U.S. patent application number 13/756687 was filed with the patent office on 2013-07-04 for pharmaceutical compositions.
This patent application is currently assigned to ARES TRADING S.A.. The applicant listed for this patent is Ares Trading S.A.. Invention is credited to BJOERN C. KAHRS.
Application Number | 20130172391 13/756687 |
Document ID | / |
Family ID | 48610741 |
Filed Date | 2013-07-04 |
United States Patent
Application |
20130172391 |
Kind Code |
A1 |
KAHRS; BJOERN C. |
July 4, 2013 |
PHARMACEUTICAL COMPOSITIONS
Abstract
The invention relates to pharmaceutical compositions comprising
PPAR agonists and Nrf2 activators and methods of using combinations
of PPAR agonists and Nrf2 activators for treating diseases such as
psoriasis, asthma, multiple sclerosis, inflammatory bowel disease,
and arthritis.
Inventors: |
KAHRS; BJOERN C.;
(COLLONGE-BELLERIVE, CH) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
Ares Trading S.A.; |
Aubonne |
|
CH |
|
|
Assignee: |
ARES TRADING S.A.
AUBONNE
CH
|
Family ID: |
48610741 |
Appl. No.: |
13/756687 |
Filed: |
February 1, 2013 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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13654632 |
Oct 18, 2012 |
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13756687 |
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61663761 |
Jun 25, 2012 |
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Current U.S.
Class: |
514/342 ;
514/369 |
Current CPC
Class: |
A61K 31/4439 20130101;
A61K 31/225 20130101; Y02A 50/30 20180101; A61P 29/00 20180101;
A61P 19/02 20180101; A61P 21/02 20180101; A61K 31/19 20130101; A61K
31/26 20130101; A61P 5/48 20180101; A61P 17/00 20180101; A61P 43/00
20180101; A61K 31/16 20130101; A61K 31/385 20130101; A61P 37/06
20180101; A61P 17/14 20180101; A61P 21/04 20180101; A61K 31/47
20130101; A61P 11/06 20180101; A61K 9/0053 20130101; A61P 13/12
20180101; A61K 31/426 20130101; A61P 11/00 20180101; A61K 31/216
20130101; A61P 25/16 20180101; A61P 25/14 20180101; A61P 17/06
20180101; A61P 25/28 20180101; A61K 31/12 20130101; A61P 1/04
20180101; A61P 25/00 20180101; A61K 31/05 20130101; A61K 31/05
20130101; A61K 2300/00 20130101; A61K 31/12 20130101; A61K 2300/00
20130101; A61K 31/16 20130101; A61K 2300/00 20130101; A61K 31/19
20130101; A61K 2300/00 20130101; A61K 31/216 20130101; A61K 2300/00
20130101; A61K 31/26 20130101; A61K 2300/00 20130101; A61K 31/385
20130101; A61K 2300/00 20130101; A61K 31/4439 20130101; A61K
2300/00 20130101; A61K 31/47 20130101; A61K 2300/00 20130101 |
Class at
Publication: |
514/342 ;
514/369 |
International
Class: |
A61K 31/4439 20060101
A61K031/4439; A61K 31/225 20060101 A61K031/225; A61K 31/426
20060101 A61K031/426 |
Foreign Application Data
Date |
Code |
Application Number |
Dec 19, 2011 |
EP |
11194292.6 |
Jun 21, 2012 |
EP |
12004652.9 |
Claims
1. A pharmaceutical composition comprising a glitazone and a
fumaric acid monoalkyl ester and/or fumaric acid dialkyl ester and,
optionally, one or more excipients.
2. The pharmaceutical composition according to claim 1, wherein the
fumaric acid dialkyl ester is selected from dimethyl fumarate or
diethyl fumarate and the fumaric acid monoalkyl ester is selected
from monomethyl hydrogen fumarate or monoethyl hydrogen
fumarate.
3. The pharmaceutical composition according to claim 1, wherein the
glitazone is pioglitazone or rosiglitazone.
4. The pharmaceutical composition according to claim 2, wherein the
fumaric acid dialkyl ester is dimethyl fumarate.
5. The pharmaceutical composition according to claim 1, wherein
said pharmaceutical composition comprises a solid oral dosage
form.
6. The pharmaceutical composition according to claim 1, wherein the
fumaric acid dialkyl ester is selected from dimethyl fumarate or
diethyl fumarate and the fumaric acid monoalkyl ester is selected
from monomethyl hydrogen fumarate or monoethyl hydrogen fumarate,
the glitazone is pioglitazone or rosiglitazone and said
pharmaceutical composition is an oral dosage form.
7. The pharmaceutical composition according to claim 6, wherein
said fumaric acid dialkyl ester is dimethyl fumarate.
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] This application is a divisional of U.S. Ser. No.
13/654,632, filed Oct. 18, 2012, which claims the benefit of U.S.
Provisional Application Ser. No. 61/663,761, filed Jun. 25, 2012,
the disclosure of which is hereby incorporated by reference in its
entirety, including all figures, tables and amino acid or nucleic
acid sequences.
[0002] Disclosed herein are pharmaceutical compositions comprising
ppar agonists and Nrf2 activators (each an "agent" and together
"agents"), and methods of using combinations of ppar agonists and
Nrf2 activators for treating diseases such as psoriasis, asthma,
multiple sclerosis, inflammatory bowel disease, and arthritis.
[0003] Perixome Proliferator Activated Receptors (PPARs) activate
transcription by binding to elements of DNA sequences, known as
peroxisome proliferator response elements (PPRE), in the form of a
heterodimer with retinoid X receptors (known as RXRs). Three
subtypes of human PPARs have been identified and described:
PPAR.alpha., PPAR.gamma. (PPAR gamma) and PPAR.delta. (or NUC1).
PPAR.alpha. is mainly expressed in the liver, while PPAR.delta. is
ubiquitous. PPAR.gamma. is the most extensively studied of the
three subtypes. See e.g. "Differential Expression of Peroxisome
Proliferator-Activated Receptor Subtypes During the Differentiation
of Human Keratinocytes", Michel Rivier et al., J. Invest.
Dermatol., 111, 1998, pp. 1116-1121, in which is listed a large
number of bibliographic references relating to receptors of PPAR
type. Mention may also be made of the report entitled "The PPARs:
From orphan receptors to Drug Discovery", Timothy M. Willson, Peter
J. Brown, Daniel D. Sternbach and Brad R. Henke, J. Med. Chem.,
2000, Vol. 43, pp. 527-550. It is suggested that PPAR.gamma. play a
critical role in regulating the differentiation of adipocytes,
where it is greatly expressed. It also has a key role in systemic
lipid homeostasis.
[0004] It has been reported that the thiazolidinedione class of
compounds (the group of so-called glitazones) including
rosiglitazone, rosiglitazone maleate, pioglitazone, pioglitazone
hydrochloride, troglitazone and ciglitazone and or its salt forms
are potent and selective activators of PPAR-gamma (so-called PPAR
gamma agonists) and bind directly to the PPAR-gamma receptor (J. M.
Lehmann et al., J. Biol. Chem. 12953-12956, 270 (1995)), providing
evidence that PPAR-gamma is a possible target for the therapeutic
actions of the thiazolidinediones. Since this observation,
activation of this nuclear hormone receptor has been shown to have
pleiotropic metabolic and nonhypoglycemic effects. Clinical use of
the agents in the treatment of Type 2 diabetes mellitus (or non
insulin dependent diabetes mellitus (NIDDM)) is associated with
sensitization to the glucose lowering effects of insulin as well as
potentiation of other biological actions of insulin in target
tissues. When used as monotherapy, there are reports of fluid
retention resulting in volume expansion and, in some patients,
clinical edema. The incidence of edema appears to be increased when
both these agents are used in combination with insulin (Nesto R. W.
et al, 2003, Circulation, 108, 2941-2948). However, the mechanisms
involved in these effects have not been well described but the
nature of the presentation suggests an integrated physiological
response which includes an effect on renal salt and water balance.
PPAR gamma receptors have been found in the renal collecting duct
(Guan Y. et al; 2001, Kidney Int. 60, 14-30) and, therefore, the
PPAR gamma agonists might be involved directly in renal tubular
metabolism or could have secondary effects on salt and water
homeostasis. The ppar gamma agonist pioglitazone has been suggested
as a treatment of psoriasis in e.g. British Journal of Dermatology
2005 152, pp 176-198.
[0005] Nuclear factor erythroid-2 related factor 2 or Nuclear
Factor E2p45-Related Factor (Nrf2) is a cap-and-collar basic
leucine zipper transcription factor, regulates a transcriptional
program that maintains cellular redox homeostasis and protects
cells from oxidative insult (Rangasamy T, et al., J Clin Invest
114, 1248 (2004); Thimmulappa R K, et al. Cancer Res 62, 5196
(2002); So H S, et al. Cell Death Differ (2006)). NRF2 activates
transcription of its target genes through binding specifically to
the antioxidant-response element (ARE) found in those gene
promoters. The NRF2-regulated transcriptional program includes a
broad spectrum of genes, including antioxidants, such as
.gamma.-glutamyl cysteine synthetase modifier subunit (GCLm),
.gamma.-glutamyl cysteine synthetase catalytic subunit (GCLc), heme
oxygenase-1, superoxide dismutase, glutathione reductase (GSR),
glutathione peroxidase, thioredoxin, thioredoxin reductase,
peroxiredoxins (PRDX), cysteine/glutamate transporter (SLC7A11) (7,
8)], phase II detoxification enzymes [NADP(H) quinone
oxidoreductase 1 (NQO1), GST, UDP-glucuronosyltransferase
(Rangasamy T, et al. J Clin Invest 114: 1248 (2004); Thimmulappa R
K, et al. Cancer Res 62: 5196 (2002)), and several ATP-dependent
drug efflux pumps, including MRP1, MRP2 (Hayashi A, et al. Biochem
Biophy Res Commun 310: 824 (2003)); Vollrath V, et al. Biochem J
(2006)); Nguyen T, et al. Annu Rev Pharmacol Toxicol 43: 233
(2003)).
[0006] Interlinked with Nrf2 is KEAP1, which is a cytoplasmic
anchor of Nrf2 that also functions as a substrate adaptor protein
for a Cul3-dependent E3 ubiquitin ligase complex to maintain
steady-state levels of NRF2 and NRF2-dependent transcription
(Kobayashi et al., Mol Cell Biol 24: 7130 (2004); Zhang D, et al.
Mol Cell Biol 24: 10491 (2004)). The Keap 1 gene is located at
human chromosomal locus 19p13.2. The KEAP1 polypeptide has three
major domains: (1) an N-terminal Broad complex, Tramtrack, and
Bric-a-brac (BTB) domain; (2) a central intervening region (IVR);
and (3) a series of six C-terminal Kelch repeats (Adams J, et al.
Trends Cell Biol 10:17 (2000)). The Kelch repeats of KEAP1 bind the
Neh2 domain of Nrf2, whereas the IVR and BTB domains are required
for the redox-sensitive regulation of Nrf2 through a series of
reactive cysteines present throughout this region (Wakabayashi N,
et al. Proc Natl Acad Sci USA 101: 2040 (2004)). KEAP1
constitutively suppresses Nrf2 activity in the absence of stress.
Oxidants, xenobiotics and electrophiles hamper KEAP 1-mediated
proteasomal degradation of Nrf2, which results in increased nuclear
accumulation and, in turn, the transcriptional induction of target
genes that ensure cell survival (Wakabayashi N, et al. Nat. Genet.
35: 238 (2003)). Prothymosin .alpha., a novel binding partner of
KEAP1, has been shown to be an intranuclear dissociator of
NRF2-KEAP1 complex and can upregulate the expression of Nrf2 target
genes (Karapetian R N, et al. Mol Cell Biol 25: 1089 (2005)).
Certain interactions between Nrf2 and ppar gamma have been
suggested, e.g. Am J Respir Crit. Care Med 2010; 182:170-182.
[0007] Nrf2 activators according to the present invention are
agents that after administration result in a stimulated and/or
increased nuclear translocation of Nrf2 protein and causes the
subsequent increases in gene products that detoxify and eliminate
cytotoxic metabolites. Nrf2 activators according to the present
invention may act directly on Nrf2, KEAP1, the NRF2-KEAP1 complex
and/or otherwise. Nrf2 activators of the present invention may
comprise a Michael addition acceptor, one or more fumaric acid
esters, i.e. fumaric acid mono- and/or diesters which are
preferably selected from the group of monoalkyl hydrogen fumarate
and dialkyl fumarate, such as monomethyl hydrogen fumarate,
dimethyl fumarate, monoethyl hydrogen fumarate, and diethyl
fumarate, furthermore ethacrynic acid, bardoxolone methyl (methyl
2-cyano-3,12-dioxooleana-1,9(11)dien-28-oate), isothiocyanate such
as sulforaphane, 1,2-dithiole-3-thione such as oltipraz,
3,5-di-tert-butyl-4-hydroxytoluene, 3-hydroxycoumarin, or a
pharmacologically active derivative or analog of the aforementioned
agents.
[0008] Very preferred Nrf2 activators for use in combination with
PPAR gamma agonists according to the present invention are
bardoxolone methyl and fumaric acid esters.
[0009] Fumaric acid esters are approved in Germany for the
treatment of psoriasis, are being evaluated in the United States
for the treatment of psoriasis and multiple sclerosis, and have
been proposed for use in treating a wide range of immunological,
autoimmune, and inflammatory diseases and conditions. FAEs and
other fumaric acid derivatives have been proposed for use in
treating a wide-variety of diseases and conditions involving
immunological, autoimmune, and/or inflammatory processes including
psoriasis (Joshi and Strebel, WO 1999/49858; U.S. Pat. No.
6,277,882; Mrowietz and Asadullah, Trends MoI Med 2005, 111(1),
43-48; and Yazdi and Mrowietz, Clinics Dermatology 2008, 26,
522-526); asthma and chronic obstructive pulmonary diseases (Joshi
et al., WO 2005/023241 and US 2007/0027076); cardiac insufficiency
including left ventricular insufficiency, myocardial infarction and
angina pectoris (Joshi et al., WO 2005/023241; Joshi et al., US
2007/0027076); mitochondrial and neurodegenerative diseases such as
Parkinson's disease, Alzheimer's disease, Huntington's disease,
retinopathia pigmentosa and mitochondrial encephalomyopathy (Joshi
and Strebel, WO 2002/055063, US 2006/0205659, U.S. Pat. No.
6,509,376, U.S. Pat. No. 6,858,750, and U.S. Pat. No. 7,157,423);
transplantation (Joshi and Strebel, WO 2002/055063, US
2006/0205659, U.S. Pat. No. 6,359,003, U.S. Pat. No. 6,509,376, and
U.S. Pat. No. 7,157,423; and Lehmann et al, Arch Dermatol Res 2002,
294, 399-404); autoimmune diseases (Joshi and Strebel, WO
2002/055063, U.S. Pat. No. 6,509,376, U.S. Pat. No. 7,157,423, and
US 2006/0205659) including multiple sclerosis (MS) (Joshi and
Strebel, WO 1998/52549 and U.S. Pat. No. 6,436,992; Went and
Lieberburg, US 2008/0089896; Schimrigk et al., Eur J Neurology
2006, 13, 604-610; and Schilling et al., Clin Experimental
Immunology 2006, 145, 101-107); ischemia and reperfusion injury
(Joshi et al., US 2007/0027076); AGE-induced genome damage
(Heidland, WO 2005/027899); inflammatory bowel diseases such as
Crohn's disease and ulcerative colitis; arthritis; and others
(Nilsson et al., WO 2006/037342 and Nilsson and Muller, WO
2007/042034). All these indications and diseases can be treated or
prevented with the combination treatment of the present
invention.
[0010] Fumaderm.RTM., an enteric coated tablet containing a salt
mixture of monoethyl fumarate and dimethylfumarate, which is
rapidly hydrolyzed to monomethyl fumarate, was approved in Germany
in 1994 for the treatment of psoriasis. Fumaderm.RTM. is dosed TID
with 1-2 grams/day administered for the treatment of psoriasis.
[0011] Fumaric acid derivatives (Joshi and Strebel, WO 2002/055063,
US 2006/0205659, and U.S. Pat. No. 7,157,423 (amide compounds and
protein-fumarate conjugates); Joshi et al., WO 2002/055066 and
Joshi and Strebel, U.S. Pat. No. 6,355,676 (mono and dialkyl
esters); Joshi and Strebel, WO 2003/087174 (carbocyclic and
oxacarbocylic compounds); Joshi et al., WO 2006/122652
(thiosuccinates); Joshi et al., US 2008/0233185 (dialkyl and diaryl
esters) and salts (Nilsson et al., US 2008/0004344) have been
developed in an effort to overcome the deficiencies of current
therapy with fumaric acid esters. Controlled release pharmaceutical
compositions comprising fumaric acid esters are disclosed by
Nilsson and Willer, WO 2007/042034. Prodrugs are described by
Nielsen and Bundgaard, J Pharm Sci 1988, 77(4), 285-298 and in
WO2010/022177.
DETAILED DESCRIPTION
[0012] Preferably, the term "alkyl" is specifically intended to
include groups having any degree or level of saturation, i.e.,
groups having exclusively single carbon-carbon bonds, groups having
one or more double carbon-carbon bonds, groups having one or more
triple carbon-carbon bonds, and groups having combinations of
single, double, and triple carbon-carbon bonds. Where a specific
level of saturation is intended, the terms alkanyl, alkenyl, and
alkynyl are used. In certain embodiments, an alkyl group can have
from 1 to 20 carbon atoms (Ci-20) in certain embodiments, from 1 to
10 carbon atoms (Ci-I0), in certain embodiments from 1 to 8 carbon
atoms (C]-8), in certain embodiments, from 1 to 6 carbon atoms
(C1-6), in certain embodiments from 1 to 4 carbon atoms (C1-4), and
in certain embodiments, from 1 to 3 carbon atoms (Ci-3). The term
"alkoxy" refers to a group O-alkyl, wherein alkyl has the meaning
indicated above. The term "perfluoroalkyl" refers to an alkyl group
wherein all hydrogen atoms have been replaced by fluoro.
[0013] "Treating" or "treatment" of any disease refers to
reversing, alleviating, arresting, or ameliorating a disease or at
least one of the clinical symptoms of a disease, reducing the risk
of acquiring a disease or at least one of the clinical symptoms of
a disease, inhibiting the progress of a disease or at least one of
the clinical symptoms of the disease or reducing the risk of
developing a disease or at least one of the clinical symptoms of a
disease. "Treating" or "treatment" also refers to inhibiting the
disease, either physically, (e.g., stabilization of a discernible
symptom), physiologically, (e.g., stabilization of a physical
parameter), or both, and to inhibiting at least one physical
parameter that may or may not be discernible to the patient. In
certain embodiments, "treating" or "treatment" refers to delaying
the onset of the disease or at least one or more symptoms thereof
in a patient which may be exposed to or predisposed to a disease
even though that patient does not yet experience or display
symptoms of the disease.
[0014] "Therapeutically effective amount" refers to the amount of a
compound that, when administered to a subject for treating a
disease, or at least one of the clinical symptoms of a disease, is
sufficient to affect such treatment of the disease or symptom
thereof. The "therapeutically effective amount" may vary depending,
for example, on the compound, the disease and/or symptoms of the
disease, severity of the disease and/or symptoms of the disease or
disorder, the age, weight, and/or health of the patient to be
treated, and the judgment of the prescribing physician. An
appropriate amount in any given instance may be ascertained by
those skilled in the art or capable of determination by routine
experimentation.
[0015] "Therapeutically effective dose" refers to a dose that
provides effective treatment of a disease or disorder in a patient.
A therapeutically effective dose may vary from compound to
compound, and from patient to patient, and may depend upon factors
such as the condition of the patient and the route of delivery. A
therapeutically effective dose may be determined in accordance with
routine pharmacological procedures known to those skilled in the
art.
[0016] Reference is now made in detail to certain embodiments of
compounds, compositions, and methods. The disclosed embodiments are
not intended to be limiting of the claims.
[0017] According to the present invention, strongly improved
treatment results are obtained in the treatment of autoimmune
and/or inflammatory diseases, when a ppar agonist and preferably a
ppar gamma agonist and an Nrf2 activator are used in the treatment
of the disease in combination as compared to the treatment with a
ppar gamma agonist or an Nrf2 activator, alone. Co-administration
of a ppar gamma agonist and an Nrf2 activator or an administration
of a fixed dose combination of a PPAR gamma agonists and an Nrf2
activator results in an improved therapeutic effect, which may be a
more than additive effect, compared to the administration of a PPAR
gamma agonist or Nrf2 activators, respectively, administered as
mono-therapy.
[0018] In particular, it has been found that the advantageous
therapeutic results in inflammatory and/or autoimmune diseases
resulting from use of compounds such as dexamethasone, having both
ppar gamma agonistic and Nrf2 activating effects, can be matched or
even surpassed by the combination treatment of the present
invention, wherein at least two individual and different compounds
having each either PPAR gamma agonistic or Nrf2 activating effects,
are employed. Thus, a combination treatment comprising at least one
PPAR gamma agonist, which may have no significant or only a minor
modulating or activating effect on Nrf2, and at least one Nrf2,
which may have no significant or only a minor modulating or
activating effect on ppar gamma, result in improved and synergistic
therapeutic effects, as compared to the administration of such PPAR
gamma agonist or such Nrf2 activator, respectively, administered as
mono-therapy. The synergistic effect is often more pronounced with
such combinations, where the agents employed are predominantly
either PPAR gamma agonists or Nrf2 activators, which each have no
significant activity on the respective other target. Nevertheless,
even in those cases where one or both of the agents display
significant PPAR gamma agonistic and Nrf2 activating effects at the
same time, such as in the case of dexamethasone and
15-deoxy-delta(12,14)-prostaglandin J(2) (15d-PGJ(2)), the
combination treatment according to the present invention can lead
to improved treatment results over the mono-therapy. A compound
having dual effects on the targets PPAR gamma and Nrf2, is unlikely
to show an ideally distributed effect on both targets for
therapeutic use. By applying the present invention each target can
be addressed individually and activated with suitable and
appropriate concentrations of the respective agents.
[0019] Thus, embodiments are preferred, wherein at least one agent
is not both, PPAR gamma agonist and Nrf2 activator at the same
time.
[0020] Combination treatments and fixed dose combinations according
to the present invention are preferred, which comprise at least two
different agents having either PPAR gamma agonistic or Nrf2
activating effects at the concentration used in the
combination.
[0021] The present invention relates to combination treatments,
compositions containing the inventive combination of agents and
related fixed-dose combinations, wherein the ppar agonist, such as
the ppar gamma agonist and the Nrf2 activator are different
compounds which are preferably not belonging to the same chemical
class. Throughout this specification, the use of a singular
includes also the plural, if not indicated otherwise.
[0022] Preferred PPAR agonists are compounds having a PPAR gamma
agonistic effect without significantly activating Nrf2. These are
preferably compounds having no ability to form covalent bonds with
organic thiol groups under physiological conditions, such as with
glutathione. Thus, preferred PPAR gamma agonists are compounds
that, contrary to e.g. 15-deoxy-delta(12,14)-prostaglandin J(2)
(15d-PGJ(2)), cannot bind covalently through e.g. Michael addition
reaction to the PPA receptor. Most preferred PPAR agonists are
glitazones, glitazars and sartans.
