WO2022208170A1 - The use of the splicing modulator brataplam for slowing progression of huntington's disease - Google Patents

The use of the splicing modulator brataplam for slowing progression of huntington's disease Download PDF

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WO2022208170A1
WO2022208170A1 PCT/IB2022/000176 IB2022000176W WO2022208170A1 WO 2022208170 A1 WO2022208170 A1 WO 2022208170A1 IB 2022000176 W IB2022000176 W IB 2022000176W WO 2022208170 A1 WO2022208170 A1 WO 2022208170A1
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week
once
branaplam
disease
huntington
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PCT/IB2022/000176
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French (fr)
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WO2022208170A8 (en
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Martin BEIBEL
Beth Borowsky
Jang-Ho CHA
Thomas Faller
Baltazar Gomez-Mancilla
Helen GU
Caroline GUBSER KELLER
Steven KOVACS
Marc LAISNEY
Wen Lin
Thomas Peters
Nicole RENAUD
Rajeev Sivasankaran
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Novartis Ag
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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/33—Heterocyclic compounds
    • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
    • A61K31/495—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with two or more nitrogen atoms as the only ring heteroatoms, e.g. piperazine or tetrazines
    • A61K31/50—Pyridazines; Hydrogenated pyridazines
    • A61K31/501—Pyridazines; Hydrogenated pyridazines not condensed and containing further heterocyclic rings
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P25/00—Drugs for disorders of the nervous system
    • A61P25/14—Drugs for disorders of the nervous system for treating abnormal movements, e.g. chorea, dyskinesia
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P25/00—Drugs for disorders of the nervous system
    • A61P25/28—Drugs for disorders of the nervous system for treating neurodegenerative disorders of the central nervous system, e.g. nootropic agents, cognition enhancers, drugs for treating Alzheimer's disease or other forms of dementia
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P43/00—Drugs for specific purposes, not provided for in groups A61P1/00-A61P41/00

Definitions

  • the invention relates to the use of a splicing modulator for a treatment slowing progression of Huntington’s disease.
  • Huntington’s disease (HD) is a hereditary, neurodegenerative and progressive disorder, which has a prevalence of about 5 in 100,000 worldwide. It is caused by CAG repeat expansions in the huntingtin gene (i.e. gene encoding the protein huntingtin) and it is characterized by motor, cognitive, psychiatric and functional capacity decline.
  • CAG trinucleotide repeat expansion results in a mutant huntingtin protein (mHTT), which is associated with neural dysfunction and ultimately death.
  • mHTT huntingtin protein
  • the number of CAG repeats in the HTT gene ranges from 6 to 35 in healthy individuals. Disease penetrance is seen to be reduced for individuals carrying 36 to 39 CAG repeats, however those with 40 or more CAG repeats are almost certain to develop the disease.
  • clinical diagnosis of HD is based on: - confirmed family history or positive genetic test (i.e.
  • the Total Functional Capacity (TFC) scale (e.g. in Movement Disorders, 1996, 11, 136-142) is a component of the UHDRS and ranges from 0 (fully dependent for all care) to 13 (fully independent) the level of independence of a person with HD.
  • This scale assesses functional status of a HD patient in terms of ability to work, handle household finances, manage domestic chores, perform activities of daily living, and level of care needed.
  • TFC total functional capacity
  • HD based on TFC score
  • Shoulson and Fahn stages are also described as early stage of HD (corresponding to stages 1 or 2, based on TFC score), moderate stage or mid stage HD (corresponding to stage 3, based on TFC score) and advanced stage or late stage HD (corresponding to stage 4 or 5, based on TFC score).
  • the invention relates to the use of branaplam, or a pharmaceutically acceptable salt thereof: in a treatment slowing progression of Huntington’s disease; in a treatment slowing progression of Huntington's disease by producing an inframe stop codon between exons 49 and 50 in the HTT mRNA; in the treatment of Huntington’s disease as a disease-modifying therapy; in a treatment slowing the decline of motor function associated with Huntington’s disease; in a treatment slowing cognitive decline associated with Huntington's disease; in a treatment slowing psychiatric decline associated with Huntington’s disease; in a treatment slowing the decline of functional capacity associated with Huntington’s disease; or, in a treatment slowing the progression of Huntington’s disease pathophysiology.
  • Figure 1 RNA-seq analysis of human fibroblast line treated with branaplam.
  • FC fold change.
  • RPKM Reads per kilo base per million mapped reads.
  • Figure 2.2a, 2b, 2c In vitro modulation of HTT transcript and protein.
  • Figure 3. A single, oral dose of branaplam elevates novel-exon-containing brain HTT transcript levels in the BacHD mouse model.
  • Figure 15 Mean concentration-time courses of branaplam in plasma after single dose of branaplam in healthy adults, dose-normalized to 1 mg as described in Example 1c.1
  • FIG. 16 Observed and fitted mean concentration-time course of branaplam in plasma after single dose in healthy adults, dose-normalized to 1 mg as described in Example 1c.1 (Note: The fitted dose-normalized PK profile is the mean of dose-normalized PK profiles from all dose-levels, which was obtained by averaging the dose-normalized PK for all four dose levels at each time point).
  • Figure 17 Parameter estimates of the mouse PK/PD model based on BacHD mouse.
  • Figure 18 Predicted distribution of mutant HTT protein in the brain cortex of BacHD mice after repeated oral branaplam administration (12 and 24 mg/kg, Example 1a). Symbols: Observed mHTT protein levels; Solid line: Median prediction; Grey area; prediction 90% confidence interval (each band corresponds to 10% confidence intervals with 9 bands).
  • Figure 19 Predicted distribution of mutant HTT protein in the brain striatum of BacHD mice after repeated oral branaplam administration, 12 and 24 mg/kg, Example 1a). Symbols: Observed mHTT protein levels; Solid line: Median prediction; Grey area; prediction 90% confidence interval (each band corresponds to 10% confidence intervals with 9 bands).
  • Figure 20 Timecourse of HTT protein lowering in the BacHD mouse striatum following repeat oral doses of Branaplam.
  • Figure 22 Parameter estimates of the human PK/PD model based on BacHD mouse
  • FIG. 23 Predicted branaplam plasma PK and mHTT protein decrease in brain after weekly dosing for 20 weeks in adult human subjects (70 kg) [i.e., using the compartmental pharmacokinetic model: Example 1c.3]
  • FIG. 24 Branaplam SimCYP® input pharmacokinetic parameters of the PBPK model.
  • B/P concentration ratio between blood and plasma;
  • Caco immortalized cell line of human colorectal adenocarcinoma cells;
  • CL clearance; Clint: intrinsic clearance;
  • fa fraction absorbed;
  • fu gu t fraction unbound gut;
  • HLM human liver microsomes;
  • kin influx rate constant; kinact maximal inactivation rate;
  • kout efflux rate constant;
  • logP ow partition coefficient octanokwater;
  • Peff.man efficacious permeability human;
  • pKa negative base- 10 logarithm of the acid dissociation constant;
  • PopPK population pharmacokinetics;
  • Qgut blood flow gut;
  • SAC
  • FIG. 25 Branaplam simulated versus observed branaplam pharmacokinetic parameters after a single oral dose of 210 mg in healthy volunteers (Example 1b).
  • a range; AUG: area under the curve; Cl: confidence interval; Cmax: maximum concentration; CV: coefficient of variation; Tmax: time of Cmax.
  • FIG. 26 Observed and Simcyp® PBPK model simulated branaplam plasma concentration - time profiles after a single 210 mg dose in healthy volunteers (Example 1b).
  • CSys mean predicted plasma concentration of branaplam
  • CSys Sth predicted plasma concentration of branaplam at Sth percentile
  • CSys 95th predicted plasma concentration of branaplam at 95th percentile
  • Obs observed mean plasma concentrations of branaplam (see Example 1b).
  • FIG. 27 Predicted branaplam plasma PK and mHTT protein decrease in brain after weekly dosing for 20 weeks in adult human subjects (70 kg) [i.e., using the physiologically-based pharmacokinetic model: Example 1c.4j. AUG: area under the curve; Cmax: maximum concentration; ss: steady state (predicted after 20 weeks of weekly administration).
  • SD Arithmetic Mean
  • branaplam may be an ideal candidate for a treatment slowing progression of Huntington's disease, having therapeutic advantages, such as one or more of the following: it is useful for the treatment of Huntington’s disease as a disease-modifying therapy; ii) it delays the onset of Huntington’s disease or the onset of symptoms associated with Huntington's disease; iii) it reduces the rate of decline of motor function associated with Huntington’s disease, for example, compared to placebo, for example, as assessed by using standard scales, such as clinical scales, for example the UHDRS motor assessment scale (e.g.
  • Huntington’s disease pathophysiology e.g. reducing the rate of brain (e.g. whole brain, caudate, striatum or cortex) volume loss (e.g. % from baseline volume) associated with Huntington’s disease [e.g. as assessed by MRI, e.g. by neuroimaging measures, such as in Lancet Neurol. 2013, 12 (7), 637-649)]; viii) it reduces decline in quality of life, for example as assessed by the Huntington's Disease Health-related Quality of Life questionnaire (HDQoL) (e.g.
  • HDQoL Huntington's Disease Health-related Quality of Life questionnaire
  • a favorable therapeutic profile such as a favorable safety profile or metabolic profile; for example a favorable profile in relation to off-target effects, psychiatric adverse events, toxicity (e.g. genotoxicity) or cardiovascular adverse events (e.g. blood pressure, heart rate, electrocardiography parameters)
  • Embodiment 1a Branaplam, or a pharmaceutically acceptable salt thereof, for use in a treatment slowing progression of Huntington’s disease, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
  • Embodiment 2a Branaplam, or a pharmaceutically acceptable salt thereof, for use in the treatment of Huntington’s disease as a disease-modifying therapy, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g.
  • Embodiment 3a Branaplam, or a pharmaceutically acceptable salt thereof, for use in a treatment slowing the decline of motor function associated with Huntington’s disease, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g.
  • Embodiment 4a Branaplam, or a pharmaceutically acceptable salt thereof, for use in a treatment slowing cognitive decline associated with Huntington's disease, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
  • Embodiment 5a Branaplam, or a pharmaceutically acceptable salt thereof, for use in a treatment slowing psychiatric decline associated with Huntington’s disease, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g.
  • 238 mg once a week is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
  • Embodiment 6a Branaplam, or a pharmaceutically acceptable salt thereof, for use in a treatment slowing the decline of functional capacity associated with Huntington’s disease, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
  • Embodiment 7a Branaplam, or a pharmaceutically acceptable salt thereof, for use in a treatment slowing the progression of Huntington’s disease pathophysiology [e.g. reducing the rate of brain (e.g. whole brain, caudate, striatum or cortex) volume loss (e.g. % from baseline volume) associated with Huntington’s disease (e.g. as assessed by MRI)], wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g.
  • Embodiment 8a Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 3a, wherein motor function comprises one or more selected from the group consisting of ocular motor function, dysarthria, dystonia, chorea, postural stability and gait.
  • Embodiment 9a Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 4a, wherein cognitive decline comprises decline of one or more selected from the group consisting of attention, processing speed, visuospatial processing, timing, emotion processing, memory, verbal fluency, psychomotor function, and executive function.
  • Embodiment 10a Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 5a, wherein psychiatric decline comprises one or more selected from the group consisting of apathy, anxiety, depression, obsessive compulsive behavior, suicidal thoughts, irritability and agitation.
  • Embodiment 11a Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 6a, wherein functional capacity comprises one or more selected from the group consisting of capacity to work, capacity to handle financial affairs, capacity to manage domestic chores, capacity to perform activities of daily living, and level of care needed.
  • Embodiment 12a Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 11a, wherein Huntington’s disease is genetically characterized by CAG repeat expansion of from 36 to 39 in the huntingtin gene on chromosome 4.
  • Embodiment 13a Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 11a, wherein Huntington’s disease is genetically characterized by CAG repeat expansion of from >39 in the huntingtin gene on chromosome 4.
  • Embodiment 14a Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 13a, wherein Huntington’s disease is manifest Huntington's disease.
  • Embodiment 15a Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 14a, wherein Huntington’s disease is juvenile Huntington’s disease or pediatric Huntington’s disease.
  • Embodiment 16a Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 15a, wherein Huntington’s disease is early stage of Huntington’s disease, middle stage of Huntington’s disease, or advanced stage of Huntington’s disease; in particular early stage of Huntington’s disease.
  • Embodiment 17a Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 16a, wherein Huntington’s disease is stage I of Huntington’s disease, stage II of Huntington’s disease, stage III of Huntington’s disease, stage IV of Huntington's disease or stage V of Huntington’s disease; in particular stage I of Huntington’s disease or stage II of Huntington's disease.
  • Embodiment 18a Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 13a, wherein Huntington’s disease is pre-manifest Huntington’s disease.
  • Embodiment 19a Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 18a, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered orally.
  • Embodiment 20a Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 19a, wherein branaplam, or a pharmaceutically acceptable salt thereof, is provided in the form of a pharmaceutical composition.
  • Embodiment 21a Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 19a, wherein branaplam, or a pharmaceutically acceptable salt thereof, is provided in the form of a pharmaceutical combination.
  • Embodiment 22a Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 21a, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered following gene therapy or treatment with an antisense compound.
  • Embodiment 23a Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 22a, wherein branaplam is administered in the form of branaplam hydrochloride salt.
  • Embodiment 1b A method of treatment for slowing progression of Huntington’s disease in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g.
  • 238 mg once a week is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
  • Embodiment 2b A method of treatment of Huntington's disease in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, as a disease-modifying therapy, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g.
  • Embodiment 3b A method of treatment for slowing the decline of motor function associated with Huntington’s disease in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g.
  • Embodiment 4b A method of treatment for slowing cognitive decline associated with Huntington's disease in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g.
  • 238 mg once a week is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
  • Embodiment 5b A method of treatment for slowing psychiatric decline associated with Huntington’s disease in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g.
  • 238 mg once a week is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
  • Embodiment 6b A method of treatment for slowing the decline of functional capacity associated with Huntington’s disease in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g.
  • 238 mg once a week is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
  • Embodiment 7b A method of treatment for slowing the progression of Huntington’s disease pathophysiology [e.g. reducing the rate of brain (e.g. whole brain, caudate, striatum or cortex) volume loss (e.g. % from baseline volume) associated with Huntington’s disease (e.g. as assessed by MRI)] in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g.
  • Embodiment 8b The method according to embodiment 3b, wherein motor function comprises one or more selected from the group consisting of ocular motor function, dysarthria, dystonia, chorea, postural stability and gait.
  • Embodiment 9b The method according to embodiment 4b, wherein cognitive decline comprises decline of one or more selected from the group consisting of attention, processing speed, visuospatial processing, timing, emotion processing, memory, verbal fluency, psychomotor function, and executive function.
  • Embodiment 10b The method according to embodiment 5b, wherein psychiatric decline comprises one or more selected from the group consisting of apathy, anxiety, depression, obsessive compulsive behavior, suicidal thoughts, irritability and agitation.
  • Embodiment 11b The method according to embodiment 6b, wherein functional capacity comprises one or more selected from the group consisting of capacity to work, capacity to handle financial affairs, capacity to manage domestic chores, capacity to perform activities of daily living, and level of care needed.
  • Embodiment 12b The method according to any one of embodiments 1b to 11b, wherein Huntington’s disease is genetically characterized by CAG repeat expansion of from 36 to 39 in the huntingtin gene on chromosome 4.
  • Embodiment 13b The method according to any one of embodiments 1b to 11b, wherein Huntington's disease is genetically characterized by CAG repeat expansion of from >39 in the huntingtin gene on chromosome 4.
  • Embodiment 14b The method according to any one of embodiments 1b to 13b, wherein Huntington’s disease is manifest Huntington’s disease.
  • Embodiment 15b The method according to any one of embodiments 1b to 14b, wherein Huntington’s disease is juvenile Huntington’s disease or pediatric Huntington’s disease.
  • Embodiment 16b The method according to any one of embodiments 1b to 15b, wherein Huntington’s disease is early stage of Huntington’s disease, middle stage of Huntington’s disease, or advanced stage of Huntington’s disease; in particular early stage of Huntington’s disease.
  • Embodiment 17b The method according to any one of embodiments 1b to 16b, wherein Huntington’s disease is stage I of Huntington’s disease, stage II of Huntington’s disease, stage III of Huntington’s disease, stage IV of Huntington’s disease or stage V of Huntington’s disease; in particular stage I of Huntington’s disease or stage II of Huntington’s disease.
  • Embodiment 18b The method according to any one of embodiments 1b to 13b, wherein Huntington’s disease is pre-manifest Huntington’s disease.
  • Embodiment 19b The method according to any one of embodiments 1b to 18b, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered orally.
  • Embodiment 20b The method according to any one of embodiments 1b to 19b, wherein branaplam, or a pharmaceutically acceptable salt thereof, is provided in the form of a pharmaceutical composition.
  • Embodiment 21b The method according to any one of embodiments 1b to 19b, wherein branaplam, or a pharmaceutically acceptable salt thereof, is provided in the form of a pharmaceutical combination.
  • Embodiment 22b The method according to any one of embodiments 1b to 21b, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered following gene therapy or treatment with an antisense compound.
  • Embodiment 23b The method according to any one of embodiments 1b to 22b, wherein branaplam is administered in the form of branaplam hydrochloride salt.
  • branaplam promotes the inclusion of a novel, 115-bp exon containing an in-frame stop codon (55bp from the 3' end of the novel exon) between exons 49 and 50 of the HTT mRNA thereby lowering HTT transcript and protein levels.
  • the invention relates to:
  • Embodiment 1c A method of treatment for slowing progression of Huntington’s disease in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, by producing an in-frame stop codon between exons 49 and 50 in the HTT mRNA, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g.
  • Embodiment 2c Branaplam, or a pharmaceutically acceptable salt thereof, for use in a treatment slowing progression of Huntington’s disease by producing an in-frame stop codon between exons 49 and 50 in the HTT mRNA, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g.
  • Embodiment 3c The method according to embodiment 1c, wherein wherein branaplam is administered in the form of branaplam hydrochloride salt
  • Embodiment 4c Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 2c, wherein wherein branaplam is administered in the form of branaplam hydrochloride salt.
  • Embodiment 5c A method of treatment according to embodiment 1c, the method further comprising the steps of: determining whether branaplam produced a novel-exon included HTT mRNA by: obtaining or having obtained a blood sample from the patient; and performing or having performed a PCR assay on the biological sample to determine if the patient has novel-exon included HTT mRNA.
  • Embodiment 6c A method of treatment according to embodiment 1c, the method further comprising the steps of: determining the decrease in HTT protein in the brain by determining HTT protein levels in surrogate matrices selected from CSF and peripheral blood based matrices (e.g. plasma, serum or PBMC), preferably by determining HTT protein levels in CSF; if the patient has a decrease of HTT protein of less than about 25% to 65%, such as of less than about 35% to 50%, as compared to baseline, then administering branaplam in an amount of from 25 mg to 250 mg once a week, until the patient has a decrease of HTT protein of about 25% to 65%, such as about 35% to 50%, as compared to baseline.
  • CSF CSF
  • peripheral blood based matrices e.g. plasma, serum or PBMC
  • Embodiment 7c-1 A method of treatment according to embodiment 1c, the method further comprising the steps of: determining whether branaplam produced a novel-exon included HTT mRNA by: obtaining or having obtained a blood sample from the patient; and performing or having performed a PCR assay on the biological sample to determine if the patient has novel-exon included HTT mRNA; and determining the decrease in HTT protein in the brain by determining HTT protein levels in surrogate matrices selected from CSF and peripheral blood based matrices (e.g.
  • HTT protein levels in CSF preferably by determining HTT protein levels in CSF; if the patient has a decrease of HTT protein of less than about 25% to 65%, such as of less than about 35% to 50%, as compared to baseline, then administering branaplam in an amount of from 25 mg to 250 mg once a week, until the patient has a decrease of HTT protein of about 25% to 65%, such as about 35% to 50%, as compared to baseline.
  • Embodiment 7c-2 A method of treatment according to embodiment 1c, the method further comprising the steps of: determining whether branaplam produced an in-frame stop codon between exons 49 and 50 in the HTT mRNA by: obtaining or having obtained a blood sample from the patient; and performing or having performed a PCR assay on the biological sample to determine if the patient has an in-frame stop codon between exons 49 and 50 in the HTT mRNA; and determining the decrease in HTT protein in the brain by determining HTT protein levels in surrogate matrices selected from CSF and peripheral blood based matrices (e.g.
  • HTT protein levels in CSF preferably by determining HTT protein levels in CSF; if the patient has a decrease of HTT protein of less than about 25% to 65%, such as of less than about 35% to 50%, as compared to baseline, then administering branaplam in an amount of from 25 mg to 250 mg once a week, until the patient has a decrease of HTT protein of about 25% to 65%, such as about 35% to 50%, as compared to baseline.
  • Embodiment 8c The method of embodiment 7c- 1 or embodiment 7c-2 wherein Huntington’s disease is manifest Huntington's disease.
  • Embodiment 9c The method of embodiment 7c- 1 or embodiment 7c-2 wherein Huntington’s disease is juvenile Huntington’s disease or pediatric Huntington’s disease.
  • Embodiment 10c The method of embodiment 7c- 1 or embodiment 7c-2 wherein Huntington’s disease is early stage of Huntington’s disease, middle stage of Huntington’s disease, or advanced stage of Huntington’s disease.
  • Embodiment 11c The method of embodiment 7c- 1 or embodiment 7c-2 wherein Huntington’s disease is stage I of Huntington’s disease, stage II of Huntington’s disease, stage III of Huntington's disease, stage IV of Huntington’s disease or stage V of Huntington's disease.
  • Embodiment 12c The method of embodiment 7c- 1 or embodiment 7c-2 wherein Huntington’s disease is pre-manifest Huntington’s disease.
  • Embodiment 13c The method of embodiment 7c- 1 or embodiment 7c-2 wherein branaplam is administered in the form of branaplam hydrochloride salt.
  • Embodiment 14c The method of embodiment 7c- 1 or embodiment 7c-2 wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in the form of a pharmaceutical composition.
  • Embodiment 15c The method of embodiment 7 c- 1 or embodiment 7c-2 wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered following gene therapy or treatment with an antisense compound.
  • Embodiment 15c-1 The method according to any one of embodiments 5c, 6c, 7c-1, 7c-2, 8c, 9c, 10c, 11c, 12c, 13c, 14c and 15c, wherein HTT protein is selected from the group consisting of wild type HTT protein, mutant HTT protein and total HTT protein.
  • Embodiment 15c-2 The method according to any one of embodiments 5c, 6c, 7c-1, 7c-2, 8c, 9c, 10c, 11c, 12c, 13c, 14c and 15c, wherein HTT protein is mutant HTT protein.
  • Embodiment 15c-3 Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 15c-1 or 15c-2, wherein HTT protein levels are determined in CSF.
  • Embodiment 16c Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 2c, the use further comprising the steps of: determining whether branaplam produced a novel-exon included HTT mRNA by: obtaining or having obtained a blood sample from the patient; and performing or having performed a PCR assay on the biological sample to determine if the patient has novel-exon included HTT mRNA.
  • Embodiment 17c Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 2c, the use further comprising the steps of: determining the decrease in HTT protein in the brain by determining HTT protein levels in surrogate matrices selected from CSF and peripheral blood based matrices (e.g.
  • HTT protein levels in CSF preferably by determining HTT protein levels in CSF; if the patient has a decrease of HTT protein of less than about 25% to 65%, such as of less than about 35% to 50%, as compared to baseline, then administering branaplam in an amount of from 25 mg to 250 mg once a week, until the patient has a decrease of HTT protein of about 25% to 65%, such as about 35% to 50% as compared to baseline.
  • Embodiment 18c-1 Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 2c, the use further comprising the steps of: determining whether branaplam produced a novel-exon included HTT mRNA by: obtaining or having obtained a blood sample from the patient; and performing or having performed a PCR assay on the biological sample to determine if the patient has novel-exon included HTT mRNA; and determining the decrease in HTT protein in the brain by determining HTT protein levels in surrogate matrices selected from CSF and peripheral blood based matrices (e.g.
  • HTT protein levels in CSF preferably by determining HTT protein levels in CSF; if the patient has a decrease of HTT protein of less than about 25% to 65%, such as of less than about 35% to 50%, as compared to baseline, then administering branaplam in an amount of from 25 mg to 250 mg once a week, until the patient has a decrease of HTT protein of about 25% to 65%, such as about 35% to 50%, as compared to baseline.
  • Embodiment 18c-2 Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 2c, the use further comprising the steps of: determining whether branaplam produced an in-frame stop codon between exons 49 and 50 in the HTT mRNA by: obtaining or having obtained a blood sample from the patient; and performing or having performed a PCR assay on the biological sample to determine if the patient has an in-frame stop codon between exons 49 and 50 in the HTT mRNA; and determining the decrease in HTT protein in the brain by determining HTT protein levels in surrogate matrices selected from CSF and peripheral blood based matrices (e.g.
  • HTT protein levels in CSF preferably by determining HTT protein levels in CSF; if the patient has a decrease of HTT protein of less than about 25% to 65%, such as of less than about 35% to 50%, as compared to baseline, then administering branaplam in an amount of from 25 mg to 250 mg once a week, until the patient has a decrease of HTT protein of about 25% to 65%, such as about 35% to 50%, as compared to baseline.
  • Embodiment 19c Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 18c- 1 or embodiment 18c-2 wherein Huntington’s disease is manifest Huntington’s disease.
  • Embodiment 20c Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 18c-1 or embodiment 18c-2 wherein Huntington’s disease is juvenile Huntington’s disease or pediatric Huntington’s disease.
  • Embodiment 21c Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 18c-1 or embodiment 18c- 2 wherein Huntington’s disease is early stage of Huntington’s disease, middle stage of Huntington’s disease, or advanced stage of Huntington’s disease.
  • Embodiment 22c Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 18c- 1 or embodiment 18c-2 wherein Huntington's disease is stage I of Huntington’s disease, stage II of Huntington’s disease, stage III of Huntington’s disease, stage IV of Huntington’s disease or stage V of Huntington’s disease.
  • Embodiment 23c Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 18c-1 or embodiment 18c-2 wherein Huntington’s disease is pre-manifest Huntington’s disease.
  • Embodiment 24c Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 18c- 1 or embodiment 18c-2 wherein branaplam is administered in the form of branaplam hydrochloride salt
  • Embodiment 25c Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 18c-1 or embodiment 18c-2 wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in the form of a pharmaceutical composition.
  • Embodiment 26c Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 18c-1 or embodiment 18c-2 wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered following gene therapy or treatment with an antisense compound.
  • Embodiment 27c Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment any one of embodiments 16c, 17c, 18c-1, 18c-2, 19c, 20c, 21c, 22c, 23c, 24c, 25c and 26c, wherein HTT protein is selected from the group consisting of wild type HTT protein, mutant HTT protein and total HTT protein.
  • Embodiment 28c Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment any one of embodiments 16c, 17c, 18c-1, 18c-2, 19c, 20c, 21c, 22c, 23c, 24c, 25c and 26c, wherein HTT protein is mutant HTT protein.
  • Embodiment 28c Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 27c or 28c, wherein HTT protein levels are determined in CSF. GENERAL DEFINITION OF TERMS
  • HD or “Huntington's disease”, as used herein, refers to the neurodegenerative disorder, characterized by motor, cognitive, psychiatric and functional capacity decline, and caused by GAG repeat expansions in the huntingtin gene.
  • manifest HD or “manifest Huntington’s disease”, as used herein, refers to having diagnosis of HD as clinically established ⁇ e.g. on the basis of: confirmed family history or positive genetic test (confirmation of GAG repeat expansion £6); and onset of motor disturbances [diagnostic confidence score (DCS) of 4, as defined by the Unified Huntington Rating Scale (UHDRS) total motor score (TMS)] ⁇ .
  • DCS diagnostic confidence score
  • UHDRS Unified Huntington Rating Scale
  • TMS total motor score
  • the term “manifest HD” or “manifest Huntington’s disease” refers to a patient having diagnosis of HD as clinically established ⁇ e.g.
  • pre-manifest HD or “pre-manifest Huntington’s disease” refers to having genetic diagnosis of HD ⁇ e.g. on the basis of: positive genetic test (confirmation of GAG repeat expansion ⁇ 40) ⁇ without onset of motor disturbances as clinically stablished, for example, as assessed according to standard scales, such as, clinical scales [e.g. on the basis of a diagnostic confidence score (DCS) of ⁇ 4, as defined by the Unified Huntington Rating Scale (UHDRS) total motor score (TMS)].
  • DCS diagnostic confidence score
  • UHDRS Unified Huntington Rating Scale
  • TMS Unified Huntington Rating Scale
  • pre-manifest HD or “pre-manifest Huntington’s disease”, as used herein, refers to a patient having genetic diagnosis of HD ⁇ e.g.
  • slowing progression of HD refers to, for example:
  • the term “rate of progression”, as used herein, refers, for example, to the annual rate of change (e.g. decline) or the rate of change (e.g. decline) per year, for example as assessed according to standard scales, such as clinical scales, or according to neuroimaging measures.
  • reducing refers to e.g. 5%, 10%, 20%, 30%, 40%, 50%, 60% or 70% reduction, for example, per year of treatment.
  • delay refers to delay for at least e.g. 0.5, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 or 15 years.
  • the term “slowing progression of HD”, “slowing progression of Huntington’s disease”, “to slow the progression of HD” or “to slow the progression of Huntington's disease”, as used herein, refers to delaying the onset of Huntington’s disease, e.g. increasing time for the onset of Huntington’s disease as defined herein. In another embodiment, it refers to reducing the rate of progression between stages of Huntington’s disease, for example, reducing the rate of progression from an initial stage of HD into a more advanced stage of HD, as assessed, for example, compared to placebo, according to standard scales, such as clinical scales [e.g.
  • TEC UHDRS total functional capacity
  • it refers to reducing the rate of progression from stage 1 of HD into stage 2 of HD (e.g. compared to placebo).
  • it refers to reducing the rate of progression from stage 2 of HD into stage 3 of HD (e.g. compared to placebo).
  • it refers to reducing the rate of progression from stage 3 of HD into stage 4 of HD (e.g. compared to placebo).
  • it refers to reducing the rate of progression from stage 4 of HD into stage 5 of HD (e.g. compared to placebo).
  • it refers to reducing the rate of progression from early HD into middle stage HD (e.g.
  • reducing the rate of progression refers, for example, to increasing time for progression of stage of HD (e.g. compared to placebo).
  • slowing progression of HD refers to delaying the onset of Huntington's disease (e.g. increasing time for the onset of Huntington’s disease as defined herein) by at least 25% (e.g. by 25% or more, such as from 25% to 50%).
  • onset of Huntington refers to clinical diagnosis of HD as generally established [e.g. onset of motor disturbances based on diagnostic confidence score (DCS) of 4, as defined by the Unified Huntington Rating Scale (UHDRS) total motor score (TMS)].
  • DCS diagnostic confidence score
  • UHDRS Unified Huntington Rating Scale
  • TMS total motor score
  • slowing progression of HD refers to delaying the onset of symptoms associated with Huntington's disease, e.g. increasing time for the onset of one or more symptom associated with Huntington's disease selected from decline of motor function associated with Huntington’s disease, cognitive decline associated with Huntington’s disease, psychiatric decline associated with Huntington’s disease and decline of functional capacity associated with Huntington’s disease, as defined herein.
  • it refers to reducing the rate of progression of one or more symptom associated with Huntington's disease selected from decline of motor function associated with Huntington's disease, cognitive decline associated with Huntington's disease, psychiatric decline associated with Huntington's disease and decline of functional capacity associated with Huntington’s disease, as defined herein.
  • the term “reducing the rate of, as used herein, refers, for example, to increasing time for onset or increasing time for a rise of severity (e.g. compared to placebo).
  • the term “slowing progression of HD”, “slowing progression of Huntington’s disease”, “to slow the progression of HD” or “to slow the progression of Huntington's disease”, as used herein, refers to reducing the rate of progression of pre-manifest HD into manifest HD [i.e. delaying the onset of manifest HD; e.g. compared to placebo; e.g. as assessed by a diagnostic confidence score (DCS) of 4, as defined by the Unified Huntington Rating Scale (UHDRS) total motor score (TMS)].
  • DCS diagnostic confidence score
  • UHDRS Unified Huntington Rating Scale
  • slowing progression of HD refers to slowing the progression of Huntington's disease pathophysiology.
  • slowing the progression of Huntington’s disease pathophysiology refers to reducing the rate of progression of Huntington’s disease pathophysiology, for example, as assessed by magnetic resonance imaging (MRI) [e.g. by neuroimaging measures, such as in Lancet Neurol. 2013, 12 (7), 637-649].
  • MRI magnetic resonance imaging
  • it refers to reducing the rate (e.g. reducing the annual rate, for example, versus placebo) of brain (e.g. whole brain, caudate, striatum or cortex) volume loss (e.g. % from baseline volume) associated with Huntington’s disease (e.g. as assessed by MRI) or it refers to reducing the rate (e.g. reducing the annual rate, for example, versus placebo) of increase in ventricular volume (e.g. % from baseline volume) associated with Huntington’s disease (e.g. as assessed by MRI).
  • MRI magnetic resonance imaging
  • motor function refers to motor features of HD comprising, for example, one or more selected from the group consisting of ocular motor function, dysarthria, chorea, postural stability and gait.
  • decline of motor function refers to decreased motor function (e.g. from normal motor function or from previous clinic visit). Decline of motor function may be assessed, for example, according to standard scales, such as clinical scales (e.g. UHDRS motor assessment scale, as measured by the UHDRS Total Motors Score; e.g. in Movement Disorders, 1996, 11, 136-142).
  • standard scales such as clinical scales (e.g. UHDRS motor assessment scale, as measured by the UHDRS Total Motors Score; e.g. in Movement Disorders, 1996, 11, 136-142).
  • slowing the decline of motor function refers to reducing the rate of decline of motor function (e.g. compared to placebo; e.g. reduction in the annual rate of decline of motor function, for example, versus placebo; e.g. as assessed by the UHDRS Total Motors Score).
  • reducing the rate refers to increasing time for onset or increasing time for a rise of severity (e.g. compared to placebo; e.g. reduction in the annual rate of decline, for example, versus placebo).
  • cogntive decline refers to decreased cognitive abilities (e.g. from normal cognition function or from previous clinic visit). In one embodiment, it comprises, for example, decline of one or more selected from the group consisting of attention, processing speed, visuospatial processing, timing, emotion processing, memory, verbal fluency, psychomotor function, and executive function. Cognitive decline may be assessed, for example, according to standard scales, such as clinical scales [e.g.
  • slow cognitive decline refers to reducing the rate of cognitive decline (e.g. compared to placebo; e.g. reduction in the annual rate of cognitive decline versus placebo; e.g. as assessed by the Symbol Digit Modalities Test, by the Stroop Word Reading Test, by the Montreal Cognitive Assessment or by the HD Cognitive Assessment Battery).
  • reducing the rate refers to increasing time for onset or increasing time for a rise of severity (e.g. compared to placebo; e.g. reduction in the annual rate of decline, for example, versus placebo).
  • psychiatric decline refers to decreased psychiatric function (e.g. from normal psychiatric function or from previous clinic visit). In one embodiment, it comprises, for example, one or more selected from the group consisting of apathy, anxiety, depression obsessive compulsive behavior, suicidal thoughts, irritability and agitation. Psychiatric decline may be assessed, for example, according to standard scales, such as clinical scales (e.g. as assessed by the Apathy Evaluation Scale or by the Hospital Anxiety and Depression Scale; e.g. in Movement Disorders, 2016, 31 (10), 1466-1478, Movement Disorders, 2015, 30 (14), 1954-1960).
  • slowing psychiatric decline or “to slow psychiatric decline”, as used herein, refers to reducing the rate of psychiatric decline (e.g. compared to placebo; e.g. reduction in the annual rate of psychiatric decline versus placebo; e.g. as assessed by the Apathy Evaluation Scale or by the Hospital Anxiety and Depression Scale).
  • reducing the rate refers to increasing time for onset or increasing time for a rise of severity (e.g. compared to placebo; e.g. reduction in the annual rate of decline, for example, versus placebo).
  • Functional capacity refers, for example, to the ability to work, handle financial affairs, manage domestic chores, perform activities of daily living, and level of care needed.
  • Functional capacity comprises, for example, one or more selected from the group consisting of capacity to work, capacity to handle financial affairs, capacity to manage domestic chores, capacity to perform activities of daily living, and level of care needed.
  • decline of functional capacity refers to decreased functional capacity (e.g. from normal functional capacity or from previous clinic visit). Decline of functional capacity may be assessed, for example, according to standard scales, such as clinical scales (e.g. UHDRS functional assessment scale and independence scale, and UHDRS Total Functional Capacity Scale e.g. in Movement Disorders, 1996, 11, 136-142).
  • clinical scales e.g. UHDRS functional assessment scale and independence scale
  • UHDRS Total Functional Capacity Scale e.g. in Movement Disorders, 1996, 11, 136-142).
  • slowing the decline of functional capacity refers to reducing the rate of decline of functional capacity (e.g. compared to placebo; e.g. reduction in the annual rate of decline of functional capacity versus placebo; e.g. as assessed by the UHDRS functional assessment scale and independence scale or by the UHDRS Total Functional Capacity Scale).
  • reducing the rate refers to increasing time for onset or increasing time for a rise of severity (e.g. compared to placebo; e.g. reduction in the annual rate of decline, for example, versus placebo).
  • decline refers, for example, to worsening over time (e.g. annually or per year) of a condition or of a particular feature of a condition, for example as assessed according to standard scales, such as clinical scales.
  • UHDRS Unified Huntington Disease Rating Scale
  • cHDRS refers to the composite Unified Huntington Disease Rating Scale, which provides composite measure of motor, cognitive and global functioning (e.g. in Neurology, 2017, 89, 2495-2502).
  • UHDRS IS Independent Scale
  • HD stage 1 refers to a disease stage of HD as clinically stablished [e.g. as assessed according to standard scales, for example, clinical scales, such as on the basis of the UHDRS total functional capacity (TFC) scale, wherein the TFC score is of 11 to 13],
  • TFC total functional capacity
  • HD stage 2 refers to a disease stage of HD as clinically stablished [e.g. as assessed according to standard scales, for example, clinical scales, such as on the basis of the UHDRS total functional capacity (TFC) scale, wherein the TFC score is of 7 to 10]
  • TFC total functional capacity
  • HD stage 3 refers to a disease stage of HD as clinically stablished [e.g. as assessed according to standard scales, for example, clinical scales, such as on the basis of the UHDRS total functional capacity (TFC) scale, wherein the TFC score is of 4 to 6],
  • TFC total functional capacity
  • HD stage 4 refers to a disease stage of HD as clinically stablished [e.g. as assessed according to standard scales, for example, clinical scales, such as on the basis of the UHDRS total functional capacity (TFC) scale, wherein the TFC score is of 1 to 3],
  • TFC total functional capacity
  • the patient is not independent, but still can reside at home with help from either family or professionals, however, requiring substantial assistance in financial affairs, domestic chores, and most activities of daily living; typically 9 to 21 years from onset of Huntington’s disease.
  • HD stage 5 refers to a disease stage of HD as clinically stablished [e.g. as assessed according to standard scales, for example, clinical scales, such as on the basis of the UHDRS total functional capacity (TFC) scale, wherein the TFC score is of 0]
  • TFC total functional capacity
  • early HD refers to “HD stage 1” or “HD stage 2”, as defined herein.
  • moderate HD refers to a disease stage of HD, wherein the patient may no be able to work, manage own finances or perform own household chores, but is able to eat, dress, and attend to personal hygiene with assistance.
  • chorea may be prominent, as well as problems with swallowing, balance, falls, weight loss, and problem solving.
