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
  • A61K31/53—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with three nitrogens as the only ring hetero atoms, e.g. chlorazanil, melamine
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
  • A61K45/06—Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P9/00—Drugs for disorders of the cardiovascular system
  • A61P9/12—Antihypertensives
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K2300/00—Mixtures or combinations of active ingredients, wherein at least one active ingredient is fully defined in groups A61K31/00 - A61K41/00

Definitions

• This invention relates to methods of treating hypertension by inhibiting aldosterone synthase (CYP 1 1 [32 beta hydroxylase).
• Aldosterone is the principal mineralocorticoid in humans, produced in the zona glomerulosa of the adrenal cortex by aldosterone synthase (CYP 1 1 [32 beta hydroxylase). Aldosterone is a key component of the renin-angiotensin-aldosterone system (RAAS), acting primarily as a regulator of electrolyte and fluid homeostasis.
• RAAS renin-angiotensin-aldosterone system
• Mineralocorticoid receptor-blocking agents such as spironolactone and eplerenone, prevent aldosterone from binding with the mineralocorticoid receptor.
• MRA mineralocorticoid receptor antagonists
• PA plasma aldosterone
• This invention provides a method of treating hypertension in a hypertensive subject, the method comprising administering to the subject a CYP 1 1 [32 beta hydroxylase inhibitor once or twice per day in an amount sufficient to inhibit 50% or more of CYP 11 [32 beta hydroxylase’s activity for 40-60% of a 24-hour period to thereby treat hypertension in the hypertensive subject.
• This invention provides a method of treating hypertension in a hypertensive subject, the method comprising administering to the subject a CYP 1 1 [32 beta hydroxylase inhibitor once or twice per day in an amount sufficient to reduce the serum aldosterone level of the subject by 50-90% relative to the subject’s pre-drug level of serum aldosterone for a period not less than eight hours and not greater than 16 hours.
• This invention provides a method of treating hypertension in a hypertensive subject, the method comprising administering to the subject a CYP 1 1 [32 beta hydroxylase inhibitor once per day in an amount sufficient to inhibit 50% or more of CYP 1 1 [32 beta hydroxylase’s activity for between 1 and 16 hours, preferably for between 3 and 8 hours
• This invention also provides a method of treating hypertension in a hypertensive subject, the method comprising administering to the hypertensive subject a CYP 1 1 [32 beta hydroxylase inhibitor once or twice per day in an amount sufficient to lower the hypertensive subject’s ambulatory systolic blood pressure by at least 10 mmHg relative to the hypertensive subject’s ambulatory systolic blood pressure prior to administration of the CYP 11 [32 beta hydroxylase inhibitor for a period of at least eight weeks.
• This invention also provides a method of reducing a hypertensive subject’s systolic blood pressure during sleep, the method comprising administering to the subject a CYP 11 [32 beta hydroxylase inhibitor once or twice per day in an amount sufficient to reduce a hypertensive subject’s systolic blood pressure during sleep BRIEF DESCRIPTION OF THE DRAWINGS
• Figure 1 Estimate of time above IC50 for various doses of Compound A HBr based on PKPD modeling from SAD study.
• Figure 2 Mean change in systolic blood pressure from baseline at week 4.
• Figure 3 Individual systolic blood pressure change from baseline in the 100 mg QD and 25 mg BID cohorts. Median values indicated by black horizontal bars on left and right of each chart.
• Figure 4 Boxplot of change in systolic blood pressure from baseline at week 4.
• Figure 5 Comparison of median serum potassium over time in placebo, 25 mg BID and 100 mg QD cohorts.
• Figure 6 Graph of all available data for serum K + values in the placebo and 100 mg QD cohorts.
• Figure 7 Individual responses in automated office-measured blood pressure (AOBP), Serum K+, and estimated glomerular filtration rate (eGFR) in the 100 mg cohort. Median values indicated by black horizontal bars on left and right of each chart.
• AOBP automated office-measured blood pressure
• Serum K+ Serum K+
• eGFR estimated glomerular filtration rate
• FIG. 10 Aldosterone time profile for single ascending dose administration by dose group.
• Day -1 is the day prior to dosing, reflecting normal circadian rhythm.
• FIG. 11 Aldosterone time profile for multiple ascending dose administration by dose group.
• Day -1 is the day prior to initiating dosing, reflecting normal circadian rhythm.
• Figure 13 Aldosterone percent change from baseline, time profile for single ascending dose administration by dose group.
• Figure 14 Individual pharmacokinetics and time course of aldosterone suppression and recovery in Part 1 single ascending dose.
• Figure 15 Effect of Compound A on aldosterone and cortisol in Part 1 single ascending dose.
• AUC0-24 area under the curve from 0 to 24 hours;
• AUC0-72 area under the curve from 0 to 72 hours.
• Figure 16 Effect of Compound A on aldosterone and cortisol in Part 1 single ascending dose.
• Cortisol AUC0-72 in Part 1 single ascending dose AUC0-24, area under the curve from 0 to 24 hours;
• AUC0-72 area under the curve from 0 to 72 hours.
• Figure 17 Effect of Compound A on plasma renin activity in Part 2 multiple ascending dose.
• Figure 18 Effect of Compound A on 11-DOC in Part 2 multiple ascending dose.
• Figure 20 Effect of Compound A on renal sodium and potassium handling. Serum K + .
• FIG. 21 Compound A HBr Study Schema.
• a If Screening results were available, inclusion/ exclusion evaluation was performed. If subject was not eligible based on Screening results, they did not continue to Visit 4. If Screening results were not available, subject proceeded to Visit 4. If Screening results were not available at Visit 4, subject should attend Visit 5 to determine final eligibility. If eligible based on Screening results, ABPM assessment begins at Visit 5.
• b The ABPM procedure initiated at home approximately 24 hours before Randomization (Study Day 1). Alternatively, sites were permitted choose to schedule an office visit on Study Day 0 (Visit 5) to initiate the ABPM procedure. Training for the ABPM procedure was done either at an office visit or via phone.
• Figure 22 Waterfall plots showing the AOBP change in systolic blood pressure at week 8. The figure shows waterfall plots of the full analysis and safety set (FAS) analysis of placebo, 50mg QD and lOOmg QD groups and the per-protocol (PP) analysis of the 100 mg group. A modeled mean and per-protocol observed mean values are also shown for each group.
• Figure 23 Waterfall plots showing the AOBP change in systolic blood pressure at week 8. The figure shows waterfall plots of the FAS analysis of 12.5mg QD, 12.5 mg BID, and 25 mg BID using all subjects with week 8 measurement. Modeled mean and per-protocol observed mean values are also shown for each group.
• Figure 24 A bar graph showing the mean change in systolic blood pressure from baseline. The figure provides a final analysis including both full analysis set (FAS, all evaluable subjects receiving at least one dose of Compound A HBr) and per-protocol (PP, only those receiving > 75% of study drug with week 8 visit). Part 2 data shows the interim average of last visit week 5-6.
• FAS full analysis set
• PP per-protocol
• Figure 25 Graph of mean observed automated office blood-pressure change from baseline at week 8 for QD dosing regimens, showing a dose-response to Compound A HBr. BID per-protocol cohorts are shown on the far right of the graph.
• Figure 26 Graph showing the systolic blood pressure change from baseline at week 8 for a 50 mg QD, 100 mg QD, 12.5 mg BID, and 25 mg BID pooled cohort, the lowest response quartile of the pooled cohorts, the highest response quartile of the pooled cohort, and placebo.
• Figure 27 A waterfall plot showing change in systolic blood pressure from placebo and 100 mg QD groups pooled from both Parts 1 and 2. Part 2 data from interim snapshot with all subjects randomized and average last visit week 5-6, minimum week 2.
