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
  • A61K31/13—Amines
  • A61K31/155—Amidines (), e.g. guanidine (H2N—C(=NH)—NH2), isourea (N=C(OH)—NH2), isothiourea (—N=C(SH)—NH2)
• • 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
  • A61K31/335—Heterocyclic compounds having oxygen as the only ring hetero atom, e.g. fungichromin
  • A61K31/35—Heterocyclic compounds having oxygen as the only ring hetero atom, e.g. fungichromin having six-membered rings with one oxygen as the only ring hetero atom
  • A61K31/352—Heterocyclic compounds having oxygen as the only ring hetero atom, e.g. fungichromin having six-membered rings with one oxygen as the only ring hetero atom condensed with carbocyclic rings, e.g. methantheline 
  • A61K31/353—3,4-Dihydrobenzopyrans, e.g. chroman, catechin
  • A61K31/355—Tocopherols, e.g. vitamin E
• • 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
  • A61K31/425—Thiazoles
  • A61K31/426—1,3-Thiazoles
• • 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
  • A61K31/438—The ring being spiro-condensed with carbocyclic or 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
  • A61K31/435—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
  • A61K31/44—Non condensed pyridines; Hydrogenated derivatives thereof
  • A61K31/4427—Non condensed pyridines; Hydrogenated derivatives thereof containing further heterocyclic ring systems
  • A61K31/4439—Non condensed pyridines; Hydrogenated derivatives thereof containing further heterocyclic ring systems containing a five-membered ring with nitrogen as a ring hetero atom, e.g. omeprazole
• • 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
  • A61K31/44—Non condensed pyridines; Hydrogenated derivatives thereof
  • A61K31/445—Non condensed piperidines, e.g. piperocaine
  • A61K31/4523—Non condensed piperidines, e.g. piperocaine containing further heterocyclic ring systems
  • A61K31/454—Non condensed piperidines, e.g. piperocaine containing further heterocyclic ring systems containing a five-membered ring with nitrogen as a ring hetero atom, e.g. pimozide, domperidone
• • 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
  • A61K38/00—Medicinal preparations containing peptides
  • A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
  • A61K38/17—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans
  • A61K38/22—Hormones
  • A61K38/26—Glucagons
• • 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
  • A61P1/00—Drugs for disorders of the alimentary tract or the digestive system
  • A61P1/16—Drugs for disorders of the alimentary tract or the digestive system for liver or gallbladder disorders, e.g. hepatoprotective agents, cholagogues, litholytics
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P29/00—Non-central analgesic, antipyretic or antiinflammatory agents, e.g. antirheumatic agents; Non-steroidal antiinflammatory drugs [NSAID]
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • 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 relates to a new method for treating non-alcoholic fatty liver disease and non-alcoholic steatohepatitis with a growth hormone secreiagogue or a combination of a growth hormone secretagogue and a drug selected from: a dipeptidyi peptidase-4 antagonist, a glucagon-like peptide receptor agonist, a thiazolidinedione, a sodium glucose transport protein 2 antagonist, metformin and vitamin E.
• a drug selected from: a dipeptidyi peptidase-4 antagonist, a glucagon-like peptide receptor agonist, a thiazolidinedione, a sodium glucose transport protein 2 antagonist, metformin and vitamin E.
• Non-alcoholic fatty liver disease is the most common liver disease in the world. It is a condition in which excess fat is stored in the liver. This condition is not caused by heavy alcohol use (which would be alcoholic liver disease).
• NAFLD leading to hepatic inflammation, fibrosis, and hepatocellular carcinoma, has become a major health problem and is associated with the increasing prevalence of obesity, insulin resistance, type 2 diabetes, and metabolic disease. The incidence in the U.S. population is estimated to be 25-30% and increasing. It is also estimated that, about 20% of the people having NAFLD also have nonalcoholic steatohepatitis (NASH), which can lead to complications such as cirrhosis and liver cancer.
• NASH nonalcoholic steatohepatitis
• the treatment of NAFLD and/or NASH is seen as another way to treat obesity, insulin resistance, type 2 diabetes, and metabolic disease.
• the present invention provides a novel method of treating non-alcoholic fatty ih'er disease with a growth hormone secretogogue (GHS).
