US20130310385A1

US20130310385A1 - Pharmaceutical Composition Comprising (1r,4r)-6'-fluoro-N,N-dimethyl-4-phenyl-4',9'-dihydro-3'H-spiro[cyclohexane-1,1'-pyrano[3,4,b]indol]-4-amine and Antidepressants

Info

Publication number: US20130310385A1
Application number: US13/892,803
Authority: US
Inventors: Stefanie Frosch; Klaus Linz; Thomas Christoph
Original assignee: Gruenenthal GmbH
Current assignee: Gruenenthal GmbH
Priority date: 2012-05-18
Filing date: 2013-05-13
Publication date: 2013-11-21
Also published as: EA027268B1; RS56856B1; JP2015520154A; DK2849744T3; CN104271131A; LT2849744T; MX2014012859A; US20170065560A1; ES2660461T3; EP2849744A1; PL2849744T3; WO2013170965A1; EA201401269A1; US10328055B2; HK1204944A1; HRP20171922T1; AU2013262071A1; AU2013262071B2; CY1119825T1; JP6116672B2

Abstract

The invention relates to a pharmaceutical composition comprising a first pharmacologically active ingredient selected from (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1′-pyrano[3,4,b]indol]-4-amine and the physiologically acceptable salts thereof, and a second pharmacologically active ingredient which is an antidepressant.

Description

The invention relates to a pharmaceutical composition comprising a first pharmacologically active ingredient selected from (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1′-pyrano[3,4,b]indol]-4-amine and the physiologically acceptable salts thereof, and a second pharmacologically active ingredient which is an antidepressant.
(1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1′-pyrano-[3,4,b]indol]-4-amine and its corresponding physiologically acceptable salts as well as methods for their preparation are well known, for example, from WO2004/043967 and WO2008/040481. The compounds exhibit analgesic properties and are particularly suitable for the treatment of acute, visceral, neuropathic or chronic (nociceptive) pain.
The term antidepressant, which is known to a person skilled in the art, is meant to include all substances listed in the Anatomical Therapeutic Chemical (ATC) classification under [N06A] as used by the WHO for classification of pharmaceutically active ingredients.
Antidepressants are primarily used for the treatment of mood disorders (affective disorders) but may also be effective in the treatment of anxiety, obsessive compulsive disorders, eating disorders, insomnia, posttraumatic stress disorder and chronic pain.
Though both of the aforementioned substance classes are therapeutically effective, side effects may occur, especially upon prolonged use or when administered at high dosages.
It is further known that specific combinations of pharmacologically active compounds exert supra-additive (synergistic) therapeutic effects upon administration. An advantage of these special cases is that the overall dose and accordingly the risk of undesired side effects may be reduced.
In a further aspect, two pharmacologically active compounds exerting a synergistic effect may be combined in one single pharmaceutical dosage form, e.g. a tablet, thus enhancing patient compliance.
It is an object of the invention to provide pharmaceutical compositions which have advantages compared to pharmaceutical compositions of the prior art. In particular, the pharmaceutical compositions should provide rapid therapeutic effects, but also should have a high tolerability, good compliance and safety.
This object has been achieved by the subject-matter of the patent claims.
It has been surprisingly found that a pharmaceutical composition comprising (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1′-pyrano[3,4,b]indol]-4-amine and an antidepressant is useful for the treatment of pain, especially chronic pain, in particular neuropathic pain.
Further it has been surprisingly found that said composition exhibits a synergistic therapeutic effect upon administration. Therefore, the overall administered dose may be lowered, so that fewer undesired side-effects will occur.
A first aspect of the invention relates to a pharmaceutical composition comprising:

- a) a first pharmacologically active ingredient selected from (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1′-pyrano[3,4,b]indol]-4-amine and the physiologically acceptable salts thereof, and
- b) a second pharmacologically active ingredient which is an antidepressant.

