NZ740157B2 - Methods of improving myocardial performance in fontan patients using udenafil compositions - Google Patents

Abstract

The present invention relates generally to the field of using udenafil or a pharmaceutically acceptable salt thereof in patients who have undergone the Fontan operation. Udenafil is administered to patients whose exercise capacity is adversely affected due to a decline in heart function after Fontan palliation, with a total daily dose of 125 mg to 175 mg. Improvement of exercise capacity is determined by maximum oxygen uptake at maximum exercise output (VO2 measurement).

Description

Methods of Improving Myocardial Performance in Fontan Patients Using il Compositions CROSS REFERENCE TO RELATED APPLICATIONS The t ion claims ty to US Provisional Application No. 62,036,506, ?led on August 12, 2014, and US Provisional Application No. 62/ 186,132, ?led on June 29, 2015, the disclosures of which are speci?cally incorporated by reference.

FIELD OF THE INVENTION The present invention relates generally to the ?eld of using phosphodiesterasc E5 (PDES) inhibitors in patients who have undergone the Fontan operation. In particular, the PDES inhibitor is udcna?l or a pharmaceutically acceptable salt thereof.

OUND OF THE INVENTION 1. Background ing the Fontan Procedure The Fontan ure, or Fontan/Kreutzcr procedure, is a palliative surgical procedure for children born with functional single ventricle congenital heart disease.

The Fontan operation was designed to provide blood ?ow in series to the pulmonary and systemic circulation without the requirement for a right ventricular pumping chamber.

The operation allows ic venous blood to ?ow directly into the pulmonary circulation on the basis of a single ventricular impetus through the arteries, capillaries, and systemic venous system. This arrangement has improved life expectancy for patients with single-ventricle and ary-out?ow obstruction compared with previous arterial shunts.

The operation, which creates a total cavopuImonary connection, separates the systemic and pulmonary circuits and ates both hypoxemia and ventricular volume overload. However, following the Fontan operation there is no ventricular pump to propel blood into the pulmonary arteries. Instead, blood returns to the lungs via passive ?ow from the systemic veins. This results in a circulation characterized by ed central venous pressure, abnormal pulmonary vascular resistance, and a chronically low cardiac output. Over time, these inherent teristics of Fontan physiology result in a predictable. persistent deterioration of cardiovascular efficiency, as marked by a ssive decline in exercise performance that begins after puberty. This decline in exercise capacity correlates with an increase in symptoms from cardiovascular dysfunction and may result in the need for alization, escalation of heart failure management, or transplant.

Those with the Fontan circulation do not have ‘normal’ heart physiology or functioning. Two major complications that might have many "downstream" effects are the following effects on increasing ("hypertension") and decreasing ("hypotension") blood pressure depending upon its location (veins or arteries). First, with Fontan circulation, there is mic venous hypertension", which means that the blood pressure in the veins (blood going back to the heart) in the body is higher than in individuals with normal heart function (not Fontan circulation). There are many ve uences that may be caused by systemic venous hypertension (congestive heart failure, edema or swelling, dysfunction of the liver, potentially protein—losing enteropathy) that are basically related to the distribution of fluids in the body. A second complication is "pulmonary arterial hypotension" where the blood pressure in arteries going towards or in the lungs (hence ary) is lower than in individuals with normal heart function. There are also a number of ve consequences associated with pulmonary arterial hypotension such as cyanosis (blue lips) or lack of exercise capacity.

Many of the subsequent medical conditions and deaths that follow the Fontan procedure (either in the short- or long-term) are thought to originate from this change in systemic and pulmonary blood pressure.

The long-term effects of marked single-ventricle preload and inefficient oxygenation via an arterial shunt rarely allow survival beyond the second or third decade of life. Uniformly lethal four decades ago, the newborn with single ventricle type ital heart disease in 2010 is now not only likely — but expected - to survive.

However, as these children have grown into adolescence and adulthood, it is clear that there are cant limitations to this strategy. While lifesaving, the Fontan/Kreutzer operation results in profound physiological disturbances with very serious consequences.

Pervasive abnormalities of multiple organ systems are affected as time goes on.

Realistically, it is unlikely that patients will survive into their third or fourth decades of life untouched by some potentially life-threatening complication. Thus, there is a clear need to fy treatments that may ameliorate the dysfunctional state of the Fontan operation. This is particularly true given the increase in the prevalence of the Fontan procedures: remarkably, the Fontan operation has become the most common ure performed for congenital heart disease after the age of 2 years. W.M. Gersony, Circulation, 1 17: 13-15 (2008).

Multiple studies looking at the results of the Fontan operation demonstrate a decrease in survival beyond 15 years after surgery. An ongoing signi?cant risk of death with continuous attrition is present, less of surgical type of cavo—pulmonary connection. In another study looking at morphologically single left ventricle after Fontan surgery, results showed that odds are 1 out 4 that a child after Fontan will be dead by the time he or she reaches their late 20s. J. Rychik, "Forty Years of the Fontan Operation: A Failed gy," ric- Cardiac Surgery Annual, 96-100(2010).

Given the increased life span for Fontan patients, researchers have sought out medical therapies to address the side effects of the Fontan y. In particular, children and young adults with single-ventricle physiology have abnormal se capacity after the Fontan operation. Strategies targeted toward improving cardiac output and reducing central venous pressure will improve their overall well-being and mitigate against the impact of this deleterious physiology.

In one study, the PDES inhibitor sildcna?l was found to signi?cantly e ventilatory ef?ciency during peak and imal exercise. There was also a suggestion of improved oxygen consumption at the anaerobic threshold in 2 subgroups.

These ?ndings suggest that sildena?l may be an ant agent for improving exercise performance in children and young adults with single-ventricle physiology after the Fontan operation. Goldberg et al., Circulation, 123: 1 185-1193 (2011).

Later studies verified that sildena?l increased cular ic clastance and improved vcntriculo-artcrial coupling in patients palliatcd with Fontan circulation.

Short-term a?l was well tolerated in most of the patients with only minor side effects. Shabanian et al., Pediarr. l., 34(1): 129-34 (2013). The structure of sildena?l is shown below: In addition, a preliminary study assessed the short-term effects ofthe PDES inhibitor tadalafil on the hemodynamic response to exercise and exercise capacity in patients with Fontan circulation. See http://clinicaltrials.gov/ct2/show/record/NCT0l291069. Short term therapy with once daily dosing of tadalafll improved ventilatory ncy and oxygen tion, but exercise capacity was unchanged in young Fontan subjects, similar to published sildcnaftl results. Mcnon ct al., Circulation, 128: Al6024 (2013). The chemical structure of tadala?l is shown below: New Q «if t 8 s <\v \ . ‘ t: :e ""1"" "x.- N " as" . _ \N.." \.~ ~~\n ." ' E - ‘‘‘‘‘‘ ,..\ E: = E ~.~""\\vaN\\WM"- _..~5"\ ‘..E‘) ,« ‘\§\I \vf%\ \ .t t .‘ For optimal effectiveness, the PDES inhibitors sildena?l or tadalafil would need to be given long term to Fontan patients to delay or t the onset of failing Fontan circulation. Fontan surgery produces chronic conditions; short term treatment is unlikely to address mortality associated with children having a Fontan surgery when they are an adolescent or adult. This is particularly true as when Fontan failure sets in, there is an inexorable namic and functional decline in the patients leading to death or cardiac transplantation. The early ence with transplantation in patients with Fontan circulation was of high operative mortality and morbidity. The assumption that if a patient survives with a Fontan circulation, then the PVR is low enough for the right ventricle of the graft after cardiac transplantation was found to be incorrect in the early experience of Fontan transplants.

While both sildena?l and tadala?l are known to have undesirable side effects, pulmonary arterial hypertension (PAH) patients switched from sildena?l to tadalafil were found to show signi?cantly different oxygen saturation, significantly different oxygen saturation after a 6-minute walk test, and signi?cantly different distances walked, thus showing that PDES inhibitors are not interchangeable when used to treat heart or cardiovascular conditions. Sabri et al., Pediatr Cardiol., 35(4):699-704 (2014).

II. ound regarding PDES Inhibitors and Udena?l PDE5 is a cyclic ine-3',5'-monophosphate (CGMP)-speci?c phosphodiesterase belonging to a class of phosphodiesterases which regulate s cell functions by catalyzing the hydrolysis of the second messenger molecules (CGMP) and cyclic ine-3',5'-monophosphate (CAMP). l et al., In! ’I J. lmpot. Res, 8:47 . e PDES is present in the arterial wall smooth muscle within the lungs, PDES inhibitors have been explored for the treatment of pulmonary ension, a disease in which blood vessels in the lungs become overloaded with ?uid, usually as a result of failure of the right ventricle of the heart.

Udena?l is a drug used in urology to treat erectile dysfunction. It belongs to a class of drugs called PDES inhibitors, which also includes a?l, tadalafil, and vardena?l. Typical doses are 100 and 200 mg. Udenafll is available in Korea, Russia, and Philippines; in the United States, it is not approved for use by the US. Food and Drug Administration.

The Fontan procedure is palliative, not curative. But in many cases it can result in normal or near-normal growth, development, exercise tolerance, and good quality of life. In 20/30% cases, patients will eventually require heart transplantation.

Modifications in the Fontan operative model was one of the early steps in improving outcome. Use of fenestration, staging of Fontan completion and better perioperative management have led to a icant drop in mortality rates in the current era. Despite this, there is late attrition of patients with complications such as arrhythmias, ventricular dysfunction, and unusual clinical mes of protein-losing enteropathy (PLE) and plastic bronchitis. Management of failing Fontan includes a ed namic and g assessment to treat any correctable lesions such as obstruction within the Fontan circuit, early control of arrhythmia and maintenance of sinus rhythm, symptomatic treatment for PLE and plastic bronchitis, lation of systemic and pulmonary vascular resistance, and Fontan conversion of less favorable atriopulmonary connection to extra-cardiac total cavopulmonary connection with arrythmia surgery. c transplantation remains the only successful definitive palliation in the failing Fontan patients. However, cardiac transplantation is not a perfect solution because the Fontan circulation has already wreaked havoc in the body such as negatively affecting hepatic or kidney function, thus ts with Fontan circulation may still be in poor shape even after a heart transplant.

There is a need in the art for improved ies relating to complications or side effects of the Fontan procedure with the goal of increasing the life span of Fontan patients, and avoiding or delaying the need for cardiac transplantation. There is also a need in the art for improved therapies to delay the onset of c failure or to improve the quality of life for patients who have had the Fontan procedure. The present invention satisfies this need, or at least provides the public with a useful choice.

SUMMARY OF THE INVENTION In one embodiment, the invention is directed to methods of treating, ting, or minimizing conditions, symptoms, or side s associated with a t who has previously had a Fontan procedure. In particular, the methods of the invention are directed the use of udenafil or a pharmaceutically acceptable salt thereof in single cle adolescent patients that have undergone the Fontan procedure for the amelioration of associated acute symptoms and chronic symptom development. The method comprises stering a therapeutically effective amount of a PDE5 tor to the patient, where the PDE5 inhibitor is udenafil or a pharmaceutically acceptable salt f. [0019A] In a particular aspect, the present invention es use of an effective dose of udenafil, or a pharmaceutically acceptable salt thereof in the cture of a medicament for the treatment of a human, who has undergone Fontan palliation for improving the human’s exercise capacity, whose exercise capacity is adversely affected due to a decline in the human’s heart function after Fontan tion, wherein the human is in need of treatment to improve the human’s exercise capacity as determined by maximum oxygen uptake at maximum exercise output (VO2 measurement), n the human has one Fontan surgery, n the human is at least 12 years old, and wherein the medicament is formulated for stration of a total daily dose of undenafil, or a ceutically acceptable salt thereof, from about 125 mg to 175 mg.

In one embodiment, the invention is directed to a method of improving cardiac output in a patient who has had a Fontan procedure. The method ses administering a therapeutically effective amount of a PDE5 inhibitor to the patient, where the PDE5 inhibitor is udenafil or a pharmaceutically acceptable salt thereof.

In another embodiment, the invention is directed to a method of decreasing pulmonary vascular resistance in a patient who has had a Fontan procedure. The method comprises administering a therapeutically effective amount of a PDE5 inhibitor to the patient, where the PDE5 inhibitor is udenafil or a pharmaceutically acceptable salt thereof.

In yet another embodiment, the invention is directed to a method of improving exercise capacity in a patient who has had a Fontan procedure. The method comprises administering a therapeutically effective amount of a PDE5 inhibitor to the patient, where the PDE5 inhibitor is udenafil or a pharmaceutically acceptable salt thereof.

In one embodiment, the invention is directed to a method of improving myocardial performance in a patient who has had a Fontan procedure. The method comprises administering a therapeutically effective amount of a PDE5 inhibitor to the t, where the PDE5 inhibitor is il or a pharmaceutically acceptable salt thereof.

[FOLLOWED BY PAGE 7a] In an exemplary embodiment, the methods of the invention comprise administering a therapeutically ive dose of udenafil, or a pharmaceutically acceptable salt thereof, once a day to a patient.

In another embodiment, the methods of the invention se administering a therapeutically effective dose of udenafil, or a pharmaceutically acceptable salt thereof, twice a day to a patient.

[FOLLOWED BY PAGE 8] In another embodiment, the patient is a pediatric patient of about 2 to about 18 years of age. Treatment of adult patients are also encompassed by the methods of the invention.

In yet another embodiment, the invention is directed to improved methods for treating a patient who has had a Fontan procedure, wherein the methods show an improvement in patient compliance with a dosing schedule of udenafil or a ceutically acceptable salt thereof, as ed to patients prescribed a non- udenafil drug.

In one embodiment, the invention is directed to improved methods for treating a t who has had a Fontan procedure, wherein the methods of the invention result in fewer or less severe adverse events as compared to conventional, methods of treating such patients. In another embodiment, the s of the invention result in few, if any, serious adverse events, moderate adverse , or mild adverse events.

In another ment, the s of the invention result in improved V02 at the patient’s maximal effort as ed to V02 at maximal effort in the absence of the methods of the invention (e.g., in the absence of udena?l administration). For example, the improvement can be about 5, about 6, about 7, about 8, about 9, about 10, about ll, about 12, about 13, about 14, about 15, about 16, about 17, about 18, about 19, about 20, about 21, about 22, about 23. about 24, about 25, about 26, about 27, about 28, about 29, or about 30% or greater as compared to V02 at maximal effort in the absence of the methods of the invention (e.g., in the absence of udena?l administration).

In another embodiment, the methods of the ion result in ed V02 at the patient’s anaerobic threshold as compared to V02 at anaerobic threshold in the absence of the methods of the invention (e.g., in the absence of udenafil administration).

For example, the improvement can be about 5, about 6, about 7, about 8, about 9, about , about 11, about 12, about 13, about 14, about 15, about 16, about 17, about 18, about 19, about 20, about 21, about 22, about 23, about 24, about 25, about 26, about 27, about 28, about 29, or about 30% or greater as compared to V02 at l effort in the absence of the methods of the invention (e.g., in the absence of udenafil administration).

In another embodiment, the methods of the invention result in the patient's blood pool MPI, or other disclosed measures of ventricular performance, ing as compared to blood pool MPI, or other disclosed measures of ventricular mance in the absence of the s of the invention (e.g., in the absence of udenafil administration). For example, the improvement can be about 5, about 6, about 7, about 8, about 9, about 10, about 11, about 12, about 13, about 14, about 15, about 16, about 17, about 18, about 19, about 20, about 21, about 22, about 23, about 24, about 25, about 26, about 27, about 28, about 29, or about 30% or greater as compared to blood pool MPI, or other disclosed measures of cular performance in the absence of the methods of the invention (e.g., in the absence of il administration).

In another ment, the methods of the ion result in the patient's log of reactive hyperemia index, or another disclosed measure of ar function, improving as compared to log of reactive mia index, or another disclosed measure of vascular function, in the absence of the methods of the invention (e.g., in the absence of il administration). For example, the improvement can be about 5, about 6, about 7, about 8, about 9, about 10, about 11, about 12, about 13, about 14, about 15, about 16, about 17, about 18, about 19, about 20, about 21, about 22, about 23, about 24, about 25, about 26, about 27, about 28, about 29, or about 30% or greater as compared to log of reactive hyperemia index, or another disclosed measure of vascular function, in the absence of the methods of the invention (e.g., in the absence of udenafil administration).

Finally, in yet another embodiment, the methods of the invention may result in a characteristic pharmacokinetic profile. The pharmacokinetic profile can comprises a Cmax between 300 and 700 ng/ml, or more specifically, about 500 ng/ml; a Tmax between 1 and 1.6 hr, or more specifically, about 1.3 hr; an AUCt between 2550 and 4150 ng•hr/ml, or more specifically, about 3350 ng•hr/ml; and an 4 between 51 10 and 8290 ng•hr/ml, or more specifically, about 6701 ng•hr/ml. [0033A] In the description in this specification reference may be made to subject matter which is not within the scope of the appended claims. That subject matter should be readily identifiable by a person skilled in the art and may assist in putting into practice the invention as defined in the appended claims.

The foregoing general description and ing detailed description are exemplary and [FOLLOWED BY PAGE 9a] atory and are intended to provide further explanation of the ion as claimed. Other objects, advantages, and novel features will be readily apparent to those skilled in the art from the following brief description of the drawings and detailed description of the invention. [0034A] Unless the context clearly requires otherwise, throughout the description and the claims, the words ‘comprise’, ‘comprising’ and the like are to be construed in an inclusive sense as opposed to an exclusive or exhaustive sense; that is to say in the sense of "including but not limited to". [0034B] In the description in this specification reference may be made to t matter which is not within the scope of the appended claims. That subject matter should be readily identifiable by a person skilled in the art and may assist in putting into practice the invention as defined in the appended .

[FOLLOWED BY PAGE 10] BRIEF DESCRIPTION OF THE DRAWINGS Figure I shows the percentage of subjects who ed at least one, three. or ?ve adverse events by treatment group.

Figure 2 shows change in peak V02 (ml/kg/min) at the maximum effort from baseline (day l) to the last visit (post-medication, day 5) by treatment group, where a positive change indicates an improvement.

Figure 3 shows peak V02 at the maximum effort at baseline (day l) and at the last visit (post-medication, day 5) by treatment group, where a positive change indicates an improvement.

Figure 4 shows change in V02 (ml/kg/min) at anaerobic threshold from baseline (day l) to the last visit (post-medication, day 5) by treatment group, where a positive change tes an improvement.

