WO2023031116A1

WO2023031116A1 - Pharmaceutical combination comprising vitamin d and vortioxetine for sequential administration

Info

Publication number: WO2023031116A1
Application number: PCT/EP2022/073942
Authority: WO
Inventors: Anne-Cecile V. Bayne; Igor Bendik; Hubert Paul HUG; Giorgio LA FATA; Araksya TOPCHYAN
Original assignee: Dsm Ip Assets B.V.
Priority date: 2021-08-31
Filing date: 2022-08-29
Publication date: 2023-03-09

Abstract

The presence of vitamin D is necessary for vortioxetine to exert its effects. Thus, when assessing the added benefit of vortioxetine in comparison with another therapy ("comparator therapy"), vitamin D deficient subjects should be excluded.The present invention relates to a 2-step treatment, wherein vitamin D is preferably administered first. Oral administration of vortioxetine hydrobromide is initiated afterwards, preferably when the calcifediol blood concentration of the patient has reached at least 50 nmol/L or preferably at least 75 nmol/L. Thus, vitamin D and vortioxetine are administered sequentially.The preferred pharmaceutical combination of the invention is suitable for sequential administration and comprises preferably vortioxetine hydrobromide and vitamin D or a metabolite thereof.

Description

Pharmaceutical combination comprising vitamin D and vortioxetine for sequential administration

Technical field

The present invention relates to the treatment of patients suffering from major depressive disorder (MDD). It also relates to personalized medicine.

Background of the invention

Trintellix® is an FDA approved medical drug comprising vortioxetine hydrobromide. Commercially available Trintellix® tablets comprise 5 mg, 10 mg, 15 mg, or 20 mg vortioxetine (as hydrobromide). Trintellix® is mostly used for treatment of depression. In some European countries, a corresponding product is or was available as Brintellix®. Similar to Trintellix®, Brintellix® can only be obtained with a prescription and is available as tablets (5, 10, 15 and 20 mg) and oral drops (20 mg/ml). The most common side effects reported with vortioxetine are nausea, diarrhea, dry mouth, constipation, vomiting, flatulence, dizziness, and sexual dysfunction.

To study mood, depression, and anxiety in rats or mice, several behavioral assays have been developed. The forced swim test (FST) measures the presence of or reduction in positive coping skills in rats and mice. When animals are treated with an effective anti-depressant prior to the test, they show reduced immobility and more climbing, suggesting that the animals do not give up, while untreated animals show increased immobility and will float more in the water. Therefore, reduced immobility and more climbing is thought to be an anti-depressive, positive coping phenotype in the FST. Guilloux et al. (2013) have found that vortioxetine (2.5-5 mg/kg) increased mobility in the FST [see Guilloux, J. P. et al., “Antidepressant and anxiolytic potential of the multimodal antidepressant vortioxetine (Lu AA21004) assessed by behavioural and neurogenesis outcomes in mice” Neuropharmacology, 73, 147-159, 2013],

The German G-BA (“Gemeinsamer Bundesauschuss”) evaluates the additional benefit of drugs with new active ingredients compared to a comparative therapy. Such benefit assessment is done in accordance with Section 35a of the German Social Code, Book V (known as the AMNOG procedure). The result of this benefit assessment is the starting point for price negotiations between the National Association of Statutory Health Insurance Funds (“GKV- Spitzenverband”) and the pharmaceutical manufacturer. At the end of the negotiations, it is determined how much the statutory health insurance will pay for the drug in the future.

In Germany, the benefit assessment of vortioxetine has been rather negative. As a result, the originator company appears to have withdrawn Brintellix® from the German market.

Whereas vortioxetine surely is an effective drug, there is a need for an improved vortioxetine therapy. Summary of the invention

Surprisingly, the presence of vitamin D is necessary for vortioxetine to exert its effects. Thus, when assessing the added benefit of vortioxetine in comparison with another therapy (“comparator therapy”), vitamin D deficient subjects should be excluded.

The present invention relates to a 2-step treatment, wherein vitamin D is preferably administered first. Oral administration of vortioxetine is initiated afterwards, preferably when the calcifediol blood concentration of the patient has reached at least 50 nmol/L or preferably at least 75 nmol/L. In such 2-step treatment, vortioxetine and a vitamin D are administered sequentially.

The present invention relates to a pharmaceutical combination that is suitable for sequential administration. A preferred pharmaceutical combination of the invention is a free combination (i.e., not a fixed combination) that comprises: i) vitamin D, and ii) vortioxetine or a pharmaceutically acceptable salt thereof.

The present invention also relates to a method of treatment, wherein a patient's insufficient vitamin D level is raised before initiating or re-initiating the vortioxetine treatment.

In one embodiment of the invention, a patient's vitamin D level is raised very quickly by intravenous or intramuscular injection of vitamin D. Thereby, intramuscular injection of vitamin D3 and/or vitamin D2 is preferred. Soon after injection, vortioxetine administration can then be initiated.

A patient's vitamin D level can also be raised by oral vitamin D supplementation. However, with most kinds of vitamin D, it can take months for the body to reach optimal vitamin D levels. As a result, the beginning of the vortioxetine treatment is delayed. For oral administration, calcifediol is therefore preferred. Calcifediol is a vitamin D metabolite that is about 3x faster and more effective than other kinds of vitamin D. For human consumption, calcifediol is commercially available under the tradename ampli-D® at DSM® Nutritional Products (Switzerland).

Figures

Figures 1 and 2 relate to Example 1 (vide infra).

Figure 1 shows a lack of effects of acute vortioxetine treatment in the forced swim test (FST) in male Balb/cJ mice that were vitamin D deficient. Vortioxetine was dosed at 5 mg/kg bw at 24, 6 and 1 hours before the FST. The immobility time in seconds [s] is shown and is expressed as means ± SE (standard error). The experiment duration was 6 minutes. In the control group, a vehicle was applied. Surprisingly, vortioxetine has no positive effect in vitamin D deficient mice. Despite of vortioxetine treatment, immobility time is about as long as in the control group. Figure 2 shows effects of acute vortioxetine treatment in the forced swim test (FST) in male Balb/cJ mice that were vitamin D deficient. Vortioxetine (5 mg/kg bw) alone or in combination with vitamin D at 0.05 (low) or 0.10 (high) mg/kg bw was given at 24, 6 and 1 hours prior to the FST. The immobility time was recorded and the data in seconds [s] is expressed as means ± SE (standard error). The experiment duration was 6 minutes. Significance (*) of p< 0.05 was tested using one-way RM ANOVA with Tukey’s post-hoc analysis. Figure 2 shows that in vitamin D deficient mice, vortioxetine has a positive effect if vitamin D is co-administered.

Figures 3 and 4 relate to Example 2 (vide infra). Figure 3 shows a lack of effects of acute vortioxetine treatment on cerebral blood flow (CBF) in male Balb/cJ mice that were vitamin D deficient. Vortioxetine was dosed at 5 mg/kg bw at 24, 6 and 1 hours before the CBF. In the control group, a vehicle was applied. The mean percentage above baseline ± SE (standard error) is shown. Trial time post dipyridamole injection lasted for 10 minutes. It is surprising that vortioxetine has no effect on CBF in vitamin D deficient mice.

