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Definitions

• the present disclosure relates to the field of medicine and the treatment of ocular disease. More specifically, the present disclosure relates to the use of Edonentan and A- 182086 endothelin receptor antagonists in the treatment or amelioration of glaucoma, diabetic retinopathy (DR), retinal vein occlusion (RVO), non-arteritic anterior ischemic optic neuropathy (NAION), arteritic anterior ischemic optic neuropathy (AION), and retinopathy of prematurity (ROP).
• DR diabetic retinopathy
• RVO retinal vein occlusion
• NAION non-arteritic anterior ischemic optic neuropathy
• AION arteritic anterior ischemic optic neuropathy
• ROP retinopathy of prematurity
• DR diabetic retinopathy
• RVO retinal vein occlusion
• NAION non-arteritic anterior ischemic optic neuropathy
• AION arteritic anterior ischemic optic neuropathy
• ROP retinopathy of prematurity
• Glaucoma is an eye disorder characterized by visual field defects and excavation of the optic nerve head. An abnormally high intraocular pressure is commonly known to be detrimental to the eye, and there are clear indications that, in glaucoma patients, this probably is the most important physical change causing degeneration of the retina. Ultimately, if untreated, there is gradual loss of vision over time. The pathophysiological mechanism of glaucoma is, however, still unknown.
• Primary glaucoma is the most common type and can be divided into open-angle and closed- angle glaucoma.
• Primary open angle glaucoma (“POAG”) is the most frequent type of glaucoma observed in the United States. POAG is usually detected in its early stages during routine eye examinations.
• Primary closed angle glaucoma also called acute glaucoma, usually has a sudden onset and is characterized by eye pain and blurred vision.
• Secondary glaucoma occurs as a complication of a variety of other conditions, such as injury, inflammation, generalized vascular disease, and diabetes. Congenital glaucoma is due to a developmental defect in the eye’s drainage mechanism.
• Diabetic retinopathy is the most common complication of diabetes and the leading cause of decreased visual acuity and blindness in working-age population in developed countries.
• the incidence of DR increases with the time of evolution of diabetes.
• 90% of patients with type 1 diabetes and 60% of patients with type 2 diabetes have some degree of DR after 20 years of evolution of diabetes.
• the prevalence of DR in Western countries is very similar and is around 30% and in 10% of cases the DR is in advanced stages that seriously threaten vision.
• DR occurs when changes in blood glucose levels cause changes in retinal blood vessels. In some cases, these vessels will swell up (macular edema) and leak fluid into the rear of the eye. In other cases, abnormal blood vessels will grow on the surface of the retina.
• DR can gradually become more serious and progress from ‘background retinopathy’ to seriously affecting vision and can lead to blindness.
• Retinal vein occlusion is a vascular disorder of the retina and one of the most common causes of vision loss worldwide. Specifically, it is the second most common cause of blindness from retinal vascular disease after diabetic retinopathy. RVO is often the result of underlying health problems (e.g., high blood pressure, high cholesterol levels, diabetes, and other health problems).
• CRVO central retinal vein occlusion
• BRVO branch retinal vein occlusion
• ischemia causes the formation of new blood vessels.
• RVO is currently treated with intravitreal injection of anti-vascular endothelial growth factor (VEGF) drugs.
• VEGF anti-vascular endothelial growth factor
• Anterior ischemic optic neuropathy results from ischemic damage to the anterior portion of the optic nerve, a region primarily supplied by the posterior ciliary artery circulation.
• Anterior ischemic optic neuropathy is divided into two types: arteritic AION (AAION), secondary to vasculitis (especially giant cell arteritis), and nonarteritic AION (NAION), secondary to non-inflammatory small vessel disease.
• NAION constitutes 95% of all AION and is the most common cause of acute optic neuropathy in people over the age of 50, affecting somewhere between 2 to 10 individuals per 100,000 (approximately 1500 to 6000 new cases per year in the United States).
• no generally accepted treatment or secondary prevention of NAION exists, however steroids have been traditionally used in some patients.
• ROP Retinopathy of prematurity
• ROP Retinopathy of prematurity
• Abnormal, leaky blood vessel growth (neovascularization) in the retina occurs secondary to other treatments for prematurity and can often lead to neonatal blindness.
• blood vessels grow from the center of a developing baby's retina 16 weeks into the mother's pregnancy, and then branch outward and reach the edges of the retina 8 months into the pregnancy.
• normal retinal vessel growth is incomplete and may therefore be more readily disrupted
• Edonentan is a highly selective and very potent endothelin A receptor antagonist Edonentan was developed as a second-generation analog following the discontinuation of the first clinical candidate, BMS-193884, which was being developed for the treatment of congestive heart failure (CHF). Edonentan was in phase I trials by April 2002, but its development was discontinued
• A-l 82086 is a potent dual ETA/ETB receptor antagonist with 4-fold ETA/ETB selectivity. A-182086 has not been studied in a clinical setting to date.
• the present invention provides a method of using the endothelin receptor antagonists for treating an ocular disease selected from glaucoma, diabetic retinopathy (DR), retinal vein occlusion (RVO), non-arteritic anterior ischemic optic neuropathy (NAION), arteritic anterior ischemic optic neuropathy (AION), and retinopathy of prematurity (ROP).
• an ocular disease selected from glaucoma, diabetic retinopathy (DR), retinal vein occlusion (RVO), non-arteritic anterior ischemic optic neuropathy (NAION), arteritic anterior ischemic optic neuropathy (AION), and retinopathy of prematurity (ROP).
• the method comprises contacting an optical tissue in a subject with a composition comprising a therapeutically effective amount of Edonentan or A- 182086, or a pharmaceutically acceptable salt thereof, in which the endothelin receptor antagonist is Edonentan or A-l 82086.
• a composition comprising a therapeutically effective amount of Edonentan or A- 182086, or a pharmaceutically acceptable salt thereof, in which the endothelin receptor antagonist is Edonentan or A-l 82086.
• Such antagonist or its pharmaceutically acceptable salt can be in a crystalline form or an amorphous form, each of which can be for pharmacologically acceptable use.
• contacting comprises administering a topical composition to a surface of an eye or a portion thereof. In other embodiments, contacting comprises injecting Edonentan or A- 182086 into an eye generally or in a specific area thereof.
