WO2021101875A1

WO2021101875A1 - Compositions and methods for treating disorders ameliorated by muscarinic receptor activation

Info

Publication number: WO2021101875A1
Application number: PCT/US2020/060859
Authority: WO
Inventors: Stephen Brannan; Andrew Miller
Original assignee: Karuna Therapeutics, Inc.
Priority date: 2019-11-18
Filing date: 2020-11-17
Publication date: 2021-05-27
Also published as: CA3161952A1; EP4061808A4; EP4061808A1; CN115667235A; JP2023503056A

Abstract

Provided herein is a method of treating schizophrenia or a disease related to schizophrenia in a patient in need thereof. The method comprises orally administering to the patient twice daily an oral pharmaceutical composition comprising a plurality of xanomeline beads comprising xanomeline or a salt thereof, and plurality of trospium beads comprising a salt of trospium, via the titration scheme that comprises up-titration of the xanomeline, or a salt thereof, and the salt of trospium.

Description

COMPOSITIONS AND METHODS FOR TREATING DISORDERS AMELIORATED BY MUSCARINIC RECEPTOR ACTIVATION

[0001] This application claims the benefit of priority of United States Provisional Patent Application Serial No. 62/936,837 filed November 18, 2019, and also claims the benefit of priority of United States Provisional Patent Application Serial No. 63/030,780 filed May 27, 2020, the disclosures of which are each incorporated by reference in their entireties for all purposes.

[0002] The present disclosure relates to compositions and their application as pharmaceuticals for treating disorders ameliorated by activating muscarinic receptors in a human or animal subject.

[0003] Schizophrenia affects about 0.5 to 1% of the population. The disease is characterized by a set of symptoms divided into positive symptoms (e.g., hallucinations, delusional thoughts, etc.), negative symptoms (e.g., social isolation, anhedonia, etc.), and cognitive symptoms (e.g., inability to process information, poor working memory, etc.). Patients who suffer from schizophrenia experience a major decline in quality of life. They are at increased risk for mortality due to many factors, such as an increased suicide rate. The cost of schizophrenia to society is high, as people living with schizophrenia are much more likely to be incarcerated, homeless, or unemployed.

[0004] Existing treatments for schizophrenia rely upon dopamine and serotonin receptors, as was the case with the first antipsychotic, chlorpromazine, discovered in 1952. For more than 60 years, the same fundamental pharmacology has been the standard of care in schizophrenia. Current antipsychotics are only efficacious toward positive symptoms, leaving negative and cognitive symptoms untreated. Alzheimer’s disease is another therapeutic area. It has proven extremely difficult to develop new therapies, with a success rate of only 0.4% for molecules that enter clinical development and receive marketing approval. Patients in these areas desperately need new treatments, but development has been extremely difficult despite substantial efforts from scientists and drug developers worldwide.

[0005] Activating the muscarinic system through muscarinic agonists may treat several diseases, such as schizophrenia, Alzheimer’s disease, Parkinson’s disease, depression, movement disorders, drug addiction, pain, and neurodegeneration, such as tauopathies or synucleinopathies. Muscarinic cholinergic receptors are G-protein coupled receptors with five different receptor subtypes (M1-M5), each of which is found in the CNS with different tissue distributions. Ml and M4 subtypes have been of interest as therapeutic targets for various diseases. For instance, mood stabilizers lithium and valproic acid, used for treating bipolar depression, may affect the muscarinic system, particularly through the M4 subtype receptor. Genetic evidence directly links the muscarinic system and alcohol addiction.

[0006] In a double-blind placebo-controlled trial of schizophrenic patients using xanomeline, a muscarinic cholinergic receptor agonist with preferential activity at the Ml and M4 subtype receptors, schizophrenia was alleviated. However, because xanomeline is also bound to muscarinic receptors outside the brain, it has many serious side effects, including GI side effects, cardiac side effects, and hypersalivation. Dose-limited adverse events were problematic and led to very high discontinuation rates (including a 56% dropout rate in a 26- week study of Alzheimer’s disease) and eventually to discontinuation of xanomeline development. Despite the early promise, xanomeline development halted for more than 15 years. Many companies attempted and failed to develop muscarinic receptor agonists for CNS disorders, which avoided these unacceptable side effects, but no such agonist has reached the market. Past development efforts focused on medicinal chemistry to develop molecules that would be more tolerable, typically selecting the Ml and M4 subtypes over the M2 and M3 muscarinic receptor subtypes. However, Ml and M4 activation outside the brain may still cause muscarinic related intolerance. Very little progress has been made to mitigate adverse effects due to the activation of peripheral muscarinic receptors.

[0007] There remains a need in the art for a pharmaceutical composition with increased tolerability for xanomeline, especially to treat cognitive and psychotic disorders. The following embodiments and aspects thereof are described and illustrated with compositions and methods, which are meant to be exemplary and illustrative, not limiting in scope. In various embodiments, one or more of the above-described problems have been reduced or eliminated, while other embodiments are directed to other improvements.

[0008] Provided herein is a method of treating schizophrenia or a disease related to schizophrenia in a patient in need thereof, the method comprising: orally administering to the patient twice daily an oral pharmaceutical composition comprising a plurality of xanomeline beads comprising xanomeline or a salt thereof, and a plurality of trospium beads comprising a salt of trospium, via a titration scheme that comprises up-titration of the xanomeline, or a salt thereof, and the salt of trospium.

[0009] Also provided is a method of treating schizophrenia or a disease related to schizophrenia in a patient in need thereof, the method comprising orally administering to the patient twice daily an oral pharmaceutical composition comprising a plurality of xanomeline beads comprising xanomeline or a salt thereof, and a plurality of trospium beads comprising a salt of trospium, via a titration scheme that comprises up-titration of the xanomeline, or a salt thereof, and the salt of trospium until an amount equivalent to 125 mg xanomeline free base and an amount equivalent to 30 mg trospium chloride is administered.

[0010] The present disclosure further provides a method of treating acute psychosis in a patient in need thereof. The method comprises orally administering to the patient twice daily an oral pharmaceutical composition comprising xanomeline or a salt thereof, and a salt of trospium, to achieve at least a 10 point mean reduction in total Positive and Negative Syndrome Scale (PANSS) score compared to placebo.

[0011] Further aspects and advantages will be apparent to those of ordinary skill in the art from a review of the following detailed description. While the dosage form, method of making, and treatment method are susceptible of embodiments in various forms, the description hereafter includes specific embodiments to understand that the disclosure is illustrative and is not intended to limit the disclosure to the specific embodiments described herein.

BRIEF DESCRIPTION OF THE DRAWINGS [0012] The disclosure will be readily understood by the following detailed description in conjunction with the accompanying drawings, wherein like reference numerals designate like structural elements. The drawings provide exemplary embodiments or aspects of the disclosure and do not limit the scope of the disclosure.

[0013] FIG. 1 depicts the mean (± standard deviation) xanomeline pharmacokinetic concentrations on Day 1 for KarXT 50/20 twice-daily treatment cohort of the KAR-003 pharmacokinetic population.

[0014] FIG. 2 depicts the mean (± standard deviation) xanomeline pharmacokinetic concentrations by treatment on Day 3 for KarXT twice-daily treatment for all cohorts of the KAR-003 pharmacokinetic population.

[0015] FIG. 3 depicts the mean (± standard deviation) xanomeline pharmacokinetic concentrations by treatment on Day 7 for KarXT 100/20, 125/40, and 150/40 twice-daily treatment cohorts of the KAR-003 pharmacokinetic population.

[0016] FIG. 4 depicts the mean (± standard deviation) xanomeline pharmacokinetic concentrations by treatment and visit for the KAR-003 pharmacokinetic population.

[0017] FIG. 5 depicts the mean (± standard deviation) xanomeline pharmacokinetic trough concentrations by treatment for the KAR-003 pharmacokinetic population. [0018] FIG. 6 depicts the mean (± standard deviation) trospium pharmacokinetics concentrations on Day 1 for the KarXT 50/20 twice-daily treatment cohort of the KAR-003 pharmacokinetics population.

[0019] FIG. 7 depicts the mean (± standard deviation) trospium pharmacokinetics concentrations by treatment on Day 3 for the KAR-003 pharmacokinetics population.

[0020] FIG. 8 depicts the mean (± standard deviation) trospium pharmacokinetics concentrations by treatment on Day 7 for the KAR-003 pharmacokinetics population.

[0021] FIG. 9 depicts the mean (± standard deviation) trospium pharmacokinetic concentrations by treatment and visit for the KAR-003 pharmacokinetic population.

[0022] FIG. 10 depicts the mean (± standard deviation) trospium pharmacokinetic trough concentrations by treatment and visit for the KAR-003 pharmacokinetic population.

[0023] FIG. 11 depicts total PANSS score change from baseline (LS mean difference) of subjects in the modified intent-to-treat (mITT) population of KAR-004 Phase II study versus time in weeks (***p<0.0001).

[0024] FIG. 12 depicts PANSS-positive subscore change from baseline (LS mean difference) of subjects in the mITT population of KAR-004 Phase II study versus time in weeks

(***p<0.0001).

[0025] FIG. 13 depicts PANSS-negative subscore change from baseline (LS mean difference) of subjects in the mITT population of KAR-004 Phase II study versus time in weeks (*p<0.05, **p<0.001).

[0026] FIG. 14 depicts the PANSS Marder Factor score of subjects in the mITT population of KAR-004 Phase II study versus Visit day.

[0027] FIG. 15 depicts the statistically significant and clinically meaningful improvement on Clinical Global Impression-Severity (CGI-S) at baseline for patients on KarXT versus placebo.

[0028] FIG. 16 depicts the statistically significant and clinically meaningful improvement on CGI-S at the endpoint of Week 5 for patients on KarXT versus placebo.

[0029] FIG. 17 depicts that the rates of adverse events related to muscarinic receptor agonism (nausea and vomiting) decreased over time in KarXT-treated patients.

[0030] FIG. 18 depicts that the rates of a peripheral anticholinergic adverse event (dry mouth) decreased over time in KarXT-treated patients.

[0031] FIG. 19 depicts a box plot of standing heart rate (beats per min, bpm) from the KarXT safety population plotted by the visit. [0032] FIG. 20 depicts a box plot of orthostatic heart rate (beats per min, bpm) from the KarXT safety population plotted by the visit.

[0033] FIG. 21 depicts a box plot of orthostatic diastolic pressure (mmHg) from the KarXT safety population plotted by the visit.

[0034] FIG. 22 depicts a box plot of the orthostatic systolic pressure (mmHg) from the KarXT safety population plotted by the visit.

DETAILED DESCRIPTION

[0035] Earlier development of xanomeline, a muscarinic receptor agonist, was halted due to peripheral cholinergic side effects. The current disclosure provides a dosage form with dissolution kinetics having a more effective therapeutic effect for both active ingredients, enhanced pharmacokinetics for trospium chloride, and greater dosing compliance. The current disclosure also provides dosage forms with different strengths or different ratios of the two actives.

[0036] Provided herein are the following specific embodiments:

[0037] Embodiment 1: A method of treating schizophrenia or a disease related to schizophrenia in a patient in need thereof, the method comprising: orally administering to the patient twice daily an oral pharmaceutical composition comprising a plurality of xanomeline beads comprising xanomeline or a salt thereof, and plurality of trospium beads comprising a salt of trospium, via a titration scheme that comprises up-titration of the xanomeline, or a salt thereof, and the salt of trospium.

[0038] Embodiment 2: A method of treating schizophrenia or a disease related to schizophrenia in a patient in need thereof, the method comprising: orally administering to the patient for at least five weeks twice daily an oral pharmaceutical composition comprising a plurality of xanomeline beads comprising xanomeline or a salt thereof, and plurality of trospium beads comprising a salt of trospium, wherein at least one adverse event which occurred at the start of oral administration is reduced to its pretreatment level after five weeks of treatment.

[0039] Embodiment 3: The method of Embodiment 1 or 2, wherein the administration occurs via a titration scheme that comprises up-titration of the xanomeline, or the salt thereof, and the salt of trospium until an amount equivalent to 125 mg xanomeline free base and an amount equivalent to 30 mg trospium chloride is administered twice daily. [0040] Embodiment 4: The method of Embodiment 1 or 2, wherein the administration occurs via a titration scheme that comprises up-titration of the xanomeline, or the salt thereof, and the salt of trospium until an amount equivalent to 150 mg xanomeline free base and an amount equivalent to 30 mg trospium chloride is administered twice daily.

[0041] Embodiment 5: The method of Embodiment 1 or 2, wherein the administration occurs via a titration scheme that comprises up-titration of the xanomeline, or the salt thereof, and the salt of trospium until an amount equivalent to 175 mg xanomeline free base and an amount equivalent to 30 mg trospium chloride is administered twice daily.

[0042] Embodiment 6: The method of Embodiment 1 or 2, wherein the administration occurs via a titration scheme that comprises up-titration of the xanomeline, or the salt thereof, and the salt of trospium until an amount equivalent to 175 mg xanomeline free base and an amount equivalent to 40 mg trospium chloride is administered twice daily.

[0043] Embodiment 7: The method of any one of the proceeding Embodiments, wherein the patient has a diagnosis of schizophrenia.

[0044] Embodiment 8: The method of any one of the proceeding Embodiments, wherein prior to administration of the oral pharmaceutical composition, the patient had a Clinical Global Impression Severity Scale (CGI-S) score of 4-7, and after administration the patient had a CGI-S score equal to 1 or 2.

[0045] Embodiment 9: The method of any one of the proceeding Embodiments, wherein the xanomeline, or the salt thereof, is administered for a first period in a first amount and then the first amount is increased to a second amount.

[0046] Embodiment 10: The method of Embodiment 9, wherein the first amount of xanomeline, or the salt thereof, is equivalent to 50 mg xanomeline free base.

[0047] Embodiment 11: The method of Embodiment 9 or 10, wherein the first period for the xanomeline administration is between 1 and 5 days.

[0048] Embodiment 12: The method of Embodiment 11, wherein the first period for the xanomeline administration is 2 days.

[0049] Embodiment 13: The method of any one of Embodiments 9 to 12, wherein the second amount of xanomeline, or the salt thereof, is equivalent to 100 mg xanomeline free base.

[0050] Embodiment 14: The method of any one of Embodiments 9 to 13, further comprising administering the xanomeline, or the salt thereof, for a second period in the second amount and then increasing the second amount to a third amount. [0051] Embodiment 15: The method of Embodiment 14, wherein the second period for xanomeline administration is between three days and a week.

[0052] Embodiment 16: The method of Embodiment 14 or 15, wherein the third amount of xanomeline, or the salt thereof, is equivalent to 125 mg xanomeline free base.

[0053] Embodiment 17: The method of any of the preceding Embodiments, wherein the salt of trospium is administered for a first time period in a first amount and the first amount is increased to a second amount.

[0054] Embodiment 18: The method of Embodiment 17, wherein the first amount of the salt of trospium is equivalent to 20 mg trospium chloride.

[0055] Embodiment 19: The method of Embodiment 17 or 18, wherein the first time period for trospium administration is at least a week.

[0056] Embodiment 20: The method of any one of Embodiments 15 to 17, wherein the second amount of the salt of trospium is equivalent to 30 mg trospium chloride.

[0057] Embodiment 21: The method of any one of the preceding Embodiments, at least one of vomiting, nausea and dry mouth which occurred at the start of oral administration is reduced to its pretreatment level after five weeks of treatment.

[0058] Embodiment 22: The method of any one of the preceding Embodiments, wherein the xanomeline, or the salt thereof, and the salt of trospium are administered without inducing a heart rate increase of more than about 5 beats per minute.

[0059] Embodiment 23: The method of any one of the preceding Embodiments, wherein the xanomeline, or the salt thereof, and the salt of trospium are administered without inducing syncope.

[0060] Embodiment 24: The method of any one of the preceding Embodiments, wherein the xanomeline, or the salt thereof, and the salt of trospium are administered without inducing a change in diastolic blood pressure of more than about 5 mmHg.

[0061] Embodiment 25: The method of any one of the preceding Embodiments, wherein the xanomeline, or the salt thereof, and the salt of trospium are administered without inducing a change in systolic blood pressure of more than about 5 mmHg.

[0062] Embodiment 26: The method of any one of the preceding Embodiments, wherein the xanomeline, or the salt thereof, and the salt of trospium are administered without causing a severe adverse event. [0063] Embodiment 27: The method of any one of the preceding Embodiments, wherein the xanomeline, or the salt thereof, and the salt of trospium are administered without causing a severe adverse event related to heart rate.

[0064] Embodiment 28: The method of any one of the preceding Embodiments, wherein the xanomeline, or the salt thereof, and the salt of trospium are administered without causing a severe adverse event related to heart rate change.

[0065] Embodiment 29: The method of any one of the preceding Embodiments, wherein the xanomeline, or the salt thereof, and the salt of trospium are administered without causing a severe adverse event related to blood pressure.

[0066] Embodiment 30: The method of any one of the preceding Embodiments, wherein the xanomeline, or the salt thereof, and the salt of trospium are administered without causing a severe adverse event related to blood pressure change.

[0067] Embodiment 31: The method of any one of the preceding Embodiments, wherein the xanomeline, or the salt thereof, and the salt of trospium are administered without increasing a liver function test (LFT).

[0068] Embodiment 32: The method of any one of the preceding Embodiments, wherein the Positive and Negative Syndrome Scale (PANSS) total score for the patient decreases by at least 10 points compared to placebo after five weeks of treatment.

[0069] Embodiment 33: The method of any one of the preceding Embodiments, wherein the PANSS positive subscore decreases by at least 3 points compared to placebo after five weeks of treatment.

[0070] Embodiment 34: The method of any one of the preceding Embodiments, wherein the PANSS negative subscore decreases by at least 2 points compared to placebo after five weeks of treatment.

[0071] Embodiment 35: The method of any one of the preceding Embodiments, wherein the size of the xanomeline beads is between 0.425 mm and 1.18 mm.

[0072] Embodiment 36: The method of any one of the preceding Embodiments, wherein the size of the xanomeline beads is between 0.6 mm and 0.85 mm.

[0073] Embodiment 37: The method of any one of the preceding Embodiments, wherein the size of the trospium beads is between 0.425 mm and 1.18 mm.

[0074] Embodiment 38: The method of any one of the preceding Embodiments, wherein the size of the trospium beads is between 0.6 mm and 0.85 mm. [0075] Embodiment 39: The method of any one of the preceding Embodiments, wherein the xanomeline beads contain about 2.5 times as much xanomeline free base as the trospium beads contain trospium salt.

[0076] Embodiment 40: The method of any one of the preceding Embodiments, the plurality of xanomeline and the plurality of trospium beads having a dissolution rate of more than about 95% within about the first 45 minutes following entry of the dosage form into an aqueous solution.

[0077] Embodiment 41: The method of Embodiment 40, having a dissolution rate of more than about 95% within about the first 20 minutes following entry of the dosage form into an aqueous solution.

[0078] Embodiment 42: The method of any one of the preceding Embodiments, wherein the salt of xanomeline is xanomeline tartrate.

[0079] Embodiment 43: The method of Embodiment 42, wherein the xanomeline beads comprise between 30 wt.% and 80 wt.% xanomeline tartrate.

[0080] Embodiment 44: The method of any Embodiment 43, wherein the xanomeline beads comprise 66 wt.% xanomeline tartrate.

[0081] Embodiment 45: The method of any one of the preceding Embodiments, wherein the xanomeline beads comprise between 15 wt.% and 65 wt.% microcrystalline cellulose.

[0082] Embodiment 46: The method of Embodiment 45, wherein the xanomeline beads comprise 33.5 wt.% microcrystalline cellulose.

[0083] Embodiment 47: The method of any one of the preceding Embodiments, wherein the xanomeline beads comprise between 0 wt.% and 2 wt.% talc.

[0084] Embodiment 48: The method of Embodiment 46, wherein the xanomeline beads comprise 0.5 wt.% talc.

[0085] Embodiment 49: The method of any one of the preceding Embodiments, wherein the xanomeline beads comprise between 30 wt.% and 80 wt.% xanomeline tartrate, between 15 wt.% and 65 wt.% microcrystalline cellulose, and between 0 wt.% and 2 wt.% talc.

[0086] Embodiment 50: The method of Embodiment 49, wherein the xanomeline beads comprise 66 wt.% xanomeline tartrate, 33.5 wt.% microcrystalline cellulose, and 0.5 wt.% talc.

[0087] Embodiment 51: The method of any one of the preceding Embodiments, wherein the salt of trospium is trospium chloride. [0088] Embodiment 52: The method of Embodiment 51, wherein the trospium beads comprise between 8 wt.% and 35 wt.% trospium chloride.

[0089] Embodiment 53: The method of Embodiment 52, wherein the trospium beads comprise 17.7 wt.% trospium chloride.

[0090] Embodiment 54: The method of any one of the preceding Embodiments, wherein the trospium beads comprise between 25 wt.% and 80 wt.% microcrystalline cellulose.

