WO2010083279A2

WO2010083279A2 - Methods for treating disorders associated with hyperlipidemia in a mammal

Info

Publication number: WO2010083279A2
Application number: PCT/US2010/020997
Authority: WO
Inventors: William J. Sasiela
Original assignee: Aegerion Pharmaceuticals, Inc.
Priority date: 2009-01-14
Filing date: 2010-01-14
Publication date: 2010-07-22
Also published as: WO2010083279A3

Abstract

The disclosure is directed to methods for treating hyperlipidemia in a mammal, e.g. by administering an MTP inhibitor and an omega-3 fatty acid (for example, fish oil). Co¬ administration of the MTP inhibitor with the omega-3 fatty acid produces a therapeutic benefit, for example, a reduction in the concentration of cholesterol and/or triglycerides in the blood stream, but with fewer or reduced side effects than when higher dosages of the MTP inhibitor are used during monotherapy to provide the same or similar therapeutic benefit.

Description

METHODS FOR TREATING DISORDERS ASSOCIATED WITH HYPERLIPIDEMIA IN A MAMMAL

REFERENCE TO RELATED APPLICATIONS

[0001] This application claims priority to U.S. Provisional Application No. 61/144,541, filed January 14, 2009, incorporated by reference herein in its entirety.

BACKGROUND

[0002] Cardiovascular disease is a major cause of mortality in the Western world. A key risk factor of cardiovascular disease is hyperlipidemia, which is an elevation of lipids in the blood. These lipids include triglycerides, cholesterol, cholesterol esters, and phospholipids. Various epidemiological studies have demonstrated that lowering of total cholesterol (TC) and low density lipoprotein (LDL) cholesterol (LDL-C) is associated with a significant reduction in cardiovascular events. The National Cholesterol Education Program's (NCEP' s) updated guidelines recommend that the overall goal for high-risk patients is to achieve less than 100 mg/dL of LDL, with a therapeutic option to set the goal for such patients to achieve less than 70 mg/dL of LDL.

[0003] The presence of elevated amounts of triglycerides in the blood is known as hypertriglyceridemia. Although triglycerides are necessary for good health, higher- than- normal triglyceride levels are often associated with increased risk of heart disease.

[0004] Another form of hyperlipidemia, known as hypercholesterolemia, is characterized by high cholesterol level, specifically very high LDL levels in the blood. High cholesterol levels can be successfully treated with medications and modifications in lifestyle. However, in some cases, as in familial hypercholesterolemia (FH), treatment can be challenging despite aggressive use of conventional therapy. FH is a serious genetic disorder due to homozygosity or compound heterozygosity for mutations in the LDL receptor. If left untreated, patients with homozygous FH (hoFH) develop atherosclerosis before the age 20 and generally do not survive past the age 30. However, patients diagnosed with hoFH are largely unresponsive to conventional drug therapy and have limited treatment options. Specifically, treatment with statins, which reduce LDL-C by inhibiting cholesterol synthesis and upregulating the hepatic LDL receptor, have negligible effect in hoFH patients whose LDL receptors are non-existent or defective. Therefore, there is a tremendous unmet medical need for new medical therapies for hoFH.

[0005] Microsomal triglyceride transfer protein (MTP) inhibitors have been shown clinically to lower plasma cholesterol levels. One exemplary MTP inhibitor is N-(2,2,2- Trifluorethyl)-9- [4- [4- [ [ [4'-(trifluoromethyl) [1,1 'biphenyl] -2- Yl] carbonyl] amino] - 1 - piperidinyl]butyl]9H-fluorene-9-carboxamide (BMS-201038), developed by Bristol-Myers Squibb. See, U.S. Patent Nos. 5,739,135; and 5,712,279. However, some patients treated with 25 mg/day of BMS-201038 experienced adverse events, for example, gastrointestinal disturbances, abnormalities in liver function, and hepatic steatosis. Another potent MTP inhibitor is known as implitapide. See, U.S. Patent Nos. 6,265,431, 6,479,503, 5,952,498. During clinical studies, dosages of implitapide of 80 mg/day or greater, although therapeutically effective, were also found to result in certain adverse events, for example, gastrointestinal disturbances, abnormalities in liver function, and hepatic steatosis. [0006] Accordingly, there is still a need for methods for aggressively treating hyperlipidemias that effectively lower, for example, circulating cholesterol and triglycerides levels but with fewer or reduced adverse effects that typically result when higher dosages of the MTP inhibitor are used alone in monotherapy.

SUMMARY [0007] The present disclosure provides methods for reducing the concentration of cholesterol and/or triglycerides in the blood of a mammal. The method includes administering a MTP inhibitor, such as AEGR-733 or implitapide, in combination with a ω-3 fatty acid, such as fish oil. The MTP inhibitors can be administered at certain lower dosages that are still therapeutically effective when combined with a ω-3 fatty acid but yet create fewer or reduced adverse effects when compared to therapies using therapeutically effective dosages of the MTP inhibitors during monotherapy. The administration of one or more MTP inhibitors, when administered in combination with one or more ω-3 fatty acids, may provide an additive or synergistic therapeutic effect, e.g. may result in reduction of blood cholesterol and/or triglyceride levels that is greater than the sum of the expected cholesterol and/or triglyceride reduction due to administration of a MTP inhibitor and ω-3 fatty acid when administered alone. In some embodiments, disclosed methods can result in fewer incidences of gastrointestinal and/or hepatic adverse events (e.g. hepatic steatosis), in a patient as compared to administration of a MTP inhibitor alone.

