SK18902000A3 - Therapeutic combinations of (selective) estrogen receptor modulators (serm) and growth hormone secretagogues (ghs) for treating musculoskeletal frailty - Google Patents

Abstract

This invention is directed to pharmaceutical combination compositions and methods comprising (-)-cis-6- phenyl-5-(4- (2-pyrrolidin-1- yl-ethoxy) -phenyl)- 5,6,7,8- tetrahydronaphthalene -2-ol or a pharmaceutically acceptable salt thereof and 2-amino-N-(1(R) -(2,4-difluoro- benzyloxymethyl) -2-oxo-2-(3- oxo-3a(R) -pyridin-2- ylmethyl)-2-( 2,2,2-trifluoro-ethyl) -2,3,3a,4,6,7 -hexahydro -pyrazolo [4,3-c]pyridin -5-yl)-ethyl) -2-methyl-propionamide or a pharmaceutically acceptable salt thereof, methods of using such compositions and kits containing such compositions. The compositions are useful for treating musculoskeletal frailty, including osteoporosis, osteoporotic fracture, low bone mass, frailty and low muscle mass.

Description

Technical field

The invention relates to a pharmaceutical combination of a selective estrogen receptor modulator (SERM) and a growth hormone secretagogue (GHS) which stimulates bone formation, increases bone mass, decreases serum lipid concentration and increases muscle mass. The invention also encompasses kits comprising said combinations and the use of these combinations for the treatment of conditions with occurrence of musculoskeletal fragility including osteoporosis, osteoporosis fracture, cortical mass loss, brittleness, low muscle mass, and similar conditions in mammals including humans. In particular, the invention relates to a combination comprising (-) - cis-6-phenyl-5- (4- (2-pyrrolidin-1-yl-ethoxy) phenyl) -5,6,7,8-tetrahydronaphthalen-2-ol or its a pharmaceutically acceptable salt and 2-amino-N- (1- (R) - (2,4-difluoro-benzyloxymethyl) -2-oxo-2- (3-oxo-3α (R) -pyridin-2-ylmethyl) - 2- (2,2,2-trifluoro-ethyl) 2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridin-5-yl) ethyl) -2-methyl propionamide or a pharmaceutically acceptable salt thereof, kits comprising said combination, and the use of the combination for the treatment of conditions with occurrence of musculoskeletal fragility including osteoporosis, osteoporosis fracture, bone loss, brittleness, low muscle mass, and similar conditions in mammals including man.

BACKGROUND OF THE INVENTION

Osteoporosis is a systemic skeletal disease characterized by a low proportion of bone mass and damage to bone tissue, resulting in an increase in bone fragility, and · · ·· ·· ················· Susceptibility to fractures. In the United States, more than 25 million people suffer from this condition and produce more than 1.3 million fractures including 500,000 vertebral fractures, 250,000 hip fractures and 240,000 wrist fractures. The most serious consequences are hip fractures, where 5-20% of patients die within one year and more than 50% of surviving patients are disabled.

Elderly people have the highest risk of osteoporosis and therefore a significant increase in osteoporosis-related problems associated with an aging population is expected. Worldwide, a three-fold increase in the number of fractures over the next 60 years is predicted, and one study estimates that there will be 4.5 million hip fractures in 2050.

Although both men and women are susceptible to musculoskeletal fragility, including osteoporosis, women are at a higher risk of osteoporosis than men. In women, there is a sharp acceleration of bone loss immediately after menopause. Other factors that increase bone loss leading to osteoporosis include smoking, alcohol consumption, sedentary lifestyle, and low calcium intake.

Estrogen is the first choice for the prevention of osteoporosis or bone loss in postmenopausal women. In addition, Black et al., In EP 0605193A1, report that estrogen, particularly when administered orally, reduces LDL levels and increases the amount of beneficial high density lipoproteins (HDL). However, long-term estrogen therapy misses participation in a variety of diseases, including an increased risk of uterine cancer, endometrial cancer, and probably breast cancer, with the result that many women are prevented or accessed for a short time only. Although the risk of endometrial cancer is believed to be reduced by concomitant administration of progesterone, there is still a link to a possible increased risk of endometrial cancer. The risk of breast cancer associated with estrogen administration. The currently proposed drug delivery schedules aimed at reducing the risk of cancer, such as the administration of combinations of progesterone and estrogen, cause excessive bleeding in patients. Furthermore, the combination of progesterone and estrogen appears to reduce the serum cholesterol lowering effects of estrogen. These significant adverse side effects associated with estrogen therapy justify the need to develop alternative therapies for osteoporosis that would have the desired beneficial effect on serum LDL and would not exhibit adverse side effects.

More selective estrogen receptor modulators have already been proposed for the treatment of osteoporosis. It is described (Osteoporosis Conference Scrip No.1812 / 13 April 16.20, 1993, p.29) that raloxifene, i. 6-hydroxy-2 - [(4-hydroxyphenyl) -3-4- (2-piperidinoethoxy) benzoyl] benzo [b] thiophene, has a similar beneficial effect as estrogen on bones and lipids but, unlike estrogen, has a minimal stimulating effect on the uterus. (Black LJ et al., Raloxifene (LY139481 HCI) Prevents Bone Loss and Reduces Serum Cholesterol Witout Causing Uterine Hypertrophy in Ovariectomized Rats, J. Clin. Invest., 1994, 93: 63-69 and Delmas PD et al., Effects of Raloxifene on Bone Mineral Density, Cholesterol Concentration Serum, and Uterine Endometrium in Postmenopausal Women, New England Journal of Medicine, 1997, 337: 1641-1647).

Compositions such as droloxifene, U.S. Pat. No. 5,254,595, prevent bone loss and thus reduce the risk of fractures without the undesirable side effects of estrogen. However, it is believed that estrogen and estrogen agonists alone, make it possible to reduce the risk of fracture by about 50%, suggesting that in about 50% of osteopenic women, the risk of fracture due to osteoporosis remains.

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In U.S. Pat. U.S. Patent No. 5,768,516; No. 5,552,442, the disclosure of which is incorporated herein by reference, discloses the SERM compounds of formula

wherein said general symbols are described in said specification.

Growth hormone (GH) is secreted by the pituitary gland, and stimulates the growth of all tissues of the body capable of growth. In addition, GH is known to have the following effects on metabolic processes in the body:

1. Increases the rate of protein synthesis in virtually all cells of the body;

2. Reduces the rate of carbohydrate consumption in cells of the body;

3. Increases the readiness of free fatty acids for their energy use.

GH deficiency leads to various disease states. For example, it causes nanism in children. In adults, the consequences of acquired GH deficiency include weight loss in muscle mass, while increasing total body fat, particularly in the torso area. Reduction of skeletal and cardiac muscle mass and muscle strength leads to a significant decrease in performance. Bone density is also reduced. Exogenous GH administration has been shown to reverse many of these metabolic changes. Other beneficial effects of said therapy include lowering LDL cholesterol and improving well-being.

