WO2006117534A2

WO2006117534A2 - New use

Info

Publication number: WO2006117534A2
Application number: PCT/GB2006/001582
Authority: WO
Inventors: Bertil Lindmark; Anders Thoren; Timothy William Higenbottam
Original assignee: Astrazeneca Ab; Astrazeneca Uk Limited
Priority date: 2005-04-30
Filing date: 2006-04-28
Publication date: 2006-11-09
Also published as: WO2006117534A3; GB0508924D0

Abstract

New Use The invention provides medicaments comprising a combination of a HMG-CoA reductase inhibitor and a drug intervening in the renin-angiotensin system selected from angiotensin II antagonists and angiotensin converting enzyme (ACE) inhibitors optionally in combination with a bronchodilator and a gluccorticosteroid in the treatment of respiratory disorders such as chronic obstructive pulmonary disease (COPD).

Description

NEW USE Field of the invention

The invention provides medicaments comprising a combination of a HMG-CoA reductase inhibitor and a drug intervening in the renin-angiotensin system selected from angiotensin II antagonists and angiotensin converting enzyme (ACE) inhibitors optionally in combination with a bronchodilator and a gluccorticosteroid in the treatment of respiratory disorders such as chronic obstructive pulmonary disease (COPD).

Background of the invention

Both diagnosis and management of many diseases focus, for obvious reasons, on typical criteria and manifestations, which are characteristic for that particular disease (thereby discriminating it from other entities). Examples are joint-related signs and symptoms in rheumatic arthritis (RA) and lung functions test in COPD.

Chronic obstructive pulmonary disease (COPD) is a term used to describe patients with irreversible airway obstruction, usually in association with chronic bronchitis and emphysema, and epidemiologically clearly linked to smoking. COPD is characterised by both an accelerated decline in lung function and periods of acute deterioration in symptoms and exercise capacity termed exacerbations. The disease thus is serious and progressive and often leads to severe breathing disabilities, hypoxemia and eventually to death. COPD is the fourth leading cause of death in the industrialised world and exerts a heavy burden on patients, their careers, healthcare resources and society, hi the western world COPD is predominantly observed in smokers, but in other parts of the world infections and in-door cooking seem to predispose. COPD is a disease where inflammation and impaired mucosal immune defence, induced by smoking, may contribute to co-morbidity. A systemic inflammation continues to be active also long after smoking cessation.

Patients with COPD are numerous and the disease is difficult to treat. Treatments exist that have effect on bronchospasm, symptoms, quality of life and exacerbations, however there is none that is able to slow down the progressive and accelerated loss of lung function. One of the primary objectives of treatment is to reduce the progression of the disease and to obtain this smoking cessation is the most important step. However, far from all COPD patients can or even wish to give up smoking and even if the patients stop smoking the airway obstruction will most often not disappear. In these cases pharmacological therapy may provide some relief. Up to date there are only a few groups of pharmacological treatments that have been tested with different results in COPD, namely bronchodilating agents and glucocorticosteroids. The bronchodilating class consists mainly of short and long-acting anticholinergics and β₂-agonists. The glucocorticosteroid treatment approach is more questioned, but with the introduction of combination therapies using the long-acting β₂- agonists such as formoterol and salmeterol together with glucocorticosteroids such as budesonide and fluticasone propionate, a new pharmacological tool has become available. In recent years combination products containing a long-acting β₂-agonist and a glucocorticosteroid e.g. formoterol/budesonide (AstraZeneca) and salmeterol /fluticasone propionate (GSK) have become available.

In addition current anti-inflammatory drugs, developed for signs and symptoms of a particular disease, may not be optimized for long-term treatment of the concomittant systemic inflammation which is hypothesized being responsible for much of the co-morbidity. Such therapy must be able to reduce an ongoing, systemic inflammation — and yet have good tolerability and safety.

In summary, based on the present knowledge of COPD, a pharmacological treatment modulating both severe exacerbation and the long-term decline OfFEV₁ would address a very important unmet medical need.

Description of the invention

Many specialists express the need for new therapies for all aspects of COPD, but it is particularly important to find ways to eliminate or at least reduce the declining of the disease with time.

Several inflammatory mediators are likely to be involved in COPD as many inflammatory cells are activated, hi medical practice for the treatment of e.g. asthma the influence on a single mediator has been unsuccessful in the development of new therapies. There are different mediators involved in COPD compared to asthma and therefore it is necessary to develop different drugs. Among targets for COPD have been mentioned leukotriene B₄ inhibitors, chemokine antagonists, neutrophil elastase inhibitors, phosphodiesterase-4 inhibitors, cathepsins, matrix metallo-proteinases (MMPs), protease inhibitors and many others. Compelling evidence suggests that the lung damage associated with COPD results from an imbalance between proteases. Matrix metalloproteinases are capable of degrading all of the components of the extracellular matrix of lung parenchyma including elastin, collagen, proteoglycans, laminin and fibronectin (FASEB J, 12 1075 (1998)). It has been developed some nonselective MMP inhibitors, but the side effects may be a problem in long-term use. More selective inhibitors of individual MMPs₅ such as MMP-9 and MMP- 12 are now in development.

Statins are increasingly being recognized as anti-inflammatory agents. Schδnbeck and Libby (Circulation, 109 (suppl. H)₅ 11-18-26 (2004)) are addressing this by reviewing in vitro and in vivo evidence regarding statins (3 -hydroxy-3 -methyl glutaryl coenzyme A (HMG-CoA reductase inhibitors) as antiinflammatory agents. Any connections of use of statins in respiratory disorders of any kind are not addressed at all by these authors.

