HK1243065A - Treatment for lipodystrophy - Google Patents

Description

Treatment of lipodystrophy

The present application is a divisional application of chinese patent application No. 201280006760.2 entitled "treatment of lipodystrophy" filed on day 2012, month 01 and 30.

Technical Field

The present invention relates to the development of therapeutic compounds for the prevention and treatment of lipodystrophy. In particular, the present invention relates to the development of therapeutic compounds for the prevention and treatment of lipodystrophy in HIV-infected patients (LDHIV). In particular, the invention further provides suitable compositions effective in treating or preventing or alleviating the symptoms of lipodystrophy in HIV-infected patients (LDHIV).

Background

Lipodystrophy is a very dreaded disease and has become a major global health problem. It is a disorder of fat metabolism that causes lipohypertrophy, subcutaneous lipoatrophy, and metabolic abnormalities. In addition, lipogenesis includes enlargement of the fat pad on the back of the neck (commonly referred to as "buffalo back"), expansion of 5-10cm around the neck, hypertrophy occurring in the chest, central trunk obesity caused by visceral fat accumulation in the abdomen, symmetric and asymmetric hyperlipidemias. One rare pattern of lipid accumulation involves the development of zonal hyperlipidemia, suprapubic fat pad (pubic lipoma), and multiple vascular lipomas that form symmetrically from the chest and grow laterally to the armpit.

Subcutaneous lipoatrophy involves temporary wasting and loss of subcutaneous fat (fat pads) from the cheek, which produces a slimy appearance with prominent nasolabial folds. Additional subcutaneous tissue is depleted from the arms, shoulders, thighs, and buttocks (limb wasting) with the bulging of superficial veins in these areas.

Metabolic abnormalities include elevated cholesterol and triglyceride levels and reduced High Density Lipoprotein (HDL) cholesterol levels, insulin resistance, type II diabetes, and lactacidosis (lactic academya).

Lipodystrophy is commonly associated with HIV patients who are receiving antiretroviral drug therapy. These drugs may include HIV-1 Protease Inhibitors (PI), Nucleoside Reverse Transcriptase Inhibitors (NRTI), non-nucleoside reverse transcriptase inhibitors (NNRTI), fusion inhibitors, entry inhibitors-CCR 5 co-receptor antagonists, HIV integrase chain transfer inhibitors, and the like. These drugs increase patient survival, but also produce lipohypertrophy, atrophy of subcutaneous fat, and other metabolic abnormalities.

In HIV infected patients LDHIV, HIV-1 Protease Inhibitor (PI) appears to be the strongest link to lipodystrophy because it inhibits the maturation of Sterol Response Element Binding Protein (SREBP), which affects intracellular fatty acid and glucose metabolism and adipocyte differentiation (Mallon et al, J infection Dis, 2005). In addition, PI also down-regulates peroxisome proliferator-activated receptor gamma (PPAR γ), an important nuclear transcription factor, which is affected by SREBP and is essential for adipocyte differentiation and function and fatty acid metabolism.

Other factors, such as the duration of HIV infection, age, and sex, may also contribute to the risk of development of LDHIV. The molecular basis of LDHIV is still unknown and there is no specific therapy available for LDHIV.

Reverse transcriptase inhibitors (nRTI) such as stavudine, didanosine and zidovudine can cause mitochondrial toxicity by inhibiting mitochondrial DNA polymerase- γ in adipose and other tissues and thus interfere with the respiratory chain complex. The result is a reduced oxidation of fatty acids and intracellular accumulation of triglycerides and lactate.

Furthermore, lipodystrophy is also observed in acute HIV infection, which also supports direct viral effects. Potential host risk factors include age, gender, and race or ethnicity. Lipodystrophy is more common in elderly patients; fat accumulation is more common in women; and subcutaneous lipoatrophy is more common in men; and non-hispanic black patients appear to be at lower risk for subcutaneous lipoatrophy. Recent analysis in the AIDS Clinical Trials Group (ACTG) study 5005s indicated a genetic makeup suggesting susceptibility or protection associated with mitochondrial DNA polymorphisms. Hulgan et al, J infection Dis,2008, described that patients homozygous for C/C at the HFE187 locus (n ═ 71) had 0.6-kg and 12.5% loss of limb fat at 48 to 64 weeks, with 37 of 71 patients (52%) diagnosed with clinical subcutaneous lipoatrophy. By comparison, heterozygous patients with HFE187C/G had 0.2-kg and 6.1% increase in limb fat, with 6 (26%) of 23 patients with clinical subcutaneous lipoatrophy (P <0.05 for all comparisons).