• Figure 28 A graph showing the change in estimated glomerular filtration rate (eGFR) in different dosing cohorts.
• Figure 29 A graph showing an example of ambulatory 24-hour blood pressure monitoring.
• the graph shows the 24-hour ambulatory blood pressure (systolic) of a subject receiving Compound A HBr lOOmg QD versus baseline, showing an average 24-hour blood pressure reduction and restoration of normal nocturnal dipping pattern.
• Figure 30 A graph showing the change in systolic blood pressure at week 8 relative to baseline as measured using the ABPM full analysis set.
• Figure 31 Waterfall plots showing the 24-hour average and overnight average ABPM change at 8 weeks relative to baseline. 100 mg QD dose levels provide excellent 24-hour blood pressure reduction. Overnight blood pressure reduction from the 100 mg QD dose level appears to be superior to 25 mg BID. DETAILED DESCRIPTION OF THE INVENTION
• This invention provides a method of treating hypertension in a hypertensive subject, the method comprising administering to the subject a CYP 1 1 [32 beta hydroxylase inhibitor once or twice per day in an amount sufficient to inhibit 50% or more of CYP 11 [32 beta hydroxylase’s activity for 40-60% of a 24-hour period to thereby treat hypertension in the hypertensive subject.
• 50% or more of CYP 11 [32 beta hydroxylase’s activity is inhibited for between 10 to 14 hours of a 24-hour period.
• This invention provides a method of treating hypertension in a hypertensive subject, the method comprising administering to the subject a CYP 1 1 [32 beta hydroxylase inhibitor once or twice per day in an amount sufficient to reduce the serum aldosterone level of the subject by 50-90% relative to the subject’s pre-drug level of serum aldosterone for a period not less than eight hours and not greater than 16 hours.
• the CYP 11 [32 beta hydroxylase inhibitor reduces the serum aldosterone level of the subject by 60-80% relative to the subject’s pre-drug level of serum aldosterone for a period not less than eight hours and not greater than 16 hours.
• the CYP 11 [32 beta hydroxylase inhibitor allows serum aldosterone of the subject to return to the subject’s pre-drug level of serum aldosterone or greater during the period between 16 and 24 hours after the dose is administered.
• This invention provides a method of treating hypertension in a hypertensive subject, the method comprising administering to the subject a CYP 11 [32 beta hydroxylase inhibitor once per day in an amount sufficient to inhibit 50% or more of CYP 1 1 [32 beta hydroxylase’s activity for between 1 and 16 hours, preferably for between 3 and 8 hours.
• This invention provides a method of treating hypertension in a hypertensive subject, the method comprising administering to the subject a CYP 11 [32 beta hydroxylase inhibitor once per day in an amount sufficient to:
• This invention provides a method of treating hypertension in a hypertensive subject, the method comprising administering to the subject a CYP 1 1 [32 beta hydroxylase inhibitor once per day in an amount sufficient to:
• the hypertensive subject is taking or has taken a hypertension medication selected from a diuretic, an ACE inhibitor, an angiotensin receptor blocker, a calcium channel blocker, or a combination of two or more thereof.
• the hypertensive subject is taking or has taken at least two of said hypertension medications.
• the CYP 11 [32 beta hydroxylase inhibitor is administered to the subject once per day.
• the amount of the CYP 11 [32 beta hydroxylase inhibitor is administered in the morning.
• the amount of the CYP 11 [32 beta hydroxylase inhibitor is administered once per day in the morning.
• the CYP 11132 beta hydroxylase inhibitor is administered to the subject twice per day.
• the CYP 11 [32 beta hydroxylase inhibitor [32 beta hydroxylase inhibitor:
• (d) is administered daily for at least eight weeks.
• the CYP 11 [32 beta hydroxylase inhibitor is selective for inhibition of CYP 11 [32 beta hydroxylase activity relative to inhibition of CYP 11 [31 beta hydroxylase activity, preferably wherein the inhibition constant (Ki) for CYP 11 pi beta hydroxylase divided by the Ki for CYP 11 P2 beta hydroxylase is greater than 100.
• the CYP 11 [32 beta hydroxylase inhibitor is administered to the hypertensive subject in an amount below the amount which causes the subject’s serum and/or plasma 11-deoxycortisterone (11-DOC) levels to exceed 600 pmol/L, preferably below the amount which causes the subject’s serum and/or plasma 11-DOC levels to exceed 400 pmol/L.
• 11-DOC 11-deoxycortisterone
• the CYP 11 [32 beta hydroxylase inhibitor is administered to the hypertensive subject in an amount below the amount which causes an accumulation of 11-DOC above 0.1 ng/ml in the subject.
• the CYP 11 [32 beta hydroxylase inhibitor is administered to the hypertensive subject in an amount which does not cause a clinically meaningful upregulation of the subject’s adrenocortical hormone synthesis.
• the administration of the CYP 11J32 beta hydroxylase inhibitor is administered to the hypertensive subject in an amount which:
• (b) does not cause a clinically meaningful increase in the subject’s serum and/or plasma 11-DOC levels relative to the subject’s serum and/or plasma 11- DOC levels prior to administration of the CYP 11 [32 beta hydroxylase inhibitor; and/or [0062]
• the CYP 11 [ 2 beta hydroxylase inhibitor is administered to the hypertensive subject in an amount:
• the CYP 11 [32 beta hydroxylase inhibitor is a compound described in US Patent No. 10,029,993, the disclosure of which is incorporated by reference herein. In embodiments, the CYP 11 [32 beta hydroxylase inhibitor is a compound described in US Patent No. 10,329,263, the disclosure of which is incorporated by reference herein. In embodiments, the CYP1 1 [32 beta hydroxylase inhibitor is a 1,2,4-triazine compound or a pharmaceutically acceptable salt thereof. [0065] In embodiments, the CYP 11 [32 beta hydroxylase inhibitor is a compound of Formula (A) or a pharmaceutically acceptable salt thereof:
• the CYP 1 1 [12 beta hydroxylase inhibitor is a pharmaceutically acceptable salt of the compound of Formula (A).
• the CYP11 [32 beta hydroxylase inhibitor is a monohydrobromide salt of the compound of Formula (A), i.e. Compound A HBr.
• the CYP1 1 [32 beta hydroxylase inhibitor is the free base form of the compound of Formula (A).
• the C YP 11132 beta hydroxylase inhibitor is a compound of formula
• R Y represents an alkyl group
• R A represents a cycloalkyl group which may be substituted, a cycloalkenyl group which may be substituted, an aryl group which may be substituted, or a 6- to 10-membered monocyclic or bicyclic heteroaryl group which may be partially hydrogenated and may be substituted;
• R 1 represents a hydrogen atom, or an alkyl group
• R 2 represents an alkyl group which may be substituted, a cycloalkyl group which may be substituted, an aliphatic heterocyclic group which may be substituted, or a heteroaryl group which may be partially hydrogenated and may be substituted;
• R 3 represents a hydrogen atom, or an alkyl group, or a pharmaceutically acceptable salt thereof.
• the subject’s office-measured systolic blood pressure is lowered relative to the subject’s office-measured systolic blood pressure prior to administration of the CYP 11 [32 beta hydroxylase inhibitor; and/or (b) the subject’s 24-hour ambulatory systolic blood pressure is lowered relative to the subject’s ambulatory systolic blood pressure prior to administration of the CYP 11 [32 beta hydroxylase inhibitor.
• the subject’s systolic blood pressure is reduced to less than 130 mmHg and/or the subject’s diastolic blood pressure is reduced to less than 80 mmHg.
• the hypertensive subject s systolic blood pressure during sleep is reduced.