• GHS growth hormone secretogogue
• the present invention provides a novel method of treating NAFLD with the ajmbination of a GHS and a drug selected from: a dipeptidyl peptidase-4 (DPP4) antagonist, a glucagon-like peptide (GLP-1) receptor agonist, a thiazolidinedione, a sodium giucose transport protein 2 (SGLT2) antagonist, metformin and vitamin E.
• a drug selected from: a dipeptidyl peptidase-4 (DPP4) antagonist, a glucagon-like peptide (GLP-1) receptor agonist, a thiazolidinedione, a sodium giucose transport protein 2 (SGLT2) antagonist, metformin and vitamin E.
• DPP4 dipeptidyl peptidase-4
• GLP-1 glucagon-like peptide
• SGLT2 sodium giucose transport protein 2
• the present invention provides a novel method of treating non-alcoholic steatohepatits with a growth hormone secretagogue.
• the present invention provides a novel method of treating NASH with the combination of a GHS and a drug selected from: a dipeptidyl peptidase-4 antagonist, a glucagon-like peptide receptor agonist, a thiazolidinedione, a sodium glucose transport protein 2 antagonist, metformin and vitamin E.
• a drug selected from: a dipeptidyl peptidase-4 antagonist, a glucagon-like peptide receptor agonist, a thiazolidinedione, a sodium glucose transport protein 2 antagonist, metformin and vitamin E.
• growth hormone secretagogues e.g. ibutamoren
• a drug selected from: a dipeptidyl peptidase-4 antagonist, a glucagon-like peptide receptor agonist, a thiazolidinedione, a sodium glucose transport protein 2 antagonist, metformin and vitamin E is expected to treat, diseases such as NAFLD and NASH.
• ibutamoren using a novel therapeutic approach which combines the growth hormone secretagogue ibutamoren with the DPP4 antagonist JanuviaTM is useful for treating NAFLD and NASH.
• ibutamoren mesylate The structure of ibutamoren, also referred to herein as ibutamoren mesylate, is shown below:
• Ibutamoren is commercially available from vendors such as, for example, Sigma Aldricb and Caymen Chemical.
• NAFLD leading to hepatic inflammation, fibrosis and hepatocellular carcinoma has become a major health problem and is associated with the increasing prevalence of obesity, insulin resistance, type 2 diabetes and metabolic disease.
• a cross-sectional study of 7,146 individuals revealed that NAFLD is associated with low circulating growth hormone (GH) (Xu, Xu et al. 2012)).
• GH circulating growth hormone
• IGF-1 and IGFBP3 are positively regulated by GH
• GH is critically important for regulating expression of the LDL receptor and levels of circulating lipoproteins (Rudling, Norstedt et al. 1992). Besides increasing IGF-1 and IGFBP3, GH treatment controls the activity of key enzymes involved in biosynthesis of cholesterol and bile acids. In addition, GH controls the expression of genes that enhance hydrolysis of triglycerides (TG), lowers storage of TG as well as increasing synthesis of diacylglycerol (Zhao, Cowley et al. 2011).
• TG triglycerides
• diacylglycerol Zhao, Cowley et al. 2011.
• GHR GH receptor
• HSD1 G-hydroxysteroid dehydrogenase type- 1 (FISDl), the enzyme responsible for local conversion of cortisone to the active glucocorticoid Cortisol; Cortisol regulates gluconeogenesis and fat deposition.
• FISDl G-hydroxysteroid dehydrogenase type- 1
• HSD1 is expressed in the liver, adipose tissue and the brain. Overproduction of HSD1 in the liver increases cortisol-induced gluconeogenesis by increasing expression of the rate-limiting gluconeogenic enzyme phosphoenol-pyruvate carboxykinase.
• HSD1 overexpression in omental fat stimulates adipogenesis that potentially causes central obesity
• inhibiting HSD1 activity to reduce local Cortisol production is a potential approach for preventing and treating type 2 diabetes, obesity, age-related cognitive dysfunction and NAFLD.
• Inhibitors of HSD1 improve insulm sensitivity and ameliorate hepatic steatosis in db/db mice ( " Yuan, Li et al. 2016). Impaired GH production increases USD! expression and GH-deficient patients exhibit a high ratio of cortisol/cortisone that can be reversed by treating with low -dose GH.
