased secretion with PYY or oxyntomodulin heals intestinal damage caused by cholestasis or cholestatic liver disease.

TGR5 receptor modulators.

In some cases, additional therapeutic components modulate bile acid receptors in the lumen of the gastrointestinal tract. In some embodiments, the additional therapeutic moiety acts as an agonist or partial agonist of bile acid receptors (eg, TGR5 receptors or Farnesoid-X receptors) in the lumen of the gastrointestinal tract. In some embodiments, the additional therapeutic moiety is a bile acid analog. In some cases, administration of a TGR5 agonist in combination with any compound described herein enhances the secretion of enteroendocrine peptides from L cells. TGR5 modulators (eg, agonists) include, but are not limited to, the compounds described in WO 2008/091540, WO 2008/067219 and US application No. 2008/0221161.

Enteroendocrine peptides.

In some embodiments, the additional therapeutic moiety is an enteroendocrine peptide. In some embodiments, the enteroendocrine peptide heals damage in the intestine or liver resulting from cholestatic liver disease. Examples of enteroendocrine peptides administered as an additional therapeutic component include, but are not limited to, GLP-1 or GLP-1 analogs such as Taspoglutide® (Ipsen) or the like.

Combination therapy with fat-soluble vitamins.

In some embodiments, methods are provided that also include the administration of one or more vitamins. In some embodiments, the vitamin is vitamin A, B1, B2, B3, B5, B6, B7, B9, B12, C, D, E, K, folic acid, pantothenic acid, niacin, riboflavin, thiamine, retinol, betacarotene, pyridoxine , ascorbic acid, cholecalciferol, cyanocobalamin, tocopherols, phylloquinone, menaquinone.

In some embodiments, the vitamin is fat soluble, such as vitamins A, D, E, K, retinol, beta-carotene, cholecalciferol, tocopherols, phylloquinone. In a preferred embodiment, the fat soluble vitamin is tocopherol polyethylene glycol succinate (TPGS).

Combination therapy with partial external biliary diversion (PEBD).

In some embodiments, methods are provided that also include the use of partial external biliary diversion to treat patients who have not yet developed cirrhosis. This treatment helps to reduce the circulation of bile acids/salts in the liver to reduce complications and prevent the need for early transplantation in many patients.

This surgical technique involves separating a 10 cm segment of intestine from the rest of the intestine for use as a bile duct (bile passage). One end of the canal is connected to the gallbladder, and the other end is brought out through the skin to form a stoma (an artificial surgical opening for the removal of waste). Partial external biliary diversion may be used for patients who are not eligible for full medical therapy, especially older patients. Such a procedure will not help young patients, such as infants. Partial external biliary diversion can reduce the intensity of itching and lead to pathologically low blood cholesterol levels.

Combination therapy with ASBTI and ursodiol.

In some embodiments, ASBTI is administered in combination with ursodiol or ursodeoxycholic acid, chenodeoxycholic acid, cholic acid, taurocholic acid, ursocholic acid, glycocholic acid, glycodeoxycholic acid, taurodeoxycholic acid, taurocholate, glycochenodeoxycholic acid, tauroursodeoxycholic acid. In some cases, an increase in the concentration of bile acids/salts in the distal intestine causes intestinal regeneration, reduces intestinal damage, reduces bacterial translocation, inhibits the release of free oxygen radicals, inhibits the formation of pro-inflammatory cytokines, or any combination of these processes.

The ASBTI and the second active ingredient are administered in such a manner as to provide a therapeutically effective amount of the composition. Such a therapeutically effective amount is derived from the combination of ASBTI with another active ingredient (e.g., ursodiol), in which each ingredient is taken in a therapeutically effective amount, or due to additional or synergistic effects occurring in the composition, with each ingredient also used in subclinical

- 53 041458 therapeutically effective amount, i. e. an amount that, when used alone, has reduced efficacy for the therapeutic purposes described herein, but when used in combination exhibits therapeutic efficacy. In some embodiments, the use of a combination of an ASBTI with any other active ingredient as described herein encompasses combinations in which the ASBTI or other active ingredient is present in a therapeutically effective amount and the other is present in a subclinical therapeutically effective amount, while the composition is therapeutically effective due to the effects of the supplement. and synergy. The term supplement effect as used herein describes the combined effect of two (or more) pharmaceutically active ingredients, which is equal to the sum of the effects of each ingredient taken separately. Any suitable combination of ASBIT with one or more of the other active ingredients mentioned above, and optionally with one or more pharmaceutically active substances, is considered to be within the scope of the described methods.

In some embodiments, the specific choice of compounds depends on the diagnosis made by the attending physicians, and their conclusion about the patient's condition and the appropriate treatment method. The compounds are optionally administered in parallel (eg, simultaneously, generally simultaneously, or in a predetermined manner) or sequentially, depending on the nature of the disease, disorder, or condition of the patient and the actual choice of compounds. In some cases, the determination of the order of re-administration and the amount of each therapeutic component during treatment is based on an assessment of the disease being treated and the condition of the patient.

In some embodiments, therapeutically effective doses vary when the drugs are used in therapeutic combinations. Methods for experimental determination of therapeutically effective doses of drugs and other components used in combination treatment regimens are described in the literature.

In some embodiments of the combination therapy described herein, the doses of the co-administered compounds vary depending on the type of additional drug used, the disease or condition to be treated, and the like. In addition, when administered in conjunction with one or more biologically active components, the proposed compound is optionally administered either simultaneously with the biologically active components or sequentially. In some cases, when sequentially administered, the attending physician decides on the sequence of administration of the therapeutic compounds described herein in combination with an additional therapeutic component.

Several therapeutic components (at least one of which is a therapeutic compound described here) are optionally administered in any order or even simultaneously. If administered simultaneously, it is not necessary to provide multiple therapeutic components in one form, unit form, or multiple forms (by way of example only, either as one pill or two pills). In some cases, one of the therapeutic components is optionally administered in multiple doses. In other cases, both components are optionally administered in multiple doses. If not administered simultaneously, the time between doses can be anything from more than zero weeks to less than four weeks, for example. In addition, combined methods, compounds and preparations should not be limited to taking only two components; also considers the use of several therapeutic components (including two or more of the compounds described here).

In some embodiments, the dosage regimen for treating, preventing, or ameliorating the condition being sought to alleviate is modified in accordance with many factors. These factors include the disorder that causes distress to the patient, as well as age, weight, sex, nutrition, and medical condition. Thus, in different embodiments, the actual dosage regimen used varies and deviates from the regimens discussed here.

In some embodiments, the pharmaceutical components included in the combination therapy described herein are offered in combination dosage form or separate dosage forms intended for simultaneous administration. In some embodiments, the pharmaceutical components included in the combination therapy are administered sequentially with any therapeutic compound administered in a regimen referred to as two-stage administration. In some embodiments, the mode of two-stage introduction provides for the sequential introduction of active components or spaced apart in time the introduction of individual active components. In some embodiments, the time period between administration of multiple compounds ranges, by way of non-limiting example, from several minutes to several hours, depending on the properties of each pharmaceutical component, such as activity, solubility, bioavailability, plasma half-life, and its kinetic profile.

In some embodiments, combination therapy methods are provided herein. In some embodiments, the compositions described herein include an additional therapeutic component. In some embodiments, the methods described herein include the introduction of a second dosage form containing an additional therapeutic component. In some embodiments, the combination therapy described herein with the compositions described herein is carried out as part of a regimen. Therefore, additional therapeutic components and/or additional therapeutic form can be administered to the patient

- 54 041458 either directly or indirectly and simultaneously or sequentially, using the compositions and preparations described here.

