US20150150846A1 - V1b receptor antagonist for use in the treatment of patients having an elevated avp level and/or an elevated copeptin level - Google Patents

V1b receptor antagonist for use in the treatment of patients having an elevated avp level and/or an elevated copeptin level Download PDF

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US20150150846A1
US20150150846A1 US14/407,594 US201314407594A US2015150846A1 US 20150150846 A1 US20150150846 A1 US 20150150846A1 US 201314407594 A US201314407594 A US 201314407594A US 2015150846 A1 US2015150846 A1 US 2015150846A1
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Florian Holsboer
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Max Planck Gesellschaft zur Foerderung der Wissenschaften
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Definitions

  • the present invention relates to a vasopressin receptor 1B (V 1B ) antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in patients showing an elevated arginine vasopressin (AVP) level and/or an elevated copeptin level.
  • V 1B vasopressin receptor 1B
  • AVP arginine vasopressin
  • the present invention further relates to methods for predicting a treatment response to a V 1B antagonist in patients with depressive symptoms and/or anxiety symptoms.
  • Vasopressin also referred to as arginine vasopressin (AVP), vasopressin argipressin or antidiuretic hormone (ADH)
  • AVP arginine vasopressin
  • ADH antidiuretic hormone
  • vasopressin plays an important role in depression and anxiety disorders is supported by increased AVP secretion from hypothalmatic neurons. Animal experiments also point to a central role of vasopressin in the development of depression and anxiety disorders (Landgraf (2006); The Involvement of the Vasopressin System in Stress - Related Disorders; CNS & Neurological Disorders 5:167-179).
  • V 1B antagonists can be predicted by determining the copeptin concentration in a blood sample of a patient and/or by determining the AVP concentration in a sample of cerebrospinal fluid of said patient.
  • a further finding of the invention is that the presence of a polymorphic variant in the vasopressin receptor 1B (AVPR1B) gene in combination with one or more further marker(s) is indicative for an elevated arginine vasopressin level and/or copeptin level and thus for a treatment response to V 1B antagonists.
  • AVPR1B vasopressin receptor 1B
  • the present invention relates to a vasopressin receptor 1B (V 1B ) antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated arginine vasopressin (AVP) level and/or an elevated copeptin level.
  • V 1B vasopressin receptor 1B
  • the present invention relates to a V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level.
  • the present invention relates to a V 1B receptor antagonist in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated copeptin level.
  • the present invention relates to a V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and an elevated copeptin level.
  • the present invention relates to the V 1B receptor antagonist for use as described above, wherein the elevated AVP level and/or the elevated copeptin level in said patient is determined by means of measurement of AVP and/or by means of copeptin measurement.
  • the copeptin measurement is performed in a blood sample of said patient.
  • the present invention relates to a vasopressin receptor 1B (V 1B ) antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated level of copeptin in the blood.
  • V 1B vasopressin receptor 1B
  • the patient has been pre-treated with dexamethasone prior to performance of the copeptin measurement and/or measurement of AVP.
  • the present invention relates to a vasopressin receptor 1B (V 1B ) antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated level of AVP in the cerebrospinal fluid.
  • V 1B vasopressin receptor 1B
  • the patient showing an elevated AVP level has an AVP concentration of at least 4 pg/ml AVP, optionally in the range from 4 to 6 pg/ml AVP.
  • a further embodiment of the invention relates to a V 1B receptor antagonist for use as described herein, wherein an elevated AVP level and/or an elevated copeptin level is detected by determining the presence or absence of at least one polymorphic variant in the AVPR1B gene in combination with the presence or absence of at least one polymorphic variant in the patient's genome excluding the AVPR1B gene.
  • the polymorphic variant in the AVPR1B gene and/or in the patient's genome excluding the AVPR1B gene is a single nucleotide polymorphism (SNP).
  • SNP single nucleotide polymorphism
  • the at least one polymorphic variant in the patient's genome excluding the AVPR1B gene is selected from the group of biomarkers comprising:
  • the group of biomarkers consists of the biomarkers as defined herein as polymorphic variants in the patient's genome excluding the AVPR1B gene.
  • the combination of the presence or absence of SNP rs28373064 with at least 1, at least 2, at least 3, at least 4, at least 5, at least 6, at least 7, at least 8, at least 9, at least 10, at least 11, at least 12, at least 13 or all of the biomarkers as defined herein as polymorphic variants in the patient's genome excluding the AVPR1B gene is determined.
  • the presence of SNP rs28373064 in combination with the presence of SNP rs9880583, SNP rs730258, SNP rs12654236, SNP rs17091872, SNP rs12254219, SNP rs11575663, SNP rs7080276, SNP rs7416, SNP rs1035050, SNP rs9959162 and SNP rs8088242 is determined.
  • the absence of SNP rs28373064 in combination with the absence of SNP rs13099050, SNP rs7441352 and SNP rs12424153 is determined.
  • the presence of SNP rs28373064 in combination with the presence of SNP rs9880583, SNP rs730258, SNP rs12654236, SNP rs17091872, SNP rs12254219, SNP rs11575663, SNP rs7080276, SNP rs7416, SNP rs1035050, SNP rs9959162 and SNP rs8088242 and the absence of SNP rs28373064 in combination with the absence of SNP rs13099050, SNP rs7441352 and SNP rs12424153 is determined.
  • a further embodiment of the invention relates to a V 1B receptor antagonist for use as described above, wherein the V 1B antagonist is selected from the group consisting of SRR149415 (SSR149415), Org 52186, ABT-436 and/or ABT-558.
  • the V 1B antagonist is selected from the group consisting of SRR149415 (SSR149415), Org 52186, ABT-436 and/or ABT-558.
  • the V 1B receptor antagonist for use as described above is administered in combination with at least one further pharmaceutically active compound suitable for the treatment of depressive symptoms and/or anxiety symptoms.
  • the at least one further pharmaceutically active compound is selected from selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, dopamine reuptake inhibitors, noradrenergic and specific serotonergic antidepressants, norepinephrine (noradrenaline) reuptake inhibitors, selective serotonin reuptake enhancers, norepinephrine-dopamine disinhibitors, norepinephrine-dopamine reuptake inhibitors, tricyclic antidepressants, tetracyclic antidepressants, monamine oxidase inhibitors, psychostimulants, mood stabilizers, amine precursors, serotonin antagonists and reuptake inhibitors, anticonvulsants, nicotine, phytopharmaceuticals, melatonin receptor antagonists, 5-HT antagonists, benzodiazepines, buspirone, azapirones, barbi
  • V 1B receptor antagonist for use as described above, wherein the treatment response to the V 1B receptor antagonist is predicted by the method as described below.
  • Another aspect relates to a method for predicting a treatment response to a V 1B receptor antagonist in a patient with depressive symptoms and/or anxiety symptoms comprising the following steps:
  • the presence or absence of at least one polymorphic variant in the AVPR1B gene in combination with the presence or absence of at least one polymorphic variant in the patient's genome excluding the AVPR1B gene is indicative for the treatment response.
  • the polymorphic variant in the AVPR1B and/or in the patient's genome excluding the AVPR1B gene is a single nucleotide polymorphism (SNP).
  • the polymorphic variant in the AVPR1B gene is an SNP.
  • the polymorphic variant in the patient's genome excluding the AVPR1B gene is an SNP.
  • the at least one polymorphic variant in the patient's genome excluding the AVPR1B is selected from the group of biomarkers comprising:
  • Another embodiment of the present invention relates to the method according to the invention, wherein the group of biomarkers for which the presence or absence is determined wherein the group of biomarkers comprises at least 2, at least 5, at least 8 or at least 11 of the biomarkers in the patient's genome excluding the AVPR1B gene defined herein.
  • the presence or absence of at least 2, at least 5, at least 8 or at least 11 polymorphic variants or biomarkers as defined above is determined in step (ii) of the method described above.
  • the group of biomarkers for which the presence or absence is determined consists of the biomarkers in the patient's genome excluding the AVPR1B gene defined herein.
  • the presence or absence of all 14 polymorphic variants or biomarkers in the patient's genome excluding the AVPR1B gene as defined above are determined in step (ii) of the method described above.
  • the combination of the presence or absence of SNP rs28373064 with the presence or absence of at least 1, at least 2, at least 3, at least 4, at least 5, at least 6, at least 7, at least 8, at least 9, at least 10, at least 11, at least 12, at least 13 or all of the biomarkers in the patient's genome excluding the AVPR1B gene as defined herein is determined.
  • the presence of SNP rs28373064 in combination with the presence of SNP rs9880583, SNP rs730258, SNP rs12654236, SNP rs17091872, SNP rs12254219, SNP rs11575663, SNP rs7080276, SNP rs7416, SNP rs1035050, SNP rs9959162 and SNP rs8088242 is determined.
  • the absence of SNP rs28373064 in combination with the absence of SNP rs13099050, SNP rs7441352 and SNP rs12424153 is determined.
  • the presence of SNP rs28373064 in combination with the presence of SNP rs9880583, SNP rs730258, SNP rs12654236, SNP rs17091872, SNP rs12254219, SNP rs11575663, SNP rs7080276, SNP rs7416, SNP rs1035050, SNP rs9959162 and SNP rs8088242 and the absence of SNP rs28373064 in combination with the absence of SNP rs13099050, SNP rs7441352 and SNP rs12424153 is determined.
  • Another aspect of the invention relates to a method for predicting a treatment response to a V 1B receptor antagonist in a patient with depressive symptoms and/or anxiety symptoms, wherein the copeptin concentration in a blood sample of said patient is determined and/or the AVP concentration in a sample of cerebrospinal fluid of said patient is determined and wherein an elevated copeptin and/or an elevated AVP concentration is indicative for a patient responding to a treatment with a V 1B receptor antagonist.
  • the above method further comprises a step of pre-treating the patient with dexamethasone and subsequently determining the copeptin concentration in the blood sample and/or the AVP concentration in the sample of cerebrospinal fluid.
  • the above described method further comprises subjecting the patient to at least one combined dexamethasone/corticotropin releasing hormone test (dex/CRH test).
  • the copeptin concentration indicative for a patient responding to a treatment with a vasopressin receptor antagonist is at least 5 pmol/L, optionally in the range of 5-7 pmol/L.
  • the elevated AVP concentration indicative for a patient responding to a treatment with a V 1B receptor antagonist is at least 4 pg/ml AVP, optionally 4 to 6 pg/ml AVP.
  • FIG. 1 Plasma copeptin levels at the first dex/CRH test in 75 patients with low and 75 patients with high HPA axis dysregulations according to this test.
  • FIG. 2 Graph of the phenotypic distribution of ln(AAUC) at in-patient admission.
  • the X-axis shows the ln of the AUC of the ACTH response and the Y-axis the frequency in total N/bin. #
  • modulation of the receptor mediated activity includes blocking of the receptor mediated activity as well as increasing the receptor mediated activity.
  • V 1B antagonists While so far clinical trials have failed to demonstrate the superiority of V 1B antagonists in the treatment of depression and/or anxiety symptoms, it has now been found that a certain patient group showing depressive symptoms and/or anxiety symptoms, i.e. patients showing an elevated arginine vasopressin level and/or an elevated copeptin level, is responsive to the treatment with V 1B antagonists.
