Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P3/00—Drugs for disorders of the metabolism
  • A61P3/06—Antihyperlipidemics
• • 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
  • A61K31/715—Polysaccharides, i.e. having more than five saccharide radicals attached to each other by glycosidic linkages; Derivatives thereof, e.g. ethers, esters
  • A61K31/716—Glucans
  • A61K31/724—Cyclodextrins
• • 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

Definitions

• Familial hypercholesterolemia is a genetic disorder that belongs to the dyslipidemic diseases. FH can be segregated into the rare homozygous (HoFH; Prevalence 1:1,000,000) and the more frequent, heterozygous FH (HeFH; prevalence: 1:200-1:500). Heterozygous FH (HeFH) patients have an estimated prevalence approximately 1 in 500 individuals in Europe. In the United States, prevalence is 1:311 individuals, or over one million individuals. It should be noted that some of these estimates likely include individuals with polygenic hypercholesterolemia (patients without true FH) and that HeFH often goes unrecognized. FH increases the chance of atherosclerotic cardiovascular disease at an early age, therefore, strongly reducing life expectancy.
• HoFH rare homozygous
• HeFH Heterozygous FH
• the present disclosure provides a method of i) alleviating or reducing inflammation and/or oxidative stress induced by oxidized LDL, ii) reducing an amount (e.g., concentration) total cholesterol, iii) reducing accumulation of total LDL, iv) reducing an amount (e.g., concentration) of and/or a size (e.g., average size, maximum size) of, and/or changing the shape of circulating (e.g., blood, serum, plasma) cholesterol crystals (and/or clots comprising cholesterol crystals), or promoting renal (and/or) hepatogenic clearance of cholesterol (derivates) in an individual.
• circulating e.g., blood, serum, plasma
• cholesterol crystals and/or clots comprising cholesterol crystals
• the method comprises administering a therapeutically effective amount of cyclodextrin or a derivative thereof to the individual, thereby alleviating or reducing inflammation and/or oxidative stress induced by oxidized LDL, and/or reducing the amount of and/or size of, and/or changing the shape of circulating cholesterol crystals (and/or clots comprising cholesterol crystals) in the individual diagnosed with or suspected to have familial hypercholesterolemia, and/or promoting renal (and/or) hepatogenic clearance of cholesterol (derivates) in an individual.
• the size (e.g., average size, maximum size) of circulating (e.g., blood, serum, plasma) cholesterol crystals (and/or clots comprising cholesterol crystals) is reduced by at least about 10% (e.g., at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, or greater) relative to the size (e.g., average size, maximum size) of circulating (e.g., blood, serum, plasma) cholesterol crystals (and/or clots comprising cholesterol crystals) prior to treatment with the cyclodextrin or the derivative thereof.
• the cyclodextrin or derivative thereof comprises 2-hydroxypropyl-beta-cyclodextrin.
• the amount (e.g., concentration) of circulating (e.g., blood, serum, plasma) cholesterol crystals (and/or clots comprising cholesterol crystals) is reduced by at least about 10% (e.g., at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, or greater) relative to the amount (e.g., concentration) of circulating (e.g., blood, serum, plasma) cholesterol crystals (and/or clots comprising cholesterol crystals) prior to treatment with the cyclodextrin or the derivative thereof.
• the treatment reduces severity or a symptom of familial hypercholesterolemia in the individual or reduces the clinical manifestation of cardiovascular disease or incidence of major cardio-and cerebrovascular complications including, but not limited to, stroke, transient ischemic attack (TIA), angina, myocardial infarction, ischemic heart failure, claudication or gangrene.
• TIA transient ischemic attack
• angina myocardial infarction
• myocardial infarction ischemic heart failure
• claudication or gangrene gangrene.
• the treatment increases renal and/or hepatogenic clearance of cholesterol or cholesterol derivates in the individual by at least about 10% (e.g., at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, at least about 75%, at least about 100%, at least about 200%, at least about 300%, at least about 400%, at least about 500%, or greater) relative to the amount of cholesterol and/or cholesterol derivates cleared prior to the treatment.
• 10% e.g., at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, at least about 75%, at least about 100%, at least about 200%, at least about 300%, at least about 400%, at least about 500%, or greater
• the present disclosure also provides a method of treating familial hypercholesterolemia and/or one or more symptoms thereof in an individual, or treating an individual suspected to have familial hypercholesterolemia and/or one or more symptoms thereof.
• the method comprises administering a therapeutically effective amount of cyclodextrin, or derivative thereof (e.g., 2-hydroxypropyl-beta-cyclodextrin), to the individual, thereby treating the familial hypercholesterolemia and/or one or more symptoms thereof in the individual.
• the treating comprises reducing a size and/or an amount of circulating (e.g., blood, plasma, serum) cholesterol crystals (and/or clots comprising cholesterol crystals) in the subject.
• the size (e.g., average size, maximum size) of circulating (e.g., blood, serum, plasma) cholesterol crystals (and/or clots comprising cholesterol crystals) is reduced by at least about 10% (e.g., at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, or greater) relative to the size (e.g., average size, maximum size) of circulating (e.g., blood, serum, plasma) cholesterol crystals (and/or clots comprising cholesterol crystals) prior to treatment with the 2- hydroxypropyl-beta-cyclodextrin.
• the amount (e.g., concentration) of circulating (e.g., blood, serum, plasma) cholesterol crystals (and/or clots comprising cholesterol crystals) is reduced by at least about 10% (e.g., at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, or greater) relative to the amount (e.g., concentration) of circulating (e.g., blood, serum, plasma) cholesterol crystals (and/or clots comprising cholesterol crystals) prior to treatment with the 2-hydroxypropyl-beta-cyclodextrin.
• the treating results in a change in shape of circulating cholesterol crystals (and/or clots comprising cholesterol crystals). In some cases, the treating results in a decrease in inflammation (e.g., as measured by, e.g., cytokine protein and/or RNA levels) as compared to a level of inflammation prior to treatment with the 2- hydroxypropyl-beta-cyclodextrin. In some cases, the treating results in an improvement in dermatologic manifestations as compared to prior to treatment.
• the treatment reduces severity or a symptom of familial hypercholesterolemia in the individual or reduces the clinical manifestation of cardiovascular disease or incidence of major cardio-and cerebrovascular complications including, but not limited to, stroke, TIA, angina, myocardial infarction, ischemic heart failure, claudication or gangrene.
• the treatment increases renal and/or hepatogenic clearance of cholesterol or cholesterol derivates in the individual by at least about 10% (e.g., at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, at least about 75%, at least about 100%, at least about 200%, at least about 300%, at least about 400%, at least about 500%, or greater) relative to the amount of cholesterol and/or cholesterol derivates cleared prior to the treatment.
• 10% e.g., at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, at least about 75%, at least about 100%, at least about 200%, at least about 300%, at least about 400%, at least about 500%, or greater
• therapeutically effective amount is from about 50 mg/kg to about 8,000 mg/kg. In any one of the preceding aspects, the therapeutically effective amount is from about 4 g to about 250 g. In any one of the preceding aspects, the therapeutically effective amount is an amount sufficient to achieve a serum, plasma, and/or whole blood concentration of 2-hydroxypropyl-beta-cyclodextrin of about 0.01 mM to about 5 mM.
• the 2-hydroxypropyl-beta-cyclodextrin is selected from the group consisting of: Kleptose ® HP Parenteral Grade, Kleptose ® HPB Parenteral Grade, Kleptose ® HPB-LB Parenteral Grade, Cavitron ® W7 HP5 Pharma cyclodextrin, Cavitron ® W7 HP7 Pharma cyclodextrin, Trappsol ® CycloTM, and VTS-270/adrabetadex.
• the subject has one or more risk factors for familial hypercholesterolemia.
• the one or more risk factors for FH is selected from the group consisting of family history of familial hypercholesterolemia, high level of LDL cholesterol in at least one of parents, a change in LDLR gene, ApoB gene, ApoE, SATP1, LDLRAPl/ARH or PCSK9 gene.
• the subject has one or more analytical lab results associated with familial hypercholesterolemia.
• the one or more analytical lab results associated with familial hypercholesterolemia is increased serum/plasma total cholesterol and/or increased low density lipoprotein (LDL).
• the individual is under 1, under 3, under 5 years old, or at least 5 (e.g., at least 10, at least 15, at least 20, at least 25, at least 30, at least 40) years old.
• the individual is a human.
• the administering further comprises: (i) administering, at a first time point, a therapeutically effective first dose of 2-hydroxypropyl-beta-cyclodextrin to the individual; and (ii) administering, at a second time point, a therapeutically effective second dose of 2- hydroxypropyl-beta-cyclodextrin to the individual.
