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• • 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
  • A61K31/54—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 sulfur as the ring hetero atoms, e.g. sulthiame
  • A61K31/5415—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 sulfur as the ring hetero atoms, e.g. sulthiame ortho- or peri-condensed with carbocyclic ring systems, e.g. phenothiazine, chlorpromazine, piroxicam
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P11/00—Drugs for disorders of the respiratory system
  • A61P11/02—Nasal agents, e.g. decongestants
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P13/00—Drugs for disorders of the urinary system
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P13/00—Drugs for disorders of the urinary system
  • A61P13/02—Drugs for disorders of the urinary system of urine or of the urinary tract, e.g. urine acidifiers
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P13/00—Drugs for disorders of the urinary system
  • A61P13/10—Drugs for disorders of the urinary system of the bladder
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P27/00—Drugs for disorders of the senses
  • A61P27/16—Otologicals
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P31/00—Antiinfectives, i.e. antibiotics, antiseptics, chemotherapeutics
  • A61P31/04—Antibacterial agents
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P31/00—Antiinfectives, i.e. antibiotics, antiseptics, chemotherapeutics
  • A61P31/10—Antimycotics
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P43/00—Drugs for specific purposes, not provided for in groups A61P1/00-A61P41/00

Definitions

• the present invention relates to the use of 10 - [(3R) -I-azabicyclo [2.2.2] oct-3-ylmethyl] -10H-phenothiazine as well as its pharmaceutically acceptable salts for the preparation of a medicament allowing in particular to prevent or treat urinary incontinence, locally and / or orally.
• 10 - [(3R) -1-azabicyclo [2.2.2] oct-3-ylmethyl] -10H-phenothiazine is derived from a racemate: d, I-mequitazine.
• mequitazine is a drug, effective in the treatment of allergic conditions such as seasonal or permanent allergic rhinitis, drug allergies, as well as dermatological manifestations of allergic or viral origin (pruritus).
• Mequitazine is an anti-histamine type anti- ⁇ l. It has an asymmetric carbon leading to two distinct spatial configurations: levorotatory and dextrorotatory (R configuration). The extensive analysis of the properties of the two enantiomers was able to show that the dextrorotatory enantiomer had a very high affinity for the muscarinic M1 / M2 / M3 receptors, which were lifted below, while the other enantiomer showed lower affinity for muscarinic receptors.
• Acetylcholine is the main neuromediator of the parasympathetic nervous system.
• the physiological actions of acetylcholine are mediated by muscarinic or nicotinic receptors.
• Each of these receptors is heterogeneous: eg, the family of muscarinic receptors comprises, to date, 5 subtypes (M.sub.l, M.sub.2, M.sub.3, M.sub.4, and M.sub.5) each of these receptors is encoded by a different gene and has a distinct physiological distribution and function.
• several muscarinic receptors can cooperate to induce a common physiological effect, as is the case with the regulation of incontinence.
• the M3 receptor is one of the contributors to the contraction of the muscle involved in the control of the bladder sphincter (detrusor: all the smooth musculature of the bladder / bladder wall).
• urinary tract infection stones (stones), constipation, for example.
• a continence disorder is linked to a drug treatment.
• Incontinence can, in the elderly, correspond to a change of the environment, to a maladaptation of the environment. In menopausal women, the decrease in estrogen impregnation is often implicated in the appearance of incontinence, hormonal substitution treatments are part of the therapeutic arsenal in this population of patients.
• incontinence can be identified by special examinations. Management of incontinence may involve medications, rehabilitation, or, in some cases, surgery. Excessive bladder reactivity can be treated with specific antispasmodic drugs. The weakness of sphincters can be improved by sympathomimetic drugs or, in women, by estrogen hormones. Sympatholytic drugs can be used to relax over-contracted sphincters.
• the first-line treatment of "overactive bladder” is based on the use of anticholinergic or anti-muscarinic drugs. Recent meta-analyzes show that the clinical benefit versus placebo is indisputable even if the treatment is accompanied by adverse effects such as tachycardia, constipation or dry mouth, which may explain the low compliance of patients to treatment (Herbison P. et al ., BMJ, 2003). This is explained by the lack of bladder selectivity of antimuscarinics compared to other organs. Although muscarinic M 2 receptors are those that are quantitatively most expressed in the bladder and lower urinary tract, the small proportion of muscarinic M3 receptors is proportionally more important in terms of functional regulation. contractions of the detrusor.
