EA048938B1 - COMBINATION OF CXCR7 ANTAGONIST WITH S1P1 RECEPTOR MODULATOR - Google Patents

Description

The present invention relates to a compound (1-pyrimidin-2-yl-cyclopropyl)amide (3S,4S)-1-cyclopropylmethyl-4-{[5-(2,4-difluorophenyl)isoxazole-3-carbonyl]amino}piperidine-3-carboxylic acid (hereinafter also referred to as COMPOUND):

and to its use as a CXCR7 CXCL11/CXCL12 receptor modulator in combination with other active ingredients or therapeutic agents containing a sphingosine-1-phosphate receptor 1 modulator (S1P1 receptor modulator) for the prophylaxis/prevention or treatment of diseases and disorders in which both the expression of CXCR7 or its ligands and S1P are important. The invention further relates to pharmaceutical compositions comprising the COMPOUND in combination with said other active ingredient(s) or therapeutic agent(s). The invention further relates to daily doses of the COMPOUND which, when administered, for example, once or twice daily, can be well tolerated and pharmaceutically effective for the prophylaxis/prevention or treatment of diseases and disorders in which the expression of CXCR7 or its ligands is important.

The COMPOUND is known from WO 2018/019929 as a modulator of the CXCR7 CXCL11/CXCL12 receptor. The crystalline form of the COMPOUND is known from WO 2019/145460. The COMPOUND may have potential use for the prophylaxis/prevention or treatment of certain diseases and disorders associated with the CXCR7 receptor or its ligands, including:

cancer such as brain tumors including malignant gliomas, glioblastoma multiforme; neuroblastoma; pancreatic cancer including pancreatic adenocarcinoma/pancreatic ductal adenocarcinoma; gastrointestinal cancer including colon carcinoma, hepatocellular carcinoma, and gastric cancer; Kaposi's sarcoma; leukemias including adult T-cell leukemia; lymphoma; lung cancer; breast cancer; rhabdomyosarcoma; prostate cancer; squamous cell carcinoma of the esophagus; squamous cell carcinoma of the oral cavity; endometrial cancer; thyroid carcinoma including papillary thyroid carcinoma; metastatic cancer; metastasis to the lung; skin cancer including melanoma and metastatic melanoma; bladder cancer; multiple myelomas; osteosarcoma; head and neck cancer; and renal carcinoma, including renal clear cell carcinoma, metastatic renal clear cell carcinoma;

inflammatory diseases such as chronic rhinosinusitis, asthma, chronic obstructive pulmonary disease, atherosclerosis, myocarditis, acute lung injury, endometriosis, uveitis, diabetic retinopathy and sarcoidosis;

Autoimmune disorders such as (inflammatory) demyelinating diseases; Multiple sclerosis (MS); Guillain-Barré syndrome; Rheumatoid arthritis (RA); Inflammatory bowel disease (IBD), especially including Crohn's disease and ulcerative colitis; Systemic lupus erythematosus (SLE), including neuropsychiatric systemic lupus erythematosus and lupus nephritis; Interstitial cystitis; Celiac disease; Autoimmune encephalomyelitis; Osteoarthritis; Type 1 diabetes; Psoriasis; Autoimmune thyroiditis; Sjogren's syndrome; Ankylosing spondylitis and vitiligo;

neurodegenerative diseases such as amyotrophic lateral sclerosis;

graft rejection (especially renal allograft rejection, cardiac allograft rejection, and graft-versus-host disease following hematopoietic stem cell transplantation);

fibrosis (especially liver fibrosis, liver cirrhosis, pulmonary fibrosis, cardiac fibrosis, especially idiopathic pulmonary fibrosis; and ischemic injury such as renal ischemia or cerebral ischemia.

Chemokine receptors are a group of G protein-coupled receptors (GPCRs) that bind peptide chemokine ligands with high affinity. The predominant function of chemokine receptors is to direct leukocyte trafficking to lymphoid organs and tissues under resting conditions and during inflammation, but a role for some chemokine receptors on non-hematopoietic cells and their precursors has also been recognized.

CXCR7 (aka ACKR3, aka RDC1, aka CMKOR1, aka GPR159) has two known chemokine ligands: CXCL12 (aka stromal cell-derived factor 1, SDF-1; aka Pre-B cell growth stimulating factor, PBSF) and CXCL11 (aka 1-TAC, aka IFN-g-induced T-cell chemoattractant). Binding of either CXCL11 or CXCL12 to CXCR7 results in internalization of the CXCR7-ligand complex (Burns JM et al. J Exp Med 2006, 203(9):2201-13) and degradation of the ligand (Naumann U et al. PLoS One 2010, 5(2): e9175). This scavenging activity promotes the establishment and maintenance of

- 1 048938 dependence of CXCL11 and CXCL12 concentration gradients from blood vessels to tissues.

CXCL12, a stromal-derived chemoattractant, is involved in immune surveillance and regulation of inflammatory responses. CXCL12 is secreted by bone marrow stromal cells, endothelial cells, heart, skeletal muscle, liver, brain, kidney, thymus, lymph nodes, parenchymal cells and plays an important role in stem cell proliferation, survival, and homing of hematopoietic/progenitor cells to the bone marrow (Rankin SM et al; Immunol let. 2012, 145(1-2):47-54). CXCL12 is induced in certain pathological conditions including ischemia, inflammation, hypoxia, cancer, neurodegenerative diseases, and autoimmune diseases (Juarez J et al. Curr Pharm Des 2004, 10(11):1245-59).

CXCL12 also recruits bone marrow progenitor cells to sites of vasculature. It also plays a prominent role in carcinogenesis. CXCL12 promotes the recruitment of endothelial progenitor cells and myeloid-derived suppressor cells to tumor sites, as well as other bone marrow-derived cells. CXCL12 also plays a role during inflammation by affecting cell migration, adhesion, and survival (Kumar R et al. Cell Immunol. 2012, 272(2):230-41). CXCL12 also drives the differentiation, maturation, and differentiation of cells such as oligodendrocyte progenitor cells (Gottle P et al. Ann Neurol. 2010, 68(6):915-24).

CXCL11 is mainly expressed in the pancreas, peripheral blood leukocytes, thymus, liver, spleen, and lung. This chemokine is induced by interferon and is activated during infection or cancer (Cole et al. J Exp Med. 1998, 187(12):2009-21).

In addition to CXCR7, CXCL12 binds and activates CXCR4 (aka Fusin, aka leukocyte seven-transmembrane domain receptor; LESTR, aka D2S201E, aka seven-transmembrane segment receptor, aka HM89, aka lipopolysaccharide-associated protein 3; lap3, aka LPS-associated protein 3), while CXCL11 binds and activates CXCR3 (aka GPR9, aka CD 183).

The interaction of CXCR7 and its ligands CXCL12 and CXCL11 (hereafter referred to as the CXCR7 axis) is thus involved in the targeting of receptor-bearing cells to specific sites in the body, particularly sites of inflammation, immune injury and immune dysfunction, and is also associated with tissue injury, induction of apoptosis, cell growth and angiostasis. CXCR7 and its ligands are activated and highly expressed in a variety of pathological conditions, including cancer, autoimmune diseases, inflammation, infection, transplant rejection, fibrosis and neurodegeneration.

CXCR7 modulators have been found to have potential use, alone or in combination, in diseases where modulation of CXCR7 (e.g., using siRNA, shRNA, microRNA, overexpression, CXCR7 knockout animals, CXCR7 agonists, CXCR7 antagonists, antibodies, or nanobodies) has been shown to regulate leukocyte migration (Berahovich RD et al.; Immunology. 2014, 141(1):111–22) and promote myelin/neuronal repair (Williams JL et al.; J Exp Med. 2014, 5; 211(5):791–9; Gottle P et al.; Ann Neurol. 2010, 68(6):915–24), exerting beneficial effects in experimental models of inflammatory, autoimmune, and demyelinating diseases, including multiple sclerosis and autoimmune encephalomyelitis (CruzOrengo L et al.; J Neuroinflammation. 2011, 6; 8:170; Bao J et al.; Biochem Biophys Res Commun. 2016 Jan 1; 469(1):1-7), Guillain-Barré syndrome or autoimmune neuritis (Brunn A et al.; Neuropathol Appl Neurobiol. 2013, 39(7):772-87), and rheumatoid arthritis (Watanabe K et al.; Arthritis Rheum. 2010, 62(11):3211-20).

In particular, the effect of CXCR7 on inflammatory demyelinating diseases is known from the literature. CXCR7 is expressed in various regions of the adult mouse brain, and its expression is increased in a mouse model of multiple sclerosis (MS) and during demyelination in a model of non-inflammatory demyelination (Banisadr G et al.; J Neuroimmune Pharmacol. 2016 Mar; 11(1):26-35; Williams JL et al.; J Exp Med. 2014, 5; 211(5):791-9; Gottle P et al.; Ann Neurol. 2010, 68(6):915-24). Patterns of altered CXCL12 expression at the blood-brain barrier (BBB) have been implicated in the development of multiple sclerosis and correlate with disease severity (McCandless EE et al.; Am J Pathol. 2008, 172(3):799-808). Functional antagonism of CXCR7 has been shown to be effective in experimental autoimmune encephalomyelitis in mice. These recent studies strongly suggest that CXCR7 is a disease-modifying molecule in multiple sclerosis through additional mechanisms: (i) by facilitating leukocyte entry into the perivascular space via redistribution to the BBB (Cruz-Orengo L et al.; J Neuroinflammation. 2011, 6; 8:170; Cruz-Orengo L et al.; J Exp Med. 2011, 14; 208(2):327-39) and regulating CXCR4-mediated integrin activation (Hartmann TN et al.; J Leukoc Biol. 2008; 84(4):113040) (ii) by directly affecting microglial chemotaxis (Bao J et al.; Biochem Biophys Res Commun. 2016 Jan 1; 469(1):1-7) and on inflammatory monocytes by facilitating their infiltration into the brain (Douglas SD et al.; J Leukoc Biol. 2017; 102:1155-1157) (iii) by promoting remyelination by increasing CXCL12 levels, which enhances CXCR4-mediated oligodendrocyte progenitor cell maturation (Williams JL et al.; J Exp Med. 2014, 5;211(5):791-9; Gottle P et al.; Ann Neurol. 2010, 68(6):915-24). Recently, Chu et al. (Neuroscientist. 2017, 23(6):627-648)

- 2 048938 looked at the importance of targeting the CXCL12/CXCR4/CXCR7 axis in demyelinating diseases due to its central role in promoting oligodendrocyte progenitor cell migration, proliferation, and differentiation. Thus, CXCR7 antagonism may therapeutically prevent inflammation and enhance myelin repair in the demyelinated adult CNS.

In particular, the potential role of CXCR7 in rheumatoid arthritis is known from the literature. CXCR7 is reported to be expressed on endothelial cells of the synovium. In addition, increased levels of CXCL12 and CXCL11 mRNA were detected in the synovial tissue of patients with rheumatoid arthritis (Ueno et al.; Rheumatol Int. 2005, 25(5):361-7). CXCL12 has been shown to play a central role in the accumulation of CD4+ T cells and monocytes in the synovium (Nanki T et al.; J Immunol. 2000, 165(11):6590-8; Blades MC et al.; Arthritis Rheum. 2002 Mar; 46(3):824-36). Furthermore, CXCL12 is involved in the rheumatoid arthritis process through its proangiogenic functions and its effects on osteoclast recruitment and differentiation. Thus, CXCL12 pathway modulators, including CXCR7 modulators, have been proposed as potential therapeutic agents for the treatment of rheumatoid arthritis. Villalvilla et al. (Expert Opin Ther Targets. 2014; 18(9): 1077–87) recently discussed preclinical and clinical data supporting the potential use of anti-CXCL12 agents in the treatment of rheumatoid arthritis. Watanabe et al. (Arthritis Rheum. 2010; 62(11):3211–20) demonstrated that a CXCR7 inhibitor prophylactically and therapeutically reduced clinical signs of the disease and angiogenesis in a collagen-induced arthritis mouse model.

In addition, CXCR7 has been reported to be involved in several inflammatory diseases, including acute and chronic inflammatory processes in the lungs such as chronic obstructive pulmonary disease, acute lung injury, asthma, pneumonia, pulmonary fibrosis, as well as atherosclerosis, liver fibrosis and cardiac fibrosis.

CXCL12 and CXCL11 have also been reported to be upregulated in inflammatory bowel disease (Koelink PJ et al; Pharmacol Ther. 2012, 133(1):1-18). CXCR7 has been found to be upregulated on peripheral blood T cells in inflammatory bowel disease (IBD) (Werner L et al; J Leukoc Biol. 2011, 90(3):583-90). The author hypothesizes that increased CXCR7 expression in the peripheral blood of IBD patients may contribute to increased T cell recruitment to sites of mucosal inflammation (Werner L et al; Theranostics. 2013, 3(1):40-6). In mouse models of IBD, CXCL12 pathway modulators can reduce T cell infiltration and attenuate tissue damage (Mikami S et al.; J Pharmacol Exp Ther. 2008, 327(2):383–92; Xia XM et al.; PLoS One. 2011, 6(11):e27282).

Elevated levels of CXCL12 and CXCL11 have also been detected in psoriasis-lesional skin (Chen SC et al.; Arch Dermatol Res. 2010, 302(2): 113–23; Zgraggen S et al.; PLoS One. 2014, 9(4):e93665). Zgraggen et al. demonstrated that CXCL12 blockade improved chronic skin inflammation in two different models of psoriasis-like skin inflammation.

Several other autoimmune diseases, such as systemic lupus erythematosus (SLE), exhibit altered CXCR7/CXCR4 expression, correlating with impaired CXCL12-driven SLE B cell migration (Biajoux V et al.; J Transl Med. 2012, 18; 10:251). Furthermore, CXCL12 was significantly upregulated in nephritic kidneys in several mouse models of lupus. Wang et al. (J Immunol. 2009, 182(7):4448-58) showed that targeting the CXCL12 axis is a good therapeutic target in lupus, as a CXCR4 antagonist significantly improved disease progression by prolonging survival and reducing nephritis and lymphoproliferation.

Matin et al. (Immunology. 2002, 107(2):222-32) demonstrated that blockade of CXCL12 with antibodies resulted in a reduction in the development of diabetes and inhibition of insulitis in a mouse model of diabetes.

CXCL12 and CXCR4 have been found to be upregulated in the thyroid glands of patients with autoimmune diseases and in animal models (Armengol MP et al.; J Immunol. 2003, 170(12):63208). Liu et al. (Mol Med Rep. 2016, 13(4):3604-12) reported that blocking CXCR4 reduced the severity of autoimmune thyroiditis in mice by reducing lymphocyte infiltration and autoantibody production.

Activation of CXCR4 has been detected in synovial tissues of patients with ankylosing spondylitis (He C et al.; Mol Med Rep. 2019, 19(4):3237–3246). Inhibition of CXCR4 resulted in decreased fibroblast proliferation and osteogenesis.

Neurodegenerative disorders have been shown to exhibit altered expression of CXCL12/CXCR4. This pathway is involved in the recruitment and differentiation of self-renewing and multipotent neural progenitor cells, which play a critical role during tissue repair. Meizhang et al. reviewed the role of CXCL12 in neurodegenerative diseases and the impact of manipulation of the CXCL12 signaling pathway on neurodegenerative disorders in aminal models (Meizhang et al. Trends Neurosci. 2012, 35(10): 619-628). Recently, CXCL12 and CXCR4 expression were found to be elevated in the peripheral blood of patients with Parkinson's disease (Bagheri et al. Neuroimmunomodulation. 2018, 25(4):201-205). The CXCR4/CXCL12 pathway is also involved in

- 3 048938 inflammation that occurs in Alzheimer's disease (Hongyan et al. Brain Circ. 2017, 3(4):199-203). Rabinovich-Nikitin et al. reported that blocking CXCR4/CXCL12 signaling reduced microglial inflammation, blood-brain barrier permeability, and increased motor neuron number, increasing survival in a mouse model of amyotrophic lateral sclerosis (ALS) (Rabinovich-Nikitin et al. J Neuroinflammation. 2016, 13: 123).

CXCR7 is also known as a phagocytic receptor for several opioid peptides, particularly enkephalins and dynorphins, regulating their availability and thus signaling through their classical opioid receptors (Meyrath M et al. Nat Commun 2020;11(1):3033). Because CXCR7 acts as a scavenger for a wide range of opioid peptides, administration of a CXCR7 antagonist may result in an increase in these opioid peptides, similar to the increase observed for the chemokine ligands CXCL11 and CXCL12. As such, modulation of endogenous opioid levels may be used to treat clinical pain and control nociception (Holden JE et al. AACN Clin Issues. 2005;16(3):291-301). Cerebrospinal fluid levels of prodynorphin-derived peptides, which have been shown to bind to CXCR7, are decreased in patients with Huntington's disease (Al Shweiki MR et al. Mov Disord. 2020; doi: 10.1002/mds.28300), therefore increasing the levels of these peptides by administering a CXCR7 antagonist may be beneficial in this disease. Endogenous opioid peptides also induce mood disorders such as depression (Pecina M et al. Mol Psychiatry. 2019; 24(4): 576-587). Therefore, it can be expected that modulating the levels of endogenous peptides by blocking the phagocytic receptor CXCR7 may be used to treat mood disorders. In line with this, CXCR7 modulator has been shown to have anxiolytic activity (Ikeda Y et al. Cell. 2013; 155(6):1323-36) in a preclinical model. Therefore, CXCR7 modulators may, in addition to the diseases and disorders associated with the CXCR7 receptor or its ligands mentioned above, also be useful for the prophylaxis/prevention or treatment of certain diseases and disorders associated with opioid receptor signaling, including neuropathic pain, neurodegenerative diseases including Huntington's disease, addiction disorders, mood disorders, anxiety disorders.

