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
  • A61K31/55—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having seven-membered rings, e.g. azelastine, pentylenetetrazole
  • A61K31/551—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having seven-membered rings, e.g. azelastine, pentylenetetrazole having two nitrogen atoms, e.g. dilazep
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
  • A61P25/14—Drugs for disorders of the nervous system for treating abnormal movements, e.g. chorea, dyskinesia
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
  • A61P25/28—Drugs for disorders of the nervous system for treating neurodegenerative disorders of the central nervous system, e.g. nootropic agents, cognition enhancers, drugs for treating Alzheimer's disease or other forms of dementia

Definitions

• ALS Amyotrophic Lateral Sclerosis
• Lou Gehrig Lou Gehrig
• ALS is a fatal neurodegenerative disease that affects motor neurons, resulting in a progressive loss of control of voluntary movements. It is associated with degeneration of upper motor neurons and their corticospinal axonal tracts (lateral sclerosis) and associated with the loss of lower motor neurons and their axons, which leads to muscle wasting (amyotrophy) and paralysis of voluntary' muscles (Mitsumoto et al., 1998).
• Upper motor neurons originate in the motor region of the cerebral cortex or brain stem and move motor information underneath motor neurons that are directly responsible for stimulation of the target muscle. Their dysfunction causes stiffness due to continuous muscle contraction that interferes with walking, movement and speech.
• Lower motor neurons connect the brainstem and spinal cord to muscle fibers. Their dysfunction causes muscle atrophy, spasms small, local, involuntary' muscle contraction. Many individuals with ALS die from respiratory failure within 48 months from the onset of symptoms and most within 3 to 5 years from onset.
• ALS is thought to be caused by a combination of genetic factors, environmental factors, and aging-related dysfunction, similar to other neurodegenerative conditions. Apart from genetic factors, age and male sex increase the risk for ALS.
• environmental risk factors for ALS such as smoking, body mass index, physical exercise, occupational and environmental exposures to metals, pesticides, P-methylamino-L-alanine, head injury', and viral infections.
• the causal relationship of these factors with ALS remains to be established (Masrori 2020).
• TDP- 43 TAR DNA-binding protein 43
• TDP-43 is the primary misfolded, mis-localized, ubiquitinated protein composing the major form of neuropathological aggregates in motor neurons in ALS.
• TDP-43 is a DNA/RNA binding protein that regulates RNA splicing and stability and microRNA.
• TDP-43 normally localizes to the nucleus where it functions in transcription, but misfolded TDP-43 aggregates in the cytosol, leading to a nuclear loss-of-function that might cause transcription deficits. It is unclear whether ALS pathogenesis is linked to loss of TDP-43 function or the pathology associated with the aggregates and cytoplasmic mis-localization.
• Rho Kinase (ROCK) Inhibitors ALS There are a number of publications addressing the use of rho kinase inhibitors in various animal models of neurodegeneration, including ALS. Most models are deficient in that they fail to reproduce the ALS (or other neurodegenerative disease) phenotype, or are pertinent only to familial ALS which is only 5-10% of ALS patients. As one example, U.S. 9,980,972 describes using fasudil in the SOD1 G93 mouse model, which harbors a mutation in the superoxide dismutase (SOD) protein.
• SOD superoxide dismutase
• Fasudil was administered to three (3) human ALS patients on a compassionate use basis (Koch et al. 2020). One patient had familial ADS and the two other patients had probable ADS. Patients were dosed with 30 mg of intravenously administered fasudil twice daily over 20 consecutive working days (not weekends). There were no conclusive results beyond safety. Currently, there are clinical trials in progress in Germany, Switzerland and France for infusion of fasudil according to the same intravenous administration and dosing schedule. (Lingor et al., 2019). The trial is designed to treat three parallel groups: fausdil 15 mg twice daily, fasudil 30 mg twice daily, and matching placebo.
• HED Human equivalent dose
• the invention contemplates the treatment of an ALS patient using fasudil.
• a method of treating a patient with amyotrophic lateral scierosis comprising administering a therapeutically effective amount of fasudil in the following alternating dosing regimen:
• the patient is treated for at least 5 days per week wherein during the first and/or second treatment phase.
• the first and second off-treatment period is between at least one month and less than six months.
• the duration of the first and second treatment phase is one month and the duration of the first and second off-treatment phase is one month.
• (a) to (c) is repeated at least once, preferably more than once.
• the duration of the first and second treatment phase is one month and the duration of the first and second off-treatment phase is one month, and this regimen (a) to (c) is repeated from at least once to the duration of the patient’s life.
• the dose in the first and second treatment phases is 30 to 60 mg/day fasudil, preferably, 60 to 120 mg/day fasudil, more preferably 120 to 180 mg/day fasudil, and most preferably 180 to 240 mg/day fasudil.
• fasudil is administered by intravenous infusion. In another embodiment, fasudil is orally administered.
• the ALS patient treated has Tar DNA Binding Protein 43 (TDP-43) inclusions.
• TDP-43 DNA Binding Protein 43
• the pathological TDP-43 is due to a sporadic mutation in the TARDBP gene encoding TDP-43.
• the ALS patient is genetically male. In another embodiment, the ALS patient is genetically female.
• treatment of an ALS patient results in a greater-than fifty-percent reduced rate of decline on the revised ALS Functional Rating Scale (ALSFRS-R) as measured over six to twelve months.
• ALSFRS-R revised ALS Functional Rating Scale
• treatment of an ALS patient results in a stabilization of the revised ALSFRS-R for at least 6 months.
• treatment of an ALS patient results in a reduction in the rate of decline of at least one of the twelve domains of the ALSFRS.
• treatment of an ALS patient results in reduced muscle wasting and reduced paralysis of voluntary muscles.
• Still other embodiments contemplate the treatment of an ALS patient with reduced slow vital capacity (SVC) as predicted by the patient’s gender, age and the patient does not present with bulbar symptoms.
• SVC slow vital capacity
• Certain embodiments involve the treatment of an ALS patient with an ALSFRS score of ⁇ 36.
• Some embodiments involve treating an ALS patient with fasudil hydrochloride, wherein the patient is also treated with riluzole and/or edaravone.
• an ALS patient is treated with fasudil hydrochloride, wherein the patient is also treated with taurursodiol and sodium phenylbutyrate.
• the invention is based on the discovery that, fasudil, can be used to ALS according to a specific dosing regimen.
• the inventive methods contemplate the administration of a rho kinase (ROCK) inhibitor in the treatment of a disease or condition.
• ROCK1 aka ROKp, Rho-kinase p, or p!60ROCK
• ROCK2 aka ROKa
• the two ROCK isoforms share 64% identity in their primary amino acid sequence, whereas the homology in the kinase domain is even higher (92%) (Jacobs 2006; Yamaguchi 2006). Both ROCK isoforms are serine/threonine kinases and have a similar structure.
• Isoquinoline derivatives are a preferred class of ROCK inhibitors.
• the isoquinoline derivative fasudil was the first small molecule ROCK inhibitor developed by Asahi Chemical Industry (Tokyo, Japan).
