TREATMENT OF RETINITIS PIGMENTOSA

The present invention relates to tetra- or pentapeptides for use in the treatment of retinitis pigmentosa.

State of the art

Retinitis pigmentosa (RP) belongs to a group of hereditary dystrophies characterised by progressive degeneration of the visual cells and abnormalities of the retinal pigment epithelium (RPE) which leads to blindness in a few decades, during which the vision slowly, but inexorably deteriorates.

Night blindness is the first manifestation of the disease, which generally arises during early adolescence, correlated with a deterioration of the rods and followed by progressive death of those cells.

Subsequently, patients suffering from RP exhibit a narrowing of the visual field (tunnel vision), resulting from a further loss of rods in the peripheral part of the retina, where those cells predominate. The disease further develops with a progressive reduction of visual acuity in the central field of vision and alterations of color perception, due to the progressive disappearance of the cones. Although said cells represent less than 5% of all the retinal photoreceptors, their role in the eyesight is crucial, and their degeneration leads to blindness in patients suffering from RP. Further complications of RP are posterior subcapsular cataract and cystoid macular oedema. Other forms of RP also exist: Usher syndrome (wherein RP is associated with deafness); Bardet Biedl syndrome (wherein RP is accompanied by Polydactyly, obesity, hypogenitalism and learning disability); and Leber congenital amaurosis (LCA), characterised by blindness from birth.

A distinguishing sign of RP is enormous genetic heterogeneity, with over 3000 mutations (Clin. Genet. 2013, 84, 132-141) in 54 different genes and 61 loci currently known to cause the non-syndromic form of the disease. The biological mechanisms connecting the mutations responsible for RP with the damage observed in the cones and rods are still not fully understood. Apoptosis is generally considered to be the main cause of photoreceptor death (Curr. Mol. Med. 2009, 9, 375-383; Prog. Retin. Eye Res. 2014, 43, 17-75). The possible causes of cone death include oxidative stress.

Although numerous treatments have been proposed for the treatment of RP, they have all exhibited very limited efficacy so far.

The most extensively studied of the possible treatments is gene therapy. The therapeutic window for gene therapy progressively narrows as the visual cells are lost. Moreover, the disappearance of the photoreceptors shows no sign of declining, even after gene therapy (N. Engl. J. Med. 2015, 372, 1887-1897; Proc. Natl. Acad. Sci. U. S. A. 2013, 1 10, E517-E525), and it is unclear whether this is due to the low doses of viral vectors used to date in humans for safety reasons, or to unknown biological factors.

In addition to the limitations described above, it is clear that gene therapy, being a customized treatment that must take account of the enormous genetic heterogeneity of the disease, is not very practicable, especially due to the very high costs of development for small groups of patients carrying the same mutation.

Another therapeutic approach is to implant various types of electronic prosthesis, which are positioned in contact with the innermost layer of the retina, close to the ganglion cells (epiretinal prostheses), or in place of the photoreceptors (subretinal implants) (Vis. Res. 2002, 42, 393e399; Ophthalmic Res. 2013, 50, 215-220; J. Biomater. Sci. Polym. Ed. 2007, 18, 1031-1055). However, these bionic implants are still rudimentary, and to date only produce a minimal ability to locate light sources, and therefore only improve performance in mobility tests.

Possible pharmacological strategies for treating RP are based on:

neuroprotection (CA2236157, FR2784898, WO2009089399,

WO20091 1 1 169, WO200701 1880); reduction of oxidative stress (US2015328337, US2014044693, US2012108654, US2008317885, WO20081 1 1497);

inhibition of photoreceptor apoptosis (JP2003089643 JP4953040);

attenuation of retinal inflammation (WO20151 10556);

- use of antiangiogenics (US2012263794, JP2012062258, US2004176290, US6451799).

Any pharmacological approach to retinal diseases must obviously enable the medicament to cross the physical and functional barriers (eye tissues and blood- retinal barrier) which in practice can prevent the medicament from reaching the target cells in the retina.

The pharmacological strategies proposed to date are based on the use of neurotrophic factors; nerve growth factor (NGF); valproic acid (VP A); vitamin A or docosahexaenoic acid (DHA); antiinflammatories (dexamethasone, fluocinolone acetonide); anti-oxidants (unopro stone); 9-cis-retinal (QLT091001); antiapoptotics; sphingolipids; and chemical photo switches.

