TW201404395A - Treatment of multiple sclerosis with combination of laquinimod and glatiramer acetate - Google Patents

Abstract

This invention provides a method of treating a patient afflicted with multiple sclerosis or presenting a clinically isolated syndrome comprising administering to the patient laquinimod as an add-on therapy to or in combination with glatiramer acetate. This invention also provides a package and a pharmaceutical composition comprising laquinimod and glatiramer acetate for treating a patient afflicted with multiple sclerosis or presenting a clinically isolated syndrome. This invention also provides laquinimod for use as an add-on therapy or in combination with glatiramer acetate in treating a patient afflicted with multiple sclerosis or presenting a clinically isolated syndrome. This invention further provides use of laquinimod and glatiramer acetate in the preparation of a combination for treating a patient afflicted with multiple sclerosis or presenting a clinically isolated syndrome.

Description

Treatment of multiple sclerosis with a combination of LAQUINIMOD and GLATIRAMER ACETATE

The present invention claims the benefit of U.S. Provisional Application Serial No. 61/512,808, filed on Jan. 28, 2011, which is incorporated herein by reference.

Throughout this application, each publication is cited in accordance with the first author and the year of publication. The complete citation of these publications is hereby incorporated by reference in its entirety. The disclosure of the cited documents and publications is hereby incorporated by reference in its entirety in its entirety in its entirety in its entirety in its entirety in the extent of the disclosure of the disclosure.

Multiple sclerosis (MS) is a neurological disease affecting more than 1 million people worldwide. It is the most common cause of neurological disorders in young and middle-aged adults and has a major impact on the physical, psychological, social, and economic health of individuals, their families, friends, and institutions responsible for health care (EMEA Guideline, 2006).

It is generally believed that MS is mediated by an autoimmune process that may be caused by infection and superimposed genetic predisposition. It is a chronic inflammatory condition that damages the central nervous system (CNS) of myelin. The pathogenesis of MS is characterized by the infiltration of T-cells directed against anti-myelin antigens from the circulation into the CNS (Bjartmar, 2002). In addition to the inflammatory phase of MS, axonal reduction occurs early in the course of the disease and can spread over time, leading to progressive, permanent neurological deficits and subsequent development of (often) severe disability (Neuhaus, 2003). Symptoms associated with the disease include fatigue, paralysis, disorders, weakness, bladder disorders and intestinal disorders, sexual dysfunction, pain, tremors, arrays Paroxysmal manifestation, visual impairment, psychological problems, and cognitive dysfunction (EMEA Guideline, 2006).

MS disease activity can be monitored by brain scans (including brain magnetic resonance imaging (MRI)), disability accumulation, and recurrence rate and severity monitoring. The clinical diagnosis of the Poser standard (Poser, 1983) confirmed that the MS had to have at least two neurological events indicative of myelin deprivation of the CNS at different times and at different locations. Clinical Single Syndrome (CIS) suggests a single, single symptomatic onset of MS, such as optic neuritis, brainstem lesions, and partial myelitis. CIS patients who experience a second clinical outbreak are generally considered to have clinically confirmed multiple sclerosis (CDMS). More than 80% of patients with CIS and MRI lesions continue to develop into MS, with approximately 20% having a self-limiting process (Brex, 2002; Frohman, 2003).

Various MS stages and/or types are described in Multiple Sclerosis Therapeutics (Duntiz, 1999). Among them, relapsing-remitting multiple sclerosis (RRMS) is the most common form of early diagnosis. Many RRMS patients have an initial relapsing-remitting process that lasts 5-15 years and then enters the secondary progressive MS (SPMS) course. Recurrence is caused by inflammation and myelin deprivation, while nerve conduction recovery and relaxation are accompanied by regression of inflammation, redistribution of sodium channels on demyelinated axons, and remyelination (Neuhaus, 2003; Noseworthy, 2000).

In April 2001, the International Committee worked with the National Multiple Sclerosis (MS) Society to recommend diagnostic criteria for multiple sclerosis. These standards are known as the McDonald standard. The McDonald standard uses MRI technology and is intended to replace the Poser standard with the earlier Schumacher standard (McDonald, 2001). The McDonald standard was revised in March 2005 by the International Commission (Polman, 2005) and revised again in 2010 (Polman, 2011).

It is recommended to intervene in the MS relapse phase with disease-modifying therapy to reduce and/or prevent the accumulation of neurodegeneration (Hohlfeld, 2000; De Stefano, 1999). The use of multiple disease mitigation drugs in relapsed MS (RMS), including RRMS and SPMS, is currently approved (The Disease Modifying Drug Brochure, 2006). These include interferon beta 1-a (Avonex® and Rebif®), interferon beta 1-b (Betaseron®), Copaxone® acetate, mitoxantrone (Novantrone®), then Natalizumab (Tysabri®) and fingolimod (Gilenya®). Most of them are considered to be immunomodulators. Mitoxantrone and natalizumab are considered immunosuppressive agents. However, the mechanism of action of each is only partially clarified. After the failure of conventional therapy, immunosuppressants or cytotoxic agents are used in some individuals. However, the relationship between the immune response induced by such preparations in MS and clinical efficacy has not been determined (EMEA Guideline, 2006).

Other treatments include symptomatic therapy, which refers to all therapies used to ameliorate the symptoms caused by the disease (EMEA Guideline, 2006), and the use of adrenal corticosteroids to treat acute relapses. Although steroids do not affect the progression of MS over time, they can reduce the duration and severity of morbidity in certain individuals.

Laquinimod

Laquinimod is a novel synthetic compound with high oral bioavailability that has been proposed as an oral formulation for the treatment of multiple sclerosis (MS) (Polman, 2005; Sandberg-Wollheim, 2005). Laquinimod and its sodium salt form are described, for example, in U.S. Patent No. 6,077,851.

The mechanism of action of laquinimod is not fully understood. Animal studies have shown that it causes Th1 (type 1 helper T cells, producing pro-inflammatory interleukins) to transform into anti-inflammatory forms of Th2 (type 2 helper T cells, producing anti-inflammatory interleukins) ) (Yang, 2004; Brück, 2011). Another study confirms (mainly via the NFkB pathway) that laquinimod causes inhibition of antigen-presenting genes and corresponding inflammatory pathways (Gurevich, 2010). Other suggested mechanisms of action include inhibition of leukocyte migration into the CNS, increased axonal integrity, regulation of interleukin production, and elevation of brain-derived neurotrophic factor (BDNF) levels (Runström, 2006; Brück, 2011).

Laquinimod showed good safety and tolerability curves in two Phase III trials (Results of Phase III BRAVO Trial Reinforce Unique Profile of Laquinimod for Multiple Sclerosis Treatment; Teva Pharma, Active Biotech Post Positive Laquinimod Phase 3 ALLEGRO Results ).

Glatiramer acetate (GA)

Glatiramer acetate (GA), also known as Copolymer-1, has been shown to be effective in the treatment of multiple sclerosis (MS) (Lampert, 1978). Daily subcutaneous injection of glatiramer acetate (20 mg/injection) reduced relapse rates, progression of disability, new lesions due to magnetic resonance imaging (MRI) (Johnson, 1995), and the appearance of "black holes" (Filippi, 2001).

COPAXONE® is the trade name for a formulation containing glatiramer acetate as the active ingredient. Glatiramer acetate is approved for reducing the recurrence rate of relapsing-remitting multiple sclerosis (RRMS). Glatiramer acetate consists of an acetate containing four synthetic amino acids: L-glutamic acid, L-alanine, L-tyrosine and L-lysine, which is averaged in COPAXONE® The molar fractions were 0.141, 0.427, 0.095 and 0.338, respectively. In COPAXONE®, the average molecular weight of glatiramer acetate is 4,700-11,000 Daltons. Chemically, glatiramer acetate is designated as L-glutamic acid polymer having L-alanine, L-lysine, L-tyrosine, and acetic acid (salt). Its structural formula is: (Glu, Ala, Lys, Tyr) _x ACH ₃ COOH (C ₅ H ₉ NO ₄ AC ₃ H ₇ NO ₂ AC ₆ H ₁₄ N ₂ O ₂ AC ₉ H ₁₁ NO ₃ ) _P APC ₂ H ₄ O ₂ CAS-147245-92-9.

The recommended dosing schedule for COPAXONE® for relapsing-remitting multiple sclerosis is daily subcutaneous injection of 20 mg (doctor's desk reference; see also U.S. Patent Nos. 3,849,550; 5,800,808; 5,858,964; 5,981,589; No. 6,048,898; 6,054,430; 6,214,791; 6,342,476 and 6,362,161 each incorporated herein by reference.

Although the mechanism of action has not been fully elucidated, GA is thought to bind to antigens in the groove of major histocompatibility complex (MHC) molecules and is shown as an antigen. Alternatively, GA is thought to be coated with antigen-presenting cells (APCs) to present fragments. Either way, the presentation of GA results in the production of GA-specific T cells. GA-specific T cells are significantly affected by helper T2 (Th2) via a mechanism that is not yet understood. Th2 cells produce Th2 interleukins, which inhibit the production of interleukins by Th1 cells or macrophages, and are often anti-inflammatory. Interferon-β is clearly active in the blood-brain barrier (BBB) and reduces inflammation Unlike cells that enter the CNS, the effects of GA on the BBB are negligible, allowing GA-specific Th2 lymphocytes to enter the CNS to reduce inflammation by bystander suppression (Yong, 2002).

Auxiliary therapy/combination therapy

The effect of adjuvant therapy or combination therapy with laquinimod and glatiramer acetate on MS patients has not been reported.

The administration of two drugs to treat a given condition (such as multiple sclerosis) creates a number of potential problems. The interaction between the two drugs in vivo is complex. The effect of any single drug is related to its absorption, distribution and elimination. When two drugs are introduced into the body, each drug can affect the absorption, distribution, and elimination of the other drug, and thus alter the effect of the other drug. For example, one drug can inhibit, activate, or induce the production of an enzyme involved in eliminating the metabolic pathway of another drug (Guidance for Industry, 1999). In one example, experiments have shown that the combination of GA and interferon (IFN) can eliminate the clinical effects of either therapy (Brod 2000). In another experiment, it was reported that the addition of dehydrocortisone in combination therapy with IFN-[beta] neutralized its upregulation effect. Therefore, when two drugs are administered to treat the same condition, it is impossible to predict whether each drug will complement, interfere with, or interfere with the therapeutic activity of another drug in a human individual.

The interaction between the two drugs not only affects the expected therapeutic activity of each drug, but the interaction increases the concentration of toxic metabolites (Guidance for Industry, 1999). Interactions can also increase or decrease the side effects of each drug. Therefore, when two drugs are administered to treat a disease, it is impossible to predict what changes will occur in the negative nature of each drug. In an example, The combination of natalizumab and interferon beta-1a exacerbates the risk of unexpected side effects (Vollmer, 2008; Rudick 2006; Kleinschmidt-DeMasters, 2005; Langer-Gould 2005).

In addition, it is difficult to accurately predict when the effects of interactions between the two drugs will become apparent. For example, metabolic interactions between drugs may become apparent when starting to administer a second drug, after both reach a steady state concentration, or when one of them is discontinued (Guidance for Industry, 1999).

Therefore, the current state of the art at the time of application is that the effects of adjuvant or combination therapies of the two drugs (specifically, laquinimod and GA) cannot be predicted until the results of the formal combination study are obtained.

The present invention provides a method for treating a human patient suffering from multiple sclerosis or a clinical single syndrome comprising orally administering to a patient a daily dose of 0.6 mg of laquinimod and subcutaneously administering a daily dose of 20 mg to the patient. Glatiramer acetate, which is more effective for treating human patients when the same amount is administered together than when each agent is administered alone.

The invention also provides a method of treating a human patient suffering from multiple sclerosis or clinically single syndrome comprising administering to the patient a certain amount of laquinimod and a certain amount of glatiramer acetate, wherein such The amount is effectively treated in human patients when administered together.

The invention also provides a method of treating a human patient suffering from an immune disease comprising periodically administering to the patient a certain amount of laquinimod and a quantity of glatiramer acetate (GA), wherein when administered together Effectively treat human patients, and the immune disease is autoimmune disease, arthritis Symptoms, myelin loss, inflammatory disease, multiple sclerosis, relapsing-remitting multiple sclerosis, diabetes, psoriasis, rheumatoid arthritis, inflammatory bowel disease, Crohn's disease or systemic lupus erythematosus .

The invention also provides a package comprising a) a first pharmaceutical composition comprising a quantity of laquinimod and a pharmaceutically acceptable carrier; b) a second pharmaceutical composition comprising a quantity of acetic acid And the pharmaceutically acceptable carrier; and c) the first and second pharmaceutical compositions are used together to treat instructions for use in a human patient having relapsing multiple sclerosis or having a clinical single syndrome.

The invention also provides laquinimod, which is used as an adjuvant therapy or in combination with glatiramer acetate to treat a human patient suffering from multiple sclerosis or having a clinically single syndrome.

The invention also provides a pharmaceutical composition comprising a certain amount of laquinimod and a certain amount of glatiramer acetate for treating a human patient suffering from multiple sclerosis or having a clinical single syndrome, wherein the pulling Quinmod and the glatiramer acetate are administered simultaneously or simultaneously.

The invention also provides a pharmaceutical composition comprising a certain amount of laquinimod and a quantity of glatiramer acetate for treating a human patient suffering from an immune disease, wherein the laquinimod and the acetic acid The thiophene is administered simultaneously or concurrently, and the immune disease is an autoimmune disease, an arthritic condition, a myelin vaginal disease, an inflammatory disease, multiple sclerosis, relapsing-remitting multiple sclerosis, diabetes, Psoriasis, rheumatoid arthritis, inflammatory bowel disease, Crohn's disease or systemic lupus erythematosus.

The invention also provides a pharmaceutical composition comprising a certain amount of laquinol De and a certain amount of glatiramer acetate.

The invention also provides a method for preparing a combination of a certain amount of laquinimod and a certain amount of glatiramer acetate for treating a human patient suffering from multiple sclerosis or having a clinical single syndrome, wherein the laquinimod and The glatiramer acetate is administered simultaneously or concurrently.

The present invention also provides a pharmaceutical composition comprising a certain amount of laquinimod as an adjuvant therapy or in combination with glatiramer acetate, by periodically administering the pharmaceutical composition to the individual and the glatiramer acetate For the treatment of individuals with multiple sclerosis or clinical single syndrome.

The invention further provides a pharmaceutical composition comprising a quantity of glatiramer acetate as adjunctive therapy or in combination with laquinimod, by periodically administering the pharmaceutical composition to the individual and the laquinimod For the treatment of individuals with multiple sclerosis or clinical single syndrome.

The present invention provides a method of treating a human patient suffering from multiple sclerosis or having a clinical single syndrome comprising orally administering to a patient a daily dose of 0.6 mg of laquinimod or a pharmaceutically acceptable salt thereof, and The patient is injected subcutaneously with a daily dose of 20 mg of glatiramer acetate, which is more effective for treating human patients when the same amount is administered together than when each agent is administered alone.

In one embodiment, the multiple sclerosis is relapsing multiple sclerosis. In another embodiment, the relapsing form of multiple sclerosis is relapsing-remitting multiple sclerosis.

In one embodiment, the amount of laquinimod and the acetate acetate when administered together The amount of Terry is effective in reducing the symptoms of multiple sclerosis in human patients. In another embodiment, the symptoms are MRI-monitoring multiple sclerosis disease activity, relapse rate, disability accumulation, frequency of recurrence, frequency of clinical exacerbations, brain atrophy, risk of confirming progression, or time to confirm disease progression.

In one embodiment, the disability accumulation is a time assessment of the disease progression as determined by the Kurtzke Extended Disability Status Scale (EDSS) score. In another embodiment, the patient has an EDSS score of 0-5 prior to administration of laquinimod. In another embodiment, the patient has an EDSS score of 1-5.5 prior to administration of laquinimod. In another embodiment, the patient has an EDSS score of 0-5.5 prior to administration of laquinimod. In another embodiment, the patient has an EDSS score of 5.5 or higher prior to administration of laquinimod. In another embodiment, the disease progression is confirmed to increase the EDSS score by one point. In yet another embodiment, the disease progression is confirmed to increase the EDSS score by 0.5 points.

In one embodiment, the time to confirm disease progression is increased by 10-100%. In another embodiment, the time to confirm disease progression is increased by 20-80%. In another embodiment, the time to confirm disease progression is increased by 20-60%. In another embodiment, the time to confirm disease progression is increased by 30-50%. In yet another embodiment, the time to confirm disease progression is increased by at least 50%.

In one embodiment, the laquinimod is laquinimod sodium.

In one embodiment, the patient is injected subcutaneously with 0.5 ml of an aqueous solution of the drug comprising 20 mg of glatiramer acetate and 20 mg of mannitol in solution. In another embodiment, the patient is injected subcutaneously with 1.0 ml of an aqueous solution of the drug comprising 20 mg of glatiramer acetate and 40 mg of mannitol in solution. In one embodiment, the dosage of glatiramer acetate is suboptimal.

In one embodiment, glatiramer acetate is administered intramuscularly. In another embodiment, glatiramer acetate is administered subcutaneously. In another embodiment, glatiramer acetate is administered 1-5 times a month. In another embodiment, the glatiramer acetate system is administered 1-3 times a month. In another embodiment, glatiramer acetate is administered 1-5 times a week. In another embodiment, glatiramer acetate is administered 1-3 times a week. In another embodiment, glatiramer acetate is administered 1-5 times a day. In another embodiment, glatiramer acetate is administered 1-3 times a day. In another embodiment, glatiramer acetate is administered every other day. In yet another embodiment, glatiramer acetate is administered daily.

In one embodiment, the administration of laquinimod is substantially prior to the administration of glatiramer acetate. In another embodiment, the administration of glatiramer acetate is substantially prior to the administration of laquinimod.

In one embodiment, the human patient is first treated with glatiramer acetate, followed by laquinimod therapy. In another embodiment, the human patient is first treated with glatiramer acetate for at least 24 weeks, followed by initiation of laquinimod therapy. In another embodiment, the human patient receives glatiramer acetate therapy for about 24 weeks, followed by initiation of laquinimod therapy. In another embodiment, the human patient is first treated with glatiramer acetate for at least 28 weeks, followed by laquinimod therapy. In another embodiment, the human patient receives glatiramer acetate therapy for about 28 weeks, followed by laquinimod therapy. In another embodiment, the human patient is first treated with glatiramer acetate for at least 48 weeks, followed by initiation of laquinimod therapy. In another embodiment, the human patient receives glatiramer acetate therapy for about 48 weeks, followed by laquinimod therapy. in In another embodiment, the human patient is first treated with glatiramer acetate for at least 52 weeks, followed by laquinimod therapy. In yet another embodiment, the human patient receives glatiramer acetate therapy for about 52 weeks, followed by laquinimod therapy.

In one embodiment, the laquinimod is administered in the morning. In another embodiment, the laquinimod is administered at night. In one embodiment, the laquinimod is administered with food. In another embodiment, the laquinimod is not administered with food.

In one embodiment, glatiramer acetate is administered in the morning. In another embodiment, glatiramer acetate is administered at night. In one embodiment, glatiramer acetate is administered with food. In another embodiment, the glatiramer acetate is not administered with food.

In one embodiment, the laquinimod is administered concurrently with glatiramer acetate. In another embodiment, the laquinimod is administered concurrently with glatiramer acetate. In another embodiment, the laquinimod is administered immediately before or after administration of glatiramer acetate. In another embodiment, the laquinimod is administered within one hour before or after administration of glatiramer acetate. In another embodiment, the laquinimod is administered within 3 hours prior to or after administration of glatiramer acetate. In another embodiment, the laquinimod is administered within 6 hours prior to or after administration of glatiramer acetate. In another embodiment, the laquinimod is administered within 12 hours prior to or after administration of glatiramer acetate. In another embodiment, the laquinimod is administered within 24 hours prior to or after administration of glatiramer acetate.

In one embodiment, the method further comprises administering a non-steroidal anti-inflammatory drug (NSAID), salicylate, slow acting drug, gold compound, hydroxychloroquine, sulfasalazine, slow acting drug combination, adrenocortical steroid, cytotoxic drug, immunosuppressive drug and/or antibody.

In one embodiment, laquinimod and glatiramer acetate are administered periodically for more than 30 days. In another embodiment, laquinimod and glatiramer acetate are administered periodically for more than 42 days. In yet another embodiment, laquinimod and glatiramer acetate are administered periodically for 6 months or longer.

In one embodiment, administration of laquinimod and glatiramer acetate inhibits symptoms of relapsing multiple sclerosis by at least 20%. In another embodiment, administration of laquinimod and glatiramer acetate inhibits symptoms of relapsing multiple sclerosis by at least 30%. In another embodiment, administration of laquinimod and glatiramer acetate inhibits symptoms of relapsing multiple sclerosis by at least 40%. In another embodiment, administration of laquinimod and glatiramer acetate inhibits at least 50% of the symptoms of relapsing multiple sclerosis. In another embodiment, administration of laquinimod and glatiramer acetate inhibits symptoms of relapsing multiple sclerosis by more than 100%. In another embodiment, administration of laquinimod and glatiramer acetate inhibits symptoms of relapsing multiple sclerosis by more than 300%. In yet another embodiment, administration of laquinimod and glatiramer acetate inhibits symptoms of relapsing multiple sclerosis by more than 1000%.

In one embodiment, the amount of laquinimod when administered alone and the amount of glatiramer acetate when administered alone are each effective to treat a human patient. In another embodiment, the amount of laquinimod when administered alone, the amount of glatiramer acetate when taken alone, or the individual amount when administered alone is not effective in treating a human patient.

