U.S. patent application number 15/918685 was filed with the patent office on 2018-07-19 for pirfenidone treatment for patients with atypical liver function.
The applicant listed for this patent is INTERMUNE, INC.. Invention is credited to Williamson Z. Bradford, Javier Szwarcberg.
Application Number | 20180200242 15/918685 |
Document ID | / |
Family ID | 41427890 |
Filed Date | 2018-07-19 |
United States Patent
Application |
20180200242 |
Kind Code |
A1 |
Bradford; Williamson Z. ; et
al. |
July 19, 2018 |
Pirfenidone Treatment for Patients with Atypical Liver Function
Abstract
Methods are provided for administering pirfenidone to a patient
that has exhibited abnormal biomarkers of liver function in
response to pirfenidone administration. The methods include
administering to a patient pirfenidone at doses lower than the full
target dosage for a time period, followed by administering to the
patient pirfenidone at the full target dosage. The methods also
include administering pirfenidone at the full target dose with no
reduction and administering permanently reduced doses of
pirfenidone.
Inventors: |
Bradford; Williamson Z.;
(Wilson, WY) ; Szwarcberg; Javier; (San Francisco,
CA) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
INTERMUNE, INC. |
Brisbane |
CA |
US |
|
|
Family ID: |
41427890 |
Appl. No.: |
15/918685 |
Filed: |
March 12, 2018 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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15669552 |
Aug 4, 2017 |
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15918685 |
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15388902 |
Dec 22, 2016 |
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15669552 |
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15148792 |
May 6, 2016 |
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15388902 |
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14866149 |
Sep 25, 2015 |
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15148792 |
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14322578 |
Jul 2, 2014 |
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14866149 |
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13128569 |
Jul 13, 2011 |
8609701 |
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PCT/US09/63702 |
Nov 9, 2009 |
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14322578 |
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12553292 |
Sep 3, 2009 |
7635707 |
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13128569 |
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61228943 |
Jul 27, 2009 |
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Current U.S.
Class: |
1/1 |
Current CPC
Class: |
A61P 11/00 20180101;
A61P 5/14 20180101; A61P 17/00 20180101; G01N 2800/52 20130101;
A61P 31/22 20180101; A61P 7/08 20180101; A61P 11/16 20180101; A61P
33/06 20180101; A61P 39/02 20180101; A61P 7/00 20180101; A61P 19/06
20180101; Y02A 50/409 20180101; A61P 19/02 20180101; A61P 43/00
20180101; A61P 37/06 20180101; G01N 33/6893 20130101; A61P 9/10
20180101; A61P 1/16 20180101; A61P 25/28 20180101; A61P 3/00
20180101; A61P 13/12 20180101; A61P 27/02 20180101; Y02A 50/30
20180101; A61K 31/4412 20130101; A61P 13/08 20180101; A61P 3/10
20180101; A61P 29/00 20180101; A61P 31/18 20180101; A61P 19/08
20180101; A61P 35/00 20180101; A61P 1/18 20180101; A61P 25/00
20180101; Y02A 50/401 20180101; A61P 37/08 20180101; Y02A 50/411
20180101; Y02A 50/475 20180101; A61P 7/02 20180101; A61P 7/06
20180101; A61P 11/06 20180101; A61P 31/16 20180101; A61P 25/16
20180101; A61P 9/04 20180101; G01N 33/576 20130101; A61P 1/00
20180101; A61P 25/14 20180101; A61P 17/06 20180101; A61P 19/04
20180101; A61P 31/04 20180101; A61P 37/02 20180101; A61P 31/08
20180101; A61P 1/04 20180101; A61P 21/04 20180101; A61K 31/4418
20130101; A61P 17/02 20180101 |
International
Class: |
A61K 31/4412 20060101
A61K031/4412; G01N 33/68 20060101 G01N033/68; A61K 31/4418 20060101
A61K031/4418; G01N 33/576 20060101 G01N033/576 |
Claims
1. A method of administering pirfenidone to treat a patient who
would benefit from pirfenidone administration, optionally a patient
with idiopathic pulmonary fibrosis (IPF), said patient having
exhibited a Grade 2 abnormality in one or more biomarkers of liver
function after pirfenidone administration, comprising (a)
administering to said patient pirfenidone at doses of at least 1600
mg/day or 1602 mg/day.
2. A method of claim 1 comprising (a) administering to said patient
pirfenidone at doses of 2400 mg/day or 2403 mg/day.
3. The method of claim 1 or 2 further comprising, prior to step
(a), administering to said patient pirfenidone at doses lower than
2400 mg/day for a time period.
4. The method of any of claims 1-3 wherein prior to step (a)
pirfenidone is discontinued until biomarkers of liver function are
within normal limits.
5. The method of any of claims 1-4 further comprising, prior to
step (a), administering about 1600 mg/day or 1602 mg/day
pirfenidone for a period of time, optionally about one week, or
until biomarkers of liver function are within normal limits.
6. The method of any of claims 1-5 further comprising, prior to
step (a), administering about 800 mg/day or 801 mg/day pirfenidone
for a period of time, optionally about one week, or until
biomarkers of liver function are within normal limits, followed by
administering about 1600 mg/day or 1602 mg/day pirfenidone for a
period of time, optionally about one week, or until biomarkers of
liver function are within normal limits.
7. The method of any of claims 1-6 further comprising, prior to
step (a), discontinuing pirfenidone for a period of time,
optionally about one week, or until biomarkers of liver function
are within normal limits.
8. The method of any of claims 1-7, wherein the pirfenidone is
administered three times per day with food.
9. The method of any of claims 1-8, wherein said one or more
biomarkers of liver function is selected from the group consisting
of alanine transaminase, aspartate transaminase, and bilirubin.
10. The method of any of claims 1-9 further comprising the step of
measuring one or more biomarkers of liver function.
11. The method of any of claims 1-10, wherein said one or more
biomarkers of liver function are alanine transaminase and aspartate
transaminase.
12. Pirfenidone for use in treating a patient who would benefit
from pirfenidone administration, optionally a patient with
idiopathic pulmonary fibrosis (IPF), said patient having exhibited
a Grade 2 abnormality in one or more biomarkers of liver function
after pirfenidone administration, wherein (a) said patient is
administered pirfenidone at doses of 2400 mg/day or 2403
mg/day.
13. Pirfenidone for use in treating a patient according to claim
11, wherein, prior to step (a), said patient is administered
pirfenidone at doses lower than 2400 mg/day for a time period.
14. Pirfenidone for use in treating a patient according to claim 11
or 12, wherein, prior to step (a), pirfenidone administration to
the patient is discontinued for a time period, optionally about one
week, or until biomarkers of liver function are within normal
limits.
15. Pirfenidone for use in treating a patient according to any of
claims 11-13, wherein, prior to step (a), about 1600 mg/day or 1602
mg/day pirfenidone is administered to the patient for a time
period, optionally about one week, or until biomarkers of liver
function are within normal limits.
16. Pirfenidone for use in treating a patient according to any of
claims 11-14, wherein, prior to step (a), about 800 mg/day or 801
mg/day pirfenidone is administered to the patient for a time
period, optionally about one week, or until biomarkers of liver
function are within normal limits, and then about 1600 mg/day or
1602 mg/day pirfenidone is administered to the patient for a time
period, optionally about one week or until biomarkers of liver
function are within normal limits.
17. Pirfenidone for use in treating a patient according to any of
claims 11-15, wherein, prior to step (a), administration of
pirfenidone is discontinued for a time period, optionally about one
week, or until biomarkers of liver function are within normal
limits, and then about 800 mg/day or 801 mg/day pirfenidone is
administered for a time period, optionally about one week or until
biomarkers of liver function are within normal limits, and then
about 1600 mg/day or 1602 mg/day pirfenidone is administered for a
time period, optionally about one week or until biomarkers of liver
function are within normal limits.
18. Pirfenidone for use in treating a patient according to any of
claims 11-16, wherein the pirfenidone is administered three times
per day with food.
19. Pirfenidone for use in treating a patient according to any of
claims 11-17, wherein said one or more biomarkers of liver function
is selected from the group consisting of alanine transaminase,
aspartate transaminase, and bilirubin.
20. Pirfenidone for use in treating a patient according to any of
claims 11-18 further comprising measuring one or more biomarkers of
liver function.
21. Pirfenidone for use in treating a patient according to any of
claims 11-19, wherein said one or more biomarkers of liver function
are alanine transaminase and aspartate transaminase.
22. Use of pirfenidone in the manufacture of a medicament for
treating a patient who would benefit from pirfenidone
administration, optionally a patient with idiopathic pulmonary
fibrosis (IPF), said patient having exhibited a Grade 2 abnormality
in one or more biomarkers of liver function after pirfenidone
administration, wherein (a) said patient is administered
pirfenidone at doses of 2400 mg/day or 2403 mg/day.
23. Use according to claim 21, wherein, prior to step (a), said
patient is administered pirfenidone at doses lower than 2400 mg/day
for a time period.
24. Use according to claim 21 or 22, wherein, prior to step (a),
pirfenidone administration to the patient is discontinued for a
time period, optionally about one week or until biomarkers of liver
function are within normal limits.
25. Use according to any of claims 21-23, wherein, prior to step
(a), about 1600 mg/day or 1602 mg/day pirfenidone is administered
to the patient for a time period, optionally about one week, or
until biomarkers of liver function are within normal limits.