A range of strategies for reducing central obesity, such as discontinuation of PI therapy, have been investigated, but are not effective. Changes in diet and exercise have resulted in improvements, but it is difficult for most patients to adhere to lifestyle changes regimens. Liposuction may be particularly applied to dorsal cervical fat deposits, i.e., "buffalo backs".

It is evident from several studies that thiazolidinediones show no change in VAT (pathobiology and treatment of lipodystrophy, vol.16, issue 4, Oct/November, 2004).

Testosterone recovery (replacement) to physiological levels in elderly non-HIV infected men with upper body obesity and low testosterone levels reduces Visceral Adipose Tissue (VAT), total fat, and abdominal fat, and improves insulin sensitivity and fat distribution (profile). In a recent study, 88 HIV-infected men with central obesity (> 100cm waist circumference) and low testosterone levels (<400ng/dL) were randomized to receive testosterone or placebo as a transdermal gel at a dose of 10 g/day for 24 weeks (Bhasin et al, J Clin Endocrinol Metab, 2007). The testosterone group had a statistically significant reduction in abdominal fat (-1.5% versus + 4.3%), abdominal Subcutaneous Adipose Tissue (SAT) (-7.2% versus + 8.1%), trunk fat (-9.9% versus + 4.6%), and limb fat (-10.1% versus + 3.1%); the latter finding is of potential concern in populations predisposed to subcutaneous lipoatrophy. No statistically significant difference was observed in the change in VAT (+ 0.9% versus + 2.3%) and no statistically significant difference was observed in the change in blood lipid levels, fasting blood glucose levels, insulin levels, or insulin resistance.

Like testosterone, Growth Hormone (GH) has the property of fat oxidation and lipolysis. A significant proportion of HIV patients with central obesity (approximately 30% to 40%) have impaired GH biological status, including reduced GH hypersecretion, reduced response to GH-releasing hormone (GHRH) and free fatty acids, and elevated somatostatin (somatostatin) which inhibits GH. Several recent studies have evaluated GH treatment in HIV patients with fat deposits. In one study, 325 HIV patients with increased waist-to-hip ratio and increased VAT measurements were received.

Although Growth Hormone (GH) and GH-releasing hormone (GHRH) therapies show some promising results due to their fat oxidizing and lipolytic properties, their use is limited. They are parenteral therapies and are expensive (rhGH) or not FDA approved (temamorelin). To date, there is evidence to suggest: there is a diminishing durability that reduces the tapering of VAT after they cease, a short-term increase in insulin resistance with respect to rhGH, and a smaller short-term decrease.

Because of some beneficial effects on lipodystrophy, recent research publications have shown the use of two lipid lowering drugs: statins and fibrates, antiretroviral switching strategies, and the use of insulin sensitizers. However, no monotherapy can achieve the ideal clinical endpoint for HIV-associated lipodystrophy.

Accordingly, it would be desirable to develop compounds that can overcome the above discussed drawbacks of the prior art and to develop therapies for HIV-related lipodystrophy.

Hypolipidemic agents (which are PPAR modulators) have been disclosed in WO 91/19702, WO 94/01420, WO 94/13650, WO 95/03038, WO 95/17394, WO 96/04260, WO 96/04261, WO 96/33998, WO 97/25042, WO 97/36579, WO 98/28534, WO 99/08501, WO 99/16758, WO 99/19313, WO99/20614, WO 00/23417, WO 00/23445, WO 00/23451, WO 01/53257.

WO 03009841 discloses compounds of the general formula

These compounds are reported to be hypolipidemic agents. This document also discloses sodium and calcium salts of some of the compounds disclosed therein. However, due to rapid degradation, it is difficult to isolate the sodium salt of the compound of the invention, while the calcium salt is poorly absorbed, limiting its efficacy and the possibility of further development. Further, calcium salt degradation was also found after long-term storage. It has now surprisingly been found that certain compounds and selected salts thereof are effective in treating lipohypertrophy, subcutaneous lipoatrophy and metabolic abnormalities in HIV patients.

Modes for carrying out the invention

In one embodiment, the present invention provides compounds of formula (I) useful for the treatment and prevention of lipodystrophy.

In one embodiment, the disorder associated with lipodystrophy includes the following symptoms: lipohypertrophy, atrophy of subcutaneous fat, and other metabolic abnormalities.

In another embodiment, the present invention provides compounds of formula (I) for use in the treatment and prevention or alleviation of the following symptoms in HIV patients: lipohypertrophy, subcutaneous lipoatrophy and metabolic abnormalities.

In a further embodiment, the present invention provides compounds of formula (I) and their pharmaceutically acceptable salts, administered alone or in combination with other suitable formulations as therapeutic agents, for the treatment and prevention or alleviation of the symptoms of lipodystrophy.

In a further embodiment, the invention provides suitable pharmaceutical compositions comprising compounds of formula (I) or suitable thereof for the treatment and prevention or alleviation of the symptoms of lipodystrophy.