• the hypertensive subject’s average systolic blood pressure during sleep is reduced:
• the duration of inhibition of CYP 11 [32 beta hydroxylase activity is sufficient to maintain a state of sodium and volume depletion in the hypertensive subject;
• the method does not produce a persistent state of hyperkalemia or mild non-anion gap metabolic acidosis in the hypertensive subject;
• the CYP 11 [32 beta hydroxylase inhibitor does not substantially accumulate in the hypertensive subject, preferably wherein the lack of substantial accumulation of the CYP 11 [32 beta hydroxylase inhibitor in the hypertensive subject allows for the hypertensive subject’s aldosterone levels to return to pre-drug baseline within 24-48 hours of the CYP 11 [32 beta hydroxylase inhibitor being administered, more preferably within 16-24 hours of the CYP 11 [32 beta hydroxylase inhibitor being administered.
• the hypertensive subject’s potassium levels are generally maintained in a clinically normal range, preferably wherein the hypertensive subject’s potassium levels are mildly elevated relative to the hypertensive subject’s potassium levels prior to administration of the CYP 11 [32 beta hydroxylase inhibitor, more preferably wherein the hypertensive subject’s potassium levels are elevated by 0.35 mmol/L or less, more preferably wherein the hypertensive subject’s potassium levels are maintained below a level of 5.5 mmol/L, more preferably wherein the hypertensive subject’s potassium levels are maintained between 3.5 mEq/1 to 5.1 mEq/1.
• the CYP 11132 beta hydroxylase inhibitor is administered to the hypertensive subject in an amount which:
• serum and/or plasma potassium levels in the subj ect are increased by at least 0.2 mMol/L relative to the serum and/or plasma potassium levels in the subject prior to administration of the CYP 11 [32 beta hydroxylase inhibitor; and/or
• PRA in the subject is increased by at least 5 ng/ml/hr relative to the PRA in the subject prior to administration of the CYP 11 [32 beta hydroxylase inhibitor.
• the hypertensive subject’s aldosterone level follows a substantially normal circadian rhythm.
• the hypertensive subject has a plasma renin activity less than or equal to 1 ng/mL/hour.
• the hypertensive subject has a plasma renin activity less than or equal to 0.6 ng/mL/hour.
• the hypertensive subject has a plasma renin activity less than or equal to 4 ng/mL/hour.
• the hypertensive subject has a plasma renin activity less than or equal to 3 ng/mL/hour. [0090] In embodiments of the invention, the hypertensive subject has a plasma renin activity less than or equal to 2 ng/mL/hour.
• the hypertensive subject has a plasma aldosterone concentration of greater than or equal to 6 ng/dL as measured by an immunoassay.
• the hypertensive subject has a plasma aldosterone concentration of greater than or equal to 1 ng/dL as measured by LC-MS.
• the hypertensive subject has a plasma renin activity less than or equal to 1 ng/mL/hour and a plasma aldosterone concentration of greater than or equal to 6 ng/dL as measured by an immunoassay.
• the hypertensive subject has a plasma renin activity less than or equal to 1 ng/mL/hour and a plasma aldosterone concentration of greater than or equal to 1 ng/dL as measured by LC-MS.
• this hypertensive subject is taking or has taken a hypertension medication selected from a diuretic, an ACE inhibitor, an angiotensin receptor blocker, a calcium channel blocker, or a combination of two or more thereof.
• This invention also provides a method of treating hypertension in a hypertensive subject, the method comprising administering to the hypertensive subject a CYP 1 1 [12 beta hydroxylase inhibitor once or twice per day in an amount sufficient to lower the hypertensive subject’s ambulatory systolic blood pressure by at least 10 mmHg relative to the hypertensive subject’s ambulatory systolic blood pressure prior to administration of the CYP 11 [32 beta hydroxylase inhibitor.
• the method lowers the hypertensive subject’s ambulatory systolic blood pressure by at least 10 mmHg relative to the hypertensive subject’s ambulatory systolic blood pressure prior to administration of the CYP 11 [32 beta hydroxylase inhibitor for a period of at least eight weeks.
• This invention also provides a method of reducing a hypertensive subject’s systolic blood pressure during sleep, the method comprising administering to the subject a CYP 11 [32 beta hydroxylase inhibitor once or twice per day in an amount sufficient to reduce a hypertensive subject’s systolic blood pressure during sleep.
• the hypertensive subject’s average systolic blood pressure during sleep is reduced: (a) by at least 10%, by between 10% and 40%, by between 10% and 30%, or by between 10% and 20% relative to the hypertensive subject’s average daytime systolic blood pressure;
• the hypertensive subject is taking or has taken a hypertension medication selected from a diuretic, an ACE inhibitor, an angiotensin receptor blocker, a calcium channel blocker, or a combination of two or more thereof. In embodiments of the invention, the hypertensive subject is taking or has taken at least two of said hypertension medications.
• 50% or more of CYP 11 [32 beta hydroxylase’s activity is inhibited for 40-60% of a 24-hour period.
• 50% or more of CYP 11 [32 beta hydroxylase’s activity is inhibited for between 10 to 14 hours of a 24-hour period.
• the CYP 11 [32 beta hydroxylase inhibitor reduces the serum aldosterone level of the subject by 50-90% relative to the subject’s pre-drug level of serum aldosterone for a period not less than eight hours and not greater than 16 hours.
• the CYP 11 [32 beta hydroxylase inhibitor reduces the serum aldosterone level of the subject by 60-80% relative to the subject’s pre-drug level of serum aldosterone for a period not less than eight hours and not greater than 16 hours.
• the CYP 11 [32 beta hydroxylase inhibitor allows serum aldosterone of the subject to return to the subject’s pre-drug level of serum aldosterone or greater during the period between 16 and 24 hours after the dose is administered.
• 50% or more of CYP 11 [32 beta hydroxylase’s activity is inhibited for between 1 and 16 hours, or preferably for between 3 and 8 hours, of a 24-hour period.
• the CYP 11 [32 beta hydroxylase inhibitor is administered to the subject once per day. In embodiments of the invention, the CYP 11 [32 beta hydroxylase inhibitor is administered in the morning. In embodiments of the invention, the CYP 1 I [12 beta hydroxylase inhibitor is administered to the subject twice per day.
• the CYP 11132 beta hydroxylase inhibitor [0106] In embodiments of the invention, the CYP 11132 beta hydroxylase inhibitor:
• (d) is administered daily for at least eight weeks.
• the hypertensive subject’s ambulatory systolic blood pressure is reduced by 10-55 mmHg, by 10-50 mmHg, by 10-45 mmHg, by 10-40 mmHg, by 10-35 mmHg, by 10-30 mmHg, by 10-25 mmHg, by 10-20 mmHg, or by 10-15 mmHg, relative to the hypertensive subject’s ambulatory systolic blood pressure prior to administration of the CYP 1 1 [32 beta hydroxylase inhibitor for a period of at least eight weeks.
• the hypertensive subject’s ambulatory systolic blood pressure is reduced by 5-25 mmHg, by 5-20 mmgHg, or by 5-15mmHg relative to the hypertensive subject’s ambulatory diastolic blood pressure prior to administration of the CYP 11 [32 beta hydroxylase inhibitor for a period of at least eight weeks.
• the duration of inhibition of CYP 11 [32 beta hydroxylase activity is sufficient to maintain a state of sodium and volume depletion in the hypertensive subject.
• the method does not produce a persistent state of hyperkalemia or mild non-anion gap metabolic acidosis in the hypertensive subject.