• contacting comprises administering a composition via an eye implant, e.g., a port delivery system
• eye implant technologies include, but are not limited to, ApidCOR, BioS eizer-ProDex, Vitrasert, Retisert, Iluvien, I-Vation, Nanoporous Silicon, Ozurdex/Novadur, OcuLief, Port Delivery System (FDS), PEA Implant, PEG-PLA Microspheres, PRINT Technology, Q-Sphera, SKS Microparticles, Verisome, Capsule Ring Device, MicroPump, Microneedle Injector, Microneedle/Needle-less Injectors, EyeCET, Gemini Refractive Capsule, IVMED, Ciliary Sulcus Ring, Episcleral Exoplant, Eye-D Implant, and Nanoliposomes.
• the eye implant technologies that can be used in the methods of this disclosure is selected from ApidCOR, BioSeizer-ProDex, Vitrasert, Retisert, Iluvien, I- Vation, Nanoporous Silicon, Ozurdex/Novadur, OcuLief, Port Delivery System (PDS), PEA Implant, PEG-PLA Microspheres, PRINT Technology, Q-Sphera, SKS Microparticles,
• the eye implant technology is ApidCOR, BioSeizer-ProDex, Vitrasert, Retisert, Iluvien, I-Vation, Nanoporous Silicon, Ozurdex/Novadur, OcuLief, Port Delivery System (PDS), PEA Implant, PEG-PLA Microspheres, PRINT Technology, Q-Sphera, SKS Microparticles, Verisome, Capsule Ring Device;, or MicroPump.
• the ocular disease is glaucoma.
• therapeutic efficacy in treating glaucoma is determined by detecting a reduction in intraocular pressure, or a reduction in the rate of optic nerve damage/retinal nerve fiber layer thinning, amount sufficient to relieve or prevent optic nerve damage.
• the therapeutic efficacy of the treatment is determined by improvement of optic nerve head blood flow.
• therapeutic efficacy of treating glaucoma is determined by measuring an improvement in retinal, optic nerve head or tissue perfusion.
• the regimen further comprises the addition of a therapeutically effective amount of an intra-ocular pressure (IOP) reducing agent or a neuroprotective agent, or a pharmaceutically acceptable salt of any of the foregoing.
• IOP intra-ocular pressure
• the IOP reducing agent is selected from the group consisting of prostaglandins (such as latanoprost or travoprost), beta-blockers (such as timolol or betaxolol), alpha adrenergic agonists (such as brimonidine, apraclonidine), carbonic anhydrase inhibitors (such as dorzolamide or brinzolamide), Rho kinase inhibitors (such as netarsudil) and miotic or cholinergic agents (such as pilocarpine).
• the neuroprotective agent is selected from the group consisting of anti-apoptotic agents (such as caspase-2 inhibitor) and neurotrophic factors (such as ciliary neurotrophic factor).
• the ocular disease is diabetic retinopathy (DR).
• DR diabetic retinopathy
• therapeutic efficacy of treating DR is determined by a decrease in retinal neovascularization, diabetic retinopathy severity score and neurodegeneration induced by diabetes.
• therapeutic efficacy of treating DR is determined by measuring an improvement in retinal or choroid perfusion.
• the disease is retinal vein occlusion (RVO).
• therapeutic efficacy of treating RVO is determined by measuring an improvement in tissue perfusion, a reduction in inflammation, or a combination of the foregoing.
• the disease is NAION.
• therapeutic efficacy of treating NAION is determined by measuring an improvement in tissue perfusion, a reduction in inflammation, or a combination of the foregoing.
• the disease is AION.
• therapeutic efficacy of treating AION is determined by measuring an improvement in tissue perfusion, a reduction in inflammation, or a combination of the foregoing.
• the ocular disease is retinopathy of prematurity (ROP).
• therapeutic efficacy of treating ROP is determined by measuring an improvement in retinal perfusion and reduction in abnormal neovascularization.
• the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof is Edonentan.
• the endothelin receptor antagonist or a pharmaceutically acceptable salt thereof is A-l 82086. In either case, the antagonist or its pharmaceutically acceptable salt can be in a crystalline form or an amorphous form, each of which can be for pharmacologically acceptable use.
• the endothelin receptor antagonist is administered in a dosage between about 1 ⁇ g and about 4 mg (e.g., between about 1 ⁇ g and about 10 ⁇ g, between about 10 ⁇ g and about 100 ⁇ g, between about 100 ⁇ g and about 500 ⁇ g, and between about 500 ⁇ g and about 4 mg). In some embodiments, the endothelin receptor antagonist is administered in a dosage between about 0.1 ⁇ g and about 10 ⁇ g. In some embodiments, the endothelin receptor antagonist is administered in a dosage between about 1 ⁇ g and about 10 ⁇ g. In further embodiments, the endothelin receptor antagonist is administered in a dosage between about 10 ⁇ g and about 100 ⁇ g.
• the endothelin receptor antagonist is administered in a dosage between about 100 ⁇ g and about 500 ⁇ g, and between about 500 ⁇ g and about 4 mg.
• FIG. 1 depicts optical coherence tomography - angiography (OCT- A) images of a representative experiment revealing severe vasospasm in the rabbit retinal vascular structure in focus 45 min after 0.5 ⁇ g of Endothelin-1 (ET-1) administration via intravitreal injection (TVT) injectioa
• OCT- A optical coherence tomography - angiography
• FIG. 2 depicts fluorescein angiography (FA) images revealing reversal of ET-1 induced vasospasm after IVT administration of 10 ⁇ g Edonentan.
• OIR oxygen-induced ischemic retinopathy
• FIG. 5 A and FIG. 5B reveal prevented RGC loss and maintained RGC function after treatment with Edonentan.
• FIG. 5C depicts pharmacokinetic profiles of topically or orally administered Edonentan in the plasma, retina/retinal pigment epithelium (RPE)/choroid, vitreous humor and aqueous humor of rats.
• RPE retina/retinal pigment epithelium
• FIG. 5C reveals the ability of Edonentan to permeate through comea/sclera and achieve retina exposure after topical administration
• FIG. 6A and FIG. 6B reveal prevented RGC loss and maintained RGC function after treatment with A-l 82086.
