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US20180280394A1 - Methods of treating liver disease - Google Patents

Methods of treating liver disease Download PDF

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Publication number
US20180280394A1
US20180280394A1 US15/935,759 US201815935759A US2018280394A1 US 20180280394 A1 US20180280394 A1 US 20180280394A1 US 201815935759 A US201815935759 A US 201815935759A US 2018280394 A1 US2018280394 A1 US 2018280394A1
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Prior art keywords
formula
pharmaceutically acceptable
compound
liver
effective amount
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US15/935,759
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Jamie Geier Bates
David Gordon Clarkson Breckenridge
John T. Liles
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Gilead Sciences Inc
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Gilead Sciences Inc
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Priority to US15/935,759 priority Critical patent/US20180280394A1/en
Assigned to GILEAD SCIENCES, INC. reassignment GILEAD SCIENCES, INC. ASSIGNMENT OF ASSIGNORS INTEREST (SEE DOCUMENT FOR DETAILS). Assignors: BATES, Jamie Geier, BRECKENRIDGE, DAVID GORDON CLARKSON, LILES, JOHN T
Publication of US20180280394A1 publication Critical patent/US20180280394A1/en
Priority to US16/803,824 priority patent/US11833150B2/en
Priority to US18/495,712 priority patent/US20240165119A1/en
Abandoned legal-status Critical Current

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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/33—Heterocyclic compounds
    • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
    • A61K31/495—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with two or more nitrogen atoms as the only ring heteroatoms, e.g. piperazine or tetrazines
    • A61K31/505—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim
    • A61K31/519—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim ortho- or peri-condensed with heterocyclic rings
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/33—Heterocyclic compounds
    • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
    • A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
    • A61K31/44—Non condensed pyridines; Hydrogenated derivatives thereof
    • A61K31/4427—Non condensed pyridines; Hydrogenated derivatives thereof containing further heterocyclic ring systems
    • A61K31/4439—Non condensed pyridines; Hydrogenated derivatives thereof containing further heterocyclic ring systems containing a five-membered ring with nitrogen as a ring hetero atom, e.g. omeprazole
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
    • A61K45/06—Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P1/00—Drugs for disorders of the alimentary tract or the digestive system
    • A61P1/16—Drugs for disorders of the alimentary tract or the digestive system for liver or gallbladder disorders, e.g. hepatoprotective agents, cholagogues, litholytics
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K2300/00—Mixtures or combinations of active ingredients, wherein at least one active ingredient is fully defined in groups A61K31/00 - A61K41/00

Definitions

  • the present disclosure relates to methods of preventing and/or treating liver diseases.
  • Liver disease is generally classified as acute or chronic based upon the duration of the disease. Liver disease may be caused by infection, injury, exposure to drugs or toxic compounds, alcohol, impurities in foods, and the abnormal build-up of normal substances in the blood, an autoimmune process, a genetic defect (such as haemochromatosis), or unknown cause(s).
  • Liver disease is a leading cause of death world wide. In particular, it has been seen that a diet high in fat damages the liver in ways that are surprisingly similar to hepatitis.
  • the American Liver Foundation estimates that more than 20 percent of the population has non-alcoholic fatty liver disease (NAFLD). It is suggested that obesity, unhealthy diets, and sedentary lifestyles may contribute to the high prevalence of NAFLD. When left untreated, NAFLD can progess to non-alcoholic steatohepatitis (NASH) causing serious adverse effects. Once NASH develops, it causes the liver to swell and scar (i.e. cirrhosis) over time.
  • NASH non-alcoholic steatohepatitis
  • liver disease can be any liver disease, including, but not limited to, chronic and/or metabolic liver diseases, nonalcoholic fatty liver disease (NAFLD), and nonalcoholic steatohepatitis (NASH).
  • NAFLD nonalcoholic fatty liver disease
  • NASH nonalcoholic steatohepatitis
  • NASH nonalcoholic steatohepatitis
  • the ACC inhibitor and the FXR agonist can be coadministered.
  • the ACC inhibitor and the FXR agonist can be administered together as a single pharmaceutical composition, or separately in more than one pharmaceutical composition.
  • a pharmaceutical composition comprising a therapeutically effective amount of an ACC inhibitor and a therapeutically effective amount of a FXR agonist.
  • FIG. 1 Liver triglycerides in umol/g in the murine FFD model. (*p ⁇ 0.05; **p ⁇ 0.01; ***p ⁇ 0.001;****p ⁇ 0.0001 significantly different from vehicle by ANOVA). Graph shows mean ⁇ SEM.
  • FIG. 2 ALT IU/L in the murine FFD model. (*** p ⁇ 0.001; significantly different from vehicle by ANOVA). Graph shows mean ⁇ SEM.
  • FIG. 3 Hepatic expression of liver fibrosis gene Col1a1 measured by quantitative RT-PCR in the murine FFD model. (**p ⁇ 0.01; ****p ⁇ 0.0001 significantly different from vehicle by ANOVA; # significantly different from either single agent by t-test). Graph shows mean ⁇ SEM.
  • FIG. 4 Hepatic expression of liver fibrosis gene Timp1 measured by quantitative RT-PCR in the murine FFD model. (*p ⁇ 0.05; ****p ⁇ 0.0001 significantly different from vehicle by ANOVA; # significantly different from either single agent by t-test). Graph shows mean ⁇ SEM.
