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
  • A61K31/495—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
  • A61K31/33—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
  • A61K31/506—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim not condensed and containing further heterocyclic rings
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P7/00—Drugs for disorders of the blood or the extracellular fluid
  • A61P7/02—Antithrombotic agents; Anticoagulants; Platelet aggregation inhibitors

Definitions

• the disclosure pertains to the use of milvexian for the treatment of thromboembolic disorders.
• Oral anticoagulants are a mainstay for prevention and treatment of venous and arterial thromboembolism. Although direct oral anticoagulants have replaced vitamin K antagonists for many indications, bleeding remains the major side effect. Fear of bleeding contributes to the underuse of anticoagulants in eligible patients with atrial fibrillation, and the inappropriate use of low dose direct oral anticoagulant regimens. (Steinberg et al., International trends in clinical characteristics and oral anti coagulation treatment for patients with atrial fibrillation: Results from the GARFIELD-AF, ORBIT-AF I, and ORBIT-AF II registries.
• Factor XI is a promising target for development of new anticoagulants because it is an important driver of thrombus growth but plays a subsidiary part in hemostasis (Weitz et al., Factor XI inhibition to uncouple thrombosis from hemostasis: JACC review topic of the week. J Am Coll Cardiol 2021;78:625-31).
• Milvexian is a direct-acting, reversible, small molecule therapeutic agent that binds to and inhibits the activated form of human coagulation Factor XI (FXIa) with high affinity and selectivity.
• Milvexian is a macrocyclic compound having the structure of Formula (I): Formula (I).
• Milvexian has the chemical name (5R,9S)-9-(4-(5-chloro-2-(4-chloro-lH- 1 ,2,3-triazol- 1 -yl)phenyl)-6-oxopyrimidin- 1 (6H)-yl)-21 -(difluoromethyl)-5-methyl-21H-3- aza-l(4,2)-pyridina-2(5,4)-pyrazolacyclononaphan-4-one.
• Milvexian and a method of preparing milvexian are described in U.S. patent 9,453,018, which is hereby incorporated by reference in its entirety.
• Amorphous solid dispersion composition of milvexian in one or more polymers has been described in W02020210629, which is hereby incorporated by reference in its entirety.
• the disclosure is directed to methods of treating or preventing a venous thromboembolic disorder, wherein the methods comprise orally administering to a patient in need thereof a total daily dose of from 25 mg to 400 mg of milvexian, or pharmaceutically acceptable salt thereof.
• the disclosure is directed to methods of preventing postoperative venous thromboembolism events in a patient recovering from surgery, said method comprising administering to said patient a daily dose of milvexian, or pharmaceutically acceptable salt thereof, wherein said administration results in the patient experiencing fewer post-operative venous thromboembolism events than would result from subcutaneous administration to the patient of 40 mg per day of enoxaparin (a low molecular weight heparin).
• Figure 1 gives an overview of the study design of the study described in Example 1 which was designed to investigate the ability of milvexian to prevent venous thromboembolic events in individuals at risk of developing venous thromboembolism, e.g., individuals undergoing total knee arthroplasty.
• Interim analysis (IA)#1 was conducted when ⁇ 50 subjects in each of the BID treatment groups had completed venography or had a symptomatic venous thromboembolism (VTE) event.
• IA#2 was an additional IA conducted at the discretion of the operations committee to determine the need for continuing the 25 mg, once a day, dose regimen.
• Figure 2 illustrates the total VTE incidence rate and 95% confidence interval for each treatment arm of the study described in Example 1.
• Figure 3 illustrates, of the subjects with deep vein thrombosis (DVT) on venography in the trial, incidence rate of clots by clot severity.
• DVD deep vein thrombosis
• Figure 4 illustrates, of the subjects with DVT on venography in the study described in Example 1, average DVT severity score.
• Figure 5 illustrates the incidence rate and 95% confidence interval for bleeding for each treatment arm of the study described in Example 1.
• Figure 6 illustrates the median activated partial -thromboplastin time ratios and rates of any bleeding or clinically relevant bleeding with milvexian and enoxaparin.
• Figure 9 illustrates the relationship between total plasma concentrations of milvexian and antithrombotic effects expressed as % reduction of thrombus weight in prevention ECAT rabbits. IV, intravenous; ECAT, electrically mediated carotid arterial thrombosis; SEM, standard error of the mean.
• Figure 11 illustrates tracking antithrombotic activity of milvexian with ex vivo aPTT in rabbit ECAT.
• aPTT activated partial thromboplastin time
• TT thrombin time
• PT prothrombin time
• ECAT electrically mediated carotid arterial thrombosis
• SEM standard error of the mean
• IV intravenous.
• Figure 12 illustrates effects of vehicle and milvexian on carotid blood flow (expressed as % of control carotid blood flow).
• vehicle or milvexian was given IV (bolus + infusion) at 15 minutes after the initiation of arterial thrombosis.
• Means ⁇ SE and n 6 per group.
• Figure 13 illustrates the dose-dependent decrease in FXI levels and clot weight observed in the rabbit ECAT model with ASO-induced inhibition of FXI.
• the term “treating” or “treatment” includes the therapeutic treatment of thromboembolic disorders.
• the term “treating” or “treatment” covers the treatment of a disease-state in a mammal, particularly in a human, and include: (a) inhibiting the disease-state, i.e., arresting it development; and/or (b) relieving the disease-state, i.e., causing regression of the disease state.
• milvexian is used for the postoperative treatment of VTE in patients undergoing surgery.
• milvexian is used for the short term treatment of VTE (i.e., acute treatment of VTE).
• prevention refers to the preventive treatment of a subclinical disease-state in a mammal, particularly in a human, aimed at reducing the probability of the occurrence of a clinical disease-state.
• Patients are selected for preventative therapy based on factors that are known to increase risk of suffering a clinical disease state compared to the general population.
