阅读说明：本技术 治疗化合物和组合物 (Therapeutic compounds and compositions ) 是由 N.J.海沃德 B.L.切纳德 Y.徐 P.E.施内根伯格 M.P.普拉西迪 W.M.盖尔 于 2020-01-24 设计创作，主要内容包括：本文提供了包含抑制因子XIa或激肽释放酶的化合物的药物组合物以及其使用方法。(Provided herein are pharmaceutical compositions comprising compounds that inhibit factor XIa or kallikrein, and methods of use thereof.)

1. An aqueous pharmaceutical composition comprising a compound of formula (I-A),

or a pharmaceutically acceptable salt thereof, a cyclodextrin and an excipient.

2. The pharmaceutical composition of claim 1, wherein the cyclodextrin is selected from the group consisting of alkyl cyclodextrins, hydroxyalkyl cyclodextrins, carboxyalkyl cyclodextrins, and sulfoalkyl ether cyclodextrins.

3. The pharmaceutical composition of claim 1 or 2, wherein the cyclodextrin is hydroxypropyl β -cyclodextrin.

4. The pharmaceutical composition of claim 1 or 2, wherein the cyclodextrin is sulfobutylether beta-cyclodextrin.

5. The pharmaceutical composition according to any one of claims 1 to 4, wherein the excipient is a sugar (e.g. a saccharide (e.g. a mono-, di-or polysaccharide)) or a sugar alcohol.

6. The pharmaceutical composition of any one of claims 1 to 5, wherein the excipient is sucrose, lactose, trehalose, dextran, erythritol, arabitol, xylitol, sorbitol, or mannitol, or a combination thereof.

7. The pharmaceutical composition according to any one of claims 1 to 6, wherein the excipient is mannitol.

8. The pharmaceutical composition according to any one of claims 1 to 6, wherein the excipient is lactose.

9. The pharmaceutical composition of any one of claims 1 to 8, further comprising a buffering agent.

10. The pharmaceutical composition of claim 9, wherein the buffering agent is a monoprotic acid or a polyprotic acid or a combination thereof.

11. The pharmaceutical composition of claim 9 or 10, wherein the buffer is a solution of one or more substances.

12. The pharmaceutical composition according to any one of claims 9 to 11, wherein the buffer is a solution of a salt of a weak acid and a weak base.

13. The pharmaceutical composition according to any one of claims 9 to 11, wherein the buffer is a solution of a salt of a weak acid and a strong base.

14. The pharmaceutical composition according to any one of claims 9 to 13, wherein the buffer is selected from the group consisting of a maleate buffer, a citrate buffer and a phosphate buffer.

15. The pharmaceutical composition according to any one of claims 9 to 14, wherein the buffer is a phosphate buffer.

16. The pharmaceutical composition of claim 15, wherein the phosphate buffer is a solution of monosodium phosphate, disodium phosphate, trisodium phosphate, or a combination thereof.

17. The pharmaceutical composition of any one of claims 1 to 17, further comprising a solubilizing agent.

18. The pharmaceutical composition of claim 17, wherein the solubilizing agent is a polyoxyethylene sorbitan ester (e.g., a polyoxyethylene sorbitan ester)20) Or polyethylene glycol (e.g., PEG 400).

19. The pharmaceutical composition of any one of claims 1 to 18, wherein the pH of the composition is from about 2 to about 8.

20. The pharmaceutical composition of any one of claims 1-19, wherein the pH of the composition is about 6.8.

21. The pharmaceutical composition according to any one of claims 1 to 20, wherein the concentration of the compound of formula (I-a) is from about 0.1mg/mL to about 100 mg/mL.

22. The pharmaceutical composition according to any one of claims 1 to 21, wherein the concentration of the compound of formula (I-a) is about 10 mg/mL.

23. The pharmaceutical composition according to any one of claims 9 to 22, wherein the buffer is at a concentration of about 1mM to about 500 mM.

24. The pharmaceutical composition of any one of claims 9-23, wherein the buffer is at a concentration of about 10 mM.

25. The pharmaceutical composition of claim 23 or 24, wherein the buffer is a phosphate buffer.

26. The pharmaceutical composition according to any one of claims 1 to 25, wherein the amount of cyclodextrin is about 0.1% to about 10% (e.g., about 0.5% to about 6% (e.g., about 0.7% to about 5.6% (e.g., about 2.1% to about 5%) by weight) relative to the weight of the compound of formula (I-a)).

27. The pharmaceutical composition according to any one of claims 1 to 26, wherein the amount of cyclodextrin is about 3.5% by weight relative to the weight of the compound of formula (I-a).

28. The pharmaceutical composition according to any one of claims 1 to 26, wherein the amount of cyclodextrin is about 5% by weight relative to the weight of the compound of formula (I-a).

29. The pharmaceutical composition of any one of claims 26-28, wherein the cyclodextrin is hydroxypropyl β -cyclodextrin.

30. The pharmaceutical composition according to any one of claims 1 to 29, wherein the amount of the excipient is from about 0.1% to about 10% by weight relative to the weight of the compound of formula (I-a).

31. The pharmaceutical composition according to any one of claims 1 to 30, wherein the amount of the excipient is about 3% by weight relative to the weight of the compound of formula (I-a).

32. The pharmaceutical composition according to any one of claims 1 to 30, wherein the amount of the excipient is about 5% by weight relative to the weight of the compound of formula (I-a).

33. The pharmaceutical composition of any one of claims 30-32, wherein the excipient is mannitol.

34. The pharmaceutical composition of any one of claims 30 to 32, wherein the excipient is lactose.

35. A pharmaceutical composition comprising particles, wherein the particles comprise a compound of formula (I-A),

or a pharmaceutically acceptable salt thereof, a cyclodextrin, and a filler.

36. The pharmaceutical composition of claim 35, wherein the cyclodextrin is selected from the group consisting of alkyl cyclodextrins, hydroxyalkyl cyclodextrins, carboxyalkyl cyclodextrins, and sulfoalkyl ether cyclodextrins.

37. The pharmaceutical composition of claim 35 or 36, wherein the cyclodextrin is hydroxypropyl β -cyclodextrin.

38. The pharmaceutical composition of claim 35 or 36, wherein the cyclodextrin is sulfobutylether beta-cyclodextrin.

39. The pharmaceutical composition of any one of claims 35 to 38, wherein the bulking agent is a sugar (e.g., a saccharide (e.g., a monosaccharide, disaccharide, or polysaccharide)) or a sugar alcohol.

40. The pharmaceutical composition of any one of claims 35 to 39, wherein the filler is sucrose, lactose, trehalose, dextran, erythritol, arabitol, xylitol, sorbitol, or mannitol, or a combination thereof.

41. The pharmaceutical composition of any one of claims 35-40, wherein the bulking agent is mannitol.

42. The pharmaceutical composition of any one of claims 35-40, wherein the filler is lactose.

43. The pharmaceutical composition of any one of claims 35-42, wherein the bulking agent is a lyoprotectant.

44. The pharmaceutical composition according to any one of claims 35 to 43, wherein the concentration of the compound of formula (I-A) is from about 0.1 to about 10% by weight of the composition.

45. The pharmaceutical composition according to any one of claims 35 to 44, wherein the concentration of the compound of formula (I-A) is about 1% by weight of the composition.

46. The pharmaceutical composition according to any one of claims 35 to 44, wherein the concentration of the compound of formula (I-A) is about 0.3% by weight of the composition.

47. The pharmaceutical composition according to any one of claims 35 to 46, wherein the amount of cyclodextrin is about 0.1% to about 10% (e.g., about 0.5% to about 6% (e.g., about 0.7% to about 5.6% (e.g., about 2.1% to about 5%) by weight) relative to the weight of the compound of formula (I-A)).

48. The pharmaceutical composition of any one of claims 35 to 47, wherein the amount of cyclodextrin is about 3.5% by weight relative to the weight of the compound of formula (I-A).

49. The pharmaceutical composition of any one of claims 35 to 47, wherein the amount of cyclodextrin is about 5% by weight relative to the weight of the compound of formula (I-A).

50. The pharmaceutical composition of any one of claims 47-49, wherein the cyclodextrin is hydroxypropyl β -cyclodextrin.

51. The pharmaceutical composition according to any one of claims 35 to 50, wherein the filler is in an amount of about 0.1% to about 10% by weight relative to the weight of the compound of formula (I-A).

52. The pharmaceutical composition according to any one of claims 35 to 51, wherein the amount of filler is about 3% by weight relative to the weight of the compound of formula (I-A).

53. The pharmaceutical composition according to any one of claims 35 to 51, wherein the filler is in an amount of about 5% by weight relative to the weight of the compound of formula (I-A).

54. The pharmaceutical composition of any one of claims 51-53, wherein the bulking agent is mannitol.

55. The pharmaceutical composition of any one of claims 51-53, wherein the filler is lactose.

56. A method for preparing an aqueous pharmaceutical composition from the pharmaceutical composition of any one of claims 35 to 55, the method comprising reconstituting the pharmaceutical composition into an aqueous medium, thereby forming the aqueous composition.

57. The method of claim 56, wherein the aqueous medium is deionized water.

58. The method of claim 56 or 57, wherein the aqueous medium comprises sodium chloride.

59. The method of claim 56 or 57, wherein the aqueous medium comprises about 5% dextrose.

60. The method of any one of claims 56-59, wherein the composition is prepared for parenteral administration to a subject in need thereof.

61. The method of any one of claims 56-59, wherein the composition is prepared for intramuscular, subcutaneous, or intravenous administration to a subject in need thereof.

62. A method of treating a thromboembolic disorder in a subject in need thereof, the method comprising administering to the subject an effective amount of the pharmaceutical composition of any one of claims 1-34, wherein the subject's blood is in contact with an artificial surface.

63. A method of reducing the risk of a thromboembolic disorder in a subject in need thereof, the method comprising administering to the subject an effective amount of the pharmaceutical composition of any one of claims 1-34, wherein the subject's blood is in contact with an artificial surface.

64. A method of preventing a thromboembolic disorder in a subject in need thereof, the method comprising administering to the subject an effective amount of the pharmaceutical composition of any one of claims 1-34, wherein the subject's blood is in contact with an artificial surface.

65. The method of any one of claims 62-64, wherein the artificial surface is in contact with blood in the circulatory system of the subject.

66. The method of any one of claims 62-65, wherein the artificial surface is an implantable device, dialysis tubing, cardiopulmonary bypass ring, artificial heart valve, ventricular assist device, small bore graft, central venous catheter, or extracorporeal membrane pulmonary oxygenation (ECMO) apparatus.

67. The method of any one of claims 62-66, wherein the artificial surface causes or is associated with a thromboembolic disorder.

68. The method of any one of claims 62-67, wherein the thromboembolic disorder is venous thromboembolism, deep vein thrombosis, or pulmonary embolism.

69. The method of any one of claims 62-67, wherein the thromboembolic disorder is a blood clot.

70. The method of any one of claims 62-69, further comprising conditioning the artificial surface with a separate dose of the pharmaceutical composition of any one of claims 1-34 prior to contacting the artificial surface with blood in the circulatory system of the subject.

71. The method of any one of claims 62-69, further comprising conditioning the artificial surface with a separate dose of the pharmaceutical composition of any one of claims 1-34 prior to or during administration of the pharmaceutical composition to the subject.

72. The method of any one of claims 62-69, further comprising conditioning the artificial surface with a separate dose of the pharmaceutical composition of any one of claims 1-34 prior to and during administration of the pharmaceutical composition to the subject.

73. The method of any one of claims 62-72, wherein the artificial surface is a cardiopulmonary bypass loop.

74. The method of any one of claims 62-72, wherein the artificial surface is an extracorporeal membrane pulmonary oxygenation (ECMO) apparatus.

75. The method of claim 74, wherein the ECMO apparatus is a venous-venous ECMO apparatus or an arterial-venous ECMO apparatus.

76. A method of preventing or reducing the risk of a thromboembolic disorder in a subject during or after a medical procedure, comprising:

(i) administering to the subject an effective amount of the pharmaceutical composition of any one of claims 1-34 before, during, or after the medical procedure; and

(ii) contacting the subject's blood with an artificial surface;

thereby preventing or reducing the risk of thromboembolic disorders during or after the medical procedure.

77. The method of claim 76, wherein the artificial surface is conditioned with the pharmaceutical composition of any one of claims 1-34 before, during, or after the medical procedure, prior to administering the pharmaceutical composition to the subject.

78. The method of claim 77, wherein the pharmaceutical composition for conditioning the artificial surface further comprises a solution, wherein the solution is selected from the group consisting of saline solution, ringer's solution, and blood.

79. The method of any one of claims 76-78, wherein the thromboembolic disorder is a blood clot.

80. The method of any of claims 76-79, wherein the medical procedure comprises one or more of: i) cardiopulmonary bypass, ii) oxygenating and pumping blood via extracorporeal membrane lung oxygenation, iii) assisting in pumping blood (internal or external), iv) hemodialysis, v) extracorporeal filtering of blood, vi) collecting the subject's blood in a reservoir for subsequent use in an animal or human subject, vii) using a venous or arterial intraluminal catheter, viii) using a device for diagnostic or interventional cardiac catheterization, ix) using an intravascular device, x) using an artificial heart valve, and xi) using an artificial graft.

81. The method of any of claims 76-80, wherein the medical procedure comprises cardiopulmonary bypass.

82. The method of any of claims 76-80, wherein the medical procedure comprises oxygenating and pumping blood via extracorporeal membrane pulmonary oxygenation (ECMO).

83. The method of claim 82, wherein said ECMO is venous-venous ECMO or arterial-venous ECMO.

84. The method of any one of claims 62-83, wherein the subject is in contact with the artificial surface for at least 1 day (e.g., about 2 days, about 3 days, about 4 days, about 5 days, about 6 days, about 1 week, about 10 days, about 2 weeks, about 3 weeks, about 4 weeks, about 2 months, about 3 months, about 6 months, about 9 months, about 1 year).

85. A method of treating blood in a subject in need thereof, the method comprising administering to the subject an effective amount of the pharmaceutical composition of any one of claims 1-34.

86. The method of any one of claims 62-85, wherein the pharmaceutical composition is administered to the subject intravenously.

87. The method of any one of claims 62-85, wherein the pharmaceutical composition is administered to the subject subcutaneously.

88. The method of any one of claims 62-85, wherein the pharmaceutical composition is administered to the subject as a continuous intravenous infusion.

89. The method of any one of claims 62-85, wherein the pharmaceutical composition is administered to the subject via bolus injection.

90. The method of any one of claims 62-89, wherein the subject is a human.

91. The method of any one of claims 62-90, wherein the subject is at elevated risk for a thromboembolic disorder.

92. The method of claim 91, wherein the thromboembolic disorder is the result of a surgical complication.

93. The method of any one of claims 62-92, wherein the subject is or has developed sensitivity to heparin.

94. The method of any one of claims 62-92, wherein the subject is resistant to heparin or has developed resistance to heparin.

95. The method of any one of claims 62-94, wherein the subject is a pediatric subject.

96. The method of any one of claims 62-94, wherein the subject is an adult.

Background

Coagulation is the first line of defense against blood loss following injury. The coagulation "cascade" involves a variety of circulating serine protease zymogens, regulatory cofactors and inhibitors. Each enzyme, once produced from its zymogen, specifically cleaves the next zymogen in the cascade to produce the active protease. This process is repeated until thrombin finally cleaves fibrinopeptides from fibrinogen to produce fibrin, which polymerizes to form a clot. Although effective coagulation limits blood loss at the wound site, it also carries the risk of systemic coagulation leading to massive thrombosis. Under normal conditions, hemostasis maintains a balance between clot formation (coagulation) and clot dissolution (fibrinolysis). However, in certain disease states such as acute myocardial infarction and unstable angina, rupture of established atherosclerotic plaques leads to abnormal thrombosis in the coronary vasculature.

Diseases derived from blood coagulation, such as myocardial infarction, unstable angina, atrial fibrillation, stroke, pulmonary embolism and deep vein thrombosis, are among the major causes of death in developed countries. Current anticoagulant therapies, such as injectable unfractionated Low Molecular Weight (LMW) heparin and orally administered warfarin (coumadin), carry the risk of bleeding episodes and exhibit inter-patient variability, which results in the need to closely monitor and titrate the therapeutic dose. Therefore, there is a great medical need for new anticoagulant drugs that lack some or all of the side effects of currently available drugs.

Factor XIa is an attractive therapeutic target involved in pathways associated with these diseases. Increased levels of factor XIa or factor XIa activity have been observed in several thromboembolic disorders, including venous thrombosis (Meijers et al, n.engl.j.med.342:696,2000), acute myocardial infarction (Minnema et al, ariterioscler wireaway Biol 20:2489,2000), acute coronary syndrome (butinas et al, thrombob Haemost 99:142,2008), coronary artery disease (butinas et al, thrombob Haemost 99:142,2008), chronic obstructive pulmonary disease (Jankowski et al, thrombob Res 127:242,2011), aortic valve stenosis (Blood coaggul fibrosis, 22:473,2011), acute cerebral vascular ischemia (Undas et al, medeur J Invest,42:123,2012), and systolic heart failure due to ischemic disease (zabuccy et al, polawn et al, polwn 120:334,2010). Patients lacking factor XI due to inherited factor XI deficiency show little, if any, ischemic stroke (Salomon et al, Blood,111:4113,2008). At the same time, loss of factor XIa activity leaves one of the pathways initiating coagulation intact, which does not disrupt hemostasis. In humans, factor XI deficiency may lead to mild to moderate bleeding disorders, especially in tissues with high levels of local fibrinolytic activity (such as the urinary tract, nose, mouth and tonsils). Furthermore, hemostasis was almost normal in factor XI deficient mice (Gailani, Blood Cooagul Fibrinolysis,8:134,1997). In addition, inhibition of factor XI has also been found to reduce arterial hypertension as well as other diseases and dysfunctions, including vascular inflammation (Kossmann et al sci. trans. med.9, eaah4923 (2017)).

Thus, compounds that inhibit factor XIa have the potential to prevent or treat a wide range of disorders while avoiding the side effects and therapeutic challenges of drugs that plague other components that inhibit the coagulation pathway. In addition, due to the limited efficacy and adverse side effects of some current therapeutic agents for inhibiting undesirable thrombosis (e.g., deep vein thrombosis, hepatic vein thrombosis, and stroke), improved compounds and methods (e.g., those associated with factor XIa) are needed to prevent or treat undesirable thrombosis.

Another therapeutic target is kallikrein. Human plasma kallikrein is a serine protease that can be responsible for activating several downstream factors (e.g., bradykinin and plasmin) that are critical for coagulation and control of, for example, blood pressure, inflammation, and pain. Kallikrein is expressed, for example, in the prostate, epidermis and Central Nervous System (CNS) and can be involved, for example, in the regulation of semen liquefaction, cleavage of cell adhesion proteins, and neuronal plasticity in the CNS. In addition, kallikrein can be involved in tumorigenesis as well as in the development of cancer and angioedema (e.g., hereditary angioedema). Over-activation of the kallikrein-kinin pathway can lead to a variety of disorders, including angioedema, such as hereditary angioedema (Schneider et al, j. To date, the treatment options for HAE have been limited (e.g. WO 2003/076458).

Pharmaceutical compositions comprising a therapeutic agent (e.g., a compound that inhibits factor Xia or kallikrein as described herein) can be administered to a human subject in need thereof by various modes of administration, e.g., parenteral (e.g., intravenous, intramuscular, subcutaneous) delivery. Particularly for intravenous or subcutaneous administration, the compositions are generally preferably pH stable or chemically stable over an extended period of time.

Disclosure of Invention

The present invention relates, in part, to pharmaceutical compositions comprising compounds of formula (I-a):

also referred to herein as "compound 1," or a pharmaceutically acceptable salt thereof.

Thus, in one aspect, provided herein is an aqueous pharmaceutical composition comprising a compound of formula (I-A),

or a pharmaceutically acceptable salt thereof, a cyclodextrin and an excipient.

In some embodiments, the pharmaceutical composition comprises a compound of formula (I-a), a cyclodextrin, and an excipient. In some embodiments, the cyclodextrin is selected from the group consisting of alkyl cyclodextrins, hydroxyalkyl cyclodextrins, carboxyalkyl cyclodextrins, and sulfoalkyl ether cyclodextrins. In some embodiments, the cyclodextrin is hydroxypropyl β -cyclodextrin. In some embodiments, the cyclodextrin is sulfobutylether beta-cyclodextrin.

In some embodiments, the excipient is a sugar (e.g., a saccharide (e.g., a monosaccharide, disaccharide, or polysaccharide)) or a sugar alcohol. In some embodiments, the excipient is sucrose, lactose, trehalose, dextran, erythritol, arabitol, xylitol, sorbitol, or mannitol, or a combination thereof. In some embodiments, the excipient is mannitol. In some embodiments, the excipient is lactose.

In some embodiments, the pharmaceutical composition further comprises a buffering agent. In some embodiments, the buffering agent is a single protic acid or a polyprotic acid, or a combination thereof. In some embodiments, the buffer is a solution of one or more substances. In some embodiments, the buffer is a solution of a salt of a weak acid and a weak base. In some embodiments, the buffer is a solution of a salt of a weak acid and a strong base. In some embodiments, the buffer is selected from the group consisting of a maleate buffer, a citrate buffer, and a phosphate buffer. In some embodiments, the buffer is a phosphate buffer. In some embodiments, the phosphate buffer is a solution of monosodium phosphate, disodium phosphate, trisodium phosphate, or a combination thereof.

In some embodiments, the pharmaceutical compositions described herein further comprise a solubilizing agent. In some embodiments, the solubilizing agent is a polyoxyethylene sorbitan ester (e.g., a polyoxyethylene sorbitan ester)20) Or polyethylene glycol (e.g., PEG 400).

In some embodiments, the pH is from about 2 to about 8. In some embodiments, the pH is about 6.8.

In some embodiments, the concentration of the compound of formula (I-A) is from about 0.1mg/mL to about 100 mg/mL. For example, the concentration of the compound of formula (I-A) may be about 10 mg/mL.

In some embodiments, the buffer is at a concentration of about 1mM to about 500 mM. For example, the concentration of the buffer may be about 10 mM. In some embodiments, the buffer is a phosphate buffer.

In some embodiments, the amount of cyclodextrin is about 0.1 wt% to about 10 wt% (e.g., about 0.5 wt% to about 6 wt% (e.g., about 0.7 wt% to about 5.6 wt% (e.g., about 2.1 wt% to about 5 wt%)) relative to the weight of the compound of formula (I-a)). For example, the amount of cyclodextrin is about 3.5 wt% relative to the weight of the compound of formula (I-A). As another example, the amount of cyclodextrin is about 5 wt% relative to the weight of the compound of formula (I-a). In some embodiments, the cyclodextrin is hydroxypropyl β -cyclodextrin.

In some embodiments, the amount of excipient is about 0.1% to about 10% by weight relative to the weight of the compound of formula (I-a). For example, the amount of excipient is about 3% by weight relative to the weight of the compound of formula (I-a). As another example, the amount of excipient is about 5% by weight relative to the weight of the compound of formula (I-a). In some embodiments, the excipient is mannitol. In other embodiments, the excipient is lactose.

In another aspect, provided herein is a pharmaceutical composition comprising particles, wherein the particles comprise a compound of formula (I-A),

or a pharmaceutically acceptable salt thereof, a cyclodextrin, and a filler.

In some embodiments, the cyclodextrin is selected from the group consisting of alkyl cyclodextrins, hydroxyalkyl cyclodextrins, carboxyalkyl cyclodextrins, and sulfoalkyl ether cyclodextrins. In some embodiments, the cyclodextrin is hydroxypropyl β -cyclodextrin. In some embodiments, the cyclodextrin is sulfobutylether beta-cyclodextrin.

