Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/495—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with two or more nitrogen atoms as the only ring heteroatoms, e.g. piperazine or tetrazines
  • A61K31/505—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim
  • A61K31/519—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim ortho- or peri-condensed with 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
  • A61K31/495—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with two or more nitrogen atoms as the only ring heteroatoms, e.g. piperazine or tetrazines
  • A61K31/4985—Pyrazines or piperazines ortho- or peri-condensed with heterocyclic ring systems
• • 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
  • A61K31/535—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with at least one nitrogen and one oxygen as the ring hetero atoms, e.g. 1,2-oxazines
  • A61K31/5375—1,4-Oxazines, e.g. morpholine
  • A61K31/5383—1,4-Oxazines, e.g. morpholine ortho- or peri-condensed with heterocyclic ring systems
• • 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
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
  • A61P25/14—Drugs for disorders of the nervous system for treating abnormal movements, e.g. chorea, dyskinesia
  • A61P25/16—Anti-Parkinson drugs
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
  • A61P25/18—Antipsychotics, i.e. neuroleptics; Drugs for mania or schizophrenia
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
  • A61P25/28—Drugs for disorders of the nervous system for treating neurodegenerative disorders of the central nervous system, e.g. nootropic agents, cognition enhancers, drugs for treating Alzheimer's disease or other forms of dementia

Definitions

• the present invention relates to use of (i) a 5-HT2A or 5-HT2A/D2 receptor ligand, for example a substituted heterocycle fused gamma-carbolines as described herein, in free, pharmaceutically acceptable salt or prodrug form, and (ii) a cyclic nucleotide phosphodiesterase 1 (PDE1) inhibitor, for example a 7,8-dihydro-imidazo[l,2-a]pyrazolo[4,3-e]pyrimidin-4-one compounds, in combination (sequentially or simultaneously, or in the form of a fixed dose combination for the prophylaxis or treatment of one or more disorders associated with dementia (including behavioral or mood disturbances (e.g., agitation/aggression), psychosis, depression and/or sleep disturbances), or enhancing cognition, for example in schizophrenia or dementia.
• a 5-HT2A or 5-HT2A/D2 receptor ligand for example a substituted heterocycle fused gamma-carbolines
• Dementia is a disorder characterized by the loss of cognitive abilities affecting memory, reasoning, judgment and behavior.
• MCI mild cognitive impairment
• incipient dementia or isolated memory impairment
• AD Alzheimer's disease
• Alzheimer's disease is the most common type of dementia and is an irreversible, progressive neurodegenerative disease that disrupts memory, perception, reasoning, judgment, information processing, emotional behavior, personality as well as social and occupational functions.
• Drugs approved in the United States for the treatment of Alzheimer's disease, which are also used to treat dementia in general include acetylcholinesterase inhibitors (e.g., Tacrine, rivastigmine (Exelon), donepezil (Aricept), and galantamine (Razadyne, formerly called Reminyl)) and NMDA receptor antagonist (e.g., memantine (Namenda)). While these drugs improve mental function (such as memory, attention, social interaction, reasoning ability, language ability, and ability to perform activities of daily living), they often cause side effects including stomach upset, diarrhea, nausea, vomiting, muscle cramps, fatigue, difficulty falling or staying asleep or excess sleepiness, depression, bradycardia and other side effects.
• acetylcholinesterase inhibitors e.g., Tacrine, rivastigmine (Exelon), donepezil (Aricept), and galantamine (Razadyne, formerly called Reminyl)
• these drugs do not treat affective symptoms and/or other behavior disruptions such as mood swing, agitation, aggressive/assaultive behavior and paranoia which are common in dementias.
• memantine a drug approved for Alzheimer's disease and often used for dementias in general, may have some adverse effects on neuropsychiatry functioning, particularly agitation/aggression, delusions or hallucinations.
• These untreated and sometimes aggravated behavioral disruptions often prevent the patients from integrating back into society, causing further distress to the caregivers and eventually leading to the patients' institutionalization.
• antipsychotic drugs are used to control aggression and psychosis in dementia, particularly in Alzheimer's disease.
• antipsychotic drugs such as haloperidol, risperidone and quetiapine are associated with serious side effects including extrapyramidal side effects (akinesia or akathisia), bone marrow
• SCN suprachiasmatic nucleus
• agents such as temazepam (Restoril), Zolpidem (Ambien), or zaleplon (Sonata), or sedating antidepressants, such as trazodone (Desyrel, Molipaxin), may be useful in managing insomnia, failure of these drugs to improve sleep quality in addition to the associated risk of falling due to drowsiness and psychomotor impairment caused by these agents render them undesirable for dementia, particularly Alzheimer's patients.
• behavioral/mood disturbances e.g., agitation, aggressive/assaultive behavior
• sleep disturbances in patients suffering from dementia or psychosis associated with dementia.
• Substituted heterocycle fused gamma-carbolines are known to be 5-HT2A or 5- HT2A/D2 receptor ligands, useful in treating central nervous system disorders. These compounds have been disclosed in U.S. Pat. No. 6,548,493; 7,238,690; 6,552,017; 6,713,471; U.S. RE39680, and U.S. RE39679, as novel compounds useful for the treatment of disorders associated with 5-HT2A receptor modulation such as obesity, anxiety, depression, psychosis, schizophrenia, sleep disorders, sexual disorders, migraine, conditions associated with cephalic pain, and social phobias. PCT/US08/03340 and U.S. Pat. No.