• prevention covers primary prevention of thromboembolic disorders in a mammal, particularly in a human, aimed at reducing the probability of the occurrence of total VTE events after TKR surgery including: proximal and/or distal deep vein thrombosis (both symptomatic DVT and asymptomatic DVT confirmed by venography assessment or objectively confirmed symptomatic); nonfatal PE; or any death during the treatment period.
• Patients are selected for preventative therapy based on factors that are known to increase risk of suffering a clinical disease state compared to the general population.
• milvexian is used for the preoperative thromboprophylaxis of VTE in patients undergoing surgery.
• milvexian is used for the postoperative thromboprophylaxis of VTE in patients undergoing surgery.
• therapeutically effective amount is intended to include an amount of milvexian, or therapeutically effective salt, or solvate thereof, that is effective when administered alone to inhibit factor Xia and/or plasma kallikrein and/or to prevent or treat the disorders listed herein.
• therapeutically effective amount is intended to include an amount of milvexian, or therapeutically effective salt thereof, that is effective when administered alone to inhibit factor Xia and/or plasma kallikrein and/or to prevent or treat the disorders listed herein.
• therapeutically effective amount of milvexian is clinically proven effective in reducing the occurrence of total VTE events in a patient during treatment period.
• therapeutically effective amount of milvexian comprises therapeutically effective solvate of milvexian, for example, the acetone monosolvate.
• thrombosis refers to formation or presence of a thrombus (pl. thrombi); clotting within a blood vessel that may cause ischemia or infarction of tissues supplied by the vessel.
• emblism refers to sudden blocking of an artery by a clot or foreign material that has been brought to its site of lodgment by the blood current.
• thromboembolism refers to obstruction of a blood vessel with thrombotic material carried by the blood stream from the site of origin to plug another vessel.
• thromboembolic disorders entails both “thrombotic” and “embolic” disorders.
• thromboembolic disorders also includes specific disorders selected from, but not limited to, atherosclerosis, atherothrombosis, peripheral occlusive arterial disease, venous thrombosis, venous thromboembolism (VTE), deep vein thrombosis, thrombophlebitis, coronary arterial thrombosis, kidney embolism, pulmonary embolism, and thrombosis resulting from medical implants, devices, or procedures in which blood is exposed to an artificial surface that promotes thrombosis.
• VTE venous thromboembolism
• VTE venous thromboembolism
• VTE venous thromboembolism
• thrombophlebitis deep vein thrombosis
• coronary arterial thrombosis kidney embolism
• pulmonary embolism pulmonary embolism
• thrombosis resulting from medical implants, devices, or procedures in which blood is exposed to an artificial surface that promotes thrombosis.
• thromboembolic disorders includes specific disorders selected from, but not limited to, atherosclerosis, peripheral occlusive arterial disease, venous thrombosis, venous thromboembolism (VTE), deep vein thrombosis, thrombophlebitis, coronary arterial thrombosis, kidney embolism, pulmonary embolism, and thrombosis resulting from medical implants, devices, or procedures in which blood is exposed to an artificial surface that promotes thrombosis.
• VTE venous thromboembolism
• thromboembolic disorders includes venous thromboembolism, deep vein thrombosis (DVT), proximal and/or distal DVT, symptomatic proximal and/or distal DVT, asymptomatic proximal and/or distal DVT, or pulmonary embolism.
• DVT deep vein thrombosis
• proximal and/or distal DVT proximal and/or distal DVT
• symptomatic proximal and/or distal DVT asymptomatic proximal and/or distal DVT
• pulmonary embolism pulmonary embolism
• milvexian is used for the primary prophylaxis of VTE in patients undergoing surgery. In some embodiments, milvexian is used for the preoperative thromboprophylaxis of VTE in patients undergoing surgery.
• the disclosure is directed to methods of treating or preventing a venous thromboembolic disorder, wherein the methods comprise orally administering to a patient in need thereof a clinically effective amount of milvexian, or pharmaceutically acceptable salt thereof.
• the clinically effective amount of milvexian, or pharmaceutically acceptable salt thereof may be a total daily dose of from 25 mg to 400 mg. In other embodiments, the clinically effective amount may be a total daily dose of from 50 mg to 400 mg.
• the disclosure is directed to methods of treating or preventing a venous thromboembolic disorder, wherein the methods comprise orally administering to a patient in need thereof a total daily dose of from 25 mg to 400 mg of milvexian, or pharmaceutically acceptable salt thereof. In other embodiments, the total daily dose is from 50 mg to 400 mg of milvexian, or pharmaceutically acceptable salt thereof.
• the methods of the disclosure are directed to treating or preventing a venous thromboembolic disorder.
• the venous thromboembolic disorder is a composite of asymptomatic deep-vein thrombosis, confirmed symptomatic venous thromboembolism (symptomatic deep-vein thrombosis of the leg or nonfatal pulmonary embolism), or death.
• the venous thromboembolic disorder is proximal deep-vein thrombosis (symptomatic or asymptomatic), distal deep-vein thrombosis (symptomatic or asymptomatic), nonfatal pulmonary embolism, or death.
• the venous thromboembolic disorder is proximal and/or distal deep vein thrombosis, nonfatal pulmonary embolism, or death.
• the venous thromboembolic disorder is proximal and/or distal deep vein thrombosis.
• the venous thromboembolic disorder is nonfatal pulmonary embolism.
• the venous thromboembolic disorder is death.
• the disclosure is directed to methods of preventing postoperative venous thromboembolism events in a patient recovering from surgery, wherein the method comprises administering to the patient a daily dose of milvexian, or pharmaceutically acceptable salt thereof, wherein the administration results in the patient experiencing fewer post-operative venous thromboembolism events than would result from subcutaneous administration to the patient of 40 mg per day of enoxaparin.
• the patient is at risk of experiencing post-operative venous thromboembolism events such as the venous thromboembolic disorders described above.
• the patient is recovering from a surgical procedure.
• the patient is recovering from abdominal surgery, knee replacement surgery, or hip replacement surgery.
