FIELD OF THE INVENTION

The present invention refers to the use of a glucagon-like peptide (GLP-1) agonist for treating loss of smell.

BACKGROUND OF THE INVENTION

Anosmia, a severe condition of hyposmia, is a part of olfactory dysfunction where the person is unable to sense smell or detect odor (Mutiawati E. et al., 2021).

The sense of smell is important to overall health and nutrition since diminished sensations can lead to poor appetite and malnutrition, especially in the elderly. An altered sense of smell may pose other health-related problems. People with anosmia may accidentally consume soured or rancid foods because they are unable to detect odors that signal spoilage. Those with anosmia may also be unaware when they are breathing toxic, polluted or smoke-filled air.

One of the major identified causes for olfactory dysfunctions are viral upper respiratory infections. Rhinoviruses (RVs), coronaviruses (CoVs), influenza viruses (IVs), parainfluenza viruses (PIVs), respiratory syncytial viruses (RSVs), adenoviruses (AdVs), and enteroviruses (EVs) collectively account for at least 70% or more of common colds and are suggested to cause olfactory dysfunction (Suzuki M. et al., 2007). Olfactory dysfunctions such as anosmia are also common amongst COVID-19 patients.

The outbreak of the COVID-19 pandemic in late 2019 has led to an unprecedented worldwide health crisis with rapid spread of a novel pathogenic member of the coronavirus family, termed SARS-CoV-2, infecting more than 540 million people worldwide. Acute SARS-CoV-2 infection may induce an inappropriate and unique inflammatory response causing the pathognomonic severe respiratory symptoms which can be further accompanied by damage of multiple organs such as brain, heart and kidneys. Accordingly, acute COVID-19 infection causes high lethality claiming more than 6.3 million deaths worldwide so far. Rather disturbingly, it has also become evident, that not all patients fully recover following SARS-CoV-2 infection. It has already been recognized that chronic persistence of COVID-19 symptoms after acute infection may constitute a novel somatic disease entity, typically termed long-COVID syndrome (LCS) although no exact definition exists. Typically, LCS patients display general fatigue, lack of concentration and physical fitness, dyspnea as well as a broad range of other clinical symptoms throughout the whole organism, which severely impedes the quality of life of affected patients.

Post-viral-long-term symptoms such as long term COVID-19 patients often reported also anosmia and dysgeusia as one of the predominant persisting symptoms (Vallee A., 2021 , Ben-Chetrit E. et al., 2021).

Anosmia is generally taught to be treated in literature with antihistamines, steroid nasal sprays, antibiotics or decongestants, however, often there is no treatment success, specifically in subjects suffering from viral infections or LCS patients.

Therefore, there is still a high need in treatments, medicinal and pharmaceutical products which can be used to treat olfactory dysfunctions such as anosmia, in particular in subjects that have been exposed to or infected with a virus.

SUMMARY OF THE INVENTION

It is the objective of the present invention to provide an anosmia treatment.

The objective is solved by the subject of the present claims and as further described herein.

The present invention provides a pharmaceutical preparation comprising a glucagon-like peptide 1 (GLP-1) agonist, in an effective amount for use in the treatment of loss of smell.

Specifically, the loss of smell is anosmia, hyposmia, or dysosmia.

Specifically, the loss of smell is caused by viral infection.

According to an embodiment of the present invention, the viral infection is an infection by rhinovirus, specifically it is rhinovirus (HRV)-40, HRV-75, HRV-78, and HRV- 80a; parainfluenza virus, influenza virus, adenovirus, Epstein-Barr virus; coronavirus, specifically it is a P-coronavirus, preferably selected from the group consisting of SARS- CoV-2, MERS-CoV, SARS-CoV-1 , HCoV-OC43, and HCoV-HKU1 , or mutants thereof.

According to an embodiment of the invention, the GLP-1 agonist is selected from the group consisting of exenatide, exendin-4, lixisenatide, semaglutide, liraglutide, albiglutide, dulaglutide, vurolenatide, tirzepatide, taspoglutide, beinaglutide, efpeglenatide (langlenatide), GLP-1 (7-37), GLP-1 (7-36) amide, and oxyntomodulin and any combination thereof.

In a specific embodiment, the pharmaceutical preparation is a medicinal product or a drug product, comprising a GLP-1 agonist and a pharmaceutically acceptable excipient. Specifically, the pharmaceutical preparation is formulated for local administration, preferably for application to the upper and lower respiratory tract, intra-nasal, or for pulmonary application.

More specifically, the pharmaceutical preparation is administered as a spray, a powder, a gel, an ointment, a liquid solution, a gargle solution, an aerosolized powder, an aerosolized liquid formulation.

Specifically, preparation is administered in the range of about 1.5 pg/day to 6 mg/day, specifically in the range of 10 pg/day to 3 mg/day, specifically in the range of 30 pg/day to 1 mg/day, specifically 60 pg/day to 500 pg/day, more specifically the dosage is 60pg/day.

According to a specific embodiment, the preparation is administered as the sole substance, or treatment is combined with a further treatment with one or more active substances, specifically selected from the group consisting of antiviral, antiinflammatory, antiallergenic, anti-hypertensive, antihistaminic, cardiovascular, antilipidemic, endocrine, diabetic, and antibiotic substances.

More specifically, the preparation is administered in combination with an active agent, specifically selected from the group consisting of nirmatrelvir, ritonavir, regdanvimab, sotrovimab, suramin, raloxifene, maraviroc, miglustat, quinacrine, glatiramer acetate, auranofin, dexamethasone, amlodipine, budesonide, celecoxib, tramadol HCI, ciprofloxacin, clarithromycin, enalapril maleate, gadopentetate dimeglumine, ganciclovir, lansoprazole, amoxicillin, clarithromycin, levofloxacin, olopatadine HCI, testosterone, amoxicillin, azithromycin, fluticasone, prednisone, diltiazem, atorvastatin, lovastatin, pravastatin, levothyroxine, and Vitamin A.

Specifically, the subject has been infected or is at risk of being infected with coronavirus.

