WO2017147104A1 - Combinaisons d'antagoniste muscarinique m2 - Google Patents

Combinaisons d'antagoniste muscarinique m2 Download PDF

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WO2017147104A1
WO2017147104A1 PCT/US2017/018794 US2017018794W WO2017147104A1 WO 2017147104 A1 WO2017147104 A1 WO 2017147104A1 US 2017018794 W US2017018794 W US 2017018794W WO 2017147104 A1 WO2017147104 A1 WO 2017147104A1
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pharmaceutically acceptable
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hydrochloride
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PCT/US2017/018794
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Thomas N. Chase
Kathleen E. Clarence-Smith
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Chase Pharmaceuticals Corporation
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    • 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
    • A61K31/41—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having five-membered rings with two or more ring hetero atoms, at least one of which being nitrogen, e.g. tetrazole
    • A61K31/4164—1,3-Diazoles
    • A61K31/4178—1,3-Diazoles not condensed 1,3-diazoles and containing further heterocyclic rings, e.g. pilocarpine, nitrofurantoin
    • 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
    • A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
    • A61K31/47—Quinolines; Isoquinolines
    • A61K31/472—Non-condensed isoquinolines, e.g. papaverine
    • A61K31/4725—Non-condensed isoquinolines, e.g. papaverine containing further heterocyclic rings
    • 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
    • A61K31/55—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having seven-membered rings, e.g. azelastine, pentylenetetrazole
    • A61K31/551—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having seven-membered rings, e.g. azelastine, pentylenetetrazole having two nitrogen atoms, e.g. dilazep
    • A61K31/5513—1,4-Benzodiazepines, e.g. diazepam or clozapine
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
    • A61K45/06—Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca

Definitions

  • the invention pertains to the field of the treatment of hypocholinergic disorders of the central nervous system, in particular of Alzheimer's Disease (AD), Alzheimer type dementia, AD-type dementia, schizophrenia, schizophrenia associated dementia, Parkinson's dementia, Lewy body diseases, Down Syndrome, and chronic neuropathic pain.
  • the present invention is a new combination of a cholinergic M 2 -receptor antagonist agent, a non- anticholinergic antiemetic agent and a cholinergic receptor antagonist, which optionally further includes an acetylcholinesterase inhibitor.
  • the invention describes a combination of a selective-muscarinic M 2 - receptor antagonist that crosses the blood-brain barrier, herein below also referred to as "M 2 -antagonist” or “M2-antagonist”, an antiemetic agent, and a non-selective peripheral muscarinic receptor antagonist, herein below referred to as non-selective Peripheral Anti-Cholinergic Agent (“nsPAChA").
  • M 2 -antagonist or M2-antagonist
  • nsPAChA non-selective Peripheral Anti-Cholinergic Agent
  • This combination provides pro-cognitive activity by enabling safe administration of a M 2 -antagonist without inducing peripheral, dose-limiting adverse effects.
  • AD Alzheimer's disease
  • PNS Peripheral Nervous System
  • Ml through M5 Five subtypes of muscarinic receptors, Ml through M5, have been identified.
  • ACh refers to the neurotransmitter acetylcholine.
  • naAEA(s) non- anticholinergic Anti-Emetic Agent(s).
  • Non-anticholinergic refers to antiemetic medications not primarily regarded as anticholinergic agents; they are entirely devoid of anticholinergic activity or have an extremely low ability to prevent acetylcholine from acting at its cholinergic receptor sites.
  • nsPAChA(s) non-selective, peripheral Anticholinergic Agent(s) acting on the AChRs which are present in the PNS.
  • Non-selective refers to nsPAChAs, and applies to muscarinic anticholinergic agents exhibiting inhibitory activity on the mAChRs broadly across the various subtypes of muscarinic M-receptors, namely the M1-M5 receptors.
  • Selective refers to M 2 -antagonists, and applies to antagonists of the mAChR sharing an affinity for the M 2 receptor subtype higher than that for the Mi and M3-M5 receptor subtypes, i.e. a muscarinic antagonist having a ratio of (Ki for Mi and, respectively, M 3 -M 5 /Ki for M 2 ) greater than 1.
  • Peripheral refers to muscarinic anticholinergic agents and applies to anticholinergics that are largely unable (have a limited ability) to enter the central nervous system following systemic administration and thus do not affect brain function to a clinically appreciable degree.
  • These drugs can include both quaternary and tertiary ammonium anticholinergic agents, especially those having low lipid solubility.
  • Anticholinergic therapy the treatment with an anticholinergic agent of such medical conditions as gastro-intestinal cramping, nausea, retching, vomiting, fecal incontinence, bladder spasms, urinary incontinence, overactive bladder, asthma, motion sickness, muscular spasms, and smooth muscle contractive disorders; or the treatment, if any, with an anticholinergic agent of side effects caused by cholinergic receptor agonists, including, but not limited to gastro-intestinal cramping, nausea, retching, vomiting, fecal incontinence, bladder spasms, urinary incontinence, overactive bladder, asthma, motion sickness, muscular spasms, and smooth muscle contractive disorders.
  • “Hypocholinergic disorder” means a pathologic condition of the CNS due to or derived from a decrease in cholinergic transmission typically associated with events or diseases including but not limited to: Alzheimer disease, Alzheimer- type dementia, mild cognitive impairment, Lewy body disease dementia, Parkinson's disease dementia, post-stroke dementia, vascular dementia, traumatic brain injury, Down syndrome, anorexia nervosa, Tourette disease, tardive dyskinesia, Pick's disease, Huntington's chorea, Friedrich's ataxia, chronic neuropathic pain, falls, post-operative delirium, schizophrenia, schizophrenia associated dementia, and schizoaffective disorders.
  • “CSF” Cerebrospinal Fluid.
  • Extended Release including sustained release, controlled release and slow release of the active ingredient from a composition by any administration route, in particular, but not limited to oral and parenteral (including transcutaneous, transdermal, intramuscular, intravenous, and subcutaneous) routes.
  • Transdermal delivery administration of drug via the skin which targets, without limitation, skin tissues just under the skin, other tissues or organs under the skin, systemic circulation, and/or the central nervous system.
  • Transdermal Therapeutic System administration of drug via transdermal delivery using transdermal drug formulations and transdermal patches incorporating such transdermal drug formulations.
  • maximum tolerated dose refers to the highest dose of a drug or treatment that does not cause unacceptable side effects.
  • the maximum tolerated dose is determined in clinical trials by testing increasing doses on different groups of people until the highest dose with acceptable side effects is found, "comprising” means that the compositions and methods include the recited elements, but do not exclude others, “comprising” is inclusive of the terms “consisting of” and “consisting essentially of”.
  • compositions may include additional steps, components or ingredients, but only if the additional steps, components or ingredients do not materially alter the basic and novel characteristics of the claimed methods and compositions.
  • consisting essentially of means that the subsequently named component(s) is necessarily included but that another unlisted ingredient(s) that does not materially affect the basic and novel properties can also be present.
  • consisting essentially of means excluding other elements of any essential significance to the combination for the intended use.
  • a composition consisting essentially of the elements as defined herein would not exclude trace contaminants and pharmaceutically acceptable carriers,
  • “and/or” is used herein to mean both “and” as well as “or”.
  • pharmaceutically acceptable salt means either a pharmaceutically acceptable acid addition salt or a pharmaceutically acceptable base addition salt of a currently disclosed compound that may be administered without any resultant substantial undesirable biological effect(s) or any resultant deleterious interaction(s) with any other component of a pharmaceutical composition in which it may be contained.
  • Combination therapy means treating a patient with a combination of a selective- muscarinic M 2 -receptor antagonist that crosses the blood-brain barrier, with a non- anticholinergic antiemetic agent and/or a non-selective peripheral muscarinic receptor antagonist, and optionally further including an acetylcholinesterase inhibitor, as a therapeutic platform in a rotating, an alternating and/or a simultaneous treatment schedule or regimen.
  • Combination therapy may include a temporal overlap of other therapeutic agents, depending on the clinical course of a given hypocholinergic disease in a subject.
  • Acetylcholinesterase inhibitors currently constitute the major drug class used to treat AD type dementias. Medications of this type serve not only as part of the standard of care for patients suffering from a dementia of the AD type, but are also used off-label for various other, generally chronic and progressive, hypocholinergic CNS disorders.
  • AChEIs have the enhancement of ACh-mediated neurotransmission as a general mechanism of action. All work to increase the availability of ACh in the brain by inhibiting its degradatory enzyme, acetylcholinesterase. Four AChEIs have been approved by the U.S. F.D.A.
  • Rivastigmine has also been approved for the treatment of Parkinson's disease dementia.
  • AChEIs are available in various formulations including immediate release forms such as tablets, capsules and solutions as well as rapid dissolving and extended release forms for oral administration as well as those for parenteral (e.g. transdermal) administration.
  • AD type dementias Unfortunately, none of the AChEIs approved for use for AD type dementias provides more than modest symptomatic benefit to any of these disorders. A critical medical need thus exists to improve the efficacy of these cholinergic replacement therapies.
  • Postsynaptic muscarinic receptor agonists especially those selective for the Mi receptor, have been reported to benefit cognitive and behavioral dysfunction in animal models and in human patients with AD type dementia (Bodick NC et al. 1997; Fisher A et al. 2003; the disclosures of which are incorporated herein in their entirety by reference).
  • Positive allosteric modulators of the Mi muscarinic receptor have also been associated with improved cognitive and behavioral disturbances in AD models (Melancon BJ et al. 2013; the disclosure of which is incorporated herein in its entirety by reference).
  • muscarinic receptor agonists relatively selective for the Mi subtype have been reported to improve cognitive disturbances associated with disorders such as schizophrenia, Traumatic Brain Injury (TBI), and Downe Syndrome (DS), albeit with generally meager efficacy and a high incidence of cholinergic adverse events that preclude further increases in the muscarinic cholinergic receptor agonist doses.
  • M 2 muscarinic receptors are generously expressed on the presynaptic terminals of cholinergic neurons projecting to the hippocampus and cerebral cortex as well as in most other brain regions involved in learning and memory (Alcantara AA et al. 2001; and Rouse ST et al.; the disclosures of which are incorporated herein in their entirety by reference).
  • these autoreceptors act to inhibit further ACh synthesis and release, thus attenuating cholinergic transmission (Tzavara ET, et al.
  • M 2 receptor knockout mice showed an impaired performance in passive avoidance testing that suggests a crucial role for these muscarinic receptors in the regulation not only of acetylcholine efflux but also of cognitive function (Tzavara ET et al., cited above, 2003).
  • drugs that block M 2 receptors increase ACh release and stimulate cholinergic transmission.
  • M 2 muscarinic receptor antagonists have been proposed as a potential cholinomimetic treatment of AD type dementia (Stoll C et al. 2009; the disclosure of which is incorporated herein in its entirety by reference).
  • BIBN-99 also improves scopolamine-induced amnesia in young animals (Quirion R et al. 1995; the disclosure of which is incorporated herein in its entirety by reference). In traumatic brain-injured rats, BIBN 99 has been found to attenuate cognitive deficits (Pike BR et al. 1995; the disclosure of which is incorporated herein in its entirety by reference). The efficacy of BIBN-99 in these studies is presumed to relate to its antagonistic properties on negative muscarinic M 2 autoreceptors. Taken together, the forgoing observations could have implications for the treatment of degenerative disorders associated with impaired cholinergic function such as the AD type dementias (Rowe WB et al. 2003; the disclosure of which is incorporated herein in its entirety by reference).
  • Piperazine, piperazinyl-piperidine and piperidinyl-piperidine derivatives form a series of muscarinic M2-antagonists studied for their pro-cognitive properties.
  • the muscarinic M 2 receptor antagonist 4-cyclohexyl-alpha-[4[[4- methoxyphenyl]sulphinyl] -phenyl] -1-piperazineacetonitrile (SCH 57790) produces a dose-related increase in brain acetylcholine release and enhances cognitive performance in rodents and nonhuman primates, effects that were qualitatively similar to those produced by the AChEI donepezil.
  • the forgoing results support the view that blockade of muscarinic M 2 receptors is a viable approach to enhancing cognitive performance (Carey GJ et al. 2001; the disclosure of which is incorporated herein in its entirety by reference).
  • the piperidinyl-piperidine derivative SCH-217443 a potent and selective M 2 antagonist, also shows activity in a rat model of cognition (Greenlee W et al. 2001; the disclosure of which is incorporated herein in its entirety by reference).
  • Methoctramine N,N'-bis[6-[([2-methoxyphenyl)methyl]amino]hexyl]-l,8- octanediamine (see Melchiorre 1987), acts as a muscarinic antagonist that binds preferently to the pre- synaptic M 2 receptor.
  • the bilateral intrastriatal infusion of methoctramine improves procedural memory performance presumably by enhancing the release of ACh (Lazaris A et al. 2003; the disclosure of which is incorporated herein in its entirety by reference).
  • drugs identified as having relatively selective M 2 muscarinic receptor antagonist activity but receiving little or no investigative attention in preclinical cognitive models, include: otenzepad (AF-DX 116 - see Engel 1989), its (+)- enantiomer (AF-DX 250) and its analog AF-DX 384, (+)-5,l l-dihydro-l l-([(2- [(dipropylamino)methyl]-l-piperidinyl)ethyl)amino]carbonyl)-6H-pyrido(2,3- b)(l,4)benzodiazepine-6-one; caproctamine; and benextramine.
  • otenzepad AF-DX 116 - see Engel 1989
  • (+)- enantiomer AF-DX 250
  • analog AF-DX 384 (+)-5,l l-dihydro-l l-([(2- [(dipropylamino)methyl]-l-piperid
  • - may be orally administered to a human being at a dose ofl20 mg bid or 240 mg bid;
  • Dimethindene also known as dimetindene (trade name Fenistil)
  • dimetindene (trade name Fenistil)
  • CAS 0005636-83-9 N,N-Dimethyl-3- [l-(2-pyridinyl)ethyl]-lH-indene-2-ethanamine, CAS 0005636-83-9. It can be prepared as described by Huebner et al, in US 2,970, 149, which also describes the optically active form of 2-(2-dimethylamino-ethyl))-3-[l-(2-pyridyl)-ethyl]-indene with an [a] D 25° of +70, or in J Am Chem Soc (I960), Vol.
  • Dimet(h)indene is sold OTC in a number of countries worldwide as orally or locally administered antipruritic. Fenistil for oral administration is available for example in IR coated tablets containing 1 mg dime(h)tindene or in ER unit forms containing 4 mg dimet(h)indene and the daily recommended dose is from 3 to 6 mg.
  • the (£)-(+)- dimethindene N,N-Dimethyl-3-[(lS)-l-(2-pyridinyl)ethyl]- lH-indene-2-ethanamine, is a potent M 2 -selective muscarinic receptor antagonist (Pfaff et al. 1995; the disclosure of which is incorporated herein in its entirety by reference).
  • the (R)-(-)- enantiomer is the eutomer (responsible for bioactivity) for histamine Hi receptor binding (Histamine Hi-receptor antagonist).
  • Binding selectivity results indicate that it binds to the muscarinic M 2 receptor with a Ki value of 0.27 +/- 0.02 nM (Maggio R et al. 1994; the disclosure of which is incorporated herein in its entirety by reference).
  • Tripitramine can be prepared as described by Melchiorre et al. 1993; the disclosure of which is incorporated herein in its entirety by reference).
  • WO0000488 discloses di-N-substituted piperazines and 1,4-di-substituted piperidines linked to a pyridine, pyrazine or tiophene group via a substituted methyl group. These compounds are muscarinic agonists useful in the treatment of cognitive disorders, pharmaceutical compositions containing the compounds, methods of treatment using the compounds, and to the use of said compounds in combination with acetylcholinesterase inhibitors.
  • a selective M 2 receptor antagonist with a bipiperidine moiety, showing superior M 2 receptor selectivity profile over SCH 211803, is "Compound 30" of formula
  • US6,906,081 (Hey et al. - see also WO02/072093), the disclosure of which is incorporated herein in its entirety by reference, discloses the use of a dual histamine H3 receptor antagonist/M 2 muscarinic antagonist, or a combination of an histamine H3 receptor antagonist with a M 2 muscarinic antagonist, for the treatment of cognition deficit disorders, in particular Alzheimer's type dementia.
  • This document also discloses said dual 5HT3-antagonist/M 2 -antagonist medicament used in combination with an AChEI.
  • WO 03/031412 Wang et al.
  • An improvement in the treatment of the cognitive disorders globally designated as dementias of Alzheimer's type is possible by combining an AChEI with a nsPAChA (US 8,404,701, the disclosure of which is incorporated herein in its entirety by reference) or with a non- anticholinergic antiemetic agent (US 8,877,768, the disclosure of which is incorporated herein in its entirety by reference).
  • WO 2014/039627 discloses combining an AChEI with a nsPAChA and, optionally, an antiemetic agent.
  • the present inventors recognized the critical need to take advantage of the potent activity of a M 2 muscarinic antagonist for the treatment of AD type dementia, schizophrenia, and schizophrenia associated dementia, as well as CNS hypocholinergic disorders including, but not limited to, AD, AD-type dementia, Mild Cognitive Impairment (MCI), Lewy Body Disease dementia (LBD), Frontotemporal degenerations, Parkinson disease dementia (PDD), post-stroke dementia, vascular dementia, Traumatic Brain Injury, Anorexia Nervosa, Down syndrome, Tourette disease, tardive dyskinesia, Pick's disease, Huntington's chorea, Friedrich's ataxia, falls, post-operative delirium, schizoaffective disorders and schizophrenia.
  • the present invention relates to a pharmaceutical combination comprising:
  • a muscarinic receptor antagonist selected from the group consisting of a centrally active, selective M 2 -muscarinic cholinergic receptor antagonists (M 2 -antagonist);
  • naAEA non-anticholinergic antiemetic agent
  • a muscarinic receptor antagonist selected from the group consisting of nonselective, peripheral anticholinergic agents (nsPAChAs); and, optionally,
  • the present inventors found that, in order to assure a safe treatment of hypocholinergic disorders and a sure synergy with the third component of the combination, i.e. the nsPAChA Component (c), the non-anticholinergic antiemetic agent Component (b) must be administered concurrently with the M 2 -antagonist Component (a) just from the beginning of the therapeutic treatment of a patient submitted to this cholinergic treatment for the first time.
  • the invention provides a combination wherein said naAEA Component (b) and said M 2 -antagonist Component (a) are present in a fixed-dose combination as a pharmaceutical composition in dosage unit form comprising said naAEA and said M 2 -antagonist in admixture with a pharmaceutical carrier, to be administered in combination with the nsPAChA Component (c).
  • the M 2 -antagonist/naAEA fixed-dose combination will also be referred to as "Component (a/b)".
  • the invention also provides the above triple combination wherein the naAEA Component (b) and the nsPAChA Component (c) are present in a fixed-dose combination as a pharmaceutical composition in dosage unit form comprising said naAEA and said nsPAChA in admixture with a pharmaceutical carrier or vehicle, to be administered in combination with the M 2 -antagonist Component (a).
  • said naAEA/nsPAChA fixed-dose combination will also be referred to as "Component (b/c)"
  • the invention also provides the above triple combination wherein the M 2 -antagonist Component (a) and the nsPAChA Component (c) are present in a fixed-dose combination as a pharmaceutical composition in dosage unit form comprising said M 2 -antagonist and said nsPAChA in admixture with a pharmaceutical carrier or vehicle, to be administered in combination with the nsPAChA Component (c).
  • said M 2 -antagonist/nsPAChA fixed-dose combination will also be referred to as "Component (a/c)".
  • the combination of the present invention may further include a Component (d) an acetylcholinesterase inhibitor (AChEI).
  • the combination of the present invention allows the administration of a M 2 - antagonist at even high doses, never previously administered to a human being, without any sign of adverse effects thus, on one side, eliminating the dose-limit that heretofore did not permit the full expression of the M 2 -antagonists' potency and, on the other side, allowing the treatment with said M 2 -antagonists of patients suffering from hypocholinergic disorders such as Alzheimer type dementia.
  • the present invention provides a combination of a M 2 -antagonist, a non- anticholinergic antiemetic agent, a non- selective, peripheral anticholinergic agent, and, optionally, an acetylcholinesterase inhibitor for use in the treatment of a hypocholinergic disorder.
  • the present invention also relates to a method of treating a hypocholinergic disorder comprising administering a pharmaceutical combination as described herein, to a mammalian subject in need thereof.
  • the method or the use according to the present invention involves administering to a patient in need thereof, an effective dose of a M 2 -antagonist, in combination with a non-anticholinergic antiemetic agent (naAEA) and a non-selective, peripheral muscarinic anticholinergic agent (nsPAChA).
  • naAEA non-anticholinergic antiemetic agent
  • nsPAChA non-selective, peripheral muscarinic anticholinergic agent
  • the hypocholinergic disorder is selected from the group consisting of schizophrenia, schizophrenia associated dementia, and schizoaffective disorders.
  • the hypocholinergic disorder is Alzheimer type dementia.
  • acetylcholine reduces levels of neurotransmitters including acetylcholine occur in dementias such as the Alzheimer disease (AD) type, and reduced cholinergic transmission is thought to attend the cognitive deficits observed in schizophrenia, and schizophrenia associated dementia.
  • AD Alzheimer disease
  • ACh acetylcholine
  • drugs known to augment cholinergic transmission in the Central Nervous System (CNS) are the mainstay of current therapy.
  • other diseases of the nervous system also involve decreased cholinergic transmission and are also known as hypocholinergic syndromes and disorders of the central nervous system, herein above referred to as "hypocholinergic disorders”.
  • the present invention provides a combination of two muscarinic antagonists with different targets, and a non-anticholinergic antiemetic agent.
  • the present invention provides a treatment based on selective M 2 antagonism at doses that could not previously be achieved due to adverse effects.
  • selective M 2 muscarinic antagonists to treat hypocholinergic disorders of the CNS such as dementia of the AD type and schizophrenia or schizophrenia associated dementia.
  • a major deterrent to such clinical investigations, as described above, is that treatment with muscarinic agonists and/or antagonists has been limited by dose-limiting side effects, especially those reflecting hyperstimulation of peripheral muscarinic receptors.
  • M 2 antagonists do not mention a possible combination of M 2 antagonists with non-selective peripheral muscarinic antagonists (nsPAChAs) and/or non- anticholinergic antiemetic agents, nor do they mention that the administration of such a combination can enable the safe and tolerable administration of doses of M 2 -antagonists capable of further potentiating central cholinergic transmission so as to achieve efficacy in those suffering from hypocholinergic disorders, such as AD type dementias and schizophrenia or schizophrenia associated dementia, as provided in the present invention.
