RU2847617C2 - Methods for treating chronic spontaneous urticaria using a bruton tyrosine kinase inhibitor - Google Patents

Abstract

FIELD: treatment of chronic spontaneous urticaria.

SUBSTANCE: a pharmaceutical composition for oral administration for the treatment of chronic spontaneous urticaria, comprising a compound of formula (I) in an amount of 10 mg, 20 mg, 25 mg or 50 mg and one or more pharmaceutically acceptable carriers.

EFFECT: provision of a safe and effective dose of the compound of formula (I).

9 cl, 11 dwg, 10 tbl, 3 ex

Description

Field of technology to which the invention relates

The present invention relates to methods for treating skin diseases caused by basophils and mast cells, such as chronic spontaneous urticaria (CSU), using a Bruton tyrosine kinase inhibitor.

Background of the invention

Urticaria is a heterogeneous group of diseases characterized by a pruritic urticarial rash and/or angioedema. Chronic urticaria is defined as urticaria that is present continuously or intermittently for more than 6 weeks ( Maurer M et al. (2013) Revisions to the international guidelines on the diagnosis and therapy of chronic urticaria. J Dtsch Dermatol Ges.; Bernstein JA, Lang DM, Khan DA, et al (2014) The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol; 133(5):1270–7). Chronic urticaria is further divided into two subgroups: chronic spontaneous urticaria (CSU) and inducible urticaria (IU), with the latter including physical urticaria such as heat, cold, and pressure urticaria, as well as special variants such as cholinergic urticaria. CSU is defined as the spontaneous occurrence of pruritic wheals, angioedema, or both for more than 6 weeks, with known or unknown causes ( Zuberbier T, et al. (2018) The EAACI/GA(2) LEN/EDF/WAO Guideline for the definition, classification, diagnosis, and management of urticaria: the 2017 revision and update. Allergy; 73(7):1393–1414 ). A combination of CSU with an inducible form of urticaria is possible, such as the frequently observed combination of symptomatic dermatographic urticaria and CSU.

Previously, all forms of chronic urticaria without a known trigger were called "chronic idiopathic urticaria" (CIU). Thanks to advances in medicine, it is now known that autoantibodies can actually be detected in some of the previously considered "idiopathic" forms of urticaria. However, the daily, unstable occurrence of symptoms in this type of chronic urticaria with autoantibodies remains unpredictable and is not triggered by an obvious trigger, resulting in spontaneous symptoms. To properly reflect in terminology the fact that some of the previously considered "idiopathic" forms may in fact have detectable autoantibodies, this population is now referred to as chronic spontaneous urticaria (CSU) in accordance with the International Guidelines ( Maurer M et al. (2013) Revisions to the international guidelines on the diagnosis and therapy of chronic urticaria. J Dtsch Dermatol Ges.; Zuberbier T, et al. (2018) The EAACI/GA(2) LEN/EDF/WAO Guideline for the definition, classification, diagnosis, and management of urticaria: the 2017 revision and update. Allergy; 73(7):1393–1414 ). The use of the expression "chronic idiopathic urticaria" in medical practice is no longer recommended. However, this new naming convention has not been implemented in all parts of the world, and in countries such as the United States, the patient population with chronic urticaria of non-specific etiology or with unknown triggers is still characterized as chronic idiopathic urticaria (CIU). According to the International Guidelines, for the sake of consistency, this nosological entity is referred to as CSU in this document.

The lifetime risk of developing CSU is approximately 1.8%, and up to 20% of patients with CSU may still have the disease after 20 years ( Greaves M (2000) Chronic urticaria. J Allergy Clin Immunol; 105(4):664–72; Zuberbier T, Balke M, Worm M, et al (2010) Epidemiology of urticaria: a representative cross-sectional population survey. Clin Exp Dermatol; 35(8):869–73). Affected patients often present with a pruritic urticarial rash with associated erythema and/or episodes of angioedema. Angioedema is reported to be associated with approximately 33-67% of CSU cases (Juhlin L (1981) Recurrent urticaria: a clinical investigation of 330 patients. Br J Dermatol; 104(4):369-81 ; Toubi E, Kessel A, Avshovich N, et al (2004) Clinical and laboratory parameters in predicting chronic urticaria duration: a prospective study of 139 patients. Allergy; 59(8):869-73; Zuberbier T, Balke M, Worm M, et al (2010) Epidemiology of urticaria: a representative cross-sectional population survey. Clin Exp Dermatol; 35(8):869-73; Maurer M, Weller K, Bindslev-Jensen C, et al (2011) Unmet clinical needs in chronic spontaneous urticaria. A GA²LEN task force report. Allergy; 66(3):317–30). The classic skin lesion of urticaria is a wheal and erythema with a pale, raised lesion and surrounding erythema ranging from a few millimeters to several centimeters across, which typically occur in clusters and often coalesce to form large, confluent lesions. CSU is associated with severe pruritus and has a major impact on patient well-being and quality of life, which appears to be comparable to that of severe coronary artery disease (Greaves MW (2003) Chronic idiopathic urticaria. Curr Opin Allergy Clin Immunol; 3(5):363–8. Review; Powell RJ, Du Toit GL, Siddique N, et al (2007) BSACI guidelines for the management of chronic urticaria and angioedema. Clin Exp Allergy; 37(5):631–50). Symptoms of urticaria and angioedema associated with urticaria negatively impact daily activities and sleep (O'Donnell BF, Lawlor F, Simpson J, et al (1997). The impact of chronic urticaria on the quality of life. Br J Dermatol; 136(2):197-201). Thus, in the management of patients with urticaria, patient-reported outcomes (e.g., DLQI) are important treatment indicators ( Kaplan A, et al. (2013) Omalizumab in patients with symptomatic chronic idiopathic/spontaneous urticaria despite standard combination therapy. J Allergy Clin Immunol; 132(1):101–9; Maurer M et al. (2013) Revisions to the international guidelines on the diagnosis and therapy of chronic urticaria. J Dtsch Dermatol Ges; Zuberbier T, Aberer W, Asero R, et al (2018) The EAACI/GA(2) LEN/EDF/WAO Guideline for the definition, classification, diagnosis, and management of urticaria: the 2017 revision and update. Allergy; 73(7):1393–1414 ).

The pathogenesis of CSU is not fully understood. Up to 50% of CSU cases are associated with histamine release-inducing autoantibodies to multiple antigens, including the high-affinity IgE receptor (FcεRI) or IgE antibodies; however, the clinical significance of these autoantibodies is not clearly established, although there are suggestions that they may be involved in the pathogenesis of the disease (Kaplan AP (2002) Chronic urticaria--new concepts regarding pathogenesis and treatment. Curr Allergy Asthma Rep; 2(4):263-4; Sabroe RA, Greaves MW (2006) Chronic idiopathic urticaria with functional autoantibodies: 12 years on. Br J Dermatol; 154(5):813-9. Review). It has also been suggested that basophils from patients with CSU may have distinct changes in FcεRIα-mediated degranulation, independent of any potential role for autoantibodies ( Eckman JA, et al. (2008) Basophil phenotypes in chronic idiopathic urticaria in relation to disease activity and autoantibodies. J Invest Dermatol; 128(8):1956-63).

Treating CSU is challenging, and non-sedating (second-generation) H1-antihistamines (H1-AH) are the mainstay of symptomatic therapy for CSU. Although H1-AH at approved doses provides relief to some patients, over 50% of patients fail to respond to H1-AH at standard doses. Even with a fourfold increase in dose compared to the approved dose, carried out in accordance with the second step of the treatment algorithm according to the current International guideline ( Zuberbier T, et al. (2018) The EAACI/GA(2) LEN/EDF/WAO Guideline for the definition, classification, diagnosis, and management of urticaria: the 2017 revision and update. Allergy; 73(7):1393–1414 ), a significant proportion of patients do not achieve control of urticaria symptoms ( Maurer M, Weller K, Bindslev-Jensen C, et al (2011) Unmet clinical needs in chronic spontaneous urticaria. A GA²LEN task force report. Allergy; 66(3):317–30; Marrouche N, Grattan C (2014) Update and insights into treatment options for chronic spontaneous urticaria. Expert Rev Clin Immunol; 10(3):397–403). For patients who fail to achieve disease control with four doses of H1-AH, the third step of the treatment algorithm according to the International Guidelines includes the addition of omalizumab, and in case of insufficient response to omalizumab, cyclosporine may be used as last-line therapy.

The experimental evidence for the efficacy of leukotriene receptor antagonists (LTRAs) in urticaria is low. With the advent of omalizumab (for off-label use), LTRAs are no longer recommended for the treatment of CSU refractory to H1-antihistamines ( Zuberbier 2018 ). Short courses (max. 10 days) of systemic corticosteroids may be added to tertiary treatment regimens if required due to exacerbations. Due to the adverse effects associated with chronic systemic corticosteroid exposure, longer courses of treatment are not recommended. Other treatment options that were previously used, such as intravenous immunoglobulin G, dapsone, hydroxychloroquine, H2-antihistamines (H2-AH), methotrexate, and cyclophosphamide, are characterized by an unfavorable risk-benefit ratio or a profile with significant side effects and are no longer recommended for the treatment of CSU (Kaplan AP (2002) Chronic urticaria--new concepts regarding pathogenesis and treatment . Curr Allergy Asthma Rep; 2(4):263-4 ; Powell RJ, Du Toit GL, Siddique N, et al (2007) BSACI guidelines for the management of chronic urticaria and angioedema. Clin Exp Allergy; 37(5):631-50; Zuberbier T, et al. (2018) The EAACI/GA(2) LEN/EDF/WAO Guideline for the definition, classification, diagnosis, and management of urticaria: the 2017 revision and update. Allergy; 73(7):1393-1414 ).

Omalizumab is an approved therapeutic agent for the treatment of CSU refractory to standard therapy and demonstrates a favorable benefit-risk ratio. It is a recombinant humanized monoclonal antibody of the IgG subclass ₁ that binds to IgE-specific epitopes within the C3 (FcεRI-binding) region of the IgE molecule. Its use is indicated in many countries for the treatment of poorly controlled moderate to severe asthma and CSU refractory to standard therapy. The exact mechanism of action of omalizumab in patients with CSU is unknown. Omalizumab is administered to patients with CSU as an injectable solution.

Despite the availability of treatments for CSU, there remains a high medical need for new treatment options for subjects with CSU. Less than 40% of subjects with CSU treated with second-generation H1-antihistamines do not respond adequately to treatment ( Guillén-Aguinaga et al 2016, Br J Dermatol; 175(6):1153-65 ). Furthermore, less than 50% of subjects treated with omalizumab achieve complete control of signs and symptoms of CSU ( Kaplan et al. 2016, J Allergy Clin Immunol; 137(2):474-81 ).

BRIEF DESCRIPTION OF THE PRESENT INVENTION

The aim of the present invention is to provide a new method for treating or preventing skin diseases caused by basophils and mast cells, such as chronic spontaneous urticaria and atopic dermatitis, in a subject in need of such treatment, comprising administering to said subject a therapeutically effective amount of N- (3-(6-amino-5-(2-( N -methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide.

Therefore, disclosed herein are methods for treating chronic spontaneous urticaria (CSU) comprising administering to a patient in need of such treatment a daily dose of from about 0.5 mg to about 600 mg, preferably from about 10 mg to about 200 mg, or more preferably at a daily dose of from about 10 mg to about 100 mg, of N- (3-(6-amino-5-(2-( N -methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide, which is a compound of formula (I),

(I), or a pharmaceutically acceptable salt thereof.

Also disclosed is N- (3-(6-amino-5-(2-(N-methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide; or a pharmaceutically acceptable salt thereof for use in the treatment of chronic spontaneous urticaria (CSU), wherein N- (3-(6-amino-5-(2-(N-methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof is administered in a daily dose of from about 0.5 mg to about 600 mg, preferably in a daily dose of from about 10 mg to about 200 mg, and most preferably in a daily dose of from about 10 to about 100 mg.

BRIEF DESCRIPTION OF GRAPHIC MATERIALS

Figure 1. Inhibitory effects of the compound of formula (I) in the reverse passive Arthus reaction.

Figure 2. BTK occupancy in the spleen 5 hours after dosing.

Figure 3. The compound of formula (I) inhibits PCA after sensitization with low doses of IgE.

Figure 4. BTK occupancy in the spleen during low-dose IgE sensitization.

Figure 5. Blood concentration versus time for compound (I) after single increasing doses in the range of 0.5 mg - 600 mg.

Figure 6. Blood concentration versus time for compound (I) after multiple ascending doses in the range 10 mg - 400 mg given q.d.

Figure 7. Blood concentration versus time for compound (I) after multiple ascending doses ranging from 100 mg bid to 200 mg bid.

Figure 8. Effect of food intake observed after a single oral dose of 60 mg of compound of formula (I).

Figure 9. The arithmetic mean (SD) of the percentage value of the degree of occupancy of BTK in peripheral blood after a single dose of the compound of formula (I).

Figure 10. Median percentage inhibition of basophil activation as a function of total daily dose of compound of formula (I) on day 12 of administration of multiple increasing doses of compound of formula (I).

Figure 11. Reduction in blister size in skin prick test with repeated increasing doses.

