Classifications

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  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
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  • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
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• • A—HUMAN NECESSITIES
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  • A61K31/135—Amines having aromatic rings, e.g. ketamine, nortriptyline
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• • A—HUMAN NECESSITIES
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• • A—HUMAN NECESSITIES
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  • A61K31/138—Aryloxyalkylamines, e.g. propranolol, tamoxifen, phenoxybenzamine
• • A—HUMAN NECESSITIES
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  • A61K31/21—Esters, e.g. nitroglycerine, selenocyanates
  • A61K31/215—Esters, e.g. nitroglycerine, selenocyanates of carboxylic acids
  • A61K31/216—Esters, e.g. nitroglycerine, selenocyanates of carboxylic acids of acids having aromatic rings, e.g. benactizyne, clofibrate
• • A—HUMAN NECESSITIES
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  • A61K31/215—Esters, e.g. nitroglycerine, selenocyanates of carboxylic acids
  • A61K31/22—Esters, e.g. nitroglycerine, selenocyanates of carboxylic acids of acyclic acids, e.g. pravastatin
  • A61K31/222—Esters, e.g. nitroglycerine, selenocyanates of carboxylic acids of acyclic acids, e.g. pravastatin with compounds having aromatic groups, e.g. dipivefrine, ibopamine
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
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  • A61K31/335—Heterocyclic compounds having oxygen as the only ring hetero atom, e.g. fungichromin
• • A—HUMAN NECESSITIES
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  • A61K31/33—Heterocyclic compounds
  • A61K31/38—Heterocyclic compounds having sulfur as a ring hetero atom
  • A61K31/381—Heterocyclic compounds having sulfur as a ring hetero atom having five-membered rings
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
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  • 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
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• • A—HUMAN NECESSITIES
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• • A—HUMAN NECESSITIES
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  • A61K31/55—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having seven-membered rings, e.g. azelastine, pentylenetetrazole
  • A61K31/553—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having seven-membered rings, e.g. azelastine, pentylenetetrazole having at least one nitrogen and one oxygen as ring hetero atoms, e.g. loxapine, staurosporine
• • A—HUMAN NECESSITIES
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  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/0012—Galenical forms characterised by the site of application
  • A61K9/0053—Mouth and digestive tract, i.e. intraoral and peroral administration
• • A—HUMAN NECESSITIES
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  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
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• • A—HUMAN NECESSITIES
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• • A—HUMAN NECESSITIES
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• • A—HUMAN NECESSITIES
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  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K2300/00—Mixtures or combinations of active ingredients, wherein at least one active ingredient is fully defined in groups A61K31/00 - A61K41/00

Definitions

• the present invention is based, at least in part, on the discovery of methods and compositions for the treatment of conditions associated with pharyngeal airway collapse while the subject is in a non-fully conscious state, e.g., snoring and sleep apnea, comprising administration of a norepinephrine reuptake inhibitor (NRI) and a muscarinic receptor antagonist.
• a norepinephrine reuptake inhibitor e.g., snoring and sleep apnea
• OSA Obstructive Sleep Apnea
• the present disclosure is based upon the surprising discovery that the administration of noradrenergic and antimuscarinic drugs can increase pharyngeal muscle activity in sleeping humans and reduce snoring and sleep apnea severity, e.g., in OSA patients.
• a subject having a condition associated with pharyngeal airway collapse while the subject is in a non-fully conscious state include administering to a subject in need thereof an effective amount of (i) a norepinephrine reuptake inhibitor (NRI) and (ii) a muscarinic receptor antagonist.
