HK1245627A1

HK1245627A1 - Compounds and compositions for the treatment or prevention of pathological conditions associated with excess fibrin deposition and/or thrombus formation

Info

Publication number: HK1245627A1
Application number: HK18104056.3A
Authority: HK
Inventors: 斯韦克．耶恩; 乔纳斯．费杰森．塞尔乔; 尼克拉斯．伯格
Original assignee: 西兰诺科学有限公司
Priority date: 2014-10-08
Filing date: 2015-10-08
Publication date: 2018-08-31

Abstract

There is herein provided valproic acid, or a pharmaceutically acceptable salt thereof, for use in treating or preventing a pathological condition associated with excess fibrin deposition and/or thrombus formation, wherein said treatment comprises treating a patient with valproic acid, or a pharmaceutically acceptable salt thereof, in a specific manner, and formulations for use or designed for use in such treatments.

Description

Compounds and compositions for treating or preventing pathological conditions associated with excessive fibrin deposition and/or thrombosis

Technical Field

The present invention relates generally to novel medical uses, methods of treatment and pharmaceutical compositions. More particularly, it relates to the use of valproic acid (VPA) and pharmaceutically acceptable salts thereof for the treatment or prevention of thrombosis and for the amelioration or normalization of endogenous vascular fibrinolysis.

Background

The listing or discussion of an apparently prior-published document in this specification is not necessarily to be taken as an admission that the document is part of the state of the art or is common general knowledge.

Cardiovascular disease has been a leading cause of morbidity and mortality in the western world over the last decades, and it has also become a rapidly growing problem in developing countries. It is estimated that eight million american adults (one third) have manifestations of one or more cardiovascular diseases (CVD), such as hypertension, coronary heart disease, heart failure, or stroke. Mortality data showed that CVD was the underlying cause of death for 35% of all deaths in the united states in 2005, most of which were associated with myocardial infarction, stroke, or complications thereof. The vast majority of patients suffering from acute cardiovascular events have been previously exposed to at least one major risk factor, such as smoking, abnormal blood lipid levels, hypertension, diabetes, abdominal obesity and low grade inflammation.

Pathophysiologically, the main events of myocardial infarction and ischemic stroke are caused by a sudden stagnation of the nutritional blood supply due to the formation of blood clots in the lumen of the arterial blood vessels. In most cases, thrombus formation is caused by rupture of a vulnerable atherosclerotic plaque, which exposes chemical agents that activate the platelet and plasma clotting systems. The activated platelets form a platelet plug, which is surrounded by fibrin produced by coagulation to form a blood clot that expands within the lumen of the blood vessel until it blocks or blocks the blood flow, which causes hypoxic tissue damage (so-called infarction). Thrombotic cardiovascular events thus occur as a result of two different processes, namely, on the one hand, slowly developing long-term vascular atherosclerosis of the vessel wall and, on the other hand, sudden acute clot formation which rapidly causes blood flow stagnation. Without wishing to be bound by theory, it is believed that the present invention relates only to the latter process.

Recently, inflammation has been recognized as an important risk factor for thrombotic events. Vascular inflammation is a characteristic of the atherosclerotic vessel wall, and inflammatory activity is a strong determinant of susceptibility of atherosclerotic plaque to rupture and initiate intravascular coagulation. Also, autoimmune conditions with systemic inflammation, such as rheumatoid arthritis, systemic lupus erythematosus and various forms of vasculitis, significantly increase the risk of myocardial infarction and stroke.

Traditional approaches to the prevention and treatment of cardiovascular events are directed to: 1) slowing the progression of the underlying atherosclerotic process; 2) preventing clot formation in the event of plaque rupture; or 3) directly removing the acute thrombotic blood flow obstruction. In short, anti-atherosclerotic treatments are aimed at modulating the effects of general risk factors, including dietary recommendations, weight loss, physical activity, cessation of smoking, cholesterol and blood pressure therapy, and the like.

Prevention of clot formation relies primarily on the use of antiplatelet drugs that inhibit platelet activation and/or aggregation, but in some cases also involves the prevention of thromboembolism with oral anticoagulants such as warfarin. Post-hoc treatment of acute arterial thrombotic events requires direct drug cleavage of the clot by thrombolytic agents such as recombinant tissue plasminogen activator, or percutaneous mechanical expansion of the occluded vessel.

Although multi-target anti-atherosclerotic treatments and clot prevention using anti-platelet agents have reduced the incidence of myocardial infarction and ischemic stroke, such events remain major group health problems. This shows that these precautions are not sufficient to completely prevent the occurrence of arterial thrombotic events in patients with cardiovascular risk factors.

Likewise, thrombotic conditions on the venous side of the circulation, as well as embolic complications thereof such as pulmonary embolism, still lead to considerable morbidity and mortality. Venous thrombosis has different clinical manifestations, with platelet activation being slightly different than the relative importance of plasma coagulation, the latter having advantages in venous thrombosis. However, despite these differences, the primary underlying mechanisms causing thrombotic vessel occlusion are similar to those acting on the arterial circulation. Furthermore, although not associated with atherosclerosis, the risk of venous thrombosis is associated with general cardiovascular risk factors, such as inflammation and metabolic abnormalities.

In combination, existing treatments and general risk factor management do not provide adequate protection against thrombotic events in both the arterial and venous circulation, and do not reverse the serious consequences of such events. This has created a need for the development of new preventive and therapeutic targets, in particular more effective methods that can ideally prevent dangerous tissue ischemia at an early stage where symptoms have not yet appeared.

Interestingly, it has been found that in healthy individuals there is a natural "last line defense" system which can be activated if the coagulation process will take place in the vascular system, although it is a precautionary measure. In short, the initiation of the thrombotic mechanisms on the arterial and venous sides of the circulation causes the activation of the innermost cell layer (endothelium) of the blood vessel, in response to which the cells rapidly release a large amount of the clot-dissolving substance tissue plasminogen activator (t-PA). This increased intraluminal t-PA levels to levels similar to clinical thrombolytic therapy (i.e., administration of recombinant t-PA), but 100-fold more potent due to the extremely rapid action of this endogenous response.

The growing accumulation of clinical, epidemiological and experimental data supports the idea that if this thrombus-protecting function of the vessel wall is intact, it provides a strong defense against blood flow-blocking thrombosis. Unfortunately, however, the ability to burst t-PA release is impaired in several conditions of increased susceptibility to thrombotic events. These include atherosclerosis, hypertension, abdominal obesity, smoking, sedentary lifestyle, and low grade inflammation. This damage is most likely due to reduced synthesis, thus reducing the availability of fibrinolytic activator in endothelial cells.

Furthermore, we and others have shown that the efficiency of the endogenous fibrinolytic reaction is reduced in patients with an increased risk of arterial thrombotic events, for example in atherosclerosis (Osterlund, b., et al., acta analhesesol Scand 52, 1375-. Recent data suggest that inflammation may be the underlying pathogenic mechanism behind the inhibited production of t-PA in this situation. We have shown that prolonged exposure to the inflammatory cytokines tumor necrosis factor alpha (TNF-alpha) and interleukin-1 beta (IL-1b) causes significant inhibition of t-PA transcription (Ulfhammer, E., et al. journal of Thrombosis and Haemostasis 4, 1781-1789(2006), Larsson, P., et al. Thromb Res 123, 342-351 (2008)). Interestingly, it is known that atherosclerotic plaques are associated with local, potentially severe inflammatory activation in the vessel wall, and it is envisaged that this inflammatory environment hampers the fibrinolytic response in specific regions of the vascular system where maintaining a high fibrinolytic capacity is critical, thus increasing the risk of thrombotic events. Similarly, it is also possible that an increased incidence of thrombotic events in patients with systemic inflammatory conditions (e.g., autoimmune diseases and metabolic syndrome) may also be associated with inhibition of t-PA synthesis by circulating pro-inflammatory cytokines, and/or with increased levels of plasminogen activator inhibitor 1 (PAI-1).

In this context, an alternative fourth approach to reducing the incidence of clinical thrombotic events is to restore the capacity of the fibrinolytic "last line of defense" system in patients with such functional impairment. A great deal of work has been done to find a viable solution to enhance background as well as stimulated endogenous fibrinolysis in subjects with risk factor-related reduction in fibrinolytic capacity. However, previous attempts to improve t-PA synthesis using, for example, statins and retinoic acid, have been disappointing. Other means of increasing fibrinolysis by blocking naturally occurring inhibitors of t-PA activity, such as plasminogen activator inhibitor-1 (PAI-1) and carboxypeptidase u (cpu), have also been unsuccessful, primarily due to limited drug availability, e.g., poor pharmacokinetic properties of drug candidates.

the fibrinolytic activity of t-PA is inhibited by plasminogen activator inhibitor 1(PAI-1), which is through complex binding to the t-PA molecule. PAI-1 reduces the ability to dissolve blood clots due to its antifibrinolytic effect, thereby increasing the risk of clinical thrombotic events (Hrafnklsdottir et al, J Thromb Haemost 2004; 2: 1960-8).

PAI-1 circulates in plasma at low concentrations (typically about 5-10ng/mL in morning samples), but plasma PAI-1 concentrations in the population show a significantly skewed distribution to the right. In general, circulating PAI-1 levels increase with age. Elevated PAI-1 levels are prone to thrombotic events. On an individual scale, levels above 100ng/mL are considered to constitute a significant risk factor for cardiovascular events, even in the absence of other traditional risk factors. In addition, elevated PAI-1 levels are often found in patients with obesity-related metabolic disorders such as type 2 diabetes and metabolic syndrome.

The circulating levels of PAI-1 show significant circadian variation with peak levels at about 06:00 and troughs at about 16:00, as illustrated in FIG. 1 (see also, e.g., Scheer and Shea, Blood 2014). As expected, morning PAI-1 improvement coincides with a temporary peak occurrence of thrombotic events such as myocardial infarction.

Patients suffering from obesity and/or metabolic syndrome have higher circulating PAI-1 levels and increased circadian peaks, as illustrated in figure 1. Plasma concentrations in morning samples of these patients typically ranged from 15-60ng/mL, but levels were non-normally distributed with significant positive bias. Plasma PAI-1 levels of between 100-500 mg/mL in morning samples are often observed in obese patients with metabolic syndrome. Thus, patients suffering from obesity and/or metabolic syndrome are at particular risk of suffering from thrombotic events caused by the inhibitory effect of PAI-1 on the action of t-PA.

Therefore, it is of interest to prevent cardiovascular events by lowering PAI-1, more specifically to eliminate early morning increases in plasma concentrations thereof. Such a method would theoretically be more effective in patients suffering from obesity and/or metabolic syndrome.

We have now surprisingly found that valproic acid (VPA) strongly reduces plasma PAI-1 levels, and that this reduction, and a corresponding reduction in PAI-1 activity, allows for an increase in endogenous t-PA activity. Thus, administration of VPA at low doses such that the plasma level of VPA or its metabolites coincides with the peak plasma level of PAI-1, has beneficial effects in the treatment and prevention of pathological conditions associated with excessive fibrin deposition and/or thrombosis.

WO 2012/120262 discusses the use of valproic acid to ameliorate or normalize endogenous fibrinolysis impaired by local or systemic inflammation. However, it does not suggest that VPA may inhibit the effects of PAI-1 and therefore does not suggest administration of VPA to combat (i.e., reduce) peak levels of PAI-1 and therefore does not provide a treatment (i.e., improved treatment) for pathological conditions associated with excessive fibrin deposition and/or thrombosis.

US2007/0232528a1 describes controlled release formulations comprising valproic acid for use in the treatment of disorders such as cancer. These publications do not suggest administration of VPA to combat peak levels of PAI-1 for treatment of pathological conditions associated with excessive fibrin deposition and/or thrombosis, and thus do not suggest formulations designed for this purpose.

Detailed description of the invention

The present invention relates to fibrin degradation or breakdown (also known as fibrinolysis), and more particularly, to compositions and methods for treating pathological conditions associated with excessive fibrin deposition and/or thrombosis (e.g., thrombosis).

In particular, the present invention relates to methods of using valproic acid or a pharmaceutically acceptable salt thereof in the treatment or prevention of pathological conditions associated with excessive fibrin deposition and/or thrombosis.

The invention also provides pharmaceutical compositions formulated to delay the release of valproic acid or a pharmaceutically acceptable salt thereof in a manner suitable for such methods.

Medical treatment

As described herein, valproic acid or a pharmaceutically acceptable salt thereof has been found to inhibit the activity of PAI-1 (e.g., by reducing PAI-1 levels), PAI-1 itself being an inhibitor of t-PA. As a result, valproic acid or a pharmaceutically acceptable salt thereof can enhance the effect of t-PA and is therefore useful in the treatment or prevention of pathological conditions associated with excessive fibrin deposition and/or thrombosis.

In particular, the inventors have unexpectedly found that human subjects treated with VPA have reduced circulating levels of PAI-1. In healthy men, circulating plasma levels of PAI-1 were significantly reduced by more than 50% after VPA treatment, and by about 45% in patients with coronary atherosclerosis, these results being further described in example 1 provided herein.

The finding that VPA treatment decreased PAI-1 plasma levels in men was unexpected, given that in vitro data from cultured endothelial cells (one of the believed producers of plasma PAI-1) did not show a decrease in PAI-1mRNA levels after VPA treatment, but rather a slight but significant 30% increase in PAI-1 production. These studies also did not detect any effect of VPA on plasma PAI-1 in vivo models of pigs (Svennerholm et al, PLoS one.2014May 12; 9(5): e97260.doi:10.1371/journal. bone.0097260. ecollection2014) or mice (unpublished data).

In a first aspect of the present invention, valproic acid or a pharmaceutically acceptable salt thereof is provided for use in the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis, wherein said treatment comprises administering at least one dose of valproic acid or a pharmaceutically acceptable salt thereof to a subject such that the maximum plasma concentration (Cmax) of valproic acid or a salt and/or metabolite thereof in said subject occurs within a time period of 4 hours before to 1 hour after the PAI-1 maximum plasma concentration (Cmax) of said subject.

In an alternative first aspect of the present invention, there is provided the use of valproic acid or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis, wherein said treatment comprises administering at least one dose of valproic acid or a pharmaceutically acceptable salt thereof to a subject such that the maximum plasma concentration (Cmax) of valproic acid or a salt and/or metabolite thereof in said subject occurs within a time period of 4 hours before to 1 hour after the maximum plasma concentration (Cmax) of PAI-1 in said subject.

