Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/41—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having five-membered rings with two or more ring hetero atoms, at least one of which being nitrogen, e.g. tetrazole
  • A61K31/4164—1,3-Diazoles
  • A61K31/4178—1,3-Diazoles not condensed 1,3-diazoles and containing further heterocyclic rings, e.g. pilocarpine, nitrofurantoin
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/16—Amides, e.g. hydroxamic acids
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/495—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with two or more nitrogen atoms as the only ring heteroatoms, e.g. piperazine or tetrazines
  • A61K31/505—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim
  • A61K31/513—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim having oxo groups directly attached to the heterocyclic ring, e.g. cytosine
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/56—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids
  • A61K31/57—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids substituted in position 17 beta by a chain of two carbon atoms, e.g. pregnane or progesterone
  • A61K31/573—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids substituted in position 17 beta by a chain of two carbon atoms, e.g. pregnane or progesterone substituted in position 21, e.g. cortisone, dexamethasone, prednisone or aldosterone
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/70—Carbohydrates; Sugars; Derivatives thereof
  • A61K31/7042—Compounds having saccharide radicals and heterocyclic rings
  • A61K31/7052—Compounds having saccharide radicals and heterocyclic rings having nitrogen as a ring hetero atom, e.g. nucleosides, nucleotides
  • A61K31/7056—Compounds having saccharide radicals and heterocyclic rings having nitrogen as a ring hetero atom, e.g. nucleosides, nucleotides containing five-membered rings with nitrogen as a ring hetero atom
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/70—Carbohydrates; Sugars; Derivatives thereof
  • A61K31/7042—Compounds having saccharide radicals and heterocyclic rings
  • A61K31/7052—Compounds having saccharide radicals and heterocyclic rings having nitrogen as a ring hetero atom, e.g. nucleosides, nucleotides
  • A61K31/706—Compounds having saccharide radicals and heterocyclic rings having nitrogen as a ring hetero atom, e.g. nucleosides, nucleotides containing six-membered rings with nitrogen as a ring hetero atom
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K38/00—Medicinal preparations containing peptides
  • A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
  • A61K38/17—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans
  • A61K38/19—Cytokines; Lymphokines; Interferons
  • A61K38/21—Interferons [IFN]
  • A61K38/215—IFN-beta
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
  • A61K45/06—Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P31/00—Antiinfectives, i.e. antibiotics, antiseptics, chemotherapeutics
  • A61P31/12—Antivirals
  • A61P31/14—Antivirals for RNA viruses

Definitions

• This invention relates to the new use of a known compound.
• a virus is a very small organism comprising genetic material (DMA or RNA) that is capable of infecting a biological organism.
• a virus invades and attaches itself to a living host ceil, often through an appropriate adhesion receptor. It will then enter a cell through an entry receptor, after which it multiplies to produce more virus particies (virions), which attach to and enter further susceptible ceils.
• viruses only infect one type of ceil, but can be transmitted in various ways, including contact with infected individuals or their bodily secretions, animals (such as arthropods), or inanimate objects. Viruses can also be transmitted by Inhalation or swallowing.
• ceils are infected by viruses, some sort of damage or injury may occur, either by kiiling cells or altering their functions, which may in turn lead to further, and/or more rapid, infection of other ceils.
• Viral diseases have their own recognized symptoms, which may vary between subjects, but which are often what leads to suspicion of the existence of a viral infection, which may then be confirmed through appropriate testing procedures.
• Symptoms of viral diseases may be a direct result of damage to cells and/or tissues caused by the virus per se, which can sometimes lead to severe illness and, in some instances, morbidity and/or death.
• symptoms may also be associated with the response of an organism's immune defence system following a viral infection.
• White blood cells like lymphocytes and monocytes attempt to attack and destroy the invasive virus. This is part of the body's immune response.
• the immune response can often lead a patient feeling unwell or fatigued. If a patient's immune system is compromised, or not effective enough to prevent the spread of a virus, this can also lead to severe illness, morbidity and/or death.
• ⁇ viruses that can seriously affect lung function and cause respiratory illnesses.
• Common respiratory viruses include corona virus (usually contracted in general usage to 'coronavirus', as used hereinafter), Influenza virus, respiratory syncytial virus, parainfluenza virus, adenovirus, rhinovirus, human metapneumovirus and enterovirus.
• Coronaviruses are a group of related viruses that cause diseases in mammals and birds. There are 7 presently-known strains of human coronaviruses:
• SARS-CoV severe acute respiratory syndrome coronavirus
• SARS-CoV-2 ⁇ severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, previously known as '2019-nCoV' or 'novel coronavirus 2019'), which is the virus that causes coronavirus disease 2019 (COVID-19), of which there are many genetic variants,
• MERS-CoV Middle East respiratory syndrome-related coronavirus
• ACE Angiotensin converting enzyme
• RAS renin- angiotensin system
• Ang II vasoconstrictor angiotensin II
• Angiotensin converting enzyme 2 is a peptidase that catalyses the conversion of angiotensin I to the nonapeptide angiotensin[1-9] and the conversion of angiotensin II to the heptapeptide angiotensin[1-7].