  • the present invention relates to a V 1B antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated arginine vasopressin (AVP) level, e.g. an elevated AVP level in the cerebrospinal fluid.
  • AVP arginine vasopressin
  • the present invention relates to a V 1B antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated copeptin level, e.g. an elevated copeptin level in the blood.
  • a further aspect of the present invention relates to a V 1B antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing both, an elevated arginine vasopressin level and an elevated copeptin level.
  • the patient showing an elevated AVP and/or an elevated copeptin level may be a patient showing depressive symptoms.
  • the patient showing an elevated AVP and/or an elevated copeptin level may be a patient showing anxiety symptoms.
  • the patient showing an elevated AVP and/or an elevated copeptin level may be a patient showing both, depressive and anxiety symptoms.
  • Depressive symptoms comprise inter alia low mood, low self-esteem, loss of interest or pleasure, psychosis, poor concentration and memory, social isolation, psychomotor agitation/retardation, thoughts of death or suicide, significant weight change (loss/gain), fatigue, and a feeling of worthlessness.
  • the depressive disorders can last for weeks to lifelong disorder with periodic reoccurring depressive episodes.
  • the Hamilton Depression Rating Scale HAM-D (Hamilton, J Neurol Neurosurg Psychiatry, 1960) may be used.
  • the depression mode may be also rated by alternative scales as the Beck Depression Inventory (BDI), the Montgomery- ⁇ sberg Depression Scale (MADRS), the Geriatric Depression Scale (GDS), the Zung Self-Rating Depression Scale (ZSRDS).
  • BDI Beck Depression Inventory
  • MADRS Montgomery- ⁇ sberg Depression Scale
  • GDS Geriatric Depression Scale
  • ZSRDS Zung Self-Rating Depression Scale
  • Anxiety symptoms comprise inter alia panic disorders, generalized anxiety disorder, phobias and posttraumatic stress disorder.
  • Typical symptoms of anxiety are avoidance behavior which may lead to social isolation, physical ailments like tachycardia, dizziness and sweating, mental apprehension, stress and tensions. The strength of these symptoms ranges from nervousness and discomfort to panic and terror in humans or animals. Most anxiety disorders may last for weeks or even months, some of them even for years and worsen if not suitably treated.
  • the Hamilton Anxiety Rating Scale HAM-A
  • STAI State-Trait Anxiety Rating Scale
  • V 1B receptor antagonist for use as described herein can be used in the treatment of any of the above mentioned anxiety symptoms or a combination of any of the above mentioned anxiety symptoms in a patient showing an elevated arginine vasopressine level and/or an elevated copeptin level.
  • V 1B receptor antagonists can be used for the treatment of a patient suffering from any of the depressive symptoms described herein and any of the anxiety symptoms as described herein showing an elevated arginine vasopressine level and/or an elevated copeptin level.
  • a healthy individual denotes any person having a score of 0-7 according to the Hamilton Depression Rating Scale and/or a score of 0-6 on the Montgomery- ⁇ sberg Depression Scale and/or a score of 20-44 on the Zung Self-Rating Depression Scale and/or a score of less than 14 on the Hamilton Anxiety Rating Scale.
  • a healthy individual denotes any person having a score considered to be normal in any of the known scales for assessment of depression and/or anxiety.
  • the neuropeptid arginine vasopressin (also denoted as vasopressin, vasopressin argipressin or antidiuretic hormone (ADH)) is a nonapeptide which is produced in the paraventricular nucleus of the hypothalamus and the supraoptic nucleus.
  • Vasopressin has the following sequence, whereby Cys and Cys are connected via an intramolecular disulfide bond:
  • Patients showing elevated arginine vasopressin levels as used herein include patients showing an increased gene activity of genes coding for AVP.
  • patients showing elevated AVP levels as used herein may include patients showing a combination of the presence or absence of at least one polymorphic variant of genes coding for the arginine vasopressine receptor (AVPR), in particular for the arginine vasopressine receptor 1B (AVPR1B), with the presence or absence of at least one polymorphic variant in the patient's genome excluding the AVPR1B gene as defined herein.
  • Patients showing elevated arginine vasopressin levels also include patients showing elevated levels of AVP in the cerebrospinal fluid and/or patients showing elevated blood levels of AVP. Specifically, the patients showing an elevated AVP level show an elevated central AVP level, i.e. elevated AVP concentrations in the CNS.
  • the present invention relates to a V 1B receptor antagonist for use as described herein, wherein an elevated AVP level in said patient is determined by means of AVP measurement.
  • the measurement of AVP may be performed in a sample of cerebrospinal fluid of said patient. Samples of cerebrospinal fluid can be obtained from the patient by any method known in the art, e.g. by lumbar puncture.
  • Methods for determination of AVP levels in a sample of cerebrospinal fluid of a patient include immunoassays, e.g. radioimmunoassays.
  • immunoassays e.g. radioimmunoassays.
  • the AVP level in the sample of cerebrospinal fluid of the patient is measured by means of immunoassay, optionally by means of radioimmunoassay.
  • an elevated AVP level denotes any AVP level higher than the AVP level measured in blood samples and/or samples of the cerebrospinal liquid of healthy individuals.
  • an elevated AVP level in a patient showing depressive symptoms and/or anxiety symptoms is indicated by an AVP concentration in the sample of cerebrospinal fluid of at least 4 pg/ml AVP, at least 5 pg/ml AVP, at least 6 pg/ml AVP, at least 7 pg/ml AVP, at least 8 pg/ml AVP, at least 10 pg/ml AVP, at least 20 pg/ml AVP, at least 30 pg/ml AVP, at least 50 pg/ml AVP, at least 70 pg/ml AVP or at least 90 pg/ml AVP.
  • Elevated AVP levels may be indicated by an AVP concentration in the sample of cerebrospinal fluid in the range from 4 to 8 pg/ml AVP, optional
  • Copeptin (also denoted as C-terminal proAVP) is a glycopeptide of a length of 39 amino acids which is produced from the C-terminal part of the AVP precursor. AVP and copeptin are released from the AVP precursor in an equimolar amount. Since copeptin is stable in blood (i.e. blood plasma, blood serum and/or whole blood) it provides the advantage that it may be used as surrogate marker for AVP levels in the blood plasma, blood serum and/or whole blood.
  • blood i.e. blood plasma, blood serum and/or whole blood
  • the present invention thus relates to a V 1B receptor antagonist for use as described herein, wherein an elevated AVP level and/or an elevated copeptin level in said patient is determined by means of copeptin measurement.
  • Methods for determination of copeptin levels in a blood sample derived from a patient include immunoassays, e.g. sandwich immunoassays.
  • immunoassays e.g. sandwich immunoassays.
  • Examples of such immunoassays are the Copeptin EIA Kit provided by BioSupply UK, the Thermo Scientific B R A H M S copeptin Kryptor assay and the Thermo Scientific B R A H M S copeptin Kryptor us assay provided by ThermoScientific.
  • the AVP level and/or copeptin level of the patient showing depressive symptoms and/or anxiety symptoms is determined by means of an immunoassay, optionally by means of a sandwich immunoassay.
  • the copeptin level is determined in a blood sample of the patient as defined herein.
  • blood sample relates to whole blood, blood serum and/or blood plasma.
  • the blood sample can be obtained from the patient by any method known in the art, e.g. with a sterile needle.
  • the copeptin level is determined in the blood plasma derived from the blood sample of said patient. It is known in the art that blood plasma may be obtained by centrifugation of a blood sample to which an anti-coagulant has been added.
  • an elevated copeptin level denotes any copeptin level higher than the copeptin level measured in blood samples of healthy individuals.
  • an elevated copeptin level and therefore also an elevated AVP level in a patient showing depressive symptoms and/or anxiety symptoms is indicated by a copeptin blood concentration of at least 5 pmol/L, at least 6 pmol/L, at least 7 pmol/L, at least 8 pmol/L, at least 9 pmol/L, at least 10 pmol/ml, at least 20 pmol/ml, at least 30 pmol/ml, at least 40 pmol/ml, at least 50 pmol/ml, at least 60 pmol/ml, at least 70 pmol/ml, at least 80 pmol/ml, at least 90 pmol/ml or at least 100 pmol/ml.
  • Elevated copeptin levels and therefore also elevated AVP levels may be indicated by a copeptin blood concentration in the range from 5 to 9 pmol
  • both the elevated copeptin level and the elevated AVP level are determined in the patient by means of copeptin measurement and measurement of AVP.
  • AVPR 1B vasopressin receptor 1B
  • AVPR1B vasopressin receptor 1B
  • the combined dexamethasone/CRH test a refined laboratory test for psychiatric disorders ., J Psychiatr Res, 1994, 28:341-356) and can be used for screening for compounds which may be useful in the treatment of depressive symptoms and/or anxiety symptoms.
  • the dex/CRH test is described further below with respect to the method according to the invention.
  • a corticotropin (ACTH) increase observed in this combined dexamethasone supression/corticotropin releasing hormone (CRH) stimulation test can be considered as a surrogate marker for an increased vasopressin level, thus indicating patients responsive to the treatment with V 1B receptor antagonists.
  • polymorphic variants may be used for identifying patients showing depressive and/or anxiety symptoms having an elevated copeptin and/or vasopressin level and, consequently, showing a treatment response to V 1B antagonists.
  • the elevated AVP level and/or copeptin level in a patient suffering from depressive and/or anxiety symptoms can be indicated by determining the combination of the presence or absence of at least one polymorphic variant in the genes coding for the AVPR1B in a nucleic acid sample of said patient with the presence or absence of at least one polymorphic variant in the patient's genome excluding the AVPR1B gene.
  • a “polymorphic site” or “polymorphic variant” as used herein relates to the position of a polymorphism or SNP as described herein within the genome or portion of a genome of a subject, or within a genetic element derived from the genome or portion of a genome of a subject.
  • the term “polymorphic variant” relates to a single nucleotide polymorphism (SNP).
  • the polymorphic variant in the AVPR1B gene and/or the patient's genome excluding the AVPR1B gene is a single nucleotide polymorphism (SNP).
  • SNP single nucleotide polymorphism
  • single nucleotide polymorphism is well understood by the skilled person and refers to a point mutation at a certain position in the nucleotide sequence. In other words, only one nucleotide differs in a certain region.
  • the polymorphic variant in the AVPR1B gene is SNP rs28373064.
  • SNP rs28373064 is represented by a single polymorphic change at position 27 of SEQ ID NO: 2, wherein in one or two alleles of the wild-type nucleotide A is replaced by indicator nucleotide G.
  • polymorphic variant in the patient's genome excluding the AVPR1B gene may be selected from the group of biomarkers comprising:
  • the SNPs as described herein may be present on the Watson or the Crick strand, with presence of the corresponding base. If, for example, a polymorphism is present on the Watson strand as A, it is present on the Crick strand as T, if the polymorphism is present on the Watson strand as T, it is present on the Crick strand as A, if the polymorphism is present on the Watson strand as G, it is present on the Crick strand as C, and if the polymorphism is present on the Watson strand as C, it is present on the Crick strand as G, and vice versa. Also the insertion or deletion of bases may be detected on the Watson and/or the Crick strand, with correspondence as defined above.