In a further alternative first aspect of the present invention is a method for treating or preventing a pathological condition associated with excessive fibrin deposition and/or thrombosis in a subject in need thereof, comprising administering to the subject at least one dose of a therapeutically effective amount of valproic acid or a pharmaceutically acceptable salt thereof such that the maximum plasma concentration (Cmax) of valproic acid or a salt and/or metabolite thereof in said subject occurs within a time period of 4 hours before to 1 hour after the maximum plasma concentration (Cmax) of PAI-1 in said subject.

Those skilled in the art will appreciate that embodiments herein that refer to particular aspects of the invention will include all other embodiments that refer to those aspects of the invention. Thus, any further embodiments of any aspect of the invention may be combined with any one or more of the other such embodiments to form more specific embodiments without departing from the disclosure of the invention provided herein.

As used herein, reference to a pathological condition associated with excessive fibrin deposition and/or thrombosis refers in particular to a pathological condition associated with thrombosis.

In a particular embodiment of the first aspect of the invention, the maximum plasma concentration (Cmax) of valproic acid or a salt and/or metabolite thereof in said subject occurs within a time period that is 4 hours before the maximum plasma concentration (Cmax) of PAI-1 in said subject.

In another particular embodiment of the first aspect of the invention, the maximum plasma concentration (Cmax) of valproic acid or a salt and/or metabolite thereof in said subject occurs within a time period of 3 hours (e.g., 2 hours before) to 1 hour after the maximum plasma concentration (Cmax) of PAI-1 in said subject.

In a more particular embodiment of the first aspect of the invention, the maximum plasma concentration (Cmax) of valproic acid or a salt and/or metabolite thereof in said subject occurs within a time period that is 3 hours (e.g., 2 hours) before the maximum plasma concentration (Cmax) of PAI-1 in said subject to that time.

In a second aspect of the present invention, valproic acid or a pharmaceutically acceptable salt thereof is provided for use in treating or preventing a pathological condition associated with excessive fibrin deposition and/or thrombosis, wherein the treatment comprises administering at least one dose of valproic acid or a pharmaceutically acceptable salt thereof to a patient such that the patient has a plasma concentration of valproic acid or a salt and/or metabolite thereof that is at least about 10 to about 100 μ g/ml, e.g., at least about 10 μ g/ml (e.g., at least about 20, about 30, about 40, about 50, about 60, about 70, about 80, about 90, or about 100 μ g/ml) when the patient experiences a PAI-1 maximum plasma concentration (Cmax).

In an alternative second aspect of the invention, there is provided the use of valproic acid or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for treating or preventing a pathological condition associated with excessive fibrin deposition and/or thrombosis, wherein said treatment comprises administering at least one dose of valproic acid or a pharmaceutically acceptable salt thereof to a patient such that the patient has a plasma concentration of valproic acid or a salt and/or metabolite thereof that is at least about 10 to about 100 μ g/ml, e.g., at least about 10, about 20, about 30, about 40, about 50, about 60, about 70, about 80, about 90, or about 100 μ g/ml, when the patient experiences a maximum plasma concentration (Cmax) of PAI-1.

In a further alternative second aspect of the present invention, there is provided a method for treating or preventing a pathological condition associated with excessive fibrin deposition in a subject in need thereof, comprising administering to the subject at least one therapeutically effective dose of valproic acid or a pharmaceutically acceptable salt thereof, such that the subject has a plasma concentration of valproic acid or a salt and/or metabolite thereof that is at least about 10 to about 100 μ g/ml, e.g., at least about 10, about 20, about 30, about 40, about 50, about 60, about 70, about 80, about 90, or about 100 μ g/ml, when the subject experiences a maximum plasma concentration (Cmax) of PAI-1.

For the avoidance of doubt, those skilled in the art will understand that references to the compounds of the invention provided above will apply to the second aspect of the invention (and its alternative aspects and/or its specific embodiments) in the same way as they apply to all other aspects of the invention described herein (and its alternative aspects and/or its specific embodiments).

As used herein, the term therapeutic window will be understood to refer to the plasma level of the relevant compound or salt and/or metabolite thereof at which the relevant (i.e., generally relevant) therapeutic effect of the compound will generally be observed. The term may refer to a range of plasma levels or to a specific plasma level.

As used herein, reference to a quantity per milliliter (/ ml) is to be understood as referring to a quantity per milliliter of plasma (i.e., the plasma of a patient). As used herein, reference to molar concentration will be understood to refer to the concentration in plasma (i.e., the plasma of a patient).

In an alternative second aspect of the invention, the patient has a plasma concentration of valproic acid or a salt and/or metabolite thereof that is less than about 50 to about 170 μ g/ml (e.g., less than about 50, about 70, about 90, about 110, about 130, about 150, or about 170 μ g/ml).

In a further alternative second aspect of the invention, the patient has a plasma concentration of valproic acid or a salt and/or metabolite thereof that is at least about 70 to about 700 μ Μ (e.g., at least about 70, about 140, about 210, about 280, about 350, about 420, about 490, about 560, about 630 or about 700 μ Μ).

In a still further alternative second aspect of the invention, the patient has a plasma concentration of valproic acid or a salt and/or metabolite thereof that is less than about 350 to about 1200 μ M (e.g., less than about 350, about 490, about 630, about 770, about 910, about 1050, or about 1190 μ M).

For the avoidance of doubt, the skilled person will understand that reference to certain maximum amounts and concentrations in plasma in the second aspect of the invention may also require a minimum therapeutically effective amount in said plasma.

In particular, those skilled in the art will appreciate that references to certain maximum (i.e., when a value is designated as "below") and minimum (i.e., when a value is designated as "at least") amounts and/or concentrations in plasma can be combined to form a range (i.e., where the amount in plasma is within the range of the minimum to the maximum).

For example, in one embodiment of the second aspect of the invention, the patient has a plasma concentration of valproic acid or a salt and/or metabolite thereof which is from about 10 to about 170 μ g/ml.

In other such embodiments, the patient has a plasma concentration of valproic acid or a salt and/or metabolite thereof that is: about 10 to about 70 μ g/ml (or about 50 to about 90, about 70 to about 110, about 90 to about 130, about 110 to about 150, about 130 to about 170, or about 150 to about 190 μ g/ml);

about 10 to about 50 μ g/ml (or about 10and to about 100, about 30 to about, about 50 to about 170, or about 70 to about 190 μ g/ml);

about 30 to about 190 μ g/ml (e.g., about 50 to about 170, about 70 to about 150, about 90 to about 130, about 30 to about 110, about 50 to about 130, or about 70 to about 170 μ g/ml).

Those skilled in the art will understand that reference herein to certain minimum plasma levels (e.g. in the second aspect of the invention) will include such levels in plasma when the patient reaches a steady state of valproic acid or a salt and/or metabolite thereof. Furthermore, one skilled in the art will appreciate that reference to a patient reaching steady state may refer to plasma levels reached after the patient has been treated with a compound of the invention (at a therapeutically effective dose thereof) for at least two to five days (e.g., for at least five days).

It will also be understood by those skilled in the art that reference to maximum and minimum plasma levels in the second aspect of the invention (including all embodiments and alternative aspects thereof) may also apply to the plasma levels observed for the Cmax of valproic acid or salts and/or metabolites thereof, as referred to in other aspects of the invention (e.g. the first aspect of the invention).

In a third aspect of the invention, there is provided valproic acid or a pharmaceutically acceptable salt thereof for use in the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis, wherein said treatment comprises administering to a patient a dose of valproic acid or a pharmaceutically acceptable salt thereof over a time period of about 20:00 to about 06: 00.

In an alternative third aspect of the invention, there is provided the use of valproic acid or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis, wherein said treatment comprises administering to a patient a dose of valproic acid or a pharmaceutically acceptable salt thereof over a time period of from about 20:00 to about 06: 00.

In a further alternative third aspect of the invention, there is provided a method of treating or preventing a pathological condition associated with excessive fibrin deposition and/or thrombosis in a patient in need thereof, comprising administering to the patient a therapeutically effective dose of valproic acid or a pharmaceutically acceptable salt thereof over a time period of about 20:00 to about 06: 00.

In a particular embodiment of the third aspect of the invention, the treatment comprises administering to the patient a therapeutically effective dose of valproic acid or a pharmaceutically acceptable salt thereof over a time period of about 21:00 to about 05:00 (e.g., about 22:00 to about 04: 00).

Those skilled in the art will appreciate that times referred to using a 24-hour system may also be referred to using a 12-hour system (i.e., times before and after 12:00 AM are denoted by AM and PM, respectively). For example, 20:00 can also be referred to as 8:00PM and 06:00 as 6:00 AM.

In a particular embodiment of the third aspect of the invention (in particular, wherein the treatment is administered as a pharmaceutical composition that is not formulated for delayed release of the active ingredient), the treatment comprises administering to the patient a therapeutically effective dose of valproic acid or a pharmaceutically acceptable salt thereof over a time period of about 02:00 to about 06:00 (e.g., about 03:00 to about 05:00, e.g., about 04: 00).

In another particular embodiment of the third aspect of the invention (particularly wherein the treatment is administered as a pharmaceutical composition that is not formulated for delayed release of the active ingredient, such as those described in the eighth aspect of the invention herein), the treatment comprises administering to the patient a therapeutically effective dose of valproic acid or a pharmaceutically acceptable salt thereof over a time period of about 20:00 to about 00:00 (e.g., about 21:00 to about 23:00, e.g., about 22: 00).

In an alternative embodiment of the third aspect of the invention, the treatment comprises administering to the patient a therapeutically effective dose of valproic acid or a pharmaceutically acceptable salt thereof over a time period determined according to the release profile of the formulation to provide the plasma concentration of valproic acid or a salt and/or metabolite thereof as claimed in the first and/or second aspect of the invention.

As described herein, one of skill in the art will be able to determine how to administer a compound of the invention in a manner (e.g., over a period of time) to achieve the parameters described herein (e.g., those described in the first and second aspects of the invention).

For the avoidance of doubt, in a particular embodiment of the third aspect of the invention, the dosage referred to is a single dose, which would mean that the dose is the only dose of the compound administered to the patient over a 24 hour period (e.g. relevant).

In a fourth aspect of the invention, there is provided valproic acid or a pharmaceutically acceptable salt thereof for use in the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis, wherein said treatment comprises administering to a patient a pharmaceutical composition comprising a dose of valproic acid or a pharmaceutically acceptable salt thereof for a time and in a form such that substantially all of said valproic acid or pharmaceutically acceptable salt thereof is released from said composition over a period of time from about 02:00 to about 06: 00.

In an alternative fourth aspect of the invention, there is provided the use of valproic acid or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis, wherein said treatment comprises administering to a patient a pharmaceutical composition comprising a dose of valproic acid or a pharmaceutically acceptable salt thereof for a time and in a form such that substantially all of said valproic acid or pharmaceutically acceptable salt thereof is released from said composition over a period of time from about 02:00 to about 06: 00.

In a further alternative fourth aspect of the invention, there is provided a method of treating or preventing a pathological condition associated with excessive fibrin deposition and/or thrombosis in a patient in need thereof, comprising administering to the patient a pharmaceutical composition comprising a therapeutically effective dose of valproic acid or a pharmaceutically acceptable salt thereof for a time and in a form such that substantially all of the valproic acid or pharmaceutically acceptable salt thereof is released from the composition over a period of time from about 02:00 to about 06: 00.

In a particular embodiment of the fourth aspect of the invention, the treatment comprises administering to the patient a pharmaceutical composition comprising a therapeutically effective dose of valproic acid or a pharmaceutically acceptable salt thereof for a time and in a form such that substantially all of the valproic acid or pharmaceutically acceptable salt thereof is released from the composition over a time period of from about 03:00 to about 05:00 (e.g., from about 04:00 to about 05:00, e.g., at about 05: 00).

In a particular embodiment of the fourth aspect of the invention, the treatment comprises administering a pharmaceutical composition as described in the eighth aspect of the invention (including all embodiments thereof) below.

In a fifth aspect of the invention, there is provided valproic acid or a pharmaceutically acceptable salt thereof for use in treating or preventing a pathological condition associated with excessive fibrin deposition and/or thrombosis in a patient, wherein said treatment comprises:

(i) monitoring the plasma concentration of PAI-1 in the subject to determine a time or period of time during which a maximum plasma concentration of PAI-1 occurs;

(ii) administering to the subject at least one dose of valproic acid or a pharmaceutically acceptable salt thereof such that the maximum plasma concentration (Cmax) of valproic acid or a salt and/or metabolite thereof in the subject occurs during a time period of from 4 hours before to 1 hour after the onset of the maximum plasma concentration of PAI-1, or during the time period during which the maximum plasma concentration of PAI-1 occurs.

In an alternative fifth aspect of the invention there is provided the use of valproic acid or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis, wherein the treatment comprises:

(i) monitoring the plasma concentration of PAI-1 in the subject to determine a time or period of time during which a maximum plasma concentration of PAI-1 occurs; and

In a further alternative fifth aspect of the invention, there is provided a method of treating or preventing a pathological condition associated with excessive fibrin deposition and/or thrombosis in a patient in need thereof, comprising the steps of:

(ii) administering to the subject at least one therapeutically effective dose of valproic acid or a pharmaceutically acceptable salt thereof such that the maximum plasma concentration (Cmax) of valproic acid or a salt and/or metabolite thereof in the subject occurs during a time period of from 4 hours before to 1 hour after the onset of the maximum plasma concentration of PAI-1, or during the time period during which the maximum plasma concentration of PAI-1 occurs.

As described herein, plasma concentrations of PAI-1 can be monitored using techniques well known to those skilled in the art. For example, PAI-1 levels are typically measured in plasma. It may be regularly within 24 hours, e.g. every hour, every 2 hours or every 3 hours from the elbowThe former syringe collects blood. Blood samples were directly centrifuged to separate plasma from serum. Thereafter PAI-1 levels in plasma are determined by using commercially available ELISA kits, e.g.PAI-1(Chromogenix)、PAI-1(Trinity Biotech)、Plasmid PAI-1(American Diagnostica), Zymutest PAI-1(Hyphen Biomed), Milliplex PAI-1(Merck Millipore), Novex PAI-1Human Elisa Kit (Life technology), PAI1(SERPINE1) Human ELISA Kit (Abcam, ab 108891).

In a particular embodiment of the fifth aspect of the invention, the maximum plasma concentration (Cmax) of valproic acid or a salt and/or metabolite thereof in said subject occurs within a time period ranging from 4 hours (e.g. 3 hours before, e.g. 2 hours before, or 1 hour before or 0.5 hour before) to the maximum plasma concentration (Cmax) of PAI-1 in said subject.

In another particular embodiment of the fifth aspect of the invention, the maximum plasma concentration (Cmax) of valproic acid or a salt and/or metabolite thereof in said subject occurs within a time period of 3 hours (e.g., 2 hours before) to 1 hour after the maximum plasma concentration (Cmax) of PAI-1 in said subject.