DETAILED DESCRIPTION OF THE INVENTION

Bruton tyrosine kinase (BTK) is a cytoplasmic tyrosine kinase and a member of the TEC kinase family. BTK is expressed in select cells of the adaptive and innate immune systems, including B cells, macrophages, mast cells/basophils, and platelets. BTK is required for signaling through the Fc epsilon receptor (FcεR1 for IgE) and activating Fc gamma receptors (FcγR for IgG), as well as through the B-cell antigen receptor (BCR) and BTK inhibitors. BTK inhibitors, such as ibrutinib, are approved for the treatment of B-cell malignancies (Hendriks et al 2014). Recently, it has been demonstrated that BTK inhibition results in inhibition of mast cell and basophil activation/degranulation in vitro and in a reduction in wheal size in skin prick tests in patients suffering from IgE-mediated allergy (Smiljkovic et al 2017; Regan et al 2017; Dispenza et al 2018). Therefore, BTK inhibition is an attractive therapeutic concept for the treatment of various autoimmune and chronic inflammatory diseases, including rheumatoid arthritis, multiple sclerosis, systemic lupus erythematosus, chronic urticaria, atopic dermatitis, asthma, and primary Sjögren's syndrome (Tan et al 2013; Whang and Chang 2014).

N- (3-(6-Amino-5-(2-(N-methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide is described in patent application WO2015/079417, filed June 4, 2015 (Attorney File Number PAT056021-WO-PCT). This compound is a selective, potent, irreversible covalent inhibitor of Bruton's tyrosine kinase (BTK).

According to the present invention, the inventors have demonstrated that N- (3-(6-amino-5-(2-(N-methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide effectively inhibits basophil activation in healthy volunteers and in atopic subjects who exhibit a pathomechanism similar to CSU, as measured by the level of inhibition of CD63 expression increase. Furthermore, the inventors have demonstrated that N- (3-(6-amino-5-(2-(N-methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide provides a reduction in wheal size in a skin prick test.

Accordingly, the present inventors have now developed dosage regimens for treating patients with CSU with a compound that is N- (3-(6-amino-5-(2-(N-methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof.

Definitions

For the purposes of interpreting this description, the following definitions shall apply and, where appropriate, terms used in the singular shall also include the plural and vice versa.

As used herein, the phrase "pharmaceutically acceptable" refers to those compounds, materials, compositions and/or dosage forms that are, within the scope of sound medical judgment, suitable for use in contact with the tissues of humans and animals without undue toxicity, irritation, allergic reaction or other problems or complications, consistent with an acceptable balance of benefit and risk.

Any formula provided herein is also intended to represent unlabeled forms as well as isotopically labeled forms of the compounds. Isotopically labeled compounds have the structures depicted by the formulas provided herein, except that one or more atoms are replaced by an atom characterized by a selected atomic mass or mass number. Isotopes that may be included in the compounds of the present invention include, for example, isotopes of hydrogen, carbon, nitrogen, oxygen, fluorine, iodine, and chlorine, such as ³ H, ¹¹ C, ¹³ C, ¹⁴ C, ¹⁵ N, ¹⁸ F, and ³⁶ Cl. Accordingly, it should be understood that the present invention provides compounds in which one or more of any of the above isotopes are incorporated, including, for example, radioactive isotopes such as ³ H and ¹⁴ C, or compounds in which non-radioactive isotopes such as ² H and ¹³ C are present. Such isotopically labeled compounds are useful in metabolism studies (using ¹⁴ C), reaction kinetics studies (using, for example, ² H or ³ H), detection or imaging techniques such as positron emission tomography (PET) or single photon emission computed tomography (SPECT), including in drug or substrate tissue distribution analyses, or in radioisotope treatment of patients. In particular, a compound labeled with ¹⁸ F may be particularly suitable for PET or SPECT studies. Isotopically labeled compounds can generally be prepared using conventional techniques known to those skilled in the art, for example, by using suitable isotopically labeled reagents in place of the unlabeled reagent previously used.

The term "pharmaceutical combination," as used herein, refers to a product obtained by mixing or combining more than one active ingredient. It should be understood that pharmaceutical combination, as used herein, includes both fixed and non-fixed combinations of active ingredients. The term "fixed combination" means that the active ingredients, such as a compound of formula (I) or a pharmaceutically acceptable salt thereof and one or more combination partners, are administered to a patient simultaneously in the form of a single preparation or dosage form. The term, in this case, refers to a fixed-dose combination in a single unit dosage form (e.g., a capsule, tablet, or sachet). Both the terms "non-fixed combination" and "kit of parts" mean that the active ingredients, for example, a compound of the present invention and one or more combination partners and/or one or more additional agents, are administered or co-administered to a patient independently as separate preparations, either simultaneously, in parallel, or sequentially without specific time limits, where such administration provides therapeutically effective levels of the two compounds in the patient's body, especially if these time intervals allow the combination partners to demonstrate a joint, for example, additive or synergistic, effect. The term "non-fixed combination" is also applied to "cocktail therapy", for example, to the administration of three or more active ingredients. The term "non-fixed combination" thus defines in particular the administration, use, composition, or formulation in the sense that the doses of the compounds described herein can be administered independently of one another, i.e., simultaneously or at different times. It should be understood that the term "non-fixed combination" also covers the use of a single agent together with one or more fixed combination products, wherein each independent formulation has different amounts of the active ingredients contained therein. It is also to be understood that the combination products described herein, as well as the term "non-fixed combinations", encompass active ingredients (including the compounds described herein) where the combination partners are administered as completely separate pharmaceutical dosage forms or as pharmaceutical formulations that are also marketed independently of one another. Instructions for use of a non-fixed combination are or may be provided in the packaging, such as a package insert, etc., or in the form of other information that is provided to physicians and/or healthcare personnel. The independent formulations or portions of the formulation, products or compositions may then be administered simultaneously or at specific intervals, meaning that each individual portion of the set of portions may be administered at different times and/or at the same or different time intervals for any portion of the set of portions. In particular, the time intervals for dosing are selected such that the effect on the disease being treated with the combined use of the portions is greater/stronger than the effect obtained with the use of only the compound of formula (I) or a pharmaceutically acceptable salt thereof; Thus, the compounds used in the pharmaceutical combination described herein are co-active. The ratio of the total amounts of the compound of formula (I) or a pharmaceutically acceptable salt thereof and the second agent to be administered as a pharmaceutical combination can be varied or adjusted to better suit the needs of a particular subpopulation of patients to be treated or the needs of an individual patient, where different needs may be related to the age, gender, body weight, etc. of the patients.

The terms "co-administration" or "combined administration" or similar terms as used herein should be understood to encompass the administration of one or more compounds described herein together with a selected combination partner to a single subject in need thereof (e.g., a patient or subject), and are intended to include treatment regimens in which the compounds are not necessarily administered by the same route of administration and/or at the same time.

The term "pharmaceutical composition" as defined herein refers to a mixture (e.g., a solution or emulsion) containing at least one active ingredient or therapeutic agent to be administered to a warm-blooded animal, such as a mammal or a human, in order to prevent or treat a specific disease or condition affecting the warm-blooded animal.

The term "therapeutically effective amount" of a compound (i.e., a compound of formula (I) or a pharmaceutically acceptable salt thereof) of the present invention refers to an amount of a compound of the present invention that will elicit a biological or medical response in a subject (patient or subject), such as a decrease or inhibition of enzyme or protein activity, or alleviate symptoms, alleviate conditions, slow down or restrain the progression of a disease, or prevent a disease, etc. A therapeutically effective dose of a compound, pharmaceutical composition, or combinations thereof depends on the patient's biological species, body weight, age, sex, and the individual condition, disorder, or disease being treated, or its severity. A physician, clinician, or veterinarian of ordinary skill can readily determine the effective amount of each of the active ingredients required to prevent, treat, or suppress the progression of a disorder or disease.

Dosing frequency may vary depending on the compound used and the specific condition being treated or prevented. Generally, the minimum dose sufficient to ensure effective therapy is preferred. Monitoring therapeutic efficacy in patients can generally be accomplished using assays appropriate to the condition being treated or prevented, as will be known to those skilled in the art.

As used herein, the terms "carrier" or "pharmaceutically acceptable carrier" include all possible solvents, dispersion media, coatings, surfactants, antioxidants, preservatives (e.g., antibacterial agents, antifungal agents), isotonicity agents, absorption delaying agents, salts, preservatives, drugs, drug stabilizers, binders, excipients, disintegrating agents, lubricants, sweeteners, flavoring agents, coloring agents, and the like, as well as combinations thereof, which will be known to those skilled in the art (see, for example, Remington's Pharmaceutical Sciences, 18th Ed. Mack Printing Company, 1990, pp. 1289-1329). Except where a conventional carrier is incompatible with the active ingredient, its use in therapeutic or pharmaceutical compositions is contemplated.

As used in this document, the term "subject" refers to an animal. Typically, the animal is a mammal. Subject also refers to, for example, primates (e.g., (humans, male or female), cows, sheep, goats, horses, dogs, cats, rabbits, rats, mice, fish, birds, etc. In certain embodiments, the subject is a primate. In a preferred embodiment, the subject is a human. The term "subject" is used interchangeably with "patient" when it refers to a human.

As used herein, a subject is "in need of" treatment if the treatment will result in the subject receiving a biological, medical, or quality of life benefit.

As used in this document, the phrase "patient population" means a group of patients.

The term "comprising" encompasses "including" as well as "consisting", e.g., a composition "comprising" X may consist solely of X or may include something additional, e.g., X+Y.

The term "approximately" when used in relation to a numerical value x means, for example, +/- 10%. When used before a numerical range or list of numbers, the term "approximately" applies to each number in the series, for example, the phrase "approximately 1-5" should be interpreted as "approximately 1 - approximately 5", or, for example, the phrase "approximately 1, 2, 3, 4" should be interpreted as "approximately 1, approximately 2, approximately 3, approximately 4, etc."

The term "treatment" or "treating" is defined herein as the use or administration of a compound of the present invention (a compound of formula (I), or a pharmaceutically acceptable salt thereof, or a pharmaceutical composition comprising said compound, to a subject or to isolated tissue or cell line from a subject, wherein the subject has a particular disease (e.g., CSU), a symptom associated with a disease (e.g., CSU), or a predisposition to developing a disease (e.g., CSU) (if applicable), wherein the objective is to cure (if applicable), delay the onset of development, reduce the severity, alleviate, alleviate one or more symptoms of the disease, improve the course of the disease, reduce or decrease the manifestation of any associated symptoms of the disease or predisposition to developing the disease. The term "treatment" or "treating" includes the treatment of a patient suspected of having a disease, as well as sick patients and patients who have been diagnosed as suffering from a disease or medical condition, and includes the suppression of a clinical relapse.

As used herein, the phrases "naive to systemic treatment for CSU" or "treatment naive" refer to a patient with CSU who has not previously been treated with a systemic agent, such as cyclosporine A, montelukast, H1-antihistamines (H1-AH), H2-antihistamines (H2-AH), and a leukotriene receptor antagonist (LTRA), a biologic agent (e.g., omalizumab), etc., for the treatment of CSU. Systemic agents (i.e., agents administered orally, by injection, etc.) differ from locally acting agents (e.g., topical agents and phototherapy) in that systemic agents have a systemic (body-wide) effect when delivered to the patient. In some embodiments of the disclosed methods, regimens, uses, kits, and pharmaceutical compositions, the patient has not previously been administered a systemic agent for the treatment of CSU.

As used herein, the phrase "previously treated with a systemic agent for the treatment of CSU" is used to refer to a patient who has previously been treated for CSU using a systemic agent. Such patients include patients previously treated with H1 antihistamines or biologics such as omalizumab, and patients previously treated with non-biologic agents such as cyclosporine. In some embodiments of the present invention, the patient has previously been administered a systemic agent for the treatment of CSU. In some embodiments, the patient has previously been administered a systemic agent for the treatment of CSU (e.g., cyclosporine), but the patient has not previously been administered a systemic biologic drug (i.e., a drug produced by a living organism, such as antibodies, decoy receptors, etc.) for the treatment of CSU (e.g., omalizumab). In this case, the patient is referred to as "biologic-naive." In some embodiments, the patient is biologic-naive.

As used in this document, the terms "selection" and "selected" when used with respect to a patient mean that a specific patient is specifically selected from a larger group of patients based on the fact that the specific patient meets predetermined criteria. Similarly, "selective treatment" refers to providing treatment to a patient with a specific disease, wherein the patient is specifically selected from a larger group of patients based on the specific patient meeting a predetermined criterion. Similarly, "selective administration" refers to administering a medicinal product to a patient who is specifically selected from a larger group of patients based on the fact that the specific patient meets a predetermined criterion. By "selection," "selective treatment," and "selective administration" is meant that a patient is provided with personalized therapy based on the patient's personal history (e.g., prior therapeutic interventions, such as prior treatment with biologics), the patient's biology (e.g., specific genetic markers), and/or the patient's presentation (e.g., failure to meet certain diagnostic criteria), rather than a standard treatment regimen based solely on the patient's membership in a larger group. Selection, as applied to treatment in the context of this document, does not refer to randomly treating a patient who meets a specific criterion, but rather refers to a deliberate decision made regarding the administration of a medicinal product to a patient based on the patient's meeting a specific criterion. Thus, selective treatment/administration differs from standard treatment/administration, which ensures that a particular medicinal product is delivered to all patients with a particular disease, regardless of their personal history, disease presentation, and/or biological characteristics. In some embodiments, the patient is selected for treatment based on the presence of CSU.

Embodiments of the present invention

Chronic urticaria and the efficacy of treatment according to the present invention

The disclosed BTK inhibitor, i.e., the compound of formula (I) or a pharmaceutically acceptable salt thereof, can be used in vitro, ex vivo, or incorporated into pharmaceutical compositions and administered in vivo to treat patients with CSU (e.g., human patients).