Figurc 5 shows peak V02 at anaerobic threshold at baseline (day l) and at the last visit medication, day 5) by treatment group, where a positive change indicates an improvement.

Figure 6 shows change in natural log of Reactive Hypcremia Index from baseline (day l) to the last visit (post-medication, day 5) by treatment group. A ve change indicates an improvement.

Figure 7 shows natural log of Reactive Hyperemia Index (RHI) at baseline (day I) and at the last visit (post—medication, day 5) by treatment group. A positive change indicates an improvement.

Figure 8 shows change in blood pool MPI from ne (day l) to the last visit (post-medication, day 5) by treatment group. A negative change indicates an improvement.

Figurc 9 shows blood pool MP1 at baseline (day 1) and at the last visit (post- medication, day 5) by treatment group. A negative change indicates an improvement.

Figure 10 shows change in tissue r MP1 from baseline (day l) to the last visit (post-medication, day 5) by treatment group. A negative change indicates an improvement.

Figure l 1 shows tissue Doppler MPl at baseline (day l) and at the last visit (post- medication, day 5) by treatment group. A negative change indicates an improvement.

Figure 12 shows change in average isovolumic contraction from baseline (day l) to the last visit (post-medication, day 5) by treatment group. A negative change indicates an improvement.

Figure 13 shows average isovolumic contraction at baseline (day 1) and at the last visit (post-medication. day 5) by ent group. A negative change indicates an improvement.

Figure 14 shows change in average umic relaxation from baseline (day l) to the last visit (post-medication, day 5) by treatment group. A ve change indicates an improvement.

Figurc 15 shows average isovolumic relaxation at baseline (day 1) and at the last visit medication, day 5) by treatment group. A negative change indicates an improvement.

Figure 16 shows individual concentration time curves strati?ed by dosing regimens of(A) 37.5 mg q24h, (B) 37.5 mg q12h, (C) 87.5 mg q24h, (D) 87.5 mg q12h, and (E) l25 mg q24h.

Figure 17 shows concentration time concentration pro?les of l in study subjects. The solid line represents the ed data, the dash line stands for the predicted data for the second dose of the day for 12 hour regimens. Data are represented as mean +/— standard deviation.

Figure 18 shows a comparison of Cmax among various dosing regimens. The box and whisker plot showed 10-90 percentile and range of observations with middle line representing median value of a dosing regimen. Signi?cant difference: 37.5 mg q24h vs 87.5 mg q12h, p < 0.001; 37.5 mg q24h vs 125 mg q24h, p < 0.001; 37.5 mg q12h vs 87.5 mg q12h, p < 0.001; 37.5 mg q12h vs 125 mg (12411, p < 0.01; 87.5 mg q24h vs 87.5 mg q12h, p < 0.05.

Figure 19 shows a comparison of (A) AUCr and (B) AUCO-24 among various dosing regimens. The box and whisker plot showed 10-90 percentile and range of observations with middle line representing median value of a dosing regimen. Signi?cant difference: A) 37.5 mg q24h vs 87.5 mg q12h, p <0.001; 37.5 mg q24h vs 125 mg q24h, p < 0.001; 37.5 mg q12h vs 87.5 mg q12h, p < 0.01; 37.5 mg q12h vs 125 mg q24h, p < 0.01; B) 37.5 mg q24h vs 87.5 mg q12h, p < 0.001; 37.5 mg q24h vs 125 mg q24h, p < 0.01; 37.5 mg q12h vs 87.5 mg q12h, p < 0.001; 87.5 mg q24h vs 87.5 mg q12h, p <0.001; 87.5 mg q12h vs 125 mg q24h, p < 0.001.

Figure 20 shows a comparison of A) CL/F and B) V/F among s dosing regimens. The box and whisker plot showed 10-90 percentile and range of observations with middle line representing median value of a dosing regimen. Signi?cant ence: A) 37.5 mg q24h vs 87.5 mg q12h, p <0.05; B) 37.5 mg q24h vs 87.5 mg (11211, p < 0.01.

Figure 21 shows DV (observed concentrations) versus subject ID.

Figure 22 shows time (hours) versus subject ID.

Figure 23 shows DV (observed concentrations) versus time after dose (TAD).

Figure 24 shows DV (observed concentrations) versus time (hours).

Figure 25 shows individual visual plots (SID 1-12) with ion between observed concentration (DV) vs predicted concentration (PRED) and individual predicted (IPRED) error vs time (h).

Figure 26 shows dual visual plots (SID 13-24) with variation between observed tration (DV) vs predicted tration (PRED) and individual predicted (IPRED) error vs time (h).

Figure 27 shows individual visual plots (SID 25-30) with variation between observed concentration (DV) vs predicted concentration (PRED) and individual predicted (IPRED) error vs time (h).

Figure 28 shows a summary of average plasma concentration per time point from pharmacokinctic studies of udcna?l in Fontan’s patients. Data are shown as mean +/- standard deviation.

Figure 29 shows non-compartmental analysis of udena?l in Fonatn’s patients strati?ed by dosing regimens. Data are shown as mean +/- standard deviation.

Figure 30 shows a ss of ?t plot of observed data versus predicted data (DV vs. PRED).

Figure 31 shows a goodness of ?t plot of observed data versus individual predicted data (DV vs. IPRED).

Figure 32 shows a ss of ?t plot of observed data versus predicted data (DV vs. PRED) of the final model.

Figure 33 shows a goodness of ?t plot of observed data versus dual predicted data (DV vs. lPRED) of the ?nal model.

Figure 34 shows teristic Fontan physiology.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS I. Fontan Physiology The Fontan physiology is the de?nitive palliation for those classes of congenital heart defects that share the common feature of a functional single ventricle. They include defects that result in hypoplastic left or right ventricles. Usually through a series of 2 or 3 operations, the systemic and pulmonary circulations are separated to eliminate the mixing of oxygenated and genated blood. This is accomplished by directly attaching the superior and inferior vena cavae to the pulmonary arteries. This results in a logy that works as follows: ( l) the single systemic ventricle pumps oxygenated blood out the aorta to the body’s systemic vascular bed. (2) Next, the systemic venous blood then returns by the vena cavae and ?ows ely through the pulmonary vascular bed without the aid of a lmonary ventricle. (3) Finally, oxygenated blood returns to the common systemic atrium and the cycle is repeated. This anatomy is illustrated in Figure 34.

The Fontan operation, which creates a total cavopulmonary connection, separates the ic and ary ts and eliminates both hypoxemia and ventricular volume overload. However, ing the Fontan operation there is no ventricular pump to propel blood into the pulmonary arteries. Instead blood returns to the lungs via passive ?ow from the systemic veins. Thus, the major logic consequence of this type of palliation is that pulmonary blood flow is completely dependent upon the pressure gradient from the systemic venous bed to the atrium. The normal circulation ?ow through the pulmonary bed is augmented by the sed pressure generated by the right ventricle. In a healthy adolescent, this results in an increase of about 20 to 25 mm Hg in the pressure present in the pulmonary arteries at rest, which may double with se.

With the Fontan physiology, there is no lmonary ventricle and thus no augmentation of pressure as the blood enters the pulmonary arteries. At rest, the pressure nt across the pulmonary vascular bed is signi?cantly less. The ability to increase this pressure gradient with exercise is extremely limited by the body’s ability to tolerate singly elevated l venous pressures.

] As a unique uence of being entirely dependent upon the passive drop in venous pressure to drive pulmonary blood ?ow, the Fontan physiology is exquisitely sensitive to changes in pulmonary vascular resistance. Even ses that are well within the normal range for pulmonary resistance in normal logy will have detrimental effects on the Fontan physiology. Likewise any decrease in resistance, even if this value is already normal, has the potential to augment pulmonary blood flow. For this reason, the use of udenafil offers a potential therapy that is unique to this class of palliated congenital heart defects. Unlike other uses for PDE-5 inhibitors, this therapy would be to lower resistance in a population without elevated pulmonary resistances or pressures. This is a distinctly different use of this class of agents as compared to patients with either structurally normal hearts and pulmonary vascular disease or the very rare patient with congenital heart disease palliatcd with a two ventricle repair (and thus having a sub-pulmonary ventricle) and associated pulmonary vascular disease.

II. Clinical Measurements Relevant to Fontan Patients For children born with functional single cle congenital heart e, the Fontan ure is the current standard of care. The Fontan procedure is palliative, rather than curative, and while it has greatly increased the survival of pediatric subjects with functional single ventricle congenital heart disease, the procedure also results in a series of side effects and complications that can lead to late attrition of patients, with complications such as arrhythmias, ventricular dysfunction, and unusual clinical syndromes of protein-losing cntcropathy (PLE) and plastic bronchitis, as well as hepatic and kidney complications.

In certain embodiments, the disclosed invention relates to improving or preventing the decline of speci?c clinically relevant measurements that are indicative of a patient’s health following a Fontan procedure. Such measurements include, but are not limited to, exercise testing, vascular function testing, and eehocardiographie assessment of ventricular performance.

Exercise Testing Exercise testing can include assessment of V02 values during maximal effort or at anaerobic threshold. V02 max, or maximal oxygen consumption, refers to the maximum amount of oxygen that an individual can utilize during intense se. This measurement is generally considered a reliable indicator of cardiovascular ?tness and aerobic nce. tically, the more oxygen a person can use during high level exercise, the more energy that person can produce. This test is the gold standard for cardiorespiratory fitness because muscles need oxygen for prolonged (aerobic) exercise; blood s oxygen to the s and the heart must pump adequate amounts of blood to meet the s of aerobic exercise.

V02 is often measured by g a mask on a subject, and measuring the volume and gas concentrations of inhaled and expired air. This measurement is often used in both clinical settings and ch and is considered the most te. Testing commonly involves either exercising on a treadmill or riding a bike at increasing intensity until exhaustion, and is designed to provide readings at a l effort of the t and/or at the subject’s anaerobic threshold. ts that have usly undergone a Fontan procedure will generally see a decline in V02 measurements over time. Treating a patient with a method according to the invention such that the patient’s V02 measurement are either ined at a similar level, demonstrating that there has been no further decline in V02 function, or improve with therapy indicates that the treatment is clinically beneficial and may improve or prevent decline in vascular function.

In one embodiment, the invention is directed to a method of improving or maintaining V02 measurements of a t who has usly had a Fontan procedure.

The method comprises administering a therapeutically effective amount of a PDE5 inhibitor to the patient, where the PDE5 inhibitor is udcnafil or a pharmaceutically acceptable salt thereof. In some embodiments, V02 is measured at maximal , while in other embodiments, V02 is measured at the subject’s anaerobic threshold.

In some embodiments, the disclosed methods and compositions are administered to a Fontan patient and result in no decrease, or a minimal decrease, in exercise capacity over time. More specifically, the disclosed methods and compositions may result in a decrease in exercise capacity of less than about 40, less than about 35, less than about 30, less than about 35, less than about 20, less than about 15, less than about 10, or less than about 5% over time. The time period between a first and second measurement used to ate the decrease in exercise capacity can be, for example, about 1, about 2, about 3, about 4, about 5, about 6, about 7, about 8, about 9, about 10, about 1 l, or about 12 months; about 1, about 2, about 3, about 4, about 5, about 6, about 7, about 8, about 9, about 10, about 11, about 12, about 13, about 14, or about 15 years, or any combination thereof, c.g., 1 year, 3 months; 4 years, 7 months, etc.

In some embodiments, the disclosed methods and compositions may be administered to a Fontan patient and result in an improvement of exercise capacity.

More specifically, the disclosed methods and compositions may result in a 1, 2, 5, 10, 15, , 25, 30, 35, 40, 45, or 50% or more improvement in V02 at maximal effort.

Alternatively, the disclosed s and compositions may result in a l, 2, 5, 10, 15, 20, , 30, 35, 40, 45, or 50% or more ement in V02 at the t’s anaerobic threshold. ar Function Testing Vascular endothelial dysfunction is an ant outcome for assessing vascular health in intervention studies. It is now well established that vascular endothelial dysfunction is vely associated with traditional cardiovascular disease (CVD) risk s, and independently ts cardiovascular events over intervals of l to 6 years.

Pulse amplitude tonometry (PAT), a FDA-approved method for assessing vascular function, is increasingly being used as an ative measure of endothelium- dependent dilation in response to reactive hyperemia and flow-mediated dilation (FMD).

The PAT device records digital pulse wave amplitude (PWA) using ?ngertip plethysmography. PWA can be measured continuously during three phases: a quiet baseline period, 5—min forearm occlusion, and reactive hypercmia following cuff release.

Unlike FMD, PAT testing is not dependent upon a highly d technician and post-test analysis is largely automated. Most importantly, at least one longitudinal study has shown that PAT measures of endothelial function predict CVD events over a 6-year follow-up period. These significant advantages may make PAT testing suitable for clinical ce if prognostic significance and reliability can be veri?ed.

Patients that have previously undergone a Fontan procedure will generally see a e in vascular function over time. Treating a patient such that the patient’s vascular function increases or preventing further decline in vascular function would indicate that the treatment is ally ial and may improve patient quality of life or prevent decline in cardiovascular on.

In one ment, the invention is directed to a method of improving or maintaining vascular function of a subject who has previously had a Fontan procedure.

The method comprises administering a therapeutically effective amount of a PDES inhibitor to the t, where the PDES inhibitor is udcna?l or a pharmaceutically acceptable salt thereof. In some embodiments, vascular function is measured using a PAT index.

In some embodiments, the disclosed methods and compositions are administered to a Fontan patient and result in no decrease, or a minimal se. in vascular function over time. Vascular function can be measured using any conventional known technique, including but not limited to pulse amplitude tonometry measurements, the natural log of reactive hypercmia index, Reactive Hyperemia Index, Framingham RH], area under the curve to max-occlusion/control, average up to max-oeelusion/eontrol, and other known EndoPAT indices. In some ments, vascular function is measured using a PAT index. More speci?cally, the disclosed methods and compositions may result in a decrease in ar function of less than about 40, less than about 35, less than about 30, less than about 35, less than about 20, less than about 15, less than about 10, or less than about 5% over time. The time period between a ?rst and second measurement used to calculate the decrease in vascular function can be, for example, about 1, about 2, about 3, about 4, about 5, about 6, about 7, about 8, about 9, about 10, about 1 1, or about 12 months; about 1, about 2, about 3, about 4, about 5, about 6, about 7, about 8, about 9, about 10, about 1 1, about 12, about 13, about 14, or about 15 years, or any combination thereof, e.g., 1 year, 3 months; 4 years, 7 months, etc.

In some embodiments, the disclosed methods and itions may be administered to a Fontan patient and result in an improvement of vaseular function.

Vascular function can be measured using any conventional known technique, ing but not limited to pulse amplitude tonometry measurements, the natural log of reactive hypercmia index, Reactive Hyperemia Index, Framingham RHI, area under the curve to max-oeclusion/control, average up to max-oeclusion/control, and other known EndoPAT indices. In some ments, vascular function is measured using a PAT index. More specifically, the disclosed methods and compositions may result in about a 1, about 2, about 5, about 10, about 15, about 20, about 25, about 30, about 35, about 40, about 45, or about 50% or more improvement in one or more measurements of vascular function, including but not limited to pulse amplitude tonometry measurement, the natural log of reactive hypercmia index, Reactive mia Index, Framingham RH], area under the curve to max-oeelusion/eontrol, average up to max-occlusion/control, and other known EndoPAT indices.

Echocardio 'ra hic Assessment 0 Ventricular Per e Ventricular performance and cardiac contractility are important ements that can reveal impairment of cardiovascular health before overt heart failure is present.

Ventricular performance can be assessed using echocardiographic methods and quanti?ed via a dial performance index or MP1. MP1 is an index that combines systolic and diastolic function. cally, MP1 is de?ned as the sum of isovolumic contraction time and isovolumic tion time divided by the ejection time.

Various versions of MP1 are known in the art, and each version of MP1 may be used to assess ventricular performance. For instance, MPI indiccs may include but are not limited to blood pool MP1, tissue r MP1, average isovolumctric contraction, and average umctric relaxation.

Patients that have previously undergone a Fontan procedure will generally see a decline in ventricular performance over time. Treating a t such that the patient’s ventricular performance is ined, exhibits minimal decrease over time, or increases indicates that the treatment is clinically bene?cial and may improve patient quality of life or prevent decline in cardiovascular function.

In one embodiment, the invention is directed to a method of maintaining, producing a minimal decrease in, or increasing ventricular mance of a subject who has previously had a Fontan procedure. The method comprises administering a therapeutically effective amount of a PDE5 inhibitor to the patient, where the PDES inhibitor is udena?l or a pharmaceutically acceptable salt thereof. In some embodiments, ventricular performance is ed using a myocardial performance index (MP1). In some embodiments, the MPI may be a blood pool MP1, while in otherembodiments the MPI may be a tissue doppler MP1.

In some embodiments, the sed methods and compositions may be administered to a Fontan patient and result in minimal or no decrease in ventricular performance over time. Ventricular performance can be measured using any tional known technique, including but not limited to myocardial performance index (MP1), blood pool MP1, tissue doppler MPI, average isovolumctric contraction and relaxation, and other known ventricular performance s. More speci?cally, the disclosed methods and compositions may result in a decrease in ventricular performance of less than about 40, less than about 35, less than about 30, less than about 35, less than about 20, less than about 15, less than about IO, or less than about 5% over time. The time period between a first and second measurement used to calculate the decrease in ventricular mance can be, for example, about 1, about 2, about 3, about 4, about 5, about 6, about 7, about 8, about 9, about 10, about 1 1, or about 12 months; about 1, about 2, about 3, about 4, about 5, about 6, about 7, about 8, about 9, about 10, about 11, about 12, about 13, about 14, or about 15 years, or any combination thereof, e.g., 1 year, 3 months; 4 years, 7 months, etc.

In some embodiments, the disclosed methods and compositions may be administered to a Fontan patient and result in an improvement of ventricular performance over time. Ventricular performance can be measured using any conventional known technique, including but not limited to myocardial mance index (MP1), blood pool MP1, tissue doppler MP1, average isovolumetric contraction and relaxation, and other known ventricular performance indiccs. For e, the disclosed methods and compositions may result in about a 1, about 2, about 5, about 10, about 15, about 20, about 25, about 30, about 35. about 40, about 45, or about 50% or more improvement in ventricular mance, as measured by any known technique, including but not limited to myocardial performance index (MP1), blood pool MP1, tissue doppler MP1, average isovolumetric contraction and relaxation, and other known ventricular performance indiccs.

