WO2024042518A1

WO2024042518A1 - Glp-1 receptor antagonist and methods of use thereof

Info

Publication number: WO2024042518A1
Application number: PCT/IL2023/050887
Authority: WO
Inventors: Moshe Arkin; Dan Goldstaub; Roy ELDOR
Original assignee: M. Arkin (1999) Ltd
Priority date: 2022-08-21
Filing date: 2023-08-21
Publication date: 2024-02-29

Abstract

Provided herein a method of reducing, alleviating or treating the side effects of GLP-1 receptor agonist therapy (such as gastrointestinal side effects), comprising administering a composition comprising an effective amount of GLP-1 receptor antagonist and a pharmaceutically acceptable carrier thereof to a subject treated with GLP-1 agonist therapy, wherein the GLP-1 receptor antagonist does not interfere, or minimally interferes with the treatment course of the GLP-1 receptor agonist.

Description

GLP-1 RECEPTOR ANTAGONIST AND METHODS OF USE THEREOF

FIELD OF THE INVENTION

[001] Provided herein a method of reducing, alleviating or treating the side effects of GLP-1 receptor agonist therapy (e.g. gastrointestinal side effect), comprising administering a composition comprising an effective amount of GLP-1 receptor antagonist and a pharmaceutically acceptable carrier thereof to a subject treated with GLP-1 agonist therapy, wherein the GLP-1 receptor antagonist does not interfere, or minimally interferes with the treatment course of the GLP-1 receptor agonist.

BACKGROUND OF THE INVENTION

[002] Glucagon-like peptide- 1 (GLP-1) is an incretin hormone that plays a crucial role in regulating glucose metabolism and satiety. It is produced by the L cells of the intestine in response to food intake and acts as an incretin hormone, which means it enhances insulin secretion from pancreatic beta cells in response to elevated blood glucose levels. GLP-1 reduces postprandial gastric and exocrine pancreatic secretion. GLP-1 also suppresses glucagon secretion, slows down gastric emptying, and reduces appetite, all of which contribute to the overall glucose homeostasis and energy balance in the body. GLP-1 has a different biological activity than glucagon. Its actions include stimulation of insulin synthesis and secretion, inhibition of glucagon secretion and inhibition of food intake. GLP-1 has been shown to reduce hyperglycemia (increased glucose levels) in diabetic patients.

[003] The discovery of the physiological effects of GLP-1 sparked interest in developing therapeutic interventions to target its signaling pathway for the treatment of type 2 diabetes and obesity. One such approach is the development of GLP-1 agonists, which mimic the effects of the endogenous GLP-1 hormone by binding to its receptor on pancreatic beta cells and other tissues, leading to increased insulin secretion and decreased glucagon release.

[004] GLP-1 receptor agonists reduce food intake and promote weight loss, a beneficial effect not only for diabetics but also for patients suffering from obesity. Obese patients have a high risk of diabetes, hypertension, hyperlipidemia, cardiovascular and musculoskeletal diseases. [005] GLP-1 receptor agonists are used as drugs for the treatment of diabetes. These drugs mimic the action of a hormone called glucagon-like peptide 1. When blood sugar levels start to rise after someone eats, these drugs stimulate the body to produce more insulin. The extra insulin helps lower blood sugar levels. Lower blood sugar levels are helpful for controlling type 2 diabetes.

[006] There is a demand for GLP-1 receptor agonists for promoting weight loss. However, many patients suffer from side effects, often transient, that lead them to discontinue therapy. Adverse effects include mainly nausea, vomiting and diarrhea.

[007] Another avenue of research focuses on GLP-1 antagonists. Unlike GLP-1 agonists, which activate the GLP-1 receptor to enhance its effects, GLP-1 antagonists inhibit the binding of endogenous GLP-1 to its receptor, effectively blocking its physiological actions. Nagell et al. (Nagell et al. Scandinavian Journal of Gastroenterology, 2007; 42: 28-33) discloses that GLP-1 receptor antagonists do not influence gastric emptying and hunger sensations in human.

[008] Exendin-[9-39], a carboxy ami dated molecule, is a shortened and modified form of Exendin-4, specifically consisting of amino acids 9 to 39 of the original peptide, that has been reported to be a potent and selective antagonist of GLP-1 receptor (Goke et al., J. Biol. Chem., 268:19650 -55, 1993; Raufman, J. P., et al., J. Biol. Chem. 266:2897-902, 1991; Schepp, W. et al., Eur. J. Pharm., 269:183-91, 1994; Monlrose-Rafiz.adeh et al., Diabetes, 45(Suppl. 2):152A, 1996). Exendin-[9-39] blocks the stimulatory actions of exendin-4 and GLP-1. Instead, it acts as a competitive antagonist, binding to the receptor without activating it, resulting in reduced insulin secretion (Wang, et al., J. Clin. Invest., 95:417-21, 1995; D'Alessio et al., J. Clin. Invest., 97: 133-38, 1996).

[009] EP 3297654 and WO 2016 191394 recite the use of GLP-1 receptor antagonists as an antidote for the treatment of hypoglycemia induced by overdosage of GLP-1 receptor agonists. However, as can be seen in the labels of GLP-1 receptor agonists drugs, hypoglycemia is not a side effect of GLP-1 receptor agonists when they are not prescribed concomitantly with other glucose lowering drugs such as insulin. Therefore, EP 3297654 and WO 2016/191394 do not teach or motivate the use of GLP-1 receptor antagonist for the alleviation of the gastrointestinal side effects of GLP-1 receptor agonists such as diarrhea as well as nausea and vomiting.

