(12) INTERNATIONAL APPLICATION PUBLISHED UNDER THE PATENT COOPERATION TREATY (PCT)
`(19) World Intellectual Property
`Organization
`International Bureau
`
`11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111
`
`(10) International Publication Number
`WO 2016/187347 A1
`
`(43) International Publication Date
`24 November 2016 (24.11.2016)
`
`(51) International Patent Classification:
`A61P 5100 (2006.01)
`A61K 45106 (2006.01)
`A61P 5/46 (2006.01)
`
`(21) h1ternational Application Number:
`
`(22) International Filing Date:
`
`(25) Filing Language:
`
`(26) Publication Language:
`
`PCT/US2016/033143
`
`18 May 2016 (18.05.2016)
`
`English
`
`English
`
`(30) Priority Data:
`62/163,130
`
`us
`INC.
`(71) Applicant: CORCEPT THERAPEUTICS,
`[US;US]; 149 Commonwealth Drive, Menlo Park, Califor(cid:173)
`nia 94025 (US).
`
`18 May 2015 (18.05.2015)
`
`(72) Inventors: BELANOFF, .Joseph K.; 149 Conm10nwealth
`Drive, Menlo Park, Califomia 94025 (US). HUNT, Hazel;
`149 Commonwealth Dlive, Menlo Park, Califomia 94025
`(US). UNITT, John Francis; 149 Commonwealth Drive,
`Menlo Park, Califomia 94025 (US). MORAITIS, An(cid:173)
`dreas G.; 149 Commonwealth Drive, Menlo Park, Califor(cid:173)
`nia 94025 (US).
`
`(74) Agents: GOETZ, David H. et al.; Kilpatrick Tmvnsend &
`Stockton LLP, Two Embarcadero Center, Suite 1900, San
`Francisco, Califomia 94111 (US).
`
`(81) Designated States (unless otherwise indicated, for every
`kind of national protection available): AE, AG, AL, AM,
`AO, AT, AU, AZ, BA, BB, BG, BH, BN, BR, BW, BY,
`BZ,CA,CH,CL,CN,CO,CR,CU,CZ,DE,DK,DM,
`DO, DZ, EC, EE, EG, ES, FI, GB, GD, GE, GH, GM, GT,
`HN, HR, HU, ID, IL, IN, IR, IS, JP, KE, KG, KN, KP, KR,
`KZ, LA, LC, LK, LR, LS, LU, L Y, MA, MD, ME, MG,
`MK, MN, MW, iviX, MY, MZ, NA, NG, NI, NO, NZ, OM,
`PA, PE, PG, PH, PL, PT, QA, RO, RS, RU, RW, SA, SC,
`SD, SE, SG, SK, SL, SM, ST, SV, SY, TH, TJ, TM, TN,
`TR, TT, TZ, UA, UG, US, UZ, VC, VN, ZA, ZM, ZW.
`
`(84) Designated States (unless otherwise indicated, for eve1y
`kind of regional protection available): ARIPO (BW, GH,
`GM, KE, LR, LS, MW, MZ, NA, RW, SD, SL, ST, SZ,
`TZ, UG, ZM, ZW), Eurasian (AM, AZ, BY, KG, KZ, RU,
`TJ, TM), European (AL, AT, BE, BG, CH, CY, CZ, DE,
`DK, EE, ES, FI, FR, GB, GR, HR, HU, IE, IS, IT, LT, LU,
`LV, MC, MK, !\IT, NL, NO, PL, PT, RO, RS, SE, SI, SK,
`SM, TR), OAPI (BF, BJ, CF, CG, CI, CM, GA, GN, GQ,
`GW, KM, ML, MR, NE, SN, TD, TG).
`
`Published:
`
`with international search report (Art. 21 (3))
`
`before the expiration of the time limit for amending the
`claims and to be republished in the event of receipt of
`amendments (Rule 48.2(h))
`
`----
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`(54) Title: METHODS FOR DIAGNOSING AND ASSESSING TREATMENT FOR CUSHING'S SYNDROME
`
`Day-19
`Prednisone 25mg
`
`Day -12
`Prednisone 25mg +
`Mifepristone 600mg
`
`I
`!