[0008] In one aspect, the disclosure provides a method of reducing the concentration of cholesterol and/or triglycerides in the blood of a mammal. The method comprises a combination therapy, which comprises administering to the mammal, for example, a human, a combination of ω-3 fatty acid and AEGR-733, wherein AEGR-733 can be administered at about 2.5 mg/day to about 50 mg/day. In one embodiment, AEGR-733 can be administered at a dosage of 10 mg/day. The ω-3 fatty acid and AEGR-733 can be administered together in the same dosage form, or they may be administered in separate dosage forms. In the case of the separate dosage forms, ω-3 fatty acid can be administered before, after, or simultaneously with AEGR-733.

[0009] In another aspect, the disclosure provides a method of reducing the concentration of cholesterol and/or triglycerides in the blood of a mammal. The method comprises a combination therapy, which comprises administering to the mammal, for example, a human, a combination of ω-3 fatty acid and implitapide, wherein implitapide can be administered at about 20 mg/day to about 40 mg/day. The ω-3 fatty acid and implitapide can be administered together in the same dosage form, or they may be administered in separate dosage forms. In the case of the separate dosage forms, ω-3 fatty acid can be administered before, after, or simultaneously with implitapide.

[0010] The present disclosure provides a method of reducing hepatic steatosis in a patient receiving a MTP inhibitor. The method comprises co-administering AEGR-733 and ω-3 fatty acid to the patient. The AEGR-733 may be administered, for example, at a dosage of 2.5 mg/day to about 50 mg/day. In one embodiment, AEGR-733 can be administered at about 10 mg/day. AEGR-733 and ω-3 fatty acid may be administered together in the same dosage form or may be administered in separate dosage forms. In the case of the separate dosage forms, ω-3 fatty acid can be administered before, after, or simultaneously with AEGR-733. AEGR-733 and ω-3 fatty acid can be administered at least daily. [0011] In another aspect, the disclosure provides a method of reducing hepatic steatosis in a patient receiving a MTP inhibitor. The method comprises co-administering implitapide and Cϋ-3 fatty acid to the patient. The implitapide may be administered, for example, at a dosage of 2.5 mg/day to about 50 mg/day. In one embodiment, implitapide can be administered at about 20 mg/day to about 40 mg/day. Implitapide and ω-3 fatty acid may be administered together in the same dosage form or may be administered in separate dosage forms. In the case of the separate dosage forms, ω-3 fatty acid can be administered before, after, or simultaneously with implitapide. Implitapide and ω-3 fatty acid can be administered at least daily.

[0012] In some embodiments, the amount of hepatic triglyceride in the patient's liver after one month is less than about 20% of the amount of hepatic triglyceride in a patient's liver if the MTP inhibitor is administered alone.

[0013] The foregoing methods can be used to treat (i) patients with hyperlipidemia, for example, hypercholesterolemia (for example, homozygous or heterozygous familial hypercholesterolemia) or hypertriglyceridemia, (ii) patients resistant to statin monotherapy, (iii) statin-intolerant patients, and/or (iv) patients having a combination of (i) and (ii), (i) and (iii), (ii) and (iii), and (i), (ii) and (iii).

BRIEF DESCRIPTION OF THE DRAWINGS

[0014] FIGURE 1 depicts a bar graph showing significantly reduced levels of hepatic triglyceride in LDLR+/+ apobec-/-hApoB mice treated with a combination of AEGR-733 and fish oil compared to mice treated with a combination of AEGR-733 and soybean oil.

[0015] FIGURE 2 depicts the compositions of the diets administered to the LDLR+/+ apobec-/-hApoB mice. DETAILED DESCRIPTION

[0016] The present disclosure relates to methods of reducing the concentration of cholesterol and/or triglycerides in the blood of a mammal. The methods are based on combination therapies where a MTP inhibitor is administered with a ω-3 fatty acid. In addition, the disclosure relates to a method of reducing hepatic steatosis induced by a MTP inhibitor by administering the MTP inhibitor together with a ω-3 fatty acid.

[0017] For convenience, before further description, the meaning of certain terms and phrases used in the specification, examples, and appended claims are provided below.

Definitions [0018] The term "combination therapy," as used herein, refers to co-administering a MTP inhibitor, for example, AEGR-733 and implitapide, or a combination thereof, and a ω-3 fatty acid, for example, fish oil, as part of a specific treatment regimen intended to provide the beneficial effect from the co-action of these therapeutic agents. The beneficial effect of the combination includes, but is not limited to, pharmacokinetic or pharmacodynamic co-action resulting from the combination of therapeutic agents. Administration of these therapeutic agents in combination typically is carried out over a defined time period (usually weeks, months or years depending upon the combination selected). Combination therapy is intended to embrace administration of multiple therapeutic agents in a sequential manner, that is, wherein each therapeutic agent is administered at a different time, as well as administration of these therapeutic agents, or at least two of the therapeutic agents, in a substantially simultaneous manner. Substantially simultaneous administration can be accomplished, for example, by administering to the subject a single tablet or capsule having a fixed ratio of each therapeutic agent or in multiple, single capsules for each of the therapeutic agents. Sequential or substantially simultaneous administration of each therapeutic agent can be achieved by any appropriate route including, but not limited to, oral routes, intravenous routes, intramuscular routes, and direct absorption through mucous membrane tissues. The therapeutic agents can be administered by the same route or by different routes. For example, a first therapeutic agent of the combination selected may be administered by intravenous injection while the other therapeutic agents of the combination may be administered orally. Alternatively, for example, all therapeutic agents may be administered orally or all therapeutic agents may be administered by intravenous injection.

