FIELD OF THE INVENTION

The invention relates to methods of treating viral infections.

BACKGROUND

Coronaviruses are a large family of viruses that usually cause mild to moderate upper-respiratory tract illnesses, like the common cold, in people. However, three times in the 21st century coronavirus outbreaks have emerged from animal reservoirs to cause severe disease and global transmission concerns.

COVID-19, for example, which emerged in December 2019 from the city of Wuhan, Hubei, China, is due to an infection by the beta-coronavirus SARS-CoV-2 (severe cute respiratory syndrome coronavirus 2). Patients initially present with fever with or without respiratory symptoms, but a large number of patients later develop various degrees of pulmonary abnormalities on chest imaging. Although the vast majority of patients only have a common, mild form of illness, approximately 15% of the patients fall into the severe group, with requirement of assisted ventilation and oxygenation. These patients suffer from acute respiratory distress syndrome. Some patients develop severe cardiovascular damage. Other complications include, e.g., acute cardiac injury, acute kidney injury, septic shock, multi-organ failure, and increased risk of death. Potential for long term damage has also been noted. Pathologic findings reveal edema and prominent proteinaceous exudates, vascular congestion, and inflammatory clusters with fibrinoid material and multinucleated giant cells.

Colchicine is an inexpensive drug that is approved for acute use in patients with gout and chronic use in patients with Familial Mediterranean Fever.

There is a need for new methods of treating a coronavirus infection (e.g., COVID-19), especially using readily available, inexpensive medications.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a schematic illustration of the consort diagram of a treatment course of patients during a doubleblind trial. 4,488 patients with COVID-19 aged >40 years were included for intention-to-treat (ITT) and received colchicine or placebo for 30 days. SUMMARY OF THE INVENTION

The invention provides a method of treating a coronavirus infection (preferably, a SARS-CoV-2 infection) in a subject; the method including administering colchicine to the subject. In some embodiments the SARS-CoV-2 infection is COVID-19.

In some embodiments, colchicine is administered daily. In some embodiments, the colchicine is administered once, twice, or three times a day. In some embodiments, colchicine is administered twice daily for 3 days. In some embodiments, colchicine is administered twice daily for 3 days followed by once daily. In some embodiments, the once daily administration is for 27 days.

In some embodiments, 0.3 to 2.4 mg of colchicine is administered daily. In some embodiments, 0.4 to 0.6 mg of colchicine is administered daily. In some embodiments, 0.5 mg of colchicine is administered daily.

In some embodiments, for subjects between 4 and 6 years old, 0.3 to 1 .8 mg of colchicine is administered daily. In some embodiments for subjects 6 to 12 years old, 0.9 to 1 .8 mg of colchicine is administered daily. In some embodiments for subjects older than 12 years, 1.2 to 2.4 mg of colchicine is administered daily.

In some embodiments, colchicine is in the form of a tablet. In some embodiments, the administration is oral administration.

In some embodiments, the subject was diagnosed with the coronavirus infection within 24 hours prior to initiating the treatment. In some embodiments, the administration of colchicine is initiated upon assessment in (a) an emergency department (ED), (b) a hospital, (c) a medical office setting, or (d) a coronavirus testing facility. In some embodiments, the subject is 70 years or more of age, has diabetes mellitus, has a systolic blood pressure >150 mm Hg, has a known respiratory disease, has known heart failure, has known coronary disease, has had a fever of >38.4°C within the last 48 hours, has dyspnea at the time of presentation, has bicytopenia, has pancytopenia, or has a combination of high neutrophil count and low lymphocyte count. In some embodiments, the known respiratory disease is asthma or chronic obstructive pulmonary disease.

In some embodiments, treatment with colchicine reduces morbidity or mortality in the clinical course of the coronavirus infection (e.g., COVID-19), reduces symptoms caused by the coronavirus infection, or reduces the need for ventilator dependency. In some embodiments, treatment with colchicine results in a decrease in one or more symptoms related to the coronavirus infection (e.g., COVID-19). In some embodiments, the one or more symptoms related to the coronavirus infection (e.g., COVID-19) is selected from the group consisting of fever, sore throat, runny nose, sneezing, nasal congestion, snoring, coughing, dry cough, shortness of breath, difficulty breathing, persistent pain or pressure in the chest, dyspnea, pneumonia, acute respiratory syndrome, cyanosis, myalgia, headache, encephalopathy, myocardial injury, heart failure, arrhythmia, coagulation dysfunction, acute kidney injury, confusion or inability to arouse, fatigue, or gastrointestinal symptoms. In some embodiments, the snoring is dry or wet snoring. In some embodiments, the cyanosis includes bluish lips or face. In some embodiments, the gastrointestinal symptoms are vomiting, abdominal pain, nausea, or diarrhea.

In some embodiments, colchicine is administered in combination with a second therapeutic. In some embodiments, the second therapeutic is an anti-viral drug (e.g., remdesivir). In some embodiments, the second therapeutic is an anti-malarial medication (e.g., chloroquine). In some embodiments, the second therapeutic is an antibiotic (e.g., azithromycin). In some embodiments, the second therapeutic is an antiinflammatory drug (e.g., a steroid, parenteral immunoglobulin, or aspirin).

In some embodiments, the subject is a human. In some embodiments, the subject is less than 21 years old (e.g., 0 to 19 years old). In some embodiments, the subject is 1 to 5 years old. In some embodiments, the subject is less than one year old. In some embodiments for subjects who are less than 21 years old (e.g., 0 to 19 years old), the subject has been diagnosed with Multisystem Inflammatory Syndrome (MIS-C or PMIS). In other embodiments for subjects who are less than 21 years old (e.g., 0 to 19 years old), the subject has been diagnosed with Kawasaki Disease or Kawasaki Disease Shock Syndrome.

The invention also provides a method of treating Kawasaki Disease or Kawasaki Disease Shock Syndrome in a subject; the method including administering colchicine to the subject.

In some embodiments, the subject is 1 to 5 years old or the subject is less than one year old.

