AU2024203992A1

AU2024203992A1 - Prophylactic or therapeutic agent for porphyria

Info

Publication number: AU2024203992A1
Application number: AU2024203992A
Authority: AU
Inventors: Kazumi HYOUDOU; Masahiro Kondo; Akihito Ogasawara; Tsuyoshi Suzuki; Fumihiro Takahashi
Original assignee: Mitsubishi Tanabe Pharma Corp
Current assignee: Mitsubishi Tanabe Pharma Corp
Priority date: 2020-06-10
Filing date: 2024-06-12
Publication date: 2024-07-04
Also published as: AU2021289913A1; PH12022553388A1; EP4585214A1; KR20230016006A; US20230248713A1; JP6959478B1; EP4166140A1; EP4166140A4; MY210457A; CN115942934A; AU2021289913B2; BR112022025099A2; CA3186880A1; MX2022015804A; JPWO2021251450A1; IL298952A

Abstract

A medicine for treating or preventing porphyria, which contains, as an active ingredient, 1-\{2 [(3S,4R)-1-\{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3-yl]carbonyl\}-4 (methoxymethyl)pyrrolidin-3-yl]-5-(trifluoromethyl)phenyl\}piperidine-4-carboxylic acid or a pharmaceutically acceptable salt or cocrystal thereof In the medicine for treating or preventing porphyria, the amount of 1-\{2-[(3S,4R)-1-\{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4 methoxyphenyl)pyrrolidin-3-yl]carbonyl\}-4-(methoxymethyl)pyrrolidin-3-yl]-5 (trifluoromethyl)phenyl\}piperidine-4-carboxylic acid or a pharmaceutically acceptable salt or cocrystal thereof to be administered is 50 to 500 mg/day.

Description

PROPHYLACTIC OR THERAPEUTIC AGENT FOR PORPHYRIA BACKGROUND OF THE INVENTION

Cross-Reference to Related Applications

[0001]

This application is a divisional of Australian Patent Application No.

2021289913, filed on 22 December 2022, and is related to International Patent

Application No. PCT/JP2021/022036, filed on 10 June 2021, and claims priority to

Japan Provisional Patent Application No. 2020-100952, filed on 20 June 2020, and

Japan Provisional Patent Application No. 2020-134451, filed on 7 August 2020; each

of which are incorporated herein by reference in their entirety.

Field of the Invention

[0001a]

The present invention relates to a pharmaceutical composition for treatment

or prevention of porphyria, comprising a compound having melanocortin receptor

(MCR) agonistic activity (agonist activity).

Description of the Related Art

[0002]

Among the light radiated from the sun, the rays having wavelengths of not

more than 300 nm are absorbed in the ozone layer in the stratosphere. Thus, the

sunlight that reaches the ground is composed of ultraviolet light having wavelengths

of not less than 300 nm, visible light, and infrared light. Physiological reactions

caused by exposure to the sunlight include solar dermatitis (sunburn), and skin

changes (wrinkling, sagging, and development of pigmented spots) called photoaging

that occur due to long-term exposure. On the other hand, there are diseases called

photodermatoses, in which pathological changes such as dermatitis occur due to light

irradiation even when the light irradiation is at a level at which healthy individuals la do not respond. One known example of photodermatoses is porphyria.

[0003]

Porphyria is a disease that develops due to accumulation of porphyrins or

precursors thereof as a result of decreased activity of heme metabolic enzyme.

Porphyria may exhibit symptoms such as photosensitivity (sunburn, burn-like

symptoms), and also gastrointestinal symptoms and neurological symptoms. Once

porphyria develops, its symptoms often continue throughout life. Since there is no

curative treatment therefor, symptomatic treatment such as light shielding is carried out as the main therapeutic method.

[0004]

For example, Patent Document 1 discloses use of MCR agonist peptides such

as afamelanotide for the purpose of treatment of photodermatoses such as

erythropoieticprotoporphyria. However, since afamelanotide is not anMC1R

selective agonist, there is a concern of the occurrence of side effects. Moreover,

since afamelanotide is a peptide, it cannot be orally administered, and its half-life is

short. Thus, there is a problem that periodic subcutaneous implanting by a medical

professional is required.

[0005]

On the other hand, Patent Document 2 discloses that pyrrolidine compounds

such as 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid, and pharmaceutically

acceptable salts, solvates, hydrates, cocrystals, and the like thereof have excellent

MCR-, especially MC1R-, activating action. Patent Document 2 discloses that the

compounds are useful for prevention or treatment of diseases or symptoms associated

with activation of MCR, especially MC1R, and that such diseases include

protoporphyria. However, the document does not specifically describe their doses.

Patent Document 3 discloses a cocrystal of1-{2-[(3S,4R)-1-{[(3R,4R)-1

cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4

(methoxymethyl)pyrrolidin-3-yl]-5-(trifluoromethyl)phenyl}piperidine-4-carboxylic

acid. However, the document does not specifically describe the dose of the

cocrystal of 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid for use in treatment of

porphyria.