[0091] Embodiment 55: The method of Embodiment 54, wherein the trospium beads comprise 46.8 wt.% microcrystalline cellulose.

[0092] Embodiment 56: The method of any one of the preceding Embodiments, wherein the trospium beads comprise between 15 wt.% and 70 wt.% lactose monohydrate.

[0093] Embodiment 57: The method of Embodiment 56, wherein the trospium beads comprise 35 wt.% lactose monohydrate.

[0094] Embodiment 58: The method of any one of the preceding Embodiments, wherein the trospium beads comprise between 0 wt.% and 2 wt.% talc.

[0095] Embodiment 59: The method of Embodiment 58, wherein the trospium beads comprise 0.5 wt.% talc.

[0096] Embodiment 60: The method of any one of the preceding Embodiments, wherein the trospium beads comprise between 8 wt.% and 35 wt.% trospium chloride, between 25 wt.% and 80 wt.% microcrystalline cellulose, between 15 wt.% and 70 wt.% lactose monohydrate, and between 0 wt.% and 2 wt.% talc.

[0097] Embodiment 61: The method of Embodiment 60, wherein the trospium beads comprise 17.7 wt.% trospium chloride, 46.8 wt.% microcrystalline cellulose, 35 wt.% lactose monohydrate, and 0.5 wt.% talc.

[0098] Embodiment 62: The method of any one of the preceding Embodiments, wherein the oral pharmaceutical composition further comprises ascorbic acid.

[0099] Embodiment 63: The method of Embodiment 62, wherein the oral pharmaceutical composition comprises between 0.2 wt.% and 1 wt.% ascorbic acid.

[0100] Embodiment 64: The method of Embodiment 63, wherein the oral pharmaceutical composition comprises about 0.5 wt.% ascorbic acid.

[0101] Embodiment 65: The method of any one of the preceding Embodiments, wherein the oral pharmaceutical composition further comprises butylated hydroxytoluene .

[0102] Embodiment 66: The method of Embodiment 64, wherein the oral pharmaceutical composition comprises between 0.01 wt.% and 0.1 wt.% butylated hydroxytoluene. [0103] Embodiment 67: The method of Embodiment 66, wherein the oral pharmaceutical composition comprises about 0.05 wt.% butylated hydroxytoluene.

[0104] Embodiment 68: The method of any one of the preceding Embodiments, wherein the oral pharmaceutical composition further comprises a capsule containing the plurality of xanomeline beads and the plurality of trospium beads.

[0105] Embodiment 69: A method of treating acute psychosis in a patient in need thereof, the method comprising: orally administering to the patient twice daily an oral pharmaceutical composition comprising xanomeline or a salt thereof, and a salt of trospium, to achieve at least a 10 point mean reduction in total Positive and Negative Syndrome Scale (PANSS) score compared to placebo.

[0106] Embodiment 70: The method of Embodiment 69, wherein at least an 11.6 point mean reduction in total PANNS score is achieved.

[0107] Embodiment 71: The method of any Embodiment 69 or 70, wherein at least a 3 point mean reduction in PANSS positive subscore compared to placebo is achieved.

[0108] Embodiment 72: The method of any one of Embodiments 69 to 71, wherein at least a 2 point reduction in the PANSS negative subscore compared to placebo is achieved.

[0109] Embodiment 73: The method of any one of Embodiments 69 to 72, wherein the reduction in PANSS score is achieved within about 5 weeks.

[0110] Embodiment 74: The method of any one of Embodiments 69 to 73, wherein before administration of the oral pharmaceutical composition, the patient had a Clinical Global Impression Severity Scale (CGI-S) score of 4-7, and after administration, the patient had a CGI-S score equal to 1 or 2.

[0111] Embodiment 75: The method of any one of Embodiments 69 to 74, wherein the patient has a diagnosis of schizophrenia.

[0112] Embodiment 76: The method of any one of Embodiments 69 to 75, wherein the xanomeline is xanomeline tartrate and the salt of trospium is trospium chloride.

[0113] Embodiment 77: The method of any one of Embodiments 69 to 76, at least one adverse event which occurred at the start of oral administration is reduced to its pretreatment level after five weeks of treatment.

[0114] Embodiment 78: The method of Embodiment 77, wherein at least one adverse event is chosen from vomiting, nausea and dry mouth. [0115] The articles “a” and “an” refer to one or more than one (i.e., to at least one) of the grammatical object of the article. By way of example, “an element” means one element or more than one element.

[0116] The terms “comprise” and “comprising” are inclusive, open sense, meaning that additional elements may be included.

[0117] The term “consisting” limits the elements to those specified except for impurities ordinarily associated in addition to that.

[0118] The term “consisting essentially of’ limits those specified elements and those that do not materially affect the basic and novel characteristics of the material or steps.

[0119] All ranges set forth herein include all possible subsets of ranges and any combinations of such subset ranges. By default, ranges include the stated endpoints, unless stated otherwise, where a range of values is provided, each intervening value between the upper and lower limit of that range and any other stated or intervening value in that stated range is encompassed within the disclosure. The upper and lower limits of these smaller ranges may independently be included in the smaller ranges and encompassed within the disclosure, subject to any specifically excluded limit in the stated range. Where the stated range includes one or both limits, ranges excluding either or both of those included limits are also contemplated to be part of the disclosure.

[0120] The term “wt.%” is the weight percent based on the total weight, e.g., of the core, or enteric coating, or total bead, as described in context. Unless stated otherwise, the wt.% is intended to describe the weight percent based on dry weight (e.g., for a core following drying).

[0121] The term “controlled release” is defined as a prolonged-release pattern of one or more drugs, such that the drugs are released over a period. A controlled release formulation has release kinetics that results in measurable serum levels of the drug over a period longer than what would be possible following intravenous injection or following administration of an immediate release oral dosage form. Controlled release, slow-release, sustained-release, extended-release, prolonged-release, and delayed-release have the same definitions.

[0122] The term “including” means “including but not limited to.” “Including” and “including but not limited to” are used interchangeably.

[0123] The term “mammal” is known in the art. Exemplary mammals include humans, primates, bovines, porcines, canines, felines, and rodents (e.g., mice and rats). [0124] A “patient,” “subject,” or “host” to be treated by the subject method means either a human or non-human mammal.

[0125] The term “pharmaceutically-acceptable carrier” is art-recognized. It refers to a pharmaceutically-acceptable material, composition or vehicle, such as a liquid or solid filler, diluent, excipient, solvent, or encapsulating material, involved in carrying or transporting any subject composition or component thereof from one organ, or portion of the body, to another organ, or portion of the body. Each carrier must be “acceptable” in the sense of being compatible with the subject composition and its components and not injurious to the patient. Some examples of materials that may serve as pharmaceutically acceptable carriers include sugars, such as lactose, glucose, and sucrose; starches, such as com starch and potato starch; cellulose and its derivatives, such as sodium carboxymethyl cellulose, ethylcellulose, and cellulose acetate; powdered tragacanth; malt; gelatin; talc; excipients, such as cocoa butter and suppository waxes; oils, such as peanut oil, cottonseed oil, safflower oil, sesame oil, olive oil, corn oil, and soybean oil; glycols, such as propylene glycol; polyols, such as glycerin, sorbitol, mannitol, and polyethylene glycol; esters, such as ethyl oleate and ethyl laurate; agar; buffering agents, such as magnesium hydroxide and aluminum hydroxide; alginic acid; pyrogen-free water; isotonic saline; Ringer’s solution; ethyl alcohol; phosphate buffer solutions; and other non-toxic compatible substances employed in pharmaceutical formulations.

[0126] The term “pharmaceutically-acceptable salt” or “salt” is art-recognized. It refers to a salt prepared from relatively nontoxic acids or bases, including inorganic acids and bases and organic acids and bases, including, for example, those contained in compositions of the present disclosure. Suitable non-toxic acids include inorganic and organic acids such as acetic, benzenesulfonic, benzoic, camphorsulfonic, citric, ethenesulfonic, fumaric, gluconic, glutamic, hydrobromic, hydrochloric, isethionic, lactic, maleic, malic, mandelic, methanesulfonic, mucic, nitric, pamoic, pantothenic, phosphoric, saccharinate, succinic, sulfuric, tartaric acid, p-toluenesulfonic, hydrochloric, hydrobromic, phosphoric, and sulfuric acids and the like.

[0127] The term “treating” is art-recognized and refers to curing as well as ameliorating at least one symptom of any condition or disorder.

[0128] In jurisdictions that forbid the patenting of methods practiced on the human body, the meaning of “administering” of a composition to a human subject shall be restricted to prescribing a controlled substance that a human subject will self-administer by any technique (e.g., orally, inhalation, topical application, injection, insertion, etc.)· The broadest reasonable interpretation consistent with laws or regulations defining patentable subject matter is intended. In jurisdictions that do not forbid the patenting of methods practiced on the human body, the “administering” of compositions includes both methods practiced on the human body and the foregoing activities.

[0129] The term “therapeutic agent” is art-recognized and refers to any chemical moiety that is a biologically, physiologically, or pharmacologically active substance acting locally or systemically in a subject. Examples of therapeutic agents, also referred to as “drugs,” are described in well-known literature references such as the Merck Index (14th edition), the Physicians’ Desk Reference (64th edition), and The Pharmacological Basis of Therapeutics (12th edition). These therapeutic agents include without limitation medicaments; vitamins; mineral supplements; substances used for the treatment, prevention, diagnosis, cure, or mitigation of a disease or illness; substances that affect the structure or function of the body, or pro-drugs, which become biologically active or more active after they have been placed in a physiological environment.

[0130] The term “psychotherapy” refers to non-pharmacological therapies. Those skilled in the art use various techniques involving verbal and other interactions with a patient to affect a positive therapeutic outcome. Such techniques include, but are not limited to, behavior therapy, cognitive therapy, psychodynamic therapy, psychoanalytic therapy, group therapy, family counseling, art therapy, music therapy, vocational therapy, humanistic therapy, existential therapy, transpersonal therapy, client-centered therapy (also called person-centered therapy), Gestalt therapy, biofeedback therapy, rational emotive behavioral therapy, reality therapy, response-based therapy, Sandplay therapy, status dynamics therapy, hypnosis, and validation therapy. Psychotherapy may involve combining two or more techniques. A therapist can select and adjust the techniques based on the individual patient's needs and the patient’s response.

[0131] The term “muscarinic disorder” refers to any disease or condition ameliorated by activating the muscarinic system. Such diseases include ones in which direct activation of muscarinic receptors themselves or inhibition of cholinesterase enzymes has produced a therapeutic effect.

[0132] The terms “diseases related to schizophrenia” and “disorders related to schizophrenia” include, but are not limited to, schizo-affective disorder, psychosis, including acute psychosis, delusional disorders, psychosis associated with Alzheimer’s disease, psychosis associated with Parkinson’s disease, psychotic depression, bipolar disorder, bipolar with psychosis, Huntington’s disease, Lewy Body dementia, or any other disease with psychotic features. [0133] “Psychosis” refers to an abnormal condition of the mind that results in difficulties determining what is real and not. Symptoms of psychosis include, but are not limited to, false beliefs (delusions), seeing or hearing things that others do not see or hear (hallucinations), incoherent speech, behavior that is inappropriate for the situation, sleep problems, social withdrawal, lack of motivation, and difficulties carrying out daily activities.

[0134] “Acute psychosis” refers to the quick or strong onset of psychotic symptoms in a patient, for example, as defined at “Acute and Transient Psychotic Disorder” (International Classification of Diseases- 10) and “Brief Psychosis”(DSM-IV). A sharp striking delusion with quick changes in the structure occurs in the individual who has acute psychosis after a short preliminary period of anxiety, insomnia, and confusion. Acute psychosis can include acute psychotic exacerbation, when a patient may respond to hallucinations or delusions. Acute psychosis lasts for a short time, typically from one to two weeks.

[0135] The term “activator” means a molecule described as an agonist, partial agonist, co- agonist, physiological agonist, potentiator, stimulator, allosteric potentiator, positive allosteric modulator, allosteric agonist, or a molecule that increases the activity or signaling of receptors directly or indirectly.

[0136] The term “inhibitor” means a molecule described as an antagonist, partial antagonist, competitive antagonist, non-competitive antagonist, uncompetitive antagonist, silent antagonist, inverse agonist, reversible antagonist, physiological antagonist, irreversible antagonist, inhibitor, reversible inhibitor, irreversible inhibitor, negative allosteric modulator, allosteric antagonist, or a molecule that decreases the activity or signaling of receptors directly or indirectly.

[0137] As used herein, an “adverse event” is any untoward medical occurrence associated with treatment with a pharmaceutical composition described herein. A “mild adverse event” is easily tolerated by the subject, causes minimal discomfort, and does not interfere with everyday activities. A “moderate adverse event” is sufficiently discomforting to interfere with everyday activities; intervention may be needed. A “severe adverse event” prevents everyday activities; treatment or other intervention is usually needed. A “serious adverse event” results in death; is life-threatening (immediate risk of death from the event as it occurred); requires or prolongs inpatient hospitalization; results in persistent or significant disability/incapacity; or results in a congenital anomaly/disability, cancer, or drug overdose. An adverse event is incapacitating or disabling if it results in a substantial or permanent disruption of the subject’s ability to carry out normal life functions.

[0138] As used herein, a patient is said to “tolerate” a dose of a compound if administering that dose to that patient does not result in an unacceptable adverse event or an unacceptable combination of adverse events. One of skill in the art will appreciate that tolerance is a subjective measure and that what may be tolerable to one patient may not be tolerable to a different patient. For example, one patient may not be able to tolerate a headache. In contrast, a second patient may find headache tolerable but is not able to tolerate vomiting. For a third patient, either headache alone or vomiting alone is tolerable. Still, the patient cannot tolerate the combination of headache and vomiting, even if the severity of each is less than when experienced alone.

[0139] The term “maximum tolerated dose” means the highest dose of a drug or therapeutic that a patient can take without the patient experiencing intolerable side effects. The maximum tolerated dose is typically determined empirically in clinical trials.

[0140] The term “muscarinic receptors” refers to G-protein linked receptors that bind the neurotransmitter acetylcholine. To date, five subtypes of the muscarinic receptor have been identified. “Ml” means the subtype one muscarinic receptor. “M2” means the subtype two muscarinic receptor. “M3” means the subtype three muscarinic receptor. “M4” means the subtype four muscarinic receptor. “M5” means the subtype five muscarinic receptor.

[0141] The term “antipsychotic” refers to a drug that diminishes psychosis, hallucinations, or delusions. Antipsychotics include, but are not limited to haloperidol, droperidol, chlorpromazine, fluphenazine, perphenazine, prochlorperazine, thioridazine, trifluoperazine, mesoridazine, periciazine, promazine, triflupromazine, levomepromazine, promethazine, pimozide, chlorprothixene, flupenthixol, thiothixene, zuclopenthixol, clozapine, olanzapine, risperidone, quetiapine, ziprasidone, amisulpride, asenapine, paliperidone, zotepine, aripiprazole, bifeprunox, and tetrabenazine.

[0142] The term “anxiolytics” refers to drugs that reduce anxiety, fear, panic, or related feelings. Such drugs include, but are not limited to, benzodiazepines (e.g., alprazolam, chlordiazepoxide, clonazepam, clorazepate, diazepam, lorazepam), buspirone, barbiturates (e.g., amobarbital, pentobarbital, secobarbital, phenobarbital), and hydroxyzine.

[0143] The term “anti-depressants” refers to drugs that alleviate depression and related conditions (e.g., dysthymia). Such drugs include, but are not limited to, selective serotonin - reuptake inhibitors (SSRIs, e.g., citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline), serotonin-norepinephrine reuptake inhibitors (SNRIs, e.g., desvenlafaxine, duloxetine, milnacipran, venlafaxine), mianserin, mirtazapine, norepinephrine reuptake inhibitors (e.g., atomoxetine, mazindol, reboxetine, viloxazine), bupropion, tianeptine, agomelatine, tricyclic antidepressants (e.g., amitriptyline, clomipramine, doxepin, imipramine, trimipramine, desipramine, nortriptyline, protriptyline), and monoamine oxidase inhibitors (e.g., isocarboxazid, moclobemide, phenelzine, selegiline, tranylcypromine) .

[0144] The terms “sedatives” or “tranquilizers” refer to drugs that induce somnolence, promote a feeling of being tired or desire to sleep, or promote a state of unconsciousness. Such drugs include, but are not limited to, benzodiazepines, barbiturates (e.g., amobarbital, pentobarbital, secobarbital, phenobarbital), eszopiclone, zaleplon, zolpidem, and zopiclone.

Pharmaceutical Compositions

[0145] Provided herein is an oral pharmaceutical composition, comprising a plurality of xanomeline beads comprising xanomeline or a salt thereof; and a plurality of trospium beads comprising a salt of trospium. In certain embodiments, the salt of trospium is chosen from trospium chloride, trospium bromide, trospium iodide, and trospium saccharinate.

[0146] In certain embodiments, the plurality of xanomeline beads has a core comprising xanomeline or a salt thereof. In certain embodiments, the plurality of trospium beads has a core comprising a trospium salt.

[0147] In certain embodiments, a capsule shell comprising hydroxypropyl methylcellulose (HPMC) containing separate populations of drug beads containing xanomeline tartrate or trospium chloride wherein the drug beads are of comparable size and release the actives rapidly and at substantially similar rates. Following the dissolution of the capsule shell in the stomach, the drug beads may dissolve in the stomach or pass through the pyloric valve into the duodenum intact or partially intact. Still, the two drugs' ratio, both in dissolved form and in undissolved form, remains relatively constant in the gastrointestinal tract until the drugs are absorbed.

[0148] The formulation for each drug bead allows substantially similar performance from two actives at different dose ranges. The actives are released into the blood serum at substantially similar rates or achieve a substantially similar T_max· In certain embodiments, a capsule comprises 50 mg xanomeline as the tartrate salt and 10 mg trospium chloride. Fifty mg xanomeline as free base corresponds to about 76 mg xanomeline tartrate. [0149] A discrepancy in the number of drug beads in the capsule increases the probability that the drug beads' ratio would not remain substantially constant after the beads are released and disperse. Thus, in certain embodiments, the trospium beads are formulated with a lower drug load. Effective doses of trospium and xanomeline are contained in roughly equivalent numbers of beads. Despite the differences in drug loads in certain embodiments, the trospium and xanomeline beads release at roughly similar rates. For example, if the dissolution of the capsules is assessed using a United States Pharmacopeia (USP) dissolution apparatus, the percentage of xanomeline dissolved is substantially equivalent to the percentage of dissolved trospium chloride, such as at 10 min, 20 min, or 30 min.

[0150] The medicament may also include one or more pharmaceutically acceptable salts. The medicament may include one or more pharmaceutically-acceptable carriers. The medicament may be administered orally. The medicament may be delivered orally using tablets, troches, liquids, emulsions, suspensions, drops, capsules, caplets or gel caps, and other methods of oral administration known to one skilled in the art.

[0151] The medicament may be in a dosage form that immediately releases the drug. In an alternative embodiment, the medicament may have a controlled release dosage form.

[0152] The medicament may be in dosage forms that use other controlled-release formulations known to one in the art.

[0153] In another embodiment, the medicament is combined with one or more therapies, including psychotherapy and drugs. Therapeutic agents include, but are not limited, to antipsychotics, anxiolytics, anti-depressants, sedatives, tranquilizers, analgesics, and other pharmacological interventions known to one skilled in the art. A therapeutic agent may fall under the category of more than one drug. For instance, benzodiazepines can be considered anxiolytics, sedatives, and tranquilizers.

Bead / Core Excipients

[0154] The bead or core can comprise one or more excipients. In one embodiment, the excipients include one or more fillers, binders, and surfactants. Other optional ingredients include, but are not limited to, glidants, lubricants, disintegrants, swelling agents, and antioxidants. The xanomeline or a pharmaceutically acceptable salt thereof and the salt of trospium may be in separate matrices within the same medicament.

[0155] The amount of xanomeline free base in the core can be at least 10 wt.% or at least 15 wt.%, or at least 20 wt.%, or at least 25 wt.%, or at least 30 wt.%. For example, the amount of xanomeline tartrate can be at least 50 wt.%, or at least 55 wt.%, or at least 60 wt.%, or at least 65 wt.%, or at least 70 wt.%, or at least 75 wt.%, or at least 80 wt.%, or at least 85 wt.% of the core, in a range of about 60 wt.% to about 90 wt.% or about 65 wt.% to about 85 wt.%. It is understood that all ranges including these values as endpoints are contemplated, for example, at least between about 15 wt.% and about 90 wt.%, between about 20 wt.% and about 85 wt.%, between about 30 wt.% and about 85 wt.%, or between about 50 wt.% and about 90 wt.%. In certain embodiments, the xanomeline beads comprise between 30 wt.% and 80 wt.% xanomeline tartrate, such as 66 wt.% xanomeline tartrate.

