WO2016085981A1 - Method of inhibiting or treating fibrosis - Google Patents

Abstract

A therapeutic use of trans-geranylgeranylacetone and its analogs is described, along with methods of inhibiting, reducing, or treating fibrosis, by administering the trans isomer of geranylgeranylacetone or an analog thereof.

Description

METHOD OF INHIBITING OR TREATING FIBROSIS

CROSS-REFERENCE TO RELATED APPLICATION

[0001] This application claims the benefit of the priority date of U.S. Provisional

Application No. 62/085,157, filed November 26, 2014, the content of which is incorporated herein in its entirety by reference.

FIELD

[0002] This technology relates to methods of inhibiting, reducing, or treating fibrosis, conditions leading to or arising from it, and/or negative effects of each thereof by administering the trans isomer of geranylgeranylacetone or an analog thereof.

BACKGROUND

[0003] Fibrosis can be generally defined as excessive deposition of extra cellular matrix (ECM) components such as fibronectin (FN) and type I collagen (Coll l) by organ fibroblasts. Organ fibrosis is the final common pathway for many diseases that result in end- stage organ failure. However, effective therapy for organ fibrosis is unavailable. Uncontrollable wound-healing responses, including acute and chronic inflammation, angiogenesis, activation of resident cells, and ECM remodeling, are thought to be involved in the pathogenesis of fibrosis. TGF-β is a prototype fibrotic cytokine that is increased in fibrotic organs and contributes to the development of fibrosis by stimulating the synthesis of ECM molecules, activating fibroblasts to a smooth muscle actin (a SMA)-expressing myofibroblasts, and downregulating matrix metalloproteinases (MMPs). However, a clinical trial of a monoclonal anti-TGF-β antibody in fibrosis patients, such as those with early secondary sclerosis (SSc), failed to show any efficacy (Varga and Pasche, Nature Reviews Rheumatology 2009; 5:200-6). In addition, certain drugs may induce fibrosis. For example, drugs for treating non- small cell lung cancer may induce pulmonary fibrosis. In other cases, pulmonary fibrosis may occur without a discernable cause, referred to as idiopathic pulmonary fibrosis. SUMMARY

[0004] Provided herein are methods for inhibiting, reducing, or treating fibrosis, conditions leading to or arising from it, and/or negative effects of each thereof. The methods include administering a compound of Formula (I) or a pharmaceutically acceptable salt thereof.

Formula (I)

[0005] In one aspect, a method is disclosed of inhibiting or treating fibrosis in a patient suffering therefrom, the method comprising: administering to the patient an effective amount of a compound of Formula (I) or a pharmaceutically acceptable salt thereof,

Formula (I)

wherein the ratio of the trans to cis isomer of Formula (I) is >1 : 1; and wherein A is optionally one of the following structures below wherein Ri is optionally H or alkyl; R₂ is optionally H or alkyl; both Ri and R₂ are optionally alkyl fragments that connect to form a cyclic acetal; R₃ is optionally H or an ester; R4 is alkyl; and X is a halogen.

[0006] In another aspect, a method of treating fibrosis with a compound of Formula

(I) or a pharmaceutically acceptable salt thereof is disclosed, wherein the ratio of trans to cis isomers of Formula (I) is greater than or equal to 95:5; 96:4; 97:3; 98:2; 99: 1; 99.9:0.1; or 99.99:0.01. In one aspect, the method of treating fibrosis comprises administering a compound of Formula (I) or a pharmaceutically acceptable salt thereof that is essentially free of the czs-isomer.

[0007] In one aspect, a method of treating fibrosis with a compound of Formula (I) or a pharmaceutically acceptable salt thereof is disclosed, wherein the compound is administered orally. In one aspect, the compound of Formula (I) or a pharmaceutically acceptable salt thereof is administered as a tablet or a capsule. In one aspect, a method of treating fibrosis with a compound of Formula (I) or a pharmaceutically acceptable salt thereof is disclosed, wherein the compound is administered as a liquid dosage form.

[0008] In one aspect, a method of treating fibrosis with a compound of Formula (I) or a pharmaceutically acceptable salt thereof is disclosed, wherein the compound is administered once, twice, or thrice daily.

[0009] In one aspect, a method of treating fibrosis with a compound of Formula (I) is disclosed, wherein Formula (I) is geranylgeranylacetone or a pharmaceutically acceptable salt thereof. [0010] In another aspect, a method of treating fibrosis is disclosed, wherein the fibrosis is located in one or more organs. In one aspect, the fibrosis is located in the lungs, referred to herein as pulmonary fibrosis. Pulmonary fibrosis is potentially caused or aggravated by drug therapies such as chemotherapy, exposure to heart medications, exposure to some antibiotics, tuberculosis, pneumonia, systemic lupus, cigarette smoking, exposure to environmental pollutants such as silica and hard metal dusts, aberrant wound healing, metabolic disease, complications from surgery, viral infection, radiation, medical intervention, injection, extreme drug-interactions such as Stevens- Johnson Syndrome, GEPvD, Chrohn's disease, Graft- versus-host Disease, bacterial infection, pleural fibrosis, genetic predisposition to fibrosis, or complications from secondary illnesses, including the fibrosis of other organs or auto-immune disorders. In one aspect, the fibrosis is idiopathic. In one aspect, the fibrosis is pleural fibrosis, which can result from a variety of inflammatory processes. The response of the pleural mesothelial cell to injury and the ability to maintain its integrity are crucial in determining whether normal healing or pleural fibrosis occurs. The pleural mesothelial cell, various cytokines, and disordered fibrin turnover are involved in the pathogenesis of pleural fibrosis.

[0011] In another aspect, the fibrosis is located in the renal system. Renal fibrosis is potentially caused or aggravated by drug therapies, aberrant wound healing, chronic kidney damage, diabetes mellitus, genetic disorders of the tubule, idiopathic focal segmental glomerulosclerosis, glomerular diseases, tubular toxins, complications from surgery, viral infection, radiation, nephrogenic system fibrosis, extreme drug-interactions such as Stevens- Johnson Syndrome, Graft-Host-Disease, Chrohn's disease, injection, chronic kidney disease, medical intervention, metabolic disease, bacterial infection, glomerulonephritis, chemotherapy, genetic predisposition to fibrosis, or complications from secondary illnesses, including the fibrosis of other organs or auto-immune disorders. In one aspect, the fibrosis is idiopathic.

[0012] In another aspect, the fibrosis is located in the liver, which may include one or more of the hepatic ducts. Liver fibrosis is caused by proliferation of tough fibrous connective tissue in the liver. Common causes of liver or hepatic fibrosis include chronic infection by hepatitis B or hepatatis C, viruses, the parasite Schistosoma, chronic alcoholism, exposure to certain drugs and toxins, infections, non-alcoholic fatty liver disease, non-alcoholic steatohepatitis (NASH), inherited metabolic diseases like hematochromatosis, Wilson's disease, a-1 antitrypsin deficiency, chronic liver disease, autoimmune diseases such as primary biliary cirrhosis and auto-immune hepatitis, genetic predisposition to fibrosis, or complications from secondary illnesses, including the fibrosis of other organs or auto-immune disorders. In one aspect, the fibrosis is idiopathic.

[0013] In another aspect, the fibrosis is located in the pancreas. Pancreatic fibrosis is potentially caused or aggravated by drug therapies, extreme drug-interactions such as Stevens- Johnson Syndrome, aberrant wound healing, injection, complications from surgery, viral infection, tobacco smoking, alcoholism, radiation, chronic kidney disease, Graft-Host- Disease, medical intervention, metabolic disease, bacterial infection, pancreatic disease, chemotherapy, hypercalcemia, hyperlipidemia, chronic renal failure, Type 1 diabetes mellitus, extensive calcification, ductal changes, genetic predisposition, neuroendocrine tumors, intrapapillary mucinous tumors, autoimmune pancreatitis. In one aspect, the fibrosis is idiopathic.

[0014] In another aspect, the fibrosis is located in the heart, e.g., cardiac fibrosis.

Cardiac fibrosis is caused by hypereosinophilia, scleroderma, sarcoidosis, radiation and drug effects, viral myocarditis and inherited genetic mutations. Normal aging is also associated with a certain degree of cardiac fibrosis, but the degree of this nonpathological fibrosis is yet to be determined. In one aspect, the fibrosis is idiopathic.

[0015] In another aspect, the fibrosis is located in the endomyocardium.