• FIG. 6C depicts pharmacokinetic profiles of topically or orally administered A-l 82086 in the plasma, retina/retinal pigment epithelium (RPE)/choroid, vitreous humor and aqueous humor of rats.
• FIG. 6C reveals the ability of A-l 82086 to permeate through comea/sclera and achieve retina exposure after topical administration.
• FIGS 7A-7L depict laser speckle flow graphs (LSFG) for the comparison of an experimental glaucoma eye and a contralateral healthy eye (control) of three non-human primates in global average mean blur rate (MBR) or MBR change from baseline over time as an index of optic nerve head (ONH) blood flow in a laser-induced glaucoma model.
• FIG. 7M shows the aggregate results from the three non-human primates.
• FIG. 7N shows an LSFG scan of one of the non-human primates at various selected time points.
• FIG. 9A, FIG. 9B, FIG. 9C and FIG. 9D depict pharmacokinetic profiles of intravitreally delivered Edonentan in the plasma, retina, iris-ciliary body (ICB), retinal pigment epithelium (RPE)/choroid, vitreous humor or aqueous humor of rabbits (FIG. 9A, FIG. 9B, FIG. 9C and FIG. 9D) - revealing longer t 1 ⁇ 2 for Edonentan.
• FIG. 10 depicts pharmacokinetic profiles of topically administered Edonentan in the plasma, retina, vitreous humor and bulbar conjunctiva of rabbits - revealing the ability of Edonentan to penetrate through ocular layers after a single topical application to the eye.
• Edonentan and A-l 82086 can be used to prevent, treat or otherwise ameliorate ocular diseases including, but not limited to, glaucoma, diabetic retinopathy (DR), retinal vein occlusion (RVO), non-arteritic anterior ischemic optic neuropathy (NAION), arteritic anterior ischemic optic neuropathy (AION), and retinopathy of prematurity (ROP).
• DR diabetic retinopathy
• RVO retinal vein occlusion
• NAION non-arteritic anterior ischemic optic neuropathy
• AION arteritic anterior ischemic optic neuropathy
• ROP retinopathy of prematurity
• Methods of the present invention include contacting the eye tissue (topically or intra- ocularly) with or administration of a therapeutically effective amount of Edonentan and A- 182086, or a pharmaceutically acceptable salt thereof.
• the antagonists are specifically Edonentan and A-l 82086, as described below.
• Methods of preparing Edonentan are well known to a person of skill in the art Suitable methods are disclosed, for example, in U.S. Patent No. 6,043,265.
• Edonentan has the chemical name ofN-[[2'-[[(4,5-dimethyl-3-isoxazolyl)amino]sulfonyl]-4-(2-oxazolyl)[l,l , -biphenyl]-2- yl]methyl]-N,3,3-trimethylbutanamide (molecular weight of 536.6 g/mol) and the structure:
• A-182086 has the chemical name of (2R,3R,4S)-4-(2H-l,3-benzodioxol-5-yl)-2-(3-fluoro-4-methoxyphenyl)-l-[2-(N- propylpentane-l-sulfonamido)ethyl]pyrrolidine-3-carboxylic acid (molecular weight of 578.7 g/mol) and the structure:
• the methods of the present disclosure include the use of Edonentan and A-l 82086 described above in the treatment and amelioration of an ocular disease selected from glaucoma, diabetic retinopathy (DR), retinal vein occlusion (RVO), non-arteritic anterior ischemic optic neuropathy (NAION), arteritic anterior ischemic optic neuropathy (AION), and retinopathy of prematurity (ROP), which are described below.
• DR diabetic retinopathy
• RVO retinal vein occlusion
• NAION non-arteritic anterior ischemic optic neuropathy
• AION arteritic anterior ischemic optic neuropathy
• ROP retinopathy of prematurity
• a “therapeutically effective amount” can be determined by assessing an improvement in retinal blood flow (RBF) over what could be achieved by the standard of care (lowering of intra-ocular pressure (IOP)).
• RBF retinal blood flow
• IOP intra-ocular pressure
• the improvement in blood flow in the healthy rabbit ocular model can be used as predictive of pharmacodynamic response (PD) in humans.
• Rabbits are commonly used to assess ocular PK/FD relationship for compounds targeting human ocular diseases due to the anatomic and functional similarities of the rabbit and human eye.
• glaucoma models are Morrison’s rat model of elevated IOP and the laser-induced non-human primate (NHP) glaucoma model.
• Glaucoma in Morrison’s rat model is induced by sustained elevation of IOP through hypertonic saline administration via episcleral veins.
• NHP glaucoma model after sustained elevation of IOP, optic nerve head blood flow has been shown to be reduced (Wang L. et al, Invest Ophthalmol Vis Sci 2012).
• the reduction in optic nerve head blood flow has been shown to correlate with long-term structural changes in the optic nerve (Cull G. et al, Invest Ophthalmol Vis Sci 2013).
• Efficacy in the above-described glaucoma models is defined as reduction in IOP, improvement in optic nerve head or retinal blood flow from baseline, prevention or slowing of the progression of structural neurodegenerative changes such as retinal nerve fiber layer thickness as measured by optical coherence tomography (OCT) or retinal ganglion cell counts on flat mount as well as functional changes such as electroretinography (ERG) or contrast sensitivity after treatment with Edonentan or A- 182086.
• OCT optical coherence tomography
• ERP retinal ganglion cell counts on flat mount as well as functional changes such as electroretinography (ERG) or contrast sensitivity after treatment with Edonentan or A- 182086.
• ECG electroretinography
• Edonentan or A- 182086 may reduce IOP and/or prevent RGC death through mechanisms independent of improvement in retinal/optic nerve head tissue perfusion. Accordingly, by using certain specific endothelin receptor antagonists, one (r) or more (IOP) of the above parameters can be altered to improve the RBF, thereby achieving therapeutic efficacy in treating glaucoma.
• the glaucoma patients are started on treatment as soon as they are diagnosed.
• Edonentan or A- 182086 is administered locally to the back of the eye using an intravitreal, topical, suprachoroidal, or implant delivery platform with a frequency of every 3 to 12 (e.g., every 3 to 6 or every 4 to 6) months.