26. Use according to any of claims 21-24, wherein, prior to step
(a), about 800 mg/day or 801 mg/day pirfenidone is administered to
the patient for a time period, optionally about one week, or until
biomarkers of liver function are within normal limits, and then
about 1600 mg/day or 1602 mg/day pirfenidone is administered to the
patient for a time period, optionally about one week, or until
biomarkers of liver function are within normal limits.
27. Use according to any of claims 21-25, wherein, prior to step
(a), administration of pirfenidone is discontinued for a time
period, optionally about one week, or until biomarkers of liver
function are within normal limits, and then about 800 mg/day or 801
mg/day pirfenidone is administered for a time period, optionally
about one week or until biomarkers of liver function are within
normal limits, and then about 1600 mg/day or 1602 mg/day
pirfenidone is administered for a time period, optionally about one
week or until biomarkers of liver function are within normal
limits.
28. Use according to any of claims 21-26, wherein the pirfenidone
is administered three times per day with food.
29. Use according to any of claims 21-27, wherein said one or more
biomarkers of liver function is selected from the group consisting
of alanine transaminase, aspartate transaminase, and bilirubin.
30. Use according to any of claims 21-28 further comprising
measuring one or more biomarkers of liver function during
administration of pirfenidone.
31. Use according to any of claims 21-29, wherein said one or more
biomarkers of liver function are alanine transaminase and aspartate
transaminase.
32. The method according to claim 1, wherein, prior to step (a),
said patient is administered pirfenidone at doses lower than 1600
mg/day for a time period.
33. The method according to claim 1 or 32, wherein, prior to step
(a), pirfenidone administration to the patient is discontinued for
a time period, optionally about one week or until biomarkers of
liver function are within normal limits.
34. The method according to any of claim 1 or 32-33, wherein, prior
to step (a), about 800 mg/day or 801 mg/day pirfenidone is
administered to the patient for a time period, optionally about one
week, or until biomarkers of liver function are within normal
limits.
35. The method according to any of claim 1 or 32-34, wherein the
pirfenidone is administered three times per day with food.
36. The method according to any of claim 1 or 32-35, wherein said
one or more biomarkers of liver function is selected from the group
consisting of alanine transaminase, aspartate transaminase, and
bilirubin.
37. The method according to any of claim 1 or 32-36 further
comprising measuring one or more biomarkers of liver function
during administration of pirfenidone.
38. The method according to any of claim 1 or 32-37, wherein said
one or more biomarkers of liver function are alanine transaminase
and aspartate transaminase.
39. Pirfenidone for use in treating a patient who would benefit
from pirfenidone administration, optionally a patient with
idiopathic pulmonary fibrosis (IPF), said patient having exhibited
a Grade 2 abnormality in one or more biomarkers of liver function
after pirfenidone administration, wherein (a) said patient is
administered pirfenidone at doses of at least 1600 mg/day or 1602
mg/day.
40. Pirfenidone for use in treating a patient according to claim
39, wherein, prior to step (a), said patient is administered
pirfenidone at doses lower than 1600 mg/day for a time period.
41. Pirfenidone for use in treating a patient according to claim 39
or 40, wherein, prior to step (a), pirfenidone administration to
the patient is discontinued for a time period, optionally about one
week or until biomarkers of liver function are within normal
limits.
42. Pirfenidone for use in treating a patient according to any of
claims 39-41, wherein, prior to step (a), about 800 mg/day or 801
mg/day pirfenidone is administered to the patient for a time
period, optionally about one week, or until biomarkers of liver
function are within normal limits.
43. Pirfenidone for use in treating a patient according to any of
claims 39-42, wherein the pirfenidone is administered three times
per day with food.
44. Pirfenidone for use in treating a patient according to any of
claims 39-43, wherein said one or more biomarkers of liver function
is selected from the group consisting of alanine transaminase,
aspartate transaminase, and bilirubin.
45. Pirfenidone for use in treating a patient according to any of
claims 39-44 further comprising measuring one or more biomarkers of
liver function during administration of pirfenidone.
46. Pirfenidone for use in treating a patient according to any of
claims 39-45, wherein said one or more biomarkers of liver function
are alanine transaminase and aspartate transaminase.
47. Use of pirfenidone in the manufacture of a medicament for
treating a patient who would benefit from pirfenidone
administration, optionally a patient with idiopathic pulmonary
fibrosis (IPF), said patient having exhibited a Grade 2 abnormality
in one or more biomarkers of liver function after pirfenidone
administration, wherein (a) said patient is administered
pirfenidone at doses of at least 1600 mg/day or 1602 mg/day.
48. The use according to claim 47, wherein, prior to step (a), said
patient is administered pirfenidone at doses lower than 1600 mg/day
for a time period.
49. The use according to claim 47 or 48, wherein, prior to step
(a), pirfenidone administration to the patient is discontinued for
a time period, optionally about one week or until biomarkers of
liver function are within normal limits.
50. The use according to any of claims 47-49, wherein, prior to
step (a), about 800 mg/day or 801 mg/day pirfenidone is
administered to the patient for a time period, optionally about one
week, or until biomarkers of liver function are within normal
limits.
51. The use according to any of claims 47-50, wherein the
pirfenidone is administered three times per day with food.
52. The use according to any of claims 47-51, wherein said one or
more biomarkers of liver function is selected from the group
consisting of alanine transaminase, aspartate transaminase, and
bilirubin.
53. The use according to any of claims 47-52 further comprising
measuring one or more biomarkers of liver function during
administration of pirfenidone.
54. The use according to any of claims 47-53, wherein said one or
more biomarkers of liver function are alanine transaminase and
aspartate transaminase.
55. The method or use of any of the preceding claims, wherein the
patient who would benefit from pirfenidone administration suffers
from a condition selected from the group consisting of pulmonary
fibrosis, idiopathic interstitial pneumonia, autoimmune lung
diseases, benign prostate hypertrophy, coronary or myocardial
infarction, atrial fibrillation, cerebral infarction, myocardiac
fibrosis, musculoskeletal fibrosis, post-surgical adhesions, liver
cirrhosis, renal fibrotic disease, fibrotic vascular disease,
scleroderma, Hermansky-Pudlak syndrome, neurofibromatosis,
Alzheimer's disease, diabetic retinopathy, skin lesions, and lymph
node fibrosis associated with HIV.
56. The method or use of any of the preceding claims wherein the
patient who would benefit from pirfenidone administration suffers
from a condition selected from the group consisting of chronic
obstructive pulmonary disease (COPD), inflammatory pulmonary
fibrosis (IPF), rheumatoid arthritis, rheumatoid spondylitis,
osteoarthritis, gout, sepsis, septic shock, endotoxic shock,
gram-negative sepsis, toxic shock syndrome, myofacial pain syndrome
(MPS), Shigellosis, asthma, adult respiratory distress syndrome,
inflammatory bowel disease, Crohn's disease, psoriasis, eczema,
ulcerative colitis, glomerular nephritis, scleroderma, chronic
thyroiditis, Grave's disease, Ormond's disease, autoimmune
gastritis, myasthenia gravis, autoimmune hemolytic anemia,
autoimmune neutropenia, thrombocytopenia, pancreatic fibrosis,
chronic active hepatitis, acute and chronic renal disease, renal
fibrosis, irritable bowel syndrome, pyresis, restenosis, cerebral
malaria, stroke and ischemic injury, neural trauma, Huntington's
disease, Parkinson's disease, acute and chronic pain, allergies,
cardiac hypertrophy, chronic heart failure, acute coronary
syndrome, cachexia, malaria, leprosy, leishmaniasis, Lyme disease,
Reiter's syndrome, acute synoviitis, muscle degeneration, bursitis;
tendonitis, tenosynoviitis, herniated, ruptured, or prolapsed
intervertebral disk syndrome, osteopetrosis, thrombosis, silicosis,
pulmonary sarcosis, bone resorption diseases, cancer,
graft-versus-host reaction; and auto-immune diseases, AIDS, Herpes
Zoster, Herpes Simplex I or II, influenza virus, Severe Acute
Respiratory Syndrome (SARS), cytomegalovirus, and diabetes
mellitus.
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] This application claims priority to U.S. patent application
Ser. No. 12/488,228, filed Jun. 19, 2009, now abandoned, which
claims the benefit of U.S. Pat. No. 7,566,729, filed Apr. 22, 2009,
which claims priority to U.S. Provisional Application Ser. No.
61/113,107, filed Nov. 10, 2008, the disclosures of which are
incorporated by reference in their entirety. This application also
claims the benefit of U.S. Provisional Application Ser. No.
61/228,943, filed Jul. 27, 2009, the disclosure of which is
incorporated by reference in its entirety.
BACKGROUND
Field of the Disclosure
[0002] The disclosure relates generally to methods for reducing
adverse effects associated with the treatment of diseases and
disorders. More particularly, the disclosure relates to methods for
reducing abnormal liver function associated with
5-methyl-1-phenyl-2-(1H)-pyridone ("pirfenidone") therapy.
Brief Description of Related Technology
[0003] U.S. Pat. Nos. 3,974,281, 4,042,699, and 4,052,509 generally
relate to pirfenidone administration. U.S. Pat. Nos. 5,310,562,
5,518,729, and 5,716,632, all to Margolin and incorporated by
reference herein, relate to pirfenidone administration.
[0004] Pulmonary fibrosis can be caused by a number of different
conditions, including sarcoidosis, hypersensitivity pneumonitis,
collagen vascular disease, and inhalant exposure. Idiopathic
pulmonary fibrosis (IPF) is a distinct entity, characterized by
breathing difficulty, radiographic abnormalities, and progressive
loss of lung function. It is invariably progressive, and carries a
grave prognosis with a median life expectancy of 2-3 years.