[0023] Ppar agonists are ppar activators (e.g., ppar gamma agonist
are ppar gamma activators). The definition "ppar agonist" and "ppar
gamma agonist" according to the present invention preferably
includes such agonists, i.e., compounds, that directly bind to the
ppa receptor and have an agonistic, i.e. activating effect, as well
as so-called physiological ppar agonists and physiological ppar
gamma agonists, which do not necessarily bind to the ppar receptor,
but result in an activation of ppar through other pathways, such as
by increasing the concentration of endogenous ppar gamma agonist
15-deoxy-Delta(12,14)-prostaglandin J(2) (15d-PGJ(2).
[0024] A large number of natural and synthetic PPAR agonists are
known (e.g. see Michalik et al. (2006) Pharmacological Reviews
58:726-725; Gilde et al. (2003) Circulation Research 92(5): .delta.
18-524; Peraza et al. (2005) Toxicological Sciences 90(2):269-295;
and Desvergne & Wahli (1999) Endocrine Reviews 20(5):649-688).
Some of these known agonists are specific for a single PPAR
isotype, whilst others target multiple PPAR subtypes. PPAR agonists
are preferred, if the ppar agonist stronger activate ppar gamma or
ppar gamma and ppar alpha simultaneously, than other isoforms.
[0025] In one embodiment, the ppar agonist may be selected from the
group consisting of ppar gamma agonists, such as glitazones and
dual ppar alpha/gamma agonists, such as glitazars. In yet further
embodiments, the glitazone may be selected from the group
consisting of troglitazone, pioglitazone, rosiglitazone,
ciglitazone, englitazone, darglitazone, netoglitazone,
isaglitazone, MC-555, balaglitazone, rivoglitazone, and the like.
In yet further embodiments, the glitazar may be selected from the
group consisting of muraglitazar, naveglitazar, tesaglitazar,
ragaglitazar, reglitazar and farglitazar. In yet further
embodiments, ppar agonists are selected from berberine, K-111,
INT-131, MBX-102 (metaglidisen), MBX-2044, FK614, GSK-376501, GW
1929, S26948, psi-baptigenin and the like, such as those disclosed
in US5002953, US4687777 and US5965584. Pioglitazone and
rosiglitazone are very preferred and most preferred are
pioglitazone hydrochloride and rosiglitazone maleate.
[0026] In a further preferred embodiment of the present inventions,
ppar gamma agonists are selected from the class of statins or
HMG-CoA reductase inhibitors, preferably selected from
atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin,
simvastatin, mevastatin and pitavastatin. Statins are a class of
drugs used to lower cholesterol levels by inhibiting the enzyme
HMG-CoA reductase, which plays a central role in the production of
cholesterol in the liver. Increased cholesterol levels have been
associated with cardiovascular diseases, and statins are therefore
used in the prevention of these diseases. Statins have also been
suggested for the treatment of multiple sclerosis (e.g. US
2004/0013643). Although statins are believed to activate ppar gamma
only indirectly (Circ Res. 2007; 100:1442-1451), as physiological
ppar gamma agonists they are included in the definition of ppar
gamma agonists for the purposes of the present invention.
[0027] In a further preferred embodiment of the present inventions,
ppar gamma agonists are selected from the chemical classes of
sartans, also known as angiotensin II receptor antagonists,
angiotensin receptor blockers (ARBs) or AT1-receptor antagonists.
Sartans, such as valsartan, losartan, azilsartan, irbesartan,
olmesartan, telmisartan, candesartan and eprosartan are a group of
pharmaceuticals which modulate the renin-angiotensin-aldosterone
system. Preferred sartans used in the present invention are
selected from losartan, irbesartan, telmisartan and candesartan,
which have shown to bind to and activate ppar gamma (Drug
Development Research 67:579-581, 2006). Treatment with sartans has
been suggested to improve multiple sclerosis. The sartanes are
predominantly used in the treatment of hypertension, diabetic
nephropathy (kidney damage due to diabetes) and chronic kidney
disease as well as congestive heart failure and are also preferably
employed for these diseases and conditions when combined with Nrf2
activators according to the present invention.
[0028] In a further preferred embodiment of the present inventions,
ppar gamma agonists are selected from nonsteroidal
anti-inflammatory drugs (NSAIDs) having ppar gamma activating
properties, preferably indomethacin, flufenamic acid, fenoprofen
and ibuprofen (The Journal of Biological Chemistry, vol. 272, no.
6, issue 7, pp. 3406-3410, 1997). NSAIDs are included in the
definition of PPAR gamma agonists for the purposes of the present
invention as they may bind directly to the PPAR or act as a
physiological PPAR gamma agonist. In one embodiment, NSAIDs other
than aspirin are preferred.
[0029] The group of NSAIDs comprises the following compounds:
Salicylates, such as aspirin (acetylsalicylic acid), diflunisal,
salsalate, propionic acid derivatives such as ibuprofen,
dexibuprofen, naproxen, fenoprofen, ketoprofen, dexketoprofen,
flurbiprofen, oxaprozin, loxoprofen, acetic acid derivatives such
asindomethacin, sulindac, etodolac, ketorolac, diclofenac,
nabumetone, enolic acid (oxicam) derivatives such as piroxicam,
meloxicam, tenoxicam, droxicam, lornoxicam, isoxicam, fenamic acid
derivatives (fenamates) such as mefenamic acid, meclofenamic acid,
flufenamic acid, tolfenamic acid, selective cox-2 inhibitors
(coxibs) such as celecoxib, rofecoxib, valdecoxib, parecoxib,
lumiracoxib, etoricoxib, firocoxib, sulphonanilides such as
nimesulide and others such as licofelone, lysine clonixinate.
[0030] Nrf2-activating compounds can be classified based on their
chemical structures: Diphenols, Michael reaction acceptors,
isothiocyanates, thiocarbamates, trivalent arsenicals,
1,2-dithiole-3-thiones, hydroperoxides, vicinal dimercaptans, heavy
metals, and polyenes. Moreover, Nrf2 activators (i) all are
chemically reactive; (ii) nearly all are electrophiles; (iii) most
are substrates for glutathione transferases; and (iv) all can
modify sulfhydryl groups by alkylation, oxidation, or reduction
(PNAS Feb. 17, 2004 vol. 101 no. 7 2040-2045, Mol. Cell. Biol.
2009, 29(2):493). The activity of the compounds can be identified
by known methods.
[0031] Preferred Nrf2 activators are compounds without significant
PPAR gamma agonistic effect. These are preferably compounds, which
may or may not bind covalently to the PPA receptor, but are not
able to change the conformation of the PPAR and preferably the PPA
gamma receptor to an extent that this would result in an activation
of the PPA receptor. According to the present invention these
preferred Nrf2 activators are small and of low molecular weight.
These compounds are preferably lacking the structural elements to
bind to the PPA receptor non-covalently with the result of a change
of conformation and activation of the PPA receptor. In a preferred
embodiment, the Nrf2 activators may be able to bind covalently to
the PPA receptor, e.g. via a Michael reaction with a thiol group of
the PPA receptor, without resulting in a conformation change of the
PPA receptor. Due to their limited size however, these preferred
Nrf2 activators may not prevent PPAR agonists, and in particular
PPAR gamma agonists, especially glitazones such as pioglitazone or
rosiglitazone from binding non-covalently to the PPA receptor with
the result of a conformation change.
[0032] In a very preferred example, the covalent binding of a Nrf2
activator such as monomethyl hydrogen fumarate or dimethyl fumarate
and the non-covalent binding of a PPAR gamma agonist such as a
glitazone, like pioglitazone or rosiglitazone leads to synergistic
and strongly improved therapeutic results.
[0033] In one embodiment, the preferred are Nrf2 activators
selected from organic compounds having not more than one or two 5-
or 6-membered carbocyclic rings or 5- or 6-membered heterocyclic
rings having 1, 2 or 3 N--, O or S-atoms as ring atoms which may be
fused to each other or preferably no or only one carbocyclic or
heterocyclic ring and/or less than 35, preferably less than 30,
more preferably less than 25 and most preferably less than 20 or
even less than 15 or less than 10 carbon atoms and/or have a
molecular weight of less than 400, preferably less than 300 and
most preferably less than 200 g/mol or less than 170 g/mol and are
selected from the chemical classes of Michael reaction acceptors,
phenols, diphenols, chalcones, isothiocyanates, thiocarbamates,
quinones, naphtoquinones and 1,2 dithiole-3-thiones, wherein one or
more, preferably up to seven H-atoms may be substituted by linear
or branched alkyl and perfluoroalkyl, such as methyl, ethyl,
trifluoromethyl, halogen such as Br, Cl, F or I, hydroxy, alkoxy
and perfluoroalkoxy, such as methoxy, ethoxy, trifluoromethoxy,
cyano and nitro.
[0034] In cases where compounds of the chemical class of quinones
are employed as Nrf2 activator, the respective hydroquinones can be
used alternatively. However the respective oxidized form, i.e. the
respective quinone, is preferred. The Nrf2 activity can be
determined according to e.g. JALA 2008; 13: 243-248. Bardoxolone
methyl and derivatives are described in U.S. Pat. No. 8,129,429,
US7435755 and US2009/0060873. Amorphous Bardoxolone methyl and
suitable formulations are disclosed in WO2010/093944.
[0035] Very preferred Nrf2 activators are capable of provoking or
inducing a stimulated and/or increased nuclear translocation of
Nrf2 protein and are:
[0036] a) selected from the group of Michael reaction acceptors,
phenols, diphenols, chalcones, isothiocyanates, thiocarbamates,
quinones, naphtoquinones and 1,2 dithiole-3-thiones; and
[0037] b) contain less than 35 carbon atoms; and/or
[0038] c) have a molecular weight of less than 600 g/mol;
and/or
[0039] d) contain no or not more than one or two fused or
monocyclic 5- or 6-membered carbocyclic or heterocyclic rings,
having 1, 2 or 3 ring atoms selected from N, O or S.
[0040] In these preferred Nrf2 activators, one or more, preferably
up to seven H-atoms may be substituted preferably by linear or
branched alkyl and perfluoroalkyl, such as methyl, ethyl,
trifluoromethyl, halogen such as Br, Cl, F or I, hydroxy, alkoxy
and perfluoroalkoxy, such as methoxy, ethoxy, trifluoromethoxy,
cyano and nitro.
[0041] More preferred embodiments of these Nrf2 activators contain
no ring system or only one or two rings, which may be carbocyclic
and/or heterocyclic rings. Even more preferred Nrf2 activators
contain less than 30, more preferably less than 25 and most
preferably less than 20 or even less than 15 or less than 10 carbon
atoms and/or have a molecular weight of less than 400 g/mol and
more preferably less than 300 g/mol and most preferably less than
200 g/mol or less than 170 g/mol. Further preferred Nrf2 activators
bind covalently to Keapl protein, preferably via an S-atom of the
proteins amino acids.
[0042] Preferred Michael reaction acceptors are ketones, aldehydes,
carboxylic acid esters and carboxylic acid amides all of which
being alpha, beta unsaturated.
[0043] More preferred Nrf2 activators are the compounds A to Z
given below, including their tautomers and stereoisomers:
##STR00001## ##STR00002## ##STR00003##
Wherein the individual radicals have the meaning given below:
R.sup.1 H, OH, Hal, CN, A, perfluoroalkyl, perfluoroalkoxy R.sup.2
H, OH, A, alkoxy, amino R.sup.3 H, alkyl R.sup.4 H, OH, alkyl,
alkoxy R.sup.5 H, OH, A, alkoxy R.sup.6 H, A, alkoxy, aryl, het
R.sup.7 H, OH, A, alkoxy
R.sup.8 A
X O, NH, S
R.sup.9 Het
[0044] m 1, 2 n 1, 2, 3
[0045] Hal is F, Cl, Br or I, preferably F or Cl.
[0046] A is preferably alkyl which denotes a straight or branched
carbon chain having 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 carbon
atoms. Alkyl preferably denotes methyl, ethyl, propyl, isopropyl,
butyl, isobutyl, sec-butyl or tert-butyl, furthermore also pentyl,
1-, 2- or 3-methylbutyl, 1,1-, 1,2- or 2,2-dimethylpropyl,
1-ethylpropyl, hexyl, 1-, 2-, 3- or 4-methylpentyl, 1,1-, 1,2-,
1,3-, 2,2-, 2,3- or 3,3-dimethylbutyl, 1- or 2-ethylbutyl,
1-ethyl-1-methylpropyl, 1-ethyl-2-methylpropyl, 1,1,2- or
1,2,2-trimethylpropyl. Alternatively, A denotes cycloalkyl having
3, 4, 5, 6 or 7 carbon atoms or branched or linear alkyl having 2
to 12 C-atoms, wherein one or more, preferably 1 to 7 H-atoms may
be replaced by Hal, alkyl, alkoxy, cycloalkyl, phenyl, p-, m-
o-hydroxyphenyl, p-, m- o-alkoxyphenyl, N(R.sup.3).sub.2, OH,
CO.sub.2H, CF.sub.3 and/or wherein one or more, preferably 1 to 7
non-adjacent CH.sub.2-groups may be replaced by --O--, --S--,
--SO--, --NR.sup.3--, --CO--, --CO.sub.2--, --CH.dbd.CH--S-- and/or
--CH.dbd.CH--. Cycloalkyl preferably denotes cyclopropyl,
cyclobutyl, cyclopentyl, cyclohexyl or cycloheptyl.
[0047] Alkoxy is preferably a group O-alkyl, wherein alkyl is
defined as above. Preferably, alkoxy denotes a group
--O--(CH.sub.2).sub.n--CH.sub.3, wherein n is 0, 1, 2, 3 or 4, more
preferably methoxy or ethoxy.
[0048] Perfluoroalkyl preferably denotes a straight or branched
alkyl chain having 1 to 8 carbon atoms, preferably 1 to 6 carbon
atoms, and wherein all hydrogen atoms are replaced by F atoms,
preferably, for example, trifluoromethyl or pentafluoroethyl.
[0049] Perfluoroalkoxy is preferably a group O-perfluoroalkyl,
wherein perfluoroalkyl is defined as above. Perfluoroalkoxy
preferably denotes OCF.sub.3.
[0050] Amino denotes preferably the group --NR'R'' where each R',
R'' is independently hydrogen or alkyl. The group --NR'R'' can also
form a cyclic group selected from piperidinyl, piperazinyl,
pyrrolyl or morpholinyl, wherein one, two or three H atoms may be
substituted by alkyl, such as methyl. In one embodiment, amino
denotes dialkylamino, wherein alkyl has the meaning given above and
is preferably dimethylamino.
[0051] Aryl preferably denotes a monocyclic or bicyclic, aromatic
carbocyclic ring having 6 to 14 carbon atoms, which is
unsubstituted or monosubstituted, disubstituted or trisubstituted
by F, Cl, Br, CF.sub.3, OCF.sub.3, NO.sub.2, CN, alkyl, alkoxy, OH,
amino, CO-amino, NHCO-alkyl, CO-alkyl, CO-alkoxy, SO.sub.2-alkyl,
SO.sub.2-amino. Most preferably, aryl denotes unsubstituted or
monosubstituted phenyl.
[0052] Het preferably denotes, notwithstanding further
substitutions, a 6 to 14 membered monocyclic or bicyclic saturated,
unsaturated or aromatic heterocyclic ring system containing 1 or 2
heteroatoms selected from N, O and S, which is unsubstituted or
monosubstituted, disubstituted or trisubstituted by F, Cl, Br,
CF.sub.3, OCF.sub.3, NO.sub.2, CN, alkyl, alkoxy, OH, amino,
CO-amino, NHCO-alkyl, CO-alkyl, CO-alkoxy, SO.sub.2-alkyl,
SO.sub.2-amino. More preferably, Het is 2- or 3-furyl, 2- or
3-thienyl, 1-, 2- or 3-pyrrolyl, 1-, 2-, 4- or 5-imidazolyl, 1-,
3-, 4- or 5-pyrazolyl, 2-, 4- or 5-oxazolyl, 3-, 4- or
5-isoxazolyl, 2-, 4- or 5-thiazolyl, 3-, 4- or 5-isothiazolyl, 2-,
3- or 4-pyridyl, 2-, 4-, 5- or 6-pyrimidinyl, furthermore
preferably 1,2,3-triazol-1-, -4- or -5-yl, 1,2,4-triazol-1-, -3- or
-5-yl, 1- or 5-tetrazolyl, 1,2,3-oxadiazol-4- or -5-yl,
1,2,4-oxadiazol-3- or -5-yl, 1,3,4-thiadiazol-2- or -5-yl,
1,2,4-thiadiazol-3- or -5-yl, 1,2,3-thiadiazol-4- or -5-yl, 3- or
4-pyridazinyl, pyrazinyl, 1-, 2-, 3-, 4-, 5-, 6- or 7-indolyl,
indazolyl, 4- or 5-isoindolyl, 1-, 2-, 4- or 5-benzimidazolyl, 1-,
3-, 4-, 5-, 6- or 7-benzopyrazolyl, 2-, 4-, 5-, 6- or
7-benzoxazolyl, 3-, 4-, 5-, 6- or 7-benzisoxazolyl, 2-, 4-, 5-, 6-
or 7-benzothiazolyl, 2-, 4-, 5-, 6- or 7-benzisothiazolyl, 4-, 5-,
6- or 7-benz-2,1,3-oxa-diazolyl, 2-, 3-, 4-, 5-, 6-, 7- or
8-quinolyl, 1-, 3-, 4-, 5-, 6-, 7- or 8-isoquinolyl, 3-, 4-, 5-,
6-, 7- or 8-cinnolinyl, 2-, 4-, 5-, 6-, 7- or 8-quinazolinyl, 5- or
6-quinoxalinyl, 2-, 3-, 5-, 6-, 7- or 8-2H-benzo-1,4-oxazinyl,
furthermore preferably 1,3-benzodioxol-5-yl, 1,4-benzodioxane-6-yl,
2,1,3-benzothiadiazol-4- or -5-yl or 2,1,3-benzoxadiazol-5-yl. The
heterocyclic radicals may also be partially or fully hydrogenated.
Het can thus also denote, for example, 2,3-dihydro-2-, -3-, -4- or
-5-furyl, 2,5-dihydro-2-, -3-, -4- or -5-furyl, tetrahydro-2- or
-3-furyl, 1,3-dioxolan-4-yl, tetrahydro-2- or -3-thienyl,
2,3-dihydro-1-, -2-, -3-, -4- or -5-pyrrolyl, 2,5-dihydro-1-, -2-,
-3-, -4- or -5-pyrrolyl, 1-, 2- or 3-pyrrolidinyl, tetrahydro-1-,
-2- or -4-imidazolyl, 2,3-dihydro-1-, -2-, -3-, -4- or
-5-pyrazolyl, tetrahydro-1-, -3- or -4-pyrazolyl, 1,4-dihydro-1-,
-2-, -3- or -4-pyridyl, 1,2,3,4-tetrahydro-1-, -2-, -3-, -4-, -5-
or -6-pyridyl, 1-, 2-, 3- or 4-piperidinyl, 2-, 3- or
4-morpholinyl, tetrahydro-2-, -3- or -4-pyranyl, 1,4-dioxaneyl,
1,3-dioxane-2-, -4- or -5-yl, hexahydro-1-, -3- or -4-pyridazinyl,
hexahydro-1-, -2-, -4- or -5-pyrimidinyl, 1-, 2- or 3-piperazinyl,
1,2,3,4-tetrahydro-1-, -2-, -3-, -4-, -5-, -6-, -7- or -8-quinolyl,
1,2,3,4-tetrahydro-1-, -2-, -3-, -4-, -5-, -6-, -7- or
-8-isoquinolyl, 2-, 3-, 5-, 6-, 7- or
8-3,4-dihydro-2H-benzo-1,4-oxazinyl, furthermore preferably
2,3-methylenedioxyphenyl, 3,4-methylenedioxyphenyl,
2,3-ethylenedioxyphenyl, 3,4-ethylenedioxyphenyl,
3,4-(difluoromethylenedioxy)phenyl, 2,3-dihydrobenzofuran-5- or
-6-yl, 2,3-(2-oxomethylenedioxy)phenyl or also
3,4-dihydro-2H-1,5-benzodioxepin-6- or -7-yl, furthermore
preferably 2,3-dihydrobenzofuranyl or 2,3-dihydro-2-oxofuranyl.
Very preferably, heteroaryl is unsubstituted or monosubstituted
2-pyridyl, pyrimidyl or imidazolyl.
[0053] R.sup.1 is preferably H, OH, F, methyl, methoxy,
trifluoromethoxy.
[0054] R.sup.2 is preferably H, OH, alkoxy, such as methoxy,
OCH.sub.2CH.sub.2-phenyl.
[0055] R.sup.3 is preferably H or alkyl, preferably H, methyl or
tert-butyl.
[0056] R.sup.4 is preferably H, OH, alkoxy, such as methoxy.
[0057] R.sup.5 is preferably H or A.
[0058] R.sup.6 is preferably H or Het.
[0059] R.sup.7 is preferably (CH.sub.2).sub.mCOR.sup.2,
(CH.sub.2).sub.mCOR.sup.2, O(CH.sub.2).sub.mCOR.sup.2 or
O(CH.sub.2).sub.mCOR.sup.2.
[0060] R.sup.8 is preferably allyl or a group selected from
(C(R.sup.3).sub.2).sub.qS-alkyl or
(C(R.sup.3).sub.2).sub.qSO-alkyl, wherein q is 1, 2, 3, 4, 5, 6, 7,
8, 9, 10, 11 or 12.
[0061] Preferred Nrf2 activators are selected from: Chalcone
derivatives as disclosed in J. Med. Chem., 2011, 54 (12), pp
4147-4159, such as 2-trifluoromethyl-2'-methoxychalcone, auranofin,
ebselen, 1,2-naphthoquinone, cynnamic aldehyde, caffeic acid and
its esters, curcumin, reservatrol, artesunate,
tert-butylhydroquinone, and -quinone, (tBHQ, tBQ), vitamins K1, K2
and K3, preferably menadione, fumaric acid esters, i.e. fumaric
acid mono- and/or diester which is preferably selected from the
group of monoalkyl hydrogen fumarate and dialkyl fumarate, such as
monomethyl hydrogen fumarate, dimethyl fumarate, monoethyl hydrogen
fumarate, and diethyl fumarate, 2-cyclopentenones, ethacrynic acid
and its alkyl esters, bardoxolone methyl (methyl
2-cyano-3,12-dioxooleana-1,9(11)dien-28-oate) (CDDO-Me, RTA 402),
ethyl 2-cyano-3,12-dioxooleana-1,9(11)dien-28-oate,
2-cyano-3,12-dioxooleana-1,9(11)dien-28-oic acid (CDDO), 1
[2-Cyano-3,12-dioxooleana-1,9(11)-dien-28-oyl]imidazole (CDDO-Im),
(2-cyano-N-methyl-3,12-dioxooleana-1,9(11)-dien-28 amide
(CDDO-methyl amide, CDDO-MA), isothiocyanate such as sulforaphane,
1,2-dithiole-3-thione such as oltipraz,
3,5-di-tert-butyl-4-hydroxytoluene, 3-hydroxycoumarin,
4-hydroxynonenal, 4-oxononenal, malondialdehyde, (E)-2-hexenal,
capsaicin, allicin, allylisothiocyanate, 6-methylthiohexyl
isothiocyanate, 7-methylthioheptyl isothiocyanate, sulforaphane,
8-methylthiooctyl isothiocyanate, corticosteroids, such as
dexamethasone, 8-iso prostaglandin A2, alkyl pyruvate, such as
methyl and ethyl pyruvate, diethyl or dimethyl oxaloproprionate,
2-acetamidoacrylate, methyl or ethyl-2-acetamidoacrylate,
hypoestoxide, parthenolide, eriodictyol, 4-Hydroxy-2-nonenal,
4-oxo-2nonenal, geranial, zerumbone, aurone, isoliquiritigenin,
xanthohumol, [10]-Shogaol, eugenol, 1'-acetoxychavicol acetate,
allyl isothiocyanate, benzyl isothiocyanate, phenethyl
isothiocyanate, 4-(Methylthio)-3-butenyl isothiocyanate and
6-Methylsulfinylhexyl isothiocyanate, ferulic acid and its esters,
such as ferulic acid ethyl ester, and ferulic acid methyl ester,
sofalcone, 4-methyl daphnetin, imperatorin, auraptene, poncimarin,
bis[2-hydroxybenzylidene]acetones, alicylcurcuminoid, 4-bromo
flavone, .beta.-naphthoflavone, sappanone A, aurones and its
corresponding indole derivatives such as
benzylidene-indolin-2-ones, perillaldehyde, quercetin, fisetin,
koparin, genistein, tanshinone HA, BHA, BHT, PMX-290, AL-1, avicin
D, gedunin, fisetin, andrographolide, tricyclic bis(cyano enone)
TBE-31
[(.+-.)-(4bS,8aR,10aS)-10a-ethynyl-4-b,8,8-trimethyl-3,7-dioxo-3,4-b,7,8,-
8a,9,10,10a-octahydrophenanthrene-2,6-dicarbonitrile], MCE-1, MCE5,
TP-225, ADT as referred to in in Medicinal Research Reviews, 32,
No. 4, 687-726, 2012, and the respective quinone or hydroquinone
forms of the aforementioned quinone and hydroquinone derivatives
and stereoisomers, tautomers or pharmacologically active
derivatives of the aforementioned agents.