• Diabetic retinopathy is the result of damage to the small blood vessels and neurons of the retina.
• the earliest changes leading to diabetic retinopathy include narrowing of the retinal arteries associated with reduced retinal blood flow, dysfunction of the neurons of the inner retina, followed in later stages by changes in the function of the outer retina, associated with subtle changes in visual function; dysfunction of the blood-retinal barrier, which protects the retina from many substances in the blood (including toxins and immune cells), leading to the leakage of blood constituents into the retinal neuropile.
• the basement membrane of the retinal blood vessels thickens, capillaries degenerate and lose cells, particularly pericytes and vascular smooth muscle cells. This leads to loss of blood flow and progressive ischemia, and microscopic aneurysms which appear as balloon-like structures jutting out from the capillary walls, which recruit inflammatory cells; and lead to advanced dysfunction and degeneration of the neurons and glial cells of the retina.
• ROP retinopathy of prematurity
• Oxygen-induced retinopathy in the mouse is a reproducible and quantifiable proliferative retinal neovascularization model suitable for examining pathogenesis and therapeutic intervention for retinal neovascularization in ROP and other vasculopathologies including DR
• the model is induced by exposure of one- week-old C57BL/6J mice to 75% oxygen for 5 days and then to room air as previously described (Smith LEH et al., Invest Ophthalmol Vis Sci 1994).
• Efficacy in this preclinical model of ROP can be assessed by studying retinal hypoxia and neovascularization.
• the current standard of care in DR includes anti-VEGF therapies which only address advanced vascular complications of disease.
• the patients with DR are started on this treatment during the nonproliferative stages of the disease.
• either Edonentan or A- 182086 is administered locally to the back of the eye using an intravitreal, topical, suprachoroidal, or implant delivery platform with a frequency of every 3 to 12 (e.g., every 3 to 6 or every 4 to 6) months.
• RVO Retinal Vein Occlusion
• RVO Retinal vein occlusion
• RVO is currently treated with intravitreal steroids and anti-VEGF agents. We that improving perfusion of existing vessels will reduce the degree of macular edema and VEGF upregulation and the downstream maladaptive changes that manifests as RVO.
• a preclinical mouse model of ischemic retinopathy can be used. Oxygen-induced retinopathy in the mouse is a reproducible and quantifiable proliferative retinal neovascularization model suitable for examining pathogenesis and therapeutic intervention for retinal neovascularization in many ischemic retinopathies including RVO.
• the model is induced by exposure of one-week- old C57BL/6J mice to 75% oxygen for 5 days and then to room air as previously described (Smith LEH et al., Invest Ophthalmol Vis Sci 1994).
• the efficacy in this preclinical model of ischemic retinopathy can be assessed by studying retinal hypoxia and neovascularization.
• a “therapeutically effective amount” of Edonentan or A-l 82086 described herein can be additive to the current standard of care by improving tissue perfusion and reducing inflammation mediated by ET-1 while avoiding the unwanted effects of local steroids.
• the Edonentan or A-l 82086 is administered locally to the back of the eye using an intravitreal, topical, suprachoroidal, or implant delivery platform. The frequency of administration will vary based on a patient’s disease course and response to therapy.
• NAION Non-Arteritic Anterior Ischemic Optic Neuropathy
• NAION Non-Arteritic Anterior Ischemic Optic Neuropathy
• NAION For NAION, there are no relevant preclinical models to test efficacy with endothelin antagonism. In addition, there are no approved therapies for non-arteritic anterior ischemic optic neuropathy.
• a “therapeutically effective” amount of an endothelin antagonist would be one which causes a clinically meaningful improvement in visual acuity and/or visual field by increasing the perfusion of the optic nerve.
• improvement in optic nerve head perfusion assessed by laser flowmeter or optical coherence tomography - A (OCT- A) and anatomical changes in retinal nerve fiber layer (RNFL) thickness determined by (OCT) will be used.
• the medication is administered locally to the back of the eye using an intravitreal, topical, suprachoroidal, or implant delivery platform with a frequency of every 4 to 6 weeks as needed based on patient’s disease course and response to therapy.
• the medication is administered locally to the back of the eye using an intravitreal injection of a suspension with a frequency of every 5 weeks as needed based on patient’s disease course and response to therapy.
• AION Arteritic Anterior Ischemic Optic Neuropathy
• Manifestations include rapid onset of unilateral visual loss accompanied by decreased visual acuity (typically severe: ⁇ 20/200 in over 60% of the patients), visual field defects (altitudinal field defect is most common) or both.
• visual acuity typically severe: ⁇ 20/200 in over 60% of the patients
• visual field defects altitudinal field defect is most common
• AION there are no relevant preclinical models to test efficacy with endothelin antagonism.
• therapies for non-arteritic anterior ischemic optic neuropathy have been traditionally used in most patients.
• visual loss occurs in 54-95% of GCA patients (16), typically within four months (10). With corticosteroid therapy, the rate of such decline is reduced to an estimated 13% (16).
• Visual recovery of the affected eye that has treatment is poor with a 15-34% improvement rate, which is higher with intravenous therapy.
• the medication is administered locally to the back of the eye using an intravitreal, topical, suprachoroidal, or implant delivery platform with a frequency of every 4 to 6 weeks as needed based on patient’s disease course and response to therapy.
• the medication is administered locally to the back of the eye using an intravitreal injection of a suspension with a frequency of every 5 weeks as needed based on patient’s disease course and response to therapy.
• ROP Retinopathy of prematurity
• ROP retinal vasoproliferative disease that affects premature infants.
• ROP continues to be a major preventable cause of blindness and visual handicaps globally.
• improved perinatal care improved survival of moderately preterm infants, and limited resources for oxygen delivery and monitoring, more mature preterm infants are developing severe ROP in developing countries.
• Phase I ROP is due to vaso-obliteration beginning immediately after birth secondary to a marked decrease in VEGF and insulin-like growth factor-1 (IGF-1).
• Phase II begins around 33 weeks' postmenstrual age (PMA). During this phase, VEGF levels increase, especially if there is retinal hypoxia with increasing retinal metabolism and demand for oxygen leading to abnormal vasoproliferation.