`~
`
`FIG. 1
`
`Day 1
`Prednisone 25mg +
`CORT125134 500mg
`
`! I
`l
`
`(57) Abstract: Methods are provided for assessing a clinical response to a glucocorticoid receptor antagonist (GRA) in a human sub(cid:173)
`ject and for diagnosing Cushing's syndrome.
`
`429
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`TEVA1035, pt. 2
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`1\IETHODS FOR Dl.AGNOSING AND ASSESSING TREATlVIENT FOR
`
`5
`
`CUSHING'S SYNDROME
`
`CROSS-REFERENCES TO RELATED APPLICATIONS
`
`[0001] TI1is application claims priority to U.S. Provisional Application No. 62/l63, 130,
`
`filed on May 18, 2015, the contents of which are hereby incorporated in the entirety :fix all
`
`10
`
`purposes.
`
`BACKGROlTND OF THE INVENTION
`
`[0002] Glucocorticoids (GCs) are a class of steroid hormones that bind to and activate the
`
`glucocorticoid receptor (GR), ·which is present in almost every vertebrate cell. 'flw GR is
`
`15
`
`pleiotropic and regulates a variety of important pathways in the ve1tebrate organism, for
`
`example, metabolism, immunity, and development. As such, detection ofGR activity or
`
`regulation can be used to diagnose a variety of different vettebrate diseases, or assess a
`
`clinical or biochemical response to treatments that modulate GR activity.
`
`[0003} For example, detection ofGR activity or regulation can be used for detection of
`
`20
`
`various forms of Cushing's syndrome. As another example, glucocorticoid receptor
`
`antagonists (GRAs) can be administered to a patient to treat a number of different diseases
`
`~md conditions, and detection of a change in GR activity in response to administration of the
`
`GRl\ can indicate or assess a clinical or biochemical response to the treatment. However,
`
`current methods and compositions for assessing GR activity suffer fi·om one or more of the
`
`25
`
`f"bllowing insufficiencies: high cost, low sensitivity, low specificity, high false positive rate,
`
`or high false negative rate. Therefore, there remains a need for improved methods and
`
`compositions for detection ofGR activity.
`
`BRIEF SUMMARY OF THE INVENTION
`
`30
`
`[0004]
`
`In a first aspect, the present invention provides a method for assessing a clinical or
`
`biochemical response to a glucocorticoid receptor antagonist (GRA) in a human subject, the
`
`method comprising: a) measuring a first amou.nt, or actrvity of 51 kDa FK506 binding protf..~in
`
`1
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`(FKBP5 protein) or a first expression level of a gene encoding FKBP5 protein in a first
`
`sample from the subject, wherein: i) the first sample comprises primary cells; and ii) the first
`
`sample is or was obtained before administeting the GRAto the subject; b) optionally
`
`administering the GRAto the subject: c) measming a second amount or activity ofFKBP5
`
`5
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`protein or a second expression level of a gene encoding FKBP5 protein in a second sample
`
`from the subject, wherein: i) the second sample comprises primary cells; and ii) the second
`
`sample is or was obtained after administering the GRA to the subject; and d) comparing the
`
`first and second amounts, activities, or expression levels, wherein a reduction in the amount
`
`or activity ofFKBP5 protein or a reduction in the expression level of the gene encoding
`
`10
`
`FKBP5 protein in the second sample as compared to the first sample indicates the clinical or
`
`biochemical response to the GRA. In some cases, the absence of a reduction indicates a lack
`
`of a clinical response or a lack ofbiochemical response to the GRA.