The invention also provides a method for treating a human patient suffering from multiple sclerosis or clinical single syndrome, comprising regularly administering to the patient a certain amount of laquinimod and a certain amount of glatiramer acetate, wherein when co-injection The same amount is effective in treating human patients. In one embodiment, the amount of laquinimod is more effective in treating a human patient when administered together with the amount of glatiramer acetate than when each agent is administered alone.

In one embodiment, the multiple sclerosis is relapsing multiple sclerosis. In another embodiment, the relapsing form of multiple sclerosis is relapsing-remitting multiple sclerosis.

In one embodiment, the amount of laquinimod and the amount of glatiramer acetate when administered together are effective to reduce the symptoms of multiple sclerosis in a human patient. In another embodiment, the symptoms are MRI-monitoring multiple sclerosis disease activity, recurrence rate, disability accumulation, frequency of relapse, shortened time to confirm disease progression, shortened time to confirm recurrence, frequency of clinical deterioration, brain atrophy, neurons Dysfunction, neuronal damage, neuronal degeneration, neuronal apoptosis, risk of confirming progression, visual function, fatigue, impaired mobility, cognitive impairment, decreased brain volume, observed in the whole brain MTR histogram Abnormalities, deterioration of overall health, functional status, quality of life, and/or severity of symptoms at work.

In one embodiment, brain volume reduction can be effectively reduced or inhibited when the amount of laquinimod is administered with the amount of glatiramer acetate. In another embodiment, brain volume is measured by brain volume change rate (PBVC).

In one embodiment, the amount of laquinimod and the amount of glatiramer acetate when administered together can effectively increase the time to confirm disease progression. In another embodiment Among them, the time to confirm the progress of the disease increased by 20-60%. In yet another embodiment, the time to confirm disease progression is increased by at least 50%.

In one embodiment, the amount of laquinimod and the amount of glatiramer acetate when administered together effectively reduces the abnormalities observed in the whole brain MTR histogram. In another embodiment, disability accumulation is measured by the Kurtzke Extended Disability Status Scale (EDSS) score. In another embodiment, the disability accumulation is a time assessment of the disease progression as determined by the Kurtzke Extended Disability Status Scale (EDSS) score. In another embodiment, the patient has an EDSS score of 0-5.5 prior to administration of laquinimod. In another embodiment, the patient has an EDSS score of 1.5-4.5 prior to administration of laquinimod. In another embodiment, the patient has an EDSS score of 5.5 or higher prior to administration of laquinimod. In another embodiment, the disease progression is confirmed to increase the EDSS score by one point. In another embodiment, the disease progression is confirmed to increase the EDSS score by 0.5 points.

In one embodiment, impaired mobility is assessed by a 25 foot time walk test. In another embodiment, impaired mobility is assessed by the 12 Multiple Sclerosis Walking Scale (MSWS-12) self-report questionnaire. In another embodiment, impaired mobility is assessed by the Walking Index (AI). In another embodiment, impaired mobility is assessed by a six minute walk (6 MW) test. In another embodiment, impaired mobility is assessed by the Lower Limb Manual Muscle Test (LEMMT).

In one embodiment, the amount of laquinimod and the amount of glatiramer acetate when administered together are effective to reduce cognitive impairment. In another embodiment, the cognitive impairment is assessed by a Signature Digital Pattern Test (SDMT) score.

In one embodiment, the overall health status is determined by European quality of life (EQ5D) Questionnaire, Individual Overall Impression (SGI) or Clinical Physician Impression (CGIC) assessment. In another embodiment, the functional status is measured by the patient's Jane General Health Survey (SF-36) Individual Report Questionnaire score. In another embodiment, the quality of life is assessed by SF-36, EQ5D, Individual Overall Impression (SGI), or a change in the overall impression of the clinician (CGIC). In another embodiment, the patient SF-36 Mental Health Total Score (MSC) is improved. In another embodiment, the patient SF-36 physical health score (PSC) is improved.

In one embodiment, the fatigue is assessed by EQ5D, the patient's revised Fatigue Impact Scale (MFIS) score, or the French Effective Version (EMIF-SEP) score of the Fatigue Impact Scale. In another embodiment, the severity of symptoms for work is measured by the Work Productivity and Activity Disorders General Health (WPAI-GH) questionnaire.

In one embodiment, the laquinimod is laquinimod sodium. In another embodiment, the laquinimod is administered by oral administration. In another embodiment, the laquinimod is administered daily. In another embodiment, laquinimod is typically administered more than once a day. In another embodiment, laquinimod is typically administered less than once a day.

In one embodiment, the amount of laquinimod administered does not exceed 0.6 mg/day. In another embodiment, the amount of laquinimod administered is from 0.1 to 40.0 mg/day. In another embodiment, the amount of laquinimod administered is 0.1-2.5 mg/day. In another embodiment, the amount of laquinimod administered is 0.25-2.0 mg/day. In another embodiment, the amount of laquinimod administered is 0.5-1.2 mg/day. In another embodiment, the amount of laquinimod administered is 0.25 mg/day. In another embodiment, the dose of laquinimod is 0.3 mg/day. In another embodiment, the amount of laquinimod administered is 0.5 mg/day. In another embodiment, pulling The dosage and amount of quinimod was 0.6 mg/day. In another embodiment, the dose of laquinimod is 1.0 mg/day. In another embodiment, the dose of laquinimod is 1.2 mg/day. In another embodiment, the amount of laquinimod administered is 1.5 mg/day. In yet another embodiment, the dose of laquinimod is 2.0 mg/day.

In one embodiment, the dosage of glatiramer acetate is from 0.1 to 1000 mg/day. In another embodiment, the dosage of glatiramer acetate is 50-150 mg/day. In another embodiment, the dosage of glatiramer acetate is 0.1-70 mg/day. In another embodiment, the dosage of glatiramer acetate is 10-80 mg/day. In another embodiment, the dosage of glatiramer acetate is 1 mg/day. In another embodiment, the dosage of glatiramer acetate is 5 mg/day. In another embodiment, the dosage of glatiramer acetate is 15 mg/day. In another embodiment, the dosage of glatiramer acetate is 20 mg/day. In another embodiment, the dosage of glatiramer acetate is 30 mg/day. In another embodiment, the dosage of glatiramer acetate is 40 mg/day. In another embodiment, the dosage of glatiramer acetate is 50 mg/day. In another embodiment, the dosage of glatiramer acetate is 100 mg/day. In another embodiment, the dosage of glatiramer acetate is 10-600 mg/week. In another embodiment, the dosage of glatiramer acetate is 300 mg/week.

In one embodiment, the administration of glatiramer acetate is performed daily. In another embodiment, the dosage of glatiramer acetate is administered twice in half per day. In another embodiment, the dosage of glatiramer acetate is administered every 5 to 9 days.

In one embodiment, glatiramer acetate is administered orally. In another embodiment, glatiramer acetate is administered nasally. In another embodiment, glatiramer acetate is inhaled. In another embodiment, glatiramer acetate is administered via subcutaneous injection. In another embodiment, the glatiramer acetate is administered over a seven day period with at least one day between each subcutaneous injection. In another embodiment, glatiramer acetate is administered via an intravenous, intraperitoneal, intramuscular, intranasal, buccal, vaginal, rectal, intraocular, intrathecal, topical or intradermal route.

In one embodiment, the patient is injected subcutaneously with 0.5 ml of an aqueous solution of the drug comprising 20 mg of glatiramer acetate and 20 mg of mannitol in solution. In another embodiment, the amount of loading dose different from the predetermined dose is administered for a period of time at the beginning of the periodic administration. In another embodiment, the starting dose is twice the predetermined dose. In another embodiment, the starting dose is administered for two days at the beginning of the periodic administration.

In one embodiment, the administration of laquinimod is substantially prior to the administration of glatiramer acetate. In another embodiment, the administration of glatiramer acetate is substantially prior to the administration of laquinimod.

In one embodiment, the human patient is first treated with glatiramer acetate, followed by laquinimod therapy. In another embodiment, the human patient is first treated with glatiramer acetate for at least 24 weeks, followed by initiation of laquinimod therapy. In another embodiment, the human patient is first treated with glatiramer acetate for at least 28 weeks, followed by laquinimod therapy. In another embodiment, the human patient is first treated with glatiramer acetate for at least 48 weeks, followed by initiation of laquinimod therapy. In another embodiment, the human patient receives acetic acid first Glatiride therapy for at least 52 weeks followed by initiation of laquinimod therapy.

In one embodiment, the method further comprises administering a non-steroidal anti-inflammatory drug (NSAID), a salicylate, a slow acting drug, a gold compound, a hydroxychloroquine, a sulfasalazine, a combination of a slow acting drug, an adrenocortical steroid, Cytotoxic drugs, immunosuppressive drugs and/or antibodies.

In one embodiment, laquinimod and glatiramer acetate are administered periodically for at least 3 days. In another embodiment, laquinimod and glatiramer acetate are administered periodically for more than 30 days. In another embodiment, laquinimod and glatiramer acetate are administered periodically for more than 42 days. In another embodiment, laquinimod and glatiramer acetate are administered periodically for 8 weeks or longer. In another embodiment, laquinimod and glatiramer acetate are administered periodically for at least 12 weeks. In another embodiment, laquinimod and glatiramer acetate are administered periodically for at least 24 weeks. In another embodiment, laquinimod and glatiramer acetate are administered periodically for more than 24 weeks. In another embodiment, laquinimod and glatiramer acetate are administered periodically for 6 months or longer.

In one embodiment, administration of laquinimod and glatiramer acetate inhibits at least 20% of the symptoms of relapsing multiple sclerosis. In another embodiment, administration of laquinimod and glatiramer acetate inhibits symptoms of relapsing multiple sclerosis by at least 30%. In another embodiment, administration of laquinimod and glatiramer acetate inhibits at least 50% of the symptoms of relapsing multiple sclerosis. In another embodiment, administration of laquinimod and glatiramer acetate inhibits at least 70% of the symptoms of relapsing multiple sclerosis. In another embodiment, administration of laquinimod and glatiramer acetate inhibits symptoms of relapsing multiple sclerosis by more than 100%. In another embodiment, administration of laquinimod and acetate acetate Terex inhibits the symptoms of relapsing multiple sclerosis by more than 300%. In another embodiment, administration of laquinimod and glatiramer acetate inhibits symptoms of relapsing multiple sclerosis by more than 1000%.

In one embodiment, the amount of laquinimod when administered alone and the amount of glatiramer acetate when administered alone are each effective to treat a human patient. In another embodiment, the amount of laquinimod when administered alone, the amount of glatiramer acetate when taken alone, or when taken alone, is not effective in treating a human patient.

In one embodiment, the patient has been determined to be a responder to glatiramer treatment. In another embodiment, the patient has been determined to be a non-responder to the glatiramer treatment.

The invention also provides a method of treating a human patient suffering from an immune disease comprising periodically administering to the patient a certain amount of laquinimod and a quantity of glatiramer acetate (GA), wherein when administered together Effectively treats human patients, and the immune disease is autoimmune disease, arthritis condition, myelin loss disease, inflammatory disease, multiple sclerosis, relapsing-remitting multiple sclerosis, diabetes, psoriasis, class Rheumatoid arthritis, inflammatory bowel disease, Crohn's disease, or systemic lupus erythematosus.

The invention also provides a package comprising a) a first pharmaceutical composition comprising a quantity of laquinimod and a pharmaceutically acceptable carrier; b) a second pharmaceutical composition comprising a quantity of acetic acid And the pharmaceutically acceptable carrier; and c) the first and second pharmaceutical compositions are used together to treat instructions for use in a human patient having relapsing multiple sclerosis or having a clinical single syndrome.

In one embodiment, the first pharmaceutical composition is in the form of an aerosol or an inhalable powder. In another embodiment, the first pharmaceutical composition is in liquid form. In another embodiment, the first pharmaceutical composition is in a solid form. In another embodiment, the first pharmaceutical composition is in the form of a capsule. In another embodiment, the first pharmaceutical composition is in the form of a tablet. In another embodiment, the tablet is coated with a coating that inhibits oxygen from contacting the core. In yet another embodiment, the coating comprises a cellulosic polymer, an anti-sticking agent, a brightening agent, and a pigment.

In an embodiment, the first pharmaceutical composition further comprises mannitol. In another embodiment, the first pharmaceutical composition further comprises an alkalizing agent. In another embodiment, the basifying agent is meglumine. In another embodiment, the first pharmaceutical composition further comprises a redox agent.

In one embodiment, the first pharmaceutical composition is stable and free of alkalizing agents or redox agents. In another embodiment, the first pharmaceutical composition is free of alkalizing agents and is free of redox agents.

In one embodiment, the first pharmaceutical composition is stable and free of disintegrants. In another embodiment, the first pharmaceutical composition further comprises a lubricant. In another embodiment, the lubricant is present in the composition as a solid particulate. In another embodiment, the lubricant is sodium stearyl fumarate or magnesium stearate.

In an embodiment, the first pharmaceutical composition further comprises a filler. In another embodiment, the filler is present in the composition as solid particles. In another embodiment, the filler is lactose, lactose monohydrate, starch, isomalt, mannitol, sodium starch glycolate, sorbitol, spray dried lactose, anhydrous lactose or combinations thereof . In another embodiment The filler is mannitol or lactose monohydrate.

In an embodiment, the package further comprises a desiccant. In another embodiment, the desiccant is silicone.

In one embodiment, the stable first pharmaceutical composition has a water content of no more than 4%. In another embodiment, the laquinimod is present as a solid particle in the composition.

In one embodiment, the package is a sealed package having a moisture permeability of no more than 15 mg/day/liter. In another embodiment, the sealed package is a blister package wherein the maximum moisture permeability does not exceed 0.005 mg/day. In another embodiment, the sealed package is a bottle. In another embodiment, the bottle is sealed by a thermally sensitive gasket. In another embodiment, the sealed package comprises an HDPE bottle. In another embodiment, the sealed package includes an oxygen absorber. In another embodiment, the oxygen absorber is iron.

In one embodiment, the amount of laquinimod in the first composition is less than 0.6 mg. In another embodiment, the amount of laquinimod in the composition is from 0.1 to 40.0 mg. In another embodiment, the amount of laquinimod in the first composition is from 0.1 to 2.5 mg. In another embodiment, the amount of laquinimod in the first composition is from 0.25 to 2.0 mg. In another embodiment, the amount of laquinimod in the first composition is from 0.5 to 1.2 mg. In another embodiment, the amount of laquinimod in the first composition is 0.25 mg. In another embodiment, the amount of laquinimod in the first composition is 0.3 mg. In another embodiment, the amount of laquinimod in the first composition is 0.5 mg. In another embodiment, the amount of laquinimod in the first composition is 0.6 mg. In another embodiment, the amount of laquinimod in the first composition is 1.0 mg. In another embodiment, the first composition is laquine The amount of Mod is 1.2 mg. In another embodiment, the amount of laquinimod in the first composition is 1.5 mg. In another embodiment, the amount of laquinimod in the first composition is 2.0 mg.

In one embodiment, the amount of glatiramer acetate in the second composition is from 0.1 to 1000 mg. In another embodiment, the amount of glatiramer acetate in the second composition is from 50 to 150 mg. In another embodiment, the amount of glatiramer acetate in the second composition is from 10 to 600 mg. In another embodiment, the amount of glatiramer acetate in the second composition is from 0.1 to 70 mg. In another embodiment, the amount of glatiramer acetate in the second composition is from 10 to 80 mg. In another embodiment, the amount of glatiramer acetate in the second composition is 1 mg. In another embodiment, the amount of glatiramer acetate in the second composition is 5 mg. In another embodiment, the amount of glatiramer acetate in the second composition is 15 mg. In another embodiment, the amount of glatiramer acetate in the second composition is 20 mg. In another embodiment, the amount of glatiramer acetate in the second composition is 30 mg. In another embodiment, the amount of glatiramer acetate in the second composition is 40 mg. In another embodiment, the amount of glatiramer acetate in the second composition is 50 mg. In another embodiment, the amount of glatiramer acetate in the second composition is 100 mg. In another embodiment, the amount of glatiramer acetate in the second composition is 300 mg.

In one embodiment, the second composition is a unit dose of 0.5 ml of an aqueous solution comprising 20 mg of glatiramer acetate. In another embodiment, the second composition is a 0.5 ml unit dose comprising an aqueous solution of 20 mg glatiramer acetate and 20 mg mannitol. In another embodiment, the second composition is a unit dose of 1 ml of an aqueous pharmaceutical solution comprising 20 mg of glatiramer acetate as a solution and 40 mg mannitol. In another embodiment, the second composition is a unit dose of 1 ml of aqueous drug solution comprising 40 mg of glatiramer acetate in solution. In another embodiment, the second composition is in an enteric coated form.

The invention also provides laquinimod, which is used as an adjuvant therapy or in combination with glatiramer acetate to treat a human patient suffering from multiple sclerosis or having a clinically single syndrome.

The invention also provides a pharmaceutical composition comprising a certain amount of laquinimod and a certain amount of glatiramer acetate for treating a human patient suffering from multiple sclerosis or having a clinical single syndrome, wherein the pulling Quinmod and the glatiramer acetate are administered simultaneously or simultaneously.

The invention also provides a pharmaceutical composition comprising a certain amount of laquinimod and a quantity of glatiramer acetate for treating a human patient suffering from an immune disease, wherein the laquinimod and the acetic acid The thiophene is administered simultaneously or concurrently, and the immune disease is an autoimmune disease, an arthritic condition, a myelin vaginal disease, an inflammatory disease, multiple sclerosis, relapsing-remitting multiple sclerosis, diabetes, Psoriasis, rheumatoid arthritis, inflammatory bowel disease, Crohn's disease or systemic lupus erythematosus.

The invention also provides a pharmaceutical composition comprising a quantity of laquinimod and a quantity of glatiramer acetate.

In one embodiment, the pharmaceutical composition is in the form of an aerosol or inhalable powder. In another embodiment, the pharmaceutical composition is in liquid form. In another embodiment, the pharmaceutical composition is in solid form. In another embodiment, the pharmaceutical composition is in the form of a capsule. In another embodiment, the pharmaceutical composition is in the form of a troche. In another embodiment, the tablet is inhibited by oxygen contact The core coating is applied. In another embodiment, the coating comprises a cellulosic polymer, an anti-sticking agent, a brightening agent, and a pigment.

In an embodiment, the pharmaceutical composition further comprises mannitol. In another embodiment, the pharmaceutical composition further comprises an alkalizing agent. In one embodiment, the basifying agent is meglumine. In another embodiment, the pharmaceutical composition further comprises a redox agent.

In one embodiment, the pharmaceutical composition is free of alkalizing agents or redox agents. In another embodiment, the pharmaceutical composition is free of alkalizing agents and is free of redox agents.

In one embodiment, the pharmaceutical composition is stable and free of disintegrants. In another embodiment, the pharmaceutical composition further comprises a lubricant. In one embodiment, the lubricant is present in the composition as solid particles. In another embodiment, the lubricant is sodium stearyl fumarate or magnesium stearate.

In an embodiment, the pharmaceutical composition further comprises a filler. In another embodiment, the filler is present in the composition as solid particles. In another embodiment, the filler is lactose, lactose monohydrate, starch, isomalt, mannitol, sodium starch glycolate, sorbitol, spray dried lactose, anhydrous lactose, or a combination thereof. In another embodiment, the filler is mannitol or lactose monohydrate.

In one embodiment, the amount of laquinimod in the composition is less than 0.6 mg. In another embodiment, the amount of laquinimod in the composition is from 0.1 to 40.0 mg. In another embodiment, the amount of laquinimod in the composition is from 0.1 to 2.5 mg. In another embodiment, the amount of laquinimod in the composition is from 0.25 to 2.0 mg. In another embodiment, the amount of laquinimod in the composition is from 0.5 to 1.2 mg. In another embodiment, the amount of laquinimod in the composition is 0.25 mg. In another embodiment, the amount of laquinimod in the composition is 0.3 mg. In another embodiment, the amount of laquinimod in the composition is 0.5 mg. In another embodiment, the amount of laquinimod in the composition is 0.6 mg. In another embodiment, the amount of laquinimod in the composition is 1.0 mg. In another embodiment, the amount of laquinimod in the composition is 1.2 mg. In another embodiment, the amount of laquinimod in the composition is 1.5 mg. In another embodiment, the amount of laquinimod in the composition is 2.0 mg.

In one embodiment, the amount of glatiramer acetate in the composition is from 0.1 to 1000 mg. In another embodiment, the amount of glatiramer acetate in the composition is from 50 to 150 mg. In another embodiment, the amount of glatiramer acetate in the composition is from 10 to 600 mg. In another embodiment, the amount of glatiramer acetate in the composition is from 0.1 to 70 mg. In another embodiment, the amount of glatiramer acetate in the composition is from 10 to 80 mg. In another embodiment, the amount of glatiramer acetate in the composition is 1 mg. In another embodiment, the amount of glatiramer acetate in the composition is 5 mg. In another embodiment, the amount of glatiramer acetate in the composition is 15 mg. In another embodiment, the amount of glatiramer acetate in the composition is 20 mg. In another embodiment, the amount of glatiramer acetate in the composition is 30 mg. In another embodiment, the amount of glatiramer acetate in the composition is 40 mg. In another embodiment, the amount of glatiramer acetate in the composition is 50 mg. In another embodiment, the amount of glatiramer acetate in the composition is 100 mg. In yet another embodiment, the amount of glatiramer acetate in the composition is 300 mg.

In one embodiment, the composition is 0.5 ml containing 20 mg of glatiramer acetate The unit dose of the aqueous solution. In another embodiment, the composition is a 0.5 ml unit dose comprising an aqueous solution of 20 mg glatiramer acetate and 20 mg mannitol. In another embodiment, the composition is a unit dose of 1 ml of aqueous pharmaceutical solution comprising 20 mg of glatiramer acetate and 40 mg of mannitol in solution. In another embodiment, the composition is a unit dose of 1 ml of aqueous drug solution comprising 40 mg of glatiramer acetate in solution.