III. s ing to the Invention In one embodiment, the invention is directed to methods of treating, preventing, or minimizing conditions, symptoms, or side effects associated with a subject who has previously had a Fontan procedure. The method comprises administering a therapeutically effective amount of a PDE5 tor to the patient, where the PDE5 inhibitor is udenaftl or a pharmaceutically acceptable salt thereof.

In the Fontan circulation, pulmonary blood flow is e, driven by the pressure difference between the systemic venous circulation and the ventricular end-diastolic re. A medication capable of allowing for more ef?cient t of blood through the pulmonary vascular bed can allow for ement in cardiac preload, and therefore improve cardiac output. l’DES tors are a class of tions that reduce ary vascular resistance and improve ventricular mance in patients with pulmonary hypertension and myocardial dysfunction.

Some studies have ted the single-use or longer-term use of sildena?l in children and young adults who have had the Fontan procedure. However, sildenafil has a short half-life, and is typically administered three to four times per day. Such an administration schedule is not convenient and is likely to reduce patient compliance. In addition, the administration of a short half-life drug results in greater ?uctuations of therapeutic levels of drug, increasing the risk that the blood level of the PDES tor will drop below the therapeutically effective level for parts of the day. The present inventors hypothesize that administration of a PDES tor having a longer half—life to patients who have had the Fontan procedure will prevent or ameliorate the decline in aerobic exercise performance in patients following the Fontan procedure.

Patient compliance is al for optimal therapeutic ef?cacy, particularly for a drug that is to be taken daily for an extended period of time, such as for several years or more. This is ularly true for Fontan patients. In particular, individuals that had the Fontan procedure most often die from heart e, stroke bosis), or some unexplained sudden death. Of note is the fact that the risk of death from heart failure is quite low within 10 years of the Fontan procedure but increases with time after 10 years post-Fontan. http://bendantzer.wordprcss.com/2013/03/13/fontan—circulation-success-or— failure/.

Not surprisingly, as time passes from the date of the Fontan ure, the risk of death or need from a heart transplant increases. This could be from some sudden death or heart failure, but it could also be from a gradual decline in heart function. As the years tick by after the Fontan procedure, heart function gets worse, which is reflected in the decline in the ability to do aerobic exercise. For example, for patients that had the Fontan early in life, they may have exercise capacity that is highly reduced (44%) compared to normal patients and this capacity to do exercise tends to decline in a linear fashion each year (declines 2.6% each year). At thirty years of age, patients with Fontan circulation have much reduced exercise capacity (55% less than normal) and the number of health problems and hospitalization rates increase dramatically. This is probably not surprising since, again, one ventricle is doing the work of two. Thus, methods according to the invention which can diminish or signi?cantly decrease decline in heart function over time, are highly desirable for Fontan patients. Key to the success of such methods is patient compliance with a preferred dosing le.

Patient compliance, or lack thereof, to a prescribed dosing le is known to be a critical factor in the success of any therapy. In particular, quality healthcare outcomes depend upon patients' adherence to recommended treatment ns. Patient nonadhcrence can be a pervasive threat to health and wellbeing and carry an appreciable economic burden as well. In some disease ions, more than 40% of patients sustain signi?cant risks by misunderstanding, forgetting, or ignoring healthcare advice.

Moreover, when preventive or treatment regimens are very complex and/or require yle changes and the modi?cation of ng habits, nonadhcrence can be as high as 70%. Martin et al., The): Clin. Risk Manag., 1(3): 189—199 (2005) ("A significant barrier to effective medical ent, however, is the patient's failure to follow the recommendations of his or her physician or other healthcare provider."). Thus, a therapy that can produce the desired results (e.g., improved cardiac output, sed ary vascular resistance, improved exercise capacity, improved myocardial performance, preventing or ameliorating the decline in aerobic exercise performance), with a preferred once or twice a day dosage, as ed to multiple daily dosages — e.g., 3 to 6x daily - required to be taken at least 4 to 6 hours apart, such as with sildena?l, is highly desirable.

Such a more simplistic dosing regimen is likely to lead to a signi?cant increase in patient compliance, and itant improved therapeutic results.

In one embodiment, the invention is directed to a method of ing c output in a patient who has had the Fontan procedure, the method sing administering a therapeutically effective amount of the PDE5 inhibitor udena?l, or a pharmaceutically acceptable salt thereof, to the patient. For example, the method of the invention can result in an improvement in c output, as compared to a subject who is not administered udenafil, of about 5%, about 8%, about 10%, about l5%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, or about 50%.

In another embodiment, the invention is directed to a method of decreasing pulmonary vascular resistance in a patient who has had the Fontan procedure, the method comprising administering a therapeutically effective amount of the PDES inhibitor udenafrl, or a pharmaceutically acceptable salt thereof, to the t. For example, the method of the invention can result in an decreased pulmonary vascular resistance, as compared to a subject who is not administered il, of about 5%, about 8%, about %, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, or about 50%.

In yet another embodiment, the invention is directed to a method of improving exercise capacity in a patient who has had the Fontan procedure, the method comprising administering a therapeutically effective amount of the PDES inhibitor udenafil, or a pharmaceutically acceptable salt thereof, to the patient. For example, the method of the ion can result in an increase in exercise capacity measured by maximal V02, as compared to a t who is not administered il, of about 5%, about 8%, about %, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, or about 50%.

In one embodiment, the invention is directed to a method of improving myocardial mance in a patient who has had the Fontan procedure, the method comprising administering a therapeutically effective amount of a PDES inhibitor to the patient. For example, the method of the invention can result in an improvement in myocardial performance, as compared to a subject who is not administered udena?l, of about 5%, about 8%, about 10%, about 15%, about 20%, about 25%, about 30%, about %, about 40%, about 45%, or about 50%.

In one embodiment, the ion is directed to a method of preventing or ameliorating the decline in aerobic exercise performance in a patient who has had the Fontan procedure, the method comprising administering a therapeutically effective amount of the PDES inhibitor udenafil, or a ceutically acceptable salt thereof, to the patient. For example, the method of the invention can result in an amelioration of the decline in aerobic se mance measured by maximal V02, as compared to a subject who is not administered udena?l, of about 5%, about 8%, about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, or about 50%.

In yet another embodiment, the invention is ed to improved s for treating a patient who has had a Fontan procedure, wherein the methods show an improvement in patient compliance with a dosing le of udcna?l or a pharmaceutically acceptable salt thereof, as compared to patients prescribed a non- udena?l drug.

Udenafil has a half-life of 7.3—12.1 hours, and is believed to possibly have a much better safety pro?le as compared to sildenafil or tadala?l. Udenafil has unique properties, with a Tmnx of l.0—l.5 h and a Tug of l 1—13 h (a relatively rapid onset and a long duration of action). Therefore, both and and once-daily use of udena?l have been reported. Udenafil’s ef?cacy and tolerability have been ted in several studies, and recent and continuing s have demonstrated udena?l’s promise in both dosing regimens. Presently, tadala?l is the only FDA-approved drug for daily dosing, but udena?l can be used as a once—daily dose for erectile dysfunction patients who cannot tolerate tadala?l due to phosphodiesterase subtype ivity. Gu Kang ct al., Ther. Adv. Urol., 5(2): 101—] 10 (20] 3). Once-daily dosing of udena?l was evaluated for the treatment of erectile dysfunction (ED), and the results showed that udenafll significantly improved erectile function among ED patients when administered in doses of 50 mg or 75 mg once daily for 12 wk. Zhao et al., Eur. .1. /ogr, ()0: 380—387 (201 1). While these reports suggest that rl may be useful as a once a day therapy for various conditions, other reports show that PDE5 inhibitors show varying ef?cacy in treating symptoms associated with the Fontan operation. Sabri et al., Pedialr. Cardiol., (4):699-704 (2014).

Thus, it was surprising that the present invention. directed to methods of treating, zing, and/or preventing symptoms associated with the Fontan operation comprising administering udenafil or a pharmaceutically acceptable salt f, shows desirable results, ably with a once or twice a day dosage. "Desirable s" e, but are not limited to, improved cardiac output, decreased pulmonary vascular resistance, improved exercise capacity, improved myocardial performance, preventing or ameliorating the decline in aerobic exercise performance, and/or an improvement in t compliance.

In one embodiment of the invention, once a day stration of a therapeutically ive dosage of uldenafil, or a pharmaceutically acceptable salt thereof, results in therapeutic levels of uldenafil, present in the patient’s blood stream, for up to about 8 hours. In other embodiments of the invention. once a day administration of a therapeutically effective dosage of uldena?l, or a pharmaceutically acceptable salt thereof, s in therapeutic levels of uldena?l, t in the patient’s blood stream, for up to about 10, about 11, about 12, about 13. about 14, about 15, about 16, about 17, about 18, about 19, about 20, about 21, about 22, about 23, or about 24 hours.

In one embodiment of the invention, twice a day administration ofa therapeutically effective dosage of udena?l, or a pharmaceutically acceptable salt thereof, results in eutic levels of udcna?l for at least about 16 hours in a 24 hour dosing period. In other ments, twice a day administration of a therapeutically effective dosage of udenafil, or a pharmaceutically acceptable salt thereof, results in therapeutic levels of udena?l for at least about 9 hours, about 10 hours, about 11 hours, about 12 hours, about 13 hours, about 14 hours, about 15 hours, about 16 hours, about 17 hours, about 18 hours, about 19 hours, about 20 hours, about 21 hours, about 22 hours, about 23 hours, or about 24 hours, in a 24 hour dosing period.

In another embodiment, it was surprising that that the methods of the invention show improved results as compared to prior art treatments using a non-udenafil PDES inhibitor. such as sildcnafil or tadala?l. In yet another embodiment, it was sing that the methods of the ion show fewer side effects, and/or less severe side effects, as ed to prior art treatments using a non-udena?l PDES inhibitor, such as sildenafil or tadala?l.

In one embodiment, it is surprising that the administration of twice a day udenafil or a pharmaceutically acceptable salt thereof results in fewer side effects than the administration of once a day udcnafil or a pharmaceutically acceptable salt thereof. In another embodiment, it is surprising that twice a day administration of udena?l or a pharmaceutically acceptable salt thereof can achieve therapeutically ive levels of udena?l at a lower total daily dosage than a once a day administration.

In one embodiment, the patient who has had the Fontan procedure is a human patient. In one embodiment, the patient is an adult human patient over about 18 years of age. In another embodiment, the patient is a pediatric patient of about 2 to about 18 years of age. In another embodiment, the patient is a pediatric patient of about 12 to about 18 years of age, or from about 12 to about 16 years of age.

IV. Pediatric ts Treatment of pediatric patients ts particular challenges, as pediatric physiology is not just a miniature version of an adult. Physical size is just one of the many differences. Children's body surface area, organ and system maturity and function, as well as ive and nal development can result in differences in response to illness, diagnosis, treatment, and medications. Even illnesses that are seen in adults can act differently in children because of their unique anatomy and physiology. Moreover, pediatric patients process drugs differently than adults, and ore the effects as well as the dosages of drugs may vary widely from those observed with adults. Since children differ from adults in many ways beyond size, simply adjusting the dose of a drug for a smaller size person will not necessarily produce the same response and can lead to adverse drug reactions. Thus, the effectiveness of a drug used in treating an adult condition does not with certainty predict success of treating a pediatric patient with the same drug.

Thus, the invention is also ed to the surprising ery that pediatric Fontan patients can be successfully treated with the methods of the invention. The methods se administering a therapeutically effective amount of a PDES inhibitor to the pediatric patient, where the PDES inhibitor is udenafil or a pharmaceutically acceptable salt thereof.

The structure of udenafil is shown below: 32.," \\c?‘p" s ,x"\\ \ flz\ 2‘ , Ma" HN‘ \‘ V. Doses and Dosage Forms In one embodiment, the udenafil or a pharmaceutically acceptable salt thereof is administered at total daily dosage amounts of about 0.01 to about 150 mg/kg. In another embodiment, the udcna?l or a pharmaceutically acceptable salt thereof is stered at total daily doses of about 0.01 mg/kg up to about 30 mg/kg. In another embodiment, the udena?l or a pharmaceutically able salt thereof is stered at total daily doses of about 5 mg, about 10 mg, about 15 mg, about 20 mg, about 25 mg, about 27.5 mg, about 30 mg, about 32.5, about 35 mg, about 37.5 mg, about 40 mg, about 42.5 mg, about 45 mg, about 47.5 mg, about 50 mg, about 55 mg, about 60 mg, about 65 mg, about 70 mg, about 75 mg, about 80 mg, about 85 mg, about 87.5 mg, about 90 mg, about 95 mg, about l00 mg, about 125 mg, about 150 mg, about 175 mg, about 200 mg, about 225 mg, about 250 mg, or about 275 mg. In one embodiment, the udcna?l or a pharmaceutically acceptable salt thereof is administered in total daily doses of about 25 mg, about 37.5 mg, about 50 mg, about 75 mg, about 87.5 mg, 125 mg, about 175 mg, about 200 mg, about 225 mg, about 250 mg, about 275 mg, about 300 mg, about 325 mg, about 350 mg, about 375 mg. about 400 mg, about 425 mg, about 450 mg, about 475 mg, about 500 mg, about 525 mg, about 550 mg, about 575 mg, about 600 mg, about 625 mg, about 650 mg, about 675 mg, or about 700 mg. In another particular embodiment, udena?l or a pharmaceutically acceptable salt thereof is administered at a total daily dose of about 37.5 mg, about 75 mg, about 87.5 mg, 125 mg, or about 175 mg.

In one embodiment, the udenafil or a pharmaceutically acceptable salt thereof is administered once a day.

In another embodiment, the udena?l or a pharmaceutically acceptable salt thereof is administered twice a day. In one embodiment, the udena?l or a pharmaceutically acceptable salt thereof is administered twice a day such that therapeutically effective blood levels are maintained for at least about 18, about 19, about 20, about 21, about 22, about 23 or about 24 hours of a 24 hour dosing period. In some ments, the total daily dosage amount of udenafil or a pharmaceutically acceptable salt administered twice a day is less than the total daily dosage amount of udenafil or a pharmaceutically acceptable salt thereof stered once a day. In some embodiments, the total daily dosage amount of udena?l or a pharmaceutically acceptable salt thereof administered twice a day, maintains therapeutically effective blood levels for the same number of hours in a 24 hour period as a higher dosage of udena?l or a pharmaceutically able salt thereof when administered once a day. In other embodiments, the total daily dosage amount of udenafil or a pharmaceutically acceptable salt thereof administered twice a day, maintains therapeutically effective blood levels for a higher number of hours in a 24 hour period as the same dosage of udenafil or a pharmaceutically acceptable salt thereof when administered once a day.

In some embodiments, the udenafil or a pharmaceutically acceptable salt thereof administered twice a day produces a r reduction in the conditions, symptoms, or side effects associated with a subject who has previously had a Fontan procedure, when compared to udena?l or a pharmaceutically acceptable salt thereof administered once a In some embodiments, the pharmaceutically acceptable salt of udenafil is an acid addition salt. In one embodiment, the acid addition salt of udena?l is an inorganic acid addition salt such as, hloric, hydrobromic, sulfuric, or phosphoric acid addition salt. In another embodiment, the acid addition salt is an organic acid addition salt such as citrate, tartarate, acetate, lactate, maleate, fumarate, gluconate, methanesulfonate (mesylate), ate, succinate, p—tolucnesulfonate ate), galaeturonate, te, ate, aspartate, oxalate, sulfonate, camphorsulfonatc, einnamate, adipate, or cyclamate. In a ular embodiment, the pharmaceutically acceptable salt of udenafil is an oxalate, benzensulfonate, camphorsulfonatc, einnamate, e, or cyclamate salt.

In one embodiment the udenafil or a pharmaceutically acceptable salt thereof is administered as a pharmaceutical ition. In one embodiment, the pharmaceutical composition comprising udenafil or a pharmaceutically able salt thereof can be formulated in a wide variety of oral or parenteral dosage forms on clinical application.

Each of the dosage forms can contain various disintegrating agents, surfactants, ?llers, thickcncrs, binders, diluents such as wetting agents or other pharmaceutically acceptable excipicnts.

The udenafil composition can be administered using any pharmaceutically acceptable method, such as asal, , sublingual, oral, rectal, ocular, parenteral (intravenously, intradcnnally, intramuscularly, subcutaneously, intracisternally, intraperitoneally), pulmonary, intravaginal, locally administered, topically administered, topically administered after scari?cation, mucosally administered, via an aerosol, or via a buccal or nasal spray formulation.

Further, the udena?l composition can be formulated into any pharmaceutically acceptable dosage form, such as a solid dosage form, tablet, pill, lozenge, e, liquid dispersion, gel, aerosol, pulmonary l, nasal aerosol, ointment, cream, semi-solid dosage form. and a suspension. Further, the ition may be a controlled release formulation, sustained release formulation, immediate release formulation, or any combination thereof. Further, the ition may be a transdcrmal delivery .

In another embodiment, the pharmaceutical composition comprising udenafil or a pharmaceutically able salt thereof can be formulated in a solid dosage form for oral administration, and the solid dosage form can be powders, granules, es, tablets or pills. In yet another embodiment, the solid dosage form can include one or more excipicnts such as calcium carbonate, starch, sucrose, lactose, microcrystalline cellulose or gelatin. In addition, the solid dosage form can include, in addition to the excipicnts, a lubricant such as talc or magnesium stearate. In some ments, the oral dosage form can be immediate release, or a modified release form. Modi?ed release dosage forms include controlled or extended release, c release, and the like. The excipients used in the modified release dosage forms are commonly known to a person of ordinary skill in the art.

In a r embodiment, the pharmaceutical composition comprising udenafil or a pharmaceutically able salt thereof can be formulated as a sublingual or buccal dosage form. Such dosage forms comprise sublingual tablets or solution compositions that are administered under the tongue and buccal tablets that are placed between the cheek and gum.

In yet a further embodiment, the pharmaceutical composition comprising udenafil or a pharmaceutically acceptable salt thereof can be formulated as a nasal dosage form.

Such dosage forms of the present invention comprise solution, suspension, and gel itions for nasal delivery.