Some sphingosine-1-phosphate receptor 1 modulators (also called S1P1 receptor modulators, including non-selective S1P1 receptor modulators such as fingolimod, as well as selective S1P1 receptor modulators) are S1P1 receptor agonists that act pharmacologically as functional antagonists at the S1P1 receptor. S1P1 receptor modulators have been described as useful for the prevention and/or treatment of diseases or disorders associated with the activated immune system (Juif et al., Exp. Op. Drug Metabol. & Tox. (2016) 12(8), 879–895). S1P1 receptor modulators indirectly antagonize S1P1 receptor function and sequester lymphocytes in the lymph nodes (Subei et al., CNS Drugs. 2015 Jul; 29(7): 565-575). Multiple S1P1 receptor modulators have been confirmed to signal identically via S1P1, resulting in S1P1 receptor degradation (Lukas et al., J. Biomol. Screening (2014) 19(3) 407-416). In clinical practice, S1P1 receptor modulators, including non-selective and selective S1P1 receptor modulators, exhibit a risk of bradyarrhythmia and atrioventricular blocks (AV blocks). Therefore, for example in the case of fingolimod, monitoring of heart rate and blood pressure is recommended in patients at the beginning of treatment. Risk reduction through the use of dose-escalating dosing regimens has been proposed and such dosing regimens are used in clinical practice (see, e.g., for fingolimod: WO2006/058316, WO2010/075239, WO2011/041145, WO2013/055833; for ponesimod: WO2009/115954, WO2016/091996; for siponimod: WO2010/072703, WO2013/057212, WO2015/155709). Another potential caveat with some of the S1P1 receptor modulators available or in development is that treatment commonly results in lymphopenia and in some cases may result in severe lymphopenia associated with an increased risk of infection. Combination with another active principle may lead to increased efficacy and/or increased lymphocyte count. In addition, combination with another active principle may allow for a reduction in the minimum effective dose of the S1P1 receptor modulator. Thus, such a combination with another active principle may be useful, especially in cases where reactivation of the immune system may be required, such as in an emergency situation such as an acute infection.

S1P1 receptor modulators, in particular, have been described as having a unique mechanism of action in the treatment of multiple sclerosis (MS) (Chaudhry et al. Neurotherapeutics (2017) 14:859–873). MS is a chronic inflammatory demyelinating disease of the central nervous system (CNS), in which the inflammatory process is associated with the destruction of myelin, leading to the formation of large focal foci of demyelination. Axonal damage and loss also occur as a consequence of inflammatory demyelination, although to varying degrees. Active remyelination processes can at least partially repair myelin damage, whereas axonal loss is permanent and irreversible. MS is primarily considered an autoimmune neurodegenerative disease, i.e., a disease caused by the adaptive immune response to self-antigens. In MS, the

- 4 048938 myelin-reactive T cells are recruited from the periphery to the CNS, leading to the activation of microglia and the recruitment of circulating macrophages (Grassi et al. Frontiers in Pharmacology 2019, doi:10.3389/fphar.2019.00807).

S1P1 receptor modulators have been found to have potential applications in neurodegenerative diseases where S1P1 receptor modulators have a direct effect on resident CNS cells such as microglia, astrocytes, neurons, oligodendrocyte progenitor cells, and oligodendrocytes (Miron et al. J Neurol Sci. 2008, 274(1-2):13-7), resident CNS cells such as microglia, astrocytes, neurons, oligodendrocyte progenitor cells, and oligodendrocytes.

In particular, the influence of S1P on neurodegenerative diseases is known from the literature. Yazdi et al. recently discussed experimental and clinical studies confirming the direct effect of S1P1 receptor modulator on myelination (Yazdi et al. J Neuro Res. 2019, 00:1-13). Angelopoulou et al. recently analyzed the involvement of S1P in the pathogenesis of Alzheimer's disease (AD) and the beneficial effect of S1P1 receptor modulator in AD models (Angelopoulou et al. Neuromolecular Med. 2019, 21(3):227-238). An S1P1 receptor modulator has been shown to improve neurological deficits and increase survival in a mouse model of amyotrophic lateral sclerosis (ALS) by modulating the neuroinflammatory response and increasing brain-derived neurotrophic factor expression (Potenza et al. Neurotherapeutics. 2016, 13(4): 918-927). Miguez et al. reported that an S1P1 receptor modulator improved hippocampal synaptic plasticity and memory in a mouse model of Huntington's disease by reducing astrogliosis and decreasing local inflammation (Miguez et al. Hum Mol Genet. 2015, 24(17):4958-70).

Fingolimod (2-amino-2-[2-(4-octylphenyl)-ethyl]-propane-1,3-diol, CAS No. 162359-55-9, e.g. WO2008/000419, WO2010/055027, WO2010/055028, WO2010/072703) is a non-selective S1P1 receptor modulator indicated for the treatment of relapsing multiple sclerosis (MS). Fingolimod 0.5 mg once daily is the first oral drug approved for the treatment of relapsing MS in many countries and for highly active relapsing-remitting MS (RRMS) in the European Union. In the US, fingolimod is indicated for the treatment of relapsing forms of multiple sclerosis (MS), including clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in patients 10 years of age and older with the recommended adult and pediatric doses of 0.5 mg orally once daily. Fingolimod remains in the blood and exerts pharmacodynamic effects, including a reduction in lymphocyte counts, for 2 months after the last dose of fingolimod. Lymphocyte counts typically return to the normal range within 1–2 months after stopping therapy. Despite the observed long washout period, it has also been shown that dose reduction of fingolimod, for example to 0.5 mg every other day, can result in disease reactivation in a significant proportion of patients (Zecca et al., Multiple Sclerosis Journal (2017) 24(2), 167–174).

Ponesimod [(R)-5-[3-chloro-4-(2,3-dihydroxy-propoxy)-benz[Z]ylidene]-2-([Z]-propylimino)-3-otolyl-thiazolidin-4-one, Reg. No. CaS 854107-55-4, e.g. WO2005/054215, WO2008/062376, WO2010/046835, WO2014/027330] is a selective S1P1 receptor agonist and its oral administration results in a consistent, sustained and dose-dependent reduction in peripheral blood lymphocyte counts. Ponesimod has been described as useful for the treatment and/or prevention of diseases or disorders associated with an activated immune system (see, for example, WO 2005/054215 and WO 2009/115954). In particular, ponesimod has demonstrated clinical benefit in phase II/phase III studies in patients with moderate to severe chronic plaque psoriasis and in patients with relapsing-remitting multiple sclerosis. Ponesimod can be prepared according to the procedures disclosed in WO 2005/054215, WO 2008/062376 and WO 2014/027330.

Cenerimod [(S)-3-[[4-[5-(2-cyclopentyl-6-methoxypyridin-4-yl)[1,2,4]oxadiazol-3-yl]-2-ethyl-6-methylphenyl]oxy]propane-1,2-diol, CAS Reg No. 1262414-04-9, e.g. WO2011/007324, WO2013/175397, WO2016/184939, Piali et al., Pharmacol Res Perspect. 2017; e00370] is a selective S1P1 receptor agonist and is being studied in a multiple-dose efficacy and safety study for the treatment of systemic lupus erythematosus. No dose escalation appears to be required for cenerimod.

Siponimod (1-(4-[1-[(E)-4-cyclohexyl-3-trifluoromethyl-benzyloxyimino]-ethyl]-2-ethyl-benzyl)azetidine-3-carboxylic acid, CAS Reg No. 1230487-00-9, e.g. WO2004/103306, WO2010/071794, WO2010/080409, WO2010/080455, WO2019/064184) is an S1P1 receptor modulator and has been studied for the treatment of secondary progressive multiple sclerosis (SPMS), which is a progressive neurological deterioration of multiple sclerosis that occurs independent of acute relapses. In active SPMS, siponimod reduces the risk of disability and relapses of MS. In the US, siponimod is indicated for the treatment of relapsing forms of multiple sclerosis (MS), including clinically isolated syndrome (defined as a first episode of neurological symptoms that lasts at least 24 hours and is caused by inflammation or demyelination in the central nervous system), relapsing-remitting disease, and active secondary progressive disease.

- 5 048938 (SPMS), in adults with the recommended maintenance dose of 2 mg orally once daily.

After discontinuation of siponimod therapy, siponimod remains in the blood for up to 10 days. Initiation of other therapies during this interval will result in concomitant exposure to siponimod. Lymphocyte counts returned to normal in 90% of patients within 10 days of discontinuation of therapy. However, residual pharmacodynamic effects, such as a decrease in peripheral lymphocytes, may persist for up to 3-4 weeks after the last dose. Use of immunosuppressants during this period may result in additive effects on the immune system, so caution should be exercised 3-4 weeks after the last dose of siponimod.

Ozanimod (5-[3-[(18)-2,3-dihydro-1-[(2-hydroxyethyl)amino]-1H-inden-4-yl]-1,2,4-oxadiazol-5-yl]-2-(1-methylethoxy)benzonitrile, CAS Reg. No. 1306760-87-1, e.g. WO2011/060392, WO2015/066515, WO2018/184185, WO2018/208855, WO2018/215807, WO2019/058290, WO2019/094409) is an investigational S1P1 receptor modulator that has been tested in phase III clinical trials for the treatment of relapsing forms of multiple sclerosis (RMS) (NCT02047734 and is additionally being tested in Crohn's disease and ulcerative colitis (UC). Since 2020, ozanimod has been indicated in the US for the treatment of relapsing forms of multiple sclerosis (MS), including clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease in adults; and in Europe for the treatment of adult patients with relapsing-remitting multiple sclerosis (RRMS) with active disease as defined by clinical or imaging features.

Etrasimod [(3R)-7-[[4-cyclopentyl-3-(trifluoromethyl)phenyl]methoxy]-1,2,3,4-tetrahydrocyclopent[b]indole-3-acetic acid, CAS No. 1206123-37-6, e.g. WO2010/011316, WO2011/094008, WO2016/112075, WO2016/209809, Al-Shamma et al., J Pharmacol Exp Ther (2019) 369:311–317] is an investigational S1P1 receptor modulator currently in development, e.g., for the treatment of inflammatory bowel diseases, including Crohn's disease and ulcerative colitis (UC).

Other S1P1 receptor modulators have been described and clinically tested, but their development may have been discontinued:

Amiselimod (MT-1303, 2-amino-2-[2-[4-(heptyloxy)-3-(trifluoromethyl)phenyl]ethyl]-1,3-propanediol, CAS Reg. No. 942399-20-4, e.g. WO2007/069712, WO2018/021517; Harada et al., Br J Clin Pharmacol (2017) 83 1011–1027; Sugahara et al., Br J Pharmacol (2017) 174 15–27);

Ceralifimod (1-[[3,4-dihydro-6-[(2-methoxy-4-propylphenyl)methoxy]-1-methyl-2-naphthalenyl]methyl]-3-azetidinecarboxylic acid, CAS Reg. No. 891859-12-4, e.g. WO2006/064757, Kurata et al. JMedChem 60(23) (2017), 9508-9530);

GSK 2018682 (4-[5-[5-chloro-6-(1-methylethoxy)-3-pyridinyl]-1,2,4-oxadiazol-3-yl]-1H-indole-1butanoic acid, e.g. WO2008/074821);

CS-0777 (1-[5-[(3R)-3-amino-4-hydroxy-3-methylbutyl]-1-methyl-1H-pyrrol-2-yl]-4-(4methylphenyl)-1-butanone, CAS Reg No. 827344-05-8, e.g., WO2005/079788, Nishi et al., Med Chem Lett. 2011 2;2(5):368-72); and

Mocravimod (2-amino-2-[2-(2-chloro-4-{[3-(phenylmethoxy)phenyl]sulfanyl}phenyl)ethyl]propane-1,3-diol; KEP203, CAS Reg No. 509092-16-4, e.g. US 9,920,005, US 6,960,692), is disclosed for participation in studies of high-risk acute myeloid leukemia.

It has now been found that COMPOUND, a CXCR7 antagonist with potential for the prophylaxis/prevention and treatment of diseases and disorders that respond to activation of CXCL12 receptors and/or CXCL11 receptors, may have an additive and even synergistic effect when combined with S1P1 receptor modulators in the treatment of such diseases and disorders that have an inflammatory autoimmune response component and/or a neurodegenerative response component. Thus, such a combination may be particularly useful for the prophylaxis/prevention and/or treatment of autoimmune and inflammatory diseases and disorders, transplant rejection and neurodegenerative diseases and disorders (especially autoimmune diseases and disorders that have an inflammatory component, in particular autoimmune and/or inflammatory demyelinating diseases and disorders, including multiple sclerosis). Furthermore, the potential remyelinating pharmacological effect of COMPOUND may be complementary to S1P1 receptor modulators, which are clinically established treatment options for such inflammatory demyelinating diseases. Furthermore, the combination of COMPOUND with an S1P1 receptor modulator may allow for a reduction in the dose of the respective S1P1 receptor modulator, perhaps even to doses that are lower than the established optimally effective doses of such S1P1 receptor modulator when administered alone, thus potentially reducing certain safety risks [e.g., cardiovascular effects (bradycardia) and/or prolonged residual effects after treatment discontinuation in a situation where S1P1 receptor modulator exposure is contraindicated, and/or (potentially severe) lymphopenia] known to be associated with some S1P1 receptor modulators.

- 6 048938

Description of figures

Fig. 1 shows the dose-dependent effect of COMPOUND on the overall severity of EAE disease, assessed by the disease composite scores.

Fig. 2 shows the dose-dependent effect of COMPOUND on plasma CXCL12 concentration in a mouse model of MOG-induced EAE.

Figure 3 shows the effect of fingolimod (0.03 mg/kg, daily) on the overall extent of EAE disease, assessed by cumulative disease scores.

Fig. 4 shows the therapeutic efficacy of COMPOUND, fingolimod and their combination in terms of mean clinical score in a mouse EAE model.

Fig. 5 shows the therapeutic effect of COMPOUND, fingolimod and their combination on the disease severity of EAE in mice, expressed as the maximum clinical score.

Fig. 6 shows the therapeutic effect of COMPOUND, fingolimod and their combination on plasma neurofilament light chain concentrations in a mouse model of EAE.

Fig. 7 shows the effect of COMPOUND, fingolimod and their combination on blood lymphocyte counts in a mouse model of EAE.

Fig. 8 shows the effect of COMPOUND, fingolimod and their combination on plasma CXCL12 concentrations in a mouse model of EAE.

Fig. 9 shows the direct effect of COMPOUND on myelination determined in a cuprizone-induced demyelination model in mice.

Fig. 10 shows the effect of COMPOUND on the number of mature oligodendrocytes in a cuprizone-induced demyelination model in mice.

Fig. 11 shows the therapeutic effect of COMPOUND or fingolimod, starting one week before cuprizone withdrawal, on demyelination/remyelination in a cuprizone-induced demyelination model in mice.

Fig. 12 shows the dose-dependent effect of COMPOUND on the overall severity of EAE disease, assessed by cumulative disease scores.

Fig. 13 shows the dose-dependent effect of COMPOUND on plasma CXCL12 concentrations in a mouse model of PLB-induced EAE.

Figure 14 shows the dose-response relationship between peak plasma CXCL12 concentrations after a single dose in healthy subjects.

Figure 15 shows the predicted steady-state response stratified by dose.

Detailed description of the invention

1) The first embodiment relates to a pharmaceutical composition containing, as an active ingredient, a COMPOUND or a pharmaceutically acceptable salt thereof, in combination with an S1P1 receptor modulator or a pharmaceutically acceptable salt thereof, as well as at least one pharmaceutically acceptable (inert) excipient.

The pharmaceutical composition according to embodiment 1) can be used as a medicine, for example, in the form of pharmaceutical compositions for enteral (eg oral) or parenteral administration (including topical application or inhalation).

2) Another embodiment relates to a pharmaceutical composition according to embodiment 1), wherein the S1P1 receptor modulator is fingolimod, ponesimod, siponimod, ozanimod, cenerimod, etrasimod, amiselimod, ceralifimod, GSK 2018682, or CS-0777; or, in addition, mocravimod (especially fingolimod, ponesimod, siponimod, or ozanimod; or, in addition, cenerimod); or a pharmaceutically acceptable salt thereof.

3) Another embodiment relates to a pharmaceutical composition according to embodiment 1), wherein the S1P1 receptor modulator or a pharmaceutically acceptable salt thereof is fingolimod, ponesimod, siponimod, ozanimod, cenerimod, or etrasimod (especially fingolimod, ponesimod, siponimod, or ozanimod) or a pharmaceutically acceptable salt thereof.

4) Another embodiment relates to a pharmaceutical composition according to embodiment 1), wherein the S1P1 receptor modulator or a pharmaceutically acceptable salt thereof is cenerimod, etrasimod or amiselimod (especially cenerimod or etrasimod), or a pharmaceutically acceptable salt thereof.

5) Another embodiment relates to a pharmaceutical composition according to embodiment 1), wherein the S1P1 receptor modulator or a pharmaceutically acceptable salt thereof is fingolimod or a pharmaceutically acceptable salt thereof.

6) Another embodiment relates to a pharmaceutical composition according to embodiment 1), wherein the S1P1 receptor modulator or a pharmaceutically acceptable salt thereof is ponesimod or a pharmaceutically acceptable salt thereof.

7) Another embodiment relates to a pharmaceutical composition according to va

- 7 048938 embodiment 1), wherein the S1P1 receptor modulator or its pharmaceutically acceptable salt is siponimod or its pharmaceutically acceptable salt.

8) Another embodiment relates to a pharmaceutical composition according to embodiment 1), wherein the S1P1 receptor modulator or a pharmaceutically acceptable salt thereof is ozanimod or a pharmaceutically acceptable salt thereof.

9) Another embodiment relates to a pharmaceutical composition according to embodiment 1), wherein the S1P1 receptor modulator or a pharmaceutically acceptable salt thereof is cenerimod or a pharmaceutically acceptable salt thereof.

10) Another embodiment relates to a pharmaceutical composition according to embodiment 1), wherein the S1P1 receptor modulator or a pharmaceutically acceptable salt thereof is etrasimod or a pharmaceutically acceptable salt thereof.

11) Another embodiment relates to a pharmaceutical composition according to embodiment 1), wherein the S1P1 receptor modulator or a pharmaceutically acceptable salt thereof is amiselimod or a pharmaceutically acceptable salt thereof.

