Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
  • A61K45/06—Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/185—Acids; Anhydrides, halides or salts thereof, e.g. sulfur acids, imidic, hydrazonic or hydroximic acids
  • A61K31/19—Carboxylic acids, e.g. valproic acid
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
  • A61K31/44—Non condensed pyridines; Hydrogenated derivatives thereof
  • A61K31/445—Non condensed piperidines, e.g. piperocaine
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • 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
  • A61K31/496—Non-condensed piperazines containing further heterocyclic rings, e.g. rifampin, thiothixene
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • 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
  • A61K31/505—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim
  • A61K31/519—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim ortho- or peri-condensed with heterocyclic rings
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/55—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having seven-membered rings, e.g. azelastine, pentylenetetrazole
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/55—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having seven-membered rings, e.g. azelastine, pentylenetetrazole
  • A61K31/551—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having seven-membered rings, e.g. azelastine, pentylenetetrazole having two nitrogen atoms, e.g. dilazep
  • A61K31/5513—1,4-Benzodiazepines, e.g. diazepam or clozapine
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
  • A61P25/18—Antipsychotics, i.e. neuroleptics; Drugs for mania or schizophrenia
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
  • A61P25/28—Drugs for disorders of the nervous system for treating neurodegenerative disorders of the central nervous system, e.g. nootropic agents, cognition enhancers, drugs for treating Alzheimer's disease or other forms of dementia

Definitions

• the present invention is directed to the use of a valproate compound and an atypical antipsychotic in the treatment of schizophrenia.
• Other aspects of the invention are directed to pharmaceutical compositions containing both a valproate compound and an atypical antipsychotic.
• Schizophrenia is characterized as having both "positive symptoms” (hallucinations, delusions, and conceptual disorganization) and "negative symptoms” (apathy, social withdrawal, affect, and poverty of speech).
• Abnormal activity of the neurotransmitter dopamine is a hallmark of schizophrenia. Dopaminergic activity is reduced in the mesocortical system (resulting in negative symptoms) and is enhanced in the mesolimbic system (resulting in positive or psychotic symptoms).
• Chlorpromazine was the first such agent to be developed for schizophrenia, dating to the 1950's. Chlorpromazine has high affinity for the D 2 receptor, functioning as an antagonist at that receptor.
• D 2 antagonists were subsequently developed. These D 2 antagonists are often referred to as "neuroleptics” or “classical antipsychotics". Examples of such D 2 antagonists include thioridazine, fluphenazine, haloperidol, thioxanthene, flupenthixol, molindone, and loxapine. These D 2 antagonists are effective for treating the positive symptoms of schizophrenia, but have little or no effect on the negative symptoms.
• a further disadvantage of D 2 antagonists is the high incidence of extrapyramidal side effects, including rigidity, tremor, bradykinesia (slow movement), and bradyphrenia (slow thought), as well as tardive dyskinesias and dystonias.
• D 2 antagonists Due to the significant side effects and limited efficacy associated with D 2 antagonists, researchers attempted to find new antipsychotic agents having differing mechanisms of action.
• 5HT serotonin
• gamma-aminobutyric acidfGABA gamma-aminobutyric acidfGABA
• researchers have also evaluated the ability of phospholipase inhibitors, neurokinin antagonists, AMPA modulators, and opioid antagonists to alleviate schizophrenia.
• GABA B agonists would have utility in schizophrenia, since these agonists down regulate dopaminergic transmission within the CNS.
• GABA agonists include the benzodiazepines (i.e. valium, librium, etc.), vinyl GABA, and valproic acid.
• Kausen et al reported on a study involving 14 chronic schizophrenics who had been maintained on clozapine (an atypical antipsychotic) for at least 2 years (Neuropsychobiology 11 :59-64 (1984). Sodium valproate was instituted in these patients for 90 days and then discontinued. The patients' symptoms were evaluated while receiving the combination and with clozapine alone. Valproate did not have any significant effect on the patients symptoms. While clozapine has shown significant efficacy in controlling the negative symptoms of schizophrenia, its widespread use has also highlighted some serious side effects. One of the more serious side effects is seizures. Balen reported on using valproate prophylactically to prevent seizures in patients taking clozapine (Int. J.
• a new therapeutic regimen for the treatment of schizophrenia has been discovered. It has been discovered that schizophrenia can be treated by concurrently administering to a patient with schizophrenia an atypical antipsychotic and a valproate compound. In a further embodiment, it has been discovered that this combination is especially beneficial for treating schizophrenics during the acute phase of their disease.
• the acute phase is characterized as a florid psychotic phase. It may include violent or dangerous behaviors, hallucinations, delusions, hostility, playful behavior, paranoia, etc. During this acute phase, it is almost impossible for patients to function in normal social settings. Patients are typically hospitalized during this acute phase. This acute phase is also typically referred to as psychosis associated with schizophrenia.
• a valproate compound will enhance the patients' recovery from this acute phase of schizophrenia.
• the symptoms of psychosis will subside at a quicker rate, than in a patient who is taking only an atypical antipsychotic.