• NRI norepinephrine reuptake inhibitor
• a muscarinic receptor antagonist a norepinephrine reuptake inhibitor
• the NRI is a norepinephrine selective reuptake inhibitor (NSRI), e.g., an NSRI selected from the group consisting of Amedalin, Atomoxetine, CP-39,332, Daledalin, Edivoxetine, Esreboxetine, Lortalamine, Nisoxetine,
• NSRI norepinephrine selective reuptake inhibitor
• the NRI is a norepinephrine non-selective reuptake inhibitor (NNRI), e.g., an NNRI selected from the group consisting of Amitriptiline, Amoxapine, Bupropion, Ciclazindol, Desipramine, Desvenlafaxine,
• NRI norepinephrine non-selective reuptake inhibitor
• the NRI is selected from the group consisting of Atomoxetine and Reboxetine.
• the NRI is Atomoxetine
• the dosage of Atomoxetine is 20 - 100 mg, e.g., 25-75 mg.
• the muscarinic receptor antagonist is an M2 receptor agonist, e.g., is selected from the group consisting of atropine, propantheline, bethanechol, solifenacin, darifenacin, tolterodine, fesoterodine, trospium, and oxybutynin.
• the muscarinic receptor antagonist is selected from the group consisting of Anisotropine, Benztropine, Biperiden, Clidinium, Cycrimine, Dicyclomine, Diphemanil, Diphenidol, Ethopropazine, Glycopyrrolate, Hexocyclium, Isopropamide, Mepenzolate, Methixene, Methscopolamine, Oxyphencyclimine, Oxyphenonium, Procyclidine, Scopolamine, Tridihexethyl and Trihexyphenidyl.
• the muscarinic receptor antagonist is in an immediate release formulation.
• the muscarinic receptor antagonist is in an extended release formulation.
• the muscarinic receptor antagonist is Oxybutynin, and in specific embodiments, the dosage of Oxybutynin is 2-15 mg. In some embodiments, the Oxybutynin is in an immediate release formulation, e.g., with a dose of 2.5 - 10 mg.
• the Oxybutynin is in an extended release formulation, e.g., with a dose of 5 - 15 mg.
• the disease or disorder is Obstructive Sleep Apnea
• the non-fully conscious state is sleep.
• the NRI and the muscarinic receptor antagonist are administered in a single composition.
• the single composition is an oral administration form.
• the oral administration form is a syrup, pill, tablet, troche, or capsule.
• the single composition is a transdermal administration form, e.g., a patch.
• compositions comprising (i) a norepinephrine reuptake inhibitor (NRI) (ii) a muscarinic receptor antagonist, and (iii) a pharmaceutically acceptable carrier.
• NRI norepinephrine reuptake inhibitor
• the NRI is a norepinephrine selective reuptake inhibitor (NSRI), e.g., selected from the group consisting of Amedalin, Atomoxetine, CP- 39,332, Daledalin, Edivoxetine, Esreboxetine, Lortalamine, Nisoxetine, Reboxetine, Talopram, Talsupram, Tandamine, and Viloxazine.
• NRI norepinephrine selective reuptake inhibitor
• the NRI is a norepinephrine non-selective reuptake inhibitor (NNRI) selected from the group consisting of Amitriptiline, Amoxapine, Bupropion, Ciclazindol, Desipramine, Desvenlafaxine, Dexmethilphenidate, Diethylpropion, Doxepin, Duloxetine,
• NRI norepinephrine non-selective reuptake inhibitor
• Protryptyline Radafaxine, Tapentadol (Nucynta), Teniloxazine (Lucelan, Metatone) and Venlafaxine.
• the NRI is selected from the group consisting of Atomoxetine and Reboxetine.
• the NRI is Atomoxetine
• the dosage of Atomoxetine is 20 - 100 mg.
• the muscarinic receptor antagonist is an M2 antagonist, e.g., selected from the group consisting of atropine, propantheline, bethanechol, solifenacin, darifenacin, tolterodine, fesoterodine, trospium, and oxybutynin.
• the muscarinic receptor antagonist component of the pharmaceutical composition is selected from the group consisting of Anisotropine, Benztropine, Biperiden, Clidinium, Cycrimine, Dicyclomine, Diphemanil,
• Mepenzolate Methixene, Methscopolamine, Oxyphencyclimine, Oxyphenonium, Procyclidine, Scopolamine, Tridihex ethyl and Trihexyphenidyl.