• Alveolar epithelial cells are an important target for coronavirus infection in the lungs (Miura and Holmes, J, Leukoc. Biol., 86, 1145 (2009)). Indeed, in human lung tissue, 83% of ACE2-expressing cells have been reported to be alveolar epithelial cells (Zhao et al (2020), https ://doi.org/10.1101/2020.01.26.91998 5 and Zhang et al, Intensive Care Med., 46, 586 (2020)). ACE2 is not sensitive to the ACE inhibitor drugs used to treat hypertension (Tipnis et al , 3. Biol. Chem., 275, 33238 (2000)).
• AT1R The angiotensin II receptor type 1 receptor
• ARBs are drugs used for treatment of e.g. hypertension and diabetic nephropathy.
• SARS-CoV and SARS-CoV-2 viruses are known to bind to and enter their target cells through ACE2 (see e.g. Zhang et al, supra and Zhou et al, Nature, 579, 270 (2020)).
• ACE2 The expression of ACE2 is substantially increased in patients who are treated with ACE inhibitors and/or ARBs, which would be expected to facilitate infection with SARS viruses. Accordingly, Fang et al, supra suggested that treatment of e.g. diabetic and hypertensive patients with ACE2-stimulating drugs may increase the risk of developing severe and fatal SARS infections such as COVID- 19.
• AT2R angiotensin II type 2 receptor
• AGTR2 angiotensin II type 2 receptor
• Activation of the AT2R receptor is also understood to enhance ACE2 expression and activity, in a similar fashion to ACE inhibitors and/or ARBs (Zhu et al, Am. J. Physiol . Heart Ore. Physiol. 309, H827 (2015). It has also been reported in a paper by Cui et al, Preprints (2020), https ://doi : 10.20944/preprints202002.0194.vl that the AT2R may, in a similar fashion to ACE2, contribute to entry of 2019-nCoV into human cells.
• C21 has been shown to increase the expression of both AT2R itself and ACE2 (in C21's case in inflamed lung tissue; Bruce et al, Br. J. Pharmacol., 172, 2219 (2015)).
• E-cadherin is a calcium-dependent epithelial ceil adhesion molecule that is known to play a critical role In viral infection at the level of host cell binding and viral entry into cells (Hu et al, Front. Ceil. Infect. Microbiol., 10, Article 74 (2020)).
• C21 does indeed have beneficial effects on human airway epithelium, and protects against SARS virus-induced pulmonary epithelial damage and dysfunction in patients in a clinical setting.
• C21 is not only capable of abrogating or preventing the development of severe respiratory viral diseases, but also that it appears to be capable of promoting accelerated resolution of such diseases.
• C21 or a pharmaceutically- acceptable salt thereof for use in a method of treatment of respiratory virus- induced tissue damage.
• Tissue damage includes injury and/or dysfunction of relevant tissues and/or the cells that comprise them.
• Relevant tissues include (e.g. mucosal) tissues of the respiratory tract, and especially those of the lung.
• Relevant tissue thus includes the respiratory epithelium, which moistens the airways and protects against Invasion of pathogens such as viruses.
• Respiratory viruses that may be mentioned include influenza viruses and, more particularly, coronaviruses such as those mentioned hereinbefore, including SARS coronaviruses, such as SARS-CoV and, especially, SARS-CoV-2.
• C21 and salts thereof may not only have a beneficial effect on tissue damage in the respiratory tract that has been caused by such a virus, but that it may also prevent and/or mitigate the damage that would otherwise have been caused by that virus in the respiratory tract, which occurs when the relevant virus enters e.g. epithelial cells in the respiratory tract.
• C21 and salts thereof may further promote accelerated resolution of such respiratory tissue damage and/or injury, and therefore accelerated resolution of respiratory diseases, with C21 and salts thereof being capable of restoring lung function and/or respiratory function.
• tissue damage Includes the therapeutic, symptomatic and palliative treatment of such damage, as well as, in principle, the prophylaxis of such damage, or during the diagnostic workup of such damage (i.e. if it is suspected). More importantly, C21 and salts thereof may abrogate or prevent the development of diseases that are caused by such tissue damage and/or the symptoms of such damage or diseases.
• C21 and salts thereof may treat, and/or arrest the progress of, diseases that are being, or have been, caused by respiratory viruses (i.e. diseases such as influenza, as well as acute lung injury (ALI), acute respiratory distress syndrome (ARDS), particularly SARS and, more particularly, COVID- 19) and their sequelae,
• respiratory viruses i.e. diseases such as influenza, as well as acute lung injury (ALI), acute respiratory distress syndrome (ARDS), particularly SARS and, more particularly, COVID- 19
• C21 and salts thereof may also treat and/or prevent the damage that is being, or has been, caused by such viruses, which includes treating and/or preventing the symptoms of such respiratory diseases, which symptoms include cough, dyspnea, respiratory distress (as manifest by e.g. the need for supplementary/supplemental oxygen (which may be administered by a face mask or via nasal cannula (high flow or otherwise)), and/or mechanical ventilation/extra-corporeal membrane oxygenation), respiratory failure, and/or pneumonia, which may occur directly (viral pneumonia) and/or indirectly (bacterial pneumonia resulting from secondary bacterial infections, which is common in influenza).