Prior Art Documents

[Patent Documents]

[0006]

[Patent Document 1] WO 2008025094

[Patent Document 2] WO 2015182723

[Patent Document 3] W02020/138481

SUMMARY OF THE INVENTION

Problems to be solved by the invention

[0007]

Methods of curative treatment of porphyria are limited, and the main method

for avoiding development of symptoms or for alleviation of symptoms has been

prevention of exposure of the skin to sunlight. In particular, it is known that

patients with photodermatoses induced by visible light tend to avoid going out in the

daytime, so that the quality of life (QOL) of the patients may be remarkably

deteriorated.

As described above, an analog of a-melanocyte-stimulating hormone (a

MSH), which is a ligand of MCR, has been developed as a therapeutic agent for

photodermatoses and the like such as erythropoietic protoporphyria (Patent

Documents). However, it is not an MC1R-selective agonist, and cannot be orally

administered since it is a peptide. Moreover, since it disappears quickly in the

human body, periodic implanting is required.

Therefore, a pharmaceutical composition for treatment or prevention of

porphyria, which pharmaceutical composition is safer and not burdensome for

patients, and which enables effective treatment, is demanded.

Means to solve the problems

[0008]

In order to solve the above problems, the present inventors intensively studied.

As a result, the present inventors discovered a dose of 1-{2-[(3S,4R)-1-{[(3R,4R)-1

cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4

acid or a pharmaceutically acceptable salt or cocrystal thereof, which dose is

especially effective in a human clinical trial and exerts an excellent therapeutic or

prophylactic effect on porphyria including erythropoietic protoporphyria (EPP) and

X-linked porphyria. In particular, a dose at which a significant pharmacological

effect can be produced relative to placebo not only in seasons with strong sunlight for

long time such as spring and summer in the Northern Hemisphere, but also in

seasons with weak sunlight for short time such as fall and winter in the Northern

Hemisphere, that is, a dose at which effective treatment or prevention of porphyria is

possible throughout the year, could be discovered. The preceding agent

afamelanotide has been confirmed to have a therapeutic effect on symptoms that

occur after exposure to direct sunlight in a clinical trial. In contrast, at the dose in

the present invention, 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or a pharmaceutically

acceptable salt or cocrystal thereof was confirmed to exert a therapeutic effect not

only on symptoms caused by exposure to direct sunlight, but also on symptoms

caused by exposure to indirect sunlight that may occur even in the inside of a

building or the like. The present invention was completed based on such findings.

[0009]

The present invention provides a medicament for treatment or prevention of

porphyria such as erythropoietic protoporphyria or X-linked porphyria, the

medicament comprising 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or a pharmaceutically acceptable salt or cocrystal thereof as an active ingredient, wherein the dose of the 1

{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3

yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or the pharmaceutically

acceptable salt or cocrystal thereof is 50 to 500 mg/day, preferably 100 to 300

mg/day.

[0010]

The present invention provides a method of treatment or prevention of

porphyria such as erythropoietic protoporphyria or X-linked porphyria, the method

comprising the step of administering an effective amount of1-{2-[(3S,4R)-1

{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4 (methoxymethyl)pyrrolidin-3-yl]-5-(trifluoromethyl)phenyl}piperidine-4-carboxylic

acid or a pharmaceutically acceptable salt or cocrystal thereof to a subject in need of

treatment or prevention, wherein the effective amount is 50 to 500 mg/day,

preferably 100 to 300 mg/day.

[0011]

The present invention provides 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3

fluoro-4-(4-methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin

3-yl]-5-(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or a pharmaceutically

acceptable salt or cocrystal thereof, for treatment or prevention of porphyria such as

erythropoietic protoporphyria or X-linked porphyria, wherein the dose of the 1-{2

[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3

yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or the pharmaceutically

acceptable salt or cocrystal thereof is 50 to 500 mg/day, preferably 100 to 300

mg/day.

[0012]

The present invention provides use of 1-{2-[(3S,4R)-1-{[(3R,4R)-1

cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4

acid or a pharmaceutically acceptable salt or cocrystal thereof, in manufacture of a

medicament for treatment or prevention of porphyria such as erythropoietic

protoporphyria or X-linked porphyria, wherein the dose of the 1-{2-[(3S,4R)-1

acid or the pharmaceutically acceptable salt or cocrystal thereof is 50 to 500 mg/day,

preferably 100 to 300 mg/day.