[0156] The amount of trospium salt in the core can be at least 10 wt.% or at least 15 wt.%, or at least 20 wt.%, or at least 25 wt.%, or at least 30 wt.%. For example, the amount of trospium chloride can be at least 50 wt.%, or at least 55 wt.%, or at least 60 wt.%, or at least 65 wt.%, or at least 70 wt.%, or at least 75 wt.%, or at least 80 wt.%, or at least 85 wt.% of the core, in a range of about 60 wt.% to about 90 wt.% or about 65 wt.% to about 85 wt.%. It is understood that all ranges including these values as endpoints are contemplated, for example, at least between about 15 wt.% and about 90 wt.%, between about 20 wt.% and about 85 wt.%, between about 30 wt.% and about 85 wt.%, or between about 50 wt.% and about 90 wt.%. In certain embodiments, the trospium is trospium chloride. In certain embodiments, the trospium beads comprise between 8 wt.% and 35 wt.% trospium chloride, such as 17.7 wt.% trospium chloride.

[0157] In a further embodiment, the matrix comprises a polymer, for example, to modify the release profile of the active in the matrix. In a further embodiment, the polymer comprises a water-soluble polymer. In a further embodiment, the water-soluble polymer is selected from Eudragit™ RL, polyvinyl alcohol, polyvinylpyrrolidone, methylcellulose, hydroxypropyl cellulose, hydroxypropylmethylcellulose, polyethylene glycol, and mixtures thereof. In a further embodiment, the polymer comprises a water-insoluble polymer. In a further embodiment, the water-insoluble polymer is selected from Eudragit™ RS, ethylcellulose, cellulose acetate, cellulose propionate, cellulose acetate propionate, cellulose acetate butyrate, cellulose acetate phthalate, cellulose triacetate, poly(methyl methacrylate), poly(ethyl methacrylate), poly(butyl methacrylate), poly(isobutyl methacrylate), poly(hexyl methacrylate), poly(isodecyl methacrylate), poly(lauryl methacrylate), poly(phenyl methacrylate), poly(methyl acrylate), poly(isopropyl acrylate), poly(isobutyl acrylate), poly(octadecyl acrylate), poly (ethylene), poly(ethylene) low density, poly(ethylene) high density, poly(propylene), poly(ethylene terephthalate), poly(vinyl isobutyl ether), poly(vinyl acetate), poly(vinyl chloride), polyurethane, and mixtures thereof.

[0158] Fillers include, but are not limited to, lactose, saccharose, glucose, starch, microcrystalline cellulose, microfine cellulose, mannitol, sorbitol, calcium hydrogen phosphate, aluminum silicate, amorphous silica, and sodium chloride, starch, and dibasic calcium phosphate dihydrate. In one embodiment, the filler is not water-soluble, although it may absorb water. In one embodiment, the filler is a spheronization aid. Spheronization aids can include one or more of crospovidone, carrageenan, chitosan, pectinic acid, glycerides, b- cyclodextrin (β-CD), cellulose derivatives, microcrystalline cellulose, powdered cellulose, polyplasdone crospovidone, and polyethylene oxide. In one embodiment, the filler includes microcrystalline cellulose.

[0159] The amount of filler in the xanomeline core is not particularly limited. In embodiments, the amount of filler (e.g., microcrystalline cellulose) can be in a range of about 10 wt.% to about 70 wt.%, or about 16 wt.% to about 23 wt.%, or at least 19 wt.% or at least 19.5 wt.%, for example about 20 wt.%. In certain embodiments, the xanomeline beads comprise between about 15 wt.% and about 65 wt.% microcrystalline cellulose, such as between about 15 wt.% and about 20 wt.%, between about 20 wt.% and about 25 wt.%, between about 25 wt.% and about 30 wt.%, between about 30 wt.% and about 35 wt.%, between about 35 wt.% and about 40 wt.%, between about 40 wt.% and about 45 wt.%, between about 45 wt.% and about 50 wt.%, between about 50 wt.% and about 55 wt.%, between about 55 wt.% and about 60 wt.%, or between about 60 wt.% and about 65 wt.%. In certain embodiments, the xanomeline beads comprise 33.5 wt.% microcrystalline cellulose. [0160] The amount of filler in the trospium core is not particularly limited. In embodiments, the amount of filler (e.g., microcrystalline cellulose or lactose) can be in a range of about 10 wt.% to about 80 wt.%, or about 16 wt.% to about 23 wt.%, or at least 19 wt.% or at least 19.5 wt.%, for example about 20 wt.%. In certain embodiments, the trospium beads comprise between 25 wt.% and 80 wt.% microcrystalline cellulose, such as between about 25 wt.% and 30 wt.%, between about 30 wt.% and 35 wt.%, between about 35 wt.% and 40 wt.%, between about 40 wt.% and 45 wt.%, between about 45 wt.% and 50 wt.%, between about 50 wt.% and 55 wt.%, between about 55 wt.% and 60 wt.%, between about 60 wt.% and 65 wt.%, between about 65 wt.% and 70 wt.%, between about 70 wt.% and 75 wt.%, or between about 75 wt.% and 80 wt.%. In certain embodiments, the trospium beads comprise 46.8 wt.% microcrystalline cellulose. [0161] In certain embodiments, the trospium beads comprise between 15 wt.% and 70 wt.% lactose monohydrate, such as between about 15 wt.% and 20 wt.%, between about 20 wt.% and 25 wt.%, between about 25 wt.% and 30 wt.%, between about 30 wt.% and 35 wt.%, between about 35 wt.% and 40 wt.%, between about 40 wt.% and 45 wt.%, between about 45 wt.% and 50 wt.%, between about 50 wt.% and 55 wt.%, between about 55 wt.% and 60 wt.%, between about 60 wt.% and 65 wt.%, or between about 65 wt.% and 70 wt.%. In certain embodiments, the trospium beads comprise 35 wt.% lactose monohydrate.

[0162] Binders include, but are not limited to, cellulose ethers, methylcellulose, ethylcellulose, hydroxyethylcellulose, propyl cellulose, hydroxypropyl cellulose, lower- substituted hydroxypropyl cellulose, hydroxypropylmethylcellulose (hypromellose, e.g., hypromellose 2910, Methocel™ E), carboxymethyl cellulose, starch, pregelatinized starch, acacia, tragacanth, gelatin, polyvinyl pyrrolidone (povidone), cross-linked polyvinyl pyrrolidone, sodium alginate, microcrystalline cellulose, and lower-alkyl-substituted hydroxypropyl cellulose. In one embodiment, the binders are selected from wet binders. In one embodiment, the binder is selected from cellulose ethers, e.g., hypromellose.

[0163] The amount of binder in the xanomeline core is not particularly limited. In embodiments, the amount of binder (e.g., hypromellose) can be in a range between about 1 wt.% and about 10 wt.%, between about 2 wt.% and about 8 wt.%, or between about 4 wt.% and about 6 wt.%, for example about 5 wt.%.

[0164] The amount of binder in the trospium core is not particularly limited. In embodiments, the amount of binder (e.g., hypromellose) can be in a range between about 1 wt.% and about 10 wt.%, between about 2 wt.% and about 8 wt.%, or between about 4 wt.% and about 6 wt.%, for example about 5 wt.%.

[0165] Surfactants include, but are not limited to, anionic surfactants, including sodium lauryl sulfate, sodium deoxycholate, dioctyl sodium sulfosuccinate, and sodium stearyl fumarate, nonionic surfactants, including polyoxyethylene ethers, and polysorbate 80, and cationic surfactants, including quaternary ammonium compounds. In one embodiment, the surfactant is selected from anionic surfactants, e.g., sodium lauryl sulfate.

[0166] The amount of surfactant, e.g., as a processing aid, is not particularly limited in the xanomeline core. In embodiments, the amount of surfactant (e.g., microcrystalline cellulose) can be in a range between about 0.1 wt.% and about 1 wt.%, between about 0.2 wt.% and about 0.8 wt.%, or between about 0.4 wt.% and about 0.6 wt.%, for example about 0.5 wt.%. [0167] The amount of surfactant, e.g., as a processing aid, is not particularly limited in the trospium core. In embodiments, the amount of surfactant (e.g., sodium lauryl sulfate) can be in a range between about 0.1 wt.% and about 1 wt.%, between about 0.2 wt.% and about 0.8 wt.%, or between about 0.4 wt.% and about 0.6 wt.%, for example about 0.5 wt.%.

[0168] Disintegrants include, but are not limited to, starch, sodium cross-linked carboxymethyl cellulose, carmellose sodium, carmellose calcium, cross-linked polyvinyl pyrrolidone, and sodium starch glycolate, low-substituted hydroxypropyl cellulose, and hydroxypropyl starch.

[0169] Glidants include, but are not limited to, polyethylene glycols of various molecular weights, magnesium stearate, calcium stearate, calcium silicate, fumed silicon dioxide, magnesium carbonate, magnesium lauryl sulfate, aluminum stearate, stearic acid, palmitic acid, cetanol, stearol, and talc.

[0170] Lubricants include, but are not limited to, stearic acid, magnesium stearate, calcium stearate, aluminum stearate, and siliconized talc. In certain embodiments, the xanomeline beads comprise between 0 wt.% and 2 wt.% talc, such as 0.5 wt.% talc. In certain embodiments, the trospium beads comprise between 0 wt.% and 2 wt.% talc, such as 0.5 wt.% talc.

[0171] In certain embodiments, the formulation further comprises one or more antioxidants. Examples of pharmaceutically-acceptable antioxidants include: (1) water soluble antioxidants, such as ascorbic acid, cysteine hydrochloride, sodium bisulfate, sodium metabisulfite, sodium sulfite and the like; (2) oil-soluble antioxidants, such as ascorbyl palmitate, butylated hydroxyanisole (BHA), butylated hydroxytoluene (BHT), lecithin, propyl gallate, alpha-tocopherol, and the like; and (3) metal chelating agents, such as citric acid, ethylenediamine tetraacetic acid (EDTA), sorbitol, tartaric acid, phosphoric acid, and the like. In certain embodiments, the formulation comprises less than 1 wt.% antioxidant, such as 0.9 wt.%, 0.8 wt.%, 0.7 wt.%, 0.6 wt.%, 0.5 wt.%, 0.4 wt.%, 0.3 wt.%, 0.2 wt.%, 0.1 wt.%, 0.09 wt.% , 0.08 wt.% , 0.07 wt.% , 0.06 wt.%, 0.05 wt.%, 0.04 wt.%, 0.03 wt.%, 0.02 wt.%, or 0.01 wt.%.

[0172] In certain embodiments, the oral pharmaceutical composition further comprises ascorbic acid. In certain embodiments, the oral pharmaceutical composition comprises between 0.2 wt.% and 1 wt.% ascorbic acid. In certain embodiments, the oral pharmaceutical composition comprises about 0.5 wt.% ascorbic acid. In certain embodiments, the oral pharmaceutical composition further comprises butylated hydroxytoluene. In certain embodiments, the oral pharmaceutical composition comprises between 0.01 wt.% and 0.1 wt.% butylated hydroxytoluene. In certain embodiments, the oral pharmaceutical composition comprises about 0.05 wt.% butylated hydroxytoluene. In certain embodiments, the formulation comprises about 0.05 wt.% BHT or 0.5 wt.% ascorbic acid. In certain embodiments, the antioxidant is present in the xanomeline core or the xanomeline beads.

[0173] In certain embodiments, the xanomeline beads comprise between 30 wt.% and 80 wt.% xanomeline tartrate, between 15 wt.% and 65 wt.% microcrystalline cellulose, and between 0 wt.% and 2 wt.% talc. In certain embodiments, the trospium beads comprise between 0.2 wt.% and 2 wt.% talc, such as 0.5 wt.% talc. In certain embodiments, the trospium beads comprise between 8 wt.% and 35 wt.% trospium chloride, between 25 wt.% and 80 wt.% microcrystalline cellulose, between 15 wt.% and 70 wt.% lactose monohydrate, and between 0.2 wt.% and 2 wt.% talc.

[0174] In certain embodiments, the xanomeline tartrate drug beads comprise 66 wt.% xanomeline tartrate, 33.5 wt.% microcrystalline cellulose and 0.5 wt.% talc. In certain embodiments, the trospium chloride beads comprise 17.7 wt.% trospium chloride, 46.8 wt.% microcrystalline cellulose, 35 wt.% lactose monohydrate, and 0.5 wt.% talc. In this example, the xanomeline tartrate beads contain about 2.5 times as much xanomeline as the trospium chloride beads contain trospium chloride.

[0175] Depending on dosing requirements, capsules can be prepared with different amounts of xanomeline tartrate and trospium chloride beads. In various embodiments, capsules contain 25 mg xanomeline and 10 mg trospium chloride, 50 mg xanomeline and 10 mg trospium chloride, 50 mg xanomeline and 20 mg trospium chloride, 75 mg xanomeline and 10 mg trospium chloride, 75 mg xanomeline and 20 mg trospium chloride, 125 mg xanomeline and 30 mg trospium chloride, or 125 mg xanomeline and 40 mg trospium chloride. In certain embodiments, the capsule contains 25 mg xanomeline as xanomeline tartrate and 10 mg trospium chloride. In certain embodiments, the capsule contains 50 mg xanomeline as xanomeline tartrate and 10 mg trospium chloride. In certain embodiments, the capsule contains 50 mg xanomeline as xanomeline tartrate and 20 mg trospium chloride. In certain embodiments, the capsule contains 75 mg xanomeline as xanomeline tartrate and 10 mg trospium chloride. In certain embodiments, the capsule contains 75 mg xanomeline as xanomeline tartrate and 20 mg trospium chloride. In certain embodiments, the capsule contains 125 mg xanomeline as xanomeline tartrate and 20 mg trospium chloride. In certain embodiments, the capsule contains 125 mg xanomeline as xanomeline tartrate and 40 mg trospium chloride. In certain embodiments, the capsule contains 150 mg xanomeline and 20 mg trospium chloride. In certain embodiments, the capsule contains 150 mg xanomeline and 30 mg trospium chloride. In certain embodiments, the capsule contains 150 mg xanomeline and 40 mg trospium chloride. In certain embodiments, the capsule contains 175 mg xanomeline and 20 mg trospium chloride. In certain embodiments, the capsule contains 175 mg xanomeline and 30 mg trospium chloride. In certain embodiments, the capsule contains 175 mg xanomeline and 40 mg trospium chloride.

[0176] In another embodiment, the medicament contains from five milligrams to 700 milligrams of xanomeline. In an embodiment, the medicament contains from 25 milligrams to 300 milligrams of xanomeline.

[0177] In another embodiment, the medicament contains from one milligram to 400 milligrams of trospium chloride. In an embodiment, the medicament contains from 6.5 milligrams to 200 milligrams of trospium chloride.

[0178] In one embodiment, trospium chloride extended-release is used as the trospium chloride in the medicament. In another embodiment, the medicament contains from one milligram to 400 milligrams of trospium chloride extended-release. In an embodiment, the medicament contains from 6.5 milligrams to 200 milligrams of trospium chloride extended- release.

[0179] In an embodiment, the medicament contains 75 mg or 225 milligrams of xanomeline, and the same medicament contains 20 mg or 40 milligrams of trospium chloride. In another embodiment, the medicament contains 75 mg or 225 milligrams of xanomeline, and a different medicament to be co-administered contains 20 mg or 40 milligrams of trospium chloride.

Bead Coatings

[0180] In other embodiments, the beads may be coated with functional or non-functional coatings, such as aesthetic, handling, or stability. In certain embodiments, the beads might be coated with a pH-sensitive coating so that they do not dissolve in the low pH of the stomach. A nonfunctional coating might be used to maintain chemical separation between the beads or for cosmetic reasons.

[0181] In a further embodiment, the controlled release formulation comprises a semi- permeable coating. The xanomeline and trospium chloride may be in different coatings in the same formulation. In another embodiment, the xanomeline and trospium chloride can be in different coatings in different formulations or dosing vehicles. In a further embodiment, the semi -permeable coating comprises a polymer. In a further embodiment, the controlled release formulation comprises a matrix that suspends the xanomeline and trospium chloride.

[0182] In certain embodiments, the distribution of coating thicknesses can be stated in the weight gain of coating material based on the total weight of the coated beads. Thus, in one embodiment, the distribution of coating thicknesses is at least 2% based on the total weight of the coated beads. In another embodiment, the distribution of coating thicknesses is at least 3%. In another embodiment, the distribution of coating thicknesses is at least 4%. In another embodiment, the distribution of coating thicknesses is at least 5%. In another embodiment, the distribution of coating thicknesses is at least 6%. In another embodiment, the distribution of coating thicknesses is at least 7%. In another embodiment, the distribution of coating thicknesses is at least 8%. In another embodiment, the distribution of coating thicknesses is at least 9%. In another embodiment, the distribution of coating thicknesses is at least 10%. In another embodiment, the distribution of coating thicknesses is at least 11%. In another embodiment, the distribution of coating thicknesses is at least 12%. In another embodiment, the distribution of coating thicknesses is at least 13%. In another embodiment, the distribution of coating thicknesses is at least 14%.

[0183] For example, the difference in coating thickness from bead to bead can be in a range of +/- 1-7% based on the coated beads' total weight. The distribution of coating thicknesses can between about 2% and about 14% based on the weight of the coated beads, such as between about 3% and about 13%, between about 4% and about 12%, between about 5% and about 11%, between about 6% to about 10%, between about 7% and 9%, between about 3% and 14%, between about 4% and 14%, between about 4% and 13%, or between 4% and about 12%.

[0184] In one embodiment, the absorption (area under the curve, AUC) of the dosage form when dosed orally is advantageously increased, compared to other dosage forms of xanomeline or trospium chloride. Without intending to be bound by any theory, the increase in absorption is influenced by the dosage form exhibiting a pseudo-extended release profile. The pseudo-extended release profile is influenced by one or more factors, including distribution of coating thicknesses when present, distribution of bead particle sizes, and the beads having irregular bead shapes. For example, in an embodiment wherein the beads have a distribution of coating thicknesses, for beads with a relatively thin coating, the coating completely dissolves at the trigger pH relatively quickly to release the xanomeline and/or trospium chloride compositions, whereas for beads having a relatively thick coating the coating takes somewhat longer to completely dissolve and release the xanomeline and/or trospium chloride compositions. In an embodiment where the beads have a distribution of particle sizes and/or irregular bead shapes, the gut transit time of the beads could be varied due to bead size and/or shape, such that the transit time until reaching the coating dissolution pH is varied, thus contributing to a pseudo-extended release profile. In another embodiment, the dosage form exhibits substantially equivalent (e.g., bioequivalent) C_max and/or AUC characteristics when administered orally inside a capsule shell or without a capsule shell. [0185] In certain embodiments, the dosage form provides a progressive and predictable absorption curve. In one embodiment, the T_max of the dosage form, when dosed orally, is more stable on a dose-to-dose basis because the beads are individually coated. A predictable, consistent T_max is advantageous for accomplishing a more consistent, sustained therapeutic effect. For example, process-related variations in coating thickness or other influences on coating dissolution affect only a fraction of the xanomeline and trospium chloride in the dosage form. They tend to lead to pseudo-extended release behavior. In contrast, coated capsules comprising xanomeline and trospium chloride microspheres exhibit significant variability in absorption time from the capsule to capsule.

[0186] In certain embodiments, the oral pharmaceutical composition comprises xanomeline and/or a salt thereof and trospium chloride for treating a muscarinic disorder in a patient in need thereof, which when administered to the patient in need thereof, the composition is sufficient to provide an in-vivo plasma profile comprising a median T_max for xanomeline of 2 hours and a median T_max for trospium of 1 hour. In certain embodiments, the in-vivo plasma profile further comprises a mean dose-normalized C_max of between 48.5 and 121.3 pg/mL/mg. In certain embodiments, the in-vivo plasma profile further comprises a mean dose-normalized C_max of trospium of between 156 and 375 pg/mL/mg. In certain embodiments, the in-vivo plasma profile further comprises a mean dose-normalized AUC_0-12 of xanomeline of between 263 and 577 hr pg/mL/mg. In certain embodiments, the in-vivo plasma profile further comprises a mean dose-normalized AUC_0-12 of trospium of between 881 and 2024 hr· pg/mL/mg. In certain embodiments, the in-vivo plasma profile further comprises a mean C_max of trospium at 7850 ± 3360 pg/mL. In certain embodiments, the in- vivo plasma profile further comprises a mean AUC_0-12 of 41900 ± 15500 hr pg/mL.

[0187] In another embodiment, the dosage form exhibits advantageous storage stability, e.g., measured by the amount of xanomeline present following storage and/or by the total amount of related substances. The storage stability can be assessed following storage at typical ambient conditions (e.g., 25 °C and 60% relative humidity) or accelerated stability conditions involving increased temperature and/or humidity.

[0188] The dosage form and methods are contemplated to include embodiments of any combination of one or more of the additional optional elements, features, and steps further described below (including those shown in the figures and Examples) unless stated otherwise. Reference to a bead and properties thereof apply equally to a collection of beads (e.g., a plurality of such beads). Likewise, referring to a core and properties thereof apply equally to a collection of cores (e.g., a plurality of such cores).