In some embodiments, the bulking agent is a sugar (e.g., a saccharide (e.g., a monosaccharide, disaccharide, or polysaccharide)) or a sugar alcohol. In some embodiments, the bulking agent is sucrose, lactose, trehalose, dextran, erythritol, arabitol, xylitol, sorbitol, or mannitol, or a combination thereof. In some embodiments, the bulking agent is mannitol. In some embodiments, the filler is lactose.

In some embodiments, the bulking agent is a lyoprotectant.

In some embodiments, the concentration of the compound of formula (I-a) is from about 0.1 to about 10% by weight of the composition. For example, the concentration of the compound of formula (I-A) is about 1% by weight of the composition. As another example, the concentration of the compound of formula (I-A) is about 0.3% by weight of the composition.

In some embodiments, the amount of cyclodextrin is about 0.1 wt% to about 10 wt% (e.g., about 0.5 wt% to about 6 wt% (e.g., about 0.7 wt% to about 5.6 wt% (e.g., about 2.1 wt% to about 5 wt%)) relative to the weight of the compound of formula (I-a)). For example, the amount of cyclodextrin is about 3.5 wt% relative to the weight of the compound of formula (I-A). As another example, the amount of cyclodextrin is about 5 wt% relative to the weight of the compound of formula (I-a). In some embodiments, the cyclodextrin is hydroxypropyl β -cyclodextrin.

In some embodiments, the amount of filler is about 0.1% to about 10% by weight relative to the weight of the compound of formula (I-a). For example, the amount of filler is about 3% by weight relative to the weight of the compound of formula (I-A). As another example, the amount of filler is about 5 wt% relative to the weight of the compound of formula (I-a). In some embodiments, the bulking agent is mannitol. In other embodiments, the filler is lactose.

In another aspect, provided herein is a method for preparing an aqueous pharmaceutical composition from a pharmaceutical composition comprising particles, wherein the particles comprise a compound of formula (I-a) or a pharmaceutically acceptable salt thereof, a cyclodextrin, and a filler, the method comprising reconstituting the pharmaceutical composition into an aqueous medium, thereby forming an aqueous composition.

In some embodiments, the aqueous medium is deionized water. In some embodiments, the aqueous medium comprises sodium chloride. In some embodiments, the aqueous medium comprises about 5% dextrose. In some embodiments, the composition is prepared for parenteral administration to a subject in need thereof. For example, the compositions are prepared for intramuscular, subcutaneous, or intravenous administration to a subject in need thereof.

The compositions described herein are useful for treating, preventing, or reducing the risk of the disorders described herein. In some embodiments, the methods described herein can include those in which the subject's blood is in contact with an artificial surface.

Accordingly, in one aspect, provided herein is a method of treating a thromboembolic disorder in a subject in need thereof, the method comprising administering to the subject an effective amount of a pharmaceutical composition described herein, wherein the subject's blood is in contact with an artificial surface.

In another aspect, provided herein is a method of reducing the risk of a thromboembolic disorder in a subject in need thereof, the method comprising administering to the subject an effective amount of the pharmaceutical composition described herein, wherein the subject's blood is in contact with an artificial surface.

Also provided herein is a method of preventing a thromboembolic disorder in a subject in need thereof, the method comprising administering to the subject an effective amount of the pharmaceutical composition described herein, wherein the subject's blood is in contact with an artificial surface.

In some embodiments of the methods described herein, the artificial surface is in contact with blood in the circulatory system of the subject.

In some embodiments, the artificial surface is an implantable device, a dialysis tubing, a cardiopulmonary bypass circuit, an artificial heart valve, a ventricular assist device, a small bore graft, a central venous catheter, or an extracorporeal membrane pulmonary oxygenation (ECMO) apparatus.

In some embodiments, the artificial surface causes or is associated with a thromboembolic disorder.

In some embodiments, the thromboembolic disorder is venous thromboembolism, deep vein thrombosis, or pulmonary embolism.

In some embodiments, the thromboembolic disorder is a blood clot.

In some embodiments, the methods described herein further comprise conditioning the artificial surface with a separate dose of a pharmaceutical composition described herein before contacting the artificial surface with blood in the circulatory system of the subject.

In some embodiments, the methods described herein further comprise conditioning the artificial surface with a separate dose of a pharmaceutical composition described herein before or during administration of the pharmaceutical composition to the subject.

In some embodiments, the methods described herein further comprise conditioning the artificial surface with a separate dose of a pharmaceutical composition described herein before and during administration of the pharmaceutical composition to the subject.

In some embodiments of the methods described herein, the artificial surface is a cardiopulmonary bypass loop.

In some embodiments of the methods described herein, the artificial surface is an extracorporeal membrane pulmonary oxygenation (ECMO) apparatus. In some embodiments, the ECMO device is a venous-venous ECMO device or an arterial-venous ECMO device.

In another aspect, disclosed herein is a method of preventing or reducing the risk of a thromboembolic disorder in a subject during or after a medical procedure, the method comprising:

(i) administering to the subject an effective amount of a pharmaceutical composition described herein before, during, or after the medical procedure; and

(ii) contacting the subject's blood with an artificial surface;

thereby preventing or reducing the risk of thromboembolic disorders during or after medical procedures.

In some embodiments, the artificial surface is conditioned (conditioned) with a pharmaceutical composition described herein before, during, or after a medical procedure, prior to administering the pharmaceutical composition to a subject.

In some embodiments, the pharmaceutical composition for conditioning an artificial surface further comprises a solution, wherein the solution is selected from the group consisting of saline solution, ringer's solution, and blood.

In some embodiments, the thromboembolic disorder is a blood clot.

In some embodiments, the medical procedure comprises one or more of: i) cardiopulmonary bypass, ii) oxygenating and pumping blood via extracorporeal membrane lung oxygenation, iii) assisting in pumping blood (internal or external), iv) hemodialysis, v) extracorporeal filtering of blood, vi) collecting the subject's blood in a reservoir for subsequent use in an animal or human subject, vii) using a venous or arterial intraluminal catheter, viii) using a device for diagnostic or interventional cardiac catheterization, ix) using an intravascular device, x) using an artificial heart valve, and xi) using an artificial graft.

In some embodiments, the medical procedure comprises cardiopulmonary bypass.

In some embodiments, the medical procedure comprises oxygenating and pumping blood via extracorporeal membrane pulmonary oxygenation (ECMO). In some embodiments, the ECMO is a venous-venous ECMO or an arterial-venous ECMO.

In some embodiments of the methods described herein, the subject is in contact with the artificial surface for at least 1 day (e.g., about 2 days, about 3 days, about 4 days, about 5 days, about 6 days, about 1 week, about 10 days, about 2 weeks, about 3 weeks, about 4 weeks, about 2 months, about 3 months, about 6 months, about 9 months, about 1 year).

In another aspect, provided herein is a method of treating blood in a subject in need thereof, the method comprising administering to the subject an effective amount of a pharmaceutical composition described herein.

In some embodiments of the methods described herein, the pharmaceutical composition is administered to the subject intravenously. In other embodiments of the methods described herein, the pharmaceutical composition is administered to the subject subcutaneously. In some embodiments, the pharmaceutical composition is administered to the subject as a continuous intravenous infusion. In some embodiments, the pharmaceutical composition is administered to the subject via bolus injection.

In some embodiments, the subject is a human. In some embodiments, the subject has an elevated risk of a thromboembolic disorder. In some embodiments, the thromboembolic disorder is the result of a surgical complication. In some embodiments, the subject is or has developed to be sensitive to heparin. In some embodiments, the subject is resistant to heparin or has developed resistance to heparin.

In another aspect, the invention also relates to a method of reducing the risk of stroke (e.g., ischemia, e.g., a transient ischemic event, large vessel acute ischemic stroke) in a subject having an ischemic event (e.g., a transient ischemic event), the method comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, administration reduces the risk of stroke (e.g., large vessel acute ischemic stroke) in the subject compared to a subject not administered the composition. In some embodiments, the administration reduces the risk of atrial fibrillation in the subject compared to a subject not administered the composition.

In one aspect, the invention relates to a method of reducing non-central nervous system systemic embolism (e.g., ischemia, e.g., a transient ischemic event) in a subject having an ischemic event (e.g., a transient ischemic event), the method comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, the administration reduces non-central nervous system systemic embolism in the subject compared to a subject not administered the composition.

In one aspect, the invention relates to a method of treating deep vein thrombosis, the method comprising administering to a subject having an ischemic event (e.g., a transient ischemic event) an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof).

In one aspect, the invention relates to a method of preventing deep vein thrombosis, the method comprising administering to a subject having deep vein thrombosis (e.g., a subject previously treated for deep vein thrombosis) an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof).

In one aspect, the invention relates to a method of reducing the risk of recurrence of deep vein thrombosis, the method comprising administering to a subject having deep vein thrombosis (e.g., a subject previously treated for deep vein thrombosis) an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, the administration reduces the risk of recurrence of deep vein thrombosis in the subject compared to a subject not administered the composition.

In one aspect, the invention relates to a method of preventing venous thromboembolism (e.g., deep vein thrombosis or pulmonary embolism) in a subject, comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, the subject is undergoing surgery. In some embodiments, the compositions described herein are administered to a subject before, during, or after surgery. In some embodiments, the subject is undergoing a knee or hip replacement surgery. In some embodiments, the subject is undergoing orthopedic surgery. In some embodiments, the subject is undergoing pulmonary surgery. In some embodiments, the subject is treating cancer, e.g., by surgery. In some embodiments, the subject has a chronic medical condition. In some embodiments, the venous thromboembolism is associated with cancer. In some embodiments, compound 1 or a pharmaceutically acceptable salt thereof in the compositions described herein is the primary agent for preventing deep vein thrombosis or venous thromboembolism. In some embodiments, compound 1 or a pharmaceutically acceptable salt thereof in the compositions described herein is used as an extended therapy.

In one aspect, the invention relates to a method of reducing the risk of venous thromboembolism (e.g., deep vein thrombosis or pulmonary embolism) in a subject, comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, the subject is undergoing surgery. In some embodiments, the compositions described herein are administered to a subject after surgery. In some embodiments, the subject is undergoing a knee or hip replacement surgery. In some embodiments, the subject is undergoing orthopedic surgery. In some embodiments, the subject is undergoing pulmonary surgery. In some embodiments, the subject is treating cancer, e.g., by surgery. In some embodiments, the subject has a chronic medical condition. In some embodiments, the thromboembolic disorder is associated with cancer. In some embodiments, compound 1 or a pharmaceutically acceptable salt thereof in the compositions described herein is the primary agent that reduces the risk of a thromboembolic disorder. In some embodiments, compound 1 or a pharmaceutically acceptable salt thereof in the compositions described herein is used as an extended therapy.

In one aspect, the invention relates to a method of reducing the risk of stroke (e.g., large vessel acute ischemic stroke) or systemic embolism in a subject in need thereof, the method comprising administering to the subject an effective amount of a composition described herein, e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has atrial fibrillation (e.g., non-valvular atrial fibrillation). In some embodiments, the subject has a renal disorder (e.g., end stage renal disease).

In one aspect, the invention relates to a method of preventing stroke (e.g., large vessel acute ischemic stroke) or systemic embolism in a subject in need thereof, the method comprising administering to the subject an effective amount of a composition described herein, e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has atrial fibrillation (e.g., non-valvular atrial fibrillation). In some embodiments, the subject has a renal disorder (e.g., end stage renal disease).

In one aspect, the invention relates to a method of reducing the risk of recurrence of a pulmonary embolism (e.g., a symptomatic pulmonary embolism), the method comprising administering to a subject with a pulmonary embolism (e.g., a subject previously treated for a pulmonary embolism) an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, the administration reduces the risk of recurrence of pulmonary embolism in the subject compared to a subject not administered the composition.

In one aspect, the invention relates to a method of preventing pulmonary embolism in a subject having pulmonary embolism (e.g., a subject previously treated for pulmonary embolism), the method comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof).

In one aspect, the invention relates to a method of reducing the risk of recurrence of a pulmonary embolism (e.g., a symptomatic pulmonary embolism), the method comprising administering to a subject having deep vein thrombosis (e.g., a subject previously treated for deep vein thrombosis) an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, the administration reduces the risk of recurrence of pulmonary embolism in the subject compared to a subject not administered the composition.

In one aspect, the invention relates to a method of preventing pulmonary embolism in a subject having deep vein thrombosis (e.g., a subject previously treated for deep vein thrombosis), the method comprising administering to the subject a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof).

In one aspect, the invention features a method of treating deep vein thrombosis in a subject who has previously been administered an anticoagulant agent, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, the anticoagulant is administered parenterally for 5-10 days.

In one aspect, the invention features a method of treating pulmonary embolism in a subject who has been previously administered an anticoagulant, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, the anticoagulant is administered parenterally for 5-10 days.

In one aspect, the invention relates to a method of treating a subject having an ischemic event (e.g., transient ischemia), the method comprising: administering to the subject a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, the compound is administered to the subject within 24 hours or less, e.g., 12, 10, 9, 8, 7, 6 hours or less, of the occurrence of an ischemic event in the subject.

In one aspect, the invention relates to a method of treating a subject having an ischemic event (e.g., transient ischemia), the method comprising: administering a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof) to a subject. In some embodiments, the composition is administered to the subject more than 2 hours to 12 hours, e.g., more than 2 hours to 10 hours or less, more than 2 hours to 8 hours or less, after the occurrence of an ischemic event in the subject.

In one aspect, the invention relates to a method of treating hypertension (e.g., arterial hypertension) in a subject, the method comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, hypertension (e.g., arterial hypertension) results in atherosclerosis. In some embodiments, the hypertension is pulmonary hypertension.

In one aspect, the invention relates to a method of reducing the risk of hypertension (e.g., arterial hypertension) in a subject, the method comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, hypertension (e.g., arterial hypertension) results in atherosclerosis. In some embodiments, the hypertension is pulmonary hypertension.

In one aspect, the invention relates to a method of preventing hypertension (e.g., arterial hypertension) in a subject, the method comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, hypertension (e.g., arterial hypertension) results in atherosclerosis. In some embodiments, the hypertension is pulmonary hypertension.

In one aspect, the invention relates to a method of reducing inflammation in a subject, the method comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, the inflammation is vascular inflammation. In some embodiments, the vascular inflammation is accompanied by atherosclerosis. In some embodiments, in the subject, the vascular inflammation is accompanied by a thromboembolic disorder. In some embodiments, the vascular inflammation is angiotensin II-induced vascular inflammation.

In one aspect, the invention relates to a method of preventing vascular leukocyte infiltration in a subject, the method comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof).

In one aspect, the invention relates to a method of preventing angiotensin II-induced endothelial dysfunction in a subject, the method comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof).

In one aspect, the invention relates to a method of preventing thrombin propagation in a subject, the method comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, thrombin transmission occurs on platelets.

In one aspect, the invention relates to a method of treating hypertension-associated renal dysfunction in a subject, the method comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof).

In one aspect, the invention relates to a method of preventing hypertension-associated renal dysfunction in a subject, the method comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof).

In one aspect, the invention relates to a method of reducing the risk of hypertension-associated renal dysfunction in a subject, the method comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof).

In one aspect, the invention relates to a method of treating renal fibrosis in a subject, the method comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof).

In one aspect, the invention relates to a method of preventing renal fibrosis in a subject, the method comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof).

In one aspect, the invention relates to a method of reducing the risk of renal fibrosis in a subject, the method comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof).

In one aspect, the invention relates to a method of treating kidney injury in a subject, the method comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof).

In one aspect, the invention relates to a method of preventing renal injury in a subject, the method comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof).

In one aspect, the invention relates to a method of reducing the risk of renal injury in a subject, the method comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof).

In one aspect, the invention relates to a method of inhibiting factor XIa in a subject, the method comprising administering to a subject who has suffered ischemia an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, the ischemia is coronary ischemia.

In some embodiments, the subject is a mammal (e.g., a human).

In some embodiments, the subject is undergoing surgery (e.g., knee replacement surgery or hip replacement surgery). In some embodiments, the ischemia is coronary ischemia. In some embodiments, the subject is a subject with non-valvular atrial fibrillation. In some embodiments, the subject has one or more of the following risk factors for stroke: past stroke (e.g., ischemic, unknown, hemorrhagic), transient ischemic attack, or non-CNS systemic embolism. In some embodiments, the subject has one or more of the following risk factors for stroke: 75 years old or older, hypertension, heart failure or left ventricular ejection fraction (e.g., less than or equal to 35%), or diabetes.

In some embodiments, the compositions are administered by oral or parenteral (e.g., intravenous) administration. In some embodiments, the composition is administered by oral administration. In some embodiments, the composition is administered by parenteral (e.g., intravenous) administration. In some embodiments, the composition is administered by subcutaneous administration.

In some embodiments, the composition is administered prior to an ischemic event (e.g., to a subject at risk of an ischemic event).

In some embodiments, the composition is administered after an ischemic event (e.g., a transient ischemic event). In some embodiments, the composition is administered about 1,2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, or 14 days or more after an ischemic event (e.g., a transient ischemic event). In some embodiments, the composition is administered about 1,2, 3, 4, 5, 6, 7, or 8 weeks or more after an ischemic event (e.g., a transient ischemic event).

In some embodiments, the composition is administered in combination with an additional therapeutic agent. In some embodiments, the additional therapeutic agent is administered after administration of the composition. In some embodiments, the additional therapeutic agent is administered orally. In some embodiments, the additional therapeutic agent is administered at least 1,2, 3, 4, 5, 6, 7, 8, 10, 12, 14, 16, 18, 20, or 24 hours or more after administration of the composition. In some embodiments, the additional therapeutic agent is administered at least 1,2, 3, 4, 5, 6, 7, 14, 21, or 28 days or more after administration of the composition. In some embodiments, the additional therapeutic agent is administered about 1 day, about 2 days, about 3 days, about 4 days, about 5 days, about 6 days, about 7 days, or more after administration of the composition.

In some embodiments, the additional therapeutic agent is administered chronically (e.g., about 1 day, about 2 days, about 3 days, about 4 days, about 5 days, about 6 days, about 7 days, about 8 days, about 9 days, about 10 days, about 11 days, about 12 days, about 13 days, or about 14 days or more) after administration of the composition.

In some embodiments, the additional therapeutic agent treats side effects (e.g., active pathological bleeding or severe hypersensitivity (e.g., anaphylaxis), spinal and/or epidural hematoma, gastrointestinal disorders (e.g., epigastric pain, dyspepsia, dental pain), systemic disorders and conditions at the site of administration (e.g., fatigue), infections and infestations (e.g., sinusitis, urinary tract infections), musculoskeletal and connective tissue disorders (e.g., back pain, osteoarthritis), respiratory, thoracic and mediastinal disorders (e.g., oropharyngeal pain), injury, toxic and surgical complications (e.g., wound secretion), musculoskeletal and connective tissue disorders (e.g., limb pain, muscle spasm), nervous system disorders (e.g., syncope), skin and subcutaneous tissue disorders (e.g., itch, blisters), blood and lymphatic system disorders (e.g., agranulocytosis), Gastrointestinal disorders (e.g., retroperitoneal hemorrhage), hepatobiliary disorders (e.g., jaundice, cholestasis, cytotoxic hepatitis), immune system disorders (e.g., allergy, anaphylaxis, anaphylactic shock, angioedema), nervous system disorders (e.g., cerebral hemorrhage, subdural hematoma, epidural hematoma, hemiparesis), skin and subcutaneous tissue disorders (e.g., stevens-johnson syndrome).

In some embodiments, the additional therapeutic agent is an NSAID (e.g., aspirin or naproxen), a platelet aggregation inhibitor (e.g., clopidogrel), or an anticoagulant (e.g., warfarin or enoxaparin).

In some embodiments, the additional therapeutic agent results in an additive therapeutic effect. In some embodiments, the additional therapeutic agent results in a synergistic therapeutic effect.

In another aspect, the invention features a method of modulating (e.g., inhibiting) factor XIa in a patient. The method comprises the following steps: administering to a patient in need thereof an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof) thereby modulating (e.g., inhibiting) factor XIa.

In another aspect, the invention features a method of treating a thromboembolic disorder in a subject in need thereof. The method comprises administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof). The thromboembolic disorder may be an arterial cardiovascular thromboembolic disorder, arterial thrombosis, a venous cardiovascular thromboembolic disorder, and a thromboembolic disorder in a ventricle; including unstable angina, acute coronary syndrome, primary myocardial infarction, recurrent myocardial infarction, ischemia (e.g., coronary ischemia, sudden ischemic death, or transient ischemic attack), stroke (e.g., large vessel acute ischemic stroke), atherosclerosis, peripheral arterial occlusive disease, venous thromboembolism, venous thrombosis, deep vein thrombosis, thrombophlebitis, arterial embolism, coronary thrombosis, cerebral embolism, renal embolism, pulmonary embolism, and thrombosis resulting from (a) artificial heart valves or other implants, (b) indwelling catheters, (c) stents, (d) cardiopulmonary bypass, (e) hemodialysis, or (f) other procedures in which blood is exposed to artificial surfaces that promote thrombosis.

In another aspect, the invention features a method of preventing a thromboembolic disorder in a subject. The method comprises administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof). The thromboembolic disorder may be an arterial cardiovascular thromboembolic disorder, arterial thrombosis, a venous cardiovascular thromboembolic disorder, and a thromboembolic disorder in a ventricle; including unstable angina, acute coronary syndrome, primary myocardial infarction, recurrent myocardial infarction, ischemia (e.g., coronary ischemia, sudden ischemic death, or transient ischemic attack), stroke (e.g., large vessel acute ischemic stroke), atherosclerosis, peripheral arterial occlusive disease, venous thromboembolism, venous thrombosis, deep vein thrombosis, thrombophlebitis, arterial embolism, coronary thrombosis, cerebral embolism, renal embolism, pulmonary embolism, and thrombosis resulting from (a) artificial heart valves or other implants, (b) indwelling catheters, (c) stents, (d) cardiopulmonary bypass, (e) hemodialysis, or (f) other procedures in which blood is exposed to artificial surfaces that promote thrombosis.

In another aspect, the invention features a method of reducing the risk of a thromboembolic disorder in a subject. The method comprises administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof). The thromboembolic disorder may be an arterial cardiovascular thromboembolic disorder, arterial thrombosis, a venous cardiovascular thromboembolic disorder, and a thromboembolic disorder in a ventricle; including unstable angina, acute coronary syndrome, primary myocardial infarction, recurrent myocardial infarction, ischemia (e.g., coronary ischemia, sudden ischemic death, or transient ischemic attack), stroke (e.g., large vessel acute ischemic stroke), atherosclerosis, peripheral arterial occlusive disease, venous thromboembolism, venous thrombosis, deep vein thrombosis, thrombophlebitis, arterial embolism, coronary thrombosis, cerebral embolism, renal embolism, pulmonary embolism, and thrombosis resulting from (a) artificial heart valves or other implants, (b) indwelling catheters, (c) stents, (d) cardiopulmonary bypass, (e) hemodialysis, or (f) other procedures in which blood is exposed to artificial surfaces that promote thrombosis.

In one aspect, the invention relates to a method of treating end-stage renal disease in a subject, the method comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof).

In one aspect, the invention relates to a method of preventing end-stage renal disease in a subject, the method comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof).

In one aspect, the invention relates to a method of reducing the risk of end stage renal disease in a subject, the method comprising administering to the subject an effective amount of a composition described herein (e.g., a composition comprising compound 1 or a pharmaceutically acceptable salt thereof).

