ZA200505143B - Therapeutic formulations for the treatment of beta-amyloid related diseases - Google Patents

Description

THERAPEUTIC FORMULATIONS FOR THE TREA_TMENT OF

BETA-AM YLOID RELATED DISEASES:

Related Applications

This application claims the priority of U.S. provisional patent application no. 60/436,379, filed 24 December 2002, entitled Combination Therapy feor The Treatment of

Alzheimer's Disease; and the priority of U.S. provisional patent application no. 60/482,214, filed 23 June 2003, entitled Therapeautic Formulations for The Treatneent of Beta-Amyloid

Related Diseases. PCT Publication I™No. WO 04/058258 claims priorit=y to these two provisional applications. This applic ation is also related to U.S. provissional patent application no. 60/480,906, which published as W.S. Patent Application Publicaticon No. 2005/0038117 filed 23 June 2003, entitled Methods~ and Compositions for Treating AM myloid-Related

Disease; and U.S. provisional patent: application no. 60/480,928, also filed 23 June 2003, and entitled Methods and Compositions For The Treatment of Amyloid- an d Epileptogenesis-

Associated Diseases which publishead as U.S. Patent Application Publ ication No. 2005/003800; as well as Method for Treating Amyloidosis, U.S. paten_t application no. 08/463,548, now U.S. Pat. No. 5,972,328. The entire contents of each of the foregoing patent applications and patents are expressly incorporated by reference in their entirety including, without limitation, the specification, claims, and abstract, as well as amy figures, tables, or drawings thereof.

Background

Alzheimer's disease is a dev astating disease of the brain that results in progressive memory loss leading to dementia, physical disability, and death over aa relatively long period of time. With the aging populations -in developed countries, the numbeer of Alzheimer's patients is reaching epidemic proportions.

People suffering from Alzheimer's disease develop a progressive dementia in adulthood, accompanied by three main structural changes in the brain : diffuse loss of neurons in multiple parts of the brain; accumulation of intracellular protein de—posits termed neurofibrillary tangles; and accumul ation of extracellular protein deposits termed amyloid or senile plaques, surrounded by missh apen nerve terminals (dystrophic neurites). A main constituent of these amyloid plaquess is the amyloid-f peptide(Ap), a 39-43 amino-acid protein that is produced through cleavage of the B-amyloid precursor —protein (APP).

Extensive research has been conducted on the relevance of A deposi ts in Alzheimer's disease, see, e.g., Selkoe, Trends in Cell Biology 8, 1

Amended sheeet: 17 September 2007

447-453 (1998). APB naturally arises from the metabolic processing of the amyloid precursor protein (“APP”) i n the endoplasmic reticulum (“ER”), the &Golgi apparatus, or the endosomal- ) lysosomal pathway, and most is normally secreted as a 40 &“APB1-40) or 42 (“AB1-42”) amino acid peptide (Sell<oe, Annu. Rev. Cell Biol. 10, 373-403 (194). A role for Ap as a primary

A 5 cause for Alzheimer’s disease is supported by the presence of extracellular amyloid 3 peptide (“AB”) deposits imn senile plaques of Alzheimer’s disease (“Alzheimer’s disease”), the increased production of AB in cells harboring mutant Alzheimer’s disease associated genes, e.g., amyloid precursor protein, presenilin I and presenilin II; and the toxzicity of extracellular soluble (oligomeric) or fibrillar AB to cells in culture. See, e.g., Gervais, Eur. Biopharm. Review, 40-42 (Autumn 2001); May, DDT 6, 459-62 (2001). Although symptomatic treatments exist for

Alzheimer’s disezase, this disease cannot be prevented or cared at this time.

Alzheimem’s disease is characterized by diffuse and neuritic plaques, cerebral angiopathy, and neurofibrillary tangles. Plaque and blood vessel amyloid is believed to be formed by the deposition of insoluble Ap amyloid protein, which may be described as diffuse or fibrillary.

Both soluble oligeomeric AS and fibrillar AB are also believed to be neurotoxic and inflammatory. Ammyloid fibrils, once deposited, can becom e toxic to the surrounding cells. For example, the AP fibrils organized as senile plaques have besen shown to be associated with dead neuronal cells ancl microgliosis in patients with Alzheimer™ s disease. When tested in vitro, AB peptide was show=n to be capable of triggering an activatiora process of microglia (brain ! macrophages), winich would explain the presence of microgliosis and brain inflammation found in the brain of patients with Alzheimer’s disease. Once the=se amyloids have formed, there is no known, widely ac=cepted therapy or treatment that significamtly dissolves amyloid deposits or prevents the form. ation of deposits i» situ . Presently availeable pharmaceutical technology for treatment of B-anmyloid diseases is almost entirely symptomatic, providing only temporary or partial clinical bemefit. Although some pharmaceutical age nts have been described that offer : partial symptomatic relief, no comprehensive pharmacological therapy is currently available for the treatment of Aalzheimer’s disease. }

Summary of The Invention . The present invention prowides a method of concomitant therapeutic treatment of a subject. The method generally includes administering to a subject in mmeed thereof an effective . amount of a pharmaceutical comp»osition for treating or preventing an aamyloid-p disease such that activities of daily living other-wise impaired by said amyloid—[ dissease are improved or stabilized. In one embodiment, thane pharmaceutical composition includes a first agent and a second agent in a pharmaceuticall y acceptable carrier, wherein said fir=st agent prevents or treats amyloid-P related disease, and said second agent is a therapeutic drug eor nutritive supplement.

In another embodiment, the present invention provides a methcad of preventing or treating 1=0 Alzheimer’s disease that includes concomitantly administering to a sutoject in need thereof an "effective amount of a first agent that is efficacious in preventing or treating Alzheimer’s disease in said subject and a second agent, wherein said first agent comprises S3-amino-1-propanesulfonic acid or a pharmaceutically acceptable salt thereof.

In another embodiment, tine present invention provides a methomd of preventing or treating 1= Mild Cognitive Impairment that iricludes concomitantly administering to a subject in need thereof an effective amount of a flirst agent that is efficacious in preventing or treating Mild

Cognitive Impairment in said subj ect and a second agent, wherein said first agent comprises 3-amino-1-propanesulfonic acid or a pharmaceutically acceptable salt &hereof,

In yet another emobidment, the present invention provides a method of preventing or 2a0 treating comprising concomitantly” administering to a subject in need timereof an effective amount of a first agent that is efficacious in preventing or treating Mild Cognitive Impairment in said subject and a second agent, wherein said first agent comprises 3-aminom-1-propanesulfonic acid or a pharmaceutically acceptable salt thereof.

In yet another embodiment, the present invention provides a mesthod of preventing or ‘2% treating Mild Cognitive Impairme nt that includes concomitantly admin: istering to a subject in need thereof an effective amount of a first agent that is efficacious in preventing or treating Mild

Cognitive Impairment in said subj ect and a second agent, wherein said first agent is 3-amino- 1-propanesulfonic acid. i

In yet another embodiment, the present invention provides a method of preventing or treating comprising concomitantly” administering to a subject in need ttmereof an effective amount of a first agent that is efficacious i n preventing or treating Mild CognitiE ve Impairment in said : subject and a second agent, where in said first agent is 3-amino-1-propa_nesulfonic acid. The second agent can be a cholinesterase inhibitor, a statin, or memantine.

: Metailed Description of the Invention “Amyloidosis” or “amyloid dis=ease” refers to a pathological cond dition characterized by ’ Che presence of amyloid fibers. Amyloid is a generic term referring to a g=roup of diverse but specific protein deposits (intracellular sor extracellular) which are seen in =a number of different cliseases. Though diverse in their occumrrence, all amyloid deposits have c-ommon morphologic oroperties, stain with specific dyes (e.&., Congo red), and have a charactemristic red-green birefringent appearance in polarized light after staining. They also share common ultrastructural

Features and common X-ray diffractiorn and infrared spectra. The term “azmyloid-B diseases” i ncludes those diseases, conditions, pathologies, and other abnormalities Of the structure or function of the brain, including compoments thereof, in which the causative agent is amyloid.

Khe area of the brain affected in an am_yloid—3 disease may be the stroma including the ‘wasculature or the parenchyma includirg functional or anatomical regions. , or neurons t hemselves. A subject need not have received a definitive diagnosis of a specifically recognized ammyloid—f disease.

Local deposition of amyloid is ecommon in the brain, particularly imn elderly individuals.

Whe most frequent type of amyloid in thhe brain is composed primarily of ZAP peptide fibrils, r-esulting in dementia associated with sgporadic (non-hereditary) Alzheime=r’s disease. In fact, the imcidence of sporadic Alzheimer’s dise ase greatly exceeds forms shown to be hereditary.

Mevertheless, fibril peptides forming pBaques are very similar in both types.

APP is expressed and constituti vely catabolized in most cells. The dominant catabolic peathway appears to be cleavage of APP within the AB sequence by an en=zyme provisionally te=rmed a-secretase, leading to release o»fa soluble ectodomain fragment kanown as APPsa. In contrast to this non-amyloidogenic patlway, APP can also be cleaved by enzymes known as B- a.nd y-secretase at the N- and C-termini of the AB, respectively, followed “by release of Af into tEae extracellular space. To date, BACES has been identified as B-secretase (Vasser, ef al., ’

Science 286:735-741, 1999) and presemuilins have been implicated in y-sec_retase activity (HDe Strooper, et al., Nature 391, 387-98 (1998).

The 39-43 amino acid Ap peptide is produced by sequential proteolytic cleavage of the a myloid precursor protein (APP) by the= enzyme(s) and y secretases. Alttough AB40 is the p redominant form produced, 5-7% of total AB exists as AB42 (Cappai ef eal., Int. J. Biochem.

Cell Biol. 31. 885-89 (1999)). The length of the AB peptide appears to drammatically alter its b iochemical/biophysical properties. Spe=cifically, the additional two amino= acids at the C- ) terminus of AB42 are very hydraphobics, presumably increasing the properasity of Ap42 to aggregate. For example, Jarrett, ef al. deemonstrated that AB42 aggregates wwery rapidly in vitro . 35 ceompared to AB -40, suggesting that the longer forms of AB may be the itmportant pathological proteins that are involved in the initial seeding of the meuritic plaques in Alzheimer’s diseamse (Jarrett, et al., Biochemistry 32, 4693-97 (1993); Jarrett, et al., Ann. N.Y. Acad. Sci. 695, 1=44-48 : (1993).

This hypothesis has been further substantiated by the recent analysis of the contribLations ) 5 of sppecific forms of AB in cases of genetic familial forms of Alzheimer’s disease (“FAD”). For exarmple, the “London” mutant form of APP (APPV7 17) linked to FAD selectively increamses the production of AP 42/43 forms versus AP 40 (Suzuki, ef al., Science 264, 1336-40 (1994)) —while the ““Swedish™ mutant form of APP (APPK670N/M671L) increases levels of both AB40 ard

AP4-2/43 (Citron, et al., Nature 360, 672-674 (1992); Cai, et al., Science 259, 514-16, (199®3)). 10 Also, it has been observed that FAD-linked mutations in the Presenilin-1 (“PS17) or Presemilin-2 : (“PS2”) genes will lead to a selective increase in AB4-2/43 production but not AB40 (Borel elt, et aZ., Neuron 17, 1005-13 (1996)). This finding was corroborated in transgenic mouse mo dels expressing PS mutants that demonstrate a selective increase in brain A342 (Borchelt, op ct;

Duf¥, et al., Neurodegeneration 5(4), 293-98 (1996)). Thus the leading hypothesis regardirg the 15 etioBogy of Alzheimer’s disease is that an increase in .AB42 production or release is a causative event in the disease pathology.

Epidemiological studies show that subjects with elevated cholesterol levels have arm increased risk of Alzheimer’s disease (Notkola, et al., Neuroepidemiology 17(1), 14-20 (15998);

Jarv ik, et al., Neurology 45(6), 1092-96 (1995). In addition to the data which suggests theat 20 elev ated levels of AP are associated with Alzheimer’s disease, other environmental and genetic risk factors have been identified. For example, a relationship exists between serum choles#erol leve Is and the incidence and the pathophysiology of Alzheimer’s disease. The best studied of these is polymorphism of the apolipoprotein E (“ApoE”) gene: subjects homozygous for th_e e4 isoform of ApoE (apoE4) have consistently been shovvn to have an increased risk for 25 Alzleimer’s disease (Strittmatter, et al., Proc. Nat'l A cad. Sci. USA 90:1977-81 (1993). B=ecause

Apo E is a cholesterol transport protein, several groups have abserved a correlation between the risk of developing Alzheimer’s disease and circulating levels of cholesterol (Mahley, Scierace 240, 622-30 (1998); Saunders, et al., Neurology 43, 1467-72 (1993); Corder, et al., Science=z 261, 921-23 (1993); Jarvik, et al., Ann. N.Y. Acad. Sci. 826 , 128-46 (1997)). Moreover, choleste=rol 30 load ing increases the production of AB protein (Simo ns, ef al., Proc. Nat'l Acad. Sci. USA 95, 6460-64 (1998)), while pharmacological reduction of cholesterol with the HMG CoA reductase inhibitor simvastatin decreases levels of both A -40 aand AP -42 (Fassbender, et al., Proc. Nat'l

Acad. Sci. USA 98, 5856-61 (2001) in vitro. Consiste mt with these data are the results of epidemiological studies which have shown that treatm ent with certain HMG CoA reductases . 35 inhibitors, commonly used to normalize cholesterol levels in humans, reduces the prevalence of

Alzhxeimer’s disease (Wolozin, er al., Arch. Neurol. 57, 1439-43 (2000); Jick, et al., Lancer 356, 1627-31 (2000). Taken together, these data suggest a [ink between regulation of cholesterol levels and Alzheimer’s disease. In addition, a relationship wilith coronary disease has been demonstrated (discuss -ed further below).

Amyloid-p peptide (AB) is a 39-43 amino acid pepticie derived by proteolysis from -a large protein known a=s Beta Amyloid Precursor Protein (“SAaPP”). Mutations in BAPP resumlt in ’ 5 familial forms of Alzhmeimer’s disease, Down’s syndrome, ce=rebral amyloid angiopathy, anc senile dementia, characterized by cerebral deposition of plaq ues composed of Ap fibrils ana other components, wh ich are described in further detail belowwv. Known mutations in APP associated with Alzheimer’s disease occur proximate to the cleavage sites of 8 or y-secretas e, or within AB. For example, position 717 is proximate to the sit-e of gamma-secretase cleavage of

APP in its processing to Ap, and positions 670/671 are proxi mate to the site of 3-secretase cleavage. Mutations zat any of these residues may result in A_lzheimer’s disease, presumably by causing an increase in the amount of the 42/43 amino acid fosrm of AB generated from APP_ The familial form of Alzheimer’s disease represents only 10% of the subject population. Most occurrences of Alzheizmer’s disease are sporadic cases where= APP and AP do not possess ary mutation.

The structure cand sequence of AP peptides of variouss lengths are well known in the art.

Such peptides can be nade according to methods known in tzhe art, or extracted from the braain according to known mmethods (e.g., Glenner and Wong, BiocFiem. Biophys. Res. Comm. 129, 885-90 (1984); Glenne=r and Wong, Biochem. Biophys. Res. Comm. 122, 1131-35 (1984)). Ln addition, various form_s of the peptides are commercially ava ilable.

As used hereima, the terms “B amyloid,” “amyloid—3,” and the like refer to amyloid B proteins or peptides, a myloid p precursor proteins or peptides, intermediates, and modifications and fragments thereof, unless otherwise specifically indicated. In particular, “AB” refers to any peptide produced by peroteolytic processing of the APP gene product, especially peptides which are associated with amyloid pathologies, including AB1-39, ~AB1-40, AB1-41, AB1-42, and

AB1-43. For convenience of nomenclature, “AB1-42" may toe referred to herein as “AB(1-4-2)” or simply as “AB42” or “ABs,” (and likewise for any other ammyloid peptides discussed herein).

As used herein, the terms “p amyloid,” “amyloid-3,” and “A _{3” are synonymous. Unless otherwise specified, tae term “amyloid” refers to amyloidoge=nic proteins, peptides, or fragments thereof which can be soluble (e.g., monomeric or oligomeric?) or insoluble (e.g, having fibrillary structure or in amyloicd plaque). See, e.g., MP Lambert, et al_., Proc. Nat'l Acad. Sci. USA 95, 6448-53 (1998).

According to czertain aspects of the invention, amyloid is a peptide having 39-43 amino-acids, or amylowid—B is an amyloidogenic peptide prod uced from BAPP. The amyloid8-f§ diseases that are the siabject of the present invention include =:age-related cognitive decline, eaarly

Alzheimer’s disease ass seen in Mild Cognitive Impairment (* “MCI”), vascular dementia, or * Alzheimer’s disease (* *AD”), which may be sporadic (non-he=reditary) Alzheimer’s disease or familial (hereditary) Alzheimer’s disease. The amyloid—B disease may also be cerebral amyloid ) angiopathy (“CAA”) or hereclitary cerebral hemorrhage. The amyloid—f3 disease may be senile dementia, Down’s syndrome, inclusion body myositis (“IBM”), or age-related macular degeneration (“ARMD”).

The present invention relates to the use of certain compounds, desnoted a “first agent,” . representative examples of w hich include substituted and unsubstituted alkanesulfonic acids, in combination with a second agzent that is biologically active for the treatranent or prevention of amyloid-B diseases, including Alzheimer’s disease and cerebral amyloied angiopathy. The invention also relates to pharemaceutical compositions for the preventiorm or treatment of such diseases and methods of prep aring and using these compositions.

The invention pertains to pharmaceutical compositions and mettmods of use thereof for the treatment of amyloid—3 disea ses. The pharmaceutical compositions cormnprise a first agent that treats or prevents an amyloid--f disease, e.g, by preventing or inhibiting= amyloid fibril formation, neurodegeneratiorn, or cellular toxicity. The pharmaceutical «composition also comprises a second agent that is an active pharmaceutical ingredient; thaat is, the second agent is therapeutic and its function is beyond that of an inactive ingredient, suck as a pharmaceutical carrier (or vehicle), preservative, diluent, or buffer. The second agent rmmay be useful in treating or preventing an amyloid—3 disease or another neurological disease. Th e first and second agents . may exert their biological effects by similar or unrelated mechanisms of™ action; or either one or both of the first and second agents may exert their biological effects by =a multiplicity of . mechanisms of action. A pha.rmaceutical composition may also comprise a third compound, or . even more yet, wherein the thuird (and fourth, etc.) compound has the sar ne characteristics of a second agent.

It should be understood that the pharmaceutical compositions de=scribed herein may have the first and second, third, or additional agents in the same pharmaceutically acceptable carrier or in a different pharmaceutically acceptable carrier for each described embodiment. It further should be understood that the first, second, third and additional agent may be administered simultaneously or sequentially within described embodiments. AlternatJively, a first and second agent may be administered sirmultaneously, and a third or additional agemnt may be administered before or after the first two agzents.

The term “combination” as in the phrase “a first agent in combin ation with a second agent” includes co-administra tion of a first agent and a second agent, winch for example may be dissolved or intermixed in ther same pharmaceutically acceptable carrier, or administration of a first agent, followed by the se cond agent, or administration of the second agent, followed by the firstagent. The present inven tion, therefore, relates to methods of comb ination therapeutic treat. ment and combination pharmaceutical compositions.

The term “concomitant” as in tine phrase “concomitant therapeutic treatment” includes . administering an agent in the presence of a second agent. A concomitant ther-apeutic treatment nmaethod includes methods in which the first, second, third, or additional agent=s are co-adminis- tered. A concomitant therapeutic treatmnent method also includes methods in which the first or i 5 a«iditional agents are administered in tine presence of a second or additional agzents, wherein the se=cond or additional agents, for examp le, may have been previously administered. A ceoncomitant therapeutic treatment method may be executed step-wise by different actors. For example, one actor may administer to 2 subject a first agent and a second actor may administer to the subject a second agent, and the administering steps may be executed at thes same time, or neearly the same time, or at distant time s, so long as the first agent (and additiconal agents) are asfter administration in the presence of #he second agent (and additional agentss). The actor and the subject may be the same entity (e.g, human).

The combination of agents usec within the methods and pharmaceutical compositions deescribed herein may have a therapeutEc additive or synergistic effect on the condition(s) or d3sease(s) targeted for treatment. The combination of agents used within the mmethods or phharmaceutical compositions described herein also may reduce a detrimental -effect associated w~ith at least one of the agents when adaministered alone or without the other a_gent(s) of the p=articular pharmaceutical composition For example, the toxicity of side effeects of one agent may be attenuated by another agent of “the composition, thus allowing a higher dosage, improv- iragpatient compliance, and improving therapeutic outcome. Physicians may achieve the clinical beenefits of previously recognized drugss while using lower dosage levels, thus minimizing aclverse side effects. The additive or synergistic effects, benefits, and advanta_ges of the coompositions apply to classes of therapweutic agents, either structural or functiconal classes, or to : iradividual compounds themselves.

The present methods and compositions relate to the treatment of amyloid—f diseases and conditions. As explained elsewhere he rein, the various diseases and conditioras involve several ba ological processes that produce the cBinically recognized disease or conditio n. The inventors believe that targeting more than one of these biological processes simultaneously by the concomitant methods described herein enhances the therapeutic benefits of thee individual agents.

Feorexample, potentiating the activity ofthe acetylcholine secreted by the remaining cholinergic nezurons by administering cholinesteras € inhibitors, while at the same time pre=venting further ne=uronal loss by enhancing clearance o~f AB from the brain, is clearly desirablee compared to the usse of only one individual treatment. Because the therapeutic targets outlined. herein are iradependent, yet interconnected, it is dezsirable to act on more than one target aat the same time. - 35 T-wo agents administered simultaneous 1y and acting on different targets may amct synergistically tc> modify or ameliorate disease progresssion or symptoms. Accordingly, one &mbodiment of the . im vention is concomitant therapy with ex pharmaceutical composition described herein. In anotheer embodiment, the combination of the first agent of the invention with a second (therapeu- ] tic) agent produces an enhanced therapeutic profile, for example, a profile that is greater than the sum o»f the benefits of the treatment with each aggent independently.

In addition, Alzheimer’s disease patients often suffer from secondary conditiors such as ’ 5 depre=ssion, delusions and psychosis, or sleep disturbance. From the point of view of e=ase of manu=facture, patient compliance, and ease of administration, it is advantageous to combine multipole medicines that the Alzheimer’s patient self-administers into one combined meaedicament.

Because of cognitive impairment, patient compli ance among Alzheimer’s disease patiesnts is very low, and therefore the methods and pharmaceutical compositions of the present invent _ion are especially advantageously applied to the treatmemt of this subject population because t his * combmnation of medicines is less likely to result iin forgotten doses and may produce ge-eater compMiance. Combination of the compounds of the invention (i.e., the first agents of the compositions discussed below) with other palliat ive medications, which may be for diseases other —than Alzheimer’s, is another beneficial app lication of the present invention.

In one embodiment, the pharmaceutical c ompositions disclosed herein prevent or inhibit Co amylcaid protein assembly into insoluble fibrils which, in vivo, are deposited in various organs, or it reve=rses or favors deposition in subjects already having deposits. In another embodi ment, the compound may also prevent the amyloid protein, in its soluble, oligomeric form or in its fibrillar form, from binding or adhering to a cell surface &and causing cell damage or toxicity. I nyet another embodiment, the composition may block. amyloid-induced cellular toxicity or mmicroglial activa-tion. In another embodiment, the compourad may block amyloid-induced neurotoxicity.

The pharmaceutical compositions of the i nvention may be administered therapeutically or prophylactically to treat diseases associated with amyloid—f3 fibril formation, aggregati on or : deposxtion. The pharmaceutical compositions of” the invention may act to ameliorate tine course of an @amyloid-P related disease using any of the following mechanisms (this list is me=ant to be illustrative and not limiting): slowing the rate of amyloid— fibril formation or depositi_on; lessen ing the degree of amyloid-f3 deposition; inhibiting, reducing, or preventing amy! o0id-B fibril Formation; inhibiting neurodegeneration or cellular toxicity induced by amyloid-[=3; inhibit- ing anyloid—P induced inflammation; or enhancing the clearance of amyloid-f from time brain.

The invention pertains to a pharmaceutical composition for the treatment of an -amyloid-p - diseas=e comprising a first agent and a second age mt in a pharmaceutically acceptable carrier, where the first agent prevents or inhibits amyloid— fibril formation, neurodegeneratiomn, or cellulamr toxicity; and the second agent is a therapeutic drug or nutritive supplement. . Similarly, the invention includes a pharmaceutical composition for the treatmerst of an amylo id-B disease comprising a first agent and a second agent in a pharmaceutically ac-ceptable

Rk carrier—, wherein the first agent prevents or inhibits amyloid—p fibril formation, neurode genera-

tion, or cellular toxicity; and the second agent is ea therapeutic drug or nutritive supplement, such i that cognitiwve function is stabilized or further detesrioration in cognitive function is gorevented, slowed, or s-topped. . In arother embodiment, the invention isa pharmaceutical composition for tke treatment - 5 ofanamylo id-B disease comprising a first agent &and a second agent in a pharmaceutically acceptable carrier, wherein the first agent prevents or inhibits amyloid-§ fibril form ation, neurodegenesration, or cellular toxicity; and the se=cond agent is a therapeutic drug or nutritive supplement,. such that activities of daily living otlnerwise impaired by an amyloid—{3 disease are improved or stabilized. .

In yet another embodiment, the invention is a pharmaceutical composition faor the treatment of= an amyloid disease comprising a first agent and a second agent in a gpharmaceuti- cally accept able carrier, wherein the first agent prevents or inhibits amyloid— fibril formation, neurodegeneeration, or cellular toxicity; and the se=cond agent is a therapeutic drug ox nutritive supplement., such that the pharmaceutical composition inhibits an interaction betwe=en an amyloidogemic protein and a glycoprotein or protesoglycan constituent of a basemen t membrane to thereby p revent or inhibit amyloid deposition.

Further aspects of the invention include a pharmaceutical composition for thme treatment ] of an amylo id-f disease comprising a first agent =and a second agent in a pharmacettically acceptable c=arrier, wherein the first agent prevent s or inhibits amyloid—3 fibril fornmation, neurodegeneeration, or cellular toxicity; and the se=cond agent is a therapeutic drug oar nutritive supplement, such that the concentration of amylo3d—[ or tau in the CSF of the subje=ct changes versus an urifreated subject.

A pharmaceutical composition for the treamtment of an amyloid—f3 disease is malso within the scope of= the invention in which the compositieon has a first agent and at least two second agents in a poharmaceutically acceptable carrier, wherein the first agent prevents or i nhibits amyloid—[3 #Fibril formation, neurodegeneration, omr cellular toxicity; and each of the second agent is a therapeutic drug or nutritive supplement.

Alsom included is a pharmaceutical compossition for the treatment of an amyloid-p disease comprising =a first agent and a second agent in a pharmaceutically acceptable carrier, wherein the ‘ first agent b inds amyloid--B; and the second agent is a therapeutic drug or nutritive Supplement; such that amyloid fibril formation, neurodegeneeration, or. cellular toxicity in the ssubject is prevented omr inhibited.

Anosher example of the invention is a pharmaceutical composition for the traeatment of an : amyloid—p clisease comprising a first agent and a second agent in a pharmaceutically acceptable carrier, wherein the first agent binds amyloid—P; zand the second agent is a therapeut=ic drug or nutritive supplement; such that cognitive function is sta_bilized or further deterioration in ecognit- . ive function is perevented, slowed, or stopped in the subJect.

In anotheer aspect, the invention pertains to a ph=armaceutical composition for the t-reat- i ment of an amyl oid—B disease comprising a first agent &and a second agent in a pharmaceutically acceptable carrier, wherein the first agent binds amyloicd-$; and the second agent is a thexapeutic drug or nutritive supplement; such that activities of dail y living otherwise impaired by thee amyloid disease are improved or stabilized in the sul>ject.

The invesntion also includes a pharmaceutical cammposition for the treatment of an amyloid-P disease comprising a first agent and a secon=d agent in a pharmaceutically acceptable carrier, wherein the first agent binds amyloid—[3; and thee second agent is a therapeutic drumg or nutritive supplemment; such that the pharmaceutical com position inhibits an interaction bestween an amyloidogen ic protein and a glycoprotein or proteogelycan constituent of a basement membrane to thesreby prevent or inhibit amyloid deposistion in the subject.

Furthermore, the invention may be a pharmacewmtical composition for the treatmemat of an 1s amyloid— disease comprising a first agent and a secon agent in a pharmaceutically acceptable carrier, wherein the first agent binds amyloid—3; and thee second agent is a therapeutic drumg or nutritive supplemxnent; such that the concentration of am—yloid— or tau in the CSF of the stabject changes versus an untreated subject.

In anotheer representation, the invention is a phamrmaceutical composition for the treeatment of an amyloid—{3 disease comprising a first agent and at least two second agents in a pharsna- ceutically acceptable carrier, wherein the first agent bin. ds amyloid—; and the second age=nt is a therapeutic drugs or nutritive supplement; such that amy loid—8 fibril formation, neurodegenera- tion, or cellular toxicity in the subject is prevented or in. hibited.

The inve=ntion also relates to methods of makings pharmaceutical compositions for use in the therapeutic &and prophylactic methods described here=in. The first agent and the second agent are supplied as &a pharmaceutical product, and they may be packaged in separate containemrs for sale or delivery +o the consumer. The first agent and thee second agent may be dissolved i. na liquid pharmace=utically acceptable carrier, or they may be provided in a solid formulatior, for example, as a homogenous mixture in a capsule or pill. The pharmaceutical composition=s may ‘30 further comprises a pharmaceutically acceptable acid, basse, buffering agent, inorganic salt, solvent, or presesrvative. Furthermore, the pharmaceutical compositions of the invention mmay also include a compound that increases the cerebral bioaavailability of either the first agent or the second agent. T he invention also relates to the use of a first agent and a second agent in t=he . preparation of a pharmaceutical composition for the treatment or prevention of an amyloied-3 disease compris ing a first agent and a second agent in a pharmaceutically acceptable carri_er,

wherein th e first agent prevents or inhibits amyloid—p fibaril formation, neurodegeneration, or cellular toxicity; and the second agent is a therapeutic dria g or nutritive supplement.

Pharmaceutical compositions of the invention may be effective in controlling amyloid— IB deposition either following their entry into the brain (following penetration of the blood brain ) 5 barrier) or from the periphery. When acting from the periphery, a compound of a pharmaceutical composition may alter the equilibrium of AB between the brain and the plasma so as to favor time exit of AB from the brain. An increase in the exit of A} fTom the brain would result in a decrease iri AP brain concentration and therefore favor a decrease in Ap deposition. Alterna- tively, compounds that penetrate the brain could control deposition by acting directly on brain

AP e.g, by maintaining it in a non-fibrillar form or favori ng its clearance from the brain, or protecting brain cells from the detrimental effect of Af}. “These compounds could also prevent

AB in the brain from interacting with a cell surface and therefore prevent neurotoxicity or : inflammat3on.

In some aspects the pharmaceutical compositions «of the invention contain a first agent that preverts or inhibits f-amyloid fibril formation, either in the brain or other organ of interest (acting locally) or throughout the entire body (acting systesmically). Without wishing to be bound by theory, the inventors believe that the first agent as described herein may inhibit or reduce an dnteraction between amyloid—fB and a cell surface constituent, for example, a glycosamimoglycan or proteoglycan constituent of a baserment membrane, and that inhibiting or reducing this interaction is primarily responsible for the o bserved neuroprotective effects. For example, t he first agent may also prevent an amyloid—f3 peptide from binding or adhering to a cell surfaces, a process which is known to cause cell damage or toxicity. Similarly, the first agemt may block amyloid-induced cellular toxicity or microglial activation or amyloid-induced } neurotoxic=ity, or inhibit amyloid-p induced inflammatiorm. The first agent may also reduce the - rate or amount of B-amyloid aggregation, fibril formation, or deposition, or the first agent lessemns the degree of amyloid—f deposition. The first agent may also inhibit, reduce, or prevent amyloid—{3 fibril formation.

Ad ditionally, the first agent may enhance the clear-ance of amyloid—3 from the brain; or the first ag-ent may favorably alter the equilibrium of amy doid-p between the brain and the plasma to adecrease the amount of amyloid-P in the brain. The first agent may lower the levels of amyloid B peptides, e.g., both AB40 and AB42 in the CSF and the plasma, or the first agent maxy lower the I evels of amyloid P peptides, e.g., AB40 and A342 in the CSF and increase it in the plasma.

Regardless of the particular mechanism by which he first agent exerts its biological : 35 effects, thes first agent prevents or treats amyloid-B diseases, such as for example Alzheimer’s disease. T he first agent may reverse or favor deposition o»f amyloid in a subject having amyloicl - deposits, o»r the first agent may favor plaque clearance or slow deposition in a subject having amyloid deposits. For example, the first agent decreases the= amyloid— concentration in the= i brain of a subject versus an untreated subject, and the first amgent penetrates into the brain, th atis, it crosses the blood-brairn barrier (“BBB”) where is exerts it= biological effect. Therefore, thes first agent may maintain soluble amyloid in a non-fibrillar form.. Accordingly, the first agent may ) 5 . increase the rate of clearance of soluble amyloid from the brain of a subject versus an untreated subject. :

The invention alsso includes a method of concomitarmt therapeutic treatment of a subject, comprising administerin gto a subject in need thereof an effective amount of a pharmaceutic=al composition for treating or preventing an amyloid} diseases, said pharmaceutical compositi on comprising a first agent -and a second agent in a pharmaceutically acceptable carrier, whereimn said first agent prevents or inhibits amyloid fibril formation, neurodegeneration, or cellular toxicity; and said second agent is a therapeutic drug or nutritive supplement.

Also within the purview of the invention is a method of concomitant therapeutic treatment of a subject, comprising administering to a subjec=t in need thereof an effective am ount of a pharmaceutical commposition for treating or preventing =an amyloid—f disease, said pharrmna- ceutical composition cornprising a first agent and a second aagent in a pharmaceutically acceptable carrier, wheresin said first agent prevents or inhibits amyloid fibril formation, neurodegeneration, or cellular toxicity; and said second age nt is a therapeutic drug or nutriti-ve supplement, such that cognitive function is stabilized or fur—ther deterioration in cognitive function is prevented, slcowed, or stopped.

Similarly, the invvention is a method of concomitant therapeutic treatment of a subjec=t, comprising administerin gto a subject in need thereof an effective amount of a pharmaceutic=al composition for treating or preventing an amyloid-p disease, said pharmaceutical compositi on comprising a first agent and a second agent in a pharmaceutically acceptable carrier, whereim said first agent prevents or inhibits amyloid—p fibril formatiz on, neurodegeneration, or cellular toxicity; and said seconc agent is a therapeutic drug or nutritive supplement, such that activities of daily living otherwise= impaired by said amyloid—f diseasse are improved or stabilized.

In another embociiment, the invention is a method of concomitant therapeutic treatment of a subject, comprising administering to a subject in need thereof an effective amount of a pharmaceutical composi tion for treating or preventing an armyloid—f disease, said pharmaceutical composi tion comprising a first agent and a second agent in a pharmaceutical ly . acceptable carrier, wherein said first agent prevents or inhibwits amyloid fibril formation, neurodegeneration, or cesllular toxicity; and said second age nt is a therapeutic drug or nutritive

Rk supplement, such that sa_id pharmaceutical composition inhibits an interaction between an amyloidogenic protein a-nd a glycoprotein or proteoglycan constituent of a basement membraane to thereby prevent or infmibit amyloid deposition.

In yet amother embodiment, the invention ma_y be a method of concomitant therapeutic ] treatment of a ssubject, comprising administering to as subject in need thereof an effective amount of a pharmaceutical composition for treating or preveenting an amyloid—( disease, samid pharmaceutical composition comprising a first agent and a second agent in a pharmaceutically ) 5 acceptable carrilier, wherein said first agent prevents cr inhibits amyloid—3 fibril formmation, neurodegenerat ion, or cellular toxicity; and said seccond agent is a therapeutic drug oor nutritive supplement, sucsh that the concentration of amyloid— 13 or tau in the CSF of said subject changes versus an untrezated subject.

The inveention also pertains to a method of coencomitant therapeutic treatmen—t of a subject, comprising administering to a subject in need thereo—f an effective amount of a pharrmaceutical composition fom treating or preventing an amyloid—-3 disease, said pharmaceutical composition comprising a fimrst agent and at least two second agents in a pharmaceutically accepteable carrier, wherein said fir-st agent prevents or inhibits amyloid— fibril formation, neurodegeneas=ration, or cellular toxicity=; and each of said second agent is a tEnerapeutic drug or nutritive supplement.

In other aspects, the invention is a method of ~ concomitant therapeutic treatm_ent of a subject, comprising administering to a subject in nee d thereof an effective amount ofa . pharmaceutical composition for treating or preventin_g an amyloid—f disease, said plarmaceuti- cal compositiorm comprising a first agent and a seconed agent in a pharmaceutically acceptable carrier, whereim said first agent binds amyloid—3; anc said second agent is a therapewutic drug or nutritive supple ment; such that amyloid— fibril formation, neurodegeneration, or ce=llular toxicity in said subject is prevented or inhibited.

In further aspects, the invention is a method of concomitant therapeutic treatmment of a subject, comprissing administering to a subject in necead thereof an effective amount o=fa pharmaceutical composition for treating or preventin gan amyloid disease, said ptarmaceuti- cal compositions comprising a first agent and a second agent in a pharmaceutically acceptable carrier, wherein_ said first agent binds amyloid—83; anc said second agent is a therapec.tic drug or nutritive supplement; such that cognitive function is stabilized or further deterioratiomn in cognitive functi on is prevented, slowed, or stopped ir said subject.

Another- method of concomitant therapeutic tareatment of a subject of the inve=ntion comprises admi nistering to a subject in need thereof san effective amount of a pharmaaceutical composition for- treating or preventing an amyloid—f3 disease, said pharmaceutical cowmposition comprising a fir-st agent and a second agent in a pharmaceutically acceptable carrier, wherein said first agent Ebinds amyloid—p; and said second age=nt is a therapeutic drug or nutri—tive supplement; such that activities of daily living otherwise impaired by said amyloid—[3 disease are improved or stabilized in said subject.

Additionally, the invention pertains to a methodll of concomitant therapeutic treatmemnt of a ] subject, cormprising administering to a subject in need thereof an effective amount of a pharmaceutical composition for treating or preventing an amyloid disease, said pharmacesuti- cal compos ition comprising a first agent and a second Agent in a pharmaceutically acceptab-le : 5 carrier, wherein said first agent binds amyloid—f3; and ssaid second agent is a therapeutic drumg or nutritive supplement; such that said pharmaceutical cormposition inhibits an interaction betvaveen an amyloidegenic protein and a glycoprotein or proteoglycan constituent of a basement membrane ®o thereby prevent or inhibit amyloid deposi tion in said subject.

A fiarther example of the invention is a method of concomitant therapeutic treatmen tof a subject, cormnprising administering to a subject in need thereof an effective amount of a pharma- ceutical cormnposition for treating or preventing an amyl oid—8 disease, said pharmaceutical compositiomn comprising a first agent and a second agert in a pharmaceutically acceptable c=arrier, wherein sai.d first agent binds amyloid—p; and said second agent is a therapeutic drug or nutritive supplement=; such that the concentration of amyloid—B or tau in the CSF of said subject chamnges versus an u nireated subject.