12) Another embodiment relates to a pharmaceutical composition according to any one of embodiments 1) to 11), wherein said S1P1 receptor modulator or a pharmaceutically acceptable salt thereof is contained in a pharmaceutical dosage form suitable for oral administration of said S1P1 receptor modulator, wherein fingolimod or a pharmaceutically acceptable salt thereof, if any, is contained in said pharmaceutical dosage form in a unit dose suitable for oral administration of a total of about 0.5 mg or less per day of fingolimod;

siponimod, or a pharmaceutically acceptable salt thereof, if any, is contained in the said pharmaceutical dosage form in a unit dose suitable for oral administration of a total of about 2 mg or less per day of siponimod;

ponesimod, or a pharmaceutically acceptable salt thereof, if any, is contained in said pharmaceutical dosage form in a unit dose suitable for oral administration of a total of about 20 mg or less per day of ponesimod; and osanimod, or a pharmaceutically acceptable salt thereof, if any, is contained in said pharmaceutical dosage form in a unit dose suitable for oral administration of a total of about 1 mg or less per day of ozanimod;

cenerimod, or a pharmaceutically acceptable salt thereof, if any, is contained in the said pharmaceutical dosage form in a unit dose suitable for oral administration of a total of about 4 mg or less per day of cenerimod;

etrasimod, or a pharmaceutically acceptable salt thereof, if any, is contained in said pharmaceutical dosage form in a unit dose suitable for oral administration of a total of about 2 mg or less per day of etrasimod; and amiselimod, or a pharmaceutically acceptable salt thereof, if any, is contained in said pharmaceutical dosage form in a unit dose suitable for oral administration of a total of about 0.4 mg or less per day of amiselimod.

The above dosage forms are specifically intended for once daily (qd) dosing of the indicated unit dose.

13) Another embodiment relates to a pharmaceutical composition according to any one of embodiments 1) to 11), wherein said S1P1 receptor modulator or a pharmaceutically acceptable salt thereof is contained in a pharmaceutical dosage form suitable for oral administration of said S1P1 receptor modulator, wherein fingolimod or a pharmaceutically acceptable salt thereof, if any, is contained in said pharmaceutical dosage form in a unit dose suitable for oral administration of a total of about 0.5 mg or less per day of fingolimod;

siponimod or a pharmaceutically acceptable salt thereof, if any, is contained in the said pharmaceutical dosage form in a unit dose suitable for oral administration of a total of about 2 mg or less per day of siponimod;

ponesimod or a pharmaceutically acceptable salt thereof, if any, is contained in said pharmaceutical dosage form in a unit dose suitable for oral administration of a total of about 10 mg or less per day of ponesimod; and ozanimod or a pharmaceutically acceptable salt thereof, if any, is contained in said pharmaceutical dosage form in a unit dose suitable for oral administration of a total of about 0.5 mg or less per day of ozanimod;

cenerimod or a pharmaceutically acceptable salt thereof, if any, is contained in the said pharmaceutical dosage form in a unit dose suitable for oral administration of a total of about 2 mg or less per day of cenerimod;

etrasimod or its pharmaceutically acceptable salt, if any, is contained in the specified pharmaceutical dosage form in a unit dose suitable for oral administration in bulk

- 8 048938 total of about 1 mg or less per day of etrasimod; and amiselimod or a pharmaceutically acceptable salt thereof, if any, is contained in said pharmaceutical dosage form in a unit dose suitable for oral administration of a total of about 0.2 mg or less per day of amiselimod.

The above mentioned dosage forms are particularly intended for once daily (qd) dosing of the indicated unit dose.

14) Another embodiment relates to a pharmaceutical composition according to any one of embodiments 1) to 13), wherein said S1P1 receptor modulator or a pharmaceutically acceptable salt thereof is contained in a dose of said S1P1 receptor modulator that is at or below the tolerable effective dose of said S1P1 receptor modulator when administered as monotherapy (e.g., as indicated in an approval letter for such S1P1 receptor modulator for a particular disease or disorder when administered as monotherapy).

15) Another embodiment relates to a pharmaceutical composition according to any one of embodiments 1) to 13), wherein said S1P1 receptor modulator or a pharmaceutically acceptable salt thereof is contained in a dose of said S1P1 receptor modulator that is below the accepted effective dose of said S1P1 receptor modulator when administered as monotherapy (e.g., as indicated in an approval letter for such S1P1 receptor modulator for a particular disease or disorder when administered as monotherapy).

Such combination pharmaceutical compositions according to embodiments 1) to 15) are particularly useful for the prophylaxis/prevention or treatment of diseases and disorders in which both the expression of CXCR7 or its ligands and S1P play a role, and in a method for the prophylaxis/prevention or treatment of diseases and disorders in which both the expression of CXCR7 or its ligands and S1P play a role, comprising administering a pharmaceutically effective dose of such combination pharmaceutical composition to a subject in need thereof.

Diseases and disorders in which both CXCR7 expression or its ligands and S1P play a role are particularly those in which both CXCR7 expression or its ligands and S1P play a role (i) in the inflammatory immune response (such as cell migration, adhesion, survival, differentiation, polarization), as occurs in a wide range of autoimmune and inflammatory diseases and/or (ii) in neurodegenerative processes (such as glial cell activation, proliferation, migration, neuronal survival, myelination).

In particular, diseases and disorders in which the expression of CXCR7 or its ligands plays a role are, in particular, diseases and disorders that respond to the activation of CXCL12 receptors and/or CXCL11 receptors; as well as diseases and disorders that respond to opioid receptor signaling.

Such diseases and disorders in which CXCR7 expression or its ligands are important are specifically defined as including:

cancer such as brain tumors including malignant gliomas, glioblastoma multiforme; neuroblastoma; pancreatic cancer including pancreatic adenocarcinoma/pancreatic ductal adenocarcinoma; gastrointestinal cancer including colon carcinoma, hepatocellular carcinoma, and gastric cancer; Kaposi's sarcoma; leukemias including adult T-cell leukemia; lymphoma; lung cancer; breast cancer; rhabdomyosarcoma; prostate cancer; squamous cell carcinoma of the esophagus; squamous cell carcinoma of the oral cavity; endometrial cancer; thyroid carcinoma including papillary thyroid carcinoma; metastatic cancer; metastasis to the lung; skin cancer including melanoma and metastatic melanoma; bladder cancer; multiple myelomas; osteosarcoma; head and neck cancer; and renal carcinomas, including renal clear cell carcinoma and metastatic renal clear cell carcinoma;

autoimmune and/or inflammatory diseases and disorders, including in particular:

autoimmune and/or inflammatory demyelinating diseases and disorders, including in particular:

multiple sclerosis (MS); idiopathic (inflammatory) demyelinating diseases; and autoimmune encephalomyelitis (including acute disseminated encephalomyelitis (ADEM) and multiphasic disseminated encephalomyelitis (MDEM));

Guillain-Barré syndrome; and chronic inflammatory demyelinating polyneuropathy (CIDP); as well as other autoimmune and/or inflammatory demyelinating diseases and disorders (which may be associated with the above autoimmune and/or inflammatory demyelinating diseases and disorders), including in particular:

neuromyelitis optica spectrum disorders (including neuromyelitis optica (Devic's disease) and (acute) optic neuritis);

myelitis (especially including transverse myelitis spectrum disorders such as especially (acute) transverse myelitis, but also acute flaccid myelitis, poliomyelitis, leukomyelitis and meningococcal

- 9 048938 myelitis);

brainstem encephalitis; and antimyelin oligodendrocyte glycoprotein (anti-MOG)-associated diseases (including anti-MOG encephalomyelitis);

rheumatoid arthritis (RA);

inflammatory bowel disease (IBD, especially including Crohn's disease and ulcerative colitis);

systemic lupus erythematosus (SLE) (including neuropsychiatric systemic lupus erythematosus and lupus nephritis);

interstitial cystitis; celiac disease; osteoarthritis; type 1 diabetes; psoriasis; autoimmune thyroiditis; Sjogren's syndrome; and vitiligo;

chronic rhinosinusitis, asthma, chronic obstructive pulmonary disease, atherosclerosis, myocarditis, acute lung injury, endometriosis, diabetic retinopathy and sarcoidosis;

Psoriatic arthritis; Antiphospholipid syndrome; Thyroiditis such as Hashimoto's thyroiditis; Lymphocytic thyroiditis; Myasthenia gravis; Episcleritis; Scleritis; Kawasaki disease; Uveo-retinitis; Uveitis including posterior uveitis and uveitis associated with Behcet's disease; Uveomeningitis syndrome; Allergic encephalomyelitis; Atopic diseases such as rhinitis, conjunctivitis, dermatitis; and Postinfectious autoimmune diseases including rheumatic fever and postinfectious glomerulonephritis;

Rasmussen's encephalitis and Susak's syndrome (retino-cochleocerebral vasculopathy);

ankylosing spondylitis, juvenile idiopathic arthritis, systemic sclerosis (systemic scleroderma), giant cell arteritis (GCA or temporal arteritis), primary biliary cholangitis (PBC or primary biliary cirrhosis); and cytokine release syndrome after severe viral infection or acute respiratory distress syndrome, including COVID-19;

transplant rejection, including but not limited to renal allograft rejection, cardiac allograft rejection, and graft-versus-host disease following hematopoietic stem cell transplantation;

fibrosis, including especially liver fibrosis, liver cirrhosis, pulmonary fibrosis, cardiac fibrosis; especially idiopathic pulmonary fibrosis;

ischemic injury, including renal ischemia or cerebral ischemia;

focal alopecia, eosinophilic esophagitis, dermatomyositis/polymyositis, atopic dermatitis and pyoderma gangrenosum;

neurodegenerative disorders, including, but not limited to, amyotrophic lateral sclerosis (ALS) and Huntington's disease; as well as Alzheimer's disease (AD), Parkinson's disease (PD) and adrenoleukodystrophy; and diseases and disorders associated with opioid receptor signaling, including, but not limited to, neuropathic pain; as well as addiction disorders, mood disorders and anxiety disorders.

It is clear that diseases and disorders in which CXCR7 expression or its ligands play a role particularly include autoimmune and/or inflammatory demyelinating diseases and disorders, including all forms of autoimmune neuritis.

Furthermore, it is clear that neuropathic pain may be associated with any other disease or disorder in which the expression of CXCR7 or its ligands is important.

In another aspect of the invention it has been found that the COMPOUND or a pharmaceutically acceptable salt thereof when administered as a single active ingredient can be used for the prophylaxis/prevention and treatment of the said diseases and disorders in which the expression of CXCR7 or its ligands as defined herein above is important, wherein the COMPOUND is preferably used/administered/to be administered in a particular pharmacologically effective dosage regimen. The COMPOUND can be used alone (i.e. as a single active ingredient), especially in such preferred particular dosage, for the prophylaxis/prevention and treatment of the said diseases and disorders; or the COMPOUND can be used, especially in such preferred particular dosage regimen, in combination with an S1P1 receptor modulator [e.g. in a fixed dose combination according to any of embodiments 1) to 15); or in an equivalent non-fixed dose combination], wherein when used in combination, the said diseases and disorders in which the expression of CXCR7 or its ligands is important are such that both the expression of CXCR7 or its ligands and S1P are important (such diseases and disorders as defined in the present invention).

Such a specific dosage regimen may comprise administering the COMPOUND, or a pharmaceutically acceptable salt thereof, at a total dose of from about 20 to about 300 mg per day, wherein said

- 10 048938 the total dose is prescribed/administered, in particular, as a single unit dose (once daily = quaque die = qd), or as two separate unit doses (twice daily = bis in die = bid). For example, the said total dose can be achieved by dosing from about 20 mg qd to about 300 mg qd, or from about 10 mg bid to about 150 mg bid.

Notably, such a dosing regimen may comprise administering the COMPOUND in a total dose of about 20 mg to 300 mg per day, about 20 mg to 200 mg per day, about 30 mg to 150 mg per day, about 40 mg to 150 mg per day, about 50 mg to 200 mg, about 50 mg to 100 mg, about 100 mg to 200 mg, or in particular about 75 mg to 150 mg per day; wherein said total dose is administered, in particular, as a single unit dose (qd), or two separate unit doses (bid). Examples of such a dosing regimen include administering a total dose of about 200 mg, about 150 mg, about 100 mg, about 75 mg, about 50 mg, about 30 mg, or about 25 mg per day as a single unit dose (qd) of the COMPOUND, or as two separate unit doses (bid) of the COMPOUND, where specific examples of such twice daily dosing would include, for example, administering about 100 mg bid, about 75 mg bid, about 50 mg bid, about 25 mg bid, or about 15 mg bid of the COMPOUND.

For the avoidance of doubt, for the present invention, any amount/unit dose in mg of COMPOUND refers to an amount/unit dose suitable for administration of the COMPOUND in the form of a free base having a molecular weight of 522.56 g/mol in such amount/unit dose. Such amount/unit dose may need to be adjusted in a pharmaceutical composition in case the COMPOUND is present in such composition in a form other than the anhydrous free base, for example, in the form of a pharmaceutically acceptable salt; and/or a solvate such as a hydrate. In case the active ingredient is administered, for example, in the form of a pharmaceutically acceptable salt, it is understood that the corresponding amount of the active pharmaceutical ingredient (e.g., said pharmaceutically acceptable salt) in the pharmaceutical composition will be adapted accordingly.

A given dosage form/dosage regimen is generally considered equivalent (bioequivalent according to FDA guidelines) if it achieves a maximum concentration (Cmax ₎ of the active ingredient between 80% and 125%, and the exposure of the active ingredient expressed as the area under the curve (AUC) between 80% and 125% of the corresponding values in plasma achieved with a given dosage form and dosage regimen.

i) Thus, one particular aspect of the present invention relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use in the prevention/prophylaxis or treatment of diseases and disorders in which the expression of CXCR7 or its ligands (as defined in the present invention) is important, wherein the COMPOUND is administered at a total dose of from about 20 mg to about 300 mg (especially from about 20 mg to about 200 mg; in particular from about 50 mg to about 150 mg) per day of the COMPOUND. In a sub-embodiment, said dose is given/administered in particular as a single unit dose per day [qd; for example, from about 20 mg qd to about 300 mg qd (in particular from about 20 mg qd to about 200 mg qd; in particular from about 50 mg qd to about 150 mg qd)], or as two separate unit doses per day [bid; for example, from about 10 mg bid to about 150 mg bid (especially from about 10 mg bid to about 100 mg bid; in particular from about 25 mg bid to about 75 mg bid)].

i) (a) In a sub-embodiment, such diseases and disorders in which expression of CXCR7 or its ligands is important include, in particular:

an autoimmune and/or inflammatory disease and disorder as defined in the present invention; wherein said disease or disorder is in particular:

autoimmune and/or inflammatory demyelinating disease or disorder including, in particular, multiple sclerosis (MS), idiopathic inflammatory demyelinating diseases, neuromyelitis optica spectrum disorders (including neuromyelitis optica and (acute) optic neuritis), autoimmune encephalomyelitis (including acute disseminated encephalomyelitis (ADEM) and multiphasic disseminated encephalomyelitis (MDEM)), myelitis (especially including transverse myelitis spectrum disorders such as especially (acute) transverse myelitis, as well as acute flaccid myelitis, poliomyelitis, leukomyelitis and meningococcal myelitis), brainstem encephalitis, anti-myelin oligodendrocyte glycoprotein (anti-MOG)-related disorders (including encephalomyelitis anti-MOG); Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy (CIDP) and peripheral neuropathy associated with anti-myelin-associated glycoprotein (anti-MAG);

rheumatoid arthritis (RA);

inflammatory bowel disease (IBD); in particular Crohn's disease or ulcerative colitis;

systemic lupus erythematosus (SLE), including neuropsychiatric systemic lupus erythematosus and lupus nephritis;

interstitial cystitis;

celiac disease;

- 11 048938 osteoarthritis;

psoriasis;

diabetes type I;

ankylosing spondylitis; or cytokine release syndrome following severe viral infection or acute respiratory distress syndrome, including COVID-19;

transplant rejection, including but not limited to renal allograft rejection, cardiac allograft rejection, and graft-versus-host disease following hematopoietic stem cell transplantation; or a neurodegenerative disorder, especially including amyotrophic lateral sclerosis (ALS) and Huntington's disease; and Alzheimer's disease (AD), Parkinson's disease (PD), and adrenoleukodystrophy.

i) (b) In another sub-embodiment, such diseases and disorders in which expression of CXCR7 or its ligands is important particularly include fibrosis, including particularly liver fibrosis, liver cirrhosis, pulmonary fibrosis, cardiac fibrosis; particularly idiopathic pulmonary fibrosis.

i) (c) In another sub-embodiment, such diseases and disorders in which expression of CXCR7 or its ligands is important particularly include ischemic injury, including renal ischemia or cerebral ischemia.

i) (d) In another sub-embodiment, such diseases and disorders in which expression of CXCR7 or its ligands is important include, in particular, diseases or disorders associated with opioid receptor signaling, in particular including neuropathic pain; as well as addiction disorders, mood disorders and anxiety disorders.

i) (d) In another sub-embodiment, such diseases and disorders in which the expression of CXCR7 or its ligands is important include in particular cancer, such as brain tumors, including malignant gliomas, glioblastoma multiforme; neuroblastoma; pancreatic cancer, including pancreatic adenocarcinoma/pancreatic ductal adenocarcinoma; gastrointestinal cancer, including colon carcinoma, hepatocellular carcinoma and gastric cancer; Kaposi's sarcoma; leukemias, including adult T-cell leukemia; lymphoma; lung cancer; breast cancer; rhabdomyosarcoma; prostate cancer; squamous cell carcinoma of the esophagus; squamous cell carcinoma of the oral cavity; endometrial cancer; thyroid carcinoma, including papillary thyroid carcinoma; metastatic cancer; metastasis to the lung; skin cancer, including melanoma and metastatic melanoma; bladder cancer; multiple myelomas; osteosarcoma; head and neck cancer; and renal cell carcinoma, including renal clear cell carcinoma, metastatic renal clear cell carcinoma.

ii) A second particular aspect of the present invention relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to embodiment i) (or any of its sub-embodiments), wherein the COMPOUND is administered/to be administered at a total dose of from about 20 to 200 mg per day of COMPOUND; especially from 30 mg to 150 mg per day, about 40 mg to 150 mg per day, about 50 mg to 200 mg, about 50 mg to 150 mg, about 50 mg to 100 mg, or about 100 mg to 200 mg per day of COMPOUND; in particular from about 75 mg to 150 mg per day of COMPOUND. In a sub-embodiment, said total dose is prescribed/administered in particular as a single dose per day (qd), or as two divided doses per day (bid).

iii) A third particular aspect of the present invention relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to embodiment i) (or any of its sub-embodiments), wherein the COMPOUND is administered/to be administered at a total dose of about 200 mg, about 150 mg, about 100 mg, about 75 mg, about 50 mg or about 30 mg per day of COMPOUND; in particular about 150 mg, about 100 mg or about 75 mg per day of COMPOUND. In a sub-embodiment, said total dose is prescribed/administered, in particular, as a single dose per day (qd), or as two divided doses per day (bid).

iv) A fourth particular aspect of the present invention relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to embodiment i) (or any of its sub-embodiments), wherein the COMPOUND is (to be) administered at a total dose of about 200 mg, about 150 mg, about 125 mg, about 100 mg, about 75 mg, about 50 mg, about 30 mg or about 25 mg per day of COMPOUND; in particular about 150 mg, about 125 mg, about 100 mg or about 75 mg per day of COMPOUND; wherein said total dose is administered as a single dose per day (qd).

v) A fifth specific aspect of the present invention relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to embodiment i) (or any of its sub-embodiments), wherein the COMPOUND is administered (to be administered) in a total dose of about 200 mg administered/administered at about 100 mg bid, about 150 mg administered/administered at about 75 mg bid, about 120 mg administered/administered at about 60 mg bid, about 100 mg administered/administered at about 50 mg bid,

- 12 048938 approximately 80 mg is prescribed/administered approximately 40 mg bid, approximately 60 mg is prescribed/administered approximately 30 mg bid, approximately 50 mg is prescribed/administered approximately 25 mg bid, or approximately 30 mg is prescribed/administered approximately 15 mg bid per day of the COMPOUND; in particular approximately 150 mg is prescribed/administered approximately 75 mg bid, or approximately 100 mg is prescribed/administered approximately 50 mg bid per day of the COMPOUND.

