TW202430159A - Methods of treatment using an inhibitor of glucosylceramide synthase - Google Patents

Abstract

Provided herein are methods in which patients are administered venglustat in combination with inhibitors of cytochrome CYP3A4. The methods may involve making specific adjustments to the venglustat dosage in order to optimise the clinical response of the patient.

Description

Treatment with glucosamine synthetase inhibitors

Provided herein are methods of administering venglustat in combination with an inhibitor of cytochrome CYP3A4, such as etofonazol or fluconazole, to a patient. The methods may involve specifically adjusting the dose of venglustat to optimize the patient's clinical response.

Venlustat (also known as ( S )-quinin-3-yl 2-(2-(4-fluorophenyl)thiazol-4-yl)propan-2-ylcarbamate) is a small molecule drug that has been proposed for the treatment of conditions including lysosomal storage diseases such as Gaucher disease (see, e.g., WO 2012/129084), protein diseases such as Alzheimer's disease and Parkinson's disease (see, e.g., WO 2016/145046), cystic diseases such as polycystic kidney disease (see, e.g., WO 2014/043068), and fibrotic diseases such as Bardet-Biedl Syndrome (see, e.g., WO 2014/043068). 2020/163337), the contents of each of which are hereby incorporated by reference in their entirety. It has been proposed that venlostat, as an inhibitor of glucosamine synthetase (GCS), may play a role in these treatments by: reducing glycolipid levels (e.g., in the case of lysosomal storage diseases); reducing protein aggregation (e.g., in the case of proteinopathies); reducing apoptosis (e.g., in the case of cystic diseases); or improving ciliary function in ciliary epithelial cells (e.g., in the case of cilia diseases).

Small molecule GCS inhibitors such as vinlustat are primarily intended for regular (e.g., daily) oral administration. Orally administered compounds may be subject to first-pass metabolic deactivation in the liver, which may reduce the oral bioavailability of the compound. Therefore, oral dosage forms may sometimes require larger doses to achieve therapeutic efficacy than the dose required to administer the active agent by another route (e.g., intravenously). In addition, there may be significant interactions (drug-drug interactions; DDIs) between an orally administered drug and an agent used to modulate one or more metabolic pathways of the drug.

In the case of venlukastat, the liver enzyme cytochrome P ₄₅₀ 3A4 (CYP3A4) has been implicated in the metabolic pathway, but the clinical significance of CYP3A4 involvement has not been established (see, e.g., Peterschmitt et al., Clin. Pharmacol. Drug Dev. (2021) 10(1):86-98). However, some clinical studies of venlukastat excluded participants who were receiving concomitant treatment with moderate or strong CYP3A4 inhibitors (see, e.g., Peterschmitt et al., J. Parkinsons Dis. (2022) 12:557-570 and supplementary information).

Patients requiring treatment for the above-mentioned conditions may have comorbid conditions that require additional pharmacological intervention. In many of these patients, co-administration of one or more drug formulations that are CYP3A4 inhibitors may be particularly desirable, such that the combination of drug formulations may be contraindicated due to DDI. Therefore, there is a need to develop safe and effective dosing regimens, dosage forms, and treatments with venlostat that address CYP3A4-related metabolic effects.

Clinical studies that have been conducted to evaluate the effects of strong CYP3A4 inhibitors on the in vivo exposure of vinlustat are described herein. In silico investigations that evaluate the effects of various other CYP3A4 inhibitors on the exposure of vinlustat are also described herein. These results enable the development of vinlustat dosing regimens, dosage forms, and treatment regimens that are tailored for vinlustat when it is co-administered with specific CYP3A4 inhibitors.

Thus, in a first aspect, provided herein is a method for treating a disease or condition in a subject in need thereof, the method comprising administering to the subject an effective amount of vinlusstat or a pharmaceutically acceptable salt thereof, wherein the subject is concurrently administered a strong or moderate CYP3A4 inhibitor.

Another aspect provides a method for treating a disease or condition in a subject in need thereof, the method comprising administering to the subject an effective amount of vinluostat or a pharmaceutically acceptable salt thereof, wherein the subject is concurrently administered a CYP3A4 inhibitor, thereby increasing the plasma exposure (e.g., AUC) of vinluostat by between about 5% and 25% compared to the exposure resulting from administration of vinluostat in the same dose, form, and regimen in the absence of the CYP3A4 inhibitor. In embodiments, the vinluostat or a pharmaceutically acceptable salt thereof is administered at a dose of about 12 mg per day or a dose of about 15 mg per day (calculated as free base).

In embodiments, the CYP3A4 inhibitor is a strong inhibitor that increases plasma exposure of vinlukast by between about 60% and 120% compared to the exposure resulting from administration of vinlukast at the same dose, form, and schedule in the absence of the CYP3A4 inhibitor, and the vinlukast or a pharmaceutically acceptable salt thereof is administered at a dose of between about 4 mg and 15 mg per day (calculated as free base). In embodiments, the vinlukast or a pharmaceutically acceptable salt thereof is administered at a dose of about 8 mg per day (calculated as free base).

In other embodiments, the CYP3A4 inhibitor is a moderate inhibitor that increases plasma exposure of vinlukast by between about 40% and 60% compared to the exposure resulting from administration of vinlukast at the same dose, form, and schedule in the absence of the CYP3A4 inhibitor, and the vinlukast or a pharmaceutically acceptable salt thereof is administered at a dose of between about 12 mg and 15 mg per day (calculated as the free base). In embodiments, the vinlukast or a pharmaceutically acceptable salt thereof is administered at a dose of about 15 mg per day (calculated as the free base).

In an embodiment, the vinlukastat is in the form of vinlukastat free base, a pharmaceutically acceptable salt of vinlukastat or a prodrug of vinlukastat, and optionally vinlukastat L-appleate salt.

In an embodiment, the vinlukastat or a pharmaceutically acceptable salt thereof is administered in combination with the CYP3A4 inhibitor, for example in the same pharmaceutical composition.

In an embodiment, the vinlukastat or a pharmaceutically acceptable salt thereof is administered orally, and the CYP3A4 inhibitor is administered transmucosally, intravenously or orally.

In embodiments, the disease or disorder is selected from lysosomal storage diseases (e.g., Gaucher's disease or Fabry's disease), protein diseases (e.g., Alzheimer's disease, Parkinson's disease, or Huntington's disease), cystic diseases (e.g., polycystic kidney disease), and fibrotic diseases (e.g., Bard-Bieder syndrome).

In an embodiment, the subject suffers from a comorbidity selected from fungal infection, viral infection, bacterial infection, affective disorder and cancer.

Also provided herein is vinlukastat or a pharmaceutically acceptable salt thereof (or a combination of vinlukastat or a pharmaceutically acceptable salt thereof and a CYP3A4 inhibitor, e.g., a composition comprising vinlukastat or a pharmaceutically acceptable salt thereof and a CYP3A4 inhibitor) for use in a method as defined above.

Also provided herein is the use of vinlukastat or a pharmaceutically acceptable salt thereof (or a combination of vinlukastat or a pharmaceutically acceptable salt thereof and a CYP3A4 inhibitor, e.g., a composition comprising vinlukastat or a pharmaceutically acceptable salt thereof and a CYP3A4 inhibitor) in the manufacture of a medicament for use in a method as defined above.

Also provided herein is a method for optimizing (e.g., reducing) the dosage of vinlukastat in a subject being treated or planned to be treated with vinlukastat or a pharmaceutically acceptable salt thereof, the method comprising administering to the subject a strong or moderate CYP3A4 inhibitor.

Also provided herein is a method for minimizing a drug-drug interaction between venlukastat and a moderate or strong CYP3A4 inhibitor in a subject having a disease or condition suitable for treatment with venlukastat or a pharmaceutically acceptable salt thereof, the method comprising: (i) determining the change in plasma exposure of venlukastat when venlukastat or a pharmaceutically acceptable salt thereof is administered in combination with the CYP3A4 inhibitor as compared to the exposure resulting from administration of venlukastat in the same dose, form, and schedule in the absence of the CYP3A4 inhibitor; and (ii) if the change in plasma exposure is an increase of more than about 25%, adjusting the dose of venlukastat or a pharmaceutically acceptable salt thereof.

Also provided herein is a method for determining the correct dose of venlukastat or a pharmaceutically acceptable salt thereof in a subject in need thereof, the method comprising: (i) determining the change in plasma exposure of venlukastat when venlukastat or a pharmaceutically acceptable salt thereof is administered in combination with a strong or moderate CYP3A4 inhibitor, compared to the exposure resulting from administration of venlukastat at the same dose, form and schedule in the absence of the CYP3A4 inhibitor; and (ii) if the change in plasma exposure is an increase of more than about 25%, reducing the dose of venlukastat or a pharmaceutically acceptable salt thereof.

Also provided herein is a method for improving the dosing regimen of vinlukastat or a pharmaceutically acceptable salt thereof in a subject in need thereof, the method comprising: (i) determining the change in plasma exposure of vinlukastat when vinlukastat or a pharmaceutically acceptable salt thereof is administered in combination with a strong or moderate CYP3A4 inhibitor, compared to the exposure resulting from administration of vinlukastat at the same dose, form, and regimen in the absence of the CYP3A4 inhibitor; and (ii) if the change in plasma exposure is an increase of more than about 25%, reducing the dose of vinlukastat or a pharmaceutically acceptable salt thereof.

Also provided herein is a method for managing the risk of a venlukastat/CYP3A4 inhibitor interaction in a subject having a disease or condition suitable for treatment with venlukastat or a pharmaceutically acceptable salt thereof, the method comprising: (i) initiating treatment with venlukastat or a pharmaceutically acceptable salt thereof at a standard indicated dose in the subject; (ii) determining the change in plasma exposure of venlukastat when venlukastat or a pharmaceutically acceptable salt thereof is administered in combination with a strong or moderate CYP3A4 inhibitor, as compared to the exposure resulting from administration of venlukastat at the same dose, form, and schedule in the absence of the CYP3A4 inhibitor; and (iii) if the change in plasma exposure is an increase of more than about 25%, reducing the dose.

Also provided herein is the use of a strong or moderate CYP3A4 inhibitor in a method for: (a) establishing the correct dosage of venlukastat or a pharmaceutically acceptable salt thereof in a subject in need thereof; (b) improving the dosing regimen of venlukastat or a pharmaceutically acceptable salt thereof in a subject in need thereof; or (c) managing the risk of a venlukastat/CYP3A4 inhibitor interaction in a subject having a disease or condition suitable for treatment with venlukastat or a pharmaceutically acceptable salt thereof, wherein the subject is being administered or is planned to be administered the CYP3A4 inhibitor.

Also provided herein is a method for inhibiting CYP3A4 activity in a subject being treated with vinlukastat or a pharmaceutically acceptable salt thereof, the method comprising co-administering the vinlukastat or a pharmaceutically acceptable salt thereof with a strong or moderate CYP3A4 inhibitor.

Also provided herein is a method for improving a therapeutic response to vinlukastat treatment in a subject in need thereof, the method comprising co-administering vinlukastat or a pharmaceutically acceptable salt thereof and a strong or moderate CYP3A4 inhibitor.

Also provided herein is a pharmaceutical composition (e.g., an oral pharmaceutical dosage form) comprising vinlusitastat or a pharmaceutically acceptable salt thereof in combination with a strong or moderate CYP3A4 inhibitor and at least one pharmaceutically acceptable excipient.

In an embodiment, the composition is formulated for oral administration. In an embodiment, the composition is a dosage form selected from a capsule (e.g., a hard capsule) and a tablet (e.g., a chewable tablet, an orally disintegrating tablet, a dispersible tablet or a classic tablet or a capsule-type tablet).

Also provided herein is a composition as defined above for use in a method as defined above.

Other features and advantages of the compositions and methods disclosed herein will become apparent from the following detailed description.

Although specific embodiments herein will now be described with reference to preparations and schemes, it should be understood that such embodiments are by way of example only and illustrate only a few of the many possible specific embodiments that can represent the application of the principles of this invention. Various changes and modifications will be apparent to those skilled in the art given the benefit of this invention and are considered to be within the spirit and scope of this invention as further defined in the appended claims.

Definition

Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by a person of ordinary skill in the art to which this document belongs. Although any methods and materials similar or equivalent to those described herein can be used in the practice or testing of this document, exemplary methods, devices and materials are now described. All technical and patent publications cited herein are incorporated herein by reference in their entirety.

Unless otherwise indicated, this article will employ conventional techniques of tissue culture, immunology, molecular biology, microbiology, cell biology, and recombinant DNA, which are within the skill of the art. See, e.g., Michael R. Green and Joseph Sambrook, Molecular Cloning (4th ed., Cold Spring Harbor Laboratory Press 2012); the series Ausubel et al., eds. (2007) Current Protocols in Molecular Biology; the series Methods in Enzymology (Academic Press, Inc., N.Y.); MacPherson et al. (1991) PCR 1: A Practical Approach (IRL Press at Oxford University Press); MacPherson et al. (1995) PCR 2: A Practical approach; Harlow and Lane, eds. (1999) Antibodies, A Laboratory Manual; Freshney (2005) Culture of Animal Cells: A Manual of Basic Technique, 5th ed.; Gait, ed. (1984) Oligonucleotide Synthesis; U.S. Patent No. 4,683,195; Hames and Higgins, eds. (1984) Nucleic Acid Hybridization; Anderson (1999) Nucleic Acid Hybridization; Hames and Higgins, eds. (1984) Transcription and Translation; Immobilized Cells and Enzymes (IRL Press (1986)); Perbal (1984) A Practical Guide to Molecular Cloning; Miller and Calos, eds. (1987) Gene Transfer Vectors for Mammalian Cells (Cold Spring Harbor Laboratory); Makrides, ed. (2003) Gene Transfer and Expression in Mammalian Cells; Mayer and Walker, eds. (1987) Immunochemical Methods in Cell and Molecular Biology (Academic Press, London); Herzenberg et al., eds. (1996) Weir's Handbook of Experimental Immunology; Manipulating the Mouse Embryo: A Laboratory Manual, 3rd edition (Cold Spring Harbor Laboratory Press (2002)); Sohail (editor) (2004) Gene Silencing by RNA Interference: Technology and Application (CRC Press).

Where appropriate, all numerical designations, such as pH, temperature, time, concentration, molecular weight, etc. (including ranges), are approximate values that vary (+) or (-) in increments of, for example, 0.1 or 1.0. It should be understood that, although not always explicitly stated, all numerical designations are preceded by the term "about", which is used to indicate conventional levels of variability. For example, a numerical designation for a "about" given value may vary by ± 10% of the value; alternatively, the variation may be ± 5%, ± 2%, or ± 1% of the value. It should also be understood that, although not always explicitly stated, the reagents described herein are exemplary only and their equivalents are known in the art.

Unless the context clearly indicates otherwise, as used in the specification and claims, the singular forms "a", "an", and "the" include plural referents. For example, the term "inhibitor" includes a plurality of inhibitors, including mixtures thereof. Unless the context clearly states or is clear, as used herein, the term "or" should be understood to be inclusive. The term "including" is used herein to mean and is used interchangeably with the phrase "including but not limited to".

As used herein, the term "comprising" or "comprises" is intended to indicate that compositions and methods include the listed elements, but do not exclude other elements. When used to define compositions and methods, "consisting essentially of" shall mean excluding other elements of any importance for the stated purpose. Thus, a composition consisting essentially of the elements defined herein would not exclude trace contaminants from separation and purification methods and pharmaceutically acceptable carriers such as phosphate buffered saline, preservatives, etc. "Consisting of" shall mean excluding other ingredients in greater amounts than trace elements and substantial method steps for administering the compositions herein, or method steps for producing the compositions or achieving the desired results. Embodiments defined by each of these transition terms are within the scope of this invention. As used herein, the term "comprising" is intended to cover both "consisting essentially of" and "consisting of."

"Subject," "individual," or "patient" are used interchangeably herein and refer to a human.

The term "healthy individual" as used herein generally refers to an individual who does not suffer from a condition that is suitable for treatment with vinlusstat. For example, a healthy individual can be an individual who does not suffer from a lysosomal storage disease (such as Gaucher's disease), a protein disease (such as Alzheimer's disease or Parkinson's disease), a cystic disease (such as polycystic kidney disease), or a fibroid disease (such as Bard-Bieder syndrome). A healthy individual generally does not have any GBA mutations. In fact, a healthy individual may lack a mutation in any gene encoding an enzyme involved in the sphingosylceramide pathway, such as mutations in genes encoding the following enzymes: ceramide synthase, glucosylceramide synthase, galactosylceramide synthase, lactosylceramide synthase, sphingomyelin synthase, ceramidase, glucocerebrosidase, saposin, galactosylceramide β-galactosidase, acid sphingomyelinase, arylsulfatase A, α-galactosidase A, β-aminohexosidase (e.g., Hex A or Hex B), sialidase, GM1-β-galactosidase, GM2 ganglioside activator, glucosyltransferase, and galactosyltransferase.

"Administration" is defined herein as a means of providing a drug (e.g., an active ingredient) or a composition containing a drug to a subject in such a manner that the drug is in the subject's body. Such administration can be performed by any route, including, but not limited to, oral, transdermal, transcutaneous, transmucosal (e.g., vaginal, rectal, buccal, or sublingual), by injection (e.g., subcutaneous, intravenous, intraperitoneal, intrathecal, intramuscular, intradermal), and by inhalation (e.g., pulmonary, intranasal). Of course, the drug formulation is given in a form suitable for each route of administration. Administration can also be local or systemic in nature. For example, while oral and injection routes of administration generally provide systemic exposure, some routes of administration provide only local exposure, such as topical transdermal administration and intradermal injection. Intranasal inhalation can provide local or systemic exposure. The compositions and methods herein typically involve enteral (eg, oral) administration.

As used herein, "simultaneous" and "concurrently" when referring to therapeutic uses means that two or more active ingredients are administered to a patient as part of a regimen for treating a disease or condition, whether the two or more active agents are given at the same time or different times, or whether they are given by the same route of administration or different routes of administration. The terms "concomitantly" and "in conjunction with" as used herein are intended to have equivalent meanings. The simultaneous administration of two or more active ingredients can be performed at different times of the same day, or on different days, or at different frequencies. The simultaneous administration of two or more active agents may be intended to treat a single disease or condition in a patient, but it is generally used herein to refer to the administration of two or more active agents that are effective in treating two or more different diseases or conditions, e.g., where each active agent is effective to treat a separate disease or condition independent of one or more other active agents.

As used herein, when referring to therapeutic uses, the term "simultaneously" means that two or more active ingredients are administered simultaneously or approximately simultaneously, usually by the same route of administration. This can refer to the administration of two or more active ingredients in a single dosage form or in multiple separate dosage forms administered simultaneously or approximately simultaneously. For example, this can refer to the administration of a single oral tablet or capsule containing two or more active ingredients to a patient, or the administration of two or more oral tablets or capsules containing two or more active ingredients therebetween. Two or more active agents will generally be intended to treat two or more different diseases or conditions, for example, each active agent is effective in treating a separate disease or condition independently of one or more other active agents.

As used herein, when referring to therapeutic uses, the term "single" means that two or more active ingredients are administered simultaneously or approximately simultaneously by different routes of administration, or two or more active ingredients are administered at different times by the same or different routes of administration. For example, the term "single" includes administering one active ingredient by injection or inhalation, and administering a single active ingredient orally, and the two administrations are performed approximately at the same time. In addition, the term "single" includes administering one active ingredient orally at a specific time of the day (e.g., in the morning), and administering a single active ingredient orally at a different time of the day (e.g., one hour later, or three hours later, or in the afternoon or evening), or on different days. Therefore, single administration also encompasses dosing regimens according to which, for example, one drug is taken on days 1, 3, 5, etc., and another drug is taken on days 2, 4, 6, etc. Likewise, two or more active ingredients or drugs are often intended to treat two or more different diseases or conditions, e.g., each active agent is effective in treating a separate disease or condition independent of one or more of the other active agents.

The phrase "simultaneously or approximately simultaneously" is understood to generally mean that the two events occur less than 30 minutes apart, such as less than 20 minutes, or less than 15 minutes, or less than 10 minutes, or less than 5 minutes. If the events themselves occur over a period of time, such as intravenous administration of a drug over a 60-minute period, "simultaneously or approximately simultaneously" includes any overlap between such time periods, or one such time period begins within about 30 minutes of the end of a previous time period.

"Treating" or "treatment" of a disease includes: (1) inhibiting the disease, i.e., arresting or reducing the development of the disease or its clinical symptoms; and/or (2) relieving the disease, i.e., causing regression of the disease or its clinical symptoms. "Preventing" or "prevention" of a disease includes preventing the onset of clinical symptoms of the disease in a patient who may be susceptible to the disease but who does not yet experience or show symptoms of the disease. A disease that is "suitable for treatment with" or "treatable by" a particular agent is a disease that can be treated and/or prevented by the agent in at least some patients who have the disease or are susceptible to the disease.

The term "suffering from" as it relates to the term "treatment" refers to a patient or individual who has been diagnosed with the disease. The term "suffering from" as it relates to the term "prevention" refers to a patient or individual who is susceptible to the disease. A patient may also be "at risk for" the disease due to a history of the disease in their family or due to the presence of a genetic mutation associated with the disease. A patient at risk for a disease has not yet developed all or part of the pathology characteristic of the disease.

An "effective amount" or "therapeutically effective amount" is an amount sufficient to achieve a beneficial or desired result. An effective amount can be administered in one or more administrations, applications, or doses. Such delivery depends on many variables, including the time period over which the individual dosage units are used, the bioavailability of the therapeutic agent, and the route of administration. However, it should be understood that the specific dosage level of the therapeutic agent herein for any particular subject depends on a variety of factors, including, for example, the activity of the specific compound employed, the age, weight, general health, sex, and diet of the subject, the time of administration, the severity of the specific condition being treated, and the form of administration. Typically, dose-effect relationships from in vitro and/or in vivo testing can initially provide useful guidance in terms of appropriate doses for patient administration. Typically, one would expect that the amount of compound administered is effective to achieve a serum level commensurate with the concentration found to be effective in vitro. The determination of these parameters is well within the skill of the art. These considerations, as well as effective formulations and administration regimens, are well known in the art and described in standard textbooks. Consistent with this definition, as used herein, the term "therapeutically effective amount" refers to an amount sufficient to treat (e.g., improve) one or more symptoms associated with a disease or disorder described herein, ex vivo, in vitro, or in vivo. A "standard indicator dose" refers to a recommended amount of a therapeutic agent for a subject in the absence of a variable that may require dose adjustment (e.g., administered simultaneously with one or more additional agents as defined herein). In the presence of such variables, an "adjusted dose" or "adjusted effective amount" may be administered, which may be the same amount or a different amount of the therapeutic agent compared to the "standard indicated dose" or "effective amount" for a different (e.g., normal) subject.