`
`roo05]
`
`In a second aspect, the present invention provides a method for assessing a clinical
`
`or biochemical response to a GRA in a human subject, the method comprising: a) measuring
`
`15
`
`a first amount, or activity of 51 kDa FK506 bmding protein (FKBP5 protein) or a first
`
`expression level of a gene encoding FKBP5 protein in a first sample from the subject,
`
`·wherein: i) the first sample comprises primary cells; and ii) the first sample is or vvas obtained
`
`before administering the GRAto the subject; b) optionally administering the GRA to the
`
`subject; c) measuring a second amount or activity ofFKBP5 protein or a second expression
`
`20
`
`level of a gene encoding FKBP5 protein in a second sample from the subject, >vvherein: i) the
`
`second sample comprises primary cells; and ii) the second sample is or was obtained after
`
`administering the GRA to the subject~ d) compating the first and second amounts, activities,
`
`or expression levels to obtain an FKBP5 difference value; e) comparing the difference value
`
`to a threshold difference value derived from a cohort of at least 20 or 30 or 50 test
`
`25
`
`individuals; and f) identifying the subject as having or not having the clinical or biochemical
`
`response to the GRA based on a comparison of the difference value and threshold difference
`
`value. In some cases, the threshold difference value is a threshold reduction value and a
`
`presence of a reduction in FKBP5 amount or activity between the first and second sample
`
`that is greater than a threshold reduction vaiue indicates a clinical or biochemical response to
`
`30
`
`the GRA. In some cases, the threshold difference value is a threshold reduction 'Value and a
`
`presence of a reduction in FKBPS amount or activity betvveen the first and second sample
`
`that is similar to (e.g, \vithin about 5'%, 10~~, 15'?;), 20%, 25%, 30%). 35'}~, 40%, 45'/;,, 50%,
`
`60~'(,, or 70'}~ of) a threshold reduction value indicates a clinical or biochemical response to
`
`2
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`the GRA. In some ca..<>es, the at least 20 or 30 or 50 test individuals are subjects kno\vn to
`
`have or suspected of having Cushing's syndrome. In some cases, the threshold diflerence
`
`value is detem1ined by subtracting a post-GRA administration FKBP5 amount, activity. or
`
`expression from a pre-GRA administration FKBP5 amount, activity, or expression in a cohort
`
`5
`
`of20 or 30 or 50 test individuals known to have or suspected of having Cushing's syndrome
`
`that is controlled or >veil-controlled by GRA administration.
`
`10006]
`
`In some embodiments, the subject is administered a GRL-\ in multiple doses and the
`
`first sample is obtained prior to administering the multiple doses of GRA and the second
`
`sample is obtained at1er administering the multiple doses of GRA to the subject. In some
`
`10
`
`embodiments the measuring of a) and/or c) comprises quantitating an ~m10unt ofmRNA
`
`encoding FKBP5 protein in the sample. In some embodiments, the measuring of a) and/or c)
`
`comprises quantitating the amount ofFKBP5 protein in the sample. In some embodiments
`
`the measuring comprises quantitating the amount ofFKBP5 protein activity in the sample. In
`
`some embodiments, the quantitating the amount ofFKBP5 protein activity in the sample
`
`15
`
`comprises measuring FKBP5 protein peptidyl-prolyl-cis-trans isomerase activity in the
`
`sample. In some embodiments, the quantitating the amount ofFKBP5 protein activity in the
`
`sample comprises measuring the amount of FKBP5 protein bound to glucocorticoid receptor
`
`(GR) in the sample.
`
`10007]
`
`In some embodiments, the administering the GRA to the subject comprises
`
`20
`
`administering mifepristone to the subject. ln some embodiments, the administering the GltA
`
`to the subject comprises admimstering a GRA that is not mifepristone to the subject. In some
`
`embodiments, the administering the GRAto the subject comprises administering a
`
`heteroaryl-ketone GRA. In some embodiments, the first or second san1ples comprise whole
`
`blood, or a fraction thereof. In some embodiments, the first and second san1ples comprise
`
`25
`
`whole blood, or a fraction thereof. Jn some embodiments, tbe first or second samples
`
`comprise nasal epithelial scraping samples. In some embodiments, the patient is in need of
`
`administration of the glucocorticoid receptor antagonist (GRA). In some embodiments, the
`
`patient has elevated levels of cOJtisol.
`
`[0008]
`
`In some embodiments, the patient has cancer and the first and second samples
`
`30
`
`comprise tumor cells. Jn some embodiments, the tirst or second san1ples comprise whole
`
`blood, or a fraction thereof. In some embodiments, the first and second samples comprise
`
`whole blood, or a fraction thereof. ln some embodiments, the method comprises
`
`3
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`administering an increased amount of GRA to the subject in the absence of a detected
`
`reduction in the ammmt or activity of FKBP5 protein or a detected reduction in the
`
`expression level ofthe gene encoding FKBP5 protein in the second sample.