  • nsPAChAs non-selective peripheral muscarinic antagonists
  • the present invention provides the combination of a centrally acting, selective muscarinic-M 2 -antagonist drug, a non- selective, peripheral-muscarinic- antagonist drug (nsPAChA) and a non- anticholinergic antiemetic agent for the safe treatment of hypocholinergic disorders such as Alzheimer, dementia of Alzheimer type, schizophrenia, schizohrenia associated dementia, and other hypocholinergic type cognitive or behavioral disorders.
  • nsPAChA non- selective, peripheral-muscarinic- antagonist drug
  • the muscarinic-M 2 -antagonist in combination with a nsPAChA and a non- anticholinergic antiemetic agent provides pro-cognitive properties for the treatment of such disorders without appreciable involvement of the PNS.
  • the present invention thus enables the heretofore inapplicable, safe and tolerable use of a presynaptic M 2 muscarinic receptor antagonist in the treatment of hypocholinergic disorders such as Alzheimer, dementia of Alzheimer type, schizophrenia, schizophrenia associated dementia, and other hypocholinergic type cognitive or behavioral disorders, such as those described above, by combining said M 2 - antagonist with a nsPAChA and a non-anticholinergic antiemetic agent.
  • M 2 -antagonists This unlikely combination of two muscarinic antagonists and a non-anticholinergic antiemetic agent, allows M 2 -antagonists to be safely used at doses higher than those reportedly tolerated in clinical studies, in order to allow therapeutically adequate blockade of M 2 -receptors in the CNS with attending safe increase in acetylcholine presynaptic release.
  • a combination of M 2 - antagonists with a nsPAChA and a non-anticholinergic antiemetic agent surprisingly acts synergistically to attenuate the dose-limiting side effects of M 2 -antagonists; thus enabling a greater increase in the MTD of M 2 -antagonists and enabling full efficacy or greater efficacy for the treatment of hypocholinergic disorders of the brain, notably AD, AD type dementia, schizophrenia, and schizophrenia associated dementia.
  • a combination of M 2 -antagonists with a nsPAChA and an antiemetic agent allows for the safe administration of M 2 -antagonists at doses never safely attained heretofore.
  • a nsPAChA and an antiemetic agent when concurrently or sequentially administered in combination with a M 2 -antagonist, is able not only to neutralize the dose-limiting adverse effects that hindered the development of a M 2 -antagonist for the treatment of central disorders due to a deficit of acetylcholine in the brain, but also to increase the supply of ACh at the cholinergic synapse in the CNS and thus increase cholinergic transmission in the CNS.
  • a nsPAChA and an antiemetic agent in combination with a M 2 - antagonist that acts both centrally (in the brain) and peripherally (outside the brain) enables the safe administration of a M 2 -antagonist at previously intolerable doses or at even higher doses for the treatment of a patient suffering from hypocholinergic disorders of the central nervous system, including but not limited to, AD, AD-type dementia, schizophrenia, schizophreniform conditions, schizophrenia associated dementia, schizoaffective disorders, Mild Cognitive Impairment (MCI), Lewy Body Disease dementia (LBD), Frontotemporal degeneration, Parkinson disease dementia (PDD), post-stroke dementia, vascular dementia, Traumatic Brain Injury, Anorexia Nervosa, Down syndrome, Tourette syndrome, tardive dyskinesia, Pick's disease, Huntington's chorea, Friedrich's ataxia, and falls.
  • a combination as described herein allows aan M 2 -antagonist to safely increase the acetylcholine presyn
  • the present invention eliminates the dose-limit that, in the past, caused the failure of all clinical trials to demonstrate efficacy, thus providing a method for treating Alzheimer type dementia as well as central hypocholinergic disorders of the CNS by enabling the full efficacy of M 2 -antagonists.
  • the present invention provides a composition useful for treating a patient with a hypocholinergic disorder as described herein, which comprises a nsPAChA and a non- anticholinergic antiemetic agent, in combination with a M 2 -antagonist.
  • a composition useful for treating a patient with a hypocholinergic disorder as described herein which comprises a nsPAChA and a non- anticholinergic antiemetic agent, in combination with a M 2 -antagonist.
  • the dose of nsPAChA is at a dose higher than that used in anticholinergic therapy.
  • the present invention provides said pharmaceutical combination or composition conprising a M 2 -antagonist, a nAEA and a nsPAChA for use for combating a hypocholinergic disorder in a patient.
  • the present invention also provides the addition of an AChEI to the above combination, thus assuring a maximum supply of acetylcholine to the CNS by the administration of a quadruple combination.
  • the present invention provides a method of treating a patient with a hypocholinergic disorder of the CNS as described herein, which comprises treating a patient in need of treatment with a nsPAChA and a non-anticholinergic antiemetic agent, in combination with a M 2 -antagonist.
  • This treatment method precludes the onset of M 2 -antagonist-associated peripheral dose-limiting adverse effects as well as the onset of nsPAChA central adverse effects.
  • the method of the present invention may further include administration of an AChEI.
  • the present invention provides a pharmaceutical combination comprising, as Components:
  • a muscarinic receptor antagonist selected from the group consisting of M 2 - muscarinic cholinergic receptor antagonists (M 2 -antagonists);
  • nAEA nonselective, peripheral anticholinergic agents
  • the combination of the present invention may further comprise a component (d) an AChEI.
  • the present invention also provides a combination consisting essentially of:
  • M2-muscarinic cholinergic receptor antagonist (a) a M2-muscarinic cholinergic receptor antagonist (M 2 -antagonist);
  • naAEA non-anticholinergic antiemetic agent
  • nsPAChA a non-selective peripheral anticholinergic agent
  • such a combination of the present invention may further comprise as a component (d) an AChEI.
  • said pharmaceutical combination comprises, as Components:
  • said pharmaceutical combination comprises, as Components:
  • nsPAChA selected from the group consisting of oxybutynin and pharmaceutically acceptable salts thereof, in a pharmaceutical composition consisting of a TTS- oxybutynin, in admixture with a pharmaceutical carrier.
  • said pharmaceutical combination comprises as Components:
  • composition in dosage unit form comprising
  • nsPAChA selected from the group consisting of oxybutynin and pharmaceutically acceptable salts thereof, in a pharmaceutical composition consisting of TTS, in admixture with a pharmaceutical carrier.
  • a preferrd pharmaceutical combination comprises
  • a M 2 -antagonist selected from the group consisting of alvameline and pharmaceutically acceptable salts thereof, in a pharmaceutical composition in admixture with a pharmaceutical carrier;
  • nAEA selected from the group consisting of ondansetron and pharmaceuticaslly acceptable salts and solvates thereof, domperidone and pharmaceutically acceptable salts and solvates thereof and metoclopramide and pharmaceutically acceptable salts and solvates thereof, in a pharmaceutical composition in admixture with a pharmaceutical carrier;
  • nsPAChA consisting of oxybutynin and pharmaceutically acceptable salts thereof, in a TTS in admixture with a pharmaceutical carrier, said TTS being a transdermal patch.
  • the present invention provides a method of using the above combinations for the treatment of hypocholinergic disorders in CNS, as described herein.
  • the present invention provides a method of treating schizophrenia, schizophrenia associated dementia, or schizoaffective disorders comprising administering to a mammalian, preferably human, subject in need thereof, a combination comprising:
  • M 2 -muscarinic cholinergic receptor antagonist (a) a M 2 -muscarinic cholinergic receptor antagonist (M 2 -antagonist);
  • naAEA non-anticholinergic antiemetic agent
  • nsPAChA a non-selective peripheral anticholinergic agent
  • the method of treating schizophrenia, schizophrenia associated dementia, or schizoaffective disorders of the present invention may further comprise administering as a component (d) an AChEI.
  • the present invention provides a method of treating AD or AD type dementia comprising administering to a mammalian subject, preferably a human, in need thereof, a combination comprising:
  • M 2 -muscarinic cholinergic receptor antagonist (a) a M 2 -muscarinic cholinergic receptor antagonist (M 2 -antagonist);
  • naAEA non-anticholinergic antiemetic agent
  • nsPAChA non-selective peripheral anticholinergic agent
  • the method of treating AD or AD type dementia of the present invention may further comprise administering as a Component
  • the present invention also provides a combination as described herein wherein
  • Components (b) and (c) are formulated in the same unit form.
  • a further AChEI Component (d) may be formulated in the same unit form.
  • the present invention also provides a combination as described herein wherein said Components (a) and (b) are formulated in the same unit form. In another embodiment, a further Component (d) may be formulated in the same unit form.
  • the present invention also provides a combination as described herein as a fixed-dose combination wherein Components (a), (b) and (c) are formulated in the same unit form.
  • Components (a), (b) and (c) are formulated in the same unit form.
  • a further AChEI Component (d) may be formulated in the same unit form as Components (a), (b) and (c).
  • the M 2 -antagonist Component (a), in admixture with a pharmaceutical carrier or vehicle may be combined with a fixed-dose Combination (b/c) essentially consisting of a pharmaceutical composition in dosage unit form comprising the naAEA Component (b) and the nsPAChA Component (c), in admixture with a pharmaceutical carrier or vehicle;
  • naAEA Component (b) in admixture with a pharmaceutical carrier or vehuicle, may be combined with a fixed-dose Combination (a/c) essentially consisting of a pharmaceutical composition in dosage unit form comprising the M 2 -antagonist Component (a) and the nsPAChA Component (c), in admixture with a pharmaceutical carrier or vehicle; and
  • nsPAChA Component (c) in admixture with a pharmaceutical carrier or vehuicle, may be combined with a fixed-dose Combination (a/b) essentially consisting of a pharmaceutical composition in dosage unit form comprising the M 2 -antagonist Component (a) and the naAEA Component (b), in admixture with a pharmaceutical carrier or vehicle
  • said Component (d) may be also present in a fixed-dose combination Component (b/d) in admixture with the naAEA Component (b) and with a pharmaceutical carrier or vehicle, as illustrated in US 9.192,591, the contents of which are incorporated herein by reference in their entirety; or in a fixed-dose combination Component (c/d), in admixture with the nsPAChA Component (c) and with a pharmaceutical carrier or vehicle, as illustrated in US 8,404,701, the contents of which are incorporated herein in their entirety.
  • kits comprising a combination selected from the group consisting of
  • a combination comprising: (a) a M 2 -antagonist in a pharmaceutical composition in a dosage unit form wherein said M 2 -antagonist is in admixture with a pharmaceutical carrier; and (b/c) a fixed-dose combination comprising a nAEA and a nsPAChA in a dosage unit form wherein said combination is in admixture with a pharmaceutical carrier or vehicle;
  • a combination comprising (a/b) a fixed-dose combination comprising a M 2 - antagonist and a nAEA in a dosage unit form wherein said combination is in admixture with a pharmaceutical carrier or vehicle; and (c) a nsPAChA in a pharmaceutical composition in a dosage unit form wherein said nsPAChA is in admixture with a pharmaceutical carrier or vehicle;
  • a combination comprising (a/c) a fixed-dose combination comprising a M 2 - antagonist and a nsPAChA in a dosage unit form wherein said combination is in admixture with a pharmaceutical carrier or vehicle; and (b) a naAEA in a pharmaceutical composition in a dosage unit form wherein said naAEA is in admixture with a pharmaceutical carrier or vehicle;
  • a combination comprising: (a) a M 2 -antagonist in a pharmaceutical composition in dosage unit form wherein said M 2 -antagonist is in admixture with a pharmaceutical carrier; (b) a nAEA in a pharmaceutical composition in dosage unit form wherein said naAEA is in admixture with a pharmaceutical carrier or vehicle; and (c) a nsPAChA in a pharmaceutical composition in a dosage unit form wherein said nsPAChA is in admixture with a pharmaceutical carrier or vehicle;
  • - a combination comprising (a) a M 2 -antagonist in a pharmaceutical composition in a dosage unit form wherein said M 2 -antagonist is in admixture with a pharmaceutical carrier or vehicle; and (b/c/d) a fixed-dose combination comprising a nsPAChA, a nAEA, and an AChEI in a dosage unit form wherein said combination is in admixture with a pharmaceutical carrier or vehicle; - a combination comprising (a/b/d) a fixed-dose combination comprising a M 2 - antagonist, a nAEA, and an AChEI in a dosage unit form wherein said combination is in admixture with a pharmaceutical carrier or vehicle; and (c) a nsPAChA in a pharmaceutical composition in a dosage unit form wherein said nsPAChA is in admixture with a pharmaceutical carrier or vehicle;
  • a combination comprising (a/c/d) a fixed-dose combination comprising a M 2 - antagonist, a nsPAChA, and an AChEI in a dosage unit form wherein said combination is in admixture with a pharmaceutical carrier or vehicle; and (b) a naAEA in a pharmaceutical composition in a dosage unit form wherein said naAEA is in admixture with a pharmaceutical carrier or vehicle;
  • a combination comprising (a/b/c) a fixed dose combination comprising a M 2 - antagonist, a nsPAChA, and a nAEA in a dosage unit form wherein said combination is in admixture with a pharmaceutical carrier or vehicle; and (d) an AChEI in a pharmaceutical composition in a dosage unit form wherein said AChEI is in admixture with a pharmaceutical carrier or vehicle; and
  • a combination comprising (a) a M 2 -antagonist in a pharmaceutical composition in dosage unit form wherein said M 2 -antagonist is in admixture with a pharmaceutical carrier or vehicle; (b) a nAEA in a pharmaceutical composition in a dosage unit form wherein naAEAis in admixture with a pharmaceutical carrier or vehicle; (c) a nsPAChA in a pharmaceutical composition in a dosage unit form wherein said nsPAChA is in admixture with a pharmaceutical carrier or vehicle; and (d) an AChEI in a pharmaceutical composition in a dosage unit form wherein said AChEI is in admixture with a pharmaceutical carrier or vehicle.
  • the fixed-dose Combination (a/b) consisting of a pharmaceutical composition comprising a M 2 -antagonist and a naAEA in a dosage unit form wherein said combination is in admixture with a pharmaceutical carrier is a novel entity that is a further object of the present invention.
  • the kit which may also contain an AChEI as described herein, can simplify the administration of the combination of the present invention to patients suffering from hypocholinergic disorders of the CNS, who are often not sufficiently able to manage multiple packages.
  • the finding of the present invention represents surprising and unexpected progress in the treatment of hypocholinergic disorders, especially in view of the lack of efficacy of M 2 -antagonists at doses previously administered to human beings, and of the intolerable adverse effects induced by said antagonists at the administered doses.
  • a nsPAChA and a nAEA when concurrently or sequentially administered in combination with a M 2 muscarinic antagonist allows for the safe administration of a M 2 antagonist, at high doses or at doses at or above the maximally tolerated dose of the M 2 -antagonist administered alone, thus, in case of a patient suffering from a hypocholinergic disorder as defined herein, allowing said M 2 muscarinic antagonist to more safely activate brain cholinergic receptors and to better improve the cognitive response or increase the therapeutic efficacy of said M 2 muscarinic antagonist for treating the hypocholinergic disorder.
  • M 2 antagonists while relatively promising in animal models, were poorly tolerated in humans and long abandoned. In the sole case of a trial for evaluating the possibility of improving the cognition of patients with a probable Alzheimer disease, the involved product was inefficacious and might even have worsened the cognition in said patients. In addition, because M 2 muscarinic receptor antagonists caused intolerable adverse effects in the tolerability tests in humans, further studies of these products were discouraged.
  • the present inventors found that the administration of a M 2 muscarinic receptor antagonist concurrently with a nsPAChA and an antiemetic agent substantially attenuates dose-limiting adverse effect not only at the M 2 muscarinic antagonist doses that have been administered to a human, but also at higher doses which were intolerable for said human.
  • this combination provides successful treatment of herein above defined hypocholinergic disorders such as Alzheimer type dementias, schizophrenia, schizophrenia associated dementia, and schio affective disorders, thus allowing said treatment at doses that previously produced dose limiting adverse reactions and even allowing treatment at doses higher than those that caused intolerable dose-limiting adverse events.
  • the adverse reactions are due exclusively or largely exclusively, to over-stimulation of peripheral cholinergic receptors of the muscarinic type. This is particularly true of the M 2 -antagonists, and is a major reason why the present inventors believe development of such drugs has long stagnated.
  • M 2 antagonists can be achieved for treatment of hypocholinergic disorders, such as dementias of the Alzheimer type, in a patient suffering from said disorder, by administering a combination of a M 2 antagonist, a nAEA and an nsPAChA as described herein.
  • the present invention also provides a pharmaceutical combination comprising as Components:
  • a muscarinic receptor antagonist selected from the group consisting of M 2 - muscarinic cholinergic receptor antagonists (M 2 -antagonist);
  • a muscarinic receptor antagonist selected from the group consisting of the nonselective, peripheral anticholinergic agents (nsPAChAs); and
  • This quadruple combination may be used for the treatment of hypocholinergic disorders as herein above defined.
  • Any M 2 -antagonist which is able to cross the brain blood barrier of a human in order to block the presynaptic muscarinic M 2 -receptor thus allowing the increase of acetylcholine transmission in the CNS may be used as Component (a) according to the present invention.
  • the M 2 -antagonists used as Component (a) are muscarinic receptor antagonists that are selective - as herein above defined - for the M 2 -receptor subtype.
  • Preferred Component (a) is a M 2 -antagonist selected from the group consisting of - 5-(2-ethyl-2H-tetrazol-5-yl)-l -methyl- 1,2, 3,6-tetrahydropyridine (alvameline) and pharmaceutically acceptable salts and solvates thereof, which can be prepared for example as described in USRE 36374E, the disclosure of which is incorporated herein in its entirety by reference, and used as free base or as its tartrate salt; - 5,1 l-dihydro-8-chloro-l l-[[4-[3-[(2,2-dimethyl-l-oxopentyl)ethylamino]propyl]-l- piperidinyl]acetyl]-6H-pyrido[2,3-b][l,4]benzodiazepin-6-one (BIBN-99) and pharmaceutically acceptable salts and solvates thereof, which can be prepared for example as described in US 5,641,772, the disclosure of
  • the present invention provides a pharmaceutical combination comprising, as Components:
  • a muscarinic receptor antagonist selected from the group consisting of M 2 - muscarinic cholinergic receptor antagonists (M 2 -antagonist);
  • a muscarinic receptor antagonist selected from the group consisting of the nonselective, peripheral anticholinergic agents (nsPAChAs).
  • the M 2 -antagonists are formulated in a pharmaceutical composition in IR-form or in ER-form, including a TTS, in admixture with a pharmaceutical carrier or vehicle.
  • the compositions in dosage unit form contain said M 2 -antagonist at a dose which is dependent on the intrinsic potency of said M 2 -antagonist and is from 0.5 mg to 1500 mg, normally from 0.5 mg to 1000 mg, when included in a pharmaceutical composition in dosage unit form, as set forth above, wherein said M 2 -antagonist is present alone or in combination with an antiemetic agent and/ with a nsPAChA in a fixed-dose combination in said unit form.
  • said M 2 -antagonists are administered to patients in need of said treatment at a daily dose of from 1.5 mg to 3000 mg, or from 1.5 mg to 1500 mg by any administration route.
  • the amount of the M 2 -antagonist Component (a) of the combination may vary according to intrinsic muscarinic cholinergic receptor potency of said component, in particular in the aforementioned range of from 0.5 mg to 1500 mg per dosage unit form, generally in a pharmaceutical composition in admixture with a pharmaceutical carrier or vehicle.
  • the pharmaceutical composition comprising the M 2 -antagonist may be used, in combination with Component (b) and with Component (c), which may be even further combined with an AChEI Componentt (d); for the treatment of a patient suffering from any of the hypocholinergic disorders described herein with a dose of M 2 -antagonist heretofore never tested for the adverse effects exhaustively illustrated herein above and in the literature.
  • compositions are preferably formulated in dosage unit forms for oral, including buccal (as orodispersible or orosoluble preparations), topical, transmucosal or parenteral, in particular, transdermal, administration, wherein the active ingredient is mixed with a pharmaceutical carrier.
  • alvameline as free base or a salt or solvate thereof, especially as its tartrate, may be present in an amount, in alvameline, of from 160 mg to 960 mg, preferably from 240 mg to 960 mg;
  • - tripitramine as free base or a salt or solvate thereof, especially as its sesquifumarate or tetraoxalate salt, may be present in an amount of from 10 mg to 200 mg, preferably from 25 mg to 100 mg;
  • - dimethindene preferably as the maleate thereof, is present as racemate or as its S(+) enantiomer, in an amount of from 1.1 mg to 32 mg, preferably from 1.2 mg to 15 mg, from 1.5 mg to 8 mg, from 1.5 to 6 mg or from 1.5 to 4 mg in a IR-form or, as the free base or the maleate thereof, in an amount of from 3 mg to 32mg, preferably from 4 mg to 32 mg , from 4.4 to 32 mg, from 6 mg to 32 mg, from 6 mg to 16 mg or from 3 mg to 10 mg, in an ER-form, including a TTS;
  • - otenzepad as free base or as the maleate (1: 1), fumarate (1: 1), dihydrochloride, dihydrochloride dihydrate, dihydrobromide or the monomethanesulfonate (INN: monomesilate, USAN: monomesylate) thereof, in an amount of fromlOO mg to 500 mg, preferably from 150 mg to 350 mg in a IR unit form or as the free base or as one of the aforementioned salts, in an amount of from 200mg to 500 mg, preferably from 300 mg 500 mg, in an ER-form, including a TTS;
  • - AQ-RX 741 as free base or as a salt or solvate thereof, especially as its monomethanesulfonate salt, may be present in an amount of from 10 mg to 500 mg, preferably from 10 mg to 250 mg in a IR-form or, as the free base or the methanesulfonate salt thereof, in an amount of from 20 mg to 500 mg, preferably from 50 mg to 500 mg, in an ER-form, including a TTS.
  • compositions are used in the treatment of hypocholinergic disorders such as AD type dementia by administering said compositions once, twice or three times per day.
  • the pharmaceutical compositions prepared by using the M 2 -antagonist Component (a), which acts as cholinergic agent in the CNS to improve the symptoms of Alzheimer type dementia, in a quantity sufficient to maximally alleviate disease-associated neurobehavioral symptoms are present in unit forms also containing other active ingredients, in particular the naAEA Component (b) to form a fixed-dose combination assuring a minimum of treatment-associated adverse effect according to the present invention, said fixed dose combination being intended to be concurrently or sequentially administered in combination with a pharmaceutical composition in dosage unit form comprising a nsPAChA in admixture with a pharmaceutical carrier.
  • Antiemetic medications commonly used to treat emesis, and not primarily regarded as anticholinergic agents, that are entirely devoid of anticholinergic activity or have an extremely low ability to prevent acetylcholine from acting at its cholinergic receptor sites in the brain may be used as Component (b) of the pharmaceutical combination of the present invention.
  • said Component (b) is a non- anticholinergic antiemetic agent selected from the group consisting of (bl) 5HT3-antagonists, (b2) DA-antagonists, (b3) HI -antagonists, (b4) cannabinoids, and (b5) NKl-antagonists.