In one embodiment, the pharmaceutical ition can be formulated in a liquid dosage form for oral administration, such as suspensions, emulsions or syrups. In other embodiments, the liquid dosage form can include, in addition to commonly used simple diluents such as water and liquid paraffin, various excipicnts such as humeetants, sweeteners, aromatics or preservatives. In particular embodiments, the composition comprising udenafil or a pharmaceutically acceptable salt thereof can be formulated to be le for administration to a pediatric patient.

In one embodiment, the pharmaceutical ition can be formulated in a dosage form for eral administration, such as sterile aqueous solutions, suspensions, emulsions, non-aqueous solutions or itories. In other embodiments, the non- aqueous solutions or suspensions can include propyleneglycol, polyethyleneglycol, vegetable oils such as olive oil or injectable esters such as ethyl oleate. As a base for suppositories, witepsol, macrogol, tween 61, cacao oil, laurin oil or glycerinated gelatin can be used.

The dosage of the pharmaceutical composition can vary depending on the patient's weight, age, gender, administration time and mode, excretion rate, and the severity of disease.

V1. Adverse Events Adverse events are an important eration, ularly when treating a susceptible population such as pediatric ts with Fontan physiology. PDE—S inhibitors may produce adverse events ing eye and/or hearing issues. Therefore, developing methods in which PDE-S inhibitors such as udcnafil or a pharmaceutically acceptable salt thereof can safely be administered to pediatric patients is one aspect of the invention.

In some embodiments, a pediatric patient with Fontan physiology may be administered a PDE-S inhibitor to treat, minimize, and/or prevent the deleterious effects of Fontan physiology. In some ments, administering the PDE-S inhibitor, speci?cally udenafil or a pharmaceutically acceptable salt thereof, results in l if any serious adverse events. In other embodiments, administering the PDE-S inhibitor, speci?cally udenafil or a ceutically able salt thereof, results in minimal if any unexpected adverse events.

In some embodiments, a pediatric patient with Fontan physiology being administered udena?l or a pharmaceutically acceptable salt thereof may experience only mild e events related to the medication, and in other ments, the patient may experience only moderate adverse events related to the medication. In some embodiments, a pediatric patient with Fontan physiology being administered udenafll or a pharmaceutically acceptable salt thereof may experience fewer, less frequent. or less severe adverse events compared to a Fontan patient receiving another PDE-S inhibitor.

Vll. Pharmacokinetic Parameters Pharmacokinetics refers to the absorption, distribution, metabolism, and excretion of a drug once it has been administered to a subject. The kinetics of a drug have an impact on the drug’s efficacy and toxicity. A given drug’s kinetic pro?le can depend not Only on the compound itself, but also on the size of the dose and the dosing regimen as well as how the drug is formulated and stered. Pharmacokinetic parameters that may be useful in determining clinical utility include but are not limited to plasma concentration, plasma concentration over time, maximum plasma tration (Cum). time to reach maximum concentration (Tnm), area under concentration time curve within the dosing interval (AUCI),daily area under concentration time curve at steady state (AUCugi); CL/F, apparent clearance; V/F, apparent volume of distribution; ke, elimination rate constant; Tl/2, al half-life.

In some embodiments, the disclosed invention is directed to methods of administering udena?l or a pharmaceutically acceptable salt thereof to a patient with Fontan physiolog, in a unique pharmacokinetic , wherein the administration results e. For instance, in some embodiments the disclosed s can produce plasma concentrations of udena?l ranging from about 10 to about 700 ng/ml, about 50 to about 650 ng/ml, about 100 to about 600 ng/ml, about 150 to about 550 ngml, or about 200 to about 500 ng/ml. 111 other words, dosing regimens of the disclosed methods may result in sustained plasma concentrations of udenafll above 25, 50, 75, 100, 125, 150, 175, 200, 225, 250, 275, 300, 325, 350, 0,425, 450, 475, 500, 525, 550, 575,600, 625, 650, 675, or 700 ng/ml. In some ments, the plasma concentration is maintained above about 140 ng/ml.

In some embodiments, the disclosed s include a characteristic pharmacokinetic pro?le in which the Cmax is about 25, about 50, about 75, about 100, about 125, about 150, about 175, about 200, about 225, about 250, about 275, about 300, about 325, about 350, about 375, about 400, about 425, about 450, about 475, about 500, about 525, about 550, about 575, about 600, about 625, about 650, about 675, or about 700 ng/ml. In some embodiments, the Cmax is about 506.

In some embodiments, the disclosed s include a characteristic pharmacokinetic pro?le in which the Tmax is about 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1.0, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 2.0, 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8, 2.9, or 3.0 hours (hr). In some embodiments, the Tmax is about 1.3 hr.

In some embodiments, the disclosed methods include a characteristic pharmacokinetic pro?le in which the area under the curve (AUC) is unique to a eutically effective dose of udenafil in a Fontan’s patient. For instance AUCI is between 750 and 4500 ng°hr/m1, 800-4000 ng°hr/ml, or 850-3500 ng°hr/ml. More speci?cally AUCI is about 750, about 800, about 850, about 900, about 950, about 1000, about 1050, about 1100, about 1150, about 1200, about 1250, about 1300, about 1400, about 1500, about 1600, about 1700, about 1800, about 1900, about 2000, about 2100, about 2200, about 2300, about 2400, about 2500, about 2600, about 2700, about 2800, about 2900, about 3000, about 3100, about 3200, about 3300, about 3400, about 3500, about 3600, about 3 700, about 3 800, about 3 900, about 4000, about 4100, about -3 2- 4200, about 4300, about 4400, or about 4500 ng-hr/ml. In some embodiments, the AUCI is about 3350.

In some embodiments, AUC0.24 is between 750 and 8500 ng-hr/ml, 800-8000 ng-hr/ml, or 850-7500 ngohr/ml. More speci?cally AUCo.24 is about 750, about 800, about 850, about 900, about 950, about 1000, about 1050, about 1100, about 1150, about 1200, about 1250, about 1300, about 1400, about 1500, about 1600, about 1700, about 1800, about 1900, about 2000, about 2100, about 2200, about 2300, about 2400, about 2500, about 2600, about 2700, about 2800, about 2900. about 3000, about 3100, about 3200, about 3300, about 3400, about 3500, about 3600, about 3700, about 3800, about 3900, about 4000, about 4100, about 4200, about 4300, about 4400, about 4500, about 4600, about 4700, about 4800, about 4900, about 5000, about 5100, about 5200, about 5300, about 5400, about 5500, about 5600, about 5700, about 5800, about 5900, about 6000, about 6100, about 6200, about 6300, about 6400, about 6500, about 6600, about 6700, about 6800, about 6900, about 7000, about 7100, about 7200, about 7300, about 7400, about 7500, about 7600, about 7700, about 7800, about 7900, about 8000, about 8100, about 8200, about 8300, about 8400, or about 8500 ng°hr/ml. In some embodiments, the AUC0-24 is about 6700.

In some embodiments, the pharmacodynamics results of administering udenafil to a t with Fontan’s logy can be uted to the characteristic pharmacokinctic pro?le of the drug administration or regimen.

V111. De?nitions As used herein, the term "about" will be understood by persons of ordinary skill in the an and will vary to some extent depending upon the context in which it is used. If there are uses of the term which are not clear to persons of ordinary skill in the art given the context in which it is used, "about" will mean up to plus or minus 10% of the particular term.

"A treatment" is intended to target the disease state and combat it, i.e., ameliorate or t the e state. The particular treatment thus will depend on the disease state to be targeted and the current or future state of medicinal therapies and therapeutic approaches. A treatment may have associated toxicities.

The terms "administration of or "administering" an active agent should be understood to mean providing an active agent of the invention to the subject in need of treatment in a form that can be introduced into that individual's body in a therapeutically useful form and therapeutically effective amount.

The term "therapeutically effective amount" refers to a sufficient quantity of the active agents of the present invention, in a suitable composition, and in a suitable dosage form to treat or prevent the symptoms, progression, or onset of the complications seen in patients who have had the Fontan procedure. The therapeutically effective amount will vary depending on the state of the patient’s condition or its severity, and the age, weight, etc., of the subject to be d. A therapeutically effective amount can vary, depending on any of a number of factors, including, e.g., the route of administration, the condition of the subject, as well as other factors understood by those in the art.

The term "treatment" or "treating" lly refers to an intervention in an t to alter the natural course of the subject being treated, and can be performed either for prophylaxis or during the course of clinical pathology. Desirable effects include, but are not limited to, preventing occurrence or recurrence of disease, alleviating ms, suppressing, diminishing or inhibiting any direct or indirect pathological consequences of the e, ameliorating or palliating the disease state, and g remission or improved prognosis.

The terms "individual," "host." "subject," and "patient" are used interchangeably herein.

As used herein, ving cardiac output" means an increase in the volume of blood pumped by the heart. The c output is ly measured as a function of the oxygen consumption.

As used , the term "exercise capacity" refers to the m amount of physical exertion that a patient can sustain. Exercise capacity can be measured by a number of different clinical methods, including by interview or by direct measurement.

The present methods include different methods of measuring exercise capacity, including but not d to, riding a cycle ergomctcr or walking on a treadmill. Thus, the term "improving exercise capacity" means increasing the ability of the patient to m any level of al exertion or exercise.

As used herein. the term "decreasing pulmonary vascular resistance" refers to decreasing or reducing the resistance offered by lung vasculature to blood flow.

As used herein, "improving dial mance" refers to an increase or decrease, as the case can be, in speci?c heart function measurements, including but not limited to, speci?c electrocardiographic readings, rdiographic gs, cardiac output measures, heart rate, systolic or diastolic pressure, forced vital capacity, oxygen saturation, and respiratory rate.

As used herein, ic exercise performance" refers to the ability of a t to perform a speci?ed aerobic exercise.

As used herein, "pediatric" refers to a population of subjects ranging between a newborn and about 18 years of age. A pediatric subject can e a subject that begins a course of ent with the disclosed compositions or according to the disclosed methods prior to turning about 18 years of age, even if the subject continues treatment beyond 18 years of age. More speci?cally, within the population of "pediatric" subjects, neonates may be de?ned as 1 week to l month in age, infants may be I to less than 2 years of age, toddlers may be 2 to less than 6 years of age, and school age may refer to subjects 6—18 years of age.

] The following examples are given to illustrate the present invention. It should be understood, however, that the invention is not to be limited to the speci?c conditions or s described in these examples. All printed publications referenced herein are speci?cally incorporated by reference.

Examples Example 1 — Phase l/ll Pharmacokinetic and Pharmacodynamic Study A Phase l/ll dose escalation trial of Udena?l in adolescents with single ventricle physiology after Fontan palliation was conducted.

The trial was conducted over a 5 month period, with an additional 3 month -up period for adverse events (AB). The 36 subjects enrolled in the trial were comprised of 6 cohorts, as described in Table 1.

Table 1 - Dose escalation desi_n _ Cohort 6 37 5 mg 37.5 mg 87 5 mg 87.5 mg Control ‘ dail twice dail dail twice dail dail (no dru_) 6 6 The goals for this trial were to assess the safety of udenafil at multiple dose levels over a ?ve-day period, the pharmacokinetic pro?le of udena?l in adolescents with Fontan physiology, and the short-term effect of udena?l on codynamic es of exercise capacity, ventricular performance, and vascular function. le doses of udena?l or a pharmaceutically acceptable salt thereof were administered to male and female Fontan patients who are 14-18 years of age.

Inclusion Criteria for the trial were: 0 Males and females with Fontan physiology who are 14-18 years of age. 0 Willingness to return to center to complete blood draws and exercise tests as described in the study protocol. 0 Patients must agree to abstain from alcohol, caffeinated beverages, and ruit juice for the duration of the trial. 0 Informed assent from subject and informed consent from parent/legal an as appropriate.

Exclusion Criteria for the study include: o Non-cardiac l, psychiatric, and/or social disorder that would prevent successful completion of planned study testing or would invalidate its results. 0 Height <1 32 cm (minimum height requirement for exercise stress testing). 0 Known Fontan baf?e obstruction, branch pulmonary artery stenosis, or pulmonary vein is resulting in a mean gradient of >4 mmHg between the regions proximal and distal to the obstruction. 0 Single lung physiology. 0 Severe ventricular dysfunction or valvular regurgitation (systemic atrioventricular or semilunar valve) determined from review of the echocardiogram performed in closest ity to study enrollment. 0 Signi?cant renal (serum nine > 2.0), hepatic (serum AST and/or ALT > 3 times upper limit of normal), gastrointestinal or biliary disorders that could impair absorption, metabolism or excretion of orally administered medications, based on laboratory assessment at the time of screening visit. 0 Hospitalization for acute decompensated heart failure within the 12 months ing study screening. 0 A diagnosis of active protein-losing enteropathy or plastic bronchitis. 0 Active evaluation or g for heart transplant. 0 History of use of a PDES inhibitor within three months of study screening. 0 Concurrent illness that, in the opinion of the investigator, precludes participation. 0 Current therapy with alpha-blockers or nitrates. 0 Pregnancy at the time of enrollment. o Latex allergy.

Table 2 presents baseline characteristics of 36 enrolled subjects — in aggregate (2nd column) and for each of the 6 individual cohorts. Median age of ed subjects is 16 years (with the range from 14 to 18 years), 58% were male, 78% were white and 6% were Hispanic. There were no signi?cant ences in ne characteristics among the cohorts (right column).

Table 2 - Baseline Characteristics for Enrolled Subjects Exercise 87.5 mg testing Overall . twice daily only Characteristic N=36 V=6 V=6 Median 16(15, [7) 16(15, [6) 16(16, 17) 15(14, [6) 15(14, 17) 17(16, 18) 16(15, [7) 0.309 (lnterquanile Rane) 3%) 4(66.7%) 3(50.0%) 3(50.0%) 3(50.0%) 4(66.7%) 4(66.7%) m -2(5.7%) [(16.7%) %) 0(0.0%) 0(0.0%) 0(0.0%1 ) 1.000 Latino/Latina Table 2 - Baseline Characteristics for Enrolled Subjects Exercise testing Overall . twice daily Characteristic N=36 )I' White/Caucasian 28 (77.8%) 3(50.0%) 4(66.7%) 6(100.0%) 6(100.0%) 4(66.7%) %) Black/African 3 (8.3%) 2 (33.3%) 1 (16.7%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) American Other/Unknown 4(11.1%) 106.7%) l(l6.7%) 0(0.0%) ) [(16.7%) l(l6.7%) [Ieight,cm 165.7:t10.l 12.9 164.9:t:lO.9 l68.6:t7.8 l64.7il4.2 171.3:73 163.666 05 M _62.4t15.9 _56.3:t:7.7 66.8tll.0 _6l.9t9.0 54.9:168 0.4Ix) ‘II Body mass 20.8132 21614.8 203:4.8 0.157 index. k m‘ *P-values for continuous les were calculated by ANOVA for parametric analysis or Kruskal-Wallis test for non— parametric analysis.

P-values for catc orical variables were calculated b Fisher's exact test.

Example 2 — Safety and Adverse Events The purpose of this example was to describe and evaluate the safety of the udena?l compositions administered in the study bed in Example 1.

Tables 3-6 t numbers of ts reporting at least one AE; data are presented by treatment group. The counts are presented by AE category (Table 3) and by red tcrm (Table 6). Tables 3-6 report all ABS by category (Table 3), serious AEs (Table 4), non-serious AEs (Table 5), and all ABS by preferred term (Table 6). No serious AEs were ed.

Table 3 - Adverse Events by Category AE Category 87.5 mg Exercise twice daily daily twice daily testing (N=6) only Adverse Event macaw/mam Gastrointestinal 2 33%) tolo . 'eal 0 0%) 1 17%) l-Ie atobilia / anereas 0 0%) 0 0%) 0 0%) Infection 0 0%) 0 0%) 0 0%) 1 17%) 0 0%) Musculoskeletal/skin l 17%) 1 l7%) 1 17%) ii.. 33%) 2 33%) 0 0%) Neuroloical/ s chiatric 3 50%) 3 50%) 5(83%) IQ 33%) 5 83%) 0 0%) Pulmona /u rres irato 2 33%) 3 50%) l 17%) l 17%) l 17%) 0(0%) Renal/ ' enitouri 11a 0 0%) .. 33%) l 17%) 0 0%) 0 0%) 0 0%) Sexual/re roductive function 0(0%) 0 0%) 0(0%) 2(33%) 2 33%) 0(0%) Vascular l 17%) 2(33%) 4 67%) l 17%) l 17%) 0 0%) Other 0 0%) 2 33%) 4 67% 3 50%) o _ u: m Co\ 0 0% At each level of ion, subjects reporting more than one adverse event are counted only once.

N=number of subjects in each cohort. n(%)=number and percentage of subjects in ry and cohort (n/N x Table 4 — Serious Adverse Events AE Category . 37.5 mg Exercise ‘ twice daily ' . testing only . N=6 Subjects Reporting at Least One 0 (0%) 0 (0%) 0 (0%) Adverse Event Serious adverse events were not re oned for this trial.

At each level of summation, subjects reporting more than one adverse event are counted only once.

N=number ot‘subiects in each . 11(%)=number and rcenta and cohort mm x [00) AE Category Subjects Reporting at Least One Adverse Event At each level of summation, subjects reporting more than one adverse event are cotmtcd only once.

N=number ot‘subiects in each cohort. n %)=number and rcenta e ot‘subiects in cate o and cohort n/N x 100) Table 6 - e Events b Preferred Term Preferred 'l‘erm . . . Exercise . - g o ,4 - u Subjects Reporting at Least 5 (83%) 6 (100%) 6 (100%) 5 (83%) 6 (100%) [(17%) One Adverse Event Abdominal fort l (17%) 0 0%) 0 0%) l 17%) l 17%) 0 0%) Abdominal ain u er 0 0%) 0 0%) 0 (0%) 0 0%) l [7%) 0 0%) Back ain 0(0%) 0(0%) 0 0%) l 17%) 0(0%) 0 0%) Chest ain 0(0%) 0 0%) 0 0%) 0 0%) l 17%) 0(0%) 0—0%> 0(0%) 0(0%) 0(0%) 1(17%> 0(0%) —__011%) 1 17%) 1 17%) 0 0%) __--o0%) 010%) 0 0%) ____o0%) o 0%1 o 0%1 _____00%1 o 0%1 Headache 3 50%) 4 67%) 4(67%) 4 67%) 5 83%) 0 0%) lniection site ain l 17%) 0(0%) 0(0%) 0(0%) 0 0%) 0 0%) ation increased 0(0%) 0(0%) 1 17%) 0 0%) 0 0%) 0 0%) Mi raine 0(0%) 0 0%) 0 0%) 0 0%) l 17%) 0(0%) Motion sickneSS 0(0%) 0(0%) 1 17%) 0 0%) 0 0%) 0 0%) M alia 0(0%) l (17%) 0(0%) 0 0%) 0(0%) 0(0%) Nasal con 1 estion 3 50%) 2(33%) 2 33%) l 17%) l 17%) 0 0%) Naso ha n itis 0 0%) l 17%) 0 0%) 0 0%) 0 0%) 0 0%) At each level of summation, subjects reporting more than one adverse event are counted only once.