• the second time point is at least 4 hours, at least 6 hours, at least 8 hours, at least 12 hours, at least 1 day, at least 2 days, at least 3 three days, at least 4 days, at least 5 days, at least 6 days, at least 1 week, at least 2 weeks, at least 3 weeks, or at least 4 weeks after the first time point.
• the administering further comprises administering every 3 days, every 7 days, every 10 days, every 14 days, every 21 days, every 28 days, every 2 months, every 3 months, every 6 months, every 12 months.
• the administering is by parenteral methods including intravenous, intravascular, intramuscular, subcutaneous, intrathecal, depot, peristaltic pump administration and/or in conjunction to plasmapheresis.
• the present disclosure also provides a method of reducing a complication related to familial hypercholesterolemia comprising administering a therapeutically effective amount of cyclodextrin or derivative thereof to the individual, thereby treating the familial hypercholesterolemia and/or one or more symptoms thereof in the individual.
• the complication comprises increased risk on progressive (accelerated or early onset) atherosclerotic disease including coronary artery (acute myocardial infarction (AMI), angina pectoris, ischemic heart failure), peripheral artery (claudication, gangrene, limb amputation), ischemic cerebrovascular disease (transient ischemic attack (TIA), cerebrovascular accidents (CVA)), renal failure, or high blood pressure (hypertension).
• AMI acute myocardial infarction
• TIA transient ischemic attack
• CVA cerebrovascular accidents
• the treating comprises reducing a size (e.g., average size, maximum size) of circulating (e.g., blood, plasma, serum) cholesterol crystals (and/or clots comprising cholesterol crystals) in the subject, reducing an amount (e.g., concentration) of circulating (e.g., blood, plasma, serum) cholesterol crystals (and/or clots comprising cholesterol crystals) in the subject, changing a shape of circulating (e.g., blood, plasma, serum) cholesterol crystals (and/or clots comprising cholesterol crystals) in the subject, reducing inflammation in the subject (e.g., as measured by, e.g., cytokine protein and/or RNA levels), promoting renal or hepatic clearance of cholesterol from circulation, improving dermatologic manifestations in the subject, and/or reducing incidence, severity or a symptom of stroke, TIA, angina, myocardial infarction, ischemic heart failure, claudication or gangrene.
• a size
• the cyclodextrin or derivative thereof comprises 2-hydroxypropyl-beta- cyclodextrin.
• the 2-hydroxypropyl-beta-cyclodextrin is selected from the group consisting of: Kleptose ® HP Parenteral Grade, Kleptose ® HPB Parenteral Grade, Kleptose ® HPB-LB Parenteral Grade, Cavitron ® W7 HP5 Pharma cyclodextrin, Cavitron ® W7 HP7 Pharma cyclodextrin, Trappsol ® CycloTM, and/or VTS-270/adrabetadex.
• cyclodextrin or derivative thereof comprises a complexed 2-hydroxypropyl-beta-cyclodextrin, and/or a cyclodextrin polymer.
• the therapeutically effective amount is from about 50 mg/kg to about 8,000 mg/kg. Alternatively and/or additionally, the therapeutically effective amount is from about 4 g to about 250 g. Alternatively and/or additionally, the therapeutically effective amount is an amount sufficient to achieve a serum, plasma, and/or whole blood concentration of 2-hydroxypropyl-beta-cyclodextrin of about 0.01 mM to about 5 mM.
• the administering further comprises: (i) administering, at a first time point, a therapeutically effective first dose of 2-hydroxypropyl-beta-cyclodextrin to the individual; and (ii) administering, at a second time point, a therapeutically effective second dose of 2-hydroxypropyl-beta-cyclodextrin to the individual.
• the administering further comprises administering every 3 days, every 7 days, every 10 days, every 14 days, every 21 days, every 28 days, every 2 months, every 3 months, every 6 months, every 12 months.
• the administering is by parenteral methods including intravenous, intravascular, intramuscular, subcutaneous, intrathecal, depot, peristaltic pump administration and/or in conjunction to plasmapheresis.
• the present disclosure also provides a method of i) reducing statins, cholesterol uptake inhibitors, or PCSK9 inhibitor treatment, or ii) reducing a frequency of or delaying plasmapheresis treatment to a subject diagnosed with or suspected to have familial hypercholesterolemia, comprising: administering a therapeutically effective amount of cyclodextrin or derivative thereof to the subject, thereby treating the familial hypercholesterolemia and/or one or more symptoms thereof in the subject.
• the cyclodextrin or derivative thereof comprises 2-hydroxypropyl-beta-cyclodextrin.
• the 2-hydroxypropyl-beta-cyclodextrin is selected from the group consisting of: Kleptose ® HP Parenteral Grade, Kleptose ® HPB Parenteral Grade, Kleptose ® HPB-LB Parenteral Grade, Cavitron ® W7 HP5 Pharma cyclodextrin, Cavitron ® W7 HP7 Pharma cyclodextrin, Trappsol ® CycloTM, and/or VTS-270/adrabetadex.
• the therapeutically effective amount is from about 50 mg/kg to about 8,000 mg/kg. Alternatively and/or additionally, the therapeutically effective amount is from about 4 g to about 250 g. Alternatively and/or additionally, the therapeutically effective amount is an amount sufficient to achieve a serum, plasma, and/or whole blood concentration of 2-hydroxypropyl-beta- cyclodextrin of about 0.01 mM to about 5 mM.
• the administering further comprises: (i) administering, at a first time point, a therapeutically effective first dose of 2-hydroxypropyl-beta-cyclodextrin to the individual; and (ii) administering, at a second time point, a therapeutically effective second dose of 2-hydroxypropyl-beta-cyclodextrin to the individual.
• the administering further comprises administering every 3 days, every 7 days, every 10 days, every 14 days, every 21 days, every 28 days, every 2 months, every 3 months, every 6 months, every 12 months.
• the administering is by intravenous administration and/or in conjunction to plasmapheresis.
• statin, cholesterol uptake inhibitors, or PCSK9 inhibitor treatment is reduced at least 30% compared to before administering the cyclodextrin or derivative thereof.
• the frequency of the plasmapheresis treatment is reduced at least 30% compared to before administering the cyclodextrin or derivative thereof.
• the plasmapheresis treatment is delayed at least 6 months.
• a pharmaceutical composition comprising: an amount of cyclodextrin or its derivative thereof (e.g., 2-hydroxypropyl-beta-cyclodextrin) effective alleviate or reduce inflammation and/or oxidative stress induced by oxidized LDL, promote renal and hepatogenic clearance of cholesterol and/or to reduce an amount of and/or a size of, and/or change a shape of circulating (e.g., blood, serum, plasma) cholesterol crystals (and/or clots comprising cholesterol crystals) in an individual diagnosed with or suspected to have familial hypercholesterolemia; and a pharmaceutically acceptable excipient.
• cyclodextrin or its derivative thereof e.g., 2-hydroxypropyl-beta-cyclodextrin
• a pharmaceutical composition comprising: an amount of cyclodextrin or its derivative thereof (e.g., 2-hydroxypropyl-beta-cyclodextrin) effective treat familial hypercholesterolemia and/or a symptom thereof, in an individual; and a pharmaceutically acceptable excipient.
• cyclodextrin or its derivative thereof e.g., 2-hydroxypropyl-beta-cyclodextrin
• the pharmaceutical composition is formulated for single dose or repeated administration. In any one of the preceding aspects, the pharmaceutical composition is formulated for parenteral methods of administration including intravenous, intravascular, intramuscular, subcutaneous, intrathecal, depot, peristaltic pump administration.
• FIG. 1A shows cholesterol crystal dissolution capacity of 2-hydroxypropyl-beta- cyclodextrin (HPBCD) in plasma sample of HoFH patients.
• FIG. IB shows mRNA expression level of ABCA1 in human peripheral whole blood sample obtained from HoFH patients.
• FIG. 1C shows mRNA expression level of SREBP2 in human peripheral whole blood sample obtained from HoFH patients.
• FIG. 2A and 2B show experimental design to evaluate the effect of 2-hydroxypropyl- beta-cyclodextrin (HPBCD) on liver weight in mouse model.
• HPBCD 2-hydroxypropyl- beta-cyclodextrin
• FIG. 3 shows that 2-hydroxypropyl-beta-cyclodextrin (HPBCD) inhibits increase of liver weight in HPBCD-treated mice as compared to untreated mice.
• HPBCD 2-hydroxypropyl-beta-cyclodextrin
• Familial hypercholesterolemia is mostly (80-90%) caused by a genetic defect in chromosome 19, which encodes for the LDL (low density lipoprotein) receptor that is responsible to bind and clean up LDL from the blood to lower or maintain LDL level.
