SI20976A - Compositions and methods for l-nucleosides, l-nucleotides, and their analogs - Google Patents

Abstract

Nucleoside and nucleotide compounds and their analogs/prodrugs are provided. Particularly contemplated compounds include 1-beta-L-ribofuranosyl-1,2,4-triazole-3-carboxamide, which may be modified and/or phosphorylated. Contemplated compounds may further be combined with other pharmacological compounds, especially including Ribavirin, antibodies, and cytokines. Preferred uses of contemplated compounds include use as an antiviral compound, anti-inflammatory compound, antineoplastic compound, and as a compound to stimulate cellular growth.

Description

SESTAVKI IN POSTOPKI ZA L-NUKLEOZIDE, ^NUKLEOTIDE IN NJIHOVE ANALOGECOMPOSITIONS AND PROCEDURES FOR L-NUCLEOSIDES, ^ NUCLEOTIDES AND THEIR ANALOGS

Ta prijava se navezuje na U.S. začasno patentno prijavo 60/173,446, vloženo 12/29/1999, U.S. začasno patentno prijavo 60/172,097, vloženo 12/23/1999, U.S.začasno patentno prijavo 60/175,111, vloženo 01/06/2000, U.S. začasno patentno prijavo 60/190,758, vloženo 3/20/2000, U.S.začasno patentno prijavo 60/226,947, vloženo 8/22/2000, U.S. začasno patentno prijavo 60/226, 875, vloženo 8/22/2000, U.S. začasno patentno prijavo 60/233,821, vloženo 9/19/2000, U.S. začasno patentno prijavo 60/233,823, vloženo 9/19/2000, U.S. začasno patentno prijavo 60/233,548, vloženo 9/19/2000, U.S.začasno patentno prijavo 60/233,822, vloženo 9/19/2000 in U.S. začasno patentno prijavo 60/235,465, vloženo 9/26/2000, od katerih so vse vključene tu z referencami.This application relates to the U.S. Provisional Patent Application 60 / 173,446, filed 12/29/1999, U.S. Pat. Provisional patent application 60 / 172,097, filed 12/23/1999, U.S. Provisional patent application 60 / 175,111, filed 01/06/2000, U.S. Pat. Provisional patent application 60 / 190,758, filed 3/20/2000, U.S. Provisional patent application 60 / 226,947, filed 8/22/2000, U.S. Pat. Provisional Patent Application 60/226, 875, filed 8/22/2000, U.S. Pat. Provisional Patent Application 60 / 233,821, filed 9/19/2000, U.S. Pat. Provisional Patent Application 60 / 233,823, filed 9/19/2000, U.S. Pat. Provisional patent application 60 / 233,548, filed 9/19/2000, U.S. Provisional patent application 60 / 233,822, filed 9/19/2000, and U.S. Pat. Provisional Patent Application 60 / 235,465, filed 9/26/2000, all of which are incorporated herein by reference.

Polje izumaField of Invention

Polje izuma so farmacevtski sestavki in njihova uporaba.Field of the invention are pharmaceutical compositions and their use.

Ozadje izumaBACKGROUND OF THE INVENTION

Obstajajo številni izzivi za posmeznikovo zdravje, mnogi izmed teh izhajajo iz okužbe ali kopičenja toksinov v nekem življensko važnem organu, kar lahko vodi dalje do škodljive reakcije imunskega sistema proti okuženemu organu. Na primer, okužba z virusom hepatitisa C (HCV) pogostokrat vodi do trdovratne vnetne virusne infekcije, pri kateri se vnetje organa ne more takoj pripisati virusu HCV ampak prej od infekcije povzročenemu neravnovesju pri imunskem odgovoru.There are numerous challenges to individual health, many of which arise from the infection or accumulation of toxins in a vital organ, which can further lead to a harmful reaction of the immune system against the infected organ. For example, hepatitis C virus (HCV) infection often leads to persistent inflammatory viral infection, in which organ inflammation cannot be immediately attributed to HCV but sooner than the infection-induced imbalance in the immune response.

Večino poznanih obdelav virusnih infekcij lahko običajno označimo kot bodisi direktno antivirusno obdelavo ali indirektno antivirusno obdelavo. Pri direktni antivirusni obdelavi je virus tarča primernega direktnega antivirusnega zdravila. Na primer, pacienti okuženi z virusom HIV tipično dobijo mešanico zdravil za zaustavitev razmnoževanja virusov, v stroki pa so znani razni razredi za direktno antivirusno zdravljenje. Na primer, razna direktna antivirusna zdravila zaustavijo reverzno transkriptazo. Zaviralci reverzne trankriptaze (RT) so tipično analogi nukleozidov kot AZT, 3TC ali ddl. Alternativno se lahko uporabljajo zaviralci nukleozidov RT, vključno s kvercetinom. In vitro so zaviralci RT tipično močna antivirusna zdravila. Vendar pa je in vivo, posebno med obdobjem relativno visoke hitrosti virusne reprodukcije, generiranje virusnih mutantov, odpornih proti zaviralcu RT, problematično.Most known treatments for viral infections can usually be referred to as either direct antivirus or indirect antivirus treatment. For direct antiviral processing, the virus is targeted by a suitable direct antiviral. For example, HIV-infected patients typically receive a mixture of drugs to stop the spread of viruses, and various classes of direct antiviral therapy are known in the art. For example, various direct antiviral drugs stop reverse transcriptase. Reverse transcriptase (RT) inhibitors are typically nucleoside analogues such as AZT, 3TC or ddl. Alternatively, nucleoside inhibitors of RT, including quercetin, may be used. In vitro, RT inhibitors are typically potent antiviral drugs. However, in vivo, especially during a period of relatively high viral reproduction rate, the generation of viral mutants resistant to RT inhibitors is problematic.

Druga direktna antivirusna zdravila zaustavijo virusno procesiranje proteinov ali pa ga motijo in so splošno znana kot zaviralci proteaze. Zaviralci proteaze so značilno visoko specifični, kar se tiče virusnih proteolitičnih encimov. Vendar pa postaja, zaradi njihove večinoma hidrofobne narave, dajanje v želeni koncentraciji problematično. Poleg tega razvoj navzkrižne odpornosti in resni stranski učinki pogostokrat sestavljajo težave, ki izhajajo iz uporabe zaviralcev proteaze. Da bi zmanjšali razvoj virusnih sevov, se lahko predpišejo mešanice zaviralcev RT in zaviralcev proteaze. Čeprav so takšne mešanice, ki so trenutno v rabi, sorazmerno uspešne, ostaja relativno visoko pojavljanje škodljivih stranskih učinkov in možnost generiranja virusnih sevov, odpornih proti mnogim zdravilom.Other direct antiviral medicines either stop or disrupt viral processing of proteins and are commonly known as protease inhibitors. Protease inhibitors are typically highly specific for viral proteolytic enzymes. However, due to their largely hydrophobic nature, administration at the desired concentration becomes problematic. In addition, the development of cross-resistance and serious side effects are often compounded by problems arising from the use of protease inhibitors. In order to reduce the development of viral strains, mixtures of RT and protease inhibitors may be prescribed. Although such mixtures currently in use are relatively successful, the relatively high incidence of adverse side effects remains and the ability to generate viral strains resistant to many drugs.

Pri indirektni antivirusni obdelavi se lahko modulira imunski odgovor na virusni izziv. Na primer, lahko se uporabljajo imunosupresivna zdravila za znižanje vnetnega stanja, ki je povezano z virusno okužbo, v stroki pa so znana razna imunosupresivna zdravila. Med drugimi imunosupresivnimi zdravili je ciklosporin A znan kot močan imunospresiv in se pogostokrat uporablja za supresijo tkivne zavrnitve po~presaditvi organov. Vendar pa se uporaba ciklosporina A nagiba k temu, da postaja problematična zaradi splošnega imunosupresivnega učinka, tako da postane bolnik bolj dovzeten za nove infekcijske bolezni. Poleg tega je dolgotrajno dajanje ciklosporina A pogostokrat povezano z resnimi stranskimi učinki, vključno s hirzutizmom in hiperplazijo dlesni.In indirect antiviral treatment, the immune response to a viral challenge can be modulated. For example, immunosuppressive drugs can be used to reduce the inflammatory condition associated with a viral infection, and various immunosuppressive drugs are known in the art. Among other immunosuppressive drugs, ciclosporin A is known as a potent immunosuppressant and is often used to suppress tissue rejection after organ transplantation. However, the use of cyclosporin A tends to become problematic due to the general immunosuppressive effect, making the patient more susceptible to new infectious diseases. In addition, prolonged administration of cyclosporin A is often associated with serious side effects, including hirsutism and gum hyperplasia.

Razen tega je biouporabnost ciklosporina A deloma odvisna od žolča, kar lahko postavlja dodatne probleme pri okužbi s hepatitisom.In addition, the bioavailability of cyclosporin A is partly bile-dependent, which may pose additional problems for hepatitis infection.

Da bi premagali vsaj nekatere od težav povezanih s ciklosporinom A, se lahko uporablja Tacrolimus (FK506) kot imunosupresivno zdravilo. Na primer, Tacrolimus je dobil priznanje pri zdravljenju facialnega atopičnega dermatitisa. Posledica lokalnega dajanja imunosupresiva je bilo pomembno izboljšanje pri 95% vseh obdelanih bolnikov [Alaiti, S. et al. Tacrolimus (FK506) ointment for atopic dermatitis: A phase I study in adults and children. J Am Acad Dermatol 1998; 38(1): 69-76], Poleg tega se zdi, da Tacrolimus ne pronica skozi kožno bariero, s čimer odpravi probleme povezane s sistemskim dajanjem. Čeprav se na splošno dobro prenaša, je zdravljenje s Tacrolimusom brez splošnega ogrožanja imunosti omejeno na lokalno dajanje. Če se daje sistemsko skozi podaljšana obdobja, vodi Tacrolimus pogostokrat k limfoproliferativnim motnjam in kardiomiopatiji.To overcome at least some of the problems associated with cyclosporin A, Tacrolimus (FK506) may be used as an immunosuppressive drug. For example, Tacrolimus has received recognition in the treatment of facial atopic dermatitis. Topical administration of immunosuppressants resulted in a significant improvement in 95% of all treated patients [Alaiti, S. et al. Tacrolimus (FK506) Ointment for atopic dermatitis: A phase I study in adults and children. J Am Acad Dermatol 1998; 38 (1): 69-76], In addition, Tacrolimus does not appear to penetrate the skin barrier, eliminating problems associated with systemic administration. Although generally well tolerated, treatment with Tacrolimus is not limited to topical administration without general compromise of immunity. When given systemically over prolonged periods, Tacrolimus often leads to lymphoproliferative disorders and cardiomyopathy.

Mnoga znana imunosupresivna zdravila zagotavljajo nekatere ublažitve pri vnetnih stanjih. Vendar pa učinek ni specifičen za organ, ko se daje sistemsko. Zato je imunost proti eksogenim in endogenim izzivom, kot so bakterijske in virusne okužbe, neoplastične ali maligne celice itd., sistemsko znižana. Tako je okno za uporabno koncentracijo imunosupresivnih zdravil definirano z maksimalno koncentracijo, ki ne bo popolnoma ogrozila bolnikov imunski sistem, in z minimalno koncentracijo, ki bo zagotavljala vsaj nekaj od želenega učinka.Many well-known immunosuppressive drugs provide some relief from inflammatory conditions. However, the effect is not organ specific when administered systemically. Therefore, immunity against exogenous and endogenous challenges such as bacterial and viral infections, neoplastic or malignant cells, etc. is systemically reduced. Thus, the window for a useful concentration of immunosuppressive drugs is defined by the maximum concentration that will not completely compromise the patient's immune system, and the minimum concentration that will provide at least some of the desired effect.

Čeprav stroka pozna razne spojine in postopke za zdravljenje infekcijskih in vnetnih bolezni, trpijo vsa ali skoraj vsa za eno ali več pomanjkljivostmi. Zato obstaja potreba po zagotavljanju izboljšanih postopkov in sestavkov za zdravljenje teh stanj.Although the art is familiar with various compounds and methods for treating infectious and inflammatory diseases, all or almost all of them suffer from one or more disadvantages. Therefore, there is a need to provide improved procedures and compositions for the treatment of these conditions.

Povzetek izumaSummary of the Invention

Pričujoči izum je usmerjen k metodam in sestavkom, pri katerih dajemo nukleozidno in/ali nukleotidno zdravilo ali njegov analog osebi v koncentraciji ali odmeijanju, ki je učinkovito za doseganje želenega farmakološkega ali fiziološkega učinka.The present invention is directed to methods and compositions in which a nucleoside and / or nucleotide drug or an analogue thereof is administered to a person in a concentration or melt that is effective to achieve the desired pharmacological or physiological effect.

Po enem od vidikov predmeta izuma, ima obravnavana spojina strukturo, ki ustreza formuli I, kjer R predstavlja H, skupine PO₃ ²', (PO3)2³’ ali (PO3)₃ ⁴'.According to one aspect of the present invention, the present compound has a structure corresponding to formula I wherein R represents H, groups PO ₃ ² ', (PO3) 2 ³ ' or (PO3) ₃ ⁴ '.

Obravnavane spojine so dalje opcijsko modificirane z modificirno skupino, ki je kovalentno vezana na karbonilov atom, dalje pa se upošteva, da imajo spojine po vsebini predmeta izuma D- ali L- konfiguracijo.The compounds in question are further optionally modified by a modifying group that is covalently bonded to the carbonyl atom, and it is further appreciated that the compounds of the invention have a D- or L-configuration.

Po drugem vidiku predmeta izuma, se obravnavane spojine uporabljajo za zdravljenje virusne infekcije in jih nadalje lahko dajemo skupaj s citokinom, prednostno z IFN-alfa2b, s protitelesom ali Ribavirinom (l-p-D-ribofuranosil-l,2,4-triazol-3-karboksamid).According to another aspect of the present invention, the compounds in question are used to treat viral infection and can further be administered together with a cytokine, preferably IFN-alpha2b, with an antibody or Ribavirin (lpD-ribofuranosyl-1,2,4-triazole-3-carboxamide) .

Po nadaljnjem vidiku predmeta izuma, je selektivnost obravnavanih spojin z ozirom na farmakološki učinek v tarčni celici povečana z modificiranjem spojin z modificirno skupino, kjer je modificirna skupina kovalentno vezana na zdravilo prek dušikovega atoma in kjer modificirno skupino encimatsko odstranimo iz zdravila v tarčni celici. Posebno upoštevane modificime skupine vključujejo =NH in -N(Ri)(R2) ali =NRi, kjer so Ri in R2 neodvisno vodik, ravni alkil, razvejani alkil, alkenil, alkinil, aralkil, aralkenil, aralkinil ali aril in kjer Ri ali R2 lahko dalje neodvisno obsegata dušikov atom, kisikov atom, žveplov atom ali halogenov atom.According to a further aspect of the invention, the selectivity of the compounds considered with respect to the pharmacological effect in the target cell is enhanced by modifying the compounds with a modifying group, wherein the modifying group is covalently bound to the drug via a nitrogen atom and where the modifying group is enzymatically removed from the drug in the target cell. Particularly considered modifiable groups include = NH and -N (R 1) (R 2) or = NR 1, wherein R 1 and R 2 are independently hydrogen, straight alkyl, branched alkyl, alkenyl, alkynyl, aralkyl, aralkenyl, aralkynyl or aryl and wherein R 1 or R 2 may further independently comprise a nitrogen atom, an oxygen atom, a sulfur atom or a halogen atom.

Po še drugem vidiku predmeta izuma ima metoda za zdravljenje bolezni, ki jo označuje vnetje nekega organa pri pacientu, stopnjo, v kateri dajemo obravnavane spojine bolniku v odmerku, ki povzroča sistemsko imunomodulacijo, ne pa sistemske imunosupresije odgovorov tipa I ali tipa II. To povzroča imunosupresijo odgovorov tipa I in tipa II v organih bolnika zaradi selektivnega kopičenja obravnavanih spojin v organu.According to another aspect of the invention, a method for treating a disease characterized by inflammation of an organ in a patient has a stage in which the compounds are administered to the patient at a dose that causes systemic immunomodulation, but not systemic immunosuppression of type I or type II responses. This causes immunosuppression of the type I and type II responses in the organs of the patient due to the selective accumulation of the compounds considered in the organ.

Po še nadaljnjem vidiku predmeta izuma ima postopek stimulacije nevronske rasti fazo, kjer je prepoznano, da so obravnavane spojine učinkovite pri stimuliranju rasti nevronov znotraj danega koncentracijskega območja. V nadaljnji fazi se spojine dovajajo nevronom znotraj danega koncentracijskega območja.According to a further aspect of the invention, the neural growth stimulation process has a phase where it is recognized that the compounds in question are effective in stimulating the growth of neurons within a given concentration range. In a further phase, the compounds are delivered to neurons within a given concentration range.

Razni smotri, posebnosti, vidiki in prednosti pričujočega izuma bodo postali bolj jasni iz sledečih podrobnih opisov raznih izvedb izuma.The various features, features, aspects and advantages of the present invention will become more apparent from the following detailed descriptions of various embodiments of the invention.

Kratek opis risbBrief description of the drawings

Slike 1A-1C so vzorčne spojine po predmetu izuma.1A-1C are exemplary compounds of the invention.

Slika 2 je vzorčna sintezna shema za sintezo 1-β-L-ribofuranozil-1,2,4-triazol-3karboksamid.Figure 2 is a sample synthesis scheme for the synthesis of 1-β-L-ribofuranosyl-1,2,4-triazole-3carboxamide.

Slika 3 je alternativna vzorčna sintezna shema za sintezo 1-β-L-ribofuranozil-1,2,4triazol-3-karboksamida.Figure 3 is an alternative exemplary synthesis scheme for the synthesis of 1-β-L-ribofuranosyl-1,2,4triazole-3-carboxamide.

Slika 5 je diagram poteka, ki opisuje vzorčni postopek za imunosupresijo pri tarčnem organu po predmetu izuma..Figure 5 is a flowchart describing a sample procedure for immunosuppression in a target organ of the invention.

Slika 6 je diagram poteka, ki opisuje vzorčni postopek za stimuliranje celične rasti po predmetu izuma.Figure 6 is a flowchart describing a model process for stimulating cell growth according to the invention.

Podrobni opisDetailed description

Obravnavane spojineCompounds under consideration

Na splošno ocenjujemo, da so vsi nukleotidi, nukleozidi in njihovi ustrezni analogi primerni za uporabo v zvezi z nauki, predstavljenimi tukaj, kjer imajo lahko vse od obravnavanih spojin njihovo L-konfiguracijo oziroma D-konfiguracijo. Vendar pa posebno prednostne spojine vključujejo fosforiliran in nefosforiliran Levovirin™ (1-βL-ribofuranozil-l,2,4-triazol-3-karboksamid, struktura 1), kjer je R lahko vodik ali skupina, ki vsebuje fosfor ali žveplo. Kjer je R fosfor vsebujoča skupina, je posebno zaželeno, daje R monofosfat, difosfat ali trifosfat, kot je prikazano na slikah 1A-1C.We generally consider that all nucleotides, nucleosides and their corresponding analogs are suitable for use in connection with the teachings presented herein, where all of the compounds discussed may have their L-configuration or D-configuration, respectively. However, particularly preferred compounds include phosphorylated and non-phosphorylated Levovirin ™ (1-βL-ribofuranosyl-1,2,4-triazole-3-carboxamide, structure 1), where R may be hydrogen or a group containing phosphorus or sulfur. Where R is phosphorus-containing group, it is particularly desirable that R is monophosphate, diphosphate or triphosphate, as shown in Figures 1A-1C.

V odvisnosti od kemičnega okolja (in posebno odvisno od pH), je treba upoštevati, da so fosfatne skupine lahko v svojih ustreznih mono-, di-, tri- in tetra-protoniranih oblikah in treba je upoštevati tudi, da se, ko so fosfatne skupine deloma ali popolnoma deprotonirane, lahko tvorijo soli z enim ali več mono- ali večvalentnimi kationi.Depending on the chemical environment (and especially on the pH), it should be taken into account that phosphate groups can be in their corresponding mono-, di-, tri- and tetra-protonated forms and it should also be taken into account that when phosphate groups partially or fully deprotonated may form salts with one or more mono- or multivalent cations.

Posebno upoštevani kationi so alkalijski kovinski ioni in kovinski ioni zemeljskih alkalij kot Mg²⁺, Ca²⁺, Na⁺ itd.Particularly considered cations are alkali metal ions and earth alkali metal ions such as Mg ²⁺ , Ca ²⁺ , Na ⁺ etc.

Po alternativnem vidiku predmeta izuma je R lahko skupina PO3²', (PO3)2³’ ali (PCL)}⁴, kjer je eden ali več kisikov zamenjanih z žveplovim atomom. Medtem ko so fosfatne skupine na splošno prednostni substituenti za R, se lahko uporabljajo tudi druge kemijske skupine, posebno pa pridejo v poštev skupine, ki vključujejo mono- ali polianionske skupine, prednostno s tetragonalno geometrijo. Tako vključujejo obravnavane spojine posebno modificiran in nemodificiran fosforiliran Levovirin™ Poleg tega je treba upoštevati, da imajo lahko obravnavane spojine tudi delež sladkoija v D-konfiguraciji, spojina s sladkoijem v D-konfiguraciji, ki pride posebno v poštev, pa je Ribavirin (l-p-D-ribofuranozil-l,2,4-triazol-3-karboksamid).According to an alternative aspect of the subject matter, R may be a group PO3 ² ', (PO3) 2 ³ ' or (PCL)} ⁴ , where one or more oxygen is replaced by a sulfur atom. While phosphate groups are generally preferred substituents for R, other chemical groups may also be used, in particular groups that include mono- or polyanionic groups, preferably with tetragonal geometry. Thus, the compounds in question include specially modified and unmodified phosphorylated Levovirin ™. In addition, it should be appreciated that the compounds discussed may also have a proportion of sugars in the D-configuration, and the compound with sugars in the D-configuration which is particularly appropriate is Ribavirin (lpD- ribofuranosyl-1,2,4-triazole-3-carboxamide).

Dalje moramo vzeti v poštev, da izkazujejo vsaj nekatere od obravnavanih spojin direktni antivirusni učinek (t.j. obravnavane spojine takoj zavirajo razmnoževanje virusov). Ker večina organizmov vsebuje fosfataze v raznih predelkih, smo vzeli v poštev, da spojine po predmetu izuma postopoma defosforiliramo, eno ali več kot eno fosfatno skupino pa lahko odstranimo naenkrat. Na primer, trifosforilirano spojino lahko pretvorimo v difosforilirano ali monofosforilirano spojino ali difosforilirano spojino pretvorimo v Levovirin™ v eni sami reakciji.It must further be borne in mind that at least some of the compounds under consideration exhibit a direct antiviral effect (i.e., the compounds considered immediately inhibit virus propagation). Since most organisms contain phosphatases in various compartments, it has been taken into account that the compounds of the invention are gradually dephosphorylated and one or more than one phosphate group can be removed at a time. For example, a triphosphorylated compound may be converted to a diphosphorylated or monophosphorylated compound or a bisphosphorylated compound converted to Levovirin ™ in a single reaction.

Z ozirom na defosforiliranje fosforiliranega Levovirina , smo posebno predvideli, da način antivirusnega delovanja pomaknemo od direktnega antivirusnega učinka k indirektnemu antivirusnemu učinku. Pomik od direktnega antivirusnega odgovora k indirektnemu antivirusnemu odgovoru je posebno koristen, ker, čeprav so obravnavane spojine metabolizirane, ohranijo antivirusno delovanje skozi podaljšano obdobje. Zaradi tega je treba upoštevati, da je način delovanja obravnavanih spojin, posebno pa fosforiliranega Levovirina™, v resnici vsaj dvojen, tako da obsega direktni del antivirusnega učinka in indirektni del antivirusnega učinka.With regard to the dephosphorylation of phosphorylated Levovirin, we specifically intended to shift the mode of antiviral activity from a direct antiviral effect to an indirect antiviral effect. Moving from a direct antiviral response to an indirect antiviral response is particularly useful because, although the compounds under consideration are metabolized, they retain antiviral activity over a prolonged period. For this reason, it should be borne in mind that the mode of action of the compounds in question, and in particular phosphorylated Levovirin ™, is in fact at least twofold, comprising the direct part of the antiviral effect and the indirect part of the antiviral effect.

Z ozirom na hitrost defosforiliranja menimo, da se fosforiliran Levovirin™ defosforilira znatno počasneje od fosforiliranega Ribavirina, učinek, za katerega menimo, da izhaja iz L-konfiguracije riboze v Levovirinu . Glede na predelek ali organ, kjer se lahko dogaja defosforiliranje, opažamo, da se fosforiliranje dogaja preferenčno v jetrih, vendar pa pridejo v poštev tudi drugi organi in predelki, vključno z ledvicami, nevronskimi celicami in krvnim obtokom.With regard to the rate of dephosphorylation, we consider that phosphorylated Levovirin ™ is dephosphorylated at a much slower rate than phosphorylated Ribavirin, an effect that is thought to result from the L-configuration of ribose in Levovirin. Depending on the compartment or organ where dephosphorylation may occur, phosphorylation occurs preferentially in the liver, but other organs and compartments, including the kidney, neural cells, and bloodstream, may also be considered.