The COMPOUND can be used as a medicinal product as a single active ingredient (optionally in combination with an S1P1 receptor modulator, i.e. without combination with such an S1P1 receptor modulator, or in combination with such an S1P1 receptor modulator) according to the present invention, for example in the form of pharmaceutical compositions, in particular for enteral or parenteral administration.

vi) Thus, another aspect of the invention relates to a pharmaceutical composition comprising the COMPOUND or a pharmaceutically acceptable salt thereof, wherein the COMPOUND is contained in a single dose suitable for administering the COMPOUND in a total dose per day as defined in any one of embodiments i) to v).

viii) Another aspect of the invention relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to any one of embodiments i) to v), wherein the COMPOUND is used for the prophylaxis/prevention or treatment of diseases and disorders in which both the expression of CXCR7 or its ligands and S1P are important; wherein the characteristics of embodiments 16) to 35) apply mutatis mutandis in the present invention below.

vii) Another aspect of the invention relates to a pharmaceutical composition comprising as an active principle a COMPOUND or a pharmaceutically acceptable salt thereof in combination with an S1P1 receptor modulator or a pharmaceutically acceptable salt thereof according to any one of embodiments 1) to 15), wherein the COMPOUND is contained in a single dose suitable for administering the COMPOUND in a total dose per day as defined in any one of embodiments i) to v); wherein such a composition is in particular intended for dosing/administration once per day (qd).

viii) Another aspect of the invention relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to any one of embodiments i) to v), wherein the COMPOUND is for use in the prophylaxis/prevention or treatment of a disease or disorder in which both the expression of CXCR7 or its ligands and S1P are important; wherein the COMPOUND is for use/administered/(to be) administered in combination with an S1P1 receptor modulator or a pharmaceutically acceptable salt thereof; wherein the characteristics of any one of embodiments 16) to 48) apply mutatis mutandis in the present invention below.

Diseases and disorders in which both the expression of CXCR7 or its ligands and S1P are important are those diseases and disorders in which the expression of CXCR7 or its ligands is important that preferably have an inflammatory immune response component.

Such diseases and disorders in which both the expression of CXCR7 or its ligands and S1P are important may be specifically defined as including autoimmune and/or inflammatory diseases and disorders, transplant rejection and neurodegenerative diseases and disorders; in particular autoimmune diseases and disorders that have an inflammatory component, in particular autoimmune and/or inflammatory demyelinating diseases and disorders.

Such diseases and disorders in which both the expression of CXCR7 or its ligands and S1P play a role may be specifically defined as including autoimmune and/or inflammatory diseases and disorders, transplant rejection and neurodegenerative diseases and disorders; especially autoimmune diseases and disorders that have an inflammatory component, in particular autoimmune and/or inflammatory demyelinating diseases and disorders.

The term transplant rejection can be defined to include rejection of transplanted organs such as kidney, liver, heart, lung, pancreas, cornea and skin; graft-versus-host disease caused by hematopoietic stem cell transplantation; chronic allograft rejection and chronic allograft vasculopathy.

The term neurodegenerative diseases and disorders may be defined to include, in particular, neurodegenerative diseases and disorders in which both the expression of CXCR7 or its ligands and S1P are important in the neurodegeneration (e.g., glial cell activation, neuronal survival, myelination) associated with such disease and disorder. Specific examples include amyotrophic lateral sclerosis (ALS), Alzheimer's disease (AD), Parkinson's disease (PD), Huntington's disease, and adrenoleukodystrophy.

The term autoimmune and/or inflammatory diseases and disorders refers in particular to any autoimmune and/or inflammatory disease or disorder where both the expression of CXCR7 or its ligands and S1P are important, especially autoimmune diseases and disorders that have an inflammatory component. Examples of such autoimmune and/or inflammatory diseases and disorders include autoimmune and/or inflammatory demyelinating diseases and disorders, including all forms of autoimmune neuritis. In particular,

- 13 048938 Autoimmune and/or inflammatory demyelinating diseases and disorders include multiple sclerosis (MS), Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy (CIDP), and other autoimmune and/or inflammatory demyelinating diseases and disorders (which may be associated with the above autoimmune and/or inflammatory demyelinating diseases and disorders), such as neuromyelitis optica spectrum disorders (including neuromyelitis optica (Devic's disease) and (acute) optic neuritis), autoimmune encephalomyelitis (including acute disseminated encephalomyelitis (ADEM) and multiphasic disseminated encephalomyelitis (MDEM)), myelitis (especially including transverse myelitis spectrum disorders such as especially (acute) transverse myelitis, including acute flaccid myelitis, poliomyelitis, leukomyelitis, and meningococcal myelitis), brainstem encephalitis and anti-myelin oligodendrocyte glycoprotein (anti-MOG)-related diseases (including anti-MOG encephalomyelitis); rheumatoid arthritis (RA); inflammatory bowel disease (IBD, especially including Crohn's disease and ulcerative colitis); systemic lupus erythematosus (SLE) (including neuropsychiatric systemic lupus erythematosus and lupus nephritis); interstitial cystitis; celiac disease; osteoarthritis; psoriasis; and type 1 diabetes. In addition, autoimmune and inflammatory diseases and disorders additionally include disorders such as psoriatic arthritis; antiphospholipid syndrome; thyroiditis such as Hashimoto's thyroiditis; lymphocytic thyroiditis; myasthenia gravis; episcleritis; scleritis; Kawasaki disease; uveo-retinitis; uveitis, including posterior uveitis and uveitis associated with Behcet's disease; uveomeningitis syndrome; allergic encephalomyelitis; atopic diseases such as rhinitis, conjunctivitis, dermatitis; and postinfectious autoimmune diseases, including rheumatic fever and postinfectious glomerulonephritis.

In addition, other autoimmune and/or inflammatory diseases or disorders in which both CXCR7 or its ligands and S1P expression are important include autoimmune and/or inflammatory demyelinating diseases and disorders such as Rasmussen encephalitis and Susac syndrome (retino-cochleo-cerebral vasculopathy); and other autoimmune and inflammatory diseases and disorders such as ankylosing spondylitis, juvenile idiopathic arthritis, systemic sclerosis (systemic scleroderma), giant cell arteritis (GCA or temporal arteritis), primary biliary cholangitis (PBC or primary biliary cirrhosis); and cytokine release syndrome after severe viral infection or acute respiratory distress syndrome, including COVID-19.

Specific examples of autoimmune and/or inflammatory diseases and disorders include:

autoimmune and/or inflammatory demyelinating diseases and disorders, especially including multiple sclerosis (MS), Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy (CIDP), and other autoimmune and/or inflammatory demyelinating diseases and disorders; rheumatoid arthritis (RA);

inflammatory bowel disease (IBD), including especially Crohn's disease and ulcerative colitis;

systemic lupus erythematosus (SLE) (including neuropsychiatric systemic lupus erythematosus and lupus nephritis); and in addition to those listed above:

ankylosing spondylitis and cytokine release syndrome following severe viral infection or acute respiratory distress syndrome, including COVID-19.

In a first sub-embodiment, the term autoimmune and/or inflammatory diseases and disorders refers in particular to autoimmune and/or inflammatory demyelinating diseases and disorders, including but not limited to multiple sclerosis (MS), Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy (CIDP), and other autoimmune and/or inflammatory demyelinating diseases and disorders as defined in the present invention, for example, in particular autoimmune encephalomyelitis and myelitis.

In a second embodiment, the term autoimmune and/or inflammatory diseases and disorders refers to inflammatory bowel diseases, including in particular Crohn's disease and ulcerative colitis.

In a third embodiment, the term autoimmune and/or inflammatory diseases and disorders refers to systemic lupus erythematosus (SLE), including neuropsychiatric systemic lupus erythematosus and lupus nephritis.

In the fourth embodiment, the term autoimmune and/or inflammatory diseases and disorders refers to ankylosing spondylitis.

In a fifth sub-embodiment, the term autoimmune and/or inflammatory diseases and disorders refers to cytokine release syndrome following severe viral infection or acute respiratory distress syndrome, including COVID-19.

The term autoimmune and/or inflammatory demyelinating diseases and disorders

- 14 048938 relates to demyelinating diseases and disorders of the central nervous system, such as in particular multiple sclerosis (MS), as well as idiopathic inflammatory demyelinating diseases, neuromyelitis optica spectrum disorders (including neuromyelitis optica (Devic's disease) and (acute) optic neuritis), autoimmune encephalomyelitis (including acute disseminated encephalomyelitis (ADEM) and multiphasic disseminated encephalomyelitis (MDEM)), myelitis (especially including transverse myelitis spectrum disorders, such as especially (acute) transverse myelitis, but also acute flaccid myelitis, poliomyelitis, leukomyelitis and meningococcal myelitis), brainstem encephalitis and anti-myelin oligodendrocyte antigen-associated diseases glycoprotein (anti-MOG) (including anti-MOG encephalomyelitis); as well as autoimmune and/or inflammatory demyelinating diseases and disorders of the peripheral nervous system, including in particular Guillain-Barré syndrome and its chronic analogue chronic inflammatory demyelinating polyneuropathy (CIDP, alternatively called chronic relapsing polyneuropathy (CRP)), and anti-myelin-associated glycoprotein (anti-MAG)-associated peripheral neuropathy.

In a first sub-embodiment, the term autoimmune and/or inflammatory demyelinating diseases and disorders refers in particular to multiple sclerosis (MS), Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy (CIDP) and other autoimmune and/or inflammatory demyelinating diseases and disorders as defined in the present invention, such as in particular autoimmune encephalomyelitis and myelitis.

In a second embodiment, the term autoimmune and/or inflammatory demyelinating diseases and disorders, namely, refers to myelitis, which is a transverse myelitis spectrum disorder, such as in particular (acute) transverse myelitis;

wherein said transverse myelitis spectrum disorder may be: idiopathic (without known cause), or caused by/associated with multiple sclerosis, or caused by/associated with SLE, neuromyelitis optica spectrum disorder, antiphospholipid syndrome, or other autoimmune and inflammatory diseases and disorders as defined in the present invention;

or caused by/associated with infectious diseases such as infection by viruses, bacteria, mold or parasites,

[especially including bacterial infection (eg, mycoplasma pneumoniae, bartonella henselae, borrelia (Lyme disease), campylobacter jejuni, syphilis, tuberculosis (TB)); and viral infection (eg, viral meningoencephalitis (meningitis), or HIV infection, herpes simplex, herpes zoster, cytomegalovirus, Epstein-Barr virus, flaviviruses such as Zika virus and West Nile virus)];

or caused by/associated with vaccination (including vaccination against coronaviruses such as SARS-CoV/SARS-CoV-1).

In a third embodiment, the term autoimmune and/or inflammatory demyelinating diseases and disorders refers in large part to neuromyelitis optica spectrum disorders, such as in particular (acute) optic neuritis, wherein said neuromyelitis optica spectrum disorders may be:

idiopathic (without known cause), or caused by/associated with multiple sclerosis or caused by/associated with SLE, or other autoimmune and/or inflammatory diseases and disorders; or caused by/associated with infectious diseases, including in particular Lyme disease.

Likewise, in a fourth sub-embodiment, the term autoimmune and/or inflammatory demyelinating diseases and disorders refers in particular to any autoimmune and/or inflammatory demyelinating disease or disorder, such as, in particular, MS, which is associated with neuromyelitis optica spectrum disorders, such as, in particular, (acute) optic neuritis.

The term idiopathic inflammatory demyelinating disease refers to an inflammatory demyelinating disease of unknown etiology; in particular to variants or borderline forms of multiple sclerosis that differ, for example, in chronicity, severity and clinical course.

A specific example of autoimmune and/or inflammatory diseases and disorders is the autoimmune demyelinating disease, multiple sclerosis (MS), with it being understood that MS can be further classified as relapsing-remitting MS, primary progressive MS, or secondary progressive MS.

A specific feature of autoimmune and/or inflammatory demyelinating diseases and disorders, such as especially MS, refers to the aspect of demyelination present in such

- 15 048938 disease or disorder. Thus, one aspect of the present invention relates to the treatment of an autoimmune and/or inflammatory demyelinating disease or disorder, such as, in particular, multiple sclerosis, in which the rate of progression of said disease or disorder is reduced, especially the rate of progression of demyelination and/or the rate of occurrence of irreversible neurodegenerative damage, such as axonal damage, is reduced. A further aspect of the present invention relates to the treatment of an autoimmune and/or inflammatory demyelinating disease or disorder, such as, in particular, MS, wherein said treatment has an effect/leads to remyelination.

The term clinically isolated syndrome (CIS) refers to a first episode of neurological symptoms that lasts at least 24 hours and is caused by inflammation or demyelination in the central nervous system (CNS). The episode is usually characteristic of an autoimmune and/or inflammatory demyelinating disease or disorder, particularly MS, but patients diagnosed with CIS may or may not subsequently develop an autoimmune and/or inflammatory demyelinating disease or disorder, particularly MS. When CIS is accompanied by lesions, such as those seen on a brain MRI (magnetic resonance imaging), that are similar to those seen in MS, the person is more likely to have a second episode of neurological symptoms and be diagnosed with relapsing-remitting MS. When CIS is not accompanied by MS-like lesions on a brain MRI, the person is much less likely to develop MS. The diagnostic criteria for MS (see, e.g., 2018 Revised Guidelines: https://www.mscare.org/page/MRI_protocol) allow for the diagnosis of MS in a patient who has had CIS and who also has certain brain MRI findings that suggest an earlier episode of injury elsewhere and that indicate active inflammation in an area other than the one causing the current symptoms. Individuals with CIS may be considered at high risk for developing MS. In the United States, such patients may be treated with disease-modifying therapies that have been approved by the US Food and Drug Administration (FDA) for this purpose. Early treatment of CIS has been shown to delay the onset of the autoimmune and/or inflammatory demyelinating disease or disorder, particularly MS.

Thus, the term prevention/prophylaxis of an autoimmune and/or inflammatory demyelinating disease or disorder specifically includes delaying the onset of such an autoimmune and/or inflammatory demyelinating disease or disorder [e.g., by preventing demyelination and/or remyelination of initial demyelination (e.g., in a clinically isolated syndrome)].

Thus, another aspect of the present invention relates to pharmaceutical compositions according to embodiments 1) to 15) for the prevention/prophylaxis of an autoimmune and/or inflammatory demyelinating disease or disorder, in particular MS, wherein said prevention/prophylaxis of an autoimmune and/or inflammatory demyelinating disease or disorder, in particular MS, comprises delaying the onset of said autoimmune and/or inflammatory demyelinating disease or disorder, in particular MS, in a patient who has suffered/has been diagnosed with suffered CIS.

In a particular embodiment of the present invention, said combined pharmaceutical compositions according to embodiments 1) to 15) prevent or treat demyelination; wherein, in particular, the subject to be treated has been diagnosed with an autoimmune and/or inflammatory demyelinating disease and disorder as defined in the present invention.

In another specific embodiment of the present invention, said combined pharmaceutical compositions according to embodiments 1) to 15) prevent or treat demyelination in a patient, wherein said prevention or treatment of demyelination further comprises a remyelinating effect; wherein, in particular, the subject to be treated has been diagnosed with an autoimmune and/or inflammatory demyelinating disease and disorder as defined in the present invention.

16) The second aspect of the invention relates to a COMPOUND or a pharmaceutically acceptable salt thereof, for use in the prophylaxis/prevention or treatment of a disease and disorder where both the expression of CXCR7 or its ligands and S1P are important, in particular in the prophylaxis/prevention or treatment of autoimmune and inflammatory diseases and disorders, transplant rejection and neurodegenerative diseases and disorders (namely, autoimmune and/or inflammatory diseases and disorders; in particular, autoimmune diseases and disorders that have an inflammatory component, in particular, autoimmune and/or inflammatory demyelinating diseases and disorders); wherein the COMPOUND is (intended) to be administered in combination with a S1P1 receptor modulator or a pharmaceutically acceptable salt thereof.