• the patient may be administered milvexian, or pharmaceutically acceptable salt thereof, beginning either just prior to undergoing the surgical procedure, or beginning just after the surgical procedure.
• the risk ratio is 0.6 or less, such as, for example, 0.55 or less, 0.5 or less, 0.45 or less, 0.4 or less, 0.35 or less, or 0.3 or less. That is, in such methods, the risk of the patient experiencing a post-operative venous thromboembolism event is 0.6 times or less the risk the patient would have experienced had the patient been administered 40 mg enoxaparin subcutaneously.
• the disclosure is directed to methods of treating or preventing thrombosis resulting from medical implants, devices, or procedures in which blood is exposed to an artificial surface that promotes thrombosis, wherein the methods comprise administering to the patient a daily dose of a therapeutically effective amount of milvexian, or pharmaceutically acceptable salt thereof.
• the disclosure provides methods of treating or preventing a venous thromboembolic disorder comprising: orally administering therapeutically effective amount of milvexian, or pharmaceutically acceptable salt thereof once or twice daily to a patient in need thereof, wherein an incidence rate of total venous thromboembolism events in the patient treated with the milvexian, or pharmaceutically acceptable salt thereof is less than 25 % with an alpha of 5%.
• the treatment with milvexian in a patient in need thereof causes a statistically significant reduction in total VTE events (p ⁇ 0.0001 (one-sided)) as compared with the incidence rate of total VTE with enoxaparin.
• the treatment with milvexian in a patient in need thereof prevents the occurrence of the total VTE events in dose-dependent response manner and the occurrence of the total VTE events is at an rate statistically lower than 30 % with an alpha of 5%; wherein the total VTE events include proximal and/or distal DVT (asymptomatic confirmed by venography assessment or objectively confirmed symptomatic), nonfatal PE, or any death) during the treatment period.
• the occurrence of the total VTE events in the patient is at a rate statistically lower than 25 % with an alpha of 5%.
• the occurrence of the total VTE events in the patient is at a rate statistically lower than 20 % with an alpha of 5%.
• the occurrence of the total VTE events in the patient is at a rate statistically lower than 15 % with an alpha of 5%.
• the occurrence of the total VTE events in the patient is at a rate statistically lower than 10 % with an alpha of 5%.
• the treatment with milvexian in a patient in need thereof causes a statistically significant reduction in total VTE events (p ⁇ 0.0001 (one-sided)) as compared with the incidence rate of total VTE with enoxaparin.
• CI Confidence Interval of the incidence rate
• the term “intention-to-treat population” refers to all randomized subjects who have signed an informed consent in a clinical trial such as that described in Example 1 below.
• the term “modified intention-to-treat population” refers to a subset of the ITT population consisting of subjects with a valid assessment of potential efficacy outcome and who take at least 1 dose of the study drug milvexian in a clinical study such as that described in Example 1 below.
• the therapeutically effective amount of milvexian, or pharmaceutically acceptable salt thereof is an amount that is clinically proven effective in achieving less than 25 % of the incidence rate of total venous thromboembolism events in the patient treated with milvexian, or pharmaceutically acceptable salt thereof.
• the 50 mg to 400 mg amount of milvexian, or the pharmaceutically acceptable salt thereof was clinically proven effective in causing a statistically significant reduction in total VTE events (p ⁇ 0.0001 (one-sided)) as compared with the incidence rate of total VTE events with enoxaparin.
• milvexian, or pharmaceutically acceptable salt thereof is orally administered to a patient.
• the dose of milvexian, or pharmaceutically acceptable salt thereof may be administered in any suitable oral dosage form, formulation or pharmaceutical formulation, such as, for example, tablets, capsules (including those that contain sustained release or timed release formulations), pills, powders, granules, elixirs, tinctures, suspensions, syrups, and emulsions.
• the dose of milvexian, or pharmaceutically acceptable salt thereof, administered may be formulated as immediate release formulation.
• the dose of milvexian administered may be formulated as immediate release capsule formulation.
• the dose of milvexian administered may be formulated as an amorphous solid dispersion composition of milvexian in one or more polymers.
• the polymer in the amorphous solid dispersion is hypromellose acetate succinate (HPMCAS).
• HPMCAS hypromellose acetate succinate
• the amorphous solid dispersion composition of milvexian in one or more polymers is prepared by spray drying.
• the amorphous solid dispersion composition of milvexian in one or more polymers comprises milvexian being molecularly dispersed in the one or more polymers.
• the patient to whom milvexian, or pharmaceutically acceptable salt thereof, is administered is a mammal.
• the patient is a human.
• the patient is a male human.
• the patient is a female human.
• the patient is a human who is 50 years of age or older.
• the patient is a human who is less than 50 years of age.
• the patient is a human who is less than 18 years or age.
• the patient is administered milvexian, or pharmaceutically acceptable salt thereof.
• the patient is administered milvexian.
• the patient is administered a pharmaceutically acceptable salt of milvexian.
• pharmaceutically acceptable salt refers to derivatives wherein a compound is modified by making an acid or a basic salts thereof.
• examples of pharmaceutically acceptable salts include, but are not limited to, mineral or organic acid salts of basic groups such as amines; and alkali or organic salts of acidic groups such as carboxylic acids.
• the pharmaceutically acceptable salts include the conventional non-toxic salts or the quaternary ammonium salts of the parent compound formed, for example, from non-toxic inorganic or organic acids.
• such conventional non-toxic salts include those derived from inorganic acids such as hydrochloric, hydrobromic, sulfuric, sulfamic, phosphoric, and nitric; and the salts prepared from organic acids such as acetic, propionic, succinic, glycolic, stearic, lactic, malic, tartaric, citric, ascorbic, pamoic, maleic, hydroxymaleic, phenylacetic, glutamic, benzoic, salicylic, sulfanilic, 2-acetoxybenzoic, fumaric, toluenesulfonic, methanesulfonic, ethane disulfonic, oxalic, and isethionic.