In some embodiments, 0.3 to 2.4 mg of colchicine is administered daily. In some embodiments, 0.3 and 1 .8 mg of colchicine is administered daily. In some embodiments, 0.4 to 0.6 mg of colchicine is administered daily. In some embodiments, 0.5 mg of colchicine is administered daily.

In some embodiments, colchicine is administered in combination with a second therapeutic. In some embodiments, the second therapeutic is an anti-inflammatory drug (e.g., a steroid, parenteral immunoglobulin, or aspirin).

Definitions

The term “colchicine,” as used herein, refers to a compound of the following structure:

The term “pharmaceutical composition,” as used herein, represents a composition formulated with a pharmaceutically acceptable excipient, and manufactured or sold with the approval of a governmental regulatory agency as part of a therapeutic regimen for the treatment of disease in a subject.

The term “subject,” as used herein, refers to a human suffering from or at risk of a coronavirus infection (e.g., a SARS-CoV-2 infection). A subject may be diagnosed as having a coronavirus infection (e.g., a SARS-CoV-2 infection) or may be one experiencing one or more symptoms of a coronavirus infection (e.g., a SARS-CoV-2 infection). Non-limiting examples of coronavirus infection (e.g., a SARS-CoV-2 infection ) symptoms include fever, sore throat, runny nose, sneezing, nasal congestion, snoring (e.g., dry or wet snoring), coughing, dry cough, shortness of breath, difficulty breathing, persistent pain or pressure in the chest, dyspnea, pneumonia, acute respiratory syndrome, cyanosis, myalgia, headache, encephalopathy, myocardial injury, heart failure, arrhythmia, coagulation dysfunction, acute kidney injury, confusion or inability to arouse, fatigue, and gastrointestinal symptoms. Subjects at risk of severe ramifications from a SARS-CoV-2 infection are those 70 years or more of age, having diabetes mellitus, having a systolic blood pressure >150 mm Hg, having a known respiratory disease, having known heart failure, having known coronary disease, having had a fever of >38.4°C within the last 48 hours, having dyspnea at the time of presentation, having bicytopenia, having pancytopenia, or having a combination of high neutrophil count and low lymphocyte count. In some instances, the subject is a pediatric or adolescent subject, e.g., a subject that is less than 21 years old, O to 19 years old, 1 to 5 years old, or less than one year old. In some instances, the pediatric or adolescent subject has been diagnosed with Multisystem Inflammatory Syndrome (PMIS or MIS-C described below), Kawasaki Disease, or Kawasaki Disease Shock Syndrome.

A diagnosis of Multisystem Inflammatory Syndrome in Children (MIS-C) may be made for a subject aged <21 years presenting with fever of greater than 100.4°F or 38.0°C for >24 hours, or report of subjective fever lasting >24 hours, laboratory evidence of inflammation (an elevated C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen, procalcitonin, d-dimer, ferritin, lactic acid dehydrogenase (LDH), or interleukin 6 (IL-6), elevated neutrophils, reduced lymphocytes and low albumin), and evidence of clinically severe illness requiring hospitalization, with multisystem (>2) organ involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurological); and no alternative plausible diagnoses; and positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or COVID-19 exposure within the 4 weeks prior to the onset of symptoms.

A diagnosis for Pediatric Multisystem Inflammatory Syndrome (PMIS) may be made for a subject presenting fever (a temperature of 100.4°F or 38.0°C or greater) lasting several days, along with other symptoms, such as irritability or sluggishness, abdominal pain without another explanation, diarrhea, vomiting, a rash, conjunctivitis (or red or pink eyes), enlarged lymph node (“gland”) on one side of the neck, red, cracked lips or red tongue that looks like a strawberry, or swollen hands and feet, which might also be red.

“Treatment” and “treating,” as used herein, refer to the medical management of a subject with the intent to improve, ameliorate, stabilize, prevent or cure a disease, disorder, or condition. This term includes active treatment (treatment directed to improve the disease, disorder, or condition); palliative treatment (treatment designed for the relief of symptoms of the disease, disorder, or condition); and supportive treatment (treatment employed to supplement another therapy). “Treatment” and “treating,” as used herein, also refers to disease modification, meaning, that the expression of the disease is modified towards a less severe expression of the symptoms. For example, a treatment may reduce the lethal outcomes in the treated subjects relative to the untreated subjects, the need for mechanical ventilation for the treated subjects relative to the untreated subjects, or the viral load in the treated subjects relative to the untreated subjects.

The term “unit dosage form,” as used herein, represents a unit of a pharmaceutical composition intended for administration to a subject as is without further modification. Non-limiting examples of a unit dosage form include a tablet, capsule, lozenge, wafer, film, sachet, and cachet. Preferably, the unit dosage form is a tablet.

DETAILED DESCRIPTION

In general, the invention provides methods of treating a coronavirus infection (e.g., a SARS-CoV-2 infection) in a subject using colchicine. The method typically involves administering colchicine to the subject in need thereof.

A coronavirus infection is caused by a coronavirus. Coronaviruses constitute the subfamily orthocoronavirinae in the family Coronaviridae. Coronaviruses often cause illness ranging from the common cold to more severe diseases, such as COVID-19 (a SARS-CoV2 infection), Middle East Respiratory Syndrome (MERS-CoV), Severe Acute Respiratory Syndrome (SARS-CoV), HCoV NL63, and HKU1 . Coronaviruses are typically zoonotic. Common symptoms of a coronavirus infection include fever, sore throat, runny nose, sneezing, nasal congestion, snoring, coughing, dry cough, shortness of breath, difficulty breathing, persistent pain or pressure in the chest, dyspnea, pneumonia, acute respiratory syndrome, cyanosis, myalgia, headache, encephalopathy, myocardial injury, heart failure, arrhythmia, coagulation dysfunction, acute kidney injury, confusion or inability to arouse, fatigue, and gastrointestinal symptoms. In more severe cases, a coronavirus infection may cause pneumonia, severe acute respiratory syndrome, kidney failure, and even death. A subject may be predisposed to a severe case of a coronavirus infection (e.g., a SARS-CoV-2 infection). For example, a subject predisposed to a severe case of a coronavirus infection (e.g., a SARS-CoV-2 infection) may be 70 years or more of age, have diabetes mellitus, have a systolic blood pressure >150 mm Hg, have a known respiratory disease, have known heart failure, have known coronary disease, have had a fever of >38.4°C within the last 48 hours, have dyspnea at the time of presentation, have bicytopenia, have pancytopenia, or have a combination of high neutrophil count and low lymphocyte count.