In another aspect, the invention features a method of treating a thromboembolic disorder in a subject in need thereof, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof), wherein the subject is exposed to an artificial surface. In some embodiments, the artificial surface contacts the blood of the subject. In some embodiments, the artificial surface is an extracorporeal surface. In some embodiments, the artificial surface is an artificial surface of an implantable device (e.g., a mechanical valve). In some embodiments, the artificial surface is an artificial surface of a dialysis tubing. In some embodiments, the artificial surface is an artificial surface of a cardiopulmonary bypass annulus. In some embodiments, the artificial surface is an artificial surface of an artificial heart valve. In some embodiments, the artificial surface is an artificial surface of a ventricular assist device. In some embodiments, the artificial surface is an artificial surface of a small-caliber graft. In some embodiments, the artificial surface is an artificial surface of a central venous catheter. In some embodiments, the artificial surface is an artificial surface of an extracorporeal membrane pulmonary oxygenation (ECMO) apparatus. In some embodiments, the artificial surface causes or is associated with a thromboembolic disorder. In some embodiments, the thromboembolic disorder is venous thromboembolism. In some embodiments, the thromboembolic disorder is deep vein thrombosis. In some embodiments, the thromboembolic disorder is pulmonary embolism.

In another aspect, the invention features a method of reducing the risk of a thromboembolic disorder in a subject in need thereof, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1, or a pharmaceutically acceptable salt thereof), wherein the subject is exposed to an artificial surface. In some embodiments, the artificial surface contacts the blood of the subject. In some embodiments, the artificial surface is an extracorporeal surface. In some embodiments, the artificial surface is an artificial surface of an implantable device (e.g., a mechanical valve). In some embodiments, the artificial surface is an artificial surface of a dialysis tubing. In some embodiments, the artificial surface is an artificial surface of a cardiopulmonary bypass annulus. In some embodiments, the artificial surface is an artificial surface of an artificial heart valve. In some embodiments, the artificial surface is an artificial surface of a ventricular assist device. In some embodiments, the artificial surface is an artificial surface of a small-caliber graft. In some embodiments, the artificial surface is an artificial surface of a central venous catheter. In some embodiments, the artificial surface is an artificial surface of an extracorporeal membrane pulmonary oxygenation (ECMO) apparatus. In some embodiments, the artificial surface causes or is associated with a thromboembolic disorder. In some embodiments, the thromboembolic disorder is venous thromboembolism. In some embodiments, the thromboembolic disorder is deep vein thrombosis. In some embodiments, the thromboembolic disorder is pulmonary embolism.

In another aspect, the invention features a method of preventing a thromboembolic disorder in a subject in need thereof, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1, or a pharmaceutically acceptable salt thereof), wherein the subject is exposed to an artificial surface. In some embodiments, the artificial surface contacts the blood of the subject. In some embodiments, the artificial surface is an extracorporeal surface. In some embodiments, the artificial surface is an artificial surface of an implantable device (e.g., a mechanical valve). In some embodiments, the artificial surface is an artificial surface of a dialysis tubing. In some embodiments, the artificial surface is an artificial surface of a cardiopulmonary bypass annulus. In some embodiments, the artificial surface is an artificial surface of an artificial heart valve. In some embodiments, the artificial surface is an artificial surface of a ventricular assist device. In some embodiments, the artificial surface is an artificial surface of a small-caliber graft. In some embodiments, the artificial surface is an artificial surface of a central venous catheter. In some embodiments, the artificial surface is an artificial surface of an extracorporeal membrane pulmonary oxygenation (ECMO) apparatus. In some embodiments, the artificial surface causes or is associated with a thromboembolic disorder. In some embodiments, the thromboembolic disorder is venous thromboembolism. In some embodiments, the thromboembolic disorder is deep vein thrombosis. In some embodiments, the thromboembolic disorder is pulmonary embolism.

In another aspect, the invention features a method of treating atrial fibrillation in a subject in need thereof, including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, the subject is also in need of dialysis, e.g., renal dialysis. In some embodiments, the compositions described herein are administered to a subject while the subject is undergoing dialysis. In some embodiments, the composition is administered to the subject before or after receiving dialysis. In some embodiments, the patient has end stage renal disease. In some embodiments, the subject does not require dialysis, e.g., renal dialysis. In some embodiments, the patient is at high risk of bleeding. In some embodiments, atrial fibrillation is associated with another thromboembolic disorder, such as a blood clot.

In another aspect, the invention features a method of reducing the risk of atrial fibrillation in a subject in need thereof, including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, the subject is at high risk of developing atrial fibrillation. In some embodiments, the subject is also in need of dialysis, e.g., renal dialysis. In some embodiments, the compositions described herein are administered to a subject while the subject is undergoing dialysis. In some embodiments, the composition is administered to the subject before or after receiving dialysis. In some embodiments, the patient has end stage renal disease. In some embodiments, the subject does not require dialysis, e.g., renal dialysis. In some embodiments, the patient is at high risk of bleeding. In some embodiments, atrial fibrillation is associated with another thromboembolic disorder, such as a blood clot.

In another aspect, the invention features a method of preventing atrial fibrillation in a subject in need thereof, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, the subject is at high risk of developing atrial fibrillation. In some embodiments, the subject is also in need of dialysis, e.g., renal dialysis. In some embodiments, the compositions described herein are administered to a subject while the subject is undergoing dialysis. In some embodiments, the composition is administered to the subject before or after receiving dialysis. In some embodiments, the patient has end stage renal disease. In some embodiments, the subject does not require dialysis, e.g., renal dialysis. In some embodiments, the patient is at high risk of bleeding. In some embodiments, atrial fibrillation is associated with another thromboembolic disorder, such as a blood clot.

In another aspect, the invention features a method of treating heparin-induced thrombocytopenia in a subject in need thereof, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof).

In another aspect, the invention features a method of reducing the risk of heparin-induced thrombocytopenia in a subject in need thereof, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof).

In another aspect, the invention features a method of preventing heparin-induced thrombocytopenia in a subject in need thereof, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof).

In another aspect, the invention features a method of treating heparin-induced thrombocytopenic thrombosis in a subject in need thereof, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof).

In another aspect, the invention features a method of reducing the risk of heparin-induced thrombocytopenic thrombosis in a subject in need thereof, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof).

In another aspect, the invention features a method of preventing heparin-induced thrombocytopenic thrombosis in a subject in need thereof, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof).

In another aspect, the invention features a method of preventing a thromboembolic disorder in a subject in need thereof, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1, or a pharmaceutically acceptable salt thereof), wherein the subject has cancer or is receiving a chemotherapeutic agent. In some embodiments, the subjects receive chemotherapy concurrently. In some embodiments, the subject has an elevated lactase dehydrogenase level. In some embodiments, the thromboembolic disorder is venous thromboembolism. In some embodiments, the thromboembolic disorder is deep vein thrombosis. In some embodiments, the thromboembolic disorder is pulmonary embolism.

In another aspect, the invention features a method of treating a thrombotic microangiopathy in a subject in need thereof, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, the thrombotic microangiopathy is Hemolytic Uremic Syndrome (HUS). In some embodiments, the thrombotic microangiopathy is Thrombotic Thrombocytopenic Purpura (TTP).

In another aspect, the invention features a method of reducing the risk of thrombotic microangiopathy in a subject in need thereof, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, the thrombotic microangiopathy is Hemolytic Uremic Syndrome (HUS). In some embodiments, the thrombotic microangiopathy is Thrombotic Thrombocytopenic Purpura (TTP).

In another aspect, the invention features a method of preventing thrombotic microangiopathy in a subject in need thereof, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, the thrombotic microangiopathy is Hemolytic Uremic Syndrome (HUS). In some embodiments, the thrombotic microangiopathy is Thrombotic Thrombocytopenic Purpura (TTP).

In another aspect, the invention features a method of preventing recurrent ischemia in a subject in need thereof, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof), wherein the subject has acute coronary syndrome. In some embodiments, the subject has atrial fibrillation. In some embodiments, the subject does not have atrial fibrillation. In another aspect, the invention features a method of treating a subject identified as at risk (e.g., high risk) of stroke (e.g., large vessel acute ischemic stroke) or thrombosis, thereby reducing the likelihood of stroke (e.g., large vessel acute ischemic stroke) or thrombosis in the subject. In some embodiments, the subject is further identified as being at risk for bleeding (e.g., excessive blood loss) or sepsis. In some embodiments, the treatment is effective without a bleeding tendency. In some embodiments, the treatment is effective to maintain patency of the infusion port and tubing. In addition, the compositions described herein are useful for the treatment and prevention of other diseases in which thrombin generation is implicated in playing a physiological role. For example, thrombin is implicated in contributing to the morbidity and mortality of chronic and degenerative diseases such as cancer, arthritis, atherosclerosis, vascular dementia and alzheimer's disease via its ability to modulate many different cell types by specifically cleaving and activating cell surface thrombin receptors, mitogenic effects, different cell functions such as cell proliferation (e.g., abnormal proliferation of vascular cells leading to restenosis or angiogenesis), PDGF release and DNA synthesis. Inhibition of factor XIa effectively blocks thrombin generation and thus neutralizes any physiological effects of thrombin on various cell types. Representative indications discussed above include some, but not all, of the potential clinical situations for which factor XIa inhibitors are indicated.

In another aspect, the invention features a method of treating a subject having edema (e.g., angioedema, e.g., hereditary angioedema), the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof).

In another aspect, the invention features a method of preventing edema (e.g., angioedema, e.g., hereditary angioedema) in a subject, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof).

In another aspect, the invention features a method of reducing the risk of edema (e.g., angioedema, e.g., hereditary angioedema) in a subject, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof).

In another aspect, the invention features a method of inhibiting kallikrein in a subject, the method including administering to a subject having edema (e.g., angioedema, e.g., hereditary angioedema) an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof).

In another aspect, the invention features a method of treating a thromboembolic consequence or complication in a subject, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, the thromboembolic outcome or complication is associated with a peripheral vascular intervention (e.g., limb), hemodialysis, catheter ablation, cerebrovascular intervention, organ (e.g., liver) transplantation, surgery (e.g., orthopedic, pulmonary, abdominal, or cardiac (e.g., open heart), transcatheter aortic valve implantation, a large caliber intervention for treating an aneurysm, a percutaneous coronary intervention, or hemophilia therapy. In some embodiments, the surgery is orthopedic surgery, pulmonary surgery, abdominal surgery, or cardiac surgery. In some embodiments, the cardiac surgery is a complex cardiac surgery or a low risk cardiac surgery. In some embodiments, the thromboembolic consequence or complication is associated with a percutaneous coronary intervention.

In another aspect, the invention features a method of preventing a thromboembolic outcome or complication in a subject, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1, or a pharmaceutically acceptable salt thereof). In some embodiments, the thromboembolic outcome or complication is associated with a peripheral vascular intervention (e.g., limb), hemodialysis, catheter ablation (e.g., atrial fibrillation catheter ablation), cerebrovascular intervention, organ (e.g., liver) transplantation, surgery (e.g., orthopedic surgery, pulmonary surgery, abdominal surgery, or cardiac surgery (e.g., open heart surgery)), transcatheter aortic valve implantation, large caliber intervention for treating an aneurysm, percutaneous coronary intervention, or hemophilia therapy. In some embodiments, the surgery is orthopedic surgery, pulmonary surgery, abdominal surgery, or cardiac surgery. In some embodiments, the cardiac surgery is a complex cardiac surgery or a low risk cardiac surgery. In some embodiments, the thromboembolic consequence or complication is associated with a percutaneous coronary intervention.

In another aspect, the invention features a method of reducing the risk of a thromboembolic outcome or complication in a subject, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1, or a pharmaceutically acceptable salt thereof). In some embodiments, the thromboembolic outcome or complication is associated with a peripheral vascular intervention (e.g., limb), hemodialysis, catheter ablation (e.g., atrial fibrillation catheter ablation), cerebrovascular intervention, organ (e.g., liver) transplantation, surgery (e.g., orthopedic surgery, pulmonary surgery, abdominal surgery, or cardiac surgery (e.g., open heart surgery)), transcatheter aortic valve implantation, large caliber intervention for treating an aneurysm, percutaneous coronary intervention, or hemophilia therapy. In some embodiments, the surgery is orthopedic surgery, pulmonary surgery, abdominal surgery, or cardiac surgery. In some embodiments, the cardiac surgery is a complex cardiac surgery or a low risk cardiac surgery. In some embodiments, the thromboembolic consequence or complication is associated with a percutaneous coronary intervention.

In another aspect, the invention features a method of treating restenosis following arterial injury in a subject, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, the arterial injury occurs after cranial arterial stent placement.

In another aspect, the invention features a method of preventing restenosis following arterial injury in a subject, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, the arterial injury occurs after cranial arterial stent placement.

In another aspect, the invention features a method of reducing the risk of restenosis following arterial injury in a subject, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, the arterial injury occurs after cranial arterial stent placement.

In another aspect, the invention features a method of treating hepatic vascular thrombosis in a subject, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof).

In another aspect, the invention features a method of preventing liver vessel thrombosis in a subject, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof).

In another aspect, the invention features a method of reducing the risk of hepatic vascular thrombosis in a subject, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof).

In another aspect, the invention features a method of treating non-ST elevation myocardial infarction or ST elevation myocardial infarction, the method including administering to a subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof).

In another aspect, the invention features a method of preventing non-ST elevation myocardial infarction or ST elevation myocardial infarction in a subject, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof).

In another aspect, the invention features a method of reducing the risk of a non-ST elevation myocardial infarction or a ST elevation myocardial infarction in a subject, the method including administering to the subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof).

In another aspect, the invention features a method of maintaining vascular patency, the method including administering to a subject an effective amount of a composition described herein (e.g., a composition including compound 1 or a pharmaceutically acceptable salt thereof). In some embodiments, the subject has acute kidney injury. In some embodiments, the subject is also undergoing continuous renal replacement therapy.

In some embodiments of any of the foregoing, the compositions described herein are administered orally or parenterally. In certain embodiments, the compositions described herein are administered parenterally. In certain embodiments, the compositions described herein are administered after the subject ceases use of the direct oral anticoagulant. In certain embodiments, the subject is administered a direct oral anticoagulant for up to about 2.5 years. In certain embodiments, the subject is a mammal, e.g., a human.

In some embodiments of the methods described herein, the pharmaceutically acceptable salt of compound 1 is a hydrochloride salt. In some embodiments, the composition is administered to the subject intravenously. In some embodiments, the composition is administered to the subject subcutaneously. In some embodiments, the composition is administered to the subject as a continuous intravenous infusion. In some embodiments, the composition is administered to the subject via bolus injection. In some embodiments, the subject is a human. In some embodiments, the subject has an elevated risk of a thromboembolic disorder. In some embodiments, the thromboembolic disorder is the result of a surgical complication.

In some embodiments, the subject is or has developed to be sensitive to heparin. In some embodiments, the subject is resistant to heparin or has developed resistance to heparin. In some embodiments, the subject is in contact with the artificial surface for at least 1 day (e.g., about 2 days, about 3 days, about 4 days, about 5 days, about 6 days, about 1 week, about 10 days, about 2 weeks, about 3 weeks, about 4 weeks, about 2 months, about 3 months, about 6 months, about 9 months, about 1 year).

Drawings

Fig. 1 depicts an exemplary HPLC chromatogram of compound 1, including baseline details.

Figure 2A depicts exemplary pH development data for compound 1 in a 10 day stability experiment at 4 ℃.

Figure 2B depicts exemplary pH development data for compound 1 in a 10 day stability experiment at 40 ℃.

Figure 3A depicts exemplary recovery data for compound 1 in a 10 day stability assessment at 4 ℃.

Figure 3B depicts exemplary recovery data for compound 1 in a 10 day stability assessment at 40 ℃.

Fig. 4A depicts an exemplary powder X-ray diffraction pattern of compound 1. HCl on a scale.

FIG. 4B depicts an exemplary powder X-ray diffraction pattern of compound 1. HCl on the d-scale.

Figure 5 depicts the lyophilization cycle parameters developed for compound 1.

Fig. 6 depicts exemplary monitoring of product temperature and product drying.

Figure 7 depicts an exemplary long-term stability study of compound 1 lyophilized drug product at-80 ℃.

Figure 8 depicts an exemplary long-term stability study of compound 1 lyophilized drug product at-20 ℃.

Figure 9 depicts an exemplary long-term stability study of compound 1 lyophilized drug product at T ═ 2-8 ℃.

Figure 10 depicts an exemplary chromatogram of a 48 hour stability sample of a compound 1 formulation diluted in physiological saline.

Figure 11 depicts the pressure gradient across the membrane oxygenator for cardiopulmonary bypass experiments performed in a beagle dog model.

Figure 12 depicts a comparison of plasma concentrations and activated partial thromboplastin time (aPTT) ratios measured in a beagle model.

Figure 13 depicts activated partial thromboplastin time (aPTT) measured in a beagle model after administration of compound 1.

Detailed Description

Described herein are pharmaceutical compositions comprising compound 1 or a pharmaceutically acceptable salt thereof, a cyclodextrin and an excipient, methods of their use and administration, methods of their preparation, and containers comprising the solutions or mixtures.

Definition of

As used herein, the terms "stabilized" and "stabilized" solutions (e.g., aqueous solutions comprising compound 1) described herein refer to "chemically stable" and "physically stable" solutions. For example, a solution comprising compound 1 is chemically stable if compound 1 does not undergo chemical transformation (e.g., hydrolysis) or degradation (e.g., racemization, epimerization, oxidation).

As used herein, "determining" refers to the process of determining the specific stability-indicating amount of a drug substance. For example, the assay may be a chromatographic method (e.g., HPLC) involving the use of a reference standard.

As used herein, "pure" means that no impurities are present, e.g., in solution or composition, relative to its parent (e.g., at time-0).

As used herein, "sterilization" refers to aseptic filling (e.g., aseptic sterilization) or terminal sterilization.

As used herein, "reconstituted solution," "reconstituted formulation," or "reconstituted drug product" refers to a solution prepared by dissolving a lyophilized drug product in a diluent such that the drug product is dissolved in an aqueous solution suitable for administration (e.g., parenteral administration).

As used herein, the term "diluent" refers to a pharmaceutically acceptable (e.g., safe and non-toxic for administration to a human) diluent material that can be used to prepare a reconstituted solution. Exemplary diluents include sterile water for injection (WFI), pH buffered solutions (e.g., phosphate buffered saline), sterile saline solutions, or dextrose solutions (e.g., 5% dextrose).

As used herein, the term "osmolality" refers to the total number of dissolved components per liter. Osmolality is similar to molarity (molarity), but includes the total moles of dissolved species in solution. Osmolality at 1Osm/L means that there are 1 mole of dissolved components per L of solution. Some solutes, such as ionic solutes that dissociate in solution, will contribute more than 1 mole of dissolved components per mole of solute in the solution. For example, NaCl dissociates to Na in solution⁺And Cl^-And thus provides 2 moles of dissolved components per 1 mole of NaCl dissolved in the solution. The osmolality is typically in the range of about 280mOsm/L to about 310 mOsm/L.

As used herein, "slurrying" refers to a process in which a compound as described herein is suspended in a solvent (e.g., a polar aprotic solvent or a non-polar solvent) and collected again (e.g., by filtration) after the suspension is stirred.

As used herein, "crystalline" refers to a solid having a highly regular chemical structure. The molecules are arranged in a regular periodic manner in the three-dimensional space of the lattice.

The term "substantially crystalline" refers to a form that may be at least a specified weight percent crystalline. A particular weight percentage is 70%, 75%, 80%, 85%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, 99.5%, 99.9%, or any percentage from 70% to 100%. In certain embodiments, a particular weight percentage of crystallinity is at least 90%. In certain other embodiments, a particular weight percentage of crystallinity is at least 95%. In some embodiments, compound 1 can be a substantially crystalline sample of any of the crystalline solid forms described herein.

The term "substantially pure" relates to a composition that can be at least a particular weight percentage of a particular crystalline solid form of compound 1 and/or other solid forms of compound 1 or a pharmaceutically acceptable salt thereof that is free of impurities. A particular weight percentage is any percentage from 70%, 75%, 80%, 85%, 90%, 95%, 99%, or 70% to 100%. In some embodiments, the crystalline solid form of compound 1 or a pharmaceutically acceptable salt thereof as described herein is substantially pure in a weight percentage of 95% to 100%, e.g., about 95%, about 96%, about 97%, about 98%, about 99%, or about 99.9%.

As used herein, and unless otherwise indicated, the terms "treat", "treating" and "treatment" contemplate an effect that occurs when a subject has a specified disease, disorder or condition, which reduces the severity of the disease, disorder or condition, or delays or slows the progression of the disease, disorder or condition (also "therapeutic treatment").

As used herein, and unless otherwise indicated, a "therapeutically effective amount" of a composition is an amount sufficient to provide a therapeutic benefit in the treatment of a disease, disorder, or condition, or to delay or minimize one or more symptoms associated with a disease, disorder, or condition. A therapeutically effective amount of a composition means an amount of a therapeutic agent, alone or in combination with other therapies, that provides a therapeutically beneficial effect in the treatment of a disease, disorder, or condition. The term "therapeutically effective amount" can encompass an amount that improves overall therapy, reduces or avoids symptoms or causes of a disease or disorder, or enhances the therapeutic efficacy of another therapeutic agent.

As used herein, and unless otherwise indicated, a "prophylactically effective amount" of a composition is an amount sufficient to prevent a disease, disorder or condition, or one or more symptoms associated with a disease, disorder or condition, or prevent relapse thereof. A prophylactically effective amount of a composition means an amount of a therapeutic agent, alone or in combination with other agents, that provides a prophylactic benefit in the prevention of a disease, disorder, or condition. The term "prophylactically effective amount" can encompass an amount that improves overall prophylaxis or enhances the prophylactic efficacy of another prophylactic agent.

Diseases, disorders, and conditions are used interchangeably herein.

A "subject" contemplated for administration includes, but is not limited to, a human (i.e., a male or female of any age group, such as a pediatric subject (e.g., an infant, a child, an adolescent) or an adult subject (e.g., a young, a middle aged, or an elderly) and/or a non-human animal, such as a mammal, such as a primate (e.g., a cynomolgus monkey, a rhesus monkey), a cow, a pig, a horse, a sheep, a goat, a rodent, a cat, and/or a dog. In certain embodiments, the subject is a human. In certain embodiments, the subject is a non-human animal. In some embodiments, the pediatric subject is between the ages of 0 and 18 years. In some embodiments, the adult subject is over 18 years of age.

As used herein, the term "artificial surface" refers to any non-human or non-animal surface that is in contact with the blood of a subject, for example, during a medical procedure. It may be a container for collecting or circulating blood of a subject outside the subject. It may also be a stent, a valve, an intraluminal catheter or a system for pumping blood. By way of non-limiting example, such artificial surfaces may be steel, any type of plastic, glass, silicone, rubber, and the like. In some embodiments, the artificial surface is exposed to at least 50%, 60%, 70%, 80%, 90%, or 100% of the subject's blood.

As used herein, the terms "conditioning" or "conditioned" with respect to an artificial surface refers to priming or rinsing the artificial surface (e.g., extracorporeal surface) with a composition described herein, which has been in a priming or rinsing solution (e.g., blood, saline solution, ringer's solution) or separately administered to the artificial surface before, during, or after a medical procedure.

Filler

As used herein, the term "bulking agent" includes agents that provide structure of the composition (e.g., in a lyophilized product) without directly interacting (e.g., chemically) with a pharmaceutical product (e.g., a drug product). In addition to providing a pharmaceutically elegant cake, the filler may impart useful qualities with respect to changing the collapse temperature, providing freeze-thaw protection, and enhancing the long-term storage stability of the Active Pharmaceutical Ingredient (API). Non-limiting examples of bulking agents include sugars (e.g., sugars such as monosaccharides, disaccharides, or polysaccharides) or sugar alcohols (e.g., sucrose, lactose, trehalose, dextran, erythritol, arabitol, xylitol, sorbitol, or mannitol, or combinations thereof). Bulking agents can be crystalline (e.g., mannitol, glycine, or sodium chloride) or amorphous (e.g., dextran, hydroxyethyl starch).