• muscarinic receptor subtype M3 was identified as the only receptor subtype involved in muscle contraction, in the rat (Longhurst PA et al., Br J. Pharmacol, 1995), rabbits (Choppin A., et al., Brit J. Pharmacol, 1998) and humans (Chess-Williams R., and coll., J. Auton Pharmacol, 2002). These data relating the importance in terms of regulation of the M 3 receptor have been confirmed in models of transgenic mice deficient in M 3 receptors (Matsui M., et al., PNAS, 2000).
• acetylcholine binds to the M 3 receptor, which releases the secondary messengers IP3 (inositol triphosphate) and DAG (diacylgycerol) inducing contraction of the smooth muscle.
• IP3 inositol triphosphate
• DAG diacylgycerol
• Acetylcholine also induces contraction by inhibiting the release of adenosine monophosphate and reversing norepinephrine-induced relaxation via ⁇ -receptors.
• the inhibitory candidate should have a mixed binding action on both the M 2 receptor and the M 3 receptor to have a complete action with respect to the induction of contraction and on its regulation.
• the M 1 muscarinic receptor which has been deconsidered in this field, also seems to play a role in the detrusor (Maruyama S., et al., J. Urol., 2006).
• transdermal In order to reduce the adverse effects induced by antimuscarinic agents, various devices have been used. They are transdermal, or placed in situ in women, in the form of vaginal ring extended release (Schroder A., et al., Urol, 2000). Transdermal oxybutynin transdermal patches have been successfully tested in order to limit side effects due to systemic dissemination of the active ingredient (Stakmann JS, et al., Urol., 2006). By this way, the limitation of the effects of dry mouth or ocular, disturbances of the vision, constipation, migraines is less observed; on the other hand the cutaneous intolerances to the device appear.
• the limitation of the active plasma metabolite level of antimuscarinic drugs can also be based, in addition to a specific route of administration, on a particular hepatic metabolism not producing active metabolites, which may exacerbate the effect of the drug initially administered, but also increase the frequency and intensity of side effects.
• the longer the half-life of the product the lower the frequency of administration, thus facilitating compliance with the treatment.
• the object of the present invention is based on the particular and unexpected properties of 10 - [(3R) -1-azabicyclo [2.2.2] oct-3-ylmethyl] -1H-phenothiazine (dextrorotatory enantiomer of mequitazine, codified here under the name VO 162).
• the following examples show that:
• the dextrorotatory enantiomer (VO 162) is more refined than the racemate and the levorotatory enantiomer vis-à-vis the muscarinic receptors.
• the muscarinic targeting is mixed with, in order of affinity: Mi>M3> M 2 , this inhibition being qualitatively and quantitatively judged optimal for the inhibition of the incontinence phenomenon.
• the dextrorotatory enantiomer is anticholinergic intravenously whereas the levorotatory enantiomer does not show any net activity. It is the same for the oral way.
• VO 162 in vivo mucosal application of the VO 162 suspension results in a net systemic passage resulting in a circulating level compatible with pharmacological activity vis-à-vis the muscarinic receptor targets.
• VO 162 induces a significant decrease in salivary secretions after oral administration.
• VO 162 in vivo in the model of vesical hyperactivity (emergency incontinence) induced by exposure to acetic acid, the VO 162 reduces the intravesical pressure evaluated by cystomanometry.
• VO 162 (10 - [(3R) -I-azabicyclo [2.2.2] oct-3-ylmethyl] -10H-phenothiazine ) is an active compound in urinary incontinence and disorders associated therewith.
• EXAMPLE 1 Affinity of VO162 (10 - [(3R) -1-azabicyclo [2.2.2] oct-3-ylmethyl] -10H-phenothiazine) with respect to human muscarinic receptors, in vitro
• the purpose of this study is to determine an affinity constant of the compound vis-à-vis the three classes of human muscarinic receptors in vitro.
• the model chosen is the C ⁇ O cell stably transfected with the cDNAs encoding each of the three types of muscarinic human receptors.