[0013]

According to the present invention, treatment or prevention of porphyria is

possible in any environment either indoors or outdoors throughout the year. 1-{2

[(3S,4R)-1-{[(3R,4R)-1-Cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3

yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or a pharmaceutically

acceptable salt or cocrystal thereof can be orally administered, and exhibits excellent

kinetics in the human body. Moreover, since itis anMC1R-selective compound, it

causes less side effects, and enables safe and effective treatment or prevention of

porphyria without imposing a burden on the patient. In particular, in porphyria such

as erythropoietic protoporphyria or X-linked porphyria, administration of 1-{2

[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3

yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or a pharmaceutically

acceptable salt or cocrystal thereof at a particular dose enables excellent therapeutic

effects such as prolongation of the time to the occurrence of phototoxicity (in other

words, time to occurrence of phototoxicity-related symptom or time to prodromal symptoms), reduction of pain events, and improvement of QOL, either indoors or outdoors throughout the year.

DETAILED DESCRIPTION OF THE INVENTION

[0014]

The present invention is described below.

[0015]

The active ingredient of the medicament of the present invention, that is, 1

{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3

yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or a pharmaceutically

acceptable salt or cocrystal thereof, is described in Patent Document 2, and can be

produced by, for example, the method described in Patent Document 2. A cocrystal

of 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid and phosphoric acid can be

obtained by a conventional method or, for example, the method described in Patent

Document 3.

In this specification, the "dose of the1-{2-[(3S,4R)-1-{[(3R,4R)-1

cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4

acid or the pharmaceutically acceptable salt or cocrystal thereof' or the dose or

amount of "Compound A" refers to the dose or amount in terms of the amount of 1

{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3

yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid as free form.

[0016]

Since 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or a pharmaceutically

acceptable salt or cocrystal thereof has excellent MC1R agonist activity, it exerts

excellent therapeutic and prophylactic effects on porphyria, such as prolongation of

the time to the occurrence of phototoxicity, reduction of pain events, and

improvement of QOL, in any environment throughout the year.

Further, 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or a pharmaceutically

acceptable salt or cocrystal thereof exerts an especially excellent effect on

prolongation of the time to the occurrence of phototoxicity in a particular patient

group (patient group whose baseline median of the erythrocyte protoporphyrin IX

level is not less than 1980.50 mcg/dL), thereby exerting excellent therapeutic and

prophylactic effects on porphyria

Furthermore, 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or a pharmaceutically

acceptable salt or cocrystal thereof exerts an excellent effect on prolongation of the

time to the occurrence of phototoxicity in a particular patient group (patient group

whose median of the melanin density is not less than 3.0915) independent of the dose,

and exerts an excellent effect on prolongation of the time to the occurrence of

phototoxicity in a particular patient group (patient group whose median of the

melanin density is less than 3.0915) at a particular dose (preferably at a daily dose of

300 mg), thereby exerting excellent therapeutic and prophylactic effects on porphyria.

Thus, a medicament containing 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3- fluoro-4-(4-methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin

acceptable salt or cocrystal thereof as an active ingredient is useful for treatment or

prevention of porphyria.

[0017]

Examples of the porphyria include erythropoietic protoporphyria, X-linked

porphyria, congenital erythropoietic porphyria, variegate porphyria, acute

intermittent porphyria, porphyria cutanea tarda, and hereditary coproporphyria.

The erythropoietic protoporphyria herein includes congenital erythropoietic

protoporphyria.

[0018]

The time to the occurrence of phototoxicity has the same meaning of the time

to occurrence of phototoxicity-related symptom, or simply a symptom. It also means

the time to prodromal symptom. Examples of phototoxicity-related symptom,

symptom or prodromal symptom include burning, tingling, itching and stinging.

[0019]

The 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid may be subjected to the

pharmaceutical use either in the free form, or in the form of a pharmaceutically

acceptable salt or cocrystal thereof.

Here, the 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or the pharmaceutically

acceptable salt or cocrystal thereof includes any of intramolecular salts and adducts,

and solvates, hydrates, crystalline polymorphs, and the like thereof.

Examples of the pharmaceutically acceptable salts, cocrystals, intramolecular salts, and adducts include those containing: an inorganic acid such as hydrochloric acid, sulfuric acid, phosphoric acid, or hydrobromic acid; or an organic acid such as acetic acid, fumaric acid, oxalic acid, citric acid, methanesulfonic acid, benzenesulfonic acid, p-toluenesulfonic acid, or maleic acid. Cocrystals with phosphoric acid are especially preferred.

[0020]

One of, or two or more of, 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3

fluoro-4-(4-methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin

3-yl]-5-(trifluoromethyl)phenyl}piperidine-4-carboxylic acid, and pharmaceutically

acceptable salts and cocrystals thereof may be administered as they are to the patient.

Preferably, however, 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or a pharmaceutically

acceptable salt or cocrystal thereof may be mixed with a pharmacologically and

pharmaceutically acceptable additive(s) to be provided as a formulation in a form

well known to those skilled in the art.