`
`[0009J
`
`In a third aspect, the present invention provides a method for diagnosing Cushing's
`
`5
`
`syndrome in a human subject, the method comprising: a) measuring an amount, or activity of
`
`51 kDa FK506 binding protein (FKBP5 protein) or an expression level of a gene encoding
`
`FKBPS protein in a sample obtained or provided from the subject, wherein the sample
`
`comprises primary cells; and b) identifying the subject as llkely to be suftering from
`
`Cushing's syndrome when the amount, activity or expression level is high relative to a
`
`10
`
`controL In some cases, the control comprises a value derived from at least l 00 or at least 200
`
`test individuals. In some cases, the test individuals are subjects that are known to not exhibit
`
`Cushing "s syndrome. In some cases, the test individuals are subjects that are known to have
`
`nonnal cortisol levels or are known to lack hypercortisolemia. In some cases, the control
`
`comprises a value derived from at least 20 or 30 or 50 test individuals. In some cases, the test
`
`15
`
`individuals are subjects diagnosed with Cushing's syndrome and undergoing therapy vvith a
`
`GRA. Tn some cases, t.he test individuals are subjects diagnosed with Cushing's syndrome,
`
`undergoing therapy with a GRA, wherein at least one symptom of the Cushing's syndrome is
`
`mitigated or eliminated by the GRA therapy.
`
`10010~ In a fourth aspect, the present invention provides a method for assessing a clinical
`
`20
`
`or biochemical response to a G1<.J:\ in a human subject, the method comprising: a) measuring
`
`an amount, or activity of 51 kDa FK506 binding protein (FKBP5 protein) or an expression
`
`level of a gene encoding FKBP5 protein in a sample from the subject, wherein: i) the sample
`
`comprises primary cells; and ii) the sarnple is or was obtained after administering the Gfu'\ to
`
`the subject; d) comparing the amount, activities, or expression level ofFKBP5 to a control
`
`25
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`value derived from a cohort of at least 1 00 or at least 200 test individuals: and f) identifying
`
`the su~ject as having or not having the clinical or biochemical response to the GRA based on
`
`a comparison of the FKBP5 amount, activity or expression level to the control value. ln
`
`some cases, the at least 100 or at least 200 test individuals are nonnal subjects that are not
`
`ott~erwise in need of a GRA. In some cases, the at least l 00 or at lea..<;t 200 test individuals do
`
`30
`
`not have Cushing's syndrome. In some cases, the at least l 00 or at least 200 test individuals
`
`do not have elevated levels of cortisol In some cases, the at least 100 or at lea;;;t 200 test
`
`individuals do not have, or do not exhibit symptoms ofhypercortisolemia.
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`100111
`
`In some embodiments, the measuring comprises quantitating an amount of mRNA
`
`encoding FKBP5 protein in the primary cells of the sample. In some embodiments, the
`
`measuring comprises quantitating the amount ofFKBP5 protein in the primary ce1ls of the
`
`sample. In some embodiments, the measuring comprises quantitating the amount ofFKBP5
`
`5
`
`protein activity in the primary cells ofthe sample. In some embodiments, the quantitating the
`
`amount ofFKBP5 protein activity in the primary cells of the sample comprises quantitating
`
`FKBP5 protein peptidyl-prolyl-cis-trans isomerase activity in the primary cells ofthe sample.
