WO2021202745A1 - Treatment of covid-19 with a sine compound - Google Patents

Abstract

The disclosure relates to a method of treating COVID-19 in a subject in need thereof comprising administering to the subject a therapeutically effective amount of a SINE compound represented by structural formula I or pharmaceutically acceptable salt thereof. The COVID-19 can be severe COVID-19 and the subject can be an adults aged 18 years or older. The SINE compound can be Selinexor that is administered orally at about 20 mg per dose or 40mg per dose.

Description

TREATMENT OF COVID-19 WITH A SINE COMPOUND

RELATED APPLICATIONS

[0001] This application claims the benefit of U.S. Provisional Application Nos. 63/002,871, filed on March 31, 2020, 63/010,482, filed on April 15, 2020 and 63/088,256, filed on October 6, 2020. The entire teachings of the above application(s) are incorporated herein by reference.

BACKGROUND OF THE INVENTION

[0002] Coronavirus disease 2019 (COVID-19) is the disease caused by a novel virus strain, severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), an enveloped, positive-sense, single-stranded RNA betacoronovirus of the family Coronaviridae. COVID- 19 was first identified in Wuhan, China in late 2019. On March 11, 2020 the World Health Organization declared outbreak of COVID-19 a pandemic. There is a critical need for therapies capable of treating COVID-19 and other diseases caused by the Coronaviridae virus family.

SUMMARY OF THE INVENTION

[0003] The disclosure relates to method of treating COVID-19, including severe COVID- 19 in a subject in need thereof comprising administering to the subject a therapeutically effective amount of a SINE compound.

[0004] In a first embodiment, the SINE compound is represented by structural formula I:

or a pharmaceutically acceptable salt thereof, wherein: R¹ is selected from hydrogen and methyl; R² is selected from pyridin-2-yl, pyri din-3 -yl, pyridin-4-yl, pyrazin-2-yl, and quinoxalin-2-yl, pyrimidin-4-yl, l,l-dioxotetrahydrothiophen-3-yl and cyclopropyl, wherein R² is optionally substituted with one or more independent substituents selected from methyl and halogen; or

R¹ and R² are taken together with their intervening atoms to form 4-hydroxypiperidin- 1-yl, pyrrolidin-l-yl, azepan-l-yl, 4-benzylpiperazin-l-yl, 4-ethylpiperazin-l-yl, 3- hydroxyazetidin-l-yl, or morpholin-4-yl;

R³ is selected from hydrogen and halo; and

>LL represents a single bond wherein a carbon-carbon double bond bound thereto is in an (E)- or (Z)-configuration.

[0005] In a second embodiment, the method of treating COVID-19 in a subject in need thereof comprises administering to the subject a therapeutically effective amount of a SINE compound represented by compound 1-3 :

or a pharmaceutically acceptable salt thereof.

[0006] In a first aspect of the first or second embodiment, the COVID-19 is severe COVID-19.

[0007] In a second aspect of the first or second embodiment or any aspect thereof, the subject is a human. For example, the subject is a human 18 years or age or older [0008] In a third aspect of the first or second embodiment or any aspect thereof, the therapeutically effective amount of the SINE compound is from about 2 mg to about 200 mg. For example, the therapeutically effective amount of the SINE compound is about 20 mg. [0009] In a fourth aspect of the first or second embodiment or any aspect thereof, the SINE compound is administered orally.

[0010] In a fifth aspect of the first or second embodiment or any aspect thereof, the SINE compound is administered in the form of a tablet. [0011] In a sixth aspect of the first or second embodiment or any one of the first through fourth aspects, the SINE compound is administered in the form of a suspension.

[0012] In a seventh aspect of the first or second embodiment or any one of the first through fourth and sixth aspects thereof, the SINE compound is administered using a nasal gastral tube or a G-tube.

[0013] In an eighth aspect of the first or second embodiment or any aspect thereof, about 20 mg of the SINE compound is orally administered to the subject for a period of two weeks on days 1, 3 and 5 of each week. In a specific aspect, the SINE compound is orally administered to the subject for an additional two weeks on days 1, 3 and 5 of each additional week.

[0014] In a ninth aspect of the first or second embodiment or any aspect thereof, the SINE compound in administered one or more times per day (e.g, 1, 2 or 3 times per day) In a specific aspect, the SINE compound in administered once per day.

[0015] In an tenth aspect of the first or second embodiment or any aspect thereof, the method further comprises administering an additional therapeutic agent. For example, the additional therapeutic agents is an antibiotic. Exemplary antibiotics include azithromycin, amoxicillin or a tetracycline.

[0016] Unless indicated otherwise the term “any aspects thereof’ includes aspects numbered both before and after the given aspect.

BREF DESCRIPTION OF THE DRAWINGS

[0017] FIG. l is a graph showing the number of plaques for various concentrations of selinexor as detailed in Experiment 1 (Pre-treatment) and Experiment 2 (Co-incubation). Selinexor is referred to as KPT-330.

[0018] FIG. 2 shows the number of plaques for various concentrations of verdinexor as detailed in Experiment 1 (Pre-treatment) and Experiment 2 (Co-incubation). Verdinexor is referred to as KPT-335.

[0019] FIG. 3A shows the Plaque Forming Units/ml for various concentration of selinexor (referred to as KPT-330) following Experiment 3-1 in linear scale.

[0020] FIG. 3B shows the Plaque Forming Units/ml for various concentration of selinexor (referred to as KPT-330) following Experiment 3-1 in loglO scale. [0021] FIGS. 3C shows the number of plaques after 4 days of incubation for cell infected with SARS-CoV-2 followed by exposture to selinexor at Ohr, 24, hr, 36hr and 48hour post infection as decscribed in Example 3-2.

[0022]

[0023] FIG. 4 A shows the Plaque Forming Units/ml for various concentration of verdinexor (referred to as KPT-335) following Experiment 3 in linear scale.

[0024] FIG. 4B shows the Plaque Forming Units/ml for various concentration of verdinexor (referred to as KPT-335) following Experiment 3 in loglO scale.

[0025] FIG. 5 shows the effect of Selinexor on Vero E6 cells.

[0026] FIG. 6A, 6B and 6C are graphs showing that Selinexor decreases SARS-CoV-2 viral load and severity of rhinitis and lung inflammation In Vivo

[0027] FIG. 7 depicts the version of the clinical trial design that was used to treat patients.

[0028] FIG. 8 lists the characteristics of the patients in the Intent to Treat (ITT) patient group.

[0029] FIG. 9 reports the efficacy of selinexor treatment in the ITT patient population. [0030] FIG. 10 is a graph showing that the time to PCR negative conversion was shorter for patients receiving selinexor than those receiving placebo.

[0031] FIG. 11 is a table comparing clinical parameters for selinexor-treated and placebo- treated patients within the Low LDH/DD subgroup.

[0032] FIG. 12 is a table comparing the PCR negative conversion rate and time to PCR negative for selinexor-treated and placebo-treated patients within the Low LDH/DD subgroup.

[0033] FIG. 13A are graphs showing the levels of the noted cytokines in COVID-19 patients in selinexor-treated and placebo-treated patients within the Low LDH/DD and High LDH/DD subgroups.

[0034] FIG. 13B are graphs showing the levels of the noted cytokines in COVID-19 patients in selinexor-treated and placebo-treated patients within the Low LDH/DD and High LDH/DD subgroups.

[0035] FIG. 13C is a graph showing the levels of the noted cytokines in COVID-19 patients in selinexor-treated and placebo-treated patients within the Low LDH/DD and High LDH/DD subgroups. DETAILED DESCRIPTION OF THE INVENTION

[0036] A description of example embodiments of the invention follows.

[0037] The teachings of all patents, published applications and references cited herein are incorporated by reference in their entirety.

SINE (Selective Inhibitor of Nuclear Export) COMPOUNDS [0038] Compounds for use in the method of treating COVID-19 and other diseases caused by a coronavirus include Selective Inhibitors of Nuclear Export (SINE). As used herein, SINE compounds are compounds that specifically bind to and inhibit the nuclear export protein, exportin 1 (XPOl, also called CRM1). In a specific embodiment, the SINE compounds used in the method of treating COVID-19 are compound represented by any one of formulas (I), (II), 1-3, (IV) and (V))

[0039] In one embodiment of the invention, the SINE compound is represented by structural formula I:

or a pharmaceutically acceptable salt thereof, wherein:

R¹ is selected from hydrogen and methyl;

R² is selected from pyridin-2-yl, pyri din-3 -yl, pyridin-4-yl, pyrazin-2-yl, and quinoxalin-2-yl, pyrimidin-4-yl, l,l-dioxotetrahydrothiophen-3-yl and cyclopropyl, wherein R² is optionally substituted with one or more independent substituents selected from methyl and halogen; or

R¹ and R² are taken together with their intervening atoms to form 4-hydroxypiperidin- 1-yl, pyrrolidin-l-yl, azepan-l-yl, 4-benzylpiperazin-l-yl, 4-ethylpiperazin-l-yl, 3- hydroxyazetidin-l-yl, or morpholin-4-yl;

R³ is selected from hydrogen and halo; and represents a single bond wherein a carbon-carbon double bond bound thereto is in an (E)- or (Z)-configuration. [0040] Compounds of structural formula (I) can be prepared according to methods described in U.S. Patent No. 8,999,996, the entire content of which is hereby incorporated by reference.