  • a non- anticholinergic antiemetic agent selected from the group consisting of (bl) 5HT3-antagonists, (b2) DA-antagonists, (b3) HI -antagonists, (b4) cannabinoids, and (b5) NKl-antagonists.
  • Typical non-anticholinergic antiemetic agents are
  • 5-HT3 receptor antagonists such as 9-methyl-3-[(2-methyl-lH- imidazol- 1 -yl)methyl] - 1 ,2,3 ,9-tetrahydrocarbazol-4-one (ondansetron) and pharmaceutically acceptable salts and solvates thereof, in particular its hydrochloride dihydrate, described in EP 191562; 3S-ondansetron; 3R-onsdansetron; (3R)-10-oxo-8- azatricyclo[5.3.1.03,8]undec-5-yl lH-indole-3-carboxylate (dolasetron) and pharmaceutically acceptable salts and solvates thereof, in particular its monomethanesulfonate (mesylate or mesilate) monohydrate, described in EP 266730; l-methyl-N-(9-methyl-9-azabicyclo[3.3.1]non-3-yl)-indazole-3-carboxamide
  • DA-antagonists such as 5-chloro-l-(l-[3-(2-oxo-2,3- dihydro- 1 H-benzo [d] imidazol- 1 -yl)propyl]piperidin-4-yl)- 1 H-benzo [d] imidazol- 2(3H)-one (domperidone) and pharmaceutically acceptable salts and solvates thereof, particularly its maleate; l-[l-[4-(4-fluorophenyl)-4-oxo-butyl]-3,6-dihydro-2H- pyridin-4-yl]-3H-benzoimidazol-2-one (droperidol); 4-[4-(4-chlorophenyl)-4-hydroxy- 1-piperidyl]- l-(4-fluorophenyl)-butan- 1-one (haloperidol); 3-(2-chloro- 10H- phenothiazin-10-
  • prochlorperazine and pharmaceutically acceptable salts and solvates thereof, particularly its dimaleate, dimesylate or 1,2-ethanedisulfonate (1: 1) (edisilate); dimethyl [ 1 - ( 1 OH-phenothiazin- 10-yl)prop an-2- yl] amine (promethazine) and pharmaceutically acceptable salts and solvates thereof, particularly its hydrochloride; 4-aminosalicylamide and benzamide derivatives like 4-amino-5-chloro-N-[2- (diethylamino)ethyl]-2-methoxybenzamide (metoclopramide) and pharmaceutically acceptable salts and solvates thereof such as its monohydrochloride monohydrate; 4- amino-5-bromo-N- [2-(diethylamino)ethyl] -2-methoxybenzamide (bromopride) and pharmaceutically acceptable salts and solvates thereof, particularly its monohydrochloride and its dihydrochloride monohydrate
  • HI histamine receptor antagonists such as l-[(4-chlorophenyl)- phenyl-methyl]-4-[(3-methylphenyl)methyl]piperazine (meclizine or meclozine) and pharmaceutically acceptable salts and solvates thereof, particularly its dihydrochloride monohydrate; dimethyl[l-(10H-phenothiazin-10-yl)propan-2-yl]amine (promethazine) and pharmaceutically acceptable salts and solvates thereof, particularly its hydrochloride; 3-(2-chloro-10H-phenothiazin-10-yl)-N,N-dimethyl-propan-l-amine (chlorpromazine) or a salt thereof, particularly its hydrochloride; 2-chloro-10-[3-(4- methyl- 1 -piperazinyl)propyl] - 1 OH-phenothiazine (prochlorperazine) and pharmaceutically acceptable salts and
  • annabinoids such as cannabis; (6aR-trans)- 6a,7,8,10a-tetrahydro-6,6,9-trimethyl-3-pentyl-6H-dibenzo[b,d]pyran-l-ol
  • NK1 -antagonists such as 5-[[(2R,3S)-2- [(lR)-l-[3,5-bis(trifluoromethyl)phenyl]ethoxy]-3-(4-fluorophenyl)-4- morpholinyl]methyl]-l,2-dihydro-3H-l,2,4-triazol-3-one (aprepitant); (2S,4S)-4-(4- Acetyl- 1 -piperazinyl)-N- [( 1R)- 1 - [3 ,5-bis(trifluoromethyl)phenyl]ethyl] -2-(4-fluoro-2- methylphenyl)-N-methyl-l-piperidinecarboxamide (casopitant); 2-[3,5- bis(trifluoromethyl)phenyl] -N,2-dimethyl- V- [4-(2-methylphenyl)-6-(4-methyl- 1 -
  • NK1 -antagonists such
  • naAEAs are the compounds available in drugs for the current antiemetic therapy, in particular,
  • alosetron hydrochloride available at the oral dose/unit form (in alosetron) of 0.5-1 mg;
  • dolasetron mesylate monohydrate available at the oral dose (in dolasetron) of 50-100 mg;
  • ondansetron hydrochloride dihydrate available at the oral dose (in ondansetron) of 4-8 mg;
  • - palonosetron hydrochloride available at a the oral dose (in palonosetron) of 0.5 mg and i.v. dose (in palonosetron) of 0.25 mg;
  • tropisetron hydrochloride available at the oral dose (in tropisetron) of 5 mg;
  • chlorpromazine hydrochloride available at the oral dose (in chlorpromazine) of 25-100 mg;
  • bromopride dihydrochloride monohydrate available at the oral dose (in bromopride) of 10 mg;
  • clebopride malate (1: 1), available at a oral dose (in clebopride) of 1 mg;
  • trimethobenzamide hydrochloride available at the oral dose (in trimethobenzamide) of 100 mg - meclizine (also called meclozine), available at the oral dose of 12.5-50 mg;
  • promethazine hydrochloride available at the oral dose (in promethazine) of 25 mg;
  • the non-anticholinergic antiemetic agent Component (b) is formulated in a pharmaceutical composition in admixture with a pharmaceutical carrier to be administered with the M 2 -antagonist Component (a), and the nsPAChA Component (c).
  • the pharmaceutical combination may further include component (d) an AChEI.
  • Component (a) sufficient to maximally alleviate disease- associated cognitive and other neurobehavioral symptoms is illustrated in the above "The M 2 -antagonists" section.
  • alosetron and pharmaceutically acceptable salts and solvates thereof especially its hydrochloride; azasetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; ondansetron and pharmaceutically acceptable salts and solvates thereof, especially its monohydrochloride dihydrate; granisetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; dolasetron and pharmaceutically acceptable salts and solvates thereof, especially its monomethanesulfonate monohydrate, ramosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; tropisetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; palonosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; domperidone and pharmaceutically acceptable salts and solvates thereof, especially its maleate; metoclopramide and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride monohydrate; brom
  • the non-anticholinergic antiemetic agent, Component (b) is present, generally in a pharmaceutical composition in admixture with a pharmaceutical carrier or vehicle, in an amount of from 50% to 600%, normally 50% to 300%, of the amount of the said non-anticholinergic antiemetic agent contained as a sole active ingredient in the aforementioned, currently used brand or generic drugs.
  • Each of said typical non-anticholinergic antiemetic agents is present in the pharmaceutical composition, as Component (b), in an amount ranging from 50% of the minimum amount to 600%, and in some cases beyond 600%, normally 300%, of the maximum amount of said typical non-anticholinergic antiemetic agent contained in the corresponding, currently used generic or brand drug for its antiemetic indication in IR form.
  • Advantageous Component (b) is selected from the group consisting of alosetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride, in an amount (in alosetron) of from 0.25 mg to 3 mg; azasetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride, in an amount (in azasetron) of from 5 mg to 60 mg; dolasetron and pharmaceutically acceptable salts and solvates thereof, in particular the mesylate, in an amount (in dolasetron) of from 25 mg to 300 mg; granisetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride, in an amount (in granisetron) of from 0.5 mg to 3 mg; ondansetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride dihydrate, in an amount (in ondansetron) of from 2 mg to 48 mg, up to 64 mg; palonosetron, and pharmaceutically acceptable salts and solvates thereof
  • Preferred Component (b) is selected from the group consisting of ondansetron and pharmaceutically acceptable salts and solvates thereof, in an amount (in ondansetron) of from 2 mg to 32 mg; granisetron and pharmaceutically acceptable salts and solvates thereof, in an amount (in granisetron) of from 0.5 mg to 3 mg; domperidone and pharmaceutically acceptable salts and solvates thereof, in an amount (in domperidone) of from 5 mg to 30 mg; metoclopramide and pharmaceutically acceptable salts and solvates thereof, in an amount (in metoclopramide) of from 5 mg to 30 mg; dronabinol, in an amount of from 1.25 mg to 30 mg; nabilone, in an amount of from 0.25 mg to 3 mg; aprepitant, in an amount of from 20 mg to 375 mg; netupitant, in an amount of from 150 mg to 1800 mg; rolapitant, in an amount of from 90 mg to 360 mg; and casopitant, in
  • the non- anticholinergic antiemetic agent is present, in an IR unit form, in an amount ranging from 50% to 200% of the maximum amount of said antiemetic agent contained in the currently administered IR dosage unit forms for the treatment of emesis or, in an ER unit form, in an amount ranging from 75% to 300% of the currently administered IR dosage unit forms for the treatment of emesis.
  • ondansetron or a pharmaceutically acceptable salt or solvate thereof, in particular its hydrochloride dihydrate is present in an amount (in ondansetron) of from 2 mg to 16 mg per dosage unit in an IR unit form or in an amount of from 3 mg to 24 mg, preferably from 8 mg to 24 mg in an ER unit form;
  • alosetron or a pharmaceutically acceptable salt thereof, in particular its hydrochloride is present in an amount (in alosetron) of from 0.25 mg to 2 mg per dosage unit in an IR unit form or in an amount of from 0.375 mg to 3 mg, preferably from 1 mg to 3 mg, in an ER unit form;
  • azasetron or a pharmaceutically acceptable salt thereof, in particular its hydrochloride is present in an amount of from 5 mg to 20 mg per dosage unit in an IR unit form or in an amount of from 7.5 mg to 30 mg, preferably from 10 mg to 30 mg, in an
  • Preferred Component (b) is a pharmaceutical composition in dosage unit form comprising a non- anticholinergic antiemetic agent selected from the group consisting of ondansetron and pharmaceutically acceptable salts and solvates thereof, in an amount (in ondansetron) of from 8 mg to 24 mg; granisetron and pharmaceutically acceptable salts and solvates thereof, in an amount (in granisetron) of from 0.5 mg to 3 mg; domperidone and pharmaceutically acceptable salts and solvates thereof, in an amount (in domperidone) of from 10 mg to 30 mg; metoclopramide and pharmaceutically acceptable salts and solvates thereof, in an amount (in metoclopramide) of from 10& mg to 30 mg; dronabinol, in an amount of from 10 mg to 30 mg; nabilone, in an amount of from 1 mg to 3 mg; aprepitant, in an amount of from 125 mg to 375 mg; netupitant, in an amount of from 300 mg to 900
  • nsPAChAs exhibiting inhibitory activity broadly across the various subtypes of muscarinic M-receptors, namely the M 1 -M5 receptors, as currently identified and are largely unable (have a limited ability) to enter the central nervous system following systemic administration and thus do not affect brain function to a clinically appreciable degree may be used as Component (c) according to the present invention.
  • These nsPAChAs include quaternary ammonium salts, sulfonium salts and tertiary amine anticholinergic agents, especially those having low lipid solubility.
  • the 4-diethylaminobut-2-ynyl 2-cyclohexyl-2-hydroxy-2-phenylethanoate known under its International Non-proprietary Name "oxybutynin", as free base or a pharmaceutically acceptable salt thereof, is a well-known non-selective anticholinergic medication used by oral route to relieve urinary and bladder difficulties, including frequent urination and urge incontinence and all the above references emphasize this use.
  • oxybutynin is a very good tool for administering anticholinergic therapy, but it is not "peripheral” as per the definition given above because it is able to cross the blood brain barrier (“BBB”) to a non-negligible extent (Rebecca J McCrery and Rodney A Appell, TherClin Risk Manag. Mar 2006; 2/1: 19-24).
  • BBB blood brain barrier
  • TTS Therapeutic Systems
  • US 5,411,740 and US 5,500,222 disclose a patch for the transdermal administration of oxybutynin base using a monoglyceride or a mixture of monoglycerides of fatty acids as skin permeation-enhancer.
  • TTS substantially consisting of an oxybutynin-containing matrix mass in the form of a layer which is self-adhesive, and in which the matrix mass consists of ammonium-group-containing (meth)acrylate copolymers, at least one citric acid triester and 5-25% by weight of oxybutynin.
  • US 6,562,3608 discloses a method for transdermally administering oxybutynin using a composition in form of a patch, a cream, a gel, a lotion or a paste comprising oxybutynin and a hydroxide-releasing agent substantially consisting of inorganic hydroxides, inorganic oxides, metal salts of weak acids, and mixtures thereof.
  • transdermal patch delivering a composition comprising oxybutynin to a subject to provide a plasma area under the curve ratio of oxybutynin to an oxybutynin metabolite of from about 0.5: 1 to about 5: 1, optional in the presence of a permeation enhancer.
  • transdermal gel formulation comprising oxybutynin providing a plasma area under the curve ratio of oxybutynin to an oxybutynin metabolite of from about 0.5: 1 to about 5: 1, optional in the presence of a permeation enhancer.
  • TTS transdermal therapeutic systems
  • These TTS comprise a substantially water vapor-impermeable backing layer, at least one pressure- sensitive adhesive matrix layer attached thereto, and a detachable protective film, said matrix layer comprising an inner phase containing the active substance oxybutynin, and an outer, pressure sensitive adhesive phase based on hydrocarbon polymers or/and silicone polymers.
  • US 2005/0064037 discloses an oxybutynin gel formulation topical gel formulation comprising oxybutynin chloride salt, a short chain alcohol, a gelling agent substantially consisting of high-molecular-weight, cross-linked polymer of acrylic acid or cross- linked copolymer of acrylic acid and C 10-30 alkyl acrylate, and optionally a permeation enhancer substantially consisting of propylene glycol, propylene glycol laurate, isopropyl myristate, and methyl lactate.
  • oxybutynin gel formulation topical gel formulation comprising oxybutynin chloride salt, a short chain alcohol, a gelling agent substantially consisting of high-molecular-weight, cross-linked polymer of acrylic acid or cross- linked copolymer of acrylic acid and C 10-30 alkyl acrylate, and optionally a permeation enhancer substantially consisting of propylene glycol, propylene glycol laurate, isopropyl myristate, and methyl lactate
  • transdermal or transmucosal pharmaceutical formulation that can be utilized for topical or transdermal application, such that solutions, creams, lotions, sprays, ointment, gels, aerosols and patch devices, for the delivery of one or more active agents, including anticholinergics, in particular oxybutynin.
  • Said formulation includes oxybutynin in a solvent system comprising a diethylene glycol monoalkyl ether and a glycol in specific ratios, alcohol and water.
  • a possible secondary active agent in addition to the anti-cholinergic agent such as oxybutynin, may be an antiperspirant, a tranquilizer or another agent capable of ameliorating hyperhidrosis.
  • the active agent may also be selected from an anti-Alzheimer's drug, in particular galantamine, rivastigmine, donepezil, tacrine, or memantine, without giving any indication of the doses to be used.
  • WO 2005/107812, US 7,425,340 and US 2008/0260842 disclose formulations containing an anticholinergic agent, in particular oxybutynin, in admixture with urea, urea congeners or urea-containing compounds as permeation enhancers.
  • WO 01/07018 and US 8,420,117 disclose a matrix patch formulation containing no water for external use, comprising, as essential components oxybutynin hydrochloride, citric acid and sodium acetate.
  • US 8,802,134 the disclosure of which is herein incorporated by reference in its entirety, discloses a method for producing a patch wherein oxybutynin is incorporated in an adhesive agent layer composition comprises the acrylic-based polymer as the adhesive base agent, and the acrylic -based polymer is a copolymer of polymethyl methacrylate with a polyacrylate.
  • US 8,877,235 discloses a patch consisting of a support layer and of an adhesive agent layer arranged on the at least one surface of the support layer, the adhesive agent layer comprising oxybutynin hydrochloride in a supersaturated concentration in a dissolved form.
  • Said layer also comprises acrylic -based polymers and rubber-based polymers, as adhesive base agents, and liquid paraffin, a sterol, an organic acid, and a tackifier.
  • Oxybutynin is also commercially presented in a 39-cm patch system containing 36 mg of oxybutynin and releasing 3.9 mg/day oxybutynin (OXYTROL ® ).
  • This patch provides significant improvements in all the measured parameters with less systemic adverse effects, as summarized by J. Jayarajan and S. B. Radomski in a review presented on 4 December 2013: "Pharmacotherapy of overactive bladder in adults: a review of efficacy, tolerability, and quality of life" (J. Jayarajan et al., Research and Reports in Urology 2014:6), the disclosure of which is herein incorporated by reference in its entirety.
  • oxybutynin is anyway deemed to cross the BBB owing to its high lipophilicity, neutrality, and small molecular size (C. A. Donnellan et al. BMJ 1997;315: 1363-4; R. Scheife and M. Takeda, ClinTher. 2005; 27: 144-53). the disclosure of which is herein incorporated by reference in its entirety.
  • Oxybutynin is also commercially presented (GELNIQUE ® ) in a TTS consisting of a hydroalcoholic gel containing 100 mg oxybutynin chloride per gram of gel and available in a 1 gram (1.14 ml) unit dose.
  • This TTS is deemed to have a pharmacokinetic profile similar to that of the patch delivery system, while producing lower N-desethyloxybutynin metabolite plasma concentrations (Vincent R Lucente et al.; Open Access Journal of Urology 2011/3, 35-42).
  • TTS Trigger TTS
  • oxybutynin in a hydroalcoholic gel containing 30 mg oxybutynin base per gram of gel and is available (ANTUROL ® ) in a 0.92 gram (1 mL) unit dose that contains 28 mg oxybutynin per gram of gel.
  • Anturol ® demonstrated plasma levels of oxybutynin comparable to the efficacious plasma levels observed for oral and patch therapies with lower N-desethyloxybutynin plasma levels (Anturol® Gel Summary by Antares Pharma).
  • the label for transdermal oxybutynin warns that a variety of CNS anticholinergic effects have been reported, including headache, dizziness, and somnolence. Patients should be monitored for signs of anticholinergic CNS effects, particularly after beginning treatment. The label further advises that patients should be told not to drive or operate heavy machinery until they know how transdermal oxybutynin affects them. The label also advises that if a patient experiences anticholinergic CNS effects, drug discontinuation should be considered. In addition, the label states that overdosage with oxybutynin has been associated with CNS anticholinergic effects including excitation, memory loss, stupor, disorientation and agitation on awakening. Hence, based on the existing literature, and the competing action of oxybutynin and an AChEI in the CNS, the combined use of such drugs would have made memory loss a-priori material risk for the treatment of Alzheimer type dementia.
  • TTS-oxybutynin may considered, in every aspect, as a nsPAChA in the context of the present invention.
  • the nsPAChAs used as Component (c) include, but are not limited to, quaternary ammonium nsPAChAs, sulfonium nsPAChAs, (1S)-(3T?)-1- azabicyclo[2.2.2]oct-3-yl 3,4-dihydro-l-phenyl-2(lH)-iso-quinolinecarboxylate (solifenacin) and pharmaceutically acceptable salts and solvates thereof, 1- methylpiperidin-4-yl) 2,2-di(phenyl)-2-propoxyacetate (propiverine) and pharmaceutically acceptable salts and solvates thereof, 1,4,5,6-tetrahydro-l- methylpyrimidin-2-ylmethyl a-cyclohexyl-oc-hydroxy-oc-phenylacetate (oxyphencyclimine) and pharmaceutically acceptable salts and solvates thereof, (R)- N,N-diisopropyl-3-(2-hydroxy)-
  • nsPAChAs are compounds with a duration of action of at least 6 hours, advantageously from 8 to 24 hours, more advantageously from 10 to 24 hours, preferably from 12 to 24 hours, even nsPAChAs having an appropriate duration of action corresponding to the duration of action of the concomitantly administered M 2 antagonist may be successfully used.
  • Typical quaternary ammonium nsPAChAs or sulfonium nsPAChAs are compounds of formula I
  • R is a radical selected from the group consisting of those of formulas (a)-(e)
  • A being methyl and A' being (Ci-C 4 )alkyl or 2-fluoroethyl group or A and A' forming a 1,4-butylene or 1,5-pentylene chain
  • L being hydrogen or methoxy
  • Alk and Alk' each being (Ci-C 4 )alkyl
  • Y being a bivalent radical selected from the group consisting of 1,2-ethylene, 1,3-propylene, 1,4-butylene and 2-oxa-l,3- propylene
  • the corresponding counter ion being a pharmaceutically acceptable anion, such as a chloro, bromo, iodo, tartrate, hydrogen tartrate, succinate, maleate, fumarate, sulfate, hydrogen sulfate or methylsulfate anion;
  • n and m independently, are zero or 1 ;
  • X is a (C 2 -C3)alkylene group
  • Ri and R 2 are each phenyl, cyclopentyl, cyclohexyl, 1-cyclohexenyl, 2-thienyl and, when R is a radical (a), also each represents (Ci-C 4 )alkyl;
  • R 3 is H or OH or, only when R is a radical (a), also a COOAlk group, Alk being a (Ci-C 4 )alkyl group.
  • At least one of m and n is i.
  • nsPAChAs of formula I above useful for the treatment of Alzheimer type dementia in combination with M 2 -antagonists and naAEAs are
  • nsPAChAs for anticholinergic therapy and useful nsPAChA- Component (c) of the combination of the present invention include, but are not limited to, anisotropine hydrobromide, atropine methobromide, atropine methonitrate, benactizine methobromide, cimetropium bromide, clidinium bromide, dibutoline sulfate, diphemanil, diponium bromide, emeprioum bromide fesoterodine fumarate, glycopyrronium bromide, isopropamide iodide, otilonium bromide, oxyphencyclimine hydrochloride, penthienate bromide, pipenzolate bromide, prifinium bromide, propiverine hydrochloride, scopolamine methobromide, scopolamine butylbromide (butylscopolamine bromide), scopolamine meth
  • nsPAChAs are the tertiary amine or quaternary ammonium compounds available in drugs for current anticholinergic therapy, in particular anisotropine hydrobromide, available with a maximum dose/unit form of 50 mg; butylscopolamine bromide, with a maximum dose/unit form of 10 mg; cimetropium bromide, with a maximum dose/unit form of 50 mg; clidinium bromide, with a maximum dose/unit form of 2.5 mg; ER fesoterodine fumarate, with a maximum dose/unit form of 8 mg; glycopyrronium bromide, with a maximum dose/unit form of 2 mg; otilonium bromide, with a maximum dose/unit form of 40 mg; oxyphencyclimine hydrochloride with a maximum dose/unit form of 10 mg: prifinium bromide, with a maximum dose/unit form of 30 mg; IR propiverine hydrochloride, with a maximum dose/unit form of
  • trospium chloride which is a nsPAChA whose absorbed amount, even though poor, has an average plasma half-life of about 18 hours
  • solifenacin succinate which also has a long half-life
  • propiverine hydrochloride and the aforementioned quaternary ammonium salts thereof, and TTS-oxybytynin are particularly preferred.