Figure 4 shows also effects of acute vortioxetine treatment in combination with different doses of vitamin D on cerebral blood flow (CBF) in male Balb/cJ mice that were vitamin D deficient. Vortioxetine (5 mg/kg bw) alone or in combination with vitamin D at 0.05 (low) or 0.10 (high) mg/kg bw was given at 24, 6 and 1 hours priorto the CBF measurement. The mean percentage above baseline ± SE (standard error) is shown. Trial time post dipyridamole injection lasted for 10 minutes. Significance (*) of p<0.05 was tested using one-way RM ANOVA with Tukey’s post- hoc analysis. Figure 4 shows that in vitamin D deficient mice, vortioxetine has only an effect on CBF, if vitamin D is co-administered.

Figure 5 relates to Example 3 (vide infra) and shows effects of acute vortioxetine treatment in the forced swim test (FST) in male Balb/cJ mice that were vitamin D deficient. Vortioxetine (5 mg/kg bw) alone or in combination with calcifediol at 0.025 mg/kg bw was given at 24, 6 and 1 hours prior to the FST. The immobility time was recorded and the data in seconds [s] is expressed as means ± SE (standard error). The experiment duration was 6 minutes. Significance (*) of p< 0.05 was tested using one-way RM ANOVA with Tukey’s post-hoc analysis. A comparison of Figure 5 with Figure 2 shows that the selected vitamin D metabolite (calcifediol) is even more effective than vitamin D3.

Figure 6 relates to Example 3 (vide infra) and shows effects of acute vortioxetine treatment in combination with different doses of vitamin D on cerebral blood flow (CBF) in male Balb/cJ mice that were vitamin D deficient. Vortioxetine (5 mg/kg bw) alone or in combination with vitamin D at 0.05 or 0.10 mg/kg bw, or in combination with calcifediol at 0.025 or 0.050 mg/kg bw, was given at 24, 6 and 1 hours prior to the CBF measurement. The mean percentage above baseline ± SE (standard error) is shown. Trial time post dipyridamole injection lasted for 10 minutes. Significance (*) of p<0.05 was tested using one-way RM ANOVA with Tukey’s post-hoc analysis. Detailed description of the invention

Hitherto, every vortioxetine patient has been treated in the same manner - regardless of his or her vitamin D status. However, to be effective, vortioxetine requires a certain amount of vitamin D in the body of the patient.

Patients who lack vitamin D are less likely to sufficiently respond to a vortioxetine treatment. Thus, vortioxetine therapy can be improved by raising the vitamin D level of the patient (step 1) before initiating or re-initating the vortioxetine treatment (step 2).

Definitions

In the context of the present invention, the term “vortioxetine” refers to vortioxetine or a pharmaceutically acceptable salt thereof. Thus, the term “vortioxetine” is to be understood in a broad manner. Preferably, the term “vortioxetine” refers to a pharmaceutically acceptable salt of vortioxetine. Most preferably, the term “vortioxetine” refers to vortioxetine hydrobromide.

In the context of the present invention, the term “vitamin D” refers to any kind of vitamin D, including all vitamers of vitamin D and also including metabolites of all vitamers of vitamin D. A vitamin D metabolite is thereby a molecule that is either a precursor, an intermediate or the final, physiologically modified product of the vitamin D pathway in the human body. Thus, in the context of the present invention, the term “vitamin D” is to be understood in a very broad manner. Preferably, the term “vitamin D” refers to D3 (cholecalciferol), vitamin D2 (ergocalciferol), to a vitamin D metabolite or a mixture thereof. More preferably, the term “vitamin D” refers to vitamin D3 (cholecalciferol), vitamin D2 (ergocalciferol) or a mixture thereof. The most preferred vitamin D metabolite is calcifediol (25-hydroxyvitamin D3, also referred to as "25-OH D3"). Thus, in an also preferred embodiment, the term “vitamin D” refers to calcifediol. Alternative vitamin D metabolites are 1 -alpha, 25-vitamin D3 and 1 -alpha, 25-vitamin D2.

Patent claims relating to a “pharmaceutical combination” are product claims. A “pharmaceutical combination for simultaneous administration” is a combination that is suitable for simultaneous administration. By "simultaneous administration", it is meant that vitamin D and vortioxetine are administered on the same day. Said two active ingredients can be administered at the same time (for fixed combinations) or one at a time (for free combinations).

A “fixed combination” is a pharmaceutical combination that delivers both actives (i.e., vitamin D and vortioxetine) at the same time to a patient. A solid oral dosage form (e.g. a tablet) comprising both, vitamin D and vortioxetine, is an example of a fixed combination. A liquid oral dosage form (e.g. oral drops) comprising both, vitamin D and vortioxetine, is another example of a fixed combination.

A “free combination” is a pharmaceutical combination that allows to administer both actives (i.e., vitamin D and vortioxetine) separately, i.e. one at a time. Treatment regimens in which vortioxetine and vitamin D are not administered by the same route of administration and/or are not administered at the same time require free combinations. A “kit” is a set of articles or equipment needed for a specific purpose. The preferred kit of the invention comprises the herein described free combination and optionally a package leaflet. Package leaflets often contain instructions.

A “pharmaceutical combination for sequential administration” is a combination that is suitable for sequential administration. By "sequential administration", it is meant that during a period of two or more days of continuous treatment, only one of vortioxetine and vitamin D is administered on any given day. By way of example, a patient's vitamin D deficiency may be treated first (i.e., before initiating the vortioxetine treatment). Vortioxetine treatment then starts afterwards. Sequential administration requires a free combination.

Fixed combinations are not suitable for sequential administration. In comparison, free combinations are more versatile: they are suitable for sequential administration and - if both actives are administered on the same day - also for simultaneous administration.

Fixed combinations are suitable for simultaneous administration if both actives (i.e., vortioxetine and vitamin D) are to be administered at the same time of the same day. However, if vortioxetine and vitamin D are to be administered on the same day but one at a time, fixed combinations are not suitable.

By "separate administration", it is meant that vitamin D and vortioxetine are administered one at a time. Thus, separate administration can referto both, sequential administration and - when referring to the administration of both actives on the same day but one at a time - also to simultaneous administration.

A “patient” is a human subject who is in need of medical advice and/or is suffering from a disease. In the context of the present invention, a “patient” is preferably a human subject that is in need of pharmaceutical drug. More preferably, it is a human subject that in need of vortioxetine or a pharmaceutically acceptable salt thereof.