Sets.

In another aspect, kits are provided herein comprising a device for rectal administration of a pharmaceutical composition previously placed therein as described herein. In some embodiments, such kits comprise an oral administration device and a pharmaceutical composition as described herein. In some embodiments, the kits include a pre-filled bag or vial for oral administration, while in other embodiments, the kits include pre-filled balloons for the administration of rectal gels. In some embodiments, the kits include pre-filled syringes for oral enemas, while in other embodiments, the kits include pre-filled syringes for administering rectal gels. In some embodiments, the kits include pre-sealed cans for the administration of rectal foam.

Release in the distal ileum and/or colon.

In some embodiments, the dosage form is a matrix (eg, a hypermellose matrix) that provides controlled release of the active ingredient in the distal small intestine, proximal ileum, distal ileum, and/or colon. In some embodiments, the dosage form is a pH sensitive polymer (eg, MMX™ matrix from Cosmo Pharmaceuticals) and provides controlled release of the active ingredient in the ileum and/or colon. Examples of such pH sensitive polymers suitable for controlled release include, but are not limited to: polyaryl polymers (e.g. anionic polymers of methacrylic acid and/or methacrylic acid esters, e.g. Carbopol® polymers) which include acidic groups (e.g. -COOH , -SO ₃ H) and swell in the intestine at basic pH (eg, pH from about 7 to about 8). In some embodiments, a dosage form suitable for controlled release in the distal ileum contains a microparticulate active ingredient (eg, a micron-sized active ingredient). In some embodiments, a non-enzymatically degradable poly(cP-lactide-co-glycolide) (PLGA) core is suitable for releasing ASBTI in the distal ileum. In some embodiments, the ASBTI dosage form is coated with an enteric polymer (e.g., Eudragit® S-100, cellulose acetate phthalate, polyvinyl acetate phthalate, hydroxypropyl methylcellulose phthalate, anionic polymers of methacrylic acid, methacrylic acid esters, etc.) for delivery to a specific ileal site. intestine and/or colon. In some embodiments, bacterial activated systems are suitable for targeted delivery to the ileum. Examples of microflora-activated systems include formulations containing pectin, galactomannan, and/or Azo hydrogels, and/or glycoside conjugates of the active ingredient (eg, D-galactoside, β-D-xylopyranoside, etc.). Examples of enzymes from the gastrointestinal microflora include bacterial glycosidases such as, for example, D-galactosidase, eD-glucosidase, aL-arabinofuranosidase, β-O-xylopyranosidase, or the like.

The solid dosage forms described herein optionally include the described additional therapeutic compound and one or more pharmaceutically acceptable additives, such as a compatible carrier, binder, filler, suspending agent, flavor, sweetener, disintegrant, dispersant, surfactant, lubricant, colorant, diluent, a solubilizer, humectant, plasticizer, stabilizer, penetration enhancer, wetting agent, defoamer, antioxidant, preservative, or one or more combinations thereof. In some aspects, sheathing is provided. In some aspects, a film coating is provided for a formulation with a compound of formula I-VI using the standard coating procedure described, for example, in Remington's Pharmaceutical Sciences, 20th Edition (2000). In one embodiment, the compound described herein is in particulate form and some or all of the compound particles are coated. In some embodiments, some or all of the particles of a compound described herein are encapsulated in microcapsules. In some embodiments, the particles of a compound described herein are not encapsulated or coated.

An ASBT inhibitor (eg a compound of formula I-VI) is used in the manufacture of medicaments for the prophylactic and/or therapeutic treatment of cholestasis or cholestatic liver disease. A method of treating any disease or condition described herein in a patient in need of such treatment comprises administering to said patient pharmaceutical compositions containing at least one ASBT inhibitor described herein or a pharmaceutically acceptable salt thereof, a pharmaceutically acceptable N-oxide, a pharmaceutically active metabolite, a pharmaceutically acceptable a prodrug or a pharmaceutically acceptable solvate thereof in a therapeutically effective amount.

Screening.

- 55 041458

In some embodiments, methods and kits are provided for identifying compounds useful in the treatment of cholestasis or cholestatic liver disease. In some embodiments, assays are provided herein to identify compounds that selectively inhibit ASBT in the following manner:

a. obtaining cells simulating intestinal cells;

b. contacting cells with a compound (eg, a compound described here);

c. determining or measuring the effect of the compound on ASBT inhibitor activity.

In some embodiments, assays are provided to identify compounds that are non-systemic in the following manner:

a. obtaining cells that model intestinal permeability (eg, Caco-2 cells);

b. culturing the cells as a monolayer on semipermeable plastic carriers fitted to the walls of a multiwell culture plate;

c. contacting the apical or basolateral surface of the cells with a compound (eg, the compound described here) and incubating for the desired period of time;

d. determination or measurement of the effect of compound concentration on both sides of the monolayer by liquid chromatography-mass spectrometry (LC-MS) and computer calculation of intestinal permeability of the compound.

In some embodiments, non-systemic compounds are identified by suitable parallel artificial membrane permeability assays (PAMPA).

In some embodiments, non-systemic compounds are identified using isolated gut preparations perfused into vessels.

In some embodiments, assays are provided to identify compounds that inhibit bile salt recycling in the following manner:

A. obtaining cells that simulate intestinal cells with apical bile acid transporters (eg, BHK cells, CHO);

b. incubating the cells with a compound (eg, a compound described here and/or an isotopically labeled bile acid (eg, ¹⁴ C taurocholate) for the desired time period;

c. washing the cells with an appropriate buffer (eg, saturated phosphate buffer);

d. determination or measurement of the residual concentration of isotopically labeled bile acid in cells.

Examples

Example 1 Synthesis of the iodine salt of 1-phenethyl-1-((1,4-diazabicyclo[2.2.2]octanyl)pentyl)imidodicarbonimide diamide

Step 1: Synthesis of 5-(1,4-diazabicyclo[2.2.2]octanyl)-1-iodopentane iodide 1,4-diazabicyclo[2.2.2]octane is suspended in THF. Iodopentane is added dropwise and the mixture is refluxed for 24 hours. The reaction mixture is filtered.

Step 2: Synthesis of N-phenethyl-5-(1,4-diazabicyclo[2.2.2]octanyl)-1-iodopentane iodide

Μ and

5-(1,4-Diazabicyclo[2.2.2]octanyl)-1-iodopentane iodide is suspended in acetonitrile. Phenethylamine is added dropwise and the mixture is refluxed overnight. The reaction mixture is filtered.

Step 3: Synthesis of 1-phenethyl-1-((1,4-diazabicyclo[2.2.2]octanyl)pentyl)imidodicarbonimide diamide iodide.

N-Phenethyl-5-(1,4-diazabicyclo[2.2.2]octanyl)-1-iodopentane iodide is heated with dicyandiamide in n-butanol for 4 hours. The reaction mixture is concentrated under reduced pressure.

Connections in the table. 1 is prepared by the methods described here using appropriate starting materials.

- 56 041458

Example 2 In Vitro Assay for Inhibition of Bile Acid Uptake in the Presence of ASBT.

Baby hamster kidney (BHK) cells were transfected with human ASBT cDNA. Cells were seeded in 96-well tissue culture plates at a density of 60,000 cells/well. Analyzes were carried out at the time of seeding for 24 h.

