Abstract:
The invention relates to novel compositions and methods of using maribavir which enhance its effectiveness in medical therapy, as well as to maribavir isomers and methods of use thereof for counteracting the potentially adverse effects of maribavir isomerization in vivo in the event it occurs.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
       [0001]    The present application claims the benefit of U.S. Provisional Patent Application No. 61/407,637, filed Oct. 28, 2010, the entire disclosure of which is incorporated by reference herein. 
     
    
     BACKGROUND OF THE INVENTION 
       [0002]    The present invention relates to compositions and methods for enhancing the therapeutic efficacy of the compound 5,6-dichloro-2-(isopropylamino)-1-(β-L-ribofuranosyl)-1H-benzimidazole (also known as 1263W94 and maribavir), as well as to maribavir isomers and a method of making such isomers. 
         [0003]    5,6-dichloro-2-(isopropylamino)-1-(β-L-ribofuranosyl)-1H-benzimidazole is a benzimidazole derivative useful in medical therapy. U.S. Pat. No. 6,077,832 discloses 5,6-dichloro-2-(isopropylamino)-1-(β-L-ribofuranosyl)-1H-benzimidazole and its use for the treatment or prophylaxis of viral infections such as those caused by herpes viruses. The compound as disclosed in U.S. Pat. No. 6,077,832 is an amorphous, non-crystalline material. 
         [0004]    The structure of 5,6-dichloro-2-(isopropylamino)-1-(β-L-ribofuranosyl)-1H-benzimidazole is: 
         [0000]    
       
                 
         
             
             
         
       
     
         [0005]    The preparation of certain unique crystalline forms and solvate forms of maribavir, as well as pharmaceutical formulations thereof and their use in therapy are described in U.S. Pat. Nos. 6,469,160 and 6,482,939. 
         [0006]    The present invention has arisen out of the unexpected discovery that maribavir may isomerize under in vivo conditions to one or more configurational stereoisomers or constitutional isomers. The maribavir compound contains 4 (four) chiral carbon centers in the ribofuranosyl moiety and therefore maribavir is just one of 16 (sixteen) potential stereoisomers that may be formed under various in vivo conditions. 
         [0007]    Under in vivo conditions, maribavir can isomerize to other compounds that may (or may not) have the same or similar chemical, physical and biological properties. The in vivo isomerization of maribavir results in conversion of maribavir to other isomers that have the same molecular formula but a different molecular structure. The different molecular structures can be grouped into isomers that have different connectivity of the constituent atoms (constitutional isomers) or grouped into isomers that have the same “connectivity” but differ in the way the atoms and groups of atoms are oriented in space (configurational stereoisomers). Such molecular conversion in vivo is believed to result in the dilution of the effective maribavir concentration in the host that was treated with maribavir. The in vivo isomerization transforms and distributes dosed maribavir material into other molecular entities that do not necessarily have the same or similar biological activity. If the isomerization results in the formation of isomers that have a lower degree of corresponding biological activity relative to the activity of maribavir, then the isomerization will decrease the effective biological activity of maribavir dose administered to a host. 
         [0008]    A recent maribavir Phase 3 clinical trial conducted by ViroPharma Incorporated (the 300 Study) that evaluated maribavir for cytomegalovirus (CMV) prophylaxis in allogeneic stem cell, or bone marrow, transplant (SCT) patients did not achieve its primary endpoint. In the primary analysis, there was no statistically significant difference between maribavir and placebo in reducing the rate of CMV disease. In addition, the study failed to meet its key secondary endpoints (ViroPharma Press Release dated Feb. 9, 2009). The 300 Study result appeared at first blush to be inconsistent with an earlier proof-of-concept (POC) maribavir Phase 2 clinical trial (the 200 Study) wherein ViroPharma reported positive preliminary results that showed that maribavir inhibited CMV reactivation in SCT patients. The data from this study demonstrate that prophylaxis with maribavir displays strong antiviral activity, as measured by significant reduction in the rate of reactivation of CMV in recipients of allogeneic stem cell (bone marrow) transplants, and that administration of maribavir for up to 12 weeks has a favorable tolerability profile in this very sick patient population (ViroPharma Press Release date Mar. 29, 2006). 
         [0009]    However, the 300 Study result can be explained in terms of the instant maribavir isomerization theory/discovery. An unrecognized key difference between the 200 Study and the 300 Study was that the former provided for a fasted dosing protocol of maribavir, whereas the latter allowed the dosing protocol to be either under fasted or fed conditions (at the discretion of the clinician). The nature of the patient population in the 300 Study suggests that probably very few patients were dosed under the strict fasted dosing protocol that was previously used in the 200 Study. The change in dosing protocol in the 300 Study changed not only the in vivo dosing conditions for maribavir, but also the nature and/or degree of isomerization of maribavir that occurs in vivo, so that more maribavir was isomerized to other less effective compounds, thereby reducing the effective bioavailable concentration of maribavir drug below levels necessary to adequately prevent CMV infection and/or CMV re-activation in the host. 
         [0010]    The degree and nature of the isomerization of maribavir depends on the particular in vivo conditions to which the drug is exposed, which are variable. The potential mechanisms for isomerizing maribavir in vivo are by chemical isomerization (acid, base and/or metal catalyzed isomerization), microbially-mediated isomerization, and/or host metabolism induced isomerization. See, for example, Okano, Kazuya, Tetrahedron, 65: 1937-1949 (2009); Kelly, James A. et al., J. Med. Chem., 29: 2351-2358 (1986); and Ahmed, Zakaria et al., Bangladesh J. Sci. Ind. Res., 25(1-4): 90-104 (2000). 
         [0011]    Thus, maribavir should be formulated, administered, packaged and promoted in ways that will prevent or at least reduce the unwanted occurrence of maribavir isomerization in vivo, thereby enhancing the drug&#39;s bioavailability and efficacy, and/or counteract the potential adverse effect(s) of maribavir isomerization in vivo, if it occurs. 
       SUMMARY OF THE INVENTION 
       [0012]    The invention generally relates to the unexpected discovery that maribavir may isomerize under in vivo conditions to one or more configurational stereoisomers and/or constitutional isomers. Aspect of the invention is illustrated below. 
         [0000]    
       