• 7,081,455 also disclose methods of making substituted heterocycle fused gamma-carbolines and uses of these gamma-carbolines as serotonin agonists and antagonists useful for the control and prevention of central nervous system disorders such as addictive behavior and sleep disorders.
• PDEl is a Ca 2+ -calmodulin-dependent phosphodiesterase (CaM-PDE), which can downregulate intracellular cAMP and cGMP signaling by hydrolyzing these cyclic nucleotides to their respective inactive 5 '-monophosphates (5 ⁇ and 5'GMP).
• CaM-PDE Ca 2+ -calmodulin-dependent phosphodiesterase
• PDEl plays a critical role in mediating signal transduction in brain cells, particularly within an area of the brain known as the basal ganglia or striatum.
• NMDA-type glutamate receptor activation and/or dopamine D2 receptor activation result in increased intracellular calcium concentrations, leading to activation of effectors such as calmodulin-dependent kinase II (CaMKII) and calcineurin and to activation of PDEl, resulting in reduced cAMP and cGMP.
• CaMKII calmodulin-dependent kinase II
• calcineurin calcineurin
• PDEl calmodulin-dependent kinase II
• Dopamine Dl receptor activation leads to activation of calcium dependent nucleotide cyclases, resulting in increased cAMP and cGMP.
• PKA protein kinase A
• PKG protein kinase G
• DARPP-32 dopamine and cAMP-regulated phosphoprotein
• CREB cAMP responsive element binding protein
• Inhibition of PDEl can thus potentiate the effect of a dopamine Dl agonist by protecting cGMP and cAMP from degradation, and likewise can inhibit dopamine D2 receptor signaling pathways, by inhibiting PDEl activity.
• WO 2014/145617 incorporated herein by reference, e.g., for its disclosure of PDEl inhibitors, describes the use of PDEl inhibitors as neuroprotective agents and/or neural regenerative agents, e.g. to prevent the development of a CNS disease or disorder in an individual at risk for the development of a CNS disease or disorder.
• PDEl inhibitors can initiate the transcription of genes that are necessary for overcoming myelin inhibition of regeneration after nerve injury and promoting neurite outgrowth and/or axonal regeneration in the case of a CNS disease, disorder, or injury, thus encouraging axonal regeneration and/or neuroprotection while simultaneously decreasing or lessening damage associated with chronically elevated intracellular calcium levels, which can lead to calmodulin activation of PDEl.
• the invention provides a method of treating dementia (including associated disorders such as behavioral or mood disturbances (e.g., agitation/aggression), psychosis, depression and/or sleep disturbances), and/or enhancing cognition, for example in patients suffering from schizophrenia or dementia, comprising administering an effective amount of (i) a 5-HT2A or 5- HT2A/D2 receptor ligand, for example a substituted heterocycle fused gamma-carbolines as described herein, in free, pharmaceutically acceptable salt or prodrug form, together with (ii) a PDEl inhibitor, as described herein.
• the 5-HT2A/D2 ligand promotes quality of sleep and reduces agitation, while the PDEl inhibitor promotes cognitive function.
• the administration may be sequential or simultaneous.
• the invention further provides a pharmaceutical composition, e.g., for use in such a method, comprising (i) a 5-HT2A or 5-HT2A/D2 receptor ligand and (ii) a PDEl inhibitor.
• a PDEl inhibitor as described herein will enhance cognition and also act to increase levels of intracellular cAMP and initiate the transcription of genes that are necessary for overcoming the inhibition of axonal regeneration and promoting neurite outgrowth and/or axonal regeneration thus inhibiting the neurodegenerative process.
• increased intracellular cAMP such as would result from PDEl inhibition, leads to increased activity of cAMP-dependent proteins, such as protein kinase C (PKC).
• PKC protein kinase C
• Another benefit of the administration of a PDEl inhibitor of the invention is an increase in intracellular cGMP.
• This increase in intracellular cGMP may lead to an increase in the activity of PKG, preventing a further rise in intracellular calcium levels.
• the administration of a PDEl inhibitor could have the dual benefit of, for example, playing a beneficial role in axonal regeneration (and/or neuroprotection) while simultaneously decreasing the deleterious effects that may be associated with elevated intracellular calcium levels.
• the 5-HT2A or 5-HT2A/D2 receptor ligand is a compound which antagonizes serotonin-2A (5-HT2A) receptor, and/ modulates dopamine receptor signaling at the level of key intra-cellular phosphoproteins and therefore is useful for the treatment of not only acute symptoms, but also residual symptoms of pyschosis, particularly schizophrenia.
• these compounds At dopamine D2 receptors, these compounds have dual properties and act as both post-synaptic antagonists and pre-synaptic partial agonists. They also stimulate phosphorylation of glutamatergic NMDA NR2B, or GluN2B, receptors in a mesolimbic specific manner.
• the combination of the PDE1 inhibitor with a 5-HT2A or 5- HT2A/D2 receptor ligand will be particularly useful, e.g., in the treatment of dementia or psychosis (e.g., schizophrenia) and disorders associated thereof.
• dementia or psychosis e.g., schizophrenia
• disorders associated thereof e.g., schizophrenia
• they are useful in treating sleep, aggression and agitation.
• they can treat acute exacerbated and residual schizophrenia, bipolar disorders, and mood disorders.
• 5-HT2A or 5-HT2A/D2 receptor ligand compounds used in the current disclosure are effective in treating not just acute symptoms, but also residual symptoms of psychosis, their combination with a PDE1 inhibitor disclosed herein, which is believed to provide a
• neuroprotective effect is useful in the treatment of a wide range of symptoms and disorders associated with dementia or psychosis such as schizophrenia.