• PNPLA3 patatin-iike phospholipase domain-containing protein 3
• Obesity arid type 2 Diabetes Mellitus are associated with insulin resistance.
• the resistance is primarily mediated at the skeletal muscle and the ability of insulin to suppress gluconeogenesis in the liver.
• the suppression of hepatic gluconeogenesis depends on the reduction of free fatty acids from adipose tissue (Bergman and Iyer 2017).
• the resistance is purely extrahepatic in skeletal muscle and adipose tissue, yet the liver retains its sensitivity to insulin to stimulate lipogenesis - this has been referred to as "selective insulin resistance" see (Titcheneli, Quinn et al. 2016).
• Treatment of diabetes mellitus is a balance on the one hand to regulate and control hyperglycemia while at the same time sot increasing hepatic lipogenesis.
• increasing insulin levels by exogenous insulin or with sulfonylurea drugs does not play a part in treating NAFLD.
• GLP-1 agonists, or DPP4 antagonists which prolong the activity of endogenous GLP-1 are preferable because they enhance insulin release in response to glucose and lower blood glucose reducing the ability to enhance lipogenesis in the liver.
• DPP4 inhibitors are ideal therapies to inhibit this process (Mest and Mentlein 2005).
• Obesity and type 2 diabetes mellitus are associated with suppressed GH secretion. Insulin and GH are secreted in a pulsatile fashion and the two are tightly regulated. For example, when insulin secretion increases there is a rapid suppression of IGFBP-1 which then results in an increase in free IGF-I which feeds back to inhibit GH secretion. Following a meal, insulin levels increase to facilitate the transport of glucose into cells and to enhance storage of energy as fat. The liver is central to the integration of metabolism and stores glycogen and fat for use during times of enhanced energy utilization, e.g. exercise or starvation (Cahill 1971).
• glycogen stores from the liver are depleted and the body then turns to fat for energy, in addition to fat being stored in the liver it is also stored in white adipose tissue (primarily subcutaneous fat), which is mobilized as needed.
• the two hormones which are primary in regulating the deposition of fat in liver and adipose tissue, and later its mobilization, are insulin and GH.
• insulin and GH are primary in regulating the deposition of fat in liver and adipose tissue, and later its mobilization.
• Both OLP-1 and Ghrelin act in an analogous fashion to augment the normal amplitude of insulin and GH pulses respectively. It is critical that insulin and GH are secreted at the appropriate time, usually in a reciprocal fashion, i.e. when insulin levels are high GH levels are suppressed.
• ibutamoren By contrast, administration of the GH-secretagogue ibutamoren enhances the amplitude of pulsatile release of endogenous GH and normalizes GH because the stimulatory effects of ibutamoren on GH pulsatility are subject to natural inhibitory feedback mediated by IGF- 1; hence, hyperstimulation of the GH/iGF-1 axis is avoided (Smith, Van der Ploeg et al. 1997). It follows that ibutamoren, by recapitulating normal GH physiology is ideal for increasing insulin sensitivity in the treatment/prevention of NAPLD.
• Type 2 diabetic patients on metformin and/or a sulphonylurea agent were allocated for 12 week treatment with the GLP-1 receptor agonist liraglutide and/or the DPP4 inhibitor sitagliptin (JanuviaTM); neither treatment reduced hepatic steatosis or fibrosis (Smits, Tonneijck et al. 2016).
• sitagliptin was no better than placebo in reducing liver fat (Cui, Philo et al. 2016).
• Another study with 12 subjects treated for 24 weeks with sitagliptin showed no improvement in fibrosis (Joy, McKenzie et al. 2017).
• the inventors suggest that a limitation of targeting the GLP-1 pathway alone for treating NAFLD is that it does not adequately relieve insulin resistance associated with NAFLD.
• ibutamoren does not suppress glucose stimulated insulin secretion; therefore, ibutamoren does not. negate the stimulatory effects of GLP- 1 on insulin release.
• a pill containing the combination of ibutamoren and a DPP4 inhibitor such as JanuviaTM would have the properties necessary for treating/preventing NAFLD.
• GH is an important regulator of hepatic fat metabolism. Fat accumulation in visceral fat and in the liver increase with aging which is associated with a progressive decline of GH secretion by 50% every 7-10 years from mid puberty such that elderly people have similar GH levels to those found in GH deficient young adults. GH deficient adults have an increased incidence of non-alcoholic fatty liver disease (NAFLD) and steatohepatitis. GH replacement therapy reverses this process.