`
`In some embodiments, the quantitating the amount ofFKBP5 protein activity in the primary
`
`cells of the sample comprises quantitating the amow1t ofFKBP5 protein bound to GRin the
`
`10
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`primary cells of the sample. In some embodiments, the sample obtained from the subject
`
`comprises whole blood, or a fraction thereof In some embodiments, the subject has
`
`undergone tnmssphenoidal surgery before the sample is obtained from the subject. In some
`
`embodiments, the sample is obtained from the subject Jess than eleven days after the subject
`
`is treated with transspbenoidal surgery. In some embodiments, the sample is obtained from
`
`15
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`the su~ject less than t\vo, four, or six weeks after the subject is treated with transsphenoidal
`
`surgery. In some embodiments, the method comprises administering a treatment ±or
`
`Cushing's syndrome vvhen the amount or activity ofFKBP5 protein or the expression level of
`
`the gene encoding FKBP5 protein is high relative to a controL In some cases, the
`
`administering the treatment for Cushing's syndrome comprises administering to the subject a
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`20
`
`glucocorticoid receptor antagonist (GRA)
`
`100121
`
`In a fifth aspect, the present invention provides a method ±or assessing a clinical or
`
`biochemical response in a human subject to adm]nistering to the subject a medical or surgical
`
`therapy for treatment ofhypercortisolemia, the method comprising: a) measuring a first
`
`:unount, or activity of 51 kDa FK506 binding protein (FKBP5 protein) or a first expression
`
`25
`
`level of a gene encoding FKBP5 protein in a first san1ple from the subject, \vherein: i) the
`
`first sample comprises primary cells: and ii) the first sample is or was obtained befbre
`
`administering the medical or surgical therapy tt)r treatment ofhypercortisolemia to the
`
`subject: b) optionally administering the medical or surgical therapy :l:or treatment of
`
`hypercortisolernia to the subject~ c) measuring a second amount or activity ofFKBP5 protein
`
`30
`
`or a second expression level of a gene encoding FKBP5 protein in a second sample from the
`
`subject, \\·herein: i) the second san1ple comprises primary cells; and ii) the second san1ple is
`
`or was obtained after administering the medical or surg]cal therapy tor treatment of
`
`hypercortisolemia k0 the subject; and d) comparing the first and second amounts, activities, or
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`expression levels, wherein a reduction in the amount or activity ofFKBP5 protein or a
`
`reduction in the expression level ofthe gene encoding FKBP5 protein in the second sample
`
`indicates the clinical response or the biochemical response to the medical or surgical therapy
`
`for treatment ofhypercortisolemia. For example, a reduction in the amount or activity of
`
`5
`
`FKBP5 protein or a reduction in the expression level of the gene encoding FKBP5 protein in
`
`the second sample can indicate that the medical or surgical therapy is successful in treating
`
`the hypercortisolism.
`
`10013}
`
`In a sixth aspect, the present invention provides a method for assessing a clinical or
`
`biochemical response to administering to the subject a medical or surgical therapy for
`
`10
`
`treatment ofhypercortisolemia, the method comprising: a) measuring a first ammmt, or
`
`activity of 51 kDa FK506 binding protein (FKBP5 protein) or a first expression level of a
`
`gene encoding FKBP5 protein in a first sample from the subject, wherein: i) the :first sample
`
`comprises primary cells; and ii) the first sample is or was obtained before administering the
`
`GRAto the subject: b) optionaUy administering the medical or surgical therapy f()r treatment
`
`15
`
`ofhypercortisolemia to the subject: c) measuring a second amount or activity ofFKBP5
`
`protein or a second expression level of a gene encoding FKBPS protein in a second sample
`
`from the subject, wherein: i) the second sample comprises primary cells; and ii) the second
`
`san1ple is or was obtained after administering the GRA. to the subject; d) comparing the first
`
`and second amounts, activ]ties, or expression levels to obtain an FKBP5 difference value; e)
`
`20
`
`comparing the difference value to a threshold difference value derived from a cohort of at
`
`least 20 or 30 or 50 test individuals; and f) identifying the subject as having or not having the
`
`clinical or biochemical response to the GRA based on a comparison of the difference value
`
`and threshold difference value. Jn some cases, the threshold difference value is a threshold
`
`reduction value and a presence of a reduction in FKBP5 amount or activity between the first
`
`25
`
`and second sample that is greater than, or similar to, a threshold reduction value indicates a
`
`clinical or biochemical response to the GRA. Tn some cases,. the at least 20 or 30 or 50 test
`
`individuals are subjects knmvn to have or suspected ofha\rlng Cushing's syndrome.