• ROP is induced by severe ischemia due to underdevelopment of retinal vessels secondary to premature birth. Therefore, as an aspect of the invention, we believe that improving perfusion of existing vessels with Edonentan or A- 182086 will reduce the degree of ischemia and VEGF upregulation and the downstream maladaptive changes that manifests as ROP.
• Oxygen-induced retinopathy in the mouse is a reproducible and quantifiable proliferative retinal neovascularization model suitable for examining pathogenesis and therapeutic intervention for retinal neovascularization in ROP. The model is induced by exposure of one- week-old C57BL/6J mice to 75% oxygen for 5 days and then to room air as previously described (Smith LEH et al., Invest Ophthalmol Vis Sci 1994).
• the efficacy in this preclinical model of ROP can be assessed by studying retinal hypoxia and neovascularization
• a “therapeutically effective amount” of Edonentan or A- 182086, as described herein will be additive to the current standard of care by improving tissue perfusion and reducing pathologic neovascularization induced by VEGF.
• the medication is administered locally to the back of the eye using an intravitreal, topical, suprachoroidal, or implant delivery platform with a frequency of every 4 to 6 weeks as needed based on patient’s disease course and response to therapy.
• the medication is administered locally to the back of the eye using an intravitreal injection with a frequency of every 5 weeks as needed based on patient’s disease course and response to therapy.
• Some embodiments described herein relates to a pharmaceutical composition, that can include a therapeutically effective amount of one of Edonentan and A- 182086, described herein, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier, diluent, excipient or combination thereof.
• a pharmaceutically acceptable carrier diluent, excipient or combination thereof.
• Such antagonist or its pharmaceutically acceptable salt can be in a crystalline form or an amorphous form, each of which can be for pharmacologically acceptable use.
• composition refers to a mixture of one or both compounds disclosed herein with other chemical components, such as diluents or carriers.
• the pharmaceutical composition facilitates administration of the compound to an organism.
• Pharmaceutical compositions will generally be tailored to the specific intended route of administration.
• compositions involve preparing a pharmaceutically acceptable salt
• Pharmaceutically acceptable salts include salts of acidic or basic groups present in compounds of the invention.
• Pharmaceutically acceptable acid addition salts include, but are not limited to, hydrochloride, hydrobromide, hydroiodide, nitrate, sulfate, bisulfate, phosphate;, acid phosphate, isonicotinate, acetate, lactate, salicylate;, citrate, tartrate, pantothenate, bitartrate, ascorbate, succinate, maleate, gentisinate, fumarate, gluconate, glucaronate, saccharate, formate, benzoate, glutamate, methanesulfonate, ethanesulfonate, benzensulfonate, p-toluenesulfonate and pamoate (i.e., 1 , 1 '-methylene-bis-(2-hydroxy-3-naphthoate)) salts.
• Suitable base salts include, but are not limited to, aluminum, calcium, lithium, magnesium, potassium, sodium, zinc, and diethanolamine salts.
• Suitable base salts include, but are not limited to, aluminum, calcium, lithium, magnesium, potassium, sodium, zinc, and diethanolamine salts.
• pharmaceutically acceptable defines a carrier, diluent, excipient, salt or composition that is safe and effective for its intended use and possesses the desired biological and pharmacological activity.
• a “carrier” refers to a compound that facilitates the incorporation of a compound into cells or tissues.
• DMSO dimethyl sulfoxide
• a “diluent” refers to an ingredient in a pharmaceutical composition that lacks pharmacological activity but may be pharmaceutically necessary or desirable.
• a diluent may be used to increase the bulk of a potent drug whose mass is too small for manufacture and/or administration. It may also be a liquid for the dissolution of a drug to be administered by injection, ingestion or inhalation.
• a common form of diluent in the art is a buffered aqueous solution such as, without Imitation, phosphate buffered saline that mimics the composition of human blood.
• an “excipient” refers to an inert substance that is added to a pharmaceutical composition to provide, without limitation, bulk, consistency, stability, binding ability, lubrication, disintegrating ability etc., to the composition.
• a “diluent” is a type of excipient
• compositions described herein can be administered to a human patient per se, or in pharmaceutical compositions where they are mixed with other active ingredients, as in combination therapy, or carriers, diluents, excipients or combinations thereof. Proper formulation is dependent upon the route of administration chosen. Techniques for formulation and administration of the compounds described herein are known to those skilled in the art.
• compositions disclosed herein may be manufactured in a manner that is itself known, e.g., by means of conventional mixing, dissolving, granulating, levigating, emulsifying, encapsulating or entrapping processes. See, e.g., Encapsulation Processes, in: Food Powders, 2005, 199-299. Additionally, the active ingredients are contained in an amount effective to achieve its intended purpose. Compounds used in the pharmaceutical combinations disclosed herein may be provided as pharmaceutically acceptable salts.
• the compounds or pharmaceutical compositions of this invention in a local manner either as a topical ophthalmic formulation or via injection of the compounds or pharmaceutical compositions directly to the ocular tissue, often in a depot or sustained release formulation.
• the manner of local administration can be intravitreal, suprachoroidal, periocular, or subconjunctival injection of a formulation, or use of an implant technology or topical application.
• the compound is administered in a liposomal preparation that slowly releases the compound sustaining the desired pharmacological effects.
• polyvinyl alcohol nanoparticles can be prepared by well-known methods to afford a sustained or extended release-formulation for topical or intra-ocular application.
• a targeted drug delivery system examples include;, but are not limited to, ApidCOR, BioSeizer-ProDex, Vitrasert, Retisert, Iluvien, I-Vation, Nanoporous Silicon, Ozurdex/Novadur, OcuLief, Port Delivery System (PDS), PEA Implant, PEG-PLA Microspheres, PRINT Technology, Q-Sphera, SKS Microparticles, Verisome, Capsule Ring Device, MicroPump, Microneedle Injector, Microneedle/Needle-less Injectors, EyeCET, Gemini Refractive Capsule, IVMED, Ciliary Sulcus Ring, Episcleral Exoplant, Eye-D Implant, and Nanoliposomes.
