US20210038636A1

US20210038636A1 - Potassium binding polymers for treating hypertension and hyperkalemia

Info

Publication number: US20210038636A1
Application number: US17/080,200
Authority: US
Inventors: Gerrit Klaerner; Lance Berman
Original assignee: Vifor International AG
Current assignee: Vifor International AG
Priority date: 2012-10-08
Filing date: 2020-10-26
Publication date: 2021-02-11
Also published as: CA2886788C; JP6475624B2; WO2014058905A2; KR20150088243A; US9492476B2; JP2020176155A; JP6817185B2; AU2020294307B2; US20140105848A1; AU2018260862A1; AU2020294307A1; HK1210705A1; KR20210005314A; EP2916851A2; US20170020916A1; US10813946B2; US20210046104A1; JP2021095421A; CA2886788A1; AU2013329451B2

Abstract

The present invention generally relates to methods of treating hypertension (HTN) in patients in need thereof wherein the patient optionally further suffers from chronic kidney disease (CKD) or Type II diabetes mellitus (T2DM). The invention also relates to methods of treating hyperkalemia in a patient in need thereof, wherein the patient suffers from CKD, T2DM or HTN and are optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent. The invention also relates to methods of treating kidney disease in a patient in need thereof, wherein the patient is optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent. The methods can comprise administering an effective amount of a potassium-binding polymer to the patient to lower the patient's blood pressure and/or increase or stabilize the patient's kidney function.

Description

REFERENCE TO RELATED APPLICATIONS

This application is a U.S. Divisional Patent Application which claims priority to U.S. Non-Provisional patent application Ser. No. 14/048,983 filed Oct. 8, 2013, which claims the benefit of U.S. Provisional Patent Application No. 61/711,184, filed Oct. 8, 2012. The entire content of the above application is hereby incorporated by reference.

FIELD OF THE INVENTION

The present invention generally relates to methods of treating hypertension (HTN) in patients in need thereof wherein the patient optionally further suffers from chronic kidney disease (CKD) or Type II diabetes mellitus (T2DM). The invention also relates to methods of treating kidney disease in a patient in need thereof, wherein the patient is optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent. The invention also relates to methods of treating hyperkalemia in a patient in need thereof, wherein the patient suffers from CKD, T2DM or HTN and are optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent. The methods can comprise administering an effective amount of a potassium-binding polymer to the patient to lower the patient's blood pressure and/or increase or stabilize the patient's kidney function.

BACKGROUND OF THE INVENTION

Normal kidney function is critical for the maintenance of potassium homeostasis. The ability of the kidney to maintain potassium homeostasis depends on several factors, including the normal production of aldosterone, sodium delivery to the distal nephron, and adequate sodium-potassium exchange in the cortical collecting duct (Palmer, B.F., N. Engl. J. Med. 2004, 351:585-92). Of these factors, aldosterone production and action is closely regulated by the renin-angiotensin-aldosterone system (RAAS), a cornerstone of the regulatory components controlling blood pressure, blood volume and cardiovascular function. RAAS inhibition, designed to limit aldosterone production and function, is therefore an important treatment strategy for hypertension, diabetes, chronic kidney disease and heart failure. Several studies have demonstrated the renal protective effects of angiotensin receptor blockers (ARBs) such as losartan or irbesartan (Brenner, B. M. et al., N. Engl. J. Med. 2001, 345:861-869; de Zeeuw, D. et al. Kidney Intl. 2004, 65:2309-2320; Miao, Y. et al., Diabetologia 2010; Lewis, E. J. et al., N. Engl. J. Med. 2001, 345:851-860; Atkins, R. C. et al., Am. J. Kidney Dis. 2005, 45:281-287), while studies using dual blockade of the RAAS with an aldosterone antagonist (spironolactone or eplerenone), added to either angiotensin converting enzyme inhibitor (ACEI) or ARB therapy, were shown to substantially reduce cardiovascular endpoints in heart failure or post-myocardial infarction patients (Pitt, B. et al., N. Engl. J. Med. 1999, 341:709-717; Pitt, B., Molecular & Cellular Endocrinol. 2004, 217:53-58; Zannad, F. et al., European J. Heart Failure 2010).
Despite the demonstrated clinical benefits of RAAS inhibitors, the fundamental mode of action of the drugs disturbs the exchange of sodium for potassium in the kidney tubule. As a result, potassium retention can precipitate hyperkalemia, defined as a serum potassium value >5.0 mEq/L. This is particularly problematic in patients with reduced renal function resulting from chronic kidney disease and common co-morbidities such as hypertension, diabetes and heart failure. In this situation, the combination of RAAS inhibition and reduced renal function can aggravate the nascent positive potassium balance and trigger a hyperkalemic event. Thus, there is a need to control blood pressure in patients and treat hyperkalemia.

SUMMARY OF THE INVENTION

One aspect of the invention is a method of treating hypertension in a patient in need thereof. The method comprises administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient.
Another aspect is a method of treating hypertension in a chronic kidney disease patient in need thereof. The patient is optionally treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent and the method comprising administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient.
A further aspect is a method of treating hypertension in a heart failure patient in need thereof. The patient is optionally treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent and the method comprises administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient.
Yet another aspect is a method of treating hypertension in a type 2 diabetes mellitus patient in need thereof. The patient is optionally treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent and the method comprises administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient.
Yet a further aspect is a method of treating hyperkalemia in a chronic kidney disease patient in need thereof optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent. The method comprises administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient to increase or stabilize the patient's kidney function by decreasing the patient's serum creatinine level as compared to the patient's serum creatinine level before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.
Another aspect of the invention is a method of treating hyperkalemia in a chronic kidney disease patient in need thereof optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent. The method comprises administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient to increase or stabilize the patient's kidney function by decreasing the time to progression of end stage renal disease as compared to a chronic kidney disease patient optionally treated with a RAAS agent but not treated with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.
A further aspect is a method of treating hyperkalemia in a chronic kidney disease patient in need thereof optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent. The method comprises administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient to increase or stabilize the patient's kidney function by increasing survival as compared to a chronic kidney disease patient optionally treated with a RAAS agent but not treated with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.
Yet another aspect is a method of treating hyperkalemia in a chronic kidney disease patient in need thereof optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent. The method comprises administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient to increase or stabilize the patient's kidney function by increasing or stabilizing estimated glomerular filtration rate (eGFR) as compared to the patient's eGFR before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.
Another aspect is a method of treating chronic kidney disease in a patient in need thereof optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent. The method comprises administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient to increase or stabilize the patient's kidney function by decreasing the patient's serum creatinine level as compared to the patient's serum creatinine level before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.
A further aspect is a method of treating chronic kidney disease in a patient in need thereof optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent. The method comprises administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient to increase or stabilize the patient's kidney function by decreasing the time to progression of end stage renal disease as compared to a chronic kidney disease patient optionally treated with a RAAS agent but not treated with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.
Yet another aspect is a method of treating chronic kidney disease in a patient in need thereof optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent. The method comprises administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient to increase or stabilize the patient's kidney function by increasing survival as compared to a chronic kidney disease patient optionally treated with a RAAS agent but not treated with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.
Another aspect is a method of treating chronic kidney disease in a patient in need thereof optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent. The method comprises administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient to increase or stabilize the patient's kidney function by increasing or stabilizing estimated glomerular filtration rate (eGFR) as compared to the patient's eGFR before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.
Other objects and features will be in part apparent and in part pointed out hereinafter.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a graph of the central lab serum potassium concentration in mEq/L versus time of treatment for patients having been treated for six months with the protocol described in Example 2 and having any albumin creatinine ratio (ACR), an ACR ≥30, and ACR >300 and an estimated glomerular filtration rate (eGFR) of 15-44 mL/min/1.73 m².

FIG. 2 is a graph of the systolic blood pressure (SBP) in mmHg versus time of treatment for patients having been treated for six months with the protocol described in Example 2 and having any albumin creatinine ratio (ACR), an ACR ≥30, and ACR ≥300 and an estimated glomerular filtration rate (eGFR) of 15-44 mL/min/1.73 m².

FIG. 3 is a graph of the diastolic blood pressure (DBP) in mmHg versus time of treatment for patients having been treated for six months with the protocol described in Example 2 and having any albumin creatinine ratio (ACR), an ACR ≥30, and ACR >300 and an estimated glomerular filtration rate (eGFR) of 15-44 mL/min/1.73 m².

FIG. 4 is a graph of the urine ACR in mg/g versus time of treatment for patients having been treated for six months with the protocol described in Example 2 and having any albumin creatinine ratio (ACR), an ACR ≥30, and ACR ≥300 and an estimated glomerular filtration rate (eGFR) of 15-44 mL/min/1.73 m².

FIG. 5 is a graph of the eGFR in mL/min/1.73 m²versus time of treatment for patients having been treated for six months with the protocol described in Example 2 and having any albumin creatinine ratio (ACR), an ACR ≥30, and ACR >300 and an estimated glomerular filtration rate (eGFR) of 15-44 mL/min/1.73 m².

FIG. 6 is a graph of eGFR versus time of treatment for a cohort of patients having pre-existing hyperkalemia on a stable dose of a RAAS inhibitor that came to the trial without a run-in period that were treated for twelve months as described in Example 2. For FIGS. 6-9, the data is presented at baseline (BL), one month (M1), two months (M2), six months (M6), and twelve months (M12).

FIG. 7 is a graph of serum potassium versus time of treatment for a cohort of patients having pre-existing hyperkalemia on a stable dose of a RAAS inhibitor that came to the trial without a run-in period that were treated for twelve months with as described in Example 2.

FIG. 8 is a graph of urine ACR versus time of treatment for a cohort of patients having pre-existing hyperkalemia on a stable dose of a RAAS inhibitor that came to the trial without a run-in period that were treated for twelve months as described in Example 2.

FIG. 9 is a graph of systolic and diastolic blood pressure versus time of treatment for a cohort of patients having pre-existing hyperkalemia on a stable dose of a RAAS inhibitor that came to the trial without a run-in period that were treated for twelve months as described in Example 2.