In cases of need to increase GH levels, the problem has usually been solved by administration of exogenous GH or by administration of a composition stimulating the production and / or release of GH. In any case, the peptidyl nature of the compound necessitates its injection. Rather, GH was obtained by extracting the pituitary glands taken from the corpses. The product thus obtained was expensive and included the risk of disease associated with the possibility of its transmission from the pituitary source to the recipient of GH (e.g. Jacob-Creutzfeld's disease).

Recombinant GH is now available where there is no longer any risk of disease transmission, but it is still a very expensive product that needs to be injected or nasally administered.

Most GH deficiencies are caused by disorders of GH release and not by primary disorders of GH synthesis in the pituitary. An alternative strategy for normalizing serum GH levels involves stimulating the release of GH from somatotropes. Increased GH secretion can be achieved by stimulating or inhibiting various systems for neurotransmission in the brain and hypothalamus. For these reasons, there is a development of synthetic GH release agents stimulating GH secretion from the pituitary gland, where therapy with these agents may have several advantages over expensive and inappropriate GH replacement therapy. Among these agents, physiological regulatory pathways are believed to stimulate pulsatile GH secretion and eliminate excessive GH levels associated with undesirable side effects when administering exogenous GH by intact negative feedback.

Physiological and pharmacological stimulators of GH secretion include arginine, L-3,4-dihydroxyphenylalanine (L-DOPA), glucagon, vasopressin, and insulin-induced hypoglycaemia, as well as activities such as sleep and exercise indirectly induce the release of GH from the pituitary by some mechanism , probably either by decreasing the secretion of somatostatin or by increasing the secretion of the known secretory GH-releasing factor (GHRF) or hitherto unknown GH-releasing hormone, or by any of these methods.

In International Patent Application Publication no. WO97 / 24369, recognized inter alia in the United States, discloses compositions promoting GH secretion of the general formula

wherein the general symbols are described in said international patent. International Patent Application Publication no. WO97 / 24369 is incorporated herein by reference.

Tan et al., In Restoring and Maintaining Bone in Osteogenic Female Rat Skeleton: I. Changes in Bone Mass and Structure, J. Bone Mineral Research 7 (9), pp.1093-1104, 1992, data related to the concept of loss, Recovery and Conservation (LRM) as a practical approach for reversing existing osteoporosis. The LRM concept utilizes anabolic agents for restoration and construction (+ phase) with a subsequent change to use a composition with a proven bone preservation capability to maintain the newly formed bone (+/- phase). In a study for sweat ο · · · Ί Ί Ί Ί Ί Ί Ί Ί Ί Ί Ί Ί Ί Ί Ί Ί Ί Ί Ί Ί In cancers using PGE ₂ and risedronate, bisphosphonate, it has been shown that most of the newly formed spongy and cortical bone portion induced by PGE ₂ can be maintained for at least 60 days after discontinuation of PGE ₂ administration by administration of risedronate.

Shen et al., Effects of Reciprocal Treatment with Estrogen and Estrogen plus Parathyroid Hormone on Bone Structure and Ovariectomized Rats, J. Clinical Investigation 1995, 96: 23312338) disclose data related to the use of a combination and / or sequential administration of antiresorptive agents. and anabolic agents for the treatment of osteoporosis.

In International Patent Application Publication no. WO97 / 31640, recognized inter alia in the US, discloses the use of some GH secretion enhancing agents in combination with some of the FERMs for the treatment of osteoporosis. International Patent Application Publication no. WO97 / 31640 is incorporated herein by reference.

SUMMARY OF THE INVENTION

The present invention is directed to a pharmaceutical composition comprising:

a) a first compound, wherein said first compound is (-) - cis-6-phenyl-5- (4- (2-pyrrolidin-1-yl-ethoxy) -phenyl) -5,6,7,8-tetrahydronaphthalene- 2-ol or a pharmaceutically acceptable salt thereof; and

b) a second compound wherein said second compound is 2-amino-N- {1- (R) - (2,4-difluoro-benzyloxymethyl) -2-oxo-2- (3-oxo-3α (R) - pyridin-2-ylmethyl) -2- (2,2,2-trifluoro-ethyl) -2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridin-5-yl) -ethyl) -2-methylpropionamide or a pharmaceutically acceptable salt thereof.

The invention is further directed to a pharmaceutical composition referred to immediately in the above paragraph additionally comprising a pharmaceutically acceptable carrier.

The invention is further directed to the composition of any one of the first two paragraphs of this section, wherein said first compound is (-) - cis-6-phenyl-5- (4- (2-pyrrolidin-1-yl-ethoxy) -phenyl) -5,6,7,8-tetrahydronaphthalen-2-ol-D-tartrate and said second compound is 2-amino-N- (1- (R) - (2,4-difluorobenzyloxymethyl) -2-oxo- 2- (3-oxo-3α (R) -pyridin-2-ylmethyl) -2- (2,2,2-trifluoroethyl) -2,3,3a, 4,6,7-hexahydro-pyrazolo [ 4,3-c] pyridin-5-yl) ethyl) -2-methyl-propionamide L-tartrate.

Still further, the invention is directed to a method of treatment, hereinafter referred to as Method A, of a mammal suffering from musculoskeletal fragility, comprising administering the pharmaceutical composition referred to in the first three paragraphs of this section.

A preferred method of treatment according to the invention of method A, referred to as method B, is a method wherein said mammal is affected by osteoporosis.

Another preferred method of treatment for Method A, referred to as Method C, is a method wherein said mammal is afflicted with osteotomy, idiopathic bone loss in childhood, or bone loss associated with periodontitis.

Still further, the invention includes a method, designated Method A ^1, for treating a mammal suffering from musculoskeletal frailty comprising administering to said mammal:

a) a first compound, wherein said first compound is (-) - cis-6-phenyl-5- (4- (2-pyrrolidin-1-yl-ethoxy) -phenyl) -5,6,7,89 ·· · Tetrahydronaphthalen-2-ol or a pharmaceutically acceptable salt thereof; and

b) a second compound wherein said second compound is 2-amino-N- (1- (R) - (2,4-difluoro-benzyloxymethyl) -2-oxo-2- (3-oxo-3a (R) - pyridin-2-ylmethyl) -2- (2,2,2-trifluoroethyl) -2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridin-5-yl) - ethyl) -2-methylpropionamide or a pharmaceutically acceptable salt thereof.

In particular, the invention is directed to a method as a process ^A1 wherein the first compound and the second compound are administered substantially simultaneously.

This invention is also directed to a method of Method ^A1, hereinafter termed Method D, wherein the second compound is administered for a period of about three months to about three years.

Still further, the invention is directed to a method of Method D, followed by administering the first compound for a period of about three months to about three years without administering said second compound for a period of about three months to about three years.

Still further, the invention is directed to a method of Method D, followed by administering the first compound for greater than about three years without administering said second compound for said period of greater than about three years.

The invention is also directed to a method of treatment, hereinafter referred to as method E, of a mammal suffering from musculoskeletal fragility, comprising administering to said mammal a therapeutically effective amount of the composition referred to in the first three paragraphs of this section.

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In Method E, a method that is used to promote bone healing following renal reconstruction, upper jaw reconstruction or lower jaw reconstruction, inducing vertebral synostosis, promoting long bone extension, promoting bone healing rate using a long graft or long bone fracture or promoting ingrowth is preferred. prosthetics.