[0021]

Examples of the pharmacologically and pharmaceutically acceptable

additive(s) include appropriate excipients, disintegrants, binders, lubricants, coating

agents, colorants, diluents, bases, and isotonic agents usually used in the production

of pharmaceuticals. Examples of the excipients include glucose, lactose, D

mannitol, starch, and crystalline cellulose. Examples of the disintegrants include

carboxymethyl cellulose, starch, and calcium carboxymethyl cellulose. Examples

of the binders include hydroxypropyl cellulose, hydroxypropyl methylcellulose,

polyvinyl pyrrolidone, and gelatin. Examples of the lubricants include magnesium

stearate and talc. Examples of the coating agents include hydroxypropyl

methylcellulose, sucrose, polyethylene glycol, and titanium oxide. Examples of the bases include vaseline, liquid paraffin, polyethylene glycol, gelatin, kaolin, glycerin, purified water, and hard fat. In addition, for formulations suitable for injection or infusion, the following may be used as formulation additives: solvents and solubilizers that may constitute aqueous injection solutions, or may constitute injection solutions to be prepared before use, such as distilled water for injection, physiological saline, and propylene glycol; isotonic agents such as glucose, sodium chloride, D-mannitol, and glycerin; pH regulators such as inorganic acids, organic acids, inorganic bases, and organic bases; and the like.

[0022]

The 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or the pharmaceutically

acceptable salt or cocrystal thereof, together with the above-described additives, may

be prepared into an appropriate dosage form (such as a powder, an injection solution,

a tablet, a capsule, or a topical preparation), and may then be administered to a

patient (human or animal) using an appropriate administration method in accordance

with the dosage form (such as intravenous administration, oral administration,

percutaneous administration, or topical administration). Among these, oral

administration is preferred.

[0023]

The dose of the medicament comprising 1-{2-[(3S,4R)-1-{[(3R,4R)-1

cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4

acid or a pharmaceutically acceptable salt or cocrystal thereof is an amount at which

the medicament can be safely used with low toxicity and at which a therapeutic effect

or prophylactic effect can be exerted on porphyria either indoors or outdoors

throughout the year. The dose in terms of the amount of 1-{2-[(3S,4R)-1-

more preferably 80 to 400 mg/day, especially preferably 100 to 300 mg/day.

Examples of the dose include 100 mg/day, 150 mg/day, 200 mg/day, 250 mg/day,

300 mg/day, and doses between these.

[0024]

Oral administration is especially preferred. The dose of the medicament

comprising 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or a pharmaceutically

acceptable salt or cocrystal thereof for oral administration, in terms of the amount of

1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin

3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or the pharmaceutically

acceptable salt or cocrystal thereof is 50 to 500 mg/day, preferably 80 to 400 mg/day,

more preferably 100 to 300 mg/day, more specifically, 100 mg/day, 150 mg/day, 200

mg/day, 250 mg/day, 300 mg/day, or a dose between these. The medicament is

especially preferably administered at a dose of 100 mg/day, 200 mg/day, or 300

mg/day.

[0025]

Still more preferably, a cocrystal of 1-{2-[(3S,4R)-1-{[(3R,4R)-1

cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4

acid and phosphoric acid is administered at a dose of 100 mg/day or 300 mg/day in

terms of the amount of 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5-

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid.

Otherwise, preferably, a cocrystal of 1-{2-[(3S,4R)-1-{[(3R,4R)-1

cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4

acid and phosphoric acid is administered at a dose of 100 mg/day or 200 mg/day in

terms of the amount of 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid.

[0026]

In another mode, a cocrystal of 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3

fluoro-4-(4-methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin

3-yl]-5-(trifluoromethyl)phenyl}piperidine-4-carboxylic acid and phosphoric acid is

administered at a dose of 100 mg/day in terms of the amount of1-{2-[(3S,4R)-1

acid.

[0027]

In another mode, a cocrystal of1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3

fluoro-4-(4-methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin

administered at a dose of 200 mg/day in terms of the amount of1-{2-[(3S,4R)-1

acid.

[0028]

In another mode, a cocrystal of1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3

fluoro-4-(4-methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-

administered at a dose of 300 mg/day in terms of the amount of1-{2-[(3S,4R)-1

acid.

[0029]

As described in the Examples below, it was shown that, at a daily dose of 100

mg or 300 mg, 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or a pharmaceutically

acceptable salt or cocrystal thereof exerts therapeutic effects such as prolongation of

the time to the occurrence of phototoxicity, reduction of pain events, and

improvement of QOL relative to placebo in patients with erythropoietic

protoporphyria and patients with X-linked porphyria. In particular, in a patient

group whose baseline median of the erythrocyte protoporphyrin IX level was not less

than 1980.50 mcg/dL, a statistically significant effect on prolongation of the time to

the occurrence of phototoxicity relative to placebo was found at a daily dose of either

100mgor300mg. According to comparison between a patient group whose

median of the melanin density was not less than 3.0915 and a patient group whose

median of the melanin density was less than 3.0915, the former group showed similar

levels of prolongation of the time to the occurrence of phototoxicity at daily doses of

both 100 mg and 300 mg, but, in the latter group, the patient group with a daily dose

of 300 mg showed better prolongation of the time to the occurrence of phototoxicity.