Preferably, the filler used in the pharmaceutical formulation promotes the formation of an aesthetically acceptable uniform or mechanically strong cake. Fillers may also preferably facilitate ease and speed of reconstitution. The filler may also preferably reduce or prevent cake collapse, eutectic melting, or retention of residual moisture. In some embodiments, the bulking agent is a lyoprotectant.

Buffering agent

In some embodiments, the aqueous pharmaceutical compositions described herein further comprise a buffering agent (e.g., a buffering agent having a pH of from about 6 to about 8 (e.g., from about 6.5 to about 7.0, or about 6.8)).

As used herein, the term "buffer", "buffer system" or "buffer component" refers to a compound that provides a chemical system in solution that exhibits a buffering capacity, i.e., the ability to neutralize within certain limits the pH lowering or raising effect of a strong acid or base (bases), respectively, wherein the change in initial pH (e.g., pH prior to being affected by, for example, a strong acid or base) is relatively small or unchanged, typically in combination with at least one other compound. For example, the buffers described herein maintain or control the pH of a solution to a particular pH range. For example, "buffering capacity" may refer to the number of millimoles (mM) of a strong acid or base (or hydrogen or hydroxide ions, respectively) required to change the pH by one unit when added to one liter (standard unit) of buffer solution. From this definition, it is apparent that the smaller the change in pH in a solution caused by the addition of a specified amount of acid or base, the greater the buffer capacity of the solution. See, e.g., Remington, The Science and Practice of Pharmacy, Mack Publishing Co., Easton, Pennsylvania (19 th edition, 1995), Chapter 17, page 225-227. The buffering capacity will depend on the type and concentration of the buffering component.

In some embodiments, the buffer comprises a monobasic acid. In some embodiments, the buffer comprises a polyacid (e.g., a maleate, citrate, or phosphate). In some embodiments, the buffer is a solution of one or more substances (e.g., salts of weak acids and weak bases; mixtures of weak acids and salts of weak acids and strong bases).

In some embodiments, the buffer is a maleate buffer. In some embodiments, the buffer is a citrate buffer. In some embodiments, the buffer is a phosphate buffer.

Freeze-drying protective agent

As used herein, the term "lyoprotectant" refers to a substance that, when combined with a drug product, reduces chemical and/or physical instability of the drug product upon lyophilization and/or subsequent storage. Exemplary lyoprotectants include sugars and their corresponding sugar alcohols, such as sucrose, lactose, trehalose, dextran, erythritol, arabitol, xylitol, sorbitol, and mannitol; amino acids such as arginine or histidine; lyotropic salts, such as magnesium sulfate; polyols such as propylene glycol, glycerol, poly (ethylene glycol) or poly (propylene glycol); and combinations thereof. Additional exemplary lyoprotectants include gelatin, dextrin, modified starch, and carboxymethyl cellulose. Sugar alcohols are those compounds obtained by reducing mono-and disaccharides such as lactose, trehalose, maltose, lactulose and maltulose.

Cyclodextrin

Cyclodextrins are cyclic oligosaccharides that contain or comprise six (alpha-cyclodextrin), seven (beta-cyclodextrin), eight (gamma-cyclodextrin) or more alpha- (1,4) -linked glucose residues. The hydroxyl groups of the cyclodextrin are directed towards the outside of the ring, while the two rings of glycosidic oxygen and non-exchangeable hydrogen atoms are directed towards the inside of the cavity.

Cyclodextrins can be chemically modified such that some or all of the primary or secondary hydroxyl groups, or both, of the macrocycle are functionalized with pendant groups. Suitable pendant groups include, but are not limited to, sulfinyl, sulfonyl, phosphate, acyl, and Cl-C12 alkyl optionally substituted with one or more (e.g., 1,2, 3, or 4) hydroxy, carboxyl, carbonyl, acyl, oxy, oxo; or a combination thereof. Methods for modifying these alcohol residues are known in the art, and many cyclodextrin derivatives are commercially available, including under the trade nameSulfobutylether beta-cyclodextrin from Ligand Pharmaceuticals (La Jolla, CA).

Cyclodextrins include, but are not limited to, alkyl cyclodextrins, hydroxyalkyl cyclodextrins such as hydroxypropyl β -cyclodextrin, carboxyalkyl cyclodextrins, and sulfoalkyl ether cyclodextrins such as sulfobutyl ether β -cyclodextrin.

In particular embodiments, the cyclodextrin is a beta cyclodextrin having multiple charges (e.g., negative or positive) on the surface. In a more specific embodiment, the cyclodextrin is a β -cyclodextrin containing or comprising a plurality of functional groups that are negatively charged at physiological pH. Examples of such functional groups include, but are not limited to, carboxylic acid (carboxylate) groups, sulfonate esters (RSO) that are negatively charged at physiological pH^3-) Phosphonate groups, phosphinate groups, and amino acids. The charged functional groups can be directly bound to the cyclodextrin or can be linked through a spacer such as an alkylene chain. The number of carbon atoms in the alkylene chain may vary, but is generally from about 1 to 10 carbons, preferably 1-6 carbons, more preferably 1-4 carbons. Highly sulfated cyclodextrins are described in U.S. patent No.6,316,613.

In one embodiment, the cyclodextrin is a β -cyclodextrin functionalized with a plurality of sulfobutyl ether groups. Such cyclodextrins are available under the trade nameAnd (5) selling.

Is a polyanionic β -cyclodextrin derivative having a sodium sulfonate salt separated from a lipophilic cavity by a butyl ether spacer or sulfobutyl ether (SBE).Rather than a single chemical species, it is composed of a variety of polymer structures of varying degrees of substitution, as well as positional/regioisomers that are specified and controlled into a uniform pattern by consistently practicing and improving the proprietary manufacturing process to control impurities.

Contains six to seven sulfobutyl ether groups per cyclodextrin molecule. Due to the very low pKa of the sulfonic acid groups,carry multiple negative charges at physiologically compatible pH values. The repulsive combination of the four carbon butyl chains and the negative terminal charge allows for "extension" of the cyclodextrin cavity. This generally results in stronger binding to the drug candidate than can be achieved using other modified cyclodextrins. It also offers the possibility of ionic charge interactions between the cyclodextrin and the positively charged drug molecule. In addition, these derivatives confer special solubility and parenteral safety to the molecule. In contrast to the beta-cyclodextrin,provides a 50-fold improvement in higher interaction characteristics and excellent water solubility over 100 grams/100 ml.

Solubilizer

As used herein, the term "solubilizer" describes a substance capable of promoting the dissolution of an insoluble or poorly soluble component in a solution containing the same. Representative examples of solubilizing agents useful in the context of the present invention include, but are not limited toAnd across e.g.80 and20. other solubilizers that can be used in the context of embodiments of the present invention include, for example, polyoxyethylene sorbitan esters, polyoxyethylene sorbitan fatty acid esters, polyoxyethylene n-alkyl ethers, polyethylene glycols (e.g., PEG200, PEG300, PEG400, PEG500, PEG600, etc.), n-alkanesAmine N-oxide, poloxamer, organic solvent, phospholipid and cyclodextrin.

Container with a lid

Also described herein are containers comprising the aqueous solutions or blends described herein. Examples of containers include bags (e.g., plastic or polymeric bags such as PVC), vials (e.g., glass vials), bottles, or syringes. In one embodiment, the container is configured to deliver the solution or admixture parenterally (e.g., intramuscularly, subcutaneously, or intravenously).

In some embodiments, a product intended for injection is packaged in a hermetically sealed glass container of appropriate size. In some embodiments, the product is intended to be diluted prior to infusion and packaged in a pharmaceutical vial or bottle (e.g., a suitable glass or plastic vial or bottle of appropriate size). In some embodiments, the product may be prepared ready for injection and may be packaged in a pre-filled syringe or other syringe device intended for infusion (e.g., a suitable glass or plastic package of suitable size) or a bulk container (e.g., a suitable glass or plastic container of suitable size). In some embodiments, the product is provided in a container that is not leached (e.g., does not introduce (or allow to grow) contaminants or impurities in the solution).

Freeze-drying

The term "lyophilization" refers to a freeze-drying process in which water is removed from a product by freezing the product and placing it under vacuum, which allows ice to change directly from a solid phase to a gas phase without passing through a liquid phase. This process consists of three separate, distinct and interrelated processes: freezing, primary drying (sublimation) and secondary drying (desorption). There are several advantages associated with lyophilization, such as: (i) ease of handling of the liquid, which simplifies aseptic handling; (ii) enhancing the stability of the dry powder; (iii) removing water without overheating the product; (iv) enhancing product stability in the dry state; and (v) the reconstituted product is fast and readily soluble.

The lyophilization process typically includes the following steps:

-dissolving the drug and excipients in a suitable solvent, typically water for injection (WFI).

-sterilizing the bulk solution by passing it through a 0.22 micron bacteria retention filter.

Filling into separate sterile containers and partially plugging the containers under sterile conditions.

-transferring the partially stoppered container to a freeze dryer and loading into a chamber under sterile conditions.

Freezing the solution by placing the partially plugged container on a cooled shelf in a freeze drying chamber or pre-freezing in another chamber.

-applying a vacuum to the chamber and heating the shelves in order to evaporate the water from the frozen state.

The blocking of the vials is usually done by a hydraulic or screw stoppering mechanism installed in the freeze dryer.

Compound (I)

The present invention relates, in part, to pharmaceutical compositions comprising compounds of formula (I-a):

also referred to herein as "compound 1," or a pharmaceutically acceptable salt thereof. In some embodiments, the pharmaceutically acceptable salt of compound 1 is a hydrochloride salt.

In some embodiments, the compounds described herein are formed as salts. The compounds described herein may be administered as the free acid, as the zwitterion, or as a salt. Salts can also be formed between a cation and a negatively charged substituent on a compound described herein (e.g., the deprotonated carboxylic acid moiety of compound 1). Suitable cationic counterions include sodium, potassium, magnesium, calcium, and ammonium ions (e.g., tetraalkylammonium cations such as tetramethylammonium). In acid addition salts may be formed between an anion and a positively charged substituent (e.g. amino) or a basic substituent (e.g. pyridyl) on a compound described herein. Suitable anions include chloride, bromide, iodide, sulfate, nitrate, phosphate, citrate, methanesulfonate, trifluoroacetate, and acetate.

Pharmaceutically acceptable salts of the compounds described herein (e.g., pharmaceutically acceptable salts of compound 1) also include those derived from pharmaceutically acceptable inorganic and organic acids and bases. Examples of suitable acidic salts include acetate, 4-acetamidobenzoate, adipate, alginate, 4-aminosalicylate, aspartate, ascorbate, benzoate, benzenesulfonate, bisulfate, butyrate, citrate, camphorate, camphorsulfonate, carbonate, cinnamate, cyclamate, caprate, sebacate, 2-dichloroacetate, digluconate, dodecylsulfate, ethanesulfonate, ethane-1, 2-disulfonate, formate, fumarate, galactarate (galactate), glucoheptonate, gluconate, glucuronate, glutamate, glutarate, glycerophosphate, glycolate, hemisulfate, heptanoate, hexanoate, hippurate, hydrochloride, hydrobromide, hydrobromate, citrate, dihydrogensulfonate, isovalerate, dihydrogensulfonate, and dihydrogensulfonate, Hydroiodide, 1-hydroxy-2-naphthoate, 2-isethionate, isobutyrate, lactate, lactobionate, laurate, malate, maleate, malonate, mandelate, methanesulfonate, naphthalene-1, 5-disulfonate, 2-naphthalenesulfonate, nicotinate, nitrate, octanoate, oleate, oxalate, 2-oxoglutarate, palmitate, pamoate (palmoate), pectate, 3-phenylpropionate, phosphate, phosphonate, picrate, pivalate, propionate, pyroglutamate, salicylate, sebacate, succinate, stearate, sulfate, tartrate, thiocyanate, tosylate, p-toluenesulfonate and undecanoate.

Salts derived from suitable bases include alkali metals (e.g., sodium), alkaline earth metals (e.g., magnesium), ammonium, and (alkyl)₄N⁺And (3) salt. The present invention also contemplates the quaternization of any basic nitrogen-containing groups of the compounds disclosed herein. Water-or oil-soluble or dispersible products can be obtained by such quaternization.

As used herein, compounds of the present invention (including compound 1) are defined to include pharmaceutically acceptable derivatives or prodrugs thereof. By "pharmaceutically acceptable derivative or prodrug" is meant any pharmaceutically acceptable salt, ester, salt of an ester, or other derivative of a compound of the invention that is capable of providing (directly or indirectly) a compound of the invention upon administration to a recipient. Particularly advantageous derivatives and prodrugs are those that increase the bioavailability of the compounds of the invention when such compounds are administered to a mammal (e.g., by allowing an orally administered compound to be more readily absorbed into the blood) or enhance delivery of the parent compound to a biological compartment (e.g., the brain or lymphatic system) with respect to the parent species. Preferred prodrugs include derivatives wherein a group that enhances water solubility or active transport through the intestinal membrane is attached to the structure of the formulae described herein.

Any formula or compound described herein is also intended to refer to unlabeled forms of the compounds as well as isotopically labeled forms, isotopically labeled compounds having the structure depicted by the formulae given herein except that one or more atoms are replaced by an atom having a selected atomic mass or mass number. Examples of isotopes that can be incorporated into compounds of the invention include isotopes of hydrogen, carbon, nitrogen, oxygen, phosphorus, fluorine and chlorine, such as²H、³H、¹¹C、¹³C、¹⁴C、¹⁵N、¹⁸F、⁵¹P、³²P、³⁵S、³⁶Cl、¹²⁵I. The invention includes various isotopically-labeled compounds as defined herein, for example, in which a radioactive isotope such as³H、¹³C and¹⁴those of C. Such isotopically-labeled compounds are useful in metabolic studies (employing¹⁴C) Reaction kinetics studies (using, for example, ` H or `³H) Detection or imaging techniques, such as Positron Emission Tomography (PET) or Single Photon Emission Computed Tomography (SPECT), including drug or substrate tissue distribution assays, or for radiotherapy of a patient. In particular, it is possible to use, for example,¹⁸f or labeled compounds may be particularly desirable for PET or SPECT studies, isotopically labeled compounds of the invention and prodrugs thereof can generally be prepared by substituting a readily available isotopically labeled reagent for a non-isotopically labeled reagentThe agent is prepared by carrying out the procedures disclosed in the schemes or examples and preparations described below.

In addition, with heavier isotopes, in particular deuterium (i.e. deuterium)²H or D) substitution may provide certain therapeutic advantages resulting from greater metabolic stability, such as increased in vivo half-life, or reduced dosage requirements or improved therapeutic index. It will be understood that deuterium in this context is considered to be a substituent of the compounds of the formulae described herein. The concentration of such heavier isotopes, in particular deuterium, can be defined by the isotope concentration coefficient. As used herein, the term "isotopic enrichment factor" means the ratio between the isotopic abundance and the natural abundance of a given isotope. If substituents in compounds of the invention are represented by deuterium, such compounds have an isotopic enrichment factor for each designated deuterium atom of at least 3500 (52.5% deuterium incorporation at each designated deuterium atom), at least 4000 (60% deuterium incorporation), at least 4500 (67.5% deuterium incorporation), at least 5000 (75% deuterium incorporation), at least 5500 (82.5% deuterium incorporation), at least 6000 (90% deuterium incorporation), at least 6333.3 (95% deuterium incorporation), at least 6466.7 (97% deuterium incorporation), at least 6600 (99% deuterium incorporation), or at least 8633.3 (99.5% deuterium incorporation).

Isotopically labeled compounds described herein can generally be prepared by conventional techniques known to those skilled in the art or by processes analogous to those described in the accompanying examples and preparations using an appropriate isotopically labeled reagent in place of the unlabeled reagent previously employed. Pharmaceutically acceptable solvates according to the invention include those in which the solvent of the crystallization may be isotopically substituted, for example D₂O、D₆-acetone, D₆-DMSO。

Any asymmetric atom (e.g., carbon, etc.) of a compound of the invention can exist in racemic or enantiomerically enriched forms, such as the (R) - (S) -or (RS) -configurations, and in certain embodiments each asymmetric atom has at least 50% enantiomeric excess, at least 60% enantiomeric excess, at least 70% enantiomeric excess, at least 80% enantiomeric excess, at least 90% enantiomeric excess, at least 95% enantiomeric excess, or at least 99% enantiomeric excess of the (R) -or (S) -configuration. The substituents on the atom having an unsaturated bond may be present in cis- (Z) -or trans- (E) -form, if possible.

Thus, as used herein, a compound of the invention may be in the form of one of the possible isomers, rotamers, atropisomers, tautomers or mixtures thereof, for example, as a substantially pure geometric (cis or trans) isomer, diastereomer, optical isomer (mirror), racemate or mixture thereof. Any resulting mixture of isomers may be separated into pure or substantially pure geometric or optical isomers, diastereomers, racemates based on the physicochemical differences of the components, for example, by chromatography or fractional crystallization.

Any resulting racemates of the final products or intermediates can be resolved into optical mirror bodies by known methods, for example by separating diastereomeric salts thereof obtained with an optically active acid or base, and liberating the optically active acidic or basic compound. Thus, an acidic moiety may be used to resolve the compounds of the invention into their optical mirror image, for example, by fractional crystallization of a salt formed with an optically active acid, such as tartaric acid, dibenzoyltartaric acid, diacetyltartaric acid, (+) -O, O' -di-p-toluoyl-D-tartaric acid, mandelic acid, malic acid or camphor-10-sulfonic acid. The racemic product can also be resolved by chiral chromatography, for example, High Pressure Liquid Chromatography (HPLC) using a chiral adsorbent.

The compounds described herein (e.g., compound 1) can also be represented in various tautomeric forms. In such cases, the invention expressly includes all tautomeric forms of the compounds described herein. All crystalline forms of the compounds described herein are specifically included in the present invention.

Method for synthesizing compound

The compounds described herein can be synthesized by conventional methods using commercially available starting materials and reagents. For example, the compounds may be synthesized using the methods set forth in U.S. patent No.7,501,404 or as described in the methods described herein.

Various techniques in the art of synthetic organic chemistry can be used to purify the compounds described herein. One or more chromatographic methods, such as column chromatography or HPLC, can be used to purify the compounds described herein. The compounds described herein can be purified by purification methods other than chromatography, such as recrystallization or slurrying. In one embodiment, recrystallization may be used to purify the compounds described herein. In another embodiment, the compounds described herein may also be purified by slurrying.

In some embodiments, a compound described herein that has been purified by chromatography may also be purified by recrystallization. The compounds described herein can also be purified by slurrying (or reslurrying) the compounds with one or more solvents (e.g., slurrying as described herein). The compounds described herein can also be purified by trituration with one or more solvents (e.g., trituration described herein). For example, compounds described herein that have been purified by chromatography can also be purified by trituration. In a chemical reactor, the milling process can be influenced by suspending or re-suspending the solid product in a solvent or a mixture of solvents under mechanical stirring. In one embodiment, the compounds described herein may also be purified by precipitation from solution using one or more anti-solvents. For example, compounds described herein that have been purified by chromatography may also be purified by precipitation. In one embodiment, the compounds described herein are purified by Simulated Moving Bed (SMB) chromatography. In one embodiment, the compounds described herein are purified by supercritical fluid chromatography, for example, supercritical fluid chromatography with liquid carbon dioxide. In one embodiment, the compounds described herein are purified by chiral chromatography, for example, High Pressure Liquid Chromatography (HPLC) using a chiral adsorbent.

Methods of treating, preventing or reducing risk

A compound described herein (e.g., compound 1 or a pharmaceutically acceptable salt thereof) can inhibit factor XIa or kallikrein. In some embodiments, a compound described herein (e.g., compound 1 or a pharmaceutically acceptable salt thereof) can inhibit both factor XIa and kallikrein. Accordingly, these compounds are useful for treating, preventing, or reducing the risk of the disorders described herein.

Exemplary disorders include thrombotic events associated with coronary and cerebrovascular disease, venous or arterial thrombosis, coagulation syndromes, ischemia (e.g., coronary ischemia) and angina (stable and unstable), Deep Vein Thrombosis (DVT), hepatic vein thrombosis, disseminated intravascular coagulopathy, Cassia Toba Meissner syndrome, pulmonary embolism, myocardial infarction (e.g., ST elevation myocardial infarction or non-ST elevation myocardial infarction (e.g., non-ST elevation myocardial infarction prior to catheterization), cerebral infarction, cerebral thrombosis, transient ischemic attack, atrial fibrillation (e.g., non-valvular atrial fibrillation), cerebral embolism, thromboembolic complications of surgery (e.g., hip or knee replacement, orthopedic surgery, cardiac surgery, pulmonary surgery, abdominal surgery, or endarterectomy), and peripheral arterial occlusion, and may also be used to treat or prevent myocardial infarction, thromboembolic complications of surgery (e.g., hip or knee replacement), and thrombotic events associated with peripheral arterial occlusion, Stroke (e.g., acute ischemic stroke in large blood vessels), angina, and other consequences of atherosclerotic plaque rupture. The compounds of the invention having factor XIa or kallikrein inhibitory activity may also be useful in preventing thromboembolic disorders, such as venous thromboembolism, in cancer patients, including those receiving chemotherapy and/or those having elevated Lactase Dehydrogenase (LDH) levels, and thromboembolic events at or after tissue plasminogen activator-based or mechanical restoration of vascular patency. The compounds of the invention having factor XIa or kallikrein inhibitory activity are also useful as coagulation inhibitors, such as during the preparation, storage and fractionation of whole blood. In addition, the compounds described herein may be used in an emergency hospital setting or perioperative period, where the patient is at risk for thromboembolic disorders or complications, and may also be used in patients in a highly thrombogenic state, such as cancer patients.

According to the present invention, factor XIa inhibition may be a more effective and safer method of inhibiting thrombosis than inhibition of other coagulation serine proteases such as thrombin or factor Xa. Administration of a small molecule factor XIa inhibitor should have the effect of inhibiting thrombin generation and clot formation with no or substantially no effect on bleeding time and little or no impairment of hemostasis. These results are substantially different from those of other "direct acting" coagulation protease inhibitors (e.g., thrombin and active site inhibitors of factor Xa), which exhibit prolonged bleeding time and less separation between antithrombotic efficacy and prolonged bleeding time. Preferred methods according to the invention comprise administering to a mammal a pharmaceutical composition comprising at least one compound of the invention.

Compounds described herein (e.g., compound 1 or a pharmaceutically acceptable salt thereof) can inhibit kallikrein. Thus, these compounds are useful in the treatment, prevention, or reduction of risk of diseases involving inflammation, such as edema (e.g., brain edema, macular edema, and angioedema (e.g., hereditary angioedema)). In some embodiments, the compounds of the invention are useful for treating or preventing hereditary angioedema. Compounds described herein (e.g., compound 1), e.g., compound 1 or a pharmaceutically acceptable salt thereof, can also be used to treat, prevent, or reduce the risk of, for example, stroke, ischemia (e.g., coronary ischemia), and perioperative blood loss. The methods of the invention are useful for treating or preventing those conditions in which the action of factor XIa or kallikrein is implicated. Thus, the methods of the invention are useful for treating the consequences of atherosclerotic plaque rupture, including cardiovascular disease associated with activation of the coagulation cascade in thrombotic or thrombophilia states.