• the valproate will serve to shorten the period of time that the patient is exhibiting these overt symptoms of psychosis and potentially shorten the duration of their hospitalization.
• a valproate compound and an atypical antipsychotic is also useful in the treatment of other mental illnesses, besides schizophrenia.
• Psychosis is often associated with schizophreniform and dementia. The psychosis associated with these diseases will resolve at a quicker rate when the patient is treated with the combination of this invention.
• Schizophrenia a major psychotic disorder, is a chronic condition that frequently has devastating effects on a patient's life and carries a high risk of suicide and other life-threatening behaviors. Manifestations of the disorder involve multiple psychological processes, including perception (e.g., hallucinations), ideation, reality testing (e.q " delusions), emotion (e.g., flatness, inappropriate affect), thought processes (e.g., loose associations), and behavior (e.g., catatonia, disorganization). The behavioral and psychological characteristics of schizophrenia are associated with a variety of impairments in social and occupational functioning.
• Positive symptoms include hallucinations, delusions, playful behavior, hostility, uncooperativeness, and paranoid ideation.
• Negative symptoms include restricted range and intensity of emotional expression (affective flattening), reduced thought and speech productivity (alogia), anhedonia, apathy, and decreased initiation of goal-directed behavior (avolition).
• Disorganized symptoms include disorganized speech (thought disorder) and behavior and poor attention.
• Subtypes of schizophrenia include the paranoid, disorganized, catatonic, undifferentiated, and residual types.
• Treatment of schizophrenia usually involves a variety of interventions (e.g., psychiatric management, psychosocial interventions, drug therapy, electroconvulsive therapy, etc.) aimed at reducing the frequency, severity, and psychosocial consequences of acute episodes and at reducing the overall morbidity and mortality of the disorder. Most patients alternate between acute psychotic episodes and stable phases with full or partial remission.
• interventions e.g., psychiatric management, psychosocial interventions, drug therapy, electroconvulsive therapy, etc.
• the acute phase of schizophrenia has also been referred to as acute exacerbation of schizophrenia, acute psychosis associated with schizophrenia, and acute schizophrenia.
• these terms should be treated as synonoms.
• therapy is aimed at minimizing stress and providing support to reduce the likelihood of relapse, enhance the patient's return to community life and facilitate continued reduction in symptoms and consolidation of remission.
• This phase can last for a period of 6 months, or longer, after the onset of an acute episode.
• patients may also benefit from the combination of a valproate compound and an atypical antipsychotic. Such a combination may reduce the incidence of the positive symptoms of schizophrenia and reduce the rate of relapse back to the acute state.
• the disorder enters the stable phase (also commonly referred to as the maintenance phase). Treatment during this phase is aimed at maintaining the patients level of functioning and quality of life, while preventing relapse.
• the combination of a valproate compound and an atypical antipsychotic may help prevent relapses back to the acute phase of schizophrenia.
• Other benefits for schizophrenics from the concurrent administration of a valproate compound and an atypical antipsychotic will become readily apparent to those skilled in the art. Further information on the diagnosis and treatment of schizophrenia may be found in the Diagnostic and Statistical Manual of Mental Disorder, Revised, 4 ,h Ed. (2000), ("DSM- IV- TR").
• the DSM- IV-TR was prepared by the Task Force on Nomenclature and Statistics of the American Psychiatric Association. Patients who would be considered schizophrenic according to the DSM criteria will typically benefit from the concurrent administration of an atypical antipsychotic and a valproate compound.
• Atypical antipsychotics are well known to those skilled in the art.
• the essential feature of an atypical antipsychotic is that it has a high level of affinity for the 5HT 2 receptor and functions as an antagonist of serotonin at that receptor. While the exact mechanism by which these compounds exert their antipsychotic effect is still under review, it is believed that at least part of their efficacy stems from their ability to modulate serotonergic transmission within the CNS. While atypical antipsychotics often have affinity for dopaminergic receptors within the CNS, they are much less potent dopaminergic antagonists than classical antipsychotics, such as chlorpromazine, haloperidol, etc.
• atypical antispychotics can be differentiated from classical antipsychotics based upon their side effect profile. Atypical antipsychotics are associated with a significantly reduced incidence of acute extrapyramidal symptoms, especially dystonias, when compared to a typical antipsychotic such as haloperidol. (Beasley, et al., Neuropsychopharmacology, 14(2), 111-123, (1996)).
• atypical antipsychotic includes, but is not limited to, olanzapine, clozapine, risperidone, sertindole, quetiapine, zotepine, eplivanserin, MDL 100 907, iloperidone, perospirone, blonanserin, Org-5222, SM-13496, aripiprazole and ziprasidone. Any other compound having a pharmacological profile analogous to the compounds exemplified above should also be considered to be encompassed by the term atypical antipsychotic even if that compound discovered after the filing of this application.
• Olanzapine 2-methyl-4-(4-methyl-1 -piperazinyl)-10H-thieno[2,3- b][1 ,5]benzodiazepine
• U.S. Pat. No. 5,229,382 is herein incorporated by reference in its entirety.