In a nother embodiment, the invention is a meth-od of concomitant therapeutic treatment of a subjects, comprising administering to a subject in n-eed thereof an effective amount of a pharmaceutical composition for treating or preventing aan amyloid disease, said pharmaceeuti- cal compos ition comprising a first agent and at least tw=o second agents in a pharmaceutical ly acceptable «carrier, wherein said first agent binds amyloeid—f3; and said second agent is a ther-a- peutic drug or nutritive supplement; such that amyloid— fibril formation, neurodegeneration, or cellular tox icity in said subject is prevented or inhibited.

As wused herein, “combination therapy” or “therapeutic combination” means the administration of two or more “first agents,” e.g., compounds represented by Formulae (I->=), or administration of one or more first agents, such as com pounds represented by Formulae (I-=X) with other Alzheimer’s disease treatments different froom the first agent, as discussed below, e.g., cholesterol biosynthesis inhibitors or lipid-lowering ag=ents, to prevent or treat Alzheimer’s

Disease, by~ for example reducing levels of one or mores amyloid B peptides, regulating production of amyloid B peptides or regulating levels o-f ApoE isoform 4 in the bloodstrean— or the brain. Such administration includes coadministratieon of these therapeutic agents in a substantially simultaneous manner, such as in a single ®tablet or capsule having a fixed ratio of active ingrezdients or in multiple, separate capsules for eeach therapeutic agent. Also, such administration includes use of each type of therapeutic agent in a sequential manner. In eitlzer case, the trezatment using the combination therapy will provide beneficial effects in treating the : 35 condition. A potential advantage of the combination ttmerapy disclosed herein may be a red uction in the required amount of an individual therapeutic compound or the overall total amount o-f . therapeutic- compounds that are effective in treating the= condition. By using a combination of therapeutic ageents, the side effects of the individual compounds can be reduced as com_pared to a monotherapy, which can improve subject compliance. Also, therapeutic agents can be =selected to provide a broaxder range of complimentary effects or complimentary modes of action. . Accorcling to the invention, “combination therapy” also includes simultaneous co-administrat_ion of a first agent (e.g., an alkanesulfomic acid) and a second agent; and the term also includes rmethods comprising the steps of administration of the first agent, followe=d by the second agent, or treatment and administration of the second agent, followed by admini=stration of the first agent.

Some general examples of compounds that many be used as a second agent acco-rding to the invention Enclude neuro-transmission enhancers; pesychotherapeutic drugs; acetylch oline- esterase inhibi. tors; calcium channel blockers; biogeni« amines; benzodiazepine tranquiz lizers; acetylcholine =synthesis, storage, or release enhancers; acetylcholine postsynaptic recepmtor agonists; moneoamine oxidase-A or —B inhibitors; N-mraethyl-D-aspartate glutamate rece=ptor antagonists; neonsteroidal anti-inflammatory drugs; antioxidants; and serotonergic recepotor antagonists.

Additiconal examples of compounds that may oe used as a second agent according to the invention incleuide agents that enhance acetylcholine sy/nthesis, storage, or release, such as phosphatidylcBholine, 4-aminopyridine, bifemelane, 3,4-diaminopyridine, choline, vesammicol, secoverine, bifemelane, tetraphenylurea, and nicotinaxmnide; postsynaptic receptor agonists, such as arecoline, o=Xotremorine, bethanechol, ethyl nipeco®ate, and levacecarnine; N-methyl -

D-aspartate glutamate receptor antagonists, such as m jlacemide and memantine; specif ic monoamine o>idase A inhibitors, such as moclobemicle; monoamine oxidase B inhibitcors, such as selegiline; t“hiamine and sulbutiamine; D-cycloserirae; anfacine; linopirdine; deferox=amine and nonsteroidal a-nti-inflammatory drugs; serotoneregic receptor antagonists, such as ketarserin and mianserin; vassodilator or other nootropic direct brain ametabolic enhancer drugs such ass idebenone, propentophylline, pentoxifylline, citicoline, piracetam, oxiracetam, aniracet-am, pramiracetam, . pyroglutamic acid, tenilsetam, rolziracestam, etiracetam, dupracetam, virapocetine (Cavinton™, CChemical Works of Gedeon Richter, Ltc1., Budapest, Hungary), ebiratide,_

B-carbolines, raloxone, ergoloid mesylates (e.g., Hydergine), cyclandelate, isoxsuprene=, nafronyl, papauverine, suloctidil, vinburnine, vincamin e, vindeburnol, flunarizine, nimodipine, nicergoline, raszobazam, exifone, rolipram, sabeluzole_, phosphatidylserine, and ifenproedil; neurotransmis sion enhancers, such as amantadine, cal cium hopantenate, lisuride, bifenmelane, and indeloxazine; -tiapride, a selective D; antagonist; psycEotherapeutic drugs, such as halo: peridol, bromperidol, t-hioridazine, thiothixene, fluphenazine, poerphenazine, and molindone; an#tioxidants, ’ 35 such as tocoplnerols, ascorbic acid, and deferoxamine; acetylcholinesterase inhibitors, ssuch as physostigmine= (optionally with lecithin), heptylphysosstigmine, tetrahydroaminoacridin_e (tacrine) : and a the relateed compound 9-amino-1,2,3,4-tetrahydr-oacridin-1-ol, metrifonate, velnaecrine maleate, sulfonyl fluorides (e. g., methanesulfonyl fluoride and phenylmeshanesulfony! fluoride), } huperzines A and B, edrophorium and miotine and derivatives therof; cal cium channel blocker agents, such as diltiazem, verapamil, nifedipine, nicardipine, isradipine, amlodipine and felodipine; biogenic amines and related compounds, such as clonidine (a noradrenergic ; 5 ag-receptor agonist), guanfacime (an adrenergic agonist), alaproclate, fipe=xide, zimeldine, and citalopram; anti-rage drugs, such as propranolol, carbamazepine, and fluosxetine; minor tranquilizers such as benzodiazepine agents; and angiotensin-converting enzyme inhibitors, such : as captopril (Capoten™ and Capozide™ (Bristol-Myers Squibb Co., New York, New York).

See, e.g, R. Anand, et al., Adw. Neurol. 51, 261-68 (1990); W.G. Bradley_ Muscle & Nerve 13, 833-42 (1990); V. Chan-Palay/, Psychopharmacology 106, S137-S139 (15392); J.K. Cooper, et al., Arch. Intern. Med. 151, 245-49 (1991); N.R. Cutler, et al., Ann. Pharrnacother. 26, 1118-22 (1992); P. Davies, Clin. Neuropharmacol. 14(Suppl. 1), S24-S33 (1991); M.W. Dysken, et al., J.

Am. Geriatr. Soc. 40, 503-06 1992); S.H. Ferris, Acta Neurol. Scand. Suppl. 129, 23-26 (1990);

P.T. Francis, et al., Ann. N.Y. _Acad. Sci. 640, 184-88 (1991); D. Groo, et eal., Drug Dev. Res. 11, 29-36 (1987); A.L. Harvey, Av. Neurol. 51, 227-33 (1990); P.L. McGeenx, et al., Neurology 42, 447-49 (1992); L. Parnetti, et al., Eur. J. Clin. Pharmacol. 42, 89-93 (199®2); M. Shimizu, et al,

Alzheimer's Dis. Assoc. Disord. 5(Suppl. 1), 813-824 (1991); J.E. Sweeney, et al,

Psychopharmaceology 102, 19 1-200 (1990); PJ. Whitehouse, Alzheimer IDis. Assoc. Disord. 5(Suppl. 1), $32-836 (1991); and R.J. Wurtman, et al., Adv. Neurol. 51, 1 17-25 (1990).

In another aspect of the invention, the amyloid— peptide is a pept=ide having 39-43 amino-acids, which is an amy oidogenic peptide produced from BAPP.

The “amyloid-B disease” (or “amyloid-f related disease,” which ®erms as used herein are synonymous) may be Mild Cognitive Impairment; vascular dementia; Alz=heimer’s disease, including sporadic (non-hered itary) Alzheimer’s disease and familial (hereeditary) Alzheimer’s disease; cerebral amyloid angt opathy or hereditary cerebral hemorrhage; senile dementia;

Down’s syndrome; inclusion body myositis; or age-related macular degen-eration.

In another embodiment, the method is used to treat Alzheimer’s di sease (e.g., sporadic or . familial Alzheimer’s disease). The method can also be used prophylactically or therapeutically to treat other clinical occurrences of amyloid—B deposition, such as in Dovwn’s syndrome individuals and in subjects with cerebral amyloid angiopathy (“CAA”) or hereditary cerebral hemorrhage.

Cerebral amyloid angiopathy (‘CAA”) refers to the specific depos ition of amyloid fibrils : in the walls of leptomingeal and cortical arteries, arterioles and in capillaries and veins. It is commonly associated with Alzheimer’s disease, Down’s syndrome and ncormal aging, as well as with a variety of familial cond itions related to stroke or dementia (see Framngione, ef al., Amyloid:

J. Protein Folding Disord. 8, Suppl. 1, 36-42 (2001)). CAA can occur sporadically or be ' hereditary. Multiple mutation sites in either AB or the APP gene have bee=n identified and are clinically associated with either dementia or cerebral hemorrhage. Exemplary CAA disorders } include, but are not limited to, hereditary cerebral hemorrhage with amyloidosis of Icelandic type (HCHWA-I); the Dutch variant o f HCHWA (HCHWA-D; a mutation in AB»; the Flemish mutation of A; the Arctic mutat®on of Af; the Italian mutation of APB; the Iowa mutation of AB; i 5 familial British dementia; and farmilial Danish dementia.

Additionally, abnormal acscumulation of APP and of amyloid—f3 protesin in muscle fibers has been implicated in the patholeogy of sporadic inclusion body myositis (“I BM”) (Askanas, et al., Proc. Natl. Acad. Sci. USA 93, 1314-19 (1996); Askanas, et al., Current Opinion in

Rheumatology 7, 486-96 (1993)). Accordingly, the compounds of the invention can be used prophylactically or therapeutically in the treatment of disorders in which am=loid—PB protein is abnormally deposited at non-neurxrological locations, such as treatment of IBM by delivery of the compounds to muscle fibers.

Additionally, it has been shown that Ap is associated with abnormal eextraceltular deposits, known as drusen, that aeccumulate along the basal surface of the ret Anal pigmented epithelium in individuals with age-related macular degeneration (ARMD). ARMD is a cause of irreversible vision loss in older irmdividuals. It is believed that AP deposition. could be an important component of the local inflammatory events that contribute to atraephy of the retinal pigmented epithelium, drusen biogenesis, and the pathogenesis of ARMD (Jeohnson, ef al., Proc.

Natl. Acad. Sci. USA 99(18), 118 30-5 (2002)). Therefore, the invention also relates to the treatment or prevention of age-re lated macular degeneration.

The invention pertains to pharmaceutical compositions and methods «of use thereof for the treatment of amyloid-f diseases. The pharmaceutical compositions comprisse a first agent that, e.g, prevents or inhibits amyloid— fibril formation, neurodegeneration, or c=ellular toxicity. The pharmaceutical composition also comprises a second agent that is an active [pharmaceutical ingredient; that is, the second age=nt is therapeutic and its function is beyond that of an inactive ingredient, such as a pharmaceuti cal carrier, preservative, diluent, or buffer. The second agent may be useful in treating or preventing an amyloid—{3 disease or another neumrological disease.

The first and second agents may exert their biological effects by similar or umrelated mechanisms of action; or either one or both of the first and second agents may exert their biological effects by a multiplicity of mechanisms of action. A pharmaceutical composition may also comprise a third compound, or even more ye=t, wherein the third (and fourth, efc.) compound has the same characteristics of a second agent. The “second agent” is selected in accord with the following therapeutic principles. ’

W 0 2004/058258 WPCT/CA2003/002011

Pharmacologic Treatment of Alzheimer’s Disease and Other Amyloid—B Dis=eases

The pathology of Alzheimer’s dise=ase includes a number of character—istic components, including but not limited to $-amyloid deposits, such as diffuse plaques and =senile plaques; cytoskeletal pathology, such as hyperphossphorylated tau and paired helical fllaments; cholinergic ) 5 degeneration, such as basal cholinergic neuronal loss and reduced ChAT in c=ortex and septum; inflammation, such as gliosis; and cogniti ve and behavioral dysfunction, such as cognitive loss, apathy and aggression. To reflect the var#ed characteristics of the disease, a variety of therapeutic approaches to the disease haves been taken. To date, clinically va lidated treatments for Alzheimer’s disease remain confined ®0 symptomatic interventions such &as treatment with enhancers of cognitive function, e.g., acetylcholinesterase, acetyl/ butyrylchomlinesterase inhibitors, or NMDA receptor antagonists: . There are no treatments known to slow the rate of cognitive decline in subjects.

Several broad therapeutic strategie=s for disease-modifying agents are currently being approached. These include, for example, the following: inhibiting the B and gamma- secretase enzymes that generate AP from APP; preventing oligomerization or fibrilloge=nesis of Ap or enhancing its clearance from the brain, e.&. by active or passive immunizatiomn with AB, by administering anti-fibrillogenic small mol «cule compounds or peptides, or by~ metal chelation; blocking or inhibiting inflammation and n eurodegeneration induced by AB; mreducing the formation of phosphorylated Tau protein i nthe neurofibrillary tangles; and nmodulating cholesterol homeostasis. A range of compounds with antioxidant, neuroprote=ctive or neurotrophic properties are contemplated or treating Alzheimer’s disease; nummerous approaches such as these and others are intended to be= within the scope of the invention. =See, e.g., I. Hardy, et al., Science 297, 353-56 (2002).

There are many different mechanisms by which these therapeutic appmroaches could treat

Alzheimer’s disease. For example, vaccirx ation therapy could stimulate an inmmune response against A} peptides, leading to clearance Of the peptides from the body. PB an d gamma- secretase inhibitors could lead to decreased production of AP peptides. Copper/zinc cha elators such as a. clioquinol could decrease the interaction o-f copper and zinc with AB peptides , leading to the clearance of amyloid plaques. Activating cx-secretase, which cleaves within A_f3, would be expected to decrease the production of AB and is thus another target.

Pathways involved in neurodegene ration or apoptosis are also targets —for therapeutic intervention. For example, the phosphory Ration of poly Q ataxin by the Akt k—inase is required for neurodegeneration, suggesting that the Akt kinase could be a target. Orr, et al., Neuron 38(3), 375-87 (2003); Zoghbi, et al., Cell W13(4), 457-68 (2003). Tau is foun in neurofibrillary : 35 tangles hyperphosphorylated and inhibitiox of the kinases involved in its phossphorylation, e.g.,

GSK-3, is also a target. See, e.g., WO 96/3 5,126.

Many strategies for targeting amyloid include, inter alia, preventing Oxidative damage . with anti-oxidants (e.g., melatonin, curcumin); inhibiting amyloid formation or deposition with anti-aggregation agents (e.g., peptides, metal chelators, glycosaminoglycan mimetics); altering

APP metabolism (e.g., with wo rtmannin or secretase inhibitors); shifting the equilibrium ’ 5 between levels of amyloidogen ic peptides in the periphery and the central ne xvous system (e.g., : with antibodies, vaccines, gelsolin, GMI, IGF-1) and decreasing microglial activation leading to inflammation (e.g., Fc, TGFBI).

Therapeutic treatment strategies may employ anti-fibrillogenic agents. For example, a therapeutic agent may bind to Ap to prevent or inhibit its fibril formation. Feor example, the

Mo 16-21 region of the AP peptide, KLVFFA, is responsible for the B-sheet formation and the intermolecular interactions of Ap during fibrillogenesis. Peptides from this region have been extensively tested for their anti fibrillogenic activity (Tjernberg LO, et al., J. _Biol. Chem. 272, 12601-05 (1997); Findeis, et aZ., Biochemistry 38, 6791-6800 (1999); Findeiss, et al., Amyloid, 231-41 (Dec 2001)). Agents, including non-peptidic agents, of the inventiorm may be used as an —15 anti-fibrillogenic agent in this way. The non-amyloidogenic pathway may be regulated through phosphorylation processes. Alteration of PKC levels and activity is one of tke most consistent findings in Alzheimer’s disease brain tissue. In addition, altered signal trans duction mechanisms, particularly PKC, are found consistently in peripheral tissues fiom Alzheimer’s disease subjects suggesting that these changes are not secondary to neuronal loss and may be =o directly involved in Alzheimer ’s disease pathogenesis. Altered APP metabo lism is a key event in the amyloid cascade hypothesis. The studies on the role of PKC in the regzulated APP processing have established that the Ap forming amyloidogenic pathway and the a -secretase non-amyloidogenic pathway appear to be balanced. The target of PKC phosphorylation is not the APP molecule itself, yet the possibility that PKC targets directly the a-se=cretase or other key 25 cellular factors possibly related to the vesicular trafficking of APP or the as ecretase, has not been resolved. M. Racchi, et aZ., Experimental Gerontology 38, 145-57 (200 3). Neurofibrillary tangles are composed of hyperphosphorylated tau proteins. One or more kirmases are principally responsible for initiating the hy/perphosphorylation of tau in vivo that leads te its apparent dissociation from microtubules and aggregation into insoluble paired helical filaments. 30 Hyperphosphorylation of tau may underlie tangle formation in Alzheimer's «disease. Caipain is responsible for cleavage of p35 and treating cells with AB aggregates can tri gger p35 activation and the subsequent cdk5-mediated phosphorylation of tau and perhaps other cytoplasmic substrates. D. Selkoe, Physiol_ Rev. 81(2), 741-66 (2001). Suitable agents f or use in the invention may target any of these biological processes. . 35 In some cases, one drug may target more than one therapeutic approach. For example, studies suggest that butyryl cholinesterase inhibitors which inhibit the activity of the . cholinesterase enzyme are also associated with Ap (Darvesh, et al., Cell. Mol. Neurobiol. 21,

285-96 (2001)). Phens.-erine, an acetylcholinesterase inhibito r, may inhibit both the activitZy of . the acetylcholinesterasee enzyme and the processing or translaation of the APP mRNA.

Cholesterol-lowering di rugs such as statins, e.g. avorstatin, could increase processing of anmyloid precursor protein by alppha-secretase, ieading to the decreasecd production of Af peptides.

Nonsteroidal anti-inflammmatory drugs such as ibuprofen, flur—biprofen, indomethacin, and : sulindac sulphide, coul_d selectively inhibit the production of ~ the AB42 peptide, in additiora to inhibiting the inflammazztion induced by AB. The decrease in AP42 peptide that occurs in transgenic mice when administered fluribuprofin, marketed zs Ansaid™ (Upjohn, now Pfmizer,

New York, New York)e, which is in Phase II human clinical trials Myriad Genetics, Inc. (Ssalt

Lake City, Utah), has boeen correlated with improved memor—y and special learning.

The method rel ates to a method for treating or preverating an amyloid—f related dissease by administering at lea_st two agents, each of which is a compound that exerts a therapeutic effect . when so administered znd is useful in treating or preventing _a neurological or psychologic=al condition or disease. Whe first compound of the invention, a=s described further below, ma_y be an alkanesulfonic acid thamt is useful for treating or preventing amn amyloid—f related disease. The second compound is thmerapeutic, i.e., its function is beyond that of an inactive ingredient, such as a pharmaceutical carrier, preservative, diluent, or buffer. Th € second compound may be useful in treating or preventirmg an amyloid—p related disease or aneother neurological disease. Time second compound may~ also be useful in diminishing specific symptoms which are characteristic of Alzheimer’s disease= (e.g. memory loss, anxiety, etc.) The first and second compounds ray . exert their biological e ffects by similar or unrelated mechani sms of action; or either one omr both of the first and second compounds may exert their biological effects by a multiplicity of mechanisms of action. A third compound, or even more yet,. may likewise be used in a meethod of the invention, where=in the third (and fourth, etc.) compoumnd has the same characteristic=s of a : second compound. .

In one embodirment, pharmaceutical compositions of the invention are formulated =o be orally administered to a subject. The first agent and said sec-ond agent may be simultaneously administered. The firs.t agent and the second agent may mocHulate different biological processes in the pathogenesis of . Alzheimer’s disease. The first agent znd the second agent may act son different targets. For eexample, the first agent may be therape=utically useful in the treatme nt of

Alzheimer’s disease, a nd the second agent may be therapeutmcally useful in the treatment Of

CAA. The first agent =and the second agent may have different binding affinities or specificities for peptides, proteins, or enzymes involved in the pathogene sis of Alzheimer’s disease. The first agent and the second a_gent, when simultaneously present in a subject, act synergistically t=o . 35 reduce, inhibit, or ame=liorate the symptoms or pathogenesis of Alzheimer’s disease.

The term “subj ect” includes living organisms in which amyloidosis can occur, or v=vhich : are susceptible to amy Joid diseases, e.g., Alzheimer’s diseasee. Examples of subjects incluzde humarms, monkeys, cows, sheep, goats, dogs, cats, amice, rats, and transgenic species the=reof, . Administration of the compositions of the present invention to a subject to be treated caan be carriecd out using known procedures, at dosages an. d for periods of time effective to moedulate amyloid aggregation or amyloid-induced neurotoxicity in the subject as further describ -ed herein, 5s An effective amount of the therapeutic compound necessary to achieve a therapeutic ef~fect may vary asccording to factors such as the amount of amyloid already deposited at the clinical site in the sulbject, the age, sex, and weight of the subject ,, and the ability of the therapeutic co mpound to mociulate amyloid aggregation in the subject. [Dosage regimens can be adjusted to p ovide the optimum therapeutic response. For example, seve ral divided doses may be administerezd daily or the do sc may be proportionally reduced as indicated by the exigencies of the therapeutic situation.

In an exemplary aspect of the invention, the subject is a human. For example, t-he subject : may b ea human over 40 years old, or a human over 50 years old, or a human over 60 years old, _or eve n a human over 70 years old. The subject nmay be a female human, including a postm enopausal female human, who may be on hormone (estrogen) replacement therapy. The subjec=t may also be a male human.

A subject may be a human at risk for Alzheimer’s disease, e.g., being over the age of 40 or hav~ing a predisposition for Alzheimer’s diseases. Alzheimer’s disease predisposing —factors identified or proposed in the scientific literature immclude, among others, a genotype predisposing a subjeect to Alzheimer’s disease; environmental factors predisposing a subject to Alzhesimer’s diseas:e; past history of infection by viral and bacterial agents predisposing a subject to

Alzhe imer’s disease; and vascular factors predisposing a subject to Alzheimer’s disease, A subjecst may also have one or more risk factors for- cardiovascular disease (e.g., atheros: clerosis of the co-ronary arteries, angina pectoris, and myocardial infarction) or cerebrovascular di sease (e.g., satherosclerosis of the intracranial or extracraanial arteries, stroke, syncope, and treansient ischermic attacks), such as hypercholesterolemia, Ixypertension, diabetes, cigarette smoking, famili al or previous history of coronary artery disease, cerebrovascular disease, and cardicovascular disease. Hypercholesterolemia typeically is defined as a serum total cholesterol conce tration of greater than about 5.2 mmol/L (a bout 200 mg/dL).

Several genotypes are believed to predispose a subject to Alzheimer’s disease. These include the genotypes such as presenilin-1, presen.ilin-2, and amyloid precursor proteira (APP) missense mutations associated with familial Alzheimer’s disease, and a-2-macroglobu lin and _ LRP-1 genotypes, which are thought to increase tkne risk of acquiring sporadic (late-onset)

Alzhesimer’s disease. E.van Uden, et al., J. Neurosci. 22(21), 9298-304 (2002); J.J.Go to, et al, ) 35 J. Mo 1. Neurosci. 19(1-2), 37-41 (2002). Another genetic risk factor for the developmeent of

Alzhesimer's disease are variants of ApoE, the gerne that encodes apolipoprotein E (particularly : the apooE4 genotype), a constituent of the low-den sity lipoprotein particle. WJ Strittmantter, et al,

Annu. Rev. Neurosci. 19, 53 -77 (1996). The molecular mechanism=s by which the various AposE alleles alter the likelihood of developing Alzheimer’s disease are urmknown, however the role of

ApoE in cholesterol metabo lism is consistent with the growing bod. y of evidence linking cholesterol metabolism to Alzheimer’s disease. For example, chromic use of cholesterol- ’ s lowering drugs such as stati ns has recently been associated with a leower incidence of

Alzheimer’s disease, and cha olesteroi-lowering drugs have been shoswn to reduce pathology in

APP transgenic mice. These and other studies suggest that cholesterol may affect APP processing. Environmental factors have been proposed as predispowsing a subject to Alzheimer’s disease, including exposure to aluminum, although the epidemiological evidence is ambiguous.

In addition, prior infection by certain viral or bacterial agents may gpredispose a subject to

Alzheimer’s disease, includ ing the herpes simplex virus and chlam_ydia pneumoniae. Finally, other predisposing factors feor Alzheimer’s disease can include risk factors for cardiovascular or cerebrovascular disease, including cigarette smoking, hypertension and diabetes. “At risk for

Alzheimer’s disease” also encompasses any other predisposing facsors not listed above or as y—et identified and includes an itcreased risk for Alzheimer’s disease caused by head injury, medications, diet, or lifestyle.

The methods of the present invention can be used for one om more of the following: to prevent, to treat Alzheimer” s disease, or ameliorate symptoms of A_lzheimer’s disease, to regu Mate production of or levels of armyloid B (AB) peptides or regulate the amount of ApoE isoform 4 Hin the bloodstream or brain of a subject. In one alternative embodime=nt, the human carries one Owr more mutations in the geness that encode B-amyloid precursor prote=in, presenilin-1 or presenilin-2. In another altemative embodiment, the human carries the Apolipoprotein £4 gen e.

In another alternative embo diment, the human has a family history of Alzheimer’s Disease or dementia illness. In another alternative embodiment, the human has trisomy 21 (Down’s

Syndrome). In another altexnative embodiment, the subject has a mormal or low serum total blood cholesterol level. In amnother embodiment, the serum total bicoad cholesterol level is less than about 200 mg/dL, or le=ss than about 180, and it can range frormn about 150 to about 200 : mg/dL. In another embodirment, the total LDL cholesterol! level is less than about 100 mg/dL, or less than about 90 mg/dL ard can range from about 30 to about 1060 mg/dL. Methods of measuring serum total bloo«d cholesterol and total LDL cholesterol are well known to those skilled in the art and for example include those disclosed in WO 95/38498 at p.11, incorporate=d by reference herein. Methods of determining levels of other sterols in serum are disclosed in Fd.

Gylling, et al., “Serum Ster ols During Stanol Ester Feeding in a M ildly Hypercholesterolemic ‘

Population”, J. Lipid Res. 4-0: 593-600 (1999). . 35 In another alternative embodiment, the subject has an eleva_ted serum total blood cholesterol level. In anothem embodiment, the serum total cholester—ol level is at least about 2000 ’ . mg/dL, or at least about 220 mg/dL and can range from about 200 —to about 1000 mg/dL. In

MNO 2004/058258 PCCT/CA2003/002011 another alternative embodiment, the ssubject has an elevated total LDL cholester=ol level. In ] another embodiment, the total LDL cholesterol level is greater than about 100 nmg/dL, or even greater than about 110 mg/dL and cam range from about 100 to about 1000 mg/dL. ] In another alternative embodi ment, the human is at least about 40 years of age. In another alternative embodiment, the human iss at least about 60 years of age. In another embodiment, the human is at least about 70 years of agze. In one embodiment, the human is between about 60 and 100 years of age.

In still a further embodiment, the subject is shown to be at risk by a diagmnostic brain imaging technique, for example, that measures brain activity, plaque deposition, or brain atrophy.

In another embodiment, the subject exhibits no symptoms of Alzheimer” s Disease. In another embodiment, the subject is a human who is at least 40 years of age and e=xhibits no symptoms of Alzheimer’s Disease. Ir another embodiment, the subject is a hum an who is at least 40 years of age and exhibits one or more symptoms of Alzheimer’s Disease.

By using the methods of the present invention, the levels of amyloid B peptides in a subject’s brain or blood can be reduc ed from levels prior to treatment from aboumt 10 to about 100 ' percent, or even about 50 to about 130 percent.

In an alternative embodiment, the subject can have an elevated level of ae myloid ABs and

ABgz peptide in the blood and CSF prior to treatment, according to the present methods, of greater than about 10 pg/mL, or greater than about 20 pg/mL, or greater than abeout 35 pg/mL, or even greater than about 40 pg/mL. Ir another embodiment, the elevated level off amyloid Ag peptide can range from about 30 pg/rmL to about 200 pg/mL, or even to about 500 pg/mL. One skilled in the art would understand thzat as Alzheimer’s disease progresses, the measurable levels of amyloid P peptide in the CSF may decrease slightly froin elevated levels pres ent before onset of the disease. This effect is attributed to increased deposition, i.e., trapping of «Ap peptide in the brain instead of normal clearance fro m the brain into the CSF.

In an alternative embodiment , the subject can have an elevated level of ammyloid AB4o peptide in the blood and CSF prior to treatment, according to the present methods, of greater than about 5 pg ABs/mL or greater than about 50 pg AB4/mL, or greater than about 400 pg/mL. In another embodiment, the elevated lewel of amyloid AP4o peptide can range from. about 200 pg/mL to about 800 pg/mL, to even about 1000 pg/mL.

In another embodiment, the subject can have an elevated level of amyloi d ABs; peptide in the CSF prior to treatment, according to the present methods, of greater than about 5 pg/mL, or ) greater than about 10 pg/mL, or greater than about 200 pg/mL, or greater than albout 500 pg/mL.

In another embodiment, the level of amyloid B peptide can range from about 10 pg/mL to about ’ 1,000 pg/mL, or even about 100 pg/mL to about 1,000 pg/mL.

In another embodiment, the subject can have an elevated level of amylo=id AB4o peptide in the CS F prior to treatment according to the present methods of greater than abosut 10 pg/mL, or greater— than about 50 pg/mL, or even greater th.an about 100 pg/mL. In another embodiment, the level 0 famyloid f peptide can range from abou t 10 pg/mL to about 1,000 pg/m.L. ) 5 The amount of amyloid P peptide in the brain or blood of a subject can Ese evaluated by enzymee-linked immunosorbent assay (“ELISA’ ) or quantitative immunoblottine g test methods or by quantitative SELDI-TOF which are well known to those skilled in the art, sumch as is disclosed by Zha_ng, et al., J. Biol. Chem. 274, 8966-72 (1 999) and Zhang, et al., Biocher istry 40, 5049-55 (2001) See also, A.K.Vehmas, et al., DNA CeZl Biol. 20(11), 713-21 (2001), P .Lewczuk, et al,

Rapid «Commun. Mass Spectrom. 17(12), 1291-96 (2003); B.M.Austen, et al., J_ Peptide Sci. 6, 459-69= (2000); and H.Davies, et al., BioTechnicgues 27, 1258-62 (1999). These= tests are perforrmed on samples of the brain or blood whi ch have been prepared in a man ner well known to one skilled in the art. Another example of a Liseful method for measuring lev—els of amyloid B peptide=s is by Europium immunoassay (EIA). See, e.g., WO 99/38498 at p.11.

In another embodiment, the amount of teotal ApoE in the bloodstream or brain of a subject can be reduced from levels prior to treatment by~ about 5 to about 75 percent, or_, in another embodiment, by about 5 to about 50 percent. Tkae amount of total ApoE can be =measured in a mannem well known to one skilled in the art, for example using an ELISA test kit such as Apo-

Tek ApoE test kit that is available from Organomn Teknica.

The methods of the invention may be ap plied as a therapy for a subject Iaving

Alzheimer’s disease or a dementia, or the methods of the invention may be appl ied as a prophylaxis against Alzheimer’s disease or dem entia for subject with such a pre=disposition, as in a subjesct, e.g., with a genomic mutation in the APP gene, the ApoE gene, or a p resenilin gene.

The subject may have (or may be predisposed to developing or may be suspecte=d of having) vasculamr dementia, or senile dementia, or Mild Cognitive Impairment. In additieon to

Alzheirmer’s disease, the subject may have another amyloid-p related disease stach as cerebral amyloiad angiopathy, or the subject may have amyloid deposits, especially amylcid-B amyloid deposit s in the subject’s brain.

Definitmon of Dementia

The essential features of a dementia are rnultiple cognitive deficits that imnclude memory impairronent and at least one of the following: aphasia, apraxia, agnosia, or a disturbance in . executi~ve functioning (the ability to think abstractly and to plan, initiate, sequen ce, monitor, and stop complex behavior). The order of onset and welative prominence of the cognIitive disturbances and associated symptoms vary with the specific type of dementia, as discussed im the following.

Memory impairment is generakly a prominent early symptom. Individuals with dementia have difficulty learning new material and may lose valuables, such as wallets andl keys, or forget food cooking on the stove, In more severe dementia, individuals also forget previ ously learned material, including the names of loved ones. Individuals with dementia may have- difficulty with ‘ § spatial tasks, such as navigating around the house or in the immediate neighborhcod (where difficulties with memory are unlikely to play a role). Poor judgment and poor insight are common as well. Individuals may exhibit little or no awareness of memory loss o-r other cognitive abnormalities. They may ma ke unrealistic assessments of their abilities and make plans that are not congruent with their deficits and prognosis (e.g, planning to start a ne2w business).

They may underestimate the risks involved in activities (e.g., driving).

In order to make a diagnosis of dementia, the cognitive deficits must be sufficiently severe to cause impairment in occupational or social functioning and must represe=nt a decline from a previous level of functioning. T he nature and degree of impairment are variable and often depend on the particular social setting of the individual. For example, Mild Cognitive

Impairment may significantly impair an individual’s ability to perform a complex= job but not a less demanding one.

Cognitive or degenerative brain disorders are characterized clinically by p=rogressive loss of memory, cognition, reasoning, judgment and emotional stability that gradually leads to profound mental deterioration and ultixmately death. It is generally believed that t he disease begins a number of years before it maraifests itself in the mild cognitive changes that are the early signs of Alzheimer’s disease. “Dementia of the Alzheimer’s Type” begins gradually, and is usually diagnosed after other specific causes have been ruled out. Diagnostic crit=eria for

Dementia of the Alzheimer’s Type inc lude the development of multiple cognitive= deficits : manifested by both memory impairment (anterograde or retrograde, i.e., impaired ability to leam new information or to recall previously learned information); and one or more of —the following cognitive disturbances: aphasia (language disturbance), apraxia (impaired ability to carry out motor activities despite intact motor function), agnosia (failure to recognize or ide=ntify objects despite intact sensory function), disturbance in executive functioning (i.e., plannirag, organizing, sequencing, and abstracting); where these cognitive deficits each cause significanst impairment in social or occupational functioning and represent a significant decline from a previ ous level of functioning. The course is characterized by gradual onset and continuing cognitive decline, and the cognitive deficits are not due to another condition that causes progressive deficits in memory and cognition (e.g, cerebrovascular disease, brain tumor, hypothyroidism, vitamir B or folic acid deficiency, niacin deficiency, hypercalcemia, neurosyphilis, HIV infection, o r chemical . 35 exposure). The cognitive disturbance rnay be accompanied by a behavioral distur bance, such as - wandering, aggression, or agitation, or a psychological disturbance, such as depre=ssion or psychosis. See “Diagnostic and Statist ical Manual of Mental Disorders,” 4™ Ed., “Text Revision,

by American Psychiatric Association (2000). For e=xample, the National Institute os fNeuro- . logical aud Communicative Disorders and Stroke-A\lzheimer’s Disease and the Alz=heimer’s

Disease and Related Disorders Association (NINCHEDS-ADRDA) criteria can be use=d to diagnose

Alzheime r’s Disease (McKhann ef al., 1984, Neurcalogy 34:939-944). The patient’ss cognitive ’ 5 function can be assessed by the Alzheimer’s Disease Assessment Scale-cognitive s ubscale (ADAS-c-og; Rosen, et al., 1984, Am. J. Psychiatry 141:1356-1364).

ABzheimer’s Disease is the prototype of a cortical degenerative disease. A mmajor componert of the presenting symptoms is usually subjective complaints of memory difficulty, language impairment, dyspraxia, at which point diamgnosis is primarily based on exclusion of other posssible etiologies for dementia. No features of the physical examination or laboratory evaluatior are pathognomonic for dementia of the ~Alzheimer’s type. Some studies: have apparentl=y discriminated patients with dementia of the Alzheimer’s type from patie=nts with dementia of other etiologies and from normal controls by using techniques such as EEG, MRI, + and SPECT, but these studies have been difficult tom replicate consistently, and at pr—esent, brain- imaging s=tudies are best used to exclude other iden=tifiable causes.

A variety of diagnostic tests have been deve=loped for Alzheimer’s disease. Clinical criteria heave been verified prospectively in autopsy studies and have been found to be highly specific a Ithough only moderately sensitive. Imple mentation of the criteria require s extensive evaluatiom, including an informant-based history, neurological examination, neuroyosychological testing, amd laboratory, and neuroimaging data. Alzheimer’s disease is characterize=d pathologically by generalized atrophy of the cerebraal cortex and by neurofibrillary —tangles, neuritic (@amyloid) plaques, and granulovacuolar de_generation. Although plaques a nd tangles may be destected in the brains of the elderly without= Alzheimer’s disease, they are rmore numerouss in patients with dementia. Controversy r—emains whether brains with plaques from individuals without Alzheimer’s diseasewere “nornmal variations” or early pathologzical signs of incipient «disease. A definitive diagnosis ultimately~ requires both the characteristic dementia in life and the characteristic pathology after death.

The natural course of Alzheimer’s disease i=s exacerbation and progression of clinical symptomatology. Brain degeneration as measured by in vivo imaging techniques such as MRI has not been found to correlate closely with the statze of clinical disease. The final azommon clinical picture is of a bedridden patient, wholly degpendent on others for all basic fi_nctions, even for turnin=g in bed. Nutrition can often be provided only by nasogastric or gastroint=estinal tubes.

The study of the pathobiology of Alzheimer—’s disease has identified at least four chromosomal loci associated with familial cases; thme degeneration of central neurochemical systems, especially basal forebrain structures relate d to acetylcholine-mediated ; neurotran.smission; factors associated with the formmation of plaques and tangles; an d exogenous ) (e.g., infectious and toxic) processes that may contribute to the development of spo radic cases. - ;

Although amyloid itsesIf is a normal brain product, excessiv € amounts of oligomeric or fibrallar } forms of AP may be meurotoxic.

For Alzheimer’s disease, advanced age and a family— history of the disease are the gi—eatest important risk factor . A family history of Down’s syndrome or of hematological malignamcies, such as leukemia, myezlolymphoma, or Hodgkin’s disease, i s also associated with an increased risk for Alzheimer’s disease. For Alzheimer’s disease, othe=rrisk factors identified tentative=ly in recent years include female sex, a past history of head trauma, and lower education. Vascu lar dementias are highly eassociated with the risk factors for cer=ebrovascular disease. Those factors include hypertension especially with systolic pressures greazter than 160 mmHg), cardiac disease, transient ischaemic attacks, diabetes mellitus, carotid bruits, and sickle cell disease.

Obesity, a sedentary |® festyle, tobacco use, alcohol consumption, and elevated serum cholesterol and lipid levels may a 1so be risk factors for cerebrovascular disease.