Urticaria is a heterogeneous group of diseases characterized by a pruritic urticarial rash and/or angioedema.

Chronic urticaria is defined as urticaria that is persistent or intermittent for more than 6 weeks (Maurer et al 2013, Bernstein et al 2014). Chronic urticaria is further divided into two subgroups: chronic spontaneous urticaria (CSU) and inducible urticaria (IU), with the latter including physical urticaria, such as heat, cold, and pressure urticaria, as well as special variants, such as cholinergic urticaria. CSU is defined as the spontaneous occurrence of pruritic wheals, angioedema, or both for ≥ 6 weeks due to known or unknown causes (Zuberbier et al. 2018). A combination of CSU with an inducible form of urticaria is possible, such as the frequently observed combination of asymptomatic dermatographic urticaria and CSU.

The effectiveness of CSU treatment is assessed using various established methods and instruments that measure CSU disease status and/or clinical response. Some examples include, for example, the Urticaria Daily Diary (UPDD), the Angioedema Activity Score (AAS), the Urticaria Severity Score (HSS7), the Pruritus Severity Score (ISS7), the Urticaria Activity Score (UAS7), and improvement in health-related quality of life measured by the Dermatology Life Quality Index (DLQI).

Urticaria Daily Diary (UPDD)

The UPDD includes an urticaria activity score (UAS), which assesses twice daily the severity of itching and number of urticaria lesions, use of rescue medications, impact on sleep and activity, incidence of angioedema, its treatment, and records calls to the health care professional (HCP).

The components are presented in Table 1 and the corresponding weekly estimates

are described below.

Table 1. UPDD

Diary component Evaluation time Urticaria Activity Score (UAS) In the morning and in the evening - Severity of itching - Number of elements of urticaria rash Impact on morning sleep In the morning Impact on daily activity in the evening In the evening Use of emergency medications in the evening In the evening Angioedema
- Did the patient have an episode?
- If the patient had an episode, how was he treated? Calls to a health professional In the evening

In some embodiments, when a population of patients with CSU is treated in accordance with the disclosed methods, the patient achieves an improved UPDD score.

Urticaria Severity Score (HSS7)

The urticaria (wheal) severity rating, defined as the number of urticaria lesions, was recorded by the subject twice daily in their electronic diary on a scale from 0 (none) to 3 (>12 urticaria lesions/12 hours; Table 2). The weekly score (HSS7) was calculated by summing the average daily scores for the 7 days preceding the visit. Thus, the possible range of weekly scores was 0 to 21.

Table 2. Urticaria severity assessment

Grade Number of hives (wheals) (every 12 hours) 0 None 1 1-6 elements of nettle rash/12 hours 2 7-12/12 hours 3 12 hives/12 hours

In some embodiments, when a population of patients with CSU is treated according to the disclosed methods, the urticaria severity score (HSS7) is improved by at least 5 points. Moreover, compared to the placebo group, the difference between the treatment group and the placebo group is at least 4 points, preferably at least 5 points. In one embodiment, when a patient is treated according to the disclosed methods, the urticaria severity score (HSS7) is less than 6, preferably less than 4, preferably less than 2 points, and most preferably the HSS7 score is 0 points.

Weekly Severity of Pruritus Assessment (ISS7)

The degree of itching intensity is recorded by the subject twice a day in his electronic diary on a scale from

0 (none) to 3 (severe) (Table 3). The weekly score (ISS7) was calculated by summing the average daily scores for the 7 days preceding the visit. Thus, the possible range of weekly scores was 0 to 21.

Table 3. Assessment of itching severity

Grade Pruritis (itching) (every 12 hours) 0 Absent 1 Light (minimal sensation, easily tolerated) 2 Moderate (a distinct sensation, disturbing but tolerable) 3 Strong (hard to bear)

In some embodiments, when a population of patients with CSU is treated according to the disclosed methods, the pruritus severity score (ISS7) is improved by at least 5 points. Moreover, compared to the placebo group, the difference between the treatment group and the placebo group is at least 4 points, preferably at least 5 points. In one embodiment, when a patient is treated according to the disclosed methods, the pruritus severity score (ISS7) is less than 6, preferably less than 4, preferably less than 2 points, and most preferably the ISS7 score is 0 points.

Urticaria Activity Score (UAS7)

The UAS7 score is the sum of the HSS7 and ISS7 scores. The possible range of weekly

UAS7 scores range from 0 to 42 (maximum activity).

In some embodiments, a patient with CSU achieves an improved UAS7 score in response to treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof.

In a preferred embodiment, when treated with the method of the present invention, a patient with CSU experiences a reduction in the number of urticaria elements and a reduction in pruritus, characterized by a UAS7 score of ≤6, by week 4 or by week 12.

In a most preferred embodiment, when treated with the method of the present invention, a patient with CSU experiences a complete absence of urticaria and pruritus by week 12, which is assessed as UAS7=0.

Moreover, compared with the placebo group, the difference between the treatment group and the placebo group is at least 8 points, preferably at least 10 points.

Weekly sleep impact assessment

The impact on sleep is assessed by the subject once a day in the morning in an electronic diary.

is rated on a scale from 0 to 3. Weekly ratings range from 0 to 21 (Table 4).

Table 4. Assessment of the impact on sleep

Grade Impact on sleep 0 There is no influence 1 Mild, minor impact on sleep 2 Moderate, some awakening, some influence on sleep 3 Significant, frequent awakening, strong influence on sleep

In some embodiments, when a population of patients with CSU is treated in accordance with the disclosed methods, the sleep impact score is improved by at least 5 points. In a preferred embodiment, when a patient is treated in accordance with the disclosed methods, the sleep impact score is less than 6, preferably less than 4, preferably less than 2 points, and most preferably the sleep impact score is 0 points.

Weekly assessment of impact on activity

Subjects rate their impact on daily activity on a scale of 0 to 3 once daily in the evening in an electronic diary. Activities of daily living may include work, school, sports, hobbies, and activities done with friends and family. Weekly impact scores range from 0 to 21 (Table 5).

Table 5. Assessment of the impact on daily activities

Grade Impact on daily activities 0 There is no influence 1 Mild, minor impact on daily activities 2 Moderate, some impact on daily activities 3 Significant, severe impact on daily activities

In some embodiments, when a population of patients with CSU is treated according to the disclosed methods, the activity impact score is improved by at least 5 points. In a preferred embodiment, when a patient is treated according to the disclosed methods, the weekly activity impact score is less than 6, preferably less than 4, preferably less than 2 points, and most preferably the weekly activity impact score is 0 points.

Use of H1-antihistamines for emergency use

The number of tablets of the relief medication taken in the last 24 hours to control conditions such as itching or hives is recorded by the subject once a day in the evening in an electronic diary. Daily dose

The dosage of an emergency drug is calculated as the number of tablets per day multiplied by the dose

of each tablet, then the weekly dose of the emergency medication is calculated as the sum of the daily dose for 7 days.

In some embodiments, when a population of patients with CSU is treated according to the disclosed methods, the number of weekly doses of the rescue medication is reduced. In one aspect of this embodiment, the use of the rescue medication is no longer necessary.

Number of phone calls made to a doctor or nurse

Number of telephone calls made to a physician, nurse, or nurse practitioner due to the subject's skin condition

recorded by the subject once a day in an electronic diary.

Angioedema Activity Score (AAS)

The AAS is recorded by the subject once daily in the evening in an electronic diary. This validated instrument assesses the frequency and severity of angioedema episodes (Weller et al (2013), Allergy 68(9): 1185-92). The frequency of angioedema episodes is recorded by the subject once daily in the evening in an electronic diary. Actions and/or treatments associated with these angioedema episodes are also recorded in the electronic diary as follows (multiple responses are possible):

Did nothing

Taking prescription or over-the-counter medications

Call your doctor, nurse, or nurse practitioner

Visited your doctor, nurse, or nurse practitioner

Went to the emergency room at the hospital

Was hospitalized

If subjects answer "no" to the introductory question, the AAS score for that day is 0. If the answer to the introductory question is "yes," the subject continues to answer questions about the duration, severity, impact on daily functioning, and occurrence of angioedema.

Each response field is assigned a score from 0 to 3. The AAS score in this study

is presented as a weekly AAS (AAS7) score. The minimum and maximum possible scores on the AAS7 scale are 0 and 105, respectively.

A higher score indicates a higher degree of severity.

In some embodiments, when a population of patients with CSU is treated in accordance with the disclosed methods, the patients achieve a reduction in AAS7 score, preferably to 0 points on the AAS7 scale, by week 12 of treatment. In another aspect of this embodiment, the patient achieves 0 on the AAS7 scale over several weeks, such as over at least 4 weeks of treatment, at least 8 weeks of treatment, or over the entire 12 weeks of treatment.

In some embodiments, when a population of patients with CSU is treated in accordance with the disclosed methods, patients achieve ≥95.5% angioedema-free days (AAS=0) from week 4 to week 12.

Moreover, when compared with the placebo group, the difference between the treatment group and the placebo group is at least 6%.

Dermatology Life Quality Index (DLQI)

The Dermatology Quality of Life Index (DLQI) is a measure of quality of life (QoL) related to skin conditions (Finlay et al 1994). The DLQI has been validated in patients aged 16 years and older. Subjects rate their dermatological symptoms and the impact of their skin condition on various aspects of their lives, taking into account the previous 7 days.

A total score is calculated and ranges from 0 to 30 (a higher score indicates worse disease-related QoL). Domain scores are calculated for the following: symptoms and feelings (0-6), daily activities

(0-6), leisure (0-6), work and school (0-3), personal relationships (0-6), treatment (0-3).

The overall range of DLQI scores was divided into specific score zones (Hongbo et al 2005) and validated against

their meaning/significance for patients as follows.

Table 6. DLQI assessment zones and their impact on the patient's life

DLQI Zone Assessment Value

0-1 No impact on the patient's life 2-5 Minor impact on patient's life 6-10 Moderate impact on patient's life 11-20 Very big impact on the patient's life 9:30 PM Extremely large impact on the patient's life

A DLQI score > 10 indicates a very high impact on patients' lives and is a justification for

prescribing a biological agent, such as for psoriasis (Kaplan et al 2005). DLQI questionnaires

completed at randomization (day 1), week 4 (day 29), and week 12 (day 85) in the electronic diary.

The DLQI assessment should be performed before any other assessment and before administration

a compound of formula (I) or a pharmaceutically acceptable salt thereof.

In some embodiments, a patient with CSU achieves an improvement in the DLQI score in response to treatment with a compound of Formula (I) or a pharmaceutically acceptable salt thereof. In some embodiments, a patient with CSU achieves a DLQI score of 0 or 1 point at week 4 or week 12 of treatment.

Chronic Urticaria Index (CU Index)

The CU-Index® is a commercially available in vitro basophil histamine release assay in which patient serum is mixed with donor basophils, and levels of released histamine are measured using a quantitative enzyme-linked immunosorbent assay. A CU-Index value of 10 or greater indicates that the patient has either an autoimmune basis for their disease (anti-IgE, FcεRI, or anti-FcεRII antibodies; a positive result does not identify the specific autoantibody) or an alternative histamine-releasing factor ( Biagtan MJ, Viswanathan RK, Evans MD, et al (2011) Clinical utility of the Chronic Urticaria Index. J Allergy Clin Immunol; 127(6):1626-7).

In some embodiments, a patient with CSU exhibits a reduction in titers of antibodies associated with the pathogenesis of CSU (e.g., autoantibodies to IgE, FcεRI, or antibodies to FcεRII) in response to treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof.

In another embodiment, a patient with CSU exhibits a reduction in the CU index value in response to treatment with a compound of Formula (I) or a pharmaceutically acceptable salt thereof. In some embodiments, the patient with CSU achieves a reduction in the CU index to less than 10 at week 4 or week 12 of treatment.

In some embodiments, the patient is treated with CSU according to the disclosed methods for at least 4 weeks, at least 12 weeks, at least 16 weeks, at least 48 weeks, or at least 2 years.

In a preferred embodiment, the patient has previously shown an inadequate response to conventional systemic therapy for CSU (e.g., second-generation H1 antihistamines).

In other preferred embodiments, the patient is an adult patient ( > 18 years of age) with moderate to severe CSU. Moderate to severe CSU is defined as CSU in which the patient has a 7-day urticaria activity score (UAS7) of ≥16 and/or a 7-day urticaria severity score (HSS7) of ≥8.

In some embodiments, in response to treatment according to the disclosed methods, the patient exhibits a rapid reduction in urticaria pruritus, as measured by the UAS7 score, as early as 4 weeks after the initial dose or 12 weeks after the initial dose. In a preferred embodiment, the patient exhibits a reduction in the number of urticaria lesions and pruritus, achieving a UAS7 score of ≤6 at week 4 or week 12. In a most preferred embodiment, the patient exhibits a complete absence of urticaria lesions and pruritus (UAS7=0) at week 4 or week 12.

In some embodiments, in response to treatment according to the disclosed methods, the patient exhibits a rapid reduction in the incidence and severity of angioedema, as measured by the AAS7 score, as early as 4 weeks after the initial dose or as early as 12 weeks after the initial dose. In one embodiment, the patient exhibits a complete absence of angioedema for at least 8 weeks out of 12 weeks of treatment (measured as an AAS7 score of zero for at least 8 weeks out of 12 weeks of treatment). In a preferred embodiment, the patient exhibits a complete absence of angioedema for the entire treatment period (measured as an AAS7 score of zero for a 12-week period).