The invention is also directed to a method of increasing muscle mass in a mammal, comprising administering to the mammal an amount of the composition according to the first three paragraphs of this section, which is effective for increasing muscle mass.

Of all the above methods of the invention, the most preferred method is wherein said mammal is a human.

The invention also encompasses a kit for treating a mammal suffering from musculoskeletal fragility, comprising:

a) (-) - cis-6-phenyl-5- (4- (2-pyrrolidin-1-yl-ethoxy) -phenyl) -5,6,7,8-tetrahydronaphthalen-2-ol or a pharmaceutically acceptable salt thereof and a pharmaceutically acceptable carrier in a first unit dosage form;

b) 2-amino-N- (1- (R) - (2,4-difluoro-benzyloxymethyl) -2-oxo-2- (3-oxo-3α (R) -pyridin-2-ylmethyl) -2- (2,2,2-Trifluoro-ethyl) -2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridin-5-yl) -ethyl) -2-methyl- propionamide or a pharmaceutically acceptable salt thereof and a pharmaceutically acceptable carrier or diluent in a second unit dosage form; and

(c) packaging.

In particular, the invention is directed to a kit described in the immediately preceding paragraph, wherein said first unit dosage form comprises (-) - cis-6-phenyl-5- (4- (211)).

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pyrrolidin-1-yl-ethoxy) -phenyl) -5,6,7,8-tetrahydronaphthalen-2-ol-D-tartrate, and said second unit dosage form comprises 2-amino-N- (1- (R)) - (2,4-difluoro-benzyloxymethyl) -2-oxo-2- (3-oxo-3a (R) -pyridin-2-ylmethyl) -2- (2,2,2-trifluoro-ethyl) -2, 3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridin-5 -yl) ethyl) -2-methyl-propionamide L-tartrate.

For all compositions, methods and kits, the use of (-) - cis-6-phenyl-5- (4- (2-pyrrolidin-1-yl-ethoxy) -phenyl) -5,6,7-D-tartrate salt is particularly preferred. , 8-tetrahydronaphthalen-2-ol and L-tartrate salt of 2-amino-N- (1- (R) - (2,4-difluorobenzyloxymethyl) -2-oxo-2- (3-oxo-3a (R)) (Pyridin-2-ylmethyl) -2- (2,2,2-trifluoro-ethyl) -2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridine-5- yl) ethyl) -2-methyl-propionamide.

A low bone mass condition means a condition where the bone mass is less than the age-appropriate content as defined by the World Health Organization in the Postmenopausal Osteoporosis (1994), Report of a World Health Organization Study Group. World Health Organization Technical Šerieš 843. Idiopathic childhood osteoporosis and primary osteoporosis are also included in these documents. Treatment of osteoporosis also includes the prevention or alleviation of long-term complications such as back distortion, weight loss, prosthetic surgery, and prevention of prostate malfunction. Treatment also includes increasing the rate of bone fracture healing and promoting the rate of successful bone grafting. Also included are periodontal disease and alveolar bone mass loss.

The term low bone mass also refers to a mammal known to be significantly more likely to develop the diseases listed above,

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including osteoporosis, such as average probability (such as post-menopausal women, men over 60 years of age, and those treated with medicines known to have osteoporosis (such as glucocorticoids) as a side effect).

It will be appreciated by those skilled in the art that the term bone mass actually means bone mass per unit area and sometimes (although not quite rightly) referred to as bone mineral density.

Musculoskeletal fragility means a condition in which the subject has a low amount of bone and / or muscle mass and includes diseases, disorders and conditions such as, but not limited to, low bone mass, osteoporosis, low muscle mass, osteotomy, idiopathic bone loss in childhood, or bone loss associated with periodontitis, persistent conditions involving bone healing following renal reconstruction, upper jaw reconstruction, or lower jaw reconstruction and bone fracture. Furthermore, the term includes conditions in which an interface between a newly implanted prosthesis and a bone occurs where it is necessary for shrinkage to occur.

The terms treatment, treat or treat used herein include therapeutic, preventive (e.g., prophylactic) and palliative care.

A negative or positive sign in parentheses and used in this specification in the chemical nomenclature means the direction of rotation of the plane of polarized light by a particular stereoisomer.

Compositions of the invention may include hydrates of the compounds used in said compositions.

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The pharmaceutical compositions and methods of the invention result in higher bone mass increments than are achievable at the same doses of (-) - cis-6-phenyl-5- (4- (2-pyrrolidin-1-yl-ethoxy) -phenyl) - 5,6,7,8-tetrahydronaphthalen-2-ol as described above or 2-amino-N- (1- (R) - (2,4-difluorobenzyloxymethyl) -2-oxo-2- (3) alone -oxo-3α (R) -pyridin-2-ylmethyl) -2- (2,2,2-trifluoro-ethyl) -2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3- c] pyridin-5-yl) -ethyl) -2-methyl-propionamide as described above. Thus, combinations of these compounds increase the amount of bone mass and reduce the number of fractures more than is achievable by any of the components alone. Said compositions increase bone density and muscle mass while reducing fat levels and overall serum cholesterol levels. Thus, the invention contributes significantly to the art by providing compositions and methods that lead to the increase and preservation of bone mass and can be used for the prevention, retardation and / or regression of osteoporosis and related bone diseases.

Other features and advantages of the invention will be apparent from the description of the invention and the appended claims.

DETAILED DESCRIPTION OF THE INVENTION

The first compound of the invention is (-) - cis-6-phenyl-5- [4- (2-pyrrolidin-1-yl-ethoxy) -phenyl] -5,6,7,8-tetrahydronaphthalen-2-ol or its pharmaceutically acceptable salt of formula (I):

HO

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(-) - cis-6-phenyl-5- [4- (2-pyrrolidin-1-yl-ethoxy) -phenyl] -5,6,7,8-tetrahydronaphthalen-2-ol and its pharmaceutically acceptable salts are prepared according to the method of US

U.S. Patent No. 5,201,516; No. 5,552,412, which is already mentioned above.

(-) - cis-6-phenyl-5- [4- (2-pyrrolidin-1-yl-ethoxy) -phenyl] -5,6,7,8-tetrahydro-naphthalen-2-ol-D-tartrate prepared as described in the paragraph immediately above, or alternatively as described in International Patent Application Publication no. WO97 / 16434 accepted in the USA, which is incorporated herein by reference.

The second compound of the invention is 2-amino-N- (1- (R) - (2,4-difluoro-benzyloxymethyl) -2-oxo-2- (3-oxo-3α (R) -pyridin-2-ylmethyl) (2- (2,2,2-Trifluoro-ethyl) -2,3,3a, 4,6,7-hexahydropyrazolo [4,3-c] pyridin-5-yl) -ethyl) -2- methyl propionamide or a pharmaceutically acceptable salt thereof of formula (II):

II

2-amino-N- (1- (R) - (2,4-difluoro-benzyloxymethyl) -2-oxo-2- (3-oxo-3a (R) -pyridin-2-ylmethyl) -2- ( 2,2,2-Trifluoro-ethyl) -2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridin-5-yl) -ethyl) 15

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The 2-methylpropionamide and its pharmaceutically acceptable salts can be prepared according to International Patent Application Publication No. WO 97/18511. WO 97/24369, recognized inter alia in the United States, which is already mentioned above.