The invention further provides for the use of a certain amount of laquinimod and a certain amount of glatiramer acetate for the preparation of a combination for treating a human patient suffering from multiple sclerosis or having a clinical single syndrome, wherein the laquinimo De and the glatiramer acetate are administered simultaneously or simultaneously.

Also disclosed is a method of treating a human patient suffering from multiple sclerosis or clinically unique syndrome comprising orally administering to a patient a daily dose of 0.6 mg laquinimod and subcutaneously administering a daily dose of 20 mg to the patient. Glatiramer acetate, wherein for the treatment of human patients, the same amount is more effective when administered together than when the individual agents are administered alone.

Also disclosed is a method of treating a human patient suffering from multiple sclerosis or a human patient presenting a clinically single syndrome of multiple sclerosis comprising periodically administering to a human patient a certain amount of laquinimod and a certain amount of acetic acid Glatiramer, wherein for treating human patients, the same amount is more effective when administered together than when the individual agents are administered alone. In one embodiment, the patient undergoes a clinical onset of multiple sclerosis and has at least one lesion suggestive of multiple sclerosis. In another embodiment, the amount of laquinimod and the amount of glatiramer acetate when administered together are more effective in delaying the patient's conversion to clinically confirmed multiple sclerosis than when the individual agents are administered alone.

The present invention also provides a pharmaceutical composition comprising a certain amount of laquinimod as an adjuvant therapy or in combination with glatiramer acetate, by periodically administering the pharmaceutical composition to the individual and the glatiramer acetate For the treatment of individuals with multiple sclerosis or clinical single syndrome.

The invention further provides a pharmaceutical composition comprising a quantity of glatiramer acetate as adjunctive therapy or in combination with laquinimod, by periodically administering the pharmaceutical composition to the individual and the laquinimod For the treatment of individuals with multiple sclerosis or clinical single syndrome.

With the foregoing embodiments, the various embodiments disclosed herein are contemplated to be applied to each of the other disclosed embodiments. Additionally, the elements recited in the packaging and pharmaceutical composition examples can be used in the method embodiments described herein.

Glatiramer acetate

Glatiramer acetate mixtures, compositions, methods for their preparation, their use in the treatment of various conditions, and corresponding dosages and methods are described, for example, in PCT International Application Publication No. WO 1998/30227, WO 2000/05250 No. WO 2000/18794, WO 2004/103297, WO 2006/029393, WO 2006/029411, WO 2006/083608, WO 2006/089164, WO 2006/116602 , WO 2009/070298, WO 2011/022063, WO 2012/051106, WO 2003/048735, and WO 2011/008274, US Patent Application Publication No. 2011-0230413 and No. 2008 No. 027,526, and U.S. Patent Nos. 8,008,258 and 7,556,767, the entireties of each of each of each of

Laquinimod

The laquinimod mixture, composition, and method of making the same are described in, for example, U.S. Patent No. 6,077,851, U.S. Patent No. 7,884,208, U.S. Patent No. 7,989,473, U.S. Patent No. 8,178,127, U.S. Application Publication No. 2010-0055072 No. 2012-0010238, and U.S. Application Publication No. 2012-0010239, the entire contents of each of which are hereby incorporated by reference.

The use of laquinimod for the treatment of various conditions and the corresponding dosages and regimens are described in U.S. Patent No. 6,077,851 (multiple sclerosis, insulin-dependent diabetes mellitus, systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel) Disease, psoriasis, inflammatory respiratory disorders, atherosclerosis, stroke, and Alzheimer's disease), US Application Publication No. 2011-0027219 (Crohn's Disease), US Application Publication No. 2010-0322900 (Relapsing-remitting multiple sclerosis), US Application Publication No. 2011-0034508 (brain-derived neurotrophic factor (BDNF)-related diseases), US Application Publication No. 2011-0218179 (active lupus nephritis), US application Publication No. 2011-0218203 (Rheumatoid Arthritis), US Application Publication No. 2011-0217295 (Active Lupus Arthritis), and US Application Publication No. 2012-0142730 (to relieve fatigue and improve quality of life for MS patients) And the provision of neuroprotection, the respective of which is incorporated herein by reference in its entirety.

The pharmaceutically acceptable salts of laquinimod as used in the present application include lithium salts and sodium salts. Potassium, magnesium, calcium, manganese, copper, zinc, aluminum and iron salts. Laquinimod salt formulations and methods for their preparation are described, for example, in U.S. Patent No. 7,589,208 and PCT International Application Publication No. WO 2005/074899, incorporated herein by reference.

Laquinimod may be suitably selected as a pharmaceutical diluent, extender, excipient or carrier in accordance with conventional pharmaceutical granules, as appropriate to the intended form of administration (collectively referred to herein as pharmaceutically acceptable The carrier is mixed and administered. The unit will be in a form suitable for oral administration. Laquinimod can be administered alone, but it is usually mixed with a pharmaceutically acceptable carrier and administered in the form of a lozenge or capsule, liposome or as agglomerated powder. Examples of suitable solid carriers include lactose, sucrose, gelatin and agar. Capsules or lozenges can be easily formulated and made easy to swallow or chew; other solid forms include granules and large amounts of powder.

Tablets may contain suitable binders, lubricants, disintegrants, colorants, flavoring agents, flow inducing agents, and thawing agents. For example, for oral administration in a unit dosage form of a lozenge or capsule, the active pharmaceutical ingredient may be combined with an oral, non-toxic, pharmaceutically acceptable inert carrier such as lactose, gelatin, agar, starch, sucrose, glucose, Cellulose, dicalcium phosphate, calcium sulfate, mannitol, sorbitol, microcrystalline cellulose, and the like. Suitable binders include starch, gelatin, natural sugars (such as glucose or beta-lactose), corn starch, natural and synthetic gums (such as acacia, tragacanth or sodium alginate), povidone, carboxymethyl fibers. , polyethylene glycol, wax, etc. Lubricants used in such dosage forms include sodium oleate, sodium stearate, sodium benzoate, sodium acetate, sodium chloride, stearic acid, sodium stearyl fumarate, talc, and the like. Decomposers (disintegrants) include, but are not limited to, starch, methyl cellulose, agar, bentonite, xanthan gum, crosslinked methylcellulose sodium, sodium starch glycolate, and the like.

Specific examples of techniques, pharmaceutically acceptable carriers, and excipients that can be used to formulate oral dosage forms of the invention are described, for example, in U.S. Patent No. No. 7,589,208, PCT International Application Publication No. WO 2005/074899, WO 2007/047863, and No. 2007/146248.

General techniques and compositions useful in the preparation of the present invention are described in the following references: Modern Pharmaceutics, Chapters 9 and 10 (Banker & Rhodes, Editors, 1979); Pharmaceutical Dosage Forms: Tablets (Lieberman et al., 1981). Ansel, Introduction to Pharmaceutical Dosage Forms 2nd Edition (1976); Remington's Pharmaceutical Sciences, 17th ed. (Mack Publishing Company, Easton, Pa., 1985); Advances in Pharmaceutical Sciences (David Ganderton, Trevor Jones, Eds., 1992) Advances in Pharmaceutical Sciences Vol 7. (David Ganderton, Trevor Jones, James McGinity, Eds., 1995); Aqueous Polymeric Coatings for Pharmaceutical Dosage Forms (Drugs and the Pharmaceutical Sciences, Series 36 (James McGinity, Ed., 1989); Pharmaceutical Particulate Carriers: Therapeutic Applications: Drugs and the Pharmaceutical Sciences, Vol 61 (Alain Rolland, Ed., 1993); Drug Delivery to the Gastrointestinal Tract (Ellis Horwood Books in the Biological Sciences. Series in Pharmaceutical Technology; JGHardy, SSDavis , Clive G.Wilson , Eds); Modern Pharmaceutics Drugs and the Pharmaceutical Sciences, Vol. 40 (Gilbert S. Banker, Christopher T. Rhodes, Eds). The entire contents of these references are hereby incorporated by reference.

A method of treating an individual having relapsing multiple sclerosis using laquinimod and glatiramer acetate is disclosed, which provides a more effective treatment than each of the individual agents. Laquinimod has been suggested for use in relapsing forms of multiple sclerosis, for example, in U.S. Patent No. 6,077,851. However, the inventors have unexpectedly discovered that the combination of laquinimod and glatiramer acetate (GA) is particularly effective in treating relapsing multiple sclerosis as compared to each agent alone.

the term

As used herein, unless otherwise indicated, each of the following terms shall have the definitions listed below.

As used herein, "laquinimod" means laquinimod acid or a pharmaceutically acceptable salt thereof.

As used herein, the "amount" or "dose" of laquinimod measured in milligrams refers to the number of milligrams of laquinimod acid present in the formulation, regardless of the form of the formulation. "Dose of 0.6 mg laquinimod" means that the amount of laquinimod acid in the preparation is 0.6 mg, regardless of the form of the preparation. Thus, when in the form of a salt, for example, laquinimod sodium salt, the salt form necessary to provide a dose of 0.6 mg laquinimod will exceed 0.6 mg (eg, 0.64 mg) due to the presence of additional salt ions. .

"About", as used herein, is intended to mean ± 10% of the recited or claimed value or range.

As used herein, a composition of a "free" chemical entity means that although the chemical entity is not part of the formulation and is not added at any point in the manufacturing process, the composition inevitably contains (if any) A certain amount of chemical entity. For example, a composition that does not contain an alkalizing agent means, The basifying agent, if present, is a minor component of the composition by weight. Preferably, when the composition is "free" of the component, the composition comprises less than 0.1 wt%, 0.05 wt%, 0.02 wt% or 0.01 wt% of the component.

As used herein, "alkaline agent" is used interchangeably with the terms "alkaline reaction component" or "alkaline agent" and refers to any drug that neutralizes the protons in the pharmaceutical composition used and raises its pH. Accepted excipients.

As used herein, "redox" refers to a group of chemicals that contain "antioxidants," "reducing agents," and "chelating agents."

As used herein, "antioxidant" refers to a compound selected from the group consisting of tocopherol, methionine, glutathione, tocotrienol, dimethylglycine, betaine, butyl. Hydroxyanisole, dibutylhydroxytoluene, curmerin, vitamin E, ascorbyl palmitate, tocopherol, deteroxime mesylate, methylparaben, pair Ethyl hydroxybenzoate, butylated hydroxyanisole, dibutylhydroxytoluene, propyl gallate, sodium metabisulfite or potassium metabisulfite, sodium sulfite or potassium sulfite, alpha tocopherol or its derivatives , sodium ascorbate, disodium edentate, BHA (butylated hydroxyanisole), pharmaceutically acceptable salts or esters of the compounds mentioned, and mixtures thereof.

The term "antioxidant" as used herein also refers to flavonoids (such as those selected from the group consisting of quercetin, mulberry pigment, naringenin, and hesperidin), Taxifolin, Afupin, and fur. Glycosides, myricetin, genistein, apigenin and garbanin A, flavonoids, flavonoids, isoflavones (such as soy isoflavones), genistein, catechins (such as tea tea) Gallic gallate, epigallocatechin, flavonol, epicatechin, hesperidin, chrysin, diosmin, hesperidin, luteolin and Rutin.

As used herein, "reducing agent" means a compound selected from the group consisting of sulfur compounds, thioglycerol, mercaptoethanol, thioglycol, thiodiglycol, cysteine, sulphur, disulfide Sugar alcohol (DTT), dithio-bis-maleimidoethane (DTME), 2,6-di-t-butyl-4-methylphenol (BHT), Sodium dithionite, sodium hydrogen sulfite, sodium metabisulfite sodium metabisulfite and ammonium hydrogen sulfite.

As used herein, "chelating agent" means a compound selected from the group consisting of penicillamine, trientine, N,N'-diethyldithiocarbamate (DDC), 2 , 3,2'-tetraamine (2,3,2'-tetra), neocopupine, N,N,N',N'-肆(2-pyridylmethyl)ethylenediamine (TPEN , 1,10-morpholine (PHE), tetraethyleneamine, triethylenetetramine and ginseng (2-carboxyethyl)phosphine (TCEP), ferric amine, CP94, EDTA, deferoxamine B (DFO) Mesylate (also known as deferoxamine b sulfate (DFOM)), Novartis (formerly known as Ciba-Giegy), and apoferritin.

As used herein, a pharmaceutical composition is "stable" when the composition retains the physical stability/integrity and/or chemical stability/integrity of the active pharmaceutical ingredient during storage. In addition, the "stabilized pharmaceutical composition" is characterized in that its degradation product level does not exceed 5% after 6 months at 40 ° C / 75% RH, or at 55 ° C / 75% RH, compared to the level of time 0. Not more than 3% after two weeks.

As used herein, "combination" means the administration of a combination of reagents for therapy by simultaneous or concurrent administration. At the same time, the administration refers to the combination of laquinimod and GA. (whether it is a true mixture, suspension, emulsion or other physical combination). In this case, the combination may be a mixture of laquinimod and GA or a separate container which is combined prior to administration. Simultaneous administration means that laquinimod is administered separately at the same time as GA, or separately when the time is close enough to observe synergistic activity relative to the individual activities of laquinimod or GA.

As used herein, "assisted" or "adjuvant therapy" refers to a combination of assays for therapeutic use in which an individual receiving therapy begins with a first treatment regimen of one or more reagents, followed by one or more A second treatment regimen for different trials other than a treatment regimen, so that not all of the trials for therapy begin at the same time. For example, laquinimod therapy is added to patients who have received GA therapy.

As used herein, when referring to the amount of laquinimod and/or glatiramer acetate (GA), "effective" means when used in accordance with the present invention, sufficient to produce the desired therapeutic response without undue adverse side effects ( Equal to this is the amount of laquinimod and/or glatiramer acetate (GA) with an appropriate benefit/risk ratio, such as toxicity, irritation or allergic reaction.

"Subject to an individual" or "administer to a (human) patient" means that the individual/patient provides, dispenses, or administers a drug, drug, or treatment to alleviate, cure, or reduce the association with the condition (eg, pathological condition). Symptoms.

"Treatment," as used herein, includes, for example, inducing inhibition, regression, or arrest of a disease or condition (eg, RMS), or reducing, suppressing, inhibiting, ameliorating the severity of a disease or condition, eliminating or substantially eliminating or ameliorating Symptoms of a disease or condition. When "treatment" is applied to patients with CIS It may mean delaying the clinical onset of multiple sclerosis (CDMS), delaying the progression to CDMS, and reducing conversion in patients undergoing first clinical episode of multiple sclerosis and high-risk patients developing CDMS. The risk of CDMS, or reduce the frequency of recurrence.

"Inhibiting" an individual's disease progression or disease complication means preventing or reducing the disease progression and/or disease complications of the individual.

"Symptoms" associated with RMS include any clinical or laboratory performance associated with RMS and are not limited to those that an individual can feel or observe.

As used herein, "an individual with relapsing multiple sclerosis" means having been clinically diagnosed with relapsing multiple sclerosis (RMS) (including relapsing-remitting multiple sclerosis (RRMS) and secondary progressive multiple Individuals with Sclerosclerosis (SPMS).

As used herein, a "responder" of a GA treatment refers to an individual who is responding, ie, the condition of the patient is improved during GA therapy. As used herein, a "non-responder" of GA therapy is defined as an individual who is underreactive to GA therapy. The "reactors" and "non-responders" of the GA treatment can be measured by methods known in the art, including PCT International Application No. WO 2006/116602, WO 2012/051106, and US Application Publication No. 2011-0230413 The methods disclosed in the numbers, which are incorporated herein by reference.

As used herein, a system at the "baseline" is administered to an individual prior to laquinimod.

As used herein, "a patient at risk of developing MS" (ie, clinically confirmed MS) is a patient with any known risk factors for MS. Known risk factors for MS include any of the following: clinical single syndrome (CIS), single suggestive MS without lesion onset, lesion (in either CNS, PNS, or myelin) without clinical onset, environment Factors (geographic location, climate, diet, toxins, sunlight), genetics (variation of genes encoding HLA-DRB1, IL7R-α, and IL2R-α) and immune components (such as caused by Epstein-Barr virus) Viral infection, high avidity CD4 ⁺ T cells, CD8 ⁺ T cells, anti-NF-L, anti-CSF 114 (Glc).

As used herein, "Clinical Single Syndrome (CIS)" refers to 1) a single clinical episode (used interchangeably with "first clinical event" and "first myelin loss event"), suggesting that MS, for example, exhibits the following episodes: optic nerve Inflammation, blurred vision, astigmatism, unconscious rapid eye movement, blindness, loss of balance, tremors, disorders, dizziness, clumsiness, lack of coordination, one or more limb weakness, muscle tone changes, muscle stiffness, cramps, tingling Feeling abnormal, burning sensation, muscle pain, facial pain, trigeminal neuralgia, sharp tingling, burning sting, sluggish speech, vague speech, changing rhythm, difficulty swallowing, fatigue, bladder problems (including urgency, frequent urination, urine) Incomplete urinary incontinence), intestinal problems (including constipation and fecal incontinence), impotence, loss of libido, loss of consciousness, sensitivity to heat, loss of short-term memory, loss of concentration, or loss of judgment or reasoning, and 2) at least A type of lesion that suggests MS. In one particular example, the CIS diagnosis will be based on a single clinical episode and at least two lesions that imply a MS measuring 6 mm or greater in diameter.

The "relapse rate" is the total number of confirmed recurrences per unit time. The "annual recurrence rate" is the total number of confirmed recurrences per patient multiplied by 365 and divided by the average number of days the patient took the study drug.

The Extended Disability Status Scale or EDSS is a rating system that is often used for the classification and standardization of conditions in patients with multiple sclerosis. The score ranged from 0.0 (normal neurological findings) to 10.0 (represents death from MS). The scoring is based on a neurological test and a functional system (FS), which is the area of the central nervous system that controls human function. Functional systems are: cone (walking ability), cerebellum (coordination), brainstem (speech and swallowing), sensation (tactile and pain), intestinal and bladder function systems, visual, psychological and other (including any other MS) And get the results of the nervous system survey) (Kurtzke JF, 1983).

The "confirmation progress" of EDSS or "confirmed disease progression" as measured by the EDSS score was defined as an increase of 1 point from baseline EDSS for at least 3 months. In addition, no confirmation of progress can be made during the recurrence.

"Adverse events" or "AE" means any adverse medical event occurring in a clinical trial individual who is administered a pharmaceutical product and has no causal relationship with the treatment. Thus, an adverse event can be any unfavorable and unexpected condition, including an abnormal discovery of the test, symptoms, or a condition associated with the use of the medical product being investigated, regardless of whether it is considered to be related to the medical product being investigated.

"Gd-enhanced lesions" refers to lesions caused by the collapse of the blood-brain barrier, which is manifested in a comparative study using sputum developers.釓 Enhancement provides information about the time of the lesion, as Gd-enhanced lesions usually appear within six weeks of the formation of the lesion.

"Magnetization transfer imaging" or "MTI" is based on the mutual magnetization (via dipole and/or chemical exchange) between the proton and the macromolecular protons. The saturation of these protons by applying an off-resonance RF pulse to the macromolecular protons Then transferred to the main body water. The result is a weakening of the signal (reduced net magnetization of protons), depending on the MT magnitude between the tissue macromolecule and the bulk water.

"MT" or "magnetization transfer" refers to the transfer of longitudinal magnetization from the hydrogen nuclei of water with restricted motion to the hydrogen nuclei of water that is largely free to move. With MTI, the presence or absence of macromolecules (eg, in membrane or brain tissue) can be observed (Mehta, 1996; Grossman, 1994).

"NMR spectroscopy" or "MRS" is a specialized technique related to magnetic resonance imaging (MRI). MRS is used to measure the concentration of different metabolites in body tissues. The MR signal produces a series of resonances that reflect the arrangement of the different molecules that are "excited" by the isotope. This signal is used to diagnose certain metabolic disorders, especially those that affect the brain (Rosen, 2007), and to provide information about tumor metabolism (Golder, 2007).

As used herein, "mobility" refers to any ability to travel, travel rate, pace, leg muscle strength, leg function, and movement with or without ancillary equipment. The motivation can be assessed by one or more of several tests including, but not limited to, walking index, 25-time walking test, six-minute walk (6 MW), lower limb manual muscle test (LEMMT), and EDSS. The motivation can also be reported by the individual, for example, by questionnaire, including but not limited to the 12 Multiple Sclerosis Walking Scale (MSWS-12). Impaired mobility refers to any damage, difficulty or disability associated with mobility.

"T1-weighted MRI image" refers to an MR-image that highlights T1 contrast, and lesions can be visualized by T1 contrast. The anomalous area is a "low signal" in the T1-weighted MRI image and appears as a dark point. These codes are usually early lesions.

"T2-weighted MRI image" refers to an MR-image that highlights T2 contrast, and lesions can be visualized by T2 contrast. T2 lesions represent recent inflammatory activity.

The “Six Minutes Walk (6 MW) Test” is a widely used test designed to assess the exercise capacity of patients with COPD (Guyatt, 1985). It is also used to measure the mobility of patients with multiple sclerosis (Clinical Trials Website).

The "25 呎 Timed Walking Test" or "T25-FW" is based on the 25 呎 Timed Walking Quantitative Action Force and Leg Performance Test. Take the patient to the end of the 25-inch runway with a clear marking and instruct to walk 25 尽快 as soon as possible under safe conditions. Calculate the time from the start of the indication until the patient reaches the 25 mark. Perform this task again immediately, and let the patient walk back the same distance. The patient can use an auxiliary device while performing this task. The T25-FW score is the average of two complete trials. This rating can be used alone or as part of the MSFC Total Website (National MS Society Website).