• NAFLD non-alcoholic fatty liver disease
• a GH secretogogue such as ibutamoren
• ibutamoren will restore pulsatile GH secretion and lower visceral fat; this is based on the observation that endogenous GH secretion correlates negatively with the amount of visceral fat and with liver fat accumulation (NAFLD) and that low dose GH reverses this process. HIV lipodystrophy is associated with both increased visceral fat accumulation and steatohepatitis. It has been treated with both supraphysiological rbGH injections and with tesarnorelin (a long acting GHRH analog ⁇ . Since ibutamoren has been demonstrated to enhance GH secretion, increase serum IGF-1 and increase lean body mass in obese individuals this hypothesis is supported.
• Ibutamoren is proposed as treatment for NAFLD and steatohepatitis due to NAFLD.
• the combination with various agents which improve insulin sensitivity is proposed to mitigate the mild diabetogenic action of the enhanced GH secretion induced by ibutamoren.
• Oxidative stress has been implicated to have an important role in the progression of NASH.
• Vitamin E is well known as a free radical scavenger, and has been prescribed for the treatment of NASH.
• Vitamin E treatment for 1 year reduced serum transaminase activities as well as TGF-jii in adult NASH patients who were refractory to dietary intervention.
• PIVENS Nonalcoholic Steatohepatitis
• vitamin E significantly reduced serum hepatobiliary enzymes, hepatic steatosis, inflammation, and hepatocellular ballooning compared with the control group. In those studies, however, fibrosis improvement was not confirmed.
• vitamin E In Japan, long-term vitamin E treatments (300 mg/day) for more than 2 years can ameliorate hepatic fibrosis in NASH patients, especially in those whose serum transaminase activities and insulin resistance can be improved. This result has suggested that metabolic factors should be controlled even when vitamin E is administrated.
• vitamin E Although vitamin E is now recommended only for biopsy-proven NASH patients without diabetes on the basis of PIVENS trial, it is associated with histological improvement regardiess of diabetic status.
• Vitamin E treatment may increase all- cause mortality, prostatic cancer (SELECT trial), and hemorrhagic stroke, although several conflicting results exist.
• treatment with lower dose 300-400 mg/day rather than 800 rag
• the present invention provides a novel method of treating non-alcoholic fatty liver disease (NAFLD) or non-alcoholic steatohepalitis (NASH), comprising: administering to a patient in need thereof a therapeutically effective amount of a growth hormone secretagogue (GHS).
• NASH non-alcoholic fatty liver disease
• GLS growth hormone secretagogue
• the novel method further comprises: administering a therapeutically effective amount of a second drug selected from: a dipeptidyi peplidase-4 (DPP4) antagonist, a glucagon-like peptide (GLP-1) receptor agonist, a thiazolidinedione, a sodium glucose transport protein 2 (SGLT2) antagonist, metformin and vitamin E.
• a second drug selected from: a dipeptidyi peplidase-4 (DPP4) antagonist, a glucagon-like peptide (GLP-1) receptor agonist, a thiazolidinedione, a sodium glucose transport protein 2 (SGLT2) antagonist, metformin and vitamin E.
• DPP4 dipeptidyi peplidase-4
• GLP-1 glucagon-like peptide
• SGLT2 sodium glucose transport protein 2
• Patient refers to a human patient, either child or adult.
• the disease is NAFLD.
• the disease is NASH.
• the GHS is ibutamoren (jibutamorea mesylate).
• 10-50 mg of ibutamoren is administered, for example, once daily. In one embodiment, 25-50 mg of ibutamoren is administered once daily. Other examples of the amount of ibutamoren administered include 10, 15, 20, 25, 30, 35, 40, 45, and 50 rag. In another aspect, ibutamoren is administered orally.
• the second drug is a DPP4 antagonist.
• the DPP4 antagonist is selected from:
• sitagliptin (tradename Januvia ® , typically dosed at 25-100 mg/day, orally);
• vildaglipiin (tradename Salvus ® , typically dosed at 50 mg twice/day, orally); saxagliptin (tradename Onglyza ® , typically dosed at 2.5 or 5 mg/day, orally); linagliptin (tradename Tradjenta* typically dosed at 5 mg/day, orally); and, a!ogJiptin (tradename Nesina ® typically dosed at 6.25, 12.5, and 25 mg/day, orally).