Also at daily doses of 100 mg and 200 mg, a test which confirms a

therapeutic effect of 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or a pharmaceutically acceptable salt or cocrystal thereof on patients with erythropoietic protoporphyria and patients with X-linked porphyria is conducted.

[0030]

Although Patent Document 2 and Patent Document 3 describe erythropoietic

protoporphyria as a target disease, these documents do not specifically describe doses.

In the clinical trial shown in the present invention, it was found that administration at

a dose including 100 mg/day and 300 mg/day, for example, 50 to 500 mg/day,

preferably 80 to 400 mg/day, more preferably 100 to 300 mg/day, enables exertion of

excellent therapeutic effects on erythropoietic protoporphyria either indoors or

outdoors throughout the year, which therapeutic effects include prolongation of the

time to the occurrence of phototoxicity, reduction of pain events, and improvement

of QOL. These finding were not described or suggested in the above documents at

all.

[0031]

Thus, one mode of the present invention provides a medicament to be

administered to a patient with porphyria for treatment or prevention of porphyria, the

medicament comprising 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or a pharmaceutically

acceptable salt or cocrystal thereof as an active ingredient, wherein the dose of the 1

{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3

yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or the pharmaceutically

acceptable salt or cocrystal thereof for the patient with porphyria is 50 to 500 mg/day,

preferably 80 to 400 mg/day, more preferably 100 to 300 mg/day, more specifically,

100 mg/day, 150 mg/day, 200 mg/day, 250 mg/day, 300 mg/day, or a dose between

these.

[0032]

In another mode of the present invention, a medicament is administered to a

patient with erythropoietic protoporphyria or a patient with X-linked porphyria for

treatment or prevention of erythropoietic protoporphyria or X-linked porphyria,

wherein the medicament comprises 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3

fluoro-4-(4-methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin

{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3

yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or the pharmaceutically

acceptable salt or cocrystal thereof for the patient with erythropoietic protoporphyria

or the patient with X-linked porphyria is 50 to 500 mg/day, preferably 80 to 400

mg/day, more preferably 100 to 300 mg/day, more specifically, 100 mg/day, 150

mg/day, 200 mg/day, 250 mg/day, 300 mg/day, or a dose between these.

[0033]

In another mode of the present invention, a medicament is administered to a

prolongation of the time to the occurrence of phototoxicity and/or reduction of pain

events, wherein the medicament comprises 1-{2-[(3S,4R)-1-{[(3R,4R)-1

cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4

acid or a pharmaceutically acceptable salt or cocrystal thereof as an active ingredient,

wherein the dose of the 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or the pharmaceutically

acceptable salt or cocrystal thereof for the patient with erythropoietic protoporphyria or the patient with X-linked porphyria is 50 to 500 mg/day, preferably 80 to 400 mg/day, more preferably 100 to 300 mg/day, more specifically, 100 mg/day, 150 mg/day, 200 mg/day, 250 mg/day, 300 mg/day, or a dose between these.

[0034]

In another mode of the present invention, a medicament is administered to a

treatment or prevention of erythropoietic protoporphyria or X-linked porphyria,

wherein a patient group is the group whose baseline median of the erythrocyte

protoporphyrin IX level is not less than 1980.50 mcg/dL, wherein the medicament

comprises 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or a pharmaceutically

{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3

yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or the pharmaceutically

mg/day, more preferably 100 to 300 mg/day, more specifically, 100 mg/day, 150

mg/day, 200 mg/day, 250 mg/day, 300 mg/day, or a dose between these.

[0035]

In another mode of the present invention, a medicament is administered to a

treatment or prevention of erythropoietic protoporphyria or X-linked porphyria,

wherein a patient group is the group whose median of the melanin density is not less

than 3.0915, wherein the medicament comprises 1-{2-[(3S,4R)-1-{[(3R,4R)-1

cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-

wherein the dose of the 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or the pharmaceutically

mg/day, more preferably 100 to 300 mg/day, more specifically, 100 mg/day, 150

mg/day, 200 mg/day, 250 mg/day, 300 mg/day, or a dose between these.

[0036]

In another mode of the present invention, a medicament is administered to a

treatment or prevention of erythropoietic protoporphyria or X-linked porphyria,

wherein a patient group is the group whose median of the melanin density is less than

3.0915, wherein the medicament comprises 1-{2-[(3S,4R)-1-{[(3R,4R)-1

cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4

wherein the dose of the 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or the pharmaceutically

mg/day, more preferably 100 to 300 mg/day, more preferably 200 to 300 mg/day,

more specifically, 100 mg/day, 150 mg/day, 200 mg/day, 250 mg/day, 300 mg/day, or

a dose between these, more preferably150 mg/day, 200 mg/day, 250 mg/day, 300

mg/day, or a dose between these.