  • the strand identity may be defined, or fixed, or may be choose at will, e.g. in dependence on factors such the availability of binding elements, GC-content etc.
  • the SNP may be defined on both strands (Crick and Watson) at the same time, and accordingly be analyzed.
  • allele or “allelic sequence” as used herein refers to a particular form of a gene or a particular nucleotide, e.g. a DNA sequence at a specific chromosomal location or locus.
  • a SNP as defined herein may be found at or on one of two alleles in the human genome of a single subject. In further specific embodiments, a SNP as defined herein may also be found at or on both alleles in the human genome of a single subject.
  • an indicator nucleotide or an indicator triplet as defined herein on both alleles may have a higher predictive value than the presence of an indicator nucleotide or an indicator triplet on one allele only, the other allele comprising a wild-type genotype.
  • the nucleotide that is present in the majority of the population is also referred to as wild-type allele or major allele.
  • the term may further refer to the sequence of the non phenotype-associated allele with the highest prevalence within a population, e.g. within a Caucasian population. As used herein, this state is defined as “absence of a SNP”.
  • the specific nucleotide that is present in the minority of the population is also referred as the point mutation, mutated nucleotide or minor allele. As used herein, this state is defined as “presence of a SNP”, “the presence of a polymorphic variant” or “the presence of a marker”.
  • the wild-type allele could be mutated to three different nucleotides.
  • the event of a mutation to a first nucleotide in the reproductive cells of an individual that gets established in a population occurs very rarely.
  • the event that the same position is mutated to a second nucleotide and established in the population virtually never occurs and can be therefore neglected. Therefore, as used herein, a certain nucleotide position in the genome of an individual can have two states, the wild-type state (absence of a SNP) and the mutated state (presence of a SNP).
  • the combination of the presence or absence of at least one polymorphic variant in the AVPR1B gene with the presence or absence of at least one polymorphic variant in the patient's genome excluding the AVPR1B gene as described herein in a sample of a patient is indicative for an elevated AVP level and/or an elevated copeptin level and, consequently, for a positive treatment response to V 1B receptor antagonists.
  • the at least one polymorphic variant in the patient's genome excluding the AVPR1B gene may be selected from a group of biomarkers, in particular from a group of SNPs.
  • biomarker relates to any nucleic acid sequence of any length, or a derivative thereof, which comprises a polymorphic variant such as the polymorphic variant in the AVPR1B gene or the polymorphic variants in the patient's genome excluding the AVPR1B gene as defined herein.
  • biomarker may relate to SNPs.
  • the presence or absence of the at least one polymorphic variant in the AVPR1B gene with the presence or absence of a polymorphic variant in the patient's genome excluding the AVPR1B gene as described herein the presence of one or more further markers for an elevated AVP and/or copeptin level, such as clinical markers may also be determined.
  • a set of biomarkers or “group of biomarkers” relates to a combination of polymorphic variants in the patient's genome, including combinations of polymorphic variants in the AVPR1B gene and/or in the patient's genome excluding the AVPR1B gene.
  • a set or group of biomarkes may relate to a set comprising at least 2, at least 5, at least 8 or at least 11 of the polymorphic variants in the AVPR1B gene and/or in the patient's genome excluding the AVPR1B gene described herein in Table 1.
  • the set or group of biomarkers may comprise any further biomarker not explicitly described herein but considered suitable by the person skilled in the art.
  • a set/group of biomarkers may consist only of the polymorphic variants in the AVPR1B gene and/or the patient's genome excluding the AVPR1B gene as described herein in Table 1.
  • “Combinations of polymorphic variants” as used herein may refer to the presence or absence of at least one polymorphic variant in the AVPR1B gene in combination with the presence or absence of a set or group of polymorphic variants in the patient's genome excluding the AVPR1B gene in a sample of a patient, e.g. to the presence of a combination of a polymorphic variant in the AVPR1B gene in combination with the presence of 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, or 14 polymorphic variant(s) as described herein for polymorphic variants in the patient's genome excluding the AVPR1B gene in Table 1.
  • Combinations of polymorphic variants may relate to the presence of at least one polymorphic variant in the AVPR1B gene, optionally SNP rs28373064, in combination with the presence of 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, or 14 polymorphic variant(s) as described herein in Table 1 for polymorphic variants in the patient's genome excluding the AVPR1B gene.
  • Combinations of polymorphic variants may also relate to the absence of at least one polymorphic variant in the AVPR1B gene, optionally SNP rs28373064, in combination with the absence of 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, or 14 polymorphic variant(s) as described herein in Table 1 for polymorphic variants in the patient's genome excluding the AVPR1B gene.
  • Combinations of polymorphic variants may also relate to the presence of at least one polymorphic variant in the AVPR1B gene, optionally SNP rs 28373064, in combination with the absence of 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, or 14 polymorphic variant(s) as described herein in Table 1 for polymorphic variants in the patient's genome excluding the AVPR1B gene.
  • Combinations of polymorphic variants may also relate to the absence of at least one polymorphic variant in the AVPR1B gene, optionally SNP rs28373064, in combination with the presence of 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, or 14 polymorphic variant(s) as described herein in Table 1 for polymorphic variants in the patient's genome excluding the AVPR1B gene.
  • combinations of polymorphic variants relate to the presence of at least one polymorphic variant in the AVPR1B gene, optionally SNP rs28373064, in combination with the presence of 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, or 14 polymorphic variant(s) as described herein in Table 1 for polymorphic variants in the patient's genome excluding the AVPR1B gene.
  • combinations of polymorphic variants relates to the absence of at least one polymorphic variant in the AVPR1B gene, optionally SNP rs28373064, in combination with the absence of 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, or 14 polymorphic variant(s) as described herein in Table 1 for polymorphic variants in the patient's genome excluding the AVPR1B gene.
  • the presence of a combination of polymorphic variants may be associated with a specific weighting factor describing the impact of the presence of such a combination on the prediction of the treatment response to a V 1B receptor antagonist.
  • a specific weighting factor describing the impact of the presence or absence of such a combination on the prediction of the treatment response to a V 1B receptor antagonist may be associated with the fact that
  • Table 1 provides an overview over SNPs (inside and outside of the AVPR1B gene) which are, alone or in combination, indicative for an elevated AVP and/or copeptin level and thus for selecting patients suffering from depressive and/or anxiety symptoms which should respond to a treatment with a V 1B antagonist.
  • the set or group of biomarkers consists of the biomarkers described in Table 1, whereby the presence or absence of the indicated polymorphic changes (i.e. the presence of the indicator nucleotides) as described herein is indicative for an elevated AVP and/or an elevated copeptin level.
  • indicator nucleotide refers to a non-wild-type nucleotide at positions of SEQ ID NO: 2 to 16 as described in Table 1.
  • SNPs (together with flanking sequences) which may be used to predict the response to V 1B receptor antagonists in patients with depressive symptoms and/or anxiety symptoms.
  • the position of the SNP is indicated as [wild-type nucleotide/indicator nucleotide].
  • One embodiment of the invention relates to a V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP and/or elevated copeptin level, wherein the elevated AVP and/or elevated copeptin level is detected or can be indicated by determining combinations of the presence or absence of at least one polymorphic variant in the AVPR1B gene with at least one polymorphic variant in the patient's genome excluding the AVPR1B gene as described in Table 1.
  • the presence of SNP rs28373064 in combination with the presence of SNP rs9880583, SNP rs730258, SNP rs12654236, SNP rs17091872, SNP rs12254219, SNP rs11575663, SNP rs7080276, SNP rs7416, SNP rs1035050, SNP rs9959162 and SNP rs8088242 is indicative for a treatment response to a V 1B receptor antagonist.
  • the absence of SNP rs28373064 in combination with the absence of SNP rs13099050, SNP rs7441352 and SNP rs12424153 is indicative for a treatment response to a V 1B receptor antagonist.
  • the presence of SNP rs28373064 in combination with the presence of SNP rs9880583, SNP rs730258, SNP rs12654236, SNP rs17091872, SNP rs12254219, SNP rs11575663, SNP rs7080276, SNP rs7416, SNP rs1035050, SNP rs9959162 and SNP rs8088242 and the absence of SNP rs28373064 in combination with the absence of SNP rs13099050, SNP rs7441352 and SNP rs12424153 is indicative for a treatment response to a V 1B receptor antagonist. It is however to be understood that the analysis of other factors, such as the gender of the patient and the presence or absence of each of the SNPs defined in Table 1 may further add to the prediction analysis for the treatment response to a V 1B receptor antagonist.
  • a person skilled in the art can derive the exact position, nucleotide sequence, and indicator sequence from the above identified rs-nomenclature, e.g. from suitable database entries and associated information systems, e.g. the Single Nucleotide Polymorphism database (dbSNP) which is incorporated herein by reference.
  • the information may also be retrievable in case of changes to the nomenclature, or to the surrounding sequence elements, e.g. based on history functions of a suitable database.
  • determining the presence or absence of a biomarker” or “determining the presence or absence of a polymorphic variant” as used herein refers to any suitable method or technique of detecting the identity of an SNP, e.g. at the positions of the biomarkers described herein.
  • the determination method may be a sequencing technique or a technique based on complementary nucleic acid binding.
  • the context of the indicated positions, as well as the strand may differ, e.g. from patient to patient, or from sample to sample etc.
  • Vasopressin receptor 1B (V 1B ) antagonist refers to any compound capable of binding directly or indirectly to a V 1B receptor so as to modulate the receptor mediated activity.
  • Vasopressin receptor 1B (V 1B ) antagonists as used herein include V 1B receptor antagonists which were tested in clinical trials as well as V 1B receptor antagonists which are currently tested in clinical trials or already admitted to the market.
  • V 1B receptor antagonists have been described in the literature and tested in clinical trials.
  • Exemplary V 1B receptor antagonists that have been tested in clinical trials comprise SSR149415 (also denoted as Nelivaptan; Sanofi-Aventis), Org 52186 (Organon), ABT-436 (Abbott) and ABT-558 (Abbott).
  • V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or copeptin level
  • the V 1B receptor antagonist is selected from the group consisting of SSR149415, Org 52186, ABT-436 and/or ABT 558.
  • a combination of any of the aforementioned V 1B receptor antagonists may be used for treatment of depressive and/or anxiety symptoms in a patient showing an elevated AVP level and/or copeptin levels.
  • a compound selected from the group consisting of SSR149415, Org 52186, ABT-436 and/or ABT 558 may be used in combination with a further V 1B receptor antagonist as defined herein for the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level.
  • the present invention relates to a V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or copeptin level, wherein the V 1B receptor antagonist is SSR149415.
