US 20130345177A1 (19) United States (12) Patent Application Publication (10) Pub. No.: US 2013/0345177 A1 Jansen et al. (43) Pub. Date: Dec. 26, 2013

(54) OLEYL PHOSPHOCHOLINE FOR THE Publication Classi?cation TREATMENT OF MYCOSIS (51) Int. Cl. (75) Inventors: Frans HerWig Jansen, Oud-Turnhout A61K 31/685 (2006.01) (BE); Annie Marie Forten, Montreal (52) US, Cl, (CA); Bruno Jansen, legal CPC ...... A61K 31/685 (2013.01) representative, Beerse (BE) USPC ...... 514/114

(73) Assignee: DAFRA PHARMA RESEARCH & (57) ABSTRACT DEVELOPMENT BVBA, Tumhout (BE) The present invention relates to the use of oleyl phosphocho line (Cl8zl-PC), or OlPC,for the treatment of mycosis, and (21) APP1- NO? 14/ 003,046 especially for the treatment of mycosis such as mycosis caused by pathogens belonging to a genus selected from the (22) PCT Filed: Feb- 24: 2012 group consisting of Candida, Aspergillus, Fusarium, Cryp lococcus, Microsporum, Sporolhrix, Trichophylon and Sce (86) PCT NO‘: PCT/EP2012/053144 dosporium, for example, Candida albicans, Candida parap § 371 (0X1), silosis, Candida glabrala, Candida krusei, Aspergillus (2)’ (4) Date; sep_ 4, 2013 fumigalus, Aspergillus niger, Aspergillus Zerreus, Fusarium solani, Scedosporium prolifacans, Cryplococcus neofor (30) Foreign Application Priority Data mans, Microsporum canis, Sporolhrix schenkii, Trichophylon rubrum, Trichophylon menlagrophyles, Aspergillus fumiga Mar. 4, 2011 (EP) ...... PCT/EPZOl 1/053345 Zus, Fusarium oxysporum. US 2013/0345177 A1 Dec. 26, 2013

OLEYL PHOSPHOCHOLINE FOR THE [0014] Cryplocaccus neoformans can cause a severe form TREATMENT OF MYCOSIS of meningitis and meningo-encephalitis for example in HIV positive patients and AIDS. Cryplococcus neoformans is a [0001] The present invention relates to the treatment of major human and animal pathogen. Cryplococcus laurenli i mycosis, and especially the treatment of virulent or invasive and Cryplocaccus albidus have been knoWn to cause moder mycosis such as candidemia, cryptococcosis or aspergillosis. ate-to-severe disease in human patients With compromised [0002] Mycosis is a fungal infection of vertebrates, includ immunity. Cryplocaccus gallii can cause disease in non-im ing humans. Mycosis is a common infection, and a variety of munocompromised people. environmental and physiological conditions can contribute to [0015] Presently, amphotericin B, voriconaZole and itra the development of mycosis. Inhalation of fungal spores or conaZole are amongst the most commonly used medicaments localized colonization of the skin may initiate persistent to combat severe forms of mycosis such as subcutaneous infections and, accordingly, mycosis often starts in the lungs mycosis and systemic mycosis. HoWever, serious side effects or on the skin. are associated With these drugs. [0003] Mycosis can be classi?ed according to the tissue [0016] Amphotericin B is a polyene anti-fungal drug often initially coloniZed. used intravenously for systemic mycosis. It Was originally [0004] Super?cial mycosis is limited to the outermost lay extracted from Slreplamyces nodasus, a ?lamentous bacte ers of the skin and hair. An example of super?cial mycosis is rium, in 1955. Tinea versicolor, a fungus infection that commonly affects [0017] TWo amphotericins, amphotericinA and amphoteri young people. cin B are knoWn, but only B is used clinically, because it is [0005] Cutaneous mycosis extends deeper into the epider signi?cantly more active in vivo. Amphotericin A is almost mis and also includes invasive hair and nail diseases. These identical to amphotericin B (having a double C:C bond diseases are restricted to the keratiniZed layers of the skin, betWeen the 27th and 28th carbon), but has little anti-fungal hair, and nails. Unlike the super?cial mycosis, host immune activity has been observed. responses may be evoked resulting in pathologic changes [0018] Currently, the drug is available as plain amphoteri expressed in the deeper layers of the skin. cin B, a cholesteryl sulfate complex, a lipid complex, and as [0006] Subcutaneous mycosis involves the dermis, subcu a liposomal formulation. taneous tissues, muscle, and fascia. These infections are [0019] One of the main intravenous uses of amphotericin B chronic and canbe initiated by piercing trauma functioning as is in treating various systemic mycoses, including cryptococ a port of entry for the fungi. These infections are dif?cult to cal meningitis, for example in critically ill, comorbidly treat and may require surgical interventions such as debride infected or immunocompromised