[0041] As described generally above, R¹ is selected from hydrogen and methyl. In some embodiments, R¹ is hydrogen. In some embodiments, R¹ is methyl.

[0042] As described generally above, R² is selected from pyridin-2-yl, pyridin-3-yl, pyridin-4-yl, pyrazin-2-yl, quinoxalin-2-yl, pyrimidin-4-yl, l,l-dioxotetrahydrothiophen-3-yl and cyclopropyl, wherein R² is optionally substituted with one or more independent substituents selected from methyl and halogen. In some embodiments of formula I, R² is pyridin-2-yl. In some embodiments of formula I, R² is pyridin-3-yl. In some embodiments of formula I, R² is pyridin-4-yl. In some embodiments of formula I, R² is pyrazin-2-yl. In some embodiments of formula I, R² is pyrimidin-4-yl. In some embodiments of formula I, R² is quinoxalin-2-yl. In some embodiments of formula I, R² is selected from pyridin-2-yl, pyridin-3-yl and pyridin-4-yl. In some embodiments of formula I, R² is selected from pyri din-2 -yl, pyridin-3-yl, pyridin-4-yl, pyrazin-2-yl and pyrimidin-4-yl. In some embodiments of formula I, R² is selected from pyridin-2-yl, pyridin-4-yl, pyrazin-2-yl and pyrimidin-4-yl.

[0043] In some embodiments, R² is selected from:

[0044] In some embodiments of formula I, R² is optionally substituted with a single substituent selected from methyl and chloro. In some embodiments of formula I, R² is optionally substituted with a methyl group. In some embodiments of formula I, R² is optionally substituted with a chloro group. In some embodiments, R² is selected from: [0045] In some embodiments, R² is selected from:

[0046] In some embodiments, R² is selected from:

[0047] In some embodiments of formula I, R¹ and R² are taken together with their intervening atoms to form 4-hydroxypiperidin-l-yl, pyrrolidin-l-yl, azepan-l-yl, 4- benzylpiperazin-l-yl, 4-ethylpiperazin-l-yl, 3-hydroxyazetidin-l-yl, or morpholin-4-yl. In some embodiments of formula I, R¹ and R² are taken together with their intervening atoms to form 4-hydroxypiperidin-l-yl.

[0048] As described generally above, R³ is selected from hydrogen and halogen. In some embodiments, R³ is hydrogen. In some embodiments, R³ is halogen (e.g., chloro, bromo, iodo or fluoro). In some such embodiments, R³ is chloro.

[0049] As described generally above, the carbon-carbon double bond in between the triazole moiety and the carbonyl moiety is in an (E)-configuration or a (Z)-configuration. In some embodiments, that double bond is in a (E)-configuration. In some embodiments, that double bond is in a (Z)-configuration and the compound is represented by formula II:

or a pharmaceutically acceptable salt thereof, wherein R¹, R² and R³ are as defined above for formula (I) and described herein.

[0050] In a first aspect of Formula (II), R¹ is as defined above; and R² is selected from pyridin-2-yl, pyridin-4-yl, pyrazin-2-yl and pyrimidin-4-yl, wherein R² is optionally substituted with a single substituent selected from methyl and chloro; or R¹ and R² are taken together with their intervening atoms to form 4-hydroxypiperidin-l-yl.

[0051] In a specific aspect of the first aspect of formula (II), R³ is hydrogen. The values and alternative values for the remaining variables are as described above for a compound of formula I, or in the compound of formula (II), or the first aspect thereof.

[0052] Exemplary compounds of formula I and formula II are set forth in Table 1.

[0053] Table 1. Exemplary compound of formula I.

[0054] In some embodiments, the compound for use in the method of treating COVID-19 is selected from any one of compounds 1-3 to 1-26. In one aspect of these embodiments, the compound is selected from compounds 1-3, 1-4, 1-5, 1-7, 1-8, 1-10, 1-12, 1-18, 1-19 and 1-24. In a more specific aspect, the compound of the invention is selected from 1-3 and 1-4.

Compound 1-4 is referred to herein as verdinexor or KPT-335.

[0055] In a most specific embodiment, the compound for use in treating COVID-19 is Compound 1-3 or a pharmaceutically acceptable salt thereof. Compound 1-3 is also referred to in the medical community as Selinexor, XPOVIO^® and KPT-330. The chemical name of Selinexor is (2Z)-3-J 3-[3,5-bis(trifluoromethyl)phenyl]- l H-\ ,2,4-triazol- 1 -yl }-A^f’-(pyrazin-2- yl)prop-2-enehydrazide. Selinexor, the compound represented by Formula 1-3, is a potent, oral, slowly reversible covalent SINE compound that specifically binds to and inhibits the nuclear export protein exportin 1 (XPOl, also called CRM1). XPOl mediates the nuclear export of proteins and ribonucleoprotein (RNP) complexes carrying a leucine-rich nuclear export sequence (NES). Over 200 XPOl cargo proteins have been identified including proteins with regulatory roles in the inflammatory response and many viral proteins.

[0056] Selinexor received accelerated approval from the FDA in July 2019 in combination with dexamethasone as a treatment for patients with relapsed or refractory multiple myeloma (RRMM). The approved dose of selinexor for RRMM is 160 mg per week (80 mg PO twice weekly). Over 3000 patients with a variety of advanced cancers have received selinexor alone or in combination with other anti -neoplastic agents in clinical studies; nearly 1000 patients have received the agent commercially.

[0057] In a further embodiment, the SINE compound for use in treating COVID-19 is represented by structural formula IV.

or a pharmaceutically acceptable salt thereof, wherein:

R² is selected from optionally substituted heteroaryl having 5 to 15 ring atoms and optionally substituted aryl having 6 to 12 ring atoms. Compounds of structural formula IV can be synthesized according to the methods disclosed in U.S. Patent No. 9,738,624, the entire content of which is hereby incorporated by reference.

[0058] In a specific aspect of formula (IV), R² is an optionally substituted heteroaryl having 5 to 15 ring atoms. For example, R² is an optionally substituted 5-6-membered heteroaryl having 1, 2 or 3 heteroatoms independently selected from the group consisting of nitrogen, oxygen and sulfur.

[0059] In a further aspect of formula (IV), R² is an optionally substituted pyrrolyl, furanyl, thiophenyl, pyrazolyl, imidazolyl, thiazolyl, isothiazolyl, oxazolyl, isoxazolyl, triazolyl, thiadiazolyl, or oxadiazolyl.

[0060] In another aspect of formula (IV), R² is an optionally substituted 6-membered heteroaryl having 1, 2 or 3 heteroatoms independently selected from the group consisting of nitrogen, oxygen and sulfur. For example, R² is an optionally substituted pyridinyl, pyrimidinyl, pyrazinyl, pyridazinyl ortriazinyl.

[0061] Optional substituents on R² include, but are not limited to, 1, 2 or 3 substituents independently selected from halogen, C1-C4 alkyl, halo-Ci-C4 alkyl, C1-C4 alkoxy, C1-C4 thioalkoxy, hydroxyl, amino, C1-C4 alkylamino, C1-C4 dialkylamino, sulfhydryl (-SH), cyano (-CN), Ce aryl and heteroaryl having 5 or 6 ring atoms. In a specific embodiment, R² is optionally substituted with 1, 2 or 3 substituents independently selected from fluoro, chloro, C1-C4 alkyl, -CF3, amino and cyano.

[0062] In a specific embodiment, a compound of formula (IV) is represented by any one of the following structural formulas:

or a pharmaceutically acceptable salt of any of the foregoing.

[0063] In a specific embodiment, he compound of formula (IV) for use in treating COVID-19 is represented by structural formula (V):

or a pharmaceutically acceptable salt thereof.

[0064] The compound of structure formula (V) is commonly referred to in the medical community as eltanexor and KPT-8602. Eltanexor is an orally bioavailable inhibitor of exportin-1 (XPOl; chromosome region maintenance 1 protein homolog; CRM1). Upon administration, eltanexor binds to the XPOl cargo binding site, which prevents the XPOl- mediated nuclear export of cargo proteins such as tumor suppressor proteins (TSPs), including p53, p73, BRCAl/2, pRB, FOXO, and other growth regulatory proteins and leads to their selective accumulation in the nuclei of tumor cells. As a selective inhibitor of nuclear export (SINE), KPT-8602 restores the nuclear localization and function of tumor suppressing proteins which leads to the induction of apoptosis in tumor cells. The IUPAC name of Eltanexor i s : (£)- 3 -(3 -(3 , 5 -bi s(trifluoromethyl)phenyl)- 1 H- 1 ,2,4-triazol- 1 -yl)-2-(pyrimidin- 5-yl)acrylamide.