[0062] Very preferred Nrf2 activators are selected from: carnosic
acid, 2-naphthoquinone, cynnamic aldehyde, caffeic acid and its
esters, curcumin, reservatrol, artesunate, tert-butylhydroquinone,
vitamins K1, K2 and K3, fumaric acid esters, i.e. fumaric acid
mono- and/or diester which is preferably selected from the group of
monoalkyl hydrogen fumarate and dialkyl fumarate, such as
monomethyl hydrogen fumarate, dimethyl fumarate, monoethyl hydrogen
fumarate, and diethyl fumarate, isothiocyanate such as
sulforaphane, 1,2-dithiole-3-thione such as oltipraz,
3,5-di-tert-butyl-4-hydroxytoluene, 3-hydroxycoumarin,
4-hydroxynonenal, 4-oxononenal, malondialdehyde, (E)-2-hexenal,
capsaicin, allicin, allylisothiocyanate, 6-methylthiohexyl
isothiocyanate, 7-methylthioheptyl isothiocyanate, sulforaphane,
8-methylthiooctyl isothiocyanate, 8-iso prostaglandin A2, alkyl
pyruvate, such as methyl and ethyl pyruvate, diethyl or dimethyl
oxaloproprionate, 2-acetamidoacrylate, methyl or
ethyl-2-acetamidoacrylate, hypoestoxide, parthenolide, eriodictyol,
4-Hydroxy-2-nonenal, 4-oxo-2nonenal, geranial, zerumbone, aurone,
isoliquiritigenin, xanthohumol, [10]-Shogaol, eugenol,
1'-acetoxychavicol acetate, allyl isothiocyanate, benzyl
isothiocyanate, phenethyl isothiocyanate, 4-(Methylthio)-3-butenyl
isothiocyanate and 6-Methylsulfinylhexyl isothiocyanate and the
respective quinone or hydroquinone forms of the aforementioned
quinone and hydroquinone derivatives, and stereoisomers, tautomers
or pharmacologically active derivatives of the aforementioned
agents. Very preferred Nrf2 activators are Michael reaction
acceptors such as dimethylfumarate, monomethyl hydrogen fumarate
isothiocyanates and 1,2-dithiole-3-thiones. In another embodiment,
very preferred Nrf2 activators are selected from monomethyl
hydrogen fumarate, dimethyl fumarate, oltipraz, 1,2-naphthoquinone,
tert-butylhydroquinone, methyl or ethyl pyruvate,
3,5-di-tert-butyl-4-hydroxytoluene, diethyl and dimethyl
oxaloproprionate, hypoestoxide, parthenolide, eriodictyol,
4-Hydroxy-2-nonenal, 4-oxo-2nonenal, geranial, zerumbone, aurone,
isoliquiritigenin, xanthohumol, [10]-Shogaol, eugenol,
1'-acetoxychavicol acetate, allyl isothiocyanate, benzyl
isothiocyanate, phenethyl isothiocyanate, 4-(Methylthio)-3-butenyl
isothiocyanate and 6-Methylsulfinylhexyl isothiocyanate. It is
particularly advantageous that the use of the PPAR gamma agonist
and the Nrf2 activator according to the present invention may allow
for the maximum dosage of each agent when used in mono-therapy,
which result in maximal therapeutic effect. No or only very limited
increase in adverse side effects known for the individual PPAR
gamma agonist or the Nrf2 activator can be observed. It may also be
advantageous to reduce the dose of one or both of the agents
employed in the combination treatment of the present invention.
Thus, side effects that may be observed in mono-therapy with the
agents may be avoided or reduced. Throughout the specification, the
term "pharmacologically active derivatives" denotes preferably
salts, amides and esters, such as alkylesters including methyl and
ethyl esters, of pharmacologically active acids and alkanoic acid
esters and ethers of pharmocologically active alcohols, such as
acetic acid esters and methyl ethers as well as alkanoic acid
amides of pharmocologically active amines, such as the respective
acetic acid amide.
[0063] The combination treatment of the present invention can be
further combined with treatments and medicaments that are generally
used in the various indications as a standard treatment. In the
treatment of multiple sclerosis for example, the combination
treatment of the present invention can be further combined with
interferon, such as interferon beta 1b or interferon beta 1a
(Rebif, Avonex) or glatiramer acetate (Copaxone), a sphingosine
1-phosphate receptor modulator, such as Fingolimod (Gilenya) and/or
methotrexate. The combination treatment of the present invention
can be further combined with RXR specific ligands, such as
9-cis-retinoic acid (RA) in order to obtain even further improved
results, particularly in the treatment of psoriasis.
[0064] The combination therapy according to the present invention
may be administered as a simultaneous or sequential regimen, also
referred to as co-administration. When administered sequentially,
the combination may be administered in two or more administrations.
It is also possible to combine any PPAR gamma agonist with an Nrf2
activator in a unitary dosage form for simultaneous or sequential
administration to a patient.
[0065] In general, for compositions containing fumaric acid esters,
an administration twice daily (BID) or thrice daily (TID) is
preferred. The dosages of the individual agents are adjusted
accordingly.
[0066] Co-administration of a PPAR gamma agonist with an Nrf2
activator according to the invention generally and preferably
refers to simultaneous or sequential administration of a PPAR gamma
agonist and an Nrf2 activator, such that therapeutically effective
amounts of the PPAR gamma agonist and the Nrf2 activator are both
present at the same time in the body of the patient.
[0067] Co-administration includes simultaneous administration and
administration of the an agent according to the invention before or
after administration of the other agent, for example,
administration of both agents according to the invention within
seconds, minutes, or hours. In one embodiment, the first agent is
administered, followed, after a period of hours, e.g., 0.25-12
hours, preferably 0.5 to 3 hours most preferably 1 to 2 hours), by
administration of the second agent.
[0068] The combination therapy and co-administration according to
the invention frequently provides "synergy" and "synergistic
effect", i.e. the therapeutic effect achieved when the PPAR gamma
agonist and the Nrf2 activator are used together is more than
additive, i.e. greater than the sum of the effects that result from
using each agent alone.
[0069] An appropriate dose of a PPAR agonist and an Nrf2 activator
or pharmaceutical composition comprising a PPAR agonist and an Nrf2
activator for use in the present invention, may be determined
according to any one of several well-established protocols. For
example, animal studies such as studies using mice, rats, dogs,
and/or monkeys may be used to determine an appropriate dose of a
pharmaceutical compound. Results from animal studies may be
extrapolated to determine doses for use in other species, such as
for example, humans.
[0070] In general, a preferred PPAR gamma agonist is administered
in combination with a preferred Nrf2 activator according to the
invention, preferably orally, in daily dosages of 0.01 mg to 50 mg
per kg body weight, dependent on the activity and safety of the
respective PPAR gamma agonist. If not indicated otherwise, the
dosages given above and below reflect the amount of free base of
the PPAR gamma agonist, even if used in form of the maleate or
another acid addition salt.
[0071] Preferred nrf 2 activators are bardoxolone methyl and
dialkyl fumarate such as dimethyl fumarate and diethyl
fumarate.
[0072] The dialkyl fumarates to be used according to the invention
are prepared by processes known in the art (see, for example, EP 0
312 697).
[0073] Preferably, the active ingredients, i.e. the agents, are
used for preparing oral preparations in the form of tablets,
micro-tablets, pellets or granulates, optionally in capsules or
sachets. Preparations in the form of micro-tablets or pellets,
optionally filled in capsules or sachets are preferred and are also
a subject matter of the invention. According to a preferred
embodiment, the size or the mean diameter, respectively, of the
pellets or micro-tablets is in the range from 300 to 2,000 .mu.m,
especially in the range of 500 or 1,000 .mu.m.
[0074] The oral preparations may be provided with an enteric
coating. Capsules may be soft or hard gelatine capsules.
[0075] The dialkyl fumarates used according to the invention may be
used alone or as a mixture of several compounds, optionally in
combination with the customary carriers and excipients. The amounts
to be used are selected in such a manner that the preparations,
such as tablets, obtained contain the active ingredient in an
amount corresponding to 10 to 300 mg of fumaric acid per dosage
unit.
[0076] Preferred preparations according to the invention contain a
total amount of 10 to 300 mg of dimethyl fumarate and/or diethyl
fumarate.
[0077] Fixed-dose combinations of a PPAR agonist and preferably a
PPAR gamma agonist with an Nrf2 activator are preferred. Fixed-dose
combinations of rosiglitazone with dimethyl fumarate and
rosiglitazone with bardoxolone methyl are particularly preferred.
Fixed-dose combinations of pioglitazone with dimethyl fumarate and
rosiglitazone with bardoxolone methyl are particularly
preferred.
[0078] In particular, rosiglitazone is preferably administered
according to the invention in form of its maleate in daily dosages
of 0.01 to 0.2 mg per kg body weight, more preferably in daily
dosages of 0.02 to 0.16 mg per kg body weight and most preferably
in daily dosages of 0.025 mg to 0.14 mg per kg body weight, such as
in daily dosages of 0.03 mg, 0.06 mg or 0.12 mg per kg body weight.
Daily oral dosages of 2 mg, 4 mg and 8 mg rosiglitazone per patient
are particularly preferred.
[0079] In particular, pioglitazone is preferably administered
according to the invention in form of its hydrochloride in daily
dosages of 0.05 to 1 mg per kg body weight, more preferably in
daily dosages of 0.1 to 0.8 mg per kg body weight and most
preferably in daily dosages of 0.15 mg to 0.7 mg per kg body
weight, such as in daily dosages of about 0.2 mg, about 0.4 mg or
about 0.6 mg per kg body weight. Daily oral dosages of about 15 mg,
about 30 mg and about 45 mg pioglitazone per patient are
particularly preferred.
[0080] In particular, ciglitazone or troglitazone are preferably
administered according to the invention in daily dosages of 1 to 20
mg per kg body weight, more preferably in daily dosages of 2 to 15
mg per kg body weight and most preferably in daily dosages of 3 mg
to 10 mg per kg body weight. Oral dosages are particularly
preferred.
[0081] In general, a preferred Nrf2 activator is administered in
combination with a preferred PPAR gamma agonist, preferably orally,
in daily dosages of 0.1 mg to 20 mg per kg body weight, dependent
on the activity and safety of the respective Nrf2 activator.
[0082] In particular, bardoxolone methyl is preferably administered
according to the invention in daily dosages of 0.1 to 3 mg per kg
body weight, more preferably in daily dosages of 0.2 to 2.5 mg per
kg body weight and most preferably in daily dosages of 0.3 mg to
2.2 mg per kg body weight, such as in daily dosages of about 0.35
mg, about 1.1 mg or about 2 mg per kg body weight. Daily oral
dosages of about 25 mg, about 75 mg and about 150 mg bardoxolone
methyl per patient are particularly preferred.
[0083] In particular, dimethyl fumarate is preferably administered
according to the invention in daily dosages of 1 to 20 mg per kg
body weight, more preferably in daily dosages of 2 to 15 mg per kg
body weight and most preferably in daily dosages of 3 mg to 12 mg
per kg body weight, such as in daily dosages of about 3.4 mg, about
7 mg or about 10 mg per kg body weight. Daily oral dosages of about
240 mg, about 480 mg and about 720 mg dimethyl fumarate per patient
are particularly preferred.
[0084] The ratio between the dosages of the PPAR gamma agonist and
the Nrf2 activator used in the combinations according to the
present invention, depends on the activity of the particular PPAR
gamma agonist and Nrf2 activator selected.
[0085] Daily oral dosages of 2 mg, 4 mg and 8 mg rosiglitazone per
patient are particularly preferred.
[0086] Daily oral dosages of about 20 mg, about 25 mg, about 75 mg
and about 150 mg bardoxolone methyl per patient are particularly
preferred. In case bardoxolone methyl is employed in amorphous
form, daily dosages of about 20 mg per patient are most
preferred.
[0087] Daily oral dosages of about 120 mg, about 240 mg, about 360
mg, about 480 mg, about 600 mg and about 720 mg dimethyl fumarate
per patient are particularly preferred.
[0088] If the Nrf2 activator is dimethyl fumarate, once or twice
daily dosing is preferred.
[0089] Preferred dosage forms and in particular oral dosage forms
such as tablets or capsules may contain:
[0090] For daily administration, dosage forms such as tablets or
capsules may contain preferably about 2 mg rosiglitazone and about
25 mg bardoxolone methyl or about 2 mg rosiglitazone and about 75
mg bardoxolone methyl or about 2 mg rosiglitazone and about 150 mg
bardoxolone methyl or about 4 mg rosiglitazone and about 25 mg
bardoxolone methyl or about 4 mg rosiglitazone and about 75 mg
bardoxolone methyl or about 4 mg rosiglitazone and about 150 mg
bardoxolone methyl or about 8 mg rosiglitazone and about 25 mg
bardoxolone methyl or about 8 mg rosiglitazone and about 75 mg
bardoxolone methyl or about 8 mg rosiglitazone and about 150 mg
bardoxolone methyl. Most preferably, a dosage form may contain
about 8 mg rosiglitazone and about 150 mg bardoxolone methyl.
[0091] For administration three times daily, preferred dosage forms
such as tablets or capsules may contain about 0.7 mg, preferably
about 0.67 mg, rosiglitazone and 240 mg dimethyl fumarate or about
1.3 mg, preferably about 1.33 mg, rosiglitazone and about 240 mg
dimethyl fumarate or about 2.7 mg preferably about 2.67 mg,
rosiglitazone and about 240 mg dimethyl fumarate or about 0.7 mg,
preferably about 0.67 mg, rosiglitazone and 120 mg dimethyl
fumarate or about 1.3 mg, preferably about 1.33 mg, rosiglitazone
and about 120 mg dimethyl fumarate or about 2.7 mg preferably about
2.67 mg, rosiglitazone and about 120 mg dimethyl fumarate. Most
preferably, a dosage form may contain about 2.7 mg preferably about
2.67 mg, rosiglitazone and about 240 mg dimethyl fumarate.
[0092] For administration two times daily, preferred dosage forms
such as tablets or capsules may contain about 1 mg rosiglitazone
and about 240 mg dimethyl fumarate or about 2 mg rosiglitazone and
about 240 mg dimethyl fumarate or about 4 mg rosiglitazone and
about 240 mg dimethyl fumarate.
[0093] For daily administration, dosage forms such as tablets or
capsules may contain preferably about 15 mg pioglitazone and about
25 mg bardoxolone methyl or about 15 mg pioglitazone and about 75
mg bardoxolone methyl or about 15 mg pioglitazone and about 150 mg
bardoxolone methyl or about 30 mg pioglitazone and about 25 mg
bardoxolone methyl or about 30 mg pioglitazone and about 75 mg
bardoxolone methyl or about 30 mg pioglitazone and about 150 mg
bardoxolone methyl or about 45 mg pioglitazone and about 25 mg
bardoxolone methyl or about 45 mg pioglitazone and about 75 mg
bardoxolone methyl or about 45 mg pioglitazone and about 150 mg
bardoxolone methyl. Most preferably, a dosage form may contain
about 45 mg pioglitazone and about 150 mg bardoxolone methyl.
[0094] For administration three times daily, preferred dosage forms
such as tablets or capsules may contain about 5 mg pioglitazone and
240 mg dimethyl fumarate or about 10 mg pioglitazone and about 240
mg dimethyl fumarate or about 15 mg pioglitazone and about 240 mg
dimethyl fumarate or about 5 mg pioglitazone and 120 mg dimethyl
fumarate or about 10 mg pioglitazone and about 120 mg dimethyl
fumarate or about 15 mg pioglitazone and about 120 mg dimethyl
fumarate, Most preferably, a dosage form may contain about 15 mg
pioglitazone and about 240 mg dimethyl fumarate.
[0095] For administration two times daily, preferred dosage forms
such as tablets or capsules may contain about 7.5 mg pioglitazone
and about 240 mg dimethyl fumarate or about 15 mg pioglitazone and
about 240 mg dimethyl fumarate or about 22.5 mg pioglitazone and
about 240 mg dimethyl fumarate.
[0096] In particular, atorvastatin is preferably administered
according to the invention in form of its calcium salt in daily
oral dosages of about 10, about 20, about 40 or about 80 mg per
patient. Preferably, atorvastatin is combined in the above dosages
with dimethylfumarate in dosages of about 120, about 240 or about
360, about 480 or about 720 mg per day. Most preferred are
combinations containing about 20 mg or about 40 mg of atorvastatin
in form of its calcium salt, and about 240 mg dimethyl
fumarate.
[0097] In a further embodiment, atorvastatin is combined in the
above dosages with bardoxolone methyl in its amorphous form in
dosages of about 20 mg per day. Most preferred are combinations
containing about 40 mg or about 80 mg of atorvastatin in form of
its calcium salt, and about 20 mg bardoxolone methyl in its
amorphous form.
[0098] In particular, losartan is preferably administered according
to the invention in daily oral dosages of about 25, about 50, about
75 or about 100 mg per patient. Preferably, losartan is combined in
the above dosages with dimethylfumarate in dosages of about 120,
about 240 or about 360, about 480 or about 720 mg per day. Most
preferred are combinations containing about 25 mg or about 50 mg of
losartan, and about 240 mg dimethyl fumarate. The combination is
preferably administered twice daily. The combination treatments of
sartanes and preferably losartan, irbesartan, telmisartan and
candesartan with Nrf2 activators such as dimethyl fumarate and
bardoxolone methyl are particularly effective for the treatment of
diabetic nephropathy (kidney damage due to diabetes) and chronic
kidney disease, but also for the treatment of multiple
sclerosis.
[0099] In a further example, losartan is combined in the above
dosages with bardoxolone methyl in its amorphous form in dosages of
about 20 mg per day. Most preferred are combinations containing
about 25 mg or about 50 mg of losartan, and about 20 mg bardoxolone
methyl in its amorphous form. The combination is preferably
administered once daily.
[0100] In particular, ibuprofen is preferably administered
according to the invention in daily dosages that are applicable to
the monotherapy with ibuprofen, such as about 600 mg, about 800 mg
or about 1200 mg or about 2400 mg per patient. Most preferred are
combinations containing about 600 mg of ibuprofen and about 240 mg
dimethyl fumarate. The combination is preferably administered twice
daily.
[0101] In a further example, ibuprofen is combined in the above
dosages with bardoxolone methyl in its amorphous form in dosages of
about 20 mg per day. Most preferred are combinations containing
about 800 mg of ibuprofen, and about 20 mg bardoxolone methyl in
its amorphous form. The combination is preferably administered once
daily.
[0102] Preferred ratios between rosiglitazone and dimethyl fumarate
are selected from 1/20 to 1/400 (w/w, rosiglitazone/dimethyl
fumarate), preferably from 1/25 to 380, more preferably from 1/28
to 1/360. Most preferably the ratios are about 1/30, about 1/45,
such as about 1/44.4, about 1/60, about 1/90, such as about 1/88.9
or about 1/92.3, about 1/120, about 1/180, such as 1/171.4 or
1/184.6, about 1/240, about 1/340, such as about 1/342.9.
[0103] Preferred ratios between pioglitazone and dimethyl fumarate
are selected from 1/3 to 1/60 (w/w, pioglitazone/dimethyl
fumarate), preferably from 1/4 to 1/55, more preferably from 1/5 to
1/52. Most preferably the ratios are about 1/5.3, about 1/8, about
1/10, such as 1/10.7, about 1/12, about 1/16, about 1/24, about
1/32, about 1 to 48.
[0104] In general, ratios between rosiglitazone and bardoxolone
methyl are selected from 1/1 to 1/100 (w/w,
rosiglitazone/bardoxolone methyl), preferably from 1/1.5 to 1/80,
more preferably from 1/2 to 1/75. Most preferably the ratios are
about 1/2.5, such as about 1/3.1 or about 1/5, such as 1/6.3, about
1/10, such as about 1/9.4 or about 1/12.5, about 1/20, such as
1/18.8, about 1/40, such as about 1/37.5, about 1/70, such as about
1/75.
[0105] In general, ratios between pioglitazone and bardoxolone
methyl are selected from 1/0.1 to 1/20 (w/w,
pioglitazone/bardoxolone methyl), preferably from 1/0.3 to 1/15,
more preferably from 1/0.4 to 1/12. Most preferably the ratios are
about 1/0.5, such as about 1/0.4 or about 1/0.6 or about 1/0.7, or
about 1/0.8, about 1/2, such as about 1/1.7 or about 1/2.5, about
1/3, such as about 1/3.3, about 1/5 or about 1/10.
[0106] In preferred embodiments of the present invention, amorphic
bardoxolone methyl is employed more preferably in a pharmaceutical
formulation comprising amorphous bardoxolone methyl, preferably
obtained as spray-dried dispersion with a glass-forming excipient,
such as methacrylic acid copolymer Type C, USP, e.g. in a 4/6
weight ratio of bardoxolone methyl to methacrylic acid copolymer
Type C, USP (Eurdagit), more preferably admixed with particles
comprised of at least one hydrophilic binder, such as
hydroxypropylmethylcellulose, according to US2012/022156. Preferred
compositions of bardoxolone methyl according to the present
invention, also contain a surface active ingredient, such as sodium
lauryl sulfate, preferably in amounts of about 1 to 5 weight %,
preferably about 3%, such as 2.73%, of the total composition.
[0107] In preferred embodiments, amorphous bardoxolone methyl is
administered according to the invention in daily dosages of 0.05 to
1 mg per kg body weight, more preferably in dosages of 0.1 to 0.8
mg per kg body weight and most preferably in dosages of 0.2 mg to
0.6 mg per kg body weight, such as in daily dosages of about 0.15
mg, about 0.25 mg or about 0.35 mg per kg body weight. Daily oral
dosages of about 10 mg, about 20 mg, and about 30 mg bardoxolone
methyl per patient are particularly preferred.