For human beings, vitamin D is essential. In that sense, everybody needs vitamin D. However, this is not what is meant by the expression “in need of vitamin D”. A patient who is “in need of vitamin D” is a patient whose vitamin D level is below the recommendation limit of a governmental or non-governmental medical organization. The recommendation limit of the Institute of Medicine (IOM) is 50 nmol calcifediol per liter blood. The recommendation limit the medical ‘Endocrine Society’ association is 75 nmol/L calcifediol per liter blood. Thus, a patient who is “in need of vitamin D” is preferably a patient whose calcifediol blood concentration is lower than 75 nmol/L or is lower than 50 nmol/L. A patient who is in need of vitamin D benefits from vitamin D supplementation (e.g. oral vitamin D supplementation). A patient whose vitamin D level is in a healthy range is not in need of vitamin D supplementation. A patient whose calcifediol blood concentration is 75 nmol/L or more is not in need of vitamin D supplementation.

A patient who is “vitamin D insufficient” has a calcifediol blood concentration preferably lower than 50 nmol/L. A patient who is “vitamin D deficient” has a calcifediol blood concentration preferably lower than 30 nmol/L. In case of a calcifediol blood concentration lower than 10 nmol/L, the patient is severely vitamin D deficient.

A “vortioxetine non-responder” is a patient who is in need of an antidepressant treatment but shows no positive response to the vortioxetine treatment. Preferably, “no positive response to vortioxetine treatment” means that a daily dosage of 20 mg vortioxetine (as hydrobromide) does not relieve the patient's symptoms.

A “vortioxetine low-responder” is a patient who is in need of an antidepressant treatment but shows poor response to vortioxetine treatment. Preferably, “poor response to vortioxetine treatment” means that a daily dosage of 10 mg or 15 mg vortioxetine (as hydrobromide) does not relieve the patient's symptoms. Vortioxetine non-responders may also be considered as vortioxetine low-responders. However, not every vortioxetine low-responder is necessarily also a vortioxetine non-responder. A not sufficient vitamin D level is believed to be a reason for being a vortioxetine non-responder or a vortioxetine low-responder.

Vitamin D

The herein disclosed pharmaceutical combination comprises vitamin D. Several kinds (vitamers) of vitamin D exist. The two major vitamers are vitamin D3and vitamin D2. Thus, a preferred pharmaceutical combination of the present invention comprises vitamin D3, vitamin D2 or a mixture thereof. In the context of the present invention, there is no reason for mixing vitamin D3 with vitamin D2. Thus, the pharmaceutical combination of the present invention comprises more preferably either vitamin D3 or vitamin D2, but not a mixture thereof.

Calcifediol is a vitamin D metabolite, more specifically a vitamin D3 metabolite. In the human body, calcifediol is the most abundant vitamin D metabolite. When determining a patient's vitamin D status (i.e. level), it is common to measure the concentration of calcifediol directly or indirectly in a sample of the patient's blood. Calcifediol for human consumption is commercially available as ampli-D® (DSM® Nutritional Products, Switzerland). Calcifediol is also available as Rayladee® (OPKO Health, Miami, FL) and as Hidroferol® oral solution (Faes Farma, S.A., Spain). When orally administered, calcifediol has excellent bioavailability and hence, is better absorbed by the body. This helps reaching optimal vitamin D levels faster. Thus, in an also preferred embodiment, the pharmaceutical combination of the present invention comprises at least one vitamin D metabolite, preferably at least one vitamin D3 metabolite and most preferably calcifediol.

Without wishing to be bound by theory, it is believed that calcifediol is improving vortioxetine treatment more effectively because a metabolic step can be skipped in the patient's body: whereas most kinds of vitamin D first need to be hydroxylated in the liver at position 25, this is not needed if calcifediol is administered.

Although there is no need to do so, a mixture comprising vitamin D and a metabolite thereof could be used. Thus, an alternative embodiment of the present invention relates to a pharmaceutical combination comprising vitamin D2 and at least one vitamin D metabolite, or vitamin D3 and at least one vitamin D metabolite, or vitamin D2, vitamin D3 and at least one vitamin D metabolite. Thereby, calcifediol is the preferred vitamin D metabolite.

Vortioxetine

The herein disclosed pharmaceutical combination comprises vortioxetine. Several kinds of vortioxetine exist, including pharmaceutically acceptable salts of vortioxetine. Most if not all commercially available products comprise a pharmaceutically acceptable salt of vortioxetine. Commercially available, solid mono-preparations comprise vortioxetine hydrobromide.

The purpose of the present invention is to improve existing vortioxetine treatments. In consideration thereof, pharmaceutically acceptable salts of vortioxetine are preferred. Vortioxetine hydrobromide is the most preferred pharmaceutically acceptable salt of vortioxetine. However, in case of liquid oral dosage forms, vortioxetine (D.L)-lactate is the preferred pharmaceutically acceptable salt of vortioxetine.

Pharmaceutical combination comprising vortioxetine and vitamin D

The preferred pharmaceutical combination of the present invention comprises vortioxetine and vitamin D and is suitable for sequential administration. Pharmaceutical combinations that are suitable for sequential administration are in most (if not all) cases free combinations. The present invention also relates to kits comprising such free combinations.

The pharmaceutical combination of the invention comprises vortioxetine and vitamin D. Regarding vortioxetine, the above-mentioned preferences apply. Thus, the herein disclosed pharmaceutical combination comprises preferably a pharmaceutically acceptable salt of vortioxetine, wherein said pharmaceutically acceptable salt of vortioxetine is preferably vortioxetine hydrobromide (with the proviso that it is not a liquid oral dosage from). Regarding vitamin D, the above-mentioned preferences also apply. Thus, the herein disclosed pharmaceutical combination comprises preferably vitamin D3 or a pharmaceutically acceptable metabolite thereof being preferably calcifediol.

A preferred pharmaceutical combination for sequential administration comprises a pharmaceutically acceptable salt of vortioxetine and vitamin D3, wherein said pharmaceutically acceptable salt of vortioxetine is preferably vortioxetine hydrobromide. An also preferred pharmaceutical combination for sequential administration comprises a pharmaceutically acceptable salt of vortioxetine and calcifediol, wherein said pharmaceutically acceptable salt of vortioxetine is preferably vortioxetine hydrobromide. An alternative pharmaceutical combination for sequential administration comprises a pharmaceutically acceptable salt of vortioxetine and vitamin D2, wherein said pharmaceutically acceptable salt of vortioxetine is preferably vortioxetine hydrobromide. In a not preferred embodiment, the pharmaceutical combination of the present invention comprises vortioxetine and a mixture of various kinds of vitamin D such as a mixture comprising vitamin D2 and D3, or a mixture comprising vitamin D2 and calcifediol, or a mixture comprising vitamin D3 and calcifediol. Also not preferred are pharmaceutical combinations comprising vortioxetine base instead of a pharmaceutically acceptable salt of vortioxetine.

Most often, intramuscular (i.m.) or intravenous (i.v.) injections are more effective and efficient than orally consumed supplements (e.g. in pill form). Vitamin D i.m. or i.v. injections are therefore recommended if someone's vitamin D level is low (e.g., a calcifediol blood concentration of less than 30 nmol/L) or even very low (e.g., a calcifediol blood concentration of less than 20 nmol/L). Vortioxetine, on the other hand, is almost never injected. In situations like this, relating to different routes of administration, free combinations are preferred or even needed.