[0010] While GLP-1 receptor agonists are generally well-tolerated, they often have side effects, some of which may be severe, leading in some reported cases to gastroparesis (a slowdown or stopping of the digestive system) or gastroenteritis (an infection and inflammation of the digestive system). With the growing prevalence of GLP-1 agonists' widespread usage, there arises an escalating imperative to effectively address and manage the treatment's accompanying side effects.

SUMMARY OF THE INVENTION

[0011] Provided herein a method of increasing compliance of patients under GLP1 therapy by reducing side effects associated with GLP-1 receptor agonist therapy, the method comprises administering a composition comprising an effective amount of GLP-1 receptor antagonist and a pharmaceutical acceptable carrier, wherein the GLP-1 receptor antagonist does not interfere with the treatment of the GLP-1 receptor agonist, or it interferes for a short time only. In another embodiment, the GLP-1 receptor antagonist is Exendin [9-39] (Avexitide).

[0012] In some embodiments, this invention provides a method of reducing, alleviating or treating gastrointestinal side effects of GLP-1 receptor agonist therapy, comprising administering a composition comprising an effective amount of GLP-1 receptor antagonist and a pharmaceutically acceptable carrier thereof to a subject treated with GLP-1 agonist therapy, for a limited duration of time. In some embodiments, the GLP-1 receptor antagonist avoids the cessation of the GLP-1 receptor agonist therapy, or minimally interferes with the treatment course of the GLP-1 receptor agonist.

[0013] In some embodiments, the GLP-1 receptor antagonist comprises Avexitide (Exendin [9- 39]), AZM-134, Bay-73-7977, 68Ga-Dfl2-exendin-4, PNU-126814, JTT-608, TB01-3 or P-017. In some embodiments, the GLP-1 receptor antagonist is Avexitide (Exendin [9-39]). In some embodiments, the GLP-1 receptor antagonist is administered following, concomitantly, or prior to the administration of a GLP-1 receptor agonist. In some embodiments, the half-life time of the GLP-1 receptor antagonist is shorter than the half-life time of the GLP-1 receptor agonist. In some embodiments, the GLP-1 receptor antagonist is administered alone, or in combination with a gastric emptying agent. In some embodiments, the GLP-1 receptor antagonist is administered at a dose of between 50 and 1000 pg/kg daily or at a dose of between 5 mg and 500 mg daily. In some embodiments, the GLP-1 receptor antagonist is administered at a dose of between 50 and 100 pg/kg daily; between 150 and 300 pg/kg daily; or between 500 and 700 pg/kg daily. In some embodiments, the GLP-1 receptor antagonist is administered at a dose of 60 pg/kg daily; 200 pg/kg daily; or 600 pg/kg daily. In some embodiments, the composition is administered by intravenous (IV) infusion, subcutaneous injection (sc), oral, inhaled, or nasal formulations. DETAILED DESCRIPTION OF THE PRESENT INVENTION

[0014] In the following detailed description, numerous specific details are set forth in order to provide a thorough understanding of the invention. However, it will be understood by those skilled in the art that the present invention may be practiced without these specific details. In other instances, well-known methods, procedures, and components have not been described in detail so as not to obscure the present invention.

Treatment of side effects of GLP-1 receptor agonists

[0015] Glucagon-like peptide- 1 (GLP-1) receptor agonists are a class of injective anti-diabetic drugs that improve glycemic control and many other atherosclerosis-related parameters in patients with type 2 diabetes (T2D) and are now used to promote weight loss.

[0016] However, the use of GLP-1 receptor agonists is associated with certain adverse effects. The most common adverse effects associated with the use of GLP-1 receptor agonists are gastrointestinal symptoms, mainly nausea, vomiting and diarrhea. Other common adverse effects include injection site reactions, headache, and nasopharyngitis. Non-limiting examples of side effects of GLP-1 receptor agonists include: gastrointestinal symptoms, delayed gastric emptying, nausea, decreased food consumption, vomiting, diarrhea, stomach discomfort, excessing bloating and belching, pain in the upper abdomen, gastroparesis, gastroenteritis, heartburn, injection site reactions, headache, dizziness or lightheadedness, pancreatitis and nasopharyngitis; each represents a separate embodiment according to this invention.

[0017] Provided herein a. method of reducing, alleviating or treating side effects of GLP-1 receptor agonist treatment in a subject, by administering an effective amount of GLP-1 receptor antagonist to said subject, thereby reducing, alleviating or treating side effects of GLP-1 receptor agonist treatment in said subject for a limited duration of time. In some embodiments, the GLP- 1 receptor antagonist does not interfere with the treatment of the GLP-1 receptor agonist in said subject. In some embodiments, the GLP-1 receptor antagonist interferes for a short time only with the treatment of the GLP-1 receptor agonist.

[0018] Provided herein a method of reducing, alleviating or treating gastrointestinal side effects of GLP-1 receptor agonist therapy, comprising administering a composition comprising an effective amount of GLP-1 receptor antagonist and a pharmaceutically acceptable carrier thereof to a subject treated with GLP-1 agonist therapy, for a limited duration of time. In some embodiments, the GLP-1 receptor antagonist does not interfere with the treatment of the GLP-1 receptor agonist in said subject. In some embodiments, the GLP-1 receptor antagonist interferes for a short time only with the treatment of the GLP-1 receptor agonist.