[0108] For daily administration of amorphous bardoxolone methyl,
the following dosages are employed per patient: About 2 mg
rosiglitazone and about 10 mg bardoxolone methyl or about 2 mg
rosiglitazone and about 20 mg bardoxolone methyl or about 2 mg
rosiglitazone and about 30 mg bardoxolone methyl or about 4 mg
rosiglitazone and about 10 mg bardoxolone methyl or about 4 mg
rosiglitazone and about 20 mg bardoxolone methyl or about 4 mg
rosiglitazone and about 30 mg bardoxolone methyl or about 8 mg
rosiglitazone and about 10 mg bardoxolone methyl or about 8 mg
rosiglitazone and about 20 mg bardoxolone methyl or about 8 mg
rosiglitazone and about 30 mg bardoxolone methyl. Most preferably,
about 8 mg rosiglitazone and about 20 mg bardoxolone methyl are
employed. In particular it is preferred if the above amounts are
used in a fixed dose combination, i.e. in a solid oral dosage
form.
[0109] Alternatively, for daily administration or amorphous
bardoxolone methyl, the following dosages are employed per patient:
About 15 mg pioglitazone and about 10 mg bardoxolone methyl or
about 15 mg pioglitazone and about 20 mg bardoxolone methyl or
about 15 mg pioglitazone and about 30 mg bardoxolone methyl or
about 30 mg pioglitazone and about 10 mg bardoxolone methyl or
about 30 mg pioglitazone and about 20 mg bardoxolone methyl or
about 30 mg pioglitazone and about 30 mg bardoxolone methyl or
about 45 mg pioglitazone and about 10 mg bardoxolone methyl or
about 45 mg pioglitazone and about 20 mg bardoxolone methyl or
about 45 mg pioglitazone and about 30 mg bardoxolone methyl. Most
preferably, about 45 mg pioglitazone and about 20 mg bardoxolone
methyl are employed. Most preferably, about 8 mg rosiglitazone and
about 20 mg bardoxolone methyl are employed. In particular it is
preferred if the above amounts are used in a fixed dose
combination, i.e. in a solid oral dosage form.
[0110] In preferred embodiments of the present invention, where
bardoxolone methyl is employed in amorphic form, preferred ratios
between rosiglitazone and bardoxolone methyl are from 1/1 to 1/20
("I" indicates "to" throughout this application, when a ratio is
concerned, w/w, rosiglitazone/bardoxolone methyl), preferably from
1/1.1 to 1/17, more preferably from 1/1.2 to 1/16. Most preferably
the ratios are about 1/1.3, such as about 1/1.25, about 1/2.5,
about 1/3.5, such as 1/3.75, about 1/5, about 7.5, about 1/10.
[0111] In further In preferred embodiments of the present
invention, where bardoxolone methyl is employed in amorphic form,
preferred ratios between pioglitazone and bardoxolone methyl are
from 1/0.1 to 1/3 (w/w, pioglitazone/bardoxolone methyl),
preferably from 1/0.15 to 1/2.5, more preferably from 1/0.2 to
1/2.2. Most preferably the ratios are about 1/0.2, such as about
1/0.22, about 1/0.3, such as about 1/0.33, about 1/0.4, such as
about 1/0.44, about 1/0.7, such as about 1/0.67, about 1/1 or about
1/2.
[0112] Dosage forms and in particular oral dosage forms such as
tablets or capsules containing both a PPAR gamma agonist and a Nrf2
activator in a fixed dose combination comprising the above
compositions in the given ratios and especially those containing
amorphic bardoxolone methyl, are preferred.
[0113] Fixed dose combinations, such as tablets containing the
active ingredients in the above amounts and ratios, are most
preferred.
[0114] Pharmaceutical compositions provided by the present
disclosure may comprise a therapeutically effective amount of a
PPAR gamma agonist and an Nrf2 activator together with a suitable
amount of one or more pharmaceutically acceptable vehicles so as to
provide a composition for proper administration to a patient.
Suitable pharmaceutical vehicles are described in the art.
[0115] In certain embodiments, a PPAR gamma agonist and an Nrf2
activator may together be incorporated into pharmaceutical
compositions to be administered orally. Oral administration of such
pharmaceutical compositions may result in uptake of the PPAR gamma
agonist and the Nrf2 activator throughout the intestine and entry
into the systemic circulation. Such oral compositions may be
prepared in a manner known in the pharmaceutical art and comprise a
PPAR gamma agonist and an Nrf2 activator and at least one
pharmaceutically acceptable vehicle. Oral pharmaceutical
compositions may include a therapeutically effective amount of a
PPAR gamma agonist and an Nrf2 activator and a suitable amount of a
pharmaceutically acceptable vehicle, so as to provide an
appropriate form for administration to a patient.
[0116] A PPAR gamma agonist and an Nrf2 activator may together be
incorporated into pharmaceutical compositions to be administered by
any other appropriate route of administration including
intradermal, intramuscular, intraperitoneal, intravenous,
subcutaneous, intranasal, epidural, oral, sublingual,
intracerebral, intravaginal, transdermal, rectal, inhalation, or
topical.
[0117] In one embodiment of the present invention, a topical
formulation is provided, containing a ppar agonist, such as a
glitazone like pioglitazone or rosiglitazone and an Nrft2
activator, preferably Nrf2 activator that does not or only rarely
cause an allergic skin reaction, such as bardoxolone methyl, CDDO,
CDDO-IM, CDDO-MA, TP-225, menadione, vitamin K1, BHA, BHT, tBHQ,
tBQ, curcumin, reservatrol, cynnamic aldehyde or oltipraz. The
topical formulation is preferably used in the treatment of
psoriasis, acne, rosacea and skin rash such as skin rash caused by
EGFR inhibitors like cetuximab, zalutumumab, nimotuzumab, and
matuzumab, gefitinib, erlotinib, and lapatinib. The formulations
are prepared with customary ingredients and processes known in the
art and/or disclosed herein.
[0118] Pharmaceutical compositions comprising a PPAR gamma agonist
and an Nrf2 activator may be manufactured by means of conventional
mixing, dissolving, granulating, dragee-making, levigating,
emulsifying, encapsulating, entrapping, or lyophilizing processes.
Pharmaceutical compositions may be formulated in a conventional
manner using one or more physiologically acceptable carriers,
diluents, excipients, or auxiliaries, which facilitate processing
of the PPAR gamma agonist and the Nrf2 activator or crystalline
forms thereof and one or more pharmaceutically acceptable vehicles
into formulations that can be used pharmaceutically. Proper
formulation is dependent upon the route of administration chosen.
Pharmaceutical compositions provided by the present disclosure may
take the form of solutions, suspensions, emulsion, tablets, pills,
pellets, capsules, capsules containing liquids, powders,
sustained-release formulations, suppositories, emulsions, aerosols,
sprays, suspensions, or any other form suitable for administration
to a patient. Pharmaceutical compositions provided by the present
disclosure may be formulated in a unit dosage form. A unit dosage
form refers to a physically discrete unit suitable as a unitary
dose for patients undergoing treatment, with each unit containing a
predetermined quantity of a PPAR gamma agonist and an Nrf2
activator calculated to produce an intended therapeutic effect. A
unit dosage form may be for a single daily dose, for administration
2 times per day, or one of multiple daily doses, e.g., 3 or more
times per day. When multiple daily doses are used, a unit dosage
form may be the same or different for each dose. One or more dosage
forms may comprise a dose, which may be administered to a patient
at a single point in time or during a time interval.
[0119] Pharmaceutical compositions comprising a PPAR gamma agonist
and an Nrf2 activator may be formulated for immediate release or
controlled or sustained or delayed release.
[0120] In certain embodiments, an oral dosage form provided by the
present disclosure may be a controlled release dosage form.
Controlled delivery technologies can improve the absorption of a
drug in a particular region or regions of the gastrointestinal
tract. Controlled drug delivery systems may be designed to deliver
a drug in such a way that the drug level is maintained within a
therapeutically effective window and effective and safe blood
levels are maintained for a period as long as the system continues
to deliver the drug with a particular release profile in the
gastrointestinal tract. Controlled drug delivery may produce
substantially constant blood levels of the PPAR gamma agonist and
the Nrf2 activator over a period of time as compared to
fluctuations observed with immediate release dosage forms. For some
PPAR gamma agonists and Nrf2 activators, maintaining a constant
blood and tissue concentration throughout the course of therapy is
the most desirable mode of treatment. Immediate release of the PPAR
gamma agonist and the Nrf2 activator may cause blood levels to peak
above the level required to elicit a desired response, which may
waste the agents and may cause or exacerbate toxic side effects.
Controlled drug delivery can result in optimum therapy, and not
only can reduce the frequency of dosing, but may also reduce the
severity of side effects. Examples of controlled release dosage
forms include dissolution controlled systems, diffusion controlled
systems, ion exchange resins, osmotically controlled systems,
erodable matrix systems, pH independent formulations, gastric
retention systems, and the like.
[0121] An appropriate oral dosage form for a particular
pharmaceutical composition provided by the present disclosure may
depend, at least in part, on the gastrointestinal absorption
properties of the PPAR gamma agonist and the Nrf2 activator and the
stability of these agents in the gastrointestinal tract, the
pharmacokinetics thereof and the intended therapeutic profile. An
appropriate controlled release oral dosage form may be selected for
a particular a PPAR gamma agonist and Nrf2 activator. For example,
gastric retention oral dosage forms may be appropriate for agents
absorbed primarily from the upper gastrointestinal tract, and
sustained release oral dosage forms may be appropriate for agents
absorbed primarily from the lower gastrointestinal tract.
[0122] In certain embodiments, pharmaceutical compositions provided
by the present disclosure may be practiced with dosage forms
adapted to provide sustained release of a PPAR gamma agonist and an
Nrf2 activator upon oral administration. Sustained release oral
dosage forms may be used to release the PPAR gamma agonist and/or
the Nrf2 activator over a prolonged time period and are useful when
it is desired that an agent be delivered to the lower
gastrointestinal tract. Sustained release oral dosage forms include
any oral dosage form that maintains therapeutic concentrations of
the agents in a biological fluid such as the plasma, blood,
cerebrospinal fluid, or in a tissue or organ for a prolonged time
period. Sustained release oral dosage forms include
diffusion-controlled systems such as reservoir devices and matrix
devices, dissolution-controlled systems, osmotic systems, and
erosion-controlled systems. Sustained release oral dosage forms and
methods of preparing the same are well known in the art.
[0123] In each of the above dosage forms, the PPAR gamma agonist
may be formulated together in admixture or preferably separately
from the Nrf2 activator. Each of the PPAR gamma agonist and Nrf2
activator may preferably be contained in separate form within the
dosage form, such as an oral dosage form, which is preferably a
tablet or capsule. In such oral dosage form, wherein the PPAR gamma
agonist and the Nrf2 activator are separated, each agent may be
formulated with different excipients. The PPAR gamma agonist and
the Nrf2 activator may also be each contained in formulations with
different release profiles, i.e. with immediate, controlled or
delayed release.
[0124] The formulations and in particular the solid oral dosage
forms containing a PPAR gamma agonist and/or an Nrf2 activator may
contain a conventional additive in the field of pharmaceutical
preparation and can be also produced according to a known method.
As the additive, for example, excipient, disintegrant, binder,
lubricant, coloring agent, pH regulator, surfactant,
release-sustaining agent, stabilizer, sour agent, flavor, glidant
and the like can be mentioned. These additives are used in an
amount conventionally employed in the field of pharmaceutical
preparation.
[0125] As the excipient, for example, starches such as corn starch,
potato starch, wheat starch, rice starch, partly pregelatinized
starch, pregelatinized starch, porous starch and the like; sugars
and sugar alcohols such as lactose, fructose, glucose, D-mannitol,
sorbitol and the like; anhydrous calcium phosphate, crystalline
cellulose, precipitated calcium carbonate, calcium silicate and the
like can be mentioned.
[0126] As the disintegrant, for example, carboxymethyl cellulose,
calcium carboxymethyl cellulose, sodium carboxymethyl starch,
croscarmellose sodium, crospovidone, low-substituted hydroxypropyl
cellulose, hydroxypropyl starch and the like are used. The amount
of the disintegrant to be used is preferably 0.5-25 parts by
weight, more preferably 1-15 parts by weight, per 100 parts by
weight of the solid preparation.
[0127] As the binder, for example, crystalline cellulose,
hydroxypropyl cellulose, hydroxypropylmethyl cellulose,
polyvinylpyrrolidone, gum arabic powder and the like can be
mentioned. The amount of the binder to be used is preferably 0.1-50
parts by weight, more preferably 0.5-40 parts by weight, per 100
parts by weight of the solid preparation.
[0128] Preferable examples of the lubricant include magnesium
stearate, calcium stearate, talc, sucrose esters of fatty acids,
sodium stearyl fumarate and the like. As the coloring agent, for
example, food colors such as Food Yellow No. 5, Food Red No. 2,
Food Blue No. 2 and the like, food lake colors, ferric oxide and
the like can be mentioned. As the pH regulator, citrate, phosphate,
carbonate, tartrate, fumarate, acetate, amino acid salt and the
like can be mentioned. As the surfactant, sodium lauryl sulfate,
polysorbate 80, polyoxyethylene (160) polyoxypropylene (30) glycol
and the like can be mentioned.
[0129] As the release-sustaining agent, for example, cellulose
polymers such as hydroxypropyl cellulose, hydroxypropylmethyl
cellulose (preferably hydroxypropylmethyl cellulose 2910,
hydroxypropylmethyl cellulose 2208 and the like), cellulose acetate
(preferably cellulose acetate having an acetyl content of
39.3-40%), cellulose diacetate, cellulose triacetate, cellulose
acetate propionate, ethyl cellulose, sodium carboxymethyl
cellulose, crystalline cellulose sodium carboxymethyl cellulose and
the like; sodium alginate, carboxyvinyl polymer; acrylic acid
polymers such as aminoalkylmethacrylate copolymer RS [Eudragit RS
(trademark), Rohm Pharma], ethyl acrylate-methyl methacrylate
copolymer suspension [Eudragit NE (trademark), Rohm Pharma] and the
like; and the like can be mentioned. The release-sustaining agent
may contain, for example, flux enhancers (e.g., sodium chloride,
potassium chloride, sucrose, sorbitol, D-mannitol, polyethylene
glycol (preferably polyethylene glycol 400 and the like), propylene
glycol, hydroxypropyl cellulose, hydroxypropylmethyl cellulose,
hydroxypropylmethyl cellulose phthalate, cellulose acetate
phthalate, polyvinyl alcohol, methacrylic acid polymer),
plasticizers (e.g., triacetin, acetylated monoglyceride, grape seed
oil, olive oil, sesame oil, acetyltributyl citrate, acetyltriethyl
citrate, glycerin sorbitol, diethyl oxalate, diethyl maleate,
diethyl fumarate, dibutyl succinate, diethyl malonate, dioctyl
phthalate, dibutyl sebacate, triethyl citrate, tributyl citrate,
glycerol tributyrate) and the like. Preferable examples of the
release-sustaining agent include (1) a semipermeable membrane
coating containing cellulose acetate (preferably cellulose acetate
having an acetyl content of 39.3-40%), polyethylene glycol
(preferably polyethylene glycol 400 and the like) and triacetin;
(2) a release-sustaining composition containing sodium
carboxymethyl cellulose, hydroxypropylmethyl cellulose 2910,
hydroxypropylmethyl cellulose 2208 and microcrystalline cellulose;
and the like.
[0130] As the stabilizer, for example, tocopherol, tetrasodium
edetate, nicotinamide, cyclodextrins and the like can be mentioned.
As the sour agent, for example, ascorbic acid, citric acid,
tartaric acid, malic acid and the like can be mentioned. As the
flavor, for example, menthol, peppermint oil, lemon oil, vanillin
and the like can be mentioned. As the glidant, for example, light
anhydrous silicic acid, hydrated silicon dioxide and the like can
be mentioned. The above-mentioned additives may be used in a
mixture of two or more kinds thereof in an appropriate ratio.
Use
[0131] An appropriate dose of each a PPAR gamma agonist and Nrf2
activator may be determined based on several factors, including,
for example, the body weight and/or condition of the patient being
treated, the severity of the disease being treated, the incidence
and/or severity of side effects, the manner of administration, and
the judgment of the prescribing physician. Appropriate dose ranges
may be determined by methods known to those skilled in the art.
[0132] In one embodiment the invention provides a combination of an
Nrf2 activator and a PPAR gamma agonist for use in the treatment of
inflammatory and autoimmune diseases.
[0133] In another embodiment, the invention provides a PPAR gamma
agonist for use in combination with a fumaric acid mono- and/or
diester, characterized in that the PPAR gamma agonist is selective
and has no substantial activity on PPAR alpha or delta.
[0134] A therapeutically effective amount of a combination of a
PPAR gamma agonist and an Nrf2 activator may be administered as a
treatment or preventative measure to a patient having a
predisposition for and/or history of immunological, autoimmune,
and/or inflammatory diseases including psoriasis, asthma and
chronic obstructive pulmonary diseases, cardiac insufficiency
including left ventricular insufficiency, myocardial infarction and
angina pectoris, mitochondrial and neurodegenerative diseases such
as Parkinson's disease, Alzheimer's disease, Huntington's disease,
retinopathia pigmentosa and mitochondrial encephalomyopathy,
transplantation rejection, autoimmune diseases including multiple
sclerosis, ischemia and reperfusion injury, advanced glycation
endproducts (AGE)-induced genome and protein damage, inflammatory
bowel diseases such as Crohn's disease and ulcerative colitis,
thyroid eye disease-related inflammation, fibrosis, such as lung
fibrosis, chronic lymphocytic leukemia, aphthous stomatitis, such
as recurrent aphthous stomatitis, acute lung injury, non-alcoholic
steatohepatitis acute renal injury and aging-related progressive
renal injury, diabetic cardiomyopathy and nephropathy. Chronic
kidney disease (CKD), Atherosclerosis, hypercholesterolemia,
hyperlipidemia, aortic stenosis, acute kidney injury (AKI) after
surgery. The present invention can also be used in the prevention
of cardiovascular disease, for plaque stabilization, reduction of
inflammation, reversal of endothelial dysfunction, and decreased
thrombogenicity and wound healing in diabetes. Moreover, the
combination treatment of the present invention can be used in the
treatment and prevention of atopic dermatitis, dementia, gastritis,
fibrosis, insulin resistance, type I and type II diabetes and
Syndrome X.
[0135] In one embodiment of the present invention, the combination
treatment is preferably used in the prophylaxis or treatment of
polycystic ovary syndrome (PCOS). It can also be found that
compounds being both, PPAR gamma agonists and Nrf2 activators, show
suitable effects as a monotherapeutic agent. Preferred compounds
which can be used in the prophylaxis and treatment of PCOS as a
single active ingredient in a dosage form such as a tablet, are
bardoxolone methyl, CDDO, CDDO-IM, CDDO-MA or TP-225. Thus, another
object of the present invention is the use of bardoxolone methyl,
CDDO, CDDO-IM, CDDO-MA or TP-225 in the prophylaxis and treatment
of PCOS and a method of treating PCOS by administration of a
pharmacologically effective amount of bardoxolone methyl, CDDO,
CDDO-1M, CDDO-MA or TP-225 to a patient in need thereof. In many
instances, the mono-therapy with the aforementioned Nrf2 activators
can be further improved with co-administration of a PPAR agonist,
such as a glitazone like pioglitazone or rosiglitazone.
[0136] NF-.kappa.B mediated and/or other diseases are described in
the following.
[0137] According to another embodiment of the invention, the
administration or co-administration of a combination of a PPAR
gamma agonist and an Nrf2 activator is effective for treating a
member of the group of diseases consisting of a neurological
disorder, an ophthalmological disorder, in a mammal, including,
without limitation, a human. According to another embodiment the
neurological disorder, an ophthalmological disorder, or a
combination thereof results from at least one member of the group
consisting of trauma, ischemia, and hypoxia. According to another
embodiment the neurological disorder, ophthalmological disorder, or
combination thereof is selected from the group consisting of
painful neuropathy, neuropathic pain, diabetic neuropathy, drug
dependence, drug addition, drug withdrawal, nicotine withdrawal,
opiate tolerance, opiate withdrawal, depression, anxiety, a
movement disorder, tardive dyskinesia, a cerebral infection that
disrupts the blood-brain barrier, meningitis, meningoencephalitis,
stroke, hypoglycemia, cardiac arrest, spinal cord trauma, head
trauma, perinatal hypoxia, cardiac arrest, hypoglycemic neuronal
damage, glaucoma, retinal ischemia, ischemic optic neuropathy,
macular degeneration, multiple sclerosis, sequalae of
hyperhomocystinemia, convulsion, pain, schizophrenia, muscle spasm,
migraine headache, urinary incontinence, emesis, brain edema,
tardive dyskinesia, AIDS-induced dementia, ocular damage,
retinopathy, a cognitive disorder, and a neuronal injury associated
with HIV infection. According to another embodiment the
neurological disorder, ophthalmological disorder, or combination
thereof is selected from the group consisting of epilepsy,
Alzheimer's disease, vascular (multi-infarct) dementia,
Huntington's disease, Parkinsonism, multiple sclerosis, amyotrophic
lateral sclerosis, and minimal cognitive impairment (MCI).
[0138] Psoriasis is characterized by hyperkeratosis and thickening
of the epidermis as well as by increased vascularity and
infiltration of inflammatory cells in the dermis. Psoriasis
vulgaris manifests as silvery, scaly, erythematous plaques on
typically the scalp, elbows, knees, and buttocks. Guttate psoriasis
occurs as tear-drop size lesions. Fumaric acid esters are
recognized for the treatment of psoriasis and dimethyl fumarate is
approved for the systemic treatment of psoriasis in Germany
(Mrowietz and Asadullah, Trends MoI Med 2005, 11(1), 43-48; and
Mrowietz et al., Br J Dermatology 1999, 141, 424-429). Efficacy for
treating psoriasis can be determined using animal models and in
clinical trials. Contrary to fumaric acid esters, it has been found
that PPAR gamma agonists are not advantageous in the treatment of
psoriasis (Placebo response in two long-term randomized psoriasis
studies that are negative for rosiglitazone. Am J Clin Dermatol.
2007; 8(2):93-102). Contrary to this result, it can be found that
PPAR gamma agonist provide therapeutic benefit in a combined
treatment of psoriasis according to the present invention.
[0139] Inflammatory arthritis includes diseases such as rheumatoid
arthritis, juvenile rheumatoid arthritis (juvenile idiopathic
arthritis), psoriatic arthritis, and ankylosing spondylitis produce
joint inflammation. The pathogenesis of immune-mediated
inflammatory diseases including inflammatory arthritis is believed
to involve TNF and NK-.kappa.B signaling pathways (Tracey et al.,
Pharmacology & Therapeutics 2008, 117, 244-279). Dimethyl
fumarate has been shown to inhibit TNF and inflammatory diseases
including inflammatory arthritis are believed to involve TNF and
NK-.kappa.B signaling and therefore may be useful in treating
inflammatory arthritis (Lowewe et al., J Immunology 2002, 168,
4781-4787).
[0140] Preferably the inventive method of treatment and
combinations can be used in the prophylaxis and treatment of
neurodegenerative diseases, such as multiple sclerosis, Parkinson's
disease, Alzheimer's disease, Huntington's disease, dementia,
mitochondrial encephalomyopathy and amyotrophic lateral sclerosis
(ALS).