Statins are the most commonly used lipid-lowering compounds. Examples are lovastatin, rosuvastatin (Crestor™, AstraZeneca), pravastatin, simvastatin, itavastatin, cerivastatin, fluvastatin, atorvastatin (Lipitor , Pfizer) and mevastatin.

WO 00/48626 (Univ. of Washington) provides a composition comprising a HMG-CoA reductase inhibitor (statin) at a concentration of less than 0.1 mg and a method of treating a pulmonary disease including COPD with an aerosol formulation of statins.

EP 1 275 388 (Takeda) provides a TNF-α inhibitor (statins) for the prevention and treatment of TNF-α-associated diseases such as inflammatory diseases including asthma and COPD.

WO 00/45818 (AstraZeneca) relates to the use of a combination of HMG CoA reductase inhibitors and an aldose reductase inhibitor (ARI), an angiotensin converting enzyme (ACE) inhibitor or an angiotensin II (All) antagonist in the improvement of diabetic neuropathy.

WO 01/76573 (Novartis) relates to a combination of at least two therapeutic combination components selected from the group consisting of (i) an AT₁ -receptor antagonist or an AT₁ receptor antagonist combined with a diuretic and (ii) a HMG-CoA reductase inhibitor and (iii) an ACE inhibitor for the treatment of diseases like hyperlipidaemia, obesity, nephropathy and renal failure and for the prevention or tretament of stroke and vascular disease.

The statin cerivastatin has been shown to reduce inflammatory activity in alveolar macrophages derived from chronic bronchitis patients (Circulation, 101 (2000), 1760). hi a study with patients receiving statins it was shown that initiation of statin therapy was associated with a significant improvement (certain patient inclusion criteria were used) in the rate OfFEV₁ decline that was unrelated to cigarette use factors. The prestatin baseline FEV₁ slope was -109.2 ml/yr and following statin therapy the slope was -46.7 ml/yr (Chest, 120 (4), suppl, p291S (2001)).

We have now found that a combination of a HMG-CoA reductase inhibitor (preferably a statin) and an antihypertensive drug selected from angiotensin II antagonists and angiotensin converting enzyme (ACE) inhibitors given separately, sequentially or simultaneously may potentiate the effect of either component and also produce a better effect than conventional COPD treatments. The therapeutic effect may be observed with regard to the fast decline in lung function that is a hallmark of COPD, and effects may be observed regarding the systemic inflammation that is also characteristic of COPD. The long-term effect of a combination according to the invention will be conservation of lung function and putatively less comorbidity (based on effects on the systemic inflammation).

In a first aspect the invention provides a pharmaceutical combination comprising, in admixture or separately: a first active ingredient which is a statin, a pharmaceutically acceptable salt or solvate thereof, or a solvate of such a salt; and either (a) or (b):

(a) a second active ingredient which is an angiotensin converting enzyme (ACE) inhibitor or a pharmaceutically acceptable salt or solvate thereof, or a solvate of such a salt and optionally a combination of a bronchodilator and glucocorticosteroid or pharmaceutically acceptable salts or solvates thereof, or solvates of such salts; or

(b) further active ingredients which are an angiotensin II antagonist or a pharmaceutically acceptable salt or solvate thereof, or a solvate of such a salt and a bronchodilator and/or a glucocorticosteroid or pharmaceutically acceptable salts or solvates thereof, or solvates of such salts.

The combinations of the invention can be used in therapy, in particular for the treatment of respiratory diseases such as asthma, COPD and fibro lytic diseases like systemic sclerosis, alveolitis, sarcoidosis and idiopathic pulmonary fibrosis. Preferably the combinations are used for the treatment or prohylaxis of COPD.

The pharmacologically active agents in accordance with the present invention include statins like lovastatin, rosuvastatin (Crestor™, AstraZeneca), pravastatin, simvastatin, itavastatin, cerivastatin, fluvastatin, atorvastatin (Lipitor™, Pfizer) and mevastatin. The preferred pharmacologically active statins for use in accordance with the present invention include rosuvastatin and atorvastatin. Suitable ACE inhibitors include, for example, benazepril, benazeprilate, captopril, delapril, enalapril, fentiapril, fosinopril, imidopril, libenzapril, lisinopril, moexipril, perindopril, pivopril, quinapril, quinaprilat, ramipril, spirapril, spiraprilat, trandolapril, zofenopril, ceronapril, enalapril, indolapril, alacepril and cilazapril. A preferred ACE inhibitor includes, for example, benazepril and most preferred is for example lisinopril or ramipril, or a pharmaceutically acceptable salt thereof.

Suitable angiotensin II antagonists (All) include, for example, eprosartan, losartan, irbesartan, telmisartan, valsartan and candesartan. A preferred All antagonist is candesartan.