                 
         
             
             
         
       
     
         [0013]    The practical applications of the instant discovery and related inventions are as follows:
       (1) The invention includes methods of making maribavir isomers under in vivo conditions (method of administering maribavir as a prodrug to make other maribavir isomers).   (2) The invention includes methods dosing maribavir so as to mitigate the impact of in vivo maribavir isomerization (such as dosing under fasted conditions, or increasing the dose of maribavir).   (3) The invention includes maribavir formulations that effectively mitigate the adverse effects of in vivo maribavir isomerization (quick release formulations, delayed/controlled release formulations, combination with antacids, intravenous (IV) formulations, combination formulations with antibiotics to prevent microbial isomerization).   (4) The invention includes methods of using one or more maribavir isomers to prevent or treat disease in host (as antivirals, for example for treating/preventing CMV, EBV, HCV).   (5) The invention includes methods of using one or more maribavir isomers as reference standards in analytical methods for monitoring the blood plasma concentrations of maribavir and related isomers.   (6) The invention includes methods of monitoring maribavir and maribavir isomers, and using the information to adjust treatment protocols (increase/decrease dose, change dosing regimen fed/fasted, discontinue maribavir therapy, start other therapy). The analytical methods for monitoring in vivo maribavir concentrations must be able discriminate between maribavir and maribavir isomers (for example chiral chromatography, and in particular LC-MS-MS using a chiral sorbent material in the LC column).   (7) The invention includes a method of more safely and effectively using maribavir to treat or prevent disease in humans by including information and guidance in the product label and/or promotional materials to inform the public as to how to use the maribavir product so as to avoid or to mitigate the adverse impact of in vivo maribavir isomerization, and thus optimize therapeutic efficacy and safety.   (8) The invention includes the corresponding inventions related to the maribavir isomers that are pyranosyl constitutional isomers of maribavir.       
 