The multiplicity of therapeutic approaches proposed demonstrates the lack of a really effective treatment for all the many forms of RP.

The advantages, and above all the limitations, of these strategies, were described recently (Progress in Retinal and Eye Research 2015, 48, 62-81).

The information set out above demonstrates the need to develop innovative treatment strategies that allow effective, non-traumatic treatment of RPs of different etiologies, all of which inexorably lead to blindness.

The pharmaceutical formulations for the prevention and treatment of the various forms of RP described below are characterized by limited costs and low- trauma administration routes, which allow repeated administrations and effective, constant levels of active ingredient over time.

Description of the invention

It has now been found that tetra- or pentapeptides, described in WO2008/017372 as cell motility inhibitors and antitumorals, are effective in the treatment of retinitis pigmentosa and the complications thereof, not only by intravitreal administration, but also by systemic, especially subcutaneous, forms of administration.

The object of the invention is therefore said peptides for use in the treatment of retinitis pigmentosa. Said peptides, preferably administered systemically, allow the prevention and treatment of the disease without significant toxic side effects.

The peptides for use according to the invention, which can be used as such or in salified form, have the general formula L1-X1-X2-X3-X4, wherein:

Li is H, or acyl, or an optionally N-acylated and/or N-alkylated and/or

Ca-alkylated amino acid selected from Glu, Gin, Pro, hydroxy-Pro, Azt, Pip, pGlu, Aib, Ac4c, Ac5c and Ac6c;

Xi and X3, which can be the same or different, are an optionally N-alkylated and/or Ca-alkylated basic amino acid, selected from Arg, Orn and optionally guanidylated Lys, and phenylalanines substituted at the meta or para positions with an amino or guanidino group;

X2 is an optionally N-alkylated amino acid selected from Glu, Lys, a-methyl-leucine, a-methyl-valine, a-methyl-glutamic acid, Aib, Ac4c, Ac5c and Ac6c;

X ₄ is a hydrophobic amino acid which is amidated or non-amidated at the

C-terminal end and optionally Ca-alkylated, selected from Phe, h-Phe, Tyr, Trp, 1-Nal, 2-Nal, h-l-Nal, h-2-Nal, Cha, Chg and Phg.

The following are the conventional abbreviations used for some of the unnatural amino acids which can be included in the formulas of the peptides according to the invention:

Azt = azetidine acid, Pip = pipecolic acid, Aib = a-amino-isobutyric acid, Ac4c = 1 -aminocyclobutane- 1 -carboxylic acid, Ac5c = 1-aminocyclopentane-l- carboxylic acid, Ac6c = 1-aminocyclohexane-l -carboxylic acid, h-Phe = homophenylalanine, 1-Nal = β-1-naphthyl-alanine, 2-Nal = β-2-naphthyl-alanine, h-l-Nal = homo- -l-naphthyl-alanine, h-2-Nal = homo-P-2-naphthyl-alanine, Cha = cyclohexyl-alanine, Chg = cyclohexyl-glycine, Phg = phenyl-glycine, pGlu = pyroglutamic acid.

The preferred peptides for use according to the invention have the sequences reported in the annexed Sequence Listing and in the table below:

