WO2023076404A1

WO2023076404A1 - Methods for treating systemic lupus erythematosus

Info

Publication number: WO2023076404A1
Application number: PCT/US2022/047908
Authority: WO
Inventors: Isaac HAKIM; Aaron DAUGHERTY; Sana MUJAHID; Anjali Pandey
Original assignee: Aria Pharmaceuticals, Inc.
Priority date: 2021-10-27
Filing date: 2022-10-26
Publication date: 2023-05-04

Abstract

Provided is a method for treating systemic lupus erythematosus (SLE) in a patient in need thereof comprising administering a therapeutically effective amount of a leucine-rich repeat kinase 2 (LRRK2) inhibitor.

Description

METHODS FOR TREATING SYSTEMIC LUPUS ERYTHEMATOSUS

CROSS REFERENCE TO RELATED APPLICATIONS

[0001] This application claims the benefit under 35 U.S.C. §119(e) to U.S. Provisional Application Numbers 63/272,560, filed October 27, 2021, which is incorporated by reference in its entirety.

FIELD

[0002] Provided is a method for treating systemic lupus erythematosus (SLE) in a patient in need thereof comprising administering a therapeutically effective amount of a leucine -rich repeat kinase 2 (LRRK2) inhibitor.

BACKGROUND

[0003] Systemic lupus erythematosus (SLE) is an autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs. It can affect the joints, skin, brain, lungs, kidneys, and blood vessels. The causes of SLE are unknown, but are believed to be linked to environmental, genetic, and hormonal factors.

[0004] SLE treatment consists primarily of immunosuppressive drugs that inhibit activity of the immune system. Hydroxychloroquine and corticosteroids (e.g., prednisone) are often used to treat SLE. The FDA approved belimumab in 2011 , the first new drug for SLE in more than 50 years. As there is no known cure for SLE, treatment generally involves identifying and treating the signs and symptoms of each individual patient. The signs and symptoms of SLE depend on which body systems are affected by the disease, and most commonly include fatigue, fever, joint pain, stiffness and swelling, rashes, such as a butterfly-shaped rash on the face that covers the cheeks and bridge of the nose, or rashes elsewhere on the body, skin lesions that appear or worsen with sun exposure, fingers and toes that turn white or blue when exposed to cold or during stressful periods, shortness of breath, chest pain, dry eyes, headaches, confusion, or memory loss. Other symptoms can include sun sensitivity, oral ulcers, arthritis, lung problems, heart problems, kidney problems, seizures, psychosis, and blood cell and immunological abnormalities.

[0005] Medications most commonly used to control lupus include nonsteroidal anti-inflammatory drugs (NSAIDs), antimalarial drugs, corticosteroids, immunosuppressants, and biologies. However, each can have side effects when taken chronically and/or in high doses.

[0006] Over-the-counter NSAIDs, such as naproxen sodium (Aleve) and ibuprofen (Advil, Motrin IB, others), may be used to treat pain, swelling and fever associated with lupus, with stronger NSAIDs available by prescription. Side effects of NSAIDs may include stomach bleeding, kidney problems, and an increased risk of heart problems.

[0007] Medications commonly used to treat malaria, such as hydroxychloroquine (Plaquenil), affect the immune system and can help decrease the risk of lupus flares. Side effects can include stomach upset and, very rarely, damage to the retina of the eye. Regular eye exams are recommended when taking these medications.

[0008] Prednisone and other types of corticosteroids can counter the inflammatory symptoms of lupus. High doses of steroids such as methylprednisolone (Medrol) are often used to control serious disease that involves the kidneys and brain. Side effects include weight gain, easy bruising, thinning bones, high blood pressure, diabetes, and increased risk of infection. The risk of side effects increases with higher doses and longer term therapy.

[0009] Drugs that suppress the immune system may be helpful in serious cases of lupus. Examples include azathioprine (Imuran, Azasan), mycophenolate (Cellcept), methotrexate (Trexall, Xatmep, others), cyclosporine (Sandimmune, Neoral, Gengraf), voclosporin (Lupkynis), and leflunomide (Arava). Potential side effects may include an increased risk of infection, liver damage, decreased fertility, and an increased risk of cancer.

[0010] The biologic belimumab (Benlysta) administered intravenously, also reduces lupus symptoms in some people. Side effects include nausea, diarrhea, and infections. Rarely, worsening of depression can occur. Rituximab (Rituxan, Truxima), also a biologic, may be beneficial for some people in whom other medications have not helped. Side effects include allergic reaction to the intravenous infusion and infections.

[0011] Among some adults, having a period of SLE symptoms, referred to as flares, may happen every so often, sometimes even years apart, and go away at other times (i.e., remission). However, other adults may experience SLE flares more frequently throughout their life.

[0012] Given the limited treatments available, as well as the potential for side effects from these treatments, people with lupus seek alternative or complementary medicine. Thus, a need exists for therapeutic agents for treating systemic lupus erythematosus (SLE).

SUMMARY

[0013] Systemic lupus erythematosus (SLE) is a prototypic autoimmune disease characterized by the presence of pathogenic autoantibodies associated with polyclonal B cell hyperreactivity causing a person’s immune system to attack the body’s own organs and tissues. Almost every system of the body can be affected by SLE.

[0014] It has been discovered that a LRRK2 inhibitor was effective at treating SLE in a mouse model, as evidence by a preservation of kidney function in test subjects with hyperactive, self-reactive B and T cells, autoantibodies directed against nuclear antigens, and defective clearance of immune complexes. Subjects displayed decreased production of double-stranded DNA antibody (anti-dsDNA antibody), decreased concentration of blood urea nitrogen (BUN), and decreased proteinuria compared with a control group. This indicates a decrease in damage to the kidneys of the subjects associated with the uncontrolled inflammation and immune response to apoptotic cell debris associated with dysfunctional immune responses, such as SLE.

[0015] Provided herein are methods for treating systemic lupus erythematosus (SLE), comprising administering to a patient in need thereof, a therapeutically effective amount of a leucine -rich repeat kinase 2 (LRRK2) inhibitor.

[0016] Provided herein are methods for treating systemic lupus erythematosus (SLE), comprising administering to a patient in need thereof, a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof.

