JP2025527188A - Dosage regimen for NLRP3 inhibitors - Google Patents

Abstract

The present disclosure relates to the field of pharmaceuticals, particularly to NLRP3 inhibitors for use in the treatment of autoinflammatory syndromes. The present disclosure also relates to an NLRP3 inhibitor, or a pharmaceutical combination comprising an NLRP3 inhibitor, or a pharmaceutically acceptable salt thereof, and at least one additional therapeutic agent, for use in the treatment of autoinflammatory syndromes; a method for treating an autoinflammatory syndrome comprising administering an NLRP3 inhibitor or combination; and the use of an NLRP3 inhibitor or combination in the manufacture of a medicament for treating an autoinflammatory syndrome. In particular, N'-((1,2,3,5,6,7-hexahydro-s-indacen-4-yl)carbamoyl)-2-(2-hydroxypropan-2-yl)thiazole-5-sulfonimideamide and its enantiomers are used to treat autoinflammatory syndromes, particularly cryopyrin-associated periodic syndromes (CAPS), familial cold autoinflammatory syndrome (FCAS), Muckle-Wells syndrome (MWS), neonatal-onset multisystem inflammatory disease/chronic infantile neurological, cutaneous, and articular syndrome (NOMID/CINCA), or familial Mediterranean fever (FMF).

Description

The present disclosure relates to the field of pharmaceuticals, particularly to NLRP3 inhibitors for use in the treatment of autoinflammatory syndromes. The present disclosure also relates to an NLRP3 inhibitor, or a pharmaceutical combination comprising an NLRP3 inhibitor, or a pharmaceutically acceptable salt thereof, and at least one additional therapeutic agent, for use in the treatment of autoinflammatory syndromes; a method for treating an autoinflammatory syndrome comprising administering an NLRP3 inhibitor or combination; and the use of an NLRP3 inhibitor or combination in the manufacture of a medicament for treating an autoinflammatory syndrome.

Cryopyrin-associated periodic syndromes (CAPS) are a group of rare diseases caused by heterozygous gain-of-function mutations in the nucleotide-binding oligomerization domain-like receptor family pyrin domain-containing 3 (NLRP3) gene, which can lead to organ damage and/or amyloidosis, and are characterized by cutaneous, musculoskeletal, ocular, and neurological symptoms and chronic systemic inflammation. CAPS is classified into three clinical phenotypes based on the spectrum of disease severity: familial cold autoinflammatory syndrome (FCAS), Muckle-Wells syndrome (MWS), and neonatal-onset multisystem inflammatory disease (NOMID), also known as chronic infantile neurological, cutaneous, and articular syndrome (CINCA) (Hoffman et al., (2019) Cryopyrin-Associated Periodic Syndromes (CAPS). In: Hashkes P, Laxer R, Simon A (eds). Textbook of Autoinflammation. Springer, Cham. pp. 347-365).

FCAS represents the mildest clinical phenotype of CAPS; symptoms are typically limited to low-grade fever, generalized rash, conjunctivitis, and polyarthralgia, which occur 1-2 hours after cold exposure and resolve within 24 hours with warming. These signs, episodes, or attacks usually begin in infancy and occur throughout life. Many patients with FCAS also show evidence of chronic inflammation between attacks, particularly a diurnal pattern of rash that may develop in the afternoon and be accompanied by headache, myalgia, and fatigue by evening; however, chronic inflammation rarely leads to amyloidosis in this patient population (approximately 2%).

Familial Mediterranean fever (FMF), caused by mutations in the MEFV gene, is the most common of all known autoinflammatory diseases. Mutations in the MEFV gene, similar to the NLRP3 gene in MWS, FCAS, and NOMID/CINCA, reduce the activity of the pyrin protein, disrupting the control of the inflammatory process. FMF is characterized by recurrent episodes of painful inflammation in the abdomen, chest, or joints. These episodes are often accompanied by fever and sometimes a rash or headache. Occasionally, inflammation occurs in other parts of the body, such as the heart; the membranes surrounding the brain and spinal cord; and the testicles in males. Episodes typically last from 12 to 72 hours and can vary in severity. The length of time between attacks is also variable, ranging from several days to several years. During these periods, affected individuals usually do not experience signs or symptoms associated with the condition. However, without treatment to help prevent attacks and complications, accumulation of protein deposits (amyloidosis) can occur in the body's organs and tissues, particularly the kidneys, which can lead to kidney failure.

Chronic inflammation and abnormal immune activity underlie and drive many serious human diseases, ranging from rare acute inflammatory disorders to rheumatoid arthritis, cardiovascular and metabolic diseases, neurodegenerative diseases, and cancer. Under these circumstances, molecular danger signals generated by dying cells, metabolic dysregulation, environmental toxins, or diet can act as stimuli to activate the NLRP3 inflammasome (Mangan MSJ et al., Targeting the NLRP3 inflammasome in inflammatory diseases. Nat Rev Drug Discov; 2018; 17(8): 588-606). Once activated, NLRP3 nucleates the assembly of inflammasome complexes that orchestrate innate and adaptive immune responses and drive potent inflammatory responses (Evavold et al., How Inflammasomes Inform Adaptive Immunity. J. Mol. Biol; 2018; 430(2): 217-237). Inflammasomes are large cytoplasmic multimeric protein complexes that assemble in response to danger signals, and inflammasome activation leads to caspase-1-mediated production of interleukin-1β (IL-1β) and interleukin-18 (IL-18) and pyroptosis, an inflammation-mediated cell death (Dinarello, A clinical perspective of IL-1β as the gatekeeper of inflammation. Eur J Immunol; 2011; 41(5):1203-17). Through the production of IL-1β and IL-18, the NLRP3 inflammasome has been implicated as a key driver of inflammation associated with autoinflammatory, acute, and chronic inflammatory diseases, such as CAPS. Potentially, NLRP3 inhibition by NLRP3 inhibitors, blockade of IL-1β, IL-18, and pyroptosis may provide treatment for these and other conditions where persistent inflammasome activation leads to pathology (Ridker PM et al., Modulation of the interleukin-6 signaling pathway and incidence rates of atherosclerotic events and all-cause mortality: analyses from the Canakinumab Anti-Inflammatory Thrombosis Outcomes Study (CANTOS). Eur. Heart. J;2018;39(38):3499-3507. ).

In autoinflammatory syndromes, NLRP3 inhibitors could address the underlying pathogenesis of the disease by directly inhibiting the NLRP3 inflammasome. MCC950, a selective small molecule inhibitor of NLRP3, inhibits NLRP3 inflammasome activation in vivo in multiple NLRP3-dependent mouse models and has demonstrated activity in inhibiting IL-1β release in ex vivo samples of peripheral blood mononuclear cells (PBMCs) from individuals with CAPS (Coll et al., A small-molecule inhibitor of the NLRP3 inflammasome for the treatment of inflammatory diseases. Nat. Med; 2015; 21(3): 248-55). However, administration of the NLRP3 inhibitor MCC950/CRID3 failed to rescue a mouse model of CAPS harboring the L351P mutation in NLRP3, which corresponds to the L353P mutation in human NLRP3 (Vande et al., MCC950/CRID3 potentially targets the NACHT domain of wild-type NLRP3 but not disease-associated mutants for inflammation inhibition. PLoS Biol; 2019; 17(9): e3000354).

While supportive care may be widely available for milder symptoms such as fever, rash, and pain, individuals with autoinflammatory syndromes may require corticosteroids and, in some cases, biologic IL-1 blockers to treat or prevent more severe inflammatory activity. NLRP3 inhibitors may offer additional benefits compared to biologics for patients, and for those whose diseases are inadequately treated with currently available therapies.

Provided herein are NLRP3 inhibitors that can be used to address unmet medical needs, including treating autoinflammatory syndromes including CAPS, MWS, FCAS, NOMID/CINCA, and FMF, by blocking or reducing the NLRP3 inflammasome response.

Described herein are methods of treating a subject using an NLRP3 inhibitor, particularly Compound I, for use in treating an autoinflammatory syndrome. Also described herein are methods of treating an autoinflammatory syndrome by administering a therapeutically effective amount of an NLRP3 inhibitor, particularly Compound I, to a subject in need thereof.

Furthermore, specific dosing regimens for the methods or uses of the NLRP3 inhibitors described herein, particularly Compound I, are provided herein.

Additionally, described herein are pharmaceutical combinations and pharmaceutical compositions comprising a) Compound I and b) at least one additional therapeutic agent, optionally in the presence of a pharmaceutically acceptable carrier, for use in treating autoinflammatory syndromes. Preferably, Compound I is Compound IA.

Further features and advantages of the described methods and uses will become apparent from the detailed description below.

Schematic overview of the treatment protocol detailed in Example 1. Schematic overview of the study design of the first-in-human (FIH) study as detailed in Example 2.

Described herein are methods for treating autoinflammatory syndromes by administering an effective amount of Compound I or a pharmaceutically acceptable salt thereof to a subject in need thereof. Accordingly, in one aspect, there is provided a method for treating autoinflammatory syndromes, comprising administering an effective amount of Compound I or a pharmaceutically acceptable salt thereof to a subject in need thereof. Also provided is Compound I for use in treating autoinflammatory syndromes. In one embodiment of any of the methods or uses described herein, Compound I is Compound IA.

Definition:
In order that this document may be more readily understood, certain terms are first defined. Additional definitions are set forth throughout this document.

All patents, published patent applications, publications, references and other materials referenced herein are hereby incorporated by reference in their entirety for purposes of disclosure.

As used herein, the term "comprising" encompasses "including" and "consisting of," e.g., a composition "comprising" X may consist exclusively of X or may include some additional components, e.g., X + Y.

As used herein, the articles "a" and "an" refer to one or to more than one (e.g., to at least one) of the grammatical object of the article.

The term "or" is used herein to mean, and is used interchangeably with, the term "and/or," unless the context clearly indicates otherwise.

As used herein, the term "about" in connection with a reference numerical value and its grammatical equivalents may include the numerical value itself and a range of values of ±10% from that numerical value. For example, the quantity "about 10" includes 10 and any quantity from 9 to 11. For example, the term "about" in connection with a reference numerical value may also include a range of values of ±10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, or 1% from that value. In some cases, a numerical value recited throughout may be "about" that numerical value even if the term "about" is not specifically recited.

As used herein, the term "baseline" refers to one or more parameters related to a subject's condition or pathology, e.g., the extent of disease, or the patient's condition, observed prior to treatment, e.g., prior to administration of a compound, e.g., prior to administration of Compound I, optionally in combination with at least one additional therapeutic agent, according to the described methods and uses.

As used herein, the term "administering" in reference to a compound, e.g., Compound I, optionally in combination with at least one additional therapeutic agent, is used to refer to delivery of the compound by any delivery route. Such delivery may be, for example, intravenous or oral administration. Such delivery may also be, for example, subcutaneous administration.

As used herein, the term "substantially" does not exclude "completely," e.g., a composition "substantially free" from Y may be completely free from Y. Where necessary, the term "substantially" may be omitted from the definition.

As used herein, the term "pharmaceutically acceptable" means a non-toxic material that does not substantially interfere with the effectiveness of the biological activity of the active ingredient(s).

As used herein, the term "patient" is used interchangeably with the term "subject" and includes any human or non-human animal. The term "non-human animal" includes all vertebrates, e.g., mammals and non-mammals, such as non-human primates, sheep, dogs, cats, horses, cows, chickens, amphibians, reptiles, etc. In specific embodiments, the compositions, methods, and uses described herein relate to a human patient or human subject.

As used herein, a subject is "in need of" treatment if such subject suffers from a condition (i.e., a disease, disorder, or syndrome) of interest and would benefit biologically, medically, or in quality of life from such treatment.

As used herein, the term "autoinflammatory syndrome" refers to a form of inflammatory response syndrome that can be induced or manifested by various factors, such as fatigue, stress or physical effort (e.g., FMF) and cold exposure (e.g., CAPS, MWS, FCAS, NOMID/CINCA).

The terms "treat," "treating," "treatment," "prevent," "preventing," or "prevention" include therapeutic procedures, prophylactic treatments, and applications that reduce a subject's risk of developing a disorder or other risk factors. Treatment does not require a complete cure of the disorder, but encompasses a reduction in symptoms or underlying risk factors.

The term "treating" includes the administration of a compound, e.g., Compound I, optionally in combination with at least one additional therapeutic agent, to prevent or delay the onset of symptoms, complications, or biochemical signs of a disease, condition, disorder, or syndrome (e.g., cryopyrin-associated periodic syndrome (CAPS), familial cold autoinflammatory syndrome (FCAS), Muckle-Wells syndrome (MWS), neonatal-onset multisystem inflammatory disease/chronic infantile neurological, cutaneous, and articular syndrome (NOMID/CINCA), or familial Mediterranean fever (FMF)), prevent recurrence of, alleviate symptoms, or arrest or inhibit further manifestations or signs of the disease, condition, disorder, or syndrome.

As used herein, the terms "prevent," "preventing," or "prevention" in connection with a disease, condition, disorder, or syndrome (e.g., cryopyrin-associated periodic syndrome (CAPS), familial cold autoinflammatory syndrome (FCAS), Muckle-Wells syndrome (MWS), neonatal-onset multisystem inflammatory disease/chronic infantile neurological, cutaneous, and articular syndrome (NOMID/CINCA), or familial Mediterranean fever (FMF)) refer to prophylactic treatment of a subject at risk of developing the condition, resulting in a reduced probability of the subject developing the condition (e.g., a particular disease or disorder or clinical symptoms thereof associated with CAPS, FCAS, MWS, NOMID/CINCA, or FMF, such as skin disease, joint pain, muscle pain, headache/migraine, conjunctivitis, fatigue/malaise, and organ or tissue damage).

For example, "treating familial cold autoinflammatory syndrome (FCAS)" can refer to ameliorating, reducing, or modulating at least one of the symptoms or pathological features associated with familial cold autoinflammatory syndrome (FCAS), such as low-grade fever, generalized rash, conjunctivitis, polyarthralgia, headache, myalgia, and fatigue; or slowing, reducing, or halting the progression of at least one of the symptoms or pathological features associated with familial cold autoinflammatory syndrome (FCAS), such as low-grade fever, generalized rash, conjunctivitis, polyarthralgia, headache, myalgia, and fatigue. It can also refer to preventing or delaying one or more of the listed symptoms, such as slowing, halting, or reversing the progression of a disease, condition, disorder, sign, or syndrome and improving clinical outcome.