In some embodiments, in response to treatment with the claimed methods, the patient experiences a decrease in titers of antibodies associated with the pathogenesis of CSU (autoantibodies to IgE, FcεRI, or antibodies to FcεRII) and/or a decrease in the CU index value to less than 10.

Pharmaceutical composition

A BTK inhibitor, i.e., a compound of formula (I) or a pharmaceutically acceptable salt thereof, can be used as a pharmaceutical composition in combination with a pharmaceutically acceptable carrier. Such a composition may contain, in addition to the compound of formula (I) or a pharmaceutically acceptable salt thereof, carriers, various diluents, fillers, salts, buffers, stabilizers, solubilizers, and other materials known in the art. The characteristics of the carrier depend on the route of administration. Pharmaceutical compositions for use in the disclosed methods may also contain additional therapeutic agents for the treatment of a particular target disorder. For example, the pharmaceutical composition may also include anti-inflammatory and antipruritic agents. Such additional factors and/or agents may be included in the pharmaceutical composition to obtain a synergistic effect with the compound of formula (I) or a pharmaceutically acceptable salt thereof, or to minimize the side effects caused by the compound of formula (I) or a pharmaceutically acceptable salt thereof. In preferred embodiments, the pharmaceutical composition for use in the disclosed methods comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof at a dose of about 5 mg, about 10 mg, about 20 mg, about 25 mg, about 50 mg, or about 100 mg.

Suitable compositions for oral administration include an effective amount of a compound of the present invention in the form of tablets, lozenges, aqueous or oily suspensions, dispersible powders or granules, emulsions, hard or soft capsules, or syrups or tinctures. Compositions intended for oral use are prepared according to any method known in the art for the manufacture of pharmaceutical compositions, and such compositions may contain one or more agents selected from the group consisting of sweetening agents, flavoring agents, coloring agents and preservatives, in order to obtain preparations that are pharmaceutically aesthetic and palatable. Tablets may contain the active ingredient in admixture with non-toxic pharmaceutically acceptable excipients that are suitable for the manufacture of tablets. Such excipients are, for example, inert diluents such as calcium carbonate, sodium carbonate, lactose, calcium phosphate or sodium phosphate; Granulating and disintegrating agents, such as corn starch or alginic acid; binding agents, such as starch, gelatin, or acacia; and lubricating agents, such as magnesium stearate, stearic acid, or talc. Tablets are uncoated or coated by known techniques to delay disintegration and absorption in the gastrointestinal tract and thus provide sustained action over a longer period. For example, a delayed-release material such as glyceryl monostearate or glyceryl distearate can be used. Formulations for oral use may be presented as hard gelatin capsules in which the active ingredient is mixed with an inert solid diluent, such as calcium carbonate, calcium phosphate, or kaolin, or as soft gelatin capsules in which the active ingredient is mixed with water or an oily vehicle, such as peanut oil, liquid paraffin, or olive oil.

Pharmaceutical compositions for use in the disclosed methods can be prepared in a conventional manner. In one embodiment, the pharmaceutical composition is for oral administration. For example, the pharmaceutical compositions are tablets or gelatin capsules containing the active ingredient together with

a) diluents such as lactose, dextrose, sucrose, mannitol, sorbitol, cellulose and/or glycine;

b) lubricants, such as silicon dioxide, talc, stearic acid, its magnesium or calcium salt and/or polyethyleneglycol; in the case of tablets also with

c) binding agents, such as magnesium aluminum silicate, starch paste, gelatin, tragacanth, methylcellulose, sodium carboxymethylcellulose and/or polyvinylpyrrolidone; if necessary

d) disintegrating agents, such as types of starch, agar, alginic acid or its sodium salt or effervescent mixtures; and/or

e) absorbents, coloring agents, flavorings and sweeteners.

The tablets may be either film-coated or enteric-coated according to methods known in the art.

Combinations

In practicing certain treatment methods or uses of the present invention, a therapeutically effective amount of a compound of formula (I) or a pharmaceutically acceptable salt thereof is administered to a patient, such as a mammal (e.g., a human). While it is understood that the disclosed methods involve treating patients with CSU using a compound of formula (I) or a pharmaceutically acceptable salt thereof, the therapy is not necessarily monotherapy. Indeed, if a patient is selected for treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof, the compound of formula (I) or a pharmaceutically acceptable salt thereof can be administered in accordance with the methods of the present invention either alone or in combination with other agents and therapeutic agents for treating patients with CSU, such as in combination with at least one additional agent for treating CSU. When co-administered with one or more additional agents for treating CSU, the compound of formula (I) or a pharmaceutically acceptable salt thereof can be administered either simultaneously with the other agent or sequentially. When administered sequentially, the attending physician will decide on the appropriate sequence of administration of the compound of formula (I) in combination with the other agents and the appropriate dosages for co-delivery.

In the treatment of CSU, various therapeutic agents may be combined with the disclosed compound of formula (I) to provide a beneficial effect. Such therapeutic agents include topical treatments (creams [non-steroidal or steroidal], washes, antiseptics), systemic treatments (e.g., using biologics, antibiotics, or chemicals) and antiseptics, photodynamic therapy, and surgery (laser treatment, drainage or incision, excision).

Non-limiting examples of topical agents for the treatment of CSU for use with the disclosed compound of formula (I) or a pharmaceutically acceptable salt thereof include benzoyl peroxide, topical steroid creams, topical aminoglycoside antibiotics such as clindamycin, gentamicin and erythromycin, resorcinol cream, iodine scrubs and chlorhexidine.

Non-limiting examples of agents for the treatment of CSU used in systemic treatment envisaged for use with the disclosed compound of formula (I) or a pharmaceutically acceptable salt thereof include IgE antagonists (omalizumab, ligezumab).

Additional agents for the treatment of CSU contemplated for use in combination with the disclosed compound of formula (I) in the treatment of CSU include cyclosporine and corticosteroids (injectable or oral).

One skilled in the art will be able to determine appropriate doses of the above CSU treatment agents for co-delivery with the disclosed compound of formula (I) or a pharmaceutically acceptable salt thereof.

Kits of the present invention

The present invention also provides kits for the treatment of CSU. Such kits comprise a BTK inhibitor, such as a compound of formula (I), or a pharmaceutical composition thereof. In one embodiment, the kit comprises two or more separate pharmaceutical compositions, at least one of which comprises a compound of formula (I) or a pharmaceutically acceptable salt thereof. In one embodiment, the kit comprises means for separately containing said compositions, such as a container, a divided bottle, or a divided foil pouch. An example of such a kit is a blister pack, typically used for packaging tablets, capsules, etc.

The kit of the present invention can be used to administer various dosage forms, such as oral and parenteral administration, to administer individual compositions at different dosing intervals, or to titrate individual compositions relative to one another. To facilitate compliance, the kit of the present invention typically includes instructions for administration.

In the combination therapies of the present invention, the compound of formula (I) or a pharmaceutically acceptable salt thereof and the other agent for treating CSU (as defined herein) may be manufactured and/or formulated by the same or different manufacturers. Furthermore, the compound of formula (I) or a pharmaceutically acceptable salt thereof and the other agent for treating CSU may be combined to form a combination therapy: (i) before the combination product reaches the physician (e.g., in the case of a kit containing a compound of formula (I) or a pharmaceutically acceptable salt thereof and another agent for the treatment of CSU); (ii) by the physicians themselves (or under the supervision of a physician) shortly before administration; (iii) in the patient's body, for example, when a compound of formula (I) or a pharmaceutically acceptable salt thereof is administered sequentially and another agent for the treatment of CSU.

Additional embodiments

The compound of formula (I) or a pharmaceutically acceptable salt thereof is conveniently administered to a patient (preferably orally) at a dose of from about 10 mg to about 200 mg per day.

The compound of formula (I) or a pharmaceutically acceptable salt thereof is conveniently administered to a patient (preferably orally) in a daily dose of from about 10 mg to about 200 mg per day.

In some embodiments, the compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of from about 10 mg to about 100 mg.

In some embodiments, the compound of Formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of about 10 mg, about 20 mg, about 25 mg, about 35 mg, about 50 mg, about 100 mg, or about 200 mg.

In other embodiments, the compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of about 100 mg.

In other embodiments, the compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of about 50 mg.

In other embodiments, the compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of about 35 mg.

In other embodiments, the compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of about 25 mg.

In other embodiments, the compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of about 20 mg.

In one embodiment, the compound of formula (I) or a pharmaceutically acceptable salt thereof is administered once daily at a dose of about 10 mg, about 35 mg, about 50 mg, or about 100 mg.

In another embodiment, the compound of formula (I) or a pharmaceutically acceptable salt thereof is administered twice daily at a dose of about 10 mg, about 25 mg, about 50 mg, or about 100 mg.

It should be understood that some patients may require a dose increase, such as CSU patients who exhibit an insufficient response (e.g., as measured by any of the CSU scoring systems disclosed herein, such as by the method of any of the preceding claims, wherein said patient achieves a sustained response, measured as a complete response (Urticaria and Pruritus Severity Score UAS7) and as a Dermatology Life Quality Index (DLQI), etc.), to treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof by week 4 or week 12 of treatment. It will also be understood that a dose reduction may also be required for certain patients, such as CSU patients who exhibit adverse events or an adverse reaction to treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof. Thus, dosages of a compound of formula (I) or a pharmaceutically acceptable salt thereof may be less than about 10 mg, about 20 mg, about 25 mg, about 50 mg, or about 100 mg.

The dosing time frame is typically measured from the day of administration of the first dose of the compound of formula (I) or its pharmaceutically acceptable salt (also known as the "baseline"). The dosing time frame is typically measured from the day of administration of the first dose of the compound of formula (I) or its pharmaceutically acceptable salt (also known as the "baseline").

However, healthcare professionals often use different naming conventions to identify dosing schedules. For clarity, as described herein, the first day of dosing is referred to as day 1. However, one skilled in the art will understand that this naming convention is used simply for consistency and should not be construed as limiting. That is, daily dosing represents the delivery of a daily dose of a compound of formula (I) or a pharmaceutically acceptable salt thereof, and the physician may refer to a specific day as "day 0" or "day 1."

Disclosed herein are methods for treating chronic spontaneous urticaria (CSU), comprising administering to a patient in need thereof a compound of formula (I) or a pharmaceutically acceptable salt thereof at a dose of from about 10 mg to about 200 mg.

This document also discloses methods for treating chronic spontaneous urticaria (CSU), comprising administering to a patient in need thereof a compound of formula (I) or a pharmaceutically acceptable salt thereof in a daily dose of from about 10 mg to about 200 mg.

Also disclosed herein is a compound of formula (I) or a pharmaceutically acceptable salt thereof for use in the treatment of CSU, wherein the daily dose of the compound is from about 10 mg to about 200 mg.

In one embodiment of the disclosed methods, uses, and kits, the compound of formula (I) or a pharmaceutically acceptable salt thereof is administered in a daily dose of from about 10 mg to about 100 mg.

In another embodiment of the disclosed methods, uses and kits, the compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of about 10 mg, about 20 mg, about 25 mg, about 35 mg, about 50 mg, about 100 mg or about 200 mg.

In another embodiment of the disclosed methods, uses and kits, the compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of about 100 mg.

In another embodiment of the disclosed methods, uses and kits, the compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of approximately 50 mg.

In another embodiment of the disclosed methods, uses and kits, the compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of approximately 35 mg.

In another embodiment of the disclosed methods, uses and kits, the compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of approximately 25 mg.

In another embodiment of the disclosed methods, uses and kits, the compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a daily dose of approximately 20 mg.

In another embodiment of the disclosed methods, uses and kits, the compound of formula (I) or a pharmaceutically acceptable salt thereof is administered once daily at a dose of about 10 mg, about 35 mg, about 50 mg, or about 100 mg.

In another embodiment of the disclosed methods, uses and kits, the compound of formula (I) or a pharmaceutically acceptable salt thereof is administered at a dose of about 10 mg, about 25 mg, about 50 mg, or about 100 mg twice daily.

In another embodiment of the disclosed methods, uses, and kits, prior to treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof, the patient has previously received treatment with a systemic agent for the treatment of CSU. In one aspect of this embodiment, the systemic agent is selected from the group consisting of H1-antihistamines (H1-AH), H2-antihistamines (H2-AH), and a leukotriene receptor antagonist (LTRA), and combinations thereof.

In another embodiment of the disclosed methods, uses and kits, prior to treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof, the patient has not previously received treatment with a systemic agent for the treatment of CSU.

In another embodiment of the disclosed methods, uses, and kits, prior to treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof, the patient has CSU of moderate to severe severity; i.e., the patient has a UAS7 score ≥16 and/or an HSS7 score ≥8.

In another embodiment of the disclosed methods, uses and kits, prior to treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof, the patient has either an autoimmune basis for their disease (autoantibodies to IgE, FcεRI or antibodies to FcεRII) or an alternative histamine releasing factor.

In another embodiment of the disclosed methods, uses, and kits, prior to treatment with a compound of Formula (I) or a pharmaceutically acceptable salt thereof, the patient has a CU index of 10 or greater. In a particular aspect of this embodiment, by week 4 or week 12 of treatment, the patient achieves a reduction in the CU index to less than 10.

In another embodiment of the disclosed methods, uses, and kits, the patient is selected according to at least one of the following criteria:

a) prior to treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof, the patient had a UAS7 score ≥16;

b) prior to treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof, the patient had an HSS7 score ≥8.

In another embodiment of the disclosed methods, uses, and kits, the patient is an adult.