A general physsical examination is a routine compon-ent of the workup for Alzheimex’s disease. It may reveaE evidence of systemic disease causing= brain dysfunction, such as an enlarged liver and hepeatic encephalopathy, or it may demonstrate systemic disease related teo particular CNS proces-ses. Focal neurological findings, suck as asymmetrical hyperreflexia or weakness, are seen moore often.in vascular than in degenerat ive diseases. Frontal release sigmns and primitive reflexes_, while suggesting pathology in the frontal lobe, are present in many disorders and often powint to a greater extent of progression. The first step in the diagnosis omf

Alzheimer’s disease iss to exclude delirium, which may be d Jstinguished from dementia by its cardinal feature: disturbance of consciousness. Level of corasciousness or arousal should be= determined to be stabl-e before a diagnosis of Alzheimer’s dM seasecan be made with confidemnce.

It should also be distirmguished from focal or specific cognitive impairments, such as those sseen in aphasic or amnestic patients. Mood disorders can presen® with cognitive symptoms, particularly in the denmentia of depression or pseudodementi a. A history of a mood disorder—or a current disturbance in neurovegetative function indicates thes possibility of a major depressiwve disorder.

The course andl prognosis of a dementia syndrome vary with its cause. Alzheimer’s diseasedoes not necessarily equal progressive deterioration, although many of the pathobiological processses underlying dementia are degenera_tive. The rate of progression maay vary within families or from individual to individual. Age a—t onset is an important feature of

Alzheimer’s disease, thhe most common cause of dementia irm the United States. Onset usual ly occurs after age 60 years and the prevalence increases exporaentially with each successive decade, although casess have been reported in patients as young as 30 years. Familial forms of : 35 dementia of the Alzhe®mer’s type appear to have an earlier a_ge at onset. Cerebrovascular : disease, the second mcost common cause of Alzheimer’s dise=ase, is associated with an earliem age . at onset overall.

As a class, the dementias can be distinguished to some extent by their course, esspecially ) earlier in the disease process. Degenerative dermentias are insidious in onset and gradu ally prosgressive. Despite the clinical rule of a steadily progressive course in dementia of th_¢ '

Alzheimer’s type, some individuals may reach ax plateau for several years in the overall : 5 furmctional impairment before progression resumes and continues on to death. Vasculae- dermentias may follow a stepwise pattern, in wh ich new deficits appear abruptly and are ass ociated with new vascular events, but the vascular dementias also often have an insi dious onsset and a slow but steadily progressive courses. The first step in the treatment of dem-entia is ver-ification of the diagnosis. Preventive pharmacological agents include antihypertensive, anticoagulant, or antiplatelet agents. Blood pressure control has been demonstrated to Smprove cognitive function in patients with vascular derraentia, but it should be noted that antihy~pertensive bet a-blocking agents have been associated with exaggeration of cognitive impairment.

An giotensin-converting enzyme (“ACE”) inhibitors and diuretics have not been linked to the exaggeration of cognitive impairment and are thaought to lower blood pressure without affecting cerebral blood flow (cerebral blood flow is pres umed to correlate with cognitive functicon).

Sumrgical removal of carotid plaques may prevent subsequent vascular events in careful Ry selected patients.

Numerous neurotransmitters, including acetylcholine, dopamine, norepinephrin e, GABA, anc] serotonin, and several neuropeptides, inclucing somatostatin and substance P, are cdecreased in clementia. Multiple neuropharmacological starategies have been devised in the hope Of repelenishing the deficient neurotransmitters. Resplacement therapy for acetylcholine ha s been the moest common and widely publicized strategy. EE fforts at replenishment have included tlhe use of ace=tylcholine precursors, e.g., choline salycilate (Arthropan™, Purdue Pharma, L.P., Stamford,

Comnecticut) and lecithin from polyenylphosphatidylcholine (Phoschol™, Nutrasal LL aC,

Ox ford, Connecticut); cholinergic agonists, e.g. ,, arecoline (methyl N-methyltetrahydromnicotinate, ancl cholinesterase inhibitors, such as described herein. Instead of targeting a neurotrarmsmitter defect, other strategies are directed toward neuronal protection and regeneration. Selegziline (El depryl™, Somerset, Tampa, Florida), a monoamine oxidase (*"MAO”) type B (“MA O-B”) inh_ibitor, slows the progression of Parkinson’s disease, presumably by limiting endogemnous geraeration of destructive oxidative products, and the same effect may be used therapeutically in the treatment of Alzheimer’s patients. Similar antioxidant treatments are being used experimentally with other dementias, including Huntington’s disease and vascular demeentia.

Na Joxone (Narcan), an opiate antagonist, is thoraght to have possible application in vascular dermentia based on animal studies in which it was demonstrated to decrease the sequela=e of . 35 cer-ebral ischemia. See, e.g., C.Stowe, et al., Anx. Pharmacother. 277, 447-48 (1993). Nerve growth factor is being studied as a means of pro moting neural regeneration or sprouting.

‘ As used herein, “treatment” of a subject includes thee application or administration of "a composition of the in=vention to a subject, or application or administration of a composition ofthe invention to a cell or issue from a subject, who has a amyBoid— related disease or conditiomn, has a symptom of suc h a disease or condition, or is at risk cf (or susceptible to) such a disease or ) 5 condition, with the purpose of curing, healing, alleviating, mrclieving, altering, remedying, ameliorating, improvi ng, or affecting the disease or conditi=on, the symptom of the disease or~ condition, or the risk «of (or susceptibility to) the disease or condition. The term “treating” re=fers to any indicia of successs in the treatment or amelioration of an injury, pathology or conditior, including any objective or subjective parameter such as abamtement; remission; diminishing o=f symptoms or making “the injury, pathology or condition mo re tolerable to the subject; slowin gin the rate of degeneration or decline; making the final point of degeneration less debilitating; improving a subject’s physical or mental well-being; or, in some situations, preventing the omset of dementia. The treatment or amelioration of symptoms c=an be based on objective or subjeactive parameters; including the results of a physical examination or a psychiatric evaluation. For example, the methods of the invention successfully treat a ssubject’s dementia by slowing the rate of or extent of cogniti ve decline.

Also, the invexition relates to a method for preventirmag or inhibiting amyloid production in a subject. For example, such a method comprises administe=ring to a subject a therapeuticallmy effective amount of a pharmaceutical composition of the in—vention capable of reducing the concentration of AB, such that amyloid production or accur-mulation is prevented or inhibited

In another aspeect, the invention relates to a method —where at least the first compound is for preventing, reducimg, or inhibiting amyloid production Ena subject. For example, such a method comprises administering to a subject a therapeutica 1ly effective amount of a pharmaceutical composition capable of inhibiting AB accurmulation, such that Ap amyloidos isis prevented, reduced, or inhibited. “Inhibition” off amyloid deposition includes preventZing or stopping of amyloid forma=tion, e.g, fibrillogenesis, cMearance of soluble Af from brain, inl=zibiting or slowing down of further amyloid deposition in a subject with amyloidosis, e.g., already having amyloid deposits, and reducing or reversing amyloid fibrillogenesis or deposits in a subject with ongoing amyloido_sis.

Inhibition of amyloid deposition is determined relative to am untreated subject, or relative to the treated subject prior tO treatment, or, e.g., determined by cli. nically measurable improvement, e.g., or in the case of aa subject with brain amyloidosis, e.g., an Alzheimer’s or cerebral amyloid angiopathy subject, stabilization of cognitive function or presvention of a further decrease in cognitive function (i.e, preventing, slowing, or stopping disease progression), or improveme nt of : 35 parameters such as thes concentration of AB or tau in the CS F. “Modulation” of amyloid deposition includes both imnhibition, as defined above, and ’ enhancement of amyloid deposition or fibril formation. Thes term “modulating” is intended,

therefore, to encompass prezvention or stopping of amyloid formation cr accumulation, inhibition or slowing down of further amyloid aggregation in a subject with ongawing amyloidosis, e.g., already having amyloid aggregates, and reducing or reversing of amyloid aggregates in a subject with ongoing amyloidosis; and enhancing amyloid deposition, e.g., inc=reasing the rate or amount ) 5 of amyloid deposition in viwo or in vitro. Amyloid-enhancing compoumnds may be useful in animal models of amyloidosis, for example, to make possible the deve Mopment of amyloid deposits in animals in a shoerter period of time or to increase amyloid Cleposits over a selected period of time. Amyloid-erihancing compounds may be useful in screening assays for * compounds which inhibit asmyloidosis in vivo, for example, in animal rmodels, cellular assays and in vitro assays for amyloidosis. Such compounds may be used, for exazmple, to provide faster or more sensitive assays for compounds. In some cases, amyloid enhanci ng compounds may also be administered for therape utic purposes, e.g., to.enhance the depositiosn of amyloid in the lumen rather than the wall of cereboral blood vessels to prevent CAA. Modulation of amyloid aggregation is determined relative to an untreated subject or relative to the treated subject prior to treatment.

In an embodiment, the method is used to treat Alzheimer’s dise ase (e.g., sporadic or familial Alzheimer’s diseas €). The method may also be used prophylasctically or therapeutically to treat other clinical occurrences of amyloid—[B deposition, such as in I Down’s syndrome individuals and in subjects with hereditary or sporadic cerebral amyloid angiopathy (“CAA™), « which lead to cerebral hemorrhage (or hemorrhagic stroke).

Additionally, abnorrmal accumulation of APP and of amyloid—3 protein in muscle fibers has been implicated in the pathology of sporadic inclusion body myosimis (“IBM”) (Askanas, et al, Proc. Natl. Acad. Sci_ USA 93, 1314-19 (1996); Askanas, et al., CCurrent Opinion in

Rheumatology 7, 486-96 (1995)). Accordingly, the compounds of the Envention can be used } 25 prophylactically or therapevatically in the treatment of disorders in which amyloid-B protein is abnormally deposited at nor-neurological locations, such as treatment cf IBM by delivery of the compounds to muscle fibers.

Additionally, it has Ibeen shown that Af is associated with abno rmal extracellular deposits, known as drusen, that accumulate along the basal surface of tEze retinal pigmented epithelium in individuals with age-related macular degeneration (“ARND"™). ARMD is a cause of irreversible vision loss ine older individuals. It is believed that AP de=position could be an important component of the: local inflammatory events that contribute tao atrophy of the retinal pigmented epithelium, drusesn biogenesis, and the pathogenesis of ARMD (Johnson, ef al., Proc. :

Natl. Acad. Sci. USA 99(18», 11830-5 (2002)). ) 35 The present inventiosn therefore relates to the use of a first agent=, e.g., an alkanesulfonic acid compound, in the prevention or treatment of amyloid related dis eases, including, inter ’ . alia, Alzheimer’s disease, cerebral amyloid angiopathy, inclusion body myositis, Down’s syndrome, Mild Cognitive Impa irment, and macular degeneration, in co-mbination with a second therapeutic agent.

Accordingly, the invention relates to methods employing and commpositions including substituted or unsubstituted alky Isulfonic acids that are substituted or urmsubstituted ) 5 straight- chain alkylsulfonic acids, substituted or unsubstituted cycioall<ylsuifonic acids, and substituted or unsubstituted brant ched- chain alkylsulfonic acids. Also, it is noted that the term “alkylsulfonic acid” as used herein is to be interpreted as being synonymous with the term “alkanesulfonic acid.”

In another embodiment, the subject has mild cognitive impairme nt (MCI), which is a condition characterized by a state of mild but measurable impairment in thinking skills, but is not necessarily associated with the presence of dementia. MCI frequently, b—ut not necessarily, precedes Alzheimer’s disease. It isa diagnosis that has most often been =associated with mild memory problems, but it can also be characterized by mild impairments in other thinking skills, such as language or planning ski Ils. However, in general, an individual vovith MCI will have more significant memory lapses than would be expected for someone of their _age or educational background. As the condition progresses, a physician may change the di agnosis to Mild-to- ~~ -

Moderate Cognition Impairment, as is well understood in this art.

In one embodiment, the pharmaceutical compositions disclosed Imerein prevent or inhibit amyloid protein assembly into irasoluble fibrils which, in vivo, are depos ited in various organs, or itreverses or favors deposition ir subjects already having deposits. In amother embodiment, the agent may also prevent the amyloid protein, in its soluble, oligomeric fomrm or in its fibrillar form, from binding or adhering to a cell surface and causing cell damage or toxicity. In yet another embodiment, the agent may block amyloid-induced cellular toxi city or microglial activation. In another embodiment, the agent may block amyloid-induce=d neurotoxicity.

The pharmaceutical compositions of the invention may be admin istered therapeutically or prophylactically to treat diseases associated with amyloid— fibril formation, aggregation or ’ deposition. The pharmaceutical compositions of the invention may act to ameliorate the course ofan amyloid-f3 related disease wising any of the following mechanisms (this list is meant to be : illustrative and not limiting): slowving the rate of amyloid—p fibril format=ion or deposition; lessening the degree of amyloid—p deposition; inhibiting, reducing, or preventing amyloid-J3 fibril formation; inhibiting neuro degeneration or cellular toxicity inducecd by amyloid—; inhibiting amyloid—P induced inflammation; or enhancing the clearance «of amyloid- from the brain jor enhancing the catabolism or degradation of amyloid-p; or lowerring the levels of amyloid-B in the CSF; or modulating the levels of amyloid- in the plasrma.. Another way of ’ 35 decreasing AB could be that these compounds act on secretases so that A_p levels are reduced (as seen with proteoglycans).

Pharmaceutical compositions of the invention may be effective in controlling ammyloid— deposition either following their entry into the brain (fosllowing penetration of the blooed brain barrier) or from the periphery. When acting from the peeriphery, an agent of a pharmaceutical compositio-n may alter the equilibrium of AP between thhe brain and the plasma so as to= favor the ‘ 5 exitof AB from the brain. An increase in the exit of A{3 from the brain would result in a decrease ine AP brain concentration and therefore favor -a decrease in AB deposition. A lterna- tively, agerts that penetrate the brain could control deposition by acting directly on bra_in Ap, e.g., by maintaining it in a non-fibrillar form or favoringg its clearance from the brain or— enhancing its degradation rate in the brain or in the peri pheral organs. These agents may also prevent A[® in the brain from interacting with a cell surface and therefore prevent neurotoxicity or inflammation.

The= compositions of the invention may be admimnistered therapeutically or prophylact®cally to treat diseases associated with amylo id—f3 fibril formation, aggregatiaon, or deposition. The compositions of the invention may act to ameliorate the course of an a_myloid— related disease by a variety of mechanisms. In one emb>odiment, the pharmaceutical compositio ns disclosed herein prevent or inhibit amyloid protein assembly into insolub=Ie fibrils ~ which, in v ivo, are deposited in various organs, or it fav ors plaque clearance or slows d~eposition in subjects already having deposits. In another embodirment, the pharmaceutical compositions may also pmrevent the amyloid protein, in its soluble, olisgomeric form or in its fibrillar feorm, from binding or adhering to a cell surface and causing cell das mage or toxicity. In yet anothe r embodiment, the pharmaceutical compositions may blocck amyloid toxicity. In other embodiments, the agent may act be slowing the rate of amyloid fibril formation or desposition.

In yet another embodiment, the agent may lessen the de gree of amyloid—p deposition. Still other examples imclude inhibiting, reducing, or preventing arrmyloid-g fibril formation; inhibi ting neurodegereration or cellular toxicity induced by amyloid-B; inhibiting amyloid-pB ind uced inflammatieon; or enhancing the clearance of amyloid—3 from the brain brain or enhancing its degradatior rate in the brain or in the peripheral organs.

At Eeast one of the therapeutic agents of the inve=ntion may be effective in controlling amyloid—P deposition either following their entry into tEae brain (following penetration - of the blood braim barrier) or from the periphery. When acting from the periphery, an agent nay alter the equilibr-ium of Ap between the brain and the plasma_ so as to favor the exit of AB from the brain. An @ncrease in the exit of Ap from the brain wou 1d result in a decrease in AP brain concentrati on and therefore favor a decrease in AP deposition. Alternatively, agents that penetrate the brain could control deposition by acting di rectly on brain Ap, e.g., by mai ntaining . 35 it in a non-Fibrillar form or favoring its clearance from tThe brain, or by favoring catabol ism or acting on secretase so that Ap production is reduced.

In one aspect, the invention relates to pharmaceutical compositions comprising “two agents, each of which exerts a therapeutic effect whens administered to a subject in need thereof, and is useful in treating or preventing a neurological disease. The first agent of a pharmaceutical composition of” the invention is selected from substitusted and unsubstituted alkanesulfonic acids and alkanesulfiaric acids that are useful for treating or preventing an amyloid—f3 related disease.

The second age=nt is therapeutic, i.e., its function is bexyond that of an inactive ingredien_t, such as a pharmaceuticzal carrier, preservative, diluent, or buff er. The second agent may be useful in treating or prev enting an amyloid—f related disease or— another neurological disease. Tie first and second agents may exert their biological effects by similar or unrelated mechanism s of action; or eithem- one or both of the first and second age=nts may exert their biological effects by a multiplicity of mechanisms of action. A pharmaceutical composition may also comprise a third agent, or even rnore yet, wherein the third (and fourth, etc.) agent has the same characteristics of a second agent.

The inv=ention also relates to packaged pharma_ceutical products containing two agents, each of which exerts a therapeutic effect when admini stered to a subject in need thereof, and is useful in treatirag or preventing a neurological disease . The first agent of a pharmaceutical ’ composition of ~ the invention may be selected from substituted and unsubstituted alkanesulfonic acids and alkan esulfuric acids that are useful for treati ng or preventing an amyloid— re=lated disease. The se=cond agent is therapeutic, i.e., its function is beyond that of an inactive ingredient, suck as a pharmaceutical carrier, preservat ive, diluent, or buffer. The secon d agent may be useful i n treating or preventing an amyloid- related disease or another neurological disease. The agents may exert their biological effects by similar or unrelated mechanisams of : action; or eithem one or more than one of the agents may exert their biological effects bys a multiplicity of mmechanisms. A pharmaceutical composition may also comprise a third aagent, or even more agerts yet, wherein the third (and fourth, earc.) agent has the same characteristics of a second agent. Mn some cases, the individual agents may be packaged in separate contaimners for sale or delivery to the consumer. The agents of the in—vention may be supplied in a solu tion with an appropriate ssolvent or in a solvent-free form (e.g., Byophilized). Additional components may include acids, oases, buffering agents, inorganic salts, solvents, antioxidants, preservati—ves, or metal chelators . The additional kit components are pr-esent as pure compositions, or as aqueous or organic solutions that incorporate one or more additional kit components. Any or all of the kit components optionally further comprise buffers.

The pre sent invention also includes packaged gpharmaceutical products containirg a first agent in combimnation with (e.g., intermixed with) a second agent. The invention also irmcludes a . 35 pharmaceutical product comprising a first agent packamged with instructions for using th e first agent in the pre=sence of a second agent or instructionss for use of the first agent in a method of the } invention. The invention also includes a pharmaceutical product comprising a second oor

. additional agents packamged with instructions for using the second cor additional agents in the ) presence of a first agent or instructions for use of the second or additional agents in a method of the invention. Alternat ively, the packaged pharmaceutical produc& may contain at least one of the agents and the prod uct may be promoted for use with a second agent. “Inhibition” of zamyloid deposition includes preventing or stopping of amyloid formation, e.g, fibrillogenesis, inkmibiting or slowing down of further amyloid deposition in a subject with amyloidosis, e.g., already having amyloid deposits, and reducing or reversing amyloid fibrillogenesis or depos=its in a subject with ongoing amyloidosis. Inhibition of amyloid deposition is determine d relative to an untreated subject, or relativee to the treated subject prior to treatment, or, e.g., in th e case of a subject with brain amyloidosis, e.g., an Alzheimer’s or cerebral amyloid angiogpathy subject, stabilization of cognitive fun ction or prevention of a further decrease in cognitive fuanction (i.e., preventing, slowing, or stoppirg disease progression).

The term “modulating” is intended to encompass preventiosn or stopping of amyloid formation or accumulat—ion, inhibition or slowing down of further mmyloid aggregation in a subject with ongoing armyloidosis, e.g., already having amyloid ag gregates, and reducing or reversing of amyloid agmgregates in a subject with ongoing amyloiclosis; and enhancing amyloid deposition, e.g., increassing the rate or amount of amyloid deposition ir vivo or in vitro,

Amyloid-enhancing commpounds may be useful in animal models of amyloidosis, for example, to make possible the deve lopment of amyloid deposits in animals in & shorter period of time or to increase amyloid depos. its over a selected period of time. Amyloidl-enhancing compounds may be useful in screening am ssays for compounds which inhibit amyloiciosis in vive, for example, in animal models, cellular assays and in vitro assays for amyloidosis. Such compounds may be used, for example, to provide faster or more sensitive assays for compounds. In some cases, amyloid enhancing corrapounds may also be administered for thera peutic purposes, e.g., to enhance the deposition of amyloid in the lumen rather than the wall] of cerebral blood vessels to prevent CAA. Modulamion of amyloid aggregation is determined relative to an untreated subject or relative to the treatecq subject prior to treatment.

As used herein, “treatment” of a subject includes the application or administration of a therapeutic agent to a sebject, or application or administration of a- therapeutic agent to a cell or tissue from a subject, who has a diseases or disorder, has a sympto am of a disease or disorder, or is at risk of (or suscepti ble to) a disease or disorder, with the purpos se of curing, healing, alleviating, relieving, all tering, remedying, ameliorating, improving, or affecting the disease or disorder, the symptom ofthe disease or disorder, or the risk of (or =susceptibility to) the disease or * disorder.

This invention as Iso relates to a pharmaceutical compositiorm for the treatment of a condition selected from mental retardation, developmental disordenrs, disruptive behavioral ’ disorders, organic ment al disorders (including dementia and psycheoactive substance induced organic mexxital disorders), psychoactive substance =buse disorders, mood disorders, anxiety ) disorders, ssomatoform disorders, dissociative disoreders, attention deficit disorder, schizophrenia oo and personality disorders in a human, comprising am acetylcholine esterase inhibitor. The= second agent may also be a neurotransmitter-release enhan cer, i.e., they possess the ability to enlx ance or stimulate thue release of neurotransmitters such as acetylcholine, dopamine, and serotonin in humans. Tkaey are therefore able to function as therapeutic agents in the treatment of a va riety of conditions i n humans, the treatment or prevention of which can be effected or facilitated by the enhancememt or stimulation of acetylcholine, doparmine, or serotonin release. Such conditions include Alz"heimer’s disease, age associated memory impairment and Mild Cognitive

Impairment , and Parkinson’s disease. They also include mental retardation, developmental disorders, disruptive behavioral disorders, organic rmnental disorders (including dementia a nd psychoactiv—e substance induced organic mental diseorders), psychoactive substance abuse disorders, mood disorders, anxiety disorders, somat-oform disorders, dissociative disorders, attention de ficit disorder, schizophrenia, and persoraality disorders.

The invention is also ideally suited for the treatment of familiar or hereditary form sof

Alzheimer’ ss disease because, for example, therapewmtic prophylactic pharmaceutical treatment could be initiated earlier in a patient’s life. Presently, all therapeutic regimens that are commercial ly available treat only the symptoms of _Alzheimer’s disease, as explained elsewhere herein. The= present invention provides methods and compositions, however, that treat the underlying etiology of the disease itself, and therefcore may be used in a prophylactic manrer.

The biological processes that give rise to Alzheimex’s disease may occur in a person for some time before clinically observable symptoms arise. Ordinarily, according to current medical science, suc-h a period in a person’s life would be urdetectable and treatment with current medicines would be useless. For people with an identified predisposition for developing

Alzheimer’s disease compositions of the present invention may delay the onset of symptoxns.

Furtlhermore, the invention pertains to any n-ovel chemical agent described herein. That is, the invention relates to novel agents, and nove! niethods of their use as described herein, including th ose coumpounds that may be within the scope of the Formulae disclosed herei n, and which are neot disclosed in the cited Patents and Patent Applications.

Example Th erapeutic Drug Targets for the Treatme nt of Alzheimer s Disease

In th_e pharmaceutical compositions of the irmvention, an alkanesulfonic acid compound ] may be combined with a second agent that is also usseful in the treatment of Alzheimer’s disease.

In general, the second agent may be any therapeutic drug. A “therapeutic drug” is a drug or medicine ad ministered for legitimate or medically-a_pproved, therapeutic or diagnostic, purpose.

Therapeutic drugs may be available over-the-counte=r or by prescription. Examples of therapeutic drugs include an adrermergic, anti-adrenergic, anti-androge=n, anti-anginal, anti-anxiety, anticonvulsant, antidepressant, anti-epileptic, antihyperl ipidemic, antihyperlipoproteinemic, antihypertensive, anti-inflammatory, antiolessional, antiparkinsonian, antipsychotic, adrenocortical steroids, adrenocortical suppressant, aldosterone antagonists, amino ’ 5 acids, anabolic steroids, analeptic agents; androgens; blood glucose regulators, cardioprotectants; cardiovascular agents; cholinergic: agonist and antagonists, cholineste=rase deactivators or inhibitors, cognition adjuvants ancl enhancers, dopaminergic agents, enzyme inhibitors, estrogen and related steroid hormones, free oxygen radical scavengers, GABA_ agonists, glutamate antagonists, hormones, antihypocholesterolemic agents, hypolipidem ic agents, hypotensive © agents, immunizing agents, immumnostimulants, monoamine oxidase i nhibitors, neuroprotective agents, NMDA antagonists, AMP_A antagonists, competitive and non -competitive NMDA antagonists, opioid antagonists, potassium channel openers, non-hornzional sterol derivatives, post-stroke and post-head trauma treatments, prostaglandins, psychot ropics, relaxants, sedatives, sedative-hypnotics, selective aden osine antagonists, serotonin antagonists, serotonin inhibitors, selective serotonin uptake inhibitcer, serotonin receptor antagonists, sodium and calcium channel blockers, steroids, stimulants, thyr-oid hormones and inhibitors, ezc. '

In one aspect, the inventiom pertains to a pharmaceutical composition comprising an alkanesulfonic acid and a second =agent that is useful in the treatment or prevention of

Alzheimer’s disease. The second agent may be curative, i.e., modula te the causative agents of =0 Alzheimer’s disease, or it may be palliative, i.e., alleviate the sympto_ms of the disease, e.g., by enhancing memory or improving cognitive function. The second age=nt may be a drug that is useful in the treatment of Alzheimmer’s disease itself, or it may be usec to treat a condition . associated with Alzheimer’s disea se, e.g. a secondary condition, or it may be a drug commonly prescribed to Alzheimer’s disease subjects.

According to current undemrstanding of the natural history of Am [zheimer’s disease, several different drug targets have been identified. A pharmaceutical composition of the invention may comprise a second agent that is sp-ecific for any one of the biological processes giving rise to the clinical presentation of Alzheimer’s disease. The invention is not to Ede considered bound by any particular theory of the etiology of€ Alzheimer’s disease, and so the se=cond agent according to the =30 pharmaceutical compositions of thme invention may be any agent that either by itself or in combination with an alkanesulfon 3c acid is empirically observed to be efficacious in the : treatment or prevention of Alzheirmer’s disease. Nevertheless, a summary of the biological processes believed to give rise to ~Alzheimer’s disease itself or the syrmptoms thereof is useful inasmuch as any one of these biolcagical processes may be modulated by a second agent ina : =35 pharmaceutical composition of thes invention.

The language “in combinaxtion with” a second agent or treatme=nt includes : co-administration of an alkanesulf onic acid, administration of an alka_nesulfonic acid first,

followed by the second, or treatment and administratiomn of the second agent first, followed by an alkanesulfon®c acid. ,

The c ondition associated with Alzheimer’s dise ase may be a symptom characteristic of

Alzheimer’s «disease, for example, hypothyroidism, cerasbrovascular or cardiovascular dise=ase, memory loss, anxiety, or a behavioral dysfunction (e.g. , apathy, aggression, or incontinence); a psychologica 1 condition or a neurological condition. Tahe neurological condition may be

Huntington’s disease, amyotrophic lateral sclerosis, acquired immunodeficiency, Parkinsom’s disease, apha sia, apraxia, agnosia, Pick disease, dementia with Lewy bodies, altered muscEe tone, seizures, sensory loss, visual field deficits, incoordinati on, gait disturbance, transient ische mic attack or strolke, transient alertness, attention deficit, fresquent falls, syncope, neuroleptic sensitivity, normal pressure hydrocephalus, subdural hematoma, brain tumor, posttraumatiec brain injury, or pos thypoxic damage. The psychological conadition is depression, delusions, illuss ions, hallucinations, sexual disorders, weight loss, psychosis, a sleep disturbance such as insomria, behavioral disinhibition, poor insight, suicidal ideation, depressed mood or irritability, 1s anhedonia, social withdrawal, or excessive guilt.

The second agent, i.e., a therapeutic drug may b e a psychotropic medication, antidepressarx t (a selective serotonin reuptake inhibitor, atypical antidepressant), antipsychotic, appetite stimulants, or another drug used to treat a condition associated with Alzheimer’s disease, or a & nutritive supplement that is a precursor o= f acetylcholine (lecithin or choline) ,

Ginkgo biloba, acetyl-L-camnitine, idebenone, propentofylline, or a xanthine derivative.

Antidepressants include selective serotonin reuptake inhibitors such as citalopram (Celexa); escmtalopram (Lexapro); fluoxetine (Prozac™"); fluvoxamine (Luvox™); paroxetine (Paxil™}); sertraline (Zolofi™); mixed norepinephrine/cJopamine reuptake inhibitors such ams bupropion (W”ellbutrin™); drugs with mixed serotonin effects such as nefazodone (Serzone=™) and trazodone (Desyrel™); mixed serotonin/norepineplarine reuptake inhibitors venlafaxine } (Effexor™); rmonoamine oxidase inhibitors including phenelzine (Nardil™) and tranylcypr—omine (Parnate™); aand tetracyclic antidepressants such as maporotiline, mirtazapine (Remeron™), amitriptyline «(Elavil™), amoxapine, clomipramine (Anaafranil™), desipramine (Norpramin_™), doxepin (Sinesquan™), imipramine (Tofranil™), nortrip tyline (Aventyl™, Pamelor™), protriptyline (CVivactil™), and trimipramine (Surmontil™¥), Antidepressants: tricyclic and selective sero®onin reuptake inhibitors; fluoxetine (Prozaac™); sertraline (Zoloft™); paroxetine (Paxil™); citzmlopram (Celexa™); nortriptyline; moclobeemide; miratazepine; Nardil™;

Parnate™; Maanerix™; Tofranil™; Elavil™,; Sinequan¥™™; Surmontil™; Anafranil™,;

Norpramine™1; Aventyl™; Effexor™; Serzone™; Welloutrin™; Desyrel™; and Remeron™™™, ’ 35 Antipyvschotics include aripiprazole (Abilify™), clozapine (Clozaril™), olanzapine (Zyprexa™), quetiapine (Seroquel™), risperidone (Rispwerdal™), and ziprasidone (Geodon™™),

Antipsychotic s: conventional and atypical; olanzapine (<Zyprexa™); quetiapine (Seroquel™=3); :

haloperidol (Haldol™); risperidone (Risperidal™); zuclopenhixol (Clopixol™); ziprazidone; } thioridazine (Mellaril™, Sandoz Pharmaceutical Corp., now Nove: rtis, Basel, Switzerland); clozapine (Clozaril™); o lanzapine; and lithium. i Still other exampMes of drugs that may be a second agent irmclude: cholinesterase inhibitors: huperzine A; z=antidepressants: venlafaxine, desipramine , nefazodone, trazodone, citalopram, escitalopram, nortriptyline, paroxetine; anti-agitation/rmood-stabilizing agents, or anti-epileptics for convul sions: carbamazepine, gabapentin, pheny%oin, clonazepam, valproic acid; neuroleptics: zipras idone, haloperidol, risperidone, olanzapirme, quetiapine; anti- inflammatory/immunomcodulating drugs: colchicine, dapsone, mel oxicam, nimesulide, flurbiprofen, cyclophosplhamide, methotrexate, B-interferon, gammna-interferon, etanercept, infliximab; chelators: pericillamine; hormonal therapies: leuprolide; homocysteine reducing vitamins: metafolin; antioxidants: lipoic acid, selegeline; anti-throxrmbotics: aspirin; others: levodopa, folic acid; anx®olytics hypnotics, and sedatives (anti-anxiety drugs): clonazepan, lorazapam, oxazepam, buapropion., benzodiazepines including diazzepam (Valium™, Roche

Products, Hoffmann-La Roche Inc. (Roche), Nutley, N.J.), chlordi azepoxide (Librium™ or

Libritabs™, F. Hoffman- LaRoche Ltd., Basel, Switzerland), lorazepam (Ativan™, Wyeth, .

Madison, New Jersey), o=xazepam (Serax™, Wyeth, Madison, Nev Jersey), buspirone (Buspar™), zolpidem (A -mbien™), bromazepam (Lectopam™), al prazolam (Xanax™), clonazepam (Rivotril™), flurazepam (Dalmane™), temazepam (R_estoril™), triazolam (Halcion™), nitrazepam «(Mogadon™); and anti-Parkinson including benztopine (Cogentin™) and procyclidine (Kernadllrin™); ACE inhibitors; analgesics; anesthetics; antienemic and mineral or vitamin dietary supple-ments; antibiotics; antidiarrheal; antiepile=ptics; antigout; antihistamines; antihypertensives; antiinflammatory and antirheumatoid; antipruritics; antithrombotics; beta- blockers; calcium channe=1 blockers; cardioactive glycosides; corticcosteroids; antitussives; diuretics; antidiabetes ; amtiseptics; antiinfectives; laxatives; psych oanaleptics and psycholeptics; serum lipid-reducing drugss; sex hormones; thyroid hormones; and urological drugs.

The First Agent

Compositions of Certain alkanesulfur-oxides, including alkanesulfonic acids and ~ alkanesulfuric acids, and more particularly including, for example, 3-amino-1-propanesulfonic acid and certain salts thereof have been shown to be useful in the tareatment of amyloid-p related diseases, including Alzhe=imer’s disease and cerebral amyloid angi©pathy. See WO 96/28187,

WO 01/85093, and U.S. Pat. No. 5,840,294. The anionic group of” the composition is believed to ’ inhibit an interaction betvwveen an amyloidogenic protein and a glyc osaminoglycan (GAG) or ) proteoglycan constituent «of a basement membrane to thus inhibit 2 myloid deposition.

The ability of a therapeutic compound of the invention to inhibit an interaction between an amyloidogenic protein and a glycoprotein or proteoglycan constituent of a basesment membrane can be assessed by an in vitro bincling assay, such as that described herein or in U.S. - Pat. No. 5,164,295. Briefly, a solid support s uch as a polystyrene microtiter plate is coated with an amyloidogenic protein (e.g., serum amyloid A protein or S-amyloid precursor gprotein (B-APP)) and any residual hydrophobic surfaces are blocked. The coated solid sumpport is incubated with various concentrations of a co nstituent of basement membrane, fomr example

HSPG, either in the presence or absence of a «compound to be tested. The solid sumpport is washed extensively to remove unbound matemrial. The binding of the basement mesmbrane : constituent (e.g., HSPG) to the amyloidogenic protein (e.g., B-APP) is then measiared using an antibody directed against the basement memb>rane constituent that is conjugated tc a detectable substance (e.g., an enzyme, such as alkaline phosphatase) by detecting the detectable substance.

A compound which inhibits an interaction beween an amyloidogenic protein and a glycoprotein or proteoglycan constituent of a basement me=mbrane will reduce the amount of stabstance detected (e.g., will inhibit the amount of enzy- me activity detected). A therapeutic= compound of the invention may interact with a binding site for a basement membrane glycoprotein or proteoglycan in an amyloidogenic protein anc3 thereby inhibit the binding of the ammyloidogenic protein to the basement membrane constituent. Basement membrane glycoprotein=s and proteoglycans include laminin, collagen type 1V, fibronectin and heparan sulfate oroteoglycan (HSPG), perlecan, and agrin. In a similar embodiment, the therapeutic compound inhibits an interaction between an amyloidogenic protein and HSPG. Consensus binding site motifs for

HSPG in amyloidogenic proteins have been described (see, e.g., Cardin and Weintraub,

Arteriosclerosis 9, 21-32 (1989)).

The method also relates to a method for treating or preventing an amyloid—p related disease by administering at least two agents, ezach of which exerts a therapeutic effect when so administered and is useful in treating or prevesnting a neurological disease. The firrst agent of the invention is selected from alkanesulfonic acid s that are useful for treating or preve=nting an amyloid-f related disease. The second agent is therapeutic, i.e., its function is beyond that of an inactive ingredient, such as a pharmaceutical carrier, preservative, diluent, or buffesr. The second agent may be useful in treating or preventing san amyloid—p related disease or anot=her neurological disease. The second agent may also be useful in diminishing specifics symptoms : which are characteristic of Alzheimer’s disease (e.g., memory loss, anxiety, etc.). "The first and second agents may exert their biological effects by similar or unrelated mechanisn—s of action; or either one or both of the first and second agents may exert their biological effects By a multiplicity of mechanisms of action. A third agent, or even more yet, may likewi se be used ina method of the invention, wherein the third (and fourth, esc.) agent has the same characteristics of a second agent. The invention relates to a met3hod of treating or preventing an amy~loid—p related disease in a subject (for example, a human) coomprising administering to the subject a therapeutic arnount of a alkanesulfonic acid, such thaat amyloid fibril formation or depositicon, , nezurodegeneration, or cellular toxicity is reduced or inhibited. In another embodiment, the im vention relates to a method of treating ©r preventing an amyloid—( related in a subject (for example, a human) comprising administe=ring to the subject a therapeutic amowx nt of an aRkanesulfonic acid, such that cognitive faunction is stabilized or further deterioration in cognitive fianction is prevented, slowed, or stopped in subjects with brain amyloidosis, e. g., Alzheimer’s disease or cerebral amyloid angiopathy. In another embodiment, the invention relatesto a " mmethod of treating or preventing an amyl-0id—( disease in a subject (for example, human) comprising administering to the subject a_ therapeutic amount of a alkanesulform ic acid, such that activities of daily living are improved or =stabilized in subjects with brain amyloidosis, e.g.,

Alzheimer’s disease.

The “first agent” according to the invention may be an alkanesulfonic a cid or an al kanolsulfuric acid. The term “alkanesu !fonic acid” includes substituted or urmsubstituted al kanesulfonic acids, and substituted or u nsubstituted lower alkanesulfonic acicls. Amino- suabstituted compounds are especially noteeworthy and the invention pertains to substituted- or ursubstituted-amino-substituted alkanesu_lfonic acids, and substituted- or unsubsstituted-amino- suabstituted lower alkanesulfonic acids, arad example of which is 3-amino-1-pro panesulfonic acid.

The methods and pharmaceutical «compositions of the invention are ther—efore directed to a fimst agent that is a substituted or unsubstmtuted alkanesulfonic acid, substituted or unsubstituted al kanesulfuric acid (also known as an alk=anol sulfuric acid), substituted or unstabstituted al_kylthiosulfonic acid, substituted or unsubstituted alkylthiosulfuric acid, or an ester or amide th_ereof, including pharmaceutically accepotable salts thereof. For example, the invention relates to- a first agent that is a substituted or unsubstituted alkanesulfonic acid, or an e_ster or amide th ereof, including pharmaceutically acceptable salts thereof. In another embod iment, the in vention pertains to a first agent that is a substituted or unsubstituted lower allkzanesulfonic acid, or an ester or amide thereof, including ph_armaceutically acceptable salts thereof. Similarly, the in vention includes a first agent that is a (ssubstituted- or unsubstituted-amino)-sebstituted alkanesulfonic acid, or an ester or amide hereof, including pharmaceutically acceptable salts th ereof. In yet another embodiment, the £irst agent is a (substituted- or unsubst ituted-amino)- sumbstituted lower alkanesulfonic acid, or &an ester or amide thereof, including plharmaceutically ac=ceptable salts thereof.

