RU2818678C2 - Methods of treating chronic spontaneous urticaria using bruton tyrosine kinase inhibitor - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to methods of treating skin diseases. Disclosed is a method of treating chronic spontaneous urticaria (CSU), comprising administering to a subject in need thereof a daily dose of approximately 10 mg to approximately 100 mg of a compound of formula

(I),

where the term "approximately" means +/−10%.

EFFECT: invention provides safe and effective treatment of spontaneous chronic urticaria.

18 cl, 11 dwg, 10 tbl, 3 ex

Description

Field of technology to which the invention relates

The present invention relates to methods of treating skin diseases caused by basophils and mast cells, such as chronic spontaneous urticaria (CSU), using a Bruton's tyrosine kinase inhibitor.

BACKGROUND OF THE INVENTION

Urticaria is a heterogeneous group of diseases characterized by a pruritic urticaria and/or angioedema. Chronic urticaria is defined as urticaria that is present continuously or intermittently for more than 6 weeks ( Maurer M et al. (2013) Revisions to the international guidelines on the diagnosis and therapy of chronic urticaria. J Dtsch Dermatol Ges.; Bernstein JA, Lang DM , Khan DA, et al (2014) The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol 133(5):1270-7). Chronic urticaria is further divided into two subgroups: chronic spontaneous urticaria (CSU) and inducible urticaria (IU), with the latter including physical urticaria such as heat, cold or pressure urticaria, as well as specific variants such as cholinergic urticaria. CSU is defined as the spontaneous onset of pruritic blisters, angioedema, or both for more than 6 weeks due to known or unknown causes ( Zuberbier T, et al. (2018) The EAACI/GA(2) LEN/EDF/WAO Guideline for the definition , classification, diagnosis, and management of urticaria: the 2017 revision and update. Allergy 73(7):1393-1414 ). A combination of CSU with an inducible form of urticaria is possible, such as the commonly observed combination of symptomatic dermatographic urticaria and CSU.

Previously, all forms of chronic urticaria without a known trigger were called "chronic idiopathic urticaria" (CIU). Thanks to advances in the medical field, it is now known that autoantibodies can actually be detected in some of the previously considered “idiopathic” forms of urticaria. However, the daily intermittent occurrence of symptoms in such chronic urticaria with autoantibodies is still unpredictable and does not have an obvious trigger, causing symptoms to appear spontaneously. To properly reflect in terminology the fact that some of the previously considered "idiopathic" forms may in fact have detectable autoantibodies, this population is now referred to as chronic spontaneous urticaria (CSU) according to International guidelines ( Maurer M et al. (2013) ) Revisions to the international guidelines on the diagnosis and therapy of chronic urticaria. Zuberbier T, et al. (2018) The EAACI/GA(2) LEN/EDF/WAO Guideline for the definition, classification, diagnosis , and management of urticaria: the 2017 revision and update. The use of the expression "chronic idiopathic urticaria" in medical practice is no longer recommended. However, this new naming convention has not been implemented in all parts of the world, and in countries such as the United States, the patient population with chronic urticaria of nonspecific etiology or with unknown triggers is still characterized as having chronic idiopathic urticaria (CIU). According to the International Guidelines, this nosological unit is called CSU in this document for the sake of uniformity.

The lifetime risk of developing CSU is approximately 1.8%, and 20% of patients with CSU may still have the disease after 20 years ( Greaves M (2000) Chronic urticaria. J Allergy Clin Immunol; 105(4):664- 72; Zuberbier T, Balke M, Worm M, et al (2010) Epidemiology of urticaria: a representative cross-sectional population survey. Clin Exp Dermatol 35(8):869-73. Affected patients often present with a pruritic, urticaria-like rash with associated erythema and/or episodes of angioedema. Angioedema is reported to be associated with approximately 33-67% of cases of CSU (Juhlin L (1981) Recurrent urticaria: clinical investigation of 330 patients. Br J Dermatol; 104(4):369-81; Toubi E, Kessel A, Avshovich N , et al (2004) Clinical and laboratory parameters in predicting chronic urticaria duration: a prospective study of 139 patients. Allergy 59(8):869-73; Zuberbier T, Balke M, Worm M, et al (2010) Epidemiology of urticaria: a representative cross-sectional population survey. Clin Exp Dermatol; 35(8):869-73; Maurer M, Weller K, Bindslev-Jensen C, et al (2011) Unmet clinical needs in chronic spontaneous urticaria. force report. Allergy; 66(3):317-30). The classic skin lesion of urticaria is a wheal and redness with a pale, raised area of the lesion and surrounding erythema ranging from a few millimeters to several centimeters across, which usually occurs in groups and often coalesce to form large confluent lesions. CSU is associated with severe pruritus and has a major impact on the patient's well-being and quality of life, which appears to be comparable to the impact of severe coronary artery disease (Greaves MW (2003) Chronic idiopathic urticaria. Curr Opin Allergy Clin Immunol; 3(5):363 -8. Review; Powell RJ, Du Toit GL, Siddique N, et al (2007) BSACI guidelines for the management of chronic urticaria and angio-oedema. Clin Exp Allergy 37(5):631-50. Symptoms of urticaria and angioedema associated with urticaria negatively affect daily activity and sleep (O'Donnell BF, Lawlor F, Simpson J, et al (1997). The impact of chronic urticaria on the quality of life. Br J Dermatol; 136(2):197-201). Thus, in the management of patients with urticaria, outcomes from the patient's perspective (eg, DLQI) are important indicators of treatment ( Kaplan A., et al. (2013) Omalizumab in patients with symptomatic chronic idiopathic/spontaneous urticaria despite standard combination therapy. J Allergy Clin Immunol; 132(1):101-9; Maurer M et al. (2013) Revisions to the international guidelines on the diagnosis and therapy of chronic urticaria. (2018) The EAACI/GA(2) LEN/EDF/WAO Guideline for the definition, classification, diagnosis, and management of urticaria: the 2017 revision and update 73(7):1393-1414 ).

The pathogenesis of CSU is not fully understood. Up to 50% of CSU cases are associated with histamine-releasing autoantibodies to multiple antigens, including high-affinity IgE receptor (FcεRI) or IgE antibodies; however, the clinical significance of these autoantibodies is not clearly established, although there are suggestions that they may be involved in the pathogenesis of the disease (Kaplan AP (2002) Chronic urticaria--new concepts regarding pathogenesis and treatment. Curr Allergy Asthma Rep; 2(4):263 -4; Sabroe RA, Greaves MW (2006) Chronic idiopathic urticaria with functional autoantibodies: 12 years on. Br J Dermatol 154(5):813-9. It has also been suggested that basophils from patients with CSU may have distinct changes in FcεRIα-mediated degranulation, independent of any potential role of autoantibodies ( Eckman JA, et al. (2008) Basophil phenotypes in chronic idiopathic urticaria in relation to disease activity and autoantibodies J Invest Dermatol; 128(8):1956-63) .

Treatment of CSU is challenging, and non-sedating (second-generation) H1 antihistamines (H1-AH) are the mainstay of symptomatic therapy for CSU. Although H1-AH at approved doses provides relief to some patients, more than 50% of patients do not respond to H1-AH at standard doses. Even with a fourfold increase in dose compared to the approved dose, carried out in accordance with the second stage of the treatment algorithm according to the current International Guideline ( Zuberbier T, et al. (2018) The EAACI/GA(2) LEN/EDF/WAO Guideline for the definition, classification, diagnosis, and management of urticaria: the 2017 revision and update. Allergy 73(7):1393-1414 ), a significant proportion of patients do not experience control of urticaria symptoms ( Maurer M, Weller K, Bindslev-Jensen C, et al ). (2011) Unmet clinical needs in chronic spontaneous urticaria. A GA²LEN task force report. Allergy; Marrouche N, Grattan C (2014) Update and insights into treatment options for chronic spontaneous urticaria. Immunol; 10(3):397-403). For patients who fail to achieve disease control with quadruple doses of H1-AH, the third step of the International Guideline treatment algorithm is the addition of omalizumab, and if the response to omalizumab is insufficient, cyclosporine can be used as last-line therapy.

The strength of the experimental evidence for the effectiveness of leukotriene receptor antagonists (LTRA) in urticaria is low. With the advent of omalizumab (for off-label use), LTRAs are no longer recommended for the treatment of CSU refractory to H1 antihistamines ( Zuberbier 2018 ). Short courses (max. 10 days) of systemic corticosteroids may be added to third-level treatment regimens if required for exacerbations. Due to the adverse effects associated with chronic systemic exposure to corticosteroids, longer courses of treatment are not recommended. Other treatment options that were previously used, such as intravenous immunoglobulin G, dapsone, hydroxychloroquine, H2-antihistamines (H2-AH), methotrexate, and cyclophosphamide, have an unfavorable risk-benefit profile or a significant side effect profile and are no longer recommended for CSU therapy (Kaplan AP (2002) Chronic urticaria--new concepts regarding pathogenesis and treatment . Curr Allergy Asthma Rep; 2(4):263-4; Powell RJ, Du Toit GL, Siddique N, et al (2007) BSACI guidelines for the management of chronic urticaria and angio-oedema. Clin Exp Allergy; 37(5):631-50; Zuberbier T, et al. (2018) The EAACI/GA(2) LEN/EDF/WAO Guideline for the definition. , classification, diagnosis, and management of urticaria: the 2017 revision and update. Allergy 73(7):1393-1414 ).

Omalizumab is an approved therapeutic agent for the treatment of CSU refractory to standard treatment and demonstrates a favorable benefit-risk profile. It is a recombinant humanized monoclonal antibody of the IgG ₁ subclass that binds to IgE-specific epitopes within the C3 (FcεRI-binding) region of the IgE molecule, and its use is indicated in many countries for the treatment of poorly controlled moderate to severe asthma and CSU refractory to standard therapy. The exact mechanism of action of omalizumab in patients with CSU is unknown. For patients suffering from CSU, omalizumab is administered as an injection solution.

Despite the availability of treatments for CSU, there remains a high need in the medical field for new treatment options for subjects with CSU. Less than 40% of subjects with CSU treated with second-generation H1 antihistamines do not respond adequately to treatment ( Guillén-Aguinaga et al 2016, Br J Dermatol; 175(6):1153-65 ). Additionally, less than 50% of subjects treated with omalizumab achieve complete control of signs and symptoms of CSU ( Kaplan et al. 2016, J Allergy Clin Immunol; 137(2):474–81 ).

BRIEF DESCRIPTION OF THE PRESENT INVENTION

An object of the present invention is to provide a new method for treating or preventing skin diseases caused by basophils and mast cells, such as chronic spontaneous urticaria and atopic dermatitis, in a subject in need of such treatment, comprising administering to said subject a therapeutically effective amount of N -(3-(6- amino-5-(2-( N -methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide.

Therefore, disclosed herein are methods of treating chronic spontaneous urticaria (CSU) comprising administering to a patient in need of such treatment a daily dose of from about 0.5 mg to about 600 mg, preferably from about 10 mg to about 200 mg, or more preferably at a daily dose of about 10 mg to about 100 mg, N -(3-(6-amino-5-(2-( N -methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl )-4-cyclopropyl-2-fluorobenzamide, which is a compound of formula (I)

(I),

or a pharmaceutically acceptable salt thereof.

Also disclosed is N -(3-(6-amino-5-(2-(N-methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide; or a pharmaceutically acceptable salt thereof for use in the treatment of chronic spontaneous urticaria (CSU), wherein N -(3-(6-amino-5-(2-(N-methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro- 2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof is administered at a daily dose of from about 0.5 mg to about 600 mg, preferably at a daily dose of from about 10 mg to about 200 mg, and most preferably at a daily dose of from about 10 to about 100 mg.

BRIEF DESCRIPTION OF GRAPHIC MATERIALS

Figure 1 . Inhibitory effects of the compound of formula (I) in the reverse passive Arthus reaction.

Figure 2 . BTK occupancy in the spleen 5 hours after dosing.

Figure 3 . The compound of formula (I) inhibits PCA after sensitization with low doses of IgE.

Figure 4 . BTK occupancy in the spleen during low-dose IgE sensitization.

Figure 5. Blood concentration as a function of time for compound (I) after single increasing doses in the range of 0.5 mg - 600 mg.

Figure 6. Blood concentration as a function of time for compound (I) after multiple ascending doses in the range of 10 mg - 400 mg when administered dose q.d.

Figure 7. Blood concentration versus time for compound (I) after multiple ascending doses ranging from 100 mg bid to 200 mg bid.

Figure 8. Effect of food intake observed after a single oral dose of 60 mg of the compound of formula (I).

Figure 9. Arithmetic mean (SD) of the percentage of BTK occupancy in peripheral blood after a single dose of the compound of formula (I).

Figure 10. Median percentage inhibition of basophil activation as a function of the total daily dose of the compound of formula (I) on day 12 of administration of multiple increasing doses of the compound of formula (I).

Figure 11. Reduction in the size of blisters in the skin prick test with repeated increasing doses.

DETAILED DESCRIPTION OF THE INVENTION

Bruton's tyrosine kinase (BTK) is a cytoplasmic tyrosine kinase and a member of the TEC family of kinases. BTK is expressed in selected cells of the adaptive and innate immune system, including B cells, macrophages, mast cells/basophils, and platelets. BTK is required for signaling through the Fc epsilon receptor (FcεR1 for IgE) and activating Fc gamma receptors (FcγR for IgG), as well as through the B cell antigen receptor (BCR) and BTK inhibitors. BTK inhibitors such as ibrutinib are approved for the treatment of B-cell malignancies (Hendriks et al. 2014). Recently, it was demonstrated that BTK inhibition leads to inhibition of mast cell and basophil activation/degranulation in vitro and to a reduction in wheal size in skin prick tests in patients suffering from IgE-mediated allergies (Smiljkovic et al. 2017; Regan et al. 2017 ; Dispenza et al. Therefore, BTK inhibition is an attractive therapeutic concept for the treatment of various autoimmune and chronic inflammatory diseases, including rheumatoid arthritis, multiple sclerosis, systemic lupus erythematosus, chronic urticaria, atopic dermatitis, asthma and primary Sjögren's syndrome (Tan et al 2013; Whang and Chang 2014) .

