Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/495—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with two or more nitrogen atoms as the only ring heteroatoms, e.g. piperazine or tetrazines
  • A61K31/4965—Non-condensed pyrazines
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
  • A61P25/18—Antipsychotics, i.e. neuroleptics; Drugs for mania or schizophrenia

Definitions

• the present invention relates to use of (thio)-carbamoyl-cyclohexane derivatives, particularly trans-4- ⁇ 2-[4-(2,3-dichlorophenyl)-piperazin-l-yl]-ethyl ⁇ - NjN-dimethylcarbamoyl-cyclohexylamine and pharmaceutically acceptable salts thereof in the manufacture of a medicament for the treatment of acute mania.
• the present invention relates to the treatment of acute mania through the administration of (thio)- carbamoyl cyclohexane derivatives, particularly trans-4- ⁇ 2-[4-(2,3-dichlorophenyl)-piperazin- 1-yl] -ethyl J-NjN-dimethylcarbamoyl-cyclohexylamine and pharmaceutically acceptable salts thereof.
• Bipolar disorder in the United States affects 5.7 million adults or about 2.6% of the population 18 years of age and older in any given year and has considerable economic impact on our society.
• an estimated annual cost of $45 billion was attributed to bipolar disorder in the United States alone (Wyatt R J, Henter L, SOc. Psychiatry Psychiatr. Epidemiol, 30(5), 213-9, 1995).
• this disorder ranked as the fifth leading cause of disability in adults between the ages of 15 and 44 (World Health Organization, World Health Report 2001, "Mental Health: New Understanding, New Hope.” http://www.who.int/whr/2001/en/2001).
• Bipolar disorder is a complex, chronic illness causing dramatic mood swings and unusual shifts in energy and behavior, ultimately resulting in functional impairments; it is associated with significant morbidity and mortality. It manifests itself as alterations in mood and energy from euphoria and excitability to depression and psychomotor retardation (Goodwin and Jamison, 1990 (Goodwin FK, Jamison KR. In: Manic-depressive illness. New York: Oxford University Press, 642-647, 1990), and is associated with significant morbidity and mortality. Suicide rates within this population are among the highest of all psychiatric illnesses (M ⁇ ller-Oerlinghausen et al, Lancet, 359 (9302), 241-7, 2002).
• Bipolar disorder is treated in phases, with each phase presenting its own set of challenges to the treating physician.
• Bipolar mania accounts for one in seven psychiatric emergencies. Acute manic and mixed episodes are frequently associated with severe behavioral, physical, functional, and cognitive disturbances, all of which can have important personal and social consequences. For the most part, bipolar mania constitutes a medical emergency requiring a hospital admission to ensure the immediate safety of the patient or others and rapid symptomatic relief (Keck, British MedicalJournal, 327 (7422), 1002-3, 2003).
• a variety of pharmacological agents are currently available for the management of acute mania, including mood stabilizers, anticonvulsants, and antipsychotics, all of which can be used as monotherapy or in combination regimens, hi recent years, the atypical antipsychotics (eg, olanzapine, risperidone, quetiapine, ziprasidone, aripiprazole) have been approved for mania in bipolar disorder.
• First- and second-generation antipsychotics are used in the acute setting in combination with mood stabilizers to achieve a more rapid control of symptoms in severely agitated patients whose treatment also necessitates hospitalization.
• atypical antipsychotics Compared to conventional agents, the side effect profile of atypical antipsychotics is more favorable. However, the atypicals have been associated with an increased risk of metabolic side effects, including body weight gain, dyslipidemia, glucose intolerance, and type II diabetes. Because of this increased risk, the FDA requires a warning label for diabetes on all atypical antipsychotics.
• Other side effects commonly associated with currently available treatment options for acute mania in bipolar patients include tremors, psychomotor slowing, cognitive impairment, exacerbation of agitation, nephrotoxicity, altered thyroid function, and sexual dysfunction.
• R 1 , R 2 , X, and n are as defined therein.
• Hungarian Patent Application No. P0700339 discloses salts of trans-4- ⁇ 2-[4-(2,3- dichlorophenyl)-piperazin- 1 -yl]-ethyl ⁇ -N ⁇ -dimethylcarbamoyl-cyclohexylamine.