[0019] Combination therapy also can embrace the administration of the therapeutic agents as described above in further combination with other biologically active ingredients and non- drug therapies. Where the combination therapy further comprises a non-drug treatment, the non-drug treatment may be conducted at any suitable time so long as a beneficial effect from the co-action of the combination of the therapeutic agents and non-drug treatment is achieved. For example, in appropriate cases, the beneficial effect is still achieved when the non-drug treatment is temporally removed from the administration of the therapeutic agents, perhaps by days or even weeks.

[0020] The components of the combination may be administered to a patient simultaneously or sequentially. It will be appreciated that the components may be present in the same pharmaceutically acceptable carrier and, therefore, are administered simultaneously. Alternatively, the active ingredients may be present in separate pharmaceutical carriers, such as, conventional oral dosage forms, that can be administered either simultaneously or sequentially.

[0021] The terms, "individual," "patient," or "subject" are used interchangeably herein and include any mammal, including animals, for example, primates, for example, humans, and other animals, for example, dogs, cats, swine, cattle, sheep, and horses. The compounds of the disclosure can be administered to a mammal, such as a human, but can also be other mammals, for example, an animal in need of veterinary treatment, for example, domestic animals (for example, dogs, cats, and the like), farm animals (for example, cows, sheep, pigs, horses, and the like) and laboratory animals (for example, rats, mice, guinea pigs, and the like).

[0022] The term, "patient resistant to statin monotherapy," as used herein includes those patients for whom conventional statin monotherapy has been found ineffective or less effective than desired. A physician designing lipid reduction therapy for a patient will be able to determine via diagnosis and observation of periodic blood cholesterol and/or triglyceride levels whether such a patient is or has been resistant to statin monotherapy. [0023] The term, "statin-intolerant patient," as used herein includes those patients for whom conventional statin therapy, for example, for serum lipid reduction, has been found to be ineffective and/or for whom an effective lipid-reducing dose of statins is too high to be tolerated or that there is an unacceptable adverse event associated with a particular dose. For example, statin therapy may be discontinued by the physician/patient due to concern over an adverse event such as Liver Function Test abnormality, muscle aches and pains or inflammation - myalgia or myostitis, elevation in enzymes (CK) showing muscle adverse event. A physician designing lipid reduction therapy for a patient will be able to determine via diagnosis and observation of periodic blood cholesterol and/or triglyceride levels whether such a patient is statin-intolerant.

[0024] The phrase "minimizing adverse effects," "reducing adverse events," or "reduced adverse events," as used herein refer to an amelioration or elimination of one or more undesired side effects associated with the use of MTP inhibitors of the present disclosure. Side effects of traditional use of the MTP inhibitors include, without limitation, nausea, diarrhea, gastrointestinal disorders, steatorrhea, abdominal cramping, distention, elevated liver function tests, fatty liver (hepatic steatosis); hepatic fat build up, polyneuropathy, peripheral neuropathy, rhabdomyolysis, arthralgia, myalgia, chest pain, rhinitis, dizziness, arthritis, peripheral edema, gastroenteritis, liver function tests abnormal, colitis, rectal hemorrhage, esophagitis, eructation, stomatitis, biliary pain, cheilitis, duodenal ulcer, dysphagia, enteritis, melena, gum hemorrhage, stomach ulcer, tenesmus, ulcerative stomatitis, hepatitis, pancreatitis, cholestatic jaundice, paresthesia, amnesia, libido decreased, emotional lability, incoordination, torticollis, facial paralysis, hyperkinesia, depression, hypesthesia, hypertonia, leg cramps, bursitis, tenosynovitis, myasthenia, tendinous contracture, myositis, hyperglycemia, creatine phosphokinase increased, gout, weight gain, hypoglycemia, anaphylaxis, angioneurotic edema, and bullous rashes (including erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis). Accordingly, the methods described herein provide an effective therapy while at the same time causing fewer or less significant adverse events.

[0025] In certain embodiments, side effects are partially eliminated. As used herein, the phrase "partially eliminated" refers to a reduction in the severity, extent, or duration of the particular side effect by at least 30%, 40%, 50%, 60%, 70%, 80%, 90%, 95% and 99% relative to that found by administering 25 mg/day of AEGR-733 during monotherapy or either 80 mg/day or 160 mg/day of implitapide during monotherapy. In certain embodiments, side effects are completely eliminated. Those skilled in the art are credited with the ability to detect and grade the severity, extent, or duration of side effects as well as the degree of amelioration of a side effect. For example, gastrointestinal side effects can be assessed, for example, using the Gastrointestinal Symptom Rating Scale. In some embodiments, two or more side effects are ameliorated.

[0026] The Gastrointestinal Symptom Rating Scale ("GSRS") is an assessment tool for patients with general gastrointestinal complaints, and has been extensively validated in previous studies. The GSRS includes up to 15 items that addresses different gastrointestinal symptoms and typically uses a 7-point Likert response scale with verbal descriptors. The response scale is designed to measure the amount of discomfort a patient has experienced (none at all, minor, mild, moderate, moderately severe, severe, and very severe). A higher score in a GSRS cluster indicates more discomfort, with the scale from 1 (no discomfort) to 7. The recall period can refer, for example, to the past week. The 15 exemplary items can combine into five symptom clusters labeled reflux, abdominal pain, indigestion, diarrhea, and constipation. From individual items within a cluster, a mean score is calculated.