[0005] Pirfenidone has been administered to IPF patients. In a
compassionate-use study, Raghu et al. ("Treatment of idiopathic
pulmonary fibrosis with a new antifibrotic agent, pirfenidone:
results of a prospective, open-label phase II study." Am J Respir
Crit Care Med 159:1061-1069, 1999) reported administration of
pirfenidone. No adverse events in hematology or blood chemistry
were noted.
[0006] Nagai et al. conducted an uncontrolled, open-label study of
pirfenidone in patients ("Open label compassionate use one
year-treatment with pirfenidone to patients with chronic pulmonary
fibrosis." Internal Medicine 41:1118-1123, 2002). During treatment,
no liver dysfunctions, hematologic abnormalities, or allergic or
shock reactions were reported.
[0007] Moises et al. "A double-blind, multicenter study comparing
pirfenidone and prednisone for moderate-to-severe pulmonary
fibrosis." Chest 124:116S, 2003 reported administration of
pirfenidone.
[0008] Azuma et al. "Double-blind, placebo-controlled trial of
pirfenidone in patients with idiopathic pulmonary fibrosis." Am J
Respir Crit Care Med 171:1040-1047, 2005) describes administration
of pirfeni done to a maximum of 1800 mg/day of pirfenidone, and
reports a protocol for stepwise reduction and rechallenge with drug
after an adverse event.
[0009] Abnormal liver function may manifest as abnormalities in
levels of biomarkers of liver function, including alanine
transaminase, aspartate transaminase, bilirubin, and/or alkaline
phosphatase, and may be an indicator of drug-induced liver injury.
See FDA Draft Guidance for Industry. Drug-Induced Liver Injury:
Premarketing Clinical Evaluation, October 2007.
SUMMARY
[0010] One aspect of the invention provides methods for
administering a therapeutically effective dose of pirfenidone to a
patient that has exhibited abnormal biomarkers of liver function
after pirfenidone administration for the treatment of fibrosis,
e.g. idiopathic pulmonary fibrosis (IPF). In some embodiments, a
patient is identified who exhibits a significantly abnormal level
of one, two, three or more biomarkers of liver function, e.g. the
level of a Grade 2 abnormality, after administration of an original
full target dose of pirfenidone, e.g. about 2400 mg/day or 2403
mg/day. In such patients, the dose of pirfenidone is reduced or
discontinued until levels of the abnormal biomarkers approach or
are within normal range, after which patients are administered
increasing doses of pirfenidone, up to the original full target
dose. Alternatively, the dose of pirfenidone is not reduced at all,
but liver biomarkers continue to be monitored. In another
embodiment, after an optional temporary dose reduction or
discontinuation, patients are administered pirfenidone at a
permanently reduced dose of 1602 mg/day. As used herein, "original
full target dose" means the therapeutically effective dose approved
by the U.S. Food and Drug Administration or a similar agency in a
foreign country, optionally other than Japan. In some embodiments,
the original full target dose is about 2400 mg/day or 2403 mg/day
pirfenidone, or about 34 mg/kg/day (e.g. 33-35 mg/kg/day), or from
2200 to 2600 mg/day pirfenidone, or from 31 mg/kg/day to 37
mg/kg/day. The total daily dose is administered one, two or three
times per day.
[0011] Thus, the invention provides methods of administering
pirfenidone to a patient at doses of 2400 mg/day or 2403 mg/day
after identifying that the patient has exhibited a liver function
Grade 2 abnormality after pirfenidone administration. In some
embodiments, the methods involve continuing the full target dose,
e.g. of 2400 mg/day or 2403 mg/day, without temporarily
discontinuing or reducing the dose. The patient's biomarkers of
liver function may continue to be monitored. In some embodiments,
the method involves (a) administering a dose lower than 2400 mg/day
for a time period, e.g., one week, two weeks, three weeks, four
weeks, one month, six weeks, or two months, followed by (b)
administering a dose of 2400 mg/day or 2403 mg/day. In specific
embodiments, the pirfenidone is temporarily discontinued before
step (a).
[0012] In some embodiments of the methods, pirfenidone is
administered to a patient exhibiting a liver function Grade 2
abnormality as follows: (a) administering about 1600 mg/day or 1602
mg/day pirfenidone for about one week, or until the liver function
biomarkers return to Grade 0 or Grade 1, and (b) administering the
original full target dose for at least one week, two weeks, three
weeks, four weeks or a month, two months, or three months, or one
year, or two years, or three years, or four years, or five years,
or seven years, or ten years. Preferably, the total daily dose is
administered three times per day, with food.
[0013] In some embodiments of the methods, pirfenidone is
administered to a patient exhibiting a liver function Grade 2
abnormality as follows: (a) administering about 800 mg/day or 801
mg/day pirfenidone for about one week, or until the liver function
biomarkers return to Grade 0 or Grade 1, (b) administering about
1600 mg/day or 1602 mg/day pirfenidone for about one week, and (c)
administering the original full target dose for a time period of at
least one week, two weeks, three weeks, four weeks or a month, two
months, or three months, or one year, or two years, or three years,
or four years, or five years, or seven years, or ten years.
Preferably, the total daily dose is administered three times per
day, with food.
[0014] In some embodiments of the methods, pirfenidone is
administered to a patient exhibiting a liver function Grade 2
abnormality as follows: (a) discontinuing pirfenidone for about one
week, or until the liver function biomarkers return to Grade 0 or
Grade 1, (b) administering about 800 mg/day or 801 mg/day
pirfenidone for about one week, (c) administering about 1600 mg/day
or 1602 mg/day pirfenidone for about one week, and (d)
administering the original full target dose for a time period of at
least one week, two weeks, three weeks, four weeks or a month, two
months, or three months, or one year, or two years, or three years,
or four years, or five years, or seven years, or ten years.
Preferably, the total daily dose is administered three times per
day, with food.
[0015] Alternatively, pirfenidone is administered to a patient
exhibiting a liver function Grade 2 abnormality at a permanently
reduced dose, e.g. 800 or 801 mg/day, or 1600 or 1602 mg/day. In
some embodiments, pirfenidone is administered to a patient
exhibiting a liver function Grade 2 abnormality as follows:
administering about 1600 mg/day or 1602 mg/day pirfenidone for a
time period of at least one week, two weeks, three weeks, four
weeks or a month, two months, or three months, or one year, or two
years, or three years, or four years, or five years, or seven
years, or ten years. In some embodiments, pirfenidone is
administered to a patient exhibiting a liver function Grade 2
abnormality as follows: (a) administering about 800 mg/day or 801
mg/day pirfenidone for about a week, or until biomarkers of liver
function are within normal limits, and (b) administering about 1600
mg/day or 1602 mg/day pirfenidone to the patient for a time period
of at least one week, two weeks, three weeks, four weeks or a
month, two months, or three months, or one year, or two years, or
three years, or four years, or five years, or seven years, or ten
years.
[0016] In other embodiments, pirfenidone is administered to a
patient exhibiting a liver function Grade 2 abnormality as follows:
(a) discontinuing pirfenidone for about one week, or until the
liver function biomarkers return to Grade 0 or Grade 1, (b)
administering about 800 mg/day or 801 mg/day pirfenidone for about
a week, or until biomarkers of liver function are within normal
limits, and (c) administering about 1600 mg/day or 1602 mg/day
pirfenidone to the patient for a time period of at least one week,
two weeks, three weeks, four weeks or a month, two months, or three
months, or one year, or two years, or three years, or four years,
or five years, or seven years, or ten years. In still other
embodiments, pirfenidone is administered to a patient exhibiting a
liver function Grade 2 abnormality as follows: (a) discontinuing
pirfenidone for about one week, or until the liver function
biomarkers return to Grade 0 or Grade 1, and (b) administering
about 1600 mg/day or 1602 mg/day pirfenidone to the patient for a
time period of at least one week, two weeks, three weeks, four
weeks or a month, two months, or three months, or one year, or two
years, or three years, or four years, or five years, or seven
years, or ten years.
[0017] The invention also provides methods of administering
pirfenidone to a patient at doses of 2400 mg/day or 2403 mg/day
after identifying that the patient has exhibited a liver function
Grade 1 abnormality after pirfenidone administration. In some
embodiments, the methods involve continuing the full target dose,
e.g. of 2400 mg/day or 2403 mg/day, without temporarily
discontinuing or reducing the dose. The patient's biomarkers of
liver function may continue to be monitored. In some embodiments,
the method involves (a) administering a dose lower than 2400 mg/day
for a time period, e.g., one week, two weeks, three weeks, four
weeks, one month, six weeks, or two months, followed by (b)
administering a dose of 2400 mg/day or 2403 mg/day. In specific
embodiments, the pirfenidone is temporarily discontinued before
step (a).
[0018] In some embodiments of the methods, pirfenidone is
administered to a patient exhibiting a liver function Grade 1
abnormality as follows: (a) administering about 1600 mg/day or 1602
mg/day pirfenidone for a time period, optionally about one week, or
until the liver function biomarkers return to Grade 0, and (b)
administering the original full target dose for at least one week,
two weeks, three weeks, four weeks or a month, two months, or three
months, or one year, or two years, or three years, or four years,
or five years, or seven years, or ten years. Preferably, the total
daily dose is administered three times per day, with food.