DESCRIPTION OF THE PREFERRED EMBODIMENTS

Potassium-binding polymers can remove potassium from the gastrointestinal tract and reduce the serum potassium level (U.S. Pat. No. 7,566,799). Various studies show that an increase in serum potassium level increases the aldosterone level and a decrease in serum potassium level decreases the aldosterone level (T. Himathongkam, et al., J. Clin. Endocrinol. Metab. 1975, 41(1):153-159). These studies have shown that a small increase or decrease in serum potassium level can cause a larger change in the aldosterone level. Further, other studies show that an increase in potassium intake can reduce blood pressure (He, F. J., et al., Hypertension 2005, 45:571-574). It has now been discovered, and clinically observed, that lowering of serum potassium levels in patients also lowers blood pressure. This finding was unexpected given that the intended primary benefit of the potassium-binding polymer was to lower serum potassium. The lowering of potassium and blood pressure using a potassium-binding polymer is beneficial in patients with renal impairment, hyperkalemia and hypertension given that these patients are at significant risk of increased morbidity and mortality. Lowering of blood pressure is also beneficial in patients without such co-morbidities who suffer from hypertension.
Thus, the invention is directed to methods of treating hypertension or hyperkalemia or kidney disease in a patient in need thereof, the method comprising administering an effective amount of a potassium-binding polymer, particularly, 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer, crosslinked in the salt or acid form to the patient. In particular, the invention is directed to methods of treating hypertension and hyperkalemia in a patient in need thereof. In particular also, the invention is directed to methods of treating kidney disease and hyperkalemia in a patient in need thereof.
The methods of treating hypertension or kidney disease can include chronic administration of the 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form. The 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form exhibits long-term tolerability, long-term safety, and/or long-term efficacy in the patient. The long-term tolerability, long-term safety, and long-term efficacy are observed over treatment periods of 12, 16, 20, 24, 28, 32, 36, 40, 44, 48, 52, or more weeks. The treatment period can also be 2 years, 3 years, 4 years, 5 years, or more. Particularly, the 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form can be administered to the patient daily for more than 8 weeks or daily for more than one year.
The methods of treating hypertension and hyperkalemia can also reduce the patient's systolic blood pressure by 5, 6, 7, 8 mmHg as compared to the patient's systolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form, and/or reduce the patient's diastolic blood pressure 2, 3, 4, 5, 6 mmHg as compared to the patient's diastolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.
The methods of treating hypertension and hyperkalemia can also reduce the patient's systolic blood pressure by 9, 10, 11, 12, 13, 14, 15, 16, 17 mmHg or more as compared to the patient's systolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form, and/or reduce the patient's diastolic blood pressure 7, 8, 9, 10, 11, 12, 13 mmHg or more as compared to the patient's diastolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.
The methods of treating hypertension and hyperkalemia can also reduce the patient's systolic blood pressure by at least 6, 7, 8, 9, 10, 11, 12, or more percent as compared to the patient's systolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form, and/or the patient's diastolic blood pressure is reduced by at least 8, 9, 10, 11, 12, 13, 14, 15, or more percent as compared to the patient's diastolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.
The 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form can be administered to a patient having a systolic blood pressure greater than 130 mmHg or ranging from 130 to 200 mmHg, 135 to 200 mmHg, 140 to 200 mmHg, 145 to 200 mmHg, or 150 to 180 mmHg before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.
The 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form can be administered to a patient having a systolic blood pressure greater than 143 mmHg or ranging from 143 to 200 mmHg or 143 to 180 mmHg before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.
The systolic blood pressure of the patient can be maintained below 130, 135, or 140 mmHg over at least 90% of the period of treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form. The diastolic blood pressure of the patient can be maintained at below 80, 85, or 90 mmHg over at least 90% of the period of treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.
The methods of treating hypertension can include administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to a heart failure patient, a type 2 diabetes mellitus patient, and/or a chronic kidney disease patient in need of hypertension treatment, the patient optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent.
The methods of treatment of hypertension can be administered to a patient suffering from chronic kidney disease, heart failure, type 2 diabetes mellitus or a combination thereof.
The 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form can be administered to a patient that is not being treated with an aldosterone antagonist. Particularly, the patient is not being treated with spironolactone.
The methods of treating hypertension can include administration of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to a patient that does not have another condition that causes hypertension such as Type 2 diabetes, chronic kidney disease, chronic heart failure or a combination thereof. Particularly, the patient does not have type 2 diabetes mellitus, or the patient that does not have chronic kidney disease (CKD).
The methods of treating hypertension can include administration of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to a patient that does not have Class II or Class III heart failure (HF).
The methods of treating hypertension can also include administration of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to a patient that is not being treated with a heart failure therapy; the heart failure therapy can be an angiotensin converting enzyme inhibitor (ACEI), an angiotensin receptor blocker (ARB), a beta blocker (BB), or a combination thereof.
The patients receiving the treatment methods of the invention need not be treated with an antihypertensive agent comprising a diuretic, a calcium channel blocker, an alpha blocker, a nervous system inhibitor, a vasodilator, an angiotensin converting enzyme inhibitor (ACEI), an angiotensin receptor blocker (ARB), a beta blocker (BB), or a combination thereof.
The methods of treating hypertension of the invention can be administered to patients that are normokalemic. Normokalemic patients have a serum potassium level of 3.5 to 5.0 mEq/L.
The present invention is directed to methods of treating hyperkalemia in a chronic kidney disease patient in need thereof optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent. The methods generally comprise administering an effective amount of a potassium-binding polymer to the patient to increase or stabilize the patient's kidney function.
The present invention is directed to methods of treating chronic kidney disease in a patient in need thereof optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent. The methods generally comprise administering an effective amount of a potassium-binding polymer to the patient to increase or stabilize the patient's kidney function.
In the methods of treating kidney disease, there are several ways in which the methods can exhibit an increase to or stabilization of the patient's kidney function, such as by decreasing the patient's serum creatinine level as compared to the patient's serum creatinine level before treatment with a potassium-binding polymer; decreasing the time to progression of end stage renal disease as compared to a chronic kidney disease patient optionally treated with a RAAS agent but not treated with a potassium-binding polymer; increasing survival as compared to a chronic kidney disease patient optionally treated with a RAAS agent but not treated with a potassium-binding polymer; and/or increasing or stabilizing estimated glomerular filtration rate (eGFR) as compared to the patient's eGFR before treatment with a potassium-binding polymer.
As detailed in Example 2, a Phase II clinical study conducted in Type 2 diabetes mellitus (T2DM) patients with chronic kidney disease (CKD) Phase 3/4 is instructive. All patients are treated with a RAAS inhibitor, and 40% of the patients have heart failure (HF). And, endpoints measure changes from baseline at various time points. The trial is an 8-week, open-label, randomized, dose ranging study to determine the optimal starting dose(s) of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form. In addition, the study contains a 44-week long-term safety extension component, in order to collect 1-year safety data that will support chronic use of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form. Patients with normal serum K⁺ levels of 4.3-5.0 mEq/L were enrolled in a run-in period during which they received the maximum labeled dose of losartan and/or additional spironolactone as needed. Patients with serum K⁺ levels >5.0 mEq/L at baseline entered the study without a run-in period. For treatment of hyperkalemia (serum K⁺>5.0 mEq/L), two potassium strata were chosen (stratum 1=serum K⁺>5.0-5.5 mEq/L; stratum 2=serum K^+>5.5-<6.0 mEq/L), based on the National Kidney Foundation Kidney Disease Outcomes Quality Initiative Guideline 11 (KDOQI, 2004) definition of hyperkalemia and serum potassium cut-off points for ACEI/ARB dose modification.
This Phase II Study was enrolled with a total of 306 subjects treated for an average duration of 9.5 months. All subjects completed the trial, with 266 subjects completing 8 weeks, 226 subjects completing 6 months and 197 patients completing one year.
Several key observations can be made. Looking at interim data, and a statistically significant number of the 182 patients had an albumin creatinine ratio (ACR) of ≥30 mg/g and others had an ACR of >300 mg/g and an estimated glomerular filtration rate (eGFR) of 15 to 44 mL/min/1.73 m²at baseline. As shown in FIG. 1, for all of these patients, the patient's serum potassium concentration decreased from an average of 5.27 mEq/L at baseline to an average of 4.57 mEq/L at 24 weeks. For patients having an ACR ≥30 mg/g, the patient's serum potassium concentration decreased from an average of 5.28 mEq/L at baseline to an average of 4.60 mEq/L at 24 weeks. For patients having an ACR >300 mg/g, the patient's serum potassium concentration decreased from an average of 5.35 mEq/L at baseline to an average of 4.65 mEq/L at 24 weeks. For patients having an eGFR of 15 to 44 mL/min/1.73 m², the patient's serum potassium concentration decreased from an average of 5.33 mEq/L at baseline to an average of 4.59 mEq/L at 24 weeks.
As shown in FIG. 2, for all of these patients, the patient's systolic blood pressure decreased from an average of 154 at baseline to an average of 137 at 24 weeks; for patients having an ACR ≥30 mg/g, the patient's systolic blood pressure decreased from an average of 154 at baseline to an average of 138 at 24 weeks; for patients having an ACR >300 mg/g, the patient's systolic blood pressure decreased from an average of 154 at baseline to an average of 137 at 24 weeks; and for patients having an eGFR of 15 to 44 mL/min/1.73 m², the patient's systolic blood pressure decreased from an average of 152 at baseline to an average of 135 at 24 weeks.
As shown in FIG. 3, for all of these patients, the patient's diastolic blood pressure decreased from an average of 83 at baseline to an average of 74 at 24 weeks; for patients having an ACR ≥30 mg/g, the patient's diastolic blood pressure decreased from an average of 84 at baseline to an average of 74 at 24 weeks; for patients having an ACR >300 mg/g, the patient's diastolic blood pressure decreased from an average of 86 at baseline to an average of 73 at 24 weeks; and or patients having an eGFR of 15 to 44 mL/min/1.73 m², the patient's diastolic blood pressure decreased from an average of 82 at baseline to an average of 73 at 24 weeks.
As shown in FIG. 4, for the patients in all groups and each group separately (e.g., ACR of ≥30 mg/g, ACR of >300 mg/g, eGFR of 15 to 44 mL/min/1.73 m²), the ACR did not significantly change over the 24 week treatment period.
As shown in FIG. 5, for patients having an eGFR of 15 to 44 mL/min/1.73 m², the patient's eGFR increased from an average of 32 mL/min/1.73 m²at baseline to an average of 38 mL/min/1.73 m²at 24 weeks. This increase in eGFR for these patients was statistically significant.
As described above, FIGS. 6-9 show data from a certain cohort of patients with pre-existing hyperkalemia taking a stable dose of a RAAS inhibitor that came into the trial without a run-in period. As shown in FIG. 6, the average of these patients' eGFR of 46 mL/min/1.73 m²at baseline did not decrease over time, as can be expected in these patients. Further data suggests that in a subset of patients, the eGFR appears to increase at one year. As shown in FIG. 7, the average of these patients' serum potassium level decreased significantly from 5.3 mEq/L at baseline into the normal range (to 4.6 mEq/L) at 12 months. As shown in FIG. 8, the average of these patients' urine ACR of 853 mg/g at baseline was not significantly different from the average of the patients' urine ACR at any other time point. As shown in FIG. 9, the average of these patients' systolic blood pressure decreased from 157 mmHg to 134 mmHg and the average of these patients' diastolic blood pressure decreased from 85 mmHg to 77 mmHg.
Additional observations can be made from the study results. First, the starting serum potassium is a factor in determining efficacy of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form. The final analysis of the 8-week Treatment Initiation Period performed for 304 subjects showed a mean decrease in serum potassium from baseline to week 8 in subjects in the upper serum potassium stratum (Stratum 2: serum K⁺>5.5 to <6.0 mEq/L) that was approximately twice that in subjects in the lower serum potassium stratum (Stratum 1: serum K⁺>5.0 to 5.5 mEq/L) (−0.90 mEq/L versus −0.47 mEq/L, respectively). This baseline effect was seen within the first week on treatment. Second, underlying RAAS inhibitor treatment does not appear to influence the efficacy of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form. Third, the efficacy of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form appears to be independent of comorbidities.
As used in this application, the potassium-binding polymer can be 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer, crosslinked in the salt or acid form. Particularly, the 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form is in the salt form. The salt form comprises the sodium, calcium, magnesium, ammonium, or a combination thereof; preferably, the salt form comprises the calcium salt form.
Also, the 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer, crosslinked in the salt form can be stabilized with a linear polyol. Particularly, the 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer, crosslinked in the salt form can be stabilized with 10 wt. % to about 40 wt. % of a linear polyol based on the total weight of the composition.
A linear polyol is added to the composition containing the salt of a potassium-binding polymer (e.g., 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer, crosslinked in the salt form) in an amount effective to stabilize the polymer salt, and generally from about 10 wt. % to about 40 wt. % linear polyol based on the total weight of the composition.
The linear polyol is preferably a linear sugar (i.e., a linear sugar alcohol). The linear sugar alcohol is preferably selected from the group consisting of D-(+)arabitol, erythritol, glycerol, maltitol, D-mannitol, ribitol, D-sorbitol, xylitol, threitol, galactitol, isomalt, iditol, lactitol and combinations thereof, more preferably selected from the group consisting of D-(+)arabitol, erythritol, glycerol, maltitol, D-mannitol, ribitol, D-sorbitol, xylitol, and combinations thereof, and most preferably selected from the group consisting of xylitol, sorbitol, and a combination thereof.
Preferably, the pharmaceutical composition contains from about 15 wt. % to about 35 wt. % stabilizing polyol based on the total weight of the composition. In various embodiments, this linear polyol concentration is sufficient to reduce the release of fluoride ion from the cation exchange polymer upon storage as compared to an otherwise identical composition containing no stabilizing polyol at the same temperature and storage time.
Further, the potassium-binding polymer can be a crosslinked cation exchange polymer comprising units having Formulae 1, 2, and 3 as represented by the following structures:
wherein R₁and R₂are independently selected from hydrogen, alkyl, cycloalkyl, or aryl; A₁is carboxylic, phosphonic, or phosphoric in its salt or acid form; X₁is arylene; X₂is alkylene, an ether moiety or an amide moiety, m is in the range of from about 85 to about 93 mol %, n is in the range of from about 1 to about 10 mol % and p is in the range of from about 1 to about 10 mol % calculated based on the ratio of monomers and crosslinkers added to the polymerization mixture.
When X₂is an ether moiety, the ether moiety can be —(CH₂)_d—O—(CH₂)_e— or —(CH₂)_d—O—(CH₂)_e—O—(CH₂)_d—, wherein d and e are independently an integer of 1 through 5.
Preferably, d is an integer from 1 to 2 and e is an integer from 1 to 3.
When X₂is an amide moiety, the amide moiety can be —C(O)—NH—(CH₂)_p—NH—C(O)— wherein p is an integer of 1 through 8. Preferably, p is an integer of 4 to 6.
The unit corresponding to Formula 2 can be derived from a difunctional crosslinking monomer having the formula CH₂═CH—X₁—CH═CH₂wherein X₁is as defined in connection with Formula 2.
The unit corresponding to Formula 3 can be derived from a difunctional crosslinking monomer having the formula CH₂═CH—X₂—CH═CH₂wherein X₂is as defined in connection with Formula 3.
In connection with Formula 1, R₁and R₂are hydrogen and A₁is carboxylic.
In connection with Formula 2, X₁is an optionally substituted phenylene, and preferably phenylene.
In connection with Formula 3, X₂is optionally substituted ethylene, propylene, butylene, pentylene, or hexylene; more specifically, X₂is ethylene, propylene, butylene, pentylene, or hexylene; and preferably X₂is butylene. Specifically, R₁and R₂are hydrogen, A₁is carboxylic acid, X₁is phenylene and X₂is butylene.
Generally, the Formulae 1, 2 and 3 structural units of the terpolymer have specific ratios, for example, wherein the structural units corresponding to Formula 1 constitute at least about 80 wt. %, particularly at least about 85 wt. %, and more particularly at least about 90 wt. % or from about 80 wt. % to about 95 wt. %, from about 85 wt. % to about 95 wt. %, from about 85 wt. % to about 93 wt. % or from about 88 wt. % to about 92 wt. % based on the total weight of structural units of Formulae 1, 2, and 3 in the polymer, calculated based on the monomers of Formulae 11, 22, and 33 used in the polymerization reaction, and the weight ratio of the structural unit corresponding to Formula 2 to the structural unit corresponding to Formula 3 is from about 4:1 to about 1:4, or about 1:1.
Further, the ratio of structural units when expressed as the mole fraction of the structural unit of Formula 1 in the polymer is at least about 0.87 or from about 0.87 to about 0.94, or from about 0.9 to about 0.92 based on the total number of moles of the structural units of Formulae 1, 2, and 3, and the mole ratio of the structural unit of Formula 2 to the structural unit of Formula 3 is from about 0.2:1 to about 7:1, from about 0.2:1 to about 3.5:1; from about 0.5:1 to about 1.3:1, from about 0.8 to about 0.9, or about 0.85:1; again these calculations are performed using the amounts of monomers of Formulae 11, 22, and 33 used in the polymerization reaction. It is not necessary to calculate conversion.
In some aspects, the crosslinked cation exchange polymer comprises units corresponding to Formulae 1A, 2A, and 3A, wherein Formula 1A, Formula 2A and Formula 3A correspond to the following structures.
In Formula 1 or 1A, the carboxylic acid can be in the acid form (i.e., balanced with hydrogen), in salt form (i.e., balanced with a counter-ion such as Ca²⁺, Mg²⁺, Na⁺, NH₄ ⁺, and the like) or in an ester form (i.e., balanced with an alkyl, such as methyl). Preferably, the carboxylic acid is in the salt form and balanced with a Ca²⁺ counterion.