The pharmaceutical composition according to the invention comprises a first pharmacologically active ingredient selected from (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1′-pyrano[3,4,b]indol]-4-amine and the physiologically acceptable salts thereof.
For the purpose of specification, (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1′-pyrano[3,4,b]indol]-4-amine is the compound according to formula (I) which can also be referred to as 1,1-(3-dimethylamino-3-phenylpentamethylene)-6-fluoro-1,3,4,9-tetrahydropyrano[3,4-b]indole (trans)
The definition of the first pharmacologically active ingredient includes (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1′-pyrano-[3,4,b]indol]-4-amine in form of the free base, i.e. the compound according to formula (I) in any possible form including solvates, cocrystals and polymorphs, and its physiologically acceptable salts, in particular acid addition salts and corresponding solvates, cocrystals and polymorphs.
The pharmacologically active ingredient (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1′-pyrano[3,4,b]indol]-4-amine may be present in the pharmaceutical composition according to the invention in form of a physiologically acceptable salt, preferably an acid addition salt, whereby any suitable acid capable of forming such an addition salt may be used.
The conversion of (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclo-hexane-1,1′-pyrano[3,4,b]indol]-4-amine into a corresponding addition salt, for example, via reaction with a suitable acid may be effected in a manner well known to those skilled in the art. Suitable acids include but are not limited to hydrochloric acid, hydrobromic acid, sulfuric acid, methanesulfonic acid, formic acid, acetic acid, oxalic acid, succinic acid, tartaric acid, mandelic acid, fumaric acid, lactic acid, citric acid, glutamic acid and/or aspartic acid. Salt formation is preferably effected in a solvent, for example, diethyl ether, diisopropyl ether, alkyl acetates, acetone and/or 2-butanone. Moreover, trimethylchlorosilane in aqueous solution is also suitable for the preparation of hydrochlorides.
In a preferred embodiment, the first pharmacologically active ingredient is (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1′-pyrano[3,4,b]indol]-4-amine in form of the free base, i.e. the compound according to formula (I).
In another preferred embodiment, the first pharmacologically active ingredient is (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1′-pyrano[3,4,b]indol]-4-amine in form of a physiologically acceptable acid addition salt, in particular the hydrochloride, hemicitrate or maleate salt.
Unless explicitly stated otherwise, all amounts of the first pharmacologically active ingredient specified in the following are given according to the corresponding amount of (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1-pyrano[3,4,b]indol]-4-amine in form of the free base, i.e. the compound according to formula (I).
The pharmaceutical composition according to the invention comprises a second pharmacologically active ingredient which is an antidepressant.
The definition of the second pharmacologically active ingredient includes antidepressants in any possible form including any enantiomers, if applicable, solvates, prodrugs, cocrystals and polymorphs, and their physiologically acceptable salts, in particular acid addition salts and corresponding solvates, cocrystals and polymorphs.
Preferred antidepressants according to the invention may be transformed into the corresponding acid addition salts as well as the corresponding metal salts. This may be effected in a manner well known to those skilled in the art, for example, via reaction with a suitable acid or base as well as metal salt. Suitable acids include but are not limited to hydrochloric acid, hydrobromic acid, sulfuric acid, methanesulfonic acid, formic acid, acetic acid, oxalic acid, succinic acid, tartaric acid, mandelic acid, fumaric acid, lactic acid, citric acid, glutamic acid and/or aspartic acid. Moreover, trimethylchlorosilane in aqueous solution is also suitable for the preparation of hydrochlorides. Suitable bases include but are not limited to the hydroxides of sodium, potassium, calcium and/or magnesium. Suitable metal salts include but are not limited to alkali salts such as sodium, potassium or lithium phosphate, sulfate, methanesulfonate, formate, acetate, oxalate, succinate, tartrate, mandelate, fumarate, lactate, citrate, glutamate, aspartate and/or silyls, as well as alkaline earth salts, in particular magnesium and calcium salts, including their phosphate, sulfate, methanesulfonate, formate, acetate, oxalate, succinate, tartrate, mandelate, fumarate, lactate, citrate, glutamate, aspartate and/or silyl salts. Salt formation is preferably effected in a solvent, for example, diethyl ether, diisopropyl ether, alkyl acetates, acetone and/or 2-butanone.
As prodrugs of antidepressants, amides are particularly preferred. Suitable methods for selecting and preparing a prodrug of a given substance are, for example, described in “Textbook of Drug Design and Discovery, 3^rdedition, 2002, chapter 14, pages 410-458, Editors: Krogsgaard-Larsen et al., Taylor and Francis.
In a preferred embodiment, the second pharmacologically active ingredient is a selective serotonin reuptake inhibitor.
In another preferred embodiment, the second pharmacologically active ingredient is a selective serotonin reuptake inhibitor selected from the group consisting of zimeldine, fluoxetine, citalopram, paroxetine, sertraline, alaproclate, fluvoxamine, etoperidone, escitalopram and the physiologically acceptable salts thereof.
In still another preferred embodiment, the second pharmacologically active ingredient is a non-selective monoamine reuptake inhibitor.
In yet another preferred embodiment, the second pharmacologically active ingredient is a non-selective monoamine reuptake inhibitor selected from the group consisting of desipramine, imipramine, imipramine oxide, clomipramine, opipramol, trimipramine, lofepramine, dibenzepin, amitryptyline, nortriptyline, protriptyline, doxepin, iprindole, melitracen, butriptylene, dosulepin, amoxapine, dimetacrine, amineptine, maprotiline, quinupramine and the physiologically acceptable salts thereof.
In a further preferred embodiment, the second pharmacologically active ingredient is selected from the group consisting of oxitriptan, tryptophan, mianserin, nomifensine, trazodone, nefazodone, minaprine, bifemelane, viloxazine, oxaflozane, mirtazapine, bupropion, medifoxamine, tianeptine, pivagabine, venlafaxine, milnacipran, reboxetine, gepirone, duloxetine, agomelatine, desvenlafaxine, vilazodone and the physiologically acceptable salts thereof, as well as Hyperici herba.
Unless explicitly stated otherwise, all amounts of the second pharmacologically active ingredient specified in the following are given according to the corresponding amount of the free compound.
In a preferred embodiment, the second pharmacologically active ingredient is an antidepressant in form of the free compound.
In another preferred embodiment, the second pharmacologically active ingredient is an antidepressant in form of its hydrochloride addition salt.
In a preferred embodiment, the second pharmacologically active ingredient is duloxetine.
In another preferred embodiment, the second pharmacologically active ingredient is (S)-duloxetine.
In still another preferred embodiment, the second pharmacologically active ingredient is reboxetine.
In a preferred embodiment, the first pharmacologically active ingredient is (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1′-pyrano[3,4,b]indol]-4-amine in form of the free base, i.e. the compound according to formula (I), and the second pharmacologically active ingredient is an antidepressant.
In another preferred embodiment, the first pharmacologically active ingredient is (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1′-pyrano[3,4,b]indol]-4-amine in form of the free base, i.e. the compound according to formula (I), and the second pharmacologically active ingredient is an antidepressant in the form of the respective hydrochloride addition salt.
In still another preferred embodiment, the first pharmacologically active ingredient is (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1′-pyrano[3,4,b]indol]-4-amine in form of the free base, i.e. the compound according to formula (I), and the second pharmacologically active ingredient is duloxetine, preferably in form of the free compound.
In yet another preferred embodiment, the first pharmacologically active ingredient is (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1′-pyrano[3,4,b]indol]-4-amine in form of the free base, i.e. the compound according to formula (I), and the second pharmacologically active ingredient is duloxetine, preferably in form of the hydrochloride addition salt.
In a further preferred embodiment, the first pharmacologically active ingredient is (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1′-pyrano[3,4,b]indol]-4-amine in form of a physiologically acceptable acid addition salt, in particular the hydrochloride, hemicitrate or maleate salt, and the second pharmacologically active ingredient is duloxetine, preferably in form of the free compound.
In still a further preferred embodiment, the first pharmacologically active ingredient is (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1′-pyrano[3,4,b]indol]-4-amine in form of a physiologically acceptable acid addition salt, in particular the hydrochloride, hemicitrate or maleate salt, and the second pharmacologically active ingredient is duloxetine, preferably in form of the hydrochloride addition salt.
In yet a further preferred embodiment, the first pharmacologically active ingredient is (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′ H-spiro[cyclohexane-1,1′-pyrano[3,4,b]indol]-4-amine in form of the free base, i.e. the compound according to formula (I), and the second pharmacologically active ingredient is reboxetine, preferably in form of the free compound.
In another preferred embodiment, the first pharmacologically active ingredient is (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1′-pyrano[3,4,b]indol]-4-amine in form of a physiologically acceptable acid addition salt, in particular the hydrochloride, hemicitrate or maleate salt, and the second pharmacologically active ingredient is reboxetine, preferably in form of the free compound.
Another aspect of the invention relates to a pharmaceutical dosage form comprising the pharmaceutical composition according to the invention.
The first and the second pharmacologically active ingredient are typically contained in the pharmaceutical dosage form according to the invention in a therapeutically effective amount. The amount that constitutes a therapeutically effective amount varies according to the pharmacologically active ingredients, the condition being treated, the severity of said condition, the patient being treated, and whether the pharmaceutical dosage form is designed for an immediate or controlled release.
In a preferred embodiment, the content of the first pharmacologically active ingredient in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, is at most 10 wt.-% or at most 5 wt.-% or at most 3 wt.-% or at most 1.0 wt.-%, more preferably at most 0.8 wt.-%, yet more preferably at most 0.5 wt.-%, still more preferably at most 0.2 wt.-%, even more preferably at most 0.1 wt.-%, most preferably at most 0.05 wt.-%, and in particular at most 0.01 wt.-% or at most 0.005 wt.-% or at most 0.001 wt.-%.
In another preferred embodiment, the content of the second pharmacologically active ingredient in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, is at most 95 wt.-%, more preferably at most 80 wt.-%, yet more preferably at most 70 wt.-%, still more preferably at most 60 wt.-%, even more preferably at most 55 wt.-%, most preferably at most 50 wt.-%, and in particular at most 45 wt.-%.
In still another preferred embodiment, the content of the first pharmacologically active ingredient in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, is at least 0.0001 wt.-%, more preferably at least 0.0003 wt.-%, yet more preferably at least 0.0005 wt.-%, still more preferably at least 0.0008 wt.-%, even more preferably at least 0.001 wt.-%, most preferably at least 0.003 wt.-%, and in particular at least 0.005 wt.-%.
In yet another preferred embodiment, the content of the second pharmacologically active ingredient in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, is at least 0.001 wt.-%, more preferably at least 0.003 wt.-%, yet more preferably at least 0.005 wt.-%, still more preferably at least 0.001 wt.-%, even more preferably at least 0.1 wt.-%, most preferably at least 0.3 wt.-%, and in particular at least 0.5 wt.-%.
In a further preferred embodiment, the content of the second pharmacologically active ingredient in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, is at least 0.1 wt.-%, more preferably at least 0.5 wt.-%, yet more preferably at least 1 wt.-%, still more preferably at least 3 wt.-%, even more preferably at least 5 wt.-%, most preferably at least 7.5 wt.-%, and in particular at least 10 wt.-%.
Unless explicitly stated otherwise, in the meaning of the invention the indication “wt.-%” shall mean weight of the respective ingredient per total weight of the pharmaceutical dosage form or per total weight of the pharmaceutical composition, respectively.
Preferably, in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, the relative weight ratio of the first pharmacologically active ingredient to the second pharmacologically active ingredient is within the range of from 1:1 to 1:1,000,000, more preferably 1:1 to 1:500,000, most preferably 1:2 to 1:100,000, and in particular 1:50 to 1:100,000.
In a preferred embodiment, in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, the relative weight ratio of the first pharmacologically active ingredient to the second pharmacologically active ingredient is within the range of from 1:1 to 1:10, more preferably 1:2 to 1:7 and most preferably 1:3 to 1:6.
In another preferred embodiment, in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, the relative weight ratio of the first pharmacologically active ingredient to the second pharmacologically active ingredient is within the range of from 1:10 to 1:100, more preferably 1:20 to 1:85, still more preferably 1:30 to 1:75, most preferably 1:35 to 1:65, and in particular 1:40 to 1:60.
In still another preferred embodiment, in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, the relative weight ratio of the first pharmacologically active ingredient to the second pharmacologically active ingredient is within the range of from 1:10 to 1:500, more preferably 1:30 to 1:400, still more preferably 1:50 to 1:250, most preferably 1:70 to 1:150, and in particular 1:80 to 1:120.
In yet another preferred embodiment, in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, the relative weight ratio of the first pharmacologically active ingredient to the second pharmacologically active ingredient is within the range of from 1:100 to 1:10,000, more preferably 1:200 to 1:7,500, still more preferably 1:500 to 1:5,000, most preferably 1:750 to 1:2,500, and in particular 1:900 to 1:2,000.
In a further preferred embodiment, in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, the relative weight ratio of the first pharmacologically active ingredient to the second pharmacologically active ingredient is within the range of from 1:1,000 to 1:100,000, more preferably 1:2,000 to 1:80,000, still more preferably 1:4,000 to 1:50,000, yet more preferably 1:6,000 to 1:20,000, most preferably 1:8,000 to 1:15,000, and in particular 1:9,000 to 1:12,500.
In still a further preferred embodiment, in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, the relative weight ratio of the first pharmacologically active ingredient to the second pharmacologically active ingredient is within the range of from 1:5,000 to 1:500,000, more preferably 1:10,000 to 1:400,000, still more preferably 1:20,000 to 1:300,000, most preferably 1:40,000 to 1:250,000, and in particular 1:50,000 to 1:200,000.
In yet a further preferred embodiment, in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, the relative weight ratio of the first pharmacologically active ingredient to the second pharmacologically active ingredient is within the range of from 1:100,000 to 1:900,000, more preferably 1:250,000 to 1:800,000, still more preferably 1:300,000 to 1:700,000, most preferably 1:350,000 to 1:650,000, and in particular 1:400,000 to 1:600,000.
In another preferred embodiment, in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, the relative weight ratio of the first pharmacologically active ingredient to the second pharmacologically active ingredient is within the range of from 1:100,000 to 1:1,000,000, more preferably 1:250,000 to 1:980,000, still more preferably 1:500,000 to 1:960,000, most preferably 1:600,000 to 1:950,000, and in particular 1:700,000 to 1:900,000.
Preferably, in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, the relative molar ratio of the first pharmacologically active ingredient to the second pharmacologically active ingredient is within the range of from 1:1 to 1:1,000,000, more preferably 1:1 to 1:500,000, most preferably 1:2 to 1:100,000, and in particular 1:50 to 1:100,000.
In a preferred embodiment, in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, the relative molar ratio of the first pharmacologically active ingredient to the second pharmacologically active ingredient is within the range of from 1:1 to 1:10, more preferably 1:2 to 1:7 and most preferably 1:3 to 1:6.
In another preferred embodiment, in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, the relative molar ratio of the first pharmacologically active ingredient to the second pharmacologically active ingredient is within the range of from 1:10 to 1:100, more preferably 1:20 to 1:85, still more preferably 1:30 to 1:75, most preferably 1:35 to 1:65, and in particular 1:40 to 1:60.
In still another preferred embodiment, in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, the relative molar ratio of the first pharmacologically active ingredient to the second pharmacologically active ingredient is within the range of from 1:10 to 1:500, more preferably 1:30 to 1:400, still more preferably 1:50 to 1:250, most preferably 1:70 to 1:150, and in particular 1:80 to 1:120.
In yet another preferred embodiment, in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, the relative molar ratio of the first pharmacologically active ingredient to the second pharmacologically active ingredient is within the range of from 1:100 to 1:10,000, more preferably 1:200 to 1:7,500, still more preferably 1:500 to 1:5,000, most preferably 1:750 to 1:2,500, and in particular 1:900 to 1:2,000.
In a further preferred embodiment, in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, the relative molar ratio of the first pharmacologically active ingredient to the second pharmacologically active ingredient is within the range of from 1:1,000 to 1:100,000, more preferably 1:2,000 to 1:80,000, still more preferably 1:4,000 to 1:50,000, yet more preferably 1:6,000 to 1:20,000, most preferably 1:8,000 to 1:15,000, and in particular 1:9,000 to 1:12,500.
In still a further preferred embodiment, in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, the relative molar ratio of the first pharmacologically active ingredient to the second pharmacologically active ingredient is within the range of from 1:5,000 to 1:500,000, more preferably 1:10,000 to 1:400,000, still more preferably 1:20,000 to 1:300,000, most preferably 1:40,000 to 1:250,000, and in particular 1:50,000 to 1:200,000.
In yet a further preferred embodiment, in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, the relative molar ratio of the first pharmacologically active ingredient to the second pharmacologically active ingredient is within the range of from 1:100,000 to 1:900,000, more preferably 1:250,000 to 1:800,000, still more preferably 1:300,000 to 1:700,000, most preferably 1:350,000 to 1:650,000, and in particular 1:400,000 to 1:600,000.
In another preferred embodiment, in the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, the relative molar ratio of the first pharmacologically active ingredient to the second pharmacologically active ingredient is within the range of from 1:100,000 to 1:1,000,000, more preferably 1:250,000 to 1:980,000, still more preferably 1:500,000 to 1:960,000, most preferably 1:600,000 to 1:950,000, and in particular 1:700,000 to 1:900,000.
The amounts of the first and the second pharmacologically active ingredient contained in the pharmaceutical dosage form according to the invention may vary depending on different factors well known to those skilled in the art, for example, the weight of the patient, the route of administration, the severity of the illness and the like.
In general, both pharmacologically active ingredients contained in the pharmaceutical dosage form according to the invention may be administered in amounts up to their maximum daily dose, which is known to those skilled in the art. For example, as the second pharmacologically active ingredient, duloxetine may preferably be administered to a patient in a maximum daily dose of up to 120 mg and reboxetine may preferably be administered to a patient in a daily dose of up to 12 mg.
When administered in the prescribed manner, e.g. once daily or twice daily, the pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, preferably contain the first and the second pharmacologically active ingredient, independently of one another, in an amount corresponding to 75±15 wt.-%, 75±10 wt.-%, 75±5 wt.-%, 50±15 wt.-%, 50±10 wt.-%, 50±5 wt.-%, 25±15 wt.-%, 25±10 wt.-% or 25±5 wt.-% of the respective maximum daily dose of the first and the second pharmacologically active ingredient, respectively.
Preferably, the pharmaceutical dosage form according to the invention contains the first pharmacologically active ingredient in a dose of from 0.1 μg to 5,000 μg, more preferably, 0.1 μg to 2,500 μg, still more preferably 1.0 μg to 1,000 μg, yet more preferably 10 to 800 μg, most preferably 15 μg to 600 μg, and in particular 20 μg to 440 μg.
In a preferred embodiment, the pharmaceutical dosage form according to the invention contains the first pharmacologically active ingredient in a dose within the range of 13±12 μg, more preferably 13±10 μg, still more preferably 13±8 μg, yet more preferably 13±6 μg, even more preferably 13±5 μg, most preferably 13±4 μg, and in particular 13±3 μg.
In another preferred embodiment, the pharmaceutical dosage form according to the invention contains the first pharmacologically active ingredient in a dose within the range of 20±15 μg, more preferably 20±13 μg, still more preferably 20±12 μg, yet more preferably 20±10 μg, even more preferably 20±8 μg, most preferably 20±6 μg, and in particular 20±5 μg.
In still another preferred embodiment, the pharmaceutical dosage form according to the invention contains the first pharmacologically active ingredient in a dose within the range of 40±35 μg, more preferably 40±30 μg, still more preferably 40±25 μg, yet more preferably 40±20 μg, even more preferably 40±15 μg, most preferably 40±10 μg, and in particular 40±5 μg.
In yet another preferred embodiment, the pharmaceutical dosage form according to the invention contains the first pharmacologically active ingredient in a dose within the range of 60±50 μg, more preferably 60±40 μg, still more preferably 60±30 μg, yet more preferably 60±20 μg, most preferably 60±10 μg, and in particular 60±5 μg.
In a further preferred embodiment, the pharmaceutical dosage form according to the invention contains the first pharmacologically active ingredient in a dose within the range of 80±70 μg, more preferably 80±60 μg, still more preferably 80±50 μg, yet more preferably 80±40 μg, even more preferably 80±20 μg, most preferably 80±10 μg, and in particular 80±5 μg.
In still a further preferred embodiment, the pharmaceutical dosage form according to the invention contains the first pharmacologically active ingredient in a dose within the range of 100±90 μg, more preferably 100±80 μg, still more preferably 100±60 μg, yet more preferably 100±40 μg, even more preferably 100±20 μg, most preferably 100±10 μg, and in particular 100±5 μg.
In yet a further preferred embodiment, the pharmaceutical dosage form according to the invention contains the first pharmacologically active ingredient in a dose within the range of 120±100 μg, more preferably 120±80 μg, still more preferably 120±60 μg, yet more preferably 120±40 μg, even more preferably 120±20 μg, most preferably 120±10 μg, and in particular 120±5 μg.
In another preferred embodiment, the pharmaceutical dosage form according to the invention contains the first pharmacologically active ingredient in a dose within the range of 150±90 μg, more preferably 150±80 μg, still more preferably 150±60 μg, yet more preferably 150±40 μg, even more preferably 150±20 μg, most preferably 150±10 μg, and in particular 150±5 μg.
In still another preferred embodiment, the pharmaceutical dosage form according to the invention contains the first pharmacologically active ingredient in a dose within the range of 170±130 μg, more preferably 170±100 μg, still more preferably 170±80 μg, yet more preferably 170±60 μg, even more preferably 170±40 μg, most preferably 170±20 μg, and in particular 170±10 μg.
In yet another preferred embodiment, the pharmaceutical dosage form according to the invention contains the first pharmacologically active ingredient in a dose within the range of 200±175 μg, more preferably 200±150 μg, still more preferably 200±125 μg, yet more preferably 200±100 μg, even more preferably 200±75 μg, most preferably 200±50 μg, and in particular 200±25 μg.
In a further preferred embodiment, the pharmaceutical dosage form according to the invention contains the first pharmacologically active ingredient in a dose within the range of 400±350 μg, more preferably 400±300 μg, still more preferably 400±250 μg, yet more preferably 400±200 μg, even more preferably 400±150 μg, most preferably 400±100 μg, and in particular 400±50 μg.
In another preferred embodiment, the pharmaceutical dosage form according to the invention contains the first pharmacologically active ingredient in a dose within the range of 600±400 μg, more preferably 600±300 μg, still more preferably 600±250 μg, yet more preferably 600±200 μg, even more preferably 600±150 μg, most preferably 600±100 μg, and in particular 600±50 μg.
In still another preferred embodiment, the pharmaceutical dosage form according to the invention contains the first pharmacologically active ingredient in a dose within the range of 800±550 μg, more preferably 800±400 μg, still more preferably 800±350 μg, yet more preferably 800±250 μg, even more preferably 800±150 μg, most preferably 800±100 μg, and in particular 800±50 μg.
In yet another preferred embodiment, the pharmaceutical dosage form according to the invention contains the first pharmacologically active ingredient in a dose within the range of 1,000±800 μg, more preferably 1,000±600 μg, still more preferably 1,000±500 μg, yet more preferably 1,000±300 μg, even more preferably 1,000±200 μg, most preferably 1,000±100 μg, and in particular 1,000±50 μg.