• the muscarinic receptor antagonist is in an immediate release formulation. In some embodiments, the muscarinic receptor antagonist is in an extended release formulation.
• the muscarinic receptor antagonist is Oxybutynin.
• the Oxybutynin is in an immediate release formulation, e.g., with a dose of 2.5 - 10 mg.
• the Oxybutynin is in an extended release formulation, e.g., with a dose of 5 - 15 mg.
• compositions described herein for use in treating a subject having a condition associated with pharyngeal airway collapse while the subject is in a non-fully conscious state.
• the disease or disorder is sleep apnea or Simple Snoring.
• the disease or disorder is Obstructive Sleep Apnea.
• the non-fully conscious state is sleep.
• the RI and the muscarinic receptor antagonist are administered in a single composition.
• the single composition is an oral administration form.
• the oral administration form is a pill, tablet, troche, or capsule.
• NRI norepinephrine reuptake inhibitor
• a muscarinic receptor antagonist for use in treating a subject having a condition associated with pharyngeal airway collapse while the subject is in a non-fully conscious state.
• kits comprising a norepinephrine reuptake inhibitor (NRI) and a muscarinic receptor antagonist, e.g., for use in method described herein, e.g., for treating a subject having a condition associated with pharyngeal airway collapse while the subject is in a non-fully conscious state.
• the kit can comprise, e.g., separate pharmaceutical compositions of any of the individual active drugs claimed herein with a pharmaceutically acceptable salt or carrier wherein said kit may contain (a) separate or common bottles or packets allowing potentially separate dosaging and (b) optionally a set of kit instructions.
• FIG. 1 Graphic illustration of an obstructive apnea.
• the top channel shows the electroencephalogram (EEG) pattern of sleep.
• the next channel represents airflow.
• the next three channels show ventilatory effort by movements of the rib cage and abdomen and changes in esophageal pressure, all of which reflect contraction of respiratory muscles.
• the last channel indicates oxyhemoglobin saturation.
• FIGs. 2A-2B Pharyngeal muscle activity decreases from wake to sleep in the presence of a placebo (2A). In contrast, Atomoxetine + Oxybutynin preserves pharyngeal muscle activity near awake values during sleep (2B).
• FIGs. 3A-3B Participants received treatment (Atomoxetine 80 mg +
• Oxybutynin 5 mg or placebo in randomized order 30 minutes before sleep.
• the results showed that the combination of Atomoxetine and Oxybutynin reduced the apnea hypopnea index (AHI) from 31 [10-54] to 8 [2-18] (3 A).
• Data are expressed as median [25th-75th percentile].
• FIG. 4 The combination of Atomoxetine and Oxybutynin increased ventilation during sleep. Ventilation was calculated on placebo and drugs night as % of eupneic ventilation at normal ventilatory drive.
• FIG. 5 OS A patients improved overnight lowest oxygen blood level from 84 [79 - 92] on placebo to 94 [89 - 95] during the Atomoxetine/Oxybutynin night.
• FIGs. 6A-6B Total sleep time (6A) and sleep efficiency (6B) were also improved on Atomoxetine/Oxybutynin night compared to placebo for the subjects with an AHI>10.
• FIG. 7 Only the combination of Atomoxetine and Oxybutynin showed a significant reduction in AHI compared to placebo, while Atomoxetine or Oxybutynin alone did not improve the AHI.
• FIG. 8 In subjects with a mild to moderate upper airway collapsibility, Atomoxetine and Fesoterodine was as effective as Atomoxetine and Oxybutynin in reducing AHI.
• FIG. 9 In 6 subjects not treated with CPAP, administration of an Atomoxetine and Oxybutynin combination (Ato 80 mg /Oxy 5 mg) provided a 63% reduction in AHI after 1 week.
• the pharyngeal airway region has no bone or cartilage support, and it is held open by muscles. When these muscles relax during sleep, the pharynx can collapse resulting in cessation of airflow.