• affinity of the cells expressing each type of receptor for a ligand which has been determined to be 100% bound to the target muscarinic receptor is determined.
• the ligand that is optimal for the recombinant Mi receptor is 2 nM tritiated pirenzepine (Dorje F., et al., JPET, 1991), that of the recombinant M 2 receptor is 2 nM tritiated methoctramine, that of the M3 receptor is 4-DAMP at 0.2nM (Peralta EG, et al., EMBO, 1987).
• the binding specificity of the receptors expressed by each cell type was verified in parallel by evaluating non-binding of atropine to 1 ⁇ M.
• the binding to the receptors is defined as follows: the difference between the overall binding and the non-specific binding determined in the presence of excess cold ligand.
• V0162 (10 - [(3R) -1-azabicyclo [2.2.2] oct-3-ylmethyl] -10H-phenothiazine) is a compound that binds strongly to muscarinic receptors Its M2 specificity ratio / M3 is between 1.5 and 2. Its affinity for Mi is also nanomolar.
• the aim of this experiment is to confirm the anticholinergic activity of the VO162 on a surviving organ.
• explants taken from the guinea pig were put into survival.
• the morphology of the preparations was homogeneous from batch to batch.
• Each explant was placed in a survival chamber and immersed in a physiological solution of composition (mM): NaCl (118): KCl (4.7); MgSO 4 (1.2); CaCl 2 (2.5); KH 2 PO 4 (1.2); NaHCO 3 (25); glucose (11) at a temperature of 37 ° C and a pH of 7.4.
• the following agents were dispersed in the survival buffer to block non-specific acetylcholine responses: propanolol (10 -6 M) to block ⁇ 2 -adrenergic responses, cimetidine (10 -5 M) to block histaminergic type 2 responses; methysergide (10 -6 M) to block serotoninergic responses and indomethacin (3.10 -6 M) to prevent the occurrence of muscle tone due to release of prostaglandins by the preparation itself.
• the tissues were connected to transponders in order to continuously record the voltage variations. After 60 min of calibration of the preparations, the tissues were exposed to varying concentrations of VO162. Acetylcholine-induced contractions in dose responses were performed to determine the response of the preparation to stimulation in the absence of inhibitor putative.
• EXAMPLE 3 Inhibitory activity of VO 162 (10 - [(3R) -I-azabicyclo [2.2.2] oct-3-ylmethyl] -10H-phenothiazine sialorrhea, in vivo.
• M 3 receptor blockade which is involved in detrusor contractions and salivary secretion, often causes dry mouth as a concomitant effect of treatment for oxybutynin or tolterodine incontinence. Investigations into new agents that inhibit incontinence have long been based on receptor selectivity. It was supposed that the specificity of an agent towards M 3 receptors rather than M 2 would make it possible to limit the inhibition to the expression zones of the receptor and thus to avoid inhibition at the level of non-physiological targets.
• the selectivity of the incontinence agents does not depend exclusively on the tissue expression selectivity of the muscarinic receptor subtype. Indeed, the distribution of these receptors is not really related to a tissue difference (ie: M 2 receptors are also found in the detrusor). Functionally, the activation of certain receptors controls the level of activation of other receptors of the same muscarinic family.
• M 2 receptors are also found in the detrusor.
• the evaluation system of salivation is validated by the action of atropine in the model.
• the results show that the exemplified compound significantly reduces salivary secretion in animals after oral administration.
• the effects obtained are dose-dependent.
• the potency of VO 162 (10- [(3R) -1-azabicyclo [2.2.2] oct-3-ylmethyl] -10H-phenothiazine) is similar to that obtained with atropine used here as a standard method.
• the VO 162 compound and its pharmaceutically acceptable salts are found to be useful for the manufacture of medicaments, particularly in a form adopted for nasal administration, for the treatment of rhinones.
• the anticholinergic activity of the two enantiomers was compared to a single dose, after oral administration according to the same experimental scheme as that previously described.