As used herein, “alkyl” groups inczlude saturated hydrocarbons having omne or more caarbon atoms, including straight-chain all<yl groups (e.g., methyl, ethyl, propyl. butyl, pentyl, hexyl, heptyl, octyl, nonyl, decyl, etc.), cyclic alkyl groups (or “cycloalkyl” or “alicyclic” or “c=arbocyclic” groups) (e.g., cyclopropyl, =cyclopentyl, cyclohexyl, cycloheptyl, cyclooctyl, eic.), br-anched-chain alkyl groups (isopropyl, tezr-butyl, sec-butyl, isobutyl, ezc.), aned alkyl-subst ituted alkyl groups (e.g., alkyl-substituted cycloalkyl groups and cycloalkyl—substituted alkyl groups). :

Accordingly, the invention relates to substituted or unsubstituted alkanesulfonic= acids . that are substituted or unsubstituted straight-chain alkan-esulfonic acids, substituted or : 5 unsubstituted cycloalkanesulfonic acids, and substituted or unsubstituted branched-chain alkanesulfonic acids.

The= structures of some of the compounds of this invention include stereogenic carbon atoms. It iss to be understood that isomers arising from scuch asymmetry (e.g., all enanti omers and diastereomsers) are included within the scope of this inve=ntion unless indicated otherwise. That is, unless otherwise stipulated, any chiral carbon center mmay be of either (R)- or (S)-stereochemistry. Such isomers can be obtained in stabstantially pure form by classical separation ®echniques and by stereochemically-controlle-d synthesis. In addition, the cosmpounds of the present invention may exist in unsolvated as well as solvated forms with acceptable solvents susch as water, THF, ethanol, and the like. In general, the solvated forms are ceonsidered equivalent to the unsolvated forms for the purposes of thme present invention. The term “solvate” represents Zan aggregate that comprises one or more molecules of a compound, with one= or more molecules of a pharmaceutical solvent, such as water, ethanol, and the like.

In certain embodiments, a straight-chain or branched-chain alkyl group may have 30 or fewer carbon atoms in its backbone, e.g., C;-Cso for straZaght-chain or C3-Csp for branched-chain. © 20 In certain e mbodiments, a straight-chain or branched-chain alkyl group may have 20 or fewer carbon atorms in its backbone, e.g., Ci-Cyo for straight-claain or C3-Cyp for branched-cha_in, and more, for example, 18 or fewer. Likewise, example cyc doalkyl groups have from 4-10 acarbon atoms in theeir ring structure, or 4-7 carbon atoms in the mring structure.

The term “lower alkyl” refers to alkyl groups haw ing from 1 to 6 carbons in the «chain, and to cycloalkzyl groups having from 3 to 6 carbons in the ring structure. Unless the numbezr of ’ carbons is Otherwise specified, “lower” as in “lower alkyl,” means that the moiety has at least one and less than about 8 carbon atoms. In certain embodiments, a straight-chain or branched-chain lower alkyl group has 6 or fewer carbon atoms in its backbone (e.g., C,—Cs for , straight-chain, C3-Cs for branched-chain),for example, methyl, ethyl, propyl, isopropyl, butyl, isobutyl, sec-butyl, and tert-butyl. Likewise, cycloalkyl groups may have from 3-8 cartoon atoms in their ring structure, for example, 5 or 6 carbons ini the ring structure. The term “C-CS4” as in “C,-Ce alky~s1" means alkyl groups containing 1 to 6 cartoon atoms.

Moreover, unless otherwise specified the term allkyl! includes both “unsubstituted alkyls” - and “substizuted alkyls,” the latter of which refers to alkuy| groups having substituents re=placing one or more hydrogens on one or more carbons of the hy~drocarbon backbone. Such substituents . may include, for example, alkenyl, alkynyl, halogeno, hy.droxyl, alkylcarbonyloxy,

arylcarbonyloxy, alkoxycarbonyloxy, aryloxycarbonyloxy, carboxylate, alkylcar—bonyl, arylcarbonyl, alkoxycarbonyl, aminoc arbonyl, alkylaminocarbonyl, dialkylamin ocarbonyl, alkylthiocarbonyl, alkoxyl, phosphate.. phosphonato, phosphinato, cyano, amino (including alkyl amino, dialkylamino, arylamine, diary~lamino, and alkylarylamino), acylamino (Sncluding alkylcarbonylamino, arylcarbonylamimio, carbamoyl and ureido), amidino, imino, sulfhydryl, alkylthio, arylthio, thiocarboxylate, sulfates, alkanesulfinyl, sulfonato, sulfamoy 1, sulfonamido, nitro, trifluoromethyl, cyano, azido, hesterocyclyl, alkylaryl, or aromatic (including heteroaromatic) groups. }

The term “amine” or “amino,” as used herein, refers to an unsubstituted sor substituted moiety of the formula -NR*R®, in whicch R® and R® are each independently hydrcagen, alkyl, aryl, or heterocyclyl, or R® and RP, taken to- gether with the nitrogen atom to which they are attached, form a cyclic moiety having from 3 tos 8 atoms in the ring. Thus, the term amino includes cyclic amino moieties such as piperidinyl or pyrrolidinyl groups, unless otherwise state=d. Thus, the term “alkylamino” as used herein meamns an alkyl group having an amino group =attached thereto.

Suitable alkylamino groups include groups having 1 to about 12 carbon atoms, for example,1 to about 6 carbon atoms. The term amin_o includes compounds or moieties in whiczh a nitrogen atom is covalently bonded to at least One carbon or heteroatom. The term “dialk=ylamino” includes groups wherein the nitrogen atom is bound to at least two alkyl groups. The term “arylamino” and “diarylamino” include groups wherein the nitrogen is bound to at least one or two aryl groups, respectively. The term “alkylarylamino” refers to an amino group which is bound to at least one alkyl group and at least one aryl group. The term “alkamiracalkyl” refers to an alkyl, alkenyl, or alkynyl group substituted with an alkylamino group. The te=rm “amide” or “aminocarbony!” includes compoundss or moieties which contain a nitrogen atormn which is bound to the carbon of a carbonyl or a thioca rbonyl group.

A “sulfonic acid” or “sulfonates” group is a -SO3H or -SO3X" group boncied to a carbon atom, where X" is a cationic counter icon group. Similarly, a “sulfonic acid” compound has a-SO3H or -SO3X" group bonded to & carbon atom, where X is a cationic grougp. A “sulfate” as used herein is a -OSO3H or -0SO;X" group (which may also be represented as —SO4H or -804X") bonded to a carbon atom, anad a “sulfuric acid” compound has a -SOsF or -0S0;X" : group bonded to a carbon atom, wheres X" is a cationic group. According to the invention, a suitable cationic group may be a hydrcogen atom. In certain cases, the cationic gmroup may actually be another group on the theragpeutic compound that is positively chargecd at physiological pH, for example an amino group. A “ecounter ion” is required to maintain electroneutrality, and is pharmaceutically acceptable in the compositions of the invention. Compound=s containing a "35 cationic group covalently bonded to ar anionic group may be referred to as an “i nternal salt.”

Unless otherwise specified, the= chemical moieties of the compounds of the invention, including those groups discussed above, may be “substituted or unsubstituted.” Mn some embodiments, the term “substituted” means that the m. oiety has substituents placed on thhe moiety ' other than hydrogen (i.e., in most cases, replacing a hydrogen), which allow the molecumle to "perform its Mintended function. Examples of substituermts include moieties selected from straight . or branched alkyl (e.g.,C,-Cs), cycloalkyl (e.g, C3-Cs®, amino groups (including -NHz). -SOsH, -OSO3H, -C=N, -NO,, halogen (e.g., -F, -C, -Br, or -I),. -CH20CH3, -OCH;, -SH, -SCH;3 , -OH, and -CO;H.

It will be understood that “substitution” or “sulbstituted with” includes the implicit proviso that such substitution is in accordance with pe rmitted valence of the substituted® atom and the substituent, and that the substitution results in a stzable compound, e.g., which does rot 16 spontaneoussly undergo transformation such as by reararangement, cyclization, eliminaticon, etc.

As used her-ein, the term “substituted” is meant to incl ude all permissible substituents o—f organic compounds— In a broad aspect, the permissible substit-uents include acyclic and cyclic, Bbranched and unbranched, carbocyclic and heterocyclic, aromat dc and nonaromatic substituents or f organic compounds— The permissible substituents can be one «or more and the same or different for appropriate organic compounds. .

In some embodiments, a “substituent” may be, selected from the group consistirg of, for example, hem logeno, trifluoromethyl, nitro, cyano, C,-Cs alkyl, C,-Cs alkenyl, C2-Cs alkynyl,

C,-Cs alkylcarbonyloxy, arylcarbonyloxy, C;-Cs alkox<ycarbonyloxy, aryloxycarbonylo xy,

C,-Cg alkylczarbonyl, C;-Cs alkoxycarbonyl, C;-Cs alk-oxy, C;-Cs alkylthio, arylthio, hestero- cyclyl, arallkzyl, and ary! (including heteroaryl) groups.

One group of example alkanesuifonic acids have the following structure as depiscted in

Formula I (sse¢ the Drawings, attached hereto) where W is either an amino group (having the formula NRRRY or a sulfonic acid group (having the ®ormula -SO5X"), n is an integer —from 1 to 5, and X is Eaydrogen or a cationic group (e.g., sodium’). Some exemplary alkanesulfoni ¢ acids include the ®hose depicted within Formula lla, Formula IIb, Formula IIc, and Formula 171d (see . Figures). . .

One embodiment of the invention is the use of 3-amino-1-propanesulfonic acid &and pharmaceutically acceptable salts thereof as a first age nt of the pharmaceutical composi tions “described herein and the methods of using them.

An ““agent,” as in a “first agent” or a “second a gent” is generally intended to des cribe a chemical co mpound of suitable purity for use in a pharmaceutical preparation. In some cases, the agent is a “small molecule,” that is, a compound th: at that is not itself the product of gene transcriptiora or translation (e.g, protein, RNA, or DNA) and has a low molecular weight, e.g., less than about 2500. In other cases, the agent may be a biological product, such as an zantibody or an immurogenic peptide.

In general, alkanesulfonic acids may be prepared by the methods illustrated in t=he general reaction schemes as, for example, described im U.S. Pat. Nos. 5,643,562; 5,972,328; 5,728,375; 5,840,294; 4,657,704; and the U.S. Provisional Patent Application No. 60/482,058, file=d 23 June 2003, entitled “Synthetic Process for Preparing Compaunds for Treating Amy~loidosis”, or by modifications thereof, using readily ava ilable starting materials, reagents and coraventional synthesis procedures, In these reactions, it is also possible to make use of variants which are in : themselves known, but are not mentioned. Fuanctional and structural equivalents of the= agents described herein and that have the same genex-al properties, wherein one or more simpl-e variations of substituents are made which do mot adversely affect the essential nature o x the utility of the agent may be prepared accordingz to a variety of methods known in the art=.

In general, the agents of the present im vention may be prepared by the methods illustrated in the general reaction schemes as, for examp le, described below, or by modifications sthereof, : using readily available starting materials, reagzents and conventional synthesis procedures. In these reactions, it is also possible to make use= of variants which are in themselves known, but are not mentioned here. Functional and structura 1 equivalents of the agents described here- in and which have the same general properties, wher-ein one or more simple variations of substituents oC are made which do not adversely affect the esssential nature or the utility of the agent. ~The agents of the present invention may be readily prepamred in accordance with the synthesis sche-mes and protocols described herein, as illustrated in thee specific procedures provided. However, those skilled in the art will recognize that other syn€hetic pathways for forming the agents of this invention may be used, and that the following: is provided merely by way of example, &and is not limiting to the present invention. See, e.g., “Comprehensive Organic Transformations, > 2" Ed., by R.C. Larock, John Wiley & Sons, Ltd. (19999); “March’s Advanced Organic Chemistry,” 5%

Ed., by M.B. Smith and J. March, John Wiley~ & Sons, Ltd. (2000); and “Reagents for @rganic

Synthesis,” Vol. I-XX, by M. Fieser and L. Fi eser, John Wiley & Sons (2000). It will Boe further recognized that various protecting and deprotescting strategies will be employed that are standard in the art (see, e.g., “Protective Groups in Org-anic Synthesis,” 3 Ed., by T.W. Greene_, John

Wiley & Sons, Ltd. (1999)). Those skilled in the relevant arts will recognize that the selection of any particular protecting group (e.g., amine arad carboxyl protecting groups) will depend on the stability of the protected moiety with regards €o the subsequent reaction conditions and will understand the appropriate selections. Further illustrating the knowledge of those skillexd in the art is the following sampling of the extensive «chemical literature: “Comprehensive Asymmetric

Catalysis”, by E.N., Jacobsen, e! al, Springer Werlag (1999) “Chemistry of the Amino Acids” by

JP. Greenstein and M. Winitz, John Wiley & Sons, Inc., New York (1961); T.D. Ocairm, et dl.,

J. Med. Chem. 31, 2193-99 (1988); EM. Gorc3on, et al., J. Med. Chem. 31, 2199-10 (1988); “Practice of Peptide Synthesis” by M. Bodans Xy and A. Bodanszky, Springer-Verlag, New York (1984); “Asymmetric Synthesis: Construction of Chiral Molecules Using Amino Acids™" by

G.M. Coppola and H.F. Schuster, John Wiley & Sons, Inc., New York (1987); “The Chmemical

Synthesis Of Peptides” by J. Jones, Oxford University Press, New York(1991); arad "Intro- duction of “Peptide Chemistry" by P.D. Bailey, J ohn Wiley & Sons, Inc., New Yo rk (1992).

The chemical structures herein are drawn according to the conventional s-tandards known in tThe art. Thus, where an atom, such as a carbon atom, as drawn appears so have an unsatisfied valency, then that valency is assume d to be satisfied by a hydrogen ateom even though thas hydrogen atom is not necessarily explicitly drawn. The structures of ssome of the compoundss of this invention include stereogeni«c carbon atoms. It is to be underst ood that 1somers ari sing from such asymmetry (e.g., all enantiomers and diastereomers) ar—e included within the =scope of this invention unless indicated otherwise. That is, unless othemwisc stipulated, any chiral carbon center may be of esther (R)-or (§)-stereochemistry. Such isomers can be obtained in substantially pure form by cl assical separation techniques and by stereochemically-controlled synthesis.

Furthermomre, alkenes can include either the £- Or Z- geometry, where appropriate=. In addition, the compowunds of the present invention may exist in unsolvated as well as solvate=d forms with accep table solvents such as water, THF, ethanol, and the like. In general, the solvated forms are considered equivalent to the unsolvatesd forms for the purposes of the p resent invention.

Fu_rther examples of compounds that maay be used as a first agent accordi ng to the present invention include those described in the US Provisional Patent Application No. 60/480,906, filed 23 June 2003, entitled "Metheeds and Compositions for Treating Amyloid-

Related Diseases” which published as U.S. Patent Application Publication No. 2(305/0038117 and Appliczation No. 60/480,928, also filed 23 June 2003 "Methods and Compositions for The

Treatment of Amlyloid- and Epileptogenesis-Asssociated Diseases” which publislned as U.S.

Patent Application Publication No. 2005/00380 00.

In an embodiment, the invention pertair-s, at least in part to a pharmaceutical compositicon having a first agent that is a compound of Formula I-A (see the Drawings sheets attached he=reto), wherein R' is a substituted or winsubstituted cycloalkyl, aryl, ary-lcycloalkyl, bicyclic or tricyclic ring, a bicyclic or tricyclic fused ring group, or a substituted wor unsubstitutted C,-Cy, alkyl group; R? is selected from a group consisting hydroger, alkyl, mercaptoailkyl, alkenyl, alkynyl, cycloalkyl, ary], arylalkyl, thiazolyl, triazolyl, irmidazolyl, benzothiaz=olyl, and benzoimidazolyl; Y is S0; =X", 0SO;X", or SSO3;X"; X* is hydrogen, a cationic gr oup, or an ester-forming group (i.e., &s in a prodrug, which are describ ed elsewhere herein); an_d each of L' and L? is independently a substituted or unsubstituted C,-€C;s alkyl group or albsent, or a pharmaceutically acceptable salt thereof, provided that whem R' is alkyl,

L'is absen-t.

In another embodiment, the invention pertains, at least in part a pharmaceeutical composition having a first agent that is a compound of Formula I-A (see the Dramwings sheets attached hezreto) wherein R' is a substituted or vansubstituted cyclic, bicyclic, tricxyclic, or benzoheter—ocyclic group or a substituted or uns-ubstituted C,-C,, alkyl group; R* is hydrogen, alkyl, mercsaptoalkyl, alkenyl, alkynyl, cycloalkyl, aryl, arylalkyl, thiazolyl, triazeolyl, imidazolyl_, benzothiazolyl, benzoimidazolyl, ox linked to R'to forma heterocycl €; Y is SO;5

X*, 080; =X, or SSO: X"; X' is hydrogen, a cationic group, or an ester forming rnoiety; m is

Qorl;niss 1,2, 46

Amended sheet: 17 September 2007

3, or 4;L is substituted or unsubstituted C;-C3 alkyl group or absent, or a pharmaceutically acceptable salt thereof, provided that when R! &salkyl, L is absent.

In yet another embodiment, the invention pertains, at least in part to a pharmas ceutical comgposition having a first agent that is a compeound of Formula I1I-A (see the Drawisngs sheets attac=hed hereto) wherein A is nitrogen or oxygen; R'! is hydrogen, salt-forming caticen, ester formming group, —CHz)x—Q, or when A is nitrogen, A and R'' taken together may be= the residue of a natural or unnatural amino acid or a salt or ester thereof; Q is hydrogen, thiazoly 1, triazolyl, imid azolyl, benzothiazolyl, or benzoimidazoly®; x is 0, 1,2, 3,0r4;nis0,1,2,3,4, 5,6, 7,8, 9, or 10; R? R® R* R* R’ R* RS R%, R’ and R™ are each independently hydrogen, alkyl, mercaptoalkyl, alkenyl, alkynyl, cycloalkyl, arsy], alkylcarbonyl, arylcarbonyl, alkoxycarbonyl, cyammo, halogen, amino, amidino, tetrazolyl, or wo R groups on adjacent ring atoms t aken togexther with the ring atoms form a double bormd, provided that one of RR, RY, R*% R® R™,

RS, IR®, R’ and R™ is a moiety of Formula ITla—A, as depicted in the Drawings, whereinm is 0, 1, 2,3, or4;R%R% RY R", and R' are independently selected from a group of hydrogen, } 15 halo:gen, hydroxyl, alkyl, alkoxyl, halogenated alkyl, mercaptoalkyl, alkenyl, alkynyL, cycloalkyl, aryl, cyano, amidino, thiazolyl, triazolyl, imida_zolyl, tetrazolyl, benzothiazolyl, and benzoimidazoly; and pharmaceutically accepta ble salts and esters thereof, provided that said comzpound is not 3-(4-phenyi-1, 2, 3, 6-tetrahycdro-1-pyridyl)-1-propanesulfonic acid —

In yet another embodiment, the inventicon pertains at least in part to a pharmaceutical comgposition having a first agent that is a comp=ound of Formula IV (see the attached Drawings) . whemrein: A is nitrogen or oxygen; R!! is hydrogen, salt-forming cation, ester formings group, —(CHH,),—Q, or when A is nitrogen, A and R'! taken together may be the residue of a. natural or unnamtural amino acid or a salt or ester thereof; & is hydrogen, thiazolyl, triazolyl, imi dazolyl, benz=othiazoly, or benzoimidazolyl; x is 0,1,2 ,3,0r4;nis0,1,2,3,4,5,6,7, 8,9, or 10; RY,

R*, RR’ R*® RS R® R’, and R™ are each indepmendently hydrogen, alkyl, mercaptoall<yl, alkenyl, alkymnyl, cycloalkyl, aryl, alkylcarbonyl, arylcaxrbonyl, alkoxycarbonyl, cyano, haloge n, amino, amidllino, tetrazolyl, R* and R® are taken togethe=r, with the ring atoms they are attache=d to, form a doutsle bond, or RE and R” are taken together, wvith the ring atoms they are attached to, form a doubole bond; m is 0, 1, 2, 3, or 4; R%, R®, R'®, R*", and R'? are independently selected from a group of hydrogen, halogen, hydroxyl, alkyl, alkoxyl, halogenated alkyl, mercaptoallsyl, alkenyl, alkynyl, cycloalkyl, aryl, cyano, amidino, thiaz ly], triazolyl, imidazolyl, tetrazolyl, benz othiazolyl, and benzoimidazolyl, and pharmmaceutically acceptable salts and ester—s thereof.

In another embodiment, the invention iracludes a pharmaceutical composition having a first aagent that is a compound of Formula V-A «(see the attached Drawings) wherein /\ is nitrogen or oxxygen; R' is hydrogen, salt-forming cation, ester forming group, —(CH.),—Q, or when A is nitro_gen, A and R!! taken together may be the residue of a natural or unnatural amino acid or a salt coor ester thereof; Q is hydrogen, thiazolyl, triazolyl, imidazolyl, benzothiazolyl, or=

’ benzoimidazolyl; x is 0, 1,2,3,0r4;nis0,1,2,3,4,5,6,7,8,9, or 10; a= is a natural or unnatural amino acid residue; m is 0, 1, 2, or 3; R' is hydrogen or protectimg group; RY is hydrogen, alkyl or aryl, and pharmaceutically acceptable salts and prodrug=s thereof.

In another embo diment, the invention includes a pharmaceutical composition having a first agent that is a compound of the Formula VI-A (see the attached Draw dings) wherein n is 1, 2,3,4,5,6,7,8,9, or 10; A is oxygen or nitrogen; R'is hydrogen, salt-forming cation, ester forming group, —(CH2),—Q, or when A is nitrogen, A and R!' taken togettmer may be the residue of a natural or unnatural amino acid or a salt or ester thereof; Q is hydrogemn, thiazolyl, triazolyl, imidazolyl, benzothiazolyl, or benzoimidazolyl; x is 0, 1, 2, 3, or 4; R'? is Ehydrogen, alkyl or aryl; Y' is oxygen, sulfur, or nitrogen; Y? is carbon, nitrogen, or oxygen; R=” is hydrogen, alkyl, . amino, mercaptoalkyl, alkenyl, alkynyl, cycloalkyl, aryl, arylalkyl, thiazolw|, triazolyl, tetrazolyl, imidazolyl, benzothiazo yl, or benzoimidazolyl; R? is hydrogen, alkyl, me=rcaptoalkyl, alkenyl, } alkynyl, cycloalkyl, ary1, arylalkyl, thiazolyl, triazolyl, tetrazolyl, imidazol yl, benzothiazolyl, benzoimidazolyl, or absent if Y2 is oxygen; R¥ is hydrogen, alkyl, mercaptoalkyl, alkenyl, alkynyl, cycloalkyl, aryX, arylalkyl, thiazolyl, triazolyl, tetrazolyl, imidazol ‘yl, benzothiazolyl, benzoimidazolyl; or R?2 is hydrogen, hydroxyl, alkoxy or aryloxy if Y! is rmitrogen; or RZ is absent if Y' is oxygen or sulfur; or R* and R*' may be linked to form a cysclic moiety if Y'is nitrogen; or pharmaceutically acceptable salts thereof.

In another embodiment, the invention includes a pharmaceutical commposition having a first agent that is a compound of Formula VII-A (see the attached Drawingzs) wherein: nis 2, 3, . or 4; A is oxygen or nitrogen; R'' is hydrogen, salt-forming cation, ester forming group, ~{CH2),—Q, or when A. is nitrogen, A and R'' taken together may be the re=sidue of a natural or unnatural amino acid or a salt or ester thereof}, Q is hydrogen, thiazolyl, tri=zolyl, imidazolyl, benzothiazolyl, or benzoimidazolyl; x is 0, 1, 2, 3, or 4; G is a direct bond «or oxygen, nitrogen, or sulfur;zis0,1,2,3,4, or5; mis 0 or 1; R?*is selected from a group consi=sting hydrogen, alkyl, mercaptoalkyl, alkenyl, alkynyl, aroyl, alkylcarbonyl, aminoalkylcarbonyl,. cycloalkyl, aryl, arylalkyl, thiazolyl, tria=olyl, imidazolyl, benzothiazolyl, and benzoimidazeolyl; each Ris independently selected from hydrogen, halogen, cyano, amidino, hydroxyl. alkoxy, thiol, amino, nitro, alkyl, aryl, carbocyclic, or heterocyclic, and pharmaceutically accept-able salts thereof,

Such compound's of the invention include, for example, compoundss of Formula I-B (see the attached Drawings) wherein X is oxygen or nitrogen; Z is C=0, S(O)z, or P(O)OR’; m and n } are each independently 0, 1,2, 3, 4, 5,6, 7, 8, 9 or 10; R' and R’ are each imndependently hydrogen, metal ion, alicyl, mercaptoalkyl, alkenyl, alkynyl, cycloalkyl, ary], a moiety together : with X to form natural or unnatural amino acid residue, or ~(CH,),—Y; Y Fshydrogenora heterocyclic moiety selected from the group consisting of thiazolyl, triazol=yl, tetrazolyl, amidino, imidazolyl, benzothiazo lyl, and benzoimidazolyl; pis 0, 1, 2, 3, or 4; R?is hydrogen, alkyl, mercaptoalkyl, alkenyl, alkynyl, cycloalkyl, aryl, alkylcarbonyl, arylcarbormyl, or alkoxycarbonyl; R is hydrogen, amino, cyano, alkyl, mercaptoalkyl, alke=nyl, alkynyl, cycloalkyl, heterocyclic, sunbstit-uted or unsubstituted aryl, heteroaryl, thi_azolyl, triazolyl, tetrazolyl, amidino, imidazolyl, enzothiazolyl, or benzoimidazolyl, and >harmaceutically acceptable salts, esters, and prod rugs thereof.

In a further embodiment, in the compounds of Formula I-B, m is O, 1, or 2. In another further embodiment, n is 0, 1, or 2. In another further embodiment, R3is aryl, e.g., heteroaryl or phenyl. In yet another embodiment, Z is S(O).

In another embodiment, ®he compound of the invention is of the F-ormula II-B (see the attached Drawings) wherein: eacchR* is independently selected from the group consisting of hydrogen, halogen, hydroxyl, tho}, amino, amidino, cyano, nitro, alkyl, aryl, carbocyclic or : heterocyclic; J is absent, oxygen , nitrogen, sulfur, or a divalent link-moie—ty comsisting of, without limiting to, lower alkylene, alkylenyloxy, alkylenylamino, alkyleenylithio, alkylenyl- oxyalkyl, alkylenylamonialkyl, ealkylenyithioalkyl, alkenyl, alkenyloxy, a_Ikenylamino, or alkenylthio; and q is 1, 2, 3, 4, oT 5, and pharmaceutically acceptable salt=s, esters and prodrugs thereof,

In a further embodiment of compounds of Formula II-B, R'is ary), e.g., substituted or unsubstituted phenyl. In anothemr embodiment, R* is halogen (e.g., chlorixie, fluorine, bromine, or iodine). In yet another embodin—ient, R? is alkyl, e.g., methyl, ethyl, prop=y], butyl, pentyl, . trifluoromethyl, etc. In another «embodiment, J is absent or oxygen. Ina further embodiment, m islornisl. In another further embodiment, the compound can be R- or S-isomer.

In yet a further embodiment, the compound may be selected from. the group consisting of those compounds depicted in either Table X or Table Y (see the attached Drawings) and pharmaceutically acceptable salts, prodrugs, and esters thereof. :

In still a further embodirment, the compound is selected from the group consisting of those compounds depicted in either Table Z-1 or Table Z-2 (see the attac. hed Drawings) and i pharmaceutically acceptable salts, prodrugs, and esters thereof.

In a further embodiment , the compound of the invention is of the Formula III-B (see the attached Drawings) wherein: X is oxygen or nitrogen; m and n are each i ndependently 0, 1,2, 3, 4,5,6,7,8,90r10;q is 1,2,3, 4,0r5; R'is hydrogen, metal ion, alkyl, mercaptoalkyl, alkenyl, alkynyl, cycloalkyl, ary), or a moiety together with X to form a natural om unnatural amino acid residue, or —(CHz);—Y; Y is hydrogen or a heterocyclic moiety selected from the group . consisting of thiazolyl, triazolyl , tetrazolyl, amidino, imidazolyl, benzothmiazolyl, and benzoimidazolyl; pis 0,1,2,3, or4; R? is hydrogen, alkyl, mercaptoalksyl, alkenyl, alkynyl, cycloalkyl, aryl, alkylcarbonyl, arylcarbonyl, or alkoxycarbonyl; R® is se=lected from the group consisting of hydrogen, halogers, amino, nitro, hydroxy, carbonyl, thiol, carboxy, alkyl, alkoxy, alkoxycarbonyl, acyl, alkylamirao, acylamino; q is an integer selected froem 1to 5; J is absent,

o»xygen, nitrogen, sulfur, or a divalent link-moie-ty comsisting of, without limiting to, lower alkylene, alkylenyloxy, alkylenylamino, alkylemx yithio, alkylenyloxyalkyl, alkylenyBMamonialkyl, an lkylenylthioalkyl, alkenyl, alkenyloxy, alkenylaamino, or alkenyithio; and pharmac- eutically amcceptable salts, esters, and prodrugs thereof.

In still yet another embodiment, the coma. pound of the invention may be a co-mpound of

Formula IV-B (see the attached Drawings). In aa related embodiment, m is 0.

Examples of compounds of the inventiom include those compounds depicteca in Table W (see the attached Drawings) and pharmaceutical ly acceptable salts, esters, and prod=xugs thereof.

Further examples of compounds of the imnvention include compounds of Table 3 (see the eattached Drawings).

In another embodiment, the invention pertains to compounds of Formula V—B (see the exattached Drawings) wherein: RY is a substituted or unsubstituted heterocyclic moietzy. Ina

Further embodiment, m is 0 or 1. In another em bodiment, nis 0 or 1. In another fu: rther embodiment, R® is thiazoly}, oxazoylyl, pyrazol vl, indolyl, pyridinyl, thiazinyl, thicophenyl, boenzothiophenyl, dihydroimidazolyl, dihydroth®azolyl, oxazolidinyl, thiazolidinyl, tetrahydropyrimidinyl, or oxazinyl. In yet anotker embodiment, Z is S(O).

In a further embodiment, the invention pertains to the following compoundss depicted in ~~ Table V (see the attached Drawings) and pharm _aceutically acceptable salts, esters, -and prodrugs thereof.

Blockers of sodium or calcium ion chanel activity are well known in the ar—tand can be . vased as the A moiety in the compounds and methods of the present invention. Similarly, any compound that opens potassium or chloride ion channels can be used as the A moie=ty in the compounds and methods of the present inventiosn. Antagonists of NMDA receptorss and 2ugmenters of endogenous GABA inhibition ares also known to one of skill in the amt and can be wased in the methods and compounds of the invemtion. For example, 2,3-quinoxalineediones are reported to have NMDA receptor antagonistic activity (see, e.g., U.S. Pat. No. 5,72 1,234). : Exemplary calcium and zinc chelators include moieties known in the art for chelatison of divalent cations, including (in addition to those mentioned supra) ethylenediaminetetraacetiec acid (EDTA), ethylene glycol bis(beta-aminocethyl ether)-N, N,N,N “tetraacetic acid, anc the like.

Exemplary iron chelators include enterobactin, goyridoxal isonicotinyl hydrazones,

TV,N -bis(2-hydroxybenzoyl)-ethylenediamine-AJ,N "-diacetic acid (HBED), 1-substistuted-2-alkyi- 3-hydroxy-4-pyridones, including 1-2’-carboxy~ethyl)-2-methyl-3-hydroxy-4-pyrid_one, and

Other moieties known in the art to chelate iron. Compounds which inhibit NO syntEnase activity are known in the art and include, e.g., Ny-substi tuted arginine analogs (especially ofthe

I. configuration), including L-Ny-nitro-arginine {a specific inhibitor of cerebral NO synthase),

I__-Ny-amino-arginine, and L-Ny-alkyl-arginines ; or an ester (for example, the methwyl ester)

S50 thereof. Exemplary antioxidants include ascorbic acid, tocopherols including alpha-tocopherol, : and the like.

In another aspect, the isnvention relates to pharmaceutical commpositions comprising a first agent, e.g., an alkanesulfonic amcid, and another drug that targets seceondary symptoms of

Alzheimer’s disease, such as behavioral and emotional difficulties. For example, some approved medications-exist that appear t=o improve memory and cognition, bus do not address the underlying pathology, as discumssed more fully elsewhere herein.

The discussion below e=xplains in more detail the various thesrapeutic approaches and classes of medications for AlzBheimer’s disease.

Cognitive Enhancers — Cholinesterase Inhibitors

Alzheimer's Disease iss associated with degeneration of cholinergic neurons in the basal _ forebrain that play a fundamertal role in cognitive functions, includB ing memory. Alzh€imer’s disease patients exhibit a mark=ed reduction in acetylcholinesterase ectivity and choline uptake.

Becker, et al., Drug Developnaent Research 12, 163-95 (1988). In one aspect, the present : invention is related to increasi ng levels of acetylcholine by the administration of an inhibitor of choline esterase (e.g., acetylchmolinesterase or butyrylcholinesterased. Cholinergic neurons make up a major neuronal system of the central and peripheral nervous sy=stems. Cholinergic nevrons _ produce the neurotransmitter excetylcholine. In the central nervous system, acetylcholine is a neurotransmitter and is release=d by cholinergic neurons in, among other places, the hippocampus and frontal cortex of the brain— The hippocampal area of the brain, particularly those areas where acetylcholine is released, is be=lieved to have functions associated with cognition, leaming, and memory. Degenerative diseasses with symptoms such as loss of cognition, leaning, and memory, have been linked to a loss in cholinergic neurons. Cholinergic dysfunction, characterized by marked degeneration of cholirnergic innervation in the basal forebra_.in, and reduction of choline acetyltransferase, acetylcholin_esterase, and the nicotinic and muscarinic receptors are known to : be very early features of Alzhesimer’s disease. Other neurotransmitaer systems, such as glutamatergic, serotonergic, amnd dopaminergic, are also disrupted ir Alzheimer’s disease, but at a later stage of the disease.

The present invention =also relates to the combination use of ~ a nicotinic acetylcholine receptor agonist or muscarinics agonist that results in cognition enhancement. Nicotinic acetylcholine receptor agonist=s improve cognitive function in Alzheimer’s patients. Wilson, et al., Pharmacol. Biochem. B ehavior 51, 509-14 (1995); Americ, e=t al., Alzheimer Disease "Assoc. Disorders 9(suppl. 2), 50-61 (1995); Buccafusco, et al., Behav. Pharmacol. 10, 681-90 (1999). Muscarinic and nicoti nic agonists have been reported to en_hance cognitive tasks in animal models and in humans. Schwarz, et al., J. Pharmacol. Experim. Thercaput. 291, 812-22 (1999); Veroff, et al., Alzheimer Disease Assoc. Disorders 12, 304-12 (1 998)= Bodick, et al.,

Alzheimer Disease Assoc. Disoraders 11(Suppl. 4), 816-22 (1997).

In subjects with Alzheirraer’s disease, the number of cholinergic neuro-ns innervating the hippocampus typically decreases, and the progressive loss of these cholinergisc neurons mirrors the loss in memory and cognitive function in these subjects. Acetylcholine is synthesized by choline acetyltransferase (“ChA_T"). Once released by the neuron, it is degracded by cholinesterases, e.g., acetylcholinesterase (“AChE”). Thus either potentiating the activity of

ChAT or inhibiting the activity ©f a cholinesterase, e.g., AchE, may raise levels of the neurotransmitter. These medications alone appear to provide primarily symptomatic improvement.

Another therapeutic strategy for increasing levels of acetylcholine is based on up-regulating ChAT in the neurons. For example, estrogen increases the leve=1 of acetylcholine by up-regulating ChAT in the h ippocampus of rats, Luine, ef al, Brain Res. 191, 273-77 (1980); Luine, Exp. Neurology 89, 484—90 (1985), Singh, et al., Brain Res. 644, 305- 12 (1994). Also clinical information implies that post-menopausal women on hormone replac-ement therapy (estrogen with or without progestins) may be less likely to develop Alzheime=r’s disease and more likely to have existing syrmptoms alleviated. See, e.g., WO 93/014085 ("indole derivatives as having the ability to enhance the release of acetylcholine); U.S. Pat. No. 5,277 8,162 (substituted ; oo 20 polycyclic compounds that enhance acetylcholine release).

Many choline esterase imhibitors are known, Certain cholinesterase imnhibitors are ' approved for use in treatments for improving memory and learning in Alzhei mer’s subjects.

Tacrine (Cognex™, Warmner-La mbert Co., now Pfizer, New York, New York) was the first } approved cholinesterase inhibit«or but is rarely used because of negative side =effects like stomach and liver problems. Donepezil (Aricept™, Eisai Co, Ltd) is more selective faor acetyl-cholinesterase and shows fewer side effects than tacrine. Rivastigmin e (Exelon™, - Novartis Pharma SA) targets a specific subtype of acetyl-cholinesterase that is present at high concentrations in the brains of Alzheimer’s subjects. Galanthamine (Reminy~I™, Janssen

Pharmaceutica Products, LP) has a dual mode of action in the brain; in addition to working as an _ 30 acetylcholinesterase inhibitor, galanthamine also appears to exert action on tlhe nicotinic acetylcholine receptors in the b rain. These cholinesterase inhibitors may be =acetyl-cholinesterase or butyryl-cholinesterase inhib&tors or both. Another example is phenserine s{currently in advanced clinical trials in the United States). In addition to its cholinergic ef tects, phenserine may inhibit B-APP production Iby a separate and distinct mechanism of actiomn at the level of the mRNA level. Another example is AIT-082 (also in advanced clinical trials).. The degradation pathway of AchE may also be &nhibited by inhibitors such as physostigmine (Synapton™, or (Antilirium Injectable™, Forrest Laboratories, New York, New York)), quilcostigmine, tolserine,

thiat-olserine, cymserine, thiacymserine, neostiggmine, eseroline, zifrosilone, mest=inon, hupearzine A and icopezil.

Phenserine, an acetylcholinesterase inh. ibitor, is in development (Axonyx , New York,

New York) for the treatment of Alzheimer’s Disease. Phenserine, which has bee=n shown to incresase memory and learning in the laborator=y animals, works through two mec=hanisms: it inhibits the degradation of the neurotransmitter acetylcholine in the brains of ani mals, and it inhiWbits the production of a toxic form of the =-amyloid protein in the brain that isthoughttobea causse of the death of brain cells in Alzheimer’ s disease. Unlike other acetylchol inesterase inhibitors that simply suppress the activity of tthe enzyme, Phenserine's dual mechanism of action suggests that it not only has the potential to irmprove memory and cognition but zalso to slow the progression of the disease. Compared to curre=ntly marketed drugs for Alzheime=r's, Phenserine is ’ more brain-targeted versus the rest of the bod’ and is more rapidly cleared from the blood. In preclinical studies, Phenserine demonstrated a= brain-to-blood ratio of 10:1. The_se properties of

Phe nserine could potentially maximize the the=rapeutic effects of the drug in the brain and reduce side= effects by clearing the drug from the bloowd quickly. Since undesirable side effects and drug inte=ractions often arise due to the presence of drugs in the body for an extended period,

Phe=nserine's rapid disappearance from the blo od suggests that it will represent a_ more tolerable treamtment option to existing therapies. Even thmough Phenserine is rapidly clearecd from the body. the drug remains bound to the acetylcholinestesrase enzyme in the brain allowing it to have a long duraation of therapeutic action. Substituted ph-enserines and phenylcarbamates o f eseroline, noreeseroline, and benzylnoreseroline are also specific inhibitors of acetylcholinesterase See, e.g.,

U.S=. Pat. Nos. 5,171,750; 5,378,723; 5,409,948; 5,998,460; 5,948,763; 6,410,74-7; 6,462,171; and_ 6,495,700; as well as WO 93/06105.