  • moderate HD refers to “HD stage 3”, as defined herein.
  • advanced HD refers to a disease stage of HD, wherein the patient requires assistance in all activities of daily living. Typically, at this stage, for example, chorea may be severe, but more often it is replaced by rigidity, dystonia, and bradykinesia.
  • “advanced HD”, “advanced Huntington’s disease”, “advanced stage of HD”, “advanced stage of Huntington’s disease”, “late HD” or “late Huntington’s disease”, “late stage of HD” or “late stage of Huntington’s disease” refers to “HD stage 4” or “HD stage 5”, as defined herein.
  • duvenile HD or “juvenile Huntington's disease”, as used herein, refers to diagnosis of HD as clinically stablished ⁇ e.g. on the basis of: confirmed family history or positive genetic test (i.e. confirmation of GAG repeat expansion ⁇ 36); and onset of symptoms by age ⁇ 21 years ⁇ .
  • HD or “pediatric Huntington’s disease” refers to a patient affected by HD ⁇ e.g. on the basis of: confirmed family history or positive genetic test (i.e. confirmation of GAG repeat expansion ⁇ 36) and clinical diagnosis ⁇ and who is aged ⁇ 18 years.
  • HD patient “Huntington's disease patient”, “patient with Huntington’s disease” or “patient with HD” refers to a patient with HD, as defined herein.
  • beneficial or desired results can include, but are not limited to, stabilizing or improving progression of stage of HD (e.g. compared to placebo).
  • beneficial or desired results can include, but are not limited to, stabilizing or improving progression of stage of HD (e.g. compared to placebo).
  • One aspect of the treatment is, for example, that said treatment should have a minimal adverse effect on the patient, e.g. the agent used should have a high level of safety, for example without producing adverse side effects.
  • method for the treatment refers to “method to treat” .
  • intermittent dosing regimen or “intermittent dosing schedule”, as used herein, means a dosing regimen that comprises administering a splicing modulator, such as those defined herein, followed by a resting period.
  • the splicing modulator is administered according to an intermittent dosing schedule of at least two cycles, each cycle comprising (a) a dosing period and thereafter (b) a resting period.
  • resting period refers, in particular, to a period of time during which the patient is not given the splicing modulator (i.e., a period of time wherein the treatment with the splicing modulator is withheld).
  • a splicing modulator such as those defined herein, is given on a daily basis, there would be rest period if the daily administration is discontinued for some time, e.g., for some number of days, or the plasma concentration of the splicing modulator is maintained at sub-therapeutic level for some time e.g., for some number of days.
  • the dosing period and/or the dose of the splicing modulator can be the same or different between cycles.
  • the total treatment time i.e., the number of cycles for treatment
  • an intermittent dosing schedule comprises at least two cycles, each cycle comprising (a) a dosing period during which a therapeutically effective amount of the splicing modulator is administered to said patient and thereafter (b) a resting period.
  • the term “intermittent dosing regimen” or “intermittent dosing schedule” refers to repeated on/off treatment, wherein the splicing modulator is administered at regular intervals in a periodic manner, for example, once a week.
  • branaplam once a week refers to branaplam administered in an amount, for example, of from 50 mg to 200 mg once a week, such as 140 mg once a week, of from 200 mg to 400 mg once a week, such as 280 mg once a week, or of from 400 mg to 700 mg once a week, such as 560 mg once a week.
  • branaplam once a week refers to branaplam administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
  • an amount e.g. mg, mg/ml, mg/m 2 , percentage
  • a pharmaceutically acceptable salt thereof for example hydrochloride salt thereof (e.g. branaplam hydrochloride monohydrate).
  • free form or “free forms” or “in free form” or “in the free form” refers to the compound in non-salt form, such as the base free form.
  • branaplam administered in an amount for example, of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g.
  • 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week), is also to be understood to refer to branaplam administered in an amount, for example, of about 25 mg to about 100 mg once a week (e.g. about 28 mg once a week, about 56 mg once a week or about 84 mg once a week), of about 100 mg to about 175 mg once a week (e.g. about 112 mg once a week, about 154 mg once a week or about 196 mg once a week), or of about 175 mg to about 250 mg once a week (e.g. about 238 mg once a week).
  • branaplam administered in an amount for example, of about 25 mg to about 100 mg once a week (e.g. about 28 mg once a week, about 56 mg once a week or about 84 mg once a week), of about 100 mg to about 175 mg once a
  • disease-modifying therapy or disease-modifying treatment
  • a drug that can modify or change the course of a condition or a disorder or a disease (i.e. a disease-modifying drug), such as HD, as defined herein.
  • the term “subject” refers to a mammalian organism, preferably a human being (male or female).
  • patienf refers to a subject who is diseased and would benefit from the treatment.
  • a subject is “in need of a treatment if such subject (patient) would benefit biologically, medically or in quality of life from such treatment.
  • a therapeutically effective amount refers to an amount of a compound of the present invention that elicits the biological or medical response of a subject.
  • the term refers to the amount of the compound of the present invention that, when administered to a subject, is effective to at least partially ameliorate a condition, or a disorder or a disease.
  • one or more refers to either one or a number above one (e.g. 2, 3, 4, 5, etc.).
  • branaplam As used herein, the compound named branaplam, as used herein above and below, is the splicing modulator also named 5-(1H-Pyrazol-4-yl)-2-(6-((2,2,6,6-tetramethylpiperidin-4- yl)oxy)pyridazin-3-yl)phenol, of formula (I):
  • Branaplam, or pharmaceutical salt thereof, such as branaplam hydrochloride salt can be prepared as described in W02014/028459, which is incorporated herein by reference, e.g. in Example17-13 therein.
  • “branaplam” refers to the free form
  • any reference to “a pharmaceutically acceptable salt thereof refers to a pharmaceutically acceptable acid addition salt thereof.
  • the term "branaplam, or a salt thereof, such as a pharmaceutically acceptable salt thereof, as used in the context of the present invention (especially in the context of the any of the embodiments, above or below, and the claims) is thus to be construed to cover both the free form and a pharmaceutically acceptable salt thereof, unless otherwise indicated herein.
  • branaplam hydrochloride salt or “branaplam monohydrochloride salt” refers to 5-(1H-Pyrazol-4-yl)-2-(6-((2,2,6,6-tetramethylpiperidin-4- yl)oxy)pyridazin-3-yl)phenol monohydrochloride salt or hydrate thereof, such as 5-(1 H-Pyrazol-4- yl)-2-(6-((2,2,6,6-tetramethylpiperidin-4-yl)oxy)pyridazin-3-yl)phenol monohydrochloride monohydrate, also named branaplam hydrochloride monohydrate.
  • branaplam is in the form of branaplam hydrochloride salt.
  • splicing modulator refers to a small molecule that directly or indirectly increases association of a target pre-mRNA sequence with the spliceosome to enhance or reduce gene expression.
  • the term “splicing modulator”, as used herein, refers to a compound, e.g., a small molecule, that alters splicing of a precursor messenger RNA (abbreviated as pre- mRNA).
  • exemplary splicing modulators alter the recognition of splice sites by the spliceosome, e.g., by interacting with components of the splicing machinery (e.g. the proteins and/or the nucleic acids (e.g., mRNAs and/or pre-mRNAs)), which leads to an alteration of normal splicing of the targeted pre-mRNA.
  • Exemplary splicing modulators thus alter the sequence (or relative level of one or more sequences) of a mature RNA product of a targeted pre-mRNA.
  • Exemplary splice modulators act by directly or indirectly altering, e.g., increasing, association of a target pre-mRNA sequence with the spliceosome to, e.g., enhance or reduce gene expression.
  • Non-limiting examples of splicing modulators are small molecules (e.g. branaplam) and oligonucleotides, such as antisense oligonucleotides and splice-switching oligonucleotides (SSOs). More examples of splicing modulators can be found e.g.
  • Antisense compounds have also been used to alter the ratio of naturally-occurring alternative splice variants such as the long and short forms of Bcl-X pre-mRNA (U.S. Pat No. 6,172.216: U.S. Pat. No. 6.214,986: Taylor et al., Nat. Biotechnol. 1999, 17, 1097-1100) or to force skipping of specific exons containing premature termination codons (Wilton et al., NeuromuscuL Disord., 1999, 9, 330-338).
  • 5,627,274 and WO 94/26887 disclose compositions and methods for combating aberrant splicing in a pre-mRNA molecule comprising a mutation using antisense oligonucleotides which do not activate RNAse H.
  • the relative expression level of a naturally-occurring alternative splice variant is altered, e.g. the ratio of one splice variant derived from a target pre-mRNA is changed with respect to another splice variant or the whole pool of splice variants derived from that pre- mRNA.
  • a new splice variant is generated while the ratio of naturally- occurring alternative splice variants may or may not be altered.
  • said new splice variant is generated by removal of one or more nucleic acids from the mRNA otherwise produced in the absence of the splice modulator. This may occur, for example, by exon skipping, i.e. wherein an exon is spliced out of the pre-mRNA and is therefore not present in the mature mRNA.
  • said new splice variant is generated by activation of an alternative donor site, where an alternative 5' splice junction (donor site) is used, changing the 3' boundary of the upstream exon.
  • said new splice variant is generated by activation of an alternative acceptor site, where an alternative 3' splice junction (acceptor site) is used, changing the 5' boundary of the downstream exon.
  • said new splice variant is generated which includes additional sequence not included in the mRNA in the absence of the splice modulator, e.g., by intron retention, where additional sequence, e.g., an intron or a portion thereof, is retained in the pre-mRNA and therefore is included in the mature mRNA.
  • said intron retention may lead to generation of, a) a splice variant encoding additional amino acids encoded by the retained intron (for example, in the case that said intron does not cause a frameshift and does not introduce a stop codon in the reading frame), or, in an embodiment, b) a splice variant containing a premature stop codon, e.g.
  • the additional sequence e.g., the intron or portion thereof, causes a frameshift and/or introduces sequence comprising an in-frame stop codon upstream of the original stop codon, and therefore the resulting splice variant mRNA encodes a protein lacking one or more amino acid residues, e.g., in the C- terminus, compared to the protein encoded by a splice variant in which said intron-retention has not taken place.
  • the expression level of the encoded protein is altered, e.g., is reduced, in the presence of the splice modulator relative to the expression level of the protein encoded by the splice variant in the absence of the splice modulator.
  • the expression level of the splice variant is less than the expression level of a splice variant without the intron retention.
  • said reduced expression levels is at least partly due to instability (e.g. reduced half-life) and/or increased degradation of the resulting mRNA or encoded polypeptide, for example via a nonsense-mediated decay mechanism (in the case of the mRNA) or increased protein degradation (in the case of the encoded polypeptide).
  • a “splice variant” as the term is used herein refers to a mature mRNA species that is produced from a particular pre-mRNA, or a polypeptide encoded by said mature mRNA species.
  • a particular pre-mRNA species of interest may produce one or more splice variants.
  • a splicing modulator is a SMN splicing modulator, for example a SMN2 splicing modulator.
  • the splicing modulator according to the present invention modulates splicing of the HTT gene between exons 49 and 50.
  • SMSN splicing modulator refers to a compound (e.g. a small molecule) that directly or indirectly increases association of the SMN2 pre-mRNA sequence with the spliceosome to enhance SMN2 exon? inclusion and increase SMN expression.
  • the splicing modulator is provided in the form of a pharmaceutical composition
  • a pharmaceutical composition comprising the splicing modulator and at least one pharmaceutically acceptable excipient.
  • the splicing modulator is provided in the form of a pharmaceutical combination”, as used herein, refers to a pharmaceutical combination comprising the splicing modulator and at least one further pharmaceutical active ingredient.
  • an “antisense compound” as used herein refers to a compound (e.g., an antisense oligonucleotide) that hybridizes (e.g., via base pairing) to a target nucleic acid and modulates the amount, activity, and/or function of the target nucleic acid.
  • antisense compounds result in altered transcription or translation of a target.
  • modulation of expression can be achieved by, for example, target RNA degradation or occupancy-based inhibition.
  • An example of modulation of RNA target function by degradation is RNase H-based degradation of the target RNA upon hybridization with a DNA-like antisense compound.
  • RNA interference RNA interference
  • RNAi refers to antisense-mediated gene silencing through a mechanism that utilizes the RNA- induced silencing complex (RISC).
  • RISC RNA- induced silencing complex
  • An additional example of modulation of RNA target function is by an occupancy-based mechanism such as is employed naturally by microRNA.
  • MicroRNAs are small non-coding RNAs that regulate the expression of protein coding RNAs. The binding of an antisense compound to a microRNA prevents that microRNA from binding to its messenger RNA targets, and thus interferes with the function of the microRNA. MicroRNA mimics can enhance native microRNA function. Certain antisense compounds alter splicing of pre-mRNA.
  • antisense compounds that target Huntington's disease are described in, for example, WO19157531, WO18022473, W017015575, WO17192664, WO15107425, WO14121287, W014059356, WO14059341, W013033223, WO12109395, WO13022990, W012012467, WO1 1097643, WO11097644, W011097641, WO11032045, WO07089584, W007089611, the contents of which are hereby incorporated by reference in their entirety. Additional examples of antisense compounds that target Huntington’s disease include RG6042 (Roche), WVE-120101 (Wave/Takeda) and WVE-120102 (Wave/Takeda).
  • gene therapy refers, for example, to AMT-130, described, for example, in WO 2016/102664, which is hereby incorporated by reference in its entirety.
  • composition is defined herein to refer, for example, to a mixture or solution containing at least one active ingredient or therapeutic agent to be administered to a subject, in order to treat a subject, for example as herein defined.
  • the term "pharmaceutically acceptable excipient” includes any and all solvents, dispersion media, coatings, surfactants, antioxidants, preservatives (e.g., antibacterial agents, antifungal agents), isotonic agents, absorption delaying agents, salts, preservatives, drug stabilizers, binders, excipients, disintegration agents, lubricants, sweetening agents, flavoring agents, dyes, and the like and combinations thereof, as would be known to those skilled in the art (see, for example, Remington's Pharmaceutical Sciences, 22 nd Ed. Mack Printing Company, 2013, pp. 1049-1070). Except insofar as any conventional carrier is incompatible with the active ingredient, its use in the therapeutic or pharmaceutical compositions is contemplated.
  • the appropriate dosage may vary depending upon a variety of factors, such as, for example, the age, weight, sex, the route of administration or salt employed.
  • the term “a,” “an,” “the” and similar terms used in the context of the present invention are to be construed to cover both the singular and plural unless otherwise indicated herein or clearly contradicted by the context.
  • compound of the present invention refers to branaplam (i.e. free form) or a pharmaceutically acceptable salt thereof.
  • free form or “free forms” refers to the compound in non-salt form.
  • salt As used herein, the terms “salt” , “salts” or “salt form” refers to an acid addition or base addition salt of a compound. “Salts” include in particular “pharmaceutically acceptable salts”.
  • pharmaceutically acceptable salts refers to salts that retain the biological effectiveness and properties of the compounds and, which typically are not biologically or otherwise undesirable.
  • Pharmaceutically acceptable acid addition salts can be formed with inorganic acids and organic acids.
  • Inorganic acids from which salts can be derived include, for example, hydrochloric acid, hydrobromic add, sulfuric add, nitric acid, phosphoric add, and the like.
  • Organic acids from which salts can be derived include, for example, acetic acid, propionic acid, glycolic acid, oxalic acid, maleic acid, malonic acid, succinic acid, fumaric acid, tartaric acid, citric acid, benzoic acid, mandelic acid, methanesulfonic acid, ethanesulfonic acid, toluenesulfonic acid, sulfosalicylic acid, and the like.
  • Pharmaceutically acceptable base addition salts can be formed with inorganic and organic bases.
  • Inorganic bases from which salts can be derived include, for example, ammonium salts and metals from columns I to XII of the periodic table.
  • the salts are derived from sodium, potassium, ammonium, calcium, magnesium, iron, silver, zinc, and copper; particularly suitable salts include ammonium, potassium, sodium, calcium and magnesium salts.
  • Organic bases from which salts can be derived include, for example, primary, secondary, and tertiary amines, substituted amines including naturally occurring substituted amines, cyclic amines, basic ion exchange resins, and the like.
  • Certain organic amines include isopropylamine, benzathine, cholinate, diethanolamine, diethylamine, lysine, meglumine, piperazine and tromethamine.
  • salts can be synthesized from a basic or acidic moiety, by conventional chemical methods.
  • such salts can be prepared by reacting the free acid forms of the compound with a stoichiometric amount of the appropriate base (such as Na, Ca, Mg, or K hydroxide, carbonate, bicarbonate or the like), or by reacting the free base form of the compound with a stoichiometric amount of the appropriate acid.
  • a stoichiometric amount of the appropriate base such as Na, Ca, Mg, or K hydroxide, carbonate, bicarbonate or the like
  • Such reactions are typically carried out in water or in an organic solvent, or in a mixture of the two.
  • use of nonaqueous media like ether, ethyl acetate, ethanol, isopropanol, or acetonitrile is desirable, where practicable.
  • drug active substance
  • active ingredient pharmaceutically active ingredient
  • active agent pharmaceutically active ingredient
  • therapeutic agenf or agenf are to be understood as meaning a compound in free form or in the form of a pharmaceutically acceptable salt.
  • combination refers to either a fixed combination in one unit dosage form, non-fixed combination, or a kit of parts for the combined administration where a compound of the present invention and one or more combination partner (e.g. another drug, also referred to as further “pharmaceutical active ingredient", “therapeutic agenf or “co-agenf ) may be administered independently at the same time or separately within time intervals, especially where these time intervals allow that the combination partners show a cooperative, e.g. synergistic effect
  • combination partners show a cooperative, e.g. synergistic effect
  • co-administration or “combined administration” or the like as utilized herein are meant to encompass administration of the selected combination partner to a single subject in need thereof (e.g.
  • fixed combination means that the active ingredients, e.g. the compound of the present invention and one or more combination partners, are both administered to a patient simultaneously in the form of a single entity or dosage.
  • non-fixed combination means that the active ingredients, e.g. a compound of the present invention and one or more combination partners, are both administered to a patient as separate entities either simultaneously or sequentially with no specific time limits, wherein such administration provides therapeutically effective levels of the two compounds in the body of the patient
  • the compound of the present invention may be administered separately, by the same or different route of administration, or together in the same pharmaceutical composition as the other agents.
  • the compound of the invention and the other therapeutic agent may be manufactured and/or formulated by the same or different manufacturers.
  • the compound of the invention and the other therapeutic may be brought together into a combination therapy: (i) prior to release of the combination product to physicians (e.g. in the case of a kit comprising the compound of the invention and the other therapeutic agent); (ii) by the physician themselves (or under the guidance of the physician) shortly before administration; (iii) in the patient themselves, e.g. during sequential administration of the compound of the invention and the other therapeutic agent.
  • CSF cerebrospinal fluid
  • cP centipoise, unit of viscosity
  • pICso -Log(ICso) where IC50 is expressed in molar or mol/L
  • BacHD Bacterial artificial chromosome-mediated transgenic Huntington's Disease model
  • CD cyclodextrin
  • PBPK Physiologically Based Pharmacokinetic
  • PK pharmacokinetics
  • pKa negative logarithm of the acid dissociation constant
  • R mutant HTT protein level at a given time
  • RO baseline of mutant HTT protein concentration (e.g. in brain)
  • SMA spinal muscular atrophy
  • V1 central volume of 2-compartment PK model
  • V2, Vc peripheral volume of 2-compartment PK model
  • AUCIast area under the plasma (or serum or blood) concentration-time curve from time zero to the time of the last quantifiable concentration
  • AUCtau area under the plasma (or serum or blood) concentration-time curve from time zero to the end of the dosing interval tau
  • Cmax observed maximum plasma (or serum or blood) concentration of a drug following administration
  • ALT alanine aminotransferase
  • SGPT serum glutamic pyruvic transaminase
  • SGOT serum glutamic oxaloacetic transaminase
  • GGT gamma-glutamyl transferase
  • BUN blood urea nitrogen
  • INR International Normalized Ratio
  • AUCinf Area under the plasma (or serum or blood) concentration-time curve from time zero to infinity
  • AeO-t Amount of drug excreted into the urine from time zero to time ‘t’ where t is a defined time point after administration
  • CLr renal clearance based on AUG and Ae (cumulative amount of unchanged drug excreted in the urine) for the scheduled time period
  • Vz/F The apparent volume of distribution during terminal phase (associated with Az) (volume)
  • ECG electrocardiogram
  • R 2 proportion of the variance in the dependent variable that is predictable from the independent variable(s)
  • CAG repeats cytosine-adenine-guanine repeats
  • HIV human immunodeficiency virus
  • IGF informed consent form
  • WOCB women of childbearing potential
  • CYP3A4 Human Cytochrome P4503A4
  • IUD intrauterine device
  • IUS intrauterine system
  • CDT carbohydrate deficient transferrin
  • PBPK Physiologically-based pharmacokinetic model
  • a normal Human Fibroblast line (HD1994) was treated with branaplam and Splice modulator 2 (described as Example 3-2 in WO 2015017589) and Splice modulator 3 (described as NVS-SM3 in NatChem Biol. 2015 Jul;11(7):511-7. doi: 10.1038/nchembio.1837) or DMSOfor24 hours.
  • the following compound doses were used:
  • Branaplam was used at an efficacious dose (100 nM) and a cytotoxic dose (5 uM).
  • Splice modulator 2 was used at 750 nM.
  • Splice modulator 3 was used at 5 uM.
  • RNA-Seq libraries were prepared using the Illumina TruSeq RNA Sample Prep kit v2 and sequenced using the Illumina HiSeq 2500 platform.
  • the three alignment files (bam files) for each of the five conditions (DMSO, branaplam at 5 uM, branaplam at 100 nM, splice modulator 2 at 500 nM and splice modulator 3 at 5 uM) were pooled before the transcript assembly by Cufflinks (2.1.1). After transcript assembly, the exon coordinates were extracted from the transcript gtf files. Exons on alternative chromosomes and on chromosome M were excluded and the strand information were ignored. That yielded 273866 putative exons.
  • a candidate, falling into the gene region of HTT (chr4:3213622-3213736) was detected and appeared to be modulated by active compounds. It was supported by the re analysis with STAR alignments. In addition, the 3’ end shows the AGA
  • the candidate chr4:3213622-3213736 introduces an in-frame stop codon (TAG) which is 55 nucleotides from the 3’ end of the exon and therefore may trigger nonsense-mediated decay.
  • TAG in-frame stop codon
  • NGS data show that expression of HTT is downregulated by the active compounds about six fold ( Figure 1).
  • a partial sequence shown only the part corresponding to exon 49, novel exon, and exon 50 of the novel-exon-containing HTT transcript is included herein as SEQ ID NO: 9. The novel exon is underlined.
  • Quantitative PCR was performed using Taqman Fast Advanced master mix (Thermo Scientific) in 20 uL with 4 uL of cDNA reaction and primers specific for each genes.
  • the PCR steps were as follows: 95 °C for 20 sec then 40 cycles of 95 °C for 1 sec, 55 °C for 20 sec.
  • sequence of primers were, for WT human HTT, forward, 5'-GTCATTTGCACCTTCCTCCT-3' (SEQ ID NO: 1); reverse, 5’- TGGATCAAATGCCAGGACAG-3’ (SEQ ID NO: 2) and sequence of probe was 56- FAM/TTG TGA AAT /ZEN/TCG TGG TGG CAA CCC /3IABkFQ/ (SEQ ID NO: 8), for HTT novel exon, forward, 5’-TCCTGAGAAAGAGAAGGACATTG-3’ (SEQ ID NO: 3); reverse, 5'- CTGTGGGCTCCTGTAGAAATC-3’ (SEQ ID NO: 4) and sequence of probe /56-FAM/AAT TCG TGG /ZEN/TGG CAA CCC TTG AGA /3IABkFQ/ (SEQ ID NO: 7). Relative quantification of gene expression was performed using 2 - ⁇ CT method. Fold changes in the mRNA expression level was calculated following normalization to mouse glucuroni
  • mice Twenty-eight BacHD mice (FVB/N-Tg(HTT*97Q)IXwy/J transgenic mice - Jackson Laboratories) were used for the experiment. Animal protocols were approved by the Children's Hospital of Philadelphia Institutional Animal Care and use Committee. Mice were housed in a temperature- controlled environment on a 12-h light/dark cycle. Food and water were provided ad libitum.
  • BacHD mice FVB/N-Tg(HTT*97Q)IXwy/J transgenic mice - Jackson Laboratories
  • Animal protocols were approved by the Children’s Hospital of Philadelphia Institutional Animal Care and use Committee. Mice were housed in a temperature-controlled environment on a 12-h light/dark cycle. Food and water were provided ad libitum.
  • a single dose of branaplam or vehicle solution was administered by oral gavage.
  • Mice were firmly restrained by grasping the loose skin to immobilize the head, maintained in a vertical position and a 22- to 26-gauge gavage needle was placed in the side of the mouth. The needle was guided following the roof of the mouth into the esophagus and allowed to gently enter in the stomach.
  • the amount of branaplam or vehicle administrated to each mouse was based on the weight recorded before treatment.
  • mice were anesthetized with a lethal dose of ketamine/xylazine (100 mL of a 10 mg:1 mg), and perfused with 18 ml of 0.9% cold saline mixed with 2 ml of RNAIater (Ambion) solution for tissue collection. Liver, skeletal muscle, cerebrum, and cerebellum samples were flash frozen in liquid nitrogen and stored at -80 °C.
  • mice were placed in a rodent anesthesia induction chamber where they are exposed to 4- 5% isoflurane in 100% oxygen carrier gas. Once an appropriate plane of anesthesia was achieved, they were moved to a nose cone so that maintenance levels of isoflurane (1-3%) could be delivered throughout the procedure.
  • the dorsal aspect of their cervical and occipital region was surgically prepped to visualize the dura mater under a microscope.
  • a glass micropipette attached to a micromanipulator was introduced to the cisterna magna via a puncture through the dura mater at a point where no vasculature was visualized, and CSF was allowed to flow into the micropipette via capillary action. After approximately 15-30 minutes, the micropipette was removed from the cistema magna, the CSF sample was transferred into Eppendorf tubes, flash frozen in liquid nitrogen, and stored at -80 °C.
  • mice were kept under anesthesia with isoflurane. Blood was obtained via submandibular vein bleeds and collected for RNA extraction (RD analysis) using RNAprotect Animal Blood Tubes, and plasma (PK analysis) using K2EDTA coated tubes. Cells were removed from plasma by centrifugation for 10 min at 2000 xg at 4 °C, and plasma samples were stored at -80 °C. Following blood collection, mice were given a lethal dose of ketamine/xylazine (100 ml of a 10 mg:1 mg), and perfused with 18 ml of 0.9% cold saline mixed with 2ml of RNAIater (Ambion) solution for tissue collection. Liver, skeletal muscle, brain striatum, brain cortex, hemibrain and cerebellum samples were flash frozen in liquid nitrogen and stored at -80 °C.
  • mice were placed in a rodent anesthesia induction chamber where they are exposed to 4-5% isoflurane in 100% oxygen carrier gas. Once an appropriate plane of anesthesia was achieved, they were moved to a nose cone so that maintenance levels of isoflurane (1-3%) could be delivered throughout the procedure.
  • the dorsal aspect of their cervical and occipital region was surgically prepped to visualize the dura mater under a microscope.
  • a glass micropipette attached to a micromanipulator was introduced to the cistema magna via a puncture through the dura mater at a point where no vasculature was visualized, and CSF was allowed to flow into the micropipette via capillary action. After approximately 15-30 minutes, the micropipette was removed from the cisterna magna, the CSF sample was transferred into Eppendorf tubes, flash frozen in liquid nitrogen, and stored at -80 °C.
  • mice were kept under anesthesia with isoflurane. Blood was obtained via submandibular vein bleeds and collected for RNA extraction (RD analysis) using RNAprotect Animal Blood Tubes, and plasma (PK analysis) using K2EDTA coated tubes. Cells were removed from plasma by centrifugation for 10 min at 2000 x g at 4 °C, and plasma samples were stored at -80 °C. Following blood collection, mice were given a lethal dose of ketamine/xylazine (100 ml of a 10 mg:1 mg), and perfused with 18 mL of 0.9% cold saline mixed with 2 mL of RNAIater (Ambion) solution for tissue collection. Liver, skeletal muscle, brain striatum, brain cortex, hemibrain and cerebellum samples were flash frozen in liquid nitrogen and stored at -80 °C. Branaplam dose
  • the branaplam dose is provided as a solution of branaplam monohydrochloride salt (10 mg/mL suspension) in methyl cellulose, medium viscosity 400cP for a 1% solution), Tween 80 (1% v/v), purified water suspension formulation.
  • RNA from cerebrum and cerebellum was extracted using RNeasy Plus kit (Qiagen) after homogenized in Precellys at 6000 rpm for 40 sec.
  • RNA from blood was extracted using PAXgene blood RNA kit (Qiagen) according to manufacturer protocol.
  • the RNA was quantified by Nanodrop 2000 (Thermo Scientific).
  • cDNAs were synthesized from 140-400 ng RNA using Maxima First strand cDNA synthesis kit using a mix of oligo dT and random hexamers (Thermo Scientific) in 20uL reaction at 25 °C for 10 min, 50 °C for 15 min then 85 °C for 5 min.
  • Quantitative PCR was performed using Taqman Fast Advanced master mix (Thermo Scientific) in 20 uL with 4 uL of cDNA reaction and primers specific for each genes.
  • the PCR steps were as follows: 95 °C for 20 sec then 40 cycles of 95 °C for 1 sec, 55 °C for 20 sec.
  • sequence of primers were, for WT human HTT, forward, S'-GTCATTTGCACCTTCCTCCT-S' (SEQ ID NO: 1); reverse, 5’- TGGATCAAATGCCAGGACAG-3’ (SEQ ID NO: 2) and sequence of probe was 56-FAM/TTG TGA AAT /ZEN/TCG TGG TGG CAA CCC Z3IABkFQ/ (SEQ ID NO: 8), for HTT novel exon, forward, 5’-TCCTGAGAAAGAGAAGGACATTG-3’ (SEQ ID NO: 3); reverse, 5’- CTGTGGGCTCCTGTAGAAATC-3’ (SEQ ID NO: 4) and sequence of probe /56-FAM/AAT TCG TGG /ZEN/TGG CAA CCC TTG AGA /3IABkFQ/ (SEQ ID NO: 7). Relative quantification of gene expression was performed using 2 - ⁇ CT CT method. Fold changes in the mRNA expression level was calculated following normalization to mouse glu
  • CSF samples were clarified after a 5 minutes centrifugation at 14,000 rpm in a centrifuge at 4 °C.
  • 96-well V-bottom plate were loaded with a CSF buffer 2.5 - 5 uL of CSF sample. This was followed by addition of MP-2B7 (magnetic particle antibody conjugated suspension) HTT antibody diluted in Erenna assay buffer.
  • Assay plate was incubated with shaking (600 rpm) at RT for 1 h and then put through a post-transfer wash program on BioTek-405. 20 ul/well of MW1 detection antibody was added to the assay plate. Plate was incubated with shaking (at 750 rpm) at room temperature for 1 hr.
  • branaplam treatment leads to a dose dependent lowering of total Huntingtin transcript to 30 - 90% of normal endogenous levels at doses ranging from 5 nM - 125 nM and a concomitant increase (100 - 500 fold) in a novel-exon-containing HTT transcript ( Figures 2a and 2b).
  • Western blot analysis revealed that this decrease in transcript was accompanied by a robust reduction of normal Huntingtin protein (50 - 70%) in the same dose range (Figure 2c).
  • EC50 for lowering of HTT transcript by Branaplam was in the 20-25 nM range while EC50 for HTT protein lowering was in the 10-25 nM range.
  • BacHD mice received a single oral dose of branaplam at either 10 mg/kg or 50 mg/kg level.
  • Total HTT transcript and novel-exon-containing HTT transcript were measured at 8 hr and 24 h for the 10 mg/kg dose and at 8 h, 24 h and 48 h for the 50 mg/kg dose.
  • Brain tissue (cerebrum, Figures 3 and 4) was evaluated by quantitative PCR for changes in levels of total HTT and HTT transcripts containing a novel exon resulting from branaplam treatment.
  • a clear, dose dependent increase in the novel-exon-containing form of HTT was apparent in both brain regions at 8 and 24 h after dosing.
  • Samples from the 50 mg/kg group collected at 48 h after dosing showed a trend towards return to vehicle levels.
  • Total HTT transcript levels at both dose levels showed a lowering trend at 8h and a greater degree of lowering at the 50 mg/kg level, 24 hours post-dosing.
  • Example 1b.1 Single ascending dose study of the safety, tolerability, and pharmacokinetics of branaplam in healthy adult subjects
  • the study is a randomized (3:1), double blind, placebo-controlled, sequential, single ascending dose design with up to five cohorts of subjects, each comprised of 8 subjects with 6 receiving branaplam and 2 receiving placebo. Cohorts are enrolled sequentially. Subjects in each cohort are randomly assigned on Day 1 to either branaplam or placebo in a ratio of 3:1. Doses for all five cohorts are listed herein:
  • Additional (optional) cohorts - dose in these additional cohorts may be lower, the same as, or higher than any of the preceding cohorts, but are capped at a maximum of up to 420 mg and 630 mg each
  • the study consists of 26 days in which screening can occur, a baseline period of up to 2 days, a 1 day treatment period, and a 2 week follow up period. Subjects who meet the eligibility criteria at screening are admitted for baseline evaluations, all baseline safety evaluation results must be available prior to dosing. Subjects may be admitted to the clinical research center for Baseline assessments on Day -2 or Day -1 (depending on scheduling at site) and remain in the clinical research center for 96 hours following dose administration. Study assessments continue for 14 days following dose administration. Safety assessments include physical examinations, ECGs, vital signs, standard clinical laboratory evaluations (hematology, blood chemistry, and urinalysis), and adverse event and serious adverse event monitoring. The sponsor and site investigator perform a joint dose escalation data review to decide whether to proceed with the next cohort
  • the protocol provides two optional, additional cohorts (Cohorts 4 and 5) that may be added during the course of the study based on the results from earlier cohorts.
  • the dose of branaplam in these additional cohorts may be lower, the same as, or higher than any of the preceding cohorts. Any dose higher than 210 mg will not exceed a 2-fold increment for increasing the dose relative to the preceding dose (i.e., 210 mg to 420 mg).
  • the study population is comprised of healthy adult male and female subjects.
  • BMI Body weight (kg) / [Height (m)] 2
  • Subjects should be excluded if their standing vital signs (relative to supine) show findings which, in the opinion of the Investigator, are associated with clinical manifestation of postural hypotension (in the absence of any other cause).
  • the Investigator should carefully consider (in consultation with the Sponsor) enrolling subjects with either a > 20 mmHg decrease in systolic or a >10 mm Hg decrease in diastolic blood pressure, accompanied by a > 20 bpm increase in heart-rate (from sitting to standing).
  • testicular disease males
  • Women of childbearing potential defined as all women physiologically capable of becoming pregnant.
  • Plasma donation (>400 ml) within 4 weeks of screening.
  • gastrointestinal tract surgery such as gastrectomy, gastroenterostomy, or bowel resection;
  • ALT SGPT
  • AST SGOT
  • GGT alkaline phosphatase and serum bilirubin
  • HBV Hepatitis B
  • HCV Hepatitis C
  • HBsAg Hepatitis Ag test, or if standard local practice, a positive HBV core antigen test, excludes a subject.
  • Subjects with a positive HCV antibody test should have HCV RNA levels measured.
  • Subjects with positive (detectable) HCV RNA should be excluded.
  • PK samples from plasma and urine are obtained from all subjects at all dose levels. Blood samples for pharmacokinetic assessments were taken on the day of dosing at predose, 1 h, 2 h, 3 h, 4 h, 6 h, 8 h, 24 h, 48 h, 72 h, 96 h, 168 h, and 336 h post dose. Analysis of samples are excluded for the placebo group, and may be excluded for urine samples in select cohorts.
  • Branaplam is determined in plasma and urine by a validated LC-MS/MS method.
  • the anticipated Lower Limit of Quantification (LLOQ) is 0.500 ng/mL. Concentrations are expressed in mass per volume units and refer to the free base (i.e. free form). Concentrations below the LLOQ is reported as “zero” and missing data is labeled as such in the Bioanalytical Data Report.
  • the following pharmacokinetic parameters are determined in plasma using the actual recorded sampling times and non-compartmental method(s) with Phoenix WinNonlin (Version 8 or higher): Cmax, Tmax, AUCIast, AUCinf, T1/2, Vz/F and CL/F from the plasma concentration-time data.
  • the linear trapezoidal rule is used for AUG calculation.
  • Regression analysis of the terminal plasma elimination phase for the determination of T1/2 includes at least 3 data points after Cmax.
  • the adjusted R 2 value of the regression analysis of the terminal phase is less than 0.75, if the observation period to estimate the T1/2 values is shorter than the estimated T1/2 value, and/or if the extrapolated AUG is greater than 20% of the estimated AUCinf, no values are reported for T1/2, AUCinf, CL/F, and Vz/F.
  • AeO-t of branaplam is determined from the urine concentration and volume-time data.
  • CLr of branaplam is determined based on AUG and Ae available for the scheduled time period.
  • HTT protein and HTT mRNA are analyzed: HTT protein and HTT mRNA.
  • HTT mRNA in whole blood is determined on the day of dosing at predose and at 1 h, 2 h, 3 h, 4 h, 6 h, 8 h, 24 h, 48 h, 72 h, 96 h and 168 h post dose.
  • Total HTT protein from PBMCs and plasma will be measured on the day of dosing at predose and at 4 h, 8 h, 24 h, 48 h, 72 h, 96 h and 168 h.
  • the absolute changes and fold-changes from baseline are calculated.
  • the biomarker data, changes and fold-changes are listed by treatment group, subject, and visit/time. Summary statistics are provided by treatment group and visit/time. The effect of branaplam treatment on biomarkers, is graphically explored using spaghetti plots (one panel by treatment group) and boxplots by timepoint and treatment group.
  • the profiles time are compared between treatment groups through analyses of longitudinal data using linear mixed models for repeated measures or other models depending on the distribution.
  • the model includes treatment, time, treatment by time interaction and baseline value use as fixed effects, where treatment and time are fitted as categorical variables and baseline is fitted as a continuous covariate.
  • An unstructured covariance matrix is fitted to allow for the within subject correlations. Point estimates and the associated 95% confidence intervals for the difference between each active treatment and placebo at each time-point is obtained. If the model fails to converge, alternative covariance structures or changes to the model may be applied.
  • Biomarker data are reported as concentration results, measured using a specific assay with a working range defined by the two limits: Lower limit of quantification (LLOQ) and Upper limit of quantification (ULOQ). Values which fall below the LLOQ or above the ULOQ are reported as ⁇ LLOQ * dilution factor (dilution factor: if sample diluted and concentration measured still below LLOQ) and > ULOQ * dilution factor, respectively.
  • LLOQ Lower limit of quantification
  • ULOQ Upper limit of quantification
  • Imputed values are used for summary statistics, inferential analyses and plots (with a special symbol). Values below LLOQ and values above ULOQ are shown as such in the listings.
  • Example 1b.4 Target engagement and HTT mRNA reduction in blood
  • Total RNA was extracted using the PAXgene Blood RNA Kit (Qiagen). Total RNA was reverse transcribed to cDNA using random hexamers and the iScripta cDNA Synthesis Kit (Bio-Rad). cDNA synthesis was performed according to manufacturer’s instructions using 400 ng of total RNA as input into a 20 pl cDNA reaction to generate an initial cDNA with a concentration of 20 ng/pl (total RNA equivalents). Finally, the cDNA was subsequently diluted 1/1 with nuclease-free water to generate a final cDNA with a concentration of 10 ng/pl (total RNA equivalents). All preparations were carried out on ice.