• Olanzapine is available commercially from Eli Lilly. The recommend dose ranges from 2.5mg to 15 mg per day.
• AHFS Drug Information 2000, page 2135, which is published by the American Society of Hospital Pharmacists (editor-McEvoy).
• Clozapine 8-chloro-11-(4-methyl-1-piperazinyl)-5H-dibenzo[b,e][1 ,4]diazepine, is described in U.S. Pat. No. 3,539,573, which is herein incorporated by reference in its entirety.
• Clinical efficacy in the treatment of schizophrenia is described by Hanes et al, Psychopharmacol. Bull., 24, 62 (1988).
• Clozapine is available commercially from Novartis. Daily doses range from 25mg/day to 900mg/day.
• AHFS Drug Information 2000
• page 2125 which is published by the American Society of Hospital Pharmacists (editor- McEvoy).
• Risperidone 3-[2-[4-(6-fluoro-1 ,2-benzisoxazol-3-yl)piperidino]ethyl]-2-methyl-6,7,8,9 - tetrahydro-4H-pyrido-[1 ,2-a]pyrimidin-4-one, and its use in the treatment of psychotic diseases are described in U.S. Pat. No. 4,804,663, which is herein incorporated by reference in its entirety. Risperidone is available commercially from Janssen. Daily doses range from 1 mg per day to 16 mg per day.
• Quetiapine 5-[2-(4-dibenzo[b,f][1 ,4]thiazepin-11 -yl -1-piperazinyl)ethoxy]ethanol, and its activity in assays which demonstrate utility in the treatment of schizophrenia are described in U.S. Pat. No. 4,879,288, which is herein incorporated by reference in its entirety.
• Quetiapine is typically administered as its (E)-2-butenedioate (2:1) salt. It is available commercially from Astra Zenecca. Daily doses range from 25mg per day to 750mg per day.
• a detailed discussion of quetiapine, its dosing schedule, potential side effects, etc. may be found in AHFS, Drug Information 2000, page 2142, which is published by the Americal Society of Hospital Pharmacists (editor-McEvoy).
• Ziprasidone 5-[2-[4-(1 ,2-benzoisothiazol-3-yl)-1-piperazinyl]ethyl]-6-chloro-1 ,3-dihyd ro-2H-indol-2-one, is typically administered as the hydrochloride monohydrate.
• the compound is described in U.S. Pat. Nos. 4,831 ,031 and 5,312,925. Its activity in assays which demonstrate utility in the treatment of schizophrenia are described in U.S. Pat. No. 4,831 ,031.
• U.S. Pat. Nos. 4,831 ,031 and 5,312,925 are herein incorporated by reference in their entirety. Daily doses range from 5 mg day to 500mg/day.
• Zotepine 2- ⁇ (8-chlorodibenzo[b,f]thiepine-10-yl)oxy]-N,N-dimethylethylamine, is available commercially from Knoll under the tradename Zoleptil®. It is approved for use as a antipsychotic in Japan and Germany. Daily doses for adults range from 25mg/day to 300 mg/day.
• Perospirone is marketed in Japan for schizophrenia by Yoshitomi. Daily doses range from 30mg to 300 mg daily. Further information regarding the compound can be obtained from Sumitomo Pharmaceutical, of Japan.
• Blonanserin is under development as an antipsychotic in Japan by Dainippon Pharmaceuticals. It is currently reported to be in Phase III trials. Further information regarding the how to prepare the compound and relevant dosing information can be obtained from Dainippon. Aripiprazole is under development as an atipsychotic in Europe and the United Sates by Bristol-Myers Squibb. It is reported to be in phase III of human trials.
• SM-13496 is under development as an antipsychotic by Astra Zeneca and based on publicly available information is in Phase II clinical trials. Further information regarding how to prepare the compound and relevant dosing information can be obtained from Astra Zenecca.
• Org-5222 is under development as an antipsychotic by Organon of the Netherlands and is reported to be in Phase II clinical trials. Further information regarding how to prepare the compound and relevant dosing information can be obtained from Organon.
• MDL 100,907 is under development as an antipsychotic by Aventis. It is reported to be in Phase III trials. Further information regarding the compound can be found in United States Patent No. 6,063,793.
• Valproic acid may be represented by the following structure:
• Valproic acid is available commercially from Abbott Laboratories of Abbott Park, Illinois. Methods for its synthesis are described in Oberreit, Ber. 29, 1998 (1896) and Keil, Z. Physiol. Chem. 282, 137 (1947). It's activity as an antiepileptic compound is described in the Physician Desk Reference, 52 nd Edition, page 421 (1998). Upon oral ingestion within the gastrointestinal tract, the acid moiety disassociates to form a carboxylate moiety (i.e. a valproate ion). The sodium salt of valproic acid is also known in the art as an anti-epileptic agent. It is also known as sodium valproate and is described in detail in The Merck Index, 12 th Edition, page 1691 (1996). Further descriptions may be found in the Physician Desk Reference, 52 nd Edition, page 417 (1998).