N -(3-(6-Amino-5-(2-(N-methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide is described in WO2015/ 079417, filed June 4, 2015 (Patent Attorney Case Number PAT056021-WO-PCT). This compound is a selective, potent, irreversible covalent inhibitor of Bruton's tyrosine kinase (BTK).

According to the present invention, the present inventors have demonstrated that N -(3-(6-amino-5-(2-(N-methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl -2-Fluorobenzamide effectively inhibits basophil activation in healthy volunteers and in atopic subjects who exhibit a similar pathomechanism to CSU, as measured by the level of inhibition of increased CD63 expression. In addition, the present inventors have demonstrated that N -(3-(6-amino-5-(2-(N-methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl -2-fluorobenzamide reduces the size of blisters in a skin prick test.

Accordingly, the inventors of the present invention have now developed dosage regimens for the treatment of patients with CSU with the compound N -(3-(6-amino-5-(2-(N-methylacrylamido)ethoxy)pyrimidin-4-yl )-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof.

Definitions

For purposes of interpretation of this description, the following definitions will apply and, where appropriate, terms used in the singular will also include the plural and vice versa.

As used herein, the phrase "pharmaceutically acceptable" refers to those compounds, materials, compositions and/or dosage forms which, within the bounds of sound medical judgment, are suitable for use in contact with tissues of humans and animals without undue toxicity, irritation, allergic reaction or other problems or complications in accordance with an acceptable benefit-risk ratio.

Any formula given herein is also intended to represent unlabeled forms as well as isotopically labeled forms of the compounds. Isotopically labeled compounds have the structures depicted by the formulas given herein, except that one or more atoms are replaced by an atom having a selected atomic mass or mass number. Isotopes that may be included in the compounds of the present invention include, for example, isotopes of hydrogen, carbon, nitrogen, oxygen, fluorine, iodine and chlorine, such as ³ H, ¹¹ C, ¹³ C, ¹⁴ C, ¹⁵ N, ¹⁸ F and ³⁶ Cl. Accordingly, it should be understood that the present invention provides compounds in which one or more of any of the above isotopes are included, including, for example, radioactive isotopes such as ³ H and ¹⁴ C, or compounds in which non-radioactive isotopes are present, such as ² H and ¹³ C. Such isotopically labeled compounds are useful in metabolic studies (using ¹⁴ C), reaction kinetics studies (using, for example, ² H or ³ H), detection or imaging techniques such as positron emission tomography (PET ) or single photon emission computed tomography (SPECT), including in drug or substrate tissue distribution assays, or in radioisotope treatment of patients. In particular, the ¹⁸ F labeled compound may be particularly suitable for PET or SPECT studies. Isotopically labeled compounds can generally be prepared using conventional techniques known to those skilled in the art, for example, using suitable isotopically labeled reagents in place of the unlabeled reagent previously used.

The term "pharmaceutical combination" as used herein means a product that is obtained by mixing or combining more than one active ingredient. It should be understood that the pharmaceutical combination used herein includes both fixed and non-fixed combinations of active ingredients. The term "fixed combination" means that the active ingredients, eg, a compound of formula (I) or a pharmaceutically acceptable salt thereof and one or more combination partners, are administered to a patient simultaneously in the form of a single preparation or dosage form. The term then refers to a fixed dose combination in a single unit dosage form (eg capsule, tablet or sachet). Both the terms "unfixed combination" or "set of parts" mean that the active ingredients, for example a compound of the present invention and one or more combination partners and/or one or more additional agents, are administered or co-administered to a patient independently as separate preparations or simultaneously , either in parallel or sequentially without specific time restrictions, where such administration provides therapeutically effective levels of the two compounds in the patient's body, especially if these time intervals allow the combination partners to demonstrate a joint, such as additive or synergistic, effect. The term "unfixed combination" also applies to "cocktail therapy", for example the administration of three or more active ingredients. The term "unfixed combination" thus defines in particular the administration, use, composition or formulation in the sense that doses of the compounds described herein can be administered independently of each other, that is, simultaneously or at different points in time. It should be understood that the term "unfixed combination" also includes the use of a single product in conjunction with one or more fixed combination products, each independent formulation having varying amounts of the active ingredients contained therein. It should also be understood that the combination products described herein, as well as the term “unfixed combinations,” cover active ingredients (including the compounds described herein) where the combination partners are administered as entirely separate pharmaceutical dosage forms or as pharmaceutical formulations , which are also sold independently of each other. Instructions for use of the loose combination are provided or may be provided in packaging, such as a package insert, etc., or other information that is provided to physicians and/or medical personnel. Independent formulations or portions of a formulation, products or compositions may then be administered simultaneously or at specific intervals, meaning that each individual portion of the set of parts may be administered at different times and/or at the same or different time intervals for any portion of the set parts. In particular, the time intervals for dosing are selected such that the effect on the disease being treated when the parts are administered in combination is greater/greater than the effect obtained when the compound of formula (I) or a pharmaceutically acceptable salt thereof is used alone; thus, the compounds used in the pharmaceutical combination described herein are co-active. The ratio of total amounts of a compound of formula (I) or a pharmaceutically acceptable salt thereof and a second agent to be administered as a pharmaceutical combination may be varied or adjusted to better suit the needs of a particular subpopulation of patients being treated or the needs of a single patient, and different needs may be related to the age, gender, body weight, etc. of the patients.

The terms “co-administration” or “combination administration” or the like as used herein should be considered to include the administration of one or more compounds described herein together with a selected combination partner to a single subject in need thereof (e.g. patient or subject) and contemplate the inclusion of treatment regimens in which the compounds are optionally administered by the same route of administration and/or at the same time.

The term "pharmaceutical composition" as defined herein refers to a mixture (eg, solution or emulsion) containing at least one active ingredient or therapeutic agent to be administered to a warm-blooded animal, such as a mammal or human, to prevent or treat a specific disease or condition affecting a warm-blooded animal.

The term "therapeutically effective amount" of a compound (i.e., a compound of formula (I) or a pharmaceutically acceptable salt thereof) of the present invention refers to the amount of a compound of the present invention that will produce a biological or medical response in a subject (patient or subject), e.g. reducing or inhibiting the activity of an enzyme or protein, or reducing symptoms, alleviating conditions, slowing or inhibiting the progression of a disease, or preventing a disease, etc. The therapeutically effective dose of a compound, pharmaceutical composition, or combinations thereof depends on the patient's biological species, body weight, age, gender and the individual condition, disorder or disease being treated, or its severity. A physician, clinician, or veterinarian of ordinary skill can readily determine the effective amount of each of the active ingredients needed to prevent, treat, or inhibit the progression of the disorder or disease.

The dosage frequency may vary depending on the compound used and the particular condition being treated or prevented. In general, use of the minimum dose sufficient to provide effective therapy is preferable. Monitoring therapeutic efficacy in patients can generally be accomplished using assays appropriate for the condition being treated or prevented, as will be known to those skilled in the art.

As used herein, the terms "carrier" or "pharmaceutically acceptable carrier" include all possible solvents, dispersion media, coatings, surfactants, antioxidants, preservatives (eg, antibacterial agents, antifungal agents), isotonicity agents, absorption retardants , salts, preservatives, drugs, drug stabilizers, binders, excipients, disintegrants, lubricants, sweeteners, flavoring agents, coloring agents, etc., as well as combinations thereof, which will be known to those skilled in the art (See, for example, Remington's Pharmaceutical Sciences, 18th Ed. Mack Printing Company, 1990, pp. 1289-1329). Unless the conventional carrier is incompatible with the active ingredient, it is contemplated for use in therapeutic or pharmaceutical compositions.

As used herein, the term "subject" refers to an animal. Typically the animal is a mammal. Subject also refers to, for example, primates (e.g. humans, male or female), cows, sheep, goats, horses, dogs, cats, rabbits, rats, mice, fish, birds, etc. In certain embodiments, the subject is a primate. In a preferred embodiment, the subject is a human. The term "subject" is used interchangeably with "patient" when referring to a person.

As used herein, a subject is “in need of” treatment if, as a result of such treatment, such subject will benefit biologically, medically, or improve his or her quality of life.

As used herein, the phrase “patient population” means a group of patients.

The term “comprising” includes “including” as well as “consisting”, for example a composition “comprising” X may consist solely of X or may include something additional, such as X+Y.

The term "about" in relation to the numerical value of x means, for example, +/-10%. When used before a numerical range or list of numbers, the term "about" applies to each number in the series, for example, the phrase "about 1-5" should be interpreted as "about 1 - about 5", or, for example, the phrase "about 1, 2 , 3, 4" should be interpreted as "about 1, about 2, about 3, about 4, etc."

The term “treating” or “treating” is defined herein as the use or administration of a compound of the present invention (a compound of formula (I), or a pharmaceutically acceptable salt thereof, or a pharmaceutical composition containing said compound, to a subject or to an isolated tissue or line cells from a subject where the subject has a specific disease (eg, CSU), a symptom associated with a disease (eg, CSU), or a predisposition to developing a disease (eg, CSU) (if applicable), where the goal is a cure (if applicable ), delaying the onset of development, reducing the severity, alleviating, reducing one or more symptoms of a disease, improving the course of a disease, reducing or decreasing the manifestation of any associated symptoms of a disease or a predisposition to developing a disease. The term “treating” or “treating” includes treating a patient suspected of having a disease. the presence of a disease, as well as sick patients and patients who have been diagnosed as suffering from a disease or medical condition, and includes suppression of clinical relapse.

As used herein, the phrases “naïve to systemic treatment for CSU” or “treatment naïve” refer to a patient with CSU who has not previously been treated with a systemic treatment, such as cyclosporine A, montelukast, H1 antihistamines ( H1-AH), H2-antihistamine (H2-AH) and leukotriene receptor antagonist (LTRA), biological agent (eg, omalizumab), etc., for the treatment of CSU. Systemic agents (i.e., agents administered orally, by injection, etc.) differ from locally acting agents (e.g., topical agents and phototherapy) in that systemic agents have a systemic (whole-body) effect when delivered to the patient . In some embodiments of the disclosed methods, regimens, uses, kits, and pharmaceutical compositions, the patient has not previously been administered a systemic treatment for CSU.

As used herein, the phrase "previously treated with a systemic agent for CSU" is used to refer to a patient who has previously been treated with a systemic agent for CSU. Such patients include patients previously treated with H1 antihistamines or biological agents, such as omalizumab, and patients previously treated with non-biological agents, such as cyclosporine. In some embodiments of the present invention, the patient has previously been administered a systemic agent to treat CSU. In some embodiments, the patient has previously been administered a systemic agent for the treatment of CSU (eg, cyclosporine), but the patient has not previously been administered a systemic biological drug (i.e., a drug produced by a living organism, such as antibodies, decoy receptors, etc. . e) for the treatment of CSU (eg, omalizumab). In this case, the patient is referred to as "biologically untreated." In some embodiments, the patient is naïve to treatment with the biological agent.

As used herein, the terms “selected” and “selected” when used in relation to a patient mean that a particular patient is specifically selected from a larger group of patients based on the fact that the particular patient meets predetermined criteria. Likewise, "selective treatment" refers to the provision of treatment to a patient having a particular disease, wherein the patient is specifically selected from a larger group of patients based on the particular patient meeting a predetermined criterion. Likewise, "selective administration" refers to the administration of a drug to a patient that is specifically selected from a larger group of patients based on the fact that the particular patient meets a predetermined criterion. By “selective,” “selective treatment,” and “selective administration,” it is meant that a patient is provided with personalized therapy based on the patient's personal history (eg, prior therapeutic interventions, such as prior biologic treatment), patient biology (eg, specific genetic markers) ) and/or manifestation in the patient (eg, failure to meet certain diagnostic criteria), rather than applying a standard treatment regimen based solely on the patient's membership in a larger group. Selection, as used in the context of this document, does not refer to randomly treating a patient who meets a particular criterion, but rather refers to an informed decision made regarding the administration of a drug to a patient based on the patient meeting a particular criterion. Thus, selective treatment/administration differs from standard treatment/administration, which provides delivery of a specific drug to all patients with a specific disease, regardless of their personal history, disease manifestations and/or biological characteristics. In some embodiments, a patient has been selected for treatment based on the presence of a CSU.

Embodiments of the Present Invention

Chronic urticaria and the effectiveness of treatment in accordance with the present invention

The disclosed BTK inhibitor, i.e., a compound of formula (I) or a pharmaceutically acceptable salt thereof, can be used in vitro, ex vivo, or formulated into pharmaceutical compositions and administered in vivo for the treatment of patients with CSU (eg, human patients).

Urticaria is a heterogeneous group of diseases characterized by a pruritic urticaria and/or angioedema.

Chronic urticaria is defined as urticaria that is continuously or intermittently present for more than 6 weeks (Maurer, et al 2013, Bernstein, et al 2014). Chronic urticaria is further divided into two subgroups: chronic spontaneous urticaria (CSU) and inducible urticaria (IU), with the latter including physical urticaria such as heat, cold or pressure urticaria, as well as specific variants such as cholinergic urticaria. CSU is defined as the spontaneous onset of pruritic wheals, angioedema, or both for ≥ 6 weeks due to known or unknown causes (Zuberbier, et al. 2018). A combination of CSU with an inducible form of urticaria is possible, such as the commonly observed combination of asymptomatic dermatographic urticaria and CSU.