Further provided herein is a pharmaceutical preparation comprising a glucagon- like peptide 1 (GLP-1) agonist in an effective amount, and further comprising an active agent, specifically selected from the group consisting of nirmatrelvir, ritonavir, regdanvimab, sotrovimab, suramin, raloxifene, maraviroc, miglustat, quinacrine, glatiramer acetate, auranofin, dexamethasone, amlodipine, budesonide, celecoxib, tramadol HCI, ciprofloxacin, clarithromycin, enalapril maleate, gadopentetate dimeglumine, ganciclovir, lansoprazole, amoxicillin, clarithromycin, levofloxacin, olopatadine HCI, testosterone, amoxicillin, azithromycin, fluticasone, prednisone, diltiazem, atorvastatin, lovastatin, pravastatin, levothyroxine, and Vitamin A. FIGURES

Figure 1 : Phases of randomized double-blinded controlled phase 2 proof-of- concept study with parallel assignment.

Figure 2: Heatmap showing the log2FC of selected genes in SUS (sustentacular) and OSN (olfactory receptor neuron) cells. Right side bar shows the association score of liraglutide.

DETAILED DESCRIPTION

The terms “comprise”, “contain”, “have” and “include” as used herein can be used synonymously and shall be understood as an open definition, allowing further members or parts or elements. “Consisting” is considered as a closest definition without further elements of the consisting definition feature. Thus “comprising” is broader and contains the “consisting” definition.

The term “about” as used herein refers to the same value or a value differing by +/-5 % of the given value.

As used herein and in the claims, the singular form, for example “a”, “an” and “the” includes the plural, unless the context clearly dictates otherwise.

Glucagon-like peptide-1 (GLP-1) agonists, also known as GLP-1 receptor agonists, incretin mimetics, or GLP-1 analogs, are a class of medications having agonistic activity toward the GLP-1 receptor. As used herein, GLP-1 agonist is a compound that, at a given in vivo or in vitro concentration, functions as an agonist or partial agonist of the glucagon-like peptide 1 receptor, notwithstanding that the compound may exhibit some secondary (weaker) antagonism of the glucagon-like peptide 1 receptor at certain other concentrations. In some cases, the GLP-1 agonists can be referred to as being “protein-based”. As used herein in this context, the term “peptide-based” refers to a compound that contains one or more chains of six or more amino acids connected by amide linkages. In some embodiments, the non-protein GLP1 R agonists have a molecular weight of no more than 2 kDa, or a molecular weight of no more than 1 .5 kDa, or a molecular weight of no more than 1 .2 kDa.

Non-limiting examples of GLP-1 agonists include liraglutide, exenatide, exendin- 4, lixisenatide, semaglutide, albiglutide, dulaglutide, vurolenatide, tirzepatide, taspoglutide, beinaglutide, efpeglenatide (langlenatide), GLP-1 (7-37), GLP-1 (7-36) amide, and oxyntomodulin. The GLP-1 agonist as described herein, may be used as a “physiologically acceptable salt”. The choice of salt is determined primarily by how acid or basic the chemical is (the pH), the safety of the ionized form, the intended use of the drug, how the drug is given (for example, by mouth, injection, or on the skin), and the type of dosage form (such as tablet, capsule, or liquid).

Exemplary salts which are physiologically acceptable are sodium salts. However, it is also possible to employ, in place of the sodium salts, other physiologically acceptable salts, e.g., other alkali metal salts, alkaline earth metal salts, ammonium salts and substituted ammonium salts. Specific examples are potassium, lithium, calcium, aluminum and iron salts. More specifically, the salts include the conventional non-toxic salts or the quaternary ammonium salts of the parent compound formed, for example, from non-toxic inorganic or organic acids. Such conventional non-toxic salts include those derived from inorganic acids such as hydrochloric, hydrobromic, sulfuric, sulfamic, phosphoric, and nitric acids; and the salts prepared from organic acids such as acetic, propionic, succinic, glycolic, stearic, lactic, malic, tartaric, citric, ascorbic, pamoic, maleic, hydroxymaleic, phenylacetic, glutamic, benzoic, salicylic, sulfanilic, 2- acetoxybenzoic, fumaric, tolunesulfonic, naphthalenesulfonic, methanesulfonic, ethane disulfonic, oxalic, and isethionic salts. Preferred substituted ammonium salts are those derived, for example, from lower mono-, di-, or trialkylamines, or mono-, di- and trialkanolamines. The free amino acids per se can also be used. Specific examples are ethylamine, ethylenediamine, diethylamine, or triethylamine salts.

The term “pharmaceutically acceptable” also referred to as “pharmacologically acceptable” means compatible with the treatment of animals, in particular, humans. The term pharmacologically acceptable salt also includes both pharmacologically acceptable acid addition salts and pharmacologically acceptable basic addition salts.

The term” pharmacologically acceptable acid addition salt” as used herein means any non-toxic organic or inorganic salt of any base compound of the disclosure, or any of its intermediates. Basic compounds of the disclosure that may form an acid addition salt include, for example, compounds that contain a basic nitrogen atom. Illustrative inorganic acids which form suitable salts include hydrochloric, hydrobromic, sulfuric and phosphoric acids, as well as metal salts such as sodium monohydrogen orthophosphate and potassium hydrogen sulfate. Illustrative organic acids that form suitable salts include mono-, di-, and tricarboxylic acids such as glycolic, lactic, pyruvic, malonic, succinic, glutaric, fumaric, malic, tartaric, citric, ascorbic, maleic, benzoic, phenylacetic, cinnamic and salicylic acids, as well as sulfonic acids such as p-toluene sulfonic and methanesulfonic acids. Either the mono-, di- or the triacid salts can be formed, and such salts may exist in either a hydrated, solvated or substantially anhydrous form. In general, the acid addition salts of the compounds of the disclosure are more soluble in water and various hydrophilic organic solvents, and generally demonstrate higher melting points in comparison to their free base forms. The selection of the appropriate salt will be known to one skilled in the art. Other non-pharmacologically acceptable acid addition salts, e.g. oxalates, may be used, for example, in the isolation of the compounds of the disclosure, for laboratory use, or for subsequent conversion to a pharmacologically acceptable acid addition salt.