When the carboxylic acid of the crosslinked cation exchange form is balanced with a divalent counterion, two carboxylic acid groups can be associated with the one divalent cation.
The polymers described herein are generally random polymers wherein the exact order of the structural units of Formulae 1, 2, or 3 (derived from monomers of Formulae 11, 22, or 33), or 1A, 2A, or 3A (derived from monomers of Formulae 11A, 22A, or 33A) is not predetermined.
A cation exchange polymer derived from monomers of Formulae 11, 22, and 33, followed by hydrolysis, can have the structure as follows:
wherein R₁, R₂, A₁, X₁, and X₂are as defined in connection with Formulae 1, 2, and 3 and m is in the range of from about 85 to about 93 mol %, n is in the range of from about 1 to about 10 mol % and p is in the range of from about 1 to about 10 mol % calculated based on the ratio of monomers and crosslinkers added to the polymerization mixture. The wavy bonds in the polymer structures of Formula 40 are included to represent the random attachment of structural units to one another wherein the structural unit of Formula 1 can be attached to another structural unit of Formula 1, a structural unit of Formula 2, or a structural unit of Formula 3; the structural units of Formulae 2 and 3 have the same range of attachment possibilities.
Using the polymerization process described herein, with monomers of Formulae 11A, 22A and 33A, followed by hydrolysis and calcium ion exchange, a polymer having the general structure shown below is obtained:
wherein m is in the range of from about 85 to about 93 mol %, n is in the range of from about 1 to about 10 mol % and p is in the range of from about 1 to about 10 mol %, calculated based on the ratios of monomers and crosslinkers added to the polymerization mixture. The wavy bonds in the polymer structures of Formula 40A are included to represent the random attachment of structural units to one another wherein the structural unit of Formula 1A can be attached to another structural unit of Formula 1A, a structural unit of Formula 2A, or a structural unit of Formula 3A; the structural units of Formulae 2A and 3A have the same range of attachment possibilities.
The crosslinked cation exchange polymer is generally a reaction product of a polymerization mixture that is subjected to polymerization conditions. The polymerization mixture may also contain components that are not chemically incorporated into the polymer. The crosslinked cation exchange polymer typically comprises a fluoro group and an acid group that is the product of the polymerization of three different monomer units where one monomer comprises a fluoro group and an acid group, another monomer is a difunctional arylene monomer and a third monomer is a difunctional alkylene, ether- or amide-containing monomer. More specifically, the crosslinked cation exchange polymer can be a reaction product of a polymerization mixture comprising monomers of Formulae 11, 22, 33. The monomer of Formula 11, the monomer of Formula 22, and the monomer of Formula 33 have the general formulas:
wherein R₁and R₂are as defined in connection with Formula 1, X₁is as defined in connection with Formula 2, X₂is as defined in connection with Formula 3, and A₁₁is an optionally protected carboxylic, phosphonic, or phosphoric.
Preferably, A₁₁is a protected carboxylic, phosphonic, or phosphoric.
The polymerization mixture typically further comprises a polymerization initiator.
The reaction product of the polymerization mixture comprising Formulae 11, 22, 33 comprises a polymer having protected acid groups and comprising units corresponding to Formula 10 and units corresponding to Formulae 2 and 3. Polymer products having protected acid groups can be hydrolyzed to form a polymer having unprotected acid groups and comprising units corresponding to Formulae 1, 2, and 3. The structural units corresponding to Formula 10 have the structure
wherein R₁, R₂, and A₁₁are as defined in connection with Formula 11 and m is as defined in connection with Formula 1.
In any of the methods of the invention wherein the crosslinked cation exchange polymer is a reaction product of a polymerization mixture of monomers, A₁₁can be a protected carboxylic, phosphonic, or phosphoric. The polymer formed in the polymerization reaction contains protected carboxylic, phosphonic, or phosphoric groups. A hydrolysis agent can be added to the polymer formed in the polymerization reaction to hydrolyze these protected groups, converting them to carboxylic, phosphonic, or phosphoric groups, or other methods of deprotection well known in the art can be used. The hydrolyzed polymer is preferably subjected to ion exchange to obtain a preferred polymer salt for therapeutic use.
Generally, the polymerization reaction mixture comprises at least about 85 wt. % or from about 80 wt. % to about 95 wt. % of monomers corresponding to Formula 11 based on the total weight of the monomers corresponding to Formulae 11, 22, and 33; and the mixture having a weight ratio of the monomer corresponding to Formula 22 to the monomer corresponding to Formula 33 from about 4:1 to about 1:4, from about 2:1 to 1:2, or about 1:1.
The polymerization reaction mixture can comprise a unit corresponding to Formula 11 having a mole fraction of at least about 0.87 or from about 0.87 to about 0.94 based on the total number of moles of the monomers corresponding to Formulae 11, 22, and 33 and the mixture having a mole ratio of the monomer corresponding to Formula 22 to the monomer corresponding to Formula 33 of from about 0.2:1 to about 7:1, from about 0.2:1 to about 3.5:1; from about 0.5:1 to about 1.3:1, from about 0.8 to about 0.9, or about 0.85:1.
Particular crosslinked cation exchange polymers are the reaction product of a monomer corresponding to Formula 11A, a monomer corresponding to Formula 22A, a monomer corresponding to Formula 33A, and a polymerization initiator. The monomers corresponding to Formulae 11A, 22A, and 33A have the structure:
wherein alkyl is preferably selected from methyl, ethyl, propyl, iso-propyl, butyl, iso-butyl, sec-butyl, tert-butyl, pentyl, iso-pentyl, sec-pentyl, or tert-pentyl. Most preferably, the alkyl group is methyl or tert-butyl. The —O-alkyl moiety protects the carboxyl moiety from reacting with other reactive moieties during the polymerization reaction and can be removed by hydrolysis or other deprotection methods as described in more detail below.
Further, the reaction mixture contains at least about 80 wt. %, particularly at least about 85 wt. %, and more particularly at least about 90 wt. % or from about 80 wt. % to about 95 wt. %, from about 85 wt. % to about 95 wt. %, from about 85 wt. % to about 93 wt. % or from about 88 wt. % to about 92 wt. % of monomers corresponding to Formula 11A based on the total weight of monomers of Formulae 11A, 22A, and 33A and has a weight ratio of the monomer corresponding to Formula 22A to the monomer corresponding to Formula 33A of from about 4:1 to about 1:4 or about 1:1. Additionally, the reaction mixture can have a mole fraction of at least about 0.87 or from about 0.87 to about 0.94 of the monomer of Formula 11A based on the total number of moles of the monomers of Formulae 11A, 22A, and 33A and the mixture has a mole ratio of the monomer of Formula 22A to the monomer of Formula 33A of from about 0.2:1 to about 7:1, from about 0.2:1 to about 3.5:1; from about 0.5:1 to about 1.3:1, from about 0.8 to about 0.9, or about 0.85:1.
Generally, the reaction mixture contains from about 80 wt. % to about 95 wt. % of monomers corresponding to Formula 11A based on the total weight of monomers corresponding to Formulae 11A, 22A, and 33A. Additionally, the weight ratio of the monomer corresponding to Formula 22A to the monomer corresponding to Formula 33A of from about 4:1 to about 1:4 or about 1:1. Further, the reaction mixture can have a mole fraction of from about 0.9 to about 0.92 of the monomer of Formula 11A based on the total number of moles of the monomers of Formulae 11A, 22A, and 33A. Also, the mixture has a mole ratio of the monomer of Formula 22A to the monomer of Formula 33A of from about 0.2:1 to about 7:1, from about 0.2:1 to about 3.5:1; from about 0.5:1 to about 1.3:1, from about 0.8 to about 0.9, or about 0.85:1.
An initiated polymerization reaction is employed where a polymerization initiator is used in the polymerization reaction mixture to aid initiation of the polymerization reaction. When preparing poly(methylfluoro acrylate) or (polyMeFA) or any other crosslinked cation exchange polymer of the invention in a suspension polymerization reaction, the nature of the free radical initiator plays a role in the quality of the suspension in terms of polymer particle stability, yield of polymer particles, and the polymer particle shape. Use of water-insoluble free radical initiators, such as lauroyl peroxide, can produce polymer particles in a high yield. Without being bound by any particular theory, it is believed that a water-insoluble free radical initiator initiates polymerization primarily within the dispersed phase containing the monomers of Formulae 11, 22, and 33. Such a reaction scheme provides polymer particles rather than a bulk polymer gel. Thus, the process uses free radical initiators with water solubility lower than 0.1 g/L, particularly lower than 0.01 g/L. Polymethylfluoroacrylate particles can be produced with a combination of a low water solubility free radical initiator and the presence of a salt in the aqueous phase, such as sodium chloride.
The polymerization initiator can be chosen from a variety of classes of initiators. For instance, initiators that generate polymer initiating radicals upon exposure to heat include peroxides, persulfates or azo type initiators (e.g., 2,2′-azobis(2-methylpropionitrile), lauroyl peroxide (LPO), tert-butyl hydro peroxide, dimethyl-2,2′-azobis(2-methylpropionate), 2,2′-azobis[2-methyl-N-(2-hydroxyethyl)propionamide], 2,2′-azobis[2-(2-imidazolin-2-yl)propane], (2,2″-azo bis(2,4-dimethylvaleronitrile), azobisisobutyronitrile (AIBN) or a combination thereof. Another class of polymer initiating radicals is radicals generated from redox reactions, such as persulfates and amines. Radicals can also be generated by exposing certain initiators to UV light or exposure to air.
For those polymerization reactions that contain additional components in the polymerization mixture that are not intended to be incorporated into the polymer, such additional components typically comprise surfactants, solvents, salts, buffers, aqueous phase polymerization inhibitors and/or other components known to those of skill in the art.
When the polymerization is carried out in a suspension mode, the additional components may be contained in an aqueous phase while the monomers and initiator may be contained in an organic phase. When an aqueous phase is present, the aqueous phase may be comprised of water, surfactants, stabilizers, buffers, salts, and polymerization inhibitors.
A surfactant may be selected from the group consisting of anionic, cationic, nonionic, amphoteric, zwitterionic, or a combination thereof. Anionic surfactants are typically based on sulfate, sulfonate or carboxylate anions. These surfactants include, sodium dodecyl sulfate (SDS), ammonium lauryl sulfate, other alkyl sulfate salts, sodium laureth sulfate (or sodium lauryl ether sulfate (SLES)), N-lauroylsarcosine sodium salt, lauryldimethylamine-oxide (LDAO), ethyltrimethylammoniumbromide (CTAB), bis(2-ethylhexyl)sulfosuccinate sodium salt, alkyl benzene sulfonate, soaps, fatty acid salts, or a combination thereof.
Cationic surfactants, for example, contain quaternary ammonium cations. These surfactants are cetyl trimethylammonium bromide (CTAB or hexadecyl trimethyl ammonium bromide), cetylpyridinium chloride (CPC), polyethoxylated tallow amine (POEA), benzalkonium chloride (BAC), benzethonium chloride (BZT), or a combination thereof.
Zwitterionic or amphoteric surfactants include dodecyl betaine, dodecyl dimethylamine oxide, cocamidopropyl betaine, coco ampho glycinate, or a combination thereof.
Nonionic surfactants include alkyl poly(ethylene oxide), copolymers of poly(ethylene oxide) and poly(propylene oxide) (commercially called Poloxamers or Poloxamines), alkyl polyglucosides (including octyl glucoside, decyl maltoside) fatty alcohols, cetyl alcohol, oleyl alcohol, cocamide MEA, cocamide DEA, or a combination thereof. Other pharmaceutically acceptable surfactants are well known in the art and are described in McCutcheon's Emulsifiers and Detergents, N. American Edition (2007).
Polymerization reaction stabilizers may be selected from the group consisting of organic polymers and inorganic particulate stabilizers. Examples include polyvinyl alcohol-co-vinylacetate and its range of hydrolyzed products, polyvinylacetate, polyvinylpyrolidinone, salts of polyacrylic acid, cellulose ethers, natural gums, or a combination thereof.
Buffers may be selected from the group consisting of, for example, 4-2-hydroxyethyl-1-piperazineethanesulfonic acid, 2-{[tris(hydroxymethyl)methyl]amino}ethanesulfonic acid, 3-(N-morpholino)propanesulfonic acid, piperazine-N,N′-bis(2-ethanesulfonic acid), sodium phosphate dibasic heptahydrate, sodium phosphate monobasic monohydrate or a combination thereof.
Polymerization reaction salts may be selected from the group consisting of potassium chloride, calcium chloride, potassium bromide, sodium bromide, sodium bicarbonate, ammonium peroxodisulfate, or a combination thereof.
Polymerization inhibitors may be used as known in the art and selected from the group consisting of 1,1,3-tris(2-methyl-4-hydroxy-5-tert-butylphenyl)butane, 1,3,5-trimethyl-2,4,6-tris(3,5-di-tert-butyl-4-hydroxybenzyl)benzene, 1-aza-3,7-dioxabicyclo[3.3.0]octane-5-methanol, 2,2′-ethylidene-bis(4,6-di-tert-butylphenol), 2,2′-ethylidenebis(4,6-di-tert-butylphenyl) fluorophosphite, 2,2′-methylenebis(6-tert-butyl-4-ethylphenol), 2,2′-methylenebis(6-tert-butyl-4-methylphenol), 2,5-di-tert-butyl-4-methoxyphenol, 2,6-di-tert-butyl-4-(dimethyl aminomethyl)phenol, 2-heptanone oxime, 3,3′,5,5′-tetramethylbiphenyl-4,4′-diol, 3,9-bis(2,4-dicumylphenoxy)-2,4,8,10-tetraoxa-3,9-diphosphaspiro[5.5]undecane, 4,4-dimethyloxazolidine, 4-methyl-2-pentanone oxime, 5-ethyl-1-aza-3,7-dioxabicyclo[3.3.0]octane, 6,6 ‘-dihydroxy-5,5’-dimethoxy-[1,1′-biphenyl]-3,3′-dicarboxaldehyde, di stearyl-3,3′-thiodipropionate, ditetradecyl-3,3′-thiodipropionate, ditridecyl-3,3′-thiodipropionate, octadecyl-3-(3,5-di-tert-butyl-4-hydroxyphenyl)propionate, pentaerythritol tetrakis(3,5-di-tert-butyl-4-hydroxyhydrocinnamate), poly(1,2-dihydro-2,2,4-trimethylquinoline), sodium D-isoascorbate monohydrate, tetrakis(2,4-di-tert-butylphenyl)-4,4′-biphenyldiphosphonite, tris(3,5-di-tert-butyl-4-hydroxybenzyl) isocyanurate, tris(4-tert-butyl-3-hydroxy-2,6-dimethylbenzyl) isocyanurate, sodium nitrite or a combination thereof.
Generally, the polymerization mixture is subjected to polymerization conditions. While suspension polymerization is preferred, as already discussed herein, the polymers of this invention may also be prepared in bulk, solution or emulsion polymerization processes. The details of such processes are within the skill of one of ordinary skill in the art based on the disclosure of this invention. The polymerization conditions typically include polymerization reaction temperatures, pressures, mixing and reactor geometry, sequence and rate of addition of polymerization mixtures and the like.
Polymerization temperatures are typically in the range of from about 50 to 100° C. Polymerization pressures are typically run at atmospheric pressure, but can be run at higher pressures (for example 130 PSI of nitrogen). Polymerization depends on the scale of the polymerization and the equipment used, and is within the skill of one of ordinary skill in the art. Various alpha-fluoroacrylate polymers and the synthesis of these polymers are described in U.S. Patent Application Publication No. 2005/0220752, herein incorporated by reference.
As described in more detail in connection with the examples herein, the crosslinked cation exchange polymer can be synthesized in a polymerization suspension polymerization reaction by preparing an organic phase and an aqueous phase. The organic phase typically contains a monomer of Formula 11, a monomer of Formula 22, a monomer of Formula 33, and a polymerization initiator. The aqueous phase contains a suspension stabilizer, a water soluble salt, water, and optionally a buffer. The organic phase and the aqueous phase are then combined and stirred under nitrogen. The mixture is generally heated to about 60° C. to about 80° C. for about 2.5 to about 3.5 hours, allowed to rise up to 95° C. after polymerization is initiated, and then cooled to room temperature. After cooling, the aqueous phase is removed. Water is added to the mixture, the mixture is stirred, and the resulting solid is filtered. The solid is washed with water, alcohol or alcohol/water mixtures.
As described above, polymerization suspension stabilizers, such as polyvinyl alcohol, are used to prevent coalescence of particles during the polymerization process. Further, it has been observed that the addition of sodium chloride in the aqueous phase decreased coalescence and particle aggregation. Other suitable salts for this purpose include salts that are soluble in the aqueous phase. Water soluble salts are added at a concentration of from about 0.1 wt. % to about 10 wt. %, particularly from about 2 wt. % to about 5 wt. % and even more particularly from about 3 wt. % to about 4 wt. %.
Preferably, an organic phase of methyl 2-fluoroacrylate (90 wt. %), 1,7-octadiene (5 wt. %) and divinylbenzene (5 wt. %) is prepared and 0.5 wt. % of lauroyl peroxide is added to initiate the polymerization reaction. Additionally, an aqueous phase of water, polyvinyl alcohol, phosphates, sodium chloride, and sodium nitrite is prepared. Under nitrogen and while keeping the temperature below about 30° C., the aqueous and organic phases are mixed together. Once mixed completely, the reaction mixture is gradually heated with continuous stirring. After the polymerization reaction is initiated, the temperature of the reaction mixture is allowed to rise up to about 95° C. Once the polymerization reaction is complete, the reaction mixture is cooled to room temperature and the aqueous phase is removed. The solid can be isolated by filtration after water is added to the mixture. The resulting product is a crosslinked (methyl 2-fluoroacrylate)-divinylbenzene-1,7-octadiene terpolymer.
As discussed herein, after polymerization, the product may be hydrolyzed or otherwise deprotected by methods known in the art. For hydrolysis of the polymer having ester groups to form a polymer having carboxylic acid groups, preferably, the polymer is hydrolyzed with a strong base (e.g., NaOH, KOH, Mg(OH)₂, or Ca(OH)₂) to remove the alkyl (e.g., methyl) group and form the carboxylate salt. Depending on the pH of the hydrolysis mixture, the proton form of the (2-fluoroacrylic acid)-divinylbenzene-1,7-octadiene terpolymer is formed. Alternatively, the polymer can be hydrolyzed with a strong acid (e.g., HCl) to form the carboxylate salt. Preferably, the (methyl 2-fluoroacrylate)-divinylbenzene-1,7-octadiene terpolymer is hydrolyzed with an excess of aqueous sodium hydroxide solution at a temperature from about 30° C. to about 100° C. to yield (sodium 2-fluoroacrylate)-divinylbenzene-1,7-octadiene terpolymer. Typically, the hydrolysis reaction is carried out for about 15 to 25 hours. After hydrolysis, the solid is filtered and washed with water and/or an alcohol.
The cation of the polymer salt formed in the hydrolysis reaction or other deprotection step depends on the base used in that step. For example, when sodium hydroxide is used as the base, the sodium salt of the polymer is formed. This sodium ion can be exchanged for another cation by contacting the sodium salt with an excess of an aqueous metal salt to yield an insoluble solid of the desired polymer salt. After the desired ion exchange, the product is washed with an alcohol and/or water and dried directly or dried after a dewatering treatment with denatured alcohol; preferably, the product is washed with water and dried directly. For example, the sodium salt of the cation exchange polymer is converted to the calcium salt by washing with a solution that substitutes calcium for sodium, for example, by using calcium chloride, calcium acetate, calcium lactate gluconate, or a combination thereof. And, more specifically, to exchange sodium ions for calcium ions, the (sodium 2-fluoroacrylate)-divinylbenzene-1,7-octadiene terpolymer is contacted with an excess of aqueous calcium chloride to yield an insoluble solid of crosslinked (calcium 2-fluoroacrylate)-divinylbenzene-1,7-octadiene terpolymer. If the pH of the hydrolysis mixture is sufficiently low, the proton form of the (2-fluoroacrylic acid)-divinylbenzene-1,7-octadiene terpolymer is formed.