Posebno je treba upoštevati, da so vse znane oblike predzdravil obravnavanih spojin primerne za uporabo v povezavi z nauki, predstavljenimi tukaj, posebno obravnavane oblike predzdravil pa vključujejo kovalentne modifikacije, ki jih lahko encimatsko (na primer z aminohidrolazo, oksidoreduktazo ali transferazo) odstranimo iz obravnavanih spojin. Zgledno primerne oblike predzdravila so opisane v U.S. Patentni prijavi številka 09/594,410, vloženi 06/16/00, ki je vključena tukaj kot referenca in v »Prodrugs« Kenneth B.Sloan (Marcel Dekker; ISBN:0824786297), ali v »Design of Prodrugs« Hans Bundgaard (ASIN: 044480675Χ), tudi vključen tukaj kot referenca.It is of particular note that all known forms of prodrugs of the present compounds are suitable for use in connection with the teachings presented herein, and the particular prodrug forms include covalent modifications which can be enzymatically (e.g. by aminohydrolase, oxidoreductase or transferase) removed from the subject of compounds. Exemplary suitable forms of prodrug are described in U.S. Pat. Patent Application No. 09 / 594,410, filed 06/16/00, incorporated herein by reference and in "Prodrugs" by Kenneth B.Sloan (Marcel Dekker; ISBN: 0824786297), or in "Design of Prodrugs" by Hans Bundgaard (ASIN: 044480675Χ), also incorporated herein by reference.

Dalje, posebno upoštevani vzorci primernih predzdravil vključujejo predzdravila, ki se tvorijo z dodatkom dušik vsebujočih skupin karboksamidnemu deležu Levovirina™, kar je lahko ugodno, ko obravnavano spojino prednostno usmerimo k jetrom. Na primer, izumitelji so odkrili (neobjavljeni rezultati), da lahko izboljšajo specifičnost Levovirina ™, z ozirom na farmakološki učinek na hepatocite, z modificiranjem Levovorina z dušik vsebujočo modificimo skupino, ki se selektivno odstrani v hepatocitih. Struktura 2 spodaj prikazuje Levovirin™, struktura 3 pa prikazuje Levovirin™, modificiran na karboksamidni skupini, tako da se tvori karboksamidinskaFurther, particularly considered exemplary exemplary prodrugs include prodrugs formed by the addition of nitrogen-containing groups to the carboxamide portion of Levovirin ™, which may be advantageous when the compound in question is preferably directed to the liver. For example, inventors have discovered (unpublished results) that they can improve the specificity of Levovirin ™ with respect to the pharmacological effect on hepatocytes by modifying Levovorin with a nitrogen-containing modifiable group that is selectively removed in hepatocytes. Structure 2 below shows Levovirin ™ and structure 3 shows Levovirin ™ modified on the carboxamide group to form carboxamidine

Posebno smo upoštevali, da se bo (1) z modifikacijo Levovirina™ s (prednostno dušik vsebujočo) modificirno skupino, ki se lahko selektivno odstrani v tarčni celici (na primer hepatocitu), zvišala selektivnost Levovirina™ glede na tarčno celico, s Čimer (2) se bo zmanjšalo celotno odmeijanje količine za doseganje želene učinkovite koncentracije in znižanje (3) možne toksičnosti v netarčnih celicah. Dalje smo upoštevali, da je modificima skupina kovalentno vezana na karbonilni atom karboksamidne skupine.In particular, we considered that (1) modifying Levovirin ™ with a (preferably nitrogen-containing) modifying group that can be selectively removed in the target cell (for example, hepatocyte) will increase the selectivity of Levovirin ™ with respect to the target cell, with Chimer (2 ) will reduce the total volume retraction to achieve the desired effective concentration and reduce (3) the possible toxicity in the non-target cells. We further considered that the modifying group is covalently bonded to the carbonyl atom of the carboxamide group.

Po nadaljnjih alternativnih vidikih ni potrebno, da se dušik vsebujoča modificirna skupina omejuje na skupino =NH, pač pa vključuje lahko tudi razne primarne in sekundarne amine. Na splošno se upošteva, da imajo primerne modificirne skupine strukturo -N(R₍)(R₂) ali =NRi, kjer sta Ri in R₂ neodvisno vodik, ravni ali razvejani alkil, alkenil, alkinil, aralkil, aralkenil ali aralkinil, aril, od katerih vsi lahko dalje vsebujejo heteroatome vključno z dušikom, s kisikom, z žveplom ali s halogenom. Posebno je zaželeno, da so alternativne skupine encimatsko odstranljive iz Levovirina ™, posebno upoštevani encimi pa vključujejo aminohidrolaze, takšne kot jetrne deaminaze (na primer adenozinske ali citozinske deaminaze), jetrne deamidaze (na primer aril deamidaze) in jetrne transaminaze (glutamat-piruvat-transaminaze).According to further alternative aspects, the nitrogen-containing modifying group is not required to be limited to the group = NH, but may also include various primary and secondary amines. Generally, suitable modifying groups are generally considered to have the structure -N (R ₍ ) (R ₂ ) or = NR 1, wherein R 1 and R _{2 are} independently hydrogen, straight or branched alkyl, alkenyl, alkynyl, aralkyl, aralkenyl or aralkynyl, aryl all of which may further contain heteroatoms including nitrogen, oxygen, sulfur or halogen It is particularly desirable that alternative groups be enzymatically removed from Levovirin ™ and particular enzymes include aminohydrolases such as hepatic deaminases (for example, adenosine or cytosine deaminase), liver deamidase (for example aryl deamidase) and liver transaminase (glutamate pyruvate transaminase).

Čeprav se ne omejujemo na izumiteljski koncept, predstavljen tukaj, smo ocenili, da modificirne skupine lahko povzročijo neučinkovitost Levovirina™ ali pa preprečijo naknadno aktivacijo, brž ko modificirani Levovirin™ dovedemo k netarčni celici. Po drugi strani dušik vsebujoča modificirna skupina lahko prepreči metabolično aktivacijo modificiranega Levovirina™. Z ozirom na stopnjo modificiranja Levovirina™ upoštevamo, da modifikacija lahko obsega organo-sintetično modifikacijo, encimatsko modifikacijo ali de-novo sintezo za pridobitev modificiranega Levovirina™.Although not limited to the inventive concept presented herein, we have evaluated that modifying groups may cause Levovirin ™ to be ineffective or prevent subsequent activation, as soon as modified Levovirin ™ is brought to a non-cell. On the other hand, a nitrogen-containing modifying group may prevent the metabolic activation of modified Levovirin ™. In view of the degree of modification of Levovirin ™, it is appreciated that the modification may involve organo-synthetic modification, enzymatic modification or de-novo synthesis to obtain modified Levovirin ™.

Z ozirom na encimatsko odstranjevanje modifikacij ske skupine, opažamo, da, v odvisnosti od vrste tarčne celice in modificirne skupine, encimatska odstranitev lahkoWith respect to the enzymatic removal of the modification group, it is observed that, depending on the type of target cell and the modifying group, enzymatic removal may

-1010 znatno variira. Encimatska odstranitev lahko vključuje encime iz raznih razredov, ki vključujejo hidrolaze, transferaze, liaze in oksidoreduktaze, posebno prednostni podrazredi pa so adenozinske in citozinske deaminaze, arginaze, transaminaze in arilamidaze. Upoštevati je treba dalje, da se obravnavani encimi za encimatsko odstranitev modifikacij ske skupine lahko izražajo izključno v tarčnih celicah, vendar pa se po alternativnih vidikih predmeta izuma primerni encimi lahko izražajo razen v tarčnih celicah tudi v drugih celicah, dokler se encim ne izrazi povsod v vseh celicah sistema, ki vsebuje celice. Dalje je treba upoštevati, da se obravnavani encimi prednostno izražajo izvirno (t.j. nerekombinantno) v svojih tozadevnih tarčnih celicah pod normalnimi in/ali patološkimi pogoji. Na primer, znano je, da se glutamin-piruvat transaminaza osnovno izraža s sorazmerno visoko selektivnostjo v jetrnih celicah in je lahko zaradi tega primeren encim za odstranitev modifikacij ske skupine. Alternativno je znano, da se citozinska deaminaza izraža v sorazmerno velikih količinah v rakastih celicah debelega črevesa, pač pa ne ali samo v manjših količinah v normalnih celicah debelega črevesa.-1010 varies significantly. Enzymatic removal may involve enzymes of various classes, including hydrolases, transferases, lyases, and oxidoreductases, and particularly preferred subclasses are adenosine and cytosine deaminases, arginases, transaminases, and arylamidases. It should further be appreciated that the enzymes for enzymatic removal of the modification group can be expressed exclusively in the target cells, but according to alternative aspects of the invention, suitable enzymes can be expressed except in the target cells, as long as the enzyme is not expressed everywhere in the target cells. all cells of a system containing cells. It should further be noted that the enzymes in question are preferably expressed originally (i.e., non-recombinantly) in their target cells under normal and / or pathological conditions. For example, it is known that glutamine-pyruvate transaminase is primarily expressed with relatively high selectivity in liver cells and may therefore be an appropriate enzyme for the removal of modifications of the group. Alternatively, cytosine deaminase is known to be expressed in relatively large amounts in colon cancer cells, but not only or in small amounts in normal colon cells.

Sinteza obravnavanih spojinSynthesis of the compounds under consideration

Na splošno predvidevamo, da lahko prilagodimo vse znane postopke za sintezo D-nukleotidov, D-nukleozidov in njihovih ustreznih analogov za sintezo obravnavanih spojin v L-konfiguraciji (na primer, z zamenjavo sladkornega deleža v D-konfiguraciji z deležem sladkoija v ustrezni L-konfiguraciji). Ekzemplarična sintetična shema za sintezo Levovirina™ (l-β- L-ribofiiranozil-l,2,4-triazol-3-karboksamid) je prikazana na sliki 2.Generally, it is contemplated that we can adapt all known methods for the synthesis of D-nucleotides, D-nucleosides and their corresponding analogs for the synthesis of the compounds under consideration in the L-configuration (for example, by replacing the sugar fraction in the D-configuration by the proportion of sugars in the corresponding L- configuration). An exemplary synthetic scheme for the synthesis of Levovirin ™ (1-β-L-ribofironosyl-1,2,4-triazole-3-carboxamide) is shown in Figure 2.

Sinteza I,2,3,5-tetra-()-acetil-fi-I,-ribofuranoze (1)Synthesis of I, 2,3,5-tetra - () - acetyl-fi-I, -ribofuranose (1)

Premešani raztopini L-riboze (50,0 g, 333,33 mmol) v brezvodnem metanolu (500 ml) pri sobni temperaturi smo dodali sveže pripravljeno raztopino HCI v suhem metanolu (40 ml, pripravljeno z vpihovanjem mehurčkov suhega plina HCI v metanol pri 0°C doTo a stirred solution of L-ribose (50.0 g, 333.33 mmol) in anhydrous methanol (500 ml) at room temperature was added freshly prepared HCI solution in dry methanol (40 ml prepared by blowing the HCI dry gas bubbles into methanol at 0 ° C to

-1111 narastka mase na 4g) z brizgalko v roku 15 min pod argonsko atmosfero. Po dodatku HCI v metanolu smo stresali reakcijsko zmes pri sobni temperaturi 3-4 ure. Dodali smo suhi piridin (100 ml) in izparevali do suhega pod visokim vakuumom pod 40°C. Ta postopek smo še enkrat ponovili z dodatkom suhega piridina (100 ml). Ostanek smo raztopili v suhem piridinu (250 ml) in ohladili v kopeli z ledom na 0°C pod argonsko atmosfero. Tej hladni premešani raztopini smo dodali anhidrid ocetne kisline (100 ml) s kapalnim lijakom v času 15 min. Po dodatku anhidrida ocetne kisline smo pustili, da se reakcijska zmes stresa pri sobni temperaturi pri izključeni vlagi 24 ur. Reakcijsko zmes smo izparili do suhega. Ostanek smo razdelili med etil acetatom (400 ml) in vodo (400 ml) in ekstrahirali v EtOAc. Vodno plast smo ponovno ekstrahirali z EtOAc (100 ml). Kombiniran ekstrakt EtOAc smo izprali z vodo (400 ml), nasičeno raztopino NaHCO3 (2x 300 ml) in slanico (200 ml). Organski ekstrakt smo sušili nad brezvodnim Na2SO₄, filtrirali, filtrat pa izparili do suhega. Ostanek smo izparili skupaj s suhim toluenom (2x150 ml) v visokem vakuumu. Sušeni oljnati ostanek (92 g, 95 %) smo uporabili kot takega za sledečo reakcijo brez nadaljne karakterizacije.-1111 mass growth at 4g) with a syringe within 15 min under argon atmosphere. After the addition of HCl in methanol, the reaction mixture was shaken at room temperature for 3-4 hours. Dry pyridine (100 ml) was added and evaporated to dryness under high vacuum below 40 ° C. This process was repeated again with the addition of dry pyridine (100 ml). The residue was dissolved in dry pyridine (250 ml) and cooled in an ice bath at 0 ° C under an argon atmosphere. Acetic anhydride (100 ml) was added to this cold stirred solution with a dropping funnel for 15 min. After the addition of acetic anhydride, the reaction mixture was allowed to shake at room temperature under humidity off for 24 hours. The reaction mixture was evaporated to dryness. The residue was partitioned between ethyl acetate (400 ml) and water (400 ml) and extracted into EtOAc. The aqueous layer was re-extracted with EtOAc (100 ml). The combined EtOAc extract was washed with water (400 ml), saturated NaHCO3 solution (2x 300 ml) and brine (200 ml). The organic extract was dried over anhydrous Na2SO _4, filtered, and the filtrate was evaporated to dryness. The residue was evaporated along with dry toluene (2x150 ml) under high vacuum. The dried oily residue (92 g, 95%) was used as such for the next reaction without further characterization.

Sirup (92 g) iz zgornje reakcije smo raztopili v ledoctu (300 ml) in obdelali z anhidridom ocetne kisline (75 ml) pri sobni temperaturi. Raztopino smo ohladili na 05°C v ledeni kopeli pod argonsko atmosfero. Počasi smo dodajali koncentrirano H2SO4 (21 ml) v času 14 min. Po dodatku H₂SO₄ smo reakcijsko zmes stresali pri sobni temperaturi 14 ur, izlili na zdrobljeni led (500 g) in stresali, dokler se led ni raztopil. Dodali smo vodo (500 ml) in ekstrahirali z CHCI3 ( 2 x 300 ml). Kloroformski ekstrakt smo izpirali z vodo (3 x 400 ml), nasičeno raztopino NaHCCh (2 x 300 ml), vodo (200 ml) in slanico (200) ml. Izprani organski ekstrakt smo sušili nad brezvodnim MgSO₄, filtrirali in izparili do suhega in dobili oljnat ostanek (99 g). Ostanek smo izparili skupaj s suhim toluenom (200 ml) in raztopili v etil etru (200 ml), kar po hlajenju en dan pri 10°C daje brezbarvne kristale. Kristalinično trdno snov smo filtrirali, izprali s heksani, etrom (2:1, 50 ml) in sušili, da bi dobili 60,5 g produkt.The syrup (92 g) from the above reaction was dissolved in ice (300 ml) and treated with acetic anhydride (75 ml) at room temperature. The solution was cooled to 05 ° C in an ice bath under an argon atmosphere. Concentrated H2SO4 (21 ml) was slowly added over a period of 14 min. After addition of H ₂ SO ₄ , the reaction mixture was shaken at room temperature for 14 hours, poured onto crushed ice (500 g) and shaken until the ice had dissolved. Water (500 ml) was added and extracted with CHCl3 (2 x 300 ml). The chloroform extract was washed with water (3 x 400 ml), saturated NaHCO 3 solution (2 x 300 ml), water (200 ml) and brine (200) ml. The washed organic extract was dried over anhydrous MgSO ₄ , filtered and evaporated to dryness to give an oily residue (99 g). The residue was evaporated along with dry toluene (200 ml) and dissolved in ethyl ether (200 ml), which gave a colorless crystals after cooling for one day at 10 ° C. The crystalline solid was filtered, washed with hexanes, ether (2: 1, 50 ml) and dried to give 60.5 g of product.

-1212-1212

Sinteza metil-l-(2,3,5-0-acetil-fi-L-ribofuranozil)-l,2,4-triazol-3-karboksilata (3) in metil-l-(2,3,5-tri-0-acetil-fi-L-ribofuranozil)-l,2,4-triazol-5-karboksilata (4)Synthesis of methyl-1- (2,3,5-0-acetyl-t-L-ribofuranosyl) -1,2,4-triazole-3-carboxylate (3) and methyl-1- (2,3,5-tri) -0-acetyl-t-L-ribofuranosyl) -1,2,4-triazole-5-carboxylate (4)

Zmes metil-l,2,4-triazol-3-karboksilata (25,4 g, 200 mmol), l,2,3,5-tetra-O-acetil-3-Lribofuranoze (63,66 g, 200 mmol) in bis(p-nitrofenil)fosfata (1 g) smo stresli v RB bučko (500 ml). Bučko smo postavili v predhodno segreto oljno kopel pri 165-175°C pod vakuumom vodne črpalke in mešali 25 min. Izločeno ocetno kislino smo lovili v z ledom hlajeni pasti, nameščeni med vodno črpalko in RB bučo. Bučko smo odstranili iz oljne kopeli in pustili, da se ohladi. Ko je temperatura bučke dosegla približno 60-70°C, smo dodali EtOAc (300 ml) in nasičeno raztopino NaHCO3 (150 ml) in ekstrahirali v EtOAc. Vodno plast smo ponovno ekstrahirali z EtOAc (200 ml). Kombiniran ekstrakt EtOAC smo izprali z nasičeno raztopino NaHCO3 (300 ml), vodo (300 ml) in slanico (200 ml). Organski ekstrakt smo sušili nad brezvodnim NajSO4, filtrirali in filtrat izparili do suhega. Ostanek smo raztopili v EtOH (100 ml) in razredčili z MeOH (60 ml), kar je po hlajenju pri 0°C 12 ur dalo brezbarvne kristale. Trdno snov smo filtrirali, izprali z minimalno količino hladnega EtOH (20 ml) in sušili pod visokim vakuumom nad trdnim NaOH za dobivanje 60 g (78 %). Filtrat smo izparili do suhega in očistili na stolpu s silicijevim oksidom z uporabo CHCl3->EtOAc (9:1) kot eluenta. Iz filtrata smo izolirali dva produkta: hitro tekoči produkt 8,5 g (11 %) in počasi tekoči produkt 5 g (6,5 %). Počasi tekoči produkt seje ujemal s kristaliziranim produktom. Za hitro tekoči produkt smo ugotovili, da je (4), dobljen kot pena. Kombinirani izkoristek za (3) je bil 65 g (84 %).Mixture of methyl 1,2,4-triazole-3-carboxylate (25.4 g, 200 mmol), 1,2,3,5-tetra-O-acetyl-3-Lribofuranose (63.66 g, 200 mmol) and bis (p-nitrophenyl) phosphate (1 g) was shaken into an RB flask (500 ml). The flask was placed in a preheated oil bath at 165-175 ° C under vacuum of a water pump and stirred for 25 min. The extracted acetic acid was fished in ice-cooled traps placed between the water pump and the RB pumpkin. The flask was removed from the oil bath and allowed to cool. When the flask temperature reached about 60-70 ° C, EtOAc (300 ml) and saturated NaHCO3 solution (150 ml) were added and extracted into EtOAc. The aqueous layer was re-extracted with EtOAc (200 ml). The combined EtOAC extract was washed with saturated NaHCO3 solution (300 ml), water (300 ml) and brine (200 ml). The organic extract was dried over anhydrous Na2SO4, filtered and the filtrate evaporated to dryness. The residue was dissolved in EtOH (100 ml) and diluted with MeOH (60 ml) which gave colorless crystals after cooling at 0 ° C for 12 hours. The solid was filtered, washed with a minimal amount of cold EtOH (20 ml) and dried under high vacuum over solid NaOH to give 60 g (78%). The filtrate was evaporated to dryness and purified on a silica column using CHCl3-> EtOAc (9: 1) as eluent. Two products were isolated from the filtrate: fast liquid product 8.5 g (11%) and slow liquid product 5 g (6.5%). The slow liquid product of the session was matched with the crystallized product. The fast-liquid product was found to be (4), obtained as a foam. The combined yield for (3) was 65 g (84%).

Sinteza l-F-ribofuranozil-l,2,4-triazol-3-karboksamida (5)Synthesis of 1-F-ribofuranosyl-1,2,4-triazole-3-carboxamide (5)

Metil-l-(2,3,5-tri-O-acetil-3-L-ribofuranozil)-l,2,4-triazol-3-karboksilat (62 g, 161 mmol) smo stresli v jekleno bombico in obdelali s sveže pripravljeno raztopino amoniaka v metanolu (350 ml, pripravljenih tako, da uvajamo suh plin NH3 v suhi metanol pri 0°C do nasičenja) pri 0°C. Jekleno bombico smo hladili pri 0°C, odprli inMethyl-1- (2,3,5-tri-O-acetyl-3-L-ribofuranosyl) -1,2,4-triazole-3-carboxylate (62 g, 161 mmol) was shaken into a steel bomb and treated with freshly prepared methanol ammonia solution (350 ml, prepared by introducing dry NH3 gas into dry methanol at 0 ° C to saturation) at 0 ° C. The steel bomb was cooled at 0 ° C, opened and

-1313 vsebino izparili do suhega. Ostanek smo obdelali s suhim etanolom (100 ml) in izpareli do suhega. Dobljeni ostanek smo strli z acetonom, da bi dobili trdno snov, ki smo jo odfiltrirali in izprali z acetonom. Trdno snov smo sušili preko noči pri sobni temperaturi in jo raztopili v vroči zmesi EtOH (600. ml) in vode (10 ml). Volumen raztopine EtOH smo zmanjšali na 150 ml s segrevanjem na vroči plošči. Pri hlajenju vroče EtOHraztopine smo dobili brezbarvne kristale, ki smo jih odfiltrirali, izprali z acetonom in sušili pod vakuumom. Nadaljnja koncentracija filtrata je dala dodatni material. Celotni izkoristek je bil 35 g (89 %).-1313 the contents were evaporated to dryness. The residue was treated with dry ethanol (100 ml) and evaporated to dryness. The resulting residue was triturated with acetone to give a solid which was filtered off and washed with acetone. The solid was dried at room temperature overnight and dissolved in a hot mixture of EtOH (600 ml) and water (10 ml). The volume of EtOH solution was reduced to 150 ml by heating on a hot plate. Cooling the hot EtOH solution gave colorless crystals, which were filtered off, washed with acetone and dried under vacuum. Further concentration of the filtrate provided additional material. The total yield was 35 g (89%).

'Tki'Tki

Po alternativnem vidiku predmeta izuma, smo predvideli, da sinteza Levovirina lahko uporablja eno ali več encimatskih pretvorb. Na primer, acetiliranje L-riboze lahko opravimo s primemo acetil-transferazo (na primer EC 2.3.1.xx). Pri drugem primeru, nastanek karboksamidne skupine iz ustreznega metil estra lahko olajšamo z enim samim ali dvojnim encimskim sistemom, ki uporablja esterazo (na primer EC 3.1.1.xx) in/ali aminotransferazo (na primer EC 2.6.1.xx). Pri še drugem primeru Levovirin™ lahko encimatsko pretvorimo v ustrezni mono-, di- ali trifosfat (na primer EC 3.1.3.xx ali EC 3.1.4.xx).According to an alternative aspect of the subject matter of the invention, it is contemplated that the synthesis of Levovirin may utilize one or more enzymatic transformations. For example, acetylation of L-ribose can be accomplished by applying acetyltransferase (for example EC 2.3.1.xx). In the second example, the formation of the carboxamide group from the corresponding methyl ester can be facilitated by a single or double enzyme system using esterase (for example EC 3.1.1.xx) and / or aminotransferase (for example EC 2.6.1.xx). In another example, Levovirin ™ can be enzymatically converted to the corresponding mono-, di- or triphosphate (for example EC 3.1.3.xx or EC 3.1.4.xx).

Še nadalje smo ocenili, da lahko uporabljamo razne katalizatoije bodisi bis(pnitrofenil)fosfat v količinah bodisi 1 g. S spreminjanjem količine (t.j. molamega deleža) katalizatoija lahko ugodno povečamo selektivnost reakcije proti višjemu izkoristku za želeni Ni- izomer (L-riboza vezana na Ni atom triazolovega obroča) glede na izomer N₂. Na primer, primerne količine bis(p-nitrofenil)fosfata obsegajo količine med 3 in 30 mmoli in več. Alternativno, kjer je primerno, se lahko uporabljajo količine nižje od 3 mmolov (0,3 mmolov - 2,99 mmolov). Pri še nadaljnjih alternativnih vidikilT predmeta izuma, ni treba, da je katalizator omejen na bis(p-nitrofenil)fosfat, med alternativne katalizatoije pa so vključene p-toluensulfonska kislina, trikloro ocetna kislina in pnitrobenzojska kislina.We further assessed that various catalysts of either bis (pnitrophenyl) phosphate can be used in amounts of either 1 g. By varying the amount (i.e. mole fraction) of the catalyst, we can advantageously increase the selectivity of the higher yield reaction for the desired Ni-isomer (L-ribose bound to the Ni atom of the triazole ring) relative to the N ₂ isomer. For example, suitable amounts of bis (p-nitrophenyl) phosphate comprise amounts of between 3 and 30 mmol or more. Alternatively, quantities below 3 mmol (0.3 mmol - 2.99 mmol) may be used where appropriate. In still further alternative aspects of the invention, the catalyst need not be limited to bis (p-nitrophenyl) phosphate, and alternative catalysts include p-toluenesulfonic acid, trichloroacetic acid and pnitrobenzoic acid.