"Treating" can also refer to slowing, halting, or reversing the progression of a disease, condition, disorder, sign, or syndrome, and improving clinical outcomes, such as moving from a higher to a lower number on a 5-point scale of clinical signs and symptoms associated with a disease, such as:

As used herein, "excipient" or "pharmaceutically acceptable excipient" means a pharmaceutically acceptable material, composition, or vehicle, such as a liquid or solid filler, diluent, carrier, solvent, or encapsulating material. In one embodiment, each component is "pharmaceutically acceptable" in the sense of being compatible with the other components of a pharmaceutical formulation, suitable for use in contact with human and animal tissues or organs, without excessive toxicity, irritation, allergic response, immunogenicity, or other problems or complications, and commensurate with a reasonable risk-benefit ratio. See, e.g., Remington: The Science and Practice of Pharmacy, 21st ed. ; Lippincott Williams & Wilkins: Philadelphia, PA, 2005; Handbook of Pharmaceutical Excipients, 6th ed. ; Rowe et al. , Eds. ;The Pharmaceutical Press and the American Pharmaceutical Association:2009;Handbook of Pharmaceutical Additives, 3rd ed. ;Ash and Ash Eds. See Pharmaceutical Preformulation and Formulation, 2nd ed.; Gibson Ed.; CRC Press LLC: Boca Raton, FL, 2009.

As used herein, the term "NLRP3 inhibitor" refers to a compound that inhibits the ability of NLRP3 to induce the production of IL-1β and/or IL-18 by directly binding to NLRP3, or by inactivating, destabilizing, altering the distribution of, or otherwise inhibiting NLRP3. Typically, an NLRP3 inhibitor has an hTHP-1 _IC50 of <1 μM in an hTHP-1 assay containing 2% fetal bovine serum as defined herein.

Preferably, the NLRP3 inhibitor is Compound I, Compound IA, or Compound IB. More preferably, the NLRP3 inhibitor is Compound IA.

As used herein, "compound of Formula I" or "compound I" are used interchangeably and refer to the compound having the structure shown below, which is known in the art and can be synthesized using procedures described in WO 2019/023147, which is incorporated by reference in its entirety.

Compound I, Compound IA or Compound IB may be used in crystalline or amorphous form, as a solvate, for example a hydrate, or in a non-solvated form.

Tautomers:
The scope of compounds disclosed herein includes tautomeric forms of the compounds.

A compound represented as comprising the moiety

It is also intended to include tautomeric forms, including:

Stereoisomers:
Non-limiting exemplary compounds of the formulas described herein contain an asymmetric sulfur atom. The present disclosure provides examples of stereoisomeric mixtures (e.g., racemic mixtures of enantiomers, mixtures of diastereomers). The present disclosure also describes and illustrates methods for separating the individual components of the stereoisomeric mixture (e.g., separating the enantiomers of a racemic mixture). For example, Compound I represents a non-racemic mixture of Compound IA and Compound IB, a racemic mixture of Compound IA and Compound IB, an enantiomerically pure form of Compound IA, or an enantiomerically pure form of Compound IB. As used herein, "Compound I" is also intended to include the enantiomeric excess of either Compound IA or Compound IB. For example, compound IA can be present in an enantiomeric excess of about 90%, about 91%, about 92%, about 93%, about 94%, about 95%, about 96%, about 97%, about 98%, about 99%, or about 99.5%. Alternatively, compound IB can be present in an enantiomeric excess of about 90%, about 91%, about 92%, about 93%, about 94%, about 95%, about 96%, about 97%, about 98%, about 99%, or about 99.5%.

Any chemical formula given herein is also intended to represent unlabeled and isotopically labeled forms of the compound. Isotopically labeled compounds have a structure represented by the chemical formula given herein, except that one or more atoms are replaced with an atom having a selected atomic mass or mass number. Isotopes that can be incorporated into the compounds of the present disclosure include, for example, isotopes of hydrogen, carbon, nitrogen, and oxygen, such as ³ H, ¹¹ C, ¹³ C, ¹⁴ C, and ¹⁵ N. Therefore, it should be understood ^that the methods of the present invention can or may include compounds that incorporate one or more of the above isotopes, including radioactive isotopes such as ³ H and 14 C, or those that incorporate non-radioactive isotopes such as ² H and ¹³ C. Such isotopically labeled compounds are useful in metabolism studies (using ^14C ), reaction kinetic studies (e.g., using ^2H 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 in radiotherapy of patients. Isotopically labeled compounds can generally be prepared by conventional techniques known to those skilled in the art, e.g., by substituting the appropriate isotopically labeled reagent for a previously used non-labeled reagent.

The present invention encompasses embodiments including all pharmaceutically acceptable salts of compounds useful according to the invention provided herein. As used herein, "pharmaceutically acceptable salts" refers to derivatives of the disclosed compounds, where the parent compound is modified by converting an existing acid or base moiety into its salt form. 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. Pharmaceutically acceptable salts include conventional non-toxic salts of the parent compound formed, for example, from non-toxic inorganic or organic acids. Pharmaceutically acceptable salts can be synthesized from the parent compound containing a basic or acidic moiety by conventional chemical methods. Generally, such salts can be prepared by reacting the free acid or base form of the compound with a stoichiometric amount of the appropriate base or acid in water or an organic solvent, or a mixture of the two; non-aqueous media like ether, ethyl acetate, ethanol, isopropanol, or acetonitrile are generally preferred. Lists of suitable salts can be found in Remington's Pharmaceutical Sciences, 17th ed., Mack Publishing Company, Easton, Pa., 1985, p. 1418, and Journal of Pharmaceutical Science, 66, 2 (1977), each of which is incorporated herein by reference in its entirety. For example, preferred pharmaceutically acceptable salts include, but are not limited to, mineral or organic acid salts of basic residues such as amines; for example, the salt may be a hydrochloride salt.

The phrase "pharmaceutically acceptable," as used herein, refers to compounds, materials, compositions, and/or dosage forms that are, within the scope of sound medical judgment, suitable for use in contact with the tissues of human beings and animals, without excessive toxicity, irritation, allergic response, or other problems or complications, consistent with a reasonable risk-benefit ratio. Unless otherwise indicated, as used herein, a "dosage" or amount of an NLRP3 inhibitor, e.g., Compound I, refers to the amount of the free base or free acid form of the compound. In the case of salt forms of the NLRP3 inhibitor, the actual amount will be adjusted based on the salt form used.

An "effective amount" refers to an amount sufficient to produce a beneficial or desired result. For example, a therapeutic amount is an amount that achieves a desired therapeutic effect. This amount can be the same as or different from a prophylactically effective amount, which is the amount necessary to prevent the onset of a disease, condition, disorder, or syndrome or related symptoms. An effective amount can be administered in one or more administrations, applications, or doses. The "therapeutically effective amount" (i.e., effective dose) of a therapeutic compound will depend on the therapeutic compound selected. Compositions can be administered from one or more times daily to one or more times weekly, including less frequent administrations, for example, as described herein. One of skill in the art will understand that certain factors, including, but not limited to, the severity of the disease, condition, disorder, or syndrome, previous treatments, the general health and/or age of the subject, and other coexisting diseases, conditions, disorders, or syndromes, can affect the dosage and timing required to effectively treat a subject. Furthermore, treatment of a subject with a therapeutically effective amount of a therapeutic compound described herein can include a single treatment or a series of treatments.

As used herein, the term "therapeutically effective amount" of a compound described herein refers to an amount of a compound that elicits a biological or medical response in a subject, e.g., ameliorates symptoms, reduces a pathological state, slows or delays disease progression, or prevents a disease, condition, disorder, symptom, or syndrome. In one non-limiting embodiment, the term "therapeutically effective amount" refers to an amount of a compound described herein that, when administered to a subject, is effective to at least partially reduce, inhibit, prevent, and/or ameliorate an autoinflammatory syndrome (e.g., cryopyrin-associated periodic syndromes (CAPS), familial cold autoinflammatory syndrome (FCAS), Muckle-Wells syndrome (MWS), neonatal-onset multisystem inflammatory disease/chronic infantile neurological, cutaneous, and articular syndrome (NOMID/CINCA), or familial Mediterranean fever (FMF).

As defined herein, "combination" refers to either a fixed combination in one unit dosage form (e.g., capsule, tablet, sachet, or vial), a loose (i.e., non-fixed) combination, or a kit of parts for combined administration, where Compound I and one or more additional therapeutic agents may be administered independently simultaneously or separately within time intervals, particularly where these time intervals allow the combination partners to exhibit a cooperative, e.g., synergistic, effect.

As used herein, terms such as "co-administration" or "administration in combination" are meant to encompass administration of an additional therapeutic agent to a single subject (e.g., a subject) in need thereof, and are intended to include treatment regimens in which Compound I and the additional therapeutic agent are not necessarily administered by the same route of administration and/or at the same time. Each component of the combinations described herein can be administered simultaneously or sequentially, and in any order. Co-administration includes simultaneous, sequential, overlapping, spaced, and/or consecutive administration, and any combination thereof.

The term "pharmaceutical combination," as used herein, means a pharmaceutical composition resulting from the combination (e.g., mixture) of two or more active ingredients, and includes both fixed and loose combinations of the active ingredients.

The term "fixed combination" means that the active ingredients are administered to a subject simultaneously in the form of a single entity or dosage.

The term "free combination" (non-fixed combination) means that the active ingredients, as defined herein, are administered to a subject as separate entities, either simultaneously, in parallel, or sequentially, in any order, without any specific time constraints, and such administration provides a therapeutically effective level of the compounds to the subject's body. In particular, as used herein (e.g., in any of the embodiments or claims herein), a "non-fixed combination" refers to a combination comprising a) Compound I and b) at least one additional therapeutic agent, which may be administered independently, simultaneously, or separately, within a time interval.

"Concurrent administration" means that the active ingredients, as defined herein, are administered on the same day. The active ingredients can be administered simultaneously (in the case of a fixed or free combination) or one at a time (in the case of a free combination).

The term "sequential administration" may mean that only one of the active ingredients, as defined herein, is administered on any given day during a period of two or more days of continuous co-administration.

"Overlapping administration" means that during a period of two or more days of consecutive co-administration, there may be at least one day of co-administration and at least one day of administration of only one of the active ingredients as defined herein.

"Consecutive administration" means a period of simultaneous administration without any expiration dates. Consecutive administration may be simultaneous, sequential, or overlapping, as described above.

The term "dose" refers to a specific amount of a drug administered at one time. The dose may be indicated, for example, on the product packaging or in a product information leaflet.

As used herein, the term "NLRP3" is meant to include, but is not limited to, nucleic acids, polynucleotides, oligonucleotides, sense and antisense polynucleotide strands, complementary sequences, peptides, polypeptides, proteins, homologous and/or orthologous NLRP3 molecules, isoforms, precursors, mutants, variants, derivatives, splice variants, alleles, variants, and active fragments thereof.

Enumerated embodiments (embodiments 1.1 to 1.32):
1.1 An NLRP3 inhibitor for use in the treatment of an autoinflammatory syndrome in a subject in need thereof. 1.2 An NLRP3 inhibitor for use according to embodiment 1.1, wherein the NLRP3 inhibitor is administered to a subject in a total daily dose of about 50 mg to about 500 mg, preferably about 50 mg to about 200 mg, in single or divided doses. 1.3 An NLRP3 inhibitor for use according to embodiment 1.2, wherein the NLRP3 inhibitor is administered to a subject in a total daily dose of about 100 mg or about 200 mg, in single or divided doses. 1.4 An NLRP3 inhibitor for use according to embodiment 1.3, wherein the NLRP3 inhibitor is administered to a subject in a dose of about 100 mg twice daily for three consecutive days and once in the morning of the fourth day at about 100 mg. NLRP3 inhibitor 1.6 for use according to any one of embodiments 1.1 to 1.4, wherein the autoinflammatory syndrome is CAPS, FCAS, MWS, NOMID/CINCA, or FMF. NLRP3 inhibitor 1.7 for use according to any one of embodiments 1.1 to 1.5, wherein the autoinflammatory syndrome is FCAS. 1.8 The NLRP3 inhibitor for use according to embodiment 1.6, wherein the patient does not have an increase in white blood cell count (WCC) of more than about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, about 100% after administration of the NLRP3 inhibitor. 1.9 The NLRP3 inhibitor for use according to embodiment 1.6, wherein, after cold exposure, the patient shows a lower score on the Physician's Global Rating scale of at least 1, at least 2, at least 3 on a scale of 1 to 10 after administration of the NLRP3 inhibitor. 1.10. The NLRP3 inhibitor for use according to embodiment 1.6, wherein after cold exposure, the patient shows a lower score on the Physician's Global Rating scale on a scale of 1 to 100 by at least 10%, at least 20%, at least 30% after administration of the NLRP3 inhibitor. 1.10. The NLRP3 inhibitor for use according to any one of embodiments 1.1 to 1.9, wherein the patient does not have an increase in C-reactive protein of more than about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, about 100% after administration of the NLRP3 inhibitor. 1.11. An NLRP3 inhibitor for use according to any one of embodiments 1.1-1.10, wherein the patient does not exhibit an increase in IL-1β or IL-18 of more than about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, about 100% after administration of the NLRP3 inhibitor. 1.12. An NLRP3 inhibitor for use according to any of the preceding enumerated embodiments, wherein the NLRP3 inhibitor is administered orally to a subject. 1.13. An NLRP3 inhibitor for use according to any of the preceding enumerated embodiments, wherein the NLRP3 inhibitor is present in a tablet formulation. 1.14. NLRP3 inhibitor for use according to any one of enumerated embodiments 1.1 to 1.6, comprising Compound I, or a pharmaceutically acceptable salt thereof:

1.15 An NLRP3 inhibitor for use according to embodiment 1.14, wherein compound I is the enantiomer of compound IA, or a pharmaceutically acceptable salt thereof:

1.16 An NLRP3 inhibitor for use according to embodiment 1.15, wherein compound I is compound IB enantiomer, or a pharmaceutically acceptable salt thereof:

1.17 The NLRP3 inhibitor for use according to embodiment 1.15, wherein compound IA has an enantiomeric excess of at least 90%. 1.18 The NLRP3 inhibitor for use according to embodiment 1.16, wherein compound IB has an enantiomeric excess of at least 90%. 1.19 A pharmaceutical composition comprising the NLRP3 inhibitor of any of embodiments 1.12-1.18, for use according to any preceding recited embodiment. 1.20 A pharmaceutical combination comprising the NLRP3 inhibitor of any of embodiments 1.12-1.18 and at least one further therapeutic agent, for use according to any preceding recited embodiment.

Uses and Methods Various embodiments of the methods and uses described herein are included below and elsewhere in this document. It will be understood that the features specified in each embodiment may be combined with other specific features to provide further embodiments.

It is taught herein that the following embodiments relate to the use of any NLRP3 inhibitor, including but not limited to Compound I. Preferably, Compound I in the following embodiments is Compound IA (i.e., the R enantiomer) in an enantiomeric excess of at least 90%, at least 91%, at least 92%, at least 93%, at least 94%, at least 95%, at least 96%, at least 97%, at least 98%, at least 99%, or at least 99.5%. Preferably, Compound IA is in an enantiomeric excess of at least 90%. More preferably, Compound IA is in an enantiomeric excess of at least 95%.

Embodiment 1
In one embodiment, provided herein is a method of treating or reducing the symptoms of an autoinflammatory syndrome in a subject in need thereof, comprising administering an effective amount of Compound I, or a pharmaceutically acceptable salt thereof. In one embodiment, provided herein is Compound I, or a pharmaceutically acceptable salt thereof, for use in treating an autoinflammatory syndrome in a subject in need thereof. In some embodiments, provided herein is the use of Compound I in the manufacture of a medicament for the treatment of an autoinflammatory syndrome.