N=numbcr of subjects in each cohort. n(%)=numbcr and percentage of subjects in category and cohort n/N x 100) Table 7 ts narratives for all adverse events (limited to non-serious at the moment of writing) classi?ed by cohort, subject, AB term, and preferred term.

Table 7 Cohort Subjec Adverse Event Term/l Preferred Term Date Date "HDisc} —--—-—NoNA —---M—NoNo —---MNoNo No No No M No NA T13 Slomach discomfort/l Abdominal----_n No discomfort m—NoNo mmNoNo —---_Yes M No No concsuon No No No No Yes No Pain/olhcr/I lnieclionsile ain Yes No T16 nasal congestion // Nasal None No 37:5 mg T21 Nose bleed // Epistaxis Moderate N nc Resolved without scquclae Yes NA IWIOC daily 37:5 mg T22 Shortness ofbrealh // Dyspnoea 1 1/05/14 1 1/05/14 Resolved without sequelae Yes NA dailv upper respiratory infection // 11/02/14 Resolved t sequelae NA U-ocr res iralo tract infeclion Facial l'lushin /‘/ Flushin ' --08/09/ 14 08/09/14 Resolved lsc-uelac No No T23 Headache // Headache --08/08/14 08/09/14 ed without se- 1elae No No tion (stu?‘y nose) // Nasal 08/08/ 14 08/08/14 Mild Possibly Resolved withoulsequelac No No congestion Table 7 Cohort Suhjec Adverse Event Term/l Onset Resolution Severity Related e Med.I Disc} Preferred Term Date Date cold/ congestion // 09/14/14 09/19/14 Resolved without sequelac NA Nasoha - 'tis al Cramps/l 08/11/14 08/16/14 Resolved without sequelae No I smenorrhoea Facial tlushin // Flushin 0&’10/14 14 Resolved without set elac a No T24 Nausea // Nausea 08/10/14 08/10/14 Resolved without so telae No No Nausea // Nausea 08/11/14 08/ll/14 Resolved without se elac No No Sorcness in chest and arms// 08/10/14 08/11/14 Resolved without sequelac N0 M al in Headache // Headache 08/08/14 14 Resolved without se elac No No Headache/module ---— Resolved willow. elac Yes NA Congestion (stuffy nose) // Nual 08/10/14 08/10/14 Resolved without sequelae No con estion enous penile erection // 14 08/11/14 Resolved without sequelac No S .ontaneotts - nile on Spontaneous penile erection // 08/14/ 14 08/ 14/ 14 Resolved without sequelae NA 51011131160115 ‘ nile erection 125 Headache // Headache 08/08/14 08/08/14 Resolved withoutse telac "No T26 illeadachel/Headache 14 08/09/14 _Mild Resolved tseqttelae .No Sinus ain // Sinus headache 08/09/14 11/18/14 Mild Probabl Resolved wilhoutse elac No No Headache // Headache 08/ 10/ 14 IIIIIIII'III09/2/14 Probabl Resolved without sc telae Yes No Fati- e// Fati' e 08/09/14 08/10/14 Resolved withoutse- telae No No 87.5 mg T31 headache // Headache 08/15/14 08/15/14 -Mild Probably Resolved without sequelae -I\’0 dail ’ headache // Headache 08/17/14 08/17/14 Mild Resolved without sequelae No b I _ ‘ _ Probably headache // Headache 14 08/18/14 Moderate Probahlv Resolved t se- telae No No congestion (stull'y nose) // Sinth 08/15/14 08/21/14 Mild Probably Resolved without sequelae No con cstion Facial ?ushin // n ' 08/18/14 08/18/14 Mild Probablv Resolved withoutse tclac No No s 1011 vision // Vision blurred 08/15/14 08/ 15/14 Mild Resolved withoulse- elac No No T32 motion sickness // Motion 08/ 15/14 08/15/14 Mild Resolved without sequelae No sickneSs headache // Headache 08/15/14 08/15/14 Mild Probeblv Resolved t se telae Yes No he // he 14 08/16/14 Mild Probablv Resolved without se elac No No headache // Headache 08/17/14 08/17/14 Probabl Resolved without so- telae No No d mouUt // Drv mouth 08.46/14 08/16/14 Resolved without se telae M No Table 7 Cohort Subjec Adverse Event Term/l Onset Resolution Severity Disc} Preferred Term Date Date T33 Head lniurv // Head iniu ' 08’21/14 08/2/14 Yes NA facial tlushin_ // Flushing 08/16/14 08/2/14 Mild No No tearin // Lacriman'on increased 08/16/14 08/22/14 Mild HNo T34 Sleepiness // Somnolenee 08/16/14 08/5/14 Mild WNo No Spontaneous penile on // 08/20/14 08/20/14 Mild Resolved without setmelae No Svontaneous . nile erection .4 08/16/14 14 Resolved with scuelae No No T35 headache // Headache 08/15/14 08/15/14 Probabl Resolved without sec telae No No 87.5. mgIIIheadache // Headache 08/16/14 08/16/14 ly Resolved withoutsequelae .No dailv stuff nose // Nasal con lion 09/20/14 09/23/14 Moderate Resolved withoutse elae No NA Nasal congestion // Nasal 08/19/14 08/21/14 Possibly Resolved without sequelae Yes No congestion . 08/15/14 08/15/14 No No Headache // Headache 08/15/14 08/15/14 Mild Resolved without - uelae No No 87.5 mg Nausea/vomiting // Nausea 0&‘26/ 14 08/26/ 14 Mild Possibly ed without sequelae No twice h discomfort // Abdominal 08/22/14 08/2/14 Mild Possibly Resolved with sequelae No discomfort Facial flushin- /'/ Flushin v 0806/14 08/26/14 Mind N ~ 0 [\0 Headache // Headache 08/23/14 08/23/14 Mild N0 N0 Headache // Headache 08/25/14 08/25/14 Mild No No Headache // Headache 08/24/14 14 Mild No No Headache // Headache 08/26/14 08/26/14 Mild No No T43 headache // he 14 08/2/14 te No headache // Headache 14 08/23/14 Mild l Resolved without se uelae No No headache // Headache 08/24/14 08/24/14 Mild No No T44 Stuff ' nose // Nasal con - estion 08/22/14 08/22/14 mu wNo Stut‘fy nose // Nasal tion 08/25/14 08/25/14 Possibly ed without sequelae No Slut { ' nose // Nasal con - estion 08/25/14 08/25/14 Mild Possibl Resolved without uelae No No spontaneous penile erection // 08/21/14 08/21/14 ed without sequclae No S ontaneous D - nile erection 87.5 mg Spontaneous penile erection // 08/21/14 08/21/14 Mild Possibly Resolved without scquelae No No twice Spontaneous penile erection dail ' Table 7 Cohort Subjec Adverse Event Term/l Onset Resolution Severity Disc} Preferred Term Date Date neous penile erection // 08/22/14 08/2! 14 Mild Possibly Resolved without sequelae No Stontaneous D nile erection spontaneous penile erection // 08/25/14 08/25/14 Possibly Resolved without sequelae No Stontaneous - nile erection Spontaneous penile on // 08/26/14 08/26/14 Mild Possibly ed without sequelae No Sontaneous nile erection Headache // Headache 08/21/14 14 N0 N0 Headache // Headache 08/22/14 08/2/14 No No headache // Headache 08/23/14 08/23/14 No No headache // Headache 08/24/14 14mmNo No T45 spontaneous penile erection l/ 0&‘3 l/ 14 08/31/14 Resolved without sequelae No S ontaneotts - nile erection sinusitis // Sinusitis 08/26/14 No No back ain // Back ain 14 owes/t4 No No ?ushin // Flushin- 08/30/14 14 No No ?ttshin //F1ushit 09/01/14 09/01/14 No No ?ushin_ //Flushine 09/02/14 No No llushin-/-/F1ushin 14 No No l-leadaehe // he Yes No No No No No 87.5 mg Fatigue // Fatigue 14 09/01/14 Mild Possibly Resolved without scquelac No No twice dailv —--@_NoNo 125 mg T51 headache // Headache - 15 Resolved without scquclae NA T52 Increased frequency of 11/07/14 1 1/08/14 Mild Possibly Resolved without seqttelae No No spontaneous penile erections // Sontaneous nile erection T53 Diarrhea l/ Diarrhoea 12/06/14 "M Resolved withoutse uelae No No 12mm 12mm Resolved wmscucac. No No Headache "Headache 12/03/14 12/03/14 Resolved withoutsc- telae No No Spontaneous penile erection // [2/04/14 Possibly Resolved without seqttelae No [\‘o' Spontaneous penile on Flushin //Flttshin 14 Probabl Resolved without se telae No No Table 7 Cohort Subjec Adverse Event Term/l Onset Resolution Severity Disc} Preferred Term Date Date lone/14 10/10/14 Resolved t sen ielae No No —oxm4tons/:4 mud ——ves No Ions/14 Modem Yes No —wnm410,1304 ModerateWm No Slut‘fy nose (congestion)// Nasal 10/11/14 Mild N0 con esuon Nose bleed // Ii istaxis 10/13/14 10/13/14 Mild Resolved without seuelae No No itch ' throat // Throat irritation 10/30/14 10/30/14 te Resolved without sc tclae Yes NA .4 1A LII Nausea // Nausea 01/13/15 01/14/15 Moderate Resolved t 5e clae Yes NA Swollen / puffy cheeks // Face 1 1/29/14 11/29/14 Mild Resolved without ae E No headache // Headache 1 1/25/14 1 1/3/14 Mild M Resolved t e No No 125 mg Headache // he 1 1/27/14 1 1/27/14 Mild Possibly Resolved withoutsequclac .No dail ‘ Headache // Headache 1 1/28/ 14 1 1/28/14 Mild ' Resolved without wuelae No No mama //mm mm 9m H:09 ne Headache // Mi inc 01/ 12/15 01/14/15 Moderate Resolved without settelac Yes NA T56 Stomach discomfort // Abdominal 09/08/14 14 Mild ly Resolved without sequelae No discomfort Stomach discomfort // Abdominal 09/06/14 09/10/14 Mild ly Resolved with scquelae No ain u er Stomach discomfort // Abdominal 09/07/14 09/07/14 Mild Resolved without sequelae No discomfort Stomach discomfort // Abdominal 09/09/14 09/09/14 Possibly Resolved without sequelae No No discomfort Chest ain // Chest ain 14 09/07/14 Possibl ed withse tielae No No Rash //Rash 09/07/14 09/10/14 Mild No No Chest ain // Chest ain 090014 0910014 Mild No No Rash // Rash 09/08/14 09/08/14 Mild No No Rash // Rash 0909/14 09/09/1490 No Rashl/Rash 09,0014 09/11/14 ""10, No Rash // Rash 09/12/14 09/12/14 Resolved without sequelae No Headache // Headache 09/06/14 09/06/ 14 Mild Probabl Resolved with se uelae Yes No Headache // Headache 09/07/14 09/07/14 Yes No Headache // Headache 09/08/14 09/08/14 -M"No No Table 7 Cohort Subjcc Adversc Evcm'l‘crm/l Onset Resolution Severity Related Outcome Disc.2 1 ID" Preferred Term Date Date ‘ Headache // Headache 09/09/14 09/09/ H Probabl Resolved without 34:: tclac Yes ‘ Headache // he 09/10/14 09/10/14 Probabl Resolved t sc-uclac Yes No Ventricularaxhythmia/I 12’11/14 12/11/14 Mild None Ventricular arrhylhmia Ventricular Tachycardia // 12/15/14 12/ 15/14 Mild Resolved without scquclac "Ventricular tach cardia Attorney Docket No.: 107984-0107 Table 8 presents numbers of subjects with number of AEs 2 n, where n=1, 2, ..,,6 by treatment group.

Table 8 - Adverse Events by ent Group 37.5 mg . 87.5 mg Exercise twice daily ' twice daily ' testing only N (%) of Subjects Reporting at Least: Tables 9-12 t ABS by preferred term (similar to Table 6), but additionally report the number of subjects with an AE and the number of AEs (Table 9), the number of AE events/subjects grouped by treatment group and by related (including possibly or probably) vs. not d to the study drug (Table 10), mild vs. moderate/severe (Table l 1), and expected vs. unexpected AEs (Table 12).

Table 9 - Adverse Events by Preferred Term 37.5 mg 87.5 mg 87.5 mg 125 mg Exercise twice daily daily twice daily daily testing only (N=6) (N=6) (N=6) (N=6) (N‘=6) 0 (0) 0(0) 3 (1) 0 (0) 0 (0) 0 (0) 0 (0) 1(1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0(0) 0(0) 0(0) 2(1) 0(0) 0(0) 0(0) 0(0) 1(1) 0(0) w» om can ea» om 1m 1m m mm 1m Table 9 - Adverse Events by Preferred Term Preferred Term, 37.5 mg 87.5 mg 87.5 mg 125 mg Exercise #Evcnts (#Subjccts) twice daily daily twice daily daily testing only (N=6) (N=6) (N=6) (N=6) (N=6) erection Throat irritation 0(0) 0(0) Uppcr respiratory tract 1(1) 0(0) infection Ventricular arrhythmia 0(0) 1(1) Ventricular tachycardia 0(0) 1(1) Vision blurred 0(0) 0(0) Table 10 - Related and ted AEs 37.5 mg twice 87.5 mg twice 37.5 mg daily daily 87.5 mg daily daily 125 mg daily Exercise only (N=6) (N=6) (N=6) (N=6) (N=6) (N=6) Preferred 'l‘erm, Drug Not Drug Not Drug Not #Events related* related d" related related" related related* related relatcd* related related* related (#Subjects) Abdominal Ao V .—- A .— V O AOV o discomfort Abdominal O AO v O AO v C AO v O AOV O pain upper _Back pain 0 Ao V v O AO v v 0 a» can _Chest pain O Ao V CC AA00 v C AO v 00 AA 00 V 0 a» mm _Diarrhoea COO AAA Coo VVV O AO v iAov 000 AAA COO vvv O a» _Dizziness C Ao v C AO v O «» ow O AO ‘4 _Dry mouth 0 Ao V O AO v m om O AO vv 0 A v C AO V O AO V O AO V A 3 O AOv A V O Ao V O Ao ‘1 C AOV menorrhoea _Dyspnoea o A0 V A :3 o Aov A S o AoV o Ao > AO v A o AOV O Ao v -Epistaxis O AO V O AO V O ACV A 3 O AOv O (,0) l A 1 V 1(1) O Aov C AOv _Face oedema O AO v O AO v O AO v O AO v O (0) 0(0) 0(0) 1(1) O AO O -Fatigue o Ao V o A0 V A C o (0) :3 (0) I0w O (0) _Flushing O (0) _I lead injury OIQ AAo— v 00 A0 Ole A IQ V (0) _Headache \O A b) v 0(0) 6(4) Injection site Lacrimation Emass C Ao V O A0) Motion sickness EMass O A0) om '-‘ A .— v Ix) A .9 _owema _aRsR Co AAA oo— VVV CO O AO v AAA/K CO VV‘1 congestion Table 10 - Related and Unrelated AEs 37.5 mg twice 87.5 mg twice 37.5 mg daily daily 87.5 mg daily daily 125 mg daily Exercise only (N=6) (N=6) (N=6) (N=6) (N=6) (N=6) Preferred 'l‘erm, Drug Not Drug Not Drug Not Drug Not Drug Not Drug Not #Events rclated" related related" related related" related related" related d" related related" related (#Subjects) Sinus Spontaneous penile 0(0) 0(0) 2(1) 0(0) 1(1) 0(0) 6(2) 0(0) 2(2) 0(0) 0(0) 0(0) erection Throat Upper r6533" 0"" 0(0) 0(0) 1(1) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) infection Ventricular Ventricular > W W Vision m13(3) 17(5) *Drug related = possibly related, probably related or related to study drug Out ot'all 36 study ts, none had adverse events d to the study drug, and l 1, 2| and 17 subjects had adverse events that were probably related, possibly related and unrelated to the study drug, respectively.

Table 11 - ABS by Severity 37.5 mg twice 87.5 mg twice 37.5 mg daily daily 87.5 mg daily daily (N=6) (H) 0%) (H) Preferred , ‘ ' . Moderate . Moderate . Moderate . .