• respiratory diseases which symptoms include cough, dyspnea, respiratory distress (as manifest by e.g. the need for supplementary/supplemental oxygen (which may be administered by a face mask or via nasal cannula (high flow or otherwise)), and/or mechanical ventilation/extra-corporeal membrane oxygenation), respiratory failure, and/or pneumonia, which may occur directly (viral pneumonia) and/or indirectly (bacterial pneumonia resulting from secondary
• Such symptoms may also include fibrosis in the lungs and other organs, such as the heart and kidneys.
• fibrosis is known to be a particular problem in many COVID-19 patients, and may result from one or more of a number of factors, including inflammation,
• C21 and salts thereof may prevent or arrest the progress of respiratory virus-induced morbidity and/or mortality, and C21 may treat, and/or arrest the development of any of the chronic symptoms identified above.
• C21 and salts thereof may be prescribed at any time subsequent a positive diagnosis of infection with a respiratory virus, including as soon as possible thereafter, with a view to preventing the symptoms described above, and/or their severity.
• Salts of C21 include pharmaceutically-acceptable add addition salts and base addition salts.
• Such salts may be formed by conventional means, for example by reaction of free compound with one or more equivalents of an appropriate acid or base, optionally in a solvent, or in a medium in which the salt is Insoluble, followed by removal of said solvent, or said medium, using standard techniques (e.g. in vacuo, by freeze-drying or by filtration). Salts may also be prepared by exchanging a counter-ion of active ingredient in the form of a salt with another counter-ion, for example using a suitable ion exchange resin.
• Preferred salts of C21 include acid addition salts, such as HCl salts, alkaline earth salts, such as magnesium and calcium salts, and alkali metal salts, such as potassium or, preferably, sodium salts.
• C21 and salts thereof may possess biological activity as such, certain pbarmaeeuticaily-acceptable (e.g. 'protected') derivatives of C21 may exist or be prepared which may not possess such activity, but may be administered and thereafter be metabolised in the body to form C21.
• Such compounds (which may possess some biological activity, provided that such activity is appreciably lower than that of C21) may therefore be described as 'precursors' or 'prodrugs' of C21.
• references to precursors or prodrugs will include compounds that form C21, in an experimentally-detectabie amount, within a predetermined time, following administration, AM precursors and prodrugs of C21 are included within the scope of the invention.
• a method of medical treatment of respiratory virus-induced tissue damage as hereinbefore defined, which method comprises administering C21 or a pharmaceutically- acceptable salt thereof to a subject in need of such treatment.
• 'Subjects' include avian and, especially, mammalian (particularly human) subjects and/or patients
• Human patients include both adult patients as well as paedeatric patients, the latter including patients up to about 24 months of age, patients between about 2 to about 12 years of age, and patients between about 12 to about 16 years of age. Patients older than about 16 years of age may be considered adults for purposes of the present invention.
• These different patient populations may be given different doses of C21, or salt thereof.
• C21 or a pharmaceutically- acceptable salt thereof is administered to adult patients/subjects, more particularly subjects that are over the age of about 20, such as over the age of about 30, including over the age of about 40, more preferably over the age of about 50, especially over the age of about 60, particularly over the age of about 70, and more particularly over the age of about 80, It is further preferred that C21 or a pharmaceutically-acceptabie salt thereof is administered to patients/subjects (whether or not such subjects are in one of the age groups specified above) with one or more of the following underlying medical conditions:
• chronic (long-term) respiratory diseases such as pulmonary fibrosis, pulmonary hypertension, pulmonary arteriai hypertension, asthma, chronic obstructive pulmonary disease (CORD), emphysema or bronchitis
• chronic cardiovascular (e.g, heart) disease such as heart failure, atrial fibrillation or hypertension
• ⁇ chronic liver disease such as hepatitis
• chronic neurological conditions such as Parkinson's disease, motor neurone disease, multipie sclerosis, a learning disability or cerebral palsy
• spleen for example, sickle cell disease or if the spleen has been removed ⁇ a weakened immune system as the result of conditions, such as HIV and AIDS, or medicines such as steroid tablets or chemotherapy
• obesity e.g. a body mass index (BMI) of 40 or above
• pregnancy e.g. a pregnancy
• C21 has a broad range of activity against respiratory virus infections, respiratory virus-induced cell and/or tissue damage, respiratory virus diseases (and symptoms thereof) that may result from such damage, and/or the longer term physiological effects of such serious diseases, which may be induced, directly or indirectly, by the viral infection.