  • FIG. 5 Percent PSR positive area by quantitative image analysis in the rat CDHFD model. (**p ⁇ 0.01, ***p ⁇ 0.001, ****p ⁇ 0.0001 significantly different from vehicle by t-test; & p ⁇ 0.001 significantly different from start of treatment by t-test). Graph shows mean ⁇ SEM.
  • FIG. 6 Percent ⁇ -SMA positive area by quantitative image analysis in the rat CDHFD model. (**p ⁇ 0.01 significantly different from vehicle by t-test; & p ⁇ 0.001 significantly different from start of treatment by t-test; # p ⁇ 0.05 significantly different from either single agent by t-test). Graph shows mean ⁇ SEM.
  • FIG. 7 Timp1 protein measured in plasma by ELISA in the rat CDHFD model. (*p ⁇ 0.05 significantly different from vehicle by t-test; & p ⁇ 0.001 significantly different from start of treatment by t-test). Graph shows mean ⁇ SEM.
  • FIG. 8 Hyaluronic acid (HA) measured in plasma by ELISA in the rat CDHFD model. **p ⁇ 0.01, ***p ⁇ 0.001, ****p ⁇ 0.0001 significantly different from vehicle by t-test). Graph shows mean ⁇ SEM.
  • FIG. 9 N-terminal propeptide of Type III Collagen (PIIINP) measured in plasma by ELISA in the rat CDHFD model. (*p ⁇ 0.05,**p ⁇ 0.01, ****p ⁇ 0.0001 significantly different from vehicle by t-test; & p ⁇ 0.001 significantly different from start of treatment by t-test; # p ⁇ 0.05 significantly different from either single agent by t-test). Graph shows mean ⁇ SEM.
  • the term “about” used in the context of quantitative measurements means the indicated amount ⁇ 10%, or alternatively the indicated amount ⁇ 5% or ⁇ 1%.
  • pharmaceutically acceptable salt refers to a salt of a compound disclosed herein that retains the biological effectiveness and properties of the underlying compound, and which is not biologically or otherwise undesirable.
  • acid addition salts and base addition salts are acid addition salts and base addition salts.
  • Pharmaceutically acceptable acid addition salts may be prepared from inorganic and organic acids.
  • Acids and bases useful for reaction with an underlying compound to form pharmaceutically acceptable salts are known to one of skill in the art.
  • methods of preparing pharmaceutically acceptable salts from an underlying compound are known to one of skill in the art and are disclosed in for example, Berge, at al. Journal of Pharmaceutical Science , January 1977 vol. 66, No. 1, and other sources.
  • “pharmaceutically acceptable carrier” includes excipients or agents such as solvents, diluents, dispersion media, coatings, antibacterial and antifungal agents, isotonic and absorption delaying agents and the like that are not deleterious to the disclosed compound or use thereof.
  • excipients or agents such as solvents, diluents, dispersion media, coatings, antibacterial and antifungal agents, isotonic and absorption delaying agents and the like that are not deleterious to the disclosed compound or use thereof.
  • the use of such carriers and agents to prepare compositions of pharmaceutically active substances is well known in the art (see, e.g., Remington's Pharmaceutical Sciences , Mace Publishing Co., Philadelphia, Pa. 17th Ed. (1985); and Modern Pharmaceutics , Marcel Dekker, Inc. 3rd Ed. (G. S. Banker & C. T. Rhodes, Eds.).
  • therapeutically effective amount and “effective amount” are used interchangibly and refer to an amount of a compound that is sufficient to effect treatment as defined below, when administered to a patient (e.g., a human) in need of such treatment in one or more doses.
  • the therapeutically effective amount will vary depending upon the patient, the disease being treated, the weight and/or age of the patient, the severity of the disease, or the manner of administration as determined by a qualified prescriber or care giver.
  • treatment means administering a compound or pharmaceutically acceptable salt thereof for the purpose of: (i) delaying the onset of a disease, that is, causing the clinical symptoms of the disease not to develop or delaying the development thereof; (ii) inhibiting the disease, that is, arresting the development of clinical symptoms; and/or (iii) relieving the disease, that is, causing the regression of clinical symptoms or the severity thereof.
  • Liver diseases are acute or chronic damages to the liver based on the duration of the disease.
  • the liver damage may be caused by infection, injury, exposure to drugs or toxic compounds such as alcohol or impurities in foods, an abnormal build-up of normal substances in the blood, an autoimmune process, a genetic defect (such as haemochromatosis), or other unknown causes.
  • liver diseases include, but are not limited to, cirrhosis, liver fibrosis, non-alcoholic fatty liver disease (NAFLD), non-alcoholic steatohepatitis (NASH), alcoholic steatohepatitis (ASH), hepatic ischemia reperfusion injury, primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), and hepatitis, including both viral and alcoholic hepatitis.
  • NAFLD non-alcoholic fatty liver disease
  • NASH non-alcoholic steatohepatitis
  • ASH alcoholic steatohepatitis
  • hepatic ischemia reperfusion injury hepatic ischemia reperfusion injury
  • PBC primary biliary cirrhosis
  • PSC primary sclerosing cholangitis
  • hepatitis including both viral and alcoholic hepatitis.
  • Non-alcoholic fatty liver disease is the build up of extra fat in liver cells that is not caused by alcohol.