• trans-4- ⁇ 2-[4-(2,3-dichlorophenyl)-piperazin-l-yl]- ethylJ-N j N-dimethylcarbamoyl-cyclohexylamine hydrochloride which is also known as trans-l ⁇ 4-[2-[4-(2,3-dichlorophenyl)-piperazin-l-yl]-ethyl]-cyclohexyl ⁇ -3,3-dimethyl-urea hydrochloride, the structural formula for which is shown below:
• trans-4- ⁇ 2-[4-(2,3- dichlorophenyl)-piperazin- 1 -yl] -ethyl ⁇ -NjN-dimethylcarbamoyl-cyclohexylamine hydrochloride have another unique feature which is that in vivo it acts as a "dopamine system stabilizer.” hi this regard, it has preferential dopaminergic actions in the limbic regions and displays both (partial) agonist and antagonist activity on biosynthesis (and release) modulating presynaptic D 2 receptors depending on the functional status of the particular dopaminergic system.
• trans-4- ⁇ 2-[4-(2,3- dichlorophenyl)-piperazin- 1 -yl] -ethyl ⁇ -NjN-dimethylcarbarnoyl-cyclohexylamine hydrochloride has a low potency at other receptor sites such as the 5-HT 2C , histamine Hi, and adrenergic receptor sites, which suggest a lower potential for side effects such as extrapyramidal symptoms (EPS) and body weight gain.
• EPS extrapyramidal symptoms
• Trans-4- ⁇ 2-[4-(2,3-dichlorophenyl)- piperazin-l-ylJ-ethylJ-N.N-dimethylcarbamoyl-cyclohexylamine hydrochloride also has considerable affinity for, and is a partial agonist at, the serotonin 5-HT 1A receptors, indicating that it may be effective in treating the depressive symptoms associated with bipolar disorder.
• the present invention relates to use of (thio)-carbamoyl-cyclohexane derivatives of formula (I), particularly trans-4- ⁇ 2-[4-(2,3-dichlorophenyl)-piperazin-l-yl]-ethyl ⁇ -N,N- dimethylcarbamoyl-cyclohexylamine and pharmaceutically acceptable salts thereof in the manufacture of a medicament for the treatment of acute mania.
• the present invention relates to the treatment of acute mania through the administration of (thio)- carbamoyl cyclohexane derivatives of formula (I), particularly trans-4- ⁇ 2-[4-(2,3- dichlorophenyl)-piperazin-l-yl]-ethyl ⁇ -N,N-dimethylcarbamoyl-cyclohexylamine and pharmaceutically acceptable salts thereof.
• the present invention relates to use of (thio)-carbamoyl-cyclohexane derivatives of formula (I)
• R 1 and R 2 are each, independently hydrogen, alkyl, alkenyl, aryl, cycloalkyl, aroyl, or R 1 and R 2 form a heterocyclic ring with the adjacent nitrogen atom;
• X is O or S; n is 1 or 2; and/or geometric isomers and/or stereoisomers and/or diastereomers and/or salts and/or hydrates and/or solvates and/or polymorphs thereof in the manufacture of a medicament for the treatment of acute mania.
• the alkyl moiety is a substituted or unsubstituted saturated hydrocarbon radical which may be straight-chain or branched-chain and contains about 1 to about 6 carbon atoms (particularly, 1 to 4 carbon atoms), and is optionally substituted with one or more C 1-6 alkoxycarbonyl, aryl (e.g., phenyl) or (Ci -6 alkoxycarbonyl)-C] -6 alkyl groups, or combinations thereof.
• R 1 and R 2 form a heterocyclic ring with the adjacent nitrogen atom, which may be a saturated or unsaturated, optionally substituted, monocyclic or bicyclic ring, which may contain further heteroatoms selected from O, N, or S.
• the heterocyclic ring can be pyrrolidine, piperazine, piperidine or morpholine.
• R 1 and/or R 2 represent alkenyl
• the alkenyl moiety may have 2 to 7 carbon atoms and 1 to 3 double bonds.
• the aryl moiety may be selected from an optionally substituted mono-, bi- or tricyclic aryl, such as, but not limited to, phenyl, naphthyl, fluorononyl, or anthraquinonyl group (e.g., phenyl or naphthyl).
• the aryl moiety may be substituted with one or more Ci -6 alkoxy, trifluoro-C 1-6 alkoxy, C 1-6 alkoxycarbonyl, C 1-6 alkanoyl, aryl, C 1-6 alkylthio, halogen, cyano groups or combinations thereof.