, Moderate . Moderate ’ ‘ ‘ ‘ A - . ‘ ‘ #Events severe 755W" "Isa?" 5‘" ‘ re "severe (#Subjects) Abdominal discomfort pain upper Table 11 - ABS by Severity 37.5 mg twice 87.5 mg twice 37.5 mg daily daily 87.5 mg daily daily 125 mg daily Exercise only (N=6) (N=6) (H) (N=6) (N=6) (N=6) Preferred Term, te Moderate Moderate Mild \l1ld #Events lscvcrc "severe ?scvere (#Subjeets) ess O Ao V O Ao v O Ao o o (0v 0(0) _. A —. v O AOv O AO v _Dry mouth O AO V O AO v O AO O 0 (0) can O AGv O AO v O Ao V Ao v .— O (0) 0 (0) 0 A v o ov o AOv menorrhoea I _Dyspnoea O Ao v _. A .— V O AO v A 3 O 0 (0) 0(0) O Aov o Ao v _Epistaxis O Ao V o Ao v O AO v — A _. v o o (0) 0( v o AOv O A0 v _Face oedema O Ao V o Ao v O AO V o ACv 0 (0) 0 A V O ACV o AC V _Fatigue C AO V o AO v .— A v O AOv —J>OO 0 0) COO O Aov O Ao v _Flushing IQ A .— V o AO V '0 A [9... v o Aov o Ao ‘1 O Ao V IIead injury iACV CO a» —O AOv O AO V O AOV O ACV O AOV ‘ a» AAACOOOO VVV _Headache '0 A '9 V \l A DJ v m AA V .— A _. v 00 un k) (l) O AOv O A0 v ion site o AoV A C iAoV o Ao ‘V o A0) 0 (0) C Ao v iAov iAOV Lacrimation o Ao v O AO V O AOV C ACv 1(1) 0(0) 0 Ao v increased Migraine O AO V O AO v O A0v o AOv 0(0) 111) O o AO v -Motion O Ao V o AC v O AO v C Ao V l) mmmmm0 CO WV sickness .l O AO v —Myalgia O AO V O A0 V .— A _. v o AOv ea» em Nasal IQ A IQ V .— A .— V [0 A IQ v o Aov I A 1 V congestion Naso- O AO V o AO v .—- A .— V o A pharyngitis _Nausea u—‘ A .— v _- A .— v IQ A _‘ V O AOv _Oedema C Ao V v O AoV o ACv _Rash O Ao v 00 AA00 V O AOv O AO V 000 (0)<0)<01 Sinus O Ao ‘V o AC v O AoV o AOv congestion Sinus O Ao v C AC v .— A .— v O ACv O headache _Sinusitis o AC V O Ao V O AOv O AOv o AO) Somnolence O AO v O AO V o Ao v O ACv .— A .— v Spontaneous penile 0(0 0(0 ls) (l) 0(0) 1(1) erection Throat AO 0(0) 0 ) irritation Table 11 - ABS by Severity 37.5 mg twice 87.5 mg twice 37.5 mg daily daily 87.5 mg daily daily 125 mg daily Exercise only (N=6) (H) (H) (N4) (N=6) (H) Preferred Term, Moderate Moderate Moderate Moderate #Events "we" "severe (severe fsevcre (#Subjects) Upper "$330" 1(1) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) infection Ventricular 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 1(1) Ventricular 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 1(1) 0() Vision (0) 1(1) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 7(4 12(4) 19<'.II 3(3) 21(0) 0(0) Out of all 36 study subjects, 27 had mild e events, 13 had moderate and 1 subject had a severe adverse event.

Table 12 - AEs by Expectedness 37.5 mg twice 87.5 mg twice 37.5 mg daily daily 87.5 mg daily daily 125 mg daily Exercise only (N=6) (N=6) (N=6) (N=6) (N=6) (N=6) Preferred 'l‘erm, Not ' 1 . Not Not Exmmd Rpm"! EXPCCMI #Events Expected Expected Expected ects) A‘bdomi‘nal 0(0) It!) 0(()) 0(0) 0(0) 0(0) 1(1) 0(0) 3(1) 0(0) 0(0) 0(0) discomlort pamuppcr so 38Vv 0"" °‘°’ 0"" 0"" coo AAA ooo Vv.’ o 8V °"" 00 AA. 00 vv " "‘0 "" o ’5v.’ °‘°> --------2(2)W"W" "0‘ °"" -------°""W-°""-°‘°’ Table 12 - ABS by Expectedness 37.5 mg twice 87.5 mg twice 37.5 mg daily daily 87.5 mg daily daily 125 mg daily Exercise only (N=6) (N=6) (N=6) (N=6) (N=6) (N=6) Preferred Term, Not [Expected E‘Pwed #Events ed (#Subjects) Fatigue i8V 0(0) II0(0) 1(1) 0 (0) Flushing N A 3 0(0) 5(2 |(l) HI Head injury 0 1 (l) 0 (0) 0 ('0) 0 (0 Headache 8(3 0 8V ll (3) H" 13 (5) ion site 0 (0) I.0A 0) 0 (0) 0 (0) 0 (0) O AO‘1 Lacrimation 0 (0 l l) 0 (0) 0 (0) 0 (0) 0 (0) 0 (O) 0 (0) increased Migraine 0(0v A OV 0(0) 0(0) 0(0) 0(0) 1(1) 0 AOv O AOV Motion 0(0) 1 (l) 0 (0) 0 (0) sickness Myalgia ll Nasal h) A to V I») ( Is) ) o 8v congestion pharyngitis Nausea IO : .a O AOv Ocdema C A0v 0 AOv c 8v I congestion Sinus 0 (0) o (0) 1 (1) o (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) headache Spontaneous penile 0(0) 0(0) 3(1) 0 (0) l (1) o (0) 6(2) 0 (0) 2(2) 0(0) 0 (0) 0 (0) erection irritation Upper respiraiory 0(0) 0(0) 0(0) 1(1) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) tract infection -53..

Table 12 - AEs by Expectedness 37.5 mg twice 87.5 mg twice 37.5 mg daily daily 87.5 mg daily daily 125 mg daily Exercise only (N=6) (N=6) (N=6) (N=6) (N=6) (N=6) Term, Not Not " ‘7 N01 Expected : .. . : . s Expected [Expected Expected Expected (#Subjeets) Ventricular 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) HI) 0(0) arrhythmia Ventricular 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) I") 0(0) tachycardta Vision 0(0) 0(0) 0(0) 0(0) 0(0) 1(1) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) blurred Out of all 36 study subjects, 27 subjects had expected and 18 had unexpected adverse .

Table 13 focuses on a subset of Table 7 limited to preferred terms for which AEs happened more than once r 2 2 AEs for one subject, or 2 2 subjects with at least one AB) in at least one .

Table 13 - Events That Occurred More Than Once in One Subject or In More Than One Subject Preferred Term, 37.5 mg 87.5 mg Exercise #Events (#Subjeets) twice daily twice daily testing only (N=6) (N=6) (N=6) 1m 3m on mm 2m om) ea» 2m w» «m 1(1) 0(0) M 12(4) 14 (5) 0 (0) Nasal congestion 3 (3) 2 (2) 3(1) 1 (1) 0 (0) Nausea 2 (1) 0 (0) 1(1) 1(1) 0(0) Rash 0 (0) 0 (0) 0(0) 5(1) 0 (0) Spontaneous penile 6(2) 2 (2) 0 (0) erection Figure l displays the percent of subjects reporting at least one, three or ?ve adverse events by treatment group (the numbers are taken from Table 6). The cohorts at horizontal axis are sorted from the lowest daily dose at the left (exercise only group; zero dose, though not a placebo) to the highest one-time dose (125 mg) at the right. The percentages vary from 100% to 0% (exercise only group). As expected, the exercise only group features the lowest percentage. The plot t suggest a clear association between the dose and percent of subjects reporting AEs.

Example 3 — se Testing The purpose of this example was to evaluate the efficacy of the treatment protocol described in Example 1 using various exercise testing parameters.

The primary outcome of this arm of the study was maximal V02 as determined by exercise testing. Table 14 summarizes results for the key outcome from the exercise testing ~ peak V02 (limited to the subjects who achieved maximum effort) by treatment group. Out of the 36 subjects ed in the trial. 33 reached max effort in the exercise testing at each of the time points, and 31 subjects at both time . The ?rst two lines present data for ne and follow-up measurements, while the third line presents differences between the two measurements (change , the outcome for this aim).

Analysis of variances suggests lack of differences between the change scores (p=0.85).

Table 14 - Peak V02 at Maximum Effort, ml/kg/min All mg Exercise N subjects N daily N daily N daily N daily only ‘ 246* 30.4: 28.4t 2 i i . 2 . .6i measurement 6.9 6.2 6.2 5.2 3.0 6.2 _ 2 . 2 . 2 . 2 .2 2 . . measurement 6.7 8.1 5.0 6.0 3 .8 5.0 Difference’ 08$ —1 .61: - l .429: 0.2:t 0.9i -0.3:t 32 .3 5 6 6 5 5 5 0.85] FU - BL l-I-"I--Illl- P-values were calculated by ANOVA.

The maximum effort was achieved when the atory quotient at peak 2 1.1.

Figures 2 and 3 present the findings for change scores in a visual way (with a positive change indicating an improvement). Figure 2 displays individual change score for each subject with paired measurements (circles) and two lines with mean and median values. The plots don’t suggest that change scores increase with the dose. Figure 3 displays maximal V02 values before and after the treatment for each subject and in each cohort.

As expected, baseline and follow-up measurements are strongly correlated, with the correlation coef?cient > 0.8.

An additional e at bic threshold, was also measured.

, V02 Similar analyses were performed for this e. Results are presented in Table 15 and s 4 and 5. Overall results are similar to those for maximal V02.

Table 15 - Peak V02 at Anaerobic Threshold, ml/kg/min . . 87.5 ‘ mg [25 mg Exercise P- subjccts N N N daily N N daily N only value Baseline 18.62]: 17.2:1: 18.0i 17.6:1: 18.3:1: 18.8i 21.7: _. 6 6 6 6 6 6 0570 -0 3.0 5.3 4.6 1.8 6.2 Follow—up 18.2i 16.32}: 18.]:t 1652*: 16.52}: 20.01 22.4:t ’‘4 5 5 0 1‘5' ’ measurement 4.4 2.0 3.0 4.8 5.2 3.2 5.5 Difference 03¢ 05¢ 0.11 4.1»: -1 .7: 1.2: 0.1x ’ *4 5 6 6 6 6 0.46 P-values were calculated by ANOVA.

Of note, both se es (peak V02 and V02 at anaerobic threshold) are highly ated (with the ation coef?cient at each visit above 0.7), which may explain rities in the trend lines in Figures 2 and 4.

Example 4 — Vascular Function Testing The primary outcome of vascular function was determined according to an endothelial pulse amplitude tonometry (PAT) index as determined by the EndoPATrEJ device (Itamar Medical, Caesarea, Israel).

Table 16 summarizes the results for the key outcome from the ar ?mction testing - natural log of Reactive Hyperemia Index (lnRHI) by treatment group. Out of the 30 subjects enrolled in the treatment arms of the trial, 27 subjects had paired measurements with an acceptable quality (with QC score equal to 3 (the best) or 2). The structure of the table is similar to the one for exercise variables.

Table 16 - Natural Log of Reactive Hyperemia Index .Iwhims Baseline 0.522t 0.481 0.60.1: 0412: 049$ 0.631 ‘$8 4 6 0704' measurement 0.28 0.31 0.30 0.25 0.12 0.37 Table 16 - Natural Log of Reactive Hyperemia Index . 87.5 87.5 mg ‘ mg twice l25 mg N subjects N N N daily N daily N daily P-value F()[[()W—up 0.4% 0.5 H: 0.531 0.45i: 0.4021: 0.521: ,) 6 5 5 6 0945 0.26 0.29 0.31 0.29 0.34 Difference -0.02i: 0.03:}: -0.07:h 0.07i l: -0. 1 0:1: ’ 27 6 5 4 6 0.902 Figures 6 and 7 present the ?ndings for change scores in a visual way (with a positive change indicating an improvement). Figure 6 displays the individual change score for each subject with paired measurements es) and two lines with mean and median values. The plots do not suggest that change scores increase with the dose.

Figure 7 displays I values before and after the treatment for each subject and in each cohort.

Baseline and follow-up measurements are moderately correlated, with an overall correlation coef?cient of 0.4.

Of note. both mean baseline and follow-up measurements are close to the cut-off value of 0.51 suggested by the EndoPAT documentation as a threshold between the normal (de?ned as lnRI-lI> 0.51) and abnormal (lnRI—II S 0.51) . Analysis of the data indicates that some patients showed as much as a 9.75% improvement in this measure.

Table I7 reports change scores only for ary EndoPAT es (RHI, Framingham RHI etc; top panel) and other EndoPAT indices. In all cases a positive change suggests a le improvement.

Table 17 - Secondary and Other EndoPAT Outcomes, FU - BL N subjects N Secondary EndoPAT outcomes vc -)(.04:l: t.)O‘i.3 _0.12i (.15) 2:1: (.(1) ) :t 42(. 1 :9: Hypcmia 27 6 6 5 4 6 0.

Index 0.56 0.84 0.50 0.34 0.38 0.78 Franlinuhan] '0.06i 4100* '0. 1 72h 0.04i 0.00i '0. 1321: ~ -77 6 6 5 4 0.901 RHI I. 0.58 0.19 0.36 0.20 0.51 Table I7 — Secondary and Other EndoPAT Outcomes, FU - BL All 37.5mg 875mg 125mg P- N sttbjccts N daily N N daily N N daily value AUCZmaxmoc: Am under 111.- 051 093 1 1% * 0" ""ch "i "is" "’i 016'i 1 80 77 4 6 'iooss Max- " 5 ' 2.91 4.37 1.84 2.49 1.08 1.18 ()cclusion/ Control AngMax_oc: average up to Occlusion/ Other EndoPAT s AUCZmax 0: Area under the curve to Max- 037* Occlusion (ratio to baseline) AUCallio: Area under the curve all- 0 18: 27 6 Occlusion (ratio to baseline) AUCall ioc: Area under the -0.60:t curve all- 27 6 Occlusion/ AngMax 70: 0 04: average upto 27 max- 0 51 sion" " Avgall‘o: 002$ average all- 27 ()cclusion* " 0 40 Avgall Voc: -0.06:l: -0.10:l: average all - Occlusion/ "77 0.54 0.66 Control P-valucs were calculated by ANOVA. ** ratio to baseline Example 5 — Echocardiographic Assessment of Ventricular Performance The primary outcome of ventricular performance with assessed using echocardiographic methods and measured according to a dial performance Index (MP1). The MP1 is a ventricular geometry-independent measure of combined systolic and lic ventricular performance (Charles S. Kleinman et al, 2008 - Health and Fitness). It is obtained by indexing the sum of isovolumetric contraction and relaxation time to ejection time.

Table 18 summarizes results for the key outcome from the Echocardiographic Assessment of cular Performance — Blood Pool MP1. Out of the 30 subjects enrolled in the treatment arms of the trial, 27 subjects had paired measurements. The structure of the table is similar to the one for exercise variables. Analysis of the data indicates that some ts showed as much as a 21.5% improvement in this measure.

Table 18 — Blood Pool MP1 All 37.5 mg 37.5 mg 87.5 mg 87.5 mg 125 mg P- N subjects N daily N twice daily N daily N twice daily N daily value Baseline 0.58M 0.5373: 0.4961: 1: 0.548t 0728* '79 V 6 0 305' ement 0.197 0.304 0.150 0.158 0.136 0.155 Follow-up 0517i 0504* (1494* 0.512i 0.410t 0.6963: 78 5 6 6 < g " ' " ' " measurement 0.165 0.187 0.087 0.163 0.078 0.202 Dillerenec,‘ ‘ -0.0 9i5 -00 -0 0033: - . 52:t . -0 076i. -0 111% . 00 4i. 5 27 5 6 6 5 5 0.744 PU - BL 0.134 0.166 0.102 0.144 0.090 0.180 Figures 8 and 9 present the findings for change scores in a visual way (with a negative change indicating an improvement). Figure 8 ys individual change score for each subject with paired measurements (circles) and two lines with mean and median values. The plots don’t suggest that change scores increase with the dose. Figure 9 displays blood pool MP1 index values before and after the treatment for each subject and in each cohort.

Baseline and follow-up measurements are strongly correlated, with the overall correlation coef?cient of 0.7 (last 2 lines). Of note, both mean baseline and -up measurements are in the ed area (>0.4).

Tables 19-21 and Figures 9-15 report similar results for three other versions of MP1: Tissue Doppler MP1, and Average Isovolumetric ction and Relaxation.

Table 19 — Tissue Doppler MP1 All 37.5 mg 37.5 mg 87.5 mg 87.5 mg [25 mg P- N subjects N daily N twice daily N daily N twice daily N daily value Baselmc', 0.760: 0.701: 0.818: 0.804: 0.540: 0.861: 28 6 6 4 0.517 measurement 0.299 0.417 0.361 0.1 18 0.019 0.323 Follow up- 0707i 0637:t :l: . . 07. 29d: 0716i . 0 638. 08. 22:: 28 5 6 6 5 0.579 measurement 0.201 0.206 0.230 0.142 0.168 0.271 nce,. .. ~ _0.056: _0.0- _:<7 _0.089: -0.089: 0.060: -0.074: 26 5 6 4 5 0.813 FU - BL 0.198 0.398 0.142 0.131 0.068 0.141 Table 20 — Average Isovolumic Contraction All 37.5 mg 37.5 mg 87.5 mg 87.5 mg 125 mg P- N subjects N daily N twice daily N daily N twice daily N daily value . .6: .2: 0 .4: 22.4: 84. : 52.4: measurement 50.5 50.7 51.1 36.7 20.3 64.4 Follow-up 107.1: 86.4: 103.6: 1 15.0: 83.8: 150.5: Din‘erence, -4.6: -35: -5.8: -74: 4.1: -8.0: 26 5 4 0.

Table 21 - Average lsovolumetric Relaxation All 37.5 mg 37.5 mg 87.5 mg mg P- N subjects N daily N twice daily N daily N N daily value -I-I--I-I-I--aBaseline 91.2: 83.8: 100.8: 93.4: 72.3: 99.5: 7 7 -up 92.0: 94.0: 101.6: 86.4: 82.4: 96.8: 28 < ' " 6 5 0674' measurement 23.8 26.7 40.0 15.3 11.4 17.4 Difference 0.1: 9.0: 0.8: -6.9: 5.2: -5.4: ' 26 5 6 6 4 5 0.354 FU-BL I-----IIIII-- For these three additional versions of MP1, a ve change also suggests a possible improvement and the overall conclusions are similar to those for Blood Pool Additionally, because positive outcomes were seen during the short duration of the studies described in Examples 1-5, administering l or a pharmaceutically acceptable salt thereof to a Fontan patient for a longer period of time could produce even more bene?cial pharmacodynamic es.

Example 6 — Pharmacokinetic Testing NONMEM version 7.2, R, =Rf= 5, Xpose, and Phoenix WinNonlin was used for the pharmacokinetic analysis.

Pharmacokinctic is was performed on Fontan patients receiving udenafil.

Figurc 16 show the results of data evaluation for individual subjects by dosing , and Figure 17 shows the concentration profiles of udcnafil in the study subjects. Plasma concentrations were determined at various time points and non-compartmental is was performed in patients and strati?ed by closing regimens.

Figures 18-20 demonstrate various comparisons among the dosing cohorts.

Based on the non-compartment analysis, Cmax was significantly increased in 87.5 mg q12h cohort and 125 mg q24h cohort compared to the 37.5 mg q12h or q24h cohorts (Figure 18).