[0141] Multiple sclerosis (MS) is an inflammatory autoimmune
disease of the central nervous system caused by an autoimmune
attack against the isolating axonal myelin sheets of the central
nervous system. Demyelination leads to the breakdown of conduction
and to severe disease with destruction of local axons and
irreversible neuronal cell death. The symptoms of MS are highly
varied with each individual patient exhibiting a particular pattern
of motor, sensible, and sensory disturbances. MS is typified
pathologically by multiple inflammatory foci, plaques of
demyelination, gliosis, and axonal pathology within the brain and
spinal cord, all of which contribute to the clinical manifestations
of neurological disability (see e.g., Wingerchuk, Lab Invest 2001,
81, 263-281; and Virley, NeuroRx 2005, 2(4), 638-649). Although the
causal events that precipitate MS are not fully understood,
evidence implicates an autoimmune etiology together with
environmental factors, as well as specific genetic predispositions.
Functional impairment, disability, and handicap are expressed as
paralysis, sensory and octintive disturbances spasticity, tremor, a
lack of coordination, and visual impairment, which impact on the
quality of life of the individual. The clinical course of MS can
vary from individual to individual, but invariably the disease can
be categorized in three forms: relapsing-remitting, secondary
progressive, and primary progressive.
[0142] Studies support the efficacy of fumaric acid esters for
treating MS and have undergone phase II clinical testing (Schimrigk
et al., Eur J Neurology 2006, 13, 604-610; and Wakkee and Thio,
Current Opinion Investigational Drugs 2007, 8(11), 955-962).
Assessment of MS treatment efficacy in clinical trials can be
accomplished using tools such as the Expanded Disability Status
Scale and the MS Functional as well as magnetic resonance imaging
lesion load, biomarkers, and self-reported quality of life. Animal
models of MS shown to be useful to identify and validate potential
therapeutics include experimental autoimmune/allergic
encephalomyelitis (EAE) rodent models that simulate the clinical
and pathological manifestations of MS and nonhuman primate EAE
models.
[0143] Inflammatory Bowel Disease (Crohn's Disease, Ulcerative
Colitis) Inflammatory bowel disease (IBD) is a group of
inflammatory conditions of the large intestine and in some cases,
the small intestine that includes Crohn's disease and ulcerative
colitis. Crohn's disease, which is characterized by areas of
inflammation with areas of normal lining in between, can affect any
part of the gastrointestinal tract from the mouth to the anus. The
main gastrointestinal symptoms are abdominal pain, diarrhea,
constipation, vomiting, weight loss, and/or weight gain. Crohn's
disease can also cause skin rashes, arthritis, and inflammation of
the eye. Ulcerative colitis is characterized by ulcers or open
sores in the large intestine or colon. The main symptom of
ulcerative colitis is typically constant diarrhea with mixed blood
of gradual onset. Other types of intestinal bowel disease include
collagenous colitis, lymphocytic colitis, ischaemic colitis,
diversion colitis, Behcet's colitis, and indeterminate colitis.
[0144] Asthma is reversible airway obstruction in which the airway
occasionally constricts, becomes inflamed, and is lined with an
excessive amount of mucus. Symptoms of asthma include dyspnea,
wheezing, chest tightness, and cough. Asthma episodes may be
induced by airborne allergens, food allergies, medications, inhaled
irritants, physical exercise, respiratory infection, psychological
stress, hormonal changes, cold weather, or other factors.
[0145] As shown in animal studies (Joshi et al., US 2007/0027076)
fumaric acid esters may be useful in treating pulmonary diseases
such as asthma and chronic obstructive pulmonary disorder.
[0146] Chronic obstructive pulmonary disease (COPD), also known as
chronic obstructive airway disease, is a group of diseases
characterized by the pathological limitation of airflow in the
airway that is not fully reversible, and includes conditions such
as chronic bronchitis, emphysema, as well as other lung disorders
such as asbestosis, pneumoconiosis, and pulmonary neoplasms {see,
e.g., Barnes, Pharmacological Reviews 2004, 56(4), 515-548). The
airflow limitation is usually progressive and associated with an
abnormal inflammatory response of the lungs to noxious particles
and gases. COPD is characterized by a shortness of breath the last
for months or years, possibly accompanied by wheezing, and a
persistent cough with sputum production. COPD is most often caused
by tobacco smoking, although it can also be caused by other
airborne irritants such as coal dust, asbestos, urban pollution, or
solvents. COPD encompasses chronic obstructive bronchiolitis with
fibrosis and obstruction of small airways, and emphysema with
enlargement of airspaces and destruction of lung parenchyma, loss
of lung elasticity, and closure of small airways.
[0147] Neurodegenerative diseases such as Parkinson's disease,
Alzheimer's disease, Huntington's disease and amyoptrophic lateral
sclerosis are characterized by progressive dysfunction and neuronal
death.
[0148] Parkinson's disease is a slowly progressive degenerative
disorder of the nervous system characterized by tremor when muscles
are at rest (resting tremor), slowness of voluntary movements, and
increased muscle tone (rigidity). In Parkinson's disease, nerve
cells in the basal ganglia, e.g., substantia nigra, degenerate, and
thereby reduce the production of dopamine and the number of
connections between nerve cells in the basal ganglia. As a result,
the basal ganglia are unable to smooth muscle movements and
coordinate changes in posture as normal, leading to tremor,
incoordination, and slowed, reduced movement (bradykinesia)
(Blandini, et al., Mol. Neurobiol. 1996, 12, 73-94).
[0149] Alzheimer's disease is a progressive loss of mental function
characterized by degeneration of brain tissue, including loss of
nerve cells and the development of senile plaques and
neurofibrillary tangles. In Alzheimer's disease, parts of the brain
degenerate, destroying nerve cells and reducing the responsiveness
of the maintaining neurons to neurotransmitters. Abnormalities in
brain tissue consist of senile or neuritic plaques, e.g., clumps of
dead nerve cells containing an abnormal, insoluble protein called
amyloid, and neurofibrillary tangles, twisted strands of insoluble
proteins in the nerve cell.
[0150] Huntington's disease is an autosomal dominant
neurodegenerative disorder in which specific cell death occurs in
the neostriatum and cortex (Martin, N Engl J Med 1999, 340,
1970-80). Onset usually occurs during the fourth or fifth decade of
life, with a mean survival at age of onset of 14 to 20 years.
Huntington's disease is universally fatal, and there is no
effective treatment. Symptoms include a characteristic movement
disorder (Huntington's chorea), cognitive dysfunction, and
psychiatric symptoms. The disease is caused by a mutation encoding
an abnormal expansion of CAG-encoded polyglutamine repeats in the
protein, huntingtin.
[0151] Amyotrophic lateral sclerosis (ALS) is a progressive
neurodegenerative disorder characterized by the progressive and
specific loss of motor neurons in the brain, brain stem, and spinal
cord (Rowland and Schneider, N Engl J Med 2001, 344, 1688-1700).
ALS begins with weakness, often in the hands and less frequently in
the feet that generally progresses up an arm or leg. Over time,
weakness increases and spasticity develops characterized by muscle
twitching and tightening, followed by muscle spasms and possibly
tremors. The average age of onset is 55 years, and the average life
expectancy after the clinical onset is 4 years. The only recognized
treatment for ALS is riluzole, which can extend survival by only
about three months.
[0152] Myasthenia gravis (MG) is a classic autoimmune disease
affecting neuromuscular junctions of striated muscle. Immunization
of different animal species with acetylcholine receptor (AChR) and
complete Freund's adjuvant (CFA) results in an animal model of MG
named experimental autoimmune myasthenia gravis (EAMG).
[0153] Alopecia greata is a common disease, but for ethical reasons
it seems difficult to perform large-scale studies to elucidate the
pathogenesis and to develop new therapeutic approaches in man. It
is therefore helpful to develop appropriate animal models. The
Dundee experimental bald rat (DEBR) and the C3H/HeJ mouse are
well-established animal models for alopecia greata and can be used
for the study of genetic aspects, pathogenesis and therapy of the
disease (J Dtsch Dermatol Ges. 2004 April; 2(4):260-73).
[0154] A mouse model for diabetic nephropathy can be utilized
according to Kidney International 77, 749-750 (May 2010), in order
to prove the effect of the combination according to the present
invention.
[0155] Thus, diseases and conditions for which treatment with the
combination of a PPAR gamma agonist and an Nrf2 activator can be
useful, include rheumatica, granuloma annulare, lupus, autoimmune
carditis, eczema, sarcoidosis, and autoimmune diseases including
acute disseminated encephalomyelitis, Addison's disease, alopecia
greata, ankylosing spondylitis, antiphospholipid antibody syndrome,
autoimmune hemolytic anemia, autoimmune hepatitis, autoimmune inner
ear disease, bullous pemphigoid, Behcet's disease, celiac disease,
Chagas disease, chronic obstructive pulmonary disease, Crohn's
disease, dermatomyositis, diabetes mellitus type I, endometriosis,
Goodpasture's syndrome, Graves' disease, Guillain-Barre syndrome,
Hashimoto's disease, hidradenitis suppurativea, Kawasaki disease,
IgA neuropathy, idiopathic thrombocytopenic purpura, interstitial
cystitis, lupus erythematosus, mixed connective tissue disease,
morphea, multiple sclerosis, myasthenia gravis, narcolepsy,
neuromyotonia, pemphigus vulgaris, pernicious anaemia, psoriasis,
psoriatic arthritis, polymyositis, primary biliary cirrhosis,
rheumatoid arthritis, schizophrena, scleroderma, Sjogren's
syndrome, stiff person syndrome, temporal arteritis, ulcerative
colitis, vasculitis, vitiligo, and Wegener's granulomatosis.
Administration
[0156] The combination of an Nrf2 activator and a PPAR gamma
agonist and pharmaceutical compositions thereof may be administered
orally or by any other appropriate route, for example, by infusion
or bolus injection, by absorption through epithelial or
mucocutaneous linings (e.g., oral mucosa, rectal, and intestinal
mucosa, etc.). Other suitable routes of administration include, but
are not limited to, intradermal, intramuscular, intraperitoneal,
intravenous, subcutaneous, intranasal, epidural, oral, sublingual,
intracerebral, intravaginal, transdermal, rectal, inhalation, or
topical.
[0157] Administration may be systemic or local. Various delivery
systems are known, e.g., encapsulation in liposomes,
microparticles, microcapsules, capsules, etc., that may be used to
administer a compound and/or pharmaceutical composition.
[0158] For systemic administration, a therapeutically effective
dose may be estimated initially from in vitro assays. For example,
a dose may be formulated in animal models to achieve a beneficial
circulating composition concentration range. Initial doses may also
be estimated from in vivo data, e.g., animal models, using
techniques that are known in the art. Such information may be used
to more accurately determine useful doses in humans. One having
ordinary skill in the art may optimize administration to humans
based on animal data.
[0159] The embodiment "PPAR gamma agonist for use in combination
with a fumaric acid mono- and/or diester in the treatment of an
autoimmune and/or inflammatory disease" relates to a method of use
of at least one PPAR gamma agonist in combination with a fumaric
acid mono- and/or diester in the treatment of an autoimmune and/or
inflammatory disease.
[0160] Preferred embodiments of the invention are described in the
following:
[0161] 1. PPAR gamma agonist for use in combination with a fumaric
acid mono- and/or diester in the treatment of an autoimmune and/or
inflammatory disease.
[0162] 2. PPAR gamma agonist such as rosiglitazone, for use in
combination with a fumaric acid mono- and/or diester according to
embodiment 1, characterized in that the autoimmune and/or
inflammatory disease is psoriasis.
[0163] 3. PPAR gamma agonist for use in combination with a fumaric
acid mono- and/or diester according to embodiment 1, characterized
in that the autoimmune and/or inflammatory disease is selected from
the group of psoriatic arthritis, multiple sclerosis, inflammatory
bowel disease (IBS), colitis ulcerosa, Crohn's disease, hepatitis,
effluvium, allopecia greata, cicatricial alopecia, diabetic
nephrophathy, CKD and myasthenia gravis.
[0164] 4. PPAR gamma agonist for use in combination with a fumaric
acid mono- and/or diester, according to the aforementioned
embodiments, characterized in that the PPAR gamma agonist is
selected from the group of rosiglitazone, pioglitazone,
troglitazone and ciglitazone.
[0165] 5. PPAR gamma agonist for use in combination with a fumaric
acid mono- and/or diester, according to the aforementioned
embodiments, characterized in that the fumaric acid mono- and/or
diester is selected from the group of monomethyl hydrogen fumarate,
dimethyl fumarate, monoethyl hydrogen fumarate and diethyl
fumarate.
[0166] 6. A pharmaceutical composition comprising a PPAR gamma
agonist and a fumaric acid mono- and/or diester and optionally one
or more excipients.
[0167] 7. A pharmaceutical composition comprising rosiglitazone,
pioglitazone, troglitazone or ciglitazone and a fumaric acid mono-
and/or diester and optionally one or more excipients.
[0168] 8. A pharmaceutical composition according to embodiments 6
or 7, characterized in that the fumaric acid mono- and/or diester
is selected from the group of monomethyl hydrogen fumarate,
dimethyl fumarate, monoethyl hydrogen fumarate, and diethyl
fumarate.
[0169] 9. A solid oral dosage form comprising a PPAR gamma agonist
and a fumaric acid mono- and/or diester.
[0170] 10. A solid oral dosage form comprising rosiglitazone,
pioglitazone, troglitazone or ciglitazone as a PPAR gamma agonist
and a fumaric acid mono- and/or diester.
[0171] 11. A solid oral dosage form according to embodiments 9 or
10, characterized in that the fumaric acid mono- and/or diester is
selected from the group of monomethyl hydrogen fumarate, dimethyl
fumarate, monoethyl hydrogen fumarate, and diethyl fumarate.
[0172] 12. A solid oral dosage form according to embodiments 9 to
10, characterized in that the PPAR gamma agonist and the fumaric
acid mono- and/or diester are each contained in the dosage form in
a separate composition optionally containing one or more
excipients.
[0173] 13. Kit of parts comprising a) a PPAR gamma agonist and b) a
fumaric acid mono- and/or diester and optionally c) instructions
for a dosing regime.
[0174] 14. Kit of parts comprising a) rosiglitazone, pioglitazone,
troglitazone or ciglitazone b) a fumaric acid mono- and/or diester
and optionally c) instructions for a dosing regime.
[0175] 15. Kit of parts according to embodiments 13 or 14,
characterized in that the fumaric acid mono- and/or diester is
selected from the group of monomethyl hydrogen fumarate, dimethyl
fumarate, monoethyl hydrogen fumarate, and diethyl fumarate.
[0176] 16. PPAR gamma agonist for use in combination with an Nrf2
activator selected from the group of monoalkyl hydrogen fumarate,
dialkyl fumarate and bardoxolone alkyl in the treatment of multiple
sclerosis.
[0177] 17. PPAR gamma agonist for use in combination with an Nrf2
activator according to the foregoing embodiment, characterized in
that multiple sclerosis includes relapsing-remitting (RR),
secondary progressive (SP), primary progressive (PP) and
progressive relapsing (PR) multiple sclerosis and the first
demyelinating event suggestive of MS or clinically isolated
syndrome (CIS).
[0178] 18. PPAR gamma agonist for use in combination with an Nrf2
activator according to the foregoing embodiments, characterized in
that the PPAR gamma agonist is a glitazone.
[0179] 19. PPAR gamma agonist for use in combination with an Nrf2
activator according to the foregoing embodiments, characterized in
that the PPAR gamma agonist is a glitazone selected from the group
of pioglitazone and rosiglitazone.
[0180] 20. PPAR gamma agonist for use in combination with an Nrf2
activator according to the foregoing embodiments, characterized in
that Nrf2 activator selected from the group of monomethyl hydrogen
fumarate, dimethyl fumarate and bardoxolone methyl.
[0181] 21. PPAR gamma agonist for use in combination with an Nrf2
activator according to the foregoing embodiments, characterized in
that ratios between rosiglitazone and dimethyl fumarate are
selected from 1/20 to 1/400 (w/w, rosiglitazone/dimethyl
fumarate).
[0182] 22. PPAR gamma agonist for use in combination with an Nrf2
activator according to the foregoing embodiments, characterized in
that ratios between pioglitazone and dimethyl fumarate are selected
from 1/3 to 1/60 (w/w, pioglitazone/dimethyl fumarate).
[0183] 23. PPAR gamma agonist for use in combination with an Nrf2
activator according to the foregoing embodiments, characterized in
that ratios between rosiglitazone and bardoxolone methyl are
selected from 1/1 to 1/100 (w/w, rosiglitazone/bardoxolone
methyl).
[0184] 24. PPAR gamma agonist for use in combination with an Nrf2
activator according to the foregoing embodiments, characterized in
that bardoxolone methyl is employed in amorphic form and ratios
between rosiglitazone and bardoxolone methyl are from 1/1 to 1/20
(w/w, rosiglitazone/bardoxolone methyl).
[0185] 25. PPAR gamma agonist for use in combination with an Nrf2
activator according to the foregoing embodiments, characterized in
that ratios between pioglitazone and bardoxolone methyl are
selected from 1/0.1 to 1/20 (w/w, pioglitazone/bardoxolone
methyl).
[0186] 26. PPAR gamma agonist for use in combination with an Nrf2
activator according to the foregoing embodiments, characterized in
that bardoxolone methyl is employed in amorphic form and ratios
between pioglitazone and bardoxolone methyl are from 1/0.1 to 1/3
(w/w, pioglitazone/bardoxolone methyl).
[0187] 27. A pharmaceutical composition comprising a PPAR gamma
agonist and an Nrf2 activator selected from the group of monoalkyl
hydrogen fumarate, dialkyl fumarate and bardoxolone alkyl and
optionally one or more excipients.
[0188] 28. A pharmaceutical composition according to embodiment 27,
characterized in that the PPAR gamma agonist is a glitazone.
[0189] 29. A pharmaceutical composition according to embodiment 28,
characterized in that the glitazone is selected from the group of
pioglitazone and rosiglitazone.
[0190] 30. A pharmaceutical composition according to embodiments 28
to 30, characterized in that Nrf2 activator selected from the group
of monomethyl hydrogen fumarate, dimethyl fumarate and bardoxolone
methyl.
[0191] 31. A pharmaceutical composition according to embodiments 28
to 30, characterized in that ratios between rosiglitazone and
dimethyl fumarate are selected from 1/20 to 1/400 (w/w,
rosiglitazone/dimethyl fumarate).
[0192] 32. A pharmaceutical composition according to embodiments 28
to 30, characterized in that ratios between pioglitazone and
dimethyl fumarate are selected from 1/3 to 1/60 (w/w,
ioglitazone/dimethyl fumarate).
[0193] 33. A pharmaceutical composition according to embodiments 28
to 30, characterized in that ratios between rosiglitazone and
bardoxolone methyl are selected from 1/1 to 1/100 (w/w,
rosiglitazone/bardoxolone methyl).
[0194] 34. A pharmaceutical composition according to embodiments 28
to 30, characterized in that bardoxolone methyl is employed in
amorphic form and ratios between rosiglitazone and bardoxolone
methyl are from 1/1 to 1/20 (w/w, rosiglitazone/bardoxolone
methyl). 35. A pharmaceutical composition according to embodiments
28 to 30, characterized in that ratios between pioglitazone and
bardoxolone methyl are selected from 1/0.1 to 1/20 (w/w,
pioglitazone/bardoxolone methyl).
[0195] 36. A pharmaceutical composition according to embodiments 28
to 30, characterized in bardoxolone methyl is employed in amorphic
form and ratios between pioglitazone and bardoxolone methyl are
from 1/0.1 to 1/3 (w/w, pioglitazone/bardoxolone methyl).
[0196] 37. A solid oral dosage form comprising the pharmaceutical
composition according to embodiments 27 to 36.
[0197] 38. A solid oral dosage form comprising a PPAR gamma agonist
and an Nrf2 activator selected from the group of monoalkyl hydrogen
fumarate, dialkyl fumarate and bardoxolone alkyl and optionally one
or more excipients, wherein the PPAR gamma agonist and the Nrf2
activator are each contained in a separate pharmaceutical
formulation.
[0198] 39. A solid oral dosage form according to embodiment 38,
wherein the PPAR gamma agonist is a glitazone and the Nrf2
activator is selected from the group of monomethyl hydrogen
fumarate, dimethyl fumarate and bardoxolone methyl.
[0199] 40. A solid oral dosage form according to the aforementioned
embodiments, wherein the Nrf2 activator is bardoxolone methyl
contained in an amorphous form.
[0200] 41. A solid oral dosage form according to the aforementioned
embodiments, wherein the Nrf2 activator is bardoxolone methyl
contained in an amorphous dispersion formulation.
[0201] 42. A solid oral dosage form according to the aforementioned
embodiments, wherein the Nrf2 activator is bardoxolone methyl
contained in an amorphous dispersion formulation obtained by spray
drying or freeze drying.
[0202] 43. A solid oral dosage form according to the aforementioned
embodiments, wherein the Nrf2 activator is bardoxolone methyl
contained in an amorphous dispersion formulation with methacrylic
acid copolymer Type C, USP.
[0203] 44. A solid oral dosage form according to the aforementioned
embodiments, wherein the Nrf2 activator is bardoxolone methyl
contained in an amorphous dispersion formulation with methacrylic
acid copolymer Type C, USP in a weight ratio of 4/6.
[0204] 45. A solid oral dosage form according to the aforementioned
embodiments, wherein the Nrf2 activator is bardoxolone methyl
contained in an amorphous dispersion formulation comprising at
least one hydrophilic binder.
[0205] 46. A solid oral dosage form according to the aforementioned
embodiments, wherein the hydrophilic binder is employed in an
amount of between about 1 and about 40% (weight % of the total
pharmaceutical composition used for the dosage form), preferably
between about 2 to about 20%, more preferably between about 4 and
about 10% even more preferably between about 5 and about 7.5% and
most preferred between about 7 and 7.5%, such as about 7%.
[0206] 47. A solid oral dosage form according to the aforementioned
embodiments, wherein the hydrophilic binder is
hydroxypropylmethylcellulose.
[0207] 48. A solid oral dosage form according to the aforementioned
embodiments, wherein the Nrf2 activator is bardoxolone methyl
contained in an amorphous dispersion formulation and wherein the
dosage form also contains a surface active agent, such as sodium
lauryl sulfate, preferably in an amount of about 3% of the total
weight of the dosage form.
[0208] 49. Kit of parts comprising a) a PPAR gamma agonist and b)
an Nrf2 activator selected from the group of monoalkyl hydrogen
fumarate, dialkyl fumarate and bardoxolone alkyl and optionally c)
instructions for a dosing regime.
[0209] 50. Kit of parts comprising a) a PPAR agonist and b) an Nrf2
activator selected from the group of monoalkyl hydrogen fumarate,
dialkyl fumarate and bardoxolone alkyl and optionally c)
instructions for a dosing regime.
[0210] 51. Kit of parts according to the foregoing embodiment,
characterized in that the PPAR gamma agonist is rosiglitazone or
pioglitazone.
[0211] 52. Kit of parts according to the foregoing embodiment,
characterized in that the Nrf2 activator is dimethyl fumarate or
bardoxolone methyl.
[0212] 53. PPAR gamma agonist for use in combination with an Nrf2
activator for the treatment of multiple sclerosis according to the
foregoing embodiments, wherein said PPAR agonist is administered to
a patient simultaneously with or up to 2 days before or after an
Nrf2 activator, such as those selected from the group of monoalkyl
hydrogen fumarate, dialkyl fumarate and bardoxolone alkyl, is
administered to said patient.
[0213] 54. PPAR gamma agonist for use in combination with an Nrf2
activator for the treatment of multiple sclerosis according to the
foregoing embodiments, wherein said PPAR agonist is administered
once or twice daily.