In another embodiment of the disclosed methods, uses, and kits, by week 4 or week 12 of treatment, the patient achieves at least one of the following:

a) a decrease in the number of urticaria elements and a decrease in itching, measured as UAS≤6, or a complete absence of urticaria and itching (UAS7=0);

b) Dermatological Life Quality Index (DLQI), ranging from 0 to 1;

c) absence of angioedema, measured as an angioedema activity score (AAS7) of zero.

In another embodiment of the disclosed methods, uses, and kits, the patient achieves a sustained response measured as a complete response including urticaria and pruritus ([UAS7]=0) and/or a Dermatology Life Quality Index (DLQI) of 0-1 and/or continued freedom from angioedema (AAS7=0) by week 4 after completion of treatment.

Additional Numbered Embodiments

1. A method for treating chronic spontaneous urticaria (CSU) comprising administering to a subject in need thereof a daily dose of from about 10 mg to about 200 mg of N- (3-(6-amino-5-(2-( N -methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof.

2. The method according to embodiment 1, wherein the daily dose of N- (3-(6-amino-5-(2-( N- methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof is from about 10 mg to about 100 mg.

3. The method according to embodiment 1, wherein the daily dose of N- (3-(6-amino-5-(2-( N- methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof is about 100 mg.

4. The method according to embodiment 1, wherein the daily dose of N- (3-(6-amino-5-(2-( N- methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof is about 50 mg.

5. The method according to embodiment 1, wherein the daily dose of N- (3-(6-amino-5-(2-( N- methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof is approximately 35 mg.

6. The method according to embodiment 1, wherein the daily dose of N- (3-(6-amino-5-(2-( N- methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof is about 25 mg.

7. The method according to embodiment 1, wherein the daily dose of N- (3-(6-amino-5-(2-( N- methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof is about 20 mg.

8. The method according to embodiment 1, wherein N- (3-(6-amino-5-(2-( N -methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof is administered once a day at a dose of about 10 mg, about 35 mg, about 50 mg, or about 100 mg.

9. The method according to embodiment 1, wherein N- (3-(6-amino-5-(2-( N -methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof is administered at a dose of about 10 mg, about 25 mg, about 50 mg, or about 100 mg twice daily.

10. The method according to any of the previous embodiments, wherein prior to treatment the subject has previously received treatment with a systemic agent for the treatment of CSU.

11. The method according to embodiment 10, wherein the systemic agent is selected from the group consisting of H1-antihistamines (H1-AH), H2-antihistamines (H2-AH), and a leukotriene receptor antagonist (LTRA), and combinations thereof.

12. The method according to any one of embodiments 1-9, wherein prior to treatment the subject has not previously received treatment with a systemic agent for the treatment of CSU.

13. The method according to any of the previous embodiments, wherein the subject has CSU with a severity ranging from moderate to severe.

14. The method according to any one of embodiments 1-13, wherein the subject is selected according to at least one of the following criteria:

(a) prior to treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof, the subject has a UAS7 score ≥16;

b) prior to treatment with a compound of formula (I) or a pharmaceutically acceptable salt thereof, the subject has an HSS7 score ≥8;

15. The method according to any of the previous embodiments, wherein the subject is an adult.

16. The method according to any of the previous embodiments, wherein by week 4 or week 12 of treatment, said subject achieves at least one of the following:

a) a decrease in the number of urticaria elements and a decrease in itching, measured as UAS≤6, or a complete absence of urticaria and itching (UAS7=0); or

b) Dermatological Life Quality Index (DLQI), ranging from 0 to 1;

c) absence of angioedema, measured as an angioedema activity score (AAS7) of zero.

17. The method of any of the previous embodiments, wherein said subject achieves a sustained response measured as a complete response including urticaria and pruritus ([UAS7]=0) and/or a dermatology life quality index (DLQI)=0-1 and/or continued freedom from angioedema (AAS7=0) by week 4 after completion of treatment.

18. The method according to any of the previous embodiments, wherein N- (3-(6-amino-5-(2-( N -methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof is placed in a pharmaceutical formulation, wherein said pharmaceutical formulation further comprises pharmaceutically acceptable carriers.

19. The method according to any one of embodiments 1-18, wherein N- (3-(6-amino-5-(2-( N- methylacrylamido)ethoxy)pyrimidin-4-yl)-5-fluoro-2-methylphenyl)-4-cyclopropyl-2-fluorobenzamide or a pharmaceutically acceptable salt thereof has a T _max of about 0.5-3 hours.

ABBREVIATIONS

AE undesirable effect.

AUC area under the curve.

AUCinf area under the plasma (or serum or blood) concentration-time curve,

from time zero to infinity (mass x time/volume).

AUClast area under the plasma (or serum or blood) concentration-time curve,

from time zero to the time at which the concentration is quantifiable (mass x time/volume).

AUCtau area under the plasma (or serum or blood) concentration-time curve,

from time zero to the end of the tau dose administration interval (mass x time/volume).

b.i.d. twice a day.

BMI body mass index.

CL/F apparent systemic (or total body) clearance from plasma (or serum, or blood)

after administration (weight/volume).

Cmax is the maximum concentration after administration of the drug.

CSU chronic spontaneous urticaria.

ECG electrocardiogram.

Emax is the maximum change in effect compared to placebo.

FcγR Fc gamma receptor.

FcεR Fc alpha receptor.

MRT mean retention time.

PK pharmacokinetics.

PD pharmacodynamics.

PRO patient-reported treatment outcomes.

QoL quality of life.

q.d. once daily.

QTcF QT interval corrected according to Frederick's formula.

SAE serious adverse effect.

Tmax is the maximum duration of the period of time until the maximum concentration is reached after administration of the drug.

T1/2 terminal half-life.

Tlast is the time of the last measured concentration in the PK profile.

Vz/F apparent volume of distribution during the terminal elimination phase

after administration (volume).

Example 1. Preclinical studies

Example 1a. Relationship between BTK occupancy and PK/PD in preclinical studies

The in vivo PD effects of an irreversible BTK inhibitor such as compound (I) are determined by the degree and duration of covalent occupancy of BTK by the inhibitor. BTK occupancy following treatment with compound of formula (I) (also referred to as compound (I)) was measured using an ex vivo immunoassay. The fraction of unoccupied BTK protein was analyzed following in vitro incubation with a covalent biotinylated BTK probe, as compound (I) and the probe bind to BTK in a mutually exclusive manner. Unoccupied BTK protein, as well as relative levels of total BTK protein, were determined in lysates of selected tissues, and unoccupied BTK protein levels were normalized to total BTK protein levels in the same samples.

In female rats, a single oral dose of 3 mg/kg compound (I) resulted in complete occupancy of the spleen by BTK, a dose of 1 mg/kg resulted in 76-81% occupancy, whereas after a single dose of 0.3 mg/kg only partial occupancy of 30% was achieved. BTK occupancy in the blood reached levels corresponding to those observed in the spleen. From the experimental data, it was evident that the short-term presence of compound (I) in the systemic circulation is sufficient to achieve complete occupancy of BTK in several tissues at low oral doses of 1-3 mg/kg. The content of compound (I) in the blood after a dose of 1 mg/kg reached 49.1 nM at 0.5 h and was 5.6 nM at 5 h post-dose. This short-term presence in the systemic circulation at very low levels is consistent with the PK/PD model typical of irreversible inhibitors.

The duration of BTK occupancy was determined in rats and mice following a single oral dose of compound (I) in the spleen, blood, lymph nodes, and lungs. In rats, occupied BTK demonstrated a long half-life in blood of approximately 87 hours. The estimated occupied half-life of BTK in the rat spleen is significantly shorter than in blood, only approximately 5 hours. The different metabolic rates may reflect the fact that B cells and monocytes in peripheral blood expressing BTK are quiescent and metabolically relatively inactive compared to those in the spleen. A longer persistence of occupied BTK in blood has been previously reported ( Advani et al 2013, J Clin Onc; 31(1):88-94 ). All other tissues analyzed (lung and lymph nodes) showed metabolism and occupied half-life of BTK similar to those in the spleen.

Example 1B . In vivo efficacy in murine models of acute cutaneous hypersensitivity

The effects of compound (I) on FcγR- and FcεR-induced hypersensitivity were assessed in two mouse models of acute cutaneous reactions. Due to the less favorable PK of compound (I) in mice, the dose was administered twice daily.

The duration of the PD effect in the skin after a single dose was assessed using the reverse passive Arthus reaction (RPA) model of FcγRIII-mediated mast cell inflammation. In this RPA model, a polyclonal IgG antibody is administered locally into the dermis, while a soluble antigen is administered systemically via intravenous injection. In this mouse model, mast cell FcγRIII plays a dominant role with minor contributions from the complement system (Hazenbos et al. 1998, Journal of Immunology, 161(6), pp. 3026; Hazenbos et al., Immunity, 1996, 5(2), pp. 181; Köhl & Gessner 1999, Molecular Immunology, 36(13-14), pp. 893; Sylvestre & Ravetch 1996, Immunity, 5(4), pp. 387; Sylvestre & Ravetch 1994, Science, 265(5175), pp. 1095). Mice genetically deficient in BTK have been shown to be protected from the passive Arthus skin reaction (Fiedler et al. 2011, blood, 117(4), pp. 1329).

Oral treatment with compound (I) at single doses of 3, 10, 30, and 100 mg/kg, administered 2 hours before RPA response induction, reduced skin edema in a dose-dependent manner. Maximum effects were observed at 30 and 100 mg/kg (inhibition levels of 73.0 and 61.2%, respectively), and partial effects were observed at 3 and 10 mg/kg (inhibition levels of 22.9 and 29.2%, respectively) (Figure 1). BTK occupancy in the spleen, observed to be fully occupied at 5 hours post-dose, correlated with efficacy against skin edema with the following values: 68.1% (3 mg/kg), 82.1% (10 mg/kg), 91.3% (30 mg/kg), 99.3% (100 mg/kg) (Figure 2).

In this model, inhibition of skin edema was maximal when compound (I) was administered 2 hours before induction of the Arthus reaction. The effect gradually diminished and returned to baseline levels when the Arthus reaction was initiated 45 hours or later after administration of compound (I). This suggests that BTK occupancy in the skin follows the same dynamics as in the spleen, lungs, and lymph nodes.

The effects of compound (I) on acute cutaneous hypersensitivity were also assessed after two oral doses of compound (I) in mice in a passive cutaneous anaphylaxis (PCA) model (Ovary, 1958). The mouse PCA model was used with a low dose of sensitizing IgE antibodies to minimize complement-dependent anaphylatoxins (Schäfer et al. 2013, The journal of allergy and clinical immunology, 131(2), pp. 541; Hata et al. 1998, Journal of Experimental Medicine, 187(8), pp. 1235). Two oral doses at each level of 3, 10, 30, or 100 mg/kg of compound (I), administered 14 and 2 hours before induction of cutaneous anaphylaxis with a hapten, showed dose-dependent inhibition of skin edema, as measured by Evans blue vascular permeability. Inhibition of skin edema, as measured by Evans blue vascular permeability, ranged from 60.7% (3 mg/kg), 66.9% (10 mg/kg), 69.2% (30 mg/kg), and 87.4% (100 mg/kg) (Figure 3). Splenic occupancy 2.5 hours after the last dose ranged from 89.1 to 99.7% (corresponding to the maximum occupancy) (Figure 4).

The studies in Examples 1a and 1b suggest that compound (I) reaches its target in the skin and effectively inhibits cutaneous inflammatory responses.

In these preclinical pharmacology studies, BTK occupancy and corresponding pharmacological data showed a strong correlation. Therefore, BTK occupancy and mast cell-mediated cutaneous hypersensitivity reactions are suitable biomarkers for PD for use in clinical trials and, therefore, were used in the Phase 1 clinical trials.

Example 2. Phase 1 clinical trial

A first-in-human study was conducted to evaluate the safety and tolerability, pharmacokinetics (PK), and pharmacodynamics (PD) of single and multiple oral doses of compound (I) administered both once daily (qd) and twice daily (bid) in healthy volunteers and patients with atopic diathesis to support further clinical development of compound (I) in autoimmune diseases. This study also examined the effect of food intake.

First-in-human study involving approximately 168 healthy volunteers (HV), of whom 64 (in parts 2 and 4) had asymptomatic atopic diathesis.

Part 1 was a double-blind (subject and investigator blinded, sponsor not blinded), placebo-controlled, dose-escalation study using single ascending doses (SAD) in 10 cohorts (N=80).

Part 2 was a double-blind (subject and investigator blinded, sponsor not), placebo-controlled, dose-escalation study using multiple ascending doses (MAD) (13 doses over 12 days) with once-daily dosing in 6 cohorts of healthy volunteers with asymptomatic atopic diathesis (N=48).

Part 3 was an open-label, crossover study of the effects of food intake on a single dose in 12 HV.

Part 4 was a double-blind (subject and investigator blinded, sponsor not), placebo-controlled, multiple-dose (25 doses over 12 days) study with twice-daily dosing in 2 cohorts of healthy volunteers with asymptomatic atopic diathesis (N=16).

The SAD portion (Part 1) comprised ten dose levels, and the MAD portions (Parts 2 and 4) comprised eight dose levels (6 once-daily cohorts in Part 2 and 2 twice-daily cohorts in Part 4). Eight subjects were randomly assigned to each cohort to receive either compound (I) or matching placebo in a 6:2 (active:placebo) ratio in the SAD and MAD portions. In the SAD portion, doses approximately 4 times the estimated pharmacologically active dose (PAD) were to be assessed before the MAD portion of the study was initiated, provided that no safety signal had been reported from the SAD portion prior to that time. The total daily dose of compound (I) used in Part 2 (MAD qd schedule) and Part 4 (multiple-dose bid schedule) did not exceed the highest dose level studied in the SAD portion. Moreover, the total daily dose in Part 4 did not exceed the total daily dose in Part 2.