[0019] In some embodiments of the methods, pirfenidone is
administered to a patient exhibiting a liver function Grade 1
abnormality as follows: (a) administering about 800 mg/day or 801
mg/day pirfenidone for a time period, optionally about one week, or
until the liver function biomarkers return to Grade 0, (b)
administering about 1600 mg/day or 1602 mg/day pirfenidone for a
time period, optionally about one week, and (c) administering the
original full target dose for a time period of at least one week,
two weeks, three weeks, four weeks or a month, two months, or three
months, or one year, or two years, or three years, or four years,
or five years, or seven years, or ten years. Preferably, the total
daily dose is administered three times per day, with food.
[0020] In some embodiments of the methods, pirfenidone is
administered to a patient exhibiting a liver function Grade 1
abnormality as follows: (a) discontinuing pirfenidone for a time
period, optionally about one week, or until the liver function
biomarkers return to Grade 0, (b) administering about 800 mg/day or
801 mg/day pirfenidone for a time period, optionally about one
week, (c) administering about 1600 mg/day or 1602 mg/day
pirfenidone for a time period, optionally about one week, and (d)
administering the original full target dose for a time period of at
least one week, two weeks, three weeks, four weeks or a month, two
months, or three months, or one year, or two years, or three years,
or four years, or five years, or seven years, or ten years.
Preferably, the total daily dose is administered three times per
day, with food.
[0021] Alternatively, pirfenidone is administered at a permanently
reduced dose, e.g. 800 or 801 mg/day, or 1600 or 1602 mg/day. In
some embodiments, pirfenidone is administered to a patient
exhibiting a liver function Grade 1 abnormality as follows:
administering about 1600 mg/day or 1602 mg/day pirfenidone for a
time period of at least one week, two weeks, three weeks, four
weeks or a month, two months, or three months, or one year, or two
years, or three years, or four years, or five years, or seven
years, or ten years. In some embodiments, pirfenidone is
administered to a patient exhibiting a liver function Grade 1
abnormality as follows: (a) administering about 800 mg/day or 801
mg/day pirfenidone for a time period, optionally about a week, or
until biomarkers of liver function are within normal limits, and
(b) administering about 1600 mg/day or 1602 mg/day pirfenidone to
the patient for a time period of at least one week, two weeks,
three weeks, four weeks or a month, two months, or three months, or
one year, or two years, or three years, or four years, or five
years, or seven years, or ten years.
[0022] In other embodiments, pirfenidone is administered to a
patient exhibiting a liver function Grade 1 abnormality as follows:
(a) discontinuing pirfenidone for a time period, optionally about
one week, or until the liver function biomarkers return to Grade 0,
(b) administering about 800 mg/day or 801 mg/day pirfenidone for
about a week, or until biomarkers of liver function are within
normal limits, and (c) administering about 1600 mg/day or 1602
mg/day pirfenidone to the patient for a time period of at least one
week, two weeks, three weeks, four weeks or a month, two months, or
three months, or one year, or two years, or three years, or four
years, or five years, or seven years, or ten years. In still other
embodiments, pirfenidone is administered to a patient exhibiting a
liver function Grade 1 abnormality as follows: (a) discontinuing
pirfenidone for a time period, optionally about one week, or until
the liver function biomarkers return to Grade 0, and (b)
administering about 1600 mg/day or 1602 mg/day pirfenidone to the
patient for a time period of at least one week, two weeks, three
weeks, four weeks or a month, two months, or three months, or one
year, or two years, or three years, or four years, or five years,
or seven years, or ten years.
[0023] In any of the embodiments described herein, any of the
reduced doses of pirfenidone may be administered for a time period
of 2 days, 3 days, 4 days, 5 days, 6 days, one week, about two
weeks, or until the level of at least one biomarker of liver
function has returned to within normal limits, or until all
biomarkers or liver function has returned to within normal
limits.
[0024] In any of the embodiments described herein, the patient can
have fibrotic lesional tissue. Such a patient is a patient who
would benefit from pirfenidone administration. In one embodiment,
the patient is suffering from pulmonary fibrosis, idiopathic
interstitial pneumonia, autoimmune lung diseases, benign prostate
hypertrophy, coronary or myocardial infarction, atrial
fibrillation, cerebral infarction, myocardiac fibrosis,
musculoskeletal fibrosis, post-surgical adhesions, liver cirrhosis,
renal fibrotic disease, fibrotic vascular disease, scleroderma,
Hermansky-Pudlak syndrome, neurofibromatosis, Alzheimer's disease,
diabetic retinopathy, and/or skin lesions. In one embodiment, the
patient is suffering from lymph node fibrosis associated with HIV.
In one embodiment, the patient is suffering from pulmonary
fibrosis, or idiopathic pulmonary fibrosis. In another embodiment,
the patient is a person who would benefit from pirfenidone
administration, optionally with the proviso that the patient is not
suffering from idiopathic pulmonary fibrosis.
[0025] In some embodiments, the biomarker of liver function is
alanine transaminase, aspartate transaminase, bilirubin, and/or
alkaline phosphatase. Elevated gamma-glutamyl transferase has been
observed in some patients receiving pirfenidone, without clinical
liver impairment, and thus elevated gamma-glutamyl transferase
alone is not necessarily a sign of liver impairment. In any of the
embodiments described herein, biomarkers of liver function can
exclude gamma-glutamyl transferase. In another embodiment, the
abnormal level of alanine transaminase, aspartate transaminase, or
alkaline phosphatase is greater than about 2.5-fold increased
compared to the upper limit of normal (ULN). In a related
embodiment, the abnormal level of alanine transaminase, aspartate
transaminase, or alkaline phosphatase is greater than about 2.5- to
about 5-fold increased compared to the upper limit of normal (ULN),
i.e. a "liver function Grade 2 abnormality". In some embodiments,
the abnormal level of bilirubin is greater than about 1.5- to about
3-fold increased compared to the upper limit of normal (ULN), i.e.,
a "liver function Grade 2 abnormality".
[0026] In some embodiments the abnormal biomarkers of liver
function, e.g. elevated alanine transaminase and/or aspartate
transaminase and/or elevated bilirubin, are accompanied by clinical
signs of impaired liver function such as jaundice.
[0027] Further aspects and advantages will be apparent to those of
ordinary skill in the art from a review of the following detailed
description, taken in conjunction with the examples. While the
method is susceptible of embodiments in various forms, the
description hereafter includes specific embodiments with the
understanding that the disclosure is illustrative, and is not
intended to limit the invention to the specific embodiments
described herein.
DETAILED DESCRIPTION
[0028] The invention provides methods for administering a full
therapeutically effective dose of pirfenidone to a patient that has
exhibited abnormal levels of biomarkers of liver function after the
patient has been treated with pirfenidone. Because liver function
abnormalities can be indicative of drug-induced liver injury
(hepatotoxicity), it is important to determine whether the
abnormalities reflect liver injury or merely indicate limited
toxicity that will resolve over time while continuing to take the
drug. According to the present invention, even patients that
exhibit abnormal liver function may continue taking pirfenidone at
the original full target dose, optionally after a short time period
of discontinuing pirfenidone or taking the pirfenidone at reduced
doses. This administration regimen has the advantage of maximizing
the time on the full target dose of drug and therefore the
potential for a beneficial therapeutic effect.
[0029] The patient may be suffering from any disease for which
pirfenidone therapy may be useful in ameliorating symptoms. Such a
patient is a patient who would benefit from pirfenidone
administration. These diseases include, but are not limited to:
chronic obstructive pulmonary disease (COPD), inflammatory
pulmonary fibrosis (IPF), rheumatoid arthritis; rheumatoid
spondylitis; osteoarthritis; gout, other arthritic conditions;
sepsis; septic shock; endotoxic shock; gram-negative sepsis; toxic
shock syndrome; myofacial pain syndrome (MPS); Shigellosis; asthma;
adult respiratory distress syndrome; inflammatory bowel disease;
Crohn's disease; psoriasis; eczema; ulcerative colitis; glomerular
nephritis; scleroderma; chronic thyroiditis; Grave's disease;
Ormond's disease; autoimmune gastritis; myasthenia gravis;
autoimmune hemolytic anemia; autoimmune neutropenia;
thrombocytopenia; pancreatic fibrosis; chronic active hepatitis
including hepatic fibrosis; acute and chronic renal disease; renal
fibrosis, irritable bowel syndrome; pyresis; restenosis; cerebral
malaria; stroke and ischemic injury; neural trauma; Alzheimer's
disease; Huntington's disease; Parkinson's disease; acute and
chronic pain; allergies, including allergic rhinitis and allergic
conjunctivitis; cardiac hypertrophy, chronic heart failure; acute
coronary syndrome; cachexia; malaria; leprosy; leishmaniasis; Lyme
disease; Reiter's syndrome; acute synoviitis; muscle degeneration,
bursitis; tendonitis; tenosynoviitis; herniated, ruptured, or
prolapsed intervertebral disk syndrome; osteopetrosis; thrombosis;
silicosis; pulmonary sarcosis; bone resorption diseases, such as
osteoporosis or multiple myeloma-related bone disorders; cancer,
including but not limited to metastatic breast carcinoma,
colorectal carcinoma, malignant melanoma, gastric cancer, and
non-small cell lung cancer; graft-versus-host reaction; and
auto-immune diseases, such as Multiple Sclerosis, lupus and
fibromyalgia; AIDS and other viral diseases such as Herpes Zoster,
Herpes Simplex I or II, influenza virus, Severe Acute Respiratory
Syndrome (SARS) and cytomegalovirus; and diabetes mellitus. In
addition, the methods of the embodiments can be used to treat
proliferative disorders (including both benign and malignant
hyperplasias), including acute myelogenous leukemia, chronic
myelogenous leukemia, Kaposi's sarcoma, metastatic melanoma,
multiple myeloma, breast cancer, including metastatic breast
carcinoma; colorectal. carcinoma; malignant melanoma; gastric
cancer; non-small cell lung cancer (NSCLC); bone metastases, and
the like; pain disorders including neuromuscular pain, headache,
cancer pain, dental pain, and arthritis pain; angiogenic disorders
including solid tumor angiogenesis, ocular neovascularization, and
infantile hemangioma; conditions associated with the cyclooxygenase
and lipoxygenase signaling pathways, including conditions
associated with prostaglandin endoperoxide synthase-2 (including
edema, fever, analgesia, and pain); organ hypoxia; thrombin-induced
platelet aggregation; protozoal diseases.