• the cycloalkyl moiety may be selected from an optionally substituted mono-, bi- or tricyclic cycloalkyl group, such as cyclohexyl or adamantyl.
• R 1 and/or R 2 represent aroyl
• the aryl moiety therein is as defined above, e.g., phenyl.
• Pharmaceutically acceptable salts include those obtained by reacting the main compound, functioning as a base with an inorganic or organic acid to form a salt, for example, salts of hydrochloric acid, sulfuric acid, phosphoric acid, methane sulfonic acid, camphor sulfonic acid, oxalic acid, maleic acid, succinic acid, citric acid, formic acid, hydrobromic acid, benzoic acid, tartaric acid, fumaric acid, salicylic acid, mandelic acid, and carbonic acid.
• Pharmaceutically acceptable salts also include those in which the main compound functions as an acid and is reacted with an appropriate base to form, e.g., sodium, potassium, calcium, magnesium, ammonium, and choline salts.
• acid addition salts of the claimed compounds may be prepared by reaction of the compounds with the appropriate inorganic or organic acid via any of a number of known methods.
• alkali and alkaline earth metal salts can be prepared by reacting the compounds of the invention with the appropriate base via a variety of known methods.
• acid salts that can be obtained by reaction with inorganic or organic acids: acetates, adipates, alginates, citrates, aspartates, benzoates, benzenesulfonates, bisulfates, butyrates, camphorates, digluconates, cyclopentanepropionates, dodecylsulfates, ethanesulfonates, glucoheptanoates, glycerophosphates, hemisulfates, heptanoates, hexanoates, fumarates, hydrobromides, hydroiodides, 2-hydroxy- ethanesulfonates, lactates, maleates, methanesulfonates, nicotinates, 2-naphthalenesulfonates, oxalates, palmoates, pectinates, persulfates, 3-phenylpropionates, picrates, pivalates, propionates
• the pharmaceutically acceptable salt is a hydrochloride salt.
• Some of the compounds useful in the present invention can exist in different polymorphic forms. As known in the art, polymorphism is an ability of a compound to crystallize as more than one distinct crystalline or "polymorphic" species. A polymorph is a solid crystalline phase of a compound with at least two different arrangements or polymorphic forms of that compound molecule in the solid state. Polymorphic forms of any given compound are defined by the same chemical formula or composition and are as distinct in chemical structure as crystalline structures of two different chemical compounds. The use of such polymorphs is within the scope of the present invention.
• Solvates of the compounds of the invention may also form when solvent molecules are incorporated into the crystalline lattice structure of the compound molecule during the crystallization process.
• suitable solvates include hydrates, e.g., monohydrates, dihydrates, sesquihydrates, and hemihydrates. The use of such solvates is within the scope of the present invention.
• the present invention particularly relates to the use of trans-4- ⁇ 2-[4-(2,3- dichlorophenyl)-piperazin-l-yl]-ethyl ⁇ -N,N-dimethylcarbamoyl-cyclohexylamine and pharmaceutically acceptable salts thereof, more particularly to the use of trans-4- ⁇ 2-[4-(2,3- dichlorophenyl)-piperazin- 1 -yl] -ethyl ⁇ -T ⁇ N-dimethylcarbamoyl-cyclohexylamine hydrochloride in the manufacture of a medicament for the treatment of acute mania.
• the present invention relates to a method of treating acute mania by administering to a patient in need thereof, an therapeutically effective amount of a compound of formula (I) and/or geometric isomers and/or stereoisomers and/or diastereomers and/or salts and/or hydrates and/or solvates and/or polymorphs thereof as the active ingredient.
• the present invention relates to a method of treating acute mania by administering to a patient in need thereof, particularly a therapeutically effective amount of trans-4- ⁇ 2-[4-(2,3-dichlorophenyl)-piperazin-l-yl]-ethyl ⁇ -N,N-dimethylcarbamoyl- cyclohexylamine or a pharmaceutically acceptable salt thereof, more particularly a therapeutically effective amount of trans-4- ⁇ 2-[4-(2,3-dichlorophenyl)-piperazin-l-yl]-ethyl ⁇ - NjN-dimethylcarbamoyl-cyclohexylamine hydrchloride, as active ingredient.