In pediatric subjects, the coronavirus infection may result in the subject exhibiting some of the clinical features of Kawasaki Disease or Kawasaki Disease Shock Syndrome (KDSS). Generally, these pediatric subjects are younger than 5 years of age. Kawasaki Disease is a rare inflammatory disease that causes blood vessels to become inflamed or swollen throughout the body. The hallmark of Kawasaki Disease is a persistent high fever (over 101 °F) for at least 4 days in addition to rash, redness to eyes, lips/tongue, swelling and redness to hands/feet and neck swelling. KDSS is a rare form of this disease characterized by severe inflammation resulting in a child becoming critically ill. KDSS refers to Kawasaki disease patients who present more than 20% decrease in systolic blood pressure compared to healthy individuals of the same age, or to those patients who show peripheral blood circulation perfusion disorder.

In other pediatric or adolescent subjects, the coronavirus invention may result in the subject exhibiting features of Multisystem Inflammatory Syndrome (PMIS or MIS-C). A key finding of Multisystem Inflammatory Syndrome is evidence of severe inflammation, which is similar to Kawasaki Disease or, in some cases, more severe than Kawasaki Disease. Children with Multisystem Inflammatory Syndrome also have high fevers and can present with red eyes and rash. However, Multisystem Inflammatory Syndrome patients tend to be older than typical Kawasaki Disease patients. Some of their blood tests, including markers of inflammation, are more abnormal than patients with Kawasaki disease. Severe abdominal pain and diarrhea is another common complaint with Multisystem Inflammatory Syndrome. Advantageously, colchicine therapy described herein may reduce lethal outcomes in the treated subjects relative to the untreated subjects, the need for mechanical ventilation for the treated subjects relative to the untreated subjects, or the viral load in the treated subjects relative to the untreated subjects.

Colchicine is preferably formulated into pharmaceutical compositions for administration to human subjects in a biologically compatible form suitable for administration in vivo. Pharmaceutical compositions described herein typically include colchicine and a pharmaceutically acceptable excipient.

Colchicine may be administered, for example, by oral, parenteral, buccal, sublingual, nasal, rectal, patch, pump, ortransdermal administration, and the pharmaceutical compositions formulated accordingly. Parenteral administration includes intravenous, intraperitoneal, subcutaneous, intramuscular, transepithelial, nasal, intrapulmonary, intrathecal, rectal, and topical modes of administration. Parenteral administration may be by continuous infusion over a selected period of time. Preferably, colchicine is administered orally.

For human use, colchicine can be administered alone or in admixture with a pharmaceutical carrier selected with regard to the intended route of administration and standard pharmaceutical practice. Pharmaceutical compositions thus can be formulated in a conventional manner using one or more physiologically acceptable carriers comprising excipients and auxiliaries that facilitate processing of colchicine into preparations which can be used pharmaceutically.

This invention also includes pharmaceutical compositions which can contain colchicine and one or more pharmaceutically acceptable carriers. In making the pharmaceutical compositions of the invention, the active ingredient (colchicine) is typically mixed with an excipient, diluted by an excipient or enclosed within such a carrier in the form of, for example, a capsule, sachet, paper, or other container. When the excipient serves as a diluent, it can be a solid, semisolid, or liquid material (e.g., normal saline), which acts as a vehicle, carrier or medium for the active ingredient. Thus, the compositions can be in the form of tablets, powders, lozenges, sachets, cachets, elixirs, suspensions, emulsions, solutions, syrups, and soft and hard gelatin capsules. As is known in the art, the type of diluent can vary depending upon the intended route of administration. The resulting compositions can include additional agents, e.g., preservatives.

The excipient or carrier is selected on the basis of the mode and route of administration. Suitable pharmaceutical carriers, as well as pharmaceutical necessities for use in pharmaceutical formulations, are described in Remington: The Science and Practice of Pharmacy, 21 ^st Ed., Gennaro, Ed., Lippencott Williams & Wilkins (2005), a well-known reference text in this field, and in the USP/NF (United States Pharmacopeia and the National Formulary). Examples of suitable excipients are lactose, dextrose, sucrose, sorbitol, mannitol, starches, gum acacia, calcium phosphate, alginates, tragacanth, gelatin, calcium silicate, microcrystalline cellulose, polyvinylpyrrolidone, cellulose, water, syrup, and methyl cellulose. The formulations can additionally include: lubricating agents, e.g., talc, magnesium stearate, and mineral oil; wetting agents; emulsifying and suspending agents; preserving agents, e.g., methyl- and propylhydroxy-benzoates; sweetening agents; and flavoring agents. Other exemplary excipients are described in Handbook of Pharmaceutical Excipients, 6 ^th Edition, Rowe et al., Eds., Pharmaceutical Press (2009).

These pharmaceutical compositions can be manufactured in a conventional manner, e.g., by conventional mixing, dissolving, granulating, dragee-making, levigating, emulsifying, encapsulating, entrapping, or lyophilizing processes. Methods well known in the art for making formulations are found, for example, in Remington: The Science and Practice of Pharmacy, 21 ^st Ed., Gennaro, Ed., Lippencott Williams & Wilkins (2005), and Encyclopedia of Pharmaceutical Technology, eds. J. Swarbrick and J. C. Boylan, 1988-1999, Marcel Dekker, New York. Proper formulation is dependent upon the route of administration chosen. The formulation and preparation of such compositions is well-known to those skilled in the art of pharmaceutical formulation. In preparing a formulation, the active compound can be milled to provide the appropriate particle size prior to combining with the other ingredients. If the active compound is substantially insoluble, it can be milled to a particle size of less than 200 mesh. If the active compound is substantially water soluble, the particle size can be adjusted by milling to provide a substantially uniform distribution in the formulation, e.g., about 40 mesh.