Embodiment 2
In one embodiment, provided herein is a method of treating or reducing symptoms of cryopyrin-associated periodic syndromes (CAPS) in a subject in need thereof, comprising administering an effective amount of Compound I, or a pharmaceutically acceptable salt thereof. In one embodiment, provided herein is Compound I, or a pharmaceutically acceptable salt thereof, for use in treating cryopyrin-associated periodic syndromes (CAPS) in a subject in need thereof. In some embodiments, provided herein is the use of Compound I in the manufacture of a medicament for the treatment of cryopyrin-associated periodic syndromes (CAPS).

Embodiment 3
In one embodiment, provided herein is a method of treating or reducing symptoms of familial cold autoinflammatory syndrome (FCAS) in a subject in need thereof, comprising administering an effective amount of Compound I, or a pharmaceutically acceptable salt thereof. In one embodiment, provided herein is Compound I, or a pharmaceutically acceptable salt thereof, for use in treating familial cold autoinflammatory syndrome (FCAS) in a subject in need thereof. In some embodiments, provided herein is the use of Compound I in the manufacture of a medicament for the treatment of familial cold autoinflammatory syndrome (FCAS).

Embodiment 4
In one embodiment, provided herein is a method of treating or reducing symptoms of Muckle-Wells Syndrome (MWS) in a subject in need thereof, comprising administering an effective amount of Compound I, or a pharmaceutically acceptable salt thereof. In one embodiment, provided herein is Compound I, or a pharmaceutically acceptable salt thereof, for use in treating Muckle-Wells Syndrome (MWS) in a subject in need thereof. In some embodiments, provided herein is the use of Compound I in the manufacture of a medicament for the treatment of Muckle-Wells Syndrome (MWS).

Embodiment 5
In one embodiment, provided herein is a method of treating or reducing symptoms of neonatal-onset multisystem inflammatory disease/chronic infantile neurological, cutaneous, and articular syndrome (NOMID/CINCA) in a subject in need thereof, comprising administering an effective amount of Compound I, or a pharmaceutically acceptable salt thereof. In one embodiment, provided herein is Compound I, or a pharmaceutically acceptable salt thereof, for use in treating neonatal-onset multisystem inflammatory disease/chronic infantile neurological, cutaneous, and articular syndrome (NOMID/CINCA) in a subject in need thereof. In some embodiments, provided herein is the use of Compound I in the manufacture of a medicament for the treatment of neonatal-onset multisystem inflammatory disease/chronic infantile neurological, cutaneous, and articular syndrome (NOMID/CINCA).

Embodiment 6
In one embodiment, provided herein is a method of treating or reducing symptoms of familial Mediterranean fever (FMF) in a subject in need thereof, comprising administering an effective amount of Compound I, or a pharmaceutically acceptable salt thereof. In one embodiment, provided herein is Compound I, or a pharmaceutically acceptable salt thereof, for use in treating familial Mediterranean fever (FMF) in a subject in need thereof. In some embodiments, provided herein is the use of Compound I in the manufacture of a medicament for the treatment of familial Mediterranean fever (FMF).

In any of the embodiments described herein, the patient does not have an increase in white blood cell count (WCC) of more than about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or about 100% after administration of the NLRP3 inhibitor.

In any of the embodiments described herein, the patient does not have an increase in C-reactive protein of more than about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or about 100% after administration of the NLRP3 inhibitor.

In any of the embodiments described herein, the patient does not exhibit an increase in IL-1β or IL-18 of more than about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or about 100% after administration of the NLRP3 inhibitor.

In any of the embodiments for treating or reducing a symptom of FCAS described herein, after cold exposure, the patient exhibits a lower score on the Physician's Global Rating scale of at least 1, at least 2, or at least 3 on a scale of 1 to 10 after administration of the NLRP3 inhibitor. In any of the embodiments for treating or reducing a symptom of FCAS described herein, after cold exposure, the patient exhibits a lower score on the Physician's Global Rating scale of at least 10%, at least 20%, or at least 30% on a scale of 1 to 100 after administration of the NLRP3 inhibitor.

In any of the embodiments described herein, Compound I or a pharmaceutically acceptable salt thereof may be administered to a subject in a total daily dose of about 50 mg to about 200 mg, measured in non-salt equivalents, in single or divided doses. In certain embodiments, Compound I is administered to a subject in a total daily dose of about 200 mg, in single or divided doses. In even more specific embodiments, Compound I is administered to a subject twice daily at a dose of about 100 mg for three consecutive days, and once in the morning of the fourth day at about 100 mg.

In some embodiments, provided herein are pharmaceutical compositions comprising Compound I or a pharmaceutically acceptable salt thereof and at least one pharmaceutically acceptable excipient. In certain embodiments, the pharmaceutical composition is a tablet. In more specific embodiments, the pharmaceutical composition is administered as a whole or crushed tablet. In some embodiments, the pharmaceutical composition comprises about 5 mg, about 10 mg, about 15 mg, about 20 mg, about 25 mg, about 30 mg, about 35 mg, about 40 mg, about 45 mg, about 50 mg, about 60 mg, about 70 mg, about 80 mg, about 90 mg, or about 100 mg per unit dose.

Provided herein is a pharmaceutical composition comprising Compound I, or a pharmaceutically acceptable salt thereof, for use in any of the embodiments described herein.

In any of the embodiments described herein, Compound I, or a pharmaceutically acceptable salt thereof, is orally administered to a subject in need thereof. In some embodiments, Compound I is in the form of a tablet that is administered either whole or comminuted, i.e., crushed prior to administration. In certain embodiments, for example, if the patient is unable to swallow, Compound I can be administered via a nasogastric tube.

For all of the embodiments defined herein, a preferred NLRP3 inhibitor is compound IA. In certain embodiments, compound IA has an enantiomeric excess of at least 90%, at least 91%, at least 92%, at least 93%, at least 94%, at least 95%, at least 96%, at least 97%, at least 98%, at least 99%, or at least 99.5%.

Subjects As discussed herein, a subject receiving an NLRP3 inhibitor as described herein may exhibit or be at risk for symptoms of familial cold autoinflammatory syndrome (FCAS), e.g., as defined above.

Combination Therapy In practicing some of the methods of treatment or uses described herein, a therapeutically effective amount of Compound I is administered to a patient, e.g., a mammal (e.g., a human). Additionally, in less severe cases of FCAS, patients may be treated supportively to manage symptoms such as fever, muscle pain, or fatigue. In more severe cases of FCAS, the use of immunosuppressants such as corticosteroids may be necessary, although discretion must be used to avoid negating the effects of drugs intended to activate the immune system.

Pharmaceutical Compositions Compound I may be used as a pharmaceutical composition when combined with a pharmaceutically acceptable carrier. Such compositions may contain, in addition to Compound I, carriers, various diluents, fillers, salts, buffers, stabilizers, solubilizers, and other known materials. The characteristics of the carrier will depend on the route of administration. Pharmaceutical compositions for use in the compositions, uses, and methods described herein may also contain at least one or more additional therapeutic agents for treating a specific target disorder, disease, condition, or syndrome. Inclusion of such additional elements and/or agents in the pharmaceutical composition may result in a synergistic effect with Compound I.

In specific embodiments, Compound I may be administered in combination with one or more conventional pharmaceutical excipients. Pharmaceutically acceptable excipients include, but are not limited to, ion exchangers, alumina, aluminum stearate, lecithin, surfactants used in pharmaceutical dosage forms such as self-emulsifying drug delivery systems (SEDDS) such as d-α-tocopherol polyethylene glycol 1000 succinate, Tweens, poloxamers, or other similar polymeric delivery matrices, serum proteins such as human serum albumin, buffer substances such as phosphate, Tris, 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, and wool fat. Cyclodextrins, e.g., α-, β-, and γ-cyclodextrin, or chemically modified derivatives, e.g., hydroxyalkyl cyclodextrins, e.g., 2- and 3-hydroxypropyl-β-cyclodextrin, or other solubilizing derivatives, can also be used to enhance delivery of the compounds described herein. Dosage forms or compositions can be prepared containing the chemical entities as described herein in the range of 0.005% to 100%, with the balance made up of non-toxic excipients. Contemplated compositions may contain 0.001% to 100%, in one embodiment 0.1 to 95%, in another embodiment 75 to 85%, and in a further embodiment 20 to 80%, of the chemical entities provided herein. Actual methods for preparing such dosage forms will be known or apparent to those skilled in the art; see, for example, Remington: The Science and Practice of Pharmacy, 22nd Edition (Pharmaceutical Press, London, UK. 2012).

Routes of Administration and Composition Components In some embodiments, the chemical entities described herein or pharmaceutical compositions thereof can be administered to a subject in need thereof by any accepted route of administration. Acceptable routes of administration include, but are not limited to, buccal, cutaneous, intracervical, endo sinusial, intratracheal, enteral, epidural, intrainterstitial, intraabdominal, intra-arterial, intrabronchial, intrasynovial, intracerebral, intracisternal, intracoronary, intradermal, intraductal, intraduodenal, intradural, intraepidermal, intraesophageal, intragastric, intragingival, intraileal, intralymphatic, intramedullary, intrameningeal, intramuscular, intraovarian, intraperitoneal, and prostatic. These include intravenous, intrapulmonary, intrasinal, intraspinal, intrasynovial, intratesticular, intrathecal, intratubular, intratumoral, intrauterine, intravascular, intravenous, intranasal, nasal, oral, parenteral, percutaneous, peridural, rectal, respiratory (inhalation), subcutaneous, sublingual, submucosal, topical, transdermal, transmucosal, transtracheal, ureteral, urethral, and vaginal. In certain embodiments, the preferred route of administration is parenteral (e.g., intratumoral).

Compositions can be formulated for parenteral administration, for example, for injection via intravenous, intramuscular, subcutaneous, or even intraperitoneal routes. Typically, such compositions can be prepared as injectables, either as liquid solutions or suspensions; solid forms suitable for use in preparing solutions or suspensions upon addition of liquid prior to injection can also be prepared; and formulations can also be emulsified. The preparation of such formulations will be known to those of skill in the art in light of the present disclosure.

Pharmaceutical forms suitable for injectable use include sterile aqueous solutions or dispersions; formulations including sesame oil, peanut oil, or aqueous propylene glycol; and sterile powders for the extemporaneous preparation of sterile injectable solutions or dispersions. In all cases, the form must be sterile and fluid to the extent that easy syringability exists. It must also be stable under the conditions of manufacture and storage and must be preserved against the contaminating action of microorganisms, such as bacteria and fungi.

The carrier can also be a solvent or dispersion medium containing, for example, water, ethanol, polyol (for example, glycerol, propylene glycol, and liquid polyethylene glycol, and the like), suitable mixtures thereof, and vegetable oils. Proper fluidity can be maintained, for example, by the use of a coating such as lecithin, by the maintenance of the required particle size in the case of dispersions, and by the use of surfactants. Prevention of the action of microorganisms can be brought about by various antibacterial and antifungal agents, for example, parabens, chlorobutanol, phenol, sorbic acid, thimerosal, and the like. In many cases, it will be preferable to include isotonic agents, for example, sugars or sodium chloride. Prolonged absorption of injectable compositions can be brought about by the use in the compositions of agents delaying absorption, for example, aluminum stearate and gelatin.

Sterile injectable solutions are prepared by incorporating the active compound in the appropriate solvent with various other ingredients enumerated above in the required amount, followed by filtered sterilization. Generally, dispersions are prepared by incorporating the various sterilized active ingredients into a sterile vehicle which contains the basic dispersion medium and the required other ingredients from those enumerated above. In the case of sterile powders for the preparation of sterile injectable solutions, the preferred methods of preparation are vacuum drying and freeze-drying techniques, which yield a powder of the active ingredient plus any additional desired ingredients from a previously sterile-filtered solution thereof.

Intratumoral injection is discussed, for example, in Lammers, et al., "Effect of Intratumoral Injection on the Biodistribution and the Therapeutic Potential of HPMA Copolymer-Based Drug Delivery Systems," Neoplasia. 2006, 10, 788-795.

In certain embodiments, the chemical entities described herein or pharmaceutical compositions thereof are suitable for localized administration to the digestive or GI tract, e.g., rectal administration. Rectal compositions include, but are not limited to, enemas, rectal gels, rectal foams, rectal aerosols, suppositories, jelly suppositories, and enemas (e.g., retention enemas).

Pharmacologically acceptable excipients that can be used in rectal compositions as gels, creams, enemas, or rectal suppositories include, but are not limited to, cocoa butter glycerides, synthetic polymers such as polyvinylpyrrolidone, PEG (PEG ointments), glycerin, glycerinated gelatin, hydrogenated vegetable oils, poloxamer, mixtures of polyethylene glycols of various molecular weights, and fatty acid esters of polyethylene glycol. Ingredients include one or more of petrolatum, anhydrous lanolin, shark liver oil, saccharin sodium, menthol, sweet almond oil, sorbitol, sodium benzoate, anoxide SBN, vanilla essential oil, aerosol, parabens in phenoxyethanol, sodium methyl p-oxybenzoate, sodium propyl p-oxybenzoate, diethylamine, carbomer, carbopol, methyloxybenzoate, macrogol cetostearyl ether, cocoyl caprylocaprate, isopropyl alcohol, propylene glycol, liquid paraffin, xanthan gum, carboxy-metabisulfite, sodium edetate, sodium benzoate, potassium metabisulfite, grapefruit seed extract, methylsulfonylmethane (MSM), lactic acid, glycine, vitamins such as vitamins A and E, and potassium acetate.

In certain embodiments, suppositories can be prepared by mixing the chemical entities described herein with a suitable non-irritating excipient or carrier, such as cocoa butter, polyethylene glycol, or a suppository wax, which is solid at ambient temperature but liquid at body temperature and will melt in the rectum to release the active compound. In other embodiments, a composition for rectal administration is in the form of an enema.

In other embodiments, the compounds described herein or pharmaceutical compositions thereof are suitable for local delivery to the digestive or GI tract via oral administration (e.g., solid or liquid dosage form).

Solid dosage forms for oral administration include capsules, tablets, pills, powders, and granules. In such solid dosage forms, the chemical entity is mixed with one or more pharmaceutically acceptable excipients, such as sodium citrate or dicalcium phosphate, and/or: a) fillers or extenders, such as starch, lactose, sucrose, glucose, mannitol, and silicic acid; b) binders, such as carboxymethylcellulose, alginates, gelatin, polyvinylpyrrolidinone, sucrose, and acacia; c) humectants, such as glycerol; d) disintegrants, such as agar-agar, calcium carbonate, jasmine, etc. They are mixed with potato or tapioca starch, alginic acid, certain silicic acids, and sodium carbonate; e) solution retarders such as paraffin; f) absorption accelerators such as quaternary ammonium compounds; g) wetting agents such as cetyl alcohol and glycerol monostearate; h) absorbents such as kaolin and bentonite clay; and i) lubricants such as talc, calcium stearate, magnesium stearate, solid polyethylene glycol, sodium lauryl sulfate, and mixtures thereof. In the case of capsules, tablets, and pills, the dosage form may also contain buffering agents. Solid compositions of a similar type may also be employed as fillers in soft- and hard-filled gelatin capsules using excipients such as lactose or milk sugar and high molecular weight polyethylene glycols.