In a further preferred embodiment, the pharmaceutical dosage form according to the invention contains the first pharmacologically active ingredient in a dose within the range of 1,200±1,000 μg, more preferably 1,200±800 μg, still more preferably 1,200±600 μg, yet more preferably 1,200±400 μg, even more preferably 1,200±200 μg, most preferably 1,200±100 μg, and in particular 1,200±50 μg.
Preferably, the pharmaceutical dosage form according to the invention contains the second pharmacologically active ingredient in a dose of from 1 mg to 1,000 mg, more preferably, 2 mg to 800 mg, still more preferably 3 mg to 700 mg, most preferably 4 mg to 600 mg, and in particular 5 mg to 500 mg.
In a preferred embodiment, the pharmaceutical dosage form according to the invention contains the second pharmacologically active ingredient in a dose within the range of 5±4 mg, more preferably 5±3 mg and most preferably 5±2 mg.
In another preferred embodiment, the pharmaceutical dosage form according to the invention contains the second pharmacologically active ingredient in a dose within the range of 10±8 mg, more preferably 10±7 mg, still more preferably 10±6 mg, yet more preferably 10±5 mg and most preferably 10±4 mg.
In still another preferred embodiment, the pharmaceutical dosage form according to the invention contains the second pharmacologically active ingredient in a dose within the range of 20±15 mg, more preferably 20±12 mg, still more preferably 20±10 mg and most preferably 20±8 mg.
In yet another preferred embodiment, the pharmaceutical dosage form according to the invention contains the second pharmacologically active ingredient in a dose within the range of 35±20 mg, more preferably 35±18 mg, still more preferably 35±15 mg, yet more preferably 35±12 mg, even more preferably 35±10 mg and most preferably 35±8 mg.
In a further preferred embodiment, the pharmaceutical dosage form according to the invention contains the second pharmacologically active ingredient in a dose within the range of 50±40 mg, more preferably 50±35 mg, still more preferably 50±30 mg, yet more preferably 50±25 mg, even more preferably 50±20 mg, most preferably 50±15 mg, and in particular 50±10 mg.
In still a further preferred embodiment, the pharmaceutical dosage form according to the invention contains the second pharmacologically active ingredient in a dose within the range of 75±55 mg, more preferably 75±45 mg, still more preferably 75±35 mg, yet more preferably 75±25 mg and most preferably 75±15 mg.
In yet a further preferred embodiment, the pharmaceutical dosage form according to the invention contains the second pharmacologically active ingredient in a dose within the range of 100±150 mg, more preferably 100±120 mg, still more preferably 100±100 mg, yet more preferably 100±80 mg, even more preferably 100±60 mg, most preferably 100±40 mg, and in particular 100±20 mg.
In another preferred embodiment, the pharmaceutical dosage form according to the invention contains the second pharmacologically active ingredient in a dose within the range of 150±100 mg, more preferably 150±80 mg, still more preferably 150±60 mg, yet more preferably 150±40 mg, most preferably 150±30 mg, and in particular 150±25 mg.
In still another preferred embodiment, the pharmaceutical dosage form according to the invention contains the second pharmacologically active ingredient in a dose within the range of 200±150 mg, more preferably 200±130 mg, still more preferably 200±110 mg, yet more preferably 200±90 mg, even more preferably 200±70 mg, most preferably 200±60 mg, and in particular 200±50 mg.
In yet another preferred embodiment, the pharmaceutical dosage form according to the invention contains the second pharmacologically active ingredient in a dose within the range of 250±200 mg, more preferably 250±180 mg, still more preferably 250±150 mg, yet more preferably 250±125 mg, even more preferably 250±100 mg, most preferably 250±75 mg, and in particular 250±50 mg.
In a preferred embodiment, the pharmaceutical dosage form according to the invention contains the second pharmacologically active ingredient in a dose within the range of 300±250 mg, more preferably 300±200 mg, still more preferably 300±150 mg, yet more preferably 300±125 mg, even more preferably 300±100 mg, most preferably 300±75 mg, and in particular 300±50 mg.
In another preferred embodiment, the pharmaceutical dosage form according to the invention contains the second pharmacologically active ingredient in a dose within the range of 500±400 mg, more preferably 500±300 mg, still more preferably 500±200 mg, yet more preferably 500±150 mg, even more preferably 500±100 mg, most preferably 500±75 mg, and in particular 500±50 mg.
In still another preferred embodiment, the pharmaceutical dosage form according to the invention contains the second pharmacologically active ingredient in a dose within the range of 750±500 mg, more preferably 750±400 mg, still more preferably 750±250 mg, yet more preferably 750±100 mg, even more preferably 750±75 mg, most preferably 750±50 mg, and in particular 750±25 mg.
In yet another preferred embodiment, the pharmaceutical dosage form according to the invention contains the second pharmacologically active ingredient in a dose within the range of 1,000±500 mg, more preferably 1,000±400 mg, still more preferably 1,000±250 mg, yet more preferably 1,000±100 mg, even more preferably 1,000±75 mg, most preferably 1,000±50 mg, and in particular 1,000±25 mg.
In a preferred embodiment, the pharmaceutical dosage form contains duloxetine, preferably (S)-duloxetine as the second pharmacologically active ingredient in a dose within the range of 10 mg to 800 mg, more preferably in the range of 15 mg to 500 mg, even more preferably in the range of 20 mg to 400 mg, most preferably in the range of 30 mg to 300 mg and in particular in the range of 40 mg to 200 mg.
In another preferred embodiment, the pharmaceutical dosage form contains reboxetine as the second pharmacologically active ingredient in a dose within the range of 1 mg to 20 mg, more preferably in the range of 2 mg to 18 mg, even more preferably in the range of 3 mg to 16 mg, most preferably in the range of 4 mg to 15 mg and in particular in the range of 5 mg to 14 mg.
In the pharmaceutical dosage form according to the invention, the dose of the first pharmacologically active ingredient is preferably within the range of from 1:20 to 20:1 of the amount which is equieffective to the dosage of the second pharmacologically active ingredient. In this regard, “equieffective” preferably means the dosage that would be required in order to achieve the equivalent desired therapeutic effect when being administered alone. A skilled person recognizes that when the desired therapeutic effect is an analgesic effect, the equieffective dosage is determined with respect to the analgesic properties of the first pharmacologically active ingredient and the second pharmacological ingredient.
For example, when the dose of the second pharmacologically active ingredient, which is contained in the pharmaceutical dosage form according to the invention, amounts to e.g. 30 mg and provides an analgesic effect E when being administered alone at this dose, and when the equieffective amount of the first pharmacologically active ingredient, i.e. the amount needed in order to provide the same analgesic effect E when being administered alone, would be e.g. 4 μg, the dosage of the first pharmacologically active ingredient, which is contained in the pharmaceutical dosage form according to the invention, may vary from 0.2 μg (4 μg/20) to 80 μg (20.4 μg).
In a preferred embodiment, the dose of the first pharmacologically active ingredient is within the range of from 1:15 to 15:1, preferably within the range of from 1:10 to 10:1, more preferably within the range of from 1:8 to 8:1, still more preferably within the range of from 1:6 to 6:1, yet more preferably within the range of from 1:4 to 4:1, most preferably within the range of from 1:3 to 3:1, and in particular preferably within the range of from 1:2 to 2:1, of the amount which is equieffective to the dose of the second pharmacologically active ingredient.
Suitable pathways of administration of the pharmaceutical dosage form according to the invention include but are not limited to oral, intravenous, intraperitoneal, intradermal, transdermal, intrathecal, intramuscular, intranasal, transmucosal, subcutaneous, local and/or rectal administration.
In a preferred embodiment, the pharmaceutical dosage form according to the invention is for oral administration.
In another preferred embodiment, the pharmaceutical dosage form according to the invention is for parenteral, in particular intravenous, intraperitoneal, intrathecal, intramuscular or subcutaneous administration.
The pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, can be solid, semi-solid or liquid.
The pharmaceutical dosage form according to the invention and the pharmaceutical composition according to the invention, respectively, may contain auxiliary agents, for example, carriers, fillers, solvents, diluents, colorants and/or binders. The selection of auxiliary agents and of the amounts of the same to be used depends, for example, on how the first and the second pharmacologically active ingredient are to be administered, e.g. orally, intravenously, intraperitoneally, intradermally, transdermally, intrathecally, intramuscularly, intranasally, transmucosally, subcutaneously, rectally or locally.
Suitable auxiliary agents are in particular any substances known to a person skilled in the art useful for the preparation of galenical dosage forms. Examples of suitable auxiliary agents include but are not limited to: water, ethanol, 2-propanol, glycerol, ethylene glycol, propylene glycol, polyethylene glycol, polypropylene glycol, glucose, fructose, lactose, saccharose, dextrose, molasses, starch, modified starch, gelatine, sorbitol, inositol, mannitol, microcrystalline cellulose, methyl cellulose, carboxymethyl cellulose, cellulose acetate, shellac, cetyl alcohol, polyvinyl pyrrolidone, paraffins, waxes, natural and synthetic gums, acacia gum, alginates, dextran, saturated and unsaturated fatty acids, stearic acid, magnesium stearate, zinc stearate, glycerol stearate, sodium lauryl sulphate, edible oils, sesame oil, coconut oil, peanut oil, soybean oil, lecithin, sodium lactate, polyoxyethylene and polypropylene fatty acid ester, sorbitan fatty acid ester, sorbic acid, benzoic acid, citric acid, ascorbic acid, tannic acid, sodium chloride, potassium chloride, magnesium chloride, calcium chloride, magnesium oxide, zinc oxide, silicon dioxide, titanium oxide, titanium dioxide, magnesium sulphate, zinc sulphate, calcium sulphate, potash, calcium phosphate, dicalcium phosphate, potassium bromide, potassium iodide, talcum, kaolin, pectin, crosspovidone, agar and bentonite.
Pharmaceutical dosage forms which are suitable for oral administration include but are not limited to tablets, effervescent tablets, chewing tablets, dragees, capsules, drops, juices and syrups. Oral pharmaceutical dosage forms may also be in the form of multiparticulates such as granules, pellets, spheres, crystals and the like, optionally compressed into a tablet, filled into a capsule, filled into a sachet or suspended in a suitable liquid medium. Oral pharmaceutical dosage forms may also be equipped with an enteric coating.
Pharmaceutical dosage forms that are suitable for parenteral, topical and inhalative administration include but are not limited to solutions, suspensions, easily reconstitutable dry preparations and sprays.
Suppositories are a suitable pharmaceutical dosage form for rectal administration. Dosage forms in a deposit, in dissolved form, for example, in a patch optionally with the addition of agents to promote skin penetration, are examples of suitable dosage forms for percutaneous administration.
In an especially preferred embodiment, the pharmaceutical dosage form according to the invention is a tablet.
In a preferred embodiment, the pharmaceutical dosage form according to the invention is for administration six times daily, five times daily, four times daily, thrice daily, twice daily, once daily, or less frequently.
In another preferred embodiment, the pharmaceutical dosage form according to the invention is adapted for administration less frequently than once daily, preferably thrice during four days (¾), twice during three days (⅔), thrice during five days (⅗), once during two days (½), thrice in a week ( 3/7), twice during five days (⅖), once during three days (⅓), twice in a week ( 2/7), once during four days (¼), once during five days (⅕), once during six days (⅙), or once in a week ( 1/7). According to this embodiment, administration once during two days (½) is particularly preferred.
In still another preferred embodiment, the pharmaceutical dosage form according to the invention is for administration once daily.
In yet another preferred embodiment, the pharmaceutical dosage form according to the invention is for administration twice daily.
In a further preferred embodiment, the pharmaceutical dosage form according to the invention is for administration thrice daily.
In still a further preferred embodiment, the pharmaceutical dosage form according to the invention is for administration less frequently than once daily, preferably thrice during five days (⅗) or once during two days (½).
Particularly when the second pharmacologically active ingredient is duloxetine or reboxetine, the pharmaceutical dosage form according to the invention is preferably for administration once, twice or thrice daily.
For the purpose of specification, “administration thrice daily” (tid) preferably means that the pharmaceutical dosage form according to the invention is adapted for being consecutively administered according to a regimen comprising the administration of three pharmaceutical dosage forms per day, wherein the time interval between the consecutive administration of two pharmaceutical dosage forms is at least 3 hours, preferably at least 4 hours, more preferably not least 6 hours and in particular, about 8 hours.
For the purpose of specification, “administration twice daily” (bid) preferably means that the pharmaceutical dosage form according to the invention is adapted for being consecutively administered according to a regimen comprising the administration of two pharmaceutical dosage forms per day, wherein the time interval between the consecutive administration of two pharmaceutical dosage forms is at least 6 hours, preferably at least 8 hours, more preferably at least 10 hours and in particular, about 12 hours.
For the purpose of specification, “administration once daily” (sid) preferably means that the pharmaceutical dosage form according to the invention is adapted for being consecutively administered according to a regimen comprising the administration of one pharmaceutical dosage form per day, wherein the time interval between the consecutive administration of two pharmaceutical dosage forms is at least 18 hours, preferably at least 20 hours, more preferably at least 22 hours and in particular, about 24 hours.
A skilled person is fully aware that the above administration regimens may be realized by administering a single pharmaceutical dosage form containing the full amount of the first pharmacologically active ingredient and the full amount of the second pharmacologically active ingredient to be administered at a particular point in time or, alternatively, administering a multitude of dose units, i.e. two, three or more dose units, the sum of which multitude of dose units containing the full amount of the first pharmacologically active ingredient and the second pharmacologically active ingredient to be administered at said particular point in time, where the individual dose units are adapted for simultaneous administration or administration within a short period of time, e.g. within 5, 10 or 15 minutes.
In the following, the doses of the first and the second pharmacologically active ingredient are expressed according to the number of prescribed administrations “n” per day, i.e. the number of administrations of the pharmaceutical dosage form according to the invention in the course of 24 hours. As an example, 100/n μg in case of an administration once daily (n=1) corresponds to a dose of 100 μg, and 100/n μg in case of an administration twice daily (n=2) corresponds to a dose of 50 μg.
In a preferred embodiment, the pharmaceutical dosage form according to the invention is for administration less frequently than once daily (n=¾, ⅔, ⅗ or ½), wherein the pharmaceutical dosage form contains the first pharmacologically active ingredient in a dose of from 15/n to 100/n μg, preferably 20/n to 80/n μg, and the second pharmacologically active ingredient in a dose of from 1/n to 1,000/n mg. According to this embodiment, the pharmaceutical dosage form according to the invention is preferably for oral administration, preferably in form of a tablet.
In another preferred embodiment, the pharmaceutical dosage form according to the invention is for administration once daily (n=1), wherein the pharmaceutical dosage form contains the first pharmacologically active ingredient in a dose of from 15/n to 100/n μg, preferably 20/n to 80/n μg, and the second pharmacologically active ingredient in a dose of from 1/n to 1,000/n mg. According to this embodiment, the pharmaceutical dosage form according to the invention is preferably for oral administration, preferably in form of a tablet.
In still another preferred embodiment, the pharmaceutical dosage form according to the invention is for administration multiple daily (n=2, 3, 4, 5 or 6), wherein the pharmaceutical dosage form contains the first pharmacologically active ingredient in a dose of from 15/n to 100/n μg, preferably 20/n to 80/n μg, and the second pharmacologically active ingredient in a dose of from 1/n to 1,000/n mg. According to this embodiment, the pharmaceutical dosage form according to the invention is preferably for oral administration, preferably in form of a tablet.
In yet another preferred embodiment, the pharmaceutical dosage form according to the invention is for administration less frequently than once daily (n=¾, ⅔, ⅗ or ½), wherein the pharmaceutical dosage form contains the first pharmacologically active ingredient in a dose of from 150/n to 1,200/n μg, preferably 200/n to 800/n μg, and the second pharmacologically active ingredient in a dose of from 1/n to 1,000/n mg. According to this embodiment, the pharmaceutical dosage form according to the invention is preferably for oral administration, preferably in form of a tablet.
In a further preferred embodiment, the pharmaceutical dosage form according to the invention is for administration once daily (n=1), wherein the pharmaceutical dosage form contains the first pharmacologically active ingredient in a dose of from 150/n to 1,200/n μg, preferably 200/n to 800/n μg, and the second pharmacologically active ingredient in a dose of from 1/n to 1,000/n mg. According to this embodiment, the pharmaceutical dosage form according to the invention is preferably for oral administration, preferably in form of a tablet.
In still a further preferred embodiment, the pharmaceutical dosage form according to the invention is for administration multiple daily (n=2, 3, 4, 5 or 6), wherein the pharmaceutical dosage form contains the first pharmacologically active ingredient in a dose of from 150/n to 1,000/n μg, preferably 200/n to 800/n μg, and the second pharmacologically active ingredient in a dose of from 1/n to 1,000/n mg. According to this embodiment, the pharmaceutical dosage form according to the invention is preferably for oral administration, preferably in form of a tablet.
The pharmaceutical dosage form according to the invention may provide under in vitro conditions immediate release or controlled release of the first pharmacologically active ingredient and/or the second pharmacologically active ingredient. In vitro release is preferably determined in accordance with Ph. Eur., preferably paddle method with sinker, 75 rpm, 37° C., 900 mL artificial gastric juice, pH 6.8.
The first pharmacologically active ingredient and/or the second pharmacologically active ingredient may independently of one another be present in the pharmaceutical dosage form at least partially in controlled-release form. For example, the first pharmacologically active ingredient and/or the second pharmacologically active ingredient may be released from the pharmaceutical dosage form in a prolonged manner, e.g. if administered orally, rectally or percutaneously. Such pharmaceutical dosage forms are particularly useful for “once-daily” or “twice-daily” preparations, which only have to be taken once a day, respectively, twice a day. Suitable controlled-release materials are well known to those skilled in the art.
The pharmaceutical dosage form according to the invention providing controlled release of the first pharmacologically active ingredient and/or the second pharmacologically active ingredient may be produced using materials, means, devices and processes that are well known in the prior art of pharmaceutical dosage forms.
In order to obtain a solid pharmaceutical dosage form such as a tablet, for example, the pharmacologically active ingredients of the pharmaceutical composition may be granulated with a pharmaceutical carrier, for example conventional tablet ingredients such as corn starch, lactose, saccharose, sorbitol, talcum, magnesium stearate, dicalcium phosphate or pharmaceutically acceptable gums, and pharmaceutical diluents, for example water, in order to form a solid composition that contains the pharmacologically active ingredients in homogeneous distribution. The term “homogeneous distribution” is taken to mean that the pharmacologically active ingredients are distributed uniformly over the entire composition, so that said composition may easily be divided into equally effective dose units, such as tablets, pills or capsules and the like. The solid composition is then divided into dose units. The tablets or pills of the pharmaceutical composition according to the invention may also be coated or compounded in a different manner, in order to provide a dosage form with a controlled release.
If one of the pharmacologically active ingredients is to be released prior to the other pharmacologically active ingredient, for example at least 30 minutes or 1 hour beforehand, pharmaceutical dosage forms having a corresponding release profile may be prepared. An example of such a pharmaceutical dosage form is an osmotically-driven release system for achieving a delayed release of either the first or the second pharmacologically active ingredient from an inner part (core) of the pharmaceutical dosage form via a coating that itself contains the other pharmacologically active ingredient which is accordingly released earlier. In a release system of this kind, which is particularly suitable for oral administration, at least part, and preferably all, of the surface of the release system, preferably those parts that will come into contact with the release medium, is/are semipermeable, preferably equipped with a semipermeable coating, so the surface(s) is/are permeable to the release medium, but substantially, preferably entirely, impermeable to the pharmacologically active ingredient contained in the core, the surface(s) and/or optionally the coating comprising at least one opening for releasing the pharmacologically active ingredient contained in the core. Moreover, precisely that/those surface(s) that is/are in contact with the release medium is/are provided with a coating containing and releasing the other pharmacologically active ingredient. This is preferably taken to mean a system in tablet form comprising a release opening, a core containing the first or the second pharmacologically active ingredient, a polymer portion that exerts pressure upon swelling, a semipermeable membrane and a coating containing the other pharmacologically active ingredient. Embodiments and examples of osmotically-driven release systems are, for example, disclosed in U.S. Pat. Nos. 4,765,989, 4,783,337 and 4,612,008.
A further example of a suitable pharmaceutical dosage form is a gel-matrix tablet. Suitable examples are provided in U.S. Pat. Nos. 4,389,393, 5,330,761, 5,399,362, 5,472,711 and 5,455,046. Particularly suitable is a retarding matrix dosage form, with an inhomogeneous distribution of the pharmaceutical composition, whereby, for example, one pharmacologically active ingredient, i.e. the first or the second pharmacologically active ingredient, is distributed in the outer region (the portion that comes into contact with the release medium most quickly) of the matrix and the other pharmacologically active ingredient is distributed inside the matrix. On contact with the release medium, the outer matrix layer initially (and rapidly) swells and firstly releases the pharmacologically active ingredient contained therein, followed by the significantly (more) controlled release of the other pharmacologically active ingredient. Examples of a suitable matrix include matrices with 1 to 80% by weight of one or more hydrophilic or hydrophobic polymers as pharmaceutically acceptable matrix formers.
Preferably, the pharmaceutical dosage form according to the invention provides immediate release of the first pharmacologically active ingredient, and immediate or controlled release of the second pharmacologically active ingredient.
In a preferred embodiment, the pharmaceutical dosage form according to the invention provides immediate release of both, the first and the second pharmacologically active ingredient. In this particular case, a multiple daily administration, in particular an administration twice daily, thrice daily, or up to six times a day is preferred.
In another preferred embodiment, the pharmaceutical dosage form according to the invention provides immediate release of the first pharmacologically active ingredient, and controlled release of the second pharmacologically active ingredient. This release profile may be realized by employing the aforementioned methods, e.g. the osmotically-driven release system providing the first pharmacologically active ingredient in the coating and the second pharmacologically active ingredient in the core, or the retarding matrix dosage form containing the first pharmacologically active ingredient in the outer matrix layer and the second pharmacologically active ingredient in the inside of the matrix.
In yet another preferred embodiment, the pharmaceutical dosage form according to the invention provides controlled release of both the first and the second pharmacologically active ingredient.
In a further aspect, the invention relates to the use of the pharmaceutical composition according to the invention, and the pharmaceutical dosage form according to the invention respectively, in the prevention or treatment of pain, mood disorders and anxiety.
In a preferred embodiment, the pharmaceutical composition according to the invention and the pharmaceutical dosage form according to the invention, respectively, are for use in the treatment of pain, wherein the pain is preferably