• the invention provides a method (Method I) for the prophylaxis or treatment of one or more disorders associated with dementia (e.g., disorders associated with mild to severe cognition impairment and dementing illnesses including senile dementia, Alzheimer's disease, Pick's disease, frontotemporal dementia, paraminenculear palsy, dementia with Lewy bodies, vascular dementia, Huntington's disease, Parkinson's disease, multiple sclerosis, amyotrophic lateral sclerosis, Down syndrome, elderly depression, Wernicke- Korsakoff s syndrome, corticobasal degenerations, and prion disease; and further including behavioral or mood disturbances (e.g., agitation/aggression), psychosis, depression and/or sleep disturbances, as well as enhancing cognition, for example in schizophrenia or dementia) comprising administering to a patient in need thereof, a therapeutically effective amount of (i) a 5-HT2A or 5-HT2A/D2 rece tor lig
• a therapeutically effective amount of i
• X is -N(H)-, -N(CH 3 )- or -0-;
• Ri is -C(0)-O-2ialkyl (e.g., -C(0)-Ci- 5 alkyl, -C(0)-C 6 -i 5 alkyl or -C(0)-Ci 6 -2ialkyl), preferably said alkyl is a straight chain, optionally saturated or unsaturated and optionally substituted with one or more hydroxy or Ci-nalkoxy (e.g., ethoxy) groups, for example Ri is -C(0)-C 6 alkyl, -C(0)-C 7 alkyl, -C(0)-C 9 alkyl, -C(0)-Cnalkyl, - C(0)-Ci3alkyl or -C(0)-Cisalkyl wherein such compound hydrolyzes to form the residue of a natural or unnatural, saturated or unsaturated fatty acid, e.g., the compound hydrolyzes to form the hydroxy compound on the one hand and octanoic acid, decanoic acid, dodecanoic
• a PDE1 inhibitor for example a compound according to Formula II
• R 2 is H and R 3 and R 4 together form a tri- or tetra-methylene bridge [pref. with the carbons carrying R 3 and R 4 having the R and S configuration respectively]; or R 2 and R 3 are each methyl and R 4 is H; or R 2 and R 4 are H and R 3 is isopropyl [pref. the carbon carrying R 3 having the R configuration] ;
• R 6 is (optionally halo-subsitututed) phenylamino or (optionally halo-subsitututed) benzylamino;
• Rio is (optionally halo-subsitututed) phenyl, (optionally halo-subsitututed) pyridyl (for example 3-fluoropyrid-2-yl), or thiadiazolyl (e.g., l,2,3-thiadiazol-4-yl);
• Method 1 may be as follows:
• Ri in the compound of Formula I is -C(0)-O-2ialkyl (e.g., -C(0)-Ci- 5 alkyl, -C(0)-C 6 -i5alkyl or -C(0)-Ci 6 -2ialkyl), preferably said alkyl is a straight chain, optionally saturated or unsaturated and optionally substituted with one or more hydroxy or O-nalkoxy (e.g., ethoxy) groups, for example Ri is -C(0)-C 6 alkyl, -C(0)-C 7 alkyl, -C(0)-C 9 alkyl, -C(0)-Cnalkyl, - C(0)-Ci3alkyl or -C(0)-Cisalkyl wherein such compound hydrolyzes to form the residue of a natural or unnatural, saturated or unsaturated fatty acid, e.g., the compound hydrolyzes to form the hydroxy compound on the one hand and oct
• C(0)-Ci- 5 alkyl e.g., -C(0)-C 3 alkyl.
• R 6 is phenylamino or 4-fluorophenylamino.
• R 6 is phenylamino or 4-fluorophenylamino and Rio is 3-fluoropyrid-2-yl or methylcarbonyl.
• Any foregoing Method comprising administration of a pharmaceutical composition comprising effective amounts of both a Compound of Formula I and a Compound of Formula II.
• Method 1.21 wherein the compound of Formula 1 is in tosylate salt form administered in a daily dose equivalent to 1 to 5 mg of free base, the compound of Formula II is in monophosphate salt form administered in a daily dose equivalent to 0.5 to 2 mg of free base.
• any foregoing Method wherein the compound of Formula I and/or of Formula II is deuterated, e.g., wherein the deuterium:protium ratio at a specified position in the molecule is significantly higher, e.g., at least 2x, for example at least lOx higher, than the natural isotope ratios.
• Any foregoing Method wherein the Compound of Formula I is a Compound of Formula 1 as described in WO 2015/154025, the contents of which are incorporated herein by reference, e.g., wherein the -CH2- adjacent to X and/or Y is -CHD- or -CD2-.
• Method 1.22 wherein the method comprises once daily administration of a unit dosage for oral administration, for example a tablet or capsule, comprising the compound of Formula I in tosylate salt form in an amount equivalent to 1 to 5 mg of free base, the compound of Formula II in monophosphate salt form in an amount equivalent to 0.5 to 2 mg of free base, and a pharmaceutically acceptable diluent or carrier.
• disorders associated with dementia are disorders associated with Huntington's disease, Parkinson's disease, Mulitple sclerosis, Amyotrophic lateral sclerosis, Down syndrome, Eldery depression, Wernicke-Korsakoff s syndrome, corticobasal degenerations, and prion disease.
• disorders associated with dementia are disorders associated with mild cognition impairment and dementing illnesses including senile dementia, Alzheimer' s disease, Pick' s disease, frontotemporal dementia, paraminenculear palsy, dementia with Lewy bodies and vascular dementia.