[0017] Also provided herein are methods for treating systemic lupus erythematosus (SLE), comprising administering to a patient in need thereof, a pharmaceutical composition, comprising a therapeutically effective amount of a leucine-rich repeat kinase 2 (LRRK2) inhibitor, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0018] Also provided herein are methods for treating systemic lupus erythematosus (SLE), comprising administering to a patient in need thereof, a pharmaceutical composition, comprising a therapeutically effective amount of Compound 1 , or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

[0019] Also provided herein are methods for treating systemic lupus erythematosus (SLE), comprising administering an effective amount of a leucine -rich repeat kinase 2 (LRRK2) inhibitor to a patient in need thereof, wherein said patient also suffers from Sjogren’s syndrome, antiphospholipid syndrome, thyroiditis, hemolytic anemia, or idiopathic thrombocytopenia purpura.

[0020] Also provided herein are methods for treating systemic lupus erythematosus (SLE), comprising administering an effective amount of Compound 1 , or a pharmaceutically acceptable salt thereof, to a patient in need thereof, wherein said patient also suffers from Sjogren’s syndrome, antiphospholipid syndrome, thyroiditis, hemolytic anemia, or idiopathic thrombocytopenia purpura.

[0021] Also provided herein are methods for improving kidney function, comprising administering to a patient in need thereof, a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof.

[0022] Also provided herein are methods for inhibiting the production of double-stranded DNA antibody (anti-dsDNA antibody), comprising administering to a patient in need thereof, a therapeutically effective amount of Compound 1 , or a pharmaceutically acceptable salt thereof.

[0023] Also provided herein are methods for decreasing the concentration of blood urea nitrogen (BUN), comprising administering to a patient in need thereof, a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof. [0024] Also provided herein are methods for decreasing proteinuria, comprising administering to a patient in need thereof, a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof.

[0025] Also provided herein are methods for treating systemic lupus erythematosus (SLE), comprising administering to a patient in need thereof, a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof, wherein the treating comprises inhibiting, lessening, or delaying the onset or progression of, fatigue, fever, joint pain, joint stiffness, joint swelling, rashes, skin lesions, shortness of breath, chest pain, dry eyes, headaches, confusion, memory loss, sun sensitivity, oral ulcers, arthritis, lung damage, heart problems, kidney damage, lupus nephritis, lymphadenopathy, seizures, psychosis, blood cell abnormalities, or immunological abnormalities.

[0026] Also provided herein are methods for treating systemic lupus erythematosus (SLE), comprising administering to a patient in need thereof, a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof, wherein the treating comprises inhibiting, lessening, or delaying the onset or progression of, skin lesions, lymphadenopathy, kidney damage, lupus nephritis, or inflammation.

[0027] Also provided herein are methods for treating systemic lupus erythematosus (SLE), comprising administering to a patient in need thereof, a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof, wherein the patient is experiencing a lupus flare.

BRIEF DESCRIPTION OF THE FIGURES

[0028] FIG. 1 shows the lymphadenopathy scores for mouse test groups over the course of study, with a group treated only with oral gavage vehicle comprising 0.5% carboxymethyl cellulose (CMC) and 5% DMSO, a reference group which received cyclophosphamide (Cyc), and a group treated with Compound 1. The group treated with Compound 1 displayed a decrease in lymphadenopathy score at days 42, 48, and 56.

[0029] FIG. 2 shows the skin lesion scores for mouse test groups over the course of study, with a group treated only with oral gavage vehicle comprising 0.5% carboxymethyl cellulose (CMC) and 5% DMSO, a reference group which received cyclophosphamide (Cyc), and a group treated with Compound 1. The group treated with Compound 1 displayed a statistically significant decrease (p value = < 0.0001) in skin lesions.

[0030] FIG. 3 shows the lymph node weight of samples collected from a group treated only with oral gavage vehicle comprising 0.5% carboxymethyl cellulose (CMC) and 5% DMSO, a reference group which received cyclophosphamide (Cyc), and a group treated with Compound 1. The group treated with Compound 1 exhibited a reduction in the inguinal lymph node weight, but it was not statistically significant (p = 0.06) when compared to animals treated with only vehicle. [0031] FIG. 4 shows the proteinuria scores for mouse test groups over the course of study, with a group treated only with oral gavage vehicle comprising 0.5% carboxymethyl cellulose (CMC) and 5% DMSO, a reference group which received cyclophosphamide (Cyc), and a group treated with Compound 1. The group treated with Compound 1 displayed a non-statistical decrease in urine protein content when compared to that seen in the group treated with only vehicle.

[0032] FIG. 5 shows the blood urea nitrogen for samples collected from a group treated only with oral gavage vehicle comprising 0.5% carboxymethyl cellulose (CMC) and 5% DMSO, a reference group which received cyclophosphamide (Cyc), and a group treated with Compound 1. The group treated with Compound 1 showed a similar decrease (p = < 0.05) in blood urea content as was observed in the group treated with cyclophosphamide.

[0033] FIG. 6 shows the anti-dsDNA IgG response in a group treated only with oral gavage vehicle comprising 0.5% carboxymethyl cellulose (CMC) and 5% DMSO, a reference group which received cyclophosphamide (Cyc), and a group treated with Compound 1. The group treated with Compound 1 displayed comparable levels of anti-dsDNA antibodies to those treated with only vehicle. The cyclophosphamide test group showed a non-statistically significant reduction in anti-dsDNA antibodies.

[0034] FIG. 7 shows tubule basophilia scores for samples collected from a group treated only with oral gavage vehicle comprising 0.5% carboxymethyl cellulose (CMC) and 5% DMSO, a reference group which received cyclophosphamide (Cyc), and a group treated with Compound 1. The group treated with Compound 1 displayed a statistically significant decrease (p = 0.01-0.05) in tubule basophilia histology score as compared to those treated with only vehicle.

[0035] FIG. 8 shows tubule dilation/casts scores for samples collected from a group treated only with oral gavage vehicle comprising 0.5% carboxymethyl cellulose (CMC) and 5% DMSO, a reference group which received cyclophosphamide (Cyc), and a group treated with Compound 1. The group treated with Compound 1 displayed a reduction in score with p = 0.1.

[0036] FIG. 9 shows glomerulonephritis scores for samples collected from a group treated only with oral gavage vehicle comprising 0.5% carboxymethyl cellulose (CMC) and 5% DMSO, a reference group which received cyclophosphamide (Cyc), and a group treated with Compound 1. The group treated with Compound 1 displayed a reduction in score with p = 0.1.