• inorganic acids such as hydrochloric, hydrobromic, sulfuric, sulfamic, phosphoric, and nitric
• organic acids such as acetic, propionic, succinic, glycolic, stearic, lactic, malic, tartaric,
• the pharmaceutically acceptable salts of milvexian can be synthesized using conventional chemical methods. Generally, such salts can be prepared by reacting t milvexian with a stoichiometric amount of the appropriate base or acid in water or in an organic solvent, or in a mixture of the two; generally, nonaqueous media like ether, ethyl acetate, ethanol, isopropanol, or acetonitrile are preferred. Lists of suitable salts are found in Remington's Pharmaceutical Sciences, 18th Edition, Mack Publishing Company, Easton, Pa. (1990), the disclosure of which is hereby incorporated by reference.
• the amount specified is on a milvexian basis. That is, an amount of the pharmaceutically acceptable salt is administered that contains the specified amount of milvexian.
• administering 50 mg of milvexian, or a pharmaceutically acceptable salt thereof refers to administering either 50 mg of milvexian, or an amount of a pharmaceutically acceptable salt of milvexian that contains 50 mg of milvexian.
• the patient is administered a total daily dose of from 50 mg to 400 mg of milvexian, or pharmaceutically acceptable salt thereof.
• total daily dose refers to the total amount of milvexian administered in a day.
• the total daily dose represents the cumulative amount administered in all dosing episodes in a given day. For example, if a patient is administered 25 mg of milvexian at each of two dosing episodes on a given day, then the total daily dose for that day is 50 mg.
• the milvexian, or pharmaceutically acceptable salt thereof is administered wherein the total daily dose is administered in a single dose.
• the single daily dose may be administered to the patient approximately once every 18-30 hours, once every 20-28 hours, once every 22-26 hours or once every 23 to 25 hours.
• the single daily dose may be administered to the patient approximately once every 20 hours, once every 21 hours, once every 22 hours, once every 23 hours, once every 24 hours, once every 25 hours, once every 26 hours, once every 27 hours or once every 28 hours.
• the milvexian, or pharmaceutically acceptable salt thereof is administered wherein the total daily dose is administered in divided doses.
• the milvexian, or pharmaceutically acceptable salt thereof is administered wherein the total daily dose is administered in two doses.
• the doses may be administered to the patient approximately once every 8-16 hours, once every 9-15 hours, once every 10-14 hours or once every 11-13 hours.
• the doses may be administered approximately once every 10 hours, once every 10.5 hours, once every 11 hours, once every 11.5 hours, once every 12 hours, once every 12.5 hours, once every 13 hours, once every 13.5 hour or once every 14 hours.
• the milvexian, or pharmaceutically acceptable salt thereof is administered wherein the total daily dose is administered in more than two doses.
• milvexian may be administered to the patient once or twice daily for at least 10 consecutive days.
• milvexian may be administered to the patient once or twice daily every day for at least 11 days, at least 12 days, at least 13 days, at least 14 days, at least 15 days, at least 30 days, at least 6 months, at least 1 year, or at least 5 years.
• milvexian or a pharmaceutically acceptable salt thereof, is administered to prevent total venous thromboembolic events (VTE) in a patient undergoing knee or hip replacement surgery
• VTE total venous thromboembolic events
• it may be administered to the patient once or twice daily for at least 10 consecutive days, at least 11 consecutive days, at least 12 consecutive days, at least 13 consecutive days or 14 consecutive days.
• the milvexian, or pharmaceutically acceptable salt thereof is administered at a total daily dose ranging from 25 mg to 400 mg, such as, for example, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 195, 200, 205, 210, 215, 220, 225, 230, 235, 240, 245, 250, 255, 260,
• the milvexian, or pharmaceutically acceptable salt thereof is administered at a total daily dose ranging from 50 mg to 400 mg, such as, for example, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185,
• the milvexian, or pharmaceutically acceptable salt thereof is administered at the total daily dose selected from the group consisting of 50 mg, 100 mg, 200 mg, and 400 mg.
• the milvexian, or pharmaceutically acceptable salt thereof is administered at the total daily dose of 25 mg.
• the milvexian, or pharmaceutically acceptable salt thereof is administered at the total daily dose of 50 mg.
• the milvexian, or pharmaceutically acceptable salt thereof is administered at the total daily dose of at least 50 mg.
• the milvexian, or pharmaceutically acceptable salt thereof is administered at the total daily dose of 100 mg.
• the milvexian, or pharmaceutically acceptable salt thereof is administered at the total daily dose of at least 100 mg.
• the milvexian, or pharmaceutically acceptable salt thereof is administered at the total daily dose of 200 mg.
• the milvexian, or pharmaceutically acceptable salt thereof is administered at the total daily dose of at least 200 mg.
• the milvexian, or pharmaceutically acceptable salt thereof is administered at the total daily dose of 400 mg.
• the milvexian, or pharmaceutically acceptable salt thereof is administered at the total daily dose of at least 400 mg.
• administering milvexian, or the pharmaceutically acceptable salt thereof, to the patient does not increase the patient’s incidence of bleeding, e.g., increase the patient’s bleeding incidence by more than 1%, more than 2%, more than 3%, more than 4%, more than 5%, more than 6%, more than 7% or more than 8%.
• the administering of milvexian, or the pharmaceutically acceptable salt thereof, to the patient does not increase the patient’s incidence of major bleeding by more than 0.5%, 0.75%, 1%, 1.25% or 1.5%.
• an amount of milvexian (or pharmaceutically acceptable salt thereof) or time interval for administering milvexian (or pharmaceutically acceptable salt thereof) may be an amount or time interval that is within 5% (greater or less than), or within 7.5% (greater or less than), or within 10% (greater or less than), or within 12.5% (greater or less than), or within 15% (greater or less than), or within 17.5% (greater or less than), or within 20% (greater or less than) any specified amount or time interval.
• Aspect 1 A method of treating or preventing a venous thromboembolic disorder comprising: orally administering to a patient in need thereof a total daily dose of from 25 mg to 400 mg of milvexian, or pharmaceutically acceptable salt thereof.