- peripheral, central or muscle skeletal pain; and/or
- acute, subacute or chronic pain; and/or
- moderate to severe pain; and/or
- neuropathic or psychogenic or nociceptive or mixed pain; and/or
- low back pain, visceral pain or headache; and/or
- post-operative (post-surgical), cancer or inflammatory pain.

For the purpose of specification, “acute pain” preferably refers to pain that lasts up to about 4 weeks, “subacute pain” preferably refers to pain that lasts from more than about 4 weeks to about 12 weeks, and “chronic pain” preferably refers to pain that lasts for more than about 12 weeks.
Preferably, the pain is selected from the group consisting of cancer pain, peripheral neuropathic pain, osteoarthritis, chronic visceral pain, neuropathic pain (diabetic polyneuropathy, HIV-associated neuropathic pain, posttraumatic neuropathic pain, postherpetic neuralgia, chemotherapy associated pain), postzosteric neuralgia, postoperative neuropathic pain, inflammatory pain, migraine, low-back pain, fibromyalgia and trigeminal neuralgia.
In the following, the doses of the first and the second pharmacologically active ingredient are again expressed according to the number of administrations “n” per day, i.e. the number of administrations of the pharmaceutical dosage form according to the invention in the course of 24 hours.
In a preferred embodiment, the pharmaceutical dosage form is for use in the treatment of neuropathic pain which may be optionally superimposed by nociceptive pain, where the dose of the first pharmacologically active ingredient contained in the pharmaceutical dosage form preferably is in the range of 1/n μg to 800/n μg or 1/n μg to 600/n μg or 1/n μg to 400/n μg or 1/n μg to 250/n μg, more preferably in the range of 5/n μg to 150/n μg, even more preferably in the range of 10/n μg to 100/n μg, most preferably in the range of 20/n μg to 80/n μg and in particular most preferably in the range of 30/n μg to 50/n μg. According to this embodiment, the dose of the second pharmacologically active ingredient contained in the pharmaceutical dosage form preferably is in the range of 1/n mg to 1,000/n mg.
In a preferred embodiment, in particular when the pharmaceutical dosage form is for use in the treatment of neuropathic pain and the second pharmacologically active ingredient is duloxetine, preferably (S)-duloxetine, the dose of the first pharmacologically active ingredient contained in the pharmaceutical dosage form preferably is in the range of 1/n μg to 800/n μg or 1/n μg to 600/n μg or 1/n μg to 400/n μg or 1/n μg to 250/n μg, more preferably in the range of 5/n μg to 150/n μg, even more preferably in the range of 10/n μg to 100/n μg, most preferably in the range of 20/n μg to 80/n μg and in particular most preferably in the range of 30/n μg to 50/n μg; and the dose of the second pharmacologically active ingredient contained in the pharmaceutical dosage form preferably is in the range of 10/n mg to 300/n mg, more preferably in the range of 15/n mg to 250/n mg, even more preferably in the range of 20/n mg to 200/n mg, most preferably in the range of 25/n mg to 150/n mg and in particular in the range of 30/n mg to 130/n mg.
In another preferred embodiment, in particular when the pharmaceutical dosage form is for use in the treatment of neuropathic pain and the second pharmacologically active ingredient contained in the pharmaceutical dosage form is reboxetine, the dose of the first pharmacologically active ingredient preferably is in the range of 1/n μg to 800/n μg or 1/n μg to 600/n μg or 1/n μg to 400/n μg or 1/n μg to 250/n μg, more preferably in the range of 5/n μg to 150/n μg, even more preferably in the range of 10/n μg to 100/n μg, most preferably in the range of 20/n μg to 80/n μg and in particular most preferably in the range of 30/n μg to 50/n μg; and the dose of the second pharmacologically active ingredient contained in the pharmaceutical dosage form preferably is in the range of 1/n mg to 20/n mg, more preferably in the range of 2/n mg to 18/n mg, most preferably in the range of 3/n mg to 16/n mg and in particular in the range of 4/n mg to 15/n mg.
In still another preferred embodiment, the pharmaceutical dosage form is for use in the treatment of nociceptive pain which may be optionally superimposed by neuropathic pain, where the dose of the first pharmacologically active ingredient contained in the pharmaceutical dosage form preferably is in the range of 50/n μg to 2,000/n μg or 50/n μg to 1,400/n μg or 50/n μg to 1,200/n μg or 50/n μg to 1,000/n μg, more preferably in the range of 100/n μg to 800/n μg, still more preferably in the range of 150/n μg to 650/n μg, even more preferably in the range of 250/n μg to 550/n μg, and most preferably in the range of 350/n μg to 450/n μg. According to this embodiment, the dose of the second pharmacologically active ingredient contained in the pharmaceutical dosage form preferably is in the range of 1/n mg to 1,000/n mg.
In a preferred embodiment, in particular when the pharmaceutical dosage form is for use in the treatment of nociceptive pain and the second pharmacologically active ingredient is duloxetine, preferably (S)-duloxetine, the dose of the first pharmacologically active ingredient contained in the pharmaceutical dosage form preferably is in the range of 50/n μg to 2,000/n μg or 50/n μg to 1,400/n μg or 50/n μg to 1,200/n μg or 50/n μg to 1,000/n μg, more preferably in the range of 100/n μg to 800/n μg, still more preferably in the range of 150/n μg to 650/n μg, even more preferably in the range of 250/n μg to 550/n μg, and most preferably in the range of 350/n μg to 450/n μg; and the dose of the second pharmacologically active ingredient contained in the pharmaceutical dosage form preferably is in the range of 10/n mg to 300/n mg, more preferably in the range of 15/n mg to 250/n mg, even more preferably in the range of 20/n mg to 200/n mg, most preferably in the range of 25/n mg to 150/n mg and in particular in the range of 30/n mg to 130/n mg.
In another preferred embodiment, in particular when the pharmaceutical dosage form is for use in the treatment of nociceptive pain and the second pharmacologically active ingredient is reboxetine, the dose of the first pharmacologically active ingredient contained in the pharmaceutical dosage form preferably is in the range of 50/n μg to 2,000/n μg or 50/n μg to 1,400/n μg or 50/n μg to 1,200/n μg or 50/n μg to 1,000/n μg, more preferably in the range of 100/n μg to 800/n μg, still more preferably in the range of 150/n μg to 650/n μg, even more preferably in the range of 250/n μg to 550/n μg, and most preferably in the range of 350/n μg to 450/n μg; and the dose of the second pharmacologically active ingredient contained in the pharmaceutical dosage form preferably is in the range of 1/n mg to 20/n mg, more preferably in the range of 2/n mg to 18/n mg, most preferably in the range of 3/n mg to 16/n mg and in particular in the range of 4/n mg to 15/n mg.
Preferably, the pharmaceutical composition contains the first and the second pharmacologically active ingredient in such a weight ratio that they will exert a synergistic therapeutic effect upon administration to a patient. Thereby, the term “synergistic therapeutic effect” may refer to a synergistic therapeutic effect with respect to the prevention or treatment of pain (synergistic analgesic effect), a synergistic therapeutic effect with respect to the prevention or treatment of anxiety (synergistic anxiolytic effect) as well as a synergistic therapeutic effect with respect to the prevention or treatment of depression (synergistic anti-depressant effect). Suitable weight ratios of the pharmacologically active ingredients generating the synergistic therapeutic effect can be determined by methods well known to those skilled in the art.
A further aspect of the invention relates to a method of treating or preventing pain, anxiety or epilepsy comprising the preferably twice daily or once daily, preferably oral administration of the pharmaceutical dosage form according to the invention to a subject in need thereof.
In a particular preferred embodiment,