• ApidCOR BioSeizer-ProDex
• Vitrasert Vitrasert, Retisert, Iluvien, I-Vation, Nanoporous Silicon, Ozurdex/Novadur, OcuLie
• the targeted drug delivery system that can be used in the methods of this disclosure is selected from ApidCOR, BioSeizer-ProDex, Vitrasert, Retisert, Iluvien, I- Vation, Nanoporous Silicon, Ozurdex/N ovadur, OcuLief, Port Delivery System (PDS), PEA Implant, PEG-FLA Microspheres, PRINT Technology, Q-Sphera, SKS Microparticles, Verisome, Capsule Ring Device, MicroPump, Microneedle Injector, Microneedle/Needle-less Injectors, EyeCET, Gemini Refractive Capsule, and IVMED.
• the targeted drug delivery system is ApidCOR, BioSeizer-ProDex, Vitrasert, Retisert, Iluvien, I-Vation, Nanoporous Silicon, Ozurdesx/Novadur, OcuLief, Port Delivery System (PDS), PEA Implant; PEG-PLA Microspheres, PRINT Technology, Q-Sphera, SKS Microparticles, Verisome, Capsule Ring Device, or MicroPump.
• the pharmaceutical composition is an ophthalmic preparation comprising a therapeutically effective amount of one or more endothelin receptor antagonists described herein, or a pharmaceutically acceptable salt thereof.
• an “ophthalmic preparation” refers to a specialized dosage form designed to be instilled onto the external surface of the eye (topical), administered inside (intraocular) or adjacent (periocular) to the eye or used in conjunction with an ophthalmic device.
• the ophthalmic preparation is in the form of a solution, suspension, or an ointment
• the ophthalmic preparation is in the form of a gel, a gel-forming solution, an ocular insert, a micro/nanoparticle preparations for topical or preferably intravitreal injection, or an implant
• the ophthalmic preparation comprises a preservative.
• suitable preservatives include, but are not limited to, cationic wetting agents (e.g, benzalkonium chloride), organic mercurials (e.g., phenylmercuric nitrate, phenylmercuric acetate), organic acids or their esters (e.g., sorbic acid, esters of p-hydroxy benzoic acid such as methyl hydroxy benzoate, propylhydroxybenzoate), and alcohol substitutes (e.g., chlorobutanol, phenylethanol).
• cationic wetting agents e.g, benzalkonium chloride
• organic mercurials e.g., phenylmercuric nitrate, phenylmercuric acetate
• organic acids or their esters e.g., sorbic acid, esters of p-hydroxy benzoic acid such as methyl hydroxy benzoate, propylhydroxybenzoate
• the preservative can be present in the ophthalmic preparation in an amount in the range of about 0.002 % w/v to about 0.5 % w/v (e.g., 0.01 - 0.25 % w/v).
• the ophthalmic preparation can further comprise a preservative aid.
• suitable preservative aid include, but are not limited to, ethylenediaminetetraacetic acid (EDTA).
• the ophthalmic preparation comprises one or more additional excipients or agents to impart viscosity or lubrication, stabilize the active ingredients against decomposition, increase solubility of an active or inactive ingredient, adjust tonicity, or act as solvent
• excipients or agents for imparting viscosity or lubrication include hypromellose, carbomer 974P, hydroxy ethyl cellulose (HEC), polyvinyl alcohol, sodium hyaluronate, sodium carboxymethyl cellulose, Carbopol 940, hydroxypropylmethyl cellulose (HPMC), poloxamer, xyloglucan, alginic acid, sodium alginate, gellan gum, cellulose acetate phthalate, and xantham gum.
• excipients or agents as stabilizers include sodium bisulfite, sodium metabisulfite, sodium thiosulfate, and sodium sulfate/sulfuric acid, which can act as antioxidants.
• excipients or agents as solubilizers include, but are not limited to, providone, creatinine, castor oil, and cyclodextrin (e.g., ⁇ -cyclodextrin).
• excipients or agents for adjusting tonicity include;, but are not limited to, sodium chloride, potassium chloride, calcium chloride dehydrate, magnesium chloride hexahydrate, sugars (e.g., sucrose, maltose, dextrose, etc.), glycerin, propylene glycol, mannitol, ascorbic acid, and acetylcysteine.
• the ophthalmic preparation comprises one or more buffers to adjust pH.
• buffers for adjusting pH include, but are not limited to, sodium citrate, monobasic sodium phosphate, dibasic sodium phosphate, boric acid, hepatahydrate, sodium acetate trihydrate, sodium citrate dihydrate, histidine, and phosphate buffered saline (PBS).
• PBS phosphate buffered saline
• the resulting composition can have a pH value of 5.0-8.5 (e.g., 5.0-6.0, 5.2-5.8, 6.0-8.0, 6.6-7.8, 6.2-8.2, and 6.2-7.5)
• the ophthalmic preparation comprises one or more surfactants.
• surfactants include sorbitan ether esters of oleic acid (e.g., polysorbate or Tween 20 and 80) and tyloxapol.
• the volume that can be injected to a human eye at one time is around 50-90 ⁇ L through the intravitreal route, up to 450 ⁇ L through a subretinal route, up to 200 ⁇ L via suprachoroidal routes, and about 40-50 ⁇ L via topical route (e.g. topical administration as an eye drop).
• the needle used in these routes is typically 27 to 30 G in size.
• the dose depends on the concentration that can be formulated to fit this volume, potency, target efficacy and pharmacokinetic profile for each indication.
• the injections to the eye will not be administered at a frequency greater than once per month per eye. For topical administrations (e.g. eye drop), in most instances, the frequency of administration to the eye does not exceed more than once or twice a day.
• the intravitreal formulation will comprise a dose of the endothelin receptor antagonist in the range of about 1 ⁇ g to about 1 mg.
• a first exemplary formulation comprises about 1 ⁇ g to about 1 mg of an endothelin receptor antagonist described above, about 10 mM histidine HC1, about 10% ⁇ , ⁇ -trehalose dihydrate, and about 0.01% polysorbate 20.
• a second exemplary formulation comprises about 1 ⁇ g to about 1 mg of endothelin receptor antagonist, about 10 mM sodium phosphate, about 40 mM sodium chloride, about 0.03% polysorbate 20, and about 5% sucrose.
• the intravitreal formulation will comprise a dose of the endothelin receptor antagonist in the range of about 10 ⁇ g to about 100 ⁇ g.