The effectiveness of CSU treatment is assessed using various known methods and instruments that provide measurements to determine CSU disease status and/or clinical response in CSU. Some examples include, for example, the Urticaria Patient Daily Diary (UPDD), Angioedema Activity Score (AAS), Weekly Urticaria Severity Score (HSS7), Weekly Pruritus Severity Score (ISS7), Weekly Urticaria Activity Score (UAS7), and Improvement health-related quality of life measured by the Dermatology Life Quality Index (DLQI).

Urticaria Patient Daily Diary (UPDD)

The UPDD provides a Urticaria Activity Assessment (UAS) that assesses severity of itching and number of urticaria, use of rescue medications, effects on sleep and activity, incidence of angioedema, its treatment, and records calls to a specialist twice daily. health care (HCP).

The components are presented in Table 1 and the corresponding weekly scores.

are described below.

Table 1. UPDD

Diary component Evaluation time Urticaria Activity Score (UAS) In the morning and in the evening - Severity of itching - Number of nettle rash elements Effect on sleep in the morning In the morning Effect on daily activities in the evening In the evening Use of rescue medications in the evening In the evening Angioedema
- Has the patient had an episode?
- If the patient had an episode, how was it treated? Calling a healthcare professional In the evening

In some embodiments, when a population of patients with CSU is treated in accordance with the disclosed methods, the patient achieves an improved UPDD score.

Weekly Nettle Rash Severity Score (HSS7)

A rating of the severity of the nettle rash (blisters), determined by the number of nettle rash features, is recorded by the subject twice daily in their electronic diary on a scale from 0 (none) to 3 (>12 nettle rash features/12 hours; Table 2). The weekly score (HSS7) was obtained by summing the average daily scores over the 7 days preceding the visit. Thus, the possible range of weekly scores was 0 to 21.

Table 2. Severity rating of nettle rash

Grade Number of nettle rash elements (blisters) (every 12 hours) 0 None 1 1-6 elements of nettle rash/12 hours 2 7-12/12 hours 3 12 elements of nettle rash/12 hours

In some embodiments, if a population of patients with CSU is treated in accordance with the disclosed methods, the nettle rash severity score (HSS7) improves by at least 5 points. Moreover, compared with the placebo group, the difference between the treatment group and the placebo group is at least 4 points, preferably at least 5 points. In one embodiment, if the patient is treated in accordance with the disclosed methods, the nettle rash severity score (HSS7) is less than 6, preferably less than 4, preferably less than 2 points, and most preferably the HSS7 score is 0.

Weekly Pruritus Severity Score (ISS7)

The degree of intensity of itching is recorded by the subject twice a day in his electronic diary on a scale from

0 (absent) to 3 (strong) (Table 3). The weekly score (ISS7) was obtained by summing the average daily scores over the 7 days preceding the visit. Thus, the possible range of weekly scores was 0 to 21.

Table 3. Rating of itching severity

Grade Pruritis (itching) (every 12 hours) 0 Absent 1 Lightweight (minimal feel, easy to carry) 2 Moderate (distinct sensation, disturbing but tolerable) 3 Strong (difficult to bear)

In some embodiments, if a population of patients with CSU is treated in accordance with the disclosed methods, the Pruritus Severity Score (ISS7) improves by at least 5 points. Moreover, compared with the placebo group, the difference between the treatment group and the placebo group is at least 4 points, preferably at least 5 points. In one embodiment, if the patient is treated in accordance with the disclosed methods, the Pruritus Severity Score (ISS7) is less than 6, preferably less than 4, preferably less than 2, and most preferably the ISS7 score is 0.

Weekly Urticaria Activity Score (UAS7)

The UAS7 score is the sum of the HSS7 and ISS7 scores. Possible weekly range

UAS7 scores range from 0 to 42 (maximum activity).

In some embodiments, a patient with CSU achieves an improved UAS7 score in response to treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof.

In a preferred embodiment, when treated with the method of the present invention, a patient with CSU experiences a reduction in the number of urticaria and a reduction in pruritus, characterized by a UAS score of 7≤6, by week 4 or week 12.

In the most preferred embodiment, when treated with the method of the present invention, the patient with CSU is completely free of urticaria and pruritus by week 12, which is scored as UAS7=0.

Moreover, compared with the placebo group, the difference between the treatment group and the placebo group is at least 8 points, preferably at least 10 points.

Weekly sleep assessment

The effect on sleep is assessed by the subject once a day in the morning in an electronic diary. It

scored on a scale from 0 to 3. Weekly scores range from 0 to 21 (Table 4).

Table 4: Sleep Impact Assessment

Grade Effect on sleep 0 No influence 1 Mild, negligible effect on sleep 2 Moderate, occasional awakenings, some effect on sleep 3 Significant, frequent awakening, strong impact on sleep

In some embodiments, if a population of patients with CSU is treated in accordance with the disclosed methods, the sleep impact score improves by at least 5 points. In a preferred embodiment, if the patient is treated in accordance with the disclosed methods, the sleep effect score is less than 6, preferably less than 4, preferably less than 2 points, and most preferably the sleep effect score is 0 points.

Weekly assessment of impact on activity

The impact on daily activities is rated by subjects on a scale from 0 to 3 once a day in the evening in an electronic diary. Daily activities may include work, school, sports, hobbies, and activities with friends and family. Weekly activity impact scores range from 0 to 21 (Table 5).

Table 5. Assessment of impact on daily activities

Grade Impact on daily activities 0 No influence 1 Mild, negligible impact on daily activities 2 Moderate, some impact on daily activities 3 Significant, strong impact on daily activities

In some embodiments, if the CSU patient population is treated in accordance with the disclosed methods, the activity impact score improves by at least 5 points. In a preferred embodiment, if the patient is treated in accordance with the disclosed methods, the weekly activity effect score is less than 6, preferably less than 4, preferably less than 2 points, and most preferably the weekly activity effect score is 0 points.

Use of emergency H1 antihistamines

The number of rescue medication tablets taken in the last 24 hours to control conditions such as itching or urticaria is recorded by the subject once daily in the evening in an electronic diary. Daily dose

rescue drug is calculated as the number of tablets per day multiplied by the dose

each tablet, then the weekly dose of the rescue drug is calculated as the sum of the daily dose for 7 days.

In some embodiments, if a population of patients with CSU is treated in accordance with the disclosed methods, the number of doses per week of the rescue drug is reduced. In one aspect of this embodiment, it is no longer necessary to use the rescue drug.

Number of telephone calls made to a doctor or nurse

Number of telephone calls made to a physician, nurse, or nurse practitioner due to the subject's skin condition

recorded by the subject once a day in an electronic diary.

Angioedema Activity Assessment (AAS)

The AAS is recorded by the subject once daily in the evening in an electronic diary. This validated tool assesses the incidence and severity of episodes of angioedema (Weller et al (2013), Allergy 68(9): 1185-92). The incidence of angioedema is recorded by the subject once daily in the evening in an electronic diary. Activities and/or treatments associated with such angioedema events are also recorded in the electronic diary as follows (multiple responses possible):

Did not do anything

Have taken prescription or over-the-counter medications

Call your doctor, nurse, or nurse practitioner

Visited your doctor, nurse, or nurse practitioner

Went to the emergency room at the hospital

Was hospitalized

If subjects answer “no” to the introductory question, the AAS score for that day is 0. If the answer to the introductory question is “yes,” the subject continues to answer questions about duration, severity, impact on daily functioning, and occurrence of angioedema.

Each response box is assigned a score from 0 to 3. AAS Score in this Study

presented as the weekly AAS score (AAS7). The minimum and maximum possible scores on the AAS7 scale are 0 and 105, respectively.

A higher score indicates higher severity.

In some embodiments, if a population of patients with CSU is treated in accordance with the disclosed methods, the patients achieve a reduction in AAS7 score, preferably to an AAS7 score of 0, by week 12 of treatment. In another aspect of this embodiment, the patient achieves an AAS7 score of zero over several weeks, eg, during at least 4 weeks of treatment, at least 8 weeks of treatment, or all 12 weeks of treatment.

In some embodiments, if the CSU patient population is treated according to the disclosed methods, the patients achieve ≥95.5% angioedema-free days (AAS=0) from week 4 to week 12.

Moreover, when compared with the placebo group, the difference between the treatment group and the placebo group is at least 6%.

Dermatological Life Quality Index (DLQI)

The Dermatology Life Quality Index (DLQI) is a measure of quality of life (QoL) related to skin diseases (Finlay et al 1994). The DLQI has been validated in patients aged 16 years and older. Subjects rate their dermatological symptoms as well as the impact of their skin condition on various aspects of their life, taking into account the previous 7 days.

A total score is calculated and ranges from 0 to 30 (higher scores indicate worse disease-related QoL). Domain scores are calculated for the following: symptoms and feelings (0-6), activities of daily living

(0-6), leisure (0-6), work and school (0-3), personal relationships (0-6), treatment (0-3).

The overall range of DLQI scores was divided into specific scoring zones (Hongbo et al 2005) and validated against

their meaning/relevance for patients is as follows.

Table 6. DLQI assessment zones and their impact on the patient's life

DLQI Zone Score Value

0-1 No impact on patient's life 2-5 Minor impact on patient's life 6-10 Moderate impact on patient's life 11-20 Very big impact on the patient's life 21-30 Extremely large impact on the patient's life

A DLQI score > 10 represents a very large impact on patients' lives and is a rationale for prescribing a biologic agent, such as for psoriasis (Kaplan et al. 2005). DLQI questionnaires are completed at randomization (day 1), week 4 (day 29) and week 12 (day 85) in an electronic diary.

The DLQI assessment should be performed before any other assessment and before administration of a compound of formula (I) or a pharmaceutically acceptable salt thereof.

In some embodiments, a patient with CSU achieves an improvement in DLQI score in response to treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof. In some embodiments, a patient with CSU achieves a DLQI score of 0 or 1 at week 4 or week 12 of treatment.

Chronic urticaria index (CU index)

CU-Index® is a commercially available in vitro basophil histamine release assay in which patient serum is mixed with donor basophils and the levels of histamine released are measured using a quantitative enzyme-linked immunosorbent assay. A CU index value of 10 or greater indicates that the patient has either an autoimmune basis for their disease (autoantibodies to IgE, FcεRI, or antibodies to FcεRII; a positive result does not determine which autoantibody) or an alternative histamine-releasing factor ( Biagtan MJ, Viswanathan RK, Evans MD, et al (2011) Clinical utility of the Chronic Urticaria Index. J Allergy Clin Immunol 127(6):1626-7).

In some embodiments, a patient with CSU, in response to treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof, experiences a decrease in titers of antibodies associated with the pathogenesis of CSU (eg, autoantibodies to IgE, FcεRI, or antibodies to FcεRII).

In another embodiment, a patient with CSU experiences a decrease in the CU index value in response to treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof. In some embodiments, a patient with CSU achieves a reduction in the CU index to less than 10 at week 4 or week 12 of treatment.

In some embodiments, the patient is treated with CSU in accordance with the claimed methods for at least 4 weeks, at least 12 weeks, at least 16 weeks, at least 48 weeks, or at least 2 years.

In a preferred embodiment, the patient has previously had an insufficient response to conventional systemic therapy for CSU (eg, second generation H1 antihistamines).

In other preferred embodiments, the patient is an adult patient ( > 18 years of age) having moderate to severe CSU. Moderate to severe CSU is defined as CSU in which the patient has a 7-day urticaria activity score (UAS7) of ≥16 and/or a 7-day urticaria severity score (HSS7) of ≥8.

In some embodiments, in response to treatment according to the claimed methods, the patient experiences a rapid reduction in urticaria pruritus, as measured by the UAS7 score, as early as 4 weeks after the initial dose or 12 weeks after the initial dose. In a preferred embodiment, the patient experiences a decrease in urticaria and pruritus, achieving a UAS7 score of ≤6 at week 4 or week 12. In the most preferred embodiment, the patient experiences complete absence of urticaria and pruritus (UAS7=0) at week 4 or week 12.

In some embodiments, in response to treatment in accordance with the claimed methods, the patient experiences a rapid reduction in the incidence and severity of angioedema, as measured by the AAS7 score, as early as 4 weeks after the initial dose or 12 weeks after the initial dose. In one embodiment, the patient has a complete absence of angioedema for at least 8 weeks of 12 weeks of treatment (measured as an AAS7 score of zero for at least 8 weeks of 12 weeks of treatment). In a preferred embodiment, the patient has a complete absence of angioedema throughout the entire treatment period (measured as an AAS7 score of zero over a 12-week period).

In some embodiments, in response to treatment with the claimed methods, the patient experiences a decrease in titers of antibodies associated with the pathogenesis of CSU (autoantibodies to IgE, FcεRI or antibodies to FcεRII), and/or a decrease in the CU index value to less than 10.