• a method of treatment and/or prevention of one or more the following conditions post-acute sequelae of e.g. SARS-CoV-2 Infection (PASC), such as what is known as ’long COVID', ’chronic COVID syndrome' (CCS) and/or ’long- haul COVID'; ⁇ acute kidney injury and/or chronic kidney disease;
• PASC SARS-CoV-2 Infection
• ⁇ respiratory diseases such as pulmonary fibrosis, pulmonary hypertension, mememonary arterial hypertension, asthma, chronic obstructive mememonary disease (CORD), emphysema and/or bronchitis; and ⁇ cardiovascular diseases such as myocardial infarction, heart failure, atrial fibrillation, hypertension or thrombosis and/or embolization in e.g. the heart, iungs and/or brain, ail of which may be induced, directly or indirectly, by respiratory viruses (such as SARS-CoV-2), which method comprises administering C21 or a pharmaceuticaliy-acceptabie salt thereof to a subject in need of such treatment and/or prevention.
• respiratory viruses such as SARS-CoV-2
• C21 and pharmaceuticaliy-acceptable salts thereof may be administered iocaliy or systemically, for example orally, intravenously or intraarterially (including by intravascular and other perivascular devices/dosage forms (e.g. stents)), intramuscularly, cutaneously, subcutaneously, transmucosaily (e.g. sublingually or buccaiiy), rectally, intravaginally, transdermaily, nasally (including nasogastrically), pulmonarily (e.g. tracheally or bronchialiy) via e.g. inhalation as a dry powder via e.g.
• intravenously or intraarterially including by intravascular and other perivascular devices/dosage forms (e.g. stents)
• intramuscularly cutaneously, subcutaneously, transmucosaily (e.g. sublingually or buccaiiy)
• rectally intravaginally
• Treatment may thus be induced by systemic administration of C21 and pharmaceuticaliy-acceptabie salts thereof, for example by way of oral administration (e.g. as described hereinafter), by way of a parenteral route (e.g. by injection), or by way of mememonary administration, for example as described in international patent application WO 2020/095042 (PCT application number GB2019/053137).
• C21 and pharmaceuticaliy-acceptabie salts thereof include topical administration.
• absorption of compound of the invention into systemic circulation may occur, or the compound of the invention may act locally at the site of administration (e.g. the respiratory mucosa).
• Administration of C21/saits thereof via inhalation and/or, in particular, orally may be done conveniently in both hospitalized and non-hospitaiized patients (out-patients); in patients exhibiting either early (e,g. pre-symptomatic and/or mild symptomatic patients) and/or late (including more severe) stages of the relevant respiratory disease (including, in the case of peroral administration, before such patients are in need of mechanical ventilation); as well as when infection may be expected or is suspected (in a largely prophylactic manner).
• C21 and salts thereof nasogastrically or via nebuiization may also be useful in the case of administration of C21 during later stages of the respiratory disease, for example in patients requiring hospitalisation, supplemental oxygenation, and particularly in patients needing critical care, including mechanical ventilation and/or extra -corporeal membrane oxygenation.
• C21 and pharmaceutically-acceptable salts thereof will generally be administered in the form of one or more formulations in admixture with an (e.g. pharmaceutically-acceptable) adjuvant, diluent or carrier, which may be selected with due regard to the intended route of administration and standard pharmaceutical practice.
• Acceptable carriers may be chemically inert to the active compounds and may have limited (or preferably no) detrimental side effects or toxicity under the conditions of use. Such carriers may also impart an immediate, or a modified, release of the active ingredient.
• Suitable pharmaceutical formulations may be commercially available or may otherwise be prepared according to techniques that are described in the literature, for example, Remington The Science and Practice of Pharmacy, 22 nd edition, Pharmaceutical Press (2012) and Martindale - The Complete Drug Reference , 38 th Edition, Pharmaceutical Press (2014) and the documents referred to therein, the relevant disclosures in all of which documents are hereby incorporated by reference. Otherwise, the preparation of suitable formulations including C21 and pharmaceutically-acceptable salts thereof may be achieved non-inventively by the skilled person using routine techniques.
• composition comprising C21 or a pharmaceutically-acceptable salt thereof, along with one or more pharmaceutically-acceptable exdpient(s), such as an adjuvant, diluent or carrier which composition is packaged and presented for use in a method of treatment of respiratory virus-induced tissue damage.
• exdpient(s) such as an adjuvant, diluent or carrier
• Administration of active ingredients may be continuous or intermittent.
• the mode of administration may also be determined by the timing and frequency of administration, but is also dependent on the severity of that condition, or otherwise on the need for treatment.
• the amount of active ingredient in a formuiation will depend, and/or may be selected depending, upon the severity of the respiratory virus-induced tissue damage, or the expectation of such severity, as well as on the subject to be treated, but may be determined by the skilled person.
• doses of C21 or salt thereof may be administered between once and four times (e.g, between 1 and 3 times) daily for up to three (e.g. two) months, such as one month, including up to three weeks, e.g, up to one week, such as 4 days or 3 days.
• Such treatment periods may be repeated as appropriate.
• treatment with C21 or salt thereof may, in addition to and/or instead of the above-mentioned acute dosing regimens, be continuous and/or as needed/required.
• Suitable oral daily doses (calculated as the free base) of C21 in adult subjects may be up to about 600 mg, including about 400 mg and about 200 mg (e.g, about 100 mg), and no lower than about 50 mg,
• the dose administered to a mammal, particuiariy a human, in the context of the present invention should be sufficient to effect a response in the subject over a reasonable timeframe (e.g. as described herein).