• the active ingredient can normally be administered in a daily dosage regimen (for an adult patient) of, for example, an oral dose between 0.1 mg and 500 mg, preferably between 10 mg and 400 mg, e.g. between 10 mg and 250 mg or an intravenous, subcutaneous, or intramuscular dose of between 0.1 mg and 100 mg, preferably between 0.1 mg and 50 mg, e.g. between 1 and 25 mg.
• a daily dosage regimen for an adult patient of, for example, an oral dose between 0.1 mg and 500 mg, preferably between 10 mg and 400 mg, e.g. between 10 mg and 250 mg or an intravenous, subcutaneous, or intramuscular dose of between 0.1 mg and 100 mg, preferably between 0.1 mg and 50 mg, e.g. between 1 and 25 mg.
• the active ingredient is administered in an amount of about 0.1 mg, about 0.2 mg, about 0.3 mg, about 0.4 mg, about 0.5 mg, about 1 mg, about 1.5 mg, about 2 mg, about 2.5 mg, about 3 mg, about 3.5 mg, about 4 mg, about 4.5 mg, about 5 mg, about 5.5 mg, about 6 mg, about 6.5 mg, about 7 mg, about 7.5 mg, about 8 mg, about 8.5 mg, about 9 mg, about 9.5 mg, about 10 mg, about 10.5 mg, about 11 mg, about 11.5 mg, or about 12 mg.
• the active ingredient is administered in an amount which ranges between any two of these dosage amounts. For example, in one embodiment, the active ingredient is administered in an amount from about 1.5 mg to about 12 mg. In another embodiment, the active ingredient is administered in an amount from about 0.5 mg to about 12 mg
• the active ingredient is administered in an amount of about 0.5 mg, about 1.0 mg, about 1.5 mg, about 3 mg, about 4.5 mg, about 6 mg, about 9 mg or about 12 mg, for example, in an amount of about 1.5 mg, about 3 mg, about 6 mg, about 9 mg or about 12 mg.
• the desired dose may be administered as one or more daily sub dose(s) administered at appropriate time intervals throughout the day, or alternatively, in a single dose, for example, for morning or evening administration.
• the daily dosage may be divided into one, into two, into three, or into four divided daily doses.
• the duration of the treatment may be decades, years, months, weeks, or days, as long as the benefits persist.
• the present invention relates to a method of treating acute mania by administering to a patient in need thereof about 0.5 mg trans-4- ⁇ 2-[4-(2,3-dichlorophenyl)- piperazin-1-yl] -ethyl J-NjN-dimethylcarbamoyl-cyclohexylamine or a pharmaceutically acceptable salt thereof.
• the present invention relates to a method of treating acute mania by administering to a patient in need thereof about 1.0 mg trans-4- ⁇ 2-[4-(2,3-dichlorophenyl)- piperazin-l-ylj-ethylJ-NjN-dimethylcarbamoyl-cyclohexylamine or a pharmaceutically acceptable salt thereof.
• the present invention relates to a method of treating acute mania by administering to a patient in need thereof about 1.5 mg trans-4- ⁇ 2-[4-(2,3-dichlorophenyl)- piperazin-l-ylJ-ethylJ-NjN-dimethylcarbamoyl-cyclohexylamine or a pharmaceutically acceptable salt thereof.
• the present invention relates to a method of treating acute mania by administering to a patient in need thereof about 3 mg trans-4- ⁇ 2-[4-(2,3- dichlorophenyl)-piperazin- 1 -yl]-ethyl ⁇ -NjN-dimethylcarbamoyl-cyclohexylarnine or a pharmaceutically acceptable salt thereof.
• the present invention relates to a method of treating acute mania by administering to a patient in need thereof about 4.5 mg trans-4- ⁇ 2-[4-(2,3- dichlorophenyl)-piperazin- 1 -yl]-ethyl ⁇ -NjN-dimethylcarbamoyl-cyclohexylamine or a pharmaceutically acceptable salt thereof.
• the present invention relates to a method of treating acute mania by administering to a patient in need thereof about 6 mg trans-4- ⁇ 2-[4-(2,3- dichlorophenyl)-piperazin- 1 -yl]-ethyl ⁇ -NjN-dimethylcarbamoyl-cyclohexylamine or a pharmaceutically acceptable salt thereof.
• the present invention relates to a method of treating acute mania by administering to a patient in need thereof about 9 mg trans-4- ⁇ 2-[4-(2,3- dichlorophenyl)-piperazin- 1 -yl]-ethyl ⁇ -NjN-dimethylcarbamoyl-cyclohexylamine or a pharmaceutically acceptable salt thereof.