[0027] The term "synergistic" refers to two or more agents, e.g. a MTP inhibitor and a ω-3 fatty acid, when taken together, produce a total joint effect that is greater than the sum of the effects of each drug when taken alone. [0028] The term, "therapeutically effective" refers to the ability of an active ingredient, for example, AEGR-733 and implitapide, to elicit the biological or medical response that is being sought by a researcher, veterinarian, medical doctor or other clinician. Non-limiting examples include reduction of cholesterol (for example, LDL) in a patient and/or reduction of triglyceride levels in a patient, and the like. [0029] The term, "therapeutically effective amount" includes the amount of an active ingredient, for example, AEGR-733 and implitapide, that will elicit the biological or medical response that is being sought by the researcher, veterinarian, medical doctor or other clinician. The compounds of the invention are administered in amounts effective at lowering the cholesterol concentration in the blood, and/or the triglyceride concentration in the blood. Alternatively, a therapeutically effective amount of an active ingredient is the quantity of the compound required to achieve a desired therapeutic and/or prophylactic effect, such as the amount of the active ingredient that results in the prevention of or a decrease in the symptoms associated with the condition (for example, to meet an end-point).

[0030] The terms, "pharmaceutically acceptable" or "pharmacologically acceptable" refer to molecular entities and compositions that do not produce an adverse, allergic or other untoward reaction when administered to an animal, or to a human, as appropriate. The term, "pharmaceutically acceptable carrier" includes any and all solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic and absorption delaying agents and the like. The use of such media and agents for pharmaceutical active substances is well known in the art. Except insofar as any conventional media or agent is incompatible with the active ingredient, its use in the therapeutic compositions is contemplated. Supplementary active ingredients can also be incorporated into the compositions.

[0031] Pharmaceutically acceptable salts of the disclosed compounds can be synthesized, for example, from the parent compound, which contains a basic or acidic moiety, by conventional chemical methods. Generally, such salts can be prepared by reacting the free acid or base forms of these compounds with a stoichiometric amount of the appropriate base or acid in water or in an organic solvent, or in a mixture of the two; generally, non-aqueous media like ether, ethyl acetate, ethanol, isopropanol, or acetonitrile are preferred. Lists of suitable salts are found in Remington's Pharmaceutical Sciences, 20th ed., Lippincott Williams & Wilkins, Baltimore, MD, 2000, p. 704.

[0032] As used herein, the term "stereoisomers" refers to compounds made up of the same atoms bonded by the same bonds but having different spatial structures which are not interchangeable. The three-dimensional structures are called configurations. As used herein, the term "enantiomers" refers to two stereoisomers whose molecules are nonsuperimposable mirror images of one another. The terms "racemate," "racemic mixture" or "racemic modification" refer to a mixture of equal parts of enantiomers. Methods of the Invention

[0033] In general the present disclosure provides methods for reducing the concentration of cholesterol and/or triglycerides in the blood of a mammal. The method comprises using one or more MTP inhibitors, for example, AEGR-733 or implitapide, in combination with a ω-3 fatty acid, for example, fish oil. The MTP inhibitors can be used at dosages lower than those already found to result in one or more adverse events, for example, gastrointestinal disorders, abnormalities in liver functional and/or hepatic steatosis (for example, 25 mg/day of AEGR- 733, 80 mg/day of implitapide and 160 mg/day of implitapide have been found to cause gastrointestinal disorders, abnormalities in liver function and/or hepatic steatosis) but at doses which are therapeutically effective when combined with a ω-3 fatty acid, for example, fish oil. The dosages need not be smaller but may additionally and/or optionally be administered less frequently. It is contemplated that such a combination may be effective at reducing the concentration of cholesterol and/or triglycerides in the blood of a mammal even when larger dosages of AEGR-733 or implitapide are administered together with a dose of a ω-3 fatty acid. Combination Therapies Using MTP Inhibitors and ω-3 Fatty Acid

[0034] The method comprises a combination therapy, which can be achieved by coadministering to the mammal a MTP inhibitor and a ω-3 fatty acid. The MTP inhibitor and the ω-3 fatty acid can be administered as a (i) single dosage form or composition, (ii) simultaneously as separate dosage forms or pharmaceutical compositions, (iii) sequentially, as separate dosage forms starting with the MTP inhibitor and then administering the ω-3 fatty acid, or starting with the ω-3 fatty acid and then administering the MTP inhibitor, (iv) successively, separated by for example 1-4 hours, 1-8 hours or 1-12 hours, a day, or 2 or more days, e.g. 2 to 3 days, or (v) individually followed by the combination. The methods disclosed herein may occur before, during, or after other dosing regimens that may include, for example MTP inhibitors, ω-3 fatty acids, and other agents for reducing cholesterol. For example, the methods disclosed herein may occur after a patient has received statin monotherapy or statin combination therapy. [0035] In some embodiments, a MTP inhibitor can be administered in escalating doses. Such escalating doses may comprise a first dose level and a second dose level. In other embodiments, escalating doses may comprise at least a first dosage level, a second dosage level, and a third dosage level, and optionally a fourth, fifth, or sixth dosage level. The ω-3 fatty acid may be provided in one dosage level when in administered in combination with a MTP inhibitor, or may be administered in escalating doses.

[0036] A first, second, third or more dosage levels can be administered to a patient for about 2 days to about 6 months or more in duration. For example, first, second and/or third dose levels are each administered to a subject for about 1 week to about 26 weeks, or about 1 week to about 12 weeks, or about 1 week to about four weeks. Alternatively, the first, second and/or third dosage levels can be administered to a subject for about 2 days to about 40 days or to about 6 months.

