Patent Description:
Benign prostatic hyperplasia (BPH) and its associated lower urinary tract symptoms (LUTS) are common in aging men. Histopathologically, BPH is characterized by an increased number of epithelial and stromal cells in the periurethral portion of the prostate. This is manifest by the appearance of microscopic nodules which progressively proliferate and enlarge to increase the mass of both the glandular and stromal prostatic tissue.

Testosterone has been proposed to be involved in the development of BPH. In the prostate, the nuclear membrane bound enzyme 5alpha-reductase converts the hormone testosterone to dihydrotestosterone (DHT). That DHT is important in causing hyperplasia is supported by the clinical observation that inhibition of 5alpha-reductase can reduce DHT levels by as much as <NUM>% - <NUM>% in the prostate and, in turn, reduce prostate volume and BPH symptoms. 5alpha-reductase inhibitors, such as finasteride and dutasteride, have been used to treat BPH worldwide.

The proliferation of stromal cells in BPH is a major contributor to development of this disease. Active smooth muscle tone is regulated by the adrenergic nervous system. Stimulation of the alpha1- adrenergic receptors mediates active tension in prostatic smooth muscle and results in an increase in prostatic urethral resistance. Alpha1-adrenoceptor antagonists, such as tamsulosin and alfuzosin, can relieve urethral obstruction associated with BPH.

The use of 5alpha-reductase inhibitors are slow-acting, associated with sexual side effects. Alpha1-adrenoceptor antagonists are more effective and fast acting, but can produce vasodilator side effects. Furthermore, these pharmacotherapies are primarily effective in mild to moderate stages of the disease. There is a clear need for improved pharmacotherapy for benign prostatic hyperplasia and lower urinary tract symptoms.

Prostate cancer is mostly a very slow progressing disease and starts in the gland cells. The prostate cancer starts with tiny alterations in the shape and size of the prostate gland cells - Prostatic intraepithelial neoplasia (PIN). Nearly <NUM>% of all <NUM>-year-old men have PIN. Any patient who was found to have high-grade PIN after a prostate biopsy is at a significantly greater risk of having cancer cells in his prostate.

A number of growth factors and cytokines have been implicated in the development of BPH and/or PIN. It has been argued that members of the FGF, IGF and TGF families, in particular, contribute to the progression of BPH. Staining for VEGF, VEGFR-<NUM>, VEGFR-<NUM> and CD105 positive microvessels was reported in human BPH tissues. This suggests an active role for VEGF in the pathological process of BPH.

These data suggest that regulation of growth factor and cytokine signaling pathways through the use of multikinase receptor inhibitors would be a novel strategy for the prevention and/or treatment of proliferative and fibrotic disorders of prostate and urinary tract and their associated symptoms.

<NPL>, discloses that treatment with nintendanib could decrease low grade prostatic intra-epithelial neoplasia and increase healthy epithelium.

<NPL>, discloses that the administration of regorafenib and sorafenib in the treatment of prostatic intra-epithelial neoplasia (PIN). However, while sorafenib had a positive effect on PIN, regorafenib had no effect on PIN lesions.

Embodiments of the invention provide agents that possess a certain spectrum of multikinase inhibitor activities and are useful in the treatment of prostatic disease or disorder associated with epithelial hyperplasia and/or fibrosis, wherein the prostatic disease or disorder is fibrosis of ureters and renal pelvis, or prostatic intraepithelial neoplasia, comprising: administering an effective amount of a multikinase inhibitor to an animal or human, wherein the multikinase inhibitor is lenvatinib. The references to methods of treatment in the summary and detailed description of the invention in this description are to be interpreted as references to the compounds, pharmaceutical compositions and medicaments of the present invention for use in a method for treatment of the human (or animal) body by therapy (or for diagnosis).

Embodiments of the disclosure are also directed to the therapeutic or prophylactic uses of such compounds and compositions, and to methods for treating prostatic disease or disorder associated with epithelial hyperplasia and/or fibrosis.