One embodiment of the invention relates to a pharmaceutical combination that is suitable for sequential administration, wherein said pharmaceutical combination is a free combination that comprises i) at least one injectable liquid which comprises vitamin D, and ii) at least one oral dosage form which comprises vortioxetine or a pharmaceutically acceptable salt thereof, and wherein said vitamin D is preferably vitamin D3. Intramuscular or intravenous injection of calcifediol is not preferred. Unless the at least one oral dosage form is a liquid oral dosage form, the preferred pharmaceutically acceptable salt of vortioxetine is also in this embodiment vortioxetine hydrobromide.

The present invention also relates to a kit that comprises i) at least one injectable liquid which comprises vitamin D, and ii) at least one oral dosage form which comprises vortioxetine or a pharmaceutically acceptable salt thereof, and wherein said vitamin D is preferably vitamin D3. A preferred kit of the invention comprises means for a vitamin D injection (e.g., a pre-filled syringe or a vial) and at least one oral dosage form which comprises vortioxetine hydrobromide. Optionally, such kit may further comprise instructions for sequential administration. Instructions for sequential administration can also be found in a Summary of Product Characteristics (SmPC) or in relevant guidelines.

Above embodiments relating to vitamin D injections are suitable to illustrate the concept of a free combination. However, the free combination of the present invention is not limited to these embodiments.

An also preferred embodiment of the present invention relates to a pharmaceutical combination for sequential administration, wherein said pharmaceutical combination is a free combination that comprises i) at least one oral dosage form which comprises vitamin D, and ii) at least one oral dosage form which comprises vortioxetine or a pharmaceutically acceptable salt thereof, and wherein said vitamin D is preferably vitamin D3, vitamin D2, at least one vitamin D metabolite or a mixture thereof, and wherein said at least one vitamin D metabolite is preferably calcifediol.

It goes without saying that each of the two at least one oral dosage forms comprise either vitamin D or vortioxetine, but not a combination thereof. If any of the two at least one oral dosage forms comprised both actives, the pharmaceutical combination would no longer be a free combination (i.e., would no longer be suitable for sequential administration).

Oral dosage forms comprising vitamin D may be liquid or solid. Oral dosage forms comprising vortioxetine may also be liquid or solid. One embodiment of the present invention relates to the herein described pharmaceutical combination for sequential administration, wherein said pharmaceutical combination is a free combination that comprises at least one solid oral dosage form and at least one liquid oral dosage form.

A preferred embodiment of the present invention relates to a pharmaceutical combination for sequential administration, comprising at least one solid oral dosage form and at least one liquid oral dosage form, wherein said at least one solid oral dosage form comprises vitamin D3 and wherein said at least one liquid oral dosage form comprises a pharmaceutically acceptable salt of vortioxetine (or vice versa). An also preferred embodiment of the present invention relates to a pharmaceutical combination for sequential administration, comprising at least one solid oral dosage form and at least one liquid oral dosage form, wherein said at least one solid oral dosage form comprises calcifediol and wherein said at least one liquid oral dosage form comprises a pharmaceutically acceptable salt of vortioxetine (or vice versa). An alternative embodiment of the present invention relates to a pharmaceutical combination for sequential administration, comprising at least one solid oral dosage form and at least one liquid oral dosage form, wherein said at least one solid oral dosage form comprises vitamin D2 and wherein said at least one liquid oral dosage form comprises a pharmaceutically acceptable salt of vortioxetine (or vice versa).

Brintellix® solution (oral drops, 20 mg/ml) is a commercially available liquid oral dosage form of vortioxetine. Each drop contains vortioxetine (D.L)-lactate equivalent to 1 mg vortioxetine. Thus, in case of a liquid oral dosage form of vortioxetine, vortioxetine (D.L)-lactate is the preferred pharmaceutically acceptable salt of vortioxetine.

Preferred oral dosage forms comprise in addition to vitamin D or vortioxetine also at least one pharmaceutically acceptable excipient, wherein said at least one pharmaceutically acceptable carrier. By way of example, a drop of Brintellix® solution contains 4.25 mg ethanol as pharmaceutically acceptable excipient.

Preferred materials which can serve as pharmaceutically acceptable excipient and/or carrier include: liquid carriers (such as water, ethanol, pyrogen-free water, isotonic saline, Ringer's solution, ethyl alcohol and phosphate buffer solutions), sugars (such as lactose, glucose and sucrose), starches (such as corn starch and potato starch), cellulose and its derivatives (such as sodium carboxymethyl cellulose, ethyl cellulose and cellulose acetate), powdered tragacanth, malt, gelatin, talc, fat and oils (such as cocoa butter, waxes, 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 and other non-toxic materials employed in pharmaceutical formulations.

Regardless of whether it is a free or fixed combination, there is usually a reason why two active ingredients are combined. Depending on the reason, the dosage of one active ingredient might depend on the dosage of the other active ingredient. In the context of the present invention, this is typically not the case: the amount of vitamin D that needs to be administered to a given patient does usually not depend on the amount of vortioxetine that is administered to the patient. The required vitamin D dosage rather depends on the vitamin D status of the patient, age, weight and on the chosen vitamin D vitamer or metabolite thereof. If the vitamin D level of a patient is very low, often a relatively high amount of vitamin D needs to be administered. This is often done by a high bolus followed be daily/weekly regular dosages. Similarly, if the vitamin D level of a patient is almost sufficient, no bolus is required, only the daily, weekly or monthly dosages need to be given. In addition, the inventors have found that calcifediol is more effective than vitamin D3 such that a relatively low amount of calcifediol may be sufficient to bring the vitamin D level of the patient back to normal. If an oral dosage form comprises vitamin D, it comprises preferably from 10 pg to 2000 pg cholecalciferol or from 5 pg to 100 pg calcifediol, and it comprises more preferably from 10 pg to 1000 pg cholecalciferol or from 5 pg to 80 pg calcifediol, and it comprises most preferably from 15 pg to 100 pg cholecalciferol or from 5 pg to 35 pg calcifediol.

The purpose of the present invention is to improve existing vortioxetine treatments. Commercially available solid mono-preparations comprise 5 mg vortioxetine hydrobromide or 10 mg vortioxetine hydrobromide or 15 mg vortioxetine hydrobromide or 20 mg vortioxetine hydrobromide. Therefore, if an oral dosage form comprises vortioxetine, it comprises preferably 5 mg vortioxetine hydrobromide or 10 mg vortioxetine hydrobromide or 15 mg vortioxetine hydrobromide or 20 mg vortioxetine hydrobromide.

One embodiment of the invention relates to a pharmaceutical combination for sequential administration comprising: i) vitamin D, and ii) vortioxetine or a pharmaceutically acceptable salt thereof, wherein said pharmaceutical combination comprises a solid oral dosage form, said solid oral dosage form comprising:

0 mg vortioxetine hydrobromide; from 10 pg to 2000 pg cholecalciferol or from 5 pg to 100 pg calcifediol; and at least one pharmaceutically acceptable excipient, and wherein said a solid oral dosage form is preferably free of any kind vortioxetine.