As used herein, "CYP" is an abbreviation for cytochrome P450 (or cytochrome oxidase P450), which is a family of mammalian enzymes expressed primarily in the liver and primarily responsible for the oxidative metabolism of many drugs. There are at least 57 common types of CYP enzymes, and these enzymes are divided into multiple families. Among other enzymes, the CYP 3A family includes the related CYP3A4 and CYP3A5 enzymes, which together are responsible for most mammalian drug metabolism. CYP3A4 is the major cytochrome involved in the metabolism of vinlustat, and it is responsible for approximately 80% of vinlustat metabolism in human liver microsomes.

As used herein, the term "inhibitor" has its generally recognized pharmacological meaning. Thus, an inhibitor is a compound (usually a small molecule) that competitively or non-competitively (e.g., allosterically) inhibits the function of an enzyme, receptor, or other macromolecular target (e.g., protein). Inhibitors generally work by binding to the active site of an enzyme or receptor, thereby blocking the entry of normal substrates, or by binding to an allosteric site, causing a conformational change in the enzyme or receptor, thereby reducing the activity of the enzyme or receptor. Competitive inhibitors bind to the active site and can cause reversible or irreversible inhibition, the latter of which is generally achieved by covalent attachment to the active site. Inhibition of an enzyme in the presence of a compound can also occur indirectly, for example, if one or more metabolites of the compound are themselves inhibitors of the enzyme (e.g., reversible or irreversible and/or competitive or non-competitive inhibitors).

As used herein, the term "CYP3A4 inhibitor" thus refers to a small molecule compound that competitively or non-competitively and reversibly or irreversibly inhibits the enzymatic activity of the CYP3A4 enzyme. CYP3A4 inhibitors can be described as strong, moderate or weak (see, e.g., "Common Medications Classified as Weak, Moderate and Strong Inhibitors of CYP3A4", EBM Consult (October 2015), which is available at https://www.ebmconsult.com/articles/medications-inhibitors-cyp3a4-enzyme ; and Flockhart "Drug Interactions: Cytochrome P450 Drug Interaction Table", Indiana University School of Medicine (2007), which is available at https://drug-interactions.medicine.iu.edu ). Examples of strong CYP3A4 inhibitors include clarithromycin, telithromycin, nefazodone, etofamalufen, ketoconazole, atazanavir, darunavir, indinavir, lopinavir, nelfinavir, ritonavir, saquinavir, tipranavir, troleandomycin, voriconazole, ceritinib, and idelalisib. Examples of moderate CYP3A4 inhibitors include fluconazole, amiodarone, erythromycin, miconazole, diltiazem, verapamil, delavirdine, amipranvir, furosemide, conivaptan, chamomile, licorice, wild cherry, echinacea angustifolia , fluvoxamine, aprepitant, ciprofloxacin, crizotinib, cyclosporine, dronedarone, imatinib, isavuconazole, and tofisopam. Examples of weak CYP3A4 inhibitors include cimetidine, chlorzoxazone, cilostazol, clotrimazole, fosaprepitant, istracaterine, ivacaftor, lomitapide, ranitidine, ranolazine, and ticagrelor.

As used herein, the term "pharmaceutically acceptable excipient" encompasses any standard pharmaceutical excipient, including carriers such as phosphate buffered saline solutions, water, and emulsions (such as oil-in-water or water-in-oil emulsions) and various types of wetting agents. Pharmaceutical compositions may also contain stabilizers and preservatives. For examples of carriers, stabilizers, and adjuvants, see Remington's Pharmaceutical Sciences (20th ed., Mack Publishing Co. 2000).

As used herein, the term "pharmaceutically acceptable salt" means a pharmaceutically acceptable acid addition salt or a pharmaceutically acceptable base addition salt of a compound disclosed herein, which can be administered without producing any one or more substantial undesirable biological effects, or without producing any one or more deleterious interactions with any other components that may be contained in the pharmaceutical composition.

Addition salts can be readily prepared using conventional techniques, for example, by treating the alkaline compound with a specified amount of a selected inorganic or organic acid in an aqueous solvent medium or in a suitable organic solvent (e.g., such as methanol or ethanol). Positively charged compounds (e.g., containing quaternary ammonium) can also form salts with the anionic components of various inorganic and/or organic acids. Acids that can be used to prepare pharmaceutically acceptable acid addition salts are those that can form non-toxic acid addition salts, such as salts containing pharmacologically acceptable anions, such as chlorides, bromides, iodides, nitrates, sulfates or hydrosulfates, phosphates or acid phosphates, acetates, lactones, or the like. acid salts, citrate or acid citrate salts, tartrate or hydrogen tartrate salts, succinate salts, apple salts, maleate salts, fumarate salts, gluconate salts, sugar salts, benzoate salts, methanesulfonate salts and bis(hydroxynaphthoate) salts. Bases useful for preparing pharmaceutically acceptable base addition salts are those that can form non-toxic base addition salts, such as salts containing pharmacologically acceptable cations (such as alkali metal cations (e.g., potassium ions and sodium ions), alkaline earth metal cations (e.g., calcium ions and magnesium ions), ammonium ions) or other water-soluble amine addition salts (such as N -methylglucamine (meglumine), lower alkoxide ammonium); and other such bases of organic amines. The addition salt of vinlustat is usually an acid addition salt. In an embodiment, the pharmaceutically acceptable salt of vinlukastat is vinlukastat apple acid salt, in particular vinlukastat L-apple acid salt.

Unless otherwise expressly stated, the mass of venlustat mentioned herein corresponds to the mass of venlustat calculated as free base. For example, "a 15 mg dose of venlustat" refers to an amount of 15 mg of venlustat free base, or an amount of a salt or prodrug that provides an equivalent molar amount of venlustat (e.g., 20 mg of venlustat apple acid salt). Therefore, "venlustat" mentioned throughout this specification includes pharmaceutically acceptable salts and prodrugs of venlustat, such as described herein.

The description of an embodiment of a variable or aspect herein includes that embodiment as any single embodiment or in combination with any other embodiment or portion thereof.

Any composition or method provided herein can be combined with one or more of any other compositions and methods provided herein.

The following abbreviations are used in this article: Aβ amyloid beta ADAM advanced solubility, absorption and metabolism ADME absorption, distribution, metabolism and excretion ADPKD autosomal dominant polycystic kidney disease AGP alpha 1-acid glycoprotein ARPKD autosomal recessive polycystic kidney disease AUC area under the plasma concentration versus time curve AUC _0-12 12-hour AUC (AUC _0-24 = 24-hour AUC) AUC _inf area under the plasma concentration versus time curve (also called AUC _∞ ) AUC _last area under the plasma concentration versus time curve from zero to _{the last} AUC _tau area under the plasma concentration versus time curve during the dosing interval BBS Bardet-Biedl syndrome B/P BID twice daily (dosage) CDI carbonyldiimidazole C _max maximum observed plasma concentration C _Cereal plasma concentration just before TP2 CL/F apparent total body clearance from plasma CL _int intrinsic clearance CL _int-CYP2D6 intrinsic metabolic clearance allocated to CYP2D6 CL _int-CYP3A4 intrinsic metabolic clearance allocated to CYP3A4 CL _r renal clearance CL _uG,int intestinal intrinsic clearance CYP cytochrome P450 (or cytochrome oxidase P450) DDI drug-drug interaction DMF dimethylformamide DNA deoxyribonucleic acid EDTA ethylenediaminetetraacetic acid f _a fraction absorbed F _g intestinal availability f _m fraction metabolized f _{u, gut} Unbound fraction in the gutf _u,mic Percentage of unbound human liver microsomal proteinsf _u,p Unbound fraction in plasmafe _0-24 Fraction unchanged in urine excretion over 24 hoursGCS Glucosylceramide synthaseGD Gaucher's diseaseGI GastrointestinalGM1 MonosialotetrahexosylgangliosideGM2 MonosialotriahexosylgangliosideHex β-hexosaminidaseHIV Human immunodeficiency virusHCV Hepatitis C virusHLM Human liver microsomesHPC HydroxypropylcelluloseHPLC High pressure/high performance liquid chromatographyHSA Human serum albuminIPA Isopropyl alcoholK _a First order absorption rate constantK _i Inhibition constantLC/MS Liquid chromatography-mass spectrometryMDCKII Madin-Darby canine kidney strain II MDR1 multidrug resistance mutant protein 1 MS mass spectrometry obs observed value OH-eticonazole hydroxyeticonazole P _app apparent permeability coefficient P _eff,man estimated in vivo permeability PBPK physiologically based pharmacokinetics Pgp P-glycoprotein PK pharmacokinetics PKD polycystic kidney disease POPPK population pharmacokinetics pred predicted value QD repeated daily (dosing) QS sufficient - sufficient to replenish the expected amount RB round bottom rHA recombinant human albumin RNA ribonucleic acid SAC monotonic compartment SAE serious adverse event SD single dose t _1/2 half-life t _1/2z terminal half-life related to the terminal slope t _last time of the last dose t _max time to reach peak concentration (C _max ) TBME Tertiary butyl methyl ether TEAE Treatment-emergent adverse event THF Tetrahydrofuran TID Three times daily (dosing) TP1 Treatment period 1 TP2 Treatment period 2 Tris Tris(hydroxymethyl)aminomethane TWEEN 20 Polysorbate 20 TWEEN 80 Polysorbate 80 Wt. % Percentage by weight UPLCMS Ultra-performance liquid chromatography-mass spectrometry V _ss Steady-state apparent distribution volume

Virustat and CYP3A4 Co-administration of inhibitors

Venlustat (free base) has a chemical structure according to formula (I) below, and it may conveniently be provided in the form of a malic acid addition salt (e.g., prepared as described in the Examples below).

Venlustat is an oral GCS inhibitor under development for the treatment of Fabry disease, Gaucher disease, and GM2 gangliosidosis. Venlustat is primarily metabolized by CYP3A4.

Several CYP3A4 inhibitors are evaluated in the following examples, including the strong CYP3A4 inhibitor etofragazole and the moderate CYP3A4 inhibitors fluconazole and fluvoxamine. etofragazole is an antifungal agent that has also been studied as an anticancer agent for patients with basal cell carcinoma, non-small cell lung cancer, and prostate cancer. It has also been studied in combination with other chemotherapies for advanced and metastatic basal cell carcinoma that cannot be treated surgically. etofragazole can be administered orally, topically, and intravenously. For oral administration, it is usually formulated as a tablet or capsule, each dose of which may contain about 100 mg of active ingredient. Fluconazole is another antifungal agent. Fluconazole can be given orally or intravenously, and typical doses are between 100 mg and 400 mg daily. Fluvoxamine is a selective serotonin reuptake inhibitor with antidepressant properties. Fluvoxamine is used to treat major depression and obsessive-compulsive disorder (OCD), as well as other anxiety disorders such as panic disorder, social anxiety disorder, and post-traumatic stress disorder. It is usually given orally, starting at 50-100 mg daily, and can be increased to a maximum of about 300 mg daily if needed.

This article and the following examples describe the development and validation of a physiologically based pharmacokinetic (PBPK) model to assess the effects of CYP3A inhibitors on the pharmacokinetics of vinlustat. The clinical studies described herein and the subsequent modeling established for the first time a quantitative relationship between CYP3A4 inhibition and changes in plasma exposure of vinlustat in vivo. Therefore, based on the studies described herein, a dosing regimen for treating vinlustat in patients who are being co-administered with CYP3A4 inhibitors is provided herein. In particular, a validation method is provided herein to address the co-administration of moderate or strong CYP3A4 inhibitors with vinlustat, thereby enabling safe and effective treatment in these patient populations. The modeling described herein can be extended to determine the effects of CYP3A4 inducers on the pharmacokinetics of vinlukast, enabling similar assessments to be performed, for example, to optimize vinlukast dosing in patients who are being co-administered CYP3A4 inducers.

Thus, in one aspect, provided herein is a method for treating a disease or condition in a subject in need thereof, the method comprising administering to the subject an effective amount of vinluostat or a pharmaceutically acceptable salt thereof, wherein the subject is concurrently administered a strong or moderate CYP3A4 inhibitor. In a related aspect, provided herein is vinluostat or a pharmaceutically acceptable salt thereof for use in a method for treating a disease or condition in a subject in need thereof, the method comprising administering to the subject an effective amount of vinluostat or a pharmaceutically acceptable salt thereof, wherein the subject is concurrently administered a strong or moderate CYP3A4 inhibitor. Another related aspect provides the use of venlukastat in the manufacture of a medicament for use in a method for treating a disease or condition in a subject in need thereof, the method comprising administering to the subject an effective amount of venlukastat and concurrently administering a strong or moderate CYP3A4 inhibitor.

In another aspect, provided herein is a method for treating a disease or condition in a subject in need thereof, the method comprising administering to the subject an effective amount of a combination of vinlustat or a pharmaceutically acceptable salt thereof and a strong or moderate CYP3A4 inhibitor (e.g., a composition comprising them). In a related aspect, provided herein is a combination of vinlustat or a pharmaceutically acceptable salt thereof and a strong or moderate CYP3A4 inhibitor (e.g., a composition comprising them) for use in a method for treating a disease or condition in a subject in need thereof. Another related aspect provides the use of vinlustat or a pharmaceutically acceptable salt thereof and a strong or moderate CYP3A4 inhibitor in the manufacture of a medicament for use in a method for treating a disease or condition in a subject in need thereof.

In embodiments, the strong or moderate CYP3A4 inhibitor is a competitive inhibitor of CYP3A4. In embodiments, one or more metabolites of the strong or moderate CYP3A4 inhibitor are capable of inhibiting CYP3A4, for example, such that the strong or moderate inhibitor can increase vinlusstat exposure by mechanism-based inhibition. In embodiments, the strong or moderate CYP3A4 inhibitor is a triazole antifungal agent, for example, etofenadine or fluconazole.

Also provided herein is a method for treating a disease or condition in a subject in need thereof, comprising administering to the subject an effective amount of vinlukastat or a pharmaceutically acceptable salt thereof, wherein the subject is concurrently administered a CYP3A4 inhibitor, whereby vinlukastat plasma exposure (e.g., AUC) is increased by at least about 25% compared to the exposure resulting from administration of vinlukastat or a pharmaceutically acceptable salt thereof in the same dose, form, and regimen in the absence of the CYP3A4 inhibitor. In a related aspect, provided herein is vinlukastat, or a pharmaceutically acceptable salt thereof, for use in a method for treating a disease or disorder in a subject in need thereof, the method comprising administering to the subject an effective amount of vinlukastat, or a pharmaceutically acceptable salt thereof, wherein the subject is concurrently administered a CYP3A4 inhibitor, whereby vinlukastat plasma exposure (e.g., AUC) is increased by at least about 25% as compared to the exposure resulting from administration of vinlukastat, or a pharmaceutically acceptable salt thereof, in the same dose, form, and regimen in the absence of the CYP3A4 inhibitor. Another related aspect provides the use of vinluostat or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for use in a method for treating a disease or condition in a subject in need thereof, the method comprising administering to the subject an effective amount of vinluostat or a pharmaceutically acceptable salt thereof, wherein the subject is concurrently administered a CYP3A4 inhibitor, thereby increasing the plasma exposure (e.g., AUC) of vinluostat by at least about 25% compared to the exposure resulting from administration of vinluostat or a pharmaceutically acceptable salt thereof in the same dose, form, and regimen in the absence of the CYP3A4 inhibitor. Methods for determining increased plasma exposure of CYP3A4 inhibitors are described herein, including detailed descriptions in the Examples below.

In another aspect, provided herein is a method for treating a disease or condition in a subject in need thereof, the method comprising administering to the subject an effective amount of a combination of vinlukastat or a pharmaceutically acceptable salt thereof and a CYP3A4 inhibitor (e.g., a composition comprising the same), thereby increasing the plasma exposure (e.g., AUC) of vinlukastat by at least about 25% compared to the exposure resulting from administration of vinlukastat or a pharmaceutically acceptable salt thereof in the absence of the CYP3A4 inhibitor in the same dose, form, and regimen. In a related aspect, provided herein is a combination of vinlukastat or a pharmaceutically acceptable salt thereof and a CYP3A4 inhibitor (e.g., a composition comprising the same) for use in a method for treating a disease or condition in a subject in need thereof, whereby the plasma exposure (e.g., AUC) of vinlukastat is increased by at least about 25% compared to the exposure resulting from administration of vinlukastat or a pharmaceutically acceptable salt thereof in the absence of the CYP3A4 inhibitor at the same dose, form, and schedule. Another related aspect provides the use of vinlukastat or a pharmaceutically acceptable salt thereof and a CYP3A4 inhibitor in the manufacture of a medicament for use in a method for treating a disease or condition in a subject in need thereof, whereby the plasma exposure (e.g., AUC) of vinlukastat is increased by at least about 25% compared to the exposure resulting from administration of vinlukastat or a pharmaceutically acceptable salt thereof in the absence of the CYP3A4 inhibitor at the same dose, form, and schedule.

In the foregoing aspects of this article, the disease or condition is suitable for treatment with vinlusstat (or a pharmaceutically acceptable salt thereof). Exemplary diseases and conditions that can be treated with vinlusstat are described herein.

In embodiments, the plasma exposure of venlukastat is the AUC of venlukastat, e.g., AUC _0-12 , AUC _0-24 , AUC _last or AUC _∞ . In embodiments, the plasma exposure of venlukastat is the AUC _last of venlukastat. In embodiments, the plasma exposure of venlukastat is measured experimentally. In other embodiments, the plasma exposure of venlukastat is estimated by modeling (e.g., by modeling as described herein).

In embodiments, vinlusstat or a pharmaceutically acceptable salt thereof and a CYP3A4 inhibitor are administered separately, for example, in separate pharmaceutical compositions, by different modes of administration, and/or at different times (e.g., on different days, or at different times on the same day). In other embodiments, vinlusstat or a pharmaceutically acceptable salt thereof is administered in combination with a CYP3A4 inhibitor, for example, in the same pharmaceutical composition.

In embodiments, the CYP3A4 inhibitor is a strong inhibitor. In embodiments, the inhibitor increases the plasma exposure of vinlukastat by at least about 50% compared to the exposure resulting from administration of vinlukastat or a pharmaceutically acceptable salt thereof in the absence of the CYP3A4 inhibitor at the same dose, form, and regimen. In embodiments, the strong inhibitor increases the plasma exposure of vinlukastat by at least about 55%, 60%, 65%, 70%, 75%, 80%, 85%, 88%, 90%, 92%, 95%, 98%, or 100% compared to the exposure resulting from administration of vinlukastat or a pharmaceutically acceptable salt thereof in the absence of the CYP3A4 inhibitor at the same dose, form, and regimen. In embodiments, a strong inhibitor increases plasma exposure of vinlukastat by between about 50% and 400%, e.g., between about 55% and 300%, between about 60% and 200%, or between about 65% and 150%, compared to the exposure resulting from administration of vinlukastat or a pharmaceutically acceptable salt thereof at the same dose, form, and schedule in the absence of the CYP3A4 inhibitor.

In embodiments, the strong inhibitor increases plasma exposure of vinlukastat by between about 50% and 150% compared to the exposure resulting from administration of vinlukastat or a pharmaceutically acceptable salt thereof at the same dose, form, and schedule in the absence of the CYP3A4 inhibitor, and vinlukastat or a pharmaceutically acceptable salt thereof is administered in an amount that is about 25% to 100% of the standard indicated dose for the disease or condition being treated (e.g., an amount that is about 50% to 100% of the standard indicated dose). In embodiments, a strong inhibitor increases plasma exposure of vinlukastat or a pharmaceutically acceptable salt thereof by between about 60% and 90% compared to the exposure resulting from administration of the same dose, form, and schedule of vinlukastat or a pharmaceutically acceptable salt thereof in the absence of the CYP3A4 inhibitor, and vinlukastat or a pharmaceutically acceptable salt thereof is administered at a dose that is 100% of the standard indicated dose for the disease or condition being treated. In embodiments, the strong inhibitor increases plasma exposure of vinlukastat by between about 90% and 120% compared to the exposure resulting from administration of vinlukastat or a pharmaceutically acceptable salt thereof at the same dose, form, and schedule in the absence of the CYP3A4 inhibitor, and the vinlukastat or a pharmaceutically acceptable salt thereof is administered in an amount that is about 50% to 75% of the standard indicated dose for the disease or condition being treated. In other embodiments, the strong inhibitor increases plasma exposure of vinlukastat or its pharmaceutically acceptable salt by between about 60% and 150% compared to the exposure resulting from administration of vinlukastat or its pharmaceutically acceptable salt at the same dose, form, and schedule in the absence of the CYP3A4 inhibitor, and vinlukastat or its pharmaceutically acceptable salt is administered at a dose of between about 4 mg and 15 mg per day (calculated as the free base), e.g., a dose of between about 8 mg and 12 mg per day (calculated as the free base).

In embodiments, the CYP3A4 inhibitor is a strong inhibitor, and vinlusstat or a pharmaceutically acceptable salt thereof is administered at a dose of about 8 mg (calculated as free base) per day (e.g., a dose of about 7.0 mg to about 9.0 mg (e.g., about 7.5 mg or about 8.0 mg) (calculated as free base) per day. For example, a dose of about 7.5 mg can be obtained by splitting a 15 mg tablet in half. For example, a dose of about 8.0 mg can be obtained by administering two 4 mg unit doses (e.g., tablets or capsules). In other embodiments, the CYP3A4 inhibitor is a strong inhibitor and vinlustat or a pharmaceutically acceptable salt thereof is administered at a dose of about 15 mg per day (calculated as free base). In embodiments, the strong inhibitor is etonazolid, which is administered at a dose of between about 50 mg and 400 mg per day (e.g., about 200 mg per day), such as a dose of about 100 mg BID.

In other embodiments, the CYP3A4 inhibitor is a moderate CYP3A4 inhibitor. In embodiments, the inhibitor increases the plasma exposure of vinlukast by between about 5% and 25% compared to the exposure resulting from administration of vinlukast or its pharmaceutically acceptable salt in the absence of the CYP3A4 inhibitor at the same dose, form and regimen. In other embodiments, the inhibitor increases the plasma exposure of vinlukast by at least about 25% compared to the exposure resulting from administration of vinlukast or its pharmaceutically acceptable salt in the absence of the CYP3A4 inhibitor at the same dose, form and regimen. In embodiments, the moderate inhibitor increases plasma exposure of vinlukastat by between about 25% and 75%, e.g., between about 30% and 65%, between about 35% and 60%, or between about 40% and 55%, compared to the exposure resulting from administration of vinlukastat or a pharmaceutically acceptable salt thereof at the same dose, form, and schedule in the absence of the CYP3A4 inhibitor.