[0037] The MTP inhibitor and/or the ω-3 fatty acid each may be administered in a therapeutically effective amount and/or each in a synergistically effective amount. Such dosages of a MTP inhibitor and/or a ω-3 fatty acid may, while not effective when used in monotherapy, may be effective when used in the combinations disclosed herein.

[0038] Administration of the MTP inhibitor and the ω-3 fatty acid may result in fewer gastrointestinal or hepatic adverse events, such as hepatic steatosis, as compared to administration of a MTP inhibitor alone. In some embodiments, administration of the MTP inhibitor and the ω-3 fatty acid may result in greater reduction of cholesterol and/or triglycerides in the blood and fewer hepatic or gastrointestinal adverse events as compared to administration of a MTP inhibitor or ω-3 fatty acid alone. The level of cholesterol or triglycerides in the blood and reduction thereof, can be measured using conventional techniques known in the art, for example, a fasting blood test. [0039] In certain other embodiments, the method produces an approximately 35%, 40% or more decrease in LDL-C in patients as compared to the patient's LDL-C level before treatment.

[0040] The methods disclosed herein may reduce or lower the concentration of serum cholesterol. It is understood that total serum cholesterol can be provided by very low density lipoproteins (VLDL), intermediate density lipoproteins (IDL), LDL and chylomicrons. Accordingly, it is contemplated that the combination therapies may reduce total blood cholesterol, or cholesterol provided by or associated with VLDL, IDL, LDL and chylomicrons. In addition, the methods disclosed herein may reduce or lower the concentration of serum triglycerides. It is understood that the serum triglycerides can be provided by VLDL and chylomicrons, and to a lesser extent by IDL and LDL. Accordingly, it is contemplated that the combination therapies may reduce triglycerides provided by or associated with VLDL, IDL, LDL and chylomicrons.

[0041] In another aspect, the present disclosure provides a method of reducing hepatic steatosis in a patient receiving MTP inhibitors. The method comprises co-administering a MTP inhibitor and a ω-3 fatty acid to the patient. The MTP inhibitor may be administered, for example, at a dosage from 2.5 mg/day to about 50 mg/day. For example, MTP inhibitors may be administered at about 20 mg/day to about 40 mg/day or more. Higher doses may be appropriate for hoFH or severe refractory patients. MTP inhibitors and ω-3 fatty acid may be administered together in the same dosage form or may be administered in separate dosage forms. In the case of separate dosage forms, ω-3 fatty acid may be administered before, after, or simultaneously with, a MTP inhibitor.

[0042] Administration of the MTP inhibitor and the ω-3 fatty acid together may result in a reduced amount of hepatic triglyceride in the patient's liver as compared to administration of a MTP inhibitor alone. For example administering to a patient a MTP inhibitor alone may cause an increase in hepatic fat from a baseline level while administering to a patient the MTP inhibitor and a ω-3 fatty acid together may eliminate or lessen hepatic fat increase. In some embodiments, the amount of hepatic triglyceride in the patient's liver after one month of daily administration of the disclosed combination is about 5%, 10%, 15%, 20%, 30%, 40%, 50%, 60%, 70%, or 80% or less, e.g. about 25% - 90% less, about 25% - 85% less, or about 30% - 80% less, than the amount of hepatic triglyceride in a patient's liver if the MTP inhibitor is administered alone. MTP Inhibitors

[0043] In one embodiment, the MTP inhibitor may be AEGR-733. As used herein, the phrase "BMS-201038" or "AEGR-733" refers to a compound known as N-(2,2,2- Trifluorethyl)-9- [4- [4- [ [ [4'-(trifluoromethyl) [1,1 'biphenyl] -2- Yl] carbonyl] amino] - 1 - piperidinyl]butyl]9H-fluorene-9-carboxamide, having the formula:

the piperidine N-oxide thereof, and stereoisomers, and pharmaceutically acceptable salts and esters thereof.

[0044] In another embodiment, the MTP inhibitor may include benzimidazole-based analogues of AEGR-733, for example, a compound having the formula shown below:

where n can be 0 to 10, and stereoisomers thereof, and pharmaceutically acceptable salts and esters thereof. [0045] In another embodiment, the MTP inhibitor may be implitapide. As used herein, the phrase "implitapide" refers to a compound (2S)-2-cyclopentyl-2-[4-[(2,4-dimethyl-9H- pyrido[2,3-b]indol-9-yl)methyl]phenyl]-N-[(lS)-2-hydroxy-l-phenylethyl]ethanamide, and having the structure shown below:

and stereoisomers thereof, and pharmaceutically acceptable salts and esters thereof.

[0046] Other MTP inhibitors include those developed by Surface Logix, Inc. e.g., SLx- 4090.

CO- 3 fatty acid

[0047] As used herein, the term, "ω-3 fatty acid" refers to a family of unsaturated fatty acids that have in common a carbon-carbon double bond in the n-3 position; that is, the third bond from the methyl end of the fatty acid.

[0048] Examples of ω-3 fatty acid include, but are not limited to, α-linolenic acid, stearidonic acid, eicosatrienoic acid, eicosatetraenoic acid, eicosapentaenoic acid, docosapentaenoic acid, docosahexaenoic acid, tetracosapentaenoic acid, and tetracosahexaenoic acid. In one embodiment, the ω-3 fatty acid is administered in the form of fish oil which contains eicosapentaenoic acid and docosahexaenoic acid.