In another embodiment, the present invention provides certain pharmaceutically acceptable salts of the compounds of formula (I).

Disclosure of Invention

The present invention provides compounds of formula (I) and their pharmaceutically acceptable salts for use in the prevention and treatment or alleviation of symptoms of lipodystrophy. The present invention provides compounds of formula (I) and their pharmaceutically acceptable salts for the prevention and treatment or alleviation of the symptoms of lipodystrophy caused by HIV infection or by treatment with antiretroviral agents. These antiretroviral agents may include HIV-1 Protease Inhibitors (PI), Nucleoside Reverse Transcriptase Inhibitors (NRTI), non-nucleoside reverse transcriptase inhibitors (NNRTI), fusion inhibitors, entry inhibitor-CCR 5 co-receptor antagonists, HIV integrase chain transfer inhibitors, and the like, or combinations involving one or more antiretroviral agents. Compounds of formula (I) inhibit lipohypertrophy, subcutaneous lipoatrophy and metabolic abnormalities in HIV patients. Furthermore, the present invention provides suitable compositions comprising a compound of formula (I) effective in treating or preventing or alleviating the symptoms of lipodystrophy in HIV-infected patients (LDHIV).

In a further embodiment, certain novel salts of compounds corresponding to formula (I) are disclosed wherein M represents K or Mg.

Detailed Description

The present invention describes compounds of formula (I) which are useful for the treatment of lipodystrophy or HIV-related lipodystrophy.

Wherein 'R' is selected from the group consisting of hydroxy, hydroxyalkyl, acyl, alkoxy, alkylthio, thioalkyl, aryloxy, arylthio, and M⁺Denotes a suitable metal cation such as Na⁺、K⁺、Ca⁺²、Mg⁺²And so on.

In a preferred embodiment, 'R' represents thioalkyl, alkoxy or hydroxyalkyl; in a more preferred embodiment, 'R' denotes-SCH₃or-OCH₃A group.

In one embodiment, there is provided a suitable pharmaceutical composition comprising a compound of formula (I) for the treatment of lipodystrophy or HIV-associated lipodystrophy. The pharmaceutical compositions of the present invention comprise a compound of formula (I) together with suitable excipients as defined hereinafter for the treatment of lipodystrophy or HIV-associated lipodystrophy.

In another embodiment, the present invention provides a method for treating a subject suffering from lipodystrophy or HIV-associated lipodystrophy, the method comprising treating a patient in need of such therapy with a compound of formula (I) or a suitable pharmaceutical composition comprising the same.

In a further embodiment, the present invention provides the use of a compound of formula (I) or a suitable pharmaceutical composition thereof for the treatment of lipodystrophy or HIV-associated lipodystrophy.

In one embodiment, the present invention provides certain novel salts of compounds of formula (Ia).

Wherein 'R' is selected from the group consisting of hydroxy, hydroxyalkyl, acyl, alkoxy, alkylthio, thioalkyl, aryloxy, arylthio, and M⁺Represents a group selected from K⁺、Mg⁺²Suitable metal cations.

In a preferred embodiment, 'R' represents thioalkyl and alkoxy or hydroxyalkyl; in a more preferred embodiment, 'R' denotes-SCH₃or-OCH₃A group. In another preferred embodiment, M⁺Represents Mg⁺²。

An effective amount of the compound of formula (I) is selected from 1mg to 500mg, preferably 1mg to 250mg, and more preferably 4mg to 50 mg. The compound of formula (I) or a suitable salt thereof is administered orally, intravenously, enterally in a subject in need thereof.

In one embodiment, the compound of formula (I) is effective for treating or preventing or alleviating the symptoms of lipodystrophy. In a preferred embodiment, the compound of formula (I) is effective for treating or preventing or alleviating the symptoms of HIV-associated lipodystrophy. In such embodiments, the lipodystrophy is a dyslipidemic disorder that causes lipohypertrophy, subcutaneous lipoatrophy, and metabolic abnormalities.

In one embodiment, the compounds of formula (1) treat or prevent or reduce at least one symptom of lipodystrophy, including, but not limited to, as an agent for lowering and/or controlling blood glucose levels, an agent for controlling blood lipid levels, for example, as an agent for lowering and/or controlling cholesterol, an antioxidant, an appetite suppressant, an anti-obesity agent, a probiotic, or an anti-inflammatory agent. In another embodiment, the compound of formula (1) treats or prevents or reduces at least one symptom of lipodystrophy, including but not limited to triglyceride levels, VLDL levels, and Apo B levels in serum. In another embodiment, the compound of formula (1) treats or prevents lipodystrophy by improving at least one state selected from HDL levels, Apo a1 levels, HOMA of c-peptide derived beta cell function.