Endomyocardial fibrosis (EMF) is a disease that is characterized by fibrosis of the apical endocardium of the right ventricle (RV), left ventricle (LV), or both. The clinical manifestations are largely related to the consequences of restrictive ventricular filling, including left and right sided heart failure. EMF refers to a specific syndrome with characteristic epidemiologic features. EMF in cardiac tissue has been linked to increased level of a cytokine, transforming growth factor-β; the underlying mechanisms of myocardial fibrosis in this specific entity remain unclear. Hypotheses include infectious, inflammatory, and nutritional processes. EMF is frequently associated with concomitant parasitic infections and their attendant eosinophilia, although the role of parasitic infections and/or the eosinophil remains speculative. The development of EMF as a sequela to toxoplasma- related myocarditis has also been described, as has a relationship of malarial infection to development of EMF. However, no specific organism has been consistently associated with EMF. The role of the eosinophil in the pathogenesis of EMF is controversial. Whether the eosinophil actually induces myocardial necrosis and subsequent fibrosis or is attracted to the endocardial surface as a result of the initial insult is unknown. The combination of high Ce levels and hypomagnesemia has been shown to produce EMF-like lesions in laboratory animals. In one aspect, the fibrosis is idiopathic.

[0016] In another aspect, the fibrosis is located in the eye. The fibrosis is sometimes located in the macula portion of the eye, resulting in conditions including macular pucker, epiretinal membrane, or cellophane maculopathy. Macular fibrosis occurs when a thin sheet of scar tissue forms on top of the macula, in response to damage or injury. Damage to the macula may occur due to eye trauma, retinal tears or detachments, the shrinking of the vitreous, or systemic disease, such as diabetes or hypertension. Abnormal scar tissue that forms because of the effects of hypertension on the macula is called a hypertensive macular pucker. Eye fibrosis can result from the response of a tissue to injury. The injury can occur as a result of a mechanical wound or various metabolic malfunctions, including responses to inflammation, ischemia, and degenerative disease. Inflammatory changes associated with neovascularization, tissue edema, and, ultimately, fibrosis of the corneal stroma, which leads to opacification and decreased vision. Although the underlying principles of wound healing in other tissues apply to this process in the eye, it is the uniqueness of the cellular composition and anatomical structure of the retina that makes this normal biological process so potentially devastating to vision. Fibrovascular scarring is a consequence of the underlying inflammatory or hypoxia-driven neovascularization and is associated fibrosis. In one aspect, the fibrosis is idiopathic.

[0017] In another aspect, the fibrosis is located in the skin organ. Skin fibrosis, in its mildest form, may present only a minor aesthetic problem, but in the most severe cases it can lead to debilitating pathologies of the skin, for example keloid and hypertrophic scars, and systemic sclerosis. A recurring and consistent theme in these studies is that inflammatory cells and their secreted mediators appear to be leading culprits in activating dermal fibroblasts to become fibrotic. Wound repair is also a primary cause of skin fibrosis. This type of fibrosis is potentially caused or aggravated by Ainhum, Amyloidosis, Atrophoderma of Pasini and Pierini, Carcinoid tumour, Carcinoid tumours and carcinoid syndrome, Dupuytren's contracture, Eosinophilic fasciitis, Graft versus host disease, Hutchinson-Gilford progeria syndrome, Lichen myxedematosus, Mixed connective tissue disease, Morphea, Peyronie's disease, Polymyositis, Porphyria cutanea tarda type 1 (sporadic), Scleroderma adultorum, Sclerodactyly, Scleroderma, and Systemic sclerosis. Nephrogenic systemic fibrosis (NSF), also known as nephrogenic fibrosing dermopathy (NFD), is a disease of fibrosis of the skin and internal organs reminiscent but distinct from scleroderma or scleromyxedema. It is caused by gadolinium exposure used in imaging in patients who have renal insufficiency. In one aspect, the fibrosis is idiopathic. Benign fibrous histiocytomas (also known as Dermal dendrocytoma, Dermatofibroma, Fibrous dermatofibroma, Fibrous histiocytoma, Fibroma simplex, Nodular subepidermal fibrosis, and Sclerosing hemangioma) are benign skin growths.

[0018] In another aspect, the fibrosis is interstitial fibrosis. Interstitial lung disease seems to occur when an injury to your lungs triggers an abnormal healing response. In interstitial lung disease, the repair process goes awry and the tissue around the air sacs (alveoli) becomes scarred and thickened. Long-term exposure to a number of toxins and pollutants can damage your lungs. These may include: Silica dust, Asbestos fibers, Grain dust, Bird and animal droppings, Radiation treatments, and Indoor hot tubs. Some people who receive radiation therapy for lung or breast cancer show signs of lung damage months or sometimes years after the initial treatment. Many drugs can damage your lungs, especially: Chemotherapy drugs; some heart medications; some antibiotics, Systemic lupus erythematosus, Rheumatoid arthritis, Sarcoidosis, and Scleroderma. In one aspect, the interstitial fibrosis is idiopathic.

[0019] In one aspect, the fibrosis is periportal fibrosis. In this pattern, fibrous tissue occupies the periportal region and may extend into the neighboring parenchyma The circumference of the portal tract may be completely or partially involved, sometimes in association with portal fibrosis, and varying degrees of bile ductular proliferation and attendant inflammation are commonly present. Periportal fibrosis can represent the first stage in the evolution to bridging fibrosis, and it therefore often connotes an aggressive or progressive process. Periportal fibrosis is a major feature of two major forms of periportal inflammation and hepatocyte necrosis, chronic active hepatitis and chronic cholestasis. In both, spurs of active fibrous tissue radiate from the portal tract, imparting an irregular stellate configuration best seen on connective tissue stains. Chronic active hepatitis is additionally characterized by piecemeal necrosis and a mononuclear inflammatory infiltrate composed predominantly of lymphocytes. Chronic cholestasis, a consequence of prolonged interference with bile flow, is commonly encountered in primary biliary cirrhosis and primary sclerosing cholangitis and is distinguished by copper accumulation, Mallory bodies, and a mixed inflammatory infiltrate that includes neutrophils and macrophages. Periportal fibrosis can also develop following other severe portal and periportal inflammatory reactions and may therefore be noted in such conditions as acute hepatitis or allograft rejection.

[0020] In one aspect, the fibrosis is located in the uterus. In one aspect, the fibrosis is located in the spleen.

[0021] In one aspect, the fibrosis affects one or more organs. In one aspect the fibrosis may involve any organ in the human organism. The fibrosis may be caused by any of the causes discussed thus far or may be idiopathic.

[0022] In one aspect, the fibrosis is multifocal fibrosclerosis, which is idiopathic and characterized by fibrous lesions occurring at a variety of sites in the body. Examples of multifocal fibrosclerosis include retroperitoneal fibrosis, mediastinal fibrosis and Riedel's struma of the thyroid.

[0023] In one aspect, the fibrosis includes or is related to the following: Crohn's Disease; myelofibrosis; proliferative fibrosis wherein the fibrous elements continue to proliferate after the original causative factor has ceased to operate; postfibrinous fibrosis occurring in tissues in which fibrin has been previously deposited; pipestem fibrosis; progressive massive fibrosis; old myocardial infarction; subepithelial fibrosis; and viral hepatitis induced fibrosis.

[0024] In one aspect of the method disclosed, the type of fibrosis treated is drug-induced fibrosis, e.g., bleomycin-induced or chemotherapy-induced pulmonary fibrosis. In one aspect of the method disclosed, the type of fibrosis treated is idiopathic pulmonary fibrosis. In another aspect of the method disclosed, the type of fibrosis is hepatic fibrosis. In another aspect, drug-induced fibrosis is excluded from the diseases treated. DETAILED DESCRIPTION

Definitions

[0025] As used herein, and in the appended claims, the singular forms "a," "an" and

"the" include plural references unless the context clearly dictates otherwise.

[0026] "Acetal" refers to compounds having the structure R₂C(OR')₂( R'≠ H ) and thus are diethers of geminal diols. Acetals include cyclic acetals wherein R' are optionally both alkyl fragments that connect to form a cyclic acetal.

[0027] "Administering" or "Administration of a drug to a patient (and grammatical equivalents of this phrase) includes both direct administration, including self-administration, and indirect administration, including the act of prescribing a drug. For example, as used herein, a physician who instructs a patient to self-administer a drug and/or provides a patient with a prescription for a drug is administering the drug to the patient.

[0028] "Alkyl" refers to a monovalent acyclic hydrocarbyl radical having 1 to-12 carbon atoms. Non-limiting examples of alkyl include methyl, ethyl, propyl, isopropyl, butyl, isobutyl, tertiary butyl, pentyl, hexyl and the like.

[0029] "Comprising" shall mean that the methods and compositions include the recited elements, but not exclude others. "Consisting essentially of when used to define methods and compositions, shall mean excluding other elements of any essential significance to the combination for the stated purpose. Thus, e.g., a composition consisting essentially of the elements as defined herein would not exclude trace contaminants from the isolation and purification method and pharmaceutically acceptable carriers, such as phosphate buffered saline, preservatives and the like. "Consisting of shall mean excluding more than trace elements of other ingredients and substantial method steps for administering the compositions of this disclosure or process steps to produce a composition or achieve an intended result. Embodiments defined by each of these transitional terms and phrases are within the scope of this disclosure.