On the day of analysis, the cell monolayer was washed with 100 ml of buffer. Test compound was added to each well along with 6 mM [ ¹⁴ C] taurocholate in buffer solution (final concentration of 3 mM [ ¹⁴ C] taurocholate per well). Cell cultures were incubated for 2 h at 37°C. The wells were washed with PBS. Fluid was added to each well to measure the scintillation count, the cells were shaken for 30 minutes to determine the radioactivity in each well. A test compound that significantly inhibits ASBT activity indicates that low levels of radioactivity are found in the cells.

Example 3 In Vitro Assay of GLP-2 Secretion.

Human NCI-H716 cells were used to model L cells. Two days prior to each assay, cells were plated in 12-well Matrigel® coated plates to induce cell adhesion. On the day of analysis, the cells were washed with buffer. The cells were incubated for 2 h with the medium or with the test compound. The extracellular medium was analyzed for the presence of GLP-2. The peptides of the medium were isolated by reverse phase adsorption and the extracts were aged until analysis. The presence of GLP-2 was analyzed by ELISA. Detection of elevated GLP-2 levels in moons

- 57 041458 ke containing the test compound shows that the test compound enhances the secretion of GLP-2 from L cells.

Example 4 In vivo bioavailability assay.

Test compounds were solubilized in saline. Sprague Dawley rats were dosed at 210 mg/kg body weight intravenously and orally. Peripheral blood samples were taken from the femoral artery at intervals of up to 8 hours. Plasma concentrations of compounds were determined by quantitative HPLC and/or mass spectrometry. For compounds, clearance and AUC values were determined.

For oral dosing, bioavailability was determined by taking blood from the portal vein. Tubes were inserted into the femoral vein and hepatic portal vein to determine total drug absorption without first-pass clearance in the liver. The absorption fraction (F) was calculated using the formula

F = AUCpo/AUCiv.

Example 5 Assay to determine the level of bile acids in enterocytes and in the lumen of the ileum.

The level of bile acids in the ileal lumen of SD rats was determined by flushing a 3 cm section of the distal ileum with sterile cold PBS. To determine the level of bile acid in interenterocytes after additional washing with PBS, the same area of the ileum was weighed and then homogenized in a fresh portion of PBS. The level of cholic acid, DCA, LCA, chenodeoxycholic acid and ursodeoxycholic acid was determined by GC/MS/MS.

Example 6 Animal for determining the effect of therapy for cholestasis or cholestatic liver disease.

The Mdr2 knockout mouse model of cholestasis or cholestatic liver disease (using carbon tetrachloride/phenobarbital) was used to test the compositions described herein in rats. Animals were orally administered a composition comprising an ASBTI such as 100B, 264W94; SD5613; SAR548304B; SA HMR1741; 1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N-[(R)-αH-(2-sulfoethyl)carbamoyl]-4-hydroxybenzyl]carbamoylmethoxy)-2,3 ,4,5-tetrahydro-1,2,5-benzothiadiazepine; 1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N-[(R)-α-[N-((S)-1-carboxy-2-(R)- hydroxypropyl)carbamoyl]-4-hydroxybenzyl]carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine; 1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N-[(R)-α-[N-((S)-1-carboxy-2-methylpropyl)carbamoyl] 4-hydroxybenzyl]carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine; 1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N-{(R)-α-[N-((S)-1-carboxypropyl)carbamoyl]-4-hydroxybenzyl }carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine; or 1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-[N-((R)-α-carboxy-4-hydroxybenzyl)carbamoylmethoxy]-2,3,4,5- tetrahydro-1,2,5-benzothiadiazepine.

Cholestasis or cholestatic liver disease was quantified based on serum total bile acids and bilirubin compared to placebo control mice/rats. Serum bile acids/salts were determined by ELISA with specific antibodies to cholic acid and CCDCA. Serum bilirubin levels were determined using automated routine assays. Alternatively, a mouse liver sample was taken and the pathology of hepatocellular damage was assessed.

Example 7 Study of the effect of oral LUM001 and 1-[4-[4-[(4R,5R)-3,3-dibutyl-7(dimethylamino)-2,3,4,5-tetrahydro-4-hydroxy-1 ,1-dioxydo-1-benzothiepin-5-yl]phenoxy]butyl]4-aza-1azonium bicyclo[2.2.2]octanemethane sulfonate (compound 100B) on the level of GLP-2 in the plasma of normal rats.

12-week-old male rats after fasting for 16 hours were given oral doses of 0, 3, 30, 100 mg/kg of ASBTI inhibitors - LUM001 or 1-[4-[4-[(4R,5R)-3,3- dibutyl-7-(diethylamino)2,3,4,5tetrahydro-4-hydroxy-1,1-dioxydo-1-benzothiepin-5-yl]phenoxy]butyl]4-aza-1-azonium bicyclo[2.2.2] octanemethane sulfonate (synthesized by Nanosyn Inc., CA, USA) in an aqueous mixture of valine pyrrolidine (n = 5 per group). Blood samples with a volume of 0.6 ml were taken at each time point from the tail vein using capillaries with heparin at 0, 1, 3, and 5 h after the administration of the compounds, and the level of GLP-2 in plasma was determined. Aprotinin and 10 μl of DPP-IV inhibitor per ml of blood were used to preserve the blood sample during the 10 min centrifugation and storage at -70°C or below. GLP-2 (active pM) was tested using any commercially available ELISA kits.

Example 8 Tablet formulations.

kg of a compound of formula I-VI is first sieved through a suitable sieve (eg 500 µm). 25 kg of lactose monohydrate, 8 kg of hydroxypropyl methylcellulose, the sieved compound of formula I-VI and 5 kg of calcium hydrogen phosphate (anhydrous) were then added to a suitable blender (eg drum blender) and mixed. The mixture was sifted through a suitable sieve (eg 500 µm) and mixed again. About 50% of the lubricant (2.5 kg, magnesium stearate) was sieved, added to the mixture and mixed briefly. The remaining lubricant (2 kg, magnesium stearate) was sieved, added to the mixture and mixed briefly. The granules were sieved to obtain the desired granule size (eg 200 µm). In some variants

- 58 041458 max to obtain a drug with prolonged release, the granules were optionally coated with a polymer that regulates the release of drugs, such as polyvinylpyrrolidone, cellulose, hydroxypropylmethylcellulose, methylcellulose or a methacrylic acid copolymer. The granules are filled into gelatin capsules.

Example 9. Preparations for children.

Preparations in the form of absorbable tablets.

The following example describes the large scale manufacture (100 kg) of an ASBTI compound of formula I-VI (eg LUM-001 or LUM-002).

Active ingredient (LUM-001) 2.5 kg Lactose Monohydrate NF 47.5 kg Pregelatinized starch NF 18 kg Microcrystalline cellulose NF 17 kg croscarmellose sodium NF 6.5 kg Povidone K29/32 USP 8.5 kg Total 100 kg

Sieved ASBTI (2.5 kg), lactose monohydrate NF (47.5 kg), pregelatinized starch NF (18 kg), microcrystalline cellulose NF (17 kg), croscarmellose sodium NF (6.5 kg) and povidone K29/32 USP (8.5 kg) through a sieve #10 mesh The screened material was loaded into a 600 Collette mixer. Stirred for 6 min at low speed without grinder. The mixture from the previous step was loaded into a 20cc V-shell blender. feet (Model C266200). Magnesium stearate NF (0.5-1 kg) was screened through a 10 mesh sieve into a suitably prepared container. Approximately half of the magnesium stearate was added to each side of the RK blender and blended for 5 minutes. The mixture from the previous step was added to the Kikusui tablet press. The compression equipment can produce 50mg tablets, 75mg tablets and 100mg tablets.