In one embodiment, the invention also provides suitable pharmaceutical compositions of compounds of formula (I) or their derivatives. The pharmaceutical composition of the present invention essentially comprises:

-a pharmaceutically active substance;

-a suitable buffer;

-a suitable stabilizer;

optionally one or more pharmaceutically acceptable excipients.

Suitable stabilizers for use in the pharmaceutical composition are selected from potassium polycryline, potassium chloride, sodium stearyl fumarate and preferably from sodium stearyl fumarate. Suitable buffers are selected from sodium acetate, ammonia solution, ammonium carbonate, sodium borate, adipic acid, glycine, monosodium glutamate and preferably from ammonia solution.

The pharmaceutically acceptable excipient is selected from at least one of: carriers, binders, antioxidants, disintegrants, wetting agents, lubricants, chelating agents, surfactants, and the like.

Diluents include, but are not limited to, lactose monohydrate, lactose, polymethacrylates selected from Eudragit (Eudragit, a pharmaceutically acceptable acrylic resin), potassium chloride, sulfobutyl ether beta-cyclodextrin, sodium chloride, spray dried lactose, and preferably sulfobutyl ether beta-cyclodextrin. Carriers include, but are not limited to, lactose, white sugar, sodium chloride, glucose, urea, starch, calcium carbonate and kaolin, crystalline cellulose, and silicic acid. Binders include, but are not limited to, carbomers selected from carbopols, gellan gum, gum arabic, hydrogenated vegetable oils, polymethacrylates selected from eucalyptus, xanthan gum, lactose, and zein. Antioxidants include, but are not limited to, hypophosphorous acid, sodium formaldehyde sulfoxylate, sulfur dioxide, tartaric acid, thymol, and methionine. Disintegrants include, but are not limited to, bicarbonate, chitin, gellan gum, polacrilin potassium, and docusate sodium. Wetting agents include, but are not limited to, glycerin, lactose, docusate sodium, and glycine. Lubricants used include, but are not limited to, glyceryl behenate, hydrogenated vegetable oil, sodium stearyl fumarate, and myristic acid. Chelating agents include, but are not limited to, maltol and pentetic acid. Surfactants include, but are not limited to, nonionic surfactants selected from the group consisting of alkyl polyglucoside, cocamide DEA, cocamide MBA, cocamide TEA, decyl maltoside, and octyl glucoside; an anionic surfactant selected from the group consisting of arachidic acid and arachidonic acid; a cationic surfactant selected from the group consisting of cetyltrimethylammonium bromide and cetylpyridinium chloride.

In one embodiment, the formulation is effective for treating or preventing or alleviating the symptoms of lipodystrophy. In a preferred embodiment, the formulation is effective in treating or preventing or alleviating the symptoms of HIV-associated lipodystrophy.

Lipodystrophy is a disorder of fat metabolism that causes lipohypertrophy, subcutaneous lipoatrophy, and metabolic abnormalities. In addition, lipogenesis includes enlargement of the fat pad on the back of the neck (commonly referred to as "buffalo back"), expansion of 5-10cm around the neck, hypertrophy occurring in the chest, central trunk obesity caused by visceral fat accumulation in the abdomen, symmetric and asymmetric hyperlipidosis. One rare pattern of lipid accumulation involves the development of zonal hyperlipidemia, suprapubic fat pads (pubic lipomas) and multiple angiolipomas that develop symmetrically from the chest and grow laterally to the armpits.

Subcutaneous lipoatrophy includes temporary wasting and loss of subcutaneous fat from the cheek (fat pads) which produces a thin appearance with prominent nasolabial folds, with the subdermal tissue being depleted from the arms, shoulders, thighs, and buttocks (limb wasting) with bulging of the superficial veins in these areas

Metabolic abnormalities include elevated and reduced High Density Lipoprotein (HDL) cholesterol levels of cholesterol and triglycerides, insulin resistance, type II diabetes, and lactacidosis.

Due to their beneficial effects on lipodystrophy, the compounds of the present invention will exert beneficial effects on redistribution of body fat (subcutaneous lipoatrophy or hypertrophy or abnormal distribution), dyslipidemia, glucose homeostasis, pro-inflammatory conditions, impact morbidity and mortality, impact on quality of life, impact on patient reported outcomes such as self-sensation, etc.