In a more particular embodiment of the fifth aspect of the invention, the maximum plasma concentration (Cmax) of valproic acid or a salt and/or metabolite thereof in said subject occurs within a time period that is 3 hours (e.g., 2 hours) before the maximum plasma concentration (Cmax) of PAI-1 in said subject to that time.

One skilled in the art will appreciate that the time and level of Cmax of VPA will depend on the dose administered (and, to an extent, the form in which the dose is administered). One skilled in the art will be able to measure the plasma concentration of VPA or metabolites and/or salts thereof and determine the time and level of Cmax (and, if necessary, adjust the dose and form of VPA accordingly). Specific doses of VPA that can be administered (i.e., therapeutic doses) as well as Cmax levels that can be obtained include those described herein.

In a sixth aspect of the invention, there is provided valproic acid or a pharmaceutically acceptable salt thereof for use in the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis in a patient, wherein said treatment comprises:

(ii) administering at least one dose of valproic acid or a pharmaceutically acceptable salt thereof to the patient such that the patient has a plasma concentration of valproic acid or a salt and/or metabolite thereof that is at least about 10 to about 100 μ g/ml (e.g., at least about 10, about 20, about 30, about 40, about 50, about 60, about 70, about 80, about 90, or about 100 μ g/ml) when the patient experiences a maximum plasma concentration of PAI-1.

In an alternative sixth aspect of the invention there is provided the use of valproic acid or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis, wherein the treatment comprises:

In a further alternative sixth aspect of the invention there is provided a method of treating or preventing a pathological condition associated with excessive fibrin deposition and/or thrombosis in a patient in need thereof, comprising the steps of:

(ii) administering at least one therapeutically effective dose of valproic acid or a pharmaceutically acceptable salt thereof to the patient such that the patient has a plasma concentration of valproic acid or a salt and/or metabolite thereof that is at least about 10 to about 100 μ g/ml (e.g., at least about 10, about 20, about 30, about 40, about 50, about 60, about 70, about 80, about 90, or about 100 μ g/ml) when the patient experiences a maximum plasma concentration of PAI-1.

In an alternative sixth aspect of the invention, the patient has a plasma concentration of valproic acid or a salt and/or metabolite thereof that is less than about 50 to about 170 μ g/ml (e.g., less than about 50, about 70, about 90, about 110, about 130, about 150, or about 170 μ g/ml).

In a further alternative sixth aspect of the invention, the patient has a plasma concentration of valproic acid or a salt and/or metabolite thereof that is at least about 70 to about 700 μ Μ (e.g., at least about 70, about 140, about 210, about 280, about 350, about 420, about 490, about 560, about 630 or about 700 μ Μ).

In a still further alternative sixth aspect of the invention, the patient has a plasma concentration of valproic acid or a salt and/or metabolite thereof that is less than about 350 to about 1200 μ M (e.g., less than about 350, about 490, about 630, about 770, about 910, about 1050, or about 1190 μ M).

For the avoidance of doubt, those skilled in the art will understand that reference herein to the levels and concentrations (e.g., plasma levels and plasma concentrations) of "valproic acid or a salt and/or metabolite thereof" will refer in particular to the levels and concentrations (e.g., plasma levels and plasma concentrations) of valproic acid.

Further, the skilled person will understand that reference to certain maximum amounts and concentrations in plasma in the sixth aspect of the invention may also require a minimum therapeutically effective amount in said plasma. Furthermore, those skilled in the art will appreciate that references to certain maximum (i.e., when a value is labeled as "below") and minimum (i.e., when a value is labeled as "at least") amounts and/or concentrations in plasma can be combined to form a range (i.e., where the amount in plasma is within the range of the minimum to the maximum).

For example, in one embodiment of the sixth aspect of the invention, the patient has a plasma concentration of valproic acid or a salt and/or metabolite thereof which is from about 10 to about 170 μ g/ml. In other such embodiments, the patient has a plasma concentration of valproic acid or a salt and/or metabolite thereof that is:

about 10 to about 70 μ g/ml (or about 50 to about 90, about 70 to about 110, about 90 to about 130, about 110 to about 150, about 130 to about 170, or about 150 to about 190 μ g/ml);

about 10 to about 50 μ g/ml (e.g., about 10 to about 100, about 30 to about, about 50 to about 170, or about 70 to about 190 μ g/ml);

In a seventh aspect of the invention, there is provided valproic acid or a pharmaceutically acceptable salt thereof for use in the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis, wherein the treatment comprises administering to the patient a single dose of valproic acid or a pharmaceutically acceptable salt thereof over a 24 hour period, wherein the dose is from about 50mg to about 1000mg (e.g., from about 200mg to about 600 mg).

In an alternative seventh aspect of the invention, there is provided the use of valproic acid or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis, wherein the treatment comprises administering a single dose of valproic acid or a pharmaceutically acceptable salt thereof to a patient over a 24 hour period, wherein the dose is from about 50mg to about 1000mg (e.g., from about 200mg to about 600 mg).

In a further alternative seventh aspect of the invention, there is provided a method of treating or preventing a pathological condition associated with excessive fibrin deposition and/or thrombosis in a patient in need thereof, comprising administering to the patient a single therapeutically effective dose of valproic acid or a pharmaceutically acceptable salt thereof over a 24 hour period, wherein the dose is from about 50mg to about 1000mg (e.g., from about 200mg to about 600 mg).

Unless otherwise indicated or clear from context (e.g., when discussed with respect to a particular formulation), reference to a dose of a compound of the invention (e.g., a dose of valproic acid or a pharmaceutically acceptable salt thereof) is to be understood as referring to a dose of valproic acid (i.e., a dose of valproic acid itself), or an effective (i.e., equivalent) dose of valproic acid when administered in a form comprising or consisting of one or more salts thereof.

In a particular embodiment of the seventh aspect of the invention, the dose is from about 200mg to about 400mg, for example about 400 or about 300 mg. In another particular embodiment of the seventh aspect of the invention, the dose is from about 300mg to about 500mg, for example about 350 mg. In another particular embodiment of the seventh aspect of the invention, the dose is from about 400mg to about 600mg, for example, about 450 or about 550 mg. In another particular embodiment of the seventh aspect of the invention, the dose is from about 400mg to about 800mg, for example, about 575, about 650 or about 700 mg.

Further, for the avoidance of doubt, all references herein to a particular aspect of the invention (e.g. the first aspect of the invention) are to include references to all alternative aspects of the invention (e.g. the alternative and further alternative first aspects of the invention).

Furthermore, those skilled in the art will appreciate that all of the embodiments, preferences, specific definitions, etc. mentioned herein may be combined with any one or more other embodiments, preferences, specific definitions, etc. also mentioned herein.

The terms "about," "left-right," and "approximately" when used herein in reference to a numerical value or quantity (including an amount of time) are to be understood to mean a value within 10% of the defined value. As used herein in reference to a particular point in time (including the beginning or end of a time period), the terms "about" and "left or right" will be understood to refer to values within 30 minutes (e.g., within 20 minutes, e.g., within 10 minutes) of the particular time. Further, it is contemplated that each reference to the terms "about," "left-right," and "approximately" (e.g., with respect to time and quantity) can be deleted entirely.

As used herein, the term "compound of the invention" will refer to valproic acid and pharmaceutically acceptable salts thereof. Those skilled in the art will appreciate that reference to valproic acid and pharmaceutically acceptable salts thereof (e.g., reference to "valproic acid or pharmaceutically acceptable salts thereof") may include reference to mixtures of different pharmaceutically acceptable salts, as well as reference to mixtures of valproic acid (i.e., non-salt forms) and pharmaceutically acceptable salts thereof (including mixtures of such salts), all of which may be referred to as compounds of the invention.

As used herein, those skilled in the art will appreciate that reference to a "preventing" particular condition may also refer to "preventing" of the condition, and vice versa. Thus, each reference herein to a "preventing" condition may be replaced with a reference to a "preventing" condition.

Those skilled in the art will understand that the terms "treatment" and "treating" are used herein in their normal meaning in the medical arts. In particular, these terms may refer to achieving a reduction in the severity of one or more clinical symptoms associated with the condition of interest.

Those skilled in the art will also understand that the terms "prevention" and "preventing" as used herein take their normal meanings in the medical field. In particular, these terms may refer to achieving a reduction in the likelihood of the relevant condition(s) occurring (e.g., a reduction of at least 10%, e.g., a reduction of at least 20%, more particularly, a reduction of at least 30%) as compared to a baseline level.

One skilled in the art will also appreciate that reference to preventing (prophyaxsis) (or preventing (prevention)) a particular condition may also include treating other conditions. For example, treating a primary condition may also be considered a form of prevention of a secondary condition.

In particular embodiments of the first to seventh aspects (including all alternative aspects) of the invention, there is provided a compound (and/or uses and/or methods thereof) for use in the prevention of a pathological condition (in particular, thrombosis) associated with excessive fibrin deposition and/or thrombosis.

As used herein, the term "pathological condition" will be understood to refer to an identifiable disease or disorder.

As described herein, pathological conditions that can be treated or prevented according to the present invention are associated with excessive fibrin deposition and/or thrombosis. These include, but are not limited to, atherosclerosis, myocardial infarction, ischemic stroke, deep vein thrombosis, superficial vein thrombosis, thrombophlebitis, pulmonary embolism, disseminated intravascular coagulation, renal vascular disease, and intermittent claudication (e.g., atherosclerosis, myocardial infarction, ischemic stroke, deep vein thrombosis, pulmonary embolism, disseminated intravascular coagulation, renal vascular disease, and intermittent claudication).

Thus, in a particular embodiment of the first to seventh aspects of the invention, said pathological condition associated with excessive fibrin deposition and/or thrombosis is selected from the group consisting of atherosclerosis, myocardial infarction, ischemic stroke, deep vein thrombosis, pulmonary embolism, disseminated intravascular coagulation, renal vascular disease and intermittent claudication.

Thus, in a more particular embodiment of the first to seventh aspects of the invention, said pathological condition associated with excessive fibrin deposition and/or thrombosis is selected from the group consisting of myocardial infarction, ischemic stroke and pulmonary embolism.

Thus, in other more particular embodiments of the first to seventh aspects of the invention, the pathological condition associated with excessive fibrin deposition and/or thrombosis is selected from the group consisting of myocardial infarction and ischemic stroke (e.g. myocardial infarction).

Those skilled in the art will appreciate that reference to ischemic stroke includes reference to major stroke events (i.e., those caused by prolonged impairment of blood flow), mini-strokes, and Transient Ischemic Attacks (TIAs).

Thus, in more particular embodiments of the first to seventh aspects of the invention, the pathological condition associated with excessive fibrin deposition and/or thrombosis is ischemic stroke, e.g., major ischemic stroke, minor ischemic stroke or TIA.

In still more particular embodiments of the first to seventh aspects of the invention, the pathological condition associated with excessive fibrin deposition and/or thrombosis is ischemic stroke, e.g., major ischemic stroke and minor ischemic stroke.

In particular, it is believed that the compounds of the invention are particularly useful in preventing pathological conditions associated with excessive fibrin deposition and/or thrombosis (e.g. ischemic stroke and/or myocardial infarction) when administered according to the modes of administration defined above (e.g. in the first to seventh aspects of the invention). Thus, all references herein to the treatment and prevention of such conditions are intended to specifically include references to the prevention of such conditions.

Thus, in still more particular embodiments of the first to seventh aspects of the invention, treating or preventing a pathological condition associated with excessive fibrin deposition and/or thrombosis would refer to preventing ischemic stroke, such as major ischemic stroke, minor ischemic stroke or TIA.

As discussed above, thrombotic cardiovascular events occur as a result of two distinct processes, namely, on the one hand, slow-developing long-term vascular atherosclerosis of the vessel wall and, on the other hand, sudden acute clot formation that rapidly causes blood flow stasis. The specific pathological conditions that can be treated are those associated with the latter process.

In particular embodiments of the first to seventh aspects of the invention, the pathological conditions which can be treated or prevented according to the invention are those which are due to local or systemic inflammation caused entirely or at least in part by increased fibrin deposition and/or decreased fibrinolytic capacity. These include, but are not limited to, myocardial infarction, stable angina, unstable angina, intermittent claudication, ischemic stroke, transient ischemic attack, deep vein thrombosis, and pulmonary embolism. These conditions may exhibit increased plasma PAI-1 levels.

In a particular embodiment of the first to seventh aspects of the invention, the pathological condition may be selected from the group consisting of deep vein thrombosis and pulmonary embolism.

In a particular embodiment of the first to seventh aspects of the invention, the pathological condition is deep vein thrombosis.

In a particular embodiment of the first to seventh aspects of the invention, the pathological condition may be selected from the group consisting of superficial venous thrombosis and thrombophlebitis.

In a more particular embodiment of the first to seventh aspects of the invention, the pathological condition is superficial venous thrombosis.

In a more particular embodiment of the first to seventh aspects of the invention, the pathological condition is thrombophlebitis.

Furthermore, the pathological conditions which can be treated according to the invention are those which are due to local or systemic inflammation, caused entirely or at least in part by increased fibrin deposition and/or decreased fibrinolytic capacity. These include, but are not limited to, atherosclerosis, metabolic syndrome, diabetes, disseminated intravascular coagulation, rheumatoid arthritis, glomerulonephritis, systemic lupus erythematosus, vasculitis, autoimmune neuropathy and granulomatous disease, and inflammation associated with other conditions (e.g., metabolic syndrome, diabetes, disseminated intravascular coagulation, rheumatoid arthritis, glomerulonephritis, systemic lupus erythematosus, vasculitis, autoimmune neuropathy and granulomatous disease, and inflammation associated with other conditions).

In addition to traditional diagnosis of systemic or local inflammation by a physician as known in the art, local or systemic inflammation may be determined in a patient using one or more biomarkers associated with inflammation. These biomarkers include, but are not limited to, C-reactive protein, TNF-alpha, high sensitivity C-reactive protein (hs-CRP), fibrinogen, IL-1beta, and IL-6. Specific methods of determining whether a patient has systemic or local inflammation include those described below.

In addition, atherosclerotic plaques are known to be associated with a very localized inflammatory process. Thus, local inflammation may also be determined indirectly by the presence of atherosclerotic plaques as diagnosed by vascular ultrasound or other imaging techniques.