2-Amino-N- (1- (R) - (2,4-difluoro-benzyloxymethyl) -2-oxo-2- (3-oxo-3a (R) -pyridin-2-ylmethyl) -2- (2 , 2,2-trifluoro-ethyl) 2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridin-5-yl) ethyl) -2-methyl-propionamide L- the tartrate can be prepared according to the above-mentioned International Patent Application Publication No. WO 97/24369. Alternatively, 2-amino-N- (1- (R) - (2,4-difluoro-benzyloxymethyl) -2-oxo-2- (3-oxo-3α (R) -pyridin-2-yl) methyl) -2 is possible. - (2,2,2-trifluoro-ethyl) 2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridin-5-yl) ethyl) -2-methyl-propionamide The L-tartrate was prepared as in Example 1 below.

In addition, when the compounds and their pharmaceutically acceptable salts used in the compositions and methods of the invention form hydrates or solvates, said hydrates and solvates also include the invention.

The pharmaceutical combinations and methods of the invention are adapted for therapeutic use in the form of compositions that either activate bone turnover or prevent bone resorption or increase bone formation in mammals, particularly humans. Since these functions are very closely related to the development of osteoporosis and related bone diseases, said combinations due to their effects on bone can be used to prevent, stop, regress or reverse osteoporosis.

Suitability of the compositions and methods of the invention as medicaments for the treatment of musculoskeletal fragility (e.g., conditions exhibiting low bone mass or low muscle mass, which include osteo16). Porosity) in mammals (e.g., human) is demonstrated by the activity of the compounds of the invention in conventional assays disclosed in U.S. Pat. U.S. Patent No. 5,768,516; Further evidence of the suitability of the present combination according to the invention is given in Example 2 below. These assays provide opportunities to compare the activities of the compounds of the invention with each other and with the activities of other known compounds. The results of these comparisons are suitable for determining dosages for a mammal, including a human, suitable for the treatment of said diseases.

The administration of the compounds of the invention may be accomplished by any suitable method, which results in the conversion of a compound included in the combination of the invention in a systemic and / or local manner. Said methods include oral, parenteral, intraduodenal and similar routes of administration. In general, the compounds of the invention are administered orally, but parenteral administration (e.g., intravenous, intramuscular, transcutaneous, subcutaneous or intramedullary) may be used, for example, when oral administration is inappropriate for the targeted area or when the patient is unable to orally receive the drug. The two different compounds of the invention may be administered simultaneously or sequentially in any order, or in the form of one medicament comprising the first compound as described above and the second compound as described above and a pharmaceutically acceptable carrier.

However, in each case treated, the dosage and time intervals of administration of the compounds will of course depend on the subject of treatment, the severity of the condition, the route of administration, and the judgment of the attending physician. Because of patient variability, dosages below may be used as a guide, and the physician may adjust doses of the drug to achieve activity (e.g., to increase caste mass) that the physician will consider sufficient for a particular patient. To assess the degree of

In a given activity, the physician must consider more different factors such as baseline bone mass, patient's age, incidence of previous illnesses as well as the concurrent incidence of others. diseases (e.g. cardiovascular). For example, administration of (-) - cis-6-phenyl-5- (4- (2-pyrrolidin-1-yl-ethoxy) -phenyl) -5,6,7,8-tetrahydronaphthalen-2-ol may have cardiovascular benefits especially in postmenopausal women. In the following paragraphs preferred dosage ranges of the various components of the invention are given.

An effective dose of (-) - cis-6-phenyl-5-4- (2-pyrrolidin-1-yl-ethoxy) -phenyl-5,6,7,8-tetrahydronaphthalen-2-ol is in the range of 0, 0001 to 100 mg / kg / day, preferably in the range of 0.001 to 10 mg / kg / day.

Effective dose of 2-amino-N- (1- (R) - (2,4-difluoro-benzyloxymethyl) -2-oxo-2- (3-oxo-3α (R) -pyridin-2-ylmethyl) -2- (2,2,2-Trifluoro-ethyl) -2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridin-5-yl) -ethyl) -2-methyl-propionamide is in the range of 0.0001 to 100 mg / kg / day, preferably in the range of 0.01 to 5.0 mg / kg / day.

When a D-tartrate salt or other pharmaceutically acceptable salt of each of the above compounds is used according to the invention, one skilled in the art will readily calculate an effective dose based on the molecular weight ratio using molecular weight.

The compounds of the invention may generally be administered in the form of a pharmaceutical composition comprising at least one of the compounds of the invention, or a pharmaceutically acceptable salt thereof, together with a pharmaceutically acceptable carrier or diluent. Thus, the compounds of the invention and their pharmaceutically acceptable salts can be administered alone or together by any conventional oral, parenteral or

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transdermal dosage forms. In separate administration, the second compound or a pharmaceutically acceptable salt thereof of the invention is administered sequentially.

For oral administration, the pharmaceutical composition may be in the form of solutions, suspensions, tablets, pills, capsules, powders, and the like. The tablets may contain various additives such as sodium citrate, calcium carbonate and calcium phosphate together with various disintegrating agents such as starch and preferably potato or tapioca starch and certain complex silicates, together with binders such as polyvinylpyrrolidone, sucrose, gelatin and acacia. Often, glidants such as magnesium stearate, sodium lauryl sulfate and talk are suitable for tabletting purposes. Solid compositions of a similar type are also used as fillers in soft and hard-filled gelatin capsules; preferred ingredients used in this context include lactose or milk sugar as well as high molecular weight polyethylene glycols. Although it is desired to prepare aqueous suspensions and / or elixirs for oral administration, the compounds or their pharmaceutically acceptable salts of the invention may be combined with various sweetening, flavoring, coloring, emulsifying and / or suspending agents, as well as diluents such as is water, ethanol, propylene glycol, glycerin and various similar combinations thereof.

For parenteral administration, solutions in sesame or peanut oil or aqueous propylene glycol as well as sterile aqueous solutions of the corresponding water-soluble salts may be used. The aqueous solutions may be suitably buffered, if necessary, and the liquid diluent first rendered isotonic to appropriate saline or glucose. Said aqueous solutions are particularly suitable for intravenous, intramuscular, subcutaneous and intraperitoneal injection. Ste19 · · · · · · 19 19 19 il il il il il il il il il il il il il il il il media for such use can be readily prepared by standard methods known to those skilled in the art.

For the purpose of transdermal (e.g. topical) administration, dilute aqueous or partially aqueous solutions (usually at a concentration of about 0.1% to 5%) otherwise prepared similar to the above parenteral solutions may be used.

Methods for preparing various pharmaceutical compositions containing certain amounts of each active ingredient are known and will be apparent to those skilled in the art from this disclosure. Exemplary embodiments are set forth, for example, in Remington's Pharmaceutical Sciences, Mack Publishing Company, Easton, Pa., 19th edition (1990).

The pharmaceutical compositions of the invention may contain 0.1% -95% of the combination of the compounds or their pharmaceutically acceptable. salts of the invention, preferably 1% -70%. In any case, the composition or composition to be administered comprises the compounds or pharmaceutically acceptable salts thereof of the invention in an amount effective to treat the disease / condition of the subject to be treated.