Furthermore, the underlying exact mechanisms of this syndrome are not well understood, and several hypotheses based on in vitro and human studies may explain the altered pathogenesis. Some experts believe that HIV 1-type (HIV-1) Protease Inhibitors (PI) and Nucleoside Reverse Transcriptase Inhibitors (NRTI), in particular stavudine and zidovudine, are involved as follows:

(i) reduced retinoic acid production and triglyceride uptake: PI has high affinity for the catalytic site of the HIV-1 protease, sharing 60% sequence homology with two proteins involved in lipid metabolism, the cytoplasmic retinoic acid binding protein type 1 (CRABP-1) and the low density lipoprotein receptor-related protein (LDLR-RP). Inhibition of CRABP-1 decreases retinoic acid production, leading to reduced fat storage and adipocyte apoptosis with subsequent release of lipids into the circulation. Inhibition of LDLR-RP leads to hyperlipidemia, secondary to failure to remove chylomicrons from the liver and endothelium and triglycerides from circulation.

(ii) Inhibition of mitochondrial dna (mtdna) polymerase γ: NRTI inhibits mtDNA polymerase γ, resulting in mtDNA depletion, respiratory chain dysfunction, and reduced energy production, which in turn causes insulin resistance and secondary dyslipidemia. Interestingly, only at normal oxygen levels, mtDNA was depleted — except after treatment with NRTI, hypoxic adipocytes did not receive triglycerides and were resistant to damage caused by mtDNA.

(iii) Inhibition of lipid metabolism: some PIs, especially ritonavir, inhibit cytochrome P4503A, a key enzyme in lipid metabolism.

(iv) Impeding adipocyte development: saquinavir, ritonavir, and nelfinavir (all PI) directly inhibit the development of adipocytes from stem cells and increase the metabolic breakdown of fat in existing adipocytes.

In one embodiment, a compound of formula (I) or a pharmaceutical composition comprising a compound of formula (I) treats or prevents or reduces at least one symptom of lipodystrophy, including, but not limited to, as an agent for lowering blood glucose levels and/or an agent for controlling blood glucose levels, an agent for controlling blood lipid levels, for example, as an agent for lowering and/or controlling cholesterol, an antioxidant, an appetite suppressant, an anti-obesity agent, an antibiotic/probiotic, or an anti-inflammatory agent. In another embodiment, the pharmaceutical composition treats or prevents or reduces at least one symptom of lipodystrophy, including but not limited to triglyceride levels, VLDL levels, and Apo B levels in serum. In another embodiment, the pharmaceutical composition treats or prevents lipodystrophy by improving at least one state selected from HDL levels, Apo a1 levels, HOMA of c-peptide derived beta cell function.

In another embodiment, the compounds according to formula (I) may be used alone or, for example, as an adjunct therapy in combination with at least one other therapeutic agent. The compounds according to formula (I) may be co-administered with therapeutic agents for attenuating one or more symptoms of lipodystrophy, including, but not limited to, agents for controlling blood glucose levels, agents for controlling blood lipid levels, e.g., agents for lowering and/or controlling cholesterol, antioxidants, appetite suppressants, anti-obesity agents, antibiotic/probiotic agents, or anti-inflammatory agents. Such combination therapy may assist in antiretroviral therapy. In a preferred embodiment, the compounds of formula (I) are administered alone or in combination for the treatment of lipohypertrophy, subcutaneous lipoatrophy and metabolic abnormalities in HIV patients.

The compounds of the invention wherein M + represents K, Mg may be prepared by the methods disclosed below and suitable modifications known to the skilled person.

Example 1

Preparation of (S) -alpha-ethoxy-4- [2- [ -methyl-5- [4- (methylthio) phenyl ] -1H-pyrrol-1-yl ] ethoxy ] benzene-propionic acid ethyl ester

In a dry 5L round bottom flask, 2.1L of toluene was added under nitrogen atmosphere. 366.1g of ethyl (S) - α -2-ethoxy-3- (4-hydroxyphenyl) propionate were added thereto at room temperature.

The reaction mixture was stirred with heating using a Dean-stark apparatus to azeotropically remove water. The reaction mixture was cooled to 50 ℃. 319g of anhydrous potassium carbonate was added thereto, and stirred at 90 to 92 ℃ for 1 hour. It is cooled to 65 ℃ and 500g of 2- (2-methyl-5- (4- (methylthio) phenyl) -1H-pyrrol-1-yl) ethyl methanesulfonate and 22g of tetrabutylammonium bromide are added. The reaction mixture was heated to 87-92 ℃ and stirred for 46 hours. Cooled to 70-75 deg.C, 1.5L toluene was added, carbonized with 75g charcoal and cooled to room temperature. The filtrate was washed with a basic solution, washed with water, dried over sodium sulfate and concentrated under vacuum to obtain (S) - α -ethoxy-4- [2- [ -methyl-5- [4- (methylthio) phenyl ] -1H-pyrrol-1-yl ] ethoxy ] benzene-propionic acid ethyl ester.

Yield: 650g, HPLC purity: 84.10 percent; % yield 76.0%.