[0189] The enteric (gastro-resistant) coating material, e.g., polymer, can be one that will dissolve in intestinal juices at a pH level higher than that of the stomach, e.g., a pH of greater than 4.5, such as within the small intestine, and therefore permit the release of the active substance in the regions of the small intestine and substantially not in the upper portion of the GI tract. In one embodiment, the enteric material begins to dissolve in an aqueous solution at pH between about 4.5 and about 5.5. In another embodiment, the enteric material rapidly dissolves in an aqueous solution at a pH of about 5. In another embodiment, the enteric material rapidly dissolves in an aqueous solution at a pH of about 5.5.

[0190] For example, pH-sensitive materials do not significantly dissolve until the dosage form has emptied from the stomach. The small intestine's pH gradually increases from about 4.5 to about 6.5 in the duodenal bulb to about 7.2 in the distal portions of the small intestine (ileum). To provide predictable dissolution corresponding to the small intestine transit time of about 3 hours (e.g., 2-3 hours) and permit reproducible release therein, the coating should begin to dissolve within the pH range of the duodenum and continue to dissolve at the pH range within the small intestine. Therefore, the amount (thickness) of enteric coating should be substantially dissolved during the about three-hour transit time within the small intestine (e.g., the proximal and mid-small intestine).

[0191] Suitable enteric (gastro-resistant) materials include, but are not limited to, cross- linked polyvinyl pyrrolidone; non-crosslinked polyvinylpyrrolidone; hydroxypropylmethyl cellulose phthalate, hydroxypropylmethyl cellulose acetate succinate, cellulose acetate succinate; cellulose acetate phthalate, hydroxypropylmethyl cellulose acetate succinate, cellulose acetate trimellitate; starch acetate phthalate; polyvinyl acetate phthalate; carboxymethyl cellulose; methyl cellulose phthalate; methyl cellulose succinate; methyl cellulose phthalate succinate; methyl cellulose phthalic acid half ester; ethyl cellulose succinate; carboxymethylamide; potassium methacrylate divinylbenzene copolymer; polyvinyl alcohols; polyoxyethylene glycols; polyethylene glycol; sodium alginate; galactomannan; carboxypolymethylene; sodium carboxymethyl starch; copolymers of acrylic acid and/or methacrylic acid with a monomer selected from the following: methyl methacrylate, ethyl methacrylate, ethyl acrylate, butyl methacrylate, hexyl methacrylate, decyl methacrylate, lauryl methacrylate, phenyl methacrylate, methyl acrylate, isopropyl acrylate, isobutyl acrylate, or octadecyl acrylate, e.g. Eudragit™ -L and -S series, including L 100-55, L 30 D-55, L 100, S 100, L 12.5, and S 12.5, available from Evonik Industries; polyvinyl acetate; fats; oils; waxes; fatty alcohols; shellac; zein; gluten; ethylacrylate-maleic acid anhydride copolymer; maleic acid anhydride- vinyl methyl ether copolymer; styrol- maleic acid copolymer; 2-ethyl-hexyl-acrylate maleic acid anhydride; crotonic acid- vinyl acetate copolymer; glutaminic acid/glutamic acid ester copolymer; carboxymethylethylcellulose glycerol monooctanoate; polyarginine; poly(ethylene); poly(propylene); poly(ethylene oxide); poly(ethylene terephthalate); poly(vinyl isobutyl ether); poly(vinyl chloride); and polyurethane. A combination of enteric materials may also be used. In one embodiment, the enteric material rapidly dissolves at pH 5.5 and higher to provide fast dissolution in the upper bowel. For example, the enteric material can be selected from a copolymer of methacrylic acid and methyl methacrylate and a copolymer of methacrylic acid and ethyl acrylate. For example, an enteric polymer is poly(methacrylic acid co-ethyl acrylate)l:l (Eudragit™ L 30 D-55 and Eudragit™ L 100-55).

[0192] Other suitable examples of enteric coating coatings include beeswax and glyceryl monostearate; beeswax, shellac and cellulose; and cetyl alcohol, mastic and shellac, and shellac and stearic acid; polyvinyl acetate and ethyl cellulose; and a neutral copolymer of polymethacrylic acid esters (Eudragit™ L 30D); copolymers of methacrylic acid and methacrylic acid methylester, or a neutral copolymer of polymethacrylic acid esters containing metallic stearates. Such coatings comprise mixtures of fats and fatty acids, shellac and shellac derivatives, and the cellulose acid phthalates, e.g., those with free carboxyl content.

[0193] One or more plasticizers can be added to enteric polymers to increase their pliability and reduce brittleness, as known in the art. Suitable plasticizers include, for example, butyl citrates, triethyl citrate, diethyl phthalate, dibutyl sebacate, polyethylene glycols (PEGs, such as PEG 6000), acetyl triethyl citrate, and triacetin. In one embodiment, the plasticizer is triethyl citrate. While some enteric materials are flexible and do not require plasticizers, more brittle polymers (e.g., Eudragit™ L/S types, Eudragit™ RL/RS, and Eudragit™ FS 30 D) benefit from plasticizers, for example, ranging from between 5 wt.% and 30 wt.% based on the dry polymer mass, between about 8 wt.% and about 12 wt.% triethyl citrate with poly(methacrylic acid co-ethyl acrylate) 1:1.

[0194] In certain embodiments, the enteric coatings comprise one or more anti-tacking agents (antiadherents) to reduce the film's tackiness and prevent agglomeration, as it is known in the art. Suitable anti-tacking agents include, but are not limited to, talc, glyceryl monostearate, fumed silica (e.g., Aerosil™ 200), precipitated silica (e.g., Sipernat™ PQ), and magnesium stearate. Anti-tacking agents can be used in any suitable quantity, for example ranging between about 10 wt.% and 100 wt.% based on dry polymer mass, between about 10 wt.% and about 50 wt.%, between about 10 wt.% and about 30 wt. %, or between about 15 wt.% and about 30 wt.%. For example, in one embodiment in ranges between 15 wt.% and about 30 wt.% based on dry polymer mass.

[0195] One or more surfactants can also be added to an enteric coating mixture to increase substrate wettability and/or stabilize suspensions, as it is known in the art. Surfactants include Polysorbate 80, sorbitan monooleate, and sodium dodecyl sulfate, and other surfactants described herein.

[0196] Any suitable process can form the enteric coating. Coating processes include pan coating, fluid bed coating, and dry coating (e.g., heat dry coating and electrostatic dry coating). Pan coating and fluid bed coating using solvent are well-established processes. In liquid coating, the enteric material and optional excipients (e.g., pigments, plasticizers, anti- tacking agents) are mixed in an organic solvent or water to form a solution or dispersion. The coating solution or dispersion is sprayed into solid dosage forms in a pan coater or a fluid bed dryer and dried by hot air. For example, in a Wurster fluid bed coating process, the coating fluid is sprayed from the fluid bed apparatus's bottom. Alternatively, the coating fluid is applied by top spraying. In certain embodiments, a tangential spray is applied.

[0197] The amount of enteric material applied is sufficient to achieve the desired acid resistance and release characteristics. For example, in one embodiment, the amount of enteric coating meets USP <711> requirements (USP 36-NF 31) for delayed-release dosage forms, thereby not releasing 10.0 wt.% of the drug after 2 hours in 0.1 N HC1. In certain embodiments, the formulation releases at least 80% of the active in 20 minutes in pH 6.8 buffer solution, e.g., using a dissolution method of USP 36-NF 31 section <711>.

[0198] In one embodiment, the enteric coating is present in an amount in a range between about 10% and 40%, or between 25% and about 35% as measured by the weight gain compared to the uncoated particle cores, or ranging between about 25% and about 31% weight gain, between about 27% and about 31% weight gain, or between about 28.5% and about 31% weight gain, based on the weight of the uncoated particle cores.

[0199] The formulation can include a capsule shell in which the beads are disposed. Soft and hard capsule shells are known. The capsule shell is a hard-capsule shell in one embodiment, e.g., a gelatin capsule shell or a vegetable-based hard capsule shell. In certain embodiments, the capsule shell comprises one or more enteric coatings described herein. During accelerated storage, gelatin capsules may collapse. Thus, in certain embodiments, the formulation can include a hydroxypropyl methylcellulose capsule shell.

[0200] Thus, for example, one embodiment combining various of the features described above includes a pharmaceutical dosage form comprising a plurality of xanomeline beads, the beads comprising a core comprising xanomeline tartrate, a filler (optionally microcrystalline cellulose), a binder (optionally hypromellose), and an enteric coating (optionally Eudragit™

L 30 D-55) surrounding the core, wherein the plurality of beads has a distribution of particle sizes ranging between about 0.7 mm and about 2.5 mm, wherein the enteric coating ranges between about 20% and about 40% based on the weight of the bead cores, and wherein the beads are disposed in a capsule shell.

Bead size and shape

[0201] The plurality of beads has a distribution of particle sizes. The plurality of beads has bead shapes. The plurality of beads has a distribution of coating thicknesses when present. [0202] Beads having a distribution of particle sizes were shown to exhibit advantageous pharmacokinetics. Without intending to be bound by any theory, it is contemplated that the pharmacokinetics are influenced by the plurality of beads having a distribution of core sizes. [0203] In one embodiment, the particle sizes of the beads range between about 0.4 mm and about 1.2 mm, such as between about 0.4 mm and about 0.5 mm, between about 0.5 mm and about 0.6 mm, between about 0.6 mm and about 0.7 mm, between about 0.7 mm and about 0.8 mm, between about 0.8 mm and about 0.9 mm, between about 0.9 mm and about 1.0 mm, between about 1.0 mm and about 1.1 mm, or between about 1.1 mm and about 1.2 mm. In certain embodiments, the size of the xanomeline beads is between about 0.425 mm and about 1.18 mm. In certain embodiments, the size of the xanomeline beads is between about 0.6 mm and about 0.85 mm. In certain embodiments, the size of the trospium beads is between about 0.425 mm and about 1.18 mm. In certain embodiments, the size of the trospium beads is between about 0.6 mm and about 0.85 mm. [0204] The beads or bead mixtures may be used, for example, in suspensions, filled into capsules, compressed into tablets, or filled into sachets. One or more types of modified release beads can be mixed and encapsulated or used as a sprinkle on the subject’s food. In certain embodiments, the oral solid dosage form may be any of these forms. In certain embodiments, the dosage form is a capsule.

[0205] As the particle size of the beads becomes too small, the variability in the content of the active increases. As the particle size becomes too large, the beads are too large for drug products labeled to be administered via sprinkling (e.g., on applesauce or other soft foods, such as jellies) and swallowed without chewing or administered via an enteral feeding tube. Also, as the particle size increases, the larger particles get coated more than the smaller particles, resulting in lower relative assay than smaller particles. Relatively more beads are needed to meet the label strength per capsule. Filling a capsule shell with enough large particles to meet the label strength per capsule becomes difficult or impossible (e.g., to fill a size 0 capsule to a 75-mg strength of xanomeline free base).

[0206] In one embodiment, the beads are formulated into capsules, e.g., with an encapsulation machine. Various capsule sizes may accommodate the strength and fill weight of the target formulations. Capsule size ranges from 00 to 5 for fill weights ranging between about 15 mg and about 630 mg.

[0207] The beads can be sorted (e.g., via sieving) to the desired particle size. In certain embodiments, the particle size range is any particle size range or combination described above regarding the cores. In one embodiment, the particle size range is the same as the particle size range of the uncoated cores. For example, the beads can be sieved such that 5% or less of the bead cores by weight is retained on a #12 mesh (1.68 mm) screen, and 10% or less by weight pass through a #20 mesh (0.84 mm) screen.

Method of Making

[0208] Provided is a method for preparing an oral pharmaceutical composition comprising admixing beads comprising a plurality of xanomeline beads comprising xanomeline or a pharmaceutically acceptable salt thereof with a plurality of trospium beads comprising a salt of trospium, such as trospium chloride. In certain embodiments, the method further comprises formulating the admixed beads into capsules.

[0209] Also disclosed herein are a method for preparing the dosage form, comprising coating a core comprising xanomeline or a pharmaceutically acceptable salt thereof and an excipient with an enteric polymer to form the enteric coating, and coating a core comprising trospium chloride or a pharmaceutically acceptable salt thereof and an excipient with an enteric polymer to form the enteric coating. Optionally, the core can be formed by a wet granulation method. Optionally, drug beads are sorted (e.g., via sieving) to a desired particle size range before enteric coating, and optionally again following enteric coating.

[0210] The drug beads may be made by different processes, including, but not limited to, spheronizing an extruded wet mass and coating of inert core spheres in a fluidized bed. In certain embodiments, the beads are prepared by extrusion and spheronization.

[0211] The beads are formulated to flow freely and to be compatible with modern encapsulation equipment. In some embodiments, the beads are blended to form a uniform mixture filled into capsules in a single stage. In other embodiments, the beads are filled separately into capsules using a two-stage capsule filler.

[0212] Any suitable process can form the cores comprising xanomeline or pharmaceutically acceptable salts thereof. In one embodiment, the core is formed by granulating a mixture of xanomeline or a pharmaceutically acceptable salt thereof with an excipient and milling to a desired particle size range. In another embodiment, the core can be formed by extrusion and spheronization of a mixture of xanomeline or a pharmaceutically acceptable salt thereof with an excipient.

[0213] Any suitable process can form the cores comprising trospium chloride or pharmaceutically acceptable salts thereof. In one embodiment, the core is formed by granulating a mixture of trospium chloride or a pharmaceutically acceptable salt thereof with an excipient and milling to a desired particle size range. In another embodiment, the core can be formed by extrusion and spheronization of a mixture of trospium chloride or a pharmaceutically acceptable salt thereof with an excipient.

[0214] Granulating processes can include fluid bed granulation, wet granulation, hot melt granulation, and spray congealing. Other processes include slugging and roller compaction. The mixtures to be granulated can first be dry -blended. The dry -blended dry ingredients can be mixed with water before extrusion.

[0215] Extrusion and spheronization of a mixture of xanomeline or a pharmaceutically acceptable salt thereof and trospium chloride with an excipient provide desirable cores with a distribution of particle sizes as described herein and one or more other desirable properties. In certain embodiments, short processing times can lead to a more stable product. For example, reducing spheronization reduces friction and related heat, reducing the time the product is exposed to air (either when moist and/or before packaging) diminishes oxidation. On the other hand, rapid processing by extrusion and spheronization can lead to a poor-quality product, such as having a large fraction of the bead cores falling outside a desired particle size range. The moisture absorbed by spheronization aids (which happens over time) influences the beads' spheronization characteristics.

[0216] Accordingly, in one embodiment, the moisture content of the granulation mixture, before drying, ranging between about 20 wt.% and about 40 wt.%, such as between 25 wt.% and about 35 wt.%, between about 28 wt.% and about 32 wt.%, at least about 28 wt.%, at least about 28.5, between about 20 wt.% and about 40 wt.%, between about 25 wt.% and about 35 wt.%, between about 27 wt.% and about 31 wt.%, or between about 28.5 wt.% and about 31 wt.%.

[0217] In certain embodiments, the wet mass can be held before extrusion, allowing the spheronization aid to swell with granulating fluid. The hold time can be at least 15 minutes, such as at least 30 minutes, at least 45 minutes, or at least 60 minutes. In certain embodiments, the hold time ranges between about 15 minutes and about 120 minutes, such as between 30 and 100 minutes or between 60 and 90 minutes.

[0218] As described above relating to cores, the method can include a step of sorting (e.g., by sieving) the cores before optional coating to retain particles in a predetermined size range, for example, sizes ranging between about 0.7 mm and about 2.8 mm, such as between about 0.7 mm and about 2.5 mm, between about 0.8 mm and about 1.7 mm, or any range described herein.

[0219] As described above relating to beads, the method can include a step of sorting (e.g., by sieving) the beads after optional coating to retain particles in a size range, for example, sizes ranging between about 0.7 mm and about 2.8 mm, such as between about 0.7 mm and about 2.5 mm, or between about 0.8 mm and about 1.7 mm, or any range described herein. [0220] In an extrusion and spheronization process, the following optional features can be employed, individually or in one or more combinations thereof. Water can be a granulation agent. Microcrystalline cellulose can be in the cores as a spheronization aid. Hypromellose can be included in the cores as a binder. The extrusion screen size can be 1.0 mm. The friction plate of the spheronizer can be cross-hatched. The friction plate of the spheronizer can be cross-hatched with a square pitch of at least about 3 mm, or greater than about 3 mm, or at least about 4 mm, or greater than about 4 mm, or ranging between about 3 mm and about 7 mm, or about 5 mm. The spheronization time can be less than about 5 minutes, or less than about 4 minutes, or less than about 3 minutes, or less than about 2 minutes, or up to 1 minute. The spheronized particles can include non-spherical particles (i.e., irregular shapes), for example, a substantial fraction thereof, such as at least about 20 wt.%, at least about 30 wt.%, at least about 40 wt.%, at least about 50 wt.%, at least about 60 wt.%, or at least about 70 wt.% thereof.

[0221] In certain embodiments, the pharmaceutical composition is stored with a desiccant, for example, pharmaceutical grades of silica gel, crystalline sodium, potassium or calcium aluminosilicate, colloidal silica, anhydrous calcium sulfate, and the like.

[0222] In certain embodiments, the pharmaceutical composition is stored with an oxygen absorber.

[0223] In certain embodiments, the pharmaceutical composition is stored under a dry inert gas such as nitrogen, helium, argon, neon, xenon, krypton, or a mixture thereof.

[0224] In certain embodiments, the pharmaceutical composition is stored under reduced pressure compared to the external ambient air.

[0225] In certain embodiments, the pharmaceutical composition is stored at a reduced temperature, e.g., at refrigerated temperatures (e.g., 2 °C to 8 °C). In certain embodiments, the pharmaceutical composition is stored in such a manner have fewer impurities, such as Impurity A, than when stored at 25 °C.

[0226] In certain embodiments, the pharmaceutical composition is stored by a manufacturer, a distributor, a pharmacy, or a hospital at a temperature of between about 2 °C and about 8 °C before dispensing the oral pharmaceutical composition to the subject. In certain embodiments, after the oral pharmaceutical composition is dispensed to the subject, the pharmaceutical composition is stored at a temperature of between about 20 °C and about 25 °C.

[0227] Also provided is a method of stabilizing a pharmaceutical dosage form or composition described herein, comprising storing the dosage form at a temperature of about 2 °C to about 8 °C.

[0228] In certain embodiments, a method for preparing a pharmaceutical dosage form comprising xanomeline beads comprises forming a wet mass comprising xanomeline tartrate and an excipient, optionally microcrystalline cellulose, with a moisture content ranging between about 20 wt.% and about 40 wt.%, extruding and spheronizing the wet mass comprising xanomeline tartrate and excipient to make cores, sorting the cores to a target particle size range, optionally between about 0.7 mm and about 2.5 mm, coating the sorted cores with a polymer to form beads comprising a core and a coating, and sorting the bead particles to a target particle size range, optionally between about 0.7 mm and about 2.5 mm. [0229] In certain embodiments, a method for preparing a pharmaceutical dosage form comprising trospium beads comprises forming a wet mass comprising trospium chloride and an excipient, optionally microcrystalline cellulose, with a moisture content ranging between about 20 wt.% and about 40 wt.%, extruding, spheronizing, and drying the wet mass comprising trospium chloride and excipient to make cores, sorting the cores to a target particle size range, optionally between about 0.7 mm and about 2.5 mm, coating the sorted cores with a polymer to form beads comprising a core and a coating, and sorting the bead particles to a target particle size range, optionally between about 0.7 mm and about 2.5 mm. Purity

[0230] Also provided is the compound 3-[(4-hexyloxy)-l,2,5-thiadizaol-3-yl]-5-hydroyl-1- methylpyridin-1-ium.

[0231] Also provided is a pharmaceutical composition, comprising xanomeline and/or a salt thereof and less than 0.5 wt.% 3-[(4-hexyloxy)-l,2,5-thiadizaol-3-yl]-5-hydroyl-1- methylpyridin-1-ium (Impurity A). In certain embodiments, the pharmaceutical composition comprises less than 0.30 wt.% of Impurity A, such as less than 0.25 wt.%, less than 0.20 wt.%, less than 0.15 wt.%, less than 0.14 wt.% or less than 0.1 wt.%. Also provided is a pharmaceutical composition, comprising xanomeline and/or a salt thereof and less than 0.15 wt.% 3-[(4-hexyloxy)-l,2,5-thiadizaol-3-yl]-5-hydroyl-1-methylpyridin-1-ium (Impurity A). [0232] Also provided is an oral pharmaceutical composition, comprising a plurality of xanomeline beads comprising xanomeline or a salt thereof and less than 0.5 wt.% 3-[(4- hexyloxy)-l,2,5-thiadizaol-3-yl]-5-hydroyl-1-methylpyridin-1-ium; and a plurality of trospium beads comprising a salt of trospium. Also provided is an oral pharmaceutical composition, comprising a plurality of xanomeline beads comprising xanomeline or a salt thereof and less than 0.15 wt.% 3-[(4-hexyloxy)-l,2,5-thiadizaol-3-yl]-5-hydroyl-1- methylpyridin-1-ium; and a plurality of trospium beads comprising a salt of trospium.