One skilled in the art will appreciate that there are several different options available for identifying an undesirable level of fibrinolysis (i.e., reduced fibrinolytic capacity) in a patient. For example, high circulating levels of PAI-1 are generally considered to be indicative of poor fibrinolysis as measured in plasma by commercially available methods (including but not limited toPAI-1(Chromgenix)、PAI-1(Trinity Biotech)、PlasmaPAI-1(American Diagnostica), Zymutest PAI-1(Hyphen Biomed), Milliplex PAI-1(Merck Millipore), Novex PAI-1Human Elisa Kit (Life technology), PAI1(SERPINE1) Human ELISA Kit (Abcam, ab 108891)). Further, low systemic levels of free active T-PA are also indicative of general poor fibrinolysis and can also be measured by commercial methods (Trinilize (T-PA antigen and activity), which exists as a low producer (T) genotype for the T-PA-7351C/T polymorphism^TM(Synapse，BV，Maastricht，the Netherlands)，IL/(Term International GmbH，Munich，Germany)，(Haemoscope，Niles)，CloFAL assay(Peikang BiotechnologyCo.Ltd.Shanghai，China))。

One skilled in the art will appreciate whether the increased fibrin deposition and/or decreased fibrinolytic capacity is due to "local or systemic inflammation" as used herein, and may be determined using one or more biomarkers associated with inflammation, including but not limited to C-reactive protein, TNF-alpha, hypersensitive C-reactive protein (hs-CRP), fibrinogen, IL-1beta, and IL-6 (e.g., increased concentrations of one or more of these biomarkers relative to control levels, as is known in the art). Commercial assay platforms that can be used to quantify these biomarkers include, but are not limited toAfinion^TM(Medinor AB、Sweden)、CA-7000(Siemens Healthcare Diagnostics Inc、NY、US)、2000Immunoassay System(Siemens Healthcare Diagnostics Inc)。

Specific biomarkers that can identify local or systemic inflammation include hypersensitive C-reactive protein (hs-CRP) (at or above 2.0mg/l serum) and fibrinogen (at or above 3g/l serum) (Corrado E., ethylene. an update on the roll of markers of inflammation in atheroclasis, Journal of atheroclasis and Thrombosis, 2010; 17:1-11, Koenig W., fibrin (ogen) in cardiovascular disease: update, Thrombosis Haemostasis 2003; 89: 601-9).

Unless otherwise specified, the term "patient" as used herein includes mammalian patients (e.g., horses, cattle, pigs, sheep, goats, primates, mice, rats, and pets, including generally dogs, cats, guinea pigs, ferrets, and rabbits). In particular, the term "patient" refers to a human.

As used herein, the skilled artisan will understand that reference to plasma will refer to the plasma of a patient.

As used herein, one of skill in the art will understand that reference to the maximum plasma concentration (or "Cmax") of a particular substance will refer to the maximum concentration of that agent in the plasma (i.e., the plasma of the patient). In the case of administration of the agent, Cmax would mean occurring as a direct result of such administration (i.e., Cmax occurring as a result of absorption of the agent).

As used herein, the time at which a Cmax occurs for a particular substance may also be referred to as Tmax.

One skilled in the art will appreciate that Cmax may occur at a particular time (i.e., a particular peak in plasma concentration), or for an extended period of time (i.e., where the plasma concentration reaches a plateau), both of which may be referred to as the time at which Cmax occurs (Tmax). The time at which Cmax occurs may also take the midpoint of the period when it occurs for an extended period of time, although it is generally understood that Cmax will occur at a particular time as a clearly discernible peak.

As described herein, plasma concentrations of PAI-1 in a patient, particularly a human, are known to follow circadian rhythms. Generally, the maximum plasma concentration (Cmax) of PAI-1 is expected to occur at about 06: 00.

Thus, reference herein to the time at which Cmax of PAI-1 occurs may instead be a reference to about 06:00 points.

All absolute times (i.e., a particular point in time and a defined period between particular points in time) expressed herein refer to the actual local time (i.e., "clock" time) experienced by the patient. Furthermore, the time assumes that the patient has adjusted to the local time (e.g., there has been sufficient time to adjust to a change in time zone, or so-called "daylight savings" time adjustment).

It will be appreciated by those skilled in the art that the time of maximum plasma concentrations of PAI-1 and a compound of the invention (or a salt and/or metabolite thereof) can be determined using techniques well known to those skilled in the art, for example, by monitoring the plasma concentrations of PAI-1 and a compound of the invention (or a salt and/or metabolite thereof) over a relevant period of time.

As described herein, the plasma levels of the compounds of the invention (or salts and/or metabolites thereof) can be monitored using techniques well known to those skilled in the art. For example, the plasma level of valproate is routinely determined clinically by homogeneous enzyme immunoassay techniques based on antibody competition between valproate in the sample and enzyme-labeled valproate added to the test (e.g., VALP2, Roche/Cobas, art nr 05108438190(Roche diagnostics Scandinavia AB). The enzyme glucose-6-phosphate dehydrogenase (G6PDH) is blocked and the test enzyme substrate is not consumed when the enzyme-labeled valproate binds to the antibody. There is a small change in light absorption at 340 nm. Consumption of the substrate produced a photochromically measurable color change at 340 and 415 nm. The light absorption is proportional to the valproate concentration in the sample.

The person skilled in the art will be able to identify compounds present in plasma as metabolites of the compounds of the invention. Specific metabolites of the compounds of the invention that may be mentioned include valproate anions (e.g., metabolites comprising a valproate anion moiety).

One skilled in the art will appreciate that reference to monitoring plasma concentrations of PAI-1 (i.e., plasma concentrations in a subject) can refer to monitoring over at least one (e.g., one) 24 hour period (e.g., prior to beginning treatment with a compound of the present invention). Such monitoring may be continuous or may involve measurements being taken at given time intervals during this period (which means that, in particular in the latter case, the time between the first and last measurement is less than 24 hours, for example about 20 hours).

Those skilled in the art will also appreciate that such monitoring may alternatively be performed for a period of time that is expected to include the Cmax of PAI-1 as estimated by those skilled in the art. For example, such monitoring can be from 04:00 to 08:00 (e.g., 05:00 to 07:00) when a Cmax of PAI-1 is expected to occur at around 06: 00.

The timing and size of the administration of the compounds of the invention will also result in low plasma concentrations of valproic acid or salts and/or metabolites thereof at a particular time.

Thus, in a particular embodiment of the first to seventh aspects of the invention, the compound of the invention is administered such that the plasma concentration of valproic acid or a salt and/or metabolite thereof is less than about 350 μ M (e.g., less than about 300 μ M, e.g., less than about 250 μ M, or more particularly, less than 200 μ M, e.g., less than about 150 μ M or less than about 100 μ M) over a period of about 14:00 to about 18:00 (e.g., about 15:00 to about 17:00, e.g., about 16: 00).

In a more particular embodiment of the first to seventh aspects of the invention, the compound of the invention is administered such that the plasma concentration of valproic acid or a salt and/or metabolite thereof is less than about 300 μ M (e.g., less than about 200 μ M (e.g., less than about 150 μ M, or less than about 100 μ M) over a period of about 15:00 to about 17:00 (e.g., about 15:30 or about 16: 30).

Further, one skilled in the art will be able to adjust the timing and dosage of administration of the compounds of the invention to meet the timing requirements for Cmax and/or the appearance of maximum or minimum concentrations in plasma at a given time.

As used herein, the terms "therapeutically effective amount" and "therapeutically effective dose" refer to the amount of active agent (i.e., a compound of the present invention) that confers the desired pharmacological or therapeutic effect on a patient, preferably without undue adverse side effects. It is to be understood that the therapeutically effective amount may be patient-to-patient.

In particular, a therapeutically effective dose of a compound according to the invention is an amount sufficient to treat or prevent the associated pathological condition and its complications, in particular it is chosen to minimize side effects (i.e. adverse events brought about by the action of a therapeutic agent). In light of the disclosure herein, those skilled in the art will be able to adjust the dosage of the compounds of the invention administered to achieve the desired biological effect, using techniques known to those skilled in the art.

One skilled in the art will appreciate that dosages of the compounds of the present invention can be titrated to determine dosages that will achieve a reduction in plasma levels of PAI-1 of at least about 20% (e.g., at least about 30%).

In certain embodiments of the present invention (e.g., certain embodiments of the first through seventh aspects of the present invention), the dose of the compound of the present invention is sufficient to achieve a reduction in PAI-1 plasma levels of at least about 20% (e.g., at least about 30%), i.e., the dose is titrated to achieve the required reduction in PAI-1 plasma levels.

In more particular embodiments of the invention (e.g., particular embodiments of the first through seventh aspects of the invention), the dose is sufficient to achieve a reduction in plasma levels of PAI-1 of at least about 40% (e.g., at least about 50%, e.g., at least about 60%).

Similar dose titrations are known in the art, and the starting dose, the amount of increase, and the time between measurements of PAI-1 (typically from morning samples), the desired decrease in PAI-1, and the amount of dose increase possible can all be selected by one skilled in the art.

In certain embodiments, the starting dose for such a dose titration can be, for example, in the range of 50, 100, 150, 200, 250, or 300mg, and the dose increase can be 20-100mg every 7-28 days after the new PAI-1 measurement. For example, in one such measurement, the initial dose for a dose titration is 50mg, and the dose is increased in increments of 50mg every 7 days until a 20% reduction in circulating PAI-1 levels is achieved. In another such measurement, the initial dose for a dose titration is 100mg, and the dose is increased in increments of 100mg every 14 days until a 20% reduction in circulating PAI-1 levels is achieved.

Without wishing to be bound by theory, it is believed that the surprising effect produced using the compounds of the present invention as described herein can be obtained by administering a dose at a level that is not expected to cause a significant level of adverse events.

Thus, in particular embodiments of the first to seventh aspects of the invention, treatment may entail administering a dose of valproic acid or a pharmaceutically acceptable salt thereof (e.g., one such dose over a 24 hour period) selected to minimize the level of adverse events resulting from such treatment (e.g., a level low enough to avoid such adverse events).

Such amounts may vary depending on the frequency and manner of administration, the sex, age, weight and general condition of the subject to be treated, the nature and severity of the condition to be treated, and/or other treatments used by the individual, and may be determined by routine techniques in the art. The amount effective for a particular therapeutic purpose will depend on the severity of the condition as well as the weight and general condition of the subject. It will be appreciated that determination of the appropriate dose may be achieved by constructing a matrix of values and testing different points in the matrix, using routine experimentation, all of which is within the ordinary skill of the person skilled in the art.

Although specific dosages provided herein are discussed, it will be understood by those skilled in the art that the amount of VPA or a pharmaceutically acceptable salt thereof and the manner of administration required to treat or prevent a pathological condition associated with excessive fibrin deposition and/or thrombosis as described herein can be determined using routine skill of the prescribing physician.

In particular embodiments of the first to seventh aspects of the invention, the compounds of the invention may be administered:

(i) as a single dose per 24 hour period (i.e., a single daily dose); and/or

(ii) As about 50mg to about 1000mg (particularly about 200mg to about 600mg, e.g., about 300mg to about 600mg)

500mg) per 24 hour period (i.e., total daily dose).

More particularly, a single daily dose as described above (e.g., point (i) above) can be administered at a time of about 20:00 to about 06: 00.

In more particular embodiments, a single daily dose (e.g., as described above at point (i)) can be administered at a time of about 21:00 to about 05:00 (e.g., about 22:00 to about 04: 00).

In still more particular embodiments (particularly where the treatment is administered as a pharmaceutical composition that is not formulated for delayed release of the active ingredient), the single daily dose (e.g., as described in point (i) above) may be administered at a time of from about 02:00 to about 06:00 (e.g., from about 03:00 to about 05:00, e.g., about 04: 00).

In further particular embodiments (particularly where the treatment is administered as a pharmaceutical composition formulated for delayed release of an active ingredient, such as those described in the eighth aspect of the invention herein), the single daily dose (e.g., as described in point (i) above) may be administered at a time of from about 20:00 to about 00:00 (e.g., from about 21:00 to about 23:00, e.g., about 22: 00).

In alternative embodiments (particularly where the treatment is administered as a pharmaceutical composition formulated for delayed release of an active ingredient, such as those described in the eighth aspect of the invention herein), the single daily dose (e.g. as described in point (i) above) may be administered before sleep (i.e. immediately before the patient begins to attempt sleep, alternatively it may be described as "before going to bed", "before sleeping", etc.).

In certain embodiments of the invention (e.g., certain embodiments of the first to seventh aspects of the invention), the compounds of the invention may be administered in a manner such that the plasma concentration of valproic acid or a salt and/or metabolite thereof over a certain period of time (e.g., a 24 hour period) mimics the plasma concentration of PAI-1 over the same period of time.

As used herein, reference to "simulating" the plasma level of another will be understood to mean that the relative plasma levels of the two agents substantially follow a similar pattern of variation (e.g., the curves obtained by plotting the plasma concentrations of the two agents may be substantially overlapping, although the absolute levels/concentrations of the two agents may be different). The term "analog" has its ordinary meaning in the art, i.e., similar, simulated, proximate, following, or mimicking, but not necessarily exactly or exactly duplicated.

Those skilled in the art will appreciate that lower morning doses may be administered in addition to the nighttime doses, which will be absorbed as the PAI-1 level begins to increase in the evening. For example, in one such treatment, 10-500mg (e.g., 50-300mg, more particularly 100 or 200mg) is administered about 10-14 hours (e.g., 12 hours) after the nighttime dose.

Thus, in a particular embodiment of the invention, a lower morning dose is administered in addition to the night dose, which will consist of about 10 to about 500mg (e.g., about 50 to about 300mg, more particularly about 100 or about 200mg), which is administered over a period of about 10 to about 14 hours after the night dose. In particular embodiments, such morning doses are about 20% to about 50% (e.g., about 20%, about 30%, or about 40%) of the nighttime dose.

In a more specific embodiment, a once daily formulation is provided that provides the same effect as the morning and evening doses described in the immediately preceding embodiments, which may be provided in the form of, for example, a bilayer formulation, with a core that gives a second small peak consistent with an increase in PAI-1, or a formulated particle having a different coating and/or formulated for such a release profile.

As described herein, valproic acid (VPA) has been found to strongly reduce plasma PAI-1 levels, and in response to this reduction, allows for an increase in endogenous t-PA activity. In particular, administration of VPA such that its plasma level coincides with the peak plasma level of PAI-1 allows the treatment or prevention of pathological conditions associated with excessive fibrin deposition and/or thrombosis.

Thus, reference herein to use in the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis (e.g., in the first through seventh aspects of the invention) may also refer to the treatment or prevention of a pathological condition that is expected to benefit from decreased PAI-1 activity (i.e., that can be treated or prevented thereby).