• the characteristic chemical structure of fasudil consists of an isoquinoline ring, connected via a sulphonyl group to a homopiperazine ring. Fasudil is a potent inhibitor of both ROCK isoforms. In vivo, fasudil is subjected to hepatic metabolism to its active metabolite hydroxyfasudil (aka, M3).
• Other examples of isoquinoline derived ROCK inhibitors include dimethyl fasudil and ripasudil.
• ROCK inhibitors are based on based on 4-aminopyridine structures. These were first developed by Yoshitomi Pharmaceutical (Uehata et al., 1997) and are exemplified by Y- 27632. Still other preferred ROCK inhibitors include indazole, pyrimidine, pyrrolopyridine, pyrazole, benzimidazole, benzothiazole, benzathiophene, benzamide, aminofurazane, quinazoline, and boron derivatives (Feng et al., 2015). Some exemplary' ROCK inhibitors are shown below:
• ROCK inhibitors according to the invention may have more selective activity for either ROCK1 or ROCK2 and will usually have varying levels of activity on PKA, PKG, PKC, and MLCK. Some ROCK inhibitors may be highly specific for ROCK1 or ROCK2 and have much lower activity against PKA, PKG, PKC, and MLCK.
• a particularly preferred ROCK inhibitor is fasudil.
• Fasudil may exist as a free base or salt and may be in the form of a hydrate, such as a hemihydrate.
• Hexahydro-l-(5-isoquinolinesuIfonyl)1H-1,4-diazepme monohydrochloride hemihydrate Fasudil is a selective inhibitor of protein kinases, such as ROCK, PKC and MLCK and treatment results in a potent relaxation of vascular smooth muscle, resulting in enhanced blood flow (Shibuya 2001).
• a particularly important mediator of vasospasm, ROCK induces vasoconstriction by phosphorylating the myosin-binding subunit of myosin light chain (MLC) phosphatase, thus decreasing MLC phosphatase activity and enhancing vascular smooth muscle contraction.
• MLC myosin light chain
• fasudil increases endothelial nitric oxide synthase (eNOS) expression by stabilizing eNOS mRNA, which contributes to an increase in the level of the potent vasodilator nitric oxide (NO), thereby enhancing vasodilation (Chen 2013).
• eNOS endothelial nitric oxide synthase
• Fasudil has a short half-life of about. 25 minutes, but it is substantially converted in vivo to its 1 -hydroxy (M3) metabolite. M3 has similar effects to its fasudil parent molecule, with slightly enhanced activity and a half-life of about 8 hours (Shibuya 2001). Thus, M3 is likely responsible for the bulk of the in vivo pharmacological activity of the molecule. M3 exists as two tautomers, depicted below:
• the ROCK inhibitors used in the invention include pharmaceutically acceptable salts and hydrates. Salts that may be formed via reaction with inorganic and organic acid. Those inorganic and organic acids are included as following: hydrochloric acid, hydrobromide acid, hydriodic acid, sulphuric acid, nitric acid, phosphoric acid, acetic acid, maleic acid, maleic acid, maleic acid, oxalic acid, oxalic acid, tartaric acid, malic acid, mandelic acid, trifluoroacetic acid, pantothenic acid, methane sulfonic acid, or para-toluenesulfonic acid.
• TDP-43 is an essential DNA/RNA binding protein that is primarily located in the nucleus and is ubiquitously expressed. Deletion of the TARDBP (TDP-43 -encoding gene) is lethal at the embryonic stage in mice. TDP-43 is a primary component of ubiquitinated and hyper-phosphorylated cytosolic aggregates observed from post-mortem tissue of patients with ALS. Abnormal TDP-43 exists in about 97% of ALS patients, primarily in the motor neurons of the cerebral cortex but also in spinal cord. Over 50 mutations in the TARDBP are known. Generally, pathological TDP-43 in ALS is in a truncated form of either 25 or 35 kD. There is frequent mis-localization of TDP-43 from the nucleus to the cytoplasm in ALS, which could block cellular trafficking in the motor neurons.
• ALS patients also exhibit mutation in proteins resulting in disruption of the ubiquitin-proteasome and autophagic clearance system which could result in the truncated TDP-43, improperly degraded.
• TDP-43 contributes to ALS pathology or is a bystander of other defects, and targeting TDP-43 may be too late to prevent neurodegeneration, disease onset or progression.
• ALS is also associated with mutations in genes encoding proteins involved in protein degradation and membrane degradation pathways, suggesting that an impairment of protein clearance is pathologic in ALS (and FTD ). These include mutations in p62, valosin-containing protein (VCP), ubiquitin 2, and optineurin, which are all effectors of the autophagy and/or ubiquitin-proteasome system (UPS) protein degradation pathways. This suggestion is bolstered by the observations with C9orf72 insufficiency.
• HRE hexanucleotide repeat expansions
• HRE in C9orf72 result in aborted RNA transcripts which then sequester RNA-binding proteins in volved in transcription and splicing resulting in protein/RNA aggregates in the nuclei of the motor and frontal cortex neurons, hippocampus, cerebellum, and spinal cord.
• Mutations in genes associated with familial ALS include single gene mutations in genes selected from C9orf72, SOD1, TARDBP, FUS and TANK -binding kinase 1 (TBKI).
• the present disclosure excludes familial (inherited) ALS due to those gene mutations.
• compositions of ROCK inhibitors for oral administration may be in the form of tablets or capsules and may be immediate-release formulations or may be controlled- or extended-release formulations, which may contain pharmaceutically acceptable excipients, such as corn starch, mannitol, povidone, magnesium stearate, talc, cellulose, methylcellulose, carboxymethylcellulose and similar substances.
• a pharmaceutical composition comprising a ROCK inhibitor and/or a salt thereof may compri se one or more pharmaceutically acceptable excipients, which are known in the art.
• Formulations include oral films, orally di sintegrating tablets, effervescent tablets and granules or beads that can be sprinkled on food or mixed with liquid as a slurry or poured directly into the mouth to be washed down.
• compositions containing ROCK inhibitors, salts and hydrates thereof can be prepared by any method known in the art of pharmaceutics.
• preparatory methods include the steps of bringing a ROCK inhibitor or a pharmaceutically acceptable salt thereof into association with a carrier or excipient, and/or one or more other accessory' ingredients, and then, if necessary/ and/or desirable, shaping, and/or packaging the product into a desired single- or multi-dose unit.
• compositions can be prepared, packaged, and/or sold in bulk, as a single unit dose, and/or as a plurality of single unit doses.
• a “unit dose” is a discrete amount of the pharmaceutical composition comprising a predetermined amount of the active ingredient.
• the amount of the active ingredient is generally equal to the dosage of the active ingredient which would be administered to a subject and/or a convenient fraction of such a dosage such as, for example, one-half or one-third of such a dosage.
• compositions of the invention will vary, depending upon the identity, size, and/or condition of the subject treated and further depending upon the route by which the composition is to be administered.
• the composition used in the methods of the present invention may comprise between 0.001% and 100% (w/w) active ingredient.