Example 10 Effervescent Tablets

The active ingredient anhydrous monosodium citrate, sodium bicarbonate and aspartame are mixed and granulated by adding an alcoholic solution of polyvinylpyrrolidone. The resulting granules are dried, passed through a calibrator and the resulting granules are then mixed with sodium benzoate and fragrances. The granular material is compressed into tablets using an alternative press with 20 mm punches.

For tableting, you can also use a rotary press with 20 mm punches.

Active ingredient 4.4 mg Bicarbonate of soda 20.5 mg Monosodium citrate anhydrous 20.6 mg aspartame 1.25 mg Polyvinylpyrrolidone 1.0 mg sodium benzoate 1.5mg Orange fragrance IFF 29G44 0.5 mg Lemon fragrance IFF 29M194 0.25 mg Absolute alcohol for granulation

Example 11 Chewable tablets.

A 40% (w/w) alcoholic solution of Eudragit E100 was added with stirring to the active ingredient and mixed to form granules. The resulting granules were dried and sifted through a 16 mesh sieve.

Active ingredient 4.0 mg Eudragit E100 0.6 mg Direct Compression Sorbitol 18.8 mg direct compression lactose 15.6 mg Croscaramellose sodium type A 1.2 mg aspartame 0.3 mg anise fragrance 0.6 mg Perfume Butterscotch 0.6 mg magnesium stearate 0.6 mg Microcrystalline cellulose 4.7 mg (Avicel RN 102) 47 mg

The active ingredient granules and excipients outside the granules were placed in a conical blender and mixed thoroughly. The resulting mixture was unloaded from the blender and pressed on a suitable rotation

- 59 041458 body press with corresponding punches.

Example 12 Oral lozenges.

The active ingredient is introduced into a fluidized bed and an ethyl cellulose alcohol solution is sprayed onto it.

The excipients are screened and the coated active ingredient is homogenized with the excipients in a dry blender.

Distribution and tabletting is carried out on appropriate equipment with punches with a diameter of 16 mm and a radius of curvature of 20 mm.

The pressure is 15 kN±1. The hardness of the tablets thus obtained is 50 N±5. The destruction time in the mouth is 15-20 s.

Active ingredient (with ethyl cellulose) 4.0 mg Reticular polyvinylpyrrolidone 20.0 mg Starch 40 mg Sweetener 1.0 mg Perfume 1.0 mg magnesium stearate 1.0 mg 67.0 mg

Example 13 Preparation in the form of a powder.

A powder mixture of the active ingredient and polyvidone (5 parts by weight) is granulated with the addition of 7% purified water (w/w).

The pre-prepared mixture includes the following components: calcium carbasalate (in an amount corresponding to parts by weight of acetylsalicylic acid); anhydrous citric acid (168 parts by weight); sodium bicarbonate (232 parts by weight); lactose (1500 parts by weight; magnesium citrate (180 parts by weight); potassium benzoate (250 parts by weight). This mixture is then dry compacted.

The powder mixture of the active ingredient and the dry tamped premix and the following compounds are mixed: aspartame and artificial flavor (vanillin), which are in the form of a powder. A mixture of powders can be immediately packed into bags.

Example 14. Toffee candies.

Approximately 50 pounds of warm water was mixed with about 50 pounds of gelatin in a mixing vessel to form 100 pounds of gelled compound consisting of a homogeneous 50/50 mixture of water and gelatin. About 0.1-10 wt% sodium bisulfate was added to the gelled compound to reduce the pH of the gelled compound to about 3.5.

The gelled compound in a mixing vessel is mixed with about 6 lb of water, 38.3 lb of sucrose and 50 lb of corn syrup to form a candy slurry. If the active ingredient is a heat insensitive drug, then it is added to the candy suspension prior to processing. About 0.1 wt% sodium citrate should be added to the candy slurry to maintain the pH of the slurry at about 3.0-3.5.

The candy slurry is heated to a temperature of about 180°F before it is passed through the storage vessel to the static heater, in the static heater the candy slurry is heated to a temperature of about 240-245°F, resulting in dehydration of the slurry to a Brix solids content of about 78.

After heating, the candy is sent to a vacuum chamber, where it is still dehydrated to a Brix of about 80. After the chamber, the heated candy is placed in a dispenser, where about 1.5 wt.% Strawberry flavor and about 1 wt.% Red cabbage dye are added to it. To balance the flavor, about 0.1 wt.% citric and about 0.1 wt.% lactic acid are added to the heated candy.

After the introduction of the flavoring, the heated candy is placed in the machine module and then cured. After the candy has cured, it is placed in a cleaning drum to remove any starch that remains on the candy. After cleaning the candy, about 1 wt% fractionated coconut oil and about 1 wt% carnauba wax are added to the drum to coat the candies and prevent sticking.

- 60 041458

Active ingredient (5 mg) 5% Lactic acid 1% Lemon acid 1% sucrose 23.5% corn syrup 50.0% Gelatin 7% sodium bisulfate 0.1%-10% Perfume (natural/artificial) 1.5% Dye (natural/artificial) 1.0%

Example 15 Taste-Masking Liquid Formulations.

The aqueous pharmaceutical compositions of the present invention are formulated by preparing a mixture of hydroxyethyl cellulose dissolved in 50 ml of purified water and 0.5 ml of orange flavor with dibasic potassium phosphate and monobasic potassium phosphate (added from hot water mixture). Then add 4.0 mg of the active ingredient and mix until dissolved. Sodium hydroxide is added to adjust the pH from 6.7 to about 6.9.

Active ingredient 4.0 mg Hydroxyethylcellulose 10 mg Dibasic potassium phosphate 4.5 mg Monobasic potassium phosphate 4.5 mg Sodium hydroxide 0.1 ml orange fragrance 0.5 ml Purified water 50 ml

Alternative liquid formulations for oral administration are provided below. In each formulation below, 0.5-2% sweetener such as sucralose, mannitol, sucrose, and/or 0.5-2% flavor such as grape, cherry, chewing gum, orange, lemon, strawberry can be added. Polypropylene glycol can be replaced with one of the PEGs.

Components Concentration LUM001 0.02-4 mg/ml propylene glycol 10-300 mg/ml Water q.s. before 1 ml Components Concentration LUM001 0.02-4 mg/ml PEG 200 (or 300, 400, 600) 10-300 mg/ml Water, q.s. before 1 ml

Components Concentration LUM001 0.02-4 mg/ml propylene glycol 10-300 mg/ml Sodium lauryl sulfate 1-10 mg/ml Water q.s. before 1 ml

Components Concentration LUM001 0.02-4 mg/ml propylene glycol 10-300 mg/ml Poloxamer 188 1-10 mg/ml Water q.s. before 1 ml

Example 16 Sachet formulations.

For the manufacture of children's medicine in the form of a sachet, the following drug is used. You can add a sweetener in the amount of 0.5-2%, such as sucralose, mannitol, sucrose, and/or flavoring in the amount of 0.5-2%, such as grape, cherry, chewing gum, orange, lemon, strawberry. Sugar and sodium lauryl sulfate can be replaced with other surfactants.

- 61 041458

Components Concentration LUM001 0.05-10 mg Soluble diluent 10-500 mg Sugar 10-250 mg Sodium lauryl sulfate 5-50 mg Perfume 10-100 mg

Example 17 Experiments on animals.