In Part 1 (SAD), a sentinel dosing strategy was to be used for the first administration at each dose level as follows. The first two subjects were dosed on day 1 (one with active drug, one with placebo). After a 48-hour observation period, doses were administered to the remaining six subjects in the cohort (five with active drug, one with placebo).

Standard safety monitoring was used throughout the study. A special assessment for potential skin bruising was included. For each cohort, a blinded review of all vital signs, physical examination and patient history, ECG, adverse events, and laboratory safety parameters (blood chemistry, hematology, and urinalysis) was required before dose escalation for up to 96 hours after the last dose, as well as PK data from the previous dose group (if available) for up to 48 hours after the last dose. Safety summary reports on reported adverse events, clinical safety laboratory parameters, QTc, and heart rate were provided after completion of each dose level.

In Parts 1, 2, and 4, each subject participated in a 28-day screening period (from Day -29 to Day -2), a baseline determination period, a treatment period, and a follow-up period that included an end-of-study assessment.

In Part 1, subjects were admitted to the study center on Day -2 or Day -1 for baseline safety assessment and confirmation of eligibility. Eligible subjects received a single dose of Compound (I) or placebo in the fasted state on Day 1. They were hospitalized from Day -1 until the morning of Day 5 (96 hours after the last drug administration).

In Parts 2 and 4, subjects were admitted on Day -2 or -1 for baseline safety assessment and confirmation of eligibility. Eligible subjects received the first dose of compound (I) in the fasting state on Day 1 and continued to take study medication in the fasting state through Day 12. Subjects were hospitalized from Day -2 or -1 until the morning of Day 16, which corresponded to 96 hours after the last dose of compound (I). In Parts 2 and 4, study medication was administered once daily and twice daily, respectively (see assessment schedule for details).

Part 3 was an open-label, randomized, two-way, single-dose crossover study to evaluate the effect of food intake. In Part 3, each subject participated in a 28-day screening period (day -29 to day -2), 2 baseline determination periods (day -1), and 2 treatment periods, each consisting of a single dose on day 1 followed by safety and PK assessments through day 5. Treatment period 2 consisted of a follow-up visit and end-of-study assessment on days 22 and 40, respectively. The two treatment periods were separated by a washout period of at least 18 days (+/- 1 day).

Main objective(s)

Target Expected results All parts: evaluation of the safety and tolerability of single and multiple ascending oral doses of compound (I). All safety assessments including physical examination and history, vital signs, ECG, safety laboratory parameters, AEs and SAEs.
A specific assessment of the incidence of skin bruising is included.

Secondary goals

Target Expected results Parts 1, 2 and 4: Evaluation of single and multiple dose PK of compound (I) in blood in healthy volunteers and atopic subjects. PK parameters for single and multiple doses such as Cmax, Tmax, AUCinf, AUClast, AUCtau, T1/2, MRT, Racc, Vz/F and Cl/F. Part 3: Evaluation of single-dose PK of compound (I) in blood under fed and fasted conditions in healthy volunteers. PK parameters for single doses: Cmax, Tmax, AUClast, AUCinf, T1/2, MRT, Vz/F and CL/F.

Research objectives

Target Expected results Parts 1, 2 and 4: PK (parts 2 and 4) and PD studies of single and multiple doses of compound (I) in urine. The degree of BTK occupancy in peripheral blood
Skin Prick Test Responses to a Known Allergen (Parts 2 and 4)
Ex vivo PD cellular biomarkers that provided additional means of measuring drug response for compound (I) through inhibition of peripheral blood basophil degranulation (FcεR-induced CD63 and CD203c expression) All parts: describe the concentration-effect relationship using PD markers (e.g., BTK occupancy, ex vivo cellular PD biomarkers) and characterize deviations from PK nonlinearity (if any) using population PK-PD models. PK parameters of the population model (e.g., CL/F, V/F, and Ka) and PD model parameters (e.g., irreversible binding constant, Kirr) and their associated intra- and interindividual variability (CV%)

Key inclusion criteria

1. Healthy male and female subjects aged 18 to 65 years (inclusive) in good health, as determined by medical history, physical examination, vital signs, electrocardiogram, and laboratory tests at screening. Healthy subjects with atopic diathesis were eligible for inclusion in Part 2 or Part 4 according to the eligibility criteria for inclusion in those specific parts of the study. Healthy volunteers with atopy had to have a positive skin prick test result to a known allergen (atopic diathesis) at screening, but they had to be clinically asymptomatic and not require any systemic medications.

2. Subjects were required to have a body weight of at least 50 kg and a body mass index (BMI) in the range of 18–30 kg/m2 (inclusive). BMI = body weight (kg)/[height (m)] ² .

3. At screening and initial baseline, vital signs (body temperature, systolic and diastolic blood pressure, and pulse) were assessed in the sitting position after the subject had been at rest for at least 3 minutes and again (if necessary) after 3 minutes of standing. Vital signs in the sitting position were required to be within the following ranges (inclusive):

body temperature when measured in the oral cavity 35.0-37.5°C,

systolic blood pressure 90-139 mmHg,

diastolic blood pressure 50-89 mmHg,

pulse 50-90 beats/min.

Key exclusion criteria

1. History of hypersensitivity to any of the studied drugs or to drugs of similar chemical classes.

2. History of clinically significant ECG abnormalities or any of the following ECG abnormalities on screening and/or before treatment:

PR interval > 200 ms,

QRS complex > 120 ms,

QTcF > 450 ms (men),

QTcF > 460 ms (women).

3. Hemoglobin levels below 12.0 g/dL at screening or first baseline determination.

4. The platelet count is outside the normal range (below 150×10 ⁹ /L or above 450×10 ⁹ ) at screening or first baseline determination.

5. Any clinically significant abnormalities in any of the standard coagulation tests, including prothrombin time (PT), partial thromboplastin time (PTT) or international normalized ratio (INR) at screening and/or baseline.

6. Presence or history of thrombotic or thromboembolic events, or increased risk of developing thrombotic or thromboembolic events.

Introduced means for treatment

Part 1 (SAD)

Subjects were assigned to one of the following 10 cohorts. Eight subjects were randomly assigned to each cohort to receive either compound (I) or matching placebo in an overall ratio of 6:2. The first subcohort was randomly assigned in a 1:1 ratio: one subject to receive compound (I) and one subject to receive matching placebo. The remaining six subjects in each cohort, who were dosed after a 48-hour observation period for the two previously dosed subjects, were randomly assigned in a 5:1 ratio.

Cohort 1: single oral dose of 0.5 mg compound (I) or matching placebo.

Cohort 2: single oral dose of 1.5 mg compound (I) or matching placebo.

Cohort 3: single oral dose of 5 mg compound (I) or matching placebo.

Cohort 4: single oral dose of 15 mg compound (I) or matching placebo.

Cohort 5: single oral dose of 30 mg compound (I) or matching placebo.

Cohort 6: single oral dose of 60 mg compound (I) or matching placebo.

Cohort 7: single oral dose of 100 mg compound (I) or matching placebo.

Cohort 8: single oral dose of 200 mg compound (I) or matching placebo.

Cohort 9: single oral dose of 400 mg compound (I) or matching placebo.

Cohort 10: single oral dose of 600 mg compound (I) or matching placebo.

Part 2 (MAD, qd scheme)

Subjects were assigned to one of the following 6 cohorts. Within each cohort, 8 subjects were randomly assigned to receive either compound (I) or the corresponding placebo in a 6:2 ratio.

Cohort 1: multiple oral doses of 10 mg compound (I) or matching placebo.

Cohort 2: multiple oral doses of 25 mg compound (I) or matching placebo.

Cohort 3: multiple oral doses of 50 mg compound (I) or matching placebo.

Cohort 4: multiple oral doses of 100 mg compound (I) or matching placebo.

Cohort 5: Multiple oral doses of 400 mg compound (I) or matching placebo.

Cohort 6: Multiple oral doses of up to 600 mg compound (I) or matching placebo.

Part 3 (the influence of food intake)

Subjects were randomly assigned to one of 2 treatment sequences (Table 9) in a 1:1 ratio.

Determining the treatment sequence for Part 3.

Subsequence Period 1 Period 2 1 Compound (I) (60 mg) on an empty stomach Compound (I) (60 mg) after meals 2 Compound (I) (60 mg) after meals Compound (I) (60 mg) on an empty stomach

Part 4 (MAD, bid scheme)

Subjects were assigned to one of the following cohorts. Within each cohort, 8 subjects were randomly assigned to receive either compound (I) or a matching placebo in a 6:2 ratio.

Cohort 1: multiple oral doses of 100 mg compound (I) or matching placebo in a bid schedule.

Cohort 2: multiple oral doses of 200 mg compound (I) or matching placebo in a bid schedule.

Pharmacokinetic data

Bioanalytical methods :

Pharmacokinetic samples were obtained from blood and assessed at all dose levels in all subjects. Samples from subjects in the placebo groups were not analyzed. Samples for PK assessment were collected from subjects at time points specified in the study. Compound (I) concentrations were determined in blood using a validated LC-MS/MS method.

Pharmacokinetics of single increasing doses of 0.5 mg - 600 mg

The mean blood concentration of compound (I) as a function of time after single increasing doses is shown in Figure 5.

Compound (I) was rapidly absorbed, with the time to reach Cmax being approximately 1-1.5 hours at all doses. The absorption phase was characterized by a single, distinct absorption peak in most subjects. A biphasic decline was demonstrated for drug distribution. The majority of the drug was eliminated during the initial distribution phase, suggesting that, in essence, drug clearance may occur before reaching equilibrium in whole-body tissues. The apparent terminal elimination phase did not occur until 12 hours after dosing and could only be measured in subjects receiving doses of 100 mg and higher. Measured terminal half-lives ranged from 4 hours (100 mg) to 18 hours (600 mg), resulting in a mean residence time (MRT) in the circulation of 1 hour to 5 hours (MRT≈ T1/2/ln2). The distribution phase demonstrated a dominant, dose-independent T1/2 of ~1 h. The estimated geometric mean blood clearance after single-dose oral administration (CL/F) ranged from 250 to 506 L/h in the SAD cohorts, with an estimated value of approximately 383 L/h in all cohorts.

Pharmacokinetics of multiple oral doses

The mean blood concentration of compound (I) as a function of time after multiple increasing doses of 10 mg - 400 mg is shown in Figure 6.

The geometric mean apparent clearance at steady state after oral dosing (CLss/F, day 12 MAD, qd) ranged from 246 L/h to 414 L/h across cohorts. Overall, lower clearance was observed at steady state compared to day 1, but this difference nearly disappeared at doses of 100 mg and higher (Table 8-1 (day 1) and Table 8-2 (day 12)). This behavior is likely due to covalent target binding (BTK) contributing to the initial clearance of compound (I). This effect is most pronounced on day 1, as remaining occupied target at trough levels reduces the contribution of target binding to clearance (CLss/F) on subsequent days. Naturally, this difference decreases with increasing dose, when target occupancy at the trough level is almost complete. Consequently, drug exposure (AUC, Cmax) was found to be higher on day 12 compared to day 1, as evidenced by the within-subject drug accumulation ratio (Racc), which ranged from 5 (low dose) to 1.2 (high dose) and was generally higher for AUC than for Cmax, confirming the possibility of an effect on systemic clearance.

Table 8-1 . Summary of PK parameters of compound (I) at multiple escalating doses from 10 to 600 mg, qd dosing

Analyte: compound of formula (I), matrix: blood and urine
Profile: Day 1 Compound of formula (I) PK parameter (unit) 10 mg qd
N=6 25 mg qd
N=6 50 mg qd
N=6 100 mg qd
N=6 400 mg qd
N=6 600 mg qd
N=6 Cmax (ng/ml) 8.40 ± 2.02 (24.1) 40.9 ± 21.6 (52.9) 76.5 ± 22.0 (28.8) 187 ± 85.0 (45.4) 518 ± 89.1 (17.2) 550 ± 87.6 (15.9) 8.03 (6.36-11.4) [6] 37.3 (14.1-80.4) [6] 70.1 (47.3-107) [6] 189 (75.6-285) [6] 513 (383-622) [6] 545 (461-691) [6] Tmax (h) 0.517 (0.500-1.00) [6] 0.875 (0.283-1.50) [6] 0.500 (0.483-2.00) [6] 0.742 (0.500-1.95) [6] 0.750 (0.500-1.50) [6] 0.750 (0.500-3.00) [6] AUClast (hr*ng/ml) 4.17 ± 1.38 (33.0) 43.9 ± 24.6 (56.2) 113 ± 34.2 (30.3) 311 ± 89.1 (28.6) 973 ± 379 (39.0) 1080 ± 377 (35.1) 4.40 (1.79-5.62) [6] 45.5 (15.3-78.5) [6] 103 (81.9-154) [6] 333 (168-416) [6] 826 (694-1720) [6] 931 (699-1700) [6] AUC0-24 (hr*ng/ml) 4.94 ± 1.35 (27.2) 44.9 ± 25.2 (56.0) 116 ± 32.9 (28.4) 315 ± 91.5 (29.0) 977 ± 378 (38.7) 1080 ± 377 (35.0) 4.94 (3.99-5.89) [2] 46.6 (15.6-79.7) [6] 107 (84.0-155) [6] 338 (168-419) [6] 826 (702-1720) [6] 932 (700-1700) [6] MRT (hr.) 0.761 ± 0.151 (19.8) 1.18 ± 0.490 (41.6) 2.53 ± 1.17 (46.4) 2.79 ± 1.28 (45.7) 3.02 ± 1.11 (36.8) 3.14 ± 0.580 (18.5) 0.766 (0.548-0.956) [6] 1.17 (0.460-1.87) [6] 2.44 (1.17-4.65) [6] 2.16 (1.65-4.62) [6] 2.94 (1.64-4.98) [6] 3.22 (2.31-3.96) [6] Statistical data are presented as mean ± SD (CV%)
Median (min-max) [n]
CV% = coefficient of variation (%) = SD / mean * 100
For Tmax and T1/2, only median (min-max) values are presented [n].