EXAMPLES

[0037]

The present invention is described below more specifically by showing

Examples. However, the scope of the present invention is not limited to the

embodiments in the following Examples.

[0038]

Compound A, which was used in the Examples, is the following compound:

cocrystal containing 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid and phosphoric acid.

[0039]

The 1-{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4

methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid was produced by the method

described in Patent Document 2, and the cocrystal with phosphoric acid was

produced by the following method.

More specifically, a solution of potassium carbonate (3.4 kg) in water (77.0

L), and water (19.3 L), were sequentially added to a suspension of 1-{2-[(3S,4R)-1

acid 1/2 ethane-1,2-disulfonic acid (19.3 kg) in ethyl acetate (86.6 kg) at 20 to 30°C,

and the resulting mixture was stirred for 10 minutes. After leaving the mixture to

stand, the aqueous layer was removed, and the organic layer was washed twice with

water (96.3 L). After concentrating the organic layer to 35 L, ethanol (75.9 kg) was

added thereto, followed by concentrating the resulting mixture to 35 L. The

resulting concentrate was diluted with ethanol (30.3 kg), and the insoluble matter

was filtered off and washed with ethanol (75.6 kg). The filtrate and washings were combined, concentrated to 35 L, and then diluted with ethanol (17.9 kg). After sequential addition of 24% aqueous sodium hydroxide solution (6.1 kg) and water

(15.6 kg) thereto at 20 to 30°C, the resulting mixture was stirred at 20 to 30°C for 5

hours. At 20 to 40°C, a solution of phosphoric acid (8.5 kg) in water (28.9 L), and

water (115.5 L), were sequentially added thereto. At 30 to 40°C, compound A (0.48

kg) was added thereto as seed crystals. The resulting mixture was stirred for 19.5

hours, and then cooled to 20°C. The solid was collected by filtration, and then

washed with water (96.3 L). The solid was dried at not more than 50°C, and

pulverized to obtain compound A (17.5 kg).

The compound A obtained was identified using IR.

[0040]

Example 1

Time to Occurrence of Phototoxicity-Related Symptom in Clinical Trial of

Compound A for Patients with Erythropoietic Protoporphyria and Patients with X

Linked Porphyria

Compound A was administered to adult male and female patients with

erythropoietic protoporphyria or X-linked porphyria for 16 weeks in a randomized

double-blind clinical trial. As a primary endpoint for the clinical effect, the time to

the first symptom due to exposure to light, including indirect sunlight as well as

direct sunlight, during the period from 1 hour after sunrise to 1 hour before sunset

was evaluated.

The baseline median of the erythrocyte protoporphyrin IX level was

determined by measuring the protoporphyrin IX level in the fraction of erythrocytes

in blood.

The median of the melanin density was determined by spectrophotometric

measurement for the skin at the following six sites: the forehead, the left cheek, the

inner side of the right upper arm, the inner side of the left forearm, the right side of the abdomen, and the left side of the hip.

[0041]

Table 1 shows the evaluation results at week 16 obtained for 35 cases in

which placebo was given, 33 cases in which 100 mg of compound A was orally taken

once daily, and 34 cases in which 300 mg of compound A was orally taken once daily.

The groups in which 100 mg or 300 mg of compound A was administered showed

lengths of time of 53.8 minutes and 62.5 minutes, respectively, indicating significant

prolongation of the length of time relative to the group in which placebo was

administered.

[0042]

[Table 1]

Compound A 100mg (N=33) vs Compound A 300mg (N=34) vs Item placebo (N=35) placebo (N=35)

Least squares mean of the 53. 8 62. 5 length of time (in minutes) before the first occurrence of a symptom in a day

P value 0.008 0.003

[0043]

According to analysis of the above item in the patient group whose baseline

median of the erythrocyte protoporphyrin IX level was not less than 1980.50 mcg/dL,

when 100 mg of compound A was administered, the least squares mean of the time

(in minutes) to the first occurrence of the symptom in a day was 69.3 minutes (P

value, 0.020), and, when 300 mg of compound A was administered, the least squares

mean of the time (in minutes) to the first occurrence of the symptom in a day was

82.6 minutes (P value, 0.003). Thus, both cases showed statistical significance.

Also in the patient group whose baseline median of the erythrocyte protoporphyrin

IX level was less than 1980.50 mcg/dL, the time to the first occurrence of the

symptom in a day tended to be prolonged.