For the avoidance of doubt, the particular conditions known to be associated with excessive fibrin deposition and/or thrombosis, as known to those skilled in the art, may also be understood as being expected to benefit from (i.e., may be treated or prevented by) reduced PAI-1 activity, which may be understood as being the result of reduced PAI-1 levels in the plasma.

In particular, in a further aspect of the present invention, there is provided a method of reducing PAI-1 levels (i.e., PAI-1 levels in plasma) in a subject in need thereof comprising the step of administering a therapeutically effective amount of valproic acid or a pharmaceutically acceptable salt thereof.

Similarly, reference herein to a particular method of treating or preventing a condition associated with excessive fibrin deposition and/or thrombosis can also be understood as a method of reducing PAI-1 levels in a subject in need thereof.

For example, in a still further alternative first aspect of the present invention there is provided a method for reducing PAI-1 levels in a subject in need thereof, comprising administering to the subject at least one dose of valproic acid or a pharmaceutically acceptable salt thereof in a therapeutically effective amount such that the maximum plasma concentration (Cmax) of valproic acid or a salt and/or metabolite thereof in said subject occurs within a time period of 4 hours before to 1 hour after the maximum plasma concentration (Cmax) of PAI-1 in said subject.

As used herein, reference to reduced PAI-1 levels (and similarly, reduced (or inhibited) PAI-1 activity, e.g., reference to inhibition PAI-1) can refer to levels of PAI-1 in the plasma that are at (e.g., reduced to or maintained at) levels below (e.g., at least 10% lower, e.g., at least 20% lower, e.g., at least 30%, at least 40%, at least 50% or at least 60% lower) the levels of PAI-1 that occur prior to treatment with a compound of the invention during treatment with a compound of the invention.

Compounds of the invention

Further, the term "compound of the invention" as indicated herein refers to valproic acid and pharmaceutically acceptable salts thereof, including mixtures thereof. In particular, those skilled in the art will appreciate that valproic acid may also be referred to as 2-valproic acid and VPA.

When relevant, the compounds presented herein include all diastereomeric, corresponding isomeric and epimeric forms. For compounds described herein that exist as tautomers, all tautomers are encompassed within the chemical formulas described herein. Further, the compounds described herein can form and/or be used as salts (e.g., pharmaceutically acceptable salts). Those skilled in the art will appreciate that reference herein to a salt of a compound will include reference to a pharmaceutically acceptable salt.

The compounds described herein can be prepared using techniques and procedures known to those skilled in the art. Exemplary synthetic methods useful for synthesizing the compounds of the present application include, for example, Nogrady (1985) medicinal chemistry A Biochemical Approach, Oxford University Press, New York, pages 388-; silverman (1992); fieser and Fieser's Reagents for Organic Synthesis, Volumes1-17(John Wiley and Sons, 1991); rodd's Chemistry of Carbon Compounds, Volumes 1-5and supplements (Elsevier Science Publishers, 1989); organic reactions, Volumes 1-40(John Wiley and Sons, 1991), March's Advanced organic chemistry (John Wiley and Sons, 4th Edition) and Larock's Comprehensive organic transformations (VCH Publishers Inc., 1989).

VPA may be commercially available, for example, a pharmaceutically acceptable salt of VPA (e.g., its sodium salt) from Sigma-Aldrich (product number P4543, 10/1/2014) may also be commercially available. It will also be appreciated that VPA or a pharmaceutically acceptable salt thereof may be synthesized using techniques well known to those skilled in the art.

As described herein, VPA may be formulated and/or administered in the form of a pharmaceutically acceptable salt thereof.

Those skilled in the art will appreciate that pharmaceutically acceptable salts (e.g., of VPA) may include, but are not limited to:

(a) when the acidic proton is replaced by a metal ion, such as an alkali metal ion (e.g., lithium, sodium, potassium), an alkaline earth metal ion (e.g., magnesium or calcium), or an aluminum ion, or by an ammonium cation (NH)₄ ⁺) Salts formed upon substitution;

(b) salts formed by reacting VPA with pharmaceutically acceptable organic bases including alkylamines, e.g., ethanolamine, diethanolamine, triethanolamine, tromethamine, N-methylglucamine, dicyclohexylamine, tris (hydroxymethyl) methylamine, and salts with amino acids such as arginine, lysine, and the like;

(c) salts formed by reacting VPA with a pharmaceutically acceptable acid, which provides an acid addition salt. Pharmaceutically acceptable acids include hydrochloric, hydrobromic, sulfuric, nitric, phosphoric, metaphosphoric and the like, or organic acids, e.g., acetic, propionic, hexanoic, cyclopentanepropionic, glycolic, pyruvic, lactic, caronic, succinic, malic, maleic, fumaric, trifluoroacetic, tartaric, citric, benzoic, 3- (4-hydroxybenzoyl) benzoic, phenylacrylic, mandelic, methanesulfonic, ethanesulfonic, 1, 2-ethanedioic, 2-hydroxyethanesulfonic, benzenesulfonic, toluenesulfonic, 2-naphthalenesulfonic, 4-methylbicyclo- [2.2.2] oct-2-ene-1-carboxylic, glucoheptonic, 4 '-methylenebis- (3-hydroxy-2-ene-1-carboxylic), benzoic, 4' -methylenebis- (3-hydroxy-2-ene-1-carboxylic, or the like, 3-phenylpropionic acid, trimethylacetic acid, t-butylacetic acid, lauroylsulfuric acid, gluconic acid, glutamic acid, hydroxynaphthoic acid, salicylic acid, stearic acid, muconic acid, and the like.

Specific pharmaceutically acceptable salts of VPA that may be mentioned include those mentioned in item (a) above. More specific pharmaceutically acceptable salts of VPA that may be mentioned include those in which the carboxylic acid proton is replaced by an alkaline earth metal ion (e.g. magnesium or calcium), or more particularly, by an alkali metal ion (e.g. lithium, sodium or potassium).

In a particular embodiment of each aspect of the invention, VPA is administered and/or formulated (as appropriate) in the form of its sodium salt (i.e. sodium valproate). In a more specific embodiment, the VPA is administered and/or formulated (as the case may be) as a mixture of VPA (i.e., non-salt form) and its sodium salt (i.e., sodium valproate), e.g., as an equal mixture thereof.

For example, in particular embodiments of the invention (i.e. each aspect of the invention), VPA may be administered and/or formulated (as appropriate) as a mixture of its sodium salt (i.e. sodium valproate) and valproic acid. Several such mixtures are known in the art, for example, semi-sodium valproate, also known as divalproex sodium (1: 1 molar relationship between valproic acid and sodium valproate), which is sold, for example, as Depakote and Depakote ER (AbbVie Inc.); and sodium valproate (ratio between valproic acid and sodium valproate 1: 2.3), which is sold, for example, as episex Chrono.

Other pharmaceutically acceptable Salts that may be mentioned include those described in Berge et al, j.pharm.sci.1977, 66, 1-19 and "Handbook of Pharmaceutical Salts, Properties, and Use", Stah and wermuth, ed; those described in Wiley-VCH and VHCA, Zurich, 2002 (the contents of which are all incorporated herein).

Reference to a "salt" of a compound of the invention is to be understood as referring to a salt form which may occur, for example, in plasma by exchange of anions or cations with the compound of the invention. In particular, the term "salt" may also refer to pharmaceutically acceptable salts, such as those described herein.

VPA may also be formulated and/or administered in the form of a prodrug thereof, or a pharmaceutically acceptable salt of the prodrug, as described herein.

As used herein, the term prodrug, when used in association with VPA, will be understood to refer to a compound that can be converted to VPA in vivo (i.e., after administration).

Such prodrugs can be identified by those skilled in the art, including ester (e.g., methyl or ethyl) or amide derivatives of VPA. Specific prodrugs that may be mentioned include 2-propylvaleramide (also known as propylvaleramide).

When the compounds of the invention are administered in the form of their prodrugs, the skilled person will be able to adjust the dosages administered to achieve the required equivalent dose of VPA.

Commercially available products containing valproic acid and/or sodium valproate or a prodrug thereof include, but are not limited to: depakote (AbbVie Inc.), Absensor (Orion corporation), Convulex (Pfizer), Convulex CR, Depakene/Depakin/Depalelept/Depraline (AbbVie Inc./Sanofi Aventis), Depakinehrono (Sanofi), Depakene-R (Kyowa Hakko), Selenica-R (Kowa), Encorate (SunPharmaceuticals indication), Encorate Chorono (N. Pharmaceuticals), Epival Sancosories (Abrayan III), Epilonie (Avicula), Avicula-release (Avicula-Abylose), Valfocal (Avicula-release) (Valconies-release ratio), Valfocal release ratio of Valfocal (Valconies) and (Valfocal), Valfocal release ratio of Valfocal lengths) (Valconies and Valfocal lengths) (Valconies release ratio of Valfocal lengths) (Valconies-release particles, controlled release tablet, tablet of Liporinies (Valfocal lengths) (Vafocal lengths of Valfocal lengths, Liporiz and Valfocal release tablet of Lipofemorale (Vafocal) and Valfocal lengths of Lipofei, Lipofemorale release tablet (Valfocal, Lipofei, Lipofemorative release tablet of Lipofemorative release tablet, Lipofei, Lipofemorative release tablet, Lipofei and Lipofemorative release tablet, Lipofei (Valfocal tablet, Lipofei tablet, Lipofemorative, Episenta prolenged release (Beacon), Valproic Acid capsule, USP (Teva), Stavzor (Noven), Orfiril (Desitin pharmaceuticals).

Commercially available products containing valproic acid and/or sodium valproate or a prodrug thereof will also include generic versions of the above formulations, which may be sold/sold under different names.

Administration of the Compounds

It will be appreciated by those skilled in the art that there is also provided a pharmaceutical composition comprising valproic acid or a pharmaceutically acceptable salt thereof, and optionally one or more pharmaceutically acceptable excipients, for use in the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis as described in the first to seventh aspects of the invention (including all embodiments thereof).

The compounds of the invention may be administered to a subject in a convenient manner, for example, by the oral, intravenous, intramuscular, subcutaneous, intraperitoneal, intranasal, buccal, transdermal, intradermal or suppository routes, as is known in the art. In particular, the compounds of the invention may be administered by the oral route; for example, as a pharmaceutical formulation suitable for oral administration (e.g., tablets, capsules, oral films, sprays, and the like).

In particular, pharmaceutical formulations suitable for oral administration may be presented as discrete units, e.g., capsules or tablets (e.g., tablets), each containing a predetermined amount of the active ingredient, which may include suitable excipients. Furthermore, orally available formulations may be in the form of powders or granules, solutions or suspensions in aqueous or non-aqueous liquids, oil-in-water or water-in-oil liquid emulsions.

Compositions for oral use may be prepared according to any known method and such compositions may contain one or more agents selected from the group consisting of sweetening agents, flavoring agents, coloring agents and preserving agents in order to provide pharmaceutically elegant and palatable preparations.

For example, a tablet may contain the active ingredient in admixture with non-toxic pharmaceutically acceptable excipients which are suitable for the manufacture of tablets. These excipients may be, for example: inert diluents, such as calcium carbonate, sodium carbonate, lactose, calcium phosphate or sodium phosphate; granules or disintegrants, for example, corn starch or alginic acid; binding agents, for example, starch, gelatin or acacia; and lubricating agents, for example, magnesium stearate, stearic acid or talc. The tablets may be uncoated or they may be coated by known techniques to delay disintegration and absorption in the gastrointestinal tract and thereby provide a sustained action over a longer period. For example, a time delay material such as glyceryl monostearate or glyceryl distearate may be employed. They may also be identified by U.S. Pat. Nos. 4,356,108; 4,166,452 and 4,265,874, the contents of which are incorporated herein by reference.

In addition, formulations for oral use may also be presented as hard gelatin capsules wherein the active ingredient is mixed with an inert solid diluent, for example, calcium carbonate, lactose, calcium phosphate or kaolin, or as soft gelatin capsules wherein the active ingredient is mixed with an aqueous (e.g., water-miscible liquid, e.g., polyethylene glycol) or oil medium, for example peanut oil, liquid paraffin, or olive oil. Such capsules can be formulated to contain granules of the active ingredient, which can be formulated (e.g., coated) in the manner described herein for tablets.

Further, formulations for oral use may be presented in the form of tablets consisting of compressed microparticles (e.g., granules), which may be coated separately.

Thus, in embodiments where the formulation comprises microparticles (e.g., in a capsule or tablet, e.g., a tablet consisting of compressed microparticles or a capsule containing granules), such microparticles may have different coatings (or be formulated for delayed release using the polymers described below) that may be selected to modulate the release of the compounds of the invention; for example, to control absorption and to make plasma profiles that mimic PAI-1 plasma profiles. The use of such coatings/formulations to control the absorption/release of drugs is known in the art and may, for example, be based on different polymers, for example acrylic acid or cellulose, as described more broadly below.

The multiple unit dosage form is less dependent on the degree of filling of the stomach and may therefore produce less variability, for example in the distribution of absorption among different patients.

The individual parts of the multiple unit dosage form may be prepared by well-known methods including granulation, slugging, extrusion, hot melt extrusion, tableting and/or coating techniques. For example, tablets and/or capsules are produced from coated granules/microtablets see, e.g., WO 96/01621, WO 96/01624, Siddique, Khanam and Bigoniya, aapspharmcitech 2010. These references also provide information on how to use different materials to control the release of a drug from a tablet or capsule (or from granules of said tablet or capsule).

In particular, those skilled in the art will recognize that valproic acid is a liquid and sodium valproate is hygroscopic. Suitable excipients and manufacturing processes for these types of ingredients are known in the art and include, for example, coating the ingredients with suitable polymers (e.g., different types of methacrylic acid copolymers) and/or water-insoluble materials, such as waxes/fatty acids and the like, to achieve reduced hygroscopicity. Such polymers may also be used to delay the release and/or absorption of the drug according to the invention.

For buccal and sublingual use, creams, ointments, gels, solutions in suspensions, etc., containing the compounds of the invention may be employed.

The pharmaceutical compositions may also be in the form of suppositories for rectal administration of the compounds of the invention. These compositions can be prepared by mixing the compounds of the present invention with a suitable non-irritating excipient which is solid at ordinary temperatures but liquid at the rectal temperature and will therefore melt in the rectum to release the drug. Such materials include, for example, cocoa butter and polyethylene glycols.

Pharmaceutical compositions comprising a compound of the invention may also be provided in the form of liposome delivery systems such as small unilamellar vesicles, large unilamellar vesicles and multilamellar vesicles. Liposomes can be formed from a variety of phospholipids, such as cholesterol, octadecylamine or phosphatidylcholine.