More specifically, the methods of the invention are useful for treating, preventing, or reducing the risk of acute coronary syndromes, such as coronary artery disease, myocardial infarction, unstable angina (including progressive angina), ischemia (e.g., caused by vascular occlusion), and cerebral infarction. The methods of the invention are also useful for treating, preventing stroke (e.g., large vessel acute ischemic stroke) and related cerebrovascular disorders (including cerebrovascular accidents, vascular dementia, and transient ischemic attacks); venous thrombosis and thromboembolism, such as Deep Vein Thrombosis (DVT) and pulmonary embolism; thrombosis associated with atrial fibrillation, ventricular dilation, dilated cardiomyopathy, or heart failure; peripheral artery disease and intermittent claudication; formation of atherosclerotic plaques and graft atherosclerosis; restenosis following arterial injury induced either endogenously (by atherosclerotic plaque rupture) or exogenously (by invasive cardiology procedures such as vascular wall injury from angioplasty or post-cranial arterial stenting); disseminated intravascular coagulopathy, Kasaphami syndrome, cerebral thrombosis and cerebral embolism, or reducing the risk thereof.

In addition, the methods of the invention can be used for treatment, prevention (e.g., prophylaxis) and cancer, thrombectomy, surgery (e.g., hip replacement, orthopedic surgery), endarterectomy, introduction of artificial heart valves, peripheral vascular intervention (e.g., limbs), cerebrovascular intervention, large-caliber intervention for treating aneurysms, vascular grafts, mechanical organs, and implants (e.g., transcatheter aortic valve implantation) or organ transplantation (e.g., transplantation of liver, tissue, or cells); percutaneous coronary intervention; catheter ablation; hemophilia therapy; hemodialysis; drugs in patients with myocardial infarction, stroke (e.g., large vessel acute ischemic stroke), pulmonary embolism, and similar conditions (such as tissue plasminogen activator or similar agents and surgical restoration of vascular patency); drugs (such as oral contraceptives, hormone replacement and heparin, e.g. for the treatment of heparin-induced thrombocytopenia); sepsis (such as sepsis associated with disseminated intravascular coagulation); pregnancy or childbirth; as well as thromboembolic consequences or complications associated with another chronic medical condition, or reducing the risk thereof. The methods of the invention are useful for treating thrombosis due to confinement (e.g., immobilization, hospitalization, bed rest, or immobilization of the limb, such as with an immobilization plaster or the like). In some embodiments, the thromboembolic consequence or complication is associated with a percutaneous coronary intervention.

In addition, a compound described herein (e.g., compound 1), or a pharmaceutically acceptable salt thereof, or a composition thereof, can be used to treat, prevent, or reduce the risk of a thromboembolic disorder, e.g., venous thromboembolism, deep vein thrombosis, or pulmonary embolism, or an associated complication, in a subject, wherein the subject is exposed to an artificial surface. The artificial surface may contact the subject's blood, for example, as an extracorporeal surface or a surface of an implantable device. Such artificial surfaces include, but are not limited to, dialysis tubing, cardiopulmonary bypass rings, artificial heart valves, such as those of Mechanical Heart Valves (MHVs), ventricular assist devices, small bore grafts, central venous catheters, extracorporeal membrane pulmonary oxygenation (ECMO) devices. In addition, thromboembolic disorders or related complications may arise from or be associated with artificial surfaces. For example, the foreign surfaces and various components of the Mechanical Heart Valve (MHV) are thrombogenic and promote thrombin generation via the intrinsic coagulation pathway. In addition, thrombin and FXa inhibitors are contraindicated for thromboembolic disorders or related complications caused by artificial surfaces (such as those of MHV), as these inhibitors are ineffective at blocking endogenous pathways at plasma levels that do not cause major bleeding. The compounds of the present invention that are useful, for example, as factor XIa inhibitors are therefore contemplated as alternative therapeutic agents for these purposes.

A compound described herein (e.g., compound 1), or a pharmaceutically acceptable salt thereof, or a composition thereof, can also be used to treat, prevent, or reduce the risk of atrial fibrillation in a subject in need thereof. For example, a subject may have a high risk of developing atrial fibrillation. The subject may also require dialysis, such as renal dialysis. A compound described herein (e.g., compound 1), or a pharmaceutically acceptable salt thereof, or a composition thereof, can be administered before, during, or after dialysis. Direct Oral Anticoagulants (DOACs), such as certain FXa or thrombin inhibitors, currently available on the market are contraindicated in atrial fibrillation in such cases. The compounds of the present invention that are useful, for example, as factor XIa inhibitors are therefore contemplated as alternative therapeutic agents for these purposes. In addition, the subject may be at high risk of bleeding. In some embodiments, the subject may have end stage renal disease. In other cases, the subject does not require dialysis, such as renal dialysis. In addition, atrial fibrillation may be associated with another thromboembolic disorder, such as a blood clot.

Furthermore, a compound described herein (e.g., compound 1), or a pharmaceutically acceptable salt thereof, or a composition thereof, can be used to treat, prevent, or reduce the risk of hypertension (e.g., arterial hypertension) in a subject. In some embodiments, hypertension (e.g., arterial hypertension) can lead to atherosclerosis. In some embodiments, the hypertension can be pulmonary hypertension.

In addition, a compound described herein (e.g., compound 1), or a pharmaceutically acceptable salt thereof, or a composition thereof, can be used to treat, prevent, or reduce the risk of a disorder such as heparin-induced thrombocytopenia, heparin-induced thrombocytopenic thrombosis, or thrombotic microangiopathy, e.g., Hemolytic Uremic Syndrome (HUS) or thrombotic thrombocytopenic purpura.

In some embodiments, the subject is or has developed to be sensitive to heparin. Heparin-induced thrombocytopenia (HIT) develops as a result of administration of various forms of heparin (low platelet count). HIT is caused by the formation of abnormal antibodies that activate platelets. HIT can be confirmed with a specific blood test. In some embodiments, the subject is resistant to heparin or has developed resistance to heparin. For example, a subject may be subjected to an Activated Clotting Time (ACT) test to test for sensitivity or resistance to heparin. The ACT test is a measure of the intrinsic coagulation pathway that detects the presence of fibrin formation. Subjects sensitive and/or resistant to standard doses of heparin will not generally achieve the target anticoagulation time. Common associated factors of heparin resistance include, but are not limited to, the previous drops of heparin and/or glycerol nitrate and reduced antithrombin III levels. In some embodiments, the subject has previously been administered an anticoagulant (e.g., bivalirudin/Angiomax).

A compound described herein (e.g., compound 1), or a pharmaceutically acceptable salt thereof, or a composition thereof, can be used to reduce inflammation in a subject. In some embodiments, the inflammation may be vascular inflammation. In some embodiments, the vascular inflammation may be accompanied by atherosclerosis. In some embodiments, the vascular inflammation may be accompanied by a thromboembolic disorder in the subject. In some embodiments, the vascular inflammation may be angiotensin II-induced vascular inflammation.

A compound described herein (e.g., compound 1), or a pharmaceutically acceptable salt or composition thereof, can be used to treat, prevent, or reduce the risk of renal disorders or renal dysfunction (including end stage renal disease, hypertension-related renal disorder in a subject), renal fibrosis, and renal injury.

The methods of the invention may also be used to maintain vessel patency, for example, in patients undergoing thrombectomy, transluminal coronary angioplasty, or in vascular procedures such as bypass grafting, arterial reconstruction, atherectomy, vascular grafts, stent patency, and organ, tissue or cell implantation and transplantation. The methods of the invention are useful for inhibiting coagulation in the preparation, storage, fractionation or use of whole blood. For example, the methods of the invention may be used to maintain whole blood and fractionated blood in a fluid phase, such as is required for analysis and biological testing, e.g., for ex vivo platelet and other cellular function studies, bioanalytical procedures, and quantification of blood-containing components, or to maintain extracorporeal blood circulation, such as in kidney replacement solutions (e.g., hemodialysis) or surgery (e.g., open heart surgery, such as coronary artery bypass surgery). In some embodiments, the kidney replacement solution can be used to treat a patient suffering from acute kidney injury. In some embodiments, the renal replacement solution can be a continuous renal replacement therapy.

In addition, the methods of the invention are useful for treating and preventing the pro-thrombotic complications of cancer. The method is useful for treating tumor growth as an adjunct to chemotherapy, for preventing angiogenesis, and for treating cancer, more particularly lung, prostate, colon, breast, ovarian and bone cancer.

Extracorporeal membrane oxygenation (ECMO)

As used herein, "extracorporeal membrane lung oxygenation" (or "ECMO") refers to extracorporeal life support with a blood pump, artificial lungs, and a vascular access cannula that is capable of providing circulatory support or generating a blood flow rate suitable for supporting blood oxygenation and optionally carbon dioxide removal. In the venous-venous ECMO, an extracorporeal gas exchange is provided to blood that has been withdrawn from the venous system; the blood is then re-infused into the venous system. In the venous-arterial ECMO, gas exchange is provided to blood withdrawn from the venous system and then infused directly into the arterial system to provide partial or complete circulation or cardiac support. The static-arterial ECMO allows for various degrees of respiratory support.

As used herein, "extracorporeal membrane lung oxygenation" or "ECMO" refers to extracorporeal life support that provides circulatory support or generates a blood flow rate sufficient to support blood oxygenation. In some embodiments, the ECMO comprises removing carbon dioxide from the blood of the subject. In some embodiments, the ECMO is performed using an extracorporeal device selected from the group consisting of a blood pump, an artificial lung, and a vascular access cannula.

As used herein, "venous-venous ECMO" refers to the class of ECMO: wherein blood is drawn from the venous system of a subject into an ECMO apparatus and subjected to gas exchange (including blood oxygenation) followed by re-infusion of the drawn blood into the venous system of the subject. As used herein, "arterio-venous ECMO" refers to the class of ECMO: wherein blood is drawn from the venous system of a subject into an ECMO apparatus and subjected to gas exchange (including blood oxygenation) followed by infusion of the drawn blood directly into the arterial system of the subject. In some embodiments, the static-arterial ECMO is performed to provide partial circulation or cardiac support to a subject in need thereof. In some embodiments, the static-arterial ECMO is performed to provide complete circulation or cardiac support to a subject in need thereof.

The compounds of the invention are useful for treating, preventing, or reducing the risk of thromboembolic disorders in a subject in need thereof, wherein the subject is exposed to an artificial surface, such as an extracorporeal membrane pulmonary oxygenation (ECMO) apparatus (see above), which may be used as a rescue therapy in response to heart or lung failure. The surface of the ECMO device that directly contacts the subject may be a thrombogenic surface that may lead to thromboembolic disorders such as venous thromboembolism (e.g., deep vein thrombosis or pulmonary embolism), resulting in difficulty in treating patients in need of ECMO. Clots in the circulation are the most common mechanical complication (19%). Large clots can lead to oxygenator failure, as well as pulmonary or systemic circulatory embolism.

ECMO is typically administered as an anticoagulant with continuous infusion of heparin to counteract clot formation. However, cannula placement can cause damage to the internal jugular vein, which causes significant internal bleeding. Bleeding occurs in 30-40% of patients receiving ECMO and can be life threatening. This severe bleeding is due to both the necessary continuous heparin infusion and platelet dysfunction. Approximately 50% of reported deaths are due to severe bleeding complications. Aubron et al Critical Care,2013,17: R73 focused on factors associated with ECMO results.

The compounds of the invention that are useful, for example, as factor XIa inhibitors are therefore contemplated as alternative replacements for heparin in ECMO therapy. The compounds of the present invention are envisaged to be effective agents that block endogenous pathways at the plasma level, which would provide effective anticoagulation/anti-thrombosis without significant bleeding tendency. In some embodiments, the subject is or has developed to be sensitive to heparin. In some embodiments, the subject is resistant to heparin or has developed resistance to heparin.

Ischemia of blood

An "ischemia" or "ischemic event" is a vascular disease that typically involves occlusion of a blood vessel or a limitation in the blood supply to a tissue. Ischemia can result in a deficiency of oxygen and glucose required for cellular metabolism. Ischemia is usually caused by problematic blood vessels that lead to tissue damage or dysfunction. Ischemia may also refer to local blood loss or hypoxia at a given site of the body caused by congestion (e.g., vasoconstriction, thrombosis, or embolism). Causes include embolism, thrombosis of atherosclerotic arteries, trauma, venous problems, aneurysms, cardiac conditions (e.g., myocardial infarction, mitral valve disease, chronic arterial fibrillation, cardiomyopathy, and prosthesis), trauma or traumatic injury (e.g., to an extremity producing partial or complete vascular occlusion), thoracic outlet syndrome, atherosclerosis, hypoglycemia, tachycardia, hypotension, external compression of blood vessels (e.g., by tumors), sickle cell disease, localized extreme cold (e.g., by freezing), tourniquet application, glutamate receptor stimulation, arteriovenous malformations, rupture of vital blood vessels supplying tissues or organs, and anemia.

A transient ischemic event generally refers to a transient (e.g., short-term) onset of neurological dysfunction caused by loss of blood flow (e.g., in the focal brain, spinal cord, or retina) without an acute infarction (e.g., tissue death). In some embodiments, the transient ischemic event lasts less than 72 hours, 48 hours, 24 hours, 12 hours, 10 hours, 8 hours, 4 hours, 2 hours, 1 hour, 45 minutes, 30 minutes, 20 minutes, 15 minutes, 10 minutes, 5 minutes, 4 minutes, 3 minutes, 2 minutes, or 1 minute.

Angioedema

Angioedema is a rapid swelling of the dermis, subcutaneous tissue, mucosa and submucosal tissue. Angioedema is generally classified as either hereditary or acquired.

"acquired angioedema" may be immunological, non-immunological, or idiopathic; caused by e.g. allergy, as a side effect of a drug, e.g. an ACE inhibitor drug.

"hereditary angioedema" or "HAE" refers to an inherited disorder that results in acute-phase edema (e.g., swelling) that can occur in almost all parts of the body, including the face, limbs, neck, throat, limbs, gastrointestinal tract, and genitalia. The onset of HAE is often life-threatening, with the severity depending on the affected area, for example, an abdominal attack can lead to ileus, while swelling of the larynx and upper airway can lead to asphyxiation. The pathogenesis of hereditary angioedema may be associated with the non-antagonistic activation of the contact pathway by the initially produced kallikrein or coagulation factor (e.g., factor XII).

Signs and symptoms include, for example, facial skills, swelling of the mucosa of the mouth or throat, and tongue. Itching, pain, hypoesthesia of the affected area, urticaria (i.e., pseudomembranous laryngitis), or wheezing of the airways may also be signs of angioedema. However, in hereditary angioedema, for example, there may be no associated pruritus or urticaria. HAE subjects can experience abdominal pain (e.g., abdominal pain lasting one to five days, abdominal attacks that increase the subject's white blood cell count), vomiting, weakness, watery diarrhea, or rash.

Bradykinin plays an important role in angioedema, particularly hereditary angioedema. Bradykinin is released by a variety of cell types in response to a variety of different stimuli and is a pain mediator. Interference with bradykinin production or degradation can lead to vascular edema. In hereditary angioedema, the continued production of kallikrein may promote bradykinin formation. Inhibition of kallikrein can interfere with bradykinin production; and treating or preventing angioedema.

The methods described herein can include administering to a subject in need thereof an effective amount of a pharmaceutical composition described herein.

In one aspect, the methods described herein can include those in which the subject's blood is in contact with an artificial surface. For example, provided herein is a method of treating a thromboembolic disorder in a subject in need thereof, the method comprising administering to the subject an effective amount of a pharmaceutical composition described herein, wherein the subject's blood is in contact with an artificial surface.

In another aspect, provided herein is a method of reducing the risk of a thromboembolic disorder in a subject in need thereof, the method comprising administering to the subject an effective amount of the pharmaceutical composition described herein, wherein the subject's blood is in contact with an artificial surface.

Also provided herein is a method of preventing a thromboembolic disorder in a subject in need thereof, the method comprising administering to the subject an effective amount of the pharmaceutical composition described herein, wherein the subject's blood is in contact with an artificial surface.

In some embodiments of the methods described herein, the artificial surface is in contact with blood in the circulatory system of the subject.

In some embodiments, the artificial surface is an implantable device, dialysis tubing, cardiopulmonary bypass ring, artificial heart valve, ventricular assist device, small bore graft, central venous catheter, or extracorporeal membrane pulmonary oxygenation (ECMO) apparatus.

In some embodiments, the artificial surface causes or is associated with a thromboembolic disorder.

In some embodiments, the thromboembolic disorder is venous thromboembolism, deep vein thrombosis, or pulmonary embolism.

In some embodiments, the thromboembolic disorder is a blood clot.

In some embodiments, the methods described herein further comprise conditioning the artificial surface with a separate dose of a pharmaceutical composition described herein before contacting the artificial surface with blood in the circulatory system of the subject.

In some embodiments, the methods described herein further comprise conditioning the artificial surface with a separate dose of a pharmaceutical composition described herein before or during administration of the pharmaceutical composition to the subject.

In some embodiments, the methods described herein further comprise conditioning the artificial surface with a separate dose of a pharmaceutical composition described herein before and during administration of the pharmaceutical composition to the subject.

In some embodiments of the methods described herein, the artificial surface is a cardiopulmonary bypass loop.

In some embodiments of the methods described herein, the artificial surface is an extracorporeal membrane pulmonary oxygenation (ECMO) apparatus. In some embodiments, the ECMO device is a venous-venous ECMO device or an arterial-venous ECMO device.

In another aspect, disclosed herein is a method of preventing or reducing the risk of a thromboembolic disorder in a subject during or after a medical procedure, the method comprising:

(i) administering to the subject an effective amount of a pharmaceutical composition described herein before, during, or after the medical procedure; and

(ii) contacting the subject's blood with an artificial surface;

thereby preventing or reducing the risk of thromboembolic disorders during or after medical procedures.

In some embodiments, the artificial surface is conditioned with a pharmaceutical composition described herein before, during, or after a medical procedure prior to administering the pharmaceutical composition to a subject.

In some embodiments, the pharmaceutical composition for conditioning an artificial surface further comprises a solution, wherein the solution is selected from the group consisting of saline solution, ringer's solution, and blood.

In some embodiments, the thromboembolic disorder is a blood clot.

In some embodiments, the medical procedure comprises one or more of: i) cardiopulmonary bypass, ii) oxygenating and pumping blood via extracorporeal membrane lung oxygenation, iii) assisting in pumping blood (internal or external), iv) hemodialysis, v) extracorporeal filtering of blood, vi) collecting the subject's blood in a reservoir for subsequent use in an animal or human subject, vii) using a venous or arterial intraluminal catheter, viii) using a device for diagnostic or interventional cardiac catheterization, ix) using an intravascular device, x) using an artificial heart valve, and xi) using an artificial graft.

In some embodiments, the medical procedure comprises cardiopulmonary bypass.

In some embodiments, the medical procedure comprises oxygenating and pumping blood via extracorporeal membrane pulmonary oxygenation (ECMO). In some embodiments, the ECMO is a venous-venous ECMO or an arterial-venous ECMO.

In some embodiments of the methods described herein, the subject is in contact with the artificial surface for at least 1 day (e.g., about 2 days, about 3 days, about 4 days, about 5 days, about 6 days, about 1 week, about 10 days, about 2 weeks, about 3 weeks, about 4 weeks, about 2 months, about 3 months, about 6 months, about 9 months, about 1 year).

In another aspect, provided herein is a method of treating blood in a subject in need thereof, the method comprising administering to the subject an effective amount of a pharmaceutical composition described herein.

In some embodiments of the methods described herein, the pharmaceutical composition is administered to the subject intravenously. In other embodiments of the methods described herein, the pharmaceutical composition is administered to the subject subcutaneously. In some embodiments, the pharmaceutical composition is administered to the subject as a continuous intravenous infusion. In some embodiments, the pharmaceutical composition is administered to the subject via bolus injection.

In some embodiments, the subject is a human. In some embodiments, the subject has an elevated risk of a thromboembolic disorder. In some embodiments, the thromboembolic disorder is the result of a surgical complication. In some embodiments, the subject is or has developed to be sensitive to heparin. In some embodiments, the subject is resistant to heparin or has developed resistance to heparin.

Pharmaceutical composition

The compositions described herein comprise a compound described herein (e.g., compound 1 or a pharmaceutically acceptable salt thereof) and an additional therapeutic agent (if present) in an amount effective to effect treatment of a disease or disease symptom (e.g., such as a disease associated with factor XIa or kallikrein).

Pharmaceutically acceptable carriers, adjuvants, and vehicles that may be used in the pharmaceutical compositions provided herein include, but are not limited to, ion exchangers, alumina, aluminum stearate, lecithin, self-emulsifying drug delivery systems (SEDDS) such as d-alpha-tocopheryl polyethylene glycol 1000 succinate, surfactants used in pharmaceutical dosage forms such as Tweens or other similar polymeric delivery matrices, serum proteins such as human serum albumin, buffer substances such as phosphates, glycine, sorbic acid, potassium sorbate, partial glyceride mixtures of saturated vegetable fatty acids, water, salts or electrolytes such as protamine sulfate, disodium hydrogen phosphate, potassium hydrogen phosphate, sodium chloride, zinc salts, colloidal silica, magnesium trisilicate, polyvinylpyrrolidone, cellulose-based substances, polyethylene glycol, sodium carboxymethylcellulose, polyacrylates, waxes, polyethylene-polyoxypropylene-block polymers, polyethylene-polyoxyethylene-block polymers, polyethylene glycol-polyoxyethylene-block polymers, and mixtures of such, Polyethylene glycol and lanolin. Cyclodextrins such as alpha-, beta-, and gamma-cyclodextrins, or chemically modified derivatives such as hydroxyalkyl cyclodextrins (including 2-and 3-hydroxypropyl-beta-cyclodextrins) or other solubilizing derivatives may also be advantageously used to enhance delivery of the compounds of the formulae described herein.

The pharmaceutical composition may be in the form of a solid composition (e.g., a lyophilized composition) that can be reconstituted prior to parenteral administration by the addition of a compatible reconstitution diluent; or in the form of a frozen composition suitable for thawing and, if desired, diluting with a compatible diluent prior to parenteral administration. In some embodiments, the pharmaceutical composition comprises a particle or powder (e.g., a lyophilized composition) dissolved in an aqueous medium (e.g., saline solution, dextrose solution) in a unit dose IV bag or vial at a concentration suitable for intravenous administration to a subject. In some embodiments, the components of a pharmaceutical composition suitable for intravenous administration are separated from each other in a single container, e.g., a powder comprising a compound described herein, or a pharmaceutically acceptable salt thereof, is separated from an aqueous medium such as a saline solution. In this latter example, the various components are separated by a seal that is capable of rupturing to bring the components into contact with one another to form a pharmaceutical composition suitable for intravenous administration.

In one aspect, provided herein is an aqueous pharmaceutical composition comprising a compound of formula (I-A),

or a pharmaceutically acceptable salt thereof, a cyclodextrin and an excipient.

In some embodiments, the pharmaceutical composition comprises a compound of formula (I-a), a cyclodextrin, and an excipient. In some embodiments, the cyclodextrin is selected from the group consisting of alkyl cyclodextrins, hydroxyalkyl cyclodextrins, carboxyalkyl cyclodextrins, and sulfoalkyl ether cyclodextrins. In some embodiments, the cyclodextrin is hydroxypropyl β -cyclodextrin. In some embodiments, the cyclodextrin is sulfobutylether beta-cyclodextrin.

In some embodiments, the excipient is a sugar (e.g., a saccharide (e.g., a monosaccharide, disaccharide, or polysaccharide)) or a sugar alcohol. For example, the excipient is sucrose, lactose, trehalose, dextran, erythritol, arabitol, xylitol, sorbitol, or mannitol, or a combination thereof. In some embodiments, the excipient is mannitol. In some embodiments, the excipient is lactose.