  • the nsPAChA Component (a) is present, generally in a pharmaceutical composition in admixture with a pharmaceutical carrier or vehicle, in an amount of from 50% to 600% of the amount of the said nsPAChA contained as a sole active ingredient in the aforementioned, currently used brand or generic drugs.
  • nsPAChA Component (c) of the present invention can be formulated in pharmaceutical compositions comprising, as an active ingredient thereof, said nsPAChA in admixture with a pharmaceutical carrier.
  • Said Component (c) is present in an amount that allows the reduction of peripherally mediated adverse effects caused by the administration of M 2 -antagonist.
  • the amount of a nsPAChA is from 0.5 to 6 times the maximum amount contained in the IR-forms of the marketed drugs.
  • the nsPAChA amount in a compositions as IR-formulation is from 0.5 to 4 times, preferably from 1.2 to 4 times the maximum amount contained in the commercial drugs in IR form and the nsPAChA amount in a compositions as ER-formulation is from 0.75-times to 6-times, preferably from 1.2-times to 6-times the maximum amount contained in the marketed drugs in IR form or in an amount of from 0.75-times to 4- times, preferably from 1.2-times to 4-times the maximum amount contained in the marketed drugs in ER form.
  • the combination of the present invention comprises, as Component (c), a nsPAChA selected from the group consisting of anisotropine methylbromide, in an amount from 25 mg to 300 mg, advantageously from 60 mg to 300 mg, normally from 60 mg to 200 mg; cimetropium bromide, in an amount from 25 mg to 300 mg, advantageously from 60 mg to 300 mg, normally from 60 mg to 200 mg; clidinium bromide, in an amount from 1.25 mg to 30 mg, advantageously from 6 mg to 30 mg, normally from 6 mg to 20 mg; fesoterodine fumarate, in an amount from 4 mg to 48 mg, advantageously from 9.6 mg to 48 mg, normally from 9.6 mg to 32 mg; glycopyrronium bromide, in an amount from 1 mg to 16 mg, advantageously from 2.4 mg to 12 mg, normally from 2.4 mg to 8 mg; otilonium bromide, in an amount from 20 mg to 240 mg, advantageously from 48 mg to 240
  • Said Component (c) is normally formulated in a pharmaceutical composition in dosage unit form, in admixture with a pharmaceutical carrier or vehicle.
  • said Component (c) as a sole active ingredient of the pharmaceutical composition, may be in a commercial preparation.
  • Component (c) of said combination is a pharmaceutical composition in an IR- or ER-form comprising a nsPAChA selected from the group consisting of anisotropine hydrobromide, in an amount of from 25 mg to 300 mg, advantageously from 60 mg to 300 mg, in IR or ER form, preferably from 60 mg to 200 mg in IR form; butylscopolamine bromide, in an amount of from 5 mg to 60 mg, advantageously from 12 mg to 60 mg in IR or ER form, preferably from 12 mg to 40 mg in IR form; cimetropium bromide, in an amount of from 25 mg to 300 mg, advantageously from 60 mg to 300 mg in IR or ER form, preferably from 60 mg to 200 mg in IR form; clidinium bromide, in an amount of from 1.253- mg to 15 mg n IR or ER form, preferably from 3 mg to 10 mg in IR form; fesoterodine fumarate ER, in an amount of
  • compositions prepared using the nsPAChAs as Component (c) of the combination according to the present invention allow the administration of heretofore never administered, high and even very high doses of a M 2 -antagonist to patients suffering from hypocholinergic disorders, such as those defined herein above, in particular Alzheimer type dementia, schizophrenia, schizophrenia associated dementia, and schioaffective disorders, without clinically significant symptoms of peripheral cholinergic system overstimulation.
  • compositions are preferably formulated in dosage unit forms for oral, including buccal (as orodispersible or orosoluble preparation), transmucosal, topical or parenteral, in particular transdermal, administration, wherein the active ingredient is mixed with a pharmaceutical carrier.
  • compositions prepared using the nsPAChAs Component (c) according to the present invention are indicated in the treatment of hypocholinergic disorders in combination with a naAEA Component (b) and even high doses of a M 2 - antagonist Component (a), concurrently or sequentially administered therewith, in order to improve to a greater extent said symptoms without adverse effects.
  • the pharmaceutical compositions may further include Component (d) an AChEI.
  • compositions and methods for treating hypocholinergic disorders which comprises administering to a patient in need of said treatment the above-illustrated combination.
  • Component (a), Component (b) and Component (c) of the combination may be administered simultaneously or sequentially to said patient, Component (a) being indifferently administered before or after Component (b) and/or Component (c).
  • Any one of Component (a), Component (b) and Component (c) may also be administered by the same or a different administration route.
  • Component (a), Component (b) and Component (c) are generally formulated in a pharmaceutical composition in admixture with a pharmaceutical carrier or vehicle, but such a treatment may also be made with a pharmaceutical composition wherein Component (a) and Component (b) are mixed together and with a pharmaceutical carrier or vehicle, in combination with a pharmaceutical composition comprising Component (c) in admixture with a pharmaceutical carrier or vehicle.
  • a Component (a)//Component (c) composition combined with a Component (b) composition
  • a Component (b)//Component (c) composition combined with a Component (a) composition and also a Component (a)/Component (b)/Component (c) composition
  • a Component (a)//Component (c) composition may be used for treating a patient suffering from a hypocholinergic disorder as defined above.
  • the invention may also include a fourth component, Component (d), that is an AChEI, also formulated in a pharmaceutical composition, that may be combined with all the Components (a), (b) and (c), as set forth above and illustrated herein below.
  • Component (d) that is an AChEI, also formulated in a pharmaceutical composition, that may be combined with all the Components (a), (b) and (c), as set forth above and illustrated herein below.
  • the present invention provides the combination of any M 2 -antagonist, any naAEA and/ any nsPAChA as exemplified in the respective sections herein, each formulated in pharmaceutical composition in admixture with a pharmaceutical carrier.
  • the combination of the present invention may be a combination comprising or consisting essentially of
  • M 2 -antagonists such as those described herein, each in a pharmaceutical composition in dosage unit form, in admixture with a pharmaceutical carrier, said M 2 -antagonist being preferably selected from the group consisting of 5-(2-ethyl- 2H-tetrazol-5-yl)- l -methyl- 1,2, 3,6-tetrahydropyridine (alvameline) and pharmaceutically acceptable salts and solvates thereof), 5, l l-dihydro-8-chloro- l l- [[4-[3- [(2,2-dimethyl- 1 -oxopentyl)ethylamino]propyl] - 1 -piperidinyl] acetyl] -6H- pyrido[2,3-b] [l,4]benzodiazepin-6-one (BIBN-99) and pharmaceutically acceptable salts and solvates thereof; racemic l l-[[2-(Diethylamino)methyl]
  • an advantageous combination may be a combination comprising or consisting essentially of
  • a M 2 -antagonist selected from the group consisting of alvameline, as free base or a salt or solvate thereof, especially as its tartrate salt may be present in an amount, in alvameline, of from 160 mg to 960 mg, preferably from 240 mg to 960 mg; tripitramine, as free base or a salt or solvate thereof, especially as its sesquifumarate or tetraoxalate salt, in an amount, in tripitramine, of from 10 mg to 200 mg, preferably from 25 mg to 100 mg; (+)-dimethindene or S(+)-dimethindene, in an amount of from 1.1 mg to 32 mg, preferably from 1.2 mg to 15 mg; otenzepad, as free base or as the maleate (1: 1), fumarate (1: 1), dihydrochloride, dihydrochloride dihydrate, dihydrobromide or the monomethanesulfonate, in an amount of from 100 mg to 500 mg, preferably
  • another advantageous combination may be a combination comprising or consisting essentially of
  • a M 2 -antagonist selected from the group consisting of alvameline, as free base or a salt or solvate thereof, especially as its tartrate, in an amount, in alvameline, of from 200 mg to 600 mg; tripitramine sesquifumarate in an amount, in tripitramine, of from 15 mg to 150 mg; (+)-dimethindene or S(+)-dimethindene maleate, in an amount of from 1.5 mg to 25 mg; otenzepad maleate (1: 1), in an amount of from 200 mg to 400 mg; and AQ-RX 741 monomethanesulfonate, in an amount of from 15 mg to 300 mg;in a pharmaceutical composition in admixture with a pharmaceutical carrier or vehicle;
  • nsPAChA in a pharmaceutical composition in admixture with a pharmaceutical carrier or vehicle.
  • the pharmaceutical combinations of this first embodiment of the present invention are useful for the treatment of hypocholinergic disorders, and even high doses of a M 2 -antagonist Component (a), may be present to improve symptoms without adverse effects to a greater extent.
  • the present invention provides a method for treating hypocholinergic disorders, which comprises administering to a patient in need of said treatment the combinations described herein in one embodiment.
  • Component (a), Component (b) and Component (c) of the combination may be administered simultaneously or sequentially to said patient, Component (a) being indifferently administered before or after Component (b) and Component (c).
  • Components (a), Component (b) and Component (c) may also be administered by the same or a different administration route.
  • the present invention provides a pharmaceutical combination comprising or consisting essentially of, as Components:
  • a nAEA selected from the group consisting of (bl) 5HT3-antagonists, (b2) DA- antagonists, (b3) Hl-antagonists, (b4) cannabinoids, (b5) NKl-antagonists, in a pharmaceutical composition in admixture with a pharmaceutical carrier or vehicle; and
  • a M 2 -antagonist in a pharmaceutical composition in admixture with a pharmaceutical carrier or vehicle.
  • a nAEA consisting of a 5HT3 -antagonist selected from the group consisting of alosetron and pharmaceutically acceptable salts and solvates thereof, azasetron and pharmaceutically acceptable salts and solvates thereof; ondansetron and pharmaceutically acceptable salts and solvates thereof; granisetron and pharmaceutically acceptable salts and solvates thereof; dolasetron and pharmaceutically acceptable salts and solvates thereof, ramosetron and pharmaceutically acceptable salts and solvates thereof; tropisetron and pharmaceutically acceptable salts and solvates thereof; and palonosetron and pharmaceutically acceptable salts and solvates thereof, alone or in combination with the NK1 -antagonist netupitant, in a pharmaceutical composition in admixture with a pharmaceutical carrier or vehicle; and
  • another advantageous combination is a combination comprising or consisting essentially of:
  • a nAEA consisting of a 5HT3 -antagonist selected from the group consisting of alosetron hydrochloride, in an amount (in alosetron) of from 0.25 mg to 3 mg; azasetron hydrochloride, in an amount (in azasetron) of from 5 mg to 30 mg; ondansetron monohydrochloride dihydrate in an amount (in ondansetron) of from 4 mg to 64 mg; granisetron hydrochloride, in an amount (in granisetron) of from 1 mg to 6 mg; dolasetron monomethanesulfonate monohydrate, ramosetron hydrochloride in an amount (in ramosetron) of from 2.5 mg to 15 mg; tropisetron hydrochloride in an amount (in tropisetron) of from 2.5 mg to 15 mg and palonosetron hydrochloride, in an amount (in palonosetron) of from 0.125 mg to 12 mg, alone or in combination with the NK1 -
  • nsPAChA in a pharmaceutical composition in admixture with a pharmaceutical carrier or vehicle.
  • a further advantageous combination is a combination comprising or consisting essentially of: (a) a M 2 -antagonist, in a pharmaceutical composition in admixture with a pharmaceutical carrier or vehicle;
  • a nAEA consisting of a DA-antagonist consisting of domperidone and pharmaceutically acceptable salts and solvates thereof such as the maleate; chlorpromazine and pharmaceutically acceptable salts and solvates thereof such as the hydrochloride; prochlorperazine and its salts and solvates, particularly the dimaleate and the dimesylate; promethazine and pharmaceutically acceptable salts and solvates thereof such as the hydrochloride; and 4-aminosalicylamide derivatives such as metoclopramide and pharmaceutically acceptable salts and solvates thereof such as the hydrochloride monohydrate, bromopride and pharmaceutically acceptable salts and solvates thereof such as the monohydrochloride or the dihydrochloride monohydrate, alizapride and pharmaceutically acceptable salts and solvates thereof such as the hydrochloride, and clebopride and pharmaceutically acceptable salts and solvates thereof such as the malate and the hydrochloride monohydrate; in a pharmaceutical composition in admix
  • nsPAChA in a pharmaceutical composition in admixture with a pharmaceutical carrier or vehicle.
  • a nAEA consisting of a DA-antagonist consisting of domperidone or a pharmaceutically acceptable salt thereof, in particular its maleate, in an amount (in domperidone) of from 5 mg to 20 mg per dosage unit in an IR unit form or in an amount of from 7.5 mg to 60 mg, preferably from 10 mg to 60 mg, in an ER unit form; metoclopramide or a pharmaceutically acceptable salt or solvate thereof, in particular its monohydrochloride monohydrate, in an amount (in metoclopramide) of from 5 mg to 20 mg per dosage unit in an IR unit form or in an amount of from 7.5 mg to 30 mg, preferably from 10 mg to 30 mg, in an ER unit form; alizapride or a pharmaceutically acceptable salt thereof, in particular its hydrochloride, in an amount (in alizapride) of from 25 mg to 100 mg per dosage unit in an IR unit form or in an amount of from 37.5 mg to 300 mg, preferably from 100 mg to 300 mg, in
  • nsPAChA in a pharmaceutical composition in admixture with a pharmaceutical carrier or vehicle.
  • a further advantageous combination according to this second embodiment is a combination comprising or consisting essentially of the following Components:
  • a nAEA consisting of a histamine HI receptor antagonists selected from the group consisting of meclizine (meclozine) and pharmaceutically acceptable salts and solvates thereof such as the hydrochloride monohydrate; promethazine and pharmaceutically acceptable salts and solvates thereof such as the hydrochloride; chlorpromazine and pharmaceutically acceptable salts and solvates thereof such as the hydrochloride, prochlorperazine and pharmaceutically acceptable salts and solvates thereof such as the dimaleate, the dimesylate or the 1,2-ethanedisulfonate (1: 1) (edisilate); hydroxyzine and pharmaceutically acceptable salts and solvates thereof such as the dihydrochloride or the 1,1 '-methylene bis(2-hydroxy-3- naphthalenecarboxylic acid (pamoate) salt; in a pharmaceutical composition in admixture with a pharmaceutical carrier or vehicle and
  • nsPAChA in a pharmaceutical composition in admixture with a pharmaceutical carrier or vehicle.
  • a further advantageous combination is a combination comprising or consisting essentially of the following Components:
  • a nAEA consisting of a histamine HI receptor antagonists selected from the group consisting of meclizine or a pharmaceutically acceptable salt thereof, in particular its hydrochloride, in an amount (in meclizine) of from 6.25 mg to 100 mg per dosage unit in an IR unit form or in an amount of from 37.5 mg to 150 mg, preferably from 50 mg to 150 mg, in an ER unit form; chlorpromazine or a pharmaceutically acceptable salt thereof, in particular its hydrochloride, in an amount (in chlorpromazine) of from 12.5 mg to 200 mg per dosage unit in an IR unit form or in an amount of from 75 mg to 300 mg, preferably from 150 mg to 300 mg, in an ER unit form; prochlorperazine or a pharmaceutically acceptable salt thereof, in particular its maleate, in an amount (in prochlorperazine) of from 6.25 mg to 100 mg per dosage unit in an IR unit form or in an amount of from 37.5 mg to 150 mg, preferably from 50 mg to 150 mg
  • nsPAChA in a pharmaceutical composition in admixture with a pharmaceutical carrier or vehicle.
  • nsPAChA in a pharmaceutical composition in admixture with a pharmaceutical carrier or vehicle.
  • compositions according to this second embodiment are indicated in the treatment of hypocholinergic disorders and even high doses of a M 2 receptor antagonist.
  • Component (a) may be present in order to improve said symptoms to a greater extent without adverse effects.
  • the present invention provides a method for treating hypocholinergic disorders, which comprises administering to a patient in need of said treatment the combinations described according to this second embodiment.
  • Component (a), Component (b) and Component (c) of the combination may be administered simultaneously or sequentially to said patient, Component (a) being indifferently administered before or after Component (b) and Component (c).
  • Components (a), Component (b) and Component (c) may also be administered by the same or a different administration route.
  • the invention provides a pharmaceutical combination comprising or consisting essentially of, as Components:
  • nsPAChA selected from the group consisting of quaternary ammonium nsPAChAs, sulfonium nsPAChAs, solifenacin and pharmaceutically acceptable salts and solvates thereof, propiverine and pharmaceutically acceptable salts and solvates thereof, oxyphencyclimine and pharmaceutically acceptable salts and solvates thereof, tolterodine and pharmaceutically acceptable salts and solvates thereof, fesoterodine and pharmaceutically acceptable salts and solvates thereof; TTS-oxybutynin; in a pharmaceutical composition in admixture with a pharmaceutical carrier or vehicle.
  • another combination is a combination comprising or consisting essentially of
  • - R is a radical selected from the group consisting of those of formulas (a)-(e)
  • A being methyl and A' being (Ci-C 4 )alkyl or 2-fluoroethyl group or A and A' forming a 1,4-butylene or 1,5-pentylene chain
  • L being hydrogen or methoxy
  • Alk and Alk' each being (Ci-C 4 )alkyl
  • Y being a bivalent radical selected from the group consisting of 1,2-ethylene, 1,3-propylene, 1,4-butylene and 2-oxa-l,3- propylene
  • the corresponding counter ion being a pharmaceutically acceptable anion, such as a chloro, bromo, iodo, tartrate, hydrogen tartrate, succinate, maleate, fumarate, sulfate, hydrogen sulfate or methylsulfate anion;
  • - n and m independently, are zero or 1 ;
  • - X is a (C2-C3)alkylene group
  • R 2 are each phenyl, cyclopentyl, cyclohexyl, 1-cyclohexenyl, 2-thienyl and, when R is a radical (a), also each represents (Ci-C 4 )alkyl;
  • R 3 is H or OH or, only when R is a radical (a), also a COOAlk group, Alk being a (Ci-C 4 )alkyl group,
  • Another advantageous combination according to this third embodiment is a combination comprising or consisting essentially of, as Components:
  • nsPAChA a quaternary ammonium nsPAChA selected from the group consisting of trospium chloride, glycopyrronium bromide, cimetropium bromide, clidinium chloride, otilonium bromide, prifinium bromide, timepidium bromide, scopolamine methobromide, scopolamine butylbromide, scopolamine methonitrate, isopropamide iodide, valethamate bromide, atropine methobromide, atropine methonitrate, diponium bromide, pipenzolate bromide, penthienate bromide, benactizine methobromide, diphemanil, emeprioum bromide and dibutoline sulfate, in a pharmaceutical composition in admixture with a pharmaceutical carrier or vehicle.
  • a quaternary ammonium nsPAChA selected from the group consisting of
  • Another advantageous combination according to this third embodiment is a combination comprising or consisting essentially of, as Components:
  • a nsPAChA selected from the group consisting of anisotropine methylbromide, in an amount from 25 mg to 300 mg, advantageously from 60 mg to 300 mg, normally from 60 mg to 200 mg; cimetropium bromide, in an amount from 25 mg to 300 mg, advantageously from 60 mg to 300 mg, normally from 60 mg to 200 mg; clidinium bromide, in an amount from 1.25 mg to 15 mg, advantageously from 3 mg to 15 mg, normally from3 mg to 10 mg; fesoterodine fumarate, in an amount from 2 mg to 48 mg, advantageously from 9.6 mg to 48 mg, normally from 9.6 mg to 32 mg; glycopyrronium bromide, in an amount from 1 mg to 12 mg, advantageously from 2.4 mg to 12 mg, normally from 2.4 mg to 8 mg; otilonium bromide, in an amount from 20 mg to 240 mg, advantageously from 48 mg to 240 mg, normally from 48 mg to 160 mg; oxyphencyc limine
  • a further advantageous combination according to this third embodiment is a combination comprising or consisting essentially of, as Components:
  • Component (c) preferably is a nsPAChA selected from the group consisting of fesoterodine fumarate, in an amount of 16 mg; glycopyrronium bromide, in an amount of & mg; oxyphencyclimine, in an amount of 20mg; propiverine hydrochloride IR, in an amount of 30 mg; propiverine ER, in an amount of 60 mg; solifenacin succinate, in an amount of 15 mg; tolterodine tartrate IR, in an amount of 4 mg; tolterodine tartrate ER, in amount of 8 mg; trospium chloride IR, in an amount of 40 mg; trospium chloride ER, in an amount of 120 mg; TTS-oxybutynin in a patch releasing from. 3.9mg/24h to 5.85mg/24h oxybutynin; and valethamate bromide, in an amount of 20 mg.
  • nsPAChA selected from the group consisting of f
  • the pharmaceutical combinations according to this third embodiment are indicated in the treatment of hypocholinergic disorders and even high doses of aan M 2 - antagonist Component (a), may be present to improve said symptoms without adverse effects to a greater extent.
  • the invention provides a method for treating hypocholinergic disorders, which comprises administering to a patient in need of said treatment the above- illustrated combinations according to this third embodiment.
  • Component (a), Component (b) and Component (c) of the combination may be administered simultaneously or sequentially to said patient, Component (a) being indifferently administered before or after Component (b) and Component (c).
  • Components (a), Component (b) and Component (c) may also be administered by the same or a different administration route.