• a first exemplary formulation comprises about 10 ⁇ g to about 100 ⁇ g of an endothelin receptor antagonist described above, about 10 mM histidine HC1, about 10% ⁇ , ⁇ -trehalose dihydrate, and about 0.01% polysorbate 20.
• a second exemplary formulation comprises about 10 ⁇ g to about 100 ⁇ g of endothelin receptor antagonist, about 10 mM sodium phosphate;, about 40 mM sodium chloride, about 0.03% polysorbate 20, and about 5% sucrose.
• the intravitreal formulation will comprise a dose of the endothelin receptor antagonist in the range of about 500 ⁇ g to about 4 mg.
• a first exemplary formulation comprises about 500 ⁇ g to about 1 mg of an endothelin receptor antagonist described above, about 0.014% potassium phosphate monobasic, 0.08% sodium phosphate dibasic, 0.7% sodium chloride, 0.02% polysorbate, and 0.5% sodium carboxymethyl cellulose.
• a second exemplary formulation comprises about 500 ⁇ g to about 1 mg of an endothelin receptor antagonist described above, about 0.04% sodium phosphate monobasic monohydrate, about 0.3% sodium phosphate dibasic heptahydrate, 0.63% sodium chloride, and about 1% to about 2.3% sodium hyaluronate.
• A-182086 described above As indicated in Table 1, at pH 2, A-182086 has a solubility superior to that of Edonentan. On the other hand, at pH 7, Edonentan has a solubility superior to that of
• Example 2 Formulation of Edonentan for Intravitreal Use in Rabbit
• An appropriate amount of Edonentan is dissolved in neat FEG400, followed by addition of a 15% CD ( ⁇ - ⁇ -cyclodextrin) solution.
• the final concentration of PEG400 is measured to be 20%.
• Target concentrations are 5 mg/ml and 0.5 mg/ml based on the amount of Edonentan.
• the resulting solution is filtered using a 0.25 micron filter.
• Example 4 Preparation of an Extended Release Formulation Containing Edonentan
• a concentrated Edonentan dispersion is made by combining Edonentan with water, Vitamin E-TPGS and ⁇ -cyclodextria These ingredients are mixed to disperse the Edonentan, and then autoclaved.
• Sodium hyaluronate may be purchased as a sterile powder or sterilized by filtering a dilute solution followed by lyophylization to yield a sterile powder.
• the sterile sodium hyaluronate is dissolved in water to make an aqueous concentrate.
• the concentrated Edonentan dispersion is mixed and added as a slurry to the sodium hyaluronate concentrate.
• compositions of extended release formulation containing Edonentan are provided in Table 2 below: Table 2.
• compositions contain a sufficient concentration of high molecular weight (i.e. polymeric) sodium hyaluronate so as to form a gelatinous plug or drug depot upon intravitreal injection into a human eye.
• high molecular weight (i.e. polymeric) sodium hyaluronate i.e. polymeric
• the average molecular weight of the hyaluronate used is less than 2 million, and more preferably the average molecular weight of the hyaluronate used is between about 1.3 million and 1.6 million.
• the Edonentan particles are, in effect, trapped or held within this viscous plug of hyaluronate, so that undesirable pluming does not occur upon intravitreal injection of the formulation.
• the risk of drug particles disadvantageously settling directly on the retinal tissue is substantially reduced, for example* relative to using a composition with a water-like viscosity, such as Kenalog® 40. Since sodium hyaluronate solutions are subject to dramatic shear thinning, these formulations are easily injected via 25 gauge, 27 gauge or even 30 gauge needles.
• a topical Edonentan formulation can be prepared following a known method (e.g. , WO 2016156639 Al). More specifically, 20 g of Cremophor ® RH40 is dissolved in 75 mL of deionized water by magnetic stirring, which is allowed to stir until completely dissolved Then 1.5 g of trometamol is added to the resulting solution and stirred for 15 minutes, achieving complete dissolution. 0.5 g of Edonentan is added and allowed to stir for 15 minutes, ensuring complete dissolution. Then 2 g of glycine and 1 g of boric acid are added and allowed to stir until completely dissolved. The resulting solution is added 100 mL deionized water in sufficient quantity. The final solution is filtered with filter paper, and a clear, colorless solution with a pH of 8.06 is obtained. The solution in dropper bottles eyedrop with a volume of 5 mL is packed.
• Nanoparticles were prepared by solvent evaporation technique. A solution of 120 mg of 50: 50 PLGA in 60 mL of ethyl acetate was prepared. To this solution it was incorporated under turboagitation an aqueous solution of 50 ml of water with 12 mg of Edonentan and 0.5 mg of polyvinyl alcohol. The resulting mixture was left under continuous agitation and under vacuum for 2 hours. Then the resulting preparation was ultra-centrifuged and washed with water three times to remove the nanoparticles from the medium. The nanoparticles thus obtained were dried in a vacuum oven and after evaluation, dispersed in an isotonic aqueous solution enough for a concentration of 5 mg/1 mL of Edonentan.
• the healthy rabbit model is used to assess the pharmacodynamic effect (in vivo) of Edonentan and or A- 182086 or pharmaceutically acceptable salts thereof. These studies are conducted with varying doses of the selected endothelin antagonists. Additional animal studies are conducted by combining endothelin antagonists with the current standard of care.
• the Morrison’s rat model of glaucoma, rat model of acutely elevated IOP and laser induced glaucoma model in the non-human primate are used to assess optic nerve head blood flow and rate of retinal ganglion cell loss with varying doses of the selected endothelin antagonists with and without standard of care.
• the improvement in blood flow in the healthy rabbit model is measured for the indicated endothelin receptor antagonists at varying doses after induction of perfusion impairment by locally administered ET-1.
• the changes in optic nerve head blood flow and retinal nerve fiber layer (RNFL) thickness in the non-human primate glaucoma models are measured for the indicated endothelin receptor antagonists at varying doses.
• the results show an improvement of RGC survival, retinal and optic nerve head blood flow and slowing of RNFL thinning due to the use of selected endothelin receptor antagonists.
• Dosing regimens for humans are predicted from the results of the healthy rabbit and non-human primate glaucoma models.