Since the invention encompasses treatment with a combination of two active ingredients that can be administered separately, the invention also encompasses the combination of separate pharmaceutical compositions in a single kit. The kit then comprises two separate pharmaceutical compositions: (-) - cis-6-phenyl-5- (4- (2-pyrrolidin-1-yl-ethoxy) -phenyl) -5,6,7,8-tetrahydronaphthalene-2 -ol or a pharmaceutically acceptable salt thereof; and 2-amino-N- (1- (R) - (2,4-difluoro-benzyloxymethyl) -2-oxo-2- (3-oxo-3a (R) - pyridine-2-ylmethyl) -2- (2,2,2-trifluoro-ethyl) 2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridin-5-yl) - ethyl) -2-methylpropionamide or a pharmaceutically acceptable salt thereof. Said kit consists of a container for the separate compositions mentioned above. Kontejner · kontejner kontejner kontejner na na na na na na na na na na na na na na na na na stored in containers such as split-form bottles or split-form foil packaging, but separate compositions may be placed; into one single package. Usually, the kit contains attached information for administration of the individual components. The kit form is particularly advantageous in cases where it is preferable to administer the individual components: in different dosage forms (e.g. oral and parenteral), at different administration intervals, or when the attending physician needs to determine the dose of the individual components of the combination.

An example of such a kit is the so-called blister pack. Blister packs are well known to those skilled in the art of packaging, and are widely used as single dose dosage forms (tablets, capsules, and the like). Generally, the blister packs are formed by a backing sheet of a relatively rigid material covered with a foil, preferably a transparent plastic foil. During processing during packaging, protrusions are formed in the plastic film. These protrusions have the shape and size of tablets or capsules to be packaged. Then, the tablets or capsules are placed in the protrusions and the backing sheet of relatively rigid material is joined to that side of the plastic sheet opposite the protrusions formed. As a result, the tablets or capsules are sealed in the protrusions between the plastic sheet and the backing sheet. Advantageously, the strength of the backing sheet is such that the tablets or capsules can be removed from the blister pack by hand pressure on the protrusions in which holes are formed in the support sheet at a location corresponding to the protrusions. Tablets or capsules can then be removed through the holes.

It is also desirable to provide the assembly with an inserted memory-enhancing label, for example in the form of numbers near tablets or capsules, where these numbers correspond to the days of the dosing schedule when the appropriately labeled tablets or capsules need to be ingested. Another example of such a memory aid is a calendar printed on a label, for example, in the form of the first week, Monday, Tuesday, etc., the second week, Monday, Tuesday ... and the like. Other such devices to aid memory in drug delivery are also readily understood. The daily dose may comprise administering one tablet or capsule on a particular day or several pills or capsules on a particular day. The daily dose of the SERM may also be a single tablet or capsule, while a daily dose of a GH secretion enhancing agent may be several tablets or capsules. This memory aid must reflect this.

Another specific embodiment of the invention includes the use of a dispenser designed to dispense daily doses one dose at a time to ensure their intended use. Preferably, the dispenser is provided with a memory aid so as to further facilitate compliance with the dosing schedule. An example of said memory aid is a mechanical computer indicating the number of daily doses already collected. Another example of said memory aid is a battery-powered microchip coupled to a liquid-crystal-counting device or providing an acoustic signal indicating when the last daily dose has been taken and / or indicating the need to take the next dose.

The following assay is useful to demonstrate that the combinations and methods of the invention increase body muscle mass and body fat mass, while administration of a GH secretion-promoting agent alone can be expected to reduce body fat without altering muscle mass and administering muscle mass alone. FERMs can be expected to increase both body muscle mass and amount. ·· ·· ·· ·· ··· body fat. Further, this combination increases bone density and decreases total serum cholesterol levels.

DETAILED DESCRIPTION OF THE INVENTION

Example 1

2-Amino-N- {1- (2,4-difluoro-benzyloxymethyl) -2-oxo-2- [3-oxo-3α-pyridin-2-ylmethyl] -2- (2,2,2-trifluoro) ethyl) 2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridin-5-yl] -ethyl} -2-methyl-propiónamidL - (+) - tartrate

A. 4-Oxo-3-pyridin-2-ylmethyl-piperidine-1,3-dicarboxylic acid 1-tert-butyl ester, 3-ethyl ester

To a solution of 4-oxo-piperidine-1,3-dicarboxylic acid 1-tert-butyl ester, 3-ethyl ester (10.34 g, 38.2 mmol) in DMF (40 mL) at about 0C was added picolyl chloride hydrochloride ( 5.7 g, 34.7 mmol), potassium carbonate (14.4 g, 104.1 mmol) and potassium iodide (5.76 g, 34.7 mmol). The reaction mixture was stirred at 0 ° C for about 2 hours and then an ice bath was added. remove and add DABCO (973 mg, 8.68 mmol). The reaction mixture was stirred for about 30 minutes and poured into a mixture of water and IPE. The organic layer was separated and washed with saturated aqueous NaHCO ₃ and saturated aqueous NaCl, dried over Na ₂ SO _4, and concentrated in vacuo. Recrystallization of the crude product from hexanes gave a white solid (8.19 g,

yield 65%) . ^ -] NMR (CDCl3) 3) δ: 1.17 (t, 3H) 1 48 (with, 9H); 1.55 (with, 2H); 2.61 (m, 1 H), 2.71 (M, 1H), 3.31-3, 50 (M, 3H); 4.11 (D, 2H), 4.49 (d, 1 H), 7.06 (br S, 1H), 7.17 (d, 1 H), 7.54 (M, 1H), 8.40 (S, 1 H). b

B. 3-Oxo-3α-pyridin-2-ylmethyl-2- (2,2,2-trifluoro-ethyl) -2,3,3a, 4,6,7-hexahydro-pyrazolo [4, 6-methyl-tert-butyl ester] 3-c] pyridine-5-carboxylic acid

70% aqueous solution of CF ₃ CH ₂ NHNH ₂ (325 mL, 1.986 mol) (from

Aldrich) was extracted with toluene (3 x 1200 mL). To a solution of the product prepared in Step A (600 g, 1.655 mol) in toluene (900 mL) was first added the combined toluene extract containing anhydrous

2.2.2-trifluoroethylhydrazine followed by acetic acid (121.4 g, 1.986 mol). The reaction mixture is then heated at 70 ° C for about 2 hours and then additional toluene extract 70% aqueous is added.

2.2.2-Trifluoroethylhydrazine (50 g). The reaction mixture was then heated at about 80 ° C for about 3.5 hours, then cooled to room temperature and diluted with saturated aqueous NaHCO ₃ (2 L). The toluene layer was then separated and washed with saturated aqueous NaCl, dried over Na ₂ SO ₄ and concentrated in vacuo to give an oil (754.8 g). Crystallization from methanol / water gave the desired product (609.5 g) as a white solid.