[0049] For example, a MTP inhibitor can be administered in combination with ω-3 fatty acid, such as fish oil. Fish oil can include eicosapentaenoic acid, or docosahexaenoic acid, or a combination of eicosapentaenoic acid and docosahexaenoic acid. Fish oil may be co- administered at a dosage in the range of about 1 g/day to about 5 g/day, e.g. 1 g/day, 2 g/day, 3 g/day, 4 g/day, or 5 g/day of fish oil. Therapies Using AEGR-733 and ω-3 fatty acid

[0050] In one aspect, the present disclosure provides a method of reducing the concentration of cholesterol and/or triglycerides in the blood of a mammal comprising administering a combination of ω-3 fatty acid and AEGR-733 to a patient. [0051] Exemplary dosages for administration of AEGR-733 in combination with a ω-3 fatty acid may include a dosage of about 2.5 mg/day to about 100 mg/day, e.g. 2.5 mg/day, 5 mg/day, 7.5 mg/day, 10 mg/day, 15 mg/day , 20 mg/day, 30 mg/day, or 50 mg/day or more of AEGR-733. In one embodiment, AEGR-733 is administered at about 10 mg/day. In some exemplary embodiments, the dosages of AEGR-733 may include lower dosages (e.g. about 2 to about 5 mg/day for one or more initial weeks of administration, and/or about 10 mg/day to about 50 mg/day for intermediate weeks of administration) but may be increased after such initial lower dosages up to doses of about 60 or 80 mg/day in combination with a ω-3 fatty acid. For some patient populations, e.g. those patients with HoFH, dosage regimens that include higher doses of AEGR-733 (such as about 50 mg/day to about 90 mg/day) administered in a regimen that included a first week or weekly administration of lower dosages in combination with ω-3 fatty acid may be necessary or useful. Because administration of ω-3 fatty acid with higher dosages of AEGR-773 (or other MTP inhibitor) may e.g., reduce the amount of hepatic fat formed when AEGR-773 is administered alone, patients (such as those with HoFH) may successfully tolerate such higher doses, using, for example, a dose-escalation regimen. [0052] In an exemplary dose escalation regimen, the first dose level of AEGR-733 may be from about 2 to about 13 mg/day, and/or the second dose level may be about 5 to about 30 mg/day.

[0053] In an exemplary protocol, AEGR-733 initially is administered at a first dosage in the range of 2.5 to 7.5 mg/day for at least 4 weeks, is then administered at a second dosage in the range of 5 to 10 mg/day for at least 4 weeks, and is then administered at a third dosage in the range of 7.5 to 12.5 mg/day for at least 4 weeks. Such dosage regimens may each be in combination with, e.g., a ω-3 fatty acid.

[0054] The first dosage of AEGR-733 can be for example 2.5 mg/day or 5 mg/day for about 4 weeks. The second dosage of AEGR-733 can be 7.5 mg/day for about 4 weeks. The third dosage of AEGR-733 can be 10 mg/day. In certain embodiments, the second dosage can be administered immediately following the first dosage, i.e., the second dosage is administered starting at five weeks from the initial first dosage. Similarly, in certain other embodiments, the third dosage of AEGR-733 can be administered immediately following the second dosage, e.g., the third dosage is administered at nine weeks from the initial first dosage. [0055] Optionally, the method may include administering a second, third, or fourth dosage period of AEGR-733 alone, or in combination with a ω-3 fatty acid. Such a fourth dosage may be in the range of 7.5-12.5 mg/day of AEGR-733 or more. A fourth dosage period may occur immediately after the second or third dosage, or may occur after a time interval, for example, a day, days, a week, or weeks after the third dosage. The fourth dosage may be administered to the subject for 1, 2, 3, 4 or more weeks.

Therapies Using Implitapide and a ω-3 fatty acid

[0056] In one aspect, the invention provides a method of reducing the concentration of cholesterol and/or triglycerides in the blood of a mammal comprising administering a combination of ω-3 fatty acid and implitapide to a patient. [0057] Implitapide may be administered at a dosage in the range of 0.01 to 60 mg/day, or in the range of 20 to 60 mg/day, for example, 20 mg/day, 25 mg/day, 30 mg/day, 35 mg/day, 40 mg/day, 60 mg/day, 80 mg/day, or more. In one embodiment, implitapide can be administered at about 20 mg/day to about 40 mg/day. A ω-3 fatty acid, for example, fish oil, can be coadministered with implitapide at a dose of about 1 g/day, 2 g/day, 3 g/day, 4 g/day, or 5 g/day. Formulation and Administration of the Active Ingredients

[0058] In certain embodiments, the MTP inhibitor (for example, AEGR-733 and implitapide) and the ω-3 fatty acid can be administrated orally. For oral administration, the active ingredients may take the form of solid dose forms, for example, tablets (both swallowable and chewable forms), capsules or gelcaps, prepared by conventional means with pharmaceutically acceptable excipients and carriers such as binding agents (e.g. pregelatinised maize starch, polyvinylpyrrolidone, hydroxypropylmethylcellulose and the like), fillers (e.g. lactose, microcrystalline cellulose, calcium phosphate and the like), lubricants (e.g. magnesium stearate, talc, silica and the like), disintegrating agents (e.g. potato starch, sodium starch glycollate and the like), wetting agents (e.g. sodium laurylsulphate) and the like. Such tablets may also be coated by methods well known in the art.

[0059] Alternatively, it is contemplated that the active ingredients may be formulated for, and administered by, parenteral routes, for example, by intravenous routes, intramuscular routes, and by absorption through mucous membranes. It is contemplated that such formulations and parenteral modes of administration are known in the art.