• Divalproex sodium is effective as an antiepileptic agent and is also used for, migraine and bipolar disorder. Methods for its preparation may be found in United States Patent No.'s 4,988, 731 and 5,212,326, the contents of both which are hereby incorporated by reference. Like valproic acid, it also disassociates within the gastrointestinal tract to form a valproate ion. Divalproex sodium is available from Abbott Laboratories.
• Dosages for divalproex sodium, valproic acid and sodium valproate are similar. They range from 250mg per day up to 1 gram per day, in selected patients up to 2 grams per day and on occasion up to 5 grams per day.
• a detailed discussion of these three compounds, their pharmacology, side effects, dosing schedule, etc. may be found in AHFS, Drug Information 2000, page 2142, which is published by the Americal Society of Hospital Pharmacists (editor-McEvoy).
• the carboxylic moiety of the valproate compound may be functionalized in a variety of ways.
• valproate amide valproimide
• other pharmaceutically acceptable amides and esters of the acid i.e. prodrugs.
• This also includes forming a variety of pharmaceutically acceptable salts.
• Suitable pharmaceutically acceptable basic addition salts include, but are not limited to cations based on alkali metals or alkaline earth metals such as lithium, sodium, potassium, calcium, magnesium and aluminum salts and the like and nontoxic quaternary ammonia and amine cations including ammonium, tetramethylammonium, tetraethylammonium, methylamine, dimethylamine, trimethylamine, triethylamine, diethylamine, ethylamine and the like.
• Other representative organic amines useful for the formation of base addition salts include ethylenediamine, ethanolamine, diethanolamine, piperidine, piperazine and the like.
• Other possible compounds include pharmaceutically acceptable amides and esters.
• “Pharmaceutically acceptable ester” refers to those esters which retain, upon hydrolysis of the ester bond, the biological effectiveness and properties of the carboxylic acid and are not biologically or otherwise undesirable.
• esters are typically formed from the corresponding carboxylic acid and an alcohol.
• ester formation can be accomplished via conventional synthetic techniques. (See, e.g., March Advanced Organic Chemistry, 3 rd Ed., John Wiley & Sons, New York p. 1157 (1985) and references cited therein, and Mark et al.
• the alcohol component of the ester will generally comprise (i) a C 2 -C 12 aliphatic alcohol that can or can not contain one or more double bonds and can or can not contain branched carbons or (ii) a C 7 -C 12 aromatic or heteroaromatic alcohols.
• This invention also contemplates the use of those compositions which are both esters as described herein and at the same time are the pharmaceutically acceptable salts thereof.
• “Pharmaceutically acceptable amide” refers to those amides which retain, upon hydrolysis of the amide bond, the biological effectiveness and properties of the carboxylic acid and are not biologically or otherwise undesirable.
• amides as prodrugs, see Bundgaard, H., Ed., (1985) Design of Prodrugs, Elsevier Science Publishers, Amsterdam. These amides are typically formed from the corresponding carboxylic acid and an amine. Generally, amide formation can be accomplished via conventional synthetic techniques. (See, e.g., March Advanced Organic Chemistry, 3 rd Ed., John Wiley & Sons, New York, p. 1152 (1985) and Mark et al. Encyclopedia of Chemical Technology, John Wiley & Sons, New York (1980), both of which are hereby incorporated by reference.
• compositions which are amides, as described herein, and at the same time are the pharmaceutically acceptable salts thereof.
• any reference to "valproate” or " a valproate compound” should be construed as including a compound which disassociates within the gastrointestinal tract, or within in-vitro dissolution media, to produce a valproate ion including, but not limited to, valproic acid, the sodium salt of valproate, divalproex sodium, any of the various salts of valproic acid described above, and any of the prodrugs of valproic acid described above.
• Divalproex sodium is the most preferred valproate compound of the present invention.
• schizophrenia can be treated by concurrently administering to a patient (i.e. a human) in need thereof, an atypical antipsychotic and a valproate compound. It has been discovered that this combination is especially useful during acute exacerbations of schizophrenia.
• the acute symptoms of schizophrenia will subside at a quicker rate in patients being treated with both a valproate compound and an atypical antipsychotic, when compared to treatment with only an atypical antipsychotic.
• the combination therapy is especially useful in relieving the positive symptoms of schizophrenia (i.e. hallucinations, delusions, paranoia, hostility, etc.)
• the term "concurrent administration” refers to administering the valproate compound to a schizophrenic, who has been prescribed (or has consumed) at least one atypical antipsychotic, at an appropriate time so that the patients symptoms may subside. This may mean simultaneous administration of the valproate compound and the atypical antipsychotic, or administration of the medications at different, but appropriate times. Establishing such a proper dosing schedule will be readily apparent to one skilled in the art, such as a psychiatrist, or other physician.
• the dosage range at which the atypical antipsychotic and the valproate compound will be administered concurrently can vary widely.
• the specific dosage will be chosen by the patients physician taking into account the particular antipsychotic chosen, the severity of the patients illness, any other medical conditions or diseases the patient is suffering from, other drugs the patient is taking and their potential to cause an interaction or adverse event, the patients previous response to these atypical antipsychotic, etc.