Animal preparation. Obese male diabetic Zucker rats (ZDF/GmiCrl-fa/fa) were obtained from Charles River (Raleigh, NC) and maintained under controlled conditions (12:12 light-dark cycle, 24°C at 50% relative humidity) with free rodent access to food (Purina 5008, Harlan Teklad, Indianapolis, IN). All rats arrived at the age of seven weeks (±3 days). After a week of assimilation period, rats were anesthetized with isoflurane (Abbott Laboratories, IL), blood samples were taken from the tail vein at 9 am without fasting. The blood glucose level was determined with a glucometer (Bayer, Leverkusen, Germany). To obtain treatment balanced groups, ZDF rats were divided into six groups based on baseline glucose levels: vehicle (0.5% HPMC, 0.1% Tween80) and five doses of 264W94 (0.001, 0.01, 0.1, 1, 10 mg/kg). All treatments were administered orally via gavage to the animals twice a day for two weeks, and blood samples were taken from the tail vein at the end of each week at 9 am without fasting. Fecal samples were collected 24 hours later during the second week of treatment.

Determination of the parameters of clinical chemistry. Fecal non-esterified fatty acids (NEFA), bile acids, and bile acids were determined using an Olympus AU640 chemical analyzer (Beckman Coulter, Irving, TX).

Change in excretion of bile acids with faeces and concentration of bile acids in plasma. Depending on the dose of 264W94, oral administration increased the content of bile acids in faeces. Faecal bile acid concentrations increased 6.5-fold at an ED ₅₀ of 0.17 mg/kg compared to vehicle-treated rats. Fecal NEFA also slightly increased in rats treated with 264W94. On the contrary, the concentration of bile acids in the plasma of treated rats decreased depending on the dose of 264W94. See fig. 1.

Plasma bile acid concentrations in ZDF rats following escalating doses of SC-435 and LUM002. Male ZDF rats (n = 4) were administered vehicle SC-435 (1, 10, or 30 mg/kg) or LUM002 (0.3, 1, 3, 10, or 30 mg/kg) orally twice a day for 2 weeks. The concentration of bile acids in plasma was determined at the end of the second week. Plasma bile acids decreased for all doses of SC-435 and LUM002. Data are presented as means±SEM. See fig. 2.

Example 18 Animal studies on the effect of duration of action and time of onset of action of ASBTI at a single oral dose of LUM001 and postprandial total serum bile acids in beagle dogs.

Test compound: LUM001 - form I.

Dose preparation and administration: LUM001 was dissolved in water to a concentration required to administer a 0.2 ml/kg solution. The solutions were placed in Torpac Inc. size 13 Batch 594 gelatin capsules, East Hanover NJ, and administered orally.

Dogs. Male Beagles were obtained from Covance Research Products, Cumberland VA or Marshall Farms USA, Inc., North Rose NY. In these experiments, a total of 20 dogs aged 1-5 years with a body weight of 6.8-15.6 were used. Dogs were maintained on a 12 hour day/night cycle with limited access to food for 1 hour per day (Richman Standard Certified Canine Diet #5007, PMI Nutrition, Inc., St. Louis MO) from 7 am to 8 am. They were trained to fast-eat a specialty food for 20 minutes (1 can. 397g, Evanger's 100% Beef for Dogs, Evanger's Dog and Cat Food Co., Inc., Wheeling IL mixed with 50g spicy cheddar cheese).

Determination of total bile acids (SBA) in serum: SBA was determined by enzyme analysis. SBA values are presented as mg total bile acids per ml serum.

Control tests to determine increase and duration of increase in serum systemic bile acids: Previous work has shown that the SBA of the Beagle dog increases to a peak value one hour after feeding as above, remains at this level for 4 hours and then decreases. For a detailed determination at this level, 6 dogs were given test food and blood samples were taken for SBA determination at 30, 0, 30, 60, 65, 70, 80, 90, 120, 180, 240, 360, 480, 720, 1410 and 1440 minutes since feeding. The remaining food was removed 20 minutes after it was offered to the dogs for the first time. To determine how the level of elevated SBA values continued, 6 dogs were given food at 0 h and another half of this food 4 h after the first meal. Blood samples were taken at 0, 1, 2, 3, 4, 4.5, 6, 7, and 8 h. If possible, in the experiments with the test compound, each dog was used as a concurrent control of the condition itself, and the mean SBA values served as a reference.

- 62 041458 rental values against which all other mean values were compared.

Experiments to determine the moment of onset of LUM001 activity: LUM001 was administered orally at concentrations of 0, 0.01, 0.05, 0.2 and 1 mg/kg to dogs, n=6, 1 hour after feeding the standard experimental food. Blood samples for SBA determination were taken 30, 0, 30, 60, 65, 70, 80, 90, 120, and 180 minutes after feeding. Each dog served as its own control and mean SBA levels were compared to mean SBA levels at 60 min.

Table 1. Initial bile acid activity of LUM001 in canine serum

Serum Bile Acids (mg/ml) S D-5613 Time (min) Water, n=6 0.01 mg/kg, n=6 0.05 mg/kg, n=6 0.2 mg/kg, n=6 1 mg/kg, n=6 Average value SEM Average value SEM Average value SEM Average value SEM Average value SEM -thirty 22 03 15 about 1 14 0 1 24 05 21 02 0 20 03 14 0 1 2 1 06 19 02 28 04 thirty 69 2 1 58 25 68 23 9 1 21 76 18 60 17 8 32 14 6 28 104 12 19 1 27 138 14 65 16 6 36 13 9 24 12 2 17 14 9 17 13 5 14 70 16 2 19 14 1 22 12 0 16 16 7 23 15.4 18 80 16 1 23 12 8 18 100 13 14 3 22 12 1 14 90 15 2 28 11 0 20 88 16 9 8' 06 7 4' 12 120 155 36 10 8 17 6 5' 12 4 8' 03 thirty' 01 180 14 7 31 11 0 16 6 5 12 40 06 26* 02

All animals were fed for 0 min and dosed for 60 min;

*= p<0.5 compared to the 60 min value of the same two-tailed two-sample curve.

Experiments to determine the duration of action LUM001. In dogs, a single experimental meal causes an increase in postprandial SBA levels, which rises to a peak at 1 h post-feed and remains constant for another 3 h. Previous experiments (2) indicate that LUM001 remains active for more than 4.5 h. the duration of action of the ASBT inhibitor based on the postprandial SBA level, it is necessary that in the control situation the SBA level remain elevated and constant throughout the duration of the action of the compound, or that the compound is administered well before the increase in the postprandial level occurs and remains active in the period without food for long periods before feeding. Accordingly, to obtain a window of permanent growth of SBA used two alternative methods that could be used to determine the duration of action of ASBT inhibitors.

Method 1: Two Feeds for Sustained SBA Boosting. LUM001 was orally administered at a concentration of 0.05 and 0.2 mg/kg to 6 dogs 1 hour after a meal. 4 hours after the meal, a second portion of food was offered in the amount of half a portion of the first. It was also eaten quickly and completely, like the first portion, and this resulted in a sustained sustained level of SBA. Blood samples for SBA determination were taken 0, 1, 1.5, 2, 4, 4.5, 5, 5.5, 6, 6.5, 7, 7.5, and 8 h after the first feeding. Mean SBA levels were compared to mean SBA levels at 1 hour, with each dog serving as its own control. It is considered that the cessation of activity occurs at the moment when the average SBA value is slightly lower than the average value after 1 hour.