• ventilatory effort continues and increases in an attempt to overcome the obstruction, shown by an increase in esophageal pressure change.
• Rib cage and abdominal movements are in the opposite direction as a result of the diaphragm contracting against an occluded airway, forcing the abdominal wall to distend out and the chest wall to cave inward.
• apnea- hypopnea index (AHI), which is the combined average number of apneas (cessation of breathing for at least ten seconds) and hypopneas (reduced airflow and oxygen saturation) that occur per hour of sleep. See, for example, Ruehland et al., The new AASM criteria for scoring hypopneas: Impact on the apnea hypopnea index. SLEEP 2009;32(2): 150-157.
• OSA When a stringent definition of OSA is used (an AHI of > 15 events per hour or AHI > 5 events per hour with daytime sleepiness), the estimated prevalence is approximately 15 percent in males and 5 percent in females. An estimated 30 million individuals in the United States have OSA, of which approximately 6 million have been diagnosed. The prevalence of OSA in the United States appears to be increasing due to aging and increasing rates of obesity. OSA is associated with major comorbidities and economic costs, including: hypertension, diabetes, cardiovascular disease, motor vehicle accidents, workplace accidents, and fatigue/lost productivity. See, for example, Young et al., WMJ 2009; 108:246; Peppard et al., Am J Epidemiol 2013; 177: 1006.
• CPAP continuous positive airway pressure
• noradrenergic and antimuscarinic drugs can increase pharyngeal muscle activity in sleeping humans and reduce snoring and sleep apnea severity in OSA patients.
• the methods described herein include methods for the treatment of disorders associated with pharyngeal airway muscle collapse during sleep.
• the disorder is Obstructive Sleep Apnea (OSA) (defined as an AHI of > 10 events per hour) or Simple Snoring.
• OSA Obstructive Sleep Apnea
• the methods include administering a therapeutically effective amount of a norepinephrine reuptake inhibitor and an antimuscarinic agent as known in the art and/or described herein, to a subject who is in need of, or who has been determined to be in need of, such treatment.
• to "treat” means to ameliorate at least one symptom of the disorder associated with pharyngeal airway collapse.
• pharyngeal airway collapse during sleep results in snoring and/or an interruption in breathing (apnea or hypopnea), arousal from sleep, and reduced oxygenation (hypoxemia); thus, a treatment can result in a reduction in one or more of snoring, apneas/hypopneas, sleep fragmentation, and hypoxemia.
• administering will result in decreased AHI.
• administration of a therapeutically effective amount of a norepinephrine reuptake inhibitor and an antimuscarinic agent for the treatment of a subject having a condition associated with pharyngeal airway collapse while the subject is in a non-fully conscious state, such as OSA will result in decreased AHI by 50% or more.
• the administration of a therapeutically effective amount of a norepinephrine reuptake inhibitor and an antimuscannic agent for the treatment of a subject having a condition associated with pharyngeal airway collapse while the subject is in a non-fully conscious state, such as OS A will result in decreased AHI by 75% or more.
• the administration of a therapeutically effective amount of a norepinephrine reuptake inhibitor and an antimuscarinic agent for the treatment of a subject having a condition associated with pharyngeal airway collapse while the subject is in a non-fully conscious state, such as OSA will result in increased ventilation.
• the administration of a therapeutically effective amount of a norepinephrine reuptake inhibitor and an antimuscannic agent for the treatment of a subject having a condition associated with pharyngeal airway collapse while the subject is in a non-fully conscious state will result in increased ventilation.
• administering will result in increased oxygen blood levels.
• administration of a therapeutically effective amount of a norepinephrine reuptake inhibitor and an antimuscarinic agent for the treatment of a subject having a condition associated with pharyngeal airway collapse while the subject is in a non-fully conscious state will result in increased oxygen blood levels.