[0030] The methods of the invention optionally include identifying
abnormal liver function in a patient receiving pirfenidone, and
monitoring biomarkers of liver function in a patient receiving a
reduced dose of pirfenidone. In any of the methods described
herein, AST and/or ALT may be elevated, e.g. to a Grade 2 or Grade
3 level. In some embodiments, the elevation is to a Grade 1 level.
Alternatively, AST and bilirubin may be elevated, or AST or ALP may
be elevated, or AST and GGT may be elevated, or ALT and bilirubin
may be elevated, or ALT and ALP may be elevated, or ALT and GGT may
be elevated, or bilirubin and ALP may be elevated, or bilirubin and
GGT may be elevated, e.g., to a Grade 1, Grade 2, or Grade 3 level.
Alternatively, three biomarkers of liver function may be elevated,
e.g., ALT and AST and bilirubin, or ALT and AST and ALP, to a Grade
1, Grade 2, or Grade 3 level. In any of the embodiments described
herein, biomarkers of liver function can exclude gamma-glutamyl
transferase.
[0031] In some embodiments of the methods, pirfenidone is
administered to a patient exhibiting a liver function Grade 2
abnormality after pirfenidone administration as follows: (a)
administering at least about 1600 mg/day or 1602 mg/day
pirfenidone, or about 23 mg/kg/day (e.g. 22-24 mg/kg/day), or from
1400-1800 mg/day pirfenidone, or from 20 mg/kg/day to 26 mg/kg/day,
for a time period. In some embodiments, step (a) is followed by (b)
administering the original full target dose. In other embodiments,
the original full target dose is continued without a temporary
reduction or discontinuation of the dose. In some embodiments, the
time period of step (a) is 2 days, 3 days, 4 days, 5 days, 6 days,
about one week, about two weeks, about three weeks, about four
weeks, about 1 month, or until the level of at least one biomarker
of liver function has returned to within normal limits, or until
all biomarkers or liver function has returned to within normal
limits. In some embodiments, step (b) is carried out for a time
period of at least one week, two weeks, three weeks, four weeks or
a month, two months, or three months, or one year, or two years, or
three years, or four years, or five years, or seven years, or ten
years, or more. Optionally the method includes measuring one or
more biomarkers of liver function during step (a) and/or step
(b).
[0032] In some embodiments of the methods, pirfenidone is
administered to a patient exhibiting a liver function Grade 2
abnormality as follows: (a) administering at least about 800 mg/day
or 801 mg/day pirfenidone, or about 11 mg/kg/day (e.g. 10-12
mg/kg/day), or from 600-1000 mg/day, or from 700-900 mg/day, or
from 8 mg/kg/day to 15 mg/kg/day, for a time period, (b)
administering at least about 1600 mg/day or 1602 mg/day
pirfenidone, or about 23 mg/kg/day (e.g. 22-24 mg/kg/day), or from
1400-1800 mg/day pirfenidone, or from 20 mg/kg/day to 26 mg/kg/day,
for a time period, and (c) administering the original full target
dose. In some embodiments, the time period of step (a) is 2 days, 3
days, 4 days, 5 days, 6 days, about one week, about two weeks,
about three weeks, about four weeks, about 1 month, or until the
level of at least one biomarker of liver function has returned to
within normal limits, or to Grade 1, or until all biomarkers or
liver function has returned to within normal limits, or to Grade 1.
In some embodiments, the time period of step (b) is 2 days, 3 days,
4 days, 5 days, 6 days, about one week, about two weeks, about
three weeks, about four weeks, about 1 month, or until the level of
at least one biomarker of liver function has returned to within
normal limits, or to Grade 1, or until all biomarkers or liver
function has returned to within normal limits, or to Grade 1. In
some embodiments, step (c) is carried out for a time period of at
least one week, two weeks, three weeks, four weeks or a month, two
months, or three months, or one year, or two years, or three years,
or four years, or five years, or seven years, or ten years, or
more. Optionally the method includes measuring one or more
biomarkers of liver function during step (a) and/or step (b) and/or
step (c).
[0033] In some embodiments of the methods, pirfenidone is
administered to a patient exhibiting a liver function Grade 2
abnormality as follows: (a) discontinuing pirfenidone for a time
period, (b) administering at least about 800 mg/day or 801 mg/day
pirfenidone, or about 11 mg/kg/day (e.g. 10-12 mg/kg/day), or from
600-1000 mg/day, or from 700-900 mg/day, or from 8 mg/kg/day to 15
mg/kg/day, for a time period, (c) administering at least about 1600
mg/day or 1602 mg/day pirfenidone, or about 23 mg/kg/day (e.g.
22-24 mg/kg/day), or from 1400-1800 mg/day pirfenidone, or from 20
mg/kg/day to 26 mg/kg/day, for a time period, and (d) administering
the original full target dose. In some embodiments, the time period
of step (a) is 2 days, 3 days, 4 days, 5 days, 6 days, about one
week, about two weeks, about three weeks, about four weeks, about 1
month, or until the level of at least one biomarker of liver
function has returned to within normal limits, or to Grade 1, or
until all biomarkers or liver function has returned to within
normal limits, or to Grade 1. In some embodiments, the time period
of step (b) is 2 days, 3 days, 4 days, 5 days, 6 days, about one
week, about two weeks, about three weeks, about four weeks, about 1
month, or until the level of at least one biomarker of liver
function has returned to within normal limits, or to Grade 1, or
until all biomarkers or liver function has returned to within
normal limits, or to Grade 1. In some embodiments, the time period
of step (c) is 2 days, 3 days, 4 days, 5 days, 6 days, about one
week, about two weeks, about three weeks, about four weeks, about 1
month, or until the level of at least one biomarker of liver
function has returned to within normal limits, or to Grade 1, or
until all biomarkers or liver function has returned to within
normal limits, or to Grade 1. In some embodiments, step (d) is
carried out for a time period of at least one week, two weeks,
three weeks, four weeks or a month, two months, or three months, or
one year, or two years, or three years, or four years, or five
years, or seven years, or ten years, or more. Optionally the method
includes measuring one or more biomarkers of liver function during
step (a) and/or step (b) and/or step (c) and/or step (d).
[0034] In some embodiments of the methods, pirfenidone is
administered to a patient exhibiting a liver function Grade 1
abnormality as follows: (a) administering at least about 1600
mg/day or 1602 mg/day pirfenidone, or about 23 mg/kg/day (e.g.
22-24 mg/kg/day), or from 1400-1800 mg/day pirfenidone, or from 20
mg/kg/day to 26 mg/kg/day, for a time period, and (b) administering
the original full target dose. In some embodiments, the time period
of step (a) is 2 days, 3 days, 4 days, 5 days, 6 days, about one
week, about two weeks, about three weeks, about four weeks, about 1
month, or until the level of at least one biomarker of liver
function has returned to within normal limits, or until all
biomarkers or liver function has returned to within normal limits.
In some embodiments, step (b) is carried out for a time period of
at least one week, two weeks, three weeks, four weeks or a month,
two months, or three months, or one year, or two years, or three
years, or four years, or five years, or seven years, or ten years,
or more. Optionally the method includes measuring one or more
biomarkers of liver function during step (a) and/or step (b).
[0035] In some embodiments of the methods, pirfenidone is
administered to a patient exhibiting a liver function Grade 1
abnormality as follows: (a) administering at least about 800 mg/day
or 801 mg/day pirfenidone, or about 11 mg/kg/day (e.g. 10-12
mg/kg/day), or from 600-1000 mg/day, or from 700-900 mg/day, or
from 8 mg/kg/day to 15 mg/kg/day, for a time period, (b)
administering at least about 1600 mg/day or 1602 mg/day
pirfenidone, or about 23 mg/kg/day (e.g. 22-24 mg/kg/day), or from
1400-1800 mg/day pirfenidone, or from 20 mg/kg/day to 26 mg/kg/day,
for a time period, and (c) administering the original full target
dose. In some embodiments, the time period of step (a) is 2 days, 3
days, 4 days, 5 days, 6 days, about one week, about two weeks,
about three weeks, about four weeks, about 1 month, or until the
level of at least one biomarker of liver function has returned to
within normal limits, or to Grade 1, or until all biomarkers or
liver function has returned to within normal limits, or to Grade 1.
In some embodiments, the time period of step (b) is 2 days, 3 days,
4 days, 5 days, 6 days, about one week, about two weeks, about
three weeks, about four weeks, about 1 month, or until the level of
at least one biomarker of liver function has returned to within
normal limits, or to Grade 1, or until all biomarkers or liver
function has returned to within normal limits, or to Grade 1. In
some embodiments, step (c) is carried out for a time period of at
least one week, two weeks, three weeks, four weeks or a month, two
months, or three months, or one year, or two years, or three years,
or four years, or five years, or seven years, or ten years, or
more. Optionally the method includes measuring one or more
biomarkers of liver function during step (a) and/or step (b) and/or
step (c).