Suitable injectable pharmaceutical forms include, but are not limited to, sterile aqueous solutions (where water soluble) or dispersions and sterile powders for the extemporaneous preparation of sterile injectable solutions or dispersions. In all cases, the form must be sterile and must be fluid to the extent that ready syringability exists. It must be stable under the conditions of manufacture and storage and must be preserved against the contaminating action of microorganisms such as bacteria and fungi. The carrier can be a solvent or dispersion medium containing, for example, sterile water, ethanol, polyol (for example, glycerol, propylene glycol, and liquid polyethylene glycols, and the like), suitable mixtures thereof, and vegetable oils. For example, proper fluidity can be maintained, for example, by the use of a coating such as lecithin, by the maintenance of the required particle size in the case of dispersions, and by the use of surfactants. Prevention of the action of microorganisms can be achieved by various antibacterial and antifungal agents, for example, parabens, chlorobutanol, phenol, sorbic acid, thimerosal, and the like. In many cases, it is preferred to include isotonic agents, for example, sugars or sodium chloride. Prolonged absorption of the injectable compositions can be brought about by the use of a combination of agents delaying absorption, for example, aluminum monostearate and gelatin.

Sterile injectable solutions are prepared by incorporating the active substance in the required amount in the appropriate solvent with various of the other ingredients enumerated above, as required, followed by filtered sterilization. Generally, dispersions are prepared by incorporating the various sterilized active ingredients into a sterile vehicle which contains a base dispersion medium and the required other ingredients from those enumerated above. For sterile powders for the preparation of sterile injectable solutions, the preferred methods of preparation are vacuum drying and lyophilization techniques that yield a powder of the active ingredient plus any additional desired ingredient from a previously sterile-filtered solution thereof.

We have found that the compounds of the invention can be conveniently administered to a subject by the oral route, particularly in the form of a tablet or capsule (e.g., tablet). Furthermore, we have found that the particular dosing regimen contemplated in the present invention is particularly suitable for oral administration in the form of tablets or capsules formulated such that release of the compounds of the invention from the tablets or capsules is delayed following oral administration.

As used herein, reference to a formulation that allows for delayed or controlled release will be understood by those skilled in the art. In this regard, it is to be understood that the terms delay and control may be used interchangeably.

In an eighth aspect of the invention, there is provided a pharmaceutical composition comprising valproic acid or a pharmaceutically acceptable salt thereof, wherein the composition is in the form of a tablet or capsule for oral administration and is formulated such that substantially all of the valproic acid or pharmaceutically acceptable salt thereof is released over a period of time from about 4 hours to about 8 hours after administration.

As used herein, reference to a capsule will include a capsule filled with the active ingredient in powder form, or in the form of granules and/or particles, which may be coated as described herein, which may themselves be coated. Furthermore, the granules may be formulated for a specific release profile using, for example, different delayed/controlled release polymers (and/or coated granules).

As used herein, reference to a tablet shall include a tablet formed from compressed granules and/or microparticles which may be coated as described herein, the tablet itself may be coated.

As used herein (particularly with respect to the eighth aspect of the invention, including all embodiments thereof), the term "substantially all" will refer to an amount that is at least 60% of the total amount present (i.e., the total amount included in the composition). In particular, the term may refer to a quantity of at least 70% of the total, for example, at least 80% of the total. More particularly, the term can refer to a quantity that is at least 90% of the total, for example, at least 95% (e.g., at least 99%) of the total.

In a particular embodiment of the eighth aspect of the invention, reference to substantially all valproic acid or pharmaceutically acceptable salt thereof being released may refer to substantially all one dose (i.e. at least one therapeutically effective dose) thereof.

One skilled in the art will appreciate that the release of the active ingredient may be delayed if the composition is administered with or shortly after the food. Thus, reference to the time it takes for an active ingredient to be released may refer to the time it takes for such release when the composition is administered to a patient at least 2 hours after the patient eats (which may be referred to as fasting administration, etc.).

It is also understood that it may be beneficial to administer the compounds of the invention with food (e.g., to reduce gastrointestinal side effects). Thus, in particular embodiments of the first to seventh aspects of the invention, the treatment comprises administering valproic acid or a pharmaceutically acceptable salt thereof with food (e.g. to a patient that eats less than 2 hours prior to administration, or is directed to eat within 30 minutes of administration).

As used herein (particularly with respect to the eighth aspect of the invention, including all embodiments thereof), reference to the active ingredient being "released" (i.e., released from a pharmaceutical formulation) will refer to the active ingredient being in a form useful for absorption (i.e., when administered orally, absorbed systemically from the Gastrointestinal (GI) tract). When used in connection with a tablet and/or capsule for oral administration, the term shall mean that the active ingredient is not contained within the tablet or capsule (which may include that the active ingredient is no longer contained within particles (e.g., coated particles) and/or microparticles contained within the tablet or capsule, but is distributed within the gastrointestinal tract).

In a particular embodiment of the eighth aspect of the invention, the pharmaceutical composition is formulated such that substantially all of the valproic acid or pharmaceutically acceptable salt thereof is released over a period of time from about 6 hours to about 8 hours after administration (e.g., from about 6 hours to about 7 hours after administration, or e.g., from about 7 hours to about 8 hours after administration, e.g., about 7 hours after administration).

In a more specific (and alternative) embodiment of the eighth aspect of the invention, the pharmaceutical composition is formulated such that substantially all of the valproic acid or pharmaceutically acceptable salt thereof is released over the following time period:

(i) about 3 hours to about 5 hours after administration (about 4 hours to about 5 hours after administration);

(ii) about 4 hours to about 6 hours after administration;

(iii) about 5 hours to about 7 hours after administration;

(iv) about 6 hours to about 8 hours after administration; or

(v) From about 8 hours to about 10 hours after administration.

In a particular embodiment of the eighth aspect of the invention, the pharmaceutical composition may further comprise one or more pharmaceutically acceptable excipients (e.g., pharmaceutically acceptable adjuvants, diluents or carriers), such as those described herein. In such embodiments, the compounds of the invention may be provided in admixture with the one or more pharmaceutically acceptable excipients.

It will be understood by those skilled in the art that a pharmaceutical formulation (i.e. tablet or capsule) comprising a compound of the invention (e.g. those described in the eighth aspect of the invention, including all embodiments thereof) will contain all or part of a therapeutically effective dose of a compound of the invention.

For the avoidance of doubt, such a dose may be provided in a single unit composition (e.g. a single tablet or capsule), or may be provided by the combined administration of several units of formulation each comprising the corresponding part of the dose (e.g. two tablets each containing half the required dose, or a plurality of microparticles each containing the required part of the required dose).

In particular, the formulation (e.g., a tablet for oral administration) may comprise a single therapeutically effective dose. Thus, in a particular embodiment of the eighth aspect of the invention, the composition comprises a dose (e.g. a total daily dose) of valproic acid or a pharmaceutically acceptable salt thereof, as defined in any one or more of the first to seventh aspects of the invention (including all embodiments thereof).

Depending on the required dosage, pharmaceutical preparations which may be mentioned include those in which the active ingredient is present in at least 1% (or at least 10%, at least 30% or at least 50%) by weight. That is, the ratio of the active ingredient to other ingredients (e.g., pharmaceutically acceptable excipients) of the pharmaceutical composition is at least 1:99 (or at least 10:90, at least 30:70, or at least 50:50) by weight.

Thus, the skilled person will appreciate that the present invention further provides a process for the preparation of a pharmaceutical formulation as described herein (e.g. those described in the eighth aspect of the invention, including all embodiments thereof), said process comprising formulating a compound of the invention in the manner described herein. In particular, such a process may comprise the steps of:

(a) associating (e.g., forming an impurity with) a compound of the invention with one or more pharmaceutically acceptable excipients; and

(b) formulated as tablets or capsules (as described herein).

Those skilled in the art will understand that the terms are associated with each other to mean that the associated ingredients are brought together in a manner suitable for administration.

As described herein, the compounds of the present invention may be administered and/or formulated in a form coated with, or administered with, a material that delays the release of the active ingredient. In particular, formulations in tablet form may be coated with such materials and/or formulated with release-modifying polymers. In addition, a formulation in the form of a capsule may be formulated such that the capsule consists of, or contains a quantity (i.e., an effective amount) of such material.

Thus, the pharmaceutical composition of the eighth aspect of the invention may be referred to as a "delayed release" or "controlled release" composition or formulation, or the like.

In such cases, one skilled in the art will appreciate that the material that delays release of the active ingredient will be selected and/or formulated in a manner to delay release of the active ingredient for a desired time (e.g., about 6 hours).

Those skilled in the art will be familiar with materials for delaying (i.e., delaying) the release of active ingredients, particularly when administered in the form of oral compositions (e.g., tablets and capsules). Such materials may be found in, for example, Remington's pharmaceutical Science and U.S. pharmaceutical (The United States pharmaceutical-National Formulary (USP-NF)), Remington: The Science and Practice of Pharmacy, 19th Ed. (Easton, Pa.: Mack Publishing Company, 1995); hoover, John e., Remington's pharmaceutical Sciences, Mack Publishing co, Easton, pa.1975; liberman, h.a. and lachman, l., eds., Pharmaceutical document Forms, Marcel Decker, New York, n.y., 1980; and Pharmaceutical document Forms and Drug Delivery Systems, 7th Ed. (Lippincott Williams 1999), the contents of which are fully incorporated herein.

For example, materials for delaying the release of the active ingredient may include sustained release polymers, such as hydroxypropyl cellulose, hydroxypropyl methylcellulose, carboxymethyl cellulose, chitosan, aloe vera gel, pectin, ethyl cellulose, polyvinyl chloride, polyethylene, and polyvinyl pyrrolidone (PVP) (e.g., hydroxypropyl cellulose, hydroxypropyl methylcellulose, carboxymethyl cellulose, chitosan, aloe vera gel, pectin, ethyl cellulose, polyvinyl chloride, and polyethylene). Furthermore, one way to achieve a sustained release coating is to mix a water soluble polymer such as HPMC and a water insoluble polymer such as ethylcellulose. Those skilled in the art will appreciate that the different materials used and their different ratios will produce different release patterns and thus will be able to adjust the formulation (i.e., to achieve the desired release profile).

One skilled in the art will appreciate that when the composition is administered and/or formulated in a form coated with, or administered with, a material that delays the release of the active ingredient, the material may consist of more than one pharmaceutically acceptable substance (e.g., one or more pharmaceutically acceptable coatings). For example, when the composition of the eighth aspect of the invention is administered in the form of a tablet, the tablet may comprise one or more pharmaceutically acceptable coatings of a material that delays the release of the active ingredient.

In such cases, the skilled artisan will appreciate that delaying the release of the active ingredient from the composition (e.g., tablet) is achieved as a combination of these coatings. For example, when a tablet is coated to delay release for a total of 6 hours following oral administration, the tablet may comprise two layers of coating, each layer of coating delaying release for 3 hours (or one coating delaying release for 2 hours, a further coating delaying release for 4 hours), i.e., the first coating is removed to expose the second coating, and so on (in other words, the coatings are exposed in a continuous manner).

In a particular embodiment of the eighth aspect of the invention, when the composition of the eighth aspect of the invention comprises one or more coatings (i.e. in the form of coated tablets), one or more of the coatings may be a coating which is used to prevent the release of the active ingredient in the stomach, or to prevent further exposure of the coating. In particular, one or more (e.g., one) of the coatings may be an enteric coating. Such enteric coatings are well known to those skilled in the art.

In certain embodiments of the eighth aspect of the invention (particularly those where the tablet has one or more coatings), the core component (e.g., of the coated tablet) may contain one or more ingredients designed to promote disintegration in aqueous media.

Thus, in a particular embodiment of the eighth aspect of the invention, the formulation is provided as a tablet (or capsule) for oral administration comprising one or more coated cores (e.g. a single coated core, or a plurality of coated granules or microparticles each having a core comprising valproic acid or a pharmaceutically acceptable salt thereof, wherein:

(i) the coating is formed of a material selected and/or formulated in a manner to delay release of the active ingredient for a desired time (e.g., about 6 hours); and

(ii) the core is formulated in a manner designed to promote disintegration in an aqueous medium (e.g., comprising one or more disintegrants).

Such disintegrants are well known to those skilled in the art and include agents designed to swell upon contact with aqueous media.

One skilled in the art will appreciate that there are several materials that can be used to form an enteric coating on a tablet/capsule and/or granule/mini-tablet/pellet/multi-granule/multi-unit dosage form. These include, but are not limited to, shellac, waxes, fatty acids, polymers, plastics and plant fibers.

Examples of such polymers include, but are not limited to, hypromellose phthalate (hydroxypropylmethyl cellulose phthalate, HPMCP), hypromellose acetate succinate, cellulose acetate trimellitate, acrylic/methacrylic acid copolymers (e.g., poly (methacrylic acid-co-methyl methacrylate), cellulose acetate phthalate (CAT), poly (vinyl acetate phthalate, PVAP), and ethyl acrylate.

Commercially available systems for enteric and sustained release coatings includeVariant (A) of (A)Colorcon)、Titancoat、(BASF)、(for example,RL、RS、S、l andE) sheffcoat EC and Sheffcoat Ent.

The skilled person will understand that different materials have different properties, e.g. in case of solubility pH values, and that the skilled person can thus be used to control the absorption pattern, e.g. to prolong the release of the drug for a specific time. In addition, the thickness of the coating may be varied to achieve a particular pattern. Furthermore, if the coated particles are used in, for example, capsules or tablets, different coatings (and/or coating thicknesses) may be used to simulate the pattern of PAI-1 plasma concentrations for the compounds of the present invention. More specifically, a combination of several (e.g., 2-5) different coated particles/microparticles may be used to achieve the desired effect in simulating the PAI-1 plasma concentration pattern for the compounds of the present invention.

One way to prolong the absorption delay of enteric coatings is to mix the enteric coating polymer with a smaller amount of sustained release polymer; such as described in tirpoude and puraik, J Adv Pharm Technol Res 2011, in which 10% of the sustained release acrylic polymer (Eudragit NE30D) is mixed with 90% of the enteric acrylic polymer (Eudragit L30D 555). Thus, materials such as polymers having different dissolution characteristics may be combined in different proportions to achieve the desired absorption pattern according to the present invention. Other examples of methods to achieve different absorption patterns by using various grades of hydrophilic polymers, and how to make matrix tablets from granules, are described in Roy, Brahma, Nandi and Parida, Int J ApplBasic Med res.2013.

Different approaches to achieving controlled release using matrix tablets are also described in http:// www.pharmainfo.net/views/matrix-tables-injector-tool-oral-controlled-release-host-forms, and descriptions of different polymers and matrices, the disclosure of which is incorporated herein by reference in its entirety.