¹ H-NMR (CDCl 3) δ: 1.50 (with, 9H), 2.53 (d, 1 H), 2.70 (br with, 2H), 2.88 (br s, 1 H), 3.31 (M, 2H); 3.97 (m, IH), 4.19 (M, 1H) F 4.46 (br s, 1 H), 4.63 (br S, 1H); 7.06 (m, 2H); 51 (M, 1H), 8.34 (m, IH).

C. 3α-Pyridin-2-ylmethyl-2- (2,2,2-trifluoroethyl) -2,3a, 4,5,6,7-hexahydro-pyrazolo [4,3-c] pyridin-3-one

To a solution of the product prepared in Step B (10 g, 24.2 mmol) in CH ₂ Cl ₂ (100 mL) was added methanesulfonic acid (11.6 g, 121 mmol) dropwise over 30 min. The reaction mixture was stirred for about 1 hour, then cooled to 0 ° C and triethylamine (18.6 mL, 133.1 mmol) was added via addition funnel. The mixture is then allowed to warm to room temperature over about 1 hour, diluted with an additional portion of CH ₂ Cl ₂ , washed with saturated aqueous NaCl, dried over Na ₂ SO ₄ and filtered and concentrated in vacuo to give the desired product as a white solid ( 7.2 g). ¹ H-NMR (CDCl ₃ ) δ: 2.51-2.72 (m, 4H), 3.35 (m, 2H), 3.49 (m, 2H), 4.03 (m, 1H), 4.25 (m, 1H); 7.08 (d, 2H); 7.51 (t, 1H); 8.37 (d, 1H).

D. 3α-Pyridin-2-ylmethyl-2- (2,2,2-trifluoroethyl) -2,3a, 4,5,6,7-hexahydro-pyrazolo [4,3-c] pyridin-3-one- (D) -tartrate

To the compound prepared in Step C (243 g, 0.78 mol) in acetone / water (9: 1, 2430 mL) in a 5L round bottom dry flask equipped with a mechanical stirrer was added under a nitrogen atmosphere at about 17 °. C - D - (-) tartaric acid (129 g, 0.86 mol) was added. The mixture was stirred overnight at room temperature, filtered, the solid was collected, washed with cold acetone and dried in vacuo. Obtained as a yellow solid (284 g, 78.8% yield).

E. 2-tert-butoxycarbonylamino-3- (2,4-difluoro-benzyloxy) -propionic acid

To a solution of N-Boc- (D) -serine (452 g, 2.2026 mol) in a mixture of THF (7 L) and DMF (3 L) was added a solution of potassium tert-butoxide (515, 8 g, 4.5963 mol). The reaction mixture was then stirred at about 0 ° C for about 30 minutes and then 2,4-difluorobenzyl bromide (456.5 g, 2.2051 mol) was added. The reaction mixture was then warmed to room temperature and concentrated in vacuo to remove THF. The reaction mixture was then partitioned between 4.5 L H ₂ O and 4.5 L IPE. The layers were separated and the pH of the aqueous layer was adjusted to about 3 with 1 N HCl. The aqueous layer was then extracted twice with 4 L portions of IPE each. The organic layer was then dried over Na ₂ SO ₄ and concentrated in vacuo to give a yellow waxy solid (518.0 g, yield: 70.9%). ¹ H-NMR (CDCl ₃ ) δ: 1.44 (s, 9H), 3.73 (m, 1H), 3.94 (d, 1H), 4.44 (br s, 1H), 4.54 (s, 2H), 5.34 (m, 1H), 6.78 (m, 1H), 6.84 (m, 1H), 7.30 (m, 1H).

F. 2-Amino-3- (2,4-difluoro-benzyloxy) -propionic acid methanesulfonate

To a solution of the product from Step E (1.19 g, 3.59 mmol) in CH ₂ C1 ₂ / IPE (1: 1, 12 mL) was added over approximately 10 minutes via syringe methanesulfonic acid (1.72 g, 17 , 95 mmol). A solid reaction product precipitated immediately from solution. After about 1 hour, the solid was filtered and washed with CH ₂ Cl ₂ / IPE (1: 1) to give 939 mg of the product (yield 80%).

G. 2- (2-tert-Butoxycarbonylamino-2-methyl-propionyl-amino) -3- (2,4-difluoro-benzyloxy) -propionic acid

To the solution prepared in Step F (520 mg, 1.46 mmol) in THF / water (4: 1, 10 mL) was added 2,5-dioxo-pyrrolidin-1-yl ester 2-tert-butoxycarbonyl- amino-2-methyl-propionic acid (438 mg, 1.46 mmol) and triethylamine (369 mg, 3.65 mmol). The reaction mixture was stirred for about 1 hour at room temperature and then quenched with 10% aqueous citric acid (10 mL). After about 15 minutes, ethyl acetate (50 mL) was added, the organic layer was separated and washed with saturated aqueous NaCl, dried over Na ₂ SO ₄ and concentrated in vacuo to give a foam (534.1 mg, 88% yield). ¹ H-NMR (CD ₃ OD) δ: 1.38 (br s, 15H), 3.77 (d, 1H), 3.92 (d, 1H), 4.52 (m, 3H), 6, 92 (m, 1H); 7.41 (m, 1H); 7.58 (d, 1H).

H. (1- (1- (2,4-Difluoro-benzyloxymethyl) -2-oxo-2- [3-oxo-3α-pyridin-2-ylmethyl) -2- (2,2-difluoro-benzyloxymethyl) -butyl ester 2-Trifluoroethyl) -2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridin-5-yl] -ethylcarbamoyl-1-methyl-ethyl) -carbamic acid

a) To a solution of the compound prepared in Step D (517 g, 1.12 mol) in a dry round bottom flask equipped with a mechanical stirrer and under nitrogen purge is added ethyl acetate (5170 mL) at about -6 ° C. The prepared solution is then cooled down to about 0 · 0 · 0 · 0 · 0 · 0 · 0 · 0 · 0 · 0 · 0 · 0 · 0 · 0 · 0 · 0 · 0 · 0 · 0 · 0 · 0 ·

-40 ° C and then triethylamine (398 mL, 2.86 mol) was added over about 45 minutes. The mixture was stirred for about 90 minutes at a temperature between about -50 ^and C to about -40 ° C, filtered into a round bottom flask with a volume of 22 1 purged with nitrogen, washed with ethyl acetate (2068 ml, precooled to about - 50 ° C) to give the free base as a white solid.

b) To an ethyl acetate solution of the product prepared in step H (a), triethylamine (654 mL, 4.69 mol) and PPAA (1-propanephosphonic acid cyclic anhydride) (50% solution in ethyl acetate, 916 mL, 1.53 mol) add at about -30 ° C the compound prepared in Step G (425 g, 1.02 mol). The reaction mixture was stirred for about 1 hour, washed with water, saturated aqueous NaCl, dried over Na ₂ SO ₄ and concentrated in vacuo to give the desired product as an oil (636 g, yield: 87.8%).