[0214] 55. PPAR gamma agonist for use in combination with an Nrf2
activator for the treatment of multiple sclerosis according to the
foregoing embodiments, wherein said Nrf2 activator is administered
once or twice daily.
[0215] 56. PPAR gamma agonist for use in combination with an Nrf2
activator in the treatment of autoimmune and/or inflammatory
diseases other than psoriasis.
[0216] 57. PPAR gamma agonist, preferably other than pioglitazone,
for use in combination with an Nrf2 activator belonging to a
different chemical class, in the treatment of autoimmune and/or
inflammatory diseases, such as multiple sclerosis, psoriasis or
chronic kidney disease.
[0217] 58. PPAR gamma agonist, preferably other than pioglitazone,
for use according to the aforementioned embodiment, wherein the
Nrf2 activator having no significant PPAR gamma agonistic
effect.
[0218] 59. PPAR gamma agonist, preferably other than pioglitazone,
having no significant activating effect on Nrf2, for use in
combination with an Nrf2 activator having no significant PPAR gamma
agonistic effect, in the treatment of autoimmune and/or
inflammatory diseases, such as multiple sclerosis, psoriasis or
chronic kidney disease.
[0219] 60. PPAR gamma agonist, preferably other than pioglitazone,
for use in combination with an Nrf2 activator belonging to
different chemical class, wherein the Nrf2 activator is other than
bardoxolone methyl and its derivatives, in the treatment of
autoimmune and/or inflammatory diseases, such as multiple
sclerosis, psoriasis or chronic kidney disease.
[0220] 61. Composition comprising a PPAR gamma agonist and an Nrf2
activator belonging to a different chemical class, for use in the
treatment of autoimmune and/or inflammatory diseases, such as
multiple sclerosis, psoriasis or chronic kidney disease.
[0221] 62. Composition according to the aforementioned embodiment,
comprising a PPAR gamma agonist having no significant activating
effect on Nrf2, and an Nrf2 activator having no significant PPAR
gamma agonistic effect, for use in the treatment of autoimmune
and/or inflammatory diseases, such as multiple sclerosis, psoriasis
or chronic kidney disease.
[0222] 63. Composition comprising a PPAR gamma agonist, such as
pioglitazone and an Nrf2 activator.
[0223] 64. Composition comprising a PPAR gamma agonist, such as
pioglitazone and an Nrf2 activator having no significant PPAR gamma
agonistic effect.
[0224] 65. Composition comprising pioglitazone and an Nrf2
activator having no significant PPAR gamma agonistic effect, for
use in the treatment of psoriasis and other autoimmune and/or
inflammatory diseases, such as multiple sclerosis, psoriasis or
chronic kidney disease.
[0225] 66. PPAR gamma agonist for use in combination with an Nrf2
activator having no significant PPAR gamma agonistic effect, in the
treatment of multiple sclerosis.
[0226] 67. PPAR gamma agonist for use in combination with an Nrf2
activator other than bardoxolone methyl, in the treatment of CKD or
multiple sclerosis.
[0227] 68. PPAR gamma agonist for use in combination with an Nrf2
activator according to the foregoing embodiment, characterized in
that multiple sclerosis includes relapsing-remitting (RR),
secondary progressive (SP), primary progressive (PP) and
progressive relapsing (PR) multiple sclerosis and the first
demyelinating event suggestive of MS or clinically isolated
syndrome (CIS).
[0228] 69. PPAR gamma agonist for use in combination with an Nrf2
activator according to the foregoing embodiments, characterized in
that the PPAR gamma agonist is a glitazone.
[0229] 70. PPAR gamma agonist for use in combination with an Nrf2
activator according to any of the foregoing embodiments,
characterized in that the PPAR gamma agonist is a glitazone
selected from the group of pioglitazone and rosiglitazone.
[0230] 71. PPAR gamma agonist for use in combination with an Nrf2
activator according to any of the foregoing embodiments,
characterized in that the Nrf2 activator is selected chemical
compounds belonging to the group of Michael reaction acceptors,
phenols, diphenols, chalcones, isothiocyanates, thiocarbamates,
quinones, naphtoquinones and 1,2 dithiole-3-thiones, wherein one or
more, preferably 1, 2, 3, 4, 5, 6 or 7 H-atoms may be substituted
by linear or branched alkyl and perfluoroalkyl, such as methyl,
ethyl, trifluoromethyl, halogen such as Br, Cl F or I, hydroxy,
alkoxy and perfluoroalkoxy, such as methoxy, ethoxy,
trifluoromethoxy, cyano and nitro, which chemical compounds have
not more than one or two 5- or 6-membered carbocyclic rings or 5-
or 6-membered heterocyclic rings having 1, 2 or 3 N-, O or S-atoms
as ring atoms which rings may be fused to each other or preferably
no or only one carbocyclic or heterocyclic ring. Compositions
containing these Nrf2 activators are preferred.
[0231] Preferred Nrf2 activators for use in combination according
to the invention and particularly according to embodiment 71 above,
are chemical compounds, containing less than 35, preferably less
than 30, more preferably less than 25 and most preferably less than
20 or even less than 15 or less than 10 carbon atoms and/or having
a molecular weight of less than 400, preferably less than 300 and
most preferably less than 200 g/mol or less than 170 g/mol and/or
having no significant PPAR gamma agonistic activity. Compositions
containing these Nrf2 activators are preferred.
[0232] 72. PPAR gamma agonist for use in combination with an Nrf2
activator and compositions according to any of the foregoing
embodiments, characterized in that the nrf2 activator is selected
from 2-naphthoquinone, cynnamic aldehyde, caffeic acid and its
esters, curcumin, reservatrol, artesunate, tert-butylhydroquinone,
vitamins K1, K2 and K3 and the respective quinone or hydroquinone
forms of the aforementioned quinone and hydroquinone derivatives,
fumaric acid esters, i.e. fumaric acid mono- and/or diester which
is preferably selected from the group of monoalkyl hydrogen
fumarate and dialkyl fumarate, such as monomethyl hydrogen
fumarate, dimethyl fumarate, monoethyl hydrogen fumarate, and
diethyl fumarate, isothiocyanate such as sulforaphane,
1,2-dithiole-3-thione such as oltipraz,
3,5-di-tert-butyl-4-hydroxytoluene, 3-hydroxycoumarin,
4-hydroxynonenal, 4-oxononenal, malondialdehyde, (E)-2-hexenal,
capsaicin, allicin, allylisothiocyanate, 6-methylthiohexyl
isothiocyanate, 7-methylthioheptyl isothiocyanate, sulforaphane,
8-methylthiooctyl isothiocyanate, 8-iso prostaglandin A2, alkyl
pyruvate, such as methyl and ethyl pyruvate, diethyl or dimethyl
oxaloproprionate, 2-acetamidoacrylate, and methyl or
ethyl-2-acetamidoacrylate, and a pharmacologically active
stereoisomer or derivative of the aforementioned agents.
[0233] 73. PPAR gamma agonist for use in combination with an Nrf2
activator and compositions according to any the foregoing
embodiments, characterized in that the nrf2 activator is selected
from monomethyl hydrogen fumarate, dimethyl fumarate, oltipraz,
1,2-naphthoquinone, tert-butylhydroquinone, methyl or ethyl
pyruvate, 3,5-di-tert-butyl-4-hydroxytoluene, diethyl and dimethyl
oxaloproprionate.
[0234] 74. Kit of parts comprising a) a PPAR gamma agonist other
than pioglitazone and b) an Nrf2 activator selected from the group
of monoalkyl hydrogen fumarate, dialkyl fumarate and bardoxolone
alkyl and optionally c) instructions for a dosing regime.
[0235] 75. Kit of parts comprising a) a PPAR gamma agonist having
no significant activating effect on Nrf2, b) an Nrf2 activator
selected from the group of monoalkyl hydrogen fumarate, dialkyl
fumarate and bardoxolone and optionally c) instructions for a
dosing regime.
[0236] 76. Kit of parts comprising a) a PPAR gamma agonist having
no significant activating effect on Nrf2, b) an Nrf2 activator
having no significant PPAR gamma agonistic effect and optionally c)
instructions for a dosing regime.
[0237] 77. Kit of parts comprising a) a PPAR gamma agonist having
no significant activating effect on Nrf2, b) an Nrf2 activator
selected chemical compounds belonging to the group of Michael
reaction acceptors, phenols, diphenols, chalcones, isothiocyanates,
thiocarbamates, quinones, naphtoquinones and 1,2
dithiole-3-thiones, wherein one or more, preferably 1, 2, 3, 4, 5,
6 or 7 H-atoms may be substituted by linear or branched alkyl and
perfluoroalkyl, such as methyl, ethyl, trifluoromethyl, halogen
such as Br, Cl F or I, hydroxy, alkoxy and perfluoroalkoxy, such as
methoxy, ethoxy, trifluoromethoxy, cyano and nitro, which chemical
compounds have not more than one or two 5- or 6-membered
carbocyclic rings or 5- or 6-membered heterocyclic rings having 1,
2 or 3 N--, O or S-atoms as ring atoms which rings may be fused to
each other or preferably no or only one carbocyclic or heterocyclic
ring and optionally c) instructions for a dosing regime.
[0238] 78. Composition comprising a) a PPAR gamma agonist,
preferably other than pioglitazone and b) an Nrf2 activator
selected from the group of monoalkyl hydrogen fumarate, dialkyl
fumarate and bardoxolone alkyl.
[0239] 79. Composition comprising a) a PPAR gamma agonist having no
significant activating effect on Nrf2, b) an Nrf2 activator
selected from the group of monoalkyl hydrogen fumarate, dialkyl
fumarate and bardoxolone.
[0240] 80. Composition comprising a) a PPAR gamma agonist having no
significant activating effect on Nrf2, b) an Nrf2 activator having
no significant PPAR gamma agonistic effect.
[0241] 81. Composition comprising a) a PPAR gamma agonist having no
significant activating effect on Nrf2, b) an Nrf2 activator
selected chemical compounds belonging to the group of Michael
reaction acceptors, phenols, diphenols, chalcones, isothiocyanates,
thiocarbamates, quinones, naphtoquinones and 1,2
dithiole-3-thiones, wherein one or more, preferably 1, 2, 3, 4, 5,
6 or 7 H-atoms may be substituted by linear or branched alkyl and
perfluoroalkyl, such as methyl, ethyl, trifluoromethyl, halogen
such as Br, Cl F or I, hydroxy, alkoxy and perfluoroalkoxy, such as
methoxy, ethoxy, trifluoromethoxy, cyano and nitro, which chemical
compounds have not more than one or two 5- or 6-membered
carbocyclic rings or 5- or 6-membered heterocyclic rings having 1,
2 or 3 N--, O or S-atoms as ring atoms which rings may be fused to
each other or preferably no or only one carbocyclic or heterocyclic
ring.
[0242] 82. Method of treating or preventing cancer, preferably
heamatological cancer such as leukemia such as acute myeloid
leukaemia (AML), comprising administration of a ppar gamma agonist
and an Nrf2 activator to a patient in need thereof, wherein said
Nrf2 activator is capable of provoking or inducing a stimulated
and/or increased nuclear translocation of Nrf2 protein and is
[0243] a) selected from the group of Michael reaction acceptors,
phenols, diphenols, chalcones, isothiocyanates, thiocarbamates,
quinones, naphtoquinones and 1,2 dithiole-3-thiones; and
[0244] b) contains less than 35 carbon atoms; and/or
[0245] c) has a molecular weight of less than 600 g/mol; and/or
[0246] d) contains no or not more than one or two fused or
monocyclic 5- or 6-membered carbocyclic or heterocyclic rings,
having 1, 2 or 3 ring atoms selected from N, O or S.
[0247] In one embodiment of the foregoing method, the Nrf2
activator is preferably other than arsenic trioxide. Preferably,
the Nrf2 activator is dimethyl fumarate, monomethyl hydrogen
fumarate or bardoloxolone methyl.
[0248] 83. Method of treating or preventing diabetes such as type
II diabetes and its complications, such as arthritis, chronic
kidney disease and syndrome x, comprising administration of a ppar
gamma agonist and an Nrf2 activator to a patient in need thereof,
wherein said Nrf2 activator is capable of provoking or inducing a
stimulated and/or increased nuclear translocation of Nrf2 protein
and is
[0249] a) selected from the group of Michael reaction acceptors,
phenols, diphenols, chalcones, isothiocyanates, thiocarbamates,
quinones, naphtoquinones and 1,2 dithiole-3-thiones; and
[0250] b) contains less than 35 carbon atoms; and/or
[0251] c) has a molecular weight of less than 600 g/mol; and/or
[0252] d) contains no or not more than one or two fused or
monocyclic 5- or 6-membered carbocyclic or heterocyclic rings,
having 1, 2 or 3 ring atoms selected from N, O or S.
[0253] In one embodiment of the foregoing method, the Nrf2
activator is preferably other than bardoxolone methyl and/or a
corticosteroide. Preferably, the Nrf2 activator is dimethyl
fumarate or monomethyl hydrogen fumarate.
[0254] 84. Method of treating or preventing cardiovascular
diseases, comprising administration of a ppar gamma agonist and an
Nrf2 activator to a patient in need thereof, wherein said Nrf2
activator is capable of provoking or inducing a stimulated and/or
increased nuclear translocation of Nrf2 protein and is
[0255] a) selected from the group of Michael reaction acceptors,
phenols, diphenols, chalcones, isothiocyanates, thiocarbamates,
quinones, naphtoquinones and 1,2 dithiole-3-thiones; and
[0256] b) contains less than 35 carbon atoms; and/or
[0257] c) has a molecular weight of less than 600 g/mol; and/or
[0258] d) contains no or not more than one or two fused or
monocyclic 5- or 6-membered carbocyclic or heterocyclic rings,
having 1, 2 or 3 ring atoms selected from N, O or S.
[0259] 85. Method of treating or preventing respiratory diseases,
such as asthma, chronic obstructive pulmonary disorder and
fibrosis, comprising administration of a ppar gamma agonist and an
Nrf2 activator to a patient in need thereof, wherein said Nrf2
activator is capable of provoking or inducing a stimulated and/or
increased nuclear translocation of Nrf2 protein and is
[0260] a) selected from the group of Michael reaction acceptors,
phenols, diphenols, chalcones, isothiocyanates, thiocarbamates,
quinones, naphtoquinones and 1,2 dithiole-3-thiones; and
[0261] b) contains less than 35 carbon atoms; and/or
[0262] c) has a molecular weight of less than 600 g/mol; and/or
[0263] d) contains no or not more than one or two fused or
monocyclic 5- or 6-membered carbocyclic or heterocyclic rings,
having 1, 2 or 3 ring atoms selected from N, O or S.
[0264] In one embodiment of the foregoing method, the Nrf2
activator is preferably other than a corticosteroide. Preferably,
the Nrf2 activator is dimethyl fumarate, monomethyl hydrogen
fumarate or bardoloxolone methyl.
[0265] 86. Method of treating or preventing graft rejection and/or
necrosis, comprising administration of a ppar gamma agonist and an
Nrf2 activator to a patient in need thereof, wherein said Nrf2
activator is capable of provoking or inducing a stimulated and/or
increased nuclear translocation of Nrf2 protein and is
[0266] a) selected from the group of Michael reaction acceptors,
phenols, diphenols, chalcones, isothiocyanates, thiocarbamates,
quinones, naphtoquinones and 1,2 dithiole-3-thiones; and
[0267] b) contains less than 35 carbon atoms; and/or
[0268] c) has a molecular weight of less than 600 g/mol; and/or
[0269] d) contains no or not more than one or two fused or
monocyclic 5- or 6-membered carbocyclic or heterocyclic rings,
having 1, 2 or 3 ring atoms selected from N, O or S.
[0270] 87. Method of treating or preventing psoriasis, comprising
administration of a ppar agonist and an Nrf2 activator to a patient
in need thereof, wherein said Nrf2 activator is capable of
provoking or inducing a stimulated and/or increased nuclear
translocation of Nrf2 protein and is
[0271] a) selected from the group of Michael reaction acceptors,
phenols, diphenols, chalcones, isothiocyanates, thiocarbamates,
quinones, naphtoquinones and 1,2 dithiole-3-thiones; and
[0272] b) contains less than 35 carbon atoms; and/or
[0273] c) has a molecular weight of less than 600 g/mol; and/or
[0274] d) contains no or not more than one or two fused or
monocyclic 5- or 6-membered carbocyclic or heterocyclic rings,
having 1, 2 or 3 ring atoms selected from N, O or S.
[0275] In one embodiment of the foregoing method, no therapeutic
amounts of hydroxurea are co-administrated to the patient. In
another embodiment of the foregoing method, no therapeutic amounts
of monomethyl hydrogen fumarate are co-administrated to the
patient. In another embodiment of the foregoing method, no
therapeutic amounts of dimethyl fumarate are co-administrated to
the patient. In another embodiment of the foregoing method, the
Nrf2 activator is bardoloxolone methyl. In another embodiment of
the foregoing method, the ppar agonist is other than pioglitazone,
such as rosiglitazone.
[0276] 88. Method of treating or preventing autoimmune and/or
inflammatory diseases other than psoriasis, comprising
administration of a ppar agonist and dialkyl fumarate and/or
monoalkyl hydrogen fumarate to a patient in need thereof.
[0277] 89. Method of treating or preventing autoimmune and/or
inflammatory diseases other than chronic kidney disease, comprising
administration of a ppar agonist and bardoxolone methyl to a
patient in need thereof
[0278] 90. Method of treating or preventing cardiovascular
diseases, respiratory disorders, graft rejection, cancer and
diabetes and its complications, comprising administration of a ppar
agonist and dimethyl fumarate and/or monomethyl hydrogen fumarate
to a patient in need thereof
[0279] 91. Method of treating or preventing autoimmune/inflammatory
and cardiovascular diseases, respiratory disorders, graft
rejection, cancer and diabetes and its complications, comprising
administration of a ppar agonist other than pioglitazone, and
dimethyl fumarate and/or monomethyl hydrogen fumarate to a patient
in need thereof.
[0280] 92. PPAR gamma agonist for use in combination with an Nrf2
activator in the treatment of an autoimmune and/or inflammatory
disease.
[0281] 93. PPAR gamma agonist for use in combination with an Nrf2
activator according to embodiment 92, characterized in that the
Nrf2 activator is dimethyl fumarate.
[0282] 94. PPAR gamma agonist for use in combination with an Nrf2
activator according to claim 92, characterized in that the Nrf2
activator is bardoxolone methyl.
[0283] 95. PPAR gamma agonist for use in combination with an Nrf2
activator according to one of the foregoing embodiments,
characterized in that the PPAR gamma agonist is pioglitazone.
[0284] 96. PPAR gamma agonist for use in combination with an Nrf2
activator according to one of the foregoing embodiments,
characterized in that the PPAR gamma agonist is selected from the
group of rosiglitazone, troglitazone and ciglitazone.
[0285] 97. PPAR gamma agonist for use in combination with an Nrf2
activator according to one of the foregoing embodiments,
characterized in that the autoimmune and/or inflammatory disease is
psoriasis.
[0286] 98. PPAR gamma agonist for use in combination with an Nrf2
activator according to one of the foregoing embodiments,
characterized in that the autoimmune and/or inflammatory disease is
multiple sclerosis.
[0287] 99. PPAR gamma agonist for use in combination with an Nrf2
activator according to one of the foregoing embodiments,
characterized in that the autoimmune and/or inflammatory disease is
colitis ulcerosa.
[0288] 100. PPAR gamma agonist for use in combination with an Nrf2
activator according to one of the foregoing embodiments,
characterized in that the autoimmune and/or inflammatory disease is
Crohn's disease.
[0289] 101. PPAR gamma agonist for use in combination with an Nrf2
activator according to one of the foregoing embodiments,
characterized in that the autoimmune and/or inflammatory disease is
allopecia greata or cicatricial alopecia.
[0290] 102. PPAR gamma agonist for use in combination with an Nrf2
activator according to one of the foregoing embodiments,
characterized in that the autoimmune and/or inflammatory disease is
diabetic nephrophathy.
[0291] 103. PPAR gamma agonist for use in combination with an Nrf2
activator according to one of the foregoing embodiments,
characterized in that the autoimmune and/or inflammatory disease is
myasthenia gravis.
[0292] 104. A pharmaceutical composition comprising pioglitazone,
dimethyl fumarate and optionally one or more excipients.
[0293] 105. A pharmaceutical composition comprising dimethyl
fumarate and a PPAR gamma agonist selected from rosiglitazone,
troglitazone and ciglitazone, and optionally one or more
excipients.
[0294] 106. A pharmaceutical composition comprising bardoxolone
methyl and a PPAR gamma agonist selected from pioglitazone,
rosiglitazone, troglitazone and ciglitazone, and optionally one or
more excipients.
[0295] 107. Method of treating or preventing neurodegenerative
diseases, comprising administration of a PPAR gamma agonist
selected from the group of glitazones and a fumaric acid monoalkyl
and/or dialkyl ester to a patient in need thereof.
[0296] 108. Method according to embodiment 107, wherein the fumaric
acid dialkyl ester is selected from dimethyl fumarate and diethyl
fumarate and the fumaric acid monoalkyl ester is selected from
monomethyl hydrogen fumarate and monoethyl hydrogen fumarate.
[0297] 109. Method according to embodiment 107 or 108, wherein the
PPAR gamma agonist glitazone is selected from pioglitazone and
rosiglitazone.
[0298] 110. Method according to embodiment 107, 108 or 109, wherein
the neurodegenerative disease is multiple sclerosis.
[0299] 111. A pharmaceutical composition comprising a ppar gamma
agonist selected from the group of glitazones and a fumaric acid
monoalkyl and/or dialkyl ester and optionally one or more
excipients.
[0300] 112. A pharmaceutical composition according to embodiment
111, wherein the fumaric acid dialkyl ester is selected from
dimethyl fumarate and diethyl fumarate and the fumaric acid
monoalkyl ester is selected from monomethyl hydrogen fumarate and
monoethyl hydrogen fumarate.
[0301] 113. A pharmaceutical composition according to embodiment
111 or 112, wherein the PPAR gamma agonist glitazone is selected
from pioglitazone and rosiglitazone.
[0302] 114. Method of treating or preventing neurodegenerative
diseases, comprising administration of a pharmaceutical composition
according to embodiments 111, 112 or 113 to a patient in need
thereof.
[0303] 115. Method according to embodiment 114, wherein the
neurodegenerative disease is multiple sclerosis.
[0304] 116. A solid oral dosage form comprising a ppar gamma
agonist selected from the group of glitazones and a fumaric acid
monoalkyl and/or dialkyl ester and optionally one or more
excipients.
[0305] 117. A solid oral dosage form according to embodiment 116,
wherein the fumaric acid dialkyl ester is selected from dimethyl
fumarate and diethyl fumarate and the fumaric acid monoalkyl ester
is selected from monomethyl hydrogen fumarate and monoethyl
hydrogen fumarate.
[0306] 118. A solid oral dosage form according to embodiment 116 or
117, wherein the PPAR gamma agonist glitazone is selected from
pioglitazone and rosiglitazone.
[0307] 119. Method of treating or preventing neurodegenerative
diseases, comprising oral administration of a solid oral dosage
form according to embodiments 116, 117 or 118 to a patient in need
thereof
[0308] 120. Method according to embodiment 119, wherein the
neurodegenerative disease is multiple sclerosis.
[0309] 121. Kit of parts comprising a) a ppar gamma agonist
selected from the group of glitazones and b) a fumaric acid
monoalkyl and/or dialkyl ester and optionally c) instructions for a
dosage regime.