[0019] Provided herein a method of reducing, alleviating or treating gastrointestinal side effect of GLP-1 receptor agonist therapy, comprising administering a composition comprising an effective amount of GLP-1 receptor antagonist and a pharmaceutically acceptable carrier thereof to a subject treated with GLP-1 agonist therapy, for a limited duration of time. In some embodiments, the GLP-1 receptor antagonist does not interfere with the treatment of the GLP-1 receptor agonist in said subject. In some embodiments, the GLP-1 receptor antagonist interferes for a short time only with the treatment of the GLP-1 receptor agonist, wherein the gastrointestinal side effect is selected from the group consisting of: delayed gastric emptying, nausea, decreased food consumption, vomiting, diarrhea, stomach discomfort, excessing bloating and belching, pain in the upper abdomen, gastroparesis, gastroenteritis, heart burn injection site reactions, and nasopharyngitis. In another embodiment, the gastrointestinal side effect is delayed gastric emptying. In another embodiment, the gastrointestinal side effect is nausea. In another embodiment, the gastrointestinal side effect is decreased food consumption. In another embodiment, the gastrointestinal side effect is vomiting. In another embodiment, the gastrointestinal side effect is diarrhea. In another embodiment, the gastrointestinal side effect is stomach discomfort. In another embodiment, the gastrointestinal side effect is excessing bloating and belching. In another embodiment, the gastrointestinal side effect is pain in the upper abdomen. In another embodiment, the gastrointestinal side effect is gastroparesis. In another embodiment, the gastrointestinal side effect is gastroenteritis. In another embodiment, the gastrointestinal side effect is heart burn injection site reactions. In another embodiment, the gastrointestinal side effect is nasopharyngitis.

[0020] In some embodiments, the methods provided herein comprise administering an effective amount of GLP-1 receptor antagonist for a limited duration of time. “Limited duration of time” refers to the time of administering the GLP-1 receptor antagonist until the side effect of GLP-1 receptor agonist is reduced to tolerable level (specifically, until the gastrointestinal side effect (caused by administering the GLP-1 receptor agonist) is reduced to tolerable level. In other embodiments, the treatment with the GLP-1 receptor antagonist may be repeated more than once upon demand and/or according to the need of the patient. In other embodiments, the treatment with the GLP-1 receptor antagonist is during the duration of the side effects of GLP-1 agonist treatment. [0021] GLP-l receptor agonist treatment comprises improvement in blood sugar control, treatment of diabetes, promoting weight loss or combination thereof.

[0022] A GLP-l receptor agonist refers herein to any known GLP-l receptor agonist. Examples of GLP-agonist for the treatment of diabetes or weight loss include:

• Dulaglutide (Trulicity) (once weekly);

• Exenatide extended release (Bydureon bcise) (once weekly);

® Exenatide immediate release (Byetta) (twice daily);

• Semaglutide (Ozempic, Wegovy) (once weekly);

® Liraglutide (Victoza, Saxenda) (once daily);

• Lixisenatide (Adlyxin, Lyxumia) (once daily);

• Semaglutide (Rybelsus) (taken orally once daily);

• Tirzepatide (Mounjaro) (once weekly)

• Albiglutide (Tanzeum) (once weekly).

[0023] Also provided herein is a method of reducing, alleviating or treating gastrointestinal disorder, wherein the gastrointestinal disorder is selected from the group consisting of: delayed gastric emptying, nausea, decreased food consumption, vomiting, diarrhea, stomach discomfort, excessing bloating and belching, pain in the upper abdomen, gastroparesis, gastroenteritis, heart burn injection site reactions, and nasopharyngitis, wherein the method comprises administering an effective amount of GLP-l receptor antagonist to a subject, thereby reducing, alleviating or treating nausea, diarrhea or vomiting in said subject. In some embodiments, the gastrointestinal disorder is a side effect of GLP-l receptor agonist treatment. In some embodiments, the GLP-l receptor antagonist is Exendin [9-39] (Avexitide). In some embodiments, the subject is concurrently receiving GLP-l agonist therapy. In some embodiments, the method does not lead to an increased food consumption by the subject.

[0024] Also provided herein is a method of reducing, alleviating or treating nausea, diarrhea or vomiting, comprising administering an effective amount of GLP-l receptor antagonist to a subject, thereby reducing, alleviating or treating nausea, diarrhea or vomiting in said subject. In some embodiments, the GLP-l receptor antagonist is Exendin [9-39] (Avexitide). In some embodiments, the nausea, diarrhea, or vomiting are side effects of GLP-l receptor agonist treatment. In some embodiments, the subject is concurrently receiving GLP-l agonist therapy. In some embodiments, the method does not lead to an increased food consumption by the subject. [0025] In some embodiments, the GLP-1 receptor antagonist is administered following the administration of a GLP-1 receptor agonist. In other embodiments, the GLP-1 receptor antagonist is administered prior to the administration of a GLP-1 receptor agonist. In other embodiments, the GLP-1 receptor antagonist is administered concomitantly with the administration of a GLP- 1 receptor agonist.