• olanzapine from about 0.25 to 50 mg, once/day; preferred, from 1 to 30 mg, once/day; and most preferably 1 to 25 mg once/day
• clozapine from about 12.5 to 900 mg daily; preferred, from about 150 to 450 mg daily
• risperidone from about 0.25 to 16 mg daily; preferred from about 2-8 mg daily
• sertindole from about 0.0001 to 1.0 mg/kg daily
• e) quetiapine from about 1.0 to 40 mg/kg given once daily or in divided doses
• ziprasidone from about 5 to 500 mg daily; preferred from about 50 to 100 mg daily
• zotepine from about 25 mg to 500mg daily, more typically from about 75mg to 300 mg /day h) divalproex
• valproate compound and the atypical antipsychotic should be administered concurrently in amounts that are effective to treat the patient's schizophrenia.
• one would create a combination of the present invention by choosing a dosage of an atypical antipsychotic and a dosage of the valproate compound according to the spirit of the above guideline.
• the antipsychotic therapy of the present invention is carried out by administering an atypical antipsychotic together with a valproate compound in any manner which provides effective levels of the compounds in the body at the same time.
• Valproate is absorbed from the Gl tract via oral administration. All of the atypical antipsychotics exemplified above are absorbed from the Gl tract. Typically, the combination will be administered orally.
• the invention is not limited to oral administration.
• the invention should be construed to cover any route of administration that is appropriate for the medications involved and for the patient.
• transdermal administration may be very desirable for patients who are forgetful or petulant about taking oral medicine. Injections may be appropriate for patients refusing their medication.
• One of the drugs may be administered by one route, such as oral, and the others may be administered by the transdermal, percutaneous, intravenous, intramuscular, intranasal or intrarectal route, in particular circumstances.
• the route of administration may be varied in any way, limited by the physical properties of the drugs and the convenience of the patient and the caregiver.
• compositions suitable for oral administration are particularly preferred.
• Such pharmaceutical compositions contain an effective amount of each of the compounds, which effective amount is related to the daily dose of the compounds to be administered.
• Each dosage unit may contain the daily doses of all compounds, or may contain a fraction of the daily doses, such as one-third of the doses. Alternatively, each dosage unit may contain the entire dose of one of the compounds, and a fraction of the dose of the other compounds.
• each drug to be contained in each dosage unit depends on the identity of the drugs chosen for the therapy, and other factors such as the indication for which the antipsychotic therapy is being given.
• compositions contain from about 0.5% to about 50% of the compounds in total, depending on the desired doses and the type of composition to be used.
• the amount of the compounds is best defined as the effective amount, that is, the amount of each compound which provides the desired dose to the patient in need of such treatment.
• compositions do not depend on the nature of the composition, so the compositions are chosen and formulated solely for convenience and economy. Any of the combinations may be formulated in any desired form of composition. Some discussion of different compositions will be provided, followed by some typical formulations.
• Capsules are prepared by mixing the compounds with a suitable diluent and filling the proper amount of the mixture in capsules.
• suitable diluents include inert powdered substances such as starch of many different kinds, powdered cellulose, especially crystalline and microcrystalline cellulose, sugars such as fructose, mannitol and sucrose, grain flours and similar edible powders.
• the capsules can be formulated so that the contents are removed from the capsules prior to ingestion by the patient.
• the medication may be diluted in foods, juices, etc., in order to simplify administration to those who have difficulty swallowing.
• Abbott Laboratories sells a preparation known as Depakote Sprinke Capsules. Methods for manufacturing such a dosage form would be readily apparent to one skilled in the art.
• the medications may also be formulated into liquids or syrups, as is known in the art, in order to simplify administration.
• the medication is dissolved in a liquid, flavorants, antioxidants, stabilizers etc. are added as is known in the art.
• Such dosage forms have particular suitability with the elderly, such as dementia patients. Tablets are prepared by direct compression, by wet granulation, or by dry granulation.
• Typical diluents include, for example, various types of starch, lactose, mannitol, kaolin, calcium phosphate or sulfate, inorganic salts such as sodium chloride and powdered sugar. Powdered cellulose derivatives are also useful.
• Typical tablet binders are substances such as starch, gelatin and sugars such as lactose, fructose, glucose and the like. Natural and synthetic gums are also convenient, including acacia, alginates, methylcellulose, polyvinylpyrrolidine and the like. Polyethylene glycol, ethylcellulose and waxes can also serve as binders.
• a lubricant is necessary in a tablet formulation to prevent the tablet and punches from sticking in the die.
• the lubricant is chosen from such slippery solids as talc, magnesium and calcium stearate, stearic acid and hydrogenated vegetable oils.
• Tablet disintegrators are substances which swell when wetted to break up the tablet and release the compound. They include starches, clays, celluloses, algins and gums. More particularly, corn and potato starches, methylcellulose, agar, bentonite, wood cellulose, powdered natural sponge, cation-exchange resins, alginic acid, guar gum, citrus pulp and carboxymethylcellulose, for example, may be used, as well as sodium lauryl sulfate.