[0030] "Effective amount" of a compound utilized herein is an amount that, when administered to a patient treated as herein, will have the intended therapeutic effect, e.g., alleviation, amelioration, palliation or elimination of one or more manifestations of the medical condition in the patient. The full therapeutic effect does not necessarily occur by administration of one dose (or dosage), and may occur only after administration of a series of doses. Thus, an effective amount may be administered in one or more administrations.

[0031] "Essentially free" of an isomer, as used herein, refers to a compound wherein the compound contains 5% or less (in moles) of the undesired isomer. For example, GGA essentially free of the cis isomer contains 5% or less (in moles) of the cis isomer.

[0032] "Fibrosis " or "fibrogenesis" refers to a formation of excess fibrous connective tissue in an organ or tissue, e.g., in a reparative or reactive process. This is as opposed to formation of fibrous tissue as a normal constituent of an organ or tissue. In the present technology, the term "fibrosis" is used to distinguish abnormal from normal healing processes. Fibrogenesis or fibrosis is the process of forming fibrous tissue usually by degeneration (e.g., fibrosis of the pulp) and a proliferation of fibroblasts. Scarring is confluent fibrosis that obliterates the architecture of the underlying organ or tissue. Examples of fibrosis include, without limitation, drug-induced fibrosis, idiopathic pulmonary fibrosis, pulmonary fibrosis, hepatic fibrosis, aberrant wound healing, alcoholic liver damage induced liver fibrosis, bridging fibrosis, Crohn's Disease, cystic fibrosis of the pancreas, cystic fibrosis of the lungs, injection fibrosis, endomyocardial fibrosis, cardiac fibrosis, fibrosis resulting from Graft- Versus-Host Disease (GVHD), fibrosis of the spleen, fibrosis of the eye, fibrotic complications of surgery, glomerulonephritis, interstitial fibrosis, keloid, hypertrophic scar, macular degeneration, mediastinal fibrosis, morphea, multifocal fibrosclerosis, myelofibrosis, nephrogenic systemic fibrosis, nodular subepidermal fibrosis, benign fibrous histiocytoma, pleural fibrosis, proliferative fibrosis, pipestem fibrosis, postfibrinous fibrosis, progressive massive fibrosis, old myocardial infarction, pancreatic fibrosis, radiation fibrosis, renal fibrosis, renal fibrosis related to or arising from chronic kidney disease, retroperitoneal fibrosis, scleroderma, systemic sclerosis, subepithelial fibrosis, uterine fibrosis, and viral hepatitis induced fibrosis.

[0033] "Pharmaceutically acceptable" refers to a therapeutic compound, drug, or formulation that is non-toxic and suitable for administration to a patient, including a human patient.

[0034] "Pharmaceutically acceptable salts" refer to salts that are non-toxic and are suitable for administration to patients. Non-limiting examples include alkali metal, alkaline earth metal, and various primary, secondary, and tertiary ammonium salts. Certain non- limiting examples of salts include sodium, potassium, and calcium salts.

[0035] "Treating" a medical condition or a patient refers to taking steps to obtain beneficial or desired results, including clinical results. For purposes of the various aspects and embodiments of the present disclosure, beneficial or desired clinical results include, but are not limited to, reduction, alleviation, or amelioration of one or more manifestations of or negative effects of idiopathic pulmonary fibrosis, improvement in one or more clinical outcomes, diminishment of extent of fibrosis, delay or slowing of fibrosis progression, amelioration, palliation, or stabilization of the fibrosis state, and other beneficial results described herein.

[0021] "Idiopathic" refers to unknown etiology.

[0036] "Clinical efficacy" refers to a qualitative and/or quantitative measurement of beneficial or desired clinical results, including but not limited to, reduction, alleviation, or amelioration of one or more manifestations of or negative effects of fibrosis, improvement in one or more clinical outcomes, diminishment of extent of fibrosis, delay or slowing of fibrosis progression, amelioration, palliation, or stabilization of the fibrosis state, and other beneficial results described herein. The efficacy of a compound utilized herein can be tested by methods well-known to the skilled artisan, such as those illustrated in the Examples section.

[0025] "Cis" and "trans" are descriptors that show the relationship between two ligands attached to separate atoms that are connected by a double bond. The two ligands are said to be located cis to each other if they lie on the same side of a plane. If they are on opposite sides, their relative position is described as trans. The appropriate reference plane of a double bond is perpendicular to that of the relevant σ-bonds and passes through the double bond. The overall double bond is referred to as "cis" or "trans" depending upon whether the ligands of higher priority are disposed trans or cis to another. In a trans double bond, the ligands of higher priority are disposed trans to one another. In a cis double bond, the ligands of higher priority are disposed cis to one another. A person of ordinary skill in the art understands how to assign priority to ligands on a double bond. In Formula (I), the wavy bond indicates that the structure includes both cis and trans isomers. Where a particular ratio of the isomers is referred to, that is explicitly indicated herein. All of the other double bonds in Formula (I) possess the isomeric conformation illustrated. One of skill in the art knows that the terms E/Z may also be used in exchange for cisl trans depending upon the number of substituents on the double bond. Where the double bond attached to group A is in the trans conformation, the entire compound is referred to as the trans isomer. Where the double bond attached to group A is in the cis conformation, the entire compound is referred to as the cis isomer. For the sake of clarity, representative structures for the trans and cis isomers of Formula (I) are shown below:

The iraw.v-isomer of formula (I)

The c/s-isomer of formula (I)

[0037] Some compounds of Formula (I) comprise chiral centers. In those embodiments, a compound of Formula (I) includes the corresponding enantiomers, diastereomers and mixtures thereof, including racemic mixtures, as utilized herein, unless otherwise specified.

Isomeric Ratio of Compounds of Formula (I)

[0038] For the sake of clarity, any discussion of translcis isomerism refers to the double bond attached to group A, as shown in Formula (I). All other double bonds possess the isomerism illustrated in Formula (I). Where the double bond attached to group A is in the trans conformation, the entire compound is referred to as the trans isomer. Where the double bond attached to group A is in the cis conformation, the entire compound is referred to as the cis isomer. In some embodiments, a compound of Formula (I) or a pharmaceutically acceptable salt thereof is administered wherein the compound has a molar ratio of the trans isomer to the cis isomer greater than or equal to 95:5. In some embodiments, a compound of Formula (I) or a pharmaceutically acceptable salt thereof is administered wherein the ratio of the trans isomer to the cis isomer is greater than or equal to 95:5, 95.5:4.5, 96:4, 96.5:3.5, 97:3, 97.5:2.5, 98:2, 98.5: 1.5, 99: 1, 99.5:0.5, 99.9:0.1, 99.99:0.01, or 100:0. Where the limits of analytical machines to detect very small quantities of the cis isomer are reached, the ratio is considered to be 100:0. In some embodiments, a compound of Formula (I) or a pharmaceutically acceptable salt thereof is administered wherein the compound is essentially free of the cz^'s -isomer.

[0039] In some embodiments, the ratio of cis/trans isomers in a compound of

Formula (I) affects clinical efficacy. In some embodiments, lowering the amount of the cis isomer of a compound of Formula (I) or a pharmaceutically acceptable salt thereof results in improved clinical efficacy upon administration. In some embodiments, the administration of a compound of Formula (I) or a pharmaceutically acceptable salt thereof that is essentially free of the cis isomer yields improved clinical efficacy compared to administration of a compound of Formula (I) or a pharmaceutically acceptable salt thereof comprising a molar ratio of trans is isomers of about 95:5, 90: 10, 85: 15, 80:20, 75:25, 70:30, 65:35, 60:40, 55:45, or 50:50. In some embodiments, administering a dosage of a compound of Formula (I) or a pharmaceutically acceptable salt thereof that is essentially free of the cis isomer yields an improved clinical outcome compared to administering the same dosage of a compound of Formula (I) that is not essentially free of the cis isomer. In some embodiments, administering a compound of Formula (I) or a pharmaceutically acceptable salt thereof comprising the trans isomer essentially free of the cis isomer presents less toxic side effects in comparison to administering a compound of Formula (I) that is not essentially free of the cis isomer. Surprisingly, in some embodiments, administration of a compound of Formula (I) or a pharmaceutically acceptable salt thereof essentially free of the cis isomer yields an improved clinical outcome compared to administering a compound of Formula (I) not essentially free of the cis isomer but containing the same molar amount of the trans isomer.

[0040] Actual dosage amounts will depend on the circumstances of the patient being treated. As those skilled in the art recognize, many factors that modify the action of the active substance will be taken into account by the treating physician such as the age, body weight, sex, diet and condition of the patient, the time of administration, and the rate and route of administration. Optimal dosages for a given set of conditions can be ascertained by those skilled in the art using conventional dosage determination tests.