The dosage of colchicine used in the methods described herein can vary depending on many factors, e.g., the pharmacodynamic properties of the compound; the mode of administration; the age, health, and weight of the recipient; the nature and extent of the symptoms; the frequency of the treatment, and the type of concurrent treatment, if any; and the clearance rate of the compound in the animal to be treated. One of skill in the art can determine the appropriate dosage based on the above factors. Colchicine may be administered initially in a suitable dosage that may be adjusted as required, depending on the clinical response. In general, a suitable daily dose of a compound of the invention may be that amount of the compound that is the lowest dose effective to produce a therapeutic effect. Such an effective dose may depend upon the factors described above.

Colchicine may be administered to the patient in a single dose or in multiple doses. When multiple doses are administered, the doses may be separated from one another by, for example, multiple hours. The compound may be administered according to a schedule or the compound may be administered without a predetermined schedule. Colchicine may be administered, for example, 1 , 2, or 3 times per day. It is to be understood that, for any particular subject, specific dosage regimes should be adjusted overtime according to the individual need and the professional judgment of the person administering or supervising the administration of the compositions. Preferably, colchicine is administered daily (e.g., once or twice daily). For example, colchicine may be administered twice daily for 3 days followed by once daily (e.g., for 27 days).

While the attending physician ultimately decide the appropriate amount and dosage regimen, an effective amount of colchicine may be, for example, a total daily dosage of, e.g., between 0.3 mg and 2.4 mg of colchicine. Preferably the daily dosage is 1.0 mg for the first three days of treatment, followed by a daily dose of 0.5 mg for the remainder of the treatment (e.g., 27 days). An effective daily dosage for subjects between 4 and 6 years old may be, for example, between 0.3 and 1.8 mg of colchicine. An effective daily dosage of subjects between 6 and 12 years old may be, for example, between 0.9 and 1.8 mg of colchicine. An effective daily dosage for subjects older than 12 years may be, for example, between 1.2 and 2.4 mg of colchicine.

Colchicine may be administered to subjects with a pharmaceutically acceptable excipient in a unit dosage form. The chemical compounds for use in such therapies may be produced and isolated by any standard technique known to those in the field of medicinal chemistry. Conventional pharmaceutical practice may be employed to provide suitable formulations or compositions to administer colchicine to subjects. Administration may begin before the patient is symptomatic. Exemplary routes of administration of colchicine include oral, sublingual, buccal, transdermal, intradermal, intramuscular, parenteral, intravenous, intra-arterial, intracranial, subcutaneous, intraorbital, intraventricular, intraspinal, intraperitoneal, intranasal, inhalation, and topical administration. Colchicine is desirably administered with a pharmaceutically acceptable excipient. Pharmaceutical formulations of colchicine formulated for treatment of the disorders described herein are also part of the present invention. Preferably, the route of administration is oral administration.

The pharmaceutical compositions contemplated by the invention include those formulated for oral administration (“oral dosage forms”). Oral dosage forms can be, for example, in the form of tablets, capsules, a liquid solution or suspension, a powder, or liquid or solid crystals, which contain the active ingredient(s) in a mixture with non-toxic pharmaceutically acceptable excipients. These excipients may be, for example, inert diluents or fillers (e.g., sucrose, sorbitol, sugar, mannitol, microcrystalline cellulose, starches including potato starch, calcium carbonate, sodium chloride, lactose, calcium phosphate, calcium sulfate, or sodium phosphate); granulating and disintegrating agents (e.g., cellulose derivatives including microcrystalline cellulose, starches including potato starch, croscarmellose sodium, alginates, or alginic acid); binding agents (e.g., sucrose, glucose, sorbitol, acacia, alginic acid, sodium alginate, gelatin, starch, pregelatinized starch, microcrystalline cellulose, magnesium aluminum silicate, carboxymethylcellulose sodium, methylcellulose, hydroxypropyl methylcellulose, ethylcellulose, polyvinylpyrrolidone, or polyethylene glycol); and lubricating agents, glidants, and antiadhesives (e.g., magnesium stearate, zinc stearate, stearic acid, silicas, hydrogenated vegetable oils, or talc). Other pharmaceutically acceptable excipients can be colorants, flavoring agents, plasticizers, humectants, buffering agents, and the like.

Formulations for oral administration may also be presented as chewable tablets, as hard gelatin capsules wherein the active ingredient is mixed with an inert solid diluent (e.g., potato starch, lactose, microcrystalline cellulose, calcium carbonate, calcium phosphate or kaolin), or as soft gelatin capsules wherein the active ingredient is mixed with water or an oil medium, for example, peanut oil, liquid paraffin, or olive oil. Powders, granulates, and pellets may be prepared using the ingredients mentioned above under tablets and capsules in a conventional manner using, e.g., a mixer, a fluid bed apparatus or a spray drying equipment.

Controlled release compositions for oral use may be constructed to release the active drug by controlling the dissolution and/or the diffusion of the active drug substance. Any of a number of strategies can be pursued in order to obtain controlled release and the targeted plasma concentration versus time profile.

In one example, controlled release is obtained by appropriate selection of various formulation parameters and ingredients, including, e.g., various types of controlled release compositions and coatings. Examples include single or multiple unit tablet or capsule compositions, oil solutions, suspensions, emulsions, microcapsules, microspheres, nanoparticles, patches, and liposomes. In certain embodiments, compositions include biodegradable, pH, and/or temperature-sensitive polymer coatings.

Dissolution- or diffusion-controlled release can be achieved by appropriate coating of a tablet, capsule, pellet, or granulate formulation of compounds, or by incorporating the compound into an appropriate matrix. A controlled release coating may include one or more of the coating substances mentioned above and/or, e.g., shellac, beeswax, glycowax, castor wax, carnauba wax, stearyl alcohol, glyceryl monostearate, glyceryl distearate, glycerol palmitostearate, ethylcellulose, acrylic resins, dl-polylactic acid, cellulose acetate butyrate, polyvinyl chloride, polyvinyl acetate, vinyl pyrrolidone, polyethylene, polymethacrylate, methylmethacrylate, 2-hydroxymethacrylate, methacrylate hydrogels, 1 ,3 butylene glycol, ethylene glycol methacrylate, and/or polyethylene glycols. In a controlled release matrix formulation, the matrix material may also include, e.g., hydrated methylcellulose, carnauba wax and stearyl alcohol, carbopol 934, silicone, glyceryl tristearate, methyl acrylate-methyl methacrylate, polyvinyl chloride, polyethylene, and/or halogenated fluorocarbon.