• the present invention relates to a method of treating acute ma by administering to a patient in need thereof about 12 mg trans-4- ⁇ 2-[4-(2,3- dichlorophenyl)-piperazin-l-yl]-ethyl ⁇ -N,N-dimethylcarbamoyl-cyclohexylamine or a pharmaceutically acceptable salt thereof.
• the active ingredient administered is trans-4- ⁇ 2-[4-(2,3- dichlorophenyl)-piperazin-l-yl]-ethyl ⁇ -N,N-dimethylcarbamoyl-cyclohexylamine hydrochloride.
• the active ingredient is administered in one or two divided daily doses.
• the administration of the active ingredient provides therapeutic effects in the treatment of acute mania associated with bipolar disorder, e.g., acute mania associated with bipolar I disorder.
• the compounds of formula (I) can be administered alone or as an active ingredient of a pharmaceutical composition.
• the mode of administration and dosage forms is closely related to the therapeutic amounts of the compounds or compositions which are desirable and efficacious for the given treatment application.
• Suitable dosage forms include but are not limited to oral, rectal, sub-lingual, mucosal, nasal, ophthalmic, subcutaneous, intramuscular, intravenous, transdermal, spinal, intrathecal, intra-articular, intra-arterial, sub-arachinoid, bronchial, lymphatic, and intra-uterille administration, and other dosage forms for systemic delivery of active ingredients. Formulations suitable for oral administration are preferred.
• the active ingredient is intimately admixed with a pharmaceutical carrier according to conventional pharmaceutical compounding techniques.
• the carrier may take a wide variety of forms depending on the form of preparation desired for administration.
• any of the usual pharmaceutical media may be employed.
• suitable carriers and additives include water, glycols, oils, alcohols, flavoring agents, preservatives, coloring agents and the like.
• suitable carriers and additives include starches, sugars, diluents, granulating agents, lubricants, binders, disintegrating agents and the like. Due to their ease in administration, tablets and capsules represent the most advantageous oral dosage unit form. If desired, tablets may be sugar coated or enteric coated by standard techniques.
• the carrier will usually comprise sterile water, though other ingredients, for example, ingredients that aid solubility or for preservation, may be included. Injectable solutions may also be prepared in which case appropriate stabilizing agents may be employed.
• the active agent in a "vectorized” form, such as by encapsulation of the active agent in a liposome or other encapsulant medium, or by fixation of the active agent, e.g., by covalent bonding, chelation, or associative coordination, on a suitable biomolecule, such as those selected from proteins, lipoproteins, glycoproteins, and polysaccharides.
• Treatment methods of the present invention using formulations suitable for oral administration may be presented as discrete units such as capsules, cachets, tablets, or lozenges, each containing a predetermined amount of the active ingredient as a powder or granules.
• a suspension in an aqueous liquor or a non-aqueous liquid may be employed, such as a syrup, an elixir, an emulsion, or a draught.
• a tablet may be made by compression or molding, or wet granulation, optionally with one or more accessory ingredients.
• Compressed tablets may be prepared by compressing in a suitable machine, with the active compound being in a free-flowing form such as a powder or granules which optionally is mixed with, for example, a binder, disintegrant, lubricant, inert diluent, surface active agent, or discharging agent.
• Molded tablets comprised of a mixture of the powdered active compound with a suitable carrier may be made by molding in a suitable machine.
• a syrup may be made by adding the active compound to a concentrated aqueous solution of a sugar, for example sucrose, to which may also be added any accessory ingredient(s).
• a sugar for example sucrose
• Such accessory ingredient(s) may include flavorings, suitable preservative, agents to retard crystallization of the sugar, and agents to increase the solubility of any other ingredient, such as a polyhydroxy alcohol, for example glycerol or sorbitol.
• Formulations suitable for parenteral administration usually comprise a sterile aqueous preparation of the active compound, which preferably is isotonic with the blood of the recipient (e.g., physiological saline solution).
• Such formulations may include suspending agents and thickening agents and liposomes or other microparticulate systems which are designed to target the compound to blood components or one or more organs.
• the formulations may be presented in unit-dose or multi-dose form.
• Parenteral administration may comprise any suitable form of systemic delivery or delivery directly to the CNS.