Formulations

[0041] The compounds utilized herein can be formulated in any pharmaceutically acceptable form, including liquids, powders, creams, emulsions, pills, troches, suppositories, suspensions, solutions, and the like. Therapeutic compositions containing the compounds utilized herein will ordinarily be formulated with one or more pharmaceutically acceptable ingredients in accordance with known and established practice. In general, tablets are formed utilizing a carrier such as modified starch, alone or in combination with carboxymethyl cellulose (Avicel), for example at about 10% by weight. The formulations are compressed at about 1,000 to 3,000 pounds of pressure in the tablet forming process. The tablets preferably exhibit an average hardness of about 1.5 to 8.0 kp/cm², preferably 5.0 to 7.5 kp/cm². Disintegration time varies from about 30 seconds to about 15 or 20 minutes.

[0042] Formulations for oral use can be provided as hard gelatin capsules wherein the therapeutically active compounds utilized herein are mixed with an inert solid diluent such as calcium carbonate, calcium phosphate or kaolin, or as soft gelatin capsules in which the compounds are mixed with an oleaginous medium, e.g., liquid paraffin or olive oil. Suitable carriers include magnesium carbonate, magnesium stearate, talc, sugar, lactose, pectin, dextrin, starch, gelatin, tragacanth, methylcellulose, sodium carboxymethyl cellulose, a low melting wax, cocoa butter, and the like.

[0043] The compounds utilized herein can be formulated as aqueous suspensions in admixture with pharmaceutically acceptable excipients such as suspending agents, e.g., sodium carboxymethyl cellulose, methylcellulose, hydroxypropylmethyl cellulose, sodium alginate, polyvinylpyrrolidone, gum tragacanth and gum acacia; dispersing or wetting agents such as naturally occurring phosphatide, e.g., lecithin, or condensation products of an alkaline oxide with fatty acids, e.g., polyoxyethylene stearate, or condensation products of ethylene oxide with long chain aliphatic alcohols, e.g, heptadecaethylene-oxycetanol, or condensation products of ethylene oxide with partial esters derived from fatty acids and a hexitol, e.g., polyoxyethylene sorbitol monoleate or condensation products of ethylene oxide with partial esters derived from fatty acids and hexitol anhydrides, e.g., polyoxyethylene sorbitan monoleate. Such aqueous suspensions can also contain one or more preservatives, e.g., ethyl- or n-propyl-p-hydroxy benzoate, one or more coloring agents, one or more flavoring agents and one or more sweetening agents, such as glycerol, sorbitol, sucrose, saccharin or sodium or calcium cyclamate.

[0044] Suitable formulations also include sustained release dosage forms, such as those described in U.S. Pat. Nos. 4,788,055; 4,816,264; 4,828,836; 4,834,965; 4,834,985; 4,996,047; 5,071,646; and, 5,133,974, the contents of which are incorporated herein in their entirety by reference.

[0045] Other forms suitable for oral administration include liquid form preparations including emulsions, syrups, elixirs, aqueous solutions, or solid form preparations which are intended to be converted shortly before use to liquid form preparations. Emulsions may be prepared in solutions, for example, in aqueous propylene glycol solutions or may contain emulsifying agents, for example, such as lecithin, sorbitan monooleate, or acacia. Aqueous solutions can be prepared by dissolving the active component in water and adding suitable colorants, flavors, stabilizing, and thickening agents. Solid form preparations may contain, in addition to the active component, colorants, flavors, stabilizers, buffers, artificial and natural sweeteners, dispersants, thickeners, solubilizing agents, and the like.

[0046] The compounds utilized herein may be formulated for parenteral administration (e.g., by injection, for example bolus injection or continuous infusion) and may be presented in unit dose form in ampoules, pre-filled syringes, small volume infusion or in multi-dose containers with an added preservative. The compositions may take such forms as suspensions, solutions, or emulsions in oily or aqueous vehicles, for example as solutions in aqueous polyethylene glycol. Examples of oily or nonaqueous carriers, diluents, solvents or vehicles include propylene glycol, polyethylene glycol, vegetable oils (e.g., olive oil), and injectable organic esters (e.g., ethyl oleate), and may contain formulatory agents such as preserving, wetting, emulsifying or suspending, stabilizing and/or dispersing agents. Alternatively, the active ingredient may be in powder form, obtained by aseptic isolation of sterile solid or by lyophilisation from solution for constitution before use with a suitable vehicle, e.g., sterile, pyrogen-free water.

[0047] The compounds utilized herein may be formulated for nasal administration.

The solutions or suspensions are applied directly to the nasal cavity by conventional means, for example, with a dropper, pipette or spray. The formulations may be provided in a single or multidose form. The patient can administer an appropriate, predetermined volume of the solution or suspension via a dropper or pipette. A spray may be administered for example by means of a metering atomizing spray pump.

[0048] The compounds utilized herein may be formulated for aerosol administration, particularly to the respiratory tract and including intranasal administration. The compound will generally have a small particle size for example of the order of 5 microns or less. Such a particle size may be obtained by means known in the art, for example by micronization. The active ingredient is provided in a pressurized pack with a suitable propellant such as a chlorofluorocarbon (CFC), (for example, dichlorodifluoromethane, trichlorofluoromethane, or dichlorotetrafluoroethane), carbon dioxide or other suitable gases. The aerosol may conveniently also contain a surfactant such as lecithin. The dose of drug may be controlled by a metered valve. Alternatively the active ingredients may be provided in a form of a dry powder, for example a powder mix of the compound in a suitable powder base such as lactose, starch, starch derivatives such as hydroxypropylmethyl cellulose and polyvinylpyrrolidine. The powder carrier will form a gel in the nasal cavity. The powder composition may be presented in unit dose form for example in capsules or cartridges of, for example gelatin or blister packs from which the powder may be administered by means of an inhaler.

[0049] The compounds utilized herein may be formulated for topical administration to the epidermis as ointments, creams or lotions, or as a transdermal patch. Ointments and creams may, for example, be formulated with an aqueous or oily base with the addition of suitable thickening and/or gelling agents. Lotions may be formulated with an aqueous or oily base and will in general also contain one or more emulsifying agents, stabilizing agents, dispersing agents, suspending agents, thickening agents, or coloring agents. Formulations suitable for topical administration in the mouth include lozenges including active agents in a flavored base, usually sucrose and acacia or tragacanth; pastilles including the active ingredient in an inert base such as gelatin and glycerin or sucrose and acacia; and mouthwashes including the active ingredient in a suitable liquid carrier.

[0050] The compounds utilized herein may be formulated for administration as suppositories. In such a formulation, a low melting wax, such as a mixture of fatty acid glycerides or cocoa butter is first melted and the active component is dispersed homogeneously, for example, by stirring. The molten homogeneous mixture is then poured into convenient sized molds, allowed to cool, and to solidify.

[0051] The compounds utilized herein may be formulated for vaginal administration. Pessaries, tampons, creams, gels, pastes, foams or sprays contain a carrier as known in the art to be appropriate.

[0052] When desired, formulations can be prepared with enteric coatings adapted for sustained or controlled release administration of the active ingredient. A common type of controlled release formulation that may be used for the purposes of the present disclosure comprises an inert core, such as a sugar sphere, a first layer, coated with an inner drug- containing second layer, and an outer membrane or third layer controlling drug release from the inner layer.

[0053] The cores are preferably of a water-soluble or swellable material, and may be any such material that is conventionally used as cores or any other pharmaceutically acceptable water-soluble or water- swellable material made into beads or pellets. The cores may be spheres of materials such as sucrose/starch (Sugar Spheres NF), sucrose crystals, or extruded and dried spheres typically comprised of excipients such as microcrystalline cellulose and lactose.

[0054] The substantially water-insoluble material in the first layer is generally a "GI insoluble" or "GI partially insoluble" film forming polymer (dispersed or dissolved in a solvent). Examples include ethyl cellulose, cellulose acetate, cellulose acetate butyrate, polymethacrylates such as ethyl acrylate/methyl methacrylate copolymer (Eudragit NE-30- D) and ammonio methacrylate copolymer types A and B (Eudragit RL30D and RS30D), and silicone elastomers. Usually, a plasticizer is used together with the polymer. Exemplary plasticizers include: dibutylsebacate, propylene glycol, triethylcitrate, tributylcitrate, castor oil, acetylated monoglycerides, acetyl triethylcitrate, acetyl butylcitrate, diethyl phthalate, dibutyl phthalate, triacetin, and fractionated coconut oil (medium-chain triglycerides).