- the first pharmacologically active ingredient is (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1′-pyrano[3,4,b]indol]-4-amine according to formula (I) in form of its free base, or a hemicitrate, hydrochloride or maleate salt thereof; and/or
- the second pharmacologically active ingredient is duloxetine or reboxetine in form of the free compound or the hydrochloride salt; and/or
- the pharmaceutical composition and the pharmaceutical dosage form, respectively, contain the first pharmacologically active ingredient in a dose of from 20 μg to 80 μg or of from 80 μg to 200 μg or of from 200 μg to 800 μg or of from 800 μg to 1,200 μg; and/or
- the pharmaceutical composition and the pharmaceutical dosage form, respectively, contain the second pharmacologically active ingredient in a dose of from 1 mg to 1,000 mg, and/or
- the relative weight ratio of the first pharmacologically active ingredient to the second pharmacologically active ingredient is within the range of from 1:1 to 1:1,000,000, preferably 1:2 to 1:100,000 in the pharmaceutical composition and the pharmaceutical dosage form, respectively; and/or
- the pharmaceutical composition is for use in the prevention or treatment of pain, anxiety or mood disorders; and/or
- the pharmaceutical composition is for use in the treatment of pain, wherein the pain is peripheral, central or muscle skeletal pain; and/or acute, subacute or chronic pain; and/or moderate to severe pain; and/or neuropathic or psychogenic or nociceptive or mixed pain; and/or low back pain, visceral pain or headache; and/or post-operative (post-surgical), cancer or inflammatory pain; and/or
- the pharmaceutical composition and the pharmaceutical dosage form, respectively, contain the first pharmacologically active ingredient and the second pharmacologically active ingredient in such a weight ratio that upon administration to a patient they will exert a synergistic therapeutic effect; and/or
- the pharmaceutical dosage form provides immediate release of the first pharmacologically active ingredient in vitro in accordance with Ph. Eur.; and/or
- the pharmaceutical dosage form provides immediate or controlled release of the second pharmacologically active ingredient in vitro in accordance with Ph. Eur.; and/or
- the pharmaceutical dosage form is for oral administration; and/or
- the pharmaceutical dosage form is for administration once, twice or thrice daily.