In one aspect, the disclosure provides agents which possess a certain spectrum of multikinase inhibitor activities and are accordingly useful in methods of treatment of disease states and/or disorders associated with benign prostate hyperplasia or lower urinary tract symptoms in humans. More specifically, the disclosure is also directed to the therapeutic or prophylactic uses of such compounds and compositions, and to methods of treating disease states and/ or disorders associated with benign prostate hyperplasia and its associated lower urinary tract symptoms, fibrosis of ureters and renal pelvis, prostate adenoma, and prostatic intraepithelial neoplasia.

In one aspect, the disclosure provides a method for treating/preventing benign prostate hyperplasia and its associated lower urinary tract symptoms by administering a therapeutically effective amount of a multikinase inhibitor to a human subject in need of such treatment or prevention, wherein the multikinase inhibitor may include, but not limited to, sunitinib, regorafenib, ponatinib, pazopanib, nintedanib and lenvatinib. The prostatic disease or disorder is selected from the group consisting of benign prostate hyperplasia and its associated lower urinary tract symptoms, fibrosis of ureters and renal pelvis, prostate adenoma, and prostatic intraepithelial neoplasia in animals and humans.

Embodiments of the invention relate to preventing and/or treating fibrosis of ureters and renal pelvis, and prostatic intraepithelial neoplasia in animals and humans.

A composition of the invention may comprise a multikinase inhibitor or a pharmaceutically acceptable salt thereof, which is lenvatinib. As used herein, the term "multikinase inhibitor" refers to an inhibitor that can inhibit multiple kinases. As used herein, the term "pharmaceutically acceptable salts" refer to derivatives of the disclosed compounds wherein the parent compound is modified by making acid or base salts thereof.

Examples of pharmaceutically acceptable salts include, but are not limited to, mineral or organic acid salts of basic residues such as amines; alkali or organic salts of acidic residues such as carboxylic acids; and the like. The pharmaceutically acceptable salts include the conventional non-toxic salts or the quaternary ammonium salts of the parent compounds/molecules formed, for example, from non-toxic inorganic or organic acids. For example, such conventional non-toxic salts may include those derived from inorganic acids such as hydrochloric acid.

In accordance with some embodiments, the present invention also includes pharmaceutical compositions which contain, as an active ingredient, one or more of the compounds/molecules of the invention herein together with at least one pharmaceutically acceptable carrier, diluent or excipient.

In some embodiments, compounds/molecules of the present invention may be administered by parenteral, intramuscular, intradermal, subcutaneous, topical, intraperitoneal, intralesional, perilesional, intraprostatic, periprostatic, transrectal, and transurethral routes.

The dosage will depend on the route of administration, the severity of the disease, age and weight of the patient and other factors normally considered by the attending physician, when determining the individual regimen and dosage level as the most appropriate for a particular patient. That is, a therapeutically effective amount would be based on the patient (age, weight, etc.), the disease conditions, the route of administration, etc. One skilled in the art would be able to determine a therapeutically effective amount without inventive efforts.

In accordance with embodiments of the invention, the administration regimen could be before (induction) surgery, post-surgery (at or before trauma/acute inflammation, proliferation, remodeling, through maturation).

In accordance with embodiments of the invention, for preparing pharmaceutical compositions from the compounds/molecules of this invention, inert, pharmaceutically acceptable carriers can be either solid or liquid.

The term composition is intended to include the formulation of the active component or a pharmaceutically acceptable salt with a pharmaceutically acceptable carrier. For example, this invention may be formulated by means known in the art into the form of, for example, aqueous or oily solutions, suspensions, emulsions, creams, ointments, gels, and for parenteral use sterile aqueous or oily solutions or suspensions or sterile emulsions.