[0026] In some embodiments GLP-1 receptor antagonists are administered for reducing or treating a subject with side effects from GLP-1 receptor agonist therapy (specifically, gastrointestinal side effect). This is particularly important for patients that are using the once weekly therapy, because in such patients even discontinuation of the GLP-1 receptor agonist after one or two days will still result in several days of serious side effect which could be avoided only by administering a GLP-1 receptor antagonist, preferably with short half-life and immediate therapeutic effect like Exendin [9-39] (Avexitide).

[0027] Therefore, in some embodiments, provided herein is a method of reducing, alleviating or treating side effects of GLP-1 receptor agonist treatment (specifically, gastrointestinal side effect), the method comprises administering an effective amount of Exendin [9-39] (Avexitide) to a subject receiving GLP-1 receptor agonist treatment. In some embodiments, the Exendin [9- 39] (Avexitide) does not interfere with the treatment of the GLP-1 receptor agonist.

[0028] In some embodiments, the method provided herein for reducing, alleviating or treating side effects of GLP-1 receptor agonist therapy (specifically, gastrointestinal side effect), does not relate to hypoglycemia, hyperinsulinemia or symptoms thereof. In some embodiments, the method does not relate to side effects of high dose of GLP-1 receptor agonist therapy. In some embodiments, the subject receiving the GLP-1 antagonist according to the methods of this invention, does not suffer from hyperinsulinemia (hypoglycemia).

[0029] In some embodiments, the GLP-1 receptor antagonist administered according to the methods of this invention, has a shorter half-life time compared to the GLP-1 receptor agonist administered in the treatment. For example, Avexitide has a short half-life time of ~2-3.5 hours compared to Dulaglutide (Trulicity), which is administered once weekly, therefore for one or two days during therapy it will not antagonize significantly the therapeutic effect of the GLP-1 receptor agonist.

GLP-1 receptor antagonist-Composition for use.

[0030] Provided herein is a composition comprising a GLP-1 receptor antagonist and a pharmaceutical acceptable carrier for use in reducing side effects of GLP-1 receptor agonist treatment. In some embodiments, the GLP-1 receptor antagonist does not interfere with the treatment of the GLP-1 receptor agonist. In some embodiments, the GLP-1 receptor antagonist minimally interferes with the treatment of the GLP-1 receptor agonist.

[0031] In some embodiments, the GLP-1 receptor antagonist avoids the cessation of the GLP-1 receptor agonist therapy , or minimally interferes with the treatment course of the GLP-1 receptor agonist.

[0032] In some embodiments, provided herein is a composition comprising a GLP-1 receptor antagonist, a GLP-1 receptor agonist, and a pharmaceutical acceptable carrier. In some embodiments, the composition is used for the treatment of diabetes and promoting weight loss without the side effects associated with GLP-1 receptor agonist treatment (specifically, gastrointestinal side effect). In some embodiments, the GLP-1 receptor antagonist does not interfere with the treatment of the GLP-1 receptor agonist. In some embodiments, the GLP-1 receptor antagonist minimally interferes with the treatment of the GLP-1 receptor agonist. In some embodiments, the GLP-1 receptor antagonist avoids the cessation of the GLP-1 receptor agonist therapy , or minimally interferes with the treatment course of the GLP-1 receptor agonist. [0033] In some embodiments, the GLP-1 receptor antagonist for use in the methods of this invention comprises Avexitide (Exendin [9-39]), AZM-134, Bay-73-7977 or Bay 27-9955, ⁶⁸Ga- Dfl2-exendin-4, PNU-126814, 4-(trans-4-Methylcyclohexyl)-4-Oxobutyric Acid (JTT-608), TB01-3 or P-017. In some embodiments, the GLP-1 receptor antagonist for use in the methods of this invention comprises at least one compound selected from: Avexitide (Exendin [9-39]), AZM-134, Bay-73-7977, ⁶⁸Ga-Dfl2-exendin-4, PNU-126814, JTT-608, TB01-3 and P-017. In another embodiment, the GLP-1 receptor antagonist is Avexitide (Exendin [9-39]). In another embodiment, the GLP-1 receptor antagonist is AZM-134 (a product developed by Alyzime as cited in Braud-et al. Future Med. Chem. (2010) 2(12), 1777-1783 which is incorporated herein by reference) . In another embodiment, the GLP-1 receptor antagonist is Bay-73-7977 or Bay 27- 9955 (a synthetic peptide a GCGR antagonist, see for example Petersen KF et al., Diabetologia. 2001 Nov;44(l l):2018-24 and WO 2008098693 which are incorporated herein by reference). In another embodiment, the GLP-1 receptor antagonist is ⁶⁸Ga-Dfl2-exendin-4 (See for example Linlin Li ^a, Nuclear Medicine and Biology, Volumes 102- 103, 2021, Pages 87-96 which are incorporated herein by reference). In another embodiment, the GLP-1 receptor antagonist is PNU- 126814 (see for example Willard FS et al., Exp Diabetes Res. 2012, volume 2012 Article ID 709893 which is incorporated herein by reference). In another embodiment, the GLP-1 receptor antagonist is 4-(trans-4-Methylcyclohexyl)-4-Oxobutyric Acid (JTT-608). In another embodiment, the GLP-1 receptor antagonist is TB01-3 (see for example Liu Q. et al., MABS, 2021VOL. 13, NO. 1, el893425 which is incorporated herein by reference). In another embodiment, the GLP-1 receptor antagonist is GUB06-046 (see for example van Witteloostuijn SB et al, . J Pept Sci. 2017 Dec;23(12):845-854). In another embodiment, the GLP-1 receptor antagonist is P-017.