In some embodiments, the pharmaceutical compositions described herein further comprise a buffering agent. In some embodiments, the buffering agent is a single protic acid or a polyprotic acid, or a combination thereof. In some embodiments, the buffer is a solution of one or more substances. In some embodiments, the buffer is a solution of a salt of a weak acid and a weak base. In some embodiments, the buffer is a solution of a salt of a weak acid and a strong base. In some embodiments, the buffer is selected from the group consisting of a maleate buffer, a citrate buffer, and a phosphate buffer. In some embodiments, the buffer is a phosphate buffer. In some embodiments, the phosphate buffer is a solution of monosodium phosphate, disodium phosphate, trisodium phosphate, or a combination thereof.

In some embodiments, the pharmaceutical composition further comprises a solubilizing agent. In some embodiments, the solubilizing agent is a polyoxyethylene sorbitan ester (e.g., a polyoxyethylene sorbitan ester)20) Or polyethylene glycol (e.g., PEG 400).

In some embodiments, the amount of solubilizer is about 0.01% to about 1%, about 0.01% to about 0.9%, about 0.01% to about 0.8%, about 0.01% to about 0.7%, about 0.01% to about 0.6, about 0.01% to about 0.5%, about 0.01% to about 0.4%, about 0.01% to about 0.3%, about 0.01% to about 0.2%, about 0.01% to about 0.1%, or about 0.01% to about 0.05% by weight relative to the weight of the compound of formula (I-a).

In some embodiments, the pH of the composition is from about 2 to about 8 (e.g., from about 3 to about 7, from about 4 to about 7, from about 5 to about 6, from about 6 to about 7, from about 6 to about 8, from about 5 to about 8, from about 4 to about 8, or from about 3 to about 8). In some embodiments, the pH is from about 6 to about 8. In some embodiments, the pH is from about 6 to about 7. In some embodiments, the pH is about 7. In some embodiments, the pH is about 6.8.

In some embodiments, the compound of formula (I-A) is at a concentration of about 0.1mg/mL to about 100mg/mL, about 0.1mg/mL to about 80mg/mL, about 0.1mg/mL to about 60mg/mL, about 0.1mg/mL to about 40mg/mL, about 0.1mg/mL to about 20mg/mL, about 0.1mg/mL to about 10mg/mL, about 1mg/mL to about 100mg/mL, about 1mg/mL to about 80mg/mL, about 1mg/mL to about 60mg/mL, about 1mg/mL to about 40mg/mL, about 1mg/mL to about 20mg/mL, about 1mg/mL to about 10mg/mL, about 10mg/mL to about 100mg/mL, about 10mg/mL to about 80mg/mL, about 10mg/mL to about 60mg/mL, or, About 10mg/mL to about 40mg/mL, about 20mg/mL to about 100mg/mL, about 20mg/mL to about 80mg/mL, about 20mg/mL to about 60mg/mL, about 40mg/mL to about 100mg/mL, about 40mg/mL to about 80mg/mL, about 60mg/mL to about 100mg/mL, about 60mg/mL to about 80mg/mL, or about 80mg/mL to about 100 mg/mL.

In some embodiments, the concentration of the compound of formula (I-A) is about 0.1mg/mL, about 1mg/mL, about 2.5mg/mL, about 5mg/mL, about 10mg/mL, about 15mg/mL, about 20mg/mL, about 25mg/mL, about 30mg/mL, about 35mg/mL, about 40mg/mL, about 45mg/mL, or about 50 mg/mL. In some embodiments, the concentration of the compound of formula (I-A) is about 10 mg/mL. In some embodiments, the concentration of the compound of formula (I-A) is about 3 mg/mL. In some embodiments, the concentration of the compound of formula (I-A) is about 1 mg/mL.

In some embodiments, the buffer is at a concentration of about 1mM to about 500mM, about 1mM to about 250mM, about 1mM to about 100mM, about 1mM to about 50mM, about 1mM to about 20mM, about 1mM to about 10mM, 10mM to about 500mM, about 10mM to about 250mM, about 10mM to about 100mM, about 10mM to about 50mM, about 10mM to about 20mM, about 20mM to about 500mM, about 20mM to about 250mM, about 20mM to about 100mM, about 20mM to about 50mM, about 50mM to about 500mM, about 50mM to about 250mM, about 50mM to about 100mM, about 100mM to about 500mM, or about 100mM to about 250 mM.

In some embodiments, the buffer is at a concentration of about 5mM, about 10mM, about 15mM, about 20mM, about 25mM, about 30mM, about 40mM, about 50mM, about 60mM, about 70mM, about 80mM, about 90mM, about 100mM, about 110mM, about 120mM, about 130mM, about 140mM, about 150mM, about 160mM, about 170mM, about 180mM, about 190mM, about 200mM, about 210mM, about 220mM, about 230mM, about 240mM, about 250mM, about 300mM, about 350mM, about 400mM, about 450mM, or about 500 mM. In some embodiments, the concentration of the buffer is about 10 mM.

In some embodiments, the buffer is a phosphate buffer.

In some embodiments, the phosphate buffer is at a concentration of about 1mM to about 500mM, about 1mM to about 250mM, about 1mM to about 100mM, about 1mM to about 50mM, about 1mM to about 20mM, about 1mM to about 10mM, 10mM to about 500mM, about 10mM to about 250mM, about 10mM to about 100mM, about 10mM to about 50mM, about 10mM to about 20mM, about 20mM to about 500mM, about 20mM to about 250mM, about 20mM to about 100mM, about 20mM to about 50mM, about 50mM to about 500mM, about 50mM to about 250mM, about 50mM to about 100mM, about 100mM to about 500mM, or about 100mM to about 250 mM.

In some embodiments, the phosphate buffer is at a concentration of about 5mM, about 10mM, about 15mM, about 20mM, about 25mM, about 30mM, about 40mM, about 50mM, about 60mM, about 70mM, about 80mM, about 90mM, about 100mM, about 110mM, about 120mM, about 130mM, about 140mM, about 150mM, about 160mM, about 170mM, about 180mM, about 190mM, about 200mM, about 210mM, about 220mM, about 230mM, about 240mM, about 250mM, about 300mM, about 350mM, about 400mM, about 450mM, or about 500 mM. In some embodiments, the concentration of phosphate buffer is about 10 mM.

In some embodiments, the amount of cyclodextrin is about 0.1 wt% to about 10 wt%, about 0.1 wt% to about 7.5 wt%, about 0.1 wt% to about 5 wt%, about 0.1 wt% to about 3.5 wt%, about 0.1 wt% to about 1 wt%, about 1 wt% to about 10 wt%, about 1 wt% to about 7.5 wt%, about 1 wt% to about 5 wt%, about 3 wt% to about 10 wt%, about 3 wt% to about 7.5 wt%, or about 3 wt% to about 5 wt%, relative to the weight of the compound of formula (I-a). In some embodiments, the amount of cyclodextrin is about 1 wt%, 1.5 wt%, 2 wt%, 2.5 wt%, 3 wt%, 3.5 wt%, 4 wt%, 4.5 wt%, or 5 wt% relative to the weight of the compound of formula (I-a). In some embodiments, the amount of cyclodextrin is about 0.1 wt% to about 10 wt% (e.g., about 0.5 wt% to about 6 wt% (e.g., about 0.7 wt% to about 5.6 wt% (e.g., about 2.1 wt% to about 5 wt%)) relative to the weight of the compound of formula (I-a)). In some embodiments, the amount of cyclodextrin is about 3.5 wt% relative to the weight of the compound of formula (I-a). In some embodiments, the amount of cyclodextrin is about 5% by weight relative to the weight of the compound of formula (I-a).

In some embodiments, the cyclodextrin is hydroxypropyl β -cyclodextrin.

In some embodiments, the amount of excipient is about 0.1% to about 10%, about 0.1% to about 7.5%, about 0.1% to about 5%, about 0.1% to about 3.5%, about 0.1% to about 1%, about 1% to about 30%, about 1% to about 20%, about 1% to about 10%, about 1% to about 7.5%, about 1% to about 5%, about 3% to about 10%, about 3% to about 7.5%, about 3% to about 20%, about 3% to about 30%, about 5%, or about 5% to about 30% by weight relative to the weight of the compound of formula (I-a). In some embodiments, the amount of excipient is about 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 10, 20, or 30 weight percent relative to the weight of the compound of formula (I-a). In some embodiments, the amount of excipient is about 3% by weight relative to the weight of the compound of formula (I-a). In some embodiments, the amount of excipient is about 5% by weight relative to the weight of the compound of formula (I-a).

In some embodiments, the excipient is mannitol. In some embodiments, the excipient is lactose.

In another aspect, provided herein is a lyophilized formulation comprising a composition that, prior to lyophilization, corresponds to an aqueous pharmaceutical composition described herein (e.g., an aqueous pharmaceutical composition comprising a compound of formula (I-a), or a pharmaceutically acceptable salt thereof, a cyclodextrin, and an excipient). In some embodiments, a lyophilized formulation as described herein is reconstituted in an aqueous medium to prepare an aqueous pharmaceutical solution suitable for parenteral administration to a subject in need thereof.

In another aspect, provided herein is a pharmaceutical composition comprising particles, wherein the particles comprise a compound of formula (I-A),

or a pharmaceutically acceptable salt thereof, a cyclodextrin, and a filler.

In some embodiments, the pharmaceutical composition comprises a compound of formula (I-a), a cyclodextrin, and a filler. In some embodiments, the cyclodextrin is selected from the group consisting of alkyl cyclodextrins, hydroxyalkyl cyclodextrins, carboxyalkyl cyclodextrins, and sulfoalkyl ether cyclodextrins. In some embodiments, the cyclodextrin is hydroxypropyl β -cyclodextrin. In some embodiments, the cyclodextrin is sulfobutylether beta-cyclodextrin.

In some embodiments, the bulking agent is a sugar (e.g., a saccharide (e.g., a monosaccharide, disaccharide, or polysaccharide)) or a sugar alcohol. In some embodiments, the bulking agent is sucrose, lactose, trehalose, dextran, erythritol, arabitol, xylitol, sorbitol, or mannitol, or a combination thereof. In some embodiments, the bulking agent is mannitol. In some embodiments, the filler is lactose.

In some embodiments, the bulking agent is a lyoprotectant.

In some embodiments, the concentration of the compound of formula (I-a) is from about 0.1% to about 10%, from about 0.1% to about 7.5%, from about 0.1% to about 5%, from about 0.1% to about 3.5%, from about 0.1% to about 1%, from about 1% to about 10%, from about 1% to about 7.5%, from about 1% to about 5%, from about 3% to about 10%, from about 3% to about 7.5%, or from about 3% to about 5%, by weight of the composition. In some embodiments, the concentration of the compound of formula (I-a) is about 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, or 10% by weight of the composition. In some embodiments, the concentration of the compound of formula (I-a) is about 1% by weight of the composition. In some embodiments, the concentration of the compound of formula (I-a) is about 0.3% by weight of the composition.

In some embodiments, the amount of cyclodextrin is about 0.1 wt% to about 10 wt%, about 0.1 wt% to about 7.5 wt%, about 0.1 wt% to about 5 wt%, about 0.1 wt% to about 3.5 wt%, about 0.1 wt% to about 1 wt%, about 1 wt% to about 10 wt%, about 1 wt% to about 7.5 wt%, about 1 wt% to about 5 wt%, about 3 wt% to about 10 wt%, about 3 wt% to about 7.5 wt%, or about 3 wt% to about 5 wt%, relative to the weight of the compound of formula (I-a). In some embodiments, the amount of cyclodextrin is about 1 wt%, 1.5 wt%, 2 wt%, 2.5 wt%, 3 wt%, 3.5 wt%, 4 wt%, 4.5 wt%, or 5 wt% relative to the weight of the compound of formula (I-a). In some embodiments, the amount of cyclodextrin is about 0.1 wt% to about 10 wt% (e.g., about 0.5 wt% to about 6 wt% (e.g., about 0.7 wt% to about 5.6 wt% (e.g., about 2.1 wt% to about 5 wt%)) relative to the weight of the compound of formula (I-a)). In some embodiments, the amount of cyclodextrin is about 3.5 wt% relative to the weight of the compound of formula (I-a). In some embodiments, the amount of cyclodextrin is about 5% by weight relative to the weight of the compound of formula (I-a).

In some embodiments, the cyclodextrin is hydroxypropyl β -cyclodextrin.

In some embodiments, the amount of excipient is about 0.1% to about 10%, about 0.1% to about 7.5%, about 0.1% to about 5%, about 0.1% to about 3.5%, about 0.1% to about 1%, about 1% to about 30%, about 1% to about 20%, about 1% to about 10%, about 1% to about 7.5%, about 1% to about 5%, about 3% to about 10%, about 3% to about 7.5%, about 3% to about 20%, about 3% to about 30%, about 5%, or about 5% to about 30% by weight relative to the weight of the compound of formula (I-a). In some embodiments, the amount of excipient is about 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 10, 20, or 30 weight percent relative to the weight of the compound of formula (I-a). In some embodiments, the amount of excipient is about 3% by weight relative to the weight of the compound of formula (I-a). In some embodiments, the amount of excipient is about 5% by weight relative to the weight of the compound of formula (I-a).

In some embodiments, the excipient is mannitol. In some embodiments, the excipient is lactose.

In another aspect, provided herein is a method for preparing an aqueous pharmaceutical composition from a pharmaceutical composition described herein (e.g., a pharmaceutical composition comprising particles, wherein the particles comprise a compound of formula (I-a) or a pharmaceutically acceptable salt thereof, a cyclodextrin, and a filler), the method comprising reconstituting the pharmaceutical composition into an aqueous medium, thereby forming an aqueous composition. In some embodiments, the aqueous medium is deionized water. In some embodiments, the aqueous medium comprises sodium chloride. In some embodiments, the aqueous medium comprises about 5% dextrose.

In some embodiments, the composition is prepared for parenteral administration to a subject in need thereof. In some embodiments, the composition is prepared for intramuscular, subcutaneous, or intravenous administration to a subject in need thereof.

In some embodiments, the pH of the reconstituted composition is from about 2 to about 8 (e.g., from about 3 to about 7, from about 4 to about 7, from about 5 to about 6, from about 6 to about 7, from about 6 to about 8, from about 5 to about 8, from about 4 to about 8, or from about 3 to about 8). In some embodiments, the pH of the reconstituted composition is from about 6 to about 8. In some embodiments, the pH of the reconstituted composition is from about 6 to about 7. In some embodiments, the pH of the reconstituted composition is about 7. In some embodiments, the pH of the reconstituted composition is about 6.8.

In some embodiments, the concentration of the compound of formula (I-A) in the reconstituted composition is from about 0.01mg/mL to about 100mg/mL, from about 0.01mg/mL to about 50mg/mL, from about 0.01mg/mL to about 10mg/mL, from about 0.01mg/mL to about 1mg/mL, from about 0.01mg/mL to about 0.1mg/mL, from about 0.1mg/mL to about 100mg/mL, from about 0.1mg/mL to about 80mg/mL, from about 0.1mg/mL to about 60mg/mL, from about 0.1mg/mL to about 40mg/mL, from about 0.1mg/mL to about 20mg/mL, from about 0.1mg/mL to about 10mg/mL, from about 1mg/mL to about 100mg/mL, from about 1mg/mL to about 80mg/mL, from about 1mg/mL to about 60mg/mL, from about 1mg/mL to about 40mg/mL, or from about 40mg/mL, About 1mg/mL to about 20mg/mL, about 1mg/mL to about 10mg/mL, about 10mg/mL to about 100mg/mL, about 10mg/mL to about 80mg/mL, about 10mg/mL to about 60mg/mL, about 10mg/mL to about 40mg/mL, about 20mg/mL to about 100mg/mL, about 20mg/mL to about 80mg/mL, about 20mg/mL to about 60mg/mL, about 40mg/mL to about 100mg/mL, about 40mg/mL to about 80mg/mL, about 60mg/mL to about 100mg/mL, about 60mg/mL to about 80mg/mL, or about 80mg/mL to about 100 mg/mL.

In some embodiments, the concentration of the compound of formula (I-A) in the reconstituted formulation is about 0.01mg/mL, 0.03mg/mL, 0.05mg/mL, 0.1mg/mL, 0.3mg/mL, 0.5mg/mL, about 1mg/mL, about 2.5mg/mL, about 5mg/mL, about 10mg/mL, about 15mg/mL, about 20mg/mL, about 25mg/mL, about 30mg/mL, about 35mg/mL, about 40mg/mL, about 45mg/mL, or about 50 mg/mL. In some embodiments, the concentration of the compound of formula (I-A) is about 10 mg/mL. In some embodiments, the concentration of the compound of formula (I-A) is about 1 mg/mL. In some embodiments, the concentration of the compound of formula (I-A) is about 0.1 mg/mL. In some embodiments, the concentration of the compound of formula (I-A) is about 0.3 mg/mL. In some embodiments, the concentration of the compound of formula (I-A) is about 0.03 mg/mL.

Route of administration

The pharmaceutical compositions provided herein can be administered orally, rectally, or parenterally (e.g., intravenous infusion, intravenous bolus, inhalation, implant). As used herein, the term parenteral includes subcutaneous, intradermal, intravenous (e.g., intravenous infusion, bolus intravenous), intranasal, inhalation, pulmonary, transdermal, intramuscular, intraarticular, intraarterial, intrasynovial, intrasternal, intrathecal, intralesional and intracranial injection or other infusion techniques. The pharmaceutical compositions provided herein can comprise any conventional non-toxic pharmaceutically acceptable carrier, adjuvant or vehicle. In some cases, the pH of the formulation may be adjusted with pharmaceutically acceptable acids, bases, or buffers to enhance the stability of the formulated compound or its delivery form.

The pharmaceutical compositions may be in the form of sterile injectable preparations, for example, as sterile injectable aqueous or oleaginous solutions or suspensions. The suspension may be formulated according to techniques known in the art using suitable dispersing or wetting agents (e.g., such as Tween 80) and suspending agents. The sterile injectable preparation may also be a sterile injectable solution or suspension in a non-toxic parenterally-acceptable diluent or solvent, for example as a solution in 1, 3-butanediol. Among the acceptable vehicles and solvents that may be employed are mannitol, water, ringer's solution and isotonic sodium chloride solution. In addition, sterile, fixed oils are conventionally employed as a solvent or suspending medium. For this purpose, any bland fixed oil may be employed including synthetic mono-or diglycerides. Fatty acids such as oleic acid and its glyceride derivatives are useful in the preparation of injectables, as are natural pharmaceutically-acceptable oils, such as olive oil or castor oil, especially in their polyoxyethylated versions. These oil solutions or suspensions may also contain a long chain alcohol diluent or dispersant, or carboxymethyl cellulose or similar dispersing agents commonly used in formulating pharmaceutically acceptable dosage forms, such as emulsions and/or suspensions. Other commonly used surfactants such as Tweens or Spans or other similar emulsifying agents or bioavailability enhancers, which are commonly used in the manufacture of pharmaceutically acceptable solid, liquid, or other dosage forms, may also be used for formulation purposes. In some embodiments, the intravenous pharmaceutical composition comprises a carrier selected from 5% w/w dextrose water ("5 DW") and saline.

The pharmaceutical compositions provided herein can be administered orally in any orally acceptable dosage form including, but not limited to, capsules, tablets, emulsions, and aqueous suspensions, dispersions, and solutions. In the case of tablets for oral use, carriers which are commonly used include lactose and corn starch. Lubricating agents, such as magnesium stearate, are also typically added. For oral administration in capsule form, useful diluents include lactose and dried corn starch. When aqueous suspensions or emulsions are administered orally, the active ingredient may be suspended or dissolved in an oily phase combined with emulsifying or suspending agents. If desired, certain sweetening or flavoring agents or coloring or taste masking agents may be added.

The compounds described herein can be administered, for example, by injection, intravenously (e.g., intravenous infusion, bolus intravenous injection), intraarterially, subdermally, intraperitoneally, intramuscularly, or subcutaneously; or orally, buccally, nasally, transmucosally, topically, in a dosage range of about 0.5 to about 100mg/kg body weight, or in a dosage range of 1mg to 1000 mg/dose, every 4 to 120 hours, or as required by the particular drug. The methods herein contemplate administration of an effective amount of a compound or compound composition to achieve a desired or stated effect. Typically, the pharmaceutical compositions provided herein will be administered from about 1 to about 6 times per day (e.g., by bolus intravenous injection) or as a continuous infusion. Such administration can be used as a chronic or acute therapy. The amount of active ingredient that may be combined with the carrier materials to produce a single dosage form will vary depending upon the host treated and the particular mode of administration. Typical formulations will contain from about 5% to about 95% active compound (w/w). Alternatively, such formulations comprise from about 20% to about 80% active compound.

In some embodiments, the compound or pharmaceutical composition is administered to the subject intravenously. In some embodiments, the compound or pharmaceutical composition is administered to the subject subcutaneously. In some embodiments, the compound or pharmaceutical composition is administered to the subject as a continuous intravenous infusion. In some embodiments, the compound or pharmaceutical composition is administered to the subject via bolus injection. In some embodiments, the compound or pharmaceutical composition is administered to the subject via bolus injection, followed by continuous intravenous infusion.

In some embodiments, a pharmaceutical composition formulated for subcutaneous or intravenous administration is administered to a subject from 1 time per day to 6 times per day (e.g., 1 time per day, 2 times per day, or 4 times per day).

Combination of

In practicing the methods of the present invention, it may be desirable to administer the compounds of the present invention (e.g., factor XIa or kallikrein inhibitors) in combination with each other and with one or more other agents useful for achieving a therapeutically beneficial effect, such as antithrombotic or anticoagulant agents, antihypertensive agents, anti-ischemic agents, antiarrhythmic agents, platelet function inhibitors, and the like. For example, the methods of the invention may be performed by administering small molecule factor XIa or a kallikrein inhibitor in combination with small molecule factor XIa or a kallikrein inhibitor. More specifically, the methods of the invention may be performed by administering small molecule factor XIa or a kallikrein inhibitor in combination with: aspirin, clopidogrel, ticlopidine or CS-747, warfarin, low molecular weight heparins (such as LOVENOX), GPIIb/GPIIIa blockers, PAI-1 inhibitors such as XR-330 and T-686, P2Y1 and P2Y12 receptor antagonists; thromboxane receptor antagonists (such as ifetroban), prostacyclin mimetics, thromboxane a synthase inhibitors (such as picolitamide), serotonin-2-receptor antagonists (such as ketanserin); compounds that inhibit other coagulation factors such as FVII, FVIII, FIX, FX, prothrombin, TAFI and fibrinogen, or other compounds that inhibit FXI or kallikrein; fibrinolytic agents such as TPA, streptokinase, PAI-1 inhibitors, and inhibitors of alpha-2-antiplasmin such as anti-alpha-2-antiplasmin antibodies, fibrinogen receptor antagonists, inhibitors of alpha-1-antitrypsin, hypolipidemic agents such as HMG-CoA reductase inhibitors (e.g., pravastatin, simvastatin, atorvastatin, fluvastatin, cerivastatin, AZ4522, and itavastatin), and microsomal triglyceride transfer protein inhibitors (such as disclosed in U.S. Pat. nos. 5,739,135, 5,712,279, and 5,760,246); antihypertensive agents such as angiotensin converting enzyme inhibitors (e.g., captopril, lisinopril, or fosinopril); angiotensin-II receptor antagonists (e.g., irbesartan, losartan, or valsartan); ACE/NEP inhibitors (e.g., olpadriac and gemotritalc); or beta-blockers (such as propranolol, nadolol, and carvedilol). The methods of the invention may be performed by administering small molecule factor XIa or a kallikrein inhibitor in combination with an antiarrhythmic agent such as that used for atrial fibrillation (e.g., amiodarone or dofetilide). The methods of the invention may also be performed in combination with continuous renal replacement therapy for the treatment of, for example, acute renal injury.