Pharmaceutical composition

A BTK inhibitor, i.e., a compound of formula (I) or a pharmaceutically acceptable salt thereof, can be used as a pharmaceutical composition in combination with a pharmaceutically acceptable carrier. Such a composition may contain, in addition to the compound of formula (I) or a pharmaceutically acceptable salt thereof, carriers, various diluents, excipients, salts, buffers, stabilizers, solubilizers and other materials known in the art. The characteristics of the carrier depend on the route of administration. Pharmaceutical compositions for use in the disclosed methods may also contain additional therapeutic agents for treating the specific target disorder. For example, the pharmaceutical composition may also include anti-inflammatory and antipruritic agents. Such additional factors and/or agents may be included in the pharmaceutical composition to obtain a synergistic effect with a compound of formula (I) or a pharmaceutically acceptable salt thereof, or to minimize side effects caused by a compound of formula (I) or a pharmaceutically acceptable salt thereof. In preferred embodiments, the pharmaceutical composition for use in the disclosed methods contains a compound of formula (I) or a pharmaceutically acceptable salt thereof at a dose of about 5 mg, about 10 mg, about 20 mg, about 25 mg, about 50 mg, or about 100 mg.

Suitable compositions for oral administration include an effective amount of a compound of the present invention in the form of tablets, lozenges, aqueous or oily suspensions, dispersible powders or granules, emulsions, hard or soft capsules, or syrups or tinctures. Compositions intended for oral administration are prepared in accordance with any method known in the art for the manufacture of pharmaceutical compositions, and such compositions may contain one or more agents selected from the group consisting of sweeteners, flavoring agents, coloring agents and preservatives, in order to obtain drugs that are pharmaceutically aesthetic and palatable. Tablets may contain the active ingredient in admixture with non-toxic pharmaceutically acceptable excipients which are suitable for the manufacture of tablets. Such excipients are, for example, inert diluents such as calcium carbonate, sodium carbonate, lactose, calcium phosphate or sodium phosphate; granulating and disintegrating agents such as corn starch or alginic acid; binders such as starch, gelatin or gum arabic; and lubricants such as magnesium stearate, stearic acid or talc. The tablets are uncoated or coated by known techniques to retard disintegration and absorption in the gastrointestinal tract and thereby ensure sustained action over a longer period. For example, a delayed release material such as glyceryl monostearate or glyceryl distearate may be used. Oral formulations may be presented as hard gelatin capsules where the active ingredient is mixed with an inert solid diluent such as calcium carbonate, calcium phosphate or kaolin, or as soft gelatin capsules where the active ingredient is mixed with water or an oily vehicle such as peanut oil, liquid paraffin or olive oil.

Pharmaceutical compositions for use in the disclosed methods can be prepared in conventional manner. In one embodiment, the pharmaceutical composition is provided for oral administration. For example, pharmaceutical compositions are tablets or gelatin capsules containing the active ingredient together with

a) diluents, for example lactose, dextrose, sucrose, mannitol, sorbitol, cellulose and/or glycine;

b) lubricants, for example silica, talc, stearic acid, its magnesium or calcium salt and/or polyethylene glycol; in the case of tablets also with

c) binders, for example magnesium aluminosilicate, starch paste, gelatin, tragacanth, methylcellulose, sodium carboxymethylcellulose and/or polyvinylpyrrolidone; if necessary

d) disintegrants, for example starches, agar, alginic acid or its sodium salt or effervescent mixtures; and/or

e) absorbents, coloring agents, flavorings and sweeteners.

Tablets can be either film-coated or enteric-coated according to methods known in the art.

Combinations

In the practice of certain treatments or uses of the present invention, a therapeutically effective amount of a compound of formula (I) or a pharmaceutically acceptable salt thereof is administered to a patient, such as a mammal (eg, a human). Although it is understood that the disclosed methods involve treating patients with CSU with a compound of formula (I) or a pharmaceutically acceptable salt thereof, the therapy is not necessarily monotherapy. Indeed, if a patient is selected for treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof, then the compound of formula (I) or a pharmaceutically acceptable salt thereof can be administered in accordance with the methods of the present invention either alone or in combination with other agents and therapeutic agents for treating patients with CSU, for example in combination with at least one additional agent for treating CSU. When co-administered with one or more additional agents for the treatment of CSU, the compound of formula (I) or a pharmaceutically acceptable salt thereof can be administered either simultaneously with the other agent or sequentially. When administered sequentially, the attending physician will decide the appropriate sequence of administration of the compound of formula (I) in combination with other agents and the appropriate dosages for co-delivery.

During the treatment of CSU, various therapeutic agents can be combined with the disclosed compound of formula (I) to provide beneficial effects. Such therapeutic agents include topical treatments (creams [nonsteroidal or steroidal], rinses, antiseptics), systemic treatments (eg, biologics, antibiotics, or chemicals) and antiseptics, photodynamic therapy, and surgery (exposure to laser, drainage or cutting, excision).

Non-limiting examples of topical treatments for CSU for use with the disclosed compound of formula (I) or a pharmaceutically acceptable salt thereof include benzoyl peroxide, topical steroid creams, topical aminoglycoside antibiotics such as clindamycin, gentamicin and erythromycin, resorcinol cream, iodine scrubs and chlorhexidine .

Non-limiting examples of agents for the treatment of CSU used in systemic treatment contemplated for use with the disclosed compound of formula (I) or a pharmaceutically acceptable salt thereof include IgE antagonists (omalizumab, ligizumab).

Additional agents for the treatment of CSU contemplated for use in combination with the disclosed compound of formula (I) in the treatment of CSU include cyclosporine and corticosteroids (injectable or oral).

One skilled in the art will be able to determine appropriate dosages of the above CSU treatment agents for co-delivery with the disclosed compound of formula (I) or a pharmaceutically acceptable salt thereof.

Kits of the present invention

The present invention also provides kits for treating CSU. Such kits contain a BTK inhibitor, for example a compound of formula (I) or a pharmaceutical composition based thereon. In one embodiment, the kit contains two or more separate pharmaceutical compositions, at least one of which contains a compound of formula (I) or a pharmaceutically acceptable salt thereof. In one embodiment, the kit contains means for containing the compositions separately, such as a container, a divided bottle, or a divided foil pouch. An example of such a set is blister packaging, usually used for packaging tablets, capsules, etc.

The kit of the present invention can be used to administer different dosage forms, for example, for oral and parenteral use, to administer individual compositions at different dosage intervals, or to titrate individual compositions against each other. To promote compliance with a treatment regimen, the kit of the present invention typically contains instructions for administration.

In the combination therapies of the present invention, the compound of formula (I) or a pharmaceutically acceptable salt thereof and the other agent for treating CSU (as defined herein) may be manufactured and/or formulated by the same or different manufacturers. Moreover, a compound of formula (I) or a pharmaceutically acceptable salt thereof and another agent for the treatment of CSU can be combined to form a combination therapy: (i) before the combination product reaches physicians (e.g. in the case of a kit containing a compound of formula (I) or a pharmaceutically acceptable salt thereof and another agent for the treatment of CSU); (ii) by the physicians themselves (or under the supervision of a physician) shortly before administration; (iii) in the patient's body, e.g. by sequential administration of a compound of formula (I) or a pharmaceutically acceptable salt thereof and another agent for the treatment of CSU.

Additional embodiments

A compound of formula (I) or a pharmaceutically acceptable salt thereof is conveniently administered to a patient (preferably orally) at a dose of from about 10 mg to about 200 mg per day.

A compound of formula (I) or a pharmaceutically acceptable salt thereof is conveniently administered to a patient (preferably orally) at a daily dose of from about 10 mg to about 200 mg per day.

In some embodiments, a compound of Formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dosage of from about 10 mg to about 100 mg.

In some embodiments, a compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of about 10 mg, about 20 mg, about 25 mg, about 35 mg, about 50 mg, about 100 mg, or about 200 mg.

In other embodiments, a compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of approximately 100 mg.

In other embodiments, a compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of approximately 50 mg.

In other embodiments, a compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of approximately 35 mg.

In other embodiments, a compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of approximately 25 mg.

In other embodiments, a compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of approximately 20 mg.

In one embodiment, a compound of formula (I) or a pharmaceutically acceptable salt thereof is administered once daily at a dose of about 10 mg, about 35 mg, about 50 mg, or about 100 mg.

In another embodiment, a compound of formula (I) or a pharmaceutically acceptable salt thereof is administered twice daily at a dose of about 10 mg, about 25 mg, about 50 mg, or about 100 mg.

It should be understood that dose escalation may be required for some patients, for example for patients with CSU who have an insufficient response (for example, when measured using any of the CSU scoring systems disclosed herein, for example using the method of any of the previous paragraphs wherein said patient achieves a sustained response, measured as a complete response (UAS7 Urticaria and Pruritus Severity Score) and Dermatological Life Quality Index (DLQI), etc.), to treatment with a compound of formula (I), or its pharmaceutically acceptable salt by week 4 or week 12 of treatment. It will also be understood that dosage reduction may also be required for certain patients, for example patients with CSU, who exhibit adverse events or adverse reactions to treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof. Thus, dosages of a compound of formula (I) or a pharmaceutically acceptable salt thereof may be less than about 10 mg, about 20 mg, about 25 mg, about 50 mg, or about 100 mg.

The timing of dosing is generally measured from the day of administration of the first dose of a compound of formula (I) or a pharmaceutically acceptable salt thereof (also known as “baseline”). The timing of dosing is generally measured from the day of administration of the first dose of a compound of formula (I) or a pharmaceutically acceptable salt thereof (also known as “baseline”).

However, health care providers often use different naming conventions to identify dosage schedules. For clarity, as described herein, the first day of dosing is referred to as day 1. However, one skilled in the art will appreciate that this naming convention is merely for consistency and should not be construed as limiting, i.e., daily dosing doses is the provision of a daily dose of a compound of formula (I) or a pharmaceutically acceptable salt thereof, and the physician may refer to a particular day as “day 0” or “day 1”.

Disclosed herein are methods of treating chronic spontaneous urticaria (CSU) comprising administering to a patient in need thereof a compound of formula (I) or a pharmaceutically acceptable salt thereof at a dose of from about 10 mg to about 200 mg.

Also disclosed herein are methods of treating chronic spontaneous urticaria (CSU) by administering to a patient in need thereof a compound of formula (I) or a pharmaceutically acceptable salt thereof at a daily dose of from about 10 mg to about 200 mg.

Also disclosed herein is a compound of formula (I) or a pharmaceutically acceptable salt thereof for use in the treatment of CSU, wherein the daily dose of the compound is from about 10 mg to about 200 mg.

In one embodiment of the disclosed methods, uses and kits, a compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of from about 10 mg to about 100 mg.

In another embodiment of the disclosed methods, uses and kits, a compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of about 10 mg, about 20 mg, about 25 mg, about 35 mg, about 50 mg, about 100 mg, or about 200 mg.

In another embodiment of the disclosed methods, uses and kits, a compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of approximately 100 mg.

In another embodiment of the disclosed methods, uses and kits, a compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of approximately 50 mg.

In another embodiment of the disclosed methods, uses and kits, a compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of approximately 35 mg.

In another embodiment of the disclosed methods, uses and kits, a compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of approximately 25 mg.

In another embodiment of the disclosed methods, uses and kits, a compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of approximately 20 mg.

In another embodiment of the disclosed methods, uses, and kits, a compound of formula (I) or a pharmaceutically acceptable salt thereof is administered once daily at a dose of about 10 mg, about 35 mg, about 50 mg, or about 100 mg.

In another embodiment of the disclosed methods, uses, and kits, a compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a dose of about 10 mg, about 25 mg, about 50 mg, or about 100 mg twice daily.

In another embodiment of the disclosed methods, uses and kits, prior to treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof, the patient has previously been treated with a systemic agent for the treatment of CSU. In one aspect of this embodiment, the systemic agent is selected from the group consisting of H1-antihistamines (H1-AH), H2-antihistamines (H2-AH) and leukotriene receptor antagonist (LTRA) and combinations thereof.

In another embodiment of the disclosed methods, uses and kits, prior to treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof, the patient has not previously been treated with a systemic agent for the treatment of CSU.

In another embodiment of the disclosed methods, uses and kits, prior to treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof, the patient has moderate to severe CSU; i.e. the patient has a UAS7 score ≥16 and/or an HSS7 score ≥8.

In another embodiment of the disclosed methods, uses and kits, prior to treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof, the patient has either an autoimmune basis for his disease (autoantibodies to IgE, FcεRI or antibodies to FcεRII) or an alternative histamine releasing factor.

In another embodiment of the disclosed methods, uses and kits, prior to treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof, the patient has a CU index of 10 or greater. In a specific aspect of this embodiment, by week 4 or week 12 of treatment, the patient achieves a reduction in CU index to less than 10.

In another embodiment of the disclosed methods, uses, and kits, a patient is selected according to at least one of the following criteria:

a) before treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof, the patient had a UAS7 score of ≥16;

b) before treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof, the patient had an HSS7 score of ≥8.

In another embodiment of the disclosed methods, uses and kits, the patient is an adult.

In another embodiment of the disclosed methods, uses and kits, by week 4 or week 12 of treatment, the patient has achieved at least one of the following:

a) a decrease in the number of nettle rash elements and a decrease in itching, measured as UAS≤6, or a complete absence of nettle rash and itching (UAS7=0);

b) dermatological life quality index (DLQI) of 0-1;

c) absence of angioedema, measured as an angioedema activity score (AAS7) of zero.

In another embodiment of the disclosed methods, uses, and kits, the patient achieves a sustained response measured as a complete response including urticaria and pruritus ([UAS7]=0) and/or as a Dermatologic Life Quality Index (DLQI) 0-1 and/or continued absence of angioedema (AAS7=0) by week 4 after completion of treatment.

Additional Numbered Embodiments

1. A method of treating chronic spontaneous urticaria (CSU), comprising administering to a subject in need thereof a daily dose of from about 10 mg to about 200 mg N -(3-(6-amino-5-(2-( N -methylacrylamido)ethoxy )pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof.