[0037] FIG. 10 shows chronic interstitial inflammation scores for samples collected from a group treated only with oral gavage vehicle comprising 0.5% carboxymethyl cellulose (CMC) and 5% DMSO, a reference group which received cyclophosphamide (Cyc), and a group treated with Compound 1. The group treated with Compound 1 displayed a statistically significant reduction (p = 0.01-0.05) in chronic interstitial inflammation, as compared to those treated with only vehicle.

[0038] FIG. 11 shows chronic papillary inflammation scores for samples collected from a group treated only with oral gavage vehicle comprising 0.5% carboxymethyl cellulose (CMC) and 5% DMSO, a reference group which received cyclophosphamide (Cyc), and a group treated with Compound 1. The group treated with Compound 1 displayed a reduction in chronic papillary inflammation, when compared to those treated with only vehicle.

[0039] FIG. 12 shows the summation of histology scores for a group treated only with oral gavage vehicle comprising 0.5% carboxymethyl cellulose (CMC) and 5% DMSO, a reference group which received cyclophosphamide (Cyc), and a group treated with Compound 1. The group treated with Compound 1 displayed an overall statistically significant reduction (p = < 0.01-0.05) in histology scores, as compared to those treated only with vehicle.

DETAILED DESCRIPTION

Definitions

[0040] Unless defined otherwise, all technical and scientific terms used herein have the same meaning as is commonly understood by one of ordinary skill in the art. As used herein, the below terms have the following meanings unless specified otherwise. Any methods, devices, and materials similar or equivalent to those described herein can be used in the practice of the compositions and methods described herein. The following definitions are provided to facilitate understanding of certain terms used frequently herein and are not meant to limit the scope of the present disclosure. All references referred to herein are incorporated by reference in their entirety.

[0041] It is noted here that as used in this specification and the appended claims, the singular forms “a” “an” and “the” and the like include plural referents unless the context clearly dictates otherwise.

[0042] The term “about” or “approximately” means within ± 30%, 20%, 15%, 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, 1%, 0.5%, or 0.05% of a given value or range. In some embodiments, “about” means ± 5% of a given value or range. In some embodiments, “about” means ± 4% of a given value or range. In some embodiments, “about” means ± 3% of a given value or range. In some embodiments, “about” means ± 2% of a given value or range. In some embodiments, “about” means ± 1% of a given value or range. In another embodiment, about means ± 0.5% of a given value or range. In some embodiments, “about” means ± 0.05% of a given value or range.

[0043] “Pharmaceutically acceptable” or “physiologically acceptable” refer to compounds, salts, compositions, dosage forms, and other materials which are useful in preparing a pharmaceutical composition that is suitable for human or veterinary pharmaceutical use.

[0044] The term “pharmaceutically acceptable salt” of a given compound refers to salts that retain the biological effectiveness and properties of the given compound, and which are not biologically or otherwise undesirable. “Pharmaceutically acceptable salts” or “physiologically acceptable salts” include, for example, salts with inorganic acids and salts with an organic acid. In addition, if the compounds described herein are obtained as an acid addition salt, the free base can be obtained by basifying a solution of the acid salt. Conversely, if the product is a free base, an addition salt, particularly a pharmaceutically acceptable addition salt, may be produced by dissolving the free base in a suitable organic solvent and treating the solution with an acid, in accordance with conventional procedures for preparing acid addition salts from base compounds. Those skilled in the art will recognize various synthetic methodologies that may be used to prepare nontoxic pharmaceutically acceptable addition salts. Pharmaceutically acceptable acid addition salts may be prepared from inorganic and organic acids. Salts derived from inorganic acids include hydrochloric acid, hydrobromic acid, sulfuric acid, nitric acid, phosphoric acid, and the like. Salts derived from organic acids include acetic acid, propionic acid, glycolic acid, pyruvic acid, oxalic acid, malic acid, malonic acid, succinic acid, maleic acid, fumaric acid, tartaric acid, citric acid, benzoic acid, cinnamic acid, mandelic acid, methanesulfonic acid, ethanesulfonic acid, p-toluene-sulfonic acid, salicylic acid, and the like. Likewise, pharmaceutically acceptable base addition salts can be prepared from inorganic and organic bases. Salts derived from inorganic bases include, by way of example only, sodium, potassium, lithium, ammonium, calcium, and magnesium salts. Salts derived from organic bases include, but are not limited to, salts of primary, secondary, and tertiary amines. Specific examples of suitable amines include, by way of example only, isopropylamine, trimethyl amine, diethyl amine, tri(iso-propyl) amine, tri(n-propyl) amine, ethanolamine, 2- dimethylaminoethanol, piperazine, piperidine, morpholine, N-ethylpiperidine, and the like.

[0045] As used herein, the term “administration” refers to introducing an agent into a patient. For example, a therapeutic amount can be administered to the patient, which can be determined by the treating physician, medical professional, or the like. In some embodiments, an oral route of administration is preferred. The related terms and phrases “administering” and “administration of,” when used in connection with a compound or tablet (and grammatical equivalents) refer both to direct administration, which may be administration to a patient by a medical professional or by selfadministration by the patient, and/or to indirect administration, which may be the act of prescribing a drug. Administration entails delivery to the patient of the drug.

[0046] The term “dose” or “dosage” refers to the total amount of an active agent (e.g., a LRRK2 inhibitor or a pharmaceutically acceptable salt thereof) administered to a patient in a single day (24-hour period). The desired dose can be administered once daily. In some embodiments, the desired dose may be administered in one, two, three, four or more sub-doses at appropriate intervals throughout the day, where the cumulative amount of the sub-doses equals the amount of the desired dose administered in a single day. The terms “dose” and “dosage” are used interchangeably herein.

[0047] As used herein, “therapeutically effective amount” or “therapeutic amount” refers to an amount of a drug or an agent (e.g., a LRRK2 inhibitor or a pharmaceutically acceptable salt thereof) that when administered to a patient suffering from a condition, will have the intended therapeutic effect, e.g., alleviation, amelioration, palliation or elimination of one or more manifestations of the condition in the patient. The full therapeutic effect does not necessarily occur by administration of one dose, and can occur only after administration of a series of doses and can be administered in one dose form or multiples thereof. Thus, a therapeutically effective amount may be administered in one or more administrations.