Using this suspension polymerization process, a cross-linked polyMeFA polymer is isolated in good yield, generally above about 85%, more specifically above about 90%, and even more specifically above about 93%. The yield of the second step (i.e., hydrolysis) preferably occurs in 100%, providing an overall yield after hydrolysis of above about 85%, more specifically above about 90%, and even more specifically above about 93%.
To add the linear polyol to the composition, the salt of the polymer is slurried with an aqueous solution of polyol (e.g., sorbitol), typically with the slurry containing an excess amount of polyol based on polymer weight. Performing this step can reduce inorganic fluoride in the composition. The slurry is maintained under conditions known to those of skill in the art, such as for at least 3 hours and ambient temperature and pressure. The solids are then filtered off and dried to desired moisture content.
The methods of treatment of hypertension, hyperkalemia, and chronic kidney disease can be used for a variety of treatment periods including treatment periods of 1, 2, 4, 6, 8, 12, 16, 20, 24, 28, 32, 36, 40, 44, 48, 52, or more weeks. The treatment period can also be 2 years, 3 years, 4 years, 5 years, or more.
When treating the patients for hyperkalemia or chronic kidney disease using the methods of the invention, the patient can have an estimated glomerular filtration rate (eGFR) from about 15 mL/min/1.73 m²to about 44 mL/min/1.73 m².
The methods of treating hyperkalemia, methods of treating hypertension in a patient having chronic kidney disease, type 2 diabetes, heart failure or a combination thereof, and methods of treating chronic kidney disease of the invention can cause several improvements such as a decrease in the patient's serum potassium level after 48 hours, or more of treatment as compared to the patient's serum potassium level before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form; an increase in the patient's eGFR after 2, 3, 4, 5, 6, months or more of treatment as compared to the patient's eGFR before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form; a decrease in the patient's urine albumin:creatinine ratio (ACR) after 2, 3, 4, 5, 6, months or more of treatment as compared to the patient's urine ACR before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form; a decrease in the patient's systolic and diastolic blood pressure after 1, 2, 3, 4, 5, 6, 7 days or more of treatment as compared to the patient's systolic and diastolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form; a decrease in the patient's serum aldosterone level after 6, 12, 24, 48, 72, hours or more of treatment as compared to the patient's serum aldosterone level before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form, or a combination thereof.
The methods of treating hyperkalemia in a chronic kidney disease patient in need thereof optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent comprise administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient and observing either (i) a decrease in the patient's serum creatinine level as compared to the patient's serum creatinine level before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form, (ii) a decrease in the time to progression of end stage renal disease as compared to a chronic kidney disease patient optionally treated with a RAAS agent but not treated with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form, (iii) an increase in survival as compared to a chronic kidney disease patient optionally treated with a RAAS agent but not treated with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form, or (iv) an increase or stabilization of estimated glomerular filtration rate (eGFR) as compared to the patient's eGFR before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form, all indicating an increase or stabilization of the patient's kidney function.
The methods of treating hyperkalemia, methods of treating hypertension in a patient having chronic kidney disease, type 2 diabetes, heart failure or a combination thereof, and methods of treating chronic kidney disease can result in the patient's eGFR after treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form being increased by at least 4, 5, 6 mL/min/1.73 m²or more as compared to the patient's eGFR before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form
When treating hypertension, hyperkalemia, or chronic kidney disease in patients in need thereof, the effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form comprises up to a maximum daily dose of 60 grams. The effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form can be a daily dose of from about 10 grams to about 60 grams; particularly, the effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form can be a daily dose of 20 gram to 60 grams.
The methods of treating hypertension, hyperkalemia, or chronic kidney disease of the invention can further comprise administering an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent to the patient; determining the serum potassium level in the patient; and increasing the amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form subsequently administered to the patient based on the serum potassium level if greater than or equal to 5.1 mEq/L. The methods of hypertension, hyperkalemia, or chronic kidney disease wherein the amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form was increased by 5 g or 10 g per day.
The methods of treating hypertension, hyperkalemia, or chronic kidney disease of the invention can further comprise administering an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent to the patient; determining the serum potassium level in the patient; decreasing the amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form subsequently administered to the patient based on the serum potassium level if less than 4.0 mEq/L. The method of treating hypertension, hyperkalemia, or chronic kidney disease wherein the amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form was decreased by 5 g or 10 g per day.
Further, the methods of treating hypertension, hyperkalemia, or chronic kidney disease may include treating the patient with an effective amount of a RAAS agent, the RAAS agent being an angiotensin converting enzyme (ACE) inhibitor, an angiotensin receptor blocker (ARB), an aldosterone antagonist (AA), an aldosterone synthase inhibitor, or a combination thereof. Particularly, the patient may be treated with an effective amount of a RAAS agent, the RAAS agent is an ACE inhibitor, an ARB, or a combination thereof.
For the methods where the patient is being treated with an effective amount of a RAAS agent, the effective amount of the RAAS agent comprises up to a maximum daily tolerated dose.
The RAAS agent comprises fosinopril, ramipril, captopril, lisinopril, trandolapril, moexipril, quinapril, enalapril, benazepril, perindopril, eprosartan, olmesartan, losartan, telmisartan, valsartan, candesartan, irbesartan, azilsartan medoxomil, spironolactone, eplerenone, or a combination thereof.
The maximum daily tolerated dose of specific RAAS agents is 4 mg/day (trandolapril), 8 mg/day (perindopril), 20 mg/day (ramipril), 30 mg/day (moexipril), 32 mg/day (candesartan), 40 mg/day (fosinopril, lisinopril, enalapril, benazepril, olmesartan), 80 mg/day (quinapril telmisartan, azilsartan, medoxomil), 100 mg/day (losartan), 300 mg/day (captopril, irbesartan), 320 mg/day (valsartan), or 800 mg/day (eprosartan).
When the RAAS agent comprises spironolactone, the maximum daily tolerated dose is 200 mg/day.
When the RAAS agent comprises eplerenone, the maximum daily tolerated dose is 50 mg/day.
Patients being treated with the methods of treating hypertension, hyperkalemia or chronic kidney disease of the invention can further be treated with an effective amount of a beta-adrenergic blocking agent. The beta-adrenergic blocking agent can comprise betaxolol, bisoprolol, atenolol, metoprolol, nebivolol, metoprolol, esmolol, acebutolol, propranolol, nadolol, carvedilol, labetalol, sotalol, timolol, carteolol, penbutolol, pindolol, or a combination thereof.
The term “treating” as used herein includes achieving a therapeutic benefit. By therapeutic benefit is meant eradication, amelioration, or prevention of the underlying disorder being treated. For example, in a hyperkalemia patient, therapeutic benefit includes eradication or amelioration of the underlying hyperkalemia. Also, a therapeutic benefit is achieved with the eradication, amelioration, or prevention of one or more of the physiological symptoms associated with the underlying disorder such that an improvement is observed in the patient, notwithstanding that the patient may still be afflicted with the underlying disorder. For example, administration of a potassium-binding polymer to a patient experiencing hyperkalemia provides therapeutic benefit not only when the patient's serum potassium level is decreased, but also when an improvement is observed in the patient with respect to other disorders that accompany hyperkalemia, like renal failure. In some treatment regimens, the crosslinked cation exchange polymer or composition of the invention may be administered to a patient at risk of developing hyperkalemia or to a patient reporting one or more of the physiological symptoms of hyperkalemia, even though a diagnosis of hyperkalemia may not have been made.
End stage renal disease is characterized by a patient being on dialysis or having a renal transplant.
The potassium-binding polymers used in the methods of the invention can be administered as pharmaceutical compositions containing an effective amount, i.e., in an amount effective to achieve therapeutic or prophylactic benefit of the potassium-binding polymer and a pharmaceutically acceptable carrier. The actual amount effective for a particular application will depend on the patient (e.g., age, weight, etc.), the condition being treated, and the route of administration. Determination of an effective amount is well within the capabilities of those skilled in the art, especially in light of the disclosure herein. The effective amount for use in humans can be determined from animal models. For example, a dose for humans can be formulated to achieve gastrointestinal concentrations that have been found to be effective in animals.
The polymers and compositions described herein can be used as food products and/or food additives. They can be added to foods prior to consumption or while packaging.
The polymers or pharmaceutically acceptable salts thereof, or compositions described herein, can be delivered to the patient using a wide variety of routes or modes of administration. The most preferred routes for administration are oral, intestinal, or rectal. Rectal routes of administration are known to those of skill in the art. Intestinal routes of administration generally refer to administration directly into a segment of the gastrointestinal tract, e.g., through a gastrointestinal tube or through a stoma. The most preferred route for administration is oral.
The polymers (or pharmaceutically acceptable salts thereof) may be administered per se or in the form of a pharmaceutical composition wherein the active compound(s) is in admixture or mixture with one or more pharmaceutically acceptable excipient. Pharmaceutical compositions for use in accordance with the present invention may be formulated in conventional manner using one or more pharmaceutically acceptable excipients comprising carriers, diluents, and auxiliaries which facilitate processing of the active compounds into preparations which can be used physiologically. Proper composition is dependent upon the route of administration chosen.
For oral administration, the polymers or compositions of the invention can be formulated readily by combining the polymer or composition with pharmaceutically acceptable excipients well known in the art. Such excipients enable the compositions of the invention to be formulated as tablets, pills, dragees, capsules, liquids, gels, syrups, slurries, suspensions, wafers, and the like, for oral ingestion by a patient to be treated. In one embodiment, the oral composition does not have an enteric coating. Pharmaceutical preparations for oral use can be obtained as a solid excipient, optionally grinding a resulting mixture, and processing the mixture of granules, after adding suitable auxiliaries, if desired, to obtain tablets or dragee cores. Suitable excipients are, in particular, fillers such as sugars, including lactose or sucrose; cellulose preparations such as, for example, maize starch, wheat starch, rice starch, potato starch, gelatin, gum tragacanth, methyl cellulose, hydroxypropylmethyl-cellulose, sodium carboxymethylcellulose, and/or polyvinyl pyrrolidone (PVP); and various flavoring agents known in the art. If desired, disintegrating agents may be added, such as the cross-linked polyvinyl pyrrolidone, agar, or alginic acid or a salt thereof such as sodium alginate.
In various embodiments, the active ingredient (e.g., polymer) constitutes over about 20%, more particularly over about 40%, even more particularly over about 50%, and most particularly more than about 60% by weight of the oral dosage form, the remainder comprising suitable excipient(s). In compositions containing water and linear polyol, the polymer preferably constitutes over about 20%, more particularly over about 40%, and even more particularly over about 50% by weight of the oral dosage form.
The polymers of the invention can be provided as pharmaceutical compositions in the form of liquid compositions. The pharmaceutical composition can contain a polymer dispersed in a suitable liquid excipient. Suitable liquid excipients are known in the art; see, e.g., Remington's Pharmaceutical Sciences.
Unless otherwise indicated, an alkyl group as described herein alone or as part of another group is an optionally substituted linear saturated monovalent hydrocarbon radical containing from one to twenty carbon atoms and preferably one to eight carbon atoms, or an optionally substituted branched saturated monovalent hydrocarbon radical containing three to twenty carbon atoms, and preferably three to eight carbon atoms. Examples of unsubstituted alkyl groups include methyl, ethyl, n-propyl, i-propyl, n-butyl, i-butyl, s-butyl, t-butyl, n-pentyl, i-pentyl, s-pentyl, t-pentyl, and the like.
The term “amide moiety” as used herein represents a bivalent (i.e., difunctional) group including at least one amido linkage (i.e.,
such as —C(O)—NR_A—R_C—NR_B—C(O)— wherein R_Aand R_Bare independently hydrogen or alkyl and R_Cis alkylene. For example, an amide moiety can be —C(O)—NH—(CH₂)_p—NH—C(O)— wherein p is an integer of 1 to 8.
The term “aryl” as used herein alone or as part of another group denotes an optionally substituted monovalent aromatic hydrocarbon radical, preferably a monovalent monocyclic or bicyclic group containing from 6 to 12 carbons in the ring portion, such as phenyl, biphenyl, naphthyl, substituted phenyl, substituted biphenyl or substituted naphthyl. Phenyl and substituted phenyl are the more preferred aryl groups. The term “aryl” also includes heteroaryl.
The terms “carboxylic acid group”, “carboxylic” or “carboxyl” denote the monovalent radical —C(O)OH. Depending upon the pH conditions, the monovalent radical can be in the form —C(O)O⁻ Q⁺ wherein Q⁺ is a cation (e.g., sodium), or two of the monovalent radicals in close proximity can bond with a divalent cation Q²⁺ (e.g., calcium, magnesium), or a combination of these monovalent radicals and —C(O)OH are present.
The term “cycloalkyl” as used herein denotes optionally an optionally substituted cyclic saturated monovalent bridged or non-bridged hydrocarbon radical containing from three to eight carbon atoms in one ring and up to 20 carbon atoms in a multiple ring group. Exemplary unsubstituted cycloalkyl groups include cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, cycloheptyl, cyclooctyl, adamantyl, norbornyl, and the like.
The term “-ene” as used as a suffix as part of another group denotes a bivalent radical in which a hydrogen atom is removed from each of two terminal carbons of the group, or if the group is cyclic, from each of two different carbon atoms in the ring. For example, alkylene denotes a bivalent alkyl group such as methylene (—CH₂—) or ethylene (—CH₂CH₂—), and arylene denotes a bivalent aryl group such as o-phenylene, m-phenylene, or p-phenylene.
The term “ether moiety” as used herein represents a bivalent (i.e., difunctional) group including at least one ether linkage (i.e., —O—). For example, in Formulae 3 or 33 as defined herein, the ether moiety can be —R_AOR_B— or —R_AOR_COR_B— wherein R_A, R_Band R_Care independently alkylene.
The term “heteroaryl,” as used herein alone or as part of another group, denotes an optionally substituted monovalent monocyclic or bicyclic aromatic radical of 5 to 10 ring atoms, where one or more, preferably one, two, or three, ring atoms are heteroatoms independently selected from N, O, and S, and the remaining ring atoms are carbon. Exemplary heteroaryl moieties include benzofuranyl, benzo[d]thiazolyl, isoquinolinyl, quinolinyl, thiophenyl, imidazolyl, oxazolyl, quinolinyl, furanyl, thazolyl, pyridinyl, furyl, thienyl, pyridyl, oxazolyl, pyrrolyl, indolyl, quinolinyl, isoquinolinyl, and the like.
The term “heterocyclo,” as used herein alone or as part of another group, denotes a saturated or unsaturated monovalent monocyclic group of 4 to 8 ring atoms, in which one or two ring atoms are heteroatom(s), independently selected from N, O, and S, and the remaining ring atoms are carbon atoms. Additionally, the heterocyclic ring may be fused to a phenyl or heteroaryl ring, provided that the entire heterocyclic ring is not completely aromatic. Exemplary heterocyclo groups include the heteroaryl groups described above, pyrrolidino, piperidino, morpholino, piperazino, and the like.
The term “hydrocarbon” as used herein describes a compound or radical consisting exclusively of the elements carbon and hydrogen.
The term “phosphonic” or “phosphonyl” denotes the monovalent radical
The term “phosphoric” or “phosphoryl” denotes the monovalent radical
The term “protected” as used herein as part of another group denotes a group that blocks reaction at the protected portion of a compound while being easily removed under conditions that are sufficiently mild so as not to disturb other substituents of the compound. For example, a protected carboxylic acid group-C(O)OP_gor a protected phosphoric acid group —OP(O)(OH)OP_gor a protected phosphonic acid group —P(O)(OH)OP_geach have a protecting group P_gassociated with the oxygen of the acid group wherein P_gcan be alkyl (e.g., methyl, ethyl, n-propyl, i-propyl, n-butyl, i-butyl, s-butyl, t-butyl, n-pentyl, i-pentyl, s-pentyl, t-pentyl, and the like), benzyl, silyl (e.g., trimethylsilyl (TMS), triethylsilyl (TES), triisopropylsilyl (TIPS), triphenylsilyl (TPS), t-butyldimethylsilyl (TBDMS), t-butyldiphenylsilyl (TBDPS) and the like. A variety of protecting groups and the synthesis thereof may be found in “Protective Groups in Organic Synthesis” by T. W. Greene and P. G. M. Wuts, John Wiley & Sons, 1999. When the term “protected” introduces a list of possible protected groups, it is intended that the term apply to every member of that group. That is, the phrase “protected carboxylic, phosphonic or phosphoric” is to be interpreted as “protected carboxylic, protected phosphonic or protected phosphoric.” Likewise, the phrase “optionally protected carboxylic, phosphoric or phosphonic” is to be interpreted as “optionally protected carboxylic, optionally protected phosphonic or optionally protected phosphoric.”
The term “substituted” as in “substituted aryl,” “substituted alkyl,” and the like, means that in the group in question (i.e., the alkyl, aryl or other group that follows the term), at least one hydrogen atom bound to a carbon atom is replaced with one or more substituent groups such as hydroxy (—OH), alkylthio, phosphino, amido (—CON(R_A)(R_B), wherein R_Aand R_Bare independently hydrogen, alkyl, or aryl), amino(-N(R_A)(R_B), wherein R_Aand R_Bare independently hydrogen, alkyl, or aryl), halo (fluoro, chloro, bromo, or iodo), silyl, nitro (—NO₂), an ether (—OR_Awherein R_Ais alkyl or aryl), an ester (—OC(O)R_Awherein R_Ais alkyl or aryl), keto (—C(O)R_Awherein R_Ais alkyl or aryl), heterocyclo, and the like. When the term “substituted” introduces a list of possible substituted groups, it is intended that the term apply to every member of that group. That is, the phrase “optionally substituted alkyl or aryl” is to be interpreted as “optionally substituted alkyl or optionally substituted aryl.”
Having described the invention in detail, it will be apparent that modifications and variations are possible without departing from the scope of the invention defined in the appended claims.