• Enteric formulations are often used to protect an active ingredient from the strongly acid contents of the stomach. Such formulations are created by coating a solid dosage form with a film of a polymer which is insoluble in acid environments, and soluble in basic environments. Exemplary films are cellulose acetate phthalate, polyvinyl acetate phthalate, hydroxypropyl methylcellulose phthalate and hydroxypropyl methylcellulose acetate succinate. Tablets are often coated with sugar as a flavor and sealant.
• the compounds may also be formulated as chewable tablets, by using large amounts of pleasant-tasting substances such as mannitol in the formulation, as is now well-established practice. Instantly dissolving tablet-like formulations are also now frequently used to assure that the patient consumes the dosage form, and to avoid the difficulty in swallowing solid objects that bothers some patients.
• Cocoa butter is a traditional suppository base, which may be modified by addition of waxes to raise its melting point slightly.
• Water-miscible suppository bases comprising, particularly, polyethylene glycols of various molecular weights are in wide use, also.
• Transdermal patches have become popular recently. Typically they comprise a resinous composition in which the drugs will dissolve, or partially dissolve, which is held in contact with the skin by a film which protects the composition. Many patents have appeared in the field recently. Other, more complicated patch compositions are also in use, particularly those having a membrane pierced with innumerable pores through which the drugs are pumped by osmotic action.
• the atypical antipsychotic and the valproate compound may be formulated into a single dosage form.
• the atypical antipsychotic and the valproate compound may each be in separate dosage forms, but yet packaged in a single container for dispensing by the pharmacist (i.e. a blister pack).
• Such packaging is typically designed to help a patient comply with a dosage regimen and to consume all of the required medication. Examples of such packaging are well known to those skilled in the pharmaceutical arts.
• Pfizer distributes an antibiotic known as Zithromax ® . Patients must consume 2 pills on the first day and one pill after that for 4 days in order to eradicate the infection.
• Pfizer packages the medication in a blister pack that is commonly referred to as a Z-pack. Similar packages are used with steroids in which the dosage must be tapered.
• Birth control pills are another example of packaging pharmaceuticals to enhance convenience (i.e. articles of manufacture).
• the atypical antipsychotic and the valproate compound may be incorporated into such packaging to enhance patient convenience. If desired, such packaging may be used even if the atypical antipsychotic and valproate compound are in a single dosage form. The particulars of such packaging will be readily apparent to one skilled in the art.
• the packaged pharmaceutical will include an insert which describes the drugs, their doses, possible side effects and indication.
• the invention should be construed to include a package containing at least one valproate compound in combination with an atypical psychotic. They may be in a single or separate dosage forms.
• the package will include an insert stating that the combination should be used to treat schizophrenia and move specifically acute exacerbations of schizophrenia.
• Schizophreniform is a condition exhibiting the same symptoms as schizophrenia, but is characterized by an acute onset with resolution in two weeks to six months. Often, schizophreniform is used to describe a patient's first schizophrenic episode. The patient presents with symptoms identical to those seen in the acute phase of schizophrenia, but the patient has no previous history of schizophrenia. Clinicians also refer to schizophreniform as "early schizophrenia". The patients symptoms are similar to those exhibited during the acute phase of schizophrenia. ( i.e. overtly psychotic behavior) which were described above in Section A. The combination of a valproate compound and an atypical antipsychotic will enhance the rate at which this psychotic behavior dissipates.
• Sections B-F are equally relevant to treating schizophreniform disorder.
• the same atypical antipsychotics may be utilized in the same doses as described above.
• the same valproate compounds may be utilized in the same doses as described above.
• the mode of administration, suitable formulations, packaging of products, etc. is the same as for schizophrenia.
• Psychotic behavior may also be associated with dementia.
• Dementia is an organic mental disorder characterized a by a general loss of intellectual abilities involving impairment of memory, judgment, abstract thinking, as well as changes in personality. The most common causes of dementia are alzheimer's disease, parkinson's disease , and multi-infarct disease. If a patient with dementia exhibits psychotic behavior; the combination of a valproate compound and an atypical antipsychotic will enhance the rate at which this psychoses dissipates. As with schizophreniform, the discussion above in Sections B-F are equally relevant to any psychoses associated with dementia.
• Formulation 1 A hard gelatin capsule is prepared using the following ingredients:
• a tablet is prepared using the ingredients below:
• Olanzapine 1.25 Divalproex sodium 250 Cellulose, microcrystalline 275 Silicon dioxide, fumed 10
• the components are blended and compressed to form tablets each weighing 541.25 mg.
• a tablet is prepared using the ingredients below:
• Risperidone 1.0 Divalproex sodium 500 Cellulose, microcrystalline 275 Silicon dioxide, fumed 10 Stearic acid 5
• the components are blended and compressed to form tablets each weighing 791 mg.