Liquid form compositions include solutions, suspensions, and emulsions. Sterile water or water-propylene glycol solutions of the active compounds/molecular may be mentioned as an example of liquid preparations suitable for parenteral administration. Liquid compositions can also be formulated in solution in aqueous polyethylene glycol solution. Aqueous solutions for oral administration can be prepared by dissolving the active component in water and adding suitable colorants, flavoring agents, stabilizers, and thickening agents as desired. Aqueous suspensions for oral use can be made by dispersing the finely divided active component in water together with a viscous material such as natural synthetic gums, resins, methyl cellulose, sodium carboxymethyl cellulose, and other suspending agents known to the pharmaceutical formulation art.

The pharmaceutical compositions can be in unit dosage form. In such form, the composition is divided into unit doses containing appropriate quantities of the active component. The unit dosage form can be a packaged preparation, the package containing discrete quantities of the preparations.

Compositions may be formulated for any suitable route and means of administration. Pharmaceutically acceptable carriers or diluents include those used in formulations suitable for rectal, topical or parenteral administration. The formulations may conveniently be presented in unit dosage form and may be prepared by any of the methods well known in the art of pharmacy.

For solid compositions, conventional non-toxic solid carriers include, for example, pharmaceutical grades of mannitol, lactose, cellulose, cellulose derivatives, starch, magnesium stearate, sodium saccharin, talcum, glucose, sucrose, magnesium carbonate, and the like may be used. Liquid pharmaceutically administrable compositions can, for example, be prepared by dissolving, dispersing, etc., an active compound/molecular as defined above and optional pharmaceutical adjuvants in a carrier, such as, for example, water, saline aqueous dextrose, glycerol, ethanol, and the like, to thereby form a solution or suspension. If desired, the pharmaceutical composition to be administered may also contain minor amounts of non-toxic auxiliary substances such as wetting or emulsifying agents, pH buffering agents and the like, for example, sodium acetate, sorbitan monolaurate, triethanolamine sodium acetate, sorbitan monolaurate, triethanolamine oleate, etc. Actual methods of preparing such dosage forms are known, or will be apparent, to those skilled in this art.

Embodiments of the invention will be illustrated with the following examples. One skilled in the art would appreciate that these examples are for illustration only and that other modifications and variations are possible without departing from the scope of the invention.

Despite morphological and anatomical differences between prostate glands in humans and rodents, there are many similarities with regard to their pharmacology and histochemistry that make study of BPH in rats a useful investigative approach. The prostate gland in both humans and rats is innervated by fine networks surrounding the glandular elements. Most of these neural structures are catecholaminergic and contain different subtypes of adrenergic receptors.

Because of the potential effect of adrenergic innervation on the growth of prostatic cells, the effects of phenylephrine administration on the prostate in rats have been examined. At a dose of <NUM>/kg per day, phenylephrine induces irregular ducts with intraluminal projections. The epithelium becomes thicker and there are even focal "piling-up" of cells. The stroma, in turn, demonstrates hyperplasia and hypertrophy of fibrocytes and smooth muscle cells. These changes correspond to the entity of benign prostatic hyperplasia in humans. In addition, phenylephrine has a dual role in the development of PIN lesions affecting both epithelial and stromal constituents of the rat prostate.

BPH is a true hyperplastic process. Histologic studies have documented an increase in cell number. A study was conducted, therefore, to determine the effects of test compounds and vehicle on testosterone (TE) and phenylephrine (PE) induced benign prostate hyperplasia in rats. Male Wistar rats were induced with testosterone (<NUM>/kg) plus phenylephrine (<NUM>/kg) administered daily by subcutaneous injection on days <NUM> through <NUM>. Vehicle or test compounds (all at <NUM>% w/w), nintedanib, sunitinib, lenvatinib, and <NUM>% doxazosin mesylate, were administered by intra-prostate injection (<NUM>) in dorsolateral and ventral lobes on days <NUM> and <NUM>. Animals were euthanized on day <NUM>. Body weights were determined and prostate glands were harvested. The experimental design is outlined in Table <NUM>.