Another embodiment of the invention relates to a pharmaceutical combination for sequential administration comprising: i) vitamin D, and ii) vortioxetine or a pharmaceutically acceptable salt thereof, wherein said pharmaceutical combination comprises a liquid oral dosage form, said liquid oral dosage form comprising:

0 mg vortioxetine hydrobromide; vitamin D, preferably vitamin D3, vitamin D2 or at least one vitamin D metabolite; and at least one pharmaceutically acceptable excipient, and wherein said a liquid oral dosage form is preferably free of any kind of vortioxetine.

Thereby, the above mentions materials can serve as the at least one pharmaceutically acceptable excipient. In case of a liquid oral dosage form, the at least one pharmaceutically acceptable excipient is preferably ethanol.

A further embodiment of the invention relates to a pharmaceutical combination for sequential administration comprising: i) vitamin D, and ii) vortioxetine or a pharmaceutically acceptable salt thereof, wherein said pharmaceutical combination comprises a solid oral dosage form, said solid oral dosage form comprising:

5 mg vortioxetine hydrobromide or 10 mg vortioxetine hydrobromide or 15 mg vortioxetine hydrobromide or 20 mg vortioxetine hydrobromide;

0 mg vitamin D2, vitamin D3 and/or calcifediol; and at least one pharmaceutically acceptable excipient, and wherein said a solid oral dosage form is preferably free of any kind vitamin D.

Medical use

The present invention relates to a pharmaceutical combination for use as a medicament, wherein said pharmaceutical combination comprises i) vitamin D, and ii) vortioxetine or a pharmaceutically acceptable salt thereof, and wherein i) vitamin D and ii) vortioxetine or a pharmaceutically acceptable salt thereof are sequentially administered. Thereby, the herein described preferences apply. Accordingly, vortioxetine or a pharmaceutically acceptable salt thereof is preferably vortioxetine hydrobromide whereas vitamin D is preferably vitamin D3, vitamin D2, at least one vitamin D metabolite or a mixture thereof.

The inventors have found that the presence of vitamin D is necessary for vortioxetine to exert its effects. This surprising finding suggests that many vortioxetine non-responders and low- responders have a suboptimal level of vitamin D in their blood (i.e., are in need of vitamin D supplementation). In one embodiment of the present invention, the suboptimal vitamin D level of vortioxetine non-responders and/or vortioxetine low-responders is raised before initiating or before re-initiating the vortioxetine treatment.

In one embodiment of the invention, the patient to be treated is a vortioxetine low-responder. In this embodiment, the positive effects of vortioxetine may be enhanced by first raising the vitamin D level of the vortioxetine low-responder. The low-responder's daily oral dosage of e.g. 10 mg vortioxetine hydrobromide may then be replaced by a daily dosage of 5 mg vortioxetine hydrobromide plus a suitable amount of vitamin D. Replacement of a high dosage with a lower dosage will reduce many, most or even all dose-dependent side-effects of vortioxetine.

In another embodiment of the invention, the patient to be treated is vortioxetine non-responder. In this embodiment, the vitamin D level of the vortioxetine non-responder is raised before initiating or re-initiating the vortioxetine treatment that has so far been unsuccessful.

Raising the vitamin D level of a patient before initiating the vortioxetine treatment is meaningful if the patient to be treated is in need of both, vitamin D and vortioxetine. Thus, a preferred embodiment of the present invention relates to the use of the herein disclosed pharmaceutical combination for use in the treatment of a patient that is in need of vortioxetine or a pharmaceutically acceptable salt thereof, wherein said patient is vitamin D deficient or insufficient, and/or wherein said patient has a calcifediol blood concentration that is lower than 75 nmol/L, preferably lower than 50 nmol/L, more preferably lower than 30 nmol/L, yet more preferably lower than 25 nmol/L, even more preferably lower than 20 nmol/L and most preferably lower than 12 nmol/L. During vitamin D supplementation, the calcifediol blood concentration will eventually rise. Therefore, these preferred calcifediol blood concentrations are concentrations that are measured before vitamin D supplementation is initiated or that are measured less than 3 days, preferably less than 2 days after the beginning of oral vitamin D supplementation.

In these embodiments, the patient that is in need of vortioxetine or a pharmaceutically acceptable salt thereof is preferably a patient that is suffering from depression, anxiety and/or chronic pain, and is most preferably a patient that is preferably suffering from major depressive disorder. Thus, the present invention also relates to a pharmaceutical combination for use in the treatment of a patient is suffering from depression, anxiety and/or chronic pain, wherein said pharmaceutical combination is a free combination that comprises i) vitamin D, and ii) vortioxetine or a pharmaceutically acceptable salt thereof, wherein i) vitamin D and ii) vortioxetine or a pharmaceutically acceptable salt thereof are not simultaneously administered, and wherein said patient is vitamin D deficient and/or has a calcifediol blood concentration that is lower than 75 nmol/L, preferably lower than 50 nmol/L, more preferably lower than 30 nmol/L, yet more preferably lower than 25 nmol/L, even more preferably lower than 20 nmol/L and most preferably lower than 12 nmol/L.

Thereby, the administration is preferably sequential, and wherein vitamin D is preferably administered first. When the calcifediol blood concentration of the patient has reached preferably at least 50 nmol/L, or preferably at least 75 nmol/L, vortioxetine administration is initiated or re-initiated.

Cerebral blood flow (CBF) is the blood supply to the brain in a given period of time. In a human adult, CBF is typically 750 millilitres per minute or 15% of the cardiac output. Cerebral blood flow is determined by a number of factors, such as viscosity of blood, how dilated blood vessels are, and the net pressure of the flow of blood into the brain, known as cerebral perfusion pressure, which is determined by the body's blood pressure. When treating such patient with the pharmaceutical combination of the present invention, the patient's cerebral blood flow (CBF) is increased. This suggests that abnormal cerebral blood flow is associated with a patient's lower or poor responsiveness to a vortioxetine treatment. Therefore, one embodiment of the present invention relates to the pharmaceutical combination of the present invention for use in the treatment of a patient suffering from major depressive disorder (MDD), wherein said patient has a suboptimal cerebral blood flow.

A suboptimal cerebral blood flow is associated with several cerebrovascular diseases such as cerebrovascular atherosclerosis. In fact, depression and cerebrovascular atherosclerosis often occur in comorbidity showing neuropsychological impairment and poor response to antidepressant treatment. Therefore, one embodiment of the present invention relates the pharmaceutical combination of the present invention for use in the treatment of a patient who is suffering from depression and from at least one cerebrovascular disease.

A preferred embodiment of the present invention relates to the herein described pharmaceutical combination for use in the treatment of a patient who

(a) is suffering from depression that is associated with cerebrovascular atherosclerosis and

(b) has a calcifediol blood concentration that is lower than 75 nmol/L, preferably lower than 50 nmol/L, more preferably lower than 30 nmol/L, yet more preferably lower than 25 nmol/L, even more preferably lower than 20 nmol/L and most preferably lower than 12 nmol/L, wherein the administration is not simultaneous, and wherein the administration is preferably sequential, and wherein vitamin D is preferably administered first, and wherein vitamin D may be administered intramuscularly or intravenously.