One of the main symptoms of multiple sclerosis is fatigue. Fatigue can be measured by several tests including, but not limited to, a reduction in the French Effective Edition score of the EMIF-SEP and the European Quality of Life (EuroQoL) Questionnaire (EQ5D). Other tests, including but not limited to the Clinician's Overall Impression Change Scale (CGIC) and Individual Overall Impression (SGI) and EQ-5D, can be used to assess the overall health and quality of life of MS patients.

The "Walking Index" or "AI" is a rating scale developed by Hauser et al. to assess mobility by assessing the time and level of assistance required for a 25-foot walk test. The score ranged from 0 (asymptomatic and energetic) to 10 (bedridden). The patient was asked to be on the marked 25-inch runway as soon as possible and as safe as possible Walk all over the place. The examiner records the time and type of assistance (eg, walking stick, walking frame, crutches) (Hauser, 1983).

"EQ-5D" is a standardized survey tool for measuring health outcomes for a range of health conditions and treatments. It provides a brief description of the state of health and a single indicator value that can be used for clinical assessment and economic assessment of health care and population health surveys. The EQ-5D was developed by the "EuroQoL" team, which includes an international, multilingual, multidisciplinary network of researchers initially from seven research centers in England, Finland, the Netherlands, Norway and Sweden. The EQ-5D Questionnaire is not subject to copyright restrictions and is available from EuroQoL.

"SF-36" is a multi-purpose short form health survey that includes 36 questions and provides an overview of 8 categories: functional health and well-being scores, as well as physical and mental health summary measurements based on psychometrics and a preference-based health utility index. It is a general measurement, unlike measurements for a specific age, disease, or treatment group. The questionnaire was developed by QualityMetric, Inc. of Providence, RI and is available therefrom.

"Pharmaceutically acceptable carrier" means a carrier or excipient suitable for human and/or animal use without excessive adverse side effects (such as toxicity, irritation and allergic reactions), and equivalent Benefit/risk ratio. It can be a pharmaceutically acceptable solvent, suspending agent or vehicle for administering the compound to an individual.

It will be appreciated that wherever a range of parameters occurs, the invention also provides all integers and their deciles within the range. For example, "0.1-2.5 mg/day" includes 0.1 mg/day, 0.2 mg/day, 0.3 mg/day, etc., up to 2.5 mg/day.

The invention will be more fully understood by reference to the details of the <RTIgt; </ RTI> <RTIgt; </ RTI> <RTIgt; </ RTI> <RTIgt; </ RTI> <RTIgt; </ RTI> <RTIgt; Description.

Experimental details Example 1: Evaluation of the additional effect of laquinimod in mice treated with glatiramer acetate (GA) or interferon-β (IFN-β)

Mice were treated with suboptimal doses of laquinimod (10 mg/kg) alone or with glatiramer acetate (12.5 mg/kg) or IFN-β (500,000 IU/mouse). In both cases, the combination treatment resulted in an increase in efficacy compared to the respective treatments.

Example 2: Evaluating the efficacy of laquinimod in combination with glatiramer acetate (GA) in a rodent EAE model

Experimental autoimmune encephalomyelitis (EAE) is an animal model of human CNS myelin deprivation disease (including MS) (mostly rodent).

Example 2.1 MOG Study

This study was designed to test the efficacy of laquinimod in eliminating MOG-induced EAE. Laquinimod (5 vs. 25 mg/kg/day) was tested separately and tested for its combination with GA blockade.

Materials and Methods: EAE induction:

EAE was induced by subcutaneous injection of an encephalitis lotion in the right flank in a volume of 0.2 ml/mouse. On the day of induction, pertussis toxin was injected intraperitoneally in a volume of 0.2 ml/mouse. The pertussis toxin was injected again 48 hours later.

Test steps:

Day 0: MOG was injected subcutaneously into the right flank, and pertussis toxin was injected intraperitoneally. Start daily laquinimod treatment.

Day 2: Intraperitoneal injection of pertussis toxin.

Day 10: The EAE clinical signs of the mice were scored.

Day 30: The study is over.

Myelin oligodendrocyte glycoprotein (MOG) disease induction: On day 0, all mice were injected with encephalitis emulsion (containing 150 μg myelin oligodendrocyte glycoprotein (MOG) and 500 μg rich in tuberculosis) CFA of M. tuberculosis . The emulsion for the GA-blocking group includes GA (250 μg/mouse). In two syringes connected to each other via a Leur lock, etc. The emulsion was prepared from the oil and liquid fraction (1:1), transferred to an insulin syringe, and 0.2 ml was injected into the right flank of each mouse. On the day of induction and 48 hours later, the mice were injected with pertussis toxin ( Intraperitoneal injection, 100 ng).

MSCH-induced EAE of CSJL/F1 mice: induced by injection of an encephalitis mixture (emulsion) consisting of MSCH containing PBS and commercial CFA containing 1 mg/mL Mycobacterium tuberculosis (1:1 ratio) EAE. A total volume of 50 μl of the emulsion was injected into the left toe of each mouse. Pertussis toxin (volume dose 0.5 ml/mouse) was injected intravenously on the day of induction and 48 hours later.

Laquinimod treatment in mice: A high dose (25 mg/10 ml/kg) solution (150 mg in 60 ml DDW) was prepared weekly and stored in amber vials at room temperature. 12 ml of this solution was added to 48 ml of DDW to give a dose of 5 mg/kg. The compound was administered once daily by gastric tube feeding in a volume of 0.2 ml/mouse throughout the experiment (30 days). Mice were observed daily from day 10 after EAE induction and clinical signs of EAE were recorded.

Test drug:

MOG (TV-4915), "Novetide"

Mycobacterium tuberculosis H37 RA (MT)

Pertussis toxin, "Sigma"

Freund's Complete Adjuvant (CFA), "Sigma"

Study Design: 92 female C57B1/6 mice, 8-10 weeks old, were randomized into 6 groups according to Table 1 below.

On the day of induction, GA-blocking was performed once by adding GA to the encephalitis emulsion. Laquinimod was administered daily throughout the experiment.

Preparation of encephalitis lotion, pertussis toxin and laquinimod:

Oil fraction: Concentrate CFA (containing 1 mg/ml MT) to a concentration of 5 mg/ml: Add 52 mg/MT to 13 ml CFA.

Liquid fraction: Groups 1-3: 10.5 mg MOG was diluted in 7 ml PBS (1.5 mg/ml, 150 mg/0.1 ml/mouse). Groups 4-6: 20 mg of GA was diluted in 8 ml PBS (2.5 mg/ml, 250 mg/0.1 ml/mouse). Will be 12 Mg MOG is added to the solution. The emulsion was prepared from an aliquot of the oil and liquid fraction (1:1) in two syringes connected to each other via a Luer lock, transferred to an insulin syringe, and 0.2 ml was injected into the right flank of each mouse. 50 ml of pertussis toxin (200 mg/ml) was added to 19.95 ml of saline to obtain 500 ng/ml (100 ng/0.2 ml/mouse). A high dose LAQ (25 mg/10 ml/kg) solution (150 mg in 60 ml DDW) was prepared weekly and stored at room temperature. 12 ml of this solution was added to 48 ml DDW to give a LAQ dose of 5 mg/kg. The compound was administered once daily by gastric tube feeding in a volume of 0.2 ml/mouse throughout the experiment (30 days).

EAE clinical signs : Mice were observed daily from day 10 after EAE induction (first injection of MOG) and scored for EAE clinical signs according to the levels described in the table below.

Results: The severity of the disease in the experiment was more extreme than expected. The mortality rate was 56%, while the group average score (GMS) was 3.27.

However, laquinimod significantly reduced all disease parameters in a dose-dependent manner (Table 3, Figure 1A). The use of GA blockade also effectively inhibited 48% of GMS (p=001). Additional oral administration of two doses of laquinimod to the same group of mice (blocked by GA) produced a synergistic effect, confirming that all of the measured parameters were significantly and significantly reduced.

The difference in weight gain is related to the severity of the disease - the higher the severity, the more weight loss. The difference is statistically significant (according to MANOVA). A pairwise comparison showed that the weight gain of all groups was fairly consistent during the first ten days after induction. However, when the first symptoms appeared, the mice began to lose weight. On days 16 and 24, the body weight of control mice was statistically different from almost all other mice (Table 4, Figure 1 B).

CONCLUSIONS: Administration of laquinimod alone significantly reduced all disease parameters in a dose-dependent manner. The combination of oral laquinimod and GA-blocking produces an additive effect in which the score for disease inhibition is higher than when each compound is used alone.

Although the disease is quite severe, both doses of laquinimod delay the onset of the first symptom and improve the pathological symptoms. In combination with GA-blocking, laquinimod was extremely effective, confirming a GMS with a high inhibition of 80%.

Example 2.2 MOG Study

This study was designed to test a single low dose of laquinimod and tested for its combination with GA-blocking. MOG is a member of the immunoglobulin superfamily that is specifically expressed in CNS myelin. It is one of the most potent encephalitis proteins and is widely used to induce EAE in different rodent lines. In C57BL/6 mice, chronic progressive EAE was induced by immunization with the MOG peptide pMOG35-55 of CFA. In this study, the dose of laquinimod was tested in GA-blocked mice.

Materials and Methods: The EAE induction and testing procedures were the same as in Example 2.1. The reagent was the same as in Example 2.1.

Study design: 105 8-10 week old female C57B1/6 mice were divided into 7 groups according to Table 5 below.

Preparation of encephalitis lotion, pertussis toxin and laquinimod:

Oil fraction: Concentrate CFA (containing 1 mg/ml MT) to a concentration of 4 mg/ml; add 45 mg MT to 15 ml CFA.

Liquid fraction: 24 mg of MOG was diluted in 8 ml PBS (3 mg/ml, stock). Groups 1, 3 and 5: 3.5 ml stock solution was diluted 1:1 with PBS. 2, 4, 6 and 7: 22.5 mg of GA was diluted in 4.5 ml PBS (5 mg/ml). Add 4.5 ml of MOG stock solution to the solution.

The emulsion was prepared from an aliquot of the oil and liquid fraction (1:1) in two syringes connected to each other via a Luer lock, transferred to an insulin syringe, and 0.2 ml was injected into the right flank of each mouse.

41 μl of pertussis toxin (200 μg/ml) was added to 21.96 ml of saline to give 375 ng/ml (75 ng/0.2 ml/mouse).

Prepare a high-dose LAQ (5 mg/10 ml/kg) solution once a week (40 mg in 80 ml DDW) and store at room temperature. 25 ml of this solution was added to 25 ml DDW to give a dose of 2.5 mg/kg LAQ. Add 5 ml of stock solution (high dose) to 20 ml DDW to get a dose of 1 mg/kg. The compound was administered once daily by gastric tube feeding in a volume of 0.2 ml/mouse throughout the experiment (30 days).

EAE clinical signs: Mice were observed daily from day 9 after EAE induction (first injection of MOG) and scored for EAE clinical signs according to the levels described in Table 2 above.

result:

In this study, although the concentration of M. tuberculosis in CFA was reduced from 5 to 4 mg/ml, the GMS of the control group was still as high as 3.24. However, all treatments significantly reduced this value (Table 6).

GA-blocking is extremely effective in suppressing all measured parameters. Laquine Maud showed a dose-dependent effect (GMS improved to 68%).

The combination of the two compounds did not show any synergistic effect, as shown in previous studies. In the present study, oral addition of laquinimod to GA-blocked mice appeared to improve neurological signs in the early stages of the disease (Figure 2).

Obviously, the onset of the disease is delayed by one to six days. However, from day 18-19, mice blocked by GA began to recover, whereas mice treated in combination continued to develop symptoms of progressive disease. Upon final calculation, the combined treatment of GA-blocking and oral laquinimod appeared to produce a negative interaction (in a down-dose-response manner).

Administration of laquinimod alone showed a dose-dependent effect (group mean score (GMS) improvement to 68%). The combination of the two compounds did not show any synergistic effect, probably because GA-blocking produced 77.5% inhibition, making it difficult to see any additive effects in the combinatorial studies. In the present study, oral administration of laquinimod to GA-blocked mice appeared to improve neurological signs in the early stages of the disease. Obviously, the onset of the disease is delayed by one to six days.

in conclusion:

In previous studies, it has been found that daily administration of laquinimod to GA-blocked EAE mice significantly improved disease performance compared to GA-blocking alone. In these studies, a relatively high dose (5 and 25 mg/kg) of laquinimod was tested.

This study tested lower doses for the first time.

Taken together, the overall impression is that high doses of laquinimod (25 mg/kg) have a significant additive effect with the GA-blocking combination (but become due to toxicological findings). Unfavorable), the medium dose (5 mg/kg) was once effective (45% improvement compared to GA-blocking), and this time has similar results. Only small doses (2.5 vs. 1 mg/kg) were tested in this study and showed a negative interaction with GA-blocking.

Experiment 2.3 MOG Study - Repeated Study

In Examples 2.1 and 2.2, higher doses of laquinimod had a significant synergistic effect, while lower doses apparently did not provide an additive effect over GA-blocking.

Example 2.2 is repeated here. Table 6 and Figure 3 show the results. Disease induction and treatment were performed according to Example 2.1.

Materials and Methods : The EAE induction and testing procedures were the same as in Example 2.1. The reagent was the same as in Example 2.1.

Study Design: 120 female C57B1/6 mice, 8-10 weeks old, were used in this study. Mice were randomly divided into 8 groups according to Table 7 below.

Preparation of encephalitis lotion

Oil fraction : Concentrate CFA (containing 1 mg/ml MT) to a concentration of 2 mg/ml: Add 16 mg/MT to 16 ml CFA.

Liquid fraction: 24 mg of MOG was diluted in 8 ml PBS (3 mg/ml, stock). Groups 1, 3, 5 and 7: 4 ml stock solution was diluted 1:1 with PBS. Groups 2, 4, 6 and 8: 22.5 mg of GA was diluted in 4.5 ml PBS (5 mg/ml). This solution was mixed 1:1 with the MOG stock solution.

The emulsion was prepared from an aliquot of the oil and liquid fraction (1:1) in two syringes connected to each other via a Luer lock, transferred to an insulin syringe, and 0.2 ml was injected into the right flank of each mouse.

Preparation of pertussis toxin

31.875 μl of pertussis toxin (200 μg/ml) was added to 25.468 ml of saline to obtain 250 ng/ml (50 ng/0.2 ml/mouse).

Preparation of laquinimod

A high dose LAQ (25 mg/10 ml/kg) solution (150 mg in 60 ml DDW) was prepared weekly and stored in amber glass at room temperature. A lower LAQ dose was prepared daily. 1.6 ml of the stock solution was added to 6.4 ml of DDW to give a dose of 5 mg/kg. 1.3 ml of the previous solution (middle dose) was added to 5.2 ml of DDW to give a dose of 1 mg/kg. The compound was administered once daily by gastric tube feeding in a volume of 0.2 ml/mouse throughout the experiment (30 days).

EAE clinical signs

Mice were observed daily from day 10 after EAE induction (first injection of MOG) and scored for clinical EAE according to the grades listed in Table 2 above.

result

As in previous studies, GA-blocking effectively inhibited all measured parameters of the disease (Table 8).

In general, laquinimod alone showed a dose-dependent effect, which was ineffective at a dose of 1 mg/kg, a 70% reduction in GMS at a dose of 5 mg/kg, and a 95% reduction at a dose of 25 mg/kg. % GMS.

In combination with GA-blocking, laquinimod showed no additive effect at low doses, while two higher doses exceeded GA, reducing GMS in the control group by ~90% (5 mg/kg) or The disease was completely inhibited (no mice were sick, 25 mg/kg).

First use the Kruskal-Wallis test The parametric variables were statistically analyzed, followed by a Mann-Whitney comparison.

Laquinimod alone showed a dose-dependent effect, which was ineffective at a dose of 1 mg/kg, a 70% reduction in GMS at a dose of 5 mg/kg, and a 95% GMS at a dose of 25 mg/kg.

Although GA-blocking alone had a greater effect (78.9%), the combination with laquinimod showed an additive effect at doses of 5 mg/kg (89.5%) and 25 mg/kg, which High doses completely inhibit the disease.

Since GA-blocking was significantly effective in this study, it was difficult to obtain a more significant improvement by combining treatment with oral laquinimod. In order to achieve a better combination effect, the dosage of GA is reduced to suboptimal.

Summary of studies on GA-blocking + laquinimod in MOG-induced EAE (Examples 2.1-2.3)

At higher doses (5 and 25 mg/kg), laquinimod provided an additive effect over GA-blocking as outlined in Table 9, and is shown in Figures 4A and 4B.

Example 2.4 MOG-induced EAE by GA block and daily subcutaneous injection (s.c) GA

The purpose of this study was to test the additive effect of laquinimod and GA in the EAE model of C57B1 mice. The C57B1 line of selected mice is based on the established EAE model.

Laquinimod was orally administered daily at a dose level of 5.0 mg/kg or 25.0 mg/kg for 30 days. The GA was administered subcutaneously at a dose of 250 mg/kg for 10 days, or at a dose level of 12.5 mg/kg.

To study the additive effect of laquinimod and GA, laquinimod was administered subcutaneously to the subcutaneous administration of GA at a dose of 250 mg/kg, or to the encephalitis substance at a dose level of 12.5 mg/kg. GA mouse group.

The inhibitory activity of the combination treated group and the group administered with laquinimod or GA alone was compared.

GA administered as an encephalitis substance (blocking) at a dose of 12.5 mg/kg was used as a positive control group.

Overall design

Disease was induced in mice by injection of encephalitis emulsion (MOG/CFA). Laquinimod was orally administered for 30 consecutive days from the start of the study. The GA was administered subcutaneously for 10 consecutive days from the start of the study.

material

Laquinimod sodium; glatiramer acetate; pure water; pertussis toxin: Sigma; MOG 35-55: Mnf Novatide; Freund's complete adjuvant (CFA): Sigma; saline: Mnf-DEMO SA; and Mycobacterium tuberculosis H37 RA (MT): Mnf-Difco.

Experimental animal Species, strains and suppliers

Healthy, unproductive, non-pregnant female C57B1 strains weighing approximately 15-22 g were delivered approximately 7-8 weeks old. Animal weights were recorded on the day of delivery.

Obviously healthy animals were arbitrarily assigned to the study group prior to initiation of treatment.

Test procedure

EAE induction EAE was induced by injection of an encephalitis mixture (emulsion) consisting of MOG (150.0 μg/mouse). A volume of 0.2 ml of the emulsion was subcutaneously injected into the flank of the mouse. Pertussis toxin was injected intraperitoneally on the day of induction and 48 hours later (total amount 0.300 μg/mouse, dose volume 0.2 ml).

Group Assignment The mice were divided into the following treatment groups as shown in Table 10:

Preparation and administration of encephalitis emulsion

Oil fraction : Concentrate CFA (containing 1 mg/ml MT) to a concentration of 2 mg/ml: Add 30.0 mg/MT to 30.0 ml CFA.

Liquid fraction: Groups 1, 4-8: 46.3 mg MOG was diluted in 15.4 ml normal saline (3.0 mg/ml MOG stock). A 11.0 mL 3.0 mg/ml stock solution was diluted in 11.0 mL of physiological saline to obtain 1.5 mg MOG/mL. Groups 2 and 3: A 5 mg/mL GA stock solution was prepared in physiological saline. 4.0 mL of this solution was mixed with 4.0 mL of 3 mg/ml MOG stock to give 1.5 mg MOG/mL and 2.5 mg GA/mL.

An emulsion is prepared from two equal parts of the oil and liquid fraction (1:1) in two syringes connected to each other via a Luer lock (for groups 2 and 3 and groups 1 and 4 to 8), transferred to insulin Syringe and 0.2 ml was injected into the right flank of each mouse. The dose of MOG in all groups (1 to 8) was 150 μg/mouse. The dose of GA in Groups 2 and 3 was 250 μg/mouse.

Preparation and administration of pertussis toxin

75 μL of pertussis toxin (200 μg/ml) was added to 40 ml of saline to obtain about 375 ng/ml. Pertussis toxin (75.0 ng/0.2 ml/mouse) was administered intraperitoneally on the day of injection of the encephalitis substance and 48 hours later.

Preparation and administration of the test formulation laquinimod:

The test concentration of laquinimod was prepared in pure water. A 2.5 mg/mL stock solution was prepared to obtain a high dose (25.0 mg/kg) (Groups #3, 6 and 8). The stock solution was diluted 1:5 to obtain 0.5 mg/mL, thereby obtaining a dose level of 5.0 mg/kg for the 5th and 7th groups. Laquinimod was administered to each group by gastric tube feeding in a volume of 0.2 ml/mouse.

Glatiramer acetate:

A 50.0 mg/ml GA stock solution was prepared in saline. 8.0 mL of 50.0 mg/mL of GA was equally divided into 10 tubes and stored at -20 °C. Thaw a tube every day and return to RT. Mice from the beginning of the study to groups 4, 7 and 8 Daily subcutaneous administration of 0.1 mL of GA was administered for 10 days.

Experimental observation

Morbidity and Mortality All animals are examined daily to find out if there are dead or dying animals.

Clinical Symptoms EAE clinical signs were scored on day 10 after EAE induction and continued daily until day 30. Clinical signs were recorded according to the scoring system shown in Table 11 below.

Mice with scores 1 and above were considered to be ill. When the first clinical signs appear, all the mice are immersed in water and the food is scattered throughout the cage. For humane considerations, animals with a score of 4 were sacrificed for three days and 5 points were given the next day. For computational purposes, the sacrificed or dead animal scores continue to be scored 5 points thereafter.

Result description Calculate the incidence rate (incidence ratio)

̇ Calculate the sum of the number of diseased mice in each group.

计算 Calculate the incidence as follows

计算 Calculate the percentage of inhibition according to the incidence rate as follows

Calculate death/death rate (death ratio)

̇ Calculate the sum of the number of dead or dying animals in each group.