[0055] The second layer containing the active ingredient may be comprised of the active ingredient (drug) with or without a polymer as a binder. The binder, when used, is usually hydrophilic but may be water-soluble or water-insoluble. Exemplary polymers to be used in the second layer containing the active drug are hydrophilic polymers such as polyvinylpyrrolidone, polyalkylene glycol such as polyethylene glycol, gelatine, polyvinyl alcohol, starch and derivatives thereof, cellulose derivatives, such as hydroxypropylmethyl cellulose (HPMC), hydroxypropyl cellulose, carboxymethyl cellulose, methyl cellulose, ethyl cellulose, hydroxyethyl cellulose, carboxyethyl cellulose, carboxymethyl hydroxyethyl cellulose, acrylic acid polymers, polymethacrylates, or any other pharmaceutically acceptable polymer. The ratio of drug to hydrophilic polymer in the second layer is usually in the range of about 1 : 100 to 100: 1 (w/w).

[0056] Suitable polymers for use in the third layer, or membrane, for controlling the drug release may be selected from water insoluble polymers or polymers with pH- dependent solubility, such as, for example, ethyl cellulose, hydroxypropylmethyl cellulose phthalate, cellulose acetate phthalate, cellulose acetate trimellitate, polymethacrylates, or mixtures thereof, optionally combined with plasticizers, such as those mentioned above.

[0057] Optionally, the controlled release layer comprises, in addition to the polymers above, another substance(s) with different solubility characteristics to adjust the permeability, and thereby the release rate, of the controlled release layer. Exemplary polymers that may be used as a modifier together with, for example, ethyl cellulose include: HPMC, hydroxyethyl cellulose, hydroxypropyl cellulose, methylcellulose, carboxymethylcellulose, polyethylene glycol, polyvinylpyrrolidone (PVP), polyvinyl alcohol, polymers with pH-dependent solubility, such as cellulose acetate phthalate or ammonio methacrylate copolymer and methacrylic acid copolymer, or mixtures thereof. Additives such as sucrose, lactose and pharmaceutical grade surfactants may also be included in the controlled release layer, if desired.

[0058] Unit dosage forms may be provided for the formulations provided herein, wherein the formulation is subdivided into unit dosages containing appropriate quantities of the active component, e.g., a compound of Formula (I) or a pharmaceutically acceptable salt thereof. The unit dosage form can be a packaged preparation, the package containing discrete quantities of preparation, such as packeted tablets, capsules, and powders in vials or ampoules. Also, the unit dosage form can be a capsule, tablet, cachet, or lozenge itself, or it can be the appropriate number of any of these in packaged form. [0059] Other suitable pharmaceutical carriers and their formulations are described in

Remington: The Science and Practice of Pharmacy 1995, edited by E. W. Martin, Mack Publishing Company, 19th edition, Easton, Pa.

[0060] Compounds of Formula (I) or a pharmaceutically acceptable salt thereof are prepared according to synthetic procedures generally known in organic chemistry. The cis and trans isomers are separated using known separation techniques, e.g., HPLC, LCMS, fractional distillation, and so forth.

[0061] The present disclosure will be understood more readily by reference to the following examples, which are provided by way of illustration and are not intended to be limiting of the present disclosure.

EXAMPLES

[0062] The following tests can be employed for demonstrating the therapeutically beneficial effects of compounds of Formula(I) or a pharmaceutically acceptable salt thereof in the treatment of fibrosis.

[0063] The effect of a compound utilized herein on fibrosis is assessed in vitro using primary human fibroblasts, myofibroblasts or cultured lung epithelial cells; ex vivo using human or mice skin; and in vivo in humans and/or mice with idiopathic pulmonary fibrosis, hepatic fibrosis or drug-induced fibrosis.

Materials and Methods

[0064] Primary fibroblast culture: The clinically involved skin of patients suffering from fibrosis of the skin and healthy donors are used for the primary fibroblast culture. Approximately 2-cm pieces of skin are minced and fibroblasts are cultured in Dulbecco's modified Eagle's medium supplemented with 10% FBS, penicillin, streptomycin, and anti- mycotic agent.

[0065] Myofibroblast culture: Myofibroblasts, activated fibroblasts which express a-

SMA, are induced by TGF-β stimulation.

[0066] Ex vivo human skin assays: Cultured human skin explants are used as an organ model to assess the effects of fibrogenic factors and for evaluating the efficacy of inhibitors/therapies to halt the progression of fibrosis and potentially reverse it. In one example, a human skin explant comprises human abdominal skin that is obtained from corrective plastic surgery. Subcutaneous fat tissue is removed uniformly and skin tissue is cut into 1.5 cm x 1.5 cm sections. Explants containing complete epidermal and dermal layers are cultured in an air liquid interface with the epidermal and keratin layers side up and exposed to air. The culture medium is replaced every other day. After 1 or 2 weeks, skin tissue corresponding to an area with 8-mm diameter centered around the injection site is harvested using a disposable 8-mm ACUPUNCH® (Acuderm Inc., Lauderdale, Fla.). Skin tissue is fixed in 10% formalin prior to embedding in paraffin.

[0067] Use of TGF-β in skin assays: Since TGF-β can act as a pro-fibrotic factor that plays a central role in fibrosis, human recombinant TGF-β is first injected intradermally to assess the level of fibrosis. TGF-β injection can increase dermal thickness in a dose- dependent manner one week post-injection. The fibrotic effect of TGF-β (10 ng/ml) resolves by two weeks.

[0068] In vivo mice assays: CB57BL6/J male mice are purchased from The Jackson

Laboratory (Bar Harbor, ME).

[0069] Use of bleomycin to induce fibrosis: In some pre-clinical models of drug- induced fibrosis, bleomycin is used to induce fibrosis in vivo in mice.

[0070] Tsk Mice Model for Scleroderma: The collagen content and thickness of a subcutaneous fibrous layer are measured in the skin of Tsk mice (Rheum. Dis. Clin. North Am. 16, 153, 1990), and compared with the control mice (pallid mice) at the ages of 5, 10, and 20 weeks (n=6). The collagen content is determined by measuring hydroxyproline, the marker for collagen, using HPLC. Fibrous layer thickness is determined by histological analysis with Azan staining followed by measuring the area of the fibrous layer using an image analysis system.

Measurement of skin dermal thickness

[0071] In skin assays, fibrosis is optionally assessed by measuring dermal thickness of H&E stained sections and/or measurement of collagen levels by Masson Trichrome staining. In some assays, six μιη sections of paraffin-embedded human and/or mouse skin tissues are stained with hematoxylin and eosin (H&E). In some assays, sections are stained with Masson trichrome which identifies collagens. Images are taken on a Nikon Eclipse 800 microscope. The thickness of the dermis is measured in 6 random fields of each section using the image/J® software.

Measuring Hydroxyproline Levels in Fibrotic Tissue

[0072] To quantify lung hydroxyproline content, tissue samples (e.g. and without limitation, 15-25 mg) are processed by an alkaline-acid hydrolysis method as follows. Tissue samples are acid-hydro lyzed with 400 of 6N HC1 at 121°C for 20 minutes, and neutralized with 400 of 4N NaOH containing 10 mg/mL activated carbon. AC buffer (2.2M acetic acid/0.48M citric acid, 400 μί) is added to the samples, followed by centrifugation to collect the supernatant. A standard curve of hydroxyproline iss constructed with serial dilutions of tra/?s-4-hydroxy-L-proline (Sigma-Aldrich, USA) starting at 16 μg/mL. The prepared samples and standards (each 400 μί) are mixed with 400 chloramine T solution (Wako Pure Chemical Industries Japan) and incubated for 25 minutes at room temperature. The samples are then mixed with Ehrlich's solution (400 μί) and heated at 65°C for 20 minutes to develop the color. After samples are cooled on ice and centrifuged to remove precipitates, the optical density of each supernatant is measured at 560 nm. The concentrations of hydroxyproline are calculated from the hydroxyproline standard curve.

Statistical analysis

[0073] All continuous variables ere expressed as the mean+/- standard deviation.

Comparisons between 2 groups are tested for statistical significance using the paired t-test or Mann- Whitney U test as appropriate. Comparison among 3 groups is performed using ANOVA followed by Bonferroni's test.

Primary Fibroblast In Vitro Assays:

[0074] Primary fibroblasts are obtained as described above in the materials and methods section. Primary fibroblasts obtained from healthy controls are treated with the following compounds in three controls assays: (1) geranylgeranylacetone essentially free of the cis isomer; (2) geranylgeranylacetone comprising about a 1 : 1 ratio of cis:trans isomers; and (3) geranylgeranylacetone essentially free of the trans isomer. Primary fibroblasts obtained from patients with scleroderma are treated with the following compounds in three assays: (1) geranylgeranylacetone essentially free of the cis isomer is injected intradermally; (2) geranylgeranylacetone comprising about a 1 : 1 ratio of cis:trans isomers; and (3) geranylgeranylacetone essentially free of the trans isomer. The results are analyzed using a cell-stain and measured via the percentage of stained area.