Example 2

Preparation of magnesium salt of (S) -alpha-ethoxy-4- [2- [ -methyl-5- [4- (methylthio) phenyl ] -1H-pyrrol-1-yl ] ethoxy ] phenylpropionic acid

To a dry 250mL round bottom flask was added 80mL of methanol. To this was added 20g of (S) - α -ethoxy-4- [2- [ -methyl-5- [4- (methylthio) phenyl ] -1H-pyrrol-1-yl ] ethoxy ] benzene-propionic acid ethyl ester at room temperature under nitrogen atmosphere. 1.89g of sodium hydroxide dissolved in 20mL of water was added thereto and stirred at room temperature for 3 hours to complete the hydrolysis. The solvent was removed under reduced pressure. 150mL of water was added to concentrate the material. Impurities are removed by solvent washing. To the aqueous layer was added 5g of magnesium acetate tetrahydrate (dissolved in 20mL of water) and stirred for 15 minutes. The viscous mass was extracted with dichloromethane and subsequently n-heptane was added to precipitate the magnesium salt of (S) - α -ethoxy-4- [2- [ -methyl-5- [4- (methylthio) phenyl ] -1H-pyrrol-1-yl ] ethoxy ] phenylpropionic acid. The solid was filtered and dried.

Yield: 10.3 g; HPLC purity: 98.32 percent; chiral purity: 97.64 percent.

Following procedures analogous to those described in examples 1 and 2, the following batches of magnesium (S) - α -ethoxy-4- [2- [ -methyl-5- [4- (methylthio) phenyl ] -1H-pyrrol-1-yl ] ethoxy ] phenylpropionate were prepared.

The invention further discloses the use of said compounds of formula (I) or their suitable pharmaceutical compositions for the treatment of lipohypertrophy, subcutaneous lipoatrophy and metabolic abnormalities in HIV patients.

Example 9

(S) -alpha-ethoxy-4- [2- [ -methyl-5- [4- (methylthio) phenyl ] -1H-pyrrol-1-yl ] ethoxy ] phenylpropionic acid potassium salt

A dry 250mL round bottom flask was charged with 72mL ethyl acetate. To this was added 10g of (S) - (-) α -1-phenylethylamine salt of (S) - α -ethoxy-4- [2- [ -methyl-5- [4- (methylthio) phenyl ] -1H-pyrrol-1-yl ] ethoxy ] benzene-propionic acid at room temperature, followed by addition of 50mL of water and 4.8mL of dilute hydrochloric acid (water 1:1: 35% HCl) and stirring at room temperature until the solid dissolved. The layers were separated and the organic layer was washed with water. Dried over sodium sulfate and the solvent removed. 9.2g of an oily substance was obtained. To this was added 50mL of methanol and stirred under nitrogen. 1.81g of potassium tert-butoxide was added thereto and stirred at room temperature for 15 minutes. The solvent was removed and n-hexane was added. Again, the n-hexane was removed and methanol was added. The solvent was removed under vacuum. A moisture-absorbing material is obtained. It was dried under vacuum to obtain (S) - α -ethoxy-4- [2- [ -methyl-5- [4- (methylthio) phenyl ] -1H-pyrrol-1-yl ] ethoxy ] phenylpropionic acid potassium salt.

Yield 7.6g (92.77%), HPLC purity 98.60%, chiral purity 99.56%

Example 10

The research subjects are: prospective, multicenter, open label, single panel study to evaluate the safety and efficacy of 4mg of compound of formula (I) in hypertriglyceridemia in HIV-associated lipodystrophy.

The purpose is as follows: the aim of this study was to evaluate the safety and efficacy of 4mg of the compound of formula (I) in hypertriglyceridemia in HIV-associated lipodystrophy.

The methodology is as follows: this is a prospective, multicenter, open label, single panel study to evaluate the safety and efficacy of 4mg of the compound of formula (I) in hypertriglyceridemia in HIV-associated lipodystrophy.

Subjects with hypertriglyceridemia associated with HIV-associated lipodystrophy were enrolled in the study after obtaining informed consent after at least 18 months of treatment with HAART and meeting inclusion and exclusion criteria. Subjects received 4mg of a tablet of the compound of formula (I) orally, once a day for a period of 12 weeks. During this 12 week schedule, safety parameters were evaluated at weeks 2, 6, and 12 and efficacy was assessed at weeks 6 and 12.

Number of patients: planning: 50, analysis: 50

The product was tested: a compound of formula (I)

Dosage of 4mg

Duration of treatment: for 12 weeks

The administration mode is as follows: is administered orally

Batch number: EMK328

Evaluation criteria: the efficacy is as follows:

the primary efficacy endpoint was the assessment of the percent change in TG levels from baseline to week 6 and 12. The secondary efficacy endpoints were the assessment of LDL, VLDL, HDL, non-HDL cholesterol, total cholesterol, Apo a1, ApoB, and C peptides and fasting insulin for HOMA β and HOMA IR.