  • NAFLD may cause the liver to swell (i.e. steatohepatitis), which in turn may cause scarring (i.e. cirrhosis) over time and may lead to liver cancer or liver failure.
  • NAFLD is characterized by the accumulation of fat in hepatocyes and is often associated with some aspects of metabolic syndrome (e.g. type 2 diabetes mellitus, insulin resistance, hyperlipidemia, hypertension). The frequency of this disease has become increasingly common due to consumption of carbohydrate-rich and high fat diets.
  • a subset ( ⁇ 20%) of NAFLD patients develop nonalcoholic steatohepatitis (NASH).
  • NASH a subtype of fatty liver disease
  • NAFLD a subtype of fatty liver disease
  • It is characterized by macrovesicular steatosis, balloon degeneration of hepatocytes, and/or inflammation ultimately leading to hepatic scarring (i.e. fibrosis).
  • Patients diagnosed with NASH progress to advanced stage liver fibrosis and eventually cirrhosis.
  • the current treatment for cirrhotic NASH patients with end-stage disease is liver transplant.
  • PSC primary sclerosing cholangitis
  • Liver fibrosis is the excessive accumulation of extracellular matrix proteins, including collagen, that occurs in most types of chronic liver diseases. Advanced liver fibrosis results in cirrhosis, liver failure, and portal hypertension and often requires liver transplantation.
  • a method of treating and/or preventing liver disease in a patient in need thereof comprising administering to the patient a therapeutically effective amount of an ACC inhibitor in combination with a therapeutically effective amount of a FXR agonist.
  • the presence of active liver disease can be detected by the existence of elevated enzyme levels in the blood.
  • blood levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) above clinically accepted normal ranges are known to be indicative of on-going liver damage.
  • Routine monitoring of liver disease patients for blood levels of ALT and AST is used clinically to measure progress of the liver disease while on medical treatment. Reduction of elevated ALT and AST to within the accepted normal range is taken as clinical evidence reflecting a reduction in the severity of the patient's on-going liver damage.
  • the liver disease is a chronic liver disease.
  • Chronic liver diseases involve the progressive destruction and regeneration of the liver parenchyma, leading to fibrosis and cirrhosis.
  • chronic liver diseases can be caused by viruses (such as hepatitis B, hepatitis C, cytomegalovirus (CMV), or Epstein Barr Virus (EBV)), toxic agents or drugs (such as alcohol, methotrexate, or nitrofurantoin), a metabolic disease (such as non-alcoholic fatty liver disease (NAFLD), non-alcoholic steatohepatitis (NASH), haemochromatosis, or Wilson's Disease), an autoimmune disease (such as Autoimmune Chronic Hepatitis, Primary Biliary Cholangitis (formerly known as Primary Biliary Cirrhosis), or Primary Sclerosing Cholangitis, or other causes (such as right heart failure).
  • viruses such as hepatitis B, hepatitis C, cytomegalovirus (CMV), or Epstein
  • cirrhosis is characterized pathologically by loss of the normal microscopic lobular architecture, with fibrosis and nodular regeneration. Methods for measuring the extent of cirrhosis are well known in the art. In one embodiment, the level of cirrhosis is reduced by about 5% to about 100%.
  • the level of cirrhosis is reduced by at least about 5%, at least about 10%, at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least 50%, at least about 55%, at least about 60%, at least about 65%, at least about 70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, or at least about 95% in the subject.
  • the liver disease is a metabolic liver disease.
  • the liver disease is non-alcoholic fatty liver disease (NAFLD).
  • NAFLD is associated with insulin resistance and metabolic syndrome (obesity, combined hyperlipidemia, diabetes mellitus (type II) and high blood pressure). NAFLD is considered to cover a spectrum of disease activity, and begins as fatty accumulation in the liver (hepatic steatosis).
  • NAFLD has several other known causes.
  • NAFLD can be caused by certain medications, such as amiodarone, antiviral drugs (e.g., nucleoside analogues), aspirin (rarely as part of Reye's syndrome in children), corticosteroids, methotrexate, tamoxifen, or tetracycline.
  • NAFLD has also been linked to the consumption of soft drinks through the presence of high fructose corn syrup which may cause increased deposition of fat in the abdomen, although the consumption of sucrose shows a similar effect (likely due to its breakdown into fructose). Genetics has also been known to play a role, as two genetic mutations for this susceptibility have been identified.
  • NAFLD non-alcoholic steatohepatitis
  • NASH non-alcoholic steatohepatitis
  • a method of treating and/or preventing nonalcoholic steatohepatitis (NASH) in a patient in need thereof comprising administering to the patient a therapeutically effective amount of an ACC inhibitor in combination with a therapeutically effective amount of a a FXR agonist.
  • liver fibrosis is the excessive accumulation of extracellular matrix proteins including collagen that occurs in most types of chronic liver diseases.
  • advanced liver fibrosis results in cirrhosis and liver failure.
  • Methods for measuring liver histologies such as changes in the extent of fibrosis, lobular hepatitis, and periportal bridging necrosis, are well known in the art.
  • the level of liver fibrosis which is the formation of fibrous tissue, fibroid or fibrous degeneration, is reduced by more that about 90%. In one embodiment, the level of fibrosis, which is the formation of fibrous tissue, fibroid or fibrous degeneration, is reduced by at least about 90%, at least about 80%, at least about 70%, at least about 60%, at least about 50%, at least about 40%, at least about 30%, at least about 20%, at least about 10%, at least about 5% or at least about 2%.