  • V 1B receptor antagonist SSR149415 (also denoted as Nelivaptan) developed by Sanofi-Aventis is a non-peptide V 1B receptor antagonist which is orally active (Serradeil-Le Gal et al. (2002); Characterization of (2 S, 4 R )-1-(5- chloro -1-[(2,4- dimethoxyphenyl ) sulfonyl ]-3-(2- methoxy - phenyl )-2- oxo -2,3- dihydro -1 H - indol -3- yl )-4- hydroxy - N,N - dimethyl -2- pyrrolidine carboxamide ( SSR 149415), a Selective and Orally Active Vasopressine V 1b , Receptor Antagonist ; JPET 300:1122-1130).
  • SSR149415 is a (2S,4R)-1-(5-chloro-1-[(2,4-dimethoxyphenyl)sulfonyl]-3-(2-methoxyphenyl)-2-oxo-2,3-dihydro-1H-indol-3-yl)-4-hydroxy-N,N-dimethyl-2-pyrrolidinecarboxamide having the structural formula
  • the present invention relates to a V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or copeptin level, wherein the V 1B antagonist is Org 52186.
  • the present invention relates to a V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or copeptin level, wherein the V 1B receptor antagonist is ABT-436.
  • the present invention relates to a V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or copeptin level, wherein the V 1B receptor antagonist is ABT-558.
  • the patient showing an elevated AVP level and/or an elevated copeptin level is treated with dexamethasone prior to the copeptin measurement or the measurement of AVP.
  • the patient showing an elevated AVP level and/or an elevated copeptin level is treated with dexamethasone prior to the copeptin measurement and the measurement of AVP.
  • the blood sample of the patient and/or the sample of the cerebrospinal fluid of the patient may be obtained after the patient has been treated with dexamethasone but before the patient has been treated with CRH.
  • the patient may be pre-treated with 0.5 mg to 3 mg of dexamethasone, optionally with 0.5 mg, 0.75 mg, 1.0 mg, 1.5 mg, 1.75 mg, 2.0 mg, 2.5 mg, 2.75 mg or 3 mg dexamethasone.
  • the patient may be pre-treated with 1.5 mg dexamethasone.
  • the blood sample and/or the sample of cerebrospinal fluid may be taken 12 to 36 hours after the patient has been pre-treated with dexamethasone, optionally 15 to 24 hours after the patient has been pre-treated with dexamethasone.
  • At least one, optionally two combined dexamethasone suppression CRH stimulation test(s) may be performed. If more than one combined dex/CRH test is performed, these tests are performed in certain intervals, e.g. intervals of days, weeks or months. Specifically, the combined dex/CRH tests may be performed in an interval of about 30 or about 60 days. It is however understood, that the length of the interval may be adapted by the person skilled in the art.
  • the combined dex/CRH test has been described by Heuser et al. ( The combined dexamethasone/CRH test: a refined laboratory test for psychiatric disorders ., J Psychiatr Res, 1994, 28:341-356) and can be used for screening for compounds which may be useful in the treatment of depressive symptoms and/or anxiety symptoms.
  • the dex/CRH test is described further below with respect to the methods for predicting a treatment response to a V 1B receptor antagonist in a patient with depressive symptoms and/or anxiety symptoms according to the invention and it is understood that all aspects of said test as described below are also relevant with respect to the combined dex/CRH test when performed in addition to the copeptin measurement and/or the measurement of AVP.
  • the V 1B receptor antagonist for use in the treatment of depressive syndromes and/or anxiety syndromes in a patient showing an elevated arginine vasopressin (AVP) level and/or an elevated copeptin level is administered in combination with at least one further pharmaceutically active compound suitable for the treatment of depressive symptoms and/or anxiety symptoms.
  • Pharmaceutically active compounds which may be administered in combination with the V 1B receptor antagonist as described herein include in particular compounds labeled for use in the treatment of depressive syndromes and/or anxiety syndromes, compounds currently studied in clinical trials for the treatment of depressive symptoms and/or anxiety symptoms and/or any other compound which is suitable for the treatment of depressive symptoms and/or anxiety symptoms (e.g.
  • each compound mentioned herein may be used in combination with the V 1B receptor antagonist for use as described herein either alone or in combination with a further compound mentioned herein.
  • a non-exhaustive list of compounds suitable for the treatment of depressive symptoms and/or anxiety symptoms includes selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, dopamine reuptake inhibitors, noradrenergic and specific serotonergic antidepressants, norepinephrine (noradrenaline) reuptake inhibitors, selective serotonin reuptake enhancers, norepinephrine-dopamine disinhibitors, norepinephrine-dopamine reuptake inhibitors, tricyclic antidepressants, tetracyclic antidepressants, monamine oxidase inhibitors, psychostimulants, mood stabilizers, amine precursors, serotonin antagonist and reuptake inhibitors, anticonvulsants, nicotine, phytopharmaceuticals, melatonin receptor antagonists, 5-HT antagonists, benzodiazepines, buspirone, azapirones,
  • SSRIs selective serotonin reuptake inhibitors
  • SSRIs are compounds specifically blocking the transporter involved in the reuptake of serotonin and constitute one of the most commonly used class of antidepressants.
  • SSRIs include citalopram, escitalopram, dapoxetine, fluoxetine, fluvoxamine, paroxetine, sertraline and vilazodone.
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is used in combination with at least one SSRI which is optionally selected from the group consisting of citalopram, escitalopram, dapoxetine, fluoxetine, fluvoxamine, paroxetine, sertraline and vilazodone.
  • the V 1B receptor antagonist for use as described herein may be used in combination with one SSRI.
  • this SSRI is selected from the group consisting of citalopram, escitalopram, dapoxetine, fluoxetine, fluvoxamine, paroxetine, sertraline and vilazodone.
  • the present invention relates to SSR149415 for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level used in combination with at least one SSRI, which is optionally selected from the group consisting of citalopram, escitalopram, dapoxetine, fluoxetine, fluvoxamine, paroxetine, sertraline and vilazodone.
  • Norepinephrine (noradrenaline) reuptake inhibitors exert their activity through blocking the norepinephrine transporter and may also be administered in combination with the V 1B receptor antagonist for used as described herein.
  • NRIs as used herein also includes selective norepinephrine reuptake inhibitors as well as NRIs having an activity at a different site.
  • NRIs are compounds such as atomoxetin, mazindol, reboxetine, esreboxetin, viloxazine, amedalin, daledalin, CP-39,332, edivoxtin, lortalamine, talopram, talsupram, tandamine, buproprion, ciclazindol and teniloxazine.
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with at least one norepinephrine reuptake inhibitor, which is optionally selected from atomoxetin, mazindol, reboxetine, esreboxetin, viloxazine, amedalin, daledalin, CP-39,332, edivoxtin, lortalamine, talopram, talsupram, tandamine, buproprion, ciclazindol and teniloxazine.
  • the V 1B receptor antagonist for use as described herein administered in combination with at least one norephinephrine reuptake inhibitor is SSR149415.
  • Serotonin-norepinephrine reuptake inhibitors may also be used for the treatment of depressive symptoms and/or anxiety symptoms.
  • SNRIs are desvenlafaxine, duloxetine, milnacipran and venlafaxine.
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with at least one SNRI, which is optionally selected from the group consisting of desvenlafaxine, duloxetine, milnacipran and venlafaxine.
  • the V 1B receptor antagonist for use as described herein administered in combination with at least one SNRI is SSR149415.
  • Dopamine reuptake inhibitors are compounds blocking the activity of the dopamine transporter and include selective dopamine reuptake inhibitors as well as other DRIs.
  • DRIs are amineptine, nomifensine, medifoxamine, methylphenidate, amfonelic acid, benzothiophenylcyclohexylpiperidine (BTCP), as well as Chaenomeles speciosa .
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with at least one DRI, which is optionally selected from the group consisting of amineptine, nomifensine, medifoxamine, methylphenidate, amfonelic acid, benzothiophenylcyclohexylpiperidine (BTCP), as well as Chaenomeles speciosa .
  • the V 1B receptor antagonist for use as described herein administered in combination with at least one DRI is SSR149415.
  • NaSSAs noradrenergic and specific serotonergic antidepressants
  • examples of NaSSAs include aptazapine, mianserin and mirtazepin.
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with at least one NaSSA which is optionally selected from the group consisting of aptazapine, mianserin and mirtazepin.
  • the V 1B receptor antagonist for use as described herein administered in combination with at least one NaSSA is SSR149415.
  • Selective serotonin reuptake enhancers such as tianeptine may also be administered in combination with the V 1B receptor antagonist for use as described herein.
  • the V 1B receptor antagonist for use as described herein is administered in combination with at least one selective serotonin reuptake enhancer is SSR149415.
  • Norepinephrine-dopamine disinhibitors denotes a class of compounds inhibiting the release of norepinephrine and dopamine such as agomelatine and may also be used in combination with the V 1B receptor antagonist for use as described herein.
  • the V 1B receptor antagonist for use as described herein administered in combination with at least one norepinephrine-dopamine disinhibitors is SSR149415.
  • Norepinephrine-dopamine reuptake inhibitors are compounds blocking the norepinephrine as well as the dopamine transporter.
  • Exemplary NDRIs are bupropion, pipradrol, dexmethylphenidate, mesocarb, methylphenidatea and pyrovalerone.
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with at least one NDRI, which is optionally selected from the group consisting of bupropion, pipradrol, dexmethylphenidate, mesocarb, methylphenidatea and pyrovalerone.
  • the V 1B receptor antagonist for use as described herein administered in combination with at least one NDRI is SSR149415.
  • Tricyclic antidepressants are cyclic or heterocyclic chemical compounds having three cycles which are useful in the treatment of depressive symptoms and/or anxiety symptoms.
  • tricylic antidepressants are amineptine, amitriptyline, amytriptylinoxide, butriptyline, clomipramine, demexiptiline, desipramine, dibenzepin, dimetacrine, dosulepin, doxepin, imipramine, imipraminoxide, iprindole, lofepramine, melitracen, metapramine, nitroxazepine, nortriptyline, noxiptiline, opipramol, pipofezine, propizepine, protriptyline, quinupramine, tianeptine and trimipramine.
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with at least one TCA, which is optionally selected from the group consisting of amineptine, amitriptyline, amytriptylinoxide, butriptyline, clomipramine, demexiptiline, desipramine, dibenzepin, dimetacrine, dosulepin, doxepin, imipramine, imipraminoxide, iprindole, lofepramine, melitracen, metapramine, nitroxazepine, nortriptyline, noxiptiline, opipramol, pipofezine, propizepine, protriptyline, quinupramine, tianeptine and trimipramine.
  • TCA which is optionally selected from the group consisting of amineptine, amitriptyline
  • TeCAs tetracyclic antidepressants
  • the tetracyclic antidepressants are also characterized by their chemical structure and are cyclic or heterocyclic compounds having four rings. TeCAs include compounds such as amoxapine, aptazapine, ciclazindol, maprotiline, mianserin, mirtazepine, oxaprotiline and setiptiline.
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with at least one TeCA, which is optionally selected from the group consisting of amoxapine, aptazapine, ciclazindol, maprotiline, mianserin, mirtazepine, oxaprotiline and setiptiline.