• Administration may for example be intravenous, intra-arterial, intrathecal, intramuscular, subcutaneous, intramuscular, intra-abdominal (e.g., intraperitoneal), etc., and may be effected by infusion pumps (external or implantable) or any other suitable means appropriate to the desired administration modality.
• Nasal and other mucosal spray formulations can comprise purified aqueous solutions of the active compounds with preservative agents and isotonic agents.
• Such formulations are preferably adjusted to a pH and isotonic state compatible with the nasal or other mucous membranes.
• they can be in the form of finely divided solid powders suspended in a gas carrier.
• Such formulations may be delivered by any suitable means or method, e.g., by nebulizer, atomizer, metered dose inhaler, or the like.
• Formulations for rectal administration may be presented as a suppository with a suitable carrier such as cocoa butter, hydrogenated fats, or hydrogenated fatty carboxylic acids.
• Transdermal formulations may be prepared by incorporating the active agent in a thixotropic or gelatinous carrier such as a cellulosic medium, e.g., methyl cellulose or hydroxyethyl cellulose, with the resulting formulation then being packed in a transdermal device adapted to be secured in dermal contact with the skin of a wearer.
• formulations of this invention may further include one or more accessory ingredient(s) selected from diluents, buffers, flavoring agents, binders, disintegrants, surface active agents, thickeners, lubricants, preservatives (including antioxidants), and the like.
• accessory ingredient(s) selected from diluents, buffers, flavoring agents, binders, disintegrants, surface active agents, thickeners, lubricants, preservatives (including antioxidants), and the like.
• formulations of the present invention can have immediate release, sustained release, delayed-onset release or any other release profile known to one skilled in the art.
• trans-4- ⁇ 2-[4-(2,3-dichlorophenyl)- piperazin-l-ylJ-ethylJ-NjN-dimethylcarbamoyl-cyclohexylamine or a pharmaceutically acceptable salt thereof is administered as an adjunctive treatment to or in combination with one or more additional therapeutic agents.
• pharmaceutically acceptable means biologically or pharmacologically compatible for in vivo use in animals or humans, and preferably means approved by a regulatory agency of the Federal or a state government or listed in the U.S. Pharmacopeia or other generally recognized pharmacopeia for use in animals, and more particularly in humans.
• treat refers to one or more of the following:
• an "effective amount” means the amount of an active ingredient that, when administered to a patient (e.g., a mammal) for treating a disease or disorder, is sufficient to effect such treatment for the disease or disorder, or an amount that is sufficient for modulating a dopamine receptor (e.g., the dopamine D 2 and/or dopamine D 3 receptor) to achieve the objectives of the invention.
• the "effective amount” will vary depending on the compound, the disease and its severity and the age, weight, responsiveness, etc., of the patient to be treated.
• a subject or patient in whom administration of the therapeutic compound is an effective therapeutic regimen for a disease or disorder is preferably a human, but can be any animal, including a laboratory animal in the context of a trial or screening or activity experiment.
• the methods, compounds and compositions of the present invention are particularly suited to administration to any animal, particularly a mammal, and including, but by no means limited to, humans, domestic animals, such as feline or canine subjects, farm animals, such as but not limited to bovine, equine, caprine, ovine, and porcine subjects, wild animals (whether in the wild or in a zoological garden), research animals, such as mice, rats, rabbits, goats, sheep, pigs, dogs, cats, etc., avian species, such as chickens, turkeys, songbirds, etc., i.e., for veterinary medical use.
• Patients must have a YMRS total score > 20 at Visit 1 and Visit 2 and a score of at least 4 on two of the following YMRS items: Irritability, Speech, Content, and Disruptive/ Aggressive Behavior
• This study will be 5 weeks in duration; 3 -weeks of double-blind treatment and 2- weeks of safety follow-up. Patients will start hospitalization during the screening phase. A no-drug washout period of up to 4 days will precede randomization. Following the washout period, patients who continue to meet all eligibility criteria will be assigned a randomization number at Visit 2 and dispensed the corresponding blister pack of double-blind study medication for Week 1 of double-blind treatment.
• the study design is shown on Figure 1.
• All study medication will be dispensed in blister packs, one for each week. Each card will contain 40 capsules arranged in 10 columns and 4 rows, adequate for the 7 days of the week plus 3 extra days.
• the configuration of the blister pack is provided in Table 1.
• AU study drugs will be administered as a single daily dose at bedtime. The dosing can be switched to morning if there are tolerability problems; however, any switch must allow at least 24 hours between two consecutive doses.