At necropsy, the ventral and dorsolateral lobes of the prostate were separated and then cut into halves. The left halves were fixed in <NUM>% neutral buffered formalin, sectioned, and stained with Hematoxylin and Eosin (H&E). Histological changes in these sections were scored. Epithelial hyperplasia was recognized as an increase in epithelial cells within normal-appearing gland profiles, primarily reflected by stratification of epithelial cells and increased presence of epithelial tufting and papillary projections. A severity grade of <NUM> (not present) through <NUM> (severe) was assigned to each sample. Representative images are presented in <FIG> and <FIG>. The mean scores (+/-SD) are shown in <FIG>.

<FIG> shows representative images from dorsolateral prostate at 100x magnifications. Panel (A) is a vehicle-treated sample, showing a normal (score = <NUM>) glandular profile. Panel (B) is a testosterone (TE) and phenylephrine (PE) induced and vehicle-treated sample, showing marked (score = <NUM>) epithelial hyperplasia. Panel (C) is a testosterone (TE) and phenylephrine (PE) induced and nintedanib-treated sample, showing moderate (score = <NUM>) epithelial hyperplasia. Panel (D) is a testosterone (TE) and phenylephrine (PE) induced and sunitinib-treated sample, showing moderate (score = <NUM>) epithelial hyperplasia. Panel (E) is a testosterone (TE) and phenylephrine (PE) induced and lenvatinib -treated sample, showing slight (score = <NUM>) epithelial hyperplasia. Panel (F) is a testosterone (TE) and phenylephrine (PE) induced and doxazosin -treated sample, showing moderate (score = <NUM>) epithelial hyperplasia.

<FIG> shows representative images from ventral prostate at 100x magnification. Panel (A) is a vehicle-treated sample, showing a normal (score = <NUM>) glandular profile. Panel (B) is testosterone (TE) and phenylephrine (PE) induced and vehicle-treated sample, showing marked (score = <NUM>) epithelial hyperplasia. Panel (C) is testosterone (TE) and phenylephrine (PE) induced and nintedanib-treated sample, showing moderate (score = <NUM>) epithelial hyperplasia. Panel (D) is testosterone (TE) and phenylephrine (PE) induced and sunitinib-treated sample, showing moderate (score = <NUM>) epithelial hyperplasia. Panel (E) is testosterone (TE) and phenylephrine (PE) induced and lenvatinib-treated sample, showing slight (score = <NUM>) epithelial hyperplasia. Panel (F) is testosterone (TE) and phenylephrine (PE) induced and doxazosin-treated sample, showing moderate (score = <NUM>) epithelial hyperplasia.

The study results indicate histological changes of glandular hyperplasia after TE and PE induction in rats, which were observed in human prostate hyperplasia and adenoma, i.e., glandular hyperplasia forming papillary structures toward lumen Test compounds of nintedanib, Sunitinib, lenvatinib, and doxazosin demonstrated reduction of glandular hyperplasia as compared to the untreated TE/PE induced prostates (<FIG> and <FIG>). Inhibition of benign prostate hyperplasia in this model by nintedanib, sunitinib, lenvatinib and doxazosin indicates that these compounds would be effective in the treatment of benign prostate hyperplasia (BPH) and proliferative and fibrotic disorders of the genitourinary tract.

Morphologically, BPH is characterized by the formation of a new architecture through the proliferation of the epithelium in pre-existing ducts. Given that stromal cells serve important paracrine regulatory functions in epithelial cell homeostasis, late stage changes in stromal-epithelial interactions could provide insight into BPH progression. A second study was conducted to determine the therapeutic effects of test compounds and vehicle, post-induction in a protocol using testosterone and/or phenylephrine induced BPH in rats.