• compositions used in the manufacture of provided pharmaceutical compositions include inert diluents, dispersing and/or granulating agents, surface active agents and/or emulsifiers, disintegrating agents, binding agents, preservatives, buffering agents, lubricating agents, and/or oils. Excipients such as cocoa butter and suppository' waxes, coloring agents, coating agents, sweetening, flavoring, and perfuming agents may also be present in the composition.
• the pharmaceutical composition used in the methods of the present invention may comprise a diluent.
• diluents include calcium carbonate, sodium carbonate, calcium phosphate, dicalcium phosphate, calcium sulfate, calcium hydrogen phosphate, sodium phosphate lactose, sucrose, cellulose, microcrystalline cellulose, kaolin, mannitol, sorbitol, inositol, sodium chloride, dry starch, cornstarch, powdered sugar, and mixtures thereof.
• the pharmaceutical composition used in the methods of the present invention may comprise a granulating and/or dispersing agent.
• exemplary granulating and/or dispersing agents include potato starch, com starch, tapioca starch, sodium starch glycolate, clays, alginic acid, guar gum, citrus pulp, agar, bentonite, cellulose, and wood products, natural sponge, cation-exchange resins, calcium carbonate, silicates, sodium carbonate, cross-linked poly(vinyl-pyrrolidone) (crospovidone), sodium carboxymethyl starch (sodium starch glycolate), carboxymethyl cellulose, cross-linked sodium carboxymethyl cellulose (croscarmellose), methylcellulose, pregelatinized starch (starch 1500), microcrystalline starch, water insoluble starch, calcium carboxymethyl cellulose, magnesium aluminum silicate (VEEGUM), sodium lauryl sulfate, quaternary' ammonium compounds, and mixtures thereof.
• VEEGUM magnesium
• the pharmaceutical composition used in the methods of the present invention may comprise a binding agent.
• binding agents include starch (e.g., cornstarch and starch paste), gelatin, sugars (e.g., sucrose, glucose, dextrose, dextrin, molasses, lactose, lactitol, mannitol, etc.), natural and synthetic gums (e.g., acacia, sodium alginate, extract of Irish moss, panwar gum, ghatti gum, mucilage of isapol husks, carboxymethylcellulose, methylcellulose, ethylcellulose, hydroxyethylcellulose, hydroxypropyl cellulose, hydroxypropyl methylcellulose, microcrystalline cellulose, cellulose acetate, poly(vinyl-pyrrolidone), magnesium aluminum silicate (VEEGUM. RTM ), and larch arabogalactan), alginates, polyethylene oxide, polyethylene glycol, inorganic calcium salts,
• the pharmaceutical composition used in the methods of the present invention may comprise a preservative.
• exemplary preservatives include antioxidants, chelating agents, antimicrobial preservatives, antifungal preservatives, antiprotozoan preservatives, alcohol preservatives, acidic preservatives, and other preservatives.
• the preservative is an antioxidant.
• the preservative is a chelating agent.
• the pharmaceutical composition used in the methods of the present invention may comprise an antioxidant.
• antioxidants include alpha tocopherol, ascorbic acid, ascorbyl palmitate, butylated hydroxyanisole, butylated hydroxytoluene, monothioglycerol, potassium metabisulfite, propionic acid, propyl gallate, sodium ascorbate, sodium bisulfite, sodium metabisulfite, and sodium sulfite.
• the pharmaceutical composition used in the methods of the present invention may comprise a chelating agent.
• chelating agents include ethylenediaminetetraacetic acid (EDTA) and salts and hydrates thereof (e.g., sodium edetate, disodium edetate, trisodium edetate, calcium disodium edetate, dipotassium edetate, and the like), citric acid and salts and hydrates thereof (e.g., citric acid monohydrate), fumaric acid and salts and hydrates thereof, malic acid and salts and hydrates thereof, phosphoric acid and salts and hydrates thereof, and tartaric acid and salts and hydrates thereof.
• EDTA ethylenediaminetetraacetic acid
• citric acid and salts and hydrates thereof e.g., citric acid monohydrate
• fumaric acid and salts and hydrates thereof e.g., malic acid and salts and hydrates thereof, phosphoric acid and salt
• Exemplary' antimicrobial preservatives include benzalkonium chloride, benzethonium chloride, benzyl alcohol, bronopol, cetrimide, cetyl pyridinium chloride, chlorhexidine, chlorobutanol, chlorocresol, chloroxylenol, cresol, ethyl alcohol, glycerin, hexetidine, imidurea, phenol, phenoxyethanol, phenylethyl alcohol, phenylmercuric nitrate, propylene glycol, and thimerosal.
• the pharmaceutical composition may comprise a buffering agent together with the ROCK inhibitor or the salt thereof.
• buffering agents include citrate buffer solutions, acetate buffer solutions, phosphate buffer solutions, ammonium chloride, calcium carbonate, calcium chloride, calcium citrate, calcium glubionate, calcium gluceptate, calcium gluconate, D-gluconic acid, calcium glycerophosphate, calcium lactate, propanoic acid, calcium levulinate, pentanoic acid, dibasic calcium phosphate, phosphoric acid, tribasic calcium phosphate, calcium hydroxide phosphate, potassium acetate, potassium chloride, potassium gluconate, potassium mixtures, dibasic potassium phosphate, monobasic potassium phosphate, potassium phosphate mixtures, sodium acetate, sodium bicarbonate, sodium chloride, sodium citrate, sodium lactate, dibasic sodium phosphate, monobasic sodium phosphate, sodium phosphate mixtures, tromethamine, magnesium hydroxide, aluminum hydrox
• the pharmaceutical composition used in the methods of the present invention may' comprise a lubricating agent.
• exemplary' lubricating agents include magnesium stearate, calcium stearate, stearic acid, silica, talc, malt, glyceryl behanate, hydrogenated vegetable oils, polyethylene glycol, sodium benzoate, sodium acetate, sodium chloride, leucine, magnesium lauryl sulfate, sodium lauryl sulfate, and mixtures thereof.
• the pharmaceutical composition of containing a ROCK inhibitor or salt thereof wall be administered as a liquid dosage form.
• Liquid dosage forms for oral and parenteral administration include pharmaceutically acceptable emulsions, microemulsions, solutions, suspensions, syrups, and elixirs.
• the liquid dosage forms may comprise inert diluents commonly used in the art such as, for example, water or other solvents, solubilizing agents and emulsifiers such as ethyl alcohol, isopropyl alcohol, ethyl carbonate, ethyl acetate, benzyl alcohol, benzyl benzoate, propylene glycol, 1 ,3-butylene glycol, dimethylformamide, oils (e.g., cottonseed, groundnut, com, germ, olive, castor, and sesame oils), glycerol, tetrahydrofurfuryl alcohol, polyethylene glycols and fatty acid esters of sorbitan, and mixtures thereof.
• inert diluents commonly used in the art such as, for example, water or other solvents, solubilizing agents and emulsifiers such as ethyl alcohol, isopropyl alcohol, ethyl carbonate, ethyl a
• the oral compositions can include adjuvants such as wetting agents, emulsifying and suspending agents, sweetening, flavoring, and perfuming agents.
