RU2828044C2 - Combined treatment of arthritis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: group of inventions relates to the treatment of arthritis. Disclosed is the use of a compound of Formula (II), including tautomeric forms thereof, enantiomeric forms, diastereomeric forms and racemic forms, or a pharmaceutically acceptable salt thereof:

in combination with methotrexate (MTX), or a prodrug thereof, for the treatment of arthritis, wherein methotrexate (MTX), or a prodrug thereof, is administered in an amount of about 1 to about 30 mg per week and the compound of formula (II) is administered in an amount of about 1 mg to about 1000 mg per day. Also disclosed is a combination for treating arthritis.

EFFECT: group of inventions provides a significantly stronger anti-arthritic action compared to the action of each of the compounds separately.

54 cl, 3 dwg, 2 tbl, 3 ex

Description

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims priority from European Patent Application No. 19173734.5, filed on 10 May 2019, the contents of which are incorporated herein by reference in their entirety.

FIELD OF TECHNICAL INVENTION

The present invention relates to a composition comprising, separately or together, methotrexate (MTX), or a prodrug thereof, and phenylpyrrole aminoguanidine derivative compounds such as AP1189, or pharmaceutically acceptable derivatives of this compound, for use in a method of treating arthritis, including rheumatoid arthritis (RA).

BACKGROUND OF THE INVENTION

Arthritis is a pathological condition that involves damage or inflammation of one or more joints. This pathological condition is often accompanied by pain, swelling, burning, redness, and limited mobility. There are many different forms of arthritis, the most common types of arthritis are osteoarthritis and rheumatoid arthritis. Osteoarthritis is a degenerative joint disease that is caused by thinning of the cartilage. Since cartilage cannot be restored to normal by the body, this can lead to the formation of new bone tissue at the edges of the joint to compensate for the loss of cartilage. This, in turn, causes thickening of the bone tissue (bony swellings), which are accompanied by painful manifestations, as the new bone tissue stretches the sensitive lining of the original bone tissue. The fingers are most often affected by this pathological condition. Rheumatoid arthritis (RA) is an autoimmune disorder that primarily affects the joints, affecting 0.5-1% of adults in developed countries. Although the causes of rheumatoid arthritis are unknown, a combination of genetic and environmental factors are thought to be involved. The goal of current treatment is to reduce pain and inflammation to improve the quality of life of patients suffering from this pathological condition. Painkillers are often used as treatment to reduce symptoms. drugs, steroids, and nonsteroidal anti-inflammatory drugs (NSAIDs). Disease-modifying antirheumatic drugs (DMARDs), such as hydroxychloroquine and especially methotrexate (MTX), may be used to slow the progression of the disease. However, MTX may require appropriate dosing to avoid side effects, and not all patients respond adequately to MTX treatment.

The melanocortin system is a set of neuropeptidergic and immunoendocrine signaling pathways that play essential roles in the homeostatic control of a wide range of physiological functions, including melanogenesis, stress response, inflammation, immunomodulation, and adrenocortical steroidogenesis. It consists of several components, including five G protein-coupled melanocortin receptors: melanocortin receptors MC1R-MC5R; peptide ligands: α, β, γ-melanocyte-stimulating hormones (α, β, γ-MSH), adrenocorticotropic hormone (ACTH) secreted by the anterior pituitary gland; and endogenous antagonists. The biological functions of the melanocortin system are mediated by five melanocortin receptors (MCRs), which have a heterogeneous tissue distribution, participate in the transduction of diverse signals, and influence the modification of biological activity in various organ systems. Adrenocorticotropic hormone (ACTH) is an endogenous peptide hormone and an agonist for all melanocortin receptors 1–5 (MC1–5R), of which MC2R binds specifically to ACTH; steroidogenesis is induced only by ACTH and is mediated by MC2R in the adrenal cortex. Alpha-melanocyte-stimulating hormone (α-MSH) is a small endogenous peptide hormone, structurally related to ACTH, that binds to all MCRs except MC2R. MC1R is highly expressed by melanocytes in the skin, represents a key control point in melanogenesis, and determines hair color.

Peripheral receptors MC1R and MC3R can be activated pharmacologically to induce an anti-inflammatory response. The endogenous agonist α-melanocyte-stimulating hormone (αMSH), like other protective mediators, is released by immune cells to counterbalance pro-inflammatory signals and thus prevent excessive tissue damage. Therapies targeting MC1R and MC3R receptors would mimic the body’s own defenses and could have fewer side effects.

Current treatments for arthritis-related disorders, such as methotrexate treatment for rheumatoid arthritis, often carry a risk of side effects and may not be fully effective when used as monotherapy, and subjects suffering from arthritis-related disorders require new and effective treatment regimens.

Phenylpyrrole aminoguanidine derivatives with melanocortin receptor activity are described in WO 2007/141343. One example of such a compound is AP1189 (( E ) -N - trans- {3-[1-(2-nitrophenyl) -1H- pyrrol-2-yl]-allylidene}-aminoguanidinium acetate), a compound with anti-inflammatory activity that was first shown to bind to MC1R (WO 2007/141343) and was later found to be a functionally selective dual agonist of MC1R and MC3R receptors that does not induce classical cAMP generation (and hence no MC1R-induced melanogenesis) but instead appears to induce alternative pathways including ERK1/2 phosphorylation and Ca ²⁺ mobilization (Montero-Melendez et al . 2015).

ESSENCE OF THE INVENTION

The present inventors have found that the phenyl pyrrole aminoguanidine derivative AP1189 (( E ) -N - trans- {3-[1-(2-nitrophenyl)-1H - pyrrol-2-yl]-allylidene}-aminoguanidinium acetate), when used in combination with the current standard treatment methotrexate (MTX), exerts a significantly more potent anti-arthritic effect compared to the effect of each of these compounds administered alone. The novel combination treatment for arthritis described in this application is provided, and thereby the present invention provides a therapeutically effective alternative to the current treatments for arthritis and an effective agent that potentially reduces the toxicity of MTX and provides a new therapeutic management for patients with a low level of clinical response to MTX, such as patients with no clinical response to MTX.

According to one aspect of the present invention, there is provided a composition comprising, separately or together, methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I) or (Ia):

Formula (I),

Formula (Ia),

including its tautomeric and isomeric forms such as enantiomeric forms, diastereomeric forms and racemic forms,

Where

n has the value 1, 2 or 3;

each R ₁ , R ₂ , R ₃ , R ₄ and R ₅ is independently selected from the group consisting of hydrogen, optionally substituted C _1-6 alkyl, optionally substituted C _3-6 cycloalkyl, optionally substituted C _2-6 alkenyl, optionally substituted C _4-6 alkadienyl, optionally substituted C _2-6 alkynyl, hydroxy, optionally substituted C _1-6 alkoxy, optionally substituted C _2-6 alkenyloxy, carboxy, optionally substituted C _1-6 alkoxycarbonyl, optionally substituted C _1-6 alkylcarbonyl, formyl, C _1-6 alkylsulfonylamino, optionally substituted aryl, optionally substituted aryloxycarbonyl, optionally substituted aryloxy, optionally substituted arylcarbonyl, optionally substituted arylamino, arylsulfonylamino, optionally substituted heteroaryl, optionally substituted heteroaryloxycarbonyl, optionally substituted heteroaryloxy, optionally substituted heteroarylcarbonyl, optionally substituted heteroarylamino, heteroarylsulfonylamino, optionally substituted heterocyclyl, optionally substituted heterocyclyloxycarbonyl, optionally substituted heterocyclyloxy, optionally substituted heterocyclylcarbonyl, optionally substituted heterocyclylamino, heterocyclylsulfonylamino, amino, mono- and di(C _1-6 -alkyl)amino, carbamoyl, mono- and di(C _1-6 -alkyl)aminocarbonyl, amino-C _1-6 -alkyl-aminocarbonyl, mono- and di(C _1-6 -alkylamino-C _1-6 -alkyl-aminocarbonyl, C _1-6 -alkylcarbonylamino, amino-C _1-6 -alkyl-carbonylamino, mono- and di(C _1-6 -alkyl)amino-C _1-6 -alkyl-carbonylamino, cyano, guanidino, carbamido, C _1-6 -alkanoyloxy, C _1-6 -alkylsulfonyl, C _1-6 -alkylsulfinyl, C _1-6 -alkylsulfonyloxy, aminosulfonyl, mono- and di(C _1-6 -alkyl)aminosulfonyl, nitro optionally substituted with C _1-6 -alkylthio and a halogen atom, wherein any C _1-6 -alkyl bonded to the nitrogen atom is optionally substituted with hydroxy, C _1-6 -alkoxy, C _2-6 -alkenyloxy, amino, mono- and di(C _1-6 -alkyl)amino, carboxy, C _1-6 -alkylcarbonylamino, halogen atom, C _1-6 -alkylthio, C _1-6 -alkylsulfonylamino or guanidine;

each R ₆ and R ₇ is independently selected from the group consisting of hydrogen, optionally substituted C _1-6 alkyl, optionally substituted C _2-6 alkenyl, optionally substituted C _4-6 alkadienyl, optionally substituted C _2-6 alkynyl, optionally substituted C _1-6 alkoxycarbonyl, optionally substituted C _1-6 alkylcarbonyl, optionally substituted aryl, optionally substituted aryloxycarbonyl, optionally substituted arylcarbonyl, optionally substituted heteroaryl, optionally substituted heteroaryloxycarbonyl, optionally substituted heteroarylcarbonyl, aminocarbonyl, mono- and di(C _1-6 alkyl)aminocarbonyl, amino-C _1-6 alkyl-aminocarbonyl and mono- and di(C _1-6 alkyl)amino-C _1-6 -alkylaminocarbonyl; or R ₆ and R ₇ together may form a five- or six-membered nitrogen-containing ring;

or a pharmaceutically acceptable derivative of this compound;

for use in the treatment of arthritis, such as arthritis diagnosed in a subject.

According to one embodiment of the present invention, there is provided a composition comprising, separately or together, methotrexate (MTX), or a prodrug thereof, and a compound of Formula (II):

Formula (II),

including its tautomeric and isomeric forms such as enantiomeric forms, diastereomeric forms and racemic forms,

or a pharmaceutically acceptable derivative of this compound,

for use in the treatment of arthritis.

According to one aspect of the present invention, there is also provided a composition comprising methotrexate (MTX), or a prodrug thereof, and a compound selected from the group consisting of {3-[1-(2-nitrophenyl)-1H - pyrrol-2-yl]-allylidene}-aminoguanidine; {3-[1-(2-nitrophenyl) -1H- pyrrol-2-yl]-allylidene}-aminoguanidinium acetate; ( E ) -N - trans- {3-[1-(2-nitrophenyl) -1H- pyrrol-2-yl]-allylidene}-aminoguanidinium acetate and ( E ) -N - trans- {3-[1-(2-nitrophenyl) -1H- pyrrol-2-yl]-allylidene}-aminoguanidinium acetate, or a pharmaceutically acceptable derivative of this compound, for use in the treatment of arthritis.

According to one embodiment of the present invention, said arthritis is rheumatoid arthritis (RA).

Definitions

The term "pharmaceutically acceptable derivative" as used herein includes pharmaceutically acceptable salts, which means a salt that is not harmful to subjects. Such salts include pharmaceutically acceptable base or acid addition salts, as well as pharmaceutically acceptable metal salts, ammonium salts, and alkylated ammonium salts. A pharmaceutically acceptable derivative further includes esters and prodrugs, or other precursors of the compound that can be biologically metabolized to form the active compound, or crystalline forms of the compound.

The term "acid addition salt" is intended to include "pharmaceutically acceptable acid addition salt", which means a salt that is not harmful to the subject. Acid addition salts include salts of inorganic acids as well as organic acids. Typical examples of suitable inorganic acids include hydrochloric, hydrobromic, hydroiodic, phosphoric, sulfuric, nitric acids, and the like. Typical examples of suitable organic acids include formic, acetic, trichloroacetic, trifluoroacetic, propionic, benzoic, cinnamic, citric, fumaric, glycolic, lactic, maleic, malic, malonic, mandelic, oxalic, picric, pyruvic, salicylic, succinic, methanesulfonic, ethanesulfonic, tartaric, ascorbic, pamoic, bis-methylenesalicylic, ethanedisulfonic, gluconic, citraconic, aspartic, stearic, palmitic, EDTA (ethylenediaminetetraacetic acid), glycolic, p -aminobenzoic, glutamic, benzenesulfonic, p- toluenesulfonic acids and the like. Other examples of pharmaceutically acceptable inorganic or organic acid addition salts include the pharmaceutically acceptable salts listed in J. Pharm. Sci. 66, 2, (1977), which are incorporated herein by reference.

The term "therapeutically effective amount" of a compound as used herein means an amount sufficient to treat, alleviate, prevent, reduce the risk of, or partially suppress the clinical manifestations of a given disease or disorder and its complications. An amount sufficient to achieve these goals is defined as a "therapeutically effective amount". The effective amount in each case will generally depend on the severity of the disease or injury and the weight and general condition of the subject. It is generally understood that determination of the appropriate dosage can be accomplished by routine experimentation, by constructing a matrix of values and testing various points on the matrix, which can be accomplished by a skilled physician or veterinarian of average competence.

The terms "treatment" and "treat" as used herein refer to the provision of medical care and monitoring of a subject for the purpose of combating a pathological condition, disease or disorder. It is intended that the term includes the full range of treatment of the pathological condition from which the subject suffers. The subject receiving the treatment is preferably a mammal, in particular a human. However, as used herein, the term "treatment" also refers to animals such as mice, rats, dogs, cats, horses, cattle, sheep and pigs. Subjects receiving the treatment may be of different ages.

The term "arthritic disease" in the context of this description refers to an inflammatory disease that involves inflammation of the joints. This disease is also known as arthritis.

The term "remission" as used herein refers to a reduction or disappearance of the signs and symptoms of arthritis. Remission may be temporary or permanent. Partial remission is a reduction in the signs and symptoms of arthritis, while complete remission as used herein refers to the disappearance of the signs and symptoms of arthritis.

DESCRIPTION OF DRAWINGS

Fig. 1: Percentage of animals developing severe arthritis, assessed by a clinical severity score of 10 or more, during the 8-day study period using mice treated with K/BxN serum (see Example 1 for details). Group 1: untreated control animals; Group 2: vehicle treated animals; Group 3: methotrexate treated animals; Group 4: AP1189 treated animals; and Group 5: methotrexate and AP1189 treated animals in combination. Group 3 and Group 5 received equal doses of methotrexate. Group 4 and Group 5 received equal doses of AP1189.

Fig. 2: Plasma concentrations following a single oral dose of test compound in healthy volunteers. Test compound (AP1189) was administered as a suspension in the morning on an empty stomach to healthy male volunteers. Dose levels of test compound were 100, 200, 400, 600, or 800 mg. Consecutive plasma samples were collected and plasma concentrations were determined using LC-MS-MS. N=6 for each dose level. Mean per group was calculated.

Fig. 3: Plasma concentrations after multiple oral doses of test compound in healthy volunteers. Test compound (AP1189) was administered as a suspension in the morning under fasting conditions to healthy male volunteers once daily for two weeks. Dose levels of test compound 1: 50, 100, 200 mg. Serial plasma samples were collected after the last dose (Day 14) and plasma concentrations were determined using LC-MS-MS. N=9 for each dose level. Mean +/- SD per group was calculated.

DETAILED DESCRIPTION OF THE INVENTION

The present invention provides a composition comprising, separately or together, methotrexate (MTX) and a compound of Formula (I), (Ia) or (II), as defined herein, for the treatment of an arthritic disease (or arthritis).