[0036] In some embodiments of the methods, pirfenidone is
administered to a patient exhibiting a liver function Grade 1
abnormality as follows: (a) discontinuing pirfenidone for a time
period, (b) administering at least about 800 mg/day or 801 mg/day
pirfenidone, or about 11 mg/kg/day (e.g. 10-12 mg/kg/day), or from
600-1000 mg/day, or from 700-900 mg/day, or from 8 mg/kg/day to 15
mg/kg/day, for a time period, (c) administering at least about 1600
mg/day or 1602 mg/day pirfenidone, or about 23 mg/kg/day (e.g.
22-24 mg/kg/day), or from 1400-1800 mg/day pirfenidone, or from 20
mg/kg/day to 26 mg/kg/day, for a time period, and (d) administering
the original full target dose. In some embodiments, the time period
of step (a) is 2 days, 3 days, 4 days, 5 days, 6 days, about one
week, about two weeks, about three weeks, about four weeks, about 1
month, or until the level of at least one biomarker of liver
function has returned to within normal limits, or to Grade 1, or
until all biomarkers or liver function has returned to within
normal limits, or to Grade 1. In some embodiments, the time period
of step (b) is 2 days, 3 days, 4 days, 5 days, 6 days, about one
week, about two weeks, about three weeks, about four weeks, about 1
month, or until the level of at least one biomarker of liver
function has returned to within normal limits, or to Grade 1, or
until all biomarkers or liver function has returned to within
normal limits, or to Grade 1. In some embodiments, the time period
of step (c) is 2 days, 3 days, 4 days, 5 days, 6 days, about one
week, about two weeks, about three weeks, about four weeks, about 1
month, or until the level of at least one biomarker of liver
function has returned to within normal limits, or to Grade 1, or
until all biomarkers or liver function has returned to within
normal limits, or to Grade 1. In some embodiments, step (d) is
carried out for a time period of at least one week, two weeks,
three weeks, four weeks or a month, two months, or three months, or
one year, or two years, or three years, or four years, or five
years, or seven years, or ten years, or more. Optionally the method
includes measuring one or more biomarkers of liver function during
step (a) and/or step (b) and/or step (c) and/or step (d).
[0037] Pirfenidone can be provided in tablet or capsule forms or
any other oral dosage form, and typically is formulated for oral
administration. Exemplary capsule formulations are described in WO
2007/038315 (Int'l Appl. No. PCT/US2006/037057).
[0038] Pirfenidone therapy can be associated with adverse effects
including photosensitivity rash, anorexia (decreased appetite),
stomach discomfort, nausea, heartburn, drowsiness (somnolence),
fatigue, upper respiratory tract infection, fever, positive urinary
occult blood, elevation of C-reactive protein (CRP), decreased
weight, headache, constipation, and malaise. Abnormal liver
function also can occur as an adverse effect (AE) in patients
receiving pirfenidone. Prior to receiving pirfenidone, the baseline
liver function of the patient can be, and typically is, normal.
Liver function can be assessed by various means known in the art,
such as blood chemistry tests measuring biomarkers of liver
function. Examples of biomarkers of liver function include, but are
not limited to, alanine transaminase (ALT), aspartate transaminase
(AST), bilirubin, alkaline phosphatase (ALP), and gamma-glutamyl
transferase (GGT).
[0039] Alanine transaminase (ALT), also called serum glutamic
pyruvate transaminase (SGPT) or alanine aminotransferase (ALAT),
catalyzes the transfer of an amino group from alanine to
.alpha.-ketoglutarate to produce pyruvate and glutamate. When the
liver is damaged, levels of ALT in the blood can rise due to the
leaking of ALT into the blood from damaged or necrosed
hepatocytes.
[0040] Aspartate transaminase (AST) also called serum glutamic
oxaloacetic transaminase (SGOT or GOT) or aspartate
aminotransferase (ASAT), catalyzes the transfer of an amino group
from aspartate to .alpha.-ketoglutarate to produce oxaloacetate and
glutamate. AST can increase in response to liver damage. Elevated
AST also can result from damage to other sources, including red
blood cells, cardiac muscle, skeletal muscle, kidney tissue, and
brain tissue. The ratio of AST to ALT can be used as a biomarker of
liver damage.
[0041] Bilirubin is a catabolite of heme that is cleared from the
body by the liver. Conjugation of bilirubin to glucuronic acid by
hepatocytes produces direct bilirubin, a water-soluble product that
is readily cleared from the body. Indirect bilirubin is
unconjugated, and the sum of direct and indirect bilirubin
constitutes total bilirubin. Elevated total bilirubin can be
indicative of liver impairment.
[0042] Alkaline phosphatase (ALP) hydrolyzes phosphate groups from
various molecules and is present in the cells lining the biliary
ducts of the liver. ALP levels in plasma can rise in response to
liver damage, and are higher in growing children and elderly
patients with Paget's disease. However, elevated ALP levels usually
reflect biliary tree disease.
[0043] Adverse effect Grades for abnormal liver function are
defined herein by the modified Common Toxicity Criteria (CTC)
provided in Table 1. See the Common Terminology Criteria for
Adverse Events v3.0 (CTCAE) published Aug. 9, 2006 by the National
Cancer Institute, incorporated herein by reference in its
entirety.
TABLE-US-00001 TABLE 1 Modified Common Toxicity Criteria Grade
Toxicity 0 1 2 3 4 ALT WNL >ULN-2.5 .times. ULN >2.5-5
.times. ULN >5-20 .times. ULN >20 .times. ULN AST WNL
>ULN-2.5 .times. ULN >2.5-5 .times. ULN >5-20 .times. ULN
>20 .times. ULN Bilirubin WNL >ULN-1.5 .times. ULN >1.5-3
.times. ULN >3-10 .times. ULN >10 .times. ULN ALP WNL
>ULN-2.5 .times. ULN >2.5-5 .times. ULN >5-20 .times. ULN
>20 .times. ULN GGT WNL >ULN-2.5 .times. ULN >2.5-5
.times. ULN >5-20 .times. ULN >20 .times. ULN (WNL = within
normal limits; ULN = upper limit of normal)
[0044] The ULN for various indicators of liver function depends on
the assay used, the patient population, and each laboratory's
normal range of values for the specified biomarker, but can readily
be determined by the skilled practitioner. Exemplary values for
normal ranges for a healthy adult population are set forth in Table
2 below. See Cecil Textbook of Medicine, pp. 2317-2341, W.B.
Saunders & Co. (1985).
TABLE-US-00002 TABLE 2 ALT 8-20 U/L AST 8-20 U/L Bilirubin 0.2-1.0
mg/dL 3.4-17.1 .mu.mol/L ALP 20-70 U/L GGT Men: 9-50 U/L Women:
8-40 U/L
[0045] Grade 0 levels are characterized by biomarker levels within
normal limits (WNL). "Normal" liver function, as used herein,
refers to Grade 0 adverse effects. "Abnormal" liver function, as
used herein, refers to Grade 1 and above adverse effects.
[0046] "Grade 1 liver function abnormalities" include elevations in
ALT, AST, ALP, or GGT greater than the ULN and less than or equal
to 2.5-times the ULN. Grade 1 liver function abnormalities also
include elevations of bilirubin levels greater than the ULN and
less than or equal to 1.5-times the ULN.
[0047] "Grade 2 liver function abnormalities" include elevations in
alanine transaminase (ALT), aspartate transaminase (AST), alkaline
phosphatase (ALP), or gamma-glutamyl transferase (GGT) greater than
2.5-times and less than or equal to 5-times the upper limit of
normal (ULN). Grade 2 liver function abnormalities also include
elevations of bilirubin levels greater than 1.5-times and less than
or equal to 3-times the ULN.
[0048] "Grade 3 liver function abnormalities" include elevations in
ALT, AST, ALP, or GGT greater than 5-times and less than or equal
to 20-times the ULN. Grade 3 liver function abnormalities also
include elevations of bilirubin levels greater than 3-times and
less than or equal to 10-times the ULN.
[0049] "Grade 4 liver function abnormalities" include elevations in
ALT, AST, ALP, or GGT greater than 20-times the ULN. Grade 4 liver
function abnormalities also include elevations of bilirubin levels
greater than 10 the ULN.
[0050] The present disclosure provides methods for treating a
patient having idiopathic pulmonary fibrosis and receiving a full
target dose of pirfenidone, wherein the full target dose is 2400 or
2403 mg pirfenidone per day. In accordance with the methods, a
patient with abnormal liver function is administered a second dose
of pirfenidone, wherein the second dose is 1600 or 1602 mg
pirfenidone per day until liver function is within normal limits,
followed by administering the patient the full target dose of 2400
or 2403 mg pirfenidone per day.
[0051] The present disclosure also provides methods for treatment
of patients that exhibit Grade 1 abnormality in one or more
biomarkers of liver function after pirfenidone administration. The
method includes administering to the patient pirfenidone at doses
of 2400 mg/day or 2403 mg/day or administering to the patient
pirfenidone at doses of 1600 mg/day or 1602 mg/day. Preferably, the
patient may be receiving pirfenidone for treatment of idiopathic
pulmonary fibrosis. Alternatively, the patient may be suffering
from a condition for which pirfenidone administration may be
beneficial. Optionally, patients may receive reduced doses or
discontinue treatment for a time period, and then resume
administration of pirfenidone.
[0052] The methods disclosed herein are contemplated to include
embodiments including any combination of one or more of the
additional optional elements, features, and steps further described
herein (including those described in the examples), unless stated
otherwise.