  • cDNA synthesis was performed on a C1000 Thermal cycler, Reaction Module 96W Fast (Bio-Rad) using the following conditions: 25°C for 5 min, 46°C for 20 min, 95°C for 1 min and hold at 4°C. cDNA samples were stored at -20°C.
  • HTT mRNA and novel-exon-included HTT mRNA were then quantified by polymerase chain reaction (PGR) using the Bio-Rad QX200 droplet digital PGR system in a duplex reaction containing a target gene assay (HTT assays) and a reference gene assay (either Glucuronidase beta (Gt/SS) or peptidylprolyl isomerase B (PPIB)).
  • Standard reaction and cycling conditions 95 °C for 10 min; 40 cycles of 94 °C for 30 sec and 60 °C for 60 sec; and 98 °C for 10 min; hold at 4 °C
  • a cDNA input total RNA equivalent
  • a customized quantitative PGR assay with forward primer 5’-TCCTGAGAAAGAGAAGGACATTG-3’ (SEQ ID NO: 3), reverse primer 5’- CTGTGGGCTCCTGTAGAAATC-3’ (SEQ ID NO: 4) and probe 5’-56- FAM/AATTCGTGG/ZEN/TGGCAACCCTTGAGA/3IABkFQ-3’ (SEQ ID NO: 7) was applied to quantify the inclusion of a novel exon into HTT mRNA (Pseudo50a).
  • Each target gene assay (Hs.PT.58.14833829, Hs.PT.58.25550542, Pseudo50a) was analyzed in a duplex reaction with a reference gene assay (either Glucuronidase beta (GUSB) or peptidylprolyl isomerase B (PPIB).
  • GUSB Glucuronidase beta
  • PPIB peptidylprolyl isomerase B
  • All target gene expression values were first normalized to the respective duplex reaction partner reference mRNA levels (GUSB or PPIB) by applying a normalization factor reflecting the normalization to the geometric mean of all GUSB or PPIB values for all samples tested in this study.
  • the arithmetic mean of the same target gene assay normalized to GUSB and PPIB mRNA levels was determined (e.g., the arithmetic mean of both PseudoSOa values normalized to GUSB and to PPIB). By applying these data processing steps, the determined values reflect the number of target gene molecules per 50ng RNA equivalent input.
  • mean levels of total HTT mRNA showed a maximum mean decrease from baseline (pre-dose) of 10% followed by a trend of recovery to baseline towards the end of the observation period at 168 h post dose.
  • the HTT mRNA changes were more pronounced with a maximum change of mean HTT mRNA from baseline ranging between 23-40% and showing a sustained effect until the end of the observation period (168 h) (Figure 29).
  • Example 1c.1 Pharmacokinetic model description - Comoartmental pharmacokinetic model
  • PK pharmacokinetics
  • the resulting profile was then fitted with a 1 -compartment PK model to estimated the PK parameters of branaplam after oral administration (software: Phoenix, v8.0, Cetera; 1 -compartment model: micro constants, extra-vascular, ‘Additive & Multiplicative’ residual error).
  • the derived PK parameters of branaplam after an oral administration of 1 mg were used to predict concentration-time profiles of branaplam after repeated weekly (QW) administration at different dose levels (28 mg, 56 mg, 84 mg, 112 mg, 156 mg, 196 mg, 238 mg).
  • PBPK Physiologically-based pharmacokinetic model
  • a first-order absorption model was used, and the fraction of dose absorbed (fa) was assumed to be completed.
  • the absorption rate constant (ka) and lag-time (Tlag) was based on population pharmacokinetic (PopPK) analysis.
  • the effective permeability in man (Peff.man) and normal flow in gut model (Qgut) values were predicted from Caco-2 permeability data of branaplam.
  • the fraction of unbound in enterocytes (fugut) value was assumed to be the same as the fraction of unbound in plasma (fup).
  • Vss volume of distribution at steady-state
  • the oral clearance in humans was also estimated based upon PopPK analysis and further optimized based on clinical data (see Example 1b).
  • the clearance pathways and their quantitative contributions for branaplam in adult humans were estimated based on clinical data (Example 1b) and rat ADME studies as ⁇ 10% renal clearance, ⁇ 10% biliary clearance and ⁇ 80% metabolism mediated elimination, where the relative contributions by CYP3A4 and other enzymes including UDP-glucuronosyltransferase (UGT) enzymes were estimated from in vitro enzyme phenotyping study, as 90% and 10%, respectively.
  • UDP-glucuronosyltransferase (UGT) enzymes were estimated from in vitro enzyme phenotyping study, as 90% and 10%, respectively.
  • the simulated steady-state median % fraction of metabolized in 100 subjects (10 trials and 10 subjects/trials aged 20-65 years with female ratio of 0.5) was 74% via CYP3A4, 8% via additional hepatic elimination, 9% via additional systemic clearance, and 9% via renal elimination.
  • Branaplam showed reversible inhibition of several CYP enzymes including CYP1A2, CYP2C9, CYP2C19, CYP2D6, CYP2E1, and CYP3A. Branaplam also showed time-dependent inhibition of CYP3A.
  • Branaplam PK was described by a linear two-compartmental model with first-order absorption and a lag time using Phoenix NLME (Version 8.1, Certara, Princeton, NJ, USA). Dose was incorporated as a covariate on bioavailability (F) and absorption rate constant (ka). The model and parameters were fitted to the data after a single oral dose (35 mg, 105 mg, 210 mg, and 420 mg, see Example 1b). A mix ratio residual error model was used as described by the equation:
  • the residual error model describes the random differences between observed values and the corresponding model predictions.
  • Inter-individual variability was implemented on the first order absorption rate constant (ka), lag time (Tlag), clearance (CL), distributional rate constants (V2 and Q) and apparent volume of distribution of the central compartment (V).
  • the exponential error model has been applied to all structural PK parameters.
  • the estimation method for model fitting was Quasi-random Parametric Expectation Maximization (QPREM).
  • QPREM Quasi-random Parametric Expectation Maximization
  • the verification of the PK prediction was performed using the available PK data from the clinical study (see Example 1b): 210 mg single dose from the highest dose group as of the available PK data in healthy volunteers (see Example 1b).
  • the Simcyp® PBPK model was used to simulate the branaplam concentration in plasma versus time profile after a single 210 mg branaplam oral dose in HVs.
  • Figure 25 shows the predictions of the PK parameters (AUC and Cmax) after a single 210 mg branaplam dose in comparison to the observed PK parameters estimated in healthy volunteers (Example 1b).
  • the concentration-time profiles of simulated branaplam are shown in Figure 26 in comparison to the profile determined in healthy volunteers (Examplelb).
  • the simulated PK parameters were comparable to those observed in the clinical study.
  • branaplam PBPK model assumes the fraction of absorption (fa) is 1.
  • a perpetrator e.g., an inhibitor or inducer of CYP3A4
  • a sensitive substrate e.g., CYP3A4 substrate, midazolam
  • Example 1c.3 Pharmacokinetic/pharmacodvnamic model description (i.e., using compartmental pharmacokinetic model)
  • PK/PD pharmacokinetic/pharmacodynamic
  • mice For the establishment of the PK/PD relationship and the development of a mouse PK/PD model, the PK parameters in mouse plasma were estimated considering branaplam PK data from studies with male C57BL/6 mice (10 mg/kg, single dose), rasH2 mice (1, 3, 4 and 10 mg/kg, repeated daily doses), and BacHD mice (10 and 50 mg/kg, single dose; 12 and 24 mg/kg, repeated, three times a week doses).
  • mice PK parameters were pooled and analyzed using a population PK model with extra-vascular administration, a lag time (Tlag), 2-compartments (V1: volume of compartment 1; V2 volume of compartment 2, Q: intercompartmental clearance; ka: first order rate of absorption; CL: clearance).
  • Tlag lag time
  • 2-compartments V1: volume of compartment 1; V2 volume of compartment 2, Q: intercompartmental clearance; ka: first order rate of absorption; CL: clearance.
  • This population PK model is described in the Monolix model library (Monolix software (Version 2018R1, Lixoft)).
  • the population PK parameter estimation was done using non-linear mixed effects techniques using the Monolix software (Version 2018R1, Lixoft).
  • mutant HTT protein concentrations were determined in both the brain cortex and brain striatum, therefore the PK/PD relationship of the changes in mutant HTT protein concentration as a function of branaplam PK were derived separately for each of these brain compartments. Still, for each compartment, all mutant HTT protein measurements were considered together to derive the PK/PD relationship.
  • the dynamic relationship between branaplam concentrations in plasma and the mutant HTT protein concentrations in the brain was investigated with a turnover model (described below) considering that branaplam can inhibit the production of mutant HTT protein in the brain with a PK to RD time delay.
  • the turnover model enabled the description of the observed time delay between Cmax of branaplam in plasma (between 3 to 6 h post dose) and maximum decrease of mutant HTT protein in the brain (about 72 h post dose).
  • the PK parameters from the previously described population PK model were fixed to the values presented in Figure 14 and the PD parameter values were estimated by fitting to the pooled PD data.
  • the Monolix software (Version 2018R1, Lixoft) and its turnover model described in the library (pkpd/oral1_2cpt_SigmoidindirectModelinhibitionKin_TlagkaCIV1QV2R0koutimaxlC50gamma) were used to determine the PD parameters in the mouse.
  • Imax maximum inhibitory effect of branaplam on mutant HTT protein synthesis
  • IC50 half-maximum inhibitory concentration of branaplam on mutant HTT protein synthesis
  • max(Cc.O) predicted branaplam plasma concentration
  • Example 1c.1 the PK parameters from healthy adult volunteers (Example 1c.1) were used to predict the concentration-time profile of branaplam in plasma after oral administration, considering a nominal body weight of 70 kg.
  • the underlying assumption was that branaplam PK parameter values in adult patients are similar to the PK parameter values in healthy adult volunteers.
  • branaplam • The potency of branaplam (IC50) was assumed to be the same in human as in BacHD mouse. The value was not corrected by the plasma protein binding because the plasma protein binding values in mouse (0.741) and human (0.8) were comparable.
  • Degradation rate or fractional turnover parameter of the mutant HTT protein synthesis can be scaled from BacHD mouse to human considering an allometric scaling method based on the assumption that endogenous turnover of proteins, peptides and hormones can be scaled across different species and are related to energy turnover or metabolic rates (Gabrielsson J, Hjorth S, Quantitative Pharmacology: An Introduction to Integrative Pharmacokinetic-Pharmacodynamic Analysis. Swedish Pharmaceutical Press;
  • kout_human kout_mouse*(body weight_human/body weight_mouse)
  • a -0.2 was used for the estimation of kout in human, with a human body weight weight of 70 kg and a mouse body weight of 0.025 kg.
  • PK parameters from healthy adult volunteers (Example 1c.1; i.e., Compartmental pharmacokinetic model) and the RD model for adult patients were coupled and simulations executed using Phoenix software (Version 8, Certara).
  • the simulations targeted a reduction of approximately 35% to 50% mutant HTT protein in the brain (Kaemmerer WF and Grondin RC, 2019, The effects of huntingtin-lowering: what do we know so far?, Degenerative Neurological and Neuromuscular Disease, 9, pp 3-17; Caron NS, Dorsey ER, and Hayden MR, 2018, Therapeutic approaches to Huntington disease: from the bench to the clinic, Nature Review-Drug Discovery, 17, pp 729-750). Modelling results - PK/PD model based on BacHD mouse
  • the parameter value estimates of the BacHD mouse PK/PD model for branaplam are presented in Figure 17.
  • the predicted distribution of mutant HTT protein in the brain (cortex and striatum) of the BacHD mouse after triple oral administration of branaplam for 3 weeks are presented in Figure 18 (for cortex) and Figure 19 (for striatum).
  • the distributions are overiayed on the measured mutant HTT protein values (filled circles).
  • Example 1c.1 i.e., Compartmental pharmacokinetic model
  • Figure 14 The scaled population PD data in adults are presented in Figure 22.
  • the PK/PD model developed to predict the effect of branaplam treatment on the concentration of mutant HTT protein in adult patients was used to simulate the plasma concentration-time profiles of branaplam and the corresponding decrease of mutant HTT protein in the brain (cortex and striatum) following weekly doses of branaplam.
  • Example 1c.4 Pharmacokinetic/oharmacodvnamic model description (i.e., using physiologically based pharmacokinetic model)
  • PK/PD pharmacokinetic/pharmacodynamic
  • the modeling strategy is similar to the strategy, which was described in Example 1c.3 with the exception that the predicted branaplam PK in humans were from healthy adult volunteers using the Physiological-based pharmacokinetic model as described in Example 1c.2.
  • Example 1c.2 The model development of the establishment of the PK/PD relationship in mouse and the model development of a PK/PD model in adult patients was similar as described in Example 1c.3.
  • the PK parameters from healthy adult volunteers (Example 1c.2) and the PD model for adult patients were coupled and simulations executed using Phoenix software (Version 8, Certara).
  • Several dose-levels with a weekly dosing regimen were simulated in adults to predict the corresponding PK/PD time profiles and PK/PD exposure and response metrics (e.g. maximum concentration, Cmax, and area under the curve, AUG; mHTT decrease in brain).
  • the simulations targeted a reduction of approximately 35% to 50% mutant HTT protein in the brain (Kaemmerer WF and Grondin RC, 2019, The effects of huntingtin-lowering: what do we know so far?, Degenerative Neurological and Neuromuscular Disease, 9, pp 3-17; Caron NS, Dorsey ER, and Hayden MR, 2018, Therapeutic approaches to Huntington disease: from the bench to the clinic, Nature Review-Drug Discovery, 17, pp 729-750).
  • the PK/PD model developed to predict the effect of branaplam treatment on the concentration of mutant HTT protein in adult patients was used to simulate the plasma concentration-time profiles of branaplam and the corresponding decrease of mutant HTT protein in the brain (cortex and striatum) following weekly doses of branaplam.
  • This study is a randomized, double-blind, placebo-controlled study with a variable treatment duration (between approximately 16 weeks to approximately 52 weeks) for the core period and a one year OLE, in 75 to 90 early stage manifest HD patients.
  • the Core Period consists of a 16-week double-blind, placebo-controlled, Dose Range Finding (DRF) portion of the study, followed by a Blinded Extension (BE) of variable duration (ranging from approximately 4-12 months; duration is dependent on timing of randomization and recruitment rate).
  • Period 1 evaluates the safety, tolerability, PK and PD of branaplam, as well as determine the optimal dose(s) to explore in further clinical evaluations using all available data collected at the time the last randomized patient in the study completes the End of DRF visit which captures a foil 16 weeks.
  • the Open Label Extension (OLE) Period is a one year open-label extension to assess both long term safety and tolerability, as well as the efficacy of the recommended optimal dose(s) for branaplam. If branaplam development in Huntington's Disease remains ongoing at the end of the OLE, the study is either (a) amended to extend the OLE beyond a year, or (b) a separate extension study is initiated to offer continued access to branaplam. Study participants from the OLE may be eligible to rollover into this separate extension study.
  • the study design uses a staggered cohort approach, allowing safety and tolerability of lower doses to be assessed before randomizing subjects to higher doses.
  • the Core Period consists of a minimum of 3 or maximum of 5 treatment arms; each treatment arm enrolls approximately 20 to 25 patients, dependent on the total number of cohorts initiated.
  • Treatment arms are defined as: Treatment Arm A: Branaplam 56mg oral solution or matching PBO, once weekly Treatment Arm B: Branaplam 112mg oral solution or matching PBO, once weekly Treatment Arm C: Branaplam 154mg oral solution or matching PBO, once weekly Treatment Arm D: Branaplam 196mg oral solution or matching PBO, once weekly Treatment Arm E: Branaplam 238mg oral solution or matching PBO, once weekly Treatment Arm X: Branaplam 84mg oral solution or matching PBO, once weekly Treatment Arm Y: Branaplam 28mg oral solution or matching PBO, once weekly
  • Cohort 1 includes Treatment Arms A (56mg) and B (112mg). After the 10th participant in each of the Treatment Arms in Cohort 1 reaches Week 8 of the DRF Treatment Period, all available data, including relevant post-dose PK timepoints, is reviewed from a safety and dose finding perspective by an independent Sponsor team in consultation with the Data Monitoring Committee (DMC) chair at the Cohort Gating Assessment 1.
  • DMC Data Monitoring Committee
  • Cohort 2 If T reatment Arm X or Y is selected for Cohort 2: total recruitment is expanded to include a total of approximately 75 participants (randomized equally across Treatment Arms A, B, and X or A, B, and Y for approximately 25 per treatment arm). The interim analysis (IA) then takes place after the last randomized participant completes the 16-Week DRF period.
  • IA interim analysis
  • T reatment Arm C is selected for Cohort 2: after approximately the 10th participant in the cohort has completed Week 8 of the DRF Treatment Period, all available data including relevant post dose PK timepoints, is again reviewed at CGA#2 by the independent Sponsor team, in consultation with the DMC chair to determine if Cohort 3 should be opened. During this time, recruitment continues in any open treatment arms (up to a maximum of 20 patients in each treatment arm). If Cohort 3 is not initiated, then total recruitment is expanded to include a total of approximately 75 participants (randomized equally across Treatment Arms A, B, and C; approximately 25 per treatment arm) and the IA then takes place after the last randomized participant completes the 16-Week DRF period.
  • an IA is conducted. All data available at this time, including, but not limited to safety/tolerability as well as mHTT and total HTT lowering in CSF, plasma and PBMCs, is assessed to determine optimal dose(s) and open label treatment regimen for OLE. After the IA and confirmation of selected dose(s) and regimen, all patients from the blinded Core Period roll over to OLE; patients are re-assigned from their blinded Core Period dosing onto the newly selected open label OLE dose(s) and dose regimen.
  • OLE is a one year open label treatment and safety monitoring part of the study.
  • participant After confirming eligibility, participants are randomized to an open cohort to receive either active or PBO treatment as an oral solution administered once. Although 5 maximum treatment arms are planned, timing during the ongoing recruitment determines which available treatment arms are actively recruiting. In addition, not all treatment arms may be initiated, as it is dependent on the available safety profile, PK and mHTT lowering data. Participants receive at least 16 weeks of treatment and remain on the initially assigned treatment arm during the Core Period in the BE until IA is completed and optimal dose(s) selected for OLE. After dose selection, patients continue participation in OLE. Premature discontinuation of study drug during Core Period;
  • Strong systemic inhibitors of CYP3A4 examples include, but are not limited to boceprevir, clarithromycin, cobicistat, conivaptan, grapefruit juice, idelalisib, indinavir, itraconazole, ketoconazole, mibefradil, nefazodone, nelfinavir, posaconazole, ritonavir, telaprevir, telithromydn, troleandomycin, voriconazole.
  • ombitasvir/paritaprevir/dasabuvir/ritonavir (Viekira Pak), indinavir/ritonavir, tipranavir/ritonavir, danoprevir/ritonavir, elvitegravir/ritonavir, saquinavir/ritonavir, lopinavir/ritonavir, atazanavir/ritonavir, darunavir/ritonavir
  • Strong systemic inducers of CYP3A4 examples include, but are not limited to apalutamide, carbamazepine, enzalutamide, mitotane, phenytoin, rifampin, St John’s wort; Go-medications metabolized via CYP3A4/5 with narrow therapeutic index examples include but are not limited to alfentanil
  • Participant has other severe, acute or chronic medical conditions including unstable psychiatric conditions, or laboratory abnormalities that in the opinion of the Investigator may increase the risk associated with study participation, or that may interfere with the interpretation of the study results
  • spermicidal agent e.g. foam, gel, cream, etc.
  • a condom is required for all sexually active male participants (unless using semen provided prior to initiation of study treatment) even if they are surgically sterile with a vasectomy to prevent them from fathering a child AND to prevent delivery of study treatment via seminal fluid to their partner.
  • Periodic abstinence e.g., calendar, ovulation, symptothermal, post-ovulation methods
  • withdrawal are not acceptable methods of contraception
  • IUD intrauterine device
  • IUS intrauterine system
  • Women are considered post-menopausal and not of childbearing potential if they have had 12 months of natural (spontaneous) amenorrhea with an appropriate clinical profile (e.g. age appropriate, history of vasomotor symptoms) or have had surgical bilateral oophorectomy (with or without hysterectomy), total hysterectomy or tubal ligation at least six weeks ago.
  • an appropriate clinical profile e.g. age appropriate, history of vasomotor symptoms
  • surgical bilateral oophorectomy with or without hysterectomy
  • total hysterectomy or tubal ligation at least six weeks ago.
  • DSM-V Diagnostic and Statistical Manual of Mental Disorders Fifth Text revision
  • ECG abnormalities indicating significant risk or safety concern for study participants such as: History of myocardial infarction (Ml), angina pectoris, heart failure, or coronary artery bypass graft (CABG) within 6 months prior to starting study treatment.
  • LVEF left ventricular ejection fraction
  • LLS Global Longitudinal Strain
  • cardiac arrhythmias e.g., sustained ventricular tachycardia, atrial fibrillation, etc
  • complete left bundle branch block e.g., highgrade AV block (e.g., bifascicular block, Mobitztype II and third degree AV block).
  • highgrade AV block e.g., bifascicular block, Mobitztype II and third degree AV block.
  • This study is a randomized, double-blind, placebo-controlled study with a variable treatment duration (between approximately 17 weeks to approximately 53 weeks) for the core period and a one-year OLE in approximately 75 early stage manifest HD patients.
  • the Core Period consists of a 17-week double-blind, placebo-controlled, Dose Range Finding (DRF) portion of the study, followed by a Blinded Extension (BE) of variable duration (up to approximately 53 weeks; duration is dependent on timing of randomization and recruitment rate).
  • the DRF Period evaluates the safety, tolerability, pharmacokinetic(s) (PK) and pharmacodynamics) (PD) of branaplam, as well as determine the optimal dose(s) to explore in further clinical evaluations using all available data collected at the time the last randomized patient in the study completes the Week 17 visit assessments which captures a full 16 weeks of treatment with study drug.
  • the Open Label Extension is a one-year open-label extension to assess both long term safety and tolerability, as well as the efficacy of the recommended optimal dose(s) for branaplam. If branaplam development in HD remains ongoing at the end of the OLE, the study is either (a) amended to extend the OLE beyond a year, or (b) a separate extension study is initiated to offer continued access to branaplam. Study participants from the OLE may be eligible to rollover into this separate extension study.
  • the study design uses a staggered cohort approach, allowing safety and tolerability of lower doses to be assessed before randomizing subjects to higher doses.
  • the Core Period consists of 3 treatment arms; each treatment arm enrolls approximately 25 patients, dependent on the total number of cohorts initiated.
  • Treatment arms are defined as:
  • Treatment Arm A Branaplam 56 mg oral solution or matching placebo (PBO), once weekly
  • Treatment Arm B Branaplam 112 mg oral solution or matching PBO, once weekly
  • Treatment Arm C Branaplam 154 mg oral solution or matching PBO, once weekly
  • Treatment Arm X Branaplam 84 mg oral solution or matching PBO, once weekly
  • Treatment Arm Y Branaplam 28 mg oral solution or matching PBO, once weekly
  • CGAs Cohort Gating Assessments
  • All available data is reviewed from a safety and dose finding perspective by an independent Sponsor team to support the decision to open the next cohort.
  • the independent Data Monitoring Committee (DMC) reviews the data separately. The decision to open a new cohort is made by the Sponsor in consultation with the DMC.
  • Cohort 1 includes Treatment Arm A (56 mg). After the 10th participant in Arm A reaches Week 9 of the DRF Treatment Period, all available data, including relevant post-dose PK time points, are reviewed from a safety and dose finding perspective by an independent Sponsor team to support the decision to open the next cohort. The independent Data Monitoring Committee (DMC) reviews the data separately. The decision to open Cohort 2 at the Cohort Gating Assessment 1 (CGA 1) is made by the Sponsor in consultation with the DMC. (Also, included in the review are PK data, blood/PBMC mHTT and total HTT levels, from a safety and not efficacy perspective, to ensure that HTT lowering is not beyond the anticipated safety threshold.) During this time, recruitment continues in Cohort 1.
  • DMC Data Monitoring Committee
  • Cohort 2 If Cohort 2 is initiated, after approximately the 10 th participant in Treatment Arm B has reached Week 9 of the DRF Treatment Period, all available data, including relevant post dose PK time points, are again reviewed at CGA 2 by the independent Sponsor team and the DMC. Based on the results from the review of the data during CGA 2, a decision is made to select the Treatment Arm in Cohort 3.
  • Cohort 3 If Cohort 3 is initiated, and based on the data review during CGA 2, the decision is made to initiate the next higher dose (Treatment Arm C, 154 mg) or an intermediary dose (Treatment Arm X, 84 mg) or a lower dose (Treatment Arm Y, 28 mg). At this time, participants are eligible to randomize into any open Treatment Arm if it has not yet been completed. Alteratively, if Cohort 1 and 2 recruitment is complete prior to the initiation of Cohort 3, participants are then only eligible for randomization into Cohort 3. The interim analysis (IA) then takes place after the last randomized participant completes the DRF period (Week 17 visit). Participants are randomized in an equal randomization rate among the open treatment arms, and then in a 4:1 ratio for active vs. placebo within each arm.
  • IA interim analysis
  • OLE is a one-year open label treatment and safety monitoring part of the study.
  • participant After confirming eligibility, participants are randomized to an open cohort to receive either active or PBO treatment as an oral solution administered once weekly. Although a maximum of 3 treatment arms are planned, timing during the ongoing recruitment determines which available treatment arms are actively recruiting. In addition, not all treatment arms may be initiated, as it is dependent on the available safety profile, PK and mHTT lowering data. Participants receive at least 16 weeks of treatment and remain on the initially assigned treatment arm during the Core Period in the BE until IA is completed and optimal dose(s) selected for OLE. After dose selection, which may be more than one selected dose, patients continue participation in OLE.
  • Strong systemic inhibitors of CYP3A4 examples include, but are not limited to boceprevir, clarithromycin, cobicistat, conivaptan, grapefruit juice, idelalisib, indinavir, itraconazole, ketoconazole, mibefradil, nefazodone, nelfinavir, posaconazole, ritonavir, telaprevir, telithromycin, troleandomycin, voriconazole.
  • ritonavir-boosted regimens considered: ombitasvir/paritaprevir/dasabuvir/ritonavir (Viekira Pak), indinavir/ritonavir, tipranavir/ritonavir, danoprevir/ritonavir, elvitegravir/ritonavir, saquinavir/ritonavir, lopinavir/ritonavir, atazanavir/ritonavir, darunavir/ritonavir; Strong systemic inducers of CYP3A4 examples include, but are not limited to apalutamide, carbamazepine, enzalutamide, mitotane, phenytoin, rifampin, St.
  • Co-medications metabolized via CYP3A4/5 with narrow therapeutic index examples include but are not limited to alfentanil, astemizole, cisapride, cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, sirolimus, tacrolimus);
  • Co-medications eliminated via renal MATE2K transporter examples include, but not limited to fexofenadine, glycopyrronium, metformin;
  • Medication(s) with a "Known Risk of Torsade de Pointes" examples include but are not limited to the following: escitalopram, citalopram, haloperidol, sulpiride, chlorpromazine, ondansetron, hydroxychloroquine ciprofloxacin, clarithromycin;
  • Medication (s) with “Potential risk of TdP” examples include but are not limited to the following: aripiprazole
  • Co-medications substrate of OCTI transporter examples include, but not limited to cephalexin, dofetilde, pilsicainide, pindolol, procainamide, ranitidine, varenicline, umeclidinium, zidovudine.
  • Participant has other severe, acute or chronic medical conditions including unstable psychiatric conditions, or laboratory abnormalities that in the opinion of the Investigator may increase the risk associated with study participation, or that may interfere with the interpretation of the study results
  • a condom is required for all sexually active male participants even if they are surgically sterile with a vasectomy to prevent them from fathering a child AND to prevent delivery of study treatment via seminal fluid to their female partner.
  • a condom is required to be used also by vasectomized men as well during intercourse with a male partner of the study participant.
  • Women of childbearing potential defined as all heterosexually active women physiologically capable of becoming pregnant, unless they are using one highly effective methods of contraception during dosing and for 7 months after stopping the study medication.
  • Highly effective methods of birth control are those methods that have a less than 1% chance of an unwanted pregnancy during 1 year.
  • a condom is required for all male partners of female participants to prevent fathering a child AND to prevent exposure of study treatment via vaginal fluid to partner, until at least 7 months following the last dose of study treatment.
  • Total abstinence, periodic abstinence (e.g., calendar, ovulation, symptothermal, postovulation methods) and withdrawal are NOT acceptable methods of contraception for heterosexually active participants.
  • Female sterilization (have had surgical bilateral oophorectomy with or without hysterectomy) total hysterectomy or bilateral tubal ligation at least six weeks before taking investigational drug. In case of oophorectomy alone, only when the reproductive status of the woman has been confirmed by follow up hormone level assessment.
  • IUD intrauterine device
  • IUS intrauterine system
  • HIV human immunodeficiency virus
  • THC Tetra-Hydro-Cannabinoid
  • cannabinoid containing substances Use of Tetra-Hydro-Cannabinoid (THC)/ cannabinoid containing substances is allowed as per local regulations and/or local medical practice if in the opinion of the Investigator, use does not represent an exclusionary condition, does not constitute abuse and does not affect cognition, and provided that participants are currently treated with a stable regimen for at least 12 weeks prior to randomization. Note: If initiated during the study, use must be withheld for 72 hours prior to any cognitive and/or motor assessments.
  • Gl Unstable chronic gastrointestinal condition
  • IBS poorly controlled irritable bowel syndrome
  • HbA1c glycated hemoglobin
  • Lipase, total bilirubin or amylase must not exceed the 1 5x upper limit of normal (ULN) Liver disease or liver injury as indicated by abnormal liver function tests
  • AV atrioventricular
  • Thrombocytopenia or platelets S100 x 10 9 /L
  • PK samples are collected at the visits defined in the assessment schedule:
  • Dose Range Finding & Blinded Extension Week 1 at 0 h (pre-dose), 4 h, 7 h, 12 h (optional), 22 h 72 h, and 168 h after first dosing; Week 3 and 5 at 0 h (predose); Week 9 at 0 h (pre-dose), 4 h, 12 h (optional), and 22 h after Week 9 dose; Week 13 at 0 h(pre-dose); Week 17 at 0 h (pre-dose), 4 h, 12 h (optional), 22 h, and 72 h after Week 17 dose; Week 25, Week 33, Week 41, Week 53 and every 8 weeks afterwards at 0 h (pre-dose).
  • Open label extension Baseline and Weeks 9, 17, 25, 33, 41, and 53 at 0 h (pre-dose)). PK samples in CSF are collected in Weeks 1, 9, 17, 33, 53, 69, 85, and 101 at 0 h (pre-dose) in the Dose Range Finding & Blinded Extension and at baseline and Weeks 17, 33, and 53 at 0 h (pre-dose) in the Open label extension.
  • PK samples from plasma and CSF are obtained from all participants at all dose levels.
  • Branaplam is determined in plasma and CSF by a validated LC-MS/MS method.
  • the anticipated Lower Limit of Quantification (LLOQ) is 0.500 ng/mL. Concentrations are expressed in mass per volume units and refer to the free base. Concentrations below the LLOQ are reported as “zero” and missing data is labeled as such in the Bioanalytical Data Report.
  • the following pharmacokinetic parameters are determined in plasma after first dosing and at the Week 17 visit using the actual recorded sampling times and non-compartmental method(s) with Phoenix WinNonlin (Version 8 or higher): the maximum concentration (Cmax), the time it takes to reach Cmax (Tmax), AUCIast, AUCtau, AUCinf, T1/2, Vz/F and CL/F from the plasma concentration-time data.
  • the linear trapezoidal rule is used for AUG calculation.
  • Regression analysis of the terminal plasma elimination phase for the determination of T1/2 includes at least 3 data points after Cmax. If the adjusted R 2 value of the regression analysis of the terminal phase is less than 0.75, if the observation period to estimate the T1/2 values is shorter than the estimated T1/2 value, and/or if the extrapolated AUG is greater than 20% of the estimated AUCinf, no values are reported for T1/2, AUCinf, CL/F, and Vz/F.
  • Mutant Huntingtin (mHTT) protein is measured in CSF on the day of dosing at predose and at week 9, week 17, to evaluate the dose-response relationship between branaplam doses and mHTT in CSF. This relationship is determined by statistical modelling based on the percent reduction of mHTT observed from BL levels.
  • mHTT in CSF continues to be monitored in the Blinded Extension phase, and Open Label Extension phase every 16 weeks.
  • Total HTT protein is measured in CSF on the day of dosing at predose and at week 8 and week 17, to evaluate the dose-response relationship between branaplam doses and total HTT in CSF.
  • total HTT in CSF continues to be monitored in the Blinded Extension phase, and Open Label Extension phase every 16 weeks.
  • Mutant Huntingtin (mHTT) protein is measured in plasma and PBMCs on the day of dosing at predose and at 22h, and 72 h, post dose, to assess the pharmacodynamic effect of branaplam administered once weekly.
  • mHTT is measured in plasma and PBMCs at week 2, 3, 5, and 9 of the dose range finding portion of the study. Thereafter, mHTT is evaluated every 4 weeks in plasma and PBMCs during the blinded extension, and every 8 weeks in the open label extension portions of the study.
  • Total HTT protein is measured in plasma and PBMCs on the day of dosing at predose and at predose and at 22h, and 72 h, post dose, to assess the pharmacodynamic effect of branaplam administered once weekly.
  • total HTT is measured in plasma and PBMCs at week 2, 3, 5, and 9 of the dose range finding portion of the study. Thereafter, total HTT is evaluated every 4 weeks in plasma and PBMCs during the blinded extension, and every 8 weeks in the open label extension portions of the study.
  • biomarkers are secondary variables: changes in brain volume as measured by volumetric MRI in selected brain regions of interest, total HTT protein in CSF, PBMCs and plasma, and mHTT in PBMCs and plasma. Biomarker data are reported over three periods:
  • DRF An analysis of change from BL to week 17 are performed using longitudinal MMRM model with treatment as factor and adjusting for important covariates for DRF period at the time of IA (based on Full Analysis Set).
  • Core + OLE descriptive statistics of the change from BL and BL-EXT to week 53-EXT are presented by treatment group originally assigned during core and by selected dose(s) for OLE(based on OLS).
  • the primary data analysis so called the IA, are performed at the end of DRF, where all randomized participants have completed their last assessment of this DRF period (Week 17, after 16 weeks on treatment).
  • the analysis may include 4 treatment groups (3 active, 1 placebo).
  • the dose finding objective is associated with the two goals below:
  • the efficacy primary endpoint is the % change from baseline of mHTT concentrations in CSF after 16 weeks of treatment, which is expressed as: (mHTT wk17- mH I I baseine)/mH I I baseine*100%.
  • the primary endpoints of the safety and tolerability objective comprise main safety data, including but not limited to AEs/SAEs, physical exam findings, clinical laboratory assessments, and HTT lowering.
  • UHDRS Unified Huntington's Disease Rating Scale
  • TFC Total Functional Capacity
  • TMS UHDRS Total Motor Score
  • IS UHDRS Independence Scale
  • vMRI Volumetric MRI
  • biomarkers total HTT and mHTT protein in CSF, PBMCs and plasma.
  • PK parameters e.g. AUCIast, AUCtau, Cmax, Tmax, Ctrough
  • Example 2.2 Evaluation of the effect of branaplam on the expression levels of Huntingtin (HTT) mRNA in infants with Type I spinal muscular atrophy
  • branaplam The effect of branaplam on the expression levels of Huntingtin (H77) mRNA was assessed in infants with Type I spinal muscular atrophy who were enrolled in an open-label multi-part first-in- human proof of concept study of oral branaplam.
  • the aim of part one of this study was to determine the safety and tolerability of ascending weekly doses and to estimate the maximum tolerated dose (MTD) of oral/enteral branaplam (see Example 3) in infants with Type 1 SMA. All patients had exactly 2 copies of the SMN2 gene, as determined e.g. by quantitative real time PCR or droplet digital PCR.
  • branaplam Patients were dosed once weekly with branaplam. The branaplam doses were escalated in subsequent cohorts until MTD was determined or when PK results confirmed that the MTD could not be reached due to a potential pharmacokinetic exposure plateau at higher doses.
  • the starting dose was 6 mg/m 2 (approximately 0.3125 mg/kg). Subsequent doses were 12 mg/m 2 , 24 mg/m 2 , 48 mg/m 2 and 60 mg/m 2 (approximately 0.625 mg/kg, 1.25 mg/kg, 2.5 mg/kg and 3.125 mg/kg, respectively). Each cohort had 2-3 patients. All doses are of branaplam (free form). 14 patients were enrolled in Part 1 ; 13 patients were exposed to branaplam. The duration of exposure ranged from 4-33 months, 7 patients remain in the study. Six of the 7 patients are receiving 60 mg/m 2 , 1 patient is receiving 48 mg/m 2 . No dose-limiting toxicity was observed.
  • Part two of this study is to evaluate the long-term safety and tolerability of 2 doses of branaplam administered weekly for 52 weeks in patients with Type 1 SMA.
  • Part 2 of the study enrolls patients into 2 cohorts: cohort 1 at a 0.625 mg/kg dose and cohort 2 at a 2.5 mg/kg dose.
  • the selected dose levels of 0.625 mg/kg and 2.5 mg/kg are based on all safety data from Part 1 , as well as, all data from chronic juvenile toxicity studies available at the time of initiation of Part 2.
  • Approximately 10 patients were planned to be enrolled in cohort 1 and 2.
  • a total of twenty-five patients were enrolled and all received the treatment at least once, to date, 22 patients are still being treated for 6 to 18 months.
  • a 0.6 mL blood sample was collected with one Multivette® 600 Potassium EDTA ( Sarstedt ). After gentle mixing, the blood was transferred directly into the solution of a PAXgene Blood RNA tube (Becton Dickinson). The sample was immediately gently inverted 8 to 10 times to prevent clotting and left at room temperature in an upright position for 2 to 3 hours. After incubation, the PAXgene Blood RNA Tubes were stored at -20 °C.
  • Total RNA was extracted using the PAXgene Blood RNA Kit (Qiagen). Total RNA was reverse transcribed to cDNA using random hexamers and the iScriptTM Advanced cDNA Synthesis Kit (Bio-Rad). cDNA synthesis was performed according to manufacturer’s instructions using 100 ng of total RNA as input into a 20 pl cDNA reaction to generate an initial cDNA with a concentration of 5 ng/pl (total RNA equivalents). Finally, the cDNA was subsequently diluted 1/1 with nuclease- free water to generate a final cDNA with a concentration of 2.5 ng/pl (total RNA equivalents). All preparations were carried out on ice.
  • cDNA synthesis was performed on a C1000 Thermal cycler, Reaction Module 96W Fast (Bio-Rad) using the following conditions: 25°C for 5 min, 46°C for 20 min, 95°C for 1 min and hold at 4°C. cDNA samples were stored at -20°C.
  • HTT mRNA and novel-exon-included HIT mRNA were then quantified by polymerase chain reaction (PGR) using the Bio-Rad QX200 droplet digital PCR system. Standard reaction and cycling conditions (95 °C for 10 min; 40 cycles of 94 °C for 30 sec and 60 °C for 60 sec; and 98 °C for 10 min; hold at 4 °C) and a cDNA input (total RNA equivalent) of 20 ng were applied.