• the CYP 11 [32 beta hydroxylase inhibitor does not substantially accumulate in the hypertensive subject, preferably wherein the lack of substantial accumulation of the CYP 11 [32 beta hydroxylase inhibitor in the hypertensive subject allows for the hypertensive subject’s aldosterone levels to return to pre-drug baseline within 24-48 hours of the CYP 11 [32 beta hydroxylase inhibitor being administered, more preferably within 16-24 hours of the CYP 11 [32 beta hydroxylase inhibitor being administered.
• the hypertensive subject’s potassium levels are generally maintained in a clinically normal range, preferably wherein the hypertensive subject’s potassium levels are mildly elevated relative to the hypertensive subject’s potassium levels prior to administration of the CYP 11 [32 beta hydroxylase inhibitor, more preferably wherein the hypertensive subject’s potassium levels are elevated by 0.35 mmol/L or less, more preferably wherein the hypertensive subject’s potassium levels are maintained below a level of 5.5 mmol/L, more preferably wherein the hypertensive subject’s potassium levels are maintained between 3.5 mEq/1 to 5.1 mEq/1.
• the CYP 11132 beta hydroxylase inhibitor is administered to the hypertensive subject in an amount which:
• serum and/or plasma potassium levels in the subj ect are increased by at least 0.2 mMol/L relative to the serum and/or plasma potassium levels in the subject prior to administration of the CYP 11 [32 beta hydroxylase inhibitor; and/or
• PRA in the subject is increased by at least 5 ng/ml/hr relative to the PRA in the subject prior to administration of the CYP 11 [32 beta hydroxylase inhibitor.
• the hypertensive subject’s aldosterone level follows a substantially normal circadian rhythm.
• said CYP 11 [32 beta hydroxylase inhibitor is selective for inhibition of CYP 11 [32 beta hydroxylase activity relative to inhibition of CYP 11 [31 beta hydroxylase activity, preferably wherein the inhibition constant (Ki) for CYP 11 pi beta hydroxylase divided by the Ki for CYP 11 P2 beta hydroxylase is greater than 100.
• the CYP 11 [32 beta hydroxylase inhibitor is administered to the hypertensive subject in an amount below the amount which causes the subject’s serum and/or plasma 11-deoxycortisterone (11-DOC) levels to exceed 600 pmol/L, preferably below the amount which causes the subject’s serum and/or plasma 11-DOC levels to exceed 400 pmol/L.
• the CYP 11132 beta hydroxylase inhibitor is administered to the hypertensive subject in an amount below the amount which causes an accumulation of 11-DOC above 0.1 ng/ml in the subject.
• the CYP 11 [ 2 beta hydroxylase inhibitor is administered to the hypertensive subject in an amount which does not cause a clinically meaningful upregulation of the subject’s adrenocortical hormone synthesis.
• the CYP 11 [ 2 beta hydroxylase inhibitor is administered to the hypertensive subject in an amount which:
• the CYP 11 [32 beta hydroxylase inhibitor is administered to the hypertensive subject in an amount:
• said CYP 11132 beta hydroxylase inhibitor is a compound of Formula (A) or a pharmaceutically acceptable salt thereof:
• the compound is in the form of an HBr salt of the compound of Formula (A).
• the hypertensive subject has a plasma renin activity less than or equal to 1 ng/mL/hour.
• the hypertensive subject has a plasma renin activity less than or equal to 0.6 ng/mL/hour.
• the hypertensive subject has a plasma renin activity less than or equal to 4 ng/mL/hour.
• the hypertensive subject has a plasma renin activity less than or equal to 3 ng/mL/hour.
• the hypertensive subject has a plasma renin activity less than or equal to 2 ng/mL/hour.
• the hypertensive subject has a plasma aldosterone concentration of greater than or equal to 6 ng/dL as measured by an immunoassay.
• the hypertensive subject has a plasma aldosterone concentration of greater than or equal to 1 ng/dL as measured by LC-MS.
• the hypertensive subject has secondary hypertension, preferably primary aldosteronism. In other embodiments of the invention, the hypertensive subject does not have primary aldosteronism, preferably wherein the hypertensive subject has primary hypertension.
• the hypertensive subject has a plasma renin activity less than or equal to 1 ng/mL/hour and a plasma aldosterone concentration of greater than or equal to 6 ng/dL as measured by an immunoassay.
• the hypertensive subject has a plasma renin activity less than or equal to 1 ng/mL/hour and a plasma aldosterone concentration of greater than or equal to 1 ng/dL as measured by LC-MS.
• this hypertensive subject is taking or has taken a hypertension medication selected from a diuretic, an ACE inhibitor, an angiotensin receptor blocker, a calcium channel blocker, or a combination of two or more thereof.
• the hypertensive subject is not taking a hypertension medication selected from a diuretic, an ACE inhibitor, an angiotensin receptor blocker, a calcium channel blocker
• the hypertensive subject has a plasma renin activity less than or equal to 0.6 ng/mL/hour and has a plasma aldosterone concentration of greater than or equal to 6 ng/dL as measured by an immunoassay or greater than or equal to 1 ng/dL as measured by LC-MS.
• This invention also provides pharmaceutical compositions for use in any one of the methods described herein.
• adjectives such as “substantially” and “about” modifying a condition or relationship characteristic of a feature or features of an embodiment of the invention are understood to mean that the condition or characteristic is defined to within tolerances that are acceptable for operation of the embodiment for an application for which it is intended.
• about means within a standard deviation using measurements generally acceptable in the art.
• about means a range extending to +/- 10% of the specified value.
• about includes the specified value.
• the word “or” in the specification and claims is considered to be the inclusive “or” rather than the exclusive or, and indicates at least one of and any combination of items it conjoins.
• each of the verbs, “comprise,” “include” and “have” and conjugates thereof, are used to indicate that the object or objects of the verb are not necessarily a complete listing of components, elements or parts of the subject or subjects of the verb.
• Other terms as used herein are meant to be defined by their well-known meanings in the art.
• “Hypertension”, also called high blood pressure, is blood pressure that is higher than normal.
• hypertension is defined as a blood pressure at or above 130 mmHg systolic blood pressure, 80 mmHg diastolic blood pressure.
• Stage 1 hypertension is defined as a blood pressure of 130-139 mmHg systolic blood pressure, 80-89 mmHg diastolic blood pressure, while stage 2 hypertension is defined as a blood pressure of greater than 140 mmHg systolic blood pressure, 90 mmHg diastolic blood pressure.
• hypertension includes both stages 1 and 2 of hypertension unless indicated to the contrary.
• the hypertensive subject has stage 1 hypertension.
• the hypertensive subject has stage 2 hypertension.
• Hypertension includes high blood pressure that is multi-factorial and doesn’t have one distinct cause (primary hypertension), and high blood pressure that has a direct cause (secondary hypertension).
• primary hypertension high blood pressure that has a direct cause
• secondary hypertension high blood pressure that has a direct cause
• hypertension includes both primary and secondary hypertension unless indicated to the contrary.
• the hypertensive subject has primary hypertension.
• the hypertensive subject has secondary hypertension.
• Primary aldosteronism (hyperaldosteronism), the most common form of secondary hypertension, is a condition that occurs when the adrenal glands produce too much aldosterone. In embodiments where the hypertensive subject has secondary hypertension, the subject has primary aldosteronism.
• CYP11P2 Cypl lB2
• CYP11P2 beta hydroxylase is a cytochrome P450 enzyme, encoded by the CYP11B2 gene in humans, which catalyzes a series of reactions leading from 11 -deoxycorticosterone (i.e., an aldosterone precursor) to aldosterone.
• 11 -deoxycorticosterone i.e., an aldosterone precursor
• aldosterone synthase Cypl lB2 is mainly expressed in an adrenal cortex spherical layer and a level of plasma aldosterone is regulated by enzymatic activity of Cypl lB2 present in the adrenal gland.