-1414-1414

Z ozirom na temperaturo reakcije, je treba vzeti v poštev, da nižje temperature lahko še nadalje povečajo selektivnost reakcije proti višjemu izkoristku za želeni izomer Ni nasproti izomeru N₂. Zaradi tega smo presodili, da primerne temperature za spojitveno reakcijo med deležem triazola in deležem riboze obsegajo temperature med okoli 155165°C, bolj prednostno med 145-165°C, najbolj prednostno pa med 130-165°C.With regard to the reaction temperature, it should be borne in mind that lower temperatures can further increase the selectivity of the higher yield reaction for the desired Ni isomer versus the N ₂ isomer. For this reason, we have determined that suitable temperatures for the coupling reaction between the triazole content and the ribose content comprise temperatures between about 155165 ° C, more preferably between 145-165 ° C, and most preferably between 130-165 ° C.

Pri nadaljnjem alternativnem vidiku predmeta izuma ocenjujemo, da na selektivnost reakcije proti višjemu izkoristku za želeni izomer Ni nasproti izomeru N₂ ugodno vpliva kemijska modifikacija metil-l,2,4-triazol-3-karboksilata. Kemijska modifikacija obsega nastanek kompleksirajoče strukture, ki vključuje atom N₂, prostorsko oviro in direktno kemijsko modifikacijo N₂-atoma. Na primer, prosti elektronski par v atomu N₂ v triazolnem deležu in elektron donor v modificirani karboksilatni skupini lahko uporabimo za kompleksiranje kovinskega iona, s čimer se zmanjša razpoložljivost atoma N₂ za spajanje z deležem riboze. Pri drugem primeru lahko modificiramo karboksilatno skupino v metil-l,2,4-triazol-3-karboksilat z relativno obsežno skupino, ki prednostno in prostorsko blokira ali zmanjša reakcijo, ki poteka na atomu N₂. Alternativno lahko atom N₂ direktno modificiramo z zaščitno skupino, primerni zaščitni skupini pa sta t-Boc in benzil.In a further alternative aspect of the invention, it is appreciated that the selectivity of the higher yield reaction for the desired Ni isomer versus the N ₂ isomer is favorably influenced by the chemical modification of methyl 1,2,4-triazole-3-carboxylate. Chemical modification involves the formation of a complexing structure that includes an N ₂ atom, a spatial obstacle, and direct chemical modification of the N ₂ atom. For example, a free electron pair in the N ₂ atom in the triazole moiety and a donor electron in the modified carboxylate group can be used to complex the metal ion, thereby reducing the availability of the N ₂ atom to bond with the ribose moiety. In the second example, the carboxylate group can be modified to methyl-1,2,4-triazole-3-carboxylate with a relatively large group that preferentially and spatially blocks or reduces the reaction taking place on the N ₂ atom. Alternatively, the N ₂ atom can be directly modified by a protecting group, and suitable protecting groups are t-Boc and benzyl.

Še nadalje smo predvideli, da višji izkoristek izomera Ni nasproti izomeru N₂ lahko dosežemo z uporabo encimatske sinteze, pri kateri služita delež riboze (ali Lribonukleotid ) in modificiran ali nemodificiran metil-l,2,4-triazol-3-karboksilat kot substrat za riboziltransferazo ( na primer EC 2.4.2.5 ali EC 2.4.2.6).We further predicted that a higher yield of the Ni isomer than the N ₂ isomer can be achieved by using enzymatic synthesis, in which the ribose (or Lribonucleotide) and modified or unmodified methyl 1,2,4-triazole-3-carboxylate serve as substrate for ribosyltransferase (for example EC 2.4.2.5 or EC 2.4.2.6).

Alternativno, Levovirin™ lahko sintetiziramo z vezavo zaščitene L-riboze na 1,2,4triazol-3-nitril s sledečo pretvorbo nitrilne skupine v karboksamid, kot je prikazano na sl. 3. Pri še eni alternativni sintezi spajanje deleža triazola z deležem riboze lahko dosežemo tudi z reakcijo, pri kateri ima (na primer z benzilom zaščitena) riboza skupino -NHNH₂ spojeno z atomom Ci, ki je reagiral z atomom Ni triazolovega karboksilata, kjer triazol karboksilat naknadno pretvorimo v karboksamidin, kot je prikazano na sl. 4.Alternatively, Levovirin ™ can be synthesized by binding the protected L-ribose to 1,2,4triazole-3-nitrile by subsequent conversion of the nitrile group to carboxamide, as shown in FIG. 3. In another alternative synthesis, coupling of the triazole moiety with the ribose moiety can also be achieved by a reaction in which the (for example benzyl protected) ribose moiety is -NHNH ₂ coupled to a Ci atom which has reacted with the Ni atom of triazole carboxylate, where triazole the carboxylate was subsequently converted to carboxamidine as shown in FIG. 4.

-1515-1515

Z ozirom na sintezo oblik predzdravil obravnavanih L-nukleotidov, L-nukleozidov in njihovih ustreznih analogov, je treba upoštevati, da bo posebna sintezna shema običajno odvisna od strukture posmezne spojine. Vendar pa upoštevamo, da so vsi načini sinteze primerni, obravnavane sintezne sheme pa vključujejo sinteze in vitro, encimatske sinteze, pretvorbe in-vivo in katerekoli kemijsko sprejemljive kombinacije le-teh. Ekzemplarične sintezne sheme za tvorbo obravnavanih predzdravil so opisane v U.S. Patentni prijavi številka 09/594,410 (zgoraj).With respect to the synthesis of the prodrug forms of the L-nucleotides, L-nucleosides and their corresponding analogues under consideration, it should be appreciated that the particular synthesis scheme will usually depend on the structure of the individual compound. However, we consider that all synthetic modes are suitable, and the synthetic schemes discussed include in vitro syntheses, enzymatic syntheses, in vivo transformations, and any chemically acceptable combinations thereof. Exemplary synthesis schemes for the formation of the prodrugs discussed are described in U.S. Pat. Patent Application No. 09 / 594,410 (supra).

Kjer so obravnavani L-nukleotidi, L-nukleozidi in njihovi ustrezni analogi fosforilirani, ocenjujemo, da so primerni vsi načini za vgradnjo fosfatne skupine v nukleotid, nukleozid ali v njihove ustrezne analoge. Pretvorbo obravnavanih nukleozidov v njihove ustrezne fosforilirane oblike lahko dosežemo sintetično (Hughes, B.G. et al. (1983); 2',5'-oligoadenylated and related 2',5-oligonucleotide analogues.l. Substrate specificity of the interferon- induced murine 2',5'-oligoadenylate synthetase and enzymatic synthesis of oligomers. Biochemistriy, 22:2116-2126). Vendar pa smo raziskali tudi razne alternativne metode, ki vključujejo encimatsko fosforilacijo (glej na primer Van Rompay, A.R., et «/.(2000): Phosphorylation of nucleosides and nucleoside analogs by mammalian nucleoside monophosphate kinases; Pharmacol. Ther. 87(23):189-198) in organokemijsko fosforilacijo v vodnem okolju (Schvvartz, A. and Ponnamperuma, C. (1968); Phosphorylation of adenosine with linear polyphosphate salts in aqueous solution (nature 218, 443).Where the L-nucleotides, L-nucleosides and their corresponding analogs are phosphorylated, we consider that all methods for incorporating the phosphate group into the nucleotide, nucleoside or their corresponding analogs are appropriate. The conversion of the nucleosides in question to their corresponding phosphorylated forms can be achieved synthetically (Hughes, BG et al. (1983); 2 ', 5'-oligoadenylated and related 2', 5-oligonucleotide analogues.l. Substrate specificity of the interferon-induced murine 2 ', 5'-oligoadenylate synthetase and enzymatic synthesis of oligomers. Biochemistriy, 22: 2116-2126). However, we have also explored various alternative methods involving enzymatic phosphorylation (see, for example, Van Rompay, AR, et. / 2000): Phosphorylation of nucleosides and nucleoside analogues by mammalian nucleoside monophosphate kinases; Pharmacol. Ther. 87 (23) : 189-198) and organochemical phosphorylation in an aqueous environment (Schvvartz, A. and Ponnamperuma, C. (1968); Phosphorylation of adenosine with linear polyphosphate salts in an aqueous solution (nature 218, 443).

Uporaba obravnavanih spojinUse of the compounds under consideration

Na splošno je treba vzeti na znanje, da obravnavane spojine lahko uporabljamo pri kateremkoli zdravljenju ali terapiji sistema, ki se pozitivno odziva na predpisovanje obravnavanih spojin. Vendar pa je posebno zaželeno, da obravnavane spojine lahko uporabljamo pri antivirusni obdelavi (kot direktno antivirusno spojino in/ali kot indirektno antivirusno spojino), pri obdelavi za moduliranje imunskega sistema in priIn general, it should be noted that the compounds discussed can be used in any treatment or therapy of a system that responds positively to the prescription of the compounds under consideration. However, it is particularly desirable that the compounds under consideration may be used in antiviral treatment (as a direct antiviral compound and / or as an indirect antiviral compound), in processing to modulate the immune system and in

-1616 zdravljenju za stimuliranje celične rasti. Dalje, posebno obravnavane uporabe vključujejo dajanje obravnavanih spojin pri antineoplastičnih zdravljenjih.-1616 cell growth stimulation treatment. Furthermore, the particular uses discussed include the administration of the compounds under consideration in antineoplastic treatments.

Antivirusno zdravljenjeAntiviral treatment

Na splošno smo ocenili, da spojine po predmetu izuma lahko uporabljamo pri virusni infekciji kot direktno in/ali indirektno antivirusno sredstvo. Posebno smo upoštevali, da postopek za zdravljenje virusne okužbe pacienta obsega stopnjo, pri kateri dajemo sestavek bolniku v odmerku, ki je učinkovit za preprečevanje razmnoževanja virusov (t.j. postopek, ki vključuje gostitelj sko celico, v kateri povzroča eden ali več virusov to, da gostiteljska celica proizvaja eno ali več kopij virusov, pri čemer se izraz “proizvajati” nanaša na sintezo nukleotida, procesiranje proteina in proteinski sestavek), kjer sestavek obsega najmanj eno od obravnavanih spojin, prednostno pa najmanj eno od spojin po strukturah 1 in 3. Prednostna odmerjanja se gibljejo v območju med 5 -2500 mg/dan, bolj prednostno med 50-500 mg/dan. Vendar pa upoštevamo tudi alternativna odmerjanja, poti, razporede in formulacije, primerna alternativna dajanja pa so opisana spodaj. Medtem ko uporaba obravnavanih spojin ni omejena na nek posebni virus pri neki posebni virusni okužbi, smo obravnavali zlasti virusne infekcije kot infekcijo s HIV, infekcijo s HCV, infekcijo s HBV, infekcijo z RSV, infekcijo z virusom influence in infekcijo z virusom parainfluence.It has generally been appreciated that the compounds of the invention can be used in viral infection as a direct and / or indirect antiviral agent. In particular, it is noted that the method of treating a patient's viral infection comprises the step of administering a composition to a patient at a dose effective to prevent virus propagation (i.e., a process involving a host cell in which one or more viruses cause the host the cell produces one or more copies of the viruses, with the term "produce" referring to nucleotide synthesis, protein processing, and protein composition), wherein the composition comprises at least one of the compounds considered and preferably at least one of the compounds of structures 1 and 3. Preferred dosages they range from 5-2500 mg / day, more preferably between 50-500 mg / day. However, alternative dosages, routes, schedules and formulations are also considered, and suitable alternative administration is described below. While the use of the compounds in question is not limited to a particular virus in a particular viral infection, we have particularly considered viral infections such as HIV infection, HCV infection, HBV infection, RSV infection, influenza virus infection, and parainfluenza virus infection.

Na splošno se uporabljajo periferne krvne mononukleame celice (PBMC) za proučevanje več različnih infekcij kot hepatitis C, HIV, hepatitis B in množice virusov herpesa. (Antivir. Chem. Chemther. 2000 July; 291-301; J. Irrfect. Dis 1998 Oct; 178(4): 1189-92; Virology 2000 Mar.; 268(1):12-60.). PMBC okužimo z želenim virusom, celične vrste pa nato proučujemo, da dobimo pomembne informacije, kako posamezna zdravila sodelujejo s PBMC in kako okužene PBMC delujejo skozi čas ali pod različnimi okoljskimi pogoji. Na osnovi proučevanj, vodenih na okuženih PBMC, lahko izdelamo modele, ki prikazujejo učinke posameznih farmacevtskih, okoljskih in/ali pogojev na PBMC-celice, okužene z virusom.Peripheral blood mononuclear cells (PBMCs) are generally used to study several different infections such as hepatitis C, HIV, hepatitis B, and multiple herpes viruses. (Antivir. Chem. Chemther. 2000 July; 291-301; J. Irrfect. Dis 1998 Oct; 178 (4): 1189-92; Virology 2000 Mar; 268 (1): 12-60.). The PMBC is infected with the desired virus, and the cell types are then examined to obtain important information on how individual drugs interact with PBMCs and how infected PBMCs function over time or under different environmental conditions. Based on studies conducted on infected PBMCs, models can be designed to demonstrate the effects of individual pharmaceutical, environmental, and / or conditions on virus-infected PBMC cells.

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Pričujoči izumitelji so odkrili (neobjavljeni rezultati), da Ribavirin izkazuje pozitivenThe present inventors have discovered (unpublished results) that Ribavirin is positive

TK/f odgovor na PBMC-celice, okužene z virusom HIV. Presenetljivo, tudi Levovirin izkazuje podobni imunomodulatomi profil proti PBMC-celicam, okuženim s HlV-om TM kljub pomanjkanju encimov v telesu, potrebnih za fosforiliranje Levovirina prisotnega v bolniku. Na osnovi zgornjih opažanj, skupaj z drugimi povezanimi informacijami in preizkusi, ugotavljamo, da Levovirin™, fosforilirani Levovirin™ in modificirani Levovirin™ po strukturi 3 lahko uporabljamo za obdelavo HlV-a in sorodnih virusov.TK / f response to HIV-infected PBMC cells. Surprisingly, Levovirin also exhibits a similar immunomodulatory profile against PBMC cells infected with HlV TM despite the lack of enzymes in the body required to phosphorylate Levovirin present in the patient. Based on the observations above, together with other related information and tests, we conclude that Levovirin ™, phosphorylated Levovirin ™ and modified Levovirin ™ according to structure 3 can be used to treat HlV and related viruses.

ImunomodulacijaImmunomodulation

Na sliki 5 ima postopek imunosupresije tarčnega organa 500 prvo stopnjo 510, pri kateri je zagotovljeno zdravilo, ki zmanjšuje oba od odgovorov tipa 1 in tipa 2, kadar se daje nad imunosupresivno koncentracijo, poveča pa se odgovor tipa 1 glede na odgovor tipa 2, kadar se daje pod imunosupresivno koncentracijo, pri čemer se zdravilo kopiči prednostno v tarčnem organu. Pri sledeči stopnji 520 zdravilo dajemo bolniku v takšnem odmerku, ki je učinkovit za kopičenje zdravila v tarčnem organu do imunosupresivne koncentracije. Zato predvidevamo, da postopek zdravljenja bolezni, ki jo označuje vnetje bolnikovih jeter, lahko obsega stopnjo, pri kateri dajemo spojino, pri čemer ta spojina obsega Levovirin, fosforiliran Levovirin™, modificiran fosforiliran Levovirin™ ali modificiran Ribavirin (zgoraj). Pri naslednji stopnji, spojino dajemu bolniku v takšnem odmerjanju, ki (a) povzroča sistemsko imunosupresijo odgovora tipa I in tipa II in (b) povzroča imunosupresijo odgovorov tipa I in tipa II v bolnikovih jetrih.In Figure 5, the target organ immunosuppression process 500 has a first stage 510, which provides a medication that reduces both type 1 and type 2 responses when administered above the immunosuppressive concentration and increases the type 1 response relative to the type 2 response when is administered below immunosuppressive concentration, with the drug accumulating preferably in the target organ. In a further step 520, the drug is administered to a patient at a dose effective to accumulate the drug in the target organ to an immunosuppressive concentration. Therefore, it is contemplated that the method of treating a disease characterized by inflammation of the patient's liver may comprise the stage at which the compound is administered, the compound comprising Levovirin, phosphorylated Levovirin ™, modified phosphorylated Levovirin ™, or modified Ribavirin (above). In a further step, the compound is administered to a patient at such dosage that (a) induces systemic immunosuppression of type I and type II responses and (b) causes immunosuppression of type I and type II responses in the patient's liver.

Izraz “imunosupresija” se nanaša na pojav, pri katerem je velikost T in/ali B -celičnih klonov limfocitov zmanjšana ali pa so suprimirani pri svoji reaktivnosti, širjenju ali diferencijaciji. Pri tem imunosupresija lahko nastane pri aktivaciji specifičnih ali nespecifičnih T- supresivnih limfocitov bodisi T ali B klonov, ali z zdravili, ki imajo posploševalne učinke na večino ali na vse limfocite T ali B. Na primer ciklosporin A inThe term "immunosuppression" refers to a phenomenon in which the size of the T and / or B-cell lymphocyte clones is reduced or suppressed in their reactivity, spread or differentiation. In this case, immunosuppression can be triggered by the activation of specific or nonspecific T-suppressing lymphocytes of either T or B clones, or with drugs that have generalizing effects on most or all of T or B lymphocytes, for example cyclosporin A and

-1818-1818

FK506 delujeta sorazmerno specifično na celice T, medtem ko so alkilirna sredstva kot ciklofosfamid manj specifična pri svojem delovanju.FK506 act relatively specific on T cells, while alkylating agents such as cyclophosphamide are less specific in their action.

Kot je tu v rabi, se izraz “citokin” nanaša na skupino topnih proteinov in peptidov, ki delujejo kot humoralni regulatorji v nano-do pikomolamih koncentracijah in ki, bodisi pod normalnimi ali patološkimi pogoji, modulirajo funkcionalne dejavnosti posameznih celic in tkiv. Citokini tudi direktno posredujejo pri medsebojnem delovanju celic in uravnavajo procese, ki potekajo izven celičnega okolja.As used herein, the term "cytokine" refers to a group of soluble proteins and peptides that act as humoral regulators at nano-to-picomolar concentrations and which, either under normal or pathological conditions, modulate the functional activities of individual cells and tissues. Cytokines also directly mediate cell interactions and regulate processes that take place outside the cellular environment.

Kot se tu dalje uporablja, se izraz “limfokini” nanaša na podvrsto citokinov, ki jih proizvajajo T-celice pomagalke, običajno predvidevamo, da spadajo v dva podrazreda, tip 1 in tip 2. Celice tipa 1 proizvajajo interleukin 2 (IL-2), tumorje nekrotizirajoči faktor (TNFa) in gama interferon (IFNy) in so prvenstveno odgovorne za imunost, ki jo posredujejo celice tipa zavlačevanja preobčutljivosti in antivirusna imunost. Nasprotno, celice tipa 2 proizvajajo interleukine HA IL-5, IL-6, IL-9, IL-10 in IL-13 in so prvenstveno udeležene pri podpori humoralnim imunskim odgovorom, takšnim, kot smo jih videli pri odgovorih na alergene (na primer IgE in IgG4 izotipni preklop protiteles).As used herein, the term "lymphokines" refers to a subtype of cytokines produced by helper T cells, typically assumed to belong to two subclasses, type 1 and type 2. Type 1 cells produce interleukin 2 (IL-2) , tumors necrotizing factor (TNF?) and gamma interferon (IFN?) and are primarily responsible for the immunity mediated by cells of the type of hypersensitivity hypersensitivity and antiviral immunity. In contrast, type 2 cells produce HA interleukins IL-5, IL-6, IL-9, IL-10, and IL-13 and are primarily involved in supporting humoral immune responses such as those seen in allergen responses (e.g. IgE and IgG4 isotype switching antibodies).

Zaradi tega je za izraza “odgovori” tipa 1 in tipa 2 mišljeno, da vključujeta celotni razpon učinkov, ki izhajajo iz indukcije reakcij limfocitov tipa 1 oziroma tipa 2. Med drugim, takšni odgovori vključujejo povečano produkcijo ustreznih citokinov, povečano razmnoževanje ustreznih limfocitov in druge učinke, povezane s povečano produkcijo citokinov, vključno z motilitetnimi učinki. Odgovor tipa 1 običajno označuje naraščanje IL-2, TNF-α in EFN-γ, medtem ko odgovor tipa 2 tipično označuje naraščanje~IL4, IL-5, IL-6 in IL-10.Therefore, the terms "type 1" and "type 2" responses are meant to include the full range of effects resulting from the induction of type 1 or type 2 lymphocyte reactions. Among others, such responses include increased production of relevant cytokines, increased reproduction of relevant lymphocytes, and other effects associated with increased cytokine production, including motility effects. The type 1 response typically indicates an increase in IL-2, TNF-α, and EFN-γ, whereas the type 2 response typically indicates an increase in ~ IL4, IL-5, IL-6, and IL-10.

Kot je tu dalje v rabi, izraz zdravilo “se kopiči prednostno” v tarčnem organu se nanaša na selektivni mehanizem tarčnega organa, ki ima za posledico povečano čisto dovzetnost ali zadrževanje zdravila v tarčnem organu glede na druga tkiva ali organe.As used herein, the term " preferential drug " in the target organ refers to the selective mechanism of the target organ that results in increased pure susceptibility or retention of the drug in the target organ relative to other tissues or organs.

-1919-1919

Pri tem mehanizem lahko vključuje aktivno vnašanje prek prenašalcev, receptorjev, mehurčkov itd, lahko pa temelji tudi na fizikalno kemijskih principih, vključno z bremenom zdravila, odvisnim od pH, z različno topnostjo zdravila v okoljih s spremenjeno ionsko močjo, s kemijsko ali encimatsko modifikacijo znotraj tarčnega organa ali tarčne celice itd.In this mechanism, it may involve active uptake via carriers, receptors, vesicles, etc., but may also be based on physico-chemical principles, including pH-dependent drug loading, with varying solubility of the drug in altered ionic environments, by chemical or enzymatic modification within target body or target cell, etc.

S prednostnga vidika je zdravilo Ribavirin, ki ga dajemo bolniku, okuženemu s HCV (hepatitis C virusom), Ribavirin pa dajemo bolniku oralno v enem samem odmerku 600 mg/dan za dobo 180 dni. En sam odmerek 600 mg/dan je običajno pod koncentracijo sistemske imunorepresije, je pa učinkovit pri prednostnem kopičenju v jetrih. Tako se bo koncentracija Ribavirina v tarčnem organu (tukaj: jetra) značilno povečala in dosegla imunosupresivno koncentracijo v jetrih. Za Ribavirin je znano, da poveča odgovor tipa 1 glede na odgovor tipa 2 in da znižuje odgovore tipa 1 in tipa 2 pri sorazmerno visokih koncentracijah. Primeri so prikazani v Mednarodni patentni prijavi številka PCT/US98/00634, vloženi 13 januarja, 1998, vključeni tukaj z referenco.Preferably, Ribavirin is given to a patient infected with HCV (hepatitis C virus) and Ribavirin is given orally to the patient at a single dose of 600 mg / day for 180 days. A single dose of 600 mg / day is usually below the concentration of systemic immuno repression, but is effective in preferentially accumulating in the liver. Thus, the concentration of Ribavirin in the target organ (here: liver) will significantly increase and reach immunosuppressive concentrations in the liver. Ribavirin is known to increase type 1 response relative to type 2 response and to decrease type 1 and type 2 responses at relatively high concentrations. Examples are illustrated in International Patent Application PCT / US98 / 00634, filed January 13, 1998, incorporated herein by reference.

Z alternativnega vidika predmeta izuma ni potrebno, da se zdravilo omejuje na Ribavirin, alternativna zdravila pa vključujejo obravnavane spojine (zgoraj), posebno modificiran in nemodificiran Levovirin in fosforiliran Levovirin . Nadaljnja alternativna zdravila pa dalje vključujejo obravnavane spojine, dokler kot alternativne spojine zmanjšujejo oba odgovora tipa 1 in tipa 2 pri imunosupresivni koncentraciji in povečajo odgovor tipa 1 glede na odgovor tipa 2 pod imunosupresivno koncentracijo.From an alternative aspect of the invention, it is not necessary for the drug to be limited to Ribavirin, and alternative medicaments include the compounds discussed above, especially modified and unmodified Levovirin and phosphorylated Levovirin. Further alternative drugs further include the compounds considered, as long as alternative compounds reduce both type 1 and type 2 responses at immunosuppressive concentration and increase the type 1 response relative to the type 2 response below immunosuppressive concentration.