• the dose can be increased to two capsules (Rows 1 and 2), if response is not adequate and there are no tolerability problems.
• the dose can be increased by one capsule to three capsules (Rows 1, 2, and 3) depending on response and tolerability.
• the dose can be increased by one capsule to a maximum of 4 capsules (Rows 1, 2, 3 and 4) depending on the response and tolerability. Any dose increases will be made in increments of one capsule.
• the dose can be decreased at any time to the prior level by eliminating the last row. For example, Row 4 can be eliminated if the patient was on four capsules; Row 3 can be eliminated if the patient was on three capsules; Row 2 can be eliminated if the patient was on two capsules. Any decreases in the dosing regimen will be carried out in decrements of one capsule. Alternatively, the dose can be skipped for 1 to 2 days if there are tolerability problems. However, frequent switching will not be allowed.
• Visits 8, 9 and 10 may be conducted up to 3 days before or after the scheduled visit.
• a washout period of up to 4 days may be required for patients who are receiving or are suspected of having received any prohibited medications.
• a 3 -day washout period will also be required for patients who have been intoxicated with alcohol or who have tested positive for tetrahydrocannabinol/cannaboids.
• a 4-day washout period will be required for patients who have taken or are suspected of taking other illicit drugs.
• This visit is to be conducted within 4 days after Visit 1.
• the inclusion/exclusion criteria will be reviewed; and, if the patient is eligible to enter the study, a randomization number will be assigned. Study procedures will then be reviewed with the patient.
• the YMRS (see, e.g., Young et al, Br. J. Psychiatry, 133, 429-35, 1978) is an 11 -item scale that assesses manic symptoms based on the patient's perception of his or her condition over the previous 48 hours, as well as the physician's clinical observations during the interview.
• the 11 items are elevated mood, increased motor activity-energy, sexual interest, sleep, irritability, rate and amount of speech, language-thought disorder, content, disruptive- aggressive behavior, appearance, and insight.
• the severity of the abnormality is rated on a five-point (0-4) or nine-point (0-8) scale; scoring between listed points is encouraged. Possible scores range from 0 to 60. This scale will be administered by a trained rater with expertise in evaluating manic patients. Assessments and ratings should be made by the same rater at approximately the same time of day.
• the CGI-S (see, e.g., Guy ECDEU Assessment Manual for Psychopharmacology. Rockville, Md: US Department of Health, Education, and Welfare, 218-22, 1976. Publication ADM 76-338) is a seven-point scale that measures the overall severity of the illness in comparison to the severity of other patients the physician has observed. For patients discharged between Day 14 through Day 21, a CGI-S is required to be conducted within 24 hours prior to discharge from the hospital. This assessment will be made by a psychiatrist. Additional Efficacy Assessments
• CGI-I Clinical Global Impressions-Improvement
• the MADRS (see e.g., Montgomery and Asberg, Br. J. Psychiatry, 134, 382-9, 1979) is a clinician-rated scale that evaluates the patient's depressive symptomatology during the past week. Patients are to be rated on 10 items assessing feelings of sadness, lassitude, pessimism, inner tension, suicidality, reduced sleep or appetite, difficulty in concentration, and lack of interest. Each item will be scored on a seven-point scale with a score of 0 reflecting no symptoms and a score of 6 reflecting symptoms of maximum severity. This scale will be administered by a trained rater with adequate experience in the assessment of the patient's depressive symptomology.
• the PANSS (see, e.g., Kay et al. Schizophr. Bull, 13, 261-76, 1987) is a 30-item rating scale that was specifically developed to assess both the positive and negative symptom syndromes of patients with schizophrenia.
• the PANSS Total Score is rated based on a structured clinical interview with the patient and supporting clinical information obtained from family, hospital staff, or other reliable informants. Each item is scored on a seven-point (1-7) continuum and provides scores in nine clinical domains, including a positive syndrome, a negative syndrome, depression, a composite index, and general psychopathology._This scale will be administered by a trained, experienced psychiatric rater with expertise in the assessment of patients with bipolar disorder and schizophrenia.

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• Pharmaceuticals Containing Other Organic And Inorganic Compounds (AREA)
• Acyclic And Carbocyclic Compounds In Medicinal Compositions (AREA)
• Organic Low-Molecular-Weight Compounds And Preparation Thereof (AREA)

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