Table 8-2.

Analyte: compound of formula (I), matrix: blood and urine
Profile: Day 12 Compound of formula (I) PK parameter (unit) 10 mg qd
N=6 25 mg qd
N=6 50 mg qd
N=6 100 mg qd
N=6 400 mg qd
N=6 600 mg qd
N=6 Cmax (ng/ml) 18.2 ± 5.90 (32.4) 85.9 ± 31.5 (36.6) 102 ± 22.0 (21.6) 233 ± 84.1 (36.1) 551 ± 263 (47.7) 563 ± 229 (40.6) 17.2 (11.8-26.4) [6] 78.4 (43.9-126) [6] 100 (73.3-131) [6] 205 (167-386) [6] 476 (260-928) [6] 475 (377-985) [6] Tmax (h) 0.625 (0.500-1.00) [6] 0.750 (0.500-1.00) [6] 1.00 (0.533-1.50) [6] 0.867 (0.733-1.50) [6] 0.758 (0.700-1.50) [6] 0.883 (0.500-3.00) [6] AUClast (hr*ng/ml) 22.9 ± 3.50 (15.3) 114 ± 59.7 (52.3) 207 ± 80.4 (38.9) 488 ± 172 (35.3) 1300 ± 602 (46.3) 1240 ± 341 (27.5) 22.4 (18.3-28.2) [6] 98.2 (30.1-190) [6] 179 (126-323) [6] 444 (336-770) [6] 1180 (650-2310) [6] 1070 (953-1740) [6] AUCinf (hr*ng/ml) 24.7 ± 3.65 (14.8) 117 ± 60.4 (51.5) 209 ± 80.0 (38.2) 577 ± 207 (35.9) 1330 ± 608 (45.8) 1260 ± 338 (26.8) 24.3 (19.6-29.9) [6] 102 (31.7-194) [6] 181 (127-325) [6] 595 (361-774) [3] 1210 (665-2330) [6] 1090 (994-1760) [6] AUC0-24 (hr*ng/ml) 24.0 ± 3.60 (15.0) 117 ± 60.9 (52.2) 209 ± 80.2 (38.4) 485 ± 179 (36.9) 1280 ± 577 (45.3) 1230 ± 356 (29.0) 23.6 (18.9-29.3) [6] 101 (30.9-194) [6] 181 (127-325) [6] 429 (336-774) [6] 1140 (677-2270) [6] 1060 (908-1740) [6] T1/2 (h.) 0.961 (0.667-1.21) [6] 1.15 (0.680-1.33) [6] 1.15 (0.813-1.55) [6] 1.41 (1.41-11.9) [3] 8.51 (1.22-22.3) [6] 8.29 (4.69-17.3) [6] Vss/F (l) 554 ± 90.4 (16.3) 407 ± 208 (51.1) 431 ± 172 (40.0) 1910 ± 2780 (145.9) 4400 ± 3340 (75.8) 7130 ± 5120 (71.9) 562 (407-657) [6] 334 (247-793) [6] 346 (313-751) [6] 338 (264-5120) [3] 3440 (624-8820) [6] 7070 (2340-16500) [6] CLss/F (l/h) 425 ± 64.8 (15.3) 307 ± 253 (82.5) 268 ± 92.8 (34.6) 198 ± 88.7 (44.8) 366 ± 150 (41.0) 521 ± 131 (25.1) 423 (341-529) [6] 248 (129-809) [6] 276 (154-395) [6] 166 (129-298) [3] 351 (177-591) [6] 569 (345-661) [6] T1/2, acc 1.00 (1.00-1.00) [6] 1.00 (1.00-1.00) [6] 1.00 (1.00-1.00) [6] 1.01 (1.00-1.73) [6] 1.18 (1.00-1.90) [6] 1.16 (1.03-1.62) [6] Extracted amount (mg) 0.0663 ± 0.0309 (46.5) 0.114 ± 0.0706 (62.0) 0.233 ± 0.0880 (37.7) 0.648 ± 0.330 (50.9) 1.25 ± 0.647 (51.7) 1.54 ± 0.915 (59.3) 0.0630 (0.0346-0.109) [6] 0.126 (0.0326-0.217) [6] 0.185 (0.165-0.378) [5] 0.561 (0.305-1.12) [6] 1.12 (0.547-2.37) [6] 1.43 (0.528-3.03) [6] Extracted amount (%) 0.663 ± 0.309 (46.5) 0.456 ± 0.283 (62.0) 0.467 ± 0.176 (37.7) 0.648 ± 0.330 (50.9) 0.313 ± 0.162 (51.7) 0.257 ± 0.153 (59.3) 0.630 (0.346-1.09) [6] 0.502 (0.130-0.868) [6] 0.370 (0.331-0.757) [5] 0.561 (0.305-1.12) [6] 0.280 (0.137-0.593) [6] 0.238 (0.0880-0.506) [6] Renal clearance (ml/min) 45.3 ± 18.0 (39.8) 16.8 ± 6.81 (40.5) 20.4 ± 2.40 (11.7) 21.6 ± 5.41 (25.1) 16.9 ± 7.13 (42.3) 20.0 ± 8.25 (41.2) 41.6 (24.4-70.3) [6] 18.9 (5.43-24.3) [6] 20.5 (17.1-23.4) [5] 21.1 (14.6-30.9) [6] 14.5 (11.5-30.7) [6] 18.1 (8.98-30.3) [6] Statistical data are presented as mean ± SD (CV%)
Median (min-max) [n]
CV% = coefficient of variation (%) = SD / mean * 100
For Tmax and T1/2, only median (min-max) values are presented [n].

Overall, blood concentrations 24 hours after the last dose were typically below 1 ng/mL, with the exception of a few subjects receiving doses of 100 mg or higher, indicating almost complete elimination of compound (I) after two consecutive doses. This also suggests that steady-state is achieved over multiple doses.

Due to more rapid tissue metabolism of BTK, dosing b.i.d. was also investigated. Mean blood concentration-time profiles obtained after multiple escalating doses of 100 mg and 200 mg twice daily are shown in Figure 7. Consistent with results from other cohorts, rapid absorption with a Tmax of approximately 1 h was observed for doses following the b.i.d. regimen. The observed accumulation ratio (Racc) was 1.5 (100 mg) and 2.0 (200 mg) for AUC and approximately 1.65 for Cmax (both doses). A dose-proportional increase in AUCtau was observed at day 12, whereas only a small increase (1.33-fold) was detected for Cmax. In conclusion, dosing of compound (I) b.i.d. allows for more rapid tissue target resynthesis during the dosing interval without compromising the overall PK profile and the need for high q.d. doses.

The Impact of Food Intake: Part 3 Results

PK data from the cohort in which the effect of food intake was determined, summarized in Table 9 below, indicate a reduced rate of absorption, as evidenced by a 1.25-fold decrease in Cmax, and more complete overall absorption, as evidenced by a 1.4-fold increase in AUC0-24. Most importantly, the mean Tmax shifted from 1 hour (fasted) to >3 hours (fed) (Figure 8).

Table 9. Summary of PK parameters: effect of food intake on compound (I) after a single 60 mg dose.

CV=coefficient of variation (%)=SD/mean*100

Pharmacodynamics

Pharmacodynamic (PD) characteristics were determined by assessing target occupancy and inhibition at the distal site of the pathway. Measured BTK occupancy in human whole blood (obtained as the ratio of free to total BTK) served as a direct marker of therapeutic effect on the target.

The relationship between the degree of BTK occupancy, dose, systemic circulating compound content, and in vivo efficacy against the complex pathway and disease data was established in preclinical models for the compound of formula (I) (e.g., Example 1).

Compound (I) is an irreversible inhibitor of BTK. The degree and duration of BTK occupancy were determined. The PD effect of compound (I) was assessed by measuring the content of both free BTK (unbound) and total BTK in whole blood using an enzyme-linked immunosorbent assay (ELISA) on the Meso Scale Diagnostics (MSD) platform in two separate assays.

The dose-pharmacodynamic relationship was characterized using measured values of BTK occupancy in human blood (obtained as the ratio of free to total BTK), a direct marker of therapeutic effect on the target. BTK occupancy was determined for single ascending doses ranging from 0.5 to 400 mg, for multiple ascending doses q.d. ranging from 10 to 400 mg, and for multiple ascending doses b.i.d. ranging from 100 to 200 mg.

Compound (I) demonstrated a clear dose-dependent increase in both the extent and duration of BTK occupancy in peripheral blood. Peak target occupancy was typically observed as early as 0.5 hours after dosing, indicating a rapid onset of action without significant hysteresis compared to peak drug levels. Based on its ability to covalently bind BTK, target occupancy persisted long after its removal from the systemic circulation, indicating a nonequilibrium PK-PD relationship. Accordingly, it is concluded that the duration of BTK occupancy is determined by the rate of de novo BTK synthesis.

In contrast to lower dose cohorts (0.5-1.5 mg), single doses of 15 mg of compound (I) and above established a maximum target occupancy approaching 100% in nearly all subjects, which remained above 80% at 24 h. While the response varied significantly among subjects at the 15 mg dose, doses of 30 mg and above provided sustained (>24 h) and near-complete (>90%) occupancy in all subjects, with clearly reduced intersubject variability. The time to turnover of the BTK protein pool to pre-dose levels was approximately 10 days, corresponding to a median T1/2 of metabolism of approximately 48 h (Figure 9).

After multiple doses of compound (I), already with 10 mg of compound (I) q.d. a residual occupancy of BTK in the blood of >96% was achieved before the dose on day 12.

Furthermore, inhibition of ex vivo basophil activation (monitored by surface expression of CD63 and CD203c) was used as a distal mechanistic biomarker to investigate the subsequent PD effects of compound (I). To determine the PD effect of compound (I) on basophil activation, whole blood was stimulated ex vivo with anti-IgE antibodies. Degranulation was assessed by the percentage of CD63+ and CD203+ basophils using flow cytometry.

Following single escalating doses of compound (I), data indicate dose-dependent inhibition of FcεR1-mediated basophil activation. Ex vivo blood basophil activation, measured by CD63, was almost completely inhibited (>89%) at 60 mg doses and reached nearly 100% inhibition at higher doses 24 h post-dose. In contrast, maximal inhibition of CD203c 24 h after a single dose of compound (I) (approximately 50% inhibition) was achieved only with 200 mg of compound (I).

At day 12, 8 h after MAD q.d. or b.i.d. administration of compound of formula (I), already the lowest dose of compound (I) tested (10 mg q.d.) resulted in >90% inhibition of the increase in CD63 expression, and the residual level of CD63 inhibition was >90% at doses of compound (I) ≥50 mg q.d. (Figure 10). The maximum residual inhibition of CD203c activation at day 12 was consistently higher than after a single dose of compound (I) and was achieved only with b.i.d. administration of 100 mg and 200 mg of compound (I).

The ability of compound (I) to inhibit the response to a specific allergen was assessed using a skin prick test (SPT) in healthy subjects with atopy in the MAD portion of the first-in-human study. SPTs were performed pre-dose (at screening, baseline, and pre-dose on Day 1) and at various time points after the first dose (Day 1) and 11 days after once-daily dosing (Day 12).

Similar to the inhibition of basophil activation ex vivo , the dose-dependent effect on wheal diameter was pronounced in the multiple escalating dose cohorts, as indicated by a decrease in mean wheal size after dosing compared to baseline (Figure 11). The effect began to plateau at approximately 100 mg of compound (I) qd.

Rationale for dose selection/conclusion

Healthy volunteers were exposed to compound (I) in Phase 1 clinical trials with doses ranging from 0.5 to 600 mg, administered as a single dose or administered once or twice daily for up to 18 days. Compound (I) was well tolerated, and there were no serious or severe adverse events associated with Compound (I). In the clinical trial, observed adverse events (AEs) did not appear to be dose-related, with most being isolated and generally mild. Thus, the clinical safety data support the doses selected for this Phase 2b study.

Dose levels of the present invention were obtained in the following assays: BTK occupancy rate, inhibition of basophil activation (monitored by increased CD63 and CD203c expression) in healthy volunteers; and the effect on skin prick tests (SPT) in healthy volunteers with asymptomatic atopy - an indirect measure of mast cell and basophil inhibition in the skin.

In the clinical trial described above, administration of 10 mg of compound (I) q.d. resulted in nearly complete occupancy of BTK in the blood, a >90% reduction in the increase in CD63 expression (at 8 hours after administration of COMPOUND (I) at steady state), and minimal inhibition of wheal size in the SPT. Thus, 10 mg of compound (I) q.d. corresponds to the onset of biological activity. At a dose of 100 mg of compound of formula (I), the mean reduction in wheal size in the SPT began to plateau. Therefore, 100 mg of the compound corresponds to the maximal effect of COMPOUND (I). The average dose of compound (I) of thirty-five mg q.d. is well suited to accurately describe the dose-response curve of COMPOUND (I) when administered q.d.