• LDL low density lipoprotein
• Other causes are manifested by mutations in the gene encoding for major structure proteins of LDL, apolipoprotein B (ApoB), ARH/LDLRAP1, ApoE, STAP1 or within Pro-protein-Convertase Subtilisin/Kexin Type 9 (PCSK9), an enzyme responsible for the degradation of LDL receptor.
• LDL-C LDL cholesterol
• xanthomas fatty skin deposit over the hands, elbows, knees, ankles, and/or around the cornea of the eye
• xanthelasma fatty skin deposit over the hands, elbows, knees, ankles, and/or around the cornea of the eye
• HoFH Clinical presentation of HoFH include skin and tendon xanthomas, total cholesterol levels typically between 500 and 1,000 mg/dL, and childhood onset of symptomatic coronary disease, as well as aortic valve and proximal aortic root disease.
• skin and tendon xanthomas are seen by the age of 10, while in HeFH they can appear in young adulthood.
• Tendon xanthomas are present in more than 70% of patients with FH by age 40 to 50. It is important to note these xanthomas can easily be missed unless specifically sought. The result is early endothelial dysfunction with accelerated atherosclerosis as compared to the other dyslipidemias and, if untreated, to premature cardiovascular disease and death.
• life span is significantly shortened (e.g., premature death), as the disease already manifests in younger patients with signs of atherosclerotic disease, such as peripheral artery disease (PAD), coronary artery disease (CAD; myocardial infarction, angina pectoris and related post-infarct congestive heart failure) and cerebrovascular artery disease (stroke, TIA).
• PID peripheral artery disease
• CAD coronary artery disease
• stroke cerebrovascular artery disease
• Clinical presentation of heterozygous FH includes patients present with symptoms or signs of cardiovascular disease or adverse cardiovascular disease events at the age of 30-50 years. Many will be identified by an LDL typically greater than the 90th percentile for age and sex when the test was performed for cardiovascular risk screening.
• the duration and degree of LDL elevation is primarily responsible for the development of atherosclerotic cardiovascular disease (CVD) rather than the specific genetic defect(s) present.
• CVD atherosclerotic cardiovascular disease
• statins in combination with cholesterol uptake inhibitors, as first-line therapy.
• statin therapy does not reduce LDL-C levels to the same degree as adults (about 25 to 40% reduction from baseline depending on dose and potency) but initiation in childhood is imperative to maximizing patient outcomes.
• lipid transport Due to the defects in lipid transport, which is based on impaired (e.g., mutated ApoB) or insufficient (e.g., mutated LDL receptor) lipid transport, the overabundance of LDL and cholesterol accumulates, and attracts phagocytic immune cells such as macrophages, which take up the lipids and turn into foam cells.
• Foam cells are a hall mark of atherosclerotic disease (plaque foam cells) but also clinically manifest by local accumulations of lipid-laden foamy macrophage, i.e., in xanthomas.
• LDL is one major risk factor; it carries most of the cholesterol and can turn into highly inflammatory oxidation products (oxLDL, acLDL).
• Cholesterol-rich LDL particles are taken up by macrophages and comprise the major source for tilting macrophage lipid homeostasis and to turn them into foam cells. Besides overloading the macrophages' lipid storage pool capacity, once ingested LDL-cholesterol precipitates as crystalline cholesterol, which is known to induce local inflammation in the vascular wall.
• HPBCD 2-hydroxypropyl-beta-cyclodextrins
• an amount e.g., concentration
• reducing accumulation of total LDL reducing accumulation of total LDL
• improving the renal and/or hepatogenic clearance of cholesterol in an individual and/or reducing the amount of and/or the size of, and/or changing the shape of circulating (e.g., blood, plasma, serum) cholesterol crystals (and/or clots comprising cholesterol crystals) in an individual (e.g., a human).
• the methods involve treating familial hypercholesterolemia (e.g., by preventing the development and progression of atherosclerotic artery disease, including increase in atherosclerotic plaque lesion load, plaque destabilization, and potential plaque rupture leading to acute vascular occlusion).
• the methods involve treating symptom and/or a clinical manifestation of familial hypercholesterolemia.
• the methods involve treating ischemia to various organs and/or tissues caused by, e.g., familial hypercholesterolemia.
• the methods involve converting inflamed atherosclerotic plaques with a lipid core (vulnerable plaque, high cholesterol plaque) with a high incidence of plaque rupture, to a more fibrotic atherosclerotic plaque (low inflammation, low necrotic core) with a low incidence of plaque rupture (and cardiovascular complications).
• the methods involve improving quality of LDL particles and/or reducing/shielding the inflammatory properties of highly oxidized LDL.
• the methods provided herein involve administering a therapeutically effective amount of a cyclodextrin or derivative thereof to a subject in need thereof (e.g., a subject having elevated levels of circulating cholesterol crystals (and/or clots comprising cholesterol crystals)).
• a cyclodextrin derivative as used herein refers a chemically modified cyclodextrin molecule.
• a cyclodextrin derivative includes a cyclodextrin molecule in which at least one -OH group is substituted with a hydroxypropyl group.
• the cyclodextrin derivative is 2-hydroxypropyl-beta-cyclodextrin.
• the cyclodextrin derivative may be a mixture of two or more 2-hydroxypropyl- beta-cycloxtrin molecule fractions with varying degrees of substitution (with for example, hydroxypropyl groups).
• cyclodextrin or derivative thereof is able to reduce cholesterol crystals formation and promote CC resorption and dissolution, improve LDL cholesterol transport into the circulation, increase endogenous cholesterol metabolisms towards oxysterols (e.g., 24,-25-, 27-hydroxycholesterol; 24S-, 25-, 27-OHC) and the local; activation of LXR transcription factor-regulated genes, including genes encoding for the reverse cholesterol transporters ABCA1 and ABCG1, which will result in improved reverse cholesterol transport (RCT) and, improved cholesterol clearance, and thus, reduced atherosclerotic plaque burden and overall risk of atherosclerotic disease and its consequences.
• oxysterols e.g., 24,-25-, 27-hydroxycholesterol; 24S-, 25-, 27-OHC
• the term “about” a number refers to that number plus or minus 10% of that number.
• the term “about” a range refers to that range minus 10% of its lowest value and plus 10% of its greatest value.
• the terms “subject,” “individual”, and “patient” are used interchangeably. None of the terms are to be interpreted as requiring the supervision of a medical professional (e.g., a doctor, nurse, physician’s assistant, orderly, hospice worker).
• the subject may be any animal, including mammals (e.g., a human or non-human animal) and non mammals. In one embodiment, the subject is a human.
• the terms “treat,” “treating”, or “treatment,” and other grammatical equivalents include ameliorating or preventing the underlying causes of one or more symptoms of a disease or condition; alleviating, abating, or ameliorating one or more symptoms of a disease or condition; ameliorating, preventing, or reducing the appearance, severity, or frequency of one or more symptoms of a disease or condition; inhibiting the disease or condition, such as, for example, arresting the development of the disease or condition, relieving the disease or condition, causing regression of the disease or condition, relieving a condition caused by the disease or condition, or inhibiting the symptoms of the disease or condition either prophylactically and/or therapeutically.
• pharmaceutically acceptable denotes an attribute of a material which is useful in preparing a pharmaceutical composition that is generally safe, non-toxic, and neither biologically nor otherwise undesirable and is acceptable for veterinary as well as human pharmaceutical use.
• “Pharmaceutically acceptable” can refer to a material, such as a carrier, or diluent, which does not abrogate the biological activity or properties of the compound, and is relatively nontoxic, e.g., the material may be administered to an individual without causing undesirable biological effects or interacting in a deleterious manner with any of the components of the composition in which it is contained.
• “Pharmaceutically acceptable excipient” as used herein refers to any pharmaceutically acceptable ingredient in a pharmaceutical composition having no therapeutic activity and being non-toxic to the subject administered, such as disintegrators, binders, fillers, solvents, buffers, tonicity agents, stabilizers, antioxidants, surfactants, carriers, diluents, excipients, preservatives, or lubricants used in formulating pharmaceutical products.
• an “effective amount” or “therapeutically effective amount,” as used herein, refer to a sufficient amount of an agent or a compound being administered which relieves, to some extent, one or more of the symptoms of the disease or condition being treated, or reduces the underlying cause of the disease or condition being treated. In some aspects, the result is a reduction and/or alleviation of the signs, symptoms, or causes of a disease, or any other desired alteration of a biological system.
• an “effective amount” for therapeutic uses is the amount of the composition including a compound as disclosed herein required to provide a clinically significant decrease in disease symptoms or underlying cause of the disease (e.g., without undue adverse side effects).
• an appropriate “effective amount” in any individual case is determined using techniques, such as a dose escalation study.
• the term “therapeutically effective amount” includes, for example, a prophylactically effective amount.