1. 2-Amino-N- {1- (2,4-difluoro-benzyloxymethyl) -2-oxo-2- [3-oxo-3α-pyridin-2-ylmethyl-2- (2,2,2-trif) Fluoro-ethyl) -2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridin-5-yl] -ethyl} -2-methyl-propionamide

To the product prepared in Step H (566 g, 0.796 mol) in a solution of CH ₂ Cl ₂ (11320 mL) in a dry 22 L round bottom flask, purged with nitrogen and equipped with a mechanical stirrer, was added acid dropwise at about 15 ° C. methanesulfonic. The mixture was then stirred for about 40 minutes at about 20 ° C and then saturated aqueous NaHCO ₃ was added to adjust the pH to about 7.8 (8.490 mL). The organic layer was separated, washed with water and saturated aqueous NaCl, dried over Na ₂ SO ₄ and concentrated in vacuo to give an oily product (388.8 g, 80% yield).

·· ···

J. 2-Amino-N- {1- (2,4-difluoro-benzyloxymethyl) -2-oxo-2- [3-oxo-3α-pyridin-2-ylmethyl-2- (2,2,2-trif) (1-chloroethyl) -2,3,3a, 4,6,727 · · · é · é · é · é · • · · ······ ··· ··· ·· ···· ·

hexahydro-pyrazolo [4,3-c] pyridin-5-yl] -ethyl} -2-methyl-propionamide L - (+) - tartrate

To a solution of the product prepared in Step I (370 g, 0.6 mol) in methanol (4070 mL) in a 12 L round bottom flask equipped with a mechanical stirrer was added L - (+) tartaric acid. The reaction mixture is stirred for about 90 minutes at about 22 ° C, then filtered and concentrated. The crude residue was diluted with ethyl acetate (4560 mL), warmed to about 70 ° C and slowly allowed to cool to room temperature over about 17 hours. The solid product was filtered off and dried to give white crystals, m.p. 188-189 ° C (348.46 g, yield 76%). ¹ H-NMR (MeOH, d ₄ ) δ: 8.28 (d, 1H), 7.59 (t, 1H), 7.41-7.39 (m, 1H), 7.18-7.13 (m, 1H), 6.92 (t, 1H), 5.2 (t, 1H), 4.56 (bs, 3H), 4.36 (s, 2H), 4.31-4.25 ( m, 1H), 4.13-4.06 (m, 1H), 3.78 (d, 2H), 3.21 (t, 1H), 3.18-2.96 (m, 2H), 2 65-2.55 (m, 2H); 1.57 (d, 6H). MS: MH + 611. 1a] ⁵⁸⁹ +22.03 (c = 11.9, MeOH).

Example 2

Female S-D rats (Harlan), 3.5 months old, are sham operated or ovariectomized (OVX). Drug administration is initiated at the age of 9 months, ie. 5.5 months after surgery. Sham-operated rats are dosed daily with a vehicle (10% ethanol in water) for 4 weeks, while OVX rats are dosed daily with a vehicle, or a daily dose of 5 mg / kg / day of 2-amino-N- (1- (R) - (2,4-Difluoro-benzyloxymethyl) -2-oxo-2- (3-oxo-3α (R) -pyridin-2-ylmethyl) -2- (2,2,2-trifluoro-ethyl) (-2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridin-5-yl) -ethyl) -2-methyl-propionamide or 0.1 mg / kg / day daily dose (-) - cis-6-phenyl-5- (4- (2-pyrrolidin-1-yl-ethoxy) -phenyl) -5,6,7,8-tetrahydronaphthalen-2-ol alone or treated simultaneously as 2 amino-N- (l- (R) - (2.428

• • ·· · · · · • • · ·· · · • • · · · • • · · · · · • 9 9 • • · • 9 9 9 • • · · • · 9 • • · · · ··· ·· · · 99 · · ·

- difluoro-benzyloxymethyl) -2-oxo-2- (3-oxo-3α (R) -pyridin-2-ylmethyl) -2- (2,2,2-trifluoroethyl) -2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridin-5-yl) -ethyl) -2-methyl-propionamide, and (-) - cis-6-phenyl-5- (4- (2) pyrrolidin-l-yl-ethoxy) -phenyl) -5,6,7,8-tetrahydronaphthalene-2-ol. In the combination treatment group, 2-amino-N- (1- (R) - (2,4-difluoro-benzyloxymethyl) -2-oxo-2- (3-oxo-3α (R) -pyridin-2-yl) -methyl) -2- (2,2,2-trifluoro-ethyl) -2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridin-5-yl) -ethyl) -2-methyl-propionamide is administered 2 hours before (-) - cis-6-phenyl-5- (4- (2-pyrrolidin-1-yl-ethoxy) -phenyl) -5,6,7,8- tetrahydronaphthalen-2-ol. Each subgroup comprises 8 to 10 rats. All rats were given 10 mg / kg of calcein (Sigma Chemical Co., St. Louis, MO) by subcutaneous injection at 13 and 3 days prior to necropsy. It will be apparent to those skilled in the art that the compounds used in the above assays may be administered in the form of their pharmaceutically acceptable salts, and that their dose can be readily determined by calculation based on the molecular weight ratio of the salt form and the parent compound.

Prior to necropsy, the final day of the experiment, all rats are anesthetized with ketamine / xylazine, and the amount of body muscle and fat is determined by dual radiation X-ray absorption spectrometry (DXA, QDR-1000 / W, Hologic Inc., Waltham, MA) provided with Rat software. Whole Body Scan (Hologic Inc., Waltham, MA). An autopsy is then performed and blood is drawn by heart puncture. Total cholesterol levels are determined colorimetrically by high-performance determination with an appropriate cholesterol assay kit (Boehringer Mannheim Biochemicals, Indianopolis, IN). The body weight gain is calculated from the difference in body weight on the day of autopsy and on day 0. At the time of autopsy, the wet weight of the uterus is also determined.

············································

At autopsy, the femur is removed from each rat and evaluated by dual radiation X-ray absorption spectrometry (DXA, QDR-1000 / W, Hologic Inc., Waltam, MA) equipped with Regional High Resolution Scan software (Hologic Inc., Waltham, MA). . The size of the sensed pole is 5.08 x 1.902 cm, the resolution is 0.0254 x 0.0127 cm, the scanning speed is 7.25 mm / s. The analysis of the respective femur images and the total femoral bone area, its mineral content and mineral density are determined as described by Ke H.Z. et al., Droloxifene, and New Estrogen Antagonist / Agonist, Prevents Bone Loss in Ovariectomized Rats; Endocrinology 136; 2435-2441, 1995.

It is to be understood that the invention is not limited to the aforementioned individual embodiments of the invention, but that various changes and modifications are possible without departing from the spirit and scope of the invention as defined in the appended claims.