• the second drug is a GLP-1 receptor agonist.
• the GLP-1 receptor agonist is selected from:
• exenatide (tradenames Byelta* and Bydureon*. typically dosed at 2 mg once/week by injection);
• liraglutide (tradenames Victoza ® and Saxenda 4 ', typically dosed at 1.2 mg ⁇ 'day by injection);
• lixisenatide (tradename Adylxin ® , typically dosed at 20 ⁇ g/day by injection); albiglutidc (tradename Tanzeum*, typically dosed at 30 mg, once/week by injection);
• dulaglutide (tradename Trulicity ® , typically dosed at 0.75-1.5 mg once/week by injection);
• the second drug is a thiazolidinedione (TZD).
• ZTD thiazolidinedione
• Thiazolidinediones also called glitazones are a class of drugs that have hypoglycemic action (e.g., antihyperglycemic and/or antidiabetic).
• the TZD is selected from:
• pioglitazone (tradename Actos ® , typically dosed at 15 mg, 30 mg, or 45 mg/day, orally);
• rosiglitazone (tradename Avandia ® , typically dosed at 4 mg (2 mg + 2 mg or 4 mg in one dose) or S mg/day, orally.
• the second drug is a sodium glucose transport protein 2 (SGLT2) antagonist.
• SGLT2 sodium glucose transport protein 2
• the SGLT2 antagonist is selected from:
• empagliflozin (tradename Jardiance ® , typically dosed at 5, 10, or 1.2.5 rng/day, orally, depending on whether dosed alone in combination with metformin);
• dapagliflozin (tradename Farxiga ® , typically dosed at 2.5, 5, or 10 mg/day, orally, depending on whether dosed alone in combination with metformin).
• the second drug is metformin.
• Metformin is available in a wide variety of dosages including immediate release tablets of 500, 850, and 1000 mg and extended-release tables of 500, 750, and 1000 mg. Metformin is typically dosed at 1500, 2000, 2500, to 2550 mg/day, orally.
• the GHS is ibutamoren and the second drug is selected from:
• the GHS is ibutamoren and the second drug is sitagliptin.
• the GHS is ibutamoren and the second drug is pioglitazone.
• the GHS is ibutamoren and the second drug is metformin.
• the present invention provides a novel method of treating treating nonalcoholic fatty liver disease (NAFLD) or non-alcoholic steatohepatitis (NASH), comprising: administering to a patient in need thereof:
• NAFLD nonalcoholic fatty liver disease
• NASH non-alcoholic steatohepatitis
• GLS growth hormone secretagogue
• a therapeutically effective amount of a second drug selected from: a dipeptidyl peptidase-4 (DPP4) antagonist, a glucagon-like peptide (GLP-1) receptor agonist, a thiazolidinedione, and, a sodium glucose transport protein 2 (SGLT2) antagonist; and,
• DPP4 dipeptidyl peptidase-4
• GLP-1 glucagon-like peptide
• SGLT2 sodium glucose transport protein 2
• a therapeutically effective amount of a third drug which is metformin.
• the second drug is selected from a dipeptidyl peptidase-4 (DPP4) antagonist, a thiazolidinedione, and, a sodium glucose transport protein 2 (SGLT2) antagonist.
• DPP4 dipeptidyl peptidase-4
• SGLT2 sodium glucose transport protein 2
• the second drug is a dipeptidyl peptidase-4 (DPP4) antagonist.
• the second drug is a thiazolidinedione.
• the second drug is a sodium glucose transport protein 2 (SGLT2) antagonist.
• SGLT2 sodium glucose transport protein 2
• the GHS is ibutamoren
• the second drug is sitagliptin
• the third drug is metformin
• the GHS is ibutamoren
• the second drug is pioglitazone
• the third drug is metformin
• the timing of the dosage of the first (i.e., the GHS) and second drugs (or first, second, and third drugs) depends on their independent dosage regimen. Examples of dosage timing include;
• Non-simultaneous dosing For drugs that are administered with different timing (e.g., daily oral dosage versus weekly injection), the drugs can be administered in accordance with their individual protocols.