• An “effective amount” of a compound disclosed herein may be an amount effective to achieve a desired effect or therapeutic improvement (e.g., without undue adverse side effects).
• An “effective amount” of a compound disclosed herein may be an amount effective to achieve one or more desired outcomes.
• an effective amount” or “a therapeutically effective amount” varies from subject to subject, due to variation in metabolism of the composition, age, weight, general condition of the subject, concomitant medications the subject may be taking, the condition being treated, the severity of the condition being treated, and the judgment of the prescribing physician.
• the disease or condition being treated is familial hypercholesterolemia.
• the disease or condition being treated is homozygous familial hypercholesterolemia.
• the disease or condition being treated is heterozygous familial hypercholesterolemia.
• the disease or condition being treated is a disease or condition associated with or caused by familial hypercholesterolemia.
• Methods of treating familial hypercholesterolemia and symptoms thereof are methods for treating a subject having, suspected of having, familial hypercholesterolemia or a symptom and/or clinical manifestation thereof (e.g., by alleviating or reducing inflammation and/or oxidative stress induced by (oxidized) LDL (e.g., oxysterol, etc.), and/or by reducing an amount and/or size of circulating cholesterol crystals (and/or clots comprising cholesterol crystals), and/or changing a shape of circulating cholesterol crystals (and/or clots comprising cholesterol crystals), and/or reducing LDL amount or level and/or promoting renal or hepatogenic cholesterol clearance).
• LDL e.g., oxysterol, etc.
• the symptom and/or clinical manifestation thereof is one or more cutaneous manifestations of familial hypercholesterolemia.
• the one or more cutaneous manifestations of familial hypercholesterolemia include, without limitation, fatty skin deposit (xanthomas) over the hands, elbows, knees, ankles, and/or around the cornea of the eye, cholesterol deposits in the eyelids (Xanthelasma).
• Clinical presentation of HoFH may include skin and tendon xanthomas, total cholesterol levels between 500 and 1,000 mg/dL, LDL levels of >500 mg/dl, and childhood onset of symptomatic coronary artery disease, as well as aortic valve and proximal aortic root disease, peripheral artery disease (PAD; including claudication, gangrene), and higher incidence of having cardiovascular artery disease (CAD), and consequently myocardial infarction, angina and congestive ischemic heart failure (MI) and/or cerebrovascular disease including TIA and stroke.
• skin and tendon xanthomas are seen by age 10, while in HeFH they can appear in young adulthood.
• Tendon xanthomas are present in more than 70% of patients with FH by age 40 to 50.
• Clinical presentation of HeFH include patients present with symptoms or signs of cardiovascular disease or adverse cardiovascular disease events at the age of 30-50 years. Many can be identified by an LDL-C greater than the 90th percentile for age and sex when the test was performed for cardiovascular risk screening.
• treating a subject as described herein alleviates or reduces inflammation and/or oxidative stress induced by oxidized LDL (e.g., oxysterol, etc.).
• Familial hypercholesterolemia is often associated with defective LDL receptor (LDLR), and/or with mutation in the gene encoding for the LDL receptor, ApoB, ARH/LDLRAPl, STAPl, ApoE or PCSK9.
• LDLR mutated variant or LDLR Adaptor Proteinl mutated
• the amount and/or level of LDL increases in the extracellular space, subjected to oxidation.
• Such oxidized LDL can be taken up by scavenger receptors (e.g., CD36), resulting in an inflammatory cell uptake (other than LDLR), cellular inflammation by activating NFkB pathway and subsequent expression of proinflammatory genes or proteins via CD36-mediated signaling pathway, deposition of cholesterol crystal leading to activation of NLRP3 inflammasomes, induction of oxidative stress (e.g., C/EBP homologous protein-mediated ER stress), etc.
• scavenger receptors e.g., CD36
• treatment a subject can alleviate and/or reduce such consequences by inducing or facilitating anti-inflammatory signaling cascades via liver X receptor (LXR)-induced ATP binding cassette transporter (ABC)-mediated reverse cholesterol transport (RCT), and/or reduction of intracellular cholesterol crystal deposition.
• LXR liver X receptor
• ABSC ATP binding cassette transporter
• RCT reverse cholesterol transport
• intracellular cholesterol crystal deposition a subject affected by mutated LDL (ApoB)
• treating a subject can alleviate and/or reduce such consequences by increasing/inducing/facilitating of cholesterol crystal loading and/or transport of LDL.
• treating a subject as described herein reduces the size (e.g., average size, maximum size) of circulating (e.g., blood, plasma, serum) cholesterol crystals (and/or clots comprising cholesterol crystals) in the subject.
• size e.g., average size, maximum size
• circulating e.g., blood, plasma, serum
• cholesterol crystals and/or clots comprising cholesterol crystals
• the size (e.g., average size, maximum size) of circulating (e.g., blood, serum, plasma) cholesterol crystals (and/or clots comprising cholesterol crystals) is reduced by at least about 10% (e.g., at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, or greater) relative to the size (e.g., average size, maximum size) of circulating (e.g., blood, serum, plasma) cholesterol crystals (and/or clots comprising cholesterol crystals) prior to treatment with the 2-hydroxypropyl-beta-cyclodextrin.
• treating a subject as described herein reduces an amount (e.g., concentration) of circulating (e.g., blood, plasma, serum) cholesterol crystals (and/or clots comprising cholesterol crystals) in the subject.
• the amount (e.g., concentration) of circulating (e.g., blood, serum, plasma) cholesterol crystals (and/or clots comprising cholesterol crystals) is reduced by at least about 10% (e.g., at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, or greater) relative to the amount (e.g., concentration) of circulating (e.g., blood, serum, plasma) cholesterol crystals (and/or clots comprising cholesterol crystals) prior to treatment with the 2-hydroxypropyl-beta-cyclodextrin.
• treating a subject as described herein leads to dissolution of circulating (e.g., blood, plasma, serum) cholesterol crystals (and/or clots comprising cholesterol crystals) in the subject.
• treating a subject as described herein results in a change in shape of circulating cholesterol crystals (and/or clots comprising cholesterol crystals).
• the amount (e.g., concentration) of cholesterol (and/ or cholesterol derivates) in urine and/or stool is increased by at least about 10% (e.g., at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, at least about 75%, at least about 100%, at least about 200%, or greater, relative to the amount (e.g., concentration) of cholesterol secreted prior to treatment with the 2-hydroxypropyl-beta-cyclodextrin.
• the amount (e.g., concentration) of cholesterol (and/ or cholesterol derivates) in urine and/or stool is increased by at least about 10% (e.g., at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, at least about 75%, at least about 100%, at least about 200%, or greater, relative to the amount (e.g.
• reducing the number and/or size, and/or changing the shape of circulating cholesterol crystals (and/or clots comprising cholesterol crystals) and /or promoting cholesterol clearance in the subject ameliorates or reduces the severity or symptoms of familial hypercholesterolemia in the subject.
• the treatment reduces severity or a symptom of familial hypercholesterolemia in the individual or reduces the clinical manifestation of cardiovascular disease or incidence of major cardio-and cerebrovascular complications including, but not limited to, stroke, TIA, angina pectoris, myocardial infarction, ischemic heart failure, claudication (intermittens) or gangrene.
• reducing the number and/or size, and/or changing the shape of circulating cholesterol crystals (and/or clots comprising cholesterol crystals) in the subject ameliorates or reduces one or more symptoms and/or clinical manifestations of familial hypercholesterolemia in the subject.
• treating a subject as described herein results in a decrease in inflammation (e.g., as measured by, e.g., cytokine protein and/or RNA levels) as compared to a level of inflammation prior to treatment with the 2-hydroxypropyl-beta- cyclodextrin.
• treating a subject as described herein results in an improvement in dermatologic manifestations as compared to prior to treatment with the 2-hydroxypropyl-beta- cyclodextrin.
• treating a subject as described herein reduces the need of or dosage of other cholesterol -reducing agents or drugs to the subject.
• the cholesterol- reducing agents or drugs includes, but not limited to, statin (e.g., atorvastatin, Fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin, etc.), cholesterol uptake inhibitors (e.g., Ezetimibe) or PCSK9 inhibitor (PCSK9i, .e.g., Evolocumab, Alirocumab, etc.).
• treating the subject as described herein can eliminate the need of the treatment with statin, cholesterol uptake inhibitor (for instance Ezetimibe) or PCSK9i.
• treating the subject as described herein can reduce the dosage (e.g., size, amount, frequency, etc.) of the statin or PCSK9i treatment at least 5%, at least 10%, at least 20%, at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, at least 90%.
• treating the subject as described herein can decrease the amount of statin, cholesterol uptake inhibitors, or PCSK9i per treatment at least 5%, at least 10%, at least 20%, at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, at least 90%.