• PANSS Positive and Negative Syndrome Scale
• BPRS-d Brief Psychiatric Rating Scale - derived from the PANSS
• CGI Global Impression Scale (Guy, 1976). All of these assessments may be used to assess the clinical utility of antipsychotic agents.
• the PANSS is designed to measure severity of psychopathology in patients with schizophrenia.
• the PANSS Positive subscale examines positive symptoms such as delusions and hallucinations; while the PANSS Negative subscale assesses negative symptoms of schizophrenia such as, emotional withdrawal and blunted affect.
• the BPRS is another standard assessment of psychopathology; it has items that overlap with those of the PANSS and therefore, can be derived from the PANSS as was done in the case with this study.
• the CGI is a two-part scale that assesses the clinician's impression of the patient's current state of illness (CGI -Severity) and the patient's improvement or worsening from baseline (CGI-lmprovement).
• the study was a randomized, double-blind, parallel-group, multicenter trial, consisting of a wash-out period and a four-week double-blind treatment period.
• the protocol was approved by the institutional review board of each participating study site. Written informed consent was obtained from each patient or the patient's legally authorized representative before enrollment into the study.
• Divalproex was initiated on day 1 at 15 mg/kg/day (administered twice daily) and was titrated to clinical response, as deemed appropriate by the investigator, over 12 days to a maximum dosage of 30 mg/kg/day.
• Olanzapine and risperidone were initiated at 5 mg/day and 2 mg/day, respectively (administered once daily), increased to 10 mg/day and 4 mg/day, respectively, on day 3, and increased to a target daily dosage of 15 mg/day and 6 mg/day, respectively, on day 6. Once these dosages were achieved, they were to be continued for the remainder of the study. The investigators were instructed to discontinue the participation of any patient who could not tolerate the fixed target dosages of olanzapine or risperidone.
• Chloral hydrate up to 2 gm/day
• zolpidem tartrate up to 10 mg/day
• Lorazepam up to 6 mg/day during the wash-out phase, up to 4 mg/day during Weeks 1 and 2 of the treatment period, and up to 2 mg/day during Week 3 of the treatment period
• the use of chloral hydrate, lorazepam, and zolpidem tartrate was prohibited during Week 4.
• Propranolol hydrochloride (per investigator's discretion) could be prescribed for akathisia, and benztropine mesylate (up to 4 mg/d) could be prescribed for control of extrapyramidal symptoms. Patients were required to remain hospitalized for 28 days. However, leave from the hospital was allowed for up to 7 days, providing that the patient completed the two-week dosage titration phase and had a CGI-lmprovement score of "much improved" after day 14.
• the data obtained to evaluate the safety of the study drugs included physical examinations, vital sign and body weight measurements, adverse events, and laboratory test results. Extrapyramidal side effects were assessed during the double-blind treatment period using a movement rating scale battery, including the Simpson-Angus Scale (SAS) (Simpson and Angus 1970), Barnes Akathisia Scale (BAS) (on days 1 , 14 and 28) (Barnes 1989), as well as Abnormal Involuntary Movement Scale (AIMS) (days 1 and 28) (Guy 1976). Patients were monitored for adverse events between the time study drug was initiated and 30 days after the discontinuation of therapy, inclusive. Plasma concentrations of valproate were evaluated on day 28.
• SAS Simpson-Angus Scale
• BAS Barnes Akathisia Scale
• AIMS Abnormal Involuntary Movement Scale
• the primary objective of this study was to evaluate the efficacy and safety of divalproex in the treatment of schizophrenia when combined with an atypical antipsychotic, with change from baseline to final evaluation on the PANSS Total Score being the primary efficacy endpoint.
• the two antipsychotic monotherapy groups were combined, as were the two combination therapy groups for comparisons of baseline characteristics and efficacy parameters.
• a target sample size of 120 patients each for the combined antipsychotic monotherapy group and the combined combination therapy group was selected in order to provide 80% power for an effect size of 0.362 and 90% power for an effect size of 0.418.
• Efficacy analyses were performed on the intent-to-treat data set, which included all patients who received at least one dose of randomized study medication and had a PANSS Total score recorded at baseline and at least once during treatment. To address missing evaluations, a "last observation carried forward" analysis was conducted. This technique was used to reduce bias caused by patients who prematurely discontinued for lack of efficacy.
• Baseline comparability between the combination and antipsychotic monotherapy groups for demographic characteristics was assessed by one-way analysis of variance (ANOVA) with treatment group as the main effect for quantitative variables (age, weight) and by Fisher's exact test for qualitative variables (gender, race). For statistical testing, race was categorized as Caucasian and non-Caucasian.
• baseline comparability between treatment groups was assessed by the Wilcoxon rank sum test (age at first diagnosis), by the Cochran-Mantel-Haenszel test (lifetime number of hospitalizations, number of suicide attempts), and by Fisher's exact test (schizophrenia subtype).
• Baseline comparability among treatment groups for all efficacy and movement rating scale scores was assessed by two-way ANOVA with factors for treatment group and investigator. Treatment differences (combination therapy vs. antipsychotic monotherapy) in the percentage of patients prematurely discontinuing from the study were assessed by Fisher's exact test both for overall and for each individual item.