• a reasonable timeframe e.g. as described herein.
• the selection of the exact dose and composition and the most appropriate delivery regimen will also be influenced by inter alia the pharmacological properties of the formulation, the physical condition of the recipient, including the age, condition, body weight, sex and response of the subject to be treated, and also the nature, stage and/or severity of the disease, and genetic differences between subjects.
• C21 and salts thereof may also be combined with one or more therapeutic agents that are useful in the treatment of patients with viral infections and/or the symptoms of diseases caused thereby.
• Therapeutic agents that may be used in conjunction with C21 in accordance with the Invention include variously-applied standard treatments for viral infections, including antiviral medicines (e.g. oseitamivir, remdesivir, faviiavir, simeprevir, daclatasvir, sofosbuvir, ribavirin, umifenovir, iopinavir, ritonavir, lopinavir/ritonavir (Kaletra; AbbVie GmbH Co.
• antiviral medicines e.g. oseitamivir, remdesivir, faviiavir, simeprevir, daclatasvir, sofosbuvir, ribavirin, umifenovir, iopinavir, ritonavir, lopinavir/ritonavir (Kaletra; AbbVie Kunststoff GmbH Co.
• TMPRSS2 inhibitor camostat and camostat mesylate, Actembra (Roche), TZLS-501, AT-100 (rhSP-D), OYA1 (QyaGen9), BPI-Q02 (BeyondSpring), NP-120 (Ifenprodii; Algernon Pharmaceuticals), Gaiidesivir (Biocryst Pharma), REGN3Q48-3051 and Kevzara (SNG001; Synairgen Research), antiinflammatory agents (e.g.
• NSAIDs such as ibuprofen, ketorolac, naproxen, and the like
• colchicine as well as chloroquine, hydroxychloroquine, interferons (e.g. interferon beta, interferon beta-la), tociiizumab (Acterma),lenaiidomide, pomalidomide and thalidomide), analgesics (e.g, paracetamol or opioids), antitusslve agents (e.g, dextromethorphan), vaccinations (e.g. INO- 4800by Inovio Pharmaceuticals and Beijing Advaccine Biotechnology, if available), antibody therapies (e.g.
• LY-CoV555/LY-CoV016 (bamlanivimab and etesevimab), LY-CoV555 (bamlanivimab, Eli Lilly), REGN-COV2 (casirivimab and imdevimab), REGN3048-3051, TZLS-501, SNG001 (Synairgen), ecuiizumab (Soiiris; Alexion Pharmaceuticals), ravulizumab (Ultomiris; Alexion Pharmaceuticals), ienzilumab, ieroniimab, tociiizumab (Actemra; Roche), sariiumab (Kevzara; Regeneron Pharma), and Octagam (Qctapharma)), and/or passive antibody therapy with antibodies from blood of people who have recovered from infection with SARS-CoV or SARS-CoV-2, including COVID-19 convalescent plasma (CCP).
• CCP convalescent plasma
• anti-fibrotics e.g. nintedanib and, particularly, pirfenidone
• vitamins e.g. vitamin B, C and D
• mucolytics such as acetylcysteine and ambroxol.
• corticosteroids include both naturally-occurring corticosteroids and synthetic corticosteroids.
• Naturally-occurring corticosteroids that may be mentioned include cortisol (hydrocortisone), aldosterone, corticosterone, cortisone, pregnenolone, progesterone, as well as naturally-occurring precursors and intermediates in corticosteroid biosynthesis, and other derivatives of naturally-occurring corticosteroids, such as 11-deoxycortisol, 21-deoxycortisol, 11- dehydrocorticosterone, 11-deoxycorticosterone, 18-hydroxy-11- deoxycorticosterone, 18-bydroxycorticosterone, 21 ⁇ deoxycortisone, 11b- hydroxypregnenolone, 11 ⁇ ,17a,21-trihydroxypregnenolone, 17a, 21- dihydroxypregnenolone, 17a-hydroxypregnenolone, 21-hydroxypregnenolone, 11-ketoprogesterone, 11 ⁇ -hydroxyprogesterone, 17a-
• Synthetic corticosteroids that may be mentioned include those of the hydrocortisone-type (Group A), such as cortisone acetate, hydrocortisone aceponate, hydrocortisone acetate, hydrocortisone buteprate, hydrocortisone butyrate, hydrocortisone valerate, tixocortol and tixocortoi pivalate, prednisolone, methylprednisolone, prednisone, chloroprednisone, cloprednoi, difluprednate, fludrocortisone, fluocinolone, fluperoione, fluprednisolone, loteprednol, prednicarbate and triamcinolone; acetonides and related substances (Group B), such as amcinonide, budesonide, desonide, fluocinolone cetonide, fiuocinonide, halcinonide, triamcinolone aceton
• Preferred corticosteroids include cortisone, prednisone, prednisolone, methylprednisolone and, especially, dexamethasone.