Suitable glucocorticosteroids include budesonide, fluticasone (e.g. as propionate ester), mometasone (e.g. as furoate ester), beclomethasone (e.g. as 17-propionate or 17,21- dipropionate esters), ciclesonide, loteprednol (as e.g. etabonate), etiprednol (as e.g. dicloacetate), triamcinolone (e.g. as acetonide), flunisolide, zoticasone, flumoxonide, rofleponide, butixocort (e.g. as propionate ester), prednisolone, prednisone, tipredane, steroid esters according to WO 2002/12265, WO 2002/12266 and WO 2002/88167 e.g. 6α,9α- difluoro- 17α-[(2-furanylcarbonyl)oxy]- 11 β-hydroxy- 16α-methyl-3 -oxo-androsta- 1 ,4-diene- 17β-carbothioic acid S-fluoromethyl ester, 6α,9α-difluoro-l lβ-hydroxy-16α-methyl-3-oxo- 17α-propionyloxy-androsta-l,4-diene-17β-carbothioic acid S-(2-oxo-tetrahydro-furan-3S-yl) ester and 6α,9α-difluoro-l lβ-hydroxy-16α-methyl-17α-[(4-methyl-l,3-thiazole-5- carbonyl)oxy]-3-oxo-androsta-l,4-diene-17β-carbothioic acid S-fluoromethyl ester, steroid esters according to DE 4129535 , steroids according to WO 2002/00679, steroids according to WO 2005/041980, steroids GSK 870086, GSK 685698, GSK 799943 and the like. Preferably the glucocorticosteroid is budesonide.

Preferably the bronchodilator is a long-acting β₂-agonist. Suitable long-acting β₂-agonists include salmeterol, formoterol, bambuterol, carmoterol (TA 2005, chemically identified as 2(1 H)-Quinolone, 8 -hydroxy-5 - [ 1 -hydroxy-2- [ [2-(4-methoxy-phenyl)- 1 -methylethyl] - amino] ethyl] -monohydrochloride, [R-(R* ,R*)] also identified by Chemical Abstract Service Registry Number 137888-11-0 and disclosed in U.S. Patent No 4.579.854), indacaterol (QAB-149), formanilide derivatives e.g. 3-(4-{[6-({(2R)-2-[3-(formylamino)-4- hydroxyphenyl]-2-hydroxyethyl} amino)hexyl]oxy} -butyl)-benzenesulfonamide as disclosed in WO 2002/76933, benzenesulfonamide derivatives e.g. 3-(4-{[6-({(2R)-2-hydroxy-2-[4- hydroxy-3-(hydroxy-methyl)phenyl]ethyl}amino)-hexyl]oxy}butyl)benzenesulfonamide as disclosed in WO 2002/88167, aryl aniline receptor agonists as disclosed in WO 2003/042164 and WO 2005/025555, indole derivatives as disclosed in WO 2004/032921, in US 2005/222144, compounds GSK 159797, GSK 159802, GSK 597901, GSK 642444, GSK 678007 and the like. Among the anticholinergic compounds may be mentioned ipratropium (e.g. as bromide), tiotropium (e.g. as bromide), oxitropium (e.g. as bromide), tolterodine, glycopyrronium bromide (AD 237 (Arakis)), GSK 656398, GSK 961081, quinuclidine derivatives as disclosed in US 2003/0055080, in WO 2003/087096, WO 2005/115467, DE 10050995 and the like. More preferably the long-acting β-agonist if formoterol, still more preferably formoterol fumarate dihydrate.

Among the PDE3/4 and PDE4 inhibitors, such as, for example, the compounds mentioned as examples in the following patent applications and patents:

EP 0163965, EP 0389282, EP 0393500, EP 0435811, EP 0482302, EP 0499216, EP 0506194, EP 0510562, EP 0528922, EP 0553174, EP 0731099, WO 9319749, WO 9500516, WO 9501338, WO 9600218, WO 9603399, WO 9611690, WO 9636625, WO 9636626, WO 9723457, WO 9728131, WO 9735854, WO 9740032, WO 9743288, WO 9809946, WO 9807715, WO 9808841, WO 9821207, WO 9821208, WO 9821209, WO 9822453, WO 9831674, WO 9840382, WO 9855481, WO 9905111, WO 9905112, WO 9905113, WO 9931071, WO 9931090, WO 9947505, WO 9957115, WO 9957118, WO 9964414, WO 0001695, WO 0012501, WO 0042017, WO 0042018, WO 0042019, WO, 0042020, WO 0042034, WO 0119818, WO 0130766, WO 0130777, WO 0151470, WO 0290345, WO 0368232, WO 0368235, WO 0404684, WO 0456823, WO 04103998, WO 0509964, WO 0509965, WO 0509966, WO 0520587, WO 0520626, WO 0520639, WO 0456823, WO 0590348, WO 0590352, WO 0590353, WO 0590254, WO 0558892, WO 0530212, WO 0587744, WO 0587745, WO 0575457, WO 0577906, WO 0575456, WO 0575437 and WO 0590311, in particular the compounds

(Z)-3-(3,5-dichloro-4-pyridyl)-2-[4-(2-indanyloxy-5-methoxy-2-pyridyl]propenenitrile, N-[9-amino-4-oxo- 1 -phenyl-3 ,4,6,7-tetrahydropyrrolo[3 ,2, 1 -jk] [ 1 ,4]benzodiazepin-3 (R)- yl]pyridine-3-carboxamide (CI-1044)

3-(benzyloxy)-l-(4-fluorobenzyl)-N-[3-(methylsulphonyl)phenyl]-lH-indole-2-carboxamide, (lS-exo)-5-[3-(bicyclo[2.2.1]hept-2-yloxy)-4-methoxyphenyl]tetrahydro-2(lH)-pyrimidinone (Atizoram), N-(3,5,dichloro-4-pyridinyl)-2-[l-(4-fluorobenzyl)-5-hydroxy-lH-indol-3-yl]-2-oxoacetamide