• • ·· · · ·· · · · · · • · • • · · · • • • · · · · • · • • • e · • · • · · • • • · • · • · · · · · · · · · · · · · · ·

Claims (29)

A pharmaceutical composition comprising: a) a first compound, wherein said first compound is (-) - cis-6-phenyl-5- (4- (2-pyrrolidin-1-yl-ethoxy) -phenyl) -5,6,7,8-tetrahydronaphthalene- 2-ol or a pharmaceutically acceptable salt thereof; and b) a second compound wherein said second compound is 2-amino-N- (1- (R) - (2,4-difluoro-benzyloxymethyl) -2-oxo-2- (3-oxo-3α (R) -pyridine) 2-ylmethyl) -2- (2,2,2-trifluoro-ethyl) 2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridin-5-yl) - ethyl) -2-methylpropionamide or a pharmaceutically acceptable salt thereof. A pharmaceutical composition according to claim 1, further comprising a pharmaceutically acceptable carrier. Pharmaceutical composition according to claim 1, characterized in that the first compound is (-) - cis-6-phenyl-5- (4- (2-pyrrolidin-1-yl-ethoxy) -phenyl) -5,6, 7,8-tetrahydronaphthalen-2-ol-D-tartrate and said second compound is 2-amino-N- (1- - (R) - (2,4-Difluoro-benzyloxymethyl) -2-oxo-2- (3-oxo-3 and (R) -pyridin-2-ylmethyl) -2- (2,2,2-trifluoro- ethyl) -2,3,3a, 4,6,7-hexahydropyrazolo [4,3-c] pyridin-5-yl) ethyl) -2-methylpropionamide L-tartrate. 4. A method of treating a mammal suffering from musculoskeletal fragility, comprising administering to said mammal the pharmaceutical composition of claim 1. • • · · · · ·· · · · · · • • • • · • · • • • • · · · • · • • • • · • • · • · · • • • • • • · • · • ·· · · · · · · · · · · · · · The process of claim 4, wherein the first compound is (-) - cis-6-phenyl-5- (4- (2-pyrrolidin-1-yl-ethoxy) -phenyl) -5,6,7 , 8-tetrahydronaphthalen-2-ol-Dartrate and the second compound is 2-amino-N- (1- (R) - (2,4-difluorobenzyloxymethyl) -2-oxo-2- (3-oxo-3a ( R) -pyridin-2-yImety1) -2- (2,2,2-trifluoro-ethyl) 2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridin-5-yl ) ethyl) -2-methyl-propionamide L-tartrate. 6. The method of claim 4, wherein said mammal is affected by osteoporosis. 7. The method of claim 4, wherein said mammal is afflicted with osteotomy, idiopathic bone loss in childhood, or bone loss associated with periodontitis. The method of claim 4, comprising bone healing following renal reconstruction, upper jaw reconstruction or lower jaw reconstruction, inducing vertebral synostosis or promoting long bone elongation, promoting skeletal graft rate healing, or promoting prosthetic ingrowth. The method of claim 8, wherein said method is treating a human bone fracture. The method of claim 6, wherein said method is to treat osteoporosis in a human. 11. A method of treating a mammal suffering from musculoskeletal fragility, comprising administering to said mammal: • • ·· · · ·· · · · · · • · • • · · · • • • · · · · • · • • • • · · • · • · · • • • • · • · • · • · · · · · · · · · · · · · · · a) a first compound, wherein said first compound is (-) - cis-6-phenyl-5- (4- (2-pyrrolidin-1-yl-ethoxy) -phenyl) -5,6,7,8-tetrahydronaphthalene- 2-ol or a pharmaceutically acceptable salt thereof; and b) a second compound wherein said second compound is 2-amino-N- (1- (R) - (2,4-difluoro-benzyloxymethyl) -2-oxo-2- (3-oxo-3α (R) -pyridine) -2-ylmethyl) -2- (2,2,2-trifluoro-ethyl) -2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridin-5-yl) -ethyl I-2-methylpropionamide or a pharmaceutically acceptable salt thereof. The method of claim 11, wherein the first and second compounds are administered substantially simultaneously. The method of claim 11, wherein the second compound is administered for a period of from about 3 months to about three years. 14. The method of claim 13, followed by administering the first compound for about three months to about three years without administering the second compound for about three months to about three years. 15. The method of claim 13, wherein the first compound is administered over a period of greater than about three years without the second compound being administered for a period of greater than three years. 16. The method of claim 11, wherein said mammal is affected by osteoporosis. · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · ··· ··· ·· ·· ·· ··· 17. The method of claim 11, wherein said mammal is afflicted with osteotomy, idiopathic bone loss in childhood, or bone loss associated with periodontitis. 18. The method of claim 11, comprising healing bone after renal reconstruction, upper jaw reconstruction or lower jaw reconstruction, inducing vertebral synostosis or promoting long bone elongation, promoting bone healing rate, or promoting prosthetic ingrowth. 19. The method of claim 18, wherein said method is treating a human bone fracture. 20. A method of increasing the amount of muscle in a mammal to be treated comprising administering to said mammal an amount of the composition of claim 1 effective to increase the amount of muscle in said mammal. 21. A kit comprising a) (-) - cis-6-phenyl-5- (4- (2-pyrrolidin-1-yl-ethoxy) -phenyl) -5,6,7,8-tetrahydronaphthalen-2-ol or a pharmaceutically acceptable salt thereof and a pharmaceutically acceptable carrier or diluent in a first unit dosage form; and b) 2-amino-N- (1- (R) - (2,4-difluoro-benzyloxymethyl) -2-oxo-2- (3-oxo-3α (R) -pyridin-2-ylmethyl) -2- (2,2,2-Trifluoro-ethyl) -2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridin-5-yl) -ethyl) -2-methyl-propionamide or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier or diluent in a second unit dosage form; and (c) packaging. The kit of claim 21, wherein the single dosage form comprises (-) - cis-6-phenyl-5- (4- (2-pyrrolidin-1-yl-ethoxy) -phenyl) -5,6,7,8-tetrahydronaphthalene The 2-ol-D-tartrate and the second single dosage form include 2-amino-N- (1- (R) - (2,4-difluoro-benzyloxymethyl) -2-oxo-2- (3-oxo-3a (R)). ) -pyridin-2-ylmethyl) -2- (2,2,2-trifluoro-ethyl) 2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridin-5-yl) - ethyl) -2-methyl-propionamide L-tartrate. Use of a pharmaceutical composition according to claim 1 for the preparation of a medicament for treating a mammal suffering from musculoskeletal fragility. The use of claim 23, wherein said first compound is (-) - cis-6-phenyl-5- (4- (2-pyrrolidin-1-yl-ethoxy) -phenyl) -5,6,7,8- tetrahydronaphthalen-2-ol-D-tartrate and said second compound is 2-amino-N- (1- (R) - (2,4-difluoro-benzyloxymethyl) -2-oxo-2- (3-oxo-3a ( R) -pyridin-2-ylmethyl) -2- (2,2,2-trifluoro-ethyl) 2,3,3a, 4,6,7-hexahydro-pyrazolo [4,3-c] pyridin-5- yl) ethyl) -2-methyl-propionamide L-tartrate. The use of claim 23, wherein said mammal is suffering from osteoporosis. The use of claim 23, wherein said mammal is suffering from osteotomy, idiopathic bone loss in childhood, or bone loss associated with periodontitis. The use of claim 23, wherein the treatment comprises bone healing after renal reconstruction, upper jaw reconstruction ·· • · • · ·· • ··· • • · · • • · · • · • · • • · · · · · · · · ♦ · or reconstruction of the lower jaw, inducing vertebral synostosis or promoting long bone extension, promoting healing rate using a bone graft, or promoting ingrowth of an orthotic. The use of claim 27, wherein the human bone fracture is treated. The use of claim 25, wherein the human osteoporosis is treated.