[0065] Chemical Definitions

[0066] As used herein, the term “alkenyl” means a saturated straight chain or branched non-cyclic hydrocarbon having from 2 to 12 carbon atoms and having at least one carbon- carbon double bond. Alkenyl groups may be optionally substituted with one or more substituents. The term “alkenyl” encompasses radicals having carbon-carbon double bonds in the “cis” and “trans” or, alternatively, the Έ” and “Z” configurations. If an alkenyl group includes more than one carbon-carbon double bond, each carbon-carbon The term “aliphatic” or “aliphatic group,” as used herein, denotes a monovalent hydrocarbon radical that is straight-chain (i.e., unbranched), branched, or cyclic (including fused, bridged, and spiro- fused polycyclic). An aliphatic group can be saturated or can contain one or more units of unsaturation, but is not aromatic. Unless otherwise specified, aliphatic groups contain 1-12 carbon atoms. However, in some embodiments, an aliphatic group contains 1-6 or 2-8 carbon atoms. In some embodiments, aliphatic groups contain 1-4 carbon atoms and, in yet other embodiments, aliphatic groups contain 1-3 carbon atoms. Suitable aliphatic groups include, but are not limited to, linear or branched, alkyl, alkenyl, and alkynyl groups, and hybrids thereof, such as (cycloalkyl)alkyl, (cycloalkenyl)alkyl or (cycloalkyl)alkenyl.

[0067] The term ’’alkyl,” as used herein, unless otherwise indicated, means straight or branched saturated monovalent hydrocarbon radicals, typically C1-C12, preferably C1-C6. As such, “C1-C6 alkyl” means a straight or branched saturated monovalent hydrocarbon radical having from one to six carbon atoms (e.g., 1, 2, 3, 4, 5 or 6). Examples of alkyl groups include, but are not limited to, methyl, ethyl, propyl, isopropyl, and t-butyl.

[0068] The term “alkoxy,” as used herein, means an “alkyl-O-” group, wherein alkyl is defined above. Examples of alkoxy include methoxy and ethoxy.

[0069] double bond is independently a cis or trans double bond, or a mixture thereof. [0070] As used herein, the term “alkynyl” means a saturated straight chain or branched non-cyclic hydrocarbon having from 2 to 12 carbon atoms and having at least one carbon- carbon triple bond. Alkynyl groups may be optionally substituted with one or more substituents.

[0071] As used herein, the term “alkylene” refers to an alkyl group having from 2 to 12 carbon atoms and two points of attachment to the rest of the compound. Non-limiting examples of alkylene groups include methylene (-CH2-), ethylene (-CH2CH2-), n-propylene (-CH2CH2CH2-), isopropylene (-CH2CH(CH3)-), and the like. Alkylene groups may be optionally substituted with one or more substituents.

[0072] The term “amino,” as used herein, refers to a chemical moiety having the formula -N(R)2, wherein each R is independently selected from hydrogen and C1-C4 alkyl. [0073] As used herein, the term “dialkylamino” means (alkyl)2-N-, wherein the alkyl groups, which may be the same or different, are as herein defined. Particular dialkylamino groups are ((Ci-C4)alkyl)2-N-, wherein the alkyl groups may be the same or different. Exemplary dialkylamino groups include dimethylamino, diethylamino and methylethylamino.

[0074] As used herein, the term “monoalkylamino” means a radical of the formula alkyl- NH, wherein the alkyl group is as herein defined. In one aspect, a monoalkylamino is a (Ci- C₆) alkyl-amino-. Exemplary monoalkylamino groups include methylamino and ethylamino. [0075] The term “aryl,” alone or in combination, as used herein, means a carbocyclic aromatic system containing one or more rings, which may be attached together in a pendent manner or may be fused. In particular embodiments, aryl is one, two or three rings. In one aspect, the aryl has six to twelve ring atoms. The term “aryl” encompasses aromatic radicals such as phenyl, naphthyl, tetrahydronaphthyl, indanyl, biphenyl, phenanthryl, anthryl and acenaphthyl. An aryl group can be optionally substituted as defined and described herein. [0076] The terms “cycloaliphatic,” “carbocyclyl,” “carbocyclo,” and “carbocyclic,” used alone or as part of a larger moiety, refer to a saturated or partially unsaturated cyclic aliphatic monocyclic or bicyclic ring system, as described herein, having from 3 to 12 members, wherein the aliphatic ring system is optionally substituted as defined and described herein. Cycloaliphatic groups include, without limitation, cycloalkyl, for example, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl and cycloheptyl and cycloalkenyl, for example cyclopentenyl, cyclohexenyl, cycloheptenyl, cyclooctenyl and cyclooctadienyl. The terms “cycloaliphatic,” “carbocyclyl,” “carbocyclo,” and “carbocyclic” also include aliphatic rings that are fused to one or more aromatic or nonaromatic rings, such as decahydronaphthyl, tetrahydronaphthyl, decalin, or bicyclo[2.2.2]octane.

[0077] The term "cycloalkyl", as used herein, means saturated cyclic hydrocarbons, i.e. compounds where all ring atoms are carbons. Examples of cycloalkyl include, but are not limited to, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, and cycloheptyl. In some embodiments, cycloalkyl can optionally be substituted with one or more substituents selected from -OH, -SH, halogen, amino, nitro, cyano, C1-C12 alkyl, C2-C12 alkenyl or C2-C12 alkynyl group, C1-C12 alkoxy, C1-C12 haloalkyl, and C1-C12 haloalkoxy.

[0078] The term “halo” or “halogen” as used herein means halogen and includes, for example, and without being limited thereto, fluoro, chloro, bromo, iodo and the like, in both radioactive and non-radioactive forms. In a preferred embodiment, halo is selected from the group consisting of fluoro, chloro and bromo. [0079] The term “haloalkyl”, as used herein, includes an alkyl substituted with one or more F, Cl, Br, or I, wherein alkyl is defined above.

[0080] The term "heteroaryl", as used herein, refers to an aromatic group containing one or more heteroatoms ( e.g ., one or more heteroatoms independently selected from O, S and N). A heteroaryl group can be monocyclic or polycyclic, e.g. a monocyclic heteroaryl ring fused to one or more carbocyclic aromatic groups or other monocyclic heteroaryl groups. The heteroaryl groups of this invention can also include ring systems substituted with one or more oxo moieties. In one aspect, heteroaryl has five to fifteen ring atoms and, preferably, 5 or 6 ring atoms. Examples of heteroaryl groups include, but are not limited to, pyridinyl, pyridazinyl, imidazolyl, pyrimidinyl, pyrazolyl, triazolyl, pyrazinyl, quinolyl, isoquinolyl, tetrazolyl, furyl, thienyl, isoxazolyl, thiazolyl, oxazolyl, isothiazolyl, pyrrolyl, quinolinyl, isoquinolinyl, indolyl, benzimidazolyl, benzofuranyl, cinnolinyl, indazolyl, indolizinyl, phthalazinyl, pyridazinyl, triazinyl, isoindolyl, purinyl, oxadiazolyl, thiazolyl, thiadiazolyl, furazanyl, benzofurazanyl, benzothiophenyl, benzotriazolyl, benzothiazolyl, benzoxazolyl, quinazolinyl, quinoxalinyl, naphthyridinyl, dihydroquinolyl, tetrahydroquinolyl, dihydroisoquinolyl, tetrahydroisoquinolyl, benzofuryl, furopyridinyl, pyrolopyrimidinyl, and azaindolyl. The foregoing heteroaryl groups may be C-attached or N-attached (where such is possible). For instance, a group derived from pyrrole may be pyrrol-l-yl (N-attached) or pyrrol-3-yl (C-attached).

[0081] “Heterocyclyl” means a cyclic 3-12 membered saturated or unsaturated aliphatic ring containing 1, 2, 3, 4 or 5 heteroatoms (e.g., one or more heteroatoms independently selected from O, S and N). When one heteroatom is S, it can be optionally mono- or di-oxygenated (i.e. -S(O)- or -S(0)2-). The heterocyclyl can be monocyclic or polycyclic, in which case the rings can be attached together in a pendent manner or can be fused or spiro.

In one aspect, a heterocyclyl is a three- to seven-membered ring system. Exemplary heterocyclyls include, for example, and without being limited thereto, piperidinyl, piperazinyl, pyrrolidinyl, tetrahydrofuranyl and the like.

[0082] “Hydroxyl” means -OH.

[0083] “Oxo” means =0.

[0084] “Thioalkoxy” means -S-alkyl, wherein alkyl is defined as above.

[0085] It is understood that substituents and substitution patterns on the compounds of the invention can be selected by one of ordinary skill in the art to provide compounds that are chemically stable and that can be readily synthesized by techniques known in the art, as well as those methods set forth below. In general, the term “substituted,” whether preceded by the term “optionally” or not, means that one or more hydrogens of the designated moiety are replaced with a suitable substituent. Unless otherwise indicated, an “optionally substituted group” can have a suitable substituent at each substitutable position of the group and, when more than one position in any given structure may be substituted with more than one substituent selected from a specified group, the substituent can be either the same or different at every position. Alternatively, an “optionally substituted group” can be unsubstitued.

[0086] The term “pharmaceutically acceptable salt” means either an acid addition salt or a basic addition salt which is compatible with the treatment of patients.