According to one aspect of the present invention, there is provided a composition comprising, separately or together, methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I) or (Ia):

Formula (I),

Formula (Ia),

including its tautomeric and isomeric forms such as enantiomeric forms, diastereomeric forms and racemic forms,

Where

n has the value 1, 2 or 3;

each R ₁ , R ₂ , R ₃ , R ₄ and R ₅ is independently selected from the group consisting of hydrogen, optionally substituted C _1-6 alkyl, optionally substituted C _3-6 cycloalkyl, optionally substituted C _2-6 alkenyl, optionally substituted C _4-6 alkadienyl, optionally substituted C _2-6 alkynyl, hydroxy, optionally substituted C _1-6 alkoxy, optionally substituted C _2-6 alkenyloxy, carboxy, optionally substituted C _1-6 alkoxycarbonyl, optionally substituted C _1-6 alkylcarbonyl, formyl, C _1-6 alkylsulfonylamino, optionally substituted aryl, optionally substituted aryloxycarbonyl, optionally substituted aryloxy, optionally substituted arylcarbonyl, optionally substituted arylamino, arylsulfonylamino, optionally substituted heteroaryl, optionally substituted heteroaryloxycarbonyl, optionally substituted heteroaryloxy, optionally substituted heteroarylcarbonyl, optionally substituted heteroarylamino, heteroarylsulfonylamino, optionally substituted heterocyclyl, optionally substituted heterocyclyloxycarbonyl, optionally substituted heterocyclyloxy, optionally substituted heterocyclylcarbonyl, optionally substituted heterocyclylamino, heterocyclylsulfonylamino, amino, mono- and di(C _1-6 -alkyl)amino, carbamoyl, mono- and di(C _1-6 -alkyl)aminocarbonyl, amino-C _1-6 -alkyl-aminocarbonyl, mono- and di(C _1-6 -alkylamino-C _1-6 -alkyl-aminocarbonyl, C _1-6 -alkylcarbonylamino, amino-C _1-6 -alkyl-carbonylamino, mono- and di(C _1-6 -alkyl)amino-C _1-6 -alkyl-carbonylamino, cyano, guanidino, carbamido, C _1-6 -alkanoyloxy, C _1-6 -alkylsulfonyl, C _1-6 -alkylsulfinyl, C _1-6 -alkylsulfonyloxy, aminosulfonyl, mono- and di(C _1-6 -alkyl)aminosulfonyl, nitro optionally substituted with C _1-6 -alkylthio and a halogen atom, wherein any C _1-6 -alkyl bonded to the nitrogen atom is optionally substituted with hydroxy, C _1-6 -alkoxy, C _2-6 -alkenyloxy, amino, mono- and di(C _1-6 -alkyl)amino, carboxy, C _1-6 -alkylcarbonylamino, halogen atom, C _1-6 -alkylthio, C _1-6 -alkylsulfonylamino or guanidine;

each R ₆ and R ₇ is independently selected from the group consisting of hydrogen, optionally substituted C _1-6 alkyl, optionally substituted C _2-6 alkenyl, optionally substituted C _4-6 alkadienyl, optionally substituted C _2-6 alkynyl, optionally substituted C _1-6 alkoxycarbonyl, optionally substituted C _1-6 alkylcarbonyl, optionally substituted aryl, optionally substituted aryloxycarbonyl, optionally substituted arylcarbonyl, optionally substituted heteroaryl, optionally substituted heteroaryloxycarbonyl, optionally substituted heteroarylcarbonyl, aminocarbonyl, mono- and di(C _1-6 alkyl)aminocarbonyl, amino-C _1-6 alkyl-aminocarbonyl and mono- and di(C _1-6 alkyl)amino-C _1-6 -alkylaminocarbonyl; or R ₆ and R ₇ together may form a five- or six-membered nitrogen-containing ring;

or a pharmaceutically acceptable derivative of this compound;

for use in the treatment of arthritis, such as arthritis diagnosed in a subject.

According to one embodiment of the present invention, there is provided methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I) or (Ia), wherein each of n, R ₁ , R ₂ , R ₃ , R ₄ , R ₅ , R ₆ and R ₇ is as defined herein, for use in the treatment of arthritis, such as arthritis diagnosed in a subject.

According to one embodiment of the present invention, there is provided a method of treating arthritis comprising one or more steps of administering to a subject, such as a subject in need of such treatment, a composition comprising, alone or together, methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I) or (Ia):

Formula (I),

Formula (Ia),

including its tautomeric and isomeric forms such as enantiomeric forms, diastereomeric forms and racemic forms,

Where

n has the value 1, 2 or 3;

each R ₁ , R ₂ , R ₃ , R ₄ and R ₅ is independently selected from the group consisting of hydrogen, optionally substituted C _1-6 alkyl, optionally substituted C _3-6 cycloalkyl, optionally substituted C _2-6 alkenyl, optionally substituted C _4-6 alkadienyl, optionally substituted C _2-6 alkynyl, hydroxy, optionally substituted C _1-6 alkoxy, optionally substituted C _2-6 alkenyloxy, carboxy, optionally substituted C _1-6 alkoxycarbonyl, optionally substituted C _1-6 alkylcarbonyl, formyl, C _1-6 alkylsulfonylamino, optionally substituted aryl, optionally substituted aryloxycarbonyl, optionally substituted aryloxy, optionally substituted arylcarbonyl, optionally substituted arylamino, arylsulfonylamino, optionally substituted heteroaryl, optionally substituted heteroaryloxycarbonyl, optionally substituted heteroaryloxy, optionally substituted heteroarylcarbonyl, optionally substituted heteroarylamino, heteroarylsulfonylamino, optionally substituted heterocyclyl, optionally substituted heterocyclyloxycarbonyl, optionally substituted heterocyclyloxy, optionally substituted heterocyclylcarbonyl, optionally substituted heterocyclylamino, heterocyclylsulfonylamino, amino, mono- and di(C _1-6 -alkyl)amino, carbamoyl, mono- and di(C _1-6 -alkyl)aminocarbonyl, amino-C _1-6 -alkyl-aminocarbonyl, mono- and di(C _1-6 -alkylamino-C _1-6 -alkyl-aminocarbonyl, C _1-6 -alkylcarbonylamino, amino-C _1-6 -alkyl-carbonylamino, mono- and di(C _1-6 -alkyl)amino-C _1-6 -alkyl-carbonylamino, cyano, guanidino, carbamido, C _1-6 -alkanoyloxy, C _1-6 -alkylsulfonyl, C _1-6 -alkylsulfinyl, C _1-6 -alkylsulfonyloxy, aminosulfonyl, mono- and di(C _1-6 -alkyl)aminosulfonyl, nitro optionally substituted with C _1-6 -alkylthio and a halogen atom, wherein any C _1-6 -alkyl bonded to the nitrogen atom is optionally substituted with hydroxy, C _1-6 -alkoxy, C _2-6 -alkenyloxy, amino, mono- and di(C _1-6 -alkyl)amino, carboxy, C _1-6 -alkylcarbonylamino, halogen atom, C _1-6 -alkylthio, C _1-6 -alkylsulfonylamino or guanidine;

each R ₆ and R ₇ is independently selected from the group consisting of hydrogen, optionally substituted C _1-6 alkyl, optionally substituted C _2-6 alkenyl, optionally substituted C _4-6 alkadienyl, optionally substituted C _2-6 alkynyl, optionally substituted C _1-6 alkoxycarbonyl, optionally substituted C _1-6 alkylcarbonyl, optionally substituted aryl, optionally substituted aryloxycarbonyl, optionally substituted arylcarbonyl, optionally substituted heteroaryl, optionally substituted heteroaryloxycarbonyl, optionally substituted heteroarylcarbonyl, aminocarbonyl, mono- and di(C _1-6 alkyl)aminocarbonyl, amino-C _1-6 alkyl-aminocarbonyl and mono- and di(C _1-6 alkyl)amino-C _1-6 -alkylaminocarbonyl; or R ₆ and R ₇ together may form a five- or six-membered nitrogen-containing ring;

or a pharmaceutically acceptable derivative of this compound.

According to one embodiment of the present invention, there is provided a method of treating arthritis comprising one or more steps of administering methotrexate (MTX), or a prodrug thereof, and one or more steps of administering a compound of Formula (I) or (Ia), wherein each of n, R ₁ , R ₂ , R ₃ , R ₄ , R ₅ , R ₆ and R ₇ is as defined herein, to a subject, such as a subject in need of such treatment.

According to one embodiment of the present invention, there is provided the use of a composition comprising, separately or together, methotrexate (MTX) and a compound of Formula (I) or (Ia):

Formula (I),

Formula (Ia),

including its tautomeric and isomeric forms such as enantiomeric forms, diastereomeric forms and racemic forms,

Where

n has the value 1, 2 or 3;

each R ₁ , R ₂ , R ₃ , R ₄ and R ₅ is independently selected from the group consisting of hydrogen, optionally substituted C _1-6 alkyl, optionally substituted C _3-6 cycloalkyl, optionally substituted C _2-6 alkenyl, optionally substituted C _4-6 alkadienyl, optionally substituted C _2-6 alkynyl, hydroxy, optionally substituted C _1-6 alkoxy, optionally substituted C _2-6 alkenyloxy, carboxy, optionally substituted C _1-6 alkoxycarbonyl, optionally substituted C _1-6 alkylcarbonyl, formyl, C _1-6 alkylsulfonylamino, optionally substituted aryl, optionally substituted aryloxycarbonyl, optionally substituted aryloxy, optionally substituted arylcarbonyl, optionally substituted arylamino, arylsulfonylamino, optionally substituted heteroaryl, optionally substituted heteroaryloxycarbonyl, optionally substituted heteroaryloxy, optionally substituted heteroarylcarbonyl, optionally substituted heteroarylamino, heteroarylsulfonylamino, optionally substituted heterocyclyl, optionally substituted heterocyclyloxycarbonyl, optionally substituted heterocyclyloxy, optionally substituted heterocyclylcarbonyl, optionally substituted heterocyclylamino, heterocyclylsulfonylamino, amino, mono- and di(C _1-6 -alkyl)amino, carbamoyl, mono- and di(C _1-6 -alkyl)aminocarbonyl, amino-C _1-6 -alkyl-aminocarbonyl, mono- and di(C _1-6 -alkylamino-C _1-6 -alkyl-aminocarbonyl, C _1-6 -alkylcarbonylamino, amino-C _1-6 -alkyl-carbonylamino, mono- and di(C _1-6 -alkyl)amino-C _1-6 -alkyl-carbonylamino, cyano, guanidino, carbamido, C _1-6 -alkanoyloxy, C _1-6 -alkylsulfonyl, C _1-6 -alkylsulfinyl, C _1-6 -alkylsulfonyloxy, aminosulfonyl, mono- and di(C _1-6 -alkyl)aminosulfonyl, nitro optionally substituted with C _1-6 -alkylthio and a halogen atom, wherein any C _1-6 -alkyl bonded to the nitrogen atom is optionally substituted with hydroxy, C _1-6 -alkoxy, C _2-6 -alkenyloxy, amino, mono- and di(C _1-6 -alkyl)amino, carboxy, C _1-6 -alkylcarbonylamino, halogen atom, C _1-6 -alkylthio, C _1-6 -alkylsulfonylamino or guanidine;

each R ₆ and R ₇ is independently selected from the group consisting of hydrogen, optionally substituted C _1-6 alkyl, optionally substituted C _2-6 alkenyl, optionally substituted C _4-6 alkadienyl, optionally substituted C _2-6 alkynyl, optionally substituted C _1-6 alkoxycarbonyl, optionally substituted C _1-6 alkylcarbonyl, optionally substituted aryl, optionally substituted aryloxycarbonyl, optionally substituted arylcarbonyl, optionally substituted heteroaryl, optionally substituted heteroaryloxycarbonyl, optionally substituted heteroarylcarbonyl, aminocarbonyl, mono- and di(C _1-6 alkyl)aminocarbonyl, amino-C _1-6 alkyl-aminocarbonyl and mono- and di(C _1-6 alkyl)amino-C _1-6 -alkylaminocarbonyl; or R ₆ and R ₇ together may form a five- or six-membered nitrogen-containing ring;

or a pharmaceutically acceptable derivative of this compound;

in obtaining a drug for the treatment of arthritis, such as the arthritis diagnosed in the subject.

According to one embodiment of the present invention, there is provided the use of methotrexate (MTX) and a compound of Formula (I) or (Ia), wherein each of n, R ₁ , R ₂ , R ₃ , R ₄ , R ₅ , R ₆ and R ₇ is as defined herein, in the preparation of a medicament for the treatment of arthritis.

Compound

The present invention provides a combination of methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I) or (Ia), wherein each of n, R ₁ , R ₂ , R ₃ , R ₄ , R ₅ , R ₆ and R ₇ is as defined herein above, for use in the treatment of arthritis. In a particular embodiment of the present invention, each of n, R ₁ , R ₂ , R ₃ , R ₄ , R ₅ , R ₆ and R ₇ is defined as described below.

According to one embodiment of the present invention, n = 1. According to one embodiment of the present invention, there is provided a composition comprising, separately or together, methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I) or (Ia), wherein each of R ₁ , R ₂ , R ₃ , R ₄ , R ₅ , R ₆ and R ₇ is as defined herein, and n = 1, for use in the treatment of arthritis.

According to one embodiment of the present invention, each R ₁ , R ₂ and R ₃ is independently selected from the group consisting of -H, -CH ₃ , -CF ₃ , -CCl ₃ , -OC _1-6 alkyl, -OH, -OCH ₃ , -NH-C _1-6 alkyl, -N(C _1-6 alkyl) ₂ , -SC _1-6 alkyl, - tert Bu, -CN, -SO ₃ -C _1-6 alkyl, -NH ₂ , -NO ₂ , -CO ₂ H, -CO ₂ -C _1-6 alkyl, -C(=O)-C _1-6 alkyl, -CHO, morpholine, pyrrolidine, pyrrole or a halogen atom.

According to one embodiment of the present invention there is provided a composition comprising, individually or together, methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I) or (Ia), wherein each of n, R ₄ , R ₅ , R ₆ and R ₇ is as defined herein and each R ₁ , R ₂ and R ₃ is independently selected from the group consisting of -H, -CH ₃ , -CF ₃ , -CCl ₃ , -OC _1-6 alkyl, -OH, -OCH ₃ , -NH-C _1-6 alkyl, -N(C _1-6 alkyl) ₂ , -SC _1-6 alkyl, - tert Bu, -CN, -SO ₃ -C _1-6 alkyl, -NH ₂ , -NO ₂ , -CO ₂ H, -CO ₂ -C _1-6 alkyl, -C(=O)-C _1-6 alkyl, -CHO, morpholine, pyrrolidine, pyrrole or a halogen atom, for use in the treatment of arthritis, such as arthritis diagnosed in a subject.

According to one embodiment of the present invention, each R ₁ and/or R ₂ is an electron-withdrawing group. According to one embodiment of the present invention, there is provided a composition comprising, alone or together, methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I) or (Ia), wherein each of n, R ₃ , R ₄ , R ₅ , R ₆ and R ₇ is as defined herein, and each R ₁ and/or R ₂ is an electron-withdrawing group, for use in the treatment of arthritis, such as arthritis diagnosed in a subject.

An electron-withdrawing group should be considered as an electron-withdrawing element or functional group that shifts the electron density from adjacent atoms to itself, usually as a result of a resonance or inductive effect. Whether a functional group is electron-withdrawing or electron-donating can be determined using the Hammett equation, an equation known to those skilled in the art. Hammett substituent constants, also known as substituent σ constants, can be used as a measure of the ability of a functional group to shift electron density from adjacent atoms to itself. An electron-withdrawing group is an electron-withdrawing element or functional group with a substituent σ constant > 0, such as in the range from 0.01 to 0.9, in particular 0.78. These values are known in the art and can be found in tables published in the scientific literature, such as J. Org. Chem. , 23, 420 (1958). Examples of electron-withdrawing groups are _CF3 , _CCl3 , F, Cl, CN, and _NO2 .