The liquid forms in which the compounds and compositions of the present invention can be incorporated for administration orally include aqueous solutions, suitably flavored syrups, aqueous or oil suspensions, and flavored emulsions with edible oils, e.g., cottonseed oil, sesame oil, coconut oil, or peanut oil, as well as elixirs and similar pharmaceutical vehicles.

Dosages for buccal or sublingual administration may be determined as required. In practice, the physician determines the actual dosing regimen which is most suitable for an individual patient, and the dosage varies with the age, weight, and response of the particular patient. The above dosages are exemplary of the average case, but individual instances exist wherein higher or lower dosages are merited, and such are within the scope of this invention.

For buccal administration, the compositions may take the form of tablets, lozenges, etc. formulated in a conventional manner. Liquid drug formulations suitable for use with nebulizers and liquid spray devices and electrohydrodynamic (EHD) aerosol devices typically include a compound of the invention with a pharmaceutically acceptable carrier. Preferably, the pharmaceutically acceptable carrier is a liquid, e.g., alcohol, water, polyethylene glycol, or a perfluorocarbon. Optionally, another material may be added to alter the aerosol properties of the solution or suspension of compounds of the invention. Desirably, this material is liquid, e.g., an alcohol, glycol, polyglycol, or a fatty acid. Other methods of formulating liquid drug solutions or suspension suitable for use in aerosol devices are known to those of skill in the art (see, e.g., Biesalski, U.S. Pat. No. 5,112,598 and Biesalski, U.S. Pat. No. 5,556,611 , each of which is herein incorporated by reference).

The following examples are meant to illustrate the invention. They are not meant to limit the invention in any way. EXAMPLES

Example 1. Colchicine May Reduce Complications of COVID-19

A study may be conducted to evaluate the performance of colchicine in the treatment of subjects diagnosed as suffering from a SARS-CoV-2 infection. In a randomized, double-blind, placebo-controlled study, subjects are randomized to receive either colchicine (0.5 mg/day) or placebo (1 :1 allocation ratio) for 30 days. All patients may receive either a bottle containing 34 tablets of 0.5 mg colchicine or a bottle containing 34 placebo tablets. All patients may receive study medication (colchicine tablet or placebo tablet) per os (orally) twice daily for the first 3 days and then once daily for the last 27 days. If a dose is missed, it should not be replaced. Follow-up phone or video assessments may occur at 15 and 30 days following randomization for evaluation of the occurrence of any trial endpoints or other adverse events.

The primary objective of this study is to determine whether short-term treatment with colchicine reduces the rate of death and lung complications related to COVID-19. The secondary objective is to determine the safety of treatment with colchicine in this patient population. The tertiary objective is to evaluate links between soluble and genetic biomarkers and treatment effects.

Subjects: males and females, at least 40 years of age, who have been diagnosed with a SARS-CoV-2 infection and have at least one high-risk criterion.

Inclusion Criteria:

• Males and females, at least 40 years of age, capable and willing to provide informed consent;

• Patient must have received a diagnosis of a SARS-CoV-2 infection (COVID-19) within the last 24 hours;

• Outpatient setting (not currently hospitalized or under immediate consideration for hospitalization);

• Patient must possess at least one of the following high-risk criteria: 70 years or more of age, diabetes mellitus, uncontrolled hypertension (systolic blood pressure >150 mm Hg), known respiratory disease (including asthma or chronic obstructive pulmonary disease), known heart failure, known coronary disease, fever of >38.4°C within the last 48 hours, dyspnea at the time of presentation, bicytopenia, pancytopenia, or the combination of high neutrophil count and low lymphocyte count;

• Female patient is either not of childbearing potential, defined as postmenopausal for at least 1 year or surgically sterile, or is of childbearing potential and practicing at least one method of contraception and preferably two complementary forms of contraception including a barrier method (e.g., male or female condoms, spermicides, sponges, foams, jellies, diaphragm, intrauterine device (IUD)) throughout the study and for 30 days after study completion; Patient must be able and willing to comply with the requirements of this study protocol.

Exclusion Criteria:

• Patient currently hospitalized;

• Patient currently in shock or with hemodynamic instability;

• Patient with inflammatory bowel disease (Crohn’s disease or ulcerative colitis), chronic diarrhea or malabsorption;

• Patient with pre-existent progressive neuromuscular disease;

• Patient with most recent level of creatinine > 2 times ULN, if known;

• Patient with a history of cirrhosis, chronic active hepatitis or severe hepatic disease;

• Female patient who is pregnant, or breast-feeding or is considering becoming pregnant during the study or for 6 months after the last dose of study medication;

• Patient currently taking colchicine for other indications (mainly chronic indications represented by Familial Mediterranean Fever or gout). There is no wash-out period required for patients who have been treated with colchicine and stopped treatment prior to enrolment;

• Patient with a history of an allergic reaction or significant sensitivity to colchicine;

• Patient undergoing chemotherapy for cancer;

• Patient is considered by the investigator, for any reason, to be an unsuitable candidate for the study.

The primary analysis of efficacy may be based on the intent-to-treat principle. The primary endpoint may be compared between the two treatment groups using a chi-square test. Logistic regression models might also be used to compare the primary endpoint between the two treatment groups while accounting for important baseline characteristics. Secondary endpoints may be analyzed similarly. Exploratory analysis (biomarkers) may include logistic regression models with the primary/secondary endpoints as dependent variables and with treatment group, biomarker and treatment group x biomarker interaction as independent variables.

All statistical tests may be two-sided and conducted at the 0.05 significance level, with the exception of the primary analysis that may be conducted at a slightly lower level to account for the interim analysis. Statistical analyses may be done using SAS version 9.4 or higher.