[0233] In certain embodiments, the pharmaceutical composition comprises less than 0.5 wt.% of Impurity A after the pharmaceutical composition is stored for at least 3 months at 40 °C and 75% relative humidity.

[0234] In certain embodiments, the total impurities in the pharmaceutical compositions provided herein are no greater than about 5% by weight, no greater than about 4% by weight, no greater than about 3% by weight, no greater than about 2.5% by weight, no greater than about 2% by weight, no greater than about 1.5% by weight, no greater than about 1% by weight, no greater than about 0.5% by weight, or no greater than about 0.1% by weight.

Method of Treating

[0235] Further provided is a method of activating muscarinic receptors in a biological sample, the method comprising contacting the biological sample with any oral pharmaceutical composition described herein. Also provided is a method for treating a disorder ameliorated by activating muscarinic receptors in a subject in need thereof, comprising administering to the subject in need thereof any oral pharmaceutical composition described herein.

[0236] While activators of M1 and M4 muscarinic receptors have been suggested to be efficacious treatments for schizophrenia, the activation of muscarinic receptors located outside the brain has resulted in side effects which barred xanomeline from the clinic. For instance, in both Phase I and subsequent trials, the muscarinic agonist xanomeline had unacceptable GI and other side effects linked to the binding of muscarinic receptors in the body’s periphery. By combining a xanomeline with trospium chloride, the desired therapeutic effect is achieved while diminishing or eliminating the side effects of activating muscarinic receptors located outside the brain.

[0237] The tolerability of xanomeline, a muscarinic activator, is increased by co- administering trospium chloride, a muscarinic antagonist. The most common adverse events observed with administering xanomeline are nausea, vomiting, diarrhea, excessive sweating, and excessive salivation (so-called cholinergic adverse events). A common anticholinergic adverse event observed with administering trospium chloride is dry mouth (xerostomia). The disclosed compositions reduced the incidence of these adverse events in humans, evincing increased xanomeline tolerability. In certain embodiments, after at least 4 weeks of treatment, the occurrence of a cholinergic or anticholinergic adverse event is not statistically distinguishable from a placebo control. In certain embodiments, after at least 4 weeks of treatment, at least one of nausea, vomiting, and dry mouth occurs at about the same rate as an untreated patient. In certain embodiments, at least one adverse event which occurred at the start of oral administration is reduced to its pretreatment level after five weeks of treatment. [0238] In one embodiment, xanomeline combined with trospium chloride treats an animal. In a further embodiment, the animal is a mammal. In an embodiment, the mammal is a human being.

[0239] In one embodiment, trospium chloride decreases the side effects associated with xanomeline. Such side effects include, but are not limited to, GI side effects, cardiac side effects, excessive sweating, and excessive salivation. The use of trospium with xanomeline allows the xanomeline to be used clinically when the xanomeline would not otherwise be used clinically due to its side effects. In another embodiment, the use of trospium chloride with the xanomeline allows for the xanomeline to achieve a higher maximum tolerated dose than xanomeline would otherwise achieve.

[0240] Various time and resource-intensive methods demonstrated the efficacy of the combination of xanomeline and trospium chloride. For example, animal models demonstrate the efficacy of new therapeutics for schizophrenia, including pharmacological models (e.g., ketamine model) and genetic models (e.g., DISCI mouse). Likewise, animal models, including rodents, dogs, and non-human primates, demonstrate the side effect profile of pharmacological agents. Animal models are an experimental proxy for humans but may suffer from deficiencies in the physiological differences between humans and animals and may have limited predictive power for human experiments, particularly for central nervous system disorders. Alternatively, the disclosed combination can be tried in controlled clinical trials of people. Standard measures based on patient self-report can be used by those skilled in the art to assess various side effects such as GI discomfort. As another example, objective physiological measures (e.g., EKGs) may be used by those skilled in the art. A set of standard measures has also been developed to assess schizophrenia symptoms, including the Brief Psychiatric Rating Scale (BPRS), the Positive and Negative Syndrome Scale (PANSS), and Clinical Global Impression (CGI). Typically, clinical trials are double-blinded, where one group of patients receives an inactive placebo, and the other group the active intervention. [0241] The Positive and Negative Syndrome Scale (PANSS) is a medical scale used for measuring symptom severity of patients with schizophrenia. The name refers to the two types of symptoms in schizophrenia, as defined by the American Psychiatric Association: positive symptoms, which refer to an excess or distortion of normal functions (e.g., hallucinations and delusions), and negative symptoms, which represent a diminution or loss of normal functions. Some of these functions which may be lost include normal thoughts, actions, the ability to tell fantasies from reality, and the ability to properly express emotions [0242] The PANSS is a relatively brief interview of about 45 to 50 minutes. The interviewer must be trained to a standardized level of reliability. The patient is rated from 1 to 7 on 30 different symptoms in three categories based on the interview and reports of family members or primary care hospital workers. The first category of the PANSS is the positive scale, comprising 7 Items (minimum score = 7, maximum score = 49): delusions, conceptual disorganization, hallucinations, excitement, grandiosity, suspiciousness/persecution, and hostility. The second category is the negative scale, comprising 7 items (minimum score = 7, maximum score = 49): blunted affect, emotional withdrawal, poor rapport, passive/apathetic social withdrawal, difficulty in abstract thinking, lack of spontaneity, and flow of conversation, stereotyped thinking. The third category is the General Psychopathology scale, which comprises 16 items (minimum score = 16, maximum score = 112): somatic concern, anxiety, guilt feelings, tension, mannerisms and posturing, depression, motor retardation, uncooperativeness, unusual thought content, disorientation, poor attention, lack of judgment and insight, disturbance of volition, poor impulse control, preoccupation, active social avoidance.

[0243] PANSS Marder factor score is the sum of five negative scales and two general scales (Nl. Blunted affect; N2. Emotional withdrawal; N3. Poor rapport; N4. Passive/apathetic social withdrawal; N6. Lack of spontaneity; G7. Motor retardation; and G16. Active social avoidance). If a patient has a PANSS assessment recorded, but any of the items are missing, the last non-missing score for the individual item from previous assessments will be carried forward. If more than 30% of the items are missing at a particular visit, the respective positive score is not calculated. It is treated as missing data in the analysis.

[0244] Because 1 rather than 0 is given the lowest score for each item, a patient cannot score lower than 30 for the total PANSS score. Subscores can be given separately for the positive items, negative items, and general psychopathology. The maximum possible total score is 210. In the original publication on the PANSS scale, 101 adult patients (20-68 years-old) with schizophrenia were ranked. Their mean scores were a positive scale of 18.20, a negative scale of 21.01, and general psychopathology of 37.74. The mean total PANSS score for these subjects was 76.95.

[0245] In certain embodiments, the Positive and Negative Syndrome Scale (PANSS) total score for the subject decreases by at least 10 points than the placebo, for example, after five treatment weeks. In certain embodiments, the PANSS positive subscore decreases by at least 3 points than the placebo, for example, after five treatment weeks. In certain embodiments, the PANSS negative subscore decreases by at least 2 points than the placebo, for example, after five treatment weeks.

[0246] Another scale used to assess patients is the Clinical Global Impression - Severity scale (CGI-S). This 7-point scale requires the clinician to rate the severity of the patient's illness at the time of assessment, relative to the clinician's experience with patients who have the same diagnosis. Possible ratings are (1) Normal, not at all ill; (2) Borderline mentally ill; (3) Mildly ill, (4) Moderately ill; (5) Markedly ill; (6) Severely ill, and (7) Among the most extremely ill patients. Among schizophrenia patients, changes in the CGI-S follow a consistent pattern relative to more objective PANSS scoring.

[0247] Before administering the disclosed combinations, patients may have a lead-in period from one to fourteen days, during which lead-in period trospium chloride is given alone. In one embodiment, the trospium chloride is administered for one or more dose periods before administering xanomeline to accumulate trospium chloride in the body or for the trospium chloride to reach or approach steady-state exposure levels. This accumulation, or higher exposure levels of the trospium chloride, increases the blockade of muscarinic receptors outside of the brain and reduces adverse events when xanomeline is administered. In another embodiment, the trospium chloride is administered for one or more days before xanomeline. [0248] Before administering the disclosed combinations, patients may discontinue any prior use of antipsychotic drugs. In some embodiments, the patients will discontinue such drugs for at least one week, such as two weeks. In some embodiments, patients do not discontinue any prior use of such antipsychotic drugs, and the disclosed combinations are co- administered with such drugs.

[0249] In one embodiment, xanomeline and trospium chloride are administered to a patient 6 times during a 24-hour period. In another embodiment, xanomeline and trospium chloride are administered to a patient 5 times during a 24-hour period. In another embodiment, xanomeline and trospium chloride are administered to a patient 4 times during a 24-hour period. In an embodiment, xanomeline and trospium chloride are administered to a patient 3 times during a 24-hour period. In another embodiment, xanomeline and trospium chloride are administered to a patient twice during a 24-hour period. In another embodiment, xanomeline and trospium chloride are administered to a patient once during a 24-hour period.

[0250] In one embodiment, an extended-release formulation of trospium chloride is used in combination with xanomeline. In another embodiment, trospium chloride extended-release is administered to a patient from one time to five times during a 24-hour period. In an embodiment, the extended release of trospium chloride is administered from one to three times during a 24-hour period. In another embodiment, from five milligrams to 400 milligrams of trospium chloride, extended-release is used during a 24-hour period. In an embodiment, from 20 milligrams to 200 milligrams of trospium chloride extended-release is used during a 24-hour period.

[0251] In one embodiment, 225 mg xanomeline and 40 mg trospium chloride are administered to a patient in a 24-hour period. In another embodiment, 100 mg xanomeline and 20 mg trospium chloride are administered to a patient in a 24-hour period. In another embodiment, 125 mg xanomeline and 20 mg trospium chloride are administered to a patient in a 24-hour period. In another embodiment, 125 mg xanomeline and 30 mg trospium chloride are administered to a patient in a 24-hour period. In another embodiment, 125 mg xanomeline and 40 mg trospium chloride are administered to a patient in a 24-hour period. In another embodiment, 200 mg xanomeline and 40 mg trospium chloride are administered to a patient in a 24-hour period. In another embodiment, 200 mg xanomeline and 80 mg trospium chloride are administered to a patient in a 24-hour period. In another embodiment, 250 mg xanomeline and 60 mg trospium chloride are administered to a patient in a 24-hour period. In another embodiment, 250 mg xanomeline and 80 mg trospium chloride are administered to a patient in a 24-hour period. In another embodiment, 300 mg xanomeline and 40 mg trospium chloride are administered to a patient in a 24-hour period. In another embodiment, 300 mg xanomeline and 60 mg trospium chloride are administered to a patient in a 24-hour period. In another embodiment, 300 mg xanomeline and 80 mg trospium chloride are administered to a patient in a 24-hour period. In another embodiment, 350 mg xanomeline and 40 mg trospium chloride are administered to a patient in a 24-hour period. In another embodiment, 350 mg xanomeline and 60 mg trospium chloride are administered to a patient in a 24-hour period. In another embodiment, 350 mg xanomeline and 80 mg trospium chloride are administered to a patient in a 24-hour period.

[0252] Treatment may be initiated with smaller dosages. After that, small increments may increase the dosage until a balance between therapeutic effect and side effects is attained. While the subject is being treated, the patient's health may be monitored by measuring one or more of the relevant indices at predetermined times during the treatment period. Treatment, including composition, amounts, administration, and formulation times, may be adjusted per such monitoring. The patient may be periodically reevaluated to determine improvement by measuring the same parameters. Adjustments to the disclosed composition administered and possibly to the administration time may be made based on these reevaluations.

[0253] Provided is a method of treating schizophrenia or a disease related to schizophrenia in a patient in need thereof, the method comprising: orally administering to the patient twice daily an oral pharmaceutical composition comprising a plurality of xanomeline beads comprising xanomeline or a salt thereof, and a plurality of trospium beads comprising a salt of trospium, via a titration scheme that comprises up-titration of the xanomeline, or a salt thereof, and the salt of trospium.

[0254] Also provided is a method of treating schizophrenia or a disease related to schizophrenia in a patient in need thereof, the method comprising: orally administering twice daily an oral pharmaceutical composition comprising a plurality of xanomeline beads comprising xanomeline or a salt thereof, and a plurality of trospium beads comprising a salt of trospium, via a titration scheme that comprises up-titration of the xanomeline, or a salt thereof, and the salt of trospium until an amount equivalent to 125 mg xanomeline free base and an amount equivalent to 30 mg trospium chloride is administered.

[0255] In certain embodiments, the xanomeline, or a salt thereof, is administered for the first period in a first amount, and then the first amount is increased to a second amount. In certain embodiments, the first amount of xanomeline is equivalent to 50 mg xanomeline free base. In certain embodiments, the first period for the xanomeline administration is between 1 and 5 days, such as 2 days. In certain embodiments, the second amount of xanomeline is equivalent to 100 mg xanomeline free base.

[0256] In certain embodiments, the method further comprises administering the xanomeline, or a salt thereof, for the second period in the second amount and then increasing the second amount to a third amount. In certain embodiments, the second period for xanomeline administration is between three days and a week. In certain embodiments, the third amount of xanomeline is equivalent to 125 mg xanomeline free base.

[0257] In certain embodiments, the salt of trospium is administered for the first period in a first amount, and the first amount is increased to a second amount. In certain embodiments, the first amount of the salt of trospium is equivalent to 20 mg trospium chloride. In certain embodiments, the first period for trospium administration is at least a week. In certain embodiments, the second amount of the salt of trospium is equivalent to 30 mg trospium chloride.

[0258] In certain embodiments, if the patient is not tolerating the higher dose of xanomeline, or a salt thereof, and the salt of trospium, the amount of xanomeline, or a salt thereof, and the salt of trospium administered to the patient is decreased.

[0259] In certain embodiments, the xanomeline, or a salt thereof, and the salt of trospium are administered without causing a severe adverse event.

[0260] “Blood pressure” refers to the pressure of circulating blood on the walls of blood vessels. Most of this pressure is due to the heart pumping blood through the circulatory system. Used without further specification, "blood pressure" usually refers to the pressure in large arteries of the systemic circulation. Blood pressure is usually expressed in terms of the systolic pressure (maximum during one heartbeat) over diastolic pressure (minimum in between two heartbeats) and is measured in millimeters of mercury (mmHg), above the surrounding atmospheric pressure. Normal resting blood pressure in an adult is about 120 mmHg (16 kPa) systolic and 80 mmHg (11 kPa) diastolic, abbreviated “120/80 mmHg.” [0261] An adverse event related to blood pressure involves untoward medical occurrence affecting the systolic or diastolic blood pressure or changes to systolic or diastolic blood pressure, including hypertension, hypotension, and syncope (fainting). In certain embodiments, the xanomeline, or a salt thereof, and the salt of trospium are administered without inducing a change in diastolic blood pressure of more than about 5 mmHg. In certain embodiments, the xanomeline, or a salt thereof, and the salt of trospium are administered without inducing a change in systolic blood pressure of more than about 5 mmHg. In certain embodiments, the xanomeline, or a salt thereof, and the salt of trospium are administered without causing a severe adverse event related to blood pressure. In certain embodiments, the xanomeline, or a salt thereof, and the salt of trospium are administered without causing a severe adverse event related to blood pressure change.

[0262] “Heart rate” refers to the speed of the heartbeat measured by the number of contractions (beats) of the heart per minute (bpm). It is usually equal or close to the pulse measured at any peripheral point. The American Heart Association states that the normal resting adult human heart rate is 60-100 bpm. Tachycardia is a fast heart rate, defined as above 100 bpm at rest. Bradycardia is a slow heart rate, defined as below 60 bpm at rest, except during sleep, when a slow heartbeat with rates around 40-50 bpm is common and normal. When the heart is not beating in a regular pattern, this is referred to as an arrhythmia. [0263] An adverse event related to heart rate involves an untoward medical occurrence, including tachycardia, bradycardia, and arrhythmia. In certain embodiments, the xanomeline, or a salt thereof, and the salt of trospium are administered without causing a severe adverse event related to heart rate. In certain embodiments, the xanomeline, or a salt thereof, and the salt of trospium are administered without causing a severe adverse event related to heart rate change.

[0264] Liver function tests (LFTs or LFs), also referred to as a hepatic panel, are groups of blood tests that provide information about the state of a patient's liver. These tests include prothrombin time (PT/INR), aPTT, albumin, bilirubin (direct and indirect), liver transaminases aspartate transaminase (AST or SGOT), alanine transaminase (ALT or SGPT), and others. A patient's blood sample is tested for functionality (e.g., albumin), integrity (e.g., transaminase), and conditions linked to the biliary tract (gamma-glutamyl transferase and alkaline phosphatase).

[0265] In certain embodiments, the xanomeline, or a salt thereof, and the salt of trospium are administered without increasing a liver function test (LFT). In certain embodiments, the xanomeline, or a salt thereof, and the salt of trospium are administered without causing elevated LFT. In some embodiments, the liver function test is chosen from prothrombin time (PT/INR), aPTT, albumin, bilirubin (direct and indirect), liver transaminases aspartate transaminase (AST or SGOT), and alanine transaminase (ALT or SGPT). In some embodiments, the xanomeline, or a salt thereof, and the salt of trospium are administered without increasing at least one of ALT, AST, Aik phos, or bilirubin. In some embodiments, the xanomeline, or a salt thereof, and the salt of trospium are administered without increasing ALT, AST, Aik phos, or bilirubin.

[0266] The present disclosure further provides a method of treating acute psychosis in a patient in need thereof. The method comprises orally administering to the patient twice daily an oral pharmaceutical composition comprising xanomeline or a salt thereof, and a salt of trospium.

[0267] In certain embodiments, at least about an 11.6 point mean reduction in total PANNS score is achieved. In certain embodiments, at least a 3 point mean reduction in PANSS positive subscore compared to placebo is achieved. In certain embodiments, at least a 2 point reduction in the PANSS negative subscore compared to placebo is achieved. In certain embodiments, the reduction in the PANSS score is achieved within about 5 weeks. In certain embodiments, before administering the oral pharmaceutical composition, the patient had a Clinical Global Impression Severity Scale (CGI-S) score of 4-7.

[0268] In certain embodiments, the patient has a diagnosis of schizophrenia. In certain embodiments, the patient has acute psychosis. In certain embodiments, the patient has psychosis associated with Alzheimer’s disease. In certain embodiments, the patient has a schizo-affective disorder. In certain embodiments, the patient has psychosis. In certain embodiments, the patient has a delusional disorder. In certain embodiments, the patient has psychosis associated with Parkinson’s disease. In certain embodiments, the patient has psychotic depression. In certain embodiments, the patient has bipolar disorder. In certain embodiments, the patient has bipolar disorder with psychosis. In certain embodiments, the patient has Huntington’s disease. In certain embodiments, the patient has Lewy Body dementia.

[0269] In certain embodiments, the patient previously had been administered one or more antipsychotics. In certain embodiments, the patient was an inadequate responder to such administration· In certain embodiments, the patient was treatment-resistant.

[0270] In certain embodiments, the patient is an adult. In certain embodiments, the patient is elderly, e.g., above the age of 65 years. In certain embodiments, the patient has dementia- related psychosis.

EXAMPLES

[0271] The following examples are provided for illustration and are not intended to limit the scope of the disclosure.

Example 1 - Immediate Release Beads

[0272] Beads were prepared for xanomeline tartrate (Table 1) and trospium chloride (Table

2).

Table 1: Xanomeline tartrate (66%) Bead without Talc

*Removed during drying.

Table 2: Trospium chloride (17.7%) Bead without Talc

*Removed during drying.

[0273] The powders were screened using Quadro Comil Model 197 equipped with 457-μm round hole screen, 0.2-inch spacer at 1625 rpm and mixed for 2 min in a Hobart low shear mixer/granulator (model N-50) at a fixed speed of 60 rpm. The dry blending step is optional, as blend uniformity is driven by subsequent wet granulation. Beads were screened by hand through a 40 mesh (425 μm) sieve.

[0274] Wetting was carried out in Hobart. The water was added using a Cole-Parmer peristaltic pump. The water addition rate (amount of water /dose time) is a process variable. [0275] The wet mass was extruded through a perforated screen (dome configuration) single screw extruder using an LCI Multi Granulator MG-55 at 30 rpm (shaft speed). The wet mass was extruded directly after wetting. Hold time, shaft speed, and extrusion rate (load) were process variables.

[0276] The extrudates were placed into an LCI Marumerizer (spheronizer) QJ-230T equipped with a 2.0 mm friction plate. The extrudates were spheronized at different plate speeds for a total of not more than 4 minutes. Spheronization speed and time are process variables.