(AWD-12-281), β-[3-(cyclopentyloxy)-4-methoxyphenyl]-l,3-dihydro-l,3-dioxo-2H-isoindole-2-ρropanamide

(CDC-801),

N-[9-methyl-4-oxo-l-phenyl-3,4,6,7-tetrahydropyrrolo[3,2,l-jk][l,4]benzodiazepin-3(R)- yl]pyridine-4-carboxamide (CI-1018), cis-[4-cyano-4-(3-cyclopentyloxy-4-methoxyphenyl)cyclohexane-l-carboxylic acid

(Cilomilast)

8-amino- 1 ,3-bis(cyclopropylmethyl)xanthine (Cipamfylline)

N-(2,5-dichloro-3-pyridinyl)-8-methoxy-5-quinolinecarboxamide (D-4418)₅

5-(3,5-di-tert-butyl-4-hydroxybenzylidene)-2-iminothiazolidin-4-one (Darbufelone),

2-methyl-l-[2-(l-methylethyl)pyrazolo[l,5-a]ρyridin-3-yl]-l-propanone (Ibudilast),

2-(2,4-dichlorophenylcarbonyl)-3 -ureidobenzofuran-6-yl methanesulphonate (Lirimilast),

(-)-(R)-5-(4-methoxy-3-propoxyphenyl)-5-methyloxazolidin-2-one (Mesopram),

(-)-cis-9-ethoxy-8-methoxy-2-methyl-l,2,3,4,4a,10b-hexahydro-6-(4- diisopropylaminocarbonylphenyl)-benzo[c][l,6]naphthyridine (Pumafentrine),

3-(cyclopropylmethoxy)-N-(3,5-dichloro-4-pyridyl)-4-(difluoromethoxy)benzamide

(Roflumilast), the N-oxide of Roflumilast,

5,6-diethoxybenzo[b]thiophene-2-carboxylic acid (Tibenelast)

2,3 ,6,7-tetrahydro-2-(mesitylimino)-9, 10-dimethoxy-3 -methyl-4H-pyrimido[6, 1 - a]isoquinolin-4-one (trequinsin) and

3-[[3-(cyclopentyloxy)-4-methoxyphenyl]-methyl]-N-ethyl-8-(l-methylethyl)-3H-ρurine-6- amine (V-11294A).

The invention also provides a method of treating a respiratory disease which comprises administering to the patient a therapeutically effective amount of a combination comprising, in admixture or separately: a first active ingredient which is a statin, a pharmaceutically acceptable salt or solvate thereof, or a solvate of such a salt; and either (a) or (b):

In a further aspect the invention provides the use of a pharmaceutical combination comprising, in admixture or separately: a first active ingredient which is a statin, a pharmaceutically acceptable salt or solvate thereof, or a solvate of such a salt; and either (a) or (b):

(b) further active ingredients which are an angiotensin II antagonist or a pharmaceutically acceptable salt or solvate thereof, or a solvate of such a salt and a bronchodilator and/or a glucocorticosteroid or pharmaceutically acceptable salts or solvates thereof, or solvates of such salts. in the manufacture of a medicament for the treatment of a respiratory disorder.

In one aspect of the invention is provided candesartan, or a pharmaceutically acceptable salt thereof or a solvate of such salt, and rosuvastatin, or a pharmaceutically acceptable salt thereof or a solvate of such salt and a combination of a bronchodilator and a glucocorticosteroid in the manufacture of a medicament for the prevention or treatment of COPD.

Preferred bronchodilators and glucocorticosteroids include formoterol fumarate dihydrate and budesonide marketed as Symbicort®.

Candesartan may suitable be in the form of candesartan, or in the pro-drug form candesartan cilexetil. These forms may be formulated with a further agent such as a diuretic such as hydrochlorothiazide (for example, as marked as Atacand Plus™). Where herein candesartan is referred to, this includes both candesaretan and candesartan cilexetil.

Preferable the calcium salt of rosuvastatin, which may be referred to as rosuvastatin calcium, is used in the various aspects of the present invention. In general, pharmaceutically acceptable salts include acid adition salts such as methanesulfonate, tosylate, α-glycerophosphate, fumarate, hydrochloride, citrate, maleate, tartrate and (less preferably) hydrobromide. Pharmaceutically acceptable salts in general also include salts formed with phosphoric and sulphuric acid. Pharmaceutically-acceptable salts generally include base salts such as an alkali metal salt for example sodium, an alkaline earth metal salt for example calcium or magnesium, an organic amine salt for example N₅N- dibenzylethylamine, tris-(2-hydroxyethyl)amine, tris(hydroxymethyl)methylammonium, N- methyl d-glucamine and amino acids such as lysine. There may be more than one cation or anion depending on the number of charged functions and the valency of the cations or anions.

Several of these compounds could be administered in the form of pharmacologically acceptable esters, salts, solvates, such as hydrates, or solvates of such esters or salts, if any. Both racemic mixtures as well as one or more optical isomers of the above compounds are within the scope of the invention.

Herein, where the term "combination" is used it is to be understood that this refers to simultaneous, separate and sequential administration. In one aspect of the invention "combination" refers to simultaneous administration, hi another aspect of the invention "combination" refers to separate administration. In a further aspect of the invention "combination" refers to sequential administration. Where the administration is sequential or separate delay in administering the second component should be such that all agents are present in the body so as to produce synergistic effect of the combination.