• adjuvants such as wetting agents, emulsifying and suspending agents, sweetening, flavoring, and perfuming agents.
• the conjugates of the invention are mixed with solubilizing agents such as CremophorTM, alcohols, oils, modified oils, glycols, polysorbates, cyclodextrins, polymers, and mixtures thereof.
• Solid dosage forms for oral administration include capsules, tablets, pills, powders, and granules.
• the active ingredient is mixed with at least one inert, pharmaceutically acceptable excipient or carrier such as sodium citrate or dicalcium phosphate and/or (a) fillers or extenders such as starches, lactose, sucrose, glucose, mannitol, and silicic acid, (b) binders such as, for example, carboxymethylcellulose, alginates, gelatin, polyvinylpyrrolidinone, sucrose, and acacia, (c) humectants such as glycerol, (d) disintegrating agents such as agar, calcium carbonate, potato or tapioca starch, alginic acid, certain silicates, and sodium carbonate, (e) solution retarding agents such as paraffin, (f) absorption accelerators such as quaternary ammonium compounds, (g) wetting agents such as, for example, cetyl alcohol and glycerol mono
• compositions of the invention relate to extended- or controlled-release formulations. These may be, for example, diffusion-controlled products, dissolution-controlled products, erosion products, osmotic pump systems or ionic resin systems.
• Diffusion-controlled products comprise a water-insoluble polymer which controls the flow of water and the subsequent egress of dissolved drug from the dosage from.
• Dissolution-controlled products control the rate of dissolution of the drug by using a polymer that slowly solubilizes or by microencapsulation of the drug - using varying thicknesses to control release.
• Erosion products control release of drug by the erosion rate of a carrier matrix.
• Osmotic pump systems release a drug based on the constant inflow of water across a semi permeable membrane into a reservoir which contains an osmotic agent.
• Ion exchange resins can be used to bind drugs such that, when ingested, the release of drug is determined by the ionic environment within the gastrointestinal tract.
• Parenteral dosage forms. Fasudil can be administered in parenteral dosage forms.
• parenteral includes, but is not limited to, subcutaneous injections, intravenous, intramuscular, intraperitoneal injections, or infusion techniques.
• compositions or formulations suitable for parenteral administration include aqueous and non-aqueous sterile injection solutions which may contain anti-oxidants, buffers, bacteriostats and solutes that render the formulation isotonic with the blood of the intended recipient, and aqueous and non-aqueous sterile suspensions which may include suspending agents and thickening agents.
• the compositions may be presented in unit-dose or multi-dose containers, sealed ampules and vials, and may be stored in a freeze-dried (lyophilized) condition requiring only the addition of the sterile liquid carrier, water for injections, immediately prior to use.
• Extemporaneous injection solutions and suspensions may be prepared from sterile powders, granules and tablets of the kind previously described.
• Parenteral pharmaceutical formulation may further contain other acceptable liquid earners in an amount that does not alter the aqueous nature of the formulation, including, vegetable oils such as peanut oil, cotton seed oil, sesame oil, as well as organic solvents, PEG, propylene glycol, glycerol, and surfactants.
• vegetable oils such as peanut oil, cotton seed oil, sesame oil, as well as organic solvents, PEG, propylene glycol, glycerol, and surfactants.
• Parenteral formulations may further comprise at least one of any suitable auxiliaries including, but not limited to, diluents, crystal inhibitors, tonicifiers, water structure forming agents or disruptors, polymers, ion pairing agents, stabilizers, buffers, salts, lipophilic solvents, preservatives, adjuvants or the like.
• suitable auxiliaries including, but not limited to, diluents, crystal inhibitors, tonicifiers, water structure forming agents or disruptors, polymers, ion pairing agents, stabilizers, buffers, salts, lipophilic solvents, preservatives, adjuvants or the like.
• Pharmaceutically acceptable auxiliaries are preferred.
• the aqueous parenteral pharmaceutical formulation comprises at least 50% water, preferably 70% or more of water.
• Routes of administration and dosages of effective amounts of the aqueous parenteral pharmaceutical formulations comprising fasudil are also provided.
• sterile suspensions and solutions are desired.
• Isotonic preparations which generally contain suitable preservatives are employed when intravenous, administration is desired.
• the pharmaceutical compositions may be administered parenterally via injection of a pharmaceutical composition comprising fasudil dissolved in an inert liquid earner.
• compositions may be prepared by dissolving or suspending the compound in the liquid carrier such that the final formulation contains from about 0.005% to 30% by weight of a compound.
• parenteral administration is intravenous.
• the pharmaceutical formulations described herein may also be administered by infusion.
• the pharmaceutical formulations described herein may also be administered by a bolus dosage, optionally combined with administration by infusion.
• the compounds described herein can be administered in combination with other pharmaceutical agents in a variety of protocols for effective treatment of disease.
• the invention contemplates treating ALS fasudil, preferably fasudil hydrochloride hemihydrate.
• Diagnosis Diagnosis of ALS can be done by clinical, electrophysiological and/or neuropathologic examination.
• ALS diagnosis is made using El Escorial diagnostic criteria (Brooks 1994) successively updated in Airlie House and Awaji-shima criteria (de Carvalho 2008) (Brooks 2011).
• the Awaji criteria proposed two changes to the revised El Escorial. The first change was to use both electromyography and clinical data simultaneously to determine the presence of lower motor neuron (LMN) dysfunction. The second proposed change was to consider fasciculation potentials as evidence of ongoing denervation, equivalent in importance to fibrillation potentials.
• ALS diagnosis requires: (1) the presence of evidence of LAIN degeneration by clinical, electrophysiological or neuropathological examination, (2) presence of upper motor neuron (UMN) degeneration by clinical examination, (3) presence of progressive spread of symptoms or signs within a region or other regions, as determined by history', clinical examination or electrophysiological tests, and (4) absence of electrophysiological or pathological evidence of other disease processes that might explain the observed clinical and electrophysiological signs.
• UPN upper motor neuron
• Diagnostic categories include: definite ALS (clinical or electrophysiological evidence by the presence of LMN as well as LOVIN signs in the bulbar region and at least two spinal regions or the presence of LMN and UMN signs in three spinal regions), probable ALS (clinical or electrophysiological evidence by LMN and UA1N signs in at least two regions with some UMN signs necessarily rostral to the LAIN signs, and possible ALS (clinical or electrophysiological signs of UMN or LAIN dysfunction in only one region or UMN signs alone in two or more regions or LMN rostral to UMN signs).
• the invention contemplates treating definite, probably and possible ALS.
• Classification according to ALS phenotype is mainly based on the relative UMN versus LMN involvement and the regional distribution of involvement.
• Electrophysiological testing includes without limitation electromyography (EMG). Ultrasound of the muscles can detect fasciculations that can aid in the diagnosis of ALS. In some instances, a muscle biopsy, which involves taking a small sample of muscle under local anesthesia, is performed.