[0034] The dosage and regimen of administration may be determined by dose finding studies, as known in the art.

[0035] In some embodiments, the GLP-1 receptor antagonist for use in the methods of this invention comprises Exendin [9-39] (Avexitide), wherein the Exendin [9-39] is administered in a 10 mg to 100 mg unit dosage form. In another embodiment, the Exendin [9-39] is administered in a 5 mg to 500 mg unit dosage form. In another embodiment, the Exendin [9-39] is administered in a 5 mg, 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 70 mg, 80 mg, 90 mg, 100 mg, 150 mg, 200 mg, 250 mf, 300 mg, 350 mg, 400 mg, 450 mg or 500 mg unit dosage form; each represents a separate embodiment according to this invention. In another embodiment, the GLP-1 receptor antagonist is administered in a dosage of between 0.05 and 1 mg/kg, between 0.05 and 0.1 mg/kg, between 0.15 and 0.3 mg/kg, between 0.5 and 0.7 mg/kg; each represents a separate embodiment according to this invention. In another embodiment in a dosage of 0.05, 0.06, 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1 mg/kg; each represents a separate embodiment according to this invention.

[0036] In some embodiments, the therapeutically effective doses for administering a GLP-1 receptor antagonist according to the methods of this invention range from 2-100 mg. In some embodiments, the dosage amount is ranging from 2-100 mg, 10-75 mg, 20-50 mg, 20-40 mg, 2- 10 mg, 2.5-10 mg, or 2.5-7.5 mg, each represents a separate embodiment according to this invention., depending upon the needs and physical attributes of the patient. In some embodiments, the therapeutically effective dosage amount ranges between 2.5 mg to 5 mg, 2.5 mg to 10 mg, 2.5 mg to 7.5 mg, or 5 mg to 30 mg dose; each represents a separate embodiment according to this invention.

[0037] In some embodiments, the therapeutically effective doses for administering a GLP-1 receptor antagonist according to the methods of this invention range from 2-1000 pg/kg daily. In some embodiments, the dosage amount is ranging from 2- 1000 pg/kg, 50-750 pg/kg, 50-100 pg/kg, 10-100 pg/kg, 100-800 pg/kg, 150-300 pg/kg, 300-1000 pg/kg, 500-700 pg/kg, or 100- 350 pg/kg daily, each represents a separate embodiment according to this invention, depending upon the needs and physical attributes of the patient. In some embodiments, the therapeutically effective dosage amount ranges between 50 and 100 pg/kg, 20 pg/kg to 800 pg/kg, 50 pg/kg to 700 pg/kg, 10 pg/kg to 100 pg/kg, 150 and 300 pg/kg, 500 and 700 pg/kg or 500 pg/kg to 800 pg/kg of daily dose; each represents a separate embodiment according to this invention. In some embodiments, the therapeutically effective dosage amount is 20 pg/kg, 50 pg/kg, 60 pg/kg, 100 pg/kg, 200 pg/kg, 500 pg/kg, or 600 pg/kg daily; each represents a separate embodiment according to this invention.

[0038] In some embodiments, the therapeutically effective dose concentration for administering a GLP-1 receptor antagonist according to the methods of this invention range from 2- 1000 pg/ml. In some embodiments, the dosage amount is ranging from 2-250 pg/ml, 10-150 pg/ml, 100-200 pg/ml, 10-50 pg/ml, 10-100 pg/ml, 12-120 pg/ml, or 100-500 pg/ml daily, each represents a separate embodiment according to this invention, depending upon the needs and physical attributes of the patient. In some embodiments, the therapeutically effective dose concentration is 10 pg/ml, 12 pg/ml, 20 pg/ml, 40 pg/ml, 50 pg/ml, 120 pg/ml, or 150 pg/ml; each represents a separate embodiment according to this invention.

[0039] Patients may receive therapy for a predetermined time, an indefinite time, or until an endpoint is reached. Treatment may be continued on a continuous daily or weekly basis for at least two to three months, six months, one year, or longer. In some embodiments, therapy is for at least 30 days, at least 60 days, at least 90 days, at least 120 days, at least 150 days, or at least 180 days. In some embodiments, treatment is continued for at least 6 months, at least 7 months, at least 8 months, at least 9 months, at least 10 months, at least 11 months, or at least one year. In some embodiments, treatment is continued for the rest of the patient's life or until administration is no longer effective in providing meaningful therapeutic benefit. In some embodiments, adult patients (60-100 kg or more) will receive therapeutic benefit from a single dose of GLP-1 receptor antagonist.

[0040] In some embodiments, the GLP-1 receptor antagonist for use in the methods of this invention is administered once a day, twice a day, three times a day, once a week, once in two weeks, twice a week, three times a week for a period of three days, 5 days, one week, two weeks, three weeks or four weeks; each represents a separate embodiment according to this invention. In some embodiments, the GLP-1 receptor antagonist for use in the methods of this invention is administered twice daily. In some embodiments, the GLP-1 receptor antagonist for use in the methods of this invention is administered once daily. [0041] In some embodiments, the therapeutically effective doses of the GLP-l receptor antagonist according io the methods of this invention are administered at least once a day, twice a day, or three times a day; each represents a separate embodiment according to this invention.