• [(3R) -1-azabicyclo [2.2.2] oct-3-ylmethyl] -10H-phenothiazine) is a potent oral anticholinergic. Moreover, it belongs to the class of potential inhibitors of incontinence because, like oxibutynin, darifenacine or tolterodine, it decreases the salivary secretion in the animal, after administration of pharmacological doses nontoxic and well tolerated. In addition, contrary to what was expected, inhibition of the cholinergic pathway is effective only after treatment of the animals by the dextrorotatory enantiomer. The laevorotatory enantiomer demonstrates anticholinergic activity in vitro, but these results are not the same after oral administration. Thus, these results show that only VO 162 exerts anticholinergic activity in vivo.
• EXAMPLE 4 Transmucosal passage of a suspension of VO 162 (10 - [(3R) -1-azabicyclo [2.2.2] oct-3-ylmethyl] -10H-phenothiazine), in vivo in the rabbit.
• VO 162 (10 - [(3R) -1-azabicyclo [2.2.2] oct-3-ylmethyl] -10H-phenothiazine
• one of the means of achieving selectivity is to reduce the systemic circulation of antimuscarinics while increasing their concentration at their site of action: the lower urinary tract.
• the vaginal application of this compound could limit the side effects while increasing the effectiveness.
• the bladder can be separated pharmacologically in two: the body and the base.
• the muscarinic receptors are distributed mainly in the body, and the contractile response to cholinergic stimulation is at the same level.
• the other mechanism involved in the maintenance of continence the direct activity on the relaxation of the muscle, sees its control situated in the same place.
• recent studies have shown the possibility of reducing contractions of the bladder by local injection of anticholinergic agents.
• anticholinergics may act not only as an antagonist of acetylcholine at contractions of the detrusor, but also by blocking the muscarinic receptors of the bladder-related pathways. Therefore, the use in situ of an antagonist compound would be an approach of choice for the treatment of incontinence especially in menopausal women.
• the major limitation is the ability of the antimuscarinic agent to cross the vaginal mucosa to target muscarinic afferents in the vicinity of the bladder (Yongtae K., et al., J. Urol., 2005).
• the VO 162 was administered by spraying the nasal mucosa in rabbits, then blood samples were taken in order to measure a possible rate.
• 48 rabbits were treated nasally daily for 28 days with a suspension titrated at 0.4% mass / volume.
• the 3 groups of animals were distributed as follows: saline solution, vehicle, VO 162. Each group consisted of males and females, equal parts.
• Administration of the nasal suspension was performed twice daily for 28 days. Plasma samples were taken on D1, D2, D7, D28, D35. The samples were analyzed by a validated LC / MS / MS VO 162 assay method.
• VO 162 results in an effective passage consistent with the circulating levels required for its anticholinergic activity. This administration does not induce deleterious effects on the nasal mucosa. The circulating levels obtained do not lead to toxic effects in this model, either historically or in terms of vital functions: respiratory rate, heart rate, behavior.
• V0162 (10 - [(3R) -1-azabicyclo [2.2.2] oct-3-ylmethyl] -10H-phenothiazine), in vivo.
• the objective of this study was to measure intravesical pressure and salivation, in animals, in order to test the uroselectivity of anti-muscarinics, when they are administered orally and vaginally.
• animal bladders were catheterized to allow recording (cystomanometry: continuous recording of bladder pressure).
• the products to be tested were administered either per os at a dose of Smg ⁇ kg- 1 or by local application of suspension of VO 162 at 0.4% in a cyclodextrin and arginine-based vehicle
• the jugular vein was also cannulated in order to administer a muscarinic agonist: bethanechol (200 ⁇ g / kg, iv)
• bethanechol 200 ⁇ g / kg, iv
• the bladder pressure variation ( ⁇ PV, mmHg) and the amount of saliva (mg) were evaluated and quantified.
• positive was a group of animals treated with oxybutynin (Ditropan®, 10, 100 and 1000 ⁇ g / kg, iv).
• the results show that compared to oxybutynin, VO 162 orally or by local application significantly reduces the intravesical pressure increase induced by the reference agonist: bethachol.
• the foregoing experiments show that VO 162 is able to induce anticholinergic activity after oral administration.
• the compound is able to cross the mucosa.
• the VO 162 compound has the characteristics of a potent anticholinergic agent: nM in vitro and mg.kg- 1 per os in vivo.It is orally active and can also be administered locally to the mucosa in the form of a gelled preparation for the purpose of targeting the zone where the muscarinic receptors directly controlling or regulating continence are represented.

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