[0053] Ranges may be expressed herein as from "about" or
"approximately" one particular value and/or to "about" or
"approximately" another particular value. When such a range is
expressed, another embodiment includes from the one particular
value and/or to the other particular value. Similarly, when values
are expressed as approximations, by use of the antecedent "about,"
it will be understood that the particular value forms another
embodiment.
[0054] It will be appreciated that the invention provides
pirfenidone as a medicament wherein the administration pattern of
the medicament comprises administering according to any of the
treatment methods described herein.
[0055] It will be appreciated that the invention provides
pirfenidone for use in treating a patient with idiopathic pulmonary
fibrosis or a patient who would benefit from pirfenidone
administration according to any of the treatment regimes as
described above with respect to the methods of the invention for
administering pirfenidone to a patient for treating idiopathic
pulmonary fibrosis or to a patient who would benefit from
pirfenidone administration. Pirfenidone is packaged and presented
for use in a treating a patient with idiopathic pulmonary fibrosis
or a patient who would benefit from pirfenidone administration
according to such treatment regimes. Pirfenidone is administered to
the patient in accordance with the treatment regimes as described
above. The patient is one who has exhibited abnormal biomarkers of
liver function after pirfenidone administration as is described
above with respect to the methods of the invention for
administering pirfenidone to a patient for treating idiopathic
pulmonary fibrosis or to a patient who would benefit from
pirfenidone administration.
[0056] In particular, the invention includes pirfenidone for use in
treating a patient with idiopathic pulmonary fibrosis or a patient
who would benefit from pirfenidone administration, said patient
having exhibited a Grade 1 or Grade 2 abnormality in one or more
biomarkers of liver function after pirfenidone administration,
wherein said patient is administered pirfenidone at doses of 2400
mg/day or 2403 mg/day. Optionally, prior to administration of
pirfenidone at doses of 2400 mg/day or 2403 mg/day, said patient is
administered pirfenidone at doses lower than 2400 mg/day for a time
period.
[0057] It will be appreciated that the invention provides the use
of pirfenidone in the manufacture of a medicament for treating a
patient with idiopathic pulmonary fibrosis or a patient who would
benefit from pirfenidone administration according to any of the
treatment regimes as described above with respect to any of the
methods. The medicaments manufactured according to this aspect of
the invention are for use in treating a patient with idiopathic
pulmonary fibrosis or a patient who would benefit from pirfenidone
administration in accordance with such treatment regimes. The
medicament so manufactured is administered to the patient in
accordance with the treatment regimes as described above. The
patient is one who has exhibited abnormal biomarkers of liver
function after pirfenidone administration as is described above
with respect to the methods of the invention for administering
pirfenidone to a patient for treating idiopathic pulmonary fibrosis
or a patient who would benefit from pirfenidone administration.
[0058] In particular, the invention includes the use of pirfenidone
in the manufacture of a medicament for treating a patient with
idiopathic pulmonary fibrosis or a patient who would benefit from
pirfenidone administration, said patient having exhibited a Grade 1
or Grade 2 abnormality in one or more biomarkers of liver function
after pirfenidone administration, wherein said patient is
administered pirfenidone at doses of 2400 mg/day or 2403 mg/day.
Optionally, prior to administration of pirfenidone at doses of 2400
mg/day or 2403 mg/day, said patient is administered pirfenidone at
doses lower than 2400 mg/day for a time period.
[0059] In respect of the aspects of the invention relating to
pirfenidone for use in treating a patient with idiopathic pulmonary
fibrosis, and to use of pirfenidone in the manufacture of a
medicament for treating a patient with idiopathic pulmonary
fibrosis, the preferences expressed with respect to the preferred
embodiments of the aspect of the invention relating to a method for
administering pirfenidone to treat a patient with idiopathic
pulmonary fibrosis apply in the same way. Similarly, the examples
relate to pirfenidone for use in treating a patient with idiopathic
pulmonary fibrosis, and to use of pirfenidone in the manufacture of
a medicament for treating a patient with idiopathic pulmonary
fibrosis, as well as to a method for administering pirfenidone to a
patient for treating idiopathic pulmonary fibrosis.
EXAMPLES
[0060] The following examples are provided for illustration and are
not intended to limit the scope of the invention.
Example 1
Pirfenidone Dosing Regimen
[0061] Patients begin pirfenidone treatment by receiving escalating
doses of pirfenidone over a period of 15 days until the full
maintenance dose is reached. Specifically, from days 1 to 7,
patients are administered one capsule of 267 mg pirfenidone three
times per day. During days 8 to 14, patients receive two capsules
of 267 mg pirfenidone three times per day. From day 15 onward,
patients are treated with three capsules of 267 mg pirfenidone
three times per day. Pirfenidone is administered orally, and each
dose should be taken with food. If the patient is unable to eat,
then the pirfenidone dose should be taken with milk or juice
(excluding grapefruit juice).
[0062] Pirfenidone is known to cause photosensitivity reactions;
therefore, throughout the treatment period, patients should use sun
block that protects against at least UV-A with a sun protective
factor (SPF) of 50. In addition, patients should wear appropriate
clothing to minimize sun exposure, and if possible, avoid other
medications known to cause photo sensitivity reactions.
[0063] Once the full maintenance dose is reached, pirfenidone is
administered orally to patients three times per day to provide a
daily dose of 2403 mg pirfenidone. Each of the three doses of 801
mg pirfenidone includes three capsules of 267 mg pirfenidone each.
The contents of the pirfenidone 267 mg capsules are pirfenidone
(82.15%); croscarmellose sodium (8.15%); microcrystalline cellulose
(7.39%); povidine, USP, EP (1.85%); and magnesium stearate
(0.46%).
[0064] Patients are treated with pirfenidone for up to 72 weeks.
Some patients are treated longer than 72 weeks. At weeks 2, 4, 6,
12, and every 12 weeks (.+-.2 weeks) thereafter during the
treatment period, with the exception of week 72 and the treatment
completion visit, patients are examined and histories are collected
as detailed in the steps below.
[0065] 1. Patient history is collected to include review of adverse
effects (AEs) and severe adverse effects (SAEs), use of concomitant
medications, use of oxygen, hospitalizations, IPF exacerbations or
acute respiratory decompensation, and dosing.
[0066] 2. Patients receive a physical examination, and vital signs
and weight are measured.
[0067] 3. Pulmonary function is assessed by spirometry before and
after administration of bronchodilators. Forced vital capacity
(FVC) and forced expiratory volume in 1 second (FEV1) are
measured.
[0068] 4. Clinical laboratory tests are performed, including
hematology, serum chemistries, pregnancy tests for women of
childbearing capacity, and urinalysis with microscopic
examination.
[0069] 5. Questionnaires are administered, including the University
of California at San Diego Shortness of Breath Questionnaire (UCSD
SOBQ), St. George's Hospital Respiratory Questionnaire (SGRQ), and
the World Health Organization Quality of Life (WHO QOL)
questionnaire. After week 72, only the UCSD SOBQ and SGRQ are
obtained at the scheduled 12 week visits.
[0070] Additionally, every 24 weeks starting with Week 12 (for
example, weeks 12, 36, and 60), electrocardiogram (ECG)
measurements are obtained. ECG data is obtained before
administering bronchodilators for the pulmonary function test (PFT)
measurements. At the week 36 visit, pharmacokinetic (PK) data is
obtained for selected patients.
[0071] If a patient experiences a Grade 1 or greater elevation in
alanine transaminase (ALT), aspartate transaminase (AST), or
bilirubin at baseline or after the start of pirfenidone dosing up
to and including week 6, an additional safety chemistry blood test
must be obtained between weeks 8 and 10.
Example 2
[0072] Modification of Pirfenidone Dosing Regimen in Response to
Grade 2 Liver Function Test (LFT) Elevations
[0073] Patients are treated with pirfenidone in accordance with
Example 1. During the course of pirfenidone treatment, patients
exhibiting abnormal liver function test results are candidates for
dose modification. As described in Example 1, serum chemistry tests
are performed at scheduled intervals during the treatment period to
monitor various parameters, including biomarkers of liver function
such as alanine transaminase (ALT), aspartate transaminase (AST),
bilirubin, alkaline phosphatase (ALP), and gamma-glutamyl
transferase (GGT).
[0074] If a patient experiences a Grade 2 increase in any one of
AST, ALT or bilirubin, the pirfenidone dose is reduced to one
capsule of 267 mg pirfenidone three times per day. While receiving
the reduced pirfenidone dose, the patient undergoes additional
monitoring of AST, ALT and bilirubin. The reduced pirfenidone dose
is continued at least until AST, ALT and bilirubin are all Grade 1
or within normal limits (Grade 0). The reduced pirfenidone dose can
be administered for a period of time after AST, ALT and bilirubin
have reached Grade 1 or Grade 0.
[0075] At any time after AST, ALT and bilirubin have resolved to
Grade 0 or Grade 1, the pirfenidone dose can be re-escalated in a
manner consistent with the initial dose escalation, up to a dose of
6 capsules per day. After AST, ALT and bilirubin have resolved to
Grade 0 or Grade 1, the pirfenidone dose also can be re-escalated
in a manner consistent with the initial dose escalation, up to the
maximum of 9 capsules per day.
[0076] Serum chemistry tests are optionally performed at scheduled
intervals during the escalation period, e.g. weekly or every 2
weeks, or every 3 weeks, or every month to monitor various
parameters, including biomarkers of liver function such as alanine
transaminase (ALT), aspartate transaminase (AST), bilirubin,
alkaline phosphatase (ALP), and gamma-glutamyl transferase
(GGT).