In embodiments, the moderate inhibitor increases the plasma exposure of vinlukastat by between about 5% and 20% compared to the exposure resulting from administration of vinlukastat or its pharmaceutically acceptable salt in the absence of the CYP3A4 inhibitor at the same dose, form and schedule, and vinlukastat or its pharmaceutically acceptable salt is administered at an amount that is 100% of the standard indicated dose for the disease or condition being treated. In embodiments, vinlukastat or its pharmaceutically acceptable salt is administered at a dose of about 15 mg per day (calculated as free base). In other embodiments, the moderate inhibitor increases plasma exposure of vinlukastat by between about 30% and 65% compared to the exposure resulting from administration of vinlukastat or a pharmaceutically acceptable salt thereof at the same dose, form, and schedule in the absence of the CYP3A4 inhibitor, and vinlukastat or a pharmaceutically acceptable salt thereof is administered in an amount that is about 75% to 100% of the standard indicated dose for the disease or condition being treated. In embodiments, the moderate inhibitor increases plasma exposure of vinlukastat or its pharmaceutically acceptable salt by between about 40% and 60% compared to the exposure resulting from administration of vinlukastat or its pharmaceutically acceptable salt at the same dose, form, and schedule in the absence of the CYP3A4 inhibitor, and vinlukastat or its pharmaceutically acceptable salt is administered at a dose that is 100% of the standard indicated dose for the disease or condition being treated. In other embodiments, the moderate inhibitor increases plasma exposure of vinlukast or its pharmaceutically acceptable salt by between about 40% and 60% compared to the exposure resulting from administration of vinlukast or its pharmaceutically acceptable salt in the absence of the CYP3A4 inhibitor at the same dose, form and schedule, and vinlukast or its pharmaceutically acceptable salt is administered at a dose of between about 10 mg and 15 mg per day (calculated as free base), e.g., a dose of about 12 mg per day or about 15 mg per day. In embodiments, the CYP3A4 inhibitor is a moderate inhibitor, and vinlukast or its pharmaceutically acceptable salt is administered at a dose of about 12 mg per day (calculated as free base). In other embodiments, the CYP3A4 inhibitor is a moderate inhibitor, and vinlusstat or a pharmaceutically acceptable salt thereof is administered in a daily dose of about 15 mg (calculated as free base). A dose of about 12 mg can be achieved, for example, by administering three 4 mg unit doses (e.g., tablets or capsules), or by administering two 6 mg unit doses (e.g., tablets or capsules). A dose of about 10 mg can be achieved, for example, by administering one 4 mg unit dose (e.g., tablets or capsules) and one 6 mg unit dose (e.g., tablets or capsules).

In embodiments, the CYP3A4 inhibitor is fluconazole, which is administered at a dose of between about 100 mg and 500 mg per day (e.g., about 200 mg or about 400 mg per day). In embodiments, the CYP3A4 inhibitor is fluvoxamine, which is administered at a dose of between about 50 mg and 300 mg per day. In other embodiments, the CYP3A4 inhibitor is not fluvoxamine. In embodiments, the CYP3A4 inhibitor is not cyclosporine. In embodiments, the CYP3A4 inhibitor is not fluvoxamine or cyclosporine.

In an embodiment, the method herein comprises administering an effective amount of vinlustat or a pharmaceutically acceptable salt thereof to a subject, wherein the subject is being administered a CYP3A4 inhibitor selected from etokonazo[pi] and fluconazole simultaneously. In other embodiments, the method comprises administering to the subject an effective amount of vinlustat or a pharmaceutically acceptable salt thereof in combination with a CYP3A4 inhibitor selected from etokonazo[pi] and fluconazole (e.g., a composition comprising them). In a related aspect, provided herein is a combination of vinlustat or a pharmaceutically acceptable salt thereof with a CYP3A4 inhibitor selected from etokonazo[pi] and fluconazole (e.g., a composition comprising them) for use in a method for treating a disease or condition suitable for treatment with vinlustat in a subject in need thereof. Another related aspect provides the use of vinlustat or a pharmaceutically acceptable salt thereof and a CYP3A4 inhibitor selected from etofenazole and fluconazole in the manufacture of a medicament for use in a method for treating a disease or condition suitable for treatment with vinlustat in a subject in need thereof.

In an embodiment, vinlustat is in the form of vinlustat free base, a pharmaceutically acceptable salt of vinlustat, or a prodrug of vinlustat. In one embodiment, vinlustat is in the form of vinlustat apple acid salt (e.g., vinlustat L-apple acid salt), optionally in crystalline form.

In an embodiment, vinlusstat or a pharmaceutically acceptable salt thereof and a CYP3A4 inhibitor are administered simultaneously, optionally in the same pharmaceutical composition (e.g., an oral dosage form).

In embodiments, vinlusstat or a pharmaceutically acceptable salt thereof and a CYP3A4 inhibitor are administered separately. In embodiments, the method comprises administering a separate pharmaceutical composition comprising a CYP3A4 inhibitor (ie, separate from a pharmaceutical composition or dosage form comprising vinlusstat or a pharmaceutically acceptable salt thereof).

In embodiments, vinlustat or a pharmaceutically acceptable salt thereof is administered orally. In embodiments, a CYP3A4 inhibitor is administered orally. In embodiments, vinlustat or a pharmaceutically acceptable salt thereof and a CYP3A4 inhibitor are administered orally.

In other embodiments, the CYP3A4 inhibitor is administered transdermally, transmucosally, intravenously, intramuscularly, subcutaneously, or intranasally. In embodiments, the CYP3A4 inhibitor is administered transmucosally, intravenously, or orally. In embodiments, the CYP3A4 inhibitor is administered transdermally, transmucosally, intravenously, intramuscularly, subcutaneously, or intranasally, and vinlusstat or a pharmaceutically acceptable salt thereof is administered orally. In embodiments, vinlusstat or a pharmaceutically acceptable salt thereof is administered orally, and the CYP3A4 inhibitor is administered transmucosally, intravenously, or orally.

In an embodiment, vinlusstat or a pharmaceutically acceptable salt thereof (and optionally a CYP3A4 inhibitor) is formulated as an oral pharmaceutical composition. In an embodiment, the pharmaceutical composition comprises at least one pharmaceutically acceptable excipient as described herein. In an embodiment, the pharmaceutical composition further comprises a CYP3A4 inhibitor.

In an embodiment, the oral pharmaceutical composition is a pill, a capsule, a capsule-type tablet, a tablet, a dragee, a powder, a granule, a film, a lozenge, or a liquid. In an embodiment, the oral pharmaceutical composition is a capsule or a tablet (e.g., a tablet). In one embodiment, the oral pharmaceutical composition is a formulation as described in International Patent Application No. PCT/IB2021/056673 (published as WO 2022/018695), the entire contents of which are incorporated herein by reference.

In an embodiment, the formulation is a capsule having the following composition: Element Quantity (Wt. %) Vinlusitol Appleate 12.2% Microcrystalline cellulose (diluent) QS (about 82%) Cross-linked carboxymethyl cellulose sodium (disintegrant) 3.0% Colloidal Silica (Flow Aid) 0.2% Magnesium stearate (lubricant) 2.0%

In an embodiment, the capsule contains 15 mg of venlukastat (20.16 mg of venlukastat appletate), the fill mass of the capsule is 165 mg, and the formulation is packaged into a size #3 capsule shell.

In other embodiments, the formulation is a tablet having the following composition: Element Quantity (Wt. %) Vinlusitol Appleate 13.4% Mannitol QS (about 68%) Crospovidone (Type A) 8.0% Low Substitution HPC 5.0% Colloidal Silica 1.0% Sodium Stearoyl Fumarate 2.5% Magnesium stearate 0.5% Seasoning 1.0% Sweetener 1.0%

In an embodiment, the tablet contains 15 mg of vinlukastat (20.16 mg of vinlukastat malate), the flavor is apricot flavor, the sweetener is sucralose, and the weight of the tablet is 150 mg.

In embodiments, the CYP3A4 inhibitor is etonazolid. In other embodiments, the CYP3A4 inhibitor is fluconazole.

In embodiments, the disease or disorder is selected from lysosomal storage diseases, protein diseases, cystic diseases, and fibrotic diseases.

In embodiments, the disease or disorder is a lysosomal storage disease selected from Fabry's disease, Gaucher's disease (e.g., GD type 1, type 2, or type 3), GM1 ganglioside storage disease, GM2 ganglioside storage disease (e.g., GM2 promoter deficiency, Tay-Sachs disease, Sandhoff disease, or AB variant), Niemann-Pick disease (e.g., type C), and Krabbe disease. In embodiments, the disease or disorder is Gaucher's disease or Fabry's disease. In embodiments, the disease or disorder is Gaucher's disease type 3 (GD3).

In embodiments, the disease or disorder is a protein disease selected from the group consisting of Alzheimer's disease, Parkinson's disease, dementia with Lewy bodies, Pick's disease, progressive supranuclear palsy, pugilistic dementia, chromosome 17-related Parkinson's syndrome, Lytico-Bodig disease, tangled-dominant dementia, argyrophilic granulopathy, ganglioglioma, gangliocytoma, meningioangiomatosis, subacute sclerosing panencephalitis, lead toxic encephalopathy, tuberous sclerosis, Hallervorden-Spatz disease, lipofuscinosis, cortical basal degeneration, frontotemporal dementia, frontotemporal degeneration, and Huntington's disease. In embodiments, the protein disease is selected from the group consisting of Alzheimer's disease, Parkinson's disease, and Huntington's disease. In embodiments, the proteinopathy is characterized by tau protein aggregates, alpha-synuclein protein aggregates, and/or amyloid beta (Αβ) aggregates in the central nervous system.

In embodiments, the disease or disorder is a cystic disease selected from polycystic kidney disease, polycystic liver disease, and polycystic ovarian disease. In embodiments, the cystic disease is polycystic kidney disease (PKD), such as autosomal dominant PKD (ADPKD) or autosomal recessive PKD (ARPKD).

In embodiments, the disease or condition is a ciliopathic disorder selected from the group consisting of Joubert syndrome, Meckel-Gruber syndrome, Senior-Lucken syndrome, orofacial-digital syndrome type I, Leber's congenital amaurosis, Bard-Bieder syndrome (BBS), Alström syndrome, Jeune asphyxiating thoracic dystrophy, Elliott syndrome, Sensenbrenner syndrome, primary ciliopathic dyskinesia, and combinations thereof. In embodiments, the ciliopathic disorder is BBS.

In embodiments, the subject has a comorbidity that can be treated with the CYP3A4 inhibitor. In embodiments, the comorbidity is selected from fungal infection, viral infection (e.g., HIV or HCV infection), bacterial infection, affective illness (e.g., depression or anxiety disorder), and cancer.

Dosage adjustment

As described herein, co-administration of vinlustat or a pharmaceutically acceptable salt thereof and a CYP3A4 inhibitor can increase the plasma exposure (e.g., AUC) of vinlustat, for example, by about 50% to about 200%. This can allow the use of an adjusted (e.g., lower) dose of vinlustat compared to the standard indicated dose for the disease or condition being treated.

Therefore, in another aspect, provided herein is a method for treating a disease or condition suitable for treatment with vinlustat in a subject in need thereof, the method comprising administering to the subject a strong or moderate CYP3A4 inhibitor and concurrently administering an adjusted effective amount of vinlustat or a pharmaceutically acceptable salt thereof. In a related aspect, provided herein is vinlustat or a pharmaceutically acceptable salt thereof for use in a method for treating a disease or condition suitable for treatment with vinlustat in a subject in need thereof, the method comprising administering to the subject a strong or moderate CYP3A4 inhibitor and concurrently administering an adjusted effective amount of vinlustat or a pharmaceutically acceptable salt thereof. In another related aspect, provided herein is a use of vinlusstat or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for use in a method for treating a disease or condition in a subject, wherein the method comprises co-administering a CYP3A4 inhibitor, and wherein the amount of vinlusstat or a pharmaceutically acceptable salt thereof in the medicament is an adjusted effective amount. In embodiments, the CYP3A4 inhibitor is selected from etokonadazole and fluconazole. In embodiments, the CYP3A4 inhibitor is not fluvoxamine.

In another aspect, provided herein is a method for treating a disease or condition suitable for treatment with vinlustat in a subject in need thereof, the method comprising administering to the subject a combination of a strong or moderate CYP3A4 inhibitor and vinlustat or a pharmaceutically acceptable salt thereof (e.g., a composition comprising them), wherein vinlustat or a pharmaceutically acceptable salt thereof is administered in an adjusted effective amount. In a related aspect, provided herein is a combination of vinlustat or a pharmaceutically acceptable salt thereof and a strong or moderate CYP3A4 inhibitor (e.g., a composition comprising them), which is used in a method for treating a disease or condition suitable for treatment with vinlustat in a subject in need thereof, the method comprising administering to the subject an adjusted effective amount of vinlustat or a pharmaceutically acceptable salt thereof. In another related aspect, provided herein is a combination of vinlustat or a pharmaceutically acceptable salt thereof and a strong or moderate CYP3A4 inhibitor (e.g., a composition comprising them) for use in the manufacture of a medicament for use in a method of treating a disease or condition in a subject suitable for treatment with vinlustat, wherein the amount of vinlustat or a pharmaceutically acceptable salt thereof in the medicament is an adjusted effective amount. In embodiments, the CYP3A4 inhibitor is selected from etofonazol and fluconazole. In embodiments, the CYP3A4 inhibitor is not fluvoxamine.

In embodiments, the adjusted effective amount of vinlusstat or its pharmaceutically acceptable salt is an amount of about 25% to 100% of the standard indicated amount for the disease or condition being treated (e.g., an amount of about 50% to 100% of the standard indicated amount). In embodiments, the adjusted effective amount of vinlusstat or its pharmaceutically acceptable salt is at least about 50% of the standard indicated amount for the disease or condition being treated, for example, at least about 55%, 60%, 65%, 70%, 75%, 80%, 85% or 90% of the standard indicated amount. In embodiments, the adjusted effective amount of vinlusstat or its pharmaceutically acceptable salt is less than 100% of the standard indicated dosage for the disease or condition being treated, for example, less than about 99%, 95%, 90%, 85%, 80%, 75%, 70%, 65%, 60% or 55% of the standard indicated dosage. In embodiments, the adjusted effective amount of vinlusstat or its pharmaceutically acceptable salt is an amount of about 50% to about 99% (e.g., about 55% to about 95%, about 60% to about 90%, or about 65% to about 75%) of the standard indicated dosage for the disease or condition being treated. In embodiments, the adjusted effective amount of vinlusstat or a pharmaceutically acceptable salt thereof is an amount that is about 50% of the standard indicated dosage for the disease or condition being treated (e.g., about 55%, 60%, 65%, 70%, 75%, 80%, 85% or 90% of the standard indicated dosage).

In embodiments, the CYP3A4 inhibitor is a strong inhibitor (e.g., etonazoli), and the adjusted effective amount of vinlusstat or a pharmaceutically acceptable salt thereof is an amount of about 50% to 100% of the standard indicated dosage for the disease or condition being treated. In embodiments, the adjusted effective amount of vinlusstat or a pharmaceutically acceptable salt thereof is 100% of the standard indicated dosage for the disease or condition being treated (e.g., a dosage of about 15 mg per day). In other embodiments, the adjusted effective amount of vinluostat or its pharmaceutically acceptable salt is an amount of about 50% to 100% (e.g., about 50% to about 90%, about 50% to about 80%, about 50% to about 70%, or about 50% to about 60%) of the standard indicated amount for the disease or condition being treated. In an embodiment, the standard indicated amount of vinluostat or its pharmaceutically acceptable salt is about 15 mg per day (calculated as free base), and the adjusted effective amount of vinluostat or its pharmaceutically acceptable salt is about 8 mg per day (calculated as free base), for example, about 7.0 mg to about 9.0 mg per day, such as about 7.5 mg or about 8.0 mg (calculated as free base). For example, by splitting a 15 mg tablet in half, a dose of about 7.5 mg can be obtained. For example, by administering two 4 mg unit doses (e.g., tablets or capsules), a dose of about 8.0 mg can be achieved.

In other embodiments, the CYP3A4 inhibitor is a moderate inhibitor (e.g., fluconazole), and the adjusted effective amount of vinluostat or its pharmaceutically acceptable salt is an amount of about 70% to 100% of the standard indicated amount for the disease or condition being treated. In embodiments, the adjusted effective amount of vinluostat or its pharmaceutically acceptable salt is 100% of the standard indicated amount for the disease or condition being treated. In other embodiments, the adjusted effective amount of vinluostat or its pharmaceutically acceptable salt is an amount of about 75% to 100% (e.g., about 80% to 100%, about 85% to 100%, about 90% to 100%, or about 95% to 100%) of the standard indicated amount for the disease or condition being treated. In an embodiment, the standard indicated dose of vinlustat is about 15 mg per day, and the adjusted effective amount of vinlustat or its pharmaceutically acceptable salt is about 10 mg to 15 mg per day, for example, about 12 mg per day or about 15 mg per day (calculated as free base). For example, a dose of about 12 mg can be achieved by administering three 4 mg unit doses (e.g., tablets or capsules), or by administering two 6 mg unit doses (e.g., tablets or capsules). For example, a dose of about 10 mg can be achieved by administering one 4 mg unit dose (e.g., tablet or capsule) and one 6 mg unit dose (e.g., tablet or capsule).

In embodiments, vinlukastat or a pharmaceutically acceptable salt thereof and/or a CYP3A4 inhibitor is as defined herein.

In embodiments, the subject treated and/or the disease or disorder to be treated is as defined herein.

In another aspect, provided herein is a method for optimizing (e.g., reducing) the dosage of vinlusstat in a subject being treated with vinlusstat or a pharmaceutically acceptable salt thereof or planned to be treated with vinlusstat or a pharmaceutically acceptable salt thereof, the method comprising administering to the subject a strong or moderate CYP3A4 inhibitor, e.g., as defined herein. In embodiments, the strong or moderate CYP3A4 inhibitor is administered concurrently with vinlusstat or a pharmaceutically acceptable salt thereof. In a related aspect, provided herein is a strong or moderate CYP3A4 inhibitor (e.g., as defined herein) for use in a method for optimizing (e.g., reducing) the dosage of vinlustat in a subject being treated with vinlustat or a pharmaceutically acceptable salt thereof or planned to be treated with vinlustat or a pharmaceutically acceptable salt thereof. In another aspect, provided herein is the use of a strong or moderate CYP3A4 inhibitor (e.g., as defined herein) in the manufacture of a medicament for use in a method for optimizing (e.g., reducing) the dosage of vinlustat in a subject being treated with vinlustat or a pharmaceutically acceptable salt thereof or planned to be treated with vinlustat or a pharmaceutically acceptable salt thereof. In an embodiment, the CYP3A4 inhibitor is a strong CYP3A4 inhibitor. In an embodiment, the CYP3A4 inhibitor is selected from etonazoli and fluconazole.

In another aspect, provided herein is a method for minimizing a drug-drug interaction between vinlukastat and a moderate or strong CYP3A4 inhibitor (e.g., as defined herein) in a subject having a disease or condition suitable for treatment with vinlukastat or a pharmaceutically acceptable salt thereof, the method comprising: (i) determining the change in plasma exposure of vinlukastat when vinlukastat or a pharmaceutically acceptable salt thereof is administered in combination with the CYP3A4 inhibitor as compared to the exposure resulting from administration of vinlukastat in the same dose, form, and schedule in the absence of the CYP3A4 inhibitor; and (ii) if the change in plasma exposure is an increase of more than about 25%, adjusting the dose of vinlukastat or a pharmaceutically acceptable salt thereof.

In embodiments, determining changes in plasma exposure of vinlustat involves measuring changes in plasma exposure after administration of vinlustat and/or a CYP3A4 inhibitor, for example, in one or more healthy subjects. In other embodiments, determining changes in plasma exposure of vinlustat involves predicting changes in plasma exposure, for example, using a computer-implemented model as described herein to predict. In embodiments, plasma exposure is determined as AUC as defined herein. In embodiments, AUC is AUC _0-12 , AUC _0-24 , AUC _last or AUC _∞ . In embodiments, plasma exposure of vinlustat is AUC _last of vinlustat.

In embodiments, the CYP3A4 inhibitor is a strong CYP3A4 inhibitor. In embodiments, the CYP3A4 inhibitor is a strong CYP3A4 inhibitor and/or if the change in plasma exposure is an increase of more than about 50%, the dose of vinlusstat or a pharmaceutically acceptable salt thereof is reduced. In embodiments, the reduced dose is an adjusted effective amount as defined herein. In embodiments, the CYP3A4 inhibitor is a strong CYP3A4 inhibitor and if the change in plasma exposure is an increase of between about 50% and 200%, the dose of vinlusstat or a pharmaceutically acceptable salt thereof is reduced by an amount between about 0% and 75% (e.g., between about 0% and 50%). In embodiments, the dose of vinlusstat or a pharmaceutically acceptable salt thereof is reduced by an amount between about 5% and 50%, for example, between about 10% and 50%, between about 25% and 50%, or between about 40% and 50%. In embodiments, if the change in plasma exposure is an increase between about 50% and 200%, the dose of vinlusstat or a pharmaceutically acceptable salt thereof is reduced to an amount between about 4 and 15 mg per day (calculated as free base), for example, if the change in plasma exposure is an increase between about 50% and 200%, the dose of vinlusstat or a pharmaceutically acceptable salt thereof is reduced to an amount between about 7 and 15 mg per day. In an embodiment, the dosage of vinlusstat or a pharmaceutically acceptable salt thereof is reduced to an amount of about 8 mg per day (calculated as free base), for example, about 7.0 to about 9.0 mg per day, such as about 7.5 mg or about 8.0 mg (calculated as free base). For example, a dosage of about 7.5 mg can be obtained by dividing a 15 mg tablet in half. For example, a dosage of about 8.0 mg can be achieved by administering two 4 mg unit doses (e.g., tablets or capsules).