[0048] As used herein, the term “patient” refers to a mammal, such as a human, bovine, rat, mouse, dog, monkey, ape, goat, sheep, cow, or deer. A patient as described herein can be a human.

[0049] As used herein, “treatment,” “treating,” and “treat” are defined as acting upon a disease, disorder, or condition with an agent to reduce or ameliorate the harmful or any other undesired effects of the disease, disorder, or condition and/or its symptoms. Treatment, as used herein, covers the treatment of a human patient, and includes: (a) reducing the risk of occurrence of the condition in a patient determined to be predisposed to the disease but not yet diagnosed as having the condition, (b) impeding the development of the condition, and/or (c) relieving the condition, i.e., causing regression of the condition and/or relieving one or more symptoms of the condition.

Methods of Treatment

[0050] Provided herein are methods for treating systemic lupus erythematosus (SLE), comprising administering a therapeutically effective amount of a leucine -rich repeat kinase 2 (LRRK2) inhibitor to a patient in need thereof.

[0051] In some embodiments, the LRRK2 inhibitor is Compound 1, MLi-2, IKK 16, IKK 16 hydrochloride, PF-06447475, PFE-360, GNE-7915, GNE-7915 tosylate, CZC-54252, CZC-54252 hydrochloride, GNE0877, LRRK2-IN-1, TAE684, G1023, BMPPB-32, PF-06371900, sunitinib, Nov- LRRK2-11, A-(2-methoxyethyl)-3-(phenylsulfonamido)benzamide, HG-10-102-01, GNE-9605, JH-II- 127, CZC-25146, CZC-25146 hydrochloride, LRRK2 inhibitor 1, DNL201, or DNL151. In some embodiments, the LRRK2 inhibitor is Compound 1. In some embodiments, the LRRK2 inhibitor is MLi- 2. In some embodiments, the LRRK2 inhibitor is IKK 16. In some embodiments, the LRRK2 inhibitor is IKK 16 hydrochloride. In some embodiments, the LRRK2 inhibitor is PF-06447475. In some embodiments, the LRRK2 inhibitor is PFE-360. In some embodiments, the LRRK2 inhibitor is GNE- 7915. In some embodiments, the LRRK2 inhibitor is GNE-7915 tosylate. In some embodiments, the LRRK2 inhibitor is CZC-54252. In some embodiments, the LRRK2 inhibitor is CZC-54252 hydrochloride. In some embodiments, the LRRK2 inhibitor is GNE0877. In some embodiments, the LRRK2 inhibitor is LRRK2-IN-1. In some embodiments, the LRRK2 inhibitor is TAE684. In some embodiments, the LRRK2 inhibitor is G1023. In some embodiments, the LRRK2 inhibitor is BMPPB- 32. In some embodiments, the LRRK2 inhibitor is PF-06371900. In some embodiments, the LRRK2 inhibitor is sunitinib. In some embodiments, the LRRK2 inhibitor is Nov-LRRK2-ll. In some embodiments, the LRRK2 inhibitor is A-(2-methoxyethyl)-3-(phenylsulfonamido)benzamide. In some embodiments, the LRRK2 inhibitor is HG-10-102-01. In some embodiments, the LRRK2 inhibitor is GNE-9605. In some embodiments, the LRRK2 inhibitor is JH-II-127. In some embodiments, the LRRK2 inhibitor is CZC-25146. In some embodiments, the LRRK2 inhibitor is CZC-25146 hydrochloride. In some embodiments, the LRRK2 inhibitor is LRRK2 inhibitor 1. In some embodiments, the LRRK2 inhibitor is DNL201. In some embodiments, the LRRK2 inhibitor is DNL151. In some embodiments, the LRRK2 inhibitor is EB-42486. In some embodiments, the LRRK2 inhibitor is G2019S-LRRK2 inhibitor 38. In some embodiments, the LRRK2 inhibitor is G2019S-LRRK2 inhibitor 22. In some embodiments, the LRRK2 inhibitor is LRRK2 inhibitor 18. In some embodiments, the LRRK2 inhibitor is LRRK2-IN- 3. In some embodiments, the LRRK2 inhibitor is LRRK2-IN-2. In some embodiments, the LRRK2 inhibitor is LRRK2-IN-4. In some embodiments, the LRRK2 inhibitor is XL01126. In some embodiments, the LRRK2 inhibitor is PF-06456384.

[0052] Also provided herein are methods of treating systemic lupus erythematosus (SLE), comprising administering a composition, comprising a therapeutically effective amount of a leucine-rich repeat kinase 2 (LRRK2) inhibitor and a pharmaceutically acceptable carrier, to a patient in need thereof.

[0053] Also provided herein are methods of improving kidney function, comprising administering a therapeutically effective amount of a leucine-rich repeat kinase 2 (LRRK2) inhibitor to a patient in need thereof.

[0054] Also provided herein is a method for inhibiting the production of double-stranded DNA antibody (anti-dsDNA antibody), comprising administering a therapeutically effective amount of a leucine -rich repeat kinase 2 (LRRK2) inhibitor to a patient in need thereof.

[0055] Also provided herein is a method for decreasing the concentration of blood urea nitrogen (BUN), comprising administering a therapeutically effective amount of a leucine-rich repeat kinase 2 (LRRK2) inhibitor to a patient in need thereof.

[0056] Also provided is a method of decreasing proteinuria, comprising administering a therapeutically effective amount of a leucine-rich repeat kinase 2 (LRRK2) inhibitor to a patient in need thereof.

[0057] In some embodiments, the therapeutically effective amount of a leucine-rich repeat kinase 2 inhibitor treats systemic lupus erythematosus in a patient in need thereof by suppressing inflammation.

[0058] In some embodiments, the therapeutically effective amount of a leucine-rich repeat kinase 2 inhibitor treats systemic lupus erythematosus in a patient in need thereof by inducing phagocyte autophagy.

[0059] In some embodiments, the patient is female. In some embodiments, the patient is less than 50 years of age.