• disorders associated with dementia are disorders associated with senile dementia, Alzheimer's disease, Pick's disease, frontotemporal dementia, paranynculear palsy, dementia with Lewy bodies and vascular dementia.
• disorders associated with dementia are disorders associated with Alzheimer's disease.
• disorders associated with dementia are disorders associated with mild cognition impairment.
• the disorder associated with dementia to be treated is selected from the group consisting of (1) behavioral or mood disorders such as agitation/irritation, aggressive/assaultive behavior, anger, physical or emotional outbursts; (2) psychosis; (3) depression; and (4) sleep disorders in patients suffering from dementia, particularly Alzheimer's disease.
• any foregoing method wherein the disorder to be treated is psychosis in a patient with dementia, particularly Alzheimer's disease.
• any foregoing method wherein the disorder to be treated is depression in a patient with dementia, particularly Alzheimer's disease.
• any foregoing method wherein the disorder to be treated is behavioral or mood disorders such as agitation/irritation, aggressive/assaultive behavior, anger, physical or emotional outbursts in a patient with dementia, particularly
• any foregoing method wherein the disorder to be treated is sleep disorders in a patient with dementia, particularly Alzheimer's disease.
• Method I et seq. wherein the disorder to be treated is sleep maintenance insomnia, frequent awakenings, and waking up feeling unrefreshed in a patient with dementia, particularly Alzheimer's disease.
• any foregoing method wherein the disorder to be treated is sleep maintenance insomnia in a patient with dementia, particularly Alzheimer's disease.
• Method I et seq. wherein the disorder to be treated is advanced sleep- phase syndrome in a patient with dementia, particularly Alzheimer's disease.
• Any foregoing method wherein the disorder to be treated is delayed sleep-phase syndrome in a patient with dementia, particularly Alzheimer's disease.
• the disorder associated with dementia is selected from behavioral or mood disturbances (e.g., agitation/aggression), psychosis, depression and/or sleep disturbances.
• behavioral or mood disturbances e.g., agitation/aggression
• psychosis e.g., depression and/or sleep disturbances.
• Any foregoing method comprising enhancing cognition, for example in schizophrenia or dementia.
• Any foregoing method further comprising administering one or more additional therapeutic agents useful for the prophylaxis or treatment of dementia, particularly Alzheimer's disease.
• the therapeutic agent useful for the prophylaxis or treatment of dementia, particularly Alzheimer' s disease is a cholinesterase inhibitor (e.g., acetylcholinesterase inhibitor) or an N-Methyl D-Asparate (NMD A) receptor antagonist, in free or pharmaceutically acceptable salt form;
• a cholinesterase inhibitor e.g., acetylcholinesterase inhibitor
• NMD A N-Methyl D-Asparate
• acetylcholinesterase inhibitor is selected from the group consisting of Tacrine, rivastigmine (Exelon), donepezil (Aricept), and galantamine (Razadyne, formerly called Reminyl)) in free or pharmaceutically acceptable salt form;
• acetylcholinesterase inhibitor is donepezil in free or pharmaceutically acceptable salt form
• NMDA receptor antagonist e.g., memantine in free or pharmaceutically acceptable salt form
• any foregoing method further comprising administering one or more additional therapeutic agents useful for the prophylaxis or treatment of dementia, particularly Alzheimer's disease, wherein the therapeutic agent useful for the prophylaxis or treatment of dementia, particularly Alzheimer' s disease is a combination of a cholinesterase inhibitor (e.g., acetylcholinesterase inhibitor) and an N-Methyl D-Asparate (NMDA) receptor antagonist, in free or
• a cholinesterase inhibitor e.g., acetylcholinesterase inhibitor
• NMDA N-Methyl D-Asparate
• the one or more therapeutic agent(s) useful for the prophylaxis or treatment of dementia, particularly Alzheimer' s disease or symptoms thereof is a combination of donepezil and memantine in free or pharmaceutically acceptable salt form.
• Any foregoing method further comprising administering one or more therapeutic agents useful for the prophylaxis or treatment of dementia, particularly
• Alzheimer's disease further comprises administering one or more therapeutic agents selected from antidepressant compounds, compounds that modulate GABA activity (e.g., enhances the activity and facilitates GABA transmission), a GABA- B agonist, a serotonin-2 antagonist/reuptake inhibitor (SARIs), an orexin receptor antagonist, an H3 agonist, a noradrenergic antagonist, a galanin agonist, a CRH antagonist, human growth hormone, a growth hormone agonist, estrogen, an estrogen agonist, a neurokinin- 1 drug, , and an antipsychotic agent, e.g., an atypical antipsychotic agent, in free or pharmaceutically acceptable salt form.