In another aspect, provided herein is a method for determining the correct dose of vinlukastat or a pharmaceutically acceptable salt thereof in a subject in need thereof, the method comprising: (i) determining the change in plasma exposure of vinlukastat when vinlukastat or a pharmaceutically acceptable salt thereof is administered in combination with a strong or moderate CYP3A4 inhibitor, compared to the exposure resulting from administration of vinlukastat at the same dose, form and schedule in the absence of the CYP3A4 inhibitor; and (ii) if the change in plasma exposure is an increase of more than about 25%, reducing the dose of vinlukastat or a pharmaceutically acceptable salt thereof.

In a related aspect, provided herein is a method for improving the dosing regimen of vinlukastat or a pharmaceutically acceptable salt thereof in a subject in need thereof, the method comprising: (i) determining the change in plasma exposure of vinlukastat when vinlukastat or a pharmaceutically acceptable salt thereof is administered in combination with a strong or moderate CYP3A4 inhibitor, as compared to the exposure resulting from administration of vinlukastat at the same dose, form, and regimen in the absence of the CYP3A4 inhibitor; and (ii) if the change in plasma exposure is an increase of more than about 25%, reducing the dose of vinlukastat or a pharmaceutically acceptable salt thereof.

In embodiments, determining changes in plasma exposure of vinlustat involves measuring changes in plasma exposure after administration of vinlustat and/or a CYP3A4 inhibitor, for example, in one or more healthy subjects. In other embodiments, determining changes in plasma exposure of vinlustat involves predicting changes in plasma exposure, for example, using a computer-implemented model as described herein to predict. In embodiments, plasma exposure is determined as AUC as defined herein. In embodiments, AUC is AUC _0-12 , AUC _0-24 , AUC _last or AUC _∞ . In embodiments, plasma exposure of vinlustat is AUC _last of vinlustat.

In embodiments, the CYP3A4 inhibitor is a strong CYP3A4 inhibitor. In embodiments, the CYP3A4 inhibitor is a strong CYP3A4 inhibitor and/or if the change in plasma exposure is an increase of more than about 50%, the dose of vinlusstat or a pharmaceutically acceptable salt thereof is reduced. In embodiments, the reduced dose is an adjusted effective amount as defined herein. In embodiments, the CYP3A4 inhibitor is a strong CYP3A4 inhibitor and if the change in plasma exposure is an increase of between about 50% and 200%, the dose of vinlusstat or a pharmaceutically acceptable salt thereof is reduced by an amount between about 0% and 50%. In embodiments, the dose of vinlusstat or a pharmaceutically acceptable salt thereof is reduced by an amount between about 5% and 50%, for example, between about 10% and 50%, between about 25% and 50%, or between about 40% and 50%. In embodiments, if the change in plasma exposure is an increase between about 50% and 200%, the dose of vinlusstat or a pharmaceutically acceptable salt thereof is reduced to an amount between about 4 and 15 mg per day (calculated as free base), for example, if the change in plasma exposure is an increase between about 50% and 200%, the dose of vinlusstat or a pharmaceutically acceptable salt thereof is reduced to an amount between about 7 and 15 mg per day. In an embodiment, the dosage of vinlusstat or a pharmaceutically acceptable salt thereof is reduced to an amount of about 8 mg per day (calculated as free base), for example, about 7.0 to about 9.0 mg per day, such as about 7.5 mg or about 8.0 mg (calculated as free base). For example, a dosage of about 7.5 mg can be obtained by dividing a 15 mg tablet in half. For example, a dosage of about 8.0 mg can be achieved by administering two 4 mg unit doses (e.g., tablets or capsules).

Another aspect of the present invention provides a method for managing the risk of a velustat/CYP3A4 inhibitor interaction in a subject having a disease or condition suitable for treatment with velustat or a pharmaceutically acceptable salt thereof, the method comprising: (i) initiating treatment with velustat or a pharmaceutically acceptable salt thereof in the subject at a standard indicated dose (e.g., a dose as described herein); (ii) determining the change in plasma exposure of velustat when velustat or a pharmaceutically acceptable salt thereof is administered in combination with a strong or moderate CYP3A4 inhibitor, as compared to the exposure resulting from administration of velustat at the same dose, form, and schedule in the absence of the CYP3A4 inhibitor; and (iii) If the change in plasma exposure is more than about a 25% increase, the dose is reduced.

In embodiments, determining changes in plasma exposure of vinlustat involves measuring changes in plasma exposure after administration of vinlustat and/or a CYP3A4 inhibitor, for example, in one or more healthy subjects. In other embodiments, determining changes in plasma exposure of vinlustat involves predicting changes in plasma exposure, for example, using a computer-implemented model as described herein to predict. In embodiments, plasma exposure is determined as AUC as defined herein. In embodiments, AUC is AUC _0-12 , AUC _0-24 , AUC _last or AUC _∞ . In embodiments, plasma exposure of vinlustat is AUC _last of vinlustat.

In embodiments, the CYP3A4 inhibitor is a strong CYP3A4 inhibitor. In embodiments, the CYP3A4 inhibitor is a strong CYP3A4 inhibitor and/or if the change in plasma exposure is an increase of more than about 50%, the dose of vinlusstat or a pharmaceutically acceptable salt thereof is reduced. In embodiments, the reduced dose is an adjusted effective amount as defined herein. In embodiments, the CYP3A4 inhibitor is a strong CYP3A4 inhibitor and if the change in plasma exposure is an increase of between about 50% and 200%, the dose of vinlusstat or a pharmaceutically acceptable salt thereof is reduced by an amount between about 0% and 50%. In embodiments, the dose of vinlusstat or a pharmaceutically acceptable salt thereof is reduced by an amount between about 5% and 50%, for example, between about 10% and 50%, between about 25% and 50%, or between about 40% and 50%. In embodiments, if the change in plasma exposure is an increase between about 50% and 200%, the dose of vinlusstat or a pharmaceutically acceptable salt thereof is reduced to an amount between about 4 and 15 mg per day (calculated as free base), for example, if the change in plasma exposure is an increase between about 50% and 200%, the dose of vinlusstat or a pharmaceutically acceptable salt thereof is reduced to an amount between about 7 and 15 mg per day. In an embodiment, the dosage of vinlusstat or a pharmaceutically acceptable salt thereof is reduced to an amount of about 8 mg per day (calculated as free base), for example, about 7.0 to about 9.0 mg per day, such as about 7.5 mg or about 8.0 mg (calculated as free base). For example, a dosage of about 7.5 mg can be obtained by dividing a 15 mg tablet in half. For example, a dosage of about 8.0 mg can be achieved by administering two 4 mg unit doses (e.g., tablets or capsules).

In another aspect, provided herein is a use of a strong or moderate CYP3A4 inhibitor in a method for: (a) determining the correct dosage of vinluostat or a pharmaceutically acceptable salt thereof in a subject in need thereof; (b) improving the dosing regimen of vinluostat or a pharmaceutically acceptable salt thereof in a subject in need thereof; or (c) managing the risk of vinluostat/CYP3A4 inhibitor interaction in a subject with a disease or condition suitable for treatment with vinluostat or a pharmaceutically acceptable salt thereof, wherein the subject is being administered or is planned to be administered the CYP3A4 inhibitor. In embodiments, the method is a method as described herein.

Other methods

In another aspect, provided herein is a method for inhibiting CYP3A4 activity in a subject being treated with vinluostat or a pharmaceutically acceptable salt thereof, the method comprising administering vinluostat or a pharmaceutically acceptable salt thereof concurrently with a strong or moderate CYP3A4 inhibitor. In a related aspect, provided herein is a strong or moderate CYP3A4 inhibitor for use in a method for inhibiting CYP3A4 activity in a subject being treated with vinluostat or a pharmaceutically acceptable salt thereof, the method comprising administering vinluostat or a pharmaceutically acceptable salt thereof concurrently with a CYP3A4 inhibitor. In another aspect, provided herein is the use of a strong or moderate CYP3A4 inhibitor in the manufacture of a medicament for inhibiting CYP3A4 activity in a subject being treated with vinluostat or a pharmaceutically acceptable salt thereof. In an embodiment, the CYP3A4 inhibitor is a strong CYP3A4 inhibitor. In an embodiment, the CYP3A4 inhibitor is selected from etonazo[pi] and fluconazole. In an embodiment, the CYP3A4 inhibitor is not fluvoxamine.

In another aspect, provided herein is a method for improving a treatment response of a subject in need thereof to treatment with vinlustat, the method comprising administering vinlustat or a pharmaceutically acceptable salt thereof simultaneously with a strong or moderate CYP3A4 inhibitor. In a related aspect, provided herein is a strong or moderate CYP3A4 inhibitor for use in a method for improving a treatment response of a subject in need thereof to treatment with vinlustat. In another aspect, provided herein is the use of a strong or moderate CYP3A4 inhibitor in the manufacture of a medicament for improving a treatment response of a subject in need thereof to treatment with vinlustat. In an embodiment, the CYP3A4 inhibitor is a strong CYP3A4 inhibitor. In an embodiment, the CYP3A4 inhibitor is selected from etokonadazole and fluconazole. In embodiments, the CYP3A4 inhibitor is not fluvoxamine.

In embodiments, vinlukastat or a pharmaceutically acceptable salt thereof and/or a CYP3A4 inhibitor is as defined herein.

In embodiments, co-administration of vinlustat or a pharmaceutically acceptable salt thereof and a CYP3A4 inhibitor allows the use of a lower dose of vinlustat or a pharmaceutically acceptable salt thereof than the standard indicated dose for the disease or condition being treated. In embodiments, the lower dose of vinlustat or a pharmaceutically acceptable salt thereof is an adjusted effective amount as described herein.

In embodiments, concurrent administration of venlukastat or a pharmaceutically acceptable salt thereof and a CYP3A4 inhibitor results in an increase in the plasma AUC of venlukastat by at least about 25% compared to the plasma AUC resulting from administration of venlukastat or a pharmaceutically acceptable salt thereof in the absence of the CYP3A4 inhibitor.

In embodiments, the subject is being treated for a disease or disorder as defined herein.

In various aspects and embodiments herein, the change in plasma exposure of vinlukast when concomitantly administered with a strong or moderate CYP3A4 inhibitor is determined by a computer-implemented method (e.g., as described in the Examples below).

Forms of Virustat

Salt forms of venlukastat are contemplated herein, such as pharmaceutically acceptable salt forms of venlukastat.

Compounds that are alkaline in nature are generally capable of forming a wide variety of different salts with various inorganic and/or organic acids. Although such salts are generally pharmaceutically acceptable for administration to animals and humans, in practice it is generally desirable to first isolate the compound as a pharmaceutically unacceptable salt from the reaction mixture, and then simply convert the latter back to the free base compound by treatment with an alkaline reagent, which is then converted into a pharmaceutically acceptable acid addition salt. Acid addition salts of alkaline compounds can be easily prepared using conventional techniques, for example, by treating the alkaline compound with substantially equal amounts of a selected inorganic or organic acid in an aqueous solvent medium or in a suitable organic solvent (e.g., such as methanol or ethanol). After careful evaporation of the solvent, the desired solid salt is obtained. Positively charged compounds (e.g., containing quaternary ammonium) can also form salts with various inorganic acids and/or the anionic components of organic acids.

Acids that can be used to prepare pharmaceutically acceptable salts of vinlusstat are those that can form non-toxic acid addition salts, such as salts containing pharmacologically acceptable anions, such as chlorides, bromides, iodides, nitrates, sulfates or hydrosulfates, phosphates or acid phosphates, acetates, Lactate, citrate or acid citrate, tartrate or hydrotartrate, succinate, appletate, maleate, fumarate, gluconate, saccharate, benzoate, methanesulfonate and bis(hydroxynaphthoate) [i.e. 1,1'-methylene-bis-(2-hydroxy-3-naphthoate)] salts.

In one embodiment, the pharmaceutically acceptable salt is a succinate. In another embodiment, the pharmaceutically acceptable salt is a 2-hydroxysuccinate, such as ( S )-2-hydroxysuccinate. In another embodiment, the pharmaceutically acceptable salt is a hydrochloride (i.e., a salt formed with HCl). In another embodiment, the pharmaceutically acceptable salt is a apple acid salt, such as L-apple acid salt.

Prodrugs of vinlustat are also contemplated herein. The pharmaceutically acceptable prodrugs disclosed herein are derivatives that can be converted into vinlustat in vivo. When a prodrug that may have some activity itself undergoes solvolysis or enzymatic degradation, for example, under physiological conditions, the prodrug becomes pharmaceutically active in vivo. Based on this article, methods for preparing prodrugs of vinlustat are clear to those skilled in the art.

In one embodiment, the carbamate portion of vinlusstat is modified. For example, the carbamate portion can be modified by adding water and/or one or two fatty alcohols. In this case, the carbon-oxygen double bond of the carbamate portion adopts what can be considered as a hemiacetal or acetal functional group. In one embodiment, the carbamate portion can be modified by adding an aliphatic diol (such as 1,2-ethylene glycol).

In one embodiment, the amine group on the quinine ring portion is modified. For example, the amine group can be modified to form an acid derivative or a quaternary ammonium salt. The derivative can be formed by reacting vinlusstat with an acetylation agent such as an acyl chloride, or with a reagent such as a halogenated alkane.

Further included herein are hydrates, solvates, and polymorphs of vinlustat. For example, vinlustat may be in one or more crystalline forms, such as described in, for example, International Patent Application No. PCT/US2014/027081 (published as WO 2014/152215). In one embodiment, vinlustat is in the form of Form A of the apple acid salt as described in PCT/US2014/027081.

Isotope-labeled compounds are also within the scope of this invention. As used herein, "isotope-labeled compounds" refer to compounds disclosed herein, including drug salts and prodrugs thereof (each as described herein), wherein one or more atoms are replaced by atoms having an atomic mass or mass number different from the atomic mass or mass number commonly found in nature. Examples of isotopes that can be incorporated into compounds disclosed herein include isotopes of hydrogen, carbon, nitrogen, oxygen, phosphorus, fluorine and chlorine, such as ² H, ³ H, ¹³ C, ¹⁴ C, ¹⁵ N, ¹⁸ O, ¹⁷ O, ³¹ P, ³² P, ³⁵ S, ¹⁸ F and ³⁶ Cl, respectively.

Pharmaceutical ingredients

In another aspect, provided herein is a pharmaceutical composition (e.g., an oral pharmaceutical dosage form) comprising vinlusstat in combination with a CYP3A4 inhibitor as defined herein and at least one pharmaceutically acceptable formulation. The composition may be suitable for use in any of the methods disclosed herein.

The pharmaceutically acceptable excipient may be any such excipient known in the art, including those described in, for example, Remington's Pharmaceutical Sciences, Mack Publishing Co., (A. R. Gennaro, ed. 1985). The pharmaceutical compositions of the compounds disclosed herein may be prepared by conventional methods known in the art, including, for example, mixing at least one compound disclosed herein with a pharmaceutically acceptable excipient.

Thus, in an embodiment, provided herein is an oral pharmaceutical dosage form comprising vinlukast in combination with a CYP3A4 inhibitor (e.g., selected from etofonazol and fluconazole) and a pharmaceutically acceptable formulation, wherein the dosage form is formulated to provide an amount of vinlukast when orally administered sufficient to treat a disease or condition as described in accordance with any of the methods herein.

In embodiments, vinlustat is a solid crystalline form (e.g., vinlustat apple acid salt form A). In other embodiments, vinlustat is a solid amorphous form. In embodiments, the dosage form comprises an amorphous solid dispersion, the dispersion comprising vinlustat and/or a CYP3A4 inhibitor and a pharmaceutically acceptable excipient.

In embodiments, the dosage form is a capsule (e.g., a hard capsule) or a tablet (e.g., a chewable tablet, an orally disintegrating tablet, a dispersible tablet, or a classic tablet or a capsule-type tablet), optionally wherein the dosage form comprises about 2 mg to about 30 mg of vinlukastat (measured as free base equivalents), for example, about 4 mg to about 20 mg, about 8 mg to about 12 mg, or about 4 mg, or about 6 mg, or about 8 mg, or about 12 mg, or about 15 mg of vinlukastat (measured as free base equivalents).

In embodiments, the dosage form is a classic tablet or a capsule-type tablet (e.g., for swallowing), a chewable tablet, an orally disintegrating tablet, or a dispersible tablet.

In an embodiment, the pharmaceutically acceptable excipient comprises one or more of the following: (a) a diluent/filler (e.g., cellulose or microcrystalline cellulose, mannitol or lactose), (b) a binder (e.g., povidone, methylcellulose, ethylcellulose, hydroxypropylcellulose (e.g., low-substituted hydroxypropylcellulose), or hydroxypropylmethylcellulose), (c) a disintegrant (e.g., crospovidone, sodium carboxymethyl starch or cross-linked sodium carboxymethyl cellulose), (d) a lubricant (e.g., magnesium stearate or sodium stearyl fumarate), (e) a glidant (e.g., silicon dioxide or talc), (f) Sweeteners (e.g., sucralose, acesulfame potassium, aspartame, saccharin, neotame, advantame), or (g) flavorings (e.g., apricot flavor), and (h) dyes or coloring agents.

In an embodiment, the pharmaceutically acceptable excipient comprises one or more hydrophilic water-soluble polymers or water-swellable polymers. In an embodiment, the polymer is selected from natural or modified cellulose polymers, or any mixture thereof.

In embodiments, any one or more pharmaceutically acceptable excipients are present in an amount of 0.01% to 80% by weight (e.g., 0.1% to 60%, or 0.1% to 40%, or 0.1% to 30%, 0.01% to 15%, or 0.01% to 10%, or 0.1% to 20%, or 0.1% to 15%, or 0.1% to 10%, or 0.5% to 10%, or 0.5% to 5%, or 1% to 5%, or 2.5% to 5%, or 1% to 3%, or 0.1% to 1%). In an embodiment, the dosage form comprises (a) 5%-95% (e.g., 60%-70% or 70%-80%, or 65%-75%, or 65%-70%, or about 68%) of one or more diluents/one or more fillers by weight; (b) 0.5%-5% (e.g., 1%-5%, or 2%-4%, or 2%-3%, or about 3%) of one or more lubricants by weight; (c) 2%-15% (e.g., 4%-12%, or 6%-10%, or 7%-9%, or about 8%) of one or more disintegrants by weight; (d) 0-12% (e.g., 2%-10%, or 2%-8%, or 3%-7%, or 4%-6%, or about 5%) of one or more binders by weight; (e) 0-5% (e.g., 0.15%-4%, or 1%-3%, or 1%-2%, or about 1%) of one or more glidants by weight; and (f) 0-2% of one or more flavoring agents by weight, 0-2% of one or more sweeteners by weight, and/or 0-2% of one or more pigments by weight, for example, about 1% of each of one or more flavoring agents, one or more sweeteners, and/or one or more pigments. In an embodiment, vinlusstat is present in an amount of 3% to 20% by weight (measured as free base). In an embodiment, the CYP3A4 inhibitor is present in an amount of 10% to 90% by weight.

In an embodiment, the dosage form is a tablet comprising a mixture of vinlustat (e.g., vinlustat appletate), a CYP3A4 inhibitor, and one or more pharmaceutically acceptable excipients. In an embodiment, the tablet is formed by directly compressing a mixture of vinlustat (e.g., vinlustat appletate), a CYP3A4 inhibitor, and one or more pharmaceutically acceptable excipients.

In an embodiment, the dosage form is a hard shell capsule, for example, wherein the capsule contains a mixture of vinlustat (e.g., vinlustat appletate), a CYP3A4 inhibitor, and one or more pharmaceutically acceptable excipients. Vinlustat, the CYP3A4 inhibitor, and other diluents/carriers may be included as granules or pellets or as a powder, and the granules, pellets, or powder are contained within the shell of the capsule.

In embodiments, vinlusstat and/or the CYP3A4 inhibitor is present at: (a) an average fineness of 5 to 150 μm, e.g., 5 to 120 μm, 5 to 100 μm, 10 to 100 μm, 15 to 85 μm, 20 to 60 μm, 30 to 40 μm; and/or (b) a D90 of 120 μm or less, e.g., 50 to 100 μm, 70 to 90 μm, or 60 to 80 μm; and/or (c) a D10 of 30 μm or less, e.g., 10 to 25 μm, 10 to 20 μm or less, or 11 to 14 μm.

In embodiments, vinlukastat and a CYP 3A4 inhibitor are mixed together to form an oral pharmaceutical dosage form, wherein the dosage form is homogeneous in terms of the distribution of vinlukastat and the CYP 3A4 inhibitor. In embodiments, vinlukastat and the CYP 3A4 inhibitor are released in the gastrointestinal cavity in substantially the same time period.

In embodiments, vinlukastat and the CYP 3A4 inhibitor are contained in separate parts of the composition or dosage form, such as in separate compartments, particles or layers. In embodiments, vinlukastat and the CYP 3A4 inhibitor are separated by a pharmacologically inert barrier, layer or shell. In embodiments, vinlukastat and the CYP3A4 inhibitor are released in the gastrointestinal cavity over substantially different time periods, or in different regions of the gastrointestinal cavity (e.g., oral cavity, stomach, duodenum, ileum or jejunum).

In embodiments, the dosage form is formulated for immediate release of vinlustat and/or immediate release of the CYP3A4 inhibitor. In embodiments, the dosage form is formulated for sustained release of vinlustat and/or sustained release of the CYP3A4 inhibitor. In embodiments, the dosage form is formulated for delayed release of vinlustat and/or delayed release of the CYP3A4 inhibitor.

In embodiments, following a single oral dose of 15 mg, the plasma AUC of vinlukast is, on average, at least 3400 ng-h/mL, such as 3400 to 6200 ng-h/mL, or 4000 to 5600 ng-h/mL, or 4400 to 5200 ng-h/mL.

The pharmaceutical composition or dosage form herein may include a reagent and another carrier, such as an inert or active compound or composition, such as a detectable reagent, a label, an adjuvant, a diluent, a binder, a stabilizer, a buffer, a salt, a lipophilic solvent, a preservative, an adjuvant, etc. Carriers also include drug formulators and additives, such as proteins, peptides, amino acids, lipids, and carbohydrates (e.g., sugars, including monosaccharides, disaccharides, trisaccharides, tetrasaccharides, and oligosaccharides; derivatized sugars, such as sugar alcohols, uronic acids, esterified sugars, etc.; and polysaccharides or sugar polymers), which may be present alone or in combination, accounting for 1% to 99.99% by weight or volume alone or in combination. Exemplary protein excipients include serum albumins such as human serum albumin (HSA), recombinant human albumin (rHA), gelatin, casein, etc. Representative amino acid/antibody components that may also function in a buffering capacity include alanine, glycine, arginine, betaine, histidine, glutamine, aspartate, cysteine, lysine, leucine, isoleucine, thioamine, methionine, phenylalanine, aspartame, etc. Carbohydrate excipients are also intended to be within the scope of this invention, examples of which include but are not limited to monosaccharides such as fructose, maltose, galactose, glucose, D-mannose, sorbose, and the like; disaccharides such as lactose, sucrose, trehalose, cellodisaccharide, and the like; polysaccharides such as raffinose, melezitose, maltodextrin, dextran, starch, and the like; and sugar alcohols such as mannitol, xylitol, maltitol, lactitol, xylitol sorbitol (glucitol), and inositol.