[0060] In some embodiments, the patient also suffers from other autoimmune conditions, like Sjogren’s syndrome, antiphospholipid syndrome, thyroiditis, hemolytic anemia, and idiopathic thrombocytopenia purpura. In some embodiments, the patient does not also suffer from other autoimmune conditions. Leucine-Rich Repeat Kinase 2 (LRRK2) Inhibitors

[0061] Leucine -rich repeat kinase 2 (LRRK2) inhibitors are a class of compounds capable of suppressing inflammation and inducing phagocyte autophagy involved throughout the innate and adaptive immune response. Similarly, LRRK2 inhibitors are capable of inhibiting macrophage differentiation, infiltration, and activation, as well as autophagy in B cells and macrophages. Monocyte recruitment and differentiation of IL-1, 6, 12, and TNF-a secreting macrophages are also decreased by LRRK2 inhibitors. Further, LRRK2 inhibitors have been shown to inhibit pro-inflammatory signaling, as well as cytokine expression and oxidative stress, while decreasing p62 expression and NF-KB activity. LRRK2 inhibition can block or reverse phenotypic changes associated with SLE, while maintaining excellent tolerability.

[0062] LRRK2 inhibitors are described in at least U.S. Pat. Nos 8,206,942, 8,404,677, 8,629,132, 9,156,845, 9,365,551, 9,493,452, 9,499,542, 9,642,855, 9,675,594, 9,695,171, 10,023,579, 10,039,753, 10,087,186, 10,294,235, 10,618,901, 10,913,744, 10,975,081, 11,028,080, and 11,034,696, and published WIPO applications WO 2009/030270, WO 2009/127642, WO 2010/080712, WO 2010/08579, WO 2011/038572, WO 2011/053861, WO 2011/057204, WO 2011/060295, WO 2011/106168, WO 2011/141756, WO 2011/151360, WO 2012/028629, WO 2012/038743, WO 2012/058193, WO 2012/062783, WO 2012/118679, WO 2012/135631, WO 2012/143143, WO 2012/143144, WO 2012/162254, WO 2012/178015, WO 2013/046029, WO 2013/139882, WO 2013/164321, WO 2013/166276, and WO 2014/001973, which are incorporated herein by reference. Examples of LRRK2 inhibitors include, but are not limited to, Compound 1, MLi-2, IKK 16, PF-06447475, PFE-360, GNE- 7915, CZC-54252, GNE0877, LRRK2-IN-1, TAE684, G1023, BMPPB-32, PF-06371900, sunitinib, Nov-LRRK2-ll, A-(2-methoxyethyl)-3-(phenylsulfonamido)benzamide, HG-10-102-01, GNE-9605, JH- 11-127, CZC-25146, LRRK2 inhibitor 1, DNL201, or DNL151.

[0063] LRRK2 inhibitors can be identified using a homogeneous time -resolved fluorescence (HTRF) assay that measures the inhibition of phosphorylation of the peptide substrate LRRKtide by baculoviral-derived recombinant 6His-Tev-LRRK2. Kinase selectivity can be assessed using standard radioactivity-based enzymatic assays against a panel of various kinases. While the direct phosphorylation substrates of LRRK2 in a cellular context are not yet validated, determining the phosphorylation of two residues known to be dependent on LRRK2 kinase activity, Ser910 and Ser935, provides insight into putative inhibitory activity of a compound in HEK293 cells transfected with LRRK2. Compounds can also be tested against endogenous phosphorylation of these two residues in human lymphoblastoid cells derived from a Parkinson’s disease patient homozygous for the LRRK2 G2019S variant.

[0064] In certain embodiments, the LRRK2 inhibitor is Compound 1, MLi-2, IKK 16, PF- 06447475, PFE-360, GNE-7915, CZC-54252, GNE0877, LRRK2-IN-1, TAE684, G1023, BMPPB-32, PF-06371900, sunitinib, Nov-LRRK2-l l, W(2-methoxyethyl)-3-(phenylsulfonamido)benzamide, HG- 10-102-01, GNE-9605, JH-II-127, CZC-25146, LRRK2 inhibitor 1, DNL201, DNL151, EB-42486, G2019S-LRRK2 inhibitor 38, G2019S-LRRK2 inhibitor 22, LRRK2 inhibitor 18, LRRK2-IN-3, LRRK2-IN-2, LRRK2-IN-4, XL01126, or PF-06456384, or a pharmaceutically acceptable salt thereof. In certain embodiments, the LRRK2 inhibitor is Compound 1, MLi-2, IKK 16, IKK 16 hydrochloride, PF- 06447475, PFE-360, GNE-7915, GNE-7915 tosylate, CZC-54252, CZC-54252 hydrochloride, GNE0877, LRRK2-IN-1, TAE684, G1023, BMPPB-32, PF-06371900, sunitinib, Nov-LRRK2-ll, N- 2- methoxyethyl)-3-(phenylsulfonamido)benzamide, HG-10-102-01, GNE-9605, JH-II-127, CZC-25146, CZC-25146 hydrochloride, LRRK2 inhibitor 1, DNL201, DNL151, EB-42486, G2019S-LRRK2 inhibitor 38, G2019S-LRRK2 inhibitor 22, LRRK2 inhibitor 18, LRRK2-IN-3, LRRK2-IN-2, LRRK2- IN-4, XL01126, or PF-06456384. Such LRRK2 inhibitors are available from the literature or commercial sources, such as from MedChemExpress USA, AdooQ Bioscience, and MedKoo Biosciences, Inc.

[0065] In certain embodiments, the LRRK2 inhibitor is Compound 1, MLi-2, IKK 16, PF- 06447475, PFE-360, GNE-7915, CZC-54252, GNE0877, LRRK2-IN-1, TAE684, G1023, BMPPB-32, PF-06371900, sunitinib, Nov-LRRK2-l l, N-(2-methoxyethyl)-3-(phenylsulfonamido)benzamide, HG- 10-102-01, GNE-9605, JH-II-127, CZC-25146, LRRK2 inhibitor 1, DNL201, or DNL151, or a pharmaceutically acceptable salt thereof. In certain embodiments, the LRRK2 inhibitor is Compound 1, MLi-2, IKK 16, IKK 16 hydrochloride, PF-06447475, PFE-360, GNE-7915, GNE-7915 tosylate, CZC- 54252, CZC-54252 hydrochloride, GNE0877, LRRK2-IN-1, TAE684, G1023, BMPPB-32, PF- 06371900, sunitinib, Nov-LRRK2-l l, N-(2-methoxyethyl)-3-(phenylsulfonamido)benzamide, HG-10- 102-01, GNE-9605, JH-II-127, CZC-25146, CZC-25146 hydrochloride, LRRK2 inhibitor 1, DNL201, or DNL151. Such LRRK2 inhibitors are available from the literature or commercial sources, such as from MedChemExpress USA, AdooQ Bioscience, and MedKoo Biosciences, Inc.