In practicing the methods of the present invention, it may be desirable to administer a compound of the present invention (factor XIa or a kallikrein inhibitor) in combination with an agent that increases cAMP or cGMP levels in a cell to obtain a therapeutically beneficial effect. For example, the compounds of the invention may have beneficial effects when used in combination with phosphodiesterase inhibitors, including PDE1 inhibitors (such as those described in Journal of Medicinal Chemistry, Vol.40, p.2196 [1997 ]), PDE2 inhibitors, PDE3 inhibitors (such as Revicazinone, pimobendan or olprinone), PDE4 inhibitors (such as rolipram, cilomilast or pyraclostrobin), PDE7 inhibitors, or other PDE inhibitors such as dipyridamole, cilostazol, sildenafil, dibutylamine (denbutyline), theophylline (1, 2-dimethylxanthine), ARIFLOT. TM. (i.e. cis-4-cyano-4- [3- (cyclopentyloxy) -4-methoxyphenyl ] cyclohexane-1-carboxylic acid), arofyline, rofluoroflorine, C-112 11294A, CDC-C-801, BAY-19-8004, Simperidone, SCH351591, YM-976, PD-189659, mesiopram, pumafentrine, CDC-998, IC-485 and KW-4490.

The methods of the invention may be performed by administering a compound of the invention in combination with a thrombolytic agent, such as tissue plasminogen activator (natural or recombinant), streptokinase, reteplase, activise, lanopropase, urokinase, prourokinase, benzylated streptokinase plasminogen activator complex (ASPAC), animal salivary gland plasminogen activator, and the like.

The methods of the invention may be performed by contacting a compound of the invention with a beta-adrenergic agonist, such as salbutamol, terbutaline, formoterol, salmeterol, bitolterol, pirbuterol, or fenoterol; anticholinergic agents such as ipratropium bromide; anti-inflammatory corticosteroids such as beclomethasone, triamcinolone, budesonide, fluticasone, flunisolide or dexamethasone; and anti-inflammatory agents such as cromolyn, nedocromil, theophylline, zileuton, zafirlukast, montelukast (montelukast), and pranlukast (pranleukast).

Small molecule factor XIa or kallikrein inhibitors may act synergistically with one or more of the above agents. Thus, a reduced dose of thrombolytic agent may be used, thereby obtaining the beneficial effects of administering these compounds while minimizing potential bleeding and other side effects.

Course of treatment

The compositions described herein comprise an effective amount of a compound of the present invention (e.g., factor XIa or a kallikrein inhibitor), optionally in combination with one or more other agents (e.g., additional therapeutic agents) such as an antithrombotic or anticoagulant agent, an antihypertensive agent, an anti-ischemic agent, an antiarrhythmic agent, an inhibitor of platelet function, and the like, to achieve a therapeutically beneficial effect.

In some embodiments, the additional therapeutic agent is administered after administration of the composition of the invention. In some embodiments, the additional therapeutic agent is administered 15 minutes, 30 minutes, 1 hour, 2 hours, 4 hours, 6 hours, 8 hours, 10 hours, 12 hours, 14 hours, 18 hours, 24 hours, 48 hours, 72 hours, or more after administration of the composition of the invention. In some embodiments, the additional therapeutic agent is administered (e.g., orally) after discharge from a medical facility (e.g., hospital).

In some embodiments, a compound of the invention (e.g., factor XIa or a kallikrein inhibitor) and an additional therapeutic agent are co-formulated into a single composition or dose. In some embodiments, the compound of the invention (e.g., factor XIa or a kallikrein inhibitor) and the additional therapeutic agent are administered separately. In some embodiments, the compound of the invention (e.g., factor XIa or a kallikrein inhibitor) and the additional therapeutic agent are administered sequentially. In some embodiments, the compound of the invention (e.g., factor XIa or a kallikrein inhibitor) and the additional therapeutic agent are administered separately and sequentially. Typically, at least one compound of the invention (e.g., factor XIa or a kallikrein inhibitor) and an additional therapeutic agent are administered parenterally (e.g., intranasally, intramuscularly, buccally, by inhalation, by implantation, transdermally, intravenously (e.g., intravenous infusion, bolus injection), subcutaneously, intradermally, intranasally, pulmonary, transdermally, intraarticularly, intraarterially, intrasynovially, intrasternally, intrathecally, intralesionally, and intracranially, or other infusion techniques); orally taking; or rectally, e.g., intramuscularly or intravenously (e.g., intravenous infusion, bolus intravenous injection)). In some embodiments, a compound of the invention is administered parenterally (e.g., intranasally, buccally, intravenously (e.g., intravenous infusion, bolus injection), or intramuscularly). In some embodiments, the additional therapeutic agent is administered orally. In some embodiments, a compound of the invention (e.g., factor XIa or a kallikrein inhibitor) is administered parenterally (e.g., intranasally, buccally, intravenously (e.g., intravenous infusion, bolus injection), or intramuscularly) and an additional therapeutic agent is administered orally.

In some embodiments, the compositions of the present invention may be administered once or several times a day. The duration of treatment may, for example, follow a period of once per day for about 1,2, 3, 4, 5, 6, 7 days or more. In some embodiments, the treatment is chronic (e.g., lifetime). In some embodiments, a single dose in the form of a single dosage unit or several smaller dosage units is administered or by divided doses administered multiple times at specific intervals. For example, the dosage unit may be administered from about 0 hours to about 1 hour, from about 1 hour to about 24 hours, from about 1 hour to about 72 hours, from about 1 hour to about 120 hours, or from about 24 hours to at least about 120 hours after injury. Alternatively, the dosage unit may be administered about 0.5, 1, 1.5, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 30, 40, 48, 72, 96, 120 hours or more after the injury. Subsequent dosage units may be administered at any time after the initial administration such that a therapeutic effect is achieved. In some embodiments, the initial dose is administered orally. In some embodiments, the dose following the initial dose is parenteral (e.g., intranasal, intramuscular, buccal, inhalation, implant, transdermal, intravenous (e.g., intravenous infusion, bolus injection), subcutaneous, intradermal, intranasal, pulmonary, transdermal, intraarticular, intraarterial, intrasynovial, intrasternal, intrathecal, intralesional and intracranial injection, or other infusion techniques); orally taking; or rectal administration.

In some embodiments, the compositions of the present invention are administered orally, e.g., in a liquid or solid dosage form for ingestion, for about 5 minutes to about 1 week; about 30 minutes to about 24 hours, about 1 hour to about 12 hours, about 2 hours to about 12 hours, about 4 hours to about 12 hours, about 6 hours to about 10 hours; from about 5 minutes to about 1 hour, from about 5 minutes to about 30 minutes; from about 12 hours to about 1 week, from about 24 hours to about 1 week, from about 2 days to about 5 days, or from about 3 days to about 5 days. In one embodiment, the composition is administered orally in a liquid dosage form. In another embodiment, the composition is administered orally in a solid dosage form.

Where a subject undergoing treatment exhibits a partial response or relapses after completion of a first cycle of treatment, a subsequent course of treatment may be required to achieve a partial or complete therapeutic response (e.g., chronic treatment, such as lifetime).

In some embodiments, the compositions described herein are administered intravenously, e.g., as an intravenous infusion or bolus injection, for about 5 minutes to about 1 week; about 30 minutes to about 24 hours, about 1 hour to about 12 hours, about 2 hours to about 12 hours, about 4 hours to about 12 hours, about 6 hours to about 10 hours; from about 5 minutes to about 1 hour, from about 5 minutes to about 30 minutes; from about 12 hours to about 1 week, from about 24 hours to about 1 week, from about 2 days to about 5 days, or from about 3 days to about 5 days. In one embodiment, the compositions described herein are administered as an intravenous infusion for about 5, 10, 15, 30, 45, or 60 minutes or more; about 1,2, 4, 6, 8, 10, 12, 16, or 24 hours or more; about 1,2, 3, 4, 5, 6, 7, 8, 9, or 10 days or more.

Dosage and dosing regimen

An effective amount of a composition to be administered according to the present invention can be determined by one of ordinary skill in the art. The specific dose level and frequency of dosage for any particular subject may be varied and will depend upon a variety of factors including the activity of the specific compound employed, the metabolic stability and length of action of that compound, the species, age, body weight, general health, sex and diet of the subject, the mode and time of administration, rate of excretion, drug combination, and the severity of the particular condition.

In ameliorating the condition of a patient, a maintenance dose of a composition or combination provided herein can be administered as needed. Subsequently, the dose or frequency of administration, or both, may be reduced as the symptoms change to a level that maintains an improved condition when the symptoms are alleviated to a desired level. However, patients may require long-term intermittent treatment based on any recurrence of disease symptoms.

Examples

In order that the invention described herein may be more fully understood, the following examples are set forth. The starting materials and various intermediates described in the following examples can be obtained from commercial sources, prepared from commercially available organic compounds, or prepared using known synthetic methods. The examples described in this application are provided to illustrate the compounds provided herein and are not to be construed in any way as limiting the scope thereof.

General procedure

All non-aqueous phase reactions were run under a nitrogen atmosphere to maintain an anhydrous atmosphere and maximize yield. All reactions were stirred with the aid of a Teflon-coated stirring bar using an overhead stirring assembly or magnetically. The expression "dried by … …" means that the reaction product solution is dried by a specified drying agent and then the solution is filtered through a suitable filter paper or through a sintered glass funnel. The description "being concentrated", "concentrated under reduced pressure" or "evaporation" refers to the removal of the solvent under reduced pressure using a rotary evaporator. Chromatography or by chromatography means the use of flash column chromatography on silica gel unless otherwise indicated. Flash chromatography refers to column chromatography under gas pressure (e.g., nitrogen) or mechanical pumps that apply solvent pressure, such as with commercial systems supplied by Biotage or other suppliers. Proton NMR Spectroscopy (unless otherwise indicated) ((¹H) Measured at 400MHz and carbon NMR spectrum: (¹³C) Measured in a specified solvent at 100 MHz.

Abbreviations used in the experimental examples are listed in the following abbreviated tables.

Abbreviation list

Example 1 exemplary Synthesis of Compound 1. HCl

Non-limiting examples of the synthesis of (2S,3R) -3- [ (2-aminopyridin-4-yl) methyl ] -1- { [ (1R) -1-cyclohexylethyl ] carbamoyl } -4-oxoazetidine-2-carboxylic acid trifluoroacetate (structure 2 below), (4-bromomethyl) pyridin-2-yl ] (4-methoxybenzyl) carbamic acid tert-butyl ester (structure 3 below) and (R) - (1-isocyanatoethyl) cyclohexane (structure 8 below) can be found in U.S. Pat. No.9,499,532, which is incorporated herein by reference.

A. Synthesis of Compound 1. HCl from 2

Acetonitrile (12 mL; 10 volumes) was added to (2S,3R) -3- [ (2-aminopyridin-4-yl) methyl ] -1- { [ (1R) -1-cyclohexylethyl ] carbamoyl } -4-oxoazetidine-2-carboxylic acid trifluoroacetate (1.23 g; 2.52mmol) to produce a cloudy solution. The mixture was extracted twice with hexane (12 mL); it was then filtered (5 microns) to give a clear solution. The solution was concentrated to 6mL (5 volumes) at which time a suspension began to form. Concentrated HCl (0.42 mL; 2 equiv.) was added. Ether (2 × 12mL) was then added in two portions to induce the formation of a precipitate. The mixture was cooled to-1 ℃ for 15 minutes. The solid was collected, washed with cold ether and air dried to give 0.82g (79%) of (2S,3R) -3- [ (2-aminopyridin-4-yl) methyl ] -1- { [ (1R) -1-cyclohexylethyl ] carbamoyl } -4-oxoazetidine-2-carboxylic acid hydrochloride as a white solid.

The highly purified sample was prepared by slurrying the solid in ether (7.5 volumes). The product was collected, rinsed with ether and dried under vacuum at 50 ℃ overnight.

¹H NMR(400MHz,CD₃OD)ppmδ7.79(1H,d,J＝6.8Hz),6.99(1H,s),6.90(1H,dd,J＝1.5,6.8Hz),6.61(1H,d J＝8.8),4.28(1H,d,J＝2.8)3.70(2H,m),3.23(2H,m)1.75(5H,m)1.40(1H,m)1.25(3H,m)1.15(3H,d,J＝6.8Hz)1.00(2H,m).

HPLC retention time: 3.21 minutes. HPLC conditions: column, Zorbax 50 mm; the flow rate is 1.5 mL/min; 240 nm; at a temperature of 30 ℃; solvent a 1mL TFA/1L water; solvent B2.8 mL TFA/4L MeCN; gradient elution order: time is 0, a: B is 95: 5; linear gradient to 2:98A: B, within 6 min; from 1 minute the linear gradient returned to a: B ═ 95: 5.

B. Synthesis of Compound 1. HCl from 3

Step 1.4 preparation: (2S,3R) -3- {2- [ (tert-Butoxycarbonyl) (4-methoxybenzyl) amino ] pyridin-4-yl) methyl) -1- (tert-butyl (dimethyl) silyl ] -4-oxoazetidine-2-carboxylic acid.

A solution of (2S) -1-tert-butyl (dimethyl) silyl-4-oxoazetidine-2-carboxylic acid (175g, 0.763mol) and THF (2L) was cooled to-25 deg.C (internal temperature). A2M solution of LDA in THF (800mL, 2.1 equiv) was added dropwise while maintaining the temperature below-10 ℃. The reaction was stirred for 30 minutes and a gel-like suspension was formed. (4-bromomethyl) pyridin-2-yl is added dropwise](4-methoxybenzyl) carbamic acid tert-butyl ester (342g, 0.84mol, 1.12 eq, Structure 3) in THF (600mL) while the reaction was maintained below-5 ℃ for 2 hours, then stirred for an additional 30 minutes. The reaction is carried out by using 1M KHSO₄Aqueous solution (2L) quench. The layers were separated and the aqueous layer was extracted with EA (2L × 2). The combined organic phases were washed with brine (1 L.times.2) and dried (MgSO)₄) Filtered and concentrated to give (2S,3R) -3- {2- [ (tert-butoxycarbonyl) (4-methoxybenzyl) amino group as an oily product]Pyridin-4-yl) methyl) -1- (tert-butyl (dimethyl) silyl]4-oxoazetidine-2-carboxylic acid, which was used without purification (436g, 70% purity).

Step 2. preparation of compound 5: (2S,3R) -3- ({2- [ (tert-Butoxycarbonyl) (4-methoxybenzyl) amino ] pyridin-4-yl } methyl) -1- [ (tert-butyl (dimethyl) silyl ] -4-oxoazetidine-2-carboxylic acid 4-methoxybenzyl ester

The crude (2S,3R) -3- {2- [ (tert-butoxycarbonyl) (4-methoxybenzyl) amino group]Pyridin-4-yl) methyl) -1- (tert-butyl (dimethyl) silyl]-4-oxoazetidine-2-carboxylic acid was dissolved in DCM (2.5L) and EDC (137g, 0.714mol, 1.3 equiv.), PMBOH (76.2g, 0.55mol,1 equiv. based on 70% pure acid reagent) and DMAP (3.4g, 0.05 equiv.). The solution was stirred at room temperature overnight. The mixture was extracted with water (500mL) and brine (500mL) and dried (MgSO)₄) And concentrated. The crude oily residue was chromatographed (eluting with a gradient of 0% to 50% EA/hexanes) to give (2S,3R) -3- ({2- [ (tert-butoxycarbonyl) (4-methoxybenzyl) amino) as a colorless oil]Pyridin-4-yl } methyl) -1- [ (tert-butyl (dimethyl) silyl)]4-methoxybenzyl-4-oxoazetidine-2-carboxylate (250g, 48% yield, two steps).

¹H NMR(400MHz,CDCl₃)ppmδ8.24(1H,d,J＝5.5Hz),7.55(1H,s),7.22(2H,d,J＝8.8Hz),7.20(2H,d,J＝8.8Hz),6.89(1H,dd,J＝1.4,5.2Hz),6.87(2H,d,J＝8.6Hz),6.79(2H,d,J＝8.6Hz),5.09(2H,s),5.06(2H,s),3.81(3H,s),3.77(1H,d,J＝3.3Hz),3.76(3H,s),3.53(1H,m),3.06(1H,dd,J＝0.6,14.6Hz),2.99(1H,dd,J＝7.6,14.6Hz),1.41(9H,s),0.82(9H,s),0.19(3H,s),-0.05(3H,s).

Step 3. preparation of compound 6: 4-methoxybenzyl (2S,3R) -3- ({2- [ (tert-butoxycarbonyl) (4-methoxybenzyl) amino ] pyridin-4-yl } methyl) -4-oxoazetidine-2-carboxylate

To (2S,3R) -3- ({2- [ (tert-butoxycarbonyl) (4-methoxybenzyl) amino group first]Pyridin-4-yl } methyl) -1- [ (tert-butyl (dimethyl) silyl)]To a solution of 4-methoxybenzyl (314g, 0.465mol) 4-oxoazetidine-2-carboxylate and methanol (1.5L) was added acetic acid (112g, 1.87mol) followed by NH₄F (20.6g, 0.556mol, pre-dissolved in 1.2L of methanol). The mixture was stirred at room temperature for 2 hours. The reaction was concentrated. The residue was dissolved in EA (2L)In and adding saturated NaHCO₃Aqueous solution (2L). The phases were separated and the organic phase was dried (MgSO₄) And concentrated. The oily residue was chromatographed (eluting with a 0% to 40% EA/hexane gradient) to give a clear oil which was crystallized from EA/hexane (1:5) to give (2S,3R) -3- ({2- [ (tert-butoxycarbonyl) (4-methoxybenzyl) amino) as a white solid]Pyridin-4-yl } methyl) -4-oxoazetidine-2-carboxylic acid 4-methoxybenzyl ester (200g, 77% yield).

¹H NMR(400MHz,CDCl₃)ppmδ8.26(1H,d,J＝5.0Hz),7.55(1H,s),7.21(2H,d,J＝8.6Hz),7.19(2H,d,J＝8.6Hz),6.91(1H,dd,J＝1.5,5.0Hz),6.88(2H,d,J＝8.8Hz),6.79(2H,d,J＝8.8Hz),5.92(1H,s),5.10(2H,s),5.06(2H,s),3.87(1H,d,J＝2.5),3.81(3H,s),3.76(3H,s),3.56(1H,m),3.14(1H,dd,J＝5.8,14.6Hz),3.03(1H,dd,J＝8.1,14.6Hz),1.42(9H,s).

Preparation of step 47: 4-methoxybenzyl (2S,3R) -3- ((2- [ (tert-butoxycarbonyl) (4-methoxybenzyl) amino ] pyridin-4-yl } methyl) -1- ([ (1R) -1-cyclohexylethyl) carbamoyl } -4-oxoazetidine-2-carboxylate.

To a solution of 4-methoxybenzyl (2S,3R) -3- ({2- [ (tert-butoxycarbonyl) (4-methoxybenzyl) amino ] pyridin-4-yl } methyl) -4-oxoazetidine-2-carboxylate (210g, 0.374mol) and DCM (3L) was added TEA (188g, 1.86mol, 5 equiv.) and (R) - (1-isocyanatoethyl) cyclohexane (143g, 0.933mol, 2.5 equiv., Structure 8). The mixture was stirred at room temperature overnight. The reaction was concentrated. The residue was chromatographed (eluting with a gradient of 0% to 40% EA/hexanes) to give 4-methoxybenzyl (2S,3R) -3- ((2- [ (tert-butoxycarbonyl) (4-methoxybenzyl) amino ] pyridin-4-yl } methyl) -1- ([ (1R) -1-cyclohexylethyl) carbamoyl } -4-oxoazetidine-2-carboxylate (159g, 60% yield) as a white foam.

¹H NMR(400MHz,CDCI₃)ppmδ8.25(1H,d,J＝5.1Hz),7.61(1H,s),7.23(2H,d,J＝8.8Hz),7.15(2H,d,J＝8.6Hz),6.85(2H,d,J＝8.8Hz),6.80(2H,d J＝8.6Hz),6.23(1H,d,J＝9.1Hz),5.12(1H,d,J＝15.9),5.11(2H,s),5.04(1H,d,J＝12.1Hz),4.23(1H,d,J＝2.8Hz),3.80(3H,s),3.78(1H,m),3.76(3H,s),3.45(1H,m),3.15(1H,dd,J＝6.5,14.8Hz),3.01(1H,dd,J＝8.9,14.8Hz),1.74(4H,m),1.68(2H,m),1.41(9H,s),1.35(1H,m),1.21(2H,m),1.14(3H,d,J＝6.8Hz),0.98(2H,m).

Step 5. preparation of Compound 1. HCl

Trifluoroacetic acid (2.1L) was added to (2S,3R) -3- ((2- [ (tert-butoxycarbonyl) (4-methoxybenzyl) amino)]Pyridin-4-yl } methyl) -1- ([ (1R) -1-cyclohexylethyl) carbamoyl } -4-oxoazetidine-2-carboxylic acid 4-methoxybenzyl ester (283g, 0.396mol) gave a red solution. Addition of Et₃SiH (138g, 1.18mol,3 eq.) and the solution became colorless. The reaction was stirred at room temperature for 4 hours. TFA was removed in vacuo overnight to give (2S,3R) -3- [ (2-aminopyridin-4-yl) methyl ] amide as a white foam]-1- ([ (1R) -1-cyclohexylethyl)]Carbamoyl } -4-oxoazetidine-2-carboxylic acid trifluoroacetate salt.

Acetonitrile (1.8L) was added to the crude TFA salt to give a cloudy solution. The solution was clarified by filtration and the residue was washed with acetonitrile (100 mL). The combined acetonitrile solutions were extracted with hexane (1.8L. times.3). The acetonitrile solution was concentrated to about 900mL under reduced pressure. Concentrated HCI (66mL, 0.792mol, 2 equivalents) was slowly added to form a suspension. TBME (3L) was added slowly with stirring. The resulting suspension was cooled to 0 ℃ for 30 minutes. The solid precipitate was isolated by filtration and washed with TBME. The solid was air dried overnight and then dried under vacuum at 50 ℃ for 5 hours to give (2S,3R) -3[ (2-aminopyridin-4-yl) methyl ] -1- { [ (1R) -1-cyclohexylethyl ] carbamoyl } -4-oxoazetidine-2-carboxylic acid hydrochloride as a white powder (130g, 80% yield).

¹H NMR(400MHz,D₂O)ppmδ7.64(1H,d,J＝6.8Hz),6.84(1H,s),6.74(1H,dd,J＝1.5,6.8Hz),4.22(1H,d,J＝2.8Hz),3.75(1H,m),3.54(1H,m),3.17(2H,m),1.58(5H,m),1.22(1H,m),1.07(6H,m),0.89(2H,m).

Example 2 HPLC method parameters for analysis of Compound 1

The HPLC method parameters are summarized in table 1. A representative chromatogram of compound 1 is shown in figure 1.

TABLE 1 summary of the Process parameters for analysis of Compound 1

Example 3 Experimental setup for testing the equilibrium solubility of Compound 1 in common buffers

Compound 1 was tested for equilibrium solubility in a common buffer (table 2) at a buffer strength of 200mM (c (buffer)). For this purpose, samples of compound 1 with c (compound 1, target) 16mg/mL were prepared in different buffer solutions (table 3), mixed by vortexing and examined for solid residues. For the case where no solid residue was observed, the solution was optionally supplemented with additional solid compound 1. This process was repeated (observed hourly) until a solid residue remained readily observable. The sample was rotated at room temperature for 24 hours.

TABLE 2 buffer conditions and samples subjected to equilibrium solubility analysis

The samples with equilibrium solubility were clarified by centrifugation (bench top centrifuge, rcf ═ 16,100 × g, 10 minutes). The supernatant was subjected to HPLC analysis and compound 1 concentration was determined in triplicate using the HPLC method described in example 2. The pH of the supernatant was measured (table 3).