• EMG electromyography
• Imaging of the brain and spinal cord by techniques including MRI to rule out other disease but use to confirm ALS is less established due to the heterogeneity of ALS.
• Various imaging techniques are reviewed in Turner et al. 2012. The most sensitive and specific techniques to diagnose the disease are diffusion-tensor MRI, MR spectroscopy, PET, a combination of several neuroimaging methods, and neuroimaging with transcranial magnetic stimulation. Diffusiontensor MRI and MR spectroscopy can be used to monitor and predict the disease course. (Bakulin 2019). Recently, one group reported MRI differences between ALS patients with C904F72 mutations and with impaired cognition, (van der Burgh et al., 2020).
• ALS a progressive neurodegenerative disease
• ALS-FTSD frontotemporal spectrum disorder
• Other symptoms of the motor neuron degeneration may be socially disabling and/or affect the patient’s quality of life include sialorrhoea (drooling, excessive salivation, thickened saliva), pseudobulbar emotional lability (pathological weeping, laughing, or yawning), cramps (especially at night), spasticity, depression and anxiety, insomnia (caused by depression, cramps, pain, and respiratory distress), constipation, and fatigue (of central and/or peripheral origin).
• Many patients report difficulties in effectively clearing bronchial secretions including tenacious sputum, and mucus accumulation is a negative prognostic factor.
• Cognitive and behavioral changes are an intrinsic component of some forms of ALS.
• ALS frontotemporal dementia
• ALS frontotemporal dementia
• ALS frontotemporal dementia
• the patient to be treated with oral fasudil has sporadic ALS.
• the sporadic ALS patient has TDP-43- associated ALS.
• the patient to be treated with oral fasudil has familial ALS.
• the patient has classical ALS. In another specific embodiment, the patient has bulbar-onset ALS.
• the ALS patient does not have another proteinopathy-associated neurodegenerative disease.
• the ALS patient treated with oral fasudil does not have frontotemporal dementia (FTD).
• the sporadic ALS patient has ALS-FTSD or ALS-FTD.
• the ALS patient treated with oral fasudil is genetically male.
• the ALS patient treated with oral fasudil is between the ages of 40-75.
• the ALS patient treated with oral fasudil is between the ages of 50-65.
• the ALS patient treated with oral fasudil is between the ages of 20-39.
• the ALS patient treated with oral fasudil hydrochloride hemihydrate.
• a therapeutically effective amount of a ROCK inhibitor or a pharmaceutically acceptable salt thereof is administered to an ALS patient one or more times a day.
• the lowest therapeutically effective amount of fasudil for example, is 60 mg per day, generally administered in 2 equal portions to obtain the full daily dose.
• the highest therapeutically effective dose may be determined empirically as the highest dose that remains effective in alleviating one or more ALS symptoms, but does not induce an unacceptable level or adverse events. Fasudil, for example, generally will not be administered in a daily dose exceeding 240 mg.
• One preferred dosing regimen involves the treatment with fasudil for at least 3 days per week followed by an off-treatment period for at least two weeks. This is followed by another fasudil treatment phase followed by a second off-treatment phase.
• the patient is treated for at least 3 days per week for at least two weeks with 30 to 60 mg/day of fasudil before the off-treatment phase of 2-4 weeks. In one embodiment, the patient is treated 5 days a week. In a preferred embodiment, the patient is subsequently treated in a second treatment phase of at least 2-4 weeks for at least 3 days per week with 30-60 mg/day of fasudil. Then, the patient is subjected to an off treatment phase of about 1 to 6 months, preferably one month.
• fasudil is administered two times per day (bid) during the treatment phase.
• the patient is treated for at least 5 days per week during the first and second treatment phase.
• the duration of the first and second treatment phase is one month.
• the duration of the first and second off-treatment period is one month.
• the first and second treatment phase is one month and the first and second off-treatment period is one month.
• the patient is treated for at least 3 days per week for at least two weeks with 60 to 120 mg/day of fasudil before the off-treatment phase of 2-4 weeks. Subsequently, the patient is subsequently treated in a second treatment phase for at least 3 days per week with 60 to 120 mg/day of fasudil. Then, the patient is subjected to an off-treatment phase of about 1 to 6 months, preferably one month. In one embodiment, fasudil is administered two times per day (bid) during the treatment phase.
• the patient is treated for at least 5 days per week during the first and second treatment phase.
• the duration of the first and second treatment phase is one month.
• the duration of the first and second off-treatment period is one month.
• the first and second treatment phase is one month and the first and second off-treatment period is one month.
• the patient is treated for at least 3 days per week for at least two weeks with 120 to 180 mg/day of fasudil before the off-treatment phase of 2-4 weeks. In one embodiment, the patient is treated 5 days a week. In a preferred embodiment, the patient is subsequently treated in a second treatment phase of at least 2-4 weeks for at least 3 days per week with 120 to 180 mg/day of fasudil. Then, the patient is subjected to an off-treatment phase of about 1 to 6 months, preferably one month.
• fasudil is administered two times per day (bid) during the treatment phase.
• the patient is treated for at least 5 days per week during the first and second treatment phase.
• the duration of the first, and second treatment phase is one month.
• the duration of the first and second off-treatment period is one month.
• the first and second treatment phase is one month and the first and second off-treatment period is one month.
• fasudil is administered two times per day (bid) or three times per day (tid) in an immediate release formulation. In another embodiment, fasudil is administered once per day in an extended-release formulation.
• the patient is treated for at least 3 days per week for at least two weeks with 180 to 240 mg/day of fasudil before the off-treatment phase of 2-4 weeks.
• the patient is subsequently treated in a second treatment phase for at least
• the second treatment phase is at least one month. Then, the patient is subjected to an off treatment phase of about 1 to
• fasudil is administered two times per day (bid) or three times per day (t.i.d.) in an immediate release formulation. In another embodiment, fasudil is administered once per day in an extended-release formulation.
• the patient is treated for at least 3 days per week for at least two weeks with 30 to 60 mg/day of fasudil before the off-treatment phase of 2-4 weeks.
• the patient is subsequently treated in a second treatment phase for at least 5 days per week with 60 to 120 mg/day of fasudil.
• the second treatment phase is at least one month. Then, the patient is subjected to an off-treatment phase of about 1 to 6 months, preferably one month.
• the patient is treated for at least 3 days per week for at least two wrecks with 60 to 120 mg/day of fasudil before the off-treatment phase of 2-4 weeks.
• the patient is subsequently treated in a second treatment phase for at least
• the second treatment phase is at least one month. Then, the patient is subjected to an off-treatment phase of about 1 to
• the patient is treated for at least 3 days per week for at least two wrecks with 120 to 180 mg/day of fasudil before the off-treatment phase of 2-4 weeks.
• the patient is subsequently treated in a second treatment phase for at least
• the second treatment phase is at least one month. Then, the patient is subjected to an off-treatment phase of about 1 to
• the doses are immediate-release formulations.
• fasudil hydrochloride may be administered once a day using an extended-release formulation.
• an extended-release dosage form will contain between 180 and 240 mg of fasudil hydrochloride hemihydrate.