The GLP-1 agonist such as, but not limited to liraglutide, may also be present in the composition in the form of base or in the form of its salts or mixtures thereof. Representative example of salts includes salts with suitable inorganic acids such as hydrochloric, hydrobromic, and the like. Representative examples of salts also include salts with organic acids such as formic acid, acetic acid, propionic acid, lactic acid, tartaric acid, ascorbic acid and the like. Representative examples of salts also include salt with base such as triethanolamine, diethylamine, meglumine, arginine, alanine, leucine, diethylethanolamine, olamine, triethylamine, tromethamine, choline, trimethylamine, taurine, benzamine, methylamine, dimethylamine, trimethylamine, methylethanolamine, propylamine, isopropylamine, adenine, guanine, cytosine, thymine, uracil, thymine, xanthine, hypoxanthine and like. Liraglutide may also be present as liraglutide acetate. In another embodiment, liraglutide is present as a tromethamine salt.

The GLP-1 agonist, e.g. liraglutide, may also be present as functional variant or conjugate.

The term “solvate” refers to a compound in the solid state, where molecules of a suitable solvent are incorporated in the crystal lattice. A suitable solvent for therapeutic administration is physiologically tolerable at the dosage administered. Examples of suitable solvents for therapeutic administration are ethanol and water, but may also be isopropanol, methanol, dimethyl sulfoxide, ethyl acetate, acetic acid, and amino ethanol. When water is the solvent, the solvate is referred to as a hydrate. In general, solvates are formed by dissolving the compound in the appropriate solvent and isolating the solvate by cooling or using an antisolvent. The solvate can be dried or azeotroped under ambient conditions. The GLP-1 agonist may be any one of liraglutide, semaglutide, exenatide, exendin-4, lixisenatide, albiglutide, dulaglutide, vurolenatide, tirzepatide, taspoglutide, beinaglutide, efpeglenatide (langlenatide), GLP-1 (7-37), GLP-1 (7-36) amide, oxyntomodulin, and any combinations thereof.

Liraglutide is a synthetic analog of human GLP-1 and acts as a GLP-1 receptor agonist. Liraglutide is 97% homologous to native human GLP-1 by substituting arginine for lysine at position 34. Liraglutide is made by attaching a C-16 fatty acid (palmitic acid) with a glutamic acid spacer on the remaining lysine residue at position 26 of the peptide precursor. Liraglutide comprises the sequence:

His-Ala-Glu-Gly-Thr-Phe-Thr-Ser-Asp-Val-Ser-Ser-Tyr-Leu-G lu-Gly-GIn-Ala-Ala- Lys(1)-Glu-Phe-lle-Ala-Trp-Leu-Val-Arg-Gly-Arg-Gly (SEQ ID NO: 1).

Its protein chemical formula is C172H265N43O51.

Liraglutide is commercially available under the trade names Saxenda® and Victoza®.

Semaglutide is chemically similar to human glucagon-like peptide-1 (GLP-1), with 94% similarity. The differences are two amino-acid substitutions at positions 8 and 34, where alanine and lysine are replaced by 2-aminoisobutyric acid and arginine, respectively. Amino-acid substitution at position 8 prevents chemical breakdown by dipeptidyl peptidase-4. In addition, the lysine at position 26 is in its derivative form (acylated with stearic diacid). Semaglutide is sold under the brand name Ozempic®.

Exenatide is a 39-amino-acid peptide; it is a synthetic version of Exendin-4, a peptide found in the venom of the Gila monster (Heloderma suspectum). Exenatide, sold under the brand name Byetta® and Bydureon®. Exenatide is of the following sequence:

H-His-Gly-Glu-Gly-Thr-Phe-Thr-Ser-Asp-Leu-Ser-Lys-GIn-Met -Glu-Glu-Glu-Ala- Val-Arg-Leu-Phe-lle-Glu-Trp-Leu-Lys-Asn-Gly-Gly-Pro-Ser-Ser- Gly-Ala-Pro-Pro-Pro- Ser-NH2 (SEQ ID NO: 2)

Lixisenatide is a peptide made of 44 amino acids, with an amide group on its C terminus. It has been described as "des-38-proline-exendin-4 (Heloderma suspectum)- (1-39)-peptidylpenta-L-lysyl-L-lysinamide", i.e. it is derived from the first 39 amino acids in the sequence of the peptide exendin-4, omitting proline at position 38 and adding six lysine residues. Its complete sequence is

H-His-Gly-Glu-Gly-Thr-Phe-Thr-Ser-Asp-Leu-Ser-Lys-GIn-Met - Glu-Glu-Glu-Ala-Val-Arg-Leu-Phe-lle-Glu-Trp-Leu-Lys-Asn-Gly- Gly-Pro-Ser- Ser-Gly-Ala-Pro-Pro-Ser-Lys-Lys-Lys-Lys-Lys-Lys-NH2 (SEQ ID NO: 3) Lixisenatide is sold under the trade name Lyxumia® in the European Union and Adlyxin® in the U.S.

Albiglutide (trade names Eperzan® in Europe and Tanzeum® in the US) is a glucagon-like peptide-1 agonist (GLP-1 agonist) drug. It is a peptide consisting of 645 proteinogenic amino acids with 17 disulfide bridges. Amino acids 1-30 and 31-60 constitute two copies of modified human GLP-1 , the alanine at position 2 having been exchanged for a glycine for better DPP-4 resistance. ^[4] The remaining sequence is human albumin. The complete sequence is HGEGTFTSDVSSYLEGQAAKEFIAWLVKGRHGEGTFTSDVSSYLEGQAAKEFIAWLV KGRDAHKSEVAHRFKDLGEENFKALVLIAFAQYLQQCPFEDHVKLVNEVTEFAKTCV ADESAENCDKSLHTLFGDKLCTVATLRETYGEMADCCAKQEPERNECFLQHKDDNP NLPRLVRPEVDVMCTAFHDNEETFLKKYLYEIARRHPYFYAPELLFFAKRYKAAFTEC CQAADKAACLLPKLDELRDEGKASSAKQRLKCASLQKFGERAFKAWAVARLSQRFP KAEFAEVSKLVTDLTKVHTECCHGDLLECADDRADLAKYICENQDSISSKLKECCEKP LLEKSHCIAEVENDEMPADLPSLAADFVESKDVCKNYAEAKDVFLGMFLYEYARRHP DYSWLLLRLAKTYETTLEKCCAAADPHECYAKVFDEFKPLVEEPQNLIKQNCELFEQ LGEYKFQNALLVRYTKKVPQVSTPTLVEVSRNLGKVGSKCCKHPEAKRMPCAEDYLS WLNQLCVLHEKTPVSDRVTKCCTESLVNRRPCFSALEVDETYVPKEFNAETFTFHA DICTLSEKERQIKKQTALVELVKHKPKATKEQLKAVMDDFAAFVEKCCKADDKETCFA EEGKKLVAASQAALGL (SEQ ID NO: 4) with disulfide bridges linking amino acids 113-122, 135-151 , 150-161 , 184-229, 228-237, 260-306, 305-313, 325-339, 338-349, 376-421 , 420-429, 452-498, 497-508, 521-537, 536-547, 574-619, 618-62.