EXAMPLES

The following non-limiting examples are provided to further illustrate the present invention.

Example 1: Sorbitol-Loaded, Crosslinked (calcium 2-fluoroacrylate)-divinylbenzene-1,7-octadiene Copolymer

Methyl 2-fluoroacrylate (MeFA) was purchased and was vacuum distilled before use. Divinylbenzene (DVB) was purchased from Aldrich, technical grade, 80%, mixture of isomers, and was used as received. 1,7-octadiene (ODE), lauroyl peroxide (LPO), polyvinyl alcohol (PVA) (typical molecular weight 85,000-146,000, 87-89% hydrolyzed), sodium chloride (NaCl), sodium phosphate dibasic heptahydrate (Na₂HPO₄.7H₂O) and sodium phosphate monobasic monohydrate (NaH₂PO₄.H₂O) were purchased from commercial sources and used as received.
In an appropriately sized reactor with appropriate stirring and other equipment, a 90:5:5 weight ratio mixture of organic phase of monomers was prepared by mixing methyl 2-fluoroacrylate, 1,7-octadiene, and divinylbenzene. One-half part of lauroyl peroxide was added as an initiator of the polymerization reaction. A stabilizing aqueous phase was prepared from water, polyvinyl alcohol, phosphates, sodium chloride, and sodium nitrite. The aqueous and monomer phases were mixed together under nitrogen at atmospheric pressure, while maintaining the temperature below 30° C. The reaction mixture was gradually heated while stirring continuously. Once the polymerization reaction has started, the temperature of the reaction mixture was allowed to rise to a maximum of 95° C.
After completion of the polymerization reaction, the reaction mixture was cooled and the aqueous phase was removed. Water was added, the mixture was stirred, and the solid material was isolated by filtration. The solid was then washed with water to yield a crosslinked (methyl 2-fluoroacrylate)-divinylbenzene-1,7-octadiene copolymer. The (methyl 2-fluoroacrylate)-divinylbenzene-1,7-octadiene copolymer was hydrolyzed with an excess of aqueous sodium hydroxide solution at 90° C. for 24 hours to yield (sodium 2-fluoroacrylate)-divinylbenzene-1,7-octadiene copolymer. After hydrolysis, the solid was filtered and washed with water. The (sodium 2-fluoroacrylate)-divinylbenzene-1,7-octadiene copolymer was exposed at room temperature to an excess of aqueous calcium chloride solution to yield insoluble cross-linked (calcium 2-fluoroacrylate)-divinylbenzene-1,7-octadiene copolymer.
After the calcium ion exchange, the wet polymer is slurried with 25-30% w/w aqueous solution of sorbitol at ambient temperature to yield sorbitol-loaded polymer. Excess sorbitol was removed by filtration. The resulting polymer was dried at 20-30° C. until the desired moisture content (10-25 w/w/%) was reached. This provided a sorbitol-loaded, crosslinked (calcium 2-fluoroacrylate)-divinylbenzene-1,7-octadiene copolymer (5016CaS).

Example 2: Phase II Clinical Study

Study Design Overview. The study has two 5016CaS treatment periods: a treatment initiation period for 8 weeks, followed by a long-term maintenance period for an additional 44 weeks which allows treatment with 5016CaS for up to a total of one year (i.e., 52 weeks). Eligible non-hyperkalemic patients start a run-in period of 1 to 4 weeks in duration (Cohorts 1 and 2). Eligible hyperkalemic patients start treatment with 5016CaS immediately (Cohort 3). At the first occurrence of serum potassium (K⁺)>5.0-<6.0 mEq/L, eligible patients from all three cohorts are assigned to one of two strata according to baseline serum potassium and received 5016CaS treatment at randomly assigned starting doses ranging from 10 to 40 g/day. The dose amount is based on the amount of the polymer anion plus calcium (e.g., on a water and sorbitol free basis). A 10 g dose of polymer anion plus calcium is equivalent to an 8.4 g dose of the polymer anion. The study duration is up to 62 weeks per patient (including screening and follow-up procedures) and the study population is approximately 306 patients. The study variables included change in serum potassium, blood pressure, estimated GFR and ACR.
Eligible patients are assigned to one of two 5016CaS treatment strata wherein Stratum 1 includes patients with serum K⁺>5.0-5.5 mEq/L, these patients are randomized in a 1:1:1 ratio to receive either 10 g/day, 20 g/day, or 30 g/day 5016CaS starting doses within each study cohort. Stratum 2 includes patients with serum K⁺>5.5-<6.0 mEq/L, these patients are randomized in a 1:1:1 ratio to receive 20 g/day, 30 g/day, or 40 g/day 5016CaS starting doses within each study cohort.
Patients start 5016CaS treatment at their assigned dose level on the evening of day 1. They continue taking losartan 100 mg/d (with or without spironolactone 25-50 mg/d) or pre-study ACEI and/or ARB with spironolactone 25-50 mg/d, (as per their Cohort 1 or 2 assignment), as well as any other protocol-allowed antihypertensive therapy. Patients in Cohort 3 continue their pre-study ACEI and/or ARB.
Dose and Route of 5016CaS Administration. 5016CaS was taken orally twice daily in equally divided doses for up to 52 weeks starting on day 1 (the evening dose only). Patients take 5016CaS twice a day with their regular meals (breakfast and dinner). The 5016CaS dose is adjusted as needed according to the appropriate titration algorithm (treatment initiation or long-term maintenance) starting on day 3 and up to the week 51 visit. The minimum allowed dose is 0 g/d (no 5016CaS dispensed) and the maximum dose is 60 g/d.
FIGS. 1-5 look at potassium reduction, blood pressure control, eGFR change and protein urea change by the following patient subtypes: (1) patients with any amount of protein in the urine (2) patients with microalbuminuria (3) patients with macroalbuminuria and (4) patients with stage 4 chronic kidney disease (CKD). FIG. 1 shows that a serum potassium reduction was experienced by all of these patient types. FIGS. 2 and 3 showed blood pressure reductions and that 5016CaS was as effective in reducing blood pressure in all of the patient types. FIG. 4 shows that there was no significant increase in protein urea levels in any of the patient types, so 5016CaS effectively stabilized the patient's protein excretion. FIG. 5 shows that renal function appeared to stabilize in all patient types with a potential for improvement in renal function in patients with stage 4 CKD.
The study protocol was completed by 182 patients for the analysis following in this Example 2. A statistically significant number of these patients had an albumin creatinine ratio (ACR) of ≥30 mg/g and others had an ACR of >300 mg/g and an estimated glomerular filtration rate (eGFR) of 15 to 44 mL/min/1.73 m²at baseline. For all of these patients, the patient's serum potassium concentration decreased from an average of 5.27 mEq/L at baseline to an average of 4.57 mEq/L at 24 weeks. For patients having an ACR ≥30 mg/g, the patient's serum potassium concentration decreased from an average of 5.28 mEq/L at baseline to an average of 4.60 mEq/L at 24 weeks. For patients having an ACR >300 mg/g, the patient's serum potassium concentration decreased from an average of 5.35 mEq/L at baseline to an average of 4.65 mEq/L at 24 weeks. For patients having an eGFR of 15 to 44 mL/min/1.73 m², the patient's serum potassium concentration decreased from an average of 5.33 mEq/L at baseline to an average of 4.59 mEq/L at 24 weeks.
For patients having an eGFR of 15 to 44 mL/min/1.73 m², the patient's eGFR increased from an average of 32 mL/min/1.73 m²at baseline to an average of 38 mL/min/1.73 m²at 24 weeks. This increase in eGFR for these patients was statistically significant.
For the patients in all groups and each group separately (e.g., ACR of ≥30 mg/g, ACR of >300 mg/g, eGFR of 15 to 44 mL/min/1.73 m²), the ACR did not significantly change over the 24 week treatment period.
For all of these patients, the patient's systolic blood pressure decreased from an average of 154 at baseline to an average of 137 at 24 weeks and the patient's diastolic blood pressure decreased from an average of 83 at baseline to an average of 74 at 24 weeks. For patients having an ACR ≥30 mg/g, the patient's systolic blood pressure decreased from an average of 154 at baseline to an average of 138 at 24 weeks and the patient's diastolic blood pressure decreased from an average of 84 at baseline to an average of 74 at 24 weeks. For patients having an ACR >300 mg/g, the patient's systolic blood pressure decreased from an average of 154 at baseline to an average of 137 at 24 weeks and the patient's diastolic blood pressure decreased from an average of 86 at baseline to an average of 73 at 24 weeks. For patients having an eGFR of 15 to 44 mL/min/1.73 m², the patient's systolic blood pressure decreased from an average of 152 at baseline to an average of 135 at 24 weeks and the patient's diastolic blood pressure decreased from an average of 82 at baseline to an average of 73 at 24 weeks.
FIGS. 6-9 present one year data from a certain cohort of 90 patients with pre-existing hyperkalemia that were taking a stable dose of a RAAS inhibitor that came into the trial without a run-in period. These figures show that kidney function (FIG. 6) and urinary protein excretion (FIG. 8) appeared to stabilize, with reductions in serum potassium (FIG. 7) and blood pressure (FIG. 9). When analyzing the twelve month data for these patients, the average eGFR was 46 mL/min/1.73 m²at baseline (BL), 49 mL/min/1.73 m²at one month (M1), 51 mL/min/1.73 m²at two months (M2), 49 mL/min/1.73 m²at six months (M6) and 48 mL/min/1.73 m²at twelve months (M12) (FIG. 6). The eGFR for these patients did not significantly change over the twelve month treatment period. These patients also experienced a significant decrease in serum potassium level. (FIG. 7) For example, the average serum potassium level was 5.3 mEq/L at baseline (BL), 4.5 mEq/L at one month (M1), 4.5 mEq/L at two months (M2), 4.6 mEq/L at six months (M6), and 4.6 mEq/L at twelve months (M12). These patients also had an average urine ACR of 853 mg/g at baseline (BL), 900 mg/g at one month (M1), 971 mg/g at two months (M2), 930 mg/g at six months (M6), and 802 mg/g at twelve months (M12). The average systolic blood pressure of these patients was 157 mmHg at baseline (BL), 138 mmHg at one month (M1), 139 mmHg at two months (M2), 138 mmHg at six months (M6), and 134 mmHg at twelve months (M12). The average diastolic blood pressure was 85 mmHg at baseline (BL), 74 mmHg at one month (M1), 73 mmHg at two months (M2), 73 mmHg at six months (M6), and 77 mmHg at twelve months (M12).
The mean change in serum potassium from baseline to week 4 or first dose titration, whichever comes first, is presented by stratum in Table 1. To be consistent with the study protocol, the most recent non-missing measurement of serum potassium was used for patients who did not titrate before the week 4 visit (last observation carried forward, i.e., LOCF). 5016CaS lowered serum potassium in all dose groups in both strata; the p-values indicate that the reduction is statistically significantly different from zero. The reference groups in both strata are the randomized starting doses chosen for the Phase III study.

TABLE 1

Estimated mean change from baseline in central serum K⁺ to week 4 or first dose titration, by randomized starting dose within stratum

	Stratum 1	Stratum 2
At week 4 or	Local serum K⁺ > 5.0-5.5 mEq/L	Local serum K⁺ > 5.5-<6.0 mEq/L

prior to first	10 g/d	20 g/d	30 g/d	Overall	20 g/d	30 g/d	40 g/d	Overall
titration	N = 74	N = 73	N = 73	N = 220	N = 26	N = 28	N = 30	N = 84

Change in serum K⁺ (mEq/L) from baseline

n^a	73	73	72	218	26	27	30	83
Least square	−0.35 ± 0.066	−0.51 ± 0.066	−0.54 ± 0.066	−0.47 ± 0.038	−0.85 ± 0.136	−0.95 ± 0.132	−0.90 ± 0.127	−0.90 ± 0.076
mean ±
standard error
95%	−0.48, −0.22	−0.64, −0.38	−0.67, −0.41	−0.54, −0.39	−1.12, −0.58	−1.21, −0.68	−1.15, −0.65	−1.05, −0.75
confidence
interval
p-value^b	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001

Comparison to reference

Mean	reference	0.17	0.19	reference	0.097	0.050
difference
95%		−0.018, 0.35	0.006, 0.37		−0.28, 0.48	−0.32, 0.42
confidence
interval
p-value^c		0.076	0.043		0.61	0.79

Column header counts include all randomized patients who received RLY5016 (intent-to-treat population) by each randomized starting dose within stratum. Each stratum is analyzed separately using a parallel lines analysis of covariance (ANCOVA) model where the outcome is change in serum K⁺ from baseline. Each model contains a fixedeffect for randomized starting dose, cohort, and continuous baseline serum K⁺. Estimates and confidence intervals for each randomized starting dose gives were generated using linear contrasts across the observed values of the covariates.
^aNumber of patients in the intent-to-treat population with non-missing baseline serum K⁺ at baseline.
^bp-values test the hypothesis that the mean change in serum K⁺ from baseline is 0.
^cp-values test the pairwise difference in change in serum K⁺ from baseline between dose groups. Positive values indicate lager reduction from baseline as compared to the reference group.