17) Another embodiment relates to a COMPOUND or its pharmaceutical administration

- 16 048938 lemoy salt for use according to embodiment 16); wherein such use is intended for the treatment of:

autoimmune and/or inflammatory disease or disorder; wherein said disease or disorder is in particular:

Autoimmune and/or inflammatory demyelinating disease or disorder including but not limited to multiple sclerosis (MS); Idiopathic inflammatory demyelinating diseases; Neuromyelitis optica spectrum disorders including Neuromyelitis optica spectrum disorder and (acute) optic neuritis; Autoimmune encephalomyelitis including Acute Disseminated Encephalomyelitis (ADEM) and Multiphasic Disseminated Encephalomyelitis (MDEM); Myelitis, especially including Transverse Myelitis Spectrum Disorders such as especially (acute) Transverse Myelitis but also Acute Flaccid Myelitis, Poliomyelitis, Leukomyelitis and Meningococcal Myelitis; Brainstem Encephalitis; Anti-Myelin Oligodendrocyte Glycoprotein (Anti-MOG) Associated Diseases including Anti-MOG Encephalomyelitis; Guillain-Barré syndrome; chronic inflammatory demyelinating polyneuropathy (CIDP); and anti-myelin-associated glycoprotein (anti-MAG)-associated peripheral neuropathy;

rheumatoid arthritis (RA);

inflammatory bowel disease (IBD); in particular Crohn's disease or ulcerative colitis;

systemic lupus erythematosus (SLE), including neuropsychiatric systemic lupus erythematosus and lupus nephritis;

interstitial cystitis;

celiac disease;

osteoarthritis;

psoriasis;

type 1 diabetes; or in addition to the above, ankylosing spondylitis; or cytokine release syndrome following severe viral infection or acute respiratory distress syndrome, including COVID-19;

transplant rejection; wherein said transplant rejection is in particular rejection of a transplanted organ such as a kidney, liver, heart, lung, pancreas, cornea or skin; graft-versus-host disease caused by hematopoietic stem cell transplantation; chronic allograft rejection and chronic allograft vasculopathy; or a neurodegenerative disease and disorder; wherein said neurodegenerative disease and disorder is in particular amyotrophic lateral sclerosis (ALS), or Huntington's disease; or further, Alzheimer's disease (AD), Parkinson's disease (PD) or adrenoleukodystrophy.

18) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to embodiment 16), wherein said disease and disorder in which both expression of CXCR7 or its ligands and S1P are important is an autoimmune and/or inflammatory disease or disorder selected from:

an autoimmune and/or inflammatory demyelinating disease or disorder, in particular selected from the following: multiple sclerosis (MS); idiopathic inflammatory demyelinating diseases; autoimmune encephalomyelitis including acute disseminated encephalomyelitis (ADEM) and multiphasic disseminated encephalomyelitis (MDEM); Guillain-Barré syndrome; chronic inflammatory demyelinating polyneuropathy (CIDP); anti-myelin-associated glycoprotein (anti-MAG) peripheral neuropathy; and myelin oligodendrocyte glycoprotein (MOG) antibody disease; and myelitis, especially including transverse myelitis spectrum disorders such as acute transverse myelitis, acute flaccid myelitis, poliomyelitis, leukomyelitis and meningococcal myelitis;

inflammatory bowel disease, especially selected from Crohn's disease and ulcerative colitis; or systemic lupus erythematosus (SLE), including neuropsychiatric systemic lupus erythematosus and lupus nephritis.

The term prophylaxis/prevention or treatment in the context of the diseases and disorders defined in the present invention, especially according to embodiments 16), 17) and 18), particularly refers to the treatment of said diseases and disorders; whereby for chronic progressive diseases and disorders (including primary- or secondary-progressive and relapsing-remitting) the term treatment particularly refers to a decrease in the rate of progression of said diseases or disorders. Such a decrease in the rate of progression can be expressed, for example, by a decrease in the rate of disability progression; a decrease in the incidence of irreversible neurodegenerative damage, such as axonal damage; a decreased rate of

- 17 048938 the rate of demyelination; or, if the said disease or disorder involves the brain/central nervous system, a decrease in the rate of brain atrophy/cerebral atrophy (e.g., particularly as diagnosed by magnetic resonance imaging (MRI)).

In another aspect, the term prophylaxis/prevention or treatment in the context of the diseases and disorders defined in the present invention, namely according to embodiments 16), 17) and 18), in particular also refers to the prophylaxis/prevention of said diseases and disorders, in particular to delay the onset of said diseases or disorders in subjects who are/have been diagnosed as being at risk for developing such a disease or disorder; for example, a subject who has/has been diagnosed as having suffered a clinically isolated syndrome (CIS), such CIS being generally known as an indication that such a subject may be at risk. Such a delay in onset may be expressed, for example, by an increase in the time until diagnosis of said disease or disorder; in particular, this may be expressed by an increase in the time until disability; an increase in the time until the first relapse, if applicable; an increase in the time until diagnosis of (progressive) irreversible neurodegenerative damage, such as axonal injury; increased time to diagnosis of demyelination; or, if the disease or disorder in question is brain/central nervous system related, increased time to diagnosis of progressive brain atrophy/cerebral atrophy (eg, particularly as diagnosed by magnetic resonance imaging (MRI)).

19) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use in the prophylaxis/prevention or treatment of a neurodegenerative disease or disorder; wherein said neurodegenerative disease or disorder is in particular amyotrophic lateral sclerosis (ALS) or Huntington's disease; or Alzheimer's disease (AD), Parkinson's disease (PD), or adrenoleukodystrophy; wherein the COMPOUND (intended for administration) is administered in combination with an S1P1 receptor modulator, or a pharmaceutically acceptable salt thereof.

20) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to embodiment 19), wherein such use is for treating a patient diagnosed with said neurodegenerative disease or disorder, wherein said treatment reduces the rate of progression of said neurodegenerative disease or disorder.

21) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to embodiment 20); wherein such reduced rate of progression of said neurodegenerative disease or disorder may be expressed by a reduced rate of brain atrophy/cerebral atrophy (such as, in particular, diagnosed by magnetic resonance imaging (MRI)).

22) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to any one of embodiments 16) to 18), wherein the COMPOUND is for use in the prophylaxis/prevention or treatment of an autoimmune and/or inflammatory demyelinating disease or disorder;

where, in particular, such autoimmune and/or inflammatory demyelinating disease or disorder is:

multiple sclerosis (MS);

idiopathic inflammatory demyelinating diseases;

neuromyelitis optica spectrum disorders (including neuromyelitis optica and (acute) optic neuritis);

autoimmune encephalomyelitis (including acute disseminated encephalomyelitis (ADEM) and multiphasic disseminated encephalomyelitis (MDEM));

myelitis (especially including transverse myelitis spectrum disorders such as acute transverse myelitis, as well as acute flaccid myelitis, poliomyelitis, leukomyelitis, and meningococcal myelitis);

brainstem encephalitis;

anti-myelin oligodendrocyte glycoprotein (anti-MOG)-associated diseases (including anti-MOG encephalomyelitis);

Guillain-Barre syndrome;

chronic inflammatory demyelinating polyneuropathy (CIDP); or antimyelin-associated glycoprotein (antiMAG)-associated peripheral neuropathy.

23) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to embodiment 22), wherein such use is for the treatment of a patient diagnosed with an autoimmune and/or inflammatory demyelinating disease or disorder, wherein said treatment reduces the rate of

- 18 048938 progression of said autoimmune and/or inflammatory demyelinating disease or disorder; in particular, such autoimmune and/or inflammatory demyelinating disease or disorder is provided in embodiment 22).

24) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to embodiment 22), wherein such use is for the prophylaxis/prevention of said autoimmune and/or inflammatory demyelinating disease or disorder; wherein the onset of said autoimmune and/or inflammatory demyelinating disease or disorder is delayed in a subject who is at risk/diagnosed as at risk of developing such disease or disorder; wherein in particular such autoimmune and/or inflammatory demyelinating disease or disorder is provided in embodiment 22).

25) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to embodiment 23); wherein such reduced rate of progression of said autoimmune and/or inflammatory demyelinating disease or disorder may be expressed by a reduced rate of demyelination and/or a reduced rate of irreversible neurodegenerative damage, such as axonal damage.

26) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to embodiment 23) or 25); wherein such reduced rate of progression of said autoimmune and/or inflammatory demyelinating disease or disorder may in particular be expressed in a reduced rate of disability progression.

27) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to embodiment 23), 25) or 26); wherein such reduced rate of progression of said autoimmune and/or inflammatory demyelinating disease or disorder may be expressed by a reduced rate of brain atrophy/cerebral atrophy (e.g., in particular diagnosed by magnetic resonance imaging (MRI)); wherein it is understood that said autoimmune and/or inflammatory demyelinating disease or disorder is, in particular, MS, in particular relapsing-remitting multiple sclerosis (RRMS), secondary progressive multiple sclerosis (SPMS) or primary progressive multiple sclerosis (PPMS).

28) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to embodiment 24), wherein said delay in the onset of said autoimmune and/or inflammatory demyelinating disease or disorder is expressed by an increase in the time until diagnosis of said disease or disorder;

increasing the period of time before disability;

if the specified disease or disorder is characterized by disease progression, including relapses, an increase in the time until the first relapse;

increasing the time to diagnosis of (progressive) (irreversible) neurodegenerative damage such as axonal injury;

by increasing the time to diagnosis of demyelination; or, if the disease or disorder in question involves the brain/central nervous system, by increasing the time to diagnosis of progressive brain atrophy/cerebral atrophy (e.g., particularly as diagnosed by magnetic resonance imaging (MRI)).

29) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to any one of embodiments 22) to 28), wherein said prophylaxis/prevention or treatment causes a remyelination effect.

The remyelination effect can be expressed, for example, in tissue restoration (e.g., extracellular matrix). Such a remyelination effect can, for example, be visualized using well-known magnetic resonance imaging (MRI) methods, including magnetization transfer imaging (MTI), and in particular diffusion-weighted magnetic resonance imaging (DWI or DW-MRI), especially diffusion tensor imaging (DTI).

30) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to embodiment 22), wherein such use is for the treatment of a patient diagnosed with MS; wherein, in particular, said treatment reduces the rate of progression of MS, wherein such reduced rate of progression of MS may in particular be expressed as a reduced rate of demyelination and/or a reduced rate of irreversible neurodegenerative damage, such as axonal damage; it being understood that such MS may in particular be relapsing-remitting multiple sclerosis (RRMS), secondary progressive multiple sclerosis (SPMS) or primary progressive multiple sclerosis (PPMS).

- 19 048938

31) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to embodiment 22), wherein such use is for the treatment of a patient diagnosed with MS; wherein, in particular, said treatment reduces the rate of progression of MS, wherein such reduced rate of progression of MS may in particular be expressed as a reduced rate of progression of disability; it being understood that such MS may in particular be relapsing-remitting multiple sclerosis (RRMS), secondary progressive multiple sclerosis (SPMS) or primary progressive multiple sclerosis (PPMS).

32) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to embodiment 22), wherein such use is for the treatment of a patient diagnosed with MS; wherein, in particular, said treatment reduces the rate of progression of MS, wherein such reduced rate of progression of MS may in particular be expressed as a reduced rate of brain atrophy/cerebral atrophy (e.g., in particular as diagnosed by magnetic resonance imaging (MRI)); it being understood that such MS may in particular be relapsing-remitting multiple sclerosis (RRMS), secondary progressive multiple sclerosis (SPMS), or primary progressive multiple sclerosis (PPMS).

33) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to embodiment 22), wherein such use is for the treatment of a patient diagnosed with MS; wherein said treatment improves the symptoms of MS, wherein such improvement in the symptoms of MS may in particular be expressed by a remyelination effect; wherein it is understood that such MS may in particular be relapsing-remitting multiple sclerosis (RRMS), secondary progressive multiple sclerosis (SPMS), or primary progressive multiple sclerosis (PPMS).

34) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to embodiment 22), wherein such use is for the prevention/prevention of MS, wherein said prevention/prevention of MS comprises delaying the onset of MS in a patient who has had/has been diagnosed with CIS; it being understood that such MS may in particular be relapsing-remitting multiple sclerosis (RRMS).

35) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to any one of embodiments 30) to 34), wherein said prophylaxis/prevention or treatment causes a remyelination effect.

36) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to any one of embodiments 16) to 35), wherein the S1P1 receptor modulator, or a pharmaceutically acceptable salt thereof, is fingolimod, ponesimod, siponimod, ozanimod, cenerimod, etrasimod, amiselimod, ceralifimod, GSK 2018682, or CS0777; or, further, mocravimod (especially fingolimod, ponesimod, siponimod, or ozanimod; or, further, cenerimod); or a pharmaceutically acceptable salt thereof.

37) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to any one of embodiments 16) to 35), wherein the S1P1 receptor modulator, or a pharmaceutically acceptable salt thereof, is fingolimod, ponesimod, siponimod, ozanimod, cenerimod, etrasimod, (especially fingolimod, ponesimod, siponimod or ozanimod; or, further, cenerimod) or a pharmaceutically acceptable salt thereof.

In one sub-embodiment, such combination use (especially with fingolimod, ponesimod, siponimod or ozanimod) is for the prevention or treatment of an autoimmune and/or inflammatory demyelinating disease or disorder (in particular multiple sclerosis (MS)), or (especially with cenerimod, ozanimod or etrasimode; in particular with cenerimod or etrasimode) for the prevention or treatment of inflammatory bowel disease, including Crohn's disease and ulcerative colitis; or systemic lupus erythematosus (SLE).

38) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to any of embodiments 16) to 35), wherein the S1P1 receptor modulator, or a pharmaceutically acceptable salt thereof, is cenerimod, ozanimod, etrasimod or amiselimod (especially cenerimod or etrasimod) or a pharmaceutically acceptable salt thereof.

In a sub-embodiment, such combination use is particularly intended for the prevention or treatment of an inflammatory bowel disease, particularly selected from Crohn's disease and ulcerative colitis; or for the prevention or treatment of systemic lupus erythematosus (SLE).

39) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to any one of embodiments 16) to 35), wherein the S1P1 receptor modulator, or a pharmaceutically acceptable salt thereof, is fingolimod or its

- 20 048938 pharmaceutically acceptable salt.

40) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to any one of embodiments 16) to 35), wherein the S1P1 receptor modulator or a pharmaceutically acceptable salt thereof is ponesimod or a pharmaceutically acceptable salt thereof.

41) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to any one of embodiments 16) to 35), wherein the S1P1 receptor modulator or a pharmaceutically acceptable salt thereof is siponimod or a pharmaceutically acceptable salt thereof.

42) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to any one of embodiments 16) to 35), wherein the S1P1 receptor modulator or a pharmaceutically acceptable salt thereof is ozanimod or a pharmaceutically acceptable salt thereof.

43) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to any one of embodiments 16) to 35), wherein the S1P1 receptor modulator or a pharmaceutically acceptable salt thereof is cenerimod or a pharmaceutically acceptable salt thereof.

In a sub-embodiment, such combination use is in particular for the prophylaxis/prevention or treatment of an autoimmune and/or inflammatory demyelinating disease or disorder according to any of embodiments 22) to 29); in particular for the prophylaxis/prevention or treatment of MS according to any of embodiments 30) to 35).

In another embodiment, such combination use is particularly intended for the prophylaxis/prevention or treatment of systemic lupus erythematosus (SLE).

44) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to any one of embodiments 16) to 35), wherein the S1P1 receptor modulator or a pharmaceutically acceptable salt thereof is etrasimod or a pharmaceutically acceptable salt thereof.

45) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to any one of embodiments 16) to 44); wherein said S1P1 receptor modulator, or a pharmaceutically acceptable salt thereof, is to be administered in a pharmaceutical dosage form suitable for oral administration of said S1P1 receptor modulator, wherein fingolimod or a pharmaceutically acceptable salt thereof, if any, is to be administered in said pharmaceutical dosage form in a unit dose suitable for oral administration of a total of about 0.5 mg or less per day of fingolimod;

siponimod or its pharmaceutically acceptable salt, if any, should be administered in the indicated pharmaceutical dosage form in a unit dose suitable for oral administration of a total of about 2 mg or less per day of siponimod;

ponesimod, or a pharmaceutically acceptable salt thereof, if present, should be administered in a specified pharmaceutical dosage form in a unit dose suitable for oral administration of generally about 20 mg or less per day (in particular about 10 to 20 mg per day, in particular 20 mg per day, or 10 mg per day) of ponesimod; and ozanimod, or a pharmaceutically acceptable salt thereof, if present, should be administered in a specified pharmaceutical dosage form in a unit dose suitable for oral administration of generally about 1 mg or less per day (in particular about 0.5 to 1 mg per day, in particular 1 mg per day, or 0.5 mg per day) of ozanimod;

cenerimod or a pharmaceutically acceptable salt thereof, if any, should be administered in the specified pharmaceutical dosage form at a unit dose suitable for oral administration of generally about 4 mg or less per day (in particular about 2 to 4 mg per day, in particular 4 mg per day, or 2 mg per day) of cenerimod;

etrasimod or a pharmaceutically acceptable salt thereof, if any, should be administered in the specified pharmaceutical dosage form in a unit dose suitable for oral administration of generally about 2 mg or less per day (in particular about 1 to 2 mg per day, in particular 2 mg per day, or 1 mg per day) of etrasimod;

amiselimod or a pharmaceutically acceptable salt thereof, if any, should be administered in the specified pharmaceutical dosage form in a unit dose suitable for oral administration of generally about 0.4 mg or less per day (in particular about 0.2 to 0.4 mg per day, in particular 0.4 mg per day, or 0.2 mg per day) of amiselimod.

The above dosage forms are specifically intended for once daily (qd) dosing of the indicated unit dose.