2. The method according to embodiment 1, wherein the daily dose of N -(3-(6-amino-5-(2-( N -methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl) -4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof is from about 10 mg to about 100 mg.

3. The method according to embodiment 1, wherein the daily dose of N -(3-(6-amino-5-(2-( N -methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl) -4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof is approximately 100 mg.

4. The method according to embodiment 1, wherein the daily dose of N -(3-(6-amino-5-(2-( N -methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl) -4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof is approximately 50 mg.

5. The method according to embodiment 1, wherein the daily dose of N -(3-(6-amino-5-(2-( N -methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl) -4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof is approximately 35 mg.

6. The method according to embodiment 1, wherein the daily dose of N -(3-(6-amino-5-(2-( N -methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl) -4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof is approximately 25 mg.

7. The method according to embodiment 1, wherein the daily dose of N -(3-(6-amino-5-(2-( N -methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl) -4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof is approximately 20 mg.

8. The method according to embodiment 1, wherein N -(3-(6-amino-5-(2-( N -methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4 α-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof is administered once daily at a dose of about 10 mg, about 35 mg, about 50 mg, or about 100 mg.

9. The method according to embodiment 1, wherein N -(3-(6-amino-5-(2-( N -methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4 α-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof is administered at a dose of about 10 mg, about 25 mg, about 50 mg, or about 100 mg twice daily.

10. The method according to any of the previous embodiments, wherein prior to treatment, the subject has previously received treatment with a systemic agent for the treatment of CSU.

11. The method according to embodiment 10, wherein the systemic agent is selected from the group consisting of H1-antihistamines (H1-AH), H2-antihistamines (H2-AH) and leukotriene receptor antagonist (LTRA) and combinations thereof.

12. The method according to any of embodiments 1-9, wherein prior to treatment, the subject has not previously received treatment with a systemic agent for the treatment of CSU.

13. The method according to any of the previous embodiments, wherein the subject has moderate to severe CSU.

14. The method according to any one of embodiments 1-13, wherein the subject is selected according to at least one of the following criteria:

a) before treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof, the subject has a UAS7 score of ≥16;

b) before treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof, the subject has an HSS7 score of ≥8;

15. The method according to any of the previous embodiments, where the subject is an adult.

16. The method according to any of the preceding embodiments, wherein by week 4 or week 12 of treatment, said subject has achieved at least one of the following:

a) a decrease in the number of nettle rash elements and a decrease in itching, measured as UAS≤6, or a complete absence of nettle rash and itching (UAS7=0); or

b) dermatological life quality index (DLQI) of 0-1;

c) absence of angioedema, measured as an angioedema activity score (AAS7) of zero.

17. The method according to any of the preceding embodiments, wherein said subject achieves a sustained response measured as a complete response including urticaria and pruritus ([UAS7]=0), and/or as a dermatological quality of life index (DLQI)=0-1, and/or continued absence of angioedema (AAS7=0) by week 4 after completion of treatment.

18. The method according to any of the previous embodiments, wherein N -(3-(6-amino-5-(2-( N -methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl) -4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof is placed in a pharmaceutical composition, wherein said pharmaceutical composition further contains pharmaceutically acceptable carriers.

19. The method according to any of embodiments 1-18, wherein N -(3-(6-amino-5-(2-( N -methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2- Methylphenyl)-4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof has a _Tmax value of approximately 0.5-3 hours.

ABBREVIATIONS

AE undesirable effect

AUC area under the curve

AUCinf area under the plasma (or serum or blood) concentration versus time curve,

from time zero to infinity (mass x time/volume)

AUClast area under the plasma (or serum or blood) concentration versus time curve,

from time zero to time point at which the concentration is quantifiable (mass x time/volume)

AUCtau is the area under the plasma (or serum or blood) concentration versus time curve,

from time zero to the end of the tau dosing interval (mass x time/volume)

b.i.d. twice a day

BMI body mass index

CL/F apparent systemic (or total body) clearance from blood plasma (or serum or blood)

after administration (weight/volume)

Cmax maximum concentration after drug administration

CSU chronic spontaneous urticaria

ECG electrocardiogram

Emax maximum change in effect compared to placebo

FcγR Fc gamma receptor

FcεR Fc alpha receptor

MRT average holding time

PK pharmacokinetics

PD pharmacodynamics

PRO patient-reported outcomes

QoL quality of life

q.d. once a day

QTcF QT interval corrected by Frederick's formula

SAE serious adverse effect

Tmax is the maximum length of time until the maximum concentration is reached after drug administration

T1/2 terminal half-life

Tlast time of the last measured concentration in the PK profile

Vz/F apparent volume of distribution during the terminal elimination phase

after administration (volume)

Example 1: Preclinical studies

Example 1a. Relationship between BTK and PK/PD occupancy in preclinical studies

The in vivo PD effects of an irreversible BTK inhibitor, such as compound (I), are determined by the extent and duration of covalent occupancy of the BTK inhibitor. BTK occupancy after treatment with a compound of formula (I) (also referred to as compound (I)) was measured using an ex vivo immunoassay. The fraction of unoccupied BTK protein was analyzed after in vitro incubation with a covalent biotinylated BTK probe, since compound (I) and the probe bind to BTK in a mutually exclusive manner. Unoccupied BTK protein as well as relative levels of total BTK protein were determined in lysates of selected tissues, and unoccupied BTK protein levels were normalized to total BTK protein levels in the same samples.

In female rats, a single oral dose of 3 mg/kg of compound (I) resulted in full splenic BTK occupancy, a dose of 1 mg/kg resulted in 76%-81% occupancy, whereas after a single dose of 0.3 mg/kg only partial occupancy was achieved. occupancy 30%. BTK occupancy in the blood reached levels consistent with those observed in the spleen. It was evident from experimental data that the short-term presence of compound (I) in the systemic circulation is sufficient to achieve full BTK occupancy in several tissues at low oral doses of 1-3 mg/kg. The content of compound (I) in the blood after a dose of 1 mg/kg reached 49.1 nM after 0.5 hours and was 5.6 nM after 5 hours after dosing. This transient presence in the systemic circulation at very low levels is consistent with the PK/PD model typical of irreversible inhibitors.

The duration of BTK occupancy was determined in rats and mice after a single oral dose of compound (I) for the spleen, blood, lymph nodes and lungs. In rats, BTK in the occupied state has demonstrated a long blood half-life of approximately 87 hours. The estimated half-life of BTK in the occupied state in the rat spleen is significantly shorter than in the blood, only approximately 5 hours. The different metabolic rates may reflect the fact that B cells and monocytes in the peripheral blood expressing BTK are quiescent and metabolically relatively inactive compared with those in the spleen. Longer persistence of BTK in the occupied state in the blood has previously been reported ( Advani et al 2013, J Clin Onc; 31(1):88-94 ). All other tissues analyzed (lungs and lymph nodes) showed metabolism and occupied half-life of BTK similar to those of the spleen.

Example 1B . In vivo efficacy in mouse models of acute cutaneous hypersensitivity

The effects of compound (I) on FcγR- and FcεR-induced hypersensitivity were assessed in two mouse models of acute skin reactions. Due to the less favorable PK of compound (I), the compound was dosed twice daily in mice.

The duration of the PD effect in the skin after a single dose was assessed in the Arthus reverse passive response (RPA) model of mast cell FcγRIII-mediated inflammation. In this model of RPA, a polyclonal IgG antibody is administered locally into the dermis, while a soluble antigen is administered systemically by intravenous injection. In this mouse model, mast cell FcγRIII plays a dominant role with minor contribution from the complement system (Hazenbos et al. 1998, journal of immunology, 161(6), pp. 3026; Hazenbos et al., Immunity, 1996, 5(2), pp. 181; Köhl & Gessner 1999, Molecular immunology, 36(13-14), pp. 893; Immunity, 5(4), pp. 387; , pp. 1095). Mice genetically deficient in BTK have been shown to be protected from passive cutaneous Arthus reaction (Fiedler et al. 2011, blood, 117(4), pp. 1329).

Oral treatment with compound (I) at a single dose of 3, 10, 30 and 100 mg/kg, given 2 hours before induction of the RPA response, reduced skin edema in a dose-dependent manner. Maximum effects were observed at 30 and 100 mg/kg (inhibition rate was 73.0 and 61.2%, respectively), and partial effects were observed at 3 and 10 mg/kg (inhibition rate was 22.9 and 29.2%, respectively) (figure 1). BTK occupancy in the spleen, observed in full 5 hours post-dose, correlated with efficacy against skin edema with the following values: 68.1% (3 mg/kg), 82.1% (10 mg/kg), 91 .3% (30 mg/kg), 99.3% (100 mg/kg) (Figure 2).

In this model, inhibition of skin edema was maximum when compound (I) was administered 2 hours before inducing the Arthus reaction. The effect gradually decreased and reached the initial level when the Arthus reaction was started 45 hours or later after dosing of compound (I). This suggests that BTK occupancy in the skin is characterized by the same dynamics as in the spleen, lungs and lymph nodes.

The effects of Compound (I) on acute cutaneous hypersensitivity were also assessed after two oral doses of Compound (I) in a mouse model of passive cutaneous anaphylaxis (PCA) (Ovary, 1958). The PCA mouse model was used with a low dose of sensitizing IgE antibodies to minimize complement-dependent anaphylatoxins (Schäfer et al. 2013, The journal of allergy and clinical immunology, 131(2), pp. 541; Hata et al. 1998, Journal of Experimental Medicine, 187(8), pp. 1235). Two oral doses at each level of 3, 10, 30, or 100 mg/kg of compound (I), administered 14 and 2 hours before inducing cutaneous anaphylaxis with a hapten, showed dose-dependent inhibition of skin edema, measured by vascular permeability dye testing. blue Evans. Inhibition of skin edema measured by vascular permeability testing using Evans blue dye ranged from 60.7% (3 mg/kg), 66.9% (10 mg/kg), 69.2% (30 mg/kg ) up to 87.4% (100 mg/kg) (Figure 3). Spleen occupancy 2.5 hours after the last dose ranged from 89.1 to 99.7% (corresponding to maximum occupancy) (Figure 4).

The studies in Examples 1a and 1b suggest that compound (I) reaches its target in the skin and effectively inhibits skin inflammatory reactions.

In these preclinical pharmacological studies, BTK occupancy and corresponding pharmacological data showed a strong correlation. Thus, BTK occupancy and mast cell-mediated cutaneous hypersensitivity responses are suitable PD biomarkers for use in clinical trials and were therefore used in phase 1 clinical trials.

Example 2. Phase 1 clinical trial

A first-in-human study was conducted to evaluate the safety and tolerability, pharmacokinetics (PK) and pharmacodynamics (PD) of single and multiple doses of compound (I) when administered orally either once daily (qd) or twice daily (bid). , in healthy volunteers and patients with atopic diathesis to support further clinical development of compound (I) in autoimmune diseases. This study also examined the effects of food intake.

A first-in-human study in approximately 168 healthy volunteers (HV), of whom 64 (in parts 2 and 4) had asymptomatic atopic diathesis.

Part 1 was a double-blind (subject and investigator blinded, sponsor not) placebo-controlled dose-escalation study using single ascending doses (SAD) in 10 cohorts (N=80).

Part 2 was a double-blind (subject and investigator blinded, sponsor not), placebo-controlled, dose-escalation study using multiple ascending doses (MAD) (13 doses over 12 days) with once-a-day dosing. day in 6 cohorts of healthy volunteers with asymptomatic atopic diathesis (N=48).

Part 3 was an open-label, single-dose crossover study of the effects of food intake in 12 HV.

Part 4 was a double-blind (subject and investigator blinded, sponsor not), placebo-controlled, multiple-dose (25 doses over 12 days) twice-daily dosing study in 2 cohorts of healthy volunteers with asymptomatic atopic diathesis (N=16).

The SAD portion (Part 1) provided ten dose levels, and the MAD portions (Parts 2 and 4) provided eight dose levels (6 once-daily dosing cohorts in Part 2 and 2 twice-daily dosing cohorts in Part 4 ). Eight subjects were randomly assigned to each cohort to receive either compound (I) or matching placebo in a 6:2 (active:placebo) ratio in the SAD and MAD portions. For the SAD portion, doses approximately 4 times the estimated pharmacologically active dose (PAD) were required to be evaluated before the MAD portion of the study was initiated, provided that no safety signal had been reported from the SAD portion prior to that time. The total daily dose of compound (I) used in part 2 (MAD qd regimen) and part 4 (bid multiple dose regimen) did not exceed the highest dose level tested in the SAD portion. Moreover, the total daily dose in part 4 did not exceed the total daily dose in part 2.

In Part 1 (SAD), for the first administration at each dose level, a sentinel dosing strategy was to be applied as follows. The first two subjects were dosed on day 1 (one with active drug, one with placebo). After a 48-hour observation period, doses were administered to the remaining 6 subjects in the cohort (five with active drug, one with placebo).

Standard safety monitoring was used in all parts of the study. A specific assessment of possible cases of skin bruising was included. For each cohort, prior to dose escalation, a blinded review of all vital signs, physical examination and patient history, ECG, adverse events, and laboratory safety parameters (blood chemistry, hematology, and urinalysis) was required until 96 hours after the last dose, and also PK data from the previous dose group (if available) up to 48 hours after the last dose. Safety summary reports for reported adverse events, clinical safety laboratory parameters, QTc, and heart rate were provided after completion of each dose level.

In Parts 1, 2, and 4, each subject participated in a 28-day screening period (day -29 to day -2), a baseline period, a treatment period, and a follow-up period that included an assessment at the end of the study.