[0087] In some embodiments, exemplary inorganic acids which form suitable salts include, but are not limited thereto, hydrochloric, hydrobromic, sulfuric and phosphoric acid and acid metal salts such as sodium monohydrogen orthophosphate and potassium hydrogen sulfate. Illustrative organic acids which form suitable salts include the mono-, di- and tricarboxylic acids. Illustrative of such acids are, for example, acetic, trifluoroacetic acid (2,2,2-trifluoroacetic acid), glycolic, lactic, pyruvic, malonic, succinic, glutaric, fumaric, malic, tartaric, citric, ascorbic, maleic, hydroxymaleic, benzoic, hydroxybenzoic, phenylacetic, cinnamic, salicylic, 2-phenoxybenzoic, p-toluenesulfonic acid and other sulfonic acids such as methanesulfonic acid and 2-hydroxyethanesulfonic acid. Either the mono- or di-acid salts can be formed, and such salts can exist in either a hydrated, solvated or substantially anhydrous form. In general, the acid addition salts of these compounds are more soluble in water and various hydrophilic organic solvents, and generally demonstrate higher melting points in comparison to their free base forms. Other non-pharmaceutically acceptable salts, e.g., oxalates may be used, for example, in the isolation of compounds described herein for laboratory use, or for subsequent conversion to a pharmaceutically acceptable acid addition salt.

[0088] A “pharmaceutically acceptable basic addition salt” is any non-toxic organic or inorganic base addition salt of the acid compounds described herein or any of its intermediates. Illustrative inorganic bases which form suitable salts include, but are not limited thereto, lithium, sodium, potassium, calcium, magnesium or barium hydroxides. Illustrative organic bases which form suitable salts include aliphatic, alicyclic or aromatic organic amines such as methylamine, trimethyl amine and picoline or ammonia. The selection of the appropriate salt may be important so that an ester functionality, if any, elsewhere in the molecule is not hydrolyzed. The selection criteria for the appropriate salt will be known to one skilled in the art.

[0089] Acid addition salts of the compounds described herein are most suitably formed from pharmaceutically acceptable acids, and include, for example, those formed with inorganic acids, e.g., hydrochloric, sulfuric or phosphoric acids and organic acids, e.g., succinic, maleic, acetic, trifluoroacetic or fumaric acid. Other non-pharmaceutically acceptable salts, e.g., oxalates may be used for example in the isolation of compounds described herein for laboratory use, or for subsequent conversion to a pharmaceutically acceptable acid addition salt. Also included within the scope of the invention are base addition salts (such as sodium, potassium and ammonium salts), solvates and hydrates of compounds of the invention. The conversion of a given compound salt to a desired compound salt is achieved by applying standard techniques, well known to one skilled in the art.

[0090] The term “pharmaceutically acceptable carrier” means a non-toxic solvent, dispersant, excipient, adjuvant or other material which is mixed with the active ingredient in order to permit the formation of a pharmaceutical composition, i.e., a dosage form capable of being administered to a subject. Pharmaceutically acceptable carriers are well known in the art.

[0091] When introducing elements disclosed herein, the articles “a”, “an”, “the”, and “said” are intended to mean that there are one or more of the elements. The terms “comprising”, “having”, “including” are intended to be open-ended and mean that there may be additional elements other than the listed elements.

[0092] COVID-19 AND SARS-CoV-2

[0093] Coronavirus disease 2019 (COVID-19) is the disease caused by a novel virus strain, severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), an enveloped, positive-sense, single-stranded RNA betacoronavirus of the family Coronaviridae . COVID- 19 was first identified in Wuhan, China in late 2019. On March 11, 2020 the World Health Organization declared the outbreak of COVID-19 a pandemic. There are currently no antiviral drugs with proven efficacy against COVID-19 nor are there any vaccines for prevention. [0094] As reported in Zhu, N. et al. (China Novel Coronavirus Investigating and Research Team. A novel coronavirus from patients with pneumonia in China, 2019. N. Engl. J. Med. 2020. 382. https://www.neim.org/doi/full/10.1056/NEJMoa2001Q17). although SARS-CoV2 is similar to some betacoronaviruses detected in bats, it is distinct from SARS- CoV and MERS-CoV. The SARS-CoV2 together with the referenced bat-derived SARS-like strains form a distinct clade. It has been found that the novel betacoronavirus belongs to the sarbecovirus subgenus of Coronaviridae family.

[0095] The most commonly reported clinical symptom in laboratory-confirmed cases of COVID-19 are fever (88%), dry cough (68%), fatigue (38%), sputum production (33%), dyspnea (19%), sore throat (14%), headache (14%) and myalgia or arthralgia (15%). Less common symptoms were diarrhea (4%) and vomiting (5%).

[0096] The cytokine profile observed in COVID-19 correlates with disease severity and is characterized by increased interleukin (IL)-2, IL-7, granulocyte-colony stimulating factor (G-CSF), interferon-g (INFy) inducible protein 10, monocyte chemoattractant protein 1 (MCP-1), macrophage inflammatory protein la (MIF-la), and tumor necrosis factor-a (TNFa) {Lancet. 2020; 395: 497-506). In 150 cases in Wuhan, China, independent predictors of fatality included elevated IL-6 levels (p<0 0001) (Ruan et al, 2020).

[0097] As such, in certain embodiments COVID-19 can be accompanied by a marked inflammatory response, which is believed to be severely detrimental to the COVID-19 afflicted patient and has been associated with multi-organ dysfunction, respiratory failure and death. One of the most problematic aspects of COVID-19 is the marked pulmonary inflammation with high levels of cytokines such as IL-6, 1-1, INFy and others.

[0098] As used herein, “Low LDH/DD subgroup of patients” is that subgroup of patients with LDH<370 U/L or D-dimer <600 mcg/L FEU.

[0099] As used herein, High LDH/DD subgroup of patients” is that subgroup of patients with LDH >370 U/L and D-dimer>600 mcg/L FEU.

[00100] As used herein, “COVID-19” is the disease caused by SARS-CoV-2.

[00101] As used herein, “moderate COVID-19” is COVID-19 wherein the patient (e.g., a human 18 years or older) has demonstrated one or more of the following: a. Currently hospitalized and requiring medical care for COVID-19, and b. Peripheral capillary oxygen saturation (Sp02, pulse oximetry), and c. Radiographic evidence of pulmonary infiltrates. [00102] As used herein, “severe COVID-19” is COVID-19 wherein the patient (e.g., a human 18 years or older) has:

At least one of the following: fever, cough, sore throat, malaise, headache, muscle pain, shortness of breath at rest or with exertion, confusion, or symptoms of severe lower respiratory symptoms including dyspnea at rest or respiratory distress

AND

Clinical signs indicative of lower respiratory infection with COVID-19, with at least one of the following: respiratory rate > 30 breaths/min, heart rate > 125/min, Sp02 <93% on room air or requires > 2L/minute oxygen by NC in order maintain Sa02 >93%, Pa02/Fi02 <300 mm/hg.

[00103] For the ITT patient population for which results are reported herein, “severe COVID-19” is COVID-19 wherein the patient (e.g., a human 18 years or older) has:

At least one of the following: fever, cough, sore throat, malaise, headache, muscle pain, shortness of breath at rest or with exertion, confusion, or symptoms of severe lower respiratory symptoms including dyspnea at rest or respiratory distress

AND

Clinical signs indicative of lower respiratory infection with COVID-19, with at least one of the following: Sp02 <92% or requires > 4L/minute oxygen by NC or nonOrebreather/Ventimask (or similar device) or high-flow nasal canula in order to maintain SP02 >92%. Patients with COPD or chronic lung disease must demonstrate evidence of increased oxygen needs above baseline.

[00104] Alternatively, “severe COVID-19” is COVID-19 wherein the patient (e.g., a human 18 years or older) has demonstrated one or more of the following: a. Respiratory rate >24 breaths/minute; b. Pulse Oxygen Saturation (Sp02) <94% without oxygen inhalation; or c. Pa02/Fi02 (fraction of inspired oxygen) <300 mm Hg.

[00105] ADMINISTRATION

[00106] The SINE Compound is administered in a therapeutically effective amount. The term “therapeutically effective amount” means that amount of active compound that elicits the desired biological response in a subject. Such response includes alleviation of the symptoms of the disease or disorder (e.g., COVID-19, such as severe COVID-19) being treated, prevention, inhibition or a delay in the recurrence of a symptom of the disease or of the disease itself, an increase in the longevity of the subject compared with the absence of the treatment, or prevention, inhibition or delay in the progression of symptom of the disease or of the disease itself. Determination of the effective amount is well within the capability of those skilled in the art. Toxicity and therapeutic efficacy of the compounds of the invention can be determined by standard pharmaceutical procedures in cell cultures and in experimental animals. The effective amount of compound of the present invention or additional therapeutic agent to be administered to a subject will depend on the stage, category and status of the disease or disorder (e.g., COVID-19 or severe COVID-19) being treated and characteristics of the subject, such as general health, age, sex, body weight and drug tolerance. The effective amount of compound of the present invention or other therapeutic agent to be administered will also depend on administration route and dosage form. Dosage amount and interval can be adjusted individually to provide plasma levels of the active compound that are sufficient to maintain desired therapeutic effects.