Myofibroblast In Vitro Assays:

[0075] Myofibroblasts, activated fibroblasts which express a-SMA, are induced by

TGF-β stimulation. Myofibroblasts are treated with the following compositions in three in vitro assays: (1) geranylgeranylacetone essentially free of the cis isomer; (2) geranylgeranylacetone comprising about a 1 : 1 ratio of cis:trans isomers; and (3) geranylgeranylacetone essentially free of the trans isomer. The assays are compared with control assays. Ex vivo human skin assays

[0076] Human abdominal skin is obtained from corrective plastic surgery as described above in the materials and methods section. The following compounds are injected intradermally into the skin substrates in separate assays: (1) geranylgeranylacetone essentially free of the cis isomer; (2) geranylgeranylacetone essentially free of the cis isomer in combination with TGF-β (10 ng/ml); (3) geranylgeranylacetone comprising about a 1 : 1 ratio of cis:trans isomers; (4) geranylgeranylacetone comprising about a 1 : 1 ratio of cis: trans isomers in combination with TGF-β (10 ng/ml); and (5) TGF-β alone (10 ng/ml). In some experiments, human skin is first injected with TGF-β for 48 h followed by administration of geranylgeranylacetone in the same injection site as TGF-β. Independent experiments are conducted in duplicate or triplicate.

In vivo mouse experiments

[0077] CB57BL6/J male mice are purchased from The Jackson Laboratory (Bar

Harbor, ME), as discussed above in the materials and methods section. In the following assays, injections are performed on the back of mice in two different skin sites. The following compounds are administered in separate assays: (1) geranylgeranylacetone essentially free of the cis isomer; (2) geranylgeranylacetone essentially free of the cis isomer in combination with TGF-β (10 ng/ml); (3) geranylgeranylacetone comprising about a 1 : 1 ratio of cis:trans isomers; (4) geranylgeranylacetone comprising about a 1 : 1 ratio of cis:trans isomers in combination with TGF-β (10 ng/ml); and (5) TGF-β alone (10 ng/ml). Mice are sacrificed one week post-injection. The skin surrounding the injection site is harvested and fixed in 10% formalin prior to embedding in paraffin for evaluation of therapeutic efficacy.

Drug-Induced Fibrosis

[0078] The efficacy of a compound of Formula (I) is assayed in the treatment of drug-induced fibrosis using bleomycin to induce fibrosis in vivo in mice. Following induction of fibrosis using bleomycin in the mice, the following compounds are administered in separate assays: (1) geranylgeranylacetone essentially free of the cis isomer; (2) geranylgeranylacetone comprising about a 1 : 1 ratio of cis:trans isomers; and (3) geranylgeranylacetone essentially free of the trans isomer. The geranylgeranylacetone compounds are administered simultaneously to mice with bleomycin-induced fibrosis and healthy mice controls. Mice are sacrificed two to three weeks after bleomycin-induced fibrosis. For these studies, fibrosis is optionally assessed by measuring dermal thickness on H&E skin sections or assessment of collagen levels by Masson Trichrome staining.

Tsk Mice Model for Scleroderma

[0079] 13-week old Tsk mice (n=5) are intraperitoneally administered (1) geranylgeranylacetone essentially free of the cis isomer; (2) geranylgeranylacetone comprising about a 1 : 1 ratio of cis:trans isomers; or (3) geranylgeranylacetone essentially free of the trans isomer for 2 weeks. Five hours after the final administration, the degree of hypertrophy of the subcutaneous fibrous layer is measured and compared with the values of the group administered saline.

In Vitro Assays Examining the Clinical Effect of the Isomer Ratios of the Compound of Formula (I)

[0080] Assays containing primary human fibroblasts are treated with (1) geranylgeranylacetone essentially free of the cis isomer; (2) geranylgeranylacetone comprising about a 1 : 1 ratio of cis:trans isomers; (3) geranylgeranylacetone essentially free of the trans isomer (4) geranylgeranylacetone comprising about a 1 : 1 mixture of cis- and trans-GGA with the same molar amount of trans-GGA as trial 1, and (5) a placebo. The table below illustrates the assay protocol.

[0081] In Vivo Assays Examining the Clinical Effect of the Isomer Ratios of the

Compound of Formula (I)

Acute pulmonary injury and fibrosis is induced in mice via tracheal bleomycin administration. Mice with pulmonary fibrosis are treated with (1) geranylgeranylacetone essentially free of the cis isomer; (2) geranylgeranylacetone comprising about a 1 : 1 ratio of cis:trans isomers; (3) geranylgeranylacetone essentially free of the trans isomer (4) geranylgeranylacetone comprising about a 1 : 1 mixture of cis- and trans-GGA with the same molar amount of trans-GGA as trial 1, and (5) a placebo. The effectiveness of these treatments are measured by monitoring body weight, fibrosis in Masson trichrome or hematoxylin-eosin-stained lung sections, infiltration of inflammatory cells and macrophage inflammatory protein-2 induction in bronchoalveolar lavage fluid, and/or apoptosis in lung tissue by TUNEL assay. The table below illustrates the clinical protocol.

[0082] Treatment of idiopathic pulmonary fibrosis in human subjects

The effects of trans-GGA on human idiopathic pulmonary fibrosis is tested by administering to patients suffering therefrom the following: (1) geranylgeranylacetone essentially free of the cis isomer; (2) geranylgeranylacetone comprising about a 1 : 1 ratio of cis:trans isomers; (3) geranylgeranylacetone essentially free of the trans isomer; (4) geranylgeranylacetone comprising about a 1 : 1 mixture of cis- and trans-GGA in double the molar amount compared to trial 1, and (5) a placebo.

Dose: The dosage used of the geranylgeranylacetone is 1500 mg/day (750 mg BID).

Duration: The study is performed for a minimum of 53 weeks up to 72 weeks. Depending on the patient tolerance, the study duration may be increased beyond 72 weeks. Trial 1 Trial 2 Trial 3 Trial 4 Trial 5

0.1 mmol of 0.1 mmol of 0.1 mmol of cis- 0.2 mmol of Placebo trans-GGA trans and cis GGA essentially trans and cis

essentially free of GGA (0.05 free of the trans GGA (0.1

the cis isomer mmol of trans isomer mmol of cis

and 0.05 mmol GGA and 0.1 of cis) mmol of trans

GGA)

Primary Outcome Measurements:

• The absolute change in percent predicted forced vital capacity (FVC)

• Mean change in percent predicted forced vital capacity (FVC) as measured from baseline

Secondary Outcome Measurements:

• Change in Six-Minute Walk Test (6MWT) Distance: The change from Baseline in distance walked during the 6-minute walk test as measured in meters (m).

• Change in Worst Oxygen Saturation by Pulse Oximetry (Sp02) Measurement

Observed During the 6-Minute Walk Test

• Change in Dyspnea Score. The mean change from baseline measured by the

University of San Diego Shortness of Breath Questionnaire (UCSD SOBQ)

• Worsening of Idiopathic Pulmonary Fibrosis (IPF): Time to acute IPF exacerbation, IPF -related death, lung transplant or respiratory hospitalization, whichever comes first. [0083] Treatment of Kidney Fibrotic Disease

The effects of trans-GGA on kidney fibrotic disease is tested by administering to patients suffering therefrom the following: (1) geranylgeranylacetone essentially free of the cis isomer; (2) geranylgeranylacetone comprising about a 1 : 1 ratio of cis trans isomers; (3) geranylgeranylacetone essentially free of the trans isomer; (4) geranylgeranylacetone comprising about a 1 :1 mixture of cis- and trans-GGA in double the molar amount compared to trial 1, and (5) a placebo.

Dose: The dosage used of the geranylgeranylacetone is 1500 mg/day (750 mg BID).

Duration: The study is performed for a minimum of 53 weeks up to 72 weeks. Depending on the patient tolerance, the study duration may be increased beyond 72 weeks.

Embodiments

A method of inhibiting or treating fibrosis in a patient suffering therefrom, the method comprising: administering to the patient an effective amount of a compound of Formula (I) or a pharmaceutically acceptable salt thereof,

wherein the ratio of the trans to cis isomer of the double bond of Formula (I) attached to group A is >1 : 1, and wherein A is optionally one of the following structures below wherein Ri is optionally H or alkyl; R₂ is optionally H or alkyl; both Ri and R₂ are optionally alkyl fragments that connect to form a cyclic acetal; R₃ is optionally H or an ester; R₄ is alkyl; and X is a halogen.