In a further aspect, the invention relates to a kit comprising a first pharmaceutical dosage form comprising the first pharmacologically active ingredient as described above, and a second pharmaceutical dosage form comprising the second pharmacologically active ingredient as described above.
A suitable embodiment is a kit in which the first pharmaceutical dosage from comprising the first pharmacologically active ingredient and the second pharmaceutical dosage form comprising the second pharmacologically active ingredient, although spatially separated, are provided in a common presentation form, e.g. packaging.
Preferably, the first and the second pharmaceutical dosage form are adapted for simultaneous or sequential administration, wherein the first pharmaceutical dosage form may be administered before or after the second pharmaceutical dosage form and wherein the first and the second pharmaceutical dosage form are administered either via the same or a different pathway of administration.
For the purpose of specification, the term “simultaneous administration” preferably refers to an administration of the first and the second pharmaceutical dosage form within a time span of 15 minutes from each other, whereas the term “sequential administration” preferably refers to an administration of the first and the second pharmaceutical dosage form within a time span of more than 15 minutes from each other.
In a preferred embodiment, the first and the second pharmaceutical dosage form are adapted for administration to the patient via the same pathway.
In another preferred embodiment, the first and the second pharmaceutical dosage form are adapted for administration to the patient via different pathways.
In a preferred embodiment, the first and the second pharmaceutical dosage form are administered simultaneously.
In another preferred embodiment, the first and the second pharmaceutical dosage form are administered sequentially.
In a preferred embodiment, the first and/or the second pharmaceutical dosage form are adapted for administration less frequently than once daily.
In another preferred embodiment, the first and/or the second pharmaceutical dosage form are adapted for once daily administration.
In still another preferred embodiment, the first and/or the second pharmaceutical dosage form are adapted for multiple daily administration, in particular twice daily or thrice daily.
In a preferred embodiment, the first pharmaceutical dosage form is adapted for once daily administration and the second pharmaceutical dosage form is adapted for multiple daily, in particular twice daily or thrice daily, administration.
Suitable pathways of administration of the pharmaceutical dosage forms contained in the kit include but are not limited to oral, intravenous, intraperitoneal, intradermal, intrathecal, intramuscular, intranasal, transmucosal, subcutaneous, and/or rectal administration.
In a preferred embodiment, one or both of the pharmaceutical dosage forms contained in the kit are for oral administration.
In another preferred embodiment, one or both of the pharmaceutical dosage forms contained in the kit are for parenteral, in particular intravenous, intraperitoneal, intrathecal, intramuscular or subcutaneous administration.
In a preferred embodiment, the first and the second pharmaceutical dosage form are for oral, simultaneous administration less frequently than once daily.
In another preferred embodiment, the first and the second pharmaceutical dosage form are each for oral, sequential administration less frequently than once daily.
In still another preferred embodiment, the first and the second pharmaceutical dosage form are for sequential administration less frequently than once daily, where the first and the second pharmaceutical dosage form are adapted for administration via different pathways, e.g. oral and parenteral administration.
In yet another preferred embodiment, the first and the second pharmaceutical dosage form are for oral, simultaneous administration once daily.
In a further preferred embodiment, the first and the second pharmaceutical dosage form are each for oral, sequential administration once daily.
In another preferred embodiment, the first and the second pharmaceutical dosage form are for sequential administration once daily each, where the first and the second pharmaceutical dosage form are adapted for administration via different pathways, e.g. oral and parenteral administration.
In still another preferred embodiment, the first and the second pharmaceutical dosage form are for oral, simultaneous administration multiple daily, in particular twice daily or thrice daily.
In a further preferred embodiment, the first and the second pharmaceutical dosage form are each for oral, sequential administration multiple daily, in particular twice daily or thrice daily.
In another preferred embodiment, the first and the second pharmaceutical dosage form are for sequential administration multiple daily each, in particular twice daily or thrice daily, where the first and the second pharmaceutical dosage form are adapted for administration via different pathways, e.g. oral and parenteral administration.
The following examples further illustrate the invention but are not to be construed as limiting its scope.