[00107] For example, in one aspect a therapeutically effective amount to treat COVID-19, such as severe COVID-19 can be an amount that can achieve one or more of the following: expedited recovery, suppression of viral load, shortened hospitalization and reduced morbidity and mortality as compared to the standard of care.

[00108] In another aspect, a therapeutically effective amount can reduce inflammation, which can lead to a reduction in levels of cytokines (e.g., pro-inflammatory cytokines) in the patient.

[00109] In yet another aspect, a therapeutically effective amount can inhibit viral replication.

[00110] In yet a further aspect, a therapeutically effect amount can reduce inflammation and levels of cytokines and also inhibit viral replication.

[00111] In a particular embodiment, the therapeutically effective amount of the SINE compound (e.g., a compound of any one of formulas (I), (II), 1-3, (IV) and (V)) is from about 200 mg per dose to about 2 mg per dose. For example, the therapeutically effective amount can be from about 100 mg per dose to about 4mg per dose, such as from about 50 mg per dose to about 8 mg per dose, such as from about 25 mg per dose to about 16 mg per dose. In a further particular embodiment, the therapeutically effect amount is about 10 mg per dose, about 20 mg per dose, about 30 mg per dose, about 40 mg per dose, about 50 mg per dose, about 60 mg per dose, about 70 mg per dose, about 80 mg per dose, about 90 mg per dose or about 100 mg per dose. In a further particular embodiment, the therapeutically effective amount of the SINE compound is about 20 mg per dose. In an additional particular embodiment, the therapeutically effective amount of the SINE compound is about 40 mg per dose. A dose can be administered one or more times during the treatment period (e.g., 1, 2, 3, 4, 5 etc. times per day (intervals between doses can be the same or different), such as a 20 mg dose at 11am and a 20 mg dose at 11pm with one day (24 hour period).

[00112] In a particular dosing regimen, the SINE compound (e.g., a compound of any one of formulas (I), (II), 1-3, (IV) and (V)) can be administered one or more times per day, such as 1-3 (e.g., 1, 2 or 3) times per day and 1-5 (e.g., 1, 2, 3, 4 or 5) times per week during the treatment period. In an example embodiment, the SINE compound can be administered at a dose of from about 2 mg to about 200 mg, such as about 20 mg, once per day on every other day (e.g., on days 1, 3 and 5 of a given week). In a specific embodiment, the SINE compound is administered once per day on days 1, 3 and 5 of a given week of treatment. The duration of treatment can be from 1-4 weeks (e.g, 1 week, 2 weeks, 3 weeks or 4 weeks). In a particular embodiment, the duration of treatment is 2 weeks. In another particular embodiment, the duration of treatment is 4 weeks.

[00113] In a very particular embodiment, a dose of 20 mg of SINE compound ((e.g., a compound of any one of formulas (I), (II), 1-3, (IV) and (V)) can be administered orally on Days 1, 3 and 5 of each week of treatment for up to 2 weeks. Optionally, dosing can continue for an additional 2 weeks on Days 15, 17, 19, 22, 2426.

[00114] In a most particular embodiment, the SINE compound is selinexor, the dose of selinexor is 20 mg and selinexor is administered orally at 20 mg on days 1, 3 and 5 of a given week for 2-4 weeks. In a specific aspect, selinexor is administered at about 20 mg per dose for 2 weeks on days 1, 3 and 5 of a given week. In another specific embodiment, selinexor is administered at about 20 mg per dose for 4 weeks on days 1, 3 and 5 of a given week.

[00115] In another example embodiment, the SINE compound can be administered at a dose of from about 2 mg to about 200 mg, such as about 40 mg, once per day on days 1 and 3 of a given week. In a specific embodiment, the SINE compound is administered once per day on days 1 and 3 of a given week of treatment. The duration of treatment can be from 1-4 weeks (e.g, 1 week, 2 weeks, 3 weeks or 4 weeks). In a particular embodiment, the duration of treatment is 2 weeks. In another particular embodiment, the duration of treatment is 4 weeks. [00116] In a very particular embodiment, a dose of 40 mg of SINE compound ((e.g., a compound of any one of formulas (I), (II), 1-3, (IV) and (V)) can be administered orally on Days 1 and 3 of each week for up to 2 weeks. Optionally, dosing can continue for an additional 2 weeks on Days 15, 17, 22 and 24.

[00117] In a most particular embodiment, the SINE compound is selinexor, the dose of selinexor is 40 mg and selinexor is administered orally at 40 mg on days 1 and 3 of a given week for 2-4 weeks. In a specific aspect, selinexor is administered at about 40 mg per dose for 2 weeks on days 1 and 3 of a given week. In another specific embodiment, selinexor is administered at about 20 mg per dose for 4 weeks on days 1 and 3 of a given week.

[00118] The term "subject" to which administration is contemplated includes, but is not limited to, humans (i.e., a male or female of any age group, e.g., a pediatric subject (e.g., infant, child, adolescent) or adult subject (e.g., young adult, middle-aged adult or senior adult, such as an adult 18 years or older)) and/or other primates (e.g., cynomolgus monkeys, rhesus monkeys); mammals, including commercially relevant mammals such as cattle, pigs, horses, sheep, goats, cats, and/or dogs; and/or birds, including commercially relevant birds such as chickens, ducks, geese, quail, and/or turkeys. In particular, subjects are humans, such as adult humans 18 years or older.

[00119] The term “treating” means to decrease, suppress, attenuate, diminish, arrest, or stabilize the development or progression of a disease (e.g., COVID-19, such as severe COVID-19), lessen the severity of the disease or improve the symptoms associated with the disease. Treatment includes treating a symptom of a disease, disorder or condition.

[00120] In one embodiment, treating COVID-19 with the SINE compounds described herein (e.g., a compound of any one of formulas (I), (II), 1-3, (IV) and (V)) can include reducing inflammation, which can lead to a reduction in levels of cytokines (e.g., pro- inflammatory cytokines) in the patient. For example, a reduction in L-l, IL-6 , TNFa and other cytokines identified by Ruan et ah, 2020, can be realized (Ruan, Q. et al. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China, Intensive Care Me. 2020.). This reduction is desirable for the treatment of subjects with COVID-19 as the severity of the disease is associated with the levels of cytokine secretion in SARS-coV infected patients. Without being bound by a particular theory, such a reduction could be linked to the inhibition of the NF-KB pathway and nuclear retention and activation of specific inhibitors of pro-inflammatory transcriptional factors such as IKB, RXRa, and PPARy..

[00121] In another embodiment, treating COVID-19 with the SINE compounds described herein (e.g., a compound of any one of formulas (I), (II), 1-3, (IV) and (V)) can result in the inhibition of viral replication (e.g„ demonstrates anti-viral activity).

[00122] In yet a further embodiment, treating COVID-19 with the SINE compounds described herein both reduces inflammation and cytokine levels and inhibits viral replication. [00123] The phrase “combination therapy” or “co-administration” embraces the administration of the SINE compounds described herein (e.g., a compound of any one of formulas (I), (II), 1-3, (IV) and (V)) and an additional therapeutic agent as part of a specific treatment regimen intended to provide a beneficial effect from the co-action of each. When administered as a combination, the SINE compound and an additional therapeutic agent can be formulated as separate compositions. Administration of these therapeutic agents in combination typically is carried out over a defined time period (usually minutes, hours, days or weeks depending upon the combination selected).

[00124] “Combination therapy” or “co-administration” is intended to embrace administration of these therapeutic agent (the SINE compounds described herein and an additional therapeutic agent) in a sequential manner, that is, wherein each therapeutic agent is administered at a different time, as well as administration of these therapeutic agents, or at least two of the therapeutic agents, in a substantially simultaneous manner. Substantially simultaneous administration can be accomplished, for example, by administering to the subject a single capsule having a fixed ratio of each therapeutic agent or in multiple, single capsules for each of the therapeutic agents. Sequential or substantially simultaneous administration of each therapeutic agent can be effected by any appropriate route including, but not limited to, oral routes, intravenous routes, intramuscular routes, and direct absorption through mucous membrane tissues. The therapeutic agents can be administered by the same route or by different routes. For example, a first therapeutic agent of the combination selected may be administered by intravenous injection while the other therapeutic agents of the combination may be administered orally. Alternatively, for example, all therapeutic agents may be administered orally or all therapeutic agents may be administered by intravenous injection. The sequence wherein the therapeutic agents are administered is not narrowly critical. [00125] In a specific embodiment, the second therapeutic agent is an antibiotic.

Exemplary anitibiotics include any anitibiotics known to be effective in treating bacterial infections of the upper respiratory tract. Such antibiotics include, azithromycin, amoxicillin and the tetracyclines.