• Aldosterone is expressed in other tissues, such as cardiovascular, kidney, adipose, and brain.
• CYPl ipi is a cytochrome P450 enzyme, encoded by the CYP11B1 gene in humans, which is involved in the biosynthesis of adrenal corticosteroids. It is referred to in the art as “steroid 1 1 P-hydroxylasc.”
• an “inhibitor” refers to a compound (e.g. compounds described herein) that reduces activity when compared to a control, such as absence of the compound or a compound with known inactivity.
• An inhibitor can be a small molecule inhibitor, an antibody inhibitor, a protein inhibitor, a biomolecule inhibitor, a natural ligand, and the like.
• An “inhibitor” may be in the form of a pharmaceutically acceptable salt, e.g. of the compounds described herein.
• Compound A refers to the disubstituted 1 , 2, 4-Triazine compound which is represented by Formula (A):
• Compound A HBr refers to the hydrobromide (HBr) salt of Compound A.
• Weights and/or strengths of “Compound A HBr,” and “the compound” of the invention refer to the weight of the free base in the HBr salt (i.e. Compound A) and not the weight of the HBr salt.
• Compound A and pharmaceutically acceptable salts thereof can be made by processes described, for example, in US Patent No. 10,029,993 and European Publication No. 3549935, the disclosures of which are incorporated by reference herein in their entirety.
• Treating” or “treatment” as used herein also broadly includes any approach for obtaining beneficial or desired results in a subject’s condition, including clinical results.
• beneficial or desired clinical results can include, but are not limited to, alleviation or amelioration of one or more symptoms or conditions, diminishment of the extent of a disease, stabilizing (i.e., not worsening) the state of disease, prevention of a disease’s transmission or spread, delay or slowing of disease progression, amelioration or palliation of the disease state, diminishment of the reoccurrence of disease, and remission, whether partial or total and whether detectable or undetectable.
• treatment includes any cure, amelioration, or prevention of a disease. Treatment may prevent the disease from occurring; inhibit the disease’s spread; relieve the disease’s symptoms, fully or partially remove the disease’s underlying cause, shorten a disease’s duration, or do a combination of these things.
• Treating” and “treatment” as used herein include prophylactic treatment.
• Treatment methods include administering to a subject a therapeutically effective amount of an active agent.
• the administering step may be a single administration or may include a series of administrations.
• the length of the treatment period depends on a variety of factors, such as the severity of the condition, the age of the patient, the concentration of active agent, the activity of the compositions used in the treatment, or a combination thereof.
• the effective dosage of an agent used for the treatment or prophylaxis may increase or decrease over the course of a particular treatment or prophylaxis regime. Changes in dosage may result and become apparent by standard diagnostic assays known in the art.
• chronic administration may be required.
• the compositions are administered to the subject in an amount and for a duration sufficient to treat the patient.
• the treating or treatment is not prophylactic treatment.
• a “diuretic” refers to a hypertension medication that increases the production of urine, thereby increasing the amount of water and salt eliminated from the body.
• the diuretic can be a carbonic anhydrase inhibitor, a loop diuretic, a potassium-sparing diuretic, a thiazide diuretic, or any other diuretic known in the art.
• Exemplary carbonic anhydrase inhibitors include acetazolamide, brinzolamide, dorzolamide, dichlorphenamide, ethoxaolamide, zoniamide, indisulam, and methazolamide.
• Exemplary loop diuretics include bumatenide, ethacrynic acid, torsemide, and furosemide.
• Exemplary potassium-sparing diuretics include epelerenone, triamterene, spironolactone, and amiloride.
• Exemplary thiazide diuretics include indapamide, hydrochlorothiazide, chlorthalidone, metolazone, methyclothiazide, chlorothiazide, methylclothiazide, metolazone, bendroflumethiazide, polythiazide, and hydroflumethiazide.
• Other diuretics include pamabrom and mannitol.
• an “angiotensin-converting enzyme inhibitor” or “ACE inhibitor” refers to a hypertension medication that block angiotensin I from being converted to angiotensin II, thereby dilating blood vessels and lowering blood pressure.
• ACE inhibitors include benazepril, zofenopril, perindopril, trandolapril, captopril, enalapril, lisinopril, and ramipril.
• an “angiotensin receptor blocker” or “angiotensin II inhibitor” refers to a hypertension medication that blocks the receptor binding of angiotensin II, thereby dilating blood vessels and lowering blood pressure.
• exemplary angiotensin receptor blockers include eprosartan, olmesartan, valsartan, candesartan, losartan, telmisartan, irbesartan, valsartan, and azilsartan medoxomil.
• a “calcium channel blocker” refers to hypertension medication that can block calcium from entering the cells of the heart and arteries via a calcium channel, thereby lowering blood pressure.
• a calcium channel blocker can be a dihydropyridine calcium channel blocker, a phenylalkylamine calcium channel blocker, a benzothiazepine calcium channel blocker, a nonselective calcium channel blocker, or any other calcium channel blocker known in the art.
• Dihydropyridine calcium channel blockers include amoldipine, aranidipine, azelnidipine, bamidipine, benidipine, cilnidine, clevidipine, efonidipine, felodipine, isradipine, lacidipine, lercanidipine, manidipine, nicardipine, nifedipine, nilvadipine, nimodipine, nisoldipine, nitrendipine, and pranidipine.
• Phenylalkylamine calcium channel blockers include fendiline, gallipamil, and verapamil.
• Benzothiazepine calcium channel blockers include diltiazem.
• Nonselective calcium channel blockers include mibefradil, bepridil, flunarizine, fluspirilene, and fendiline.
• Other calcium channel blockers include gabapentin, pregabalin,
• a “normal circadian rhythm” for aldosterone level follows a diurnal pattern wherein the nadir is in the late evening and the peak is in the early morning, pre-arousal.
• the hypertensive subject’s aldosterone level follows a substantially normal circadian rhythm.
• the CYP 11 [ 2 beta hydroxylase inhibitor of the invention when dosed once daily in the morning after waking, suppresses the abnormally elevated production of Aldosterone during waking hours. In the early evening suppression of Aldosterone production starts to wane and the normal increase in serum Aldosterone returns towards normal by dawn, as it would under normal circumstances.
• This invention provides methods that reduce a hypertensive subject’s systolic blood pressure “during sleep”.
• “during sleep” refers to the period of sleep in the hypertensive subject’s normal sleep/wake cycle.
• “during sleep” refers to the hypertensive subject’s approximately seven to nine hours of sleep (typically at night) that occurs daily in between their approximately 15 to 17 hours of wakefulness and not to any short period of sleep that may occur outside of the sleep phase of the subject’s normal sleep/wake cycle (i.e. naps).
• the blood pressure of non-hypertensive individuals typically dips during sleep, with approximately 10% to 15% lower blood pressure values during sleep relative to during wakefulness.
• hypertensive subjects may experience a smaller dip in blood pressure during sleep or may not experience any dip in blood pressure at all.
• methods of the invention help hypertensive subjects restore the dip in blood pressure that normal, nonhypertensive subjects experience during sleep.
• a subject’s “pre-drug level” of serum aldosterone refers to the subject’s level of serum aldosterone, at the same time of day, in the absence of being treated with the CYP 11 [32 beta hydroxylase inhibitor. As discussed above, aldosterone level follows a diurnal pattern where the nadir is in the late evening and the peak is in the early morning, pre-arousal.
• the reduction in serum aldosterone is measured relative to the same subject’s serum aldosterone level in the absence of administration of the CYP 11 [32 beta hydroxylase inhibitor at the same time of day.