Table 2. Time of action of LUM001 on bile acids in canine serum

Serum bile acids (mcg/ml) SD-5613 Water, η =6 0.05 mg/kg , n=6 0.2 mg/kg. n=6 Time (hour) Average value SEM Average value SEM Average value SEM 0 25 05 14 0 1 13 0 1 1 13 1 1 h 92 18 11 1 15 1.5 9.6 2.0 9.1 0.6 2 14.6 1.2 6.7 0.6 3.8' 0.4 3 14.4 17 4 14.8 1.2 5 1' 0.7 2.5' 0.4 4.5 16.6 1.5 6.4 0.7 33' 0.6 5 15 8 20 7.0 0.7 3.1' 0.4 6 15 5 2 1 70 09 3.6' 0.7 7 14 4 25 74 08 3 9' 0.5 8 13 3 15 65 eleven 5.8* 0.8

All animals received a full meal at 0 h, were given oral test compound after 1 h, and were then fed a second half meal at 4 h. -test.

Method 2: Single feeding and extended interval between dosing and feeding. Alter

- 63 041458 natively 6 dogs were administered orally water or LUM001 at a concentration of 0.05 mg/kg 1.5 hours before meals or 0.05 or 0.2 mg/kg 2 hours before meals. This resulted in the elevated plateau shifting over time from the time of dosing. Blood samples for SBA determination were taken immediately before dosing (0 or 0.5 h) after feeding (2 h), 2.5, 3, 4 and 5 h after feeding. This allowed activity to be determined up to 5.5 and 6 hours post-dose without a second feeding to the dogs. Mean SBA levels were compared with corresponding mean SBA levels in control animals given water. The termination of activity is considered to occur at the first time point at which the SBA mean is not significantly below the corresponding control mean.

Table 3. Time of action of LUM001 on bile acids in canine serum

Serum bile acids (mcg/ml) Time of dose administration Feeding time 2 hour 0.5 hour 2 hour Ochas 2 hour hour 2 hour SD-5613 Water, η 1=6 0.05 mg/kg, n=9 0.05 mg/kg, n=9 0.2 mg/kg, g 1=6 Time (hour) Average Average Average Average meaning SEM meaning SEM meaning SEM meaning SEM 0 1.7 0.1 13 0.1 0.5 1.8 03 2 20 03 1.7 01 20 0 5 17 03 2.5 6.9 2.1 2.5 0.6 3 17 8 3.2 9.7 2.6 9.0* 1.4 4.1* 0.6 4 15 5 3.6 124 2.0 108 1.2 6.5* 0 8 5 14.7 3.1 11.6 24 10.6 0.9 7.9* 1.1

*p<0.05 compared to water treatment in a two-tailed two-sample t-test without the assumption of equal variances.

Conclusion. In a canine SBA model, a dose of ED ₅₀ (0.2 mg/kg) of LUM001 administered orally 1 hour post-feeding markedly reduced serum bile acid levels within 30 minutes post-dose, and this level remained significantly reduced for at least 6 h. In comparison, the threshold dose of 0.05 mg/kg significantly reduced the level of SBA for about 1-2 hours after dosing, but the significant decrease did not persist beyond 3 hours after dosing. Increasing the dose above the ED ₅₀ level by 1 mg/kg did not lead to a decrease in the time of onset of action and a significant decrease in SBA and maintained maximum inhibition for 2 hours after dosing. When LUM001 was administered 2 hours before feeding, a dose of 0.2 mg/kg was needed to achieve a marked effect, which was maintained for at least 2-3 hours after feeding. The results of this study indicate that the presence of food in the GI tract has a strong effect on the pharmacodynamic activity of the ASBT inhibitor, most likely by changing the residence time of the drug in the small intestine.

Example 19 Randomized, double-blind, placebo-controlled study of the safety, tolerability, pharmacokinetics and pharmacodynamics of increasing oral doses of LUM001 in healthy patients.

A phase 1 study of escalating multiple oral doses of LUM001 in healthy patients was conducted in a randomized, double-blind, placebo-controlled manner. This study was conducted at one center. 13 LUM001 dosing groups were used: 10, 20, 60, 100, and 20 mg every morning (qAM) (2) (i.e. the second time regimen was tested during the study), 5 mg every evening (qPM), 0.5, 1, 2.5, 5, 2.5 (2), 5 (2) 0.5-5 mg qAM dose adjustment. The bulk of the dosing groups included patients who were treated with the respective placebo. The graphs show data for the 0.5 (n=16), 1.0 (n=8), 2.5 (n=8), 5.0 (n=8), and 10 mg (n=8) dose groups.

For each qAM dosing group, LUM001 or placebo was administered every day for the duration of treatment (28 days) just prior to the morning feeding at approximately 08:00 and thereafter, blood was collected for analysis as needed.

Serum bile acid analysis (SBA). On day 1, blood was taken to determine the baseline SBA value approximately 30 minutes before and after breakfast and 30 minutes after lunch and dinner. During treatment, samples for analysis were taken on days 2, 14 or 28 (data on day 14 are shown in Fig. 3) at -30, 30, 60, 120 and 240 minutes after each of the 3 meals. Approximately 3 ml of venous blood was collected for each sample by venopuncture or through a venous catheter plug.

SBAs were analyzed as part of routine clinical analysis of serum samples at each time point.

Analysis of bile acids in faeces. Fecal samples were taken for all dosing groups except for the dose titration group: 2.5 (2) and 5 mg (2) from days 9 to 14 and from days 23 to 28 (the data obtained are shown in Fig. 4). Excreta collected over the 24 hours from days 9 to 14 and from days 23 to 28 were quantified by the Pharmacia method. Faeces were collected in a collection container 24 hours in advance, starting at 08:00 and ending 24 hours later. This procedure was performed from days 9 to 14 and from 23 to 28 days with new containers

- 64 041458 for collection during each 24-hour period. The weight of each 24 hour fecal collection was recorded on CRFs. Prior to analysis, the samples were stored in 24-hour containers frozen to about -80°C.

Aliquots of each 24-hour fecal sample collected from days 23 to 28 were pooled, homogenized and analyzed for bile acids by the ANAPHARM method. Bile acids analyzed include chenodeoxycholic acid, cholic acid, deoxycholic acid, and lithocholic acid.

Conclusion. The results obtained showed a significant decrease in the content of bile acids in the serum and a marked increase in the amount of bile acids in the faeces.

Example 20 Study of the efficacy of ASBTI in reducing serum bile acids in children.

LUM001 was administered to 40 patients aged 18 years. The table shows the characteristics of five children who received LUM001. The drug was administered once daily (QD) in the morning for fourteen days. Levels of systemic exposure to LUM001 were determined on the eighth day and confirmed that the drug was minimally absorbed in children. These doses are close to those used to treat children with cholestatic liver disease.

Table 4 Pharmacokinetics of LUM001 in children (Study NB-00-02-014)

Patient number Treatment LUM001 (mg) Floor Dose mcg/kg Mean drug exposure in serum Average serum drug exposure (ng/ml) 0309 1.0 HUSBAND 35.0 0.0 0304 1.0 HUSBAND 24.3 0.0 0308 1.0 HUSBAND 28.9 0.0 0410 2.5 WOMAN 42.0 0.0 0510 5.0 HUSBAND 168.4 0.0

The effectiveness of LUM001 was determined in children and adolescents at the age of eighteen years by measuring the amount of serum bile acids eight days after dosing. Serum bile acid levels were determined thirty minutes before the next dose at approximately 8 am. The child was not fed for 12 hours prior to the collection of this sample, which was considered the level of content of bile acid in the fasting serum. After breakfast, serum bile acids were determined for up to 4 hours (from 8 hours to noon) and the serum bile acid concentration was determined. In general, LUM001 has been shown to lower peak serum bile acid levels both on an empty stomach and after a meal (see table). Table 5 shows that placebo patients had an average serum bile acid level of 8.6 µmol/l and 11.9 µmol/l after meals. In patients treated with LUM001, these values were 6.5 µmol/l and 9.2, respectively, indicating a decrease of 24 and 23% (see Fig. 5).