Dulaglutide is a glucagon-like peptide-1 receptor agonist (GLP-1 agonist) consisting of GLP-1 (7-37) covalently linked to an Fc fragment of human lgG4. It is sold under the brand name Trulicity®.

Vurolenatide is a long acting GLP-1 analogue.

Tirzepatide is an analogue of gastric inhibitory polypeptide (GIP), a human hormone that stimulates the release of insulin from the pancreas. Tirzepatide is a linear polypeptide of 39 amino acids that has been chemically modified by lipidation to improve its uptake into cells and its stability to metabolism. Tirzepatide is sold under the brand name Mounjaro®. Taspoglutide is the peptide with the sequence H2N-His-2-methyl-Ala-Glu-Gly-Thr- Phe-Thr-Ser-Asp-Val-Ser-Ser-Tyr-Leu-Glu-Gly-GIn-Ala-Ala-Lys- Glu-Phe-lle-Ala-Trp- Leu-Val-Lys-2-methyl-Ala-Arg-CONH ₂ . (SEQ ID NO:5)

It is the 8-(2-methylalanine)-35-(2-methylalanine)-36-L-argininamide derivative of the amino acid sequence 7-36 of human glucagon-like peptide I.

Beinaglutide (benaglutide) is a GLP-1 RA, and is a recombinant human glucagon- like peptide-1 and shares 100% homology with human GLP-1 (7-36)

Efpeglenatide, also known as langlenatide, is a long-acting exendin 4 (exenatide) analogue and glucagon-like peptide-1 (GLP-1) agonist.

GLP-1 (7-37) is of the sequence

His-Ala-Glu-Gly-Thr-Phe-Thr-Ser-Asp-Val-Ser-Ser-Tyr-Leu-G lu-Gly-GIn-Ala-Ala- Lys-Glu-Phe-lle-Ala-Trp-Leu-Val-Lys-Gly-Arg-Gly-OH (SEQ ID NO:6)

GLP-1 (7-36) amide has the sequence

H-His-Ala-Glu-Gly-Thr-Phe-Thr-Ser-Asp-Val-Ser-Ser-Tyr-Leu -Glu-Gly-GIn-Ala- Ala-Lys-Glu-Phe-lle-Ala-Trp-Leu-Val-Lys-Gly-Arg-NH2 (SEQ ID NO:7)

Oxyntomodulin is a naturally occurring 37-amino acid peptide hormone with the sequence:

H-His-Ser-GIn-Gly-Thr-Phe-Thr-Ser-Asp-Tyr-Ser-Lys-Tyr-Leu -Asp-Ser-Arg-Arg- Ala-GIn-Asp-Phe-Val-GIn-Trp-Leu-Met-Asn-Thr-Lys-Arg-Asn-Arg- Asn-Asn-lle-Ala-OH (SEQ ID NO:8)

The term “loss of smell” or “loss of olfaction” refers to a partial or complete loss of the ability to perceive the environment, food or other things through the sense of smell.

The term "anosmia" as used herein refers to a partial or complete loss of the sense of smell, which may be temporary or permanent in duration.

The term “hyposmia” as used herein refers to a decreased sense of smell, or a decreased ability to detect odors through the nose.

The term “dysosmia” as used herein refers to a change of the ability to smell. There are two types of smell changes associated with dysosmia: parosmia: The smell of a familiar object has changed, or something that usually smells pleasant now has an unpleasant scent. For example, coffee suddenly smells like gasoline or garbage, phantosmia: one smells something that isn’t there, like a rotten odor, cigarette smoke, or chemicals like ammonia.

Loss of smell is specifically due to a viral infection, such as, but not limited to infection by rhinovirus, specifically it is rhinovirus (HRV)-40, HRV-75, HRV-78, and HRV- 80a; parainfluenza virus, influenza virus, adenovirus, Epstein-Barr virus; coronavirus, specifically it is a P-coronavirus, preferably selected from the group consisting of SARS- CoV-2, MERS-CoV, SARS-CoV-1 , HCoV-OC43, and HCoV-HKU1 , coronavirus lineages such as Pango lineages A.1 - A.30, B.1 , such as B.1.1.529, including BA.1 , BA.2, BA.3, BA.4, BA.5 (WHO label: Omicron), C.1 - C.40, etc., or mutants thereof (cov- lineages.org, https://cov-lineages.org/lineage_list.html).

Specifically, loss of smell is due to COVID-19.

“COVID-19” is a disease caused by an infection of the “SARS-CoV-2” virus. These names were standardized by the World Health Organization (WHO) and the International Committee on Taxonomy of Viruses (ICTV). Because of the rapidity of SARS-CoV-2 spread worldwide, a number of names have been used for SARS-CoV-2 including: COVID-19, COVID-19 virus, 2019-nCoV, Novel coronavirus pneumonia, Wuhan coronavirus, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV- 2). A subject with the disease of COVID-19 would have an infection of SARS-CoV-2 vims and, conversely, a subject with an infection of SARS-CoV-2 has the disease COVID-19. However, a subject with a SARS-CoV-2 infection may be asymptomatic or may have not yet developed all the symptoms.

The term "long COVID" also known as "Post-Acute Sequelae of SARS-CoV-2 infection (PASC)”, "chronic COVID syndrome (CCS)”, and "long-haul COVID”, as used herein, refers to a condition whereby an individual apparently affected by a COVID-19 infection (i.e. , displaying at least one symptom of a COVID-19 infection) does not recover for an extended period of time (e.g, several weeks or months after the typical convalescence period of COVID-19) following the onset of one or more symptoms suggestive of COVID-19, regardless of whether or not the subject has been tested for SARS-CoV-2. Persistent symptoms include, but are not limited to, fatigue, headaches, shortness of breath, anosmia, muscle weakness, low fever, and cognitive dysfunction (i.e., brain fog). Studies suggest that approximately 10% of people who tested positive for SARS-CoV-2 experienced one or more symptoms for longer than 12 weeks. Anyone infected with SARS-CoV-2 can suffer from long COVID after the infection is considered to have ended, including young, healthy people, and even if the initial disease was mild.