patients. ment. [0020] Another intravenous use of amphotericin B is as a [0007] Systemic mycosis generally starts With infection of drug of last resort in otherWise untreatable parasitic proto the lungs, but also other ports of entry are knoWn, and may Zoan infections such as visceral leishmaniasis and primary spread to many organ systems and tissues. Pathogenic fungi amoebic meningoencephalitis. causing systemic mycosis are inherently virulent. [0021] Amphotericin B is Well-knoWn for its severe and [0008] A special class of systemic mycosis is systemic potentially lethal side effects. Very often, a serious acute mycosis caused by opportunistic pathogens. Systemic myco reaction after the infusion (1 to 3 hours later) is noted, con sis caused by opportunistic pathogens is often an infection in sisting of high fever, shaking chills, hypotension, anorexia, patients With immune de?ciencies. Examples of immuno nausea, vomiting, headache, dyspnea and tachypnea, droWsi compromised conditions include AIDS, alteration of normal ness, and generalised Weakness. To decrease the likelihood ?ora by antibiotics, immunosuppressive therapy and meta and severity of the symptoms, initial doses should be loW, and static cancer. Examples of opportunistic mycosis include can increased sloWly. didiasis, cryptococcosis and aspergillosis. [0022] Intravenously administered amphotericin B has also [0009] Pathogenic fungi and especially pathogenic fungi been associated With multiple organ damage in therapeutic causing systemic mycosis are, for example, fungi belonging doses. Nephrotoxicity (kidney damage) is a frequently to the genus Candida, the genus Aspergillus and the genus reported side effect and can be severe and/ or irreversible. Cryplococcus. [0023] VoriconaZole (VFEND) is a triaZole anti-fungal [0010] Candida species, such as Candida albicans, are medication that is generally used to treat virulent or invasive major human pathogens that are knoWn for causing oppor mycosis. This type of mycosis is generally seen in patients tunist infections in immunocompromised hosts such as trans Who are immunocompromised, and includes invasive can plant patients, patients suffering from AIDS and cancer didiasis, invasive aspergillosis, and certain emerging fungal patients. Infections are dif?cult to treat and can be very seri infections. ous, i.e. 30% to 40% of the systemic infections result in death. [0024] VoriconaZole has become the neW standard of care [0011] AerosoliZed Aspergillus spores are found nearly in the treatment of invasive aspergillosis, Which may occur in everyWhere and constant exposure to Aspergillus is common. immunocompromised patients, including allogeneic BMT, Aspergillus can generally cause serious mycosis in three other hematologic cancers, and solid organ transplants. Ways: through the production of mycotoxins; through induc [0025] VoriconaZole is better tolerated than amphotericin tion of allergenic responses; and through systemic infections. B, With feWer adverse effects and a longer duration of therapy. [0012] The most common pathogenic species areAspergil [0026] VoriconaZole has proven to be as effective as a regi lusfumigalus and Aspergillus?avus. Aspergillus?avus pro men of intravenous amphotericin B folloWed by oral ?ucona duces an a?atoxin Which is both a toxin and a carcinogen. Zole in patients With culture-proven candidemia. Voricona [0013] Mycosis caused by Aspergillus is generally desig Zole cleared Candida yeast from the bloodstream as quickly nated as aspergillosis. The symptoms of aspergillosis include as amphotericin B (median 2 days) and shoWed a trend toWard fever, cough, chest pain or breathlessness. better survival. VoriconaZole is also associated With feWer US 2013/0345177 A1 Dec. 26, 2013

serious adverse events and cases of renal toxicity, but a higher [0040] Invasive mycosis as used herein indicates a primary incidence of visual disturbances Was observed. fungal infection capable of further infecting, or spreading to, [0027] VoriconaZole has also been proven effective against other organs or tissues. a number of other serious fungal pathogens. These include [0041] In the present context, mycosis can be both virulent infections by Fusarium spp. and Scedasporium apiospermum and invasive. (asexual form of Pseudallescheria boydii). [0042] According to a preferred embodiment of this aspect [0028] Although infrequently seen in the present clinical of the present invention, the present mycosis is selected from setting, these fungi are emerging as more common and deadly the group consisting of super?cial