According to one embodiment of the present invention, said R ₁ is selected from the group consisting of CF ₃ , CCl ₃ , F, Cl, CN and NO ₂ . According to one embodiment of the present invention, there is provided methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I) or (Ia), wherein each of n, R ₂ , R ₃ , R ₄ , R ₅ , R ₆ and R ₇ is as defined herein, and said R ₁ is selected from the group consisting of CF ₃ , CCl ₃ , F, Cl, CN and NO ₂ , for use in the treatment of arthritis, such as arthritis diagnosed in a subject.

According to one embodiment of the present invention, each said R ₂ and/or R ₃ is a hydrogen atom. According to one embodiment of the present invention, there is provided methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I) or (Ia), wherein each of n, R ₁ , R ₄ , R ₅ , R ₆ and R ₇ is as defined herein, and each said R ₂ and/or R ₃ is a hydrogen atom, for use in the treatment of arthritis, such as arthritis diagnosed in a subject.

According to one embodiment of the present invention, each R ₄ and R ₅ is independently selected from the group consisting of -H, C _1-6 alkyl, halogen, -O(C _1-6 alkyl), -NH(C _1-6 alkyl) and -C(=O)C _1-6 alkyl.

According to one embodiment of the present invention, there is provided methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I) or (Ia), wherein each of n, R ₁ , R ₂ , R ₃ , R ₆ and R ₇ is as defined herein, and each R ₄ and R ₅ is independently selected from the group consisting of -H, C _1-6 alkyl, halogen, -O(C _1-6 alkyl), -NH(C _1-6 alkyl) and -C(=O)C _1-6 alkyl, for use in the treatment of arthritis, such as arthritis diagnosed in a subject.

According to one embodiment of the present invention, each R ₆ and R ₇ is independently selected from the group consisting of hydrogen, methyl, ethyl and propyl.

According to one embodiment of the present invention, each of said R ₆ and R ₇ represents a hydrogen atom.

According to one embodiment of the invention, said R ₆ is a hydrogen atom and R ₇ is methyl or ethyl. According to one embodiment of the invention, said R ₆ is a hydrogen atom and R ₇ is methyl. According to one embodiment of the invention, said R ₆ is a hydrogen atom and R ₇ is ethyl. According to one embodiment of the invention, both said R ₆ and R ₇ are methyl. According to one embodiment of the invention, both said R ₆ and R ₇ are ethyl.

According to one embodiment of the present invention, there is provided methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I) or (Ia), wherein each of n, R ₁ , R ₂ , R ₃ , R ₄ , R ₅ is as defined herein, and each R ₆ and R ₇ is independently selected from the group consisting of hydrogen, methyl, ethyl and propyl, for example where

each of R ₆ and R ₇ represents a hydrogen atom, or

said R ₆ represents a hydrogen atom and R ₇ represents methyl or ethyl, or

said R ₆ represents a hydrogen atom and R ₇ represents methyl, or

said R ₆ represents a hydrogen atom and R ₇ represents ethyl, or

both of R ₆ and R ₇ are methyl, or

both R ₆ and R ₇ are ethyl,

for use in the treatment of arthritis, such as arthritis diagnosed in a subject.

According to one embodiment of the present invention, each of said R ₂ , R ₃ , R ₄ , R ₅ , R ₆ and R ₇ represents a hydrogen atom, and said R ₁ is selected from the group consisting of CF ₃ , CCl ₃ , F, Cl, NO ₂ and CN.

According to one embodiment of the present invention, there is provided methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I) or (Ia), wherein n is 1, 2 or 3, each of said R ₂ , R ₃ , R ₄ , R ₅ , R ₆ and R ₇ is a hydrogen atom, and said R ₁ is selected from the group consisting of CF ₃ , CCl ₃ , F, Cl, NO ₂ and CN, for use in the treatment of arthritis, such as arthritis diagnosed in a subject.

According to one embodiment of the present invention, each of said R ₂ , R ₃ , R ₄ , R ₅ , R ₆ and R ₇ represents a hydrogen atom, said R ₁ is selected from the group consisting of CF ₃ , CCl ₃ , F, Cl, NO ₂ or CN, and n = 1.

According to one embodiment of the present invention, there is provided methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I) or (Ia), wherein n = 1, each of said R ₂ , R ₃ , R ₄ , R ₅ , R ₆ and R ₇ is a hydrogen atom and said R ₁ is selected from the group consisting of CF ₃ , CCl ₃ , F, Cl, NO ₂ and CN, for use in the treatment of arthritis, such as arthritis diagnosed in a subject.

According to one embodiment of the present invention, said R ₃ is in position 4.

According to one embodiment of the present invention, said R ₃ is selected from the group consisting of F, Cl and Br.

According to one embodiment of the present invention, there is provided methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I) or (Ia), wherein each of n, R ₁ , R ₂ , R ₄ , R ₅ , R ₆ and R ₇ is as defined herein, and said R ₃ is in position 4 and/or said R ₃ is selected from the group consisting of F, Cl and Br, for use in the treatment of arthritis, such as arthritis diagnosed in a subject.

According to one embodiment of the present invention, there is provided a composition comprising, separately or together, methotrexate (MTX), or a prodrug thereof, and a compound of Formula (II):

Formula (II),

including its tautomeric and isomeric forms, such as enantiomeric forms, diastereomeric forms and racemic forms, or a pharmaceutically acceptable derivative of the compound,

for the treatment of arthritis, such as arthritis diagnosed in the subject.

According to one embodiment of the present invention, said compound is {3-[1-(2-nitrophenyl)-1H - pyrrol-2-yl]-allylidene}-aminoguanidine, preferably ( E ) -N - trans- {3-[1-(2-nitrophenyl) -1H- pyrrol-2-yl]-allylidene}-aminoguanidine, or a pharmaceutically acceptable derivative thereof, such as a pharmaceutically acceptable salt thereof.

According to one embodiment of the present invention, there is provided a composition comprising methotrexate, or a prodrug thereof, and a compound of Formula (I), (Ia) or (II), as defined herein, including pharmaceutically acceptable derivatives of this compound, for use in the treatment of arthritis, characterized in that the pharmaceutically acceptable derivative of said compound is a pharmaceutically acceptable salt of an inorganic acid or a pharmaceutically acceptable salt of an organic acid.

According to one embodiment of the present invention, said organic acid is selected from the group consisting of formic acid, acetic acid, trichloroacetic acid, trifluoroacetic acid, propionic acid, benzoic acid, cinnamic acid, citric acid, fumaric acid, glycolic acid, lactic acid, maleic acid, malic acid, malonic acid, mandelic acid, oxalic acid, picric acid, pyruvic acid, salicylic acid, succinic acid, methanesulfonic acid, ethanesulfonic acid, tartaric acid, ascorbic acid, pamoic acid, bis-methylene salicylic acid, ethanedisulfonic acid, gluconic acid, citraconic acid, aspartic acid, stearic acid, palmitic acid, EDTA, glycolic acid, para -aminobenzoic acid, glutamic acid, benzenesulfonic acid and p -toluenesulfonic acid.

According to one embodiment of the present invention, said organic acid is acetic acid, succinic acid, tartaric acid or propionic acid.

According to one embodiment of the present invention, said inorganic acid is selected from the group consisting of: hydrochloric acid, hydrobromic acid, hydroiodic acid, phosphoric acid, sulfuric acid and nitric acid.

According to one embodiment of the present invention, said pharmaceutically acceptable acid is acetic acid.

According to one embodiment of the present invention, said compound is {3-[1-(2-nitrophenyl) -1H- pyrrol-2-yl]-allylidene}-aminoguanidinium acetate, preferably ( E ) -N - trans- {3-[1-(2-nitrophenyl) -1H- pyrrol-2-yl]-allylidene}-aminoguanidinium acetate (AP1189).

In a specific embodiment, the present invention provides a composition comprising, separately or together, methotrexate (MTX) and ( E ) -N - trans- {3-[1-(2-nitrophenyl)-1H - pyrrol-2-yl]-allylidene}-aminoguanidinium acetate (AP1189), for use in the treatment of arthritis.

In a specific embodiment, the present invention provides a composition comprising, separately or together, methotrexate (MTX) and ( E ) -N - trans- {3-[1-(2-nitrophenyl)-1H - pyrrol-2-yl]-allylidene}-aminoguanidinium acetate (AP1189), for use in the treatment of rheumatoid arthritis (RA).

According to one embodiment of the present invention, there is provided methotrexate (MTX) and ( E ) -N - trans- {3-[1-(2-nitrophenyl)-1H - pyrrol-2-yl]-allylidene}-aminoguanidinium acetate (AP1189), for use in the treatment of arthritis, such as rheumatoid arthritis.

"( E )- N - trans- {3-[1-(2-nitrophenyl)-1 H -pyrrol-2-yl]-allylidene}-aminoguanidinium acetate" and " EN- [ trans -3-{1-(2-nitrophenyl)-1 H -pyrrol-2-yl}-allylideneamino]guanidinium acetate" (IUPAC) are used interchangeably in this description.

According to one embodiment of the present invention, there is provided a composition comprising methotrexate, or a prodrug thereof, and a compound of Formula (Ia), wherein each said R ₂ , R ₃ , R ₄ and R ₅ is a hydrogen atom, each R ₆ and R ₇ is independently selected from the group consisting of a hydrogen atom, methyl, ethyl and propyl, said R ₁ is selected from the group consisting of CF ₃ , CCl ₃ , F, Cl, NO ₂ or CN, and n = 1, for use in the treatment of arthritis.

According to one embodiment of the present invention, there is provided a composition comprising methotrexate, or a prodrug thereof, and a compound of Formula (Ia), wherein each said R ₂ , R ₃ , R ₄ , R ₅ , R ₆ and R ₇ is a hydrogen atom, said R ₁ is selected from the group consisting of CF ₃ , CCl ₃ , F, Cl, NO ₂ or CN, and n = 1, for use in the treatment of arthritis.

In one embodiment of the invention, a composition for use according to the present invention is provided, characterized in that the composition additionally contains one or more pharmaceutically acceptable carriers and/or excipients.

In one embodiment of the invention, a composition for use according to the present invention is provided, characterized in that the composition further comprises, alone or together with other components, folic acid, for example folic acid in a dose of at least 5 mg/week. Folic acid may be provided to further minimize the toxicity of MTX.

According to one embodiment of the present invention there is provided a composition comprising, separately or together, methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I), (Ia) or (II) as defined herein, for use in the treatment of arthritis, characterized in that said methotrexate or prodrug thereof is selected from the group consisting of methotrexate (systemic), methotrexate (oral), methotrexate in tablet form, methotrexate in oral solution form, methotrexate (injectable), methotrexate sodium, Methotrexate LPF (sodium methotrexate), Trexall (Xatmep), Rheumatrex, Rasuvo, Otrexup, Alltrex, Beltrax, Biotrexate, Caditrex, Carditrex, Cytotrex, Dermotrex, Folitrax, HI-Trex, Imutrex, Merex, Methocip, Methorex, Methotrexate, Metorex, Metrex, Mexate, MTX-Korea, Neotrexate, Nidtrex, Oncotrex, Onotrex, Plastomet, Remtrex, Rextop, Roxate, Tevatrex, Throtex, Trex, Thixilem and Vibzi and Zexate.

Arthritis

The present invention provides methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I) or (Ia), wherein each of n, R ₁ , R ₂ , R ₃ , R ₄ , R ₅ , R ₆ and R ₇ is as defined herein, for use in the treatment of arthritis, such as arthritis diagnosed in a subject; the meaning of the term "arthritis" is defined herein below.

The terms "arthritic disease" and "arthritis" may be used interchangeably in this description.

The term " arthritis " is often used to describe any disorder that affects the joints. These disorders fall under the broader category of rheumatic diseases. " Arthritis " literally means inflammation of the joints, which is a feature of this disease.

According to one embodiment of the present invention, arthritis is an autoimmune disease and/or an inflammatory disease that is accompanied by inflammation of the joints.

According to one embodiment of the present invention, arthritis is selected from the group consisting of inflammatory arthritis, degenerative arthritis, metabolic arthritis, reactive arthritis and infectious arthritis.

According to one embodiment of the present invention, the arthritis is inflammatory arthritis. According to one embodiment of the present invention, the inflammatory arthritis is selected from the group consisting of rheumatoid arthritis (RA), psoriatic arthritis, and ankylosing spondylitis.

According to one embodiment of the present invention, the degenerative arthritis is osteoarthritis.

According to one embodiment of the present invention, the metabolic arthritis is gouty arthritis.

According to one embodiment of the present invention, reactive and/or infectious arthritis is arthritis associated with one or more infectious infections caused by hepatitis C virus, chlamydia, gonococcus, salmonella or shigella.

According to one embodiment of the present invention, the arthritis is arthritis that is part of a systemic inflammatory disease.

According to one embodiment of the present invention, arthritis is part of a systemic inflammatory disease, such as an inflammatory disease selected from the group consisting of systemic lupus erythematosus, mixed connective tissue disease, Still's disease, and polymyalgia rheumatica.

According to one embodiment of the present invention, rheumatoid arthritis is juvenile rheumatoid arthritis (JRA). JRA is an autoimmune non-infectious inflammatory joint disease lasting more than 6 weeks, occurring in children under 16 years of age. This disease usually occurs in children aged 1 to 6 years, but can also develop in children over 15 years of age.

According to one embodiment of the present invention, the JRA is selected from the group consisting of oligoarticular JRA, systemic-onset JRA, polyarticular JRA, and seronegative spondylitis.

According to one embodiment of the present invention, there is provided a composition comprising, separately or together, methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I), (Ia) or (II), as defined herein, for use in the treatment of arthritis selected from the group consisting of

- an autoimmune disease or an inflammatory disease that is accompanied by inflammation of the joints;

- inflammatory arthritis, such as inflammatory arthritis selected from the group consisting of rheumatoid arthritis (RA), psoriatic arthritis and ankylosing spondylitis,

- degenerative arthritis such as osteoarthritis,

- metabolic arthritis, such as gouty arthritis,

- reactive and/or infectious arthritis, such as arthritis associated with one or more infectious infections caused by hepatitis C virus, chlamydia, gonococcus, salmonella or shigella,

- arthritis that is part of a systemic inflammatory disease, such as an inflammatory disease selected from the group consisting of systemic lupus erythematosus, mixed connective tissue disease, Still's disease and polymyalgia rheumatica,

- juvenile rheumatoid arthritis (JRA), such as JRA selected from the group consisting of oligoarticular JRA, systemic-onset JRA, polyarticular JRA, and seronegative spondyloarthritis.

According to one embodiment of the present invention, arthritis is present in combination with synovitis. Synovitis refers to inflammation of the synovial membrane, which is a specialized connective tissue lining the inner surface of the capsules of synovial joints and tendon sheaths.

According to one embodiment of the present invention, there is provided a composition comprising, separately or together, methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I), (Ia) or (II), as defined herein, for use in the treatment of joint inflammation.

According to one embodiment of the present invention, there is provided a composition comprising, separately or together, methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I), (Ia) or (II), as defined herein, for use in the treatment of synovitis.

According to one embodiment of the present invention, arthritis affects one or more of the joints of the hand, knee, hip, spine, wrist, ankle, thigh, toe, and/or elbow.

In one embodiment of the invention, the composition for use according to the present invention provides for the treatment of arthritis, which is accompanied by one or more additional symptoms selected from the group consisting of joint stiffness, joint pain, inability to use the hands, inability to walk, malaise, fatigue, weight loss, poor sleep, muscle pain, pain, muscle weakness, loss of flexibility and deterioration of aerobic fitness.