  • the compounds provided herein reduce the level of fibrogenesis in the liver.
  • Liver fibrogenesis is the process leading to the deposition of an excess of extracellular matrix components in the liver known as fibrosis. It is observed in a number of conditions such as chronic viral hepatitis B and C, alcoholic liver disease, drug-induced liver disease, hemochromatosis, auto-immune hepatitis, Wilson disease, Primary Biliary Cholangitis (formerly known as Primary Biliary Cirrhosis), sclerosing cholangitis, liver schistosomiasis and others.
  • the level of fibrogenesis is reduced by more that about 90%.
  • the level of fibrogenesis is reduced by at least about 90%, at least about 80%, at least about 70%, at least about 60%, at least about 50%, at least 40%, at least about 30%, at least about 20%, at least about 10%, at least about 5% or at least 2%.
  • provided herein is a method of treating and/or preventing primary sclerosing cholangitis (PSC) in a patient in need thereof, comprising administering to the patient a therapeutically effective amount of an ACC inhibitor in combination with a therapeutically effective amount of a FXR agonist.
  • PSC primary sclerosing cholangitis
  • NASH non-alcoholic fatty acid deficiency
  • compounds useful for the treatment of NASH would be useful for slowing, improving or reversing epigenetic age or effects of aging due to NASH.
  • combination therapies for the treatment of NASH such as, for example, the combination of an ACC inhibitor with an an FXR agonist as disclosed herein may be useful for improvement or reversal of aging effects due to NASH.
  • the ACC inhibitor and the FXR agonist may be administered together in a combination formulation or in seperate pharmaceutical compositions, where each inhibitor may be formulated in any suitable dosage form.
  • the methods provided herein comprise administering separately a pharmaceutical composition comprising an ACC inhibitor and a pharmaceutically acceptable carrier or excipient and a pharmaceutical composition comprising a FXR agonist and a pharmaceutically acceptable carrier or excipient.
  • Combination formulations according to the present disclosure comprise an ACC inhibitor and a FXR agonist together with one or more pharmaceutically acceptable carriers or excipients and optionally other therapeutic agents.
  • Combination formulations containing the active ingredient may be in any form suitable for the intended method of administration.
  • the ACC inhibitor is a compound having the structure of Formula (I):
  • the ACC inhibitor is a compound having the structure of Formula (II):
  • the ACC inhibitor is the compound of Formula (I) or a pharmaceutically acceptable salt thereof. In one embodiment, the ACC inhibitor is the compound of Formula (II) or a pharmaceutically acceptable salt thereof.
  • the FXR agonist is a compound having the structure of Formula (III):
  • the FXR agonist is a compound having the structure of Formula (IV):
  • the compounds of Formula (III) and Formula (IV) may be synthesized and characterized using methods known to those of skill in the art, such as those described in U.S. Publication No. 2014/0221659.
  • compositions both for veterinary and for human use, of the disclosure comprise at least one of the active ingredients, together with one or more acceptable carriers therefor and optionally other therapeutic ingredients.
  • the carrier(s) must be “acceptable” in the sense of being compatible with the other ingredients of the formulation and physiologically innocuous to the recipient thereof.
  • Each of the active ingredients can be formulated with conventional carriers and excipients, which will be selected in accord with ordinary practice.
  • Tablets can contain excipients, glidants, fillers, binders and the like.
  • Aqueous formulations are prepared in sterile form, and when intended for delivery by other than oral administration generally will be isotonic. All formulations will optionally contain excipients such as those set forth in the Handbook of Pharmaceutical Excipients (1986). Excipients include ascorbic acid and other antioxidants, chelating agents such as EDTA, carbohydrates such as dextrin, hydroxyalkylcellulose, hydroxyalkylmethylcellulose, stearic acid and the like.
  • the pH of the formulations ranges from about 3 to about 11, but is ordinarily about 7 to 10.
  • each active ingredient will be administered in a dose from 0.01 milligrams to 1 gram.
  • the dosage will be from about 10 milligrams to 450 milligrams.
  • the dosage will be from about 25 to about 250 milligrams.
  • the dosage will be about 50 or 100 milligrams.
  • the dosage will be about 100 milligrams.
  • 20 mg of an ACC inhibitor is administered.
  • 20 mg of a compound of Formula (II) is administered.
  • 30 mg of an FXR agonist is administered.
  • 30 mg of a compound of Formula (III) is administered. It is contemplated that the active ingredients may be administered once, twice or three times a day. Also, the active ingredients may be administered once or twice a week, once every two weeks, once every three weeks, once every four weeks, once every five weeks, or once every six weeks.
  • the pharmaceutical composition for the active ingredient can include those suitable for the foregoing administration routes.
  • the formulations can conveniently be presented in unit dosage form and may be prepared by any of the methods well known in the art of pharmacy. Techniques and formulations generally are found in Remington's Pharmaceutical Sciences (Mack Publishing Co., Easton, Pa.). Such methods include the step of bringing into association the active ingredient with the carrier which constitutes one or more accessory ingredients. In general the formulations are prepared by uniformly and intimately bringing into association the active ingredient with liquid carriers or finely divided solid carriers or both, and then, if necessary, shaping the product.