Z ozirom na bolnika smo razen okužbe s HCV obravnavali tudi razne druge virusne okužbe, vključno z okužbami z arbovirusi. Zato tarčni organ ni omejen Ife na jetra temveč lahko vključuje tudi druge organe kot možgane, pljuča, vranico, timus, ledvice itd. Na splošno smo ocenili, da bo bolezen, ki jo lahko zdravimo s postopkom po predmetu, predstavljenem tukaj, odvisna od specifičnega modela kopičenja zdravila (t.j. v katerem organu se zdravilo prednostno kopiči). Na primer, Ribavirin in Levovirin™ se oba prednostno kopičita v jetrih in oba znižujeta odgovore tipa 1 in tipa 2 nadIn addition to HCV infection, various other viral infections, including arbovirus infections, were also considered with respect to the patient. Therefore, the target organ is not restricted to the Ife by the liver but may include other organs such as the brain, lungs, spleen, thymus, kidneys, etc. In general, it has been estimated that the disease that can be treated by the process of the subject presented herein will depend on the specific model of drug accumulation (i.e., in which organ the drug preferentially accumulates). For example, Ribavirin and Levovirin ™ both preferentially accumulate in the liver and both reduce type 1 and type 2 responses over

-2020 imunosupresivno koncentracijo. Zaradi tega smo bolezni, pri katerih je zaželen imunosupresivni odgovor v jetrih, posebno obravnavali, vključujejo pa hepatitis C, avtoimuni/lupoidni hepatitis, prejemnike jetrnih presadkov itd.-2020 immunosuppressive concentration. For this reason, diseases for which an immunosuppressive response in the liver is desirable have been specifically addressed and include hepatitis C, autoimmune / lupoid hepatitis, liver transplant recipients, etc.

Upoštevati je treba zlasti, da postopek po predmetu izuma ni namenjen zagotavljanju direktnega anti virusnega zdravljenja ampak je namenjen vsaj delni supresiji imunskega odgovora v nekem organu, ki je okužen z virusom. Ugotovljeno je bilo, da je imunosupresija tarčnega organa posebno prednostna pri hepatitisu C, kjer poškodbo organa ne moremo takoj pripisati virusu HCV ampak prej od okužbe povzročenemu neravnovesju med odgovorom tipa 1 in odgovorom tipa 2. Zaradi tega predvidevamo, da postopek zdravljenja z zdravilom, ki specifično zmanjšuje oba odgovora tipa 1 in tipa 2 v jetrih bolnika, okuženega s HCV, profilaktično preprečuje poškodbo jeter kot tudi pri terapevtskem pristopu. Ker je toleranca človeka za Ribavirin in Levovirin™ odlična, sta posebno koristna dolgoročna profilaksa in dolgoročno zdravljenje.In particular, it is to be appreciated that the method of the invention is not intended to provide direct anti-viral treatment but is intended to at least partially suppress the immune response in some organ infected with the virus. The target organ immunosuppression has been found to be particularly preferred in hepatitis C, where organ damage cannot be immediately attributed to HCV but sooner than infection-induced imbalance between type 1 and type 2 responses. Therefore, it is assumed that the drug treatment process specifically reduces both type 1 and type 2 responses in the liver of an HCV-infected patient, prophylactically preventing liver injury as well as in the therapeutic approach. Because human tolerance for Ribavirin and Levovirin ™ is excellent, long-term prophylaxis and long-term treatment are especially helpful.

Glede na dajanje (pot, odmerjanje, razpored, termin itd.) Ribavirina ali alternativnih obravnavanih spojin, velja isti premislek, kot je opisano spodaj. Predvideno je dalje, da Ribavirin ali alternativne obravnavane spojine lahko uporabljamo za splošno vzpostavitev zdravja, v nasprotju s klinično ali terapevtsko vzpostavitvijo. Zato smo upoštevali, da Ribavirin ali alternativne obravnavane spojine lahko uporabljamo tudi za izboljšanje prebave. Na primer, eno ali več spojin lahko jemlje oseba, ki trpi za slabo prebavo - bodisi, da je slaba prebava nastala zaradi stanja jeter kot pri okužbi s hepatitisom B ali C ali sploh zaradi drugih pogojev, ki jih označuje vnetje jeter. V tem primeru lahko izboljšamo prebavo, tako da oseba jemlje Ribavirin ali Ribavirinu podobno spojino pod količino, ki normalno povzroča sistemsko imunosupresijo toda v količini, ki se akumulira v jetrih do koncentracije, ki povzroča imunosupresijo v posmeznikovih jetrih.Depending on the administration (route, dosage, schedule, term, etc.) of ribavirin or the alternative compounds considered, the same considerations apply as described below. It is further contemplated that Ribavirin or the alternative compounds discussed may be used for general health restoration as opposed to clinical or therapeutic establishment. Therefore, we have taken into account that Ribavirin or the alternative compounds considered can also be used to improve digestion. For example, one or more compounds may be taken by a person suffering from indigestion - whether the indigestion is due to a condition of the liver such as a hepatitis B or C infection, or at all due to other conditions indicated by inflammation of the liver. In this case, digestion can be improved by taking Ribavirin or Ribavirin-like compound below the amount that normally causes systemic immunosuppression but in the amount that accumulates in the liver to the concentration that causes immunosuppression in the liver of the individual.

Še en primer neklinične, neterapevtske uporabe je ta, da oseba vzame Ribavirin ali alternativne obravnavane spojine kot sredstvo za izboljšanje barve kože. Posebno smoAnother example of a non-clinical, non-therapeutic use is that a person takes Ribavirin or alternative treatment compounds as a skin color enhancer. We are special

-2121 predvideli, da barvo kože lahko izboljšamo tako, da oseba vzame Ribavirin ali alternativno obravnavane spojine pod količino, ki normalno povzroča sistemsko imunosupresijo toda v količini, ki se kopiči v jetrih do koncentracije, ki povzroči imunosupresijo v posameznikovih jetrih.Predicted that skin color can be improved by taking Ribavirin or alternatively treated compounds below the amount that normally causes systemic immunosuppression, but in an amount that accumulates in the liver to the concentration that causes immunosuppression in the individual's liver.

Pri vseh teh postopkih smo obravnavali zlasti uporabo Ribavirina (l-(5-deoksi-0-Dribofuranozil)-l,2,4-triazol-3-karboksamid) ali Levovirina™ (1 -(5-deok si-β-Lribofuranozil)- 1,2,4-triazol-3 -karboksamid) ali katerihkoli mono-, di- ali trifosforiliranih oblik le-teh. Vzeta ali dana količina prednostno zadostuje za proizvajanje sistemske imunomodulacije odgovorov tipa I in tipa II in supresijo odgovorov obeh tipov I in II v jetrih. Posebno prednostne so količine med okoli 300 mg/dan in okoli 800 mg/dan, čeprav je pri nekaterih osebah razpon lahko tako nizek kot okoli 50-100 mg/dan do tako visokega kot 2000-2400 mg/dan. Opazovali smo tudi učinke na druge organe, vključno z možgani ali drugimi organi, za katere je znano, da se v njih Ribavirin precej kopiči.In all of these procedures, the use of Ribavirin (1- (5-deoxy-0-Dribofuranosyl) -1,2,4-triazole-3-carboxamide) or Levovirin ™ (1- (5-deoxy-β-Lribofuranosyl) was considered in particular - 1,2,4-triazole-3-carboxamide) or any mono-, di- or triphosphorylated forms thereof. The amount taken or administered is preferably sufficient to produce systemic immunomodulation of type I and type II responses and suppression of responses of both types I and II in the liver. Particularly preferred are amounts between about 300 mg / day and about 800 mg / day, although in some subjects the range may be as low as about 50-100 mg / day to as high as 2000-2400 mg / day. We also observed effects on other organs, including the brain or other organs, which are known to be highly accumulated in Ribavirin.

Stimulacija nevronske rastiStimulation of neural growth

Kot ga tu uporabljamo, se izraz “stimuliranje nevronske rasti” nanaša na proces, pri katerem se rast celice in/ali delitev začne bodisi iz mirujoče celice ali pa je rast pospešena pri rastoči in/ ali deleči se celici, pri čemer se “nevronska” nanaša na vse celice, ki so direktno ali indirektno udeležene pri prenosu kognitivnih, senzorskih ali motornih signalov. Na primer, predvideva se, da so nevroni direktno vpleteni pri prenosu signalov, medtem ko so celice z mielinsko ovojnico ali glia -celice indirektno vpletene s pomočjo njihove izolirajoče funkcije ali struktume/metaboličrie podpore nevronu. Podobno se receptoiji obravnavajo tudi kot nevronske celice po smotru te definicije. Nasprotno se celice, ki tvorijo notranjo in zunanjo plast dure, ne prištevajo nevronskim celicam, ker niso direktno ali indirektno udeležene pri prenosu kognitivnih, senzorskih ali motornih signalov.As used herein, the term "neural growth stimulation" refers to a process in which cell growth and / or division begins either from a stationary cell or is accelerated by a growing and / or dividing cell, whereby "neural" refers to all cells directly or indirectly involved in the transmission of cognitive, sensory or motor signals. For example, neurons are assumed to be directly involved in signal transduction, whereas cells with myelin envelope or glia cells are indirectly implicated by their insulating function or structure / metabolic support of the neuron. Similarly, receptos are also treated as neural cells following the definition of this definition. In contrast, cells that make up the inner and outer layers of the dura are not assigned to neural cells because they are not directly or indirectly involved in the transmission of cognitive, sensory, or motor signals.

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Izumitelji so presenetljivo odkrili, da je Ribavirin učinkovit pri stimuliranju rasti nevronov, izumitelji pa dalje predvidevajo, da so tudi razni fosoforilirani analogi Ribavirina lahko učinkoviti za stimulacijo takšne rasti. Še nadalje se predvideva, da so Levovirin™ in njegovi fosforilirani analogi lahko učinkoviti na podoben način. V posebnem eksperimentu je bilo ugotovljeno, daje Levovirin™ učinkovit pri stimulaciji rasti enopolnih nevronskih celic in vitro znotraj koncentracijskega razpona od 0,5 μΜThe inventors have surprisingly discovered that Ribavirin is effective in stimulating neuronal growth, and the inventors further speculate that various phosphorylated Ribavirin analogs may also be effective in stimulating such growth. It is further contemplated that Levovirin ™ and its phosphorylated analogs may be similarly effective. In a special experiment, Levovirin ™ was found to be effective in stimulating the growth of single-pole neural cells in vitro within a concentration range of 0.5 μΜ

TTLf do 500 μΜ. Zato se lahko uporablja dodajanje Levovirina okolju kulture v koncentraciji okoli 5,0 μΜ za stimulacijo rasti enopolnih nevronskih celic.TTLf up to 500 μΜ. Therefore, the addition of Levovirin to the culture medium at a concentration of about 5.0 μΜ can be used to stimulate the growth of single-pole neural cells.

Dalje je treba upoštevati, da ni potrebno, da se postopki stimuliranja nevronske rasti omejujejo na enopolne nevronske celice temveč vključujejo lahko razne alternativne celice vključno z dvopolnimi in večpolnimi nevronskimi celicami. Razen tega predvidevamo, da po alternativnih vidikih postopkov stimuliranja nevronske rasti so lahko posamezne celične vrste tarča v množici drugih nevronsih celic. Na primer na enopolne, dvopolne in večpolne nevronske celice lahko ciljamo v kompleksnih nevronskih strukturah kot v možganih, hrbtnem mozgu ali očeh. Zato so nevroni lahko del nevronskega tkiva, ki vključuje najmanj štiri od naslednjih celičnih vrst: astrocit, dendrocit, celica z mielinsko ovojnico, glia celica, enopolna nevronska celica, bipolna nevronska celica, večpolna nevronska celica in receptorska celica.It should further be noted that the stimulation processes of neural growth need not be confined to single-pole neural cells but may include various alternative cells including two-pole and multipole neural cells. In addition, we anticipate that, by alternative aspects of neural growth stimulation processes, individual cell types may be targeted in a plurality of other neuronal cells. For example, single-pole, two-pole and multipole neural cells can be targeted in complex neural structures such as the brain, spinal cord or eyes. Therefore, neurons may be part of a neural tissue that includes at least four of the following cell types: astrocyte, dendrocyte, myelin envelope cell, glia cell, single-pole neuron cell, bipolar neural cell, multipole neuron cell, and receptor cell.

Zato ni potrebno, da se obravnavane metode omejujejo na stimuliranje nevronske rasti v celični kulturi. Pri nadaljnjih alternativnih vidikih predmeta izuma je predvideno, da celice lahko stimuliramo v tkivni kulturi, zlasti pa je predvideno, da celice lahko stimuliramo in vivo. Stimulacija nevronske rasti in vivo se lahko koristno uporablja kot profilaktična obdelava ali terapevtska obdelava. Na primer, obravnavane metode po predmetu izuma lahko uporabljamo za preprečevanje motenj zaradi demielizacije ali nevrodegenerativnih bolezni kot Alzheimerjeve bolezni ali Parkinsonove bolezni, ali pa kot preventivno obdelavo pred operacijskimi posegi v bolniku. Obravnavane terapevtske obdelave vključujejo nazadovanje ali ublažitev dušilnih, traumatičnih,Therefore, it is not necessary to limit the present methods to stimulating neural growth in cell culture. In further alternative aspects of the object of the invention, it is contemplated that the cells can be stimulated in tissue culture, and in particular it is provided that the cells can be stimulated in vivo. Stimulation of neural growth in vivo can be useful as a prophylactic treatment or therapeutic treatment. For example, the methods of the present invention may be used to prevent disorders of demyelination or neurodegenerative diseases such as Alzheimer's disease or Parkinson's disease, or as a preventative treatment prior to surgery in a patient. Treatment treatments discussed include the regression or mitigation of damping, traumatic,

-2323 toksičnih, infekcioznih, degenerativnih, metaboličnih, ishemičnih ali hipoksičnih poškodb.-2323 toxic, infectious, degenerative, metabolic, ischemic or hypoxic injuries.

Zato, kot prikazuje slika 6, ima postopek 600 za izboljšanje koordinacije pri pacientu prvo stopnjo 610, pri kateri je prepoznano, da sta fosforilirani ali nefosforilirani Ribavirin ali Levovirin™ učinkovita pri stimulaciji rasti nevronov in vivo znotraj danega koncentracijskega območja. Pri naslednji stopnji 620 bolnik vzame takšno količino fosforiliranega ali nefosforiliranega Ribavirina ali Levovirina™, ki je učinkovita za stimulacijo rasti vsaj nekaj od nevronov osebe. Obravnavali smo zlasti koordinacijo oko-roka.Therefore, as shown in Figure 6, the patient coordination process 600 has a first step 610 that recognizes that phosphorylated or unphosphorylated Ribavirin or Levovirin ™ is effective in stimulating neuronal growth in vivo within a given concentration range. At the next level of 620, the patient takes an amount of phosphorylated or unphosphorylated Ribavirin or Levovirin ™ that is effective for stimulating the growth of at least some of the person's neurons. In particular, we discussed the coordination of the deadline.

Pri prednostnem postopku za izboljšanje koordinacije pri posamezniku smo spoznali, da je Ribavirin učinkovit za stimuliranje rasti nevronskih celic in vivo, znotraj koncentracijskega območja od 0,5 μΜ do 500 μΜ, Ribavirin pa dajemo oralno bolniku, ki trpi za traumatsko poškodbo nervus-a ischiadicus-a, z odmerjanjem 1200 mg/dan.In a preferred method of improving coordination in an individual, we have learned that Ribavirin is effective for stimulating neural cell growth in vivo, within a concentration range of 0.5 μΜ to 500 μΜ, and Ribavirin is administered orally to a patient suffering from traumatic nerve ischiadicus injury -a, at a dose of 1200 mg / day.

Z ozirom na bolnika smo obravnavali razen traumatskih poškodb nervus-a ischiadicus-a razna druga stanja, vključno z mehanskimi in kemičnimi poškodbami večjega števila živčnih celic, infekcijo nevronskih celic z bakterijami in/ali virusi in degenerativne bolezni. Neglede na naravo bolnikovega stanja smo predvideli, da postopek po predmetu izuma lahko stimulira širok razpon nevronskih celic, zlasti pa smo upoštevali, da stimulirani nevroni komunicirajo med možgani osebe in voluntamimi mišicami ali med posameznikovini možgani in kožnimi senzorji.In addition to the traumatic injuries of the ischiadicus nervus, with respect to the patient, various other conditions, including mechanical and chemical damage to a large number of nerve cells, infection of neural cells by bacteria and / or viruses, and degenerative diseases, were addressed. Regardless of the nature of the patient's condition, it has been contemplated that the method of the invention can stimulate a wide range of neural cells, and in particular, it has been taken into account that stimulated neurons communicate between a person's brain and voluntary muscles or between an individual's brain and skin sensors.

Še en razred obravnavanih metod vključuje izboljšanje tipalne ali druge^-senzorske občutljivosti pri bolniku. Še en razred obravnavanih metod vključuje izboljšanje grobega in finega motoričnega nadzora.Another class of the present methods includes improving tactile or other ^- sensory sensitivity in a patient. Another class of methods considered involves the improvement of coarse and fine motor control.

Ne da bi želeli biti vezani na neko posebno teorijo, smo predvideli, da dajanje Ribavirina, Levovirina™ ali mono-, di- in fosforiliranih oblik Levovirina™ aliWithout wishing to be bound by any particular theory, we intended that administration of Ribavirin, Levovirin ™ or mono-, di- and phosphorylated forms of Levovirin ™ or

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Ribavirina lahko povzroči spremembo odgovorov tipa 1 in tipa 2 pri bolniku, kar lahko sočasno vodi k nevrozaščitnemu statusu ali k stimulaciji nevronske rasti. Zato smo predvideli, da spojine po predmetu izuma lahko dajemo kot del zdravljenja bolnikove bolezni v območju odmerjanja, ki je učinkovito za povečanje odgovora tipa 1 in zmanjšanje odgovora tipa 2 pri bolniku. Z ozirom na dajanje Ribavirina ali alternativnih obravnavanih spojin in vivo (pot, odmerjanje, razpored, termin itd.) veljajo iste ocene, kot so opisane spodaj.Ribavirin may cause changes in the type 1 and type 2 responses in the patient, which may simultaneously lead to neuroprotective status or to stimulation of neural growth. Therefore, it has been contemplated that the compounds of the invention may be administered as part of the treatment of a patient's disease within a dosage range that is effective to increase the type 1 response and reduce the type 2 response in the patient. With respect to the administration of Ribavirin or the alternative in vivo compounds considered (route, dosage, schedule, term, etc.), the same estimates as described below apply.

Antineoplastično zdravljenjeAntineoplastic treatment

Dalje smo predvideli, da spojine po predmetu izuma lahko uporabljamo kot antineoplastična sredstva pri obdelavi trdnega ali limfatičnega tumorja, obravnavane neoplazme pa vključujejo razne karcinome, sarkome in limfome, zlasti pa vključujejo akutno mieloidno leukemijo in kronično mieloidno leukemijo v krizi izbruha.. Treba je nadalje upoštevati, da poteka dajanje obravnavanih spojin pri antivirusnih obdelavah običajno po poti, odmerjanju, po razporedu in terminu, kot se uporabljajo pri znanih Dnukleotidih, D-nukleozidih oziroma pri njihovih analogih pri antineoplastičnih obdelavah.It has further been contemplated that the compounds of the invention may be used as antineoplastic agents in the treatment of solid or lymphatic tumors, and the neoplasms discussed include various cancers, sarcomas and lymphomas, and in particular include acute myeloid leukemia and chronic myeloid leukemia in an outbreak crisis. note that administration of the compounds under consideration in antiviral treatments is usually by route, dosage, schedule and term, as used in known Dnucleotides, D-nucleosides, or their analogues in antineoplastic treatments.

Dajanje obravnavanih spojinAdministration of the compounds under consideration

Z ozirom na dajanje obravnavanih spojin, je treba upoštevati, da spojine lahko dajemo po primernem protokolu v katerikoli primerni farmacevtski formulaciji. Običajno ima prednost oralno dajanje obravnavanih spojin. Pri alternativnih vidikih predmeta izuma je treba upoštevati, da so primerna tudi razna alternativna dajanja, dalje se je treba zavedati, da bo neko posebno dajanje običajno odvisno od kemične stabilnosti, biouporabnosti, odmerjanja, formulacije in/ali od farmakokinetičnih/farmakodinamičnih lastnosti obravnavanih spojin. Tako bo primerno dajanje vključevalo lokalno dovajanje (na primer mazilo, pršilo, krema itd ), parenteralno sistemsko dovajanje (na primerWith respect to the administration of the compounds under consideration, it should be appreciated that the compounds can be administered according to a suitable protocol in any suitable pharmaceutical formulation. Oral administration of the compounds under consideration is generally preferred. In the alternative aspects of the subject matter, it is to be appreciated that various alternative administrations are also suitable, it should further be appreciated that a particular administration will usually depend on the chemical stability, bioavailability, dosage, formulation and / or on the pharmacokinetic / pharmacodynamic properties of the compounds under consideration. Thus, appropriate administration will include local delivery (e.g., ointment, spray, cream, etc.), parenteral systemic delivery (e.g.

-2525 vdihavanje) in direktno ali indirektno dovajanje (na primer i v. ali i.m. vbrizgovanje itd.)-2525 inhalation) and direct or indirect delivery (eg v. Or i.m. injection, etc.)

Zato se lahko formulacija obravnavanih spojin znatno spreminja. Na primer tam, kjer zdravilo ali sestavek zdravil izkazuje zadovoljivo stabilnost pri prehodu skozi 'gastrointestinalni sistem brez neželenih kemijskih ali encimatskih modifikacij, oralna formulacija lahko vključuje sirup, tablete, gelske kapsule, prašek itd. Po drugi strani, ko sta absorpcija ali prehod obravnavanih spojin skozi gastro-intestinalni trakt v krvni obtok problematična, primerne formulacije vključujejo zlasti vbrizgljive raztopine ali suspenzije (na primer fiziološke solne raztopine, zapuffane na pH okoli 7,2 do 7,5).Therefore, the formulation of the compounds under consideration may vary significantly. For example, where the drug or drug composition exhibits satisfactory stability in passage through the gastrointestinal system without undesirable chemical or enzymatic modifications, the oral formulation may include syrup, tablets, gel capsules, powder, etc. On the other hand, when the absorption or passage of the compounds under consideration through the gastrointestinal tract into the bloodstream is problematic, suitable formulations include, in particular, injectable solutions or suspensions (for example, saline solids, pH 7.2 to 7.5).

Glede odmerjanja obravnavanih spojin je treba upoštevati, da so primerna razna odmerjanja, predvidena odmerjanja pa se tipično gibljejo v območju od 1 mg do več 100 mg in celo več. Na primer, kjer se obravnavane spojine izločajo ali pa so metabolizirane s sorazmerno nizko hitrostjo ali kjer se želi dolgoročno zdravljenje, bodo odmerjanja tipično v razponu med 5 mg in 200 mg na dan. Po drugi strani, kjer je biouporabnost obravnavanih spojin sorazmerno nizka ali kjer je metabolična pretvorba (na primer defosforiliranje) sorazmerno hitra, se bodo odmerjanja gibala v območju med 100 mg in 2500 mg na dan.With respect to the dosage of the compounds under consideration, it is to be appreciated that various dosages are appropriate, and the dosages contemplated typically range from 1 mg to more than 100 mg and even more. For example, where the compounds in question are excreted or metabolized at a relatively low rate or where long-term treatment is desired, dosages will typically be in the range of 5 mg to 200 mg per day. On the other hand, where the bioavailability of the compounds under consideration is relatively low or where the metabolic conversion (eg dephosphorylation) is relatively rapid, dosages will range between 100 mg and 2500 mg per day.

Glede odmerjanja L-nukleozidov, in posebno Levovirina™ je treba dalje upoštevati, da ne kaže, da bi bil Levovirin™ fosforiliran in vivo, vsaj ne v hepatocitih ali eritrocitih, in ker utegne biti, da je antivirusni učinek Ribavirina odvisen od fosforilacije, običajni strokovnjak ne bi pričakoval, da ima Levovirin™ direkten antivirusni učinek. Dejansko, eksperimenti (neobjavljeni) ne kažejo direktnega antivirusnega učinka. Zdi se, da antivirusni učinek Levovirina™ presenetljivo nastaja pri odmerjanjih ne več kot 200 mg na dan, prednostno v razponu od 10 do 200 mg, še bolj prednostno pa v razponu od 50 do 200 mg in celo bolj prednostno v razponu od 50 do 100 mg. To potijuje eksperimentalni razvid, ki prikazuje, da je pri danem odmerku raven Levovirina v krvnem serumu petkrat večja kot pri ekvivalentnem odmerku Ribavirina.With regard to dosage of L-nucleosides, and in particular Levovirin ™, it should be further taken that it does not appear that Levovirin ™ is phosphorylated in vivo, at least not in hepatocytes or erythrocytes, and that the antiviral effect of Ribavirin may be phosphorylation dependent, one would not expect Levovirin ™ to have a direct antiviral effect. In fact, experiments (unpublished) show no direct antiviral effect. The antiviral effect of Levovirin ™ appears to be surprisingly occurring at doses of no more than 200 mg per day, preferably in the range of 10 to 200 mg, more preferably in the range of 50 to 200 mg and even more preferably in the range of 50 to 100 mg. This gives rise to experimental evidence showing that at a given dose, the blood serum level of Levovirin is five times higher than the equivalent dose of Ribavirin.