[0060] The dosages described above may be administered in single or divided dosages of one to four times daily. The MTP inhibitor and ω-3 fatty acid may be employed together in the same dosage form or in separate dosage forms taken at the same time, or at different times. [0061] The methods described herein are particularly useful for treating patients, for example, LDL reduction-resistant patients, patients unable to achieve the cholesterol and/or LDL cholesterol goals desired by their physicians and/or outlined by the NCEP guidelines. This inability may be due to an inability to tolerate an MTP inhibitor (e.g., AEGR-733 and implitapide) and/or a ω-3 fatty acid, or the inability of existing agents to provide sufficient cholesterol lowering to achieve these goals (for example, too much active ingredient is required achieve the desired end point). The methods described herein are especially useful for higher risk patients, for example, patients with coronary heart disease or with a similar risk of a coronary event. Such patients may have a 10 year risk of a coronary event of greater than 20%.

[0062] For example, the disclosed methods may be useful at treating LDL reduction- resistant patients, for example, patients with coronary heart disease or patients with severe hypercholesterolemia of any etiology unable to come within 25%, or 15%, of their NCEP LDL cholesterol goal on maximal tolerated oral therapy, as determined by their prescribing physician based upon established NCEP guidelines. In another embodiment, the methods may be used for the treatment of severe hypercholesterolemia of any etiology unable to come within 75 mg/dL of NCEP LDL cholesterol goal on maximal tolerated oral therapy. The methods disclosed herein may include patients with severe hypertriglyceridemia unable to reduce total triglyceride (Tg) levels to <1000 or <500 mg/dL on maximal tolerated therapy.

[0063] In another embodiment, patients who have demonstrated intolerance to statins may be treated using the disclosed methods. For example, such methods may be effective for a statin intolerant patient, for example, where the therapy has been discontinued by the patient' s physician and/or by the patient due to concern over an adverse event (for example, a liver function test abnormality, muscle aches and pains or inflammation such as myalgia or myostitis, and/or elevation in enzymes (CK) showing muscle adverse event).

[0064] In certain embodiments, the methods disclosed herein, may minimize at least one of side effects associated with the administration of AEGR-733 and/or implitapide. Such side effects include, for example, diarrhea, nausea, gastrointestinal disorders, steatorrhea, abdominal cramping, distention, elevated liver function tests such as increases in liver enzymes such as alanine, minor fatty liver; hepatic fat build up, hepatic steatotis, polyneuropathy, peripheral neuropathy, rhabdomyolysis, arthralgia, myalgia, chest pain, rhinitis, dizziness, arthritis, peripheral edema, gastroenteritis, liver function tests abnormal, colitis, rectal hemorrhage, esophagitis, eructation, stomatitis, biliary pain, cheilitis, duodenal ulcer, dysphagia, enteritis, melena, gum hemorrhage, stomach ulcer, tenesmus, ulcerative stomatitis, hepatitis, pancreatitis, cholestatic jaundice, paresthesia, amnesia, libido decreased, emotional lability, incoordination, torticollis, facial paralysis, hyperkinesia, depression, hypesthesia, hypertonia, leg cramps, bursitis, tenosynovitis, myasthenia, tendinous contracture, myositis, hyperglycemia, creatine phosphokinase increased, gout, weight gain, hypoglycemia, anaphylaxis, angioneurotic edema, and bullous rashes (including erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis). In some embodiments the minimization of the side effect is determined by assessing the grade, severity, extent, or duration by subject questionnaire.

EXAMPLES

[0065] The examples that follow are intended in no way to limit the scope of this invention but are provided to illustrate the methods present invention. Many other embodiments of this invention will be apparent to one skilled in the art.

Example 1 - AEGR-733 and Fish Oil Combination Therapy [0066] This study showed that AEGR-733 in combination with ω-3 fatty acid, provided significant reduction of hepatic triglyceride compared to AEGR-733 in combination with soybean oil. [0067] LDLR+/+ apobec-/-hApoB mice (University of Pennsylvania, Pennsylvania, U.S.A.) were fed a chow diet ad libitum. Mice were dosed by oral gavage for four successive days with four protocols: (i) a diet that included soybean oil (180 g) (Diet 1), (ii) a diet that included soybean oil (180 g) (Diet 1), and AEGR-733, (iii) a diet that includeds fish oil (158 g) (Diet 2), or (iv) a diet that included fish oil (158 g) (Diet 2), and AEGR-733, at about 9:00AM. Compositions of Diet 1 and Diet 2 are depicted in Figure 2. AEGR-733 was dissolved in M- pyrol and diluted to appropriate concentration in vehicle. Final vehicle composition was 10% M-pyrol, 80% water, 5% cremophore, and 5% ethanol. Dosing volume was 200 μl. The mice were euthanized approximately 6 hours after the last dose. Livers were perfused, excised, weighed, and frozen. A portion was used to determine hepatic triglyceride and cholesterol content. Figure 1 demonstrates that LDLR+/+ apobec-/-hApoB mice treated with AEGR-733 and fish oil showed significantly lower hepatic triglyceride levels compared to mice treated with AEGR-733 and soybean oil.

Example 2 - AEGR-733 and ω-3 Fatty Acid Combination Therapy [0068] This study is designed to show that doses of AEGR-733 significantly lower than 25 mg/day, in combination with ω-3 fatty acid, can provide clinically significant reductions in LDL-C while still providing an improved adverse event profile. The primary parameter of efficacy in this study will be the percentage change in LDL-C after 12 weeks of therapy.