The final analysis of the primary endpoint may be conducted at a significance level slightly below the 0.05 level to account for the interim analysis. However, since this may have a negligible impact on power, the sample size calculation was calculated using a significance level of 0.05. Example 2. Colchicine Effectively Reduces Complications of COVID-19

Methods Trial Design

COLCORONA was a randomized, double-blind, placebo-controlled, investigator-initiated trial comparing colchicine (0.5 mg twice daily for the first three days and then once daily for 27 days thereafter) with placebo in a 1 :1 ratio. Trial Population

Patients were eligible if they were at least 40 years of age, had received a diagnosis of COVID-19 within 24 hours of enrollment, were not currently hospitalized and not under immediate consideration for hospitalization, and presented at least one of the following high-risk criteria: age of 70 years or older, obesity (body-mass index of 30 kg/m ² or more), diabetes, uncontrolled hypertension (systolic blood pressure >150 mm Hg), known respiratory disease, known heart failure, known coronary disease, fever of at least 38.4°C within the last 48 hours, dyspnea at the time of presentation, bicytopenia, pancytopenia, or the combination of high neutrophil and low lymphocyte counts. The diagnosis of COVID-19 was made by local laboratories using polymerase chain reaction testing on a naso-pharyngeal swab specimen.

Given the restrictions in laboratory testing early in the pandemic, a diagnosis was also accepted as an epidemiological link with a household member who had a positive nasopharyngeal test result for patients with symptoms compatible with COVID-19, or by a clinical algorithm in a symptomatic patient without an obvious alternative cause as per official guidelines (Table 1).

Table 1. Diagnosis of COVID-19 in Colchicine Coronavirus SARS-CoV2 Trial

Women were either not of childbearing potential or practicing adequate contraception.

Patients were excluded if they had inflammatory bowel disease, chronic diarrhea or malabsorption; preexistent progressive neuromuscular disease; estimated glomerular filtration rate less than 30 ml_/minute/1 .73 m ² ; severe liver disease; current treatment with colchicine; current chemotherapy for cancer; or a history of significant sensitivity to colchicine. Written informed consent was obtained electronically or on paper from all patients before enrollment following a telemedicine or in-person visit, respectively. Blinded randomization was centralized and performed electronically through an automated interactive web response system (IWRS). Allocation sequence was computer-generated in a 1 :1 ratio using a blocking schema with blocks of size 6. Allocation sequence was not stratified. Eligible patients were randomized by research nurses through the IWRS system that provided the bottle number to send to patients. Study nurses and patients were blinded to the treatment received. Study medication was delivered at the patient's house within 4 hours of enrollment. Clinical evaluations occurred by telephone at 15 and 30 days following randomization.

Endpoints

The primary efficacy endpoint was a composite of death or hospitalization due to COVID-19 infection in the 30 days following randomization. The secondary endpoints consisted of the components of the composite primary endpoint; and the need for mechanical ventilation in the 30 days following randomization. Pneumonias, other serious adverse events, and non-serious adverse events were also collected.

Statistical Analyses

It was estimated that a sample size of approximately 6,000 randomized patients with 3,000 patients in each treatment group would be required to detect a 25% relative risk reduction with colchicine with a power of 80% given a primary endpoint event rate of 7% in the placebo group and a two-sided test at the 0.05 significance level. The efficacy analyses were conducted according to the intention-to-treat (ITT) principle. The primary endpoint was compared between the two treatment groups using a chi-square test and the odds ratio along with 95.1% confidence interval was provided. Secondary endpoints were analyzed similarly. Because of potential limitations to the specificity of COVID-19 diagnosis made on clinical or epidemiological criteria alone, a pre-specified subgroup analysis examined those patients who were enrolled based on a positive polymerase chain reaction test. Pre-specified subgroup analyses were conducted using logistic regression models including the treatment group, the subgroup factor and the treatment x subgroup factor interaction. A pre-specified sensitivity analysis to account for missing data was conducted where the analysis of the primary endpoint was repeated imputing an event in all event- free subjects who did not complete the study.

Interim analyses were planned after 25%, 50% and 75% of the primary endpoint events had occurred.

The pre-specified stopping rule for efficacy was based on the Lan-DeMets procedure with the O'Brien- Fleming alpha-spending function. Following its review of the first two interim results, the monitoring board recommended that the trial should continue as planned. On December 11 , 2020, the steering committee chairman informed the data safety monitoring board that the investigators had decided to terminate the study once 75% of the planned patients were recruited and had completed the 30-day follow-up. This decision was made due to significant logistical, personnel and budgetary issues related to maintaining the central study call center active 24 hours per day for a prolonged period of time, which were compounded by the inability to reliably model the additional time required to reach the target number of patients through the successive waves of the pandemic. To account for the interim analyses, the statistical significance level was set to 0.0490 for the final analysis of the primary endpoint. All other statistical tests were two-sided and conducted at the 0.05 significance level.

Statistical analyses were performed using SAS version 9.4. There was no prespecified plan to adjust for multiple comparisons across the multiple methods used to analyze the primary outcome and secondary endpoints; results of these analyses are reported with point estimates and 95% confidence interval (Cl), without P-values. 95% Cls were not adjusted for multiple comparisons and inferences drawn from them may not be reproducible.

Trial Registration Colchicine Coronavirus SARS-Cov2 Trial (COLCORONA)

ClinicalTrials.gov number: NCT04322682

Results

Patients Trial enrollment began in March 2020 and was completed in December 2020; the last trial visit was in January 2021 . A total of 4488 patients underwent randomization and were followed for 30 days. At the time of database lock and unblinding on January 20, 2021 , vital and primary endpoint event status were available for all except for 93 patients (97.9%). Details regarding the disposition of the patients are provided in FIG. 1.

The baseline characteristics of patients are shown in Table 2. Patients were enrolled a mean of 5.3 days after the onset of COVID-19 symptoms. The mean age of participants was 54.7 years, 53.9% of the patients were women, mean body-mass index was 30.0 kg/m2, and 19.9% had diabetes. The mean treatment duration with the trial medication was 26.2 days.