[0066] In some embodiments, the LRRK2 inhibitor is selected from the compounds in Table 1, or a pharmaceutically acceptable salt thereof.

Table 1. LRRK Inhibitors

Compound 1 and Compositions Thereof

[0067] In one embodiment, the LRRK2 inhibitor is Compound 1. Compound 1 is described in U.S.

Pat. Nos 8,778,939 and 10,058,559, and published WIPO applications WO 2016/007540 and WO 2019/221566. The chemical name of Compound 1 is 2-(benzyloxy)-5-(2-fluoropyridin-4-yl)-N-(pyridin- 3-yl)benzamide, and the compound has the following structure:

[0068] The synthesis of Compound 1 is known in the art. Compound 1 is also commercially available (Tocris Biosciences, product no. 4629).

LRRK2 Inhibitors and Pharmaceutical Compositions

[0069] Also provided herein, in some embodiments, are pharmaceutical compositions that comprise compounds as described herein, and one or more pharmaceutically acceptable vehicles selected from carriers, adjuvants, and excipients.

[0070] Suitable pharmaceutically acceptable vehicles may include, for example, inert solid diluents and fillers, diluents, including sterile aqueous solution and various organic solvents, permeation enhancers, solubilizers, and adjuvants. Such compositions are prepared in a manner well known in the pharmaceutical art. See, e.g., Remington’s Pharmaceutical Sciences, Mace Publishing Co., Philadelphia, Pa. 17th Ed. (1985); and Modern Pharmaceutics, Marcel Dekker, Inc. 3rd Ed. (G.S. Banker & C.T. Rhodes, Eds.).

[0071] The pharmaceutical compositions may be administered in either single or multiple doses. The pharmaceutical composition may be administered by various methods including, for example, rectal, buccal, intranasal, and transdermal routes. In certain embodiments, the pharmaceutical composition may be administered by intra-arterial injection, intravenously, intraperitoneally, parenterally, intramuscularly, subcutaneously, orally, topically, or as an inhalant.

[0072] One mode for administration is parenteral, for example, by injection. The forms in which the pharmaceutical compositions described herein may be incorporated for administration by injection include, for example, aqueous or oil suspensions, or emulsions, with sesame oil, corn oil, cottonseed oil, or peanut oil, as well as elixirs, mannitol, dextrose, or a sterile aqueous solution, and similar pharmaceutical vehicles.

[0073] Oral administration may be another route for administration of the compounds described herein. Administration may be via, for example, capsule or enteric coated tablets. In making the pharmaceutical compositions that include at least one compound described herein, the active ingredient is usually diluted by an excipient and/or enclosed within such a carrier that can be in the form of a capsule, sachet, paper or other container. When the excipient serves as a diluent, it can be in the form of a solid, semi-solid, or liquid material, which acts as a vehicle, carrier or medium for the active ingredient. Thus, the compositions can be in the form of tablets, pills, powders, lozenges, sachets, cachets, elixirs, suspensions, emulsions, solutions, syrups, aerosols (as a solid or in a liquid medium), ointments containing, for example, up to 10% by weight of the active compound, soft and hard gelatin capsules, sterile injectable solutions, and sterile packaged powders.

[0074] Some examples of suitable excipients include lactose, dextrose, sucrose, sorbitol, mannitol, starches, gum acacia, calcium phosphate, alginates, tragacanth, gelatin, calcium silicate, microcrystalline cellulose, polyvinylpyrrolidone, cellulose, sterile water, syrup, and methyl cellulose. The formulations can additionally include lubricating agents such as talc, magnesium stearate, and mineral oil; wetting agents; emulsifying and suspending agents; preserving agents such as methyl and propylhydroxybenzoates; sweetening agents; and flavoring agents.

[0075] The compositions that include at least one compound described herein can be formulated so as to provide quick, sustained or delayed release of the active ingredient after administration to the subject by employing procedures known in the art. Controlled release drug delivery systems for oral administration include osmotic pump systems and dissolutional systems containing polymer-coated reservoirs or drug-polymer matrix formulations. Examples of controlled release systems are given in U.S. Patent Nos. 3,845,770; 4,326,525; 4,902,514; and 5,616,345. Another formulation for use in the methods disclosed herein employ transdermal delivery devices (“patches”). Such transdermal patches may be used to provide continuous or discontinuous infusion of the compounds described herein in controlled amounts. The construction and use of transdermal patches for the delivery of pharmaceutical agents is well known in the art. See, e.g., U.S. Patent Nos. 5,023,252, 4,992,445, and 5,001,139. Such patches may be constructed for continuous, pulsatile, or on demand delivery of pharmaceutical agents.

[0076] For preparing solid compositions such as tablets, the principal active ingredient may be mixed with a pharmaceutical excipient to form a solid preformulation composition containing a homogeneous mixture of a compound described herein. When referring to these preformulation compositions as homogeneous, the active ingredient may be dispersed evenly throughout the composition so that the composition may be readily subdivided into equally effective unit dosage forms such as tablets, pills, and capsules.

[0077] The tablets or pills of the compounds described herein may be coated or otherwise compounded to provide a dosage form affording the advantage of prolonged action, or to protect from the acid conditions of the stomach. For example, the tablet or pill can include an inner dosage and an outer dosage component, the latter being in the form of an envelope over the former. The two components can be separated by an enteric layer that serves to resist disintegration in the stomach and permit the inner component to pass intact into the duodenum or to be delayed in release. A variety of materials can be used for such enteric layers or coatings, such materials including a number of polymeric acids and mixtures of polymeric acids with such materials as shellac, cetyl alcohol, and cellulose acetate.

[0078] Compositions for inhalation or insufflation may include solutions and suspensions in pharmaceutically acceptable, aqueous or organic solvents, or mixtures thereof, and powders. The liquid or solid compositions may contain suitable pharmaceutically acceptable excipients as described herein. In some embodiments, the compositions are administered by the oral or nasal respiratory route for local or systemic effect. In other embodiments, compositions in pharmaceutically acceptable solvents may be nebulized by use of inert gases. Nebulized solutions may be inhaled directly from the nebulizing device or the nebulizing device may be attached to a facemask tent, or intermittent positive pressure breathing machine. Solution, suspension, or powder compositions may be administered, preferably orally or nasally, from devices that deliver the formulation in an appropriate manner.