• GABA activity e.g., enhances the activity and facilitates GABA transmission
• GABA- B agonist e.g., a GABA- B agonist
• SARIs serotonin-2 antagonist/reuptake inhibitor
• an orexin receptor antagonist e.g., an H3 agonist, a noradrene
• the invention provides a pharmaceutical composition
• Composition 1 for the prophylaxis or treatment of one or more disorders associated with dementia (e.g., disorders associated with mild to severe cognition impairment and dementing illnesses including senile dementia, Alzheimer's disease, Pick's disease, frontotemporal dementia, paraminenculear palsy, dementia with Lewy bodies, vascular dementia, Huntington's disease, Parkinson's disease, multiple sclerosis, amyotrophic lateral sclerosis, Down syndrome, elderly depression, Wernicke-Korsakoff s syndrome, corticobasal degenerations, and prion disease, e.g., for use in any of Methods 1 et seq.],
• disorders associated with dementia e.g., disorders associated with mild to severe cognition impairment and dementing illnesses including senile dementia, Alzheimer's disease, Pick's disease, frontotemporal dementia, paraminenculear palsy, dementia with Lewy bodies, vascular dementia, Huntington's disease, Parkinson's disease, multiple sclerosis, amyotroph
• a 5-HT2A or 5-HT2A/D2 rece tor ligand for example a compound of Formula I:
• X is -N(H)-, -N(CH 3 )- or -0-;
• Ri is -C(0)-O-2ialkyl (e.g., -C(0)-Ci- 5 alkyl, -C(0)-C 6 -i 5 alkyl or -C(0)-Ci 6 -2ialkyl), preferably said alkyl is a straight chain, optionally saturated or unsaturated and optionally substituted with one or more hydroxy or Ci-nalkoxy (e.g., ethoxy) groups, for example Ri is -C(0)-C 6 alkyl, -C(0)-C 7 alkyl, -C(0)-C 9 alkyl, -C(0)-Cnalkyl, - C(0)-Ci3alkyl or -C(0)-Cisalkyl wherein such compound hydrolyzes to form the residue of a natural or unnatural, saturated or unsaturated fatty acid, e.g., the compound hydrolyzes to form the hydroxy compound on the one hand and octanoic acid, decanoic acid, dodecanoic
• a PDE1 inhibitor for example a compound according to Formula II
• R 2 is H and R 3 and R 4 together form a tri- or tetra-methylene bridge [pref. with the carbons carrying R 3 and R 4 having the R and S configuration respectively]; or R 2 and R 3 are each methyl and R 4 is H; or R 2 and R 4 are H and R 3 is isopropyl [pref. the carbon carrying R 3 having the R configuration] ;
• R 6 is (optionally halo-subsitututed) phenylamino or (optionally halo-subsitututed) benzylamino; for example, phenylamino or 4-fluorophenylamino;
• Rio is methylcarbonyl, (optionally halo-subsitututed) phenyl, (optionally halo- subsitututed) pyridyl (for example 3-fluoropyrid-2-yl), or thiadiazolyl (e.g., 1,2,3- thiadiazol-4-yl);
• Composition 1 includes, inter alia, the following embodiments:
• Composition I wherein X in the compound of Formula I is -N(H)-, -N(CH 3 )- or -0-;
• composition I or 1.1 wherein X in the compound of Formula I is -N(CH 3 )-; Composition I or 1.1, wherein X in the compound of Formula I is -0-;
• composition I or any of formulae 1.1-1.4, wherein Y in the compound of Formula
• Composition I or any of formulae 1.1-1.4, wherein Y in the compound of Formula I is -C(H)(OH);
• Composition I or any of formulae 1.1-1.4, wherein Y in the compound of Formula I is -C(H)(ORi);
• Ri in the compound of Formula I is -C(0)-Ci- iialkyl (e.g., -C(0)-Ci- 5 alkyl, -C(0)-C 6 -i5alkyl or -C(0)-Ci 6 -2ialkyl), preferably said alkyl is a straight chain, optionally saturated or unsaturated and optionally substituted with one or more hydroxy or O-nalkoxy (e.g., ethoxy) groups, for example Ri is -C(0)-C 6 alkyl, -C(0)-C 7 alkyl, -C(0)-C 9 alkyl, -C(0)-Cnalkyl, - C(0)-Ci3alkyl or -C(0)-Cisalkyl wherein such compound hydrolyzes to form the residue of a natural or unnatural, saturated or unsaturated fatty acid, e.g., the compound hydrolyzes to form the hydroxy compound on the one hand and oc
• C(0)-Ci- 5 alkyl e.g., -C(0)-C 3 alkyl.
• Composition I or an of 1.1- 1.5 or 1.7, wherein the Compound of Formula I is:
• Composition I or any of 1.1- 1.5 or 1.7, wherein the Compound of Formula I is:
• Composition I or an of 1.1- 1.5 or 1.7, wherein the Compound of Formula I is:
• Composition I or any of 1.1, 1.3. 1.5 or 1.7, wherein the Compound of Formula I is:
• Composition I or any of 1.1, 1.3, 1.5 or 1.6, wherein the Compound of Formula I is:
• Composition 1.14 wherein the Compound of Formula I is in the form of the tosylate salt. Any foregoing Composition wherein, in the Compound of Formula II, R 6 is phenylamino or 4-fluorophenylamino.
• R 6 is phenylamino or 4-fluorophenylamino and Rio is 3-fluoropyrid-2-yl or methylcarbonyl.
• any foregoing Composition comprising effective amounts of both a Compound of Formula I and a Compound of Formula II.
• any foregoing Composition in unit daily dosage form comprising 1 mg to 60 mg, e.g. 1 mg to 10 mg, e.g. 2 mg to 7mg of the Compound of Formula 1.
• composition in unit daily dosage form comprising 0.1 mg to 10 mg e.g., lmg to 5 mg, of the Compound of Formula II,
• composition further comprising a pharmaceutically acceptable diluent or carrier.
• composition in the form of a transdermal patch.
• Compound of Formula II are in a bioerodable matrix, e.g., a bioerodable copolymer, for example poly(lactic-co-glycolic acid), e.g., for administration by injection to form a depot.