Example 3
Temporary Discontinuation of Pirfenidone Dosing in Response to
Grade 2 Liver Function Test (LFT) Elevations
[0077] Patients are treated with pirfenidone in accordance with
Example 1. During the course of pirfenidone treatment, patients
exhibiting abnormal liver function test results are candidates for
dose modification. As described in Example 1, serum chemistry tests
are performed at scheduled intervals during the treatment period to
monitor various parameters, including biomarkers of liver function
such as alanine transaminase (ALT), aspartate transaminase (AST),
bilirubin, alkaline phosphatase (ALP), and gamma-glutamyl
transferase (GGT).
[0078] If a patient experiences a Grade 2 increase in any one of
AST, ALT or bilirubin, the pirfenidone dose is discontinued.
Following discontinuation of the pirfenidone dose, the patient
undergoes additional monitoring of AST, ALT and bilirubin.
Pirfenidone dosing is discontinued at least until AST, ALT and
bilirubin are all Grade 1 or within normal limits (Grade 0). The
pirfenidone dose can be discontinued for a period of time after
AST, ALT and bilirubin have reached Grade 1 or Grade 0.
[0079] After AST, ALT and bilirubin have resolved to Grade 0 or
Grade 1, if the patient has been off drug for 14 days or more, the
pirfenidone dose is re-escalated in a manner consistent with the
initial dose escalation, up to a dose of 6 or 9 capsules per day,
i.e. 1602 mg/day or 2403 mg/day. Alternatively, after AST, ALT and
bilirubin have resolved to Grade 0 or Grade 1, the pirfenidone dose
is re-instituted at a dose of 6 capsules per day, i.e. 1602 mg/day,
and re-escalated after 1 week to the maximum of 9 capsules per
day.
[0080] Serum chemistry tests are optionally performed at scheduled
intervals during the escalation period, e.g. weekly, or every 2
weeks, or every month, to monitor various parameters, including
biomarkers of liver function such as alanine transaminase (ALT),
aspartate transaminase (AST), bilirubin, alkaline phosphatase
(ALP), and gamma-glutamyl transferase (GGT).
Example 4
Modification of Pirfenidone Dosing Regimen to 2 Capsules Three
Times per Day in Response to Grade 2 Liver Function Test (LFT)
Elevations
[0081] Patients are treated with pirfenidone in accordance with
Example 1. During the course of pirfenidone treatment, patients
exhibiting abnormal liver function test results are candidates for
dose modification. As described in Example 1, serum chemistry tests
are performed at scheduled intervals during the treatment period to
monitor various parameters, including biomarkers of liver function
such as alanine transaminase (ALT), aspartate transaminase (AST),
bilirubin, alkaline phosphatase (ALP), and gamma-glutamyl
transferase (GGT).
[0082] If a patient experiences a Grade 2 increase in any one of
AST, ALT or bilirubin, the pirfenidone dose is reduced to two
capsules of 267 mg pirfenidone three times per day, i.e. 1602
mg/day. While receiving the reduced pirfenidone dose, the patient
undergoes additional monitoring of AST, ALT and bilirubin. The
reduced pirfenidone dose is continued at least until AST, ALT and
bilirubin are all Grade 1 or within normal limits (Grade 0). The
reduced pirfenidone dose can be administered for a period of time
after AST, ALT and bilirubin have reached Grade 1 or Grade 0.
[0083] After 1 week of treatment at 1602 mg/day, if AST, ALT and
bilirubin have resolved to Grade 0 or Grade 1, the pirfenidone dose
can be re-escalated to the maximum of 9 capsules per day, i.e. 2403
mg.
Example 5
No Modification of Pirfenidone Dosing Regime in Response to a Grade
1 or Grade 2 Liver Function Test (LFT) Elevations
[0084] Patients were treated with pirfenidone in accordance with
Example 1. During the course of pirfenidone treatment, some
patients exhibited abnormal liver function test results. As
described in Example 1, serum chemistry tests were performed at
scheduled intervals during the treatment period to monitor various
parameters, including biomarkers of liver function such as alanine
transaminase (ALT), aspartate transaminase (AST), bilirubin,
alkaline phosphate (ALP), and gamma-glutamyl transferase (GGT).
[0085] If a patient exhibited a Grade 1 or Grade 2 increase in any
one of AST, ALT, or bilirubin, the pirfenidone dose was not reduced
for some patients. The patient continued to receive the full target
dose of 2403 mg/day. While receiving the full target dose, the
patient was monitored for AST, ALT, and bilirubin levels.
Example 6
Incidence of Liver Function Abnormality and Dosing Regimen
Response
[0086] Grade 1 Abnormalities in Liver Function
[0087] In a study of 345 patients with idiopathic pulmonary
fibrosis receiving pirfenidone three times per day for a total
daily dose of 2403 mg/day, 49 patients without a baseline liver
function abnormality exhibited a Grade 1 elevation in AST or ALT
levels after pirfenidone administration. Of the 49 patients, three
patients with a Grade 1 liver function test elevation had a
treatment emergent adverse event of increased AST or ALT. In one
patient, study drug dose was reduced to 1602 mg/day for the
remainder of study participation (from Day 51 to Day 602), and the
Grade 1 AST or ALT abnormality returned to Grade 0. For the second
patient, study drug dose was reduced to 1602 mg/day and then
increased to 2403 mg/day for remainder of study participation, and
ALT returned to Grade 0. The third patient had study drug dose
reduced to 801 mg/day, ultimately completing study at 1602 mg/day,
at which time ALT returned to Grade 0. The remaining patients (46
patients) received no dose modification.
[0088] Grade 2 Abnormalities in Liver Function
[0089] Fifteen patients developed a Grade 2 liver function test
abnormality in AST and/or ALT levels after pirfenidone
administration of 2403 mg/day. Of the fifteen patients, 12 had
reported treatment emergent adverse events of increased AST or ALT
or hepatitis. The liver function test elevations for the remaining
three patients were not documented as an adverse event (discussed
below).
[0090] Of the twelve patients, two patients received continued
administration of pirfenidone at the full daily dose of 2403
mg/day. The liver function test of one patient resolved to a Grade
0. The other patient had a history of steatosis and a Grade 1
abnormality prior to pirfenidone treatment and underwent a dose
reduction for unrelated reasons (rash and diarrhea), not for
abnormal liver function tests, and ended the study with a Grade 1
elevation.
[0091] Two patients had a temporary dose reduction or a temporary
discontinuation of pirfenidone, and were rechallenged and escalated
back to full dose. They completed the study at the full dose of
2403 mg/day with normal liver enzymes.
[0092] Seven patients underwent a permanent dose reduction of
pirfenidone, in some cases after a temporary discontinuation of
drug; by completion of the study, 3 patients were receiving 801
mg/day and 4 patients were receiving 1602 mg/day. With the
exception of one patient, rechallenge with a higher dose was not
attempted with these patients. The patient that was rechallenged
received the full dose of 2403 mg/day, but the dose was later
reduced due to a recurrence of Grade 2 elevation in ALT levels. All
seven patients completed the study with resolution of
transaminases, except for one patient that had a Grade 1 elevation
at study completion.
[0093] One patient discontinued treatment due to abnormal liver
function tests in AST and/or ALT levels. The dose for this patient
was initially decreased to 1602 mg/day, then discontinued, and then
resumed at 1602 mg/day. For this patient, however, treatment was
permanently discontinued because a Grade 2 elevation of AST
coincided with a Grade 3 ALT elevation in liver function tests.
[0094] Of the three patients whose liver function test elevations
were not documented as an adverse event, one had Grade 1 AST and
ALT elevation at baseline, and experienced a Grade 1 elevation of
AST at the last documented assessment. This patient received no
dose modification after a Grade 2 elevation in AST and/or ALT
levels. A second patient with a Grade 2 transaminase elevation had
treatment temporarily discontinued for acute cerebral artery
occlusion. Transaminase levels returned to normal once the dose was
escalated back to 2403 mg/day, and the patient completed the study
on full dose with normal transaminases. The third patient had no
liver function test abnormalities while on treatment until Day 422,
then the patient experienced a Grade 2 AST and Grade 1 ALT
elevation with respiratory failure due to IPF. Study drug was
discontinued the same day for respiratory failure. The patient was
hospitalized on Day 434 and died on Day 439 due to respiratory
failure.
[0095] Grade 3 Abnormalities in Liver Function
[0096] Four patients developed Grade 3 liver function abnormality
in AST and/or ALT levels after pirfenidone administration, all of
who had a treatment emergent adverse event of either increased AST
and/or ALT. Two of the four patients discontinued study drug for
elevated liver function tests. In both instances, the abnormalities
had not resolved, with Grade 2 and Grade 3 abnormalities last
documented. The two other patients had Grade 1 abnormalities at
screening and/or baseline. One patient discontinued for lung
transplant at which time the last documented values showed a Grade
1 abnormality. The other patient interrupted study drug
(investigator decision), and subsequently discontinued study drug
(sponsor decision). The AST and ALT elevations had normalized at
the last documented value.
[0097] The foregoing description is given for clearness of
understanding only, and no unnecessary limitations should be
understood therefrom, as modifications within the scope of the
invention may be apparent to those having ordinary skill in the
art. Although methods have been described with reference to
particular embodiments, a person of ordinary skill in the art will
readily appreciate that other ways of performing the acts
associated with the methods may be used.
[0098] All patents, publications and references cited herein are
hereby fully incorporated by reference. In case of conflict between
the present disclosure and incorporated patents, publications and
references, the present disclosure should control.
* * * * *