• treating the subject as described herein can decrease the frequency of statins, cholesterol uptake inhibitors or PCSK9i per treatment at least 5%, at least 10%, at least 20%, at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, at least 90%, e.g., from every day to every 3 day, from every day to every 5 days, from every day to every 7 days, from every 7 days to every 2 weeks, from every 2 weeks to every 4 weeks, from every 4 weeks to 6 weeks or more, etc.
• treating the subject as described herein maintains the effect of the treatment with statins, cholesterol uptake inhibitors, or PCSK9i to the subject at least at least 60%, at least 70%, at least 80%, at least 90%, or even increases the effect at least 5%, at least 10%, at least 20%, at least 30%, at least 40%, or at least 50%.
• treating the subject as described herein can decrease the frequency of or delaying plasmapheresis treatment to the subject diagnosed with or suspected to have familial hypercholesterolemia at least 5%, at least 10%, at least 20%, at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, at least 90%, e.g., from every day to every 3 day, from every day to every 5 days, from every day to every 7 days, from every 7 days to every 2 weeks, from every 2 weeks to every 4 weeks, from every 4 weeks to more than 6 weeks, etc.
• the methods involve administering a cyclodextrin to a subject (e.g., having, suspected of having, or at risk of developing familial hypercholesterolemia and/or one or more diseases or conditions associated therewith).
• Cyclodextrins are a family of cyclic oligosaccharides, consisting of a cyclic (e.g., macrocyclic) ring of glucose subunits joined by a- 1,4 glycosidic bonds. Cyclodextrins contain a number of glucose monomers in a ring formation.
• cyclodextrins include alpha-cyclodextrins (consisting of six glucose monomers), beta- cyclodextrins (consisting of seven glucose monomers), gamma-cyclodextrins (consisting of eight glucose monomers), and delta-cyclodextrins (consisting of nine glucose monomers).
• the outer portion of the ring structure is hydrophilic and the inner cavity of the ring structure is hydrophobic; thus, cyclodextrins generally are water soluble (e.g., due to the hydrophilic exterior), and capable of incorporating hydrophobic molecules in the cavity (e.g., due to the hydrophobic cavity).
• parent cyclodextrins have limited water solubility; therefore, several chemically modified cyclodextrins have been synthesized where the hydroxyl groups are substituted with other chemical moieties to, e.g., increase solubility.
• the methods provided herein involve administering a cyclodextrin to a subject (e.g., a human) in need thereof (e.g., having an elevated amount of circulating cholesterol crystals (and/or clots comprising cholesterol crystals); e.g., having, suspected of having familial hypercholesterolemia).
• the subject has, is suspected of having, or is at risk of developing circulating cholesterol crystals (and/or clots comprising cholesterol crystals) or elevated levels of circulating cholesterol crystals (and/or clots comprising cholesterol crystals) (e.g., after rupture of an atherosclerotic plaque).
• any atom of the cyclodextrins described herein e.g., 2-hydroxypropyl-beta-cyclodextrin
• any suitable isotope may be substituted with any suitable isotope.
• any one or more hydrogen atoms of the cyclodextrins described herein may be substituted or replaced with deuterium atoms.
• Such cyclodextrins are expected to have similar or improved properties as compared to the original cyclodextrin that does not contain deuterium.
• Deuterium is a safe, stable, non-radioactive isotope of hydrogen. Compared to hydrogen, deuterium forms stronger bonds with carbon. In some instances, the increased bond strength imparted by deuterium can positively impact properties of the cyclodextrins, creating the potential for improved drug efficacy, safety, and/or tolerability.
• deuteration may cause decreased metabolic clearance in vivo , thereby increasing the half-life and circulation of the compound.
• deuteration may cause decreased metabolic clearance in vivo , thereby increasing the half-life and circulation of the compound.
• the size and shape of deuterium are essentially identical to those of hydrogen, replacement of hydrogen by deuterium would not be expected to affect the biochemical potency and selectivity of the compound as compared to the original chemical entity that contains only hydrogen.
• the cyclodextrin is 2-hydroxypropyl-beta-cyclodextrin (HPBCD), also known as hydroxypropyl betadex and hydroxypropyl beta-cyclodextrin.
• HPBCD 2-hydroxypropyl-beta-cyclodextrin
• the 2-hydroxypropyl-beta-cyclodextrin is selected from the group consisting of: Kleptose ® HP Parenteral Grade (Roquette Freres, #346114; accessible at roquette.
• the cyclodextrin molecules or compositions comprising the cyclodextrin molecules described herein may comprise a b- cyclodextrin cavity.
• the b-cyclodextrin cavity may comprise a cavity consisting of seven 1.4-linked glucose units.
• one or more hydrogen atoms the cyclodextrins described herein may be substituted with a substituent.
• the substituent may be a 2-hydroxypropyl unit.
• the cyclodextrin molecules described herein may be characterized by average degree of substitution.
• degree of substitution or “DS” refers to the total number of substituents substituted directly or indirectly on a beta-cyclodextrin molecule.
• average degree of substitution or “average DS” refers to the total number of substituents in a population of beta- cyclodextrin molecules divided by the number of beta-cyclodextrin molecules.
• the average DS of the molecule is measured using Electron Spray Ionization-Mass Spectrometry (ESI-MS) analysis (e.g., HPLC-ESI-MS, etc.).
• ESI-MS Electron Spray Ionization-Mass Spectrometry
• average degree of substitution of the cyclodextrin molecules described herein is from 1 to 16, from 2 to 14, from 3 to 12, from 4 to 10, from 6 to 8.
• the average DS of the molecule is determined by peak heights of an electrospray MS spectrum. In some aspects, the average DS of the molecule is determined by multiplying the MS by 7.
• the cyclodextrin molecules or compositions provided herein contain a plurality of beta-cyclodextrin molecules having an average MS of at least about 0.3.
• the cyclodextrin molecules or compositions provided herein contain a plurality of beta-cyclodextrin molecules having an average MS of about 0.3 to 1.2.
• the (e.g., pharmaceutical) compositions provided herein contain a plurality of beta-cyclodextrin molecules having an average MS of 0.8 - 1.2.
• the cyclodextrin molecules described herein e.g., 2-hydroxypropyl-beta-cyclodextrin
• the cyclodextrin is a polymer.
• the cyclodextrin polymer is an a-cyclodextrin-based polymer, a b-cyclodextrin-based polymer, or a g- cyclodextrin-based polymer.
• a therapeutically effective amount of cyclodextrin or cyclodextrin derivative is administered to the subject (e.g., FH patients, HoFH patients, HeFH patients).
• administration of a therapeutically effective amount of 2-hydroxypropyl-beta-cyclodextrin increases a circulating and/or systemic level of one or more derivative of cholesterol as compared to a baseline in the subject before administering the 2-hydroxypropyl-beta-cyclodextrin.
• administration of a therapeutically effective amount of 2-hydroxypropyl-beta-cyclodextrin reduces the amount and/or size of the cholesterol crystals in the subject as compared to a baseline or before administering the 2-hydroxypropyl-beta-cyclodextrin.
• administration of a therapeutically effective amount of 2-hydroxypropyl-beta-cyclodextrin increase expression of ABCA1 gene at least 5%, at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, at least 90%, at least 100%, at least 200% in the subject as compared to a baseline before administering the 2-hydroxypropyl- beta-cyclodextrin.
• administration of a therapeutically effective amount of 2- hydroxypropyl-beta-cyclodextrin maintains lipid homeostasis in the subject.
• administration of a therapeutically effective amount of 2-hydroxypropyl-beta-cyclodextrin maintains SREBP2 gene expression differing by within about ⁇ 5%, within about ⁇ 10%, within about ⁇ 15%, within about ⁇ 20% in the subject as compared to a baseline before administering the 2-hydroxypropyl-beta-cyclodextrin.
• administration of a therapeutically effective amount of 2-hydroxypropyl-beta-cyclodextrin inhibits increase of liver weight of the subject by less than about 30%, about 25%, about 20%, about 15%, about 10%, or about 5% in the subject as compared to a baseline before administering the 2-hydroxypropyl-beta- cyclodextrin.
• administration of a therapeutically effective amount of 2- hydroxypropyl-beta-cyclodextrin maintains liver weight of the subject differing by within about ⁇ 5%, within about ⁇ 10%, within about ⁇ 15%, within about ⁇ 20% in the subject as compared to a baseline before administering the 2-hydroxypropyl-beta-cyclodextrin.
• administration of a therapeutically effective amount of 2-hydroxypropyl-beta-cyclodextrin reduces liver weight by at least about 0.5%, at least about 1%, at least about 5%, at least about 10%, at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40% in the subject as compared to a baseline before administering the 2-hydroxypropyl-beta-cyclodextrin.