Pharmacological Methods:

In Vivo Experiments According to Chung

In the following, all amounts of the first pharmacologically active ingredient are specified as the hemicitrate salt.
As a second pharmacologically active ingredient, reboxetine and duloxetine and were employed.
Duloxetine was utilized in form of the (S)-enantiomer.
In the following, when the second pharmacologically active ingredient is (S)-duloxetine, all amounts are specified as the hydrochloride salt.
In the following, when the second pharmacologically active ingredient is reboxetine, all amounts are specified as the mesylate salt.
The weight ratios of the first and the second pharmacologically active ingredient that will lead to a supra-additive effect/synergistic effect may be determined in the test of Kim & Chung (Kim S H, Chung J M, An experimental model for peripheral mononeuropathy produced by segmental spinal nerve ligation in the rat, Pain 1992; 50: 355-63) as described in Schröder et al. Eur J Pain 2010, 14: 814. Said references are hereby incorporated by reference and form part of the disclosure.
Ligatures were applied to the left L5/L6 spinal nerves of male Sprague-Dawley rats (140-160 g body weight, Janvier, Genest St. Isle, France). Animals developed tactile allodynia at the ipsilateral paw. Four weeks after the operation the tactile allodynia threshold baseline (withdrawal threshold) was measured on the ipsilateral and contralateral hind paw by an electronic von Frey anaesthesiometer (Somedic, Schweden). After test and measurement of the baseline, the first pharmacologically active ingredient (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1′-pyrano[3,4,b]indol]-4-amine in form of the hemicitrate salt, and the second pharmacologically active ingredient according to the invention were each dissolved in a mixture of DMSO (10%), Cremophor (5%) and glucose solution (85%) and injected by the intravenous (i.v.) route (application volume 5 ml/kg). The first and the second pharmacologically active ingredient were either administered as the respective single substance or both at the same time. Animals were randomly assigned to groups of 10 for each test dose and vehicle (DMSO (10%), Cremophor (5%) and glucose solution (85%)) and tactile withdrawal thresholds were tested 0.5 h before administration and on several time points (0.5, 1 and 3 hours) after intravenous administration. Ipsi- and contralateral hindpaws were tested. The median of the withdrawal threshold for each animal at a given time is calculated from five individual stimulations with the electronic von Frey filament. Withdrawal thresholds of the injured paws are expressed as % MPE (Maximum possible effect) comparing predrug threshold of Chung-Animals (=0% MPE) and control threshold of sham-animals (100% MPE). A cut-off is set at 100% MPE. The effect of each compound and vehicle is calculated for each testing time point as interindividual % MPE value.
Data (anti-allodynic efficacy (% MPE), ipsi-lateral, paw withdrawal threshold, ipsi- and conralateral) were analyzed by means of a two-factor analysis of variance (ANOVA) with repeated measures. In case of a significant treatment effect, post hoc analysis with Bonferroni adjustment was performed. Results were considered statistically significant if p<0.05.

Results:

a) Duloxetine as the Second Pharmacologically Active Ingredient

The first pharmacologically active ingredient (0.0316 μg/kg body weight i.v.) showed a withdrawal threshold of the ipsi-lateral hind paw with an efficacy of 21.0% MPE at 30 min after administration.
The second pharmacologically active ingredient (0.100 mg/kg body weight i.v.) showed a withdrawal threshold of the ipsi-lateral hind paw with an efficacy of 25.3% MPE at 30 min after administration.
When administered as a combination, the first and the second pharmacologically active ingredient were tested in a fixed ratio of 1:3,164 (first to second pharmacologically active ingredient) in doses of 0.0316 μg/kg body weight+0.100 mg/kg body weight i.v. of the first and the second pharmacologically active ingredient, respectively. This combined administration of the first and the second pharmacologically active ingredient resulted in a supra-additive increase in the withdrawal threshold of the ipsi-lateral hind paw compared to the administration of the single pharmacologically active ingredients showing a synergistic effect with 54.7% MPE at 30 min after administration.
FIG. 1 shows % MPE in dependence of the time elapsed after administration.

 vehicle (n=10)
▴ first pharmacologically active ingredient (0.0316 μg/kg, n=10)
▾ second pharmacologically active ingredient (0.100 mg/kg, n=10)
combination of first and second pharmacologically active ingredient (0.0316 μg/kg+0.100 mg/kg, n=10)
----- theoretical additive value

Experimental results demonstrating supra-additive effects of the combination of the first and the second pharmacologically active ingredient are summarized in the following table 1.