  • Formulations suitable for oral administration can be presented as discrete units such as capsules, cachets or tablets each containing a predetermined amount of the active ingredient; as a powder or granules; as a solution or a suspension in an aqueous or non-aqueous liquid; or as an oil-in-water liquid emulsion or a water-in-oil liquid emulsion.
  • the active ingredient may also be administered as a bolus, electuary or paste.
  • the active ingredient may be administered as a subcutaneous injection.
  • a tablet can be made by compression or molding, optionally with one or more accessory ingredients.
  • Compressed tablets can be prepared by compressing in a suitable machine the active ingredient in a free-flowing form such as a powder or granules, optionally mixed with a binder, lubricant, inert diluent, preservative, or surface active agent.
  • Molded tablets may be made by molding in a suitable machine a mixture of the powdered active ingredient moistened with an inert liquid diluent.
  • the tablets may optionally be coated or scored and optionally are formulated so as to provide slow or controlled release of the active ingredient therefrom.
  • the active ingredient can be administered by any route appropriate to the condition. Suitable routes include oral, rectal, nasal, topical (including buccal and sublingual), vaginal and parenteral (including subcutaneous, intramuscular, intravenous, intradermal, intrathecal and epidural), and the like. It will be appreciated that the preferred route may vary with for example the condition of the recipient. In certain embodiments, the active ingredients are orally bioavailable and can therefore be dosed orally. In one embodiment, the patient is human.
  • the ACC inhibitor and the FXR agonist can be administered together in a single pharmaceutical composition, e.g. a fixed dose combination, or seperately (either concurrently or sequentially) in more than one pharmaceutical composition.
  • the ACC inhibitor and the FXR agonist are administered together.
  • the ACC inhibitor and the FXR agonist are administered separately.
  • the ACC inhibitor is administered prior to the FXR agonist.
  • the FXR agonist is administered prior to the ACC inhibitor.
  • the ACC inhibitor and the FXR agonist can be administered to the patient by the same or different routes of delivery.
  • compositions of the disclosure comprise an effective amount of an ACC inhibitor selected from the group consisting of a compound of Formula (I) and a compound of Formula (II), or a pharmaceutically acceptable salt thereof, and an effective amount of a FXR agonist selected from the group consisting of a compound of Formula (III) and a compound of Formula (IV), or a pharmaceutically acceptable salt thereof.
  • compositions intended for oral use may be prepared according to any method known to the art for the manufacture of pharmaceutical compositions and such compositions may contain one or more agents including sweetening agents, flavoring agents, coloring agents and preserving agents, in order to provide a palatable preparation. Tablets containing the active ingredient in admixture with non-toxic pharmaceutically acceptable excipient which are suitable for manufacture of tablets are acceptable.
  • excipients may be, for example, inert diluents, such as, for example, calcium or sodium carbonate, lactose, lactose monohydrate, croscarmellose sodium, povidone, calcium or sodium phosphate; granulating and disintegrating agents, such as, for example, maize starch, or alginic acid; binding agents, such as, for example, cellulose, microcrystalline cellulose, starch, gelatin or acacia; and lubricating agents, such as, for example, magnesium stearate, stearic acid or talc.
  • inert diluents such as, for example, calcium or sodium carbonate, lactose, lactose monohydrate, croscarmellose sodium, povidone, calcium or sodium phosphate
  • granulating and disintegrating agents such as, for example, maize starch, or alginic acid
  • binding agents such as, for example, cellulose, microcrystalline cellulose, starch, gelatin or aca
  • Tablets may be uncoated or may be coated by known techniques including microencapsulation to delay disintegration and adsorption in the gastrointestinal tract and thereby provide a sustained action over a longer period.
  • a time delay material such as, for example, glyceryl monostearate or glyceryl distearate alone or with a wax may be employed.
  • Formulations for oral use may be also presented as hard gelatin capsules where the active ingredient is mixed with an inert solid diluent, for example calcium phosphate or kaolin, or as soft gelatin capsules wherein the active ingredient is mixed with water or an oil medium, such as, for example, peanut oil, liquid paraffin or olive oil.
  • an inert solid diluent for example calcium phosphate or kaolin
  • an oil medium such as, for example, peanut oil, liquid paraffin or olive oil.
  • Aqueous suspensions of the disclosure contain the active materials in admixture with excipients suitable for the manufacture of aqueous suspensions.
  • excipients include a suspending agent, such as, for example, sodium carboxymethylcellulose, methylcellulose, hydroxypropyl methylcelluose, sodium alginate, polyvinylpyrrolidone, gum tragacanth and gum acacia, and dispersing or wetting agents such as, for example, a naturally occurring phosphatide (e.g., lecithin), a condensation product of an alkylene oxide with a fatty acid (e.g., polyoxyethylene stearate), a condensation product of ethylene oxide with a long chain aliphatic alcohol (e.g., heptadecaethyleneoxycetanol), a condensation product of ethylene oxide with a partial ester derived from a fatty acid and a hexitol anhydride (e.g., polyoxyethylene sorbitan monooleate
  • the aqueous suspension may also contain one or more preservatives such as, for example, ethyl or n-propyl p-hydroxy-benzoate, one or more coloring agents, one or more flavoring agents and one or more sweetening agents, such as, for example, sucrose or saccharin.