The present invention specifically refers to the use of GLP-1 agonists for treating Long COVID symptom of loss of smell.

Specifically, the GLP-1 agonist described herein, specifically liraglutide, may dysregulate transcripts or genes in sustentacular (SUS) cells and olfactory sensory neurons (OSNs). SUS cells, which provide structural and metabolic support for OSNs, are supposed to be the primary site of COVID-19 infection in the olfactory epithelium. The use of the GLP-1 agonist, specifically of liraglutide may result in counter-regulation of genes which are differentially regulated in the same direction in both cells, thus beneficially impacting COVID-19 induced changes related to anosmia.

These genes can be, but are not limited to genes encoding CHUK, GSK3B, KLF2, GPX4, FOXO3, and CEBPB.

CHUK, the component of inhibitor of nuclear factor kappa B (NFKB) kinase complex, triggers the degradation of the inhibitor via the ubiquitination pathway, thereby activating the transcription factor NFKB. NFKB is a master regulator in inflammatory processes and downregulation of NFKB is supposed to have a beneficial impact on COVID-19 disease progression. CHUK is upregulated after COVID-19 infection in SUS and OSN cells and the GLP-1 agonist described herein can have a negative impact on CHUK, thus counterbalancing inflammation.

GSK3B, glycogen synthase kinase 3 beta, is linked to neuroinflammation and is associated with the development of neurodegenerative diseases. GSK3B is upregulated after COVID-19 infection in SUS and OSN cells and the GLP-1 agonist described herein can have a negative impact on GSK3B thus counterbalancing neuroinflammatory processes.

KLF2, the KLF transcription factor 2, is among other functions crucial for epithelial integrity with reduced levels of KLF2 being linked to immunofibrosis and microvascular inflammation. KLF2 is downregulated after COVID-19 infection in SUS and OSN cells and and the GLP-1 agonist described herein can have a positive impact on KLF2 thus counterbalancing inflammatory and fibrotic processes.

GPX4, the glutathione peroxidase 4, is essential for maintaining oxidative homeostasis in epithelial cells. GPX4 is downregulated after COVID-19 infection in SUS and OSN cells and I and the GLP-1 agonist described herein can have a positive effect on GPX4 thus stabilizing oxidative homeostasis.

FOXO3, the forkhead box 03 transcription factor, was shown to alleviate inflammation and oxidative stress via regulation of TGF-beta and HO-1 signaling. FOXO3 is linked to neurological diseases such as Parkinson disease or Alzheimer’s disease and promotes oxidative stress induced autophagy. FOXO3 is downregulated after COVID-19 infection in SUS and OSN cells and the GLP-1 agonist described herein can have a positive effect on FOXO3 thus beneficially impacting inflammation and oxidative stress.

CEBPB, the CCAAT enhancer binding protein beta, is a transcription factor heavily involved in immune and inflammatory processes. CEBPB is downregulated after COVID-19 infection in SUS and OSN cells and the GLP-1 agonist described herein can have a positive effect on CEBPB.

The terms “subject”, “individual” and “patient” are used interchangeably herein and will be understood to refer to a warm-blooded animal, particularly a mammal. Nonlimiting examples of animals within the scope and meaning of this term include dogs, cats, rabbits, rats, mice, guinea pigs, chinchillas, hamsters, ferrets, horses, pigs, goats, cattle, sheep, zoo animals, camels, llamas, non-human primates, including Old and New World monkeys and non-human primates (e.g., cynomolgus macaques, chimpanzees, rhesus monkeys, orangutans, and baboons), and humans.

Unit-dose or multi-dose containers may be used, for example, sealed ampoules and vials, or multi-use sprays, and may be stored comprising a liquid or dry phase, e.g., in a freeze-dried (lyophilized) condition requiring only the addition of the sterile liquid carrier, for example water for injection, immediately prior to use. Preferred unit dosage formulations are those containing a daily dose or unit daily sub-dose, or multiple doses, comprising the GLP-1 agonist or a salt, solvate or combination thereof.

A single-dose or amount for single-use is the amount intended for administration that is meant for use in a single subject, such as a patient, either human or animal for a single case/procedure/administration. Packages comprising the single-dose are typically labelled as such by the manufacturer. The single-dose amount is specifically understood as a daily dose for an individual, like a child or adult, to provide an effective amount.

The pharmaceutical preparation or medicinal product described herein is specifically provided as human or veterinary pharmaceutical composition or medicinal product. Medicinal products are understood as substances that are used to treat diseases, to relieve complaints, or to prevent such diseases or complaints in the first place. This definition applies regardless of whether the medicinal product is administered to humans or to animals. The substances can act both within or on the body.

Specific medicinal products or pharmaceutical compositions described herein comprise one or more GLP-1 agonists and a pharmaceutically acceptable carrier or excipient. Specifically, the daily dosage of the GLP-1 agonist, specifically of liraglutide is in the range of about 1.5 pg to 6 mg, specifically the daily dosage is in the range of 10 pg to 3 mg, specifically in the range of 30 pg to 1 mg, specifically 60 pg to 500 pg, more specifically the dosage is 1 , 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 110, 120, 130, 140, 150, 160, 170, 180, 190, 200, 250, 300, 350, 400, 450, 500 pg.

A “pharmaceutically acceptable carrier” refers to an ingredient in a formulation for medicinal or medical use, other than an active ingredient, which is nontoxic to a subject. A pharmaceutically acceptable carrier includes, but is not limited to, a buffer, excipient, stabilizer, or preservative, and the like.

The GLP-1 agonist as used herein can be formulated with conventional carriers and excipients, which will be selected according to ordinary practice.

Commercially available GLP-1 agonist formulations may also be used for the prophylactic or therapeutic treatment of a disease condition which is caused by or associated with a viral infection by a coronavirus described herein.

Pharmaceutically acceptable carriers generally include any and all suitable solvents, dispersion media, coatings, antiviral, antibacterial and antifungal agents, isotonic and absorption delaying agents, and the like that are physiologically compatible with an antiviral small molecule compound or related composition or combination preparation described herein.