[0069] Approximately 60 subjects will be randomized into one of three treatment arms with equal probability. The subjects will have a baseline LDL of 130-250 mg/dL and baseline triglyceride level of less than 400 mg/dL. In treatment arm 1, subjects will receive AEGR-733 (5 mg) plus ω-3 fatty acid placebo. In effect, treatment arm 1 represents monotherapy with AEGR-733. In treatment arm 2, subjects will receive AEGR-733 placebo plus ω-3 fatty acid (fish oil). In effect, treatment arm 2 represents monotherapy with ω-3 fatty acid. In treatment arm 3, subjects will receive AEGR-733 (5 mg) plus ω-3 fatty acid. Treatment arm 3 patients, in effect, will receive a combination therapy.

[0070] After 4 weeks of treatment, subjects in arms 1 and 3 will receive a step-up in concentration of AEGR-733 from 5 mg to 7.5 mg for 4 weeks. Thereafter, subjects in arms 1 and 3 then will receive a second step-up in concentration in AEGR-733 from 7.5mg to 10 mg for 4 more additional weeks of treatment. Subjects in arm 2 will continue to receive AEGR- 733 matching placebo for the entire 12 weeks of treatment. Subjects randomized to ω-3 fatty acid in arms 2 and 3 and ω-3 fatty acid placebo in arm 1 will remain on these doses for the entire 12- week treatment period.

[0071] Throughout the study, blood samples will be removed from each of the test patients for testing, for example, for testing the level of LDL-C, total cholesterol, triglycerides, HDL-C, Non-HDL-C, Apo B, and Apo Al in each patient. Changes in body weight of the subjects will be measured as part of vital signs collection.

References

[0072] All publications and patents mentioned herein, including those items listed below, are hereby incorporated by reference in their entirety as if each individual publication are patent was specifically and individually incorporated by reference. In case of conflict, the present application, including any definitions herein, will control.

EQUIVALENTS

[0073] It is understood that the disclosed invention is not limited to the particular methodology, protocols, and dosages described as these may vary. It is also to be understood that the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to limit the scope of the present invention which will be limited only by the appended claims.

[0074] What is claimed is:

Claims

1. A method of reducing the concentration of cholesterol and/or triglycerides in the blood of a mammal in need thereof, comprising administering to the mammal a combination of ω-3 fatty acid and a MTP inhibitor, wherein the method reduces the concentration of at least one of cholesterol or triglycerides in the blood but with a reduced incidence of an adverse event as compared to administration of the MTP inhibitor alone.

2. The method of claim 1, wherein the MTP inhibitor is N-(2,2,2-Trifluorethyl)-9-[4-[4- [ [[4'-(trifluoromethyl) [1,1 'biphenyl] -2- Yl] carbonyl] amino] - 1 -piperidinyl] butyl] 9H-fluorene-9- carboxamide or pharmaceutically acceptable salts thereof.

3. The method of claim 1, wherein the MTP inhibitor is implitapide or pharmaceutically acceptable salts thereof.

4. The method of claims 1 or 2, wherein the MTP inhibitor is administered at about 2.5 mg/day to about 50 mg/day.

5. The method of claim 4, wherein MTP inhibitor is administered at about 10 mg/day.

6. The method of claim 3, wherein the MTP inhibitor is administered at about 20 to 40 mg/day.

7. The method of any one of claims 1-6, wherein the ω-3 fatty acid and the compound are administered together in the same dosage form.

8. The method of any one of claims 1-6, wherein the ω-3 fatty acid and the compound are administered in separate dosage forms.

9. The method of any one of claims 1-8, wherein the mammal is a human.

10. The method of claim 9, wherein the human is a patient resistant to statin monotherapy.

11. The method of claim 9, wherein the human is a statin-intolerant patient.

12. The method of claim 9, wherein the human has at least one of: hyperlipidemia, hypercholesterolemia, hypertriglyceridemia, or hyperchylomicronemia.

13. The method of claim 9, wherein the hypercholesterolemia is homozygous or heterozygous familial hypercholesterolemia.

14. The method of any one of claims 1-13, wherein the ω-3 fatty acid is administered in the form of fish oil.

15. The method of any one of claims 1-14, wherein the adverse event is hepatic steatosis.

16. A method of reducing the amount of hepatic triglyceride in a patient receiving a MTP inhibitor, comprising co-administering the MTP inhibitor and a ω-3 fatty acid to the patient.

17. The method of claim 16, wherein the MTP inhibitor is N-(2,2,2-Trifluorethyl)-9-[4-[4- [ [[4'-(trifluoromethyl) [1,1 'biphenyl] -2- Yl] carbonyl] amino] - 1 -piperidinyl] butyl] 9H-fluorene-9- carboxamide or pharmaceutically acceptable salts thereof.

18. The method of claim 16, wherein the MTP inhibitor is implitapide or pharmaceutically acceptable salts thereof.

19. The method of claim 17, wherein the MTP inhibitor is administered at about 2.5 mg/day to about 50 mg/day.

20. The method of claim 18, wherein the MTP inhibitor is administered at about 20 to 40 mg/day.

21. The method of any one of claims 16-20, wherein the MTP inhibitor and fish oil are administered at least daily.

22. The method of any one of claims 16-21, wherein the amount of hepatic triglyceride in the patient' s liver after one month is less than about 20% of the amount of hepatic triglyceride in a patient's liver if the MTP inhibitor is administered alone.