  • PGR polymerase chain reaction
  • a customized quantitative PCR assay with forward primer 5’-TCCTGAGAAAGAGAAGGACATTG-3’ (SEQ ID NO: 3), reverse primer 5’- CTGTGGGCTCCTGTAGAAATC-3’ (SEQ ID NO: 4) and probe 5’-56- FAM/AATTCGTGG/ZEN/TGGCAACCCTTGAGA/3IABkFQ-3‘ (SEQ ID NO: 7) was applied to quantify the inclusion of a novel exon into HTT mRNA.
  • HEX/ACGCAGAAA/ZEN/ATACGTGGTTGGAGAGC/3IABkFQ-3’ (SEQ ID NO: 18), purchased from Integrated DNA Technologies, Inc.) was used to assess GUSB mRNA levels.
  • HTT Huntingtin
  • HTT mRNA levels returned to values around baseline levels between study days 904 and 1450 (Figure 13).
  • Our results demonstrate that branaplam treatment of infants with Type I spinal muscular atrophy induces the inclusion of a novel exon into blood HTT mRNA and lowers blood HTT mRNA levels by up to 50% as compared to baseline.
  • Figure 12 Weekly oral doses of branaplam induced and elevated blood HTT transcript levels with inclusion of a novel exon in infants with SMA Type 1. Longitudinal data from study days 358 to 1450 were available from only 1-5 subjects depending on progress of the individual subjects within the study. Error bars represent standard error.
  • Figure 13 Weekly oral doses of branaplam lower blood HTT transcript levels in infants with SMA Type 1. Longitudinal data from study days 358 to 1450 were available from only 1-5 subjects depending on progress of the individual subjects within the study. Error bars represent standard error.
  • the required amount of 2-hydroxypropyl-beta-cyclodextrin was dissolved in 80% volume of target water (i.e. final intended volume) and stirred for 30 minutes.
  • the required amount of branaplam monohydrochloride salt was then added to said solution, under stirring, at room temperature.
  • the solution was stirred for 45 minutes after the addition was completed or for longer until a particle- free (i.e. to naked eye) solution was obtained.
  • Initial pH adjustment was performed using NaOH 0.1M or HCI 0.1M to reach the intended pH ( ⁇ 0.25).
  • the required volume of water was added to the solution to reach the final intended volume and stirred for at least 10 minutes at 25 ⁇ 3 °C after the addition was completed.
  • Final pH adjustment was performed using NaOH 0.1M or HCL 0.1M to reach the intended pH.

Abstract

Use of a splicing modulator for a treatment slowing progression of Huntington's disease.

Description

THE USE OF A SPLICING MODULATOR FOR A TREATMENT SLOWING PROGRESSION OF HUNTINGTON’S DISEASE FIELD OF THE INVENTION The invention relates to the use of a splicing modulator for a treatment slowing progression of Huntington’s disease. BACKGROUND OF THE INVENTION Huntington’s disease (HD) is a hereditary, neurodegenerative and progressive disorder, which has a prevalence of about 5 in 100,000 worldwide. It is caused by CAG repeat expansions in the huntingtin gene (i.e. gene encoding the protein huntingtin) and it is characterized by motor, cognitive, psychiatric and functional capacity decline. The CAG trinucleotide repeat expansion results in a mutant huntingtin protein (mHTT), which is associated with neural dysfunction and ultimately death. The number of CAG repeats in the HTT gene ranges from 6 to 35 in healthy individuals. Disease penetrance is seen to be reduced for individuals carrying 36 to 39 CAG repeats, however those with 40 or more CAG repeats are almost certain to develop the disease. As described in European Journal of Neurology, 2017, 24- 34, clinical diagnosis of HD is based on: - confirmed family history or positive genetic test (i.e. confirmation of CAG repeat expansion_≥36); and - onset of motor disturbance as defined by the Unified Huntington’s Disease Rating Scale (UHDRS) total motor score (TMS) diagnostic confidence score (DCS), which rangesfrom 0 (no motor abnormalities suggestiveof HD)to 4 (motorabnormalities≥ 99% likely to be due to HD), wherein a score of 4 defines “motor onset” or “manifest” HD. Typically, age of onset (i.e. once the DCS reaches 4) ranges between 30 to 50 years and average duration of survival after clinical diagnosis is 15 to 20 years. Currently, after onset, it is “function” (i.e. assessment of functional capacities), rather than motor signs, which determines disease stage (e.g. in Neurology, 1979, 29, 1-3 or in Neurology, 1981, 31, 1333-1335). The Total Functional Capacity (TFC) scale (e.g. in Movement Disorders, 1996, 11, 136-142) is a component of the UHDRS and ranges from 0 (fully dependent for all care) to 13 (fully independent) the level of independence of a person with HD. This scale assesses functional status of a HD patient in terms of ability to work, handle household finances, manage domestic chores, perform activities of daily living, and level of care needed. Based on the UHDRS total functional capacity (TFC), HD is divided into stages 1 to 5 of disease progression. The categorization of HD, based on TFC score (also referred to as Shoulson and Fahn stages), are also described as early stage of HD (corresponding to stages 1 or 2, based on TFC score), moderate stage or mid stage HD (corresponding to stage 3, based on TFC score) and advanced stage or late stage HD (corresponding to stage 4 or 5, based on TFC score).
At present, only symptomatic treatments are available. Thus, to date, there is no therapy available to slow the progression of HD. Accordingly, there is a need to find disease-modifying therapies for HD (i.e. therapeutic options that can slow disease progression).
SUMMARY OF THE INVENTION
The invention relates to the use of branaplam, or a pharmaceutically acceptable salt thereof: in a treatment slowing progression of Huntington’s disease; in a treatment slowing progression of Huntington's disease by producing an inframe stop codon between exons 49 and 50 in the HTT mRNA; in the treatment of Huntington’s disease as a disease-modifying therapy; in a treatment slowing the decline of motor function associated with Huntington’s disease; in a treatment slowing cognitive decline associated with Huntington's disease; in a treatment slowing psychiatric decline associated with Huntington’s disease; in a treatment slowing the decline of functional capacity associated with Huntington’s disease; or, in a treatment slowing the progression of Huntington’s disease pathophysiology.
BRIEF DESCRIPTION OF DRAWINGS Figure 1. RNA-seq analysis of human fibroblast line treated with branaplam. FC: fold change. RPKM: Reads per kilo base per million mapped reads. Figure 2.2a, 2b, 2c: In vitro modulation of HTT transcript and protein. Figure 3. A single, oral dose of branaplam elevates novel-exon-containing brain HTT transcript levels in the BacHD mouse model. P values: (Vehicle 8hrs vs 50mg/kg, 8hrs) **P = 0.0034, (Vehicle 24hrs vs 50mg/kg, 24hrs) ****P < 0.0001, (Vehicle 24hrs vs 50mg/kg, 48 hrs) **P = 0.0020. Figure 4. A single, oral dose of branaplam lowers total brain HTT transcript levels in the BacHD mouse model. Figure 5. A single, oral dose of branaplam elevates novel-exon-containing blood HTT transcript levels in the BacHD mouse model. Figure 6. A single, oral dose of branaplam lowers total blood HTT transcript levels in the BacHD mouse model. Figure 7. Repeat oral doses of branaplam in the BacHD mouse model lowers mutant Huntingtin protein in the striatum. P values: (Vehicle vs 12mg/kg, 24hrs) **P = 0.048, (Vehicle vs 24mg/kg, 72hrs) ***P = 0.0003, (Vehicle vs 24mg/kg, 72hrs) ****P < 0.0001. Figure 8. Repeat oral doses of branaplam in the BacHD mouse model lowers mutant HTT protein in the cortex. P values - (Vehicle vs 12mg/kg, 24hrs) **P = , (Vehicle vs 24mg/kg, 72hrs) ***P , (Vehicle vs 24mg/kg, 72hrs) ****P < 0.0001. Figure 9. Repeat oral doses of branaplam in the BacHD mouse model lowers mutant HTT protein in the liver. Figure 10. Repeat oral doses of branaplam in the BacHD mouse model lowers total HTT transcript in blood. Figure 11. Repeat oral doses of branaplam in the BacHD mouse model lowers HTT mutant HTT protein in the CSF. Figure 12. Normalized relative quantities of blood transcripts with inclusion of a novel exon into HTT mRNA in infants with SMA Type 1 with weekly administration of branaplam. Figure 13. Median change from baseline in blood HTT mRNA levels in infants with SMA Type 1 with weekly administration of branaplam. Figure 14. PK parameters of a mean, dose-normalized concentration-time course of branaplam in plasma after oral administration to healthy adult volunteers.
Figure 15. Mean concentration-time courses of branaplam in plasma after single dose of branaplam in healthy adults, dose-normalized to 1 mg as described in Example 1c.1
Figure 16. Observed and fitted mean concentration-time course of branaplam in plasma after single dose in healthy adults, dose-normalized to 1 mg as described in Example 1c.1 (Note: The fitted dose-normalized PK profile is the mean of dose-normalized PK profiles from all dose-levels, which was obtained by averaging the dose-normalized PK for all four dose levels at each time point).
Figure 17. Parameter estimates of the mouse PK/PD model based on BacHD mouse.
Figure 18. Predicted distribution of mutant HTT protein in the brain cortex of BacHD mice after repeated oral branaplam administration (12 and 24 mg/kg, Example 1a). Symbols: Observed mHTT protein levels; Solid line: Median prediction; Grey area; prediction 90% confidence interval (each band corresponds to 10% confidence intervals with 9 bands).
Figure 19. Predicted distribution of mutant HTT protein in the brain striatum of BacHD mice after repeated oral branaplam administration, 12 and 24 mg/kg, Example 1a). Symbols: Observed mHTT protein levels; Solid line: Median prediction; Grey area; prediction 90% confidence interval (each band corresponds to 10% confidence intervals with 9 bands).
Figure 20. Timecourse of HTT protein lowering in the BacHD mouse striatum following repeat oral doses of Branaplam. P values - (Vehicle vs 24mg/kg, 72hrs, 3w), ***‘! P < 0.0001, (Vehicle vs 24mg/kg, 168hrs, 3w) **P = 0.0031 , (Vehicle vs 24mg/kg, 240hrs, 3w) **P = 0.0017.
Figure 21. Timecourse of HTT protein lowering in the BacHD mouse cortex following repeat oral doses of Branaplam. P values - (Vehicle vs 24mg/kg, 72hrs) **P = 0.0060
Figure 22. Parameter estimates of the human PK/PD model based on BacHD mouse
Figure 23. Predicted branaplam plasma PK and mHTT protein decrease in brain after weekly dosing for 20 weeks in adult human subjects (70 kg) [i.e., using the compartmental pharmacokinetic model: Example 1c.3]
Figure 24. Branaplam SimCYP® input pharmacokinetic parameters of the PBPK model. B/P: concentration ratio between blood and plasma; Caco: immortalized cell line of human colorectal adenocarcinoma cells; CL: clearance; Clint: intrinsic clearance; fa: fraction absorbed; CLr renal clearance; fut>: fraction unbound blood; fugut: fraction unbound gut; HLM: human liver microsomes; ka: absorption rate constant; Ki,u: unbound inhibition constant; Ki,u: unbound concentration at half maximal inactivation rate; kin: influx rate constant; kinact maximal inactivation rate; kout: efflux rate constant; logPow: partition coefficient octanokwater; Peff.man: efficacious permeability human; pKa: negative base- 10 logarithm of the acid dissociation constant; PopPK: population pharmacokinetics; Qgut: blood flow gut; SAC: single adjusting compartment; TDI: time-dependent inhibition; Tlag: lag time; Vsac: volume of single adjusting compartment; Vss: volume of distribution at steady state
Figure 25. Branaplam simulated versus observed branaplam pharmacokinetic parameters after a single oral dose of 210 mg in healthy volunteers (Example 1b). a: range; AUG: area under the curve; Cl: confidence interval; Cmax: maximum concentration; CV: coefficient of variation; Tmax: time of Cmax.
Figure 26. Observed and Simcyp® PBPK model simulated branaplam plasma concentration - time profiles after a single 210 mg dose in healthy volunteers (Example 1b). CSys: mean predicted plasma concentration of branaplam, CSys Sth: predicted plasma concentration of branaplam at Sth percentile; CSys 95th: predicted plasma concentration of branaplam at 95th percentile; Obs: observed mean plasma concentrations of branaplam (see Example 1b).
Figure 27. Predicted branaplam plasma PK and mHTT protein decrease in brain after weekly dosing for 20 weeks in adult human subjects (70 kg) [i.e., using the physiologically-based pharmacokinetic model: Example 1c.4j. AUG: area under the curve; Cmax: maximum concentration; ss: steady state (predicted after 20 weeks of weekly administration).
Figure 28. Arithmetic Mean (SD) plots of HIT mRNA (PseudoSOa) in Whole Blood (number of molecules/ 50ng RNA equivalent) - absolute change from baseline (safety analysis set), n = Number of subjects. Treatment: 35 mg of branaplam, 105 mg of branaplam, 210 mg of branaplam, 420 mg of branaplam.
Figure 29. Arithmetic Mean (SD) plots of HTT mRNA (combined assays) in Whole Blood (number of molecules/ 50ng RNA equivalent) - percentage change from baseline (Safety analysis set), n = Number of subjects. Treatment: 35 mg of branaplam, 105 mg of branaplam, 210 mg of branaplam, 420 mg of branaplam. DETAILED DESCRIPTION OF THE INVENTION
It has been found that branaplam, or a pharmaceutically acceptable salt thereof, may be an ideal candidate for a treatment slowing progression of Huntington's disease, having therapeutic advantages, such as one or more of the following: it is useful for the treatment of Huntington’s disease as a disease-modifying therapy; ii) it delays the onset of Huntington’s disease or the onset of symptoms associated with Huntington's disease; iii) it reduces the rate of decline of motor function associated with Huntington’s disease, for example, compared to placebo, for example, as assessed by using standard scales, such as clinical scales, for example the UHDRS motor assessment scale (e.g. in Movement Disorders, 1996, 11, 136-142); iv) it reduces the rate of cognitive decline associated with Huntington's disease, for example, compared to placebo, for example, as assessed by using standard scales, such as clinical scales [e.g. as assessed by the Symbol Digit Modalities Test, the Stroop Word Reading Test, the Montreal Cognitive Assessment or the HD Cognitive Assessment Battery (comprising the Symbol Digit Modalities Test, Trail Making Test B, One Touch Stockings, Paced Tapping, Emotion Recognition Test, Hopkins Verbal Learning Test); e.g. in Movement Disorders, 2014, 29 (10), 1281-1288]; v) it reduces the rate of psychiatric decline associated with Huntington’s disease, for example, compared to placebo, for example, as assessed by using standard scales, such as clinical scales [for example the Apathy Evaluation Scale or by the Hospital Anxiety and Depression Scale; e.g. in Movement Disorders, 2016, 31 (10), 1466-1478, Movement Disorders, 2015, 30 (14), 1954-1960]; vi) it reduces the rate of decline of functional capacity associated with Huntington’s disease, for example, compared to placebo, for example, as assessed by using standard scales, such as clinical scales, for example the UHDRS Total Functional Capacity, Functional Assessment and Independence scales (e.g. in Movement Disorders, 1996, 11, 136-142); vii) it reduces the rate of progression of Huntington’s disease pathophysiology [e.g. reducing the rate of brain (e.g. whole brain, caudate, striatum or cortex) volume loss (e.g. % from baseline volume) associated with Huntington’s disease [e.g. as assessed by MRI, e.g. by neuroimaging measures, such as in Lancet Neurol. 2013, 12 (7), 637-649)]; viii) it reduces decline in quality of life, for example as assessed by the Huntington's Disease Health-related Quality of Life questionnaire (HDQoL) (e.g. in Movement Disorders, 2018, 33 (5), 742-749), for example compared to a sham or placebo; ix) it has a favorable therapeutic profile, such as a favorable safety profile or metabolic profile; for example a favorable profile in relation to off-target effects, psychiatric adverse events, toxicity (e.g. genotoxicity) or cardiovascular adverse events (e.g. blood pressure, heart rate, electrocardiography parameters)
Embodiments of the present invention are described herein below:
EMBODIMENTS (A):
Embodiment 1a: Branaplam, or a pharmaceutically acceptable salt thereof, for use in a treatment slowing progression of Huntington’s disease, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
Embodiment 2a: Branaplam, or a pharmaceutically acceptable salt thereof, for use in the treatment of Huntington’s disease as a disease-modifying therapy, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week). Embodiment 3a: Branaplam, or a pharmaceutically acceptable salt thereof, for use in a treatment slowing the decline of motor function associated with Huntington’s disease, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
Embodiment 4a: Branaplam, or a pharmaceutically acceptable salt thereof, for use in a treatment slowing cognitive decline associated with Huntington's disease, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
Embodiment 5a: Branaplam, or a pharmaceutically acceptable salt thereof, for use in a treatment slowing psychiatric decline associated with Huntington’s disease, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
Embodiment 6a: Branaplam, or a pharmaceutically acceptable salt thereof, for use in a treatment slowing the decline of functional capacity associated with Huntington’s disease, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
Embodiment 7a: Branaplam, or a pharmaceutically acceptable salt thereof, for use in a treatment slowing the progression of Huntington’s disease pathophysiology [e.g. reducing the rate of brain (e.g. whole brain, caudate, striatum or cortex) volume loss (e.g. % from baseline volume) associated with Huntington’s disease (e.g. as assessed by MRI)], wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
Embodiment 8a: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 3a, wherein motor function comprises one or more selected from the group consisting of ocular motor function, dysarthria, dystonia, chorea, postural stability and gait.
Embodiment 9a: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 4a, wherein cognitive decline comprises decline of one or more selected from the group consisting of attention, processing speed, visuospatial processing, timing, emotion processing, memory, verbal fluency, psychomotor function, and executive function.
Embodiment 10a: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 5a, wherein psychiatric decline comprises one or more selected from the group consisting of apathy, anxiety, depression, obsessive compulsive behavior, suicidal thoughts, irritability and agitation.
Embodiment 11a: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 6a, wherein functional capacity comprises one or more selected from the group consisting of capacity to work, capacity to handle financial affairs, capacity to manage domestic chores, capacity to perform activities of daily living, and level of care needed. Embodiment 12a: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 11a, wherein Huntington’s disease is genetically characterized by CAG repeat expansion of from 36 to 39 in the huntingtin gene on chromosome 4.
Embodiment 13a: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 11a, wherein Huntington’s disease is genetically characterized by CAG repeat expansion of from >39 in the huntingtin gene on chromosome 4.
Embodiment 14a: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 13a, wherein Huntington’s disease is manifest Huntington's disease.
Embodiment 15a: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 14a, wherein Huntington’s disease is juvenile Huntington’s disease or pediatric Huntington’s disease.
Embodiment 16a: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 15a, wherein Huntington’s disease is early stage of Huntington’s disease, middle stage of Huntington’s disease, or advanced stage of Huntington’s disease; in particular early stage of Huntington’s disease.
Embodiment 17a: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 16a, wherein Huntington’s disease is stage I of Huntington’s disease, stage II of Huntington’s disease, stage III of Huntington’s disease, stage IV of Huntington's disease or stage V of Huntington’s disease; in particular stage I of Huntington’s disease or stage II of Huntington's disease.
Embodiment 18a: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 13a, wherein Huntington’s disease is pre-manifest Huntington’s disease.
Embodiment 19a: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 18a, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered orally.
Embodiment 20a: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 19a, wherein branaplam, or a pharmaceutically acceptable salt thereof, is provided in the form of a pharmaceutical composition. Embodiment 21a: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 19a, wherein branaplam, or a pharmaceutically acceptable salt thereof, is provided in the form of a pharmaceutical combination.
Embodiment 22a: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 21a, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered following gene therapy or treatment with an antisense compound.
Embodiment 23a: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to any one of embodiments 1a to 22a, wherein branaplam is administered in the form of branaplam hydrochloride salt.
EMBODIMENTS (B):
Embodiment 1b: A method of treatment for slowing progression of Huntington’s disease in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
Embodiment 2b: A method of treatment of Huntington's disease in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, as a disease-modifying therapy, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week). Embodiment 3b: A method of treatment for slowing the decline of motor function associated with Huntington’s disease in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
Embodiment 4b: A method of treatment for slowing cognitive decline associated with Huntington's disease in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
Embodiment 5b: A method of treatment for slowing psychiatric decline associated with Huntington’s disease in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
Embodiment 6b: A method of treatment for slowing the decline of functional capacity associated with Huntington’s disease in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
Embodiment 7b: A method of treatment for slowing the progression of Huntington’s disease pathophysiology [e.g. reducing the rate of brain (e.g. whole brain, caudate, striatum or cortex) volume loss (e.g. % from baseline volume) associated with Huntington’s disease (e.g. as assessed by MRI)] in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
Embodiment 8b: The method according to embodiment 3b, wherein motor function comprises one or more selected from the group consisting of ocular motor function, dysarthria, dystonia, chorea, postural stability and gait.
Embodiment 9b: The method according to embodiment 4b, wherein cognitive decline comprises decline of one or more selected from the group consisting of attention, processing speed, visuospatial processing, timing, emotion processing, memory, verbal fluency, psychomotor function, and executive function.
Embodiment 10b: The method according to embodiment 5b, wherein psychiatric decline comprises one or more selected from the group consisting of apathy, anxiety, depression, obsessive compulsive behavior, suicidal thoughts, irritability and agitation.
Embodiment 11b: The method according to embodiment 6b, wherein functional capacity comprises one or more selected from the group consisting of capacity to work, capacity to handle financial affairs, capacity to manage domestic chores, capacity to perform activities of daily living, and level of care needed.
Embodiment 12b: The method according to any one of embodiments 1b to 11b, wherein Huntington’s disease is genetically characterized by CAG repeat expansion of from 36 to 39 in the huntingtin gene on chromosome 4.
Embodiment 13b: The method according to any one of embodiments 1b to 11b, wherein Huntington's disease is genetically characterized by CAG repeat expansion of from >39 in the huntingtin gene on chromosome 4.
Embodiment 14b: The method according to any one of embodiments 1b to 13b, wherein Huntington’s disease is manifest Huntington’s disease.
Embodiment 15b: The method according to any one of embodiments 1b to 14b, wherein Huntington’s disease is juvenile Huntington’s disease or pediatric Huntington’s disease.
Embodiment 16b: The method according to any one of embodiments 1b to 15b, wherein Huntington’s disease is early stage of Huntington’s disease, middle stage of Huntington’s disease, or advanced stage of Huntington’s disease; in particular early stage of Huntington’s disease.
Embodiment 17b: The method according to any one of embodiments 1b to 16b, wherein Huntington’s disease is stage I of Huntington’s disease, stage II of Huntington’s disease, stage III of Huntington’s disease, stage IV of Huntington’s disease or stage V of Huntington’s disease; in particular stage I of Huntington’s disease or stage II of Huntington’s disease.
Embodiment 18b: The method according to any one of embodiments 1b to 13b, wherein Huntington’s disease is pre-manifest Huntington’s disease.
Embodiment 19b: The method according to any one of embodiments 1b to 18b, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered orally.
Embodiment 20b: The method according to any one of embodiments 1b to 19b, wherein branaplam, or a pharmaceutically acceptable salt thereof, is provided in the form of a pharmaceutical composition.
Embodiment 21b: The method according to any one of embodiments 1b to 19b, wherein branaplam, or a pharmaceutically acceptable salt thereof, is provided in the form of a pharmaceutical combination. Embodiment 22b: The method according to any one of embodiments 1b to 21b, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered following gene therapy or treatment with an antisense compound.
Embodiment 23b: The method according to any one of embodiments 1b to 22b, wherein branaplam is administered in the form of branaplam hydrochloride salt.
EMBODIMENTS (C):
It has been surprisingly found that branaplam promotes the inclusion of a novel, 115-bp exon containing an in-frame stop codon (55bp from the 3' end of the novel exon) between exons 49 and 50 of the HTT mRNA thereby lowering HTT transcript and protein levels. Thus, in another aspect, the invention relates to:
Embodiment 1c: A method of treatment for slowing progression of Huntington’s disease in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, by producing an in-frame stop codon between exons 49 and 50 in the HTT mRNA, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
Embodiment 2c: Branaplam, or a pharmaceutically acceptable salt thereof, for use in a treatment slowing progression of Huntington’s disease by producing an in-frame stop codon between exons 49 and 50 in the HTT mRNA, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week). Embodiment 3c: The method according to embodiment 1c, wherein wherein branaplam is administered in the form of branaplam hydrochloride salt
Embodiment 4c: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 2c, wherein wherein branaplam is administered in the form of branaplam hydrochloride salt.
Embodiment 5c: A method of treatment according to embodiment 1c, the method further comprising the steps of: determining whether branaplam produced a novel-exon included HTT mRNA by: obtaining or having obtained a blood sample from the patient; and performing or having performed a PCR assay on the biological sample to determine if the patient has novel-exon included HTT mRNA.
Embodiment 6c: A method of treatment according to embodiment 1c, the method further comprising the steps of: determining the decrease in HTT protein in the brain by determining HTT protein levels in surrogate matrices selected from CSF and peripheral blood based matrices (e.g. plasma, serum or PBMC), preferably by determining HTT protein levels in CSF; if the patient has a decrease of HTT protein of less than about 25% to 65%, such as of less than about 35% to 50%, as compared to baseline, then administering branaplam in an amount of from 25 mg to 250 mg once a week, until the patient has a decrease of HTT protein of about 25% to 65%, such as about 35% to 50%, as compared to baseline.
Embodiment 7c-1: A method of treatment according to embodiment 1c, the method further comprising the steps of: determining whether branaplam produced a novel-exon included HTT mRNA by: obtaining or having obtained a blood sample from the patient; and performing or having performed a PCR assay on the biological sample to determine if the patient has novel-exon included HTT mRNA; and determining the decrease in HTT protein in the brain by determining HTT protein levels in surrogate matrices selected from CSF and peripheral blood based matrices (e.g. plasma, serum or PBMC), preferably by determining HTT protein levels in CSF; if the patient has a decrease of HTT protein of less than about 25% to 65%, such as of less than about 35% to 50%, as compared to baseline, then administering branaplam in an amount of from 25 mg to 250 mg once a week, until the patient has a decrease of HTT protein of about 25% to 65%, such as about 35% to 50%, as compared to baseline.
Embodiment 7c-2: A method of treatment according to embodiment 1c, the method further comprising the steps of: determining whether branaplam produced an in-frame stop codon between exons 49 and 50 in the HTT mRNA by: obtaining or having obtained a blood sample from the patient; and performing or having performed a PCR assay on the biological sample to determine if the patient has an in-frame stop codon between exons 49 and 50 in the HTT mRNA; and determining the decrease in HTT protein in the brain by determining HTT protein levels in surrogate matrices selected from CSF and peripheral blood based matrices (e.g. plasma, serum or PBMC), preferably by determining HTT protein levels in CSF; if the patient has a decrease of HTT protein of less than about 25% to 65%, such as of less than about 35% to 50%, as compared to baseline, then administering branaplam in an amount of from 25 mg to 250 mg once a week, until the patient has a decrease of HTT protein of about 25% to 65%, such as about 35% to 50%, as compared to baseline.
Embodiment 8c: The method of embodiment 7c- 1 or embodiment 7c-2 wherein Huntington’s disease is manifest Huntington's disease. Embodiment 9c: The method of embodiment 7c- 1 or embodiment 7c-2 wherein Huntington’s disease is juvenile Huntington’s disease or pediatric Huntington’s disease.
Embodiment 10c: The method of embodiment 7c- 1 or embodiment 7c-2 wherein Huntington’s disease is early stage of Huntington’s disease, middle stage of Huntington’s disease, or advanced stage of Huntington’s disease.
Embodiment 11c: The method of embodiment 7c- 1 or embodiment 7c-2 wherein Huntington’s disease is stage I of Huntington’s disease, stage II of Huntington’s disease, stage III of Huntington's disease, stage IV of Huntington’s disease or stage V of Huntington's disease.
Embodiment 12c: The method of embodiment 7c- 1 or embodiment 7c-2 wherein Huntington’s disease is pre-manifest Huntington’s disease.
Embodiment 13c: The method of embodiment 7c- 1 or embodiment 7c-2 wherein branaplam is administered in the form of branaplam hydrochloride salt.
Embodiment 14c: The method of embodiment 7c- 1 or embodiment 7c-2 wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in the form of a pharmaceutical composition.
Embodiment 15c: The method of embodiment 7 c- 1 or embodiment 7c-2 wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered following gene therapy or treatment with an antisense compound.
Embodiment 15c-1: The method according to any one of embodiments 5c, 6c, 7c-1, 7c-2, 8c, 9c, 10c, 11c, 12c, 13c, 14c and 15c, wherein HTT protein is selected from the group consisting of wild type HTT protein, mutant HTT protein and total HTT protein.
Embodiment 15c-2: The method according to any one of embodiments 5c, 6c, 7c-1, 7c-2, 8c, 9c, 10c, 11c, 12c, 13c, 14c and 15c, wherein HTT protein is mutant HTT protein.
Embodiment 15c-3: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 15c-1 or 15c-2, wherein HTT protein levels are determined in CSF.
Embodiment 16c: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 2c, the use further comprising the steps of: determining whether branaplam produced a novel-exon included HTT mRNA by: obtaining or having obtained a blood sample from the patient; and performing or having performed a PCR assay on the biological sample to determine if the patient has novel-exon included HTT mRNA.
Embodiment 17c: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 2c, the use further comprising the steps of: determining the decrease in HTT protein in the brain by determining HTT protein levels in surrogate matrices selected from CSF and peripheral blood based matrices (e.g. plasma, serum or PBMC), preferably by determining HTT protein levels in CSF; if the patient has a decrease of HTT protein of less than about 25% to 65%, such as of less than about 35% to 50%, as compared to baseline, then administering branaplam in an amount of from 25 mg to 250 mg once a week, until the patient has a decrease of HTT protein of about 25% to 65%, such as about 35% to 50% as compared to baseline.
Embodiment 18c-1: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 2c, the use further comprising the steps of: determining whether branaplam produced a novel-exon included HTT mRNA by: obtaining or having obtained a blood sample from the patient; and performing or having performed a PCR assay on the biological sample to determine if the patient has novel-exon included HTT mRNA; and determining the decrease in HTT protein in the brain by determining HTT protein levels in surrogate matrices selected from CSF and peripheral blood based matrices (e.g. plasma, serum or PBMC), preferably by determining HTT protein levels in CSF; if the patient has a decrease of HTT protein of less than about 25% to 65%, such as of less than about 35% to 50%, as compared to baseline, then administering branaplam in an amount of from 25 mg to 250 mg once a week, until the patient has a decrease of HTT protein of about 25% to 65%, such as about 35% to 50%, as compared to baseline.
Embodiment 18c-2: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 2c, the use further comprising the steps of: determining whether branaplam produced an in-frame stop codon between exons 49 and 50 in the HTT mRNA by: obtaining or having obtained a blood sample from the patient; and performing or having performed a PCR assay on the biological sample to determine if the patient has an in-frame stop codon between exons 49 and 50 in the HTT mRNA; and determining the decrease in HTT protein in the brain by determining HTT protein levels in surrogate matrices selected from CSF and peripheral blood based matrices (e.g. plasma, serum or PBMC), preferably by determining HTT protein levels in CSF; if the patient has a decrease of HTT protein of less than about 25% to 65%, such as of less than about 35% to 50%, as compared to baseline, then administering branaplam in an amount of from 25 mg to 250 mg once a week, until the patient has a decrease of HTT protein of about 25% to 65%, such as about 35% to 50%, as compared to baseline.
Embodiment 19c: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 18c- 1 or embodiment 18c-2 wherein Huntington’s disease is manifest Huntington’s disease.
Embodiment 20c: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 18c-1 or embodiment 18c-2 wherein Huntington’s disease is juvenile Huntington’s disease or pediatric Huntington’s disease.
Embodiment 21c: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 18c-1 or embodiment 18c- 2 wherein Huntington’s disease is early stage of Huntington’s disease, middle stage of Huntington’s disease, or advanced stage of Huntington’s disease. Embodiment 22c: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 18c- 1 or embodiment 18c-2 wherein Huntington's disease is stage I of Huntington’s disease, stage II of Huntington’s disease, stage III of Huntington’s disease, stage IV of Huntington’s disease or stage V of Huntington’s disease.
Embodiment 23c: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 18c-1 or embodiment 18c-2 wherein Huntington’s disease is pre-manifest Huntington’s disease.
Embodiment 24c: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 18c- 1 or embodiment 18c-2 wherein branaplam is administered in the form of branaplam hydrochloride salt
Embodiment 25c: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 18c-1 or embodiment 18c-2 wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in the form of a pharmaceutical composition.
Embodiment 26c: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 18c-1 or embodiment 18c-2 wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered following gene therapy or treatment with an antisense compound.
Embodiment 27c: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment any one of embodiments 16c, 17c, 18c-1, 18c-2, 19c, 20c, 21c, 22c, 23c, 24c, 25c and 26c, wherein HTT protein is selected from the group consisting of wild type HTT protein, mutant HTT protein and total HTT protein.
Embodiment 28c: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment any one of embodiments 16c, 17c, 18c-1, 18c-2, 19c, 20c, 21c, 22c, 23c, 24c, 25c and 26c, wherein HTT protein is mutant HTT protein.
Embodiment 28c: Branaplam, or a pharmaceutically acceptable salt thereof, for use according to embodiment 27c or 28c, wherein HTT protein levels are determined in CSF. GENERAL DEFINITION OF TERMS
The term “HD” or “Huntington's disease”, as used herein, refers to the neurodegenerative disorder, characterized by motor, cognitive, psychiatric and functional capacity decline, and caused by GAG repeat expansions in the huntingtin gene.
The term “manifest HD” or “manifest Huntington’s disease", as used herein, refers to having diagnosis of HD as clinically established {e.g. on the basis of: confirmed family history or positive genetic test (confirmation of GAG repeat expansion £36); and onset of motor disturbances [diagnostic confidence score (DCS) of 4, as defined by the Unified Huntington Rating Scale (UHDRS) total motor score (TMS)]}. In one embodiment, the term “manifest HD" or “manifest Huntington’s disease”, as used herein, refers to a patient having diagnosis of HD as clinically established {e.g. on the basis of: confirmed family history or positive genetic test (confirmation of GAG repeat expansion £36); and onset of motor disturbances [diagnostic confidence score (DCS) of 4, as defined by the Unified Huntington Rating Scale (UHDRS) total motor score (TMS)]}.
The term “pre-manifest HD" or “pre-manifest Huntington’s disease", as used herein, refers to having genetic diagnosis of HD {e.g. on the basis of: positive genetic test (confirmation of GAG repeat expansion ≥40)} without onset of motor disturbances as clinically stablished, for example, as assessed according to standard scales, such as, clinical scales [e.g. on the basis of a diagnostic confidence score (DCS) of <4, as defined by the Unified Huntington Rating Scale (UHDRS) total motor score (TMS)]. In one embodiment, term “pre-manifest HD" or “pre-manifest Huntington’s disease”, as used herein, refers to a patient having genetic diagnosis of HD {e.g. on the basis of positive genetic test (confirmation of GAG repeat expansion £40)} without onset of motor disturbances as clinically stablished, for example, as assessed according to standard scales, such as, clinical scales [e.g. on the basis of a diagnostic confidence score (DCS) of <4, as defined by the Unified Huntington Rating Scale (UHDRS) total motor score (TMS)].
In one embodiment, the term “slowing progression of HD", “slowing progression of Huntington’s disease", “to slow the progression of HD" or “to slow the progression of Huntington’s disease”, as used herein, refers to, for example:
- reducing the rate of Huntington’s disease progression (e.g. reducing the rate of progression between stages of Huntington’s disease);
- delaying the onset of Huntington's disease; - delaying the onset of symptoms associated with Huntington's disease;
- reducing the rate of progression (e.g. reducing the annual rate of decline) of symptoms (e.g. one or more symptoms) associated with Huntington's disease; or
- reducing the rate of progression of Huntington’s disease pathophysiology;
(e.g. compared to placebo or compared to natural history control group; e.g. according to standard scales, such as clinical scales, herein above or below, or according to neuroimaging measures).
In one embodiment, the term “rate of progression”, as used herein, refers, for example, to the annual rate of change (e.g. decline) or the rate of change (e.g. decline) per year, for example as assessed according to standard scales, such as clinical scales, or according to neuroimaging measures.
The term “reducing”, as used herein, refers to e.g. 5%, 10%, 20%, 30%, 40%, 50%, 60% or 70% reduction, for example, per year of treatment.
The term “delaying”, as used herein, refers to delay for at least e.g. 0.5, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 or 15 years.
In one embodiment, the term “slowing progression of HD”, “slowing progression of Huntington’s disease”, “to slow the progression of HD” or “to slow the progression of Huntington's disease", as used herein, refers to delaying the onset of Huntington’s disease, e.g. increasing time for the onset of Huntington’s disease as defined herein. In another embodiment, it refers to reducing the rate of progression between stages of Huntington’s disease, for example, reducing the rate of progression from an initial stage of HD into a more advanced stage of HD, as assessed, for example, compared to placebo, according to standard scales, such as clinical scales [e.g. according to the UHDRS total functional capacity (TEC) scale, for example, in Neurology, 1979, 29, 1-3], In one embodiment, it refers to reducing the rate of progression from stage 1 of HD into stage 2 of HD (e.g. compared to placebo). In another embodiment, it refers to reducing the rate of progression from stage 2 of HD into stage 3 of HD (e.g. compared to placebo). In another embodiment, it refers to reducing the rate of progression from stage 3 of HD into stage 4 of HD (e.g. compared to placebo). In another embodiment, it refers to reducing the rate of progression from stage 4 of HD into stage 5 of HD (e.g. compared to placebo). In a further embodiment, it refers to reducing the rate of progression from early HD into middle stage HD (e.g. compared to placebo). In a further embodiment, it refers to reducing the rate of progression from middle stage HD into advanced HD (e.g. compared to placebo). The term “reducing the rate of progression”, as used herein, refers, for example, to increasing time for progression of stage of HD (e.g. compared to placebo).
In another embodiment, the term “slowing progression of HD”, “slowing progression of Huntington’s disease”, “to slow the progression of HD” or “to slow the progression of Huntington’s disease”, as used herein, refers to delaying the onset of Huntington's disease (e.g. increasing time for the onset of Huntington’s disease as defined herein) by at least 25% (e.g. by 25% or more, such as from 25% to 50%).
The term “onset of Huntington’s disease”, as used herein, refers to clinical diagnosis of HD as generally established [e.g. onset of motor disturbances based on diagnostic confidence score (DCS) of 4, as defined by the Unified Huntington Rating Scale (UHDRS) total motor score (TMS)].
In another embodiment, the term “slowing progression of HD”, “slowing progression of Huntington’s disease”, “to slow the progression of HD” or “to slow the progression of Huntington’s disease”, as used herein, refers to delaying the onset of symptoms associated with Huntington's disease, e.g. increasing time for the onset of one or more symptom associated with Huntington's disease selected from decline of motor function associated with Huntington’s disease, cognitive decline associated with Huntington’s disease, psychiatric decline associated with Huntington’s disease and decline of functional capacity associated with Huntington’s disease, as defined herein. In another embodiment, it refers to reducing the rate of progression of one or more symptom associated with Huntington's disease selected from decline of motor function associated with Huntington's disease, cognitive decline associated with Huntington's disease, psychiatric decline associated with Huntington's disease and decline of functional capacity associated with Huntington’s disease, as defined herein. The term “reducing the rate of, as used herein, refers, for example, to increasing time for onset or increasing time for a rise of severity (e.g. compared to placebo). In one embodiment, the term “slowing progression of HD”, “slowing progression of Huntington’s disease”, “to slow the progression of HD” or “to slow the progression of Huntington's disease", as used herein, refers to reducing the rate of progression of pre-manifest HD into manifest HD [i.e. delaying the onset of manifest HD; e.g. compared to placebo; e.g. as assessed by a diagnostic confidence score (DCS) of 4, as defined by the Unified Huntington Rating Scale (UHDRS) total motor score (TMS)].