  • an advantageous combination may be a combination comprising or consisting essentially of
  • a pharmaceutical composition comprising alvameline or a pharmaceutically acceptable salt or solvate thereof, an amount, in alvameline, of from 160 mg to 960 mg, preferably from 240 mg to 960 mg,
  • a pharmaceutical composition comprising a naAEA selected from the group consisting of alosetron and pharmaceutically acceptable salts and solvates thereof, azasetron and pharmaceutically acceptable salts and solvates thereof; ondansetron and pharmaceutically acceptable salts and solvates thereof; granisetron and pharmaceutically acceptable salts and solvates thereof; dolasetron and pharmaceutically acceptable salts and solvates thereof, ramosetron and pharmaceutically acceptable salts and solvates thereof; tropisetron and pharmaceutically acceptable salts and solvates thereof; and palonosetron and pharmaceutically acceptable salts and solvates thereof, domperidone and pharmaceutically acceptable salts and solvates thereof such as the maleate; chlorpromazine and pharmaceutically acceptable salts and solvates thereof such as the hydrochloride; prochlorperazine and its salts and solvates, particularly the dimaleate and the dimesylate; promethazine and pharmaceutically acceptable salts and solvates thereof such as the hydrochloride; and 4-ami
  • nsPAChA being preferably selected from the group consisting of anisotropine hydrobromide, butylscopolamine bromide, cimetropium bromide, clidinium bromide, fesoterodine fumarate, glycopyrronium bromide, otilonium bromide, oxyphencyclimine hydrochloride, prifinium bromide, propiverine hydrochloride, solifenacin succinate, tolterodine tartrate, timepidium bromide, trospium chloride; TTS-oxybutynin; and valethamate bromide;
  • An advantageous combination according to this fourth embodiment may be a combination comprising or consisting essentially of, as Components:
  • a pharmaceutical composition comprising alvameline tartrate, in an amount, in alvameline, of from 200 mg to 600 mg, in admixture with a pharmaceutical carrier;
  • a pharmaceutical composition comprising a nAEA selected from the group consisting of alosetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride, in an amount (in alosetron) of from 0.25 mg to 6 mg; azasetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride, in an amount (in azasetron) of from 5 mg to 60 mg; dolasetron and pharmaceutically acceptable salts and solvates thereof, in particular the mesylate, in an amount (in dolasetron) of from 25 mg to 600 mg; granisetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride, in an amount (in granisetron) of from 0.5 mg to 6 mg; ondansetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride dihydrate, in an amount (in ondansetron) of from 2 mg to 64 mg; palonosetron and pharmaceutically acceptable salts and solvated thereof
  • a pharmaceutical composition comprising a nsPAChA selected from the group consisting of anisotropine hydrobromide, in an amount of from 25 mg to 300 mg, advantageously from 60 mg to 300 mg, normally from 60 mg to 200 mg; butylscopolamine bromide in an amount of from 5 mg to 600 mg, advantageously from 12 mg to 60 mg, normally from 12 mg to 40 mg; cimetropium bromide, in an amount of from 25 mg to 300 mg, advantageously from 55 mg to 200 mg; clidinium bromide in an amount of from 1.25 mg to 15 mg, advantageously from 3 mg to 15 mg, normally from 3 mg to 12 mg; fesoterodine fumarate, in an amount of from 4 mg to 32 mg, advantageously from 9.6 mg to 32 mg; glycopyrronium bromide in an amount of from 1 mg to 12 mg, advantageously from 2.2 to 12 mg, normally from 2.2 to 8 mg; otilonium bromide in an amount of from 20 mg to 240 mg, advantageously from
  • the pharmaceutical composition Component (a) comprises alvameline, as free base or as its tartrate, in an amount from 160 mg to 960 mg, in particular, from 160 mg to 480 mg in an IR- formulated oral composition or in an amount of from 240 mg to 960 mg in an ER- formulated composition or device, including a TTS, in admixture with a pharmaceutical carrier or vehicle.
  • an advantageous M 2 - antagonist/naAEA/nsPAChA combination according to the present invention may be a combination comprising or consisting essentially of
  • a pharmaceutical composition comprising dimethindene or R-(-)- dimethindene, or a pharmaceutically acceptable salt or solvate thereof, in an amount, in dimethindene or S-(+)-dimethindene, of from 1.1 mg to 32 mg, normally from 1.5 mg to 32 mg, in admixture with a pharmaceutical carrier or vehicle;
  • a pharmaceutical composition comprising a naAEA selected from the group consisting of alosetron and pharmaceutically acceptable salts and solvates thereof, azasetron and pharmaceutically acceptable salts and solvates thereof; ondansetron and pharmaceutically acceptable salts and solvates thereof; granisetron and pharmaceutically acceptable salts and solvates thereof; dolasetron and pharmaceutically acceptable salts and solvates thereof, ramosetron and pharmaceutically acceptable salts and solvates thereof; tropisetron and pharmaceutically acceptable salts and solvates thereof; and palonosetron and pharmaceutically acceptable salts and solvates thereof, domperidone and pharmaceutically acceptable salts and solvates thereof such as the maleate; chlorpromazine and pharmaceutically acceptable salts and solvates thereof such as the hydrochloride; prochlorperazine and its salts and solvates, particularly the dimaleate and the dimesylate; promethazine and pharmaceutically acceptable salts and solvates thereof such as the hydrochloride; and 4-ami
  • a pharmaceutical composition comprising a nsPAChA being preferably selected from the group consisting of anisotropine hydrobromide, butyl scopolamine bromide, cimetropium bromide, clidinium bromide, fesoterodine fumarate, glycopyrronium bromide, otilonium bromide, oxyphencyclimine hydrochloride, prifinium bromide, propiverine hydrochloride, solifenacin succinate, tolterodine tartrate, timepidium bromide, trospium chloride; TTS-oxybutynin; and valethamate bromide, in admixture with a pharmaceutical carrier or vehicle.
  • a nsPAChA being preferably selected from the group consisting of anisotropine hydrobromide, butyl scopolamine bromide, cimetropium bromide, clidinium bromide, fesoterodine fumarate, glycopyrroni
  • An advantageous combination according to this fifth embodiment may be a combination comprising or consisting essentially of, as Components:
  • a pharmaceutical composition comprising dimethindene or £-(+)- dimethindene, or a pharmaceutically acceptable salt or solvate thereof, in an amount, in dimethindene or S-(+)-dimethindene, of from 1.1 mg to 32 mg, normally from 1.5 mg to 32 mg, in admixture with a pharmaceutical carrier or vehicle;
  • a pharmaceutical composition comprising a nAEA selected from the group consisting of a nAEA selected from the group consisting of alosetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride, in an amount (in alosetron) of from 0.25 mg to 6 mg; azasetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride, in an amount (in azasetron) of from 5 mg to 60 mg; dolasetron and pharmaceutically acceptable salts and solvates thereof, in particular the mesylate, in an amount (in dolasetron) of from 25 mg to 600 mg; granisetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride, in an amount (in granisetron) of from 0.5 mg to 6 mg; ondansetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride dihydrate, in an amount (in ondansetron) of from 2 mg to 64 mg; palo
  • a pharmaceutical composition comprising a nsPAChA selected from the group consisting of anisotropine hydrobromide, in an amount of from 25 mg to 300 mg, advantageously from 60 mg to 300 mg, normally from 60 mg to 200 mg; butylscopolamine bromide in an amount of from 5 mg to 60 mg, advantageously from 12 mg to 60 mg, normally from 12 mg to 40 mg; cimetropium bromide, in an amount of from 25 mg to 300 mg, advantageously from 55 mg to 200 mg; clidinium bromide in an amount of from 1.25 mg to 15 mg, advantageously from 3 mg to 15 mg, normally from 3 mg to 12 mg; fesoterodine fumarate, in an amount of from 4 mg to to 32 mg, advantageously from 9.6 mg to 32 mg, normally from 9.6 mg to 24 mg; glycopyrronium bromide in an amount of from 1 mg to 12 mg, advantageously from 2.2 mg to 12 mg, normally from 2.2 mg to 8 mg; otilonium bromide in an amount
  • the pharmaceutical composition Component (a) comprises a pharmaceutical composition comprising dimethindene or S- (+)-dimethindene, as free base or as maleate, in an amount, in dimethindene or £-(+)- dimethindene, of from 1.1 mg to 16 mg, normally from 1.5 mg to mg, in admixture with a pharmaceutical carrier in an IR-unit form or in an amount of from 4.1 mg to 32 mg, normally from 6 mg to 32 mg, preferably from 6 mg to 24 mg, in admixture with a pharmaceutical carrier in a ER-unit form, including TTS forms
  • the pharmaceutical composition Component (a) comprises a pharmaceutical composition comprising dimethindene or S-(+)-dimethindene, as free base or as maleate, in an amount, in dimethindene or S-(+)-dimethindene, selected from the groups ranges consisting of: from 1.5 mg to 8 mg; from 1.5 to 6 mg and from 1.5 to 4 mg, in admixture with a pharmaceutical carrier in an IR-unit form.
  • Component (c) is TTS-oxybutynin, as a patch releasing 3.9mg/24h oxybutynin, in admixture with a pharmaceutical carrier or vehicle.
  • the pharmaceutical composition Component (a) comprises a pharmaceutical composition comprising dimethindene or S-(+)-dimethindene, as free base or as maleate, in an amount, in dimethindene or S-(+)-dimethindene, selected from the groups ranges consisting of: from 3 mg to 32 mg; from 4 mg to 32 mg; from 4.4 to 32 mg; from 6 mg to 32 mg; from 6 mg to 16 mg; and from 3 mg to 10 mg, in admixture with a pharmaceutical carrier in an ER-form, including a TTS.
  • an advantageous M 2 - antagonist/naAEA/nsPAChA/combination may be a combination comprising or consisting essentially of
  • composition comprising otenzepad or a pharmaceutically acceptable salt or solvate thereof, in an amount of 100 mg to 500 mg, normally from 150 mg to 350 mg, in admixture with a pharmaceutical carrier or vehicle;
  • a pharmaceutical composition comprising a naAEA selected from the group consisting of alosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; azasetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; ondansetron and pharmaceutically acceptable salts and solvates thereof, especially its monohydrochloride dihydrate; granisetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; dolasetron and pharmaceutically acceptable salts and solvates thereof, especially its monomethanesulfonate monohydrate, ramosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; tropisetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; palonosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; domperidone and pharmaceutically acceptable salts and solvates thereof, especially its maleate; metoclopramide and pharmaceutically acceptable salts
  • nsPAChA being preferably selected from the group consisting of anisotropine hydrobromide, butylscopolamine bromide, cimetropium bromide, clidinium bromide, fesoterodine fumarate, glycopyrronium bromide, otilonium bromide, oxyphencyclimine hydrochloride, prifinium bromide, propiverine hydrochloride, solifenacin succinate, tolterodine tartrate, timepidium bromide, trospium chloride; TTS-oxybutynin; and valethamate bromide; in admixture with a pharmaceutical carrier or vehicle.
  • an advantageous M 2 - antagonist/naAEA/nsPAChA/combination may be a combination comprising or consisting essentially of
  • composition comprising otenzepad or a pharmaceutically acceptable salt or solvate thereof, in an amount of 100 mg to 500 mg, normally from 150 mg to 350 mg, in admixture with a pharmaceutical carrier or vehicle;
  • a pharmaceutical composition comprising a nAEA selected from the group consisting of alosetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride, in an amount (in alosetron) of from 0.25 mg to 6 mg; azasetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride, in an amount (in azasetron) of from 5 mg to 60 mg; dolasetron and pharmaceutically acceptable salts and solvates thereof, in particular the mesylate, in an amount (in dolasetron) of from 25 mg to 600 mg; granisetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride, in an amount (in granisetron) of from 0.5 mg to 6 mg; ondansetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride dihydrate, in an amount (in ondansetron) of from 2 mg to 64 mg; palonosetron and pharmaceutically acceptable salts and solvated thereof
  • clebopride of from 0.25 mg to 3 mg; levosulpiride, in an amount of from 12.5 mg to 600 mg; alizapride and pharmaceutically acceptable salts thereof, in particular the hydrochloride, in an amount (in alizapride) of from 25 mg to 300 mg; trimethobenzamide and pharmaceutically acceptable salts thereof such as the monohydrochloride, in an amount (in trimethobenzamide) of from 50 mg to 600 mg; meclizine (also called meclozine) and pharmaceutically acceptable salts and solvates thereof, in an amount (in meclizine) of from 6.25 mg to 300 mg; promethazine and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride, in an amount (in promethazine) of from 12.5 mg to 150 mg; dronabinol in an amount of from 1.25 mg to 60 mg; nabilone, in an amount of from 0.5 mg to 6 mg; aprepitant, in an amount of from 20 mg to 750 mg
  • a pharmaceutical composition comprising a nsPAChA selected from the group consisting of anisotropine hydrobromide, in an amount of from 25 mg to 300 mg, normally from 60 mg to 200 mg; butylscopolamine bromide in an amount of from 5 mg to 60 mg, normally from 12 mg to 40 mg; cimetropium bromide, in an amount of from 25 mg to 200 mg; clidinium bromide in an amount of from 1.25 mg to 15 mg, normally from 3 mg to 12 mg; fesoterodine fumarate, in an amount of from 4 mg to 48 mg, normally from 9.6 mg to 32 mg; glycopyrronium bromide in an amount of from 1 mg to 12 mg, normally from 2.2 to 8 mg; otilonium bromide in an amount of from 20 mg to 240 mg, normally from 48 mg to 160 mg; prifinium bromide in an amount of from 15 mg to 180 mg, normally from 36 mg to 120 mg; propiverine hydrochloride, in an amount of from from 25
  • solifenacin succinate in an amount of from 5 mg to 30 mg, normally from 12 to 21 mg
  • tolterodine tartrate in an amount of from 1 mg to 16 mg, normally from 4.8 mg to 16 mg
  • timepidium bromide in an amount of from 7.5 mg to 180 mg, normally from 36 mg to 120 mgr
  • trospium chloride in an amount of from 24 mg to 240 mg
  • TTS-oxybutynin as a patch releasing from 3.9mg/24 to 7.8mg/24h oxybutynin
  • valethamate bromide in an amount of from 5 mg to 60 mg, normally from 12 mg to 60 mg
  • the pharmaceutical composition Component (a) comprises a pharmaceutical composition comprising otenzepad, as free base or as the maleate (1: 1), fumarate (1: 1), dihydrochloride, dihydrochloride dihydrate, dihydrobromide or the monomethanesulfonate thereof, in an amount of from 100 mg to 500 mg, preferably from 150 mg to 350 mg in a IR unit form or as the free base or as one of the aforementioned salts, in an amount of from 200 mg to 500 mg, preferably from 300 mg 500 mg, in an ER-form, including a TTS.
  • otenzepad as free base or as the maleate (1: 1), fumarate (1: 1), dihydrochloride, dihydrochloride dihydrate, dihydrobromide or the monomethanesulfonate thereof, in an amount of from 100 mg to 500 mg, preferably from 150 mg to 350 mg in a IR unit form or as the free base or as one of the aforementioned salts, in an amount of from 200
  • the present invention also provides a pharmaceutical combination that comprises or consists essentially of, as Components: (a) a M 2 -antagonist selected from the group consisting of otenzepad and pharmaceutically acceptable salts thereof in an amount, in otenzepad, of from 100 mg to 500 mg, in a pharmaceutical composition in admixture with a pharmaceutical carrier or vehicle;
  • a naAEA essentially consisting of palonosetron hydrochloride, in an amount, in palonosetron, of 0.5 mg; and netupitant, in an amount of 300 mg, in a pharmaceutical composition in admixture with a pharmaceutical carrier or vehicle;
  • nsPAChA which is TTS-oxybutynin as a patch releasing from 3.9mg/24h to 7.8mg/24 oxybutynin, wherein oxybutyinin is admixture with a pharmaceutical carrier or vehicle.
  • an advantageous M 2 - antagonist/naAEA/nsPAChA combination according to the present invention is a combination comprising or consisting essentially of, as Components,
  • a pharmaceutical composition comprising AQ-RX 741 or a pharmaceutically acceptable salt or solvate thereof, in an amount of from 10 mg to 500 mg, normally from 10 mg to 250 mg, in admixture with a pharmaceutical carrier or vehicle;
  • a pharmaceutical composition comprising a naAEA selected from the group consisting of alosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; azasetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; ondansetron and pharmaceutically acceptable salts and solvates thereof, especially its monohydrochloride dihydrate; granisetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; dolasetron and pharmaceutically acceptable salts and solvates thereof, especially its monomethanesulfonate monohydrate, ramosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; tropisetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; palonosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; domperidone and pharmaceutically acceptable salts and solvates thereof, especially its maleate; metoclopramide and pharmaceutically acceptable salts
  • nsPAChA being preferably selected from the group consisting of anisotropine hydrobromide, butylscopolamine bromide, cimetropium bromide, clidinium bromide, fesoterodine fumarate, glycopyrronium bromide, otilonium bromide, oxyphencyclimine hydrochloride, prifinium bromide, propiverine hydrochloride, solifenacin succinate, tolterodine tartrate, timepidium bromide, trospium chloride; TTS-oxybutynin; and valethamate bromide;
  • M2-antagonist/naAEA/nsPAChA combination may be a combination comprising or consisting essentially of
  • a pharmaceutical composition comprising AQ-RX 741 or a pharmaceutically acceptable salt or solvate thereof, in an amount of from 10 mg to 500 mg, normally from 10 mg to 250 mg, in admixture with a pharmaceutical carrier or vehicle;
  • a pharmaceutical composition comprising a nAEA selected from the group consisting of alosetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride, in an amount (in alosetron) of from 0.25 mg to 6 mg; azasetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride, in an amount (in azasetron) of from 5 mg to 60 mg; dolasetron and pharmaceutically acceptable salts and solvates thereof, in particular the mesylate, in an amount (in dolasetron) of from 25 mg to 600 mg; granisetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride, in an amount (in granisetron) of from 0.5 mg to 6 mg; ondansetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride dihydrate, in an amount (in ondansetron) of from 2 mg to 64 mg; palonosetron and pharmaceutically acceptable salts and solvated thereof
  • a pharmaceutical composition comprising a nsPAChA selected from the group consisting of anisotropine hydrobromide, in an amount of from 25 mg to 300 mg, normally from 60 mg to 200 mg; butylscopolamine bromide in an amount of from 5 mg to 60 mg, normally from 12 mg to 40 mg; cimetropium bromide, in an amount of from 25 mg to 200 mg; clidinium bromide in an amount of from 1.25 mg to 15 mg, normally from 3 mg to 12 mg; fesoterodine fumarate, in an amount of from 4 mg to 48 mg, normally from 9.6 mg to 32 mg; glycopyrronium bromide in an amount of from 1 mg to 12 mg, normally from 2.2 to 8 mg; otilonium bromide in an amount of from 20 mg to 240 mg, normally from 48 mg to 160 mg; prifinium bromide in an amount of from 15 mg to 180 mg, normally from 36 mg to 120 mg; propiverine hydrochloride, in an amount of from 7.5
  • the pharmaceutical composition Component (a) comprises AQ-RX 741 as free base or as monomethanesulfonate, in an amount of from 10 mg to 500 mg, normally from 10 mg to 250 mg, in admixture with a pharmaceutical carrier formulated IR or ER administration.
  • Component (a) comprises AQ-RX 741 as free base or as monomethanesulfonate, in an amount of from 10 mg to 500 mg, preferably from 10 mg to 250 mg in a IR-form or, as the free base or the methanesulfonate salt thereof, in an amount of from 20 mg to 500 mg, preferably from 50 mg to 500 mg, in an ER-form, including a TTS.
  • solifenacin succinate is preferably present as Component (c) in an amount selected from the group consisting of from 5 mg to 30 mg; from 12 mg to 30 mg, and from 12 mg to 21 mg.
  • AChEI may include, but is not limited to, 1,2,3,4- tetrahydro-9-acridinamine (tacrine) and pharmaceutically acceptable salts and solvates thereof, (+)-2,3-dihydro-5,6-dimethoxy-2-[[l-(phenylmethyl)-4-piperidinyl]methyl]- lH-inden-l-one (donepezil) and pharmaceutically acceptable salt and solvates thereof, (S)-N-Ethyl-N-methyl-3-[l-(dimethylamino)ethyl]-phenyl carbamate (rivastigmine) and pharmaceutically acceptable salts and solvates thereof, or 4aS,6R,8aS-3-methoxy-l l- methyl-4a,5,9,10,l l,12-hexahydroxy-6H-benzofuro[3a,3,2-
  • Donepezil hydrochloride available in 5-mg, 10-mg and 23-mg tablets; rivastigmine, preferably as free base or as hydrogen tartrate, available in 1.5-mg, 3-mg and 6-mg, capsules, as a 2-mg/dose oral solution, and in form of a transdermal patch releasing rivastigmine at 4.6 mg/24 hours, 9.5 mg/24 hour or 13.3 mg/24h; and galantamine, preferably as hydrobromide, available as a 4-mg/ml oral solution, in 4- mg, 8-mg and 12-mg IR-tablets and in 8-mg, 16-mg and 24-mg ER-capsules; are particularly preferred AChEIs.
  • said AChEI Component (d) may be formulated, in admixture with a pharmaceutical carrier or vehicle, in a pharmaceutical composition or device in dosage unit form or also used as a brand preparation.
  • rivastigmine may be also used by orally administering EXELON ® immediate-release 6 mg-capsules or by applying one or more EXELON ® patches releasing 4.6mg/24 hours, 9.5mg/24 hours, or 13.3 mg/24 hours on the subject's skin, to daily release rivastigmine at a dose/24h of from 4.6 mg to 53.2 mg or from 19.95 to 53.2 mg, normally from 14.1 mg to 46 m, in combination with the above-illustrated M2- M2-antagonist/naAEA combination.
  • Donepezil hydrochloride may be also used by orally administering one or more ARICEPT ® immediate-release 5mg- or lOmg-tablets or the 23 -mg tablets.
  • donepezil hydrochloride may be orally administered, in combination with the above- illustrated M2-antagonist /naAEA combination, at a daily dose of from 5 mg to 100 mg or from 15 mg to 70 mg.
  • galantamine may be also administered as a brand preparation, for example by orally administering RAZADYNE ® immediate-release 8mg- or 12mg-tablets or RAZADYNE ® ER 8mg-, 16mg- or 24mg-capsules.
  • galantamine hydrobromide may be orally administered, in combination with the above-illustrated M2-antagonist/naAEA combination, at a daily dose (in galantamine) of from 36 mg to 96 mg, normally at a daily dose or from 36 mg to 72 mg, preferably in an ER-form.
  • the AChEI Component (d) when included in the combination with Component (a), Component (b) and Component (c) as described herein, may be present in an amount of from about 100% to about 1000% of a recommended dose of Component (d) contained in a unit form used for the treatment of Alzheimer type dementia.
  • donepezil hydrochloride is present at a dose of from 5 mg to 98 mg, advantageously from 10 mg to 98 mg, preferably from 15 mg to 69 mg, normally from 15 mg to 60 mg; rivastigmine, as hydrogen tartrate, is present, in a composition for oral administration, at a dose, in rivastigmine, of from 1.5 mg to 30 mg, advantageously from 6 mg to 30 mg, preferably from 9 mg to 24 mg, normally from 9 mg to 18 mg; rivastigmine, as the free base, is present in patch releasing from 4.6mg/24h to 52mg/24h, advantageously from 9.6mg/24h to 39.9mg/24h, normally from 13.3mg/24h to 39.9mg/24h or from 4.6mg/24h to 13.3mg/24h rivastigmine; and galantamine, as hydrobromide, is present in an amount of from 4 mg to
  • kits or package containing a combination as described herein, accompanied by instructions for use are provided.
  • a kit of the present invention is a kit comprising a combination of medicaments for the treatment of hypocholinergic disorders of the CNS.