In addition, analysis of the above item was carried out after dividing the

subjects into the patient group whose median of the melanin density was not less

than 3.0915 and the patient group whose median of the melanin density was less than

3.0915. As a result, in the former group, when 100 mg of the compound was

administered, the least squares mean of the time (in minutes) to the first occurrence

of the symptom in a day was 85.0 minutes (P value, < 0.001), and, when 300 mg of

the compound was administered, it was 80.3 minutes (P value, 0.002). In the latter

group, when 100 mg of the compound was administered, the least squares mean of

the time (in minutes) to the first occurrence of the symptom in a day was 23.2

minutes (P value, 0.499), and, when 300 mg of the compound was administered, it

was 63.7 minutes (P value, 0.051), indicating that the effect that prolongs the time to

the occurrence of the phototoxicity-related symptom is higher at 300 mg.

[0044]

Example 2

Time to Occurrence of Phototoxicity-Related Symptom (Clinical Primary Endpoint)

in Patients with Erythropoietic Protoporphyria and Patients with X-Linked Porphyria

Evaluated for Subgroup in Which Initial Dosing of Compound A Was Carried Out in

Spring or Summer and Subgroup in Which Initial Dosing of Compound A Was

Carried Out in Fall or Winter

The test in Example 2 was conducted in the Northern Hemisphere. Table 2

shows the evaluation results at week 16 obtained for a subgroup in which initial

dosing of compound A was carried out in spring or summer (20 cases in which

placebo was given, 18 cases in which 100 mg of compound A was orally taken once

daily, and 18 cases in which 300 mg of compound A was orally taken once daily) and

a subgroup in which initial dosing of compound A was carried out in fall or winter

(15 cases in which placebo was given, 15 cases in which 100 mg of compound A was

orally taken once daily, and 16 cases in which 300 mg of compound A was orally taken once daily). In the spring-summer subgroup, the groups in which 100 mg or

300 mg of compound A was administered showed lengths of time of 54.4 minutes

and 42.2 minutes, respectively, indicating prolongation of the length of time relative

to the group in which placebo was administered. In the fall-winter subgroup, the

groups in which 100 mg or 300 mg of compound A was administered showed lengths

of time of 52.8 minutes and 95.8 minutes, respectively, indicating significant

prolongation of the length of time relative to the group in which placebo was

administered. Thus, both groups in which 100 mg or 300 mg of compoundAwas

administered showed prolongation of the length of time irrespective of the season.

[0045]

[Table 2]

Subgroup in which initial dosing of compound A was carried out in spring or summer

Items Compound A 100mg (N=18) Compound A 300mg (N=18) vs Placebo (N=20) vs Placebo (N=20) Least squares mean of the 54.4 42.2 length of time (in minutes) before the first occurrence of a symptom in a day

Pvalue 0.073 0.168 Subgroup in which initial dosing of compound A was carried out in fall or winter

Compound A 100mg (N=15) Compound A 300mg (N=16)

vs Placebo (N=15) vs Placebo (N=15) Least squares mean of the 52.8 95.8 length of time (in minutes) before the first occurrence of a symptom in a day

Pvalue 0.029 <0.001

[0046]

Example 3

Number of Pain Events Recorded in Electronic Diary by Patients during Evaluation

Period of 16 Weeks in Clinical Trial of Compound A for Patients with Erythropoietic

Protoporphyria and Patients with X-Linked Porphyria

Compound A was administered to adult male and female patients with

double-blind clinical trial. As another endpoint for the clinical effect, the number of

pain events during the evaluation period of 16 weeks was recorded in an electronic

diary by the patients themselves.

[0047]

Table 3 shows the evaluation results obtained for 23 cases in which placebo

was given, 24 cases in which 100 mg of compound A was orally taken once daily,

and 24 cases in which 300 mg of compound A was orally taken once daily. The

incidence rates of pain during the evaluation period in the placebo administration

group, the 100-mg compound A-administration group, and the 300-mg compound A

administration group were 7.5, 3.3, and 3.5, respectively. Thus,the100-mg

compound A-administration group and the 300-mg compound A-administration

group significantly showed reduction of pain events by 60% and 50%, respectively,

relative to the placebo administration group (Table 3).

[0048]

[Table 3]

Item Placebo Compound A 100mg Compound A 300mg

N (number) 23 24 24 Incidence rate of pain 7. 5 3. 3 3. 5 Ratio to placebo - 0.4 0. 5 P value 0.027 0.028

[0049]

Example 4

Evaluation of Health-Related QOL of Patients in Clinical Trial of Compound A for

Patients with Erythropoietic Protoporphyria and Patients with X-Linked Porphyria

Compound A was administered to adult male and female patients with

erythropoietic protoporphyria or X-linked porphyria for 16 weeks in a randomized double-blind clinical trial. As a secondary endpoint for the clinical effect, the PGIC

(Patient Global Impression of Change) score, which is a health-related QOL, of each

patient at week 16 was recorded by the patients themselves. More specifically, each

patient was provided with a questionnaire for scoring the degree of improvement of

the overall physical and mental health conditions on a 7-point scale. In this case,

the score 1 of the PGIC score indicates that no change occurred or that exacerbation

occurred, and wherein the score 7 indicates that remarkable improvement was

achieved.