[0310] 122. Kit of parts according to embodiment 121, wherein the
fumaric acid dialkyl ester is selected from dimethyl fumarate and
diethyl fumarate and the fumaric acid monoalkyl ester is selected
from monomethyl hydrogen fumarate and monoethyl hydrogen
fumarate.
[0311] 123. Kit of parts according to embodiment 121 or 122,
wherein the PPAR gamma agonist glitazone is selected from
pioglitazone and rosiglitazone.
[0312] Preferably, the PPAR agonist and the Nrf2 activator used in
the present invention do not belong to the same chemical class of
compounds, i.e. the Nrf2 activator preferably belongs to a
different class of compounds as the PPAR agonist.
[0313] Solid oral dosage forms comprising the inventive
combinations for use in treatment of inflammatory and/or autoimmune
diseases are preferred.
[0314] Preferred is also a composition comprising dimethyl
fumarate, monomethyl fumarate, optionally in form of its zinc,
magnesium and/or calcium salts and a PPAR agonist. The use of this
composition in the treatment of psoriasis is particularly
preferred.
[0315] Preferred is also a PPAR gamma agonist for use in
combination with an Nrf2 activator in the treatment of an
autoimmune and/or inflammatory disease, according to any of the
foregoing embodiments, characterized in that the treatment does not
comprise or excludes the administration of hydroxyurea
(hydroycarbamid).
[0316] Pioglitazone and rosiglitazone tablets are commercially
available and can be used as such for the combination therapy
according to the invention.
[0317] In one embodiment, preferred tablets are film-coated tablets
containing rosiglitazone maleate equivalent to rosiglitazone, 2 mg,
4 mg, or 8 mg, for oral administration, with the following inactive
ingredients: Hypromellose 2910, lactose monohydrate, magnesium
stearate, microcrystalline cellulose, polyethylene glycol 3000,
sodium starch glycolate, titanium dioxide, triacetin, and 1 or more
of the following: Synthetic red and yellow iron oxides and
talc.
[0318] In one embodiment, preferred tablet for oral administration
contain 15 mg, 30 mg, or 45 mg of pioglitazone (as the base)
formulated with the following excipients: lactose monohydrate NF,
hydroxypropylcellulose NF, carboxymethylcellulose calcium NF, and
magnesium stearate NF.
[0319] Other formulations can be obtained in analogy to US6355676,
US7976853 and 6403121.
[0320] Throughout the specification, the term "no significant PPAR
gamma agonistic activity" or "no significant PPAR gamma agonistic
effect" means that at the therapeutically useful concentration of
the Nrf2 activator, no therapeutically useful PPAR gamma activation
can be obtained or measured.
[0321] Throughout the specification, the term "no significant
effect on Nrf2" or "no significantly activating effect on Nrf2" or
"no significant effect on Nrf2 activity" means that at the
therapeutically useful concentration of the PPAR gamma agonist, no
therapeutically useful Nrf2 activation can be obtained or
measured.
[0322] The term monoalkyl fumarate and monoalkyl hydrogen fumarate
are used synonymously, such as monomethyl fumarate and monomethyl
hydrogen fumarate.
EXAMPLES
Example 1
Preparation of Enteric-Coated Micro-Tablets in Capsules Containing
120.0 mg of Dimethyl Fumarate
[0323] Following U.S. Pat. No. 7,320,999, 12.000 kg of dimethyl
fumarate are crushed, mixed and homogenized by means of a sieve
800. Then an excipient mixture with the following composition is
prepared: 17.50 kg of starch derivative (STA-RX.RTM. 1500), 0.30 kg
of microcrystalline cellulose (Avicel.RTM. PH 101), 0.75 kg of PVP
(Kollidon.RTM. 120), 4.00 kg of Primogel.RTM., 0.25 kg of colloidal
silicic acid (Aerosil.RTM.). Dimethyl fumarate is added to the
entire powder mixture, mixed, homogenized by means of a sieve 200,
processed in the usual manner with a 2% aqueous solution of
polyvidon pyrrolidone (Kollidon.RTM. K25) to obtain a binder
granulate and then mixed in the dry state with the outer phase.
Said outer phase consists of 0.50 kg of Mg stearate and 1.50 kg of
talcum.
[0324] The powder mixture is compressed in the usual manner into 10
mg-micro tablet cores.
[0325] To achieve resistance to gastric acid a solution of 2.250 kg
of hydroxy propyl methyl cellulose phthalate (HPMCP,
Pharmacoat.RTM. HP 50) is dissolved in portions in a mixture of the
following solvents: 13.00 L of acetone, 13.50 L of ethanol (94
wt.-%, denatured with 2% of ketone) and 1.50 L of demineralised
water. As a plasticiser, castor oil (0.240 kg) is added to the
finished solution, which is applied in portions onto the micro
tablet cores in the customary manner.
[0326] After drying is completed, a suspension of the following
composition is applied as a film coat in the same apparatus: 0.340
kg of talcum, 0.400 kg of titanium(VI) oxide Cronus RN 56, 0.324 kg
of coloured lacquer L-Rot-lack 86837, 4.800 kg of Eudragit E 12.5%
and 0.120 kg of polyethylene glycol 6000, pH 11 XI in a solvent
mixture of the following composition: 8.170 kg of 2-propanol, 0.200
kg of demineralised water and 0.600 kg of glycerine triacetate
(Triacetin). This procedure resulted in enteric-coated
micro-tablets.
[0327] Subsequently, the enteric-coated micro-tablets are filled
into hard gelatine capsules and are sealed for use according to the
invention.
[0328] Micro pellets can be obtained similarly according to
US7320999.
Example 2
Preparation of Tablets Containing Pioglitazone and Dimethyl
Fumarate in Separate Tablet Layers
[0329] According to U.S. Pat. No. 807,113, a mixture of
pioglitazone hydrochloride (99.2 g), croscarmellose sodium (13.2 g)
and lactose (184.9 g) is granulated by spraying thereon 136.2 g of
an aqueous solution of hydroxypropylcellulose (6.81 g), in a fluid
bed granulator (manufactured by Powrex Corp., Model: LAB-1). The
resulting granulated powder is then granulated by spraying a
suspension obtained by dispersing lactose (36 g) in 148.6 g of an
aqueous solution of hydroxypropylcellulose (7.59 g) thereon in a
fluid bed granulator (manufactured by Powrex Corp., Model: LAB-1)
to obtain pioglitazone hydrochloride-containing granulated powder
coated with lactose. To a part (23.18 g) of the granulated powder
thus obtained, croscarmellose sodium (0.728 g) and magnesium
stearate (0.096 g) are added and mixed to obtain pioglitazone
hydrochloride-containing mixed powder. The pioglitazone
hydrochloride-containing mixed powder is compressed in the form of
laminate with a powder obtained according to example 1, containing
dimethyl fumarate, a starch derivative (STA-RX.RTM. 1500),
microcrystalline cellulose (Avicel.RTM. PH 101), PVP (Kollidon.RTM.
120), Primogel.RTM., and colloidal silicic acid (Aerosil.RTM.).
Example 3
[0330] According to US7976853, hydroxypropyl cellulose (26.4 g,
Grade SSL, Nippon Soda Co., Ltd.) (viscosity of 5% aqueous solution
at 20.degree. C.: 8 mPas), polyethylene glycol 6000 (1.32 g),
titanium oxide (2.64 g) and pioglitazone hydrochloride (16.5 g) are
dispersed in water (297 g) to give a coating solution. The enteric
coated micro-tablets obtained in example 1 are fed in a film
coating equipment (Hicoater-Mini, Freund Industrial Co. Ltd.) and
coated with the aforementioned coating solution to give a coated
preparation. Subsequently, these enteric-coated micro-tablets,
which are coated with pioglitazone hydrochloride, are filled into
hard gelatine capsules and are sealed for use according to the
present invention.
[0331] Alternatively, according to example 1, an enteric-coated
tablet containing the desired amount of dimethyl fumarate can be
obtained, followed by a coating with a pioglitazone formulation as
described above. The tablets can be used as such for the
combination treatment according to the invention.
Example 4
[0332] A mixture of pioglitazone hydrochloride (99.2 g),
croscarmellose sodium (13.2 g) and lactose (184.9 g) which is
granulated by spraying thereon 136.2 g of an aqueous solution of
hydroxypropylcellulose (6.81 g), in a fluid bed granulator
(manufactured by Powrex Corp., Model: LAB-1). The resulting
granulated powder is then granulated by spraying a suspension
obtained by dispersing lactose (36 g) in 148.6 g of an aqueous
solution of hydroxypropylcellulose (7.59 g) thereon in a fluid bed
granulator (manufactured by Powrex Corp., Model: LAB-1) to obtain
pioglitazone hydrochloride-containing granulated powder coated with
lactose. A desired amount of the granulated powder thus obtained,
is filled in a capsules containing dimethyl fumarate enteric-coated
micro tablets obtained according to example 1, which are thereafter
sealed.
Example 5
[0333] A capsule is filled a dispersion of 20 mg of amorphous
bardoxolone methyl in methacrylic acid copolymer Type C, USP in a
4/6 weight ratio of bardoxolone methyl to methacrylic acid
copolymer Type C, USP having the following composition is prepared
according to US2012/022156:
[0334] Amorphous bardoxolone methyl as 40% dispersion: 11.36%
[0335] SMCC (90LM, silicified microcrystalline cellusose, as listed
in the FDA Inactive Ingredients Guide): 36.36%
[0336] lactose monohydrate: 40.91%
[0337] hydroxypropyl methylcellulose: 6.82%
[0338] colloidal silicon dioxide: 0.91%
[0339] magnesium Stearate: 0.91%
[0340] sodium lauryl sulphate: 2.73%.
[0341] In addition, the capsule is filled with an equivalent of 45
mg of pioglitazone in form of its hydrochloride as a granulated
powder coated with lactose obtained according to the first part of
example 4. The capsule is thereafter sealed for use.
[0342] Alternatively, the bardoxolone methyl containing mixture and
the pioglitazone containing mixture can be compressed into a
tablet, preferably a layered tablet, wherein the formulations are
arranged in a laminar manner. In one embodiment, an enteric coat is
applied to the tablet.
General Experimental Protocols
[0343] Treatment in the following animal models consists of, or
animals are treated with, dimethyl fumarate and pioglitazone which
are dissolved or dispersed in 0.5% methocellulose/0.1% Tween80 in
distilled water and administered by oral gavage twice daily.
Treatment groups are generally as follows: vehicle alone, dimethyl
fumarate alone, pioglitazone alone or the combination of dimethyl
fumarate and pioglitazone. The combination according to the
invention results in an improved response to treatment over the
vehicle and the respective agents alone.
[0344] The effect of the combinations according to the present
invention in the treatment of cancer and preferably hematologic
cancers such as CLL and AML can be found according to Blood. 2006
Nov. 15; 108(10):3530-7 and Cancer Res Jun. 15, 2010 70; 4949.
EAE Animal Model for Assessing Therapeutic Effect of the
Combination of a PPAR Gamma Agonist and an Nrf2 Activator for
Treating Multiple Sclerosis
[0345] Animals and EAE Induction Female C57BL/6 mice, 8-10 weeks
old (Harlan Laboratories, Livermore, Calif.), are immunized
subcutaneously in the flanks and mid-scapular region with 200 .mu.g
of myelin oligodendrocyte glycoprotein peptide (MOG3S-Ss)
(synthesized by Invitrogen) emulsified (1:1 volume ratio) with
complete Freund's adjuvant (CFA) (containing 4 mg/nL Mycobacterium
tuberculosis). Emulsion is prepared by the syringe-extrusion method
with two glass Luer-Lock syringes connected by a 3-way stopcock.
Mice are also given an intraperitoneal injection of 200 ng
pertussis toxin (List Biological Laboratories, Inc, Campbell,
Calif.) on the day of immunization and on day two post
immunization. Mice are weighed and examined daily for clinical
signs of experimental autoimmune encephalomyelitis (EAE). Food and
water is provided ad libitum and once animals start to show
disease, food is provided on the cage bottom.
Clinical Evaluation
[0346] Mice are scored daily beginning on day 7 post immunization.
The clinical scoring scale is as follows (Miller and Karplus,
Current Protocols in Immunology 2007, 15.1.1-15.1.18): 0=normal;
1=limp tail or hind limb weakness (defined by foot slips between
bars of cage top while walking); 2=limp tail and hind limb
weakness; 3=partial hind limb paralysis (defined as no weight
bearing on hind limbs but can still move one or both hind limbs to
some extent); 4=complete hind limb paralysis; 5=moribund state
(includes forelimb paralysis) or death.
Use of an Animal Model to Assess Effect in Treating Psoriasis
[0347] The severe, combined immunodeficient (SCID) mouse model can
be used to evaluate the efficacy of compounds for treating
psoriasis in humans (Boehncke, Ernst Schering Res Found Workshop
2005, 50, 213-34; and Bhagavathula et al, J Pharmacol Expt 7
Therapeutics 2008, 324(3), 938-947).
[0348] SCID mice are used as tissue recipients. One biopsy for each
normal or psoriatic volunteer is transplanted onto the dorsal
surface of a recipient mouse. Treatment is initiated 1 to 2 weeks
after transplantation. Animals with the human skin transplants are
divided into treatment groups. Animals are treated twice daily for
14 days. At the end of treatment, animals are photographed and then
euthanized. The transplanted human tissue along with the
surrounding mouse skin is surgically removed and fixed in 10%
formalin and samples obtained for microscopy. Epidermal thickness
is measured. Tissue sections are stained with an antibody to the
proliferation-associated antigen Ki-67 and with an anti-human CD3+
monoclonal antibody to detect human T lymphocytes in the
transplanted tissue. Sections are also probed with antibodies to
c-myc and .beta.-catenin. A positive response to treatment is
reflected by a reduction in the average epiderma thickness of the
psoriatic skin transplants. A positive response is also associated
with reduced expression of Ki-67 in keratinocytes.
Animal Model for Assessing Therapeutic Effect of the Combination of
a PPAR Gamma Agonist and an Nrf2 Activator for Treating Multiple
Sclerosis
[0349] Experiments are conducted on female mice aged 4-6 weeks
belong to the C57BL/6 strain weighing 17-20 g. Experimental
autoimmune encephalomyelitis (EAE) is actively induced using
>95% pure synthetic myelin oligodendrocyte glycoprotein peptide
35-55 (MOG35-55, MEVGWYRSPFSRVVHLYRNGK, SEQ ID NO: 1). Each mouse
is anesthetized and receives 200 .mu.g of MOG peptide and 15 .mu.g
of Saponin extract from Quilija bark emulsified in 100 .mu.L of
phosphate-buffered saline. A 25 .mu.L volume is injected
subcutaneously over four flank areas. Mice are also
intraperitoneally injected with 200 ng of pertussis toxin in 200
.mu.L of PBS. A second, identical injection of pertussis toxin is
given after 48 h.
[0350] Daily treatment extends from day 26 to day 36
post-immunization. Clinical scores are obtained daily from day 0
post-immunization until day 60. Clinical signs are scored using the
following protocol: 0, no detectable signs; 0.5, distal tail
limpness, hunched appearance and quiet demeanor; 1, completely limp
tail; 1.5, limp tail and hindlimb weakness (unsteady gait and poor
grip with hindlimbs); 2, unilateral partial hindlimb paralysis;
2.5, bilateral hindlimb paralysis; 3, complete bilateral hindlimb
paralysis; 3.5, complete hindlimb paralysis and unilateral forelimb
paralysis; 4, total paralysis of hindlimbs and forelimbs (Eugster
et al., Eur J Immunol 2001, 31, 2302-2312).
[0351] Inflammation and demyelination are assessed by histology on
sections from the CNS of EAE mice. Mice are sacrificed after 30 or
60 days and whole spinal cords are removed and placed in 0.32 M
sucrose solution at 40.degree. C. overnight. Tissues are prepared
and sectioned. Luxol fast blue stain is used to observe areas of
demyelination. Haematoxylin and eosin staining is used to highlight
areas of inflammation by darkly staining the nuclei of mononuclear
cells. Immune cells stained with H&E are counted in a blinded
manner under a light microscope. Sections are separated into gray
and white matter and each sector is counted manually before being
combined to give a total for the section. T cells are immunolabeled
with anti-CD3+ monoclonal antibody. After washing, sections are
incubated with goat anti-rat HRP secondary antibody. Sections are
then washed and counterstained with methyl green. Splenocytes
isolated from mice at 30 and 60 days post-immunization are treated
with lysis buffer to remove red blood cells. Cells are then
resuspended in PBS and counted. Cells at a density of about
3.times.106 cells/mL are incubated overnight with 20 .mu.g/mL of
MOG peptide. Supernatants from stimulated cells are assayed for
IFN-.gamma. protein levels using an appropriate mouse IFN-.gamma.
immunoassay system.
Use of an Animal Model to Assess Effect in Treating Inflammatory
Bowel Disease
[0352] Animal models of inflammatory bowel disease are described by
Jurjus et al, J Pharmaocol Toxicol Methods 2004, 50, 81-92;
Villegas et al, Int'l Immunopharmacol 2003, 3, 1731-1741; and
Murakami et al, Biochemical Pharmacol 2003, 66, 1253-1261. For
example, the following protocol can be used to assess the effect of
the combination according to the present invention for treating
inflammatory bowel disease, morbus Crohn and colitis.
[0353] Female ICR mice are used. Mice are divided into treatment
groups. Groups are given either water (control), 5% DSS in tap
water is given at the beginning of the experiment to induce
colitis, or treatment is given. After administering the treatment
for 1 week, 5% DSS in tap water is also administered to the groups
receiving treatment for 1 week. At the end of the experiment, all
mice are killed and the large intestine is removed. Colonic mucosa
samples are obtained and homogenized. Proinflammatory mediators
(e.g., IL-1.alpha., IL-1.beta., TNF-.alpha., PGE2, and PGF2.alpha.)
and protein concentrations are quantified. Each excised large
intestine is histologically examined and the damage to the colon
scored.
Clinical Trial for Assessing Effect in Treating Asthma
[0354] Adult subjects (nonsmokers) with stable mild-to-moderate
asthma are enrolled (see, e.g., Van Schoor and Pauwels, Eur Respir
J 2002, 19, 997-1002). A randomized, double-blind,
placebo-controlled, two-period crossover design is used. Placebo,
dimethyl fumarate alone, pioglitazone alone and a combination of
dimethyl fumarate and pioglitazone is administered orally in
different arms. The combination according to the invention results
in an improved response to treatment over the vehicle and the
agents alone.
Use of an Animal Model to Assess Effect in Treating Chronic
Obstructive Pulmonary
[0355] Disease animal model using mice chronically exposed to
cigarette smoke can be used for assessing efficacy in treating
emphysema (see, e.g., Martorana et al., Am J Respir Crit. Care Med
2005, 172, 848-835; and Cavarra et al., Am J Respir Crit. Care Med
2001, 164, 886-890). Six-week old C57B1/6J male mice are used. In
the acute study, the mice are exposed either to room air or to the
smoke of five cigarettes for 20 minutes. In the chronic study, the
mice are exposed to either room air or to the smoke of three
cigarettes/day for 5 days/week for 7 months.
[0356] In the acute study, mice are divided into three groups.
These groups are then divided into four subgroups of 10 mice each
as follows: (1) no treatment/air-exposed; (2) no
treatment/smoke-exposed; (3) the combination of dimethyl fumarate
and pioglitazone plus smoke-exposed; and (4) pioglitazone plus
smoke-exposed; and (5) dimethyl fumarate plus smoke-exposed. In the
first group, trolox equivalent antioxidant capacity is assessed at
the end of the exposure in bronchoalveolar lavage fluid. In the
second group, cytokines and chemokines are determined in
bronchoalveolar lavage fluid using a commercial cytokine panel at 4
hours; and in the third group bronchoalveolar lavage fluid cell
count is assessed at 24 hours.
Animal Models for Assessing Therapeutic Effect of the Combination
of a PPAR Gamma Agonist and an Nrf2 Activator for Treating
Parkinson's Disease
MPTP Induced Neurotoxicity
[0357] MPTP, or 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine is a
neurotoxin that produces a Parkinsonian syndrome in both man and
experimental animals. Studies of the mechanism of MPTP
neurotoxicity show that it involves the generation of a major
metabolite, MPP+, formed by the activity of monoamine oxidase on
MPTP. Inhibitors of monoamine oxidase block the neurotoxicity of
MPTP in both mice and primates. The specificity of the neurotoxic
effects of MPP+ for dopaminergic neurons appears to be due to the
uptake of MPP+ by the synaptic dopamine transporter. Blockers of
this transporter prevent MPP+ neurotoxicity. MPP+ has been shown to
be a relatively specific inhibitor of mitochondrial complex I
activity, binding to complex I at the retenone binding site and
impairing oxidative phosphorylation. In vivo studies have shown
that MPTP can deplete striatal ATP concentrations in mice. It has
been demonstrated that MPP+ administered intrastriatally to rats
produces significant depletion of ATP as well as increased lactate
concentration confined to the striatum at the site of the
injections. Compounds that enhance ATP production can protect
against MPTP toxicity in mice.
[0358] Mice or rats are treated either with vehicle alone, dimethyl
fumarate alone pioglitazone alone or the combination of dimethyl
fumarate and pioglitazone for three weeks before treatment with
MPTP. MPTP is administered at an appropriate dose, dosing interval,
and mode of administration for 1 week before sacrifice. Control
groups receive either normal saline or MPTP hydrochloride alone.
Following sacrifice the two striate are rapidly dissected and
placed in chilled 0.1 M perchloric acid. Tissue is subsequently
sonicated and aliquots analyzed for protein content using a
fluorometer assay. Dopamine, 3,4-dihydroxyphenylacetic acid
(DOPAC), and homovanillic acid (HVA) are also quantified.
Concentrations of dopamine and metabolites are expressed as nmol/mg
protein.
Haloperidol-Induced Hypolocomotion
[0359] The ability of a compound to reverse the behavioral
depressant effects of dopamine antagonists such as haloperidol, in
rodents and is considered a valid method for screening drags with
potential antiparkinsonian effects (Mandhane, et al., Eur. J.
Pharmacol 1997, 328, 135-141). Hence, the ability of the treatment
to block haloperidol-induced deficits in locomotor activity in mice
can be used to assess both in vivo and potential anti-Parkinsonian
efficacy.
[0360] Mice used in the experiments are housed in a controlled
environment and allowed to acclimatize before experimental use. One
and one-half (1.5) hours before testing, mice are administered 0.2
mg/kg haloperidol, a dose that reduces baseline locomotor activity
by at least 50%. Treatment is administered a suitably long prior to
testing. The animals are then placed individually into clean, clear
polycarbonate cages with a flat perforated lid.
[0361] Horizontal locomotor activity is determined by placing the
cages within a frame containing a 3.times.6 array of photocells
interfaced to a computer to tabulate beam interrupts. Mice are left
undisturbed to explore for 1 h, and the number of beam
interruptions made during this period serves as an indicator of
locomotor activity, which is compared with data for control animals
for statistically significant differences.
6-Hydroxydopamine Animal Model
[0362] The neurochemical deficits seen in Parkinson's disease can
be reproduced by local injection of the dopaminergic neurotoxin,
6-hydroxydopamine (6-OHDA) into brain regions containing either the
cell bodies or axonal fibers of the nigrostriatal neurons. By
unilaterally lesioning the nigrostriatal pathway on only one-side
of the brain, a behavioral asymmetry in movement inhibition is
observed. Although unilaterally-lesioned animals are still mobile
and capable of self maintenance, the remaining dopamine-sensitive
neurons on the lesioned side become supersensitive to stimulation.