Carriers that can be used include buffers or pH adjusters; typically, the buffer is a salt prepared from an organic acid or base. Representative buffers include organic acid salts, such as citric acid, ascorbic acid, gluconic acid, carbonic acid, tartaric acid, succinic acid, acetic acid or phthalic acid salts; Tris, tromethamine hydrochloride or phosphate buffers. Additional carriers include polymeric formulators/additives such as polyvinylpyrrolidone, ficoll (a polymeric sugar), dextrates (e.g., cyclodextrins such as 2-hydroxypropyl-β-cyclodextrin), polyethylene glycol, flavorings, antimicrobial agents, sweeteners, antioxidants, antistatic agents, surfactants (e.g., polysorbates (e.g., "TWEEN 20" and "TWEEN 80"), lipids (e.g., phospholipids, fatty acids), steroids (e.g., cholesterol), and chelating agents (e.g., EDTA).

Also provided herein are pharmaceutical compositions and kits comprising the compositions, the compositions comprising vinlusstat (or a pharmaceutically acceptable salt or prodrug thereof) and a CYP3A4 inhibitor as described herein. Also provided herein are kits comprising a first pharmaceutical composition and a second pharmaceutical composition, the first pharmaceutical composition comprising vinlusstat or a pharmaceutically acceptable salt thereof (e.g., as described herein), and the second pharmaceutical composition comprising a strong or moderate CYP3A4 inhibitor as described herein.

The pharmaceutical composition can be formulated to release the active ingredient therein slowly, to extend the release or to control the release, for example, using hydroxypropylmethylcellulose (changing the ratio to provide the desired release curve), other polymer matrices, liposomes and/or microspheres to formulate. The pharmaceutical composition can also contain a sunscreen as appropriate, and can have a composition that releases one or more active ingredients only or preferentially in a certain part of the gastrointestinal tract, optionally in a delayed manner, for example, by using an enteric coating to achieve. Examples of embedded compositions include polymeric substances and waxes. The active ingredient can also be in the form of microencapsulation, if appropriate, using one or more pharmaceutically acceptable carriers, excipients or diluents well known in the art (see, for example, Remington's). The compounds disclosed herein can be formulated for sustained delivery according to methods known to those of ordinary skill in the art. Examples of such formulations can be found in U.S. Patents 3,119,742; 3,492,397; 3,538,214; 4,060,598; and 4,173,626.

In solid dosage forms for oral administration (e.g., capsules, tablets, pills, dragees, powders, granules, etc.), the active ingredient is mixed with one or more pharmaceutically acceptable carriers, excipients or diluents (e.g., sodium citrate or dicalcium phosphate and/or any of the following): (1) fillers or extenders, such as starch, lactose, sucrose, glucose, mannitol, microcrystalline cellulose, calcium phosphate and/or silicic acid; (2) binders, such as, for example, carboxymethyl cellulose, alginate, gelatin, pregelatinized corn starch, polyvinylpyrrolidone, hydroxypropyl methylcellulose, sucrose and/or gum arabic; (3) Humectants such as glycerol; (4) disintegrants such as agar, calcium carbonate, sodium carboxymethyl starch, potato or tapioca starch, alginic acid, certain silicates and sodium carbonate; (5) solution retarders such as wax; (6) absorption enhancers such as quaternary ammonium compounds; (7) wetting agents such as, for example, sodium lauryl sulfate, acetyl alcohol and glycerol monostearate; (8) absorbents such as kaolin and bentonite; (9) lubricants such as talc, silica, calcium stearate, magnesium stearate, solid polyethylene glycols, sodium lauryl sulfate and mixtures thereof; and (10) coloring agents. In the case of capsules, tablets and pills, the pharmaceutical composition may also contain a buffering agent. Similar types of solid compositions may also be prepared using fillers in soft and hard-filled gelatin capsules, and molding agents such as lactose or milk sugar, as well as high molecular weight polyethylene glycols and the like.

Tablets can be prepared by compression or molding, optionally with one or more auxiliary ingredients. Compressed tablets can be prepared using a binder (e.g., gelatin or hydroxypropylmethylcellulose), a lubricant, an inert diluent, a preservative, a disintegrant (e.g., sodium carboxymethyl starch or cross-linked sodium carboxymethyl cellulose), a surfactant or a dispersant. Molded tablets can be prepared by molding in a suitable machine a mixture of the powdered active ingredient moistened with an inert liquid diluent. Tablets and other solid dosage forms such as dragees, capsules, pills and granules may be scored or prepared with coatings and shells, such as enteric coatings and others well known in the art, as appropriate.

In an embodiment, the pharmaceutical composition is administered orally in liquid form. Liquid dosage forms for oral administration of active ingredients include pharmaceutically acceptable emulsions, microemulsions, solutions, suspensions, syrups and elixirs. Liquid preparations for oral administration can be presented as dry products for reconstitution with water or other suitable media before use. In addition to the active ingredient, the liquid dosage form may contain an inert diluent commonly used in the art, such as water or other solvents, solubilizers and emulsifiers, such as ethanol, isopropyl alcohol, ethyl carbonate, ethyl acetate, benzyl alcohol, benzyl benzoate, propylene glycol, 1,3-butylene glycol, oils (e.g., cottonseed oil, peanut oil, corn oil, germ oil, olive oil, castor oil and sesame oil), glycerol, tetrahydrofurfuryl alcohol, polyethylene glycol and fatty acid esters of sorbitan and mixtures thereof. In addition to inert diluents, liquid pharmaceutical compositions may include adjuvants, such as wetting agents, emulsifiers and suspending agents, sweeteners, flavoring agents, coloring agents, aromas and preservatives, etc. In addition to one or more active ingredients, the suspension may contain a suspending agent such as, but not limited to, ethoxylated isostearyl alcohol, polyoxyethylene sorbitol and desorbitan esters, microcrystalline cellulose, aluminum metahydride, bentonite, agar and tragacanth and mixtures thereof. Suitable liquid formulations may be prepared by conventional means with one or more pharmaceutically acceptable additives such as: suspending agents (e.g., sorbitol syrup, methylcellulose or hydrogenated edible fats); emulsifiers (e.g., lecithin or acacia); non-aqueous vehicles (e.g., almond oil, oily esters or ethanol); and/or preservatives (e.g., methyl or propyl p-hydroxybenzoate or sorbic acid). One or more active ingredients may also be administered as a bolus, electuary or paste.

In some embodiments of the methods described herein, the pharmaceutical composition may take the form of tablets or lozenges formulated for buccal administration in a conventional manner.

In some embodiments of the methods described herein, the pharmaceutical composition is administered non-orally (e.g., by topical application, transdermal application, injection, etc.). In related embodiments, the pharmaceutical composition is administered parenterally by injection, infusion, or implantation (e.g., intravenously, intramuscularly, intraarterially, subcutaneously, etc.).

In some embodiments of the methods described herein, the compounds disclosed herein can be formulated for parenteral administration by injection (including using conventional catheter insertion techniques or infusion). Formulations for injection can be in unit dosage form (e.g., in ampoules or in multi-dose containers) and preservatives added. The composition can take the form of a suspension, solution, or emulsion in an oily or aqueous vehicle, and can contain a preparatant, such as a suspending agent, stabilizer, and/or dispersant recognized by a person skilled in the art. Alternatively, the active ingredient can be in the form of a powder for reconstitution with a suitable vehicle (e.g., sterile pyrogen-free water) before use.

In some embodiments of the methods described herein, the pharmaceutical composition can be in the form of a sterile injection. The pharmaceutical composition can be sterilized, for example, by filtering through a bacteria-retaining filter or by incorporating a sterilizing agent in the form of a sterile solid composition, which can be dissolved in sterile water or some other sterile injectable medium immediately before use. In order to prepare such a composition, the active ingredient is dissolved or suspended in a liquid medium that is acceptable to the parenteral administration. Exemplary vehicles and solvents include, but are not limited to, water, water adjusted to a suitable pH by adding an appropriate amount of hydrochloric acid, sodium hydroxide or a suitable buffer, 1,3-butanediol, Ringer's solution, and isotonic sodium chloride solution. The pharmaceutical composition may also contain one or more preservatives, such as methyl p-hydroxybenzoate, ethyl p-hydroxybenzoate or n-propyl p-hydroxybenzoate. To improve solubility, a dissolution promoter or solubilizer may be added, or the solvent may contain 10%-60% w/w of propylene glycol, etc.

In some embodiments of the methods described herein, the pharmaceutical composition may contain one or more pharmaceutically acceptable sterile isotonic or non-aqueous solutions, dispersions, suspensions or emulsions, or sterile powders that can be dissolved back into sterile injectable solutions or dispersions immediately before use. Such pharmaceutical compositions may contain antioxidants; buffers; bacteriostatic agents; solutes that make the formulation isotonic with the blood of the intended recipient; suspending agents; thickening agents; preservatives, etc.

Examples of suitable aqueous and non-aqueous carriers that can be used in any of the pharmaceutical compositions described herein include water, ethanol, polyols (such as glycerol, propylene glycol, polyethylene glycol, etc.) and suitable mixtures thereof, vegetable oils (such as olive oil) and injectable organic esters (such as ethyl oleate). Suitable fluidity can be maintained, for example, by using coating materials (such as lecithin), by maintaining the required fineness in the case of dispersions, and by using surfactants. In some embodiments, in order to prolong the effect of the active ingredient, it is necessary to slow down the absorption of the compound from gastrointestinal administration or from subcutaneous or intramuscular injection. This can be achieved by using a liquid suspension of a crystalline or amorphous material with poor water solubility. The absorption rate of the active ingredient depends on its dissolution rate, which in turn may depend on the crystal fineness and crystalline form. Alternatively, delayed absorption of a parenterally administered active ingredient can be accomplished by dissolving or suspending the compound in an oil vehicle. Additionally, prolonged absorption of the injectable drug form can be accomplished by including an agent that delays absorption, such as aluminum monostearate and gelatin.

Controlled release parenteral compositions can be in the form of aqueous suspensions, microspheres, microcapsules, magnetic microspheres, oily solutions, oily suspensions, emulsions, or the active ingredient can be incorporated into one or more biocompatible carriers, liposomes, nanoparticles, implants or infusion devices. Materials used in the preparation of microspheres and/or microcapsules include, but are not limited to, biodegradable/bioerodible polymers such as polylactic acid hydroxyacetic acid (polyglactin), poly (isobutyl cyanoacrylate), poly (2-hydroxyethyl-L-glutamine) and poly (lactic acid). Biocompatible carriers that can be used when formulating controlled release parenteral formulations include carbohydrates (such as dextran), proteins (such as albumin, lipoproteins or antibodies). Materials for use in implants may be non-biodegradable, such as polydimethylsiloxane, or biodegradable, such as, for example, poly(caprolactone), poly(lactic acid), poly(glycolic acid), or poly(orthoesters).

In some embodiments of the methods described herein, for topical administration, the compounds disclosed herein can be formulated as ointments or creams. The compounds disclosed herein can also be formulated into rectal compositions such as suppositories or retention enemas, for example containing conventional suppository bases such as cocoa butter or other glycerides.

In other aspects, provided herein is a dosage form or pharmaceutical composition as described herein for use in therapy, e.g., for use in a method as defined herein.

Although generally described herein, the following non-limiting examples are provided to further illustrate the present invention.

Examples

Examples 1A : ( S )- Quinine ring -3- base 2-(2-(4- Fluorophenyl ) Thiazole -4- base ) C -2- Synthesis of vinlustat

To a stirred solution of 4-fluorothiobenzamide (8.94 g, 57.6 mmol) in ethanol (70 mL) was added ethyl 4-chloroacetylacetate (7.8 mL, 58 mmol). The reaction was heated at reflux for 4 h, treated with another aliquot of ethyl 4-chloroacetylacetate (1.0 mL, 7.4 mmol), and refluxed for an additional 3.5 h. The reaction was then concentrated and the residue partitioned between ethyl acetate (200 mL) and aqueous NaHCO ₃ (200 mL). The organic layer was combined with the stripping of the aqueous layer (ethyl acetate, 1 × 75 mL), dried (Na ₂ SO ₄ ), and concentrated. The resulting amber oil was purified by flash chromatography using a hexanes/ethyl acetate gradient to afford ethyl 2-(2-(4-fluorophenyl)thiazol-4-yl)acetate (13.58 g, 89%) as a low melting, nearly colorless solid.

To a stirred solution of ethyl 2-(2-(4-fluorophenyl)thiazol-4-yl)acetate (6.28 g, 23.7 mmol) in DMF (50 mL) was added sodium hydroxide [60% dispersion in mineral oil] (2.84 g, 71.0 mmol). The foamy mixture was stirred for 15 minutes, then cooled in an ice bath and iodomethane (4.4 mL, 71 mmol) was added. The reaction was stirred overnight, allowing the cooling bath to slowly warm to room temperature. The mixture was then concentrated and the residue partitioned between ethyl acetate (80 mL) and water (200 mL). The organic layer was washed with a second portion of water (1 × 200 mL), dried (Na ₂ SO ₄ ) and concentrated. The resulting amber oil was purified by flash chromatography using a hexanes/ethyl acetate gradient to give ethyl 2-(2-(4-fluorophenyl)thiazol-4-yl)-2-methylpropanoate (4.57 g, 66%) as a colorless oil.

To a stirred solution of ethyl 2-(2-(4-fluorophenyl)thiazol-4-yl)-2-methylpropanoate (4.56 g, 15.5 mmol) in 1 : 1 : 1 THF/ethanol/water (45 mL) was added lithium hydroxide monohydrate (2.93 g, 69.8 mmol). The reaction was stirred overnight, concentrated, and redissolved in water (175 mL). The solution was washed with ether (1 × 100 mL), acidified by addition of 1.0 N HCl (80 mL), and extracted with ethyl acetate (2 × 70 mL). The combined extracts were dried (Na ₂ SO ₄ ) and concentrated to give 2-(2-(4-fluorophenyl)thiazol-4-yl)-2-methylpropanoic acid (4.04 g, 98%) as a white solid. This material was used in the next step without purification.

To a stirred and cooled (0ºC) solution of 2-(2-(4-fluorophenyl)thiazol-4-yl)-2-methylpropanoic acid (4.02 g, 15.2 mmol) in THF (100 mL) was added trimethylamine (4.2 mL, 30 mmol) followed by isobutyl chloroformate (3.0 mL, 23 mmol). The reaction was stirred cold for an additional hour before a solution of sodium azide (1.98 g, 30.5 mmol) in water (20 mL) was added. The reaction was stirred overnight, allowing the cooling bath to slowly warm to room temperature. The mixture was then diluted with water (100 mL) and extracted with ethyl acetate (2 x 60 mL). The combined extracts were washed with aqueous NaHCO ₃ (1 × 150 mL) and brine (1 × 100 mL), dried (Na ₂ SO ₄ ) and concentrated. After coevaporation with toluene (2 × 50 mL), the resulting white solid was taken up in toluene (100 mL) and refluxed for 4 h. (S)-3-quininol (3.87 g, 30.4 mmol) was then added and reflux continued overnight. The reaction was concentrated and the residue was partitioned between ethyl acetate (100 mL) and aqueous NaHCO ₃ (150 mL). The organic layer was washed with water (1 × 150 mL), dried (Na ₂ SO ₄ ) and concentrated. The resulting off-white solid was purified by flash chromatography using a chloroform/methanol/ammonia gradient to give the title compound as a white solid (4.34 g, 73%). ¹ H NMR (400 MHz, CDCl ₃ ) δ 7.96-7.88 (m, 2H), 7.16-7.04 (m, 3H), 5.55 (br s, 1H), 4.69-4.62 (m, 1H), 3.24-3.11 (m, 1H), 3.00-2.50 (m, 5H), 2.01-1.26 (m, 11H) ppm. ¹³ C NMR (400 MHz, CDCl ₃ ) δ 166.4, 165.1, 163.8 (d, J =250.3 Hz), 162.9, 155.0, 130.1 (d, J =3.3 Hz), 128.4 (d, J = 8.5 Hz), 115.9 (d, J = 22.3 Hz), 112.5, 71.2, 55.7, 54.2, 47.5, 46.5, 28.0, 25.5, 24.7, 19.6 ppm. Purity: 100% UPLCMS (210 nm and 254 nm); Retention time 0.83 min; (M + 1) 390.

Examples 1B : Free base form ( S )- Quinine ring -3- base (2-(2-(4- Fluorophenyl ) Thiazole -4- base ) C -2- base ) Preparation of carbamate (Venlustat)

Step 1 : Dimethylation with iodomethane

Equip a 3N RB flask with a thermometer, addition funnel, and nitrogen inlet. Flush the flask with nitrogen and weigh potassium tert-butoxide (MW 112.21, 75.4 mmol, 8.46 g, 4.0 equiv, white powder) and add to the flask via a powder funnel followed by THF (60 mL). Most of the potassium tert-butoxide dissolves to give a cloudy solution. Cool this mixture to 0ºC-2ºC (internal temperature) in an ice-water bath. In a separate flask, dissolve the starting ester (MW 265.3, 18.85 mmol, 5.0 g, 1.0 equiv) in THF (18 mL + 2 mL as rinse) and transfer to the addition funnel. Add this solution dropwise to the cooled mixture over a period of 25-30 min, maintaining the internal temperature below 5ºC during the addition. Cool the reaction mixture back to 0ºC-2ºC. In a separate flask, prepare a solution of iodomethane (MW 141.94, 47.13 mmol, 6.7 g, 2.5 equiv) in THF (6 mL) and transfer to the addition funnel. The flask containing the iodomethane solution is then rinsed with THF (1.5 mL) and then transferred to the addition funnel which already contains the clear, colorless solution of iodomethane in THF. Carefully add this solution dropwise to the dark brown reaction mixture over a period of 30-40 min, maintaining the internal temperature below 10ºC during the addition. After the addition was complete, the slightly turbid mixture was stirred for an additional 1 h, during which the internal temperature dropped to 0ºC-5ºC. After stirring at 0ºC-5ºC for 1 hour, the reaction mixture was quenched by slowly adding 5.0 M aqueous HCl (8 mL) dropwise over a period of 5-7 min. The internal temperature was kept below 20ºC during this addition. After the addition, water (14 mL) was added and the mixture was stirred for 2-3 min. Stirring was stopped and the two layers were allowed to separate. The two layers were then transferred to a 250 mL 1N RB flask and THF was evaporated as much as possible in vacuo to obtain a biphasic layer of THF/product and water. The two layers were allowed to separate. The THF solution of the product of step 1 was used in the next reaction.

Step 2 : Hydrolysis of ethyl ester with LiOH monohydrate

The crude ester in THF was added to a reaction flask. Separately, LiOH.H ₂ O (MW 41.96, 75.0 mmol, 3.15 g, 2.2 eq) was weighed in a 100 mL flask and a stirring bar was added thereto. Water (40 mL) was added and the mixture was stirred until all solids were dissolved to obtain a clear colorless solution. This aqueous solution was then added to a 250 mL RB flask containing a solution of the ester in tetrahydrofuran (THF). A condenser was attached to the neck of the flask and a nitrogen inlet was attached to the top of the condenser. The mixture was heated under reflux for 16 hours. After 16 hours, the heating was stopped and the mixture was cooled to room temperature. The THF was evaporated in vacuo to obtain a brown solution. An aliquot of the brown aqueous solution was analyzed by HPLC and LC/MS to confirm complete hydrolysis of the ethyl ester. Water (15 mL) was added and the alkaline aqueous solution was extracted with TBME (2 x 40 mL) to remove the tertiary butyl ester. The aqueous alkaline layer was cooled to 0ºC-10ºC in an ice-water bath and acidified to pH approximately 1 by dropwise addition of concentrated HCl with stirring. To this viscous solid in the acidic aqueous solution was added TBME (60 mL) and the mixture was shaken and then stirred vigorously to dissolve all of the acid into the TBME layer. Both layers were transferred to a separatory funnel and the TBME layer was separated. The light yellow acidic aqueous solution was re-extracted with TBME (40 mL) and the TBME layer was separated and combined with the previous TBME layer. The aqueous acidic layer was discarded. The combined TBME layers were dried over _{anhydrous Na2SO4} , filtered and evaporated in vacuo to remove TBME and afford the crude acid as an orange/dark yellow oil which solidified to a dirty yellow solid under high vacuum. The crude acid was weighed and crystallized by heating in heptane/TBME (3:1, 5 mL/g of crude) to afford the acid as a yellow solid.

Step 3 : Formation of isohydroxyoxime acid with _NH2OH.HCl

The carboxylic acid (MW 265.3, 18.85 mmol, 5.0 g, 1.0 equiv) was weighed and transferred to a 25 mL 1N RB flask under nitrogen. THF (5.0 mL) was added and the acid readily dissolved to give a clear dark yellow to brown solution. The solution was cooled to 0ºC-2ºC (bath temperature) in an ice bath and N,N'-carbonyldiimidazole (CDI; MW 162.15, 20.74 mmol, 3.36 g, 1.1 equiv) was added slowly in small portions over a period of 10-15 minutes. The ice bath was removed and the solution was stirred at room temperature for 1 h. After stirring for 1 h, the solution was cooled again in an ice-water bath to 0ºC-2ºC (bath temperature). Hydroxylamine hydrochloride ( _NH2OH.HCl ; MW 69.49, 37.7 mmol, 2.62 g, 2.0 equiv) was added slowly as a solid in small portions over a period of 3-5 minutes as this addition was exothermic. After the addition was complete, water (1.0 mL) was added dropwise to the heterogeneous mixture over a period of 2 minutes and the reaction mixture was stirred in an ice-water bath at 0ºC-10ºC for 5 minutes. The cooling bath was removed and the reaction mixture was stirred at room temperature overnight under nitrogen for 20-22 h. The solution became clear as all the _NH2OH.HCl dissolved. After 20-22 h, an aliquot of the reaction mixture was analyzed by high pressure liquid chromatography (HPLC). THF was then evaporated in vacuo, and the residue was taken up in dichloromethane (120 mL) and water (60 mL). The mixture was transferred to a separatory funnel, where the mixture was shaken and the two layers were separated. The aqueous layer was discarded, and the dichloromethane layer was washed with 1N hydrochloric acid (HCl; 60 mL). The acid layer was discarded. The dichloromethane layer was dried over _{anhydrous Na2SO4} , filtered and the solvent was evaporated in vacuo to obtain the crude isohydroxyoxic acid as a light yellow solid, which was dried in high vacuum overnight.