Compound (I) inhibits BTK via covalent binding. While the occupancy time of BTK in blood is >24 hours (h), the rapid metabolism of BTK in tissue (e.g., approximately 5 h in rodent spleen) may require administration of compound (I) b.i.d. to achieve maximum efficacy. Doses of 10, 25, and 100 mg of compound (I) b.i.d., respectively, accurately describe the dose-response curves for compound (I) when administered twice daily.

Safety for humans

For adverse event analysis, subjects receiving placebo from all SAD and MAD cohorts (2 per cohort) and subdivided into SAD and MAD groups were pooled into a single placebo group (n=20 for SAD and n=16 for MAD) for comparison with each individual Compound (I) dose group (n=6 each) and with the overall Compound (I) group (n=60 for SAD and n=48 for MAD). No significant differences in demographic data were observed between the placebo and active ingredient groups for either the SAD or MAD populations. Safety assessment in the FIH study in healthy volunteers revealed no significant safety concerns at doses up to 600 mg.

Example 3. Efficacy and safety data in patients with CSU whose symptoms persist despite standard treatment

A Phase 2b study is being conducted as a multicenter, randomized, double-blind, placebo-controlled, parallel-group study to investigate the safety, tolerability, and efficacy of six dose groups of orally administered compound of formula (I) in subjects with inadequately controlled CSU despite treatment with H1-antihistamines (second generation).

Throughout the study (i.e., from day -14 to day 113), subjects were on a stable treatment regimen of a second-generation H1-antihistamine at a locally approved, licensed dosing schedule (the "background medication").

Subjects may receive an additional second-generation H1-antihistamine that is eliminated primarily by renal excretion (e.g., cetirizine, levocetirizine, or bilastine) as a rescue medication. The rescue H1-antihistamine must be different from the background H1-antihistamine and may be used only for the treatment of intolerable symptoms (itching) of CSU on a daily basis throughout the study (from day -14 to day 113).

All other CSU therapies (including H1 antihistamines at doses higher than approved) are prohibited (see Table 10).

The research plan outline includes three periods:

screening period (10-14 days before randomization): during the screening period, subjects who have provided informed consent are assessed for eligibility for inclusion in the study;

Treatment period (Day 1 to Day 85): After screening for eligible subjects, subjects are randomly assigned to one of the following treatment groups in a 1:1:1:1:1:1:1 ratio:

10 mg of compound (I) once daily;

35 mg of compound (I) once daily;

100 mg of compound (I) once daily;

10 mg of compound (I) twice daily;

25 mg of compound (I) twice daily;

100 mg of compound (I) twice daily;

placebo;

An interim analysis is conducted to assess the dose-response relationship of the compound of formula (I) after all subjects have completed their visit at week 4 (primary endpoint);

Follow-up period (day 86 to day 113): Subjects will be followed to assess the durability of response after treatment discontinuation and to further assess safety.

Table 10. Prohibited drugs

medicinal product Period during which use is prohibited Biologic agents for the treatment of CSU (including omalizumab and ligelizumab) Starting from 4 months before screening until the end of the study Regular (daily or every other day for 5 or more consecutive days) doses of systemic corticosteroids Starting from 30 days before screening until the end of the study
Note: From day 1 (baseline) to week 12 (treatment end period), the use of systemic corticosteroids is generally prohibited. Leukotriene receptor antagonists (including montelukast and zafirlukast) From screening to the end of the study H2 antihistamines From screening to the end of the study First-generation antihistamines From screening to the end of the study Second-generation antihistamines, except for certain background medications and emergency medications. From screening to the end of the study Other immunosuppressive drugs with or without known effect on CSU, including but not limited to hydroxychloroquine, methotrexate, cyclosporine A, cyclophosphamide, tacrolimus, and mycophenolate mofetil Starting from 30 days or 5 half-lives (whichever is longer) before screening until the end of the study Intravenous (i.v.) immunoglobulins or plasmapheresis Starting from 30 days before screening until the end of the study Regular use (daily or every other day) of doxepin (orally) Starting from 14 days before screening until the end of the study Live attenuated vaccine Starting from 6 weeks before screening until the end of the study Any drug that prolongs the QTc interval (see guidelines at https://crediblemeds.org) Starting from 5 half-lives or until the pharmacodynamic effect disappears before baseline (whichever is longer) and until the end of the study Antiplatelet drugs or anticoagulants (eg, warfarin, clopidogrel, or newer oral anticoagulants - NOACs) other than acetylsalicylic acid (up to 100 mg/day) From screening to the end of the study

Summary of the Protocol

Concept and rationale The aim of this study is to collect data on the efficacy and safety of the compound of formula (I) in subjects suffering from CSU that is not adequately controlled by H1-antihistamines. Secondary goals To evaluate the efficacy of compound (I) compared with placebo on the change in UAS7 value from baseline to week 12.
To evaluate the efficacy of compound (I) compared with placebo in terms of change in UAS7 value from baseline over time.
Evaluation of the efficacy of compound (I) compared with placebo in achieving complete clinical response (UAS7=0) over time.
To assess the efficacy of compound (I) compared with placebo in achieving disease control (UAS7≤6) over time.
To assess the effect of compound (I) on angioedema (AAS7) in terms of the number of weeks with AAS7 response=0 from baseline to week 12.
To assess the effect of compound (I) on disease-related quality of life in terms of achieving a DLQI score of 0 or 1 at week 4 and week 12.
To assess the effect of compound (I) on CSU-related quality of life in terms of change in DLQI from baseline to week 4 and week 12.
Pharmacokinetic (PK) assessment of compound (I) following oral dosing (PK sampling is performed at week 4 and week 12).
Evaluation of the safety and tolerability of compound (I) in subjects with CSU. Population The study population consists of approximately 308 adult female and male patients with chronic spontaneous urticaria, at least moderately active, inadequately controlled by second-generation H1-antihistamines. Key inclusion criteria Adult male and female subjects aged ≥18 years.
Diagnosis of CSU made ≥ 6 months before screening.
The diagnosis of CSU inadequately controlled by second-generation H1-antihistamines is defined by the following:
presence of pruritus and urticaria for ≥6 consecutive weeks prior to screening, despite use of non-sedating H1-antihistamines according to local treatment guidelines during this time period;
UAS7 score (range 0-42) ≥16 and HSS7 score (range 0-21) ≥8 within 7 days prior to randomization (day 1);
The presence of urticaria must be documented within three months prior to randomization (either at screening and/or randomization, or documented in the subject's medical record). Key exclusion criteria Subjects with a clearly defined predominant or single trigger for their chronic urticaria (chronic inducible urticaria), including self-induced urticaria (symptomatic dermographism), cold urticaria, heat urticaria, solar urticaria, pressure urticaria, delayed pressure urticaria, aquagenic urticaria, cholinergic urticaria, or contact urticaria.
Other conditions with symptoms of urticaria or angioedema, including but not limited to urticarial vasculitis, urticaria pigmentosa, erythema multiforme, mastocytosis, hereditary urticaria, or acquired/drug-induced urticaria.
Any other skin disease associated with chronic pruritus that the investigators consider may influence the study assessments and results, such as atopic dermatitis, bullous pemphigoid, dermatitis herpetiformis, senile pruritus, or psoriasis.
The presence at the time of the study or in the medical history of diagnosed ECG abnormalities from the norm indicating a significant safety risk to subjects participating in the study, such as the following:
• concomitant clinically significant forms of cardiac arrhythmia, such as sustained ventricular tachycardia and clinically significant second- or third-degree atrioventricular block without a pacemaker;
• history of hereditary long QT syndrome or known family history of torsades de pointes;
• resting heart rate (medical examination or 12-lead ECG) < 60 bpm;
• QTcF at rest ≥450 ms (men) or ≥460 ms (women) before treatment [at screening] or inability to determine the QTcF interval;
• use of drugs known to prolong the QT interval unless they can be discontinued for the duration of the study.
Significant risk of bleeding or bleeding disorders.
History of known or suspected current, chronic, or recurrent infectious disease, including but not limited to opportunistic infections (e.g., tuberculosis, atypical mycobacterioses, listeriosis, or aspergillosis), HIV, hepatitis B/C. Performance evaluations In this study, all effectiveness measures are PROs.
Urticaria Daily Patient Diary (UPDD), including the following:
urticaria activity score (UAS);
Angioedema Activity Score (AAS);
assessment of the impact of CSU on sleep and daily activity;
Dermatological Life Quality Index (DLQI). Key safety assessments Monitoring of adverse events (AE)
Physical examination
Vital signs
Monitoring laboratory markers in blood and urine
ECG monitoring Data analysis The primary objective of this study is to characterize the dose-response relationship for doses of compound (I) q.d. and b.i.d. and placebo in terms of change in UAS7 value from baseline at week 4 and to select the appropriate dose for use in phase 3 studies. Therefore, the sequential steps are as follows: (1) confirm the overall dose-response signal, (2) estimate the dose-response curve to enable selection of dose(s) for phase 3 studies. To achieve these objectives, the MCP-Mod methodology is used (Bretz et al 2005, biometrics, 61(3):738-48, Pinheiro et al 2014; Stat Med; 33(10):1646-61, Qualification Opinion on MCP-Mod EMA 2014, FDA endorsement 2016). For secondary endpoints, summary tables are presented by treatment group and visit (if applicable) using descriptive statistics that include absolute and relative frequencies for categorical variables and arithmetic mean, standard deviation deviation, minimum, maximum, median, and first and third quartiles for continuous variables.

Primary endpoints

The primary variable for the study is the change in UAS7 from baseline to week 4. UAS7 is the sum of averaged daily UAS scores over 7 days. Note that the weekly score is calculated using the last 7 days prior to the visit.

Secondary endpoints

The efficacy of this method is analyzed by treatment group and visit (if applicable) using descriptive statistics, including absolute and relative frequencies for categorical variables and the mean, standard deviation, minimum, maximum, median, and first and third quartiles for continuous variables. For secondary analyses of UAS7, complete clinical response, disease control, and AAS7=0, pairwise comparisons of each dose of compound (I) with placebo are performed.

UAS7

Summary statistics of absolute and percentage change in UAS7 from baseline are analyzed by treatment group and visit during the treatment and follow-up periods.

Complete clinical response

A complete clinical response, i.e., absence of urticaria and pruritus, is defined as subjects achieving UAS7=0.

Number of subjects with UAS7=0 by treatment group and visit during the treatment and follow-up periods.

Pairwise comparisons between treatment groups (individual compound (I) groups versus placebo).

Controlled disease (UAS7≤6)

Number of subjects with UAS7≤6 by treatment group and visit during treatment and follow-up periods.

Pairwise comparisons between treatment groups (individual compound (I) groups versus placebo).

Absence of angioedema (AAS7=0)

Cumulative number of weeks with AAS7=0 response between baseline and week 12.

The score is derived from the AAS electronic diary. The weekly AAS7 score was obtained by summing the daily scores for the 7 days preceding the visit and ranges from 0 to 105. Missing AAS7 scores are considered nonresponse for the cumulative number of weeks in which subjects achieved an AAS7=0 response. The cumulative number of weeks in which subjects achieved an AAS7=0 response between baseline and week 12 is modeled using a negative binomial regression model with a log-link, using treatment group, randomization strata, and AAS7=0 status at baseline.

DLQI

Seven scores are derived from the DLQI: the score for each of the six parameters, as well as the overall DLQI score, are calculated based on the developers' rules. For each of these seven scores, the change from baseline and percentage change from baseline are also obtained. Summary statistics are calculated for absolute values, as well as for change and percentage change by visit and treatment group.

Number of subjects with DLQI score 0 or 1 depending on treatment group and visit.

Security endpoints

All safety endpoints (i.e., AEs, laboratory data, vital signs, and ECG, as well as potential risks identified in the safety profiling plan) are summarized by treatment for all subjects in the safety population. All data are included in the analysis regardless of whether rescue medications were used.

The data obtained in the clinical study, as well as the preclinical data presented above, demonstrate that compound (I), at daily doses of 10 mg to 200 mg, is safe and pharmacologically active in the treatment of skin diseases caused by basophils and mast cells.

Claims (15)

1. A pharmaceutical composition for oral administration comprising a compound of formula (I) in the amount of 10 mg, 20 mg, 25 mg or 50 mg and one or more pharmaceutically acceptable carriers for the treatment of chronic spontaneous urticaria (CSU) in a subject in need of such treatment. 2. A pharmaceutical composition according to claim 1, comprising a compound of formula (I) in an amount of 50 mg. 3. A pharmaceutical composition according to claim 1, comprising a compound of formula (I) in an amount of 25 mg. 4. A pharmaceutical composition according to claim 1, comprising a compound of formula (I) in an amount of 20 mg. 5. A pharmaceutical composition according to claim 1, comprising a compound of formula (I) in an amount of 10 mg. 6. The pharmaceutical composition of any one of the preceding claims, wherein the subject has CSU with a severity ranging from moderate to severe. 7. A pharmaceutical composition according to any of the preceding claims, wherein the subject is an adult. 8. A pharmaceutical composition according to any of the preceding claims, intended for the treatment of a subject who has previously received treatment with a systemic agent for the treatment of CSU. 9. A pharmaceutical composition according to any of the preceding claims, wherein the subject is selected according to at least one of the following criteria: (a) prior to treatment with a compound of formula (I), the subject has a UAS7 score that is greater than or equal to 16; b) prior to treatment with the compound of formula (I), the subject has an HSS7 score greater than or equal to 8.