In a further embodiment, the term “slowing progression of HD”, “slowing progression of Huntington’s disease”, “to slow the progression of HD” or “to slow the progression of Huntington’s disease", as used herein, refers to slowing the progression of Huntington's disease pathophysiology.
The term “slowing the progression of Huntington’s disease pathophysiology", as used herein, refers to reducing the rate of progression of Huntington’s disease pathophysiology, for example, as assessed by magnetic resonance imaging (MRI) [e.g. by neuroimaging measures, such as in Lancet Neurol. 2013, 12 (7), 637-649]. For example, it refers to reducing the rate (e.g. reducing the annual rate, for example, versus placebo) of brain (e.g. whole brain, caudate, striatum or cortex) volume loss (e.g. % from baseline volume) associated with Huntington’s disease (e.g. as assessed by MRI) or it refers to reducing the rate (e.g. reducing the annual rate, for example, versus placebo) of increase in ventricular volume (e.g. % from baseline volume) associated with Huntington’s disease (e.g. as assessed by MRI).
The term “motor function”, as used herein, refers to motor features of HD comprising, for example, one or more selected from the group consisting of ocular motor function, dysarthria, chorea, postural stability and gait.
The term “decline of motor function", as used herein, refers to decreased motor function (e.g. from normal motor function or from previous clinic visit). Decline of motor function may be assessed, for example, according to standard scales, such as clinical scales (e.g. UHDRS motor assessment scale, as measured by the UHDRS Total Motors Score; e.g. in Movement Disorders, 1996, 11, 136-142).
The term “slowing the decline of motor function" or “to slow the decline of motor function", as used herein, refers to reducing the rate of decline of motor function (e.g. compared to placebo; e.g. reduction in the annual rate of decline of motor function, for example, versus placebo; e.g. as assessed by the UHDRS Total Motors Score). The term “reducing the rate”, as used herein, refers to increasing time for onset or increasing time for a rise of severity (e.g. compared to placebo; e.g. reduction in the annual rate of decline, for example, versus placebo).
The term “cognitive decline", as used herein, refers to decreased cognitive abilities (e.g. from normal cognition function or from previous clinic visit). In one embodiment, it comprises, for example, decline of one or more selected from the group consisting of attention, processing speed, visuospatial processing, timing, emotion processing, memory, verbal fluency, psychomotor function, and executive function. Cognitive decline may be assessed, for example, according to standard scales, such as clinical scales [e.g. as assessed by the Symbol Digit Modalities Test, the Stroop Word Reading Test, the Montreal Cognitive Assessment or the HD Cognitive Assessment Battery (comprising the Symbol Digit Modalities Test, Trail Making Test B, One Touch Stockings, Paced Tapping, Emotion Recognition Test, Hopkins Verbal Learning Test); e.g. in Movement Disorders, 2014, 29 (10), 1281-1288],
The term “slowing cognitive decline” or “to slow cognitive decline”, as used herein, refers to reducing the rate of cognitive decline (e.g. compared to placebo; e.g. reduction in the annual rate of cognitive decline versus placebo; e.g. as assessed by the Symbol Digit Modalities Test, by the Stroop Word Reading Test, by the Montreal Cognitive Assessment or by the HD Cognitive Assessment Battery). The term “reducing the rate", as used herein, refers to increasing time for onset or increasing time for a rise of severity (e.g. compared to placebo; e.g. reduction in the annual rate of decline, for example, versus placebo).
The term “psychiatric decline”, as used herein, refers to decreased psychiatric function (e.g. from normal psychiatric function or from previous clinic visit). In one embodiment, it comprises, for example, one or more selected from the group consisting of apathy, anxiety, depression obsessive compulsive behavior, suicidal thoughts, irritability and agitation. Psychiatric decline may be assessed, for example, according to standard scales, such as clinical scales (e.g. as assessed by the Apathy Evaluation Scale or by the Hospital Anxiety and Depression Scale; e.g. in Movement Disorders, 2016, 31 (10), 1466-1478, Movement Disorders, 2015, 30 (14), 1954-1960).
The term “slowing psychiatric decline" or “to slow psychiatric decline", as used herein, refers to reducing the rate of psychiatric decline (e.g. compared to placebo; e.g. reduction in the annual rate of psychiatric decline versus placebo; e.g. as assessed by the Apathy Evaluation Scale or by the Hospital Anxiety and Depression Scale). The term “reducing the rate”, as used herein, refers to increasing time for onset or increasing time for a rise of severity (e.g. compared to placebo; e.g. reduction in the annual rate of decline, for example, versus placebo).
The term “functional capacity", as used herein, refers, for example, to the ability to work, handle financial affairs, manage domestic chores, perform activities of daily living, and level of care needed. Functional capacity comprises, for example, one or more selected from the group consisting of capacity to work, capacity to handle financial affairs, capacity to manage domestic chores, capacity to perform activities of daily living, and level of care needed.
The term “decline of functional capacity”, as used herein, refers to decreased functional capacity (e.g. from normal functional capacity or from previous clinic visit). Decline of functional capacity may be assessed, for example, according to standard scales, such as clinical scales (e.g. UHDRS functional assessment scale and independence scale, and UHDRS Total Functional Capacity Scale e.g. in Movement Disorders, 1996, 11, 136-142).
The term “slowing the decline of functional capacity" or “to slow the decline of functional capacity”, as used herein, refers to reducing the rate of decline of functional capacity (e.g. compared to placebo; e.g. reduction in the annual rate of decline of functional capacity versus placebo; e.g. as assessed by the UHDRS functional assessment scale and independence scale or by the UHDRS Total Functional Capacity Scale). The term “reducing the rate”, as used herein, refers to increasing time for onset or increasing time for a rise of severity (e.g. compared to placebo; e.g. reduction in the annual rate of decline, for example, versus placebo).
The term “decline”, as used herein, refers, for example, to worsening over time (e.g. annually or per year) of a condition or of a particular feature of a condition, for example as assessed according to standard scales, such as clinical scales.
The term “Unified Huntington Disease Rating Scale” or “UHDRS” as used herein, refers to the clinical rating scale developed by the Huntington Study Group (e.g. in Movement Disorders, 1996, 11, 136-142, which is incorporated fully herein by reference), which assesses domains of clinical performance and capacity in HD. It comprises rating scales for motor function, cognitive function and functional capacity. It yields scores assessing primary features of HD (e.g. motor and cognitive) and overall functional impact of these features. The term “cHDRS” refers to the composite Unified Huntington Disease Rating Scale, which provides composite measure of motor, cognitive and global functioning (e.g. in Neurology, 2017, 89, 2495-2502).
The term “Unified Huntington Disease Rating Scale IS” or “UHDRS IS” as used herein, refers to the Independent Scale (IS) component of the UHDRS, which assesses the participants level of independence, including topics of employment, finances, self-care and feeding. The scale has 19 discrete scores, from 10 (tube fed, total bed care) to 100 (no special care needed) with 5 point increments in between.
The term “HD stage 1”, “HD stage I", “Huntington’s disease stage 1", “Huntington’s disease stage I”, “stage 1 of Huntington’s disease” or “stage I of Huntington’s disease”, as used herein, refers to a disease stage of HD as clinically stablished [e.g. as assessed according to standard scales, for example, clinical scales, such as on the basis of the UHDRS total functional capacity (TFC) scale, wherein the TFC score is of 11 to 13], At HD stage 1, typically, the patient has been clinically diagnosed with HD, is fully functional at home and at work and maintains independence as regards functional capacities; typically 0 to 8 years from onset of Huntington’s disease. The term “HD stage 2”, “HD stage II”, “Huntington’s disease stage 2”, “Huntington’s disease stage II", “stage 2 of Huntington’s disease" or “stage II of Huntington’s disease”, as used herein, refers to a disease stage of HD as clinically stablished [e.g. as assessed according to standard scales, for example, clinical scales, such as on the basis of the UHDRS total functional capacity (TFC) scale, wherein the TFC score is of 7 to 10], At HD stage 2, typically, the patient is still functional at work, however at lower capacity, is mostly able to carry out daily activities, despite some difficulties, and usually requires only slight assistance; typically 3 to 13 years from onset of Huntington’s disease.
The term “HD stage 3”, “HD stage III", “Huntington’s disease stage 3", “Huntington’s disease stage III”, “stage 3 of Huntington’s disease” or “stage III of Huntington’s disease”, as used herein, refers to a disease stage of HD as clinically stablished [e.g. as assessed according to standard scales, for example, clinical scales, such as on the basis of the UHDRS total functional capacity (TFC) scale, wherein the TFC score is of 4 to 6], At HD stage 3, typically, the patient can no longer conduct work or manage household chores, requires substantial help for daily financial affairs, domestic responsibilities, and activities of daily living; typically 5 to 16 years from onset of Huntington’s disease.
The term “HD stage 4”, “HD stage IV", “Huntington’s disease stage 4”, “Huntington’s disease stage IV”, “stage 4 of Huntington’s disease" or “stage IV of Huntington’s disease”, as used herein, refers to a disease stage of HD as clinically stablished [e.g. as assessed according to standard scales, for example, clinical scales, such as on the basis of the UHDRS total functional capacity (TFC) scale, wherein the TFC score is of 1 to 3], At HD stage 4, typically, the patient is not independent, but still can reside at home with help from either family or professionals, however, requiring substantial assistance in financial affairs, domestic chores, and most activities of daily living; typically 9 to 21 years from onset of Huntington’s disease.
The term “HD stage 5”, “HD stage V”, “Huntington’s disease stage 5”, “Huntington’s disease stage V”, “stage 5 of Huntington's disease” or “stage V of Huntington’s disease”, as used herein, refers to a disease stage of HD as clinically stablished [e.g. as assessed according to standard scales, for example, clinical scales, such as on the basis of the UHDRS total functional capacity (TFC) scale, wherein the TFC score is of 0], At HD stage 5, typically, the patient needs total support in daily activities from professional nursing care; typically 11 to 26 years from onset of Huntington’s disease. The term “early HD”, “early Huntington’s disease”, “early stage of HD” or “early stage of Huntington’s disease", as used herein, refers to a disease stage of HD, wherein the patient is largely functional and may continue to work and live independently, despite suffering from, for example, one or more selected from the group consisting of minor involuntary movements, subtle loss of coordination and difficulty thinking through complex problems. In one embodiment, early HD", “early Huntington’s disease”, “early stage of HD" or “early stage of Huntington’s disease" refers to “HD stage 1” or “HD stage 2”, as defined herein.
The term “moderate HD", “moderate Huntington’s disease", “moderate stage of HD", “moderate stage of Huntington’s disease”, “middle stage HD”, “middle stage Huntington’s disease”, “middle stage of HD” or “middle stage of Huntington’s disease”, as used herein, refers to a disease stage of HD, wherein the patient may no be able to work, manage own finances or perform own household chores, but is able to eat, dress, and attend to personal hygiene with assistance. Typically, at this stage, for example, chorea may be prominent, as well as problems with swallowing, balance, falls, weight loss, and problem solving. In one embodiment, moderate HD”, “moderate Huntington’s disease”, “moderate stage of HD”, “moderate stage of Huntington’s disease", “middle stage HD", “middle stage Huntington’s disease”, “middle stage of HD" or “middle stage of Huntington’s disease” refers to “HD stage 3”, as defined herein.
The term “advanced HD”, “advanced Huntington’s disease”, “advanced stage of HD”, “advanced stage of Huntington’s disease”, “late HD” or “late Huntington’s disease”, “late stage of HD” or “late stage of Huntington's disease”, as used herein, refers to a disease stage of HD, wherein the patient requires assistance in all activities of daily living. Typically, at this stage, for example, chorea may be severe, but more often it is replaced by rigidity, dystonia, and bradykinesia. In one embodiment, “advanced HD”, “advanced Huntington’s disease”, “advanced stage of HD”, “advanced stage of Huntington’s disease”, “late HD” or “late Huntington’s disease”, “late stage of HD” or “late stage of Huntington’s disease” refers to “HD stage 4” or “HD stage 5”, as defined herein.
The term “juvenile HD" or “juvenile Huntington's disease", as used herein, refers to diagnosis of HD as clinically stablished {e.g. on the basis of: confirmed family history or positive genetic test (i.e. confirmation of GAG repeat expansion ≥36); and onset of symptoms by age < 21 years}. In one embodiment, the term “juvenile HD” or “juvenile Huntington’s disease”, as used herein, refers to a patient affected by HD {e.g. on the basis of: confirmed family history or positive genetic test (i.e. confirmation of GAG repeat expansion £36)} and who has onset of symptoms by age < 21 years. The term “pediatric HD” or “pediatric Huntington’s disease", as used herein, refers to a patient affected by HD {e.g. on the basis of: confirmed family history or positive genetic test (i.e. confirmation of GAG repeat expansion ≥36) and clinical diagnosis} and who is aged <18 years.
The term “HD patient", “Huntington's disease patient”, “patient with Huntington’s disease” or “patient with HD” refers to a patient with HD, as defined herein.
The term “treat' “treating” “treatment” or “therapy”, as used herein, means obtaining beneficial or desired results, for example, clinical results. Beneficial or desired results can include, but are not limited to, stabilizing or improving progression of stage of HD (e.g. compared to placebo). One aspect of the treatment is, for example, that said treatment should have a minimal adverse effect on the patient, e.g. the agent used should have a high level of safety, for example without producing adverse side effects. In one embodiment, the term “method for the treatment” , as used herein, refers to “method to treat” .
The term “intermittent dosing regimen” or “intermittent dosing schedule”, as used herein, means a dosing regimen that comprises administering a splicing modulator, such as those defined herein, followed by a resting period. For example, the splicing modulator is administered according to an intermittent dosing schedule of at least two cycles, each cycle comprising (a) a dosing period and thereafter (b) a resting period. As used herein, the term “resting period” refers, in particular, to a period of time during which the patient is not given the splicing modulator (i.e., a period of time wherein the treatment with the splicing modulator is withheld). For example, if a splicing modulator, such as those defined herein, is given on a daily basis, there would be rest period if the daily administration is discontinued for some time, e.g., for some number of days, or the plasma concentration of the splicing modulator is maintained at sub-therapeutic level for some time e.g., for some number of days. The dosing period and/or the dose of the splicing modulator can be the same or different between cycles. The total treatment time (i.e., the number of cycles for treatment) may also vary from patient to patient based, for example, on the particular patient being treated (e.g., Stage I HD patient). In one embodiment, an intermittent dosing schedule comprises at least two cycles, each cycle comprising (a) a dosing period during which a therapeutically effective amount of the splicing modulator is administered to said patient and thereafter (b) a resting period. The term “intermittent dosing regimen” or “intermittent dosing schedule”, as used herein, refers to both a dosing regimen for administering the splicing modulator alone (i.e. monotherapy) or a dosing regimen for administering the splicing modulator in combination with at least a further active ingredient (i.e. combination therapy). In one embodiment, the term “intermittent dosing regimen” or “intermittent dosing schedule” refers to repeated on/off treatment, wherein the splicing modulator is administered at regular intervals in a periodic manner, for example, once a week.
The term “once a week" or “once weekly” or “QW in the context of administering a drug means herein administering one dose of a drug once each week, wherein the dose is, for example, administered on the same day of the week. In one embodiment, the term administering or administration of branaplam once a week, as used herein above or below, in particular in the embodiments and the claims, refers to branaplam administered in an amount, for example, of from 50 mg to 200 mg once a week, such as 140 mg once a week, of from 200 mg to 400 mg once a week, such as 280 mg once a week, or of from 400 mg to 700 mg once a week, such as 560 mg once a week. In particular the term administering or administration of branaplam once a week, as used herein above or below, in particular in the embodiments and the claims, refers to branaplam administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
As used herein, reference to an amount (e.g. mg, mg/ml, mg/m2, percentage) of branaplam, or a pharmaceutical acceptable salt thereof, is to be understood to refer the amount of the compound of formula (I), as herein below, in the free form, which will be adapted accordingly for a pharmaceutically acceptable salt thereof, for example hydrochloride salt thereof (e.g. branaplam hydrochloride monohydrate).
As used herein, the terms “free form” or “free forms” or “in free form” or “in the free form" refers to the compound in non-salt form, such as the base free form.
The term “about” in relation to a numerical value X means, for example, X ± 15%, including all the values within this range. In one embodiment, the term “of from... to” in relation to a numerical value means “from about... to about”, wherein about is as defined herein. For example, as used herein above or below, in particular in the embodiments and the claims, reference to branaplam administered in an amount, for example, of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week), is also to be understood to refer to branaplam administered in an amount, for example, of about 25 mg to about 100 mg once a week (e.g. about 28 mg once a week, about 56 mg once a week or about 84 mg once a week), of about 100 mg to about 175 mg once a week (e.g. about 112 mg once a week, about 154 mg once a week or about 196 mg once a week), or of about 175 mg to about 250 mg once a week (e.g. about 238 mg once a week).
The term “disease-modifying therapy" or disease-modifying treatment" , as used herein, refers to a drug that can modify or change the course of a condition or a disorder or a disease (i.e. a disease-modifying drug), such as HD, as defined herein.
As used herein, the term “subject” refers to a mammalian organism, preferably a human being (male or female).
As used herein, the term “patienf refers to a subject who is diseased and would benefit from the treatment.
As used herein, a subject is “in need of a treatment if such subject (patient) would benefit biologically, medically or in quality of life from such treatment.
The term "a therapeutically effective amount" or “an effective amounf of a compound of the present invention refers to an amount of a compound of the present invention that elicits the biological or medical response of a subject. In another embodiment, the term refers to the amount of the compound of the present invention that, when administered to a subject, is effective to at least partially ameliorate a condition, or a disorder or a disease.
The term "one or more" refers to either one or a number above one (e.g. 2, 3, 4, 5, etc.).
As used herein, the compound named branaplam, as used herein above and below, is the splicing modulator also named 5-(1H-Pyrazol-4-yl)-2-(6-((2,2,6,6-tetramethylpiperidin-4- yl)oxy)pyridazin-3-yl)phenol, of formula (I):
Figure imgf000033_0001
Branaplam, or pharmaceutical salt thereof, such as branaplam hydrochloride salt, can be prepared as described in W02014/028459, which is incorporated herein by reference, e.g. in Example17-13 therein. As used herein, “branaplam" refers to the free form, and any reference to “a pharmaceutically acceptable salt thereof refers to a pharmaceutically acceptable acid addition salt thereof. As used herein, the term "branaplam, or a salt thereof, such as a pharmaceutically acceptable salt thereof, as used in the context of the present invention (especially in the context of the any of the embodiments, above or below, and the claims) is thus to be construed to cover both the free form and a pharmaceutically acceptable salt thereof, unless otherwise indicated herein. In one embodiment, the term "branaplam hydrochloride salt” or “branaplam monohydrochloride salt" refers to 5-(1H-Pyrazol-4-yl)-2-(6-((2,2,6,6-tetramethylpiperidin-4- yl)oxy)pyridazin-3-yl)phenol monohydrochloride salt or hydrate thereof, such as 5-(1 H-Pyrazol-4- yl)-2-(6-((2,2,6,6-tetramethylpiperidin-4-yl)oxy)pyridazin-3-yl)phenol monohydrochloride monohydrate, also named branaplam hydrochloride monohydrate. In a particular embodiment, branaplam is in the form of branaplam hydrochloride salt.
In one embodiment, the term “splicing modulator”, as used herein, refers to a small molecule that directly or indirectly increases association of a target pre-mRNA sequence with the spliceosome to enhance or reduce gene expression.
In one embodiment, the term “splicing modulator", as used herein, refers to a compound, e.g., a small molecule, that alters splicing of a precursor messenger RNA (abbreviated as pre- mRNA). Exemplary splicing modulators alter the recognition of splice sites by the spliceosome, e.g., by interacting with components of the splicing machinery (e.g. the proteins and/or the nucleic acids (e.g., mRNAs and/or pre-mRNAs)), which leads to an alteration of normal splicing of the targeted pre-mRNA. Exemplary splicing modulators thus alter the sequence (or relative level of one or more sequences) of a mature RNA product of a targeted pre-mRNA. Exemplary splice modulators act by directly or indirectly altering, e.g., increasing, association of a target pre-mRNA sequence with the spliceosome to, e.g., enhance or reduce gene expression. Non-limiting examples of splicing modulators are small molecules (e.g. branaplam) and oligonucleotides, such as antisense oligonucleotides and splice-switching oligonucleotides (SSOs). More examples of splicing modulators can be found e.g. in W02014/028459, WO2014/116845 and WO2015/017589, which are incorporated herein by reference in their entirety, or in W02020/005873, W02020/005877, W02020/005882 and W02019/191092, which are incorporated herein by reference in their entirety. Certain oligomeric compounds and nucleobase sequences that may be used to alter splicing of a pre-mRNA may be found for example in U.S. Pat. No. 6,210,892; U.S. Pat. No. 5,627,274; U.S. Pat. Nos. 5,665,593; 5,916,808; U.S. Pat No. 5,976,879; US2006/0172962; US2007/002390; US2005/0074801 ; US2007/0105807; US2005/0054836; WO 2007/090073; W02007/047913, Hua et al., PLoS Biol 5(4):e73; Vickers et al., J. Immunol. 2006 Mar. 15; 176(6):3652-61; and Hua et al., American J. of Human Genetics (April 2008) 82, 1-15, each of which is hereby incorporated by reference in its entirety for any purpose. Antisense compounds have also been used to alter the ratio of naturally-occurring alternative splice variants such as the long and short forms of Bcl-X pre-mRNA (U.S. Pat No. 6,172.216: U.S. Pat. No. 6.214,986: Taylor et al., Nat. Biotechnol. 1999, 17, 1097-1100) or to force skipping of specific exons containing premature termination codons (Wilton et al., NeuromuscuL Disord., 1999, 9, 330-338). U.S. Pat. No. 5,627,274 and WO 94/26887 disclose compositions and methods for combating aberrant splicing in a pre-mRNA molecule comprising a mutation using antisense oligonucleotides which do not activate RNAse H.
In one embodiment, the relative expression level of a naturally-occurring alternative splice variant is altered, e.g. the ratio of one splice variant derived from a target pre-mRNA is changed with respect to another splice variant or the whole pool of splice variants derived from that pre- mRNA.
In another embodiment, a new splice variant is generated while the ratio of naturally- occurring alternative splice variants may or may not be altered. In one embodiment, said new splice variant is generated by removal of one or more nucleic acids from the mRNA otherwise produced in the absence of the splice modulator. This may occur, for example, by exon skipping, i.e. wherein an exon is spliced out of the pre-mRNA and is therefore not present in the mature mRNA. In another embodiment, said new splice variant is generated by activation of an alternative donor site, where an alternative 5' splice junction (donor site) is used, changing the 3' boundary of the upstream exon. In another embodiment, said new splice variant is generated by activation of an alternative acceptor site, where an alternative 3' splice junction (acceptor site) is used, changing the 5' boundary of the downstream exon. In a preferred embodiment, said new splice variant is generated which includes additional sequence not included in the mRNA in the absence of the splice modulator, e.g., by intron retention, where additional sequence, e.g., an intron or a portion thereof, is retained in the pre-mRNA and therefore is included in the mature mRNA. Therefore, if the retained sequence, e.g., intron or portion thereof, is in the coding region, said intron retention may lead to generation of, a) a splice variant encoding additional amino acids encoded by the retained intron (for example, in the case that said intron does not cause a frameshift and does not introduce a stop codon in the reading frame), or, in an embodiment, b) a splice variant containing a premature stop codon, e.g. inclusion of the additional sequence, e.g., the intron or portion thereof, causes a frameshift and/or introduces sequence comprising an in-frame stop codon upstream of the original stop codon, and therefore the resulting splice variant mRNA encodes a protein lacking one or more amino acid residues, e.g., in the C- terminus, compared to the protein encoded by a splice variant in which said intron-retention has not taken place. In a preferred embodiment, the expression level of the encoded protein is altered, e.g., is reduced, in the presence of the splice modulator relative to the expression level of the protein encoded by the splice variant in the absence of the splice modulator. In a preferred embodiment, the expression level of the splice variant (transcript) is less than the expression level of a splice variant without the intron retention. In particular, said reduced expression levels is at least partly due to instability (e.g. reduced half-life) and/or increased degradation of the resulting mRNA or encoded polypeptide, for example via a nonsense-mediated decay mechanism (in the case of the mRNA) or increased protein degradation (in the case of the encoded polypeptide).
A “splice variant” as the term is used herein refers to a mature mRNA species that is produced from a particular pre-mRNA, or a polypeptide encoded by said mature mRNA species. A particular pre-mRNA species of interest may produce one or more splice variants.
In one embodiment, a splicing modulator is a SMN splicing modulator, for example a SMN2 splicing modulator. In a preferred embodiment, the splicing modulator according to the present invention modulates splicing of the HTT gene between exons 49 and 50.
The term “SMN splicing modulator” (e.g. SMN2 splicing modulator) refers to a compound (e.g. a small molecule) that directly or indirectly increases association of the SMN2 pre-mRNA sequence with the spliceosome to enhance SMN2 exon? inclusion and increase SMN expression.
The term “the splicing modulator is provided in the form of a pharmaceutical composition", as used herein, refers to a pharmaceutical composition comprising the splicing modulator and at least one pharmaceutically acceptable excipient.
The term “the splicing modulator is provided in the form of a pharmaceutical combination”, as used herein, refers to a pharmaceutical combination comprising the splicing modulator and at least one further pharmaceutical active ingredient.
An “antisense compound” as used herein refers to a compound (e.g., an antisense oligonucleotide) that hybridizes (e.g., via base pairing) to a target nucleic acid and modulates the amount, activity, and/or function of the target nucleic acid. For example, in certain instances, antisense compounds result in altered transcription or translation of a target. Such modulation of expression can be achieved by, for example, target RNA degradation or occupancy-based inhibition. An example of modulation of RNA target function by degradation is RNase H-based degradation of the target RNA upon hybridization with a DNA-like antisense compound. Another example of modulation of gene expression by target degradation is RNA interference (RNAi). RNAi refers to antisense-mediated gene silencing through a mechanism that utilizes the RNA- induced silencing complex (RISC). An additional example of modulation of RNA target function is by an occupancy-based mechanism such as is employed naturally by microRNA. MicroRNAs are small non-coding RNAs that regulate the expression of protein coding RNAs. The binding of an antisense compound to a microRNA prevents that microRNA from binding to its messenger RNA targets, and thus interferes with the function of the microRNA. MicroRNA mimics can enhance native microRNA function. Certain antisense compounds alter splicing of pre-mRNA. Examples of antisense compounds that target Huntington's disease are described in, for example, WO19157531, WO18022473, W017015575, WO17192664, WO15107425, WO14121287, W014059356, WO14059341, W013033223, WO12109395, WO13022990, W012012467, WO1 1097643, WO11097644, W011097641, WO11032045, WO07089584, W007089611, the contents of which are hereby incorporated by reference in their entirety. Additional examples of antisense compounds that target Huntington’s disease include RG6042 (Roche), WVE-120101 (Wave/Takeda) and WVE-120102 (Wave/Takeda).
The term gene therapy, as used herein, refers, for example, to AMT-130, described, for example, in WO 2016/102664, which is hereby incorporated by reference in its entirety.
The term “pharmaceutical composition” is defined herein to refer, for example, to a mixture or solution containing at least one active ingredient or therapeutic agent to be administered to a subject, in order to treat a subject, for example as herein defined.
As used herein, the term "pharmaceutically acceptable excipient" includes any and all solvents, dispersion media, coatings, surfactants, antioxidants, preservatives (e.g., antibacterial agents, antifungal agents), isotonic agents, absorption delaying agents, salts, preservatives, drug stabilizers, binders, excipients, disintegration agents, lubricants, sweetening agents, flavoring agents, dyes, and the like and combinations thereof, as would be known to those skilled in the art (see, for example, Remington's Pharmaceutical Sciences, 22nd Ed. Mack Printing Company, 2013, pp. 1049-1070). Except insofar as any conventional carrier is incompatible with the active ingredient, its use in the therapeutic or pharmaceutical compositions is contemplated.
For the above-mentioned uses/treatment methods the appropriate dosage may vary depending upon a variety of factors, such as, for example, the age, weight, sex, the route of administration or salt employed. As used herein, the term "a,” "an,” "the” and similar terms used in the context of the present invention (especially in the context of the embodiments and claims) are to be construed to cover both the singular and plural unless otherwise indicated herein or clearly contradicted by the context.
The use of any and all examples, or exemplary language (e.g. "such as”) provided herein is intended merely to better illuminate the invention and does not pose a limitation on the scope of the invention otherwise claimed.
The term “compound of the present invention”, as used herein, refers to branaplam (i.e. free form) or a pharmaceutically acceptable salt thereof.
As used herein, the terms “free form” or “free forms” refers to the compound in non-salt form.
As used herein, the terms “salt" , “salts” or “salt form” refers to an acid addition or base addition salt of a compound. “Salts” include in particular “pharmaceutically acceptable salts”. The term “pharmaceutically acceptable salts” refers to salts that retain the biological effectiveness and properties of the compounds and, which typically are not biologically or otherwise undesirable.
Pharmaceutically acceptable acid addition salts can be formed with inorganic acids and organic acids.
Inorganic acids from which salts can be derived include, for example, hydrochloric acid, hydrobromic add, sulfuric add, nitric acid, phosphoric add, and the like.
Organic acids from which salts can be derived include, for example, acetic acid, propionic acid, glycolic acid, oxalic acid, maleic acid, malonic acid, succinic acid, fumaric acid, tartaric acid, citric acid, benzoic acid, mandelic acid, methanesulfonic acid, ethanesulfonic acid, toluenesulfonic acid, sulfosalicylic acid, and the like.
Pharmaceutically acceptable base addition salts can be formed with inorganic and organic bases.
Inorganic bases from which salts can be derived include, for example, ammonium salts and metals from columns I to XII of the periodic table. In certain embodiments, the salts are derived from sodium, potassium, ammonium, calcium, magnesium, iron, silver, zinc, and copper; particularly suitable salts include ammonium, potassium, sodium, calcium and magnesium salts.
Organic bases from which salts can be derived include, for example, primary, secondary, and tertiary amines, substituted amines including naturally occurring substituted amines, cyclic amines, basic ion exchange resins, and the like. Certain organic amines include isopropylamine, benzathine, cholinate, diethanolamine, diethylamine, lysine, meglumine, piperazine and tromethamine.
Pharmaceutically acceptable salts can be synthesized from a basic or acidic moiety, by conventional chemical methods. Generally, such salts can be prepared by reacting the free acid forms of the compound with a stoichiometric amount of the appropriate base (such as Na, Ca, Mg, or K hydroxide, carbonate, bicarbonate or the like), or by reacting the free base form of the compound with a stoichiometric amount of the appropriate acid. Such reactions are typically carried out in water or in an organic solvent, or in a mixture of the two. Generally, use of nonaqueous media like ether, ethyl acetate, ethanol, isopropanol, or acetonitrile is desirable, where practicable. Lists of additional suitable salts can be found, e.g., in “Remington's Pharmaceutical Sciences”, 22nd edition, Mack Publishing Company (2013); and in “Handbook of Pharmaceutical Salts: Properties, Selection, and Use” by Stahl and Wermuth (Wiley-VCH, Weinheim, 2011, 2nd edition).
The terms "drug", "active substance", "active ingredient", "pharmaceutically active ingredient", "active agent", “therapeutic agenf or “agenf are to be understood as meaning a compound in free form or in the form of a pharmaceutically acceptable salt.
The term “combination” or “pharmaceutical combination” refers to either a fixed combination in one unit dosage form, non-fixed combination, or a kit of parts for the combined administration where a compound of the present invention and one or more combination partner (e.g. another drug, also referred to as further “pharmaceutical active ingredient", “therapeutic agenf or “co-agenf ) may be administered independently at the same time or separately within time intervals, especially where these time intervals allow that the combination partners show a cooperative, e.g. synergistic effect The terms “co-administration” or “combined administration" or the like as utilized herein are meant to encompass administration of the selected combination partner to a single subject in need thereof (e.g. a patient), and are intended to include treatment regimens in which the agents are not necessarily administered by the same route of administration or at the same time. The term “fixed combination” means that the active ingredients, e.g. the compound of the present invention and one or more combination partners, are both administered to a patient simultaneously in the form of a single entity or dosage. The term “non-fixed combination” means that the active ingredients, e.g. a compound of the present invention and one or more combination partners, are both administered to a patient as separate entities either simultaneously or sequentially with no specific time limits, wherein such administration provides therapeutically effective levels of the two compounds in the body of the patient
The compound of the present invention may be administered separately, by the same or different route of administration, or together in the same pharmaceutical composition as the other agents. In the combination therapies of the invention, the compound of the invention and the other therapeutic agent may be manufactured and/or formulated by the same or different manufacturers. Moreover, the compound of the invention and the other therapeutic may be brought together into a combination therapy: (i) prior to release of the combination product to physicians (e.g. in the case of a kit comprising the compound of the invention and the other therapeutic agent); (ii) by the physician themselves (or under the guidance of the physician) shortly before administration; (iii) in the patient themselves, e.g. during sequential administration of the compound of the invention and the other therapeutic agent.
ABBREVIATIONS: h = hr = hour(s) min = minute(s) sec = second(s) msec = millisecond(s) mg = milligram(s)
Kg = kg = kilogram(s) ml = mL = milli liter(s) uL ul = microliter(s)
PCR = polymerase chain reaction rpm = revolutions per minute
°C = degree(s) Celsius xg = times gravity (centrifugal force)
HTT = Huntingtin mHTT = mutant Huntingtin tHTT = total Huntingtin
HTRF= Homogenous Time Resolved Fluorescence n = number of animals
CSF = cerebrospinal fluid cP = centipoise, unit of viscosity pICso = -Log(ICso) where IC50 is expressed in molar or mol/L
RT = room temperature (25±3 °C)
56-FAM = 5' 6-FAM (Fluorescein) 3IABKFQ = 3' Iowa Black® FAM quencher ZEN = ZEN™ internal quencher USA = United States of America
BacHD = BACH = Bacterial artificial chromosome-mediated transgenic Huntington's Disease model
ACAT = Advanced Compartmental And Transit
AUC = area under the curve
BIW = twice per week
CD = cyclodextrin
CL = clearance of elimination from central compartment
Cmax = maximum concentration
Ctrough = minimum concentration F = bioavailability
Fa = fraction absorbed
IC50 = half-maximum inhibitory concentration Imax: maximum inhibition effect k12 = first-order rate constant from compartment 1 to compartment 2 k21 = first-order rate constant from compartment 2 to compartment 1 ka = first-order absorption rate constant kin = synthesis rate of mutant HIT protein kout = degradation rate or fractional turnover parameter of the mutant HTT protein synthesis
LogP = logarithm of partition coefficient between organic and aqueous solution
MTD = maximum tolerated dose
PBPK = Physiologically Based Pharmacokinetic (PBPK)
PD = pharmacodynamics
Peff = effective permeability
PK = pharmacokinetics pKa =negative logarithm of the acid dissociation constant
Q = intercompartmental clearance
QW = once per week
R = mutant HTT protein level at a given time
RO = baseline of mutant HTT protein concentration (e.g. in brain)
RSE = relative standard error reported on the approximate standard deviation scale (SE/variance)/2
SE = standard deviation scale ss = steady state
SMA = spinal muscular atrophy
Tlag = lag time of absorption
Tmax = time of maximum concentration
V1 = central volume of 2-compartment PK model
V2, Vc = peripheral volume of 2-compartment PK model
T1/2 = apparent terminal elimination half life
DRF = dose range finding
BE = blinded extension
OLE = open label extension
UHDRS Independence Scale (IS) = Independent Scale (IS) component of the UHDRS
UHDRS = Unified Huntington Disease Rating Scale
AUCIast = area under the plasma (or serum or blood) concentration-time curve from time zero to the time of the last quantifiable concentration AUCtau = area under the plasma (or serum or blood) concentration-time curve from time zero to the end of the dosing interval tau
Cmax = observed maximum plasma (or serum or blood) concentration of a drug following administration
BL = baseline
PBO = placebo
PMBC or PBMCs = peripheral blood mononuclear cell(s)
CGA = core gating assessment
IA = interim analysis
VES = visit evaluation schedule
EOT CRF = end of treatment case report form
IRT = interactive response technology
CRF = Case Report/Record Form (paper or electronic)
ALT = alanine aminotransferase
SGPT = serum glutamic pyruvic transaminase
AST = aspartate aminotransferase
SGOT = serum glutamic oxaloacetic transaminase
GGT = gamma-glutamyl transferase
ELISA = Enzyme-linked immunosorbent assay
LLOQ = Lower Limit of Quantification
ULOQ = Upper limit of quantification (ULOQ)
ULN = upper limit of normal
BUN = blood urea nitrogen
INR = International Normalized Ratio
PT = prothrombin time
C-SSRS = Columbia Suicide Severity Rating Scale y-GT = Gamma-glutamyl transpeptidase APTT = activated partial thromboplastin time
AUCinf = Area under the plasma (or serum or blood) concentration-time curve from time zero to infinity
AeO-t = Amount of drug excreted into the urine from time zero to time ‘t’ where t is a defined time point after administration
CL/F = Total body clearance of drug from the plasma
CLr = renal clearance based on AUG and Ae (cumulative amount of unchanged drug excreted in the urine) for the scheduled time period
QT = time between the start of the Q wave and the end of the T wave of the ECG
QTcF = heart rate corrected QT interval using the Fridericia correction
Vz/F = The apparent volume of distribution during terminal phase (associated with Az) (volume)
PR = time between the start of the P wave and the R peak of the QRS complex of the ECG
ECG = electrocardiogram
R2 = proportion of the variance in the dependent variable that is predictable from the independent variable(s)
CAG repeats = cytosine-adenine-guanine repeats
HIV = human immunodeficiency virus
IGF = informed consent form
WOCB = women of childbearing potential
LP = lumbar puncture
HD = Huntington Disease vMRI = Volumetric Magnetic Resonance Imaging
MRI = magnetic resonance imaging
DMC = Data Monitoring Committee
CGA = Cohort Gating Assessment IA = interim analysis
TdP = Torsades de pointes
AE(s) = adverse event(s)
SAE(s) = serious adverse event(s)
CYP3A4 = Human Cytochrome P4503A4
IUD = intrauterine device
IUS = intrauterine system
CDT = carbohydrate deficient transferrin
Ctrough = drug concentration observed at the last planned timepoint prior to dosing
Gl = gastrointestinal
DR = dose response
PBPK = Physiologically-based pharmacokinetic model
EXAMPLES
EXAMPLE 1a: Pre-clinical evaluation of branaplam
Methods
RNA-seq analysis of human cells treated with splice modulators
A normal Human Fibroblast line (HD1994) was treated with branaplam and Splice modulator 2 (described as Example 3-2 in WO 2015017589) and Splice modulator 3 (described as NVS-SM3 in NatChem Biol. 2015 Jul;11(7):511-7. doi: 10.1038/nchembio.1837) or DMSOfor24 hours. The following compound doses were used:
Branaplam was used at an efficacious dose (100 nM) and a cytotoxic dose (5 uM).
Splice modulator 2 was used at 750 nM.
Splice modulator 3 was used at 5 uM.
There were 3 biological replicates per group. Total RNA was isolated using the Qiagen RNeasy Mini isolation kit. RNA-Seq libraries were prepared using the Illumina TruSeq RNA Sample Prep kit v2 and sequenced using the Illumina HiSeq 2500 platform.