• the one or more derivative of cholesterol is a by-product of cholesterol biosynthesis.
• the one or more derivative of cholesterol comprises a hydrogenated product, products with differently hydrogenated 1H- cyclopenta[a]phenanthren-3-ol products, or products formed with a hydroxyl, epoxyl, or keto group.
• the one or more derivative of cholesterol is an oxysterol or a sterol.
• the therapeutically effective amount of cyclodextrin or cyclodextrin derivative is an amount suitable to achieve the therapeutic effect described herein.
• the therapeutically effective amount is at least about 50 mg/kg, at least about 100 mg/kg, at least about 200 mg/kg, at least about 300 mg/kg, at least about 400 mg/kg, at least about 500 mg/kg, at least about 600 mg/kg, at least about 700 mg/kg, at least about 800 mg/kg, at least about 900 mg/kg, at least about 1000 mg/kg, at least about 1100 mg/kg, at least about 1200 mg/kg, at least about 1300 mg/kg, at least about 1400 mg/kg, at least about 1500 mg/kg, at least about 1600 mg/kg, at least about 1700 mg/kg, at least about 1800 mg/kg, at least about 1900 mg/kg, at least about 2000 mg/kg, at least about 2100 mg/kg, at least about 2200 mg/kg, at least about 2300 mg/kg, at least about 2400 mg/kg, at least about 2500 mg/kg, at least about 3500 mg/kg, at least about 3500 mg/kg, at least about 4000 mg/kg
• the therapeutically effective amount of cyclodextrin or cyclodextrin derivative is at least about 100 mg/kg. In some aspects, the therapeutically effective amount of cyclodextrin or cyclodextrin derivative (e.g., 2-hydroxypropyl-beta-cyclodextrin) is at least about 250 mg/kg. In some aspects, the therapeutically effective amount of cyclodextrin or cyclodextrin derivative (e.g., 2-hydroxypropyl-beta-cyclodextrin) is at least about 500 mg/kg.
• the therapeutically effective amount of cyclodextrin or cyclodextrin derivative is at least about 1000 mg/kg. In some aspects, the therapeutically effective amount of cyclodextrin or cyclodextrin derivative (e.g., 2- hydroxypropyl-beta-cyclodextrin) is at least about 1500 mg/kg.
• the therapeutically effective amount of cyclodextrin or cyclodextrin derivative is an amount suitable to achieve the therapeutic effect described herein.
• the therapeutically effective amount is from about 50 mg/kg to about 2500 mg/kg (e.g., from about 50 mg/kg to about 1000 mg/kg, from about 500 mg/kg to about 1000 mg/kg, from about 500 mg/kg to about 1500 mg/kg, from about 800 mg/kg to about 1500 mg/kg, from about 800 mg/kg to about 1200 mg/kg, from about 1000 mg/kg to about 1500 mg/kg, from about 1000 mg/kg to about 2500 mg/kg.
• the therapeutically effective amount of 2-hydroxypropyl-beta-cyclodextrin is from about 500 mg/kg to about 1500 mg/kg. In some aspects, the therapeutically effective amount of cyclodextrin or cyclodextrin derivative (e.g., 2-hydroxypropyl-beta-cyclodextrin) is from about 800 mg/kg to about 1200 mg/kg.
• the therapeutically effective amount of cyclodextrin or cyclodextrin derivative is an amount suitable for achieving the therapeutic effect described herein.
• the therapeutically effective amount is at least about 4 g (e.g., at least about 10 g, at least about 25 g, at least about 50 g, at least about 75 g, at least about 100 g, at least about 125 g, at least about 150 g, at least about 175 g, at least about 200 g, at least about 250 g).
• the therapeutically effective amount of 2- hydroxypropyl-beta-cyclodextrin may be from about 4 g to about 250 g (e.g., from about 4 g to about 200 g, from about 4 g to about 150 g, from about 4 g to about 100 g, from about 4 g to about 50 g, from about 50 g to about 250 g, from about 50 g to about 200 g, from about 50 g to about 150 g, from about 50 g to about 100 g, from about 100 g to about 250 g, from about 100 g to about 200 g).
• the total amount of cyclodextrin or cyclodextrin derivative (e.g., 2- hydroxpropyl-beta-cyclodextrin) administered may depend on a number of factors, including, without limitation, the subject’s age, gender, weight, and the like.
• the therapeutically effective amount of cyclodextrin or cyclodextrin derivative is an amount sufficient to achieve a whole blood, serum, and/or plasma concentration of cyclodextrin or cyclodextrin derivative (e.g., 2- hydroxypropyl-beta-cyclodextrin) suitable for achieving the therapeutic effect described herein.
• the whole blood, serum, and/or plasma concentration is at least about 0.01 mM (e.g., at least about 0.05 mM, at least about 0.1 mM, at least about 0.2 mM, at least about 0.3 mM, at least about 0.4 mM, at least about 0.5 mM, at least about 0.6 mM, at least about 0.7 mM, at least about 0.8 mM, at least about 0.9 mM, at least about 1.0 mM, at least about 1.5 mM, at least about 2.0 mM, or at least about 2.5 mM).
• 0.01 mM e.g., at least about 0.05 mM, at least about 0.1 mM, at least about 0.2 mM, at least about 0.3 mM, at least about 0.4 mM, at least about 0.5 mM, at least about 0.6 mM, at least about 0.7 mM, at least about 0.8 mM, at least about 0.9 mM, at
• the methods disclosed herein may further comprise administering, at a first time point, a therapeutically effective first amount of cyclodextrin or cyclodextrin derivative (e.g., 2- hydroxypropyl-beta-cyclodextrin) to a subject, and administering, at a second time point, a therapeutically effective second amount of cyclodextrin or cyclodextrin derivative (e.g., 2- hydroxypropyl-beta-cyclodextrin) to the subject.
• a therapeutically effective first amount of cyclodextrin or cyclodextrin derivative e.g., 2- hydroxypropyl-beta-cyclodextrin
• the second time point can be at least 4 hours, at least 6 hours, at least 8 hours, at least 12 hours, at least 1 day, at least 2 days, at least 3 days, at least 4 days, at least 5 days, at least 6 days, at least 1 week, at least 2 weeks, at least 3 weeks, or at least 4 weeks after the first time point.
• the administering further comprises administering every 3 days, every 7 days, every 10 days, every 14 days, every 21 days, every 28 days, every 2 months, every 3 months, every 6 months, every 12 months.
• the administering continues at least 1 year, at least 2 years, at least 3 years, at least 5 years, at least 7 years, at least 10 years, at least 15 years, at least 20 years, or as long as the cyclodextrin or cyclodextrin derivative (e.g., 2-hydroxypropyl-beta-cyclodextrin) is effective in ameliorating at least one symptom of the familial hypercholesterolemia.
• the administering may be by intravenous administration.
• the treatment of cyclodextrin or cyclodextrin derivative is combined with other cholesterol-reducing treatment and/or LDL inhibitors (e.g., statins, cholesterol uptake inhibitors, or PSCK9 inhibitor).
• LDL inhibitors e.g., statins, cholesterol uptake inhibitors, or PSCK9 inhibitor.
• the cyclodextrin or cyclodextrin derivative with other cholesterol-reducing treatment is co administered concurrently to the individual.
• the cyclodextrin or cyclodextrin derivative with other cholesterol-reducing treatment is sequentially administered to the individual.
• the second time point may be determined based on one or more indicators that an additional dose of drug would be beneficial to the subject.
• the second time point may be administered after the therapeutic benefit of the first dose has diminished or has started to diminish.
• the subject can be a human.
• the subject may be of any age that is at risk of or more prone to developing elevated levels of circulating cholesterol crystals (and/or clots comprising cholesterol crystals) and/or familial hypercholesterolemia.
• the subject may be under 1, under 3, under 5 years old, or at least 5 years old (e.g., at least 10, at least 15, at least 20, at least 25, at least 30, at least 40).
• the subject can be diagnosed with atherosclerosis and/or atherosclerotic cardiovascular disease.
• the subject has advanced atherosclerosis.
• the subject has undergone a medical procedure involving the blood vessels, such as vascular surgery or angiography.
• the subject has commenced treatment with an anticoagulant or a thrombolytic medication.
• the subject may have one or more risk factors for 5 (e.g., at least 10, at least 15, at least 20, at least 25, at least 30, at least 40).
• Risk factors for familial hypercholesterolemia include, but are not limited to, a family history of familial hypercholesterolemia, high level of LDL cholesterol in at least one parent, a change in LDLR gene, ApoB gene, or PCSK9 gene.
• the subject can be diagnosed with familial hypercholesterolemia and/or may have a symptom and/or a clinical manifestation of familial hypercholesterolemia, or has manifestations in consanguineous family.