• therapeutic agents that may be used in conjunction with C21 or salts thereof include H2 receptor blockers, anticoagulants, anti-platelet drugs, as well as statins, antimicrobial agents and anti-allergic/anti-asthmatic drugs.
• H2 receptor blockers that may be mentioned include famotidine.
• Anticoagulants that may be mentioned include heparin and low-molecular-weight heparins (e.g. bemiparin, nadroparin, reviparin, enoxaparin, parnaparin, certoparin, dalteparin, tinzaparin); directly acting oral anticoagulants (e.g.
• coumarin type vitamin K antagonists e.g. coumarin, acenocoumarol, phenprocoumon, atromentin and phenindione
• synthetic pentasaccharide inhibitors of factor Xa e.g. fondaparinux, idraparinux and idrablotaparinux
• Anti-plateiet drugs include irreversible cyclooxygenase inhibitors (e.g, aspirin and triflusal); adenosine diphosphate receptor inhibitors (e.g. cangreior, ciopidogrei, prasugrel, ticagrelor and tidopidine); phosphodiesterase inhibitors (e.g. ciiostazol); protease-activated receptor- 1 antagonists (e.g. vorapaxar); glycoprotein IIB/IIIA inhibitors (e.g. abciximab, eptifibatide and tirofiban); adenosine reuptake inhibitors (e.g.
• irreversible cyclooxygenase inhibitors e.g, aspirin and triflusal
• adenosine diphosphate receptor inhibitors e.g. cangreior, ciopidogrei, prasugrel, ticagrelor and tido
• thromboxane Inhibitors e.g. terutroban, ramatroban, seratrodast and picotamide.
• Statins that may be mentioned include atorvastatin, simvastatin and rosuvastatin.
• Antimicrobial agents include azithromycin, ceftriaxone, cefuroxime, doxycyciine, fiuconazoie, piperacillin, tazobactam and teicoplanin.
• Anti-allergic/anti-asthmatic drugs that may be mentioned include chlorphenamine, ievocetirizine and montelukast.
• C21 and salts thereof may also be used in conjunction with anti-hypertensive drugs, such as ARBs (e.g. azilsartan, candesartan, eprosartan, irbesartan, iosartan, oimesartan, telmisartan and valsartan) and ACE inhibitors (e.g.
• ARBs e.g. azilsartan, candesartan, eprosartan, irbesartan, iosartan, oimesartan, telmisartan and valsartan
• ACE inhibitors e.g.
• Subjects may be (and/or may be already) receiving one or more of any of the other therapeutic agents mentioned above, by which we mean receiving a prescribed dose of one or more of those other therapeutic agents, prior to, in addition to, and/or following, treatment with C21/salt.
• the active Ingredients may be administered together in the same formulation, or administered separately (simultaneously or sequentially) in different formulations,
• Such combination products provide for the administration of C21/sait in conjunction with the other therapeutic agent, and may thus be presented either as separate formulations, wherein at least one of those formulations comprises C21/salt, and at least one comprises the other therapeutic agent, or may be presented (i.e. formulated) as a combined preparation (i.e. presented as a single formulation including C21/salt and the other therapeutic agent).
• a pharmaceutical formulation including C21 or a pharmaceutically- acceptable salt thereof; a therapeutic agent that is useful in the treatment of a viral infection; and a pharmaceutically-acceptable adjuvant, diluent or carrier (which formulation is hereinafter referred to as a 'combined preparation'); and
• (B) a pharmaceutical formulation including a therapeutic agent that is useful in the treatment of a viral infection, in admixture with a pharmaceutically-acceptable adjuvant, diluent or carrier, which components (A) and (B) are each provided in a form that is suitable for administration in conjunction with the other.
• Such combined preparations and kits of parts may thus be used in the treatment of respiratory virus-induced tissue damage.
• such additional therapeutic agents including some of those that are useful in the treatment of a viral infection, may be termed 'standard of care' in relation to a particular respiratory viral condition.
• the term 'standard of care' will be understood by the skilled person to include a treatment processes that a clinician should, and/or Is expected to, follow for certain types of patients, illnesses and/or clinical circumstances.
• standard of care may change and/or develop over time.
• a method of making a kit of parts as defined above which method comprises bringing component (A), as defined above, into association with a component (B), as defined above, thus rendering the two components suitable for administration in conjunction with each other.
• components (A) and (B) of the kit of pails may be:
• kit of parts comprising:
• kits of parts described herein may comprise more than one formulation including an appropriate quantity/dose of C21/salt, and/or more than one formulation including an appropriate quantity/dose of the other therapeutic agent, in order to provide for repeat dosing. If more than one formulation (comprising either active compound) is present, such formulations may be the same, or may be different in terms of the dose of either compound, chemical composition(s) and/or physical form(s).
• kits of parts as described herein by 'administration in conjunction with', we include that respective formulations comprising a C21/salt and other therapeutic agent are administered, sequentially, separately and/or simultaneously, over the course of treatment of the condition.
• the term 'in conjunction with' includes that one or other of the two formulations may be administered (optionally repeatedly) prior to, after, and/or at the same time as, administration of the other component.