In one embodiment, the composition will be in the form of a unit dosage form such as a pill or tablet. Therefore, the composition may contain, along with the chemical entities provided herein, diluents such as lactose, sucrose, dicalcium phosphate, etc.; lubricants such as magnesium stearate; and binders such as starch, acacia gum, polyvinylpyrrolidine, gelatin, cellulose, cellulose derivatives, etc. In another solid dosage form, a powder, quince, solution, or suspension (e.g., in propylene carbonate, vegetable oil, PEG, poloxamer 124, or triglycerides) is encapsulated in a capsule (e.g., a gelatin- or cellulose-based capsule). Unit dosage forms in which one or more chemical entities or additional active agents provided herein are physically separated are also contemplated; for example, a capsule (or tablet within a capsule) with granules of each drug; a bilayer tablet; a bicompartment gelcap, etc. Enteric-coated or delayed-release oral dosage forms are also contemplated.

Other physiologically acceptable compounds include wetting agents, emulsifying agents, dispersing agents, or preservatives, which are particularly useful for preventing the growth or action of microorganisms. Various preservatives are well known and include, for example, phenol and ascorbic acid.

In certain embodiments, the excipients are sterile and generally free of undesirable matter. These compositions can be sterilized by conventional, well-known sterilization techniques. Sterility is not required for excipients in various oral dosage forms, such as tablets and capsules; USP/NF standards are usually sufficient.

In certain embodiments, the solid oral dosage form may further comprise one or more components that chemically and/or structurally facilitate delivery of the chemical entity to the stomach or lower GI; for example, the ascending colon and/or transverse colon and/or distal colon and/or small intestine. Exemplary formulation techniques are described, for example, in Filipski, K. J., et al., Current Topics in Medicinal Chemistry, 2013, 13, 776-802, which is incorporated herein by reference in its entirety.

Examples include upper GI targeting technologies such as accordion pills (Intec Pharma), floating capsules, and materials capable of adhering to mucosal walls.

Other examples include lower GI targeting technologies. Several enteric/pH-responsive coatings and excipients are available for targeting various regions of the intestinal tract. These materials are typically polymers designed to dissolve or erode at specific pH ranges, selected based on the GI region of desired drug release. These materials also function to protect or limit the exposure of acid-labile drugs from gastric fluids if the active ingredient may be irritating to the upper GI (e.g., hydroxypropyl methylcellulose phthalate series, Coateric (polyvinyl acetate phthalate), cellulose acetate phthalate, hydroxypropyl methylcellulose acetate succinate, Eudragit series (methacrylic acid-methyl methacrylate copolymer), and Marcoat). Other technologies include dosage forms that respond to the local bacterial flora in the GI tract, pressure-controlled colonic delivery capsules, and Pulsincap.

Ophthalmic compositions may include, but are not limited to, any one or more of the following: viscogens (e.g., carboxymethylcellulose, glycerin, polyvinylpyrrolidone, polyethylene glycol); stabilizers (e.g., Pluronic (triblock copolymer), cyclodextrin); preservatives (e.g., benzalkonium chloride, ETDA, SofZia (boric acid, propylene glycol, sorbitol, and zinc chloride; Alcon Laboratories, Inc.), Purite (stabilized oxychloro complex; Allergan, Inc.)).

Topical compositions can include ointments and creams. Ointments are typically semi-solid preparations based on petrolatum or other petroleum derivatives. Creams containing the selected active agent are typically viscous liquid or semi-solid emulsions, often either oil-in-water or water-in-oil. Cream bases are typically water-washable and contain an oil phase, an emulsifier, and an aqueous phase. The oil phase, sometimes referred to as the "internal" phase, generally consists of petrolatum and a fatty alcohol such as cetyl or stearyl alcohol; the aqueous phase usually, although not necessarily, exceeds the oil phase in volume and generally contains a humectant. Emulsifiers in cream formulations are generally nonionic, anionic, cationic, or amphoteric surfactants. Like other carriers or vehicles, ointment bases should be inert, stable, non-irritating, and non-sensitizing.

In any of the foregoing embodiments, the pharmaceutical compositions described herein may include one or more of the following: lipids, interbilayer crosslinked multilamellar vesicles, biodegradable poly(D,L-lactic-co-glycolic acid) [PLGA]-based or polyanhydride-based nanoparticles or microparticles, and nanoporous particle-supported lipid bilayers.

Dosage regimens and modes of administration Dosage regimens are adjusted to provide the optimum desired response (e.g., therapeutic response). The dosing regimen, i.e., the dose and/or frequency of administration of a pharmaceutical composition comprising Compound I, can vary depending on the compound used, the disease, condition, disorder, or syndrome targeted, and its associated stage. The dosing regimen, i.e., the dose and/or frequency of administration of a pharmaceutical combination comprising a) Compound I and b) at least one additional therapeutic agent, can vary depending on the compound used, the disease, condition, disorder, or syndrome targeted, and its associated stage.

For administration of Compound I in methods for treating autoinflammatory syndromes, the dosage ranges from about 0.0001 to about 100 mg/kg, and more usually from about 0.01 to about 30 mg/kg, of the subject's body weight. In certain embodiments, Compound I is administered in a daily dose of about 50 mg to about 500 mg, about 50 mg to about 200 mg, about 50 mg to about 150 mg, about 50 mg to about 100 mg, or about 50 mg. In certain embodiments, Compound I is administered in a daily dose of about 50 mg, about 100 mg, about 150 mg, or about 200 mg. In certain embodiments, Compound I is administered once daily. In other embodiments, Compound I is administered two, three, or four times daily. In a preferred embodiment, Compound I is administered in a total daily dose of about 200 mg, administered in one or two divided doses. Preferably, Compound I is Compound IA. Preferably, Compound IA is administered at a total daily dose of about 50-500 mg. More preferably, Compound IA is administered at a daily dose of 200 mg.

In some embodiments, Compound IA is administered at a daily dose of 200 mg. In some embodiments, Compound IA is administered at 100 mg twice daily.

In some embodiments, the administration period of the compounds described herein is 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, 8 days, 9 days, 10 days, 11 days, 12 days, 13 days, 14 days, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 11 weeks, 12 weeks, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 12 months, or more. In further embodiments, the period during which administration is suspended is 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, 8 days, 9 days, 10 days, 11 days, 12 days, 13 days, 14 days, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 11 weeks, 12 weeks, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 12 months, or more. Doses are repeated as needed and may range from about once per week to about once every 10 weeks, e.g., once every 4 weeks or once every 8 weeks.

Kits Also encompassed herein are kits for use in methods for treating or preventing cytokine release syndrome or cytokine storm syndrome, which may include Compound I in liquid or lyophilized form or a pharmaceutical composition comprising Compound I. In addition, such kits may include a means for administering Compound I (e.g., a syringe and vial, a prefilled syringe, a prefilled pen) and instructions for use. These kits may also contain additional therapeutic agents (described elsewhere herein), for example, when delivered in combination with Compound I.

The phrase "means for administering" is used to refer to any available device for administering a drug systemically to a patient, including, but not limited to, droppers, prefilled syringes, vials and syringes, pen syringes, autoinjectors, intravenous drips and bags, pumps, etc. Using such items, a patient may self-administer a drug (i.e., administer the drug for themselves), a caregiver may administer the drug to a patient, or a physician or other healthcare professional may administer the drug.

Each component of the kit is typically enclosed in an individual container, and all of the various containers are included in a single package along with instructions for use.

It should be understood that each embodiment can be combined with one or more other embodiments to the extent that such combination is consistent with the description of the embodiment. It should further be understood that the embodiments presented above are to be understood to include all embodiments, including embodiments resulting from combinations of embodiments.

Other features, objects, and advantages of the described methods and uses will be apparent from the description and drawings, and from the claims.

Synthesis of Compound I Compounds I, IA, and IB were synthesized according to the synthesis defined in WO 2019/023147, e.g., 4, 5, and 6, and as detailed below. However, the compounds can be assembled in a variety of ways to build the final molecule using related reaction procedures in a modular fashion that allows for different reaction sequences and/or different reagents.

Reaction progress was often monitored by TLC or LC-MS. Product identity was often confirmed by LC-MS. LC-MS was recorded using the following method:
Method A: Shim-pack XR-ODS, C18, 3 x 50 mm, 2.5 um column, 1.0 uL injection, 1.5 mL/min flow rate, scan range 90-900 amu, UV range 190-400 nm, gradient of 5-100% (1.1 min), 100% (0.6 min) with ACN (0.05% TFA) and water (0.05% TFA), 2 min total run time

The final target was purified by preparative HPLC, which was performed using the following method:
Method B: Preparative HPLC: Column, XBridge Shield RP18 OBD (19 x 250 mm, 10 um); Mobile phase, water (10 mmol/L NH4HCO3) and ACN, UV detection 254/210 nm

NMR was recorded on a BRUKER NMR 300.03 MHz, DUL-C-H, ULTRASHIELD™ 300, AVANCE II 300B-ACS™ 120 or a BRUKER NMR 400.13 MHz, BBFO, ULTRASHIELD™ 400, AVANCE III 400, B-ACS™ 120 or a BRUKER AC250 NMR instrument, referenced to TMS measured in ppm (parts per million).
Scheme 1:

Compound I: N'-(1,2,3,5,6,7-hexahydro-s-indacen-4-ylcarbamoyl)-2-(2-hydroxypropan-2-yl)thiazole-5-sulfonimidamide Step 1: N-(tert-butyldimethylsilyl)-N'-(1,2,3,5,6,7-hexahydro-s-indacen-4-ylcarbamoyl)-2-(2-hydroxypropan-2-yl)thiazole-5-sulfonimidamide
A 50 mL round-bottom flask was charged with a solution of N'-(tert-butyldimethylsilyl)-2-(2-hydroxypropan-2-yl)thiazole-5-sulfonimidamide (Intermediate I) (336 mg, 1.0 mmol) in THF (10 mL). To this solution, NaH (60% wt, 80 mg, 2.0 mmol) was added portionwise at 0°C. The solution was stirred at 0°C for 15 min, followed by the dropwise addition of a solution of 4-isocyanato-1,2,3,5,6,7-hexahydro-s-indacene (209 mg, 1.1 mmol) in THF (5 mL) with stirring at RT. The resulting solution was stirred at RT for 12 h. The reaction was then quenched by the addition of 10 mL of NH4Cl (sat.). The resulting solution was extracted with 3 x 10 mL of DCM, and the combined organic layers were concentrated under vacuum. This gave 535 mg (crude) of the title compound as a brown oil: MS-ESI: 535.0 (M+1).

Step 2: N'-(1,2,3,5,6,7-hexahydro-s-indacen-4-ylcarbamoyl)-2-(2-hydroxypropan-2-yl)thiazole-5-sulfonimidamide:
A 50 mL round-bottom flask was charged with a solution of N-(tert-butyldimethylsilyl)-N'-(1,2,3,5,6,7-hexahydro-s-indacen-4-ylcarbamoyl)-2-(2-hydroxypropan-2-yl)thiazole-5-sulfonimidamide (535 mg, crude, 1.0 mmol). To this solution was added HF/Py (70% wt, 143 mg, 5.0 mmol) dropwise at 0°C. The solution was stirred at RT for 4 h. The reaction was then quenched by the addition of 10 mL of water. The resulting solution was extracted with 3 x 10 mL of ethyl acetate, and the combined organic layers were concentrated under vacuum. The crude product was purified by preparative HPLC using Method B with ACN/water (20% to 60% within 10 min). This afforded 189 mg (45%, 2 steps) of compound I as a white solid.
Compound I: MS-ESI: 421.0 (M+1). 1H NMR (400MHz, DMSO-d6) δ 8.46 (br s, 1H), 8.04 (s, 1H), 7.80 (br s, 2H), 6.86 (s, 1H), 6.28 (s, 1H), 2.88-2.71 (m, 4H), 2.71-2.56 (m, 4H), 2.02-1.80 (m, 4H), 1.49 (s, 6H).

Compound IA and Compound IB:

Compounds IA and IB: (R) and (S)—N′-(1,2,3,5,6,7-hexahydro-s-indacen-4-ylcarbamoyl)-2-(2-hydroxypropan-2-yl)thiazole-5-sulfonimidamide:
Step 3: Chiral Separation The compound I product (189 mg) obtained as described in the previous step was separated by chiral preparative HPLC using the following conditions: column, CHIRAL Cellulose-SB, 2 ^* 25 cm, 5 μm; mobile phase, Hex (0.1% DEA) and EtOH (hold 20% EtOH over 16 min); flow rate, 20 mL/min; detector, UV 254/220 nm. This gave 70 mg of compound IB (front peak, 99% ee) as a white solid and 65 mg of compound IA (second peak, 97.5% ee) as a white solid.
Compound IB: MS-ESI: 421.0 (M+1). 1H NMR (400MHz, DMSO-d6) δ 8.43 (br s, 1H), 8.05 (s, 1H), 7.83 (br s, 2H), 6.87 (s, 1H), 6.29 (s, 1H), 2.82-2.71 (m, 4H), 2.71-2.56 (m, 4H), 2.02-1.80 (m, 4H), 1.50 (s, 6H).
Compound IA: MS-ESI: 421.0 (M+1). 1H NMR (400MHz, DMSO-d6) δ 8.41 (br s, 1H), 8.05 (s, 1H), 7.83 (s, 2H), 6.87 (s, 1H) 6.27 (s, 1H), 2.82-2.71 (m, 4H), 2.71-2.56 (m, 4H), 2.02-1.80 (m, 4H), 1.50 (s, 6H).

Intermediate I of Scheme 1 was synthesized according to the synthesis described in WO 2019/023147 and as presented in Scheme 2 below.
Scheme 2:

N'-(tert-butyldimethylsilyl)-2-(2-hydroxypropan-2-yl)thiazole-5-sulfonimidamide:
Step 1: 2-(2-methyl-1,3-dioxolan-2-yl)thiazole:
A 500 mL round-bottom flask was charged with a solution of 1-(thiazol-2-yl)ethanone (20 g, 157.0 mmol) and ethane-1,2-diol (19.5 g, 314 mmol) in toluene (300 mL). To the solution was added TsOH (2.7 g, 15.7 mmol). The resulting solution was refluxed overnight, during which time water separated from the solution. The resulting solution was diluted with 200 mL of water and extracted with 2 x 100 mL of ethyl acetate. The organic layers were combined, dried _over anhydrous _Na2SO4 , and then concentrated under vacuum. This afforded 26.6 g (99%) of the title compound as a pale yellow oil. MS-ESI: 172.0 (M+1).