In a specific embodiment of the present invention, the arthritis is undifferentiated polyarthritis (UP).

In a particular embodiment of the present invention, the arthritis is rheumatoid arthritis (RA). According to one embodiment of the present invention, there is provided a composition comprising, separately or together, methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I), (Ia), or (II), as defined herein, for use in the treatment of rheumatoid arthritis (RA).

According to one embodiment of the present invention, rheumatoid arthritis is severe RA in an active form (CDAI>22). According to one embodiment of the present invention, rheumatoid arthritis is RA with CDAI>22.

In one embodiment of the invention, the composition for use according to the present invention provides treatment for subjects with newly diagnosed severe RA in active form (CDAI>22).

According to one embodiment of the present invention, rheumatoid arthritis is RA characterized by a DAS28 score greater than 5.1.

In one embodiment of the invention, a composition for use according to the present invention is provided, characterized in that the subject has positive tests for rheumatoid factor and/or IgG antibodies against cyclic citrullinated peptide (CCP) prior to treatment.

Subjects and assessment of disease severity

The subject receiving the treatment is preferably a mammal, in particular a human. However, the treatment of animals such as mice, rats, dogs, cats, horses, cattle, sheep and pigs is also included in the scope of the present invention. The subjects receiving the treatment may be of different ages.

The severity of arthritis, as well as the effectiveness of drug treatment in a subject, can be assessed using several different clinical scoring systems, such as the DAS28 score, CDAI score, and ACR score.

For example, the change achieved in one or more clinical scales after treatment can be assessed by determining the change achieved using the clinical scales in question and comparing it with baseline or placebo.

There are a wide variety of assessments of disease activity in a subject with rheumatoid arthritis, which include:

examination of the subject's joints for swelling and tenderness (they determine the swollen joint count (SJC) and tender joint count (TJC));

global indicators for assessing pain and the general condition of the subject;

markers of inflammation detected by blood tests (such as the erythrocyte sedimentation rate (ESR), which indirectly measures the degree of inflammation in a subject's body, and the level of C-reactive protein (CRP) in a subject's blood, which is measured using a C-reactive protein test);

questionnaires (e.g. the Health Assessment Questionnaire-Disability Index (HAQ-DI), which assesses the subject's functional status, and the Functional Assessment of Chronic Illness Therapy (FACIT), which is calculated based on the assessment of fatigue);

imaging techniques such as radiography, ultrasound imaging, and magnetic resonance imaging (MRI).

In one embodiment of the invention, the treatment according to the present invention results in an improvement in the subject's physical functioning, as determined by the Health Assessment Questionnaire-Disability Index (HAQ-DI).

In one embodiment of the invention, the treatment according to the present invention results in an improvement in the functional status of the subject, as determined by the Functional Assessment of Chronic Disease Treatment-Fatigue Score (FACIT-Fatigue).

In one embodiment of the invention, the composition for use according to the present invention results in partial or complete remission of one or more symptoms of arthritis.

In one embodiment of the invention, the composition for use according to the present invention reduces joint inflammation.

In one embodiment of the invention, the composition for use according to the present invention reduces the level of C-reactive protein (CRP) in the blood.

In one embodiment of the invention, the composition for use according to the present invention reduces the number of painful joints and/or reduces the number of swollen joints.

DAS28-indicator

The DAS28 score measures disease activity in subjects with rheumatoid arthritis (RA). DAS stands for "disease activity score" and the number 28 indicates that the score includes examination of 28 joints.

The DAS28 is a summary score derived from the 4 above-mentioned indices. The "28" version is a simplification of the original DAS, which requires that 44 joints be taken into account. Other versions of the DAS28 allow the use of CRP instead of ESR, or the omission of any of these markers. The DAS28-CRP is included in many DAS scores for the assessment of RA and is very useful for obtaining an objective, reproducible, and comparable assessment of rheumatoid arthritis activity. The DAS28-CRP specifically takes into account the following indices:

TJC28: Number of painful joints (0-28).

SJC28: number of swollen joints (0-28).

CRP: C-reactive protein level (mg/L).

GH: global assessment of the patient's health (from 0 (best) to 100 (worst)).

Calculating the number of painful or swollen joints involves examining the same 28 joints (shoulders, elbows, wrists, metacarpophalangeal joints, proximal interphalangeal joints, and knees). The following equation can be used to calculate this number:

Remission is generally considered to be achieved if this indicator is in the range of 0 to <2.6. Low disease activity corresponds to values from 2.6 to <3.2. Moderate disease activity is characterized by a range from 3.2 to ≤5.1, while high disease activity is strictly above 5.1.

According to one embodiment of the present invention, there is provided a composition as described herein for use in the treatment of arthritis, such as RA, wherein the disease activity score 28 (DAS28) is determined before and after treatment of the subject, and the treatment results in a decrease in the DAS28 score,

for example, as a result of treatment, the DAS28 score becomes below 5.1, such as having a value such as 5.0 or lower, such as 4.8 or lower, such as 4.6 or lower, such as 4.4 or lower, such as 4.2 or lower, such as 4.0 or lower, such as 3.8 or lower, such as 3.6 or lower, such as 3.4 or lower, such as 3.2 or lower, such as 3.0 or lower, such as 2.8 or lower, such as 2.6 or lower, such as 2.4 or lower, such as 2.2 or lower, such as 2.0 or lower, such as 1.8 or lower, such as 1.6 or lower,

for example, as a result of treatment, the DAS28 score becomes lower than 5.1, preferably 3.2 or lower, more preferably 2.6 or lower.

In one embodiment of the invention, the composition of the present invention is administered to a subject with a DAS28 score of 5.1 or higher. According to one embodiment of the present invention, said DAS28 score of the subject during and/or after treatment is reduced to values in the range of 3.2 to ≤5.1 (moderate activity), such as reduced to values in the range of 2.6 to <3.2 (low activity), such as reduced to values in the range of 0 to <2.6 (remission).

In one embodiment of the invention, the composition of the present invention is administered to a subject with a DAS28 score in the range of 3.2 to ≤5.

In one embodiment of the invention, the composition of the present invention is administered to a subject with a DAS28 score in the range of 2.6 to <3.2.

In a preferred embodiment of the invention, the DAS28 score decreases and becomes below 3.2 as a result of the treatment according to the present invention (low disease activity). In a preferred embodiment of the invention, the DAS28 score decreases and becomes below 2.6 as a result of the treatment according to the present invention (remission).

CDAI indicator

The Clinical Disease Activity Index (CDAI) is a useful clinical summary score for the evaluation of patients with rheumatoid arthritis. The CDAI is the sum of 4 primary parameters: the number of tender and swollen joints (among 28 joints assessed) and the patient's and physician's global assessments of disease activity (on a 0-10 cm visual analogue scale). The CDAI is a simplified disease activity index (SDAI), except that the SDAI includes an assessment of C-reactive protein levels.

Descriptive changes in CDAI, where CDAI = SJC(28) + TJC(28) + PGA + IGA:

SJC (28): the number of swollen joints among 28 joints (shoulder joints, elbow joints, wrist joints, MCP (metacarpophalangeal) joints, PIP (proximal interphalangeal) joints including the interphalangeal joints of the thumb, and knee joints);

TJC (28): number of painful joints among 28 joints (shoulder joints, elbow joints, wrist joints, MCP joints, PIP joints including the interphalangeal joints of the thumb, and knee joints);

PGA (Patient Global Disease Activity): Patient's overall assessment of disease activity (patient's self-assessment of overall RA activity on a scale of 0-100, where 100 represents maximum activity);

IGA: Physician's Global Assessment of Disease Activity (the examiner's assessment of the overall activity of the subject's RA on a scale of 0-100, where 100 represents maximum activity).

Remission is considered to be achieved if this indicator is in the range from 0 to <2.8; low disease activity corresponds to values from 2.8 to <10. Moderate disease activity is characterized by a range from 10 to ≤22, while high disease activity is strictly above 22 (CDAI>22).

In one embodiment of the invention, the composition of the present invention is administered to a subject with a CDAI score of 22 or higher. According to one embodiment of the present invention, said CDAI score of the subject during and/or after treatment is reduced to values in the range of 10 to ≤22 (moderate activity), such as reduced to values in the range of 2.8 to <10 (low activity), such as reduced to values in the range of 0 to <2.8 (remission).

In one embodiment of the invention, the composition of the present invention is administered to a subject with a CDAI score in the range of 10 to ≤22.

In one embodiment of the invention, the composition of the present invention is administered to a subject with a DAS28 score in the range of 2.8 to <10.

According to one embodiment of the present invention, said CDAI score of the subject during and/or after treatment is reduced by 5 points, such as reduced by 10 points, such as reduced by 15 points.

In a preferred embodiment of the invention, the CDAI score decreases and becomes below 10 as a result of the treatment according to the present invention (low disease activity). In a preferred embodiment of the invention, the DAS28 score decreases and becomes below 2.8 as a result of the treatment according to the present invention (remission).

According to a preferred embodiment of the present invention, the CDAI score is reduced by 5 points or more, such as 10 points or more, such as 15 points or more.

ACR-indicator

The ACR (American College of Rheumatology) criterion is a standard criterion for measuring the effectiveness of various drugs or treatments for arthritis in RA clinical trials.

ACR response rates ACR20, ACR50, and ACR70 are defined as ≥20%, ≥50%, and ≥70% improvement in swollen joint count and tender joint count (SJC/TJC) scores, respectively, and the same improvement in 3 of the following 5 outcome measures: patient global assessment of disease activity, physician global assessment of disease activity, patient pain score, Health Assessment Questionnaire-Disability Index (HAQ-DI), and C-reactive protein (CRP)

In a preferred embodiment of the invention, the ACR score is improved as a result of the treatment according to the present invention. In a preferred embodiment of the invention, the therapy according to the present invention results in ≥20%, ≥50% or ≥70% improvement in the ACR response scores.

According to one embodiment of the present invention, there is provided a composition comprising, separately or together, methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I), (Ia) or (II), as defined herein, for use in the method of

- improvement of physical functioning of a subject suffering from arthritis, determined using the Health Assessment Questionnaire-Disability Index (HAQ-DI),

- functional improvement in a subject with arthritis, as determined by the Functional Assessment of Chronic Disease Treatment-Fatigue Score (FACIT-Fatigue),

- achieving partial or complete remission of one or more arthritis symptoms,

- reducing joint inflammation,

- reducing the level of C-reactive protein (CRP) in the blood,

- reducing the number of painful joints and/or reducing the number of swollen joints,

- a decrease in the DAS28 score, such as a decrease in the DAS28 score to values in the range of 3.2 to ≤5.1 (moderate disease activity), such as a decrease to values in the range of 2.6 to <3.2 (low disease activity), such as a decrease to values in the range of 0 to <2.6 (remission),

- a decrease in the CDAI score, such as a decrease in the CDAI score to values in the range of 10 to ≤22 (moderate disease activity), such as a decrease to values in the range of 2.8 to <10 (low disease activity), such as a decrease to values in the range of 0 to <2.8 (remission),

- a decrease in the CDAI score by 5 points or more, for example by 10 points or more, for example by 15 points or more,

- improvement in ACR, such as improvement in ACR response rates by ≥20%, ≥50%, or ≥70%, and/or

- reducing MTX concentrations and/or improving the MTX response in a subject suffering from arthritis such as RA.

MTX-answer

Methotrexate (MTX) remains the first-line disease-modifying antirheumatic drug in rheumatoid arthritis (RA), but response is variable. Observational studies suggest that approximately 30% of patients discontinue methotrexate treatment in the medium term: about half due to treatment failure and the other half due to adverse events.

Predicting non-response to MTX could provide earlier access to alternative or additional drug treatments and monitoring of disease progression. In a recent study, 43% of patients with RA were classified as non-responders to MTX (Sergeant et al . Arthritis Research & Therapy (2018) 20:147).

Lack of response to MTX treatment at 6 months can be defined as "no response" using the EULAR (European League Against Rheumatism) response criterion, i.e. improvement in disease activity score in 28 joints (DAS28) ≤ 0.6, or improvement in DAS28 > 0.6 but ≤ 1.2 and DAS28 at 6 months > 5.1.

The definition of non-responder at 6 months includes those who continue to take the drug but do not show sufficient improvement to be classified as moderate or good responders, as well as those who discontinue the drug due to its ineffectiveness or start taking a bDMARD (biologic DMARD (disease-modifying antirheumatic drug)).

Patients with a "moderate" or "good" response according to the clinical outcome criteria are defined as those who discontinue MTX after 6 months due to remission.

According to one embodiment of the present invention, the lack of clinical response to MTX in patients is predicted using a model for predicting non-response in patients that identifies an individual at high risk of non-response, such as the model described by Sergeant et al. (2018). The baseline predictors of non-response in this multivariable logistic regression model are RF (rheumatoid factor) negativity, an elevated HAQ (Health Assessment Questionnaire) score, an elevated number of painful joints, an elevated HADS (Hospital Anxiety and Depression Scale) anxiety score, and a reduced disease activity score (a reduced baseline DAS28-CRP score).

According to one embodiment of the present invention, there is provided a composition comprising, separately or together, methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I), (Ia) or (II), as defined herein, for example AP1189, for use in the treatment of arthritis, such as RA, in patients who have not responded clinically to MTX.

According to one embodiment of the present invention, a patient with no clinical response to MTX is selected from the group consisting of

- a subject with no clinical response to treatment after 6 months,

- a subject with no clinical response to treatment at 6 months, defined as "no response" using the EULAR response criteria,

- a subject with no clinical response to treatment at 6 months, assessed as an improvement in the disease activity score in 28 joints (DAS28) ≤ 0.6, or an improvement in DAS28 > 0.6 but ≤ 1.2 and DAS28 at 6 months > 5.1,

- a subject who discontinued MTX after 6 months, i.e. stopped taking MTX and did not plan to resume it due to its ineffectiveness,

- a subject with one or more baseline predictors of non-response selected from RF (rheumatoid factor) negativity, elevated HAQ (Health Assessment Questionnaire) score, elevated painful joint count (TJC28), elevated HADS (Hospital Anxiety and Depression Scale) anxiety score, and reduced disease activity (reduced baseline DAS28-CRP score),

- an individual with a high risk (or high probability) of non-response, identified using the model described by Sergeant et al. (2018),

- a female subject,

- a subject who currently smokes, and

- a subject with a high BMI (body mass index).

According to one embodiment of the present invention, there is provided a composition comprising, separately or together, methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I), (Ia) or (II), as defined herein, for example AP1189, for use in the treatment of arthritis, such as RA, in a subject with a low or insignificant response to MTX.

In one embodiment of the invention, there is provided a composition for use according to the present invention, characterized in that treatment with methotrexate (MTX) and a compound of Formula (I), (Ia) or (II), as defined herein, is initiated substantially simultaneously.

In one embodiment of the invention, there is provided a composition for use according to the present invention, characterized in that treatment with methotrexate (MTX) is continued and treatment with a compound of Formula (I), (Ia) or (II), as defined herein, is initiated at a time when it is determined that the subject does not have a clinical response to MTX.

In one embodiment of the invention, there is provided a composition for use according to the present invention, characterized in that the subject has received MTX for the treatment of arthritis, such as RA, prior to initiating co-treatment with methotrexate and a compound of Formula (I), (Ia) or (II), as defined herein. According to one embodiment of the present invention, pre-treatment with methotrexate (MTX) does not allow an optimal outcome to be achieved prior to initiating treatment with a compound of Formula (I), (Ia) or (II).

Dosage

According to one embodiment of the present invention, there is provided a composition comprising, separately or together, methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I), (Ia) or (II), as defined herein, for use in the treatment of arthritis, characterized in that said MTX and said compound are contained in a therapeutically effective amount.