  • TeCA is optionally selected from the group consisting of amoxapine, aptazapine, ciclazindol, maprotiline, mianserin, mirtazepine, oxaprotiline and setiptiline.
  • the V 1B receptor antagonist for use as described herein administered in combination with at least one TeCA is SSR149415.
  • MAOIs Monoamine oxidase inhibitors denote compounds blocking the degradation of amines by inhibiting the activity of the enzyme monoamine oxidase.
  • MAOIs includes irreversible, reversible and pseudo-irreversible MAOIs as well as compounds selectively inhibiting either monoamine oxidase type A (MAO-A) or monoamine oxidase type B (MAO-B) or showing a non-selective inhibition of MAO.
  • Examplary MAOIs include isocaboxazid, moclobemide, phenelzine, selegiline and trancylcypromine.
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with at least one MAOI, which is optionally selected from the group consisting of isocaboxazid, moclobemide, phenelzine, selegiline and trancylcypromine.
  • the V 1B receptor antagonist for use as described herein administered in combination with at least one MAOI is SSR149415.
  • psychostimulants includes any compound which acts stimulating on a body e.g. by improving the mental and/or physical function of the body.
  • exemplary types of psychostimulants include xanthines, piperazine derivatives and amphetamine derivatives (such as methylphenidate).
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with at least one psychostimulant, which is optionally selected from the group consisting of xanthines, piperazine derivatives and amphetamine derivatives.
  • the V 1B receptor antagonist for use as described herein administered in combination with at least one psychostimulant is SSR149415.
  • Mood stabilizers which can be used in combination with the V 1B receptor antagonist for use as described herein are any compound useful for treatment fast and unstable mood changes.
  • mood stabilizers include lithium, valproic acid, carbamazepine, lamotrigine, oxacabezipine, riluzole and gabapentin.
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with at least one mood stabilizer, which is optionally selected from the group consisting of lithium, valproic acid, carbamazepine, lamotrigine, oxacabezipine, riluzole and gabapentin.
  • at least one mood stabilizer is SSR149415.
  • amine precursors i.e. metabolic precursors of monoamine neurotransmitter (such as dopamine, noradrenaline, serotonin and acetylcholine).
  • monoamine neurotransmitters include L-tryptophan, phenylalanine, 5-hydroxytryptophan, dopamine, L-tyrosine, cholin and L-DOPA.
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with at least one amine precursor, which is optionally selected from the group consisting of L-tryptophan, phenylalanine, 5-hydroxytryptophan, dopamine, L-tyrosine, cholin and L-DOPA.
  • the V 1B receptor antagonist for use as described herein administered in combination with at least one amine precursor is SSR149415.
  • Serotonin antagonists and reuptake inhibitors exert their activity by antagonizing serotonin receptors and include compounds such as nefazodon, etoperidone, lorpiprazole, lubazodone, trazodone and mepiprazole.
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with at least one SARI, which is optionally selected from the group consisting of nefazodon, etoperidone, lorpiprazole, lubazodone, trazodone and mepiprazole.
  • SARI is SSR149415.
  • Anticonvulsant as used herein relates to any compound useful in the treatment and/or prevention of seizures, such as barbiturates, benzodiazepines, carboxamides, valproic acid and hydantoin derivatives.
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with at least one anticonvulsant, which is optionally selected from the group consisting of barbiturates, benzodiazepines, carboxamides, valproic acid and hydantoin derivatives.
  • the V 1B receptor antagonist for use as described herein administered in combination with at least one anticonvulsant is SSR149415.
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with nicotine.
  • the V 1B receptor antagonist for use as described herein administered in combination with nicotine is SSR149415.
  • Phytopharmaceuticals as used herein includes any composition wherein the active ingredients are solely derived from plants (e.g. from Saint John's wort) and which are useful in the treatment of depressive symptoms and/or anxiety symptoms.
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with at least one phytopharmaceutical.
  • the V 1B receptor antagonist for use as described herein administered in combination with at least one phytopharmaceutical is SSR149415.
  • anxiolytics Compounds useful in the treatment of anxiety symptoms include e.g. benzodiazepines, azapirones, barbiturates, pregabalin, hydroxyzine and buspirone.
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with at least one anxiolytic, which is optionally selected from the group consisting of benzodiazepines, azapirones, barbiturates, pregabalin, hydroxyzine and buspirone.
  • the V 1B receptor antagonist for use as described herein administered in combination with at least one anxiolytic is SSR149415.
  • V 1B receptor antagonists include further receptor antagonists such as 5-HT receptor antagonists, melatonin receptor antagonists, corticotropin-releasing hormone (CRH) receptor antagonists, neurokinin receptor antagonists and glucocorticoid receptor antagonists.
  • CHL corticotropin-releasing hormone
  • neurokinin receptor antagonists and glucocorticoid receptor antagonists are administered in combination with the V 1B receptor antagonist for use as described herein.
  • 5-HT (5-hydroxytryptamine, serotonin) receptor antagonists refer to any compound capable of binding directly or indirectly to a 5-HT receptor so as to modulate the receptor mediated activity.
  • 5-HT receptor families i.e. the 5-HT 1 receptor family, 5-HT 2 receptor family, 5-HT 3 receptor family, 5-HT 4 receptor family, 5-HT 5 receptor family, 5-HT 6 receptor family and 5-HT 5 receptor family are known in the art, which may be further subdivided in various subtypes.
  • the 5-HT receptor antagonists as used herein may be directed against any of the aforementioned 5-HT receptor families and against any known subtype of these families, in particular against the 5-HT 2 family, specifically against the 5-HT 2A , 5-HT 2B and/or 5-HT 2c subtype.
  • Exemplary 5-HT receptor antagonists include azapirones (5-HT 1A and 5-HT 2A receptor antagonists), aripiprazole (5-HT 2A ) and agomelatin (5-HT 2c receptor antagonists).
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with at least one 5-HT receptor antagonist, which is optionally selected from the group consisting of antagonists against the 5-HT 1 receptor family, the 5-HT 2 receptor family, the 5-HT 3 receptor family, the 5-HT 4 receptor family, the 5-HT 5 receptor family, the 5-HT 6 receptor family and the 5-HT 7 receptor family.
  • the V 1B receptor antagonist for use as described herein administered in combination with at least one 5-HT receptor antagonist is SSR149415.
  • the V 1B receptor antagonist for use as described herein administered in combination with at least one 5-HT receptor antagonist selected from the group consisting of antagonists against a receptor of the 5-HT 1 receptor family, the 5-HT 2 receptor family, the 5-HT 3 receptor family, the 5-HT 4 receptor family, the 5-HT 5 receptor family, the 5-HT 6 receptor family and the 5-HT 7 receptor family is SSR149415.
  • Melatonin receptor antagonists as used herein refer to any compound capable of binding directly or indirectly to the melatonin receptor so as to modulate the receptor mediated activity.
  • An example of a melatonin receptor antagonist is the melatonergic antidepressant agomelatine.
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with at least one melatonin receptor antagonist, which is optionally agomelatine.
  • the V 1B receptor antagonist for use as described herein administered in combination with at least one melatonin receptor antagonist is SSR149415.
  • CRH receptor antagonists refers to any compound capable of binding directly or indirectly to a CRH receptor 1 or a CRH receptor 2 so as to modulate the receptor mediated activity.
  • CRHR1 antagonists are well known in the literature and are e.g. described in WO 94/13676, EP 0 773 023, WO 2004/047866, WO 2004/094420, WO 98/03510, WO 97/029109, WO 2006/044958, WO 2001/005776 and WO 95/033750.
  • Exemplary CRHR1 antagonists comprise NBI30775/R121919 (Neurocrine), CP316.311 (Pfizer), CP154,526 (Pfizer), Emicerfont (Glaxo), ONO-2333Ms (Ono Pharmaceutical), Pexacerfont (BristolMyers-Squibb), SSR125543 (Sanofi-Aventis), NBI-34101 (Neurocrine) and TAI041 (Taisho).
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with at least one CRH receptor antagonist, particularly a CRHR1 antagonist, which is optionally selected from the group consisting of NBI30775/R121919, CP316.311, CP154,526, Emicerfont, ONO-2333Ms, Pexacerfont, SSR125543, NBI-34101 and TAI041.
  • a CRHR1 antagonist which is optionally selected from the group consisting of NBI30775/R121919, CP316.311, CP154,526, Emicerfont, ONO-2333Ms, Pexacerfont, SSR125543, NBI-34101 and TAI041.
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with at least one CRHR2 receptor antagonist.
  • the V 1B receptor antagonist for use as described herein administered in combination with at least one CRH receptor antagonist is SSR149415.
  • Neurokinin (NK) receptor antagonists also known as tachykinin receptor antagonists
  • NK receptor antagonists refers to any compound capable of binding directly or indirectly to a neurokinin receptor (e.g. NK 1 , NK 2 or NK 3 ) so as to modulate the receptor mediated activity.
  • the NK receptor antagonists are NK 1 receptor antagonists.
  • Exemplary NK receptor antagonists are the NK 1 receptor antagonists vestipitant, L-733,060, Orveptitan, AV608, LY686017, 6R205171, L759274, CPR2721, Casopitant, Aprepitant, the NK 2 receptor antagonist saredutant and the NK 3 receptor antagonists osanetant and talnetant.
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with at least one NK receptor antagonist, which is optionally selected from the group consisting of vestipitant, L-733,060, Orveptitan, AV608, LY686017, 6R205171, L759274, CPR2721, Casopitant, Aprepitant, saredutant, osanetant and talnetant.
  • the V 1B receptor antagonist for use as described herein administered in combination with at least one NK receptor antagonist, optionally in combination with at least one NK 1 receptor antagonist is SSR149415.
  • Glucocorticoid receptor antagonists refers to any compound capable of binding directly or indirectly to a glucocorticoid receptor so as to modulate the receptor mediated activity such as the compounds RU-43044 and RU 38486 (mifepristone).
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with at least one glucocorticoid receptor antagonist, which is optionally selected from the group consisting of RU-43044 and RU 38486 (mifepristone).
  • the V 1B receptor antagonist for use as described herein administered in combination with at least one glucocorticoid receptor antagonist is SSR149415.
  • the V 1B receptor antagonist for use in the treatment of depressive symptoms and/or anxiety symptoms in a patient showing an elevated AVP level and/or an elevated copeptin level as described herein is administered in combination with oxytocin.
  • the V 1B receptor antagonist for use as described herein administered in combination with oxytocin is SSR149415.
  • the V 1B receptor antagonist for use as described herein and the at least one further pharmaceutically active compound may be administered at the same time or at different time points.
  • the V 1B receptor antagonist for use as described herein may be administered first, followed by the administration of the at least one pharmaceutically active compound mentioned herein or vice versa.
  • Any sequence of administration of the V 1B receptor antagonist for use as described herein and the at least one further pharmaceutically active compound is encompassed in the present invention, e.g. the V 1B receptor antagonist for use as described herein may also be administered in between two further pharmaceutically active compounds.
  • a patient showing an elevated AVP level and/or an elevated copeptin level is identified by (i) determining in a patient's sample the status of a biomarker or a group of biomarkers as described herein; and (ii) identifying the patient as eligible for a therapy with a V 1B receptor antagonist where the patient's sample is classified as showing the presence or absence of indicator nucleotides as defined herein below.