The 87.5 mg q12h cohort exhibited increased Cmax compared to its q24h rpart (Figure 18). AUCT was significantly increased in 87.5 mg q12h cohort and 125 mg q24h cohort compared to the 37.5 mg q12h or q24h cohorts (Figure 19). AUC0.24 was significantly increased in 125 mg q24h cohort compared to the 37.5 mg q24h s. The 87.5 mg q12h cohort showed increased highest AUC0.24 among all the regimens tested (Figure 19). No signi?cant difference was observed in CL/F or V/F among dosing regimens, expect the significant differences between 37.5 mg q24h and 87.5 mg (11211 (Figure 20). There was no statistically signi?cant difference in kc, Tug, or Tmax among all 5 tested dosing regimens.

Population PK Model pment The tion PK analysis was performed using a non-linear mixed effects modeling approach. This approach estimates the typical value of parameters and their variances. It was assumed subjects were at steady state (SS): at a time (t) after dose (D) given at time tD after ed administration of dose D given at interval 1 (t 2 to) as PK samples/ udcnafil concentrations were taken on study day 6.

As only the drug administration at Day 6 was supplied, it is expected that the subjects have taken the drug at regular intervals at home; due to this a steady state flag will be tested to account for the doses which are not ble. As stated, it is assumed steady state has been reached by Day 6, as us s of udenafil have stated that during multiple dosing, steady state is reached in 5 days, with apparently little additional accumulation occurring after dosing for 7 days. If there were missed doses during the study period prior to the PK sampling, this can affect the ability to determine whether steady state could be assumed or not for the PK profile. If two or more additional drug administration dates and times were available prior to the visit where the PK samples were taken, then a much better dosing pro?le could be used for analysis.

Structural Model One- and two-compartment models were explored (based on literature and available data). The equation for the Input model for the drug described oral absorption.

For the one-compartment model, the following equation may apply to the model: -. m-.k) 5% And considering that CL = kl0 * V, the following equation may also apply: - MN .wx -. it». .51» st. 3 htc. t.- The two-compartment model can be described by the following differential ~~~~~~~~~~~~~~ R’s: .53? 23:3; . \‘33 {k} a ices} ox: Drug Amount in the body after oral stration may be described by the following differential equation: {if}? 2:: A Q gm<"{ g 8 ’ 5'" i"? 4 {"< .1 "?rm: The ness of the ?nal model was assessed in PDxPOPGi: 5 by bootstrap re- sampling (n=1000). Values obtained with the bootstrap (based on all runs with successful minimization) were compared to the parameter estimates from the ?nal model. To evaluate the accuracy of the model predictions, normalized prediction distribution errors (NPDE) was performed.

Certain a priori information was used in guiding the pment of the models.

One- and mpartment models with oral absorption input were evaluated using initial tes obtained from the literature as described above, and were explored to determine the potential structure of the model. The models were evaluated during the model building process by using objective function value, level of statistical signi?cance, goodness of ?t plots, and standard error.

The only covariate ble for analysis was current body weight. Weight was tested as a ?xed effect on typical values for clearance and volume of distribution (e.g., weight has a "?xed effect" on clearance). Median weight in the dataset was 65.3 kg.

] The "typical value" for nce is ted per 70 kg patient using weight (WT) in the data set. The estimated THETA( l) and THETA(2) for subjects of known WT can be directly compared with CL and V values in subjects of ard" weight, e.g. WTs=70 kg.

Concern is sometimes expressed that scaling parameter values estimated in children in terms of an adult size standard of 70 kg may bias the estimates, or affect the precision of estimation. There is no basis for this concern. This can be seen by inspection of the allometric scaled covariate model which may be re-arranged and is simply a nt that is determined by whatever weight is chosen for standardization. The precision of a parameter estimate will not be changed by multiplying the parameter value by an ad hoc constant. The criteria for covariate on selection for weight in the model was statistical signi?cance.

Figures 21-29 show the results of the pharmacokinetic data analysis.

During the model building process. a number of residual error models were evaluated. Proportional and exponential error models were unable to run, these terminated every time. ve error models were able to run, but the GOF plots showed a poor ?t for one-compartment models with a better ?t in the two compartment model. The choice was made to use a ed error model for the base model, despite the high CV% in the residual variability, as this model gave good estimates for other parameters, 95% Cls and showed a good ?t on visual inspection of GOF plots (Figures -31). It may be possible to control for the high CV% if all of the doses from days l-5 were included from each subject in the dataset before the day 6 dose, around which the sampling occurred. It is not be necessary to do this as the model ?t is good as presently described, but this may further reduce the % CV5.

After comparing observed data and ted data, a ?nal model was produced.

GOF plots for the ?nal model are found in Figures 32 and 33.

Bootstrap re-sampling was undertaken to e the parameter estimates from the ?nal model with those determined following 1000 bootstrap runs. In addition: visual tive cheeks (plot comparing 95% prediction al with observed data) and normalized prediction distribution errors (NPDE) techniques were applied for ?nal model tion. onally a visual predictive check was performed. |0207] Udena?l pharmacokinctics were well described by a mpartment model with combined additive and proportional error. Apparent clearance (CL/F) were scaled using current body weight standardized to adult , 70kg. Absorption rate constant was estimated as 0.28 h-l (95% CI 0.16-0.39), apparent clearance (CL/F/70kg) 36 L/h (95% CI 28.5-43.1), central volume of distribution (V2/F) 74 L (95% Cl 362-] 12), inter-compartmental clearance (Q/F) 2| .1 L (95% CI 10.4-3 LS) and peripheral volume of distribution (V3/F) 181 L (95% Cl 141-221). The ?nal model was evaluated by bootstrap re-sampling, normalized prediction distribution , and visual predictive check techniques. These techniques demonstrated a good fit of the ?nal covariate model to the data.

A two-compartment model with absorption rate nt successfully described the pharmacokinctics of udena?l in adolescents with single ventricle physiology after Fontan palliation. There was a statistically signi?cantly in?uence on apparent clearance (CL/F) when subject body weight was standardized to adult weight. 70kg included in the ?nal model, CL/F L/hr/70kg.

Example 7 — Phase [I] Study of Udena?l in Fontan Patients A Phase III study of udena?l in Fontan patients will determine the safety of udenafil (87.5 mg, twice daily) in an adolescent population with single ventrile congenital heart disease palliated with the Fontan procedure. The study will also evaluate the pharmacodynamics pro?le of l over a period of time ranging from at least six months and up to one year. Pharmacodynamie outcomes will include exercise ty, cchocardiographic measures of ventricular function, endothelial function, and serum biomarkers, as well as measures of functional health status/quality of life. It is expected that udenafll (87.5 mg, twice daily) will be safe. and effective for improving exercise capacity and other endpoints of cardiovascular health, as well as ing quality of life.

Methodology - ized, -blind, placebo-controlled clinical trial of a six month to one-year treatment with an 87.5 mg/ twice a day dose in 300 ts between 12 and 19 years of age who have had the Fontan surgery before 5 years of age.

] Inclusion Criteria for the study include: o Males or females age 12-19. 0 Fontan surgery before 5 years of age.

Exclusion Criteria for the study include: 0 Height < 132 cm. 0 Hospitalization for acute decompensated heart failure within the last 12 . 0 Current enous inotropic drugs. 0 Undergoing evaluation for heart transplantation or listed for transplantation. 0 Diagnosis of protein losing enteropathy, plastic bronchitis, liver sis. 0 Known Fontan baf?e obstruction, branch pulmonary artery stenosis, or pulmonary vein stenosis resulting in a mean gradient of > 4 mm Hg between the regions proximal and distal to the obstruction as measured by either catheterization or echocardiography. 0 Single lung physiology. 0 Severe ventricular dysfunction assessed qualitatively by clinical rdiography within 6 months prior to enrollment. 0 Severe valvar regurgitation, ventricular out?ow obstruction, or aortic arch obstruction assessed by clinical echocardiography within 6 months prior to ment. 0 Signi?cant renal, hepatic. gastrointestinal or biliary disorders that could impair absorption, metabolism or excretion of orally administered medications. o Inability to complete exercise g at baseline screening. 0 History of PDE-S inhibitor use within 3 months before study onset. 0 Use of any other drug to treat pulmonary hypertension within 3 months before study onset. 0 Known intolerance to oral udcna?l. o Frequent use of medications or other substances that inhibit or induce CYP3A4. 0 Current use of alpha-blockers or nitrates. o Ongoing or planned participation in another research protocol that would either prevent successful tion of planned study testing or invalidate its results. 0 Noncardiac medical, psychiatric, and/or social disorder that would prevent successful completion of d study testing or would invalidate its results. 0 Cardiac care, ongoing or planned, at a non-study center that would impede study completion. 0 For s: Pregnancy at the time of screening, pregnancy planned before study tion. or refusal to use an acceptable method of contraception for study duration. 0 Unable to abstain or limit intake of ruit juice during the duration of the trial. 0 Refusal to provide written informed consent/assent. o In the opinion of the primary care physician, the subject is likely to be non- compliant with the study protocol.

The study will include baseline es of the ed pharmacodynamics (PD) endpoints as well as quality of life surveys. For example, EndoPAT vascular ment will be completed as the ?rst PD tcst following t. This must be performed in a fasting (from midnight until after the test), non- caffeinated state. After the vascular ment, subjects will have a targeted echoeardiogram to assess cular function. A short break will be given, either after the vascular assessment or after the echocardiogram, and a light snack will be provided. Safety labs will be med following the vascular ment, cehocardiogram, and break. These will include collection of blood to evaluate serum creatinine and liver enzyme (aspanate transaminase and alanine transaminase) levels for all participants, and a urine pregnancy test for female ipants. If the pregnancy test is positive all further testing will be stopped, the patient will not be enrolled into the trial and the result will be conveyed to the subject and/or guardians by the site-principal investigator in accordance with local lRB ures. After the safety labs, an exercise test will be administered using a braked cycle ergometer ing a ramp protocol usly published in the PI-lN Fontan Cross-Sectional Study. After exercise g. subjects will have completed the baseline testing. Additionally, The Feds QL, cardiac specific Pcds QL, and PCQLI will be administered during the baseline testing visit.

A study coordinator will call each subject weekly for four weeks and then monthly thereafter to collect adverse events and answer questions related to the study.

At the end of the study, subjects will arrive in a fasting, ffeinated state, and ?rst undergo vascular function assessment including ing the baseline tests as well as the quality of life surveys. Follow up with subjects may occur at 30 and 90 days following end—of—study testing to record any additional adverse events possibly or probably related to the study drug that may have occurred in the 90 days following completion of the study protocol.

It is expected that udenafil (87.5 mg bid) in adolescents with Fontan physiology over a 6-12 month period will be safe and well tolerated, with few, if any, serious adverse events related to udenafil. The severity of adverse events is determined according to the Common Terminology Criteria for Adverse Events (CTCA E) Version 4.0 MedDRA 12.1 (http://etep.caneer.gov). Likewise, the effect of udenafil on pharmacodynamic outcomes including exercise capacity, rdiographic measures of cular function, endothelial function, and biomarkers associated with heart failure is expected to improve over the course of treatment. The outcomes to be measured to determine the efficacy of udenafil in this patient tion will include: 0 Exercise: Change in maximal oxygen ption from baseline to end-of- study testing measured using a standardized exercise test; 0 Echo: Change in myocardial performance index as measured by pulse wave Doppler echocardiography from ne to end—of-study testing; 0 Endothelial Function: Change in log-transformed Reactive Hyperemia Index d from the Endol’AT-R‘v device; and o Biomarkers: Change in serum BNP level from ne to end-of-study.

As well as: 0 Exercise: Submaximal measures of exercise capacity will be collected and evaluated. 0 Echo: Measure of systolic and diastolic function will be collected from a targeted echocardiogram.

The study may also look at outcomes related to ventricular cavity size, eccentricity, and mass; systolic on as ted using mean dP/dt during isovolumetric contraction (dP/dtic) and peak systolic annular velocity (8’) on tissue Doppler; tissue Doppler based estimates of diastolic function and MP1; and qualitative and quantitative estimate of AV valve insuf?ciency.

It is also expected that functional health status will improve following administration of udcnafil. The change in functional health status from baseline to the end of the study may be ed by the full scale Peds QL, Peds QL physical functioning score, Peds QL psychosocial functioning score, Peds QL cardiac-speci?c module quality of life score, and/or the pediatric c quality of life inventory (PCQLI) score.

Furthermore, c al may be collected during the study to fy genetic determinants of response to udena?l after the Fontan procedure in persons with single-ventricle lesions. This will provide an indication of whether speci?c sub- populations of patients will have a more positive se to udenafil than others. For instance, the response to udena?l may be in?uenced by variants related to the vascular response to udena?l. Variants in the endothelial nitric oxide synthase gene have been reported to in?uence the response to sildena?l in patients with erectile dysfunction, although this has not been studied for udenafll. Variation in genes that regulate the vascular, inotropic and chronotropic response to exercise may influence the exercise capacity of patients after the Fontan ure as well as the response to udenafil. DNA will be stored to perform future ping studies to analyze the genetic contribution to the response to udena?l.

Additional covariate measures will include, but may not be limited to, age, gender, race/ethnicity, height/weight, ventricular morphology, resting oxygen tion, ne codynamics test results, and current medication use. Observance of these variables will allow for the identification of associations between a variety of clinical factors and both safety and PD outcomes.

Data collection will include recording demographic information including age, gender, race, ethnicity, cardiac y, date of Fontan procedure, presence of a fenestration, degree of atrioventricular valve regurgitation, grade of ventricular on, concomitant medications, and significant co- morbidities. Safety data will reviewed with each subject at each study visit and during one encounters. These events will be recorded and graded by severity and relationship to the study drug based upon established criteria. Two additional telephone encounters will take place 30 days and 90 days following end-of-study testing to assess for any e events ly or probably d to the study drug in the period following the completion of study procedures.

Other data collection will include: 0 Exercise stress test - Data from the braked cycle crgometry exercise stress tests will be collected according to protocol established in the PHN Fontan Cross- Sectional Study3. 0 Assessment of ventricular performance - Each study echoeardiogram will be stored in a de~identi?ed manner and sent to a core laboratory, which will perform the data analysis and submit the ements to the PHN Data Coordinating Center (DCC). 0 Vascular function testing - nti?ed data from EndoPAT-R;= testing will be collected according to a standardized protocol. These data will be sent to a vascular core lab, which will perform the analysis and submit the measurements to the PHN DCC. o Biomarkers - Scrum for measurement of BNP level will be sent to a core al lab. Results will be sent directly to the PHN DCC. 0 Quality of life survey - s of the Quality of life surveys will be submitted to the PHN DCC. 0 Samples for the biorepository - Samples collected for the biorepository will be shipped directly to the biorepository for future analysis.

Subjects will be treated with other medications at the discretion of their physicians. At the study visits, current medications will be recorded on the study forms.

If a subject begins open-label use of any other PDE-S inhibitor at any time during the study, withdrawal from the study drug is ed.

When an individual subject completes the study, the subject’s primary cardiologist will be d, and the study drug will be stopped; there is no need to wean subjects off of the study drugs. The decision of r to continue the use of an off label PDE-S inhibitor for individual subjects will be decided by the subjects and their y cardiologist.

While n of the preferred embodiments of the present invention have been described and speci?cally exemplified above, it is not intended that the invention be limited to such embodiments. Various modifications may be made thereto without departing from the scope and spirit of the present invention.

HAS512599NZPR 304562159 In a first ular embodiment the invention provides a method of treating, preventing, and/or minimizing conditions, symptoms, and/or side effects associated with a patient who has had a Fontan procedure, the method comprising administering to the patient a therapeutically effective amount of udenafil or a pharmaceutically acceptable salt f.

In a second particular embodiment the invention provides a method according to the first particular embodiment, wherein the condition, symptom, and/or side effect is: (a) cardiac output, and the method results in ing cardiac output; (b) pulmonary vascular resistance, and the method results in decreasing pulmonary vascular resistance; (c) exercise capacity, and the method results in sing exercise capacity; (d) myocardial performance, and the method results in improving myocardial performance; (e) aerobic exercise performance, and the method results in improving aerobic exercise performance; or (f) any combination thereof.

In a third particular embodiment the invention es a method according to the second ular embodiment, wherein: (a) cardiac output is improved by an amount selected from the group consisting of about %, about 8%, about 10%, about 15%, about 20%, about 25%, about 30%, about %, about 40%, about 45%, and about 50%; (b) pulmonary vascular resistance is decreased by an amount ed from the group consisting of about 5%, about 8%, about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, and about 50%; (c) exercise ty is increased by an amount selected from the group consisting of about 5%, about 8%, about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, and about 50%; (d) myocardial performance is ed by an amount selected from the group consisting of about 5%, about 8%, about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, and about 50%; (e) c exercise performance is improved by an amount selected from the group consisting of about 5%, about 8%, about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, and about 50%; or (f) any combination thereof. 599NZPR 304562159 In a fourth particular embodiment the ion es a method according to any one of the first to third particular embodiments, wherein the patient who has had the Fontan procedure is a human patient.

In a fifth particular embodiment the invention provides a method according to the fourth particular embodiment, wherein the patient: (a) is an adult human patient over about 18 years of age; (b) is a pediatric patient of about 2 to about 18 years of age; (c) is a pediatric patient of about 12 to about 18 years of age; or (d) is a pediatric patient from about 12 to about 16 years of age.

In a sixth particular ment the invention provides a method according to the first particular embodiment, wherein the udenafil or the pharmaceutically acceptable salt f is in a solid oral dosage form.

In a seventh particular embodiment the invention provides a method according to the sixth particular embodiment, wherein the solid oral dosage form is a table or capsule.

In an eighth particular embodiment the invention es a method according to the first particular embodiment, wherein the udenafil or a pharmaceutically acceptable salt thereof is administered in a total daily dose between about 25 mg and about 600 mg.

In a ninth particular embodiment the invention provides a method according to the eighth particular embodiment, wherein the udenafil or a ceutically acceptable salt f is administered at a total daily dose of about 37.5 mg, about 75 mg, about 87.5 mg, about 125, or about 175 mg.

In a tenth particular embodiment the invention provides a method according to the first particular embodiment, n the udenafil or a pharmaceutically acceptable salt f is administered once a day.

In an eleventh particular embodiment the invention provides a method according to the tenth particular embodiment, wherein once a day administration of a therapeutically effective dosage of udenafil, or a pharmaceutically acceptable salt thereof, results in therapeutic levels of udenafil, present in the patient's blood stream for up to about 8 hours.