• Aspect 2 The method according to aspect 1, wherein the total daily dose is from 50 mg to 400 mg.
• Aspect 3 The method according to aspect 1, wherein the total daily dose is 25 mg.
• Aspect 4 The method according to aspect 1, wherein the total daily dose is 50 mg.
• Aspect 5 The method according to aspect 1, wherein the total daily dose is 100 mg.
• Aspect 6 The method according to aspect 1, wherein the total daily dose is 150 mg.
• Aspect 7 The method according to aspect 1, wherein the total daily dose is 200 mg.
• Aspect 8 The method according to any one of aspects 1 to 7, wherein the total daily dose is administered in a single dose.
• Aspect 9 The method according to any one of aspects 1 to 7, wherein the total daily dose is administered in divided doses.
• Aspect 10 The method according to aspect 9, wherein the total daily dose is administered in two doses.
• Aspect 11 The method according to any one of aspects 1 to 10, wherein the venous thromboembolic disorder is proximal and/or distal deep vein thrombosis, nonfatal pulmonary embolism, or death.
• Aspect 12 The method according to aspect 11, wherein the venous thromboembolic disorder is proximal and/or distal deep vein thrombosis.
• Aspect 13 The method according to aspect 11, wherein the venous thromboembolic disorder is nonfatal pulmonary embolism.
• Aspect 14 The method according to aspect 11, wherein the venous thromboembolic disorder is death.
• a method of preventing post-operative venous thromboembolism events in a patient recovering from surgery comprising administering to said patient a daily dose of milvexian, or pharmaceutically acceptable salt thereof, wherein said administration results in the patient experiencing fewer postoperative venous thromboembolism events than would result from subcutaneous administration to the patient of 40 mg per day of enoxaparin.
• Aspect 16 The method according to aspect 15, wherein the patient is recovering from abdominal surgery, knee replacement surgery, or hip replacement surgery.
• Aspect 17 The method according to aspect 15 or aspect 16, wherein the daily dose of milvexian, or pharmaceutically acceptable salt thereof, is 50 mg.
• Aspect 18 The method according to aspect 15 or aspect 16, wherein the daily dose of milvexian, or pharmaceutically acceptable salt thereof, is 100 mg.
• Aspect 19 The method according to aspect 15 or aspect 16, wherein the daily dose of milvexian, or pharmaceutically acceptable salt thereof, is 150 mg.
• Aspect 20 The method according to aspect 15 or aspect 16, wherein the daily dose of milvexian, or pharmaceutically acceptable salt thereof, is 200 mg.
• Aspect 21 The method according to any one of aspects 15 to 20, wherein the daily dose of milvexian, or pharmaceutically acceptable salt thereof, is administered in a single dose.
• Aspect 22 The method according to any one of aspects 15 to 20, wherein the daily dose of milvexian, or pharmaceutically acceptable salt thereof, is administered in divided doses.
• a method of treating or preventing a venous thromboembolic disorder comprising: orally administering therapeutically effective amount of milvexian, or pharmaceutically acceptable salt thereof once or twice daily to a patient in need thereof, wherein an incidence rate of total venous thromboembolism events in the patient treated with the milvexian, or pharmaceutically acceptable salt thereof is less than 25% with an alpha of 5%.
• Aspect 24 The method of aspect 23, wherein the incidence rate of total venous thromboembolism events is less than 20 %.
• Aspect 25 The method of aspect 23, wherein the incidence rate of total venous thromboembolism events is less than 15%.
• Aspect 26 The method of aspect 23, wherein the incidence rate of total venous thromboembolism events is less than 10%.
• Aspect 27 The method of aspect 23, wherein the milvexian, or pharmaceutically acceptable salt thereof is administered at a total daily dose ranging from 50 mg to 400 mg.
• Aspect 28 The method of aspect 23, wherein the milvexian, or pharmaceutically acceptable salt thereof is administered at the total daily dose selected from the group consisting of 50 mg, 100 mg, 200 mg, and 400 mg.
• Aspect 29 The method of aspect 23, wherein the milvexian, or pharmaceutically acceptable salt thereof is administered at the total daily dose of 50 mg.
• Aspect 30 The method of aspect 23, wherein the milvexian, or pharmaceutically acceptable salt thereof is administered at the total daily dose of 100 mg.
• Aspect 31 The method of aspect 23, wherein the milvexian, or pharmaceutically acceptable salt thereof is administered at the total daily dose of 150 mg.
• Aspect 32 The method of aspect 23, wherein the milvexian, or pharmaceutically acceptable salt thereof is administered at the total daily dose of 200 mg.
• Aspect 33 The method of aspect 23, wherein the milvexian, or pharmaceutically acceptable salt thereof is administered at the total daily dose of 400 mg.
• Aspect 34 The method of any one of aspects 23 to 33, wherein milvexian is administered twice daily.
• Aspect 35 The method of any one of aspects 23 to 33, wherein milvexian is administered once daily.
• Aspect 36 The method of any one of aspects 23 to 35, wherein the rate of venous thromboembolism occurs in a dose dependent manner without increasing the risk of bleeding compared with enoxaparin.
• Aspect 37 The method of any one of aspects 23 to 36, wherein the therapeutically effective amount is clinically proven effective in achieving less than 25 % of the incidence rate of total venous thromboembolism events in the patient treated with milvexian, or pharmaceutically acceptable salt thereof.
• Aspect 38 Use of an oral dosage form of milvexian, or pharmaceutically acceptable salt thereof, for manufacture of a medicament for treating or preventing a venous thromboembolic disorder by orally administering to a patient in need thereof a total daily dose of from 25 mg to 400 mg of milvexian, or pharmaceutically acceptable salt thereof.
• Aspect 39 The use according to aspect 38, wherein the total daily dose is from 50 mg to 400 mg.
• Aspect 40 The use according to aspect 38, wherein the total daily dose is 25 mg.