Safety:

clinical examination and documentation of Adverse Events (AEs) were performed in all surveys (visit). Electrocardiograms were recorded at the screening survey and at week 12. The urine pregnancy test was performed at the time of screening investigation.

Hematological tests include hemoglobin, hematocrit, Red Blood Cell (RBC) count, White Blood Cell (WBC) count (neutrophils, lymphocytes, monocytes, eosinophils, and basophils), and platelet count.

Biochemical tests include AST, ALT, ALP, total bilirubin, serum proteins, total albumin and globulin, γ -GTT, BUN, serum creatinine, serum uric acid, CPK, and urinary R/M (including microalbuminuria and ketonuria).

All laboratory parameters were evaluated at the enrollment survey (week 0) and at weeks 2, 6, and 12.

Statistical method

For efficacy endpoints, treatment efficacy was evaluated using an analysis of variance (ANOVA) model with factors for baseline and treatment. Treatment effect was estimated using Least Squares (LSM) and 95% Confidence Intervals (CI) from the ANOVA model. Statistical significance was defined as a two-sided p-value < 0.05. All other secondary endpoints were analyzed using appropriate statistical methods.

For safety analysis, frequency tables of abnormal physical examination and abnormal clinical laboratory parameters were provided for each survey. Summary statistics of clinical laboratory parameters and vital signs are provided for each survey. A list of combinations used during the study is summarized.

Adverse events are encoded with a Medical Dictionary (MedDRA) for normative activities (version 14). Adverse events and SAE are summarized collectively by System Organ Classification (SOC) and by preferred terms of MedDRA for Treatment of Emergency Adverse Events (TEAE). All AEs were included in the list, including AEs generated before and after treatment. Separate lists are provided for SAE and AE leading to study discontinuation.

Design of research

This is a safety and efficacy study for evaluating 4mg of the compound of formula (I) in the hypertriglyceridemia aspect of HIV-associated lipodystrophy. This is a tentative proof of proof concept studies for assessing safety and efficacy in a proposed population. In dyslipidemic subjects, the results from the phase II study of compounds of formula (I) indicate that: 4mg of the compound of formula (I) is well tolerated and a once daily dose is effective. Phase I studies show that food significantly affects the absorption of the compound of formula (I), so it is recommended that the drug be administered preferably under fasting conditions. Based on these observations, 4mg once a day in the fasting state was selected for the study.

Selection of study population

Inclusion criteria

In this study, subjects meeting all of the following criteria were enrolled:

males and females between 1.18-65 years old.

2. HIV1 was confirmed and HAART was used for at least 18 months.

3. A stable ART regimen was used at least 8 weeks prior to inclusion in the study and no changes in ART regimen were expected during the next 3 months.

4. Subject clinically diagnosed with HIV lipodystrophy (at least one moderate or severe lipodystrophy specified by physicians and patients, except for abdominal obesity alone)

5. Triglycerides >200 to 500 mg%.

CD4 count>50/mm³

7. Subjects who had submitted informed consent to this trial.

Treatment of

Administered treatment

This study was conducted in a single group. In the morning, prior to breakfast, subjects received 4mg of the compound of formula (I) orally, once daily for a period of 12 weeks.

Determination of one or more test drugs (Identity)

The compound of formula (I) is a divalent magnesium salt of a carboxylic acid in the form of a white amorphous powder which is readily soluble in dimethyl sulfoxide, dichloromethane, sparingly soluble in methanol and insoluble in water. The drug was provided as a non-coated tablet of 4mg of the active ingredient.

The feed from lot number EMK328 was used in the study. The study drug was manufactured and packaged in the cGMP facility.

One or more primary efficacy variables

The primary efficacy endpoint was the determination of the percent change in TG levels from baseline to week 6 and week 12.

Secondary variable of therapeutic effect

The secondary efficacy endpoint was the determination of the percent change in LDL, VLDL, HDL, total cholesterol, non-HDL cholesterol (measured), Apo a1, Apo B, C peptide and fasting insulin and HOMA IR levels for HOMA β from baseline to weeks 6 and 12.

Planned statistical method in treatment planning and sample size determination

Statistical and analytical planning

Demographic and baseline characteristics were summarized for the 4mg treatment group of compound of formula (I). For consecutive measurements such as age, mean, median, Standard Deviation (SD) and range are tabulated. For categorical measurements such as gender, the frequency is calculated.

Analysis of efficacy

The primary efficacy variable was the reduction in TG at weeks 6 and 12 of the treatment period compared to baseline. The change from baseline was determined as the difference between the mean and baseline for the treatment period (week 6/week 12).