When administered separately, administration can be via alternative routes. For example the statin can be administered orally and the second drug selected from the group consisting of an angiotensin II antagonist and an angiotensin converting enzyme (ACE) inhibitor can be administered via inhalation. And, for example, the statin and the angiotensin π/ACE antagonist can be administered as an oral formulation while the bronchodilator and/or glucocorticosteroid could be administered by inhalation.

The composition described herein may be in the form suitable for oral administration, for example as a tablet or capsule, for inhalation (including use of dry powder inhalers (DPI), pressurized metered dose inhalers (pMDI) and nebulizers), for parenteral injection (including intravenous, subcutanesous, intramuscular, intravascular or infusion) for example as a sterile solution, suspension or emulsion, for topical administration for example as an ointment or cream, for rectal adminsitration for example as a suppository. In general the compositions described herein may be prepared in a conventional manner using conventional excipients or carriers that are well known in the art.

Suitable pharmaceutically-acceptable excipients or carriers for a tablet formulation include, for example, inert excipients such as lactose, sodium carbonate, calcium phosphate or calcium carbonate, granulating and disintegrating agents such as com starch or alginic acid; binding agents such as gelatin or starch; lubricating agents such as magnesium stearate, stearic acid or talc; preservative agents such as ethyl- or propyl 4-hydroxybensoate, and antioxidants, such as ascorbic acid. Tablet formulations may be uncoated or coated either to modify their disintegration and the subsequent absorption of the active ingredient within the gastrointestinal tract, or to improve their stability and/or appearance, in either case using conventional coating agents and procedures well known in the art.

Compositions for oral use may be in the form of hard capsules in which the active ingredient is mixed with an inert solid excipient, for example, calcium carbonate, calcium phosphate or kaolin, or as soft gelatin capsules in which the active ingredient is mixed with water or an oil such as peanut oil, liquid paraffin or olive oil.

Candesartan is commercially available as Atacand™ and Atacand Plus™. Rosuvastatin calcium is commercially available as Crestor™. Suitable formulations for the present invention include those which are commercially available.

Suitable dosages of each component of the combination are those of the marketed commercial products. Alternatively, the synergy between the components may allow a lower dosage of one or both components to be used. For example, a dose of 4 mg, 8 mg, 16 mg, 32 mg or up to 160 mg of candesartan in combination with a dose of 80 mg, 40 mg, 20 mg, 10 mg, 5 mg or 2,5 mg of rosuvastatin may be used. It will be understood that any one of the doses of candesartan may be combined with any suitable dose of rosuvastatin.

Preferably the two components of the combination are both administered orally.

Preferably the two components of the combination are administered as a single oral formulation.

Preferably the combination is formulated for once-a-day dosing. Conveniently, the combination is formulated as a single tablet or capsule.

The suitable daily dose of the long-acting β₂-agonists is in the range of 1 μg to 100 mg depending on potency of each compound e.g. for formoterol the daily dose is in the range of 1 to 100 μg with the preferred dose of 3 to 48 μg (as fumarate dihydrate). The suitable daily dose for the glucocorticosteroids is in the range of 50 μg to 2000 μg, where e.g. for budesonide the daily dose is in the range of 50 μg to 1600 μg. The doses for inhalation of the anticholinergic agents are from 1 microgram to 300 micrograms, preferably for ipratropium bromide (Atrovent™, Boehringer Ingelheim) the dose is 10 to 200 microgram and for tiotropium (Spiriva™, Boehringer Ingelheim) the dose is 1 to 50 ug. The doses for the PDE4 compounds range from 10 ug to 50, preferably from 10 ug to 1 mg.

The effective dose of the components will strongly depend on the particular compound used and the mode of administration, as well as the weight and disease state of the individual being treated. An orally administered unit dose of the statins will generally range from about 0.01 mg to about 200 mg, preferably from 1 to 80 mg, more preferably from 1 to 40 mg; for inhalation a dose range of 0.001 mg to about 25 mg is preferred, even more preferably is a dose from 0.1 to 25 mg. A unit dose formulation will contain 0.1 mg to 100 mg of an All antagonist or/and 0.1 to 100 mg of an ACE inhibitor.

Examples of respiratory diseases that can be treated according to the invention include asthma, chronic obstructive pulmonary disease (COPD), systemic sclerosis, alveolitis, sarcoidosis, cystic fibrosis, fibrinous and pseudomembraneous rhinitis and idiopathic pulmonary fibrosis.

The invention further provides a process for the preparation of a pharmaceutical composition of the invention which comprises mixing a first active ingredient which is a statin, a pharmaceutically acceptable salt or solvate thereof, or a solvate of such a salt; and either (a) or (b):

(b) further active ingredients which are an angiotensin II antagonist or a pharmaceutically acceptable salt or solvate thereof, or a solvate of such a salt and a bronchodilator and/or a glucocorticosteroid or pharmaceutically acceptable salts or solvates thereof, or solvates of such salts, with a pharmaceutically acceptable adjuvant, diluent or carrier.

The therapeutically active ingredients may be administered prophylactically as a preventive treatment or during the course of a medical condition as a treatment or cure. The composition used in the invention optionally additionally comprises one or more pharmaceutically acceptable additives, diluents and/or carriers. When the composition is in the form of a powder for inhalation, wherein the particles of the pharmaceutically active ingredients have an aerodynamic medium diameter of less than 10 μm.