46) Another embodiment relates to the COMPOUND or its pharmaceutical administration

- 21 048938 lemoy salt for use according to any of embodiments 16) - 45); wherein said S1P1 receptor modulator, or a pharmaceutically acceptable salt thereof, should be administered in a pharmaceutical dosage form suitable for oral administration of said S1P1 receptor modulator, wherein fingolimod or a pharmaceutically acceptable salt thereof, if any, should be administered in said pharmaceutical dosage form in a unit dose suitable for oral administration of a total of about 0.5 mg or less per day of fingolimod;

siponimod or its pharmaceutically acceptable salt, if any, should be administered in the indicated pharmaceutical dosage form in a unit dose suitable for oral administration of a total of about 2 mg or less per day of siponimod;

ponesimod or a pharmaceutically acceptable salt thereof, if any, should be administered in the specified pharmaceutical dosage form at a unit dose suitable for oral administration of a total of about 10 mg or less per day of ponesimod; and osanimod or a pharmaceutically acceptable salt thereof, if any, should be administered in the specified pharmaceutical dosage form at a unit dose suitable for oral administration of a total of about 0.5 mg or less per day of ozanimod;

cenerimod or its pharmaceutically acceptable salt, if any, should be administered in the indicated pharmaceutical dosage form in a unit dose suitable for oral administration of a total of about 2 mg or less per day of cenerimod;

etrasimod or its pharmaceutically acceptable salt, if any, should be administered in the indicated pharmaceutical dosage form in a unit dose suitable for oral administration of a total of about 1 mg or less per day of etrasimod;

Amiselimod or a pharmaceutically acceptable salt thereof, if any, should be administered in the indicated pharmaceutical dosage form at a unit dose suitable for oral administration of a total of about 0.2 mg or less per day of amiselimod.

The above dosage forms are specifically intended for once daily (qd) dosing of the indicated unit dose.

47) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to any one of embodiments 16) to 46), wherein said S1P1 receptor modulator or pharmaceutically acceptable salt thereof is to be administered at a dose that is a tolerable effective dose when administered as monotherapy (e.g., as specified in an approval letter of such S1P1 receptor modulator for the relevant disease or disorder when administered as monotherapy), or at a dose that is lower than such tolerable effective dose when administered as monotherapy.

48) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for use according to any one of embodiments 16) - 46), wherein said S1P1 receptor modulator or pharmaceutically acceptable salt thereof is to be administered at a dose that is below the tolerated effective dose when administered as monotherapy (e.g., as indicated in an approval letter of such S1P1 receptor modulator for the relevant disease or disorder when administered as monotherapy).

49) Another embodiment relates to a COMPOUND or a pharmaceutically acceptable salt thereof for combination use according to any one of embodiments 16) to 48), wherein the COMPOUND is administered (to be administered) in a total dose of from about 20 mg to about 300 mg (in particular from about 20 mg to about 200 mg; in particular from about 50 mg to about 150 mg) per day of the COMPOUND. In a sub-embodiment, said total dose is administered/administered in particular as a single dose per day (qd; for example, from about 20 mg qd to about 300 mg qd (namely from about 20 mg qd to about 200 mg qd; in particular from about 50 mg qd to about 150 mg qd)), or as two separate doses per day (bid; for example, from about 10 mg bid to about 150 mg bid (namely from about 10 mg bid to about 100 mg bid; in particular from about 25 mg bid to about 75 mg bid)).

In a sub-embodiment of this embodiment 49), the specific characteristics of embodiments ii) to v) of the present invention apply mutatis mutandis above.

50) Another embodiment thus relates to a COMPOUND or a pharmaceutically acceptable salt thereof for combination use according to any one of embodiments 16) to 48), wherein the COMPOUND is administered/to be administered in a total dose of from about 20 mg to 200 mg per day of COMPOUND; namely from about 30 mg to 150 mg per day, from about 40 mg to 150 mg per day, from about 50 mg to 200 mg, from about 50 mg to 150 mg, from about 50 mg to 100 mg, or from about 100 mg to 200 mg per day of COMPOUND; in particular from about 75 mg to 150 mg per day of COMPOUND. In a sub-embodiment, said total dose is prescribed/administered in particular as a single dose per day (qd) or as two divided doses per day (bid).

Accordingly, the COMPOUND or a pharmaceutically acceptable salt thereof according to the present invention is intended in particular for use in combination (or co-therapy)

- 22 048938 pii) with the specified other pharmaceutically active ingredients.

Combination therapy (or co-therapy) may be given simultaneously (at a fixed dose or at a non-fixed dose), separately, or over a period of time (especially at the same time).

At the same time, when referring to the type of administration, in the present invention means that the type of administration in question consists of administering two or more active ingredients and/or treatments at approximately the same time; it is understood that the simultaneous administration will result in the simultaneous exposure of the subject to two or more active ingredients and/or treatments. In this context, the term at the same time refers in particular to a dosing regimen/frequency that is substantially daily for all active ingredients, i.e. the administration of said two or more active ingredients and/or treatments occurs on the same day, especially at least once at approximately the same time on said day.

When administered simultaneously, said two or more active ingredients may be administered: in a fixed dose combination or in a non-fixed dose combination which is equivalent to a fixed dose combination (e.g. using two or more different pharmaceutical compositions for administration, preferably by the same route of administration, at about the same time), wherein in particular said non-fixed dose combination is to be administered according to the same dosing/frequency regimen (e.g. all active ingredients are to be administered in particular once daily (qd), or are to be administered twice daily (bid), or the like), or in a non-fixed dose combination using two or more different routes of administration or dosing/frequency regimen (e.g. one or more active ingredients are to be administered once daily (qd), while at least one other active ingredient is to be administered, preferably by the same route of administration, in a different dosing regimen such as twice daily (bid), or three times daily (tid) or every other day);

wherein said co-administration results in substantially simultaneous exposure of the subject to a pharmaceutically effective amount of two or more active ingredients and/or treatments. An example of co-administration of a non-fixed dose combination using two different pharmaceutical compositions for administration, preferably by the same route of administration, at approximately the same time is a non-fixed dose combination in which the COMPOUND is (to be administered) once daily and the corresponding S1P1 receptor modulator is (to be administered) once daily. An example of co-administration of a non-fixed dose combination using two different routes of administration or dosing/frequency regimen is a non-fixed dose combination in which the COMPOUND is (to be administered) twice daily and the corresponding S1P1 receptor modulator is (to be administered) once daily. Another example would be that the COMPOUND is administered (to be administered) once or twice daily and the corresponding S1P1 receptor modulator is administered (to be administered) every other day (it being understood that such co-administration will result in the subject being exposed to up to a pharmaceutically effective amount of the COMPOUND and said S1P1 receptor modulator simultaneously at all times). When used in combination with an S1P1 receptor modulator, the COMPOUND should especially be used concurrently.

A fixed dose combination, when referring to a type of administration, means in the present invention that the type of administration in question consists of administering one single pharmaceutical composition containing two or more active ingredients, for example, especially the pharmaceutical compositions of any of embodiments 1) to 15).

Separately, when speaking of a type of administration, in the present invention means that the type of administration in question consists of administering two or more active ingredients and/or treatments at different points in time; it is understood that separate administration will result in a treatment phase (for example at least 1 hour, such as at least 6 hours, in particular at least 12 hours), when the subject is exposed to two or more active ingredients and/or treatments during the same time; but separate administration may also result in a treatment phase, when during a certain period of time (for example at least 12 hours, in particular at least one day) the subject is exposed to only one of the two or more active ingredients and/or treatments. Separate administration particularly applies to situations where at least one of the active ingredients and/or treatments is administered at a frequency that is substantially different from daily administration (e.g. once or twice daily) (e.g. where one active ingredient and/or treatment is administered, for example, once or twice daily, and the other is administered, for example, once a week or even over longer intervals).

By administration over a period of time, in the present invention, is meant the subsequent administration of two or more active ingredients and/or treatments at different times. The term particularly refers to a method of administration according to which the complete administration of one of the active ingredients and/or treatments is completed before the start of the administration of the other/others. Thus, it is possible to administer

- 23 048938 one of the active ingredients and/or treatment for several months before the introduction of the other active ingredient(s) and/or treatment(s).

The term pharmaceutically effective amount or pharmaceutically effective amount shall be understood as at least the minimum amount of the respective active ingredient that elicits a pharmacological response in a subject (minimum pharmacologically effective amount). A pharmacological response may, for example, be inferred if the active ingredient in question is present (at some time during treatment, such as at T _max or trough level; for active ingredients intended for chronic administration, especially throughout the entire treatment period (e.g. including trough level)) at a concentration that (in the case of an antagonist) blocks at least 20% (in particular at least 50%) of the biological target in question. Furthermore, a pharmacological response may be inferred if a biomarker that responds to such blockade of the biological target in question is (significantly) increased/decreased compared to an untreated reference (such as baseline or placebo); whereby such increase/decrease may be observed at some time during treatment, such as at T _max or trough level; for active ingredients intended for long-term use, especially over the entire treatment period (e.g. including the minimum level). Preferably, the pharmaceutically effective amount is in the range of therapeutic doses of the active ingredient, such range being typically defined by the range between the minimum effective dose (MED) and the maximum tolerated dose (MTD).

As used in the present invention, the term subject refers to a mammal, especially a human; especially a patient, in particular a human patient. Preferably, the term refers to a (human) subject who is at risk/has been diagnosed as at risk of developing a certain disease or disorder and therefore needs prophylaxis/prevention of such disease or disorder;

or the term refers to a (human) patient who has been diagnosed with/has a particular disease or disorder and therefore requires treatment for such disease or disorder.

It is understood that any embodiment relating to a COMPOUND or a pharmaceutically acceptable salt thereof for use in the prophylaxis/prevention or treatment of a certain disease and disorder wherein both the expression of CXCR7 or its ligands and S1P as specifically defined herein are important, wherein the COMPOUND is to be administered (intended to be administered) in combination with an S1P1 receptor modulator (especially an S1P1 receptor modulator as specifically defined in such embodiment), also relates to such S1P1 receptor modulator or a pharmaceutically acceptable salt thereof for use in the prophylaxis/prevention or treatment of said disease and disorder wherein both the expression of CXCR7 or its ligands and S1P are important; wherein said S1P1 receptor modulator is to be administered (intended to be administered) in combination with the COMPOUND, or a pharmaceutically acceptable salt thereof;

to the use of the COMPOUND or a pharmaceutically acceptable salt thereof for the manufacture of a medicinal product/pharmaceutical composition comprising the COMPOUND or a pharmaceutically acceptable salt thereof and such an S1P1 receptor modulator or a pharmaceutically acceptable salt thereof for use in the prophylaxis/prevention or treatment of the said disease and disorder in which both the expression of CXCR7 or its ligands and S1P are important;

to the use of the COMPOUND or a pharmaceutically acceptable salt thereof for the manufacture of a medicinal product/pharmaceutical composition containing the COMPOUND or a pharmaceutically acceptable salt thereof as an active ingredient for use in the prophylaxis/prevention or treatment of said disease and disorder in which both the expression of CXCR7 or its ligands and S1P are important; wherein said medicinal product/pharmaceutical composition (is) intended for use in combination with such an S1P1 receptor modulator or a pharmaceutically acceptable salt thereof;

to the use of such an S1P1 receptor modulator or a pharmaceutically acceptable salt thereof for the manufacture of a medicament/pharmaceutical composition comprising, as an active ingredient, said S1P1 receptor modulator or a pharmaceutically acceptable salt thereof for use in the prophylaxis/prevention or treatment of said disease and disorder in which both the expression of CXCR7 or its ligands and S1P are important; wherein said medicament/pharmaceutical composition (is) intended for use in combination with a COMPOUND or a pharmaceutically acceptable salt thereof;

to the use of a pharmaceutical composition comprising a COMPOUND or a pharmaceutically acceptable salt thereof and such a S1P1 receptor modulator or a pharmaceutically acceptable salt thereof for the prophylaxis/prevention or treatment of the said disease and disorder in which both the expression of CXCR7 or its ligands and S1P are important;

- 24 048938 to a medicinal product for the prophylaxis/prevention or treatment of the said disease and disorder, in which both the expression of CXCR7 or its ligands and S1P are important, the said medicinal product contains a COMPOUND or a pharmaceutically acceptable salt thereof; wherein the said medicinal product is administered (intended for administration) in combination with the said S1P1 receptor modulator, or a pharmaceutically acceptable salt thereof;

to a method for the prophylaxis/prevention or treatment of the said disease and disorder, in which both the expression of CXCR7 or its ligands and S1P are important, comprising administering to a subject in need thereof (preferably a human) an effective amount of a COMPOUND or a pharmaceutically acceptable salt thereof, wherein the COMPOUND is administered in combination with an effective amount of such a modulator of the S1P1 receptor or a pharmaceutically acceptable salt thereof;

to a method for the prophylaxis/prevention or treatment of said disease and disorder, in which both the expression of CXCR7 or its ligands and S1P are important, comprising administering to a subject in need thereof an effective amount of a pharmaceutical composition comprising a COMPOUND or a pharmaceutically acceptable salt thereof and such an S1P1 receptor modulator or a pharmaceutically acceptable salt thereof; and to a method for the prophylaxis/prevention or treatment of said disease and disorder, in which both the expression of CXCR7 or its ligands and S1P are important, comprising administering to a subject in need thereof (preferably a human) an effective amount of such an S1P1 receptor modulator or a pharmaceutically acceptable salt thereof, wherein said S1P1 receptor modulator is administered in combination with an effective amount of a COMPOUND, or a pharmaceutically acceptable salt thereof.

Likewise, any embodiment relating to a COMPOUND or a pharmaceutically acceptable salt thereof for use in the prophylaxis/prevention or treatment of a certain disease and disorder in which the expression of CXCR7 or its ligands is important, should be understood as also relating to the use of the COMPOUND or a pharmaceutically acceptable salt thereof in the prophylaxis/prevention or treatment of said certain disease and disorder; and to a method for the prophylaxis/prevention or treatment of said certain disease and disorder, said method comprising administering to a subject in need thereof an effective amount of a pharmaceutical composition comprising the COMPOUND or a pharmaceutically acceptable salt thereof.

When the plural form is used to denote compounds, salts, pharmaceutical compositions, diseases, etc., it also implies a single compound, salt, etc.

The definitions provided herein are intended to apply uniformly to compositions as defined in any of embodiments 1) to 50), and, mutatis mutandis, throughout the specification and claims, unless another explicitly stated definition provides a broader or narrower definition. It is well known that a definition or preferred definition of a term defines and may replace the corresponding term independently of (and in combination with) any definition or preferred definition of any or all other terms defined herein.

Any reference to compounds should be understood as also referring to salts (and especially pharmaceutically acceptable salts) of such compounds, where appropriate and useful.

The term pharmaceutically acceptable salts refers to salts that retain the desired biological activity of the compound in question and exhibit minimal undesirable toxicological effects. Such salts include addition salts with inorganic or organic acids and/or bases depending on the presence of basic and/or acidic groups in the compound in question. For reference, see, e.g., Handbook of Pharmaceutical Salts. Properties, Selection and Use., P. Heinrich Stahl, Camille G. Wermuth (Eds.), Wiley-VCH, 2008; and Pharmaceutical Salts and Cocrystals, Johan Wouters and Luc Quere (Eds.), RSC Publishing, 2012.

The term consisting essentially of in the context of the present invention means in particular that the respective composition consists in an amount of at least 90, especially at least 95, especially at least 99 and preferably in an amount of 100 percent by weight (i.e. in the meaning of consisting of) of the respective composition in the amounts as expressly stated in the respective embodiment. The term comprising is preferably to be understood in the meaning of the term consisting essentially of.

The term “essentially” in the context of the present invention means in particular that the respective amount/purity/time etc. is at least 90, especially at least 95 and especially at least 99 percent of the respective total amount.

For example, when used in the term substantially simultaneous exposure, it is understood in particular that the relevant exposure results in simultaneous exposure to pharmaceutically effective amounts of all combinations of active ingredients for at least 90, especially at least 95 and especially at least 99 percent of the time, i.e. per day, if predetermined

- 25 048938 requires continuous/sustained exposure to pharmaceutically active ingredients.

For example, when using a term such as substantially pure, in the context of the present invention it is understood in particular that the corresponding composition/compound, etc. consists in an amount of not less than 95 and, in particular, not less than 99 percent by weight of the corresponding pure composition/compound/crystalline form, etc.

The term enantiomerically enriched in the context of the present invention means in particular that at least 90, preferably at least 95 and most preferably at least 99 percent by weight of the COMPOUND are present in the form of a single enantiomer of the COMPOUND. It is understood that the COMPOUND is present in an enantiomerically enriched absolute (3S,4S) configuration, preferably in a substantially pure absolute (3S,4S) configuration.

For the avoidance of any doubt, it is well known that any pharmaceutical composition comprising the COMPOUND in a pharmaceutically effective amount may additionally contain other conventional excipients and/or additives which can be used singly or in combination (quantum satis, i.e. where the maximum amounts of said additional conventional ingredients and/or additives may be reduced to make up a total wt.% of 100). It is understood that the total amount expressed in wt.% of a certain composition is 100. The expression wt.% (or % (w/w)) refers to a percentage by weight compared to the total weight of the composition in question.

The manufacture of the pharmaceutical compositions according to the invention can be carried out in a manner familiar to anyone skilled in the art (see, for example, R.C. Rowe, P.J. Seskey, S.C. Owen, Handbook of Pharmaceutical Excipients, 5th edition, Pharmaceutical Press 2006; Remington, The Science and Practice of Pharmacy, 21st edition (2005), Part 5, Pharmaceutical Manufacturing [published by Lippincott Williams & Wilkins]), by introducing a combination of active ingredients according to the invention, optionally in combination with other therapeutically valuable substances, into a galenic form for administration together with suitable, non-toxic, inert, pharmaceutically acceptable solid or liquid carrier materials and, if desired, conventional pharmaceutical adjuvants. The pharmaceutical composition for oral administration may in particular be in the form of a capsule or in the form of a tablet.

Dosage forms suitable for enteral administration may be tablets. Alternatively, dosage forms suitable for enteral administration may be capsules (especially hard gelatin capsules) filled with a pharmaceutical composition containing an effective amount of the COMPOUND. Any type of capsule that is commonly used to contain pharmaceutical compositions in powder or pellet form, such as hard gelatin capsules, HPMC capsules, etc., may be used in the present invention. It is understood that the capsule or tablet will contain, in addition to the COMPOUND or a pharmaceutically acceptable salt thereof, optionally in combination with an S1P1 receptor modulator or a pharmaceutically acceptable salt thereof, as defined in the present invention, and at least one pharmaceutically acceptable inert substance. As used in the present invention, the term pharmaceutical composition is interchangeable with the terms composition, formulation or drug.