The compounds as described herein may be provided in controlled release pharmaceutical ("controlled release formulations") in which the release of the GLP-1 agonist is controlled and regulated to allow less frequency dosing or to improve the pharmacokinetic or toxicity profile of a given active ingredient.

Pharmaceutical compositions may also be coated by conventional methods, typically with pH or time-dependent coatings, such that the subject agent is released in the gastrointestinal tract in the vicinity of the desired topical application, or at various times to extend the desired action. Such dosage forms typically include, but are not limited to, one or more of cellulose acetate phthalate, polyvinyl acetate phthalate, hydroxypropyl methyl cellulose phthalate, ethyl cellulose, waxes, and shellac.

Additional pharmaceutically acceptable carriers are known in the art and described in, e.g., Remington: The Science and Practice of Pharmacy, (Adeboye Adejare, ed., Pharmaceutical Press, 2020, 23 ^rd edition). Liquid formulations can be solutions, emulsions or suspensions and can include excipients such as suspending agents, solubilizers, surfactants, preservatives, and chelating agents.

The preferred preparation is in a ready-to-use, storage stable form, with a shelflife of at least one or two years.

The pharmaceutical preparation is specifically formulated for local administration, preferably for application to the upper and lower respiratory tract, intra-nasal, or for pulmonary application.

The terms "intranasal" or "intranasally," as used herein, refers to a route of delivery of an active compound to a patient by inhalation to the nasal mucosa, the airway, the lung, or a combination thereof.

Useful administration forms can be sprays, powders, gels, ointments, liquid solutions, gargle solutions, aerosolized powders, or aerosolized liquid formulations.

For pulmonary administration, inhalers may be used and the pharmaceutical preparation is formulated accordingly, e.g. as aerosols. As used herein, the term "inhaler" refers to a drug delivery device used to administer medication in the form of a mist inhaled through the nose. Nebulizers may use oxygen, compressed air, ultrasonic power, mechanical means, etc., to break up medical solutions and suspensions into small aerosol droplets that can be directly inhaled from the device.

As used herein, the term "aerosol" refers to a mixture of gas and liquid particles, and the best example of a naturally occurring aerosol is mist, formed when small vaporized water particles mixed with hot ambient air are cooled down and condense into a fine cloud of visible airborne water droplets. In one embodiment of the present disclosure, an aerosol may be produced through an aerosol spray or a sprayer. As used herein, the term "aerosol spray" or "a sprayer" refers to a type of dispensing system which creates an aerosol mist of liquid particles. This is used with a can or bottle that contains a liquid under pressure. When the container's valve is opened, the liquid is forced out of a small hole and emerges as an aerosol or mist. As the gas expands to drive out the payload, only some propellant evaporates inside the can to maintain an even pressure. Outside the can, the droplets of propellant evaporate rapidly, leaving the payload suspended as very fine particles or droplets. An atomizer is a similar device that is pressurized by a hand-operated pump rather than by stored gas.

A particle, droplet, or an aerosol, and the like in this description may be a liquid suspension particle or a dry particle. A dry particle may be dry as it is produced, as it is administered, and/or as it exits an apparatus. It can be a dry particle even if the particle, droplet, or an aerosol starts out as a liquid because the liquid may be a fast-evaporating liquid. Therefore, by the time the particle, droplet, or an aerosol contacts the subject, it will be dry. Also, it is possible a liquid particle, droplet, or an aerosol will dry after contact with a subject, for example, by rapid evaporation of the liquid component.

The term “effective amount” as used herein, shall refer to an amount (in particular a predetermined amount) that has a proven therapeutic effect. The amount is typically a quantity or activity sufficient to, when administered to a subject effect beneficial of desired results, including increase of smell capabilities. A therapeutically effective amount can be adjusted by one of ordinary skill in the art, will vary, depending on the age, health, physical condition, sex, weight, extent of the dysfunction of the recipient, frequency of treatment and the nature and scope of the dysfunction.

An effective amount of a pharmaceutical preparation or drug is intended to mean that amount of a compound that is sufficient to treat, prevent or inhibit a disease, disease condition or disorder, specifically loss of smell. Such an effective dose specifically refers to that amount of the compound sufficient to result in healing, prevention or amelioration of conditions related to diseases or disorders described herein.

The amount of the compound that will correspond to such an effective amount will vary depending on various factors, such as the given drug or compound, the formulation, the route of administration, the identity of the subject or host being treated, the assessment of the medical situations and other relevant factors, but can nevertheless be routinely determined by one skilled in the art.

The pharmaceutical preparation can be administered with the GLP-1 agonist as the sole substance.

The treatment can be combined with a further treatment with one or more active substances, selected from the group consisting of antiviral, antimicrobial, antiinflammatory, antiallergenic, anti-hypertensive, antihistaminic, cardiovascular, antilipidemic, endocrine, diabetic, and antibiotic substances, preferably wherein the pharmaceutical preparation is administered before, during (e.g., by co-administration or in parallel), or after said antiviral, anti-inflammatory or antibiotic treatment.

The agents can be in separate containers or mixed in a single container.

The active agents described herein can also be formulated in a pharmaceutical composition in the presence of the GLP-1 agonist.

The term “antiviral” as used herein shall refer to any substance, drug, or preparation, that effects the biology of a virus and attenuates or inhibits viral attachment, entry, replication, shedding, latency or a combination thereof, resulting in reduction of viral load or infectivity. The terms “attenuating”, “inhibiting”, “reducing”, or “preventing”, or any variation of these terms includes any measurable decrease or complete inhibition to achieve a desired result, e.g., reduction in the risk of viral infection (pre-exposure), or reduction of post-exposure viral survival, load, or growth.

Antiviral and antibacterial (antibiotic) substances may be, but are not limited to nirmatrelvir, sold under the trade name Paxlovid, ritonavir, regdanvimab, sold under the trade name Regkirona, sotrovimab, sold under the trade name Xevudy, suramin, raloxifene, maraviroc, quinacrine, iprofloxacin, clarithromycin, ganciclovir, amoxicillin, clarithromycin, levofloxacin, amoxicillin, azithromycin.

The term “anti-inflammatory” refers to any substance, drug or preparation, that reduces inflammation or swelling.

Antiallergenic and antihistaminic drugs can be, but are not limited to, fluticasone, prednisone, olopatadine HCI.