[0042] In some embodiments, the therapeutically effective dose of the GLP-l receptor antagonist according to the methods of this invention is administered with each meal, with a particular meal, before each meal, before a particular meal, after each meal, or after a particular meal; each represents a separate embodiment according to this invention.

[0043] In some embodiments, the therapeutically effective doses of the GLP- l receptor antagonist according to the methods of this invention are administered at a certain time before a meal. In some embodiments, between 15 minutes to two hours before a meal. In other embodiments, 15 min, 30 min, one hour, 1.5 hour, or 2 hours before a meal; each represents a separate embodiment according to this invention. In some embodiments, the therapeutically effective doses of the GLP-l receptor antagonist according to the methods of this invention are administered at a certain time after a meal. In some embodiments, between 15 minutes to two hours after a meal. In other embodiments, 15 min, 30 min, one hour, 1.5 hour, or 2 hours after a meal; each represents a separate embodiment according to this invention.

[0044] In some embodiments, the therapeutically effective doses of the GLP- l receptor antagonist according to the methods of this invention are administered in an immediate release or extended-release formulation. In one embodiment, this dose is administered BID using an immediate release formulation, with the first dose in the morning, typically before the first meal, e.g. at least 60 minutes before, and the second about twelve hours later. In another embodiment, this dose is administered qD in an extended-release formulation that is dosed either in the morning, as above, or in the evening, e.g., before or after the last meal of the day, including, e.g. before retiring.

[0045] In some embodiments, the therapeutically effective dose of the GLP-l receptor antagonist according to the methods of this invention is administered in a composition comprising both GLP-l receptor agonist and antagonist.

[0046] In some embodiments, this invention provides a composition comprising an effective amount of a GLP-l agonist and a GLP-l antagonist, and a pharmaceutically acceptable carrier.

[0047] In some embodiments, the GLP- l receptor antagonist is administered to a patient in need thereof by any suitable route of administration, such as subcutaneously, parenterally, transmusocally, transdermally, intramuscularly, intravenously, intra-derm ally, intra-peritonealy, orally, or nasally. [0048] In some embodiments, the GLP-1 receptor antagonist for use in the methods of this invention is administered orally, by injection or by infusion. In other embodiments, the GLP-1 receptor antagonist is administered by peripheral injection. In other embodiments, the GLP-1 receptor antagonist is administered by intraperitoneal injection (i.p). In other embodiments, the GLP-1 receptor antagonist is administered by subcutaneous injection (s.c). In other embodiments, the peripheral injection is intramuscular (i.m.) injection. In other embodiments, the peripheral injection is intravenous (i.v.) injection. In other embodiments, the peripheral injection is intravenous (i.v.) injection. More particularly, peripheral administration comprises systemic injections, such as intramuscular (i.m.). intravenous (i.v.), intra-arterial, sub-cutaneous or transdermic injections. Peripheral administration also includes oral administration, delivery using implants, or administration by instillation through the respiratory system, e.g., using sprays, aerosols or any other appropriate formulations. Most preferred peripheral administration includes peripheral injection, in particular systemic injection, most preferably i.m., or i.v. injection.

[0049] In some embodiments, the GLP-1 receptor antagonist, such as exendin (9-39) or a homologue, analogue, or variant thereof, is subcutaneously administered to a patient in need thereof. Sites of injection, include, but not limited to, injection in the thigh, abdomen, upper arm region, or upper buttock region.

[0050] While the present invention provides a variety of methods and materials for treatment and prevention of side effects induced by GLP-1 agonist treatment (specifically, gastrointestinal side effects) one aspect of this invention relates to the pharmaceutical compositions and methods involving subcutaneous delivery of exendin (9-39) in doses therapeutically effective for this indication. In many embodiments, these formulations for subcutaneous administration are formulated as immediate release preparations, and are conveniently packaged, for example, in the form of the dual-chamber pen device provided by the invention, for patients or their care providers to administer therapeutically effective amounts in doses ranging from 2-100 mg.

[0051] The present invention also provides GLP-1 receptor antagonist (e.g., exendin (9-39)) compositions suitable for oral administration. Exendin (9-39) can be formulated for oral delivery with a formulation consisting of a protease inhibitor to prevent digestion and an absorption enhancer to facilitate passive diffusion through the intestine wall. The formulation can be filled into a capsule coated with an enteric coating using pH sensitive polymers such as Eudragit® to protect from the acidic pH in the stomach (see, www.oramed.com/technology/scientific- abstracts/). In some embodiments an oral formulation of exendin (9-39) of the instant invention combines an absorption-enhancing excipient, such as Eligen® so as to inhibit acid and peptidase- mediated degradation, and improve passive transport across the enterocyte lumen and into the intracellular space.

[0052] The present invention also provides methods and compositions in which GLP-1 receptor antagonist (e.g., exendin (9-39)) is administered by inhalation. Some patients may prefer inhalation over subcutaneous or other forms of delivery, and the present invention provides suitable dry powder inhalation formulations, generally constituting a room temperature stable powder containing exendin (9-39), that can be supplied in capsules and delivered by a device, for example and without limitation, as used for the recently approved inhaled insulin, Afrezza (see, www. healthline. com/diabetesmine/welcome-afrezza-inhaled-insulin-gets-real#5).

[0053] The compositions according to the invention are pharmaceutical compositions, and especially injectable compositions, which may be in any form conventionally used for injectable application.

[0054] Pharmaceutical carriers or vehicles suitable for preparation of the injectable compositions provided herein include any such carriers known to those skilled in the art to be suitable for the injection mode of administration.