计算 Calculate disease mortality as follows

计算 Calculate the percentage of inhibition based on mortality as follows

Computational course

The average disease duration is expressed in days, as calculated below.

Calculate the mean delay in onset

The mean incidence of sputum is expressed in days, as calculated below

The mean delay in onset of sputum is expressed in days, calculated by subtracting the mean of the onset of the control group from the mean incidence of the test group.

Calculate the average highest score and percent inhibition

The average highest score (MMS) of each group is calculated as follows

计算 Calculate the percentage of inhibition according to MMS as follows

Calculated group average score and percent inhibition

̇ Calculate the sum of daily scores for each mouse in the test group and calculate individual daily average scores (IMS) as follows

计算 Calculate the group average score (GMS) as follows

计算 Calculate the percentage of inhibition as follows

result

Summary Table 12 shows an overview of morbidity, mortality, MMS, GMS, duration of disease, onset, and activity of each group based on incidence, MMS, and GMS.

Clinical signs and mortality No clinical symptoms were observed during the first 10 days of the study (before starting with the EAE score). There was no morbidity and mortality before the onset of EAE disease.

Incidence, onset, and duration of disease The incidence of the negative control group treated with vehicle was 17/20, compared with 8/20 for the GA block. There was no mortality in the other treatment groups.

Average highest score (MMS) and group average score (GMS)

For MMS, the vehicle-treated negative control group was 3.4, while the GA block positive control group was 0.5.

The group treated with laquinimod (5 mg/kg) with a dose of 250 mg/kg of GA (subcutaneous injection) showed an additive effect (85.2% according to GMS), but it was not significant because only Quinol showed high activity (71.4% according to GMS). Subcutaneous administration of GA exhibited 38.1% activity.

According to GMS, the inhibition of EAE in the GA-blocked positive control group and the laquinimod (25 mg/kg) treatment group was 76.2% (p=0.00001) and 95.2% (p>0.00001), respectively, compared with the negative control group. . In the group receiving the combination treatment (GA blocking and laquinimod-25 mg/kg), the activity was found to be 100%.

in conclusion

This test is valid. Both the incidence rate (85%) and the average highest score (3.4) are in accordance with the acceptance criteria due to the calculation parameters of the negative control group. In the present study, the group treated with laquinimod (5 mg/kg) with a dose of 250 mg/kg of GA (subcutaneous injection) exhibited an additive effect (85.2%). However, the additive effect was not significant because only laquinimod exhibited high activity (71.4%).

Example 2.5 MOG-induced EAE by GA block and daily subcutaneous injection (s.c) GA

The purpose of this study was to test the inhibition of the combination of laquinimod and glatiramer acetate in the EAE model of C57B1 mice. To study the additive effect, laquinimod was administered alone or in combination with GA to compare the inhibitory activity of the combination treated group with the laquinimod or GA alone. GA was administered subcutaneously for 10 days at a dose of 250 mg/kg. Laquinimod was orally administered at a dose level of 2.5 mg/kg and 5.0 mg/kg. GA administered as an encephalitis substance (blocking) at a dose of 12.5 mg/kg was used as a positive control group.

EAE is an animal model of multiple sclerosis. The C57B1 line of selected mice is based on the established EAE model.

Overall design

EAE was induced in mice by injection of encephalitis emulsion (MOG/CFA). Oral administration of laquinimod for 30 consecutive days. The GA was administered subcutaneously for 10 consecutive days from the start of the study.

material

Laquinimod sodium; glatiramer acetate; pure water; pertussis toxin: Sigma; MOG 35-55: Mnf Novatide; Freund's complete adjuvant (CFA): Sigma; saline: Mnf-DEMO SA; and Mycobacterium tuberculosis H37 RA (MT): Mnf-Difco.

Experimental animal

Healthy, unproductive, non-pregnant female C57B1 strains weighing approximately 15-22 g were delivered approximately 7-8 weeks old. Animal weights were recorded on the day of delivery. Obviously healthy animals were arbitrarily assigned to the study group prior to initiation of treatment.

Test procedure

EAE induction EAE was induced by injection of an encephalitis mixture (emulsion) consisting of MOG (150.0 mg/mouse). 0.2 ml of the emulsion was subcutaneously injected into the flank of the mouse. Pertussis toxin was injected intraperitoneally on the day of induction and 48 hours later (total amount 0.150 + 0.150 = 0.300 μg / mouse, dose volume 0.2 ml).

Group assignments The mice were divided into the following treatment groups (Table 13):

Preparation and administration of encephalitis emulsion

Oil fraction : Concentrate CFA (containing 1 mg/ml MT) to a concentration of 2 mg/ml: 33.5 mg/MT was added to 33.5 ml CFA.

Liquid fraction: Groups 1, 3-8: 45.9 mg MOG was diluted in 15.3 ml normal saline (3.0 mg/ml MOG stock). 12.5 mL of the 3.0 mg/ml stock solution was diluted in 12.5 mL of physiological saline to obtain 1.5 mg MOG/mL. Group 2: A 5 mg/mL GA stock solution was prepared in physiological saline. 2.5 mL of this solution was mixed with 2.5 mL of 3 mg/ml MOG stock to give 1.5 mg MOG/mL and 2.5 mg GA/mL. An emulsion was prepared from an aliquot of the oil and liquid fraction (1:1) in two syringes connected to each other via a Luer lock, transferred into an insulin syringe, and 0.2 ml was injected into the right flank of each mouse. The dose of MOG in all groups (1 to 8) was 150 mg/mouse. The dose of GA in Group 2 was 250 mg/mouse.

Preparation and administration of pertussis toxin 60 mL of pertussis toxin (200 mg/ml) was added to 31.940 ml of saline to obtain about 375 ng/ml. Pertussis toxin (75.0 ng/0.2 ml/mouse) was administered intraperitoneally on the day of injection of the encephalitis substance and 48 hours later.

Preparation and administration of LAQ formulations:

The test concentration of laquinimod was prepared in pure water. For high doses (25.0 mg/kg), a 2.5 mg/mL stock solution (Group 8) was prepared. The 2.5 mg/mL stock was diluted 1:5 and 1:10 to give 0.5 and 0.25 mg/mL, respectively, at doses of 5.0 mg/kg for groups 5 and 7 and 2.5 mg/kg for groups 4 and 6. From the beginning of the study, laquinimod was administered to each group daily by gastric tube feeding in a volume of 0.2 ml/mouse.

Glatiramer acetate:

A 50.0 mg/ml GA stock solution was prepared in saline. 5.0 mL of 50.0 mg/mL GA was aliquoted into 10 tubes and stored at -20 °C. Thaw a tube every day and return to RT. From the start of the study, mice in groups 3, 4, and 5 were subcutaneously administered with a volume of 0.1 mL of GA for 10 days.

Experimental observation

Morbidity and Mortality All animals are examined daily to find out if there are dead or dying animals.

Clinical signs The EAE clinical signs were scored on the 10th day after EAE induction and continued daily until day 30. Clinical signs were recorded according to the scoring system shown in Table 2 above.

All mice with a score of 1 or higher were considered to be ill. When the first clinical signs appear, all the mice are immersed in water and the food is scattered throughout the cage. Based on humane considerations, mice with a score of 5 were sacrificed for three days and given 6 points the next day. For the purpose of calculation, sacrifice or death of the animal is scored (6).

Result description

Same as example 2.4.

result

Summary Table 14 shows an overview of morbidity, mortality, MMS, GMS, duration of disease, onset, and activity of each group based on incidence, MMS, and GMS.

Clinical signs and mortality No clinical symptoms were observed during the first 10 days of the study (before starting with the EAE score). There was no morbidity and mortality before the onset of EAE disease. One mouse died in the 2.5 mg/kg laquinimod treatment group. No mortality occurred in the other treatment groups.

Incidence, onset, and duration of disease The incidence of the negative control group treated with vehicle was 14/15, compared with 6/15 for the GA block. The incidence and course of the negative control group treated with vehicle were 14.9±4.9 and 16.1±4.9, respectively, compared with 26.1±7.0 and 12.1±5.3 in the positive control group.

Average highest score (MMS) and group average score (GMS)

For MMS, the vehicle-treated negative control group was 3.4+1.1, while the GA block positive control group was 1.3+1.8. According to GMS, compared with the negative control group, GA blocking positive control group (12.5 mg/kg) and laquinimod (25 mg/kg) treatment group inhibited EAE by 66.7% (p=0.0004) and 100.0% (p>0.000001), respectively. Subcutaneous administration of GA did not exhibit inhibitory activity - 4.8% (p = 0.7). The group treated with laquinimod (5 mg/kg) with a dose of 250 mg/kg of GA (subcutaneous injection) showed an additive effect - 81.0% activity according to GMS (p=0.000001), but not Significantly, only laquinimod exhibited high activity - 71.4% according to GMS (p = 0.00001). Subcutaneous administration of GA did not exhibit inhibitory activity - 4.8% (p = 0.7). Groups treated with laquinimod (2.5 mg/kg) with a dose of 250 mg/kg of GA (subcutaneous injection) did not exhibit an additive effect - 76.2% according to GMS.

in conclusion

This test is valid. Due to the calculation parameters of the negative control group, both the incidence rate (93.3%) and the average highest score (3.4) are in accordance with the acceptance criteria. In the present study, the group treated with laquinimod (2.5 mg/kg) with a dose of 250 mg/kg of GA (subcutaneous injection) did not exhibit any additive effect. In the group treated with laquinimod (5 mg/kg) and GA administered subcutaneously at a dose level of 250 mg/kg, the additive effect was not significant. The activity was 81.0%, compared to only laquinimod (5 mg/kg) which showed 71.4% activity.

Overview of Group Mean Score (GMS) Inhibition in MOG Portfolio Study (Examples 2.1-2.5)

Example 2.6: Combination study of Biozzi mice

The purpose of this study was to test the optimal effective dose of laquinimod, and to study the use and use of laquinimod with GA alone, once daily by gastric tube feeding for 59 days, to Biozzi Inhibition of relapsing palliative (RR) EAE in mice (preventive mode).

EAE is an animal model of multiple sclerosis. RR EAE can be induced in Biozzi AB/H EAE mice. In this model, unlike the Lewis rat model and many other acute EAE models in mice, the mice do not become refractory to disease induction after an acute episode. Re-injection of encephalitogenic substances can induce chronic recurrent disease, thus making it possible to measure the long-term effects of subsequent recurrences rather than immediate effects.

material

Glatiramer acetate drug substance; laquinimod drug substance; freeze-dried mouse spinal cord homogenate (MSCH) from ICR mice; Freund's incomplete adjuvant (ICFA) "Difco"; Milli-Q pure water ( pH 2 O); Mycobacterium tuberculosis, H37Ra (MT); and Difco PBS, "Sigma".

Experimental animal

Healthy, non-specific pathogens, female Biozzi mice were used in this study. At the time of induction, the mice were 6-11 weeks old and weighed 20 g ± 15%.

Test procedure

EAE induction: EAE induction according to the "RR-EAE.Biozzi" procedure. Biozzi mice were weighed and injected subcutaneously with an encephalitis agent (MSCH emulsion) and injected again one week later. In each of the two sites of the right flank of each mouse, 0.3 mL of an encephalitis agent containing 1.0 mg of MSCH and 200.0 μg of MT (0.15 mL per position) was injected subcutaneously. A week later, a second injection was made in a similar manner in the left flank.

Treatment component: Biozzi mice were randomly divided into eight treatment groups on the day of the first injection of encephalitogenic substances according to Table 16-17 below.

Process timeline during the study Preparation test formulation

The working concentration of laquinimod and GA was prepared in pure water.

Prepare 5.0 mg/mL laquinimod stock solution and 1.25 mg/mL GA stock solution. The 5.0 mg/mL laquinimod stock was diluted 1:2, 1:4, and 1:10 to obtain 2.5, 1.25, and 0.5 mg/mL, respectively, to obtain dose levels of 25.0 mg/kg, 12.5 mg/ Kg and 5.0 mg/kg laquinimod. The 2.5 mg/mL GA stock was diluted 1:2 to obtain 1.25 mg/mL, which was used to obtain a GA at a dose level of 12.5 mg/kg. The 2.5 mg/mL GA stock was diluted 1:2 with 5.0 mg/mL laquinimod to obtain 1.25 mg/mL GA and 2.5 mg/mL laquinimod, which was used to obtain a dose level of 12.5 mg/kg GA. With 25 mg/kg laquinimod. The 5.0 mg/mL laquinimod stock was diluted 1:5 to give 1 mg/mL. The 2.5 mg/mL GA stock was diluted 1:2 with 1.0 mg/mL laquinimod to obtain 1.25 mg/mL GA and 0.5 mg/mL laquinimod, which was used to obtain a dose level of 12.5 mg/kg. GA and 5.0 mg/kg laquinimod.

Test item investment

From the day the mice were divided into treatment groups (the first injection of encephalitis substances), various test formulations were administered daily to all groups of mice by oral gastric tube feeding at a dose level of 250. mL/mouse was administered for 59 consecutive days until the end of the study.

Clinical observation and scoring

Mice were examined according to the table below and scored until the end of the study (60 days after the start of treatment).

Result description

The activity of the test article was calculated for the first and second RR EAEs by comparing the morbidity, mortality, morbidity and disease duration, group mean score, and average highest score to the control group. The calculations were performed separately or together for the first and second relapses. The calculation method is as shown in Example 2.4.

result

Summary Tables 19-21 show an overview of morbidity, mean highest score, group mean score/individual mean score, and mean disease duration during the first episode, the second episode, and the first and second seizures.

During the observation period, 2 and 3 mice were sacrificed in the group treated with GA (12.5 mg/kg) and water (control), respectively.

During the first and second episodes, and when calculating the scores for the first and second episodes of EAE, the dose level was 12.5 and 5.0 mg/kg of laquinimod at a dose level of 12.5. The GA/kg group of mg/kg is most effective in inhibiting EAE.

During the first episode, the average score for individuals in these groups was 82.0% and 66.3% lower than the control group administered with water (see Table 20). During the second episode, the average score for individuals in these groups was 84.6% and 64.5% lower than the control group administered with water (see Table 21).

When the first and second seizure scores of EAE were calculated together, the average score of the groups in these groups was 82.6% and 60.9% lower than the control group administered with water (see Table 19).

Only the group treated with laquinimod inhibited EAE more effectively during the first relapse than during the second relapse.

During the first episode, the groups treated with 5, 12.5 and 25.0 mg/kg laquinimod were 38.2%, 53.3% and 42.8% lower than the water-administered control group (see Table 20). During the second episode, the groups treated with 5, 12.5 and 25.0 mg/kg laquinimod were 18.4%, 41.4% and 29.2% lower than the water-administered control group (see Table 21).

During the first, second, and first and second episodes, GA alone at the dose level of 12.5 mg/kg was 15.6%, 35.5%, and 21.7% lower than the control group administered with water, respectively.

Example 2.7 MSCH-induced EAE in CSJL mice

The purpose of this study was to compare the inhibitory activity against the EAE model of CSJL/F1 mice after daily administration of laquinimod by oral gastric tube feeding and administration of laquinimod with GA.

MS is an immune-mediated condition of the CNS, leading to a gradual decline in motor and sensory function, further causing permanent disability. The CSJL/FI mouse strain line was chosen because it was used to test established EAE models for the efficacy of candidate molecules for the treatment of MS.

Overall design Disease was induced in all mice by injection of encephalitogenic emulsion (MSCH/CFA). The test article and the vehicle were administered orally twice a day.

material

Glatiramer acetate; laquinimod; pure water (RO water); pertussis toxin, "Sigma"; freeze-dried mouse spinal cord homogenate (MSCH); Complete Adjuvant (CFA) "Sigma".

Experimental animal

Healthy, unproductive, and non-pregnant female CSJL/FI strain mice weighing approximately 17-20 g were approximately 10 weeks old. Animal weights were recorded on the day of delivery. Obviously healthy animals were arbitrarily assigned to the study group prior to initiation of treatment.

Test procedure

Group Assignment The mice were divided into 8 treatment groups in Table 22 below:

Preparation and administration of encephalitis emulsion

Oil fraction: CFA (containing 1 mg/ml MT).

Liquid fraction: For groups 1 and 3 to 6, 160.2 mg MSCH was suspended in 4.0 ml PBS to give a 40 mg/ml MSCH suspension. For groups 2, 7 and 8, GA was dissolved in PBS to give 0.4 mg/mL GA/ml. 60.0 mg MSCH was suspended in 1.5 ml of 0.4 mg/ml GA solution to give a 40 mg/ml MSCH suspension in 0.4 mg/ml GA solution.

An emulsion is prepared from an aliquot of the oil and liquid portion in two syringes connected to each other via a Luer lock and transferred to an insulin syringe.

0.05 ml was injected into the left toe of each mouse.

The MSCH concentration of the emulsion in all groups was 20 mg/mL. The dose of MSCH in all groups was 1.0 mg/0.05 ml/mouse. The MT concentration of the emulsion in all groups was 0.5 mg/mL. The dose of MT in all groups was 0.025 mg/0.05 ml/mouse. The GA concentration of the emulsion in all groups was 0.2 mg/mL. The dose of GA in groups 2, 7 and 8 was 10 mg/0.05 ml/mouse, equivalent to 0.5 mg/kg. This is a sub-therapeutic dose that is 25 times lower than the therapeutic dose of 12.5 mg/kg (250 mg/mouse).

Preparation and administration of pertussis toxin

70 mL of pertussis toxin (200 mg/ml) was added to 69.93 ml of PBS to give 200 ng/ml. Pertussis toxin (100.0 ng/0.5 ml/mouse) was administered intravenously on the day of injection of the encephalitis substance and 48 hours later.

Preparation and administration of laquinimod to a concentration of 0.001, 0.01, 0.03, and 0.1 mg/mL of laquinimod solution in water to obtain dose levels of 0.01, 0.1, 0.3, and 1.0 mg/kg, respectively. . The test formulations were stored in an amber bottle at 2 to 8 °C prior to use. Mice were dosed with various dose levels of laquinimod at a volume level of 200 mL/mouse. The test formulation was vortexed prior to dispensing to the syringe. Test article formulations were administered to each group by oral gastric tube feeding. The vehicle (pure water) was administered to the negative control group (Group 1) and the second group in a similar manner. A different dose level of laquinimod was administered to each group daily.

Experimental observation

Morbidity and Mortality All animals are examined daily to find out if there are dead or dying animals.

Clinical Symptoms EAE clinical signs were scored on day 10 after EAE induction and continued daily until day 23. Clinical signs were recorded according to the scoring system shown in Table 23 below.

All mice with a score of 1 or higher were considered to be ill. Mice with a score of 4 for more than three days were given 5 points and sacrificed for human factors. For computational purposes, the sacrificed or dead animal scores continue to be scored 5 points thereafter.

Result description

The calculation method is as shown in Example 2.4.

result

Summary Table 24 shows an overview of morbidity, mortality, MMS, GMS, duration of disease, onset, and activity of each group based on incidence, MMS, and GMS.

Clinical signs and mortality

Severe EAE clinical signs were observed, resulting in the death of all 10 mice in the control group as of the 16th day of the study. 0 to 8 mice died in the other treatment groups. Due to the severity of the disease, the efficacy of laquinimod was lower than in previous studies.

Incidence, morbidity and course of disease

The incidence of the vehicle-treated negative control group was 10/10. The incidence of the group treated with only different dose levels of laquinimod was observed to be 90 to 100%. In the group treated with suboptimal dose of GA (0.5 mg/kg), 7/10 of the mice were ill with the administration of encephalitogenic substances.

When laquinimod (0.1 mg/kg) was administered to a suboptimal dose of GA (0.5 mg/kg), the incidence was 6/10 (40% active). The incidence and duration of the disease were 18.8 ± 4.9 and 4.1 ± 4.5, respectively, compared with 12.2 ± 0.8 and 11.8 ± 0.8 for the vehicle-treated negative control group.

Average highest score (MMS) and group average score (GMS)

The MMS of the vehicle-treated negative control group was 5.0 ± 0.0 because all mice died. In comparison, the dose of laquinimod (0.1 mg/kg) administered to the suboptimal dose of GA was 1.7 ± 1.6 (66% activity according to MMS). According to GMS, this group inhibited EAE by 80.9% (p < 0.000001) compared to the negative control group.

According to GMS, the 1.0 mg/kg dose level was most effective in the dose-treated laquinimod group compared with the control group, with an activity of 38.1% (p=0.006). The sub-optimized dose of GA treated group showed 61.9% activity (p=0.0002). According to GMS, when laquinimod (0.01 mg/kg) was administered to the suboptimal dose of GA treatment compared to the negative control group At the time, the activity was observed to be 57.1% (p = 0.000001).

in conclusion

Under the test conditions, with the sub-optimal dose of GA (0.5 mg / kg), oral administration of laquinimod by the gastric tube feeding method at a dose level of 1.0 mg / kg daily showed an additive effect, and the ratio was Administration of laquinimod (1.0 mg/kg) or suboptimal dose of GA (0.5 mg/kg) alone was more effective in inhibiting chronic MOG-induced EAE in C57B1 mice.

Example 2.8 MSCH-induced EAE in CSJL/F1 mice

The purpose of this study was to compare CSJL/F1 after daily administration of laquinimod by oral gastric tube feeding and administration of laquinimod with GA. Inhibitory activity of the EAE model of mice.

MS is an immune-mediated condition of the CNS, leading to a gradual decline in motor and sensory function, further causing permanent disability. The CSJL/FI mouse strain line was chosen because it was used to test established EAE models for the efficacy of candidate molecules for the treatment of MS.