Antilipidemic drugs can be, but are not limited to, atorvastatin, lovastatin, pravastatin,

Endocrine and diabetic drugs can be, but are not limited to, levothyroxine, testosterone.

Further drugs may be, but are not limited to, miglustat, glatiramer acetate, auranofin, dexamethasone, amlodipine, budesonide, celecoxib, tramadol HCI, enalapril maleate, gadopentetate dimeglumine, lansoprazole, diltiazem, and Vitamin A.

A treatment or prevention regime of a subject with an effective amount of the GLP- 1 agonist described herein may consist of a single application or administration, or alternatively comprise a series of applications and administrations, respectively. For example, the GLP-1 agonist may be used at least once a month, or at least once a week, or at least once a day. However, in certain cases of an acute phase, e.g. upon suspected or confirmed exposure to a virus, or after virus infection has been determined, the GLP- 1 agonist may be used more frequently, e.g. 1-10 times a day.

Specifically, a combination therapy is provided which includes treatment with the preparation described herein and standard therapy of a coronavirus-caused disease, specifically therapy of LCS.

The length of the treatment period depends on a variety of factors, such as the severity of the disease, either acute or chronic disease, the age of the patient, and the concentration of gefitinib, liraglutide or combination thereof. It will also be appreciated that the effective dosage used for the treatment or prophylaxis may increase or decrease over the course of a particular treatment or prophylaxis regime. Changes in dosage may result and become apparent by standard diagnostic assays known in the art.

As used herein, "treating" of loss of smell can include one or more of: reducing the frequency or severity of symptoms, elimination of symptoms or their underlying cause, or improvement or remediation of damage. For example, treatment of olfactory dysfunction can include, for example, increasing smell acuity from a patient suffering from a Coronavirus infection, such as a patient with COVID-19 or LCS, and/or causing the regression or disappearance of olfactory dysfunction.

EXAMPLES

The foregoing description will be more fully understood with reference to the following examples. Such examples are, however, merely representative of methods of practicing one or more embodiments of the present invention and should not be read as limiting the scope of invention.

Example 1 :

Randomized double-blinded controlled phase 2 proof-of-concept study with parallel assignment.

The study described herein comprises the use of liraglutide. However, liraglutide can be replaced by any GLP-1 agonist may be used in the study described below.

The study consists of the following phases (see Figure 1 below): o A three-week run-in phase which serves to enroll the patients in the study and to perform the necessary preliminary examinations (e.g. examination of the inclusion criteria, ascertainment of previous illnesses, COVID test, smell test, etc.). o Subsequently, the six-week Treatment Phase 1 - double-blind study phase starts, in which 50% of the patients receive liraglutide and 50% receive placebo. o The next step is the six-week Treatment Phase 2, in which all patients are treated with liraglutide as an open label application. o In the three-week follow-up phase, the patients will undergo final examinations by the investigator.

During Treatment Phase 1 and 2, patients are required to self-medicate and keep a study diary. Inclusion criteria: o 18-75 years o Olfactory disorder (defined as <31 points on the Sniffin' Sticks Test) that has been present for >3 months following confirmed COVID-19 infection. o Written Informed Consent Form after being informed in detail about the nature, risks, and scope of the clinical trial and the expected effects associated with the study drug. o Ability and willingness to cooperate with the investigator and meet the requirements of the study as a whole.

Exclusion Criteria: o History of olfactory dysfunction prior to COVID-19 infection. o Known nasal polyps, prior sinonasal or anterior cranial surgery. o History of neurodegenerative disease (i.e., Alzheimer's dementia, Parkinson disease, Lewy body dementia, frontotemporal dementia). o History of olfactory dysfunction longer than 18 months. o Use of adjunctive therapies specifically to treat olfactory dysfunction. o Comorbid conditions such as diabetes. o History of allergic reaction or other contraindications to liraglutide. o Clinically relevant findings on physical examination, vital signs, and laboratory parameters at screening that are deemed clinically significant by the medical staff. o History of drug or alcohol abuse in the past two years. o Pregnancy or lactation. o Patients of childbearing age who refuse to use an effective method of contraception during the study. o Ongoing history or symptoms of clinically relevant disease in the 3 weeks prior to the first study day. o History of malignancy that has not been adequately treated, basal cell or squamous cell carcinoma in the last 5 years. o Participation in another investigational drug study within 28 days prior to screening or during the course of this study. o Inability to comply with study procedures and assessments, including the ability to use the study drug intranasally. o Any objections to participation are at the discretion of the investigator. Study Medication: liraglutide diluted in isotonic nasal saline, 30pg/ml, 0.5ml per nostril twice daily (0.5ml per nostril twice daily means 30pg per use or 60pg per day).

Placebo: 0.5ml nasal saline, 0.5ml per nostril twice daily.

Administration: both study medication and placebo are administered as intranasal nasal drops in the Kaiteki position. This is a comfortable side-lying position in which subjects tilt their head and turn their chin upward.

Study duration: 3 weeks run-in phase, max. 12 weeks active treatment duration,

3 weeks run-out phase.

□ Recruitment period: 5.5 months

Outcome Parameter: o Primary endpoint: change in TDI score from Sniffin’ Sticks Test after 6 weeks of treatment (comparison between groups).

Sniffin' Sticks Test is an objective test of olfactory performance in which reusable felt-tip sticks are filled with odorants and can be used to test various "odor dimensions" such as odor detection thresholds (threshold), odor discrimination (discriminative ability), and odor identification (identification ability). The test comprises 3 subtests, resulting in

4 scores: T threshold score, D discrimination score, I identification score and TDI global olfactory score. Added scores (TDI) are also used to identify olfactory dysfunction at baseline (see inclusion criteria, definition of OD < 31 points). o Secondary endpoint: Change in TDI scores (individual dimensions and summed scores) after 6 weeks of treatment (per patient).

Clinical Global Impression (CGI) Scale: the CGI improvement scale of 1-7 (1 is very much improved, 7 is very much worsened) measures subjective changes in olfactorial dysfunction. Each rating has a definition to better explain what a particular rating might mean to reduce variability among patient responses with the same subjective degree of dysfunction or improvement.