The combination treatment for use according to the present invention may provide a reduction in toxicity to the subject, preferably by administering a lower dose of methotrexate than the dose used to treat arthritis with methotrexate monotherapy.

Alternatively, the combination treatment for use according to the present invention may provide an enhancement of the treatment effect observed in a subject, preferably by enhancing the effect of methotrexate, compared to the use of methotrexate monotherapy for the treatment of arthritis.

In one embodiment of the invention, there is provided a composition for use according to the present invention, characterized in that methotrexate (MTX), or a prodrug thereof, is administered in an amount of from about 1 to about 30 mg per week, for example about 15 mg per week.

In one embodiment of the invention there is provided a composition for use according to the present invention, characterized in that methotrexate (MTX), or a prodrug thereof, is administered in an amount of from 1 to 1.5 mg/week, and also in an amount of, for example, from 1.5 to 2, for example from 2 to 2.5, for example from 2.5 to 3, for example from 3 to 3.5, for example from 3.5 to 4, for example from 4 to 4.5, for example from 4.5 to 5, for example from 5 to 5.5, for example from 5.5 to 6, for example from 6 to 6.5, for example from 6.5 to 7, for example from 7 to 7.5, for example from 7.5 to 8.5, for example from 8.5 to 9, for example from 9 to 9.5, for example from 9.5 to 10, for example from 10 to 10.5, for example, from 10.5 to 11, for example, from 11 to 11.5, for example, from 11.5 to 12, for example, from 12 to 12.5, for example, from 12.5 to 13, for example, from 13 to 13.5, for example, from 13.5 to 14, for example, from 14 to 14.5, for example, from 14.5 to 15, for example, from 15 to 15.5, for example, from 15.5 to 16, for example, from 16 to 16.5, for example, from 16.5 to 17, for example, from 17 to 17.5, for example, from 17.5 to 18, for example, from 18 to 18.5, for example, from 18.5 to 19, for example, from 19 to 19.5, for example, from 19.5 to 20, for example, from 20 to 20.5, for example, from 20.5 to 21, for example, from 21 to 21.5, for example, from 21.5 to 22, for example, from 22 to 22.5, for example, from 22.5 to 23, for example, from 23 to 23.5, for example, from 23.5 to 24, for example, from 24 to 24.5, for example from 24.5 to 25, for example from 25 to 25.5, for example from 25.5 to 26, for example from 26 to 26.5, for example from 26.5 to 27, for example from 27 to 27.5, for example from 27.5 to 28, for example from 28 to 28.5, for example from 28.5 to 29, for example, from 29 to 29.5, for example, from 29.5 to 30 mg/week.

In one embodiment of the invention, there is provided a composition for use according to the present invention, characterized in that methotrexate (MTX), or a prodrug thereof, is administered in an amount of from about 5 to 10 mg, from 5 to 15 mg, from 10 to 15 mg, from 5 to 20 mg, from 10 to 20 mg, from 10 to 25 mg, or from 15 to 20 mg per week.

In one embodiment of the invention, a composition for use according to the present invention is provided, characterized in that methotrexate (MTX), or a prodrug thereof, is administered in an oral dosage form in an amount of from about 10 to about 25 mg/week once a week. Once a week means once every 7 days, preferably on the same day of the week.

In one embodiment of the invention, a composition for use according to the present invention is provided, characterized in that methotrexate (MTX), or a prodrug thereof, is administered subcutaneously in an amount of from about 5 to about 25 mg/week once a week. Once a week means once every 7 days, preferably on the same day of the week.

In one embodiment of the invention, there is provided a composition for use according to the present invention, characterized in that the compound of Formula (I), (Ia) or (II) is administered in an amount of from about 1 mg to about 1000 mg per day, for example from about 500 to about 1000 mg per day, for example from about 50 to about 800 mg per day.

In one embodiment of the invention there is provided a composition for use according to the present invention, characterized in that the compound of Formula (I), (Ia) or (II) is administered in an amount of from 1 to 5 mg, from 5 to 10 mg, from 10 to 15 mg, from 15 to 20 mg, from 20 to 30 mg, from 30 to 60 mg, from 60 to 80 mg, from 80 to 100 mg, from 100 to 130 mg, from 130 to 160 mg, from 160 to 200 mg, from 200 to 240 mg, from 240 to 280 mg, from 280 to 320 mg, from 320 to 360 mg, from 360 to 400 mg, from 400 to 440 mg, from 440 to 500 mg, from 500 to 560 mg, 560 to 620 mg, 620 to 680 mg, 680 to 740 mg, 740 to 800 mg, 800 to 860 mg, 860 to 920 mg, 920 to 980 mg, 980 to 1000 mg/day.

In one embodiment of the invention there is provided a composition for use according to the present invention, characterized in that the compound is {3-[1-(2-nitrophenyl) -1H- pyrrol-2-yl]-allylidene}-aminoguanidine, such as ( E ) -N - trans- {3-[1-(2-nitrophenyl) -1H- pyrrol-2-yl]-allylidene}-aminoguanidine, or a pharmaceutically acceptable salt thereof, such as ( E ) -N - trans- {3-[1-(2-nitrophenyl) -1H -pyrrol-2-yl]-allylidene}-aminoguanidinium acetate (AP1189), and said compound is administered once daily in an amount of 50 mg, as well as in an amount of, for example, 100 mg, such as 200 mg, such as 400 mg, such as 600 mg, such as 800 mg.

According to one embodiment of the present invention, there is provided a composition comprising, separately or together, methotrexate (MTX) and ( E ) -N - trans- {3-[1-(2-nitrophenyl)-1H - pyrrol-2-yl]-allylidene}-aminoguanidinium acetate (AP1189), for use in the treatment of arthritis, such as rheumatoid arthritis (RA),

characterized in that said compound is administered once a day in an amount of about 50 mg, such as 100 mg, such as 200 mg, such as 400 mg, such as 600 mg, such as 800 mg, and said MTX is administered orally once a week in an amount of from about 10 to about 25 mg,

or characterized in that said MTX is administered subcutaneously once a week in an amount of from about 5 to about 15 mg.

In a preferred embodiment of the present invention, MTX, or a prodrug thereof, is administered once a week. Commercially available dosage forms of MTX can be used for oral administration or subcutaneous administration. Both forms should be administered once a week, preferably on the same day of the week.

In a preferred embodiment of the present invention, the compound of Formula (I), (Ia) or (II) is administered daily, such as once daily, twice daily or three times daily.

According to one embodiment of the present invention, a composition comprising, separately or together, methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I), (Ia) or (II), as defined herein, is administered for 1 week, and also, for example, for more than 1 week, for example for 2 weeks or more than 2 weeks, for example for 3 weeks or more than 3 weeks, for example for 4 weeks or more than 4 weeks,

for example, for 1 month or more than 1 month, for example, for 2 months or more than 2 months, for example, for 3 months or more than 3 months, for example, for 4 months or more than 4 months, for example, for 5 months or more than 5 months, for example, for 6 months or more than 6 months, for example, more than 1 year.

In one embodiment of the invention, there is provided a composition for use according to the present invention, characterized in that co-administration with a compound of Formula (I), (Ia) or (II) allows MTX, or a prodrug thereof, to be administered at a subtherapeutic dose, or a reduced dose (i.e., at a dose that is lower than the standard prescribed dose).

According to one embodiment of the present invention, treatment with a compound of Formula (I), (Ia) or (II) and MTX or a prodrug thereof has a synergistic effect. According to one embodiment of the present invention, treatment with a compound of Formula (I), (Ia) or (II) and MTX or a prodrug thereof has an additive effect.

According to one embodiment of the present invention, administration of a compound of Formula (I), (Ia) or (II) as defined herein, such as AP1189, and MTX or a prodrug thereof, has a synergistic effect.

According to one embodiment of the present invention, administration of a compound of Formula (I), (Ia) or (II), as defined herein, such as AP1189, and MTX, or a prodrug thereof, results in an interaction that provides a combined effect that is greater than the sum of their individual effects.

In a particular embodiment of the invention, there is provided a composition for use according to the present invention, characterized in that the compound of Formula (I), (Ia) or (II) is administered daily and MTX, or a prodrug thereof, is administered weekly.

In one embodiment of the invention, a composition for use according to the present invention is provided, characterized in that the compound of Formula (I), (Ia) or (II) is administered before the administration of MTX or a prodrug thereof, and/or simultaneously with MTX or a prodrug thereof, and/or after the administration of MTX or a prodrug thereof.

In one embodiment of the invention, a composition for use according to the present invention is provided, characterized in that treatment with methotrexate (MTX) is discontinued while treatment with a compound of Formula (I), (Ia) or (II) is still ongoing.

Preparations

A composition for use in the treatment of arthritis comprises, separately or together, a compound of Formula (I), (Ia) or (II) and methotrexate (MTX), or a prodrug thereof, in the form of any suitable preparation.

In one embodiment of the invention, there is provided a composition for use according to the present invention, characterized in that MTX, or a prodrug thereof, is present in the form of a preparation for oral administration, for example in the form of tablets or capsules.

According to one embodiment of the present invention, MTX, or a prodrug thereof, is present in the form of a liquid preparation. The liquid may be used for intravenous administration or injection, such as subcutaneous injection.

According to one embodiment of the present invention, MTX, or a prodrug thereof, is present as a sustained release preparation. According to one embodiment of the present invention, MTX, or a prodrug thereof, is present as an immediate release preparation.

In one embodiment of the invention, a composition for use according to the present invention is provided, characterized in that the compound of Formula (I), (Ia) or (II) is present in the form of a preparation for oral administration, for example in the form of tablets or capsules.

According to one embodiment of the present invention, the compound of Formula (I), (Ia) or (II) is present in the form of a liquid preparation, such as a liquid for intravenous administration or continuous infusion or a liquid for injection.

In one embodiment of the invention, a composition for use according to the present invention is provided, characterized in that the compound of Formula (I), (Ia) or (II) is present as a preparation for prolonged release. According to one embodiment of the present invention, the compound of Formula (I), (Ia) or (II) is present as a preparation for immediate release.

In one embodiment of the invention, a composition for use according to the present invention is provided, characterized in that the compound of Formula (I), (Ia) or (II) is present in the form of a preparation for oral administration and MTX, or a prodrug thereof, is present in the form of a preparation intended for oral, intravenous, intramuscular or subcutaneous administration.

In a particular embodiment of the invention, there is provided a composition for use according to the present invention, characterized in that the compound of Formula (I), (Ia) or (II) is present in the form of a preparation for oral administration.

In a particular embodiment of the invention there is provided a composition for use according to the present invention, characterized in that the compound is {3-[1-(2-nitrophenyl) -1H- pyrrol-2-yl]-allylidene}-aminoguanidine, such as ( E ) -N - trans- {3-[1-(2-nitrophenyl) -1H- pyrrol-2-yl]-allylidene}-aminoguanidine, or a pharmaceutically acceptable salt thereof, such as ( E ) -N - trans- {3-[1-(2-nitrophenyl)-1H - pyrrol-2-yl]-allylidene}-aminoguanidinium acetate (AP1189), and said compound is present in the form of a preparation for oral administration.

According to one embodiment of the present invention, said compound is present in the form of a solid dosage form intended for oral administration, such as a tablet.

According to one embodiment of the present invention, said compound is present as a powder preparation, for example an oral powder, such as an oral powder suitable for suspension in a liquid.

According to one embodiment of the present invention, said compound is present as a suspension preparation containing a dissolved oral powder.

According to one embodiment of the present invention, said compound is present as a preparation in the form of an oral suspension, such as a suspension intended for oral administration.

Composition

According to one aspect of the present invention, there is also provided a composition, such as a pharmaceutical composition, comprising, separately or together, methotrexate (MTX), or a prodrug thereof, and a compound of Formula (I) or (Ia):

Formula (I),

Formula (Ia),

including its tautomeric and isomeric forms such as enantiomeric forms, diastereomeric forms and racemic forms,

Where

n has the value 1, 2 or 3;

each R ₁ , R ₂ , R ₃ , R ₄ and R ₅ is independently selected from the group consisting of hydrogen, optionally substituted C _1-6 alkyl, optionally substituted C _3-6 cycloalkyl, optionally substituted C _2-6 alkenyl, optionally substituted C _4-6 alkadienyl, optionally substituted C _2-6 alkynyl, hydroxy, optionally substituted C _1-6 alkoxy, optionally substituted C _2-6 alkenyloxy, carboxy, optionally substituted C _1-6 alkoxycarbonyl, optionally substituted C _1-6 alkylcarbonyl, formyl, C _1-6 alkylsulfonylamino, optionally substituted aryl, optionally substituted aryloxycarbonyl, optionally substituted aryloxy, optionally substituted arylcarbonyl, optionally substituted arylamino, arylsulfonylamino, optionally substituted heteroaryl, optionally substituted heteroaryloxycarbonyl, optionally substituted heteroaryloxy, optionally substituted heteroarylcarbonyl, optionally substituted heteroarylamino, heteroarylsulfonylamino, optionally substituted heterocyclyl, optionally substituted heterocyclyloxycarbonyl, optionally substituted heterocyclyloxy, optionally substituted heterocyclylcarbonyl, optionally substituted heterocyclylamino, heterocyclylsulfonylamino, amino, mono- and di(C _1-6 -alkyl)amino, carbamoyl, mono- and di(C _1-6 -alkyl)aminocarbonyl, amino-C _1-6 -alkyl-aminocarbonyl, mono- and di(C _1-6 -alkylamino-C _1-6 -alkyl-aminocarbonyl, C _1-6 -alkylcarbonylamino, amino-C _1-6 -alkyl-carbonylamino, mono- and di(C _1-6 -alkyl)amino-C _1-6 -alkyl-carbonylamino, cyano, guanidino, carbamido, C _1-6 -alkanoyloxy, C _1-6 -alkylsulfonyl, C _1-6 -alkylsulfinyl, C _1-6 -alkylsulfonyloxy, aminosulfonyl, mono- and di(C _1-6 -alkyl)aminosulfonyl, nitro optionally substituted with C _1-6 -alkylthio and a halogen atom, wherein any C _1-6 -alkyl bonded to the nitrogen atom is optionally substituted with hydroxy, C _1-6 -alkoxy, C _2-6 -alkenyloxy, amino, mono- and di(C _1-6 -alkyl)amino, carboxy, C _1-6 -alkylcarbonylamino, halogen atom, C _1-6 -alkylthio, C _1-6 -alkylsulfonylamino or guanidine;

each R ₆ and R ₇ is independently selected from the group consisting of hydrogen, optionally substituted C _1-6 alkyl, optionally substituted C _2-6 alkenyl, optionally substituted C _4-6 alkadienyl, optionally substituted C _2-6 alkynyl, optionally substituted C _1-6 alkoxycarbonyl, optionally substituted C _1-6 alkylcarbonyl, optionally substituted aryl, optionally substituted aryloxycarbonyl, optionally substituted arylcarbonyl, optionally substituted heteroaryl, optionally substituted heteroaryloxycarbonyl, optionally substituted heteroarylcarbonyl, aminocarbonyl, mono- and di(C _1-6 alkyl)aminocarbonyl, amino-C _1-6 alkyl-aminocarbonyl and mono- and di(C _1-6 alkyl)amino-C _1-6 -alkylaminocarbonyl; or R ₆ and R ₇ together may form a five- or six-membered nitrogen-containing ring;

or a pharmaceutically acceptable derivative of this compound.

According to one embodiment of the present invention, there is provided a composition, such as a pharmaceutical composition, comprising, separately or together, methotrexate (MTX), or a prodrug thereof, and a compound of Formula (II):

Formula (II),

including its tautomeric and isomeric forms such as enantiomeric forms, diastereomeric forms and racemic forms, or a pharmaceutically acceptable derivative of the compound.