Method of treatment

The present invention also relates to a method of treatment, wherein a patient's vitamin D level has been risen first, i.e. before initiating or re-initiating the patient's vortioxetine treatment. To do so, a pharmaceutical combination that is suitable for sequential administration is used. Pharmaceutical combinations that are suitable for sequential administration are herein disclosed (vide supra).

The preferred method of treatment is thus a two-step treatment, wherein vitamin D and vortioxetine are not administered on the same day. Instead, vitamin D is administered before the administration of vortioxetine is initiated or re-initiated. The duration of the first step of the two-step treatment (i.e. the vitamin D step) can vary but is preferably at least one day.

In case vitamin D is intramuscularly or intravenously administered to the patient, healthy vitamin D levels are reached very quickly. In one embodiment, vitamin D is administered to the patient on day 1 of the patient's treatment; the vortioxetine administration (i.e. second step of the two- step treatment) is then initiated on day 2 of the patient's treatment and may last for weeks, months or even years.

When orally administering vitamin D to a patient, it might take longer until healthy vitamin D levels are reached. In case of oral administration of vitamin D2, D3 or a mixture thereof, the first step of the two-step treatment may have a duration of weeks or months, depending how low the vitamin D level of the patient is when the treatment starts. In case of oral administration of calcifediol, the first step of the two-step treatment is considerably shorter but might still have a duration of several weeks.

The second step of the two-step treatment (i.e. vortioxetine administration) is preferably initiated when the calcifediol blood concentration of the patient has reached at least 50 nmol/L or preferably at least 75 nmol/L. It is therefore recommended to regularly measure the vitamin D level of the patient to be treated.

In the second step of the two-step treatment, a vortioxetine mono-preparation is preferably administered. Nevertheless, it is to be understood that a risen calcifediol blood concentration may drop again, e.g. below 75 nmol/L or worse below 50 nmol/L. This is particularly true for elderly patients who are struggling in keeping up a healthy vitamin D level. Thus, in one embodiment of the invention, the herein described fixed combination (e.g., a solid oral dosage form comprising both, vitamin D and vortioxetine) is administered even though a patient’s vitamin D level has been risen.

Thus, an alternative embodiment of the invention relates to a method of treatment, said method comprising the steps:

1 . raising a patient's vitamin D level

2. initiating the patient’s vortioxetine treatment, preferably when the calcifediol blood concentration of the patient has reached at least 50 nmol/L or at least 75 nmol/L

3. continuing the patient’s vortioxetine treatment, characterized in that a fixed combination is administered in the second and/or third step, wherein said fixed combination comprises: i) vitamin D, and ii) vortioxetine or a pharmaceutically acceptable salt thereof. Novel use of a vitamin D measurement device

The preferred method of treatment is a 2-step method. In a first step, vitamin D is administered to a patient who has a suboptimal vitamin D level. Vitamin D supplementation (orally, intramuscularly and/or intravenously) will raise the vitamin D level of the patient. Once the vitamin D level of the patient is back to normal, vortioxetine administration is initiated (second step). Such instructions may be found in the package leaflet or SmPC of the pharmaceutical combination of the present invention.

For executing the instructions, the vitamin D level of a patient is preferably measured at least twice (e.g. before and after vitamin D supplementation). To determine the vitamin D level of a patient, it is preferred to measure (directly or indirectly) the calcifediol blood concentration. Preferably, said measurement is done ex vivo in a blood sample of the patient.

Devices for ex vivo measurement of vitamin D concentrations are well known and commercially available. Some of these devices are relatively small and cheap. They may therefore be included in the herein described kit. One embodiment of the present invention relates to a kit comprising means facilitating the ex vivo measurement of calcifediol in a blood sample, wherein said means is preferably a device for measuring ex vivo the concentration of calcifediol in a blood sample. Some parts of the device may be reusable, whereas other parts may be expendable material that is consumed when running the device. Parts that are reusable do not need to be included in each and every kit. Therefore, a preferred kit of the inventions comprises means facilitating the ex vivo measurement of calcifediol in a blood sample, wherein said means are preferably expendable materials that are consumed when running a device for measuring ex vivo the concentration of calcifediol in a blood sample.

So far, vitamin D measurement devices have not been used in the context of vortioxetine treatments.

One embodiment of the present invention relates to the use of a measurement device in the sequential administration of vitamin D and vortioxetine or a pharmaceutically acceptable salt thereof, wherein said measurement device is suitable for measuring the concentration of calcifediol ex vivo in a blood sample.

A preferred embodiment of the present invention relates to the use of a measurement device in the sequential administration of vitamin D3 and vortioxetine hydrobromide, wherein vitamin D3 is first administered to a patient, and wherein said measurement device is used for determining if the concentration of calcifediol in a blood sample of the patient has reached a predetermined threshold such that vortioxetine treatment can be initiated. An also preferred embodiment of the present invention relates to the use of a measurement device in the sequential administration of calcifediol and vortioxetine hydrobromide, wherein calcifediol is first administered to a patient, and wherein said measurement device is used for determining if the concentration of calcifediol in a blood sample of the patient has reached a predetermined threshold such that vortioxetine treatment can be initiated or re-initated. In both of these preferred embodiments, the preferred predetermined threshold is 50 nmol or even 75 nmol calcifediol per liter (L) blood.

Examples

In below Examples 1 to 4, the following materials and methods were used:

Test Article Identification and Preparation. Pre-formulated diets lacking vitamin D (Modified AIN-93G Rodent Diet with no added vitamin D3: Research Diets, New Brunswick, NJ; catalogue No. D10073001 , lot No. 20090401) was shipped ambient and stored at -20°C prior to use. ROVIMIX® Hy-D® 1.25% (DSM Nutritional Products, Lot No. WB01990008) and dry Vitamin D3 100 CWS/AM (DSM Nutritional Products, lot No. UT19010007) were prepared for PO (per os) dosing at 10 mL/kg in vehicle (1 % fish gelatin in PBS). ROVIMIX® Hy-D® 1.25% is a formulation comprising 1 .25 weight-% 25-Hydroxy-vitamin D3, based on the total weight of the formulation. Vortioxetine (Advanced Chemblock Inc., Cat. P50895, CAS 960203-27-4, Batch 19394) was prepared in for PO dosing at 10 mL/kg in vehicle. The purchased vortioxetine is vortioxetine hydrobromide. Thus, in the context of the examples, “vortioxetine” refers to vortioxetine hydrobromide. The vehicle for mock PO dosing of the test articles was sterile saline. Dipyridamole was used for induction of vasodilation during the assays of cerebral blood flow. Dipyridamole (Millipore-Sigma, catalog No. D9766; Lot No. BCCB0805) was prepared fresh in a 20% b-cyclodextrin solution in sterile water (VetOne, lot No. A1806022) on study days 64 through 67 for intraperitoneal (IP) injection at 1 mL/kg.