         [0022]    The present invention also relates to a package or kit comprising therapeutically effective dosage forms of maribavir, prescribing information and a container for the dosage form. The prescribing information includes advice to a patient receiving maribavir therapy regarding the administration of maribavir without food to improve bioavailability. 
       DETAILED DESCRIPTION OF THE INVENTION 
       [0023]    The following table contains list of useful dosing protocols that may be used to improve the efficacy and safety for treating a patient with maribavir. 
         [0000]    
       
         
               
               
               
               
               
             
           
               
                   
                   
               
               
                   
                   
                   
                 Fasting 
                   
               
               
                   
                 Maribavir 
                   
                 conditions 
                 Route of admin- 
               
               
                   
                 dosing 
                 Dosing 
                 (before/after 
                 istration and 
               
               
                   
                 Protocol 
                 amount 
                 dosing) 
                 dosage form. 
               
               
                   
                   
               
             
             
               
                   
                 01 
                 3200 mg/ 
                 None 
                 Oral - tablet - 
               
               
                   
                   
                 2 x day 
                   
                 immediate release 
               
               
                   
                 02 
                 3200 mg/ 
                 None 
                 IV 
               
               
                   
                   
                 2 x day 
               
               
                   
                 03 
                 1600 mg/ 
                 None 
                 Oral - tablet - 
               
               
                   
                   
                 2 x day 
                   
                 w/antacids 
               
               
                   
                 04 
                 1600 mg/ 
                 None 
                 Oral- tablet - 
               
               
                   
                   
                 1 x day 
                   
                 w/antibiotics 
               
               
                   
                 05 
                 800 mg/ 
                 None 
                 Oral- tablet - 
               
               
                   
                   
                 3 x day 
                   
                 delayed release 
               
               
                   
                 06 
                 800 mg/ 
                 None 
                 Oral- tablet - 
               
               
                   
                   
                 2 x day 
                   
                 immediate release 
               
               
                   
                 07 
                 800 mg/ 
                 None 
                 IV 
               
               
                   
                   
                 1 x day 
               
               
                   
                 08 
                 400 mg/ 
                 None 
                 Oral - tablet - 
               
               
                   
                   
                 4 x day 
                   
                 w/antacids 
               
               
                   
                 09 
                 400 mg/ 
                 None 
                 Oral- tablet - 
               
               
                   
                   
                 3 x day 
                   
                 w/antibiotics 
               
               
                   
                 10 
                 400 mg/ 
                 None 
                 Oral- tablet - 
               
               
                   
                   
                 2 x day 
                   
                 delayed release 
               
               
                   
                 11 
                 400 mg/ 
                 None 
                 Oral - tablet - 
               
               
                   
                   
                 1 x day 
                   
                 immediate release 
               
               
                   
                 12 
                 3200 mg/ 
                 12 hrs/ 
                 IV 
               
               
                   
                   
                 2 x day 
                 3 hrs 
               
               
                   
                 13 
                 3200 mg/ 
                 12 hrs/ 
                 Oral - tablet - 
               
               
                   
                   
                 2 x day 
                 3 hrs 
                 w/antacids 
               
               
                   
                 14 
                 1600 mg/ 
                 12 hrs/ 
                 Oral- tablet - 
               
               
                   
                   
                 2 x day 
                 3 hrs 
                 w/antibiotics 
               
               
                   
                 15 
                 1600 mg/ 
                 12 hrs/ 
                 Oral- tablet - 
               
               
                   
                   
                 1 x day 
                 3 hrs 
                 delayed release 
               
               
                   
                 16 
                 800 mg/ 
                 12 hrs/ 
                 Oral- tablet - 
               
               
                   
                   
                 3 x day 
                 3 hrs 
                 immediate release 
               
               
                   
                 17 
                 800 mg/ 
                 12 hrs/ 
                 IV 
               
               
                   
                   
                 2 x day 
                 3 hrs 
               
               
                   
                 18 
                 800 mg/ 
                 12 hrs/ 
                 Oral - tablet - 
               
               
                   
                   
                 1 x day 
                 3 hrs 
                 w/antacids 
               
               
                   
                 19 
                 400 mg/ 
                 12 hrs/ 
                 Oral- tablet - 
               
               
                   
                   
                 4 x day 
                 3 hrs 
                 w/antibiotics 
               
               
                   
                 20 
                 400 mg/ 
                 12 hrs/ 
                 Oral- tablet - 
               
               
                   
                   
                 3 x day 
                 3 hrs 
                 delayed release 
               
               
                   