[0277] The beads were dried using an Aeromatic™ Strea- 1 fluid bed at an inlet temperature of 60 °C until a water content of not more than 3% was obtained. Because beads melted after a few minutes at 60 °C, the beads were dried at 30 °C.

[0278] Water content was evaluated gravimetrically by loss-on-drying (LOD) using a Mettler Toledo Halogen Moisture Analyser, type HR83. The beads were heated at 105 °C until the weight loss rate dropped to less or equal to 0.0 % within 60 seconds.

Table 3: Extrusion/Spheronization Process Parameters

Example 2 - Scaling up Immediate Release Bead Formulations

[0279] The beads from Example 1 were scaled-up with and without talc (Tables 4-7).

Extrusion/Spheronization process parameters are shown in Table 8.

Table 4: Xanomeline Tartrate (66%) Beads Without Talc

*Removed during drying.

Table 5: Xanomeline tartrate (66%) Bead with Talc

Abbreviations: Ph. Eur = European Pharmacopeia, USP = United States Pharmacopeia * - Evaporated during the process thus not included in total weight

Table 6: Trospium Chloride (17.7%) Beads Without Talc

*Removed during drying.

Table 7: Trospium chloride (17.7%) Bead with Talc

Abbreviations: NF = National Formulary, Ph. Eur = European Pharmacopeia, USP = United States Pharmacopeia. * - Evaporated during process

Table 8: Extrusion/Spheronization Process Parameters

Example 3 - Capsule Stability and Dissolution Testing

[0280] An oral pharmaceutical composition comprising a plurality of xanomeline beads comprising xanomeline or a salt thereof, and a plurality of trospium beads comprising a salt of trospium is referred to as “KarXT.” KarXT may be formulated in many dosage strengths, for example, as exemplified below KarXT 50/10, KarXT 50/20, and KarXT 75/20, wherein the number before the slash is the milligrams of xanomeline free base in the composition (X) and the number after the slash is the milligrams of trospium chloride in the composition (T). [0281] Capsules were produced by weighing beads and filling into HPMC capsules manually. Beads were encapsulated by hand using an Accofil™ capsule filling machine where beads premixed with talc (0.5%) were filled individually /one-after-the-other in the capsule, as shown in Table 19.

Table 9: Composition of Xanomeline / Trospium Chloride Capsules. Ingredients are listed in milligrams per capsule.

[0282] After drying, the beads were screened by shaking 5 min through 16 mesh (1.18 mm) and 40 mesh (0.425 mm) screens. The beads in size between sieves 1.18 mm and 0.425 mm were retained for further analysis. [0283] The morphology and surface characteristics of beads were examined by scanning electron microscopy (SEM) using a JSM-6010LV InTouchScope™ (JEOL Ltd, Tokyo, JP) microscope with a back-scattered electron detector (BES). Samples were placed on metallic stubs using double-sided carbon conductive tape. The images were obtained with accelerating voltages of 20 kV under low vacuum (60 Pa) and magnification 30x.

[0284] Bulk and tapped density were determined in duplicate using the USP <616> method using a tapped density tester (JV 1000, Copley Scientific). The bulk density was measured from the volume of a known mass of powder sample in a graduated cylinder. The tapped density was measured by mechanically tapping the measuring cylinder until the volume changed no further.

[0285] The powder flow properties were evaluated using Carr’s Compressibility Index and Hausner ratio. Both were derived using the measured values for bulk and tapped density. Carr’s Compressibility Index (Cl) was calculated using bulk and tapped density data when fitted into the equation: Compressibility Index = (Tapped density - Bulk density) / Tapped density x 100%. Hausner Ratio (H) was calculated as the ratio of tapped to bulk density. Capsules were analyzed for appearance, assay, related substances, water content, and dissolution.

[0286] The beads were further sized between 0.6 mm and 0.85 mm. Some beads exhibited similar morphological properties. Modifications in some other beads decreased the density of beads and led to rough surfaces and sphericity loss. Scanning electron microscope (SEM) images of xanomeline tartrate 66% beads and trospium chloride 17.7% beads at 30x magnification showed that the beads are sized between 0.6 mm and 0.85 mm. These beads were used in xanomeline/trospium capsules. Particle size distribution (PSD) of beads was determined by mechanical sieving. As shown in Table 10, most beads for both APIs were sized between 0.425 and 1.18 mm.

Table 10: Particle Size Distribution by Mechanical Sieving of Beads

[0287] Table 11 shows the densities and flow properties of beads collected between 0.425 mm and 1.18 mm sieves. Xanomeline tartrate and trospium chloride IR beads showed different densities and flow properties, which can be critical when mixing bead systems.

Table 11: Density and Flow Properties of 0.425-1.18 mm Beads

[0288] The analysis in Table 12 shows favorable results for assay and related substances and moisture content for 50 mg xanomeline and 20 mg trospium chloride capsules. Data in Table 13 show that these attributes were retained during storage stability studies. Similar data are provided for the 50 mg xanomeline and 10 mg trospium chloride capsules in Table 14. Dissolution data for these two dosage forms are provided in Table 15 and Table 16.

Table 12: Analytical Results

Table 13: Stability of KarXT 50/20

Table 14: Dissolution of KarXT 50/20

Table 15: Assay and Related Substances of KarXT 50/10

Table 16: Dissolution of KarXT 50/10

were stable for at least 12 months 25°C/60%RH. Based on available data, a shelf-life of 15 months at 25°C/60%RH is proposed.

[0290] The dissolution results show that the two compounds release quickly, which may increase their bioavailability. They also release at comparable rates despite substantial differences in compositions between the two bead formulations. Both xanomeline and trospium chloride have low bioavailabilities, and rapid release can increase bioavailability by overwhelming saturable processes that limit absorption into the general circulation.

[0291] An unknown xanomeline impurity with a relative retention time of about 1.09 was observed during stability studies of the combination drug products. The impurity was first observed during testing at the three-month time point for the 50 mg xanomeline/10 mg trospium chloride drug product and at the initial time point for the other three combination products, both of which occurred at the same time. The impurity peak increased both with time and with increasing storage temperature. The impurity had not been observed before the present studies.

[0292] Preliminary studies suggest that the RRT 1.09 impurity is 3-[(4-hexyloxy)-1,2,5- thiadizaol-3-yl]-5-hydroxyl-1-methylpyridin-1-ium (C₁₄H₂₀N₃O₂S⁺, MW = 294.1271 Da):

[0293] The RRT 1.09 impurity is a hydroxylated version of Compound V (C₁₄H₂₀N₃OS⁺, MW = 278.1322 Da), which is the penultimate intermediate in the synthesis of xanomeline with negative mutagenic potential:

[0294] To reduce the presence of the impurity, the storage temperature for the drug product was lowered. Bottles were flushed with argon to minimize headspace oxygen during packaging. In certain embodiments, the xanomeline bead formulation was formulated with an antioxidant, such as 0.5 wt.% ascorbic acid or 0.05 wt.% BHT.

Example 4 - KAR-001 Phase I study of Combination of Xanomeline and Trospium Chloride

[0295] A Phase I, double-blind, randomized multiple-dose pilot study was conducted with xanomeline administered alone compared to xanomeline administered with trospium chloride in normal healthy volunteers. The primary objectives of this study were (1) to assess the safety and tolerability of administering, for 7 days, 225 mg daily of xanomeline with 40 mg daily of trospium chloride, versus administering 225 mg daily of xanomeline alone for 7 days; and (2) to determine whether adding trospium 40 mg daily (20 mg BID) to xanomeline 225 mg daily (75 mg TID) over 7 days significantly reduces peripheral cholinergic side effects (nausea, diarrhea, vomiting, sweating, excess salivation) versus xanomeline 225 mg daily, alone. Table 17 lists the parameters from this study.

Table 17: Parameters of the KAR-001 study

[0296] Seventy total study subjects were randomized, and of these, 68 study subjects received at least one assessment on day 3, which was the first day of xanomeline administration. Table 18 lists the demographics of the study subjects.

Table 18: Demographics of the KAR-001 study subjects

[0297] The most common adverse events with xanomeline are the so-called cholinergic adverse events of nausea, vomiting, diarrhea, excessive sweating, and excessive salivation. In this study, the co-administration of trospium chloride with xanomeline led to a statistically significant (p = 0.016) 43% reduction in the incidence rate of cholinergic adverse events compared to xanomeline co-administered with placebo. In the xanomeline + placebo arm of the study, 63% of subjects reported at least one cholinergic adverse event, compared to only 34% of subjects reporting such an event in the xanomeline + trospium chloride arm of the study.

[0298] Further, in the study, each kind of individual cholinergic adverse event also had a decreased incidence rate in subjects administered xanomeline + trospium chloride, compared to the incidence rate in subjects administered xanomeline + placebo. The decrease in the incidence rate of sweating was statistically significant on its own, at 20.0% in the xanomeline + trospium chloride arm, down from 48.5% in the xanomeline + placebo arm, which was a 59% reduction (p = 0.013).

[0299] The overall cholinergic adverse event rate in the xanomeline + trospium chloride arm of the study was very similar to the 32% incidence rate reported during the two-day run-in period for subjects on placebo + placebo. Although these two data points did not occur during different periods of the study, the fact that the cholinergic adverse event rate was comparable to that of placebo suggests that the 43% reduction in adverse events due to trospium chloride may have been close to the maximum reduction possible in this study.

[0300] Table 19 shows the incidence and number of cholinergic adverse events in the evaluable population of the study were as follows, with all p- values based on a chi-squared test, except those marked with an *, which were based on a Fisher’s exact test.

Table 19: Cholinergic adverse events

[0301] There were no meaningful differences between treatment groups in heart rate, resting blood pressure, orthostatic blood pressure, or electrocardiogram (ECG) parameters, including QT. A small subset of subjects in both treatment arms had transient increases in heart rate and orthostatic blood pressure changes, which may have contributed to syncope and postural dizziness in those subjects. Two subjects (both in the xanomeline alone arm) experienced syncope. The incidence of orthostatic adverse events in the xanomeline + trospium group was about one-half of subjects in the xanomeline alone group. Only one subject discontinued due to a treatment-emergent adverse event in the xanomeline + trospium group regarding blood pressure.

[0302] In addition to evaluating whether adding trospium chloride increased the tolerability of xanomeline, the study also provided data about the overall safety and tolerability of xanomeline + trospium chloride. Table 20 shows that the combination was well tolerated with no severe adverse events and no serious adverse events, and with most adverse events being mild.

Table 20: Tolerability

[0303] This study's tolerability profile allowed future studies of the combination of xanomeline and trospium chloride to proceed.

Example 5 - KAR-003 Phase I Study of KarXT, a xanomeline + trospium combined formulation

[0304] This study was a Phase 1 , randomized, multiple-dose, adaptive design, inpatient study to assess the safety and tolerability of KarXT in normal healthy volunteers aged 18 to 60 years. Subjects signed the informed consent and underwent Screening assessments on Days -21 to -1. Upon completing all Screening assessments, subjects returned to the study clinic on Day 0 for baseline safety assessments and enrollment into the study. They were randomized 3: 1 in each cohort into one of two treatment arms: KarXT or placebo. Subjects were assigned to 1 of 4 cohorts (Cohort 1, 2, 3, or 4).

[0305] Study drug was administered BID on Days 1 through 7. A combination dosage formulation of both xanomeline and trospium was used in all cohorts. All cohorts began with a 2-day lead-in of KarXT 50/20 BID (for subjects randomized to active treatment); after the 2-day lead-in period, the unblinded pharmacist dispensed the study drug to each subject per the subject’s randomization assignment for 5 days of specified cohort dosing, for a total of 7 days of treatment. A matching placebo was administered throughout the study to maintain the blind. A sentinel group was introduced to the study for Cohorts 2 to 4. It was monitored for safety and tolerability by the Data Safety Evaluation Group (DSEG), such that about 30% of the proposed cohort was treated and assessed for safety before the rest of the cohort was dosed. Subjects and study clinic staff were blinded to treatment. The Dose Selection Committee (DSC) was unblinded to decide to dose for subsequent treatment groups.

[0306] Serial blood samples for the PK assessment of xanomeline and trospium were drawn on Days 1, 3, and 7. More blood was sampled at routine intervals for monitoring trough concentrations of xanomeline and trospium and clinical laboratory assessments. On Day 1, saliva volume was collected twice. A saliva volume was measured predose on Day 1 and then daily (afternoon) on Days 1 through 7 at about the same time of day to avoid diurnal variations. Other assessments included pupil size measurements and Bristol stool scale assessments. Subjects remained in the study clinic for the full duration of treatment (7 days). Following a safety assessment on Day 8, subjects were discharged from the study clinic and asked to return about 14 days after administering the study drug for a final safety assessment. [0307] During the study, following the 2-day lead-in of KarXT 50/20 BID (for subjects randomized to active treatment) in each cohort, subjects were dosed as follows:

• In Cohort 1, subjects completed Days 3 through 7 of dosing of KarXT 100/20 BID (total daily dose (TDD) of 200 mg xanomeline plus 40 mg trospium) or placebo.

• In Cohort 2, the sentinel group (Group 2a) discontinued dosing after the Day 4 morning dose. The dosage for subjects in Cohort 2 was KarXT 150/20 BID (TDD of 300 mg xanomeline plus 40 mg trospium) or placebo. Dosing of Cohort 2 was discontinued (DSEG decision based on observed tolerability concerns). The study dosing the Cohort 3 sentinel group (Group 3 a) as the DSC determined that further dosing of Cohort 2 with KarXT 150/20 BID was unlikely to be tolerated well enough to warrant further developing this dose combination for a clinical population.

• In Cohort 3, the sentinel group (Group 3 a) completed Days 3 through 7 of the dosing of KarXT 150/40 BID (TDD of 300 mg xanomeline plus 80 mg trospium) or placebo.

The second group in Cohort 3 (Group 3b) discontinued dosing after the Day 5 morning dose.

• In Cohort 4, the sentinel group (Group 4a), the second group (Group 4b), and the remaining group (Group 4c) completed Days 3 through 7 of the dosing of KarXT 125/40 BID (TDD of 250 mg xanomeline plus 80 mg trospium) or placebo.

[0308] Ninety-six subjects were planned, 248 subjects were screened, 69 subjects were randomized, 51 subjects completed the study, and 18 subjects discontinued the study. The population included healthy male and female subjects aged 18 to 60 years at screening with a body mass index of 18 to 40 kg/m². Subjects were excluded from the study if they had a history of irritable bowel syndrome or serious constipation requiring treatment within 6 months before Screening. Subjects were also excluded from the study if they had a history or presence of any disease or condition, including psychiatric or neurological diseases that would have jeopardized the subject’s safety or the study in the Investigator’s opinion’s validity. Table 21 summarizes the demographics and baseline characteristics by treatment group. The demographic and baseline characteristics were consistent between the Safety Population and the PK Population.

Table 21: Summary of Demographics and Baseline Characteristics by Treatment Group - Safety Population

[0309] Serial blood samples for assessing the PK of xanomeline and trospium were collected from all subjects in each cohort on Days 1, 3, and 7 before the morning dose and at 1, 2, 3, 4, 6, 8, 10, and 12 hours after the morning dose. The PK parameters listed below were calculated from the individual xanomeline and trospium concentration-time profiles by standard non-compartmental methods. Dose-normalized parameters were calculated for C_max and area under the concentration-time curve (AUC) values. During the study, additional blood samples for monitoring trough concentrations of xanomeline and trospium were collected on Days 2, 4, 5, and 6 before the morning dose and before discharge on Day 8. [0310] Safety evaluations included spontaneously reported adverse events, ECGs, laboratory assessments, vital signs, assessments of saliva volumes, Bristol stool scale, pupil size, and physical examinations· Descriptive statistics (n, mean, standard deviation, median, minimum, and maximum) summarized the treatment group's continuous data. Geometric mean (GM), geometric percent coefficient of variation (CV%), quartiles, or box plots was generated. The count and frequency tabulated categorical measurements, although formal statistics were not conducted. [0311] Treatment groups were summarized as follows unless otherwise specified: KarXT 50/20 BID (for adverse events and Day 1 PK summaries only), KarXT 100/20 BID, KarXT 125/40 BID, KarXT 150/20 BID, KarXT 150/40 BID, and placebo (Empty Vcaps^® Plus Capsules and Capsugel^®; all cohort placebo groups combined). The safety evaluation was based on reported adverse events, ECGs, laboratory assessments, and vital signs. Exploratory analyses of saliva volumes, Bristol stool scale, and pupil size were also conducted.

[0312] Xanomeline was well absorbed into the systemic circulation following oral administration of the KAR-003 formulation at all dosages. Peak concentrations of xanomeline were observed at a median time of 2 hours across all treatment groups and study days.

[0313] Median t_1/2 values for xanomeline were similar between treatment groups and across study days, indicating that t_1/2 was not dose-dependent. Median t_1/2 ranged from 3.4 to 5.8 hours.

[0314] GM xanomeline exposures did not increase dose-proportionally on Day 3 from 100 to 150 mg when xanomeline was administered with 20 mg trospium or 125 to 150 mg when administered with 40 mg trospium. Lower xanomeline exposures were observed following treatment with KarXT 150/40 compared to KarXT 125/40. Day 3 GM xanomeline exposures (C_max, AUC_0-last, and AUC_0-12hr) were similar when the 150 mg xanomeline dose was administered with 20 and 40 mg trospium. On Day 7, GM xanomeline exposures increased slightly more than dose-proportionally from 125 to 150 mg when xanomeline was administered 40 mg trospium.

[0315] Minimal to no xanomeline accumulated in plasma from Day 3 to Day 7 following treatment with KarXT 100/20 BID and KarXT 125/40 BID; however, there was accumulation following administration of KarXT 150/40 BID in 3 of the 4 subjects who completed the study. The KarXT 150/40 BID group's mean accumulation ratios were 366.2% for RAUC and 445.4% for RC_max.

Example 6 - Xanomeline pharmacokinetics of KAR-003 compared to KAR-001 [0316] Comparing xanomeline GM exposures between KAR-001 (75 mg xanomeline TID ±20 mg trospium BID) and the KarXT 100/20 BID group from KAR-003 showed that C_max values and AUC_0-6hr (KAR-003) or AUC_0-tau (KAR-001) values were greater in KAR-003 (Days 3 and 7) than the corresponding exposures from KAR-001 (Days 3 and 9). The median T_max was observed at 2 hours in both studies and both days (Days 3 and 9 for KAR-001, and Days 3 and 7 for KAR-003). These data indicate that the KarXT formulation enhanced xanomeline exposures.

[0317] Trospium was absorbed into the systemic circulation following oral administration of the KarXT formulation at all dosages. Peak concentrations of trospium were observed at a median time of 1.0 hour across all treatment groups and study days.

[0318] Median t_1/2 values for trospium were similar between treatment groups on Day 3, with values ranging between 4.1 and 4.8 hours. On Day 7, median t_1/2 values were similar for the KarXT 100/20 BID (4.9 hours) and KarXT 125/40 BID (4.5 hours) treatments but were slightly longer for the KarXT 150/40 BID group (7.1 hours).

[0319] GM trospium exposures increased slightly less than dose-proportionally on Day 3 from 20 to 40 mg when administered with 150 mg xanomeline. Day 3 GM trospium exposures (C_max, AUC_0-last, and AUC_0-12hr) were greater when the 20 mg BID dose of trospium was administered with 100 mg BID xanomeline compared to 150 mg BID xanomeline. Day 3 GM trospium exposures were similar when the 40 mg trospium BID dose was given 125 mg xanomeline BID and 150 mg xanomeline BID.

[0320] Trospium did not accumulate in plasma from Day 3 to Day 7 following administration of KarXT 100/20 BID, KarXT 125/40 BID, and KarXT 150/40 BID. Trospium accumulated in plasma from Day 1 to Day 7 for the KarXT 100/20 BID group. Mean Day 7/Day 1 accumulation ratios were 348.7% (RAUC) and 379.9% (RC_max).

[0321] Comparing trospium GM exposures between KAR-001 and the KarXT 100/20 BID group from KAR-003 showed that C_max and AUC_0-12hr values from KAR-003 were greater than the corresponding exposures from KAR-001 on both days (Days 3 and 9 for KAR-001 and Days 3 and 7 for KAR-003). The median T_max for trospium was observed at 1.0 hour in both studies on both days. These data indicate that the KarXT formulation enhanced trospium exposures.