  • a patient showing an elevated AVP level and/or an elevated copeptin level is identified by predicting the patient's treatment response to the V 1B receptor antagonist by the prediction methods as described herein below.
  • a further aspect of the present invention relates to a method for predicting a treatment response to a V 1B receptor antagonist in a patient with depressive symptoms and/or anxiety symptoms, comprising the following steps:
  • the polymorphic variant in the AVPR1B gene and/or in the patient's genome excluding the AVPR1B gene may be a single nucleotide polymorphism (SNP).
  • SNP single nucleotide polymorphism
  • determining the presence or absence of a biomarker or “determining the presence or absence of a polymorphic variant in the AVPR1B gene” or “determining the presence or absence of a polymorphic variant in the patient's genome excluding the AVPR1B gene” as used herein refers to any suitable method or technique of detecting the identity of an SNP, e.g. at the positions of the biomarkers described herein in a sample derived from the patient.
  • the determination method may be a sequencing technique or a technique based on complementary nucleic acid binding.
  • the context of the indicated positions, as well as the strand may differ, e.g. from patient to patient, or from sample to sample etc.
  • a “nucleic acid sample” or “patient's sample” as used herein may be any sample derived from any suitable part or portion of a subject's body such as a blood sample, a hair sample, a skin sample or a salvia sample of the patient from which nucleic acids can be extracted. In some embodiments, blood or saliva samples are used.
  • the sample used in the context of the present invention for detecting the presence of a polymorphic variant or an SNP should be collected in a clinically acceptable manner, in particular in a way that nucleic acids and/or proteins are preserved. Usually, nucleic acid or DNA is extracted or isolated or purified from the sample prior to determining the presence or absence of the polymorphic variants described herein, e.g. in Table 1.
  • Suitable methods comprise inter alia steps such as centrifugation steps, precipitation steps, chromatography steps, dialyzing steps, heating steps, cooling steps and/or denaturation steps.
  • the polymorphic variant in the AVPR1B gene for which the presence or absence is determined is SNP rs28373064 which is represented by a single polymorphic change at position 27 of SEQ ID NO: 2, wherein in one or two alleles of the wild-type nucleotide A is replaced by indicator nucleotide G.
  • the at least one polymorphic variant in the patient's genome excluding the AVPR1B gene for which the presence or absence is determined is selected from the group of biomarkers comprising:
  • a further embodiment of the present invention relates to the method described herein, wherein the at least one polymorphic variant in the AVPR1B gene and/or in the patient's genome excluding the AVPR1B gene for which the presence or absence is determined is selected from a set/group of biomarkers comprising at least 2, at least 5, at least 8 or at least 11 of the markers as defined in Table 1.
  • the at least one polymorphic variant in the AVPR1B gene and/or in the patient's genome excluding the AVPR1B gene for which the presence or absence is determined is selected from a set or group of biomarkers consisting of the biomarkers as defined in Table 1.
  • the combination of the presence or absence of SNP rs28373064 with the presence or absence of at least 1, at least 2, at least 3, at least 4, at least 5, at least 6, at least 7, at least 8, at least 9, at least 10, at least 11, at least 12, at least 13 or at least 14 polymorphic variants in the patient's genome excluding the AVPR1B gene as defined in Table 1 (excluding SNP rs28373064) is determined.
  • the presence of SNP rs28373064 in combination with the presence of SNP rs9880583, SNP rs730258, SNP rs12654236, SNP rs17091872, SNP rs12254219, SNP rs11575663, SNP rs7080276, SNP rs7416, SNP rs1035050, SNP rs9959162 and SNP rs8088242 is indicative for a treatment response to a V 1B receptor antagonist.
  • the absence of SNP rs28373064 in combination with the absence of SNP rs13099050, SNP rs7441352 and SNP rs12424153 is indicative for a treatment response to a V 1B receptor antagonist.
  • the presence of SNP rs28373064 in combination with the presence of SNP rs9880583, SNP rs730258, SNP rs12654236, SNP rs17091872, SNP rs12254219, SNP rs11575663, SNP rs7080276, SNP rs7416, SNP rs1035050, SNP rs9959162 and SNP rs8088242 and the absence of SNP rs28373064 in combination with the absence of SNP rs13099050, SNP rs7441352 and SNP rs12424153 is indicative for a treatment response to a V 1B receptor antagonist. It is however to be understood that the analysis of other factors, such as the gender of the patient and the presence or absence of each of the SNPs defined in Table 1 may further add to the prediction analysis for the treatment response to a V 1B receptor antagonist.
  • Such further marker(s), such as clinical markers may be determined in addition to the presence of the herein-described markers.
  • clinical markers may include the AVP and/or copeptin level.
  • the presence or absence of the polymorphic variant in the AVPR1B gene and the presence or absence of the one or more further markers may determined by single nucleotide polymorphism genotyping analysis.
  • SNP single nucleotide polymorphism genotyping analysis
  • the determination of the nucleotide sequence and/or molecular structure may be carried out through allele-specific oligonucleotide (ASO)-dot blot analysis, primer extension assays, iPLEX SNP genotyping, Dynamic allele-specific hybridization (DASH) genotyping, the use of molecular beacons, tetra primer ARMS PCR, a flap endonuclease invader assay, an oligonucleotide ligase assay, PCR-single strand conformation polymorphism (SSCP) analysis, quantitative real-time PCR assay, SNP microarray based analysis, restriction enzyme fragment length polymorphism (RFLP) analysis, targeted resequencing analysis and/or whole genome sequencing analysis.
  • ASO allele-specific oligonucleotide
  • primer extension assays iPLEX SNP genotyping
  • DASH Dynamic allele-specific hybridization
  • DASH Dynamic allele-specific hybridization
  • a patient showing an elevated AVP level and/or an elevated copeptin level can be identified by (i) determining in a patient's sample the status of a biomarker or a group of biomarkers as defined above;
  • One aspect of the invention thus concerns the provision of such an algorithm for predicting a treatment response to V 1B receptor antagonists in patients with depressive symptoms and/or anxiety symptoms.
  • the method may comprise the following steps:
  • a single nucleotide polymorphism (SNP) genotyping analysis in a group of patients with depressive symptoms and/or anxiety symptoms is performed.
  • a “group of patients” as used herein comprises at least two patients, such as at least 10 patients, or at least 100 patients, or at least 150 patients. Patients included in the analysis of step (a) may exhibit at least a moderate to severe depressive mode. The group of patients may comprise patients with CRH overactivity and/or patients with normal CRH activity.
  • SNP genotyping analysis can be performed by methods known in the art such as the methods mentioned herein.
  • any of the methods described herein comprises the determination of the haplotype for two copies of the chromosome comprising the SNPs identified herein.
  • a SNP is considered in the genotyping analysis if it occurs in a certain percentage in the population, for example in at least 5% or at least 10% of the population.
  • the minor allele frequency (MAF) is larger than 0.05 or 0.10 (MAF>0.05 or MAF>0.10).
  • a nucleic acid or DNA sample from a patient may be used.
  • the nucleic acid or DNA sample can be a blood sample, a hair sample, a skin sample or a salvia sample of the patient. Any other sample obtainable from the patient and containing patient nucleic acid or DNA can also be used.
  • the sample can be collected from the patient by any method known in the art. For example, a blood sample can be taken from a patient by use of a sterile needle. The collection of salvia out of the mouth and throat of the patient can be performed by use of a sterile cotton bud or by flushing said area and collecting the flushing solution.
  • the nucleic acid or DNA is extracted or isolated or purified from the sample prior to SNP genotyping analysis.
  • Any method known in the art may be used for nucleic acid or DNA extraction or isolation or purification. Suitable methods comprise inter alia steps such as centrifugation steps, precipitation steps, chromatography steps, dialyzing steps, heating steps, cooling steps and/or denaturation steps.
  • a certain nucleic acid or DNA content in the sample may be reached. Nucleic acid or DNA content can be measured for example via UV spectrometry as described in the literature.
  • SNP genotyping analysis may also be performed by using a non-extracted or non-purified sample.
  • Nucleic acid or DNA amplification may also be useful prior to the SNP analysis step. Any method known in the art can be used for nucleic acid or DNA amplification.
  • the sample can thus be provided in a concentration and solution appropriate for the SNP analysis.
  • the analyzed SNPs may be represented by values 0, 1 or 2.
  • the value “0” may indicate that the SNP is present on none of the two homologous chromosomes.
  • the value “1” may indicate that the SNP is present on one of the two homologous chromosomes.
  • the value “2” may indicate that the SNP is present on both homologous chromosomes.
  • Homologous chromosomes correspond to each other in terms of chromosome length, gene loci and staining pattern. One is inherited from the mother, the other from the father.
  • a value indicative for CRH activity in each patient is determined.
  • a “value indicative for CRH activity”, a “value indicative for CRH overactivity” and/or a “value indicative for normal CRH activity” can be obtained by determining the concentration or activity of CRH and/or of a downstream target of the CRHR1 receptor.
  • the analysis is usually set up in a way that it can be excluded that the modulation of activity or concentration of a downstream target of the CRHR1 receptor is due to another disturbance than CRH activity.
  • the concentrations or activities of adrenocorticotrophin (ACTH) and/or cortisol are useful biomarkers for determining a value indicative for CRH overactivity.
  • the CRH overactivity in each patient may be determined by measuring the ACTH and/or cortisol level response to a combined dexamethasone suppression/CRH stimulation test as described herein.
  • Steps (c) and (d) of the method for providing a prediction algorithm may analyze the association of the analyzed SNPs with the value indicative for CRH overactivity and/or normal CRH activity and generate an algorithm for predicting the treatment response to V 1B receptor antagonists.
  • steps (c) and (d) of the method for providing a prediction algorithm may analyze the association of a combination of the presence or absence of at least two of the analyzed SNPs, in particular a combination of the presence or absence of at least one SNP in the AVPR1B gene with the presence or absence of at least one SNP in the genome of the patient excluding the AVPR1B gene with a value indicative for CRH overactivity and/or normal CRH activity and generate an algorithm for predicting the treatment response to V 1B receptor antagonists.
  • steps (c) and (d) of the method for providing a prediction algorithm may analyze the association of the gender of the patient from which the sample was derived with a value indicative for CRH overactivity and/or normal CRH activity and generate an algorithm for predicting the treatment response to V 1B receptor antagonists.
  • the group of patients may be split into two sets of similar size and similar values for descriptors such as demographic descriptors or clinical descriptors. These two sets are hereinafter also referred to as “training set” and “test set”.
  • step (c) of the method of this exemplary embodiment at least one SNP associated with the value indicative for CRH overactivity and/or normal CRH activity as determined in step (b) is identified in the training set.
  • the association of a combination of the analyzed SNPs with a value indicative for CRH overactivity and/or normal CRH activity as determined in step (b) may be identified in the training set.
  • the association of the gender of the patient from which the sample was derived with a value indicative for CRH overactivity and/or normal CRH activity as determined in step (b) is identified in the training set.