`
`[0014]
`
`In some embodiments, the medical or surgical therapy fi.)r treatment of
`
`hypercortisolemia is selected from the group consisting of: inhibition of steroidogenesis,
`
`30
`
`administration of an ACTH modulator, GRA administration,: transsphenoidal stugery, repeat
`
`transsphenoidal surgery, unilateral adrenalectomy, bilateral adrenalectomy, radiotherapy,
`
`resection of a non-pituitary ACTII-secreting tumor, treatment \vith a peptide receptor
`
`radionuclide therapy, and combinations thereof. In some embodiments, the inhibition of
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`steroidogenesis comprises administration of ketoconazole, levoketoconazole, metyrapone,
`
`LCI699, mitot:'lne, aminoglutethimide, etomidate, m a combination thereof In some
`
`embodiments, the administration of an ACTH modulator comprises administration of a
`
`dopamine agonist, somatostatin, a somatostatin analog, retinoic acid, R-roscovitine, or a
`
`5
`
`combination thereof In some embodiments, the dopamine agonist is selected fl·om the group
`
`consisting ofbromocriptine and cabergoline. In some embodiments, the method comprises
`
`administering an additional medical or surgical therapy for treatment ofbypercortisolemia in
`
`an absence of a detected reduction in the amount or activity of FKBP5 protein or reduction in
`
`the expression level ofthe gene encoding FKBP5 protein in the second sample.
`
`10
`
`[0015]
`
`In some embodiments the measuring of a) and/or c) comprises quantitating an
`
`amount of mRNA encoding FKBP5 protein in the sample. In some embodiments, the
`
`measuring of a) and/or c) comprises quantitating the amount ofFKBP5 protein in the san1ple.
`
`In some embodiments the measuring comprises quantitating the amount of FKBP5 protein
`
`activity in the sample. In some embodiments, the quantitating the amount of FKBPS protein
`
`15
`
`activity in the sample comprises measuring FKBP5 protein peptidyl-prolyl-cis-trans
`
`isomerase activity in the sample. In some embodiments, the quantitating the amount of
`
`FKBP5 protein activity in the sample comprises measuring the ~m1m.mt of FKBPS protein
`
`bound to glucocorticoid receptor (GR) in the sample.
`
`10016~ In some embodiments, the GRA administration comprises administering
`
`20 mitepristone to the subject. ln some embodiments, the GRL\ administration comprises
`
`administering a GRA that is not mifepristone to the subject. In some embodiments, GRA
`
`a.t.iministration comprises administering a heteroaryl-ketone GRA .. In some embodiments, the
`
`first or second samples comprise \vhole blood. or a fraction thereof. ln some embodiments,
`
`the first and second san1ples comprise whole blood, or a fraction thereof. In some
`
`25
`
`embodiments, the first or second samples comprise nasal epithelia! scraping samples. In
`
`some embodiments, the patient is in need of a medical or surgical therapy for treatment of
`
`hypercortisolemia. In some embodiments, the patient has elevated levels of cortisol.
`
`BRIEF DESCRIP110N OF THE DRA W1NGS
`
`30
`
`[0017~ FIG. 1: depicts a study scheme for examining the expression level of the gene
`
`FKBP5, which encodes the FKBP5 protein, in response to administration of a GR modulator.
`
`ln this scheme, healthy subjects are administered a GR agonist, tollmved by co-
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`administration of a GR agonist and a GR antagonist (GRA). Blood samples are obtained
`
`from 10 subjects before each dose and at various time points after each dose. FKBP5
`
`expression levels are measured before dosing on each day. and at selected times after dosing
`
`on each day
`
`5
`
`[0018] F'IG. 2: depicts the fold difference in GAPDH normalized FKBP5 expression levels
`
`in samples taken befbre and after administration of the indicated GR agonist (prednisone), or
`
`before and after administration of the indicated GR agonist in combination with the indicated
`
`GRarl.!:agonist (mifepristone or CORT125134).
`
`10
`
`DEFINITIONS
`rool9] The abbreviations used herein have their conventional meaning within the chemical
`
`and biological a1ts. As used in this specification and the appended claims, the singular f(.mns
`
`"a," "an," and "the" include plural reference unless the context clearly dictates otherwise.
`
`[0020] As used herein, "glucocorticoid receptor" ("GR") refers to the type II GR or nuclear
`
`15
`
`receptor subfamily 3, group C, member 1 (NR3Cl), vvhich specifically binds to cortisol
`
`and/or cortisol analogs such a'S dexamethasone (S'ee, e.g., Turner & J\1uller, J lVfol Endocrinol
`
`October 1, 2005 35 283-292). The GR is also referred to as the cortisol receptor. The tem1
`
`includes isoforms of GR, recombinant GRand mutated GR.