TABLE 3 equilibrium solubility data in different buffer solutions

Example 4 Experimental setup for testing the pH-dependent stability and pH Rate Profile of Compound 1

The stability of compound 1 was evaluated over a period of 10 days at several pH values (pH 2, 3, 4, 5, 6, 7, 8) and at two different temperatures (4 ℃,40 ℃). Samples of compound 1 with c (buffer) ═ 0.1mg/mL were prepared in standard buffer (table 2) at a buffer strength of c (buffer) ═ 100mM and incubated at T ═ 4 ℃ or T ═ 40 ℃ (protected from light during incubation and analysis). At an initial point in time (t)₀) And on days 1,2, 3, 4, 7 and 10 (Δ t ═ day × 24 hours), the concentration of compound 1 was assessed in such samples via HPLC analysis. The pH was monitored at the same time points during the 10 day period.

Over a 10 day period of these two temperatures, the pH of the sample solution was monitored (fig. 2A & 2B), and the recovery (R%) of compound 1 (fig. 3A & 3B) was calculated via:

and c (compound 1, theoretical) is 0.1mg/mL, and c (compound 1, actual) is determined by HPLC analysis via integration of compound 1 parent peak area.

Compound 1 is stable in aqueous buffered solutions over a wide pH range (pH 2-8) when stored at 4 ℃ in the dark. Significant degradation was observed at elevated temperatures (T ═ 40 ℃, in the dark). The trend of stability/pH-dependence is clear, with compound 1 tending to be more stable at low pH and less stable at higher pH. It can be excluded that the observed difference in stability may be due to a change in pH, since the pH of the study solution remained constant over the 10 days of the experiment. All solutions were clear throughout the experiment; no precipitation of the drug compound was observed.

EXAMPLE 5 solid State characterization of Compound 1. HCl

An exemplary sample of compound 1. HCl in solid state was evaluated by powder X-ray diffraction (XPRD) using a Rigaku Miniflex X-ray diffractometer (Cu-ka source, NaI-scintillation counter, U-30 kV, I-15 mA).

The solid compound 1. HCl (m 15-20mg) was analyzed in a zero background holder silicon (Si). Using 2 θ -scan (2 θ ═ 3 ° → 40 °, Δ 2 θ ═ 0.05 °, t_Counting20 seconds) was scanned in FT mode. The diffraction pattern obtained is shown on a 2 theta-scale in fig. 4A, and the sample size is shown in real space (d-scale) in fig. 4B. In addition, representative peaks from an exemplary XRD pattern of compound 1. HCl can be indicated by their values for 2 θ, d-spacing, and relative intensity (e.g., in table 4 below). At low d, the indication of a fully reflective plateau indicates proper sample alignment.

The defined peak pattern obtained for compound 1. HCl shows that the drug compound is crystalline, which may cause that a crystalline drug product will result from the drug compound pairing with a crystallization excipient, such as mannitol, alone during the lyophilization process. On the other hand, the use of amorphous excipients may shift the crystallization process towards amorphous drug products potentially containing enhanced properties with respect to reconstitution, dissolution and solubility.

TABLE 4 data of experimental powder XRD pattern for selection of compound 1. HCl

Example 6 Experimental setup and details for testing vehicle

Two additional vehicles: sodium citrate (50mM) and PBS (commercial) were formulated at different concentrations (table 5, table 6). The two vehicles were compounded at any concentration using the appropriate final sodium hydroxide concentration (0.1M NaOH stock solution).

TABLE 5 compounding information for citrate and PBS formulations

TABLE 6 concentration and recovery of citrate and PBS formulations (HPLC analysis)

PBS vehicle was compounded to two different pH values while citrate vehicle was compounded at different concentrations at the same target pH and tested for stability over the course of 24 hours (room temperature, protected from light). To evaluate the potential presence of particles by precipitation, a filtration step (0.2 μm microcentrifuge filter) was included at each time point.

In the case of sample No. 27, the amount of HCl (aqueous solution) (0.1M stock solution) added instead of the NaOH solution was mixed with 10 × PBS buffer solution, and added to the aqueous solution of compound 1 in a single step.

In the case of PBS formulations at low concentrations of compound 1 with c (compound 1) ═ 0.5mg/mL, the concentration of HCl (aqueous solution) or NaOH (aqueous solution) was carefully determined in iterative compounding titrations (see above). Compound 1 was confirmed to be stable in citrate buffer for 24 hours at; the loss is comparable to the degradation of compound 1 that is typically observed under the application conditions (ambient temperature). No precipitation of compound 1 was observed over this time frame.

Example 7 development of the lyophilization Process

A conservative lyophilization cycle was developed for lyophilization of the compound 1 target formulation (fig. 5). The freeze-drying cycle included an annealing step and a primary drying time of 20 hours. During cycle development, the annealing temperature and the preliminary drying temperature (shelf temperature) were varied to achieve optimal dryingCharacteristics and economical time of use. FIG. 5 shows shelf temperature (T) of lyophilizer as measured by Differential Scanning Calorimetry (DSC)_{Shelf board}) And exemplary parameters for early formulations of Compound 1, where Tg' is the glass transition temperature, T_{(melting, initiation)}As a melting start temperature, and T_(freezing)As the freezing temperature of the formulation.

Product temperature T due to the enthalpy of evaporation of the aqueous phase during the drying process (100 mTorr)_{Product of}Typically below the shelf temperature of the freeze dryer; below T-40 ℃, water vapor on ice approaches zero. The change in shelf temperature is carried out to achieve a slow preliminary drying, where the preliminary drying temperature is below the Tg' of the formulation (amorphous product) or the eutectic melting temperature (T)_euCrystalline product), but higher than T_{Product of}>-40 ℃. During test lyophilization, product vials were equipped with a temperature sensor to record T_{Product of}In the final cycle, at T_{Shelf board}T is observed at-35 ℃_{Product of}-38.5 ℃ (fig. 6). The end of the primary drying is determined by measuring the release of water vapour over time as a function of the pressure difference between the product chamber and the vacuum circuit of the freeze dryer (fig. 6). It should be noted that in the presence of certain excipients (e.g., mannitol) and at certain concentrations of those excipients, it may be well above Tg' or T_euThen the preliminary drying is completed.

The parameters for optimizing the lyophilization cycle can be seen in table 7. The residual moisture content of the lyophilized formulation vehicle was determined by thermogravimetric analysis (TGA) to be about 1.5-1.7% (w/w).

TABLE 7 details of lyophilization cycle procedure

The lyophilization cycle developed was successfully applied to the compound 1 formulation.

Example 8 exemplary formulations

The target product summary (TPP) is defined as:

c (Compound 1) 10mg/mL

Sodium phosphate buffer, pH 6.8,

minimum number and concentration of excipients (bulking agents, solubilizers) that facilitate robust preparation of lyophilized pharmaceutical products

Neutralization of compound 1. HCl during liquid compounding during preparation of lyophilized fill solutions

A limited formulation matrix of 108 formulations was produced. The matrix contained different concentrations of bulking agent, co-solvent, cyclodextrin (table 8); the concentrations of sodium phosphate (10mM) and API (10mg/mL) were kept constant.

TABLE 8 excipients evaluated in a constrained formulation test matrix

The formulations always contained mannitol or lactose as a filler, as well as varying amounts of cyclodextrin and co-solvent. The concentration of the filler is typically varied to maintain the osmolality (osmolality) within a suitable range. Lyophilization at increased total volume consistent with lower concentrations of all formulation components compared to final reconstitution strength was evaluated.

108 formulations (including the neutralizing compound 1. HCl) were compounded from stock solutions and lyophilized on a 1mL scale in triplicate and in duplicate using 5mL lyophilization vials. The concentration of the excipient, expressed as a percentage w/w, is relative to the weight of compound 1. The concentration of excipients in percent (w/w or w/v) can only be considered approximate and does not reflect the absolute w/w or w/v percent, since the neutralization compounding by stock solution involves dilution without regard to defined mass or volume ratios.

The following formulations represent the best, equally well performing candidates, with mannitol-containing formulations providing a more refined cake structure and lactose formulations achieving cleaner, less foam reconstitution.

Formulation 1: compound 1 at 10mg/mL, 10mM sodium phosphate, pH 6.8, 5% HP β CD, 3% mannitol

Formulation 2: compound 1 at 10mg/mL, 10mM sodium phosphate, pH 6.8, 5% HP β CD, 3% mannitol, 0.05% PEG400

Formulation 3: compound 1 at 10mg/mL, 10mM sodium phosphate, pH 6.8, 5% HP β CD, 5% lactose

Formulation 4: compound 1 at 10mg/mL, 10mM sodium phosphate, pH 6.8, 5% HP β CD, 5% lactose, 0.05% PEG400

Formulation 5: compound 1 at 10mg/mL, 10mM sodium phosphate, pH 6.8, 3.5% HP β CD, 3% mannitol

Formulation 6: compound 1 at 10mg/mL, 10mM sodium phosphate, pH 6.8, 3.5% HP β CD, 5% lactose

Example 9 preparation of formulation 5 on an increased laboratory Scale

Formulation 5 was prepared at a 210mL scale to a target concentration of c (compound 1) 10 mg/mL. First, a liquid fill solution is compounded, including neutralization of the compound 1. HCl component, then the lyophilization vessel is filled and lyophilized. Applications V_{Container with a lid}Amber lyophilization container of 20mL and V_{Filling in}Fill volume of 5 mL.

The fill solution was compounded from stock solutions at given multiple concentrations:

i. compound 1 stock aqueous solution, c (compound 1) 40mg/mL, [4X ]

ii.10% mannitol stock solution (w/v), [3.33X ]

iii 28% HP β CD stock solution (w/w), [8X ]

iv.500mM sodium hydroxide stock solution [12.82X ]

v.100mm aqueous sodium phosphate buffer, pH 6.8[10 ×).

To prepare the fill solution, a residual volume of water was added to the compound 1 stock solution under constant stirring to reach the target concentration. Subsequently, mannitol and HP β CD stock solutions were dispensed into the mixture, followed by the addition of sodium hydroxide stock solution to yield final c (naoh) 39 mM. In the final step, 10X sodium phosphate buffer was added and the solution was allowed to cool to ambient temperature.

Mannitol, HP β CD and buffer stock solutions (0.2 μm PES membrane, 20mm syringe filter, Acrodisc super EKV) were filtered prior to compounding without any difficulty observed. Under optimal cleaning conditions, the ready compounded lyophilized fill solution was also filtered (0.2 μm PES membrane, 20mm syringe filter, Acrodisc super EKV) before dispensing into lyophilized vials.

The 40 resulting compact packages of freeze-dried vials were placed in the center of the freeze-drying and placed on the center shelf of the freeze dryer product chamber. The product vial is surrounded by a vial filled with buffer solution. The lyophilization cycle developed from example 7 was applied to the lyophilization of product vials; the vial was manually stoppered after the vacuum was released to ambient air.

Example 10 reconstitution and reconstitution stability of lyophilized Compound 1 drug product

In-use DI water V_{DI water}After reconstitution of 5mL, the lyophilized compound 1 drug product was subjected to the reconstitution test and stability test for 6 hours.

The lyophilized cake was easily reconstituted within 10-20 seconds. The solution during reconstitution appeared very foamy and contained many bubbles, which became clear within about 2 minutes of adding the reconstituted solution. Residual microbubbles on the walls of the vessel can be removed by vortexing (2 seconds) or sonication (2 seconds). The reconstituted solution appeared clear and colorless. The pH of the reconstituted solution was measured at pH 6.81; the osmolality is determined asThe reconstituted solution is almost free of particulate matter, as counted by liquid particles (LPC, HIAC: V)_{Sample (I)}＝5mL，n_{Operation of}Discard run 1 ═ 4, f_{Dilution of}＝10，V_{Nominal, container}2mL) and a cumulative count of 3200 particles of 10 μm size and 667 particles of 25 μm size.

Recovery of compound 1 was monitored for 24 hours after reconstitution to test the use stability of the reconstituted solution (table 9).

TABLE 9 excipients evaluated in a constrained formulation test matrix

Recovery ofBecause of V_{Filling in}Solution ═ V_{DI water, reconstitution}(ii) a # different dilutions were used for preparing HPLC samples

Current phosphate-based formulations containing HP β CD and mannitol showed a loss of approximately 7% of compound 1 recovery over the course of 24 hours.

Example 11 compatibility with infusion vehicle and storage of use of reconstituted Compound 1 formulation

The compatibility of the reconstituted compound 1 formulation with two infusion vehicles (saline (NS) and 5% dextrose in water (D5W)) was tested for two concentrations (high/low) of c (compound 1, target) and c (compound 1, target) 1.0mg/mL and after Δ t 4 hours under ambient conditions (table 10). The average% recovery is relative to t₀Reconstituted drug product diluted in DI water.

TABLE 10 evaluation of compatibility with infusion vehicle

Recovery ofBecause of V_{Filling solution}＝V_{DI water, reconstitution}；

Both the infusions NS and D5W were compatible with the reconstituted compound 1 drug product at the tested concentrations and over the course of 4 hours under ambient temperature and light conditions.

Example 12 compatibility of reconstituted Compound 1 formulations with vials and stoppers

The reconstituted compound 1 formulation tested for contact time Δ t 1 hr at c (compound 1, target) 10mg/mL under ambient conditions for compatibility with aseptically manufactured vials and stoppers (table 17). The average% recovery is relative to reconstituted drug product not contacted with the test material.

TABLE 11 evaluation of compatibility with manufacturing vials and stoppers

Recovery ofBecause of V_{Filling solution}＝V_{DI water, reconstitution}。

Table 11 shows that the vial and stopper materials tested were compatible with the reconstituted compound 1 drug product at the tested concentrations and over the course of 1 hour under ambient temperature and light conditions.

Example 13 compatibility of reconstituted Compound 1 formulation with sterile Filter

The feasibility of sterile processing was evaluated and three different filter materials were tested for compatibility with the reconstituted compound 1 formulation. Aseptic processing is a commonly proposed method of sterilization of compound 1, as compound 1 contains reduced stability at elevated temperatures and only dry sterilization cycles (T160 ℃, T120 minutes) are suitable for lyophilizing pharmaceutical products as a final sterilization option.

Filter compatibility of reconstituted compound 1 drug product was tested with different filter materials (table 17) composed of Polyethersulfone (PES), nylon, and polyvinylidene fluoride (PVDF). To this end, let V_{Filter passing through}The corresponding filters were passed through for a volume of 10mL, and the recovery of compound 1 was determined for the first 10% and last 10% of the filtered volume (table 12).

TABLE 12 evaluation of compatibility with sterilizing Filter

Recovery ofBecause of V_{Filling solution}＝V_{DI water, reconstitution}。

The average% recovery is relative to reconstituted drug product not contacted with the test material. No increase in back pressure was observed with any of the tested filters. No significant loss in compound 1 recovery was observed at the filter pass volumes and concentrations studied.

Example 14 compatibility of reconstituted Compound 1 formulation with infusion bags and IV systems

The reconstituted compound 1 formulation was tested for compatibility with two infusion bags (different volumes and materials) and two IV lines at c (compound 1) ═ 0.1mg/mL (table 13). After injection of the reconstituted drug product solution into the NS-filled infusion bag, i) directly after mixing with the infusion vehicle (t)₀Table 14) and ii) the recovery of compound 1 was measured after 10 minutes of contact with the infusion bag (table 15). In addition, storage in infusion bags under ambient temperature and light conditions was evaluated for Δ t 6 hours (table 15). The average% recovery is relative to reconstituted drug product not contacted with the test material.

TABLE 13 infusion bag and IV System materials tested

Table 14 evaluation of compatibility with infusion bags at t 0.

Recovery ofBecause of V_{Filling solution}＝V_{DI water, reconstitution}。

TABLE 15 evaluation of compatibility with infusion bags when stored in infusion bags for 10 min and 6 hours

Recovery ofBecause of V_{Filling solution}＝V_{DI water, reconstitution}。

By filling the IV line with diluted (NS) drug product solution and bringing V at a flow rate of 5mL/min_{Flow Through (FT)}Compatibility of both IV systems with reconstituted drug product solutions was evaluated by flowing 101mL through the respective IV systems. i) Immediately (V)_FT0mL), ii) at V_FTAfter 10mL and iii) at V_FTAfter 100mL V was collected_{Sample (I)}Flow through sample 1 mL. Flow through sample was determined for recovery of Compound 1 and compared with t₀The infusion solutions in the reservoirs were compared (table 16).

TABLE 16 evaluation of compatibility with IV System

Recovery of

The infusion bag and IV system materials tested were compatible with the reconstituted compound 1 drug product at the tested concentrations and exposure times. Although stored in the infusion bag for up to 6 hours and t₀The concentration of compound 1 in the corresponding infusion vehicle was unchanged compared (approximately 1 minute after exposure), but it appeared that some of the compound 1 material was adsorbed by the infusion bag material immediately after contact. Thus, the observed change in recovery of compound 1 was independent of the surface area of the test infusion bag, but appeared to be dependent on the infusion bag material. Infusion bag No. 1 (Viaflo) showed a lesser degree of adsorption of compound 1 than infusion bag No. 2 (Viaflex).

Both IV systems appear to be inert to binding of compound 1; no change in compound 1 recovery was observed after compound 1 solution resulting from dilution of reconstituted drug product solution was passed through either IV test system.

Example 15 materials and devices

TABLE 17 materials

TABLE 18. apparatus

EXAMPLE 16 Long term stability Studies

An exemplary long-term stability study of compound 1 lyophilized drug product is shown in fig. 7-9 (T ═ 80 ℃, T ═ 20 ℃, and T ═ 2-8 ℃, respectively). By collecting the initial time points (t)₀) And subjecting the required amount of sample to the corresponding test conditions to begin the study. Stability of compound 1 lyophilized drug product was evaluated after 1 month, 3 months, 6 months, 9 months, and 12 months. The test includes appearance, reconstitution time, reconstitution appearance, recovery&Impurities (HPLC assay), pH and LPC (HIAC, particulate).

Example 17 Compounding (Compounding) method for Compound 1 liquid injectable formulations

A compounding method for a liquid formulation of compound 1 (designed for dilution in an infusion vehicle) was developed with 3.0mg/mL of compound 1 (or 3.13mg/mL of compound 1 free base equivalent), Phosphate Buffered Saline (PBS), and a pH of 6.4-7.2. The compounding method was applied over a wide range of scales (25-500 mL).

Compounding of pharmaceutical products requires a neutralization step using 0.5N sodium hydroxide solution and buffered with PBS to adjust the pH to a value compatible with IV infusion. The compounding process also requires a filtration step, which also serves as an aseptic process. Minimal or no loss of compound 1 was observed.

Dilution of the compounded formulation into the infusion vehicle: saline, 5% dextrose in water (D5W) and lactated ringer's solution (buffered and unbuffered). The dilution in physiological saline was performed at 100-fold and 600-fold dilutions.

The compound 1 formulation was stable at 2-8 ℃ for at least one week with a nominal degradation < 4%. Compound 1 was observed to be within error of sample preparation, so it is feasible that no measurable degradation occurred during the time frame studied. The resulting infusion of c (compound 1) to 0.03mg/mL was stable at ambient temperature for at least 48 hours when the compound 1 formulation was diluted into physiological saline. The pH was constant over 48 hours and no significant loss of recovery of compound 1 was observed. The purity of compound 1 appeared to be unchanged within 48 hours, and the chromatographic trace recorded after 48 hours showed no additional peaks or growth of the observed degradants (figure 10).

EXAMPLE 18 Effect study of Compound 1 in Hunter dog cardiopulmonary bypass model

The objective of this study was to demonstrate the efficacy of compound 1 in preventing activation of coagulation components when using cardiopulmonary bypass (CPB) cycles during extended runtime on day 1 in a mixed breed hound model compared to standard of care (SOC) heparin. The study design is shown in table 19:

TABLE 19 Experimental design (target dose of Compound 1)^b)

NA-not applicable

^aAnimal number 1001 received 0.6. mu.g/mL and animal number 1004 received 3 mg/mL.

^bThe doses indicated are the target of administration in this study; actual dose values are shown in the results section.

The following parameters and endpoints were evaluated in this study: mortality, body weight, body, clinicopathological parameters (hematology and coagulation), clotting time, and bioanalytical parameters.

Design of experiments

Administration of drugs

Dosing vehicle and test article were administered once on day 1 via Intravenous (IV) infusion for 135 minutes (starting 30 minutes before beginning cardiopulmonary bypass (CPB) and continuing for 105 minutes of CPB). Group 2 animals received a bolus IV dose of 0.6 μ g/mL or 3.0mg/mL immediately prior to the start of the IV infusion. Animals in groups 3, 4 and 5 received a 10mg/kg IV bolus dose prior to starting the IV infusion; wherein the CPB machine was primed with 10. mu.g/mL of test article.

Surgical procedure

The infusion pump of group 1 is set to an open system/reservoir. Compound 1 infusion was started 30 minutes before animals were placed on the CPB pump. The CPB pump was primed with 0.9% saline.

The infusion pumps of groups 2, 3 and 4 are configured as open systems/reservoirs. Venous and arterial sheaths were flushed with compound 1 at a concentration of 10 μ g/mL. The IV bolus dose of the test article was administered immediately prior to the start of infusion. Compound 1 infusion was started 30 minutes before animals were placed on the CPB pump. CPB patients were perfused with 10 μ g/mL of compound 1 before the CPB pump was started.

The infusion pumps of group 5 were set up as a closed system/"bag". The venous and arterial sheaths were then flushed with 10 μ g/mL of Compound 1. Compound 1 IV bolus dose was administered immediately prior to the start of infusion. Compound 1 infusion was started 30 minutes before animals were placed on the CPB pump.

Results

Figure 11 shows the pressure gradient evaluated across the membrane oxygenator. Previous studies performed without anticoagulant showed that the pressure across the membrane oxygenator was built up within 15 minutes of pump start-up and increased exponentially over the next 30 minutes, causing the oxygenator to block and the cycle to stop, while for compound 1 at multiple doses, the pressure gradient across the membrane oxygenator remained consistent throughout the run, indicating that the test article successfully maintained anticoagulation, allowing pump operation to continue throughout the protocol.

Figure 12 shows the correlation between compound 1 plasma concentration and aPTT. All animals survived until the end of the study. In summary, compound 1 was not associated with any increase in morbidity or mortality at the dose levels used in this study during cardiopulmonary bypass/ECMO protocols.

During compound 1 infusion and prior to CPB, aPTT was moderately to significantly prolonged in all animals (fig. 13). Prolongation of aPTT continued throughout compound 1 infusion and CPB. In the group receiving the loading dose of compound 1 (groups 2 to 5), the prolongation of aPTT was most pronounced before CPB (groups 3 to 5) or during the first 30 minutes of CPB (group 2), but then improved slightly before reaching steady state. Group 1 animals did not receive a compound 1 loading dose and the extension of aPTT remained relatively consistent at all measured time points during compound 1 infusion in this group. In all groups after discontinuation of compound 1 infusion and CPB, aPTT trended towards baseline values but remained moderately prolonged at the end of the study.

Conclusion

Administration of compound 1 to the model successfully prevented activation of coagulation in the cardiopulmonary bypass fraction. The anticoagulant effect of compound 1 is selective for inhibition of the activated partial thromboplastin time (aPTT). In addition, the data indicate that addition of bolus doses immediately prior to initiation of infusion enables rapid achievement of target plasma levels of compound 1 as well as desired steady state levels, and is sufficient to achieve successful 105-minute CPB runs and prevent clotting in most circulating components.

Taken together, these data indicate that compound 1 may be an acceptable alternative to heparin in preventing coagulation in components of cardiopulmonary bypass.