Step 2: 2-(2-methyl-1,3-dioxolan-2-yl)thiazole-5-sulfonamide:
A 500 mL three-necked round-bottom flask purged with nitrogen and maintained under nitrogen was charged with a solution of 2-(2-methyl-1,3-dioxolan-2-yl)thiazole (14 g, 81.6 mmol) in THF (200 mL). This was followed by the dropwise addition of n-BuLi (2.5 M in THF, 35.2 mL, 88.0 mmol) with stirring at −78°C. The resulting solution was stirred at −78°C for 0.5 h, and then _SO2 was introduced into the reaction mixture. The reaction was gradually warmed to RT, and then NCS (12.8 g, 95.86 mmol) was added. The resulting solution was stirred at RT for 1 h. The solids were filtered. The resulting filtrate was concentrated under vacuum and then diluted with DCM (160 mL). To it was added a saturated solution of ammonia in DCM (300 mL). The resulting solution was stirred at RT for 3 h and then concentrated in vacuo. The residue was applied to a silica gel column and eluted with an ethyl acetate/petroleum ether gradient (1:20 to 1:5). This afforded 12.5 g (61%) of the title compound as a yellow solid. MS-ESI: 251.0 (M+1).

Step 3: 2-acetylthiazole-5-sulfonamide:
A 250 mL round-bottom flask was charged with a solution of 2-(2-methyl-1,3-dioxolan-2-yl)thiazole-5-sulfonamide (12.5 g, 50.0 mmol) in THF (125 mL). To it was added aq. HCl (4 N, 50.0 mL). The resulting solution was stirred at 70° C. for 6 hours. The resulting solution was diluted with 100 mL of water and extracted with 2×200 mL of ethyl acetate. The organic layers were combined, dried over anhydrous Na ₂ SO ₄ , and then concentrated under vacuum. The residue was applied to a silica gel column and eluted with a gradient of ethyl acetate/petroleum ether (1:2 to 1:1). This afforded 9.3 g (90%) of the title compound as a yellow solid. MS-ESI: 207.0 (M+1).

In steps 4-6, intermediate I was obtained from compound I-d using the same specific procedure for converting compound Z to compound Y shown in Scheme 3. MS-ESI: 336.1 (M+1).
Scheme 3:

N'-(tert-Butyldimethylsilyl)-5-(2-hydroxypropan-2-yl)thiazole-2-sulfonimidamide Step 1: Methyl 2-mercaptothiazole-5-carboxylate. A 2-L round-bottom flask was charged with methyl 2-bromothiazole-5-carboxylate (100 g, 450 mmol), EtOH (1000 mL), and sodium hydrogen sulfide (50 g, 890 mmol). The resulting solution was stirred at 80°C for 2 hours and then cooled to 0°C in a water/ice bath. The pH value of the solution was adjusted to 3 with hydrogen chloride (1N). The solid was collected by filtration. This afforded 63.2 g (80%) of the title compound as a pale yellow solid. MS-ESI: 176.0 (M+1).

Step 2: Methyl 2-(chlorosulfonyl)thiazole-5-carboxylate. A 1 L round-bottom flask was charged with methyl 2-mercaptothiazole-5-carboxylate (30 g, 170 mmol) and acetic acid (300 mL). This was followed by the portionwise addition of sodium hypochlorite (300 mL, 8%-10% wt.) at 0° C. The resulting solution was stirred at RT for 2 h and then diluted with 500 mL of water. The solution was extracted with 3×300 mL of DCM, and the combined organic layers were washed with 2×300 mL of brine and dried over anhydrous Na ₂ SO ₄ . The crude product as a yellow solution in DCM was used in the next step.

Step 3: Methyl 2-sulfamoylthiazole-5-carboxylate. A 2 L round-bottom flask was charged with methyl 2-(chlorosulfonyl)thiazole-5-carboxylate as a crude solution in DCM (900 mL). To the solution was introduced NH3(g) for 20 min below 0 °C. The resulting solution was stirred at RT for 1 h and then concentrated under vacuum. The residue was applied to a silica gel column and eluted with ethyl acetate/petroleum ether (1:5 to 1:3). This afforded 23 g (75%, 2 steps) of the title compound as a white solid. MS-ESI: 223.0 (M+1).

Step 4: 5-(2-Hydroxypropan-2-yl)thiazole-2-sulfonamide. A 500 mL round-bottom flask purged with nitrogen and maintained under nitrogen was charged with a solution of methyl 2-sulfamoylthiazole-5-carboxylate (15 g, 67.5 mmol) in THF (150 mL). This was followed by the dropwise addition of MeMgBr/THF (3 M, 90 mL) with stirring at 0° C. The resulting solution was stirred at RT for 14 h and then quenched by the addition of 100 mL of NH ₄ Cl (sat.). The resulting solution was extracted with 3×150 mL of DCM. The organic layers were combined, dried over anhydrous Na ₂ SO ₄ , and then concentrated under vacuum. The residue was applied to a silica gel column and eluted with ethyl acetate/petroleum ether (1:5 to 1:3). This afforded 11.5 g (78%) of the title compound as a white solid. MS-ESI: 223.0 (M+1), 221.0 (M-1) (positive and negative ion mode, respectively).

Step 5: N-(tert-Butyldimethylsilyl)-5-(2-hydroxypropan-2-yl)thiazole-2-sulfonamide. A 250 mL three-necked round-bottom flask purged with nitrogen and maintained under nitrogen was charged with a solution of 5-(2-hydroxypropan-2-yl)thiazole-2-sulfonamide (5 g, 22.5 mmol) in THF (100 mL). To this was then added NaH (60% wt, 1.8 g, 45.0 mmol) portionwise in an ice/water bath. After stirring in the water/ice bath for 20 min, this was followed by the dropwise addition of a solution of TBSCl (4.1 g, 27.2 mmol) in THF (10 mL) with stirring at 0 °C. The resulting solution was stirred at RT for 4 h. The reaction was quenched with saturated NH ₄ Cl (100 mL). The resulting solution was extracted with 3 x 100 mL of ethyl acetate, _and the combined organic layers were dried over _Na2SO4 and concentrated under vacuum. The crude solid was washed with ethyl acetate/hexane (1:5) (2 x 100 mL). This gave 6.81 g (90%) of the title compound as a yellow solid. MS-ESI: 337.1 (M+1), 335.1 (M-1) (positive and negative ion modes, respectively).

Step 6: N'-(tert-Butyldimethylsilyl)-5-(2-hydroxypropan-2-yl)thiazole-2-sulfonamide. A 100 mL three-necked round-bottom flask purged with nitrogen and maintained under nitrogen was charged with a solution _{of PPh3Cl2 (} 3 g, 9.0 mmol) in _CHCl3 (100 mL). This was followed by the dropwise addition of DIEA (1.54 g, 11.9 mmol) with stirring at RT. The resulting solution was stirred at RT for 10 min. This was followed by the dropwise addition of a solution of N-(tert-butyldimethylsilyl)-5-(2-hydroxypropan-2-yl)thiazole-2-sulfonamide (2.0 g, 5.9 mmol) in _CHCl3 (30 mL) with stirring to an ice/water bath. The resulting solution was stirred in the ice/water bath for 30 min. To it was introduced NH ₃ (g) at below 0° C. for 15 min. The resulting solution was stirred at RT for 20 min. The solid was filtered, the filtrate was concentrated, and the residue was dissolved in 300 mL of ethyl acetate. The solution was washed with brine (2×100 mL), dried over Na ₂ SO ₄ , and concentrated under vacuum. The crude solid was washed with CHCl ₃ (100 mL). The filtrate was then concentrated under vacuum, and the residue was further purified by silica gel column with ethyl acetate/petroleum ether (1:10 to 1:3). The original washed solid and the solid from the silica gel purification were combined. This gave 1.2 g (60%) of the title compound as a white solid. MS-ESI: 336.1 (M+1). 1H-NMR (300MHz, DMSO-d6) δ 7.66 (s, 1H), 7.12 (s, 2H), 5.78 (s, 1H), 1.51 (s, 6H), 0.86 (s, 9H), 0.02 (s, 3H), 0.01 (s, 3H).

The following abbreviations have the meanings indicated:
ACN = acetonitrile, BTC = trichloromethyl chloroformate, Boc = t-butyloxycarbonyl, Davephos = 2-dicyclohexylphosphino-2'-(N,N-dimethylamino)biphenyl, DCM = dichloromethane, DEA = diethylamine, DMF = N,N-dimethylformamide, DMSO = dimethyl sulfoxide, DIEA = N,N-diisopropylethylamine, DPPA = diphenylphosphoryl azide, dppf = 1,1'-bis(diphenylphosphino)ferrocene, EtOH = ethanol, HATU = 1-[bis(dimethylamino)methylene]-1H-1,2,3-triazolo[4,5-b]pyridinium 3-oxide hexafluorophosphate, Hex = hexane, HPLC = high performance liquid chromatography, LC-MS = liquid chromatography-mass spectrometry, LiHMDS = lithium bis(trimethylsilyl)amide, LDA = lithium diisopropylamide, M = mol/L
Me = methyl MeOH = methanol MSA = methanesulfonic acid NBS = N-bromosuccinimide NCS = N-chlorosuccinimide NMR = nuclear magnetic resonance Pd(dppf)Cl ₂ = dichloro[1,1'-bis(diphenylphosphino)ferrocene]palladium Ph = phenyl PPh ₃ Cl ₂ = dichlorotriphenylphosphorane Py = pyridine RT = room temperature Rt = retention time Rf = retardation factor Sat. = saturated TBAF = tetrabutylammonium fluoride TBS = tert-butyldimethylsilyl TBSCl = tert-butyldimethylsilyl chloride TBDPSCl = tert-butyldiphenylsilyl chloride TEA = triethylamine TFA = trifluoroacetic acid THF = tetrahydrofuran TLC = thin layer chromatography TsOH = 4-methylbenzenesulfonic acid UV = ultraviolet b.i. d = twice daily WCC = white blood cell count EP = endpoint y = year y/n = yes/no

The following examples illustrate the methods and uses described herein. However, they are in no way intended to limit the scope of the described methods and uses. Other variations of the embodiments will be readily apparent to those skilled in the art and are encompassed by the appended claims.

Example 1: Clinical Trial with Compound IA An open-label, single-arm Phase II study of Compound IA to evaluate the safety, tolerability, and efficacy in participants with familial cold autoinflammatory syndrome (FCAS) who showed evidence of inflammatory activity after cold challenge was conducted during screening. Figure 1 is a schematic overview of the treatment protocol with Compound IA (i.e., the R enantiomer of Compound I). Compound IA is administered at 100 mg twice daily for 3 days and 100 mg in the morning on the fourth day.

The primary objective of this study is to evaluate the efficacy of Compound IA in reducing cold-induced inflammation in participants with FCAS.

The primary endpoint (EP) is the change in white blood cell count (WCC) from pre-challenge to the highest post-challenge value.

The secondary objectives of the study are:
1. To evaluate the safety and tolerability of Compound IA 2. To evaluate the efficacy of Compound IA in improving the signs and symptoms of FCAS 3. To evaluate the effect of Compound IA on patient-reported outcomes

The secondary endpoints (EP) are:
1. Safety endpoints (including vital signs, ECG parameters, safety laboratory assessments, and adverse events)
2. Change from pre- to post-challenge in physician's global assessment of autoinflammatory disease activity and physician's severity assessment of signs and symptoms of autoinflammatory disease. 3. Change from pre- to post-challenge in patient's global assessment of disease activity.

Study Design This is an open-label, single-arm, multiple-dose study of approximately six participants with FCAS who have confirmed gain-of-function mutations in NLRP3 with evidence of inflammatory activity following cold challenge performed during screening.

A cold challenge protocol was developed to examine acute inflammatory mechanisms following whole-body cold exposure in patients with FCAS and to examine the effects of pretreatment with an IL-1-blocking therapeutic agent. Following cold exposure with warming relief, participants with a history of transient, self-limited rash, fever, and/or joint pain characteristic of FCAS were domiciled in a clinical setting under medical supervision while undergoing up to two controlled cold challenges to induce a transient inflammatory response. After the 45-minute cold challenge, participants were returned to ambient temperature of approximately 25°C in the clinical setting for at least 24 hours to ensure recovery of the inflammatory response.

Typical symptoms and signs induced by cold exposure in participants with FCAS include elevated markers of systemic inflammation (e.g., WCC, neutrophils), low-grade fever, rash, and arthralgia, beginning 1 hour after exposure, peaking 4-8 hours later, and resolving by the next day, with no reported long-term sequelae (Hoffman et al., Prevention of cold-associated acute inflammation in familial cold autoinflammatory syndrome by interleukin-1 receptor antagonist. Lancet; 2004; 364(9447):1779-85.).

The study included three periods:
- Screening period (maximum 3 months) including screening cold challenge
A treatment period including a second cold challenge (total duration of 5 days)
A follow-up period (10 days post-dose) conducted in conjunction with the end-of-study visit

A screening period to ensure study inclusion and exclusion criteria are met and to conduct clinical observations and biological sampling:
Screening Visit: Informed consent is collected and participants are assessed for eligibility. For participants who qualify for the screening cold challenge, prohibited medications are stopped. Results from laboratory samples collected at the screening visit, as well as active disease reports from participants, must be available before the screening cold challenge is scheduled.
Screening Cold Challenge: Participants will be settled for 3 days in conjunction with the Screening Cold Challenge. On Day 1 (Day -10), participants will be admitted in the morning, undergo safety assessments, and then remain indoors at ambient temperature, preferably above 25°C, to ensure stable status before the cold challenge. On Day 2 (Day -9), after the pre-challenge assessment and breakfast, participants will undergo a 45-minute cold challenge and then be monitored for the next 23 hours. On Day 3 (Day -8), participants will be discharged after the final assessment or later at the investigator's discretion. Participants must have a minimum of 1 week of recovery from the cold challenge prior to enrollment and initiation of treatment.

Treatment Period Treatment Initiation Visit: Participants who meet all inclusion criteria, no exclusion criteria, and who show evidence of inflammatory activity, e.g., after cold challenge administered during screening, will be enrolled and treatment will begin on Day 1.
The first dose of Compound IA will be administered in the clinic, and study treatment will be distributed to participants for continued treatment at home. Participants may be stationed for the duration of treatment for participant convenience and/or logistical reasons, at the discretion of the participant and investigator.
Cold challenge: Participants will be admitted to the clinic in the morning of Day 3, the day before the cold challenge, and will remain there for a total of 3 days or more if directed by the investigator or local regulations. On Day 3, participants will undergo a safety assessment and then remain indoors at ambient temperature, preferably above 25°C, to ensure a stable state before the cold challenge. On the morning of Day 4, pre-challenge assessments will be conducted and breakfast will be served. Immediately after breakfast, a pre-dose PK sample will be collected and the final dose of study treatment will be administered. One hour after study treatment administration, another PK sample will be collected and the cold challenge will begin. The cold challenge will last for 45 minutes. After completion of the cold challenge, participants will be monitored until the following morning (Day 5). Participants will be discharged at the investigator's discretion after the final assessment on Day 5 or later.