• the administration of a therapeutically effective amount of a norepinephrine reuptake inhibitor and an antimuscarinic agent for the treatment of a subject having a condition associated with pharyngeal airway collapse while the subject is in a non-fully conscious state such as OSA
• antimuscarinic agent can be administered in one or more administrations, applications or dosages, simultaneously or separately.
• a norepinephrine reuptake inhibitor and an antimuscarinic agent can be formulated as a single dosage form, e.g., a capsule, tablet or solution, containing both a
• norepinephrine reuptake inhibitor and an antimuscarinic agent or as separate dosage forms, e.g., one a capsule, tablet or solution, containing a norepinephrine reuptake inhibitor and another capsule, tablet or solution containing an antimuscarinic agent.
• Each of the norepinephrine reuptake inhibitor and the antimuscarinic agents can be administered, simultaneously or separately from one or more times per day to one or more times per week; including once every other day. In some embodiments, the norepinephrine reuptake inhibitor and the antimuscarinic agent are administered daily.
• treatment of a subject with a therapeutically effective amount of the therapeutic compounds described herein can include a single treatment or a series of treatments.
• Dosage, toxicity and therapeutic efficacy of the therapeutic compounds can be determined by standard pharmaceutical procedures in cell cultures or experimental animals, e.g., for determining the LD50 (the dose lethal to 50% of the population) and the ED50 (the dose therapeutically effective in 50% of the population).
• the dose ratio between toxic and therapeutic effects is the therapeutic index and it can be expressed as the ratio LD50/ED50.
• the data obtained from cell culture assays and animal studies can be used in formulating a range of dosages for use in humans.
• the dosage of such compounds lies preferably within a range of circulating concentrations that include the ED50 with little or no toxicity.
• the dosage may vary within this range depending upon the dosage form employed and the route of administration utilized.
• the therapeutically effective dose can be estimated initially from cell culture assays.
• a dose may be formulated in animal models to achieve a circulating plasma concentration range that includes the IC50 (i.e., the concentration of the test compound which achieves a half- maximal inhibition of symptoms) as determined in cell culture.
• IC50 i.e., the concentration of the test compound which achieves a half- maximal inhibition of symptoms
• levels in plasma can be measured, for example, by high performance liquid chromatography.
• the methods include administering a dose of 20-100 mg Atomoxetine (or a dose equivalent thereof of another NRI) and a dose of 2-15 mg Oxybutynin (or a dose equivalent thereof of another muscarinic receptor antagonist). In some embodiments, the methods include administering 80 mg Atomoxetine /5 mg Oxybutynin; 75 mg Atomoxetine /5 mg Oxybutynin; 75 mg Atomoxetine 16 mg Oxybutynin; 50 mg Atomoxetine /4 mg Oxybutynin; or 25 mg Atomoxetine/3 mg Oxybutynin.
• the methods include administering a dose of 20- 100 mg Atomoxetine (or a dose equivalent thereof of another NRI) and a dose of 2-15 mg Oxybutynin (or a dose equivalent thereof of another muscarinic receptor antagonist) within an hour of sleep time.
• the methods include administering 80 mg Atomoxetine /5 mg Oxybutynin; 75 mg Atomoxetine /5 mg Oxybutynin; 75 mg Atomoxetine 16 mg Oxybutynin; 50 mg Atomoxetine /4 mg Oxybutynin; or 25 mg Atomoxetine/3 mg Oxybutynin, 15-60, e.g., 20-45, 15-25, or 20-30 minutes before sleep time.
• the methods include administering
• Atomoxetine/Oxybutynin in a 12.5 to 1 ratio by weight include administering Atomoxetine/Oxybutynin in a 12.5 to 1 ratio by weight at 15-60, e.g., 20-45, 15-25, or 20-30, minutes before sleep time.
• the methods described herein include the use of pharmaceutical compositions comprising a norepinephrine reuptake inhibitor and an antimuscarinic agent as active ingredients.
• the norepinephrine reuptake inhibitor and antimuscarinic agent can be administered in a single composition or in separate compositions.