  • the result may be a categorical answer whether the patient responds to V 1B receptor antagonist treatment or not.
  • the prediction algorithm may provide the answer to which degree the patient responds or does not respond to the treatment. Depending on the desired result provided by the prediction algorithm the way of determining the algorithm may differ.
  • the prediction algorithm will analyze whether a patient responds or does not respond to V 1B receptor antagonist treatment, the values indicative for CRH activity may be provided as logic data variable (Boolean type; 0 vs. 1; true vs. false, high vs. low responder). Therefore, if the test performed to determine values indicative for CRH overactivity provides a data range, the patients may be dichotomized by a threshold into high vs. low responders.
  • the values indicative for CRH activity may be provided as numerical values.
  • SNPs that are modified in a significant percentage of the population are used in the method for providing a prediction algorithm. For example, only SNPs with a minor allele frequency (MAF) greater than 0.05 or 0.10 may be selected for further analysis. This means that only SNPs that are modified in at least 5% or 10% of the population are selected for further analysis.
  • MAF minor allele frequency
  • Association for all SNPs or combinations of SNPs with the value indicative for CRH activity is tested by an association analysis testing the likelihood for a patient to be CRH overactive vs. CRH non-overactive in dependence of the genotype of said patient.
  • Said association analysis may be conducted for example by an additive genetic model and/or by a logistic regression.
  • a SNP or combination of at least two SNPs is e.g. identified to be associated with a value indicative for CRH overactivity if the corresponding p-value is at least 1 ⁇ 10 ⁇ 3 or at least 1 ⁇ 10 ⁇ 4 or at least 1 ⁇ 10 ⁇ 5 . The lower the p-value the more the SNP is associated with a value indicative for CRH overactivity.
  • an SNP or combination of at least two SNPs is e.g. identified to be associated with a value indicative for normal CRH activity if the corresponding p-value is at least 1 ⁇ 10 ⁇ 3 or at least 1 ⁇ 10 ⁇ 4 or at least 1 ⁇ 10 ⁇ 5 .
  • only SNPs or combinations of SNPs with a p-value of ⁇ 1 ⁇ 10 ⁇ 5 are used.
  • the algorithm for predicting a treatment response to V 1B receptor antagonist may be determined by the use of SNPs or combinations of SNPs in the test set by a machine learning method.
  • algorithm for predicting may refer to a classification function (also known as binary classification test).
  • machine-learning may refer to a method known to the person skilled in the art of machine learning.
  • machine learning is concerned with the design and development of algorithms that allow computers to evolve behaviors based on empirical data, such as from sensor data or databases. It may be selected from the group consisting of artificial neural network learning, decision tree learning, support vector machine learning, Bayesian network learning, clustering, and regression analysis.
  • the term “reliable prediction of the treatment response to a V 1B receptor antagonist” as used herein may refer to a high performance of the prediction algorithm.
  • the evaluation of the performance of the prediction algorithm may depend on the problem the algorithm is applied for. If the algorithm is used to identify patients that are likely to response to the treatment with V 1B receptor antagonists the performance is usually expressed by a high accuracy and/or sensitivity and/or precision. If patients should be identified which are likely not to respond to the treatment with V 1B receptor antagonist, specificity and/or negative predictive value are typical statistical measures to describe the performance of the prediction algorithm.
  • the step of determining the algorithm by a machine-learning method in a first subset of the test set and testing the prediction performance in an second independent subset of the test set may be repeated based on different numbers and groups of SNPs, until the desired prediction performance is reached.
  • Accuracy, sensitivity, precision, specificity and negative predictive value are exemplary statistical measure of the performance of the prediction algorithm. In the following, examples are given for determining the performance of the prediction algorithm.
  • accuracy may be calculated as (number of true positives+number of true negatives)/(number of true positives+number of false positives+number of true negatives+number of false negatives), e.g. (number of patients correctly diagnosed as responding to V 1B receptor antagonist+number of patients correctly diagnosed as not responding to V 1B receptor antagonist)/(number of patients correctly diagnosed as responding to V 1B receptor antagonist+number of patients wrongly diagnosed as responding to V 1B receptor antagonist+number of patients correctly diagnosed as not responding to V 1B receptor antagonist+number of patients wrongly diagnosed as not responding to V 1B receptor antagonist).
  • the accuracy of prediction may e.g. be at least 60%, at least 70%, at least 80% or at least 90%.
  • sensitivity may be calculated as (true positives)/(true positives+false negatives), e.g.: (number of patients correctly diagnosed as responding to V 1B receptor antagonist)/(number of patients correctly diagnosed as responding to V 1B receptor antagonist+number of patients wrongly diagnosed as not responding to V 1B receptor antagonist).
  • the sensitivity of prediction may be at least 60%, at least 70%, at least 80% or at least 90%.
  • precision also referred to as positive predictive value
  • precision may be calculated as (true positives)/(true positives+false positives), e.g.: (number of patients correctly diagnosed as responding to V 1B receptor antagonist)/(number of patients correctly diagnosed as responding to V 1B receptor antagonist+number of patients wrongly diagnosed as responding to V 1B receptor antagonist).
  • the precision of prediction may be at least 60%, at least 70%, at least 80% or at least 90%.
  • specificity is calculated as (true negatives)/(true negatives+false positives), e.g.: (number of patients correctly diagnosed as not responding to V 1B receptor antagonist)/(number of patients correctly diagnosed as not responding to V 1B receptor antagonist+number of patients wrongly diagnosed as responding to V 1B receptor antagonist).
  • the specificity of prediction may be at least 60%, at least 70%, at least 80% or at least 90%.
  • negative predictive value is calculated as (true negatives)/(true negatives+false negatives), e.g.: (number of patients correctly diagnosed as not responding to V 1B receptor antagonist)/(number of patients correctly diagnosed as not responding to V 1B receptor antagonist+number of patients wrongly diagnosed as not responding to V 1B receptor antagonist).
  • the negative predictive value may be at least 60%, at least 70%, at least 80% or at least 90%.
  • a prediction algorithm with high sensitivity may have low specificity and vice versa.
  • the decision to select an algorithm having certain statistical characteristics such as accuracy, sensitivity or specificity may also depend on the costs associated with a treatment with a V 1B receptor antagonist should the prediction be positive and/or whether such a treatment is detrimental in cases where the result is a false positive.
  • the prediction algorithm may be based on a number of SNPs and/or combinations of SNPs sufficient to achieve a prediction sensitivity and/or precision of at least 55%, optionally at least 80%.
  • the prediction algorithm may be based on a number of SNPs and/or combinations of SNPs sufficient to achieve a prediction specificity and/or negative predictive value of at least 55%, optionally at least 80%.
  • the prediction algorithm may be based on a number of SNPs and/or combinations of SNPs sufficient to achieve sensitivity and/or precision and/or specificity and/or negative predictive value of at least 55%, optionally at least 80%.
  • a number N of SNPs and/or combinations of SNPs is associated with a value indicative for CRH overactivity or normal CRH activity in step (c) of the method for providing an algorithm, wherein N is sufficient to provide an accuracy of at least 80% and a sensitivity of at least 70% and a specificity of at least 70%. In another embodiment, N is sufficient to provide an accuracy of at least 85% and a sensitivity of at least 80% and a specificity of at least 80%.
  • a sufficient number N of SNPs and/or combinations of SNPs comprises at least one polymorphic variant in the AVPR1B gene in combination with a set or group of polymorphic variants in the patient's genome excluding the AVPR1B gene, e.g. to a combination of a polymorphic variant in the AVPR1B gene, optionally SNP rs28373064, with at least 1, at least 2, at least 3, at least 4, at least 5, at least 6, at least 7, at least 8, at least 9, at least 10, at least 11, at least 12, at least 13, or at least 14 polymorphic variant(s) as described herein for polymorphic variants in the patient's genome excluding the AVPR1B gene.
  • the presence or absence of a number M of SNPs and/or combinations of SNPs is determined in step (a) of the method for predicting a treatment response, wherein M is sufficient to provide an accuracy of at least 80% and a sensitivity of at least 70% and a specificity of at least 70%. In another embodiment, M is sufficient to provide an accuracy of at least 85% and a sensitivity of at least 80% and a specificity of at least 80%. In one embodiment, a sufficient number M of SNPs and/or combinations of SNPs comprises at least one polymorphic variant in the AVPR1B gene in combination with a set or group of polymorphic variants in the patient's genome excluding the AVPR1B gene, e.g.
  • a polymorphic variant in the AVPR1B gene optionally SNP rs28373064, with at least 1, at least 2, at least 3, at least 4, at least 5, at least 6, at least 7, at least 8, at least 9, at least 10, at least 11, at least 12, at least 13, or at least 14 polymorphic variant(s) as described herein for polymorphic variants in the patient's genome excluding the AVPR1B gene.
  • At least 2, at least 5, at least 8 or at least 11 SNPs and/or combinations of SNPs are used for determination of the algorithm in step (d) of the method for providing a prediction algorithm.
  • the method for predicting a treatment response to a V 1B receptor antagonists further comprises a step (iii), wherein the treatment response to V 1B receptor antagonists is predicted by linking the algorithm provided by the method for providing a prediction algorithm with the presence or absence of at least one SNP and combination of SNPs as determined in step (i) and (ii) of said method.
  • said SNPs correspond to the SNPs shown herein in Table 1 and the combinations of SNPs described herein.
  • Linking an algorithm for predicting a treatment response to V 1B receptor antagonist in patients having depressive symptoms and/or anxiety symptoms with the presence or absence of the at least one SNP and/or combination of SNPs may refer to using such an algorithm to predict the treatment response based on the determined presence or absence of the at least one SNP and/or combination of SNPs, e.g. by integrating the at least one SNP and/or combination of SPCs determined in step (a) of the above method by the algorithm.
  • the presence of SNP rs28373064 in combination with the presence of SNP rs9880583, SNP rs730258, SNP rs12654236, SNP rs17091872, SNP rs12254219, SNP rs11575663, SNP rs7080276, SNP rs7416, SNP rs1035050, SNP rs9959162 and SNP rs8088242 may be integrated by the algorithm.
  • the absence of SNP rs28373064 in combination with the absence of SNP rs13099050, SNP rs7441352 and SNP rs12424153 may be integrated by the algorithm.
  • the presence of SNP rs28373064 in combination with the presence of SNP rs9880583, SNP rs730258, SNP rs12654236, SNP rs17091872, SNP rs12254219, SNP rs11575663, SNP rs7080276, SNP rs7416, SNP rs1035050, SNP rs9959162 and SNP rs8088242 and the absence of SNP rs28373064 in combination with the absence of SNP rs13099050, SNP rs7441352 and SNP rs12424153 may be integrated by the algorithm.
  • further factors such as the gender of the patient and the presence or absence of the SNPs defined herein in Table 1 may also be integrated by the algorithm.