Follow-up period to ensure participant safety after treatment discontinuation and recovery from cold challenge Participants will be followed through completion of study assessments at the End-of-Study visit approximately 10 days after the last dose.

Key Inclusion Criteria 1. Written informed consent must be obtained before any study-specific assessments are conducted. 2. Male and female participants, ages 18-80 years, inclusive. 3. Body mass index in the range of 18-35 kg/ ^m². 4. Participants with a genetic diagnosis of FCAS. 5. Participants with clinical history and investigation findings consistent with FCAS, in the absence of a history or diagnosis of amyloidosis and/or organ damage (e.g., hearing loss, periorbital edema, lymphadenopathy, and serositis). 6. Participants with evidence of inflammatory activity after the screening cold challenge. 7. Clinical history of active disease within the screening period in response to cold exposure under at least one circumstance, as assessed by a Physician's Global Assessment of Autoinflammatory Disease Activity >minimal.

Key Exclusion Criteria 1. Participants with NLRP3 mutations that have not responded to NLRP3 inhibition, including but not limited to L353P carriers (based on lead investigator/registry data, published evidence, and/or Novartis internal studies) 2. Participants are currently being treated with anti-rejection and/or immunomodulatory medications, and treatment cannot be discontinued or switched to a different medication within 28 days or 5 half-lives (whichever is longer, if required by local regulations), or until the expected pharmacodynamic effect has returned to baseline for immunomodulatory therapeutic antibodies prior to the screening cold challenge and over the duration of the study. The exceptions are anakinra, canakinumab, and/or other investigational IL-1/NLRP3 binding or blocking therapies, which must be discontinued at screening. Once the criteria for evidence of active disease are met, participants may proceed to the screening cold challenge. 3. 1. Clinically significant, suspected active or chronic bacterial (including Mycobacterium tuberculosis), viral, or fungal infection within 30 days prior to dosing; 2. Participants with innate immune deficiency (e.g., TLR immunodeficiency, IFN-γ signaling deficiency) or acquired immune deficiency (e.g., AIDS); 3. Presence of human immunodeficiency virus (HIV) infection, hepatitis B surface antigen (HBsAg) or hepatitis B core antibody (anti-HBc), or hepatitis C antibody at screening; 4. Live vaccine within 4 weeks of Day 1 (i.e., first dose of Compound IA); 5. Absolute peripheral blood neutrophil count of ≦1000/mm3; 6. Presence of HIV infection, hepatitis B surface antigen (HBsAg) or hepatitis B core antibody (anti-HBc), or hepatitis C antibody at screening; 7. Absolute peripheral blood neutrophil count of ≦1000/mm3; 8. Presence of HIV infection, hepatitis B surface antigen (HBsAg) or hepatitis B core antibody (anti-HBc), or hepatitis C antibody at screening; 9. Presence of HIV infection, hepatitis B surface antigen (HBsAg) or hepatitis B core antibody (anti-HBc), or hepatitis C antibody at screening; 10. Presence of HIV infection, hepatitis B surface antigen (anti-HBsAg) or hepatitis B core antibody (anti-HBc), or hepatitis C antibody at screening; 11. Presence of HIV infection, hepatitis B surface antigen (anti-HBsAg) or hepatitis B core antibody (anti-HBc), or hepatitis ^C antibody at screening; 12. Presence of HIV infection, hepatitis B surface antigen (anti-HBsAg) or hepatitis B core antibody (anti-HBc), or hepatitis C antibody at screening; 13. Presence of Estimated GFR (eGFR) ≤ 90 mL/min/1.73 m2 (based on the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula)
9. History or current diagnosis of ECG abnormalities that present a significant safety risk for the enrolled participant. 10. Pregnant or nursing (lactating) women, where pregnancy is defined as the state of a woman after conception and until the end of pregnancy, confirmed by a positive human serum chorionic gonadotropin (hCG) laboratory test. 11. Women of childbearing potential, defined as all women who are physiologically capable of becoming pregnant unless highly effective methods of contraception are used during treatment and for 10 days after discontinuation of study treatment. 12. Any significant concurrent medical condition that, in the opinion of the investigator, may affect the participant's ability to tolerate and complete the study.

Efficacy assessment:
・White blood cell count (WCC)
Physician's global assessment of autoinflammatory disease activity Physician's severity assessment of autoinflammatory disease signs and symptoms Patient's global assessment of disease activity

Key safety assessments: Physical examination, vital signs, ECG parameters, pregnancy and fertility assessments, monitoring of blood and urine laboratory markers, and monitoring of adverse events and serious adverse events.

Other assessments: Inflammatory markers (including but not limited to absolute neutrophil count (ANC), high-sensitivity C-reactive protein (hsCRP), and serum amyloid A (SAA))
Plasma concentrations and pharmacokinetic parameters of Compound IA. Pharmacodynamic inflammasome pathway and inflammation-related biomarkers in serum, e.g., IL-1β, IL-6, IL-18, IL-18 binding protein (IL-18BP), CXCL10, caspase-1, and proteomics.

Data Analysis The primary objective will be achieved and Compound IA will be considered effective in treating cold-induced inflammation in participants with FCAS if the estimated difference in change from pre-challenge in total WCC between the treatment and screening periods is:
1. Statistically significant (p<0.10) and 2. Less than -4 x 109 cells/L

Changes from pre-loading to peak post-loading WCC will be analyzed using a linear model that takes into account within-participant correlation and includes the effects of pre-loading values and modeling period as covariates.

Rationale for Dose/Regimen, Duration of Treatment A dose of 100 mg administered twice daily as a tablet has been selected for this study based on preliminary PK results and preliminary PK/PD relationships. Compound IA tablets will be administered immediately after completion of a meal, and all doses will be taken approximately 12 hours apart (+/- 1 hour).

A positive food effect on PK (a 2.05-fold increase in peak plasma levels (Cmax) and a 1.49-fold increase in AUClast) was demonstrated with the 100 mg tablet. The apparent terminal elimination half-life of Compound IA tablets under fed conditions is approximately 10 hours; therefore, steady state is predicted by day 4 after multiple dosing.

There are no established occupancy markers for NLRP3. Ex vivo whole blood LPS-stimulated IL-1β secretion data from the FIH study were used to estimate the effective dose. Based on the results of this assay, the mean total Compound IA plasma trough concentration required to inhibit 90% of stimulated IL-1β release (IC90) in healthy participants averaged 3.17 μM, equivalent to approximately 1.3 μg/mL.

Based on the 3- to 5-fold greater in vitro IC50 values for inhibition of IL-1β secretion measured in PBMCs from patients with specific FCAS-associated mutations compared to healthy participants, higher concentrations are likely required in participants with FCAS. This is likely due to mutations in the NLRP3 protein that affect the compound's binding KD. Assuming that plasma levels 5-fold above the IC90 values obtained from preliminary 24-hour PK/PD studies are required to maintain full target occupancy in participants with FCAS, a 100 mg dose administered twice daily immediately after the completion of a meal would ensure full NLRP3 inhibition by day 4.

In human studies in healthy volunteers, a = 200 mg dose of Compound 1A administered once daily for up to 14 days, with mean AUC0-24h and Cmax at steady state of 182 μg ^* h/mL and 26.4 μg/mL. For the 100 mg tablet administered twice daily, the predicted mean steady state AUC0-24h (225 μg ^* h/mL) is 1.2-fold higher and Cmax (12.1 μg/mL) is 2.2-fold lower than the corresponding PK parameters in healthy volunteers receiving 200 mg of Compound 1A.

Safety during the treatment period is supported by a 13-week Good Laboratory Practice (GLP) toxicology study in rats and cynomolgus monkeys.

Given the short treatment duration of 4 days and the ample safety margin, administration of Compound IA in this study is considered safe.

Drug-drug interaction challenges:
Evaluation and recommendation for clinical drug-drug interaction studies of cytochrome P450 (CYP) substrates/modulators and Compound IA is based on in vitro/preclinical data and physiologically based PK simulations. Compound IA is expected to be eliminated primarily via hepatic CYP-mediated metabolism with CYP2C9 (68%) and CYP3A4 (29%) as the major contributing enzymes. Participants who are poor CYP2C9 metabolizers will be excluded from this study.

Considering the duration of treatment and a sufficient safety margin, administration of Compound IA is considered safe even under conditions of increased exposure to Compound IA.

Prohibited drugs and herbal remedies:
- Anti-rejection/immunomodulatory therapy (e.g., anakinra, canakinumab, or other investigational IL-1/NLRP3 binding or blocking therapy)
- Live vaccines - Strong or moderate inducers of CYP2C9 or strong inducers of CYP3A, including carbamazepine, enzalutamide, lumacaftor, phenobarbital, phenytoin, rifabutin, mitotane, and St. John's wort (Hypericum perforatum) - Strong inhibitors of CYP2C9, including miconazole, berberine (botanical), sulfaphenazole, fluconazole, resveratrol (botanical) - Other investigational drugs

Drugs to use with caution:
Drugs metabolized by CYP3A: In vitro metabolism studies have shown that Compound IA may have the potential to induce the metabolism of drug substrates metabolized by the isoenzyme CYP3A. Therefore, investigators may administer concomitant medications known to be metabolized by CYP3A4/5 at their discretion. Patients receiving such medications may require dose titration or increased concomitant medication. Caution is advised, particularly when Compound IA is coadministered with drugs that are sensitive substrates of CYP3A and/or have a narrow therapeutic index. Drugs that are strong or moderate inhibitors of CYP3A: Because Compound IA was identified in vitro as a substrate of CYP3A, increased systemic exposure of Compound IA cannot be excluded when coadministered with strong CYP3A inhibitors, such as antivirals (e.g., ritonavir), antifungals (e.g., itraconazole, ketoconazole), and antibiotics (e.g., erythromycin, clarithromycin). Investigators may, at their discretion, co-administer known inhibitors of CYP3A, but their duration should be kept as short as possible and patients should be closely monitored.

Example 2: Clinical First-in-Human (FIH) Study with Compound IA:
Study Design The study design consisted of four parts: single ascending dose (SAD; Part A), relative bioavailability of tablet formulation (Part B), multiple ascending dose (MAD; Part C), and relative bioavailability and food effect (Part D) (Figure 2). In each group in Part A and Part C, eight subjects were randomized in a 3:1 ratio to receive Compound IA (6 subjects) or matching placebo (2 subjects).

For Part A, eight groups of eight eligible subjects were enrolled. Each subject received a single oral dose of Compound IA (3, 10, 30, 100, or 300 mg of crystal suspension and 100, 300, or 600 mg of SDD under fasting conditions). In Group 1 of Part A, two sentinel subjects were dosed at least 24 hours before dosing the remainder of the group to ensure maximum safety.

Part B was skipped because the data collected in Part A provided sufficient comparison of the crystalline and SDD formulations.

In Part C, eligible subjects were enrolled in six different groups. Each subject received multiple doses of Compound IA once daily (QD) under fasted conditions (10, 30 mg crystal suspension and 100, 200 mg SDD suspension over 14 days) or twice daily (BID) under fed conditions (25, 50 mg encapsulated crystal tablet over 13 days and a single dose or placebo on day 14). Subjects in Part C were dosed following review of available safety, tolerability, and PK data from the preceding groups in Part A.

Part D had an open-label, randomized, three-period crossover design consisting of one group of six subjects. The PK characteristics of a crystalline tablet formulation, an evaluation supported by the Compound IA nonclinical safety pharmacology and toxicology program, were compared between fed and fasted conditions and with the PK characteristics of a crystalline suspension of Compound IA under fasted conditions. Subjects received three doses of Compound IA with a 7-14 day washout period between doses (Dose 1: 100 mg oral suspension under fasted conditions; Dose 2: 100 mg oral tablet under fasted conditions; Dose 3: 100 mg oral tablet under fed conditions). Based on these doses, subjects were randomly assigned to one of six treatment sequences (one subject per sequence) prepared using a Williams design (Wang B-S, Wang X-J, Gong L-K. The Construction of a Williams Design and Randomization in Cross-Over Clinical Trials Using SAS. Journal of Statistical Software 2009;29).

Subjects Eligible subjects were healthy volunteers aged 18-64 years with a body mass index (BMI) ≥ 18.5 and ≤ 30.0 kg/ ^m² . No subject participated in more than one part or group. Written informed consent was obtained before any study procedures. Subjects participating in Part D had to be willing and able to consume an overall high-fat breakfast within the specified time frame. Subjects were excluded if they had a history of major psychiatric disorder, a diagnosis of intellectual disability, clinically significant vital sign abnormalities, or tobacco product use within 90 days prior to (initial) drug administration through follow-up.

Blinding In Parts A and C, the active and placebo treatments, which could not be distinguished based on the label, were identical in appearance and had similar taste and odor. To maintain blinding, the same number of tablets or suspensions were administered to each subject within each cohort. Investigators and subjects remained blinded throughout the relevant part of the study, and the blinding remained uninterrupted throughout. The sponsor had unblinded access to all study data and was provided with a copy of the randomization code to support decisions made regarding the study. Part D was unblinded, and only Compound IA was administered to subjects in one of six treatment sequences (one subject per sequence) according to the Williams design.

Objectives The primary objective of the study was to evaluate the safety and tolerability of oral administration of SAD and MAD of Compound IA in healthy subjects in all parts of the study. Key secondary objectives were to characterize the PK properties of Compound IA after single and multiple doses and to evaluate the effect of food on the PK properties of Compound IA.

Safety Assessments Safety assessments in all parts of the study included adverse events (AEs) reporting using the Regulatory Information Glossary (Version 22.1), clinical laboratory tests (biochemistry, hematology, and urinalysis), vital signs, electrocardiogram (ECG), physical examination, and skin biopsy (where applicable).

Pharmacokinetic (PK) Evaluation In the single-dose part, blood samples were collected to measure Compound IA concentrations at the following time points for dosing on Day 1: pre-dose and 0.25, 0.5, 0.75, 1, 1.5, 2, 3, 4, 6, 8, 12, 24, 36, and 48 hours after dosing, and at the follow-up visit. In the multiple-dose part, blood samples were collected at pre-dose and 0.25, 0.5, 0.75, 1, 1.5, 2, 3, 4, 6, 8, and 12 hours after dosing on Days 1 and 14; for Days 2, 4, 7, 9, and 11: pre-dose; after the final dose on Day 14: 24 and 36 hours (Day 15), and 48 hours (Day 16) after dosing; and at the follow-up visit.

During the multiple ascending dose (MAD) portion, urine pools were collected over 24 hours for QD dosing (0-12 hours and 12-24 hours) and over 12 hours for BID dosing on days 1 and 14. Plasma samples were analyzed by a fully validated liquid chromatography-tandem mass spectrometry (LC-MS/MS). Compound IA concentrations >1 ng/mL (lower limit of quantitation, LLOQ) were measured with a precision of ≤4.4% and an accuracy of -2.0% to 1.5% relative error. Urine samples were analyzed by LC-MS/MS with an LLOQ of 1 ng/mL. Concentrations below the LLOQ were set to 0.