• the methods include administering a norepinephrine reuptake inhibitor and an antimuscarinic agent, and no other active ingredients, i.e., the norepinephrine reuptake inhibitor and the antimuscarinic agent are the sole active agents.
• Exemplary norepinephrine reuptake inhibitors include the selective RIs, e.g., Amedalin (UK-3540-1), Atomoxetine (Strattera), CP-39,332, Daledalin (UK-3557-15), Edivoxetine (LY-2216684), Esreboxetine, Lortalamine (LM-1404), Nisoxetine (LY-94,939), Reboxetine (Edronax, Vestra), Talopram (Lu 3-010), Talsupram (Lu 5-005), Tandamine (AY-23,946), Viloxazine (Vivalan); and the nonselective NRIs, e.g., Amitriptiline, Amoxapine, Bupropion, Ciclazindol, Desipramine, Desvenlafaxine, Dexmethilphenidate, Diethylpropion, Doxepin, Duloxetine,
• selective RIs e.g., Amedal
• Phenmetrazine Protryptyline, Radafaxine (GW-353, 162), Tapentadol (Nucynta), Teniloxazine (Lucelan, Metatone) and Venlafaxine.
• antimuscarinics include Atropine, Propantheline, Bethanechol, Solifenacin, Darifenacin, Tolterodine, Fesoterodine, Trospium, and Oxybutynin, which have activity on the M2 receptor.
• antimuscarinics include Anisotropine, Benztropine, Biperiden, Clidinium, Cycrimine, Dicyclomine, Diphemanil, Diphenidol, Ethopropazine, Glycopyrrolate, Hexocyclium, Isopropamide, Mepenzolate, Methixene, Methscopolamine, Oxyphencyclimine, Oxyphenonium, Procyclidine, Scopolamine, Tridihex ethyl, and Trihexyphenidyl.
• the norepinephrine reuptake inhibitor is Atomoxetine.
• the antimuscarinic agent is Oxybutynin (e.g., N- desethyloxybutynin).
• compositions typically include a pharmaceutically acceptable carrier.
• pharmaceutically acceptable carrier includes saline, solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic and absorption delaying agents, and the like, compatible with pharmaceutical administration.
• Supplementary active compounds can also be incorporated into the compositions, e.g., hypnotics including Zolpidem, eszopiclone, benzodiazepines, gabapentin, tiagabine, and xyrem.
• compositions are typically formulated to be compatible with their intended route of administration.
• routes of administration include systemic oral or transdermal administration.
• oral compositions generally include an inert diluent or an edible carrier.
• the active compound(s) can be incorporated with excipients and used in the form of pills, tablets, troches, or capsules, e.g., gelatin capsules.
• Oral compositions can also be prepared using a fluid carrier. Pharmaceutically compatible binding agents, and/or adjuvant materials can be included as part of the composition.
• the tablets, pills, capsules, troches and the like can contain any of the following ingredients, or compounds of a similar nature: a binder such as microcrystalline cellulose, gum tragacanth or gelatin; an excipient such as starch or lactose, a disintegrating agent such as alginic acid, Primogel, or corn starch; a lubricant such as magnesium stearate or Sterotes; a glidant such as colloidal silicon dioxide; a sweetening agent such as sucrose or saccharin; or a flavoring agent such as peppermint, methyl salicylate, or orange flavoring.
• a binder such as microcrystalline cellulose, gum tragacanth or gelatin
• an excipient such as starch or lactose, a disintegrating agent such as alginic acid, Primogel, or corn starch
• a lubricant such as magnesium stearate or Sterotes
• a glidant such as colloidal silicon dioxide
• transdermal means i.e., one or both of a norepinephrine reuptake inhibitor and a muscarinic receptor antagonist
• transdermal means e.g., using a patch, gel, lotion, or thin film, to be applied to the skin.
• penetrants appropriate to the permeation of the epidermal barrier can be used in the formulation. Such penetrants are generally known in the art.
• penetrants are generally known in the art.
• the active compounds can be formulated into ointments, salves, gels, or creams as generally known in the art.