TABLE 1

% MPE (Maximum possible effect) of the first and the second
pharmacologically active ingredient and the combination of the first
and the second pharmacologically active ingredient:
% MPE

	30 min.	60 min.	180 min.
	(n = 10)	(n = 10)	(n = 10)
Dose	Mean SEM	Mean SEM	Mean SEM

Vehicle	−1.5 ± 3.6	−5.9 ± 6.1	3.0 ± 5.1
first pharmacologically	21.0 ± 12.5	8.4 ± 10.9	−1.4 ± 6.1
active ingredient
second pharmacologically	25.3 ± 12.4	15.1 ± 7.6	10.8 ± 6.7
active ingredient
first + second	54.7 ± 10.3	20.6 ± 7.4	5.1 ± 6.2
pharmacologically active
ingredient

The experimental % MPE value of 54.7 (30 min.) in case of the combined administration of the first and the second pharmacologically active ingredient according to the invention is above the theoretical additive % MPE value of the respective single pharmacologically active ingredients. Thus, the interaction of the first and the second pharmacologically active ingredient is synergistic.
The results of the statistical analysis of the experimental data are summarized in table 2.

TABLE 2

Statistical evaluation of the data following two-factor analysis of variance
(ANOVA) and post hoc analysis with Bonferroni adjustment.

Statistical evaluation: % MPE

	treatment	time	interaction

repeated	F(3,36) = 3.576	F(2,72) = 10.226	F(6,72) = 2.935
measures	p = 0.023	p = 0.000	p = 0.013
ANOVA

post hoc analysis
Bonferroni adjustment
	30 min.	60 min.	180 min.

vehicle +	first pharmacologically	p = 0.822	p = 1.000	p = 1.000
vehicle vs.	active ingredient +
	vehicle
	vehicle + second	p = 0.455	p = 0.460	p = 1.000
	pharmacologically active
	ingredient
	first + second	p = 0.003	p = 0.165	p = 1.000
	pharmacologically active
	ingredient

p: Level of statistical significance.

As can be seen from table 2, the experimental results are statistically significant (p<0.05). The synergistic effect of the first and the second pharmacologically active ingredient according to the invention is verified by the Bonferroni adjustment giving a value of p<0.05.
Thus, synergistic effects of the first and the second pharmacologically active ingredient results in increased anti-nociceptive effects.

b) Reboxetine as the Second Pharmacologically Active Ingredient

The first pharmacologically active ingredient (0.0316 μg/kg body weight i.v.) showed a withdrawal threshold of the ipsi-lateral hind paw with an efficacy of 20.9% MPE at 30 min after administration.
The second pharmacologically active ingredient (0.316 mg/kg body weight i.v.) showed a withdrawal threshold of the ipsi-lateral hind paw with an efficacy of 25.7% MPE at 30 min after administration.
When administered as a combination, the first and the second pharmacologically active ingredient were tested in a fixed ratio of 1:10,000 (first to second pharmacologically active ingredient) in doses of 0.0316 μg/kg body weight+0.316 mg/kg body weight i.v. of the first and the second pharmacologically active ingredient, respectively. This combined administration of the first and the second pharmacologically active ingredient resulted in a withdrawal threshold of the ipsi-lateral hind paw of 34.4% MPE at 30 min after administration. None of the treatments resulted in a statistically significant increase in paw withdrawal thresholds.
FIG. 2 shows % MPE in dependence of the time elapsed after administration.

 vehicle (n=10)
▴ first pharmacologically active ingredient (0.0316 μg/kg, n=10)
▾ second pharmacologically active ingredient (0.316 mg/kg, n=10)
combination of first and second pharmacologically active ingredient (0.0316 μg/kg+0.316 mg/kg, n=10)
---- theoretical additive value

Experimental results of the combination of the first and the second pharmacologically active ingredient are summarized in the following table 3.

TABLE 3

% MPE (Maximum possible effect) of the first and the second
pharmacologically active ingredient and the combination of the first
and the second pharmacologically active ingredient:
% MPE

	30 min.	60 min.	180 min.
	(n = 10)	(n = 10)	(n = 10)
Dose	Mean SEM	Mean SEM	Mean SEM

Vehicle	−1.5 ± 3.6	−5.8 ± 6.1	3.0 ± 5.1
first pharmacologically	20.9 ± 12.5	8.4 ± 10.8	−1.4 ± 6.1
active ingredient
second pharmacologically	25.7 ± 12.8	0.1 ± 10.6	−1.7 ± 6.1
active ingredient
first + second	34.4 ± 11.1	12.1 ± 13.4	−1.5 ± 6.0
pharmacologically active
ingredient

The results of the statistical analysis of the experimental data are summarized in table 4.

TABLE 4

Statistical evaluation of the data following two-factor analysis of variance
(ANOVA) and post hoc analysis with Bonferroni adjustment.

Statistical evaluation: % MPE

	treatment	time	interaction

repeated	F(3,36) = 0.935	F(2,72) = 8.365	F(6,72) = 1.495
measures	p = 0.434	p = 0.001	p = 0.192
ANOVA

post hoc analysis
Bonferroni adjustment
	30 min.	60 min.	180 min.

vehicle +	first pharmacologically	p = 0.887	p = 1.000	p = 1.000
vehicle vs.	active ingredient +
	vehicle
	vehicle + second	p = 0.484	p = 1.000	p = 1.000
	pharmacologically active
	ingredient
	first + second	p = 0.183	p = 1.000	p = 1.000
	pharmacologically active
	ingredient

p: Level of statistical significance.

Claims

1. A pharmaceutical composition comprising:

a) a first pharmacologically active ingredient selected from (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1′-pyrano-[3,4,b]indol]-4-amine and the physiologically acceptable salts thereof, and

b) a second pharmacologically active ingredient which is an antidepressant.

2. The pharmaceutical composition according to claim 1, wherein the first pharmacologically active ingredient is (1r,4r)-6′-fluoro-N,N-dimethyl-4-phenyl-4′,9′-dihydro-3′H-spiro[cyclohexane-1,1′-pyrano[3,4,b]indol]-4-amine.

3. The pharmaceutical composition according to claim 1, wherein the second pharmacologically active ingredient is a selective serotonin reuptake inhibitor.

4. The pharmaceutical composition according to claim 3, wherein the selective serotonin reuptake inhibitor is selected from the group consisting of zimeldine, fluoxetine, citalopram, paroxetine, sertraline, alaproclate, fluvoxamine, etoperidone, escitalopram and the physiologically acceptable salts thereof.

5. The pharmaceutical composition according to claim 1, wherein the second pharmacologically active ingredient is a non-selective monoamine reuptake inhibitor.

6. The pharmaceutical composition according to claim 5, wherein the non-selective monoamine reuptake inhibitor is selected from the group consisting of desipramine, imipramine, imipramine oxide, clomipramine, opipramol, trimipramine, lofepramine, dibenzepin, amitryptyline, nortriptyline, protriptyline, doxepin, iprindole, melitracen, butriptylene, dosulepin, amoxapine, dimetacrine, amineptine, maprotiline, quinupramine and the physiologically acceptable salts thereof.

7. The pharmaceutical composition according to claim 1, wherein the second pharmacologically active ingredient is selected from the group consisting of oxitriptan, tryptophan, mianserin, nomifensine, trazodone, nefazodone, minaprine, bifemelane, viloxazine, oxaflozane, mirtazapine, bupropion, medifoxamine, tianeptine, pivagabine, venlafaxine, milnacipran, reboxetine, gepirone, duloxetine, agomelatine, desvenlafaxine, vilazodone and the physiologically acceptable salts thereof, as well as Hyperici herba.

8. The pharmaceutical composition according to claim 1, which contains the first and the second pharmacologically active ingredient in such a weight ratio that they will exert a synergistic therapeutic effect upon administration to a patient.

9. The pharmaceutical composition according to claim 1, wherein the relative weight ratio of the first pharmacologically active ingredient to the second pharmacologically active ingredient is within the range of from 1:1 to 1:1,000,000.

10. The pharmaceutical composition according to claim 1 for use in the prevention or treatment of pain, anxiety or a mood disorder.

11. The pharmaceutical composition according to claim 10, wherein the pain is:

peripheral, central or muscle skeletal pain; and/or

acute, subacute or chronic pain; and/or

moderate to severe pain; and/or

neuropathic or psychogenic or nociceptive or mixed pain; and/or

low back pain, visceral pain or headache; and/or

post-operative, cancer or inflammatory pain.

12. A pharmaceutical dosage form comprising the pharmaceutical composition according to claim 1.

13. The pharmaceutical dosage form according to claim 12, which contains the first pharmacologically active ingredient in a dose of from 10 to 1,200 μg.

14. The pharmaceutical dosage form according to claim 12, which contains the second pharmacologically active ingredient in a dose of from 1 mg to 1,000 mg.

15. A kit comprising a first pharmaceutical dosage form comprising the first pharmacologically active ingredient as defined in claim 1, and a second pharmaceutical dosage form comprising the second pharmacologically active ingredient as defined in claim 1.