Overall design

Disease was induced in all mice by injection of encephalitogenic emulsion (MSCH/CFA). The test article and the vehicle were administered orally twice a day.

material

Glatiramer acetate; laquinimod; pure water (RO water); pertussis toxin, "Sigma" freeze-dried mouse spinal cord homogenate (MSCH); Freund's complete adjuvant (CFA) "Sigma"; Complete adjuvant (ICFA), Difco; and PBS "Sigma".

Experimental animal

Healthy, unproductive, and non-pregnant female CSJL/FI strains weighing approximately 17-20 g were delivered approximately 9 weeks old. Animal weights were recorded on the day of delivery.

Obviously healthy animals were arbitrarily assigned to the study group prior to initiation of treatment.

Test procedure Group assignment

The mice were divided into 8 treatment groups in Table 25 below:

Preparation and administration of encephalitis emulsion

Oil fraction: CFA (containing 1 mg/ml MT) + ICFA in a ratio of 1:2, giving 0.5 mg/mL Mycobacterium tuberculosis.

Liquid fraction: For groups 1 and 3 to 6, 360.0 mg MSCH was suspended in 3.0 ml PBS to give a 120 mg/ml MSCH suspension. For groups 2, 7 and 8, GA was dissolved in PBS to give 0.4 mg/mL GA/ml. 180.0 mg MSCH was suspended in 1.5 ml of 0.4 mg/ml GA solution to obtain a 120 mg/ml MSCH suspension in 0.4 mg/ml GA solution.

An emulsion is prepared from an aliquot of the oil and liquid portion in two syringes connected to each other via a Luer lock and transferred to an insulin syringe.

0.05 ml was injected into the left toe of each mouse. The MSCH concentration of the emulsion in all groups was 60 mg/mL. The dose of MSCH in all groups was 3.0 mg/0.05 ml/mouse. The MT concentration of the emulsion in all groups was 0.25 mg/mL. The dose of MT in all groups was 0.0125 mg/0.05 Ml/mouse. The GA concentration of the emulsion in all groups was 0.2 mg/mL.

The dose of GA in groups 2, 7 and 8 was 10 μg/0.05 ml/mouse, equivalent to 0.5 mg/kg. This is a sub-therapeutic dose that is 25 times lower than the therapeutic dose of 12.5 mg/kg (250 μg/mouse).

Preparation and administration of pertussis toxin

36 μL of pertussis toxin (200 μg/ml) was added to 44.964 ml of PBS to give 160 ng/ml. Pertussis toxin (80.0 ng/0.5 ml/mouse) was administered intravenously on the day of injection of the encephalitis substance and 48 hours later.

Preparation and administration of working concentration of laquinimod

Laquinimod solutions at concentrations of 0.001, 0.01, 0.03, and 0.1 mg/mL were prepared in water to give dose levels of 0.01, 0.1, 0.3, and 1.0 mg/kg, respectively. The test formulations were stored in an amber bottle at 2 to 8 °C prior to use.

Mice were dosed with various dose levels of laquinimod at a volume dose level of 200 μL/mouse. The test formulation was vortexed prior to dispensing to the syringe.

Test article formulations were administered to each group by oral gastric tube feeding. The vehicle (pure water) was administered to the negative control group (Group 1) and the second group in a similar manner.

A different dose level of laquinimod was administered to each group daily.

Experimental observation Morbidity and mortality

Check all animals daily to find out if there are dead or dying animals.

Clinical signs

EAE clinical signs were scored on day 10 after EAE induction and continued daily until day 23. Clinical signs were recorded on the observation card according to the scoring system shown in Table 23 above. Animals that scored 4 for more than three days were given 5 points and sacrificed for human factors. For calculation purposes, the sacrificed or dead animal scores (5) will continue to score 5 points thereafter.

Result description

The calculation method is as shown in Example 2.4.

result

Summary Table 26 shows an overview of morbidity, mortality, MMS, GMS, duration of disease, onset, and activity of each group based on incidence, MMS, and GMS.

Clinical signs and mortality

Seven mice died in the vehicle-treated control group due to severe clinical signs of EAE. The other treatment groups died from 0 to 2 mice.

Incidence, morbidity and course of disease

The incidence of the vehicle-treated negative control group was 11/11. The incidence of the laquinimod (0.01 mg/kg) treatment group was observed to be 91%.

Activity was observed to be dose dependent at different dose levels of laquinimod compared to vehicle treated controls. According to the incidence rate, the activity was observed to be 9.1% at dose levels of 0.01, 0.1, 0.3, and 1.0 mg/kg in the laquinimod-treated group compared with the vehicle-treated control group. 27.3%, 36.4%, 90.9%.

4/11 of the mice were ill in the group treated with suboptimal dose of GA (0.5 mg/kg) with the administration of encephalitogenic substances.

When laquinimod (0.1 mg/kg) was administered to the suboptimal dose of GA (0.5 In the group treated with mg/kg), the incidence rate was 0/1/1 (100% active), suggesting an additive effect.

However, when laquinimod (0.01 mg/kg) was administered to a suboptimal dose of GA (0.5 mg/kg), the incidence of 4/11 was compared with GA alone (0.5 mg/kg). Kg) is similar, suggesting that the activity of the two test articles does not interfere with each other.

Compared with the control group, the incidence and course of disease were delayed in a dose-dependent manner at different doses of laquinimod, with the exception of the lowest dose of laquinimod (0.01 mg/kg), of which the course and onset were 13.7± 3.8 and 9.5 ± 3.9, which is similar to the control group, in which the course of disease and onset are 11.5 ± 2.7 and 11.5 ± 0.7, respectively.

Average highest score (MMS) and group average score (GMS)

The MMS of the vehicle-treated negative control group was 4.5 ± 0.8.

MMS was observed to be 1.1 ± 15 in the group treated with suboptimal dose of GA (0.5 mg/kg) with the administration of encephalitogenic substances.

According to GMS, activity was observed at dose levels of 0.01, 0.1, 0.3, and 1.0 mg/kg in the groups treated with different dose levels of laquinimod, 35.3%, 55.9%, 73.5%, and 97.1%. .

According to GMS, the suboptimal dose of GA treated group showed 79.4% activity (p=0.0002). When laquinimod (0.1 mg/kg) was administered to the suboptimal dose of GA treated group, 100.0% activity was observed (p < 0.000001) compared to the negative control group.

in conclusion

Under the test conditions, laquinimod was orally administered daily by gastric tube feeding, and its activity was observed at doses of 0.01, 0.1, 0.3, and 1.0 mg/kg. The dose was dose dependent.

Oral administration of laquinimod at 1.0 mg/kg daily with a suboptimal dose of GA (0.5 mg/kg), and laquinimod was administered alone. 1.0 mg/kg (55.9%) or suboptimal dose of GA-0.5 mg/kg (79.4%) was more effective in inhibiting chronic MOG-induced EAE (100% activity) in C57B1 mice.

Results / discussion

It is important to note that the dose of mice presented herein cannot be used to determine the human dose by simply adjusting body weight, since one gram of mouse tissue is not equivalent to one gram of human tissue. Therefore, the National Institutes of Health (NIH) provides the following table of equivalent surface area dose conversion factors (Table 27), which provides The conversion factor between surface area to weight ratio between species.

Example 3: Clinical Trial (Phase II) - The additional effect of laquinimod on relapsing multiple sclerosis (RMS) individuals treated with glatiramer acetate (GA) or interferon-beta (IFN-β) Evaluation

To evaluate two daily doses of oral laquinimod (0.6 mg or 1.2 mg) supplemented with glatiramer acetate (GA) or interferon-beta (IFN-β)-1a/1b in relapsing multiple sclerosis (RMS) Safety, Tolerance, and Efficacy in Individuals, multinational, multicenter, randomized, double-blind, parallel, placebo-controlled studies followed by a double-blind active extension.

Study duration

The total duration of study for each eligible individual will be up to 19 months:

Screening phase: up to about 1 month.

Double-blind treatment period: In addition to current therapies (ie, subcutaneous administration of GA 20 mg or any of the following IFN-β preparations: Avonex ^® , Betaseron ^® / Betaferon ^® , Rebif ^® or Extavia ^® ), oral administration of laquine once daily Maud 0.6 mg/day, 1.2/day or placebo for approximately 9 months.

̇ Double Blind Active Extension (DBAE) Period: Provides an opportunity for all individuals who have completed the 9-month DBPC treatment period to continue the DBAE period. During this time, all individuals continued to receive the same background injection therapy as used in the DBPC phase.

Individuals initially assigned to either the active oral treatment group (0.6 mg or 1.2 mg laquinimod) continued their initial oral treatment assignment. Individuals initially assigned to the placebo group also received 0.6 mg or 1.2 mg of laquinimod at random. This phase lasts for 9 months.

Research group

Compound multiple sclerosis (RMS).

Research design

Eligible individuals (1:1:1) were randomly assigned to one of the following treatment groups:

1. 20 mg GA or any of the IFN-β preparations + daily oral administration of 0.6 mg laquinimod capsules.

2. 20 mg GA or any of the IFN-β preparations + daily oral administration of 1.2 mg laquinimod capsules.

3. 20 mg GA or any IFN-β formulation + daily oral placebo.

The 0.6 mg laquinimod capsule can be used according to the method disclosed in PCT International Application Publication No. WO/2007/146248, issued on Dec. 21, 2007 (see, page 10, line 5 to page 11, line 3). Manufacturing.

Randomization was such that the number of individuals treated via GA in each group was stratified in the same manner as the number of individuals treated via IFN-β formulations (Avonex ^® , Betaseron ^® / Betaferon ^® , Rebif ^® or Extavia ^® ).

During the DBAE phase, the individual continued to receive the same background injection therapy as used in the DBPC phase. Individuals initially assigned to either active oral group [0.6 mg (Group 1) or 1.2 mg (Group 2) laquinimod] continued their initial oral treatment assignment. Individuals initially assigned to the placebo group (Group 3) also received 0.6 mg or 1.2 mg of laquinimod at random.

During the DBPC period, individuals regularly visit the research site 11 times in the following month to evaluate it: January-Month (screening), month 0 (baseline), and thereafter monthly, until September (terminating/early termination) ).

During the DBAE period, individuals in the 9th month [baseline EXT; termination of DBPC period], 10/1AE, 11/2AE, 12/3AE, 15/4AE, and 18/5AE (end of DBAE period/early termination visit) Visit the research site 6 times and evaluate it.

Make the following assessments at the specified point in time:

1. During the two periods of DBPC and DBAE, vital signs were measured at each study visit.

2. During the DBPC period, physical examinations were performed at -1 month (screening) and 0 (baseline), 1, 3, 6 and September (end of DBPC period/early termination visit). During the DBAE period, a physical examination was performed at the 9th month (baseline EXT; termination of the DBPC period), 10/1 AE, 12/3 AE, and 18/5 AE (end of DBAE period/early termination visit).

3. Conduct the following clinical laboratory safety tests:

a During all regular visits between DBPC and DBAE Complete blood counts (CBC) were performed and compared for differences.

b Serum chemistry (including electrolytes, liver enzymes, creatinine, direct bilirubin and total bilirubin, and pancreatic amylase) and urine analysis during all regular visits between DBPC and DBAE. The lipase was tested to prevent abnormal pancreatic amylase production. Glomerular filtration rate (GFR) was calculated before the first month (screening) and before each MRI scan.

c Complete the lipid profiles (total cholesterol, HDL, LDL and triglycerides) during the first month (screening) or month 0 (baseline) of the DBPC period under fasting conditions.

d During the DBPC phase, thyroid function tests (TSH, T3, and free T4) were performed at 0 (baseline), 6 and September (end of DBPC phase/early termination visit). During the DBAE period, thyroid function tests (TSH, T3, and free T4) were performed at 9 months (baseline EXT; termination of DBPC phase visit), 15/4 AE, and 18/5 AE (end of DBAE phase/early termination visit).

e Perform urine analysis during screening visits.

f Serum β-hCG (human chorionic hormone beta) was analyzed in women with fertility potential during each of the DBPC and DBAE periodic study visits.

4 In the two periods of DBPC and DBAE, urine test strips were tested for β-hCG in women with fertility potential during all post-screening study visits and early termination visits. In addition, during the DBAE period, the urine beta-hCG test was performed twice at home during regular visits to the gap:

a. During the 13th and 14AE months (30±4 days and 60±4 days after the 12AE AE respectively).

b. During the 16th and 17th AE months (30±4 days and 60±4 days after the 15AE AE respectively).

The individual is contacted by the designated staff within 72 hours of the preparation for the test, and the specific question is asked about the test. In the event of a suspected pregnancy (positive urine β-hCG test), the attendant should inform the individual to stop taking the study drug and bring all the study drugs to the site as soon as possible (but only within 10 days).

5 During the DBPC phase, at -1 (screening), 0 (baseline; three times before the first dose, 10 minutes in between), 1, 2, 3, 6 and September (end of DBPC period / Early termination visits were performed for electrocardiogram (ECG) analysis. During the DBAE period, at the 9th month (baseline EXT; termination of the DBPC period), 10/1AE, 11/2AE, 12/3AE, 15/4AE, and 18/5AE (end of DBAE period/early termination visit) ECG.

6 If chest X-rays are not performed within 6 months prior to screening visits, they are performed at the first month (screening).

7 Monitor adverse events (AEs) throughout the study.

8 Concomitant medications were monitored throughout the study (two periods).

9 During the DBPC phase, neurological assessments were performed at -1 (screening), 0 (baseline), 3, 6, and September (end of DBPC phase/early termination), including extended disability status scale (EDSS), walking Index (AI) and functional system score (FS). During the DBAE period, in the 9th month (baseline; Neurological assessment, including EDSS, AI, and FS scores, was performed on the termination of the DBPC period, 12/3AE, 15/4AE, and 18/5AE (end of DBAE phase/early termination).

10 During the DBPC period, the Symbolic Digital Pattern Test (SDMT) was performed at 0 (baseline), 6 and September (end of DBPC period/early termination visit). During the DBAE period, SDMT was performed at the 9th month (baseline EXT; termination of the DBPC period), 15/4 AE, and 18/5 AE (end of DBAE period/early termination visit).

11 During the DBPC phase, each individual underwent 3 MRI scans at 0 (baseline), 3 and September (end of DBPC phase/early termination visit). During the DBAE period, each individual underwent 2 MRI scans at 9 months (baseline EXT; DBPC phase termination visit scan) and 18/5 AE (DBAE phase termination/early termination visit).

12 During the DBPC phase, neurological assessments were performed at -1 (screening), 0 (baseline), 3, 6 and September (end of DBPC phase/early termination), including extended disability status scale (EDSS), walking Index (AI) and functional system score (FS). During the DBAE period, neurological assessment, including EDSS, AI, and FS, was performed at 9 months (baseline; termination of DBPC phase visit), 12/3 AE, 15/4 AE, and 18/5 AE (end of DBAE phase/early termination) score.

13 During the DBPC period, the Symbolic Digital Pattern Test (SDMT) was performed at 0 (baseline), 6 and September (end of DBPC period/early termination visit). During the DBAE period, in September (baseline EXT; termination of DBPC period), 15/4AE and 18/5AE (DBAE period) Termination / early termination of visits) for SDMT.

14 During the DBPC phase, each individual underwent 3 MRI scans at 0 (baseline), 3 and September (end of DBPC phase/early termination visit). During the DBAE period, each individual underwent 2 MRI scans at 9 months (baseline EXT; DBPC phase termination visit scan) and 18/5 AE (DBAE phase termination/early termination visit).

15 Confirmed/monitored recurrence (both periods) throughout the study period.

Recurrent treatment

The approved relapse treatment was intravenous injection of Methylprednisolone, 1 gr/day, for up to 5 consecutive days.

monitor

During the course of the study, individuals were strictly monitored by an external independent data monitoring committee (DMC).

MRI Activity Alert Guidelines

To avoid 5 or more GdE-T1 lesions on MRI scans, the MRI Reading Center issues a notification letter to sponsors, researchers, and the DMC. MRI activity parameters are not considered a stopping criterion, and the decision of a single individual to participate in the trial is carefully made by the attending physician.

Auxiliary research:

Pharmacogenetic Genetics (PGx) Assessment: Collecting all individuals who signed informed consent during the DBPC period, preferably during the month of the month (baseline) or any other post-zero month visit, while waiting for approval by Ethics Committees Blood sample for obtaining PGx parameters.

Number of individuals

About 600 individuals.

Inclusion/exclusion criteria Inclusion criteria

1. The individual is required to have an MS diagnostic certificate as defined in the revised McDonald standard [Ann Neurol 2011: 69: 292-302] with a relapsing course.

2. Individuals need no recurrence, nerves are stable, and no adrenal corticosteroid treatment [intravenous (IV), intramuscular (IM) and / or oral] 60 days before randomization.

3. Individuals need to be treated with a stable dose of GA (Copaxone ^® ) or IFN-β (Avonex ^® , Betaseron ^® / Betaferon ^® , Rebif ^® or Extavia ^® ) for at least 6 months, followed by randomization (before randomization 6 During the month, it is allowed to change within the IFN-β preparation; it is not allowed to change between any IFN-β preparation and GA, or vice versa), and there is no plan to change the individual injection treatment (Copaxone® or IFN-β) during the study. preparation).

4. Individuals need to have an EDSS score of 1.5-4.5 (inclusive) when randomized.

5. Individuals need to be between 18 and 55 years old, included.

6. Women with fertility potential need to implement acceptable birth control measures. Acceptable birth control measures in this study include: surgical birth control, intrauterine contraceptives, oral contraceptives, contraceptive patches, long-acting injectables, spouse vasectomy, or double disability (containment with spermicide) Set or diaphragm).

7. Individuals need to be able to sign a written informed consent form and record the date prior to entering the study.

8. Individuals are willing and able to comply with the agreement requirements during the study period.

Exclusion criteria

1. Has a non-recurrent, progressive MS (eg, PPMS) (as defined by Lublin and Reingold, 1996).

2. Recurrence, neurological instability or any adrenal corticosteroids [intravenous (iv), intramuscular (im) and / or oral (po)] or corticotropin treatment (steroids) 60 days prior to randomization The last day of treatment should be 60 days prior to randomization or earlier).

3. Use experimental or research drugs and/or participate in drug clinical studies within 6 months prior to randomization.

4. Use an immunosuppressant within 6 months prior to randomization.

5. Use natalizumab (Tysabri ^® ), gammonya ^® or anti-B cell therapy within 2 years prior to randomization.

6. Previously used any of the following: cytotoxic agents, Novantrone ^® , cladribine, laquinimod, whole body irradiation, total lymphatic irradiation, stem cell therapy, autologous bone marrow transplantation or allogeneic Bone marrow transplantation.

7. Intravenous injection of immunoglobulin (IVIG) or plasmapheresis within 2 months prior to randomization.

8. Use a mild inhibitor/strong inhibitor of CYP3A4 within 2 weeks prior to randomization.

9. Use the inducer of CYP3A4 within 2 weeks prior to randomization.

10. Pregnancy or breastfeeding.

11. Increase in serum alanine transaminase (ALT) or aspartate transaminase (AST) during screening 2xULN.

12. Serum direct bilirubin at screening 2xULN.

13. Individuals with potentially clinically significant or unstable medical or surgical conditions that impede safety and full participation in the study, as determined by medical history, physical examination, ECG, laboratory tests, or chest X-ray. These conditions may include:

a. Cardiovascular or respiratory diseases that are not reasonably controlled by standard treatments permitted by the study protocol.

b. Kidney disease.

c. Any form of acute or chronic liver disease.

d. Human immunodeficiency virus (HIV) is known to be positive.

e. History of drug abuse and/or alcohol abuse.

f. Unstable mental illness.

g. Have had any malignancy in the past 5 years, with the exception of basal cell carcinoma (BCC).

14. Glomerular filtration rate (GFR) was less than 60 ml/min during screening visits.

15. A history of sputum (Gd) sensitivity is known.

16. Cannot accept MRI scans smoothly.

17. Endovascular treatment of chronic cerebrospinal venous insufficiency (CCSVI).

18. It is known to rule out drug allergy to laquinimod, such as allergy to mannitol, meglumine or sodium stearyl fumarate.

Routes and dosage forms

1. 20 mg GA or any interferon-β (IFN-β) preparation + daily oral administration of 0.6 mg laquinimod capsule (a 0.6 mg laquinimod capsule and a substitute for laquinimod) Capsules) (applicable to DBPC and DBAE two stages).

2. 20 mg/l mL of GA or IFN-β preparation + daily oral administration of 1.2 mg laquinimod (2 0.6 mg laquinimod capsules) (for both DBPC and DBAE).

3. 20 mg GA or IFN-β formulation + daily oral administration of placebo (2 placebo capsules in place of laquinimod) (only for DBPC stage).

Result measurement

The primary objective of this study was to evaluate two daily doses of oral laquinimod (0.6 mg or 1.2 mg) supplemented with GA or IFN-β preparations (Avonex ^® , Betaseron ^® / Betaferon ^® , Rebif ^® or Extavia ^® ) in RMS Safety, tolerability and efficacy in vivo.

The main efficacy evaluation indicators of the DBPC period:

Brain volume change rate (PBVC) from month 0 (baseline) to month 9 (terminus/early termination after the sixth month of the DBPC period).

Key exploratory efficacy assessment indicators for the DBPC period:

变化Changes between the 0th month (baseline) and the 9th month (termination/early termination after the 6th month of the DBPC phase) in the full brain magnetic transfer rate (MTR) histogram.

̇ Confirm the time of disease progression (CDP). Define CDP as The 1-point EDSS continued to increase from baseline for at least 3 months. Progress cannot be confirmed during the relapse.

Exploratory assessment indicators for the DBPC period

Percentage change in the thickness of the mesothelium between the 0th month (baseline) and the 9th month (end/early termination visit after the 6th month).

The cumulative number of new T1 low-signal lesions in the 3rd and 9th months (terminating after the 6th month/early termination visit).