Table 5. Fasting SBA and post-meal morning peak in children

Patients 301 307 405 408 508 304 308 309 401 510 Dose of drug (mg) placebo placebo placebo placebo placebo 1 1 1 2.5 5 Bile acid in fasting serum (µmol/l) 9.1 7.4 10.5 8.3 7.7 5.6 6.8 6.9 6.0 7.4 Morning peak after meals (µmol/l) 11.9 10.7 13.1 13.4 10.4 8.4 9.3 10.0 6.8 11.3

Example 21 Clinical testing of the efficacy of ASBTI in the treatment and/or improvement of symptoms of cholestasis or cholestatic liver disease in children.

This study aims to determine the effectiveness of ASBTI treatment in children suffering from cholestasis or cholestatic liver disease.

Selected children under the age of 12 years who were clinically diagnosed with cholestasis or cholestatic liver disease. Patients were diagnosed with symptoms such as jaundice, chronic pruritus, a general increase in serum bile acids/bilirubin.

Patients with life-threatening kidney disease, cardiovascular disease, or malformations were excluded.

Patients were administered a daily oral dose of compound LUM001 formulated for release in the distal ileum. Alternatively, any of the following compounds may participate in clinical testing: 264W94; SAR548304B; SA HMR1741; 1,1-dioxo-3,3-dibutyl5-phenyl-7-methylthio-8-(N-[(R)-α-[N-(2-sulfoethyl)carbamoyl]-4-hydroxybenzyl]carbamoylmethoxy)- 65 041458

2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine; 1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N-[(R)-α-[N((S)-1-carboxy-2-(R)-hydroxypropyl )carbamoyl]-4-hydroxybenzyl]carbamoylmethoxy)-2,3,4,5tetrahydro-1,2,5-benzothiadiazepine; 1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N-[(R)-α-[N-((S)-1carboxy-2-methylpropyl)carbamoyl]-4 -hydroxybenzyl]carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine; 1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N-{(R)-α-[N-((S)-1-carboxypropyl)carbamoyl]-4-hydroxybenzyl }carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine; or 1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-[N-((R)-α-carboxy-4-hydroxybenzyl)carbamoylmethoxy]-2,3,4,5- tetrahydro-1,2,5-benzothiadiazepine.

The primary endpoint identified the proportion of patients who showed improvement in major signs and symptoms, eg jaundice, total elevation of bile acids/salts and/or serum bilirubin, pruritus.

Example 22 Clinical testing of the efficacy of ASBTI in the treatment and/or symptomatic relief of progressive familial intrahepatic cholestasis 1 (PFIC-1).

This study aims to determine the efficacy of ASBTI in the treatment of children with PFIC1.

Patients with genetically diagnosed abnormalities in the ATP8B1, ABCB11 or ABCB4 genes, as well as PFIC-1, are included in this study.

Inclusion criteria include severe itching (more severe than grade II); lack of response to ursodiol; own liver; genetic or immunohistochemical features consistent with PFIC1 or Alagille syndrome; informed consent; age 12 months or older.

Criteria for exclusion include chronic diarrhea requiring IV fluids and nutrients; surgery for enterohepatic circulation or decompensated cirrhosis (RT > 16 s, alb < 3.0 g/dl, ascites, diuretic therapy, venous bleeding, encephalopathy.

Patients were administered a daily oral dose of compound LUM001 formulated for release in the distal ileum. Alternatively, any of the following compounds may participate in clinical testing: 264W94; SAR548304B; SA HMR1741; 1,1-dioxo-3,3-dibutyl5-phenyl-7-methylthio-8-(N-[(R)-α-[N-(2-sulfoethyl)carbamoyl]-4-hydroxybenzyl]carbamoylmethoxy)2,3 ,4,5-tetrahydro-1,2,5-benzothiadiazepine; 1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N-[(R)-α-[N((S)-1-carboxy-2-(R)-hydroxypropyl )carbamoyl]-4-hydroxybenzyl]carbamoylmethoxy)-2,3,4,5tetrahydro-1,2,5-benzothiadiazepine; 1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N-[(R)-α-[N-((S)-1carboxy-2-methylpropyl)carbamoyl]-4 -hydroxybenzyl]carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine; 1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N-{(R)-α-[N-((S)-1-carboxypropyl)carbamoyl]-4-hydroxybenzyl }carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine; or 1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-[N-((R)-α-carboxy-4-hydroxybenzyl)carbamoylmethoxy]-2,3,4,5- tetrahydro-1,2,5-benzothiadiazepine.

At a stage 1 study within 4 weeks of the results of increasing the dose to determine the minimum tolerated dose by the patient. Dose 1: 14 mcg/kg/day for 7 days; dose 2: 35 mcg/kg/day for 7 days; dose 3; 70 mcg/kg/day for 7 days; dose 4: 140 mcg/kg/day for 7 days.

Stage 2 is a double-blind, placebo-controlled cross-over study. Patients are randomized to the maximum tolerated dose or placebo for 8 weeks, followed by a 2-week drug holiday and a crossover study to determine an alternative regimen for 8 weeks.

The main expected outcome is the proportion of patients who show improvement in major signs and symptoms, eg jaundice, serum bile acids/salts and/or bilirubin levels, pruritus.

Example 23 Clinical testing of the efficacy of ASBTI in the treatment and/or improvement of symptoms of benign recurrent intrahepatic cholestasis or cholestatic liver disease (BRIC).

The aim of this study is to determine the effect of a non-systemic suspension of ASBTI in the treatment of BRIC. The pH-released ASBTI suspension of ASBTI can also be administered to the patient once a day.

Select children with genetically diagnosable abnormalities in the ATP8B1, ABCB11 or ABCB4 genes and with symptoms of non-chronic but recurrent cholestasis or cholestatic liver disease.

Patients were administered a daily oral dose of compound LUM001 formulated for release in the distal ileum. Alternatively, any of the following compounds may participate in clinical testing: 264W94; SD5613; SAR548304B; SA HMR1741; 1,1-dioxo-3,3dibutyl-5-phenyl-7-methylthio-8-(N-[(R)-α-[N-(2-sulfoethyl)carbamoyl]-4-hydroxybenzyl]carbamoylmethoxy)-2, 3,4,5-tetrahydro-1,2,5-benzothiadiazepine; 1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8(N-[(R)-α-[N-((S)-1-carboxy-2-(R)-hydroxypropyl )carbamoyl]-4-hydroxybenzyl]carbamoylmethoxy)- 66 041458

2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine; 1,1-dioxo-3,3-dubutyl-5-phenyl-7-methylthio-8-(N-[(R)-α-[N((S)-1-carboxy-2-methylpropyl)carbamoyl]- 4-hydroxybenzyl]carbamoylmethoxy)-2,3,4,5-tetrahydro1,2,5-benzothiadiazepine; 1,1-dioxo-3,3-dubutyl-5-phenyl-7-methylthio-8-(N-{(R)-α-[N-((S)-1-carboxypropyl)carbamoyl]-4-hydroxybenzyl }carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine;

or 1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-[N-((R)-α-carboxy-4-hydroxybenzyl)carbamoylmethoxy]-2,3,4,5- tetrahydro-1,2,5-benzothiadiazepine. The main expected outcome is the proportion of patients showing improvement in major signs and symptoms, eg jaundice, bile acid/salt and/or serum bilirubin levels, pruritus.