  • Oil suspensions may be formulated by suspending the active ingredient in a vegetable oil, such as, for example, arachis oil, olive oil, sesame oil or coconut oil, or in a mineral oil such as, for example, liquid paraffin.
  • the oral suspensions may contain a thickening agent, such as, for example, beeswax, hard paraffin or cetyl alcohol.
  • Sweetening agents such as, for example, those set forth above, and flavoring agents may be added to provide a palatable oral preparation.
  • These compositions may be preserved by the addition of an antioxidant such as, for example, ascorbic acid.
  • Dispersible powders and granules of the disclosure suitable for preparation of an aqueous suspension by the addition of water provide the active ingredient in admixture with a dispersing or wetting agent, a suspending agent, and one or more preservatives.
  • a dispersing or wetting agent and suspending agents are exemplified by those disclosed above. Additional excipients, for example sweetening, flavoring and coloring agents, may also be present.
  • the pharmaceutical compositions of the disclosure may also be in the form of oil-in-water emulsions.
  • the oily phase may be a vegetable oil, such as, for example, olive oil or arachis oil, a mineral oil, such as, for example, liquid paraffin, or a mixture of these.
  • Suitable emulsifying agents include naturally-occurring gums, such as, for example, gum acacia and gum tragacanth, naturally occurring phosphatides, such as, for example, soybean lecithin, esters or partial esters derived from fatty acids and hexitol anhydrides, such as, for example, sorbitan monooleate, and condensation products of these partial esters with ethylene oxide, such as, for example, polyoxyethylene sorbitan monooleate.
  • the emulsion may also contain sweetening and flavoring agents. Syrups and elixirs may be formulated with sweetening agents, such as, for example, glycerol, sorbitol or sucrose. Such formulations may also contain a demulcent, a preservative, a flavoring or a coloring agent.
  • compositions of the disclosure may be in the form of a sterile injectable preparation, such as, for example, a sterile injectable aqueous or oleaginous suspension.
  • a sterile injectable preparation such as, for example, a sterile injectable aqueous or oleaginous suspension.
  • This suspension may be formulated according to the known art using those suitable dispersing or wetting agents and suspending agents which have been mentioned above.
  • the sterile injectable preparation may also be a sterile injectable solution or suspension in a non-toxic parenterally acceptable diluent or solvent, such as, for example, a solution in 1,3-butane-diol or prepared as a lyophilized powder.
  • a non-toxic parenterally acceptable diluent or solvent such as, for example, a solution in 1,3-butane-diol or prepared as a lyophilized powder.
  • acceptable vehicles and solvents that may be employed are water, Ringer's solution
  • sterile fixed oils may conventionally be employed as a solvent or suspending medium.
  • any bland fixed oil may be employed including synthetic mono- or diglycerides.
  • fatty acids such as, for example, oleic acid may likewise be used in the preparation of injectables.
  • a time-release formulation intended for oral administration to humans may contain approximately 1 to 1000 mg of active material compounded with an appropriate and convenient amount of carrier material which may vary from about 5 to about 95% of the total compositions (weight:weight).
  • the pharmaceutical composition can be prepared to provide easily measurable amounts for administration.
  • an aqueous solution intended for intravenous infusion may contain from about 3 to 500 ⁇ g of the active ingredient per milliliter of solution in order that infusion of a suitable volume at a rate of about 30 mL/hr can occur.
  • the formulation is typically administered about twice a month over a period of from about two to about four months.
  • Formulations suitable for parenteral administration include aqueous and non-aqueous sterile injection solutions which may contain anti-oxidants, buffers, bacteriostats and solutes which render the formulation isotonic with the blood of the intended recipient; and aqueous and non-aqueous sterile suspensions which may include suspending agents and thickening agents.
  • the formulations can be presented in unit-dose or multi-dose containers, for example sealed ampoules and vials, and may be stored in a freeze-dried (lyophilized) condition requiring only the addition of the sterile liquid carrier, for example water for injection, immediately prior to use.
  • sterile liquid carrier for example water for injection
  • Extemporaneous injection solutions and suspensions are prepared from sterile powders, granules and tablets of the kind previously described.
  • Preferred unit dosage formulations are those containing a daily dose or unit daily sub-dose, as herein above recited, or an appropriate fraction thereof, of the active ingredient.
  • NASH non-alcoholic steatohepatitis
  • FFD mice were subsequently treated with placebo (vehicle), an ACC inhibitor (Formula (I)), an FXR agonist (Formula (III)), or with the combination of Formula (I) and Formula (III) for 1 month.
  • Control mice remained on a normal chow diet for the entire 6 month study period.
  • Endpoint analyses included biochemical quantification of liver triglycerides, plasma ALT, and measurement of the pro-fibrotic transcripts Timp1 and Col1A1 in liver.
  • mice Male C57CL/6 mice (aged 12 weeks at study inception) were used in this study. All procedures used to study the animals were in the compliance with the U.S. Department of Agriculture's Animal Welfare Act (9 CFR Parts 1, 2, and 3); the Guide for the Care and Use of Laboratory Animals (Institute for Laboratory Animal Research, The National Academys Press, Washington, D.C.); and the National Institutes of Health, Office of Laboratory Animal Welfare.
  • the experimental design is shown in Table 1.