• a process for the preparation of a combined preparation as hereinbefore defined comprises bringing into association C21 or a pharmaceutically-acceptabie salt thereof, a therapeutic agent that is useful in the treatment of a viral infection, and at least one pharmaceutically-acceptabie excipient.
• the word 'about' is employed herein, for example in the context of numbers or amounts, such as concentrations and/or doses of active ingredients, ages, etc., it will be appreciated that such variables are approximate and as such may vary by ⁇ 10%, for example ⁇ 5% and preferably ⁇ 2% (e.g. ⁇ 1%) from the numbers specified herein.
• the term 'about 10% means e.g. ⁇ 10% about the number 10, i.e. between 9% and 11%.
• C21 has the advantage that it is more effective, has considerably less side effects, and/or is much safer, than current treatments of respiratory viral infections, and the (e.g. serious) diseases that are or may be caused thereby, such as those mentioned hereinbefore.
• the uses and methods described herein may also have the advantage that, in the treatment of respiratory virus-induced tissue damage, they may be more convenient for the subject than, be more efficacious than, be less toxic than, have a broader range of activity than, be more potent than, produce fewer side effects than, or that they may have other useful pharmacological properties over, similar methods (treatments) known in the prior art, whether for use in the treatment of respiratory virus-induced tissue damage, viral infections and/or virai diseases generally, or otherwise.
• Figure 1 shows the need for supplemental oxygen over time in a clinical trial conducted in COVID-19 patients that received either placebo or 100 mg C21 orally b.i.d over 7 days.
• E-cadherin is a calcium-dependent epithelial cell adhesion molecule and has been suggested to contribute to disease progression (Gabrowska and Day, Front. Biosci. (Landmark Ed.), 17, 1948 (2014)), and also to play a critical role In viral infection at the level of host ceil binding and viral entry into ceils (see Hu et al, Front. Cell. Infect.
• Other relevant/equivalent cell types including alveolar epithelial type II (ATI I) ceils
• ATI I alveolar epithelial type II ceils
• the cells Prior to and/or during exposure of ceils to different amounts of virus, the cells are incubated with different concentration (e.g, from 0.1 nM to 1 mM) of C21 for different periods of time.
• PCLuS Precision Cut Lung Slices from explanted diseased (with idiopathic pulmonary fibrosis) human lung tissue were used.
• PCLuS were prepared from expianted human lung tissue collected at the time of lung transplantation, PCLuS were rested for 48 hours to allow the post-slicing stress period to elapse before experiments begin.
• PCLuS were cultured in the presence or absence of 10 ⁇ M of the Alk5 inhibitor SB-525334 (Sigma, #58822), a potent activin receptor-like kinase (ALK5)/ type I TGF ⁇ -receptor kinase inhibitor.
• PCLuS pro-fibrotic growth factor transforming growth factor- ⁇ 1
• TGF- ⁇ 1 pro-fibrotic growth factor- ⁇ 1
• the key objectives/endpoints of the study are to evaluate the safety and efficacy of C21 in participants with infection with SARS-CoV-2 virus.
• Evaluation of efficacy of C21 is determined by determining inter alia:
• ⁇ improvement in signs, symptoms, quality of life, manifestations and/or complications related to the disease including fever, pulmonary and/or cardiac function, blood oxygen tension/hypoxia, cough, shortness of breath, multiple organ dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS), secondary pneumonia by other microorganisms and/or patient and/or clinician reported quality of life (QoL) outcome measures; ⁇ duration of hospital stay; ⁇ need for invasive and/or non-invasive ventilation; ⁇ surrogate markers of Inflammation, Immune response and/or infection, including radiography, ultra-sound, magnetic resonance Imaging (MRI), computed tomography (CT) and/or other imaging modalities; composite measures and/or ordinal scales that determine disease severity, for example time to clinical recovery and/or sequential organ failure assessment score (SOFA score); viral titers and/or seroconversion; morbidity and/or mortality; and/or effects on relevant biomarkers, Including those of epithelial damage/dysfunction (including MMP7, GDF15, CA125
• Subjects for inclusion in the trial are those diagnosed with SARS-CoV-2 infection confirmed by polymerase chain reaction (PCR) test (or another releva nt/equiva lent test for this purpose), subjects that have been exposed to SARS-COV-2, and/or symptomatic subjects that are suspected to have a SARS- CoV-2 infection.
• PCR polymerase chain reaction
• exclusion criteria are defined in detail by the sponsor together with the investigators, and may include subjects that inter alia:
• ⁇ have a BMI of >32 or ⁇ 18;
• ⁇ have a concurrent respiratory disease such as asthma, COPD or an interstitial lung disease;
• ⁇ have used medications known to chronically alter drug absorption or elimination processes within 30 days before the first dose administration; ⁇ have participated in a clinical study involving administration of an investigational drug or a marketed drug within the past 3 months; ⁇ have ailments that, in the opinion of the investigator, would Interfere with the evaluation of the results or constitute a health risk for the study subject; ⁇ have serum hepatitis or are carriers of the hepatitis B surface antigen (HBsAg) or hepatitis C antibody; ⁇ have had positive result to the test for HIV antigens and/or antibodies; ⁇ are current or previous ( ⁇ 6 months) smokers; ⁇ have a susceptibility to severe allergic reactions; ⁇ have donated blood or suffered a loss of a significant amount of blood within 2 months prior to the first study treatment administration; ⁇ have had a positive urine drug screen result at screening or randomly thereafter;
• HBsAg hepatitis B surface antigen
• ⁇ have had positive result to the test for HIV antigens and/or antibodies
• ⁇ are pregnant women, or are women with childbearing potential not using regular contraceptives
• ⁇ are men that are unwilling to use a condom for contraception when having sexual intercourse with a fertile woman, during the entire study and at least for 7 days after the last IMP intake.