According to one embodiment of the present invention, there is provided a composition, such as a pharmaceutical composition, comprising, separately or together, methotrexate (MTX) and ( E ) -N - trans- {3-[1-(2-nitrophenyl) -1H- pyrrol-2-yl]-allylidene}-aminoguanidinium acetate (AP1189).

According to one embodiment of the present invention, there is provided a composition comprising, separately or together, methotrexate (MTX), or a prodrug thereof, a compound of Formula (I), (Ia) or (II), as defined herein, and folic acid.

Examples

Example 1. Combination treatment with methotrexate and AP1189 (( E )- N - trans -{3-[1-(2-nitrophenyl)-1 H -pyrrol-2-yl]-allylidene}-aminoguanidinium acetate).

Materials and methods

Six-week-old C57/BL6 mice were obtained from Charles River and acclimated for one week prior to the experiment.

Mice were randomly assigned to the following groups:

Group 1: Control group of animals to monitor the time trend of changes in health status, without intervention;

Group 2: Animals in which arthritis was induced and treated with vehicle for methotrexate (vehicle 2) and for AP1189 (vehicle 1):

Group 3: Animals in which arthritis was induced and treated with methotrexate and vehicle for AP1189 (vehicle 1);

Group 4: Animals in which arthritis was induced and treated with methotrexate vehicle (vehicle 2) and treated with AP1189;

Group 5: Animals in which arthritis was induced and treated with methotrexate and AP1189.

N=6 in all groups.

Arthritis was induced by two intraperitoneal injections of 100 μl K/BxN serum on day 0 and day 2 (for details see J Immunol 2015; 194:3381–3388).

AP1189 and vehicle 1 (20% PEG-200 in PBS (phosphate-buffered saline)) were administered orally from day 2 to day 7 (total volume: 200 μL).

Methotrexate and vehicle 2 (12.5% carbonate buffer) were administered on days 3, 5, and 7 by i.p. injection (injected volume: 200 μl).

Preparation of methotrexate preparation: A small volume of 0.1 M carbonate-bicarbonate buffer pH 9.6 was used to dissolve methotrexate (Sigma, catalog number: A6770). PBS (phosphate buffered saline) was then used to achieve the desired concentration. The final buffer was 12.5% carbonate buffer. The dissolved compound was divided into single-use aliquots, which were stored at -20°C until use.

Arthritis development was monitored daily from day 0 to day 8.

Mice were sacrificed on day 8 after daily measurements were performed.

K/BxN serum was generated by crossing KRN mice with NOD/Lt mice. The offspring developed spontaneous arthritis, evident at 6 weeks, at a rate of 100%. Serum was collected after nine weeks and stored at -80°C until use, and arthritis induced using a serum transfusion model was due to the administration of pooled serum to wild-type (WT) mice (for details, see Trends Mol Med, 2004;10:40-5).

Visible signs of arthritis were scored using the scoring methodology described in Am J Pathol, 2014; 184(8):2333–41, which consists of assigning a score of 0–3 per paw, with a maximum score of 12 per mouse:

Score 0: no signs of inflammation.

Score 1: mild inflammation, localized.

Rating 2: Easily identifiable but localized.

Score 3: severe inflammation, not localized.

This clinical score was used to calculate the following parameters (for details, see J Immunol, 2015; 194(7):3381-8):

Arthritis incidence (mice showing external signs of inflammation, i.e. with a score ≥1);

Joints with severe inflammation (number of affected paws per mouse, maximum score achievable 3);

Frequency of severe arthritis (number of mice with score >10).

Swelling in the lower paws was measured using plethysmometry (Ugo Basile).

Results

The incidence of severe arthritis was calculated as the % of mice in each group that received a total score ≥ 10.

None of the animals in Group 1 (the control group to monitor the time trend of health status, where arthritis was not induced) developed arthritis.

In Group 2 (animals with arthritis that were given vehicle), 5 of 6 animals developed severe arthritis.

The incidence of severe arthritis in animals treated with methotrexate alone (Group 3) or AP1189 alone (Group 4) was 50%.

Surprisingly, none of the animals given the combination of methotrexate and AP1189 developed severe arthritis.

Conclusions

The treatment of arthritis was unexpectedly effective when the combination of methotrexate and AP1189 was administered, as none of the animals given the combination developed severe arthritis.

Example 2

Clinical study

The first dose of AP1189 was administered to healthy volunteers in a single ascending dose study using the oral suspension (Part I - Fig. 2), in a bioequivalence study using the oral suspension as well as tablets (Part II), and in a 14-day multiple dose study (Fig. 3). Fourteen-day multiple dose administration was initiated using the tablet formulation (Part III) and continued (Part IV) using the oral suspension.

The total number of subjects randomized was 111: 104 young healthy male volunteers and eight (8) postmenopausal women. In Part I, 56 subjects received a single oral dose once (42 subjects received AP1189 and 14 subjects received placebo). In Part II, eight (8) subjects received a single oral dose of AP1189 three times with one-week washout intervals. In Part III, eleven (11) subjects received a single oral dose daily for 14 days (8 subjects received AP1189 and three (3) subjects received placebo), and in Part IV, thirty-six (36) subjects received AP1189/placebo once daily for 14 days (27 subjects received AP1189 and nine (9) subjects received placebo).

Summary of Phase I Clinical Trial Results; Parts I, II and III

Parts I and II of the clinical study have been completed. Part I of the clinical study was a randomized, double-blind, placebo-controlled, single-ascending dose study using AP1189 or placebo administered as an oral suspension. Seven healthy male groups (48 men) and 1 female group (8 healthy postmenopausal women) (defined as at least two years of amenorrhea and FSH >30 IU/L) received a single ascending dose of AP1189/placebo administered in the fasted state as an investigational medicinal product (IMP) oral suspension dissolved in SyrSpend ALKA. The first two male groups consisted of 3 subjects receiving active IMP and one subject receiving placebo; the other groups consisted of 6 subjects receiving active IMP and two subjects receiving placebo. Forty-eight (48) healthy male volunteers aged 19 to 39 years and eight (8) healthy postmenopausal female volunteers aged 47 to 60 years were included in the study.

Subjects in the male groups were treated with oral suspensions containing AP1189 at doses of 15-800 mg (15 mg, 50 mg, 100 mg, 200 mg, 400 mg, 600 mg, or 800 mg) or placebo. Women were treated with suspensions containing 400 mg AP1189 or placebo (see Fig. 2).

Pharmacokinetic (PK) data showed that in male subjects in the dose groups ranging from 50 to 800 mg, AP1189 was rapidly absorbed, with median t _max (time to reach C _max (maximum plasma concentration)) ranging from 1 to 4 h. Between-subject variability in C _max (maximum plasma concentration) and AUC (area under the curve) (< 36%) was low to moderate. The mean t _1/2 (half-life) was close to 20 h (CV% (coefficient of variation) < 20%).

The mean Vd/F (apparent volume of distribution) ranged from 556 to 784 L with a CV% below 35%, and the mean CL/F (apparent total plasma clearance) ranged from 20.26 to 31.26 L/h with a CV% below 50%.

In subjects in the female group, C _max and AUC were slightly higher after administration of AP1189 at a dose of 400 mg compared with those values in subjects in the male groups. The apparent clearance was lower in women (17.26 L/h) and the apparent volume of distribution was similar. Based on statistical data, it was not possible to conclude whether there were gender effects.

Twenty (20) subjects reported a total of 38 treatment-emergent adverse events (TEAEs). All TEAEs were mild (27) or moderate (11). No severe AEs or serious AEs were reported during the study. Twenty-two (22) of the 38 TEAEs were considered treatment-related in this study: 21 of these events occurred following administration of AP1189 at doses ranging from 200 to 800 mg, and one event occurred following administration of placebo.

Among the treatment-related TEAEs, the most common were gastrointestinal disorders (19 events reported by fourteen (14) subjects), namely nausea (7 events), abdominal pain (5 events), vomiting (3 events), diarrhea (2 events), flatulence (1 event), and dyspepsia (1 event). The incidence of treatment-related TEAEs increased with increasing dose. However, the amount of vehicle in the suspension increased with dose, resulting in a thicker consistency and increased taste of the study drug. Among the TEAEs considered as non-treatment-related in this study, headache was reported by seven (7) subjects. Other TEAEs were isolated events.

Some average changes and individual pathological deviations were observed in laboratory parameters, vital signs and ECG (electrocardiogram) parameters. Most of these changes and pathological deviations were limited in nature and were considered clinically insignificant.

A total of four (4) subjects in the male groups who received AP1189 treatment experienced increases in aminotransferase levels (no associated changes in alkaline phosphatase or bilirubin levels were observed). A 1.6-fold increase in the upper limit of normal for ALT (alanine aminotransferase) was observed in one (1) subject who received 400 mg, two (2) subjects who received 600 mg, and one (1) subject who received 800 mg. No increases in aminotransferase levels above the upper normal range were observed in subjects who received placebo.

No treatment-related changes in vital signs were detected.

No AP1189-associated increase in QTcF (Fredericia-corrected QT interval) or changes in other cardiac parameters were observed in data obtained during continuous 24-hour Holter ECG monitoring at 1000 Hz.

It can be concluded that the maximum tolerated dose (MTD) was not reached. The resulting maximum administrated dose (MAD) exposure was more than 10 times the expected exposure level required to achieve therapeutic efficacy.

Clinical Study, Part II

Part II of the clinical study was a comparative clinical study of the bioavailability of AP1189 as a tablet and as an oral suspension with an additional assessment of the effect of food intake after tablet administration, according to a three-way crossover design. AP1189 200 mg was administered once as an oral suspension and on two separate occasions as two 100 mg AP1189 tablets; testing was performed once in the fasted state and once after a high-fat breakfast. The results of testing after administration of the suspension confirmed the data obtained in Part I of the study. The data after tablet administration indicated a decrease in exposure with higher variability compared to the results of testing after administration of the suspension.

The effect of AP1189 tablets administered daily at doses of 100 mg (Group 1), 200 mg (Group 2), and 400 mg (Group 3) was studied. Part III was designed as a randomized, double-blind, placebo-controlled study with repeated administration of escalating doses of AP118 tablets.

Pharmacokinetic (PK) data obtained in Cohort 1 of Part III of the clinical study following 14 days of repeated dosing demonstrated high and unexpected bioavailability in subjects. The range of exposure levels, as assessed by _Cmax, ranged from below the limit of quantification (BLQ) to levels more than three times the expected exposure level required to produce therapeutic effects.

Clinical Study, Part IV

Part IV was an extension of the clinical study, which was identical to Part III of the clinical study except that the oral suspension was administered on an empty stomach.

Summary of Part IV Results

Part IV of the clinical trial was a randomized, double-blind, placebo-controlled, multiple-dose study of AP1189 or placebo as an oral suspension administered to the subject once daily for 14 days. Three cohorts of 12 subjects each (9 subjects received active drug; 3 subjects received placebo) received the same drug used in Part 1 of the clinical trial. Dose levels tested were 50 mg, 100 mg, or 200 mg with matching placebo (see Fig. 3).

FC, Part IV, Cohort 1

Dose: 50 mg once daily. C _max was observed 1-2.5 hours after dosing regardless of the day of administration. Steady-state C _max , which was achieved on day 7, was approximately 180 ng/mL.

FC, Part IV, Cohort 2

Dose: 100 mg once daily.

Based on PK analysis, there was a sharp increase in plasma concentration and the C _max level reached approximately 400 ng/mL at steady state, i.e., an approximately 2-fold increase in peak value compared to the data in cohort 1.

FC Part IV Cohort 3

Dose: 200 mg once daily. As with the other two cohorts, C _max was observed 1-2 hours after dosing. C _max was as high as 900 ng/mL (group average), with the highest recorded being 1300 ng/mL.

Safety Assessment in Part 4

Fourteen (14) subjects reported a total of 35 treatment-emergent adverse events (TEAEs). All TEAEs were mild (27) or moderate (8). No severe AEs or serious AEs were reported during the study. Four (4) of the 35 TEAEs were considered to be possibly related to the treatment in this study. All 4 cases were gastrointestinal disorders and occurred following administration of the clinical trial drug (two cases (2) were reported in the same subject at the 50 mg dose level (one case of diarrhea and one case of abdominal cramps), two cases (2) were reported in the same subject at the 200 mg dose level (one case of nausea and one case of vomiting)). Among the TEAEs considered unrelated to treatment in this study, headache was reported by nine (9) subjects, seven (7) of whom were treated with the clinical trial drug and two (2) of whom were treated with placebo. Other TEAEs were isolated events.

Some average changes and individual abnormalities were observed in laboratory parameters, vital signs, and ECG parameters. Most of these changes and abnormalities were limited in nature and were considered clinically insignificant. There were no individual clinically significant QTcF values during the entire duration of this part of the study with multiple recordings of the standard 12-lead safety ECG.

A total of five (5) subjects in Cohort 3 (200 mg), three (3) receiving active drug and two (2) receiving placebo, experienced increases in aminotransferases (no concomitant changes in alkaline phosphatase or bilirubin). These increases were most pronounced in subjects receiving active drug, with ALT increases of 3.6-fold and 2.9-fold the upper limit of normal. All values returned to normal after study completion.

It can be concluded that MTD was not achieved.

Example 3

For this study, AP1189 doses of 50 mg and 100 mg were selected.

Peak and trough concentrations determined in the repeated-dose portion of the AP1189 clinical study at steady state were as follows:

C _max (mean +/- SD, N=9) C _trough (mean +/- SD, N=9) 50 mg once daily 180 ± 38 ng/ml 46 ± 14 ng/ml 100 mg once daily 427 ± 76 ng/ml 100 ± 25 ng/ml 200 mg once daily 893 ± 198 ng/ml 186 ± 45 ng/ml

Primary safety endpoint

The safety of AP1189 compared with placebo was assessed based on observed adverse events (AEs), serious adverse events (SAEs), and laboratory abnormalities.

Primary efficacy endpoint

The change in CDAI after 4 weeks of treatment compared with baseline was determined by assessing the following parameters in the treatment group:

Mean change in CDAI from baseline to week 4;

Proportions of subjects with a change in CDAI score from values consistent with severe disease (CDAI > 22) to values consistent with moderate disease (CDAI ≤ 22) at 4 weeks compared with baseline.

Secondary efficacy endpoints

The effects of AP1189 treatment relative to placebo were determined by assessing the following parameters in the treatment group:

Proportions of subjects achieving recovery of more than ten (10) swollen and/or tender joints (SJC and TJC scores combined) at 4 weeks compared with baseline;

Proportions of subjects achieving change in CDAI score at 4 weeks compared to baseline:

The share of subjects with a decrease in the indicator by 5 points,

The proportion of subjects with a decrease in the indicator by 10 points,

Share of subjects with a decrease in the indicator by 15 points;

Proportions of subjects achieving a change in DAS28 score from DAS28 >3.2 to DAS28 ≤3.2 at 4 weeks compared with baseline;

Changes in HAQ-DI after 4 weeks compared to baseline;

Changes in FACIT-Fatigue after 4 weeks compared to baseline;

Proportions of subjects with ACR response assessed as ACR20, ACR50, and ACR70.

Tertiary efficacy endpoints

The effect of AP1189 treatment relative to placebo at 4 weeks compared with baseline was further determined by assessing the following parameters in the treatment group:

CXCL13, IL-1β, IL-6, IL-10 and TNF-α;

Biomarkers in synovial biopsy samples at baseline and after 4 weeks of treatment (Part 2 only in selected clinical trial sites).

Clinical trial design

This study was a multicenter, two-part, randomized, double-blind, placebo-controlled, 4-week, multiple-dose study of AP1189. The study population consisted of subjects with newly diagnosed, severe, active RA (CDAI > 22) scheduled to begin MTX dose escalation. A minimum of 90 subjects were expected to complete the study. Up to 120 subjects were planned to be enrolled, with the expectation that up to 25% of subjects would discontinue the study.