Tobacco smoke model of COPD

Compounds and combinations of compounds can be tested in an acute smoke model. In this model, mice are exporesed to tobacco smoke once or twice daily for 1-9 days. Read-outs in the model include cell infiltration and inflammatory mediators in broncho-alveolar lavage and tissue histopathology. The model can also be applied to guinea pigs. In an extended version of the model, effects of compounds on chronic pathologic changes to lungs over 3-6 months can be determined.

Biological Data

As stated above COPD is a chronic disease, triggered by smoking in susceptible individuals. It is characterised by various respiratory symptoms such as breathlessness, productive cough and wheezing. These symptoms may increase sharply by acute exacerbations at various intervals. Respiratory infections are important triggers for exacerbations which can be life-threatening and have an important impact on quality of life. A number of drugs have shown some preventive effect on the incidence of exacerbations, such as inhaled corticosteroids (ICS), particularly in combination with long acting beta agonists (LABA). Symbicort^®, a fixed combination of budesonide and formoterol, has been approved for treatment of COPD based on the effect of symptoms, quality of life, and prevention of severe exacerbations. This effect includes the most strict definition of severe exacerbations: Need for hospitalisation due to respiratory symptoms or need for a course of oral corticosteroids. However, none of the existing medications for COPD has been shown to modify the long-term decline in lung function (measured as FEV₁) that is the hallmark of this disease (Global Initiative for Chronic Obstructive Lung Disease - GOLD - Executive summary (2004): Evidence A. http://www.goldcopd.com/). Thus, association between effect on exacerbations and long-term effect on FEVi decline has not been clearly demonstrated.

In post-hoc analyses of clinical long-term trials of COPD a positive effect on FEVi decline has been observed in patients treated with statins. This effect was not seen with any other established treatment including ICS. It was found that drugs intervening in the renin- angiotensin system, ATC code C09 (from now on called ACE inhibitors) have a moderate independent effect on FEV₁ decline. Surprisingly, the combined effect of statins and ACE inhibitors demonstrated a spectacular synergistic effect on FEV₁ decline.

Further searching for an optimal treatment combination in COPD would also require effect on severe exacerbations. The combination of formoterol and budesonide (Symbicort^®) is approved for the preventive effect on severe exacerbations. The ACE inhibitors had no effect on COPD exacerbations by its own, but when combined with Symbicort^® further prevented the occurrence of severe exacerbations.

Methods

A meta-analysis was performed from 4 clinical trials in moderate to severe COPD, one study had 6 months duration, the other 3 lasted 12 months. In this pooled group, patients with allowed medication including statins and/or ACE inhibitors were examined for change of fevi during treatment.

For the purpose of analysing the effect on exacerbation only 2 of the 4 studies were selected (both were 12 months studies) for a meta analysis. The reason for this was that the placebo groups in these 2 selected studies did not contain any patients with inhaled corticosteroids (ICS) (any kind) as allowed concomitant medication, and it is known that ICS by its own can have some effect on the incidence of exacerbations hi addition, these 2 studies had an overall higher incidence of exacerbation allowing for a better analysis of treatment effects.

Results

The result of the FEVi analysis is shown in Table 1. The positive effect of statin treatment on FEV₁ decline is demonstrated and a similar, but more moderate effect was seen with ACE inhibitors. The combined effect of statins and ACE inhibitors demonstrated a spectacular synergistic effect on FEV₁ decline.

Table 1. Effects on FEVi decline by statins and drugs intervening in the renin- angiotensin system ("ACE inhibitors") alone and combined

! Non-treated patients (n=1642) had a mean FEVi decline of -45 ml/year

Table 2 shows the effect on severe exacerbations by formoterol + budesonide (Symbicort) alone and combined with statins and ACE inhibitors respectively. All treatment groups described in this table excluded patients with double treatment unless specified. As expected, a reduced incidence of exacerbations was seen by Symbicort^® and statins respectively, but not with ACE inhibitors. Most interestingly, the reduced incidence on exacerbations by formoterol + budesonide (Symbicort) was further augmented not only by statins but also by ACE inhibitors. Thus, both statins and ACE inhibitors exerted an independent synergistic effect with formoterol + budesonide (Symbicort) in reducing the rate of severe exacerbations on COPD.

Table 2. Effect on severe COPD exacerbations by different treatments. (N=Number of treated patients)

I In this context, drugs intervening in the renin-angiotensin system (ATC code C09) are called ACE inhibitors Combined treatment with statins and drugs intervening in the renin-angiotensin system, a bronchodilator + glucocorticosteroid offers a new and powerful treatment option in COPD by a synergistic effect on the most devastating effects of the disease: long-term FEVi decline and exacerbations respectively.

Claims

1. A pharmaceutical combination comprising, in admixture or separately: a first active ingredient which is a statin, a pharmaceutically acceptable salt or solvate thereof, or a solvate of such a salt; and either (a) or (b):

2. A combination according to claim 1 in which the statin is lovastatin, rosuvastatin (Crestor™, AstraZeneca), pravastatin, simvastatin, itavastatin, cerivastatin, fluvastatin, atorvastatin (Lipitor™, Pfizer) and mevastatin and pharmaceutically acceptable salts or solvates thereof, or a solvates of such a salt.