• Familial hypercholesterolemia can be diagnosed by a genetic screening test or in combination with other clinical tests e.g., a biopsy (e.g., a skin biopsy, a muscle biopsy, a kidney biopsy, bone marrow biopsy, gastric mucosa biopsy, colonic mucosa biopsy) or typical dermatological manifestations including xanthoma, and xanthelasma or other signs of poor skin perfusion at an early age (including gangrene, livedo reticularis, cyanotic toes or fingers), and or histological manifested accumulation of foamy macrophages in skin or plaque lesions, increased total cholesterol levels, increased LDL levels, with atherosclerotic disease comorbidity or incidences thereof, such as atherosclerotic peripheral artery, coronary artery and
• the subject can be diagnosed by a combination of characteristic manifestations of the disease including significant LDL-C levels or early onset atherosclerotic disease with a strong familial predisposition, or dermatological signs (e.g., including xanthomas, xanthelasma, cutaneous, renal, central nervous system, ocular manifestations (e.g., Hollenhorst plaques), e.g., as described herein).
• dermatological signs e.g., including xanthomas, xanthelasma, cutaneous, renal, central nervous system, ocular manifestations (e.g., Hollenhorst plaques), e.g., as described herein).
• the subject can be diagnosed by a non-invasive imaging modality (e.g., abdominal ultrasound, chest/abdominal computerized tomography (CT), transthoracic echocardiogram (TTE), transesophageal echocardiogram (TEE) showing early-onset or rapid progressive atherosclerosis).
• a non-invasive imaging modality e.g., abdominal ultrasound, chest/abdominal computerized tomography (CT), transthoracic echocardiogram (TTE), transesophageal echocardiogram (TEE) showing early-onset or rapid progressive atherosclerosis.
• the subject can have one or more analytical laboratory results consistent with familial hypercholesterolemia.
• the one or more analytical laboratory results consistent with familial hypercholesterolemia may include, without limitation, high total cholesterol (up to 200 mg/dL, up to 250 mg/dL, up to 300 mg/dL, up to 350 mg/dL, up to 400 mg/dL, up to 500 mg/dl, up to 600 mg/dl, up to 700 mg/dl, up to 800 mg/dl, up to 900 mg/dl, up to 1,000 mg/dl), high LDL levels (> 200 mg/dL, > 250 mg/dL, > 300 mg/dL, > 350 mg/dL, > 400 mg/dL, >500 mg/dl).
• familial hypercholesterolemia involves secondary manifestations.
• LDL >200mg/dl, >300mg/dl, >400mg/dl, or >500mg/dl, and/or and total cholesterol >650- lOOOmg/dl or premature coronary heart disease ( ⁇ 55 years men; ⁇ 60 years women) in a first degree relative is sufficient for a clinical diagnosis of FH.
• DNA tests can confirm the diagnosis in 80% of cases. Since cholesterol levels are elevated from early childhood, in some aspects, children are screened before the age of 1, 2, 3, 4, 5, age 10, age 20, age 30, etc.
• the subject may be treated (e.g., by the methods described herein) before developing symptoms of familial hypercholesterolemia.
• a subject at risk of developing familial hypercholesterolemia e.g., a subject with elevated levels of circulating cholesterol crystals (and/or clots comprising cholesterol crystals), a family history of familial hypercholesterolemia, high level of LDL cholesterol in at least one of parents, a change in LDLR gene or LDLR adapter protein 1 (LDLRAP1), ApoB gene, or PCSK9 gene
• LDLRAP1 LDLR adapter protein 1
• ApoB gene or PCSK9 gene
• a subject having one or more risk factors for familial hypercholesterolemia is treated prior to developing elevated levels of circulating cholesterol to prevent further development of atherosclerotic coronary artery, peripheral artery or cerebrovascular disease.
• the subject may be treated (e.g., by the methods described herein) after developing familial hypercholesterolemia and/or a symptom or clinical manifestation thereof.
• the methods disclosed herein can be used to treat familial hypercholesterolemia and/or one or more symptoms and/or clinical manifestations thereof.
• the methods disclosed herein can be used to treat progressive coronary artery disease (and ischemic cardiomyopathy), ischemic cerebrovascular disease, or cutaneous manifestations of familial hypercholesterolemia (e.g., xanthomas, xanthelasma, livedo reticularis, cyanosis).
• the methods described herein cause, or lead to a reduction in the size (e.g., average size, maximum size) of circulating (e.g., blood, plasma, serum) cholesterol crystals (and/or clots comprising cholesterol crystals) in the subject.
• the size (e.g., average size, maximum size) of circulating (e.g., blood, plasma, serum) cholesterol crystals (and/or clots comprising cholesterol crystals) may be reduced relative to the size (e.g., average size, maximum size) of the circulating (e.g., blood, plasma, serum) cholesterol crystals (and/or clots comprising cholesterol crystals) prior to the treating.
• the size (e.g., average size, maximum size) of circulating (e.g., blood, plasma, serum) cholesterol crystals (and/or clots comprising cholesterol crystals) may be reduced by at least about 0.5%. In some aspects, the size (e.g., average size, maximum size) of circulating (e.g., blood, plasma, serum) cholesterol crystals (and/or clots comprising cholesterol crystals) may be reduced by at least about 0.5%, at least about 1%, at least about 5%, at least about 10%, at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, at least about 55%, at least about 60%, at least about 65%, at least about 70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, or greater.
• the methods described herein causes, or lead to an increase of ABCA1 gene expression in the subject.
• ABCA1 gene expression in the subject is increased by at least about 0.5%, at least about 1%, at least about 5%, at least about 10%, at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, at least about 55%, at least about 60%, at least about 65%, at least about 70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, or greater.
• the increase of ABCA1 gene expression is not accompanied with increase or decrease of SREBP2 gene expression.
• the methods described herein causes, or lead to reduction of liver weight by at least about 0.5%, at least about 1%, at least about 5%, at least about 10%, at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%.
• the methods described herein causes, or lead to a reduction in the amount (e.g., concentration) of circulating (e.g., blood, plasma, serum) cholesterol crystals (and/or clots comprising cholesterol crystals) in the subject.
• the circulating cholesterol crystals derive from abundant LDL levels resulting in uncontrolled intra- or extracellular cholesterol crystal deposition.
• the amount (e.g., concentration) of circulating (e.g., blood, plasma, serum) cholesterol crystals (and/or clots comprising cholesterol crystals) may be reduced relative to the amount (e.g., concentration) of circulating (e.g., blood, plasma, serum) cholesterol crystals (and/or clots comprising cholesterol crystals) prior to the treating.
• the amount (e.g., concentration) of circulating (e.g., blood, plasma, serum) cholesterol crystals (and/or clots comprising cholesterol crystals) may be reduced by at least about 0.5%.
• the amount (e.g., concentration) of circulating (e.g., blood, plasma, serum) cholesterol crystals (and/or clots comprising cholesterol crystals) may be reduced by at least about 0.5%, at least about 1%, at least about 5%, at least about 10%, at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, at least about 55%, at least about 60%, at least about 65%, at least about 70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, or greater.
• the methods described herein result in a change in the shape of circulating cholesterol crystals (and/or clots comprising cholesterol crystals).
• the methods described herein cause, or lead to a decrease in inflammation (e.g., as measured by, e.g., cytokine protein and/or RNA levels) as compared to a level of inflammation prior to treatment with the 2-hydroxypropyl-beta-cyclodextrin.
• the methods described herein result in an improvement in dermatologic manifestations as compared to prior to treatment with the 2-hydroxypropyl-beta-cyclodextrin.
• the methods involve treating a subject (e.g., having, suspected of having, or at risk of developing familial hypercholesterolemia) with a combination of 2- hydroxypropyl-beta-cyclodextrin and an additional treatment (e.g., therapeutic pharmaceutical compound, medical procedure, or therapy).
• a subject e.g., having, suspected of having, or at risk of developing familial hypercholesterolemia
• an additional treatment e.g., therapeutic pharmaceutical compound, medical procedure, or therapy.
• the additional treatment comprises pheresis (e.g., plasmapheresis). In some cases, the additional treatment comprises cholesterol lowering treatment. In some cases, the additional treatment comprises LDL-lowering treatment or LDL-lowering medicaments.
• the additional treatment comprises therapeutics that is selected from the group consisting of: a HMG-CoA reductase inhibitor (statin), cholesterol uptake inhibitor (for instance ezetimibe, fibrin), lomitapide, an anti-inflammatory drug (e.g., low-dose acetyl salicylic acid (ASS), canakinumab), a corticosteroid, and a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor and/or plasmapheresis.
• the additional treatment comprises two or more treatment, medicaments, medical procedures described above.