                 21 
                 400 mg/ 
                 12 hrs/ 
                 Oral - tablet - 
               
               
                   
                   
                 2 x day 
                 3 hrs 
                 immediate release 
               
               
                   
                 22 
                 400 mg/ 
                 12 hrs/ 
                 Oral- tablet - 
               
               
                   
                   
                 1 x day 
                 3 hrs 
                 immediate release 
               
               
                   
                 23 
                 3200 mg/ 
                 6 hrs/ 
                 Oral - tablet - 
               
               
                   
                   
                 2 x day 
                 2 hrs 
                 immediate release 
               
               
                   
                 24 
                 3200 mg/ 
                 6 hrs/ 
                 IV 
               
               
                   
                   
                 2 x day 
                 2 hrs 
               
               
                   
                 25 
                 1600 mg/ 
                 6 hrs/ 
                 Oral - tablet - 
               
               
                   
                   
                 2 x day 
                 2 hrs 
                 w/antacids 
               
               
                   
                 26 
                 1600 mg/ 
                 6 hrs/ 
                 Oral- tablet - 
               
               
                   
                   
                 1 x day 
                 2 hrs 
                 w/antibiotics 
               
               
                   
                 27 
                 800 mg/ 
                 6 hrs/ 
                 Oral- tablet - 
               
               
                   
                   
                 3 x day 
                 2 hrs 
                 delayed release 
               
               
                   
                 28 
                 800 mg/ 
                 6 hrs/ 
                 Oral- tablet - 
               
               
                   
                   
                 2 x day 
                 2 hrs 
                 immediate release 
               
               
                   
                 29 
                 800 mg/ 
                 6 hrs/ 
                 IV 
               
               
                   
                   
                 1 x day 
                 2 hrs 
               
               
                   
                 30 
                 400 mg/ 
                 6 hrs/ 
                 Oral - tablet - 
               
               
                   
                   
                 4 x day 
                 2 hrs 
                 w/antacids 
               
               
                   
                 31 
                 400 mg/ 
                 6 hrs/ 
                 Oral- tablet - 
               
               
                   
                   
                 3 x day 
                 2 hrs 
                 w/antibiotics 
               
               
                   
                 32 
                 400 mg/ 
                 6 hrs/ 
                 Oral- tablet - 
               
               
                   
                   
                 2 x day 
                 2 hrs 
                 delayed release 
               
               
                   
                 33 
                 400 mg/ 
                 6 hrs/ 
                 Oral - tablet - 
               
               
                   
                   
                 1 x day 
                 2 hrs 
                 immediate release 
               
               
                   
                 34 
                 3200 mg/ 
                 3 hrs/ 
                 IV 
               
               
                   
                   
                 2 x day 
                 1 hr 
               
               
                   
                 35 
                 3200 mg/ 
                 3 hrs/ 
                 Oral - tablet - 
               
               
                   
                   
                 2 x day 
                 1 hr 
                 w/antacids 
               
               
                   
                 36 
                 1600 mg/ 
                 3 hrs/ 
                 Oral- tablet - 
               
               
                   
                   
                 2 x day 
                 1 hr 
                 w/antibiotics 
               
               
                   
                 37 
                 1600 mg/ 
                 3 hrs/ 
                 Oral- tablet - 
               
               
                   
                   
                 1 x day 
                 1 hr 
                 delayed release 
               
               
                   
                 38 
                 800 mg/ 
                 3 hrs/ 
                 Oral- tablet - 
               
               
                   
                   
                 3 x day 
                 1 hr 
                 immediate release 
               
               
                   
                 39 
                 800 mg/ 
                 3 hrs/ 
                 IV 
               
               
                   
                   
                 2 x day 
                 1 hr 
               
               
                   
                 40 
                 800 mg/ 
                 3 hrs/ 
                 Oral - tablet - 
               
               
                   
                   
                 1 x day 
                 1 hr 
                 w/antacids 
               
               
                   
                 41 
                 400 mg/ 
                 3 hrs/ 
                 Oral- tablet - 
               
               
                   
                   
                 4 x day 
                 1 hr 
                 w/antibiotics 
               
               
                   
                 42 
                 400 mg/ 
                 3 hrs/ 
                 Oral- tablet - 
               
               
                   