5016CaS lowered serum potassium in all dose groups in both strata regardless of dose titration beginning as early as Day 3 and stabilizing after approximately Week 2. Most patients were able to maintain serum potassium before and after dose titration in the range of 4.0 mEq/L to 5.0 mEq/L in all dose groups in both strata.
The primary outcome, mean change from baseline in serum K (mEq/L) at week 4 or first 5016CaS dose titration analyzed using a parallel lines ANCOVA model, was −0.47±0.038 (p<0.001) in S1 and −0.90±0.076 (p<0.001) in S2. Mean K reduction after a median 2 days of treatment was −0.29±0.03 (S1) and −0.55±0.05 mEq/L (S2). Table 2 summarizes the means and changes from baseline, allowing titration.

	TABLE 2

	Stratum 1 ((S1), BL K > 5.0-5.5 mEq/L)	Stratum 2 ((S2), BL K > 5.5-<6.0 mEq/L)

Baseline	Week	4	Week 8	Baseline	Week	4	Week 8
(n = 217)	(n = 197)	(n = 185)	(N = 84)	(n = 70)	(n = 70)

Mean K (SE)	5.15	4.54	4.59	5.64	4.65	4.52
(mEq/L)	(0.02)	(0.03)	(0.03)	(0.04)	(0.06)	(0.06)
LS Mean change	—	−0.61	−0.55	—	−0.97	−1.10
(SE) (mEq/L)		(0.03)	(0.03)		(0.06)	(0.06)

5016CaS reduced serum K within days of treatment initiation, an effect sustained over twelve months without significant adverse effects.

Example 3: Analysis of Systolic Blood Pressure from Phase II Clinical Study

The following section contains results of the repeated measures analyses of mean systolic blood pressure during the 8-week treatment initiation period of the Phase II Clinical Study disclosed in Example 2. Table 3 through Table 6 present the analyses of mean change from baseline. Tables 3 and 4 present the results for all patients; Tables 5 and 6 present subsets of the analyses according to hyperkalemia status at screening (Cohort 3). In general, patients in Stratum 2 (patients with serum K⁺>5.5-<6.0 mEq/L) experience smaller mean decreases in blood pressure than patients in Stratum 1 (patients with serum K⁺>5.0-5.5 mEq/L). Patients in Cohort 3, who entered the study hyperkalemic and did not participate in the run-in phase, contributed to the reduction in mean systolic blood pressure (Tables 5 and 6).
For Tables 3-6, column header counts include all randomized patients who received RLY5016 (intent-to-treat population) by each randomized starting dose within stratum. The data were derived from a mixed model for repeated measures where the outcome variable was a change in systolic blood pressure (SBP) from baseline. Each stratum was analyzed separately. Each model contained a fixed effect for cohort, randomized starting dose, time (visit), continuous baseline SBP, and randomized starting dose by visit interaction. The within-patient correlation was modeled using heterogeneous Toeplitz structure. Estimates, standard errors (SE), and confidence intervals for each randomized starting dose were generated using linear contrasts across the observed values of the covariates. Overall estimates, standard errors, and confidence intervals across randomized dosing groups assume equal distribution across dosing groups. The total patients in the analysis, N, were determined by the number of randomized patients who received RLY5016, had a baseline measure, and contributed at least one post-baseline measure to this analysis. Not all patients contributed measures at each visit.

TABLE 3

Estimated mean change from baseline in systolic blood pressure by randomized starting dose,
all patients Stratum 1

Stratum 1-Local serum K+ >5.0-5.5 mEq/L

Change in SBP from	10 g/d	20 g/d	30 g/d	Overall
baseline (mmHg)	N = 74	N = 73	N = 73	N = 220

Patients in analysis, N	74	73	73	220
Day 3, n	70	70	72	212
Least squares mean ± SE	−9.3 ± 1.8	−4.9 ± 1.8	−10.3 ± 1.8	−8.2 ± 1.0
95% confidence interval	−12.8, −5.7	−8.5, −1.4	−13.9, −6.8	−10.2, −6.1
Week 1, n	72	71	72	215
Least squares mean ± SE	−11.1 ± 1.9	−8.8 ± 2.0	−12.0 ± 1.9	−10.6 ± 1.1
95% confidence interval	−14.9, −7.3	−12.6, −4.9	−15.8, −8.2	−12.8, −8.4
Week 2, n	70	70	71	211
Least squares mean ± SE	−12.4 ± 2.0	−5.7 ± 2.0	−13.8 ± 2.0	−10.6 ± 1.1
95% confidence interval	−16.3, −8.5	−9.6, −1.8	−17.7, −9.9	−12.9, −8.4
Week 3, n	64	69	71	204
Least squares mean ± SE	−11.5 ± 2.1	−7.5 ± 2.0	−12.5 ± 2.0	−10.5 ± 1.2
95% confidence interval	−15.6, −7.4	−11.5, −3.5	−16.4, −8.6	−12.8, −8.2
Week 4, n	65	67	69	201
Least squares mean ± SE	−13.3 ± 2.0	−8.0 ± 2.0	−12.4 ± 2.0	−11.2 ± 1.1
95% confidence interval	−17.2, −9.3	−11.9, −4.1	−16.2, −8.5	−13.5, −9.0
Week 5, n	65	66	67	198
Least squares mean ± SE	−12.0 ± 2.0	−9.6 ± 2.0	−13.7 ± 2.0	−11.8 ± 1.2
95% confidence interval	−15.9, −8.0	−13.5, −5.7	−17.7, −9.8	−14.0, −9.5
Week 6, n	65	66	64	195
Least squares mean ± SE	−13.3 ± 2.1	−6.9 ± 2.0	−12.8 ± 2.1	−11.0 ± 1.2
95% confidence interval	−17.3, −9.3	−10.9, −2.9	−16.8, −8.7	−13.3, −8.7
Week 7, n	64	64	65	193
Least squares mean ± SE	−15.6 ± 2.0	−9.5 ± 2.0	−11.0 ± 2.0	−12.0 ± 1.2
95% confidence interval	−19.5, −11.6	−13.6, −5.5	−15.0, −7.0	−14.3, −9.7
Week 8, n	66	64	66	196
Least squares mean ± SE	−16.3 ± 2.0	−12.0 ± 2.0	−13.8 ± 2.0	−14.0 ± 1.1
95% confidence interval	−20.2, −12.5	−15.9, −8.1	−17.7, −10.0	−16.3, −11.8

TABLE 4

Estimated mean change from baseline in systolic blood pressure by randomized starting
dose, all patients Stratum 2

Stratum 2-Local serum K+ >5.5-<6.0 mEq/L

Change in SBP from	20 g/d	30 g/d	40 g/d	Overall
baseline (mmHg)	N = 26	N = 28	N = 30	N = 84

Patients in analysis, N	26	28	29	83
Day 3, n	26	27	29	82
Least squares mean ± SE	−7.3 ± 3.5	−9.6 ± 3.4	−6.6 ± 3.3	−7.8 ± 2.0
95% confidence interval	−14.2, −0.4	−16.3, −2.9	−13.1, −0.08	−11.7, −4.0
Week 1, n	24	28	28	80
Least squares mean ± SE	−6.2 ± 4.2	−11.5 ± 3.9	−4.8 ± 3.9	−7.5 ± 2.3
95% confidence interval	−14.4, 1.9	−19.2, −3.9	−12.5, 2.8	−12.1, −3.0
Week 2, n	24	27	26	77
Least squares mean ± SE	−5.8 ± 4.2	−7.7 ± 4.0	−3.3 ± 4.0	−5.6 ± 2.4
95% confidence interval	−14.2, 2.5	−15.6, 0.2	−11.3, 4.6	−10.3, −1.0
Week 3, n	24	25	25	74
Least squares mean ± SE	−12.0 ± 3.8	−10.0 ± 3.6	−8.3 ± 3.6	−10.1 ± 2.1
95% confidence interval	−19.4, −4.6	−17.2, −2.9	−15.5, −1.2	−14.3, −5.9
Week 4, n	24	25	24	73
Least squares mean ± SE	−9.6 ± 3.1	−10.7 ± 3.0	−3.8 ± 3.0	−8.1 ± 1.7
95% confidence interval	−15.7, −3.5	−16.6, −4.9	−9.7, 2.1	−11.5, −4.6
Week 5, n	24	25	23	72
Least squares mean ± SE	−8.3 ± 3.6	−9.4 ± 3.5	−6.0 ± 3.5	−7.9 ± 2.0
95% confidence interval	−15.3, −1.2	−16.2, −2.7	−13.0, 0.9	−11.9, −3.9
Week 6, n	24	25	22	71
Least squares mean ± SE	−7.5 ± 3.6	−11.4 ± 3.4	−5.4 ± 3.6	−8.1 ± 2.0
95% confidence interval	−14.5, −0.5	−18.1, −4.6	−12.4, 1.6	−12.1, −4.1
Week 7, n	24	25	22	71
Least squares mean ± SE	−10.4 ± 3.4	−8.4 ± 3.3	−1.3 ± 3.4	−6.7 ± 1.9
95% confidence interval	−17.1, −3.7	−14.8, −1.9	−8.0, 5.4	−10.5, −2.9
Week 8, n	24	26	24	74
Least squares mean ± SE	−7.8 ± 3.5	−11.0 ± 3.4	−1.7 ± 3.5	−6.9 ± 2.0
95% confidence interval	−14.8, −0.9	−17.6, −4.4	−8.5, 5.1	−10.8, −3.0

TABLE 5

Estimated mean change from baseline in systolic blood pressure by randomized starting dose,
patients who were hyperkalemic at screening Stratum 1

Stratum 1-Local serum K+ >5.0-5.5 mEq/L

Change in SBP from	10 g/d	20 g/d	30 g/d	Overall
baseline (mmHg)	N = 57	N = 57	N = 56	N = 170

Patients in analysis, N	57	57	56	170
Day 3, n	56	56	56	168
Least squares mean ± SE	−9.8 ± 2.0	−5.6 ± 2.0	−12.5 ± 2.0	−9.3 ± 1.2
95% confidence interval	−13.8, −5.8	−9.6, −1.6	−16.5, −8.5	−11.6, −7.0
Week 1, n	55	55	55	165
Least squares mean ± SE	−11.4 ± 2.2	−9.9 ± 2.2	−12.7 ± 2.2	−11.3 ± 1.3
95% confidence interval	−15.7, −7.1	−14.2, −5.6	−16.9, −8.4	−13.8, −8.9
Week 2, n	54	54	54	162
Least squares mean ± SE	−12.3 ± 2.3	−5.8 ± 2.3	−15.2 ± 2.3	−11.1 ± 1.3
95% confidence interval	−16.8, −7.8	−10.3, −1.3	−19.8, −10.7	−13.7, −8.5
Week 3, n	49	53	54	156
Least squares mean ± SE	−11.6 ± 2.5	−10.2 ± 2.4	−13.8 ± 2.4	−11.9 ± 1.4
95% confidence interval	−16.4, −6.7	−14.9, −5.5	−18.5, −9.1	−14.6, −9.1
Week 4, n	51	52	53	156
Least squares mean ± SE	−13.4 ± 2.3	−10.8 ± 2.3	−14.2 ± 2.3	−12.8 ± 1.3
95% confidence interval	−18.0, −8.8	−15.4, −6.3	−18.7, −9.7	−15.4, −10.2
Week 5, n	50	51	53	154
Least squares mean ± SE	−11.4 ± 2.3	−10.5 ± 2.3	−15.0 ± 2.3	−12.3 ± 1.3
95% confidence interval	−16.0, −6.8	−15.1, −5.9	−19.5, −10.5	−14.9, −9.7
Week 6, n	50	51	52	153
Least squares mean ± SE	−12.3 ± 2.2	−6.8 ± 2.2	−15.0 ± 2.2	−11.4 ± 1.3
95% confidence interval	−16.6, −7.9	−11.1, −2.5	−19.3, −10.7	−13.8, −8.9
Week 7, n	50	49	52	151
Least squares mean ± SE	−14.5 ± 2.1	−9.0 ± 2.1	−13.2 ± 2.1	−12.2 ± 1.2
95% confidence interval	−18.6, −10.3	−13.2, −4.8	−17.3, −9.1	−14.6, −9.8
Week 8, n	51	49	52	152
Least squares mean ± SE	−16.6 ± 2.2	−13.0 ± 2.3	−14.9 ± 2.2	−14.8 ± 1.3
95% confidence interval	−21.0, −12.3	−17.4, −8.6	−19.2, −10.5	−17.3, −12.3

TABLE 6

Estimated mean change from baseline in systolic blood pressure by randomized starting
dose, patients who were hyperkalemic at screening Stratum 2

Stratum 2-Local serum K⁺ >5.5-<6.0 mEq/L

Change in SBP from	20 g/d	30 g/d	40 g/d	Overall
baseline (mmHg)	N = 24	N = 24	N = 25	N = 73

Patients in analysis, N	24	24	24	72
Day 3, n	24	23	24	71
Least squares meanSE	−10.2 ± 3.6	−11.2 ± 3.7	−6.5 ± 3.7	−9.3 ± 2.1
95% confidence interval	−17.3, −3.0	−18.5, −3.9	−13.6, 0.7	−13.4, −5.1
Week 1, n	22	24	23	69
Least squares mean ± SE	−8.4 ± 4.4	−13.8 ± 4.3	−2.1 ± 4.3	−8.1 ± 2.5
95% confidence interval	−17.0, 0.3	−22.2, −5.4	−10.7, 6.4	−13.0, −3.2
Week 2, n	22	23	21	66
Least squares mean ± SE	−8.0 ± 4.3	−10.4 ± 4.2	−0.3 ± 4.3	−6.2 ± 2.5
95% confidence interval	−16.4, 0.4	−18.6, −2.1	−8.8, 8.2	−11.1, −1.4
Week 3, n	22	21	20	63
Least squares mean ± SE	−14.1 ± 3.9	−12.8 ± 3.9	−6.7 ± 4.0	−11.2 ± 2.3
95% confidence interval	−21.7, −6.4	−20.5, −5.1	−14.5, 1.2	−15.6, −6.7
Week 4, n	22	21	19	62
Least squares mean ± SE	−12.0 ± 3.2	−13.6 ± 3.2	−4.0 ± 3.3	−9.9 ± 1.9
95% confidence interval	−18.3, −5.8	−19.9, −7.3	−10.6, 2.5	−13.5, −6.2
Week 5, n	22	21	18	61
Least squares mean ± SE	−10.1 ± 3.7	−12.9 ± 3.8	−4.1 ± 4.0	−9.1 ± 2.2
95% confidence interval	−17.5, −2.8	−20.3, −5.5	−11.9, 3.7	−13.4, −4.7
Week 6, n	22	21	17	60
Least squares mean ± SE	−9.9 ± 3.5	−14.2 ± 3.6	−2.1 ± 3.8	−8.7 ± 2.1
95% confidence interval	−16.8, −3.0	−21.2, −7.2	−9.6, 5.5	−12.9, −4.6
Week 7, n	22	21	17	60
Least squares mean ± SE	−12.7 ± 3.5	−11.9 ± 3.5	1.9 ± 3.8	−7.6 ± 2.1
95% confidence interval	−19.5, −5.9	−18.8, −5.0	−5.5, 9.4	−11.6, −3.5
Week 8, n	22	22	19	63
Least squares mean ± SE	−11.4 ± 3.6	−14.4 ± 3.5	−0.3 ± 3.8	−8.7 ± 2.1
95% confidence interval	−18.4, −4.4	−21.3, −7.4	−7.7, 7.1	−12.8, −4.6

Example 4: Analysis of Diastolic Blood Pressure from Phase II Clinical Study

This section contains results of the repeated measures analyses of diastolic blood pressure during the 8-week treatment initiation period of the Phase II Clinical Study disclosed in Example 2. Table 7 through Table 10 present the analyses of mean change in diastolic blood pressure from baseline. Tables 7 and 8 present the results for all patients; Tables 9 and 10 present subsets of the analyses according to hyperkalemia status at screening (Cohort 3). Patients in both cohorts and strata experienced modest mean reductions in diastolic blood pressure.
For Tables 7-10, column header counts include all randomized patients who received RLY5016 (intent-to-treat population) by each randomized starting dose within stratum. The data were derived from a mixed model for repeated measures where the outcome variable was a change in diastolic blood pressure (DBP) from baseline. Each stratum was analyzed separately. Each model contained a fixed effect for cohort, randomized starting dose, time (visit), continuous baseline DBP, and randomized starting dose by visit interaction. The within-patient correlation was modeled using heterogeneous Toeplitz structure. Estimates, standard errors (SE), and confidence intervals for each randomized starting dose were generated using linear contrasts across the observed values of the covariates. Overall estimates, standard errors, and confidence intervals across randomized dosing groups assume equal distribution across dosing groups. The total patients in the analysis, N, were determined by the number of randomized patients who received RLY5016, had a baseline measure, and contributed at least one post-baseline measure to this analysis. Not all patients contributed measures at each visit.