In a twelfth particular embodiment the invention provides a method according to the eleventh particular embodiment, wherein therapeutic levels of il are present in the patient's blood stream for a time period selected from the group consisting of up to about 10, about 1 1, about 12, about 13, about 14, about 15, about 16, about 17, about 18, about 19, about 20, about 21, about 22, about 23, and about 24 hours.

HAS512599NZPR 304562159 In a thirteenth particular embodiment the invention provides a method according to the first particular embodiment, wherein the udenafil or a pharmaceutically acceptable salt thereof is administered twice a day.

In a fourteenth particular embodiment the invention provides a method according to the thirteenth particular embodiment, wherein twice a day stration of a therapeutically ive dosage of udenafil, or a pharmaceutically acceptable salt thereof, s in therapeutic levels of il, present in the patient's blood stream for at least about 16 hours in a 24 hour dosing period.

In a fifteenth particular embodiment the invention provides a method according to the fourteenth particular embodiment, wherein therapeutic levels of udenafil are present in the patient's blood stream for a time period of at least about 9 hours, about 10 hours, about 1 1 hours, about 12 hours, about 13 hours, about 14 hours, about 15 hours, about 16 hours, about 17 hours, about 18 hours, about 19 hours, about 20 hours, about 21 hours, about 22 hours, about 23 hours, or about 24 hours, in a 24 hour dosing period.

In a sixteenth particular embodiment the invention provides a method ing to the first particular embodiment, wherein: (a) the patient does not ence any serious adverse events; or (b) the patient does not experience any moderate adverse .

In a seventeenth particular embodiment the invention provides a method according to the first particular embodiment, wherein: (a) V02 at maximal effort is maintained over time; (b) over time V02 at maximal effort decreases by less than about 5%, less than about %, less than about 15%, less than about 20%, less than about 25%, less than about %, less than about 35%, or less than about 40%; (c) V02 at maximal effort improves by at least about 10%, about 15%, about 20%, about %, about 30%, about 35%, about 40%, about 45%, or about 50%; (d) V02 at an anaerobic threshold is maintained over time; (e) over time V02 at an anaerobic threshold decreases by less than about 5%, less than about 10%, less than about 15%, less than about 20%, less than about 25%, less than about 30%, less than about 35%, or less than about 40%; or (f) V02 at anaerobic old improves by at least about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, or about 50%.

In an enth particular embodiment the invention es a method according to the first particular embodiment, wherein: (a) exercise capacity is maintained over time; HAS512599NZPR (b) over time exercise ty decreases by less than about 5%, less than about 10%, less than about 15%, less than about 20%, less than about 25%, less than about 30%, less than about 35%, or less than about 40%; or (c) exercise capacity improves by at least about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, or about 50%.

In a nineteenth particular embodiment the invention provides a method according to the first particular embodiment, wherein: (a) vascular function is maintained over time; (b) over time vascular function decreases by less than about 5%, less than about 10%, less than about 15%, less than about 20%, less than about 25%, less than about 30%, less than about 35%, or less than about 40%; (c) vascular function improves by at least about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, or about 50%; and/or (d) vascular function is measured by any one of a PAT index, pulse amplitude tonometry, natural log of reactive hyperemia index, reactive hyperemia index, Framingham RHI, area under the curve to max-occlusion/control, and average up to maxocclusion /control.

In a twentieth particular embodiment the ion provides a method according to the first particular ment, wherein: (a) ventricular performance is maintained over time; (b) over time ventricular performance ses by less than about 5%, less than about %, less than about 15%, less than about 20%, less than about 25%, less than about %, less than about 35%, or less than about 40%; (c) ventricular performance improves by at least about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, or about 50%; and/or (d) ventricular mance is measured by any one of myocardial performance index (MPI), blood pool MPI, tissue Doppler MPI, and average isovolumetric contraction and relaxation.

In a twenty-first particular embodiment the invention provides a method according to the first particular embodiment, n blood pool MPI improves by at least 20%.

In a twenty-second particular embodiment the ion provides a method according to the first particular embodiment, wherein administering a therapeutically effective amount of udenafil or a pharmaceutically able salt thereof results in a characteristic pharmacokinetic profile.

HAS512599NZPR 304562159 In a twenty-third particular embodiment the invention provides a method according to the twenty-second particular embodiment, wherein the characteristic pharmacokinetic e comprises: (a) a Cmax between 300 and 700 ng/ml; (b) a Cmax of about 500 ng/ml; (c) a Tmax between 1 and 1.6 hr; (d) a Tmax of about 1.3 hr; (e) an AUC?? between 2550 and 4150 ng• hr/ml; (f) an AUC?? of about 3350 ng •hr/ml; (g) an AUC0-24 between 5110 and 8290 ng • hr/ml; (h) an AUC0-24 is about 6701 ng• hr/ml.

In a -fourth r particular embodiment, the invention relates to the use of an effective dose of udenafil, or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for the treatment of a patient born with functional single cle congenital heart disease who has undergone Fontan palliation for improving the patient’s exercise capacity or for increasing the likelihood of ing the patient’s exercise capacity, whose exercise ty is adversely affected due to a decline in the patient’s heart function after Fontan palliation, wherein the patient is in need of treatment to improve the patient’s exercise capacity or to increase the likelihood of ing the patient’s exercise capacity as determined by m oxygen uptake at m exercise output (VO2 measurement), said method sing: orally administering to the patient in accordance with a treatment regimen an oral dosage form comprising an effective dose of udenafil, or a pharmaceutically acceptable salt thereof, to improve the patient’s VO2 measurement or to increase the likelihood of improving the patient’s VO2 measurement for improving the patient’s exercise capacity or for increasing the likelihood of improving the t’s exercise capacity, wherein the patient is a human, wherein the patient has undergone Fontan surgery, wherein the human patient is between about 12 years old and under about 18 years HAS512599NZPR wherein the ive dose of udenafil, or a pharmaceutically acceptable salt thereof, is about 87.5 mg, and wherein the treatment regimen comprises orally administering the oral dosage form to the human adolescent twice daily.

In a further particular embodiment of the twenty-fourth particular embodiment, the invention relates to the use of the twenty-fourth particular embodiment, wherein the oral dosage form is a tablet.

In a further particular embodiment of the twenty-fourth particular embodiment, the ion relates to the use of the twenty-fourth particular embodiment, wherein the oral dosage form is a solid or semi-solid oral dosage form selected from a group of solid or semisolid oral dosage forms consisting of a tablet, a capsule, a gel, a liquid dispersion, a pill, a powder and a suspension.

In a twenty-fifth particular embodiment, the invention relates to the use of an ive dose of udenafil, or a pharmaceutically acceptable salt thereof in in the manufacture of a medicament for the treatment of a patient born with functional single ventricle congenital heart disease who has undergone Fontan palliation for improving the patient’s exercise capacity or for increasing the likelihood of improving the patient’s exercise capacity, whose exercise capacity is adversely affected due to a decline in the patient’s heart function after Fontan palliation, wherein the t is in need of treatment to improve the patient’s exercise capacity or to increase the hood of improving the patient’s exercise capacity as determined by maximum oxygen uptake at maximum exercise output (VO2 measurement), said method comprising: orally administering to the patient in accordance with a treatment n an oral dosage form sing an effective dose of udenafil, or a pharmaceutically acceptable salt thereof, to improve the patient’s VO2 ement or to increase the likelihood of ing the patient’s VO2 measurement for improving the patient’s exercise ty or for increasing the likelihood of improving the patient’s exercise capacity, n the patient is a human, wherein the patient has undergone Fontan surgery, wherein the human patient is between about 12 years old and under about 18 years old, and wherein the total daily dose of udenafil, or a pharmaceutically acceptable salt thereof, is from about 125 mg to about 175 mg HAS512599NZPR 304562159 In a further particular embodiment of the twenty-fifth ular embodiment, the invention relates to the use of the twenty-fifth particular embodiment, n the oral dosage form is a .

In a further ular embodiment of the -fifth particular embodiment, the ion relates to the use of the twenty-fifth ular embodiment, wherein the oral dosage form is a solid or semi-solid oral dosage form selected from a group of solid or semisolid oral dosage forms consisting of a tablet, a capsule, a gel, a liquid sion, a pill, a powder and a suspension.

In a twenty-sixth particular embodiment, the invention relates to the use of an effective dose of udenafil, or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for the treatment of a patient born with a congenital heart defect who has undergone Fontan palliation for improving the patient’s exercise ty or for increasing the likelihood of improving the patient’s exercise capacity, whose exercise capacity is adversely affected due to a decline in the patient’s heart function after Fontan palliation, wherein the t is in need of treatment to improve the t’s exercise capacity or to increase the likelihood of improving the patient’s exercise capacity as determined by maximum oxygen uptake at maximum exercise output (VO2 measurement), said method comprising: orally administering to the patient in accordance with a treatment regimen an oral dosage form sing an effective dose of udenafil, or a pharmaceutically acceptable salt thereof, to improve the patient’s VO2 measurement or to increase the likelihood of improving the patient’s VO2 measurement for improving the patient’s se capacity or for increasing the hood of improving the patient’s exercise capacity, wherein the patient is a human, wherein the patient has undergone Fontan surgery, wherein the human patient is between about 12 years old and under about 18 years wherein the effective dose of udenafil, or a pharmaceutically acceptable salt thereof, is about 87.5 mg, and wherein the treatment regimen comprises orally administering the oral dosage form to the human adolescent twice daily.

In a further particular embodiment of the twenty-sixth particular embodiment, the invention relates to the use of the twenty-sixth particular embodiment, wherein the oral dosage form is a tablet.

HAS512599NZPR 304562159 In a further particular embodiment of the twenty-sixth ular embodiment, the ion relates to the use of the twenty-sixth particular embodiment, wherein the oral dosage form is a solid or semi-solid oral dosage form ed from a group of solid or lid oral dosage forms ting of a tablet, a capsule, a gel, a liquid dispersion, a pill, a powder and a suspension.

In a twenty-seventh particular embodiment, the invention relates to the use of an effective dose of udenafil, or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for the ent of a patient born with a congenital heart defect who has undergone Fontan palliation for improving the patient’s exercise capacity or for increasing the likelihood of improving the patient’s exercise capacity, whose exercise capacity is adversely affected due to a decline in the t’s heart function after Fontan palliation, wherein the patient is in need of treatment to improve the patient’s exercise capacity or to increase the likelihood of improving the patient’s exercise capacity as determined by maximum oxygen uptake at maximum exercise output (VO2 measurement), said method comprising: orally administering to the patient in accordance with a treatment regimen an oral dosage form comprising an effective dose of udenafil, or a pharmaceutically acceptable salt thereof, to improve the patient’s VO2 measurement or to increase the likelihood of improving the patient’s VO2 measurement for improving the patient’s exercise capacity or for increasing the likelihood of improving the patient’s exercise capacity, wherein the t is a human, wherein the patient has undergone Fontan surgery, wherein the human patient is n about 12 years old and under about 18 years old, and wherein the total daily dose of udenafil, or a ceutically able salt f, is from about 125 mg to about 175 mg.

In a further particular embodiment of the twenty-seventh particular embodiment, the invention s to the use of the twenty-seventh particular embodiment, wherein the oral dosage form is a tablet.

In a further particular embodiment of the twenty-seventh particular embodiment, the invention relates to the use of the twenty-seventh particular embodiment, wherein the oral dosage form is a solid or semi-solid oral dosage form selected from a group of solid or semisolid oral dosage forms consisting of a , a capsule, a gel, a liquid dispersion, a pill, a powder and a suspension.

HAS512599NZPR 304562159 In a twenty-eighth particular embodiment, the invention relates to the use of an effective dose of udenafil, or a pharmaceutically acceptable salt thereof in the manufacture of a ment for the treatment of a patient who has undergone Fontan tion for improving the patient’s exercise capacity or for increasing the likelihood of improving the patient’s exercise capacity, whose exercise capacity is adversely affected due to a e in the patient’s heart function after Fontan palliation, wherein the patient is in need of treatment to e the patient’s exercise capacity or to increase the hood of improving the patient’s exercise capacity as determined by maximum oxygen uptake at maximum exercise output (VO2 ement), said method comprising: orally administering to the patient in accordance with a treatment regimen an oral dosage form comprising an effective dose of udenafil, or a pharmaceutically able salt thereof, to improve the patient’s VO2 measurement or to increase the likelihood of improving the patient’s VO2 measurement for improving the t’s exercise capacity or for increasing the likelihood of improving the patient’s exercise capacity, wherein the patient is a human, wherein the patient has undergone Fontan surgery, n the human patient is between about 12 years old and under about 18 years wherein the effective dose of udenafil, or a pharmaceutically acceptable salt f, is about 87.5 mg, and wherein the treatment regimen comprises orally administering the oral dosage form to the human adolescent twice daily.

In a further particular ment of the -eighth particular embodiment, the invention relates to the use of the twenty-eighth particular embodiment, wherein the oral dosage form is a .

In a further particular embodiment of the twenty-eighth particular embodiment, the invention relates to the use of the twenty-eighth particular embodiment, wherein the oral dosage form is a solid or semi-solid oral dosage form selected from a group of solid or semisolid oral dosage forms consisting of a , a capsule, a gel, a liquid dispersion, a pill, a powder and a suspension.

In a further particular embodiment of the twenty-eighth particular embodiment, the invention s to the use of the twenty-eighth particular embodiment, wherein the patient is born with a single functional ventricle.

HAS512599NZPR 304562159 In a r particular embodiment of the twenty-eighth ular embodiment, the invention relates to the use of the twenty-eighth particular embodiment, wherein the patient is born with a congenital heart defect.

In a twenty-ninth particular embodiment, the invention relates to the use of an effective dose of udenafil, or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for the treatment of a patient who has undergone Fontan palliation for ing the patient’s exercise capacity or for sing the likelihood of improving the patient’s exercise capacity, whose exercise capacity is adversely affected due to a decline in the patient’s heart function after Fontan palliation, wherein the patient is in need of ent to improve the patient’s exercise capacity or to increase the likelihood of improving the patient’s exercise capacity as determined by maximum oxygen uptake at maximum exercise output (VO2 measurement), said method comprising: orally administering to the patient in accordance with a treatment regimen an oral dosage form comprising an effective dose of il, or a pharmaceutically acceptable salt thereof, to improve the patient’s VO2 measurement or to se the likelihood of ing the patient’s VO2 measurement for improving the patient’s exercise capacity or for increasing the likelihood of improving the patient’s exercise capacity, wherein the patient is a human, wherein the patient has one Fontan surgery, wherein the human patient is between about 12 years old and under about 18 years old, and wherein the total daily dose of udenafil, or a pharmaceutically acceptable salt thereof, is from about 125 mg to about 175 mg.

In a further particular embodiment of the twenty-ninth particular embodiment, the invention relates to the use of the twenty-ninth particular embodiment, wherein the oral dosage form is a tablet.

In a further particular embodiment of the twenty-ninth particular ment, the ion relates to the use of the twenty-ninth particular embodiment, wherein the oral dosage form is a solid or semi-solid oral dosage form selected from a group of solid or semisolid oral dosage forms consisting of a , a capsule, a gel, a liquid dispersion, a pill, a powder and a suspension.

In a further particular embodiment of the twenty-ninth particular embodiment, the invention relates to the use of the twenty-ninth particular ment, wherein the t is born with a single functional ventricle.

HAS512599NZPR 304562159 In a further particular ment of the twenty-ninth particular embodiment, the invention relates to the use of the twenty-ninth particular embodiment, wherein the patient is born with a congenital heart defect.

Claims (15)

WHAT IS D IS:

1. Use of an effective dose of udenafil, or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for the treatment of a human, who has one Fontan palliation for improving the human’s exercise capacity, whose se capacity is adversely affected due to a decline in the human’s heart function after Fontan palliation, wherein the human is in need of treatment to improve the human’s exercise capacity as ined by maximum oxygen uptake at maximum exercise output (VO2 measurement), wherein the human has undergone Fontan surgery, wherein the human is at least 12 years old, and wherein the medicament is formulated for administration of a total daily dose of undenafil, or a pharmaceutically acceptable salt thereof, from about 125 mg to 175 mg.

2. The use of claim 1, wherein the ive dose of undenafil, or a pharmaceutically acceptable salt thereof, is about 87.5 mg, and wherein the medicament is formulated as an oral dosage form for twice daily administration.

3. The use of claim 2, wherein the human has single ventricle heart disease.

4. The use of claim 1, wherein the human has single ventricle heart e, and wherein the medicament is formulated as an oral dosage form.

5. The use of any one of claims 2 to 4, wherein the oral dosage form is a tablet.

6. The use of any one of claims 2 to 4, wherein the oral dosage form is a solid or olid oral dosage form selected from a group of solid or semi-solid oral dosage forms consisting of a tablet, a capsule, a gel, a liquid dispersion, a pill, a powder, and a suspension.

7. The use as claimed in claim 1, wherein the human is between about 12 years old and under about 18 years old.

8. The use of claim 7, wherein the effective dose of udenafil, or a pharmaceutically acceptable salt thereof, is about 87.5 mg, and wherein the medicament is formulated as an oral dosage form for twice daily administration.

9. The use of claim 8, wherein the human has single ventricle heart disease.

10. The use of claim 7, wherein the human has single cle heart disease, and wherein the medicament is formulated as an oral dosage form.

11. The use of any one of claims 8 to 10, wherein the oral dosage form is a tablet.

12. The use of any one of claims 8 to 10, wherein the oral dosage form is a solid or semi-solid oral dosage form ed from a group of solid or semi-solid oral dosage forms consisting of a tablet, a capsule, a gel, a liquid dispersion, a pill, a , and a suspension.

13. The use of any one of claims 7 to 12, wherein the human is a .

14. The use of any one of claims 7 to 12, wherein the human is a male.

15. The use as claimed in claim 1, substantially as hereinbefore described with particular reference to any one or more of the figures and/or examples. we 5“ Event £30 nun/«nannnu Suggests, nanny” Adverse 4 %3 ’Y’" Percentage Reported 48 uufwununnnnnn Wm & ‘3 event a 3 events; i “““““““““ a 5 events 0 ‘w «3’ : : é. ~~.~~“““.«“~“.-~~~~“e Exercise 3?.5 mg 37.5 mg 87,5: mg 835 mg 125 mg mg dam twice daiéy daiig Moe gaéiy dam: