Classifications

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  • A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
  • A61K38/17—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans
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  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/495—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with two or more nitrogen atoms as the only ring heteroatoms, e.g. piperazine or tetrazines
  • A61K31/4985—Pyrazines or piperazines ortho- or peri-condensed with heterocyclic ring systems
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  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/495—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with two or more nitrogen atoms as the only ring heteroatoms, e.g. piperazine or tetrazines
  • A61K31/505—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim
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  • A61K31/495—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with two or more nitrogen atoms as the only ring heteroatoms, e.g. piperazine or tetrazines
  • A61K31/505—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim
  • A61K31/519—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim ortho- or peri-condensed with heterocyclic rings
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  • A61K31/53—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with three nitrogens as the only ring hetero atoms, e.g. chlorazanil, melamine
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  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/535—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with at least one nitrogen and one oxygen as the ring hetero atoms, e.g. 1,2-oxazines
  • A61K31/5375—1,4-Oxazines, e.g. morpholine
  • A61K31/5377—1,4-Oxazines, e.g. morpholine not condensed and containing further heterocyclic rings, e.g. timolol
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  • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
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  • A61P3/08—Drugs for disorders of the metabolism for glucose homeostasis
  • A61P3/10—Drugs for disorders of the metabolism for glucose homeostasis for hyperglycaemia, e.g. antidiabetics
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Definitions

• This invention relates to the use of selective cGMP PDE5 inhibitors and in particular to selective cGMP PDE5 inhibitor compounds such as the compound sildenafil for the treatment of the Insulin Resistance Syndrome.
• the Insulin Resistance Syndrome as defined herein means the concomitant existence in a subject of two or more of: dyslipidemia, hypertension, type 2 diabetes mellitus or impaired glucose tolerance (IGT) or a family history of type 2 diabetes mellitus, hyperuricaemia and/or gout, a pro-coagulant state, atherosclerosis, truncal obesity.
• a family history of type 2 diabetes mellitus as defined herein means having a first degree relation, sibling, parent or grandparent with type 2 diabetes mellitus.
• At the centre of the Insulin Resistance Syndrome also known as "Syndrome X" and "Metabolic Syndrome” in the biomedical literature is the common feature of tissue resistance to the action of insulin.
• the early adaptive response to insulin resistance in many individuals having the insulin resistance syndrome produces compensatory hyperinsulinaemia.
• subjects with the insulin resistance syndrome become progressively insulin resistant, they manifest varying degrees of change in clinical parameters, including blood pressure, and/or increased levels of serum glucose, and/or cholesterol and/or triglycerides, and/or uric acid, and/or factors that increase coagulation.
• clinical parameters including blood pressure, and/or increased levels of serum glucose, and/or cholesterol and/or triglycerides, and/or uric acid, and/or factors that increase coagulation.
• the patient with the IRS may differentially manifest well-recognised clinical conditions or diagnoses. These conditions include:
• ITT Impaired Glucose Tolerance
• DM type 2 diabetes mellitus
• Hypercoagulability defined as an abnormal, increased tendency for clots to form, particularly inside blood vessels
• the Insulin Resistance Syndrome It is difficult to estimate the prevalence of the Insulin Resistance Syndrome in the general populace due to both the diversity of the collective risk factors associated with the syndrome and the likelihood that many individuals affected by the Insulin Resistance Syndrome go undetected because they may exhibit no exterior symptoms and have no prior history of coronary heart disease. It is however possible to postulate that at a minimum the patient population at risk for the development of the Insulin Resistance Syndrome includes individuals with obesity, particularly truncal (abdominal) obesity. As obesity is an extremely common problem in the industrialized world and is associated with the clinical conditions mentioned above, it is very likely that the prevalence of IRS is very high. Considering this potential patient group alone forms an immense population potentially at risk for the development of complications of the Insulin Resistance Syndrome.
• nitric oxide is not only from insulin, but also from other important vasodilators like acetylcholine.
• endothelial dysfunction contributes to the risk factors for cardiovascular disease which are associated with the Insulin Resistance Syndrome. It is thought that the vascular effect of insulin contributes to the effect of insulin to regulate metabolism, particularly, but not necessarily limited to, glucose metabolism.
• NO In addition to the vascular actions of nitric oxide, NO also has direct effects on glucose uptake by skeletal muscle. That is, treatment with a NO-donor substance (nitroprusside) or an analogue of cGMP treatment in vitro increases glucose uptake (transport by GLUT4 glucose transporters). This vasodilation- independent pathway is described in G. J. Etgen, D. A. Fryburg and E. M. Gibbs in Diabetes, 46, 1997 pp. 1915-1919 the contents of which are incorporated herein by reference. It is proposed herein that, taken together, nitric oxide and cGMP likely have direct tissue level and vascular actions that influence, mediate, or mimic insulin's actions.
• vascular smooth muscle cell vascular smooth muscle cell
• proliferation and migration which are key steps in atherosclerotic plaque formation which can lead to stroke
• platelet aggregation and adhesiveness cGMP driven
• lipid peroxidation an effect on the inhibition of cell adhesion molecule expression including vascular cell adhesion molecule (VCAM-1), intracellular adhesion molecule (ICAM) and E- selectin.
• VCAM-1 vascular cell adhesion molecule
• IAM intracellular adhesion molecule
• E- selectin E- selectin.
• Impaired endothelial NO release also impacts on the activity of inflammatory cytokines such as tumour necrosis factor- , and the production of monocyte chemoattractant factor through decreased activity of the transcriptional activator nuclear factor k B.
• the present invention is concerned with the search for a pharmaceutical treatment for individuals with the Insulin Resistance Syndrome as defined hereinbefore.
• the Insulin Resistance Syndrome has many manifestations an important underlying mechanistic basis for the condition resides in a resistance to both the vascular and metabolic effects of insulin. It is also understood that the underlying pathology of vascular resistance in insulin resistance syndrome, is a diminished amount of NO produced by the endothelial cells in response to insulin. In the insulin pathway in insulin resistant individuals, there may be impaired signalling of insulin for glucose uptake (from the phosphatidylinositol 3-kinase, PI3K, pathway) which may lead to an inefficient GLUT-4 transport mechanism. Whilst not wishing to be bound by any particular theory it is proposed herein that the pathway for the GLUT-4 transport mechanism and the cGMP-NO mechanistic pathway are somehow inter-linked.
• Blood glucose control In patients with diabetes mellitus or impaired glucose tolerance (IGT), it is postulated herein that an improvement in insulin resistance should result in a decrease in plasma glucose concentrations (either fasting or after an oral glucose tolerance test or a meal). In a related manner, as regulated by the patient's pathophysiology, there will likely be an improvement in serum insulin concentrations in either the fasting state or after a glucose load or meal. These improvements in blood glucose control, should the subjects have type 2 diabetes mellitus, would manifest as improvements in measures of long-term blood glucose control, such as, but not limited to, haemoglobin A1c (glycosylated haemoglobin) or fructosamine; and/or
• Lipids It is postulated herein that an improvement in insulin resistance may also yield improvements in serum lipids, including, but not limited to, serum cholesterol and triglycerides; and/or ' 4.
• Uric Acid It is postulated herein that an improvement in insulin resistance may also yield improvements in serum uric acid; and/or
• Coagulation Factors It is postulated herein that an improvement in insulin resistance would also restore, towards normal, factors that worsen the procoagulant state.
• cGMP PDE 5 inhibitors prevent the effect of the phosphodiesterase 5 enzyme that converts cGMP to inactive GMP thus increasing the amount of accumulated cGMP. This accumulation would amplify the vasodilatory, metabolic, and anti-atherogenic effects of the available nitric oxide and insulin. It is postulated herein that this amplification action (of plasma cGMP) will mitigate the adverse effects associated with the IRS and improve one or more of the associated conditions.
• Sildenafil (Viagra ® ) is an orally-active, potent and selective inhibitor of cyclic guanosine monophosphate (cGMP) specific phosphodiesterase type 5 (PDE5) which is the predominant PDE5 isoenzyme in human corpora cavemosa. Consequently, sildenafil has been shown to be effective in the treatment of male erectile dysfunction. It is proposed herein that by inhibiting the cGMP to GMP conversion pathway, selective cGMP PDE5 inhibitors and in particular Sildenafil increase the intracellular concentrations of nitric oxide (NO) derived cGMP. This accumulation would amplify the vasodilatory, metabolic, and anti-atherogenic effects of the available nitric oxide and insulin.
• NO nitric oxide
• a method of treating the insulin resistance syndrome which comprises treating the patient with an effective amount of a selective cGMP PDE5 inhibitor or a pharmaceutical composition thereof wherein the insulin resistance syndrome means the concomitant existence in a subject of two or more of: dyslipidemia; hypertension; type 2 diabetes mellitus, impaired glucose tolerance (IGT) or having a family history of diabetes; hyperuricaemia and/or gout; a pro-coagulant state; atherosclerosis; or truncal obesity.
• ITT impaired glucose tolerance
• the method may have a beneficial effect on one or more of conditions associated with the IRS as defined herein.
• the present invention additionally provides a method of treating type 2 diabetes mellitus or impaired glucose tolerance (IGT); or dyslipidemia, or hyperuricemia and/or gout, or the procoagulant state which comprises treating the patient with an effective amount of a cGMP PDE5 inhibitor or a pharmaceutical composition thereof.
• ITT type 2 diabetes mellitus or impaired glucose tolerance
• the procoagulant state which comprises treating the patient with an effective amount of a cGMP PDE5 inhibitor or a pharmaceutical composition thereof.
• the present invention additionally provides a method of treating type 2 diabetes mellitus or impaired glucose tolerance (IGT) in a patient wherein the patient does not have other risk factors associated with the IRS which comprises treating the patient with an effective amount of a selective pyrazolopyrimidinone cGMP PDE5 inhibitor as defined hereinafter or a pharmaceutically acceptable salt or a pharmaceutical composition thereof.
• ITT impaired glucose tolerance
• the present invention additionally provides a method for the prevention of progression in a subject of impaired glucose tolerance (IGT) to type 2 diabetes mellitus via treatment of a patient in need of such treatment with an effective amount of a selective pyrazolopyrimidinone cGMP PDE5 inhibitor as defined hereinafter or a pharmaceutically acceptable salt or a pharmaceutical composition thereof.
• ITT impaired glucose tolerance
• the present invention provides a method of treating the insulin resistance syndrome which comprises treating the patient with an effective amount of a cGMP PDE5 inhibitor or a pharmaceutical composition thereof wherein the insulin resistance syndrome means the concomitant existence in a subject of three or more of: dyslipidemia; hypertension; type 2 diabetes mellitus, impaired glucose tolerance (IGT) or having a family history of diabetes; hyperuricaemia and/or gout; a pro-coagulant state; atherosclerosis; or truncal obesity.
• a cGMP PDE5 inhibitor or a pharmaceutical composition thereof wherein the insulin resistance syndrome means the concomitant existence in a subject of three or more of: dyslipidemia; hypertension; type 2 diabetes mellitus, impaired glucose tolerance (IGT) or having a family history of diabetes; hyperuricaemia and/or gout; a pro-coagulant state; atherosclerosis; or truncal obesity.
• ITT impaired glucose tolerance
• the present invention provides a method of treating the insulin resistance syndrome which comprises treating the patient with an effective amount of a cGMP PDE5 inhibitor or a pharmaceutical composition thereof wherein the insulin resistance syndrome means the concomitant existence in a subject of four or more of: dyslipidemia; hypertension; type 2 diabetes mellitus, impaired glucose tolerance (IGT) or having a family history of diabetes; hyperuricaemia and/or gout; a pro-coagulant state; atherosclerosis; or truncal obesity.
• a cGMP PDE5 inhibitor or a pharmaceutical composition thereof wherein the insulin resistance syndrome means the concomitant existence in a subject of four or more of: dyslipidemia; hypertension; type 2 diabetes mellitus, impaired glucose tolerance (IGT) or having a family history of diabetes; hyperuricaemia and/or gout; a pro-coagulant state; atherosclerosis; or truncal obesity.
• ITT impaired glucose tolerance
• the present invention provides a method of treating the insulin resistance syndrome which comprises treating the patient with an effective amount of a cGMP PDE5 inhibitor or a pharmaceutical composition thereof wherein the insulin resistance syndrome means the concomitant existence in a subject of five or more of: dyslipidemia; hypertension; type 2 diabetes mellitus, impaired glucose tolerance (IGT) or having a family history of diabetes; hyperuricaemia and/or gout; a pro-coagulant state; atherosclerosis; or truncal obesity.
• a cGMP PDE5 inhibitor or a pharmaceutical composition thereof wherein the insulin resistance syndrome means the concomitant existence in a subject of five or more of: dyslipidemia; hypertension; type 2 diabetes mellitus, impaired glucose tolerance (IGT) or having a family history of diabetes; hyperuricaemia and/or gout; a pro-coagulant state; atherosclerosis; or truncal obesity.
• ITT impaired glucose tolerance
• the present invention provides a method of treating the insulin resistance syndrome which comprises treating the patient with an effective amount of a cGMP PDE5 inhibitor or a pharmaceutical composition thereof wherein the insulin resistance syndrome means the concomitant existence in a subject of : dyslipidemia; hypertension; type 2 diabetes mellitus or impaired glucose tolerance (IGT); and truncal obesity.
• a cGMP PDE5 inhibitor or a pharmaceutical composition thereof wherein the insulin resistance syndrome means the concomitant existence in a subject of : dyslipidemia; hypertension; type 2 diabetes mellitus or impaired glucose tolerance (IGT); and truncal obesity.
• the present invention provides a method of treating the insulin resistance syndrome which comprises treating a patient with type 2 diabetes mellitus, impaired glucose tolerance (IGT) or a family history of diabetes and at least one of the following conditions : dyslipidemia; hypertension; hyperuricaemia and/or gout; a pro-coagulant state; atherosclerosis; or truncal obesity with an effective amount of a cGMP PDE5 inhibitor or a pharmaceutical composition thereof.
• ITT impaired glucose tolerance
• the present invention provides a method of treating the insulin resistance syndrome which comprises treating a patient with type 2 diabetes mellitus, impaired glucose tolerance (GT) or a family history of diabetes and at least two of the following conditions : dyslipidemia; hypertension; hyperuricaemia and/or gout; a pro-coagulant state; atherosclerosis; or truncal obesity with an effective amount of a cGMP PDE5 inhibitor or a pharmaceutical composition thereof.
• GT impaired glucose tolerance
• the present invention provides a method of treating the insulin resistance syndrome which comprises treating a patient with type 2 diabetes mellitus, impaired glucose tolerance (IGT) or a family history of diabetes and at least three of the following conditions : dyslipidemia; hypertension; hyperuricaemia and/or gout; a pro-coagulant state; atherosclerosis; or truncal obesity with an effective amount of a cGMP PDE5 inhibitor or a pharmaceutical composition thereof.
• ITT impaired glucose tolerance
• the present invention provides a method of treating the insulin resistance syndrome which comprises treating a patient with type 2 diabetes mellitus, impaired glucose tolerance (IRS) or a family history of diabetes and at least three of the following conditions : dyslipidemia; hypertension; hyperuricaemia and/or gout; a pro-coagulant state; atherosclerosis; or truncal obesity with an effective amount of a cGMP PDE5 inhibitor or a pharmaceutical composition thereof.
• IRS impaired glucose tolerance
• the present invention provides a method of treating the insulin resistance syndrome which comprises treating a patient with type 2 diabetes mellitus, impaired glucose tolerance (IGT) or a family history of diabetes and at least four of the following conditions : dyslipidemia; hypertension; hyperuricaemia; a pro-coagulant state; atherosclerosis; or truncal obesity with an effective amount of a cGMP PDE5 inhibitor or a pharmaceutical composition thereof.
• ITT impaired glucose tolerance
• the present invention provides a method of treating the insulin resistance syndrome which comprises treating a patient with type 2 diabetes mellitus, impaired glucose tolerance (IGT) or a family history of diabetes and at least five of the following conditions : dyslipidemia; hypertension; hyperuricaemia and/or gout; a pro-coagulant state; atherosclerosis; or truncal obesity with an effective amount of a cGMP PDE5 inhibitor or a pharmaceutical composition thereof.
• ITT impaired glucose tolerance
• the present invention additionally provides a method for the reduction in the risk of the development of cardiovascular disease in patients identified as being at risk of developing the insulin resistance syndrome wherein said method comprises treating the patient with an effective amount of a cGMP PDE5 inhibitor or a pharmaceutical composition thereof and wherein a patient at risk of developing the insulin resistance syndrome is defined as an individual having at least one of the following conditions: dyslipidemia; hypertension; type 2 diabetes mellitus, impaired glucose tolerance (IGT) or having a family history of diabetes; hyperuricaemia and/or gout; a pro-coagulant state; atherosclerosis; or truncal obesity and whom on subsequent analysis is found to have at least two of said conditions.
• a patient at risk of developing the insulin resistance syndrome is defined as an individual having at least one of the following conditions: dyslipidemia; hypertension; type 2 diabetes mellitus, impaired glucose tolerance (IGT) or having a family history of diabetes; hyperuricaemia and/or gout; a pro-coagulant state; atherosclerosis; or truncal
• the present invention provides a method for treating the insulin resistance syndrome as defined hereinbefore in a polygenic insulin resistant individual which comprises treating the individual with an effective amount of a cGMP PDE5 inhibitor or a pharmaceutical composition thereof.
• Suitable PDE ⁇ i's for use in the pharmaceutical compositions according to the present invention are the cGMP PDE ⁇ i's hereinafter detailed. Particularly preferred for use herein are potent and selective cGMP PDE ⁇ i's.
• Suitable cGMP PDE5 inhibitors for the use according to the present invention include:
• Preferred selective type V phosphodiesterase inhibitors for the use according to the present invention include:
• the present invention provides for the use of a selective pyrazolopyrimidinone cGMP PDE5 inhibitor or a pharmaceutical composition thereof in the preparation of a medicament for the curative, palliative or prophylactic treatment of the insulin resistance syndrome in a mammal
• the selective cGMP PDE5 inhibitor is selected from : sildenafil, 5-(2-ethoxy-5- morpholinoacetylphenyl)-1-ethyl-3-n-propyl-1 ,6-dihydro-7H-pyrazolo[4,3- yrimidin-7-one, 3-ethyl-5-[5-(4-ethylpiperazin-1-ylsulphonyl)-2-n- propoxyphenyl]-2-(pyridin-2-yl)methyl-2,6-dihydro-7H-pyrazolo[4,3- ]pyrimidin-7- one, 3-ethyl-5-[5-(4-ethyl
• the present invention provides a method of treating a patient with the insulin resistance syndrome which comprises treating the patient with an effective amount of a selective pyrazolopyrimidinone cGMP PDE5 inhibitor selected from sildenafil, 5-(5-Acetyl-2-butoxy-3-pyridinyl)-3-ethyl-2-(1-ethyl-3- azetidinyl)-2,6-dihydro-7H-pyrazolo[4,3- ⁇ f]pyrimidin-7-one or 5-[2-ethoxy-5-(4- ethylpiperazin-1-ylsulphonyl)pyridin-3-yl]-3-ethyl-2-(2-methoxyethyl)-2,6-dihydro- 7H-pyrazolo[4,3- ⁇ dpyrimidin-7-one or pharmaceutically acceptable salts, solvates, pro-drugs, polymorphs or pharmaceutical compositions thereof.
• the invention also provides for the use of a selective pyrazolopyrimidinone cGMP PDE5 inhibitor and in particular sildenafil, 5-(5-Acetyl-2-butoxy-3-pyridinyl)- 3-ethyl-2-(1-ethyl-3-azetidinyl)-2,6-dihydro-7H-pyrazolo[4,3-c ]pyrimidin-7-one or 5- [2-ethoxy-5-(4-ethylpiperazin-1-ylsulphonyl)pyridin-3-yl]-3-ethyl-1-(2- methoxyethyl)-1 ,6-dihydro-7H-pyrazolo[4,3- ⁇ yrimidin-7-one for the manufacture of a composition for the treatment or prophylaxis of the insulin resistance syndrome.
• sildenafil 5-(5-Acetyl-2-butoxy-3-pyridinyl)- 3-ethyl-2-(1-e
• the present invention additionally provides for the use of sildenafil or a pharmaceutically acceptable salt or of a pharmaceutical composition thereof for the treatment of the insulin resistance syndrome in a subject having type 2 diabetes mellitus, impaired glucose tolerance (IGT) or having a family history of diabetes and at least one of the following conditions : dyslipidemia; hypertension; hyperuricaemia and/or gout; a pro-coagulant state; atherosclerosis; or truncal obesity.
• ITT impaired glucose tolerance
• the present invention additionally provides for the use of sildenafil or a pharmaceutically acceptable salt or of a pharmaceutical composition thereof for the treatment of the insulin resistance syndrome in a subject having type 2 diabetes mellitus, impaired glucose tolerance (IGT) or having a family history of diabetes and one or more of the following conditions : dyslipidemia; hypertension; or truncal obesity.
• ITT impaired glucose tolerance
• the present invention additionally provides for the use of sildenafil or a pharmaceutically acceptable salt or of a pharmaceutical composition thereof for the treatment of the insulin resistance syndrome in a subject having type 2 diabetes mellitus, or impaired glucose tolerance (IGT) or having a family history of diabetes and dyslipidemia and hypertension and truncal obesity.
• ITT impaired glucose tolerance
• Preferred pharmaceutically acceptable salts of sildenafil for use herein are sildenafil citrate and sildenafil mesylate.
• cGMP PDE5 inhibitors as defined herein and in particular potent and selective cGMP PDE5 inhibitors and most particularly sildenafil, 5-(5-Acetyl-2- butoxy-3-pyridinyl)-3-ethyl-2-(1 -ethyl-3-azetidinyl)-2,6-dihydro-7H-pyrazolo[4,3- ⁇ f]pyrimidin-7-one or 5-[2-ethoxy-5-(4-ethylpiperazin-1 -ylsulphonyl)pyridin-3-yl]-3- ethyl-1 -(2-methoxyethyl)-1 ,6-dihydro-7H-pyrazolo[4,3-c(
• PDE inhibitors suitable for use herein include:
• Still other type cGMP PDE5 inhibitors useful in conjunction with the present invention include:4-bromo-5-(pyridylmethyIamino)-6-[3-(4-chlorophenyl)-propoxy]- 3(2H)pyridazinone; 1-[4-[(1 ,3-benzodioxol-5- ylmethyl)amiono]-6-chloro-2- quinozolinyl]-4-piperidine-carboxylic acid, monosodium salt; (+)-cis-5,6a,7,9,9,9a- hexahydro-2-[4-(trifluoromethyl)-phenylmethyl-5-methyl-cyclopent-4,5]imidazo[2,1- b]purin-4(3H)one; furazlocillin; cis-2-hexyl-5-methyl-3,4,5,6a,7,8,9,9a- octahydrocyclopent[4,5]
• cGMP PDE5 inhibitor The suitability of any particular cGMP PDE5 inhibitor can be readily determined by evaluation of its potency and selectivity using literature methods followed by evaluation of its toxicity, absorption, metabolism, pharmacokinetics, etc in ' accordance with standard pharmaceutical practice.
• the cGMP PDE5 inhibitors have an IC 5 o against the PDE5 enzyme of less than 100 nanomolar (preferably, at less than 50 nanomolar).
• the present invention provides for the use of a selective pyrazolopyrimidinone cGMP PDE5 inhibitor or a pharmaceutical composition thereof in the preparation of a medicament for the curative, palliative or prophylactic treatment of type 2 diabetes mellitus or IGT in a mammal
• the selective cGMP PDE5 inhibitor is selected from : sildenafil, 5-(2-ethoxy-5- morpholinoacetylphenyl)-1-ethyl-3-n-propyl-1 ,6-dihydro-7H-pyrazolo[4,3- ⁇ yrimidin-7-one, 3-ethyl-5-[5-(4-ethylpiperazin-1-ylsulphonyl)-2-n- propoxyphenyl]-2-(pyridin-2-yI)methyI-2,6-dihydro-7H-pyrazolo[4,3- ⁇ yrimidin-7- one, 3-ethyl-5-[
• the present invention provides a method of treating a patient with type 2 diabetes mellitus, IGT or IR which comprises treating the patient with an effective amount of a selective pyrazolopyrimidinone cGMP PDE5 inhibitor selected from sildenafil, 5-(5-Acetyl-2-butoxy-3-pyridinyl)-3-ethyl-2-(1- ethyl-3-azetidinyl)-2,6-dihydro-7H-pyrazolo[4,3- ⁇ yrimidin-7-one or 5-[2-ethoxy-5- (4-ethylpiperazin-1-ylsulphonyl)pyridin-3-yl]-3-ethyl-2-(2-methoxyethyl)-2,6- dihydro-7H-pyrazolo[4,3- ⁇ yrimidin-7-one or pharmaceutically acceptable salts, solvates, pro-drugs, polymorphs or pharmaceutical compositions thereof.
• the invention also provides for the use of a selective pyrazolopyrimidinone cGMP PDE5 inhibitor and in particular sildenafil, 5- (5-Acetyl-2-butoxy-3-pyridinyl)-3-ethyl-2-(1 -ethyl-3-azetidinyl)-2,6-dihydro-7H- pyrazolo[4,3- ⁇ yrimidin-7-one or 5-[2-ethoxy-5-(4-ethylpiperazin-1 - ylsulphonyl)pyridin-3-yl]-3-ethyl-1 -(2-methoxyethyl)-1 ,6-dihydro-7H-pyrazolo[4,3- ' ⁇ yrimidin-7-one for the manufacture of a composition for the treatment or prophylaxis of type 2 diabetes mellitus, IGT or IR.
• sildenafil 5--5-Acetyl-2-butoxy-3-pyridiny
• the present invention additionally provides for the use of sildenafil or a pharmaceutically acceptable salt thereof or a pharmaceutical composition thereof for the treatment of type 2 diabetes mellitus, IGT or IR.
• IC50 values for the cGMP PDE5 inhibitors may be determined using the PDE5 assay in the Test Methods Section hereinafter.
• the cGMP PDE5 inhibitors used in the pharmaceutical compositions according to the present invention are selective for the PDE5 enzyme.
• they have a selectivity of PDE5 over PDE3 of greater than 100 more preferably greater than 300.
• the PDE5 has a selectivity over both PDE3 and PDE4 of greater than 100, more preferably greater than 300.
• IC50 values for the PDE3 and PDE4 enzyme may be determined using established literature methodology, see S A Ballard ⁇ t al, Journal of Urology, 1998, vol. 159, pages 2164-2171 and as detailed herein after.
• the invention provides the use of a pharmaceutical medicament for use according to any aspect of the invention hereinbefore or hereinafter detailed which is adapted for administration by mouth, said medicament comprising a PDE5 inhibitor having and IC 50 of less than 100 nanomolar and a selectivity over PDE3 of greater than 100.
• said oral use is for the treatment of the insulin resistance syndrome, or type 2 diabetes mellitus or IGT or IR according to any aspect of the invention detailed herein before preferably said PDE5 inhibitor is a pyrazolopyrimidinone, more preferably sildenafil, 5-(2-ethoxy-5-morpholinoacetylphenyl)-1 -ethyl-3-n-propyI-1 ,6-dihydro- 7H-pyrazolo[4,3- ⁇ yrimidin-7-one, 3-ethyl-5-[5-(4-ethylpiperazin-1-ylsulphonyl)-2- n-propoxyphenyl]-2-(pyridin-2-yl)methyl-2,6-dihydro-7H-pyrazolo[4,3-G] ⁇ yrimidin-7- one, 3-ethyl-5-[5-(4-ethylpiperazin-1-ylsulphonyl)-2-(2-methoxyethoxy
• said oral administration of a PDE5 inhibitor is for the treatment of insulin resistance; type 2 diabetes mellitus; impaired glucose tolerance (IGT); dislipidemia; hyperuricemia and/or gout; or a proco-agulant state
• said PDE5 inhibitor is a pyrazolopyrimidinone, more preferably sildenafil, 5-(2-ethoxy-5- morpholinoacetylphenyl)-1-ethyl-3-n-propyl-1 ,6-dihydro-7H-pyrazolo[4,3- ⁇ yrimidin-7-one, 3-ethyl-5-[5-(4-ethylpiperazin-1-ylsulphonyl)-2-n- propoxyphenyl]-2-(pyridin-2-yl)methyl-2,6-dihydro-7H-pyrazolo[4,3- ⁇ yrimidin-7- one, 3-ethyl-5-[5-(4-ethylpiperazin-1-yl
• the present invention additionally provides a method for improving insulin action (treating insulin resistance) wherein said method comprises treating a patient with the insulin resistance syndrome which comprises treating a patient with underlying insulin resistance with an effective amount of a selective pyrazolopyrimidinone cGMP PDE5 inhibitor (as detailed hereinbefore).
• the present invention additionally provides a method for treating insulin resistance which comprises treating a patient with underlying insulin resistance with an effective amount of a selective pyrazolopyrimidinone cGMP PDE5 inhibitor selected from sildenafil, 5-(5-Acetyl-2-butoxy-3-pyridinyl)-3-ethyl-2-(1-ethyl-3- azetidinyl)-2,6-dihydro-7H-pyrazolo[4,3- ⁇ yrimidin-7-one or 5-[2-ethoxy-5-(4- ethylpiperazin-1-yIsulphonyl)pyridin-3-yl]-3-ethyl-2-(2-methoxyethyl)-2,6-dihydro- 7H-pyrazolo[4,3- ⁇ yrimidin-7-one or pharmaceutically acceptable salts, solvates, pro-drugs, polymorphs or pharmaceutical compositions thereof.
• the present invention additionally provides a method of treating type 2 diabetes mellitus or impaired glucose tolerance (IGT); or dyslipidemia, or hyperuricemia, or the procoagulant state wherein said method comprises treating a patient with underlying insulin resistance with an effective amount of a selective pyrazolopyrimidinone cGMP PDE5 inhibitor (as detailed hereinbefore).
• ITT impaired glucose tolerance
• a selective pyrazolopyrimidinone cGMP PDE5 inhibitor as detailed hereinbefore.
• the present invention additionally provides a method for treating type 2 diabetes mellitus or impaired glucose tolerance (IGT); or dyslipidemia, or hyperuricemia, or the procoagulant state which comprises treating a patient with an effective amount of a selective pyrazolopyrimidinone cGMP PDE5 inhibitor selected from sildenafil, 5-(5-Acetyl-2-butoxy-3-pyridinyl)-3-ethyl-2-(1-ethyl-3- azetidinyl)-2,6-dihydro-7H-pyrazolo[4,3- ⁇ yrimidin-7-one or 5-[2-ethoxy-5-(4- ethylpiperazin-1-ylsulphonyl)pyridin-3-yl]-3-ethyl-2-(2-methoxyethyl)-2,6-dihydro- 7H-pyrazolo[4,3- ⁇ yrimidin-7-one or pharmaceutically acceptable salts, solvates, pro-drugs,
• the pharmaceutically acceptable salts of the selective cGMP PDE5 inhibitor compounds as disclosed herein for use in the treatment of the insulin resistance syndrome in accordance with the present invention which contain a basic centre are, for example, non-toxic acid addition salts formed with inorganic acids such as hydrochloric, hydrobromic, hydroiodic, sulphuric and phosphoric acid, with carboxylic acids or with organo-sulphonic acids.
• Examples include the HCI, HBr, HI, sulphate or bisulphate, nitrate, phosphate or hydrogen phosphate, acetate, benzoate, succinate, saccarate, fumarate, maleate, lactate, citrate, tartrate, gluconate, camsylate, methanesulphonate, ethanesulphonate, benzene- sulphonate, p-toluenesulphonate and pamoate salts.
• the selective cGMP PDE5 inhibitor compounds for use in the present invention can also provide pharmaceutically acceptable metal salts, in particular non-toxic alkali and alkaline earth metal salts, with bases. Examples include the sodium, potassium, aluminium, calcium, magnesium, zinc and diethanolamine salts.
• cGMP PDE5i compounds suitable for use in accordance with any aspect of the present invention as disclosed herein, their pharmaceutically acceptable salts, and pharmaceutically acceptable solvates of either entity can be administered alone but, in human therapy will generally be administered in admixture with a suitable pharmaceutical excipient diluent or carrier selected with regard to the intended route of administration and standard pharmaceutical practice.
• the cGMP PDE5i compounds suitable for use in accordance with the present invention or salts or solvates thereof can be administered orally, buccally or sublingually in the form of tablets, capsules (including soft gel capsules), multi-particulate, gels, films, ovules, elixirs, solutions or suspensions, which may contain flavouring or colouring agents, for immediate-, delayed-, modified-, sustained-, dual-, controlled-release or pulsatile delivery applications.
• Such compounds may also be administered via fast dispersing or fast dissolving dosages forms or in the form of a high energy dispersion or as coated particles.
• Suitable pharmaceutical formulations may be in coated or un-coated form as desired.
• Such solid pharmaceutical compositions for example, tablets may contain excipients such as microcrystalline cellulose, lactose, sodium citrate, calcium carbonate, dibasic calcium phosphate, glycine and starch (preferably corn, potato or tapioca starch), disintegrants such as sodium starch glycollate, croscarmellose sodium and certain complex silicates, and granulation binders such as polyvinylpyrrolidone, hydroxypropylmethyl cellulose (HPMC), hydroxypropylcellulose (HPC), sucrose, gelatin and acacia. Additionally, lubricating agents such as magnesium stearate, stearic acid, glyceryl behenate and talc may be included.
• excipients such as microcrystalline cellulose, lactose, sodium citrate, calcium carbonate, dibasic calcium phosphate, glycine and starch (preferably corn, potato or tapioca starch), disintegrants such as sodium starch glycollate, croscarmellose sodium and certain complex
• Solid compositions of a similar type may also be employed as fillers in gelatin capsules or HPMC capsules.
• Preferred excipients in this regard include lactose, starch, a cellulose, milk sugar or high molecular weight polyethylene glycols.
• the cGMP PDE5i compounds may be combined with various sweetening or flavouring agents, colouring matter or dyes, with emulsifying and/or suspending agents and with diluents such as water, ethanol, propylene glycol and glycerin, and combinations thereof.
• Modified release and pulsatile release dosage forms may contain excipients such as those detailed for immediate release dosage forms together with additional excipients that act as release rate modifiers, these being coated on and/or included in the body of the device.
• Release rate modifiers include, but are not exclusively limited to, hydroxypropylmethyl cellulose, methyl cellulose, sodium carboxymethylcellulose, ethyl cellulose, cellulose acetate, polyethylene oxide, Xanthan gum, Carbomer, ammonio methacrylate copolymer, hydrogenated castor oil, carnauba wax, paraffin wax, cellulose acetate phthalate, hydroxypropylmethyl cellulose phthalate, methacrylic acid copolymer and mixtures thereof.
• Modified release and pulsatile release dosage forms may contain one or a combination of release rate modifying excipients.
• Release rate modifying excipients maybe present both within the dosage form i.e. within the matrix, and/or on the dosage form i.e. upon the surface or coating.
• Fast dispersing or dissolving dosage formulations may contain the following ingredients: aspartame, acesulfame potassium, citric acid, croscarmellose sodium, crospovidone, diascorbic acid, ethyl acrylate, ethyl cellulose, gelatin, hydroxypropylmethyl cellulose, magnesium stearate, mannitol, methyl methacrylate, mint flavouring, polyethylene glycol, fumed silica, silicon dioxide, sodium starch glycolate, sodium stearyl fumarate, sorbitol, xylitol.
• dispersing or dissolving as used herein to describe FDDFs are dependent upon the solubility of the drug substance used i.e. where the drug substance is insoluble a fast dispersing dosage form can be prepared and where the drug substance is soluble a fast dissolving dosage form can be prepared.
• cGMP PDE5i compounds suitable for use in accordance with the present invention can also be administered parenterally, for example, intracavernosally, intravenously, intra-arterially, intraperitoneally, intrathecally, intraventricularly, intraurethrally intrasternally, intracranially, intramuscularly or subcutaneously, or they may be administered by infusion or needle-free techniques.
• parenteral administration they are best used in the form of a sterile aqueous solution which may contain other substances, for example, enough salts or glucose to make the solution isotonic with blood.
• the aqueous solutions should be suitably buffered (preferably to a pH of from 3 to 9), if necessary.
• the preparation of suitable parenteral formulations under sterile conditions is readily accomplished by standard pharmaceutical techniques well- known to those skilled in the art.
• the daily dosage level of the selective cGMP PDE5 inhibitor compounds for use according to any aspect of the present invention as disclosed herein or salts or solvates thereof will usually be from 5 to 500 mg (in single or divided doses).
• the dosage may by via single dose, divided daily dose, multiple daily dose, acute dosing, continuous (chronic) daily dosing for a specified period which may be from one to five or 5 or more, such as up to 10 or more days.
• the treatment of the Insulin Resistance Syndrome may be affected by continuous dosing, such as for example, via a controlled release dosage form wherein such continuous dosage form can be administered on a daily basis for a number of days or wherein such continuous dosing can be affected via a slow-release formulation which doses for more than one day at a time.
• continuous dosing such as for example, via a controlled release dosage form wherein such continuous dosage form can be administered on a daily basis for a number of days or wherein such continuous dosing can be affected via a slow-release formulation which doses for more than one day at a time.
• treatment may be effected via continuous daily dosing or via repeated regular dosing of controlled or sustained release formulation or such like. All references to the form of treatment may be equally applied to further aspects of the present invention as described herein such as for the treatment of type 2 diabetes mellitus, IGT or insulin resistance.
• tablets or capsules of the cGMP PDE5i compounds suitable for use in accordance with the present invention or salts or solvates thereof may contain from 5 mg to 250 mg of active compound for administration singly or two or more at a time, as appropriate.
• the physician in any event will determine the actual dosage which will be most suitable for any individual patient and it will vary with the age, weight and response of the particular patient.
• the above dosages are exemplary of the average case. There can, of course, be individual instances where higher or lower dosage ranges are merited and such are within the scope of this invention.
• a tablet formulation could typically contain between about 0.01 mg and 500mg of selective cGMP PDE5 inhibitor compounds for use in accordance with the present invention (or a salt thereof) whilst tablet fill weights may range from 50mg to 1000mg.
• An example formulation for a 10mg tablet is illustrated:
• a tablet is prepared using the following ingredients : Quantity (mq/tablet) sildenafil 250 cellulose, microcrystalline 400 silicon dioxide, fumed 10 stearic acid 5 total 665m ⁇
• the components are blended and compressed to form tablets each weighing 665mg.
• An intravenous formulation may be prepared as follows:
• sildenafil 100mg isotonic saline 1 ,000ml
• cGMP PDE5i compounds suitable for use in accordance with the present invention can also be administered intranasally or by inhalation and are conveniently delivered in the form of a dry powder inhaler or an aerosol spray presentation from a pressurised container, pump, spray or nebuliser with the use of a suitable propellant, e.g.
• the dosage unit may be determined by providing a valve to deliver a metered amount.
• the pressurised container, pump, spray or nebuliser may contain a solution or suspension of the active compound, e.g.
• Capsules and cartridges (made, for example, from gelatin) for use in an inhaler or insufflator may be formulated to contain a powder mix of a compound of the invention and a suitable powder base such as lactose or starch.
• Aerosol or dry powder formulations are preferably arranged so that each metered dose or "puff" contains from 1 to 50 mg of a compound of the invention for delivery to the patient.
• the overall daily dose with an aerosol will be in the range of from 1 to 50 mg which may be administered in a single dose or, more usually, in divided doses throughout the day.
• cGMP PDE5i compounds suitable for use in accordance with the present invention may also be formulated for delivery via an atomiser.
• Formulations for atomiser devices may contain the following ingredients as solubilisers, emulsifiers or suspending agents: water, ethanol, glycerol, propylene glycol, low molecular weight polyethylene glycols, sodium chloride, fluorocarbons, polyethylene glycol ethers, sorbitan trioleate, oleic acid.
• the cGMP PDE5i compounds suitable for use in accordance with the present invention or salts or solvates thereof can be administered in the form of a suppository or pessary, or they may be applied topically in the form of a gel, hydrogel, lotion, solution, cream, ointment or dusting powder.
• the cGMP PDE5i compounds suitable for use in accordance with the present invention or salts or solvates thereof may also be dermally or transdermally administered, for example, by the use of a skin patch. They may also be administered by the pulmonary or rectal routes.
• the compounds may also be administered by the ocular route.
• the compounds can be formulated as micronised suspensions in isotonic, pH adjusted, sterile saline, or, preferably, as solutions in isotonic, pH adjusted, sterile saline, optionally in combination with a preservative such as a benzylalkonium chloride.
• they may be formulated in an ointment such as petrolatum.
• the cGMP PDE5i compounds suitable for use in accordance with the present invention or salts or solvates thereof can be formulated as a suitable ointment containing the active compound suspended or dissolved in, for example, a mixture with one or more of the following: mineral oil, liquid petrolatum, white petrolatum, propylene glycol, polyoxyethylene polyoxypropylene compound, emulsifying wax and water.
• ком ⁇ онентs can be formulated as a suitable lotion or cream, suspended or dissolved in, for example, a mixture of one or more of the following: mineral oil, sorbitan monostearate, a polyethylene glycol, liquid paraffin, polysorbate 60, cetyl esters wax, cetearyl alcohol, 2-octyldodecanol, benzyl alcohol and water.
• the cGMP PDE5i compounds suitable for use in accordance with the present invention may also be used in combination with a cyclodextrin.
• Cyclodextrins are known to form inclusion and non-inclusion complexes with drug molecules. Formation of a drug-cyclodextrin complex may modify the solubility, dissolution rate, bioavailability and/or stability property of a drug molecule. Drug- cyclodextrin complexes are generally useful for most dosage forms and administration routes.
• the cyclodextrin may be used as an auxiliary additive, e.g. as a carrier, diluent or solubiliser.
• Alpha-, beta- and gamma-cyclodextrins are most commonly used and suitable examples are described in WO-A-91/11172, WO-A-94/02518 and WO-A- 98/55148.
• oral administration is the preferred route, being the most convenient.
• the drug may be administered parenterally, sublingually or buccally.
• a compound, or a veterinarily acceptable salt thereof, or a veterinarily acceptable solvate or pro-drug thereof is administered as a suitably acceptable formulation in accordance with normal veterinary practice and the veterinary surgeon will determine the dosing regimen and route of administration which will be most appropriate for a particular animal.
• tablets or capsules of selective cGMP PDE5 inhibitor compounds for use in accordance with the invention or salts or solvates thereof may contain from 5 mg to 250 mg of active compound for administration singly or two or more at a time, as appropriate.
• the physician in any event will determine the actual dosage which will be most suitable for any individual patient and it will vary with the age, weight and response of the particular patient.
• the above dosages are exemplary of the average case. There can, of course, be individual instances where higher or lower dosage ranges are merited and such are within the scope of this invention.
• the present invention additionally comprises treatment of the insulin resistance syndrome with a combination of a cGMP PDE 5 inhibitor compound as defined herein with one or more additional pharmaceutically active agents such as:
• prostaglandins for use herein include compounds such as alprostadii, prostaglandin E ⁇ prostaglandin E 0 , 13, 14 - dihydroprosta glandin
• EL prostaglandin E2 eprostinol, natural synthetic and semi-synthetic prostaglandins and derivatives thereof including those described in WO- 00033825 and/or US 6,037,346 issued on 14th March 2000 all incorporated herein by reference, PGE 0 , PGE 1 ; PGA ⁇ PGBi , PGF-i ⁇ , 19-hydroxy PGA ⁇ 19- hydroxy - PGBL PGE 2 , PGB 2 , 19-hydroxy-PGA 2 , 19-hydroxy-PGB 2 , PGE 3 ⁇ , carboprost tromethamine dinoprost, tromethamine, dinoprostone, lipo prost, gemeprost, metenoprost, sulprostune, tiaprost and moxisylate; and/or
• ⁇ -blockers Suitable compounds for use herein include: the ⁇ -adrenergic receptor blockers as described in PCT application WO99/30697 published on 14th June 1998, the disclosures of which relating to ⁇ -adrenergic receptors are incorporated herein by reference and include, selective a adrenoceptor or ⁇ 2 -adrenoceptor blockers and non-selective adrenoceptor blockers, suitable ⁇ radrenoceptor blockers include: phentolamine, phentolamine mesylate, trazodone, alfuzosin, indoramin, naftopidil, tamsulosin, dapiprazole, phenoxybenzamine, idazoxan, efaraxan, yohimbine ( ⁇ 2 -blocker), rauwolfa alkaloids, Recordati 15/2739, SN
• NO-donor compounds for use herein include organic nitrates, such as mono- di or tri- nitrates or organic nitrate esters including glyceryl trinitrate (also known as nitroglycerin), isosorbide 5-mononitrate, isosorbide dinitrate, pentaerythritol tetranitrate, erythrityl tetranitrate, sodium nitroprusside (SNP), 3- morpholinosydnonimine molsidomine, S-nitroso- N-acetyl penicilliamine (SNAP) S-nitroso-N-glutathione (SNO-GLU), N-hydroxy - L-arginine, amylnitrate, linsidomine, linsidomine chlorohydrate, (SIN-1) S-nitroso - N- cysteine, diazenium diola
• potassium channel openers or modulators include nicorandil, cromokalim, levcromakalim, lemakalim, pinacidil, cliazoxide, minoxidil, charybdotoxin, glyburide, 4-amini pyridine, BaCI 2 ; and/or
• one or more dopaminergic agents preferably apomorphine or a selective D2, D3 or D2/D 3 agonist such as, pramipexole and ropirinol (as claimed in WO- 0023056) ,L-Dopa or carbidopa, PNU95666 (as claimed in WO-0040226); and/or
• vasodilator agents include nimodepine, pinacidil, cyclandelate, isoxsuprine, chloroprumazine, halo peridol, Rec 15/2739, trazodone, and/or
• ergot alkaloids are described in US patent 6,037,346 issued on 14th March 2000 and include acetergamine, brazergoline, bromerguride, cianergoline, delorgotrile, disulergine, ergonovine maleate, ergotamine tartrate, etisulergine, lergotrile, lysergide, mesulergine, metergoline, metergotamine, nicergoline, pergolide, propisergide, proterguride, terguride; and/or
• Atrial naturetic factor also known as atrial naturetic peptide
• B type and C type naturetic factors such as inhibitors of neutral endopeptidase
• angiotensin receptor antagonists such as losartan
• cholesterol lowering agents such as statins (e.g. atorvastatin/ Lipitor- trade mark) and fibrates; and/or
• antiplatelet and antithrombotic agents e.g. tPA, uPA, warfarin, hirudin and other thrombin inhibitors, heparin, thromboplastin activating factor inhibitors; and/or
• insulin sensitising agents such as Rezulin, Avandia or Actos and hypoglycaemic agents such as, but not limited to, glipizide (sulfonylureas), metformin, or acarbose; and/or
• estrogen receptor modulators and/or estrogen agonists and/or estrogen antagonists preferably raloxifene or lasofoxifene, (-)-cis-6-phenyl-5-
• a further PDE inhibitor more particularly a PDE 2, 4, 7 or 8 inhibitor, preferably a PDE2 inhibitor said inhibitors preferably having an IC50 against the respective enzyme of less than 100nM: and/or 24) one or more of an NPY (neuropeptide Y) inhibitor, more particularly NPY1 or NPY5 inhibitor, preferably NPY1 inhibitor, preferably said NPY inhibitors (including NPY Y1 and NPY Y5) having an IC50 of less than 100nM , more preferably less than 50nM, suitable NPY and in particular NPY1 inhibitor compounds are described in EP-A-1097718; and/or
• VIP vasoactive intestinal peptide
• VIP mimetic more particularly mediated by one or more of the VIP receptor subtypes VPAC1 NPAC or PACAP (pituitary adenylate cyclase activating peptide), one or more of a VIP receptor agonist or a VIP analogue (eg Ro-125-1553) or a VIP fragment, one or more of a ⁇ -adrenoceptor antagonist with VIP combination (eg Invicorp, Aviptadil); and/or
• a melanocortin receptor agonist or modulator or melanocortin enhancer such as melanotan II, PT-14, PT-141 or compounds claimed in WO- 09964002, WO-00074679, WO-09955679, WO-00105401 , WO-00058361 , WO- 00114879, WO-00113112, WO-09954358 and/or
• a serotonin receptor agonist, antagonist or modulator more particularly agonists, antagonists or modulators for 5HT1A (including VML 670), 5HT2A, 5HT2C, 5HT3 and/or 5HT6 receptors, including those described in WO- 09902159, WO-00002550 and/or WO-00028993; and/or
• a testosterone replacement agent inc dehydroandrostendione
• testostemone Teostrelle
• dihydrotestosterone dihydrotestosterone or a testosterone implant
• estrogen, estrogen and medroxyprogesterone or medroxyprogesterone acetate (MPA) (i.e. as a combination), or estrogen and methyl testosterone hormone replacement therapy agent (e.g. HRT especially Premarin, Cenestin, Oestrofeminal, Equin, Estrace, Estrofem, Elleste Solo, Estring, Eastraderm TTS, Eastraderm Matrix, Dermestril, Premphase, Preempro, Prempak, Premique, Estratest, Estratest HS, Tibolone); and /or 30) one or more of a modulator of transporters for noradrenaline, dopamine and/or serotonin, such as bupropion, GW-320659
• NK neurokinin
• an opioid receptor agonist, antagonist or modulator preferably agonists for the ORL-1 receptor and/or;
• an agonist or modulator for oxytocin/vasopressin receptors preferably a selective oxytocin agonist or modulator and/or;
• angiotensin-converting enzyme such as enapril
• one or more combined inhibitors of angiotensin-converting enzyme and neutral endopeptidase such as omapatrilat
• one or more protein kinase C- ⁇ inhibitors such as LY333531; and/or
• one or more activators of AMP-activated protein kinase such as 5-amino-4- imidazolecarboxamide ribonucleoside; and/or
• one or more dipeptidyl peptidase IV inhibitors such as NVP DPP728 or P32/98; and/or
• one or more glucagon antagonists such as NNC25-2504
• glycogen synthase kinase-3 inhibitors such as Chir98014;
• GLP-1 agonists such as GLP1 , NN-2211 or exendin 4; and/or
• one or more PPAR-gamma agonists such as Rezulin, Avandia, Actos or CS011 ; and/or,
• one or more PPAR-alpha agonists such as fenofibrate; and/or
• one or more dual PPAR-alpha/PPAR-gamma agonists such as farglitazar, rosiglitasone, pioglitazone, GW1929, DRF2725, AZ242 or KRP 297, and/or
• one or more sorbitol dehydrogenase inhibitors such as CP-470711 ; and/or
• one or more aldose reductase inhibitors such as zopolrestat, zenarestat, or fidarestat.
• an NEP inhibitor preferably wherein said NEP is EC 3.4.24.11 and more preferably wherein said NEP inhibitor is a selective inhibitor for EC 3.4.24.11 , more preferably a selective NEP inhibitor is a selective inhibitor for EC 3.4.24.11 , which has an IC 50 of less than 100nM (e.g. ompatrilat, sampatrilat) suitable NEP inhibitor compounds are described in EP-A-1097719 and/or;
• the present invention comprises treatment of type 2 diabetes mellitus or IGT or IR with a combination of a cGMP PDE5 inhibitor compound which is a pyrazolopyrimidinone, more preferably sildenafil, 5-(2- ethoxy-5-morpholinoacetylphenyi)-1 -ethyl-3-n-propyl-1 ,6-dihydro-7H-pyrazolo[4,3- ⁇ yrimidin-7-one, 3-ethyl-5-[5-(4-ethylpiperazin-1-ylsulphonyl)-2-n- propoxyphenyl]-2-(pyridin-2-yl)methyl-2,6-dihydro-7H-pyrazolo[4,3-c/]pyrimidin-7- one, 3-ethyl-5-[5-(4-ethylpiperazin-1-ylsulphonyl)-2-(2-methoxyethoxy)pyridin-3
• Preferred combinations for use according to any of the aspects of the present invention as described herein include a combination of a cGMP PDE5i, and in particular sildenafil with one or more additional agents selected from (16), (40), (41), (42), (43), (50), (51), (52), (53) or (54) as detailed hereinbefore.
• PHARMACOKINETICS BIOAVAILABILITY a combination of a cGMP PDE5i, and in particular sildenafil with one or more additional agents selected from (16), (40), (41), (42), (43), (50), (51), (52), (53) or (54) as detailed hereinbefore.
• the PDE5 inhibitor compounds for use in the present invention are orally bioavailable.
• Oral bioavailablity refers to the proportion of an orally administered drug that reaches the systemic circulation.
• the factors that determine oral bioavailability of a drug are dissolution, membrane permeability and metabolic stability.
• a screening cascade of firstly in vitro and then in vivo techniques is used to determine oral bioavailablity.
• the solubilisation of the drug by the aqueous contents of the gastrointestinal tract can be predicted from in vitro solubility experiments conducted at appropriate pH to mimic the GIT.
• the PDE5 inhibitor compounds for use according to the present invention have a minimum solubility of 50 mcg/ml. Solubility can be determined by standard procedures known in the art such as described in Adv. Drug Deliv. Rev. 23, 3-25, 1997.
• Membrane permeability refers to the passage of the compound through the cells of the GIT. Lipophilicity is a key property in predicting this and is defined by in vitro Log D 7 . 4 measurements using organic solvents and buffer.
• the compounds of the invention have a Log D . of -2 to +4, more preferably -1 to +3.
• the log D can be determined by standard procedures known in the art such as described in J. Pharm. Pharmacol. 1990, 42:144.
• Caco-2 flux a Caco-2 flux of greater than 2x10 "6 cms "1 , more preferably greater than 5x10 "6 cms "1 .
• the Caco-2 flux value can be determined by standard procedures known in the art such as described in J. Pharm. Sci, 1990, 79, 595-600
• Metabolic stability addresses the ability of the GIT or the liver to metabolise compounds during the absorption process: the first pass effect.
• Assay systems such as microsomes, hepatocytes etc are predictive of metabolic liability.
• the compounds of the Examples show metabolic stablity in the assay system that is commensurate with an hepatic extraction of less then 0.5. Examples of assay systems and data manipulation are described in Curr. Opin. Drug Disc. Devel., 201 , 4, 36-44, Drug Met. Disp.,2000, 28, 1518-1523
• Preferred PDE compounds suitable for use in accordance with the present invention are potent and selective cGMP PDE5 inhibitors.
• In vitro PDE inhibitory activities against cyclic guanosine 3 ⁇ 5'-monophosphate (cGMP) and cyclic adenosine 3',5'-monophosphate (cAMP) phosphodiesterases can be determined by measurement of their IC 5 o values (the concentration of compound required for 50% inhibition of enzyme activity).