[0055] The composition may be a solution, a suspension, an emulsion or the like and is formulated as any other sterile formulation suitable for injection administration.

Definitions

[0056] Unless defined otherwise, all technical and scientific terms used herein have the same meaning as is commonly understood by one of skill in the art to which the invention pertains. In case of conflict, the specification, including definitions, takes precedence. All patents, patent applications, published applications, articles, publications and other published materials referred to throughout the entire disclosure herein, unless noted otherwise, are incorporated by reference in their entirety.

[0057] As used herein, "Exendin (9-39)" refers to a 31 amino acid peptide with an empirical formula of C149H234N40O47S and a molecular weight of 3369.8 Daltons (CAS No. 133514- 43-9). Exendin(9-39) comprises residues 9-39 of the GLP-1 receptor agonist exendin-4 and is a GLP-1 receptor antagonist. See, Montrose-Rafizadeh et al., Journal of Biological Chemistry, 272:21201-21206 (1997). As used herein, the term "Exendin (9-39)" encompasses pharmaceutically acceptable salts of exendin (9-39), including but not limited to sulfate, hydrochloride, phosophate, sulfamate, acetate, citrate, lactate, tartrate, methanesulfonate, ethanesulfonate, benzenesulfonate, p-toluenesulfonate, cyclohexylsulfamate and quinate salts. In some embodiments, exendin (9-39) is in the form of exendin (9-39) acetate or exendin (9-39) trifluoroacetate.

[0058] As used herein, the indefinite articles "a" and "an" mean "at least one" or "one or more" unless the context clearly dictates otherwise.

[0059] As used herein, the term "treating" or” treatment" includes curing a condition, treating a condition, preventing a condition, treating symptoms of a condition, curing symptoms of a condition, ameliorating symptoms of a condition, treating effects of a condition, ameliorating effects of a condition, and preventing results of a condition.

[0060] As used herein, a "pharmaceutical composition" refers to a composition comprising one or more active ingredients with other components such as pharmaceutically acceptable ingredients or excipients. The purpose of a pharmaceutical composition is to facilitate administration of an active ingredient to a subject.

[0061] Whenever a numerical range is indicated herein, it is meant to include any cited numeral (fractional or integral) within the indicated range. The phrases “ranging/ranges between” a first indicate number and a second indicate number and “ranging/ranges from” a first indicate number “to” a second indicate number are used herein interchangeably and are meant to include the first and second indicated numbers and all the fractional and integral numerals therebetween.

[0062] As used herein, numerical ranges preceded by the term “about” should not be considered to be limited to the recited range. Rather, numerical ranges preceded by the term “about” should be understood to include a range accepted by those skilled in the art for any given element in formulations according to the present invention.

[0063] As used herein, when a numerical value is preceded by the term "about", the term "about" is intended to indicate +/-10%.

[0064] The terms "comprise", "comprising", "includes", "including", “having” and their conjugates mean "including but not limited to".

[0065] The term “consisting of’ means “including and limited to”.

[0066] The term "consisting essentially of" means that the composition, method formulation may include additional ingredients, steps and/or parts, but only if the additional ingredients, steps and/or parts do not materially alter the basic and novel characteristics of the claimed composition, method or structure.

[0067] As used herein the term "method" refers to manners, means, techniques and procedures for accomplishing a given task including, but not limited to, those manners, means, techniques and procedures either known to, or readily developed from known manners, means, techniques and procedures by practitioners of the chemical, pharmacological, biological, biochemical and medical arts.

[0068] The following examples are presented in order to more fully illustrate the preferred embodiments of this invention. They should in no way, however, be construed as limiting the broad scope of this invention.

EXAMPLES

EXAMPLE 1

Clinical Trial Design for Reducing GLP-1 receptor Agonist Adverse Effect

Phase I/II

[0069] 24 healthy subjects receiving a short acting GLP-1 receptor-agonist full dose are randomized into two groups receiving GLP-1 receptor-antagonist (such as avexitide 45mg twice daily or 90mg once daily) or a matching placebo.

[0070] Primary endpoints are safety, tolerability of the GLP-1 receptor-antagonist vs Placebo.

[0071] Secondary Endpoint are the proportion of subjects experiencing serious AEs in the Placebo group vs GLP-1 receptor- Agonist group.

Phase II/III

[0072] 48 overweight patients treated with a once weekly GLP-1 receptor-agonist for obesity (such as semaglutide 2.4m g are randomized into two equal groups and are treated through the week with either GLP-1 receptor- antagonist or a matching placebo.

[0073] The Primary Endpoints are the proportion of subjects experiencing AEs and severity of AEs, in the Placebo group vs GLP-1 receptor- Agonist group.

[0074] Secondary Endpoints include safety and tolerability endpoints, length of the study is determined.

Pivotal Phase III

[0075] 200 or more overweight patients treated with once weekly GLP-1 receptor-agonist for obesity are randomized into two equal groups and are treated with either GLP-1 receptorantagonist (such a avexitide 45 mg twice daily or 90mg once daily) on demand , whenever a need to alleviate side effects arises, or a matching placebo on demand. [0076] The Primary Endpoints are the proportion of subjects experiencing AEs and severity of AEs, in the Placebo group vs GLP-1 receptor- Agonist group.