Male Wistar rats were induced with testosterone (<NUM>/kg) plus phenylephrine (<NUM>/kg) administered daily by subcutaneous injection on days <NUM> through <NUM>. Vehicle or test compounds sorafenib (<NUM>% w/w), pirfenidone (<NUM>% w/w), and riociguat (<NUM>% w/w) were administered by intra-prostate injection (<NUM>) in the dorsolateral lobe on days <NUM> and <NUM>. Animals were euthanized on day <NUM>. Body weights were determined. Prostate glands were harvested and weighed. The experimental design is outlined in Table <NUM>.

Prostate weight/<NUM> body weight was determined for each treatment group. As shown in <FIG>, sorafenib and pirfenidone did not show a reduction in mean prostate weight compared to vehicle. In a similar test (with TE induction), riociguat treatment reduced the mean prostate weight, as compared to the vehicle control.

At necropsy, the dorsolateral and ventral lobes of the prostate were separated and cut into halves. The left halves were fixed in <NUM>% neutral buffered formalin, sectioned, and stained with Hematoxylin and Eosin (H&E). Epithelial hyperplasia was recognized as an increase in epithelial cells within normal appearing gland profiles, as reflected in the stratification of epithelial cells and increased presence of epithelial tufting and papillary projections. Stromal changes were examined microscopically. These changes included inflammation and tissue fibroplasia. Each section was given a severity score ranging from <NUM> (not present) through <NUM> (severe).

<FIG> shows representative images from dorsolateral prostate at 100x magnification. Panel (<NUM>) is the image of Group <NUM> (vehicle) rat showing normal (score = <NUM>) glandular profile. Panel (<NUM>) is the image of Group <NUM> (TE + PE induced and vehicle-treated) rat showing slight (score = <NUM>) epithelial hyperplasia. Panel (<NUM>) is the image of Group <NUM> (TE + PE induced and sorafenib <NUM>%-treated) rat showing slight (score = <NUM>) epithelial hyperplasia. Panel (<NUM>) is the image of Group <NUM> (TE + PE induced and pirfenidone <NUM>%-treated) rat showing minimal (score = <NUM>) epithelial hyperplasia. Panel (<NUM>) Group <NUM> is the image of (TE-induced) rat showing slight (score = <NUM>) epithelial hyperplasia. Panel (<NUM>) Group <NUM> (TE induced and riociguat <NUM>%-treated) rat showing minimal (score = <NUM>) epithelial hyperplasia. These scores are summarized in a bar graph, shown in <FIG>.

This study shows that resolution of induced BPH in the rat model over time led to a reduction in the response to test compounds of pirfenidone and riociguat. Riociguat showed an effect on prostate volume and histological changes in epithelial hyperplasia. It was also observed that sorafenib, a multikinase inhibitors with anti-VEGFR and anti-PDGFR activity, was not an effective inhibitor of benign prostate hyperplasia. Therefore, not all multikinase inhibitors will offer preventive or therapeutic benefits in prostatic hyperplasia and/or fibrotic disorders.

In this study, single intraprostate injections of sorafenib were administered on Days <NUM> and <NUM>. Animals were euthanized on Day <NUM> and prostate tissue samples were obtained for analysis. Tissue samples were prepared using a Bead Ruptor homogenizer, followed by extraction with acetonitrile and high-speed centrifugation. An LC-MS/MS method for measurement of sorafenib was used.

On day <NUM>, the mean concentration in the prostate for sorafenib was <NUM>/gm. These tissue concentrations are higher than required for inhibition of VEGFR and PDGFR activity. This study supports the idea that despite good sorafenib exposure in the prostate, sorafenib did not show any therapeutic effect in the prostate.

Fibroplasia is generally a late phase reactive and/or reparative response in tissues associated with disease, trauma, genetic disorders, or infection. There is a strong overlap in the pathophysiology regardless of the organ or tissue involved. Observations made in tissues other than prostate could contribute to our understanding of fibrotic disease progression and regression relevant to prostatic diseases or disorders, such as benign prostatic hyperplasia and its associated lower urinary tract symptoms.