Each sample was sequenced on four different lanes belonging to the same flow cells to a length of 2x76 base-pairs (bp). The quality of the generated reads was assessed by running FastQC (version 0.10.1) on the FASTQ files. The average quality per base in Phred score was computed for each sample. The reads were of excellent quality (mean Phred score > 28 for all base positions). A total of 847 million 76-base-pair (bp) paired-end reads were mapped to the Homo sapiens genome (hg19), the human RefSeq (Pruitt et al., 2007) transcripts (release 59, May 3, 2013) using TopHat (2.0.3).
In order to increase the ability to detect exons, the three alignment files (bam files) for each of the five conditions (DMSO, branaplam at 5 uM, branaplam at 100 nM, splice modulator 2 at 500 nM and splice modulator 3 at 5 uM) were pooled before the transcript assembly by Cufflinks (2.1.1). After transcript assembly, the exon coordinates were extracted from the transcript gtf files. Exons on alternative chromosomes and on chromosome M were excluded and the strand information were ignored. That yielded 273866 putative exons. Exons that do not intersect any RefSeq exon (release 59, May 3, 2013) were considered as candidates for non-annotated splice in events. That resulted in 19474 candidates. To gain further confidence, we merged overlapping exons in the full set of all RefSeq exons plus the initial 19474 candidates resulting in 229665 non-overlapping exons. For this set of exons, all possible exon-exon junctions within each RefSeq gene were considered. A junction database was created using R (2.15.2) scripts and bedtools (2.15.0). The first mate of each paired end read was then mapped against the database. Only non-annotated exons supported by at least one junction alignment were retained. This excludes in particular candidates not attached to a RefSeq gene. That left 10898 final candidates. Sequences for these candidates were extracted from hg19 using bedtools. To assess variability, separate Cufflinks assemblies for each replicate were also computed and presence of each candidate in such an assembly was checked. In addition, the alignments against the junction database were used to determine the number of junctions that skip over a novel exon. That information was used to estimate a splice in fraction. Further, the read coverage for the 10898 candidates was determined for each replicate using bedtools on the TopHat alignments (bam files) and then aggregated within each of the five conditions. The original fastq files were reprocessed with STAR (020201) and aligned against the human genome (hg38). The 10898 candidate exons were lifted over to hg38 using the UCSC genome browser tools - 7 candidates could not be lifted. The junctions detected by STAR were mapped to the remaining 10891 candidates and provide an alternative source of junction counts.
A candidate, falling into the gene region of HTT (chr4:3213622-3213736) was detected and appeared to be modulated by active compounds. It was supported by the re analysis with STAR alignments. In addition, the 3’ end shows the AGA|GT motif that is associated to the mode of action of the active compounds. Finally, this candidate (comprised in the splice variant herein referred to as the novel-exon-containing HTT transcript) could be verified by PCR as described below. The candidate chr4:3213622-3213736 introduces an in-frame stop codon (TAG) which is 55 nucleotides from the 3’ end of the exon and therefore may trigger nonsense-mediated decay. NGS data show that expression of HTT is downregulated by the active compounds about six fold (Figure 1). A partial sequence (showing only the part corresponding to exon 49, novel exon, and exon 50) of the novel-exon-containing HTT transcript is included herein as SEQ ID NO: 9. The novel exon is underlined.
SEQ ID NO: 9
Figure imgf000047_0001
In vitro evaluation of Branaplam
Cultured human neuroblastoma (SH-SY5Y cell line) cells were treated at doses ranging from 5 nM - 125 nM for 24 hours (for transcript evaluation) or 48 hours (for protein evaluation). RNA was quantified by Nanodrop 2000 (Thermo Scientific). cDNAs were synthesized from 140-400 ng RNA using Maxima First strand cDNA synthesis kit using a mix of oligo dT and random hexamers (Thermo Scientific) in 20 uL reaction at 25 °C for 10 min, 50 °C for 15 min then 85 °C for 5 min. Quantitative PCR was performed using Taqman Fast Advanced master mix (Thermo Scientific) in 20 uL with 4 uL of cDNA reaction and primers specific for each genes. The PCR steps were as follows: 95 °C for 20 sec then 40 cycles of 95 °C for 1 sec, 55 °C for 20 sec. The sequence of primers were, for WT human HTT, forward, 5'-GTCATTTGCACCTTCCTCCT-3' (SEQ ID NO: 1); reverse, 5’- TGGATCAAATGCCAGGACAG-3’ (SEQ ID NO: 2) and sequence of probe was 56- FAM/TTG TGA AAT /ZEN/TCG TGG TGG CAA CCC /3IABkFQ/ (SEQ ID NO: 8), for HTT novel exon, forward, 5’-TCCTGAGAAAGAGAAGGACATTG-3’ (SEQ ID NO: 3); reverse, 5'- CTGTGGGCTCCTGTAGAAATC-3’ (SEQ ID NO: 4) and sequence of probe /56-FAM/AAT TCG TGG /ZEN/TGG CAA CCC TTG AGA /3IABkFQ/ (SEQ ID NO: 7). Relative quantification of gene expression was performed using 2-ΔΔCT method. Fold changes in the mRNA expression level was calculated following normalization to mouse glucuronidase beta (Gusb) as an endogenous reference (Figures 2a and 2b).
For protein analysis, cells were lysed in RIPA buffer with protease and phosphatase inhibitor (Thermo Scientific). Supernatant was obtained by centrifugation for 20 min at 13,000 rpm at 4 °C. Total protein concentration was quantified using the BCA protein Assay (Thermo Scientific). Samples were resolved in 3-8% Tris-Acetate protein gel under reducing condition. Proteins were transferred onto PVDF membrane (Millipore) and western blot analysis was performed using rabbit anti-Huntingtin antibody (Millipore #MAB2166), mouse anti-actin (Sigma, #A5316) and mouse anti-vinculin (Bio-Rad, #MCA465). Protein bands were quantified by Image J.
BacHD mice
Twenty-eight BacHD mice (FVB/N-Tg(HTT*97Q)IXwy/J transgenic mice - Jackson Laboratories) were used for the experiment. Animal protocols were approved by the Children's Hospital of Philadelphia Institutional Animal Care and use Committee. Mice were housed in a temperature- controlled environment on a 12-h light/dark cycle. Food and water were provided ad libitum.
For the repeat dosing study, twenty-four BacHD mice (FVB/N-Tg(HTT*97Q)IXwy/J transgenic mice - Jackson Laboratories) were used for the experiment. Animal protocols were approved by the Children’s Hospital of Philadelphia Institutional Animal Care and use Committee. Mice were housed in a temperature-controlled environment on a 12-h light/dark cycle. Food and water were provided ad libitum.
Branaplam treatment
A single dose of branaplam or vehicle solution was administered by oral gavage. Mice were divided in seven groups (n=4 mice/group) and treated with branaplam (10 mg/kg - 2 groups) and 50 mg/kg -3 groups), or vehicle (2 groups) as control. Mice were firmly restrained by grasping the loose skin to immobilize the head, maintained in a vertical position and a 22- to 26-gauge gavage needle was placed in the side of the mouth. The needle was guided following the roof of the mouth into the esophagus and allowed to gently enter in the stomach. The amount of branaplam or vehicle administrated to each mouse was based on the weight recorded before treatment.
For the repeat dosing study, branaplam or vehicle was administered by oral gavage 3 times a week for 3 consecutive weeks. Mice were divided in 4 groups (n=6 mice/group) and treated with branaplam (12 mg/kg - 1 group, or 24 mg/kg - 2 groups), or vehicle (1 groups) as control. Mice were firmly restrained by grasping the loose skin to immobilize the head, maintained in a vertical position and a 22- to 26-gauge gavage needle was placed in the side of the mouth. The needle was guided following the roof of the mouth into the esophagus and allowed to gently enter in the stomach. The amount of branaplam or vehicle administrated to each mouse was based on the weight recorded the day of dosing.
Blood collection and tissue sampling
At 8 h, 24 h (vehicle and branaplam 10 mg/kg & 50 mg/kg), and 48 h (branaplam 50 mg/kg) after oral gavage, blood and tissue samples were obtained for PK and PD analysis. Mice were anesthetized with isoflurane and blood was obtained via submandibular vein bleeds and collected for RNA extraction (PD analysis) using RNAprotect Animal Blood Tubes, and plasma (PK analysis) using K2EDTA coated tubes. Cells were removed from plasma by centrifugation for 10 min at 2000 x g at 4 °C, and plasma samples were stored at -80 °C. Following blood collection, mice were anesthetized with a lethal dose of ketamine/xylazine (100 mL of a 10 mg:1 mg), and perfused with 18 ml of 0.9% cold saline mixed with 2 ml of RNAIater (Ambion) solution for tissue collection. Liver, skeletal muscle, cerebrum, and cerebellum samples were flash frozen in liquid nitrogen and stored at -80 °C.
Blood and CSF collection, and tissue sampling for repeat dose study
At 24 h (vehicle and branaplam 12mg/Kg & 24mg/Kg), and 72 h (branaplam 24mg/Kg) after the last treatment, blood, CSF, and tissue samples were obtained for PK and RD analysis. To collect CSF, mice were placed in a rodent anesthesia induction chamber where they are exposed to 4- 5% isoflurane in 100% oxygen carrier gas. Once an appropriate plane of anesthesia was achieved, they were moved to a nose cone so that maintenance levels of isoflurane (1-3%) could be delivered throughout the procedure. The dorsal aspect of their cervical and occipital region was surgically prepped to visualize the dura mater under a microscope. A glass micropipette attached to a micromanipulator was introduced to the cisterna magna via a puncture through the dura mater at a point where no vasculature was visualized, and CSF was allowed to flow into the micropipette via capillary action. After approximately 15-30 minutes, the micropipette was removed from the cistema magna, the CSF sample was transferred into Eppendorf tubes, flash frozen in liquid nitrogen, and stored at -80 °C.
Following CSF collection, mice were kept under anesthesia with isoflurane. Blood was obtained via submandibular vein bleeds and collected for RNA extraction (RD analysis) using RNAprotect Animal Blood Tubes, and plasma (PK analysis) using K2EDTA coated tubes. Cells were removed from plasma by centrifugation for 10 min at 2000 xg at 4 °C, and plasma samples were stored at -80 °C. Following blood collection, mice were given a lethal dose of ketamine/xylazine (100 ml of a 10 mg:1 mg), and perfused with 18 ml of 0.9% cold saline mixed with 2ml of RNAIater (Ambion) solution for tissue collection. Liver, skeletal muscle, brain striatum, brain cortex, hemibrain and cerebellum samples were flash frozen in liquid nitrogen and stored at -80 °C.
Blood and CSF collection, and tissue sampling for repeat dose timecourse study
At 72 h 168 h, 240 h and 336 h (branaplam 24 mg/kg) after the last treatment (vehicle or 24 mg/kg branaplam for 1 week or 3 weeks), blood, CSF, and tissue samples were obtained for PK and RD analysis. To collect CSF, mice were placed in a rodent anesthesia induction chamber where they are exposed to 4-5% isoflurane in 100% oxygen carrier gas. Once an appropriate plane of anesthesia was achieved, they were moved to a nose cone so that maintenance levels of isoflurane (1-3%) could be delivered throughout the procedure. The dorsal aspect of their cervical and occipital region was surgically prepped to visualize the dura mater under a microscope. A glass micropipette attached to a micromanipulator was introduced to the cistema magna via a puncture through the dura mater at a point where no vasculature was visualized, and CSF was allowed to flow into the micropipette via capillary action. After approximately 15-30 minutes, the micropipette was removed from the cisterna magna, the CSF sample was transferred into Eppendorf tubes, flash frozen in liquid nitrogen, and stored at -80 °C.
Following CSF collection, mice were kept under anesthesia with isoflurane. Blood was obtained via submandibular vein bleeds and collected for RNA extraction (RD analysis) using RNAprotect Animal Blood Tubes, and plasma (PK analysis) using K2EDTA coated tubes. Cells were removed from plasma by centrifugation for 10 min at 2000 x g at 4 °C, and plasma samples were stored at -80 °C. Following blood collection, mice were given a lethal dose of ketamine/xylazine (100 ml of a 10 mg:1 mg), and perfused with 18 mL of 0.9% cold saline mixed with 2 mL of RNAIater (Ambion) solution for tissue collection. Liver, skeletal muscle, brain striatum, brain cortex, hemibrain and cerebellum samples were flash frozen in liquid nitrogen and stored at -80 °C. Branaplam dose
In experiments, as herein described, the branaplam dose is provided as a solution of branaplam monohydrochloride salt (10 mg/mL suspension) in methyl cellulose, medium viscosity 400cP for a 1% solution), Tween 80 (1% v/v), purified water suspension formulation.
RNA extraction and Real time quantitative PCR
Total RNA from cerebrum and cerebellum was extracted using RNeasy Plus kit (Qiagen) after homogenized in Precellys at 6000 rpm for 40 sec. RNA from blood was extracted using PAXgene blood RNA kit (Qiagen) according to manufacturer protocol. The RNA was quantified by Nanodrop 2000 (Thermo Scientific). cDNAs were synthesized from 140-400 ng RNA using Maxima First strand cDNA synthesis kit using a mix of oligo dT and random hexamers (Thermo Scientific) in 20uL reaction at 25 °C for 10 min, 50 °C for 15 min then 85 °C for 5 min. Quantitative PCR was performed using Taqman Fast Advanced master mix (Thermo Scientific) in 20 uL with 4 uL of cDNA reaction and primers specific for each genes. The PCR steps were as follows: 95 °C for 20 sec then 40 cycles of 95 °C for 1 sec, 55 °C for 20 sec. The sequence of primers were, for WT human HTT, forward, S'-GTCATTTGCACCTTCCTCCT-S' (SEQ ID NO: 1); reverse, 5’- TGGATCAAATGCCAGGACAG-3’ (SEQ ID NO: 2) and sequence of probe was 56-FAM/TTG TGA AAT /ZEN/TCG TGG TGG CAA CCC Z3IABkFQ/ (SEQ ID NO: 8), for HTT novel exon, forward, 5’-TCCTGAGAAAGAGAAGGACATTG-3’ (SEQ ID NO: 3); reverse, 5’- CTGTGGGCTCCTGTAGAAATC-3’ (SEQ ID NO: 4) and sequence of probe /56-FAM/AAT TCG TGG /ZEN/TGG CAA CCC TTG AGA /3IABkFQ/ (SEQ ID NO: 7). Relative quantification of gene expression was performed using 2-ΔΔCTCT method. Fold changes in the mRNA expression level was calculated following normalization to mouse glucuronidase beta (Gusb) as an endogenous reference.
Protein preparation and Western blot analysis
Snap-frozen mouse tissue samples were homogenized in RIPA buffer with protease and phosphatase inhibitor (Thermo Scientific) by Precellys at 6000 rpm for 40 sec. Supernatant was obtained by centrifugation for 20 min at 13,000 rpm at 4 °C. Total protein concentration was quantified using the BCA protein Assay (Thermo Scientific). Samples were resolved in 3-8% Tris- Acetate protein gel under reducing condition. Proteins were transferred onto PVDF membrane (Millipore) and western blot analysis was performed using rabbit anti-Huntingtin antibody (Millipore #MAB2166), mouse anti-actin (Sigma, #A5316) and mouse anti-vinculin (Bio-Rad, #MCA465). Protein bands were quantified by Image J.
Protein analysis on CSF samples
CSF samples were clarified after a 5 minutes centrifugation at 14,000 rpm in a centrifuge at 4 °C. 96-well V-bottom plate were loaded with a CSF buffer 2.5 - 5 uL of CSF sample. This was followed by addition of MP-2B7 (magnetic particle antibody conjugated suspension) HTT antibody diluted in Erenna assay buffer. Assay plate was incubated with shaking (600 rpm) at RT for 1 h and then put through a post-transfer wash program on BioTek-405. 20 ul/well of MW1 detection antibody was added to the assay plate. Plate was incubated with shaking (at 750 rpm) at room temperature for 1 hr. Plate was washed on BioTek-405 and after serial buffer washes, assay plate was placed on magnetic rack till all beads were pulled to the magnet (approximately 5 min), 10 uL of sample from the assay plate were transferred to a 384-well plate. The plate was left at room temperature for 30 mins and then run on the Erenna machine using a run time of 60 seconds.
Conclusions
In vitro evaluation of branaplam in human neuroblastoma cell line (SHSY5Y) revealed that branaplam treatment leads to a dose dependent lowering of total Huntingtin transcript to 30 - 90% of normal endogenous levels at doses ranging from 5 nM - 125 nM and a concomitant increase (100 - 500 fold) in a novel-exon-containing HTT transcript (Figures 2a and 2b). Furthermore, Western blot analysis revealed that this decrease in transcript was accompanied by a robust reduction of normal Huntingtin protein (50 - 70%) in the same dose range (Figure 2c). EC50 for lowering of HTT transcript by Branaplam was in the 20-25 nM range while EC50 for HTT protein lowering was in the 10-25 nM range.
To confirm these findings in vivo a humanized mouse model of HD, the BacHD model (Gray et al, J. Neurosci 2008; 28(24); 6182-6195), which harbors the full length mutant human HTT gene with a CAG expansion of 97 and expressing mutant protein at ~1.5 X normal mouse HTT was used. BacHD mice received a single oral dose of branaplam at either 10 mg/kg or 50 mg/kg level. Total HTT transcript and novel-exon-containing HTT transcript were measured at 8 hr and 24 h for the 10 mg/kg dose and at 8 h, 24 h and 48 h for the 50 mg/kg dose. Brain tissue (cerebrum, Figures 3 and 4) was evaluated by quantitative PCR for changes in levels of total HTT and HTT transcripts containing a novel exon resulting from branaplam treatment. A clear, dose dependent increase in the novel-exon-containing form of HTT was apparent in both brain regions at 8 and 24 h after dosing. Samples from the 50 mg/kg group collected at 48 h after dosing showed a trend towards return to vehicle levels. Total HTT transcript levels at both dose levels showed a lowering trend at 8h and a greater degree of lowering at the 50 mg/kg level, 24 hours post-dosing.
Furthermore, evaluation of blood samples from the same animals revealed robust modulation of novel-exon-containing HTT transcript and lowering of total HTT transcripts (Figures 5 and 6).
To evaluate the effect of branaplam on mutant HTT protein a repeat dosing study was carried out in the same mouse model. BacHD mice received thrice weekly doses of branaplam at 12 mg/kg or 24 mg/kg for three weeks. Western Blot analysis revealed a dose dependent, significant lowering of mutant HTT protein at the 12 mg/kg dose and at the 24 mg/kg doses 24 h post-dosing in the striatum (Figure 7) as well as cortex (Figure 8), with greater HTT reduction evident in the striatum. Evaluation of mutant HTT protein in CSF samples from the same animals revealed a -50% lowering at the 12 mg/kg and 24 mg/kg, 24 hrs post-last dose (Figure 11). A trend towards further lowering of mutant HTT protein, relative to that seen at 24 h was apparent from the 24 mg/kg cohort takedown 72 h post-dose. Additionally, peripheral effect on HTT level was confirmed via robust lowering of mHTT protein in the liver (Figure 9) and total HTT transcript in blood (Figure 10). Effects of branaplam are specific to human HTT with no lowering effect seen on endogenous mouse HTT transcript or protein.
With a view to characterize the time course of HTT protein lowering and recovery and to better model the PK-PD relationship an extended time-course study was performed. BacHD mice received three weekly, oral doses of 24 mg/kg branaplam for three weeks. Animals were taken down and tissues collected 72, 168, 240 or 336 hours after the last dose, An additional cohort of animals received 24 mg/kg dose for one week, with tissues being collected 72 hours after the last dose. Western Blot analysis revealed a time-dependent lowering trend for mutant HTT protein going from 1 week of dosing to 3 weeks of dosing. After 3 weeks of dosing with branaplam maximal HTT protein lowering of approximately 45% (relative to vehicle) was observed at 72 h with a return to baseline between 72 -168 h (cortex, Figure 21) or between 72 - 336 h (striatum, Figure 20).
Our results show that intermittent weekly dosing of branaplam results in robust lowering of mutant HTT protein in key areas of the brain (striatum and cortex) impacted in Huntington's disease. The level of mutant HTT protein lowering observed in the CNS is in line with levels expected to provide therapeutic benefit (slowing of HD progression) based on preclinical observations with other HTT lowering modalities (Stanek et al, Hum Gen Ther 2014, 25, 461-474; Kordasiewicz et al, Neuron 2012, 74(6), 1031-1044 ; Southwell et al, Sci Transl Med 2018, 10, 1-12). Branaplam also lowers peripheral HTT levels offering potential opportunities to address systemic issues (e.g. cardiac, skeletal or metabolic issues) associated with Huntington’s disease (van der Burg et al., The Lancet (Neurology) 2009; Vol 8, Issue 8, 765-774).
EXAMPLE 1b: Clinical Evaluation of Branaplam in healthy adult subjects
Example 1b.1: Single ascending dose study of the safety, tolerability, and pharmacokinetics of branaplam in healthy adult subjects
Figure imgf000054_0001
The study is a randomized (3:1), double blind, placebo-controlled, sequential, single ascending dose design with up to five cohorts of subjects, each comprised of 8 subjects with 6 receiving branaplam and 2 receiving placebo. Cohorts are enrolled sequentially. Subjects in each cohort are randomly assigned on Day 1 to either branaplam or placebo in a ratio of 3:1. Doses for all five cohorts are listed herein:
Figure imgf000055_0001
‘Additional (optional) cohorts - dose in these additional cohorts may be lower, the same as, or higher than any of the preceding cohorts, but are capped at a maximum of up to 420 mg and 630 mg each
The study consists of 26 days in which screening can occur, a baseline period of up to 2 days, a 1 day treatment period, and a 2 week follow up period. Subjects who meet the eligibility criteria at screening are admitted for baseline evaluations, all baseline safety evaluation results must be available prior to dosing. Subjects may be admitted to the clinical research center for Baseline assessments on Day -2 or Day -1 (depending on scheduling at site) and remain in the clinical research center for 96 hours following dose administration. Study assessments continue for 14 days following dose administration. Safety assessments include physical examinations, ECGs, vital signs, standard clinical laboratory evaluations (hematology, blood chemistry, and urinalysis), and adverse event and serious adverse event monitoring. The sponsor and site investigator perform a joint dose escalation data review to decide whether to proceed with the next cohort
The protocol provides two optional, additional cohorts (Cohorts 4 and 5) that may be added during the course of the study based on the results from earlier cohorts. The dose of branaplam in these additional cohorts may be lower, the same as, or higher than any of the preceding cohorts. Any dose higher than 210 mg will not exceed a 2-fold increment for increasing the dose relative to the preceding dose (i.e., 210 mg to 420 mg). Population
The study population is comprised of healthy adult male and female subjects.
Inclusion criteria
Subjects eligible for inclusion in this study must meet all of the following criteria:
1. Written informed consent must be obtained before any assessment is performed.
2. Healthy male and female subjects 18 to 60 years of age included, and in good health as determined by past medical history, physical examination, vital signs, electrocardiogram, and laboratory tests at screening.
3. Subjects must weigh at least 50 kg at screening to participate in the study, and must have a body mass index (BMI) within the range of 18.0 - 30.0 kg/m2. BMI = Body weight (kg) / [Height (m)]2
4. At screening, and baseline, vital signs (oral body temperature, systolic and diastolic blood pressure and pulse rate) are assessed in the supineposition and again (when required) in the standing position. Supine vital signs should be within the following ranges:
- oral body temperature between 35.0-37.5 °C systolic blood pressure, 90-139 mmHg diastolic blood pressure, 50-89 mmHg pulse rate, 40-90 bpm
Subjects should be excluded if their standing vital signs (relative to supine) show findings which, in the opinion of the Investigator, are associated with clinical manifestation of postural hypotension (in the absence of any other cause). The Investigator should carefully consider (in consultation with the Sponsor) enrolling subjects with either a > 20 mmHg decrease in systolic or a >10 mm Hg decrease in diastolic blood pressure, accompanied by a > 20 bpm increase in heart-rate (from sitting to standing).
5. Able to communicate well with the investigator, to understand and comply with the requirements of the study.
Exclusion criteria
1. Use of other investigational drugs at the time of screening, or within 5 half-lives of screening, or within 30 days, whichever is longer; or longer if required by local regulations. 2. History of hypersensitivity or other intolerance to cyclodextrin-containing medicinal products or foods.
3. A history of clinically significant ECG abnormalities, or any of the following ECG abnormalities at screening, baseline, or pre-treatment:
- PR > 200 msec
- QRS complex > 120 msec
- QTcF > 450 msec (males)
- QTcF > 460 msec (females)
4. Known family history or known presence of long QT syndrome.
5. Known history or current clinically significant arrhythmias.
6. Concomitant use of agents known to prolong the QT interval unless they can be permanently discontinued for the duration of study.
7. History of malignancy of any organ system (other than localized basal cell carcinoma of the skin or in-situ cervical cancer), treated or untreated, within the past 5 years, regardless of whether there is evidence of local recurrence or metastases.
8. History or evidence of retinal disease.
9. History or evidence of testicular disease (males).
10. Pregnant or nursing (lactating) women.
11. Women of childbearing potential, defined as all women physiologically capable of becoming pregnant.
Women are considered post-menopausal and not of childbearing potential if they have had 12 months of natural (spontaneous) amenorrhea with an appropriate clinical profile (e.g. age appropriate, history of vasomotor symptoms) or have had surgical bilateral oophorectomy (with or without hysterectomy) or total hysterectomy at least six weeks prior to screening. In the case of oophorectomy alone, only when the reproductive status of the woman has been confirmed by follow up hormone level assessment is she considered not of childbearing potential.
12. Sexually active males unwilling to use a condom during intercourse while enrolled in the study and for three months after participating in the study. A condom is required for all sexually active male participants to prevent them from fathering a child AND to prevent delivery of the investigational drug via seminal fluid to their partner. In addition, male participants should not donate sperm for the time period specified above. 13. History or evidence of use of any tobacco or other nicotine-containing products in the 3 months prior to screening including but not limited to cigarettes, cigars, chewing tobacco, vaporizers, and electronic cigarettes. Urine cotinine levels are measured at screening and at baseline for all subjects. Any subject who reports a history of tobacco/nicotine use, a history of "vaping", and/or who has a positive urine cotinine test is ineligible for the study.
14. Use of any prescription drugs; dietary, herbal, body-building, or athletic performance enhancing supplements; prescribed medicinal or recreational use of cannabis/marijuana (even if legal), within eight weeks of screening. If needed, (i.e. an incidental and limited need) paracetamol/acetaminophen is acceptable, but must be documented in the Concomitant medications / Significant non-drug therapies page of the CRF.
15. Donation or loss of 450 mL or more of blood within eight weeks prior to initial dosing, or longer if required by local regulation.
16. Plasma donation (>400 ml) within 4 weeks of screening.
17. Hemoglobin levels below 12.0 g/dL at screening or baseline.
18. Significant illness which has not resolved within two (2) weeks prior to initial dosing.
19. Recent (within the last three years prior to screening) and/or recurrent history of autonomic dysfunction (e.g., recurrent episodes of fainting, palpitations, etc.).
20. Recent (within the last three years prior to screening) and/or recurrent history of acute or chronic bronchospastic disease (including asthma and chronic obstructive pulmonary disease, treated or not treated).
21. History of multiple and recurring allergies or allergy to the investigational compound/compound class being used in this study.
22. Any surgical or medical condition which might significantly alter the absorption, distribution, metabolism, or excretion of drugs, or which may jeopardize the subject in case of participation in the study. The Investigator should make this determination in consideration of the subject’s medical history and/or clinical or laboratory evidence of any of the following:
- Inflammatory bowel disease, peptic ulcers, gastrointestinal including rectal bleeding;
Major gastrointestinal tract surgery such as gastrectomy, gastroenterostomy, or bowel resection;
Pancreatic injury or pancreatitis; Liver disease or liver injury as indicated by abnormal liver function tests. ALT (SGPT), AST (SGOT), GGT, alkaline phosphatase and serum bilirubin are tested and must be within normal limits for the subject to be eligible;
History or presence of impaired renal function as indicated by clinically significantly abnormal creatinine or BUN and/or urea values, or abnormal urinary constituents (e.g. albuminuria);
- Evidence of urinary obstruction or difficulty in voiding at screening
23. History or evidence of immunodeficiency or a confirmed positive HIV test result (i.e., ELISA and Wester blot) at screening regardless of immune status.
24. Chronic infection with Hepatitis B (HBV) or Hepatitis C (HCV). A positive HBV surface antigen (HBsAg) test, or if standard local practice, a positive HBV core antigen test, excludes a subject. Subjects with a positive HCV antibody test should have HCV RNA levels measured. Subjects with positive (detectable) HCV RNA should be excluded.
25. History of drug abuse or unhealthy alcohol use* within the 12 months prior to dosing, or evidence of such abuse as indicated by the tests conducted during screening or baseline. *Un heal thy alcohol use is defined as a history of, or current alcohol misuse/abuse, defined as “Five or more drinks on the same occasion on each of 5 or more days in the past 30 days or having 15 or more drinks per week."
Example 1b.2: Pharmacokinetics
PK samples from plasma and urine are obtained from all subjects at all dose levels. Blood samples for pharmacokinetic assessments were taken on the day of dosing at predose, 1 h, 2 h, 3 h, 4 h, 6 h, 8 h, 24 h, 48 h, 72 h, 96 h, 168 h, and 336 h post dose. Analysis of samples are excluded for the placebo group, and may be excluded for urine samples in select cohorts. Branaplam is determined in plasma and urine by a validated LC-MS/MS method. The anticipated Lower Limit of Quantification (LLOQ) is 0.500 ng/mL. Concentrations are expressed in mass per volume units and refer to the free base (i.e. free form). Concentrations below the LLOQ is reported as “zero” and missing data is labeled as such in the Bioanalytical Data Report.
The following pharmacokinetic parameters are determined in plasma using the actual recorded sampling times and non-compartmental method(s) with Phoenix WinNonlin (Version 8 or higher): Cmax, Tmax, AUCIast, AUCinf, T1/2, Vz/F and CL/F from the plasma concentration-time data. The linear trapezoidal rule is used for AUG calculation. Regression analysis of the terminal plasma elimination phase for the determination of T1/2 includes at least 3 data points after Cmax. If the adjusted R2 value of the regression analysis of the terminal phase is less than 0.75, if the observation period to estimate the T1/2 values is shorter than the estimated T1/2 value, and/or if the extrapolated AUG is greater than 20% of the estimated AUCinf, no values are reported for T1/2, AUCinf, CL/F, and Vz/F.
AeO-t of branaplam is determined from the urine concentration and volume-time data. CLr of branaplam is determined based on AUG and Ae available for the scheduled time period.
Example 1b.3: Biomarkers
The following biomarkers are analyzed: HTT protein and HTT mRNA. HTT mRNA in whole blood is determined on the day of dosing at predose and at 1 h, 2 h, 3 h, 4 h, 6 h, 8 h, 24 h, 48 h, 72 h, 96 h and 168 h post dose. Total HTT protein from PBMCs and plasma will be measured on the day of dosing at predose and at 4 h, 8 h, 24 h, 48 h, 72 h, 96 h and 168 h.
The absolute changes and fold-changes from baseline are calculated. The biomarker data, changes and fold-changes are listed by treatment group, subject, and visit/time. Summary statistics are provided by treatment group and visit/time. The effect of branaplam treatment on biomarkers, is graphically explored using spaghetti plots (one panel by treatment group) and boxplots by timepoint and treatment group.
Additionally, the profiles time are compared between treatment groups through analyses of longitudinal data using linear mixed models for repeated measures or other models depending on the distribution. The model includes treatment, time, treatment by time interaction and baseline value use as fixed effects, where treatment and time are fitted as categorical variables and baseline is fitted as a continuous covariate. An unstructured covariance matrix is fitted to allow for the within subject correlations. Point estimates and the associated 95% confidence intervals for the difference between each active treatment and placebo at each time-point is obtained. If the model fails to converge, alternative covariance structures or changes to the model may be applied.
If the distribution is not deemed normal, then log-transformation may be applied or alternative non parametric models may be used. Handling of LLOQ and ULOQ
Biomarker data are reported as concentration results, measured using a specific assay with a working range defined by the two limits: Lower limit of quantification (LLOQ) and Upper limit of quantification (ULOQ). Values which fall below the LLOQ or above the ULOQ are reported as < LLOQ * dilution factor (dilution factor: if sample diluted and concentration measured still below LLOQ) and > ULOQ * dilution factor, respectively.
To ensure that biomarkers only have numerical values, censored values are imputed as follows
• Values below the LLOQ are replaced by LLOQ/2.
• Values above the ULOQ are replaced by ULOQ.
Imputed values are used for summary statistics, inferential analyses and plots (with a special symbol). Values below LLOQ and values above ULOQ are shown as such in the listings.
If the proportion of imputed data is more than 20% for any treatment group at any time point, summary statistics may be heavily biased and inferential analyses may not be provided.
Example 1b.4: Target engagement and HTT mRNA reduction in blood
In the single ascending dose in healthy adult subjects (Example 1b.1 hereinabove) single oral doses of 35, 105, 210 and 420 mg showed target engagement of branaplam, evidenced by an increase of HTT transcripts with inclusion of pseudoexon 50a (Figure 28) and a subsequent decrease of levels of total HTT mRNA (Figure 29).
Blood collection
Whole blood samples were collected from healthy subjects in scope of the study (Example 1b.1 hereinabove), at 13 different time points (at screening, pre-dose and 1, 2, 3, 4, 6, 8, 24, 48, 72, 96, 168 h post dose). Blood samples were collected in PAXgene Blood RNA tubes according to the manufacturer’s recommendations (PreAnalytiX, Hombrechtikon, Switzerland). Samples were stored at approximately -80°C until analysis.
RNA extraction and Quantitative PCR
Total RNA was extracted using the PAXgene Blood RNA Kit (Qiagen). Total RNA was reverse transcribed to cDNA using random hexamers and the iScripta cDNA Synthesis Kit (Bio-Rad). cDNA synthesis was performed according to manufacturer’s instructions using 400 ng of total RNA as input into a 20 pl cDNA reaction to generate an initial cDNA with a concentration of 20 ng/pl (total RNA equivalents). Finally, the cDNA was subsequently diluted 1/1 with nuclease-free water to generate a final cDNA with a concentration of 10 ng/pl (total RNA equivalents). All preparations were carried out on ice. cDNA synthesis was performed on a C1000 Thermal cycler, Reaction Module 96W Fast (Bio-Rad) using the following conditions: 25°C for 5 min, 46°C for 20 min, 95°C for 1 min and hold at 4°C. cDNA samples were stored at -20°C.
Levels of HTT mRNA and novel-exon-included HTT mRNA were then quantified by polymerase chain reaction (PGR) using the Bio-Rad QX200 droplet digital PGR system in a duplex reaction containing a target gene assay (HTT assays) and a reference gene assay (either Glucuronidase beta (Gt/SS) or peptidylprolyl isomerase B (PPIB)). Standard reaction and cycling conditions (95 °C for 10 min; 40 cycles of 94 °C for 30 sec and 60 °C for 60 sec; and 98 °C for 10 min; hold at 4 °C) and a cDNA input (total RNA equivalent) of 50 ng were applied.
For HTT mRNA levels, two independent predesigned quantitative PGR assays (Assay Hs.PT.58.14833829 with forward primer 5’-GAGACTCATCCAGTACCATCAG-3’ (SEQ ID NO: 10), reverse primer 5’-GATGTCAGCTATCTGTCGAGAC-3' (SEQ ID NO: 11) and probe 5’-56- FAM/CGCTTCCAC/ZEN/TTGTCTTCATTCTCCTTGT/3IABkFQ-3’ (SEQ ID NO: 12) and assay Hs.PT.58.25550542 with forward primer 5’-GTAGAACTTCAGACCCTAATCCTG-3’ (SEQ ID NO: 13), reverse primer 5’-CACCACTCTGGCTTCACAA-3’ (SEQ ID NO: 14) and probe 5'-56- FAM/CCCGACAGC/ZEN/GAGTCAGTGATTGTT/3IABkFQ-3’ (SEQ ID NO: 15), purchased from Integrated DNA Technologies, Inc.) were used. A customized quantitative PGR assay with forward primer 5’-TCCTGAGAAAGAGAAGGACATTG-3’ (SEQ ID NO: 3), reverse primer 5’- CTGTGGGCTCCTGTAGAAATC-3’ (SEQ ID NO: 4) and probe 5’-56- FAM/AATTCGTGG/ZEN/TGGCAACCCTTGAGA/3IABkFQ-3’ (SEQ ID NO: 7) was applied to quantify the inclusion of a novel exon into HTT mRNA (Pseudo50a). Each target gene assay (Hs.PT.58.14833829, Hs.PT.58.25550542, Pseudo50a) was analyzed in a duplex reaction with a reference gene assay (either Glucuronidase beta (GUSB) or peptidylprolyl isomerase B (PPIB). To assess GUSB and PPIB mRNA levels, predesigned quantitative PGR assays (GUSB assay Hs.PT.39a.22214857 with forward primer 5’-TCACTGAAGAGTACCAGAAAAGTC-3’ (SEQ ID NO: 16, reverse primer 5’-TTTTATTCCCCAGCACTCTCG-3’ (SEQ ID NO: 17) and probe 5’- HEX/ACGCAGAAA/ZEN/ATACGTGGTTGGAGAGC/3IABkFQ-3’ (SEQ ID NO: 18), PPIB assay Hs. PT.58.40006718 with forward primer 5’-GCCCGTAGTGCTTCAGTT-3’ (SEQ ID NO: 5), reverse primer 5’-GATTTGGCTACAAAAACAGCA-3’ (SEQ ID NO: 6) and probe 5’- HEX//TCGTGTAAT/ZEN/CAAGGACTTCATGATCCAGG/3IABkFQ-3’ (SEQ ID NO: 19), both assays purchased from Integrated DNA Technologies, Inc.) were used. The following duplex ddPCR reactions were performed: Hs.PT.58.14833829 / Hs.PT.39a.22214857; Hs.PT.58.25550542 / Hs.PT.39a.22214857; PseudoSOa / Hs.PT.39a.22214857;
Hs.PT.58.14833829 / Hs.PT.58.40006718; Hs.PT.58.25550542 / Hs.PT.58.40006718;
Pseudo50a / Hs.PT.58.40006718.
All target gene expression values were first normalized to the respective duplex reaction partner reference mRNA levels (GUSB or PPIB) by applying a normalization factor reflecting the normalization to the geometric mean of all GUSB or PPIB values for all samples tested in this study. In a next step the arithmetic mean of the same target gene assay normalized to GUSB and PPIB mRNA levels was determined (e.g., the arithmetic mean of both PseudoSOa values normalized to GUSB and to PPIB). By applying these data processing steps, the determined values reflect the number of target gene molecules per 50ng RNA equivalent input.
In a last data processing step, to obtain a single value for the HTT mRNA level, the normalized values of the two independent HTT assays Hs.PT.58.14833829, Hs.PT.58.25550542 were combined by determining the arithmetic mean of both values.
Conclusions
Inclusion of pseudoexon 50a reached a maximum at 24 h after branaplam administration and appeared to be dose-dependent, while no clear differentiation was seen between the mean values of the two highest doses, 210 mg and 420 mg, respectively. After reaching the maximum levels of HTT transcripts with inclusion of pseudoexon 50a started to decline but still showed a sustained elevation (above 50% of maximal elevation) at all dose levels at the end of the observation period (168 h) (Figure 28).
At 35 mg, mean levels of total HTT mRNA showed a maximum mean decrease from baseline (pre-dose) of 10% followed by a trend of recovery to baseline towards the end of the observation period at 168 h post dose. After single doses of 105 mg, 210 mg and 420 mg, the HTT mRNA changes were more pronounced with a maximum change of mean HTT mRNA from baseline ranging between 23-40% and showing a sustained effect until the end of the observation period (168 h) (Figure 29).