3. A combination according to claim 1 or 2 in which the ACE inhibitor is benazepril, benazeprilate, captopril, delapril, enalapril, fentiapril, fosinopril, imidopril, libenzapril, lisinopril, moexipril, perindopril, pivopril, quinapril, quinaprilat, ramipril, spirapril, spiraprilat, trandolapril, zofenopril, ceronapril, , indolapril, alacepril or cilazapril and pharmaceutically acceptable salts thereof.

4. A combination according to claim 1 or 2 in which the ACE inhibitor is ramipril or lisinopril, and pharmaceutically acceptable salts thereof.

5. A combination according to any one of claims 1 to 4 in which the bronchodilator is a long-acting β₂-agonist selected from salmeterol, formoterol, bambuterol, indacaterol, 2(1H)- Quinolone, 8-hydroxy-5-[l-hydroxy-2-[[2-(4-methoxy-phenyl)-l-methylethyl]-amino]ethyl]- monohydrochloride, [R-(R*,R*)], 3-(4- {[6-({(2R)-2-[3-(formylamino)-4-hydroxyphenyl]-2- hydroxyethyl} amino)hexyl]oxy} -butyl)-benzenesulfonamide or 4- {[6-( {(2R)-2-hydroxy-2-[4- hydroxy-3-(hydroxy-methyl)phenyl]ethyl}amino)-hexyl]oxy}butyl)benzenesulfonamide.

6. A combination according to any one of claims 1 to 5 in which the glucocorticosteroid is budesonide, fluticasone (e.g. as propionate ester), mometasone (e.g. as furoate ester), beclomethasone (e.g. as 17-propionate or 17,21-dipropionate esters), ciclesonide, loteprednol (aas e.g. etabonate), etiprednol (as e.g. dicloacetate), triamcinolone (e.g. as acetonide), flunisolide, zoticasone, flumoxonide, rofleponide, butixocort (e.g. as propionate ester), prednisolone, prednisone, tipredane, 6α,9α-difluoro-17α-[(2-furanylcarbonyl)oxy]-llβ- hydroxy-16α-methyl-3-oxo-androsta-l,4-diene-17β-carbothioic acid S-fluoromethyl ester, 6α,9α-difluoro- 11 β-hydroxy- 16α-methyl-3-oxo-l 7α-propionyloxy-androsta- 1 ,4-diene- 17β- carbothioic acid S-(2-oxo-tetrahydro-furan-3S-yl) ester or 6α,9α-difluoro-llβ-hydroxy-16α- methyl-17α-[(4-methyl-l,3-thiazole-5-carbonyl)oxy]-3-oxo-androsta-l,4-diene-17β- carbothioic acid S-fluoromethyl ester.

7. A a method of treating a respiratory disease which comprises administering to the patient a therapeutically effective amount of a combination comprising, in admixture or separately: a first active ingredient which is a statin, a pharmaceutically acceptable 'salt or solvate thereof, or a solvate of such a salt; and either (a) or (b):

(a) a second active ingredient which is an angiotensin converting enzyme (_^ACE) inhibitor or a pharmaceutically acceptable salt or solvate thereof, or a solvate of such a salt and optionally a combination of a bronchodilator and glucocorticosteroid or pharmaceutically acceptable salts or solvates thereof, or solvates of such salts; or

8. A method according to claim 7 in which the respiratory disease is COPD.

9. A method according to claim 7 or 8 in which the statin is lovastatin, rosuvastatin (Crestor™, AstraZeneca), pravastatin, simvastatin, itavastatin, cerivastatin, fluvastatin, atorvastatin (Lipitor™, Pfizer) and mevastatin and pharmaceutically acceptable salts or solvates thereof, or a solvate of such a salt.

10. A method according to any one of claims 7 to 9 in which the ACE inhibitor is benazepril, benazeprilate, captopril, delapril, enalapril, fentiapril, fosinopril, imidopril, libenzapril, lisinopril, moexipril, perindopril, pivopril, quinapril, quinaprilat, ramipril, spirapril, spiraprilat, trandolapril, zofenopril, ceronapril, indolapril, alacepril or cilazapril and pharmaceutically acceptable salts thereof.

11. A method according to any one of claims 7 to 9 in which the ACE inhibitor is ramipril or lisinopril, and pharmaceutically acceptable salts thereof.

12. A method according to any one of claims 7 to 11 in which the bronchodilator is a long- acting β₂-agonist selected from salmeterol, formoterol, bambuterol, indacaterol, 2(1H)- Quinolone, 8 -hydroxy-5 - [ 1 -hydroxy-2-[ [2-(4-methoxy-phenyl)- 1 -methylethyl] -amino] ethyl] - monohydrochloride, |^-(R*^*)], 3-(4-{[6-({(2R)-2-[3<foimylamino)^-hydioxyplienyl]-2- hydroxyethyl}amino)hexyl]oxy}-butyl)-benzenesulfonamide or 4-{[6-({(2R)-2-hydroxy-2-[4- hydroxy-3-(hydroxy-methyl)phenyl]ethyl}amino)-hexyl]oxy}butyl)benzenesulfonamide.