A study was conducted to determine the potential beneficial effects of topical administration of test compounds and vehicle in a suture induced fibrosis model in rabbits. Sutures were placed intrastromally, under a microscope, in the cornea of rabbits. In each eye, one <NUM>-<NUM> silk suture was placed, in a vertical position, temporal to the center of the cornea and a second suture was placed nasal to the corneal center. Each suture had two stromal incursions approximately <NUM> from the limbus. Test compounds having a certain spectrum of multikinase inhibition activities, or vehicle, were topically instilled (35µL/eye) in the eyes three times daily for <NUM> days following surgery. The treatment groups include vehicle, nintedanib (<NUM>%, w/w), sorafenib (<NUM>%, w/w) and lenvatinib (<NUM>%, w/w). Six left eyes were used per treatment group.

During the in-life phase, gross ocular observations of very slight to moderate conjunctival congestion and swelling were similar among groups, including the vehicle control. The animals were sacrificed on Day <NUM> and eyes enucleated and dissected for histopathological evaluation. The results are shown in <FIG>.

The results show that nintedanib and lenvatinib significantly reduced fibroplasia and/or collagen density, as evidenced by histological staining (see <FIG>). In contrast, sorafenib had little or no effect on fibroplasia or collagen formation, as revealed by Masson's trichrome test to differentiate cells from surrounding connective tissue, especially collagen formation in fibrotic responses. In addition, nintedanib and lenvatinib significantly reduced alpha SMA staining by immunohistochemical analysis, while sorafenib had no effect on alpha SMA relative to vehicle treatment. Alpha SMA is a key marker of myofibroblasts, whose function in wound healing and extracellular matrix formation is associated with fibrotic disease.

Increased expression of angiogenic factors, such as VEGF and bFGF, along with increased microvessel density, have been reported in benign prostatic hyperplasia, high grade prostate intraepithelial neoplasia and prostate cancer. This suggests a role for inhibition of these factors in the regulation of BPH. In this example, the effect of local administration of multikinase inhibitors in a rat model of neovascularization was examined. New vessel growth is regulated by growth factor receptor signaling pathways, the functions of which broadly overlap among organs and tissues. In this study, effects of local administration of the multikinase inhibitors nintedanib and lenvatinib were examined by intravitreal injection or topical application to rat eyes following laser induced choroidal neovascularization.

A <NUM>-day study was conducted to determine the effects of test agents, positive control, or vehicle on the development of new vessels. On Day <NUM>, laser treatments were performed on all animals using a <NUM> thermal laser to generate a total of three lesions per eye. On Days <NUM>-<NUM>, bilateral topical administration of vehicle, <NUM>% nintedanib, or <NUM>% lenvatinib was performed three times a day. On Day <NUM>, bilateral intravitreal injection of vehicle, <NUM>µg/eye of rat anti-VEGF antibody, <NUM>µg/eye of nintedanib, or <NUM> ug/eye of lenvatinib was performed in a second group of animals.

On Day <NUM>, fluorescein angiography was performed on all animals and lesion size/area was determined using image analysis software (ImageJ). As shown in <FIG>, when delivered via intravitreal injections, nintedanib and lenvatinib treatments significantly reduced lesion sizes relative to those of the vehicle-treated eyes. In addition, intravitreal injection of lenvatinib also significantly reduced lesion sizes relative to those of the positive control, rat anti-VEGF.

In addition to intravitreal injection, compounds of the invention can also be used in topical application. As shown in <FIG>, topical eyedrop administration of either nintedanib or lenvatinib reduced lesion sizes relative to those of the vehicle.

Claim 1:
A multikinase inhibitor for use in preventing, treating and/or improving a prostatic disease or disorder associated with epithelial hyperplasia and/or fibrosis, wherein the prostatic disease or disorder is fibrosis of ureters and renal pelvis, or prostatic intraepithelial neoplasia, wherein an effective amount of the multikinase inhibitor is administered to a subject in need thereof, and wherein the multikinase inhibitor is lenvatinib.