`
`[0021]
`
`"Glucocorticoid receptor antagonist" ("GRA") refers to any composition or
`
`20
`
`compound which partially or completely inhibits (antagonizes) the binding of a
`
`glucocorticoid receptor (GR) agonist, such as cortisol, or cortisol analogs, synthetic or
`
`naturaL to a GR. A "specific glucocorticoid receptor antagonist" refers to any composition or
`
`compound which inhibits any biological response a.<>;sociated vvith the binding of a GR to an
`
`agonist. By "specific," the drug preferentially binds to the GR rather than other nuclear
`
`25
`
`receptors, such as mineralocorticoid receptor (MR), androgen receptor (AR), or progesterone
`
`receptor (PR). It is preferred that the specific glucocorticoid receptor antagonist bind GR
`
`with an affinity that is 1 O-t<.1ld greater ( 1/1 oth the Kd value) than its affinity to the MR, AR. or
`
`PR. both the MR and PR. both the MR and AR, both the AR and PR, or to the 1\i[R, AR, and
`
`PR In a more pretened embodiment, the specific glucocorticoid receptor antagonist binds
`
`30 GR with an affinity that is 1 OO-f<.1ld greater ( l/1 OO'h the Kd value) than its affinity to the J'VIR,
`
`AR, or PR, both the MR and PR, both the MR and AR, both the AR and PR. or to the MR,
`
`AR, andPR
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`100221
`
`"Human subjecC refers to a human primate. The human subject can be a person
`
`having, or suspected of having, Cushing's syndrome or a disease or condition that can be
`
`treated with a GRA. Similarly. "a patient in need of administration of a glucocorticoid
`
`receptor antagonist (GRA)" can be a person having or, or suspected of having, Cushing's
`
`5
`
`syndrome or a disease or condition that can be treated \vith a GRA. Exemplary diseases or
`
`conditions that can be treated with a GRA include, but are not limited to cancer, breast
`
`cancer, triple negative breast cancer, prostate cancer, metastatic prostate cancer, ovarian
`
`c.:mcer, Cushing's syndrome, or Cushing's disease. In some cases, the human subject c<:m be
`
`a person that has been previously treated with transsphenoidal surgery (e.g, to remove
`
`10
`
`tumors of the pituitary gland, such as pituitary adenomas). For example the subject may have
`
`undergone transsphenoidal surgery to treat Cushing's disease. In some cases, the human
`
`subject previously treated \vith transsphenoidal surgery c.:m be a subject that has undergone
`
`transsphenoidal surgery less than, or less than about, 20 days, 19 days, 18 days, 17 days, l6
`
`days, 15 days, 14 days, 13 days, 12 days, ll days, 10 days, 9 days, 8 days, 7 days, 6 days, 5
`
`15
`
`days, 4 days, 3 days, 2 days, or l day ago.
`
`[0023]
`
`••Assessing a clinical or biochemical response to a glucocorticoid receptor
`
`;mtagonist (GRAY refers to detecting or quantifying a response to an administered GRA.
`
`Tbe clinical response can be an indication that the GRA .. is likely to be successful in treating a
`
`disease or condition, or successfl!J in mitigating or ameliorating one or more symptoms of a
`
`20
`
`disease or condition. The biochemical response c:m be an indication that the GRA is at a
`
`dose that is sufficient to alter, or significantly alter, the physiology of the subject to which the
`
`GRA is administered. The biochemical response can be an indication that the GRA is likely
`
`to be successful in treating a disease or condition, or successful in mitigating or ameliorating
`
`one or more symptoms of a disease or condition. The disease or condition can be, e.g.,
`
`25
`
`hypercortisoiemia or Cushing's syndrome. The clinical or biochemical response can be
`
`assessed by detecting a change in GR activity or regulation caused by or correlated with
`
`administration of a GRA. For exan1ple, a change in the amount or activity of FKBP5 protein,
`
`or the expression level of a gene encoding FKBP5 protein, in response to administration of a
`
`GRA can be detected to assess a clinical response or a biochemical response to a GRA.