Suitable cholinesterase inhibitors inclLade galanthamine derivatives avail able from Jansssen, metrifonate available from Bayer Co_xp., ipidacrine available from Nikl<en Chemicals

Co. Ltd, TAK-147, T-82 available from SS P=harmaceutical Co. Ltd., methanesmulfonyl fluoride,

CH_F-2819, phenserine, physostigmine availalole from Forest Laboratories, Inc., huperzine, cymnserine available from Axonyx Inc., tolserine available from National Institu-tes of Health,

ER --127528 available from Eisai Co. Ltd., andl combinations thereof. :

In addition, the present invention relat-es to a method for maintaining or preventing a dec=rease in the levels of acetylcholine in the frontal cortex or hippocampus regieons of the brain in rnammals comprising administering to a maammal in need thereof, an effective amount of a firs: t agent, e.g., an alkanesulfonic acid or a plaarmaceutically acceptable salt the reof, and opt ionally a choline esterase inhibitor.

Further, the present invention relates to a method for inhibiting conditioms or detrimental effects caused by a deficiency of choline acet=vltransferase or acetylcholine in th_e frontal cortex "or kaippocampus regions of the brain in mammals comprising administering to a mammal in need

* thereof, an effective amount of & first agent, e.g., an alkanesulfonic acid, or aa pharmaceutically acceptable salt thereof, and optinally a choline esterase inhibitor.

Moreover, the present in. vention relates to a pharmaceutical formulat=ion comprisinga first agent, e.g., an alkanesulfon ic acid or a pharmaceutically acceptable salt= thereof, and optionally a choline esterase inhmibitor; and a pharmaceutical carrier, diluent... or excipient.

Another embodiment of the present invention is where the condition caused by a decrease of choline acetyltransferase or a«cetylcholine in the frontal cortex or hippocampus regions of the brain is Alzheimer’s disease. :

As used herein, the term “effective amount” means an amount of a frst agent, e.g., an alkanesulfonic acid, that is capable of maintaining brain cell ability to produmce stable levels of acetylcholine in the brain, such as in the hippocampus and frontal cortex regions, or inhibiting conditions or detrimental effectss caused by a decrease of acetylcholine in m=ammals. When an alkanesulfonic acid or other such first agent is co-administered with an AChmE inhibitor the term “effective amount” also means san amount of such an agent capable of inhibiting AChE. An inhibitor of AChE may be represented as “AChEi.”

In this context, the term “inhibiting” in the context of inhibiting conditions or detrimental effects caused by a deficiency o Ff ChAT or acetylcholine in the frontal corte or hippocampus regions of the brain includes its generally accepted meaning, i.e., prohibitings, restraining, alleviating, ameliorating, slowirag, stopping, or reversing the progression or severity of a decrease in ChAT and acetylcholine and the pathological sequelae, i.e., symmptoms, resulting from that event.

The term “up-regulating ChAT” refers to increasing the enzymatic activity of ChAT, ie., promoting the conversion of choline to acetylcholine. This promotion woul include an increase in the efficiency or rate of reaction of ChAT and choline or an increase in thme amount of ChAT present at the site of action. Thiss increase in the amount of enzyme present =may be due to gene regulation or another synthetic sstep in the enzyme’s formation or a decrease= in the enzyme’s

A de-activation and metabolism.

It has been shown that ALB can inhibit the efflux of acetylcholine fromm neurons upon new stimulation, and in addition that: exogenous AB may inhibit high affinity choline uptake.

Normally acetylcholine efflux levels (e.g. from hippocampus) are decreased in the presence of

AP in the brain. AB may act in =several different ways to exert these effects, such as acting at the choline transporter, modulating post synaptic events, or acting on neuronal acety] cholinesterase receptors (e.g., nAChr (a7, a2B<4). It has been shown that antibodies capabl e of binding to AB can normalize acetylcholine efflux levels, which are usually reduced in the gpresence of AB in the . 35 brain (Bales, et al., Cholignergiec dysfunction in APP V717F transgenic mic. € is normalized following anti-Ap antibody adnainistration. See, Abstract from Neurosciencse Meeting, New

Orleans, Nov. 2003 pmrogram no. 133.9.). A first agent of the i nvention, e.g., an alkanesuifonic : acid, may act similarly to normalize acetylcholine levels by banding to AP. The presence of an alkanesulfonic acid mmay thus prevent AB from inhibiting the e=filux of acetylcholine, thereby leading to an increase= in the amount of acetylcholine at the symnapse. It is likely therefore that an alkanesulfonic acid ard an acetylcholinesterase inhibitor will aact synergistically to ameliorate cholinergic neurotran -smission, as both agents act to potentiate= the levels of acetylcholine,

Ester Neurosc=iences (Herzlia Pituach, Israel) antisense drug (EN101) for the treatment of myasthenia gravis, desmonstrated for the first time effective amd safe use of an orally- administered antisensse therapy for a neurological condition th at lessened the severity of - symptoms of myasthenia gravis , with no cholinergic symptorms nor significant adverse events based on balancing cEholinergic transmission via controlled modulation of the company’s novel target, a stress-respormse variant of acetylcholinesterase . AChE is an enzyme that degrades the : neurotransmitter acetylcholine. EN101 selectively inhibits thee production of the target at the : critical stage of its bieosynthesis, thereby allowing an effective= treatment, while minimizing side effects and substantizally improving upon the short-duration palliative relief currently observed with conventional inbibitors. EN101 is the lead compound in Ester’s disease-modifying platform technology —for the pre-expression control of a specifSic variant of the AChE protein, which is applicable te a wide range of neurological disorders.

Useful muscacrinic receptor agonists include cevimelinme, PD-151832 available from Pfizer

Inc., YM-796 availabole from Yamanouchi Pharmaceutical Inc, and P-58 available from

Phytopharm plc. Suitable acetylcholine release stimulators irmclude minaprine, and montirelin available from Grune=nthal GmbH, T-588 available from Toyzama Chemical Co. Ltd., XE-991.

Useful choline uptakee stimulators include MKC-231 available from Mitsubishi-Tokyo

Pharmaceuticals Inc. Suitable nicotinic cholinergic receptor agonists include altinicline available . 25 from SIBIA Neurosciences, Inc., SIB-1553A, ABT-089 (U.S - Pat. No. 5,278,176, Abbott

Laboratories), nicotire patch, GRS-21, and TC-2403.

In 1993, tacri ne became the first agent approved speci fically for the treatment of cognitive symptoms -of Alzheimer’s disease. Tacrine is a reversible cholinesterase inhibitor and is thought to work byw increasing the availability of intrasynapwtic acetylcholine in the brains of

Alzheimer’s disease patients. The medication may also have other actions. Donepezil, another reversible cholinesterase inhibitor, is now available for the tre=atment of Alzheimer’s disease.

Another example of aa second agent is xanomeline, which isa muscarinic selective ml and m4 (muscarinic) acetylcEoline receptor agonist and shows moder ate improvement in cognitive performance, greater efficacy in decreasing psychotic symptomms, and agitation. N.C.Bodick, etal “Effects of xan omeline, a selective muscarinic receptor agonist, on cognitive function and behavioral symptomses in Alzheimer disease.” Arch. Neurol. 5=4,465-73 (1997). The second agent may also be an ergot alkaloid or a vinca alkaloid, such as Hyclergine™ (Sandoz Pharmaceutical

Corp., now Novartis, Basel, Switzerlarad) and nicergolin; or it may be a noot=ropic, such as piracetam, oxiracetam, pramiracetam, and aniracetam; which have cholinergsic and dopaminergic properties as well as effects on protein processing. B.Saletu, ef al, “Nicergooline in senile dementia of Alzheimer type and multi—infarct dementia: a double-blind, placebo-controlled, clinical and EEG/ERP mapping study. > Psychopharmacology 117, 385-95 (C1995). In yet another embodiment, the second agen may be a carbamate derivative of physostigmine, such as eptastigmine, which is an inhibitor of aacetylicholinesterase. A. Norberg, er al, “Cholinesterase inhibitors in the treatment of Alzheimer’s disease: a comparison of tolerability and pharmacology.” Drug Saf. 19, 465-80 (1998).

Cognitive Enhancers — NMDA Receptor Antagonists ’ Excessive excitation by neuro€ransmitters can cause the degeneration and death of ; neurons. It is believed that this degeneration is in part mediated by the excitotoxic actions of the excitatory amino acids glutamate and aspartate at the N-methyl-D-Aspartates (NMDA) receptor.

An increased level of one or more glu tamate-related compounds is associat=ed with many neurodegenerative disorders and neur<odegeneration associated with long te rm disease states such as Huntington’s disease, Alzheimer’s disease, amyotrophic lateral sclerosis (ALS, which is also known as motor neuron disease), Parl<inson’s disease and acquired immuncdeficiency (AIDS).

Excitatory amino acid receptor antagonists that block NMDA receptors are recognized for usefulness in the treatment of disorde xs. NMDA receptors are intimately iravolved in the phenomenon of excitotoxicity, which may be a critical determinant of outcome of several neurological disorders. Disorders knoswn to be responsive to blockade of th € NMDA receptor include acute cerebral ischemia (stroke or cerebral trauma, for example), mm uscular spasm, convulsive disorders, neuropathic pai m and anxiety, and may be a significamt causal factor in chronic neurodegenerative disorders ssuch as Parkinson’s disease, amyotrophic lateral sclerosis (ALS), Alzheimer's disease and Hun®ington’s disease. Compounds that effect the greatest protection of neurons from NMDA resceptor-mediated injury, e.g., that inju ry resulting from stimulation of the NMDA receptor by~ glutamate or other excitatory amino acids or structurally similar compounds may be used in ore embodiment of the invention.

Some examples of NMDA receptor antagonists are known and conmmercially available.

Memantine (Ebixa™ or Axura™, rec=ently available in the U.S. from Merz Pharmaceuticals,

Frankfurt am Main, Germany), whicl operates by yet another mechanism, appears to prevent or reduce the brain damage caused by Alzheimer’s disease by blocking NMID A receptors in the brain. See U.S. Pat. No. 5,614,560. Nvemantine (1-amino-3,5-dimethyl ademmantine) reduces neuronal damage by blocking NMDA receptor-operated channel activation by excitatory amino acids (such as glutamate-related compounds) at concentrations that are reacily obtainable in human subjects taking the drug (Wesemann, et al., ~J. Neural Transmission (Supp.) 16, 1 43 (198 0). :

Several drugs have NMDA antagonist activ ity without causing hypofunction beczause of activity at some other type of receptor. In the braims of healthy lab animals, such NMDA antagonists do not cause the vacuoles and other toxic side effects that are caused by NVEEDA antageonists such as PCP and MK-801, because of anctivity at the additional neuronal receptors.

Such drugs, and the receptors they interact with in addition to NMDA receptors, include= the following: Ibogaine, which also suppresses excitatory activity at sigma receptors and which may also be active at serotonin receptors, and Eliprodil, which also increases inhibitory actiwity at sigmmareceptors; Certain anticholinergic drugs suc has procyclidine, trihexyphenydyl, aand bipe-riden, which also suppress excitatory activity aut muscarinic acetylcholine receptors; and

Certain quinoxalinediones, including NBQX, ACE A 1021, and ACEA 1031, which are discwussed below, and which suppress activity at non-NMDA receptors (i.e., kainic acid receptors and AMPA receptors), in addition to NMDA recep tors. As described in Example 11, NEBQX bloc=ks non-NMDA receptors so strongly that it acts as a safener agent when co-adminis tered withm MK-801. Accordingly, these and other quino>xalinediones are of great interest to phar-maceuticel companies, and offer strong promisse as inherently safened NMDA antagonists.

Low=-toxicity NMDA antagonists offer good candiclates both for treating Alzheimer’s di sease, and for additional developmental research to identi fy analogs having adjusted balances Jn their dual or multiple receptor binding affinities. For example, the anti-parkinsonian agents proc=yclidine, trihexyphenydyl, and biperiden all hemve affinities for muscarinic receptors. that are seve=ral times higher than for NMDA receptors. Fumrther examples of NMDA receptor antagonists include those in U.S. Pat. No. 4,906,77 9, which discloses disubstituted guarm idines, e.g.» NN’-di-m-toly! guanidine, N,N -di-o-ethylpheny! guanidine, NN ’-di-m-ethylpheny~] guanidine, and N,N -di-o-iodophenyl-guanidine; U .S. Pat. No. 5,498,610, which disclos-es 5-(1—hydroxy-2-piperidino)-propyl-2(1 #,3H)-indot one analogs. A muscarinic agonist may also be u sed in this invention. A class of styryl amidine= derivatives, which are antagonists ofthe human NMDA receptor, are selective for those comtaining the NR2B subunit, and may, in some emb odiments, be used in the invention. U.S. Published Application No. 2003/0,119,87 KE.

Suitable NMDA receptor antagonists also include i penoxazone, which is available from Nippon

Chezmiphar Co. Ltd.

The term “agonist,” as used herein, refers to amolecule which, when interacting witha biologically active molecule, causes a change (e.g... enhancement) in the biologically active molecule, or which positively modulates the activity of the biologically active molecule— An 3s agoriist interacts with a receptor and initiates a physiological or a pharmacological respcmnse characteristic of that receptor. As known in the art., agonists include, but are not limited to protezins, nucleic acids, carbohydrates, lipids or any~ other molecules which bind or interact with biologically active nmolecules. The terms “antagonist” or “inmhibitor,” as used herein, refer vtoa : molecule which, wheen interacting with a biologically active molecule, blocks or negatively modulates the biological activity of the biologically active molecule. Antagonists oppose the receptor-associated responses normally induced by other biowactive agents (i.e., agonists).

Antagonists and inhibitors include, but are not limited to, preoteins, nucleic acids, carbohydrates, lipids or any other molecules that bind or interact with biologically active molecules. Inhilibitors and antagonists may effect the biology of entire cells, organss, or organisms (e.g., an inhibitor that slows or prevents ne=uronal degeneration and death).

Estrogens .

Estrogen pla-ys a powerful, pleiotropic role in many meurodegenerative conditions including Alzheime r’s disease. Women have been shown tO have increased risk, earlier omset, and more rapid progression of Alzheimer’s Disease than men, although not gender-specific morbidity. Postmeropausal loss of estrogens leads to generally reversible decreases in memory that respond to estrogen replacement therapy. Besides mechanisms of blocking neurotoxi city directly, estrogen acts at various levels of plasticity: axon sprouting, synaptogenesis, and promoting synaptic transmission (electrophysiologically aned biochemically). These effecats may be ascribed to eithemr receptor-dependent mechanisms, primaarily transcriptional, including direct effects of ER in trarseription and indirect effects through o®ther transcription factors like C”REB and Akt, as well as their retrograde transport or receptor-inclependent (rapid) mechanisms involving activatioral effects of second messenger systems, coexisting neurofransmission , or coordinated activation of both, as well as oxidative effects cf the estrogen molecule. Estreogen replacement decrea=ses the risk of Alzheimer’s disease in postmenopausal women, delays —the age of onset, and perhagps slows the decline. Estrogenic agent imnclude estrogen, lasofoxifene, droloxifene, tamoxifen, and raloxifene (Evista™, Eli Lilly, Indianapolis, Indiana).

Also useful with the present invention are composit Sons or therapeutic combinatio ns that further comprise hcormone replacement agents and composi tions. Useful hormone agents =and compositions include androgens, estrogens, progestins, their pharmaceutically acceptable salts and derivatives. Coembinations of these agents and composi tions also are useful.

Examples o festrogens include, but are not limited to, androgen and estrogen combinations such as the combination of esterified estrogers (sodium estrone sulfate and sodium equilin sulfate) and. methyltestosterone available from Solv ay Pharmaceuticals, Inc., Marietta,

GA., as Estratest™- ; the blend of nine synthetic estrogenic substances including sodium estrone sulfate, sodium equmilin sulfate, sodium 17a-dihydroequilin sulfate, sodium 17a-estradiol =sulfate, sodium 17p-dihydr-oequilin sulfate, sodium 17a-dihydroeq_silenin sulfate, sodium 17p-dihydroequilermain sulfate, sodium equilenin sulfate and sodium 17-estradiol sulfate;

available from Duramed Pharmaceuticals, Inc., Cincinnati, Ohio, as Cenestin™; ethinyl estradiol, available by Schering Plough Corporation, Kenilworth, N.J., as Estinyl™; «esterified estrogen combinations such as sodium estrone sulfate and sodium equilin sulfate; available from

Solvay as Estratab™ and from Monarch Pharmaceuticals, Bristol, Tenn., as MenestT estropipate, available from Pharmacia & Upjohn, Peapack, N.J., as Ogen™ and fronrm Women

First Health Care, Inc., San Diego, Calif., as Ortho-Est™; and conjugated estrogens «170 dihydroequilin, 170-estradiol, and 17B-dihydroequilin), available from ‘Wyeth, Philadelphia, Pa., as Premarin™. Another estrogen example is disclosed in U.S. Pat. No. 6,610,706.

Progestins and estrogens may also be administered as combinations including estradiol and norethindrone, available from Pharmacia & Upjohn, Peapack, N.J., as Activella™™; levonorgestrel and ethinyl estradiol, from Wyeth as Alesse™, from Watson Laboratories, Inc.,

Corona, Calif, as Levora™ and Trivora™, Monarch Pharmaceuticals, as Nordette™?, and from

Wyethas Triphasil™; ethynodiol diacetate and ethinyl estradiol™; available from G_ D. Searle &

Co., as Demulen™ and Watson ™ as Zovia™; desogestrel and ethinyl estradiol™, from Organon as Desogen™ and Mircette™, and from Ortho-McNeil Pharmaceutical, Raritan, N.J ., as Ortho-

Cept™; norethindrone and ethinyl estradiol; available from Parke-Davis, Morris Pla ins, NJ, under the tradenames Estrostep™ and Femhrt™, from Watson as Microgestin™, Ne=con™, and

Tri-Nerinyl™, from Ortho-McNeil as Modicon™ and Ortho-Novem™, and from W=amer

Chilcott Laboratories, Rockaway, N.J., under the tradename Ovcon™,; the combinat3on of norgestrel and ethinyl estradiol; available from Wyeth under the tradenames Ovral™ and

Lo/Ovral™, and from Watson under the tradenames Ogestrel™ and Low-Ogestrel™1; the combination of norethindrone, ethinyl estradiol, and mestranol, from Watson as Bre=wicon™ and

Norinyl™, the combination of 17B-estradiol and micronized norgestimate, from Ortk10-McNeil under the tradename Ortho-Pre fest™,; the combination of norgestimate and ethinyl e=stradiol; available from Ortho-McNeil under the tradenames Ortho Cyclen™ and Ortho Tri-Ccyclen™; and the combination of conjugated estrogens (sodium estrone sulfate and sodium equilin sulfate) and medroxyprogesterone acetate, from Wyeth under the tradenames Premphase™ amnd }

Prempro™, :

Examples of progestins include norethindrone; available from ESI Lederle, [mnc.,

Philadelphia, Pa., as Aygestin™, from Ortho-McNeil under the tradename Micronor=™, and from

Watson as NOR-QD™,; norgestrel; available from Wyeth as Ovrette™; micronized progesterone, from Solvay as Prometrium™; and medroxyprogesterone acetate; avai lable from

Pharmacia & Upjohn under the tradename Provera™.

Non-Steroidal Anti-Inflamn atory Drugs

Nonsteroidal anti-infFlammatory drugs (“NSAIDs”) appear to te associated with a lower likelihood of developing Al=zheimer’s disease. Anti-inflammatory dregs are believed to interfere : with aspects of the microglial, astrocytic, and cytokine responses that occur in Alzheimer’s disease. NSAIDs, including ibuprofen, naproxen, sulindac, and indormethacin, have been shown to be selective Ap42-loweri ng agents. A subset of NSAIDs lower ammyloidogenic AB42 independently of cyclooxygrenase activity. S.Weggen, ef al., “A subs«et of NSAIDs lower amyloidogenic AP42 independently of cyclooxygenase activity.” Nar ure 414, 212-16 (2001).

Although the mechanisms by which these NSAIDs lower AB42 have not been established, the effect is independent of cyclooxygenase inhibition, which is the prim =ary anti-inflammatory target of these compounds. NSAEDs do not appear to change the total level of AB produced but shift cleavage from AB42 to a le=ss toxic shorter 38—amino acid AP peptides (A338), which suggests that they interact with y-seccretase. One class of developmental comp=ounds are inhibitors of

PDE4, which act as anti-inflammatory drug in mice. These anti-inflammatory agent, e.g., rolipram, appear to block thae microglial inflammatory response, and may have toxic side effects, but newer analogs without ssuch properties are in development. Wilceock, et al., “Intracranially

Administered Anti-Abeta Antibodies Reduce Beta-Amyloid Deposition by Mechanisms Both

Independent of and Associzated with Microglial Activation. J. Neurosci. 23(9), 3745-51 (2003).

For example, Memory Pharmaceutical’s MEM 1414 is a PDE4 inhib itor currently in testing for

Alzheimer’s disease.

Suitable anti-inflam matory agents include COX-2 inhibitors (such as Vioxx™ and

Celebrex™), cytokine inhibitors (such as thalidomide disclosed in W”O 95/04533 and dexanabinol) complement &nhibitors, leukotriene receptor antagonistss and combinations thereof. . Examples include acetic ac id aerivatives sulindac (Clinoril™, Merck_ & Co., Inc., Rahway, New "25 Jersey), indomethacin (Indocin™, Merck & Co., Inc., Rahway, New Jersey); etodolac (Lodine™, Wyeth, Madison, New Jersey), nabumetone (Relafen™, GlaxoSmithKline,

Middlesex, England), tolmestin sodium (Tolectin™, McNeil Pharmac=euticals, Spring House,

Pennsylvania); anthranilic sacid derivatives: meclofenamate sodium (MMeclomen™, Pfizer, New

York, New York), mefenarmic acid (Ponstel™, Pfizer, New York, Ne=w York); enolic acid derivatives: piroxicam (Fel dene™, Pfizer, New York, New York), m. obic (meloxicam); phenylacetic acid derivativees: arthrotec (diclofenac/misoprostol), Vo ltaren™ (diclofenac); propionic acid derivatives: naproxen sodium (Anaprox™, Naprosyn™™, Hoffmann-La Roche Inc. (Roche), Nutley, N.1.), flur-biprofen (Ansaid™, Upjohn, now Pfizer, New York, New York), oxaprozin (Daypro™, G.D Searle, now Pfizer, New York, New Yorls); ibuprofen (Motrin™,

Upjohn, now Pfizer, New Work, New York), fenoprofen calcium (Namlfon™, Dista, Ranbaxy,

Princeton, NJ), , ketoprofex (Oruvail™ or Orudis™, Wyeth, Madisomn, New Jersey), ketorolac tromethamine (Toradol™, Syntex Laboratories, Hoffmann-La Roche= Inc. (Roche), Nutley, N.J.);

salicylic acid derivative: diflunisal (Dolobid™, Merck & Co., Imc., Rahway, New Jersey); and

COX-2 selective inhibitors: Bextra™ (valdecoxib), Celebrex™ «celecoxib, Pfizer, New York,

New York), a nd Vioxx™ (rofecoxib, Merck & Co., Inc., Rahwasy, New Jersey). Flurbiprofen is currently the subject of clinical trials with Alzheimer’s patients Eby Myriad Genetics.

Maas BiclAB (Albuquerque, New Mexico) is developingg cyclosporin as an anti- inflammatory” neuroprotection agent. EP 813,420 BI. Cyclospcorins, a class of drugs best know as immunosu ppressants, were discovered to have a new use as tlhe most effective neuroprotectants across the spectrum of neurological disease models when they cross the blood- brain barrier. Cyclosporins protect the brain’s mitochondria anc prevent neuron death due to traumatic bra in and spinal cord injury, stroke, Alzheimer’s, Parl=cinson’s, Huntington’s diseases and amyotrophic lateral sclerosis (ALS) animal models. Anti-Oxidant.s

As a Ripid rich organ, the CNS is particularly susceptible= to effects of lipid peroxidation in modulating cellular signaling pathways, cell dysfunction, anc cell death in the nervous systen—.

In Alzheimer’s disease, emerging evidence provides strong support for a role for oxidative stres=s in neurodege neration, as multiple indices of oxidative stress hawe been observed, including protein oxidation, decreased polyunsaturated fatty acids, mitockondrial and nuclear DNA damage. ’

Free radicals (e.g., superoxide radicals) are used by phagocytes to kill bacteria and to oxidatively destroy foreign matter. Ordinarily excess superoxicle is quenched by superoxide dismutase, however if oxidative stress causes the overproductio n of radicals, or if the productiorn of the superoxide exceeds the capacity of superoxide dismutase _,, then unintended oxidative damage may occur. B. Halliwell, dcta Neurol. Scand. 126, 23—33 (1989). In Alzheimer’s . subjects, protein oxidation, DNA oxidation, and lipid peroxidatScn are greater than in age- matched controls. S.S. Pitchumoni, et al., N. Engl. J. Med. 46(M2), 1566-72 (1998).

An “antioxidant” is any substance capable of protecting against the damages of oxidatives stress caused by reactive oxygen species such as free radicals. =Antioxidants are generally desined so teat they may be oxidized over other materials. In aaddition to superoxide dismutase, catalase and glutathione peroxidase react with hydrogen peroxicde and convert it to water and diatomic oxy gen. Other antioxidants include vitamin E (a-tocopherol), vitamin C (ascorbic acid), vitami:n A (retinoic acid), co-enzyme Q, and selegiline.

Vitarnin B, a-tocopherol, quenches a free radical by don_ ating a hydrogen atom thereby producing a gocopheroxy radical, which scavenges yet another poeroxyl radical to produce a-tocopherol quinone, a stable compound. Unlike many other amntioxidants, vitamin E is lipophilic and therefore soluble in the central mervous system and able to localize ina cell membrane thus preventing lipid peroxidation. Glutamate and AB together have been shown to stimu ate the production of free radicals in cultured neurons, but this process is retarde=d by the . additi . on of catalase or a-tocopherol and agentss that increase catalase activity. H. Hare, er al., Braire Res. 510, 335-38 (1990). Vitamin E hass been shown to slow cognitive decline in

Alzhe=imer’s disease and in rat models. Patients with Alzheimer’s disease treated with vitamin E showeed a decreased rate of functional decline. Although it is not clear what causal relation oxidation has to Alzheimer’s disease etiology, e.g., whether it is a secondary effect of” the stress cause=d by synaptic or neuronal loss, antioxidamt therapies have shown limited but pro mising efficamcy in treating Alzheimer’s disease. Vitamin E lacks negative medication interaction and may 5 used in combination with other Alzhei mer’s disease therapies. C.Behl, ef al., “Vitamin E protescts nerve cells from beta-amyloid proteire. toxicity.” Biochem. Biophys. Res. Conamun. 186, 944-550 (1992); M.Sano, ef al., “Rationale and design of a multicenter study of selegil ine and a- tocopherol in the treatment of Alzheimer disease using novel clinical outcomes.” AlzFaeimer Dis.

Assoc. Disord. 10, 132-40 (1996); H.Kappus, ef al., “Tolerance and safety of vitamin E:a toxicenlogical position report.” Free Radic. Bical. Med. 13, 55-74 (1992)).

Selegiline inhibits monoamine oxidase=, which may convert certain protoxins i nto toxins.

L.S. Schneider, J. Clin. Psychiatry 57, 30-36 (C1996). Selegiline and other monoamine oxidase type IB inhibitors may protect neurons from oxxidative damage while not interfering w ith the action of type A inhibitors, which metabolize -serotonin and norepinephrine. Selegilire also inhib Zits oxidative deamination of dopamine, which prevents the formation of free rad icals and subse=quent neuronal damage. M. Sano, ef al., Alzheimer Dis. Assoc. Disord. 10, 132—140 (1996). . Selegziline, through its anti-oxidative and neuroprotective properties may slow progresssion of

Alzhe=imer’s disease. Selegiline effect on cate cholamine metabolism may also contriloute to the efficamcy of selegiline in delaying the progressi on of Alzheimer’s disease in patients with mode=rate impairment.

Other antioxidants include free radical scavengers (Egb-761, yuyu Industrial, «CP1-21, dexarabinol and iron chelators, which prevent: iron from reacting to form hydroxyl radicals.

Desfesmioxamine prevents radical damage in v_ivo, and clinical trial shows that it may _slow the progression of Alzheimer’s disease. Yet another example is HCT-1026 (NO-flurbipreofen), whichis a nitric oxide-donating derivative of Slurbiprofen presently being developed in human clinic=al trials by NicOx SA (Sophia Antipolis, France). The chronic use of certain NSAIDS may resultz in gastrointestinal ulcers and impaired kidney function. Nitric oxide is believecd to prevent or reverse such side-effects, thus making HCT -1026 particularly noteworthy.

Peroxisome Proliferator-Activcated Receptor (PPAR) Agonists

Also useful in the presemt invention are compositions or therapeutic combinations that further comprise at least one (one or more) activators for peroxisome prolifer=xtor-activated receptors (“PPAR”). The activators act as agonists for the peroxisome prolifemrator-activated receptors. Three subtypes of PEPAR have been identified, and these are design -ated as peroxisome proliferator-activated receptor &lpha (“PPAR”), peroxisome proliferator-acti vated receptor gamma (“PPAR”) and peroxissome proliferator-activated receptor delta (“PP..ARS,” which is also known as “PPARB” or “NUC1 *),

Exposure of mammalian cells to PPAR agonists, particularly PPARa. or PPARS agonists, modulates, e.g., decreases the production or release of AB, particularly AB42_, from the cells.

See, U.S. Patent Application Pesblication No. 2003/0125338, which describes administrations of peroxisome proliferator-activated receptors for the treatment of amyloidosis and conditions and diseases associated therewidth~ The peroxisome proliferator-activated receptors (PPAR,

PPARS, PPAR, and PPARy) are a subfamily of the nuclear receptor gene family, Desvergne, et al., Endocrine Rev. 20, 649- 88 (1999)). PPARs are usually activated by fa=tly acids and similar derivatives. PPARS has been &dentified as being useful in increasing high density lipoprotein (HDL) levels in humans. See, e.g., WO 97/28149, which describes PPAR agonists that are useful for raising high density lipoprotein (HDL) plasma levels in mammals. PPAR activator compounds are useful for, among other things, lowering triglycerides, moderately lowering LDL levels and increasing HDL levels. Useful examples of PPAR: activators incl ude fibrates.

In contrast to PPARaq, the function of PPARS is not well understood. Although PPARS : is ubiquitously expressed the brain, adipose tissue and skin have higher levels of relative nRNA ) expression (J.M. Peters, et al., Mol. Cell. Biol. 20, 5119-28 (2000)). The exp=ression profile of

PPARS suggests that it may bes involved in brain functions. G. Xing, et al., Biochem. Biophys.

Res. Commun. 217, 1015-25 (1995). Furthermore, PPARS may be implicated in reverse cholesterol transport, W.R. Olivet, ef al, Proc. Nat'l. Acad. Sci. USA 98, 5306-11 (2001).

Examples of PPARS agonists finclude valproic Acid (Lampen, et al., Tox. Apapl. Pharmacol. 160, 238-49 (1999)), GW501516 (\V.R. Oliver, et al., Proc. Nat'l Acad. Sci. USA 98, 5306-11 (2001)), L-165041, L-165461, L-783483, and L-796449 (Berger, et al., J. Biol Chem. 274, 6718-25 (1999). - Routine experimentation may be performed to determine if a compos3tion affects the release of AB from at least one cell in vivo. A suitable assay involves SM-4 cells, which are stably transfected with Swedis h mutant amyloid Precursor Protein, and then €rcated with a

PPAR or PPARS agonist, such as pirinixic acid, or derivative thereof. After treatment, the media is collected and assayed for ABs or APs. A statistically significant de=crease (p<0.05) in . . Ago or Asa concentration in the media compared to appropriate control(s) i ndicates that the treatment inhibited or prevented ABs or ABq; production or release from the cells. Ifa compound decreases AB, production or release by a statistically significant amount relative to control (absence of the compound cr presence of vehicle) it is considered to be an Af4- : modulating agent according to the &nvention.

An exemplary PPAR agonist is pirinixic acid, which has been shown to induce a decrease in APas2 production or release from SM-4 cells ina concentration-dependeent manner. Pirinixic acid has been identified as a hypoli pidemic agent, see, U.S. Pat. No. 3,81 4,761, which character- ized it and related compounds as asnti-lipidemic agents. Although it migh—t be tempting to view the activity of pirinixic acid on AB-42 production or release as being direc=tly related to its hypo- lipidemic role, particularly in view of the clinical correlation between hy —percholesterolemia and

Alzheimer’s disease. Wolozin, Prec. Nat'l Acad. Sci. USA 98, 5371-73 ®2001)). Fibrates are known to act as cholesterol-lowerimng agents but they generally are not krown to reduce AB42 production or release. For examples, it has been reported that when SM-4R cells were treated with clofibrate and the culture media weas collected in order to assay AB42 levels, clofibrate was found to increase AP42 extracellul ar levels at a concentration range of 563-500 uM. Similar results were found with 5,8,11,14-esicosatetraynoic acid (‘ETYA”™) at 20—50 uM concentrations.

The fact that three PPAR agonist s (all of which are cholesterol lowering agents) have disparate effects on AB42 production or rele ase from SM-4 cells implies that somes PPARa agonists affect

AP42 production or release via a mechanism that is not strictly concomit=ant with their role as ‘ cholesterol lowering agents. See, TJ.S. Patent Application Publication Neo. 2003/0013699, which describes novel heterocycles desig med to prevent, treat, or ameliorate syrptoms of Alzheimer’s

Disease, regulating production or 1 evels of amyloid-B peptides in the blo odstream or brain.

Non-limiting examples of suitable fibric acid derivatives (“fibrate=s”) include clofibrate (such as ethyl 2-(p-chlorophenoxy)-2-methylpropionate, for example Atr—omid-S™ capsules, : which are commercially available —from Wyeth, Madison, New Jersey); gzemfibrozil (such as 5-(2,5-dimethylphenoxy)-2,2-dime=thylpentanoic acid, for example, Lopi d™ tablets, which are commercially available from Pfize r, New York, New York); ciprofibrate= (C.A.S. Registry No. 52214-84-3, see, U.S. Pat. No. 3,9<48,973, which describes the synthesis - of such halocyclopropyl substitutedphenoxyalkanoic acids zand esters); bezafibrate (C.A.S. Regist=ry No. 41859-67-0, see,

U.S. Pat. No. 3,781,328, which describes the synthesis of novel phenoxy—-alkyl-carboxylic acid compounds and their ability to low~er the serum lipid and cholesterol leve=l); clinofibrate (C.A.S.

Registry No. 30299-08-2, see, U.S . Pat. No. 3,716,583, which describes —the preparation of novel anti-atherosclerosis agents); binifiborate (C.A.S. Registry No. 69047-39-8=); lifibrol (C.A.S. .

Registry No. 96609-16-4); fenofibrate (such as Tricor™ micronized fenofibrate (2-[4-(4-chloro- : benzoyl)-phenoxy]-2-methylpropamoic acid, 1-methylethyl ester), which is available from Abbott

Laboratories, Abbott Park, Illinois, or Lipanthyl™ micronized fenofibratze, available from

Laboratoire Founier, Chenéve, Fracnce).

Other examples of PPA. Ro activators include suitable fluorophen_yl compounds as disclosed in U.S. Pat. Na. 6,028,109, which describes the use of agnosts -of PPARa for the manufacture of a medicament for the treatment of obesity and the methods of treating obesity; certain substituted phenylpropE onic compounds as disclosed in WO 00/7=5103, which describes novel substituted phenylpropicenic acid derivatives capable of binding as a ligand to PPARa to thereby activate the receptor ard thus show a potent effect of lowering bMood lipid; and PPARa activator compounds as disclosed in WO 98/43081, which describes methods and compositions for treating a host having a gastrointestinal disease by administering to tie host a composition containing a pharmaceutically effective amount of a modulator of a PPAR. Non-limiting examples of suitable PPARy activators include derivatives of glitazones -or thiazolidinediones, such as, troglitazone (such as Rezulin™ 5[[4-[(3,4-dihydro-6-hydroxy-2 5 5,7,8-tetramethyl- 2H-1-benzopyran-2-yl) metho=xy]phenyl]methyl]-2,4-thiazolidinedione) commercially available from Pfizer, New York, New Work); rosiglitazone (such as Avandia™ rosiglitazone maleate 5-[[4-[2-(methyl-2-pyridinylarmino)ethoxy]phenyl)methyl]-2,4-thiazolid@nedione, (Z)-2-butene- dioate) available from GlaxoSmithKline, Middlesex, England) and pioglitazone (such as Actos™ pioglitazone hydrochloride (5- [[4-[2-(5-ethyl-2-pyridinyl)ethoxy]phenyl_Jmethyl]-2,4-}-thiazoli- dine-dione monohydrochlorides) commercially available from Takeda Phe armaceuticals, Lincoln- shire, Illinois). Other useful th#azolidinediones include ciglitazone, engli—tazone, darglitazone and

BRL 49653, see, WO 98/0533 1, which relates such compounds for the perevention and treatment of type 2 diabetes and cardiovaascular disease; PPARY activator compoumds disclosed in WO 00/76488, which describes methods for delaying or preventing the onset of Type 1 diabetes; and

PPARy activator compounds disclosed in U.S. Pat. No.-5,994,554, whickn describes a method for determining whether a compo und does or does not interact directly with. PPARy using radiolabeling.

Other useful PPARy activator compounds include certain acetylp- henols, see, e.g., U.S.

Pat. No. 5,859,051, which describes acetylphenol and its analogues for u se as antiobesity and antidiabetic compounds; certai n quinoline phenyl compounds as disclose=d in WO 99/20275, which describes the use of such compounds for mediating the activity of ~ PPAR receptors with such compounds; aryl compoumds as disclosed by WO 99/38845, which describes such com- pounds for use as PPARy mocHulators for the treatment for conditions su=ch as type 2 diabetes and obesity; certain 1,4-disubstitutesd phenyl compounds as disclosed in WO 00/63161, which describes such compounds as Iighly selective agonists for the PPAR receptor or prodrugs of agonists for the PPARy recept or, and therefore useful in the treatment ofE type 2 diabetes; certain aryl compounds as disclosed ira WO 01/00579, which describes such compounds as modulators of PPARy activity which are usseful in pharmaceutical compositions and amethods for the treatment of conditions such ass type 2 diabetes and obesity; benzoic acid compounds as disclosed in WO 01/12612 & WO 01/12 187, which describe such compounds as PPAR agonists, in particular PPARY, and so are u seful in the treatment of states of insulin resistance, including type

2 diabetes mellituss; and substituted 4-hydroxy-phenylalcoric acid compounds as disclosed Xn activity, to PPARES, thereby enabling them to modulate the= blood glucose levels in mammals.