Questionnaire for Olfactory Dysfunction (QOD): This test, in the form of a questionnaire, measures changes in participants' health-related quality of life based on four factors as defined by Mattos et al. This will qualify which factor (eating, mental health, social interactions, or fear of function) was most affected by the proposed intervention. The survey also includes questions about parosmia, a phenomenon of COVID-related OD. Olfactory Dysfunction Outcomes Rating (ODOR): ODOR is a new diseasespecific questionnaire that assesses physical, functional, and emotional impairments in participants with olfactory dysfunction of any etiology. Based on recurrent impairments for participants with postviral OD related to eating/appetite, environmental safety, interpersonal relationships, hygiene, and mood, 28 items were generated to create the new patient-reported outcome measure.

The Sniffin' Sticks Test is administered multiple times during the study, and each time the three aforementioned survey questionnaires are also answered (Smell Test and Questionnaires row). This allows a broad observation and evaluation of the change in smelling ability from multiple perspectives.

Statistical Analysis: o Sample Size: To date, there are no studies investigating the efficacy of liraglutide in COVID-19-related OD. Due to the lack of preliminary data and effect size, the sample size for this study will be determined based on feasibility. It is planned to enroll 50 subjects* for this pilot study. The sample size of 50 subjects is feasible given the study center's current patient enrollment of >200. It is anticipated a dropout or withdrawal rate of no more than 15% during the first 6 weeks of the treatment phase. This is included in our sample size calculation below.

Assuming an actual difference between the test and control groups of 6 points in the TDI score (a difference of 5.5 was suggested to be clinically relevant) and a pooled standard deviation of 4 points (data from the literature and previous studies), this study would require a sample size of 22 subjects for each group (i.e. , total sample size of 44 with the same group size) to achieve 80% power and 5% significance, i.e., a total sample size of 44 with the same group size) to achieve 80% power and 5% significance to show that liraglutide is superior to placebo by at least 3 units. o Analysis Plan: An intention-to-treat analysis will be used in which all participants will be studied in the groups to which they were originally assigned, regardless of the treatment they actually received. Standard descriptive-statistical measures will be used to assess the demographics, clinical characteristics, and olfactory test scores of the study population.

Mixed-model analysis will be used to compare the change in outcomes between study groups at different study evaluations. A contrast test will be considered as the primary analysis, which will show whether there are differences between liraglutide and placebo treatment at week 6. For exploratory purposes, the effects of liraglutide will also be analyzed after delayed treatment initiation or prolonged treatment at week 12.

Effect sizes with a 95% confidence interval are reported for each analysis. All statistical analyses are performed in R (http://www.r-project.org/).

Example 2:

Measuring gene expression of key molecules in cell culture as a surrogate for the mode of action of GLP-1 agonists in anosmia.

Key genes and their transcripts and protein products are measured in sustentacular (SUS) cells or olfactory sensory neurons (OSNs) from primary or immortalized origin, both in vitro or in vivo in relevant models.

SUS or OSN cells, such as Sertoli cells from human and mouse origin (human: Hs I .Tes [ATCC-CRL-7002] ; mouse: 15P-1 [ATCC-CRL-2618]; LGC Standards GmbH, Wesel, Germany), are cultured in DMEM/F-12 culture medium (Sigma-Aldrich) supplemented with 50 units/ml penicillin, 50 pg/ml streptomycin and 10% FCS and cultured at 5% CO2 and 37°C in humidified atmosphere. Cells are propagated in 75 cm ² cell culture flasks until 80% confluence and then seeded into cell culture well plates for exposure experiments.

Sertoli cells are exposed for increasing duration, such as 1 , 5, 20, and 60 minutes to sodium dodecyl sulfate (SDS) at a suitable concentration such as 0.40 mM or a similar relevant cytotoxic stress to induce SUS or OSN cell injury, followed by incubation with normal growth medium for varying periods (0-24h) with or without GLP-1 agonists at an effective dose (e.g. 60 nM liraglutide). FCS can be added to all final mixtures to yield a final concentration of 10%. Parallel incubation with stressor-free medium, with or without GLP-1 agonists at the same dose as above, serves as negative-control.

Following experimental treatments, cells are washed twice with phosphate- buffered saline (PBS), lysed in 350 pl /12-well RLT buffer (Qiagen, Hilden, Germany) and stored at -80°C. Total RNA isolation is performed by silica-membrane columns (RNeasy kits, Qiagen) per manufacturer’s protocol. RNA concentration and quality were determined byAgilent 2100 Bioanalyzer (Agilent Technologies Inc., Palo Alto, CA, USA). Samples with RNA integrity number (RIN) score > 9.0 are used for further analysis. 100 ng RNA is transcribed into cDNA (LunaScript RT SuperMix Kit (New England BioLabs, Ipswitch, MA, USA) per manufacturer’s protocol. The qPCR reaction is performed (Luna Universal qPCR Master Mix, New England BioLabs) with 20 pl of diluted cDNA and primers for selected genes (e.g., GPX4, FOXO3, CEBPB, KLF2, GSK3B, CHUK - see description for details on selected genes in SUS and OSN cells) and mRNA levels are analysed using a real-time PCR cycler (e.g., CFX Opus 96, BioRad, Hercules, CA, USA). Primer pairs are purchased from Qiagen. Specific amplification is controlled by melting curve analysis. The expression changes are calculated using the 2 ^-AACt method. The fold-change in mRNA expression is quantified relative to untreated control samples from the same experiment. 18S or GAPDH are used as housekeeping genes. Relevant proteins may be assessed by Western blot and/or mass spectrometry.

Anticipated Results:

For those genes where the cytotoxic stress can reproduce the anosmia pattern, liraglutide counter-regulation confirms the mode of action proposed by the molecular models for anosmia and GLP-1 agonists (see Figure 2 for pattern of up- or downregulation of genes in SUS or OSN cells in anosmia, counter-regulated by liraglutide).

REFERENCES

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Suzuki M. et al., Identification of Viruses in Patients With Postviral Olfactory Dysfunction, Laryngoscope, 117:272-277, 2007

Vallee A, Dysautonomia and Implications for Anosmia in Long COVID-19 Disease, J. Clin. Med. 2021 , 10, 5514. https://doi.org/10.3390/jcm10235514

Ben-Chetrit E. et al., Anosmia and dysgeusia amongst COVID-19 patients are associated with low levels of serum glucagon-like peptide 1 , Int J Clin Pract. 2021 ;00:e14996