-2626-2626

Eksperimenti kažejo, da se Ribavirin odstrani iz seruma tako, da postane fosforiliran v rdečih krvnih celicah (glej Homma, M. et al.; High performance liquid chromatographic determination of Ribavirin in whole blood to assess disposition in erytrocytes; Antimicrob. Agents Chemother, (1999), 43 (11):2716-9). Ko je enkrat fosforiliran, Ribavirin ne more zapustiti celic. Zato delujejo rdeče krvne celice kot odtok za Ribavirin, potrebni pa so višji odmerki Ribavirina, da dobimo neko dano raven v serumu. Levovorin™ ni fosforiliran, zaradi tega ni nagnjen h kopičenju v rdečih krvnih celicah. Iz tega izhaja, da rdeče krvne celice pri Levovirinu™ ne delujejo kot odtok in zadostujejo nižji odmerki Levovirina™ za doseganje želenega nivoja v serumu.Experiments show that Ribavirin is removed from the serum by becoming phosphorylated in red blood cells (see Homma, M. et al .; High performance liquid chromatographic determination of Ribavirin in whole blood to assess disposition and erytrocytes; Antimicrob. Agents Chemother, ( 1999), 43 (11): 2716-9). Once phosphorylated, Ribavirin cannot leave the cells. This is why red blood cells act as a drain for Ribavirin, and higher doses of Ribavirin are needed to get a certain serum level. Levovorin ™ is not phosphorylated and therefore is not prone to accumulation in red blood cells. It follows that the red blood cells at Levovirin ™ do not function as an outflow and lower doses of Levovirin ™ are sufficient to reach the desired serum level.

Razpored dajanja se lahko znatno spreminja, obravnavani razporedi pa vključujejo posamezni odmerek skozi celotni potek zdravljenja, večkratne posamezne dnevne odmerke skozi celotni potek zdravljenja, večkratne dnevne odmerke in stalno odmerjanje (na primer stalna infuzija, vsajena ozmotska črpalka itd.) vsaj za del poteka zdravljenja. Medtem ko je običajno bolj zaželeno da primerni razporedi vzdržujejo stalno dovajanje obravnavanih spojin, je primemo tudi prebitno dovajanje (t.j. vsaj eno dajanje v prvem odmerku, ki mu sledi vsaj še eno dajanje v odmerku, ki je nižji od prvega odmerka). Glede časa (t.j. trajanja) zdravljenja, ocenjujemo, da primerna trajanja lahko variirajo med posameznim dajanjem in več dni, več tednov, več let in celo dlje. Na primer, kjer obravnavane spojine uporabljamo v celični kulturi, zadostuje lahko eno samo dajanje ali sorazmerno kratko dajanje. Po drugi strani, kjer se obravnavane spojine dajejo za zdravljenje akutne bolezni jeter, se primerno trajanje zdravljenja giblje v razponu med več dni in več tednov. Podobno, kjer zdravimo kronično obolenje jeter z dajanjem obravnavanih spojin, je lahko primerno podaljšano dajanje skozi eno ali več let.The schedule of administration can vary significantly, and the schedules considered include single dose throughout the course of treatment, multiple single daily doses throughout the course of treatment, multiple daily doses, and continuous dosing (eg, continuous infusion, implanted osmotic pump, etc.) for at least part of the course of treatment . While it is generally preferable that suitable schedules maintain a constant delivery of the compounds under consideration, an excess delivery is also acceptable (i.e., at least one administration in the first dose followed by at least another administration in a dose lower than the first dose). With regard to the duration (i.e. duration) of treatment, we estimate that appropriate durations may vary between administration and several days, several weeks, several years, and even longer. For example, where the compounds in question are used in cell culture, a single administration or relatively short administration may be sufficient. On the other hand, where the compounds in question are administered for the treatment of acute liver disease, the appropriate duration of treatment ranges from several days to several weeks. Similarly, where chronic liver disease is treated by administration of the compounds under consideration, prolonged administration over one or more years may be appropriate.

Pri še nadaljnjih vidikih predmeta izuma, lahko obravnavane spojine kombiniramo z dodatnimi farmacevtsko aktivnimi snovmi za pomoč pri zdravljenju raznih bolezni, zlasti pa virusnih okužb. Dodatne farmacevtsko aktivne substance lahko dajemo ločenoIn still further aspects of the invention, the compounds contemplated may be combined with additional pharmaceutically active agents to aid in the treatment of various diseases, and in particular viral infections. Additional pharmaceutically active substances may be administered separately

-2727 ali skupaj, ko pa jih dajemo ločeno, poteka dajanje sočasno ali ločeno po kateremkoli redu. Posebno upoštevane dodatne farmacevtsko aktivne snovi vključujejo antivirusna sredstva in imunomodulatome snovi. Na primer, antivirusna sredstva vključujejo inhibitorje proteaze, analoge nukleotidov in/ali nukleozidov (in posebno Ribavirin), imunomodulatome snovi pa lahko vključujejo citokine (na primer interferon a in7, IL2, IL4, BL6, IL8, IL10 in IL12).-2727 or together, but given separately, administration is performed simultaneously or separately in any order. Particularly considered additional pharmaceutically active substances include antiviral agents and immunomodulatory agents. For example, antiviral agents include protease inhibitors, nucleotide analogues and / or nucleosides (and especially Ribavirin), and immunomodulatory substances may include cytokines (for example, interferon a and7, IL2, IL4, BL6, IL8, IL10, and IL12).

Dalje vključujejo obravnavana farmakološka aktivna sredstva protiglivična sredstva kot Tolnaftat, Fungizon™, Lotrimin™, Mycelex™, Nistatin in Amfoteracin; antiparazite kot Mintezol™, Niklocid™, Vermox™ in Flagyl™, črevesna sredstva kot Immodium™, Lomotil™ in Phazyme™; antitumoma sredstva kot interferon a un γ, Adriamycin™, Cytoxan™, Imuran™, Methotrexate, Mithracin™, Tiazofurin™, Taxol™; dermatološka sredstva kot Aclovate™, Cyclocort™, Denorex™, Florone™, Oxsoralen™, premogov katran in salicilno kislino; pripravke za migreno kot ergotaminske spojine; steroide in imunosupresive, ki niso navedeni zgoraj, vključno s ciklosporini, Diprosonom™, hidrokortizonom; Floron™, Lidex™, Topicort™ in Valisoneon™; in metabolična sredstva kot inzulin in druga zdravila, ki ne spadajo v zgornje kategorijeFurther include the pharmacologically active agents considered antifungal agents such as Tolnaftat, Fungizon ™, Lotrimin ™, Mycelex ™, Nistatin and Amphoteracin; antiparasites such as Mintezol ™, Niklocid ™, Vermox ™ and Flagyl ™, intestinal agents such as Immodium ™, Lomotil ™ and Phazyme ™; antitumor agents such as interferon a un γ, Adriamycin ™, Cytoxan ™, Imuran ™, Methotrexate, Mithracin ™, Tiazofurin ™, Taxol ™; dermatological agents such as Aclovate ™, Cyclocort ™, Denorex ™, Florone ™, Oxsoralen ™, coal tar and salicylic acid; migraine preparations as ergotamine compounds; steroids and immunosuppressants not listed above, including ciclosporins, Diprosone ™, hydrocortisone; Floron ™, Lidex ™, Topicort ™ and Valisoneon ™; and metabolic agents such as insulin and other drugs not falling into the above categories

Prednostne kombinacije obravnavanih spojin z interferonomPreferred combinations of the compounds considered with interferon

Pri posebno prednostnem vidiku predmeta izuma obravnavamo sinergistično kombinacijo Levovirina™ z vsaj enim interferonom, prednostno z IFN-a-2b. Levovirin™ se tipično ne fosforilira v eritrocitih, ali samo v znatno manjši meri kot Ribavirin, medtem ko še vedno izkazuje antivirusno in imunomodulatomo “dejavnost. Zato ocenjujemo, da farmakološko delovanje interferona, zlasti pri zdravljenju jetrnih obolenj, lahko povečamo s skupnim dajanjem z Levovirinom™ ob znatno nižjem odmerjanju v primerjavi z Ribavirinom. Na primer predvidevamo, da so učinkoviti sinergistični odmerki Levovirina™ v kombinaciji z interferonom, potrebni za zdravljenje okužbe s HCV, načrtovani tako, da se gibljejo v območju 1 - 600 mg, boljIn a particularly preferred aspect of the invention, a synergistic combination of Levovirin ™ with at least one interferon, preferably IFN-a-2b, is considered. Levovirin ™ is typically not phosphorylated in erythrocytes, or only to a much lesser extent than Ribavirin, while still showing antiviral and immunomodulatory activity. Therefore, we estimate that the pharmacological action of interferon, especially in the treatment of liver disease, can be increased by co-administration with Levovirin ™ at a significantly lower dose compared to Ribavirin. For example, the effective synergistic doses of Levovirin ™ in combination with interferon required for the treatment of HCV infection are predicted to range from 1 - 600 mg, more

-2828 prednostno v območju 10 - 400 mg, še bolj prednostno v območju 50-300 mg in najbolj prednostno v območju 100-300 mg. Predvideni ekvivalentni sinergistični odmerki Ribavirina se gibljejo med 600 in 800 mg.-2828 preferably in the range of 10-400 mg, more preferably in the range of 50-300 mg and most preferably in the range of 100-300 mg. The intended equivalent synergistic doses of Ribavirin range from 600 to 800 mg.

Pri drugen vidiku predmeta izuma, smo predvideli, da bo sinergistična kombinacija Levovirina™ z interferonom povzročila zmanjšano toksičnost glede na kombinacijo Ribavirina z interferonom pri ekvivalentnem učinkovitem odmerjanju, pretežno zaradi pomanjkanja značilne fosforilacije v eritrocitih. Gledano iz še druge perspektive, predvidevamo, da sinergistična kombinacija Levovirina™ z interferonom specifično omogoča ciljanje jeter zaradi pomanjkljive fosforilacije Levovirina v drugih predelkih poleg jeter, posebno eritrocitov.In another aspect of the invention, it is contemplated that the synergistic combination of Levovirin ™ with interferon will result in reduced toxicity over the combination of Ribavirin with interferon at an equivalent effective dosage, predominantly due to a lack of characteristic phosphorylation in erythrocytes. From another perspective, it is contemplated that the synergistic combination of Levovirin ™ with interferon specifically enables the targeting of the liver due to the lack of phosphorylation of Levovirin in other compartments besides the liver, especially erythrocytes.

Z ozirom na dajanje Levovirina™ skupaj z interferonom smo predvideli, da so primerne vse ustrezne poti in protokoli, posebno pa ima prednost dajanje Levovirina™ in interferona po protokolu, ki je podoben poznanim protokolom dajanja Ribavirina in interferona. Na primer Levovirin™ lahko dajemo oralno, medtem ko interferon lahko vbrizgamo podkožno. Na splošno predvidevamo, da dajanje Levovirina™ skupaj z interferonom uporablja lahko medsebojno neodvisne razporede in poti tako dolgo, dokler imata oba zdravila v krvnem serumu merljivo koncentracijo ob istem času. Dalje smo predvideli, da učinkovito odmerjanje Levovirina™ lahko načrtujemo iz učinkovite koncentracije Ribavirina v jetrih, kjer smo Ribavirin dali.With regard to the administration of Levovirin ™ together with interferon, all appropriate routes and protocols have been considered appropriate, and the administration of Levovirin ™ and interferon in particular is advantageous according to a protocol similar to the known administration protocols of Ribavirin and interferon. For example, Levovirin ™ can be given orally, while interferon can be given subcutaneously. Generally, it is anticipated that administration of Levovirin ™ together with interferon may use mutually independent schedules and pathways as long as both drugs have blood concentrations at the same time in the blood serum. We further predicted that effective dosage of Levovirin ™ can be planned from the effective concentration of Ribavirin in the liver where Ribavirin was administered.

Medtem ko smo Levovirin™ posebno obravnavali, so primerne tudi kemijske modifikacije, vključno z oblikami predzdravil kot modificiran Levovirin™ (l-β- Lribofuranozil-l,2,4-triazol-3-karboksamidin), mono,-di- in trifosforiliran Levovirin™ in stereokemijske variante (na primer enantiomeri, izomeri itd ). Primeri za ustrezne kemijske modifikacije in oblike predzdravil so opisani v U.S. Patentni prijavi številka 09/594410 (zgoraj). Dalje smo predvideli, da ustrezna predzdravila lahko vključujejo razen Levovirina™ in njegovih inačic tudi druga zdravila, posebno obravnavanaWhile Levovirin ™ has been specifically discussed, chemical modifications are also appropriate, including forms of prodrugs such as modified Levovirin ™ (l-β-Lribofuranosyl-1,2,4-triazole-3-carboxamidine), mono-, di-and triphosphorylated Levovirin ™ and stereochemical variants (such as enantiomers, isomers, etc.). Examples of suitable chemical modifications and forms of prodrugs are described in U.S. Pat. Patent Application No. 09/594410 (supra). We further anticipated that suitable prodrugs may include, in addition to Levovirin ™ and its variants, other medicines specifically addressed

-2929 alternativna zdravila pa vključujejo specifična jetrna zdravila z aminskim ali amidnimi skupinami, ki se lahko encimatsko deaminirajo/damidirajo v jetrih.-2929 Alternative medicines include specific hepatic drugs with amine or amide groups that can be enzymatically deaminated / damidated in the liver.

Glede interferona ocenjujemo, da ni potrebno, da bi bilo dajanje skupaj z Levovirinom™ omejeno na IFN-a-2b, skupno dajanje pa lahko vključuje tudi naravne ali sintetične fragmente, izoforme in soglasne oblike interferona-alfa. Razen tega so poleg interferona-alfa ustrezni tudi drugi interferoni, vključno z interferonom-beta in njegovimi naravnimi in sintetičnimi fragmenti, izoformi in soglasnimi oblikami. Medtem ko smo obravnavali zlasti interferon, so poleg interferona ustrezni tudi citokini in kemokini, vključno z IL-2, IL-12 in TNF. Posebno smo predvideli, da so pegilirane oblike obravnavanih interferonov (t.j. obravnavani interferoni združeni s polietilen glikolom) ustrezne za uporabo v zvezi z nauki, predstavljenimi tukaj.With regard to interferon, it is assessed that administration with Levovirin ™ is not required to be restricted to IFN-α-2b, and co-administration may also include natural or synthetic fragments, isoforms and consonant forms of interferon-alpha. In addition, interferon-alpha, other interferons, including interferon-beta and its natural and synthetic fragments, isoforms and consonant forms, are also relevant. While we specifically considered interferon, cytokines and chemokines including IL-2, IL-12 and TNF are also relevant in addition to interferon. In particular, we have contemplated that the pegylated forms of the interferons under consideration (i.e., the interferons combined with polyethylene glycol) are suitable for use in connection with the teachings presented herein.

Kombinacija obravnavanih spojin z drugo spojino, ki veže virusni protein ali citokinA combination of the compounds under consideration with another compound that binds a viral protein or cytokine

Kjer se pri antivirusni terapiji uporablja kombinacija obravnavanih spojin z drugimi farmakološko aktivnimi sredstvi, smo posebno upoštevali, da takšne kombinacije lahko obsegajo obravnavane spojine z direktnim ali indirektni antivirusnim učinkom in drugo spojino, ki zveča celotni antivirusni učinek (celotni antivirusni učinek vključuje direktni antivirusni učinek in indirektni antivirusni učinek), pri čemer druga spojina specifično veže virusni protein ali citokin.Where combination of the compounds under consideration with other pharmacologically active agents is used in antiviral therapy, particular consideration is given to the fact that such combinations may include the compounds considered to have a direct or indirect antiviral effect and another compound that increases the overall antiviral effect (the total antiviral effect includes a direct antiviral effect and indirect antiviral effect), wherein the second compound specifically binds the viral protein or cytokine.

Glede obravnavanih spojin v kombinaciji, imajo prednost analogi nukleozidov, celo bolj zaželeno je, da je nukleozid Ribavirin (l-(5-deoksi-3-D-ribofuranozil)-1,2,4triazol-3-karboksamid). Za Ribavirin je znano, da ima direktni antivirusni učinek pri zaviranju virusne replikacije RNK in DNK [Huffman et al., Antimicrob. Agents Chemother (1973), 3: 235; Sidwell et al., Science (1972), 177:705) in indirektni antivirusni učinek pri supresiji od celic T posredovanih odgovorov tipa 2 in pri promoviranju od celic T posredovanih odgovorov tipa 1, kot je opisano v U.S. PatentniWith respect to the compounds considered in combination, nucleoside analogues are preferred, even more preferably, the nucleoside is Ribavirin (1- (5-deoxy-3-D-ribofuranosyl) -1,2,4triazole-3-carboxamide). Ribavirin is known to have a direct antiviral effect in inhibiting viral replication of RNA and DNA [Huffman et al., Antimicrob. Agents Chemother (1973), 3: 235; Sidwell et al., Science (1972), 177: 705) and indirect antiviral effect in suppression of type 2 T-cell-mediated responses and in promotion of type-1 T-mediated responses, as described in U.S. Pat. Patent

-3030 prijavi številka 09/156,646, ki je kot referenca vključena tukaj. Vendar pa smo obravnavali razen Ribavirina tudi druge spojine, med katerimi so vključeni zlasti analogi L-nukleozidov, dokler imajo takšne alternativne spojine direktni in indirektni antivirusni učinek. Na primer, kjer želimo posebno visoko koncentracijo analoga Lnukieozida, lahko uporabimo Levovirin™-3030 report number 09 / 156,646, which is incorporated herein by reference. However, in addition to Ribavirin, we have also considered other compounds, which include, in particular, L-nucleoside analogues, as long as such alternative compounds have direct and indirect antiviral effects. For example, where a particularly high concentration of the Lnukieoside analogue is desired, Levovirin ™ may be used

Dalje je treba upoštevati, da ima lahko, v odvisnosti od kemijske narave prve spojine, prva spojina izrazitejši direktni antivirusni učinek ali izrazitejši indirektni antivirusni učinek. Obravnavani direktni antivirusni učinki vključujejo zaviranje virusne replikacije, na primer, zaviranje reverzne transkriptaze, medtem ko obravnavani antivirusni učinki vključujejo pomik ravnovesja tipal/tip 2 proti odgovoru tipa 1 ali tipa 2, kot je opisano v U.S. Patentni prijavi številka 09/156,646. Treba je upoštevati tudi, da indirektni antivirusni učinek lahko obsega supresijo odgovora tipa 1 in tipa 2, kar je podrobneje opisano v U.S. Začasni patentni prijavi številka 60/172,097 (zgoraj). Pomik ravnovesja tipa 1/tip 2 proti odgovoru tipa 1 ali tipa 2 ali supresijo odgovora tip 1/tip 2 lahko uspešno nadzorujemo s prvo spojino, pri čemer odmerjanje prve spojine določa pomik ali supresijo odgovora tipa 1 ali tipa 2.It should further be noted that, depending on the chemical nature of the first compound, the first compound may have a more pronounced direct antiviral effect or a more pronounced indirect antiviral effect. The direct antiviral effects discussed include inhibition of viral replication, for example, inhibition of reverse transcriptase, while the antiviral effects considered include a shift of the tip / type 2 balance toward the type 1 or type 2 response as described in U.S. Pat. Patent Application No. 09 / 156,646. It should also be borne in mind that the indirect antiviral effect may comprise suppression of type 1 and type 2 responses, which is described in more detail in U.S. Pat. Provisional Patent Application No. 60 / 172,097 (supra). The displacement of the type 1 / type 2 equilibrium toward the type 1 or type 2 response or the suppression of the type 1 / type 2 response can be successfully controlled by the first compound, wherein the dosage of the first compound determines the displacement or suppression of the type 1 or type 2 response.

Glede druge spojine, je prednost v tem, da druga spojina obsega protitelo (t.j. monoklonsko ali poliklonsko telo). Vendar pa je treba upoštevati, da po alternativnih vidikih predmeta izuma ni potrebno, da se protitelo omejuje na naravno pojavljajočo se obliko protitelesa temveč vključuje lahko tudi sintetično obliko protitelesa (na primer mini protitelesa, dobljena s presejanjem fagov ali druge tehnologije molekulske evolucije) ali fragmente protiteles. Posebno so ustrezni fragmenti protiteles, kjer takšne fragmente proizvajajo rekombinantne celice ali kjer mora biti molekulska masa druge spojine sorazmerno nizka (t.j. pod 75 kDa). Obravnavani fragmenti protiteles vključujejo Fab, F(ab)₂ in scFab. Razen tega smo predvideli, da ustrezna protitelesa lahko modificiramo, da bi uvedli razne dodatne lastnosti, vključno z reportersko skupino, drugim afinitetnim deležem (na primer bispecifično protitelo) ali farmakološko aktivno molekulo. Na primer, reporterska skupina lahko vključuje radioizotop aliWith respect to the second compound, the advantage is that the second compound comprises an antibody (i.e., a monoclonal or polyclonal body). However, it should be borne in mind that according to alternative aspects of the invention, the antibody need not be limited to the naturally occurring form of the antibody, but may also include a synthetic form of the antibody (for example, mini antibodies obtained by phage screening or other molecular evolution technology) or fragments antibodies. Particularly suitable are antibody fragments where such fragments are produced by recombinant cells or where the molecular weight of the other compound must be relatively low (ie below 75 kDa). The antibody fragments considered include Fab, F (ab) ₂ and scFab. In addition, it has been contemplated that suitable antibodies can be modified to introduce various additional properties, including a reporter group, another affinity moiety (such as a bispecific antibody), or a pharmacologically active molecule. For example, a reporter group may include a radioisotope or

-3131 kovino, ki jo lahko tn vivo detektiramo s skanirajočimi pripravami (na primer slikanje z magnetno resonanco). Obravnavane farmakološko aktivne molekule lahko obsegajo reverzne zaviralce transkriptaze, zaviralce proteaze ali citotoksična sredstva. Proizvodnja rekombinantnih ali nerekombinantnih protiteles je dobro poznana v stroki (naprimer glej Current Protocols in Immunology: John Wiley & Sons (1999);-Edited by: John E. Coligan, Ada M.Kruisbeek David H.Margulies, Ethan M Shevach, Warren Strober), upoštevamo pa, da so vsi poznani postopki za njihovo produkcijo primerni za uporabo s pouki, predstavljenimi tukaj. Protitelesa tipično dajemo z vbrizganjem (na primer i.v. vbrizganje), dejanski odmerek pa se tipično giblje med 0,01 mg in več 10 mg, vendar pa so predvideni tudi nižji odmerki tam, kjer je to ustrezno.-3131 metal that can be detected tn vivo by scanning devices (for example, magnetic resonance imaging). The pharmacologically active molecules under consideration may comprise reverse transcriptase inhibitors, protease inhibitors, or cytotoxic agents. The production of recombinant or non-recombinant antibodies is well known in the art (for example, see Current Protocols in Immunology: John Wiley & Sons (1999); - Edited by: John E. Coligan, Ada M.Kruisbeek, David H.Margulies, Ethan M Shevach, Warren Strober ), but note that all known production processes are suitable for use with the lessons presented here. Typically, antibodies are administered by injection (for example i.v. injection), and the actual dose typically ranges from 0.01 mg to more than 10 mg, but lower doses are also provided where appropriate.

Dalje je treba upoštevati, da je vezava druge spojine na virusni protein ali citokin posebno prednostna, kjer vezava vodi k inaktivaciji virusnega proteina in/ali citokina, ocenjujemo pa, da inaktivacija lahko poteka prek raznih mehanizmov. Na primer, inaktivacijo virusa lahko dosežemo z obarjanjem, posredovanim od protitelesa (t.j. tvorba molekulskega omrežja med protitelesi in virusi). Alternativno, vezava druge spojine lahko inaktivira virus z blokiranjem ali drugačno obstrukcijo proteinov ali drugih virusnih površinskih struktur, ki so bistvene za infektivnost ali razmnoževanje virusov. Še nadalje, vezava druge spojine se lahko dogaja z nestruktumimi virusnimi proteini, vključno z virusnimi polimerazami in proteazami. Na primer obravnavana vezna sredstva (t.j. hapteni) vključujejo proteine kot gpl20/41 virusa HIV, toda tudi proteine kot reverzno transkriptazo virusa HIV. Dalje predvideni virusni proteini vključujejo proteine iz virusa HIV, virusa hepatitisa, virusa influence in virusa RSV. Glede citokinov ocenjujemo, da inaktivacijo lahko dosežemo z izločitvijo citokina iz zbiralnika citokinov. Na primer, ko je hapten za obravnavane druge spojine citokin tipa 1, posebno upoštevani citokini vključujejo interleukin-2, interferon gama in tumorje nekrotizirajoči faktor-beta, medtem ko v primerih, ko je hapten za drugo spojino citoksin tipa 2, posebno upoštevani citokini vključujejo interleukin-4, interleukin-5 in interleukin 10.It should further be appreciated that the binding of another compound to a viral protein or cytokine is particularly preferred, where binding leads to inactivation of the viral protein and / or cytokine, and it is appreciated that inactivation can be via various mechanisms. For example, virus inactivation can be achieved by antibody-mediated precipitation (i.e., the formation of a molecular network between antibodies and viruses). Alternatively, the binding of another compound may inactivate the virus by blocking or otherwise obstructing proteins or other viral surface structures that are essential for the infectivity or propagation of the viruses. Furthermore, the binding of another compound may occur with non-structural viral proteins, including viral polymerases and proteases. For example, the binders discussed (i.e., haptens) include proteins as HIV gpl20 / 41, but also proteins as HIV reverse transcriptase. Further predicted viral proteins include proteins from HIV, hepatitis, influenza, and RSV. With regard to cytokines, we estimate that inactivation can be achieved by eliminating the cytokine from the cytokine pool. For example, when the hapten for the other cytokine type 1 compounds considered, the cytokines specifically considered include interleukin-2, interferon gamma and tumors necrotizing factor-beta, whereas in the case of the hapten for the other cytokine type 2 compound, the cytokines specifically considered include interleukin-4, interleukin-5, and interleukin 10.