Step 3 : Conversion of isohydroxyoxime to cyclic intermediate (not isolated)

The crude isohydroxyoxime (MW 280.32, 5.1 g) was transferred to a 250 mL 1N RB flask with a nitrogen inlet. A stir bar was added followed by acetonitrile (50 mL). The solid was insoluble in acetonitrile. The yellow heterogeneous mixture was stirred under nitrogen for 2-3 minutes, and CDI (MW 162.15, 20.74 mmol, 3.36 g, 1.1 eq.) was added in a single portion at room temperature. No exotherm was observed. The solid dissolved immediately, and the clear yellow solution was stirred at room temperature for 2-2.5 h. After 2-2.5 h, an aliquot was analyzed by HPLC and LC/MS, which showed that the isohydroxyoxime was converted to the desired cyclic intermediate.

The acetonitrile was then evaporated in vacuo to give the crude cyclic intermediate as a reddish thick oil. The oil was taken up in toluene (60 mL) and the reddish mixture was heated to reflux for 2 hours, during which time the cyclic intermediate liberated _CO2 and rearranged to the isocyanate (see below).

Step 3 : Convert isocyanate to free base

The reaction mixture was cooled to 50-60°C and ( S )-(+)-quininol (MW 127.18, 28.28 mmol, 3.6 g, 1.5 eq) was added as a solid in a single portion to the mixture. The mixture was heated to reflux for another 18 h. After 18 h, an aliquot was analyzed by HPLC and LC/MS, which showed complete conversion of the isocyanate to the desired product. The reaction mixture was transferred to a separatory funnel and toluene (25 mL) was added. The mixture was washed with water (2 x 40 mL) and the aqueous layer was separated. The combined aqueous layers were re-extracted with toluene (30 mL) and the aqueous layer was discarded. The combined toluene layers were extracted with 1N HCl (2 x 60 mL) and the toluene layer (containing O-acyl impurities) was discarded. The combined HCl layers were transferred to a 500 mL Erlenmeyer flask equipped with a stir bar. This stirred clear yellow/reddish orange solution was basified to pH 10-12 by dropwise addition of 50% w/w aqueous NaOH solution. The desired free base precipitated out of solution as a dirty yellow sticky solid which stuck to the stir bar. To this mixture was added isopropyl acetate (100 mL) and the mixture was stirred vigorously for 5 minutes at which time the sticky solid went into the isopropyl acetate. Stirring was stopped and the two layers were allowed to separate. The yellow isopropyl acetate layer was separated and the alkaline aqueous layer was re-extracted with isopropyl acetate (30 mL). The alkaline aqueous layer was discarded and the combined isopropyl acetate layers were dried over _{anhydrous Na2SO4} , filtered into a pre-weighed RB flask, and the solvent was evaporated in vacuo to obtain the crude free base as a light brown to brown solid, which was dried in high vacuum overnight.

Steps 3 Continued: Recrystallization of crude free base

The crude free base was weighed as a light brown to brown solid and recrystallized from heptane/isopropyl acetate (3:1, 9.0 mL of solvent/g of crude free base). An appropriate amount of heptane/isopropyl acetate was added to the crude free base along with a stir bar and the mixture was heated to reflux for 10 min (the free base was initially partially soluble but dissolved when heated to reflux to give a clear, light reddish orange solution). The heat was removed and the mixture was allowed to cool to room temperature with stirring, at which point a white precipitate formed. After stirring at room temperature for 3-4 h, the precipitate was filtered off using a Buchner funnel under hose vacuum, washed with heptane (20 mL), and dried on the Buchner funnel under hose vacuum overnight. The precipitate was transferred to a crystallization dish and dried in a vacuum oven at 55°C overnight. ¹ H NMR (400 MHz, CDCl ₃ ) δ 8.04 – 7.83 (m, 2H), 7.20 – 6.99 (m, 3H), 5.53 (s, 1H), 4.73 – 4.55 (m, 1H), 3.18 (dd, J = 14.5, 8.4 Hz, 1H), 3.05 – 2.19 (m, 5H), 2.0 – 1.76 (m, 11H) ppm. ¹³ C NMR (100 MHz, CDCl ₃ ) δ 166.38, 165.02, 162.54, 162.8-155.0 (d, CF), 130.06, 128.43, 128.34, 116.01, 115.79, 112.46, 71.18, 55.7 0, 54.13, 47.42, 46.52, 27.94, 25.41, 24.67, 19.58 ppm.

Examples 2 : ( S )- Quinine ring -3- base (2-(2-(4- Fluorophenyl ) Thiazole -4- base ) C -2- base ) Preparation of crystalline form of carbamate (vinlusitol) salt

The crystalline salt of ( S )-quinin-3-yl(2-(2-(4-fluorophenyl)thiazol-4-yl)propan-2-yl)carbamate can be formed from the free base prepared as described in Example 1B.

For example, the free base of ( S )-quinin-3-yl(2-(2-(4-fluorophenyl)thiazol-4-yl)propan-2-yl)carbamate (approximately 50 mmol) is dissolved in IPA (140 ml) at room temperature and filtered. The filtrate is added to a 1 L round bottom flask equipped with an overhead stirrer and nitrogen inlet/outlet. L-Apple acid (approximately 50 mmol) is dissolved in IPA (100 + 30 ml) at room temperature and filtered. The filtrate is added to the above 1 L flask. The resulting solution is stirred under nitrogen at room temperature (with or without seeding) for 4 to 24 hours. During this time period, crystals form. The product is collected by filtration and washed with a small amount of IPA (30 ml). The crystalline solid was dried in a vacuum oven at 55°C for 72 hours to obtain the desired apple ate.

Crystalline forms of other salts (e.g., acid addition salts with succinic acid or HCl) can be prepared in a similar manner.

Examples 3 ：Clinical study of vinlusitastat in healthy volunteers

Several Phase 1 studies were conducted in healthy volunteers to determine the pharmacokinetics, pharmacodynamics, safety, and tolerability of venlustat and to evaluate food effects on pharmacokinetics. These studies evaluated single-dose administration and food effects of venlustat L-appleate (clinical trial reference NCT01674036) as well as repeated-dose administration (clinical trial reference NCT01710826).

Study NCT01674036 was divided into two parts. The first part (referred to herein as TDU12766) was a double-blind, randomized, placebo-controlled, sequential-ascending single-dose study. The second part (referred to herein as FED12767) was an open-label, randomized, 2-sequence, 2-period, 2-treatment crossover study with a minimal washout period to obtain preliminary information on the pharmacokinetics, tolerability, and safety of venlostat following a single oral dose under fed and fasting conditions. Study NCT01710826 was a double-blind, randomized, placebo-controlled study of the safety, tolerability, pharmacokinetics, and pharmacodynamics of ascending 14-day repeated oral doses of venlafil in healthy male and female subjects (referred to herein as TDR12768).

Details of the study design, drugs, assessments, parameters measured, and results are described in detail in Peterschmitt et al. (Clin. Pharmacol. Drug Dev. (2021) 10(1):86-98) and in the corresponding clinicaltrials.gov entries for the two trials cited above. Some conclusions are summarized below.

Pharmacokinetics of venlostat after a single dose

In a single ascending dose study (TDU12766), at single oral doses of venlukast apple salt evaluated (2-150 mg), venlukast was absorbed with a median _tmax of 3.00 to 5.50 hours and eliminated with a geometric mean t1 _{/2 of 28.9 hours. On Day 14, the mean CL/F ranged from 5.18 to 6.43 L/h across dose groups. Exposure increased in a nearly dose-proportional manner across the dose range: a 75-fold increase in dose resulted in 97.3-} fold, 89.2-fold, and 85.9-fold increases in the geometric mean _Cmax , _AUClast , and _AUCinf, respectively. The mean 48-hour urine excretion fraction was 14.7% to 23.5% in the 2 to 150 mg dose range. During the study, a total of 4 mild treatment-emergent adverse events (TEAEs) were reported in the 50-150 mg dose group. No adverse events were reported in the 2-25 mg dose group.

Food Effect

In the preliminary evaluation of the effect of food on the pharmacokinetics of venlukast, administration of 5 mg venlukast applete concomitantly with a high-fat meal had no effect on venlukast exposure compared to fasting conditions. The _final fed/fasted geometric mean ratios for C _max and AUC were 0.92 and 0.91, respectively. Intra-subject variability (i.e., fed vs. fasted) accounted for less than half of the total subject variability. The median t _max was 6.00 hours, whether fed or fasted. One subject reported a mild TEAE during the fed phase of the study.

Pharmacokinetics of venlostat after repeated dosing

In a repeated escalating dose study (TDR12768), in subjects who received 5, 10, or 20 mg vinlustat applete once daily for 14 days, vinlustat was absorbed with a median _tmax of 2.00 to 5.00 hours after dosing on Days 1 and 14. Steady-state appeared to be achieved within 5 days of repeated dosing. Within the 5-20 mg vinlustat applete dose range, vinlustat exposure increased in a nearly dose-proportional manner: on Day 14, this 4-fold dose increase resulted in a 3.76-fold and 3.69-fold increase in the geometric mean _Cmax and _AUC0-24 values, respectively. After 14 days of administration, the combined venlukast accumulation ratios were 2.10 for _Cmax and 2.22 for AUC _0-24 , independent of dose and sex. Dose and sex also had no effect on t1 _/2 . The point estimates of the intra-subject variability were approximately 14% for _Cmax and 13% for AUC _0-24 . Following 14 once-daily doses of venlukast applete, the 24-hour unchanged urinary fractional excretion of venlukast (mean fe _0-24 ) ranged between 26.3% and 33.1%. Mean _CLR(0-24) ranged from 1.49 to 2.07 L/h, approximately 3.18-fold to 3.86-fold lower than observed plasma CL/F. The geometric mean plasma Day 14/Day 1 ratio of 4β-hydroxycholesterol showed no significant difference between the placebo and vinlukast-treated groups, suggesting minimal induction of CYP3A4. A total of 32 mild TEAEs were reported by 17 subjects during the study, including 10 TEAEs in the placebo group and 22 TEAEs in the 5, 10, and 20 mg dose groups. In the vinlukast applete dose group, TEAEs reported by the investigator as related to study drug were constipation, diarrhea, dry mouth, bloating, pruritus, and fatigue.

Conclusion

Following a single oral dose of venlukastat apple salt, venlukastat exhibits linear pharmacokinetics, rapid absorption (median t _max , 3.00-5.50 hours), systemic exposure that is not affected by food, low apparent total body clearance (mean CL/F, 5.18-6.43 L/h), and a pooled geometric mean t _1/2z of 28.9 hours. After repeated once-daily oral dosing for 14 days, apparent stability occurred within 5 days of repeated dosing, and the pooled cumulative ratios were 2.10 for C _max and 2.22 for AUC _0-24 , with no statistically significant effects of dose or sex on accumulation. Across the doses and dosing regimens tested, venlostat demonstrated a favorable safety and tolerability profile with no serious adverse events (SAEs) or deaths. There were a few TEAEs in both the single-dose and multiple-dose groups.

Examples 4 : Clinical study of venlostat co-administered with isoflavone

Study Design

A Phase I, single-center, open-label, 2-period, single-sequence, nonrandomized, drug-drug interaction (DDI) study was conducted to evaluate the effect of multiple doses of etofenadazole 100 mg BID on the pharmacokinetics of a single dose of venlukast in healthy male subjects under fed conditions, with a washout duration of 7 days between treatment periods. The duration of treatment period 1 (TP1) was 1 day, and the duration of treatment period 2 (TP2) was 13 days (see Figure 1).

Eight subjects were enrolled and completed the study. Subjects were males aged 20-43 years, with a mean age of 28.8 years. On day 1 of TP1, venlustat (in the form of apple salt) was administered to subjects as a hard capsule containing 15 mg venlustat (measured as free base, corresponding to approximately 20 mg of venlustat apple salt). Blood samples were collected before dosing on day 1 and at 1, 2, 3, 4, 5, 6, 8, 10, 12, 24, 48, 72, 96, 120, 144, and 168 hours after dosing. Samples were processed to obtain plasma, and the plasma concentration of venlustat was determined by HPLC-tandem MS, with a lower limit of quantification of 0.5 ng/mL. The subjects then entered a 7-day washout period.

At the end of the washout period, TP2 began. From day 1 to day 12 of TP2, subjects were administered ethconazole as commercially available capsules containing 100 mg ethconazole twice daily (just after breakfast and dinner). On day 6 of TP2, venlustat appletate was co-administered to subjects in addition to the ethconazole dose as a hard capsule containing 15 mg ethconazole (measured as free base). Blood samples were collected before dosing and at 1, 2, 3, 4, 5, 6, 8, 10, 12, 24, 48, 72, 96, 120, 144, and 168 hours after dosing on day 6, before dosing on days 8 and 10, and 12 hours after dosing on day 12. All samples were processed to obtain plasma, and the plasma concentration of venlukast free base was determined for all day 6 samples by HPLC-tandem MS, with a limit of quantification of 0.5 ng/mL. Samples from pre-dose to 12 hours post-dose on day 6 and samples on days 8, 10, and 13 were also analyzed by HPLC-tandem MS for concentrations of etonazolid and hydroxyetonazolid, with a limit of quantification of 1 ng/mL and 2 ng/mL, respectively.

The primary endpoint of the study was to evaluate the effect of multiple doses of etofonazol (100 mg BID) on the pharmacokinetics of a single dose of venlustat (15 mg, measured as the free base). Secondary endpoints were to evaluate the safety and tolerability of a single dose of venlustat with and without co-administration of multiple doses of etofonazol and to evaluate the pharmacokinetics of etofonazol/hydroxyetofonazol.

The subjects were also monitored for any adverse events (subject-reported or investigator-observed), and physical examinations and clinical laboratory evaluations (hematology, biochemistry, urinalysis) were performed. The subjects' temperature, weight, vital signs (heart rate, supine and standing systolic and diastolic blood pressures), and 12-lead electrocardiograms were also recorded.

result

Overall, venlukastat and etokonazole were well tolerated in all subjects. No severe adverse events, adverse events of special concern, or adverse events leading to study discontinuation were reported. Two subjects reported treatment-emergent adverse events, one during TP1 and one during TP2. Both were mild in nature. One subject reported infrequent stools on day 4 of TP1, which was not considered related to venlukastat. Infrequent stools were treated with a daily dose of 5.5 oz of prune juice for 5 days. One subject reported a maculopapular rash approximately 3 hours after co-administration of venlukastat and etokonazole on day 6 of TP2. This rash is listed as a common adverse event on the FDA label for etofenadazole and was treated with 50 mg of diphenhydramine (an antihistamine) daily for 6 days.

Figure 2 shows the mean plasma concentrations of vinlustat in the presence and absence of etofenadazole. The pharmacokinetic results are summarized in Table 1 below.

surface 1 : A single dose of vinlustat ( TP1 ) and a single dose of vinlustat co-administered with repeated doses of etonazolid ( TP2 ) after vinlusitastat PK Parameters - average value ± SD (Geometric mean) [CV%] Drugs PK Parameters treatment Virustat (TP1) Virustat + Itoconazole (TP2) Virustat C _max (ng/mL) 57.5 ± 19.6 (54.4) [34] 63.2 ± 17.0 (61.0) [27] t _max (h) ^a 4.50 (3.00 – 8.00) 5.50 (3.00 – 8.00) AUC _final (ng·h/mL) 2330 ± 884 (2200) [38] 4110 ± 1290 (3930) [31] AUC(ng·h/mL) 2400 ± 937 (2260) [39] 4810 ± 1630 (4580) [34] _tLast (h) ^a 168.0 (168.0 – 168.0) 168.0 (168.0 – 168.3) t _1/2z (h) 31.2 ± 3.66 (31.0) [12] 58.7 ± 6.49 (58.4) [11] CL/F(L/h) 7.05 ± 2.48 (6.65) [35] 3.44 ± 1.15 (3.28) [33] Etoconazole C _max (ng/mL) - 656 ± 167 (637) [25] C _grain (ng/mL) - 314 ± 59.7 (309) [19] t _max (h) ^a - 4.50 (3.00 – 5.00) AUC _0-12 (ng·h/mL) - 5090 ± 1240 (4970) [24] Hydroxyethyltoconazole C _max (ng/mL) - 951 ± 194 (935) [20] C _grain (ng/mL) - 749 ± 140 (737) [19] t _max (h) ^a - 5.00 (4.00 – 5.02) AUC _0-12 (ng·h/mL) - 9550 ± 1820 (9400) [19] ^a Median （ min - max ） AUC _finally = From zero to t _finally The area under the plasma concentration vs. time curve (where t _finally = time to the final concentration above the limit of quantitation); AUC = The area under the curve extrapolated to infinity (computed as AUC _finally + C _finally /λ _z ); _Cmax = Maximum observed plasma concentration; C _Grain = Close to TP2 Previous plasma concentration; t _max = arrive C _max time; t _1/2z = The terminal half-life associated with the terminal slope (calculated as 0.693/λ _z ); CL/F = Apparent total plasma clearance (calculated as dose /AUC );and AUC _0-12 = 12 Hours AUC .

These results demonstrate that repeated oral doses of 100 mg etofenadazole (a strong CYP3A4 inhibitor) BID with a single dose of 15 mg venlukastat increased venlukastat AUC _final and AUC by 1.79-fold (90% CI: 1.61 - 1.99) and 2.03-fold (90% CI: 1.81 - 2.27), respectively, confirming that venlukastat is a CYP3A4 substrate in vivo. C _max of venlukastat increased by 1.12-fold, while t _1/2z increased by 1.88-fold. Venlukastat and etofenadazole were well tolerated when given alone or co-administered.

Examples 5 ：For vinlustat plasma concentration PBPK Model development and validation

The objectives of this study were to develop and validate a PBPK model using available in vitro and in vivo PK information and to use the PBPK model to predict the PK of venlostat alone or co-administered with a CYP3A inhibitor in healthy subjects to support dosing recommendations.

The venlukastat PBPK model was developed based on in vitro/in vivo absorption, distribution, metabolism, and excretion (ADME) data and PK data from a Phase 1 clinical study in healthy subjects (Example 3). The Simcyp default “Sim Healthy Volunteers” population was used to generate the virtual population. The PBPK model performance was confirmed using observed single-dose and repeated-dose PK data of venlukastat from a Phase 1 study in healthy adult subjects. The simulation results of drug-drug interactions were validated using results from an in vivo drug-drug interaction study with etofenadine, a known strong CYP3A4 inhibitor (Example 4) to evaluate the effect of CYP3A inhibition on venlukastat exposure.

The PBPK model was validated by comparing the predicted and observed plasma concentration-time profiles of venlukast after single oral doses of 11.2 mg, 18.6 mg, and 112 mg venlukast and after QD oral doses of 3.72 mg, 7.44 mg, and 14.9 mg venlukast for 14 days in healthy subjects. The simulation results of the DDI were validated using a clinical drug interaction study (Example 4) with a known strong inhibitor, etokonazoli, to assess the contribution of CYP3A4-mediated metabolism in the elimination of venlukast after a single oral dose of 15 mg (measured as the free base). The trial design (dose, dosing schedule, age range, and number of virtual subjects) was replicated as closely as possible to ensure that the characteristics of the virtual subjects matched those described in the clinical study report.

Software tools, model development and input parameters

PBPK model development and analogies were performed in ^Simcyp® Population-Based Simulator V17 (Simcyp Ltd, part of Certara, Sheffield, UK) running on Windows Server 2012 R2 Standard Edition with Excel 2013.

The physicochemical properties of venlostat and its absorption, distribution, metabolism, and excretion (ADME) parameters were used as PBPK model inputs, and the sources are summarized in Table 2 .

surface 2 : PBPK Venlustat infusion in the model PK Parameters Composite Model Parameters value describe Physicochemical and blood binding parameters Molecular weight (free base) 389.49 LogP 3.79 Compound type Monobasic alkali pKa1 9.00 pKa2 Removal Unbound fraction in plasma ( _fu ) 0.18 Average value based on in vitro data Whole blood-plasma distribution ratio 1.3 Average value based on in vitro data HSA/AGP HSA selected   Absorption (Model: First Order) f _a 0.978 Prediction from Caco-2 data f _g 0.99 Prediction from Caco-2 data _Ka (h ^-1 ) 1.514 Predicted value Lag time (h) 0.458 Estimated from a population PK model developed using a Phase 1 study (Example 3) including TDU12766, FED12767, and TDR12768 P _app (x 10 ^-6 cm/s): Caco-2 system (A/B, pH 7.4/7.4) 27 (reference: propranolol is 42) Measured in in vitro Caco-2 studies Unbound fraction in the intestine ( _{fu, intestinal} ) 1 Hypothetical Distribution (Model: Minimal PBPK with SAC) V _ss (L/kg) 3.12(30%CV) V2/F + V3/F estimated from the population PK model (same as above) SAC(L/Kg) 0.67 V3/F estimated from the population PK model (same as above) SAC CL _{input / output} (L/h) 7.63 Estimated from the group PK model (same as above) Elimination (Enzyme kinetics) System Human liver microsomes CL _int -CYP2D6 and 3A4 values were back-calculated from CL _po /F by the population PK model (supra). Measured in in vitro metabolic stability studies in HLM, reaction phenotypic studies (f _{m_CYP3A} , 0.8; f _{m_CYP2D6} , 0.2; in HLM) and microsomal binding CL _int-CYP2D6 (µL/min/mg microsomal protein) 0.464 CL _int-CYP3A4 (µL/min/mg microsomal protein) 1.86 f _u,mic 0.45 CL _r (L/h) 1.7 30% of the total clearance (CL/F, supra) estimated based on urinary excretion of unchanged drug in Study TDR12768 Pgp (gut) interactions K _i (µM) 54 Measured in in vitro MDR1 basal potential assessment studies using the MDCKII-MDR1 cell model CLr = Renal clearance; CL _int-CYP2D6 = Assign to CYP2D6 Intrinsic metabolic clearance rate; CL _int-CYP3A4 = Assign to CYP3A4 Intrinsic metabolic clearance rate; CYP = Cytochrome P450 ; _{f , mic} = The fraction of unbound drug in the in vitro microsome culture system; HLM = Human liver microsomes; K _i = Suppression constant; LogP = Octanol - Calculation logarithm of water partition coefficient; obs = Observed value; Papp = Apparent permeability coefficient; pred = predicted value; V _ss = Steady-state apparent distribution volume.