For more details on enteric coatings see, e.g., Singh Deep Hussan et al, IOSRjournal of Pharmacy (2012) and the Handbook of Pharmaceutical Excipients Rowe, Raymond C; sheskey, Paul J; cook, Walter G; fenton, Marian E., Seventh edition, the disclosure of which is incorporated herein by reference in its entirety.

Certain coatings may require the use of plasticizers to obtain good results, the use of such agents being known in the art. Such plasticizers include, for example, citric acid esters, glycerin, propylene glycol, diethyl phthalate, dibutyl sebacate, tributyl citrate, acetylated monoglycerol fatty acid esters, triacetin, and triacetin.

Pigments and/or these plasticizers may be added to, for example, the polymerization solution to improve, for example, the technical properties of the film or to modify the release characteristics.

The compounds of the present invention may be coated with or applied with materials to prevent their inactivation. For example, the active substance may be administered in an adjuvant, co-administered with, for example, an enzyme inhibitor, or administered in liposomes. Adjuvants contemplated herein include, but are not limited to, resorcinol, non-ionic surfactants such as polyoxyethylene oleyl ether and n-hexadecyl polyethylene ether. Enzyme inhibitors include, but are not limited to, pancreatic trypsin inhibitor, Diisopropyl Fluorophosphate (DFP), and aprotinin. Liposomes include water-in-oil-in-water P40 emulsions as well as conventional liposomes. Dispersions can also be prepared in glycerol, liquid polyethylene glycols, and mixtures thereof, as well as in oils. Under ordinary storage conditions and use, these preparations contain a preservative to prevent the growth of microorganisms.

As described herein, one skilled in the art will appreciate that when administered orally, the active compound may be combined with an inert diluent or with an edible carrier, or may be enclosed in hard or soft shell capsules, or may be compressed into tablets, or may be incorporated directly into the diet. For oral therapeutic administration, the active substance may be combined with excipients and used in the form of ingestible tablets, buccal tablets, troches, capsules, elixirs, suspensions, syrups, wafers, and the like. In addition, the active substance may be incorporated into sustained release preparations and formulations. For example, the active substance may be incorporated into enteric tablets/capsules and/or dual stage release formulations, which will be known to those skilled in the art. For example, a dual stage release formulation may be of the type described in US2007/0232528a1 (which is incorporated herein in its entirety), which may be suitable for administration over a time period of about 22:00 to 00: 00.

As used herein, the term "pharmaceutically acceptable excipient" will include pharmaceutically acceptable adjuvants, diluents and carriers, which are known to those skilled in the art. This may include any and all solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic and absorption delaying agents, and the like.

Thus, tablets, troches, pills, capsules and the like may also contain the following: binders, such as gum tragacanth, acacia, corn starch or gelatin; excipients, such as dicalcium phosphate; disintegrating agents such as corn starch, potato starch, alginic acid, and the like; lubricants, such as magnesium stearate; and a sweetening agent such as sucrose, lactose or saccharin may be added, or a flavoring agent such as peppermint, oil of wintergreen, or cherry flavoring. When the dosage unit form is a capsule, it can contain, in addition to materials of the above type, a liquid carrier. Various other materials may be present as coatings or otherwise modify the physical form of the dosage unit. For example, tablets, pills, or capsules may be coated with shellac, sugar or both. A syrup or elixir may contain the active compound, sucrose as a sweetening agent, methyl and propylparabens as preservatives, a dye and flavoring such as cherry or orange flavor. Of course, any material used in preparing any dosage unit form should be pharmaceutically pure and substantially non-toxic in the amounts employed.

The use of such excipients is well known in the art; see, for example, Remington's pharmaceutical Science and U.S. Pharmacopea (The United States Pharmacopea-national formulary (USP-NF)), Remington: The Science and Practice of Pharmacy, 19th Ed. (Easton, Pa.: Mack Publishing Company, 1995); hoover, John e., Remington's pharmaceutical Sciences, Mack Publishing co, Easton, pa.1975; liberman, h.a. and lachman, l., eds., Pharmaceutical document Forms, Marcel Decker, New York, n.y., 1980; and Pharmaceutical document Forms and Drug Delivery Systems, 7th Ed. (Lippincott Williams Wilkins 1999).

As described herein, tablets and/or capsules formulated to delay release of a compound of the invention from the tablet following oral administration (as described in the eighth aspect of the invention and embodiments thereof) are particularly useful for treating or preventing pathological conditions associated with excessive fibrin deposition and/or thrombosis according to the particular dosing regimens described herein.

Thus, in a ninth aspect of the invention there is provided a pharmaceutical composition as described in the eighth aspect of the invention (including any one or more embodiments thereof) for use in the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis, wherein the treatment is as described in any one of the first to seventh aspects of the invention (including any one or more embodiments thereof).

In an alternative ninth aspect of the invention there is provided the use of a pharmaceutical composition as described in the eighth aspect of the invention (including one or more embodiments thereof) in the manufacture of a medicament for the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis, wherein the treatment is as described in any one of the first to seventh aspects of the invention (including any one or more embodiments thereof).

Thus, in a further alternative ninth aspect of the invention there is provided a method of treating or preventing a pathological condition associated with excessive fibrin deposition and/or thrombosis in a patient in need thereof as described in any one of the first to seventh aspects of the invention (including any one or more embodiments thereof), wherein valproic acid or a pharmaceutically acceptable salt thereof is administered in the form of a pharmaceutical composition as described in the eighth aspect of the invention (including any one or more embodiments thereof).

As described herein, one of skill in the art will be able to adjust the formulation and mode of administration of the compounds of the present invention to achieve desired parameters, e.g., desired timing and/or plasma concentration levels of a particular agent.

For example, the skilled person will know that various formulations of the compounds of the invention are commercially available and may be administered in a manner suitable for use in the treatment described in particular in the first to seventh aspects of the invention.

Thus, in certain embodiments of the present invention (e.g. of the first to seventh and ninth aspects of the invention), there is provided valproic acid or a pharmaceutically acceptable salt thereof for use in the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis, wherein said treatment comprises administering to the patient a pharmaceutical composition in the form (i.e. in a specific formulation) comprising a dose of valproic acid or a pharmaceutically acceptable salt thereof at a specific dose and time indicated in the following table.

As used herein, references to the names of certain formulations will refer to the corresponding formulations sold/marketed in the relevant country (e.g., the united states, uk, or sweden) at 10/1 of 2014.

References to a particular formulation by a particular name in the above table are intended to include references to substantially the same formulation (i.e., the same formulation sold and/or marketed using a different product name) which may be referred to by other names.

As described herein, one skilled in the art will appreciate that administration of the formulation to a patient with food or shortly thereafter, may delay the release of the active ingredient, and will be able to adjust the time of administration accordingly. Unless otherwise specified, reference herein to the administration of a particular formulation at a particular time (e.g., within a particular time period) will refer to administration to a patient on an empty stomach.

Combination therapy

The compounds of the invention may also be administered in combination with (e.g., in a formulation combined with) other therapeutic agents useful in treating or preventing pathological conditions associated with excessive fibrin deposition and/or thrombosis.

In particular, a pharmaceutical composition as described in the eighth aspect of the invention (including embodiments thereof) may comprise a compound of the invention, together with one or more pharmaceutically acceptable excipients, and one or more other therapeutic agents useful in the treatment or prevention of pathological conditions associated with excessive fibrin deposition and/or thrombosis.

In a particular embodiment of the first to seventh aspects of the invention, valproic acid or a pharmaceutically acceptable salt thereof is administered in combination with one or more (e.g. one) other therapeutic agents useful in treating or preventing pathological conditions associated with excessive fibrin deposition and/or thrombosis.

In a particular embodiment of the eighth aspect of the invention, the pharmaceutical formulation further comprises one or more (e.g. one) other therapeutic agents useful in treating or preventing a pathological condition associated with excessive fibrin deposition and/or thrombosis. In such embodiments, the compounds of the invention may be provided in admixture with the one or more other therapeutic agents.

Thus, it will be appreciated by those skilled in the art that the present invention further provides a process for the preparation of a pharmaceutical formulation as described herein (e.g. those described in the eighth aspect of the invention, including embodiments thereof), said process comprising the steps of:

(a) associating a compound of the invention with one or more pharmaceutically acceptable excipients (e.g., forming an impurity thereof) and/or one or more (e.g., one) other therapeutic agents useful in treating or preventing excessive fibrin deposition and/or a pathological condition associated with thrombosis; and

(b) formulated as a tablet or capsule (as described herein, e.g., with one or more coatings).

As mentioned herein, other therapeutic agents useful in treating or preventing pathological conditions associated with excessive fibrin deposition and/or thrombosis include: one or more anti-thrombolytic agents; and/or one or more anticoagulant agents; and/or one or more antiplatelet agents; and/or one or more vasodilators, as known to those skilled in the art.

In particular embodiments, the compounds of the present invention may be administered and/or formulated in combination with:

-one or more antiplatelet agents including, but not limited to, aspirin, dipyridamole, ticagrelor and clopidogrel;

-one or more anticoagulant agents, such as heparin, Low Molecular Weight Heparin (LMWH), warfarin, anisindione, fenningdon, dicoumarin, bivalirudin, eptifibatide; one or more vasodilators, such as nitriles (e.g., amyl nitrite, glycerol nitrate, sodium nitrile, isosorbide dinitrate), papaverine, nicotinic acid, and cyclanoate.

-one or more cardiovascular event preventing agents such as, but not limited to, statins, beta blockers, angiotensin converting enzyme inhibitors, angiotensin II receptor antagonists or diuretics; and/or

One or more anti-inflammatory agents including steroids and NSAIDs (including but not limited to aspirin, ibuprofen, naproxen, and diclofenac);

-one or more thrombolytic agents selected, for example, from recombinant t-PA, prourokinase, urokinase or streptokinase.

In a more particular embodiment, the compounds of the present invention may be administered and/or formulated in combination with aspirin (i.e., a therapeutically effective amount of aspirin).

In yet more particular embodiments, the compounds of the present invention may be administered and/or formulated in combination with clopidogrel (i.e., a therapeutically effective amount of clopidogrel) or ticagrelor (i.e., a therapeutically effective amount of ticagrelor).

For the avoidance of doubt, the skilled person will understand that the term "administered in combination with" includes concomitant, sequential and independent administration. In this regard, continuous administration may refer to administration within the same therapeutic intervention (i.e., within 1 hour of the compound of the invention).

Those skilled in the art will appreciate that references to an agent administered in combination with other agents may also include kits of parts containing the relevant agent (i.e., as separate components within the same kit).

One skilled in the art will also understand that reference to a first agent administered in combination with a second agent will also be a second agent administered in combination with the first agent, and so forth.

Patient group

It will be understood by those skilled in the art that reference herein to a "patient" will refer to a living animal, which may undergo the treatment or prevention described herein. In particular, the term patient will refer to a mammal. More particularly, the term patient will refer to a human (e.g., an adult).

The compounds of the invention may be particularly useful in treating or preventing (particularly, preventing) pathological conditions associated with excessive fibrin deposition and/or thrombosis in patients at increased risk of developing one or more pathological conditions associated with excessive fibrin deposition and/or thrombosis.

In particular embodiments of the first to seventh aspects of the invention (including all embodiments thereof), the treatment or prevention (e.g. prevention, which may also be referred to as prophylaxis) is in a patient at increased risk of developing a pathological condition associated with excessive fibrin deposition and/or thrombosis (which one of skill in the art will understand to mean reducing the risk of the associated condition as described herein).

As described herein, several conditions and risk factors are associated with increased susceptibility to thrombotic events (i.e., thrombosis). These include atherosclerosis, hypertension, abdominal obesity, smoking, sedentary lifestyle, and low grade inflammation. Thus, in particular embodiments of the first to seventh aspects of the invention (including all embodiments thereof), the treatment or prevention (e.g. prevention, which may also be referred to as prevention (prophyaxsis)) is in a patient having one or more of such conditions/risk factors.

In a more particular embodiment, the patient at increased risk of developing a pathological condition associated with excessive fibrin deposition and/or thrombosis is a patient who:

(i) suffering from one or more medical conditions associated with an increased risk of thrombosis, such as metabolic syndrome (e.g., type II diabetes), neoplastic disease, heart failure, renal failure, and/or sepsis;

(ii) the onset of one or more pathological conditions associated with excessive fibrin deposition and/or thrombosis, e.g., the onset of one or more of myocardial infarction, ischemic stroke, and pulmonary embolism (e.g., the onset of ischemic stroke, e.g., one or more of major ischemic stroke, minor ischemic stroke, or TIA); and/or

(iii) Having one or more lifestyle and/or environmental factors that put them at the increased risk, e.g., the patient is a smoker, obese, and/or reduced activity (e.g., the patient is bedridden, e.g., the patient is in a medical unit or an elderly care unit).

Thus, in particular embodiments, reference to a patient at increased risk of developing a pathological condition associated with excessive fibrin deposition and/or thrombosis will include reference to an obese patient, e.g., a patient with a Body Mass Index (BMI) above 25 (e.g., above 30 and above 35).

As used herein, reference to a patient at increased risk of developing a pathological condition associated with excessive fibrin deposition and/or thrombosis may also include patients aged 50 years or older (e.g., 60 years or older) (e.g., human male patients).

In particular embodiments, a patient at increased risk of developing a pathological condition associated with excessive fibrin deposition and/or thrombosis may also be a patient having elevated PAI-1 levels.

For example, as described herein, a patient at increased risk of developing a pathological condition associated with excessive fibrin deposition and/or thrombosis may also be a patient suffering from local or systemic inflammation, such as inflammation associated with elevated PAI-1 levels.

Thus, in particular embodiments, a patient at increased risk of developing a pathological condition associated with excessive fibrin deposition and/or thrombosis may be a patient having a PAI-1 level in morning plasma of greater than about 20ng/ml (e.g., greater than about 40ng/ml, e.g., greater than about 60ng/ml, e.g., greater than about 80ng/ml, or more particularly, greater than about 100 ng/ml).

For example, a patient at increased risk of developing a pathological condition associated with excessive fibrin deposition and/or thrombosis may be a patient who has a PAI-1 level in morning plasma of greater than about 20ng/ml (e.g., greater than about 40ng/ml, e.g., greater than about 60ng/ml, e.g., greater than about 80ng/ml, or more particularly, greater than about 100ng/ml) and has experienced one or more occurrences of myocardial infarction, ischemic stroke, and pulmonary embolism (e.g., one or more occurrences of ischemic stroke, such as major ischemic stroke, minor ischemic stroke, or TIA).