[0079] In some embodiments, the therapeutically effective amount of the leucine-rich repeat kinase 2 inhibitor is administered once daily. In some embodiments, the therapeutically effective amount of the leucine-rich repeat kinase 2 inhibitor is administered over two doses in a day.

[0080] In some embodiments, the therapeutically effective amount of the leucine -rich repeat kinase 2 inhibitor is formulated for oral administration. In some embodiments, the therapeutically effective amount of the leucine-rich repeat kinase 2 inhibitor is in tablet form or capsule form.

[0081] In some embodiments, the therapeutically effective amount of the leucine -rich repeat kinase 2 inhibitor is formulated for parenteral administration.

[0082] In some embodiments, the therapeutically effective amount of the leucine -rich repeat kinase 2 inhibitor is formulated for inhalation.

[0083] In some embodiments, the leucine -rich repeat kinase 2 inhibitor is Compound 1 or a pharmaceutically acceptable salt thereof.

[0084] In some embodiments, the therapeutically effective amount of Compound 1 is about 1 mg/kg to about 500 mg/kg. In some embodiments, the therapeutically effective amount of Compound 1 is about 25 mg/kg to about 400 mg/kg. In some embodiments, the therapeutically effective amount of Compound 1 is about 50 mg/kg to about 300 mg/kg. In some embodiments, the therapeutically effective amount of Compound 1 is about 75 mg/kg to about 200 mg/kg. In some embodiments, the therapeutically effective amount of Compound 1 is about 100 mg/kg to about 150 mg/kg.

[0085] In some embodiments, the therapeutically effective amount of Compound 1 is about 1 mg/kg. In some embodiments, the therapeutically effective amount of Compound 1 is about 25 mg/kg. In some embodiments, the therapeutically effective amount of Compound 1 is about 50 mg/kg. In some embodiments, the therapeutically effective amount of Compound 1 is about 75 mg/kg. In some embodiments, the therapeutically effective amount of Compound 1 is about 100 mg/kg. In some embodiments, the therapeutically effective amount of Compound 1 is about 150 mg/kg. In some embodiments, the therapeutically effective amount of Compound 1 is about 200 mg/kg. In some embodiments, the therapeutically effective amount of Compound 1 is about 300 mg/kg. In some embodiments, the therapeutically effective amount of Compound 1 is about 400 mg/kg. In some embodiments, the therapeutically effective amount of Compound 1 is about 500 mg/kg.

Combination Therapy

[0086] In some embodiments, methods provided herein further comprise administering one or more of an additional therapeutic agent. In some embodiments, the additional therapeutic agent is an antiinflammatory agent.

[0087] In some embodiments, the anti-inflammatory agent is a corticosteroid, such as beclomethasone, betamethasone, budesonide, clobetasol, flunisolide, fluocinolone, fluocinonide, fluticasone, halobetasol, hydrocortisone, methylprednisone, mometasone, prednisolone, prednisone, and triamcinolone. In some embodiments, the anti-inflammatory agent is a non-steroidal anti-inflammatory (NSAIDs), such as a non-selective COX inhibitor or a selective COX-2 inhibitor. Non-selective COX inhibitors include, but are not limited to, salicylic acid derivates (e.g., aspirin, sodium salicylates, choline magnesium trisalicylate, salsalate, diflunisal, sulfasalazine, mesalamine, and olsalazine), paraaminophenol derivatives (e.g., acetaminophen), indole and indene acetic acids (e.g., tolmetin, diclofenac, and ketorolac), heteroaryl acetic acids (e.g., flurbiprofen, ketoprofen, fenprofen, ibuprofen, naproxen, and oxaprozin), anthranilic acids or fenamates (e.g., mefenamic acid and meclofenamic acid), enolic acids (e.g., piroxicam and meloxicam), and alkanones (e.g., nabumetone). Selective COX-2 inhibitors include, but are not limited to, diaryl-substituted pyrazoles (e.g., celecoxib), indole acetic acids (e.g., etodolac), and sulfonanilides (e.g., nimesulide).

[0088] In some embodiments, the additional therapeutic agent is an immunosuppressive agent. Nonlimiting examples of immunosuppressive agents include methotrexate, cyclophosphamide, mizoribine, chlorambucil, cyclosporine, tacrolimus, mycophenolate mofetil, azathioprine, sirolimus, voclosporin, deoxyspergualin, leflunomide, and its malononitrilo amide analogs.

[0089] It is understood that modifications which do not substantially affect the activity of the various embodiments of this disclosure are also included within the definition of the disclosure provided herein. Accordingly, the following examples are intended to illustrate but not limit the present disclosure.

EXAMPLES

Example 1: MRL Murine Model Study

[0090] Female MRL/MpJ-Fas^/J mice, a well-accepted standard for the study of human SLE, due to a mutation that leads to the spontaneous development of an autoimmune disease, presenting with hyperactive, self-reactive B and T cells, autoantibodies directed against nuclear antigens, and defective clearance of immune complexes leading to fatal immune glomerulonephritis, were separated into test groups (group size, n=10). Test agents were administered before presentation of disease symptoms, at a test subject age of 8-9 weeks. Compound 1 was dosed orally at 30 mg/kg. The reference group received cyclophosphamide via intraperitoneal injection, dosed at 50 mg/kg. During the in-life phase of the study, the Compound 1 test group was compared to a negative control group (vehicle only) and a positive control group (cyclophosphamide treatment), using multiple efficacy measures assessing the health of test subjects’ lymph nodes and kidneys. Lymphadenopathy, skin lesion, and proteinuria scoring parameters are presented in Table 2.

Table 2: In-Life Scoring Parameters

[0091] On day 61, the test groups were euthanized, and lymph node weight and kidney histology scores were compared for the Compound 1 test group, the negative control group, and the positive control group. Samples were graded for severity, with histological scoring parameters for tubule basophilia, tubule dilation, glomerulonephritis, chronic interstitial inflammation, and chronic papillary inflammation presented in Table 3. Table 3: Histological Scoring Parameters

[0092] Mice treated with Compound 1 exhibited a decrease in lymphadenopathy score, a measure of the size and characteristics of the lymph nodes in the subjects, as compared to the negative control group at days 42, 48, and 56 (FIG. 1). Similarly, upon sacrifice of the test groups at completion of the study, the group treated with Compound 1 exhibited reduced inguinal lymph node weight, but it was not statistically significant (p = 0.06) when compared to samples collected from subjects treated with only vehicle (FIG. 3). Swelling of lymph nodes is a common manifestation in SLE.