• 2-hyroxypropyl-beta-cyclodextrin and the additional therapeutic are administered to the subject at or near the same time (e.g., in a single formulation, or as separate formulations).
• 2-hydroxypropyl-beta-cyclodextrin and the additional therapeutic are administered at different times (e.g., in separate formulations).
• the additional therapeutic is administered prior to administration with 2-hydroxypropyl-beta-cyclodextrin.
• the additional therapeutic is administered concurrently with 2-hydroxypropyl-beta- cyclodextrin.
• the additional therapeutic is administered after administration of 2- hydroxypropyl-beta-cyclodextrin.
• the subject may have previously been undergoing treatment with an additional therapeutic (e.g., prior to administration with 2-hydroxypropyl-beta-cyclodextrin).
• the treatment with the additional therapeutic may be ineffective or may have limited efficacy.
• subjects treated with 2-hydroxypropyl-beta-cyclodextrin e.g., after treatment with the additional therapeutic, or concurrently with the additional therapeutic may exhibit a greater therapeutic benefit than administration of the additional therapeutic alone.
• subjects treated with both 2-hydroxypropyl-beta-cyclodextrin and an additional therapeutic may exhibit a therapeutic benefit greater than the therapeutic benefit exhibited by treatment with either the additional therapeutic or the 2-hydroxypropyl-beta- cyclodextrin alone.
• treatment with both the additional therapeutic and 2- hydroxypropyl-beta-cyclodextrin has a synergistic effect, such that the interaction between the additional therapeutic and 2-hydroxypropyl-beta-cyclodextrin causes the total effect of the therapeutics to be greater than the sum of the individual effects of each therapeutic.
• treatment with both the additional therapeutic and 2-hydroxypropyl-beta-cyclodextrin has an additive effect.
• compositions comprising an amount of 2-hydroxypropyl-beta-cyclodextrin effective to treat familial hypercholesterolemia and/or one or more symptoms and/or clinical manifestations thereof, in a human; and an excipient.
• the excipient can be a pharmaceutically acceptable excipient.
• the excipient may comprise a tonicity adjusting agent, a preservative, a solubilizing agent, a buffer, a solution (e.g., an IV solution), or any combination thereof.
• the tonicity adjusting agent can be dextrose, glycerol, sodium chloride, glycerin, mannitol, or a combination thereof.
• the preservative can be an antioxidant, an antimicrobial, a chelating agent, or a combination thereof.
• the antioxidant can be ascorbic acid, acetylcysteine, a sulfurous acid salt (e.g., bisulfite, metabi sulfite), a monothioglycerol, or a combination thereof.
• the antimicrobial can be a phenol, meta-cresol, benzyl alcohol, paraben, benzalkonium chloride, chlorobutanol, thimerosal, phenylmercuric salts (e.g., acetate, borate, nitrate), or a combination thereof.
• the chelating agent can be calcium disodium ethylenediaminetetraacetic acid (EDTA), disodium EDTA, sodium EDTA, calcium versetamide sodium, calteridol, diethylenetriaminepenta acetic acid (DTP A), or a combination thereof.
• the solubilizing agent can be a surfactant or a co solvent.
• the surfactant can be polyoxyethylene sorbitan monooleate (Tween 80), sorbitan monooleate polyoxyethylene sorbitan monolaurate (Polysorbat 20, Tween ® 20), lecithin, polyoxyethylene-polyoxypropylene copolymers (Pluronics), or a combination thereof.
• the co solvent can be propylene glycol, glycerin, ethanol, polyethylene glycol (PEG), sorbitol, dimethylacetamide, Cremophor EL, or a combination there.
• the polyethylene glycol can be PEG 300, PEG 400, PEG 600, PEG 3350, or PEG 4000.
• the buffer can comprise sodium acetate, acetic acid, glacial acetic acid, ammonium acetate, ammonium sulfate, ammonium hydroxide, arginine, aspartic acid, benzene sulfonic acid, benzoate sodium, benzoic acid, sodium bicarbonate, boric acid, sodium boric acid, sodium carbonate, citrate acid, sodium citrate, disodium citrate, trisodium citrate, diethanolamine, glucono delta lactone, glycine, glycine HC1, histidine, histidine HC1, hydrochloric acid, hydrobromic acid, lysine, maleic acid, meglumine, methanesulfonic acid, monoethanolamine, phosphate acid, monobasic potassium, dibasic potassium, monosodium phosphate, di sodium phosphate, tri sodium phosphate, sodium hydroxide, succinate sodium, sulfuric acid, tartarate sodium, tartaric acid, tromethamine (Tris), or
• the pharmaceutical composition can comprise at least about 4 g, at least about 10 g, at least about 50 g, at least about 100 g, at least about 150 g, at least about 200 g, or at least about 250 g of 2-hydroxypropyl-beta-cyclodextrin. In some aspects, the pharmaceutical composition comprises at least about 4 g of 2-hydroxypropyl-beta-cyclodextrin. In some aspects, the pharmaceutical composition comprises at least about 50 g of 2-hydroxypropyl-beta- cyclodextrin. In some aspects, the pharmaceutical composition comprises at least about 100 g of 2-hydroxypropyl-beta-cyclodextrin.
• the pharmaceutical composition comprises at least about 200 g of 2-hydroxypropyl-beta-cyclodextrin. In some aspects, the pharmaceutical composition comprises from about 4 g to about 250 g of 2-hydroxypropyl-beta-cyclodextrin (e.g., from about 4 g to about 100 g, from about 4 g to about 50 g, from about 50 g to about 150 g, from about 50 g to about 250 g, from about 100 g to about 200 g, from about 100 g to about 250 g, from about 150 g to about 250 g).
• the pharmaceutical composition can be formulated for single dose administration.
• the pharmaceutical composition can be formulated for intravenous administration.
• the pharmaceutical composition can be formulated to be isotonic.
• Example 1 Cholesterol Crystal Dissolution Capacity in HoFH Patients
• D6-labeled cholesterol crystals were added to human plasma collected from homozygous familial hypercholesterolemia (HoFH) patients treated with HPBCD (2-hydroxypropyl-beta- cyclodextrin).
• the reaction mixtures were filtered to remove crystals and the filtrate was assayed for the presence of D6-labeled cholesterol using gas chromatography-mass spectroscopy (GC-MS). Cholesterol measured in the filtrate indicated the ability of HPBCD (2- hydroxypropyl-beta-cyclodextrin) to dissolve cholesterol crystals.
• HPBCD gas chromatography-mass spectroscopy
• HPBCD (2-hydroxypropyl-beta-cyclodextrin) significantly increased cholesterol crystal dissolution compared to control group.
• HPBCD (2-hydroxypropyl-beta-cyclodextrin) has therapeutic potential to remove cholesterol crystals from the circulation.
• the dissolution of cholesterol crystals in HoFH patients will reduce inflammation in atheromas.
• plaque progression can be reduced and plaque stability can be improved. This would significantly reduce the incidence of significant atheroma-related adverse clinical outcomes such as cardiovascular death, myocardial infarction, or hospitalization for heart failure.
• Example 2 Effects on Cholesterol Efflux Capacity in HoFH Patients
• HPBCD (2-hydroxypropyl-beta- cyclodextrin)
• cholesterol efflux capacity in HoFH patients.
• HPBCD was added to whole blood obtained from HoFH patients at concentration of 1.2 mM. Untreated samples were used as control. The mixtures were incubated for 6 hours. Total mRNA was isolated and mRNA expression levels were measured. Data is shown as the level of gene expression normalized to saline control.
• FIG. 1 As shown in FIG.
• HPBCD (2-hydroxypropyl-beta-cyclodextrin) caused a significant induction in the reverse cholesterol transporter ABCA1 in human whole blood.
• LXR targeting is generally associated with upregulation of SREBP2.
• mRNA expression level of SREBP2 in HoFH patients treated with HPBCD is similar to control group. This example illustrates that HPBCD (2-hydroxypropyl-beta-cyclodextrin can cause the removal of excess cholesterol from cells without increasing circulating cholesterol levels (i.e., maintaining cholesterol homeostasis).
• mice were fed normal chow diet (NC) or high-fat (42%), high-cholesterol (1.2) diet Western diet (WD) as described in Table 1 and Table 2. After five weeks, the mice were subcutaneously injected with 2g/kg BPBCD. The livers were excised and weighed after five weeks (Group 1, 2, 6), six weeks (Group 3), seven weeks (Group 4), and nine weeks (Group 5), respectively.
• NC normal chow diet
• WD high-cholesterol
• mice Western diet
• mice were subcutaneously injected with 2g/kg BPBCD.
• the livers were excised and weighed after five weeks (Group 1, 2, 6), six weeks (Group 3), seven weeks (Group 4), and nine weeks (Group 5), respectively.

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