mycosis, cutaneous myco causes of fungal infection in immunocompromised patients, sis, subcutaneous mycosis, and systemic mycosis and espe and the development of voriconaZole has been an important cially invasive or virulent subcutaneous mycosis or invasive advance in their treatment as they are generally resistant to or virulent systemic mycosis. other antifungal agents (including amphotericin B). [0043] According to another preferred embodiment of this [0029] The most common side effects associated With vori aspect of the present invention, the present vertebrate is a conaZole include transient visual disturbances, fever, rash, human, preferably an immunocompromised patient. vomiting, nausea, diarrhea, headache, sepsis, peripheral [0044] According to yet another preferred embodiment of edema, abdominal pain, and respiratory disorder. Also cases this aspect of the present invention, the causative pathogen of of serious hepatic reactions during treatment With voricona the present mycosis is selected from the genus Candida, Zole have been reported. Aspergillus, Fusarium, Cryplococcus, Microsporum, Spora [0030] ItraconaZole is a triaZole anti-fungal agent that is Zhrix, Trichophylon and Scedosporium. prescribed to patients With mycosis. The drug may be given [0045] According to an especially preferred embodiment of orally or intravenously. this aspect of the present invention, the present oleyl phos [0031] ItraconaZole has a broader spectrum of activity than phocholine is used for the treatment of mycosis caused patho ?uconaZole (but not as broad as voriconaZole or posacona gens selected from the group consisting of Candida albicans, Zole). In particular, it is active against Aspergillus, Which Candida parapsilosis, Candida glabrala, Candida krusei, ?uconaZole is not. It has been approved for the treatment of Aspergillusfumigalus, Aspergillus niger, Aspergillus Zerreus, blastomycosis, histoplasmosis and onychomycosis. It is also Fusarium solani, Scedosporium prolifacans, Cryplococcus prescribed for systemic infections such as aspergillosis, can neoformans, Microsporum canis, Sporolhrix schenkii, Tri didiasis and cryptococcosis Where other antifungal drugs are chophylon rubrum, Trichophylon menlagrophyles, Aspergil inappropriate or ineffective. lusfumigalus, Fusarium oxysporum. [0032] ItraconaZole is a relatively Well-tolerated drug (al [0046] According to another preferred embodiment of this though not as Well tolerated as ?uconaZole or voriconaZole) aspect of the present invention, the present oleyl pho sphocho and the range of adverse effects it produces is similar to the line is formulated for parenteral, oral or topical administra other aZole anti-fungals. tion. Especially in case the present mycosis is subcutaneous [0033] Elevated alanine aminotransferase levels are found mycosis oleyl phosphocholine is formulated for topical or in 4% of people taking itraconaZole forming a risk of devel oral administration and in case the present mycosis is sys oping congestive heart failure. Other reported adverse effects temic mycosis oleyl phosphocholine is formulated intrave of itraconaZole are nausea, vomiting, abdominal pain, nous, parenteral or oral administration. fatigue, loss of appetite, yelloW skin (jaundice), yelloW eyes, [0047] According to an especially preferred embodiment of itching, dark urine, and/or pale stool. the present invention, the present oleyl phosphocholine is [0034] Considering the above, there is a need in the art for used for the treatment of a mycosis selected from the group anti-fungal agents being similarly effective as amphotericin consisting of candidemia, aspergillosis and cryptococcosis. B, voriconaZole and/ or itraconaZole With respect to anti-fun [0048] Considering the effective anti-fungal activity of gal activity but Which are better tolerated, i.e. With less, oleyl phosphocholine, the present invention, according to reduced or less severe side effects. another aspect, relates to methods for treatment of mycosis [0035] Further, considering the rapid development of resis comprising administering to, or applying on a vertebrate suf tance against knoWn anti-fungal compounds, there is a con fering from mycosis, preferably invasive or virulent mycosis, tinuing need in the art for further compounds With anti-fungal a therapeutically effective dose of oleyl phosphocholine. activity, and especially anti-fungal compounds effective [0049] According to a preferred embodiment of this aspect, against life threatening invasive or virulent fungal pathogens. the present mycosis is caused by a