• a bioerodable matrix e.g., a bioerodable copolymer, for example poly(lactic-co-glycolic acid), e.g., for administration by injection to form a depot.
• Composition 1.30 in the form of a tablet or capsule for oral administration comprising the compound of Formula I in tosylate salt form in an amount equivalent to 1 to 5 mg of free base, the compound of Formula II in monophosphate salt form in an amount equivalent to 0.5 to 2 mg of free base, and a pharmaceutically acceptable diluent or carrier.
• any foregoing Composition wherein the compound of Formula I and/or of Formula II is deuterated e.g., wherein the deuterium:protium ratio at a specified position in the molecule is significantly higher, e.g., at least 2x, for example at least lOx higher, than above the natural isotope ratios.
• the disclosure further provides the use of a compound of Formula I as hereinbefore described in combination with a compound of Formula II as hereinbefore described, for use in the manufacture of a medicament, e.g., according to any of Composition 1, et seq., for use in any of Methods 1 et seq.
• the 5-HT2A or 5-HT2A/D2 receptor ligand for use in the foregoing Methods and Compositions may for example be a 5-HT2A or 5-HT2A/D2 receptor ligand compound as disclosed in any of the following: U.S. Pat. No. 6,548,493; 7,238,690; 6,552,017; 6,713,471; U.S. RE39680, U.S. RE39679; for example as disclosed in US 8,598,119, or WO 2011/133224 or WO 2015/154025, for example, a Compound of Formula I as described above.
• the compounds of Formula I and their pharmaceutically acceptable salts and salt crystals may be made using the methods as described and exemplified in any of the following patents or applications: U.S. Pat. No. 6,548,493; 7,238,690; 6,552,017; 6,713,471; U.S. RE39680; U.S. RE39679; PCT/US08/03340; U.S. Application Serial No. 10/786,935; WO 2009/114181 and WO 2011/133224, the contents of each of which are incorporated by reference in their entirety.
• the Compounds of Formula I as hereinbefore described have a selective receptor profile wherein at low doses, e.g., 5-10 mg, they fully saturate the 5-HT2A receptors and only partially occupy (e.g. 5%- 15% occupancy) the dopamine D2 receptors, and also bind to dopamine D2 receptors more extensively and to serotonin reuptake transporter (SERT) at a higher dose.
• low doses e.g., 5-10 mg
• they fully saturate the 5-HT2A receptors and only partially occupy (e.g. 5%- 15% occupancy) the dopamine D2 receptors, and also bind to dopamine D2 receptors more extensively and to serotonin reuptake transporter (SERT) at a higher dose.
• SERT serotonin reuptake transporter
• the Compounds of the Invention are effective in treating one or more disorders associated with dementia, e.g., one or more disorders associated with mild cognition impairment and dementing illnesses including senile dementia, Alzheimer's disease, Pick's disease, frontotemporal dementia, paraminenculear palsy, dementia with Lewy bodies, vascular dementia, Huntington's disease, Parkinson's disease, multiple sclerosis, amyotrophic lateral sclerosis, Down syndrome, elderly depression, Wernicke-Korsakoff s syndrome, corticobasal degenerations, and prion disease, particularly behavioral/mood disturbances (e.g., agitation, aggressive/assaultive behavior) and sleep disorders, which are inadequately treated by the current marketed drugs for dementia and Alzheimer's disease, as well as treating psychosis and depressive disorders in patients suffering from dementia.
• dementia e.g., one or more disorders associated with mild cognition impairment and dementing illnesses including senile dementia, Alzheimer's disease, Pick's disease,
• the PDE1 inhibitor may for example be a PDE1 inhibitor compound as disclosed in any of the following: WO 2006/133261, WO 2007/025103, WO 2007/143705, WO
• the PDE1 inhibitor may be a compound of Formula II as hereinbefore described.
• the combinations as disclosed may be administered simultaneously, separately or sequentially with one or more other active agents to treat dementia or dementing illnesses as hereinbefore described, particularly Alzheimer' s disease or symptoms thereof.
• the second or further therapeutic agents useful for the prophylaxis or treatment of dementia as hereinbefore described, particularly Alzheimer's disease, e.g., as described in Method 1 and 2 above, include but are not limited to a cholinesterase inhibitor and/or N-Methyl D-Asparate (NMDA) receptor antagonist.
• NMDA N-Methyl D-Asparate
• Cholinesterase inhibitors e.g., acetylcholinesterase inhibitors
• acetylcholinesterase inhibitors are known in the art and/or are described e.g., in U.S. Pat No. 4,895,841; and U.S. Pat. 4,948,807, the contents of each of which are incorporated by reference in their entirety.
• Preferred cholinesterase inhibitors to be used with the compound of the present invention include donepezil, rivastignmine, galantamine and tacrine.
• NMDA receptor antagonists are also known in the art and are described in U.S. Pat. 5,061,703, the contents of which are incorporated by reference in their entirety.
• Preferred NMDA receptor antagonist to be used with the compound of the present invention is memantine.
• Compounds of Formula I normalize brain dopamine activity, particularly in the prefrontal cortex.
• the Compounds of Formula I bind to 5- HT2A and dopamine D 2 receptors.
• Compounds of Formula I also exhibit nanomolar binding affinity for SERT compared to known antidepressants. Therefore, the compounds of Formula I are useful for the treatment of (1) behavioral or mood disorders such as agitation/irritation, aggressive/assaultive behavior, anger, physical or emotional outbursts; (2) psychosis; (3) depression; and (4) sleep disorders in patients suffering from dementia, particularly Alzheimer's disease.