The method of Embodiment 1, wherein the ratio of trans to cis isomers of Formula (I) is greater than or equal to 95:5; 96:4; 97:3; 98:2; 99:1; 99.9:0.1; or 99.99:0.01. The method of any one of Embodiments 1-2, wherein Formula (I) is essentially free of the cz^'s-isomer. The method of any one of Embodiments 1-3, wherein the compound is administered orally. The method of any one of Embodiments 1-4, wherein the compound is administered as a tablet or a capsule. The method of any one of Embodiments 1-5, wherein the compound is administered once, twice, or thrice daily. The method of any one of Embodiments 1-4 and 6, wherein the compound is administered as a liquid dosage form. The method of any one of Embodiments 1-7, wherein Formula (I) is gerany lgerany lacetone . The method of any one of Embodiments 1-8, wherein: the fibrosis is selected from idiopathic pulmonary fibrosis, drug-induced fibrosis, pulmonary fibrosis, hepatic fibrosis, aberrant wound healing, alcoholic liver damage induced liver fibrosis, bridging fibrosis, Crohn's Disease, cystic fibrosis of the pancreas, cystic fibrosis of the lungs, injection fibrosis, endomyocardial fibrosis, cardiac fibrosis, fibrosis resulting from Graft- Versus-Host Disease (GVHD), fibrosis of the spleen, fibrosis of the eye, fibrotic complications of surgery, glomerulonephritis, interstitial fibrosis, keloid, hypertrophic scar, macular degeneration, mediastinal fibrosis, morphea, multifocal fibrosclerosis, myelofibrosis, nephrogenic systemic fibrosis, nodular subepidermal fibrosis, benign fibrous histiocytoma, pleural fibrosis, proliferative fibrosis, pipestem fibrosis, postfibrinous fibrosis, progressive massive fibrosis, old myocardial infarction, pancreatic fibrosis, radiation fibrosis, renal fibrosis, renal fibrosis related to or arising from chronic kidney disease, retroperitoneal fibrosis, scleroderma, systemic sclerosis, subepithelial fibrosis, uterine fibrosis, and viral hepatitis induced fibrosis. The method of any one of Embodiments 1-9, wherein the fibrosis is drug-induced fibrosis. The method of any one of Embodiments 1-9, wherein the fibrosis is pulmonary fibrosis. The method of any one of Embodiments 1-9, wherein the fibrosis is hepatic fibrosis. The method of any one of Embodiments 1-9 or 11, wherein the fibrosis is idiopathic pulmonary fibrosis. The method of any one of Embodiments 1-9, wherein the drug-induced fibrosis is excluded from the diseases treated. A compound of Formula (I) for use in inhibiting or treating fibrosis in a patient suffering therefrom comprising administering to the patient an effective amount of the compound of Formula (I) or a pharmaceutically acceptable salt thereof, wherein Formula (I) has the structure:

Formula (I) wherein the ratio of the trans to cis isomer of the double bond of Formula (I) attached to group A is >1 : 1, and wherein A is optionally one of the following structures below wherein Ri is optionally H or alkyl; R₂ is optionally H or alkyl; both Ri and R₂ are optionally alkyl fragments that connect to form a cyclic acetal; R₃ is optionally H or an ester; R₄ is alkyl; and X is a halogen.

The compound of Embodiment 15, wherein the ratio of trans to cis isomers Formula (I) is greater than or equal to 95:5; 96:4; 97:3; 98:2; 99: 1; 99.9:0.1; 99.99:0.01. The compound of any one of Embodiments 15-16, wherein: the fibrosis is selected from idiopathic pulmonary fibrosis, drug-induced fibrosis, pulmonary fibrosis, hepatic fibrosis, aberrant wound healing, alcoholic liver damage induced liver fibrosis, bridging fibrosis, Crohn's Disease, cystic fibrosis of the pancreas, cystic fibrosis of the lungs, injection fibrosis, endomyocardial fibrosis, cardiac fibrosis, fibrosis resulting from Graft-Versus-Host Disease (GVHD), fibrosis of the spleen, fibrosis of the eye, fibrotic complications of surgery, glomerulonephritis, interstitial fibrosis, keloid, hypertrophic scar, macular degeneration, mediastinal fibrosis, morphea, multifocal fibrosclerosis, myelofibrosis, nephrogenic systemic fibrosis, nodular subepidermal fibrosis, benign fibrous histiocytoma, pleural fibrosis, proliferative fibrosis, pipestem fibrosis, postfibrinous fibrosis, progressive massive fibrosis, old myocardial infarction, pancreatic fibrosis, radiation fibrosis, renal fibrosis, renal fibrosis related to or arising from chronic kidney disease, retroperitoneal fibrosis, scleroderma, systemic sclerosis, subepithelial fibrosis, uterine fibrosis, and viral hepatitis induced fibrosis. The compound of any one of Embodiments 15-17, wherein the fibrosis is pulmonary fibrosis. The compound of any one of Embodiments 15-17, wherein the fibrosis is hepatic fibrosis. The compound of any one of Embodiments 15-18, wherein the fibrosis is idiopathic pulmonary fibrosis. Use of a compound of Formula (I) in the manufacture of a medicament for inhibiting or treating fibrosis in a patient suffering therefrom comprising administering to the patient an effective amount of the compound of Formula (I) or a pharmaceutically acceptable salt thereof, wherein Formula (I) has the structure:

Formula (I) wherein the ratio of the trans to cis isomer of the double bond of Formula (I) attached to group A is >1 : 1, and wherein A is optionally one of the following structures below wherein Ri is optionally H or alkyl; R₂ is optionally H or alkyl; both Ri and R₂ are optionally alkyl fragments that connect to form a cyclic acetal; R₃ is optionally H or an ester; R₄ is alkyl; and X is a halogen.

The use of Embodiment 21, wherein the ratio of trans to cis isomers of Formula (I) is greater than or equal to 95:5; 96:4; 97:3; 98:2; 99: 1; 99.9:0.1; or 99.99:0.01. The use of any one of Embodiments 21-22, wherein: the fibrosis is selected from idiopathic pulmonary fibrosis, drug-induced fibrosis, pulmonary fibrosis, hepatic fibrosis, aberrant wound healing, alcoholic liver damage induced liver fibrosis, bridging fibrosis, Crohn's Disease, cystic fibrosis of the pancreas, cystic fibrosis of the lungs, injection fibrosis, endomyocardial fibrosis, cardiac fibrosis, fibrosis resulting from Graft- Versus-Host Disease (GVHD), fibrosis of the spleen, fibrosis of the eye, fibrotic complications of surgery, glomerulonephritis, interstitial fibrosis, keloid, hypertrophic scar, macular degeneration, mediastinal fibrosis, morphea, multifocal fibrosclerosis, myelofibrosis, nephrogenic systemic fibrosis, nodular subepidermal fibrosis, benign fibrous histiocytoma, pleural fibrosis, proliferative fibrosis, pipestem fibrosis, postfibrinous fibrosis, progressive massive fibrosis, old myocardial infarction, pancreatic fibrosis, radiation fibrosis, renal fibrosis, renal fibrosis related to or arising from chronic kidney disease, retroperitoneal fibrosis, scleroderma, systemic sclerosis, subepithelial fibrosis, uterine fibrosis, and viral hepatitis induced fibrosis.

24. The use of any one of Embodiments 21-23, wherein the fibrosis is pulmonary fibrosis.

25. The use of any one of Embodiments 21-23, wherein the fibrosis is hepatic fibrosis.

21. The use of any one of Embodiments 21-24, wherein the fibrosis is idiopathic pulmonary fibrosis.

[0085] While certain embodiments have been illustrated and described, it should be understood that changes and modifications can be made therein in accordance with ordinary skill in the art without departing from the technology in its broader aspects as defined in the following claims.

[0086] The embodiments, illustratively described herein may suitably be practiced in the absence of any element or elements, limitation or limitations, not specifically disclosed herein. Thus, for example, the terms "comprising," "including," "containing," etc. shall be read expansively and without limitation. Additionally, the terms and expressions employed herein have been used as terms of description and not of limitation, and there is no intention in the use of such terms and expressions of excluding any equivalents of the features shown and described or portions thereof, but it is recognized that various modifications are possible within the scope of the claimed technology.

[0087] The present disclosure is not to be limited in terms of the particular embodiments described in this application. Many modifications and variations can be made without departing from its spirit and scope, as will be apparent to those skilled in the art. Functionally equivalent methods and compositions within the scope of the disclosure, in addition to those enumerated herein, will be apparent to those skilled in the art from the foregoing descriptions. Such modifications and variations are intended to fall within the scope of the appended claims. The present disclosure is to be limited only by the terms of the appended claims, along with the full scope of equivalents to which such claims are entitled. It is to be understood that this disclosure is not limited to particular methods, reagents, compounds, compositions or biological systems, which can of course vary. It is also to be understood that the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to be limiting.