• the precise duration of the first treatment phase will depend on the patient’s condition and response to treatment. Most preferred methods contemplate that treatment begins after the onset or appearance of symptoms.
• dose ranges as described herein provide guidance for the administration of provided pharmaceutical compositions to an adult.
• the amount to be administered to, for example, a child or an adolescent can be determined by a medical practitioner or person skilled in the art and can be lower or the same as that administered to an adult.
• fasudil is administered combination with a second therapeutic agent that treats ALS or symptoms thereof.
• the second therapeutic agent is selected from riluzole, edaravone, tetrabenazine, masitinib, tofersen, ravulizumab — -wevz, mesenchymal stem cell (MSC)-neurotrophic factor (NTF) cells, AMX0035 (phenylbutyrate and taurursodiol), talampanel, tamoxifen, methyl cobalamine, Aeol 10150.
• the ALS patient is administered fasudil in combination with riluzole or edavarone at about 50 to 100 mg day.
• riluzole is administered 50 mg twice daily.
• agents can be co-administered to treat symptoms of ALS or associated comorbidities, including respiratory function, eating, depression and anxiety, pain, dysarthria, dysphagia, sialorrhoea, insomnia, behavior or mood, and constipation can also be co-administered.
• fasudil can be co-administered with other agents that have been used to treat or mitigate symptoms of ALS.
• agents include antidepressants, benzodiazepines, amiltriptyline, dextromethorphan hydrobromide/ quinidine sulfate, anti-inflammatories, muscle relaxants (baclofen, botulinum toxin), anticonvulsants (gabapentin, sodium valproate), anticholinergic drugs (glycopyrronium bromide), atorvastatin, lithium carbonate, avanier 07-ACR- 123 (Zenvia®), SB-509, thalidomide, arimoclomol, olanzapine, memantine, tamoxifen, pioglitazone, creatine monohydrate, botulinum toxin type B, dronabinol, coenzyme Q10, escital opram (Lexapro®), sodium phenylbutyrate,
• the second therapeutic agent is to be administered sequentially or simultaneously.
• the patient is administered fasudil in combination with tetrabenzaine.
• the tetrabenzaine is administered in a dose from 12.5 to 100 mg/patient/day.
• the patient is administered fasudil in combination with an antiinflammatory.
• the patient is administered fasudil in combination with an agent that enhances proteasome activity.
• agents include proflavine pimozide, cyclosporin A, mifepristone, chlorpromazine, loperamide, dipyrimidole, methylbenzethonium, verapamil, ursolic acid, betulinic acid, rolipram, DPCPX, PD 169316, PAP1, PA26, PA28, TCH-165, MK- 886, and AM-404.
• the patient is administered fasudil in combination with an agent that enhances autophagy.
• the autophagy enhancer is BRD5631, carbamazepine, rapamycin, trehalose, trifluoperazine niguldipine, metformin, lithium carbonate, sodium valproate, and ABT-737.
• the patient treated with fasudil is being treated for depression.
• the patient is treated with an anti-depressant such as citalopram or escitalopram.
• ALSFRS-R revised ALS Functional Rating Scale
• ALSFRS-R revised ALS Functional Rating Scale
• Improvement in ALSFRS- R with fasudil can be measured in a change from baseline over time after treatment.
• ALSFRS-R can also be used to delay progression compared to untreated ALS patients. An ALS patient on average will show an approximately 1 point per month decline in the ALSFRS-R.
• the 12 domains of the ALSFRS assess speech, salivation, swallowing, cutting food, dressing and hygiene, turning in bed, walking, climbing stairs, dyspnea, orthopnea and respiratory insufficiency.
• Progression of muscle weakness can also include strength testing (muscles), peripheral nerve and muscle imaging with ultrasound and MRI to measure muscle atrophy, respiratory function assessment (pulmonary 7 testing), and bulbar dysfunction testing (swallowing, tongue, lip and cheek strength).
• Handheld dynamometry/ (Hl H). also called quantitative myometry) is a commonly used methodology for assessment of muscle strength in ALS clinical trials. Electrophysiological assessments of muscles can also be used to measure disease progression. These include compound motor action potential (CMAP) and motor unit number estimates (MUNE, MIJNIX) which are nerve conduction assessments used to quantify the numbers of motor units innervating an individual muscle. Isometric testing using e.g., Tufts Quantitative Neuromuscular Exam (TQNE) or the accurate test of limb isometric strength (ATLIS) can be used to measure upper and lower extremity muscles. (Andres 2013). ATLIS measures isometric strength in 12 muscle groups in the arms and legs. Electrical impedance myography (EIM) is also used to evaluate how electrical currents flow through muscle.
• CMAP compound motor action potential
• MUNE motor unit number estimates
• Isometric testing using e.g., Tufts Quantitative Neuromuscular Exam (TQNE) or the accurate test of limb isometric
• FVC forced vital capacity
• lung measurements that can be used include the maximum mid-flow expiratory/ flow rate and peak cough flow. The latter involves coughing once the lungs have been emptied. Respiratoory pressure meters can also assess respiratoory strength to determining the maximum inspiratory pressure (MEP).
• MEP maximum inspiratory pressure
• Weight loss is a predictor of shorter survival in amyotrophic lateral sclerosis (ALS).
• treatment of an ALS patient with fasudil reduces or reverses the progression ALS.
• this is measured using the ALSFRS-R and treatment with fasudil will slow the rate of decline in one or more of the twelve domains.
• the average rate of decline is one point per month, but it should be determined empirically over two to twelve months prior to fasudil treatment and then the effectiveness of fasudil treatment is determined by assessing progression over the same duration following starting fasudil treatment. Slowing or stopping the decline based on the ALSFRS is considered a successful treatment, as is reversing the decline.
• treatment of an ALS patient with fasudil reduces or reverses the loss of motor neuron demyelination or deterioration. Less deterioration can be measured by techniques including imaging, for example, diffusion-tensor MRI, MR spectroscopy, PET, neuroimaging with transcranial magnetic stimulation, or any combination thereof.
• treatment of an ALS patient with fasudil improves muscle deterioration (atrophy), reduces muscle paralysis or contraction, and reduces or prevents spreading of muscle fasciculations (twitches).
• treatment of an ALS patient with fasudil reduces extremity muscle deficits.
• Muscle weakness can be evaluated using any method, e.g., strength testing, dynamometry (including hand-held), force transducers (strain gauges), electrophysiological assessments, isometric testing, and peripheral nerve and muscle imaging with ultrasound and MRI.
• bulbar dysfunction is improved upon treatment of an ALS patient with fasudil as determined using e.g., the Iowa Oral Performance Instrument measurements of tongue, lip, and cheek strength or the Sydney Swallow Questionnaire.
• fasudil treatment of an ALS patient improves swallowing and eating, reduces or delays progression of dysphagia, reduces slurred speech (dysarthria), and enables the ALS patient to retain a healthy weight.
• Assessments such as clinical MRI, needle EMG, the Frenchay Dysarthria Assessment, the Videofluoroscopic Swallowing Exam (VFSE), Maximum Tongue Pressure Test, and/or the EAT- 10 screening tool, Improvements can also be assessed by speech pathologists and dieticians.