TABLE 7

Estimated mean change from baseline in diastolic blood pressure by randomized starting dose,
all patients Stratum 1

Stratum 1-Local serum K⁺ >5.0-5.5 mEq/L

Change in DBP from	10 g/d	20 g/d	30 g/d	Overall
baseline (mmHg)	N = 74	N = 73	N = 73	N = 220

Patients in analysis, N	74	73	73	220
Day 3, n	70	70	72	212
Least squares mean ± SE	−3.8 ± 1.1	−3.1 ± 1.1	−5.8 ± 1.1	−4.2 ± 0.6
95% confidence interval	−6.0, −1.7	−5.2, −1.0	−7.9, −3.7	−5.5, −3.0
Week 1, n	72	71	72	215
Least squares mean ± SE	−6.0 ± 1.2	−5.4 ± 1.2	−7.0 ± 1.2	−6.1 ± 0.7
95% confidence interval	−8.3, −3.7	−7.7, −3.1	−9.3, −4.7	−7.4, −4.8
Week 2, n	70	70	71	211
Least squares mean ± SE	−6.6 ± 1.3	−6.1 ± 1.3	−6.1 ± 1.3	−6.3 ± 0.7
95% confidence interval	−9.0, −4.1	−8.6, −3.6	−8.6, −3.7	−7.7, −4.8
Week 3, n	64	69	71	204
Least squares mean ± SE	−5.0 ± 1.2	−6.0 ± 1.2	−8.0 ± 1.2	−6.3 ± 0.7
95% confidence interval	−7.4, −2.5	−8.4, −3.6	−10.4, −5.7	−7.7, −4.9
Week 4, n	65	67	69	201
Least squares mean ± SE	−5.8 ± 1.2	−6.5 ± 1.2	−8.0 ± 1.2	−6.7 ± 0.7
95% confidence interval	−8.1,−3.4	−8.8,−4.1	−10.3,−5.7	−8.1,−5.4
Week 5, n	65	66	67	198
Least squares mean ± SE	−6.0 ± 1.3	−5.9 ± 1.3	−8.4 ± 1.3	−6.8 ± 0.7
95% confidence interval	−8.6, −3.5	−8.5, −3.4	−10.9, −5.9	−8.2, −5.3
Week 6, n	65	66	64	195
Least squares mean ± SE	−5.7 ± 1.3	−6.4 ± 1.3	−6.6 ± 1.3	−6.2 ± 0.8
95% confidence interval	−8.3, −3.1	−9.0, −3.8	−9.2, −4.0	−7.7, −4.8
Week 7, n	64	64	65	193
Least squares mean ± SE	−6.3 ± 1.4	−6.0 ± 1.4	−6.5 ± 1.3	−6.3 ± 0.8
95% confidence interval	−8.9, −3.6	−8.7, −3.4	−9.2, −3.9	−7.8, −4.8
Week 8, n	66	64	66	196
Least squares mean ± SE	−7.6 ± 1.4	−7.3 ± 1.4	−6.8 ± 1.4	−7.2 ± 0.8
95% confidence interval	−10.3, −4.9	−10.1, −4.6	−9.5, −4.1	−8.8, −5.7

TABLE 8

Estimated mean change from baseline in diastolic blood pressure by randomized starting
dose, all patients Stratum 2

Stratum 2-Local serum K⁺ >5.5-<6.0 mEq/L

Change in DBP from	20 g/d	30 g/d	40 g/d	Overall
baseline (mmHg)	N = 26	N = 28	N = 30	N = 84

Patients in analysis, N	26	28	29	83
Day 3, n	26	27	29	82
Least squares mean ± SE	−1.7 ± 2.0	−3.9 ± 2.0	−5.4 ± 1.9	−3.7 ± 1.1
95% confidence interval	−5.6, 2.3	−7.8, −0.08	−9.1, −1.7	−5.9, −1.5
Week 1, n	24	28	28	80
Least squares mean ± SE	−1.4 ± 2.5	−5.3 ± 2.4	−4.4 ± 2.3	−3.7 ± 1.4
95% confidence interval	−6.4, 3.5	−9.9, −0.7	−9.0, 0.2	−6.4, −1.0
Week 2, n	24	27	26	77
Least squares mean ± SE	−7.2 ± 2.0	−3.0 ± 1.9	−5.5 ± 1.9	−5.3 ± 1.1
95% confidence interval	−11.2, −3.3	−6.8, 0.8	−9.4, −1.7	−7.5, −3.0
Week 3, n	24	25	25	74
Least squares mean ± SE	−7.0 ± 2.1	−7.1 ± 2.0	−5.9 ± 2.0	−6.7 ± 1.2
95% confidence interval	−11.1, −2.8	−11.1, −3.1	−9.9, −1.9	−9.0, −4.3
Week 4, n	24	25	24	73
Least squares mean ± SE	−7.7 ± 2.2	−6.3 ± 2.2	−1.9 ± 2.2	−5.3 ± 1.3
95% confidence interval	−12.1, −3.3	−10.6, −2.0	−6.2, 2.4	−7.8, −2.8
Week 5, n	24	25	23	72
Least squares mean ± SE	−8.2 ± 1.8	−6.8 ± 1.8	−4.4 ± 1.8	−6.5 ± 1.0
95% confidence interval	−11.8, −4.7	−10.3, −3.4	−8.0, −0.9	−8.5, −4.5
Week 6, n	24	25	22	71
Least squares mean ± SE	−7.1 ± 2.0	−8.9 ± 2.0	−4.3 ± 2.0	−6.8 ± 1.2
95% confidence interval	−11.1, −3.1	−12.8, −5.1	−8.4, −0.3	−9.1, −4.5
Week 7, n	24	25	22	71
Least squares mean ± SE	−7.3 ± 1.9	−9.0 ± 1.8	−3.4 ± 1.9	−6.6 ± 1.1
95% confidence interval	−10.9, −3.6	−12.6, −5.4	−7.1, 0.3	−8.7, −4.5
Week 8, n	24	26	24	74
Least squares mean ± SE	−4.5 ± 2.1	−7.0 ± 2.0	−1.8 ± 2.0	−4.4 ± 1.2
95% confidence interval	−8.5, −0.4	−10.9, −3.1	−5.8, 2.2	−6.7, −2.1

TABLE 9

Estimated mean change from baseline in diastolic blood pressure by randomized starting
dose, patients who were hyperkalemic at screening Stratum 1

Stratum 1-Local serum K⁺ >5.0-5.5 mEq/L

Change in DBP from	10 g/d	20 g/d	30 g/d	Overall
baseline (mmHg)	N = 57	N = 57	N = 56	N = 170

Patients in analysis, N	57	57	56	170
Day 3, n	56	56	56	168
Least squares mean ± SE	−3.7 ± 1.3	−4.5 ± 1.3	−7.1 ± 1.3	−5.1 ± 0.7
95% confidence interval	−6.1, −1.2	−7.0, −2.0	−9.6, −4.6	−6.5, −3.7
Week 1, n	55	55	55	165
Least squares mean ± SE	−5.8 ± 1.3	−6.6 ± 1.3	−7.5 ± 1.3	−6.6 ± 0.8
95% confidence interval	−8.4, −3.2	−9.2, −3.9	−10.2, −4.9	−8.1, −5.1
Week 2, n	54	54	54	162
Least squares mean ± SE	−7.1 ± 1.5	−7.4 ± 1.5	−6.5 ± 1.5	−7.0 ± 0.9
95% confidence interval	−10.0, −4.1	−10.4, −4.5	−9.5, −3.6	−8.7, −5.3
Week 3, n	49	53	54	156
Least squares mean ± SE	−5.2 ± 1.5	−7.4 ± 1.4	−9.7 ± 1.4	−7.4 ± 0.8
95% confidence interval	−8.1, −2.2	−10.2, −4.5	−12.5, −6.8	−9.0, −5.7
Week 4, n	51	52	53	156
Least squares mean ± SE	−5.6 ± 1.4	−8.5 ± 1.4	−10.0 ± 1.3	−8.0 ± 0.8
95% confidence interval	−8.2, −2.9	−11.2, −5.9	−12.6, −7.3	−9.6, −6.5
Week 5, n	50	51	53	154
Least squares mean ± SE	−6.5 ± 1.5	−8.3 ± 1.5	−9.5 ± 1.4	−8.1 ± 0.8
95% confidence interval	−9.4, −3.6	−11.1, −5.4	−12.3, −6.7	−9.7, −6.4
Week 6, n	50	51	52	153
Least squares mean ± SE	−5.6 ± 1.5	−7.3 ± 1.5	−7.7 ± 1.5	−6.8 ± 0.9
95% confidence interval	−8.6, −2.6	−10.3, −4.3	−10.7, −4.7	−8.6, −5.1
Week 7, n	50	49	52	151
Least squares mean ± SE	−5.5 ± 1.6	−7.1 ± 1.6	−7.7 ± 1.5	−6.8 ± 0.9
95% confidence interval	−8.6, −2.4	−10.2, −4.0	−10.8, −4.7	−8.5, −5.0
Week 8, n	51	49	52	152
Least squares mean ± SE	−7.2 ± 1.6	−8.1 ± 1.6	−8.1 ± 1.6	−7.8 ± 0.9
95% confidence interval	−10.4, −4.1	−11.4, −4.9	−11.3, −5.0	−9.7, −6.0

TABLE 10

Estimated mean change from baseline in diastolic blood pressure by randomized starting
dose, patients who were hyperkalemic at screening Stratum 2

Stratum 2-Local serum K⁺ >5.5-<6.0 mEq/L

Change in DBP from	20 g/d	30 g/d	40 g/d	Overall
baseline (mmHg)	N = 24	N = 24	N = 25	N = 73

Patients in analysis, N	24	24	24	72
Day 3, n	24	23	24	71
Least squares mean ± SE	−1.6 ± 2.2	−4.1 ± 2.2	−5.9 ± 2.2	−3.9 ± 1.3
95% confidence interval	−5.9, 2.6	−8.5, 0.3	−10.1, −1.6	−6.4, −1.4
Week 1, n	22	24	23	69
Least squares mean ± SE	−1.5 ± 2.7	−6.4 ± 2.7	−4.4 ± 2.7	−4.1 ± 1.6
95% confidence interval	−6.9, 3.9	−11.6, −1.2	−9.7, 0.9	−7.2, −1.1
Week 2, n	22	23	21	66
Least squares mean ± SE	−7.7 ± 2.2	−4.0 ± 2.2	−4.7 ± 2.2	−5.5 ± 1.3
95% confidence interval	−12.0, −3.4	−8.3, 0.2	−9.0, −0.3	−7.9, −3.0
Week 3, n	22	21	20	63
Least squares mean ± SE	−7.2 ± 2.3	−7.6 ± 2.3	−6.9 ± 2.3	−7.2 ± 1.3
95% confidence interval	−11.7, −2.7	−12.1, −3.1	−11.5, −2.3	−9.9, −4.6
Week 4, n	22	21	19	62
Least squares mean ± SE	−8.0 ± 2.4	−6.9 ± 2.5	−2.6 ± 2.6	−5.8 ± 1.4
95% confidence interval	−12.7, −3.2	−11.7, −2.0	−7.6, 2.4	−8.6, −3.0
Week 5, n	22	21	18	61
Least squares mean ± SE	−8.6 ± 1.9	−7.3 ± 2.0	−5.1 ± 2.1	−7.0 ± 1.1
95% confidence interval	−12.4, −4.9	−11.2, −3.5	−9.1, −1.0	−9.3, −4.8
Week 6, n	22	21	17	60
Least squares mean ± SE	−7.6 ± 2.1	−10.0 ± 2.2	−4.8 ± 2.3	−7.5 ± 1.3
95% confidence interval	−11.8, −3.4	−14.2, −5.8	−9.3, −0.2	−10.0, −5.0
Week 7, n	22	21	17	60
Least squares mean ± SE	−7.5 ± 2.0	−9.4 ± 2.1	−3.0 ± 2.2	−6.6 ± 1.2
95% confidence interval	−11.5, −3.5	−13.5, −5.4	−7.4, 1.4	−9.0, −4.3
Week 8, n	22	22	19	63
Least squares mean ± SE	−4.8 ± 2.2	−8.6 ± 2.2	−2.1 ± 2.3	−5.2 ± 1.3
95% confidence interval	−9.1, −0.4	−12.9, −4.3	−6.7, 2.5	−7.7, −2.6

When introducing elements of the present invention or the preferred embodiments(s) thereof, the articles “a”, “an”, “the” and “said” are intended to mean that there are one or more of the elements. The terms “comprising”, “including” and “having” are intended to be inclusive and mean that there may be additional elements other than the listed elements.
In view of the above, it will be seen that the several objects of the invention are achieved and other advantageous results attained.
As various changes could be made in the above methods without departing from the scope of the invention, it is intended that all matter contained in the above description and shown in the accompanying figure[s] shall be interpreted as illustrative and not in a limiting sense.

Claims

What is claimed is:

1. A method of treating hypertension in a patient in need thereof, the method comprising administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient.

2. The method of claim 1 wherein the 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form is administered chronically.