Example 24 Clinical testing of the efficacy of ASBTI in the treatment and/or amelioration of symptoms of cholestasis or cholestatic liver disease associated with total parenteral nutrition (TPN-AC).

The aim of this study is to determine the effect of non-systemic administration of ASBTI suspension in the treatment of TPN-AC. The pH-released ASBTI suspension of ASBTI can also be administered to the patient once a day.

Select children with clinically diagnosed TPN-AC and associated symptoms.

Patients were administered a daily oral dose of compound LUM001 formulated for release in the distal ileum. Alternatively, any of the following compounds may participate in clinical testing: 264W94; SAR548304B; SA HMR1741; 1,1-dioxo-3,3-dibutyl5-phenyl-7-methylthio-8-(N-[(R)-α-[N-(2-sulfoethyl)carbamoyl]-4-hydroxybenzyl]carbamoylmethoxy)2,3 ,4,5-tetrahydro-1,2,5-benzothiadiazepine; 1,1-dioxo-3,3-dubutyl-5-phenyl-7-methylthio-8-(N-[(R)-α-[N((S)-1-carboxy-2-(R)-hydroxypropyl )carbamoyl]-4-hydroxybenzyl]carbamoylmethoxy)-2,3,4,5tetrahydro-1,2,5-benzothiadiazepine; 1,1-dioxo-3,3-dubutyl-5-phenyl-7-methylthio-8-(N-[(R)-α-[N-((S)-1carboxy-2-methylpropyl)carbamoyl]-4 -hydroxybenzyl]carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine; 1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-(N-{(R)-α-[N-((S)-1-carboxypropyl)carbamoyl]-4-hydroxybenzyl }carbamoylmethoxy)-2,3,4,5-tetrahydro-1,2,5-benzothiadiazepine; or 1,1-dioxo-3,3-dibutyl-5-phenyl-7-methylthio-8-[N-((R)-α-carboxy-4-hydroxybenzyl)carbamoylmethoxy]-2,3,4,5- tetrahydro-1,2,5-benzothiadiazepine. The main expected outcome is the proportion of patients showing improvement in major signs and symptoms, eg jaundice, bile acid/salt and/or serum bilirubin levels, pruritus.

Example 25 Clinical testing of the efficacy of LUM-001 in the treatment and/or amelioration of symptoms of FIC1 disease or Alagille syndrome.

Testing children suffering from FIC1 disease (n=15) or Alagille syndrome (n=20) aged 12 months and older.

Selection criteria include (1) severe pruritus (> grade II) without response to routine pharmacological therapy; (2) own liver; (3) genetic or clinical features consistent with FIC1 disease or genetic features of Alagille syndrome; and (4) informed consent.

Exclusion criteria include (1) chronic diarrhea requiring intravenous fluids or nutrients and/or its sequelae or (2) surgery to the enterohepatic circulation; (3) decompensated cirrhosis (PT > 16s, alb < 3.0 g/dl, ascites, diuretic therapy, venous bleeding, encephalopathy.

In Stage 1, doses of LUM-001 (adolescent/adult doses) were increased over 4 weeks to determine the maximum patient tolerated dose. Dose 1-14 mcg/kg/day for seven days; dose 2-35 mcg/kg/day for seven days; dose 3-70 mcg/kg/day for seven days; dose 4-140 mcg/kg/day for seven days.

Stage 2 is a double-blind, placebo-controlled cross-over study. Patients are randomized to the maximum tolerated dose or placebo for 8 weeks, followed by a 2-week washout and cross-over study to determine an alternative regimen for 8 weeks.

Stage 3 with unmasked therapy is possible.

Main Expected Result: Safety and tolerability of LUM-001.

Secondary endpoints: change in pruritus area, clinical findings, faecal bile acid excretion, serum bile acids, and serum 7a-hydroxy-4-cholesten-3-one (7aC4).

Baseline examination includes: FIC1 or Jagged 1 genotyping, complete history and physical condition, complete clinical test list, 72-hour fecal bile acid collection, serum bile acid level, bile acid synthesis marker (7aC4).

Stage 1 - baseline examinations (excluding genotyping, medical history and physical condition) are repeated at the end of each 7-day treatment period. Areas of itching are determined by the parents, the child (if possible), and clinicians at the beginning and end of each dose study.

Stage 2 - baseline examinations (excluding genotyping, medical history and physical condition) are repeated at the end of each 8-week treatment period.

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Claims (14)

Multiple doses of LUM-001 have been shown to be well tolerated: 2 weeks every day up to 5 mg/day (39 patients aged 10-17 years treated). While preferred embodiments of the invention have been shown and described herein, it will be apparent to those skilled in the art that these embodiments are exemplary only. Professionals will have many options, changes and substitutions that do not deviate from the spirit of the invention. It should be understood that various alternatives to the embodiments of the invention described herein may be practiced. The following claims are intended to define the scope of the invention, methods and structures within the scope of the claims, and their equivalents. CLAIM 1. A pediatric dosage form containing an apical sodium dependent transporter inhibitor (ASBTI), which is p-B and 'OH or a pharmaceutically acceptable salt thereof and a pharmaceutically acceptable excipient, wherein the dosage form is an oral liquid solution formulated for release in the distal ileum, and suitable for the treatment of cholestatic liver disease in children, wherein the cholestatic liver disease in children is progressive familial intrahepatic cholestasis (PFIC), Alagille syndrome (ALGS), childhood primary sclerosing cholangitis (PSC), or biliary atresia (VA). 2. The pediatric dosage form of claim 1, wherein the dosage form reduces serum bile acids or hepatic bile acids in a patient. 3. Children's dosage form according to any one of claims 1, 2, wherein the dosage form reduces by at least 20% the content of serum bile acids or hepatic bile acids in the patient. 4. The pediatric dosage form of claim 1, wherein the cholestatic liver disease in children is biliary atresia (BA). 5. The pediatric dosage form of claim 1, wherein the cholestatic liver disease in children is progressive familial intrahepatic cholestasis (PFIC), type 1 PFIC, type 2 PFIC, or type 3 PFIC. 6. The pediatric formulation of claim 1, wherein the cholestatic liver disease in children is Alagille syndrome (ALGS). 7. The pediatric dosage form of claim 1, wherein the cholestatic liver disease is primary sclerosing cholangitis (PSC). 8. Children's dosage form according to any one of claims 1 to 7, wherein the dose of ASBTI is from 1 μg/kg/day to 10 mg/kg/day. 9. Children's dosage form according to any one of claims 1 to 8, while the dose of ASBTI is from 5 μg/kg/day to 5 mg/kg/day 10. A pediatric dosage form according to any one of claims 1 to 9, wherein the dose of ASBTI is from 0.4 to 1.5 mg/day. 11. A pediatric dosage form according to any one of claims 1 to 9, wherein the dose of ASBTI is administered twice a day. 12. A pediatric dosage form according to any one of claims 1 to 11, wherein less than 10% ASBTI is absorbed systemically. 13. The pediatric dosage form of claim 1, wherein the pharmaceutically acceptable adjuvant is a diluent, a taste-masking agent, an antioxidant, a bulking agent, an acidifier, or combinations thereof. 14. Children's dosage form according to any one of claims 1 to 13, wherein the dose volume is from 5 to 50 ml. -