̇ The activity of the third month (new T2 or GdE-T1) lesions developed into the number of black holes in the 9th month (terminating after the 6th month/early termination visit).

The cumulative number of GdE-T1 lesions in the 3rd and 9th months (terminating after the 6th month/early termination visit).

The change in the volume of the ̇T2 lesion from the 0th month (baseline) to the 9th month (terminating after the 6th month/early termination visit).

The change in the volume of the GdE-T1 lesion from the 0th month (baseline) to the 9th month (terminating after the 6th month/early termination visit).

̇ The change in SDMT score from baseline to September (terminating after 6 months/early termination visit).

The overall health status is assessed by the European Quality of Life (EQ5D) questionnaire.

̇ Use the Work Productivity and Activity Disorders General Health (WPAI-GH) questionnaire to assess general health and the severity of symptoms of work.

The annual recurrence rate (ARR).

̇ The first time to confirm the recurrence.

Pharmacokinetics of quinazine.

Exploratory assessment indicators for the DBAE period

A similar set of evaluation metrics was analyzed for the DBAE period.

DPBC safety and tolerability assessment indicators

The cumulative number of GdE-T1 lesions in the 3rd and 9th months.

The cumulative number of 唯一 combination only active (CUA) lesions in the 3rd and 9th months.

数目 The number of individuals with adverse events.

数目 The number of individuals with potentially clinically significant abnormalities based on laboratory tests and vital signs and ECG during the study period.

The proportion of individuals who prematurely terminated the study (%), the reason for termination, and the time of withdrawal.

The proportion (%) of individuals who prematurely terminated the study due to adverse events (AE) and the time of withdrawal.

Results / discussion

This study evaluated the safety, tolerability, and efficacy of laquinimod supplemented with glatiramer acetate (GA) or interferon-β (IFN-β) in individuals with relapsing multiple sclerosis (RMS). The mechanism of action of laquinimod and GA has not been fully elucidated, so the effect of combination therapy cannot be predicted and needs to be evaluated experimentally.

Daily administration of laquinimod (oral, 0.6 mg/day and 1.2 mg/day) to patients who have received glatiramer acetate (GA) (subcutaneous injection, 20 mg/day) as adjuvant therapy in relapsed multiple Severen sclerosing disease (RMS) provides an enhanced therapeutic effect (providing an additive effect or an additive effect) without excessively increasing adverse side effects or affecting treatment safety.

Daily administration of laquinimod (oral, 0.6 mg/day and 1.2 mg/day) as adjunctive therapy with glatiramer acetate (GA) (subcutaneous, 20 mg/day) for the treatment of relapsing multiple Patients with sclerosis (RMS) are also safe.

Administered with laquinimod (oral, 0.6 mg/day and 1.2 mg/day) as acetate Adjuvant therapy with latieride (GA) (subcutaneous injection, 20 mg/day) provides clinically significant advantages and is more effective than when the GA is administered separately in the following manner (at the same dose) Treatment of patients with relapsing multiple sclerosis (RMS) with additive effects or more than additive effects:

1. Auxiliary therapy is more effective (providing additive effect or more additive effect) to reduce brain volume reduction in patients with relapsing multiple sclerosis (RMS) (measured by brain volume change rate (PBVC)); Sexual therapy is more effective (providing an additive effect or an additive effect) to increase the time to confirm disease progression (CDP) in patients with relapsing multiple sclerosis (RMS), where CDP is defined as The 1-point EDSS continued to increase from baseline for at least 3 months. Progress cannot be confirmed during relapse. 3. Auxiliary therapy is more effective (providing an additive effect or a more additive effect) to reduce abnormalities observed in the whole brain MTR histogram of patients with relapsing multiple sclerosis (RMS).

4. Adjuvant therapy is more effective (providing an additive effect or a more additive effect) to reduce the number of confirmed relapses in patients with relapsing multiple sclerosis (RMS), thus reducing the recurrence rate.

5. Adjuvant therapy is also more effective (providing an additive effect or a more additive effect) to reduce the disability accumulation of patients with relapsing multiple sclerosis (RMS), as measured by the time of confirmation of progression by EDSS.

6. Auxiliary Therapy is more effective (providing an additive effect or a more additive effect) to reduce MRI-monitoring disease activity in patients with relapsing multiple sclerosis (RMS), which is enhanced by T1-Gd-up on T1-weighted images Lesion Cumulative number, cumulative number of new T1 low-signal lesions, cumulative number of new T2 lesions, cumulative number of new T1 low-signal lesions (black holes) on T1-weighted images, activity (new T2 or GdE-T1) The number of lesions, the presence or absence of GdE lesions, the total volume change of T1 Gd-enhanced lesions, the total volume change of T2 lesions, and/or the measurement of cortical thickness.

7. Adjuvant therapy is more effective (providing an additive effect or a more additive effect) to reduce brain atrophy in patients with relapsing multiple sclerosis (RMS).

8. Adjuvant therapy is more effective (providing an additive effect or a more additive effect) to reduce the frequency of recurrence, frequency of clinical deterioration, and risk of progression in patients with relapsing multiple sclerosis (RMS).

9. Adjuvant therapy is more effective (providing an additive effect or a more additive effect) to improve the time to relapse in patients with relapsing multiple sclerosis (RMS).

10. Adjuvant therapy is more effective (providing additive effect or more additive effect) to improve the overall health of patients with relapsing multiple sclerosis (RMS) (as assessed by the European Quality of Life (EQ5D) questionnaire), symptoms of work Severity (assessed by the Work Productivity and Activity Disorders General Health (WPAI-GH) Questionnaire) and quality of life.

11. Adjuvant therapy is more effective (providing additive effects or more additive effects) reducing brain dysfunction/cognitive impairment in patients with relapsing multiple sclerosis (RMS) during a double-blind study (by symbolic digital model test (SDMT) ) evaluation).

Administered with laquinimod (oral, 0.6 mg/day and 1.2 mg/day) as acetate The adjuvant therapy of latieride (GA) (subcutaneous injection, 20 mg/day) provides clinically significant advantages and is more effective than when the GA system (at the same dose) is administered alone (providing an additive effect) Or more than additive effects) Delayed presentation of CIS patients suggesting MS conversion to clinically confirmed MS.

Administration of laquinimod (oral, 0.6 mg/day and 1.2 mg/day) as adjunctive therapy with glatiramer acetate (GA) (subcutaneous injection, 20 mg/day) provides clinically significant advantages and The GA system (at the same dose) is more effective (providing an additive effect or a more additive effect) than when administered alone. It reduces the rate of clinically proven MS, the rate of new lesions detected by MRI in the brain, and the brain. The accumulation of lesion area and the development of brain atrophy in the high-risk group of MS, and more effectively reduce the incidence of clinically confirmed MS and prevent irreversible brain damage in these people.

Based on the foregoing, similar treatments are expected with the combination of laquinimod (oral, 0.6 mg/day and 1.2 mg/day) and glatiramer acetate (GA) (subcutaneous injection, 20 mg/day). Specifically, daily combination of laquinimod (oral, 0.6 mg / day and 1.2 mg / day) and glatiramer acetate (GA) (subcutaneous injection, 20 mg / day) in relapsing multiple sclerosis The disease (RMS) provides an enhanced therapeutic effect (providing an additive effect or an additive effect) over the administration of each agent without excessively increasing the adverse side effects or affecting the safety of the treatment.

Daily combination of laquinimod (oral, 0.6 mg/day) and glatiramer acetate (GA) (subcutaneous, 20 mg/day) for the treatment of patients with relapsing multiple sclerosis (RMS) It is safe.

Administration of laquinimod (oral, 0.6 mg/day) with glatiramer acetate (GA) The combination of (subcutaneous injection, 20 mg/day) provides clinically significant advantages and is more effective than when each agent is administered separately (in the same dose) in the following manner (providing an additive effect or more than adding Effect of treatment) in patients with relapsing multiple sclerosis (RMS): the combination of laquinimod (oral, 0.6 mg/day and 1.2 mg/day) with glatiramer acetate provides clinically significant advantages, and Patients with relapsing multiple sclerosis (RMS) are more effective when the glatiramer acetate is administered alone (in the same dose) when administered alone (providing an additive effect or an additive effect):

12. Combination therapy is more effective (providing an additive effect or an additive effect) to reduce the reduction in brain volume in patients with relapsing multiple sclerosis (RMS) (as measured by brain volume change rate (PBVC)).

13. Combination therapy is more effective (providing an additive effect or a more additive effect) to increase the time to confirm disease progression (CDP) in patients with relapsing multiple sclerosis (RMS), which defines CDP as The 1-point EDSS continued to increase from baseline for at least 3 months. Progress cannot be confirmed during the relapse.

14. Combination therapy is more effective (providing an additive effect or a more additive effect) to reduce abnormalities observed in the whole brain MTR histogram of patients with relapsing multiple sclerosis (RMS).

15. Combination therapy is more effective (providing an additive effect or an additive effect) to reduce the number of confirmed relapses in patients with relapsing multiple sclerosis (RMS), thereby reducing the recurrence rate.

16. Combination therapy is also more effective (providing additive effects or more effective) Should reduce the accumulation of disability in patients with relapsing multiple sclerosis (RMS) as measured by the time of confirmation of progression by EDSS.

17. Combination therapy is more effective (providing an additive effect or a more additive effect) to reduce MRI-monitoring disease activity in patients with relapsing multiple sclerosis (RMS) by T1-Gd-enhanced lesions on T1-weighted images Cumulative number, cumulative number of new T1 low-signal lesions, cumulative number of new T2 lesions, cumulative number of new T1 low-signal lesions (black holes) on T1-weighted images, activity (new T2 or GdE-T1) The number of lesions, the presence or absence of GdE lesions, the total volume change of T1 Gd-enhanced lesions, the total volume change of T2 lesions, and/or the measurement of cortical thickness.

18. Combination therapy is more effective (providing an additive effect or a more additive effect) to reduce brain atrophy in patients with relapsing multiple sclerosis (RMS).

19. Combination therapy is more effective (providing an additive effect or an additive effect) to reduce the frequency of recurrence, frequency of clinical deterioration, and risk of progression in patients with relapsing multiple sclerosis (RMS).

20. Combination therapy is more effective (providing an additive effect or a more additive effect) to improve the time to relapse in patients with relapsing multiple sclerosis (RMS).

21. Combination therapy is more effective (providing additive effect or more additive effect) to improve the overall health of patients with relapsing multiple sclerosis (RMS) (assessed by the European Quality of Life (EQ5D) questionnaire), the severity of symptoms of work (Assessed by the Work Productivity and Activity Disorders General Health (WPAI-GH) Questionnaire) and quality of life.

22. Combination therapy is more effective (providing additive effects or more additive effects) reducing brain dysfunction/cognitive impairment in patients with relapsing multiple sclerosis (RMS) during a double-blind study (assessed by the signed digital pattern test (SDMT)) ).

The combination of laquinimod (oral, 0.6 mg/day and 1.2 mg/day) with glatiramer acetate provides clinically significant advantages and is associated with glatiramer acetate (at the same dose). More effective (providing an additive effect or a more additive effect) delays in the conversion of CIS patients suggesting MS to clinically confirmed MS.

The combination of laquinimod (oral, 0.6 mg/day and 1.2 mg/day) with glatiramer acetate provides clinically significant advantages when administered alone when glatiramer acetate (at the same dose) is administered In comparison, it is more effective (providing additive effect or more additive effect) to reduce the speed of clinical confirmation of MS, the new incidence of lesions detected by MRI in the brain, the accumulation of lesions in the brain, and the development of the brain of high risk of MS. Atrophy, and more effectively reduce the incidence of clinically confirmed MS and prevent irreversible brain damage in these people.

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Figure 1 : Figure 1 graphically illustrates the experimental results of Example 2.1. The graph shows the clinical score (y-axis) of each group of EAE rodents relative to the number of days after induction of disease (x-axis).

Figure 2 : Figure 2 graphically illustrates the experimental results of Example 2.2. The graph shows the clinical score (y-axis) of each group of EAE rodents relative to the number of days after induction of disease (x-axis).

Figure 3 ; Figure 3 graphically illustrates the experimental results of Example 2.3. The graph shows the clinical score (y-axis) of each group of EAE rodents relative to the number of days after induction of disease (x-axis).

Figure 4 ; Figure 4 graphically illustrates an overview of the experimental results of Examples 2.1 through 2.3. Figure 4A shows the clinical score (y-axis) of each group of EAE rodents relative to days after induction of disease (x-axis). Figure 4B shows the percent inhibition of each group of EAE rodents.

Figure 5 ; Figure 5 graphically illustrates the experimental results of Example 2.8. The graph shows the daily average clinical score (y-axis) of each group of EAE rodents relative to the number of days of observation (x-axis).

Claims (260)