• the subject’s serum aldosterone level at 11 AM when administered a CYP 11 [32 beta hydroxylase inhibitor would be measured relative to that same subject’s serum aldosterone level at 11 AM prior to any administration of the CYP 11 [32 beta hydroxylase inhibitor.
• Placebo group Oral administration of a placebo tablet matched for size, color, and shape of study drug once in the morning each day;
• Figure 4 provides a boxplot of the change in systolic blood pressure from baseline at week 4. Both the lOOmg QD and 25mg BID dose levels produced a reduction in systolic blood pressure that was significantly greater than that seen in the placebo group.
• Formal inter cohort comparisons will be completed at the end of the study using a mixed-effects model. The table below summarizes the results:
• Figure 7 shows all the individual responses in automated office-measured blood pressure (AOBP), Serum K + , and estimated glomerular filtration rate (eGFR) in the 100 mg cohort.
• AOBP automated office-measured blood pressure
• Serum K + Serum K +
• eGFR estimated glomerular filtration rate
• Example 2 The double-blinded, randomized, placebo-controlled trial described in Example 2 demonstrates that once daily administration of a 100 mg dose and twice daily administration of a 25 mg dose of Compound A HBr have the greatest effect on systolic blood pressure of all dosing regimens tested. See Figure 2. Based on PKPD modeling of data from a SAD study as summarized in Example 1 , it was determined that these dosing regimens provide, on average, a time above IC50 (for inhibition of CYP 11 [32 beta hydroxylase) of about 12.5 to 13.5 hours per 24 hour period.
• the effectiveness of the 100 mg QD dosing regime in reducing blood pressure of hypertensive subjects is informative.
• the CYP 11 [32 beta hydroxylase inhibitor was administered once daily in the morning.
• the results of the 100 mg QD dosing regimen demonstrate that inhibition of CYP 11 [32 beta hydroxylase for approximately half of the day is effective in reducing blood pressure in hypertensive subjects.
• results from the 25 mg BID dosing regimen confirm that exposure to a CYP 11 [32 beta hydroxylase inhibitor exceeding the IC50 for aldosterone production for approximately 12 hours is effective in reducing blood pressure regardless of whether this was achieved by once- daily or twice-daily dosing.
• the inhibition constants of Compound A (free base) and osilodrostat on hCYPl 1B2 were calculated based on the rate of aldosterone generation (pg/pg protein/h) from the substrate 11-DOC with the mitochondrial fraction of V79 cells stably expressing hCYPHB2 as the enzyme source.
• the inhibition constants of Compound A and osilodrostat on hCYPl 1B1 were calculated based on the rate of cortisol generation (pmol/mg protein/h) from the substrate 11 -deoxy cortisol with the mitochondrial fraction of V79 cells stably expressing hCYPl IB 1 as the enzyme source.
• Compound A at a concentration of 10 pmol/L, was screened against 46 targets in receptor binding and enzyme inhibition studies to determine if Compound A interacted with any off-target enzymes or receptors.
• a sodium-depleted cynomolgus monkey model with secondary hyperaldosteronism was performed to evaluate the effect of Compound A on plasma aldosterone concentrations (PACs).
• the model used a low-sodium diet and 3 doses of 5 mg/kg furosemide.
• Two animals each were assigned to 6 groups consisting of a vehicle group and 5 Compound A (free base) groups (0.3, 1, 3, 10, and 30 mg/kg).
• Six crossovers were performed so that every animal was assigned to each group.
• Hyperaldosteronism was induced once every 3 weeks.
• PAC was determined by radioimmunoassay and measured during the 24 hours after Compound A administration.
• An adrenocorticotropic hormone (ACTH)-treated cynomolgus monkey model was performed to evaluate the effect of Compound A on plasma cortisol concentrations (PCCs).
• a dose of Compound A, as free base, that was 100-fold higher than required to reduce PACs (0.3 mg/kg by mouth) was administered, followed immediately by ACTH (50 pg/kg subcutaneously).
• PACs were also evaluated in the animals. PACs and PCCs were determined by radioimmunoassay and measured during the 24 hours after Compound A administration. Toxicology Studies
• the toxicologic profile of Compound A was assessed in several toxicology studies, including 13 -week repeat-dose oral studies in Sprague Dawley rats and cynomolgus monkeys, a standard battery of genotoxicity studies, preliminary embryo-fetal development studies in rats and rabbits, and in vitro and in vivo phototoxicity studies. Rats and monkeys were selected for the general toxicology studies on the basis of pharmacology and metabolism data that indicated these animals would have metabolism similar to that of humans. Studies were performed in accordance with GLP regulations.
• a 4-part, Phase 1 randomized, double-blind, placebo-controlled, first-in-human study was performed to determine the safety, tolerability, PK, and PD of single ascending doses (SADs; part 1) and multiple ascending doses (MADs; part 2) of Compound A HBr in healthy participants.
• the study also assessed whether there were sex (part 3) and age-related (part 4) effects on the PK of a single dose of Compound A HBr.
• the study was approved by the local independent ethics committee; the BEBO foundation in Assen, Netherlands; and the Central Committee on Research Involving Human Subjects in The Hague, Netherlands; and conducted according to the provisions of the Declaration of Helsinki. Written informed consent was obtained from each study participant before conducting any protocol-related procedures.
• Compound A HBr or placebo was administered to 64 healthy Caucasian men aged 18 to 55 years (inclusive) in 8 cohorts of 8 participants each. In each cohort, 6 participants were randomized to receive a single dose of Compound A HBr and 2 participants were randomized to receive matching placebo. All cohorts included2 sentinel participants of whom 1 received Compound A HBr and 1 received matching placebo. The remaining 6 participants, of whom 5 received Compound A HBr and 1 received placebo, were dosed >24 hours following the sentinel participants. The dosing cohorts were 5, 10, 20, 50, 100, 200, 400, and 800 mg. Doses were administered in an ascending order per cohort, with a minimum 10- day interval between consecutive dose levels. Participants received a single dose of Compound A HBr or placebo in the fasted state.
• Compound A HBr or placebo was administered to a total of 36 healthy Caucasian men aged 19 to 54 years (inclusive) in 3 cohorts of 12 participants each. In each cohort, 9 participants were randomized to receive multiple doses of Compound A HBr and 3 participants were randomized to receive matching placebo. The participants received daily doses in the fed state from Day 1 to Day 7. The doses were administered in an ascending order per cohort.
• Progression to the next dose level and dose selection were based on available data from part 1 and the preceding dose cohort in part 2 (safety, tolerability, and PD data [up to 48 hours post-final dose] and available PK data [up to 24 hours post-final dose] from a minimum of 10 participants [Compound A HBr n >7] in the preceding dose cohort).
• the final dose levels of Compound A HBr for part 2 were 40, 120, and 360 mg.
• An ACTH challenge test was performed on Day -2 and on Day 6 to evaluate Compound A HBr selectivity for aldosterone synthesis. Plasma concentrations of aldosterone and 11 -deoxycortisol and serum concentrations of cortisol and 11-DOC were measured pre- ACTH dose and 30 and 60 minutes post- ACTH dose on Day -2 and Day 6.
• Part 3 of the study evaluated the sex-related effects on the safety, tolerability, and PK of Compound A HBr.
• 1 cohort of 8 healthy Caucasian women aged 20 to 35 years (inclusive) 6 participants were randomized to receive a single 100-mg dose of Compound A HBr and 2 participants were randomized to receive matching placebo.
• Compound A HBr or placebo was administered in the fasted state. The results were compared with those in the cohort at the same dose as in Part 1.
• Part 4 of the study evaluated the age-related effects on safety, tolerability, and PK of Compound A HBr.