In Part 1, subjects entered the study site on day -2 or -1 for baseline safety assessment and confirmation of study eligibility criteria. Eligible subjects received a single dose of compound (I) or placebo on an empty stomach on day 1. They were hospitalized from day -1 until the morning of day 5 (96 hours after the last drug administration).

In parts 2 and 4, subjects were admitted on day -2 or -1 to assess safety at baseline and confirm eligibility for study inclusion. Eligible subjects received the first dose of compound (I) on an empty stomach on day 1 and continued to take the study drug on an empty stomach until day 12 inclusive. Subjects were hospitalized from day -2 or -1 until the morning of day 16, which corresponded to 96 hours after the last dose of compound (I). In parts 2 and 4, the study drug was given once daily and twice daily, respectively (see assessment schedule for details).

Part 3 was an open-label, single-dose, randomized, two-way, crossover study to evaluate the effect of food intake. In Part 3, each subject participated in a 28-day screening period (day -29 to day -2), 2 baseline periods (day -1), and 2 treatment periods, each consisting of a single dose on day 1 followed by safety and PK assessments until day 5. Treatment period 2 consisted of a follow-up visit and end-of-study assessment on days 22 and 40, respectively. The two treatment periods were separated by a washout period of at least 18 days (+/- 1 day).

Main goal(s)

Target Expected results All parts: assessment of the safety and tolerability of single and multiple escalating oral doses of compound (I). All safety assessments including physical examination and history, vital signs, ECG, laboratory safety parameters, AE and SAE.
A specific assessment of the incidence of skin bruising is included.

Secondary Goals

Target Expected results Parts 1, 2 and 4: assessment of PK of single and multiple doses of compound (I) in blood in healthy volunteers and atopic subjects. PK parameters for single and multiple doses such as Cmax, Tmax, AUCinf, AUClast, AUCtau, T1/2, MRT, Racc, Vz/F and Cl/F. Part 3: assessment of PK of single doses of compound (I) in the blood under fasted and fasted conditions in healthy volunteers. PK parameters for single doses: Cmax, Tmax, AUClast, AUCinf, T1/2, MRT, Vz/F and CL/F.

Research objectives

Target Expected results Parts 1, 2 and 4: study of PK (parts 2 and 4) and PD of single and multiple doses of compound (I) in urine. Degree of BTK occupancy in peripheral blood
Answers to a known allergen in a skin prick test (parts 2 and 4)
Ex vivo cellular PD biomarkers, which provided an additional means of measuring drug response for compound (I) by inhibiting peripheral blood basophil degranulation (FcεR-induced CD63 and CD203c expression) All parts: describe effect-concentration relationships using PD markers (e.g., BTK occupancy, ex vivo cellular PD biomarkers) and characterize deviations from PK nonlinearity (if any) using PK-PD population models. Population model PK parameters (e.g., CL/F, V/F, and Ka) and PD model parameters (e.g., irreversible binding constant, Kirr) and their associated intra- and interindividual variability (CV%)

Key inclusion criteria

1. Healthy male and female subjects aged 18 to 65 years (inclusive) in good health as determined by history, physical examination, vital signs, electrocardiogram, and laboratory tests at screening. Healthy subjects participated in Part 2 or Part 4 with atopic diathesis according to the eligibility criteria for study inclusion in those specific parts of the study. Healthy atopic volunteers at screening were required to have a positive skin prick test for a known allergen (atopic diathesis) but were required to be clinically asymptomatic and not require any systemic medications.

2. Subjects were required to have a body weight of at least 50 kg and a body mass index (BMI) between 18-30 kg/m2 (inclusive). BMI=body weight (kg)/[height (m)] ²

3. At screening and the first baseline, vital signs (body temperature, systolic and diastolic blood pressure, and pulse) were assessed in a sitting position after the subject had been at rest for at least 3 minutes and again (if necessary) thereafter. 3 minutes in a standing position. Sitting vital signs had to be within the following ranges (inclusive):

body temperature when measured in the oral cavity 35.0-37.5°C

systolic blood pressure 90-139 mm Hg. Art.

diastolic blood pressure 50-89 mm Hg. Art.

pulse 50-90 beats/min.

Key exclusion criteria

1. History of hypersensitivity to any of the study drugs or to drugs of similar chemical classes.

2. History of clinically significant ECG abnormalities or any of the following ECG abnormalities at screening and/or before treatment:

PR interval > 200 ms

QRS complex > 120 ms

QTcF > 450 ms (men)

QTcF > 460 ms (women)

3. Hemoglobin levels below 12.0 g/dL at screening or first baseline determination.

4. The platelet count is outside the normal range (below 150×10 ⁹ /L or above 450×10 ⁹ ) at screening or first baseline determination.

5. Any clinically significant abnormalities in any of the standard coagulation studies, including prothrombin time (PT), partial thromboplastin time (PTT), or international normalized ratio (INR) at screening and/or baseline.

6. Presence or history of thrombotic or thromboembolic events, or an increased risk of developing thrombotic or thromboembolic events.

Injected agents for treatment

Part 1 (SAD)

Subjects were assigned to one of the following 10 cohorts. Each cohort was randomly assigned to 8 subjects to receive either compound (I) or matching placebo in an overall ratio of 6:2. The first subcohort was randomly assigned in a 1:1 ratio: one subject to receive compound (I) and one subject to receive the corresponding placebo. The remaining 6 subjects in each cohort who were dosed after a 48-hour observation period of the 2 previously dosed subjects were randomized in a 5:1 ratio.

Cohort 1: single oral dose of 0.5 mg of compound (I) or matching placebo.

Cohort 2: single oral dose of 1.5 mg of compound (I) or matching placebo.

Cohort 3: single oral dose of 5 mg of compound (I) or matching placebo.

Cohort 4: single oral dose of 15 mg of compound (I) or matching placebo.

Cohort 5: single oral dose of 30 mg of compound (I) or matching placebo.

Cohort 6: single oral dose of 60 mg of compound (I) or matching placebo.

Cohort 7: single oral dose of 100 mg of compound (I) or matching placebo.

Cohort 8: single oral dose of 200 mg of compound (I) or matching placebo.

Cohort 9: single oral dose of 400 mg of compound (I) or matching placebo.

Cohort 10: single oral dose of 600 mg of compound (I) or matching placebo.

Part 2 (MAD, qd diagram)

Subjects were assigned to one of the following 6 cohorts. In each cohort, 8 subjects were randomly assigned to receive either compound (I) or matching placebo in a 6:2 ratio.

Cohort 1: multiple oral doses of 10 mg of compound (I) or matching placebo.

Cohort 2: multiple oral doses of 25 mg of compound (I) or matching placebo.

Cohort 3: multiple oral doses of 50 mg of compound (I) or matching placebo.

Cohort 4: multiple oral doses of 100 mg of compound (I) or matching placebo.

Cohort 5: multiple oral doses of 400 mg of compound (I) or matching placebo.

Cohort 6: multiple oral doses of up to 600 mg of compound (I) or matching placebo.

Part 3 (effects of food intake)

Subjects were randomly assigned to one of 2 treatment sequences (Table 9) in a 1:1 ratio.

Determine the treatment sequence for part 3.

Subsequence Period 1 Period 2 1 Compound (I) (60 mg) on an empty stomach Compound (I) (60 mg) after meals 2 Compound (I) (60 mg) after meals Compound (I) (60 mg) on an empty stomach

Part 4 (MAD, bid scheme)

Subjects were assigned to one of the following cohorts. In each cohort, 8 subjects were randomly assigned to receive either compound (I) or matching placebo in a 6:2 ratio.

Cohort 1: multiple oral doses of 100 mg of compound (I) or matching placebo in a bid regimen.

Cohort 2: multiple oral doses of 200 mg of compound (I) or matching placebo in a bid regimen.

Pharmacokinetic data

Bioanalytical methods :

Pharmacokinetic samples were obtained from blood and assessed at all dose levels in all subjects. Samples from subjects in the placebo groups were not analyzed. Samples for PK assessment from subjects were collected at time points defined in the study. Concentrations of compound (I) were determined in blood using a validated LC-MS/MS method.

Pharmacokinetics of single increasing doses of 0.5 mg - 600 mg

The mean concentration of compound (I) in the blood as a function of time after single ascending doses is shown in Figure 5.

Compound (I) was rapidly absorbed, with time to Cmax of approximately 1-1.5 hours at all doses. The absorption phase was characterized by a single distinct absorption peak in most subjects. A biphasic decline was shown for drug distribution. Most of the drug was cleared in the initial distribution phase, suggesting that essentially drug clearance may occur before equilibrium is reached in tissues throughout the body. The apparent terminal elimination phase did not occur until 12 hours after dosing and could only be measured in subjects receiving doses of 100 mg or higher. Measured terminal half-lives ranged from 4 hours (100 mg) to 18 hours (600 mg), resulting in a mean retention time (MRT) in the bloodstream of 1 hour to 5 hours (MRT≈ T1/2/ ln2). The distribution phase demonstrated a dominant dose-independent T1/2 of ~1 hour. Estimated geometric mean single-dose oral clearance (CL/F) ranged from 250 to 506 L/h in the SAD cohorts, with an estimated a value of approximately 383 l/h in all cohorts.

Pharmacokinetics of multiple oral doses

The average concentration of compound (I) in the blood as a function of time after repeated increasing doses of 10 mg - 400 mg is shown in figure 6.

Geometric mean apparent clearance at steady state after oral dosing (CLss/F, day 12 MAD, qd) ranged from 246 L/h to 414 L/h across cohorts. Overall, lower clearance was observed at steady state compared with day 1, but this difference almost disappeared at doses of 100 mg and above (Table 8-1 (Day 1) and Table 8-2 (Day 12)). The reason for this behavior is likely to be covalent binding of the target (BTK), which promotes the initial clearance of compound (I). This effect is most noticeable on day 1, as on subsequent days the remaining target in the occupied state at minimal levels reduces the contribution of target binding to clearance (CLss/F). Naturally, this difference decreases with increasing dose, when target occupancy at the minimum level is almost complete. Consequently, drug content (AUC, Cmax) was found to be higher on day 12 compared to day 1, as evidenced by the (within-subject) drug accumulation coefficient (Racc), which ranged from 5 (low dose) to 1 .2 (high dose) and was generally higher for AUC than Cmax, suggesting a possible effect on systemic clearance.

Table 8-1 . Summary of PK parameters of compound (I) at multiple increasing doses from 10 to 600 mg, dose administration qd

Analyte: compound of formula (I), matrix: blood and urine
Profile: day 1 Compound of formula (I) PK parameter (unit) 10 mg qd
N=6 25 mg qd
N=6 50 mg qd
N=6 100 mg qd
N=6 400 mg qd
N=6 600 mg qd
N=6 Cmax (ng/ml) 8.40 ± 2.02 (24.1) 40.9 ± 21.6 (52.9) 76.5 ± 22.0 (28.8) 187 ± 85.0 (45.4) 518 ± 89.1 (17.2) 550 ± 87.6 (15.9) 8.03 (6.36-11.4) [6] 37.3 (14.1-80.4) [6] 70.1 (47.3-107) [6] 189 (75.6-285) [6] 513 (383-622) [6] 545 (461-691) [6] Tmax (h) 0.517 (0.500-1.00) [6] 0.875 (0.283-1.50) [6] 0.500 (0.483-2.00) [6] 0.742 (0.500-1.95) [6] 0.750 (0.500-1.50) [6] 0.750 (0.500-3.00) [6] AUClast (h*ng/ml) 4.17 ± 1.38 (33.0) 43.9 ± 24.6 (56.2) 113 ± 34.2 (30.3) 311 ± 89.1 (28.6) 973 ± 379 (39.0) 1080 ± 377 (35.1) 4.40 (1.79-5.62) [6] 45.5 (15.3-78.5) [6] 103 (81.9-154) [6] 333 (168-416) [6] 826 (694-1720) [6] 931 (699-1700) [6] AUC0-24 (h*ng/ml) 4.94 ± 1.35 (27.2) 44.9 ± 25.2 (56.0) 116 ± 32.9 (28.4) 315 ± 91.5 (29.0) 977 ± 378 (38.7) 1080 ± 377 (35.0) 4.94 (3.99-5.89) [2] 46.6 (15.6-79.7) [6] 107 (84.0-155) [6] 338 (168-419) [6] 826 (702-1720) [6] 932 (700-1700) [6] MRT (hours) 0.761 ± 0.151 (19.8) 1.18 ± 0.490 (41.6) 2.53 ± 1.17 (46.4) 2.79 ± 1.28 (45.7) 3.02 ± 1.11 (36.8) 3.14 ± 0.580 (18.5) 0.766 (0.548-0.956) [6] 1.17 (0.460-1.87) [6] 2.44 (1.17-4.65) [6] 2.16 (1.65-4.62) [6] 2.94 (1.64-4.98) [6] 3.22 (2.31-3.96) [6] Statistics are presented as mean ± SD (CV%)
Median (min.-max.) [n]
CV%=coefficient of variation (%)=SD/mean*100
For Tmax and T1/2 only median values (min.-max.) [n] are presented.

Table 8-2.