EXAMPLE 1c: Dose Selection for Clinical Evaluation of Branaplam
Example 1c.1: Pharmacokinetic model description - Comoartmental pharmacokinetic model
Modeling strategy and development
The pharmacokinetics (PK) of branaplam in adult subjects was described and parameterized using mean concentration-time profiles measure from the plasma of healthy adult volunteers after single oral administration of branaplam at dose levels of 35 mg, 105 mg, 210 mg, and 420 mg. These mean concentration-time profiles were dose-normalized to a branaplam dose of 1 mg by dividing the mean concentrations at each time point by the respective dose. Next, a single, mean, dose-normalized plasma profile of branaplam was calculated by averaging the dose-normalized concentration-time profiles across the four dose levels. The resulting profile was then fitted with a 1 -compartment PK model to estimated the PK parameters of branaplam after oral administration (software: Phoenix, v8.0, Cetera; 1 -compartment model: micro constants, extra-vascular, ‘Additive & Multiplicative’ residual error).
The derived PK parameters of branaplam after an oral administration of 1 mg were used to predict concentration-time profiles of branaplam after repeated weekly (QW) administration at different dose levels (28 mg, 56 mg, 84 mg, 112 mg, 156 mg, 196 mg, 238 mg).
Results - PK parameters of branaplam in healthy adult volunteers
The mean concentration-time profiles of branaplam after oral administration of 35 mg, 105 mg, 210 mg, and 420 mg to healthy adult volunteers were plotted in semi-logarithmic scale (see Example 1b). These profiles indicated a mono-exponential elimination of the drug with time at all dose levels suggesting that branaplam pharmacokinetics in healthy adult volunteers can be fitted by a 1 -compartment model.
When plotting the dose-normalized (normalized to 1 mg) mean concentration-time profiles on a semi-logarithmic scale, it was observed that the mean PK profiles at 105, 210, and 420 mg were superimposed, while the PK profile at 35 mg was slightly lower (Figure 15). Overall, it was concluded that the PK of branaplam shows approximately dose-linear PK in healthy adult volunteers across the observed dose range, allowing for a mean, dose-normalized concentrationtime profile to be calculated across all doses. This derived mean plasma PK profile was fitted with a 1 -compartment model with linear elimination (Figure 16). The derived micro-constants of the fitting are presented in tabular format in Figure 14. Example 1c.2: Pharmacokinetic model description - Phvsiologicallv-based pharmacokinetic model
Modeling strategy and development
Physiologically-based pharmacokinetic model (PBPK) was developed by incorporation of absorption, distribution, elimination and drug interaction characteristics of branaplam into the Simcyp® population-based simulator (Certara, L.P., Sheffield, UK). The input parameters for branaplam are detailed below and summarized in Figure 24.
Absorption
A first-order absorption model was used, and the fraction of dose absorbed (fa) was assumed to be completed. The absorption rate constant (ka) and lag-time (Tlag) was based on population pharmacokinetic (PopPK) analysis. The effective permeability in man (Peff.man) and normal flow in gut model (Qgut) values were predicted from Caco-2 permeability data of branaplam. The fraction of unbound in enterocytes (fugut) value was assumed to be the same as the fraction of unbound in plasma (fup).
Distribution
The minimal PBPK model in Simcyp® was used with a single adjusting compartment. The volume of distribution at steady-state (Vss) was estimated based upon PopPK analysis and further optimized based on clinical data (see Example 1b).
Elimination
The oral clearance in humans was also estimated based upon PopPK analysis and further optimized based on clinical data (see Example 1b). The clearance pathways and their quantitative contributions for branaplam in adult humans were estimated based on clinical data (Example 1b) and rat ADME studies as ~10% renal clearance, ~10% biliary clearance and ~80% metabolism mediated elimination, where the relative contributions by CYP3A4 and other enzymes including UDP-glucuronosyltransferase (UGT) enzymes were estimated from in vitro enzyme phenotyping study, as 90% and 10%, respectively. The simulated steady-state median % fraction of metabolized in 100 subjects (10 trials and 10 subjects/trials aged 20-65 years with female ratio of 0.5) was 74% via CYP3A4, 8% via additional hepatic elimination, 9% via additional systemic clearance, and 9% via renal elimination.
Drug interaction Branaplam showed reversible inhibition of several CYP enzymes including CYP1A2, CYP2C9, CYP2C19, CYP2D6, CYP2E1, and CYP3A. Branaplam also showed time-dependent inhibition of CYP3A.
PopPK analysis
Branaplam PK was described by a linear two-compartmental model with first-order absorption and a lag time using Phoenix NLME (Version 8.1, Certara, Princeton, NJ, USA). Dose was incorporated as a covariate on bioavailability (F) and absorption rate constant (ka). The model and parameters were fitted to the data after a single oral dose (35 mg, 105 mg, 210 mg, and 420 mg, see Example 1b). A mix ratio residual error model was used as described by the equation:
Observed Concentration = Concentration + Additive Error + Concentration*Additive Error*CMixRatio (Ratio of the proportional error standard deviation to additive error standard deviation).
The residual error model describes the random differences between observed values and the corresponding model predictions. Inter-individual variability was implemented on the first order absorption rate constant (ka), lag time (Tlag), clearance (CL), distributional rate constants (V2 and Q) and apparent volume of distribution of the central compartment (V). Inter-subject random effects for PK parameters were assumed log normally distributed with means of zero and with correlation between each other as expressed by the equation: Individual Parameter Value = Parameter Typical Value * exp (ETA) in which ETA refers to the specified parameter random effect. For between subject variability, the exponential error model has been applied to all structural PK parameters. The estimation method for model fitting was Quasi-random Parametric Expectation Maximization (QPREM). The estimated absorption and disposition parameters were applied to development of Simcyp® PBPK model.
Qualification of PBPK model for branaplam and simulated trials
The verification of the PK prediction was performed using the available PK data from the clinical study (see Example 1b): 210 mg single dose from the highest dose group as of the available PK data in healthy volunteers (see Example 1b). The Healthy Volunteer (HV) population in Simcyp® was used with 10 trials of 10 individuals (n=100) and proportion of female of 0.5.
The Simcyp® PBPK model was used to simulate the branaplam concentration in plasma versus time profile after a single 210 mg branaplam oral dose in HVs. Figure 25 shows the predictions of the PK parameters (AUC and Cmax) after a single 210 mg branaplam dose in comparison to the observed PK parameters estimated in healthy volunteers (Example 1b). The concentration-time profiles of simulated branaplam are shown in Figure 26 in comparison to the profile determined in healthy volunteers (Examplelb). The simulated PK parameters were comparable to those observed in the clinical study.
Model assumptions and limitations
Models assumes the fraction of absorption (fa) is 1. Currently, as a victim drug, the branaplam PBPK model was built based upon the results of the rat ADME study and in vitro enzyme phenotyping studies. At this time, no clinical data with a perpetrator (e.g., an inhibitor or inducer of CYP3A4) of a major elimination pathway has been used to verify the contribution of this pathway for branaplam. As a perpetrator drug, no clinical study with a sensitive substrate (e.g., CYP3A4 substrate, midazolam) is available to verify the in vivo inhibition potential of branaplam.
Example 1c.3: Pharmacokinetic/pharmacodvnamic model description (i.e., using compartmental pharmacokinetic model)
The pharmacokinetic/pharmacodynamic (PK/PD) model in adult subjects was developed using the branaplam PK parameters from healthy adult volunteers derived as described in Example 1c.1 (i.e., Compartmental pharmacokinetic model) and coupling them with a PD model in Phoenix software (Version 8, Certara).
Modeling strategy
• Establishment of PK/PD relationship using data from the BacHD mouse model (see Example 1a) and development of a mouse PK/PD model.
• Development of a PK/PD model in for adult patients by scaling the PD parameters from the BacHD mouse to human and connecting them to the human PK model derived from branaplam PK in healthy adult volunteers (see Example 1c.1; i.e., Compartmental pharmacokinetic model).
• Estimation of the anticipated efficacious dose range via simulation of the human PK/PK model. Model development
For the establishment of the PK/PD relationship and the development of a mouse PK/PD model, the PK parameters in mouse plasma were estimated considering branaplam PK data from studies with male C57BL/6 mice (10 mg/kg, single dose), rasH2 mice (1, 3, 4 and 10 mg/kg, repeated daily doses), and BacHD mice (10 and 50 mg/kg, single dose; 12 and 24 mg/kg, repeated, three times a week doses). To generate a robust estimate of mouse PK parameters, these data were pooled and analyzed using a population PK model with extra-vascular administration, a lag time (Tlag), 2-compartments (V1: volume of compartment 1; V2 volume of compartment 2, Q: intercompartmental clearance; ka: first order rate of absorption; CL: clearance). This population PK model is described in the Monolix model library (Monolix software (Version 2018R1, Lixoft)). The population PK parameter estimation was done using non-linear mixed effects techniques using the Monolix software (Version 2018R1, Lixoft).
For the development of the PK/PD relationship, the concentration of mutant HTT protein in the brain of BacHD mice and its changes after branaplam administration were used as PD biomarker (Example 1a). Data from three studies in branaplam-treated BacHD mice were pooled: (10 and 50 mg/kg, single dose; and two studies both using 12 and 24 mg/kg, repeated, three times a week doses but different PD sampling times, ranging from 0-72 hours or 72-336 hours after last dose). In these studies, mutant HTT protein concentrations were determined in both the brain cortex and brain striatum, therefore the PK/PD relationship of the changes in mutant HTT protein concentration as a function of branaplam PK were derived separately for each of these brain compartments. Still, for each compartment, all mutant HTT protein measurements were considered together to derive the PK/PD relationship.
The dynamic relationship between branaplam concentrations in plasma and the mutant HTT protein concentrations in the brain was investigated with a turnover model (described below) considering that branaplam can inhibit the production of mutant HTT protein in the brain with a PK to RD time delay. The turnover model enabled the description of the observed time delay between Cmax of branaplam in plasma (between 3 to 6 h post dose) and maximum decrease of mutant HTT protein in the brain (about 72 h post dose). To parameterize the population PK/PD model, the PK parameters from the previously described population PK model were fixed to the values presented in Figure 14 and the PD parameter values were estimated by fitting to the pooled PD data. The Monolix software (Version 2018R1, Lixoft) and its turnover model described in the library (pkpd/oral1_2cpt_SigmoidindirectModelinhibitionKin_TlagkaCIV1QV2R0koutimaxlC50gamma) were used to determine the PD parameters in the mouse. The PD component of the model can be described by the following equation: change in mutant HTT protein change over time = kin * (1-lmax*max(Cc,0)/(max(Cc,0)+IC50))-kout*R where: kin: synthesis rate of mutant HTT protein kout: degradation rate of mutant HTT protein
Imax: maximum inhibitory effect of branaplam on mutant HTT protein synthesis
IC50: half-maximum inhibitory concentration of branaplam on mutant HTT protein synthesis max(Cc.O): predicted branaplam plasma concentration
R: mutant HTT protein level at a given time
The maximum inhibitory effect (Imax) was set to 1, corresponding to the assumption that full inhibition of mutant HTT protein can be achieved if using sufficiently high doses of branaplam. This is supported by the fact that after a single administration of the highest dose tested in the BacHD mouse (50 mg/kg), mean decrease in mutant HTT mRNA in the brain was already 66%. Additionally, the baseline value for mutant HTT protein, RO, was set to 1 since only relative changes to the baseline were determined in the BacHD mouse (Example 1a). Finally, because to achieve steady state of mutant HTT protein concentration in untreated mice it must be true that R0= kin/kout (mutant HTT protein synthesis rate/mutant HTT protein degradation rate) and that kin and kout are equal. Therefore, only one of these two parameter values was estimated.
Next, for the development of a PK/PD model in adult patients, the PK parameters from healthy adult volunteers (Example 1c.1) were used to predict the concentration-time profile of branaplam in plasma after oral administration, considering a nominal body weight of 70 kg. The underlying assumption was that branaplam PK parameter values in adult patients are similar to the PK parameter values in healthy adult volunteers. Administration of branaplam led to a dosedependent decrease in mHTT protein in the brain of the BacHD mouse and, therefore, the PD parameters of the population PK/PD model in mouse were scaled for brain cortex and brain striatum from BacHD mouse to human according to following assumptions: • Mutant HTT protein baseline level in brain (R0) was kept equal to 1 as the levels measured in BacHD mouse model were described as relative change vs vehicle-treated group.
• The potency of branaplam (IC50) was assumed to be the same in human as in BacHD mouse. The value was not corrected by the plasma protein binding because the plasma protein binding values in mouse (0.741) and human (0.8) were comparable.
• Degradation rate or fractional turnover parameter of the mutant HTT protein synthesis (kout) can be scaled from BacHD mouse to human considering an allometric scaling method based on the assumption that endogenous turnover of proteins, peptides and hormones can be scaled across different species and are related to energy turnover or metabolic rates (Gabrielsson J, Hjorth S, Quantitative Pharmacology: An Introduction to Integrative Pharmacokinetic-Pharmacodynamic Analysis. Swedish Pharmaceutical Press;
1 edition (May 7, 2012)). The exponent of -0.2 empirically used for scaling rate constants (Mahmood I, et al, 1996, Interspecies scaling: predicting clearance of drugs in humans: Three different approaches. Xenobiotica 26:887-895 and Mahmood 1, 2005, Prediction of oral pharmacokinetic parameters in humans, in Interspecies Pharmacokinetic Scaling: Principles and Application of Allometric Scaling pp 144-167, Pine House Publishers, Rockville, MD) was used for the allometric scaling. Therefore, the equation kout_human = kout_mouse*(body weight_human/body weight_mouse)A-0.2 was used for the estimation of kout in human, with a human body weight weight of 70 kg and a mouse body weight of 0.025 kg. Note that in our case, mHTT baseline R0 = 1, so that kin = kout (since R0 = kin/kout; i.e. mHTT protein synthesis rate/mHTT protein degradation rate).
For the estimation of the anticipated efficacious dose range, the PK parameters from healthy adult volunteers (Example 1c.1; i.e., Compartmental pharmacokinetic model) and the RD model for adult patients were coupled and simulations executed using Phoenix software (Version 8, Certara). Several dose-levels with a weekly dosing regimen were simulated in adults to predict the corresponding PK/PD time profiles and PK/PD exposure and response metrics (e.g. maximum concentration, Cmax, and area under the curve, AUG; mHTT decrease in brain). To derive an anticipated efficacious dose range, the simulations targeted a reduction of approximately 35% to 50% mutant HTT protein in the brain (Kaemmerer WF and Grondin RC, 2019, The effects of huntingtin-lowering: what do we know so far?, Degenerative Neurological and Neuromuscular Disease, 9, pp 3-17; Caron NS, Dorsey ER, and Hayden MR, 2018, Therapeutic approaches to Huntington disease: from the bench to the clinic, Nature Review-Drug Discovery, 17, pp 729-750). Modelling results - PK/PD model based on BacHD mouse
The parameter value estimates of the BacHD mouse PK/PD model for branaplam are presented in Figure 17. The predicted distribution of mutant HTT protein in the brain (cortex and striatum) of the BacHD mouse after triple oral administration of branaplam for 3 weeks are presented in Figure 18 (for cortex) and Figure 19 (for striatum). In both figures, the distributions (shaded areas, representing each decile of prediction confidence interval (90%, 80%, ...)) are overiayed on the measured mutant HTT protein values (filled circles).
Modelling results - PK/PD model in adult patients
The PK parameter values estimated from observed branaplam PK in healthy adult volunteers are presented in Example 1c.1 (i.e., Compartmental pharmacokinetic model) and Figure 14. The scaled population PD data in adults are presented in Figure 22.
Modelling results - Anticipated efficacious dose in adult patients
The PK/PD model developed to predict the effect of branaplam treatment on the concentration of mutant HTT protein in adult patients was used to simulate the plasma concentration-time profiles of branaplam and the corresponding decrease of mutant HTT protein in the brain (cortex and striatum) following weekly doses of branaplam. As stated above (Model development), the simulations targeted a maximum of about 35% to 50% reduction in mutant HTT protein in the brain (Kaemmerer WF and Grondin RC, 2019, The effects of huntingtin-lowering: what do we know so far?, Degenerative Neurological and Neuromuscular Disease, 9, pp 3-17; Caron NS, Dorsey ER, and Hayden MR, 2018, Therapeutic approaches to Huntington disease: from the bench to the clinic, Nature Review-Drug Discovery, 17, pp 729-750). The simulations suggest that at all doses investigated an impact on the mutant HTT protein in brain can be expected and that the decrease of mutant HTT protein in the brain would be more pronounced with increasing doses. However, the potential increase of the adverse events has to be balanced in a risk-benefit assessment
The predicted exposure parameters and the predicted, corresponding steady state decrease of mutant HTT protein in the brain for the identified dose range (28, 56, 84, 112, 156, 196, 238 mg) are presented in tabular format in Figure 23. Example 1c.4: Pharmacokinetic/oharmacodvnamic model description (i.e., using physiologically based pharmacokinetic model)
The pharmacokinetic/pharmacodynamic (PK/PD) model in adult subjects was developed using the branaplam PK parameters from healthy adult volunteers derived as described in Example 1c.2 (Physiologically-based pharmacokinetic model) and coupling them with a PD model in Phoenix software (Version 8, Certara).
Modeling strategy
The modeling strategy is similar to the strategy, which was described in Example 1c.3 with the exception that the predicted branaplam PK in humans were from healthy adult volunteers using the Physiological-based pharmacokinetic model as described in Example 1c.2.
Model development
The model development of the establishment of the PK/PD relationship in mouse and the model development of a PK/PD model in adult patients was similar as described in Example 1c.3. For the estimation of the anticipated efficacious dose range, the PK parameters from healthy adult volunteers (Example 1c.2) and the PD model for adult patients were coupled and simulations executed using Phoenix software (Version 8, Certara). Several dose-levels with a weekly dosing regimen were simulated in adults to predict the corresponding PK/PD time profiles and PK/PD exposure and response metrics (e.g. maximum concentration, Cmax, and area under the curve, AUG; mHTT decrease in brain). To derive an anticipated efficacious dose range, the simulations targeted a reduction of approximately 35% to 50% mutant HTT protein in the brain (Kaemmerer WF and Grondin RC, 2019, The effects of huntingtin-lowering: what do we know so far?, Degenerative Neurological and Neuromuscular Disease, 9, pp 3-17; Caron NS, Dorsey ER, and Hayden MR, 2018, Therapeutic approaches to Huntington disease: from the bench to the clinic, Nature Review-Drug Discovery, 17, pp 729-750).
Modelling results - PK/PD model based on BacHD mouse
Results are presented in Example 1c.3.
Modelling results - PK/PD model in adult patients
Input parameters to the physiologically-based pharmacokinetic model by Simcyp® populationbased simulator and the qualification of the model is described in Example 1c.2. Modelling results - Anticipated efficacious dose in adult patients
The PK/PD model developed to predict the effect of branaplam treatment on the concentration of mutant HTT protein in adult patients was used to simulate the plasma concentration-time profiles of branaplam and the corresponding decrease of mutant HTT protein in the brain (cortex and striatum) following weekly doses of branaplam. As stated above (Model development), the simulations targeted a maximum of about 35% to 50% reduction in mutant HTT protein in the brain (Kaemmerer WF and Grondin RC, 2019, The effects of huntingtin-lowering: what do we know so far?, Degenerative Neurological and Neuromuscular Disease, 9, pp 3-17; Caron NS, Dorsey ER, and Hayden MR, 2018, Therapeutic approaches to Huntington disease: from the bench to the clinic, Nature Review-Drug Discovery, 17, pp 729-750).
The simulations using the physiologically-based pharmacokinetic model suggest that a decrease of mutant HTT protein in brain is expected at all investigated doses and that the decrease of mutant HTT protein in the brain would be more pronounced with increasing doses.
The predicted exposure parameters and the predicted, corresponding steady state decrease of mutant HTT protein in the brain for the identified dose range (28, 56, 84, 112, 154, 196, 238 mg) are presented in tabular format in Figure 27.
EXAMPLE 2: Clinical Evaluation of Branaplam
Example 2.1a:
This study is a randomized, double-blind, placebo-controlled study with a variable treatment duration (between approximately 16 weeks to approximately 52 weeks) for the core period and a one year OLE, in 75 to 90 early stage manifest HD patients.
Figure imgf000073_0001
Figure imgf000074_0001
Figure imgf000075_0001
After screening period and BL assessments, this study is conducted in two Treatment Periods: The Core Period consists of a 16-week double-blind, placebo-controlled, Dose Range Finding (DRF) portion of the study, followed by a Blinded Extension (BE) of variable duration (ranging from approximately 4-12 months; duration is dependent on timing of randomization and recruitment rate). Period 1 evaluates the safety, tolerability, PK and PD of branaplam, as well as determine the optimal dose(s) to explore in further clinical evaluations using all available data collected at the time the last randomized patient in the study completes the End of DRF visit which captures a foil 16 weeks.
The Open Label Extension (OLE) Period is a one year open-label extension to assess both long term safety and tolerability, as well as the efficacy of the recommended optimal dose(s) for branaplam. If branaplam development in Huntington's Disease remains ongoing at the end of the OLE, the study is either (a) amended to extend the OLE beyond a year, or (b) a separate extension study is initiated to offer continued access to branaplam. Study participants from the OLE may be eligible to rollover into this separate extension study.
The study design uses a staggered cohort approach, allowing safety and tolerability of lower doses to be assessed before randomizing subjects to higher doses. The Core Period consists of a minimum of 3 or maximum of 5 treatment arms; each treatment arm enrolls approximately 20 to 25 patients, dependent on the total number of cohorts initiated. Treatment arms are defined as: Treatment Arm A: Branaplam 56mg oral solution or matching PBO, once weekly Treatment Arm B: Branaplam 112mg oral solution or matching PBO, once weekly Treatment Arm C: Branaplam 154mg oral solution or matching PBO, once weekly Treatment Arm D: Branaplam 196mg oral solution or matching PBO, once weekly Treatment Arm E: Branaplam 238mg oral solution or matching PBO, once weekly Treatment Arm X: Branaplam 84mg oral solution or matching PBO, once weekly Treatment Arm Y: Branaplam 28mg oral solution or matching PBO, once weekly
Randomization into treatment arms is staggered into 4 Cohorts: Cohort 1 includes Treatment Arms A (56mg) and B (112mg). After the 10th participant in each of the Treatment Arms in Cohort 1 reaches Week 8 of the DRF Treatment Period, all available data, including relevant post-dose PK timepoints, is reviewed from a safety and dose finding perspective by an independent Sponsor team in consultation with the Data Monitoring Committee (DMC) chair at the Cohort Gating Assessment 1. (Also, included in the review is PK data, blood/PBMC mHTT and total HTT levels, from a safety and not efficacy perspective, to ensure that HTT lowering is not beyond the anticipated safety threshold.) During this time, recruitment continues in Cohort 1 (up to a maximum of 20 patients per treatment Arm if the Cohort Gating Assessment (CGA) has not been completed). Based on the results from the review of the data during CGA#1, a decision is made to initiate the next higher dose (Treatment Arm C, 156mg) or an intermediary dose (Treatment Arm X, 84mg) or a lower dose (Treatment Arm Y, 28 mg). At this time, participants are eligible to randomize into any open Treatment Arm if it has not yet been yet been completed. Alternatively, if Cohort 1 recruitment is complete prior to the initiation of Cohort 2, participants are then only eligible for randomization into Cohort 2.
Cohort 2: If T reatment Arm X or Y is selected for Cohort 2: total recruitment is expanded to include a total of approximately 75 participants (randomized equally across Treatment Arms A, B, and X or A, B, and Y for approximately 25 per treatment arm). The interim analysis (IA) then takes place after the last randomized participant completes the 16-Week DRF period.
If T reatment Arm C is selected for Cohort 2: after approximately the 10th participant in the cohort has completed Week 8 of the DRF Treatment Period, all available data including relevant post dose PK timepoints, is again reviewed at CGA#2 by the independent Sponsor team, in consultation with the DMC chair to determine if Cohort 3 should be opened. During this time, recruitment continues in any open treatment arms (up to a maximum of 20 patients in each treatment arm). If Cohort 3 is not initiated, then total recruitment is expanded to include a total of approximately 75 participants (randomized equally across Treatment Arms A, B, and C; approximately 25 per treatment arm) and the IA then takes place after the last randomized participant completes the 16-Week DRF period.
If Cohort 3 is initiated after approximately the 10th participant in Treatment Arm D has completed Week 8 of the DRF Treatment Period, all available data, including relevant post dose PK timepoints, is again reviewed at CGA#3 by the independent Sponsor team, in consultation with the DMC chair to determine if Cohort 4 should be opened. During this time, recruitment continues in any open treatment arms (up yo a maximum of 20 patients in each treatment arm) if Cohort 4 is not initiated, then total recruitment is expanded to include a total of approximately 80 participants (randomized equally across Treatment Arms A, B, C and D; 20 per treatment arm) and the IA takes then place after the last randomized participant completes the 16-Week DRF period
If Cohort 4 is initiated: Recruitment in Treatment Arm E is 20 patients. Total recruitment is approximately 100 participants randomized across Treatment Arms A, B, C, D and E with 20, 20, 20, 20 and 20 patients, respectively and the IA takes place after the last randomized participant completes the 16-Week DRF period.
Participants are randomized in a 4:1 active: vs.placebo within each arm.
After a participant completes the 16-week DRF period he/she seamlessly transitions to the BE, by continuing on their blinded DRF treatment. All patients remain in the BE until the results of the IA are available and the recommended optimal extension dose(s) is/are selected for Period 2. Duration in the BE is therefore variable, longer for those that were randomized earlier in the study.
After the last randomized participant in the study completes all the 16-Week DRF assessments, an IA is conducted. All data available at this time, including, but not limited to safety/tolerability as well as mHTT and total HTT lowering in CSF, plasma and PBMCs, is assessed to determine optimal dose(s) and open label treatment regimen for OLE. After the IA and confirmation of selected dose(s) and regimen, all patients from the blinded Core Period roll over to OLE; patients are re-assigned from their blinded Core Period dosing onto the newly selected open label OLE dose(s) and dose regimen.
OLE is a one year open label treatment and safety monitoring part of the study.
Core Period: Dose Range Finding & Blinded Extension
Following a 4 week Screening period, patients complete a baseline assessment (can be performed over a 7 day time frame) and a multi-dose, treatment period (varying across patients) at the assigned treatment arm. Safety, tolerability, PD biomarker (fluid and images), PK and clinical endpoints relevant to HD are collected.
After confirming eligibility, participants are randomized to an open cohort to receive either active or PBO treatment as an oral solution administered once. Although 5 maximum treatment arms are planned, timing during the ongoing recruitment determines which available treatment arms are actively recruiting. In addition, not all treatment arms may be initiated, as it is dependent on the available safety profile, PK and mHTT lowering data. Participants receive at least 16 weeks of treatment and remain on the initially assigned treatment arm during the Core Period in the BE until IA is completed and optimal dose(s) selected for OLE. After dose selection, patients continue participation in OLE. Premature discontinuation of study drug during Core Period;
11. If a patient prematurely discontinues treatment with study drug before the end of the 16 week DRF period, the EOT case report form (CRF) should be completed, but all assessments corresponding to visits during the DRF period should still be completed as described in the VES.
12. If a patient prematurely discontinues treatment with study drug during the blinded extension (after the 16 week DRF period) and therefore does not continue in the OLE, the EOT CRF should be completed and no further assessments are expected.
Any patient that completes the EOT CRF at any given timepoint during the DRF or the BE, must be followed up for safety for 30 days after the last dose of study drug is administered
Open-Label Extension (OLE)
Once the optimal dose(s) is/are selected, sites are notified and active participants roll over to OLE at a subsequent study visit The specific timing for each patient is determined based on site readiness to conduct the OLE. Prior to commencing dosing in OLE, a series of assessments (rebaselining) may be collected. If more than one dose is selected for the OLE, then patients are reassigned via IRT to one of the selected open label dose cohorts.
Study visits take place every 4 weeks in OLE period (approximately 52 weeks).
Population
Approximately 75 to 90 male or female patients with confirmed Stage 1 or 2 Huntington's Disease and a UHDRS TFC score of >8 are enrolled in this study to allow for a completion rate of approximately 15 to 25 participants per treatment arm (in a minimum of 3 and maximum of 5 treatment arms).
Inclusion criteria
Participants eligible for inclusion in this study must meet all of the following criteria:
1. Signed informed consent must be obtained prior to participation in the study
2. Must be capable of providing informed consent (in the opinion of the Investigator)
3. Clinically diagnosed Stage 1 or 2 Huntington's disease with a diagnostic confidence interval (DCL) =4 and a UHDRS Total Functional Capacity (TFC) >8 at screening 4. Genetically confirmed Huntington's disease, with presence of £40 GAG repeats in the huntingtin gene
5. Male and female participants between 25 to 75 years of age, inclusive, on the day of Informed Consent signature
Exclusion criteria
1. Use of other investigational drugs within 5 half-lives of the first dose of study drug, or within 30 days, whichever is longer. Patients who participated in clinical trials investigating huntingtin-lowering compounds are excluded.
2. History of hypersensitivity to any of the study drugs or its excipients or to drugs of similar chemical classes.
3. Participants taking medications prohibited by the protocol: Strong systemic inhibitors of CYP3A4 examples include, but are not limited to boceprevir, clarithromycin, cobicistat, conivaptan, grapefruit juice, idelalisib, indinavir, itraconazole, ketoconazole, mibefradil, nefazodone, nelfinavir, posaconazole, ritonavir, telaprevir, telithromydn, troleandomycin, voriconazole. As strong systemic inhibitors of CYP3A4 are also combination of ritonavir-boosted regimens considered: ombitasvir/paritaprevir/dasabuvir/ritonavir (Viekira Pak), indinavir/ritonavir, tipranavir/ritonavir, danoprevir/ritonavir, elvitegravir/ritonavir, saquinavir/ritonavir, lopinavir/ritonavir, atazanavir/ritonavir, darunavir/ritonavir; Strong systemic inducers of CYP3A4 examples include, but are not limited to apalutamide, carbamazepine, enzalutamide, mitotane, phenytoin, rifampin, St John’s wort; Go-medications metabolized via CYP3A4/5 with narrow therapeutic index examples include but are not limited to alfentanil, astemizole, cisapride, cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, sirolimus, tacrolimus); Co-medications eliminated via renal MATE2K transporter of clinical-relevant examples include, but not limited to fexofenadine, glycopyrronium, metformin; Medication(s) with a "Known Risk of Torsade de Pointes" examples include but are not limited to the following: escitalopram, citalopram, haloperidol, sulpiride, chlorpromazine, ondansetron, hydroxychloroquine ciprofloxacin, clarithromycin; Medication (s) with “Potential risk of TdP” examples include but are not limited to the following: aripiprazole, clozapine, deutetrabenazine, tetrabenazine, levetiracetam; Medication (s ) with a “Conditional Risk of TdP examples include but are not limited to the following: diphenhydramine, doxepin .fluoxetine, hydrochlorothiazide, furosemide, metoclopramide, olanzapine, paroxetine, quetiapine, risperidone, sertraline, trazodone, ziprasidone; Antiplatelet or anticoagulant therapy including but not limited to aspirin (unless s 81 mg/day), clopidogrel, dipyridamole, warfarin, heparinoids and direct coagulation factor inhibitors e.g. apixaban, dabigatran, rivaroxaban.
4. Any medical history, lumbar surgery or condition that would interfere with the ability to complete the protocol specified assessments, (e.g., history of brain or spinal injury that would interfere with the LP or CSF circulation, implanted cerebrospinal shunt, conditions precluding MRI scans, etc.)
5. History of malignancy of any organ system (other than localized basal cell carcinoma of the skin or in situ cervical cancer), treated or untreated, regardless of whether there is evidence of local recurrence or metastases.
6. Participant has other severe, acute or chronic medical conditions including unstable psychiatric conditions, or laboratory abnormalities that in the opinion of the Investigator may increase the risk associated with study participation, or that may interfere with the interpretation of the study results
7. Score “yes” on item 4 or item 5 of the Suicidal Ideation section of the C-SSRS, if this ideation occurred in the past 6 months from the Screening visit, or “yes” on any item of the Suicidal Behavior section, except for the “Non-Suicidal Self-Injurious Behavior” (item also included in the Suicidal Behavior section), if this behavior occurred in the past 2 years.
8. Pregnant or nursing (lactating) women
9. Sexually active males unwilling to use a condom together with a spermicidal agent (e.g. foam, gel, cream, etc.) during intercourse while taking study treatment and for 90 days plus 5 times half life of the study drug after the last dose of the study treatment. A condom is required for all sexually active male participants (unless using semen provided prior to initiation of study treatment) even if they are surgically sterile with a vasectomy to prevent them from fathering a child AND to prevent delivery of study treatment via seminal fluid to their partner.
10. Women of childbearing potential, defined as all women physiologically capable of becoming pregnant, unless they are using highly effective methods of contraception during dosing and for 6 months after stopping the study medication. Highly effective contraception methods include:
- Total abstinence (when this is in line with the preferred and usual lifestyle of the subject). Periodic abstinence (e.g., calendar, ovulation, symptothermal, post-ovulation methods) and withdrawal are not acceptable methods of contraception
- Female sterilization (have had surgical bilateral oophorectomy with or without hysterectomy) total hysterectomy or tubal ligation at least six weeks before taking investigational drug. In case of oophorectomy alone, only when the reproductive status of the woman has been confirmed by follow up hormone level assessment
- Male sterilization (at least 6 months prior to screening). For female subjects on the study, the vasectomized male partner should be the sole partner
- Use of an intrauterine device (IUD) or intrauterine system (IUS)
- Oral contraception cannot be considered due to potential decreased efficacy as potential DDI with branaplam
- In case local regulations deviate from the contraception methods listed above, local regulations apply and are described in the IGF
- Women are considered post-menopausal and not of childbearing potential if they have had 12 months of natural (spontaneous) amenorrhea with an appropriate clinical profile (e.g. age appropriate, history of vasomotor symptoms) or have had surgical bilateral oophorectomy (with or without hysterectomy), total hysterectomy or tubal ligation at least six weeks ago. In the case of oophorectomy alone, only when the reproductive status of the woman has been confirmed by follow up hormone level assessment is she considered not of childbearing potential.
11. History of:
- Gene therapy or cell transplantation or any other experimental brain surgery
- Hepatitis B or hepatitis C or serologic evidence for active viral hepatitis (HBsAg and HCVab test)
- Immunodeficiency diseases, including a positive HIV (ELISA and Western blot) test result
- History or current evidence of drug or alcohol abuse in the 12 months prior to screening, as defined by the Diagnostic and Statistical Manual of Mental Disorders Fifth Text revision (DSM-V) criteria for substance abuse. For former abusers, abstinence should be confirmed by laboratory tests (drug testing and/or carbohydrate deficient transferrin (DOT) level in blood.) (Use of Tetra-Hydro-Cannabinoid (THC)/ cannabinoid containing substances is allowed if their use does not constitute abuse per local regulations and/or local medical practice)
12. Any surgical or medical condition which might put the participant at risk in case of participation in the study. The Investigator should make this determination in consideration of the participant’s medical history and/or clinical or laboratory evidence of any of the following at the Screening visit • Unstable chronic gastrointestinal condition including metabolic disorders
• Neurologic or neuromuscular conditions other than HD
• History of peripheral neuropathy
• Uncontrolled hypertension (average 3 systolic blood pressure [SBP] readings) at screening >165mmHg or average diastolic blood pressure [DBF] £100 mmHg or any documented resting supine systolic blood pressure of >180 mmHg or a diastolic blood pressure of £100 mmHg at screening or baseline
• Participants who have a known diagnosis of diabetes mellitus or who do not have a known diagnosis of diabetes with a hemoglobin A1C>6.5%
• Lipase and/or amylase must not exceed the 1.5 x upper limit of normal (ULN)
• Liver disease or liver injury as indicated by abnormal liver function tests
• Any of the following single parameters in serum of ALT, AST, y-GT, alkaline phosphatase or bilirubin must not exceed 1.5 x upper limit of normal (ULN).
• Any elevation above ULN of more than one parameter of ALT, AST, y-GT, alkaline phosphatase or serum bilirubin exclude a participant from participation in the study.
• History of renal injury / renal disease or presence of impaired renal function as indicated by any elevation above ULN of creatinine or BUN and/or urea values, or estimated glomerular filtration rate (eGFR) using the modification of diet in renal disease (MDRD) equation of < 40 mL/min/1.73 m2, or the presence >3+ proteinuria/ hematuria on repeated urinalysis
• Evidence of urinary obstruction or difficulty in voiding at screening
. Clinically significant signs of testicular abnormalities
• Clinically significant retinal abnormalities on opthamologic examinationby a local Ophthalmologist
• Clinically significant illness which has not resolved within two weeks prior to first dose of study drug
• Active infection requiring systemic antiviral or antimicrobial therapy that is not completed at least 3 days prior to first study drug administration (Day 1)
13. Cardiovascular exclusion criteria:
• History or current diagnosis of ECG abnormalities indicating significant risk or safety concern for study participants such as: History of myocardial infarction (Ml), angina pectoris, heart failure, or coronary artery bypass graft (CABG) within 6 months prior to starting study treatment. Screening ECHO abnormalities per investigator’s medical judgement including but not limited to left ventricular ejection fraction (LVEF) < 50%, change in LVEF 2: 10%, and change in Global Longitudinal Strain (GLS) 2: 15%.
• History or concomitant clinically significant cardiac arrhythmias (e.g., sustained ventricular tachycardia, atrial fibrillation, etc), complete left bundle branch block, highgrade AV block (e.g., bifascicular block, Mobitztype II and third degree AV block).
• History of familial long QT syndrome or known family history of Torsade de Pointes, risks for TdP including uncorrected hypokalemia or hypomagnesemia, history of clinically significant/symptomatic bradycardia and a family history of idiopathic sudden death. Resting QTcF 2:450 msec (male) or 2:460 msec (female) at pretreatment [screening or baseline] or inability to determine the QTcF interval.
• Use of agents known to prolong the QT interval or with a known risk of Torsade de Pointe unless it can be permanently discontinued for the duration of study.
• Uncontrolled hypertension (average 3 systolic blood pressure [SBPJreadings) at screening >140mmHg or average diastolic blood pressure [DBP] > 90 mmHg
14. Any clinically significant hematological abnormality as assessed by the Site Investigator at screening and/or laboratory evidence of any of the following:
• I NR, PT, or APTT that are not within normal ranges
• Anemia or hemoglobin <110 g/L (females) or <120 g/L (males)
• Thrombocytopenia or platelets S100 x 109/L
• Neutropenia or neutrophil count <1.5 x 109/L
• Leukopenia or leukocytes <3.0 x 109/L
Example 2.1b:
This study is a randomized, double-blind, placebo-controlled study with a variable treatment duration (between approximately 17 weeks to approximately 53 weeks) for the core period and a one-year OLE in approximately 75 early stage manifest HD patients.
Figure imgf000083_0001
Figure imgf000084_0001
After Screening period and BL assessments, this study is conducted in two Treatment Periods: The Core Period consists of a 17-week double-blind, placebo-controlled, Dose Range Finding (DRF) portion of the study, followed by a Blinded Extension (BE) of variable duration (up to approximately 53 weeks; duration is dependent on timing of randomization and recruitment rate). The DRF Period evaluates the safety, tolerability, pharmacokinetic(s) (PK) and pharmacodynamics) (PD) of branaplam, as well as determine the optimal dose(s) to explore in further clinical evaluations using all available data collected at the time the last randomized patient in the study completes the Week 17 visit assessments which captures a full 16 weeks of treatment with study drug.