[00126] MODES OF ADMINISTRATION

[00127] The SINE compounds described herein (e.g., a compound of any one of formulas (I), (II), 1-3, (IV) and (V)) can be administered orally, nasally, ocularly, transdermally, topically, intravenously (both bolus and infusion), and via injection (intraperitoneally, subcutaneously, intramuscularly, intratumorally, or parenterally) either as alone or as part of a pharmaceutical composition comprising the SINE compound and a pharmaceutically acceptable excipient. The composition may be in a dosage unit such as a tablet, pill, capsule, powder, granule, liposome, ion exchange resin, sterile ocular solution, or ocular delivery device (such as a contact lens and the like facilitating immediate release, timed release, or sustained release), parenteral solution or suspension, metered aerosol or liquid spray, drop, ampoule, auto-injector device, or suppository.

[00128] In a particular embodiment, the SINE compound is administered orally. Compositions of the invention suitable for oral administration include solid forms such as pills, tablets, caplets, capsules (each including immediate release, timed release, and sustained release formulations), granules and powders; and, liquid forms such as solutions, syrups, elixirs, emulsions, and suspensions. In a specific aspect, the SINE compound is in the form of a tablet (e.g., tablet comprising 20 mg of SINE compound, such as selinexor).

[00129] SUSPENSION: In certain instances, the patient being treated for COVID-19, including severe COVID-19, cannot receive the SINE compound orally as a tablet (e.g, cannot swallow). The following protocol can be used to prepare a suspension of the SINE compound. Although the protocol described below is specific for selinexor tablets, the protocol can be applied to other SINE compounds for use in treating patients suffering from COVID-19, such as severe COVID-19, who are unable to receive drug orally as a tablet (e.g., cannot swallow). The suspension can be for oral administration or for administration via a nasal gastral tube (NGT) or a G-tube.

[00130] PREPARATION OF SUSPENSION: a) Place one 20 mg tablet (selinexor or placeblo) in an amber bottle. b) Add 3 mL of water in the bottle. c) Cap bottle and intermittently swirl the contents for about 10 minutes to disperse the particles as the table disintegrates. d) Add 9 mL of Ora-Blend to the bottle (Ora-Blend^® (Perrigo) is a commercially available aqueous-based vehicle consisting of a synergistic blend of suspending agents that have a high degree of colloidal activity. Ora-Plus^® or Ora-Blend SF^® can be substituted if Ora-Blend^® is not available. If the listed Perrigo Ora products are not available, one of the following can be substituted: Oral Suspend (Medisca, Versa Plus (Humco), Versa Free (Humco), Flavor Blend (Humco) or Flavor Puls (Humco). e) Optional: Insert a syringe adaptor into the bottle and then cap the bottle. f) Gently invert and reinvert the capped bottle approximately 20 times to prepare the final suspension. g) The suspension should be prepared one 20 mg dose at a time and used within 4 hours under room temperature conditions.

[00131] DOSING AND ADMINISTRATION OF SUPSPENSION a) Selinexor suspension can be administered PO, by NGT or by G-tube. The bottle, syringe and tube should be rinsed with 40-100 ml of water, and the rinxe dosed to the patient to ensure complete delivery of the selinexor dose. b) Use of a syringe adapter/insert on the bottle can make filling the syringe for NGT and G-tube dosing easier. c) Selinexor suspension can be dosed with or without food, but dosing within 30- minutes of food consumption or nutritional supplement may help with nausea.

[00132] EXEMPLIC ATION - CLINICAL TRIAL I

[00133] STUDY DESIGN: A Randomized Single-Blind Study of low dose selinexor versus placebo to evaluate the activity and safety as well as reduction in mortality in patients with severe COVID-19. A dose of 20 mg selinexor or matching placebo will be administered orally on Days 1, 3 and 5 of each week for up to 2 weeks. If the patient is tolerating therapy and clinically benefitting, dosing can continue for an additional 2 weeks on Days 15, 17, 19, 22, 2426. The clinical trial design will be characterized as either Phase lb, Phase lb/2 or Phase 2 as required. [00134] STUDY POPULATION: The study population will consist of hospitalized patients >18 years old with COVID-19. The enrollment will be stratified by: a. Region b. Use of concomitant therapies: an anti-viral (e.g. remdesivir) or an anti-inflammatory (e.g. hydroxychloroquine, biologies targeting e.g. IL-6 or IL-1, or both anti-viral and anti inflammatory therapies or neither. Note: acetaminophen and NSAIDs will not constitute anti-inflammatory agents for the purposes of stratification.

Inclusion Criteria:

1. Age >18 years

2. Clinically suspected and subsequently confirmed; or laboratory diagnosis confirming patient is positive for SARS-CoV2 nucleic acid by RT-PCR (by local labs)

3. Currently hospitalized and consented within the first 48 hours of hospitalization

4. Informed consent provided as above

5. Has symptoms of severe COVID-19 as demonstrated by: a. Respiratory rate >24 breaths/minute OR b. Pulse Oxygen Saturation (Sp0₂) <94% without oxygen supplementation, OR c. Pa0₂/Fi0₂ (fraction of inspired oxygen) <300 mm Hg

6. Concurrent anti-virals and/or anti-inflammatory agents (e.g., biologies, hydroxychloroquine) are permitted at baseline for patients entering the study

7. Female patients of childbearing potential must have a negative serum pregnancy test at Screening. Female patients of childbearing potential and fertile male patients who are sexually active with a female of childbearing potential must use highly effective methods of contraception throughout the study and for 1 week following the last dose of study treatment.

[00135] 117 PATIENTS ENROLLED FOR PART 6 (PV6) OF TRIAL:

[00136] For the main part of the trial (Part 6; the ITT population) 117 hospitalized patients with COVID-19 were enrolled. Eligible patients had symptoms of COVID-19 as demonstrated by:

AT LEAST 1 OF THE FOLLOWING: Fever, Cough, Sore throat, Malaise, Headache, Muscle pain, Shortness of breath at rest or with exertion, Confusion, Symptoms of severe lower respiratory symptoms including dyspnea at rest or respiratory distress; AND

CLINICAL SIGNS INDICATIVE OF LOWER RESPIRATORY INFECTION WITH COVID-19, WITH AT LEAST 1 OF THE FOLLOWING:

^■ Sp02 <92% or requires >4 LPM oxygen by nasal canula, or

^■ Non-rebreather/Ventimask (or similar device) or

^■ High-flow nasal canula in order to maintain Sp02 >92%.

^■ Patients with COPD or chronic lung disease must demonstrate evidence of increased oxygen needs above baseline.

Patient characteristics in the Intent to Treat population are provided in FIG. 8.

[00137] STUDY TREATMENT/TREATMENT GROUPS, DOSE, AND MODE OF ADMINISTRATION: Oral 20 mg selinexor or placebo administered on Days 1, 3, 5, 8, 10, 12. If the patient is tolerating therapy well and clinically benefitting in the opinion of the treating physician, dosing can continue for additional 2 weeks on Days 15, 17, 19, 22, 24, 26. [00138] OBJECTIVES AND ENDPOINTS: To determine the impact of low dose oral selinexor (20 mg on QoD (every other day) each week) to expedite the clinical recovery, suppress the viral load, shorten the hospitalization and reduce morbidity and mortality in patients with severe COVID-19 compared to standard of care.

[00139]

[00140] The Primary endpoints and Key Secondary endpoints were further revised for Part 6 of the trial (ITT patient population of 117) as follows (see also FIG. 7):

Primary endpoints:

Day 14 Ordinal Scale Improvement (OSI) -

Proportion of patients with at least a 2-point improvement in the Ordinal Scale from baseline to Day 14

Key Secondary endpoints:

Overall death rate on Day 28;

Rate of mechanical ventilation;

Time to mechanical ventilation; and

Time to an improvement of 2 points using Ordinal Scale Improvement (TTCI-2).

The Ordinal Scale used is the same as that described below for CLINICAL TRIAL II.

[00141] The efficacy of the treatment as described for CLINICAL TRIAL I for the ITT patient population is shown in FIG. 9.

[00142] TIME TO PCR NEGATIVE CONVERSION: The time to PCR negative conversion was measured as an assessment of selinexor’s ability to inhibit viral propagation in patients with severe COVID19. Viral load in the study was measured as PCR positive or PCR negative. All patients enrolled in the study had a positive PCR result at study entry. A patient was only considered to have PCR negative results if two consecutive PCR tests were negative following the initiation of treatment. The time to PCR negative conversion was shorter for patients receiving selinexor than those receiving placebo: median 36 days versus not reached (results are shown graphically in FIG. 10.

[00143] PATIENT SUBGROUPS:

[00144] When patients subgroups were defined by looking at the clinical parameters lactate dehydrogenase (LDH) and D-dimer (DD, a fibrinolytic marker), patients with low LDH/DD showed improved clinical status as compared to placebo in that subgroup. Lactate dehydrogenase is an enzyme elevated following tissue breakdown. Elevated serum LDH is present in numerous clinical conditions, such as hemolysis, cancer, severe infections, sepsis, liver diseases, and hematologic malignancies. It also is involved in various pathophysiological processes and serves as a nonspecific indicator of cellular death in many diseases. In COVID-19, elevated LDH may reflect the nonspecific responses to hypoxia, tissue injury, and necrosis, indicating a correlation between infectious cells, immune system and inflammatory response. D-dimer is a fibrin degradation product, a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis. Monocytes and other cells are activated after injury, causing the release of cytokines and the expression of tissue factors, and lead to hypercoagulable state. Coagulation activation is also associated with sustained inflammatory response. Up to 20% of patients with COVID-19 have abnormal coagulation function and elevated D-dimer.