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Na splošno se ocenjuje, da ima inaktivacija virusa ali citokina s pomočjo druge spojine lahko več želenih učinkov, ki lahko izkazujejo ali pa ne izkazujejo dodatnega ali sinergističnega učinka v kombinaciji s prvo spojino. Na primer, predvideno je, da v primerih, kjer ima prva spojina direktni antivirusni učinek (iz česar izhaja pomembno zmanjšanje virusnega titra), druga spojina lahko celo še nadalje zmanjša virusni titer z obarjanjem preostalih virusov. Alternativno lahko druga spojina znižuje število infekcionznih virusnih delcev z vezavo na virusne komponente, ki so bistvene za infektivnost. Dalje opažamo, da, kjer druga spojina veže citokin, lahko druga spojina pomakne ravnovesje tipa 1/tip 2 proti odgovoru tipa 1 z zaplembo enega ali več citokinov tipa 2 iz zbiralnika citokinov, s čimer pa pomaga pri obnovi celične imunosti, medtem ko se že znatno zmanjša virusno breme. Pri drugem primeru opažamo, da, ko ima prva spojina indirektni antivirusni učinek (iz česar izhaja tudi znatno znižanje virusnega titra), lahko druga spojina še nadalje zmanjša virusni titer z obarjanjem preostalih virusov. Alternativno, enega ali več citokinov tipa 1 in/ali tipa 2 lahko zapleni druga spojina ali zmes drugih spojin, pri čemer “fino uglašuje” (t.j. modulira) odgovor tipa 1 ali tipa 2, ki ga povzroča prva spojina.It is generally appreciated that inactivation of a virus or cytokine by a second compound may have several desired effects that may or may not have an additional or synergistic effect in combination with the first compound. For example, it is contemplated that in cases where the first compound has a direct antiviral effect (resulting in a significant reduction in viral titre), the second compound may even further decrease viral titer by precipitating the remaining viruses. Alternatively, the second compound may reduce the number of infectious viral particles by binding to viral components essential for infectivity. We further observe that where another compound binds a cytokine, the second compound can shift the type 1 / type 2 balance toward the type 1 response by confiscating one or more type 2 cytokines from the cytokine pool, thereby helping to restore cellular immunity while already significantly reduces viral load. In the second example, it is observed that when the first compound has an indirect antiviral effect (which also results in a significant decrease in viral titer), the second compound can further reduce viral titer by precipitating the remaining viruses. Alternatively, one or more type 1 and / or type 2 cytokines may be confined to another compound or a mixture of other compounds, with a "fine-tuning" (i.e., modulating) type 1 or type 2 response caused by the first compound.

Upoštevati je treba, da bo kombinacija prve spojine, ki ima direkten in indirekten antivirusni učinek z drugo spojino, ki specifično veže virus in/ali citokin, znižala virusni titer ne samo z mehanističnim (t.j. encimskim zaviranjem), toda tudi s sistemskim (t.j. stimulacijo/modulacijo imunosti) dejanjem. Posebno je predvideno, da prednostni antivirusni sestavek zdravil vključuje prvo in drugo spojino, ki imata sinergistični učinek, ki bo ugodno pomagal pri zmanjšanju učinkovitega odmerka prve in druge spojine. Še nadalje je predvideno, da se ustrezni antivirusni sestavki zdravil lahko uporabljajo tudi pri profilaktičnem zdravljenju. -3333It should be borne in mind that the combination of the first compound having a direct and indirect antiviral effect with the second virus- and / or cytokine-binding compound will lower the viral titer not only by mechanistic (ie enzymatic inhibition) but also by systemic (ie, stimulation) / modulation of immunity) by action. It is specifically contemplated that the preferred antiviral drug composition comprises a first and a second compound having a synergistic effect which will advantageously help reduce the effective dose of the first and second compound. It is further contemplated that suitable antiviral drug compositions may also be used in prophylactic treatment. -3333

Kombinacija obravnavanih spojin z RibavirinomCombination of the compounds under consideration with Ribavirin

Posebno upoštevamo, da bo dajanje Levovirina™ skupaj z Ribavirinom zmanjšalo škodljive stranske učinke in izboljšalo toleranco za Ribavirin in/ali Levovirin™. Z ozirom na razmerje med Ribavirinom in Levovirinom™ pri skupnem dajanju, je zaželeno, da je Levovirin™ prisoten v vsaj ekvimolami količini Ribavirina. Vendar pa je treba upoštevati, da so tudi razna alternativna razmeija ustrezna, posamezno razmerje pa bo pretežno odvisno od želenega učinka in odmerjanja/poti dajanja. Na primer, kjer je skrb namenjena zlasti hemolitični anemiji, je Levovirin™ lahko prisoten pri skupnem dajanju v območju od okoli 51 mol% do okoli 80 mol% ali več. Po drugi strani, kjer je toleranca na Levovirin omejujoča, je Levovirin lahko prisoten pri skupnem dajanju v količini v območju od okoli 49 mol% do okoli 20 mol % ali manj.In particular, administration of Levovirin ™ together with Ribavirin will reduce adverse side effects and improve tolerance to Ribavirin and / or Levovirin ™. In view of the ratio of Ribavirin to Levovirin ™ co-administered, it is desirable that Levovirin ™ be present in at least equimolar amounts of Ribavirin. However, it should be borne in mind that various alternative conditions are also appropriate, and the individual relationship will largely depend on the desired effect and the dosage / route of administration. For example, where hemolytic anemia is of particular concern, Levovirin ™ may be present in co-administration in the range of about 51 mol% to about 80 mol% or more. On the other hand, where tolerance to Levovirin is limiting, Levovirin may be present when co-administered in an amount in the range of about 49 mol% to about 20 mol% or less.

Upoštevati je treba dalje, da ni potrebno, da bi dajanje Ribavirina skupaj z Levovirinom™ uporabljalo isto pot dajanja. Izraz “skupno dajanje”, kot ga uporabljamo tukaj, se nanaša na katerokoli obliko dajanja Ribavirina in Levovirina™, tako da sta Ribavirin in Levovirin™ prisotna v merljivi količini v sistemu ob istem času. Zaradi tega obravnavano skupno dajanje vključuje protokole, pri katerih Ribavirin dajemo po eni poti, Levovirin™ pa dajemo po drugi poti, pri čemer skupno dajanje lahko izvedemo hkrati ali ob dveh različnih časovnih točkah. Na primer, Ribavirin lahko dajemo oralno, medtem ko Levovirin™ lahko vbrizgamo intravenozno. Pri drugem primeru, Ribavirin lahko dajemo oralno BID, Levovirin™ pa lahko dajemo oralno QID.It should also be noted that Ribavirin administration with Levovirin ™ does not need to use the same route of administration. The term "co-administration" as used herein refers to any form of administration of Ribavirin and Levovirin ™ such that Ribavirin and Levovirin ™ are present in a measurable amount in the system at the same time. For this reason, the co-administered administration involves protocols in which Ribavirin is administered one route and Levovirin ™ is administered the other route, whereby co-administration can be performed simultaneously or at two different time points. For example, Ribavirin can be given orally, while Levovirin ™ can be given intravenously. In the second case, Ribavirin can be given oral BID, and Levovirin ™ can be given oral QID.

Posebno smo predvideli, da s spreminjanjem molame frakcije Ribavirina in Levovirina™ v protokolu skupnega dajanja, lahko posebno želene biološke učinke krojimo glede na specifične potrebe bolnika, vključno z modulacijo citokinskega ravnovesja tipa 1/tip 2, z direktnim antivirusnim učinkom, redukcijo hematotoksičnih lastnosti itd.We specifically envisaged that by modifying the molar fraction of Ribavirin and Levovirin ™ in the co-administration protocol, specific biological effects could be tailored to the specific needs of the patient, including modulation of type 1 / type 2 cytokine balance, direct antiviral activity, reduction of haematotoxic properties, etc. .

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Pri še enem vidiku predmeta izuma smo predvideli, da bo dajanje ali skupno dajanje Ribavirina in Levovirina™ vključevalo kontinuirno izločanje in/ali zmanjšano odmerjanje v presledkih, ki so pogostejši. Predvideli smo zlasti, da bo kontinuirno izločanje in/ali zmanjšanje odmerjanja v pogostih presledkih zmanjšalo neželene stranske učinke in bo lahko zvečalo direktni ali indirektni antivirusni učinek. Medtem ko je na splošno predvideno, da spojine po predmetu izuma lahko dajemo kateremukoli sistemu, je zaželeno, da obravnavane spojine dajemo sesalcem, prednostno človeku ali celici ali tkivni kulturi.In another aspect of the invention, it is contemplated that administration or co-administration of Ribavirin and Levovirin ™ will involve continuous elimination and / or reduced dosage at more frequent intervals. In particular, we predicted that continuous elimination and / or dose reduction at regular intervals will reduce adverse side effects and may increase direct or indirect antiviral effects. While it is generally contemplated that the compounds of the invention may be administered to any system, it is desirable to administer the compounds in question to a mammal, preferably to a human or cell or tissue culture.

Metaboliti obravnavanih spojinMetabolites of the compounds under consideration

Običajno upoštevamo, da je Levovirin™ metabolično inerten, ko ga dajemo sistemu, vendar pa so izumitelji opazili tudi, da ima Levovirin™ lahko metabolite, ki so prikazani v strukturah od 4 do 8.Usually, Levovirin ™ is metabolically inert when administered to the system, but the inventors have also observed that Levovirin ™ may have metabolites that are shown in structures 4 to 8.

OCOCH₃ OCOCH ₃

Struktura 7Structure 7

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Struktura 4 je triazol karboksamid, struktura 5 je triazol karboksilna kislina, struktura 6 je L-ribofiiranozil triazol karboksamid, struktura 7 je 5'-acetil L-ribofuranozil triazol karboksamid in struktura 8 je 5'-acetil-a- L- ribofuranozil triazol karboksamid.Structure 4 is triazole carboxamide, structure 5 is triazole carboxylic acid, structure 6 is L-ribofironosyl triazole carboxamide, structure 7 is 5'-acetyl L-ribofuranosyl triazole carboxamide and structure 8 is 5'-acetyl-α-L-ribofuranosyl triazole carboxamide .

Medtem ko običajno predvidevamo, da se metabolični produkti Levovirina™ tvorijo kot produkt encimatske reakcije, se je treba tudi zavedati, da se pod ustreznimi pogoji znotraj ali izven celice v celičnem sistemu lahko tvorijo metaboliti brez encimatske reakcije. Tako lahko tvorba metabolitov iz Levovirina™ vključuje redoks reakcije (posebno oksidacijo), encimatsko katalizirane reakcije (na primer hidrolizo) in fotokemijsko reakcijo.While it is generally assumed that Levovirin ™ metabolic products are formed as a product of an enzymatic reaction, it should also be borne in mind that metabolites without enzymatic reaction can be formed under appropriate conditions inside or outside the cell in the cellular system. Thus, the formation of metabolites from Levovirin ™ may include redox reactions (especially oxidation), enzymatically catalyzed reactions (such as hydrolysis), and a photochemical reaction.

Obravnavani reakcijski produkti so tipično razkrojni produkti Levovirina™, vendar pa moramo vedeti, da metaboliti lahko vključujejo tudi produkte, nastale z adicijo kemijskih skupin (na primer glikozilacija ali acetilacija) in da so tako modificirane spojine lahko predmet nadaljnjega razkroja v istem ali različnem predelku. Medtem ko na splošno ocenjujemo, da imajo metaboliti znatno zmanjšan farmakološki učinek v primerjavi z Levovirinom™ ,je treba upoštevati, da imajo metaboliti lahko podoben farmakološki učinek kot Levovirin™. Na primer, delež triazola ali riboze lahko služi kot učinkovalec (effector) (na primer alosterični inhibitor).The reaction products under consideration are typically degradation products of Levovirin ™, but it should be noted that metabolites may also include products formed by the addition of chemical groups (for example glycosylation or acetylation) and that the modified compounds may be further degraded in the same or different compartment. While it is generally estimated that metabolites have a significantly reduced pharmacological effect compared to Levovirin ™, it should be borne in mind that metabolites may have a similar pharmacological effect to Levovirin ™. For example, a proportion of triazole or ribose may serve as an effector (for example, an allosteric inhibitor).

Nadalje ocenjujemo, da od posebnega odmerka Levovirina™, ki ga dajemo sistemu, se v nemetabolizirani obliki izloči med 20 % in 50 %, preferenčno med 51 %in 75 %, bolj preferenčno med 76 % in 99 % in najbolj preferenčno 100 %.We further estimate that from the specific dose of Levovirin ™ administered to the system, between 20% and 50%, preferably between 51% and 75%, more preferably between 76% and 99%, and most preferably 100%, are eliminated in non-metabolized form.

PrimeriExamples

Ciliana jetrna imunosupresija z uporabo RibavirinaCiliana liver immunosuppression using Ribavirin

Izvedli smo tri proučevanja Ribavirina pri zdravljenju kroničnega hepatitisa C, nadzorovana s placebom. Ta proučevanja so vključevala 134 osebe, zdravljene zWe conducted three studies of Ribavirin in the treatment of chronic placebo-controlled hepatitis C. These studies included 134 subjects treated with

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Ribavirinom in 97 oseb, ki so dobivale placebo. Bila sta tudi dva nekontrolirana proučevanja faze II, ki so vključevala vsega skupaj 23 bolnikov, zdravljenih z Ribavirinom. Glavni parameter odgovora je bila normalizacija ali znižanje nivojev ALT v serumu. Odgovor smo ocenili tudi z ozirom na eliminacijo ali znižanje nivojev HCV RNA v serumu in izboljšanje jetrne histologije, kot je bilo ugotovljeno glede na spremembe Knodellovih števil točk.Ribavirin and 97 placebo recipients. There were also two uncontrolled Phase II studies involving a total of 23 patients treated with Ribavirin. The main parameter of the response was the normalization or reduction of serum ALT levels. We also evaluated the response with respect to the elimination or reduction of serum HCV RNA levels and improvement in liver histology, as determined by changes in Knodell score.

Pri vseh kontroliranih in nekontroliranih proučevanjih, uporabljajoč definicijo odgovora, podrobno obrazloženo v protokolih in analiznih načrtih, je bil Ribavirin statistično značilno boljši od placeba pri normaliziranju in znižanju nivojev ALT med zdravljenjem. Pri integriranih analizah, temelječih na vseh bolnikih pri kontroliranih proučevanjih, z uporabo enotne definicije odgovora vključno z normalizacijo ALT na koncu zdravljenja ali klinično značilnim nivojem delnega dogovora, je 46 % Ribavirinovih bolnikov odgovorilo v primerjavi s 4 % placebo-bolnikov (p<0,001). Bolniki so običajno odgovorili po dveh do treh mesecih zdravljenja, odgovor pa se je ohranjal tako dolgo, dokler se je zdravljenje nadaljevalo. Ni bilo nobenega dokaza izgube odgovora ALT s povečanjem trajanja zdravljenja. Po umiku Ribavirina na koncu aktivne faze zdravljenja je 11,5 % bolnikov z odgovorom imelo trajni odgovor skozi kontrolno obdobje po zdravljenju.In all controlled and uncontrolled studies, using the answer definition detailed in protocols and analysis plans, Ribavirin was statistically significantly superior to placebo in normalizing and reducing ALT levels during treatment. In integrated analyzes based on all patients in controlled trials, using a single response definition including ALT normalization at the end of treatment or clinically significant level of partial agreement, 46% of Ribavirin patients responded compared with 4% of placebo patients (p <0.001) . Patients usually responded after two to three months of treatment, and the response was maintained for as long as treatment continued. There was no evidence of loss of ALT response by increasing treatment duration. Following withdrawal of Ribavirin at the end of the active phase of treatment, 11.5% of patients with a response had a sustained response throughout the post-treatment control period.

Glede izboljšanja jetrne histologije je bil pri vseh kontroliranih proučevanjih neznačilen trend v korist Ribavirina pri spremembah celotnega Knodellovega števila točk in mnogih števil točk komponent. Analiza kombiniranih podatkov z analizo kovariance, uporabljajoč Knodellovo število točk referenčnega nivoja kot kovariat, je dala statistično značilne razlike v korist Ribavirina za celotno število točk in vSakega od števil točk komponent. Tako ima Ribavirin pri kotrolnih proučevanjih, ob primerjanju vseh bolnikov zdravljenih z Ribavirinom s prejemniki placeba, skromen toda dejanski učinek na izboljšanje jetrne histologije. Znotraj Ribavirinove skupine je primerjava med bolniki z odgovorm ALT in bolniki brez odgovora ALT razkrila, da so bolniki z odgovorom ALT doživeli značilno večje izboljšanje jetrne histologije v primerjavi zRegarding the improvement in liver histology, in all controlled studies, there was a non-significant trend in favor of Ribavirin in changes in the total Knodell score and many component scores. Combined data analysis with covariance analysis using Knodell's reference level score as a covariate gave statistically significant differences in favor of Ribavirin for the total score and in each of the item scores. Thus, when compared to all patients treated with Ribavirin with placebo recipients, Ribavirin has a modest but effective effect on improving liver histology when compared with all patients treated with Ribavirin. Within the Ribavirin group, a comparison between patients with ALT response and patients without ALT response revealed that patients with ALT response experienced significantly greater improvement in hepatic histology compared to

-3737 bolniki brez odgovora ALT. Poprečni padec celotnega Knodellovega števila točk je bil približno dve točki za bolnike z odgovorom ALT v primerjavi z eno točko za vse bolnike, zdravljene z Ribavirinom. Padec Knodellovih rezultatov za dve točki hepatologi običajno ocenjujejo kot klinično značilnega. Tako je obstajala statistično značilna korelacija med odgovorom ALT in klinično značilno stopnjo izboljšanja jetrne histologije.-3737 patients without ALT response. The average drop in total Knodell score was approximately two points for patients with ALT response compared to one point for all patients treated with Ribavirin. The decline in Knodell scores by two points is usually considered clinically significant by hepatologists. Thus, there was a statistically significant correlation between ALT response and clinically significant improvement in liver histology.

Pri vseh proučevanjih je bila glavna končna točka definirana kot znižanje nivoja ALT. Pri vseh proučevanjih je bil popoln odgovor ALT definiran kot normalizacija ALTnivoja na koncu zdravljenja. Delni odgovor ALT je bil definiran kot bodisi 50 % ali večje znižanje na koncu zdravljenja od vrednosti bolnikovega referenčnega nivoja ali 50 % ali večje znižanje do nivoja, ne višjega od 1,5 kratne zgornje meje normalnega.In all studies, the main endpoint was defined as a decrease in ALT levels. In all studies, a complete ALT response was defined as normalization of ALTnivo at the end of treatment. A partial ALT response was defined as either a 50% or greater reduction at the end of treatment from the patient's reference level or a 50% or greater reduction to a level no higher than 1.5 times the upper limit of normal.

Pri proučevanjih 92-001 in 91-DK-178, smo obdelane skupine primerjali z ozirom na učinek študijskega zdravljenja na simptome, pomembne za hepatitis. Tega nismo mogli izvesti pri študiju CT00/002, ker obrazec za bolnikov izvid ni dovolil sistematičnega zbiranja simptomskih podatkov.In Studies 92-001 and 91-DK-178, the treated groups were compared with respect to the effect of study treatment on symptoms relevant to hepatitis. We were not able to perform this in study CT00 / 002 because the patient report form did not allow the systematic collection of symptomatic data.

Pri proučevanju 92-001 je obstajala statistično značilna razlika v korist Ribavirina za upadanje preobremenitve. Na koncu obdelave in na koncu kontrolnega obdobja po obdelavi je večji delež Ribavirinovih pacientov pokazal nekaj izboljšanja od referenčnega nivoja preobremenitve v primerjavi s placebo-pacienti (p=0,04 za konec obdelave in p=0,006 za konec kontrolnega obdobja po obdelavi). Pri tem proučevanju ni bilo pomembne razlike med obdelanimi skupinami pri kateremkoli drugem simptomu.In the 92-001 study, there was a statistically significant difference in Ribavirin's benefit in reducing congestion. At the end of the treatment and at the end of the post-treatment control period, a higher proportion of Ribavirin patients showed some improvement from the reference level of congestion compared to placebo patients (p = 0.04 for the end of treatment and p = 0.006 for the end of the post-treatment control period). In this study, there was no significant difference between the treatment groups for any other symptom.

Pri proučevanju 91-DK-178 so se pojavile izolirane značilne razlike med obdelanimi skupinami pri individualnih simptomih na individualnih vizitah, pri čemer so nekatere bile v prid placebo-skupini in nekatere v prid Ribavirinovi skupini, ni pa bilo nobenih celotnih trendov, ki bi bili v prid eni od obeh obdelanih skupin.Study 91-DK-178 showed isolated significant differences between treatment groups in individual symptoms on individual visits, with some favoring the placebo group and some favoring the Ribavirin group, but no overall trends that would in favor of one of the two treated groups.

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Tabela 1 prikazuje hitrosti odgovorov z ozirom na izboljšanje jetrne histologije. Ni bilo nobene statistično značilne razlike med obdelanimi skupinami in spremembami Knodellovih rezultatov, čeprav so bili numerični trendi v prid Ribavirina. Pri študiji CTO0/002 je bila razlika v korist Ribavirina pri enem od sekundarnih parametrov (limfoidni agregati, p=0,05).Table 1 shows the response rates with respect to improvement in liver histology. There was no statistically significant difference between the treated groups and changes in Knodell results, although the numerical trends were in favor of Ribavirin. In the CTO0 / 002 study, the difference in Ribavirin's benefit was in one of the secondary parameters (lymphoid aggregates, p = 0.05).

Protokol Protocol Protokolna definicija odgovora Protocol response definition Definicija odgovora po analiznem planu Definition of the answer according to the analysis plan Rezultat The result 92-001 92-001 Primerjava obdelanih skupin z ozirom na spremembe pred obdelavo in po njej pri vsaki Knodellovi uvrstitvi bolnika Comparison of treatment groups with respect to pre- and post-treatment changes at each Knodell patient rank Isto The same Ni pomembne razlike med obdelanimi skupinami There is no significant difference between the treated groups 91-DK-178 91-DK-178 Dolgororočni odgovor: Izboljšanje jetrne histopatologije s “slepo razvrstitvijo jetrnih biopsij za stopnjo tekoče jetrne poškodbe z uporabo Wilcoxonovega testa z vsoto rangov Long-term answer: Improvement in hepatic histopathology by 'blind classification of hepatic biopsies for the degree of fluid hepatic injury using the Wilcoxon rank sum test Primerjava obdelanih skupin z ozirom na spremembe pred obdelavo in po njej pri vsaki Knodellovi uvrstitvi bolnika Comparison of treatment groups with respect to pre- and post-treatment changes at each Knodell patient rank Ni pomembne razlike med obdelanimi skupinami There is no significant difference between the treated groups CT00/002 CT00 / 002 Izboljšanje pri stopnji vnetne aktivnosti pred obdelavo in po njej kot ocenjeno po Knodellovih rezultatih Improvement in the level of inflammatory activity before and after treatment as assessed by Knodell results Primerjava obdelanih skupin z ozirom na spremembe nastale pred obdelavo in po njej pri vsaki Knodellovi uvrstitvi bolnika Spremembe pred obdelavo in po njej pri drugih histoloških parametrih, za katere ocenjujemo, da so pomembni za hepatitis C Comparison of treated groups with respect to changes occurring before and after each treatment Knodell's patient rankings Changes before and after treatment for other histological parameters for which are estimated to be relevant for hepatitis C Ni pomembne razlike med obdelanimi skupinami There is no significant difference between the treated groups Zmanjšanje limfoidnih agregatov v skupini Ribavirina Reduction of lymphoid aggregates in the group Ribavirina

Tabela 1 : Primerjava rezultatov kontroliranih proučevanj- Jetrna histologijaTable 1: Comparison of the results of controlled studies- Liver histology

Nadaljnje analize smo izdelali z ozirom na različna proučevanja. Vendar pa smo z namenom povečanja pomembnosti rezultatov podatke iz kontrolnih proučevanj kombinirali, da bi bila velikost vzorca večja.Further analyzes were made with respect to different studies. However, in order to increase the significance of the results, we combined the data from the control studies to increase the sample size.