                   
                 3 x day 
                 1 hr 
                 delayed release 
               
               
                   
                 43 
                 400 mg/ 
                 3 hrs/ 
                 Oral - tablet - 
               
               
                   
                   
                 2 x day 
                 1 hr 
                 immediate release 
               
               
                   
                 44 
                 400 mg/ 
                 3 hrs/ 
                 Oral- tablet - 
               
               
                   
                   
                 1 x day 
                 1 hr 
                 immediate release 
               
               
                   
                   
               
             
          
         
       
     
         [0024]    In carrying out the method of the invention, it is preferably to determine the presence and/or concentration of maribavir isomers, especially isomers of diminished therapeutic efficacy in patient blood plasma samples as part of the method. 
         [0025]    As used herein, the terms “fasted conditions”, “fasting conditions” and “without food” are defined to mean, in general, the condition of not having consumed food during the period between from at least about 3 to 12 hours prior to the administration of maribavir to at least about 1 to 3 hours after the administration of maribavir. Other narrower “fasted conditions” are also contemplated herein and described below. 
         [0026]    The term “with food” is defined to mean, in general, the condition of having consumed food prior to, during and/or after the administration of maribavir that is consistent with the relevant intended definition of “fasted conditions” (which may be narrow or broad depending on the circumstances). Preferably, the food is a solid food sufficient bulk and fat content that it is not rapidly dissolved and absorbed in the stomach. More preferably, the food is a meal, such as breakfast, lunch or dinner. 
         [0027]    The term “isomers” means compounds that have the same molecular formula but a different molecular structure. 
         [0028]    The term “constitutional isomers” is defined to mean isomers that have the same molecular formula but a different molecular structure wherein the molecular structures of the isomers have different connectivity of the constituent atoms. 
         [0029]    The term “configurational stereoisomers” is defined to mean isomers that have the same “connectivity” but differ in the molecular structure in the way the atoms and groups of atoms are oriented in space. 
         [0030]    The term “immediate release” is defined to mean release of drug from drug formulation by dissolution is less than 60 minutes or is otherwise release from the drug formulation in less than 60 minutes. 
         [0031]    The term “IV” is defined to mean intravenous. 
         [0032]    The chemical structure of maribavir and some maribavir isomers are shown below. The instant invention contemplates novel formulations, dosage levels and methods of use of maribavir, the maribavir isomers MFI-01 to MFI-015 (configurational stereoisomers), as well as the maribavir isomers MPI-01 to MPI-016 (constitutional isomers). The invention also contemplates the corresponding acyclic constitutional isomers wherein the sugar moiety is an open chain and attached to the benzimidazole. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0033]      FIG. 1  shows chemical structures of maribavir and maribavir configurational stereoisomers that have the same configuration at the furanosyl anomer carbon. 
           [0034]      FIG. 2  shows chemical structures of maribavir configurational stereoisomers that have the opposite configuration at the furanosyl anomer carbon. 
           [0035]      FIG. 3  shows chemical structures of maribavir “pyranosyl” constitutional isomers) 
       
    
    
       [0036]    A number of patent and non-patent documents are cited in the foregoing specification in order to describe the state of the art to which this invention pertains. The entire disclosure of each of these citations is incorporated by reference herein. 
         [0037]    While certain of the preferred embodiments of the present invention have been described and specifically exemplified above, it is not intended that the invention be limited to such embodiments. Various modifications may be made thereto without departing from the scope and spirit of the present invention, as set forth in the following claims. Furthermore, the transitional terms “comprising”, “consisting essentially of” and “consisting of” define the scope of the appended claims, in original and amended form, with respect to what unrecited additional claim elements or steps, if any, are excluded from the scope of the claims. The term “comprising” is intended to be inclusive or open-ended and does not exclude additional, =recited elements, methods step or materials. The phrase “consisting of” excludes any element, step or material other than those specified in the claim, and, in the latter instance, impurities ordinarily associated with the specified materials. The phrase “consisting essentially of” limits the scope of a claim to the specified elements, steps or materials and those that do not materially affect the basic and novel characteristic(s) of the claimed invention. All compositions or formulations identified herein can, in alternate embodiments, be more specifically defined by any of the transitional phases “comprising”, “consisting essentially of” and “consisting of”.