Consistent with the results of earlier clinical studies, food intake had no effect on venlustat PK. Therefore, under fed conditions, the first-order absorption parameters of venlustat (e.g., _fa , _Ka ) remained the same as those used in the fasting state. The drug distribution of venlustat was reflected by a minimal PBPK model with a single adjustable compartment, which considered both hepatic and intestinal metabolism and other tissues as a whole. It was assumed that the transporter had little effect on venlustat PK.

Model performance was demonstrated by ratios of predicted to observed venlukast exposures of 0.93 to 1.2 following single or repeated oral doses and 1.1 to 1.3 for venlukast alone or co-administered with etokonazoli. Venlukast exposures following co-administration with moderate (fluconazole and fluvoxamine, CYP2D6 inhibition off) and weak (cimetidine, CYP2D6 inhibition off) CYP3A inhibitors were predicted to be 1.52-fold, 1.08-fold, and 1.08-fold, respectively, of venlukast alone (see Example 5).

For oral administration, first-order absorption was assumed in all simulations. The values of the fraction absorbed ( _fa ) and the first-order absorption rate constant ( _Ka ) were derived from estimates of the in vivo permeability _{Peff , man} , which in turn was inferred from Caco-2 data using standard assays. Intestinal availability ( _Fg ) was predicted by the Q- _gut model, which represents the nominal blood flow and is a mixed parameter that reflects the rate of drug absorption from the intestinal lumen, the removal of drug from the enterocytes by the enterocyte blood supply, and the volume of the enterocytes. In the absence of any information on the uptake of active drug into the intestinal epithelium, _{fu ,gut} was set to a default value of 1 (assuming that there is not sufficient time for plasma protein binding equilibration or erythrocyte uptake before drug is eliminated from the basal side of the intestinal epithelium). The calculation of intestinal intrinsic clearance (CLuG _,int ) is based on the assumption that the intrinsic clearance per pmol CYP is the same in both the intestine and the liver.

The fraction unbound in plasma ( _fu,p ), the whole blood-plasma partition ratio (B/P), and the mean percentage of unbound human liver microsomal proteins ( _{fu , mic} ) of venlustat were measured using standard assays. Clinical data from the completed Phase 1 study were first modeled using a population PK (POPPK) approach to export PK parameters (e.g., distribution parameters, _Vss , and SAC) for PBPK model input. The fraction metabolized ( _fm ) of CYP3A4 and CYP2D6 was based on in vitro intrinsic metabolic clearance data. To recover in vivo clearance in the PBPK simulation, intrinsic clearance mediated by CYP3A4 and CYP2D6 was calculated based on _fm and oral clearance (CL/F) from the preliminary POPPK model using the ^Simcyp® built-in retrograde calculator. Based on earlier studies, the contribution of renal components to in vivo clearance was estimated to be approximately 30%. The _IC50 value of vinlustat for human MDR1-mediated transport was determined in-house using a standard assay.

Clinical use for model validation PK material

Concentration-time data of venlustat from the Phase 1 single-ascending dose and multiple-ascending dose clinical trials (Example 3) were used for venlustat model validation in healthy subjects. The venlustat PBPK model was further validated for PK predictions in the absence and presence of etonazolid (a strong CYP3A inhibitor) in healthy subjects using available data from the clinical DDI study (Example 4). A summary of the clinical study design for the studies used for venlustat PBPK model validation is provided in Table 3.

surface 3 : Used for Virustat PBPK Model Validation Research Dosage (mg , measured as free alkali ) N male / female (%) Age ( Years old ) Dosage plan 11.2 6 100/0 19-31 Day 1: Single Dose 18.6 6 100/0 24-45 Day 1: Single Dose 112 5 100/0 25-35 Day 1: Single Dose 3.72 9 44.4/55.6 21-41 Repeat medication, QD for 14 days 7.44 9 55.6/44.4 19-39 Repeat medication, QD for 14 days 14.9 9 76.7/33.3 23-43 Repeat medication, QD for 14 days 15 8 100/0 20-43 Treatment period 1: 15 mg vinlukast SD on day 1; Treatment period 2: 15 mg vinlukast SD on day 6, etorconazole 100 mg BID from day 1 to day 12

The PBPK model of isotonic acid and its primary metabolites was validated using the PK data from the study in Example 4.

Simulations were performed with 10 virtual trials at each dose and dosing regimen. Simcyp ^® uses Monte Carlo methods to simulate the variability of the "Sim Healthy Volunteers" population. Physiological variability between individuals (height, weight, age, lymphatic flow, etc.) and phenotypic changes (if any) are automatically calculated using the database within the library. The "PK curve" option was selected for this analysis. Therefore, all calculations (dynamic modeling) are time- and concentration-dependent. The option to overlap with observed values is used to allow validation of the PBPK model based on a comparison of the concentration-time curve between observed and predicted values. To export PK parameters (e.g., AUC), for groups receiving a single dose, simulations of at least 3 half-lives of vinlustat were performed in healthy subjects. For groups receiving multiple doses, simulations were performed until the end of the dosing interval of the last dose, as described, for example, in the clinical studies disclosed herein.

The validation of the PBPK model of venlostat in healthy subjects consisted of the following:

A.    Graphical comparison of the mean (5th and 95th percentile) predicted plasma concentrations (venlukastat) from the Phase 1 trial (Case 3 and 4) and the observed plasma concentrations alone.

B. Compare the observed venlostat exposures ( _Cmax , AUC [single dose], AUC _0-24h [repeated dosing]) in the clinical studies with those predicted by ^Simcyp® . Also calculate the observed and predicted PK parameters and the corresponding mean ratios (predicted/observed). These ratios should be within the two-fold interval [0.5-2].

C. Validate the performance of the Simcyp ^® V17 built-in model for the CYP3A inhibitor etofaraconazole (SV etofaraconazole_feeding capsule) and its primary metabolite (SV-OH-etofaraconazole) model by comparing model-predicted and observed data from a clinical study in healthy subjects (Example 4). The performance of the PBPK model to predict the venlustat-etofaraconazole interaction was validated using the following approach:

•       Visual prediction checks that compare model-predicted means and 90% prediction intervals for plasma concentration-time curves of venlafaxine, etofenadazole, and OH-etofenadazole to individual observations;

• Comparison of PBPK-predicted PK parameters of etonazole and OH-etonazole with observed data (steady-state C _max , C _grit , AUC _0-12h ) and the corresponding mean ratios (predicted value/observed value);

• The observed and predicted drug interaction ratios ( _Cmax ratio, _AUClast ratio, and AUC ratio) for venlostat PK and the corresponding geometric mean ratios (predicted value divided by observed value) were also calculated. The predicted value to observed value ratio should be within the two-fold interval [0.5-2].

The final PBPK model was used to predict the effect of CYP3A4 inhibitors on the steady-state PK of vinlustat in healthy subjects. Each simulation was performed with 10 virtual trials of 10 subjects, aged 18 to 65 years, with a 50/50 male/female ratio, co-administered with the inhibitor after repeated dosing of vinlustat to achieve steady-state. A library virtual population "Sim Healthy Volunteers" was implemented for model application. Study designs varied depending on inhibitor properties and assumed clinical scenarios. When co-administered, simulations were run long enough to achieve steady-state PK of vinlustat and CYP3A inhibitors in healthy subjects.

To predict the DDI between venlukastat and CYP3A inhibitors, 2 scenarios were evaluated, namely, first, assuming that the subject was already receiving venlukastat treatment and required a CYP3A inhibitor concomitant medication, and second, assuming that the subject was already receiving a CYP3A inhibitor prior to starting venlukastat treatment. The simulation study design for each of these scenarios for each inhibitor (perpetrator) is described below. For inhibitors, the maximum dose and dosing regimen most commonly used in clinical practice or the highest approved dose was generally selected to maximize the DDI potential.

Each dummy subject received multiple oral doses of 15 mg QD or 8 mg QD venlustat starting on day 1. In healthy subjects, repeated doses of 100 mg BID etofenadazole were co-administered with venlustat from day 6 to day 17.

To simulate venlostat exposure when co-administered with strong CYP3A inhibitors (e.g., etofenadazole), the following clinical scenario was hypothesized:

•       Each dummy subject received multiple oral doses of venlukast 15 mg QD from days 1 to 5, then switched to 8 mg QD from days 6 to 17. In healthy subjects, repeated doses of 100 mg BID etofenadazole were co-administered with venlukast from days 6 to 17.

Each dummy subject received multiple oral doses of 100 mg BID etofenadole starting on day 1. Starting on day 10, repeated doses of 15 mg QD or 8 mg QD venluconazol were co-administered with etofenadole until venluconazol stability was achieved.

As a final step, the above model was compared to a similar model built using an updated version of Simcyp ^® (V19) with an updated library model of SV-Itoconazole_Feeding Capsules. In V19, in addition to the first-order absorption model as the default Itoconazole cmpz file, the user can also select the Advanced Dissolution, Absorption, and Metabolism (ADAM) option to reflect factors that affect the rate and extent of oral drug absorption. Based on the evaluation shown above, it was concluded that the Itoconazole compound library file used in V17 adequately describes Itoconazole PK. Most of the model parameters remained the same in the V19 Itoconazole cmpz library file compared to V17. The small differences in the predicted _Vss are likely due to the addition of updated system parameter values and inhibition parameters for multiple transporters expressed in the gut and liver. To further understand the impact of the V19 update on the prediction results, two models for etonazolid (first-order absorption and ADAM model) were partially validated using the Example 4 data. The simulation settings were the same as those shown above.

The predicted PK parameters of vinlusstat (including _Cmax , _AUClast , AUC, and drug interaction ratios) by the V19 model were generally comparable to the values obtained using the V17 model. However, the prediction accuracy of the V19 etonazolid model with ADMA absorption was unacceptable, so the model was not used for further modeling.

result - Single and repeated doses of vinlustat QD Give medicine

The observed and predicted venlukast concentrations in healthy male subjects following single oral doses of 11.2 mg, 18.6 mg, and 112 mg (calculated as free base) venlukast using the PBPK model are presented in Figures 3 and 4. The venlukast PK parameters observed in the clinical study were compared with those predicted by the PBPK model, and the results are shown in Table 4 below.

surface 4 : Observed (clinical study) and predicted mean changes in vinlukastat in healthy male subjects after a single oral administration of vinlukastat PK Parameters ( CV% ） Dosage (mg) ^a Parameters C _max (ng/mL) AUC (ng∙h/mL) 11.2 Observed value Average value (N = 6) 53.0 2070 CV(%) 31.5 29.0 Predicted value Average value (N = 60) 56.3 2120 CV(%) 35 32 Ratio of predicted to observed values 1.1 1.0 18.6 Observed value Average value (N = 6) 84.4 3810 CV(%) 37.7 28.4 Predicted value Average value (N = 60) 91.4 3570 CV(%) 38 32 Ratio of predicted to observed values 1.1 0.94 112 Observed value Average value (N = 5) 529 20600 CV(%) 20.7 32.2 Predicted value Average value (N = 50) 556 22000 CV(%) 38 30 Ratio of predicted to observed values 1.1 1.1 ^a The nominal dose is shown for the free base form; the corresponding dose for the apple phosphate salt in clinical studies is 15 mg , 25 mg and 150 mg .

The observed and predicted venlukast concentrations in healthy male and female subjects following repeated QD dosing of 3.72 mg, 7.44 mg, and 14.9 mg venlukast using the PBPK model are presented in Figures 5 and 6. The venlukast PK parameters observed in the clinical studies are compared with those predicted by the PBPK model in Table 5 below.

surface 5 : Observed (clinical study) and predicted mean changes in vinlukastat in healthy subjects after repeated oral administration of vinlukastat PK Parameters ( CV% ） Dosage (mg) ^a Parameters No. 1 sky No. 14 sky C _max (ng/mL) AUC _0-24 (ng∙h/mL) C _max (ng/mL) AUC _0-24 (ng∙h/mL) 3.72 Observed value Average value (N = 9) 18.5 296 37.0 642 CV(%) 17.3 18.3 17.2 18.8 Predicted value Average value (N = 90) 20.3 303 42.3 741 CV(%) 40 30 28 29 Ratio of predicted to observed values 1.1 1.0 1.1 1.2 7.44 Observed value Average value (N = 9) 38.5 635 89.7 1550 CV(%) 19.3 20.8 32.5 30.0 Predicted value Average value (N = 90) 39.7 593 83.6 1470 CV(%) 40 30 28 30 Ratio of predicted to observed values 1.0 0.93 0.93 0.95 14.9 Observed value Average value (N = 9) 68.0 1100 142 2420 CV(%) 23.1 19.2 28.3 29.2 Predicted value Average value (N = 90) 78.6 1180 167 2960 CV(%) 39 28 26 29 Ratio of predicted to observed values 1.2 1.1 1.2 1.2 ^a The nominal dose is shown for the free base form; the corresponding dose for the apple phosphate salt in clinical studies is 5 mg , 10 mg and 20 mg .

As demonstrated by the graphical comparisons shown in Figures 3 to 6, most of the individual observed concentration-time points were within the 5th and 95th percentiles of the predicted plasma concentrations. The PBPK model was able to adequately predict venlukastat exposure in healthy subjects following a single dose of venlukastat on Day 1 and repeated QD doses of venlukastat on Day 14. The differences between the mean observed and predicted PK parameters were within 20%, and the mean predicted/observed ratios were within the range of 0.93-1.2, which is within the predefined two-fold interval.

result - A single dose of vinlustat in the absence and presence of isoflurane

Analog plasma concentration-time profiles of venlukast after a single dose of 15 mg (calculated as free base) on Day 6 in the absence and presence of co-administration of 100 mg etofenadazole BID from Day 1 to Day 12 are shown in Figures 7 and 8, respectively. Venlukast (15 mg single dose) was administered alone in Treatment Period 1 (as in Example 4). The observed and analog PK profiles are shown in Figures 7A and 8A, but over a limited time range of 120 to 288 hours. Virtual healthy male subjects were generated and randomly assigned to ten different trials of 8 subjects to indicate inter-group variability. For each simulation, a concentration-time curve representative of the total phantom population (n = 80) is shown. The predicted mean _Cmax , _AUClast , and AUCratio are shown in Table 6 below.

surface 6 : In the absence and with isotonic acid 100 mg BID Continuous 12 In the case of combined use of 6 sky 15 mg observed in healthy male subjects after a single oral dose of 4 ) and the predicted mean venlukast PK Parameters ( CV% ） Parameters No interaction There is interaction Treatment rate * C _max AUC _finally AUC C _max AUC _finally AUC C _max ratio AUC _finally ratio AUC ratio Observed values (N = 8) Average value 57.5 2330 2400 63.2 4110 4810 1.12 1.79 2.03 CV(%) 34 38 39 27 31 34 (1.05‒1.20) (1.61‒1.99) (1.81‒2.27) Predicted value (N = 80) Average value 71.0 2820 3010 74.1 4390 5320 1.04 1.56 1.76 CV(%) 36 28 30 36 28 32 (1.04‒1.05) (1.53‒1.60) (1.71‒1.80) Ratio of predicted to observed values 1.2 1.2 1.3 1.2 1.1 1.1 0.93 0.87 0.87 * In the presence and absence of isoflurane, vinlustra C _max , AUC _finally and AUC Ratios are presented as geometric means and in parentheses 90% CI .

Figures 9 and 10 show the analog concentration-time curves and superimposed observations of etonazolate and its primary metabolite (hydroxyetonazolate), respectively. The observed PK parameters of etonazolate and hydroxyetonazolate in the clinical study (Example 4) are compared with those predicted by the PBPK model in Table 7 below.

surface 7 : Repeated oral administration of etokonadazole capsules under fed conditions 100 mg BID and a single dose of venlafil, in the 6 observed in healthy male subjects (Example 4 ) and the predicted average of isotonic acid and hydroxy isotonic acid PK Parameters ( CV% ） No. 6 Heaven PK Parameters Itoconazole Hydroxyethyltoconazole C _max (ng/mL) t _max *(h) AUC _0-12 (ng.h/mL) C _max (ng/mL) _tmax *(h) AUC _0-12 (ng.h/mL) Observed value Average value (N = 8) 656 4.50 5090 951 5.00 9550 CV(%) 25 (3.00–5.00) twenty four 20 (4.00–5.02) 19 Predicted value Average value (N = 80) 393 3.13 4040 737 4.61 8100 CV(%) 99 (1.61–4.87) 111 87 (1.67‒12.0) 97 Ratio of predicted to observed values 0.60 0.70 0.79 0.77 0.92 0.85 * Observed / Predicted t _max Values are presented as median and minimum to maximum values in brackets.

As demonstrated by the graphical comparisons shown in Figures 7 to 10, almost all individual observed concentration-time points are within the 5th and 95th percentiles of the predicted plasma concentrations. The PBPK model is able to adequately predict the exposure of vinlusitol in healthy male subjects without and with the combination of etokonadazole. The ratio of the geometric means of the observed and predicted treatment ratios (C _max ratio, AUC _last ratio, AUC ratio) is approximately 0.9. Therefore, the model performance is considered acceptable. In addition, the PBPK model accurately captures the PK curves of etokonadazole and hydroxyetokonadazole on the 6th day after repeated BID doses in healthy subjects, with the difference between the observed and predicted values within 2 times. In conclusion, the collected evidence confirms the adequacy of the PBPK model for the prediction of DDI of venlostat with CYP3A inhibitors, including etofenadole.

Examples 6 : PBPK Model prediction and CYP3A Application of Steady-State Plasma Concentrations of Venlustat Co-administered with Inhibitors

The validated PBPK model of Example 5 was used to predict the PK of repeated doses of 8 mg and 15 mg of venlafil co-administered with other CYP3A inhibitors in healthy subjects to guide dosing recommendations.

method

The pharmacokinetics (PK) of venlustat were simulated using 10 virtual trials of 10 subjects aged 18 to 65 years with a 50/50 male/female ratio, who were co-administered with a CYP3A inhibitor after repeated dosing of venlustat to achieve stability. The ^Simcyp® built-in "Sim Healthy Volunteers" was used to generate the virtual population. The predicted PK parameters and DDI ratios (C _max , AUC _tau , C _max ratio and AUC _tau ratio) of venlustat for the last dose were calculated.

Steady-state plasma concentrations of vinlustat were predicted in healthy subjects following repeated oral dosing of vinlustat and: (i) fluconazole, a moderate CYP3A4 inhibitor; (ii) fluvoxamine, a moderate CYP3A4 inhibitor; and (iii) cimetidine, a weak CYP3A inhibitor. CYP2D6 inhibition was turned off in the model.

The Simcyp ^® V17 library model for the moderate CYP3A inhibitor fluconazole (SV-fluconazole) was used for model application without any changes. The model input parameters for fluvoxamine (moderate CYP3A inhibitor) and cimetidine (weak CYP3A inhibitor) in the simulation had the default values indicated in the compound library files (SV-fluvoxamine and SV-cimetidine, respectively) within Simcyp Simulator (V17), except for a minor modification to turn off inhibition of CYP2D6, as both CYP3A and CYP2D6 inhibition were already built into the library model. This allowed the effects of fluvoxamine and cimetidine on venlostat to be evaluated via the CYP3A pathway alone.

The fluconazole PBPK model was further validated using clinical data from the literature (Olkkola et al., Anesth. Analg. (1996) 82(3):511-516) on the effect of fluconazole on midazolam exposure. The predicted midazolam _Cmax and AUC ratios in healthy subjects following a single oral administration of midazolam 7.5 mg on Day 1 and Day 6 in the absence and presence of fluconazole are shown in Table 8 below. For comparison with the observed AUC ratios (which were derived from the reported AUC from time 0 to infinity), two independent simulations were performed to generate corresponding ratios for midazolam on Day 1 and Day 6.

surface 8 : No and no combination therapy with fluconazole ( 1 sky 400 mg SD and 2 Tianzhidi 6 sky 200 mg QD ) in the case of 1 Tianhedi 6 sky 7.5 mg Observed and predicted midazolam effects in healthy subjects after a single oral dose of midazolam PK Parameters Used for CYP3A Clinical research on inhibitor model validation CYP3A Pledge PK Parameters Treatment rate * C _max ratio AUC ratio Fluconazole: (Olkkola et al., 1996) Midazolam (Day 1) Observed value Average value (N = 12) 2.50 3.51 Predicted value Average (N = 120) 1.92 3.11 Test scope 1.75 – 2.17 2.89-3.52 Ratio of predicted to observed values 0.77 0.89 Midazolam (Day 6) Observed value Average value (N = 12) 1.74 3.60 Predicted value Average (N = 120) 2.10 3.75 Test scope 1.85 – 2.30 3.10-4.08 Ratio of predicted to observed values 1.2 1.0 * Observed C _max and AUC Ratios are expressed as arithmetic means. Forecasts show arithmetic means and are derived from 10 The scope of the simulation trial was matched to the clinical study design.

The ratio of predicted to observed PK parameters was approximately 1. The results demonstrate the good quality of the model for DDI prediction using fluconazole as a moderate CYP3A inhibitor.