• Comparisons of the combination and monotherapy groups were made for mean trough total valproic acid plasma concentrations using a mixed effects model (with effects for treatment group, visit, treatment group by visit interaction, study center, age, and weight). Treatment differences in the percentage of patients who were granted hospital leave as well as the percentage of patients using adjunctive medication were assessed by Fisher's exact test. Treatment differences in the number and percentage of days each medication was prescribed and in the average daily dose of each medication were evaluated by a oneway ANOVA, Treatment differences in the mean change from baseline to each evaluation for the
• PANSS Total score and subscales, BPRSd Total score and subscales, the supplemental anger item from the PANSS, and the CGI Severity score were assessed using a two-way ANOVA with factors for treatment and investigator. Because there were baseline differences for PANSS Positive Scale score and the PANSS individual item of delusions, an analysis of covariance (ANCOVA) with factors for treatment and investigator and with baseline as the covariate was conducted. A post-hoc repeated measures ANOVA was also conducted on observed cases data using PROC MIXED with fixed-effect factors for scheduled visit day, treatment, and investigator, and an AR (1) covariance structure. Treatment differences in the percentage of patients with at least a 20% and 30% improvement from baseline to final evaluation on the PANSS Total score at each scheduled visit were assessed by the Cochran- Mantel-Haenszel test, with investigators as strata.
• Safety analyses were performed for all patients who received at least one dose of randomized study medication. Because of the differing safety profiles of olanzapine and risperidone, safety data for the each antipsychotic monotherapy group were compared with that of the corresponding divalproex/antipsychotic group. Fisher's exact test was used to assess treatment group differences in treatment-emergent adverse event incidence rates. Treatment differences in mean change from baseline to final evaluation for the movement rating scales (SAS, BAS, AIMS) were assessed by a two-way ANOVA with factors for treatment and investigator. Treatment differences in laboratory data and vital signs (including weight) for mean change from baseline to the final evaluation were assessed by one-way ANOVA.
• the mean age of the intent-to-treat study population was 38.8 years (range, 18 to 63 years). The majority was male (76%), and there was an equal distribution between Caucasians (46%) and Blacks (49%). Most patients had a history of paranoid schizophrenia (82%), 56% were hospitalized six or more times for their schizophrenia, and 46% made at least one suicide attempt. At the time of their enrollment in the study, 214 patients (88%) were treated with an antipsychotic(s), including 78 patients (32%) with olanzapine and 81 patients (33%) with risperidone. The mean baseline PANSS score was 100 and 103 for patients in the antipsychotic monotherapy and combination therapy groups, respectively, with no significant difference between treatment groups.
• adjunctive rescue medications i.e., lorazepam, chloral hydrate, zolpidem, benztropine mesylate, and propranolol
• lorazepam a compound that has a high calcium phosphate
• zolpidem a compound that has a high calcium phosphate
• benztropine mesylate a compound that has a high calcium phosphate
• propranolol by 50% of patients (for a mean of 5.6 days) for agitation
• propranolol by 8% of patients for akathisia
• benztropine mesylate by 19% of patients for extrapyramidal symptoms.
• ⁇ ieure 2 Changes' in Effect Size ahd Variability Over Time for PANSS'Tota' ScPre 3 5 7 10 14 21 28
• Figure 3 Mean Change From Baseline to Each Evaluation for PANSS Total Score for Each Treatment Group for Last Observation Carried Forward (Intent-to-Treat Dataset)
• Clinical improvement defined as a > 20% or > 30% reduction from baseline in PANSS Total score was consistently observed in a higher proportion of patients in the combination therapy group compared to the antipsychotic monotherapy group (p ⁇ 0.05 on days 3, 5, 7, and 10 for the >20% and > 30% thresholds and on day 14 for >20% only) (Figure 4).
• a 20% or greater improvement in PANSS Total score was observed in 53% of patients in the combination group on day 7, but not until day 14 in the antipsychotic monotherapy group.
• Figure 4 Percentage of Patients With >20% or >30% Improvement in PANSS Total Score Improvements favoring combination therapy were also observed across all the evaluation points for mean PANSS Positive Scale score (Figure 5), with statistically significant treatment differences noted at days 3, 5, and 7 (by ANCOVA).
• PANSS General Psychopathology Scale score (p ⁇ 0.05 at days 5, 7, 10, and 14), and the PANSS Supplemental Anger Item (p ⁇ 0.05 at days 3 and 7) favoring combination therapy were also noted.
• PANSS Negative Scale showed little treatment difference (p ⁇ 0.05 at day 10).
• results of the BPRSd Total and subscales scores were consistent with those from the PANSS.
• Statistically significant treatment differences favoring the combination therapy group were noted at several evaluation points for BPRSd Total (days 3, 5, 7, 10, and 14), positive symptoms (days 3, 5, and 7), and agitation (days 7 and 14) scores.
• a numerical, but not a statistically significant, difference was also noted.
• AIMS Abnormal Involuntary Movement Scale ALT Alanine aminotransferase

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