The following PK parameters were determined: non-compartmental maximum concentration in plasma (C _max ); time to maximum concentration (t _max ); concentration 24 hours post-dose (C _24h ) (Part A); lag time: observed time to first quantifiable concentration (t _lag ); time of last quantifiable concentration (t _last ); area under the concentration-time curve from 0 hours to last quantifiable concentration (AUC _0-last ); area under the plasma concentration-time curve from 0 hours to infinity (AUC _0-inf ); area under the plasma concentration-time curve from 0 hours to 24 hours post-dose (AUC _0-24 ); terminal-phase rate constant (K _el ); terminal-phase half-life (t _1/2 ); apparent total body clearance (CL/F); and apparent volume of distribution during the terminal phase (V _z /F); and further for Part C only: area under the plasma concentration-time curve over the dosing interval from 0 to 12 hours post-dose (AUC _0-tau ); apparent clearance at steady state (CLss/F); accumulation ratio based on AUC _0-tau (R _ac , AUC); and accumulation ratio based on C _max (R _ac , C _max ).

Pharmacodynamic (PD) Evaluation To measure PD responses to the NLRP3 inhibitory pathway, whole blood samples were collected for exploratory PD analysis (Part A and Part C, Groups 1-3). Analysis of the inflammatory marker IL-1β was performed after ex vivo stimulation of whole blood samples with lipopolysaccharide (LPS). Whole blood stimulation with 1 μg/mL LPS was successful, and analysis of IL-1β concentrations in plasma samples, performed using a validated electrochemiluminescence assay, was found to be valid and scientifically acceptable. The LLOQ after dilution was 64.6 ng/L.

Statistical Analysis All data will be summarized using descriptive statistics and listed and summarized in tabular and/or graphical format. Descriptive statistics for all relevant PK parameters included n, arithmetic mean, standard deviation (SD), coefficient of variation (CV%), minimum, median, maximum, geometric mean, and geometric CV%. For _tmax , only median, minimum, and maximum values are presented. PK parameters were calculated using non-compartmental methods using Phoenix Version 8.1 software. Concentrations below the lower limit of quantification were treated as 0 in summary statistics limited to concentration data. The linear trapezoidal method was used to calculate AUC. Regression analysis of the terminal plasma elimination phase to determine _t½ included at least three data points after _Cmax . Parameters with adjusted ^r² less than 0.80 were flagged but included in the descriptive statistics. AUC _0-inf , %AUC _extra , CL/F, and VZ/F parameters were excluded from the descriptive statistics if the %AUC _extra was greater than 20%.

In Part A, dose proportionality was explored using a regression exponential model for log-transformed C _max , AUC _0-last , and AUC _0-inf versus log-transformed dose level. Point estimates for the intercept and slope and corresponding 90% confidence intervals (CI) for the slope were calculated. For Part C, dose proportionality was not explored. In Part D, the relative bioavailability of the crystal tablet versus the crystal suspension, and the effect of food, were explored using an analysis of variance (ANOVA) model for the PK data. The ANOVA model included fixed effects for treatment, period, and sequence, and a random effect for subject within sequence.

Least-squares geometric mean ratios are presented with 90% CI for the following treatments: fasted 100 mg Compound IA tablet over fasted 100 mg Compound IA suspension; fed 100 mg Compound IA tablet over fasted 100 mg Compound IA tablet.

Combined individual and mean plots of IL-1β concentration versus time are presented by treatment.

A Bayesian Emax PK/PD model was applied to characterize the inhibitory potency of Compound IA on IL-1β release. The model was developed using the rstan library in the free software environment R (version 4.0.5). Convergence issues (likely related to fitting baseline values with interindividual variability) were the final rationale for selecting the Bayesian method over the frequentist method (which was also evaluated initially because it included only one parameter with interindividual variability). Two results are presented: one with an estimate of maximal inhibition, and one that assumes complete inhibition ( _Emax = 1) is possible. In vitro LPS-stimulated results were corrected for unstimulated results for the same samples. Concentrations below the LLOQ were set to half the LLOQ (IL-1β) and 0 (Compound IA).

Results Subject Disposition and Demographics A total of 122 subjects were enrolled in the study. All 122 were included in the safety and PD analysis set, and 94 subjects receiving active treatment (Compound IA) were included in the PK analysis set. Overall, 58 (48%) male and 64 (52%) female subjects, aged 18-64 years and with a BMI of 18.9-29.4 kg/ ^m2 , participated in the study. The majority of subjects (105 [86%]) (Part A, n=57; Part C, n=42; Part D, n=6) were Caucasian.

Of the enrolled subjects, 107 (88%) completed the study per protocol, and 15 (12%) discontinued the study prematurely. Premature discontinuations included 1 of 64 (2%) subjects in Part A, 13 of 52 (25%) subjects in Part C, and 1 of 6 (17%) subjects in Part D. Reasons for discontinuation included drug withdrawal due to AEs in 12 (10%) subjects, with one (1%) subject each discontinuing the study due to either consent withdrawal, loss to follow-up, or the study being temporarily put on hold due to the COVID-19 pandemic (preventing visits; unrelated to the safety of Compound IA). Overall, four discontinued subjects were replaced in Part C.

Safety Single and multiple doses of Compound IA were generally well tolerated. No deaths or serious AEs (SAEs) were reported during the study. Overall, 87/122 subjects (71%) reported treatment-emergent AEs (TEAEs): 66/94 subjects (70%) in the Compound IA arm and 21/28 subjects (75%) in the placebo arm. While the majority of TEAEs reported by 84 (69%) subjects were mild, 15 subjects (12%) reported moderate TEAEs. Frequently reported system organ class (SOC) events in >20% of subjects were nervous system disorders (34%), systemic disorders and administration site conditions (29%), and gastrointestinal disorders (27%).

Forty-six related TEAEs reported by a total of 24/122 subjects (20%) were considered related to study drug, including 21/94 subjects (22%) who received Compound IA and 3/28 subjects (11%) who received placebo. For 12/122 subjects (10%), 20 TEAEs of maculopapular rash and/or pruritus were considered to be related to study drug and therefore were considered AEs of particular interest. All 12 subjects received Compound IA as either a single dose (100 mg CS [n=1] or 600 mg SDD [n=1]) or multiple doses (30 mg QD CS [n=2], 100 mg QD SDD [n=3], 200 mg QD SDD [n=2], or 50 mg BID ECT [n=3]). These TEAEs were mild to moderate in severity, generally began within 1 to 17 days of initiating treatment with Compound IA, and resolved within 1 to 18 days of onset; all cases resolved without concomitant therapy. TEAEs led to treatment discontinuation in 10 subjects. Two other subjects discontinued early due to TEAEs unrelated to study drug.

Moderate decreases in neutrophil and white blood cell counts were considered non-clinically significant and were occasionally noted, which may be consistent with the PD effect of Compound IA due to inhibition of IL-1β signaling downstream of NLRP3. One subject had second-degree atrioventricular block, which was not considered related to study drug. No other clinically relevant findings were reported on vital signs, 12-lead ECG, 24-hour Holter monitoring, or physical examination.

Pharmacokinetics: Plasma exposure to a single dose of Compound IA, as indicated by dose-normalized Cmax and AUC, increased less than dose-proportionally when Compound IA was administered as a crystalline suspension (3-300 mg, slope [90% CI]: 0.518 [0.460; 0.577] for Cmax and 0.701 [0.614; 0.788] for AUC0-last). While mean AUC0 _-last appeared to increase dose-proportionally at the lowest dose levels (3 mg-30 mg), mean AUC0 _-last was similar at the 100 mg and 300 mg dose levels (79,500 ng h/mL (CV 54.8%) vs. 64,400 ng h/mL (CV 23.5%), respectively). Exposure increased dose-proportionally when administered as an SDD suspension (100-600 mg, slope [90% CI]: 0.913 [0.802; 0.1.024] for Cmax and 1.121 [0.977; 0.1.265] for AUC _0-last ).

After 2 weeks of QD administration of Compound IA at doses ranging from 30 to 200 mg, only limited drug accumulation of approximately 1.1-1.3 fold was observed in reaching steady state. This corresponds to a mean t _1/2 ranging from 9.83 to 16.2 hours across the QD and BID dose levels. At steady state, Compound IA showed low to moderate intersubject variability across the QD and BID dose levels of Compound IA, with very low CLss/F (approximately 0.83-1.11 L/hr) and Vss/F (approximately 12.6-23.3 L).

The total cumulative amount of Compound IA excreted in urine increased linearly with increasing multiple dose levels. Compound IA was largely excreted within 12 hours. On Days 1 and 14, the mean fraction of the excreted dose was within the ranges of 0.3%-0.4% and 0.7%-1.1%, respectively, and renal clearance was within the ranges of 3.6-5.0 mL/hour and 6.8-9.1 mL/hour, respectively.

Administration of a single 100 mg dose of Compound IA as a crystalline suspension under fed conditions resulted in a 2.05-fold increase in _Cmax and a 1.49-fold increase in AUC0 _-last of Compound IA compared to fasted conditions. For the crystalline tablet (100 mg Compound IA under fasted conditions), the median _tmax of Compound IA was delayed from 2 to 5 hours, _Cmax was 78% lower, AUC was similar (104%), and t1 _/2 was comparable between the crystalline tablet and suspension. The encapsulated crystalline tablet (25 mg and 50 mg BID under fed conditions) was characterized by a median lag time of 0.75 and 0.25 hours, respectively, and a median _tmax of 4 hours on Day 1. The mean t1 _/2 of Compound IA was comparable between the tablet (18.6 hours) and suspension (17.7 hours) formulations.

Pharmacodynamics: A dose-dependent decrease in the concentration of in vitro stimulated IL-1β (mean nadir concentrations of approximately 5% to 20% of baseline values) was observed with increasing single and multiple oral doses of Compound IA. At the highest dose level of Compound IA, inhibition of IL-1β release was observed from 1 hour post-dose through the final sampling time point for single (Day 3 or for up to 6 hours at the lowest dose level ≦10 mg) and multiple (Day 15) oral doses of Compound IA.

Based on the fractional maximum stimulation effect (E _max ) model tested using the Hill coefficient, the typical baseline (E ₀ ) (± _SD ) of the observed stimulatory effect of IL-1β was 1820 (±102) ng/L; the E _max of IL-1β was −0.985 (±0.00277) and the Hill coefficient was 0.758 (±0.0351). The effective concentrations for the estimated maximum effect of Compound IA obtained from in vitro stimulated IL-1β release were EC ₅₀ : 59 ng/mL (90% CI: 48, 72), EC ₉₀ : 1080 ng/mL (90% CI: 942, 1240). Considering complete inhibition (fixing E _max =1), the plasma concentrations of compound IA that inhibited 50% and 90% of LPS in vitro-stimulated IL-1β release (IC ₅₀ and IC ₉₀ ) were 61 ng/mL (90% CI: 50; 70) and 1340 ng/mL (90% CI: 1190; 1490), respectively, with a Hill coefficient of 0.715 (±0.0333). The similarity between the models indicates that imputation of values below the LOQ down to LOQ/2 has limited impact.

Discussion: There is an unmet medical need to expand treatment modalities for patients suffering from inflammasome-mediated NLRP3-mediated inflammatory, metabolic, and neurodegenerative diseases, providing effective and predictable treatment options without increased risk of AEs. In this study, the NLRP3 antagonist Compound IA was orally administered to human subjects for the first time to explore its safety, tolerability, PK, and PD properties. The initial dose was selected based on nonclinical safety from animal and in vitro data, along with predicted human PK and predicted effective dose.

Safety Single and multiple doses of Compound IA or placebo were generally well tolerated. No deaths or SAEs were reported during the study. Similar TEAE rates were observed between subjects receiving Compound IA (70%) and placebo (75%). The majority of TEAEs reported by subjects were mild (69%) or moderate (12%) in severity. Subcutaneous and gastrointestinal TEAEs were reported exclusively in subjects receiving Compound IA and not in those receiving placebo. Maculopapular and/or pruritic rash was most frequently reported at the highest multiple dose level of Compound IA, suggesting a relationship to exposure to Compound IA, independent of the formulation used. Safety and tolerability data for other NLRP3 inhibitors tested in clinical trials, such as ZYIL1 or dapasuntril (Parmar DV, Kansagra KA, Momin T, Patel HB, Jansari GA, Bhavsar J, Shah C, Patel JM, Ghoghari A, Barot A, Sharma B, Viswanathan K, Patel HV, Jain MR. Safety, Tolerability, Pharmacokinetics, and Pharmacodynamics of the Oral NLRP3 Inflammatory Inhibitor ZYIL1: First-in-Human Phase 1 Studies (Single Ascending Dose and Multiple Ascending Dose). Clin Pharmacol Drug Dev. 2023;12:202-211;Marchetti C, Swartzwelter B, Gamboni F, Neff CP, Richter K, Azam T, Carta S, Tengesdal I, Nemkov T, D'Alessandro A, Henry C, Jones GS, Goodrich SA, Laurent JP, Jones TM, Scribner CL, Barrow RB, Altman RD, Skouras DB, Gattorno M, Grau V, Janciauskiene S, Rubartelli A, Joosten LAB, Dinarello CA. OLT1177, a β-sulfonyl nitrile compound, safe in humans, inhibits the NLRP3 inflammasome and reverses the metabolic cost of inflammation. Proc Natl Acad Sci USA. 2018;115:E1530-E1539; Klueck V, Jansen TLTA, Janssen M, Comarniceanu A, Efde M, Tengesdal IW, Schraa K, Cleophas MCP, Scribner CL, Skouras DB, Marchetti C, Dinarello CA, Joosten LAB. Dapansutrile, an oral selective NLRP3 inflammasome inhibitor, for treatment of gout flares: an The open-label, dose-adaptive, proof-of-concept, phase 2a trial. Lancet Rheumatol. 2020;2:e270-e280) was free of any drug-related skin reactions, which are not attributable to the mode of action and point to effects related to the specific Compound IA.

Pharmacokinetics: Following a single oral dose of Compound IA as a suspension (3-300 mg CS, 100-600 mg SDD) under fasted conditions, Compound IA was generally rapidly absorbed, with median _tmax ranging from 0.76 to 3.00 hours across dose levels. However, at the highest dose range of 30-600 mg, the median _tmax was somewhat delayed (1.5-3.0 hours) compared to lower doses (3 mg and 10 mg: 0.76 and 1.00 hours, respectively). While the increase in drug exposure was less than dose-proportional for the crystalline suspensions (particularly 100 mg and 300 mg), a dose-proportional increase in exposure was observed for the SDD suspensions (100-600 mg), indicating solubility-limited absorption of the crystalline material at doses ≥ 100 mg.