Analyte: compound of formula (I), matrix: blood and urine
Profile: day 12 Compound of formula (I) PK parameter (unit) 10 mg qd
N=6 25 mg qd
N=6 50 mg qd
N=6 100 mg qd
N=6 400 mg qd
N=6 600 mg qd
N=6 Cmax (ng/ml) 18.2 ± 5.90 (32.4) 85.9 ± 31.5 (36.6) 102 ± 22.0 (21.6) 233 ± 84.1 (36.1) 551 ± 263 (47.7) 563 ± 229 (40.6) 17.2 (11.8-26.4) [6] 78.4 (43.9-126) [6] 100 (73.3-131) [6] 205 (167-386) [6] 476 (260-928) [6] 475 (377-985) [6] Tmax (h) 0.625 (0.500-1.00) [6] 0.750 (0.500-1.00) [6] 1.00 (0.533-1.50) [6] 0.867 (0.733-1.50) [6] 0.758 (0.700-1.50) [6] 0.883 (0.500-3.00) [6] AUClast (h*ng/ml) 22.9 ± 3.50 (15.3) 114 ± 59.7 (52.3) 207 ± 80.4 (38.9) 488 ± 172 (35.3) 1300 ± 602 (46.3) 1240 ± 341 (27.5) 22.4 (18.3-28.2) [6] 98.2 (30.1-190) [6] 179 (126-323) [6] 444 (336-770) [6] 1180 (650-2310) [6] 1070 (953-1740) [6] AUCinf (h*ng/ml) 24.7 ± 3.65 (14.8) 117 ± 60.4 (51.5) 209 ± 80.0 (38.2) 577 ± 207 (35.9) 1330 ± 608 (45.8) 1260 ± 338 (26.8) 24.3 (19.6-29.9) [6] 102 (31.7-194) [6] 181 (127-325) [6] 595 (361-774) [3] 1210 (665-2330) [6] 1090 (994-1760) [6] AUC0-24 (h*ng/ml) 24.0 ± 3.60 (15.0) 117 ± 60.9 (52.2) 209 ± 80.2 (38.4) 485 ± 179 (36.9) 1280 ± 577 (45.3) 1230 ± 356 (29.0) 23.6 (18.9-29.3) [6] 101 (30.9-194) [6] 181 (127-325) [6] 429 (336-774) [6] 1140 (677-2270) [6] 1060 (908-1740) [6] T1/2 (h.) 0.961 (0.667-1.21) [6] 1.15 (0.680-1.33) [6] 1.15 (0.813-1.55) [6] 1.41 (1.41-11.9) [3] 8.51 (1.22-22.3) [6] 8.29 (4.69-17.3) [6] Vss/F (l) 554 ± 90.4 (16.3) 407 ± 208 (51.1) 431 ± 172 (40.0) 1910 ± 2780 (145.9) 4400 ± 3340 (75.8) 7130 ± 5120 (71.9) 562 (407-657) [6] 334 (247-793) [6] 346 (313-751) [6] 338 (264-5120) [3] 3440 (624-8820) [6] 7070 (2340-16500) [6] CLss/F (l/h) 425 ± 64.8 (15.3) 307 ± 253 (82.5) 268 ± 92.8 (34.6) 198 ± 88.7 (44.8) 366 ± 150 (41.0) 521 ± 131 (25.1) 423 (341-529) [6] 248 (129-809) [6] 276 (154-395) [6] 166 (129-298) [3] 351 (177-591) [6] 569 (345-661) [6] T1/2, ac 1.00 (1.00-1.00) [6] 1.00 (1.00-1.00) [6] 1.00 (1.00-1.00) [6] 1.01 (1.00-1.73) [6] 1.18 (1.00-1.90) [6] 1.16 (1.03-1.62) [6] Amount Extracted (mg) 0.0663 ± 0.0309 (46.5) 0.114 ± 0.0706 (62.0) 0.233 ± 0.0880 (37.7) 0.648 ± 0.330 (50.9) 1.25 ± 0.647 (51.7) 1.54 ± 0.915 (59.3) 0.0630 (0.0346-0.109) [6] 0.126 (0.0326-0.217) [6] 0.185 (0.165-0.378) [5] 0.561 (0.305-1.12) [6] 1.12 (0.547-2.37) [6] 1.43 (0.528-3.03) [6] Amount extracted (%) 0.663 ± 0.309 (46.5) 0.456 ± 0.283 (62.0) 0.467 ± 0.176 (37.7) 0.648 ± 0.330 (50.9) 0.313 ± 0.162 (51.7) 0.257 ± 0.153 (59.3) 0.630 (0.346-1.09) [6] 0.502 (0.130-0.868) [6] 0.370 (0.331-0.757) [5] 0.561 (0.305-1.12) [6] 0.280 (0.137-0.593) [6] 0.238 (0.0880-0.506) [6] Renal clearance (ml/min.) 45.3 ± 18.0 (39.8) 16.8 ± 6.81 (40.5) 20.4 ± 2.40 (11.7) 21.6 ± 5.41 (25.1) 16.9 ± 7.13 (42.3) 20.0 ± 8.25 (41.2) 41.6 (24.4-70.3) [6] 18.9 (5.43-24.3) [6] 20.5 (17.1-23.4) [5] 21.1 (14.6-30.9) [6] 14.5 (11.5-30.7) [6] 18.1 (8.98-30.3) [6] Statistics are presented as mean ± SD (CV%)
Median (min.-max.) [n]
CV%=coefficient of variation (%)=SD/mean*100
For Tmax and T1/2 only median values (min.-max.) [n] are presented.

Overall, blood concentrations 24 hours after the last dose were generally below 1 ng/mL, with the exception of a few subjects taking doses of 100 mg and above, indicating almost complete washout of compound (I) over two consecutive doses. The latter also assumes that the equilibrium state is reached over several doses.

Due to the faster tissue metabolism of BTK, dosing b.i.d. Mean blood concentration profiles over time obtained after multiple ascending doses of 100 mg and 200 mg twice daily are shown in Figure 7. Consistent with the results of other cohorts, rapid absorption with a Tmax of approximately 1 hour was observed for doses following the b.i.d. regimen. The observed accumulation ratio (Racc) was 1.5 (100 mg) and 2.0 (200 mg) for AUC and approximately 1.65 for Cmax (both doses). A dose-proportional increase in AUCtau was observed on day 12, whereas only a small increase (1.33-fold) was found in Cmax. In conclusion, dosing of compound (I) b.i.d allows for faster tissue resynthesis of the target during the dosing interval without compromising the overall PK profile and the need for high dose q.d treatment.

Impact of food intake: result of part 3

PK data from the meal effect cohort, summarized in Table 9 below, indicate a reduced rate of absorption, as evidenced by a 1.25-fold decrease in Cmax, and more complete total absorption, as evidenced by an increase in AUC0-24 in 1.4 times. Most importantly, the mean Tmax shifted from 1 hour (fasting) to >3 hours (postprandial) (Figure 8).

Table 9. Summary of PK parameters: effect of food intake on compound (I) after a single 60 mg dose.

CV=coefficient of variation (%)=SD/mean*100

Pharmacodynamics

Determination of pharmacodynamic (PD) characteristics was carried out by assessing the degree of target occupancy and inhibition in the distal portion of the pathway. Measured BTK occupancy rates in human whole blood (obtained as the ratio of free to total BTK) served as a direct marker of therapeutic effect on the target.

The relationship between BTK occupancy rate, dose, systemic compound content and in vivo pathway efficacy and disease data was established in preclinical models for the compound of formula (I) (eg, Example 1).

The compound of formula (I) is an irreversible inhibitor of BTK, the degree and duration of BTK occupancy was determined. The PD effect of compound (I) was assessed by measuring both free BTK (unbound) and total BTK in whole blood using an enzyme-linked immunosorbent assay (ELISA) on the Meso Scale Diagnostics (MSD) platform in two separate assays.

The relationship between dose and pharmacodynamic parameters was characterized using measured BTK occupancy rates in human blood (obtained as the ratio of free to total BTK), a direct marker of therapeutic effect on the target. The degree of BTK occupancy was determined for single increasing doses in the range from 0.5 to 400 mg, for multiple increasing doses q.d. ranging from 10 to 400 mg and for multiple increasing doses b.i.d. in the range from 100 to 200 mg.

The compound of formula (I) demonstrated a clear dose-dependent increase in both the extent and duration of BTK occupancy in peripheral blood. Peak target occupancy was typically observed as early as 0.5 hours post-dose, indicating a rapid onset of action without significant hysteresis of drug action relative to peak drug loading. Based on its ability to covalently bind BTK, target occupancy persisted long after its removal from the systemic circulation, indicating a disequilibrium PK-PD relationship. Accordingly, it is concluded that the duration of BTK occupancy is determined by the rate of de novo BTK synthesis.

In contrast to the lower dose cohorts (0.5-1.5 mg), single doses of 15 mg of compound (I) and above produced a maximum target occupancy rate approaching 100% in almost all subjects, which remained above 80 % at 24 hours. While the response varied significantly among subjects at the 15 mg dose, doses of 30 mg and above provided sustained (>24 hours) and almost complete (>90%) occupancy in all subjects with clearly reduced intersubject variability. The time to update the BTK protein pool to pre-dose levels was approximately 10 days, corresponding to a median T1/2 metabolism of approximately 48 hours (Figure 9).

After multiple doses of compound (I), already using 10 mg of compound (I) q.d. achieved a residual BTK occupancy rate of >96% in the blood before dosing on day 12.

In addition, ex vivo inhibition of basophil activation (monitored by surface expression of CD63 and CD203c) was used as a distal mechanistic biomarker to examine the downstream PD effects of compound (I). To determine the PD effect of compound (I) on basophil activation, whole blood was stimulated ex vivo with anti-IgE antibodies. Degranulation was assessed by the percentage of CD63+ and CD203+ basophils using flow cytometry.

Following single escalating doses of compound (I), data indicate dose-dependent inhibition of FcεR1-mediated basophil activation. Ex vivo blood basophil activation, as measured by CD63, was almost completely inhibited (>89%) at 60 mg doses and reached almost 100% inhibition at higher doses at 24 hours post-dose. In contrast, maximum inhibition of CD203c 24 hours after a single dose of compound (I) (approximately 50% inhibition) was achieved only with 200 mg of compound (I).

On day 12, 8 hours after administration of MAD q.d. or b.i.d. compound of formula (I), even the lowest dose of compound (I) tested (10 mg q.d.) resulted in >90% inhibition of CD63 upregulation, and the residual level of CD63 inhibition was >90% at doses of compound (I) ≥50 mg q.d. (figure 10). The maximum residual inhibition of CD203c activation at day 12 was consistently greater than after a single dose of compound (I) and was only achieved with b.i.d. 100 mg and 200 mg of compound (I).

The ability of Compound (I) to inhibit the response to a specific allergen was assessed using a skin prick test (SPT) in healthy atopic subjects in the MAD portion of the first-in-human study. SPT was performed predose (at screening, baseline, and predose on day 1) and at various time points after the first dose (day 1) and 11 days after dosing once daily (day 12).

Similar to the ex vivo inhibition of basophil activation, the dose-dependent effect on wheal diameter was pronounced in the multiple escalating dose cohorts, as indicated by a decrease in mean post-dose wheal size compared to baseline (Figure 11). The effect began to plateau at approximately 100 mg of compound (I) qd

Rationale for dose selection/conclusion

Healthy volunteers were exposed to Compound (I) in Phase 1 clinical studies with doses ranging from 0.5 to 600 mg, administered as a single dose or administered for up to 18 days once or twice daily. Compound (I) was well tolerated and there were no serious or severe adverse events associated with administration of Compound (I). In the clinical study, adverse events (AEs) observed did not appear to be dose-related; most were isolated and generally mild in nature. In summary, clinical safety information supports the doses selected for this phase 2b study.

Dose levels of the present invention were obtained in the following assays: BTK occupancy rate, inhibition of basophil activation (monitored by increased expression of CD63 and CD203c) in healthy volunteers; and the effect on skin prick tests (SPT) in healthy volunteers with asymptomatic atopy - an indirect measure of inhibition of mast cells and basophils in the skin.

In this above-described clinical trial, administration of 10 mg of compound (I) q.d. resulted in almost complete BTK occupancy in the blood, a >90% reduction in the increase in CD63 expression (8 hours after administration of COMPOUND (I) at steady state), and minimal inhibition of wheal size in SPT. Thus, 10 mg of compound (I) q.d corresponds to the onset of biological activity. At a dose of 100 mg of the compound of formula (I), the average reduction in wheal size in SPT began to plateau. Therefore, 100 mg of compound corresponds to the maximum effect of COMPOUND (I). An average dose of compound (I) of thirty-five mg q.d. is well suited to accurately describe the dose-response curve of COMPOUND (I) when administered q.d.

The compound of formula (I) inhibits BTK by covalent binding. While the duration of BTK occupancy in the blood is >24 hours (h), rapid tissue metabolism of BTK (eg, approximately 5 hours in the spleen of rodents) may require administration of compound (I) b.i.d. to achieve maximum efficiency. Doses of 10, 25 and 100 mg of compound (I) b.i.d. accordingly accurately describe the dose-response curves for compound (I) when administered twice daily.

Safety for humans

For analysis of adverse effects, placebo-treated subjects from all SAD and MAD cohorts (2 per cohort) and stratified by SAD and MAD were combined into one placebo group (n=20 for SAD and n=16 for MAD ), for comparison with each individual compound (I) dose group (n=6 each) and with the total compound (I) group (n=60 for SAD, and n=48 for MAD). There were no apparent major differences in demographic data between the placebo group and the active ingredient groups for either the SAD or MAD populations. The safety assessment in the FIH study in healthy volunteers revealed no significant safety concerns at doses up to 600 mg.

Example 3: Efficacy and Safety Data in Patients with CSU Who Continue Symptoms Despite Standard Treatment

Phase 2b is a multicenter, randomized, double-blind, placebo-controlled, parallel-group study to examine the safety, tolerability, and efficacy of six dose groups of an orally administered compound of formula (I) in subjects with inadequately controlled CSU despite treatment with H1-antihistamines ( second generation).