[0050]

Table 4 shows the evaluation results obtained for 30 cases in which placebo

was given, 25 cases in which 100 mg of compound A was orally taken once daily,

and 24 cases in which 300 mg of compound A was orally taken once daily. The

PGIC scores at week 16 in the placebo-administration group, the 100-mg compound

A-administration group, and the 300-mg compound A-administration group were 2.9,

6.4, and 6.6, respectively. Thus, the 100-mg compound A-administration group and

the 300-mg compound A-administration group showed significant increases in the

PGIC score relative to the placebo-administration group, indicating their global

impression improvement (Table 4).

[0051]

[Table 4] Item Placebo Compound A 100mg Compound A 300mg

N (number) 30 25 24

Least squares mean of the scores 2.9 6.4 6.6 P value - <0. 001 <0. 001

[0052]

Example 5 Phase III Trial Using Compound A as Test Substance

Subjects: Male and female patients with erythropoietic protoporphyria or X-linked

porphyria, whose ages range from 12 years old to 75 years old.

Outline of Trial: Randomized Double-Blind Clinical Trial

In 53 cases, placebo is given. In 53 cases, 100 mg of compound A is orally

takenoncedaily. In 53 cases, 200 mg of compound A is orally taken once daily.

Test Items

(1) The time to the occurrence of a phototoxicity-related symptom in a

clinical trial of compound A for patients with erythropoietic protoporphyria and

patients with X-linked porphyria

In a randomized double-blind clinical trial, compound A is administered to

the subjects for 26 weeks, and, depending on conditions, additional administration is

carried out for26 weeks orup to 58 weeks. Asa primary endpoint for the clinical

effect, the time to the first occurrence of a symptom due to exposure to light in a day

is evaluated at week 26.

(2) The number of pain events recorded in an electronic diary by patients

during an evaluation period of 26 weeks in a clinical trial of compound A for patients

with erythropoietic protoporphyria and patients with X-linked porphyria

In a randomized double-blind clinical trial, compound A is administered to

carried out for 26 weeks or up to 58 weeks. As another endpoint for the clinical

effect, the number of pain events during the evaluation period of 26 weeks is

recorded in an electronic diary by the patients themselves.

(3) Evaluation of the health-related QOL of patients in a clinical trial of

compound A for patients with erythropoietic protoporphyria and patients with X

linked porphyria

In a randomized double-blind clinical trial, compound A is administered to

carried out for 26 weeks or up to 58 weeks. As a secondary endpoint for the

clinical effect, the PGIC (Patient Global Impression of Change) score, which is a health-related QOL, of each patient at week 26 is recorded by the patients themselves.

More specifically, each patient is provided with a questionnaire for scoring the

degree of improvement of the overall physical and mental health conditions on a 7

point scale. In this case, the lowest score of the PGIC score, 1 point, indicates

"Very Much Improved" and wherein the highest score, 7 points, indicates "Very

Much Worse".

Claims

1. A medicament for treatment or prevention of porphyria, comprising 1-{2

[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3

yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or a pharmaceutically

{2-[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3

yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or the pharmaceutically

acceptable salt or cocrystal thereof is 50 to 500 mg/day.

2. The medicament according to claim 1, wherein the dose of the 1-{2-[(3S,4R)

1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3-yl]carbonyl}

4-(methoxymethyl)pyrrolidin-3-yl]-5-(trifluoromethyl)phenyl}piperidine-4

carboxylic acid or the pharmaceutically acceptable salt or cocrystal thereof is 100 to

300 mg/day.

3. The medicament according to claim 1 or 2, wherein the dose of the 1-{2

[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3

yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or the pharmaceutically

acceptable salt or cocrystal thereof is 100 mg/day, 200 mg/day, or 300 mg/day.

4. The medicament according to any one of claims I to 3, wherein the porphyria

is erythropoietic protoporphyria, X-linked porphyria, congenital erythropoietic

porphyria, variegate porphyria, acute intermittent porphyria, porphyria cutanea tarda,

or hereditary coproporphyria.

5. The medicament according to claim 4, wherein the porphyria is erythropoietic

protoporphyria or X-linked porphyria.

6. The medicament according to any one of claims I to 5, wherein the 1-{2

[(3S,4R)-1-{[(3R,4R)-1-cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3

yl]carbonyl}-4-(methoxymethyl)pyrrolidin-3-yl]-5

(trifluoromethyl)phenyl}piperidine-4-carboxylic acid or the pharmaceutically

acceptable salt or cocrystal thereof is a cocrystal of1-{2-[(3S,4R)-1-{[(3R,4R)-1

cyclopentyl-3-fluoro-4-(4-methoxyphenyl)pyrrolidin-3-yl]carbonyl}-4

acid and phosphoric acid.