Subjects who met the inclusion criteria were randomly assigned in a 2:1 ratio to groups A and B. One group received the active drug as treatment, and the other group received placebo. Groups C/D had the same 2:1 ratio of subjects receiving active drug and placebo.

Arm A (12 subjects): AP1189 dose 50 mg once daily for 4 weeks (28 days) plus MTX (10-25 mg) weekly

Group B (6 subjects): placebo for 4 weeks (28 days) plus MTX (10-25 mg) weekly

Group C (12 subjects): AP1189 dose 100 mg once daily for 4 weeks (28 days) plus MTX (10-25 mg) weekly

Group D (6 subjects): placebo for 4 weeks (28 days) plus MTX (10-25 mg) weekly

Number of subjects in Part 1

A minimum of 36 subjects were expected to complete Part 1 of the study. Approximately 48 subjects were planned to be enrolled in the study, with the expectation that the rate of subjects discontinuing participation in the study would be approximately 25%.

Part 2

All subjects were randomly assigned to participate in only one study design, i.e., Study Design 1, 2, or 3:

Design 1: AP1189 50 mg (36 subjects) or placebo (18 subjects), once daily for 4 weeks (28 days) plus MTX (10-25 mg) weekly;

Design 2: AP1189 dose 100 mg (36 subjects) or placebo (18 subjects), once daily for 4 weeks (28 days) plus MTX (10-25 mg) weekly;

Design 3: Maintained the same doses as Part 1, with a 1:1:1 subject group ratio (AP1189 50 mg (18 subjects), AP1189 100 mg (18 subjects), or placebo (18 subjects)), plus MTX (10-25 mg) weekly.

Number of subjects in Part 2

A minimum of 54 subjects were expected to complete Part 2 of the study. Approximately 72 subjects were planned to be enrolled, with the expectation that the rate of subjects discontinuing participation in the study would be approximately 25%.

Duration of the study

The total duration of the study was 18 months, and each subject's participation in the study lasted approximately 10 weeks.

Number of research centers

The study should be conducted in European centres.

Study sample

The study population consisted of subjects with severe active RA, defined as RA with a CDAI > 22, who were about to begin MTX dose escalation.

Inclusion Criteria

1. Written informed consent was obtained before any study procedures were performed.

2. Male and female subjects aged 18 to 85 years

3. Confirmed diagnosis of RA according to the 2010 ACR/EULAR RA classification criteria

4. Arthritis accompanied by swelling and tenderness in at least three joints out of 68 joints tested

5. Candidate for treatment with methotrexate (MTX)

6. Subject about to be started on methotrexate (MTX) treatment

7. Subject has positive tests for anti-CCP antibodies and/or rheumatoid factor

8. Severe active RA (CDAI > 22) at screening and at study inclusion

9. Negative QFG-IT (Mantoux test can be used if QFG-IT is not possible)

10. Subjects must be able to complete (read and sign) PRO questionnaires

11. Women of childbearing potential may participate in the study only if they use reliable contraception (for more details, see section 17.8), or postmenopausal women (with an amenorrhea period of at least 12 months before enrollment) may participate. Women who have been surgically sterilized at least 6 months before screening

12. Women of childbearing potential must have a negative pregnancy test at screening and at the time of study inclusion

Non-inclusion criteria

Subjects who meet any of the following criteria are ineligible to participate in the study:

1. Participation in any other study using a drug(s) undergoing clinical investigation less than 4 weeks prior to study entry;

2. Major surgery (including joint surgery) less than 8 weeks before screening or planned surgery within 1 month after randomization;

3. Autoimmune rheumatic disease other than RA, including SLE (systemic lupus erythematosus), MCTD (mixed connective tissue disease), scleroderma, polymyositis, or significant systemic involvement due to RA (eg, vasculitis, pulmonary fibrosis, or Felty's syndrome). Sjogren's syndrome in combination with RA is acceptable;

4. Functional class IV as defined by the ACR criteria for classification of RA functional status, or wheelchair/bed rest;

5. Inflammatory joint disease other than RA, history or current (eg, gout, reactive arthritis, psoriatic arthritis, seronegative spondyloarthropathy, Lyme disease);

6. Subjects suffering from fibromyalgia;

7. Initiation of NSAIDs (non-steroidal anti-inflammatory drugs) or changes in their dosage (including low dose aspirin and COX-2 (cyclooxygenase 2) inhibitors) less than 2 weeks before IMP administration;

8. Corticosteroids are prohibited less than 2 weeks before screening (and throughout the treatment period, and until the final visit (Visit 7);

9. Confirmed serious uncontrolled concomitant cardiovascular disease, nervous system disease, pulmonary disease (including obstructive pulmonary disease), renal disease, liver disease, endocrine disease (including uncontrolled diabetes mellitus), or gastrointestinal disease;

10. The subject has a previous renal transplant, is currently on hemodialysis, or has severe renal failure (characterized by a glomerular filtration rate (GFR), calculated using the Cockcroft-Gault formula, ≤30 mL/min/1.73 ^m2 , determined by a regional laboratory);

11. Uncontrolled painful conditions such as asthma, psoriasis or inflammatory bowel disease, acute exacerbations of which are usually treated with oral or parenteral corticosteroids;

12. Confirmed active malignant disease (except basal cell skin cancer that has been surgically removed and cured);

13. Pregnant or breastfeeding women;

14. History of abuse of alcohol, drugs or addictive chemicals less than 6 months prior to screening;

15. Neuropathies or other painful conditions that could influence pain assessment;

16. Body weight over 150 kg.

17. Confirmed moderate and/or severe organ dysfunction;

18. Abnormal chest X-ray (at the discretion of the researcher);

19. Confirmed positive serological test for hepatitis;

20. Confirmed peptic ulcer.

Information about the study drug is presented in the tables below.

Table 1. Treatments tested

Name AP1189 Dosage 50 mg, 100 mg Preparation Powder Route of administration Oral Supplier SynAct Pharma

Table 2. Reference treatment

Name Placebo Dosage 0 mg Preparation Powder Route of administration Oral Supplier SynAct Pharma

Description AP1189

IUPAC: E - N -[ trans -3-{1-(2-nitrophenyl)-1 H -pyrrol-2-yl}-allylideneamino]guanidinium acetate.

This compound is a salt of acetic acid, which has the appearance of a yellow solid and is odorless.

Structural formula:

.

https://labtestsonline.org/glossary/acute-phase-reactant

https://labtestsonline.org/glossary/proteinhttps://labtestsonline.org/glossary/inflammation

Molecular formula: C ₁₆ H ₁₈ N ₆ O ₄

The molecular weight of the salt is 358.35 and that of the free base is 298.30.

Methotrexate (MTX)

All subjects must follow regional guidelines for initiation of methotrexate (MTX) treatment and continuation of MTX treatment during the clinical trial.

MTX Treatment Instructions for Elevated Liver Enzymes

If liver enzyme levels are elevated, it is recommended to have blood tests done more frequently.

Increased transaminase levels:

Laboratory test data Action Increase in ALT and/or AST (aspartate aminotransferase) levels > 1 to values ≤ 3x ULN (upper limit of normal)
And the bilirubin level is in the normal range. IMP and MTX treatment remains the same.
If liver enzyme levels are elevated, it is recommended to have blood tests done more frequently. Increases in ALT and/or AST levels > 3 to values ≤ 5x ULN
And the bilirubin level is in the normal range. Temporarily discontinue IMP until ALT and/or AST levels are < 3x ULN and follow recommendations above for > 1 to < 3x ULN
After normalization of ALT and/or AST levels, resume IMP administration.
If the level continuously increases to > 3x ULN, discontinue IMP administration. ALT and/or AST level > 5x ULN Stop administration of MTX and IMP. Bilirubin level > normal range values Stop MTX and IMP treatment.

Folic acid

AEs commonly associated with MTX treatment can be expected to occur. To minimize MTX toxicity, all subjects receiving MTX treatment should be given folic acid or its equivalent at a dose of at least 5 mg/week, according to regional guidelines and at the discretion of the investigator. Folic acid can be given either as a single dose weekly or in divided daily doses to achieve a total dose of folic acid of at least 5 mg per week.

Prohibited drugs

The following drugs that are CYP1A2 substrates are contraindicated: alosetron, clozapine, flutamide, frovatriptan, melatonin, mexiletine, mirtazapine, olanzapine, ramelteon, rasagiline, ropinirole, tacrine, theophylline, tizanidine, triamterene, and zolmitriptan.

Laboratory research

It is essential to use the most recent reference range updates from your regional laboratory.

Hematological analysis

Hemoglobin, white blood cell (WBC) count (total and by types: leukocytes, neutrophils, eosinophils, basophils, lymphocytes, monocytes), red blood cells (RBC), platelets and hemoglobin A1c (HbA1C). Blood samples for hematological analysis were collected at screening, at study inclusion, after treatment for 2 weeks and 4 weeks.

Biochemical analysis

Sodium, potassium, chloride, calcium, glucose, creatinine, urea, albumin, unconjugated and total bilirubin, aspartate transaminase (AST), alanine transaminase (ALT), alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT) and INR (international normalized ratio). Blood samples for biochemical analysis were collected during all visits. A pregnancy test for the presence of β-hCG (beta subunit of human chorionic gonadotropin) in the blood serum was performed during screening.

Thyroid function

Thyroxine (T4) free, triiodothyronine (T3) total or free and thyroid stimulating hormone (TSH). Blood samples are taken to measure thyroid function.

Urine analysis

Urine dipstick testing for blood, protein, and glucose was performed on-site during the screening visit. A urine sample may be sent for bacterial culture.

Serological analysis

RF or antibodies against CCP, HBsAg (hepatitis B virus surface antigen), antibodies against HBV (hepatitis B virus) and antibodies against HCV (hepatitis C virus).

RF is an antibody that is found in the blood of approximately 80% of adults with rheumatoid arthritis (RA).

CRP is an acute-phase reactant, a protein synthesized in the liver and released into the blood within hours of tissue injury, the onset of infection, or inflammation from another cause. CRP levels are most often elevated as a result of inflammation. One of the goals of treatment is to lower CRP levels to normal levels. CRP levels were measured at screening, at study entry, and after treatment for 2 weeks and 4 weeks.

Safety (AE and SAE)

Safety monitoring (AE, SAE, including laboratory abnormalities) was performed throughout the study.

Safety assessment (substudy, Part 2 only)

In the arthroscopy substudy of Part 2 of the clinical trial, the effect of AP1189/placebo treatment over 4 weeks was assessed compared with baseline by examining synovial fluid: the relative change (expressed as a percentage) in polymorphs, monocytes and lymphocytes in synovial fluid was assessed.

In rheumatoid arthritis (RA), the immunohistologic characteristics of synovial inflammation change as clinical manifestations change in response to standard disease-modifying antirheumatic drugs, pulse methylprednisolone therapy, or intra-articular glucocorticoids.

Evaluation of effectiveness

Swollen Joint Count (SJC) and Tender Joint Count (TJC)

A total of 66 joints were assessed for swelling and 68 joints were assessed for tenderness at screening, study entry, and after treatment for 2 weeks and 4 weeks. Joints were assessed and classified as swollen/not swollen and painful/not tender by applying pressure to the joints and manipulating the joints during physical examination. The subject was asked about the pain experienced during these manipulations and their spontaneous pain responses were observed. Any positive response to pressure, movement, or both was then classified as painful/not tender. Swelling was defined as palpable fluctuant synovitis of the joint. Swelling due to osteoarthritis was scored as nonswollen unless obvious fluctuation was present.

Joint assessments in a single subject should be performed by the same examiner (if possible) throughout the study to minimize interobserver inconsistency.

Clinical Disease Activity Index (CDAI)

The CDAI is a clinical summary score for patients with rheumatoid arthritis (RA).

Descriptive changes in CDAI, where CDAI = SJC(28) + TJC(28) + PGA + IGA:

SJC (28): the number of swollen joints among 28 joints (shoulder joints, elbow joints, wrist joints, MCP (metacarpophalangeal) joints, PIP (proximal interphalangeal) joints including the interphalangeal joints of the thumb, and knee joints);

TJC (28): number of painful joints among 28 joints (shoulder joints, elbow joints, wrist joints, MCP joints, PIP joints including the interphalangeal joints of the thumb, and knee joints);

PGA: Patient Global Assessment of Disease Activity (patient's self-assessment of overall RA activity on a scale of 0-100, where 100 represents maximum activity);

IGA: Physician's Global Assessment of Disease Activity (the examiner's assessment of the overall activity of the subject's RA on a scale of 0-100, where 100 represents maximum activity).

CDAI was assessed at screening, study entry, 2 weeks and 4 weeks post-treatment.

Disease Activity Scale 28 (DAS28)

DAS28 is a composite index for measuring disease activity in rheumatoid arthritis (RA). This index includes the number of swollen joints and the number of tender joints, CRP, and general health status. In this study, CRP was used to calculate the DAS28 score. This index was calculated using the following formula:

DAS28-CRP(4) = 0.56*sqrt(TJC28) + 0.28*sqrt(SJC28) + 0.36*ln(CRP+1) + 0.014*GH + 0.96,

where TJC = number of tender joints among 28 joints, SJC = number of swollen joints among 28 joints, ln = natural log, CRP = C-reactive protein and GH = general health status, i.e., the patient's overall assessment of disease activity (on a 100-mm VAS (visual analogue scale)).

The DAS28 provides an absolute indication of disease activity in rheumatoid arthritis (RA) on a scale from 0.49 to 9.07:

DAS28 value >5.1 corresponds to high disease activity;

DAS28 value in the range from 3.2 to 5.1 corresponds to moderate disease activity;

DAS28 value in the range from 2.6 to 3.2 corresponds to low disease activity;

DAS28 value < 2.6 corresponds to remission.

The disease activity of a subject compared to the baseline value can be classified as follows:

Current value of DAS28 Decrease in DAS28 compared to baseline > 1,2 > 0.6 but ≤ 1.2 ≤ 0.6 ≤ 3.2 Lack of activity Significant improvement Moderate improvement No improvement >3.2 but ≤ 5.1 Moderate activity Moderate improvement Moderate improvement No improvement > 5.1 High activity Moderate improvement No improvement No improvement

DAS28 was assessed at study entry, 2 weeks and 4 weeks after treatment.

VAS scale for overall assessment of disease activity by the physician ("Investigator's Overall VAS Scale")

The physician's assessment of the subject's current disease activity using a 100-mm horizontal VAS scale. The far left end of the scale should be described as "no disease activity" (asymptomatic disease and no arthritis symptoms) and the far right end of the scale as "maximal disease activity." The efficacy assessor should consider these data. Investigator's overall VAS measurements were made at screening, study entry, and after treatment for 2 weeks and 4 weeks.

VAS scale for the overall assessment of disease activity by the patient ("Patient Overall VAS Scale")

The subject's overall assessment of their current disease activity on a 100-mm horizontal VAS scale. The far left end of the scale should be described as "no disease activity" (asymptomatic disease and no arthritis symptoms) and the far right end of the scale as "maximum disease activity" (maximum arthritis activity). Patient overall VAS measurements were taken at screening, study entry, 2 weeks, and 4 weeks after treatment.

VAS scale for patient assessment of pain ("Patient VAS pain scale")

The subject's assessment of his or her current pain level on a 100-mm horizontal VAS scale. The far left end of the scale should be described as "no pain," and the far right end of the scale as "unbearable pain." Patient VAS pain scale measurements were taken at screening, study entry, and after 2 weeks and 4 weeks of treatment.