When not used in relation to temperatures, the term approximately preceding a numerical value X in the present invention refers to a range extending from X minus 10% of X to X plus 10% of X, and preferably to a range extending from X minus 5% of X to X plus 5% of X. In the particular case of temperatures, the term approximately preceding a temperature Y in the present invention refers to a range extending from a temperature Y minus 10°C to Y plus 10°C, preferably to a range extending from Y minus 5°C to Y plus 5°C, namely to a range extending from Y minus 3°C to Y plus 3°C. Room temperature means a temperature of approximately 25°C. When the term n equivalent(s) is used in the present invention, where n is a number, then within the scope of the present invention this means that n refers to an approximate number n, preferably n refers to an exact number n.

Whenever the word between or to is used to describe a numerical range, it is understood that the endpoints of the stated range are expressly included in the range. For example: if a temperature range is described as between 40°C and 80°C (or from 40°C to 80°C), this means that the endpoints 40°C and 80°C are included in the range; or if a variable is defined as an integer between 1 and 4 (or from 1 to 4), this means that the variable is the integer 1, 2, 3, or 4.

Specific embodiments of the invention are described in the following examples, which serve to illustrate the invention in more detail without in any way limiting its scope.

Experimental procedures.

Abbreviations.

The following abbreviations are used in the description and examples:

bid. (twice in day): also bid; twice a day;

CFA - complete Freund's adjuvant;

KPZ - cuprizone;

- 26 048938

EAE - experimental autoimmune encephalomyelitis;

Fig. - Figure;

h - hour(s);

IBD - inflammatory bowel disease;

MOG - myelin oligodendrocyte glycoprotein;

PC - multiple sclerosis;

NFL - neurofilament light chain;

ns - not significant;

PLB - proteolipid protein;

Daily (quaque die): also qd; once a day;

SEM - standard error of the mean.

Examples of therapeutic applications of COMPOUND as monotherapy or in combination with an S1P1 receptor modulator.

Therapeutic effects can be modeled in several animal models of diseases and disorders in which both CXCR7 or its ligands and S1P expression are important.

Example A.

The efficacy of COMPOUND and fingolimod alone or in combination can be determined in a mouse model of inflammatory demyelinating diseases such as multiple sclerosis (MS).

Plasma CXCL12 or CXCL11 concentrations can be determined using methods well known in the art, such as the Ella® immunoassay (Bio-Techne®), or the commercial quantikine ELISA CXCL12/SDF1a mouse kit from R&D systems.

a. Dose-finding experiments in intact mice:

In a pilot experiment, healthy female C57BL/6 mice were orally administered COMPOUND at doses of 30 and 100 mg/kg, twice daily (b.i.d.) for 3 days. The objective is to evaluate the dose-dependence of COMPOUND on the increase in plasma CXCL12 levels (which is an established biomarker for monitoring the pharmacological activity of CXCR7 receptor antagonist) in this mouse strain over 24 h.

Based on this experiment, only the highest dose of the COMPOUND tested provided minimal plasma COMPOUND exposure (14 hours after the last dose) to maintain the increase in plasma CXCL12 levels for 24 hours in naive C57BL/6 mice (100 mg/kg dose, b.i.d.).

In parallel to the COMPOUND target binding measurement, a second pilot experiment is conducted. Healthy female C57BL/6 mice are given fingolimod at different doses ranging from 0.01 to 0.3 mg/kg once daily (QD). The objective is to evaluate the dose-response relationship of fingolimod on peripheral blood lymphocyte count (an established biomarker for monitoring the pharmacological activity of S1P1 receptor modulators) in this mouse strain over 24 h. Based on this experiment, the selected fingolimod dose for the combination experiment shows partial efficacy in reducing lymphocyte count over 24 h (0.03 mg/kg QD).

b. Experiment on the efficacy of monotherapy in the model of experimental autoimmune encephalomyelitis (OAE), induced by myelin oligodendrocyte glycoprotein (MOG):

The efficacy of COMPOUND in myelin oligodendrocyte glycoprotein (MOG)-induced experimental autoimmune encephalomyelitis (EAE) can be determined in a pilot study. The objective is to evaluate the dose-effect relationship of COMPOUND on the efficacy and increase in plasma CXCL12 in a mouse model of PC.

Female C57BL/6 mice were immunized with an emulsion of MOG in complete Freund's adjuvant (CFA) and pertussis toxin (day 0). A total of 150 μg of MOG was injected subcutaneously into mice at two sites on each side of the abdomen. Mice were re-injected intraperitoneally with pertussis toxin 2 days after the first injection (day 2). Within 9-14 days, mice show signs of paralysis, which are scored on a scale of 0 to 5, evaluating the condition of the tail and limbs as follows: 0 = no clinical signs of EAE, 0.5 = tail tip paralysis or weakness of one limb, 1 = tail paralysis or weakness of both limbs, 1.5 = tail paralysis and weakness of one hind limb, 2 = tail paralysis and bilateral partial hind limb paralysis, 2.5 = tail paralysis and unilateral complete hind limb paralysis, 2.75 = 2.5 scale + unilateral partial hind limb paralysis, 3 = complete bilateral hind limb paralysis, 3.25 = 3 + unilateral complete forelimb paralysis, 3.5 = 3 + unilateral complete forelimb paralysis, 4 = complete paralysis (moribund), and 5 = death or euthanasia.

The course of the disease is chronic, progressive, without remission.

Groups of 9-10 mice were orally administered, starting on the day of disease induction (day 0), various

- 27 048938 doses of COMPOUND. It consists of four treatment groups:

1) carrier (water) b.i.d., from day 0;

2) COMPOUND (10 mg/kg) b.i.d., from day 0;

3) COMPOUND (30 mg/kg) b.i.d., from day 0;

4) COMPOUND (100 mg/kg) b.i.d., from day 0.

Clinical scores are assessed daily and disease progression is compared between vehicle-treated and COMPOUND-treated mice. A cumulative disease score is calculated for each mouse by summing all daily clinical scores over the 29-day study period. The experiment is terminated on day 29, 1-4 hours post-dose. Plasma samples are collected to determine COMPOUND concentrations and to measure a biomarker for binding to the CXCR7 target (CXCL12 levels). Plasma CXCL12 concentrations are determined using the commercial quantikine ELISA kit for mice CXCL12/SDF1a from R&D systems, according to the manufacturer's instructions.

The results of the efficacy experiment are shown in Figs. 1-2. COMPOUND administered prophylactically exhibited dose-dependent efficacy on the overall disease burden of EAE, as evidenced by a reduction in the mean cumulative disease score over the 29-day study (Fig. 1). The efficacy was associated with a dose-dependent increase in plasma CXCL12 levels (Fig. 2).

Based on the pilot experiments described above, a single dose of COMPOUND is selected for the combination efficacy trial. The selected dose provides the minimum plasma exposure of COMPOUND to maintain plasma CXCL12 levels for 24 hours and significantly reduces the overall disease burden associated with EAE when used prophylactically (dose: 100 mg/kg, b.i.d.).

In parallel with the measurement of the dose-dependent efficacy of COMPOUND in the EAE model, a second pilot experiment is being conducted to assess the efficacy of the selected dose of fingolimod.

Groups of 10 mice were dosed orally starting on the day of disease induction (day 0). It consisted of two treatment groups:

1) vehicle (0.5% methylcellulose/0.5% Tween® 80) b.i.d., from day 0;

2) fingolimod (0.03 mg/kg) daily + vehicle daily, from day 0.

Clinical scores are assessed daily, and disease progression is compared between vehicle-treated and fingolimod-treated mice. A cumulative disease score is calculated for each mouse by summing all daily clinical scores over the 27-day study period. The experiment is terminated on day 27.

Fingolimod administered prophylactically at the selected dose (0.03 mg/kg) was effective in reducing overall EAE disease burden, as demonstrated by a reduction in cumulative disease scores over the 27-day study (Fig. 3). Fingolimod efficacy was not associated with increases in plasma CXCL12 levels.

c. Experiment on the effectiveness of the combination in the model of EAE induced by MOG:

The combination efficacy experiment is conducted on the same mouse model of EAE as for the pilot experiments.

Groups of 10 mice are dosed orally, starting just before disease onset (day 7). It consists of four treatment groups:

1) Vehicle (0.5% methylcellulose/0.5% Tween® 80) b.i.d., beginning on day 7;

2) Fingolimod (0.03 mg/kg) daily + vehicle daily, starting from the 7th day;

3) COMPOUND (100 mg/kg) bid., starting from the 7th day;

4) Fingolimod (0.03 mg/kg) daily + COMPOUND (100 mg/kg) b.i.d., starting on day 7.

Clinical scores are assessed daily and disease progression is compared between vehicle-treated mice and mice receiving the different treatments. The experiment is terminated on day 16 or 17. Hematological parameters, including lymphocyte counts, are measured at the end of the experiment. Plasma samples are collected to determine COMPOUND concentrations and to measure a biomarker for CXCR7 target binding (CXCL12 levels) and axonal injury (neurofilament light chain (NFL) levels). Plasma CXCL12 concentrations are determined using the commercial quantikine ELISA kit for mice CXCL12/SDF1a from R&D systems, according to the manufacturer's instructions.

This experiment is suitable to show whether adding a dose of COMPOUND that shows consistent target binding and efficacy as monotherapy in the EAE model demonstrates additional benefit compared to a dose of fingolimod that is only partially effective on lymphocyte counts.

The results of the combination efficacy experiment are shown in Figs. 4-8. COMPOUND and fingolimod administered in the therapeutic setting immediately before initiation exhibited moderate and minimal efficacy, respectively, on clinical disease endpoints.

- 28 048938 in a mouse model of EAE (Fig. 4). When combined, the two compounds showed synergistic efficacy from day 14 onwards on the course of EAE disease, reducing disease severity (Fig. 4 and Fig. 5) and plasma NFL concentrations (Fig. 6); the presence of NFL is indicative of irreversible axonal damage. This synergistic effect could not be explained by an additive effect of the combination, nor by the fingolimod-induced decrease in peripheral blood lymphocyte counts (Fig. 7), nor by the COMPOUND-induced increase in plasma CXCL12 levels at the end of the experiment (Fig. 8).

Figure 1 shows the dose-response effect of COMPOUND on overall EAE disease burden assessed by cumulative disease scores, defined as the sum of clinical scores for each mouse over the 29-day study. Mice were treated from day 0. Data are presented as mean + SEM; n=9-10/group. *p<0.05, ****p<0.0001 compared to vehicle-treated EAE mice using the Kruskal-Wallis test followed by Dunn's multiple comparisons test.

Figure 2 shows the dose-dependent effect of COMPOUND on plasma CXCL12 concentration in a mouse model of MOG-induced EAE. Data are presented as means + SEM; n = 7-10/group. ****p < 0.0001 compared to vehicle-treated EAE mice using one-way ANOVA followed by Dunnett's multiple comparison test.

Figure 3 shows the effect of fingolimod (0.03 mg/kg, daily) on overall EAE disease burden assessed by cumulative disease scores, defined as the sum of clinical scores for each mouse over the 27-day study. Mice were treated from day 0. Data are presented as mean + SEM; n = 10/group., ** p < 0.01 compared to vehicle-treated EAE mice using the Mann-Whitney test.

Fig. 4 shows the therapeutic efficacy of COMPOUND, fingolimod, and their combination by mean clinical score in the mouse EAE model. Mice were treated from day 7 until the end of the study. Data are presented as mean + SEM; n = 10/group. *p < 0.05, **p < 0.01 compared with vehicle-treated EAE mice using the Kruskal-Wallis test followed by Dunn's multiple comparison test.

Figure 5 shows the therapeutic effect of COMPOUND, fingolimod and their combination on the disease severity of EAE in mice, expressed as the maximum clinical score achieved during the 16 days of the study. Data are presented as mean + SEM; n = 10/group. *p < 0.05, **p < 0.01 using the Kruskal-Wallis test followed by uncorrected Dunn's multiple comparison test.

Figure 6 shows the therapeutic effect of COMPOUND, fingolimod and their combination on plasma neurofilament light chain concentrations in a mouse EAE model. Data are presented as mean + SEM; n = 8-9/group. *p < 0.05, **p < 0.01 using one-way ANOVA followed by Fisher's LSD uncorrected multiple comparisons test.

Figure 7 shows the effect of COMPOUND, fingolimod, and their combination on blood lymphocyte counts in a mouse model of EAE. Data are presented as means + SEM; n = 810/group. **p < 0.01, using one-way ANOVA followed by Fisher's uncorrected multiple comparisons test of LSD versus vehicle-treated EAE mice.

Figure 8 shows the effect of COMPOUND, fingolimod, and their combination on plasma CXCL12 concentrations in a mouse model of EAE. Data are presented as means + SEM; n = 8-10/group. ****p < 0.0001, using one-way ANOVA followed by Fisher's LSD uncorrected multiple comparisons test.

Example B.

Experiment 1): The direct effect of COMPOUND on myelination can be determined in a mouse model of cuprizone-induced demyelination, where the primary demyelination is not immune-mediated.

Male C57BL/6 mice were exposed to cuprizone (CUP; 150 mg/kg, b.i.d.), a chelating agent that causes death of mature oligodendrocytes, by oral gavage twice daily for six weeks. COMPOUND (100 mg/kg, b.i.d.) was administered either prophylactically, i.e., co-administered with cuprizone, beginning on day 0 (COMPOUND pre-CUP); or therapeutically, i.e., beginning 3 weeks after initiation of cuprizone exposure until the end of the experiment (COMPOUND post-CUP).

The experiment is terminated after 6 weeks of cuprizone exposure. Plasma samples are collected to determine COMPOUND concentrations and to measure biomarkers for CXCR7 target binding (CXCL12 levels). Plasma CXCL12 concentrations are measured as described previously in Example A. Brain samples are isolated and fixed for histopathology and immunohistochemistry to assess the extent of demyelination (Luxol Fast Blue for myelin staining) and loss of mature oligodendrocytes (GST staining).

The results of this study are shown in Figs. 9-10. After 6 weeks of exposure, cuprizone caused significant demyelination (Fig. 9) and significant loss of mature oligodendrocytes (Fig. 10).

- 29 048938

While cuprizone was still being administered, both COMPOUND treatment regimens (prophylactic: COMPOUND before CPT and therapeutic: COMPOUND after CPT) significantly increased myelin staining (Fig. 9) and the number of mature oligodendrocytes (Fig. 10) in the corpus callosum.

Figure 9 shows the effect of COMPOUND co-administered with cuprizone in the same formulation starting at day 0 (COMPOUND pre-CPE) or starting after 3 weeks of cuprizone exposure (COMPOUND post-CPE) on demyelination in cuprizone-induced mice. Rostral coronal sections were stained with Luxol Fast Blue, and the staining intensity of the corpus callosum was quantified using Orbit image analysis software. Results are expressed as mean + SEM, n = 7-8 mice per group. * p < 0.05, ** p < 0.01, **** p < 0.0001, compared with vehicle-treated CPE mice using a one-way ANOVA test followed by Fisher's uncorrected LSD multiple comparisons test.

Figure 10 shows the effect of COMPOUND co-administered with cuprizone, in the same formulation, starting at day 0 (COMPOUND pre-CPE) or starting after 3 weeks of cuprizone exposure (COMPOUND post-CPE) on the number of mature oligodendrocytes in a cuprizone-induced demyelination model in mice. Rostral coronal sections were stained with GSTn and corpus callosum quantification was determined using Orbit image analysis software. Results are expressed as mean cell number normalized to the selected region of interest in ^mm2 + SEM, n=6-8 mice per group. *p<0.05, **p<0.01, ****p<0.0001, compared to vehicle-treated CPE mice using a one-way ANOVA test followed by Fisher's uncorrected LSD multiple comparisons test.

Experiment 2): In the second experiment, the therapeutic effect of COMPOUND on myelination is determined in a cuprizone-induced toxic demyelination model, where spontaneous remyelination occurs after cuprizone withdrawal.

Male C57BL/6 mice were exposed to a diet containing 0.2% cuprizone for six weeks and then switched to a control diet for another week. Groups of 8 to 9 mice were dosed orally starting at five weeks of cuprizone exposure. This consisted of three treatment groups:

1) vehicle (0.5% methylcellulose/0.5% Tween® 80) b.i.d., weeks 5–7;

2) fingolimod (0.3 mg/kg) daily + vehicle daily, from 5 to 7 weeks;

3) Compound (100 mg/kg) b.i.d., weeks 5 through 7.

The experiment is terminated after two weeks of treatment (week 7), i.e. one week after cuprizone is discontinued. Hematological parameters, including lymphocyte counts, are measured at the end of the experiment, one hour after the last dose. Plasma samples are collected to determine COMPOUND concentrations and to measure biomarkers for binding to the CXCR7 target (CXCL12 levels). Brain samples are isolated and fixed for histopathological and immunohistochemical examination to assess the degree of demyelination (Luxol Fast Blue for myelin staining).

This experiment is suitable for a direct comparison of the COMPOUND dose that shows target binding at all times and efficacy as monotherapy in both the EAE and cuprizone models with the fingolimod dose that is fully effective in reducing lymphocyte counts within 24 hours (dose: 0.3 mg/kg, daily).

The results of this study are shown in Fig. 11. After 6 weeks of cuprizone treatment followed by one week of control chow, vehicle-treated mice showed significant demyelination of the corpus callosum. One week after CPD withdrawal, COMPOUND significantly accelerated spontaneous remyelination, whereas fingolimod had no effect (Fig. 11).

Figure 11 shows the therapeutic effect of COMPOUND and fingolimod, starting one week before cuprizone withdrawal, on demyelination/remyelination in a cuprizone-induced demyelination model in mice. Rostral coronal sections were stained with Luxol Fast Blue and the staining intensity of the corpus callosum was quantified using Orbit image analysis software. Results are expressed as mean + SEM, n = 7-8 mice per group. * p < 0.05, **** p < 0.0001, compared with vehicle-treated BC mice using one-way ANOVA followed by uncorrected Fisher's LSD multiple comparison test.