These modified PBPK models were validated for the effects of fluvoxamine/cimetidine on sensitive CYP3A substrates based on published clinical data investigating the effects of fluvoxamine on a sensitive CYP3A substrate (midazolam) and the effects of cimetidine on multiple sensitive CYP3A substrates (midazolam, nifedipine, and sildenafil) (see, e.g., Lam et al., J. Clin. Pharmacol. (2003) 43(11):1274-1282; Fee et al., Clin. Pharmacol. Ther. (1987) 41(1):80-84; Schwartz et al., Clin. Pharmacol. Ther. (1988) 43(6):673-80; and Wilner et al., Br. J. Clin. Pharmacol. (2002) 53(Suppl 1):31S-36S). The predicted mean _Cmax and AUC ratios in healthy subjects following a single oral dose of midazolam/nifedipine/sildenafil in the absence and presence of a CYP3A inhibitor are shown in Table 9 below.

surface 9 : In the absence and with fluvoxamine ( 50 mg , BID ) and in combination with 10 mg After a single oral dose of midazolam, and without and with cimetidine, 400 mg/BID , 300 mg/QD or 800 mg/QD In the case of combined use of the dosing regimen 15 mg Midazolam, 20 mg Nifedipine or 50 mg Observed and predicted changes in healthy subjects after a single oral dose of sildenafil CYP3A pledged PK Parameters Used for CYP3A Clinical research on inhibitor model validation CYP3A Pledge PK Parameters Treatment rate * C _max ratio AUC ratio Fluvoxamine: (Lam et al., 2003) Midazolam Observed value Average value (N = 10) 1.38 1.39 Predicted value Average value (N = 100) 1.25 1.37 Test scope 1.17 – 1.32 1.23 – 1.47 Ratio of predicted to observed values 0.91 0.99 Cimetidine: (Fee et al., 1987) Midazolam Observed value Average value (N = 8) NA 1.35 Predicted value Average value (N = 80) 1.32 1.39 Test scope 1.30 – 1.36 1.36 – 1.43 Ratio of predicted to observed values NA 1.0 Cimetidine: (Schwartz et al., 1988) Nifedipine Observed value Average value (N = 11) 1.60 1.80 Predicted value Average value (N = 110) 1.20 1.32 Test scope 1.17 – 1.22 1.29 – 1.34 Ratio of predicted to observed values 0.75 0.73 Cimetidine: (Wilner et al., 2002) Sildenafil ^† Observed value Average value (N = 10) 1.54 1.56 95% CI (1.14, 2.09) (1.21, 2.03) Predicted value Average value (N = 100) 1.36 1.41 95% CI (1.33, 1.38) (1.38, 1.43) Ratio of predicted to observed values 0.88 0.90 NA = Not applicable * Apart from Wilner et al. ( Br. J. Clin. Pharmacol. (2002) 53(Suppl 1):31S-36S ) situation, the observed C _max and AUC Ratios are expressed as arithmetic means. Forecasts show averages and are derived from 10 The scope of the simulation trial was matched to the clinical study design. † Observed and predicted sildenafil in the presence and absence of cimetidine C _max or AUC Ratios are presented as geometric means and in parentheses 95% CI .

The PBPK model was able to adequately predict the DDI potential of fluvoxamine and cimetidine in healthy subjects. The ratio of predicted to observed PK parameters was approximately 1. In summary, the results confirmed the good quality of the model for DDI prediction using fluvoxamine and cimetidine as moderate and weak CYP3A inhibitors, respectively.

Total invested in other CYP3A4 Effects of inhibitors on vinlustat exposure

Plasma PK parameters of vinlustat in healthy subjects after repeated dosing of 15 mg or 8 mg in the absence and presence of etonazolid (strong CYP3A inhibitor), fluconazole (moderate CYP3A inhibitor), fluvoxamine (moderate CYP3A inhibitor), and cimetidine were simulated and the results are shown in Table 10 below. Virtual subjects (age 18-65 years; female, 50%) were generated and randomly assigned to ten different trials of 10 subjects to indicate inter-group variability. Predicted mean _Cmax and AUC _tau ratios of vinlustat at steady state in the presence and absence of the corresponding inhibitors were also generated.

surface 10 ：In the total CYP3A In the case of inhibitors 15 mg or 8 mg Stable vinlustat in healthy subjects after repeated administration PK Parameters Dosage plan Prediction PK Parameter average ( No. 5 Percentile - No. 95 Percentile )(N = 100) Ratio Average ( No. 5 Percentile - No. 95 Percentile )(N = 100) Virustat CYP3A Inhibitors C _max (ng/mL) AUC _tau (ng.h/mL) C _max AUC _tau 15 mg QD for 17 days Itoconazole (Day 6-Day 17, 100 mg BID) 259 (132‒367) 5170 (2640‒7550) 1.51 (1.27‒1.77) 1.69 (1.36‒2.03) 8 mg QD for 17 days Itoconazole (Day 6-Day 17, 100 mg BID) 138 (70.6‒196) 2760 (1410‒4030) 1.51 (1.27‒1.78) 1.69 (1.36‒2.03) 15 mg QD for 5 days; 8 mg QD on days 6-17 Itoconazole (Day 6-Day 17, 100 mg BID) 141 (70.9‒198) 2810 (1410‒4090) 1.52 (1.28‒1.80) 1.71 (1.38‒2.06) Day 10-Day 26 15 mg QD Itoconazole (100 mg BID for 26 days) 262 (133‒369) 5240 (2640‒7640) 1.53 (1.28‒1.81) 1.72 (1.37‒2.07) Day 10-Day 26 8 mg QD Itoconazole (100 mg BID for 26 days) 140 (70.9‒197) 2790 (1410‒4080) 1.53 (1.28‒1.81) 1.72 (1.37‒2.07) 15 mg QD for 17 days Fluconazole (400 mg QD on Day 6, then 200 mg QD on Days 7-17) 233 (151‒338) 4560 (2860‒6530) 1.37 (1.18‒1.57) 1.52 (1.23‒1.88) Day 6-17 15 mg QD 6-17 Fluconazole (400 mg QD on day 1, then 200 mg QD on days 2-17) 230 (149‒334) 4490 (2860‒6480) 1.36 (1.17‒1.57) 1.51 (1.23‒1.88) 15 mg QD for 17 days Fluvoxamine (Day 6-Day 17, 100 mg BID) 184 (105‒281) 3310 (1660‒4910) 1.06 (1.03‒1.11) 1.08 (1.03‒1.15) Day 6-17 15 mg QD 6-17 Fluvoxamine (100 mg BID for 17 days) 183 (105‒278) 3280 (1660‒4870) 1.06 (1.03‒1.11) 1.08 (1.03‒1.15) 15 mg QD for 17 days Cimetidine (Day 6-Day 17, 400 mg TID) 182 (103‒277) 3270 (1630‒4770) 1.06 (1.03‒1.09) 1.08 (1.04‒1.12) Day 6-17 15 mg QD 6-17 Cimetidine (400 mg TID for 17 days) 181 (103‒276) 3230 (1630‒4650) 1.06 (1.03‒1.08) 1.08 (1.04‒1.12) NB : Predicted under steady state C _max and AUC _tau express 10 In trials 100 The mathematical average of the virtual subjects. C _max and AUC _tau Ratio expression 10 In trials 100 The numerical average of the virtual subjects (using inhibitors compared to not using inhibitors).

Conclusion

This analysis allowed the development of a PBPK model for vinlustat in healthy adults based on available physicochemical and in vitro/in vivo absorption, distribution, metabolism and excretion (ADME) data. The model was fully validated using information from clinical studies of vinlustat with mono- and multi-increased doses (Example 3) and clinical DDI studies with etofonazol as a strong CYP3A inhibitor (Example 4). The predicted plasma concentration profiles (vinlustat, etofonazol and hydroxyetofonazol) were consistent with the observed data in the clinical studies. Almost all observed individual concentrations fell within the predicted 90% confidence intervals, and the ratios of predicted to observed values for the PK parameters were within 2-fold. Drug interaction ratios were also well captured, further confirming the contribution of CYP3A4-mediated metabolism to the overall clearance of vinlustat in healthy subjects. Therefore, the vinlustat model developed and validated using Simcyp V17 can be used to predict the PK of vinlustat when co-administered with other CYP3A inhibitors.

In April 2020, Simcyp Ltd released Simcyp ^® Population-Based Simulator V19 with updated library models for SV-Itraconazole_Fed Capsule. Based on the above evaluation, it was decided to use the Itraconazole PBPK model V17 for the final analogy. The library model for SV-Fluconazole was used without any changes and its good performance for model application was demonstrated by further validation with available clinical data. As mentioned above, the modified Simcyp library model for Fluvoxamine/Cimetidine was validated for the effects on sensitive CYP3A substrates based on published clinical data and the model performance was considered acceptable for model application.

In summary, a PBPK model for venlurestat was developed using Simcyp V17. The PK predictions of this model were validated in the absence and presence of a strong CYP3A inhibitor (etconazole) in healthy adult subjects. Co-administration of venlurestat with CYP3A inhibitors is predicted to result in higher exposure, with the magnitude of the effect depending on the degree of potency of the inhibitor. The steady-state AUC _tau of venlurestat following co-administration with strong and moderate CYP3A inhibitors is predicted to be 1.69-fold when co-administered with etconazole, 1.52-fold when co-administered with fluconazole, and 1.08-fold when co-administered with fluvoxamine. The effect of the weak CYP3A inhibitor, cimetidine, on the systemic exposure of venlurestat is expected to be small (1.08-fold).

These results suggest that concomitant administration of some, but not all, CYP3A4 inhibitors may require adjustments in the venlukast dose to maximize the safety and efficacy of treatment. The results observed across inhibitors in the model also suggest that the effect of any given inhibitor on venlukast exposure is not easily predictable, and thus the selection of appropriate dose adjustments may not be straightforward without the guidance of the PBPK model developed herein.

It should be understood that although this article has been described in conjunction with the above embodiments, the foregoing description and examples are intended to illustrate rather than limit the scope of this article. Other aspects, advantages and modifications within the scope of this article will be clear to those skilled in the art to which this article belongs.

In addition, where a feature or aspect is described in terms of a Markush group, one skilled in the art will recognize that such feature or aspect is also thereby described in terms of any individual member or subgroup of members of the Markush group.

All publications, patent applications, patents, and other references mentioned herein are expressly incorporated by reference in their entirety to the same extent as if each were individually incorporated by reference. In the event of a conflict, the present specification, including definitions, will control.

without

Figure 1 shows the study design of the clinical study described in Example 4.

Figure 2 shows the mean (+SD) plasma concentrations of venlustat after a single dose of 15 mg venlustat alone (calculated as free base—open triangles) and after co-administration of 15 mg venlustat with repeated doses of itraconazole (100 mg BID—open circles).

FIG3 shows the observed (clinical study) and mean (5th and 95th percentiles) predicted venlukastat plasma concentrations (Cartesian scale) in healthy male subjects after a single oral dose of 11.2 mg ( FIG3A ), 18.6 mg ( FIG3B ), and 112 mg ( FIG3C ) venlukastat. The gray lines represent predictions from individual trials. The dashed lines represent the 5th and 95th percentiles for the total phantom population. The solid black lines represent the simulated mean plasma concentration-time curves. The open circles represent the individual observed concentrations from the clinical studies.

FIG4 shows the observed (clinical study) and mean (5th and 95th percentiles) predicted venlukastat plasma concentrations (semi-log scale) in healthy male subjects after a single oral dose of 11.2 mg ( FIG4A ), 18.6 mg ( FIG4B ), and 112 mg ( FIG4C ) venlukastat. The gray lines represent predictions from individual trials. The dashed lines represent the 5th and 95th percentiles for the total phantom population. The solid black lines represent the simulated mean plasma concentration-time curves. The open circles represent the individual observed concentrations from the clinical studies.

FIG5 shows the observed (clinical study) and mean (5th and 95th percentiles) predicted venlukastat plasma concentrations (Cartesian scale) following repeated QD oral doses of 3.72 mg ( FIG5A ), 7.44 mg ( FIG5B ), and 14.9 mg ( FIG5C ) venlukastat in healthy male subjects. The gray lines represent predictions from individual trials. The dashed lines represent the 5th and 95th percentiles for the total phantom population. The solid black line represents the simulated mean plasma concentration-time curve. The open circles represent the individual observed concentrations from the clinical studies.

FIG6 shows observed (clinical study) and mean (5th and 95th percentiles ) predicted venlukastat plasma concentrations (semi-log scale) following repeated QD oral doses of 3.72 mg ( FIG6A ), 7.44 mg ( FIG6B ), and 14.9 mg ( FIG6C ) venlukastat in healthy male subjects. The gray lines represent predictions from individual trials. The dashed lines represent the 5th and 95th percentiles for the total phantom population. The solid black lines represent the simulated mean plasma concentration-time curves. The open circles represent the individual observed concentrations from the clinical studies.

FIG7 shows the simulated mean (5th and 95th percentile) venlustat plasma concentrations (Cartesian scale) after a single oral dose of 15 mg venlustat in healthy male subjects without ( FIG7A ) and with ( FIG7B ) concomitant administration of etofenadole 100 mg BID. The analog curves are superimposed with the observed venlustat concentrations alone (open circles). In each case, the solid black line represents the simulated mean plasma concentration-time curve of venlustat in the absence of an etofenadole interaction, and the solid gray lines represent the 5th and 95th percentiles of the total phantom population. The black dashed line represents the simulated mean plasma concentration-time curve of vinlurestat in the presence of etofenadole interaction, and the gray dashed lines represent the 5th and 95th percentiles of the total phantom population. The open circles represent the concentrations observed individually in the study of Example 4.

FIG8 shows the simulated mean (5th and 95th percentile) venlustat plasma concentrations (semi-log scale) after a single oral dose of 15 mg venlustat in healthy male subjects without ( FIG8A ) and with ( FIG8B ) concomitant administration of etofenadole 100 mg BID. The analog curves are superimposed with the observed venlustat concentrations alone (open circles). In each case, the solid black line represents the simulated mean plasma concentration-time curve of venlustat in the absence of an etofenadole interaction, and the solid gray lines represent the 5th and 95th percentiles of the total phantom population. The black dashed line represents the simulated mean plasma concentration-time curve of vinlurestat in the presence of etofenadole interaction, and the gray dashed lines represent the 5th and 95th percentiles of the total phantom population. The open circles represent the concentrations observed individually in the study of Example 4.

FIG9 shows the observed (Example 4 ) and mean (5th and 95th percentiles) predicted plasma concentrations (Cartesian scale) of etofonazol ( FIG9A ) and its primary metabolite hydroxyetofonazol ( FIG9B ) in healthy male subjects after etofonazol 100 mg BID. The solid gray line represents the predictions from individual trials. The dashed lines represent the 5th and 95th percentiles of the total phantom population. The solid black line represents the simulated mean plasma concentration-time curve. The gray dots (at approximately 125, 160, and 220 hours) represent the concentrations observed individually in the study of Example 4.

FIG10 shows the observed (Example 4 ) and mean (5th and 95th percentiles) predicted plasma concentrations (semi-log scale) of etokonazole ( FIG10A ) and its primary metabolite hydroxyetokonazole ( FIG10B ) in healthy male subjects after etokonazole 100 mg BID. The solid gray line represents the prediction from a single trial. The dotted lines represent the 5th and 95th percentiles of the total phantom population. The solid black line represents the simulated mean plasma concentration-time curve. The gray dots (at approximately 125, 160, and 220 hours) represent the concentrations observed individually in the study of Example 4.

without

Claims (26)

A method for treating a disease or condition in a subject in need thereof, the method comprising administering to the subject an effective amount of venglustat or a pharmaceutically acceptable salt thereof, wherein the subject is concurrently administered a strong or moderate CYP3A4 inhibitor. A method for treating a disease or disorder in a subject in need thereof, the method comprising administering to the subject an effective amount of venlukastat or a pharmaceutically acceptable salt thereof, wherein the subject is concurrently administered a CYP3A4 inhibitor, whereby venlukastat plasma exposure (e.g., AUC) is increased by between about 5% and 25% compared to the exposure resulting from administration of venlukastat at the same dose, form, and schedule in the absence of the CYP3A4 inhibitor. The method of claim 2, wherein the vinlustat or a pharmaceutically acceptable salt thereof is administered at a daily dose of about 12 mg or a daily dose of about 15 mg (calculated as a free base). The method of claim 1, wherein the CYP3A4 inhibitor is a strong inhibitor that increases the plasma exposure of vinlukast by between about 60% and 120% compared to the exposure caused by administration of vinlukast at the same dose, form and schedule in the absence of the CYP3A4 inhibitor, and wherein the vinlukast or a pharmaceutically acceptable salt thereof is administered at a dose of between about 4 mg and 15 mg per day (calculated as free base). The method of claim 4, wherein the vinlustat or a pharmaceutically acceptable salt thereof is administered at a daily dose of about 8 mg (calculated as free base). The method of claim 1, wherein the CYP3A4 inhibitor is a moderate inhibitor that increases the plasma exposure of vinlukast by between about 40% and 60% compared to the exposure caused by administration of vinlukast at the same dose, form and schedule in the absence of the CYP3A4 inhibitor, and the vinlukast or a pharmaceutically acceptable salt thereof is administered at a dose of between about 12 mg and 15 mg per day (calculated as free base). The method of claim 6, wherein the vinlusstat or a pharmaceutically acceptable salt thereof is administered at a daily dose of about 15 mg (calculated as free base). The method of any one of claims 1 to 7, wherein the vinlukastat is in the form of vinlukastat free base, a pharmaceutically acceptable salt of vinlukastat or a prodrug of vinlukastat, and optionally vinlukastat L-appleate salt. The method of any one of claims 1-8, wherein the vinlukast or a pharmaceutically acceptable salt thereof is administered in combination with the CYP3A4 inhibitor, for example in the same pharmaceutical composition. The method of any one of claims 1 to 9, wherein the vinlustat or a pharmaceutically acceptable salt thereof is administered orally, and the CYP3A4 inhibitor is administered transmucosally, intravenously or orally. A method as described in any of claims 1-10, wherein the disease or condition is selected from lysosomal storage diseases (e.g., Gaucher disease or Fabry disease), proteinopathies (e.g., Alzheimer's disease, Parkinson's disease, or Huntington's disease), cystic diseases (e.g., polycystic kidney disease), and fibrotic diseases (e.g., Bardet-Biedl syndrome). The method of any one of claims 1 to 11, wherein the subject suffers from a co-morbidity selected from the group consisting of a fungal infection, a viral infection, a bacterial infection, a mood disorder, and cancer. A vinlukastat or a pharmaceutically acceptable salt thereof (or a combination of vinlukastat or a pharmaceutically acceptable salt thereof and a CYP3A4 inhibitor, such as a composition comprising vinlukastat or a pharmaceutically acceptable salt thereof and a CYP3A4 inhibitor) for use in a method as defined in any one of claims 1 to 12. A use of vinlukastat or a pharmaceutically acceptable salt thereof (or a combination of vinlukastat or a pharmaceutically acceptable salt thereof and a CYP3A4 inhibitor, such as a composition comprising vinlukastat or a pharmaceutically acceptable salt thereof and a CYP3A4 inhibitor) in the manufacture of a pharmaceutical product for use in a method as defined in any one of claims 1 to 12. A method for optimizing (e.g., reducing) the dose of vinlustat in a subject being treated with or planning to be treated with vinlustat or a pharmaceutically acceptable salt thereof, the method comprising administering to the subject a strong or moderate CYP3A4 inhibitor. A method for minimizing a drug-drug interaction between venlukastat and a moderate or strong CYP3A4 inhibitor in a subject having a disease or condition suitable for treatment with venlukastat or a pharmaceutically acceptable salt thereof, the method comprising: (i) determining the change in plasma exposure of venlukastat when venlukastat or a pharmaceutically acceptable salt thereof is administered in combination with the CYP3A4 inhibitor as compared to the exposure resulting from administration of venlukastat at the same dose, form, and schedule in the absence of the CYP3A4 inhibitor; and (ii) if the change in plasma exposure is an increase of more than about 25%, adjusting the dose of venlukastat or a pharmaceutically acceptable salt thereof. A method for establishing the correct dose of venlukastat or a pharmaceutically acceptable salt thereof in a subject in need thereof, the method comprising: (i) determining the change in plasma exposure of venlukastat when venlukastat or a pharmaceutically acceptable salt thereof is administered in combination with a strong or moderate CYP3A4 inhibitor as compared to the exposure resulting from administration of venlukastat at the same dose, form and schedule in the absence of the CYP3A4 inhibitor; and (ii) if the change in plasma exposure is an increase of more than about 25%, reducing the dose of venlukastat or a pharmaceutically acceptable salt thereof. A method for improving the dosing regimen of venlukastat or a pharmaceutically acceptable salt thereof in a subject in need thereof, the method comprising: (i) determining the change in plasma exposure of venlukastat when venlukastat or a pharmaceutically acceptable salt thereof is administered in combination with a strong or moderate CYP3A4 inhibitor as compared to the exposure resulting from administration of venlukastat at the same dose, form, and regimen in the absence of the CYP3A4 inhibitor; and (ii) if the change in plasma exposure is an increase of more than about 25%, reducing the dose of venlukastat or a pharmaceutically acceptable salt thereof. A method for managing the risk of a venlukastat/CYP3A4 inhibitor interaction in a subject having a disease or condition suitable for treatment with venlukastat or a pharmaceutically acceptable salt thereof, the method comprising: (i) initiating treatment with venlukastat or a pharmaceutically acceptable salt thereof at a standard indicated dose in the subject; (ii) determining the change in plasma exposure of venlukastat when venlukastat or a pharmaceutically acceptable salt thereof is administered in combination with a strong or moderate CYP3A4 inhibitor, as compared to the exposure resulting from administration of venlukastat at the same dose, form, and schedule in the absence of the CYP3A4 inhibitor; and (iii) if the change in plasma exposure is an increase of more than about 25%, reducing the dose. A use of a strong or moderate CYP3A4 inhibitor for use in the following methods: (a) establishing the correct dosage of venlukastat or a pharmaceutically acceptable salt thereof in a subject in need thereof; (b) improving the dosing regimen of venlukastat or a pharmaceutically acceptable salt thereof in a subject in need thereof; or (c) managing the risk of venlukastat/CYP3A4 inhibitor interaction in a subject having a disease or condition suitable for treatment with venlukastat or a pharmaceutically acceptable salt thereof, wherein the subject is being administered or is planned to be administered the CYP3A4 inhibitor. A method for inhibiting CYP3A4 activity in a subject being treated with vinlukastat or a pharmaceutically acceptable salt thereof, the method comprising co-administering the vinlukastat or a pharmaceutically acceptable salt thereof with a strong or moderate CYP3A4 inhibitor. A method for improving a therapeutic response to vinlukastat in a subject in need thereof, the method comprising co-administering vinlukastat or a pharmaceutically acceptable salt thereof and a strong or moderate CYP3A4 inhibitor. A pharmaceutical composition (e.g., an oral pharmaceutical dosage form) comprising vinlukastat or a pharmaceutically acceptable salt thereof and at least one pharmaceutically acceptable excipient in combination with a strong or moderate CYP3A4 inhibitor. The composition of claim 23, wherein the composition is formulated for oral administration. A composition as described in claim 24, wherein the composition is a dosage form selected from the following: capsules (e.g., hard capsules) and tablets (e.g., chewable tablets, orally disintegrating tablets, dispersible tablets or classic tablets or capsule-type tablets). A composition as described in any one of claims 23 to 25, which is used in a method as described in any one of claims 1 to 22.