• Aspect 41 The use according to aspect 38, wherein the total daily dose is 50 mg.
• Aspect 42 The use according to aspect 38, wherein the total daily dose is 100 mg.
• Aspect 43 The use according to aspect 38, wherein the total daily dose is 150 mg.
• Aspect 44 The use according to aspect 38, wherein the total daily dose is 200 mg.
• Aspect 45 The use according to any one of aspects 38 to 44, wherein the total daily dose is administered in a single dose.
• Aspect 46. The use according to any one of aspects 38 to 44, wherein the total daily dose is administered in divided doses.
• Aspect 47 The use according to aspect 46, wherein the total daily dose is administered in two doses.
• Aspect 48 The use according to any one of aspects 38 to 47, wherein the venous thromboembolic disorder is proximal and/or distal deep vein thrombosis, nonfatal pulmonary embolism, or death.
• Aspect 49 The use according to aspect 48, wherein the venous thromboembolic disorder is proximal and/or distal deep vein thrombosis.
• Aspect 50 The use according to aspect 48, wherein the venous thromboembolic disorder is nonfatal pulmonary embolism.
• Aspect 51 The use according to aspect 48, wherein the venous thromboembolic disorder is death.
• Aspect 52 Use of an oral dosage form of milvexian, or pharmaceutically acceptable salt thereof, for manufacture of a medicament for preventing post-operative venous thromboembolism events in a patient recovering from surgery, wherein administration of said medicament to said patient results in the patient experiencing fewer post-operative venous thromboembolism events than would result from subcutaneous administration to the patient of 40 mg per day of enoxaparin.
• Aspect 53 The use according to aspect 52, wherein the patient is recovering from abdominal surgery, knee replacement surgery, or hip replacement surgery.
• Aspect 54 The use according to aspect 52 or aspect 53, wherein the daily dose of milvexian, or pharmaceutically acceptable salt thereof, is 50 mg.
• Aspect 55 The use according to aspect 52 or aspect 53, wherein the daily dose of milvexian, or pharmaceutically acceptable salt thereof, is 100 mg.
• Aspect 56 The use according to aspect 52 or aspect 53, wherein the daily dose of milvexian, or pharmaceutically acceptable salt thereof, is 150 mg.
• Aspect 58 The use according to any one of aspects 52 to 57, wherein the daily dose of milvexian, or pharmaceutically acceptable salt thereof, is administered in a single dose.
• Aspect 59 The use according to any one of aspects 52 to 57, wherein the daily dose of milvexian, or pharmaceutically acceptable salt thereof, is administered in divided doses.
• Aspect 60 Use of a solid dosage form of milvexian, or pharmaceutically acceptable salt thereof, for manufacture of a medicament adapted for once or twice daily administration to a patient for treating or preventing a venous thromboembolic disorder wherein said administration results in an incidence rate of total venous thromboembolism events in the patient that is less than 25% with an alpha of 5%.
• Aspect 61 The use of aspect 60, wherein the incidence rate of total venous thromboembolism events is less than 20 %.
• Aspect 62 The use of aspect 60, wherein the incidence rate of total venous thromboembolism events is less than 15%
• Aspect 63 The use of aspect 60, wherein the incidence rate of total venous thromboembolism events is less than 10%.
• Aspect 64 The use of aspect 60, wherein the milvexian, or pharmaceutically acceptable salt thereof is administered at a total daily dose ranging from 50 mg to 400 mg.
• Aspect 65 The use of aspect 60, wherein the milvexian, or pharmaceutically acceptable salt thereof is administered at the total daily dose selected from the group consisting of 50 mg, 100 mg, 200 mg, and 400 mg.
• Aspect 66 The use of aspect 60, wherein the milvexian, or pharmaceutically acceptable salt thereof is administered at the total daily dose of 50 mg.
• Aspect 67 The use of aspect 60, wherein the milvexian, or pharmaceutically acceptable salt thereof is administered at the total daily dose of 100 mg.
• Aspect 68 The use of aspect 60, wherein the milvexian, or pharmaceutically acceptable salt thereof is administered at the total daily dose of 150 mg.
• Aspect 69 The use of aspect 60, wherein the milvexian, or pharmaceutically acceptable salt thereof is administered at the total daily dose of 200 mg.
• Aspect 70 The use of aspect 60, wherein the milvexian, or pharmaceutically acceptable salt thereof is administered at the total daily dose of 400 mg.
• Aspect 71 The use of any one of aspects 60 to 70, wherein milvexian is administered twice daily.
• Aspect 72 The use of any one of aspects 60 to 70, wherein milvexian is administered once daily.
• Aspect 73 The use of any one of aspects 60 to 72, wherein the rate of venous thromboembolism occurs in a dose dependent manner without increasing the risk of bleeding compared with enoxaparin.
• Aspect 74 The use of any one of aspects 60 to 73, wherein the therapeutically effective amount is clinically proven effective in achieving less than 25 % of the incidence rate of total venous thromboembolism events in the patient treated with milvexian, or pharmaceutically acceptable salt thereof.
• the study was a randomized, open-label, study drug-dose blind, multicenter study to evaluate the efficacy and safety of milvexian, an oral factor Xia inhibitor, versus subcutaneous enoxaparin in subjects undergoing elective total knee replacement surgery.
• VTE total venous thromboembolism
• DVT distal deep vein thrombosis
• PE nonfatal pulmonary embolism
• This study was a dose guiding study for the direct factor Xia inhibitor milvexian.
• the objective of the study was the assessment of safety, tolerability and efficacy of milvexian at different oral doses (twice daily (BID or bid) and once daily (QD or qd)) compared with subcutaneously administered enoxaparin 40 mg in the prevention of venous thromb oemboli sm .
• the study is a Phase 2, open-label, double-blinded, randomized, active- controlled, multicenter dose-ranging study of milvexian in subjects undergoing primary elective unilateral total knee replacement (TKR) surgery.
• TRR total knee replacement
• the study used a prospective, randomized, open-label, blinded endpoint (PROBE) design.