For efficacy endpoints, an analysis of variance (ANOVA) model with factors for baseline and treatment was used to evaluate treatment efficacy. Treatment effect was estimated by ANOVA model using Least Squares (LSM) and 95% Confidence Intervals (CI). Statistical significance was defined as a two-sided p-value < 0.05. All other secondary endpoints were analyzed using appropriate statistical methods.

For the above studies, an intention-to-treat (ITT) assay and/or a protocol (PP) assay were performed. In the experimental analysis, the PP analysis was considered unambiguous and the ITT analysis was considered supportive.

Efficacy results and tabulated results for individual patient data

Analysis of efficacy

One subject, a 35 year old male, identified as EHT004 in the study reported abnormally low levels of HDL (3.95mg/L) and LDL (6.25mg/L) at survey 1. Although the subject completed the study and the efficacy was evaluable, it was decided to exclude the subject from the efficacy analysis. Thus, the efficacy of a total of 49 subjects was analyzed.

Primary endpoint

The percentage change in serum TG levels from baseline was statistically significant at weeks 6 and 12 after 4mg of compound of formula (I) (40.98 + -4.89 and 45.11 + -3.60 [ p value: <0.0001, respectively) [ Table 1 ].

Secondary endpoint

HDL cholesterol:

HDL cholesterol levels are elevated after administration of 4mg of the compound of formula (I). The percentage change in HDL cholesterol from baseline was statistically significant at weeks 6 and 12 after 4mg of the compound of formula (I) was administered (29.92 ± 5.73 and 34.56 ± 6.13[ respective p values: <0.0001]) (table 2).

Insulin-resistant C-peptide HOMA:

insulin resistance increases after treatment with a compound of formula (I). The percentage change in HOMA IR from baseline was statistically significant at 6 and 12 weeks after 4mg of the compound of formula (I) was administered (27.87. + -. 4.22 and 58.29. + -. 5.74[ respective p values: <0.0001]) (Table 3).

Insulin (fasting):

insulin resistance increases after treatment with a compound of formula (I). The percent change in insulin from baseline was statistically significant at 6 and 12 weeks after 4mg of the compound of formula (I) was administered (23.71 + -3.55 and 47.10 + -4.21 [ p value: <0.0001, respectively) [ Table 4 ].

β cell-functional insulin HOMA:

the HOMA of insulin-derived beta cell function is increased after treatment with a compound of formula (I). The percentage change from baseline in HOMA of insulin-derived beta cell function was statistically significant at weeks 6 and 12 (52.50 ± 14.94 and 45.64 ± 6.22[ p values 0.0010 and <0.0001, respectively ]) (table 5).

Conclusion on therapeutic effect

Primary end point:

at weeks 6 and 12 after administration of 4mg of the compound of formula (I), there was a statistically significant decrease in serum TG levels from baseline (percentage change of-40.98. + -. 4.89 and-45.11. + -. 3.60[ respective p values: <0.0001])

Secondary endpoint:

no statistically significant change in non-HDL cholesterol levels from baseline at weeks 6 and 12 after 4mg of the compound of formula (I) (p values 0.3963 and 0.4646, respectively)

There were statistically significant increases in HDL cholesterol levels from baseline at weeks 6 and 12 after 4mg of the compound of formula (I) (percentage changes were 29.92. + -. 5.73 and 34.56. + -. 6.13[ p values: <0.0001, respectively ]).

There was a statistically significant increase from baseline in the HOMA of C-peptide-derived β -cell function at 6 and 12 weeks after administration of 4mg of the compound of formula (I) (68.25 ± 25.58 and 71.67 ± 16.20[ p values 0.0104 and <0.0001, respectively ]).

There was a statistically significant increase from baseline in the HOMA derived from insulin resistance at 6 and 12 weeks after treatment with the compound of formula (I) (percentage change 29.10. + -. 3.94 and 42.65. + -. 3.79[ p value: <0.0001] respectively).

Thus, the compounds of the present invention, including pharmaceutical compositions comprising the compounds of the present invention, have been found to be effective in treating lipohypertrophy, subcutaneous lipoatrophy and metabolic abnormalities in HIV patients.

Claims (5)

1. A compound of formula (Ia)

Wherein 'R' is-SCH₃And M is⁺Represents Mg⁺²。

2. A compound according to claim 1 for use in the treatment of lipodystrophy.

3. The compound of claim 2, wherein the lipodystrophy is HIV-associated lipodystrophy.

4. The compound of any one of claims 2 to 3, which reduces the concentration of triglycerides, very low density lipoproteins, Apo B levels.

5. The compound of any one of claims 2 to 4 which increases high density lipoprotein, Apo A1 levels.