[00145] The low LDH/DD subgroup was comprised of patients with LDH <370 U/L or D- dimer <600 mcg/L FEU (Fibrinogen Equivalent Units). The improved clinical status in this selinexor treated subgroup as compared to the placebo treated subgroup is shown in FIG. 11. From FIG. 11 it can be seen that the Low LDH/DD patient subgroup treated with selinexor had an improved clinical status (measured as Hospital Discharged by Day 14 and Ordinal Scale Improvement (OSI) by Day 14) as compared to placebo in that subgroup.

[00146] A further comparison of selinexor-treated and placebo-treated patients within the Low LDH/DD subgroup showed that selinexor treatment improved PCR negative conversion rate and time to PCR negative as compared with placebo. Results are shown in FIG. 12. [00147] Compared with patients receiving placebo, cytokine values for patients receiving selinexor showed significant reductions in the Low LDH/DD subpopulation. Significantly lower IL1-RA, IL-6, IL-7, IP-10 and TNF-a values were observed within 8 days of selinexor treatment compared with patients receiving placebo in the low-risk population (p<0.05). Results are shown in FIG. 13.

[00148] CLINICAL TRIAL II:

[00149] STUDY: This Study is a randomized, open-label, multicenter phase 2 study to evaluate the activity and safety, as well as reduction in mortality, of two regimens of low dose selinexor in patients with moderate or severe COVID-19. The trial design may be recharacterized as a Phase lb, Phase lb/2 as required.

[00150] The study has 2 arms and will evaluate two regimens of low-dose oral selinexor; Regimen A (dose of 40 mg on Days 1 and 3 of each week) and Regimen B (dose of 20 mg on Days 1, 3 and 5 of each week).

[00151] Selinexor will be administered for up to 2 weeks as follows: • Regimen A: a selinexor dose of 40 mg will be administered orally on Days 1 and 3 of each week.

OR

• Regimen B: a selinexor dose of 20 mg will be administered orally on Days 1, 3, and 5 of each week.

[00152] If the patient is tolerating therapy and clinically benefitting (i.e., not meeting any of the criteria for stopping therapy listed below), dosing can continue for an additional 2 weeks on either Regimen A (on Days 15, 17, 22, 24) or Regimen B (on Days 15, 17, 19, 22, 24, and 26).

[00153] Patients who achieve ANY of the following criteria will be considered as having clinical benefit for the purpose of continuing dosing for an additional 2 weeks.

1. Patients who remain hospitalized and: a. Have not had a selinexor-related Grade 4 AE or selinexor-related serious AE (SAE)

AND b. Have not had >1 level ordinal score reduction (worsening)

OR c. Have no more than a 2 level reduction (worsening) in the ordinal score with a corresponding decrease of at least 20% in their oxygen requirement from their peak oxygen requirement

[00154] STUDY POPULATION: The study population will consist of hospitalized patients >18 years old with COVID-19. The enrollment will be stratified by:

• Moderate or Severe Symptoms

• Patient comorbidities of immune compromise, hypertension, or pulmonary disease (smoking history or moderate to severe chronic obstructive pulmonary disease [COPD]), cardiac disease

[00155] INCLUSION CRITERIA: Patients are eligible to be included in the study only if they meet all of the following criteria:

1. Age >18 years

2. Confirmed laboratory diagnosis of SARS-CoV2 by standard approved RT-PCR assay or equivalent approved testing (by local labs)

3. Currently hospitalized and consented within the first 48 hours of hospitalization

4. Informed consent provided as above (patients must be dosed with study drug within 12 hours of consent) 5. Has symptoms of moderate or severe COVID-19 as demonstrated by:

Moderate COVID-19: a. Currently hospitalized and requiring medical care for COVID-19, and b. Peripheral capillary oxygen saturation (Sp02, pulse oximetry), and c. Radiographic evidence of pulmonary infiltrates Severe COVID-19: a. At least one of the following: fever, cough, sore throat, malaise, headache, muscle pain, shortness of breath at rest or with exertion, confusion, or symptoms of severe lower respiratory symptoms including dyspnea at rest or respiratory distress

AND b. Clinical signs indicative of lower respiratory infection with COVID-19, with at least one of the following: respiratory rate > 30 breaths/min, heart rate > 125/min, Sp0₂ <93% on room air or requires > 2L/minute oxygen by NC in order maintain Sa0₂ >93%, Pa0₂/Fi0₂ <300 mm/hg

6. Female patients of childbearing potential must have a negative serum pregnancy test at Screening and must use highly effective methods of contraception throughout the study and for 3 months following the last dose of study treatment.

7. Males who are sexually active must commit to use a highly effective method of contraception while receiving selinexor and for 3 months after the last selinexor dose, or consent to total sexual abstinence (abstinence must occur from enrollment and continue for 3 months after the last selinexor dose).

[00156] STUDY TREATMENT/TREATMENT GROUPS, DOSE AND MODE OF ADMINISTRATION:

[00157] OBJECTIVE AND ENDPOINTS: To compare the impact of two regimens (Regimen A and Regimen B described above) of low dose oral on improvement in clinical outcomes, the ability to suppress viral load, shorten hospitalization, and reduction in morbidity and mortality, and safety and tolerability in patients with moderate or severe COVID-19.

[00158] ORDINAL SCORE:

[00159] The Ordinal score is a composite measure of clinical improvement and/or survival, assessed on a daily basis. A special WHO committee arrived at the ordinal scale that measures illness severity over time. The severity rating is on an 8-point ordinal scale:

1. Death;

2. Hospitalized, on invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO);

3. Hospitalized, on non-invasive ventilation or high flow oxygen devices;

4. Hospitalized, requiring supplemental oxygen;

5. Hospitalized, not requiring supplemental oxygen - requiring ongoing medical care (COVID-19 related or otherwise);

6. Hospitalized, not requiring supplemental oxygen - no longer requires ongoing medical care;

7. Not hospitalized, limitation on activities and/or requiring home oxygen;

8. Not hospitalized, no limitations on activities.

[00160] INHIBITION OF VIRAL PROPAGATION-EXPERIMENTS 1, 2 AND 3 [00161] EXPERIMENTS 1 AND 2: The ability of selinexor and verdinexor to inhibit viral propagation was evaluated using two approaches: (1) prophylactic of cells with selinexor prior to infection (pre-infection) and (2) concurrent treatment with selinexor at the time of infection (co-infection).

1. PROPHYLACTIC TREATMENT :

Vero E6 cells (immortalized monkey cells) were incubated for 6 hours with drug (selinexor or verdinexor) at the following concentrations: 0, 10, 30, 100 and 300 nM and 1, 3 and 10 mM.

Media was then removed and fresh drug was added and infection with SARS-CoV2 was conducted for 1 hour at 37°C.

Overlay was added and incubation was conducted for 4 days.

Inhibition of the production of new virus was assessed using a standard plaque assay. Viral controls and cellular controls were included and worked well.

2. CO-INFECTION EXPERIMENT

Media was removed from Vero cells and the cells washed with PBS.

Media containing drug and SARS CoV2 virus was added to the cells.

Infection was conducted for 1 hour at 37°C. Overlay was added and incubation was conducted for 4 days.

Inhibition of the production of new virus was assessed using a standard plaque assay. Viral controls and cellular controls were included and worked well.

RESULTS OF EXPERIMENTS 1 AND 2: FIGs. 1 and 2 show that selinexor inhibited the production of new virus by 90% at a concentration of 100 nM and by 50% at lOnM, and was significantly better than verdinexor. In FIG. 1 Selinexor is referred to as KPT-330 (Compound 1-3 of Table 1) and in FIG. 2 verdinexor is referred to as KPT- 335 (Compouond 1-4 of Table 1).

[00162] EXPERIMENT 3-1 : THE EFFECT OF THE ANIT- VIRAL ACTIVITY OF SELINEXOR ON UNINFECTED NEIGHBORING CELLS a) Vero E6 cells were pretreated with selinexor and verdinexor at 0, 10, 30, 100 and 300 nM and 1, 3 and 10 mM in triplicate for 6 hours prior to infection with SARS-CoV2. b) Following pre-treatment media was removed and cells were infected for 1 hour at 37°C with SARS-CoV2. c) Infection media was removed and fresh infection media with drugs at the same concentration as use for pre-treatment was added. d) Cells with compound were incubated for 96 hours. e) Supernatant was pulled off and tenfold viral dilutions were made for each drug treatment: -2 through -6 including media from a control cell. f) Vero cells were washed in 6-well plates and the viral dilutions from the previous step were added to the wells without drug. g) Cells were incubated for 1 hour at 37°C. h) Overlay was added and incubation was conducted for 96 hours. i) The number of Plaque Forming Units (PFU)/ml were assessed using the standard plaque assay and were reported to reflect the viral media dilution reported in step e) above j) Viral controls and cellular controls were included and worked well.