PPARS co mpounds are useful for, among other thimngs, lowering triglyceride levels @or raising HDL level.s. Non-limiting examples of PPARS activators include suitable thiazole =and oxazole derivative=s, such as C.A.S. Registry No. 317318-324, see, e.g., WO 01/00603, wh ich . describes the use of pamoic acid or one of its derivatives feor the preparation of a medicame nt for the treatment of diseases characterized by deposits of amy loid aggregates; suitable non-f- oxidizable fatty acid analogues); certain fluoro, chloro or t=hio phenoxy phenylacetic acids; —see, eg, WO 97/2814 9, which describes such compounds as um seful for raising high density lipo- protein (HDL) plasma levels in mammals and for preventi ng, halting or slowing the progre=sssion of atherosclerotic cardiovascular diseases and related concRitions; see, e.g., U.S. Pat. No. 5,093,365, which describes the ability of such fatty acid amalogues to lower the concentratison of cholesterol and triglyceride in the blood; and PPARS compounds as disclosed in WO 99/048 815, which describes mmedicinal compositions with a cholesterom]-lowering effect containing, as tie active ingredient, compounds having the effect of activatimng a PPARS receptor, thereby hawving an LDL-cholester—ol-lowering effect. . Moreover, compounds that have multiple functionality for activating various combinations of PPARa, PPARy and PPARS are also use—ful with the practice of the presermt invention. Non-limmiting examples include certain substitused aryl compounds as disclosed in

U.S. Pat. No.-6,2<18,781, which describes the ability of such compounds in the treatment or— - ’ prevention of con ditions mediated by nuclear receptors, irm particular PPAR; WO 00/23416 ; WO 00/23415; WO 000/23425; WO 00/23445; WO 00/23451; =and WO 00/63153, all of which describe compourds that may be utilized in the treatment of conditions mediated by PPARex or

PPARYy activator compounds, such as diabetes and obesity=. Other non-limiting examples of= useful PPAR or PPARy activator compounds include acEivator compounds as disclosed irm WO 97/25042, which edescribes the use of a pharmaceutically e=ffective amount of an agonist of

PPARc and PPARRY for the treatment or prophylaxis of Sy~ndrome X; activator compounds as disclosed in WO ®@00/63190, which describes novel comporands that may be utilized in the treatment or prevention of conditions mediated by nuclear— receptors, in particular PPAR; activator compouzmds as disclosed in WO 01/21181, whichm describes novel drugs efficaciouis against diseases im association with glycometabolism and lipid metabolibsm by inhibiting car promoting PPAR or PPARY; biaryl-oxa(thia)zole compo unds as disclosed in WO 01/161 220, in which modulators of PPARs are useful in the treatment of ~ type 2 diabetes and of cardiovascular diseases; compounds as disclosed in WO 00/63196, whichm describes compounds that are useful - in the treatment of conditions mediated by nuclear receptomrs, in particular Retinoid X Recegptor and PPARs familmes; and WO 00/63209, which describes aa pharmaceutical composition useful in the treatmesnt or prevention of conditions mediated by PIPARs; substituted 5-aryl-2,4-thiazolidine= diones compounds as disclosed in U.S. Pat. No. 6,008,237, which describes substituted S-aryl- 2,4-thiazoRidinediones as potent agonists of PPAR, and are therefore useful in the treatment, control or prevention of diabetes, hyperglycemia, vacular restenosis, and other PPAR mediated diseases; aarylthiazolidinedione and aryloxazolidinedionee compounds as disclosed in WO ’ 00778312 sand WO 00/78313, which describe substitutec 5-aryl-2,4-thiazolidinediones and oxazolidimmediones as potent agonists of PPAR, and are therefore useful in the treatment, control or prevent ion of PPAR « or y mediated diseases; GW2331 or (2-(4-[diflucrophenyl]-1-heptyl ureido)-ethhyl]-phenoxy)-2-methylbutyric compounds, see, e.g., WO 98/05331, which describes such compounds for the prevention and treatment of type 2 diabetes and cardiovascular disease with diabe=tic or pre-diabetic conditions or symptoms by~ behaving as both a PPARo. agonist and a PPARy =agonsit, or activating both PPARa and PPAR-y; aryl compounds as disclosed in U.S.

Pat. No. 6,166,049, which describes a method comprisimng the administration of PPARa and

PPARS ; Oxazole compounds as disclosed in WO 01/17°994, which describes chemical 1s modificat@on of a phosphorous-based PPAR agonist; an d dithiolane compounds as disclosed in

WO 01/25225, and WO 01/25226, which describes methods for synthesizing novel dithiolane derivative s with high affinity for PPARo or PPARY.

Ot her useful PPAR activator compounds includes substituted benzylthiazolidine-2,4-diorme compouncis as disclosed in WO 01/14349, WO 01/1435 0, and WO 01/04351, all of which show how such acompound, as a ligand of human PPAR, enkbances the transcriptional activity of the receptor and effects the lowering of blood sugar level amid lipid level; mercaptocarboxylic compouncds as disclosed in WO 00/50392, which demomstrates how such compounds exhibit excellent antihyperglycemic and PPAR-activating effects; ascofuranone compounds as disclose=d in WO 00./53563, which demonstrates how such compo-unds are usable in preventing or treating 2s diabetes, chronic inflammation, digestive cancers, efc.; carboxylic compounds as disclosed in

WO 99/465232, which have and effect of regulating PPARs; compounds as disclosed in WO 99/12534, which describes aromatic compounds that ex hibit control effects against PPAR; benzene ¢ ompounds as disclosed in WO 99/15520, which describes compounds that exhibit control effects against PPAR and therefore useful for the treatment of related diseases; o-anisamiede compounds as disclosed in WO 01/21578, which describes the ability of such compouncisto serve as PPAR agonists; and PPAR activ-ator compounds as disclosed in

WO 01/403192, which describes heterocyclic compound s-that have the effects of lowering blood glucose le ve), lowering blood lipid level, ameliorating imsulin resistance and activating PPAR .

Cholesterol-Lowezring Agents

Since one: aspect of the present invention relates to treating Alzheimer’s disease, - regulating producstion of or levels of amyloid B (AB) peptides or regulating the amount of ApoE lL) isoform 4 in the bloodstream or brain by treatment with za combination of active ingred ients wherein the activee ingredients may be administered sepamrately, the invention also relatess to combining separamte pharmaceutical compositions in kit feorm. That is, the invention includes a kit wherein two s=eparate units are combined: a pharmace utical composition comprising at least a compound of any of the Formulae described herein and a separate pharmaceutical com position comprising at lea=st one cholesterol biosynthesis inhibitor or lipid-lowering agent as described above. In one embodiment, the kit may include directiorms for the administration of the separate components. The kit form is particularly advantageous when the separate components must be administered in d ifferent dosage forms (e.g., oral and par-enteral) or are administered at= different dosage intervals.

In another— alternative embodiment, the compositicons used in the methods of the= present i 15 invention can further comprise one or more AcylCoA:Ch. olesterol Q-acyltransferase (“aACAT™)

Inhibitors, which can reduce LDL and VLDL levels, coaciministered with or in combination with the compound(s) =of the Formulae herein discussed above . ACAT is an enzyme respons ible for ] esterifying excesss intracellular cholesterol and may reduc=e the synthesis of VLDL, which isa ‘ product of choles®erol esterification, and overproduction of apo B-100-containing lipop=roteins.

Non-limit@ing examples of useful ACAT inhibitors include avasimibe ([[2,4,6-tris(1-mesthylethyl)phenyl]acetyl}sulfamic acid, 2=,6-bis(1-methylethyl)pheny! e=ster, formerly known aus CI-1011), HL-004, lecimibide (DuP-1 28) and CL-277082 (N-(2,4-difluoroplhenyl)-N-[[4-(2,2-dimethylpropyl)phenyy|]methyl]-N-heptylurea). See P. Chang et al., “Current, Nlew and Future Treatments in Dyslipidasemia and Atherosclerosis”, Drugs 60(1), 55-93 (2000).

There is a complex relationship between Alzheimesr’s disease, cholesterol homeostasis, and agents used for regulating cholesterol levels in the bo dy. WO 00/28981 discloses time administration of aan inhibitor of HMG CoA reductase (3-Thydroxy-3-methylglutaryl Co~A reductase) to redu ce the risk of onset of Alzheimer’s disezase. The inhibitors used were Eovastatin, pravastatin, or a ceombination thereof. However, a similar correlation was not seen with simvastatin, WO (00/31548 also discloses inhibitors of HNAG CoA reductase, particularly statins.

Interestingly, simvastatin is a suggested inhibitor, contrasting with the results disclosed in WO (0/28981, which sstates that the prevalence of Alzheimer’s disease in simvastatin-treatecd subjects was not decreased. 4 35 More than half of the total body cholesterol in huncians is derived from intrinsic Wbio- ’ synthesis. HMG-CCoA (3-hydroxy-3-methylglutaryl-coen==yme A ) reductase is the enzyme catalyzing the early rate-limiting step in cholesterol biosynthesis, i.e., conversion of HV-1G-CoA to mevalonate. Cholesterol and triglycerides circulate in the bloodstream as part of lipoprotein : complexes. These complexes may be separated by densisty ultracentrifugation into high (HDL), » intermedi ate (IDL), low (LDL), and very low (VLDL) de=nsity lipoprotein fractions. Trimiglycer- v 5 ides (TG) and cholesterol synthesized in the liver are incorporated into VLDLs and released into the plasm a for delivery to pheripheral tissues. In a series of subsequent steps, VLDLs amre : transform ed into IDLs and cholesterol-rich LDLs. HDLs , containing apolipoprotein A, are hypothesi zed to participate in the reverse transport of chos lesterol from tissues back to th_e liver.

Elevated levels of total cholesterol, i.e., hypercholesterolesmia, low LDL-cholesterol (LTOL-C), and apolipoprotein B (a membrane transport protein for L_DL) promote human atherosclerosis.

Similarly, decreased levels of HDL-cholesterol (HDL-C) and its transport complex, apo dipo- protein A are associated with the development of atherosclerosis. Cardiovascular morbiclity and mortality vary directly with the level of total cholesterol aand LDL-C, and inversely with the level of HDL-C. HMG-CoA reductase inhibitors have been sheown to reduce total serum cholesterol . 15 levels, LIDL-C, and apolipoprotein B, most likely by incre=asing the catabolism of LDL a_nd : hepatic exctraction of LDL precursors, blocking enzymatic= cholesterol synthesis, and simultane ously increasing HD levels.. These lipid lowerimng drugs lower serum cholestemrol levels and reduce the incidence of both cardiovascular and cerebrovascular events. See, e.g., UNS, Pat.

Nos. 5,83 1,115; 5,807,834; 5,801,143; 5,798,375; and 5,7 86,485. Statins, well known for the treatment of prevention of coronary heart disease, block a rate-limiting step in the biosyrathesis of cholesterol by HMG-CoA reductase. See U.S. Pat. No. 6 465,516.

While Alzheimer’s disease is typically characterizeed pathologically by the presermce of senile placjues and neurofibrillary tangles found at autopsy. in the brains of subjects afflicted with . the diseases, vascular components of the disease have also been noted. These include lesicons in the cerebral microcirculation and vascular deposits of AB protein, which is also a major constituent of the senile plaques found in Alzheimer’s disease.

In addition to a relationship with coronary disease, it is known that there is a relationship "between serum cholesterol levels and the incidence and thee pathophysiology of Alzheimer's disease. Epidemiological studies show that subjects with e=levated cholesterol have an increased risk of Alzheimer’s disease. (Notkola er al., “Serum total cholesterol, apolipoprotein E epsilon 4 allele, and Alzheimer’s disease,” Neuroepidemiology; 17( 1): 14-20 (1998); Jarvik et al, “Interactions of apolipoprotein E genotype, total cholestereol level, age and sex in prediction of

Alzheimer’s disease: a case-control study,” Neurology 45( 6):1092-6 (1995).) Other studies have established that subjects possessing the apolipoprotein £4 genotype (“apoE4”) that codes for a variant of apolipoprotein, a cholesterol transport protein, h ave an increased risk for Aizhe=imer’s : disease, as well as for elevated levels of cholesterol and foar heart disease. R.Mahley,

Bs “Cholesterol transport protein with expanding role in cell biology,” Science 240, 622-30 1988); v

Saunders, et al.,. “Association of apolipoprotein E allele= ¢4 with late-onset familial and sporadic

Alzheimer’s dis-ease,” Neurology 43, 1467-72 (1993); Corder, et al., “Gene dose of : apolipoprotein EE type 4 allele and the risk of Alzheimer’s disease in late-onset families,” > 1] Science 261:92 1k -923 (1993); Jarvik, et al., “Coronary a_rtery disease, hypertension, ApoE and v 5 cholesterol: a lirik to Alzheimer’s disease?” Ann. N.Y. Acad. Sci. 826:128-146 (1997). FRoth apoE4 and a sec=ond putative risk factor for Alzheimer’ ss disease, 0-2-macroglobulin, bin_dto a receptor, the lipeoprotein receptor related protein, which is important for cellular uptake of cholesterol. (Na rita er al., “Alpha2-macroglobulin com polexes with and mediates the end ocytosis of beta-amyloid peptide via cell surface low-density lipsoprotein receptor-related protein”

J. Neurochem. 9(5):1904-11 (1997); and Blacker et al_ , “Alpha-2 macroglobulin is gen etically associated with _Alzheimer’s disease,” Nature Genetics 19:357-60 (1998).) Other studiess have shown that cholesterol increases the production of AR gprotein, which accumulates in thez brains : of subjects with Alzheimer’s disease and is thought by mmany researchers to cause the : neurodegenerati on underlying the disease. D.J.Selkoe, © “Cell biology of the beta-amyloicll precursor protein and the genetics of Alzheimer’s disea=se,” Cold Spring Harbor Sympos ia on

Quantitative Biology, 61, 587-96 (1996); and Simons, e=t al., “Cholestercl depletion inhibits the generation of B-amyloid in hippocampal neurons,” Proc. Nat'l. Acad. Sci. USA, 95, 6460-04 (1998).

The apolipoprotein E isoform 4 (ApoE isoform =4) is a major genetic risk factor for

Alzheimer’s dise=ase. PCT Patent Application No. WO ©95/06470 discloses administratior of an

HMG-CoA reductase inhibitor (statin) to regulate levels of (ApoE isoform 4) in humans to prevent and treat Alzheimer’s Disease. A normal cellul ar function of ApoE is uptake an d delivery of lipid s. The ApoE isoform correlates with ara increased risk for atherosclerosis, increased amy!lo- id plaque deposition and increased risk of Alzheimer’s disease. K.Fasstwender, et al, “Simvastatin Strongly Reduces Levels of Alzheirmner’s Disease B-amyloid peptidess Ap42 and AB40 in vitro and in vivo”, Proc. Nat'l Acad. Sci. LJS4 98: 5856-5861 (2001). PCT Patent

Application WO® 00/2898] discloses at page 3 that patie-nts possessing the ApoE isoform 4 have an increased risk for Alzheimer’s disease, as well as ele—vated levels of cholesterol and in creased risk for heart disease.

Levels oxf cholesterol in the brain are critical for synapse formation and maintenamce and recent studies id-entify cholesterol as a limiting factor in synaptogenesis. Reduced cholesterol may place a limEt on plastic processes thus reducing the tendency to develop Alzheimer’ =s disease. An issume for very long axons is the ability to sumpply sufficient cholesterol for rapid axonal growth, e=specially in regeneration. Alzheimer’s disease brain contains less cholessterol, ] 35 and this contribustes to Alzheimer’s disease-related alterzations in membrane composition, membrane fluidi ty, and lipid bilayer structure and dynarmnics. Statins, as inhibitors of cholesterol] © synthesis, may re=duce the prevalence of Alzheimer’s dissease. Long term potentiation is Mnhibited

* by cholesterol biosynthesis inhibitors and long term potentiation induction iss associated with pathway-specific increases in lipi d production. For example, axonal growth ceases when : cholesterol synthesis is inhibited by pravastatin and could be reactivated by addition of , cholesterol to either cell bodies om distal axons. v 5 The term, “HMG CoA recluctase inhibitor,” refers to any compound which inhibits the bioconversion of 3-hydroxy-3-mesthylglutaryl coenzyme A to mevalonic acidl catalyzed by the enzyme HMG CoA reductase. Thue inhibiting effect of any such compounds an be readily determined by those skilled in thes art according to standard assays. HMG CoA reductase inhibitors will be known to those skilled in the art. Non-limiting examples o-fsuitable cholesterol biosynthesis inhibitors include co mpetitive inhibitors of HMG CoA reductases, the rate-limiting step in cholesterol biosynthesis, s«qualene synthase inhibitors, squalene epoxi-dase inhibitors and mixtures thereof. The HMG CoA reductase inhibitors suitable for use in the invention include, but are not limited to, pravastatin (for example Pravachol™ which is availabMe from Bristol

Meyers Squibb) and related compounds, as disclosed in U.S. Pat. No. 4,346,227; and lovastatin and related compounds, as disclosed in U.S. Pat. Nos. 4,231,938 and 4,346,227. In some embodiments, lovastatin and prav-astatin are used as HMG CoA reductase inhibitors in the invention. Lovastatin, marketed Lander the trade name Mevacor™, is a comp etitive inhibitor of : HMG CoA reductase.

Other HMG CoA reductasse inhibitors which may be employed in the invention include atorvastatin (Lipitor™, Pfizer, New York, New York) and other 6-[2-(substit uted-pyrrol-1- yDalkyllpyran-2-ones and derivat ives, such as disclosed in U.S. Pat. No. 4,647,576; fluvastatin . (Lescol™, Novartis, Basel, Switzerland); fluindostatin (Sandoz XU-62-320); pyrazole analogs of mevalonolactone derivatives as dE sclosed in PCT application WO 86/03488; _rivastatin and other pyridyldihydroxyheptenoic acids as disclosed in European Patent 491226A; Searle’s SC 45355 (a 3-substituted pentanedioic acid derivative) dichloroacetate; imidazole analeogs of mevalonolactone, as disclosed in PCT application WO 86/07054; 3-carboxy-22-hydroxy-propane- phosphonic acid derivatives, as di sclosed in French Patent No. 2,596,393; 2,3 -di-substituted pyrrole, furan, and thiophene derivatives, as disclosed in European Patent Ap plication No. 0221025; naphthyl analogs of mewalonolactone, as disclosed in U.S. Pat. No. 4,686,237; octahydronaphthalenes, such as those disclosed in U.S. Pat. No. 4,499,289; keeto analogs of mevinolin (lovastatin), as disclose=d in European Patent Application No. 0,142,146 A2; as well as other HMG CoA reductase inhibitors.

Other examples of suitables HMG CoA reductase inhibitors include statins such as fluvastatin, simvastatin (for example Zocor™ which is available from Merck & Co.), . 3s atorvastatin, cerivastatin, CI-981 and pitavastatin (such as NK-104 of Negma Kowa of Japan), rosuvastatin; HMG CoA synthetase inhibitors, for example L-659,699 ((£,E)—11-[3’R-(hydroxy- , methyl)-4’-oxo-2’R-oxetanyl]-3,5 , 7R-tri- methyl-2,4-undecadienoic acid); sq ualene synthesis inhibitors, for example squalestatin 1; and squal ene epoxidase inhibitors, for example, NB-598 ((E)-N"<ethyl-N-(6,6-dimethyl-2-hepten-4-ynyl)- 3-[(3,3 *-bithiophen-5-yl)me- thoxy]beenzene- : methamamine hydrochloride) and other sterol biosynthesis inhibitors such as DMP-5655.

In addition, other compounds useful in irhibiting HMG-CoA reductase suitabele for use v 5 herein are disclosed in U.S. Pat. No. 4,904,646 and 5,091,378. Examples of statins irciude

Advicor™ (lovastatin/niacin); cerivastatin (Baycol™, Bayer Corp., withdrawn from W.S. market); Mevacor™ (lovastatin, Merck & Co., I mc., Rahway, New Jersey); rivastatins rosuva statin; pitavastatin; mevastatin; velostatin 5 and Zocor™ (simvastatin, Merck & Co., Inc.,

Rahway, New Jersey). Further examples of HME G-CoA reductase inhibitors include pyrazole analog=s of a mevalonolactone, indene analogs of mevalonolactone, 3-carboxy-2-hydr oxy- propamephosphinic acid derivatives, 6-[2-(substi tuted-pyrrol-1-yl)-alkyl]pyran-2-one, heterocyclic analogs of mevalonolactone includi ng imidazole analogs, naphthyl analogs of mevalonolactone, octahydro-naphthalene derivatives, keto analogs of lovastatin, and 2,3-di-=substituted pyrrole, furan, or thiophene casmpounds.

In addition to their direct effects on lipid cholesterol biosynthesis and metaboF ism, statins . incom bination with-substrates of nitric oxide symthase are known to facilitate transposrt of drugs across “the blood brain barrier (“BBB”). Inasmuch as Alzheimer’s disease is a diseases of the brain, ean especially useful pharmaceutical composition is a combination of a statin second agent and a nitric oxide synthase substrate second agermt (e.g., L-Arg) as well as a first agent as describ-ed herein. A family of enzymes called NX tric Oxide Synthase (“NOS”) form n itric oxide from L—arginine, and the nitric oxide produced is responsible for the endothelium depesndent relaxat®mon and activation of soluble guanylate cyclase, neurotransmission in the central and periphesral nervous systems, and activated macrophage cytotoxicity. Nitric Oxide Synthase, occurs in many distinct isoforms which include a constitutive form (cNOS) and an inclucible form (ilNOS). The constitutive form is present in. normal endothelial cells, neurons an d some other ti=ssues. Formation of nitric oxide by the constitutive form in endothelial cells is thought to play an important role in normal blood pressure regulation, prevention of endothelial dysfunction such as hyperlipodemia, arteriosclerosis, thrombosis, and restenosis. The inducible fo rm of nitric ‘oxide s=ynthase has been found to be present in activated macrophages and is induced En vascular smooth muscle cells, for example, by various cytokines or microbial products. The conversion of precursor substrates such as L-arginine into nitric oxide is enzymatically catalyzed Ty NOS and the resulting by-product of the conversion of L-arginine is L-citrulline, L-arginine as used : herein i ncludes all biochemical equivalents (i.e. salts, precursors, and its basic form).

In one embodiment, this invention provides a method to enhance delivery of a first agent . 35 to brain tissue of an individual comprising introducing the composition into the blood stream of the individual substantially contemporaneously with a blood flow enhancing amount o f , L-arginine. In another embodiment, this inventiom provides a method to enhance delivery of a

T= desired composition to brain tissue of an individual comprising introducing the composition into the blood stream of the individual substantially contemporaneously with a blood flow enhancing - amount of L-arginine or a blo od flow-enhancing amount of a non-ecNOS INO-generating system.

In another alternative embodiment, the compositions used in the mesthods of the present - 5 invention may further comprise one or more Cholesteryl Ester Transfer Protein (“CETP”)

Inhibitors coadministered with or in combination with the compound(s) of the Formulae described herein. CETP is responsible for the exchange or transfer of cholwesteryl ester carrying " HDL and triglycerides in VLIDL.

Non-limiting examples of suitable CETP inhibitors are disclosed in. PCT Patent

Application No. WO 00/3872 1 and U.S. Pat. No. 6,147,090, which are incorporated herein by reference. Pancreatic cholesteryl ester hydrolase (pCEH) inhibitors such ass WAY-121898 also may be coadministered with or in combination with the fibric acid derivatiwve(s) and sterol absorption inhibitor(s) discussed above.

In another alternative embodiment, the compositions used in the me=thods of the present invention may further comprise probucol or derivatives thereof (such as ACSI-1067 and other derivatives disclosed in U.S. Pat. Nos. 6,121,319 and 6,147,250), which maay reduce LDL and

HDL levels, coadministered writh or in combination with the compounds of= the Formulae herein.

In another alternative embodiment, the compositions used in the me=thods of the present invention may further compris € one or more low-density lipoprotein (LDL)= receptor activators, coadministered with or in com bination with a compound of any Formula di scussed above. Non- + limiting examples of suitable L_DL-receptor activators include HOE-402, ar imidazolidinyl- + pyrimidine derivative that dire ctly stimulates LDL receptor activity. See, MK. Huettinger et al., “Hypolipidemic activity of HOE-402 is Mediated by Stimulation of the LD_L Receptor .

Pathway.” Arterioscler. Thronab. 13, 1005-12 (1993). .

In another alternative embodiment, the compositions used in the meathods of the present invention can further comprise plant sterols, plant stanols or fatty acid esters of plant stanols, such as sitostanol ester used in Benecol™ margarine, which can reduce cho lesterol levels, coadministered with or in combination with a compound of any Formula he rein. Generally, a total daily dosage of plant sterols, plant stanols or fatty acid esters of plant s=tanols can range from about 0.5 to about 20 grarns per day in single or 2-4 divided doses.

In another alternative exmbodiment, the compositions used in the met=hods of the present invention can further comprise one or more antioxidants, such as probucol, ®ocopherol, ascorbic acid, B-carotene and selenium, or vitamins such as vitamin Bg or vitamin B, —, coadministered . with or in combination with a compound of any Formula herein. Generally, atotal daily dosage of antioxidants or vitamins can range from about 0.05 to about 10 grams per~ day in single or 2-4 divided doses.

In another alternative: embodiment, the compositions used i nthe methods of the present invention can further compri se monocyte and macrophage inhibitors such as polyunsaturated ) fatty acids (PUFA), thyroid Inormones including throxine analoguess such as CGS-26214 (a thyroxine compound with a Fluorinated ring), gene therapy and use- of recombinant proteins such » 5 as recombinant apo E, coadministered with or in combination with acompound of any Formula herein. Generally, a total dailly dosage of these agents can range fromm about 0.01 to about 1000 mg/day in single or 2-4 divided doses.

Fassbender ef al. disc lose that use of simvastatin and lovast-atin, alone or in combination with methyl-B-cyclodextrin, «an reduce intracellular and secreted Amp levels in vitro and that treatment of animals with sincivastatin reduces brain and cerebrospimnal fluid levels of AB in vivo.

U.S. Pat. No. 6,071,899 discloses compounds, which may have a general application in any disorder that involves endothelial dysfunction, such as atherosclerosis, or may have a general application in any disorder thx at involves lipid peroxidation in conjumnction with enzyme activity, including inflammatory cond itions of the brain such as Alzheimer’ ss Disease (see col. 5, lines 16-29). . PCT Patent Application WO 99/38498 discloses methods foor preventing or treating

Alzheimer’s disease by admimistering a plasma-triglyceride level-lcawering agent (e.g., fibrates), optionally in combination wikh a cholesterol level-lowering agent smuch as statins, bile acid sequestrants or agents that block intestinal cholesterol absorption (e-.g., B-sitosterol, SCH 48461 ((3R,45)-1,4-bis-(4-methoxyphenyl)-3-(3-phenylpropyl)-2-azetidi- none), CP-148,623, saponins, neomycin and ACAT inhibitors). :

U.S. Pat. Nos. 5,767,1 15, 5,624,920, 5,688,990, 5,656,624 amend 5,688,787, respectively, disclose hydroxy-substituted zzetidinone compounds and substituted B-lactam compounds useful for lowering cholesterol or in inhibiting the formation of cholestero_1-containing lesions in mam- malian arterial walls, but doess not disclose treatment of Alzheimer’ ss Disease.

Simvastatin has been wised to reduce levels of §-amyloid pepstides AB4; and Ay in vitro and in vivo, for example, in guinea pigs. Wolozin, B. et al., Arch. Neurol. 57:1439-1443, 2000, describe the analysis of a subj ect population treated with HMG-CoA reductase inhibitors. The authors reported that the prevalence of Alzheimer’s disease was 60-73% lower in these subjects than in subjects taking other rnedications. In this study, a causal relationship could not be established. Jick, H. et al., The Lancet 356:1627-1631, 2000, also re=viewed subject records and found that in individuals 50 ye=ars and older, statin administration was associated with a substantially lowered risk of cdementia, including Alzheimer’s diseasse and other conditions. . Similarly, Acyl-CoA: cholesterol acyltransferase (ACAT) inhibitors: have been used to decrease =35 plasma cholesterol in various animal models including rats, guinea pigs and rabbits (Tanaka etal, J Med Chem. 41:2390—2410, 1998; Junquero et al., Biochem. Pharmacol. 61:97-108,

2001). Examples of ACAT inhibitors include but are not limited to Glibenclamide, CI-976 (PD128042), TNTE-122, Fatty acid Anilides, F12511, Avasimibe, TS-962 (HL-004), N- . Chlorosulfons/! isocyanate and derivatives, SR-9223i_ Pyripyropenes, PD-132301, PD-132301-2,

DUP-128, YNA-17E, BW447A, Alzheimer’s disease 6591, CL-277,082, Melinamide, . 5 Hydroxyphen-yl Urea derivatives, R-106578, Indoline derivatives with amide or urea moiety, 57-118, 58-0385, CI-999, CI-1011, N-alkyl-N-[(fluorogohenox- y)benzyl}-N -arylureas and derivatives, SAF-99085, EAB309, N-alkyl-N-(heterar-yl-substituted benzyl)-N -arylureas amd derivatives, F—1394, N-alkyl-N-biphenyllylmethyl-N '—aryl ureas and derivatives, CL 277,032,

CL 283,546, CL 283,796, CP-113,818, CP-105,191, Polyacetylene analogs-panaxynol, panaxydol, pa naxydiol and panaxytriol, T-2591, 4,4-beis(triflucromethyl)imidazolines and derivatives, FER145237, FR186054, FR129169, Naringgenin, Ulmoidol, 23-hydroxyursolic a cid, 27-trans-p-couamaroyloxyursolic acid, 27-cis-p-coumaaroyloxyursolic acid, Triterpenes and derivatives, N—(4,5-diphenylthiazol-2-yl)-N aryl or al kyl (thio)ureas and derivatives, N-(4,5- diphenylthiazol-2-yl)alkanamide- s and derivatives, R P73163, RP64477, Diaryl-substitutecll heterocyclic u reas and derivatives, Heterocyclic amidess and derivatives, Cyclic sulfides derived : from hetero-D=iels-Alder reaction of thioaldehydes with 1,3-dienes, E5324, Tetrazole amide= derivatives of (+/-)-2-dodecyl-alpha-p- henyl-N-(2,4,6-trimethoxyphenyl)-2H-tetrazole-5- acetamide, Ep icochlioquinone A, acyclic(diphenylethwyl) diphenylacetamides, 2-(1,3-dioxara- 2-yh)-4,5-diphesnyl-1H-imidazoles and derivatives, N-(2,2-dimethyl-2,3-dihydrobenzofuran— 7-ylamide derivatives, FCE 27677, GERI-BP002-A, "TMP-153, amides of 1,2-diarylethylammines and derivatives, F-1394, N-(4-oxochroman-8-yl)amide derivatives, terpendoles, short chain ceramide and cdihydroceramide, FY-087, 447C88, cycBandelate, 3-quinolylurea derivatives,

N-phenyl-6,11 -dihydrodibenz[b,eJoxepin-11-carboxarmides and related derivatives, Gypseti n,

AS-183, AS-1386, 2,6-disubstituted-3-imidazolylbenzo pyrane derivatives, Lateritin, 2-(alkyl thio)- 4,5-diphenyl-1 H-imidazoles derivatives, glisoprenins, acaterin, U-73482, purpactins, and chlorpromazine.

Amyloid InhibF tors (Anti-Amyloid Therapeutic Approaches)

Other immportant targets for therapeutic interven tion are the mechanisms which convert

APP into AB. In particular, down-regulation of the B and gamma-secretases and up-regulati on of alpha-secretase= (which cleaves within the AB peptide) would inhibit the production of AB peptide. B-secmretase or BACE has been identified by several groups and is an aspartyl prote ase enzyme. However the molecular identity of the gammaa-site APP processing enzyme, gamme a- secretase, still Eremains to be determined. It is clear that presenilins are required for y-secretzase \ : cleavage of AP*P. Ap secretion is almost completely bLocked in neurons lacking presenilin L .

There are a nurmber of possibilities for the function of presenilins: (1) They could be requirecd for intracellular trafficking and sorting of APP to the y-secretase co mpartment, or (2) They could serve as a co-factor for y-secretase cleavage. (C. Haass, ef al., Secience 286, 916-19 (1999); : MS Wolfe, et al., Biochemis-try 38, 4720-27 (1999); T. Bayer, ea al., Brain Pathology 11, 1-11 (2001); B. De Strooper, et ad., Nature 391, 387-91 (1998)). See also, WO 2003/103652 and - 5 WO 2003/103653. y-Secretase cleaves at the C-terminus of AB and is primarily responsible for generatings the pathogenic 42-amino aci d form of AB, AB42, which forms imnsoluble toxic fibrils and accumulates in senile plaque=s. Ml. Hutton, et al., Essays Biocherm:. 33, 117-31 (1998); R.L.

Nussbaum and C.E. Ellis, N. Engl. J. Med. 348(14), 1356-64 (20003); T. Iwatsubo, ef al., Neuron 13, 45-53 (1994), W.P. Esler and M.S. Wolfe, Science 293, 1449-54 (2001). Although the normal function of APP is uriknown, it is predominantly expresssed in the brain and is suspecte-d of participating in cell adhes Jon, synaptic growth, and neural repair.

Amyloid—B forms a continuum of aggregation species: monomeric amyloid-B, soluble oligomeric amyloid-B, insolmible protofibrils, amyloid—j, diffuses amyloid, compact amyloid, and neuritic or senile amyloid, th e latter two being the pathologic and diagnostic hallmarks of

Alzheimer’s disease. Indepe=ndent of fibril or plaque formation, however, amyloid— may altemr membrane potential and firirmg, synaptic transmission, synaptic pwlasticity, and learning.

Amyloid, especially amyloid—f 1-42, has been shown to be neurotoxic. Accordingly, amyloid itself represents a_ significant drug target. Recent evicience suggests that plaques pex se are less toxic than oligomers or protofibrils. These oligomeric forms of AB could be responsible for the first stages of the disease when neuronal cell dileath is initiated. See also,

WO 03/050073; WO 03/0475576; WO 03/045378; WO 03/04398 7; WO 03/043975;

WO 03/043618; U.S. Pat. No. 6,569,851; WO 03/040096; U.S. Pat. No. 6,552,013;

WO 03/037325; WO 03/030886; WO 03/029169; EP 1,298,436; WO 03/027068; U.S. Pat.

No. 6,528,505; WO 03/0203°70; U.S. Pat. No. 6,509,331; WO 03 /006453; WO 03/006423;

WO 03/006021; WO 03/006013; U.S. Pat. No. 6,509,331; U.S. Pat. No. 6,486,350;

WO 03/002122; U.S. Pat. Now. 6,476,263; WO 03/000261; WO 0_2/100856; WO 02/100820;

WO 02/100818; WO 02/1004310; WO 02/100399; WO 02/09884=9; WO 02/094768; U.S. Pat.

No. 6,476,263; WO 02/076440; U.S. Pat. No. 2002/16320 Al; U.S. Pat. No. 6,329,163;

WO 00/202520; WO 00/2025 18; WO 00/202512; WO 00/20250e6; WO 00/202505; U.S. Pat.

No. 6,284,221; U.S. Pat. No. 6,221,645; WO 00/175165; WO 00./170672; U.S. Pat.

No. 6,262,302; U.S. Pat. No. 6,191,166; U.S. Pat. No. 6,262,302 U.S. Pat. No. 6,153,652;

WO 96/40885; U.S. Pat. No. 5,942,400; U.S. Pat. No. 5,744,346; and WO 98/21589.

Dense microspheres o»r spherons may be turned into plaqumes when they are burst in vitres . 35 or when injected into experirraental animals. P. Averback, J. Alzfzeimer’s Disease 1, 1-34 (1998).

The compound NX-D2858 (Nymox Pharmaceutical Corp., Dorval, Québec, Canada) blocks the= , transformation of spherons in-to senile plaques and may stop or sleow the progress of Alzheimer’ s

=lisease. U.S. published application no. 20403-0083298. Another compound that may be used in “the pharmaceutical compositions of the invention is Ateroid™ (Hunter-Fleming,.) and related : Zmucopolysaccharides, such as glycosamincglycans having an average molecular— weight equal to 22,400 Da, which have been described as sumitable for the treatment of Alzheimer?’ s disease. . 5 TEP 1,181,024

Another compound is indole-3-propoionic acid (Oxygon™, Mindset), whi ch is described as preventing the cytotoxic effects of amyleoid beta protein on cells, as well as bleocking amyloid leposition and therefore useful in treating = fibrillogenic disease, such as Alzheimer’s disease.

WJ.S. Pat. No. 6,395,768 Bl. Suitable amyloid aggregation inhibitors also includes reumacon

Available from Conpharm AB.

Additional examples include a variesty of polysaccharide compounds. U.S. Pat. No. 65,607,758, WO 03/013442, US 2002/197692, US 2002/150637, and CA 2,323,050

Yet another approach is exemplifiecd by a new chelating agent. “Targeted

Pharmacological depletion of serum amyloid P component for treatment of humamn amyloidosis.” P™.B.Pepys, et al., Nature 417(6886), 254-59, lmyloid-Formation Inhibitors

The present invention pertains to a rmethod for treating or preventing a disease state - associated with amyloidosis, the method co mprising administering to a subject a therapeutically e=ffective amount of an agent for reducing the concentration of fibrillar or soluble A, such that s=aid disease state associated with amyloidosis is treated or prevented.

In an embodiment, the methods of thne invention are based, at least in part_, on inhibiting a_n interaction between an amyloidogenic protein and a constituent of basement nmembrane to imhibit amyloid deposition. The constituent of basement membrane is a glycoprotein or proteoglycan, e.g., heparan sulfate proteoglsycan. A therapeutic agent used in the method of the iravention may interfere with binding of a basement membrane constituent to a target binding site o-n an amyloidogenic protein, thereby inhibi ting amyloid deposition. In some asp ects, the methods of the invention involve administering to a subject a therapeutic agent which inhibits ) amyloid deposition. “Inhibition of amyloid deposition” is intended to encompass prevention of amyloid formation, inhibition of further amyloid deposition in a subject with ongoing amyloidosis and reduction of amyloid depossits in a subject with ongoing amyloideosis. Inhibition of amyloid deposition is determined relative: to an untreated subject or relative to ®the treated . stabject prior to treatment. Amyloid deposition is inhibited by inhibiting an interaction between am amyloidogenic protein and a constituent of basement membrane. “Basement n—iembrane” , refers to an extracellular matrix comprising gglycoproteins and proteoglycans, incleiding laminin,

collagen type IV, fibroraectin and heparan sulfate proteoglycan (‘““*HSPG”). In one embodiment , amyloid deposition is irhibited by interfering with an interaction between an amyloidogenic i protein and a sulfated g lycosaminoglycan such as HSPG. Sulfatesd glycosaminoglycans are known to be present in all types of amyloids (see Snow, et al. Leb. Invest. 56, 120-23 (1987) . 5 and amyloid deposition and HSPG deposition occur coincidental ly in animal models of amyloidosis (see Snow, et al. Lab. Invest. 56, 665-75 (1987)).