• treatment of an ALS patient with fasudil improves respiratory function.
• fasudil treatment improves F VC%, oxygen saturation.
• treatment of an ALS patient reduces fatigues, improves poor balance and reduces tripping, improves grip.
• the improvement is measured by improvements in the 48-point ALSFRS-R rating scale score, or any sub-scale thereof such as the activities of daily living (ADL) sub-score, relative to the score before being treated with fasudil hydrochloride.
• the scale is the ALSAQ-40
• winch is a disease-specific questionnaire that was created specifically to assess health-related quality of life in patients with ALS. (Jenkinson et al., 1999).
• improvement occurs with a higher score from baseline.
• a consistent score over time without dropping is evidence of delayed progression of ALS.
• the improvement i measured by delayed reductions in the ALSFRS-R rating scale score relative to patients with ALS patient not being treated with fasudil.
• treatment of an ALS patient with fasudil reduces motor neuroinfl ammati on.
• the invention provides a method of reducing, reversing, or preventing the accumulation of TDP-43 in an ALS patient, the method comprising administering to said subject an effective amount of fasudil or a pharmaceutically acceptable salt thereof.
• TDP-43 cytoplasmic mis-localization is reduced upon treatment of an ALS patient with fasudil.
• the TDP-43 aggregation, phosphorylation and/or ubiquitination is reduced by at least about 5%, at least about 10%, at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, at least about 55%, at least about 60%, at least about 65%, at least about 70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, at least about 95%, or about 100% upon treating an ALS patient with fasudil.
• fasudil treatment reduces or mitigates symptoms of /ALS.
• treatment of an ALS patient improves survival (delays death).
• survival is extended beyond the typical 2 years.
• survival is extended beyond 2 years, beyond 3 years, beyond 4 years, and beyond 5 years.
• survival is extended by 3 months to a year.
• Certain patient sub-populations such as renally impaired patients and/or older patients (e.g., 65 or older) may need lower doses or extended release formulations instead of immediate release formulations. Fasudil hydrochloride hemihydrate may have higher steady-state concentrations when given at usual doses to patients with renal disease and lower doses to lower the Cmax or delay the time to Cmax (increase the Tmax) may be required.
• Renal dysfunction occurs with age and as the result of numerous disorders, including liver cirrhosis, chronic kidney disease, acute kidney injury (for example, due to administering a contrast agent), diabetes (Type 1 or Type 2), autoimmune diseases (such as lupus and IgA nephropathy), genetic diseases (such as polycystic kidney disease), nephrotic syndrome, urinary' tract problems (from conditions such as enlarged prostate, kidney stones and some cancers), heart attack, illegal drug use and drag abuse, ischemic kidney conditions, urinary tract problems, high blood pressure, glomerulonephritis, interstitial nephritis, vesicoureteral, pyelonephritis, sepsis. Kidney dysfunction may occur in other diseases and syndromes, including non-kidney- related diseases that may occur along with kidney dysfunction, for example pulmonary arteryhypertension, heart failure, and cardiomyopathies, among others.
• Kidney function is most often assessed using serum (and/or urine) creatinine. Creatinine is a breakdown product of creatine phosphate in muscle cells and it is produced at a constant rate. It is excreted by the kidneys unchanged, principally through glomerular filtration. Accordingly, elevated serum creatinine is a marker for kidney dysfunction and it is used to estimate glomerular filtration rate.
• Normal levels of creatinine in the blood are approximately 0.6 to 1.2 mg/dL in adult males and 0.5 to 1.1 mg/dL in adult females. When creatinine levels exceed these figures, the subject has renal dysfunction, and is, therefore, treatable according to the invention. Mild renal impairment/dysfunction occurs in the range of 1.2 mg/dL to 1.5 mg/dL. Moderate renal impairment/dysfunction is considered to occur at creatinine levels exceeding 1.5 mg/dL. Severe renal impairment, which includes what is considered to be renal failure, is defined as a serum creatinine level of > 2.0 mg/dL or the use of renal replacement therapy (such as dialysis). Treating subjects with mild, moderate and severe renal impairment is specifically contemplated.
• Patient size is an important factor to consider when using creatinine-based estimates of renal function.
• the units of drag clearance are volume/time (niL/min), whereas the units of estimated GFR for chronic renal disease are volume/time/ standard size (mL/min/1.73ni 2 ).
• doses may be adjusted down (e.g., 40-50 mg per day) for smaller patients and up for larger (e.g., 120 mg per day) for obese patients.
• a smaller male would be about 160 pounds or less.
• a smaller female patient would weigh about 130 pounds or less.
• Patients having a Body Mass Index of 30 and higher is considered obese.
• older patients may need a lower dose at initiation, with a gradual increase to the recommended dose after days or weeks.
• older patients may need lower doses, e.g., 90 mg/day, for the duration of treatment, with anticipated titration up to the 180 to 240 mg/day dose.
• dose ranges as described herein provide guidance for the administration of provided pharmaceutical compositions to an adult.
• the amount to be administered to, for example, a child or an adolescent can be determined by a medical practitioner or person skilled in the art and can be lower or the same as that administered to an adult.
• EXAMPLE 1 TREATMENT OF AN ALS WITH FASUDIL-A Phase 2a Open-Label Preliminary Safety, Efficacy, and Biomarker Study of Fasudil HCI in Patients with ALS
• the aim of the study is to assess the preliminary' safety, efficacy, and effect on biomarkers of oral fasudil HCI hemihydrate, in patients with ALS.
• Patients will be cohorted into treatment groups. One group will be treated 5 days a week for one month at a dose of 60 mg/day of fasudil (30 mg bid; immediate release tablets), followed by a one month off-treatment phase. That same cohort will then be treated with 60 mg/day of fasudil (30 mg bid; immediate release tablets) 5 days a w'eek for one month. This will be followed by another off-treatment phase for one month.
• the second cohort will be treated 5 days a week at a higher dose of 180 mg/day (60 mg tid) immediate release tablets for one month, followed by a one month off-treatment phase. That same cohort will then be treated with 180 mg/day of fausidil 5 days a week for one month. This will be followed by another off-treatment phase for a month.
• Patients can maintain their current doses of riluzole or edaravone.
• Use of more than one of the following drug classes will be disallowed: long-acting nitrates, beta-blockers, or calcium channel blockers. (Note: subjects may be on one of the drug classes.)
• the study will evaluate the effects of Fasudil on changes in the slope of decline in the Revised ALS Functional Rating Scale (ALSFRS-R), slow vital capacity (SVC) and hand-held dynamometry (HHD). Specifically, the study objectives are:
• CSF cerebrospinal fluid
• Each cohort of approximately 20 subjects between the ages of 18 and 75 with possible, probable laboratory-supported, probable, or definite ALS, as defined by El Escorial Revised ALS diagnostic criteria are eligible for inclusion in the study, provided their ALSFRS-R is declining by an average of 0.5-1.5 points per 4 weeks at the time of Screening 1 (see Inclusion Criterion 3 for estimation methods).