RESULTS OF EXPERIMENT 3-1: FIGS. 3 A, 3B, 4A and 4B show that selinexor reduced the ability of the virus to infect new cells by about 99% and was significantly better than verdinexor. The results also show that selinexor inhibited SARS-CoV-2 viral shedding and therefore protected the infection of neighboring cells with an IC9₀ <10nM. In the FIGs. 3A/B and 4A/B Selinexor is referred to as KPT-330 and verdinexor is referred to as KPT-335.

EXPERIMENT 3-2: INHIBITION OF VIRAL PROPAGATION AFTER INFECTION [00163] To test the duration of selinexor’ s inhibition of viral propagation after SARS-

CoV-2 viral infection, Vero E6 cells were infected with SARS-CoV-2 at a multiplicity of infection (MOI) of 0.01 for 1 hour and selinexor was added to media at 0, 24, 36, and 48 hours post infection. Viral load was assessed by plaque assay after 4 days of incubation. The results from this study showed that selinexor inhibited SARS-CoV-2 viral propagation in vitro even when added up to 48 hours after infection. Results as shown in FIG. 3C.

[00164] EXPERIMENT 4: SELINEXOR INDUCES NUCLEAR ACCUMULATION OF ACE2 IN VITRO

[00165] SARS-C0V2 utilizes the host protein angiotensin-converting enzyme 2 (ACE2) as a cellular receptor for entry and infection, after its spike protein is activated by the transmembrane host protease serine 2 (TMPRSS2). In order to test if inhibition of XPOl by selinexor could affect the sub-cellular distribution of ACE2 in vitro , Vero E6 cells were treated with selinexor for 24 hours and ACE2 localization was analyzed by immunofluorescence and sub-cellular fractionation. Immunofluorescence of cells treated with selinexor or DMSO demonstrated that selinexor induced the nuclear retention of the ACE2 receptor, while DMSO-treated cells showed membrane bound ACE2 (FIG. 5). More specifically, Vero E6 cells (monkey kidney, ATCC: #CRL-1586) were incubated with 500nM selinexor or DMSO for 24 hours. Cells were fixed with 3% PFA and incubated with anti-ACE2-GFP antibody (Invitrogen Catalog # MA5-32307) and visualized by the Echo Revolve fluorescent microscope (ECHO) at 60x magnification. Membrane-bound ACE-2 receptors are visualized in DMSO-treated cells only (white arrows in FIG. 5).

[00166] EXPERIMENT 5 : TESTING OF ORAL SELINEXOR IN FERRETS INFECTED

WITH SARS-CoV-2

[00167] The objective of the ferret in vivo study was to assess therapeutic efficacy of selinexor against SARS-CoV-2 infection. The endpoints for evaluating the efficacy of the treatment was viral load and histopathological changes in the respiratory tract and nasal tissues. [00168] Ferrets were infected intranasally on Day 0 with 10⁶ SARS-CoV-2. There were 4 different treatment groups, including:

• SARS-CoV-2 + vehicle (n=6)

• SARS-CoV-2 + selinexor (n=6)

• No infection + vehicle (n=3)

• No infection + selinexor (n=3)

[00169] Four hours after infection, animals received the first oral treatment of either selinexor (5 mg/kg) or placebo (vehicle only). Animals were treated twice daily (every 12 hours, on Days 1, 2, and 3) and euthanized on Day 4.

[00170] Lung viral loads were measured by qPCR postmortem on Day 4 and nasal turbinates and lungs were evaluated histopathologically. Animals were weighed each day during the infection phase (Days 0 to 4). In the ferret COVID19 model, infected animals show spontaneous recovery from the virus after Day 5. Therefore, the longest observation period in the model is 4 days.

[00171] No unwanted toxic effects were observed, evidenced by the absence of spontaneous death for the duration of the study in either the SARS-CoV-2 or non-infected ferrets treated with selinexor. On Day 4, the SARS-CoV-2 infected animals treated with placebo had a mean viral RNA of 4.6 loglO viral copies per gram (vc/g)of lung tissue while selinexor-treated animals had a significantly lower mean viral RNA of 3.8 vc/g (p=0.0335).

In these assays the lower limit of detection for PCR was 1.9 LoglO CP/ml (CP = copies). TaqMan PCR levels were classified as <1.9 LoglO CP/ml (below the lower limit of detection) or positive (>1.9 LoglO CP/ml). Treatment with selinexor resulted in viral load levels similar to ferrets that were not infected with SARS-CoV-2. Results are shown in FIG. 6A and show that selinexor enhanced SARS-CoV-2 viral clearance, on Day 4, in the lungs of treated animals.

[00172] Histophathological analysis of formalin-fixed tissue from animals that had been infected with SARS-CoV-2 had severe neutrophilic rhinitis with lamina propria necrosis and inflammation in the lamina propria when treated with placebo, however animals treated with selinexor had mild to moderate neutrophilic rhinitis with mild and focal epithelial necrosis that was significantly less severe (p=0.0001; FIG. 6B). The extent of alveolitis was significantly decreased in SARS-CoV-2 infected selinexor-treated animals with a score of 1.5 (out of a range of 3) compared with placebo-treated animals with an average score of 2.04 (p=0.0449; FIG. 6C). Based on these results, ferrets infected with SARS-CoV-2 and administered 5 mg/kg selinexor orally twice per day, for 4 days had a lower viral load in the lungs, less severe rhinitis, and a lesser extent of lung inflammation characterized by alveolitis.

[00173] While this invention has been particularly shown and described with references to example embodiments thereof, it will be understood by those skilled in the art that various changes in form and details may be made therein without departing from the scope of the invention encompassed by the appended claims.

Claims

CLAIMS What is claimed is:

1. A method of treating COVID-19 in a subject in need thereof comprising administering to the subject a therapeutically effective amount of a SINE compound represented by structural formula I:

or a pharmaceutically acceptable salt thereof, wherein:

R¹ is selected from hydrogen and methyl;

R² is selected from pyridin-2-yl, pyri din-3 -yl, pyridin-4-yl, pyrazin-2-yl, and quinoxalin-2-yl, pyrimidin-4-yl, l,l-dioxotetrahydrothiophen-3-yl and cyclopropyl, wherein R² is optionally substituted with one or more independent substituents selected from methyl and halogen; or

R¹ and R² are taken together with their intervening atoms to form 4-hydroxypiperidin- 1-yl, pyrrolidin-l-yl, azepan-l-yl, 4-benzylpiperazin-l-yl, 4-ethylpiperazin-l-yl, 3- hydroxyazetidin-l-yl, or morpholin-4-yl;

R³ is selected from hydrogen and halo; and represents a single bond wherein a carbon-carbon double bond bound thereto is in an (E)- or (Z)-configuration.

2. A method of treating COVID-19 in a subject in need thereof comprising administering to the subject a therapeutically effective amount of a SINE compound represented by compound 1-3 :

or a pharmaceutically acceptable salt thereof.

3. The method of Claim 1 or Claim 2, wherein the COVID-19 is severe COVID-19.

4. The method of any one of Claims 1-3, wherein the subject is a human.

5. The method of Claim 4, wherein the human is 18 years or age or older.

6. The method of any one of Claims 1-5, wherein the therapeutically effective amount of the SINE compound is from about 2 mg per dose to about 200 mg per dose.

7. The method of any one of Claims 1-5, wherein the therapeutically effective amount of the SINE compound is about 20 mg per dose.

8. The method of any one of Claims 1-5, wherein the therapeutically effective amount of the SINE compound is about 40 mg per dose.

9. The method of any one of Claims 1-8, wherein the SINE compound is administered orally.

10. The method of Claim 9, wherein the SINE compound is administered in the form of a tablet.

11. The method of Claim 9, wherein the SINE compound is administered in the form of a suspension.

12. The method of Claim 11, wherein the SINE compound is administered using a nasal gastral tube or a G-tube.

13. The method of any one of Claims 1-7 and 9-12, wherein about 20 mg of the SINE compound is orally administered to the subject for a period of two weeks on days 1, 3 and 5 of each week.

14. The method Claim 13, further comprising orally administering about 20 mg of the SINE compound to the subject for an additional two weeks on days 1, 3 and 5 of each additional week.

15. The method of any one of Claims 1-6 and 8-12, wherein about 40 mg of the SINE compound is orally administered to the subject for a period of two weeks on days 1 and 3 of each week.

16. The method Claim 15, further comprising orally administering about 40 mg of the SINE compound to the subject for an additional two weeks on days 1 and 3 of each additional week.

17. The method of any one of Claims 1-16, wherein the SINE compound in administered one or more times per day.

18. The method of Claim 17, wherein the compound is administered once per day.

19. The method of any one of Claims 1-18, wherein the method further comprises administering an additional therapeutic agent.

20. The method of Claim 19, wherein the additional therapeutic agents is an antibiotic.

21. The method of Claim 20, wherein the additional therapeutic agent is azithromycin, amoxicillin or a tetracycline.

22. The method of any one of Claim 1-21, wherein the subject has an LDH level that is less than or equal to 370 U/L.

23. The method of any one of Claims 1-21, wherein the subject has a D-dimer value that is less than or equal to 600 mcg/L FEU.