The ability of a ~therapeutic compound of the invention to inhibit an interaction between an amyloidogenic prote in and a glycoprotein or proteoglycan corastituent of a basement membrane may be assessed by an in vitro binding assay, such as that described in U.S. Pat.

No. 5,164,295. Alterna tively, the ability of a compound to bind =o an amyloidogenic protein omr to inhibit the binding of a basement membrane constituent (e.g., “HSPG) to an amyloidogenic protein (e.g., AP) may bbe measured using a mass spectrometry assay where soluble protein, e.g=.,

AB, is incubated with thae compound. A compound that binds to, e.g., AB, will induce a change in the mass spectrum of the protein.

For example, a therapeutic agent of the invention may int eract with a binding site for a basement membrane glwsycoprotein or proteoglycan in an amyloideogenic protein and thereby inhibits the binding of tthe amyloidogenic protein to the basemenst membrane constituent.

Basement membrane glycoproteins and proteoglycans include laminin, collagen type IV, fibronectin and HSPG. In an embodiment, the therapeutic agent inhibits an interaction betweer . an amyloidogenic prote in and HSPG. Consensus binding site motifs for HSPG in amyloidogermic proteins have been described (see, e.g., Cardin and Weintraub, d@teriosclerosis 9, 21-32 (1989)m).

Metal Chelators

Zn** mediates nesurodegenerative processes observed in seizure, ischemia, trauma, and

Alzheimers disease. Zm?" is observed in the extracellular plaque and degenerating neurons in

Alzheimer’s disease, which may contribute to neuronal degenerasion in Alzheimer’s disease.

Oxidative damage in the neocortex associated with Alzheimer’s (disease may be the result of gradual build up of metal ions like zinc and copper. Copper and z=inc have particularly high concentrations in the B-zamyloid plaques in the brains of Alzheimer’s subjects. Both metals are : essential, but normally <nly small amounts are required and exce=ss metals are excreted. It is hypothesized that f-amsyloid converts dissolved oxygen to hydrogen peroxide, which in turn causes cell damage. Me tal chelators may be used to diminish the oxidative burden. In APP transgenic mice treated -with clioquinol (an antibiotic and bioavai_lable Cu/Zn chelator), marked : reduction in AP deposition occurred after several months of treatmnent. Zinc and other divalent cations appear necessary for A3 aggregation. Thus, metal chelation may have some therapeutic : 35 benefit in the treatment of Alzheimer’s disease, either by preventing AP aggregation or by disrupting preformed aggregates. In the laboratory, the copper-zinc chelator clioquinol may dissolve amyloid-beta deposits in postmortem brain tissue from Alzheimer’s disease subjects. In : APP transgenic mice treated w ith clioquinol (an antibiotic and bioavailables Cu/Zn chelator), marked reduction in AB deposi tion occurred after several months of treatnaent A new study . 5 extends these results to mice genetically prone to overproduce amyloid-B. Clioquinol cut amyloid deposits in half over a nine week period with no adverse effects. ~The mice treated with clioquinol also exhibited significantly improved scores on a behavioral rating scale. The affinity of clioquinol for Zn is in the namnomolar range, whereas the affinity of AR £or Zn?" is in the low micromolar range. Clioquinol had been approved by the FDA as an antibisotic, but was removed from the market about 30 yearss ago because of side effects involving the loss of Vitamin B-12.

The antibiotic clioquinol, also lknown as 5-chloro-7-iodo-8-hydroxyquinol £ ne or iodochlorhydroxyquin, a knowm copper/zinc chelator is a reasonably well t-olerated drug in humans and is currently in a phease II clinical trial for Alzheimer’s disease. T.E. Golde, J. Clin.

Invest. 111, 11-18 (2003). Clicquinol chelates copper and zinc in vitro, anad reduces A deposition in a mouse model. Moreover, interim results from a randomized, double-blind, placebo-controlled clinical trial in 32 subjects with Alzheimer’s disease sugzgested that this drug slows the rate of cognitive decl ine in the most severely affected group.

Suitable copper/zinc chelators include clioquinol available from PNT Gerolymatos SA.

Preliminary positive results have been generated by a human clinical trial imn which clioquinol, supplemented with B-12, appeanrs to be helpful in humans with Alzheimer’=s. Bush, ef al, Proc. ) Nat'l Acad. Sci. US4 99, 7317- 19 (1999), U.S. Publshed Patent Applicatior No. 2002/0,025,944.

See also, “Treatment with a copper-zinc chelator markedly and rapidly inhibits beta-amyloid accumulation in Alzheimer’s disease transgenic mice.” R.A. Cherny, et al. , Neuron 30, 665-76 : (2001); and “The galvanization of B-amyloid in Alzheimer’s disease” A.l. Bush and R.E. Tanzi

Proc. Nat'l Acad. Sci. USA 99, 7317-19 (2002).

Phanquinone (4,7-phenanthroline-5,6-dione) has hitherto been used for the treatment of various disorders, such as amoe=biasis. However, its use for the treatment or— prevention of memory improvement has beer suggested. Phanquinone has been markete=d by Ciba-Geigy as ' Entobex™. Phanquinone is alse a metal chelator in the same family as cliosquinol. According to the present invention the use of phanquinone for the manufacture of a pharrnaceutical } composition for the treatment ox prevention of memory impairment is provided.

Behavioral Management of AlzFaeimer’s disease : Patients with Alzheimer “s disease may also be treated for behavioral disturbances associated with progression of the disease. Use of such treatments is intend®ed to decrease ) 35 psychotic symptoms such as paranoia, delusions and hallucinations, and ass:ociated or independent agitation, screami. ng, combativeness or violence, ard thereby increase the comfort and safety of patients. Anti-pssychotics and antidepressants can be used intermittently in patients ) with defined psychotic symptosms,

Benzodiazepines may toe used briefly and judiciously fomr emergency sedation but v 5 otherwise should be avoided bsecause they can produce delirium and tend to further compromise residual cognitive capacities. Lithium (Eskalith), centrally actives B-adrenergic blockers, carbamazepine (Tegretol™, Ciba-Geigy Pharmaceuticals, now ENovartis, Basel, Switzerland), and valproate {Depakene) have been used empirically in the treatment of affective lability and aggressive outbursts. Respericlone can also be used for psychos: es associated with Alzheimer’s disease. Olanzabine, sertindolee, and quetiapine can also be usec. Still other examples include trazodone; 3 blockers, propranolol, metoprolol and pindotol (especially for some agitated patients with dementia). Wher male patients display intrusive dlisinhibited sexual behavior, a particular problem in patients with frontal lobe dementias, medr-oxyprogesterone and related hormonal agents may be employed. Glycosaminoglycan polysu. late (Ateroid™) can also improve depressive symptomatology in old-age dementia. Prog=. Newropsychopharmacol. Biol,

Psychiatry 13, 977-81 (1989).

Treatment of apathy is =also considered. Dopaminergic a_gents, such as psychostimulant

CD-amphelamine, methylphenidate), amantadine (Symmetrel™=1, Du Pont Multi-Source

Products, Wilmington, DE), br-omocriptine and buproprion are Imelpful in the treatment of severe apathy. A.E. Wallace, ef al., “IDouble-blind, placebo-controlled atrial of methylphenidate in older, depressed, medically ill patient=s.” 4m. J. Psychiatry 152, 929-3 1 (1995).

SSRIs are often chosen as the initial treatment because oftheir better side effect profiles.

Once-a-day dosing may be appwropriate. Examples of SSRIs incBude fluoxetine (Prozac™,

Pulvules, Dista, Eli Lilly, Indianapolis, Indiana), paroxetine, serstraline, bupropion, and venlagaxin, Among the tricycli cand heterocyclic agents, theoretical reasoning and clinical : experience suggest avoiding agents with prominent anticholinergic activity (e.g., amitriptyline, imipramine). Among the rema._ ining agents, sample dosing strategies are given here for nortriptyline. MAOIs are also -considered for individuals unresp onsive to or unable to take other agents (tranylcypromine and plmenelzine are examples)

When sleep disturbance=s occur without other psychiatric symptoms beyond the dementia itself, some clinicians prescribes trazodone or zolpidem. Benzod®azepines (e.g., lorazepam or oxazepam) and chloral hydrate may be used. Triazolam in particular is not recommended for individuals with dementia because of its association with amnesiZa. Diphenhydramine, which is found in most over-the-counter sleep preparations, is used by sore clinicians, but its : 35 anticholinergic properties makes it suboptimal for the treatment o f demented patients.

Some individuals with dementia show disinkaibited behavior, including making inappropriate jokes, neglecting personal hygiene, exhibiting undue familiarity with strargers, or ) disregarding conventional rules of social conduct. Occasionally, they may harm others boy striking out. Suicidal behavior may occur, especiall>y in mildly impaired individuals, whao are , 5 more likely to have insight into their deficits and to be capabie of formulating (and carrsying out) a plan of action. Anxiety is fairly common, and sone patients manifest "catastrophic rections," overwhelming emotional responses to relatively minor stressors, such as changes in rou—tine or environment. Depressed mood, with or without neumovegetative changes, is quite commmon, as are sleep disturbances independent of depression. Delusions can occur, especially those inveolving themes of persecution (e.g., the belief that misplaceed possessions have been stolen).

Misidentifications of familiar people as unfamiliar Cor vice versa) frequently occur.

Hallucinations can occur in all sensory modalities, but visual hallucinations are most common.

Some patients exhibit a peak period of agitation (or other behavioral disturbances) durirmg the evening hours, which is sometimes referred to as "smundowning."

Delirium is frequently superimposed on demraentia because the underlying brain disease increases susceptibility to the effects of medications or concurrent general medical conditions.

Individuals with dementia may also be especially vtalnerable to psychosocial stressors (e=.g., going to the hospital, bereavement), which may exa«cerbate their intellectual deficits and_ associated problems.

Dementia is sometimes accompanied by moor disturbances, which may include gait difficulties, slurred speech, and a variety of abnormal! movements. Other neurological sy~mptoms, such as myoclonus and seizures, may also occur.

When male patients display intrusive disinhi bited sexual behavior, a particular paroblem in patients with frontal lobe dementias, medroxyprogessterone and related hormonal agents are sometimes recommended (H.Kyomen, e? al., “The wmse of estrogen to decrease aggressiv € physical behavior in elderly men with dementia.” J. Am. Geriatr. Soc. 39, 1110-12 (19971);

S.S.Rich, et al., “Leuprolide acetate for exhibitionisan in Huntingtons disease.” Mov. Daisord. 9, 353-57 (1994); P.G. Weiler, ef al., “Propranolol for the control of disruptive behavior in senile dementia.” J. Geriatr. Psychiatry Neurol. 1, 226-30 (1988), but only case series support this recommendation at present.

Glycosaminoglycan polysulfate (e.g., Ateroi«d™) in old-age dementias: effects upgpon depressive symptomatology in geriatric patients. Preog. Neuropsychopharmacol. Biol. Psychiatry 13, 977-81 (1989)) The literature concerning the treatment of apathy is much sparser. T _here is minimal evidence that dopaminergic agents, such as psychostimulants (d-amphetamine, ’ 35 methylphenidate), amantadine, bromocriptine, and beupropion, are helpful in the treatmer—t of severe apathy, but promising case reports suggest that efficacy studies are warranted . (A.E.Wallace, er al., “Double-blind, placebo-control led trial of methylphenidate in older—,

depressed, medica Rly ill patients.” Am. J, Psychiatry 1522, 929-31 (1995)). Psychostimul=ants have also received some support for the treatment of de=pression in elderly individuals with : severe general meclical disorders (P.Pickett, ef al., “Psy«chostimulant treatment of geriatriec depressive disorders secondary to medical illness.” .J. Geriatr. Psychiatry Neurol. 3, 146—51 . 5 (1990); L.W.Lazar-us, er al., “Methylphenidate and nortriptyline in the treatment of poststroke depression: a retrosspective comparison.” Arch. Phys. Med. Rehabil. 75, 403-06 (1994);

T.R Price, et al., “Safety and efficacy of ECT in depres=sed patients with dementia: a review of clinical experience .” Convulsive Ther. 5, 1-74 (1989).

SSRIs are caften chosen as the initial treatment beecause of their better side effect p rofiles. Once-a-day dosing is appropriate. Fluoxetine, Paroxetimne,. Sertraline, bupropion and ven lagaxin are examples of SS- Rls treatment. Among the tricyclic a nd heterocyclic agents, theoretical reasoning and clini-cal experience suggest avoiding agermts with prominent anticholinergic activity (e.g., amitr iptyline, imipramine). Among the rer maining agents, sample dosing strategies are given here for mortriptyline

Among the tricyclic and heterocyclic agents, the =oretical reasoning and clinical experience suggest avoiding agents with prominent anticholinergic activity (e.g., amitriptyline, imipramine).

Among the remaini ng agents, sample dosing strategies are given here for ndrtriptyline, desipramine, and tr=azodone.

Depression is common in patients with dementia. Patients with depression should be carefully evaluated for suicide potential. Depressed moowd may respond to improvements i nthe living situation or s—timulation-oriented treatments, but paatients with severe or persistent depressed mood winth or without a full complement of ne=urovegetative signs should be treated with antidepressant medications. Although formal evaluzation of the efficacy of antidepres=sants for demented paticrmts is limited, there is considerable cli nical evidence supporting their usse. The choice among agents is based on the side effect profile amd the characteristics of a given patient. :

MAOIs are also corasidered for individuals unresponsive to or unable to take other agents (tranylcypromine arad phenelzine are examples).

Treatment o=f sleep disturbance in dementia is aimed at decreasing the frequency arad severity of insomnia, interrupted sleep, and nocturnal corfusion in patients with dementia. The goals are to increases patient comfort and to decrease the «disruption to families and caregiveers.,

Sleep disorder is commmon in dementia (Satlin A: Sleep disorders in dementia. Psychiatr. A nn. 24, 186-90 (1994); CC.C.Hoch, et al., “Sleep patterns in A_lzheimer, depressed, and healthy elderly.” West J. Nu.rs. Res. 10,239-56 (1988)) and is nog always so disruptive that the risic of medication side effe:cts is outweighed by the need for a p_harmacologic trial. When sleep : 35 disturbances occur vwithout other psychiatric symptoms b eyond the dementia itself, some clinicians prescribe #trazodone or zolpidem. Benzodiazep ines (e.g., lorazepam or oxazepam) and . chloral hydrate may in some cases be used. Triazolam in particular is not recommended fomr

’ individuals with dementia becaause of its association with amnesia. DiphenExydramine, which is found in most over-the-counte r sleep preparations, is used by some cliniciars,. but its : anticholinergic properties make it suboptimal for the treatment of dementedE patients.

Nutritional supplements: Vitaranin B12 homocysteine

Pyrrolidone or pyrrolick ine derivatives for improving memory have teen suggested in

EP 239500, EP 165919, BE 892942, U.S. Pat. No. 5,102,882, EP 296978, F=P 296979. Pyridine derivatives for the treatment off impairment of short-term memory are disclosed in U.S. Pat.

No. 4,448,779. Choline derivatives for treating mental decline in the elderlsy are suggested in EP 201623. Indole or indolin derivatives for the improvement of processes involved in learning are disclosed in EP 241006, JP 6107544, U.S. Pat. No. 5,494,928, WO 97/4759 8, and U.S. Pat.

No. 4,778,812. Pilocardin deriwatives for improving memory functions are Risclosed in U.S, Pat. . No. 4,977,176. Glycine-contaiming compositions for enhancing cognitive fu mctions are disclosed in U.S. Pat. No. 5,731,349. Peptide derivatives for treating mental decline arid improving mental capacity are disclosed in U.S. Pat. No. 5,439,930, RU 2099078, and WO.95~15310. Xanthine , 1s derivatives for the treatment of age-related memory impairment are disclose din WO 94/19349.

Compounds enhancing the stimulus-induced release of neurotransmi—tters, especially acetylcholine, may also be used to treat memory impairment. Examples are =2-benzyl-2-propyl 2- amino-2-R-acetate derivatives «disclosed in EP 293351, 1-(4-chlorophenyl)-2-methyl-2-propyl 2- amino-3-methyl-butanoate disczlosed in GB 2205097, polycyclic hetero-aronatic derivatives disclosed in U.S. Pat. No. 5,300,642, 5-phenyl-4,4-dimethyl-3-0xo or hydro=y-pentylamine derivatives disclosed in EP 322.391, 1-oxa-8-azaspiro(4.5)decane derivatives disclosed in

EP 491562, derivatives of azacyclic and azabicyclic hydroxylamine disclose din WO 94/00448, halogenated aromatic derivativess disclosed in EP 627400, derivatives of acyclic and cyclic amides disclosed in WO 95/2999, carbamoyloxypropylamine or carbamoyl -oxyethylamine derivatives disclosed in WO 96 _/08468.

Compounds that modulate the function of the kainate receptor may bee used to improve memory, e.g., alkyl carboxy anmino acids, such as (28,4R)-4-methyl glutamic acid.

WO 96/25387.

Hypothalamic hypophyssiotropic hormones, such as somatostatin and growth-hormone : 30 releasing factor, may improve lesarning abilities. EP 326381

Uronic acids improve cesrebral efficiency in general, such as improvexnent of memory, . DE 2555010.

WO» 2004/058258 PCT/CA2003/002011 : Improvement of memory occurs 1apon administering spiro(V -methy—1-4’-piperidyl)-N- ethyl-succinimide, a parasympathicomim_etic substance also having cholinommnimetic, analgetic ) and sedative activity. U.S. Pat. No. 4,48 ®,206.

WO 98/33498 discloses the use of breflate or analogous compounds thereof for the ’ 5 treatment of a mammal suffering from a cognitive dysfunction. Breflate or &analogous compounds thereof enhance the long-term potential o-f nerve cells. Suitable moncamine= reuptake inhibitors include NS-2330. Suitable nootropic age=nts include oxiracetam available fiom ISF Societa Per

Azioni, pramiracetam available from Waarner Lambert Co., idebenone available from Takeda

Chemical Inds. Ltd., anapsos available freom ASAC Pharmaceuticals Internamtional, nebracetam : 10 available from Boehringer Ingelheim Cor-p., JTP-2942 available from Japan Tobacco Inc., fasoracetam available from Nippon Shinyaku Co. Ltd., bacosides available from Central Drug ’

Research Institute, alzene available from Bar-Ilan University, KA-672 available from Dr.

Willmar Schwabe GmbH & Co., alaptid available from VUFB, 1Q-200, AL_E-26015 available from Allelix Pharm-Eco LP and combina tions thereof,

A useful dopamine receptor agonist is speramine. Useful AMPA rec eptor ligands include

CX-516, CX-691 available from Cortex FPharmaceuticals Inc. and combinations thereof. Suitable calcium channel blockers include tamolar-izine available from Nippon Cherraiphar Co., Ltd., nimodipine available from Bayer AG, PIZ3-1 76078 available from Elan Pharmaceuticals, Inc., and combinations thereof. Suitable apop®osis inhibitors include acetyl-L.-camrnitine, CEP-1347 : 20 available from Cephalon, Inc., TCH-346 available from Novartis AG and combinations thereof. -

A useful caspase inhibitor is pralnacasan. Suitable monoamine oxidase inhi bitors include moclobemide available from Roche Hold ing AG, selegiline, rasagiline avail able from Teva

Pharmaceutical Inds, Lid., SL-25.1188, RZ 0-41-1049 available from Roche Folding AG, and combinations thereof. A useful 5-HT1a receptor agonist is AP-159 availablee from Asahi Kasei

Corp.; a suitable NGF stimulator is xalipr-odene available from Sanofi-Syntiaelabo. Suitable neuroprotective agents include citicholines, GS-1590 available from Leo Pha_rmaceutical Products

Ltd. A/S, CPI-1189 available from Centawir Pharmaceuticals Inc., SR-57667 available from

Sanofi-Synthelabo and combinations thereof. Suitable H3 histamine receptor antagonists include © GT-2016 and GT-2331 (both available from Gliatech, Inc.) and combinatiors thereof.

Useful prolylendopeptidase inhibi tors include ONO-1603 available £rom Ono

Pharmaceutical Co. Ltd., Z-321 available from Zeria Pharmaceutical Co. Ltd. and combinations thereof. A useful calcium modulator includes neurocalc available from Aposlio Biopharma- ceuticals, Inc. A suitable corticortropin rezleasing factor receptor antagonist includes NBI-113 available from Neurocrine Biosciences, Irc. A useful GABA modulator inc ludes NGD 97-1 . 35 available from Neurogen Corp. A suitabl e sigma receptor ligand is igmesines available from

Pfizer Inc. A useful imidazoline/alpha ad. renergic receptor antagonist is efar-oxan available from . ‘Reckitt & Colman PLC. A suitable vasoactive intestinal peptide receptor agonist is stearyi-

NIe-VIP. A useful benzodiazepine inverse agonist is S3-8510 available from Shionogi &= Co. Ltd.

A suitable cannabinoid receptor agonist is dronabinol available from Unimed Pharmacewuticals ’ Inc. Useful thyrotropin releasing hormone receptor agonists include taltireline available= from

Tanabe Seiyaku Co. Ltd. and protirelin available from Takeda Chemical Inds., Inc. A swuiitable 5- . 5 HT3 antagonist is GYKI-46903. A useful topoisomerase 11 inhibitor is iododoxorubicin available from Pharmacia & Upjohn AB. A suitable steroid receptor agonist is GL-701 =available from Lezland Stanford Junior University. A useful corticosteroid receptor antagonist is a nticort.

A suitable nitric oxide modulator is GL-701. A suitabBe RAGE inhibitor is ALT-711 available from ANteon Inc. RAGE is a multiligand receptor of trae immunoglobulin superfamily timat is implicated in homeostasis and chronic disease. Bucciamrelli, ez al., Cell Mol Life Sei. 39(7), 1117-28 (2002). . “The invention also relates to a pharmaceutical composition comprising at least ore compound selected from the group consisting of D-phosphoserine and L-phosphoserine sand a second &herapeutic agent selected from the group consi sting of antipsychotics, antidepresssants, psychostimulants, and Alzheimer’s disease therapeutics. In these pharmaceutical compomsitions, the second therapeutic agent is an antipsychotic selecte d from the group consisting of typical antipsychotics, atypical antipsychotics, and depot antip sychotics. Examples of second therapetatic agents include Chlorpromazine, Thioridazire, Mesoridazine, Fluphenazine,

Perphen azine, Trifluoperazine, Thiothixene, Haloperideol (Haldol™, McNeil Pharmaceut icals,

Spring House, Pennsylvania), Loxapine, Molindone (VEoban™, Du Pont Multi-Source Products,

Wilmington, DE), Clozapine, Risperidone, Olanzapine, Quetiapine, Haloperidol decanoa te,

Fluphen azine decanoate, Fluphenazine enanthate, Amitriptyline, Amoxapine, Bupropion_,

Bupropi on SR, Clomipramine, Desipramine, Doxepin, Fluoxetine, Fluvoxamine, Imiprarmine,

Maprotildine, Mirtazapine, Nefazodone, Nortriptyline, P aroxetine, Phenelzine, Protriptylirae, Sertralime, Tranylcypromine, Trazodone, Trimipramine , Venlafaxine, Velafaxine XR,

Dextroasmphetamine, Methamphetamine, Methylphenid._ ate, Pemoline, Donepezil, Tacrinee™,

Acetoplenazine, Chlorprothixene, Droperidol, Pimozide, Butaperazine, Carphenazine

Remoxiporide, Piperacetazine, Sulpiride, and Ziprasidon -e.

Im another alternative embodiment, the composistions used in the methods to treat <r prevent & neuropsychiatric disorder characterized by attesnuated NMDA neurotransmissiomn. The neuropsychiatric disorder may be Alzheimer’s disease, MDown’s syndrome, depression, benign forgetful ness, cerebral amyloid angiopathy, vascular dermentia, hemorrhagic stroke, Mild

Cognitiv € Impairment (“MCI”), or close head injury.

Ir another alternative embodiment, the composit-ions used in the methods of the present . 35 invention can further comprise one or more bile acid sequestrants (insoluble anion exchange resins), c-oadministered with or in combination with a compound of any Formula herein.

Bile aacid sequestrants bind bile acids in the intestine, interrupting the enterohepatzic circulation o=f bile acids and causing an increase in thes faecal excretion of steroids. Use o fbile ’ acid sequestmrants is desirable because of their non-sysstemic mode of action. Bile acid sequestrants can lower intrahepatic cholesterol and pr-omote the synthesis of apo B/E (LIDL) . 5 receptors wimich bind LDL from plasma to further red wce cholesterol levels in the blood.

Non- limiting examples of suitable bile acid se questrants include cholestyramine (Ca styrene-divirylbenzene copolymer containing quaterrmary ammonium cationic groups capmable of binding bile acids, such as Questran™ cholestyramine which are available from Bristol-Myers

Squibb), colesstipol (a copolymer of diethylenetriamin € and 1-chloro-2,3-epoxypropane, ssuch as

Colestid™ teablets which are available from Pharmacia), colesevelam hydrochloride (suck as

WelChol™ "Tablets (poly(allylamine hydrochloride) cross-linked with epichlorohydrin ard alkylated with 1-bromodecane and (6-bromohexyl)-trimethylammonium bromide) which are available fromm Sankyo), water soluble derivatives such as 3,3-ioene, N-(cycloalkyl) alkyl=amines and poligluszam, insoluble quaternized polystyrenes, s=aponins and mixtures thereof, Other— useful bile acid sequuestrants are disclosed in PCT Patent Applications Nos. WO 97/11345 and

WO 98/5765 2, and U.S. Pat. No. 3,692,895 and 5,703 ,188 which are incorporated herein by reference. Suitable inorganic cholesterol sequestrants include bismuth salicylate plus montmorillorite clay, aluminum hydroxide and calciu 1m carbonate antacids.

In an alternative embodiment, the composition s used in the methods of the presen®t invention car further comprise one or more ileal bile amcid transport (“IBAT”) inhibitors (or apical sodiunen co-dependent bile acid transport (‘ASB ~T”) inhibitors) coadministered with_ or in combination with a compound of any Formula herein. The IBAT inhibitors can inhibit bil e acid transport to resduce LDL cholesterol levels. Non-limitimng examples of suitable IBAT inhibitors include benzothiepines such as therapeutic compounds comprising a 2,3,4,5-tetrahydro-1— benzothie- pime 1,1-dioxide structure such as are disclosed in PCT Patent Application WO 00/38727 whch is incorporated herein by reference. :

In an«other alternative embodiment, the compo sitions used in the methods of the present invention can_ further comprise nicotinic acid (niacin) or derivatives thereof coadministere d with or in combination with a compound of any Formula he=rein. - As use=d herein, “nicotinic acid derivative” mea ns a compound comprising a pyridi_ ne-3- carboxylate s#ructure or a pyrazine-2-carboxylate struc ture, including acid forms, salts, es&ers, zwitterions ard tautomers, where available. Examples «of nicotinic acid derivatives include= niceritrol, niceofuranose and acipimox (5-methyl pyrazi ne-2-carboxylic acid 4-oxide). Nicotinic acid and its de=rivatives inhibit hepatic production of VILDL and its metabolite LDL and in=creases ’ 35 HDLand apo A-1 levels. An example of a suitable nicotinic acid product is Niaspan™ (ni acin extended-rele.ase tablets) which are available from Kos .

The compositions, therapeutic combinations or methods of the present invention can fumrther comprise one or more obesity contro! medications. Useful obesity constrol medications imclude, but are not limited to, drugs that reduce energy intake or suppress apgpetite, drugs that increase energy expenditure and nutrient-pae rtitioning agents. Suitable obesity control : 5 m edications include, but are not limited to, mnoradrenergic agents (such as diet=hylpropion, ‘ m azindol, phenylpropanolamine, phentermi ne, phendimetrazine, phendamine tartrate, methamphetamine, phendimetrazine and tartrate); serotonergic agents (such a_s sibutramine, fe- nfluramine, dexfenfluramine, fluoxetine, &luvoxamine and paroxtine); thermogenic agents (s"uch as ephedrine, caffeine, theophylline, aund selective B3-adrenergic agonists); an alpha- bl ocking agent; a kainite or AMPA receptor antagonist; a leptin-lipolysis stimmulated receptor; a phosphodiesterase enzyme inhibitor; a compound having nucleotide sequence=s of the mahogany ge=ne; a fibroblast growth factor-10 polypeptide; a monoamine oxidase inhibit-or (such as bez floxatone, moclobemide, brofaromine, ph_enoxathine, esuprone, befol, tolox=atone, pirlindol, armiflamine, sercloremine, bazinaprine, lazalbemide, milacemide and caroxazoene); a compound fo rincreasing lipid metabolism (such as eveesdiamine compounds); and a lipases inhibitor (such as orlistat). Generally, a total dosage of the abcave-described obesity control med ications can range from 1 to 3,000 mg/day, desirably from abowut 1 to 1,000 mg/day and more desirably from about 1 st0 200 mg/day in single or 2-4 divided dosses.

The compositions, therapeutic comb Enations or methods of the present invention can fu rther comprise one or more blood modifie xs. Useful blood modifiers include= but are not limited to anti-coagulants (argatroban, bivalirudin, Jalteparin sodium, desirudin, dicummnarol, lyapolate 50 dium, nafamostat mesylate, phenprocoum «on, tinzaparin sodium, warfarin scadium); antithrombotic (anagrelide hydrochloride, bi valirudin, cilostazol, dalteparin sodium, danaparoid so dium, dazoxiben hydrochloride, efegatran sulfate, enoxaparin sodium, flure®tofen, ifetroban, ifestroban sodium, lamifiban, lotrafiban hydreochloride, napsagatran, orbofiban acetate, roxifiban acetate, sibrafiban, tinzaparin sodium, trifenaagrel, abciximab, zolimomab aritomx); fibrinogen receptor antagonists (roxifiban acetate, fradaw fiban, orbofiban, lotrafiban hydro chloride, tirofiban, xe milofiban, monoclonal antibody 7E3, sibraafiban); platelet inhibitors (cilosta=zol, clopidogrel " bissulfate, epoprostenol, epoprostenol sodiumra, ticlopidine hydrochloride, aspiri n, ibuprofen, naproxen, sulindde, idomethacin, mefenamate, droxicam, diclofenac, sulfinpyr-azone, piroxicam, dipyridamole); platelet aggregation inhibitor s (acadesine, beraprost, beraprost sodium, ciprostene caJcium, itazigrel, lifarizine, lotrafiban hydrochloride, orbofiban acetate, oxagr—elate, fradafiban, orBoofiban, tirofiban, xemilofiban); hemorrhe ologic agents (pentoxifylline); lipsoprotein associated co=agulation inhibitor; Factor Via inhibitors (4H-31-benzoxazin-4-ones, 4H-3,, I-benzoxazin-4- thi ones, quinazolin-4-ones, quinazolin-4-thiones, benzothiazin-4-ones, imidazoolyl-boronic acid- ’ demrived peptide analogues TFPI-derived peptides, naphthalene-2-sulfonic acid {1-[3- (arminoiminomethyl)-benzyl]-2-oxo-pyrrol- i din-3-(S)-yl} amide trifluoroacetamte, dibenzofuran- . 2-ssulfonic acid {1-[3-(aminomethyl)-benzyl] -5-oxo-pyrrolidin-3-yl}-amide, to- lulene-4-sulfonic acid {1-[3-(aminoiminomethyl)-benzyl]-2-oxo -pyrrolidi- n-3-(S8)-yl}-amide triflucroacestate, 3,4—dihydro-1H-isoquinoline-2-sulfonic acid { 1-[3-(aminoiminomethyl)-benzyl]-2-oxo—pyrrolin- 3-(S)-yl}-amide trifluoroacetate); Factor Xa in hibitors (disubstituted pyrazolines, disub stituted tria=zolines, substituted n-[(aminoiminomethyl)» phenyl] propylamides, substituted N-[(armino- . s metzhyl)phenyl] propylamides, tissue factor pathway inhibitor (TFPI), low molecular wezight hep~arins, heparinoids, benzimidazolines, benzoxazolinones, benzopiperazinones, indan ones, dibzasic (amidinoaryl) propanoic acid derivatives, amidinophenyl-pyrrolidines, amidinogphenyl- pyrmolines, amidinophenyl-isoxazolidines, ami dinoindoles, amidinoazoles, bis-arlysulfonyl- ami nobenzamide derivatives, peptidic Factor 3<a inhibitors).

The compositions, therapeutic combinations or methods of the present inventiora can furt ‘her comprise one or more cardiovascular agents. Useful cardiovascular agents include but are not limited to calcium channel blockers (clentizazem maleate, amlodipine besylate, isradllipine {Dy-naCirc™, Reliant Pharmaceuticals, Liberty” Comer, NJ), nimodipine, felodipine (Plendil™,

Memck & Co., Inc., Rahway, New Jersey), nilvadipine, nifedipine, teludipine hydrochloride, diltmazem hydrochloride ((Cardizem™ or Card izem SR™, Aventis, Strasbourg, France) , belfZosdil, verapamil hydrochloride (Calan™ ox- Calan SR™, G.D. Searle LLC, Skokie, IL), fostzedil); adrenergic blockers (fenspiride hydrochloride, labetalol hydrochloride, proroxzan, alfimzosin hydrochloride, acebutolol, acebutolo X hydrochloride, alprenolol hydrochloride=, aterolol, bunolol hydrochloride, carteolol hydrochloride, celiprolol hydrochloride, cetarmolol hyd rochloride, cicloprolol hydrochloride, dexp ropranolol hydrochloride, diacetolol hydaro- chloride, dilevalol hydrochloride, esmolol hydeochloride, exaprolo! hydrochloride, flest olol sulfate, labetalol hydrochloride, levobetaxolol hydrochloride, levobunolol hydrochlorides, metalo} hyd rochloride, metoprolol, metoprolol tartrate, nadolol, pamatolol sulfate, penbutolol sualfate, pracstolol, propranolol hydrochloride (Inderal™4, Wyeth, Madison, New Jersey), sotalol Thydro- chloride, timolol, timolol maleate, tiprenolo! hydrochloride, tolamolol, bisoprolol, bisoprolol fummarate, nebivolol); adrenergic stimulants; an giotensin converting enzyme (ACE) inhibitors {berazepril hydrochloride, benazeprilat, captopril (Capoten™, Bristol-Myers Squibb Co., New

York, New York), delapril hydrochloride, fosiraopril sodium, libenzapril, moexipril hydmo- chloride, pentopril, perindopril, quinapril hydrochloride, quinaprilat, ramipril (Altace™_, Hoechst

Marion Roussel, Inc., now Aventis, Strasbourg, France), spirapril hydrochloride, spirapmrilat, tepr-otide, enalapril maleate (Vasotec™, Merck. & Co., Inc., Rahway, New Jersey), lisineopril (Zesstril™, Stuart, AstraZenica, Wilmington, D elaware), zofenopril calcium, perindopril. erbuumine); antihypertensive agents (althiazide, benzthiazide, captopril, carvedilol, chlor-othiazide sodium, clonidine hydrochloride (Catapres™, Boehringer Ingelheim, Ridgefield, Conne=cticut), cycMothiazide, delapril hydrochloride, dilevalol hydrochloride, doxazosin mesylate, fosiropril ’ sod E um, guanfacine hydrochloride (Tenex™, R_obins, ESP Pharmaceuticals, Flanders, NIJ), met_hyidopa, metoprolol succinate, moexipril hydrochloride, monatepil maleate, pelanse rin : hydwrochloride, phenoxybenzamine hydrochlori de, prazosin hydrochloride, primidolol, q uinapril hydrochloride, quinaperilat, ramipril, terazosin hydrochloride=, candesartan, candesartan cilexzetil, telmisartan, amiodipirie besylate, amlodipine maleate (Norvaasc™, Pfizer, New York New York), ) bevantolol hydrochlor-ide); angiotensin II receptor antagonists (candesartan, irbesartan, losamtan potassium, candesarta n cilexetil, telmisartan); anti-anginal aggents (amlodipine besylate, ‘ 5 amlodipine maleate, bsetaxolol hydrochloride, bevantolol hydrochloride, butoprozine hydrochloride, carved ilol, cinepazet maleate, metoprolol suc=cinate, molsidomine, monatepill maleate, primidolol, reanolazine hydrochoride, tosifen, verapaamil hydrochloride); coronary vasodilators (fostedil, azaclorzine hydrochloride, chromonar— hydrochloride, clonitrate, diltiamzem hydrochloride, dipyridamole, droprenilamine, erythrityl tetreanitrate, isosorbide dinitrate, isosorbide mononitratee, lidoflazine, mioflazine hydrochlorid e, mixidine, molsidomine, nicorandil, nifedipine (Procardia™, Pfizer, New York, New York), nisoldipine, nitroglyceri me, oxprenolol hydrochlor-ide, pentrinitrol, perhexiline maleate, gprenylamine, propaty! nitrate, . terodiline hydrochloride, tolamolol, verapamil); diuretics (th_e combination product of hydrom- chlorothiazide and spi ronolactone and the combination prodmuct of hydrochlorothiazide and ftriamterene).

Blood-Brain Barrier

Nitric oxide is a vasodilator of the peripheral vascula ture in normal tissue of the body.

Increasing generation of nitric oxide by nitric oxide synthase= causes vasodilation without loss of blood pressure. The b lood-pressure-independent increase in blood flow through brain tissue= increases cerebral bioavailability of blood-bom composition=s. This increase in nitric oxide rnay be stimulated by administering L-arginine. As nitric oxide iss increased, cerebral blood flow is consequently increasead, and drugs in the blood stream are ca rried along with the increased flow into brain tissue. Ther—efore, L-arginine may be used in the p harmaceutical compositions of athe invention to enhance delivery of agents to brain tissue after introducing a pharmaceutical composition into the b lood stream of the subject substantiallwy contemporaneously with a blo od flow enhancing amourat of L-arginine. WO 00/56328 : '

Agents of the invention that exert their physiological effect in vivo in the brain may oe more useful if they gai n access to target cells in the brain. Neon-limiting examples of brain cells are neurons, glial cells (astrocytes, oligodendrocytes, microglia), cerebrovascular cells (muscle cells, endothelial cells), and cells that comprise the meningess. The blood brain barrier (“BBIB”) typically restricts access to brain cells by acting asa physical and functional blockade that separates the brain pareenchyma from the systemic circulation (see, e.g., Pardridge, et al., J. ‘ Neurovirol. 5(6), 556-€59 (1999); Rubin, et al., Rev. Neurosci. 22, 11-28 (1999)). Circulating molecules are normally able to gain access to brain cells via one of two processes: lipid-med iated . 35 transport through the E3BB by free diffusion, or active (or cat=alyzed) transport.

The agents of #the invention may be formulated to improve «distribution ir vive, for example as powdered or liquid tablet or solution for oral administration or as a nasal spray, nose drops, a gel or ointment, through a tube or catheter, by syringe, by packtail, by pledget, or by submucosal infusion. For example, the blood-brain barrier (BBB) excludes many highly : 5 hydrophilic agents. Teo ensure that the more hydrophilic therapeutic agents of the invention cross the BBB, they may be formulated, for example, in liposomes. For methods of manufacturing liposomes, see, e.g., U.S. Pat. Nos. 4,522,811; 5,374,548; and 5,39 9,331. The liposomes may comprise one or more moieties which are selectively transported irmto specific cells or organs (“targeting moieties” cr “targeting groups” or “transporting vectors”), thus providing targeted drug delivery (see, e.g~., V.V. Ranade J. Clin. Pharmacol. 29, 685 (( 1989). Likewise, the agents may be linked to targe=ting groups that facilitate penetration of the bslood brain barrier. In one embodiment, the methx od of the present invention employs a natura. lly occurring polyamine linked to an agent that is a small molecule and is useful for inhibitimg AB deposition.