  • Study animals were administered either a standard chow diet (Harlan Teklad Global Diets 2014, TD2014) or a commercially available high fat, high cholesterol diet (Research Diets Inc, DB12079B) (the FFD).
  • Animals receiving the FFD were administered fructose/glucose in drinking water formulated as follows: 23.1 g fructose (Sigma, F2543) and 17.2 g of glucose (Sigma, 49158) was mixed into 1000 mL of drinking water.
  • the compound of Formula (I) and the compound of Formula (III) were formulated in 0.5% sodium carboxymethylcellulose (medium viscosity), 1% w/w ethanol, 98.5% w/w 50 mM Tris Buffer, pH 8 in reverse osmosis water.
  • the compound of Formula (I) was formulated at either 0.1 or 0.2 mg/mL and given in the dose provided in Table 1
  • the compound of Formula (III) was formulated at 2 mg/mL and given in the dose provided in Table 1.
  • mice in groups 1-6 were sham dosed with vehicle BID.
  • the sham dosing was designed to acclimate animals to oral gavage dose administration.
  • animals in all dose groups were dosed three times daily; twice sequentially in the AM (7:00+/ ⁇ 1 hour), and once in the evening (19:00+/ ⁇ 1 hr), with the same volume of formulation containing no compound (group 1, vehicle) or the appropriate compounds as outlined below (Table 1) for 28 days (until dosing Day 29). Each group was split into two and half were sacrificed 2 hours post dose, and half were sacrificed 8 hours post dose on Day 29.
  • Mouse liver tissue samples (25 ⁇ 10 mg, accurately weighed in frozen state) were homogenized and extracted with a water immiscible organic solvent mixture that extracts the triacylglyceride fraction as well as the free and esterified cholesterol fractions into the organic phase. After centrifugation, an aliquot of the organic upper layer, containing the triacylglycerides, cholesterol and cholesterol esters was diluted either 10-fold or 25-fold with ethanol. Two separate aliquots of this dilution were taken. One aliquot was analyzed for triacylglycerides, the second aliquot was used for the total cholesterol determination.
  • Triacylglyceride determination For the triacylglyceride determination, one aliquot of the 25-fold dilution (or no dilution in the case of samples which have low triacylglyceride content) was evaporated under a stream of nitrogen. The dried extract was reconstituted stepwise with a 0.1% sodium dodecyl sulfate in PBS solution under ultrasonication followed by mixing with the Triacylglyceride Determination Reagent (InfinityTM Triglycerides Liquid Stable Reagent, Thermo Scientific, Product Data Sheet, InfinityTM, Triglycerides Liquid Stable Reagent).
  • This reagent solution contained several enzymes, cofactors and the chromogenic reagent 4-aminoantipyrine.
  • TAG triacylglycerides
  • Triacylglyceride Determination Reagent After incubation with the Triacylglyceride Determination Reagent for 30 min at 37° C., samples were transferred into a microtiter plate, and the absorbance is measured at 540 nm in a microplate reader (SpectraMax M2, Molecular Devices). Quantitation was performed using a linear least squares regression analysis generated from fortified calibration standards using glyceryl trioleate (triolein) as triacylglyceride reference standard. Calibration standard samples were taken through the same extraction and incubation steps as the tissue samples. Weight corrections and concentration calculations were performed using Microsoft Excel 2013. Final tissue contents were given in ⁇ mol Triacylglyceride (TAG)/g Liver Tissue.
  • TAG Triacylglyceride
  • Serum ALT was measured by Pyruvate with pyridoxal-5′-phosphate and analyzed on the Cobas Hitachi 6000 Chemistry System, Roche Diagnostics.
  • NanoString assays were carried out with all reagents and consumables contained in an nCounter master kit (NanoString) according to manufacturer instructions to measure RNA transcripts. Briefly, the color coded reporter probe targeting 110 liver fibrosis related genes and 6 control housekeeping genes (Table 2) were hybridized overnight in a pre-heated 65° C. thermocycler for 16 to 22 hours with 100 ng RNA samples in a reaction that includes a hybridization buffer and a capture probe.
  • Example 1 demonstrates that a combined treatment with an ACC inhibitor and an FXR agonist results in greater efficacy than either agent administered alone in the mouse model of NASH.
  • FIG. 1 shows a significant reduction in liver triglycerides with the combination of the compound of Formula (I) and the compound of Formula (III) relative to the individual agents
  • FIG. 2 shows a significant reduction in serum ALT with the combination of the compound of Formula (I) and the compound of Formula (III) relative to the individual agents
  • FIG. 3 and FIG. 4 show a significant reduction in liver expression of Col1a1 and Timp1 with the combination of the compound of Formula (I) and the compound of Formula (III) relative to the individual agents, respectively.
  • NASH non-alcoholic steatohepatitis
  • 5.12 g of Tris HCl was added to the container.
  • 2.12 g of Tris base was added to the container.
  • QS water was added to 1 L with gentle mixing.
  • Tissues were collected by Charles River in Reno, Nev., processed and embedded in paraffin at Histo-tec in Hayward, Calif. and then shipped to Gilead Sciences in Foster City. Samples were sectioned at 5 ⁇ m and sections were mounted on glass slides for subsequent staining.