yeast or fungus belonging [0036] Accordingly, it is an object of the present invention, to a genus selected from the group consisting of Candida, amongst other objects, to provide anti-fungal compounds Aspergillus, Fusarium, Cryplococcus, Microsporum, Spora meeting the above needs in the art. Zhrix, Trichophylon and Scedasporium such as pathogens [0037] According to the invention, this object, amongst selected from the group consisting of Candida albicans, Can other objects, according to a ?rst aspect is met by appended dida parapsilosis, Candida glabrala, Candida krusei, claim 1. Aspergillusfumigalus, Aspergillus niger, Aspergillus Zerreus, [0038] Speci?cally, this object, amongst other objects, Fusarium solani, Scedosporium prolifacans, Cryplococcus according to a ?rst aspect is met by oleyl phosphocholine for neoformans, Microsporum canis, Sporolhrix schenkii, Tri use in the treatment of mycosis in a vertebrate, preferably for chophylon rubrum, Trichophylon menlagrophyles, Aspergil use in the treatment of invasive or virulent mycosis in a lusfumigalus, Fusarium oxysporum. vertebrate. [0050] According to yet another preferred embodiment of [0039] Virulent mycosis as used herein indicates a primary this aspect, the present invention relates to the present use of fungal infection capable of extending, or spreading, the oleyl phosphocholine formulated by parenteral, oral or topi infected area of an organ or tissue infected. cal administration. US 2013/0345177 A1 Dec. 26, 2013

[0051] According to a particularly preferred embodiment TABLE 2 of this aspect, oleyl phosphocholine is used for the treatment of candidemia, aspergillosis and cryptococcosis. Minimum inhibitory concentration required inhibiting the [0052] The present invention Will be further detailed and groWth of50% or 100% ofthe microorganisms illustrated in the examples beloW representing particularly Dafra preferred embodiments of the present invention. MIC100 ITR VRZ AMB IHEM (48 h) (MIC50) (MIC50) (M10100) EXAMPLES Yeast No (pg/ml) (pgml) (pg/ml) (pg/ml)

Candida albicans 3731 2.5 0.032 0.064 0.5 Example 1 Candida albicans 19114 2.5 >16 >16 0.5 Candida 3270 5 0.064 0.125 1 [0053] The following ten strains Were tested for assaying parapsilasis the anti-fungal activity of oleyl phosphocholine. One Can Candida gZabrala 19371 5 0.5 0.25 0.5 dida strain, i.e. 19114, Was selected because ofits resistance Candida krasei 9560 5 0.25 0.5 1 against voriconaZole and itraconaZole Dafra MIC100 ITR VRZ AMB TABLE 1 IHEM (48 h) (M10100) (M10100) (M10100) Fungi N° (Hg/ml) (Hg/ml) (ug/ml) (Hg/ml) Strain tested for anti-fungal activity of oleyl phosphocholine AspergiZZas 18963 5 0.5 1 2 famigalas Strain strain isolate remark AspergiZZas niger 5788 10 0.5 1 1 Aspergillus 13669 10 0.25 0.5 >8 Yeasts lerreas Fasariam saZani 18489 5 >16 16 2 Candida albicans 3731 ATCC 10231 Scedaspariam 22387 5 >16 16 >8 Candida albicans 19114 clinical blood prali?cans isolate resistant for voriconazole and itraconazole Candida parapsilasis 3270 ATCC 22019 [0058] As can be seen in the above table, oleyl phospho Candida gZabrala 19371 clinical blood choline Was capable of inhibiting the groWth of yeast and isolate fungi in a similar concentration range as the commonly used Candida krusei 9560 ATCC 6258 anti-fungal agents amphotericin B, voriconaZole and itra ?lamentous fungi conaZole. Aspergillasfamigalas 18963 NCPF 7367 [0059] Further, the results for the resistant Candida strain AspergiZZas niger 5788 ATCC 10864 19114 shoW that oleyl phosphocholine provides a suitable AspergiZZas lerreas 13 669 clinical isolate alternative for the knoWn anti-fungal agents against Which Fasariam saZani 18489 clinical isolate resistance has been developed. Scedaspariam 22387 clinical blood pralifacans isolate [0060] Of special interest is the anti-fungal activity of oleyl phosphocholine against Fusarium salani and Scedasporium prali?cans, tWo emerging pathogens, against at least tWo of [0054] The above strains Were contacted With oleyl phos the knoWn anti-fungal agents, i.e. voriconaZole and itracona phocholine on microplates and the anti-fungal activity of Zole, are less effective. oleyl phosphocholine Was determined. In comparison, the same test Was performed using amphotericin B (AMB), vori Example 2 conaZole (VRZ) and itraconaZole (ITR). [0055] The test protocol used Was in conformity With the [0061] The folloWing strains Were tested for assaying the standard CLSI method: anti-fungal activity of oleyl phosphocholine. Clinical and Laboratory Standards Institute/National Com mittee for Clinical