• the milvexian 25 mg once daily dose-regimen was halted by an unblinded Operations Committee (OC), responsible for reviewing ongoing safety and efficacy data by subject treatment assignments approximately every 3 to 8 weeks, during an ad hoc interim analysis (IA); enrollment in the 25 mg once daily milvexian treatment arm was truncated at 34 subjects. At that time, an amendment to the protocol allowed for the initiation of a milvexian 50 mg once daily regimen. Under a subsequent recommendation of the OC, the randomization ratio was modified enabling the milvexian 50 mg once daily arm to achieve it full complement of 150 subjects randomized.
• Figure 1 provides the study design, including number of subjects randomized into each study arm.
• the study consisted of three phases: an up to 30-day screening phase before TKR surgery, a 10 to 14 day postoperative dosing phase (mean duration of treatment for both the milvexian- and enoxaparin-treated groups was 11.7 days) and a 4-week follow up phase.
• the first dose of milvexian was administered 12 to 24 hours post-surgery which was defined as beginning at wound closure.
• the primary efficacy outcome was venous thromboembolism, defined as the composite of asymptomatic deep-vein thrombosis (detected by mandatory unilateral venography performed 10 to 14 days after surgery), confirmed symptomatic venous thromboembolism (symptomatic deep-vein thrombosis of the leg or nonfatal pulmonary embolism), or death.
• Unilateral venography performed only on the operated leg detects over 90% of deep-vein thrombosis in patients undergoing unilateral knee arthroplasty and reduces the risk for the patient (Buller et al. Factor XI antisense oligonucleotide for prevention of venous thrombosis.
• the major secondary efficacy outcomes were: (a) proximal deep-vein thrombosis (symptomatic or asymptomatic), (b) distal deep-vein thrombosis (symptomatic or asymptomatic) (c) nonfatal pulmonary embolism, and (d) death.
• An exploratory efficacy outcome was the extent of venous thrombosis on venography, which was assessed by the adjudication committee using predefined categories.
• the principal safety outcome was any bleeding, which was defined as the composite of major, clinically relevant nonmajor, and minimal bleeding. Secondary safety outcomes were: (a) major bleeding, (b) clinically relevant nonmajor bleeding, (c) clinically relevant bleeding, defined as the composite of major and clinically relevant nonmajor bleeding, and (d) minimal bleeding. Bleeding was classified as major if it was overt and associated with a decrease in hemoglobin of 2 g/dL or more or necessitated transfusion of 2 or more units of blood with a temporal association within 24 to 48 hours of the bleed; or if it occurred in a critical area or organ or contributed to death.
• Bleeding at the surgical site was defined as major only if it required intervention; caused hemodynamic instability; or caused hemarthrosis that delayed mobilization or wound healing and resulted in prolonged hospitalization or deep wound infection. Overt bleeding not meeting the criteria for major bleeding, but that necessitated medical examination or intervention or had clinical consequences, was classified as clinically relevant nonmajor bleeding. Bleeding not meeting the criteria for major or clinically relevant nonmajor bleeding was classified as minimal bleeding (Schulman et al., Definition of major bleeding in clinical investigations of antihemostatic medicinal products in surgical patients. J Thromb Haemost 2010;8:202-4).
• the activated partial -thromboplastin time and prothrombin time were measured in a central laboratory using Actin FS and Innovin, respectively (Siemens Healthcare, Tarrytown, NY). Activated partial-thromboplastin time and prothrombin time ratios were calculated by dividing postoperative values by those measured preoperatively.
• the primary efficacy outcome focused on twice-daily milvexian regimens because with a half-life of about 11 hours, milvexian is suitable for twice daily dosing.
• Proof-of-efficacy is defined as either a statistically significant doseresponse or a primary endpoint event rate for the combined BID milvexian groups that is statistically lower than 30% with 95% confidence interval (95%CI, one-sided alpha of 5%) from the network meta-analysis.
• Data from the network meta-analysis estimated the placebo incidence rate of total VTE to be 50% (95% CI, 40, 60).
• a more conservative incidence rate of 30% was chosen.
• the primary analysis for efficacy was performed in the modified intention- to-treat population, which included all patients who received at least one dose of study medication and had an evaluable venogram within the prespecified time window, a documented symptomatic venous thromboembolic event, or a fatal event.
• the rate of venous thromboembolism in the combined milvexian twice-daily dose groups was compared with 30% using the binomial test.
• Evidence for a dose-response trend with the twice-daily milvexian regimens was evaluated with the MCP-Mod framework using pre-specified models (Pinheiro et al., Model-based dose finding under model uncertainty using general parametric models. Statistics in Medicine 2014;33:1646-61).
• the risk ratio, and the corresponding confidence interval for each milvexian group relative to enoxaparin were calculated using the Cochran-Mantel-Haenszel method with study region as a stratification factor.
• VTE total venous thromboembolism events
• Efficacy outcomes are provided in Table 2.
• the primary efficacy outcome occurred in 63 of 518 patients (12.2%) given twice daily milvexian; a rate significantly lower (P ⁇ 0.0001 (onesided)) than the prespecified benchmark of 30%. Thus, both proof-of-efficacy criteria were met.
• the primary objective of the study was to determine the efficacy of milvexian in preventing total VTE.
• Total VTE was defined as proximal and/or distal deep vein thrombosis ((DVT); asymptomatic confirmed by venography assessment or objectively confirmed symptomatic), nonfatal pulmonary embolism (PE), or any death during the 10-14 day treatment period.
• Proof-of efficacy was defined as either a statistically significant doseresponse or a primary endpoint event rate for the combined BID milvexian groups that was statistically lower than 30%.
• the study met this primary objective of total VTE for the pooled milvexian BID dose regimens compared to the prespecified target of 30% (with statistically significant reduction in total VTE (p ⁇ 0.0001 (one-sided))).