[0322] All cohorts of KAR-003 started with a 2-day lead-in period of KarXT 50/20 BID for subjects randomized to KarXT. FIG. 1 presents the mean (± SD) xanomeline PK concentrations, and Table 22 summarizes xanomeline PK parameters on Day 1 for KarXT 50/20 BID treatment of all cohorts for the PK Population. No sample collected before administering the first dose of xanomeline on Day 1 displayed measurable concentrations of xanomeline. Concentrations of xanomeline were quantifiable (>50 pg/mL) at all time points after administering the Day 1 morning dose through 12 hours. Table 22: Xanomeline PK Parameters on Day 1 for KarXT 50/20 BID (All Cohorts)

[0323] FIG. 2 presents the mean (± SD) xanomeline PK concentrations by treatment on Day 3 for the PK population, and Table 23 summarizes these parameters. Concentrations of xanomeline were quantifiable in samples before administering the morning dose of the study drug on Day 3 and at all time points after administering the Day 3 morning dose through 12 hours for all cohorts, except for one subject who had a xanomeline plasma concentration <50.0 pg/mL at 12 hours post-dose. Inter-subject variability ranged from 23.7 % to 58.2% (CV%) for T_max, 79.8% to 136.3% (geometric CV%) for C_max, 21.6% to 26.3% (CV%) for t_1/2, and 77.1% to 96.1% (geometric CV%) for AUC_0-12hr across the four treatment groups. The median T_maX for xanomeline on Day 3 was 2 hours for the KarXT 100/20 BID,

KarXT 125/40 BID, KarXT 150/20 BID, and KarXT 150/40 BID groups. Individual T_max values range from 1.0 to 6.0 hours across the four treatment groups. The t_1/2 was estimated in 51 of 53 subjects, in contrast to the previous study, KAR-001, where the elimination phase was not well characterized. The median t_1/2 on Day 3 for xanomeline was numerically similar across the four treatment groups. Median t_1/2 ranged from 3.4 to 4.3 hours. Individual t_1/2 values ranged from 2.4 to 8.6 hours across the four treatment groups.

Table 23: Xanomeline PK Parameters by Treatment on Day 3

[0324] When KarXT was administered BID, as the xanomeline dose increased from 100 mg (Cohort 1) to 150 mg (Cohort 2) without changing the trospium dose (20 mg), the Day 3 dose-normalized GM exposures (dose-normalized GM C_max and dose-normalized GM AUC_0- _last and AUC_0-12hr) for xanomeline decreased. Similarly, as the xanomeline dose increased from 125 mg (Cohort 4) to 150 mg (Cohort 3) without changing the trospium dosage (40 mg), the Day 3 dose-normalized GM exposures for xanomeline decreased slightly (i.e., xanomeline exposures were lower following treatment with KarXT 150/40 BID compared to treatment with KarXT 125/40 BID). Comparing xanomeline exposures following 150 mg xanomeline BID administration with either 20 or 40 mg trospium BID showed that the Day 3 GM, C_max, AUC_0-last, and AUC_0-12hr for xanomeline were similar.

[0325] FIG. 3 presents the mean (± SD) xanomeline PK concentrations by treatment on Day 7 for the PK population, and Table 24 summarizes these parameters. Concentrations of xanomeline were quantifiable in samples collected before administering the morning dose of the study drug on Day 7 and at all time points after the Day 7-moming dose through 12 hours for the KarXT 100/20 BID, KarXT 125/40 BID, and KarXT 150/40 BID groups. Inter-subject variability ranged from 38.3% to 47.9% (CV%) for T_max, 81.4% to 106.8% (geometric CV%) for C_max, 15.4% to 42.1% (CV%) for t_1/2, and 45.2% to 71.2% (geometric CV%) for AUC_0- _12hr across the KarXT 100/20 BID, KarXT 150/40 BID, and KarXT 125/40 BID groups. The median T_max for xanomeline on Day 7 was 2.0 hours for the KarXT 100/20 BID,

KarXT 125/40 BID, and KarXT 150/40 BID groups. Individual T_max values ranged from 0.0 to 6.0 hours across the KarXT 100/20 BID, KarXT 150/40 BID, and KarXT 125/40 BID groups. The median t_1/2 for xanomeline on Day 7 was numerically similar for the KarXT 100/20 BID, KarXT 125/40 BID, and KarXT 150/40 BID groups. Median t_1/2 for xanomeline ranged from 4.6 to 5.8 hours. Individual tm values ranged from 3.6 to 14.0 hours across the KarXT 100/20 BID, KarXT 150/40 BID, and KarXT 125/40 BID groups.

Table 24: Xanomeline PK Parameters by Treatment on Day 7

[0326] When KarXT was administered BID, as the xanomeline dose increased from 125 mg (Cohort 4) to 150 mg (Cohort 3) without changing the trospium dosage (40 mg), the Day 7 dose-normalized GM exposures (dose-normalized GM C_max, AUC_0-last and AUC_0-12hr) for xanomeline increased.

[0327] Table 25 summaries xanomeline PK accumulation ratios (Day 7/Day 3) by treatment for the PK population. Based upon mean accumulation ratios of xanomeline following treatment with KarXT 100/20 BID (Cohort 1) and KarXT 125/40 BID (Cohort 4), minimal to no xanomeline accumulated in plasma from Day 3 to Day 7. The KarXT 100/20 BID group's mean accumulation ratios were 133.4% for RAUC and 130.5% for RC_max, and for the KarXT 125/40 BID group was 143.9% for RAUC and 151.0% for RC_max. Only one subject in the KarXT 100/20 BID group showed lower exposures on Day 7 compared to Day 3. In contrast, xanomeline accumulated moderately in three of the four subjects in the KarXT 150/40 BID group who completed the study. The other subject in the KarXT 150/40 BID group showed similar exposures on Days 3 and 7. The KarXT 150/40 BID group's mean accumulation ratios were 366.2% (RAUC) and 445.4% (RC_max). Table 25: Xanomeline PK Accumulation Ratios (Day 7/Day 3) by Treatment

[0328] FIG. 4 compares the mean (± SD) xanomeline PK concentration-time profiles by treatment and visit (Day) for the PK population. FIG. 5 presents mean (± SD) xanomeline PK trough concentrations by treatment for the PK population. Attaining a steady-state was not assessed.

[0329] Comparing xanomeline GM exposures between KAR-001 (75 mg xanomeline TID ± 20 mg trospium BID) (Table 23) and the KarXT 100/20 BID group from KAR-003 (Table 21) showed that C_max values and AUC_0-6hr (KAR-003) or AUC_0-tau (AUC from time 0 to 6 hours) values (KAR-001) values on Day 3 for the KarXT 100/20 BID group (KAR-003) were about 2.3 to 2.6-fold greater than corresponding exposures from KAR-001 on Day 3.

[0330] Comparing Day 7 GM exposures for xanomeline for the KarXT 100/20 BID group from KAR-003 (Table 22) with Day 9 exposures from the xanomeline alone and xanomeline + trospium arms from KAR-001 (Table 23) showed that values on Day 7 for the KarXT 100/20 BID group (KAR-003) were about 1.4 to 1.8-fold greater than corresponding exposures from KAR-001 on Day 9. The median T_max was 2.0 hours on Day 3 and Day 7 for KAR-003 (Table 22) and Day 3 and Day 9 for KAR-001 (Table 23). These data indicate that the KAR-003 formulation provided sufficient exposures and PK properties.

[0331] Table 26 summarizes a subset of KAR-003 xanomeline PK parameters for the KarXT 100/20 BID group on Day 3 and Day 7 for the PK Population. Table 27 presents a summary of a subset of KAR-001 xanomeline PK parameters for the treatments of KAR-001 on Day 3 and Day 9 for the PK Population.

Table 26: Subset of Xanomeline PK Parameters KarXT 100/20 BID on Days 3 and 7

Table 27: Subset Xanomeline PK Parameters for KAR-001 on Days 3 and 9

[0332] FIG. 6 presents mean (± SD) trospium PK concentrations on Day 1 for the KarXT 50/20 BID treatment (all cohorts) for the PK population, and Table 28 summarizes these parameters. No samples collected before administering the first dose of trospium on Day 1 displayed measurable concentrations of trospium. Concentrations of trospium were quantifiable (>20 pg/mL) at all time points after administration of the Day 1 morning dose through 12 hours.

Table 28: Trospium PK Parameters on Day 1 for KarXT 50/20 BID (All Cohorts)

[0333] FIG. 7 presents mean (± SD) trospium PK concentrations by treatment on Day 3 for the PK population, and Table 29 summarizes these parameters. Concentrations of trospium were quantifiable in samples collected before administering the morning dose of the study drug on Day 3 and at all time points after administering the Day 3 morning dose through 12 hours for all treatment groups (except for one subject who had a trospium plasma concentration <20.0 pg/mL at 12 hours post-dose. Inter-subject variability ranged from 0.0% to 83.0% (CV%) for T_max, 54.8% to 80.7% (geometric CV%) for C_max, 9.1% to 34.0% (CV%) for t _1/2 , and 59.0% to 67.6 % (geometric CV%) for AUC_0-12hr across the four treatment groups.

Table 29: Trospium PK Parameters by Treatment on Day 3

[0334] The median T_max for trospium on Day 3 was 1.0 hour for the KarXT 100/20 BID, KarXT 125/40 BID, KarXT 150/20 BID, and KarXT 150/40 BID groups. Individual T_max values ranged from 1.0 to 6.0 hours across the 4 treatment groups. The median t_1/2 for trospium on Day 3 was numerically similar across the 4 treatment groups; median t_1/2 ranged from 4.1 to 4.8 hours. Individual t_1/2 values ranged from 2.8 to 9.0 hours across the 4 treatment groups.

[0335] When KarXT was administered BID, as the trospium dose increased from 20 mg (Cohort 2) to 40 mg (Cohort 3) without changing xanomeline dose (150 mg), the Day 3 dose- normalized GM exposures for trospium increased. Comparing Day 3 trospium exposures following administration of 20 mg trospium BID with either 100 mg (Cohort 1) or 150 mg (Cohort 2) xanomeline BID showed that GM C_max, AUC_0-last, and AUC_0-12hr for trospium were greater when the 20 mg BID dose of trospium was administered with 100 mg xanomeline BID compared to 150 mg xanomeline BID.

[0336] Similarly, comparing trospium exposures following administration of 40 mg trospium BID with either 125 mg (Cohort 4) or 150 mg (Cohort 3) xanomeline BID showed that the GM C_max, AUC_0-last, and AUC_0-12hr for trospium were generally similar when trospium was administered with 125 and 150 mg xanomeline BID on Day 3.

[0337] FIG. 8 presents mean (± SD) trospium PK concentrations by treatment on Day 7 for the PK population, and Table 30 summarizes the parameters. Concentrations of trospium were quantifiable in samples collected before administering the morning dose of the study drug on Day 7 and at all time points after the Day 7 morning dose through 12 hours for the KarXT 100/20 BID, KarXT 125/40 BID, and KarXT 150/40 BID groups. Inter-subject variability ranged from 0.0% to 86.3% (CV%) for T_max, 51.2% to 93.8% (geometric CV%) for Cmax, 23.0% to 44.5% (CV%) for ti/2, and 59.4% to 76.7% (geometric CV%) for AUC_0-12hr across the KarXT 100/20 BID, KarXT 150/40 BID, and KarXT 125/40 BID groups.

Table 30: Trospium PK Parameters by Treatment on Day 7

0338] The median T_max for trospium on Day 7 was 1.0 hour for the KarXT 100/20 BID, KarXT 125/40 BID, and KarXT 150/40 BID treatments. Individual T_max values ranged from 0.0 to 6.0 hours across the KarXT 100/20 BID, KarXT 150/40 BID, and KarXT 125/40 BID groups.

[0339] The median t_1/2 for trospium on Day 7 was similar for the KarXT 100/20 BID (4.9 hours) and KarXT 125/40 BID (4.5 hours) groups. The median t_1/2 was 7.1 hours for the KarXT 150/40 BID group. Individual t_1/2 values ranged from 3.1 to 11.9 hours across the KarXT 100/20 BID, KarXT 150/40 BID, and KarXT 125/40 BID groups.

[0340] As observed on Day 3, comparing Day 7 trospium exposures following administration of 40 mg trospium BID with either 125 mg (Cohort 4) or 150 mg (Cohort 3) xanomeline BID showed that the GM C_max, AUC_0-last, and AUC_0-12hr for trospium were similar when trospium was administered with 125 and 150 mg xanomeline BID.

[0341] Table 31 summarizes trospium PK accumulation ratios (Day 7/Day 3; Day 7/Day 1) by treatment for the PK Population. Based upon mean trospium PK accumulation ratios, trospium accumulated minimally in the plasma from Day 3 to Day 7 following administration of KarXT 100/20 BID (Cohort 1) and had little to no accumulation following administration of KarXT 125/40 BID (Cohort 4) and KarXT 150/40 BID (Cohort 3). Two subjects showed lower exposures on Day 7 compared to Day 3 in the KarXT 100/20 BID group.

[0342] Accumulation ratios from Day 3 to Day 7 varied widely between subjects in the KarXT 125/40 BID and KarXT 150/20 BID groups. Mean accumulation ratios ranged from 108.6% to 141.4% for RAUC and from 111.0% to 135.8% for RC_max. Trospium accumulated moderately in the plasma from Day 1 to Day 7 for the KarXT 100/20 BID group. All but one subject showed higher trospium exposures on Day 7 compared to Day 1. Mean accumulation ratios were 348.7% for RAUC and 379.9% for RC_max. The possible effect of the increase in xanomeline dose (from 50 mg BID to 100 mg BID beginning on Day 3) on the PK and bioavailability of trospium cannot be ruled out as contributing to the increased exposures from Day 1 to Day 7.

Table 31: Trospium PK Accumulation Ratios (Day 7/Day 3; Day7/Day 1) by Treatment

[0343] FIG. 9 compares mean (± SD) trospium PK concentration-time profiles by treatment and visit (Day) for the PK Population. FIG. 10 presents mean (± SD) trospium PK trough concentrations by treatment and visit (Day) for the PK Population. Attaining a steady state was not assessed.

Example 7 - Trospium pharmacokinetics of KAR-003 compared to KAR-001 [0344] Comparing GM exposures for trospium from Day 1 of KAR-001 (first dose of trospium alone with no prior treatment) (Table 33) and Day 1 of KAR-003 (first dose of xanomeline + trospium with no prior treatment) (Table 32) shows that the trospium exposures from KAR-003 are about 2.1- to 2.5-fold higher than those obtained from KAR-001.

Although the comparison of Day 3 GM exposures between studies is not a head-to-head comparison (xanomeline dosing did not start until Day 3 in the KAR-003 study), the number of doses and a daily dose of trospium administered to subjects is the same. The Day 3 GM trospium exposures from KAR-003 (Table 32) are also ~2.4- to 3.3-fold higher than those obtained from KAR-001 (Table 33). Comparing Day 7 GM exposures for trospium for the KarXT 100/20 BID cohort (Cohort 1) from KAR-003 (Table 32) with Day 9 exposures from the xanomeline + trospium arm from KAR-001 (Table 33) indicates that exposures were once again higher (by approximately 3.5- to 4.3-fold) than those obtained from KAR-001.

[0345] The median T_max for trospium was 1.0 hour on Day 3 and Day 7 for the KarXT 100/20 BID group for KAR-003 and Day 3 and Day 9 for the xanomeline + trospium arm for KAR- 001. Median T_max for trospium was lower (1.0 hour) on Day 1 for the KarXT 50/20 BID group (KAR-003) compared to the median T_max for trospium (3.0 hours on Day 1 for the trospium alone arm (KAR-001).

[0346] Table 32 summarizes a subset of KAR-003 trospium PK parameters for the KarXT 50/20 BID treatment (all cohorts) on Day 1 and the KarXT 100/20 BID treatment Day 3 and Day 7 for the PK Population. Table 33 summarizes a subset of KAR-001 trospium PK parameters for the trospium-alone treatment on Day 1 and the xanomeline + trospium treatment on Day 3 and Day 9 for the PK Population. Table 32: Subset of KAR-003 Trospium PK Parameters for KarXT 50/20 BID (All Cohorts) on Day 1 and KarXT 100/20 BID on Days 3 and 7

Table 33: Subset of Trospium PK Parameters for KAR-001 on Days 1, 3, and 9

[0347] Table 34 lists the incidence of cholinergic TEAEs by system organ class (SOC) and preferred term for the Safety Population in the KAR-001 study. The overall subject incidence of cholinergic TEAEs was similar between the xanomeline + trospium arm (12 [34.3%] subjects) in KAR-001, the KarXT 100/20 BID group (7 [38.9%] subjects), and the KarXT 125/40 BID group (6 [33.3%] subjects).

Table 34: KAR-001 Incidence of Cholinergic Treatment-Emergent Adverse Events by System Organ Class and Preferred Term - Safety Population

[0348] Subject incidence of salivary hypersecretion, hyperhidrosis, and diarrhea was higher in the xanomeline + trospium arm in KAR-001 compared to the KarXT 100/20 BID and KarXT 125/40 BID groups. Salivary hypersecretion occurred in 25.7 % of subjects in the xanomeline + trospium arm in KAR-001, 5.6% of subjects in the KarXT 100/20 BID group, and no subjects in the KarXT 125/40 BID group. Hyperhidrosis occurred in 20.0% of subjects in the xanomeline + trospium arm in KAR-001, 5.6% of subjects in the KarXT 100/20 BID group, and 11.1% of subjects in the KarXT 125/40 BID group. Diarrhea occurred in 5.7% of subjects in the xanomeline + trospium arm in KAR-001, and no subjects in the KarXT 100/20 BID group or the KarXT 125/40 BID group.

[0349] The xanomeline + trospium arm in KAR-001 showed no other apparent trends than the KarXT 100/20 BID and KarXT 125/40 BID groups for nausea and vomiting. Nausea occurred in 17.1% of subjects in the xanomeline + trospium arm in KAR-001 and 22.2% of subjects in each KarXT 100/20 BID and KarXT 125/40 BID groups. Vomiting occurred in 5.7% of subjects in the xanomeline + trospium arm in KAR-001, 27.8% of subjects in the KarXT 100/20 BID group, and 5.6% of subjects in the KarXT 125/40 BID group.

[0350] Xanomeline and trospium were absorbed into the systemic circulation following oral administration of the KAR-003 formulation at all dosages. The PK results suggest that neither xanomeline nor trospium meaningfully impacted the PK behavior of the other drug. The KAR-003 formulation provided enhanced xanomeline and trospium blood levels compared to KAR-001, where both compounds were dosed apart.

[0351] No new safety signals were reported with the KarXT formulation. All TEAEs were mild or moderate in severity with no SAEs or deaths. Subject incidence of salivary hypersecretion, hyperhidrosis, and diarrhea was higher in the xanomeline + trospium arm in KAR-001 compared to the KarXT 100/20 BID and KarXT 125/40 BID groups in KAR-003. Example 8 - KAR-004 Phase II Study

[0352] This Phase II, randomized, double-blind, placebo-controlled, inpatient study was designed to assess the efficacy of KarXT (a fixed combination of xanomeline and trospium) versus placebo in reducing Positive and Negative Syndrome Scale (PANSS) total scores in adult inpatients with a diagnosis of schizophrenia. The five secondary objectives were to assess overall safety and tolerability of KarXT in adult inpatients with a DSM-5 diagnosis of schizophrenia, to assess spontaneously reported adverse events (AEs) in subjects treated with KarXT versus placebo, to assess spontaneously reported cholinergic symptoms in subjects treated with KarXT versus placebo, to assess orthostatic vital signs in subjects treated with KarXT versus placebo, and to assess ECG parameters in subjects treated with KarXT versus placebo.

[0353] The total study duration was up to 7 weeks, including a 7-day screening phase (up to a 7-day extension of the screening phase was allowed, if necessary), and a 5-week treatment period. Subjects were randomized in a 1:1 ratio to either KarXT or placebo group. The key inclusion and exclusion criteria for the Phase II study are shown in Table 35. The demographics and baseline characteristics of the enrolled patients are shown in Table 36. Table 35: Key Inclusion and Exclusion Criteria

Table 36: Demographics and Baseline Characteristics of the Enrolled Patients

[0354] The study employed a flexible-dose, two-arm trial with 1 : 1 randomization to KarXT or placebo with a five- week treatment period:

Days 1-2: 50/20 KarXT BID (50 mg xanomeline/ 20 mg trospium)

- Days 3-7: 100/20 KarXT BID

Days 8-35: 100/20 KarXT BID with an optional increase to 125/30 KarXT BID; titration based only on tolerability.

[0355] The primary endpoint was a change in total PANSS score from baseline versus placebo at week 5. The other endpoints included CGI, PANSS-positive and -negative subscales, PANSS Marder factor, cognitive battery, and others. A CGI-S responder is defined as a subject with a CGI-S score equal to 1 or 2. A CGI-S non-responder is defined as a subject with a CGI-S scale equal to 3 to 7. The subject required a CGI-S score of ≥ 4 at screening and baseline visits. CGI-S score legend rated 1 as normal, 2 as borderline ill, 3 as mildly ill, 4 as moderately ill, 5 as markedly ill, 6 as severely ill, and 7 as extremely ill. The safety endpoints comprised monitoring for spontaneous adverse events, orthostatic vital signs (supine and standing after 2 minutes), blood pressure (systolic and diastolic) and heart rate (beats/minute), clinical laboratory evaluations (hematology, clinical chemistry, coagulation, urinalysis, and drug screen), 12-lead ECG, physical examination, and rating suicidal ideation with the Columbia Suicide Severity Rating Scale (C-SSRS).