Table 2. Characteristics of the Trial Patients at Randomization

Abbreviations: Ml, myocardial infarction; no., number Clinical Efficacy Endpoints

A primary endpoint event occurred in 4.7% of the patients in the colchicine group, as compared with 5.8% of the patients in the placebo group (odds ratio, 0.79; 95.1% confidence interval [Cl], 0.61 to 1 .03; P=0.08). Table 3 shows the event rates and odds ratios for the components of the primary endpoint, which included death (odds ratio, 0.56; 95% Cl, 0.19 to 1.67) and hospitalization due to COVID-19 (odds ratio, 0.79; 95% Cl, 0.60 to 1 .03), as well as for the secondary efficacy endpoint of the need for mechanical ventilation (odds ratio, 0.53; 95% Cl, 0.25 to 1.09). Table 3: Rates and Odds Ratios for Major Clinical Outcomes

Abbreviations: ITT, Intention-to-Treat; no., number; PCR, polymerase chain reaction. In a pre-specified sensitivity analysis of the primary endpoint to account for missing data where an event was imputed in all event-free subjects who did not complete the study (32 patients and 49 patients in the study groups), the primary endpoint event rate was 6.1% in the colchicine group and 8.0% in the placebo group (odds ratio, 0.75; 95% Cl, 0.59 to 0.94; P=0.01). In the pre-specified analysis of the 4,159 patients with COVID-19 confirmed by a polymerase chain reaction test, the rates of the primary endpoint were 4.6% and 6.0% in the colchicine and placebo groups, respectively (odds ratio, 0.75; 95% Cl, 0.57 to 0.99; P=0.04). Among these patients with confirmed COVID-19, the odds ratios were 0.75 (95% Cl, 0.57 to 0.99) for hospitalization due to the infection and 0.56 (95% Cl, 0.19 to 1 .66) for death. The secondary efficacy endpoint of the need for mechanical ventilation occurred in 0.5% of the patients in the colchicine group, as compared with 1.0% of the patients in the placebo group (odds ratio, 0.50; 95% Cl, 0.23 to 1 .07).

Efficacy results in prespecified subgroups are shown in Table 4.

Table 4. Primary Efficacy Composite Endpoint in Prespecified Subgroups

Abbreviations: ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin-receptor blocker

Among the patients with diabetes, the primary endpoint occurred in 6.1% of those in the colchicine group and 9.6% in the placebo group (odds ratio, 0.61 ; 95% Cl, 0.37 to 1 .01). The primary endpoint event rate in men was 5.8% in the colchicine group and 8.4% in the placebo group (odds ratio, 0.67; 95% Cl, 0.48 to 0.95), whereas the corresponding values in women were 3.7% and 3.5% (odds ratio, 1 .07; 95% Cl, 0.70 to 1.65).

Safety and Adverse Events The rates of serious adverse events were 4.9% in the colchicine group and 6.3% in the placebo group (P=0.05), and pneumonia occurred in 2.9% and 4.1% of the patients in the two groups (P=0.02). Pulmonary embolism was diagnosed in 11 patients (0.5%) in the colchicine group and 2 patients (0.1%) in the placebo group (P=0.01). These pulmonary emboli did not lead to the need for mechanical ventilation or to death, were all considered unrelated to the study medication by the physician in charge, and were included as hospitalizations due to COVID-19 in the analysis of the primary efficacy endpoint. No deep venous thrombosis was reported. Dehydration was reported in 3 patients (0.1%) in the colchicine group and 6 patients (0.3%) in the placebo group (P=0.51).

The rates of adverse events that were considered related to trial medication were 24.2% and 15.5% (Table 4). At least one treatment-emergent gastro-intestinal adverse event occurred in 23.9% of the patients in the colchicine group, as compared with 14.8% of the patients in the placebo group. Diarrhea was reported in 13.7% and 7.3% of patients in the two trial groups (P<0.0001).

Table 4: Proportions of Patients with Adverse Events in the Safety Population

Abbreviations: AE, adverse event; Gl, gastro-intestinal; no., number; SAE, serious adverse event. The safety population refers to patients who took at least one dose of the trial medication.

Taken together, these results demonstrate that of the total of 4,488 patients (women 53.9%, mean age 54.7 years) enrolled in the study, the primary endpoint occurred in 4.7% of patients in the colchicine group and 5.8% of those in the placebo group (odds ratio, 0.79; 95.1% confidence interval (Cl), 0.61-1.03; P=0.08). Among the 4,159 patients with PCR-confirmed COVID-19, the primary endpoint occurred in 4.6% and 6.0% of patients in the colchicine and placebo groups, respectively (odds ratio, 0.75; 95% Cl, 0.57-0.99; P=0.04). In these patients with PCR-confirmed COVID-19, the odds ratios were 0.75 (95%CI, 0.57-0.99) for hospitalization due to COVID-19, 0.50 (95% Cl, 0.23-1 .07) for mechanical ventilation, and 0.56 (95% Cl, 0.19-1 .66) for death. Serious adverse events were reported in 4.9% and 6.3% in the colchicine and placebo groups (P=0.05); pneumonia occurred in 2.9% and 4.1% of patients (P=0.02). Diarrhea was reported in 13.7% and 7.3% in the colchicine and placebo groups (P<0.0001).

Conclusions

In the colchicine Coronavirus SARS-Cov2 Trial (COLCORONA), the risk of the primary composite efficacy endpoint of death or hospitalization due to COVID-19 infection in the 30 days following randomization was numerically lower among the patients who were randomly assigned to receive colchicine than among those who received placebo, but the difference did not reach statistical significance (P=0.08). Because of the shortage of reagents for polymerase chain reaction tests and the restriction in the use of such testing early in the pandemic, diagnosis of probable COVID-19 through an epidemiological link or compatible symptoms was initially allowed in the study. These patients had a primary event rate that was half (3.0%) of the one observed in those with confirmed diagnosis by polymerase chain reaction testing (6.0%).

When the 93% of patients who had a confirmed diagnosis of COVID-19 are considered, the benefit of colchicine on the primary efficacy endpoint was more marked (25%) and statistically significant.