Test System Identification. Male Balb/cJ mice (N = 96; stock number 000651) were obtained from The Jackson Laboratory (Bar Harbor, ME). The mice were 4 weeks old and weighed approximately 17 to 22 grams (mean of 20.2 g) at enrollment on study day 0. The animals were identified by marks at the base of tail delineating animal number. After randomization, all cages were labeled with protocol number, group number, and animal numbers.

Environment and Husbandry. Upon arrival, the animals were housed 3 per cage in polycarbonate cages with wire tops, wood chip bedding, and suspended food and water bottles. The mice were housed either in shoebox cages (static airflow, approximately 0.045 m2 floor space) with filter tops or in individually ventilated pie cages (passive airflow, approximately 0.045-0.048 m2 floor space). An attending veterinarian was on site or on call during the live phase of the study. No concurrent medications were given.

The animals were acclimated for 7 days prior to being placed in the study. During the acclimation and study periods, the animals were housed in a laboratory environment with temperatures ranging 19°C to 25°C and relative humidity of 30% to 70%. Automatic timers provided 12 hours of light and 12 hours of dark. Animals were allowed access ad libitum to Envigo Teklad 8640 diet or vitamin D-deficient diet and fresh municipal tap water. Animal care including room, cage, and equipment sanitation conformed to the guidelines cited in the Guide for the Care and Use of Laboratory Animals and the applicable SOPs.

Experimental Design. The animals were given immediate ad libitum access to water and standard rodent chow and acclimated to the facility for 7 days prior to any further intervention. After 7 days of acclimatization, the animals were randomized by weight, placed on chow deficient in vitamin D, and subjected to mock oral gavage on a twice-weekly basis for 6 weeks. For behavioral testing the study was divided into 4 cohorts of 24 animals each (3 mice/group per cohort) with dosing and testing of each cohort proceeding on successive days. The mice were dosed by oral gavage 24, 6, and 1 hour prior to behavioral testing.

Example 1. Vortioxetine alone is not effective in vitamin D deficient animals. A combination of vitamin D and vortioxetine is needed for anti-depressive effects in the forced swim test.

The forced swim test (FST) is a test centered on a rodent’s response to unescapable stress. Results of this test have been interpreted as a measure of susceptibility to negative mood. It is used to measure the effectiveness of antidepressants. Forced swim tests were performed in groups of 12 mice, per treatment. We provided the substances to the animals per gavage at 24, 6 and 1 hours before the FST. The animals were acclimated to the testing room for 1 hour prior to testing. Four animals were tested simultaneously. The animals were each placed in a plexiglass cylindrical container (45 cm x 20 cm; Stoelting Co., Wood Dale, IL) filled with fresh water (25- 27°C) to 30 cm above the bottom. The animals remained in the containers for 6 minutes and were monitored by a computer program with tracking software (Ethovision, Noldus). The mice were observed constantly to mitigate the outside chance that an animal drowned or began to drown (i.e., spent more than 5 seconds completely submerged). After 6 minutes, the animals were removed, towel-dried, and returned to their holding cages. The chambers were drained and cleaned with 70% ethanol then refilled between tests. The animals were returned to their home cage and room after all of the animals in the cohort were tested. All videos were checked and threshold-ed post-hoc by an experimenter blind to the group assignments. Total time swimming or immobile was then acquired via computer-driven video analysis. Swimming was defined as movement of the forelimbs and hind limbs that did not break the surface of the water. Immobility was defined as absence of any movement except for slight movements necessary for the animal to keep its head above water. Data was statistically analyzed using the GraphPad Prism software (San Diego, CA, USA).

Surprisingly, it was observed that in the forced swim test (FST) vitamin D deficient mice treated with vortioxetine did not differ from the vehicle control group as shown in Figure 1 . This result of Example 1 differs from those of Guilloux et al. (2013) in which vortioxetine (5 mg/kg) increased the time in mobility in the FST. In contrast to the animals of Example 1 , the animals of Guilloux et al. (2013) were not vitamin D deficient. This suggests that the presence of vitamin D might be necessary for vortioxetine to exert the effects. We tested this hypothesis by combining vortioxetine with vitamin D at two different doses. Interestingly, in the acute FST depression model we could show that the combination of vortioxetine together with a sufficient dose of vitamin D improved the depression scores. In Figure 2, mice having sufficient vitamin D in the vortioxetine combination (vortioxetine_D2_high) showed reduced immobility scores.

Example 1 shows the benefit of administering vortioxetine together with vitamin D when treating vitamin D deficient subjects.

Example 2. In vitamin D deficient animals, vortioxetine showed an improvement in cerebral blood flow only in combination with vitamin D

For the cerebral blood flow (CBF) measurement, the animals were anesthetized one hour after the last test article administration using 2% isoflurane (VetOne, catalogue No. 502017), and each animal's skull was exposed by a midline scalp incision. The scalp was removed to visualize the brain without disturbing the overlying skull. The animals were then injected (IP) with dipyridamole (DP; 10 mg/kg) and placed in the prone position under the laser Doppler device (MoorLDI2; Moor Instruments, Wilmington, DE). Body temperature was maintained at approximately 30°C with a heating pad, and anesthesia and immobility were maintained with 1 .5% isoflurane. The surface of the brain was diffusely illuminated by a 785-nm laser light. The scattered light was filtered and detected by a digital camera positioned above the animal's head. Raw speckle images were used to compute the speckle contrast, which is a measure related to the number and velocity of moving particles (i.e., CBF). Thirteen, color-coded, blood-flow images were compiled for each animal at 45-second intervals, resulting in CBF monitoring for 10 minutes post-DP injection. The first 5 scans were averaged as baseline CBF, and all subsequent scans were normalized to the baseline as the CBF response to DP.

Interestingly, vortioxetine did not show any significant change in CBF when compared to the control group in vitamin D deficient animals (Figure 3).

It can be assumed that vitamin D deficiency is the explanation why vortioxetine did not exert its effects in the forced swim test (cf. Example 1). Therefore, we were interested to see additional hint in the brain when adding vitamin D to the vortioxetine treatment. And surprisingly, the combination of vortioxetine and vitamin D was effective in the CBF experiment. Interestingly enough, using the CBF methodology, the combined effect of vortioxetine can already be seen at the lower dose of vitamin D (0.05 mg/kg bw) (Figure 4). The observation that cerebral blood flow is improved in the brain of vitamin D deficient subjects by administering vortioxetine in combination with vitamin D is consistent with the results shown in Figure 2. Example 3. The combination of vortioxetine and calcifediol, a metabolite of vitamin D3, relieved the depressive mood in mice in the forced swim test (FST).