  • the kit allows for the maximal functional capacity and safety during the treatment of a patient with a combination wherein the components may be administered concurrently or sequentially.
  • Component (a), Component (b) and Component (c) may be present in the kit all in IR or in ER form or one of the Components is in IR form and at least one of the others are in ER form, each in admixture with a pharmaceutical carrier in a composition formulated as illustrated in "The Formulations" section, according to known technologies.
  • kit according to the present invention may also comprise an AChEI Component (d), also in an IR or ER form, in admixture with a pharmaceutical carrier in a composition formulated as illustrated in "The Formulations" section below, according to known technologies.
  • AChEI Component (d) also in an IR or ER form, in admixture with a pharmaceutical carrier in a composition formulated as illustrated in "The Formulations" section below, according to known technologies.
  • the AChEI Component (d) When the AChEI Component (d) is present in the kit, it may be in a separate unit form wherein said AChEI is mixed with a pharmaceutical carrier in a pharmaceutical composition formulated in an IR or ER unit formr
  • kit of the present invention comprises
  • composition in IR or ER dosage unit form comprising or consisting essentially of a therapeutically effective amount of a M 2 -antagonist in admixture with a pharmaceutical carrier or vehicle;
  • composition in IR or ER dosage unit form comprising or consisting essentially of a therapeutically effective amount of a naAEA in admixture with a pharmaceutical carrie or vehicle;
  • composition in IR or ER dosage unit form comprising or consisting essentially of a therapeutically effective amount of a nsPAChA in admixture with a pharmaceutical carrier or vehicle,
  • compositions may be packaged in any manner suitable for administration to a patient suffering from a hypocholinergic disorder of the CNS dementia and the packaging is manufactured according to known technologies and completed with instructions for use clearly showing to the patient or to the caregiver how to take each of the units forms to be administered.
  • Said kit comprises a Component (a) selected among the M 2 -antagonists illustrated in the above section "The M 2 -antagonists", a Component (b) selected among the naAEAs illustrated in the above section “The naAEAs” and a Component (c) selected among the nsPAChAs illustrated in the above section "The nsPAChAs.”
  • the kit of the present invention comprises (a) a M 2 -antagonist selected from the group consisting of 5-(2-ethyl-2H-tetrazol-5-yl)- 1 -methyl- 1,2, 3,6-tetrahydropyridine (alvameline) and pharmaceutically salts and solvates thereof, 5,1 l-dihydro-8-chloro-l l-[[4-[3-[(2,2-dimethyl-l- oxopentyl)ethylamino]propyl] - 1 -piperidinyl] acetyl] -6H-pyrido [2,3 - b][l,4]benzodiazepin-6-one (BIBN-99) and pharmaceutically acceptable salts and solvates thereof; racemic l l-[[2-(Diethylamino)methyl]-l-piperidinyl]-acetyl]- 5,l l-dihydro-6H-pyrid
  • a nAEA selected from the group consisting of (bl) 5HT3 -antagonists, (b2) DA- antagonists, (b3) Hl-antagonists, (b4) cannabinoids, (b5) NKl-antagonists; and
  • nsPAChA selected from the group consisting of quaternary ammonium nsPAChAs, sulfonium nsPAChAs, solifenacin and its pharmaceutically acceptable salts, propiverine and its pharmaceutically acceptable salts, oxyphencyclimine and its pharmaceutically acceptable salts, tolterodine and its pharmaceutically acceptable salts, fesoterodine and its pharmaceutically acceptable salts;
  • said combination being in a fixed-dose combination formulated in admixture with a pharmaceutical carrier.
  • the fixed-dose (a/b/c) combination illustrated in the "The Fixed Combinations" section, is administered to a patient in need of the treatment as a single unite form at the doses illustrated in said section.
  • the invention provides a kit comprising
  • composition in dosage unit form comprising or consisting essentially of a M 2 -antagonist in admixture with a pharmaceutical carrier or vehicle;
  • kits have the advantage of allowing an improvement in the treatment of a patient suffering from a hypocholinergic disorder.
  • the kit of the present invention allows the administration of a composition (b/c) comprising a nAEA and a nsPAChA that may be administered once a day, thus rendering the treatment easier for the patient or for the caregiver.
  • the naAEA and the nsPAChA presnt in said composition act synergistically thus allowing for an increase of the M 2 -antagonist dose.
  • kit according to this second embodiment may comprise:
  • a pharmaceutical composition in dosage unit form comprising or consisting essentially of a M 2 -antagonist selected from the group consisting of alvameline, as free base or a salt or solvate thereof, especially as its tartrate salt, in an amount, in alvameline, of from 160 mg to 960 mg, preferably from 240 mg to 960 mg; tripitramine, as free base or a salt or solvate thereof, especially as its sesquifumarate or tetraoxalate salt, in an amount, in tripitramine, of from 10 mg to 200 mg, preferably from 25 mg to 100 mg; (+)-dimethindene or S(+)-dimethindene, in an amount of from 1.1 mg to 32 mg, preferably from 1.2 mg to 15 mg; otenzepad, as free base or as the maleate (1: 1), fumarate (1: 1), dihydrochloride, dihydrochloride dihydrate, dihydrobromide or the monomethanesulfonate,
  • a nAEA selected from the group consisting of alosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; azasetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; ondansetron and pharmaceutically acceptable salts and solvates thereof, especially its monohydrochloride dihydrate; granisetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; dolasetron and pharmaceutically acceptable salts and solvates thereof, especially its monomethanesulfonate monohydrate, ramosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; tropisetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; palonosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; domperidone and pharmaceutically acceptable salts and solvates thereof, especially its maleate; metoclopramide and pharmaceutically acceptable salts and solvates thereof, especially
  • nsPAChA selected from the group consisting of quaternary ammonium nsPAChAs, sulfonium nsPAChAs, (lS)-(3tf)-l-azabicyclo[2.2.2]oct-3-yl 3,4- dihydro-l-phenyl-2(lH)-iso-quinolinecarboxylate (solifenacin) and its pharmaceutically acceptable salts, l-methylpiperidin-4-yl) 2,2-di(phenyl)-2- propoxyacetate (propiverine) and its pharmaceutically acceptable salts, 1,4,5,6- tetrahydro- 1 -methylpyrimidin-2-ylmethyl oc-cyclohexyl-oc-hydroxy-oc- phenylacetate (oxyphencyclimine) and its pharmaceutically acceptable salts, (R)-N,N-diisopropyl-3-(2-hydroxy-5-methylphenyl)-3-phenylpropanamine
  • a pharmaceutical composition in dosage unit form comprising or consisting essentially of a M 2 -antagonist selected from the group consisting of alvameline tartrate, in an amount, in alvameline, of from 200 mg to 600 mg; tripitramine sesquifumarate in an amount, in tripitramine, of from 15 mg to 150 mg; (+)- dimetindene or S(+)-dimethindene maleate, in an amount of from 1.5 mg to 25 mg; otenzepad maleate (1: 1), in an amount of from 200 mg to 400 mg; and AQ-RX 741 monomethanesulfonate, in an amount of from 15 mg to 300 mg;
  • nsPAChA selected from the group consisting of nsPAChA is selected from the group consisting of anisotropine hydrobromide, in an amount of from 25 mg to 300 mg, normally from 60 mg to 200 mg; butylscopolamine bromide in an amount of from 5 mg to 60 mg, normally from 12 mg to 40 mg; cimetropium bromide, in an amount of from 25 mg to 200 mg; clidinium bromide in an amount of from 1.25 mg to 15 mg, normally from 3 mg to 12 mg; fesoterodine fumarate, in an amount of from 4 mg to 48 mg, normally from 9.6 mg to 32 mg; glycopyrronium bromide in an amount of from 1 mg to 12 mg, normally from 2.2 to 8 mg; otilonium bromide in an amount of from 20-mg to 240 mg, normally from 48 mg to 160 mg; prifinium bromide in an amount of from 15 mg to 180 mg, normally from 36 mg to 120 mg; propiverine
  • nsPAChA selected from the group consisting of glycopyrronium pharmaceutically acceptable salts, especially the bromide, trospium pharmaceutically acceptable salts, especially the chloride, propiverine and its pharmaceutically acceptable addition salts, especially the hydrochloride; and solifenacin its pharmaceutically acceptable addition salts, especially the succinate, in admixture with a pharmaceutical carrier or vehicle.
  • compositions comprising or consisting essentially of, for example:
  • a pharmaceutical composition in dosage unit form comprising or consisting essentially of a M 2 -antagonist consisting of alvameline tartrate, an amount, in alvameline, of from 160 mg to 960 mg, preferably from 240 mg to 960 mg, in admixture with a pharmaceutical carrier or vehicle; and
  • nAEA consisting of ondansetron hydrochloride dihydrate, in an amount (in ondansetron of from 4 mg to 24 mg , preferably from 8 mg to 24 mg;
  • nsPAChA consisting of solifenacin succinate, in an amount of from 5 mg to 30 mg, advantageously from 12 mg to 30 mg, preferably from 12 mg to 21 mg, in admixture with a pharmaceutical carrier or vehicle.
  • compositions comprising or consisting essentially of, for example:
  • a pharmaceutical composition in dosage unit form comprising or consisting essentially of a M 2 -antagonist consisting of alvameline tartrate, an amount, in alvameline, of from 160 mg to 960 mg, preferably from 240 mg to 960 mg, in admixture with a pharmaceutical carrier or vehicle; and
  • nAEA consisting of ondansetron hydrochloride dihydrate, in an amount (in ondansetron of from 4 mg to 24 mg , preferably from 8 mg to 24 mg;
  • nsPAChA consisting of propiverine hydrochloride, in an amount of from 7.5 mg to 180 mg, advantageously from 15 mg to 120 mg, advantageously from 20 mg to 60 mg, normally from 30 to 60 mg;
  • the invention provides a kit comprising (a/c) a fixed-dose combination that is a pharmaceutical composition comprising or consisting essentially of
  • composition in dosage unit form comprising or consisting essentially of a nAEA in admixture with a pharmaceutical carrier.
  • M 2 -antagonist selected from the group consisting of M 2 -antagonist being preferably selected from the group consisting of 5-(2-ethyl-2H-tetrazol-5-yl)-l- methyl-1,2, 3,6-tetrahydropyridine (alvameline) and pharmaceutically salts and solvates thereof; 5,1 l-dihydro-8-chloro-l l-[[4-[3-[(2,2-dimethyl-l- oxopentyl)ethylamino]propyl] - 1 -piperidinyl] acetyl] -6H-pyrido[2,3- b][l,4]benzodiazepin-6-one (BIBN-99) and pharmaceutically acceptable salts and solvates thereof; racemic l l-[[2-(Diethylamino)methyl]-l-piperidinyl]- acetyl] -5,11 -dihydro-6H-pyr
  • a pharmaceutical composition in dosage unit form comprising or consisting essentially of a nAEA selected from the group consisting of alosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; azasetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; ondansetron and pharmaceutically acceptable salts and solvates thereof, especially its monohydrochloride dihydrate; granisetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; dolasetron and pharmaceutically acceptable salts and solvates thereof, especially its monomethanesulfonate monohydrate, ramosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; tropisetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; palonosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; domperidone and pharmaceutically acceptable salts and solvates thereof, especially its maleate; metoclopr
  • a M 2 -antagonist selected from the group consisting of alvameline, as free base or a salt or solvate thereof, especially as its tartrate, in an amount, in alvameline, of from 160 mg to 960 mg, preferably from 240 mg to 960 mg; tripitramine, as free base or a salt or solvate thereof, especially as its sesquifumarate or tetraoxalate salt, in an amount, in tripitramine, of from 10 mg to 200 mg, preferably from 25 mg to 100 mg; (+)-dimetindene or S(+)- dimethindene, in an amount of from 1.1 mg to 32 mg, preferably from 1.2 mg to 15 mg; otenzepad, as free base or as the maleate (1 : 1), fumarate (1 : 1), dihydrochloride, dihydrochloride dihydrate, dihydrobromide or the monomethanesulfonate, in an amount of from 100 mg to 500 mg, preferably from 150 mg to
  • nsPAChA selected from the group consisting of from 25 mg to 300 mg, normally from 60 mg to 200 mg; butylscopolamine bromide in an amount of from 5 mg to 60 mg, normally from 12 mg to 40 mg; cimetropium bromide, in an amount of from 25 mg to 200 mg; clidinium bromide in an amount of from 1.25 mg to 15 mg, normally from 3 mg to 12 mg; fesoterodine fumarate, in an amount of from 4 mg to 48 mg, normally from 9.6 mg to 32 mg; glycopyrronium bromide in an amount of from 1 mg to 12 mg, normally from 2.2 to 8 mg; otilonium bromide in an amount of from 20 mg to 240 mg, normally from 48 mg to 160 mg; prifinium bromide in an amount of from 15 mg to 180 mg, normally from 36 mg to 120 mg; propiverine hydrochloride, in an amount of from 7.5 mg tp 180 mg, normally from 18 mg to 120 mg; solifenac
  • a pharmaceutical composition in dosage unit form comprising or consisting essentially of a nAEA selected from the group consisting of alosetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride, in an amount (in alosetron) of from 0.25 mg to 6 mg; azasetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride, in an amount (in azasetron) of from 5 mg to 60 mg; dolasetron and pharmaceutically acceptable salts and solvates thereof, in particular the mesylate, in an amount (in dolasetron) of from 25 mg to 600 mg; granisetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride, in an amount (in granisetron) of from 0.5 mg to 6 mg; ondansetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride dihydrate, in an amount (in ondansetron) of from 2 mg to 64 mg; palonosetron and pharmaceutically
  • Composition (a/c) of the kits of this third embodiment may be a pharmaceutical composition in dosage unit form comprising or consisting essentially of, as active ingredient, a combination of a M 2 -antagonist and of a nsPAChA at specific doses.
  • the present invention provides the fixed-dose Combination (a/c) as a pharmaceutical composition in dosage unit form comprising or consisting essentially of
  • nsPAChA selected from the group consisting of from 25 mg to 300 mg, normally from 60 mg to 200 mg; butylscopolamine bromide in an amount of from 5 mg to 60 mg, normally from 12 mg to 40 mg; cimetropium bromide, in an amount of from 25 mg to 200 mg; clidinium bromide in an amount of from 1.25 mg to 15 mg, normally from 3 mg to 12 mg; fesoterodine fumarate, in an amount of from 4 mg to 48 mg, normally from 9.6 mg to 32 mg; glycopyrronium bromide in an amount of from 1 mg to 12 mg, normally from 2.2 to 8 mg; otilonium bromide in an amount of from 20 mg to 240 mg, normally from 48 mg to 160 mg; prifinium bromide in an amount of from 15 mg to 180 mg, normally from 36 mg to 120 mg; propiverine hydrochloride, in an amount of from 7.5 mg tp 180 mg, normally from 18 mg to 120 mg; solifenac
  • a M 2 -antagonist selected from the group consisting of alvameline, as free base or a salt or solvate thereof, especially as its tartrate salt may be present in an amount, in alvameline, of from 160 mg to 960 mg, preferably from 240 mg to 960 mg; tripitramine, as free base or a salt or solvate thereof, especially as its sesquifumarate or tetraoxalate salt, in an amount, in tripitramine, of from 10 mg to 200 mg, preferably from 25 mg to 100 mg; (+)-dimetindene or S(+)-dimethindene, in an amount of from 1.1 mg to 32 mg, preferably from 1.2 mg to 15 mg; otenzepad, as free base or as the maleate (1: 1), fumarate (1: 1), dihydrochloride, dihydrochloride dihydrate, dihydrobromide or the monomethanesulfonate, in an amount of from 100 mg to 500 mg, preferably from
  • nsPAChA selected from the group consisting of from 25 mg to 300 mg, normally from 60 mg to 200 mg; butylscopolamine bromide in an amount of from 5 mg to 60 mg, normally from 12 mg to 40 mg; cimetropium bromide, in an amount of from 25 mg to 200 mg; clidinium bromide in an amount of from 1.25 mg to 15 mg, normally from 3 mg to 12 mg; fesoterodine fumarate, in an amount of from 4 mg to 48 mg, normally from 9.6 mg to 32 mg; glycopyrronium bromide in an amount of from 1 mg to 12 mg, normally from 2.2 to 8 mg; otilonium bromide in an amount of from 20 mg to 240 mg, normally from 48 mg to 160 mg; prifinium bromide in an amount of from 15 mg to 180 mg, normally from 36 mg to 120 mg; propiverine hydrochloride, in an amount of from 7.5 mg tp 180 mg, normally from 18 mg to 120 mg; solifenac
  • the invention provides a kit comprising
  • composition in dosage unit form comprising or consisting essentially of a nsPAChA in admixture with a pharmaceutical carrier.
  • a M 2 -antagonist selected from the group consisting of 5-(2-ethyl-2H-tetrazol-5- yl)-l -methyl- 1,2, 3,6-tetrahydropyridine (alvameline) and pharmaceutically acceptable salts and solvates thereof; 5,l l-dihydro-8-chloro-l l-[[4-[3-[(2,2- dimethyl- 1 -oxopentyl)ethylamino]propyl] - 1 -piperidinyl] acetyl] -6H-pyrido [2,3 - b][l,4]benzodiazepin-6-one (BIBN-99) and pharmaceutically acceptable salts and solvates thereof; racemic l l-[[2-(Diethylamino)methyl]-l-piperidinyl]- acetyl] -5,11 -dihydro-6H-pyrido [2,3 -b] [ 1 ,
  • naAEA selected from the group consisting of alosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; azasetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; ondansetron and pharmaceutically acceptable salts and solvates thereof, especially its monohydrochloride dihydrate; granisetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; dolasetron and pharmaceutically acceptable salts and solvates thereof, especially its monomethanesulfonate monohydrate, ramosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; tropisetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; palonosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; domperidone and pharmaceutically acceptable salts and solvates thereof, especially its maleate; chlorpromazine and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride
  • a pharmaceutical composition in dosage unit form comprising or consisting essentially of a nsPAChA selected from the group consisting of anisotropine pharmaceutically acceptable salts, butylscopolamine pharmaceutically acceptable salts, cimetropium pharmaceutically acceptable salts, clidinium pharmaceutically acceptable salts, fesoterodine and pharmaceutically acceptable salts thereof, glycopyrronium pharmaceutically acceptable salts, otilonium pharmaceutically acceptable salts, oxyphencyclimine and pharmaceutically acceptable salts thereof, prifinium pharmaceutically acceptable salts, propiverine and pharmaceutically acceptable salts thereof, solifenacin and pharmaceutically acceptable salts thereof, tolterodine and pharmaceutically acceptable salts thereof, timepidium pharmaceutically acceptable salts, trospium pharmaceutically acceptable salts TTS- oxybutynin; and valethamate pharmaceutically acceptable salts,
  • a M 2 -antagonist selected from the group consisting of alvameline, as free base or a salt or solvate thereof, especially as its tartrate salt, in an amount, in alvameline, of from 160 mg to 960 mg, preferably from 240 mg to 960 mg; tripitramine, as free base or a salt or solvate thereof, especially as its sesquifumarate or tetraoxalate salt, in an amount, in tripitramine, of from 10 mg to 200 mg, preferably from 25 mg to 100 mg; (+)-dimetindene or S(+)- dimethindene, in an amount of from 1.1 mg to 32 mg, preferably from 1.2 mg to 15 mg; otenzepad, as free base or as the maleate (1 : 1), fumarate (1 : 1), dihydrochloride, dihydrochloride dihydrate, dihydrobromide or the monomethanesulfonate, in an amount of from 100 mg to 500 mg, preferably from 150 mg
  • a nAEA selected from the group consisting of alosetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride, in an amount (in alosetron) of from 0.25 mg to 6 mg; azasetron and pharmaceutically acceptable salts and solvates thereof, in particular the hydrochloride, in an amount (in azasetron) of from 5 mg to 60 mg; dolasetron and pharmaceutically acceptable salts and solvates thereof, in particular the mesylate, in an amount
  • a nsPAChA selected from the group consisting of anisotropine hydrobromide, in an amount of from 25 mg to 300 mg, normally from 60 mg to 200 mg; butylscopolamine bromide in an amount of from 5 mg to 60 mg, normally from 12 mg to 40 mg; cimetropium bromide, in an amount of from 25 mg to 200 mg; clidinium bromide in an amount of from 1.25 mg to 15 mg, normally from 3 mg to 12 mg; fesoterodine fumarate, in an amount of from 4 mg to 48 mg, normally from 9.6 mg to 32 mg; glycopyrronium bromide in an amount of from 1 mg to 12 mg, normally from 2.2 to 8 mg; otilonium bromide in an amount of from 20 mg to 240 mg, normally from 48 mg to 160 mg; prifinium bromide in an amount of from 15 mg to 180 mg, normally from 36 mg to 120 mg; propiverine hydrochloride, in an amount of from 7.5 mg to 180 mg,
  • kits of the present invention comprises each of the drugs making up the composition of the invention, along with instructions for use.
  • each of the drug components of the combination may be combined into a single administrable dosage form such as a capsule.
  • Said kit may include one or more tablets, hard or soft capsules containing the Component (a/b) and Component (c), in the dosage amounts within the ranges described above.
  • composition (a/b) of the kits of the present invention consisting of pharmaceutical composition in dosage unit form comprising, as active ingredient, a combination with a M 2 -antagonist and of a nAEA is novel and a further object of the present invention.
  • the present invention further provides a pharmaceutical composition in dosage unit form comprising or consisting essentially of
  • solifenacin succinate when present as Component (c), preferably is in an amount selected from the group consisting of "from 5 mg to 30 mg", “from 12 mg to 30 mg”, and "from 12 mg to 21 mg".
  • each of the above kits may comprise, as a further component of the combinations contained therein, Component (dg), an AChEI also formulated in a pharmaceutical composition, said AChEI being selected from the group consisting of l,2,3,4-tetrahydro-9-acridinamine (tacrine) and pharmaceutically acceptable salts and solvates thereof, (+)-2,3-dihydro-5,6-dimethoxy-2-[[l- (phenylmethyl)-4-piperidinyl] methyl] - 1 H-inden- 1 -one (donepezil) and pharmaceutically acceptable salt and solvates thereof, (S)-N-Ethyl-N-methyl-3-[l- (dimethylamino)ethyl] -phenyl carbamate (rivastigmine) and pharmaceutically acceptable salts and solvates thereof, 4aS,6R,8aS-3-methoxy-l l-methyl- 4a,5,9,10
  • donepezil hydrochloride is generally present at a dose of from 5 mg to 98 mg, advantageously from 15 mg to 69 mg, normally from 15 mg to 60 mg; rivastigmine, as hydrogen tartrate, is present, in a composition for oral administration, at a dose in rivastigmine, of from 1.5 mg to 30 mg, advantageously from 6 mg to 24 mg, normally from 9 mg to 18 mg; rivastigmine, as the free base, is present in patch releasing from 4.6mg/24h to 52mg/24h, advantageously from 9.6mg/24h to 39.9mg/24h, normally from 13.3mg/24h to 39.9mg/24h rivastigmine; and galantamine, as hydrobromide, is present in an amount of from 4 mg to 96 mg, advantageously from 12 mg to 96 mg, normally from 18 mg to 48 mg.