Multiple doses and formulations of Compound IA showed no deviation from dose-proportional drug exposure after 2 weeks, indicating that multiple-dose PK parameters were linear and not limited by solubility. After oral administration of Compound IA on Day 1, a slight delay in absorption was observed for the encapsulated crystalline tablet under fed conditions. This slower absorption was consistent with the bioavailability results, in which no significant effect of food on _Tmax was observed. These findings suggest that the delayed absorption time was due to encapsulation. Renal clearance was determined to be approximately 0.004 L/hr (Day 1) or 0.008 L/hr (Day 14), approximately <0.8% of the oral dose. This indicates that direct urinary excretion of Compound IA is not expected to be the primary elimination route for this drug in humans.

Compound IA as a 100 mg crystalline tablet demonstrated a positive food effect (greater exposure with food), with a 2.05-fold and 1.49-fold increase in _Cmax and AUC, respectively, in the fed state (high-fat, high-calorie meal) relative to the fasted state. The median _Tmax for the 100 mg crystalline tablet was 5 hours, while shorter _Tmax values (0.76-3.0 hours) were reported for the suspension. Compound IA has a very low apparent oral clearance (CLss/F ∼1.0 L/hr), which is associated with ≤2% of human hepatic blood flow and a low apparent volume of distribution (Vss/F) of ∼12.6-23.3 L. When measured for the crystalline tablet when administered with food, slight drug accumulation of ∼1.2-fold after QD dosing and 2-fold after BID dosing was observed in reaching steady state, consistent with an effective _t½ of ∼10 hours.

Pharmacodynamics Nonclinical studies suggest that Compound IA uses various NLRP3-dependent activators to block the release of IL-1β. This is observed, for example, in the case of MCC950, which selectively inhibits the activation of NLRP3 (Tapia-Abellan A, Angosto-Bazarra D, Martinez-Banaclocha H, de Torre-Minguela C, Cerón-Carrasco JP, Perez-Sanchez H, Arostegui JI, Pelegrin P. MCC950 closes the active conformation of NLRP3 to an inactive state. Nat Chem Biol 2019;15:560-64), or in the case of the ZYIL1 compound, which showed >90% IL-1b inhibition in healthy subjects. In contrast, another NLRP3 inhibitor, dapanstril (OLT1177), only partially reduced IL-1b release in healthy subjects and patients with gouty erythema.

In this study, a dose-dependent decrease in IL-1β levels was observed with increasing single and multiple oral doses of Compound IA. IL-1β production can be mediated by other inflammasomes or by inflammasome-independent pathways (Gaidt MM, Hornung V. Alternative inflammasome activation enables IL-1β release from living cells. Curr Opin Immunol 2017;44:7-13); therefore, inhibitors targeting IL-1β may have unintended immunosuppressive effects. Therefore, a pharmacological inhibitor that specifically targets the NLRP3 inflammasome alone may be a better option for the treatment of NLRP3-related diseases (Zahid A, Li B, Kombe AJK, Jin T, Tao J. Pharmacological Inhibitors of the NLRP3 Inflammasome. Front Immunol 2019;10:2538). Safety findings included mild, non-clinically significant decreases in neutrophil and white blood cell counts in 27 subjects. This may be consistent with Compound IA's PD effects resulting from inhibition of signaling downstream of NLRP3, similar to the known effects of the anti-IL-1β monoclonal antibody canakinumab (Dhimolea E. Canakinumab. Mabs 2010;2:3-13). Compound IA demonstrated a rapid onset of action for IL-1b inhibition, with a clear dose response across the entire dose range studied, with no apparent delay in onset after both single and multiple doses, suggesting a direct PK/PD relationship. A dose of 25 mg twice daily as a crystalline tablet was selected for Phase 2a trials in knee osteoarthritis to maintain approximately 90% IL-1b inhibition over 24 hours.

Additionally, a recent report from an early Phase 2a clinical trial of Compound IA, including patients with COVID-19-associated pneumonia and respiratory dysfunction, showed that a 50 mg BID tablet of Compound IA was well tolerated in this group of patients, with no new safety signals identified. Results showed a trend toward improved response in patients administered Compound IA on top of SoC versus SoC alone. A subanalysis in patients with more severe inflammation (high CRP) but lower corticosteroid doses showed a more rapid decline and normalization of inflammatory markers in the Compound IA + SoC group (Madurka I, Vishnevsky A, Soriano JB, Gans SJ, Ore DJS, Rendon A, Ulrik CS, Bhatnagar S, Krishnamurthy S, McHarry K, Welte T, Fernandez AA, Mehes B, Meiser K, Gatlik E, Sommer U, Junge G, Rezende E. COMPOUND IA: a new oral NLRP3 inhibitor-tested in an early phase 2a randomized clinical trial in patients with COVID-19 pneumonia and impaired Respiratory function. Infection 2022:1-14).

In summary, single and multiple oral doses of Compound IA were well tolerated in healthy subjects for up to 14 days, with no safety or tolerability concerns raised. The PK profile of Compound IA is compatible with a BID dosing regimen and PK/PD data support dose and formulation selection for further development. The safety and tolerability, PK, and PD results suggest that Compound IA has the potential to be an effective, oral, first-in-class innate immune modulator that warrants further clinical evaluation.

Example 3
The following procedure is suitable for testing the activity of NLRP3 inhibitors according to the present disclosure.

Procedure 1: IL-1β Production in PMA-Differentiated THP-1 Cells Stimulated with Gramicidin. THP-1 cells were purchased from the American Type Culture Collection and passaged according to the supplier's instructions. Prior to the experiment, cells were cultured in complete RPMI 1640 containing 10% heat-inactivated FBS, penicillin (100 units/ml), and streptomycin (100 μg/ml) and maintained in logarithmic phase before experimental setup. Prior to the experiment, THP-1 cells were treated with PMA (phorbol 12-myristate 13-acetate) (20 ng/ml) for 16-18 hours. Compounds were dissolved in dimethyl sulfoxide (DMSO) to make 30 mM stocks. On the day of the experiment, the medium was removed, and adherent cells were detached with trypsin for 5 minutes. Cells were then harvested, washed with complete RPMI 1640, spun down, and resuspended in RPMI 1640 containing 2% heat-inactivated FBS, penicillin (100 units/ml), and streptomycin (100 μg/ml). Cells were plated at a density of 50,000 cells/well in a 384-well plate (final assay volume of 50 μl). Compounds were first dissolved in assay medium to obtain a 5× top concentration of 500 μM. Ten serial dilutions (1:3) were then made in assay medium containing 1.67% DMSO. The 5× compound solution was added to the medium to achieve the desired final concentrations (e.g., 100, 33, 11, 3.7, 1.2, 0.41, 0.14, 0.046, 0.015, 0.0051, 0.0017 μM). The final DMSO concentration was 0.37%. Cells were incubated with compounds for 1 hour and then stimulated with gramicidin (5 μM) (Enzo) for 2 hours. Plates were then centrifuged at 340 g for 5 minutes. Cell-free supernatants (40 μL) were collected using a 96-channel PlateMaster (Gilson), and IL-1β production was assessed by HTRF (cisbio). A vehicle-only control and a dose titration of CRID3 (100-0.0017 μM) were run concurrently with each experiment. Data were normalized to vehicle-treated samples (equivalent to 0% inhibition) and 100 μM CRID3 (equivalent to 100% inhibition). Compounds showed concentration-dependent inhibition of IL-1β production in PMA-differentiated THP-1 cells.

Step 2:
1. Experimental Procedure:
1.1 Cell Culture 1) Cultivate THP-1 cells in complete RPMI-1640 medium containing 10% FBS at 37°C and 5% CO2 _. 2) Passage cells every 3 days by seeding 3 x ¹⁰⁵ cells per ml.

1.2 Compound Preparation Using the TECAN EVO system, prepare 3-fold serial dilutions of compounds in DMSO in 384-well LDV microplates, creating a compound source plate with 10 concentrations. The highest concentration is 30 mM. Figure 3 shows the layout of the microplate.

1.3 Cell Preparation 1) Centrifuge THP-1 cells at 350 g for 5 minutes 2) Resuspend cells in complete RMPI-1640 medium and count cells 3) Seed cells into T225 flasks (approximately 2.5 x ¹⁰ cells/flask) and treat cells with 20 ng/ml PMA (final DMSO concentration <1%)
4) Incubate overnight 1.4 THP-1 Stimulation 1) Wash adherent THP-1 cells with PBS and detach cells with 4 ml trypsin in a T225 flask 2) Centrifuge cells at 350 g for 5 minutes, resuspend cells in RPMI-1640 medium containing 2% FBS, and count cells with trypan blue 3) Transfer 50 nl/well of serial dilutions of test compounds into a 384-well plate by Echo; for high level control and point 1 of CRID3 (MCC950), mirror 165 nl and then backfill, making DMSO concentrations consistent in all wells, plate layout is as follows: 4) Seed 50 kJ cells into 40 ul of RPMI-1640 with 2% FBS/well in a 384-well plate 5) Incubate for 1 hour at ₃₇ °C, 5% CO2 6) Prepare 5x gramicidin and add 10 μl/well (final concentration is 5 μM) and incubate for 2 hours at 37°C, 5% _CO2 7) Centrifuge for 1 minute at 350 g Pipette 16 μl of supernatant by apricot and transfer to a white 384 proxyplate. HC: 100 μM CRID3 (MCC950) + 5 μM gramicidin LC: 5 μM gramicidin 8) Pipette 16 μl of supernatant by apricot and transfer to a white 384 proxyplate. Figure 3 shows the plate layout: HC: 100 μM CRID3 (MCC950) + 5 μM gramicidin LC: 5 μM gramicidin.

1.5 IL-1β Detection 1) Homogenize 5x Diluent #5 by vortexing and add 1 volume of stock to 4 volumes of distilled water 2) Thaw 20x stock solutions of anti-IL1β-cryptate antibody and anti-IL1β XL antibody. Dilute these two antibodies to 1x in Detection Buffer #3 3) Premix the two ready-to-use antibody solutions immediately before use 4) Dispense 4 ul of premixed anti-IL1β antibody working solution into all wells 5) Seal the plate and incubate overnight at 4°C 6) Read the cell plate using EnVison and plot the reading versus test compound concentration to calculate the _IC50

2. Data analysis:
1. The _IC50 of a compound can be calculated using the following formula: _IC50 Formula % Inhibition = 100 - 100 x [ _HCave - Reading/( _HCave - _LCave )]
2. The normalized data is fitted in a dose-response manner using XLfit to calculate compound concentrations

Table 2 shows the biological activity of compounds in the hTHP-1 assay containing 2% fetal bovine serum: <0.008 μM = "++++++"; ≥0.008 and <0.04 μM = "++++++"; ≥0.04 and <0.2 μM = "++++"; ≥0.2 and <1 μM = "+++"; ≥1 and <5 μM = "++"; ≥5 and <30 μM = "+"

All publications and patent documents cited in this specification are herein incorporated by reference as if each such publication or document was specifically and individually indicated to be incorporated by reference. The present invention and its embodiments have been described in detail. However, it is not intended that the scope of the present invention be limited to the particular embodiments of any process, manufacture, composition, compound, means, methods, and/or steps described herein. Various modifications, substitutions, and variations can be made to the disclosed material without departing from the spirit and/or essential characteristics of the invention. Accordingly, those skilled in the art will readily appreciate that subsequent modifications, substitutions, and/or variations that perform substantially the same function or achieve substantially the same results as the embodiments described herein can be utilized in accordance with such related embodiments of the invention. Accordingly, the following claims are intended to include, within their scope, modifications, substitutions, and variations of the processes, manufacture, compositions, compounds, means, methods, and/or steps disclosed herein. The claims should be read as limited to the described order or elements unless otherwise stated to that effect. It should be understood that various changes in form and detail may be made without departing from the scope of the appended claims.

Claims (20)

A method for treating an autoinflammatory syndrome in a patient in need thereof, comprising administering a therapeutically effective amount of an NLRP3 inhibitor. A method for reducing symptoms of an autoinflammatory syndrome in a patient in need thereof, comprising administering a therapeutically effective amount of an NLRP3 inhibitor. The method of claim 1 or 2, wherein the NLRP3 inhibitor is administered to the subject in a total daily dose of about 50 mg to about 500 mg, optionally about 50 mg to about 200 mg, in single or divided doses. The method of claim 3, wherein the NLRP3 inhibitor is administered to the subject in a total daily dose of about 100 mg, in single or divided doses. The method of claim 4, wherein the NLRP3 inhibitor is administered to the subject at a dose of about 100 mg twice daily for three consecutive days and at a dose of about 100 mg once in the morning on the fourth day. The method according to any one of claims 1 to 5, wherein the autoinflammatory syndrome is cryopyrin-associated periodic syndrome (CAPS), familial cold autoinflammatory syndrome (FCAS), Muckle-Wells syndrome (MWS), neonatal-onset multisystem inflammatory disease/chronic infantile neurological, cutaneous, and articular syndrome (NOMID/CINCA), or familial Mediterranean fever (FMF). The method of any one of claims 1 to 6, wherein the autoinflammatory syndrome is familial cold autoinflammatory syndrome (FCAS). The method of any one of claims 1 to 7, wherein the patient does not have an increase in white blood cell count (WCC) of more than about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or about 100% after administration of the NLRP3 inhibitor. The method of any one of claims 1 to 7, wherein after cold exposure, the patient exhibits a lower score on a Physician's Global Rating scale of at least 1, at least 2, or at least 3 on a scale of 1 to 10 after administration of the NLRP3 inhibitor. The method of any one of claims 1 to 7, wherein after cold exposure, the patient exhibits a lower score on a Physician's Global Rating scale of at least 10%, at least 20%, or at least 30% on a scale of 1 to 100 after administration of the NLRP3 inhibitor. The method of any one of claims 1 to 10, wherein the patient does not have an increase in C-reactive protein of more than about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or about 100% after administration of the NLRP3 inhibitor. The method of any one of claims 1 to 11, wherein the patient does not have an increase in IL-1β or IL-18 of more than about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or about 100% after administration of the NLRP3 inhibitor. The method of any one of claims 1 to 12, wherein the NLRP3 inhibitor is orally administered to the subject. The method of any one of claims 1 to 13, wherein the NLRP3 inhibitor is present in a tablet formulation. The method of any one of claims 1 to 14, further comprising administering at least one additional therapeutic agent. The NLRP3 inhibitor is Compound I, or a pharmaceutically acceptable salt thereof:

The method according to any one of claims 1 to 15, wherein Compound I is the enantiomer of Compound IA, or a pharmaceutically acceptable salt thereof:

17. The method of claim 16, wherein: 18. The method of claim 17, wherein compound IA has an enantiomeric excess of at least 90%, at least 91%, at least 92%, at least 93%, at least 94%, at least 95%, at least 96%, at least 97%, at least 98%, at least 99%, or at least 99.5%. Compound I is the enantiomer of Compound IB, or a pharmaceutically acceptable salt thereof:

17. The method of claim 16, wherein: 20. The method of claim 19, wherein compound IB has an enantiomeric excess of at least 90%, at least 91%, at least 92%, at least 93%, at least 94%, at least 95%, at least 96%, at least 97%, at least 98%, at least 99%, or at least 99.5%.