[0356] The Intent-to-Treat (ITT) population comprised all subjects who were randomized to the study. The Safety population comprised all subjects who received at least one dose of study medication. The Safety population was used for all analyses of safety endpoints. The modified Intent-to-Treat (mITT) population comprised all subjects who were randomized, received at least one dose of study medication, and had a baseline and at least one post- baseline PANSS assessment. The mITT population was used for all analyses of efficacy endpoints. The PK population comprised all subjects who received at least one dose of the study drug and had at least one measurable PK concentration. If any subjects were found to be noncompliant with respect to dosing, have incomplete data, or other clinical events potentially interfering with the pharmacokinetic profile, exclusion from PK analysis was determined. The Completer population comprised all mITT subjects who had a valid PANSS total score at Visit 9. The Completer population was used for sensitivity analysis of the primary efficacy endpoint. Per- Protocol (PP) population comprised all subjects who were randomized, received at least one dose of study medication, had a baseline and at least one post-baseline PANSS assessment, and had no major protocol deviations. The PP population was used for sensitivity analysis of the primary efficacy endpoint. All subjects were analyzed according to randomized treatment.

[0357] The demographics from the ITT population are shown in Table 37. There were no significant differences between the treatment groups.

Table 37: Key Demographics and Baseline Characteristics of the mITT Population

Plus-minus values are mean ± SD

[0358] For the primary endpoint, the KarXT treatment group demonstrated clinically meaningful and statistically significant improvement in total PANSS score versus placebo (FIG. 11). The subjects improved by 11.6 points compared to placebo at week 5 (p<0.0001). Statistical separation occurred at every assessment timepoint. Cohen’s d effect size was 0.75. Historically, changes as small as 5 points in the total PANSS score have been determined as efficacious for the current antipsychotics used as the standard of care.

[0359] For the secondary endpoints, the KarXT treatment group demonstrated clinically meaningful and statistically significant improvement in total PANSS-positive subscore versus placebo (FIG. 12). The subjects improved by 3.2 points compared to placebo at week 5 (p<0.0001). Statistical separation occurred at every assessment timepoint. [0360] The KarXT treatment group also demonstrated a clinically meaningful and statistically significant improvement in total PANS S -negative versus placebo (FIG. 13). The subjects improved by 2.3 points compared to placebo at week 5 (p<0.001). Statistical separation occurred at every assessment timepoint. FIG. 14 depicts the PANSS Marder Factor score of subjects in the mITT population of KAR-004 Phase II study versus Visit day.

[0361] Moreover, CGI-S showed highly significant improvements in a consistent pattern with the PANSS. The non-parametric comparison of KarXT versus placebo using the Mann- Whitney Wilcoxon test showed that CGI-S scores shifted from baseline (p<0.001). At baseline, the percentage of patients with scores 5 or 6 for KarXT compared to placebo 84% vs. 80% (FIG. 15). At the endpoint, the percentage of patients with scores rated 5-7 for KarXT compared to placebo was 33% versus 60%, and the percentage of patients rated mildly ill or better (scores rated 1, 2, or 3) for KarXT compared to placebo were 37% versus 11% (FIG. 16). Statistical separation occurred at every assessment time point (weeks 2, 4, and 5).

[0362] Overall, KarXT was safe and well-tolerated. The overall discontinuation rate on KarXT (20%) was similar to placebo (21%). The number of discontinuations due to treatment-emergent adverse events (TEAEs) was equal in the KarXT and placebo arms (n = 2 in each group). Dose escalation rate on KarXT was high and similar to placebo: 91% of KarXT subjects escalated to 125/30 KarXT (vs. 97% on placebo), 4% percent de-escalated back to 100/20 KarXT dose (vs. 1% on placebo).

[0363] Overall adverse event rate on KarXT was 54% versus 43% on placebo (Table 38):

Table 38: Adverse Events over Course of Study

Values are number (percent) of patients. SAE = serious adverse event, GGT = gamma- glutamyltransferase

[0364] The most common adverse events were constipation, nausea, dry mouth, dyspepsia, and vomiting. These adverse events represent a balance of events caused by xanomeline and events caused by trospium. For example, xanomeline alone causes sweating, nausea, vomiting, diarrhea, and excess salivation, as well as orthostasis and syncope. Trospium causes constipation, dry mouth, and stomach upset. Unlike in earlier xanomeline trials, no sweating was reported or observed.

[0365] The majority of the most common cholinergic/anticholinergic adverse events associated with KarXT treatment decreased throughout the study. Specifically, the rates of cholinergic adverse events (nausea and vomiting shown in FIG. 17) and anticholinergic adverse events (dry mouth, shown in FIG. 18) consistently decreased in the KarXT group (gray bars). By the endpoint at week 5, the rates of nausea, vomiting, and dry mouth for the KarXT were statistically indistinguishable from the placebo group's rates. The rates of constipation in the KarXT group showed less of a downward trend (data not shown). Black bars represent corresponding AE rates for the placebo group throughout the study. [0366] There was no syncope in the KarXT treated group. The mean resting orthostatic and standing heart rate increased only 4.4 bpm over placebo (FIGS. 19 and 20). The effect on heart rate was markedly lower compared to prior studies and was trending toward resolution. There was no mean change in orthostatic systolic or diastolic blood pressures (FIGS. 21 and 22). There were no notable postural effects between orthostatic and standing measurements. [0367] Somnolence, weight gain, and extrapyramidal symptoms/akathisia were similar to placebo. No significant changes were observed in the Barnes akathisia scale, Simpson-Angus scale, or the abnormal involuntary movement scale. These are the adverse events typically observed with the current standard of care. These adverse events were not manifest in KarXT treatment.

[0368] The liver enzymes in the LFT were comparable to placebo (Table 39). Two KarXT- treated patients had elevated GGT (> 2X ULN) and one placebo-treated patient with elevated ALT (> 3X ULN), AST (> 3X ULN), and GGT (> 2X ULN). Specifically, one subject discontinued due to elevated gamma-glutamyltransferase (GGT) present in the LFT.

Table 39: Adverse Events over Course of Study

Plus-minus values are mean ± SD; Abbreviations: ALT = alanine aminotransferase; AST = aspartate aminotransferase; Aik phos = alkaline phosphatase; GGT = gamma- glutamyltransferase.

[0369] One serious adverse event on KarXT was recorded — a patient discontinued and sought hospital care for worsening psychosis. Although this event met the technical definition of serious adverse events per regulation, psychosis was caused by schizophrenia, not by KarXT. The patient did not withdraw because of a symptom caused by KarXT administration. Thus, this result reflected the lack of efficacy of KarXT for one patient rather than the lack of tolerability caused by the drug making new symptoms.

[0370] This Phase 2 study showed robust antipsychotic efficacy and favorable safety /tolerability of KarXT in hospitalized patients with schizophrenia. KarXT showed early

(2 weeks) and sustained (entire 5 weeks) separation from the placebo arm on the primary efficacy measure (PANSS total) and four of the five secondary outcome measures. The safety profile consistent with prior work with KarXT combination. All but one treatment-emergent adverse event was rated mild or moderate. Most cholinergic and anticholinergic adverse events decreased throughout the study to levels statistically indistinguishable from the placebo group.

[0371] The foregoing description is given for clearness of understanding only, and no unnecessary limitations should be understood therefrom, as modifications within the scope of the disclosure may be apparent to those having ordinary skill in the art. Throughout the specification, where compositions are described as including components or materials, it is contemplated that the compositions can also consist essentially of, or consist of, any combination of the recited components or materials, unless described otherwise. Likewise, where methods are described as including steps, it is contemplated that the methods can also consist essentially of, or consist of, any combination of the recited steps, unless described otherwise. The disclosure illustratively disclosed herein suitably may be practiced in the absence of any element or step which is not specifically disclosed herein.

[0372] The practice of a method disclosed herein, and individual steps thereof, can be performed manually and/or with the aid of or automation provided by electronic equipment. Although processes have been described with reference to embodiments, a person of ordinary skill in the art will readily appreciate that other ways of performing the acts associated with the methods may be used. For example, the order of various of the steps may be changed without departing from the scope or spirit of the method, unless described otherwise. In addition, some of the individual steps can be combined, omitted, or further subdivided into additional steps.

[0373] It is appreciated that certain features of the invention, which are, for clarity, described in the context of separate embodiments, may also be provided in combination in a single embodiment. Conversely, various features of the invention, which are, for brevity, described in the context of a single embodiment, may also be provided separately or in any suitable subcombination. All combinations of the embodiments pertaining to the chemical groups represented by the variables contained within the generic chemical formulae described herein are specifically embraced by the present invention just as if each and every combination was individually explicitly recited, to the extent that such combinations embrace stable compounds (i.e., compounds that can be isolated, characterized and tested for biological activity). In addition, all subcombinations of the chemical groups listed in the embodiments describing such variables, as well as all subcombinations of uses and medical indications described herein, are also specifically embraced by the present invention just as if each and every subcombination of chemical groups and subcombination of uses and medical indications was individually and explicitly recited herein.

[0374] All patents, publications and references cited herein are hereby fully incorporated by reference. In case of conflict between the present disclosure and incorporated patents, publications and references, the present disclosure should control.

Claims

CLAIMS What is claimed is:

1. A method of treating schizophrenia or a disease related to schizophrenia in a patient in need thereof, the method comprising: orally administering to the patient twice daily an oral pharmaceutical composition comprising a plurality of xanomeline beads comprising xanomeline or a salt thereof, and plurality of trospium beads comprising a salt of trospium, via a titration scheme that comprises up-titration of the xanomeline, or a salt thereof, and the salt of trospium.

2. A method of treating schizophrenia or a disease related to schizophrenia in a patient in need thereof, the method comprising: orally administering to the patient for at least five weeks twice daily an oral pharmaceutical composition comprising a plurality of xanomeline beads comprising xanomeline or a salt thereof, and plurality of trospium beads comprising a salt of trospium, wherein at least one adverse event which occurred at the start of oral administration is reduced to its pretreatment level after five weeks of treatment.

3. The method of claim 1 or 2, wherein the administration occurs via a titration scheme that comprises up-titration of the xanomeline, or the salt thereof, and the salt of trospium until an amount equivalent to 125 mg xanomeline free base and an amount equivalent to 30 mg trospium chloride is administered twice daily.

4. The method of claim 1 or 2, wherein the administration occurs via a titration scheme that comprises up-titration of the xanomeline, or the salt thereof, and the salt of trospium until an amount equivalent to 150 mg xanomeline free base and an amount equivalent to 30 mg trospium chloride is administered twice daily.

5. The method of claim 1 or 2, wherein the administration occurs via a titration scheme that comprises up-titration of the xanomeline, or the salt thereof, and the salt of trospium until an amount equivalent to 175 mg xanomeline free base and an amount equivalent to 30 mg trospium chloride is administered twice daily.

6. The method of claim 1 or 2, wherein the administration occurs via a titration scheme that comprises up-titration of the xanomeline, or the salt thereof, and the salt of trospium until an amount equivalent to 175 mg xanomeline free base and an amount equivalent to 40 mg trospium chloride is administered twice daily.

7. The method of any one of the proceeding claims, wherein the patient has a diagnosis of schizophrenia.

8. The method of any one of the proceeding claims, wherein prior to administration of the oral pharmaceutical composition, the patient had a Clinical Global Impression Severity Scale (CGI-S) score of 4-7, and after administration the patient had a CGI-S score equal to 1 or 2.

9. The method of any one of the proceeding claims, wherein the xanomeline, or the salt thereof, is administered for a first period in a first amount and then the first amount is increased to a second amount.

10. The method of claim 9, wherein the first amount of xanomeline, or the salt thereof, is equivalent to 50 mg xanomeline free base.

11. The method of claim 9 or 10, wherein the first period for the xanomeline administration is between 1 and 5 days.

12. The method of claim 11, wherein the first period for the xanomeline administration is 2 days.

13. The method of any one of claims 9 to 12, wherein the second amount of xanomeline, or the salt thereof, is equivalent to 100 mg xanomeline free base.

14. The method of any one of claims 9 to 13, further comprising administering the xanomeline, or the salt thereof, for a second period in the second amount and then increasing the second amount to a third amount.

15. The method of claim 14, wherein the second period for xanomeline administration is between three days and a week.

16. The method of claim 14 or 15, wherein the third amount of xanomeline, or the salt thereof, is equivalent to 125 mg xanomeline free base.

17. The method of any of the preceding claims, wherein the salt of trospium is administered for a first time period in a first amount and the first amount is increased to a second amount.

18. The method of claim 17, wherein the first amount of the salt of trospium is equivalent to 20 mg trospium chloride.

19. The method of claim 17 or 18, wherein the first time period for trospium administration is at least a week.

20. The method of any one of claims 15 to 17, wherein the second amount of the salt of trospium is equivalent to 30 mg trospium chloride.

21. The method of any one of the preceding claims, at least one of vomiting, nausea and dry mouth which occurred at the start of oral administration is reduced to its pretreatment level after five weeks of treatment.

22. The method of any one of the preceding claims, wherein the xanomeline, or the salt thereof, and the salt of trospium are administered without inducing a heart rate increase of more than about 5 beats per minute.

23. The method of any one of the preceding claims, wherein the xanomeline, or the salt thereof, and the salt of trospium are administered without inducing syncope.

24. The method of any one of the preceding claims, wherein the xanomeline, or the salt thereof, and the salt of trospium are administered without inducing a change in diastolic blood pressure of more than about 5 mmHg.

25. The method of any one of the preceding claims, wherein the xanomeline, or the salt thereof, and the salt of trospium are administered without inducing a change in systolic blood pressure of more than about 5 mmHg.

26. The method of any one of the preceding claims, wherein the xanomeline, or the salt thereof, and the salt of trospium are administered without causing a severe adverse event.

27. The method of any one of the preceding claims, wherein the xanomeline, or the salt thereof, and the salt of trospium are administered without causing a severe adverse event related to heart rate.

28. The method of any one of the preceding claims, wherein the xanomeline, or the salt thereof, and the salt of trospium are administered without causing a severe adverse event related to heart rate change.

29. The method of any one of the preceding claims, wherein the xanomeline, or the salt thereof, and the salt of trospium are administered without causing a severe adverse event related to blood pressure.

30. The method of any one of the preceding claims, wherein the xanomeline, or the salt thereof, and the salt of trospium are administered without causing a severe adverse event related to blood pressure change.

31. The method of any one of the preceding claims, wherein the xanomeline, or the salt thereof, and the salt of trospium are administered without increasing a liver function test (LFT).

32. The method of any one of the preceding claims, wherein the Positive and Negative Syndrome Scale (PANSS) total score for the patient decreases by at least 10 points compared to placebo after five weeks of treatment.

33. The method of any one of the preceding claims, wherein the PANSS positive subscore decreases by at least 3 points compared to placebo after five weeks of treatment.

34. The method of any one of the preceding claims, wherein the PANSS negative subscore decreases by at least 2 points compared to placebo after five weeks of treatment.

35. The method of any one of the preceding claims, wherein the size of the xanomeline beads is between 0.425 mm and 1.18 mm.

36. The method of any one of the preceding claims, wherein the size of the xanomeline beads is between 0.6 mm and 0.85 mm.

37. The method of any one of the preceding claims, wherein the size of the trospium beads is between 0.425 mm and 1.18 mm.

38. The method of any one of the preceding claims, wherein the size of the trospium beads is between 0.6 mm and 0.85 mm.

39. The method of any one of the preceding claims, wherein the xanomeline beads contain about 2.5 times as much xanomeline free base as the trospium beads contain trospium salt.

40. The method of any one of the preceding claims, the plurality of xanomeline and the plurality of trospium beads having a dissolution rate of more than about 95% within about the first 45 minutes following entry of the dosage form into an aqueous solution.

41. The method of claim 40, having a dissolution rate of more than about 95% within about the first 20 minutes following entry of the dosage form into an aqueous solution.

42. The method of any one of the preceding claims, wherein the salt of xanomeline is xanomeline tartrate.

43. The method of claim 42, wherein the xanomeline beads comprise between 30 wt.% and 80 wt.% xanomeline tartrate.

44. The method of any claim 43, wherein the xanomeline beads comprise 66 wt.% xanomeline tartrate.

45. The method of any one of the preceding claims, wherein the xanomeline beads comprise between 15 wt.% and 65 wt.% microcrystalline cellulose.

46. The method of claim 45, wherein the xanomeline beads comprise 33.5 wt.% microcrystalline cellulose.

47. The method of any one of the preceding claims, wherein the xanomeline beads comprise between 0 wt.% and 2 wt.% talc.

48. The method of claim 46, wherein the xanomeline beads comprise 0.5 wt.% talc.

49. The method of any one of the preceding claims, wherein the xanomeline beads comprise between 30 wt.% and 80 wt.% xanomeline tartrate, between 15 wt.% and 65 wt.% microcrystalline cellulose, and between 0 wt.% and 2 wt.% talc.

50. The method of claim 49, wherein the xanomeline beads comprise 66 wt.% xanomeline tartrate, 33.5 wt.% microcrystalline cellulose, and 0.5 wt.% talc.

51. The method of any one of the preceding claims, wherein the salt of trospium is trospium chloride.

52. The method of claim 51, wherein the trospium beads comprise between 8 wt.% and 35 wt.% trospium chloride.

53. The method of claim 52, wherein the trospium beads comprise 17.7 wt.% trospium chloride.

54. The method of any one of the preceding claims, wherein the trospium beads comprise between 25 wt.% and 80 wt.% microcrystalline cellulose.

55. The method of claim 54, wherein the trospium beads comprise 46.8 wt.% microcrystalline cellulose.

56. The method of any one of the preceding claims, wherein the trospium beads comprise between 15 wt.% and 70 wt.% lactose monohydrate.

57. The method of claim 56, wherein the trospium beads comprise 35 wt.% lactose monohydrate.

58. The method of any one of the preceding claims, wherein the trospium beads comprise between 0 wt.% and 2 wt.% talc.

59. The method of claim 58, wherein the trospium beads comprise 0.5 wt.% talc.

60. The method of any one of the preceding claims, wherein the trospium beads comprise between 8 wt.% and 35 wt.% trospium chloride, between 25 wt.% and 80 wt.% microcrystalline cellulose, between 15 wt.% and 70 wt.% lactose monohydrate, and between 0 wt.% and 2 wt.% talc.

61. The method of claim 60, wherein the trospium beads comprise 17.7 wt.% trospium chloride, 46.8 wt.% microcrystalline cellulose, 35 wt.% lactose monohydrate, and 0.5 wt.% talc.

62. The method of any one of the preceding claims, wherein the oral pharmaceutical composition further comprises ascorbic acid.

63. The method of claim 62, wherein the oral pharmaceutical composition comprises between 0.2 wt.% and 1 wt.% ascorbic acid.

64. The method of claim 63, wherein the oral pharmaceutical composition comprises about 0.5 wt.% ascorbic acid.

65. The method of any one of the preceding claims, wherein the oral pharmaceutical composition further comprises butylated hydroxytoluene.

66. The method of claim 64, wherein the oral pharmaceutical composition comprises between 0.01 wt.% and 0.1 wt.% butylated hydroxytoluene.

67. The method of claim 66, wherein the oral pharmaceutical composition comprises about 0.05 wt.% butylated hydroxytoluene.

68. The method of any one of the preceding claims, wherein the oral pharmaceutical composition further comprises a capsule containing the plurality of xanomeline beads and the plurality of trospium beads.

69. A method of treating acute psychosis in a patient in need thereof, the method comprising: orally administering to the patient twice daily an oral pharmaceutical composition comprising xanomeline or a salt thereof, and a salt of trospium, to achieve at least a 10 point mean reduction in total Positive and Negative Syndrome Scale (PANSS) score compared to placebo.

70. The method of claim 69, wherein at least an 11.6 point mean reduction in total PANNS score is achieved.

71. The method of any claim 69 or 70, wherein at least a 3 point mean reduction in PANSS positive subscore compared to placebo is achieved.

72. The method of any one of claims 69 to 71, wherein at least a 2 point reduction in the PANSS negative subscore compared to placebo is achieved.

73. The method of any one of claims 69 to 72, wherein the reduction in PANSS score is achieved within about 5 weeks.

74. The method of any one of claims 69 to 73, wherein before administration of the oral pharmaceutical composition, the patient had a Clinical Global Impression Severity Scale (CGI- S) score of 4-7, and after administration, the patient had a CGI-S score equal to 1 or 2.

75. The method of any one of claims 69 to 74, wherein the patient has a diagnosis of schizophrenia.

76. The method of any one of claims 69 to 75, wherein the xanomeline is xanomeline tartrate and the salt of trospium is trospium chloride.

77. The method of any one of claims 69 to 76, at least one adverse event which occurred at the start of oral administration is reduced to its pretreatment level after five weeks of treatment.

78. The method of claim 77, wherein at least one adverse event is chosen from vomiting, nausea and dry mouth.