SEQ ID 20 Ace Arg Aib N(Me)Arg Tyr-NH ₂

SEQ ID 21 Ace Arg Aib N(Me)Arg Τφ-ΝΗ ₂

SEQ ID 22 pGlu Arg Aib N(Me)Arg Phe-NH ₂

SEQ ID 23 pGlu Arg Aib N(Me)Arg Tyr-NH ₂

SEQ ID 24 pGlu Arg Aib N(Me)Arg Τφ-ΝΗ ₂

SEQ ID 25 pGlu Arg Aib Arg Phe-NH ₂

SEQ ID 26 pGlu Arg Aib Arg Tyr-NH ₂

SEQ ID 27 pGlu Arg Aib Arg Τφ-ΝΗ ₂

SEQ ID 28 Ace Arg Ac5c Arg Phe-NH ₂

SEQ ID 29 Ace Arg Ac5c Arg Tyr-NH ₂

SEQ ID 30 Ace Arg Ac5c Arg Τφ-ΝΗ ₂

SEQ ID 31 Ace Arg Ac5c N(Me)Arg Phe-NH ₂

SEQ ID 32 Ace Arg Ac5c N(Me)Arg Tyr-NH ₂

SEQ ID 33 Ace Arg Ac5c N(Me)Arg Τφ-ΝΗ ₂

SEQ ID 34 pGlu Arg Ac5c N(Me)Arg Phe-NH ₂

SEQ ID 35 pGlu Arg Ac5c N(Me)Arg Tyr-NH ₂

SEQ ID 36 pGlu Arg Ac5c N(Me)Arg Τφ-ΝΗ ₂

SEQ ID 37 pGlu Arg Ac5c Arg Phe-NH ₂

SEQ ID 38 pGlu Arg Ac5c Arg Tyr-NH ₂

SEQ ID 39 pGlu Arg Ac5c Arg Τφ-ΝΗ ₂

SEQ ID 40 Ace Arg Glu Arg Phe-OH

SEQ ID 41 Ace Arg Glu Arg Tyr-OH

SEQ ID 42 Ace Arg Glu Arg Τφ-ΟΗ

SEQ ID 43 Ace Arg Glu Arg(Me) Tyr-OH

SEQ ID 44 pGlu Arg Glu Arg(Me) Phe-OH

SEQ ID 45 pGlu Arg Glu Arg Τφ-ΟΗ

SEQ ID 46 Ace Arg Aib Arg Phe-OH SEQ ID 47 Ace Arg Aib Arg(Me) Phe-OH

SEQ ID 48 pGlu Arg Aib Arg(Me) Tyr-OH

SEQ ID 49 pGlu Arg Aib Arg Trp-OH

SEQ ID 50 Ace Arg Ac5c Arg Phe-OH

SEQ ID 51 Ace Arg Ac5c Arg(Me) Tyr-OH

SEQ ID 52 pGlu Arg Ac5c Arg(Me) Trp-OH

SEQ ID 53 pGlu Arg Ac5c Arg Trp-OH

SEQ ID 54 Ace N(Me)Arg Aib Arg Phe-NH ₂

SEQ ID 55 Ace N(Me)Arg Aib N(Me)Arg Phe-NH ₂

SEQ ID 56 Ace Arg Aib N(Me)Arg Phe-NH ₂

SEQ ID 57 Ace Arg Aib Arg a(Me)Phe-NH ₂

SEQ ID 58 Ace N(Me)Arg Aib Arg a(Me)Phe-NH ₂

SEQ ID 59 Ace N(Me)Arg Aib N(Me)Arg a(Me)Phe-NH ₂

SEQ ID 60 Ace Arg Aib N(Me)Arg a(Me)Phe-NH ₂

SEQ ID 61 Ace-Aib N(Me)Arg Aib Arg Phe-NH ₂

SEQ ID 62 Ace-Aib N(Me)Arg Aib N(Me)Arg Phe-NH ₂

SEQ ID 63 Ace-Aib Arg Aib N(Me)Arg Phe-NH ₂

SEQ ID 64 Ace-Aib Arg Aib Arg a(Me)Phe-NH ₂

SEQ ID 65 Ace-Aib N(Me)Arg Aib Arg a(Me)Phe-NH ₂

SEQ ID 66 Ace-Aib N(Me)Arg Aib N(Me)Arg a(Me)Phe-NH ₂

SEQ ID 67 Ace-Aib Arg Aib N(Me)Arg a(Me)Phe-NH ₂

The peptides Ac-Arg-Aib-Arg-a(Me)Phe-NH ₂ and Ac-Aib-Arg-Aib-Arg- a(Me)Phe-NH ₂ are particularly preferred.

Other types of applications of these peptides, in particular as antitumorals, are known from the literature (FEBS Letters, 582, (2008) 1 141-1 146. Mol Cancer Ther, 8, (2009) 2708-2717, Mol Cancer Ther, 12, (2013) 1981-1993, Mol Cancer Ther, 13, (2014) 1092-1 104). The activity of Ac-Arg-Aib-Arg-a(Me)Phe-NH ₂ (SEQ ID 64) (also called UPARANT) in reducing retinal neovascularization in mice with oxygen-induced retinopathy (OIR), repairing dysfunctions of the blood- retinal barrier, and reducing the anti-inflammatory markers, when administered by intravitreal injection, is also known (IOVS, (2015), 56(4) 2392-2407).