  • the present invention also provides a kit comprising or essentially consisting of
  • compositions in dosage unit form essentially consisting of a M 2 - antagonist, in admixture with a pharmaceutical carrier or vehicle;
  • compositions in dosage unit form essentially consisting of a naAEA, in admixture with a pharmaceutical carrier or vehicle;
  • compositions in dosage unit form essentially consisting of a nsPAChA, in admixture with a pharmaceutical carrier or vehicle;
  • a pharmaceutical composition dosage unit form essentially consisting of an AChEI selected from the group consisting of donepezil hydrochloride in an amount of from 5 mg to 98 mg, advantageously from 15 mg to 69 mg, normally from 15 mg to 60 mg; rivastigmine, as hydrogen tartrate, in an amount, in rivastigmine, of from 1.5 mg to 30 mg, advantageously from 6 mg to 24 mg, normally from 9 mg to 18 mg; rivastigmine, as the free base, in patch releasing from 4.6mg/24h to 52mg/24h, advantageously from 9.6mg/24h to 39.9mg/24h, normally from 13.3mg/24h to 39.9mg/24h rivastigmine; and galantamine, as hydrobromide, in an amount (in galantamine, of from 4 mg to 96 mg, advantageously from 12 mg to 96 mg, normally from 18 mg to 48 mg,
  • the AChEI Component (d) may be combined with any M 2 -antagonist Component (a) and with any naAEA Component (b) and with any nsPAChA Component (c) illustrated in this section, in a quadruple combination useful as a cocktail for combating hypocholinergic disorders of the CNS as herein above defined.
  • a M 2 -antagonist selected from the group consisting of alvameline, as free base or a salt or solvate thereof, especially as its tartrate salt, in an amount, in alvameline, of from 160 mg to 960 mg, preferably from 240 mg to 960 mg; tripitramine, as free base or a salt or solvate thereof, especially as its sesquifumarate or tetraoxalate salt, in an amount, in tripitramine, of from 10 mg to 200 mg, preferably from 25 mg to 100 mg; (+)-dimethindene or S(+)- dimethindene, in an amount of from 1.1 mg to 32 mg, preferably from 1.2 mg to 15 mg; otenzepad, as free base or as the maleate (1 : 1), fumarate (1 : 1), dihydrochloride, dihydrochloride dihydrate, dihydrobromide or the monomethanesulfonate, in an amount of from 100 mg to 500 mg, preferably from 150
  • a pharmaceutical composition in dosage unit form essentially consisting of a nsPAChA selected from the group consisting of anisotropine hydrobromide, in an amount of from 25 mg to 300 mg, normally from 60 mg to 200 mg; butylscopolamine bromide in an amount of from 5 mg to 60 mg, normally from 12 mg to 40 mg; cimetropium bromide, in an amount of from 25 mg to 200 mg; clidinium bromide in an amount of from 1.25 mg to 15 mg, normally from 3 mg to 12 mg; fesoterodine fumarate, in an amount of from 4 mg to 48 mg, normally from 9.6 mg to 32 mg; glycopyrronium bromide in an amount of from 1 mg to 12 mg, normally from 2.2 to 8 mg; otilonium bromide in an amount of from 20 mg to 240 mg, normally from 48 mg to 160 mg; prifinium bromide in an amount of from 15 mg to 180 mg, normally from 36 mg to 120 mg; propiverine hydrochloride
  • a kit according to a preferred form of this second aspect of this third embodiment essentially consists of a combination of the above Components (a) and (b) with
  • a pharmaceutical composition in dosage unit form comprising or essentially consisting of the nsPAChA TTS -oxybutynin, as a patch releasing from 3.9mg/24 to 7.8mg/24h, advantageously grom 3.9mg/24h, normally 3.9mg/24h oxybutynin, in admixture with a pharmaceutical carrier or vehicle; and
  • composition in dosage unit form comprising or essentially consisting of the AChEI rivastigmine in a patch releasing from 4.6mg/24h to
  • a particularly preferred form of this second aspect of this third embodiment essentially consists of a combination of the above Component (a/b) fixed-dose combination with a Component (c/d) fixed-dose combination that is a pharmaceutical composition in dosage unit form comprising or consisting essentially of
  • Said patch advantageously releases from 3.9mg/24h to 7.85mg/24h, normally 3.9 mg/24h oxybutynin; and from 4.6mg/24h to 39.9mg/24h, normally from 4.6mg/24h to 13.3mg/24h rivastigmine.
  • compositions (a/b) of the kits of the present invention described above are each novel and a further object of the present invention.
  • the invention also provides a kit comprising
  • composition in dosage unit form comprising or consisting essentially of a M 2 -antagomist in admixture with a pharmaceutical carrier or vehicle;
  • nsPAChA selected from the group consisting of solifenacin succinate, in an amout of from 5 mg to 30 mg, normally from 10 mg to 21 mg, propiverine hydrochloride, in an amount of from 7.5 mg to 180 mg, normally from 30 mg to
  • glycopyrronium bromide in an amount of from 1 mg to 12 mg, normally fom 2 mg to 8 mg,; and trospium chloride, in an amount of from 10 mg to 240 mg, normally from 20 mg to 80 mg,
  • composition in dosage unit form comprising or consisting essentially of anAChEI, essentially consisting of donepezil hydrochloride, in an amount of from 5 mg to 60 mg, in admixture with a pharmaceutical carrier or vehicle,
  • the (b/c) fixed-dose combination is administered to a patient in need of the treatment as a single unit form at the doses illustrated in "The Combinations" section.
  • This kit has the advantage of allowing an improvement in the treatment of a patient suffering from a hypocholinergic disorder due to synergistic action of the antiemetic/anticholinergic combination .
  • compositions prepared by using the nsPAChAs according to the present invention are present in unit forms also containing a M 2 -antagonist that acts by presynaptically releasing acetylcholine in the CNS to improve the symptoms of Alzheimer type dementia.
  • a muscarinic receptor antagonist selected from the group consisting of selective M 2 - antagonists;
  • naAEA non-anticholinergic antiemetic agent
  • a muscarinic receptor antagonist selected from the group consisting of nonselective, peripheral anticholinergic agents (nsPAChAs); and, optionally,
  • unit form will also be used to designate a “pharmaceutical composition in dosage unit form”.
  • the pharmaceutical composition to improve the treatment of human hypocholinergic disorders comprises or consists essentially of a mixture of a M 2 -antagonist [Component (a)], a nAEA [Component (b)] and of a nsPAChA [Component (c)] wherein Component (a) is present in a quantity sufficient or effective to maximally alleviate disease-associated neurobehavioral symptoms for the treatment of hypocholinergic disorders, and wherein Component (b) and Component (c), the latter not appreciably penetrating the blood brain barrier, surprisingly act synergistically to attenuate the dose-limiting side effects of the M 2 - antagonists, thus enabling a greater increase in the MTD of said M 2 -antagonists, with attending increase in the therapeutic efficacy of M 2 -antagonists.
  • Such a composition allows high doses of M 2 -antagonist Component (a) to be safely used, that would have otherwise been dangerous in the absence of Components (b) and (c)]
  • the pharmaceutical composition of the present invention improves the treatment of human hypocholinergic disorders of the CNS as described above, such as dementias of the Alzheimer type and schizophrenia.
  • Any M 2 -antagonist, any naAEA and any nsPAChA as described herein, and exemplified in the above "The Combinations" section may be formulated in a pharmaceutical composition in a single unit form, in admixture with at least one pharmaceutical carrier according to conventional methods in the art, and as exemplified in the "The Formulations” section below.
  • the M 2 -antagonist Component (a) is present in an amount of from 0.5 mg to 1500 mg.
  • the M 2 - antagonist Component (a) is present, in an IR-form, in an amount of from 0.5 mg to 1000 mg and in an ER-form in an amount of from 1.5 mg to 1500 mg.
  • Any one of the antagonists of the M 2 receptor subtype illustrated in the above "The M 2 -Antagonists" section may be a suitable Component (a), a M 2 -antagonist selected from the group consisting of alvameline, ⁇ 3 ⁇ -99, otenzepad, (S)-(+)- otenzepad, AF-DX 384, dimethindene, (S)-(+)-dimethindene, tripitramine, himbacine, (+)-himbacine, the himbacine analog, i.e.
  • a a M 2 -antagonist selected from the group consisting of alvameline, ⁇ 3 ⁇ -99, otenzepad, (S)-(+)- otenzepad, AF-DX 384, dimethindene, (S)-(+)-dimethindene, tripitramine, himbacine, (+)-himbacine, the himbacine analog, i.e.
  • a M2-antagonist selected from the group consisting of
  • alvameline as free base or a salt or solvate thereof, especially as its tartrate, may be present in an amount, in alvameline, of from 160 mg to 960 mg, preferably from 240 mg to 960 mg;
  • - tripitramine as free base or a salt or solvate thereof, especially as its sesquifumarate or tetraoxalate salt, in an amount of from 10 mg to 200 mg, preferably from 10 mg to 100 mg in a IR-form or from 25 mg to 200 mg in an ER-form;
  • - dimetindene preferably as the maleate thereof, as racemate or as its S(+) enantiomer, in an amount of from 1.2 mg to 30 mg, preferably from 1.2 mg to 15 mg in a IR-form or, as the free base or the maleate thereof, in an amount of from 3 mg to 30 mg, preferably from 3 mg to 10 mg, in an ER-form, including a TTS;
  • - otenzepad as free base or as the maleate (1 : 1), fumarate (1 : 1), dihydrochloride, dihydrochloride dihydrate, dihydrobromide or the monomethanesulfonate (INN: monomesilate, USAN: monomesylate) thereof, in an amount of from 100 mg to 500 mg, preferably from 150 mg to 350 mg in a IR unit form or as the free base or as one of the aforementioned salts, in an amount of from 200 mg to 500 mg, preferably from 300 mg 1500 mg, in an ER-form, including a TTS;
  • - AQ-RX 741 as free base or as a salt or solvate thereof, especially as its monomethanesulfonate salt, in an amount of from 10 mg to 500 mg, preferably from 10 mg to 250 mg in a IR-form or, as the free base or the methanesulfonate salt thereof, in an amount of from 20 mg to 500 mg, preferably from 50 mg to 500 mg, in an ER- form, including a TTS;
  • Any non- anticholinergic antiemetic agents especially those illustrated in the above "The naAEAs" section may be a suitable Component (b).
  • the Component (b) of the fixed-dose combination may be a non- anticholinergic antiemetic agent selected from the group consisting of (bl) 5HT3- antagonists, (b2) DA-antagonists, (b3) Hl-antagonists, (b4) cannabinoids, (b5) NK1- antgagonists.
  • a non- anticholinergic antiemetic agent selected from the group consisting of (bl) 5HT3- antagonists, (b2) DA-antagonists, (b3) Hl-antagonists, (b4) cannabinoids, (b5) NK1- antgagonists.
  • Component (b) of the fixed-dose combination is selected from the group consisting of alosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; azasetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; ondansetron and pharmaceutically acceptable salts and solvates thereof, especially its monohydrochloride dihydrate; granisetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; dolasetron and pharmaceutically acceptable salts and solvates thereof, especially its monomethanesulfonate monohydrate, ramosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; tropisetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; palonosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; domperidone and pharmaceutically acceptable salts and solvates thereof, especially its maleate; metoclopramide and pharmaceutically acceptable
  • any one of the non-selective, muscarinic antagonists that do not appreciably penetrate into the CNS, especially those illustrated in the above "The nsPAChAs" section may be a suitable Component (c).
  • nsPAChAs are solifenacin and its salts, propiverine and its salts, oxyphencyclimine and its salts, tolterodine and its salts, fesoterodine and its salts; and quaternary ammonium salts or sulfonium salts of formula I above, such as homatropine quaternary salts, anisotropine quaternary salts, trospium quaternary salts, clidinium quaternary salts, benzilonium quaternary salts and glycopyrronium quaternary salts.
  • Suitable quaternary ammonium salts are scopolamine methobromide, scopolamine butylbromide, scopolamine methonitrate, isopropamide iodide, valethamate bromide, atropine methobromide, atropine methonitrate, diponium bromide, pipenzolate bromide, penthienate bromide, benactizine methobromide, diphemanil, emeprioum bromide and dibutoline sulfate.
  • Anisotropine hydrobromide; butylscopolamine bromide; cimetropium bromide; clidinium bromide; glycopyrronium bromide; methylpropiverinium iodide or bromide; otilonium bromide; prifinium bromide; timepidium bromide; trospium chloride, succinate, maleate, fumarate or tartrate; valethamate bromide; fesoterodine and its fumarate; oxyphencyclimine and its hydrochloride; propiverine and its hydrochloride; solifenacin and its succinate; tolterodine and the L-hydrogen tartrate thereof; fesoterodine and the fumarate thereof; and TTS-oxybutynin are particularly advantageous nsPAChAs used as Component (c).
  • the nsPAChA Component (c) is preferably present in an amount of from 50% to 600%, preferably from 1.2-fold to 6 times the maximum IR amount of said nsPAChA contained in the currently administered IR dosage unit forms for the anticholinergic theerapy.
  • the nsPAChA is present, in an IR unit form, in an amount ranging from 50% to 400%, preferably from 120% to 400%, the maximum amount of said nsPAChA contained in the currently administered IR dosage unit forms for the anticholinergic therapy or, in an ER unit form, in an amount ranging from 75% to 600%, preferably from 120% to 600%, the maximum amount of said nsPAChA contained in the currently administered unit dosage IR forms for the anticholinergic therapy.
  • nsPAChAs used as Component (c) of the fixed-dose combination.
  • anisotropine hydrobromide is present in an amount of from 25 mg to 300 mg, advantageously from 60 mg to 300 mg, in IR or ER form, preferably from 60 mg to
  • butylscopolamine bromide is present in an amount of from 5 mg to 60 mg, advantageously from 12 mg to 60 mg in IR or ER form, preferably from 12 mg to 40 mg in IR form;
  • - cimetropium bromide is present in an amount of from 25 mg to 300 mg, advantageously from 60 mg to 300 mg in IR or ER form, preferably from 60 mg to 200 mg in IR form;
  • - clidinium bromide is present in an amount of from 1.25 mg to 15 mg, advantageously from 3 mg to 15 mg in IR or ER form, preferably from 3 mg to 10 mg in IR form;
  • - fesoterodine fumarate ER is present in an amount of from 4 mg to 32 mg, advantageously from 9.6 mg to 32 mg, preferably from 9.6 mg to 24 mg;
  • - glycopyrronium bromide is present in an amount of from 1 mg to 8 mg, advantageously from 2.4 mg to 8 mg in IR or ER form, preferably from 2.4 mg to 4 mg in IR form;
  • - otilonium bromide is present in an amount of from 20 mg to 160 mg, advantageously from 48 mg to 160 mg in IR or ER form, preferably from 48 mg to 120 mg in IR form;
  • - oxyphencyclimine is present in an amount of from 5 mg to 60 mg, advantageously from 18 mg to 60 mg in IR or ER form, preferably from 18 mg to 40 mg in IR form;
  • - prifinium bromide is present in an amount of from 15 mg to 120 mg, 36 mg to 120 mg in IR or ER form, preferably from 36 mg to 90 mg in IR form;
  • - propiverine hydrochloride IR is present in an amount of from 7.5 mg to 90 mg. advantageously from 18 mg to 60 mg, preferably from 18 mg to 45 mg;
  • - propiverine hydrochloride ER is present in an amount of from 15 mg to 180 mg, advantageously from 36 mg to 180 mg, preferably from 36 mg to 120 mg;
  • - solifenacin succinate is present in an amount of from 5 mg to 30 mg, advantageously from 12 mg to 30 mg, normally from 12 mg to 21 mg;
  • - tolterodine hydrogen tartrate is present in an amount of from 2 mg to 24 mg, advantageously from 4.8 mg to 24 mg in IR or ER form, preferably from 4.8 mg to 16 mg in IR form;
  • timepidium bromide is present in an amount of from 15 mg to 36 mg, advantageously from 36 mg to 180 mg IR or ER form, preferably from 36 mg to 120 mg in IR form;
  • - trospium chloride IR is present in an amount of from 10 mg to 120 mg, advantageously from 24 mg to 120 mg, normally from 24 mg to 80 mg;
  • - trospium chloride ER is present in n an amount of from 30 mg to 480 mg, advantageously from 72 mg to 360 mg, normally from 72 mg to 240 mg;
  • valethamate bromide is present in an amount of from 5 mg to 60 mg, advantageously from 12 mg to 60 mg in IR or ER form, preferably from 12 mg to 40 mg in IR form.
  • any one of the Components (a) may be combined with any one Component (b) and with any one Component (c) in a ternary fixed-dose combination comprising said Component (a), said Component (b) and said Component (c) in a pharmaceutical composition in dosage unit form in admixture with a pharmaceutical carrier for IR or ER administration.
  • the fixed-dose combination of the invention consists of a pharmaceutical composition in dosage unit form comprising or consisting essentially of (a) any of the M 2 -antagonists as illustrated in the above "The M 2 -antagonists" section, each in a pharmaceutical composition in admixture with a pharmaceutical carrier, said M 2 -antagonist being preferably selected from the group consisting of 5-(2- ethyl-2H-tetrazol-5-yl)-l -methyl- 1, 2,3, 6-tetrahydropyridine (alvameline) and pharmaceutically salts and solvates thereof, 5,l l-dihydro-8-chloro-l l-[[4-[3-[(2,2- dimethyl- 1 -oxopentyl)ethylamino]propyl] - 1 -piperidinyl] acetyl] -6H-pyrido[2,3- b][l,4]benzodiazepin-6-one (BIBN-99) and pharmaceutically
  • any of the naAEAs as illustrated in the above "The naAEAs" section said naAEA being preferably selected from the group consisting of alosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; azasetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; ondansetron and pharmaceutically acceptable salts and solvates thereof, especially its monohydrochloride dihydrate; granisetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; dolasetron and pharmaceutically acceptable salts and solvates thereof, especially its monomethanesulfonate monohydrate, ramosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; tropisetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; palonosetron and pharmaceutically acceptable salts and solvates thereof, especially its hydrochloride; domperidone and pharmaceutically acceptable salts and
  • any of the nsPAChAs as illustrated in the above "The nsPAChAs" section said nsPAChA being preferably selected from the group consisting of anisotropine pharmaceutically acceptable quaternary salts, butylscopolamine pharmaceutically acceptable salts, cimetropium pharmaceutically acceptable salts, clidinium pharmaceutically acceptable salts, fesoterodine and pharmaceutically acceptable salts thereof, glycopyrronium pharmaceutically acceptable salts, otilonium pharmaceutically acceptable salts, oxyphencyclimine and pharmaceutically acceptable salts thereof, prifinium pharmaceutically acceptable salts, propiverine and pharmaceutically acceptable salts thereof, solifenacin and pharmaceutically acceptable salts thereof, tolterodine and pharmaceutically acceptable salts thereof, timepidium pharmaceutically acceptable salts, trospium pharmaceutically acceptable salts and valethamate pharmaceutically acceptable salts;
  • an advantageous fixed-dose combination consists of a pharmaceutical composition comprising or consisting essentially of
  • a M 2 -antagonist selected from the group consisting of alvameline, as free base or a salt or solvate thereof, especially as its tartrate salt may be present in an amount, in alvameline, of from 160 mg to 960 mg, preferably from 240 mg to 960 mg; tripitramine, as free base or a salt or solvate thereof, especially as its sesquifumarate or tetraoxalate salt, in an amount, in tripitramine, of from 10 mg to 200 mg, preferably from 25 mg to 100 mg; (+)-dimetindene or S(+)-dimethindene, in an amount of from 1.1 mg to 32 mg, preferably from 1.2 mg to 15 mg; otenzepad, as free base or as the maleate (1: 1), fumarate (1: 1), dihydrochloride, dihydrochloride dihydrate, dihydrobromide or the monomethanesulfonate, in an amount of from 100 mg to 500 mg, preferably from
  • nsPAChA selected from the group consisting of
  • anisotropine hydrobromide in an amount of from 25 mg to 300 mg, advantageously from 60 mg to 300 mg, normally from 60 mg to 200 mg;
  • butylscopolamine bromide in an amount of from 12 mg to 60 mg, advantageously from 12 mg to 60 mg, normally from 12 mg to 40 mg;
  • - clidinium bromide in an amount of from 1.5 mg to 15 mg, advantageously from 3 mg to 15 mg, normally from 3 mg to 12 mg;
  • - otilonium bromide in an amount of from 20 mg to 240 mg, advantageously from 48 mg to 240 mg, normally from 48 mg to 160 mg;
  • - prifinium bromide in an amount of from 15 mg to 180 mg, advantageously from 36 mg to 180 mg, notmally from 36 mg to 120 mg;
  • - trospium chloride in an amount of from 10 mg to 480 mg, advantageously from 24 mg to 360 mg, normally from 24 mg to 240 mg;
  • valethamate bromide in an amount of from 5 mg to 60 mg, advantageously from 12 mg to 60 mg, normally from 12 mg to 40 mg,
  • composition being formulated in an IR dosage unit form in admixture with a pharmaceutical carrier or vehicle.