  • Sections were pretreated in 0.2% Phosphomolybdic Acid (EMS, Cat#26357-01) and then subsequently incubated in 0.1% (W/V) Sirius Red 88-89-1 in saturated Picric acid solution (EMS, Cat#26357-02) for 1 hour at room temperature. This was followed by differentiation in 0.01N HCl (EMS, Cat#26357) and dehydration in graded alcohols.
  • EMS Phosphomolybdic Acid
  • Sections were deparaffinized in 3 changes of xylene for 5 minutes each, and subsequently rehydrated in 3 changes of 100% EtOH, 1 change of 95% EtOH, 1 change of 80% EtOH for 3 minutes each; followed by 2 successive rinses in distilled water.
  • the sections were then incubated in Peroxidazed 1 (Biocare Medical, Cat# PX968) endogenous peroxidase blocker for 5 minutes and rinsed in distilled water. Heat induced epitope retrieval was then performed using Reveal Decloaker (Biocare Medical, Cat# RV1000M) at 95° C.
  • ⁇ -SMA stained slides were captured using a Leica AT2 scanner at 40 ⁇ magnification. Digital slide images were checked for scanning quality, annotated and exported to appropriate network folders within Leica Digital Image Hub archive. Quantitative image analysis was performed on the whole slide images using Visiopharm image analysis software (Visiopharm, Hoersholm, Denmark) to determine the extent and intensity of ⁇ -SMA. The total ⁇ -SMA-stained area was measured and expressed as a percentage of total liver area stained.
  • Plasma TIMP-1 ELISA Plasma TIMP-1 ELISA
  • Plasma TIMP-1 concentrations were determined in duplicate using a commercially available rat TIMP-1 specific ELISA kit (R&D Systems, Minneapolis, Minn., Cat # RTM100). TIMP-1 was assayed in plasma according to the manufacturer's specifications with minor modifications. Buffer RD1-21 (50 ⁇ l) was added to ELISA plate wells pre-coated with mouse anti-TIMP-1. Prior to ELISA, a seven point standard curve of rat TIMP-1 (NS0-expressed recombinant TIMP-1: 2400-37.5 pg/mL) was generated and plasma samples were diluted 1:20 in buffer RD5-17.
  • O.D. absorbance was immediately determined at 450 nm on a SpectraMax 190 microplate reader (Molecular Devices, Sunnyvale Calif.). Relative O.D.s for each standard and sample were background corrected against blank samples, and standard curves for conversion of O.D.s to TIMP-1 concentration were generated using a 4 Parameter curve fit method. Unknown sample TIMP-1 concentrations were determined using SoftMax ProS software using a dilution factor of 20. Results are shown in FIG. 7 .
  • Plasma PIIINP concentrations were determined in duplicate using a commercially available rat Procollagen III N-Terminal Propeptide (PIIINP) ELISA Kit (Biomatik, Wilmington, Del., Cat# EKU06788). PIIINP was assayed in plasma diluted 50 fold in PBS according to the manufacturer's specifications with minor modifications. 7 standards (2,000 pg/mL, 1,000 pg/mL, 500 pg/mL, 250 pg/mL, 125 pg/mL, 62.5 pg/mL, 31.2 pg/mL) were prepared from standard stock which was reconstituted in Standard Diluent. 100 ⁇ L each of standards, blank and samples were added into the appropriate wells.
  • PIIINP Procollagen III N-Terminal Propeptide
  • the plate was covered with the plate sealer and incubated for 1 hour at 37° C. After removing liquid from each well, 100 ⁇ L of Detection Reagent A working solution was added to each well and covered with the plate sealer then incubated for 1 hour at 37° C. The wells were washed with 350 ⁇ L of 1 ⁇ Wash and sit for 1 ⁇ 2 minutes for 3 times. After the last wash, any remaining wash buffer was removed by decanting and blotting against absorbent paper. Then 100 ⁇ L of Detection Reagent B working solution was added to each well, plate was covered with the plate sealer and incubated for 30 minutes at 37° C. The aspiration/wash process was repeated for total 5 times.
  • Plasma HA concentrations were determined in duplicate using a commercially available HA Test Kit (Corgenix, Inc., Broomfield, Colo., Cat#029-001). HA was assayed in plasma according to the manufacturer's specifications with minor modifications. Prior to assay, a seven point standard curve of HA reference solution (800-12.5 ng/mL) was generated and each reference sample and plasma sample was diluted 1 part to 10 parts Reaction Buffer (30 ⁇ l reference/sample to 300 ⁇ l Reaction Buffer). Samples and standards (100 ⁇ l) were added in duplicate to microplate wells pre-coated with HA binding protein (HABP) and incubated (room temperature) for 60 minutes on an orbital plate shaker (300 rpm).
  • HABP HA binding protein
  • Example 2 demonstrates that a combined treatment with an ACC inhibitor and an FXR agonist results in greater efficacy than either agent administered alone in the rat model of NASH.
  • FIG. 5-9 shows a significant reduction markers of fibrosis including percent picrosirius positive area, percent ⁇ -SMA positive area, and three plasma markers associated with fibrosis, TIMP1, HA, and PIIINP with the combination of the compound of Formula (I) and the compound of Formula (III) relative to the vehicle.
  • FIG. 6 and FIG. 9 show a significant reduction ⁇ -SMA and PIIINP with the combination of the compound of Formula (I) and the compound of Formula (III) relative to the individual agents, respectively.

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