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Rezultati integriranih analizResults of integrated analyzes

Analiza odgovora na Ribavirin po kriteriih primerne učinkovitosti - Odgovor ALT med terapijo z RibavirinomResponse analysis of Ribavirin according to the Efficacy Criteria - ALT response during Ribavirin therapy

Za namene integriranih analiz učinkovitosti smo uporabljali naslednje definicije ALTodgovora:For the purposes of integrated performance analyzes, we used the following ALT answer definitions:

popolni odgovor: povratek v normalno območje na koncu obdelave.full answer: return to normal area at the end of processing.

parcialni odgovor: 50 % ali večje znižanje iz bolnikovega referenčnega nivoja na ne več kot 1,5 kratno zgornjo mejo normalnega na koncu obdelave.partial response: 50% or greater reduction from the patient's reference level to no more than 1.5 times the upper limit of normal at the end of treatment.

bolnik z odgovorom: ustreza zgornjim definicijam bodisi popolnega ali parcialnega odgovora. Definicija “bolnika z odgovorom” je bila določena z grafičnim prikazom ALT vrednosti proti času, ki ga je vsaka skupina uporabila za prilagajanje raznim definicijam odgovorov v vsaki študiji. (Podatki so bili prilagojeni z uporabo kubičnega zlepka kot gladilne funkcije Reinish 1967). Uporabili smo tri definicije odgovora:patient with answer: fits the above definitions of either full or partial answer. The definition of “answer patient” was determined by graphically displaying the ALT values against the time each group used to adjust to the different answer definitions in each study. (Data were adjusted using a cubic spline as a smoothing function of Reinish 1967). We used three definitions of the answer:

a. Popoln odgovor = ALT v normalnem območju na koncu obdelave.a. Complete answer = ALT in the normal range at the end of processing.

b. Parcialni odgovor (A) = 50 % ali večje znižanje od bolnikovega referenčnega nivoja, nivo znotraj 1,5 kratne zgornje meje normalnega na koncu obdelave.b. Partial response (A) = 50% or greater reduction from the patient's reference level, a level within 1.5 times the upper limit of normal at the end of treatment.

c. Parcialni odgovor (B) = 50 % ali večje znižanje od bolnikovega referenčnega nivoja na koncu obdelave.c. Partial response (B) = 50% or greater reduction from the patient's reference level at the end of treatment.

Vse ostale paciente smo ocenili kot brez odgovora. Izdelali smo grafične prikaze tudi za bolnike brez odgovora, obdelane z Ribavirinom, v vsaki študiji in za vse placebobolnike (z odgovorom in brez odgovora) v vsaki študiji.All other patients were evaluated as unanswered. We also produced graphical representations for the unanswered patients treated with Ribavirin in each study, and for all placebo patients (with and without answer) in each study.

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Tri krivulje za “popoln odgovor” so pokazale, da smo ta odgovor dobili po približno eni tretjini časa obdelave, ohranil pa se je tudi za tem. Tri krivulje za “parcialni odgovor (A)” so pokazale podobni vzorec odgovora. Tri krivulje za “parcialni odgovor (B)” so razločno pokazale večjo spremenljivost nivojev ALT med potekom obdelave. Grafični prikazi za bolnike brez odgovora, obdelanih z Ribavirinom in grafični prikazi za placebo-bolnike so pokazali, kot pričakovano, raztros podatkovnih točk, ki se ni spremenil v kakršenkoli razpoznavni vzorec skozi obdelavo in v časih kontrolnih preiskav. Odločili smo se, da je bila definicija “parcialni odgovor (B)” neprimerna za namen integriranih analiz učinkovitosti. Zaradi doslednega vzorca odgovora, ki ga kažeta definiciji “popolni odgovor” in “parcialni odgovor (A)” in dejstva, da sta ti definicij klinično značilni, smo sklenili, da za namen integrirane analize učinkovitosti “odgovor” definiramo bodisi kot “popolni odgovor” ali “parcialni odgovor (A)”.Three curves for the “perfect answer” indicated that we received this answer after about one-third of the processing time, and remained there after that. The three curves for “partial response (A)” showed a similar pattern of response. The three “partial response (B)” curves clearly showed greater variability in ALT levels during the course of processing. Graphics for unanswered patients treated with Ribavirin and graphs for placebo patients showed, as expected, a scatter of data points that did not change into any identifiable pattern through the treatment and at the time of controls. We decided that the definition of "partial answer (B)" was inappropriate for the purpose of integrated performance analyzes. Due to the consistent response pattern shown by the definitions of “complete answer” and “partial answer (A)” and the fact that these definitions are clinically significant, we have decided to define either “answer” for the purpose of integrated efficacy analysis or as “complete answer”. or "partial answer (A)".

Tabela 2 prikazuje rezultate za vsako študijo in za kombinirane baze podatkov z uporabo zgornje definicije odgovora ALT. Delež bolnikov z odgovorom pri obeh skupinah v obdelavi smo primerjali bodisi z uporabo χ-kvadrata ali Fisherjevega ekzaktnega testa.Table 2 shows the results for each study and for the combined databases using the ALT response definition above. The proportion of patients with a response in both treatment groups was compared either using the χ-square or Fisher's exact test.

Študija Study Ribavirin n/N (%) Ribavirin n / N (%) Placebo n/N (%) Placebo n / n (%) p vrednost p value 92-001 92-001 15/28 (53,6) 15/28 (53.6) 1/30 (3,3) 1/30 (3.3) <0,001 <0.001 91-DK-178 91-DK-178 11/29 (37,9) 11/29 (37,9) 1/29 (3,4) 1/29 (3.4) <0,001 <0.001 CT00/002 CT00 / 002 32/70 (45,7) 32/70 (45,7) 2/36 (5,6) 2/36 (5,6) <0,001 <0.001 Kombinirana podatkovna baza Combined database 58/127 (45,7) 58/127 (45.7) 4,95 (4,2) 4.95 (4.2) <0,001 <0.001 N = število bolnikov z odgovorom ALT (integrirana definicija) N= vsi obdelani pacienti (populacija namenjena za obdelavo) razen tistih brez veljavnih nemanjkajočih opazovanj. N = number of patients with ALT response (integrated definition) N = all treated patients (population intended for treatment) except those without valid non-existent observations.

Tabela 2: Odstotek razmerij odgovora ALT.Table 2: Percentage of ALT response ratios.

Za identifikacijo vrednosti ALT, ki ustrezajo koncu obdelave, smo zadnja veljavna nemanjkajoča opazovanja, maksimalno dve viziti nazaj, nadaljevali pri tistih pacientih, ki so pogrešali takšno resnično vrednost. Isto politiko smo uporabili pri dveh od treh kontroliranih študij (91-DK-178 on CT00/002 ). Devet pacientov v Ribavirinovi skupiniIn order to identify ALT values corresponding to the end of treatment, the last valid non-existent observation, a maximum of two back visits, was continued in those patients who missed such true value. We applied the same policy to two of the three controlled studies (91-DK-178 on CT00 / 002). Nine patients in the Ribavirin group

-4141 in dva placebo-pacienta ni imelo takšnega uporabnega veljavnega nemanjkajočega opazovanja. Razmerja odgovorov ALT so bila konsistentna prek treh kontroliranih študij in so se gibala od 37,9 do 53,6 %. Ko smo podatke kombinirali, je bilo razmerje odgovora ALT 45,7%. V vseh primerih so bila razmerja odgovorov ALT pri bolnikih, obdelanih z Ribavirinom statistično značilno boljša od razmerij pri bolnikih, obdelanih s placebom. V placebo-skupini so bila razmerja odgovorov ALT dosledno nizka in so se gibala od 3,3 do 5,6 % in so bila 4,2 %, ko smo podatke kombinirali.-4141 and two placebo patients did not have such a useful valid non-observational observation. The ALT response rates were consistent across the three controlled studies and ranged from 37.9 to 53.6%. When we combined the data, the ALT response rate was 45.7%. In all cases, the ALT response rates in the Ribavirin treated patients were statistically significantly better than those in the placebo treated patients. In the placebo group, the ALT response ratios were consistently low, ranging from 3.3 to 5.6% and 4.2% when combined.

Odgovori ALT pri kontroli bolnikov po zdravljenjuALT responses in post-treatment patient control

Tabela 3 prikazuje povzetek razmerij trajnih odgovorov v študijah 92-001 in 91-DK178 in v teh dveh kombiniranih študijah. Uporabili smo posamezno študijo in analizno plansko definicijo trajnega odgovora. Trajni bolnik z odgovorom je v bistvu bolnik bodisi z normalizacijo ALT ali s parcialnim odgovorom na koncu obdelave, ki še ustreza obem tem kriterijem skozi kontrolo po zdravljenju. Ni bilo mogoče zagotoviti isto analizo za študijo CT00/002, ker je premalo pacientov imelo popolne podatke skozi čas preiskav po zdravljenju.Table 3 provides a summary of the ratios of sustained responses in Studies 92-001 and 91-DK178 and in these two combined studies. We used a single study and an analysis plan definition of a durable response. A durable patient with an answer is essentially a patient either with ALT normalization or a partial end-of-treatment response that still meets both of these criteria through post-treatment control. The same analysis could not be provided for study CT00 / 002 because too few patients had complete data throughout the post-treatment examinations.

Študija Study Ribavirin n/N (%) Ribavirin n / N (%) Placebo n/N (%) Placebo n / n (%) 92-001 92-001 1/15 (6,7) 1/15 (6,7) 0/1 (0,0) 0/1 (0,0) 91-DK-178 91-DK-178 2/11(18,2) 2/11 (18,2) 0/1 (0,0) 0/1 (0,0) Kombinirana podatkovna baza Combined database 3/26(11,5) 3/26 (11,5) 0/2 (0,0) 0/2 (0,0)

n = število bolnikov s trajnim odgovorom ALT N = število pacientov s popolnim ali parcialnim odgovorom na koncu obdelave (definicije analiznega plana študije)n = number of patients with a permanent ALT response N = number of patients with a complete or partial response at the end of the treatment (study plan definition)

Tabela 3: Odstotek razmerij trajnih odgovorov ALT - Definicije protokolaTable 3: Percentage of ALT Permanent Response Ratios - Protocol Definitions

V dveh analiziranih študijah sta bila razmeija trajnega odgovora 6,7 % in 18,2 % za bolnike, zdravljene z Ribavirinom v primeijavi z 0 % za bolnike, ki so dobili placebo. Zaradi majhne velikosti vzorca in zelo nizkega števila placebo-bolnikov z odgovorom nismo izvedli statistične analize.In the two studies analyzed, the sustained response rates were 6.7% and 18.2% for patients treated with Ribavirin compared with 0% for patients receiving placebo. Due to the small sample size and the very low number of placebo-responders, no statistical analysis was performed.

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Izboljšanje Knodellovih rezultatovImproving Knodell results

V vsaki od treh kontroliranih študij je bil stanoviten numerični trend v korist Ribavirina pri spremembah celotnih točk in točk komponent. Isti trend se je tako pojavil, ko smo podatke iz vseh treh študij kombinirali. Trend velja ne samo za izboljšanje števila točk ampak tudi za poslabšanje, kar kaže, da, dasi se nobeni bolniki v obeh obdelanih skupinah niso izboljšali, se tedaj manjše število pacientov v Ribavirinovi skupini slabša. To je važno opažanje, če upoštevamo, da je eden od ciljev obdelave preprečiti poslabšanje nekega kroničnega in napredujočega stanja. Analiza kombiniranih podatkov s CMH χ-kvadrat testom ne pokaže nobene statistično značilne razlike. Analiza kombiniranih podatkov z analizo variance (kot se uporablja v študijah 92-001 in 91DK-178) je pokazala statistično značilno razliko v korist Ribavirina za celotno Knodellovo število točk ne pa za kateregakoli od števil točk komponent.In each of the three controlled studies, there was a consistent numerical trend in favor of Ribavirin in changes in the total and component points. The same trend emerged when the data from all three studies were combined. The trend applies not only to the improvement in the number of points, but also to the worsening, which indicates that, although no patients in both treatment groups improved, then the smaller number of patients in the Ribavirin group worsened. This is an important observation, considering that one of the goals of processing is to prevent the worsening of some chronic and progressive condition. Analysis of the combined data with the CMH χ-square test shows no statistically significant difference. Combined data analysis with variance analysis (as used in Studies 92-001 and 91DK-178) showed a statistically significant difference in favor of Ribavirin for the total Knodell score but not for any of the component scores.

Jetrne histološke podatke smo dalje preiskali z analizo kovariance z uporabo Knodellovega števila točk referenčnega nivoja kot kovariat. Regresijska analiza Knodellovega števila točk referenčnega nivoja proti številu točk na koncu obdelave za vse kombinirane paciente, zdravljene z Ribavirinom in placebo-paciente, je dala nagib manj od 1,0 toda večji kot nič. To je pokazalo, daje Knodellovo število točk vplivalo na pričakovanje izida obdelave, neglede na katerokoli razliko med Ribavirinom in placebom. Kjer se regresijski nagib izrazito razlikuje od 1,0, je analiza kovariance primernejši test od analize variance (Fisher 1951). Rezultat analize kovariance je prikazan v Tabeli 4. Poprečne spremembe števila točk za paciente, zdravljene z Ribavirinom, so samo majhne zaradi majhnih varianc, razlike iz placeba so statistično značilne. Zanimivo je opomniti, da je edino Knodellovo podštevilo točlg ki se ne izboljša, fibroza in da je manj poslabšanja pri Ribavirinovi skupini kot pri placeboskupini.Liver histologic data were further investigated by analysis of covariance using Knodell's reference-point count as a covariate. A Knodell regression analysis of the reference-level score against the end-of-treatment score for all Ribavirin-treated and placebo-treated combination patients gave a slope of less than 1.0 but greater than zero. This showed that Knodell score influenced the expectation of the treatment outcome, regardless of any difference between Ribavirin and placebo. Where regression slope differs markedly from 1.0, covariance analysis is a more appropriate test than variance analysis (Fisher 1951). The result of the covariance analysis is shown in Table 4. Cross-sectional changes in the number of points for Ribavirin-treated patients are only small due to small variance, and the differences from placebo are statistically significant. It is interesting to note that the only Knodell subheading that does not improve is fibrosis and there is less worsening in the Ribavirin group than in the placebo group.

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Poprečna sprememba števila točk od referenčnega nivoja do konca obdelave Transverse change in the number of points from the reference level to the end of processing Knodellova komponenta Knodell component Ribavirin N= 107 Ribavirin N = 107 Placebo N = 78 p- vrednost Placebo N = 78 p- value Periportalna aktivnost in nekroza -0,40 Periportal activity and necrosis -0.40 -0,01 -0.01 0,0004 0,0004 Portalno vnetje Portal inflammation -0,30 -0,30 -0,10 -0.10 0,0206 0,0206 Lobulama nekroza Necrosis lobules -0,33 -0.33 -0,13 -0.13 0,0019 · 0.0019 · Fibroza Fibrosis +0,07 +0.07 +0,25 +0.25 0,0071 0,0071 Totalno število točk Total points -1,11 -1.11 -0,05 -0.05 0,0091 0,0091

Tabela 4: Primerjava Ribavirina in placeba z ozirom na spremembe Knodellovega števila točk od referenčnega nivoja do konca obdelave - Analiza kovariance z uporabo Knodellovega števila točk referenčnega nivoja kot kovariat. Vse faze III študij kombinirane.Table 4: Comparison of Ribavirin and placebo with respect to changes in Knodell number of points from the reference level to the end of processing - Analysis of covariance using Knodell number of points of reference level as a covariate. All Phase III studies combined.

Preiskava korelacije med odgovorom ALT in izboljšanjem Knodellovega števila točkInvestigation of the correlation between ALT response and Knodell score improvement

Pri vseh treh kontroliranih študijah je bil Ribavirin značilno bolj učinkovit kot placebo pri normalizaciji in znižanju nivojev ALT (zvišan nivo ALT-e v serumu je biokemični indikator vnetja jeter). Obstajala je tudi korelacija med odgovorom na terapijo z Ribavirinom z ozirom na normalizacijo ali redukcijo nivojev ALT v posameznem pacientu in z izboljšanjem jetrne histologije, kot so pokazala Knodellova števila točk. Ugotovili smo, da je bil resnično stalen trend proti pozitivnemu razmerju med odgovorom ALT in izboljšanjem Knodellovih števil točk, ko sta oba parametra obdelana na kategoričen način. Pri kombinirani podatkovni bazi je bil trend stastistično značilen za celotno Knodellovo število točk (p = 0,008), fibrozo (p = 0,014) in Portalno vnetje (p = 0,022) z uporabo Cochran-Mantel-Haenszel (CMH) χ-kvadrat testa (tabela 5 -7).In all three controlled studies, Ribavirin was significantly more effective than placebo in normalizing and reducing ALT levels (elevated serum ALT is a biochemical indicator of liver inflammation). There was also a correlation between the response to Ribavirin therapy with respect to the normalization or reduction of ALT levels in the individual patient and with improvement in liver histology, as indicated by Knodell score. We found that there was indeed a steady trend toward a positive relationship between the ALT response and the improvement in Knodell point numbers when both parameters were processed in a categorical manner. For the combined database, the trend was statistically significant for Knodell's total score (p = 0.008), fibrosis (p = 0.014), and portal inflammation (p = 0.022) using the Cochran-Mantel-Haenszel (CMH) χ-squared test (Table 5 -7).

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Bolnik z ogovorom Patient with a speech Bolnik brez odgovora Patient unanswered Protokol Protocol Odgovor The answer n n % % n n % % P-vrednost' P-value ' 92-001 92-001 Izboljšan Improved 7 7 46,7 46,7 4 4 33,3 33,3 0,099 0,099 Nespremenjen Unchanged 7 7 46,7 46,7 3 3 25,0 25,0 Poslabšan Poor 1 1 6,7 6,7 5 5 41,7 41,7 91-DK- 91-DK- Izboljšan Improved 10 10 90,9 90,9 7 7 38,9 38,9 0,021 * 0.021 * 178 178 Nespremenjen Unchanged 1 1 9,1 9.1 5 5 27,8 27.8 Poslabšan Poor 0 0 0,00 0.00 6 6 33,3 33,3 CT00/002 CT00 / 002 Izboljšan Improved 11 11 42,3 42.3 12 12 48,0 48,0 0,171 0,171 Nespremenjen Unchanged 11 11 42,3 42.3 5 5 20,0 20,0 Poslabšan Poor 4 4 15,4 15.4 8 8 32,0 32,0 Integrirano Integrated Izboljšan Improved 28 28 53,8 53,8 23 23 41,8 41,8 0,008 * 0.008 * Nespremenjen Unchanged 19 19 36,5 36,5 13 13 23,6 23.6 Poslabšan Poor 5 5 9,6 9.6 19 19 34,5 34.5

N = Število bolnikov v študiji n = število bolnikov v kategoriji bolnikov z odgovorni % = (n/N)* 100 ' CMH statistika * p<0,05N = Number of patients in the study n = Number of patients in the category of patients with responsible% = (n / N) * 100 'CMH statistics * p <0.05

Tabela 5: Status Knodellovega odgovora iz kontroliranih študij - Celota iz odgovora ALTTable 5: Knodell response status from controlled studies - Total from ALT response

Bolnik z odgovorom Patient with answer Bolnik brez odgovora Patient unanswered Protokol Protocol Odgovor The answer n n % % n n % % P-vrednost' P-value ' 92-001 92-001 Izboljšan Improved 2 2 13,3 13.3 1 1 0,00 0.00 0,434 0,434 th most common Nespremenjen Unchanged 12 12 80,0 80,0 11 11 91,7 91,7 Poslabšan Poor 1 1 6,7 6,7 1 1 8,3 8.3 91-DK-178 91-DK-178 Izboljšan Improved 5 5 45,5 45.5 2 2 u,i in, and 0,119 0,119 Nespremenjen Unchanged 4 4 36,4 36,4 11 11 61,1 61,1 Poslabšan Poor 2 2 18,2 18,2 5 5 27,8 27.8 CT00/002 CT00 / 002 Izboljšan Improved 6 6 23,1 23.1 1 1 4,0 4.0 0,120 0,120 th most common Nespremenjen Unchanged 18 18 69,2 69,2 20 20 80,0 80,0 Poslabšan Poor 2 2 7,7 7.7 4 4 16,0 16.0 Integrirano Integrated Izboljšan Improved 13 13 25,0 25,0 3 3 5,5 5.5 0,014 * 0.014 * Nespremenjen Unchanged 34 34 65,4 65,4 42 42 76,4 76,4 Poslabšan Poor 5 5 9,6 9.6 10 10 18,2 18,2 N = število pacientov v študiji N = number of patients in the study n= : n =: število pacientov v number of patients in kategoriji odgovora %= answer category% = (n/N)* 100 ' CMH (n / N) * 100 'CMH statistika *P<0,05 statistics * P <0.05

Tabela 6: Knodellov odgovor iz kontroliranih študij - Fibroza iz odgovora ALTTable 6: Knodell response from controlled studies - Fibrosis from ALT response

-4545-4545

Bolnik z odgovorom Patient with answer Bolnik brez odgovora Patient unanswered Protokol Protocol Odgovor The answer n n % % n n % % P-vrednost' P-value ' 92-001 92-001 Izboljšan Improved 5 5 33,3 33,3 3 3 25,0 25,0 0,220 0.220 Nespremenjen Unchanged 9 9 60,0 60.0 5 5 41,7 41,7 Poslabšan Poor 1 1 6,7 6,7 4 4 33,0 33,0 91-DK-178 91-DK-178 Izboljšan Improved 5 5 45,5 45.5 4 4 22,2 22,2 0,227 0.227 Nespremenjen Unchanged 6 6 54,5 54.5 11 11 61,1 61,1 Poslabšan Poor 0 0 0,00 0.00 3 3 16,7 16.7 CT00/002 CT00 / 002 Izboljšan Improved 5 5 19,2 19,2 6 6 24,0 24,0 0,159 0.159 Nespremenjen Unchanged 21 21 80,8 80.8 16 16 64,0 64,0 Poslabšan Poor 0 0 0,00 0.00 3 3 12 12 Integrirano Integrated Izboljšan Improved 15 15 28,8 28,8 13 13 23,6 23.6 0,022 * 0.022 * Nespremenjen Unchanged 36 36 69,2 69,2 32 32 58,2 58,2 Poslabšan Poor 1 1 1,9 1.9 10 10 18,2 18,2

N = število pacientov v študiji n = število pacientov v kategoriji odgovora %= (n/N)* 100 ' CMH statistika *P<0,05N = number of patients in the study n = number of patients in the response category% = (n / N) * 100 'CMH statistics * P <0.05

Tabela 7: Status Knodellovega odgovora iz kontroliranih študij - Portalno vnetje iz odgovora ALT.Table 7: Knodell response status from controlled studies - Portal inflammation from ALT response.

Zvezo med odgovorom ALT in izboljšanjem jetrne histologije smo proučevali dalje, da bi lahko kvantificirali izboljšanje jetrne histologije pri bolnikih, ki so se odzivali na Ribavirin in da bi ugotovili, ali je obstajala podskupina bolnikov, ki potegnejo znatno več klinične koristi iz zdravljenja z Ribavirinom. V vseh treh kontroliranih študijah smo primerjali bolnike z odgovorom zdravljene z Ribavirinom in bolnike brez odgovora z ozirom na poprečne spremembe celotnih Knodellovih števil točk skozi potek obdelave. Ta analiza, prikazana v tabeli 8, tako kvantificira usmeritvene spremembe, prikazane v tabeli 5.The relationship between ALT response and improvement in hepatic histology was further studied to quantify improvement in hepatic histology in patients responding to Ribavirin and to determine whether there was a subset of patients pulling significantly more clinical benefit from Ribavirin treatment. In all three controlled studies, patients were compared with the response treated with Ribavirin and the patients without response with respect to transverse changes in the total Knodell score across the course of treatment. This analysis, shown in Table 8, thus quantifies the orientation changes shown in Table 5.

Lahko vidimo, da je pri vsaki študiji obstajala korelacija med odgovorom ALT in izboljšanjem jetrne histologije, pri čemer smo povezali odgovor ALT ~z večjim izboljšanjem jetrne histologije v primerjavi z bolniki brez odgovora ALT. Ta učinek je bil posebno osupljiv pri študiji 91-DK-178, kjer je bilo zmanjšanje poprečnega Knodellovega števila točk za 4,09 pri bolnikih z odgovorom ALT v primerjavi z 0,17 pri bolnikih brez odgovora ALT. Uporabili smo regresijski model za preiskavo zveze med ALT-odgovorom in spremembami Knodellovega števila točk. To je pokazalo, daIt can be seen that in each study, there was a correlation between ALT response and improvement in liver histology, correlating the ALT ~ response with greater improvement in liver histology compared to patients without an ALT response. This effect was particularly striking in Study 91-DK-178, where the reduction in transverse Knodell score was 4.09 for patients with ALT response compared to 0.17 for patients without ALT response. We used a regression model to investigate the relationship between the ALT response and changes in Knodell score. It showed that

-4646 je bil odgovor ALT pri vseh treh študijah značilen napovednik izboljšanja jetrne histologije. Tako ALT normalizacija ali znižanje korelirata z izboljšanjem jetrne histologije pri pacientih s hepatitisom C, zdravljenih z Ribavirinom, pri pacientih, ki dosežejo ALT-odgovor, pa je možno, da potegnejo iz tega znatno klinično korist. Pri pacientih, zdravljenih z Ribavirinom, ki ne dosežejo ALT-odgovora, kaže, da ni nobene klinične koristi v primeijavi s pacienti, ki so dobili placebo.-4646, the ALT response in all three studies was a significant predictor of improvement in liver histology. Thus, ALT normalization or decrease correlates with improvement in liver histology in patients with hepatitis C treated with Ribavirin, and in patients achieving an ALT response, it is possible to derive significant clinical benefit from this. In patients treated with Ribavirin who do not reach the ALT response, there is no clinical benefit when compared with patients who received placebo.