13. A method according to any one of claims 7 to 12 in which the glucocorticosteroid is budesonide, fluticasone (e.g. as propionate ester), mometasone (e.g. as furoate ester), beclomethasone (e.g. as 17-propionate or 17,21-dipropionate esters), ciclesonide, loteprednol (aas e.g. etabonate), etiprednol (as e.g. dicloacetate), triamcinolone (e.g. as acetonide), flunisolide, zoticasone, flumoxonide, rofleponide, butixocort (e.g. as propionate ester), prednisolone, prednisone, tipredane, 6α,9α-difluoro-17α-[(2-furanylcarbonyl)oxy]-l lβ- hydroxy-16α-methyl-3-oxo-androsta-l,4-diene-17β-carbothioic acid S-fluoromethyl ester, 6α,9α-difluoro- 11 β-hydroxy- 16α-methyl-3-oxo- 17α-propionyloxy-androsta- 1 ,4-diene-l 7β- carbothioic acid S-(2-oxo-tetrahydro-furan-3S-yl) ester or 6α,9α-difluoro- 11 β-hydroxy- 16α- methyl-17α-[(4-methyl-l,3-thiazole-5-carbonyl)oxy]-3-oxo-androsta-l,4-diene-17β- carbothioic acid S-fluoromethyl ester.

14. Use of a pharmaceutical combination comprising, in admixture or separately. a first active ingredient which is a statin, a pharmaceutically acceptable salt or solvate thereof, or a solvate of such a salt; and either (a) or (b):

(a) a second active ingredient which is an angiotensin converting enzyme (ACE) inhibitor or a pharmaceutically acceptable salt or solvate thereof, or a solvate of such a salt and optionally a combination of a bronchodilator and glucocorticosteroid; or

(b) further active ingredients which are an angiotensin II antagonist or a pharmaceutically acceptable salt or solvate thereof, or a solvate of such a salt and a bronchodilator and/or a glucocorticosteroid or pharmaceutically acceptable salts or solvates thereof, or solvatse of such salts, in the manufacture of a medicament for the prevention or treatment of a respiratory disorder.

15. Use according to claim 14 in which the respiratory disorder is COPD.

16. Use according to claim 14 or 15 in which the statin is lovastatin, rosuvastatin (Crestor™, AstraZeneca), pravastatin, simvastatin, itavastatin, cerivastatin, fluvastatin, atorvastatin (Lipitor™, Pfizer) and mevastatin and pharmaceutically acceptable salts or solvates thereof, or a solvate of such a salt.

17. Use according to any one of claims 14 to 16 in which the ACE inhibitor is benazepril, benazeprilate, captopril, delapril, enalapril, fentiapril, fosinopril, imidopril, libenzapril, lisinopril, moexipril, perindopril, pivopril, quinapril, quinaprilat, ramipril, spirapril, spiraprilat, trandolapril, zofenopril, ceronapril, indolapril, alacepril or cilazapril and pharmaceutically acceptable salts thereof.

18. Use according to any one of claims 14 to 17 in which the ACE inhibitor is ramipril or lisinopril, and pharmaceutically acceptable salts thereof.

19. Use according to any one of claims 14 to 18 in which the bronchodilator is a long-acting β₂-agonist selected from salmeterol, formoterol, bambuterol, indacaterol, 2(1H)-Quinolone, 8- hydroxy-5 - [ 1 -hydroxy-2- [ [2-(4-methoxy-phenyl)- 1 -rnethylethyl] -amino] ethyl] - monohydrochloride, [R-(R* ,R*)], 3-(4-{[6-({(2R)-2-[3-(formylamino)-4-hydroxyphenyl]-2- hydroxyethyl} amino)hexyl]oxy}-butyl)-benzenesulfonamide or 4- {[6-({(2R)-2-hydroxy-2-[4- hydroxy-3-(hydroxy-methyl)plienyl]ethyl}amino)-hexyl]oxy}butyl)benzenesulfonamide.

20. Use according to any one of claims 14 to 21 in which the glucocorticosteroid is budesonide, fluticasone (e.g. as propionate ester), mometasone (e.g. as furoate ester), beclomethasone (e.g. as 17-propionate or 17,21-diproρionate esters), ciclesonide, loteprednol (aas e.g. etabonate), etiprednol (as e.g. dicloacetate), triamcinolone (e.g. as acetonide), flunisolide, zoticasone, fiumoxonide, rofleponide, butixocort (e.g. as propionate ester), prednisolone, prednisone, tipredane, 6α,9α-difluoro-17α-[(2-furanylcarbonyl)oxy]-l lβ- hydroxy-16α-methyl-3-oxo-androsta-l,4-diene-17β-carbothioic acid S-fluoromethyl ester, 6α,9α-difluoro-llβ-hydroxy-16α-methyl-3-oxo-17α-propionyloxy-androsta-l,4-diene-17β- carbothioic acid S-(2-oxo-tetrahydro-furan-3S-yl) ester or 6α,9α-difluoro-l lβ-hydroxy-16α- methyl- 17α-[(4-methyl-l ,3-thiazole-5-carbonyl)oxy]-3-oxo-androsta- 1 ,4-diene- 17β- carbothioic acid S-fluoromethyl ester.

21. Use of a combination comprising candesartan, or a pharmaceutically acceptable salt thereof or a solvate of such salt, and rosuvastatin, or a pharmaceutically acceptable salt thereof or a solvate of such salt and optionally a combination of a bronchodilator and a glucocorticosteroid in the manufacture of a medicament for the prevention or treatment of COPD.

22. Use of a combination comprising candesartan, or a pharmaceutically acceptable salt thereof or a solvate of such salt, and rosuvastatin, or a pharmaceutically acceptable salt thereof or a solvate of such salt and a combination of a budesonide and formoterol fumarate dihydrate in the manufacture of a medicament for the prevention or treatment of COPD .