• One of the potential benefits of the present invention is the potential to administer the first and second (or first, second, and third) drugs simulataneously.
• the first and second (or second and third) drugs can be formulated into a single, oral dosage (e.g., pill, tablet, capsule, powder, liquid suspension, etc.).
• the present invention provides a novel drug composition, comprising:
• GHS growth hormone secretagogue
• DPP4 dipeptidyl peptidase-4
• SGLT2 sodium glucose transport protein 2
• metformin a second drug selected from: dipeptidyl peptidase-4 (DPP4) antagonist, a thiazolidinedione, a sodium glucose transport protein 2 (SGLT2) antagonist, and metformin; and,
• composition is useful in treating NAFLD and/or NASH.
• composition is orally or parenterally adrainisterable.
• the second drug is a DPP4 antagonist.
• the GHS is ibutamoren and the second drug is sitagliptin.
• the second drug is a thiazolidinedione.
• the GHS is ibutamoren and the second drug is piogiifazane.
• the second drug is a SGLT2 antagonist.
• the second drug is metformin.
• the GHS is ibutamoren and the second drug is metformin.
• the present invention provides a novel triple drug composition, comprising: (i.) a therapeutically effective amount of a growth hormone secretogogue (GHS); and, (ii.) a therapeutically effective amount of a second drug selected from: dipeptidyl peptidase-4 (DPP4) antagonist, a thiazolidinedione, and a sodium glucose transport protein 2 (SGLT2) antagonist;
• GGS growth hormone secretogogue
• DPP4 dipeptidyl peptidase-4
• SGLT2 sodium glucose transport protein 2
• composition is useful in treating NAFLD and/or NASH.
• the triple drug composition is orally or parentally administerable.
• the second drug is a DPP4 antagonist.
• the GHS is ibutamoren and the second drug is sitagliptin.
• the second drug is a thiazoiidinedione.
• the GHS is ibutamoren and the second drug is pioglitazone.
• the second drug is a SGLT2 antagonist.
• the present, invention provides a novel packaging kit, comprising:
• the present invention provides a novel packaging kit, comprising:
• At least one first compartment comprising: a therapeutically effective amount of a growth hormone secretagogue (GHS) and a pharmaceutically acceptable carrier
• at least one second compartment comprising: a therapeutically effective amount of a second drug selected from: dipeptidyl peptidase-4 (DPP4) antagonist, a thiazolidinedione, and a sodium glucose transport protein 2 (SGLT2) antagonist and a pharmaceutically acceptable carrier;
• DPP4 dipeptidyl peptidase-4
• SGLT2 sodium glucose transport protein 2
• At least one third compartment comprising: a therapeutically effective amount of a third drug, which is metformin and a pharmaceutically acceptable carrier.
• the present invention provides the use of the first and second drugs for the manufacture of a medicament for the treatment of an indication recited herein.
• the present invention provides the use of the first, second, and third drugs for the manufacture of a medicament for the treatment of an indication recited herein.
• the present invention provides a novel composition comprising the first and second drugs for use in the treatment of an indication recited herein.
• the present invention provides a novel composition comprising the first, second, and third drugs for use in the treatment of an indication recited herein.
• ibutamoren is a mesylate, ibutamoren mesylate. While the approved salt is what is referenced abo ve, other pharmaceutically acceptable salts are considered to be part of the presently claimed invention.
• Treating covers the treatment of a disease-state in a mammal, and includes: (a) preventing the disease-state from occurring in a mammal, in particular, when such mammal is predisposed to the disease-state but has not yet been diagnosed as having it; (b) inhibiting the disease-state, e.g., arresting it development; and/or (c) relieving the disease-state, e.g., causing regression of the disease state until a desired endpoint is reached. Treating also includes the amelioration of a symptom of a disease (e.g., lessen the pain or discomfort), wherein such amelioration may or may not be directly affecting the disease (e.g., cause, transmission, expression, etc.).
• “Pharmaceutically acceptable salts” refer to derivatives of the disclosed compounds wherein the parent compound is modified by making acid or base salts thereof.
• pharmaceutically acceptable salts include, but are not limited to, mineral or organic acid salts of basic residues such as amines; aikali or organic salts of acidic residues such as carboxylic acids; and the like.
• the pharmaceutically acceptable salts include the conventional non-toxic salts or the quaternary ammonium salts of the parent compound formed, for example, from non-toxic inorganic or organic acids.