• the methods of the invention as hereinbefore described may optionally further comprises one or more therapeutic agents selected from antidepressant compounds, compounds that modulate GABA activity (e.g., enhances the activity and facilitates GABA transmission), a GABA-B agonist, a 5-HT modulator (e.g., a 5 -HTIA agonist, a 5-HT2A antagonist, a 5-HT2A inverse agonist, etc.), a melatonin agonist, an ion channel modulator (e.g., blocker) , a serotonin-2 antagonist/reuptake inhibitor (SARIs), an orexin receptor antagonist, an H3 antagonist, a noradrenergic antagonist, a galanin agonist, a CRH antagonist, human growth hormone, a growth hormone agonist, estrogen, an estrogen agonist, a neurokinin- 1 drug, , and an antipsychotic agent, e.g., an atypical antipsychotic agent, in
• the therapeutic agents may be adjunctive to the compounds of the invention.
• adjunctive refers to any treatment that is used in conjunction with another to increase the chance of cure, or to increase the first treatment's efficacy.
• adjunctive therapy acts as an aid to the primary treatment.
• the combinations of the invention can include mixtures of the combined drugs, as well as two or more separate compositions of the drugs, which individual compositions can be, for example, co-administered together to a patient at the same of different times.
• the antidepressant useful for the invention may be selected from amitriptyline, amoxapine, bupropion, citalopram, clomipramine, desipramine, doxepin, duloxetine,
• escitaloprame fluoxetine, fluvoxamine, imipramine, isocarboxazid, maprotiline, mirtazapine, nefazodone, nortriptyline, paroxetine, phenelzine sulfate, protiptyline, sertraline,
• the antidepressant(s) is a selective serotonin reuptake inhibitor (SSRI).
• the SSRI compound is selected from the group consisting of citalopram , escitalopram oxalate, fluoxetine, fluvoxamine maleate, paroxetine, sertraline, and dapoxetine, in free or pharmaceutically acceptable salt form.
• the dosages for combined therapy with a compound of Formula I, a compound of Formula II, and a further therapeutic agent can be the same as or lower than the approved dosage for the drug, the clinical or literature test dosage or the dosage used for the drug as a
• the dosages of a compound of Formula I of Formula II, and/or the additional therapeutic agents are lower than when used in a monotherapy.
• GABA A refers to gamma- aminobutyric acid.
• the GABA compounds are compounds which bind to the GABA receptor, and include, but are not limited to one or more of doxepin, alprazolam, bromazepam, clobazam, clonazepam, clorazepate, diazepam,
• flunitrazepam flurazepam, lorazepam, midazolam, nitrazepam, oxazepam, temazapam, triazolam, indiplon, zopiclone, eszopiclone, zaleplon, Zolpidem, gabaxadol, vigabatrin, tiagabine, EVT 201 (Evotec Pharmaceuticals) or estazolam.
• 5HT 2 A antagonists include ketanserin, risperidone, eplivanserin, volinanserin (Sanofi- Aventis, France), pruvanserin, pimavanserin (ACP-103), MDL 100907 (Sanofi-Aventis, France), HY10275 (Eli Lilly), APD125 (Arena Pharmaceuticals, San Diego, CA), AVE8488 (Sanofi- Aventis, France) and pizotifen.
• 5HTIA agonists include repinotan, sarizotan, eptapirone, buspirone and MN-305
• Melatonin agonists include melatonin, ramelteon (ROZEREM ® , Takeda
• VEC- 162 (Vanda Pharmaceuticals, Rockville, MD)
• PD-6735 Phase II Discovery
• agomelatine
• Ion channel blockers such as lamotrigine, gabapentin or pregabalin.
• Orexin receptor antagonists include orexin, a 1,3-biarylurea, SB-334867-a
• Serotonin-2 antagonist/reuptake inhibitors include Org 50081 (Organon -
• Neurokinin- 1 drugs include Casopitant (GlaxoSmithKline).
• additional therapeutic agents useful for the current invention include modafinil, armodafinil, doxepin, alprazolam, bromazepam, clobazam, clonazepam, clorazepate, diazepam, flunitrazepam, flurazepam, lorazepam, midazolam, nitrazepam, oxazepam, temazapam, triazolam, indiplon, zopiclone, eszopiclone, zaleplon, Zolpidem, gabaxadol, vigabatrin, tiagabine, EVT 201 (Evotec Pharmaceuticals), estazolam, ketanserin, risperidone, eplivanserin, volinanserin (Sanofi-Aventis, France), pruvanserin, pimavanserin (ACP-103), pizotifen, MDL 10090
• treatment and “treating” are to be understood accordingly as embracing prophylaxis and treatment or amelioration of symptoms of disease and/or treatment of the cause of the disease.
• the word “treatment” and “treating” refers to prophylaxis or amelioration of symptoms of the disease.
• patient may include a human or non-human patient.
• dementia is intended to refer to a condition or disorder characterized by the loss of cognitive ability affecting memory, thinking, language, judgment and behavior.
• Early symptoms of dementia may include difficulty performing tasks that require some thought (balancing a checkbook, playing games (such as bridge); learning new information; getting lost on familiar routes; having language difficulties (difficulties in finding name of familiar objects); losing interest in things previously enjoy; losing social skills.
• More severe symptoms of dementia include change in sleep patterns, often waking up at night; difficulty performing basic tasks such as brushing teeth or preparing a meal; forgetting details about current events; having hallucinations, violent behavior, delusions, depression, agitation; difficulty reading or writing; having poor judgment or loss of ability to recognize danger; losing the ability to recognize family members or understand language.