This is demonstrated by the observation that following systemic
administration of dopamine agonists, such as apomorphine, animals
show a pronounced rotation in a direction contralateral to the side
of lesioning. The ability of compounds to induce contralateral
rotations in 6-OHDA lesioned rats has been shown to be a sensitive
model to predict drug efficacy in the treatment of Parkinson's
disease.
[0363] Male Sprague-Dawley rats are housed in a controlled
environment and allowed to acclimatize before experimental use.
Fifteen minutes prior to surgery, animals are given an
intraperitoneal injection of the noradrenergic uptake inhibitor
desipramine (25 mg/kg) to prevent damage to nondopamine neurons.
Animals are then placed in an anesthetic chamber and anesthetized
using a mixture of oxygen and isoflurane. Once unconscious, the
animals are transferred to a stereotaxic frame, where anesthesia is
maintained through a mask. The top of the head is shaved and
sterilized using an iodine solution. Once dry, a 2 cm long incision
is made along the midline of the scalp and the skin retracted and
clipped back to expose the skull. A small hole is then drilled
through the skull above the injection site. In order to lesion the
nigrostriatal pathway, the injection cannula is slowly lowered to
position above the right medial forebrain bundle at -3.2 mm
anterior posterior, -1.5 mm medial lateral from the bregma, and to
a depth of 7.2 mm below the duramater. Two minutes after lowering
the cannula, 6-OHDA is infused at a rate of 0.5 .mu.L/min over 4
min, to provide a final dose of 8 .mu.g. The cannula is left in
place for an additional 5 min to facilitate diffusion before being
slowly withdrawn. The skin is then sutured shut, the animal removed
from the sterereotaxic frame, and returned to its housing. The rats
are allowed to recover from surgery for two weeks before behavioral
testing.
[0364] Rotational behavior is measured using a rotameter system
having stainless steel bowls (45 cm dia.times.15 cm high) enclosed
in a transparent Plexiglas cover around the edge of the bowl and
extending to a height of 29 cm. To assess rotation, rats are placed
in a cloth jacket attached to a spring tether connected to an
optical rotameter positioned above the bowl, which assesses
movement to the left or right either as partial (45.degree.) or
full (360.degree.) rotations.
[0365] Treatment is given for a suitable period prior to testing.
Animals are given a subcutaneous injection of a subthreshold dose
of apomorphine, and are then placed in the harness. The number of
rotations are recorded for one hour. The total number of full
contralateral rotations during the hour test period serves as an
index of antiparkinsonian drug efficacy.
Animal Model for Assessing Therapeutic Effect for Treating
Alzheimer's Disease
[0366] Heterozygous transgenic mice expressing the Swedish AD
mutant gene, hAPPK670N, M671L (Tg2576; Hsiao, Learning & Memory
2001, 8, 301-308) are used as an animal model of Alzheimer's
disease. Animals are housed under standard conditions with a 12:12
light/dark cycle and food and water available ad libitum. Beginning
at 9 months of age, mice are divided into two groups. The groups of
animals receive treatment over six weeks.
[0367] Behavioral testing is performed at each drug dose using the
same sequence over two weeks in all experimental groups: (1)
spatial reversal learning, (2) locomotion, (3) fear conditioning,
and (4) shock sensitivity.
[0368] Acquisition of the spatial learning paradigm and reversal
learning are tested during the first five days of test compound
administration using a water T-maze as described in Bardgett et
al., Brain Res Bull 2003, 60, 131-142. Mice are habituated to the
water T-maze during days 1-3, and task acquisition begins on day 4.
On day 4, mice are trained to find the escape platform in one
choice arm of the maze until 6 to 8 correct choices are made on
consecutive trails. The reversal learning phase is then conducted
on day 5. During the reversal learning phase, mice are trained to
find the escape platform in the choice arm opposite from the
location of the escape platform on day 4. The same performance
criteria and inter-trial interval are used as during task
acquisition.
[0369] Large ambulatory movements are assessed to determine that
the results of the spatial reversal learning paradigm are not
influenced by the capacity for ambulation. After a rest period of
two days, horizontal ambulatory movements, excluding vertical and
fine motor movements, are assessed in a chamber equipped with a
grid of motion-sensitive detectors on day 8. The number of
movements accompanied by simultaneous blocking and unblocking of a
detector in the horizontal dimension are measured during a one-hour
period.
[0370] The capacity of an animal for contextual and cued memory is
tested using a fear conditioning paradigm beginning on day 9.
Testing takes place in a chamber that contains a piece of absorbent
cotton soaked in an odor-emitting solution such as mint extract
placed below the grid floor. A 5-min, 3 trial 80 db, 2800 Hz
tone-foot shock sequence is administered to train the animals on
day 9. On day 10, memory for context is tested by returning each
mouse to the chamber without exposure to the tone and foot shock,
and recording the presence or absence of freezing behavior every 10
seconds for 8 minutes. Freezing is defined as no movement, such as
ambulation, sniffing or stereotypy, other than respiration.
[0371] On day 11, the response of the animal to an alternate
context and to the auditory cue is tested. Coconut extract is
placed in a cup and the 80 dB tone is presented, but no foot shock
is delivered. The presence or absence of freezing in response to
the alternate context is then determined during the first 2 minutes
of the trial. The tone is then presented continuously for the
remaining 8 minutes of the trial, and the presence or absence of
freezing in response to the tone is determined.
[0372] On day 12, the animals are tested to assess their
sensitivity to the conditioning stimulus, i.e., foot shock.
Following the last day of behavioral testing, animals are
anesthetized and the brains removed, post-fixed overnight, and
sections cut through the hippocampus. The sections are stained to
image .beta.-amyloid plaques.
[0373] Data is analyzed using appropriate statistical methods.
Animal Model for Assessing Therapeutic Effect for Treating
Huntington's Disease
[0374] Neuroprotective Effects in a Transgenic Mouse Model of
Huntington's Disease Transgenic HD mice of the N171-82Q strain and
non-transgenic littermates are treated from 10 weeks of age. The
mice are placed on a rotating rod ("rotarod"). The length of time
at which a mouse falls from the rotarod is recorded as a measure of
motor coordination. The total distance traveled by a mouse is also
recorded as a measure of overall locomotion. Mice showing improved
response to treatment with the combination of dimethyl fumarate and
pioglitazone remain on the rotarod for a longer period of time and
travel farther than mice administered vehicle or either agent
alone.
Malonate Model of Huntington's Disease
[0375] A series of reversible and irreversible inhibitors of
enzymes involved in energy generating pathways has been used to
generate animal models for neurodegenerative diseases such as
Parkinson's and Huntington's diseases. In particular, inhibitors of
succinate dehydrogenase, an enzyme that impacts cellular energy
homeostasis, has been used to generate a model for Huntington's
disease.
[0376] In this malonate model for Huntington's disease, treatment
is administered at an appropriate dose, dosing interval, and route,
to male Sprague-Dawley rats. Treatment is administered for two
weeks prior to the administration of malonate and then for an
additional week prior to sacrifice. Malonate is dissolved in
distilled deionized water and the pH adjusted to 7.4 with 0.1 M
HCl. Intrastriatal injections of 1.5 .mu.L of 3 .mu.mol malonate
are made into the left striatum at the level of the Bregma 2.4 mm
lateral to the midline and 4.5 mm ventral to the dura. Animals are
sacrificed at 7 days by decapitation and the brains quickly removed
and placed in ice cold 0.9% saline solution. Brains are sectioned
at 2 mm intervals in a brain mold. Slices are then placed posterior
side down in 2% 2,3,5-tiphenyltetrazolium chloride. Slices are
stained in the dark at room temperature for 30 min and then removed
and placed in 4% paraformaldehyde pH 7.3. Lesions, noted by pale
staining, are evaluated on the posterior surface of each section.
The measurements are validated by comparison with measurements
obtained on adjacent Nissl stain sections.
Animal Model for Assessing Therapeutic Effect for Treating
Amyotrophic Lateral Sclerosis
[0377] A murine model of SOD1 mutation-associated ALS has been
developed in which mice express the human superoxide dismutase
(SOD) mutation glycine--alanine at residue 93 (SOD1). These SOD1
mice exhibit a dominant gain of the adverse property of SOD, and
develop motor neuron degeneration and dysfunction similar to that
of human ALS. The SOD1 transgenic mice show signs of posterior limb
weakness at about 3 months of age and die at 4 months. Features
common to human ALS include astrocytosis, microgliosis, oxidative
stress, increased levels of cyclooxygenase/prostaglandin, and, as
the disease progresses, profound motor neuron loss. Studies are
performed on transgenic mice overexpressing human Cu/Zn-SOD G93A
mutations (B6S JL-TgN(SOD1-G93A) 1 Gur) and non-transgenic B6/SJL
mice and their wild litter mates. Mice are housed on a 12-hr
day/light cycle and (beginning at 45 d of age) allowed ad libitum
access to either test compound-supplemented chow, or, as a control,
regular formula cold press chow processed into identical pellets.
Genotyping can be conducted at 21 days of age as described in
Gurney et al., Science 1994, 264(5166), 1772-1775. The SOD1 mice
are separated into groups and treatment is administered for a
suitable period.
[0378] The mice are observed daily and weighed weekly. To assess
health status mice are weighed weekly and examined for changes in
lacrimation/salivation, palpebral closure, ear twitch and pupillary
responses, whisker orienting, postural and righting reflexes and
overall body condition score. A general pathological examination is
conducted at the time of sacrifice.
[0379] Motor coordination performance of the animals can be
assessed by one or more methods known to those skilled in the art.
For example, motor coordination can be assessed using a
neurological scoring method. In neurological scoring, the
neurological score of each limb is monitored and recorded according
to a defined 4-point scale: 0--normal reflex on the hind limbs
(animal will splay its hind limbs when lifted by its tail);
1--abnormal reflex of hind limbs (lack of splaying of hind limbs
weight animal is lifted by the tail); 2--abnormal reflex of limbs
and evidence of paralysis; 3--lack of reflex and complete
paralysis; and 4--inability to right when placed on the side in 30
seconds or found dead. The primary end point is survival with
secondary end points of neurological score and body weight.
Neurological score observations and body weight are made and
recorded five days per week. Data analysis is performed using
appropriate statistical methods. The rotarod test evaluates the
ability of an animal to stay on a rotating dowel allowing
evaluation of motor coordination and proprioceptive sensitivity.
The apparatus is a 3 cm diameter automated rod turning at, for
example, 12 rounds per min. The rotarod test measures how long the
mouse can maintain itself on the rod without falling. The test can
be stopped after an arbitrary limit of 120 sec. Should the animal
fall down before 120 sec, the performance is recorded and two
additional trials are performed. The mean time of 3 trials is
calculated. A motor deficit is indicated by a decrease of walking
time.
[0380] In the grid test, mice are placed on a grid (length: 37 cm,
width: 10.5 cm, mesh size: 1.times.1 cm2) situated above a plane
support. The number of times the mice put their paws through the
grid is counted and serves as a measure for motor coordination. The
hanging test evaluates the ability of an animal to hang on a wire.
The apparatus is a wire stretched horizontally 40 cm above a table.
The animal is attached to the wire by its forepaws. The time needed
by the animal to catch the string with its hind paws is recorded
(60 sec max) during three consecutive trials.
[0381] Electrophysiological measurements (EMG) can also be used to
assess motor activity condition. Electromyographic recordings are
performed using an electromyography apparatus. During EMG
monitoring mice are anesthetized. The measured parameters are the
amplitude and the latency of the compound muscle action potential
(CMAP). CMAP is measured in gastrocnemius muscle after stimulation
of the sciatic nerve. A reference electrode is inserted near the
Achilles tendon and an active needle placed at the base of the
tail. A ground needle is inserted on the lower back of the mice.
The sciatic nerve is stimulated with a single 0.2 msec pulse at
supramaximal intensity (12.9 mA). The amplitude (mV) and the
latency of the response (ms) are measured. The amplitude is
indicative of the number of active motor units, while distal
latency reflects motor nerve conduction velocity. The effect of the
combinations according to the present invention can also be
evaluated using biomarker analysis. To assess the regulation of
protein biomarkers in SOD1 mice during the onset of motor
impairment, samples of lumbar spinal cord (protein extracts) are
applied to ProteinChip Arrays with varying surface
chemical/biochemical properties and analyzed, for example, by
surface enhanced laser desorption ionization time of flight mass
spectrometry. Then, using integrated protein mass profile analysis
methods, data is used to compare protein expression profiles of the
various treatment groups. Analysis can be performed using
appropriate statistical methods.
Animal Model for Assessing Therapeutic Effect in Myasthenia
Gravis
[0382] Induction and clinical evaluation of EAMG according to
International Immunology, Vol. 10, No. 9, pp. 1359-1365
[0383] B6 and .mu.MT mice are immunized s.c. along the shoulders
and back with 20 .mu.g AChR with CFA in a total volume of 100
.mu.l, and boosted twice at monthly intervals with 20 .mu.g of AChR
in CFA s.c. at four sites on the shoulders and thighs. The mice are
observed every other day in a blinded fashion for signs of muscle
weakness characteristic of EAMG. The clinical symptoms are graded
between 0 and 3 (4): 0, no definite muscle weakness; 1, normal
strength at rest but weak with chin on the floor and inability to
raise the head after exercise consisting of 20 consecutive paw
grips; 2, as grade 1 and weakness at rest; and 3, moribund,
dehydrated and paralyzed. Clinical EAMG is confirmed by injection
of neostigmine bromide and atropine sulfate. The mice are grouped
and treatment is administered for a suitable period before
testing.
Animal Model for Assessing the Therapeutic Effect in Alopecia
[0384] The Dundee experimental bald rat (DEBR) and the C3H/HeJ
mouse are well-established animal models for alopecia greata and
can be used for the study of genetic aspects, pathogenesis and
therapy of the disease. In C3H/HeJ mice alopecia greata can be
experimentally induced by grafting lesional skin from an affected
mouse to a histocompatible recipient which offers the possibility
to study the influence of various factors on the development of the
disease. The mice are grouped and treatment is administered for a
suitable period before testing.
General Experimental Protocol
[0385] Treatment in the following animal models consists of,
dimethyl fumarate dissolved or dispersed in 0.5% Hydroxypropyl
methylcellulose (HPMC) K4 M/0.25% Tween 20 and pioglitazone
dissolved or dispersed in kleptose in distilled water. Treatments
were administered by oral gavage once or twice daily. Treatment
groups were generally as follows: appropriate vehicles, dimethyl
fumarate, pioglitazone or the combination of dimethyl fumarate and
pioglitazone. The combination according to the invention results in
an improved response to treatment over the vehicle and the
respective agents alone.
EAE Animal Model for Assessing Therapeutic Effect of the
Combination of the PPAR Gamma Agonist and nrf2 Activator for
Treating Multiple Sclerosis
[0386] Female C57BL/6 mice are ordered (Janvier France or Charles
River) between 7-8 weeks old and used between 9-11 weeks after an
acclimatization period. Experimental autoimmune encephalomyelitis
(EAE) is actively induced using >95% pure synthetic myelin
oligodendrocyte glycoprotein peptide 35-55 (MOG35-55),
Met-Glu-Val-Gly-Trp-Tyr-Arg-Ser-Pro-Phe-Ser-Arg-Val-Val-His-Leu-Tyr-Arg-A-
sn-Gly-Lys (SEQ ID NO: 1), Ref SC1272, NeoMPS). Each mouse is
anesthetized and receives a subcutaneous injection of 100 .mu.l of
a Complete Freunds Adjuvant (Ref 263810, Difco) emulsion containing
200 .mu.g of MOG35-55 and 250 .mu.g of dried and killed M.
tuberculosis H37 Ra, Ref 231141 Difco) into the lower back. The
emulsion is prepared by the syringe method with two syringes
connected through a Luer-lock tube. Mice also receive an
intra-peritoneal injection of 300 ng of Pertussis Toxin (Ref
BML-G100, Enzo Lifescience) diluted in 200 .mu.l PBS. Pertussis
Toxin injection is repeated 48 hours later. Mice are weighed and
examined daily for clinical signs of EAE. Food and water are
provided ad libitum.
Clinical Evaluation
[0387] Animals were assessed for neurological deficits (clinical
score) and weighed daily. The clinical scoring scale is as follows;
0=no signs; 0.5=distal limp tail; 1=complete tail paralysis;
1.5=hind limb weakness; 2=unilateral partial hind limb paralysis;
2.5=bilateral partial hind limb paralysis; 3=complete bilateral
hind limb paralysis; 3.5=fore limb weakness and complete bilateral
hind limb paralysis; 4=quadriplegia/moribund; 5=death from EAE.
Results: Assessment of Treatment with Dimethyl Fumarate in
Combination with Pioglitazone in Form of its Hydrochloride
[0388] Forty female C57BL/6 mice aged 8-9 weeks were immunized
according to the EAE protocol described in the methods section.
Mice were assorted into 4 different treatment groups (n=10) and
received treatment with HPMC 0.5%/Tween20 0.25% (vehicle for
dimethyl fumarate) b.i.d. plus Kleptose 20% (vehicle for
pioglitazone) q.d., dimethyl fumarate 60 mg/kg b.i.d. plus Kleptose
20% q.d., pioglitazone 10 mg/kg q.d. plus HPMC 0.5%/Tween20 0.25%
b.i.d. or dimethyl fumarate 60 mg/kg b.i.d plus pioglitazone 10
mg/kg q.d. For simplicity, the vehicle treatments were not
mentioned in graph legends and the groups above were named as
control, dimethyl fumarate 60 mg/kg bid, pioglitazone 10 mg/kg q.d
or dimethyl fumarate+pioglitazone, respectively. Drug treatment
started at day 0 post-immunisation. As shown in FIG. 1A,
immunization of C57BL/6 mice with MOG35-55 induces locomotor
disability with the clinical signs arising around day 9
post-immunisation.
[0389] The effect of the combination (dimethyl
fumarate+pioglitazone) treatment significantly reduced average
daily clinical scores (FIG. 1A). The combination efficacy was more
pronounced and statistically different from the effect of
individual treatments. Suppression of inflammation-induced cachexia
acts as a reliable marker of treatment benefit. Combination
treatment (dimethyl fumarate+pioglitazone) treatment significantly
improved body weight in comparison to vehicle or single drug
treatments (FIG. 1B).
[0390] The effect of drug treatment on the prevalence of disease is
analysed on FIG. 2. The onset of disease is defined at the point
each mouse first exhibit a clinical score .gtoreq.1. FIG. 2A
depicts a Kaplan Meier analysis showing that control group mice
start developing EAE from day 9 with complete susceptibility by day
14 post-immunisation. The combination treatment with dimethyl
fumarate+pioglitazone shifted the EAE onset curve. Not all animals
treated with the drug combination developed signs of disease until
the termination of the experiment i.e. day 22 post-immunisation.
The effect of the combination treatment was statistically different
not only in comparison with the control group, but also in
comparison with each of the drugs dosed alone. FIG. 2B is a
different representation of the same data. On average, mice treated
with vehicle, dimethyl fumarate or pioglitazone alone indistinctly
exhibited first clinical signs of disease around day 12-13
post-immunisation, whereas in the combination group the average
onset of EAE was around day 17 post-immunisation. The effect of the
combination treatment was again statistically different from and
more potent than the other treated groups. This data shows that
combination treatment results in a synergistic treatment effect
which is not observed by individual treatments.
[0391] Gastrointestinal changes including haemorrhage are known
side-effects of dimethyl fumarate treatment. Combination treatment
and dimethyl fumarate alone treatment resulted in similar
hyperplasia of the macrovilosity of the stomach. There was no
worsening of symptoms with combination treatment. Representative
images of the stomach of mice chronically treated for 22 days with
dimethyl fumarate, pioglitazone or their vehicles are shown in FIG.
3 to demonstrate some of these observations. Importantly, the
synergistic efficacy discussed in the previous paragraphs was not
associated with increased gastrointestinal adverse events.
BRIEF DESCRIPTION OF THE FIGURES
[0392] FIGS. 1A-1B: Combination treatment with dimethyl
fumarate+pioglitazone is significantly more efficacious than each
individual drug as stand-alone treatments or treatment with vehicle
on mean clinical scores and also on body weight changes associated
with disease. Average clinical scores (A) and percentual body
weight changes (B) of MOG35-55 mice treated with vehicle, dimethyl
fumarate, pioglitazone or a combination of both drugs from day
O-post immunisation. Kruskal-Wallis (non-parametric ANOVA) with
Dunn's multiple test correction was applied in A and Student's
t-test in B. Horizontal bars represent P<0.05 where .lamda.
compares combination treatment versus vehicle; If combination
treatment versus dimethyl fumarate and .PHI. combination treatment
versus pioglitazone.
[0393] FIGS. 2A-2B: Combination treatment with dimethyl
fumarate+pioglitazone causes a delay on the onset of disease in
comparison with each individual drug as stand-alone treatments or
treatment with vehicle. Kaplan Meier analysis of the disease
prevalence curves (A) and average day of onset of disease (B) of
MOG35-55 mice treated with vehicle, dimethyl fumarate, pioglitazone
or a combination of both drugs from day O-post immunisation. The
onset of disease was defined as the day mice first exhibit a
clinical score .gtoreq.1. Gehan-Breslow-Wilcoxon test was applied
in A and Kruskal-Wallis followed by Dunn's multiple test correction
in B. Horizontal bars represent P<0.05 where X compares
combination treatment versus vehicle; .PSI. combination treatment
versus dimethyl fumarate and .PHI. combination treatment versus
pioglitazone.
[0394] FIGS. 3A-3E: Alteration in the macroscopical appearance of
the stomach of mice chronically treated with dimethyl fumarate, but
not with pioglitazone or vehicle. Forty C57BL/6 mice immunized with
MOG35-55 and treated by oral gavage for 22 days with a combination
of HPMC0.5%/Tween20 0.25% b.i.d. plus Kleptose 20% q.d. (A),
dimethyl fumarate 60 mg/kg b.i.d. plus Kleptose 20% q.d (B),
pioglitazone 10 mg/kg q.d. plus HPMC 0.5%/Tween20 0.25% b.i.d. (C)
or dimethyl fumarate 60 mg/kg b.i.d plus pioglitazone 10 mg/kg q.d.
(D). An additional group of five mice were sham-immunized (emulsion
without MOG35-55) and treated with HPMC0.5%/Tween20 0.25% b.i.d.
plus Kleptose 20% q.d. (E). Throughout the length of the experiment
three mice were either sacrificed due to humane end-points or
succumbed to disease. The forty-two remaining animals were
euthanized under pentobarbital terminal anesthesia, the right
atrium of the heart was incised and mice were perfused with 4%
paraformaldehyde through the left ventricle. The stomach of each
mouse was dissected by a transection of the proximal segment of the
oesophagus and the duodenum then cut open via a longitudinal
incision through the longest possible axis linking the remaining
stretch of duodenum and the Fundus. Each piece was washed with
phosphate buffered saline and open-mounted. The images shown are
from one representative mouse from each group. Note the normal
appearance of stomachs of all groups of mice that were not exposed
to dimethyl fumarate (A, C, E) and the seemingly pathological
increase in macrovilosity of the stomachs of groups B and D that
were treated with dimethyl fumarate as stand-alone or combination
treatment with pioglitazone, respectively, giving them a thickened
and rugous appearance.
Sequence CWU 1
1
1121PRTArtificial sequenceSynthetic construct 1Met Glu Val Gly Trp
Tyr Arg Ser Pro Phe Ser Arg Val Val His Leu 1 5 10 15 Tyr Arg Asn
Gly Lys 20
* * * * *