Laboratory Standards (2002) Reference TABLE 3 method for broth dilution antifungal susceptibility testing of Strains used for assaying the anti-?angal yeasts. Approved Standard document M27-A2. Clinical and activity of oleyl phosphocholine. Laboratory Standards Institute/National Committee for Clinical Laboratory Standards Institute, Wayne Pa. Candida albicans Clinical and Laboratory Standards Institute/National Com Candida albicans B59630 (R) Candida albicans B63195 (S) mittee for Clinical Laboratory Standards. (2002) Reference Candida parapsilasis B66126 method for broth dilution antifungal susceptibility testing of Cryplacaccas neafarmans ?lamentous fungi. Approved Standard document M38-A. Cryplacaccas neafarmans B66663 Clinical and Laboratory Standards Institute/National Com Micrasparam canis mittee for Clinical Laboratory Standards Institute, Wayne Sparalhrix schenkii Sparalhrix schenkii B62482 [0056] The folloWing concentrations of oleyl phosphocho Trichaphylan rubrum line (Dafra), amphotericin B (AMB), voriconaZole (V RZ) Trichaphylan rubrum B68183 and itraconaZole (ITR) Were tested: 10, 5, 2.5, 1.25, 0.625, Trichaphylan menlagraphyles B70554 0.312, 0.15, 0.078, 0.039, 0.019, 0.009, and 0.004 ug/ml Aspergillasfamigalas Aspergillasfamigalas B42928 [0057] The results, after visual and spectrophometric read Aspergillasfamigalas B19119 ing after 48 hours of incubation, are presented as MIC50 and Fasariam saZani IHEM22128 MIC 100, i.e. the minimum inhibitory concentration required Fasariam axysparum IHEM3014 inhibiting the groWth of 50% or 100% of the microorganisms, respectively. US 2013/0345177 A1 Dec. 26, 2013

[0062] The above strains Were contacted oleyl phospho 13. The method according to claim 11, Wherein said myco choline on microplates and the anti-fungal activity of oleyl sis is at least one of invasive subcutaneous mycosis, virulent phosphocholine Was determined. subcutaneous mycosis, invasive systemic mycosis, or viru [0063] Anti-fungal activity Was expressed as ICSO, i.e. the lent systemic mycosis. concentration oleyl phosphocholine needed to kill 50% of the 14. The method according to claim 11, Wherein said ver pathogens. The results are summarised in Table 4 beloW: tebrate is a human.

TABLE 4 15. The method according to claim 11, Wherein said myco sis is caused by a pathogen selected from the group consisting In vitro ef?cacy of OlPC against yeasts and ?ingi of Candida, Aspergillus, Fusarium, Cryplococcus, expressed as 1C 0 concentration Microsporum, Sporolhrix, Trichophylon and Scedosporium. OlPC 16. The method according to claim 11, Wherein said myco Icso sis is caused by a pathogen selected from the group consisting Yeasts/Fungi (11M) of Candida albicans, Candida parapsilosis, Candida gla Candida albicans 7.89 brala, Candida krusei, Aspergillus fumigalus, Aspergillus Candida albicans B59630 (R) 8.00 niger, Aspergillus Zerreus, Fusarium solani, Scedosporium Candida albicans B63195 (S) 7.77 prolifacans, Cryplococcus neoformans, Microsporum canis, Candida parapsilosis B66126 8.00 Cryplococcus neoformans 4.50 Sporolhrix schenkii, Trichophylon rubrum, Trichophylon Cryplococcus neoformans B66663 0.50 menlagrophyles, Aspergillus fumigalus, and Fusarium Microsporum canis 1.66 oxysporum. Sporolhrix schenkii 8.16 Sporolhrix schenkii B62482 1.97 17. The method according to claim 11, Wherein said oleyl Trichophylon rubrum 5 .87 phosphocholine is administered parenterally, orally, or topi Trichophylon rubrum B68183 2.00 cally. Trichophylon menlagrophyles B70554 2.00 Aspergillusfumigalus 18.76 18. The method according to claim 11, Wherein said myco Aspergillusfumigalus B42928 8.00 sis is systemic mycosis and said oleyl phosphocholine is Aspergillusfumigalus B19119 1.87 Fusarium s0Zani1HEM22128 2.31 administered intravenously or orally. Fusarium oxysporum 1HEM3014 2.55 19. The method according to claim 11, Wherein said myco sis is subcutaneous mycosis and said oleyl phosphocholine is 1-10. (canceled) administered topically or orally. 11. A method for treatment of mycosis comprising admin 20. The method according to claim 11, Wherein said myco istering to a vertebrate suffering from mycosis, a therapeuti sis is selected from the group consisting of candidemia, cally effective dose of oleyl phosphocholine aspergillosis and cryptococcosis. 12. The method according to claim 11, Wherein said myco sis is selected from the group consisting of super?cial myco 21. The method according to claim 14, Wherein the human sis, cutaneous mycosis, subcutaneous mycosis, and systemic is immunocompromised. mycosis. * * * * *