For the duration of the study (i.e., from day -14 to day 113), subjects were on a stable regimen of second-generation H1 antihistamine drug on a locally approved, licensed dosing regimen (“background drug”).

Subjects may take an additional second-generation H1 antihistamine that is eliminated primarily by renal excretion (eg, cetirizine, levocetirizine, or bilastine) as a rescue drug. The rescue H1 antihistamine must be different from the background H1 antihistamine and can only be used to treat intolerable symptoms (itching) of CSU on a daily basis throughout the study (day -14 to day 113).

All other therapies for CSU (including H1 antihistamines at doses higher than approved) are prohibited (see Table 10).

The research design outline includes three periods:

Screening period (10-14 days before randomization): During the screening period, subjects who have provided informed consent are assessed for eligibility for inclusion in the study;

Treatment Period (Day 1 to Day 85): After screening, eligible subjects are randomly assigned to one of the following treatment groups in a 1:1:1:1:1:1:1 ratio:

10 mg of compound (I) once daily;

35 mg of compound (I) once daily;

100 mg of compound (I) once daily;

10 mg of compound (I) twice a day;

25 mg of compound (I) twice a day;

100 mg of compound (I) twice a day;

placebo;

An interim analysis was conducted to evaluate the dose-response relationship of the compound of formula (I) after all subjects had completed their week 4 visit (primary endpoint);

Follow-up Period (Day 86 to Day 113): Subjects are followed up to assess the durability of response after treatment is discontinued and to further assess safety.

Table 10. Prohibited drugs

Medicine Period during which use is prohibited Biologics for CSU (including omalizumab and ligelizumab) From 4 months before screening until the end of the study Regular (daily or every other day for 5 or more days in a row) doses of systemic corticosteroids From 30 days before screening until the end of the study
Note: From day 1 (baseline) to week 12 (end of treatment period), the use of systemic corticosteroids is generally prohibited. Leukotriene receptor antagonists (including montelukast and zafirlukast) From screening to the end of the study H2-antihistamines From screening to the end of the study First generation antihistamines From screening to the end of the study Second generation antihistamines, excluding certain background and emergency medications. From screening to the end of the study Other immunosuppressive drugs with or without a known effect on CSU, including but not limited to hydroxychloroquine, methotrexate, cyclosporine A, cyclophosphamide, tacrolimus, and mycophenolate mofetil From 30 days or 5 half-lives (whichever is longer) before screening until the end of the study Intravenous (i.v.) immunoglobulins or plasmapheresis From 30 days before screening until the end of the study Regular use (daily or every other day) of doxepin (oral) From 14 days before screening until the end of the study Live attenuated vaccine From 6 weeks before screening until the end of the study Any drug that prolongs the QTc interval (see guideline at https://crediblemeds.org) From 5 half-lives or until pharmacodynamic effect subsides before baseline determination (whichever is longer) until the end of the study Antiplatelet drugs or anticoagulants (eg, warfarin, clopidogrel, or new oral anticoagulants - NOACs) other than acetylsalicylic acid (up to 100 mg/day) From screening to the end of the study

Summary of the protocol

Purpose and rationale The purpose of this study is to collect data on the effectiveness and safety of the compound of formula (I) in subjects suffering from CSU, which is not adequately controlled by H1-antihistamines. Secondary Goals Evaluation of the effectiveness of compound (I) compared to placebo in terms of change in UAS7 value from baseline to week 12.
Evaluation of the effectiveness of compound (I) compared to placebo on change in UAS7 value from baseline over time.
Evaluation of the effectiveness of compound (I) compared to placebo in achieving complete clinical response (UAS7=0) over time.
Evaluation of the effectiveness of compound (I) compared to placebo in achieving disease control (UAS7≤ 6) over time.
Evaluation of the effect of compound (I) on angioedema (AAS7) in relation to the number of weeks with an AAS7=0 response from baseline to week 12.
Evaluation of the effect of compound (I) on disease-related quality of life in relation to achieving a DLQI score of 0 or 1 at week 4 and week 12.
Evaluation of the effect of compound (I) on CSU-related quality of life in terms of change in DLQI from baseline to week 4 and week 12.
Evaluation of the pharmacokinetics (PK) of compound (I) resulting from oral dosing (PK sampling at week 4 and week 12).
Evaluation of the safety and tolerability of compound (I) in subjects with CSU. Population The study population consists of approximately 308 adult female and male patients with chronic spontaneous urticaria, at least moderately active, poorly controlled by second-generation H1 antihistamines. Key inclusion criteria Male and female adult subjects aged ≥18 years.
Diagnosis of CSU made ≥ 6 months before screening.
Diagnosis of CSU not adequately controlled by second generation H1 antihistamines, defined by the following:
the presence of pruritus and urticaria for ≥6 consecutive weeks before screening, despite the use of non-sedating H1 antihistamines according to local treatment guidelines during this time period;
UAS7 score (range 0–42) ≥16 and HSS7 score (range 0–21) ≥8 within 7 days before randomization (day 1);
the presence of nettle rash must be documented within three months prior to randomization (either at screening and/or randomization, or documented in the subject's medical record). Key exclusion criteria Subjects with a clearly defined predominant or sole trigger for their chronic urticaria (chronic inducible urticaria), including self-induced urticaria (symptomatic dermographism), cold, heat, solar urticaria, pressure urticaria, delayed pressure urticaria, aquagenic, cholinergic, or contact urticaria.
Other diseases with symptoms of urticaria or angioedema, including but not limited to urticarial vasculitis, urticaria pigmentosa, erythema multiforme, mastocytosis, hereditary urticaria, or acquired/drug-induced urticaria.
Any other skin disease associated with chronic pruritus that the investigators believe may influence study assessments and results, such as atopic dermatitis, bullous pemphigoid, dermatitis herpetiformis, pruritus, or psoriasis.
Presence at the time of the study or a history of diagnosed ECG abnormalities indicating a significant safety risk for subjects participating in the study, such as the following:
• concomitant clinically significant forms of cardiac arrhythmia, such as sustained ventricular tachycardia and clinically significant second or third degree AV block without a pacemaker;
• a history of hereditary long QT syndrome or a known family history of bidirectional fusiform ventricular tachycardia;
• resting heart rate (physical examination or 12-lead ECG) < 60 bpm;
• QTcF at rest ≥450 ms (men) or ≥460 ms (women) before treatment [at screening] or impossibility of determining the QTcF interval;
• use of drugs known to prolong the QT interval unless they can be discontinued for the entire study period.
Significant risk of bleeding or bleeding disorders.
History of known or suspected current, chronic or recurrent infectious disease, including but not limited to opportunistic infections (eg, tuberculosis, atypical mycobacteriosis, listeriosis or aspergillosis), HIV, hepatitis B/C. Performance ratings In this study, all performance measures are PROs.
Urticaria Patient Daily Diary (UPDD), including the following:
Urticaria Activity Score (UAS);
assessment of angioedema activity (AAS);
assessing the impact of CSU on sleep and daily activities;
Dermatological Life Quality Index (DLQI). Key Safety Assessments Adverse Event (AE) Monitoring
Physical examination
Vital Signs
Monitoring laboratory markers in blood and urine
ECG monitoring Data analysis The main objective of this study is to characterize the dose-response relationship for doses of compound (I) q.d. and b.i.d and placebo on the change in UAS7 value from baseline at week 4 and select the appropriate dose for use in the phase 3 studies. Thus, the sequential steps are as follows: (1) confirm the overall dose-response signal, (2) estimate the dose curve -response to enable selection of dose(s) for phase 3 studies. To achieve these goals, the MCP-Mod methodology is used (Bretz et al 2005, biometrics, 61(3):738-48, Pinheiro et al 2014; Stat Med; 33(10):1646-61, Qualification Opinion on MCP-Mod EMA 2014, FDA endorsement 2016) For secondary endpoints, summary tables are presented by treatment group and visit (if applicable) using descriptive statistics that include absolute and relative frequencies for categorical variables and arithmetic mean, standard deviation, minimum, maximum, median and first and third quartiles for continuous variables.

Primary endpoints

The primary variable for the study is the change in UAS7 from baseline to week 4. UAS7 is the sum of the 7-day average of daily UAS scores. Please note that the weekly estimate is calculated using the last 7 days prior to the visit.

Secondary endpoints

The effectiveness of the present method is analyzed by treatment group and visit (if applicable) using descriptive statistics that include absolute and relative frequencies for categorical variables and arithmetic mean, standard deviation, minimum, maximum, median, and first and third quartiles for continuous variables. For secondary analysis of UAS7, clinical complete response, disease controllability, and AAS7=0, pairwise comparisons of each dose of compound (I) with placebo were performed.

UAS7

Summary statistics of absolute and percentage change in UAS7 value from baseline are analyzed by treatment group and visit during the treatment and follow-up periods.

Complete clinical response

Complete clinical response, i.e. absence of urticaria and pruritus, is defined as subjects achieving UAS7=0.

Number of subjects with UAS7=0 by treatment group and visit during the treatment and follow-up periods.

Pairwise comparisons between treatment groups (individual compound (I) versus placebo groups).

Controlled disease (UAS7≤ 6)

Number of subjects with UAS7≤ 6 by treatment group and visit during the treatment and follow-up periods.

Pairwise comparisons between treatment groups (individual compound (I) versus placebo groups).

Absence of angioedema (AAS7=0)

Cumulative number of weeks with AAS7=0 response between baseline and week 12.

The indicator is obtained based on the AAS electronic diary. The weekly AAS7 score was obtained by summing the daily scores for the 7 days preceding the visit and ranges from 0 to 105. If the AAS7 score is missing, it is considered as non-response for the cumulative number of weeks in which subjects achieve an AAS7 response=0 . The cumulative number of weeks to achieve an AAS7=0 response between baseline and week 12 was modeled using a negative binomial regression model with a log link, using treatment group, randomization strata, and AAS7=0 status at baseline.

DLQI

Seven scores are derived from the DLQI: the score for each of the six dimensions, as well as the overall DLQI score, are calculated based on the developers' rules. For each of these seven scores, change from baseline and percentage change from baseline are also obtained. Summary statistics are calculated for absolute values as well as change and percentage change by visit and treatment group.

Number of subjects with a DLQI score of 0 or 1 by treatment group and visit.

Security endpoints

All safety endpoints (i.e., AEs, laboratory data, vital signs and ECG, and potential risks identified in the safety profiling plan) are summarized by treatment for all subjects in the safety sample. All data are included in the analysis regardless of whether rescue medications were used.

The data obtained in the clinical study, as well as the preclinical data presented above, demonstrate that compound (I), at daily doses of 10 mg to 200 mg, is safe and pharmacologically active in the treatment of skin diseases caused by basophils and mast cells.

Claims (25)

1. A method of treating chronic spontaneous urticaria (CSU), comprising administering to a subject in need thereof a daily dose of from about 10 mg to about 100 mg of a compound of formula (I) (I), where the term “about” means +/-10%. 2. Method according to claim 1, where the daily dose is 100 mg +/-10%. 3. Method according to claim 1, where the daily dose is 50 mg +/-10%. 4. Method according to claim 1, where the daily dose is 35 mg +/-10%. 5. Method according to claim 1, where the daily dose is 25 mg +/-10%. 6. Method according to claim 1, where the daily dose is 20 mg +/-10%. 7. The method of claim 1, wherein the compound of formula (I) is administered once daily at a dose of about 10 mg, about 35 mg, about 50 mg, or about 100 mg and where the term “about” means +/-10%. 8. The method of claim 1, wherein the compound of formula (I) is administered at a dose of about 10 mg, about 25 mg or about 50 mg twice daily and where the term “about” means +/-10%. 9. The method of any one of the preceding claims, wherein before treatment with a compound of formula (I), the subject has previously received treatment with a systemic agent for the treatment of CSU. 10. The method of claim 9, wherein the systemic agent is selected from the group consisting of H1-antihistamines (H1-AH), H2-antihistamines (H2-AH) and leukotriene receptor antagonist (LTRA) and combinations thereof. 11. Method according to any one of paragraphs. 1-8, wherein before treatment with a compound of formula (I), the subject has not previously received treatment with a systemic agent for the treatment of CSU. 12. The method of any one of the preceding claims, wherein the subject has moderate to severe CSU. 13. Method according to any one of paragraphs. 1-11, where the subject is selected in accordance with at least one of the following criteria: a) before treatment with a compound of formula (I), the subject has a UAS7 score that is greater than or equal to 16; b) before treatment with a compound of formula (I), the subject has an HSS7 score that is greater than or equal to 8. 14. The method according to any of the previous paragraphs, where the subject is an adult. 15. The method of any one of the preceding claims, wherein said subject achieves at least one of the following by week 4 or week 12 of treatment: a) a decrease in the number of elements of nettle rash and itching, measured as a UAS value that is less than or equal to 6, or a complete absence of nettle rash and itching (UAS7 value equal to 0); or b) dermatological life quality index (DLQI) of 0-1; c) absence of angioedema, measured as an angioedema activity score (AAS7) of zero. 16. The method of any of the preceding claims, wherein said subject achieves a sustained response, measured as a complete response that includes urticaria and pruritus ([UAS7] equal to 0), and/or as a dermatological life quality index (DLQI) , equal to 0-1, and/or continued absence of angioedema (AAS7 equal to 0) by week 4 after completion of treatment. 17. The method according to any of the previous claims, wherein the compound of formula (I) is placed in a pharmaceutical composition and wherein said pharmaceutical composition further contains pharmaceutically acceptable carriers. 18. Method according to any one of paragraphs. 1-16, wherein the maximum length of time the compound of formula (I) reaches its maximum concentration after administration is approximately 0.5-3 hours and where the term “about” means +/-10%.