• Subjects are also asked to abstain from drinking alcoholic beverages for 12 hours before screening and during the study.
• CYP3A4 inducers e.g, rifampicin, phenytoin, St John's Wort
• CYP3A4 inhibitors e.g, clarithromycin, ketoconazoie, nefazodone, itraconazole, ritonavir
• medicines that are substrates of CYP1A2, CYP3A4 or CYP2C9 with a narrow therapeutic range
• ⁇ BCRP sensitive substrates e.g. sulphasalazine, rosuvastatin
• the safety and efficacy of C21 is determined by conducting early access to C21 on a compassionate-use basis such as a named (individual) patient program and/or an early access program on a cohort basis.
• the primary objective of the study was to investigate the efficacy of C21 200 mg daily dose (100 mg b.i.d.) on COVID-19 infection not requiring mechanical invasive or non-invasive ventilation.
• the secondary objectives were to evaluate the effect on inflammation and the safety profile of C21 at the same daily dose. Exploratory objectives include the investigation of a range of laboratory parameters as potential biomarkers of inflammation and viral load, following oral administration of that daily dose.
• CRP C-reactive protein
• Exclusion criteria at the outset include one or more of the following:
• Concurrent respiratory disease such as chronic obstructive pulmonary disease, idiopathic pulmonary disease (IFF) and/or intermittent, persistent or more severe asthma requiring daily therapy or any subjects that have had an asthma flare requiring corticosteroids in the 4 weeks (28 days) prior to COVlD-19 diagnosis,
• IFF idiopathic pulmonary disease
• CYP 3A4 Treatment with any of the medications listed below within 1 week prior to Visit 1 : o strong Cytochrome p450 (CYP) 3A4 inducers (e.g, rifampicin, phenytoin, St, John's Wort, phenobarbital, rifabutin, carbamazepine, anti HIV drugs, barbituates); or o warfarin.
• CYP 3A4 e.g, rifampicin, phenytoin, St, John's Wort, phenobarbital, rifabutin, carbamazepine, anti HIV drugs, barbituates
• o warfarin e.g, rifampicin, phenytoin, St, John's Wort, phenobarbital, rifabutin, carbamazepine, anti HIV drugs, barbituates
• IMP was delivered as 50 mg capsules (HPMC hard capsules) with a final composition as set out in Table 1 below.
• Table 1 Capsules were packed in plastic container units with 28 capsules in each. Each unit contained either C21 or matching placebo (the same composition except that C21 was replaced with mannitol.
• IMP was stored separately from normal clinic stocks in a securely locked area only accessible to authorised trial personnel. Labeling of the IMP was in the relevant local language (English) and was done in compliance with GMP (GMP 2003) and local regulatory requirements,
• IMP was administered twice daily to the subjects for 7 days as follows: ⁇ Morning dose: Two 50 mg capsules (100 mg C21 or placebo) to be taken with a glass of water after minimum 2 hours fasting
• Concomitant medication was given if in accordance with local standards of care (which did develop and/or change during the course of the study as more was discovered and/or understood about the pathology of COVID-19).
• Subjects were not allowed to take the foliowing medications at least 1 week before Visit 1 and during the trial period: ⁇ strong CYP3A4 inducers (e.g. rifampidn, phenytoin, St. John's Wort, phenobarbital, rifabutin, carbamazepine, anti HIV drugs, barbituates)
• ⁇ strong CYP3A4 inducers e.g. rifampidn, phenytoin, St. John's Wort, phenobarbital, rifabutin, carbamazepine, anti HIV drugs, barbituates
• the patients were randomised to receive C21 (100 mg b.i.d., n ⁇ 51) or placebo (n ⁇ 55) for 7 days on top of standard of care.
• the treatment groups were well balanced in relation to age, sex and concomitant medications.
• Data from HRCT may provide further characterisation as to the long-term clinical effect of C21 (7 days treatment during the trial described in Example 6) in subjects with COVID- 19.
• Eligible subjects who provide written informed consent for the additional data to be collected are enrolled in this study. Beyond consenting, these subjects undergo no additional procedures or treatment as a result of being involved in this study.
• HRCT data are collected retrospectively by reviewing the subject's medical records. Any available HRCT recorded within 28 days before the Example 6 trial baseline visit, during the conduct of the trial and up to 24 weeks after completion of the trial is collected and assessed by a central, blinded HRCT reader.

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