3. The method of claim 1 or 2 wherein the patient's systolic blood pressure is reduced by 5, 6, 7, 8 mm Hg or more after 4 weeks of treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form as compared to the patient's systolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

4. The method of claim 1 or 2 wherein the patient's systolic blood pressure is reduced by 9, 10, 11, 12, 13, 14, 15, 16, 17 mm Hg or more after 4 weeks of treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form as compared to the patient's systolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

5. The method of any one of claims 1 to 4 wherein the patient's diastolic blood pressure is reduced by 2, 3, 4, 5, 6 mm Hg as compared to the patient's diastolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

6. The method of any one of claims 1 to 4 wherein the patient's diastolic blood pressure is reduced by 7, 8, 9, 10, 11, 12, 13 mm Hg or more as compared to the patient's diastolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

7. The method of any one of claims 1 to 6 wherein the patient's systolic blood pressure is reduced by at least 6, 7, 8, 9, 10, 11, 12, or more percent as compared to the patient's systolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

8. The method of any one of claims 1 to 7 wherein the patient's diastolic blood pressure is reduced by at least 8, 9, 10, 11, 12, 13, 14, 15, or more percent as compared to the patient's diastolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

9. The method of any one of claims 1 to 8 wherein the patient had a systolic blood pressure of from 130 mmHg to 200 mm Hg before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

10. The method of any one of claims 1 to 8 wherein the patient had a systolic blood pressure of from 135 mmHg to 200 mm Hg before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

11. The method of any one of claims 1 to 8 wherein the patient had a systolic blood pressure of from 140 mmHg to 200 mm Hg before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

12. The method of any one of claims 1 to 8 wherein the patient had a systolic blood pressure of from 143 mmHg to 200 mm Hg before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

13. The method of any one of claims 1 to 8 wherein the patient had a systolic blood pressure of from 145 mmHg to 180 mmHg before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

14. The method of any one of claims 1 to 8 wherein the patient had a systolic blood pressure of from 148 mmHg to 180 mmHg before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

15. The method of any one of claims 1 to 14 wherein the systolic blood pressure of the patient is maintained below 130 mm Hg over at least 90% of the period of treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

16. The method of any one of claims 1 to 16 wherein the diastolic blood pressure of the patient is maintained at below 80 mm Hg over at least 90% of the period of treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

17. The method of any one of claims 1 to 16 wherein the patient is not being treated with an aldosterone antagonist.

18. The method of any one of claims 1 to 17 wherein the patient does not have another condition that causes hypertension.

19. The method of claim 18 wherein the patient does not have Type 2 diabetes.

20. The method of claim 18 wherein the patient does not have Class II or Class III heart failure (HF).

21. The method of any one of claims 1 to 20 wherein the patient is not being treated with a heart failure therapy.

22. The method of claim 21 wherein the heart failure therapy is an angiotensin converting enzyme inhibitor (ACEI), an angiotensin receptor blocker (ARB), a beta blocker (BB), or a combination thereof.

23. The method of any one of claims 1 to 22 wherein the patient is not being treated with an antihypertensive agent comprising a diuretic, a calcium channel blocker, an alpha blocker, a nervous system inhibitor, a vasodilator, an angiotensin converting enzyme inhibitor (ACEI), an angiotensin receptor blocker (ARB), a beta blocker (BB), or a combination thereof.

24. The method of any one of claims 1 to 23 wherein the patient is normokalemic.

25. A method of treating hypertension in a chronic kidney disease patient in need thereof, the patient optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent, the method comprising administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient.

26. A method of treating hypertension in a heart failure patient in need thereof, the patient optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent, the method comprising administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient.

27. A method of treating hypertension in a type 2 diabetes mellitus patient in need thereof, the patient optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent, the method comprising administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient.

28. The method of claim 25 wherein the patient further suffers from heart failure and type 2 diabetes mellitus.

29. The method of claim 26 or 27 wherein the patient further suffers from chronic kidney disease.

30. The method of claim 27 wherein the patient further suffers from heart failure.

31. The method of any one of claims 25 to 30 wherein the patient's systolic blood pressure is reduced by 5, 6, 7, 8 mm Hg as compared to the patient's systolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

32. The method of any one of claims 25 to 30 wherein the patient's systolic blood pressure is reduced by 9, 10, 11, 12, 13, 14, 15, 16, 17 mm Hg or more as compared to the patient's systolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

33. The method of any one of claims 25 to 32 wherein the patient's diastolic blood pressure is reduced by 2, 3, 4, 5, 6 mm Hg as compared to the patient's diastolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

34. The method of any one of claims 25 to 32 wherein the patient's diastolic blood pressure is reduced by 7, 8, 9, 10, 11, 12, 13 mm Hg or more as compared to the patient's diastolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

35. The method of any one of claims 25 to 30 and 32 to 34 wherein the patient's systolic blood pressure is reduced by at least 6, 7, 8, 9, 10, 11, 12, or more percent as compared to the patient's systolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

36. The method of any one of claims 25 to 32, 34, and 35 wherein the patient's diastolic blood pressure is reduced by at least 8, 9, 10, 11, 12, 13, 14, 15, or more percent as compared to the patient's diastolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

37. A method of treating hyperkalemia in a chronic kidney disease patient in need thereof optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent, the method comprising:

administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient and observing a decrease in the patient's serum creatinine level as compared to the patient's serum creatinine level before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form indicating an increase or stabilization of the patient's kidney function.

38. A method of treating hyperkalemia in a chronic kidney disease patient in need thereof optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent, the method comprising:

administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient and observing a decrease in the time to progression of end stage renal disease as compared to a chronic kidney disease patient optionally treated with a RAAS agent but not treated with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form indicating an increase or stabilization of the patient's kidney function.

39. A method of treating hyperkalemia in a chronic kidney disease patient in need thereof optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent, the method comprising:

administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient and observing an increase in survival as compared to a chronic kidney disease patient optionally treated with a RAAS agent but not treated with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form indicating an increase or stabilization of the patient's kidney function.

40. A method of treating hyperkalemia in a chronic kidney disease patient in need thereof optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent, the method comprising:

administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient and observing an increase or stabilization of estimated glomerular filtration rate (eGFR) as compared to the patient's eGFR before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form indicating an increase or stabilization of the patient's kidney function.

41. A method of treating chronic kidney disease in a patient in need thereof optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent, the method comprising:

administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient to increase or stabilize the patient's kidney function by decreasing the patient's serum creatinine level as compared to the patient's serum creatinine level before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

42. A method of treating chronic kidney disease in a patient in need thereof optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent, the method comprising:

administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient to increase or stabilize the patient's kidney function by decreasing the time to progression of end stage renal disease as compared to a chronic kidney disease patient optionally treated with a RAAS agent but not treated with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

43. A method of treating chronic kidney disease in a patient in need thereof optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent, the method comprising:

administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient to increase or stabilize the patient's kidney function by increasing survival as compared to a chronic kidney disease patient optionally treated with a RAAS agent but not treated with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

44. A method of treating chronic kidney disease in a patient in need thereof optionally being treated with an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent, the method comprising:

administering an effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form to the patient to increase or stabilize the patient's kidney function by increasing or stabilizing estimated glomerular filtration rate (eGFR) as compared to the patient's eGFR before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

45. The method of any one of claims 41 to 44 further comprising treating hyperkalemia in a patient in need thereof.

46. The method of any one of claims 25 to 45 wherein the treatment period is 1, 2, 4, 6, 8, 12, 16, 20, 24, 28, 32, 36, 40, 44, 48, 52, or more weeks.

47. The method of any one of claims 25 to 46 wherein the patient has a baseline estimated glomerular filtration rate (eGFR) of from about 15 mL/min/1.73 m²to about 44 mL/min/1.73 m².

48. The method of any one of claims 25 to 47 wherein the patient's eGFR after treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form is not significantly different from the patient's eGFR before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

49. The method of any one of claims 25 to 47 wherein the patient's eGFR is increased after 2, 3, 4, 5, 6 months or more of treatment as compared to the patient's eGFR before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

50. The method of claim 49 wherein the patient's eGFR after treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form increased by at least 4, 5, 6 mL/min/1.73 m²or more as compared to the patient's eGFR before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

51. The method of any one of claims 25 to 50 wherein the patient's serum potassium level is decreased after 1, 2, 3, 4, 5, 6, 7 days or more of treatment as compared to the patient's serum potassium level before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

52. The method of any one of claims 25 to 51 wherein the patient's urine albumin:creatinine ratio (ACR) is not significantly different after 2, 3, 4, 5, 6 months or more of treatment as compared to the patient's urine ACR before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

53. The method of any one of claims 25 to 52 wherein the patient's systolic and diastolic blood pressure is decreased after 1, 2, 3, 4, 5, 6, 7 days or more of treatment as compared to the patient's systolic and diastolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

54. The method of claim 53 wherein the patient's systolic blood pressure is reduced by 5, 6, 7, 8 mm Hg or more as compared to the patient's systolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

55. The method of claim 53 wherein the patient's systolic blood pressure is reduced by 9, 10, 11, 12, 13, 14, 15, 16, 17 mm Hg or more as compared to the patient's systolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

56. The method of any one of claims 53 to 55 wherein the patient's diastolic blood pressure is reduced by 2, 3, 4, 5, 6 mm Hg as compared to the patient's diastolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

57. The method of any one of claim 53 or 55 wherein the patient's diastolic blood pressure is reduced by 7, 8, 9, 10, 11, 12, 13 mm Hg or more as compared to the patient's diastolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

58. The method of any one of claims 53 and 55 to 57 wherein the patient's systolic blood pressure is reduced by at least 6, 7, 8, 9, 10, 11, 12, or more percent as compared to the patient's systolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

59. The method of any one of claims 53 to 55, 57, and 58 wherein the patient's diastolic blood pressure is reduced by at least 8, 9, 10, 11, 12, 13, 14, 15, or more percent as compared to the patient's diastolic blood pressure before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

60. The method of any one of claims 1 to 59 wherein the patient's serum aldosterone level is decreased after four weeks or more of treatment as compared to the patient's serum aldosterone level before treatment with 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form.

61. The method of any one of claims 1 to 60 wherein the effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form comprises up to a maximum daily dose of 60 grams.

62. The method of claim 61 wherein the effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form comprises a daily dose of from 10 grams to 60 grams.

63. The method of claim 61 wherein the effective amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form comprises a daily dose of from 20 grams to 60 grams.

64. The method of any one of claims 1 to 63 further comprising:

administering an effective amount of a renin-angiotensin-aldosterone system (RAAS) agent to the patient;

determining the serum potassium level in the patient; and

increasing the amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form subsequently administered to the patient based on the serum potassium level if greater than or equal to 5.1 mEq/L.

65. The method of claim 64 wherein the amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form was increased by 5 g per day.

66. The method of claim 64 wherein the amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form was increased by 10 g per day.

67. The method of any one of claims 64 to 66 further comprising decreasing the amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form subsequently administered to the patient based on the serum potassium level if less than 4.0 mEq/L.

68. The method of claim 67 wherein the amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form was decreased by 5 g per day.

69. The method of claim 67 wherein the amount of 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form was decreased by 10 g per day.

70. The method of any one of claims 1 to 69 wherein 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form is in the salt form.

71. The method of claim 70 wherein the salt form comprises the sodium, calcium, magnesium, ammonium, or a combination thereof.

72. The method of claim 71 wherein the salt form comprises the calcium salt form.

73. The method of any one of claims 70 to 72 wherein the 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt form is stabilized with a linear polyol.

74. The method of claim 73 wherein the 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt form is stabilized with sorbitol.

75. The method of any one of claims 25 to 74 wherein the 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form is administered chronically.

76. The method of any one of claims 1 to 75 wherein the 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form exhibits long-term tolerability in the patient.

77. The method of any one of claims 1 to 76 wherein the 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form exhibits long-term safety in the patient.

78. The method of any one of claims 1 to 77 wherein the 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form exhibits long-term efficacy in the patient.

79. The method of any one of claims 1 to 78 wherein the 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form is administered to the patient daily for more than 8 weeks.

80. The method of any one of claims 1 to 78 wherein the 2-fluoroacrylate-divinylbenzene-1,7-octadiene copolymer crosslinked in the salt or acid form is administered to the patient daily for more than one year.

81. The method of any one of claims 1 to 16, 18 to 20 and 24 to 80 wherein the patient is being treated or further treated with an effective amount of a RAAS agent, the RAAS agent being an angiotensin converting enzyme (ACE) inhibitor, an angiotensin receptor blocker (ARB), an aldosterone antagonist (AA), an aldosterone synthase inhibitor, or a combination thereof.

82. The method of claim 81 wherein the RAAS agent is the ACE inhibitor, the ARB, or a combination thereof.

83. The method of claim 81 or 82 wherein the effective amount of the RAAS agent comprises up to a maximum daily tolerated dose.

84. The method of any one of claims 81 to 83 wherein the RAAS agent comprises fosinopril, ramipril, captopril, lisinopril, trandolapril, moexipril, quinapril, enalapril, benazepril, perindopril, eprosartan, olmesartan, losartan, telmisartan, valsartan, candesartan, irbesartan, azilsartan medoxomil, spironolactone, eplerenone, or a combination thereof.

85. The method of claim 84 wherein the RAAS agent comprises fosinopril and the maximum daily tolerated dose is 40 mg/day.

86. The method of claim 84 wherein the RAAS agent comprises ramipril and the maximum daily tolerated dose is 20 mg/day.

87. The method of claim 84 wherein the RAAS agent comprises captopril and the maximum daily tolerated dose is 300 mg/day.

88. The method of claim 84 wherein the RAAS agent comprises lisinopril and the maximum daily tolerated dose is 40 mg/day.

89. The method of claim 84 wherein the RAAS agent comprises trandolapril and the maximum daily tolerated dose is 4 mg.

90. The method of claim 84 wherein the RAAS agent comprises moexipril and the maximum daily tolerated dose is 30 mg/day.

91. The method of claim 84 wherein the RAAS agent comprises quinapril and the maximum daily tolerated dose is 80 mg/day.

92. The method of claim 84 wherein the RAAS agent comprises enalapril and the maximum daily tolerated dose is 40 mg/day.

93. The method of claim 84 wherein the RAAS agent comprises benazepril and the maximum daily tolerated dose is 40 mg/day.

94. The method of claim 84 wherein the RAAS agent comprises perindopril and the maximum daily tolerated dose is 8 mg/day.

95. The method of claim 84 wherein the RAAS agent comprises eprosartan and the maximum daily tolerated dose is 800 mg/day.

96. The method of claim 84 wherein the RAAS agent comprises olmesartan and the maximum daily tolerated dose is 40 mg/day.

97. The method of claim 84 wherein the RAAS agent comprises losartan and the maximum daily tolerated dose is 100 mg/day.

98. The method of claim 84 wherein the RAAS agent comprises telmisartan and the maximum daily tolerated dose is 80 mg/day.

99. The method of claim 84 wherein the RAAS agent comprises valsartan and the maximum daily tolerated dose is 320 mg/day.

100. The method of claim 84 wherein the RAAS agent comprises candesartan and the maximum daily tolerated dose is 32 mg/day.

101. The method of claim 84 wherein the RAAS agent comprises irbesartan and the maximum daily tolerated dose is 300 mg/day.

102. The method of claim 84 wherein the RAAS agent comprises azilsartan medoxomil and the maximum daily tolerated dose is 80 mg/day.

103. The method of claim 84 wherein the RAAS agent comprises spironolactone and the maximum daily tolerated dose is 200 mg/day.

104. The method of claim 84 wherein the RAAS agent comprises eplerenone and the maximum daily tolerated dose is 50 mg/day.

105. The method of any one of claims 1 to 20 and 24 to 104 wherein the patient is further being treated with an effective amount of a beta-adrenergic blocking agent.

106. The method of claim 105 wherein the beta-adrenergic blocking agent comprises betaxolol, bisoprolol, atenolol, metoprolol, nebivolol, metoprolol, esmolol, acebutolol, propranolol, nadolol, carvedilol, labetalol, sotalol, timolol, carteolol, penbutolol, pindolol, or a combination thereof.