• the term "dementia” refers to any of the dementing illnesses as described herein regardless of etiology and therefore shall include but not limited to mild or severe cognition impairment and dementing illnesses such as senile dementia,
• Alzheimer's disease Pick's disease, frontotemporal dementia, parenculear palsy, dementia with Lewy bodies, vascular dementia, Huntington's disease, Parkinson's disease, multiple sclerosis, amyotrophic lateral sclerosis, Down syndrome, elderly depression, Wernicke- Korsakoff s syndrome, corticobasal degenerations, and prion disease.
• Alzheimer's disease Pick's disease, frontotemporal dementia, parenculear palsy, dementia with Lewy bodies, vascular dementia, Huntington's disease, Parkinson's disease, multiple sclerosis, amyotrophic lateral sclerosis, Down syndrome, elderly depression, Wernicke- Korsakoff s syndrome, corticobasal degenerations, and prion disease.
• dementia refers to mild cognitive impairment. In another embodiment, dementia refers to Alzheimer's disease.
• disorder associated with dementia means common co-morbid psychiatric disorders or conditions associated with dementia, which include but not limited to (1) behavioral or mood disorders such as agitation/irritation, aggressive/assaultive behavior, anger, physical or emotional outbursts; (2) psychosis; (3) depression; and (4) sleep disorders.
• the disorders associated with dementia are disorders associated Alzheimer's disease.
• MCI cognitive impairment
• incipient dementia or isolated memory impairment
• Symptoms of MCI include difficulty performing more than one task at a time, solving problems or making decisions, forgetting recent events or
• Alkyl as used herein is a saturated or unsaturated hydrocarbon moiety, e.g., one to twenty-one carbon atoms in length, which may be linear or branched (e.g., n-butyl or tert-butyl), preferably linear, unless otherwise specified.
• “Ci-21 alkyl” denotes alkyl having 1 to 21 carbon atoms.
• alkyl is optionally substituted with one or more hydroxy or Ci- 22 alkoxy (e.g., ethoxy) groups.
• alkyl contains 1 to 21 carbon atoms, preferably straight chain and optionally saturated or unsaturated
• Ri is an alkyl chain containing 1 to 21 carbon atoms, preferably 6-15 carbon atoms, 16-21 carbon atoms, e.g., so that together with the -C(O)- to which it attaches, e.g., when cleaved from the compound of Formula I, forms the residue of a natural or unnatural, saturated or unsaturated fatty acid.
• the 5-HT2A or 5-HT2A/D2 receptor ligand for example a substituted heterocycle fused gamma-carbolines as described herein and/or the PDE1 inhibitor for use in the Methods and Compositions of the disclosure may be in free, pharmaceutically acceptable salt or prodrug form.
• Pharmaceutically acceptable salts include, for example, the tosylate salts in the case of
• the 5-HT2A or 5-HT2A/D2 receptor ligand and/or the PDE1 inhibitor may in some cases also exist in prodrug form.
• a prodrug form is compound which converts in the body to the active compound.
• compounds which contain hydroxy or carboxy substituents may form physiologically hydrolysable and acceptable esters.
• physiologically hydrolysable and acceptable ester means esters which are hydrolysable under physiological conditions to yield acids (in the case of compounds which have hydroxy substituents) or alcohols (in the case of compounds which have carboxy substituents) which are themselves
• Y of the compound of Formula I is -C(H)(ORi)
• Ri is -C(0)-C 1-21 alkyl, e.g., -C(0)-C 3 alkyl or -C(0)-C 9 alkyl
• these compounds may hydrolyze under physiological condition to yield a compound of Formula I wherein Y is -C(H)(OH) on the one hand and Ci- 2 ialkyl-C(0)OH, e.g., C alkyl-C(0)OH or C9alkyl-C(0)OH on the other hand.
• the term thus embraces conventional pharmaceutical prodrug forms.
• a prodrug e.g., the compound of formula (I) wherein Ri is -C(0)-Ci-2ialkyl
• the term "simultaneously" when referring to a therapeutic use means administration of two or more active ingredients at or about the same time by the same route of administration.
• the term "separately" when referring to a therapeutic use means administration of two or more active ingredients at or about the same time by different route of administration.
• disorder(s) associated with Alzheimer's disease includes, but is not limited to (1) behavioral or mood disorders such as agitation/irritation, aggressive/assaultive behavior, anger, physical or emotional outbursts; (2) psychosis; (3) depression; and (4) sleep disorders in patients suffering from Alzheimer's disease.
• an amount of an active compound for administration refers to or is based on the amount of the compound in free form (i.e., the calculation of the amount is based on the amount of active moiety in free form, not taking into account the weight of the counter ion in the case of a salt).
• a prodrug e.g., the compound of formula (I) wherein Ri is -C(0)-Ci-2ialkyl
• Compounds of the Invention may be administered by any suitable route, including orally, intra-muscularly, subcutaneously, parenterally or transdermally, but are preferably administered orally.
• Compounds of the Invention may be administered by any suitable route, including orally, parenterally or transdermally, but are preferably administered orally.
• any disclosure of a numerical range, e.g., "up to X” amount is intended to include the upper numerical limit X. Therefore, a disclosure of "up to 60mg” is intended to include 60mg.
• compositions comprising compounds of the Invention may be prepared using conventional diluents or excipients and techniques known in the galenic art.
• oral dosage forms may include tablets, capsules, solutions, suspensions and the like.

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