`
`30
`
`[0024]
`
`'"Assessing a clinical or biochemical response to administering a medical or surgical
`
`therapy for treatment of hypercOJtisolcmia" and the like, refers to detecting or quantitating a
`
`response to the administered therapy. The clinical response can be an indication that the
`
`therapy is likely to be successful in treating the hypercortisolemia, or successful in mitigating
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`or ameliorating one or more symptoms of the h:rrpercortisolemia. The biochemical response
`
`can be an indication that the administered therapy has altered, or significantly altered, the
`
`physiology of the subject to which the therapy is administered. The biochemical response
`
`can be an indication that the therapy is likely to be successful in treating the
`
`5
`
`hypercortisolemia, or successful in mitigating or ameliorating one or more symptoms of the
`
`hypercortisolemia.
`
`10025]
`
`"Mea...;;uring an amount or activity ofFKBP5 protein" refers to measuring the
`
`amount of FKBP5 protein or measuring the amount of an activity of the FKBP5 protein in a
`
`sample. The activity can be cis-trans prolyl isomerase activity, FK506 or rapamycin binding
`
`10
`
`activity, GR binding activity, or chaperone activity (e.g, steroid hormone chaperone
`
`activity).
`
`10026]
`
`"Mea...;;uring an expression level of a gene encoding FKBPS protein" generally refers
`
`to measurement of the amount of mRNA encoding FKBP5 protein in a sample, or measuring
`
`the production of mRNA encoding FKBP5 protein in the sample. Methods for measuring
`
`15 mRNA or mR:.'\IA production include, but are not limited to, RT-PCR, digital RT-PCR, RNA(cid:173)
`
`seq (e.g, l'V1ethods Mol Bioi. 2014:1158:71-91), and microarray analysis.
`
`[0027]
`
`"Primary cells" reters to cells that have not been immortalized or passaged more
`
`than one time. Primary cells include human cells that have been taken directly from an
`
`individual v>.'ithout any subsequent culturing or division.
`
`20
`
`[0028J
`
`"Sample" refers to a biological sample obtained from any tissue or organ of a
`
`human subject. The sample can be any cell or tissue sample from a human subject. Samples
`
`can be subject to various treatment, stor.:tge or processing procedures before being analyzed
`
`according to the methods described herein. Generally, the terms "sample" or "samples" are
`
`not intended to be limited by their source, origin, manner of procurement, treatmeni,
`
`25
`
`processing, storage or analysis, or any modification. The biological sample ca..'1 contain
`
`primary cells originating from a human subject. The sample can contain an FKBP5
`
`polypeptide or portion thereof a nucleic acid encoding an FKBP5 polypeptide or portion
`
`thereof, an amplification or reverse transcription product of a nucleic acid encoding an
`
`FKBP5 polypeptide or portion thereof, or combination of a..'1y two or more ofthe foregoing
`
`30
`
`polypeptides, nucleic acids, an1plification products, reverse tnmscription products, or portions
`
`thereof
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`10029]
`
`'"\Vhole blood" refers to blood collected from a human subject that is not subject to
`
`serum or plasma separation. "A fraction thereof' in the context of such whole blood refers to
`
`any fraction of\vhole blood, such as plasma, serum, a leukocyie fi·action, a red blood ceil
`
`fraction, a sample of peripheral blood mononuclear cells, and the like.
`
`5
`
`[0030]
`
`"Control" or "control value" in the context of amount or activity ofFKBP5 protein,
`
`expression levels ofthe FKBP5 gene, or a fold-change in FKBP5 amount, ac6vity, or
`
`expression leveL can refer to a level that is typically found in a subject under various clinical
`
`conditions. For example, the control value can be an amount typically found in a Cushing's
`
`patient. As another example, the control value can be an amount typically t(mnd in a healthy
`
`10
`
`(e.g., non-Cushing's) patient. As another example, the control value can be a H1ld-change
`
`typically observed \vhen a patient or cells of a patient are administered a GRl\ (e.g., at a
`
`typical dose), wherein the patient or cells of the patient exhibit a clinical response to the GRA
`
`or exhibit a biochemical response to the GRA. As another example, a control value can be a
`
`t<.1ld-change that is typically observed when a patient or cells of a patient are administered a
`
`15
`
`GRA (e.g., at a typical dose), wherein the