[0077] Secondary Endpoints include efficacy safety and tolerability endpoints. The study finds out if improved tolerability achieved by G1P 1 antagonists affects the weight loss of the treated patients, length of the study: about one year.

EXAMPLE 2

Effect of GLP1 receptor antagonism on GLP1 receptor agonist induced nausea in mice

[0078] A study is designed to determine the efficacy of Exendin 9-39, a GLP1R antagonist, on reduction of Exenatide 1-39, a GLP1R agonist, induced nausea in mice. A secondary objective of the study is to determine the effect of Exendin 9-39 on Exenatide 1-39 induced weight reduction in mice.

[0079] The study is carried out in mice, for 5-days, as described in Table 1 below.

Table 1. description of a 5-day mouse study (doses) for determining the efficacy of Exendin 9- 39 on reduction of Exenatide 1-39 induced nausea in mice.

[0080] Acclimation Period for the study: 7 days

[0081] A total of 20 BALB/C mice were used in this study [0082] The formulation used in this study and the routes of its administration are described in

Table 2 below:

Table 2. Study drugs and formulations

Assessments

[0083] Side effects are checked twice daily. The primary efficacy is assessed according to the ability of Exendin 9-39 to attenuate Exenatide 1-39 induced nausea (reduction in food consumption) on day 1, day 2, day 3, day 4 and day 5. A secondary efficacy is assessed according to the ability of Exendin 9-39 to attenuate Exenatide 1-39 induced weight loss on day 1, day 2, day 3, day 4 and day 5.

[0084] Statistical analysis is carried out using ANOVA and Tukey HSD

[0085] Safety results: There are no significant apparent changes in mice behavior, and no deaths expected.

[0086] The food consumption and the weight gain observed in the study, according to the various groups vs. group 1 (vehicle) are described in Table 3 below.

Table 3. Food consumption and weight gain according to study groups, vs. vehicle (%)

Discussion and conclusions

[0087] These findings suggest that administration of a GLP1R antagonist is capable of ameliorating GLP1R agonist induced reduction in food consumption.

[0088] While certain features of the invention have been illustrated and described herein, many modifications, substitutions, changes, and equivalents will now occur to those of ordinary skill in the art. It is, therefore, to be understood that the appended claims are intended to cover all such modifications and changes as fall within the true spirit of the invention.

Claims

CLAIMS What is claimed is:

1. A method of reducing, alleviating or treating gastrointestinal side effects of GLP-1 receptor agonist therapy, comprising administering a composition comprising an effective amount of GLP-1 receptor antagonist and a pharmaceutically acceptable carrier thereof to a subject treated with GLP-1 agonist therapy, for a limited duration of time.

2. The method of claim 1, wherein the GLP-1 receptor antagonist avoids the cessation of the GLP-1 receptor agonist therapy , or minimally interferes with the treatment course of the GLP- 1 receptor agonist.

3. The method of claim 1 or 2, wherein the GLP-1 receptor antagonist is a competitive or noncompetitive antagonist.

4. The method of any one of claims 1-3, wherein the GLP-1 receptor antagonist comprises Avexitide (Exendin [9-39]), AZM-134, Bay-73-7977, ⁶⁸Ga-Dfl2-exendin-4, PNU-126814, JTT-608, TB01-3, or P-017.

5. The method of any one of claims 1-4, wherein the GLP-1 receptor agonist therapy comprises at least one selected from: Dulaglutide, Exenatide, Semaglutide, Esemaglutide, Liraglutide, Lixisenatide, Tirzepatide and Albiglutide.

6. The method of any one of claims 1-5, wherein the GLP-1 receptor antagonist is Avexitide (Exendin [9-39]).

7. The method of any one of claims 1-6, wherein the GLP-1 receptor antagonist is administered following the administration of a GLP-1 receptor agonist.

8. The method of any one of claims 1-6, wherein the GLP-1 receptor antagonist is administered concomitantly with the administration of a GLP-1 receptor agonist.

9. The method of any one of claims 1-6, wherein the GLP-1 receptor antagonist is administered prior to the administration of the GLP-1 receptor agonist.

10. The method of any one of claims 1-9, wherein the half-life time of the GLP-1 receptor antagonist is shorter than the half-life time of the GLP-1 receptor agonist. The method of any one of claims 1-10 wherein the gastrointestinal side effects of GLP-1 receptor agonist comprise delayed gastric emptying, nausea, decreased food consumption, vomiting, diarrhea, stomach discomfort, excessing bloating and belching, pain in the upper abdomen, gastroparesis, gastroenteritis, heart burn injection site reactions, and nasopharyngitis. The method of any one of claims 1-11, wherein the GLP-1 receptor antagonist is administered alone, or in combination with a gastric emptying agent. The method of any one of claims 1-12, wherein the GLP-1 receptor antagonist is administered at a dose of between 50 and 1000 pg/kg daily or at a dose of between 5 mg and 500 mg daily. The method of any one of claims 1-13, wherein the GLP-1 receptor antagonist is administered at a dose of between 50 and 100 pg/kg daily; between 150 and 300 pg/kg daily; or between 500 and 700 pg/kg daily. The method of any one of claims 1-14, wherein the GLP-1 receptor antagonist is administered at a dose of 60 pg/kg daily; 200 pg/kg daily; or 600 pg/kg daily. The method of any one of claims 1-15, wherein the composition is administered by intravenous infusion (iv), subcutaneous injection (sc), oral, inhaled, or nasal formulations.