Vortioxetine alone was not effective in ameliorating depressive mood in vitamin D deficient Balb/cJ mice in the forced swim test (cf. Example 1). After having observed the vitamin D effect in vortioxetine treatment (cf. Example 2), we were interested whether other vitamin D metabolites could have a similar action. Therefore, calcifediol (25-hydroxy vitamin D3, 25D3) co-administration was tested in the FST. Intriguingly, a low dose of calcifediol (0.025 mg/kg bw) had the same effect like the high dose of vitamin D3 (0.10 mg/kg bw), when together with vortioxetine to vitamin D deficient mice. Figure 5 shows that the combination of calcifediol with vortioxetine effectively improves the anti-depressive behavior of vitamin D deficient mice in the FST as seen by reducing the immobility per minute.

Example 4. Both combinations, ‘vortioxetine and vitamin D’ and ‘vortioxetine and calcifediol’, improved cerebral blood flow in a dose-depending manner.

Similar to Example 2, calcifediol was tested in two different concentrations (0.025 mg/kg bw; 0.050 mg/kg bw) in combination with vortioxetine in the CBF experiment vitamin D deficient mice. A dose dependent effect was observed. A two times higher oral dose of vitamin D resulted in less improved cerebral blood flow than calcifediol (Figure 6).

The result of Example 4 shows a dose-effect relationship for both, vitamin D and calcifediol.

Example 5a. Mono-therapy; comparison with comparator therapy.

In Example 5a, vortioxetine is compared with another therapy (“comparator therapy”) to assess its added benefit. Both drugs are approved for patient treatment by the drug authorities. They have a positive benefit-risk ratio, i.e. both are effective and safe.

To assess the added benefit, 100 patients are split into two groups. A first group is treated with a vortioxetine, whereas a second group is treated with a comparator therapy. Patient-relevant endpoints (“positive effects") from which the additional benefit is to be derived are defined. An additional benefit is attested if, for example, a significant improvement of disease symptoms or an avoidance of side effects can be shown compared to the comparative therapy.

In Example 5a shows that vortioxetine has little added benefit.

Example 5b. Mono-therapy; subjects with low vitamin D level are excluded.

In Example 5b, the assessment of Example 5a is repeated. However, to participate in the assessment, patients must have a healthy vitamin D level (i.e., low vitamin D level is an exclusion criterion). The calcifediol blood concentration of patients is measured. Patients having a calcifediol blood concentration of less than 50 nmol/L receive suitable vitamin D supplementation.

100 patients that have calcifediol blood concentration of more than 50 nmol/L are split into two groups. A first group is treated with vortioxetine, whereas a second group is treated with a comparator therapy. The same patient-relevant endpoints (“positive effects") as in Example 5a are applied. The duration of the assessment is as long as in Example 5a, but at least 6 months.

In Example 5b, vortioxetine has a significant added benefit.

A comparison of Examples 5a and 5b shows the relevance of a healthy vitamin D level when treating a patient with vortioxetine: to unfold the full potential of vortioxetine, the patient to be treated should have a healthy vitamin D level.

Example 5c. Combination therapy; low vitamin D subjects receive vitamin D supplementation.

In Example 5c, the assessment of Example 5a is repeated. However, to participate in the assessment, patients must have a low vitamin D level (i.e., normal vitamin D level is an exclusion criterion).

100 patients that have a calcifediol blood concentration of less than 30 nmol/L are split into two groups. A first group is treated with a fixed combination (namely with a solid oral dosage form comprising vortioxetine and calcifediol), whereas a second group is treated with a comparator therapy. The same patient-relevant endpoints (“positive effects") as in Example 5a are applied. The duration of the assessment is as long as in Example 5a, but at least 6 months.

In Example 5c, the combination therapy (vortioxetine + calcifediol) has a significant added benefit.

Examples 5c shows that a low vitamin D level of a patient does not need to be a show stopper. Oral supplementation of vitamin D (via fixed combination) brings the patient's vitamin D level back to normal and thus, makes vortioxetine treatment successful.

Claims

1 . Pharmaceutical combination for sequential administration comprising: i) vitamin D, and ii) vortioxetine or a pharmaceutically acceptable salt thereof.

2. Pharmaceutical combination according to claim 1 , wherein said pharmaceutical combination is a free combination that comprises i) at least one injectable liquid which comprises vitamin D, and ii) at least one oral dosage form which comprises vortioxetine or a pharmaceutically acceptable salt thereof, and wherein said vitamin D is preferably vitamin D3.

3. Pharmaceutical combination according to claim 1 , wherein said pharmaceutical combination is a free combination that comprises i) at least one oral dosage form which comprises vitamin D, and ii) at least one oral dosage form which comprises vortioxetine or a pharmaceutically acceptable salt thereof, and wherein said vitamin D is preferably vitamin D3, vitamin D2, at least one vitamin D metabolite or a mixture thereof, and wherein said at least one vitamin D metabolite is preferably calcifediol.

4. Pharmaceutical combination according to claim 3, wherein said pharmaceutical combination is a free combination that comprises at least one solid oral dosage form and at least one liquid oral dosage form.

5. Pharmaceutical combination according to any one of the preceding claims, wherein said pharmaceutically acceptable salt of vortioxetine is vortioxetine hydrobromide or vortioxetine (D,L)-lactate.

6. Kit comprising the pharmaceutical combination according to any one of the preceding claims, wherein said kit further comprises instructions for sequential administration.

7. Pharmaceutical combination according to any one of claims 1 -5 for use as a medicament.

8. Pharmaceutical combination according to any one of claims 1-5 for use in the treatment of a patient who

(a) is suffering from depression, anxiety and/or chronic pain; and

(b) has a calcifediol blood concentration that is lower than 75 nmol/L, preferably lower than 50 nmol/L, more preferably lower than 30 nmol/L, yet more preferably lower than 25 nmol/L, even more preferably lower than 20 nmol/L and most preferably lower than 12 nmol/L.

9. Pharmaceutical combination for use according to claim 8, wherein said patient is suffering from depression and from at least one cerebrovascular disease, and wherein said patient is preferably suffering from depression that is associated with cerebrovascular atherosclerosis.

10. Pharmaceutical combination for use according to claim 8 or 9, wherein the administration is not simultaneous.

11 . Pharmaceutical combination for use according to any one of claims 8 to 10, wherein the administration is sequential, and wherein vitamin D is preferably administered first.

12. Pharmaceutical combination for use according to any one of claims 8 to 11 , wherein vitamin D is administered intramuscularly or intravenously, and wherein preferably vitamin D3 or vitamin D2 is administered intramuscularly.

13. Pharmaceutical combination for use according to any one of claims 8 to 12, wherein vortioxetine administration is initiated or re-initiated when the calcifediol blood concentration of the patient has reached at least 50 nmol/L or preferably at least 75 nmol/L.

14. Use of a measurement device in the sequential administration of vitamin D and vortioxetine or a pharmaceutically acceptable salt thereof, wherein said measurement device is suitable for measuring the concentration of calcifediol ex vivo in a blood sample.

15. Use according to claim 14, wherein vitamin D is first administered to a patient, and wherein said measurement device is used for determining if the concentration of calcifediol in a blood sample of the patient has reached a predetermined threshold such that vortioxetine treatment can be initiated or re-initiated.