• the study will enroll sufficient subjects such that approximately 20 subjects have an average ALSFRS-R decrease between Screening 1 and V3ZD1 of 0.5-1.5 points per 4 weeks. Replacement of subjects not considered evaluable may be considered.
• ALS assessments of ALSFRS-R/SVC/HHD will be performed, as will safety assessments.
• Subjects who meet the pertinent inclusion/ exclusion criteria will return for a second screening visit (Screening 2/V2) approximately 4 weeks later, and ALS and safety assessment will again be conducted.
• Subjects who meet the pertinent Screening 2 study entry criteria will be enrolled into the study.
• evaluations will be performed and dosing with study drug will begin for the first treatment phase as outlined above for each cohort (60 mg or 180 mg) 5 days per week for one month, followed by a one month off-treatment phase. Immediately following, the same cohort will be treated 5 days per week for one-month at the same dose, followed by another off- treatment phase for one month.
• Participants will have an in-person or telephone visit at Week 1 post-treatment to assess for safety and drag compliance. Additional follow-up visits will occur at Weeks 4, 8, and 12, during which ALS assessments of ALSFRS-R/SVC/HHD will be performed. A final visit will be conducted at Week 16 (or 7 ⁇ 2 days after early termination) for post-treatment follow-up evaluations.
• Plasma biomarker collection will occur between enrollment and commencement of treatment, and at Week 4 and Week 12.
• CSF biomarker collection will occur between enrollment and commencement of treatment, and at Week 12.
• visits/ study procedures may be performed outside of the clinic (e.g., at home or other sample collection site), and interviews may be performed by telephone and/or telemedicine as appropriate.
• Safety. Safety wall be assessed by examining the incidence of AEs and SAEs, clinically significant abnormal physical and neurological examination findings, changes in vital signs, 12- lead ECG, and hematology, blood chemistry, liver function, and urine tests.
• ALSFRS-R Changes in slope of decline in HHD measurements during treatment vs. pre-treatment.
• the ALSFRS-R is a validated rating instrament for monitoring the progression of disability in patients with ALS and is utilized for monitoring functional change in ALS patients. The score assesses various 4 domains including: (i) bulbar function (speech, salivation, swallowing),
• fine motor task handwriting, cutting food and handling utensils, with or without gastrostomy, dressing and hygiene
• gross motor task turning in bed, walking, climbing stairs
• respiratory function respiratory function
• Each item within a domain is attributed a score of 0 (complete loss of function) to 4 (normal ), yielding a maximum score of 48 when the function is preserved.
• ALSFRS-R Evaluators performing ALSFRS-R must be certified by the Northeast Amyotrophic Lateral Sclerosis Consortium (NEALS). Use of alternative certifications must be approved in writing by the Sponsor. The ALSFRS-R should be performed by the same rater at each visit if feasible.
• NEALS Northeast Amyotrophic Lateral Sclerosis Consortium
• SVC amyotrophic lateral sclerosis
• the vital capacity will be determined using the upright SVC method.
• the SVC will be measured using the study-approved portable spirometer, and assessments will be performed using a face mask.
• Three SVC trials are required for each testing session, however up to 5 trials may be performed if the variability between the highest and second highest SVC is 10% or greater for the first 3 trials. Only the 3 best trials are recorded on the electronic case report form (eCRF). The highest SVC recorded is utilized for eligibility. At least 3 measurable SVC trials must be completed to score SVC for all visits after screening.
• Predicted SVC values and percent- predicted SVC values will be calculated using the Quanjer Global Lung Initiative equations.
• Evaluators performing the SVC must be certified by NEALS. Use of alternative certifications must be approved in writing by the Sponsor. The SVC should be performed by the same rater at each visit if feasible.
• Muscle strength will be assessed by hand-held dynamometer (HHD). A spring-loaded device that “breaks” at pre-set forces will be used to assess readings obtained by HHD throughout the study. Grip strength dynamometry for both hands will be acquired, and the mean force in kilograms will be calculated. Measures will be obtained from each hand in triplicate.
• HHD hand-held dynamometer
• HHD Evaluators performing HHD must be certified by NEALS. Use of alternative certifications must be approved in writing by the Sponsor. The HHD should be performed by the same rater at each visit if feasible.
• Changes in plasma biomarkers of neurodegeneration e.g., neurofilament light chain [NfL.] and phosphorylated neurofilament heavy subunit [pNfH]
• inflammatory markers e.g., IFN-y, VCAM-1, ICAM-1, IL-1 , IL-6, IL-17a, TNF-a and Clq
• markers of inflammation and neurodegeneration in neuronal and/or astrocytic exosomes e.g., IL-6, tau, protein kinase B [AKT] and phosphorylated-AKT [p-AKT]
• CSF biomarkers of axonal degeneration and/or apoptosis e.g., tau and NIL
• inflammation e.g., inflammation
• markers of drug target engagement e.g., species of phosphorylated tau [p-tau], p-NfL PTEN and AKT/p-AKT
• Changes in plasma biomarkers of muscle loss e.g., actin, myosin, myosin light chain, troponin, titin, myozenin, alpha-actinin, nebulin, cofilin 2, tropomyosin 2, creatine kinase, myoglobin, sarcospan, integrin alpha 7, agrin, laminin 211, collagen IV, collagen VI, and collagen fragments
• actin e.g., actin, myosin, myosin light chain, troponin, titin, myozenin, alpha-actinin, nebulin, cofilin 2, tropomyosin 2, creatine kinase, myoglobin, sarcospan, integrin alpha 7, agrin, laminin 211, collagen IV, collagen VI, and collagen fragments
• CSF will be analyzed for biomarkers of neurodegeneration, which may include but are not limited to:
• phosphorylated tau species e.g., P-tau181, pS202, pS386, Thr245, Thr377, Ser409
• ALSFRS-R ALS Functional Rating Scale
• SVC a reduction in the slope since the slope is correlated with disease progression.
• the decline is less than the average 2.5-3.0% per month.
• the rate of respiratory decline is slowed to an average of 1 .5 percentage points per month.
• HHD Hand-held dynamometry
• Fasudil treatment will reduce the presence of and/or levels of biomarkers associated with neuronal and axonal degeneration, and reduce the amount of biomarkers associated with muscle loss by 25-50%.
• treatment with Fasudil is expected to reduce the presence of and/or levels of biomarkers associated with neuronal and axonal degeneration, and reduce the presence of biomarkers associated with muscle loss as compared to that reported for patients not administered Fasudil.
• the ALSFRS-R a revised ALS functional rating scale that incorporates assessments of respiratory function.
• BDNF ALS Study Group Phase III. J Neurol Sci. 1999 Oct 31; 169(1-2): 13-21.
• Gurney ME et al. Motor neuron degeneration in mice that express a humand Cu,Zn superoxide dismutase mutation. Science. 1994; 264(5166): 1722-25.
• Amyotrophic Lateral Sclerosis and Frontotemporal Degeneration 2017; 18: 153-174.

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