• the required PDE enzymes can be isolated from a variety of sources, including human corpus cavernosum, human and rabbit platelets, human cardiac ventricle, human skeletal muscle and bovine retina, essentially by the method of W.J. Thompson and M.M. Appleman (Biochem., 1971 , 10, 311).
• the cGMP-specific PDE (PDE5) and the cGMP-inhibited cAMP PDE (PDE3) can be obtained from human corpus cavernosum tissue, human platelets or rabbit platelets; the cGMP-stimulated PDE (PDE2) can be obtained from human corpus cavernosum; the calcium/calmodulin (Ca/CAM)-dependent PDE (PDE1) from human cardiac ventricle; the cAMP-specific PDE (PDE4) from human skeletal muscle; and the photoreceptor PDE (PDE6) from bovine retina.
• Phosphodiesterases 7-11 can be generated from full length human recombinant clones transfected into SF9 cells.
• Assays can be performed either using a modification of the "batch" method of W.J. Thompson et al. (Biochem., 1979, 18, 5228) or using a scintillation proximity assay for the direct detection of AMP/GMP using a modification of the protocol described by Amersham pic under product code TRKQ7090/7100.
• PDE inhibitors were investigated by assaying a fixed amount of enzyme in the presence of varying inhibitor concentrations and low substrate, (cGMP or cAMP in a 3:1 ratio unlabelled to [ 3 H]-labeled at a cone -1/3 K m ) such that IC 5 o ⁇ Kj.
• the final assay volume was made up to 10O ⁇ l with assay buffer [20 mM Tris-HCI pH 7.4, 5 mM MgCI 2 , 1 mg/ml bovine serum albumin]. Reactions were initiated with enzyme, incubated for 30-60 min at 30°C to give ⁇ 30% substrate turnover and terminated with 50 ⁇ l yttrium silicate SPA beads (containing 3 mM of the respective unlabelled cyclic nucleotide for PDEs 9 and 11).
• the selective PDE5 inhibitor compounds to be tested were solubilized in 10% DMSO/0.1% pluronics and dosed via oral gavage using mouse oral feeding needles (20 gauge, Popper & Sons, Inc., New Hyde Park, NY). A volume of 4 ml/kg weight was administered for each dose. Compounds were tested at doses ranging from 1-50 mg/kg. Alternatively, the test selective PDE5 inhibitor compound was administered in the drinking water and found to produce similar reductions in plasma glucose and triglycerides to the reductions observed for the same compound when administered by oral gavage.
• mice Male ob/ob mice obtained from Jackson Laboratories (Bar Harbor, ME) were used in the studies at 6 to 10 weeks of age. Mice were housed five per cage and allowed free access to D11 mouse chow (Purina, Brentwood, MO) and water.
• mice were allowed to acclimate to the Pfizer animal facilities for 1 week prior to the start of the study. On day one, retro-orbital blood samples were obtained and plasma glucose was determined as described hereinafter. Mice were then sorted into groups of five such that mean plasma glucose concentrations for each group did not differ. On day one, mice were dosed with vehicle or a test selective PDE5 inhibitor compound only in the afternoon. Subsequently, mice were dosed twice a day on day 2-4 in the morning and in the afternoon. On day 5, the mice received an a.m. dose and bled 3 hours later for plasma preparation for glucose and triglyceride analysis as described below.
• test selective PDE5 inhibitor compound was administered in the drinking water commencing on the afternoon of day 1 and continuing through day 5, when mice were then bled for plasma preparation for glucose and triglyceride analysis as described below. Terminal plasma samples were collected on day 5 following the retro-orbital sinus bleed as described below. Body weight was measured on days 1 and 5 of the study, and food consumption was assessed over the 5 day period.
• mice were dosed with test compound or vehicle at approximately 8:00 am. Three hours after dosing, 25 ⁇ L of blood was obtained via the retro-orbital sinus and added to 100 ⁇ L of 0.025 % heparinized-saline in Denville Scientific microtubes. The tubes were spun at the highest setting in a Beckman Microfuge 12 for 2 minutes. Plasma was collected for plasma glucose and triglyceride determination. The mice were then sacrificed by decapitation and ⁇ 1 ml of blood was collected in Becton-Dickinson Microtainer brand plasma separator tubes with lithium heparin. The tubes were spun in a Beckman Microfuge 12 at the maximum setting for five minutes. Plasma was collected in 1.5 ml Eppendorf tubes and snap frozen in liquid nitrogen. Plasma samples were stored at - 80° C until analyzed.
• Plasma glucose and triglycerides were measured using the Alcyon Clinical Chemistry Analyzer (Abbott Laboratories, Abbott Park, IL) using kits supplied by Abbott.
• Plasma cGMP was measured using the Biotrak enzyme-immunoassay system by Amersham (Piscataway, NJ). Via a similar technique the plasma insulin can be assessed by the Mercodia ELISA Insulin kit by ALPCO (Uppsala, Sweden). All assays were conducted according to instructions provided by the manufacturers.
• Table 1 illustrates the changes in plasma glucose levels over a 5 day period observed with selective PDE5 inhibitor compounds.
• Table 1 The data in Table 1 are presented as mean ⁇ standard error of the mean. These numbers reflect absolute decreases in plasma glucose levels. Significant differences from the Vehicle control are indicated as *p ⁇ 0.05.
• Table 2 illustrates the change in plasma cGMP and plasma triglyceride levels in ob/ob mice observed with the test selective PDE5 inhibitor compounds A and B.
• Table 3 illustrates the reduction in plasma glucose levels over a 5 day period observed with selective a PDE5 inhibitor compound administered in the drinking water of the mice.
• Table 3 The data in Table 3 are presented as mean ⁇ standard error of the mean. Positive values in this table reflect a decrease in plasma glucose level. Significant differences from the Vehicle control are indicated as ⁇ p ⁇ 0.1.
• Table 4 illustrates the triglyceride levels in ob/ob mice treated with the test selective PDE5 inhibitor compound C administered in the drinking water of the mice.
• Table 5 illustrates the sub-division of the IRS components amongst the subjects studied.
• Coronary artery disease (CAD) / ischaemic heart disease (IHD) is one clinical end- point in subjects having the Insulin Resistance Syndrome. For this reason the presence of CAD/IHD was taken as evidence to support the existence of the Insulin Resistance Syndrome in patients with only one of the defined risk factors.
• BMI -Body Mass Index Table 6 illustrates the collective totals of the number of IRS components within the subject group.
• the present invention additionally comprises treatment of insulin resistance with a selective pyrazolopyrimdinone cGMP PDE5 inhibitor (as defined hereinbefore).
• the present invention provides a method of treatment of type 2 diabetes mellitus comprising treating a subject in need of such treatment with a selective pyrazolopyrimidinone cGMP PDE5 inhibitor (as defined hereinbefore) and especially sildenafil.
• a selective pyrazolopyrimidinone cGMP PDE5 inhibitor as defined hereinbefore
• sildenafil is especially sildenafil.
• said treatment is effected by the oral route.
• results of clinical trial 2 are supporting for the use of a selective cGMP PDE5 inhibitor as defined hereinbefore, and especially sildenafil for the treatment of IGT.
• the present invention additionally comprises the combination of a selective PDE5 inhibitor and a glucose-lowering agent for the treatment of the IRS.
• said combined treatment is effected by the oral route.
• the present invention provides a combination therapy suitable for use in the treatment of the IRS, IR, type 2 diabetes mellitus, impaired glucose tolerance (IGT), hyperuricaemia and/or gout, dyslipidemia, the procoagulant state or truncal obesity
• said combination comprises a selective cGMP PDE5 inhibitor, preferably a pyrazolopyrimidinone, especially sildenafil with an additional agent active as defined hereinbefore and preferably (16), (40), (41), (42), (50), (52), (53) and/or (54), more preferably one or more of : weight loss agents, sulfonyl ureas, insulin, Rezulin, Avandia, Actos, Glipizide, Metformin, Acarbose, rosiglitasone, pioglitazone, farglitazar, LY333531 , CS011 , PPAR-alpha agonists, and/or CP-470711.
• combination treatment(s) is/are effected orally and further may be in the form.of a kit.

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