In certain embodiments, the patient does not have:

(i) CNS or psychiatric disorders, such as epilepsy, migraine and/or bipolar disorders; and/or

(ii) Fragile X syndrome and/or familial adenomatous polyposis.

Thus, in particular embodiments of the first to seventh aspects of the invention (including all embodiments thereof), the treatment or prevention (e.g. prophylaxis) is in a patient who:

(a) an increased risk of developing pathological conditions (in particular as defined herein) associated with excessive fibrin deposition and/or thrombosis; and

(b) without CNS or psychiatric disorders (as defined herein, in particular epilepsy and/or bipolar disorders).

Drawings

FIG. 1 shows a schematic representation of the circadian rhythm (i.e., variation) of PAI-1 levels in adult humans over a typical 24-hour period. The lower curve represents the change in PAI-1 levels in normal (i.e., healthy) patients. The upper curve represents changes in PAI-1 levels in patients with elevated PAI-1 levels (e.g., patients with obesity and/or metabolic syndrome). The y-axis represents the appropriate plasma levels, abbreviated to illustrate a positive skewed distribution towards high plasma levels in obesity/metabolic syndrome. The x-axis represents clock time.

Examples

The following examples are included to further illustrate the invention, and those skilled in the art will appreciate that the invention is not limited in any way to the specific aspects described therein.

Example 1 VPA and PAI-1

The effect of VPA on PAI-1 was analyzed in two different concept-evidence studies in healthy subjects and in patients with overt atherosclerotic disease. The study used a random crossover design to study PAI-1 levels before and after HDAC inhibition with valproic acid. PAI-1 plasma levels were measured in the morning of the first day of the study and at the end of the treatment period with VPA (see example 2 for details of the PAI-1 analysis).

In the first study, 10 healthy non-smoking caucasian male subjects aged 50-70 years (mean BMI approximately 26) were included and treated twice daily with 500mg valproic acid (Ergenyl record, Sanofi) over a 14 day period. Unexpectedly, we detected more than a 50% reduction in circulating plasma PAI-1 levels during mid-morning hours (from 22.2 to 10.8ng/ml, p <0.05) compared to mid-morning hours found prior to treatment with VPA.

In a second study, 16 non-smoking caucasian male patients aged 50-80 years with a history of myocardial infarction were included. On top of their general prescription (beta-blockers, ACE-inhibitors, statins, aspirin), they were treated twice daily with 500mg valproic acid (Ergenyl red, Sanofi) during a 28 day period. In this study, we detected a 45% reduction in circulating plasma PAI-1 levels during mid-morning hours (from 19.6ng/ml to 11ng/ml (p ═ 0.01)).

Example 2-intermediate endpoint study: effect of valproic acid on PAI-1 in vivo in Male

Intermediate endpoint concept-evidence studies were performed in patients with TIA/mini-stroke studied before and after treatment with valproic acid. Valproic acid is administered as an enteric coated tablet that delays absorption.

The study contained 20 patients with TIA/mini-stroke. Patients were studied before and after oral treatment with 400mg valproic acid once daily at 11pm for 2 weeks. Plasma PAI-1 levels and plasma concentrations of valproic acid were followed daily during the study at the following time points: the levels of 3am, 6am, 10am, 16pm, 22pm, PAI-1 were measured by a commercially available ELISA kit (Coaliza PAI-1, Chromogenix AB), and the plasma concentrations of valproic acid and its metabolites were analyzed according to clinical practice at the university of Sahlgrenska laboratory, Goldberg, Sweden.

Plasma concentrations of valproic acid were found to peak between 3am and 6am, and thereafter to decrease to very low levels during the trough of PAI-1 concentrations. The peak in plasma valproic acid coincides with the peak level of plasma PAI-1 between 3am and 6 am. Plasma concentrations of valproic acid and plasma PAI-1 levels follow each other with a significant circadian rise, with its peak during the morning hours. Plasma PAI-1 levels decreased by approximately 30% after treatment.

Example 3 clinical outcome study Using Valproic acid to prevent recurrent thromboembolic events in high-risk patients

Clinical outcome studies were conducted in high-risk patients who experienced recent major arterial thrombotic cardiovascular events (myocardial infarction or TIA/ischemic stroke) to investigate the prophylactic effect of valproic acid treatment on the risk of recurrent events. The one year risk of recurrent arterial thrombotic events in the population studied is estimated to be about 7%.

Patients were randomized in a parallel study design and received double-blind oral treatment of 400mg valproic acid (as in example 2) once daily at 11pm or placebo, in addition to optimal conventional treatment. The event rate was monitored by Kaplan-Meyer statistics. The primary efficacy endpoint is mortality, or a composite measure of non-fatal myocardial infarction or ischemic stroke. The study was event driven, for a total of 180 events.

The results of the study are expected to show that long-term valproic acid treatment reduces this risk by about 30%, i.e. by an annual absolute event rate to about 5%, outside of conventional treatments. Thus, this study is expected to confirm the clinical efficacy and feasibility of using valproic acid as a secondary prophylactic agent for cardiovascular disease.

Claims

1. Valproic acid or a pharmaceutically acceptable salt thereof, for use in the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis, wherein said treatment comprises administering to a patient at least one dose of valproic acid or a pharmaceutically acceptable salt thereof such that the maximum plasma concentration (Cmax) of valproic acid or a salt and/or metabolite thereof in said patient occurs within a time period of 4 hours before the maximum plasma concentration (Cmax) of PAI-1 to 1 hour after the maximum plasma concentration (Cmax) in said patient.

2. The compound for use according to claim 1, wherein the maximum plasma concentration (Cmax) of valproic acid or a salt and/or metabolite thereof in said subject occurs within a time period of 3 hours (e.g., 2 hours before) before the maximum plasma concentration (Cmax) of PAI-1 to 1 hour after the maximum plasma concentration (Cmax) of PAI-1 in said subject.

3. The compound for use according to claim 1, wherein the maximum plasma concentration (Cmax) of valproic acid or a salt and/or metabolite thereof in said subject occurs within a time period ranging from 3 hours (e.g., 2 hours) before the maximum plasma concentration (Cmax) of PAI-1 to the time of the maximum plasma concentration (Cmax) of PAI-1 in said subject.

4. Valproic acid or a pharmaceutically acceptable salt thereof for use in treating or preventing a pathological condition associated with excessive fibrin deposition and/or thrombosis, wherein said treatment comprises administering at least one dose of valproic acid or a pharmaceutically acceptable salt thereof to a patient such that said patient has a plasma concentration of valproic acid or a salt and/or metabolite thereof of at least 10-100 μ g/ml while said patient experiences a maximum plasma concentration (Cmax) of PAI-1.

5. The compound for use of claim 4, wherein the patient has a plasma concentration of valproic acid or a salt and/or metabolite thereof that is 10-70 μ g/ml (or 50-90, 70-110, 90-130, 110-150, 130-170, or 150-190 μ g/ml) when the patient experiences the maximum plasma concentration (Cmax) of PAI-1.

6. Valproic acid or a pharmaceutically acceptable salt thereof for use in the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis, wherein the treatment comprises administering to the patient a dose of valproic acid or a pharmaceutically acceptable salt thereof over a time period of 20:00 to 06: 00.

7. The compound for use of claim 6, wherein the treatment comprises administering to the patient a therapeutically effective dose of valproic acid or a pharmaceutically acceptable salt thereof over a time period of 21: 00-05: 00 (e.g., 22: 00-04: 00).

8. The compound for use of claim 6, wherein the treatment comprises administering to the patient a therapeutically effective dose of valproic acid or a pharmaceutically acceptable salt thereof over a time period of 02: 00-06: 00 (e.g., 03: 00-05: 00, e.g., 04: 00).

9. Valproic acid or a pharmaceutically acceptable salt thereof for use in the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis, wherein the treatment comprises administering to a patient a pharmaceutical composition comprising a dose of valproic acid or a pharmaceutically acceptable salt thereof for a time and in a form such that substantially all of the valproic acid or pharmaceutically acceptable salt thereof is released from the composition over a time period of 02:00 to 06: 00.

10. A compound for use according to claim 9, wherein the treatment comprises administering to the patient a pharmaceutical composition comprising a therapeutically effective dose of valproic acid or a pharmaceutically acceptable salt thereof for a time and in a form such that substantially all of the valproic acid or pharmaceutically acceptable salt thereof is released from the composition over a time period of 03: 00-05: 00 (e.g. 04: 00-05: 00, e.g. 05: 00).

11. Valproic acid or a pharmaceutically acceptable salt thereof for use in treating or preventing a pathological condition associated with excessive fibrin deposition and/or thrombosis in a patient, wherein the treatment comprises:

(i) monitoring the plasma concentration of PAI-1 in the subject to determine a time or period of time at which a maximum plasma concentration of PAI-1 occurs; and

(ii) administering to the subject at least one dose of valproic acid or a pharmaceutically acceptable salt thereof such that the maximum plasma concentration (Cmax) of valproic acid or a salt and/or metabolite thereof in the subject occurs within the time period from the first 4 hours to the first 1 hours before the maximum plasma concentration of PAI-1 occurs, or within the time period during which the maximum plasma concentration of PAI-1 occurs.

12. The compound for use according to claim 11, wherein the maximum plasma concentration (Cmax) of valproic acid or a salt and/or metabolite thereof in said subject occurs within a time period ranging from 3 hours (e.g., 2 hours) before the maximum plasma concentration (Cmax) of PAI-1 in said subject to the time of the maximum plasma concentration.

13. Valproic acid or a pharmaceutically acceptable salt thereof for use in treating or preventing a pathological condition associated with excessive fibrin deposition and/or thrombosis in a patient, wherein the treatment comprises:

(ii) administering at least one dose of valproic acid or a pharmaceutically acceptable salt thereof to the patient such that the patient has a plasma concentration of valproic acid or a salt and/or metabolite thereof of at least 10-100 μ g/ml at the time the patient experiences the maximum plasma concentration of PAI-1.

14. The compound for use of claim 13, wherein the patient has a plasma concentration of valproic acid or a salt and/or metabolite thereof that is 10-70 μ g/ml (or 50-90, 70-110, 90-130, 110-150, 130-170, or 150-190 μ g/ml) when the patient experiences the maximum plasma concentration (Cmax) of PAI-1.

15. A compound for use according to any one of the preceding claims, wherein the treatment comprises administering a single dose of valproic acid or a pharmaceutically acceptable salt thereof to the patient over a 24 hour period, wherein the dose is from 50mg to 1000 mg.

16. Valproic acid or a pharmaceutically acceptable salt thereof for use in the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis, wherein the treatment comprises administering to the patient a single dose of valproic acid or a pharmaceutically acceptable salt thereof over a 24 hour period, wherein the dose is from 200mg to 600 mg.

17. The compound for use according to claim 16, wherein the dose is 300mg to 500mg, e.g. 350 mg.

18. The compound for use according to any one of the preceding claims, wherein the valproic acid or pharmaceutically acceptable salt thereof is administered such that the plasma concentration of valproic acid or salt and/or metabolite thereof is below 350 μ M (e.g. below 200 μ M, e.g. below 150 μ M) during 14: 00-18: 00 (e.g. 15: 00-17: 00, e.g. at 15: 30).

19. The compound for use according to any one of the preceding claims, wherein valproic acid or a pharmaceutically acceptable salt thereof is administered:

(i) as a single dose per 24 hour period (i.e., a single daily dose); and/or

(ii) In a total dose (i.e. total daily dose) of 50mg to 1000mg (particularly 200mg to 600mg, for example 300mg to 500mg) per 24 hour period.

20. The compound for use according to any one of the preceding claims, wherein valproic acid or a pharmaceutically acceptable salt thereof is administered:

(i) as a single dose per 24 hour period (i.e., a single daily dose); and/or (e.g., and)

(ii) At a dose sufficient to achieve at least a 20% (e.g., at least 30%) reduction in plasma levels of PAI-1.

21. The compound for use according to any one of the preceding claims, wherein the valproic acid or a pharmaceutically acceptable salt thereof is administered in such a way that the plasma concentration of valproic acid or a salt and/or metabolite thereof over the 24 hour period mimics the plasma concentration of PAI-1 over the same period.

22. The compound for use according to any one of the preceding claims, wherein the pathological condition associated with excessive fibrin deposition and/or thrombosis is selected from the group consisting of atherosclerosis, myocardial infarction, ischemic stroke, deep vein thrombosis, superficial vein thrombosis, thrombophlebitis, pulmonary embolism, disseminated intravascular coagulation, renal vascular disease and intermittent claudication.

23. The compound for use according to any one of the preceding claims, wherein the pathological conditions associated with excessive fibrin deposition and/or thrombosis are:

(a) ischemic stroke, e.g., major ischemic stroke and minor ischemic stroke; and/or

(b) Myocardial infarction.

24. A compound for use according to any one of the preceding claims, wherein the treatment or prevention is in a human.

25. A compound for use according to any one of the preceding claims, wherein the treatment or prevention is in a patient at high risk of developing a pathological condition associated with excessive fibrin deposition and/or thrombosis.

26. A compound for use according to any one of the preceding claims, wherein the treatment or prevention comprises administration of valproic acid or a pharmaceutically acceptable salt thereof in combination with aspirin, clopidogrel and/or ticagrelor.

27. A pharmaceutical composition comprising valproic acid or a pharmaceutically acceptable salt thereof, and optionally comprising one or more pharmaceutically acceptable excipients, for use in the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis as claimed in any one of claims 1 to 26.

28. A pharmaceutical composition comprising valproic acid or a pharmaceutically acceptable salt thereof, and optionally one or more pharmaceutically acceptable excipients, wherein the composition is in the form of a tablet or capsule for oral administration and is formulated such that substantially all of the valproic acid or pharmaceutically acceptable salt thereof is released over a period of 4 to 8 hours after administration.

29. The pharmaceutical composition of claim 28, wherein substantially all of the valproic acid or pharmaceutically acceptable salt thereof is released over a period of 6 to 8 hours after administration (e.g., 6 to 7 hours after administration, or such as 7 to 8 hours after administration, e.g., 8 hours after administration).

30. The pharmaceutical composition of any one of claims 27 to 29, wherein the composition further comprises aspirin, clopidogrel, and/or ticagrelor.

31. A pharmaceutical composition according to any one of claims 28 to 30 for use in the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis, wherein the treatment comprises administering the composition to the patient over a time period of from about 20:00 to 00: 00.

32. A pharmaceutical composition according to any one of claims 28 to 31 for use in the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis, wherein the treatment or prevention of a pathological condition associated with excessive fibrin deposition and/or thrombosis is as defined in any one of claims 1 to 26.

33. A use compound or composition, use, method or composition substantially as described herein with reference to the examples.