All the peptides according to the invention are characterised by high affinity for the formyl-peptide receptor (N-formyl-Met-Leu-Phe; FPR) and, by binding to it, exhibit their biological activity. Moreover, although it has been reported that the peptide Ac-Arg-Aib-Arg-a(Me)Phe-NH ₂ (SEQ ID 64) (IOVS, (2015), 56(4) 2392- 2407) does not modify the structure of the retina, it has even more surprisingly been found that said peptide is able to restore nearly all the strongly deteriorated retinal structure in RCS/KYO rats, one of the most accredited animal models for the study of RP. Finally, despite their peptide nature, the compounds according to the invention exhibit an excellent pharmacological profile and, when administered systemically, especially subcutaneously, cross the blood-eye barrier. In particularly serious cases of RP, intravitreal administration is preferable, and can subsequently be replaced by maintenance treatment comprising systemic administration.

The hydrophilic nature of the peptides according to the invention allows the use of simple, low-cost pharmaceutical formulations which are particularly suitable for injectable formulations for the treatment of RP.

For therapeutic use in the treatment of RP and its various forms, such as

Usher syndrome, Bardet Biedl syndrome and Leber congenital amaurosis, as well as its complications, such as posterior subcapsular cataract and cystoid macular oedema, the peptides according to the invention can be formulated as such, or in the form of salts, in liquid or solid pharmaceutical compositions, which can be administered subcutaneously, intramuscularly, intravenously, intraocularly, orally, nasally, sublingually, topically, transdermally or by inhalation, or applied as eyedrops and ointments. Subcutaneous administration is preferred.

The doses of the peptide in humans can vary within wide ranges, typically from 10 μg to 500 mg per dose, and preferably between 1 mg and 200 mg. However, said doses can easily be determined by the expert, depending on the stage of the disease and taking account of the patient's weight, gender and age, and obviously the administration method.

Examples of pharmaceutical compositions of the peptides according to the invention include: a) liquid preparations, such as suspensions, syrups or elixirs for oral, nasal, anal, vaginal or intragastric administration, or for mucosal administration (e.g. perlingual, alveolar or gingival, and via the olfactory or respiratory mucosa); b) sterile solutions, suspensions or emulsions for parenteral, ocular, subcutaneous, intradermal, intramuscular or intravenous administration. In addition to one or more of the peptides according to the invention, said compositions can also contain other active ingredients and rheological compounds commonly used in pharmaceutical technology.

The following examples illustrate the invention in greater detail.

EXAMPLE 1 - Formulations containing Ac-Arg-Aib-Arg-a(Me)Phe-NH2

(SEQ 19) or Ac-Aib-Arg-Aib-Arg-a(Me)Phe-NH ₂ (SEQ ID 64)

A) The peptide Ac-Arg-Aib-Arg-a(Me)Phe-NH2 or Ac-Aib-Arg-Aib-Arg- a(Me)Phe-NH2 in the form of acetate or succinate salt is dissolved at the active ingredient concentration of 1.2, 7.6 or 16.6 mg/mL in 0.9% aqueous NaCl. The pH is adjusted to 7.2 with an 0.1 M solution of NaOH. After sterilization by filtration, the formulation is ready for use.

B) The peptide Ac-Arg-Aib-Arg-a(Me)Phe-NH2 or Ac-Aib-Arg-Aib-Arg- a(Me)Phe-NH2 in the form of acetate or succinate salt is dissolved at the active ingredient concentration of 1.2, 7.6 or 16.6 mg/mL in a buffer solution containing: KC1=0.2 g/L; KH ₂ PO ₄ =0.24 g/L; NaCl=8.0 g/L; Na ₂ HPO ₄ (anhydrous)=1.44 g/L. After sterilization by filtration, the formulation is ready for use.

C) The peptide Ac-Arg-Aib-Arg-a(Me)Phe-NH2 or Ac-Aib-Arg-Aib-Arg- a(Me)Phe-NH2 in the form of acetate or succinate salt is dissolved at the active ingredient concentration of 1.2, 7.6 or 16.6 mg/mL in a buffer solution containing: CaC 2H ₂ O=0.133g/L; MgCl ₂ 6H ₂ O=0.1g/L; KC1=0.2 g/L; KH ₂ PO ₄ =0.2 g/L; NaCl=8.0 g/L; Na ₂ HPO ₄ (anhydrous)=1.15 g/L. After sterilization by filtration, the formulation is ready for use.