• RR Relative Risk Ratio
• CI 95% Confidence Interval of the incidence rate
• Cochran-Mantel-Haenszel method with region as a stratification factor was used for the calculation of RR
• VTE Venous thromboembolism
• DVT - Deep vein thrombosis
• Table 3 Total VTE events, by event type, per clinical events committee, through day 14
• Milvexian at TDDs of >100 mg not only significantly reduced the number of total VTE events compared to enoxaparin, it also significantly reduced severity of DVT, the largest contributor to the number of total VTE events, in subjects with DVT.
• Venograms assessed by independent blinded adjucators, were used to identify, and to assign DVT severity scores to, subjects with DVT. For each assessed venogram, 11 segments were evaluated for the presence and extent of clot. For each evaluated segment, a severity score was assigned depending on the presence and, if present, extension of the clot in the segment of the vein.
• 0 no clot
• 1 less than 1/3
• 2 greater than or equal to 1/3 but less than 2/3
• 3 greater than 2/3 the length of the vein segment.
• Any Bleeding was defined as the composite of major bleeding according to the International Society on Thrombosis and Haemostasis (ISTH) criteria modified for the surgical setting, clinically relevant nonmajor bleeding events or minimal bleeding events as assessed by the clinical events committee (CEC).
• IHH International Society on Thrombosis and Haemostasis
• CEC clinical events committee
• the rates of venous thromboembolism were significantly lower with daily milvexian doses of 100 mg or more than that with enoxaparin.
• the bleeding outcomes are provided in Table 4.
• the principal safety outcome of any bleeding occurred in 38 of 923 patients (4.1%) given milvexian and in 12 of 296 patients (4.1%) given enoxaparin.
• Most bleeds were in the minimal category and involved the surgical site. There were no major bleeds with milvexian and 1 with enoxaparin. Rates of clinically relevant nonmajor bleeding with milvexian and enoxaparin were 0.8 % and 1.4 %, respectively.
• RR Relative Risk Ratio.
• CI 95% Confidence Interval of the incidence rate; Cochran-Mantel-Haenszel method with region as a stratification factor was used for the calculation of RR.
• On-Treatment period is defined as from the initial administration of the study drug through the day of last dose + 2 days.
• the middle line indicates the median; the top and bottom of the box indicate the upper and lower limits, respectively, of the interquartile range; and the vertical lines above and below the box indicate the upper and lower limits, respectively, of the range.
• the squares indicate rates of any bleeding, while the circles indicate the rates of clinically relevant bleeding, the composite of major and clinically relevant nonmajor bleeding.
• aPTT denotes activated partial-thromboplastin time.
• Thrombosis was induced by electrical stimulation of the control carotid artery for 3 minutes at 4 mA using an external stainless-steel bipolar electrode. Carotid blood flow was measured with an electromagnetic flow probe continuously over a 90-minute period to monitor thrombosis induced occlusion. Integrated carotid blood flow was measured by the area under the flowtime curve see Wong et al.). In addition, thrombus from the injured artery was removed, blotted twice on a weighing paper to remove residual fluid, and weighed.
• Fig. 7 shows the effects of vehicle and milvexian on carotid blood flow after thrombus induction in the prevention ECAT rabbit model. Following electric current stimulation, thrombus formation was induced, blood flow was decreased to zero, and the artery was occluded in about 40 to 45 minutes in vehicle-treated animals. Milvexian was associated with a dose-dependent increase in duration of the patency of the carotid artery.
• Fig. 8 shows the effects of vehicle and milvexian on integrated blood flow in the prevention ECAT rabbit model. Integrated blood flow averaged 11 ⁇ 2% in vehicle-treated animals following thrombus induction. By blocking the formation of thrombus, milvexian was associated with a dose-dependent increase in integrated blood flow. At the highest dose, integrated blood flow was 76 + 5% of the control level.
• Milvexian was associated with a dose-dependent reduction in thrombus weight. At the highest dose, thrombus weight was reduced by 70 + 2% of the control level.
• Fig. 10 shows ex vivo effects of milvexian on aPTT, TT, and PT. Milvexian elevated aPTT significantly at the highest 2 doses and did not alter TT and PT significantly, consistent with the mechanism of FXIa inhibition.
• Fig. 11 also shows that a 1.6-fold prolongation of aPTT may be needed to achieve 50% thrombus weight reduction in this model.
• Fig 12 shows antithrombotic effects of vehicle and milvexian in the treatment ECAT.
• blood flow was gradually decreased to similar levels at 15 min among different groups.
• the rabbit ECAT model described by Wong et al. was used in the rabbit ECAT study (Wang et al. J. Pharmacol. Exp. Ther. 295:212-8, 2002).
• the ECAT model was conducted 3 to 4 days after the last dose of vehicle, FXLASO2, or FXLASO1.
• FXI-ASO1 has the nominal nucleotide sequence of GTAACATGTGCCCTTTCCTT and is complementary to a sequence within rabbit FXI mRNA.
• FXLASO2 control ASO
• Oligonucleotides were chemically modified with phosphorothioate in the backbone and 2'-O-methoxyethyl on the wings with a central deoxy gap (so-called 5-10-5 design). Cytosine bases were rendered as 5 -methylcytosine.
• Thrombosis was induced by electrical stimulation of the carotid artery for 3 min at 4 mA using an external stainless-steel bipolar electrode. Carotid blood flow was measured with an electromagnetic flow probe continuously beginning 30 min before the electrical stimulation and over a 90-min period after stimulation to monitor thrombosis-induced occlusion.
• Integrated carotid blood flow as a percentage of pre-electrical stimulation control period, was measured by the area under the flow-time curve.
• thrombus from the injured artery was removed, blotted twice on a weighing paper to remove residual fluid, and weighed.
• FXI-ASO2 did not reduce thrombus weight.
• FXI-ASO1 caused a dosedependent reduction in thrombus weight.
• thrombus weight was reduced by 82% as compared to vehicle.
• Figure 13 shows the dose-dependent decrease in FXI levels and clot weight observed in the rabbit ECAT model with ASO-induced inhibition of FXI.

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