Example C.

The therapeutic efficacy of COMPOUND and siponimod, alone or in combination, can be determined in a mouse model of inflammatory demyelinating disease.

a. Dose-finding experiments in healthy mice:

In a pilot experiment, healthy female SJL/J mice were orally administered siponimod at different doses ranging from 0.03 to 1 mg/kg once daily for 2-3 days. The objective was to evaluate the dose-response relationship of siponimod on the peripheral blood lymphocyte count (an established biomarker for monitoring the pharmacological activity of S1P1 receptor modulators) in this mouse strain over 24 h. Based on this experiment, the selected

- 30 048938 siponimod dose for the combination experiment demonstrates full efficacy in reducing lymphocyte counts over 24 h (0.3 mg/kg dose, daily). Combining siponimod at the dose selected with COMPOUND at 100 mg/kg, b.i.d. does not affect either of the other's biomarkers, namely increases in lymphopenia and plasma CXCL12, respectively, nor their respective plasma pharmacokinetics.

b. Experiment on the efficacy of monotherapy in the model of EAE induced by proteolipid protein (PLP):

The therapeutic efficacy of COMPOUND in PLB-induced EAE can be determined in a pilot study. The objective is to evaluate the dose-effect relationship of COMPOUND on efficacy and on the increase of both CXCL11 and CXCL12 in plasma.

Female SJL/J mice were immunized with an emulsion of PLB in CFA and pertussis toxin (day 0). A total of 100 μg of PLB was injected subcutaneously into mice at two sites on each side of the abdomen. Mice were re-injected intraperitoneally with pertussis toxin 2 days after the first injection (day 2). Within 9 to 16 days, mice develop signs of paralysis and are scored on a scale of 0 to 5, evaluating the condition of the tail and limbs as follows: 0 = no clinical signs of EAE, 0.5 = tail tip paralysis or weakness of one limb, 1 = tail paralysis or weakness of both limbs, 1.5 = tail paralysis and weakness of one hind limb, 2 = tail paralysis and bilateral partial hind limb paralysis, 2.5 = tail paralysis and unilateral complete hind limb paralysis, 2.75 = tail paralysis and unilateral complete hind limb paralysis, 3 = complete bilateral hind limb paralysis, 3.25 = 3 + unilateral complete forelimb paralysis, 3.5 = 3 + unilateral complete forelimb paralysis, 4 = complete paralysis (moribund), and 5 = death or euthanasia. The progression of the disease occurs according to the relapsing-remitting type with the first peak of the disease occurring three to five days after the onset of the disease, followed by a phase of remission and a second peak of the disease 20 to 30 days after the induction of EAE.

Groups of 14 to 16 mice were given varying doses of COMPOUND orally, beginning at the first sign of disease in each mouse. The study consisted of four treatment groups:

1) carrier (water) b.i.d., from the onset of disease for each mouse;

2) COMPOUND (10 mg/kg) b.i.d., from disease onset for each mouse;

3) COMPOUND (100 mg/kg) b.i.d., from disease onset for each mouse;

4) COMPOUND (150 mg/kg) b.i.d., from disease onset for each mouse.

Clinical scores are assessed daily in a blinded manner and disease progression is compared between vehicle-treated and COMPOUND-treated mice. A cumulative disease score is calculated for each mouse by summing all daily clinical scores for 30 days after the start of treatment. The experiment is terminated on the day of enrollment of mice, 30 to 33 days after COMPOUND treatment, i.e., between 42 and 48 days after EAE induction. Plasma samples are collected to determine COMPOUND concentrations and to measure biomarkers for binding to the CXCR7 target (CXCL11 and CXCL12 levels). Plasma CXCL12 concentrations are determined as described previously in Example A.

The results of the efficacy experiment are shown in Fig. 12. COMPOUND administered under therapeutic conditions exhibited dose-dependent efficacy on overall disease severity as evidenced by a significant reduction in mean cumulative disease scores (Fig. 12). The efficacy was associated with a dose-dependent increase in plasma CXCL11 and CXCL12 levels (Fig. 13).

Figure 12 shows the dose-response effect of COMPOUND on the overall extent of EAE disease as assessed by cumulative disease scores, defined as the sum of clinical scores for each mouse for 30 days after initiation of treatment. Mice were treated individually starting at the first signs of disease. Data are presented as means + SEM; n = 1416/group. *p < 0.05 compared with vehicle-treated EAE mice using the Kruskal-Wallis test followed by Dunn's multiple comparisons test.

Figure 13 shows the dose-dependent effect of COMPOUND on plasma CXCL12 concentrations in a mouse model of PLB-induced EAE. Data are presented as means + SEM; n = 13-14/group. ****p < 0.0001, using a one-way ANOVA test followed by Fisher's LSD uncorrected multiple comparisons test.

Based on the pilot experiment described above, a single dose of COMPOUND (dose: 100 mg/kg, b.i.d.) was selected for the combination efficacy experiment. The selected dose increased trough plasma CXCL11 and CXCL12 levels and maximally reduced clinical indices in the PLB-induced EAE model.

c. Experiment on the effectiveness of a combination in the model of EAE induced by:

The combination efficacy experiment is conducted on the same mouse model of EAE as for the pilot experiments.

Groups of 10 to 15 mice are dosed orally, starting at the onset of disease for each

- 31 048938 shi. The study consists of four treatment groups:

1) vehicle (0.5% methylcellulose/0.5% Tween® 80) b.i.d., from the onset of EAE;

2) siponimod (0.3 mg/kg) daily + Vehicle daily, from the onset of EAE;

3) COMPOUND (100 mg/kg) b.i.d., from the onset of EAE;

4) siponimod (0.3 mg/kg) daily + COMPOUND (100 mg/kg) b.i.d., from the onset of EAE.

Clinical parameters are assessed daily in a blinded manner, and disease progression is compared between vehicle-treated mice and mice receiving the different treatments, as well as between combination and monotherapy treatments. In parallel, body weights of mice are recorded daily to monitor general health. The experiment is terminated after at least 30 days of COMPOUND treatment for each mouse. Binding to S1P1 and CXCR7 targets, namely lymphocyte counts and plasma CXCL11 and CXCL12 levels, respectively, are measured at the end of the experiment. Plasma samples are also collected to determine COMPOUND and siponimod concentrations.

Example D. A study of the safety, tolerability, pharmacokinetics and pharmacodynamics of the COMPOUND may be conducted following a single dose in healthy male subjects.

a. Study design (ClinicalTrials.gov: NCT03869320).

In a randomized, double-blind, placebo-controlled study conducted for the first time in humans, six dose levels of COMPOUND are being tested, namely 1, 3, 10, 30, 100, and 200 mg. In each dose level group, six healthy male subjects receive COMPOUND and two healthy male subjects receive a matching placebo orally on an empty stomach in the morning.

Following each dose, subjects are monitored for 14 days to examine (i) tolerability and safety (adverse events, vital signs, clinical laboratory, ECG), (ii) pharmacokinetics (plasma COMPOUND concentrations), and (iii) pharmacodynamics (plasma CXCL11 and CXCL12). In the 30 mg dose level group, the effect of food is further examined by administering the same treatment to the same subjects after a standardized high-fat breakfast. Mass balance and ADME are further examined by administering orally a COMPOUND microtracer or matching placebo in combination with the assigned treatment in the 100 mg dose level group. Absolute bioavailability is further examined by administering i.v. a COMPOUND microtracer or matching placebo in combination with the assigned treatment in the 200 mg dose level group.

Results.

COMPOUND is safe and well tolerated over the entire single oral dose range of 1 to 200 mg. At doses >10 mg, t _max ranges from 1.3 to 3.0 h and terminal ti/g ranges from 17.8 to 23.6 h. The increase in exposure over the entire dose range is essentially dose proportional and there is no significant effect of food on the pharmacokinetics. In this study, COMPOUND was found to be excreted primarily in the faeces and to a minor extent in the urine. Absolute bioavailability was approximately 50%.

Plasma concentrations of the target binding biomarker CXCL12 increased dose-dependently across the dose range tested, with approximately 2-fold increases from baseline. Plasma CXCL12 concentrations and fold changes from baseline were similar after administration of 100 mg and 200 mg COMPOUND (Figure 14). The indirect response pharmacokinetic/pharmacodynamic model, which predicts the steady-state response, fits the relationship between COMPOUND and CXCL12 concentrations well (Figure 15). CXCL11 concentrations were essentially unchanged in healthy volunteers in this study.

Figure 14 shows the dose-dependent peak plasma CXCL12 concentrations in healthy volunteers enrolled in the study. Data are presented as fold change from baseline, where horizontal lines represent the mean and dots represent individual data points.

Figure 15 shows the predicted steady-state dose-response relationship stratified by dose. The dots represent the mean predicted fold change from baseline and the error bars represent the 80% prediction interval.

Example E. A study of the safety, tolerability, pharmacokinetics and pharmacodynamics of a COMPOUND can be determined after administration of different doses to healthy men and women.

a. Study design (ClinicalTrials.gov: NCT04286750).

In a randomized, double-blind, placebo-controlled study, different dose levels of COMPOUND, e.g., 30, 100, and 200 mg, are investigated. In each dose level group, eight healthy subjects (4 males and 4 females) receive COMPOUND and two healthy subjects (1 male and 1 female) receive matching placebo orally in the fasted state once daily for 7 days, e.g., in the morning. For 7 days post-dose and up to 8 days after the last dose, subjects are monitored to study (i) tolerability and safety (adverse events, vital signs, clinical laboratory, ECG), (ii) pharmacokinetics (COMPOUND concentration

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(iii) pharmacodynamics (including for example plasma CXCL11 and CXCL12 levels) and (iii) pharmacodynamics (including for example plasma CXCL11 and CXCL12 levels).

Claims (11)

1. A pharmaceutical composition containing (1-pyrimidin-2-yl-cyclopropyl)amide (3 S,4S)-1-cyclopropylmethyl-4-{[5-(2,4-difluorophenyl)isoxazole-3-carbonyl]amino} piperidine-3-carboxylic acid as an active ingredient: or a pharmaceutically acceptable salt thereof, in combination with an S1P1 receptor modulator, which is fingolimod or siponimod, or a pharmaceutically acceptable salt thereof, and at least one pharmaceutically acceptable excipient. 2. The use of (1-pyrimidin-2-yl-cyclopropyl)amide (3S,4S)-1-cyclopropylmethyl-4-{[5-(2,4-difluorophenyl)isoxazole-3-carbonyl]amino}piperidine-3-carboxylic acid or a pharmaceutically acceptable salt thereof for combination for the prevention or treatment of an autoimmune and/or inflammatory disease or disorder; wherein said disease or disorder is an autoimmune and/or inflammatory demyelinating disease or a disorder selected from multiple sclerosis (MS); idiopathic inflammatory demyelinating diseases; autoimmune encephalomyelitis including acute disseminated encephalomyelitis (ADEM) and multiphasic disseminated encephalomyelitis (MDEM); antimyelin oligodendrocyte glycoprotein (anti-MOG)-associated diseases, including anti-MOG encephalomyelitis; or Guillain-Barré syndrome; wherein (1-pyrimidin-2-yl-cyclopropyl)amide (3S,4S)-1-cyclopropylmethyl-4-{[5-(2,4-difluorophenyl)isoxazole-3-carbonyl]amino}piperidine-3-carboxylic acid is intended for administration in combination with an S1P1 receptor modulator, which is fingolimod or siponimod, or a pharmaceutically acceptable salt thereof. 3. The use of (1-pyrimidin-2-yl-cyclopropyl)amide (3S,4S)-1-cyclopropylmethyl-4-{[5-(2,4-difluorophenyl)isoxazole-3-carbonyl]amino}piperidine-3-carboxylic acid or a pharmaceutically acceptable salt thereof for the combination according to claim 2, wherein such use is intended for the treatment of a patient diagnosed with an autoimmune and/or inflammatory disease or disorder, wherein said treatment reduces the rate of progression of said autoimmune and/or inflammatory disease or disorder. 4. The use of (1-pyrimidin-2-yl-cyclopropyl)amide (3S,4S)-1-cyclopropylmethyl-4-{[5-(2,4-difluorophenyl)isoxazole-3-carbonyl]amino}piperidine-3-carboxylic acid or a pharmaceutically acceptable salt thereof for the combination according to claim 3, wherein said autoimmune and/or inflammatory disease or disorder is an autoimmune and/or inflammatory demyelinating disease or disorder selected from multiple sclerosis (MS); idiopathic inflammatory demyelinating diseases; autoimmune encephalomyelitis, including acute disseminated encephalomyelitis (ADEM) and multiphasic disseminated encephalomyelitis (MDEM); brainstem encephalitis; Guillain-Barré syndrome; chronic inflammatory demyelinating polyneuropathy (CIDP); antimyelin-associated glycoprotein (anti-MAG)-associated peripheral neuropathy; and myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease. 5. The use of (1-pyrimidin-2-yl-cyclopropyl)amide (3S,4S)-1-cyclopropylmethyl-4-{[5-(2,4-difluorophenyl)isoxazole-3-carbonyl]amino}piperidine-3-carboxylic acid or a pharmaceutically acceptable salt thereof for the combination according to claim 2, wherein such use is intended for the prevention or treatment of an autoimmune and/or inflammatory demyelinating disease or disorder. 6. The use of (1-pyrimidin-2-yl-cyclopropyl)amide (3S,4S)-1-cyclopropylmethyl-4-{[5-(2,4-difluorophenyl)isoxazole-3-carbonyl]amino}piperidine-3-carboxylic acid or a pharmaceutically acceptable salt thereof for the combination according to claim 5, where such use is intended: for the treatment of a patient diagnosed with MS, wherein said treatment reduces the rate of progression of MS; and/or improves symptoms of MS; and/or reduces the rate of demyelination; and/or reduces the rate of irreversible neurodegenerative damage such as axonal injury; and/or has a remyelination effect; and/or reduces the rate of brain atrophy/cerebral atrophy; or - 33 048938 for the prevention of MS, wherein said prevention of MS includes delaying the onset of MS in a subject who is at risk/who has been diagnosed with a risk of developing MS; wherein said subject is, in particular, a subject who has suffered from clinically isolated syndrome (CIS) or who has been diagnosed with suffered from CIS. 7. The use of (3S,4S)-1-cyclopropylmethyl-4-{[5-(2,4-difluorophenyl)isoxazole-3-carbonyl]amino}piperidine-3-carboxylic acid (1-pyrimidin-2-yl-cyclopropyl)amide or a pharmaceutically acceptable salt thereof for combination for the prevention or treatment of a neurodegenerative disease and disorder; wherein said neurodegenerative disease and disorder is amyotrophic lateral sclerosis (ALS), Huntington's disease, Alzheimer's disease (AD) or Parkinson's disease (PD); wherein (1-pyrimidin-2-yl-cyclopropyl)amide (3S,4S)-1-cyclopropylmethyl-4-{[5-(2,4-difluorophenyl)isoxazole-3-carbonyl]amino}piperidine-3-carboxylic acid is intended for administration in combination with an S1P1 receptor modulator, which is fingolimod or siponimod, or a pharmaceutically acceptable salt thereof. 8. The use of (3S,4S)-1-cyclopropylmethyl-4-{[5-(2,4-difluorophenyl)isoxazole-3-carbonyl]amino}piperidine-3-carboxylic acid (1-pyrimidin-2-yl-cyclopropyl)amide or a pharmaceutically acceptable salt thereof for the combination of claim 2, wherein said S1P1 receptor modulator, or a pharmaceutically acceptable salt thereof, is to be administered in a pharmaceutical dosage form suitable for oral administration of said S1P1 receptor modulator, and fingolimod or a pharmaceutically acceptable salt thereof, if present, is to be administered in said pharmaceutical dosage form at a unit dose suitable for oral administration, generally about 0.5 mg or less per day of fingolimod; Siponimod or a pharmaceutically acceptable salt thereof, if any, should be administered in the indicated pharmaceutical dosage form at a unit dose suitable for oral administration of a total of about 2 mg or less per day of siponimod. 9. The use of (3S,4S)-1-cyclopropylmethyl-4-{[5-(2,4-difluorophenyl)isoxazole-3-carbonyl]amino}piperidine-3-carboxylic acid (1-pyrimidin-2-yl-cyclopropyl)amide or a pharmaceutically acceptable salt thereof for the combination of claim 7, wherein said S1P1 receptor modulator, or a pharmaceutically acceptable salt thereof, should be administered in a pharmaceutical dosage form suitable for oral administration of said S1P1 receptor modulator, wherein fingolimod or a pharmaceutically acceptable salt thereof, if present, should be administered in said pharmaceutical dosage form at a unit dose suitable for oral administration, generally about 0.5 mg or less per day of fingolimod; Siponimod or a pharmaceutically acceptable salt thereof, if any, should be administered in the indicated pharmaceutical dosage form at a unit dose suitable for oral administration of a total of about 2 mg or less per day of siponimod. 10. The use of (1-pyrimidin-2-yl-cyclopropyl)amide (3S,4S)-1-cyclopropylmethyl-4-{[5-(2,4-difluorophenyl)isoxazole-3-carbonyl]amino}piperidine-3-carboxylic acid or a pharmaceutically acceptable salt thereof according to any one of claims 2 to 9, wherein said S1P1 receptor modulator or a pharmaceutically acceptable salt thereof should be administered at a dose that is a tolerated effective dose when administered as monotherapy; or at a dose that is lower than such a tolerated effective dose when administered as monotherapy. 11. The use of an S1P1 receptor modulator which is fingolimod or siponimod, or a pharmaceutically acceptable salt thereof, for a combination as defined in any of claims 2 to 10, wherein said S1P1 receptor modulator is intended to be administered in combination with (3S,4S)-1-cyclopropylmethyl-4-{[5-(2,4-difluorophenyl)isoxazole-3-carbonyl]amino}piperidine-3-carboxylic acid (1-pyrimidin-2-yl-cyclopropyl)amide or a pharmaceutically acceptable salt thereof.