Študija Study CT00/002 CT00 / 002 92-001 92-001 91-DK-178 91-DK-178 Kombinirana baza podatkov Combined database Trajanje obdelave Processing time 24 24 36 36 48 48 (tedni) (these days) Poprečna Knodellova Cross Knodell's -1,23 -1.23 -1,47 -1.47 -4,09 -4.09 -1,90 -1.90 sprememba (območje) change (area) (-7,4) (-7.4) (-8,2) (-8,2) (-9,0) (-9.0) (-9,4) (-9.4) pri bolnikih z in patients with odgovorom ALT* ALT reply * n = 26 n = 26 n = 15 n = 15 n = 11 n = 11 n = 52 n = 52 Poprečna Knodellova Cross Knodell's -0,96 -0.96 +0,58 +0.58 -0,17 -0.17 -0,36 -0.36 sprememba (Območje) change (Area) (-9,4) (-9.4) (-3,6) (-3,6) (-6,7) (-6,7) (-9,7) (-9.7) pri bolnikih brez in patients without odgovora answers n = 25 n = 25 n= 12 n = 12 n= 18 n = 18 n = 55 n = 55 P-vrednost ** P-value ** 0,004 0.004 0,0001 0,0001 0,002 0.002 0,00 0.00 Poprečna Knodellova Cross Knodell's -1,10 -1.10 -0,56 -0.56 -1,65 -1.65 -1,11 -1.11 sprememba (območje) change (area) (-9,4) (-9.4) (-8,6) (-8.6) (-9,7) (-9.7) (-9,7 (-9.7 Vsi Ribavirinovi All the Ribavirins n=51 n = 51 n = 27 n = 27 n = 29 n = 29 n= 107 n = 107 pacienti patients Poprečna Knodellova Cross Knodell's -0,09 -0.09 +0,44 +0.44 -0,52 -0.52 -0,51 -0.51 sprememba (območje) change (area) (-4,4) (-4,4) (-3,5) (-3,5) (8,4) (8,4) (-8,5) (-8.5) Vsi placebo- pacienti All placebo patients n = 23 n = 23 n = 27 n = 27 n = 27 n = 27 n = 77 n = 77 P-vrednost P-value NS NS NS NS NS NS 0,01 0.01

* ALT-odgovor je bil definiran kot normalizacija na koncu obdelave ali 50 % ali večje znižanje od referenčnega nivoja do ne več kot 1,5 kratne zgornje meje normalnega na koncu obdelave ** Regresijska analiza* ALT response was defined as normalization at the end of treatment or 50% or greater reduction from the reference level to not more than 1.5 times the upper limit of normal at the end of treatment ** Regression analysis

Tabela 8Table 8

Tako je bila, v povzetku, faza III programa na Ribavirinu pri kroničnem hepatitisu C sestavljena iz treh naključno razporejenih, dvojno slepih, s placebom kontroliranih, vzporednih skupinskih študij. Vseh 134 pacientov je bilo naključno razporejenih za prejemanje Ribavirina in 97 za prejemanje placeba. Odgovor na obdelavo je bil ocenjen z uporabo treh parametrov:Thus, in summary, phase III of the Ribavirin program for chronic hepatitis C consisted of three randomized, double-blind, placebo-controlled, parallel group studies. All 134 patients were randomly assigned to receive Ribavirin and 97 to receive placebo. The response to processing was evaluated using three parameters:

-4747-4747

1. Znižanje in normalizacija ALT-nivoja (zvišanje ALT-e je biokemijsko znmenje za vnetje jeter).1. ALT level decrease and normalization (ALT elevation is a biochemical hallmark for liver inflammation).

2. Izboljšanje jetrne histologije, kot dokazuje znižanje Knodellovega števila točk (sistem Knodellovih števil točk kvantificira stopnjo poškodbe jeter, tako da pripisuje točke raznim značilnim mikroskopskim karakteristikam in sešteje ta podštevila točk, da dobi celotno število točk)2. Improving liver histology, as evidenced by the decrease in Knodell score (Knodell's point number system quantifies the degree of liver damage by assigning points to various characteristic microscopic characteristics and summing these sub-points to obtain the total number of points)

3. Eliminacija virusa hepatitisa C iz krvi ali zmanjšanje količine prisotnih virusov.3. Elimination of hepatitis C virus from the blood or reducing the amount of viruses present.

Od 134 pacientov v fazi III študij jih je bilo 101, ki so imeli popolne podatke za ALTnivoje, Knodellova števila točk in nivoje virusov. Med 101 pacienti je 24 pacientov ustrezalo kriterijem za optimalni klinični odgovor na terapijo z Ribavirinom. Kriterji so normalizacija ali klinično značilno znižanje ALT-nivoja in znižanje celotnega Knodellovega števila točk za dve ali več točk. Za teh 24 pacientov je bil klinični odgovor dobljen brez spremljajočega znižanja nivoja virusov v krvi. Tabela 9 povzema podatke za ALT- nivoje in Knodellova števila točk za 24 odzivajočih se pacientov v primerjavi s preostalimi 77 pacienti, ki so izkazali manjše stopnje odgovorov.Of the 134 patients in Phase III studies, 101 had complete ALT data, Knodell score, and viral levels. Among 101 patients, 24 patients met the criteria for optimal clinical response to Ribavirin therapy. The criteria are normalization or a clinically significant decrease in ALT level and a decrease in total Knodell score by two or more points. For these 24 patients, a clinical response was obtained without an accompanying reduction in virus levels in the blood. Table 9 summarizes data for ALT levels and Knodell score for 24 responding patients compared to the remaining 77 patients who showed lower response rates.

Bolniki z odgovorom N=24 Patients with N = 24 response Bolniki brez odgovora N=77 Patients unanswered N = 77 Poprečni nivo ALT (območje) ALT transversal level (area) 142,5 (52-269) 142.5 (52-269) 176,0 (35-629) 176.0 (35-629) v U/L in U / L Poprečni konec obdelave ALT (območje)' Cross-cutting ALT (area) ' * 36,8 (21-62 * 36.8 (21-62 91,7 (13-286) 91.7 (13-286) U/L U / L Poprečno znižanje Knodellovega števila Transverse decrease in Knodell number 4,1 (2-9) 4.1 (2-9) 0,15 (-7 do+9) 0.15 (-7 to + 9) točk (območje) points (area) * zgornja meja ali normalno je U/L * upper limit or normal is U / L

Tabela 9Table 9

Tako so bili razgrnjene specifične izvedbe in uporabe nukleozidov, nukleotidov in njihovih analogov. Vendar pa mora biti jasno, da je za strokovnjake možno veliko več modifikacij poleg že opisanih, ne da bi se oddaljili od tukajšnjega izumiteljskegaThus, specific embodiments and uses of nucleosides, nucleotides and their analogs were revealed. However, it should be clear that much more modification is possible for professionals beyond what has already been described, without departing from the inventor herein

-4848 koncepta. Predmet izuma se zato ne sme omejiti razen v duhu priloženih zahtevkov. Poleg tega pri interpretaciji specifikacije in zahtevkov morajo biti vsi izrazi interpretirani na po možnosti najširši način v skladu s kontekstom. Zlasti izraza “obsega” in “ki obsega” se morata interpretirati tako, kot da se nanašata na elemente, komponente ali stopnje na neizključujoč način, s čimer pokažeta, da so elementi, komponente ali stopnje z navedenimi viri lahko prisotni ali se lahko uporabljajo ali kombinirajo z drugimi elementi, komponentami ali stopnjami, za katere niso izrecno navedeni viri.-4848 concepts. The object of the invention should therefore not be limited except in the spirit of the appended claims. In addition, when interpreting specifications and claims, all terms should be interpreted as broadly as possible in the context. In particular, the terms "scope" and "scope" must be interpreted as referring to the elements, components or stages in a non-exclusive manner, indicating that the elements, components or stages with those resources may be present or may be used or combine with other elements, components or grades for which no sources are explicitly stated.

Claims (54)

PATENTNI ZAHTEVKIPATENT APPLICATIONS 1. Spojina, ki ima strukturo kjer R predstavlja PO3², (PCh^³' ali (PCbfi⁴.A compound having the structure wherein R represents PO ^{3 2} , (PCh ^ ³ 'or (PCbfi ⁴ . 2. Spojina, ki ima strukturo2. A compound having a structure 3. Spojina, ki ima strukturo3. A compound having a structure -5050 kjer je W -N(Ri)(R2) ali =NRi, kjer sta Ri in R2 neodvisno vodik, ravni alkil, razvejani alkil, alkenil, alkinil, aralkil, aralkenil, aralkinil ali aril.-5050 where W is -N (R 1) (R 2) or = NR 1, wherein R 1 and R 2 are independently hydrogen, straight alkyl, branched alkyl, alkenyl, alkynyl, aralkyl, aralkenyl, aralkynyl or aryl. 4. Spojina po zahtevku 3, v kateri Ri ali R2 neodvisno dalje obsegata dušikov atom, kisikov atom, žveplov atom ali halogenov atom.The compound of claim 3, wherein R 1 or R 2 independently further comprise a nitrogen atom, an oxygen atom, a sulfur atom or a halogen atom. 5. Uporaba spojine po zahtevku 1, zahtevku 2, zahtevku 3 ali zahtevku 4 za izdelavo zdravila za zdravljenje virusne infekcije pri bolniku, ki obsega dajanje zdravila v takšnem odmerjanju, ki je učinkovito pri zaviranju razmnoževanja virusov.Use of a compound according to claim 1, claim 2, claim 3 or claim 4 for the manufacture of a medicament for treating a viral infection in a patient, comprising administering the medicament in such a dosage as is effective in inhibiting the propagation of the viruses. 6. Uporaba po zahtevku 5, pri kateri se odmerjanje giblje med 50 in 500 mg/dan.Use according to claim 5, wherein the dosage is between 50 and 500 mg / day. 7. Uporaba po zahtevku 5, pri kateri se odmerjanje giblje med 500 in 2500 mg/dan.Use according to claim 5, wherein the dosage is between 500 and 2500 mg / day. 8. Uporaba po zahtevku 5, pri kateri izberemo virusno infekcijo iz skupine, ki jo sestavljajo infekcija s HIV, infekcija s HCV, infekcija s HBV, infekcija s RSV, infekcija z virusom influence in infekcija z virusom parainfluence.Use according to claim 5, wherein the viral infection is selected from the group consisting of HIV infection, HCV infection, HBV infection, RSV infection, influenza virus infection and parainfluenza virus infection. 9. Uporaba po zahtevku 5, ki dalje obsega skupno dajanje citokina bolniku.The use of claim 5, further comprising co-administering the cytokine to the patient. 10. Uporaba po zahtevku 9, pri kateri je citokin interferon.Use according to claim 9, wherein the cytokine is interferon. 11. Uporaba po zahtevku 10, pri kateri je interferon interferon alfa-2b.The use of claim 10, wherein the interferon is interferon alfa-2b. 12. Uporaba po zahtevku 5, ki dalje obsega dajanje Ribavirina.The use of claim 5, further comprising administering Ribavirin. 13. Spojina po zahtevku 1, v kateri je R PO3²'.The compound of claim 1, wherein R is PO ^{3 2} '. -5151-5151 14. Uporaba spojine po zahtevku 13 pri izdelavi zdravila za zdravljenje virusne infekcije pri bolniku, ki obsega dajanje zdravila v odmerjanju, ki je učinkovito pri zaviranju razmnoževanja virusov.Use of a compound according to claim 13 in the manufacture of a medicament for treating a viral infection in a patient, comprising administering the medicament in a dosage that is effective in inhibiting the propagation of the viruses. 15. Spojina po zahtevku 1, kjer je R (PCh)2³’.The compound of claim 1, wherein R (PCh) is 2 ³ '. 16. Uporaba spojine po zahtevku 15 pri izdelavi zdravila za zdravljenje virusne infekcije pri bolniku, ki obsega dajanje zdravila v odmerjanju, ki je učinkovito pri zaviranju razmnoževanja virusov.The use of a compound according to claim 15 in the manufacture of a medicament for treating a viral infection in a patient, comprising administering the medicament in a dosage that is effective in inhibiting the propagation of the viruses. 17. Spojina po zahtevku 1, kjer je R (POs)/'.The compound of claim 1, wherein R (POs) / '. 18. Uporaba spojine po zahtevku 17 pri izdelavi zdravila za zdravljenje virusne infekcije pri bolniku, ki obsega dajanje zdravila v odmerjanju, ki je učinkovito pri zaviranju razmnoževanja virusov.Use of a compound according to claim 17 in the manufacture of a medicament for treating a viral infection in a patient, comprising administering the drug in a dosage effective in inhibiting the propagation of viruses. 19. Postopek za zvečanje selektivnosti farmakološko aktivne molekule z ozirom na farmakološki učinek v tarčni celici, ki obsega:A method of increasing the selectivity of a pharmacologically active molecule with respect to a pharmacological effect in a target cell comprising: zagotovitev zdravila, pri čemer je zdravilo 1 -β-L-ribofuranozil-1,2,4-triazol-3karboksamid;providing a medicament, wherein the medicament is 1-β-L-ribofuranosyl-1,2,4-triazole-3carboxamide; modificiranje zdravila z modificirno skupino, pri čemer je modificirna skupina kovalentno vezana na zdravilo prek dušikovega atoma, in pri čemer je modificirna skupina encimatsko odstranjena iz zdravila v tarčni celici.modifying the drug with a modifying group, wherein the modifying group is covalently bound to the drug via a nitrogen atom, and wherein the modifying group is enzymatically removed from the drug in the target cell. -5252-5252 20. Postopek po zahtevku 19, pri katerem je modificima skupina =NH in pri katerem je modificirna skupina kovalentno vezana na karbonilov atom v zdravilu.20. The method of claim 19, wherein the modifying group is = NH and wherein the modifying group is covalently bonded to the carbonyl atom in the drug. 21. Postopek po zahtevku 19, pri katerem je modificima skupina -N(Ri)(R₂) ali =NRi, kjer sta Ri in R₂ neodvisno vodik, ravni alkil, razvejani alkil, alkenil, alkinil, aralkil, aralkenil, aralkinil ali aril.The method of claim 19, wherein the modifying group is -N (R 1) (R ₂ ) or = NR 1, wherein R 1 and R _{2 are} independently hydrogen, straight alkyl, branched alkyl, alkenyl, alkynyl, aralkyl, aralkenyl, aralkynyl or aryl. 22. Postopek po zahtevku 21, pri katerem Ri in R₂ dalje neodvisno obsegata dušikov atom, kisikov atom, žveplov atom ali halogenov atom.The method of claim 21, wherein R 1 and R ₂ further independently comprise a nitrogen atom, an oxygen atom, a sulfur atom or a halogen atom. 23. Uporaba spojine po zahtevku 1, zahtevku 2 ali zahtevku 3 pri izdelavi zdravila za zdravljenje obolenja, ki ga označuje vnetje bolnikovega organa, ki obsega:Use of a compound according to claim 1, claim 2 or claim 3 in the manufacture of a medicament for the treatment of a disease characterized by inflammation of a patient's organ comprising: dajanje spojine bolniku v odmerjanju, ki (a) povzroča sistemsko imunomodulacijo ne pa sistemske imunosupresije odgovorov tipa I in tipa II in ki (b) povzroča imunosupresijo odgovorov tipa I in tipa II v bolnikoven organu.administering the compound to a patient at a dose that (a) induces systemic immunomodulation but not systemic immunosuppression of type I and type II responses and which (b) causes immunosuppression of type I and type II responses in the patient's organ. 24. Uporaba po zahtevku 23, pri kateri je spojina spojina po zahtevku 1.The use of claim 23, wherein the compound is a compound of claim 1. 25. Uporaba po zahtevku 23, pri kateri je spojina spojina po zahtevku 2.The use of claim 23, wherein the compound is the compound of claim 2. 26. Uporaba po zahtevku 23, pri kateri je spojina spojina po zahtevku 3.The use of claim 23, wherein the compound is the compound of claim 3. 27. Uporaba po zahtevku 23, pri kateri so organ jetra in pri kateri so jetra inficirana z virusom.Use according to claim 23, wherein the organ is a liver and wherein the liver is infected with a virus. 28. Uporaba po zahtevku 27, pri kateri je virus virus HCV.Use according to claim 27, wherein the virus is HCV virus. 29. Postopek za in vitro stimulacijo rasti nevronov, ki obsega:29. A method for in vitro stimulation of neuronal growth, comprising: -5353 spoznavanje, da je spojina, ki ima strukturo I, učinkovita pri stimulaciji rasti nevronov in vitro znotraj danega koncentracijskega območja;-5353 recognizing that a compound having structure I is effective in stimulating neuronal growth in vitro within a given concentration range; Struktura 1 kjer je Y Ι-β-L-ribofuranozil, l-3-L-ribofuranozil-5-fosfat, Ι-β-L-ribofuranozil5-difosfat, l^-L-ribofuranozil-5-trifosfat, Ι-β-D-ribofuranozil, Ι-β-Dribofuranozil-5-fosfat, l^-D-ribofuranozil-5-difosfat ali l^-D-ribofuranozil-5trifosfat; in dovajanje spojine nevronom in vitro v danem koncentracijskem območju.Structure 1 wherein Y is Ι-β-L-ribofuranosyl, 1-3-L-ribofuranosyl-5-phosphate, Ι-β-L-ribofuranosyl 5-diphosphate, 1-L-ribofuranosyl-5-triphosphate, Ι-β- D-ribofuranosyl, N-β-Dribofuranosyl-5-phosphate, N -D-ribofuranosyl-5-diphosphate or N -D-ribofuranosyl-5-triphosphate; and administering the compound to a neuron in vitro within a given concentration range. 30 Postopek po zahtevku 29, pri katerem je spojina Ribavirin.The method of claim 29, wherein the compound is Ribavirin. 31. Postopek po zahtevku 29, pri katerem je spojina fosforiliran Ribavirin.The process of claim 29, wherein the compound is phosphorylated Ribavirin. 32. Postopek po zahtevku 29, pri katerem je spojina Ι-β-L-ribofuranozil-1,2,4triazol-3-karboksamid.The method of claim 29, wherein the compound is N-β-L-ribofuranosyl-1,2,4triazole-3-carboxamide. 33. Postopek po zahtevku 29, pri katerem je spojina fosforiliran Ι-β-L-ribofuranozil1,2,4-triazol-3-karboksamid.The method of claim 29, wherein the compound is phosphorylated N-β-L-ribofuranosyl 1,2,4-triazole-3-carboxamide. 34. Uporaba spojine po strukturi 1 pri izdelavi zdravila za stimulacijo nevronske rasti pri nevronih34. Use of a compound of structure 1 in the manufacture of a medicament for stimulating neural growth in neurons -5454 η₂ν-5454 η ₂ ν S 7S 7 N—N kjer je Υ Ι-β-L-ribofuranozil, l^-L-ribofuranozil-5-fosfat, Ι-β-L-ribofuranozil 5-difosfat, l^-L-ribofuranozil-5-trifosfat, Ι-β-D-ribofuranozil, Ι-β-Dribofuranozil-5-fosfat, l^-D-ribofuranozil-5-difosfat ali 1-3-D-ribofuranozil-5trifosfat, in kjer zdravilo dajemo kot del zdravljenja bolnikove bolezni v območju odmerjanja, ki je učinkovito pri zvišanju odgovora tipa 1 in znižanju odgovora tipa 2 pri bolniku.N-N where Υ-β-L-ribofuranosyl, 1-L-ribofuranosyl-5-phosphate, Ι-β-L-ribofuranosyl 5-diphosphate, 1-L-ribofuranosyl-5-triphosphate, Ι-β -D-ribofuranosyl, Ι-β-Dribofuranosyl-5-phosphate, 1-D-ribofuranosyl-5-diphosphate or 1-3-D-ribofuranosyl-5trifosphate, and where the drug is administered as part of the treatment of a patient's disease in the dosage range which is effective in raising the type 1 response and lowering the type 2 response in the patient. 35. Uporaba iz zahtevka 34, ki dalje obsega ciljanje na enopolne nevronske celice v nevronih.The use of claim 34, further comprising targeting single-pole neural cells in neurons. 36. Uporaba iz zahtevka 34, ki dalje obsega ciljanje na dvopolne nevronske celice v nevronih.The use of claim 34, further comprising targeting bipolar neural cells in neurons. 37. Uporaba iz zahtevka 34, pri katerem so nevroni del nevronskega tkiva, ki obsega vrsto celice, izbrano iz skupine, ki jo sestavljajo, astrocit, dendrocit, celica z mielinsko ovojnico, glia celica, enopolna nevronska celica, dvopolna neuronska celica, mnogopolna neuronska celica in receptorska celica.The use of claim 34, wherein the neurons are part of a neural tissue comprising a cell type selected from the group consisting of, astrocyte, dendrocyte, myelin envelope cell, glia cell, single-pole neural cell, two-pole neural cell, multipole neural cell and receptor cell. 38. Antivirusni sestavek zdravil, ki obsega.38. An antiviral composition of medicines comprising. prvo spojino, ki ima direktni antivirusni učinek in indirektni antivirusni učinek; inthe first compound having a direct antiviral effect and an indirect antiviral effect; and -5555 drugo spojino, ki poveča celotni antivirusni učinek, pri čemer celotni antivirusni učinek vključuje direktni antivirusni učinek in indirektni antivirusni učinek in pri čemer druga spojina specifično veže hapten, izbran iz skupine, ki sestoji iz virusnega proteina in citokina.-5555 another compound that enhances the overall antiviral effect, wherein the total antiviral effect includes direct antiviral effect and indirect antiviral effect and wherein the second compound specifically binds a hapten selected from the group consisting of viral protein and cytokine. 39. Antivirusni sestavek zdravil po zahtevku 38, v katerem prva spojina obsega analog nukleozida.The antiviral drug composition of claim 38, wherein the first compound comprises a nucleoside analog. 40. Antivirusni sestavek zdravil po zahtevku 38, v katerem je analog nukleozida Ribavirin.The antiviral drug composition of claim 38, wherein the nucleoside analogue is Ribavirin. 41. Antivirusni sestavek zdravil po zahtevku 38, po katerem je analog nukleozida 1β-L-ribofuranozil-1,2,4-triazol-3-karboksamid.The antiviral drug composition of claim 38, wherein the nucleoside analog is 1β-L-ribofuranosyl-1,2,4-triazole-3-carboxamide. 42. Antivirusni sestavek zdravil po zahtevku 38 ali po zahtevku 39, v katerem je analog nukleozida v obliki predzdravila.The antiviral drug composition of claim 38 or claim 39, wherein the nucleoside analog is in the form of a prodrug. 43. Antivirusni sestavek zdravil po zahtevku 38, pri katerem direktni antivirusni učinek obsega zaviranje virusne reprodukcije.The antiviral drug composition of claim 38, wherein the direct antiviral effect comprises inhibition of viral reproduction. 44. Antivirusni sestavek zdravil po zahtevku 38, pri katerem indirektni antivirusni učinek obsega pomik ravnovesja tipa 1/tip 2 proti odgovoru tipa I.The antiviral drug composition of claim 38, wherein the indirect antiviral effect comprises a shift of type 1 / type 2 equilibrium toward a type I response. 45. Antivirusni sestavek zdravil po zahtevku 38, pri katerem indirektni antivirusni učinek obsega supresijo odgovora tipa 1 in tipa 2.The antiviral drug composition of claim 38, wherein the indirect antiviral effect comprises suppression of type 1 and type 2 responses. 46. Antivirusni sestavek zdravil po zahtevku 38, pri katerem druga spojina obsega protitelo.The antiviral drug composition of claim 38, wherein the second compound comprises an antibody. -5656-5656 47. Antivirusni sestavek zdravil po zahtevku 46, pri katerem je protitelo izbrano iz skupine, ki sestoji iz monoklonskega protitelesa, poliklonskega protitelesa, sintetičnega protitelesa in fragmenta protitelesa.The antiviral drug composition of claim 46, wherein the antibody is selected from the group consisting of a monoclonal antibody, a polyclonal antibody, a synthetic antibody, and an antibody fragment. 48. Antivirusni sestavek zdravil po zahtevku 38, pri katerem je virusni protein protein virusa, izbranega iz skupine, ki sestoji iz virusa HIV, virusa hepatitisa, virusa influence, virusa parainfluence in virusa RSV.The antiviral drug composition of claim 38, wherein the viral protein is a protein of a virus selected from the group consisting of HIV, hepatitis, influenza, parainfluenza, and RSV. 49. Antivirusni sestavek zdravil po zahtevku 38, v katerem je virusni protein reverzna transkriptaza.The antiviral drug composition of claim 38, wherein the viral protein is reverse transcriptase. 50. Antivirusni sestavek zdravil po zahtevku 38, v katerem je citokin citokin tipa 1.The antiviral drug composition of claim 38, wherein the cytokine is a type 1 cytokine. 51. Antivirusni sestavek zdravil po zahtevku 38, pri katerem imata prva spojina in druga spojina sinergistični učinek.51. The antiviral drug composition of claim 38, wherein the first compound and the second compound have a synergistic effect. 52. Antivirusni sestavek zdravil po zahtevku 38, pri katerem se najmanj ena od prvih spojin in drugih spojin selektivno kopiči v organu.The antiviral drug composition of claim 38, wherein at least one of the first compounds and the second compounds selectively accumulates in the organ. 53. Antivirusni sestavek zdravil po zahtevku 52, pri katerem organ izberemo iz skupine, ki sestoji iz jeter in možganov.The antiviral drug composition of claim 52, wherein the organ is selected from the group consisting of liver and brain. 54. Antivirusni sestavek zdravil po zahtevku 38, v katerem je prva spojina Ribavirin in druga spojina protitelo, ki specifično veže citokin tipa 2.The antiviral drug composition of claim 38, wherein the first compound is Ribavirin and the second compound is an antibody that specifically binds type 2 cytokines.