• IOP was measured twice a week throughout the entire duration of the experiment Seven to ten days following the surgery, IOP elevation was observed in the operated eye of rats. After detecting an elevation of IOP for two consecutive days, topical administration of eye drops (20 ⁇ L (100 ⁇ g) per dose of the tested compounds in the IOP elevated eye) was commenced and carried out for five days a week for a total of four weeks. In the 4th week of treatment, PERG analysis was carried out and rats were sacrificed by an overdose of pentobarbital (Fatal-Plus). Aqueous humor was collected from the rat eyes, frozen and shipped for analysis. Retinal flat mounts were prepared, immunostained with the RGC marker, Bm3a antibody and surviving RGCs were counted in two eccentricities (central and peripheral).
• the immunostained retinal flat mounts were obtained to measure the retinal ganglion cell (RGC) counts.
• RGC retinal ganglion cell
• the eyes were euthanized after the treatments and then their eyes were enucleated.
• the eye cups were fixed overnight at 4 °C in 4% paraformaldehyde (PFA) and retinal flat mounts were prepared for collecting images.
• the retinal ganglion cell (RGC) counting was conducted using the images of immunostained retinal flat mounts.
• the images were uploaded to Imaged, a photo editor designed for biology research (Rasband, 1997-2018) and the labeled retinal ganglion cells were counted manually in two eccentricities (central and peripheral).
• FIG. 5A shows the comparison of RGC counts in the peripheral retinal between vehicle and Edonentan
• FIG. 6A shows the comparison between vehicle and A-l 82086.
• Pattern ERG was used to assess the RGC function.
• a UTAS Visual Electrodiagnostic System (LKC, Gaithersburgh, MD, USA) was used following the method described by Porciatti et al. (Porciatti V, Saleh M, Nagaraju M. The pattern electroretinogram as a tool to monitor progressive retinal ganglion cell dysfunction in the DBA/2J mouse model of glaucoma. Invest Ophthalmol Vis Sci. 2007;48(2): 745-751 ). Briefly, PERG signals were acquired from a DTL-plus electrode placed on the lower part of the comeal surface and the PERG waves were analyzed using the EMWIN software (LKC).
• FIG. 5B shows IOP-mediated PERG changes between vehicle and Edonentan
• FIG. 6B shows the changes between vehicle and A- 182086.
• the animals were euthanized at different time points (e.g. 4 and 8 hours) and tissues were collected for analysis.
• List of tissues collected include plasma, retina/retinal pigment epithelium (RPE)/choroid, vitreous humor and aqueous humor.
• the pharmacokinetic properties of topically or orally administered Edonentan in rats is shown in FIG. 5C.
• the pharmacokinetic properties of topically or orally administered A-l 82086 in rats is shown in FIG. 6C.
• FIG. 5C and FIG. 6C show that both Edonentan and A- 182086 are detected 4 and 8 hours post-topical administration in the retina/RPE/choroid, aqueous humor and vitreous humor.
• mice with oxygen-induced ischemic retinopathy were given an injection of ET-1 antagonist (1 ⁇ L of 2 ⁇ g/ ⁇ L Edonentan formulation, single dose) in one eye and PBS in the fellow eye.
• ET-1 antagonist 1 ⁇ L of 2 ⁇ g/ ⁇ L Edonentan formulation, single dose
• the area of NV, area of retinal hypoxia, and the area of retinal nonperfusion were determined for each retina.
• FIGS 7A-7L show the ONH blood flow in the three non-human primates after IVT administration of a vehicle alone (FIG. 7A, FIG. 7E, and FIG. 71), 0.02 mg/mL of Edonentan (FIG. 7B, FIG. 7F, and FIG. 7J), 0.2 mg/mL of Edonentan (FIG. 7C, FIG. 7G, and FIG. 7K) or 2.0 mg/mL of Edonentan (FIG. 7D, FIG. 7H, and FIG. 7L).
• FIGS 7A-7L reveal the improvement of ONH blood flow in a dose-dependent manner after treatment with Edonentan.
• FIG. 7M The aggregate results from the three non-human primates are shown in FIG. 7M, which show that Edonentan clearly exhibits does-related increase of ONH blood flow, resulting from dilation of retinal arteries, veins, and capillaries in experimental glaucoma eyes, as compared to control eyes.
• a single dose of 0.5% Timolol or a single dose of 2 mg/mL Edonentan was topically administered to three non-human primates that have laser-induced glaucoma in their right eyes (OD) with 1-week wash-out in a randomized order.
• Control 1 A single dose of 50 ⁇ L of topical Timolol 0.5% in each eye showed an 10P reduction of about 20% from pre-dose to post-dose (120 minutes).
• Control 2 A single dose of 50 ⁇ L of topical Timolol 0.5% in each eye showed an IOP reduction of about 30% from pre-dose to post-dose (120 minutes).
• Non-human Primate 1 50 ⁇ L of Edonentan eyedrop (2 mg/mL) in the experimental glaucoma eye showed an IOP reduction of about 60% from pre-dose to post-dose (120 minutes) and in the contralateral healthy eye showed an IOP reduction of about 10% from pre-dose to post-dose (120 minutes).
• Non-human Primate 2 50 ⁇ L of Edonentan eyedrop (2 mg/mL) in the experimental glaucoma eye showed an IOP reduction of about 50% from pre-dose to post-dose (15 minutes) and about 30% from pre-dose to post-dose (120 minutes). 50 ⁇ L of Edonentan eyedrop (2 mg/mL) in the contralateral healthy eye showed an IOP reduction of about 20% from pre-dose to post-dose (15 minutes) and about 0% from pre-dose to post-dose (120 minutes).
• Non-human Primate 3 50 ⁇ L of Edonentan eyedrop (2 mg/mL) in the experimental glaucoma eye showed an IOP reduction of about 40% from pre-dose to post-dose (15 minutes) and about 40% from pre-dose to post-dose (120 minutes). 50 ⁇ L of Edonentan eyedrop (2 mg/mL) in the contralateral healthy eye showed an IOP reduction of about 10% from pre-dose to post-dose (15 minutes) and about 40% from pre-dose to post-dose (120 minutes).

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• 2020
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• 2022
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• 2023
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