The Open Label Extension (OLE) is a one-year open-label extension to assess both long term safety and tolerability, as well as the efficacy of the recommended optimal dose(s) for branaplam. If branaplam development in HD remains ongoing at the end of the OLE, the study is either (a) amended to extend the OLE beyond a year, or (b) a separate extension study is initiated to offer continued access to branaplam. Study participants from the OLE may be eligible to rollover into this separate extension study.
The study design uses a staggered cohort approach, allowing safety and tolerability of lower doses to be assessed before randomizing subjects to higher doses.
The Core Period consists of 3 treatment arms; each treatment arm enrolls approximately 25 patients, dependent on the total number of cohorts initiated.
Treatment arms are defined as:
Treatment Arm A: Branaplam 56 mg oral solution or matching placebo (PBO), once weekly
Treatment Arm B: Branaplam 112 mg oral solution or matching PBO, once weekly
Treatment Arm C: Branaplam 154 mg oral solution or matching PBO, once weekly
Treatment Arm X: Branaplam 84 mg oral solution or matching PBO, once weekly
Treatment Arm Y: Branaplam 28 mg oral solution or matching PBO, once weekly At the time of the Cohort Gating Assessments (CGAs), all available data is reviewed from a safety and dose finding perspective by an independent Sponsor team to support the decision to open the next cohort. The independent Data Monitoring Committee (DMC) reviews the data separately. The decision to open a new cohort is made by the Sponsor in consultation with the DMC.
Randomization into treatment arms is staggered into 3 Cohorts:
Cohort 1 includes Treatment Arm A (56 mg). After the 10th participant in Arm A reaches Week 9 of the DRF Treatment Period, all available data, including relevant post-dose PK time points, are reviewed from a safety and dose finding perspective by an independent Sponsor team to support the decision to open the next cohort. The independent Data Monitoring Committee (DMC) reviews the data separately. The decision to open Cohort 2 at the Cohort Gating Assessment 1 (CGA 1) is made by the Sponsor in consultation with the DMC. (Also, included in the review are PK data, blood/PBMC mHTT and total HTT levels, from a safety and not efficacy perspective, to ensure that HTT lowering is not beyond the anticipated safety threshold.) During this time, recruitment continues in Cohort 1. Based on the results from the review of the data during CGA 1, a decision is made regarding the initiation of Cohort 2 (Treatment Arm B, 112 mg). At this time, participants is eligible to randomize into any open Treatment Arm if it has not yet been completed. Alternatively, if Cohort 1 recruitment is complete prior to the initiation of Cohort 2, participants are then only eligible for randomization into Cohort 2.
Cohort 2: If Cohort 2 is initiated, after approximately the 10th participant in Treatment Arm B has reached Week 9 of the DRF Treatment Period, all available data, including relevant post dose PK time points, are again reviewed at CGA 2 by the independent Sponsor team and the DMC. Based on the results from the review of the data during CGA 2, a decision is made to select the Treatment Arm in Cohort 3.
Cohort 3: If Cohort 3 is initiated, and based on the data review during CGA 2, the decision is made to initiate the next higher dose (Treatment Arm C, 154 mg) or an intermediary dose (Treatment Arm X, 84 mg) or a lower dose (Treatment Arm Y, 28 mg). At this time, participants are eligible to randomize into any open Treatment Arm if it has not yet been completed. Alteratively, if Cohort 1 and 2 recruitment is complete prior to the initiation of Cohort 3, participants are then only eligible for randomization into Cohort 3. The interim analysis (IA) then takes place after the last randomized participant completes the DRF period (Week 17 visit). Participants are randomized in an equal randomization rate among the open treatment arms, and then in a 4:1 ratio for active vs. placebo within each arm.
After a participant completes the DRF period (Week 17) he/she seamlessly transitions to the BE, by continuing on his/her blinded DRF treatment. All patients remain in the BE until the results of the IA are available and the recommended optimal extension dose(s) is/are selected for OLE. Duration in the BE is therefore variable, longer for those that were randomized earlier in the study.
After the last randomized participant in the study completes all the DRF (Week 17) assessments, an un-blinded IA is conducted. All data available at this time, including, but not limited to safety/tolerability as well as PK, mHTT and total HTT lowering in CSF, plasma and peripheral blood mononuclear cell(s) (PBMCs), is assessed to determine optimal dose(s) for OLE. After the IA and confirmation of selected dose(s), all patients from the blinded Core Period roll over to OLE; patients are re-assigned from their blinded Core Period dosing onto the newly selected open label OLE dose(s).
OLE is a one-year open label treatment and safety monitoring part of the study.
Core Period: Dose Range Finding & Blinded Extension
Following a 6-week Screening period, patients complete a baseline assessment (can be performed over a 6 day time frame) and a multi-dose, treatment period (with duration varying across patients) at the assigned treatment arm. Safety, tolerability, PD biomarker (fluid and images), PK and clinical endpoints relevant to HD are collected as outlined in the assessment schedule.
After confirming eligibility, participants are randomized to an open cohort to receive either active or PBO treatment as an oral solution administered once weekly. Although a maximum of 3 treatment arms are planned, timing during the ongoing recruitment determines which available treatment arms are actively recruiting. In addition, not all treatment arms may be initiated, as it is dependent on the available safety profile, PK and mHTT lowering data. Participants receive at least 16 weeks of treatment and remain on the initially assigned treatment arm during the Core Period in the BE until IA is completed and optimal dose(s) selected for OLE. After dose selection, which may be more than one selected dose, patients continue participation in OLE.
Open-Label Extension (OLE)
Once the optimal dose(s) is/are selected, sites are notified and active participants roll over to OLE at a subsequent study visit. The specific timing for each patient is determined based on site readiness to conduct the OLE. Prior to commencing dosing in OLE, a series of assessments (rebaselining) may be collected. If more than one dose is selected for the OLE, then patients are reassigned via IRT to one of the selected open label doses.
Study visits take place every 4 weeks in OLE period (approximately 52 weeks). If branaplam development in HD remains ongoing at the end of the OLE, the study is either (a) amended to extend the OLE beyond a year, or (b) a separate extension study is initiated to offer continued access to branaplam.
Population
Approximately 75 male or female patients with confirmed Stage 1 or 2 Huntington's Disease and a UHDRS TFC score of >8 are enrolled in this study to allow for of approximately 25 participants per treatment arm.
Inclusion criteria
Participants eligible for inclusion in this study must meet all of the following criteria:
• Signed informed consent must be obtained prior to participation in the study
• Must be capable of providing informed consent (in the opinion of the Investigator)
• Clinically diagnosed Stage 1 or 2 Huntington's disease with a diagnostic confidence level (DCL) = 4 and a UHDRS Total Functional Capacity (TFC) >8 at screening
• Genetically confirmed Huntington's disease, with presence of 540 CAG repeats in the huntingtin gene.
For participants without prior documentation, a sample must be sent to the central study laboratory and confirmation of the CAG repeat length for these participants must be obtained prior to randomization
For participants with previously existing documentation of their CAG repeat length, it is acceptable to use this prior data to qualify for randomization. These participants must also submit a sample for CAG repeat testing to be conducted by the central study laboratory.
• Male and female participants between 25 to 75 years of age, inclusive, on the day of Informed Consent signature Exclusion criteria
Participants meeting any of the following criteria are not eligible for inclusion in this study:
1. Use of other investigational drugs within 5 half-lives of the first dose of study drug, or within 30 days, whichever is longer.
2. Prior participation in clinical trial investigating a huntingtin-lowering therapy (unless participant received only placebo)
3. History of hypersensitivity to any of the study drugs or its excipients or to drugs of similar chemical classes.
4. Participants taking medications prohibited by the protocol: : Strong systemic inhibitors of CYP3A4 examples include, but are not limited to boceprevir, clarithromycin, cobicistat, conivaptan, grapefruit juice, idelalisib, indinavir, itraconazole, ketoconazole, mibefradil, nefazodone, nelfinavir, posaconazole, ritonavir, telaprevir, telithromycin, troleandomycin, voriconazole. As strong systemic inhibitors of CYP3A4 are also combination of ritonavir-boosted regimens considered: ombitasvir/paritaprevir/dasabuvir/ritonavir (Viekira Pak), indinavir/ritonavir, tipranavir/ritonavir, danoprevir/ritonavir, elvitegravir/ritonavir, saquinavir/ritonavir, lopinavir/ritonavir, atazanavir/ritonavir, darunavir/ritonavir; Strong systemic inducers of CYP3A4 examples include, but are not limited to apalutamide, carbamazepine, enzalutamide, mitotane, phenytoin, rifampin, St. John’s wort; Co-medications metabolized via CYP3A4/5 with narrow therapeutic index examples include but are not limited to alfentanil, astemizole, cisapride, cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, sirolimus, tacrolimus); Co-medications eliminated via renal MATE2K transporter examples include, but not limited to fexofenadine, glycopyrronium, metformin; Medication(s) with a "Known Risk of Torsade de Pointes" examples include but are not limited to the following: escitalopram, citalopram, haloperidol, sulpiride, chlorpromazine, ondansetron, hydroxychloroquine ciprofloxacin, clarithromycin; Medication (s) with “Potential risk of TdP” examples include but are not limited to the following: aripiprazole, clozapine, deutetrabenazine, tetrabenazine, levetiracetam; Medication (s ) with a “Conditional Risk of TdP examples include but are not limited to the following: diphenhydramine, doxepin .fluoxetine, hydrochlorothiazide, furosemide, metoclopramide, olanzapine, paroxetine, quetiapine, risperidone, sertraline, trazodone, ziprasidone; Antiplatelet or anticoagulant therapy including but not limited to aspirin (unless s 81 mg/day), clopidogrel, dipyridamole, warfarin, heparinoids and direct coagulation factor inhibitors e.g. apixaban, dabigatran, rivaroxaban; Co-medications substrate of OCTI transporter examples include, but not limited to cephalexin, dofetilde, pilsicainide, pindolol, procainamide, ranitidine, varenicline, umeclidinium, zidovudine.
5. Any medical history, lumbar surgery or condition that would interfere with the ability to complete the protocol specified assessments, (e.g., history of brain or spinal injury that would interfere with the LP or CSF circulation, implanted cerebrospinal shunt, conditions precluding MRI scans, herniated disc, etc.)
6. History of malignancy of any organ system (other than localized basal cell carcinoma of the skin or in situ cervical cancer), treated or untreated, regardless of whether there is evidence of local recurrence or metastases.
7. Participant has other severe, acute or chronic medical conditions including unstable psychiatric conditions, or laboratory abnormalities that in the opinion of the Investigator may increase the risk associated with study participation, or that may interfere with the interpretation of the study results
8. Score “yes" on item 4 or item 5 of the Suicidal Ideation section of the Columbia Suicide Severity Rating Scale (C-SSRS), if this ideation occurred in the past 6 months from the Screening visit, or “yes” on any item of the Suicidal Behavior section, except for the “Non-Suicidal Self-Injurious Behavior” (item also included in the Suicidal Behavior section), if this behavior occurred in the past 2 years.
9. Pregnant or nursing (lactating) women. WOCB potential should not become pregnant during the study or within 7 months from stopping study medication.
10. Sexually active males unwilling to use a condom during intercourse while taking study treatment and for 120 days (4 months) after the last dose of the study treatment. A condom is required for all sexually active male participants even if they are surgically sterile with a vasectomy to prevent them from fathering a child AND to prevent delivery of study treatment via seminal fluid to their female partner. A condom is required to be used also by vasectomized men as well during intercourse with a male partner of the study participant.
11. Women of childbearing potential, defined as all heterosexually active women physiologically capable of becoming pregnant, unless they are using one highly effective methods of contraception during dosing and for 7 months after stopping the study medication. Highly effective methods of birth control are those methods that have a less than 1% chance of an unwanted pregnancy during 1 year.
In addition to one highly effective method of contraception, a condom is required for all male partners of female participants to prevent fathering a child AND to prevent exposure of study treatment via vaginal fluid to partner, until at least 7 months following the last dose of study treatment.
Total abstinence, periodic abstinence (e.g., calendar, ovulation, symptothermal, postovulation methods) and withdrawal are NOT acceptable methods of contraception for heterosexually active participants.
Highly effective contraception methods include:
Female sterilization (have had surgical bilateral oophorectomy with or without hysterectomy) total hysterectomy or bilateral tubal ligation at least six weeks before taking investigational drug. In case of oophorectomy alone, only when the reproductive status of the woman has been confirmed by follow up hormone level assessment.
Male sterilization of partners (at least 6 months prior to screening). For female subjects on the study, the vasectomized male partner should be the sole partner.
Use of an intrauterine device (IUD) or intrauterine system (IUS) which is MRI compatible.
In case local regulations deviate from the contraception methods listed above, local regulations apply and are described in the IGF.
Women are considered post-menopausal if they have had 12 months of natural (spontaneous) amenorrhea with an appropriate clinical profile (e.g. age appropriate, history of vasomotor symptoms). Women are considered not of childbearing potential if they are post-menopausal or have had surgical bilateral oophorectomy (with or without hysterectomy), total hysterectomy or bilateral tubal ligation at least six weeks prior to Screening. In the case of oophorectomy alone, only when the reproductive status of the woman has been confirmed by follow up hormone level assessment is she considered not of childbearing potential.
12. History of:
- Gene therapy or cell transplantation or any other experimental brain surgery
- Hepatitis B or hepatitis C or serologic evidence for active viral hepatitis (HBsAg and HCVab test)
- Immunodeficiency diseases, including a positive human immunodeficiency virus (HIV) test result
- Current evidence of drug or alcohol abuse in the 12 months prior to screening, as defined by the DSM-V criteria for substance abuse. For former abusers, abstinence should be confirmed by laboratory tests (drug testing and/or CDT level in blood).
- Use of Tetra-Hydro-Cannabinoid (THC)/ cannabinoid containing substances is allowed as per local regulations and/or local medical practice if in the opinion of the Investigator, use does not represent an exclusionary condition, does not constitute abuse and does not affect cognition, and provided that participants are currently treated with a stable regimen for at least 12 weeks prior to randomization. Note: If initiated during the study, use must be withheld for 72 hours prior to any cognitive and/or motor assessments.
13. Any surgical or medical condition which might put the participant at risk in case of participation in the study. The Investigator should make this determination in consideration of the participant’s medical history and/or clinical or laboratory evidence of any of the following at the Screening visit:
- Unstable chronic gastrointestinal (Gl) condition such as history of Crohn’s disease, Ulcerative colitis, poorly controlled irritable bowel syndrome (IBS) or similar chronic Gl conditions
Neurologic or neuromuscular conditions other than HD History of peripheral neuropathy
Participants who have a known diagnosis of diabetes mellitus or who do not have a known diagnosis of diabetes with a glycated hemoglobin (HbA1c) > 6.5%
Lipase, total bilirubin or amylase must not exceed the 1 5x upper limit of normal (ULN) Liver disease or liver injury as indicated by abnormal liver function tests
Any of the following single parameters in serum of ALT, AST, GOT, and alkaline phosphatase must not exceed 2.0 x upper limit of normal (ULN).
Any elevation above ULN of more than one parameter of ALT, AST, GGT, alkaline phosphatase or serum bilirubin excludes a participant from participation in the study.
History of renal injury / renal disease or presence of severe impaired renal function as indicated by any elevation above ULN of creatinine or blood urea nitrogen (BUN) and/or urea values, or estimated glomerular filtration rate (eGFR) using the modification of diet in renal disease (MDRD) equation < 30 (mL/min/1.73 m2) allowing for age-related GFR decline in the mild to moderate range or the presence >3+ proteinuria/ hematuria on a single (one time) repeated urinalysis
Evidence of urinary obstruction or difficulty in voiding at screening
Diagnosis of testicular atrophy
Diagnosis of primary ovarian failure
Clinically significant retinal abnormalities on ophthalmologic examination by a local Ophthalmologist
- Active infection requiring systemic antiviral or antimicrobial therapy that is not completed at least 3 days prior to first study drug administration (Day 1)
- Any objects and/or implants in the body which may be contraindicated for MRI, such as pacemakers and some IUD
14. Cardiovascular exclusion criteria:
History or current diagnosis of ECG abnormalities indicating significant risk or safety concern for study participants such as: History of myocardial infarction, angina pectoris, heart failure, or coronary artery bypass graft (CABG).
Screening ECHO abnormalities per investigator’s medical judgement including but not limited to left ventricular ejection fraction (LVEF) <50%.
Screening or baseline not within normal range Troponin or NTproBNP values.
History or concomitant clinically significant cardiac arrhythmias (e.g., sustained ventricular tachycardia, atrial fibrillation, etc.), complete left bundle branch block, high-grade atrioventricular (AV) block (e.g., bifascicular block, Mobitz type II and third-degree AV block). History of familial long QT syndrome or known family history of Torsade de Pointe, risks for TdP including uncorrected hypokalemia or hypomagnesemia, history of clinically significant/symptomatic bradycardia and a family history of idiopathic sudden death.
Resting QTcF £450 msec (male) or £460 msec (female) at pretreatment [screening or baseline] (as mean of triplicate ECGs), or inability to determine the QTcF interval.
- Use of agents known to prolong the QT interval or with a known risk of T orsade de Pointe unless it can be permanently discontinued for the duration of study.
- Uncontrolled hypertension (average 3 systolic blood pressure [SBPJreadings) at screening >140 mmHg or average diastolic blood pressure [DBP] > 90 mmHg
15. Any clinically significant hematological abnormality as assessed by the Site Investigator at screening and/or laboratory evidence of any of the following:
- INR, PT, or activated partial thromboplastin time (APTT) that are not within normal ranges
Anemia or hemoglobin <110 g/L (females) or <120 g/L (males)
Thrombocytopenia or platelets S100 x 109/L
Platelets count >500x109/L
Neutropenia or neutrophil count <1.5 x 109/L
Leukopenia or leukocytes <3.0 x 109/L
Pharmacokinetics
Pharmacokinetic (PK) samples are collected at the visits defined in the assessment schedule:
Dose Range Finding & Blinded Extension: Week 1 at 0 h (pre-dose), 4 h, 7 h, 12 h (optional), 22 h 72 h, and 168 h after first dosing; Week 3 and 5 at 0 h (predose); Week 9 at 0 h (pre-dose), 4 h, 12 h (optional), and 22 h after Week 9 dose; Week 13 at 0 h(pre-dose); Week 17 at 0 h (pre-dose), 4 h, 12 h (optional), 22 h, and 72 h after Week 17 dose; Week 25, Week 33, Week 41, Week 53 and every 8 weeks afterwards at 0 h (pre-dose). Open label extension: Baseline and Weeks 9, 17, 25, 33, 41, and 53 at 0 h (pre-dose)). PK samples in CSF are collected in Weeks 1, 9, 17, 33, 53, 69, 85, and 101 at 0 h (pre-dose) in the Dose Range Finding & Blinded Extension and at baseline and Weeks 17, 33, and 53 at 0 h (pre-dose) in the Open label extension.
PK samples from plasma and CSF are obtained from all participants at all dose levels. Branaplam is determined in plasma and CSF by a validated LC-MS/MS method. The anticipated Lower Limit of Quantification (LLOQ) is 0.500 ng/mL. Concentrations are expressed in mass per volume units and refer to the free base. Concentrations below the LLOQ are reported as “zero” and missing data is labeled as such in the Bioanalytical Data Report.
If feasible, the following pharmacokinetic parameters are determined in plasma after first dosing and at the Week 17 visit using the actual recorded sampling times and non-compartmental method(s) with Phoenix WinNonlin (Version 8 or higher): the maximum concentration (Cmax), the time it takes to reach Cmax (Tmax), AUCIast, AUCtau, AUCinf, T1/2, Vz/F and CL/F from the plasma concentration-time data.
The linear trapezoidal rule is used for AUG calculation. Regression analysis of the terminal plasma elimination phase for the determination of T1/2 includes at least 3 data points after Cmax. If the adjusted R2 value of the regression analysis of the terminal phase is less than 0.75, if the observation period to estimate the T1/2 values is shorter than the estimated T1/2 value, and/or if the extrapolated AUG is greater than 20% of the estimated AUCinf, no values are reported for T1/2, AUCinf, CL/F, and Vz/F.
For plasma samples collected at other times (Ctrough values) and CSF samples, mean concentrations are calculated.
Biomarkers
The following biomarkers are analyzed:
Mutant Huntingtin (mHTT) protein is measured in CSF on the day of dosing at predose and at week 9, week 17, to evaluate the dose-response relationship between branaplam doses and mHTT in CSF. This relationship is determined by statistical modelling based on the percent reduction of mHTT observed from BL levels. In addition, mHTT in CSF continues to be monitored in the Blinded Extension phase, and Open Label Extension phase every 16 weeks. Total HTT protein is measured in CSF on the day of dosing at predose and at week 8 and week 17, to evaluate the dose-response relationship between branaplam doses and total HTT in CSF. In addition, total HTT in CSF continues to be monitored in the Blinded Extension phase, and Open Label Extension phase every 16 weeks.
Mutant Huntingtin (mHTT) protein is measured in plasma and PBMCs on the day of dosing at predose and at 22h, and 72 h, post dose, to assess the pharmacodynamic effect of branaplam administered once weekly. In addition, mHTT is measured in plasma and PBMCs at week 2, 3, 5, and 9 of the dose range finding portion of the study. Thereafter, mHTT is evaluated every 4 weeks in plasma and PBMCs during the blinded extension, and every 8 weeks in the open label extension portions of the study.
Total HTT protein is measured in plasma and PBMCs on the day of dosing at predose and at predose and at 22h, and 72 h, post dose, to assess the pharmacodynamic effect of branaplam administered once weekly. In addition, total HTT is measured in plasma and PBMCs at week 2, 3, 5, and 9 of the dose range finding portion of the study. Thereafter, total HTT is evaluated every 4 weeks in plasma and PBMCs during the blinded extension, and every 8 weeks in the open label extension portions of the study.
The following biomarkers are secondary variables: changes in brain volume as measured by volumetric MRI in selected brain regions of interest, total HTT protein in CSF, PBMCs and plasma, and mHTT in PBMCs and plasma. Biomarker data are reported over three periods:
1. DRF: An analysis of change from BL to week 17 are performed using longitudinal MMRM model with treatment as factor and adjusting for important covariates for DRF period at the time of IA (based on Full Analysis Set).
2. Core: descriptive statistics of the change from BL to the end of Core are presented by treatment group and compare to placebo (based on Full Analysis Set)
3. Core + OLE: descriptive statistics of the change from BL and BL-EXT to week 53-EXT are presented by treatment group originally assigned during core and by selected dose(s) for OLE(based on OLS).
Data analysis
In the analysis all participants assigned to placebo in different treatment arms are pooled together as one placebo group. Hence, there are 4 treatment groups in total (3 active, 1 placebo). Analysis of the primary endpoint(s)/estimand(s)
The primary data analysis, so called the IA, are performed at the end of DRF, where all randomized participants have completed their last assessment of this DRF period (Week 17, after 16 weeks on treatment). The analysis may include 4 treatment groups (3 active, 1 placebo).
There are two primary objectives in this study:
1. To assess the dose-response relationship of branaplam administered over 16 weeks on mHTT protein change from baseline in CSF.
2. To evaluate the safety and tolerability of various doses of branaplam over 16 weeks or longer in patients with HD.
The dose finding objective is associated with the two goals below:
1. To confirm an overall dose response (DR) signal, versus placebo, based on data of 16 weeks of treatment
2. To identify the dose(s) that correspond(s) to the optimal treatment effect based on the estimated DR relationship
The efficacy primary endpoint is the % change from baseline of mHTT concentrations in CSF after 16 weeks of treatment, which is expressed as: (mHTT wk17- mH I I baseine)/mH I I baseine*100%.
The primary endpoints of the safety and tolerability objective comprise main safety data, including but not limited to AEs/SAEs, physical exam findings, clinical laboratory assessments, and HTT lowering.
Analysis of secondary endpoints/estimands
Secondary variables are:
1. Clinical endpoints: Unified Huntington's Disease Rating Scale (UHDRS) Total Functional Capacity (TFC), UHDRS Total Motor Score (TMS), UHDRS Independence Scale (IS)
2. Volumetric MRI (vMRI): Ventricular, Caudate and Total Brain Volume
Other biomarkers: total HTT and mHTT protein in CSF, PBMCs and plasma.
In addition to the above listed efficacy and biomarker outcomes, the following are secondary PK outcome parameters: 1. PK parameters (e.g. AUCIast, AUCtau, Cmax, Tmax, Ctrough) of branaplam in plasma across the study duration
2. Concentrations of branaplam in CSF and concentration ratio CSF/plasma of the analytes
No multiplicity adjustment is carried out for secondary analyses.
Example 2.2: Evaluation of the effect of branaplam on the expression levels of Huntingtin (HTT) mRNA in infants with Type I spinal muscular atrophy
Methods
Open-label multi-part first-in-human proof of concept study of oral branaplam
The effect of branaplam on the expression levels of Huntingtin (H77) mRNA was assessed in infants with Type I spinal muscular atrophy who were enrolled in an open-label multi-part first-in- human proof of concept study of oral branaplam.
The aim of part one of this study was to determine the safety and tolerability of ascending weekly doses and to estimate the maximum tolerated dose (MTD) of oral/enteral branaplam (see Example 3) in infants with Type 1 SMA. All patients had exactly 2 copies of the SMN2 gene, as determined e.g. by quantitative real time PCR or droplet digital PCR.
Patients were dosed once weekly with branaplam. The branaplam doses were escalated in subsequent cohorts until MTD was determined or when PK results confirmed that the MTD could not be reached due to a potential pharmacokinetic exposure plateau at higher doses.
The starting dose was 6 mg/m2 (approximately 0.3125 mg/kg). Subsequent doses were 12 mg/m2, 24 mg/m2, 48 mg/m2 and 60 mg/m2 (approximately 0.625 mg/kg, 1.25 mg/kg, 2.5 mg/kg and 3.125 mg/kg, respectively). Each cohort had 2-3 patients. All doses are of branaplam (free form). 14 patients were enrolled in Part 1 ; 13 patients were exposed to branaplam. The duration of exposure ranged from 4-33 months, 7 patients remain in the study. Six of the 7 patients are receiving 60 mg/m2, 1 patient is receiving 48 mg/m2. No dose-limiting toxicity was observed.
The aim of part two of this study is to evaluate the long-term safety and tolerability of 2 doses of branaplam administered weekly for 52 weeks in patients with Type 1 SMA. Part 2 of the study enrolls patients into 2 cohorts: cohort 1 at a 0.625 mg/kg dose and cohort 2 at a 2.5 mg/kg dose. The selected dose levels of 0.625 mg/kg and 2.5 mg/kg are based on all safety data from Part 1 , as well as, all data from chronic juvenile toxicity studies available at the time of initiation of Part 2. Approximately 10 patients were planned to be enrolled in cohort 1 and 2. A total of twenty-five patients were enrolled and all received the treatment at least once, to date, 22 patients are still being treated for 6 to 18 months.
Blood collection
Whole blood samples from patients enrolled in part 1 and part 2 of the study were collected at baseline prior to treatment and at several time-points during treatment with branaplam (day 85 and then every 91 days). Parents of all examined participants provided written informed consent for additional biological research.
A 0.6 mL blood sample was collected with one Multivette® 600 Potassium EDTA ( Sarstedt ). After gentle mixing, the blood was transferred directly into the solution of a PAXgene Blood RNA tube (Becton Dickinson). The sample was immediately gently inverted 8 to 10 times to prevent clotting and left at room temperature in an upright position for 2 to 3 hours. After incubation, the PAXgene Blood RNA Tubes were stored at -20 °C.
RNA extraction and quantitative PCR
Total RNA was extracted using the PAXgene Blood RNA Kit (Qiagen). Total RNA was reverse transcribed to cDNA using random hexamers and the iScript™ Advanced cDNA Synthesis Kit (Bio-Rad). cDNA synthesis was performed according to manufacturer’s instructions using 100 ng of total RNA as input into a 20 pl cDNA reaction to generate an initial cDNA with a concentration of 5 ng/pl (total RNA equivalents). Finally, the cDNA was subsequently diluted 1/1 with nuclease- free water to generate a final cDNA with a concentration of 2.5 ng/pl (total RNA equivalents). All preparations were carried out on ice. cDNA synthesis was performed on a C1000 Thermal cycler, Reaction Module 96W Fast (Bio-Rad) using the following conditions: 25°C for 5 min, 46°C for 20 min, 95°C for 1 min and hold at 4°C. cDNA samples were stored at -20°C.
Levels of HTT mRNA and novel-exon-included HIT mRNA were then quantified by polymerase chain reaction (PGR) using the Bio-Rad QX200 droplet digital PCR system. Standard reaction and cycling conditions (95 °C for 10 min; 40 cycles of 94 °C for 30 sec and 60 °C for 60 sec; and 98 °C for 10 min; hold at 4 °C) and a cDNA input (total RNA equivalent) of 20 ng were applied.
For HTT mRNA levels, two independent predesigned quantitative PCR assays (Assay Ms. PT.58.14833829 with forward primer 5’-GAGACTCATCCAGTACCATCAG-3’ (SEQ ID NO: 10), reverse primer 5’-GATGTCAGCTATCTGTCGAGAC-3‘ (SEQ ID NO: 11) and probe 5’-56- FAM/CGCTTCCAC/ZEN/TTGTCTTCATTCTCCTTGT/3IABkFQ-3’ (SEQ ID NO: 12) and assay Hs.PT.58.25550542 with forward primer 5’-GTAGAACTTCAGACCCTAATCCTG-3’ (SEQ ID NO: 13), reverse primer 5'-CACCACTCTGGCTTCACAA-3’ (SEQ ID NO: 14) and probe 5’-56- FAM/CCCGACAGC/ZEN/GAGTCAGTGATTGTT/3IABkFQ-3’ (SEQ ID NO: 15), purchased from Integrated DNA Technologies, Inc.) were used. A customized quantitative PCR assay with forward primer 5’-TCCTGAGAAAGAGAAGGACATTG-3’ (SEQ ID NO: 3), reverse primer 5’- CTGTGGGCTCCTGTAGAAATC-3’ (SEQ ID NO: 4) and probe 5’-56- FAM/AATTCGTGG/ZEN/TGGCAACCCTTGAGA/3IABkFQ-3‘ (SEQ ID NO: 7) was applied to quantify the inclusion of a novel exon into HTT mRNA.
All gene expression values were normalized to Glucuronidase beta (GUSB) mRNA levels. A predesigned quantitative PCR assay (Assay Hs.PT.39a.22214857 with forward primer 5’- TCACTGAAGAGTACCAGAAAAGTC-3’ (SEQ ID NO: 16, reverse primer 5*-
TTTTATTCCCCAGCACTCTCG-3’ (SEQ ID NO: 17) and probe 5*-
HEX/ACGCAGAAA/ZEN/ATACGTGGTTGGAGAGC/3IABkFQ-3’ (SEQ ID NO: 18), purchased from Integrated DNA Technologies, Inc.) was used to assess GUSB mRNA levels.
Conclusions
The effect of branaplam on the expression levels of Huntingtin (HTT) mRNA was assessed in infants with Type I spinal muscular atrophy who were enrolled in an open-label multi-part first-in- human proof of concept study of oral branaplam. Patients were dosed once weekly with branaplam. The longitudinal gene expression analysis of blood samples showed that the inclusion of the novel exon into HTT mRNA was induced after first weekly doses of branaplam and was kept sustained at constant levels over a period of 1450 study days (Figure 12). In addition, blood HTT mRNA levels decreased by up to 50% from baseline over a period of 904 study days (Figure 13). Afterwards, as assessed from only 1-5 long-term treated subjects depending on their progress within the clinical study, HTT mRNA levels returned to values around baseline levels between study days 904 and 1450 (Figure 13). Our results demonstrate that branaplam treatment of infants with Type I spinal muscular atrophy induces the inclusion of a novel exon into blood HTT mRNA and lowers blood HTT mRNA levels by up to 50% as compared to baseline. These results demonstrate that sustained lowering of HTT to target therapeutic levels can be attained via intermittent dosing of branaplam.
Figure 12: Weekly oral doses of branaplam induced and elevated blood HTT transcript levels with inclusion of a novel exon in infants with SMA Type 1. Longitudinal data from study days 358 to 1450 were available from only 1-5 subjects depending on progress of the individual subjects within the study. Error bars represent standard error.
Figure 13: Weekly oral doses of branaplam lower blood HTT transcript levels in infants with SMA Type 1. Longitudinal data from study days 358 to 1450 were available from only 1-5 subjects depending on progress of the individual subjects within the study. Error bars represent standard error.
Example 3: Oral formulation of branaplam
Procedure
The required amount of 2-hydroxypropyl-beta-cyclodextrin was dissolved in 80% volume of target water (i.e. final intended volume) and stirred for 30 minutes. The required amount of branaplam monohydrochloride salt was then added to said solution, under stirring, at room temperature. The solution was stirred for 45 minutes after the addition was completed or for longer until a particle- free (i.e. to naked eye) solution was obtained. Initial pH adjustment was performed using NaOH 0.1M or HCI 0.1M to reach the intended pH (±0.25). The required volume of water was added to the solution to reach the final intended volume and stirred for at least 10 minutes at 25±3 °C after the addition was completed. Final pH adjustment was performed using NaOH 0.1M or HCL 0.1M to reach the intended pH.
Figure imgf000101_0001

Claims

1. A method of treatment for slowing progression of Huntington’s disease in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
2. A method of treatment of Huntington’s disease in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, as a disease-modifying therapy, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
3. A method of treatment for slowing the decline of motor function associated with Huntington’s disease in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
4. A method of treatment for slowing cognitive decline associated with Huntington’s disease in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
5. A method of treatment for slowing psychiatric decline associated with Huntington’s disease in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
6. A method of treatment for slowing the decline of functional capacity associated with Huntington’s disease in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
7. A method of treatment for slowing the progression of Huntington’s disease pathophysiology [e.g. reducing the rate of brain (e.g. whole brain, caudate, striatum or cortex) volume loss (e.g. % from baseline volume) associated with Huntington’s disease (e.g. as assessed by MRI)] in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
8. The method according to claim 3, wherein motor function comprises one or more selected from the group consisting of ocular motor function, dysarthria, dystonia, chorea, postural stability and gait.
9. The method according to claim 4, wherein cognitive decline comprises decline of one or more selected from the group consisting of attention, processing speed, visuospatial processing, timing, emotion processing, memory, verbal fluency, psychomotor function, and executive function.
10. The method according to claim 5, wherein psychiatric decline comprises one or more selected from the group consisting of apathy, anxiety, depression, obsessive compulsive behavior, suicidal thoughts, irritability and agitation.
11. The method according to claim 6, wherein functional capacity comprises one or more selected from the group consisting of capacity to work, capacity to handle financial affairs, capacity to manage domestic chores, capacity to perform activities of daily living, and level of care needed.
12. The method according to any one of claims 1 to 11, wherein Huntington’s disease is genetically characterized by CAG repeat expansion of from 36 to 39 in the huntingtin gene on chromosome 4.
13. The method according to any one of claims 1 to 11, wherein Huntington’s disease is genetically characterized by CAG repeat expansion of from >39 in the huntingtin gene on chromosome 4.
14. The method according to any one of claims 1 to 13, wherein Huntington’s disease is manifest Huntington’s disease.
15. The method according to any one of claims 1 to 14, wherein Huntington's disease is juvenile Huntington’s disease or pediatric Huntington’s disease.
16. The method according to any one of claims 1 to 15, wherein Huntington's disease is early stage of Huntington’s disease, middle stage of Huntington’s disease, or advanced stage of Huntington’s disease; in particular early stage of Huntington’s disease.
17. The method according to any one of claims 1 to 16, wherein Huntington’s disease is stage I of Huntington’s disease, stage II of Huntington's disease, stage III of Huntington’s disease, stage IV of Huntington’s disease or stage V of Huntington’s disease; in particular stage I of Huntington's disease or stage II of Huntington’s disease.
18. The method according to any one of claims 1 to 13, wherein Huntington’s disease is premanifest Huntington’s disease.
19. The method according to any one of claims 1 to 18, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered orally.
20. The method according to any one of claims 1 to 19, wherein branaplam, or a pharmaceutically acceptable salt thereof, is provided in the form of a pharmaceutical composition.
21. The method according to any one of claims 1 to 19, wherein branaplam, or a pharmaceutically acceptable salt thereof, is provided in the form of a pharmaceutical combination.
22. The method according to any one of claims 1 to 21 , wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered following gene therapy or treatment with an antisense compound.
23. The method according to any one of claims 1 to 22, wherein branaplam is administered in the form of branaplam hydrochloride salt.
24. A method of treatment for slowing progression of Huntington’s disease in a subject, in need thereof, comprising administering to said subject an effective amount of branaplam, or a pharmaceutically acceptable salt thereof, by producing an in-frame stop codon between exons 49 and 50 in the HTT mRNA, wherein branaplam, or a pharmaceutically acceptable salt thereof, is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week, 154 mg once a week or 196 mg once a week), or of from 175 mg to 250 mg once a week (e.g. 238 mg once a week); in particular is administered in an amount of from 25 mg to 100 mg once a week (e.g. 28 mg once a week, 56 mg once a week or 84 mg once a week), of from 100 mg to 175 mg once a week (e.g. 112 mg once a week or 154 mg once a week).
25. A method of treatment according to claim 24, the method further comprising the steps of: determining whether branaplam produced a novel-exon included HTT mRNA by: obtaining or having obtained a blood sample from the patient; and performing or having performed a PCR assay on the biological sample to determine if the patient has novel-exon included HTT mRNA.
26. A method of treatment according to claim 24, the method further comprising the steps of: determining the decrease in HTT protein in the brain by determining HTT protein levels in surrogate matrices selected from CSF and peripheral blood based matrices (e.g. plasma, serum or PBMC), preferably by determining HTT protein levels in CSF; if the patient has a decrease of HTT protein of less than about 25% to 65%, such as of less than about 35% to 50%, as compared to baseline, then administering branaplam in an amount of from 25 mg to 250 mg once a week, until the patient has a decrease of HTT protein of about 25% to 65%, such as about 35% to 50%, as compared to baseline.
27. A method of treatment according to claim 24, the method further comprising the steps of: determining whether branaplam produced a novel-exon included HTT mRNA by: obtaining or having obtained a blood sample from the patient; and performing or having performed a PCR assay on the biological sample to determine if the patient has novel-exon included HTT mRNA; and determining the decrease in HTT protein in the brain by determining HTT protein levels in surrogate matrices selected from CSF and peripheral blood based matrices (e.g. plasma, serum or PBMC), preferably by determining HTT protein levels in CSF; if the patient has a decrease of HTT protein of less than about 25% to 65%, such as of less than about 35% to 50%, as compared to baseline, then administering branaplam in an amount of from 25 mg to 250 mg once a week, until the patient has a decrease of HTT protein of about 25% to 65%, such as about 35% to 50%, as compared to baseline.
28. A method of treatment according to claim 24, the method further comprising the steps of: determining whether branaplam produced an in-frame stop codon between exons 49 and 50 in the HTT mRNA by: obtaining or having obtained a blood sample from the patient; and performing or having performed a PCR assay on the biological sample to determine if the patient has an in-frame stop codon between exons 49 and 50 in the HTT mRNA; and determining the decrease in HTT protein in the brain by determining HTT protein levels in surrogate matrices selected from CSF and peripheral blood based matrices (e.g. plasma, serum or PBMC), preferably by determining HTT protein levels in CSF; if the patient has a decrease of HTT protein of less than about 25% to 65%, such as of less than about 35% to 50%, as compared to baseline, then administering branaplam in an amount of from 25 mg to 250 mg once a week, until the patient has a decrease of HTT protein of about 25% to 65%, such as about 35% to 50%, as compared to baseline.
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