[0088] As will be understood by one skilled in the art, for any and all purposes, particularly in terms of providing a written description, all ranges disclosed herein also encompass any and all possible subranges and combinations of subranges thereof. For example, ranges describing isomeric ratios disclosed herein encompass any and all possible subranges of ratios thereof. Any listed range can be easily recognized as sufficiently describing and enabling the same range being broken down into at least equal halves, thirds, quarters, fifths, tenths, etc. As a non-limiting example, each range discussed herein can be readily broken down into a lower third, middle third and upper third, etc. As will also be understood by one skilled in the art all language such as "up to," "at least," "greater than," "less than," and the like, include the number recited and refer to ranges which can be subsequently broken down into subranges as discussed above. Finally, as will be understood by one skilled in the art, a range includes each individual member.

[0089] All publications, patent applications, issued patents, and other documents referred to in this specification are herein incorporated by reference as if each individual publication, patent application, issued patent, or other document was specifically and individually indicated to be incorporated by reference in its entirety. Definitions that are contained in text incorporated by reference are excluded to the extent that they contradict definitions in this disclosure.

[0090] Other embodiments are set forth in the following claims.

Claims

WHAT IS CLAIMED IS:

1. A method of inhibiting or treating fibrosis in a patient suffering therefrom, the method comprising: administering to the patient an effective amount of a compound of Formula (I) or a pharmaceutically acceptable salt thereof,

Formula (I) wherein the ratio of the trans to cis isomer of the double bond of Formula (I) attached to group A is >1 : 1, and wherein A is optionally one of the following structures below wherein Ri is optionally H or alkyl; R₂ is optionally H or alkyl; both Ri and R₂ are optionally alkyl fragments that connect to form a cyclic acetal; R₃ is optionally H or an ester; R₄ is alkyl; and X is a halogen.

2. The method of claim 1, wherein the ratio of trans to cis isomers of Formula (I) is greater than or equal to 95:5; 96:4; 97:3; 98:2; 99: 1; 99.9:0.1; or 99.99:0.01.

3. The method of claim 1 , wherein Formula (I) is essentially free of the cz^'s -isomer.

4. The method of claim 1, wherein the compound is administered orally.

5. The method of claim 4, wherein the compound is administered as a tablet or a capsule.

6. The method of claim 1, wherein the compound is administered once, twice, or thrice daily.

7. The method of claim 4, wherein the compound is administered as a liquid dosage form.

8. The method of claim 1, wherein Formula (I) is geranylgeranylacetone.

9. The method of claim 1, wherein: the fibrosis is selected from idiopathic pulmonary fibrosis, drug-induced fibrosis, pulmonary fibrosis, hepatic fibrosis, aberrant wound healing, alcoholic liver damage induced liver fibrosis, bridging fibrosis, Crohn's Disease, cystic fibrosis of the pancreas, cystic fibrosis of the lungs, injection fibrosis, endomyocardial fibrosis, cardiac fibrosis, fibrosis resulting from Graft- Versus-Host Disease (GVHD), fibrosis of the spleen, fibrosis of the eye, fibrotic complications of surgery, glomerulonephritis, interstitial fibrosis, keloid, hypertrophic scar, macular degeneration, mediastinal fibrosis, morphea, multifocal fibrosclerosis, myelofibrosis, nephrogenic systemic fibrosis, nodular subepidermal fibrosis, benign fibrous histiocytoma, pleural fibrosis, proliferative fibrosis, pipestem fibrosis, postfibrinous fibrosis, progressive massive fibrosis, old myocardial infarction, pancreatic fibrosis, radiation fibrosis, renal fibrosis, renal fibrosis related to or arising from chronic kidney disease, retroperitoneal fibrosis, scleroderma, systemic sclerosis, subepithelial fibrosis, uterine fibrosis, and viral hepatitis induced fibrosis.

10. The method of claim 9, wherein the fibrosis is drug-induced fibrosis.

11. The method of claim 9, wherein the fibrosis is pulmonary fibrosis.

12. The method of claim 9, wherein the fibrosis is hepatic fibrosis.

13. The method of claim 9, wherein the fibrosis is idiopathic pulmonary fibrosis.

14. The method of claim 9, wherein the drug-induced fibrosis is excluded from the diseases treated.

15. A compound of Formula (I) for use in inhibiting or treating fibrosis in a patient suffering therefrom comprising administering to the patient an effective amount of the compound of Formula (I) or a pharmaceutically acceptable salt thereof, wherein Formula (I) has the structure:

Formula (I) wherein the ratio of the trans to cis isomer of the double bond of Formula (I) attached to group A is >1 : 1, and wherein A is optionally one of the following structures below wherein Ri is optionally H or alkyl; R₂ is optionally H or alkyl; both Ri and R₂ are optionally alkyl fragments that connect to form a cyclic acetal; R₃ is optionally H or an ester; R₄ is alkyl; and X is a halogen.

16. The compound of claim 15, wherein the ratio of trans to cis isomers of Formula (I) is greater than or equal to 95:5; 96:4; 97:3; 98:2; 99: 1; 99.9:0.1; or 99.99:0.01.

17. The compound of claim 15, wherein: the fibrosis is selected from idiopathic pulmonary fibrosis, drug-induced fibrosis, pulmonary fibrosis, hepatic fibrosis, aberrant wound healing, alcoholic liver damage induced liver fibrosis, bridging fibrosis, Crohn's Disease, cystic fibrosis of the pancreas, cystic fibrosis of the lungs, injection fibrosis, endomyocardial fibrosis, cardiac fibrosis, fibrosis resulting from Graft-Versus-Host Disease (GVHD), fibrosis of the spleen, fibrosis of the eye, fibrotic complications of surgery, glomerulonephritis, interstitial fibrosis, keloid, hypertrophic scar, macular degeneration, mediastinal fibrosis, morphea, multifocal fibrosclerosis, myelofibrosis, nephrogenic systemic fibrosis, nodular subepidermal fibrosis, benign fibrous histiocytoma, pleural fibrosis, proliferative fibrosis, pipestem fibrosis, postfibrinous fibrosis, progressive massive fibrosis, old myocardial infarction, pancreatic fibrosis, radiation fibrosis, renal fibrosis, renal fibrosis related to or arising from chronic kidney disease, retroperitoneal fibrosis, scleroderma, systemic sclerosis, subepithelial fibrosis, uterine fibrosis, and viral hepatitis induced fibrosis.

18. The compound of claim 17, wherein the fibrosis is pulmonary fibrosis.

19. The compound of claim 17, wherein the fibrosis is hepatic fibrosis.

20. The compound of claim 17, wherein the fibrosis is idiopathic pulmonary fibrosis.

21. Use of a compound of Formula (I) in the manufacture of a medicament for inhibiting or treating fibrosis in a patient suffering therefrom comprising administering to the patient an effective amount of the compound of Formula (I) or a pharmaceutically acceptable salt thereof, wherein Formula (I) has the structure:

Formula (I) wherein the ratio of the trans to cis isomer of the double bond of Formula (I) attached to group A is >1 : 1, and wherein A is optionally one of the following structures below wherein Ri is optionally H or alkyl; R₂ is optionally H or alkyl; both Ri and R₂ are optionally alkyl fragments that connect to form a cyclic acetal; R₃ is optionally H or an ester; R₄ is alkyl; and X is a halogen.

22. The use of claim 21, wherein the ratio of trans to cis isomers of Formula (I) is greater than or equal to 95:5; 96:4; 97:3; 98:2; 99: 1; 99.9:0.1; or 99.99:0.01.

23. The use of claim 21, wherein: the fibrosis is selected from idiopathic pulmonary fibrosis, drug-induced fibrosis, pulmonary fibrosis, hepatic fibrosis, aberrant wound healing, alcoholic liver damage induced liver fibrosis, bridging fibrosis, Crohn's Disease, cystic fibrosis of the pancreas, cystic fibrosis of the lungs, injection fibrosis, endomyocardial fibrosis, cardiac fibrosis, fibrosis resulting from Graft- Versus-Host Disease (GVHD), fibrosis of the spleen, fibrosis of the eye, fibrotic complications of surgery, glomerulonephritis, interstitial fibrosis, keloid, hypertrophic scar, macular degeneration, mediastinal fibrosis, morphea, multifocal fibrosclerosis, myelofibrosis, nephrogenic systemic fibrosis, nodular subepidermal fibrosis, benign fibrous histiocytoma, pleural fibrosis, proliferative fibrosis, pipestem fibrosis, postfibrinous fibrosis, progressive massive fibrosis, old myocardial infarction, pancreatic fibrosis, radiation fibrosis, renal fibrosis, renal fibrosis related to or arising from chronic kidney disease, retroperitoneal fibrosis, scleroderma, systemic sclerosis, subepithelial fibrosis, uterine fibrosis, and viral hepatitis induced fibrosis.

24. The use of claim 23, wherein the fibrosis is pulmonary fibrosis.

25. The use of claim 23, wherein the fibrosis is hepatic fibrosis.

26. The use of claim 23, wherein the fibrosis is idiopathic pulmonary fibrosis.