• 1 cohort of 8 healthy Caucasian men aged 68 to 80 years 6 participants were randomized to receive a single 100-mg dose of Compound A HBr and 2 participants were randomized to receive matching placebo.
• Compound A HBr or placebo were administered in the fasted state. The results were compared with those in the cohort at the same dose as in Part 1.
• Plasma PK parameters were derived by non-compartmental analysis using WinNonlin® (version 6.3). Dose proportionality was assessed using the power model with AUG)--, AUCo-iast, and C max for part 1 (SAD) and with AUCo-iast, AUG)--, AUCO-T, and C max for part 2 (MAD).
• Plasma concentrations of aldosterone, 11 -deoxycortisol, and ACTH; renin activity; renin concentration; and serum concentrations of cortisol and 11 -DOC were measured in all parts of the study.
• the amount of aldosterone, cortisol, sodium, and potassium excreted and the urinary logio (10 x Na + /K + ) ratio were listed per collection interval.
• PD parameters were derived by non-compartmental analysis using WinNonlin® Professional (version 6.3). AUCo-24 was determined where possible for plasma aldosterone and serum cortisol.
• the LSM difference between each Compound A HBr dose compared with placebo was obtained from the model with the 90% CI and then back-transformed (exponentiated) to obtain estimates of the ratio of adjusted geometric means and 90% CL Log- transformed change from baseline (time-matched) from 0 to 24 hours post-dose in plasma aldosterone and serum cortisol as repeated measures was analyzed using a linear mixed model with dose group (each active Compound A HBr dose and pooled placebo) as fixed effects, corresponding time-matched values on Day -1 as covariate, and unstructured covariance. The pre-dose time point on Day 1 was used as the 24-hour time point on Day -1.
• the LSM difference between each Compound A HBr dose compared with placebo was obtained from the model together with the 90% CI, and then back-transformed to obtain estimates of the ratio of adjusted geometric means and 90% Cis.
• the calculated AUC parameters were analyzed using a linear model.
• the log-transformed parameter of interest was the dependent variable with dose group (each Compound A HBr dose and pooled placebo) as the fixed effect and log- transformed AUCO-24 on Day -1 as the covariate.
• the LSM difference between each Compound A HBr dose compared with placebo and 90% Cis was calculated and then back-transformed to obtain estimates of the ratio of adjusted geometric means and 90% Cis.
• Compound A at a concentration of 10 pmol/L did not substantially inhibit activity of any of the 46 primary molecular target receptors or enzymes.
• Half-maximal inhibitory concentration (IC50) of Compound A for any of these off- target receptors or enzymes is >10 pmol/L, which indicated a low risk for off-target pharmacologic effects.
• Table 4 Pharmacokinetics for multiple ascending dose groups, mean (SD).
• PAC showed maximum decreases at 4 hours and 8 hours post-dose (geometric mean ratio [90% CI]: 0.20 [0.15-0.26] and 0.15 [0.11-0.21], respectively, for 400-mg dose over pooled placebo).
• Single doses of Compound A HBr ranging from 10 to 800 mg, particularly reduced the AUCo-24 for PAC in a dosedependent manner, with statistically significant decreases ranging from -36% to -77% vs placebo (Table 5 and Table 6).
• Single 100-mg doses of Compound A HBr and multiple 120- mg doses of Compound A HBr allowed for the return of baseline aldosterone levels by 16 hours ( Figure 10 to Figure 12).
• Compound A HBr completely blunted the ACTH- stimulated aldosterone response on Day 6 compared to placebo while there was no effect on the cortisol response.
• ACTH stimulation on Day 6 showed a trend in increase in 11-DOC and 11-deoxycortisol concentrations compared to placebo.
• Table 5 Aldosterone AUCo-24 for the single ascending dose groups, Dav 1, mean (SD).
• RAAS renin-angiotensin-aldosterone system
• One such limitation is the hyperkalemia associated with MR antagonists, especially in chronic kidney disease (CKD). Additionally, cortisol binds to the MR, and the MR is colocalized with an enzyme that degrades cortisol. In CKD, this activity is low and cortisol stimulates the MR. Blocking the effect of both aldosterone and cortisol in CKD can result in hyperkalemia. Pfizer (2020). Since aldosterone synthase inhibitors (ASIs) do not interfere with the binding of corticosteroids to the MR, they can function as weak agonists on the MR, resulting in less hyperkalemia in patients with impaired renal function. Deleterious organ remodelling, such as vascular smooth muscle cell hypertrophy, cardiovascular fibrosis, and interstitial fibrosis of the kidney, is mediated by aldosterone at least partly via non-MR dependent effects of aldosterone.
• ASIs aldosterone synthase inhibitors
• PA Primary aldosteronism
• BAH adrenal adenoma or unilateral or bilateral adrenal hyperplasia
• Unilateral adenoma can be cured surgically, while MR antagonists are the treatment of choice for non-surgically resectable causes.
• PA causes more endorgan damage and is associated with excess cardiovascular morbidity, including heart failure, stroke, nonfatal myocardial infarction, and atrial fibrillation.
• MR blockers have been associated with an approximately 10% incidence of clinically meaningful, and occasionally lifethreatening, hyperkalemia — particularly in individuals with concomitant heart failure or CKD and in those being treated with a complex drug regimen, including renin-angiotensin system pathway blockers.
• Kem, David C., et al. “Circadian rhythm of plasma aldosterone concentration in patients with primary aldosteronism.” The Journal of clinical investigation 52.9 (1973): 2272-2277.
• Aldosterone synthase (CYP11B2) is a mitochondrial cytochrome P450 (CYP) enzyme that converts 11-DOC to aldosterone in 3 consecutive steps: 11-DOC converts to corticosterone, which converts to 11 -hydroxy-corticosterone, which converts to aldosterone.
• CYP11B1 a key enzyme in glucocorticoid biosynthesis, has a high homology to CYP11B2 (>93%).
• High selectivity for CYP11B2 over CYP11B1 is an essential characteristic for a successful ASI. Hartmann, R. et al. (2003).
• CYP11B2 is a novel synthetic, orally administered, non-peptide small molecule that is a highly selective inhibitor of CYP11B2.
• Compound A demonstrated optimized pharmacokinetic (PK) and pharmacodynamic (PD) evidence of inhibition of renal tubular aldosterone signaling across a broad dose range with no suppression of basal or stimulated cortisol production. Based on these findings, Compound A has been advanced to a novel, targeted Phase II trial in individuals with hypertension and evidence of autonomous aldosterone overproduction. Trial on the Safety and Efficacy of Compound A in Patients with Uncontrolled Hypertension (Target-HTN). ClinicalTrials.gov identifier: NCT05001945.
• Compound A is a potent inhibitor of hCYPHB2 and has minimal inhibition of hCYPUBl (1.27 nmol/L vs 475 nmol/L, respectively) at projected clinical doses.
• the approximately 374-fold selectivity of Compound A for hCYPl 1B2 vs hCYPl 1B1 was much greater than the 3.6-fold selectivity observed with the reference compound osilodrostat.
• single oral administration of the free base of Compound A significantly decreased PAC in a sodium-depleted monkey model, whereas PCCs were not affected in ACTH-loaded monkeys, demonstrating the highly potent and selective inhibition of CYP11B2 by Compound A in vivo. Findings from the toxicology studies were considered to be related to its pharmacologic activity.
• Hyperkalemia is known to be an issue with the MR antagonist spironolactone, which has a complex set of active metabolites, some of which have half-lives in excess of 24 hours.
• Spironolactone is associated with up to an 10% risk of hyperkalemia and is used relatively infrequently despite being a very effective antihypertensive agent.