D) An 0.5% solution of sodium hyaluronate (average molecular weight 1200 kDa) in 248.8 mM ammonium acetate (total 50 mL) is washed by dialysis against 24.88 mM ammonium acetate in a membrane with an 8 kDa cutoff. Four washes are conducted: lxl L for 7 h; 1x500 mL for 7h; 2x500 mL against water for 7h. 505.5 mg of Ac-Arg-Aib-Arg-a(Me)Phe-NH ₂ as acetate salt is added to the ammonium hyaluronate solution present in the dialysis membrane (68.5 mL). After stirring for 2h, the solution is freeze-dried. A salt containing peptide/hyaluronic acid (monomer)/acetate in the ratio 1/1/1 in moles is obtained. Said salt is dissolved in water and the pH adjusted to 7.2 with 0.1M NaOH, until hyaluronic acid concentrations of 14.8 mg/mL, peptide = 24.0 mg/mL, are obtained. After sterilization by filtration, the formulation is ready for use.

EXAMPLE 2 - Efficacy in the treatment of CS/KYO rats by intravitreal or subcutaneous administration.

The RCS/Kyo rat (Royal College of Surgeons rat) represents the most commonly used model in the study of this eye disease. RCS rats present retinal degeneration that makes them the ideal model for the study of this disease. In particular, due to deletion in the Mertk gene encoding for a tyrosine kinase receptor, the rats exhibited retinal degeneration from the age of three weeks. The epithelial cells of the retina in these animals are unable to ingest the epithelial photoreceptor cells, and those photoreceptors therefore die.

45 male and female RCS/Kyo rats, aged 14/21 days, were employed, using the tetrapeptide Ac-Arg-Aib-Arg-a(Me)Phe-NH ₂ , formulated as reported in example 1A, at the concentration of 1.2 mg/mL for intravitreal injection, or 7.6 mg/mL for subcutaneous injection. The treatment regimen used is set out below:

After euthanasia of the rats at the age of 49 days, the thickness of the retina e various groups was measured under the microscope:

Study group Retinal thickness μηι % of control

S-ivt-sd-t 132.08 1 10

S-sc-rd-t 182.67 153

S-sc-rd-p 155.25 130

C-sc 1 19.75 100

C-ivt 120.00 100 In all the treated groups, a considerable increase in retinal thickness was observed after both preventive treatment, albeit to a lesser extent, and repeated subcutaneous treatment.

The thickness of the outer layer of granules (outer nuclear layer, ONL, cell body of cones and rods) was also measured.

In this case, an increase in the thickness of the ONL was observed for both preventive treatment and therapeutic treatment. A single dose of 4 μg per eye increases the photoreceptor layer by 34%, while repeated subcutaneous doses actually double the thickness of the layer.

EXAMPLE 3 - Pharmacokinetics and tissue distribution in the rat of subcutaneous and intravitreal administrations of Ac-Arg-Aib-Arg-a(Me)Phe-NH2.

10 Male Sprague-Dawley rats were used. The rats were divided into two groups of 5 for determination of plasma pharmacokinetics and tissue distribution, by single subcutaneous administration at the dose of 16.6 mg/kg in a volume of 1 mL/kg. Blood samples were taken after 0.25, 0.5, 1, 2, 4, 6, 8 and 24 hours; subsequently, in the second group of rats, tissue samples were taken at Tmax. The kinetic equation, Cmax, Tmax, plasma half-life and AUC were determined. The concentrations were measured by LC-MS. The pharmacokinetic parameters are set out in the table below:

After the subcutaneous injection a moderate absorption process was observed, as demonstrated by a Tmax of about 2 hours and a Cmax of 5.91 ± 1.18 μg/mL. Said process was followed by disappearance of the compound from the plasma up to 24 hours, albeit with concentration values lower than the sensitivity limit of the method. The kinetic equation can be written as C(t)=Co(e ^" o.32it_ _e -o,674t^ if t i _s expressed in hours and C as mg/L.

This study demonstrates that the subcutaneous administration route makes the compound available. Moreover, as well as reaching the systemic circulation from the injection site, the compound is also present in the various tissues examined, as summarized in the table below:

The table shows the tissue concentrations expressed as mg/kg at Tmax after administration. As will be seen, the kidney is the organ with the highest values compared with the other tissues. However, in the eyes, which represent the target tissue, the peptide is present with a tissue plasma ratio of about 5.