Quality of life and physical functioning

Functional Assessment of Chronic Illness Treatment-based Fatigue Score (FACIT-Fatigue)

The FACIT-Fatigue assessment is a 13-item questionnaire, each rated by the subject on a 5-point scale. This assessment was originally developed for chronic diseases and is now validated for patients with rheumatoid arthritis (RA).Rating FACIT-Fatigue was performed at study entry, 2 weeks and 4 weeks after treatment.

Health Assessment Questionnaire-Disability Index (HAQ-DI)

The HAQ-DI is a validated instrument for assessing physical functioning. This questionnaire consists of 20 questions covering 8 component categories: dressing/grooming, lifting, eating, walking, hygiene, reaching, squeezing, and activity. The HAQ-DI was calculated at study entry, 2 weeks, and 4 weeks post-treatment.

Response rates according to American College of Rheumatology criteria

The ACR (American College of Rheumatology) criteria are a standard criterion for measuring the effectiveness of various drugs or treatments for arthritis in clinical trials of rheumatoid arthritis (RA).

ACR response rates ACR20, ACR50, and ACR70 are defined as ≥20%, ≥50%, and ≥70% improvement in the swollen joint count and tender joint count (SJC/TJC) scores, respectively, and the same improvement in 3 of the following 5 outcome measures: patient global assessment of disease activity (see above), physician global assessment of disease activity (see above), patient pain score (see above), Health Assessment Questionnaire-Disability Index (HAQ-DI, see above), and C-reactive protein (CRP).

Evaluation of pharmacokinetic data

Sampling for PK analysis

Plasma PK samples for exposure-response analysis were collected after treatment for 1, 2, 3, and 4 weeks.

Cytokine Assays

Plasma samples for analysis of CXCL13, IL-1β, IL-6, IL-10, and TNF-α were collected at study entry, after 2 weeks of treatment, and after 4 weeks of treatment.

Storage of biological samples

The following samples were stored frozen in a biobank or similar storage facility, depending on the country, during the study:

Cytokines (CXCL13, IL-1β, IL-6, IL-10 and TNF-α), plasma

FC, plasma

All cytokine and PK analyses were performed in a central laboratory. Samples were sent and analyzed regularly.

Safety

Classification by severity

The severity of adverse events was assessed to classify them into subcategories. Severity is not the same as seriousness. A very serious adverse event may not be serious, and a serious adverse event may be a mild event according to the severity classification. Each adverse event was classified by severity using the Common Terminology Criteria for Adverse Events (CTCAE) rating scale version v. 4.03 of June 14, 2010.

The following gradation of adverse events was used:

Mild (Grade 1) - Mild; asymptomatic or with mild symptoms; clinical or diagnostic observations only; no intervention required.

Moderate (Grade 2) - Moderate; requires minimal, local, or noninvasive intervention; limits age-appropriate instrumental activities of daily living (ADL).

Severe (Grade 3) - Severe or clinically significant but not immediately life-threatening; requires hospitalization or prolongation of existing hospitalization; disabling; limits self-care ADLs.

Life-threatening (Grade 4) - Life-threatening consequences; immediate intervention required.

Fatal outcome (Grade 5) related to AE.

The presence of a relationship (if any) between the adverse event and the study drug was established. A causal relationship was considered to be present if it was established that there was a reasonable possibility that the adverse event could have been caused by the study drug.

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54. Sergeant et al . Arthritis Research & Therapy (2018) 20:147).

Claims (82)

1. Use of the compound of Formula (II) Formula (II), including its tautomeric forms, enantiomeric forms, diastereomeric forms and racemic forms, or a pharmaceutically acceptable salt thereof; in combination with methotrexate (MTX), or its prodrug, for the treatment of arthritis, wherein methotrexate (MTX), or a prodrug thereof, is administered in an amount of from about 1 to about 30 mg per week and the compound of Formula (II) is administered in an amount of from about 1 mg to about 1000 mg per day. 2. The use according to claim 1, characterized in that said compound is selected from the group consisting of {3-[1-(2-nitrophenyl) -1H- pyrrol-2-yl]-allylidene}-aminoguanidine and ( E )- N - trans- {3-[1-(2-nitrophenyl) -1H- pyrrol-2-yl]-allylidene}-aminoguanidine, or a pharmaceutically acceptable salt thereof. 3. The use according to claim 1, characterized in that said pharmaceutically acceptable salt is a pharmaceutically acceptable salt of an inorganic acid or an organic acid. 4. The use according to claim 3, characterized in that said organic acid is selected from the group consisting of formic acid, acetic acid, trichloroacetic acid, trifluoroacetic acid, propionic acid, benzoic acid, cinnamic acid, citric acid, fumaric acid, glycolic acid, lactic acid, maleic acid, malic acid, malonic acid, mandelic acid, oxalic acid, picric acid, pyruvic acid, salicylic acid, succinic acid, methanesulfonic acid, ethanesulfonic acid, tartaric acid, ascorbic acid, pamoic acid, bis-methylene salicylic acid, ethanedisulfonic acid, gluconic acid, citraconic acid, aspartic acid, stearic acid, palmitic acid, EDTA, glycolic acid, para -aminobenzoic acid, glutamic acid, benzenesulfonic acid and p -toluenesulfonic acid. 5. Use according to any of paragraphs 3, 4, characterized in that the said organic acid is acetic acid, succinic acid, tartaric acid or propionic acid. 6. The use according to paragraph 3, characterized in that said inorganic acid is selected from the group consisting of hydrochloric acid, hydrobromic acid, hydroiodic acid, phosphoric acid, sulfuric acid and nitric acid. 7. Use according to any of paragraphs 3, 4, characterized in that said pharmaceutically acceptable acid is acetic acid. 8. The use according to claim 1, characterized in that said compound is selected from the group consisting of {3-[1-(2-nitrophenyl)-1 H -pyrrol-2-yl]-allylidene}-aminoguanidinium acetate and ( E )- N - trans -{3-[1-(2-nitrophenyl)-1 H -pyrrol-2-yl]-allylidene}-aminoguanidinium acetate. 9. The use according to claim 1, characterized in that said compound is ( E )- N - trans- {3-[1-(2-nitrophenyl) -1H- pyrrol-2-yl]-allylidene}-aminoguanidinium acetate (AP1189). 10. Use according to claim 1, characterized in that arthritis is an autoimmune disease and/or an inflammatory disease that is accompanied by inflammation of the joints. 11. The use according to claim 1, characterized in that the arthritis is selected from the group consisting of inflammatory arthritis, degenerative arthritis, metabolic arthritis, reactive arthritis and infectious arthritis. 12. The use according to claim 11, characterized in that the inflammatory arthritis is selected from the group consisting of rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis. 13. The use according to claim 11, characterized in that the degenerative arthritis is osteoarthritis. 14. The use according to paragraph 11, characterized in that the metabolic arthritis is gouty arthritis. 15. The use according to claim 11, characterized in that reactive and/or infectious arthritis is arthritis associated with one or more infectious infections caused by the hepatitis C virus, chlamydia, gonococci, salmonella or shigella. 16. The use according to claim 1, characterized in that the arthritis is undifferentiated polyarthritis (UP). 17. The use according to claim 1, characterized in that the arthritis is rheumatoid arthritis (RA). 18. The use according to claim 1, characterized in that the arthritis is severe rheumatoid arthritis (RA) in an active form, such as newly diagnosed severe RA in an active form. 19. The use according to claim 1, characterized in that the arthritis is rheumatoid arthritis with a DAS28 score above 5.1 and/or with a CDAI > 22. 20. The use according to claim 1, characterized in that the arthritis is rheumatoid arthritis with a DAS28 score of 5.1 or higher (high disease activity), or, for example, with a DAS28 score of 3.2 to ≤5.1 (moderate disease activity), or, for example, with a DAS28 score of 2.6 to <3.2 (low disease activity). 21. The use according to claim 1, characterized in that the arthritis is rheumatoid arthritis with a CDAI score of 22 or higher (high disease activity), or, for example, with a CDAI score of 10 to ≤22 (moderate disease activity), or, for example, with a CDAI score of 2.8 to <10 (low disease activity). 22. The use according to claim 21, characterized in that the rheumatoid arthritis is juvenile rheumatoid arthritis (JRA). 23. The use according to claim 22, characterized in that the JRA is selected from the group consisting of oligoarticular JRA, systemic onset JRA, polyarticular JRA, and seronegative spondyloarthritis. 24. Use according to paragraph 1, characterized in that arthritis is present in combination with synovitis. 25. Use according to claim 1, characterized in that the arthritis affects one or more of the joints of the hand, knee, hip, spine, wrist, ankle, thigh, toe and/or elbow. 26. The use according to claim 1, characterized in that the arthritis is accompanied by one or more additional symptoms selected from the group consisting of joint stiffness, joint pain, inability to use the hands, inability to walk, malaise, fatigue, weight loss, poor sleep, muscle pain, pain, muscle weakness, loss of flexibility, and deterioration in aerobic fitness. 27. The use according to paragraph 1, characterized in that the use i) reduces joint inflammation, ii) reduces the number of painful joints and/or reduces the number of swollen joints, iii) reduces the level of C-reactive protein (CRP) in the blood, iv) results in partial or complete remission of one or more symptoms of arthritis, v) results in an improvement in the subject's physical functioning, as measured by the Health Assessment Questionnaire-Disability Index (HAQ-DI), vi) results in functional improvement in the subject as measured by the Functional Assessment of Chronic Disease Treatment-Fatigue Score (FACIT-Fatigue), vii) reduces the DAS28 score, e.g. reduces the DAS28 score to values in the range of 3.2 to ≤5.1 (moderate disease activity), e.g. to values in the range of 2.6 to <3.2 (low disease activity), e.g. to values in the range of 0 to <2.6 (remission), viii) reduces the CDAI score, e.g. reduces the CDAI score to values in the range of 10 and ≤22 (moderate disease activity), e.g. to values in the range of 2.8 and <10 (low disease activity), e.g. to values in the range of 0 and <2.8 (remission), ix) reduces the CDAI score by 5 points or more, for example by 10 points or more, for example by 15 points or more, x) results in ≥20%, ≥50%, or ≥70% improvement in ACR response rates. 28. The use according to claim 1, characterized in that the subject has positive tests for rheumatoid factor and/or IgG antibodies against cyclic citrullinated peptide (CCP) prior to treatment. 29. The use of claim 1 for the treatment of arthritis, such as RA, in a subject with no clinical response to MTX. 30. The use according to claim 29, characterized in that said subject with no clinical response to MTX is selected from the group consisting of: a) a subject with no clinical response to treatment after 6 months, b) a subject with no clinical response to treatment at 6 months, defined as "no response" using the EULAR response criteria, c) a subject with no clinical response to treatment at 6 months, assessed as an improvement in the Disease Activity Score in 28 joints (DAS28) ≤ 0.6, or an improvement in DAS28 > 0.6 but ≤ 1.2 and DAS28 at 6 months > 5.1, d) a subject who discontinued MTX after 6 months, i.e. stopped taking MTX and did not plan to resume it due to its ineffectiveness, e) a subject with one or more baseline predictors of non-response selected from RF (rheumatoid factor) negativity, elevated HAQ (Health Assessment Questionnaire) score, elevated painful joint count (TJC28), elevated HADS (Hospital Anxiety and Depression Scale) anxiety score, and reduced disease activity (reduced baseline DAS28-CRP score), f) an individual with a high risk (or high probability) of non-response, identified using the model described by Sergeant et al. (2018), g) a female subject, h) a subject who currently smokes, and i) a subject with a high BMI (body mass index). 31. The use according to claim 1, characterized in that methotrexate (MTX), or a prodrug thereof, is administered in an amount of from about 10 to 25 mg once a week, for example from about 5 to 15 mg per week. 32. Use according to claim 1, characterized in that MTX, or its prodrug, is administered once a week. 33. The use according to claim 1, characterized in that the compound of Formula (II) is administered in an amount of from about 50 to about 800 mg per day, for example 50 mg, 100 mg, 200 mg, 400 mg, 600 mg or 800 mg per day. 34. Use according to claim 1, characterized in that the compound of Formula (II) is administered daily, for example once a day, twice a day or three times a day. 35. Use according to claim 1, characterized in that the combination is administered for 1 week, and also, for example, for more than 1 week, for example for 2 weeks or more than 2 weeks, for example for 3 weeks or more than 3 weeks, for example for 4 weeks or more than 4 weeks, for example for 1 month or more than 1 month, for example for 2 months or more than 2 months, for example for 3 months or more than 3 months, for example for 4 months or more than 4 months, for example for 5 months or more than 5 months, for example for 6 months or more than 6 months, for example more than 1 year. 36. Use according to claim 1, characterized in that the compound of Formula (II) is administered before the administration of MTX or its prodrug, and/or simultaneously with MTX or its prodrug, and/or after the administration of MTX or its prodrug. 37. The use according to claim 1, characterized in that the treatment with the compound of Formula (II) and MTX, or its prodrug, has a synergistic effect. 38. The use according to claim 1, characterized in that the treatment with the compound of Formula (II) and MTX, or its prodrug, has an additive effect. 39. The use according to claim 1, characterized in that the compound of Formula (II) is administered daily and MTX, or a prodrug thereof, is administered once a week. 40. Use according to claim 1, characterized in that treatment with methotrexate (MTX) is discontinued while treatment with the compound of Formula (II) is still ongoing. 41. The use according to claim 1, characterized in that MTX, or a prodrug thereof, is present in the form of a preparation for oral administration, for example in the form of tablets or capsules. 42. The use according to claim 1, characterized in that MTX, or its prodrug, is administered orally. 43. The use according to claim 1, characterized in that MTX, or a prodrug thereof, is present in the form of a liquid preparation for injection. 44. The use according to claim 1, characterized in that MTX, or a prodrug thereof, is administered by subcutaneous injection. 45. Use according to claim 1, characterized in that the compound of Formula (II) is present in the form of a preparation for oral administration. 46. The use according to claim 1, characterized in that the compound of Formula (II) is presented in a solid dosage form intended for oral administration, such as a tablet or capsule. 47. The use according to claim 1, characterized in that the compound of Formula (II) is presented in the form of a powder, for example a powder for oral administration, such as a powder for oral administration suitable for suspension in a liquid. 48. The use according to claim 1, characterized in that the compound of Formula (II) is presented in the form of an oral suspension, such as a suspension intended for oral administration. 49. The use according to claim 1, characterized in that MTX was administered for the treatment of arthritis prior to initiation of treatment with the compound of Formula (II). 50. The use according to claim 49, characterized in that preliminary treatment of said arthritis with methotrexate (MTX) does not allow achieving an optimal result before initiating treatment with the compound of Formula (II). 51. Use according to claim 1, characterized in that said compound is also used in combination with folic acid or its equivalent. 52. A combination for the treatment of arthritis comprising about 1 to 30 mg of methotrexate (MTX), or a prodrug thereof, and about 1 to 1000 mg of a compound of Formula (II) Formula (II), including its tautomeric forms, enantiomeric forms, diastereomeric forms and racemic forms, or a pharmaceutically acceptable salt thereof. 53. The combination according to claim 52, characterized in that said compound is selected from the group consisting of {3-[1-(2-nitrophenyl) -1H- pyrrol-2-yl]-allylidene}-aminoguanidine and ( E )- N - trans- {3-[1-(2-nitrophenyl) -1H- pyrrol-2-yl]-allylidene}-aminoguanidine, or a pharmaceutically acceptable salt thereof, for example, characterized in that said compound is selected from the group consisting of {3-[1-(2-nitrophenyl)-1 H -pyrrol-2-yl]-allylidene}-aminoguanidinium acetate and ( E )- N - trans -{3-[1-(2-nitrophenyl)-1 H -pyrrol-2-yl]-allylidene}-aminoguanidinium acetate. 54. A combination according to any one of paragraphs 52 and 53, characterized in that said combination additionally contains folic acid or its equivalent.