• Once-daily dosing of Compound A without substantial accumulation is anticipated to be an important determinant of safety. In the event that hyperkalemia does develop, cessation of Compound A dosing should allow for rapid resolution of hyperkalemia.
• One of the limiting factors for osilodrostat was excessive accumulation of 11-DOC. Because 11-DOC is itself a MR agonist, its accumulation can oppose the potential benefit of aldosterone synthesis inhibition. In the MAD part of the study, Compound A was observed to increase serum levels of 11-DOC. However, the accumulation was relatively insignificant in the 40- and 120-mg daily cohorts and did not exceed the normal range. In contrast, the 360-mg daily dose cohort showed a much more dramatic increase in 11-DOC, to a level that might be anticipated to be problematic.
• the 11- DOC accumulation data suggest that the dose selection for the treatment of hypertension should avoid the higher dose level and focus on doses up to 120 mg daily.
• Compound A is a novel CYP 11132 beta hydroxylase inhibitor that
• (a) is selective for CYP 11
• the study consists of two parts.
• a subject For enrollment into Part 1 of the study, a subject’s value of plasma renin activity (PRA) must be ⁇ 1 ng/mL/h based on morning measurement. If the value of PRA > 1 ng/mL/h based on morning measurement, then subjects may be eligible to enter Part 2 of the study.
• PRA plasma renin activity
• Subjects orally administered the assigned study drug (Compound A HBr or placebo) according to the assigned dosing regimen for 8 weeks beginning on Study Day 1. All subjects in Part 1 (regardless of dosing group) received BID dosing to preserve the integrity of the blind; active drug is administered as the morning dose for all QD dose groups.
• BP blood pressure
• Ambulatory blood pressure monitoring was accomplished with an ambulatory blood pressure monitoring device that consists of a blood pressure cuff worn on a subject’s arm attached to a small recording device that is typically attached to the subject’ s belt or waistband.
• the ABPM device is worn for 24 hours. Throughout that period, the device records the subject’s blood pressure at regular intervals, during the subject’s routine daily activities and while they are sleeping. The ABPM thus provides a complete record of the subject’s blood pressure over a 24-hour period.
• 24-hour ABPM was measured in the clinic at baseline and Study Week 7. If, for any reason, the ABPM procedure was deemed a failure at the end of Study Week 7, it may have been repeated at Study Week 8 and therefore no imputation was employed regardless of use of rescue medications. Additionally, ABPM was also collected at the end of Study Week 4 in Part 2. If a repeat test was performed, it supersedes the original test results for that visit.
• Specific derived variables based on ABPM measurements include mean 24-hour, mean Daytime, and mean Nighttime of SBP, DBP, and heart rate.
• the nighttime dip is defined as
• the primary endpoint is the change in office-measured (mean of last 2 of 5 unattended measurements using an automated oscillometric sphygmomanometer device after approximately 5 minutes of rest in the seated position) systolic blood pressure (SBP) from baseline to the end of Study Week 8.
• SBP systolic blood pressure
• Pharmacokinetic endpoints of this study are PK parameters, including, of area under the plasma concentration versus time curve (AUC), maximum plasma concentration (Cmax), time to maximum concentration (Tmax), and half-life (ti/2) will be summarized descriptively for Randomization (baseline) and Study Weeks 1, 4, and 8
• the FAS includes all randomized subjects who have received at least 1 dose of randomized study treatment (MLS-101 or placebo).
• the FAS will be the primary set for efficacy analyses. In analyses performed on the FAS, unless otherwise specified, subjects will be analyzed according to the randomized study treatment group.
• the Per Protocol Set includes all subjects in the FAS who have completed the Study Week 8 visit without any major protocol violations that could influence the validity of the data for the primary efficacy evaluations.
• subjects will be analyzed according to the randomized study treatment group. All criteria to exclude subjects from the PPS will be made based on a blinded review of the data prior to the unblinding of the study.
• a subject may be excluded from the Per Protocol Analysis Set if any of the following criteria are met:
• the Safety Analysis Set includes all enrolled subjects who received at least one dose of study treatment (MLS-101 or placebo). In analyses performed on the Safety Analysis Set, subjects will be analyzed according to their actual treatment received.
• PKPD PK/PD Analysis Set
• PK/PD Analysis Set includes all subjects in the SAF who have sufficient data available for the analysis of pharmacokinetic and pharmacodynamic measurements. In the analyses based on PKPD, subjects will be analyzed according to the actual treatment received.
• Baseline is defined as the last available observed value of the parameter of interest prior to the first administration of the investigational medicinal product (IMP) for the doubleblinded treatment period.
• baseline is defined as the mean of the last two non-missing values prior to first administration of the IMP for the doubleblinded treatment period.
• Percentage change from baseline is calculated as: (change from baseline / baseline result) x 100%.
• a full analysis and safety set (FAS) analysis was conducted using all subjects with week 8 measurement.
• a per-protocol (PP) analysis was also conducted using all subjects completing treatment through the eighth week visit.
• Waterfall plots showing the AOBP change in systolic blood pressure at week 8 from the FAS analysis of placebo, 50mg QD and lOOmg QD groups and the PP analysis of the 100 mg group is provided in Figure 22.
• Waterfall plots showing the AOBP change in systolic blood pressure at week 8 from the FAS analysis of 12.5mg QD, 12.5 mg BID, and 25 mg BID groups is provided in Figure 23.
• a modeled mean and per-protocol observed mean are also shown for each group.
• FIG. 24 Mean change in systolic blood pressure from baseline is shown in Figure 24.
• the figure provides a final analysis including both full analysis set (FAS, all evaluable subjects receiving at least one dose of Compound A HBr) and per-protocol (PP, only those receiving > 75% of study drug with week 8 visit).
• FAS full analysis set
• PP per-protocol
• FIG. 25 shows the mean observed automated office blood-pressure change from baseline at week 8 for QD dosing regimens. BID per-protocol cohorts are shown on the far right of this graph.
• An analysis was conducted in which the change in systolic blood pressure from baseline at week 8 were pooled for the 50 mg QD, 100 mg QD, 12.5 mg BID, and 25 mg BID cohorts and then separated into quartiles based on degree of systolic blood pressure response.
• Figure 26 is a graph showing the systolic blood pressure change from baseline at week 8 for the pooled cohorts, the lowest response quartile, the highest response quartile, and placebo. 25% of subjects achieved > -23mmHg fall in systolic blood pressure, with mean reduction of - 33.4 +1.5 mmgHg. 41% of subjects achieved a > 15 mmHg fall in systolic blood pressure.
• Figure 27 is a waterfall plot showing change in systolic blood pressure from placebo and 100 mg QD groups pooled from both Parts 1 and 2. Part 2 data from interim snapshot with all subjects randomized and average last visit week 5-6, minimum week 2.
• a graph showing an example of ambulatory 24-hour blood pressure monitoring is providing in Figure 29.
• the graph shows the 24-hour ambulatory blood pressure (systolic) of a single subject receiving Compound A HBr lOOmg QD versus baseline, showing an average 24-hour blood pressure reduction and restoration of normal nocturnal dipping pattern.
• a graph showing the change in systolic blood pressure at week 8 relative to baseline as measured using the ABPM full analysis set is provided in Figure 30.
• Waterfall plots showing the 24-hour average and overnight average ABPM change at 8 weeks relative to baseline is provided in Figure 31.
• 100 mg QD dose levels provide excellent 24-hour blood pressure reduction. Overnight blood pressure reduction from the 100 mg QD dose level appears to be superior to 25 mg BID.
• Night-time dip defined as 100% x (24-hour ambulatory Daytime SBP - 24-hour ambulatory monitoring Night-time SBP)/24-hour ambulatory monitoring Daytime

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