• such conventional non-toxic salts include, but are noi limited to, those derived from inorganic and organic acids selected from 1, 2-ethanedisulfbnic, 2- acetoxybenzoic, 2-hydroxyethanesulfbnic, acetic, ascorbic, benzenesulfonic, benzoic, bicarbonic, carbonic, citric, edetic, ethane disulfonic, ethane sulfonic, fumaric, glucoheptonic, gluconic, glutamic, glycoiic, glycollyarsanilic, hexylresorcinic, hydrabamie, hydrobromic, hydrochloric, hydroiodide, hydroxymaleic, hydroxynaphthoic, isethionic, lactic, lactobionic, lauryl sulfonic, maleic, malic, mandelic, methanesulfonic, napsylic, nitric, oxalic, pamoic, pan
• the pharmaceutically acceptable salts of the present invention can be synthesized from the parent compound that contains a basic or acidic moiety by conventional chemical methods. Generally, such salts can be prepared by reacting the free acid or base forms of these compounds with a stoichiometric amount of the appropriate base or acid in water or in an organic solvent, or in a mixture of the two; generally, non-aqueous media like ether, ethyl acetate, ethanol, isopropano!, or acetonitrile are useful. Lists of suitable salts are found in Remington's
• Therapeutically effective amount includes an amount of a compound of the present invention that is effective when administered alone or in combination to treat obesity, diabetes, dyslipidemias, cardiovascular disorders, inflammatory disorders, hepatic disorders, cancers, and a combination or comorbitity thereof, or another indication listed herein.
• “Therapeutically effective amount” also includes an amount of the combination of compounds claimed that is effective to treat the desired indication.
• the cfjmbination of compounds can be a synergistic combination. Synergy, as described, for example, by Chou and Talalay, Adv. Enzyme Regul.
• Synergy can be in terms of lower cytotoxicity, increased effect, or some other beneficial effect of the amibination compared with the individual components.
• the compound(s) of the present invention can be administered in any convenient manner (e.g., enterally or parenterally).
• methods of administration include orally and transdermally.
• routes of administering the compounds of the present invention may vary significantly, in addition to other oral administrations, sustained and/or modified release compositions may be favored.
• Other acceptable routes may include injections (e.g., intravenous, intramuscular, subcutaneous, and intraperitoneal); subderrnal implants; and, buccal, sublingual, topical, rectal, vaginal, and intranasal administrations.
• Bioerodible, non-bioerodible, biodegradable, and non-biodegradable systems of administration may also be used.
• oral formulations include tablets, coated tablets, hard and soft gelatin capsules, solutions, emulsions, powders, granules, and suspensions.
• the active ingredient(s) can be mixed with a pharmaceutical vehicle, examples of which include silica, starch, lactose, magnesium stearate, and talc.
• the tablets can be optionally coated with sucrose or another appropriate substance or they can be treated so as to have a sustained or delayed activity and so as to release a predetermined amount of active ingredient continuously.
• Capsules can be obtained, for example, by mixing the active ingredientfs) with a diluent and incorporating the resulting mixture into soft or two piece hard capsules.
• a syrup or elixir can contain the active ingredient(s) in conjunction with a sweetener, which is typically calorie-free, an antiseptic (e.g., methylparaben and/or propylparaben), a flavoring, and an appropriate color.
• a sweetener typically calorie-free
• an antiseptic e.g., methylparaben and/or propylparaben
• Water-dispersible powders or granules can contain the active ingredients) mixed with dispersants or wetting agents or with suspending agents such as polyvinylpyrrolidone, as well as with sweeteners or taste correctors.
• Rectal administration can be effected using suppositories, which are prepared with binders melting at the rectal temperature (e.g., cocoa butter and/or polyethylene glycols), gels or foams.
• Parenteral administration can be effected using aqueous suspensions, isotonic saline solutions, or injectable sterile solutions, which contain pharmacologically compatible dispersants and/or wetting agents (e.g., propylene glycol and/or polyethylene glycol).
• the active ingredient(s) can also be formulated as microcapsules or microspheres, optionally with one or more carriers or additives.
• the active ingredient(s) can also be presented in the form of a complex with a cyclodextrin, for example ⁇ -, ⁇ -, or ⁇ -cyclodextrin, 2-hydroxypropyl-P-cyclodexirin, and/or methyl-p-cyclodextrin.