  • a particularly advantageous fixed-dose combination consists of a pharmaceutical unit form comprising or consisting essentially of
  • alvameline, as free base or a salt or solvate thereof, especially as its tartrate salt may be present in an amount, in alvameline, of from 160 mg to 960 mg, preferably from 240 mg to 960 mg; tripitramine, as free base or a salt or solvate thereof, especially as its sesquifumarate or tetraoxalate salt, in an amount, in tripitramine, of from 10 mg to 200 mg, preferably from 25 mg to 100 mg; (+)-dimetindene or S(+)- dimethindene, in an amount of from 1.1 mg to 32 mg, preferably from 1.2 mg to 15 mg; otenzepad, as free base or as the maleate (1 : 1), fumarate (1 : 1), dihydrochloride, dihydrochloride dihydrate, dihydrobromide or the monomethanesulfonate, in an amount of from 100 mg to 500 mg, preferably from 150 mg to 350 mg; and AQ- RX 741
  • nsPAChA selected from the group consisting of
  • - solifenacin succinate in an amount of from 12 mg to 30 mg, normally from 12 mg to 21 mg;
  • a particularly advantageous fixed-dose combination consists of a pharmaceutical dosage unit form comprising or consisting essentially of
  • alvameline, as free base or a salt or solvate thereof, especially as its tartrate salt may be present in an amount, in alvameline, of from 160 mg to 960 mg, preferably from 240 mg to 960 mg; tripitramine, as free base or a salt or solvate thereof, especially as its sesquifumarate or tetraoxalate salt, in an amount, in tripitramine, of from 10 mg to 200 mg, preferably from 25 mg to 100 mg; (+)-dimetindene or S(+)- dimethindene, in an amount of from 1.1 mg to 32 mg, preferably from 1.2 mg to 15 mg; otenzepad, as free base or as the maleate (1 : 1), fumarate (1 : 1), dihydrochloride, dihydrochloride dihydrate, dihydrobromide or the monomethanesulfonate, in an amount of from 100 mg to 500 mg, preferably from 150 mg to 350 mg; and AQ- RX 741
  • ondansetron as free base or hydrochloride dihydrate, in an amount (in ondansetron) of from 2 mg to 64 mg;
  • propiverine as a salt thereof such as its hydrochloride, in an amount of from 7.5 mg to 180 mg, advantageously from 15 mg to 120 mg, normally from 45 mg to 90 mg;
  • each of the above fixed-dose combinations may include, as a further component (d), an AChEI also formulated in a pharmaceutical composition, said AChEI being selected from the group consisting of 1,2,3,4- tetrahydro-9-acridinamine (tacrine) and pharmaceutically acceptable salts and solvates thereof, (+)-2,3-dihydro-5,6-dimethoxy-2-[[l-(phenylmethyl)-4-piperidinyl]methyl]- lH-inden-l-one (donepezil) and pharmaceutically acceptable salt and solvates thereof, (S)-N-Ethyl-N-methyl-3-[l-(dimethylamino)ethyl]-phenyl carbamate (rivastigmine) and pharmaceutically acceptable salts and solvates thereof, 4aS,6R,8aS-3-methoxy-l l- methyl-4a,5,9, 10,l l, 12-hexahydroxy-6H-benz
  • any of the above fixed-dose combinations and any of the pharmaceutical compositions that are part of the above combinations and kits are formulated with pharmaceutical carriers, diluents, vehicles and devices according to known and conventional methods and/or technologies in the art and as illustrated in the "The Formulations" section below.
  • any of the above fixed-dose combinations and any of the above pharmaceutical compositions may further include a component (d) an AChEI.
  • the AChEI Component (d) when included in the combination with Component (a), Component (b) and Component (c) as described herein, may be present in an amount of from about 100% to about 1000% of a recommended dose of Component (d) contained in a unit form used for the treatment of Alzheimer type dementia.
  • donepezil hydrochloride is present at a dose of from 5 mg to 98 mg, advantageously from 10 mg to 98 mg, preferably from 15 mg to 69 mg, normally from 15 mg to 60 mg; rivastigmine, as hydrogen tartrate, is present, in a composition for oral administration, at a dose, in rivastigmine, of from 1.5 mg to 30 mg, advantageously from 6 mg to 30 mg, preferably from 9 mg to 24 mg, normally from 9 mg to 18 mg; rivastigmine, as the free base, is present in patch releasing from 4.6mg/24h to 52mg/24h, advantageously from 9.6mg/24h to 39.9mg/24h, normally from 13.3mg/24h to 39.9mg/24h or from 4.6mg/24h to 13.3mg/24h rivastigmine; and galantamine, as hydrobromide, is present in an amount of from 4 mg to
  • the unit form of the present invention may be a tablet, a capsule, a pre-measured volume of a liquid solution or suspension for oral administration or a TTS as a gel or patch, including spray patches, for transdermal application.
  • the nsPAChA and M 2 antagonist, as free base are as a pharmaceutically acceptable salt or solvate thereof, may be mixed together or separated according to known technologies in admixture with a pharmaceutical carrier in a pharmaceutical composition.
  • Component (a), Component (b) and/or Component (c), and optionally a further Component (d), are formulated with conventional pharmaceutical carriers in known formulations for oral use wherein said components are mixed together or separated, for example in two or three tablets introduced in a capsule or in a two-compartment capsule, wherein one of the Components (a), (b) and (c), is in a first of the two compartments and the two other Components are in the second of the two compartments, or in a multilayer (di-layer or tri-layer) tablet wherein the three components are all in IR or in ER form or one or two Components is in IR form and the other(s) is/are in ER form, according to known technologies.
  • Component (d) may be optionally included in the first or second compartment, or optionally included in a multilayer tablet as described herein above, with one or more of Components (a), (b) and (c).
  • the pharmaceutical carriers and vehicles are those commonly used for the preparation of compositions for oral, buccal, including sublingual, and parenteral, in particular transdermal, administration.
  • Appropriate unit forms comprise the oral forms such as tablets, including orodispersible tablets and orosoluble tablets, soft or hard gelatin capsules, powders or granulates in sachets and suitably measured oral solutions or suspensions as well as patches for transdermal administration.
  • Component (a), Component (b) and/or Component (c), with optionally a further Component (d), may also be present in form of one of their complexes with a cyclodextrin, for example oc-cyclodextrin, ⁇ -cyclodextrin, ⁇ -cyclodextrin, 2- hydroxypropyl- -cyclodextrin or methyl- -cyclodextrin.
  • a cyclodextrin for example oc-cyclodextrin, ⁇ -cyclodextrin, ⁇ -cyclodextrin, 2- hydroxypropyl- -cyclodextrin or methyl- -cyclodextrin.
  • Component (a), Component (b) and/or Component (c), with optionally a further Component (d), may also be formulated in the form of microcapsules, optionally with one or more carriers or additives.
  • Component (a), Component (b) and/or Component (c), with optionally a further Component (d), together or separately, are formulated by mixing the active ingredient with conventional pharmaceutical acceptable carriers enabling said active ingredients to be formulated in tablets, dragees, orally disintegrating tablets, capsules, liquid solutions or suspensions, syrups and the like.
  • Carriers for IR tablets may include, but are not limited to, starches, cellulose and derivatives thereof; lubricants such as talc, stearic acid or magnesium stearate; diluents such as talc, powdered cellulose, lactose, starches such as maize or corn starch, mannitol, sorbitol; disaggregating agents such as microcrystalline cellulose or crospovidone; lubricants such as polyethylene glycol or magnesium stearate; ligands such as methylcellulose, sodium carboxymethylcellulose, alginic acid, alginates; sweeteners, such as sucrose, dextrose, mannitol, saccharin; or flavoring agents such as natural or synthetic oils.
  • lubricants such as talc, stearic acid or magnesium stearate
  • diluents such as talc, powdered cellulose, lactose, starches such as maize or corn starch, mannitol,
  • Carriers for orally disintegrating tablets may include, but are not limited to, lubricants, aggregating, sweetening, flavoring or disaggregating agents as well as agents improving the buccal mucosa absorption of Component (a), Component (b) and/or Component (c), with optionally a further Component (d), such as sorbitol, mannitol, lactose and cellulose.
  • Carriers for liquid, normally aqueous, suspensions or solutions may include, but are not limited to, antioxidants, such as sodium metabisulfite or sodium sulfite, thickening agents, such as microcrystalline cellulose, hydroxypropylcellulose, carboxymethylcellulose or polyvinylpyrrolidone, preservatives such as methyl paraben, ethyl paraben, sodium ethylenediaminotetracetate, sodium benzoate or an alkaline salt of sorbic acid, as well as flavoring and sweetening agents.
  • antioxidants such as sodium metabisulfite or sodium sulfite
  • thickening agents such as microcrystalline cellulose, hydroxypropylcellulose, carboxymethylcellulose or polyvinylpyrrolidone
  • preservatives such as methyl paraben, ethyl paraben, sodium ethylenediaminotetracetate, sodium benzoate or an alkaline salt of sorbic acid, as well as flavoring and sweetening agents.
  • the sweeteners contained in the orally disintegrating tablets and the liquid suspensions or solutions may be natural, optional reduced sugars such as sucrose, dextrose, xylitol, mannitol or sorbitol, or synthetic product such as sodium saccharine or aspartame.
  • the flavoring agents are pharmaceutically acceptable flavors and tastes of synthetic and natural oils, the latter extracted from plants, leaves, flowers, fruits and their combinations, which include, but are not limited to, cinnamon, peppermint, anise and citron leaves, bitter almond, or citrus fruits, in particular orange and/or lemon, linden and grapefruit oils.
  • chocolate, vanilla or eucalyptus flavor and essences of fruit, in particular apple, pear, peach, strawberry, cherry, apricot, orange, lemon and/or grapes may be advantageously used.
  • composition according to the present invention may be in form of a capsule containing two tablets as described herein above, one of them comprising Component (a), and the other comprising Component (b) and Component (c) in admixture with each other and with a pharmaceutical carrier.
  • the unit form may also be a capsule containing two tablets as described herein above, one of them comprising Component (b), and the other comprising Component (a) and Component (c) in admixture with each other and with a pharmaceutical carrier.
  • the unit form may also be a capsule containing two tablets as described herein above, one of them comprising Component (c), and the other comprising Component (a) and Component (b) in admixture each other and with a pharmaceutical carrier.
  • Component (d) may be optionally included in the composition as described herein above, with one or more of Components (a), (b) and (c).
  • the unit form may also be a capsule containing three tablets as described herein above, one of them comprising Component (a), the second comprising Component (a) and the third comprising Component (c) in admixture with each other and with a pharmaceutical carrier.
  • Component (d) may be optionally included in the unit form as described herein above, with one or more of Components (a), (b) and (c).
  • the combination may be formulated in tablets in which one or both of the two components is in controlled-release formulation, for example as a dispersion of said component in hydroxypropyl methyl cellulose or in a film-coated microgranule.
  • the M 2 antagonist, in an ER-formulation is in the core and the nsPAChA and the naAEA, in IR-formulation, are in the outer layer in multi-layer tablets in which, for example, both the core and the outer layers are coated with a film.
  • capsules made of two separated compartments, one containing Component (a), in IR- or ER-formulation and the other containing Component (b) and Component (c), in ER- or, preferably, in IR formulation, may be used.
  • Component (d) may be optionally included in the combination as described herein above, with one or more of Components (a), (b) and (c).
  • Carriers and vehicles for ER tablets may include, but are not limited to, retardant materials such as acrylic and methacrylic acid polymers and copolymers; cellulose derivatives such as hydroxypropylmethylcellulose, hydroxyethylcellulose, hydroxypropylethylcellulose, hydroxypropylcellulose, methylcellulose, ethylcellulose, or sodium carboxymethylcellulose; gums; waxes; glycerides or aliphatic alcohols or a mixture thereof.
  • Component (a), Component (b) and/or Component (c), with optionally a further Component (d), as the base thereof or as a pharmaceutically acceptable salt thereof, may also be formulated, together or separately in any TTS such as a patch, a gel, a cream, a spray, an ointment, a lotion or a paste.
  • Component (a) or Component (b) or Component (c) is present in admixture with the common diluents and permeation enhancers for the TTS administration; or Component (a) and Component (c) are both present in admixture with the common diluents and permeation enhancers for the TTS administration; or the Component (a) and Component (c) are both present in admixture with the common diluents and permeation enhancers , or Component (a), Component (b) and Component (c) are altogether present in admixture with the common diluents and permeation enhancers.
  • Component (d) may be optionally included in the TTS as described herein above, with one or more of Components (a), (b) and (c).
  • the permeation enhancer may be any compound which allows the improved permeation of drugs through the skin (see for example the review in Pharmaceutical Technology, November 1997, pages 58-66, the disclosure of which is herein incorporated by reference in its entirety).
  • Such substances may include, but are not limited to, be lower (Ci-C 4 ) alkanols; fatty alcohols such as lauryl alcohol (dodecanol), alone or in combination with a lower alkanol; fatty acids such as linolenic acid or oleic acid; fatty acid esters such as isopropyl palmitate, stearate, linoleate, oleate or myristate; glycerol; glycerol monoesters such as glycerol monostearate, monolinoleate or monooleate; glycerol diesters; glycerol triesters such as triacetin; sucrose monostearate, monolinoleate or monooleate; sorbit
  • permeation enhancers are present in an amount from 0.01 to 20% by weight of the total weight of the composition, advantageously in an amount of from 0.05 to 10% by weight, preferably from 0.1 to 5% by weight.
  • mice were placed individually in cages without any bedding materials. During the experiment the number of fecal pellets were counted at different time-points, starting one hour before the time of the administration of the test compound (TO), as outlined below:
  • T+2h to T+4h counting of the accumulated fecal pellets excreted ⁇ The total number of fecal pellets for each mouse was counted over time. An analysis of variance (ANOVA) was performed on the results. Fisher's Protected Least Significant Difference was used for pairwise comparisons;p values ⁇ 0.05 were considered significant. Grubbs' test (http://www.graphpad.com/quickcalcs/Grubbsl.cfm) was used to detect outliers for each parameter in each experimental group.
  • solifenacin a representative peripheral muscarinic receptor antagonist
  • vehicle 30 minutes later animals were treated with otenzepad at a dose that caused an increase in the accumulated fecal pellets excreted (as determined in Experiment 1).
  • the dose of solifenacin ordinarily ranged from 2 to 40 mg/kg.
  • mice were placed individually in cages without any bedding materials. During the experiment the number of fecal pellets was counted at different time-points as outlined below:
  • T30 min administration of vehicle or otenzepad.
  • T 30min to T 2.5h counting of accumulated fecal pellets excreted.
  • T+2.5h to T+4.5h counting of accumulated fecal pellets excreted.
  • Results showed that solifenacin dose-dependently antagonized the increase in accumulated fecal pellets induced by otenzepad, thus confirming that the representative nsPAChA solifenacin suppresses the adverse effects of the representative M 2 -antagonist otenzepad.
  • T-maze continuous alternation task (T-CAT) is useful as model for studying compounds with cognitive enhancing properties.
  • the T-maze consists of 2 choice arms and 1 start arm mounted to a square centre. Manual doors are provided to close specific arms during the force choice alternation task.
  • mice Thirty minutes later mice were treated with either vehicle or one of two doses of otenzepad:
  • mice were randomly assigned to one of the different experimental treatment groups. Each animal was identified by its group name, cage number, series (day) of experiment, and number (1 to 10) written with permanent ink on the tail.
  • the T-maze apparatus was made of gray Plexiglas with a main stem (55 cm long x 10 cm wide x 20 cm high) and two arms (30 cm long x 10 cm wide x 20 cm high) positioned at 90 degree angle relative to the main stem.
  • a start box (15 cm long x 10 cm wide) was separated from the main stem by a guillotine door. Horizontal doors were also provided to close specific arms during the force choice alternation task.
  • the experimental protocol consisted of one single session, which started with 1 "forced- choice” trial, followed by 14 "free-choice” trials.
  • animals were confined for 5 seconds to the start arm and then were released while either the left or the right goal arm was blocked by the horizontal door. Animals then negotiated the maze, eventually entering the open goal arm, and returned to the start position. Immediately after the return of the animals to the start position, the left or right goal door was opened and the animals were allowed to choose freely between the left and right goal arm ("free choice trials). An animal was considered as having entered in arm when it placed its four paws in the arm.
  • a session was terminated and animals were removed from the maze as soon as 14 free-choice trials had been performed or 10 min had elapsed, whichever event occurred first.
  • the apparatus was cleaned between each animal using 40% ethanol. Urine and feces were removed from the maze. During the trials, animal handling and the visibility of the operator was minimized as much as possible.
  • the percentage of alternation over the 14 free-choice trials was determined for each mouse and was used as an index of working memory performance. This percentage is defined as entry in a different arm of the T-maze over successive trials (i.e., left-right- left-right, etc).
  • T-maze continuous alternation task was used as described in the above Example 2.
  • Animals were pre-treated with solifenacin succinate, as a representative nsPAChA, at the dose that antagonized fecal pellet excretion in Experiment 2 of Example 1 and with ondansetron, as a representative antiemetic agent, at a dose shown effective in a mouse model of nausea/vomiting. Thirty minutes later mice were treated with either vehicle or one of three doses of otenzepad:
  • Component (a), Component (b) and Component (c) may be administered concurrently or sequentially to a patient suffering from a hypocholinergic disorder of the CNS such as Alzheimer type dementia and schizophrenia.
  • a Component (d) an AChEI may be further administered with Component (a), Component (b) and Component (c) as described herein.
  • Component (a), Component (b) and Component (c) can be administered in a specific dosage regimen as illustrated above - to treat Alzheimer type dementia, schizophrenia, schizophrenia associated dementia, and/or schizoaffective disorders.
  • Component (a), Component (b) and Component (c) being administered simultaneously or sequentially to one another, in each case by the same or different administration route.
  • Component (a), Component (b) and Component (c) act synergistically with Component (a) to allow for the safe administration of high doses of Component (a) without dangerous adverse effects linked to the peripheral cholinergic action of said Component (a). Accordingly, the therapeutic efficacy of Component (a) to safely improve cognition of patients suffering from a hypocholinergic disorder of the CNS such as Alzheimer type dementia, schizophrenia, schizophrenia associated dementia, or schizoaffective disorders is enhanced, due to the synergistic combination of Component (b) and Component (c) with Component (a).
  • a hypocholinergic disorder of the CNS such as Alzheimer type dementia, schizophrenia, schizophrenia associated dementia, or schizoaffective disorders
  • the present invention in one aspect, provides a combination comprising or consisting essentially of, as Components:
  • M 2 -antagonist a M 2 - muscarinic cholinergic receptor antagonists (M 2 -antagonist);
  • nsPAChAs non-selective, peripheral anticholinergic agents
  • M 2 -antagonists used as Component (a) their properties and doses are described in the "M 2 -antagonists" section above.
  • naAEA used as Component (b), their properties and doses are described in the "The naAEAs section" above.
  • nsPAChA used as Component (c), their properties and doses are described in the "nsPAChAs" section above.
  • Component (a), Component (b) and Component (c), together or separately, are formulated in pharmaceutical compositions prepared as described in the "Formulation” section above.
  • the present invention in another aspect, provides a method for treating a hypocholinergic disorder of the CNS, which comprises administering to a patient in need of said treatment a combination comprising or consisting essentially of, as Components:
  • M 2 - antagonist a selective M2-muscarinic cholinergic receptor antagonists
  • nsPAChAs non-selective, peripheral anticholinergic agents
  • the method is carried out by administering Component (a), Component (b) and Component (c) of said combination concurrently, or sequentially.
  • Component (a), Component (b) and Component (c) may be independently administered by oral or parenteral route, in particular by intramuscular or intravenous injection or by transdermal administration by a TTS such as a gel or a patch.
  • the M 2 -antagonists used as Component (a), their properties and doses are described in the "The M 2 -antagonist" section above.
  • naAEA used as Component (b), their properties and doses are described in the "The naAEAs section" above.
  • nsPAChA used as Component (c) their properties and doses are described in the "The nsPAChAs section" above.
  • Component (a), Component (b) and Component (c), together or separately, are formulated in pharmaceutical compositions prepared as described in the "Formulation" section above.
  • Component (a), Component (b) and Component (c), in admixture with a pharmaceutical carrier or vehicle may be associated in the same pharmaceutical composition, formulated as described in "The Formulations" section above, in a unit dose for oral or parenteral, including transdermal route, according to known or conventional methods or technologies in the art.
  • Component (d) an AChEI may be further administered with Component (a), Component (b) and Component (c) as described herein.
  • M Muscarinic receptors in coronary circulation: gene-targeted mice define the role of M2 and M3 receptors in response to acetylcholine. Arterioscler Thromb Vase Biol. 2004; Jul, 24(7): 1253- 1258.

Abstract

L'invention concerne une combinaison d'un antagoniste de récepteur M2, d'un agent antiémétique non anticholinergique, d'un antagoniste des récepteurs muscariniques constituée d'un agent anticholinergique périphérique non sélectif, et éventuellement d'un inhibiteur d'anticholinestérase, pour traiter des troubles hypocholinergiques tels que la démence du type Alzheimer, la schizophrénie, la démence associée à la schizophrénie et les troubles schizo-affectifs.
PCT/US2017/018794 2016-02-24 2017-02-22 Combinaisons d'antagoniste muscarinique m2 WO2017147104A1 (fr)

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US10265311B2 (en) 2009-07-22 2019-04-23 PureTech Health LLC Methods and compositions for treatment of disorders ameliorated by muscarinic receptor activation
US10369144B2 (en) 2009-07-22 2019-08-06 PureTech Health LLC Methods and compositions for treatment of disorders ameliorated by muscarinic receptor activation
US10369143B2 (en) 2009-07-22 2019-08-06 PureTech Health LLC Methods and compositions for treatment of disorders ameliorated by muscarinic receptor activation
US10695339B2 (en) 2009-07-22 2020-06-30 PureTech Health LLC Methods and compositions for treatment of disorders ameliorated by muscarinic receptor activation
US10238643B2 (en) 2009-07-22 2019-03-26 PureTech Health LLC Methods and compositions for treatment of disorders ameliorated by muscarinic receptor activation
EP3324966A4 (fr) * 2015-07-20 2019-04-10 Chase Pharmaceuticals Corporation Combinaison muscarinique d'un antagoniste sélectif du récepteur m2 et d'un antagoniste non sélectif périphérique pour le traitement de troubles hypocholinergiques
EP4019018A1 (fr) * 2015-09-11 2022-06-29 Chase Pharmaceuticals Corporation Combinaisons muscariniques et leur utilisation pour lutter contre des troubles hypocholinergiques du système nerveux central
EP3347012A4 (fr) * 2015-09-11 2019-04-17 Chase Pharmaceuticals Corporation Combinaisons muscariniques et leur utilisation pour lutter contre des troubles hypocholinergiques du système nerveux central
EP3347011A4 (fr) * 2015-09-11 2019-06-19 Chase Pharmaceuticals Corporation Combinaison muscarinique et son utilisation pour lutter contre des troubles hypocholinergiques du système nerveux central
US10925832B2 (en) 2018-09-28 2021-02-23 Karuna Therapeutics, Inc. Compositions and methods for treatment of disorders ameliorated by muscarinic receptor activation
US10933020B2 (en) 2018-09-28 2021-03-02 Karuna Therapeutics, Inc. Compositions and methods for treating disorders ameliorated by muscarinic receptor activation
US11452692B2 (en) 2018-09-28 2022-09-27 Karuna Therapeutics, Inc. Compositions and methods for treating disorders ameliorated by muscarinic receptor activation
US11471413B2 (en) 2018-09-28 2022-10-18 Karuna Therapeutics, Inc. Compositions and methods for treating disorders ameliorated by muscarinic receptor activation
US11890378B2 (en) 2018-09-28 2024-02-06 Karuna Therapeutics, Inc. Compositions and methods for treating disorders ameliorated by muscarinic receptor activation
CN114630669A (zh) * 2020-10-14 2022-06-14 参天制药株式会社 稳定的医药组合物
CN114630669B (zh) * 2020-10-14 2023-03-24 参天制药株式会社 稳定的医药组合物

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