A method of treating a human patient suffering from multiple sclerosis or cli-nically isolated syndrome, comprising orally administering to a patient a daily dose of 0.6 mg of laquinimod, and The patient was injected subcutaneously with a daily dose of 20 mg of glatiramer acetate, which was more effective for treating human patients when the same amount was administered together than when each agent was administered alone. The method of claim 1, wherein the multiple sclerosis is relapsing type multiple sclerosis. The method of claim 2, wherein the relapsing type multiple sclerosis is relapsing-remitting multiple sclerosis. The method of any one of claims 1 to 3, wherein the amount of laquinimod and the amount of glatiramer acetate when administered together are effective to reduce the symptoms of multiple sclerosis in a human patient. The method of claim 4, wherein the symptom is MRI-monitored multiple sclerosis disease activity, relapse rate, disability accumulation, frequency of recurrence, frequency of clinical deterioration, brain atrophy, risk of confirming progression, or time to confirm disease progression. The method of claim 5, wherein the disability accumulation is an assessment of the time to confirm disease progression as measured by the Kurtzke Extended Disability Status Scale (EDSS) score. The method of claim 6, wherein the patient has an EDSS score of 0-5.5 prior to administration of laquinimod. The method of claim 6, wherein the patient has prior to administration of laquinimod EDSS score of 5.5 or higher. The method of any one of claims 6 to 8, wherein the disease progression is confirmed to increase the EDSS score by one point. The method of any one of claims 6 to 8, wherein the disease progression is confirmed to be an increase of 0.5 points in the EDSS score. The method of any one of claims 5 to 10, wherein the time to confirm the progression of the disease is increased by 20-60%. The method of claim 11, wherein the time to confirm the progression of the disease is increased by at least 50%. The method of any one of claims 1 to 12, wherein the laquinimod is laquinimod sodium. The method of any one of claims 1 to 13, wherein the patient is subcutaneously injected with 0.5 ml of an aqueous drug solution comprising 20 mg of glatiramer acetate and 20 mg of mannitol in solution. The method of any one of claims 1 to 14, wherein the administration of laquinimod is substantially prior to the administration of glatiramer acetate. The method of any one of claims 1 to 14, wherein the administration of glatiramer acetate is substantially prior to the administration of laquinimod. The method of claim 16, wherein the human patient receives glatiramer acetate therapy first, followed by laquinimod therapy. The method of claim 17, wherein the human patient receives glatiramer acetate therapy for at least 24 weeks, followed by laquinimod therapy. The method of claim 18, wherein the human patient receives glatiramer acetate therapy for at least 28 weeks, followed by laquinimod therapy. The method of claim 19, wherein the human patient receives glatiramer acetate therapy for at least 48 weeks, followed by laquinimod therapy. The method of claim 20, wherein the human patient receives glatiramer acetate therapy for at least 52 weeks, followed by laquinimod therapy. The method of any one of claims 1 to 21, further comprising administering a non-steroidal anti-inflammatory drug (NSAIDs), a salicylate, a slow acting drug, a gold compound, hydroxychloroquine, sulfasalazine, slow A combination of drugs, corticosteroids, cytotoxic drugs, immunosuppressive drugs and/or antibodies. The method of any one of claims 1 to 22, wherein the periodic administration of laquinimod and glatiramer acetate lasts for more than 30 days. The method of claim 23, wherein the periodic administration of laquinimod and glatiramer acetate lasts for more than 42 days. The method of claim 24, wherein the periodic administration of laquinimod and glatiramer acetate lasts for 6 months or longer. The method of any one of claims 1 to 25, wherein the administration of laquinimod and glatiramer acetate inhibits symptoms of relapsing multiple sclerosis by at least 30%. The method of any one of claims 26, wherein the administration of laquinimod and glatiramer acetate inhibits at least 50% of the symptoms of relapsing multiple sclerosis. The method of any one of claims 27, wherein the administration of laquinimod and glatiramer acetate inhibits symptoms of relapsing multiple sclerosis by more than 100%. The method of any one of claims 28, wherein the administration of laquinimod and glatiramer acetate inhibits symptoms of relapsing multiple sclerosis by more than 300%. The method of any one of claims 29, wherein the administration of laquinimod and glatiramer acetate inhibits symptoms of relapsing multiple sclerosis by more than 1000%. A method of treating a human patient suffering from multiple sclerosis or clinically unique syndrome comprising administering to the patient a certain amount of laquinimod and a certain amount of glatiramer acetate, wherein when administered together The amount is effective in treating human patients. The method of claim 31, wherein the amount of laquinimod administered together with the amount of glatiramer acetate is more effective in treating a human patient than when the agents are administered alone. The method of claim 31 or 32, wherein the multiple sclerosis is relapsing multiple sclerosis. The method of claim 33, wherein the relapsing form of multiple sclerosis is relapsing-remitting multiple sclerosis. The method of any one of claims 31 to 34, wherein the amount of laquinimod and the amount of glatiramer acetate when administered together are effective to reduce the symptoms of multiple sclerosis in a human patient. The method of claim 35, wherein the symptom is MRI-monitored multiple sclerosis disease activity, recurrence rate, disability accumulation, frequency of relapse, shortened time to confirm disease progression, shortened time to confirm recurrence, frequency of clinical deterioration, brain atrophy , neuronal dysfunction, neuronal damage, neuronal degeneration, neuronal apoptosis, risk of confirming progression, visual function, fatigue, impaired mobility, cognitive impairment, decreased brain volume, whole brain MTR histogram Observed abnormalities, overall health status, functional status, and lifestyle Deterioration, and / or severity of symptoms of work. The method of claim 36, wherein the amount of laquinimod and the amount of glatiramer acetate when administered together are effective to reduce or inhibit brain volume reduction. The method of claim 37, wherein the brain volume is measured by a percentage change in brain volume (PBVC). The method of claim 36, wherein the amount of laquinimod and the amount of glatiramer acetate when administered together are effective to increase the time to confirm the progression of the disease. The method of claim 39, wherein the time to confirm the progression of the disease is increased by 20-60%. The method of claim 40, wherein the time to confirm the progression of the disease is increased by at least 50%. The method of claim 36, wherein the amount of laquinimod and the amount of glatiramer acetate when administered together is effective to reduce an abnormality observed in the whole brain MTR histogram. The method of claim 36, wherein the disability accumulation is measured by a Kurtzke Extended Disability Status Scale (EDSS) score. The method of claim 36, wherein the disability accumulation is a time assessment of the disease progression as determined by the Kurtzke Extended Disability Status Scale (EDSS) score. The method of claim 43 or 44, wherein the patient has an EDSS score of 0-5.5 prior to administration of laquinimod. The method of claim 43 or 44, wherein the patient has an EDSS score of 1.5-4.5 prior to administration of laquinimod. The method of claim 43 or 44, wherein the patient is administered with laquinimod Have an EDSS score of 5.5 or higher. The method of any one of claims 36 to 47, wherein the disease progression is confirmed to increase the EDSS score by one point. The method of any one of claims 36 to 47, wherein the disease progression is confirmed to increase the EDSS score by 0.5. The method of claim 36, wherein the impaired mobility is assessed by a 25 呎 time walk test. The method of claim 36, wherein the impaired mobility is assessed by the 12 Multiple Sclerosis Walking Scale (MSWS-12) self-report questionnaire. The method of claim 36, wherein the impaired activity capability is assessed by an walking index (AI). The method of claim 36, wherein the impaired mobility is assessed by a six minute walk (6 MW) test. The method of claim 36, wherein the impaired mobility is assessed by a lower limb manual muscle test (LEMMT). The method of claim 36, wherein the amount of laquinimod and the amount of glatiramer acetate when administered together are effective to reduce cognitive impairment. The method of claim 55, wherein the cognitive impairment is assessed by a Signature Digital Pattern Test (SDMT) score. The method of claim 36, wherein the overall health status is assessed by a European Quality of Life (EuroQoL) (EQ5D) questionnaire, an individual's overall impression (SGI), or a change in the overall impression of the clinician (CGIC). The method of claim 36, wherein the functional status is measured by a patient's Jane General Health Survey (SF-36) Individual Report Questionnaire score. The method of claim 36, wherein the quality of life is assessed by SF-36, EQ5D, individual overall impression (SGI), or a change in the overall impression of the clinician (CGIC). The method of claim 58 or 59, wherein the patient SF-36 mental health total score (MSC) is improved. The method of claim 58 or 59, wherein the patient SF-36 physical health total score (PSC) is improved. The method of claim 36, wherein the fatigue is assessed by EQ5D, a patient's revised fatigue impact scale (MFIS) score, or a French effective version (EMIF-SEP) score of the fatigue effect scale. The method of claim 36, wherein the severity of the symptoms of the work is measured by the Work Productivity and Activity Disorders General Health (WPAI-GH) questionnaire. The method of any one of claims 31 to 63, wherein the laquinimod is laquinimod sodium. The method of any one of claims 31 to 64, wherein the laquinimod is administered orally. The method of any one of claims 31 to 65, wherein the laquinimod is administered daily. The method of any one of claims 31 to 65, wherein the laquinimod is usually administered more than once a day. The method of any one of claims 31 to 65, wherein the laquinimod is usually administered less than once a day. The method of any one of claims 31 to 68, wherein the laquinimod dosage is no more than 0.6 mg/day. The method of any one of claims 31 to 69, wherein the laquinimod is administered in an amount of from 0.1 to 40.0 mg/day. The method of claim 70, wherein the dose of laquinimod is 0.1-2.5 mg/day. The method of claim 71, wherein the dose of laquinimod is 0.25-2.0 mg/day. The method of claim 72, wherein the dose of laquinimod is 0.5-1.2 mg/day. The method of claim 70, wherein the dose of laquinimod is 0.25 mg/day. The method of claim 70, wherein the dose of laquinimod is 0.3 mg/day. The method of claim 70, wherein the dose of laquinimod is 0.5 mg/day. The method of claim 70, wherein the dose of laquinimod is 0.6 mg/day. The method of claim 70, wherein the dose of laquinimod is 1.0 mg/day. The method of claim 70, wherein the dose of laquinimod is 1.2 mg/day. The method of claim 70, wherein the dose of laquinimod is 1.5 mg/day. The method of claim 70, wherein the laquinimod is administered in an amount of 2.0 mg/day. The method of any one of claims 31 to 81, wherein the dosage of glatiramer acetate is 0.1-1000 mg/day. The method of claim 82, wherein the dosage of glatiramer acetate is 50-150 mg/day. The method of claim 82, wherein the dosage of glatiramer acetate is 0.1-70 mg/day. The method of claim 82, wherein the dosage of glatiramer acetate is 10-80 mg/day. The method of claim 82, wherein the dosage of glatiramer acetate is 1 mg/day. The method of claim 82, wherein the dosage of glatiramer acetate is 5 mg/day. The method of claim 82, wherein the dosage of glatiramer acetate is 15 mg/day. The method of claim 82, wherein the dosage of glatiramer acetate is 20 mg/day. The method of claim 82, wherein the dosage of glatiramer acetate is 30 mg/day. The method of claim 82, wherein the dosage of glatiramer acetate is 40 mg/day. The method of claim 82, wherein the dosage of glatiramer acetate is 50 mg/day. The method of claim 82, wherein the dosage of glatiramer acetate is 100 mg/day. The method of any one of claims 31 to 81, wherein the dosage of glatiramer acetate is 10-600 mg/week. The method of claim 94, wherein the dosage of glatiramer acetate is 300 mg/week. The method of any one of claims 31 to 95, wherein the administration of glatiramer acetate is performed daily. The method of any one of claims 31 to 95, wherein the administration of glatiramer acetate is performed twice daily in half the amount. The method of any one of claims 31 to 95, wherein the administration of glatiramer acetate is performed every 5 to 9 days. The method of any one of claims 31 to 98, wherein glatiramer acetate is administered orally. The method of any one of claims 31 to 98, wherein the glatiramer acetate is administered nasally. The method of claim 99 or 100, wherein the glatiramer acetate is inhaled. The method of any one of claims 31 to 98, wherein the glatiramer acetate is administered via subcutaneous injection. The method of claim 102, wherein the glatiramer acetate is administered over a period of seven days, at least one day between each subcutaneous injection. The method of any one of claims 31 to 98, wherein the glatiramer acetate is via an intravenous, intraperitoneal, intramuscular, intranasal, buccal, vaginal, rectal, intraocular, intrathecal, topical or intradermal route Cast. The method of any one of claims 31 to 104, wherein the patient is subcutaneously injected with 0.5 ml of 20 mg of glatiramer acetate and 20 mg of mannose as a solution. An aqueous solution of an alcoholic drug. The method of any one of claims 31 to 105, wherein a loading dose different from the predetermined dose is administered for a period of time at the beginning of the periodic administration. The method of claim 106, wherein the starting dose is twice the predetermined dose. The method of claim 106 or 107, wherein the starting dose is administered for two days at the beginning of the periodic administration. The method of any one of claims 31 to 108, wherein the administration of laquinimod is substantially prior to the administration of glatiramer acetate. The method of any one of claims 31 to 108, wherein the administration of glatiramer acetate is substantially prior to the administration of laquinimod. The method of any one of claims 31 to 108, wherein the human patient receives the glatiramer acetate therapy first, followed by the laquinimod therapy. The method of claim 111, wherein the human patient receives glatiramer acetate therapy for at least 24 weeks, followed by laquinimod therapy. The method of claim 112, wherein the human patient is first treated with glatiramer acetate for at least 28 weeks, followed by initiation of laquinimod therapy. The method of claim 113, wherein the human patient receives glatiramer acetate therapy for at least 48 weeks, followed by laquinimod therapy. The method of claim 114, wherein the human patient receives glatiramer acetate therapy for at least 52 weeks, followed by laquinimod therapy. The method of any one of claims 31 to 115, further comprising administering a non-steroidal anti-inflammatory drug (NSAIDs), a salicylate, a slow acting drug, a goldation Compound, hydroxychloroquine, sulfasalazine, slow acting drug combination, corticosteroid, cytotoxic drug, immunosuppressive drug and/or antibody. The method of any one of claims 31 to 116, wherein the periodic administration of laquinimod and glatiramer acetate is continued for at least 3 days. The method of claim 117, wherein the periodic administration of laquinimod and glatiramer acetate lasts for more than 30 days. The method of claim 118, wherein the periodic administration of laquinimod and glatiramer acetate lasts for more than 42 days. The method of claim 119, wherein the periodic administration of laquinimod and glatiramer acetate is continued for 8 weeks or longer. The method of claim 120, wherein the periodic administration of laquinimod and glatiramer acetate is continued for at least 12 weeks. The method of claim 121, wherein the periodic administration of laquinimod and glatiramer acetate is continued for at least 24 weeks. The method of claim 122, wherein the periodic administration of laquinimod and glatiramer acetate lasts for more than 24 weeks. The method of claim 123, wherein the periodic administration of laquinimod and glatiramer acetate lasts for 6 months or longer. The method of any one of claims 31 to 124, wherein the administration of laquinimod and glatiramer acetate inhibits at least 20% of the symptoms of relapsing multiple sclerosis. The method of claim 125, wherein the administration of laquinimod and glatiramer acetate inhibits at least 30% of the symptoms of relapsing multiple sclerosis. The method of claim 126, wherein laquinimod and glatiramer acetate Injecting and inhibiting the symptoms of relapsing multiple sclerosis by at least 50%. The method of claim 127, wherein the administration of laquinimod and glatiramer acetate inhibits at least 70% of the symptoms of relapsing multiple sclerosis. The method of claim 128, wherein the administration of laquinimod and glatiramer acetate inhibits symptoms of relapsing multiple sclerosis by more than 100%. The method of claim 129, wherein the administration of laquinimod and glatiramer acetate inhibits symptoms of relapsing multiple sclerosis by more than 300%. The method of claim 130, wherein the administration of laquinimod and glatiramer acetate inhibits symptoms of relapsing multiple sclerosis by more than 1000%. The method of any one of claims 31 to 131, wherein the amount of laquinimod when administered alone and the amount of glatiramer acetate when administered alone are each effective to treat a human patient. The method of any one of claims 31 to 131, wherein the amount of laquinimod when administered alone, the amount of glatiramer acetate when administered alone, or each dose is not effective when administered alone Human patient. The method of any one of claims 31 to 133, wherein the patient has been determined to be a responder to glatiramer treatment. The method of any one of claims 31 to 133, wherein the patient has been determined to be a non-responder to the glatiramer treatment. A method of treating a human patient suffering from an immune disease comprising periodically administering to the patient a quantity of laquinimod and a quantity of glatiramer acetate (GA), wherein when administered together, the amount is effective to treat the human Patient, and wherein the immune disease is autoimmune disease, arthritis condition, myelin loss disease, inflammatory disease, multiple sclerosis, relapsing type multiple hard Syndrome, diabetes, psoriasis, rheumatoid arthritis, inflammatory bowel disease, Crohn's disease or systemic lupus erythematosus. A package comprising (a) a first pharmaceutical composition comprising a quantity of laquinimod and a pharmaceutically acceptable carrier; (b) a second pharmaceutical composition comprising a quantity of glatiramer acetate And a pharmaceutically acceptable carrier; and (c) a first and second pharmaceutical composition for use in the treatment of a human patient having relapsing form of multiple sclerosis or having a clinical single syndrome. The package of claim 137, wherein the first pharmaceutical composition is in the form of an aerosol or an inhalable powder. The package of claim 137, wherein the first pharmaceutical composition is in liquid form. The package of claim 137, wherein the first pharmaceutical composition is in a solid form. The package of claim 140, wherein the first pharmaceutical composition is in the form of a capsule. The package of claim 140, wherein the first pharmaceutical composition is in the form of a tablet. The package of claim 142, wherein the tablets are coated with a coating that inhibits oxygen from contacting the core. A package according to claim 143, wherein the coating comprises a cellulosic polymer, an anti-sticking agent, a brightening agent, and a pigment. The package of any one of claims 137 to 144, wherein the first pharmaceutical composition further comprises mannitol. The package of any one of claims 137 to 145, wherein the first pharmaceutical composition further comprises an alkalizing agent. A package according to claim 146, wherein the basifying agent is meglu-mine. The package of any one of claims 137 to 147, wherein the first pharmaceutical composition further comprises a redox agent. The package of any one of claims 137 to 145, wherein the first pharmaceutical composition is stable and free of an alkalizing agent or a redox agent. The package of claim 149, wherein the first pharmaceutical composition is free of alkalizing agents and does not contain a redox agent. The package of any one of claims 137 to 150, wherein the first pharmaceutical composition is stable and free of disintegrants. The package of any one of claims 137 to 151, wherein the first pharmaceutical composition further comprises a lubricant. A package according to claim 152, wherein the lubricant is present in the composition as solid particles. A package according to claim 152 or 153, wherein the lubricant is sodium stearyl fumarate or magnesium stearate. The package of any one of claims 137 to 154, wherein the first pharmaceutical composition further comprises a filler. A package according to claim 155, wherein the filler is present in the composition as solid particles. A package according to claim 155 or 156, wherein the filler is lactose, lactose monohydrate, starch, isomalt, mannitol, sodium starch glycolate, sorbitol, spray dried lactose, anhydrous Lactose or a combination thereof. The package of claim 157, wherein the filler is mannitol or lactose monohydrate. The package of any one of claims 137 to 158, further comprising a desiccant. The package of claim 159, wherein the desiccant is silicone. The package of any one of claims 137 to 160, wherein the stable first pharmaceutical composition has a water content of no more than 4%. The package of any one of claims 137 to 161, wherein laquinimod is present in the composition as solid particles. The package of any one of claims 137 to 162, wherein the package is a sealed package having a moisture permeability of no more than 15 mg/day/liter. The package of claim 163, wherein the sealed package is a blister pack, wherein the maximum moisture permeability does not exceed 0.005 mg/day. The package of claim 163, wherein the sealed package is a bottle. The package of claim 165, wherein the bottle is sealed by a thermally sensitive gasket. The package of any one of claims 163 to 166, wherein the sealed package comprises an HDPE bottle. The package of any one of claims 163 to 167, wherein the sealed package comprises an oxygen absorber. The package of claim 168, wherein the oxygen absorber is iron. The package of any one of claims 163 to 169, wherein the amount of laquinimod in the first composition is less than 0.6 mg. The package of any one of claims 163 to 169, wherein the amount of laquinimod in the composition is from 0.1 to 40.0 mg. A package according to claim 171, wherein the amount of laquinimod in the first composition is from 0.1 to 2.5 mg. . The package of claim 172, wherein the amount of laquinimod in the first composition is from 0.25 to 2.0 mg. A package according to claim 173, wherein the amount of laquinimod in the first composition is from 0.5 to 1.2 mg. A package according to claim 171, wherein the amount of laquinimod in the first composition is 0.25 mg. A package according to claim 171, wherein the amount of laquinimod in the first composition is 0.3 mg. The package of claim 171, wherein the amount of laquinimod in the first composition is 0.5 mg. The package of claim 171, wherein the amount of laquinimod in the first composition is 0.6 mg. The package of claim 171, wherein the amount of laquinimod in the first composition is 1.0 mg. The package of claim 171, wherein the amount of laquinimod in the first composition is 1.2 mg. The package of claim 171, wherein the amount of laquinimod in the first composition It is 1.5 mg. The package of claim 171, wherein the amount of laquinimod in the first composition is 2.0 mg. The package of any one of claims 137 to 182, wherein the amount of glatiramer acetate in the second composition is from 0.1 to 1000 mg. A package according to claim 183, wherein the amount of glatiramer acetate in the second composition is from 50 to 150 mg. A package according to claim 183, wherein the amount of glatiramer acetate in the second composition is from 10 to 600 mg. A package according to claim 183, wherein the amount of glatiramer acetate in the second composition is from 0.1 to 70 mg. A package according to claim 183, wherein the amount of glatiramer acetate in the second composition is from 10 to 80 mg. A package according to claim 183, wherein the amount of glatiramer acetate in the second composition is 1 mg. A package according to claim 183, wherein the amount of glatiramer acetate in the second composition is 5 mg. The package of claim 183, wherein the amount of glatiramer acetate in the second composition is 15 mg. A package according to claim 183, wherein the amount of glatiramer acetate in the second composition is 20 mg. A package according to claim 183, wherein the amount of glatiramer acetate in the second composition is 30 mg. A package according to claim 183, wherein the second composition is glatiramer acetate The amount is 40 mg. A package according to claim 183, wherein the amount of glatiramer acetate in the second composition is 50 mg. A package according to claim 183, wherein the amount of glatiramer acetate in the second composition is 100 mg. A package according to claim 183, wherein the amount of glatiramer acetate in the second composition is 300 mg. A package according to claim 191, wherein the second composition is a unit dose of 0.5 ml of an aqueous solution comprising 20 mg of glatiramer acetate. The package of claim 197, wherein the second composition is a 0.5 ml unit dose comprising an aqueous solution of 20 mg glatiramer acetate and 20 mg mannitol. The package of claim 191, wherein the second composition is a unit dose of 1 ml of aqueous drug solution, comprising 20 mg of glatiramer acetate and 40 mg of mannitol in solution. The package of claim 193, wherein the second composition is a unit dose of 1 ml of aqueous drug solution, which comprises 40 mg of glatiramer acetate in solution. The package of any one of claims 137 to 200, wherein the second composition is in an enteric coated form. A laquinimod that is used as an add-on therapy or in combination with glatiramer acetate to treat a human patient suffering from multiple sclerosis or having a clinically single syndrome. A pharmaceutical composition comprising a certain amount of laquinimod and a certain amount of glatiramer acetate for treating a human patient suffering from multiple sclerosis or having a clinical single syndrome, wherein the laquinimod and the acetic acid Gera The Thunder system is administered simultaneously or concurrently. A pharmaceutical composition comprising a certain amount of laquinimod and a certain amount of glatiramer acetate for treating a human patient suffering from an immune disease, wherein the laquinimod and the glatiramer acetate are simultaneously or simultaneously Administered, and wherein the immune disease is autoimmune disease, arthritis condition, myelin loss disease, inflammatory disease, multiple sclerosis, relapsing-remitting multiple sclerosis, diabetes, psoriasis, rheumatoid arthritis , inflammatory bowel disease, Crohn's disease or systemic lupus erythematosus. A pharmaceutical composition comprising a quantity of laquinimod and a quantity of glatiramer acetate. The pharmaceutical composition of claim 204 or 205, wherein the pharmaceutical composition is in the form of an aerosol or a smokable powder. The pharmaceutical composition of claim 204 or 205, which is in liquid form. A pharmaceutical composition according to claim 204 or 205 which is in solid form. The pharmaceutical composition of claim 208, which is in the form of a capsule. The pharmaceutical composition of claim 208, which is in the form of a tablet. The pharmaceutical composition of claim 210, wherein the tablets are coated with a coating that inhibits oxygen from contacting the core. The pharmaceutical composition of claim 211, wherein the coating comprises a cellulosic polymer, an anti-sticking agent, a brightening agent, and a pigment. The pharmaceutical composition of any one of claims 204 to 212, further comprising mannitol. The pharmaceutical composition according to any one of claims 204 to 213, further comprising an alkalizing agent. The pharmaceutical composition of claim 214, wherein the alkalizing agent is meglumine. The pharmaceutical composition of any one of claims 204 to 215, further comprising a redox agent. A pharmaceutical composition according to any one of claims 204 to 213 which is free of an alkalizing agent or a redox agent. A pharmaceutical composition according to claim 217 which is free of an alkalizing agent and which does not contain a redox agent. The pharmaceutical composition of any one of claims 204 to 218 which is stable and free of disintegrants. The pharmaceutical composition according to any one of claims 204 to 219, further comprising a lubricant. The pharmaceutical composition of claim 220, wherein the lubricant is present in the composition as solid particles. The pharmaceutical composition of claim 220 or 221, wherein the lubricant is sodium stearyl fumarate or magnesium stearate. The pharmaceutical composition according to any one of claims 204 to 222, further comprising a filler. The pharmaceutical composition of claim 223, wherein the filler is present in the composition as solid particles. The pharmaceutical composition of claim 223 or 224, wherein the filler is lactose, lactose monohydrate, starch, isomalt, mannitol, sodium starch glycolate, sorbitol, spray dried lactose, anhydrous lactose Or a combination thereof. The pharmaceutical composition of claim 225, wherein the filler is mannitol or Lactose monohydrate. The pharmaceutical composition of any one of claims 204 to 226, wherein the amount of laquinimod in the composition is less than 0.6 mg. The pharmaceutical composition according to any one of claims 204 to 226, wherein the amount of laquinimod in the composition is from 0.1 to 40.0 mg. The pharmaceutical composition of claim 228, wherein the amount of laquinimod in the composition is from 0.1 to 2.5 mg. The pharmaceutical composition of claim 228, wherein the amount of laquinimod in the composition is from 0.25 to 2.0 mg. The pharmaceutical composition of claim 228, wherein the amount of laquinimod in the composition is from 0.5 to 1.2 mg. The pharmaceutical composition of claim 228, wherein the amount of laquinimod in the composition is 0.25 mg. The pharmaceutical composition of claim 228, wherein the amount of laquinimod in the composition is 0.3 mg. The pharmaceutical composition of claim 228, wherein the amount of laquinimod in the composition is 0.5 mg. The pharmaceutical composition of claim 228, wherein the amount of laquinimod in the composition is 0.6 mg. The pharmaceutical composition of claim 228, wherein the amount of laquinimod in the composition is 1.0 mg. The pharmaceutical composition of claim 228, wherein the amount of laquinimod in the composition is 1.2 mg. The pharmaceutical composition of claim 228, wherein the composition is laquinimod The amount is 1.5 mg. The pharmaceutical composition of claim 228, wherein the amount of laquinimod in the composition is 2.0 mg. The pharmaceutical composition according to any one of claims 204 to 239, wherein the amount of glatiramer acetate in the composition is from 0.1 to 1000 mg. The pharmaceutical composition of claim 240, wherein the amount of glatiramer acetate in the composition is from 50 to 150 mg. The pharmaceutical composition of claim 240, wherein the amount of glatiramer acetate in the composition is from 10 to 600 mg. The pharmaceutical composition of claim 240, wherein the amount of glatiramer acetate in the composition is from 0.1 to 70 mg. The pharmaceutical composition of claim 240, wherein the amount of glatiramer acetate in the composition is from 10 to 80 mg. The pharmaceutical composition of claim 240, wherein the amount of glatiramer acetate in the composition is 1 mg. The pharmaceutical composition of claim 240, wherein the amount of glatiramer acetate in the composition is 5 mg. The pharmaceutical composition of claim 240, wherein the amount of glatiramer acetate in the composition is 15 mg. The pharmaceutical composition of claim 240, wherein the amount of glatiramer acetate in the composition is 20 mg. The pharmaceutical composition of claim 240, wherein the amount of glatiramer acetate in the composition is 30 mg. The pharmaceutical composition of claim 240, wherein the composition is substituted with acetic acid The amount of thunder is 40 mg. The pharmaceutical composition of claim 240, wherein the amount of glatiramer acetate in the composition is 50 mg. The pharmaceutical composition of claim 240, wherein the amount of glatiramer acetate in the composition is 100 mg. The pharmaceutical composition of claim 240, wherein the amount of glatiramer acetate in the composition is 300 mg. The pharmaceutical composition of claim 248, wherein the composition is 0.5 ml of a unit dose comprising an aqueous solution of 20 mg of glatiramer acetate. The pharmaceutical composition of claim 254, wherein the composition is a 0.5 ml unit dose comprising an aqueous solution of 20 mg glatiramer acetate and 20 mg mannitol. The pharmaceutical composition of claim 248, wherein the composition is a unit dose of 1 ml of an aqueous pharmaceutical solution comprising 20 mg of glatiramer acetate and 40 mg of mannitol in solution. The pharmaceutical composition of claim 250, wherein the composition is a unit dose of 1 ml of an aqueous solution of the drug, which comprises 40 mg of glatiramer acetate in solution. A use of a certain amount of laquinimod and a quantity of glatiramer acetate for the preparation of a combination for treating a human patient suffering from multiple sclerosis or having a clinical single syndrome, wherein the laquinimod or The pharmaceutically acceptable salt and the glatiramer acetate are administered simultaneously or simultaneously. A pharmaceutical composition comprising a quantity of laquinimod as adjunctive therapy or in combination with glatiramer acetate, administered to individuals on a regular basis The pharmaceutical composition and the glatiramer acetate are used to treat an individual having multiple sclerosis or having a clinical single syndrome. A pharmaceutical composition comprising a quantity of glatiramer acetate as adjunctive therapy or in combination with laquinimod, the pharmaceutical composition and the laquinimod are administered to an individual on a regular basis for the treatment of a patient Individuals with multiple sclerosis or clinically single syndrome.