• the dose of the compound of the present invention administered daily will vary on an individual basis and to some extent may be determined by the severity of the disease being treated (e.g., NAFLD or NASH).
• the dose of the compound of the present invention will also vary dependi ng on the drug or drugs administered. Examples of dosages of compounds of the present invention have been provided above but may vary based on synergistic effects of a combination of two or three drugs.
• the compound cart be administered in a single dose or in a number of smaller doses over a period of time.
• the length of time during which the compound is administered varies on an individual basis and can continue until the desired results are achieved (i.e., reduction of body fat, or prevention of a gain in body fat).
• oral compositions of the present invention are provided in the present table (only active ingredients are shown).
• oral compositions of the present invention are provided present table (only active ingredients are shown):
• Growth hormone is a hormone produced in the pituitary gland that helps regulate metabolism and growth. Individuals with obesity, on average, secrete less growth hormone than individuals without obesity. There are data to suggest that growth hormone may help to reduce the amount of fat in the liver, and may also reduce inflammation in Hie liver, both of which would be helpful to individuals with NAFLD.
• the purpose of this proposed study is to investigate whether treatment with ibutamoren, also known as ibutamoren mesylate, which is a growth hormone secretogogue, will decrease liver fat and improve liver inflammation and scarring in obese individuals with N AFLD.
• Quadruple Participant, Care Provider, Investigator, Outcomes
• NAS -NAFLD Activity Score
• CCTA coronary computed tomography angiography
• Non-HDL Non-high density lipoprotein
• -Hepatic steatosis as demonstrated by either a) Grade 1+ steatosis on a liver biopsy performed within 12 months of the baseline visit, without >10% reduction in body ' or addition of medications to treat fatty liver, or b) liver fat fraction >5% on hydrogen magnetic resonance spectroscopy (1 Ei-MRS) -Hepatitis C antibody and Hepatitis B surface antigen negative
• -Heavy alcohol use defined as consumption of > 20 grams daily for women or > 30 grans daily for men for at least 3 consecutive months over the past 5 years assessed using the Lifetime Drinking History Questionnaire
• cirrhosis Child-Pugh score >7, stage 4 fibrosis on biopsy, or clinical evidence of cirrhosis or portal hypertension on imaging or exam. If a subject is not known to be cirrhotic at screen but is found to be cirrhotic based on the results of liver biopsy at baseline, this subject will be referred to a hepatologist for clinical care and will be excluded from further participation in the study.
• PSA prostate specific antigen
• MRI magnetic resonance imaging
• beta-blocker or nitroglycerin which are part of the coronary angiography
• -Significant radiation exposure including any history of radiation therapy, or any of the following in the 12 months prior to randomization: a) more than 2 percutaneous coronary interventions; b) more than 2 myocardial perfusion studies; 3) more than 2 computed tomography angiograms
• ibutamoren also known as ibutamoren mesylate, which is a growth hormone secretagogue, in a>mbination with a second active ingredient, will decrease liver fat and improve liver inflammation and scarring in obese individuals with NAFLD.
• NAFLD Activity Score (NAS, scored between 0-8) from liver biopsy
• CCTA coronary computed tomography angiography
• Non-HDL Non-high density lipoprotein
• -Heavy alcohol use defined as consumption of > 20 grams daily for women or > 30 grans daily for men for at least 3 consecutive months over the past 5 years assessed using the Lifetime Drinking History Questionnaire
• cirrhosis Child-Pugh score >7, stage 4 fibrosis on biopsy, or clinical evidence of cirrhosis or portal hypertension on imaging or exam. If a subject is not known to be cirrhotic at screen but is found to be cirrhotic based on the results of liver biopsy at baseline, this subject will be referred to a hepatologist for clinical care and will be excluded from further participation in the study.
• PSA prostate specific antigen
• MR magnetic resonance imaging
• -Significant radiation exposure including any history of radiation therapy, or any of the following in the 12 months prior to randomization: a) more than 2 percutaneous coronary interventions; b) more than 2 myocardial perfusion studies; 3) more than 2 computed tomography angiograms -Active consideration for a procedure or treatment that involves significant radiation exposure as defined above in the 12 months following randomization

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