• the gel and/or lotion can be provided in individual sachets, or via a metered-dose pump that is applied daily; see, e.g., Cohn et al., Ther Adv Urol. 2016 Apr; 8(2): 83-90.
• the therapeutic compounds are prepared with carriers that will protect the therapeutic compounds against rapid elimination from the body, such as a controlled release formulation, including implants and microencapsulated delivery systems.
• a controlled release formulation including implants and microencapsulated delivery systems.
• Biodegradable, biocompatible polymers can be used, such as ethylene vinyl acetate, polyanhydrides, polyglycolic acid, collagen, polyorthoesters, and polylactic acid.
• Such formulations can be prepared using standard techniques, or obtained commercially, e.g., from Alza Corporation and Nova Pharmaceuticals, Inc.
• Liposomal suspensions can also be used as pharmaceutically acceptable carriers. These can be prepared according to methods known to those skilled in the art, for example, as described in U.S. Patent No. 4,522,811.
• compositions can be included in a container, pack, or dispenser together with instructions for administration or use in a method described herein.
• FIGs 2A-B show data for the three individuals who took the combination of Atomoxetine and Oxybutynin.
• Figure 2A is the placebo night.
• the graphs in the first column are the genioglossus muscle activity (EMGGG, quantified as a percentage of maximum) during quiet wakefulness.
• EMGGG genioglossus muscle activity
• Each circle represents the peak EMGGG of a single breath and is plotted against the corresponding epiglottic pressure.
• the graphs in the second column were obtained during stable NREM sleep. Note that there is a variable but clear reduction in EMGGG activity during sleep on the placebo night. In contrast, when these same three individuals took Atomoxetine + Oxybutynin, the sleep-related reduction in pharyngeal muscle activity was partially or completely prevented (Figure 2B).
• obstructive sleep apnea human patients was performed. Participants received treatment (Atomoxetine 80 mg + Oxybutynin 5 mg) or placebo in randomized order 30 minutes before sleep. The trial showed that the combination of Atomoxetine and Oxybutynin reduced the apnea hypopnea index (AHI) from 31 [10- 54] to 8 [2-18]. Data are expressed as median [25th-75th percentile] ( Figure 3 A). During the trial, 5 subjects showed absence of clinically-significant OSA on the placebo night.
• AHI apnea hypopnea index
• Fesoterodine (a newer, extended-release antimuscarinic drug) was used in combination with 80 mg Atomoxetine in 3 subjects with a mild to moderate upper airway collapsibility (ventilation during sleep with normal effort was above 50% of eupneic ventilation on placebo).
• Fesoterodine was as effective as Oxybutynin in reducing the AHI.
• Atomoxetine/Fesoterodine did not reduce the AHI, whereas Atomoxetine/Oxybutynin did.
• Atomoxetine 80 mg in combination with Oxybutynin 5 mg In three patients we tested lower doses of the combination, i.e., Atomoxetine 80 mg in combination with Oxybutynin 5 mg, Atomoxetine 50 mg in combination with Oxybutynin 4 mg, and Atomoxetine 25 mg in combination with Oxybutynin 3 mg.
• the AHI showed a dose-dependent reduction compared to placebo, suggesting that lower doses than 80/5 mg may be effective in treating less severe disease.
• mild disease 5 ⁇ AHI ⁇ 15
• moderate disease 15 ⁇ AHI ⁇ 30 events/hour.
• Muscle responsiveness reflects the change in genioglossus muscle electromyographic activity (percent of baseline) per change in esophageal pressure (Pes) swings during spontaneous breathing in non-REM sleep (see FIG. 10B for physiological context). Note that the median responsiveness on ato-oxy (slope of solid line) is greater than the
• FIG. 10B shows exemplary raw data to provide context.
• the signals illustrate a spontaneous increase in genioglossus muscle activity with increasing Pes swings during sleep. Note the restoration of airflow (Flow) accompanying increasing muscle activity.

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