Treatment with colchicine was associated with concordant effects on hospitalizations, use of mechanical ventilation and deaths in patients with a diagnosis of COVID-19 confirmed by polymerase chain reaction testing. The effect of colchicine on the primary endpoint was consistent across subgroups of patients based on various clinical characteristics. Although the benefits of colchicine appeared to be more marked in patients with diabetes and men, there was no significant heterogeneity in the results. Because the event rates were higher in patients with these characteristics, the effect of colchicine might have been more readily detectable. Diabetes is a pro-inflammatory state, which might explain the greater risk of complications of COVID-19 in patients afflicted by that disease. Despite the link between weight, insulin resistance and type 2 diabetes, the effects of colchicine did not differ whether the body-mass index was above or below 30 kg per square meter. In contrast, there is no readily obvious basis for a sex-related difference in responses to colchicine. Of note, the concomitant use of an inhibitor of the renin-angiotensin system did not appear to modify the clinical response to colchicine.

The most common adverse events observed were gastro-intestinal. Diarrhea was reported by 13.7% and 7.3% of patients in the colchicine and placebo groups, respectively. Dehydration was reported in 3 patients (0.1%) in the colchicine group and 6 patients (0.3%) in the placebo group. Deleterious effects of COVID-19 are multiple and can affect among others the lungs, heart and brain. The seriousness of the disease is reflected by the high incidence of serious adverse events in patients of the placebo group in COLCORONA. The number of patients with any serious adverse event was smaller in the colchicine group compared to placebo (4.9% versus 6.3%), which might reflect the benefits of systemic inflammation reduction in this disease. Pneumonia was reported less frequently in patients of the colchicine group (2.9%) than those of the placebo group (4.1 %). This is concordant with the significant reduction of hospitalizations in patients with confirmed COVID-19 treated with colchicine, as well as the trend for reduced need of mechanical ventilation. Our results are supported by the results of two smaller clinical trials showing reductions in the need for oxygen supplementation, the duration of hospitalization and the deterioration of clinical status (Deftereos et al., JAMA Network Open. 3(6):e2013136 (2020), Lopes et al., RMD Open. 7(1):e001455 (2021)). Colchicine has previously been shown to reduce acute lung injury in an experimental model of acute respiratory distress syndrome (Dupuis et al., PLoS One.

15(12):e0242318 (2020)). The risk of viral inflammatory pneumonitis therefore appears to be lowered by colchicine in patients with COVID-19. Reassuringly, there was no evidence of an increased risk of bacterial pneumonia in COLCORONA.

The number of reported cases of pulmonary embolism was higher in patients of the colchicine group compared to placebo in COLCORONA (11 versus 2). These 13 events were included in the analysis of the primary composite endpoint as hospitalizations due to COVID-19. Despite this apparent imbalance, the numbers of hospitalizations, use of mechanical ventilation and deaths were numerically lower in the colchicine group than in the placebo group. Additionally, the pulmonary emboli did not lead to the need for mechanical ventilation or to death in these 13 patients. In contrast, there was no imbalance in other thrombotic or embolic events such as deep venous thrombosis or myocardial infarction. A systematic review and meta-analysis of randomized controlled trials involving more than 10,000 patients with coronary disease followed for approximately 2 years has not shown a significant difference in the rate of pulmonary embolism or deep venous thrombosis between the colchicine and placebo groups (Samuel et al., Can J Cardiol. S0828-282X(20)31053-9.doi, 2020). In addition, a significant reduction in the concentration of D-dimer, a plasma biomarker used for the diagnostic evaluation of pulmonary embolism, was observed with colchicine compared to the control arm in the GRECCO study (Deftereos et al., JAMA Network Open. 3(6):e2013136 (2020)). Furthermore, colchicine has previously been shown in murine models to lower the release of alpha-defensin associated with large thrombus burdens and in clinical studies to reduce the aggregation between neutrophils and platelets (Abu-Fanne et al., Blood. 133(5):481-493 (2019), Shah et al., Inflammation, 39(1): 182-189 (2016)). Thus, there is no known potential biologic basis to suggest a causal link between colchicine therapy and thrombo-embolic disease. The incidence of pulmonary embolism is very high in COVID-19, up to 25% in patients with associated pneumonia (Bompard et al., Eur Respir J. 56(1):2001365 (2020)). More than 57% of patients dying from COVID-19 have evidence of deep venous thrombosis or pulmonary embolus at autopsy (Wichman et al., Ann Intern Med. 173(12):268-277 (2020)). In COLCORONA, the incidence of pulmonary embolism in patients requiring hospitalization was 10.9% (11/101) in the colchicine group and 1.6% (2/128) in the placebo group. The totality of evidence suggests that the very low rate of pulmonary embolisms in the placebo group represents an anomaly. The more common presence and greater severity of COVID-19 pneumonia infiltrates in patients receiving placebo might have reduced the clinical suspicion for pulmonary embolism in symptomatic patients.

The study was stopped when 75% of the planned patients were recruited and had completed the 30-day follow-up. The duration of follow-up was relatively short at approximately 30 days. The evolution of persistent COVID-19 symptoms and the effects of longer-term treatment with colchicine were not evaluated. The benefit of a shorter course of colchicine therapy for less than 30 days is also not entirely known, although the results of two smaller trials showed benefits of treatment administered for 10 to 21 days ^{15 16} . Finally, our results apply to patients who have a proven diagnosis of COVID-19, are at risk of clinical complications and are not hospitalized at the time of treatment initiation.

In non-hospitalized patients including those without a mandatory diagnostic test, the effect of colchicine on COVID-19-related clinical events was not statistically significant. Among patients with PCR-confirmed COVID-19, colchicine led to a lower rate of the composite of death or hospitalization than placebo. OTHER EMBODIMENTS

Various modifications and variations of the described invention will be apparent to those skilled in the art without departing from the scope and spirit of the invention. Although the invention has been described in connection with specific embodiments, it should be understood that the invention as claimed should not be unduly limited to such specific embodiments. Indeed, various modifications of the described modes for carrying out the invention that are obvious to those skilled in the art are intended to be within the scope of the invention.

Other embodiments are in the claims.