  • Another aspect of the invention relates to a method for predicting a treatment response to a V 1B receptor antagonist in a patient with depressive symptoms and/or anxiety symptoms, wherein the copeptin concentration in a blood sample of said patient is determined and/or the AVP concentration in a sample of cerebrospinal fluid of said patient is determined and wherein an elevated copeptin and/or an elevated AVP concentration is indicative for a patient responding to a treatment with a V 1B receptor antagonist.
  • another aspect of the present invention relates to a method for predicting a treatment response to a V 1B receptor antagonist in a patient with depressive symptoms and/or anxiety symptoms, wherein the copeptin concentration in a blood sample of said patient is determined or the AVP concentration in a sample of cerebrospinal fluid of said patient is determined and wherein the presence of an elevated copeptin or an elevated AVP concentration is indicative for a patient responding to a treatment with a V 1B receptor antagonist.
  • Another aspect of the present invention relates to a method for predicting a treatment response to a V 1B receptor antagonist in a patient with depressive symptoms and/or anxiety symptoms, wherein both the copeptin concentration in a blood sample of said patient is determined and the AVP concentration in a sample of cerebrospinal fluid of said patient are determined and wherein the presence of both, an elevated copeptin and an elevated AVP concentration is indicative for a patient responding to a treatment with a V 1B receptor antagonist.
  • the patient may be a patient showing depressive symptoms.
  • the patient may be a patient showing anxiety symptoms.
  • the patient may be a patient showing both, depressive and anxiety symptoms.
  • treatment response to a V 1B antagonist in patients with depressive symptoms and/or anxiety symptoms refers to a response in a patient with depressive symptoms and/or anxiety symptoms during and/or after the treatment with one or more V 1B antagonists compared to the state before the treatment.
  • the response may range from a partial alleviation of the symptoms to a complete remission of the symptoms, indicated by the change of symptoms strength and/or frequency of relapse of individual symptoms and/or the mean change on a depression scale, e.g. as described herein.
  • the response can occur shortly after treatment or after a certain time period.
  • a decrease in symptom severity from pre-treatment of 25% or more is usually considered a partial alleviation of symptoms.
  • Remission may be defined as achieving a value of 8 or less on the Hamilton Depression Rating Scale (HAM-D) or equivalent values on other rating scales named herein.
  • the blood sample and the sample of cerebrospinal fluid can be obtained from the patient by any method known in the art.
  • a blood sample can be taken from a patient by use of a sterile needle and a cerebrospinal fluid sample can be taken by lumbar puncture.
  • All steps necessary for preparing the sample for the respective measurement are also encompassed in the method according to the invention.
  • Such preparation steps include e.g. the preparation of the blood sample in order to obtain blood plasma as described above and are known to the person skilled in the art.
  • the blood sample of the patient and/or the sample of the cerebrospinal fluid of the patient is/are taken after the patient has been treated with dexamethasone. Subsequently, the copeptin concentration in the blood sample and/or the AVP concentration in the sample of cerebrospinal fluid of said patient is/are determined.
  • the patient may be pre-treated with 0.5 mg to 3 mg of dexamethasone, optionally with 0.5 mg, 0.75 mg, 1.0 mg, 1.5 mg, 1.75 mg, 2.0 mg, 2.5 mg, 2.75 mg or 3 mg dexamethasone.
  • the patient may be pre-treated with 1.5 mg dexamethasone.
  • the blood sample may be taken 12 to 36 hours after the patient has been treated with dexamethasone, optionally 15 to 24 hours after the patient has been treated with dexamethasone.
  • the patient is additionally subjected to at least one combined dexamethasone suppression CRH stimulation test (dex/CRH test).
  • dexamethasone suppression CRH stimulation test dex/CRH test
  • these tests are performed in certain intervals, e.g. intervals of days, weeks or months.
  • the patient is subjected to at least one, particular two combined dex/CRH tests, whereby the tests are performed in an interval of about 30 days or of about 60 days. It is however understood that the length of the interval between the tests may be adapted as considered necessary by the person skilled in the art.
  • the combined dex/CRH test has been described by Heuser et al. ( The combined dexamethasone/CRH test: a refined laboratory test for psychiatric disorders ., J Psychiatr Res, 1994, 28:341-356) and can be used for screening for compounds which may be useful in the treatment of depressive symptoms and/or anxiety symptoms.
  • subjects are pre-treated with dexamethasone (e.g. 1.5 mg dexamethasone) and blood is drawn in certain intervals after the dexamethasone treatment. This blood sample shows the suppression of cortisol by dexamethasone.
  • the pre-treatment is normally performed in the evening prior to the day of the CRH administration.
  • Human CRH (e.g. 100 ⁇ g CRH) is administered after the first pre-treatment with dexamethasone, e.g. 16 hours after the pre-treatment. Subsequently, blood samples are drawn (e.g. in intervals of 15 minutes) from the patient and the plasma ACTH and/or cortisol concentrations are determined. The neuroendocrine response to the dex/CRH test may be analyzed using the total area under the curve (AUC) of the ACTH response.
  • AUC total area under the curve
  • Patients suffering from depression normally show an increased release of cortisol and of adrenocorticotropic hormone (ACTH) in response to the combined treatment with dexamethasone and CRH as performed during the test, thus indicating a dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis.
  • Patients with a high HPA axis dysregulation show AUC values of cortisol of between 3000 and 18000 AUC units (ng/ml ⁇ 75 min) and/or AUC values of ACTH of between 1000 and 6500 AUC units (pg/ml ⁇ 75 min).
  • Treatment response to antidepressants can thus be determined by performing a second dex/CRH test after treatment with the antidepressant and comparing the neuroendocrine response to the one shown in a combined dex/CRH test performed prior to treatment with the antidepressant.
  • an elevated AVP level in said patient is determined by means of AVP measurement in a sample of cerebrospinal fluid of said patient.
  • Samples of cerebrospinal fluid can be obtained from the patient by any method known in the art, e.g. by lumbar puncture.
  • Methods for determination of AVP levels in a sample of cerebrospinal fluid of a patient include immunoassays, e.g. radioimmunoassays.
  • the AVP level in the sample of cerebrospinal fluid of the patient is measured by means of immunoassay, optionally by means of radioimmunoassay.
  • an elevated AVP level denotes any AVP level higher than the AVP level measured in blood samples and/or samples of the cerebrospinal liquid of healthy individuals.
  • an elevated AVP level in a patient showing depressive symptoms and/or anxiety symptoms is indicated by an AVP concentration in the sample of cerebrospinal fluid of at least 4 pg/ml AVP, least 5 pg/ml AVP, least 6 pg/ml AVP, least 7 pg/ml AVP, least 8 pg/ml AVP, at least 10 pg/ml AVP, at least 20 pg/ml AVP, at least 30 pg/ml AVP, at least 50 pg/ml AVP, at least 70 pg/ml AVP or at least 90 pg/ml AVP.
  • the present invention relates to method for predicting a treatment response to a V 1B receptor antagonist in a patient with depressive symptoms and/or anxiety symptoms as described herein, wherein an elevated AVP level and/or an elevated copeptin level in said patient is determined by means of copeptin measurement.
  • Methods for determination of copeptin levels in a blood sample derived from a patient include immunoassays, e.g. sandwich immunoassays.
  • immunoassays e.g. sandwich immunoassays.
  • Examples of such immunoassays are the Copeptin EIA Kit provided by BioSupply UK, the Thermo Scientific B R A H M S copeptin Kryptor assay and the Thermo Scientific B R A H M S copeptin Kryptor us assay provided by ThermoScientific.
  • the AVP level and/or copeptin level of the patient showing depressive symptoms and/or anxiety symptoms is determined by means of an immunoassay, optionally by means of a sandwich immunoassay.
  • the copeptin level is determined in a blood sample of the patient as defined herein.
  • the blood sample can be obtained from the patient by any method known in the art, e.g. with a sterile needle.
  • the copeptin level is determined in the blood plasma derived from the blood sample of said patient. It is known in the art that blood plasma may be derived by centrifugation of a blood sample to which an anti-coagulant has been added.
  • an elevated copeptin level denotes any copeptin level higher than the copeptin level measured in blood samples of healthy individuals. Specifically, an elevated copeptin level and therefore also an elevated AVP level in a patient showing depressive symptoms and/or anxiety symptoms is indicated by a copeptin blood concentration of at least 5 pmol/L, at least 6 pmol/L, at least 7 pmol/L, at least 8 pmol/L, at least 9 pmol/L, at least 10 pmol/ml, at least 20 pmol/ml, at least 30 pmol/ml, at least 40 pmol/ml, at least 50 pmol/ml, at least 60 pmol/ml, at least 70 pmol/ml, at least 80 pmol/ml, at least 90 pmol/ml or at least 100 pmol/ml.
  • Elevated copeptin levels and therefore also elevated AVP levels may be indicated by a copeptin blood concentration in the range from 5 to 9 pmol/L, optionally in the range from 5 to 7 pmol/L. Such elevated copeptin levels are indicative for a patient responding to a treatment with a V 1B receptor antagonist as described herein.
  • V 1B receptor antagonists can be replaced by any other compound that interferes with the V 1B receptor mediated pathway and leads to a reduction and/or remission of depressive symptoms and/or anxiety symptoms patients with elevated arginine vasopressine (AVP) level and/or elevated copeptin level.
  • AVP arginine vasopressine
  • Copeptin was measured in the plasma samples of the combined dex/CRH test using the first specimen, which was obtained under dex suppression, but prior to CRH stimulation.
  • DSM Diagnostic and Statistical Manual of Mental Disorders
  • the dex-CRH test was administered as described in detail in Heuser et al. Shortly, subjects were pre-treated with 1.5 mg of dexamethasone per os at 11 pm. The following day, at 3 pm, 3.30 pm, 3.45 pm, 4 pm and 4.15 pm blood was drawn. An intravenous bolus of 100 ⁇ g of human CRH (Ferring, Kiel, Germany) was given at 3.02 pm. Plasma ACTH concentrations were assessed by an immunometric assay without extraction (Nichols Institute, San Juan Capistrano, Calif.; USA). The neuroendocrine response to the dex/CRH test was analyzed using the total area under the curve (AUC) of the ACTH response.
  • AUC total area under the curve
  • Genotyping was performed on Illumina Human 610k quad genotyping arrays (Illumina Inc., San Diego, USA) according to the manufacturer's standard protocols. The average call rate exceeded 99%, with samples below 98% being either retyped or excluded from the study. The reproducibility for samples genotyped twice was 99.99% or better.

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US10857129B2 (en) 2012-06-15 2020-12-08 B.R.A.H.M.S Gmbh V1B receptor antagonist for use in the treatment of patients having an elevated AVP level and/or an elevated copeptin level
US10190168B2 (en) 2013-06-17 2019-01-29 MAX-PLANCK-Gesellschaft zur Förderung der Wissenschaften e.V. Method for predicting a treatment response to a CRHR1 antagonist and/or a V1B antagonist in a patient with depressive and/or anxiety symptoms
US10837062B2 (en) 2013-06-17 2020-11-17 MAX-PLANCK-Gesellschaft zur Förderung der Wissenschaften e.V. Method for predicting a treatment response to a CRHR1 antagonist and/or a V1B antagonist in a patient with depressive and/or anxiety symptoms

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