[0093] The appearance and severity of skin lesions present in the group treated with Compound 1 was significantly lower (p value = < 0.0001) than those present in the negative control group, and comparable to the test group being treated with cyclophosphamide (FIG. 2), indicating a decrease in inflammation and immune response when compared with the untreated test group.

[0094] Proteinuria is a standard clinical measure of renal function, with healthy kidneys filtering little protein from blood for excretion. The damage present in kidneys from the immune response and inflammation associated with SLE can be observed by tracking protein concentration in test subject urine. The test group treated with Compound 1 displayed a non-statistical decrease in urine protein content when compared to that seen in the negative control group, treated with only vehicle (FIG. 4).

[0095] Similarly, the presence of urea in blood is also indicative of ineffective filtering and poor renal function. The test group treated with Compound 1 showed a comparable decrease (p = < 0.05) in blood urea content as was observed in the group treated with cyclophosphamide, with both having blood urea concentrations notably lower than that observed in the negative control group (FIG. 5).

[0096] Anti-double stranded DNA antibodies form during the autoimmune response to extracellular DNA in patients with SLE, leading to inflammation and subsequent kidney and skin damage. The test group treated with Compound 1 displayed comparable levels of anti-dsDNA antibodies to those treated with only vehicle. The cyclophosphamide treated group showed a non-statistically significant reduction in anti-dsDNA antibodies (FIG. 6). [0097] Kidney samples were collected from the sacrificed test groups for histological analysis. Mice treated with Compound 1 showed a statistically significant decrease (p = 0.01-0.05) in tubule basophilia histology scores (FIG. 7), and a reduction (p = 0.1) in tubule dilation/casts histology scores (FIG. 8), when compared to those administered only vehicle, indicating a decrease in observed renal inflammation and damage.

[0098] Similarly, histological analysis of kidney tissue from the test groups for glomerulonephritis, inflammation of the kidney’s filter structures, showed a reduction (p = 0.1) in inflammation for the test group treated with Compound 1, when compared to the test group administered only vehicle (FIG. 9).

[0099] Further, kidney tissue samples from mice treated with Compound 1 exhibited a statistically significant reduction (p = 0.01-0.05) in histology scoring for chronic interstitial inflammation (FIG. 10), a reduction in histology scoring for chronic papillary inflammation (FIG. 11), and an overall statistically significant reduction (p = < 0.01-0.05) in the summation of histology scores (FIG. 12), when compared to the test group administered only vehicle, indicating a decrease in observed renal damage.

[00100] Although the disclosure has been described with reference to the disclosed embodiments, those skilled in the art will readily appreciate that the specific examples and studies detailed above are only illustrative. It should be understood that various modifications can be made without departing from the spirit of the disclosure.

Claims

WHAT IS CLAIMED:

1. A method for treating systemic lupus erythematosus (SLE), comprising administering to a patient in need thereof, a therapeutically effective amount of Compound 1 :

or a pharmaceutically acceptable salt thereof.

2. A method for improving kidney function, comprising administering to a patient in need thereof, a therapeutically effective amount of Compound 1 :

or a pharmaceutically acceptable salt thereof.

3. A method for inhibiting the production of double-stranded DNA antibody (anti-dsDNA antibody), comprising administering to a patient in need thereof, a therapeutically effective amount of

Compound 1:

or a pharmaceutically acceptable salt thereof.

4. A method for decreasing the concentration of blood urea nitrogen (BUN), comprising administering to a patient in need thereof, a therapeutically effective amount of Compound 1 :

25 or a pharmaceutically acceptable salt thereof.

5. A method for decreasing proteinuria, comprising administering to a patient in need thereof, a therapeutically effective amount of Compound 1 :

or a pharmaceutically acceptable salt thereof.

6. The method of any preceding claim, wherein the treating comprises inhibiting, lessening, or delaying the onset or progression of, fatigue, fever, joint pain, joint stiffness, joint swelling, rashes, skin lesions, shortness of breath, chest pain, dry eyes, headaches, confusion, memory loss, sun sensitivity, oral ulcers, arthritis, lung damage, heart problems, kidney damage, lupus nephritis, lymphadenopathy, seizures, psychosis, blood cell abnormalities, or immunological abnormalities.

7. The method of any preceding claim, wherein the treating comprises inhibiting, lessening, or delaying the onset or progression of, skin lesions, lymphadenopathy, kidney damage, lupus nephritis, or inflammation.

8. The method of any preceding claim, wherein the patient is experiencing a lupus flare.

9. The method of any preceding claim, wherein the compound, or pharmaceutically acceptable salt thereof, is administered in a pharmaceutical composition.

10. The method of claim 9, wherein the pharmaceutical composition is formulated for oral administration.

11. The method of claim 10, wherein the pharmaceutical composition is in tablet form or capsule form.

12. The method of any one of claims 9-11, wherein the pharmaceutical composition is administered once daily.

13. The method of any preceding claim, wherein the patient also suffers from another autoimmune condition.

14. The method of claim 13, wherein the autoimmune condition is Sjogren’s syndrome, antiphospholipid syndrome, thyroiditis, hemolytic anemia, or idiopathic thrombocytopenia purpura.

15. The method of any preceding claim, further comprising administering an additional therapeutic agent.

16. The method of claim 15, wherein the additional therapeutic agent is selected from the group consisting of a nonsteroidal anti-inflammatory drug (NSAID), an antimalarial drug, a corticosteroid, an immunosuppressant, and a biologic.

17. The method of claim 15, wherein the additional therapeutic agent is naproxen sodium, ibuprofen, hydroxychloroquine, prednisone, methylprednisolone, azathioprine (Imuran, Azasan), mycophenolate (Cellcept), methotrexate (Trexall, Xatmep, others), cyclosporine (Sandimmune, Neoral, Gengraf), leflunomide (Arava), belimumab (Benlysta), voclosporin (Lupkynis), or rituximab.