To facilitate treansport of agents of the invention across the IBBB, they may be coupled to 1s a BBB transport vecto r (for review of BBB transport vectors and mechanisms, see, Bickel, et al.,

Adv. Drug Delivery Rezviews 46, 247-79 (2001)). Exemplary transport vectors include cationized albumin or the 0X26 rmonoclonal antibody to the transferrin recept or; these proteins undergd absorptive-mediated amd receptor-mediated transcytosis through thes BBB, respectively. Natural cell metabolites that mx ay be used as targeting groups, include, inter alia, putrescine, spermidine, spermine, or DHA. Omher exemplary targeting moieties include fol ate or biotin (see, e.g., U.S.

Pat. No. 5,416,016); mu annosides (Umezawa, et al., Biochem. BiopFays. Res. Commun. 153, 1038 (1988)); antibodies (P. G. Bloeman, et al., FEBS Lett. 357, 140 (1995); M. Owais, ef al.,

Antimicrob. Agents Crremother. 39, 180 (1995)); surfactant protein A receptor (Briscoe, et al.,

Am. J. Physiol. 1233, 1 34 (1995)); gp120 (Schreier, et al., J. Biol. Chem. 269, 9090 (1994); see also, K. Keinanen and M.L. Laukkanen, FEBS Lett. 346, 123 (1994); 1.1. Killion and LJ. Fidler,

Immunomethods 4, 2733 (1994).

Examples of otTher BBB transport vectors that target recepto r-mediated transport systems into the brain include factors such as insulin, insulin-like growth factors (“IGF-I,” and “IGF-IT"), angiotensin II, atrial armd brain natriuretic peptide (“ANP,” and “BNFP”), interleukin I (“IL-1") and transferrin. Monoclonal antibodies to the receptors that bind th ese factors may also be used as BBB transport vectcers. BBB transport vectors targeting mechani sms for absorptive-mediated transcytosis include cationic moieties such as cationized LDL, alburmin or horseradish peroxidase coupled with polylysin«e, cationized albumin or cationized immunoglobulins. Small basic oligopeptides such as the dynorphin analogue E-2078 and the ACTE analogue ebiratide may . 35 also cross the brain via absorptive-mediated transcytosis and are potential transport vectors.

Other BBB tram sport vectors target systems for transporting nutrients into the brain. . Examples of such BBB: transport vectors include hexose moieties, e_g., glucose and monocarboxylic acids, e.g., lactic acid and neutral amino acids, e.g., phenylalanine and amines, e.g, choline and basic amino acids, e.g., arginine, nucleosides, e.g., adencsine and purine bases, e.g., adenine, and thyroid hormone, e.g., triiodothyridine. Antibodies to the extracellular domain of nutrient transporters may also be used as transport vectors, Other possible vectors include . 5 angiotensin Il and ANP, which may be involved in regulating BBB perme=ability.

In some cases, the bond linking the therapeutic agent to the transpeort vector may be . cleaved following transport into the brain in order to liberate the biologically active agent.

Exemplary linkers include disulfide bonds, ester-based linkages, thioether linkages, amide bonds, acid-labile linkages, and Schiff base linkages. Avidin/biotin linkers, in whhich avidin is 1.0 covalently coupled to the BBB drug transport vector, may also be used. Aavidin itself may be a drug transport vector.

Transcytosis, including receptor-mediated transport of compositiomns across the blood brain barrier, may also be suitable for the agents of the invention. Transfe=rrin receptor-mediated delivery is disclosed in U.S. Pat. Nos. 5,672,683; 5,383,988; 5,527,527: 5.977,307; and 1.5 6,015,555. Transferrin-mediated transport is also known. P.M. Friden, ez al., Pharmacol, Exp,

Ther. 278, 1491-98 (1996); H.J. Lee, J. Pharmacol. Exp. Ther. 292, 1048—52 (2000). EGF receptor-mediated delivery is disclosed in Y. Deguchi, et al., Bioconjug. Chem. 10, 32-37 (1999), and transcytosis is described in A. Cerletti, ef al., J. Drug Target. =8, 435-46 (2000).

Insulin fragments have also been used as carriers for delivery across the blood brain barrier .

M.Fukuta, er al., Pharm. Res. 11 . 1681-88 (1994). Delivery of agents via a conjugate of neutral avidin and cationized human albLamin has also been described. Y.S. Kang, et al., Pharm. Res. 1, 1257-64 (1994). :

Other modifications in order to enhance penetration of the agents of the invention across "the blood brain barrier may be accomplished using methods and derivativess known in the art. 2 5 Forexample, U.S. Pat. No. 6,024,977 discloses covalent polar lipid conjugates for targeting to brain and central nervous system. U.S. Pat. No. 5,017,566 discloses cyclo dextrin derivatives comprising inclusion complexes of lipoidal forms of dihydropyridine redox targeting moieties.

U.S. Pat. No. 5,023,252 discloses the use of pharmaceutical compositions ~comprising a neurologically active drug and a compound for facilitating transport of the drug across the blood- 3 0 brain barrier including a macrocyclic ester, diester, amide, diamide, amidire, diamidine, thioester, dithioester, thioamide, ketone or lactone, U.S. Pat. No. 5,024,99 8 discloses parenteral solutions of aqueous-insoluble drugs with cyclodextrin derivatives. U.S. P=at. No. 5,039,794 discloses the use of a metastatic tumor-derived egress factor for facilitating the transport of compounds across the blood-brain barrier. U.S. Pat. No. 5,112,863 disclosses the use of N-acyl 3 5 amino acid derivatives as antipsychotic drugs for delivery across the blood -brain barrier. U.S.

Pat. No. 5,124,146 discloses a method for delivery of therapeutic agents ac=ross the blood-brain . barrier at sites of increase permea bility associated with brain lesions. U.S. Pat. No. 5,153,179 discloses acylated glycerol and derivatives for use in a medicament for immproved penetration of cell membranes. U.S. Pat. No. 5,177,064 discloses the use of lipoidal phosphonate derivatives of ’ nucleoside antiviral agents for delivery across the blood-brain barrier. U.=S, Pat. No. 5,254,342 discloses receptor-mediated tran scytosis of the blood-brain barrier using the transferrin receptor . 5 in combination with pharmaceut ical compounds that enhance or accelerate this process. U.S.

Pat. No. 5,258,402 discloses treatment of epilepsy with imidate derivatives of anticonvulsive sulfamate. U.S. Pat. No. 5,270,3 12 discloses substituted piperazines as ce=ntral nervous system agents. U.S. Pat. No. 5,284,876 discloses fatty acid conjugates of dopami ne drugs. U.S. Pat. No. 5,389,623 discloses the use of lipid dihydropyridine derivatives of anti-in#lammatory steroids or steroid sex hormones for delivery across the blood-brain barrier. U.S. Pat . No. 5,405,834 discloses prodrug derivatives of thyrotropin releasing hormone. U.S. Pat. No. 5,413,996 discloses acyloxyalkyl phosphonate conjugates of neurologically-active de-ugs for anionic sequestration of such drugs in brain tissue. U.S. Pat. No. 5,434,137 disclomses methods for the selective opening of abnormal brain tissue capillaries using bradykinin infused into the carotid artery. U.S. Pat. No. 5,442,043 discloses a peptide conjugate between a peptide having a biological activity and incapable of crossing the blood-brain barrier and a peptide which exhibits no biological activity and is capa ble of passing the blood-brain barrier by mreceptor-mediated endocytosis. U.S. Pat. No. 5,466,683 discloses water soluble analogues of an anticonvulsant for the treatment of epilepsy. U.S. Pat. No. 5,525,727 discloses compositions for differential uptake and retention in brain tissue comprising a conjugate of a narcotic analgesic and agonists and antagonists thereof with a lipid form of dihydropyridine that forms a redox salt upon uptake across the blood-brain barrier tha t prevents partitioning back to the system ic circulation.

Still further examples of modifications that enhance penetration of the blood brain barrier are described in International (PC_T) Application Publication Number WO 85/02342, which discloses a drug composition comprising a glycerolipid or derivative thereeof. PCT Publication

Number WO 089/11299 discloses a chemical conjugate of an antibody wit Th an enzyme which is delivered specifically to a brain lesion site for activating a separately-administered neurologically-active prodrug. P«CT Publication Number WO 91/04014 di=scloses methods for delivering therapeutic and diagno stic agents across the blood-brain barrier by encapsulating the drugs in liposomes targeted to brain tissue using transport-specific receptom ligands or antibodies.

PCT Publication Number WO 91./04745 discloses transport across the blocwd-brain barrier using cell adhesion molecules and fragrments thereof to increase the permeability of tight junctions in vascular endothelium. PCT Publication Number WO 91/14438 discloses the use of a modified, chimeric monoclonal antibody for facilitating transport of substances acros sthe blood-brain barrier. PCT Publication Number- WO 94/01131 discloses lipidized proteiras, including antibodies. PCT Publication Number WO 94/03424 discloses the use of amino acid derivatives as drug conjugates for facilitating transport across the blood-brain barrier. PCT Publication : Number WO 94/06450 discloses conjugates of neurologically-active drugs with a :

dihydropyridine-type redox targetf ng moiety and comprising an amino acid litakage and an aliphatic residue. PCT Publicatiora Number WO 94/02178 discloses antibody—targeted liposomes for delivery across the blood-brain barrier. PCT Publication Number WO 95/@7092 discloses the use of drug-growth factor conjugates for delivering drugs across the blood-bramin barrier. PCT : 5 Publication Number WO 96/0053 discloses polymeric microspheres as injec®able drug-delivery vehicles for delivering bioactive agents to sites within the central nervous system. PCT

Publication Number WO 96/0400 1 discloses omega-3-fatty acid conjugates of neurologically- active drugs for brain tissue delive ry. PCT WO 96/22303 discloses fatty acid and glycerolipid conjugates of neurologically-actives drugs for brain tissue delivery.

In general, it is well within the ordinary skill in the art to prepare an es ‘ter, amide or hydrazide derivative of an agent of the invention, for example, from the corressponding carboxylic acid and a suitable reagent. For instance, a carboxylic acid-contairm ing compound, or a reactive equivalent thereof, may be reacted with a hydroxyl-containing compound, or a reactive equivalent thereof, so as to provide the corresponding ester. See, e.g., “Compmrehensive Organic 1.5 Transformations,” 2" Ed., by R.C. Larock, VCH Publishers John Wiley & Somns, Ltd. (199989); “March’s Advanced Organic Chemistry,” 5% Ed., by M.B. Smith and J. Marcia, John Wiley &

Sons, Ltd. (2000).

The compound may also act from the periphery, causing a change in thme equilibrium of the amyloid protein concentration in the two compartments i.e. (systemic vs central), In this case 2 0 acompound may not be required to penetrate the brain to induce or decrease tlhe concentration of

AB in the brain (a “sink” effect)

Prodrugs

The present invention is also related to prodrugs of the agents of the Fcarmulae disclosed herein. Prodrugs are agents which are converted in vivo to active forms (see, e=.g., R.B. 2 5 Silverman, 1992, “The Organic Ch emistry of Drug Design and Drug Action,” _Academic Press,

Chp. 8). Prodrugs can be used to a_lter the biodistribution (e.g., to allow agentss which would not typically enter the reactive site of tte protease) or the pharmacokinetics for a p-articular agent.

For example, a carboxylic acid group, can be esterified, e.g., with a methyl grosup or an ethyl group to yield an ester. When the ester is administered to a subject, the ester iss cleaved, : 3 0 enzymatically or non-enzymaticallzy, reductively, oxidatively, or hydrolyticallzy, to reveal the _ anionic group. An anionic group ¢ an be esterified with moieties (e.g., acyloxy methyl esters) which are cleaved to reveal an intermediate agent which subsequently decompaoses to yield the ’ active agent. The prodrug moieties may be metabolized in vive by esterases or= by other mechanisms to carboxylic acids.

Examples of prodrugs and their uses are well know=n in the art (see, e.g., Berge, ef aul, “Pharmaceutical Salts”, J. Pharm. Sci. 66, 1-19 (1977)). T he prodrugs can be prepared in situ during the final isoR ation and purification of the agents, or “by separately reacting the purified agent in its free acied form with a suitable derivatizing agermt. Carboxylic acids can be conv=erted : 5 into esters via treatrment with an alcohol in the presence of a catalyst.

Examples of cleavable carboxylic acid prodrug moieties include substituted and unsubstituted, branched or unbranched lower alkyl ester moieties, (e.g., ethyl esters, propyl esters, butyl esters, pentyl esters, cyclopentyl esters, hexyl esters, cyclohexyl esters), lower ‘ alkenyl esters, dilovover alkyl-amino lower-alkyl esters (e.g. , dimethylaminoethy) ester), acylamino lower alkyl esters, acyloxy lower alkyl esters (e—g., pivaloyloxymethyl ester), army! esters (phenyl esterD), aryl-lower alkyl esters (e.g., benzyl esster), substituted (e.g., with methayl, halo, or methoxy sumbstituents) aryl and aryl-lower alkyl esters, amides, lower-alky! amides dilower alkyl amide=s, and hydroxy amides.

Pharmaceutical Prezparations

In another exmbodiment, the present invention relate=s to pharmaceutical compositiorms comprising agents amccording to any of the Formulae herein for the treatment of an amyloid—p related disease, as well as methods of manufacturing such poharmaceutical compositions.

In general, thhe agents of the present invention may Wbe prepared by the methods illus—trated in the general reacti on schemes as, for example, in the pate nts and patent applications refered to herein, or by modifi cations thereof, using readily available starting materials, reagents and conventional synthe=sis procedures. In these reactions, it is also possible to make use of var&ants which are in themse=lves known, but are not mentioned heres. Functional and structural equivalents of the aggents described herein and which have &he same general properties, whe rein one or more simple variations of substituents are made whi=ch do not adversely affect the essential nature or the utility of the agent.

The agents o»f the invention may be supplied in a soBution with an appropriate solvermt or in a solvent-free formm (e.g., lyophilized). In another aspect of the invention, the agents and buffers necessary fo r carrying out the methods of the inven®ion may be packaged as a kit. The kit may be commercially used according to the methods described herein and may include instructions for use ¥n a method of the invention. Additional kit components may include acids, bases, buffering age mts, inorganic salts, solvents, antioxidarts, preservatives, or metal chelastors. ; The additional kit components are present as pure compositions, or as aqueous or organic solutions that incorpmwarate one or more additional kit compo_nents. Any or all of the kit components optionally further comprise buffers,

The thmerapeutic agent may also be administered parenterally, intraperitoneally, } intraspinally, or intracerebrally. Dispersions can be prepared in glycerol, liquid polyethylere glycols, and mixtures thereof and in oils. Under ordinary conditions of storage and use, the=se preparations ray contain a preservative to prevent the growth of microorganisms.

To administer the therapeutic agent by other thean parenteral administration, it may be necessary to c=oat the agent with, or co-administer the a gent with, a material to prevent its inactivation. For example, the therapeutic agent may b e administered to a subject in an appropriate caarrier, for example, liposomes, or a diluen t. Pharmaceutically acceptable diluemts include saline- and aqueous buffer solutions. Liposome s include water-in-oil-in-water CGF emulsions as well as conventional liposomes (Strejan ez al., J. Neuroimmunol, 7,27 (1984)®.

Pharmaceutical compositions suitable for injectable use include sterile aqueous solutions (where water _soluble) or dispersions and sterile powders for the extemporaneous preparation of sterile injectable solutions or dispersion. In all cases, tlhe composition must be sterile and mmust be fluid to the extent that easy syringability exists. It mraust be stable under the conditions of manufacture amnd storage and must be preserved against= the contaminating action of microorganisrms such as bacteria and fungi.

Suitab de pharmaceutically acceptable carriers in clude, without limitation, any non-immunog;enic pharmaceutical adjuvants suitable foer oral, parenteral, nasal, mucosal, transdermal, imntravascular (IV), intraarterial (IA), intrarmuscular (IM), and subcutaneous (SC) administratiorm routes, such as phosphate buffer saline (PBS).

The ve=hicle can be a solvent or dispersion medimum containing, for example, water, ethanol, polyo-1 (for example, glycerol, propylene glyco 1, and liquid polyethylene glycol, and the like), suitable mixtures thereof, and vegetable oils. The= proper fluidity can be maintained, feor example, by the use of a coating such as lecithin, by thes maintenance of the required particle size inthe case of dispersion and by the use of surfactants. ¥Prevention of the action of microorganisms can be achieved by various antibacterial and antifungal agents, for example parabens, chlo=robutanol, phenol, ascorbic acid, thimero=sal, and the like. In many cases, isotonic agents are incl uded, for example, sugars, sodium chloricie, or polyalcohols such as mannitol and sorbitol, in thes composition. Prolonged absorption of thac injectable compositions can be brought about by inclu ding in the composition an agent which d-elays absorption, for example, aluminum monostearate or gelatin,

Sterile injectable solutions can be prepared by irmcorporating the therapeutic agent in the required amou nt in an appropriate solvent with one or a combination of ingredients enumera_ted . above, as required, followed by filtered sterilization. Ge nerally, dispersions are prepared by incorporating the therapeutic agent into a sterile vehicle which contains a basic dispersion medium and tae required other ingredients from those emumerated above. In the case of sterile powders for the preparation of sterile injectable solutions, the methodss of preparation are vacuum drying and freeze-drying which yields a powder of the active ingrediemt (i.e., the therapeutic agent) plus any additional desired ingredient from a previously sterile—filtered solution thereof.

The therapeutic agent can be orally administered, for example, with an inert diluent or an . assimilable edible carrier. The therapeutic agent and other ingredients may also be enclosed in a . hard or soft shell gelatin caps ule, compressed into tablets, or incorporamted directly into the subject’s diet. For oral therapeutic administration, the therapeutic agemt may be incorporated with excipients and used in thie form of ingestible tablets, buccal tablets, troches, capsules, elixirs, suspensions, syrups, vwafers, and the like. The percentage of thes therapeutic agent in the compositions and preparation s may, of course, be varied. The amount =of the therapeutic agent in such therapeutically useful compositions is such that a suitable dosage will be obtained.

It is especially advantageous to formulate parenteral compositieons in dosage unit form for ease of administration and uniformity of dosage. Dosage unit form as used herein refers to physically discrete units suited as unitary dosages for the subjects to be treated; each unit containing a predetermined quantity of therapeutic agent calculated to produce the desired therapeutic effect in association with the required pharmaceutical vehicle. The specification for the dosage unit forms of the irivention are dictated by and directly dependent on (a) the unique characteristics of the therapeutic agent and the particular therapeutic effect to be achieved, and (b) the limitations inherent in the art of compounding such a therapeuti c agent for the treatment of amyloid deposition in subjects.

The present invention therefore includes pharmaceutical formuBations comprising the agents of the Formulae described herein, including pharmaceutically acceptable salts thereof, in . pharmaceutically acceptable carriers for aerosol, oral and parenteral ad ministration. Also, the present invention includes such agents, or salts thereof, which have bee=n lyophilized and which may be reconstituted to form pharmaceutically acceptable formulations for administration, as by intravenous, intramuscular, or subcutaneous injection. Administration may also be intradermal or transdermal.

In accordance with the present invention, an agent of the Formulae described herein, and pharmaceutically acceptable salts thereof, may be administered orally or through inhalation as a solid, or may be administered intramuscularly or intravenously as a solution, suspension or emulsion. Alternatively, the a gents or salts may also be administered b y inhalation, intravenously or intramuscularly as a liposomal suspension.

Pharmaceutical formulations are also provided which are suitab Je for administration as an . aerosol, by inhalation. These formulations comprise a solution or suspension of the desired agent of any Formula herein, or a salt thereof, or a plurality of solid particles of the agent or salt.

The desired formulation may be placed in a small chamber and nebulize=d. Nebulization may be accomplished by compressed air or by ultrasonic energy to form a plurality «of liquid droplets or solid particles comprising the agents or salts. The liquid droplets or solid particles should have a particle size in the range of about 0.5 to about 5 microns. The solid particless can be obtained by processing the solid agent of any Formula described herein, or a salt thereof” in any appropriate ; 5 manner known in the art, such as by micronization. The size of the solid pamticles or droplets will be, for example, from about 1 to about 2 microns. In this respect, commercial nebulizers are available to achieve this purpose.

A pharmaceutical formulation suitable for administration as an aerossol may be in the form of a liquid, the form ulation will comprise a water-soluble agent of any Formula described herein, or a salt thereof, in a carrier which comprises water. A surfactant may be present which lowers the surface tension of the formulation sufficiently to result in the forrmation of droplets within the desired size range when subjected to nebulization.

Peroral compositions also include liquid solutions, emulsions, suspersions, and the like.

The pharmaceutically acceptable carriers suitable for preparation of such comnpositions are well known in the art. Typical components of carriers for syrups, elixirs, emulsions and suspensions include ethanol, glycerol, propylene glycol, polyethylene glycol, liquid sucrose, sorbitol. and . ‘water. For a suspension, typical suspending agents include methyl cellulose , sodium carboxymethyl! cellulose, tragacanth, and sodium alginate; typical wetting ag=ents include lecithin and polysorbate 80; and typical preservatives include methyl paraben and so dium benzoate. Peroral liquid compositions may also contain one or more components such as sweeteners, flavoring agents and colorants disclosed above.

Pharmaceutical compositions may also be coated by conventional me=thods, typically with pH or time-dependent coatings, such that the subject agent is released in the gastrointestinal tract in the vicinity of the desired topical application, or at various times to extend the desired action.

Such dosage forms typically include, but are not limited to, one or more of ceellulose acetate phthalate, polyvinylacetate phthalate, hydroxypropy! methyl! cellulose phthalate, ethyl cellulose, waxes, and shellac.

Other composition s useful for attaining systemic delivery of the subject agents include ‘sublingual, buccal and nasal dosage forms. Such compositions typically comprise one or more of soluble filler substances such as sucrose, sorbitol and mannitol; and bindemrs such as acacia, microcrystalline cellulose, carboxymethyl cellulose and hydroxypropyl meth yl cellulose.

Glidants, lubricants, sweeteners, colorants, antioxidants and flavoring agents disclosed above may also be included. ; The compositions of this invention can also be administered topically to a subject, e.g., by the direct laying on or spreading of the composition on the epidermal or eppithelial tissue of . the subject, or transdermal ly via a “patch”. Such compositions include, for example, lotions,

creams, solutions, gels and solids. These to pical compositions may comprise an effective amosunt, usually at least about 0.1%, or evar from about 1% to about 5%, of amn agent of the inve=ntion. Suitable carriers for topical adm Rnistration typically remain in placze on the skin as a contzinuous film, and resist being removed bey perspiration or immersion in wamter. Generally, the . 5 carrier is organic in nature and capable of hzaving dispersed or dissolved there in the therapeutic agerat. The carrier may include pharmaceutically acceptable emolients, emulssifiers, thickening ager2ts, solvents and the like.

Active agents are administered at a therapeutically effective dosage sum fficient to inhibit amy loid deposition in a subject. A “therape utically effective” dosage inhibits amyloid deposition by, for example, at least about 20%, or by at least about 40%, or even by at least abotat 60%, or by at least about 80% relative to untreated subjects. In the case= of an Alzheimer’s : subjecct, a “therapeutically effective” dosage stabilizes cognitive function or pmrevents a further decrease in cognitive function (i.e., preventimg, slowing, or stopping disease p=rogression). The present invention accordingly provides therampeutic drugs. By “therapeutic” or= “drug” is meant an agent having a beneficial ameliorative or prophylactic effect on a specific cisease or condition in a Biving human or non-human animal.

Furthermore, active agents are admirmistered at a therapeutically effecti ve dosage suffiecient to decrease deposition in a subject of amyloid protein, e.g., AB40 or AB42. A theraupeutically effective dosage inhibits amy~loid deposition by, for example, amt least about 15%, or by~ at least about 40%, or even by at least &60%, or at least by about 80% relative to untreated subjects.

In another embodiment, active agents are administered at a therapeutic=zally effective dosage sufficient to increase or enhance amyloid protein, e.g., AB40 or AP42, _in the.blood of a subjezct A therapeutically effective dosage irmcreases the concentration by, for example, at least aboum 15%, or by at least about 40%, or even: by at least 60%, or at least by about 80% relative to untre ated subjects. :

In yet another embodiment, active agesnts are administered at a therapev_itically effective dosage sufficient to improve ADAS-cog test scores by, e.g., at least about 1 po=int, at least about 2 poimts, at least about 3 points, at least about 4 points, at least about 5 points, =at least about 10 pointss, at least about 12 points, at least about 15 points, or at least about 20 poi nits relative to } untreaated subjects.

Toxicity and therapeutic efficacy of smuch agents can be determined by sstandard pharmnaceutical procedures in cell cultures or experimental animals, e.g., for de -termining the ] LD50 (the dose lethal to 50% of the population) and the EDS0 (the dose therapeutically effective in 502% of the population). The dose ratio bet-ween toxic and therapeutic effectss is the therapeutic index and can be expressed as the ratio LD50/ED50, and usually a larger therapeutic index are more efficacious. While agents that exhibit toxic side effects may be used, care should be taken to design a delivery system that targets such agents to the site of affected tissue in order to ) minimize potential damage to uninfected cells and, thereby, reduce side effects.

It is understood that appropriate doses depend upon a number of factors within tlhe ken of ) 5 the ordinarily skilled physician, veterinarian, or researcher. The dose(s) of the small mamlecule will vary, for example, depending upon the identity, size, and condition of the subject or— sample being treated, further depending upon the route by which the composition is to be admimmistered, if applicable, and the effect which the practitioner desires the small molecule to have up=on the nucleic acid or polypeptide of the invention. Exemplary doses include milligram or mic rogram amounts of the small molecule per kilogram of” subject or sample weight (e.g., about 1 microgram per kilogram to about 500 milligrams per kilogram, about 100 micrograms peer kilogram to about 5 milligrams per kilogram, or about 1 microgram per Kilogram to abort 50 micrograms per kilogram). 1t is furthermore understood that appropriate doses depend u_pon the potency with respect to the expression or activity to be modulated. Such appropriate doses may be determined using the assays described herein. When one or more of these small mole=cules is to be administered to an animal (e.g, a human) in order to modulate expression or activi~ty of a polypeptide or nucleic acid of the invention, a physician, veterinarian, or researcher may _, for . example, prescribe a relatively low dose at first, subsequently increasing the dose until amn appropriate response is obtained. In addition, it is understood that the specific dose leveE for any particular animal subject will depend upon a va riety of factors including the activity of the specific agent employed, the age, body weight, general health, gender, and diet of the subject, the time of administration, the route of administrati on, the rate of excretion, any drug combiration, and the degree of expression or activity to be modulated.

The ability of an agent to inhibit amyloid deposition can be evaluated in an animzal model system that may be predictive of efficacy in inh ibiting amyloid deposition in human diseaases, , such as a transgenic mouse expressing human APP or other relevant animal models where AB deposition is seen. Likewise, the ability of an agent to prevent or reduce cognitive impaimment in a model system may be indicative of efficacy in humans. Alternatively, the ability of an . agent can be evaluated by examining the ability of the agent to inhibit amyloid fibril formation in vitro, e.g., using a fibrillogenesis assay such as that described herein, including a ThT, CD, or FEM assay. Also the binding of an agent to amyloid fibrils may be measured using a MS assay. as described herein. ‘ Pharmaceutically Acceptable Salts

Certain embodiments of the present agents can contain a basic functional group, swuch as . 35 amino or alkylamino, and are, thus, capable of forming pharmaceutically acceptable salts with pharmaceutically acceptable acids. The term “pharmacer tically acceptable salts” in t=his respect, refers to the relati-vely non-toxic, inorganic and organic a-cid addition salts of agents of the present invention. These salts can be prepared in situ dur-ing the final isolation and pwurification of the agents of the invention, or by separately reacting a purified agent of the invention in its . 5 free base form witth a suitable organic or inorganic acid, Zand isolating the salt thus for—med.

Representative salts include the hydrohalide (including hydrobromide and hydrochloride), suc Ifate, bisulfate, phosphate, nitrate, acetate, valerate, oleate, palmitate, stearate, laurate, benzoate, lactate, phosphate, tosylate, citrate, mall eate, fumarate, succinate, ta rate, napthylate, mesylate, glucoheptonate, lactobionate, 2-hydE® roxyethanesulfonate, and : 10 laurylsulphonate s alts and the like. See, e.g., Berge ef al. “Pharmaceutical Salts”, J. #Pharm. Sci. 66, 1-19 (1977).

In other ca=ses, the agents of the present invention may contain one or more acmdic functional groups =and, thus, are capable of forming pharmaceutically acceptable salts with pharmaceutically &acceptable bases. The term “pharmacevatically acceptable salts” in t_hese instances refers to the relatively non-toxic, inorganic and organic base addition salts o=f agents of the present inventi on.

These salts can likewise be prepared #n situ duringz the final isolation and purif ication of the agents, or by separately reacting the purified agent in Mts free acid form with a suitable base, such as the hydrox_ide, carbonate or bicarbonate of a pharrmaceutically acceptable metal cation, © 20 with ammonia, or with a pharmaceutically acceptable org=nic primary, secondary or tertiary amine. Representamtive alkali or alkaline earth salts includ=e the lithium, sodium, potassium, calcium, magnesiu m, and aluminum salts and the like. Re=presentative organic amines- useful for the formation of bamse addition salts include ethylamine, di cthylamine, ethylenediamines, ethanolamine, diethanolamine, piperazine and the like.

Those skilled in the art will recognize, or be able tc ascertain using no more thaan routine experimentation, mmany equivalents to the specific embodirments and methods describeed herein.

Such equivalents amre intended to be encompassed by the scope of the following claims . All patents, patent appM ications, and literature references cited herein are hereby expressly incorporated by reference in their entirety. This invention is further illustrated by the Following examples which sheould not be construed as limiting. “Pharmace-atically acceptable salts” also includes, #or example, derivatives of agents modified by makingg acid or base salts thereof, as describec further below and elsewher—e in the present application. Examples of pharmaceutically acceptable salts include mineral or organic . acid salts of basic residues such as amines; and alkali or or ganic salts of acidic residuess such as carboxylic acids. P~harmaceutically acceptable salts include the conventional non-toxic salts or the quaternary ammonium salts of the parent agent formed_, for example, from non-toxi ¢ inorganic or organic acids. Such conventional non-toxic salts include those der ived from inorganic acids such as hydrochloric, hhydrobromic, sulfuric, sulfamic, phosphomric, and nitric acid; and the salts prepared from orgamic acids such as acetic, propionic, succin ic, glycolic, stearic, lactic, malic, tartaric, citric, ascorbic, palmoic, maleic, hydroxymaleic, gphenvlacetic, : 5 glutamic, benzoic, salicylic, sulfanilic , 2-acetoxybenzoic, fumaric, toluenesulfo nic, methanesulfonic, ethane disulfonic, oxalic, and isethionic acid. Pharmaceutical ly acceptable salts may be synthesized from the parent agent which contains a basic or acidic moiety by conventional chemical methods. Generally, such salts may be prepared by reac ting the free acid or base forms of these agents with a stoichiometric amount of the appropriate bzase or acid in 1 0 water or in an organic solvent, or in a mixture of the two.

Examples

Those skilled in the art will recognize, or be able to ascertain using no nore than routine experimentation, numerous equivalents to the specific procedures, embodimentss, claims, and examples described herein. Such equivalents were considered to be within the sscope of this 1 5 invention and covered by the claims appended hereto. The contents of all references, issued patents, and published patent applications cited throughout this application are kaereby incorporated by reference. The invention is further illustrated by the following example, which should not be construed as further lim iting.

Binding and Antifibrillogenic Assays

Test compounds were purchased from commercial sources or synthesize=d and screened by mass spectroscopy (“MS”) assays. The MS assay gives data on the ability o=f compounds to bind to an amyloid.

In the mass spectroscopy (“MS”) assay, samples were prepared as aqueous solutions containing 20% ethanol, 200 uM of a test compound and 20 uM of solubilized ~AB40. The pH 2.5 value of each sample was adjusted to “7.4 (0.2) by addition of 0.1% aqueous so dium hydroxide.

The solutions were then analyzed by electrospray ionization mass spectroscopy using a Waters

ZQ 4000 mass spectrometer. Samples were introduced by direct infusion at a fl ow-rate of 25 pL/min within 2 hr. after sample preparation. The source temperature was kept at 70 °C and the cone voltage was 20 V for all the analysis. Data were processed using Masslyn=x 3.5 software. . 3 0 The MS assay gives data on the ability” of compounds to bind to soluble AP, wheereas the ThT,

EM and CD assays give data on inhibi tion of fibrillogenesis. The results from the assay for binding to AP are summarized in Table 2. “+++” indicates strong binding; “4++™ indicates moderate binding; “+” indicates weak binding; “-” indicates no detectable binding; and entries ] left blank were not dete=mined.

An ultraviolet absorption assay is also available, and this assay gives an indication off the . ability of test compounds to bind to (fibrillar) AB. The expe riments were carried out in a blinded fashion. Test compourndat 20 uM was incubated with 50 pM AB(1-40) fibers for 1 h at 37°«C in

Tris buffered saline (20 mM Tris, 150 mM NaCl, pH 7.4 cortaining 0.01 sodium azide).

Following incubation, ®he solution was centrifuged for 20 m3n at 21,000 g to sediment the

APB(1-40) fibers along wwvith any bound test compound. The zamount of test compound remaiming in the supernatant was «determined by reading the absorbances. The fraction of test compound bound was then calculamted by comparing the amount remaining in the supematants of incubations with AB to the amount remaining in control incumbations which do not contain A B fibers. Thioflavin T amd Congo Red, both of which are knov=vn to bind to AB fibers, are included in each assay run as po sitive controls. Before assaying, test =compounds were diluted to 40 mM, which is twice the concentration in the final test, and then sc anned using the Hewlett Packared 8453 UV/VIS spectrop hotometer to determine if the absorbance was sufficient for detection —

Observed Synergistic F=flects of Combination Therapy in Husnan Patients :

In this example, mild and moderate patients have bee=n treated with an alkanesulfonic acid, namely 3-amino- 1 -propanesulfonic acid, in combinatio=n with other therapeutic compowinds used to diminish sympt=oms characteristic of Alzheimer’s dissease (e.g., loss of cognitive functions). The exampmles comprise the use of an alkanesulfconic acid in combination with cognitive enhancers such as acetylcholine esterase inhibitors- (“AChEi”). The effect of these= combination therapies aon the change in ADAS-cog score in ®he patients was determined.

Patients were tr-eated with the test alkanesulfonic acicd for a period of 9 months. A group of patients received the= test compound alone while another g=roup were treated with the test compound in combinat ion with an AChEi, namely donepezil.

Effect on ADAS™-Cog. Upon entering the study, Alzheeimer’s patients were categorize=d as being “mild” or “moderate” according to their MMSE (“Mimi Mental State Examination”) score.

B.W.Rover, et al., “Mimi-mental state exam in clinical practi ce.” Hospital Practice 22(1A), S9 et seq. (1987). (Accorcling to this examination a MMSE score in the range of 19 to 26 was considered “mild,” and_ ascore in the range 13 to 18 was commsidered “moderate.” Then, the change in mental functJon of these patients was analyzed by using their ADAS-Cog scores, ‘ which were recorded peeriodically over a nine month period. During this time, certain of the patients received the te_stalkanesulfonic acid compound, and others received the same } alkanesulfonic acid coracomitantly with donepezil, an acetylcholinesterase inhibitor. The average change in ADAS-Cog score for each group of patients was compared to the sstandard reported } change in'similar Alzheimer’s disease patients who have been treated with deonepezil alone. The reference and experimental data. are tabulated below, according to the particumlar therapeutic regimen and the patient population: ) 5

Group(s) over 9 mon-ths : Ach€Ei alone combined : . combined

A positive change in ADIAS-Cog score reflects a deterioration of cognitive function of a “mild AD” patient; stabilization is seen by a change of £!; and a negative change shows an improvement in cognitive function. The medical literature predicts that patie=nts with

Alzheimer’s disease who do not receive any treatment will, on average, have achange in ADAS- cog score over nine months varying from +2.5 (for “mild” patients) to +5 (four “moderate” patients).

As the results indicate, patients who were treated with the test compowund alone had a stable ADAS-Cog score (-0.5 on average, both the mild and moderate groupss are considered together for convenience), and therefore the test compound appears to have 1® mited a further decrease in the cognitive function of patients in this group over the test period.

The quantitative effects for each therapeutic drug regimen when administered separately are known. An additive effect for the combined mild plus moderate patient g-roup would . therefore be in the in the range of (+5.0 to +2.5) + (-0.5), which calculates to a deterioration on the ADAS-Cog scale of +2.0to +4.5 points. Surprisingly, the opposite effec tis observed. The effect of concomitant administration of the test alkanesulfonic acid compound with the acetylcholinesterase inhibitor led to an improvement of cognitive function (-3.0), whereas the predicted result is a decline. These results show an example of the benefit of having combination therapy for Alzheirmer’s disease patients.

The alkanesulfonic acid wsed in the study is known to have an effect cn the concentration of AB in the brain. We also determined the effect of test compound on the ch_ange in Ap CSF levels of patients with mild to m oderate Alzheimer’s disease compared to that seen in patients treated with a triple combination of test compound with AChEi and statin.

Patients treated with alkanesulfonic test comppound in the presence or absenc=e of AchEi . and stati n were evaluated for their AB CSF concentration at time 0 and 3 months foE lowing the *initiatior of treatment with the alkanesulfonic acid. ~The change in ABs; CSF concemntration was compare=d to the respective placebo group.

P™atients treated with the test compound had aa decrease of 34% in Af} CSF concentration.

The test compound was previously shown to decreasse the levels of both soluble and insoluble

AB in £he brain of transgenic mice. Based on the mice studies the test compound i s hypothes- ized to fZavor the clearance of A from the brain and CSF prior to its deposition. Thee decrease in

AB CSF concentration seen in patients treated with thhe test compound is greater thar that seen in the place=bo group, where patients showed a non-sigraificant increase of 15% in their Af} CSF concentration. This result demonstrates a difference of 49% between the two group=s. Patients treated vevith the triple therapy (test compound and AcchEi and statin) showed a decrease of 31% while pa—tients on AChEi and statin showed an increase of 45% in their AP42 CSF le=vels. This triple the=rapy showed a greater effect on the change «-76%) of ABs2 CSF concentration when compare d to the appropriate controls.

Imn sum, when compared to the respective placebo group, the combination of test compourd with AchEi and statin showed a much gre=ater effect on the Ap CSF conceentration than test compound alone.

Methodology. CSF was obtained from patien®s before and after treatment with the test compourd at daily doses of 100 mg, 200 mg, or 300 mg. CSF was fractionated by FPLC followingg treatment with formic acid, and then the A {3 containing fraction was lyophmilised. The amount cof AP peptide was measured using an ELISA assay (Biosource). The test al kanesulfonic acid-containing composition was found to reduce thes CSF level of AB when patients were treated with 200 or 300 mg daily doses. A majority of patiemts on placebo and on 100 mg daily doses showed sstable AB CSF levels over a 3-month period, whereas the greatest reduction of AB occurred in patients receiving 200 or 300 mg daily doses. The presence of a drug in the cerebrosppinal fluid suggests that the drug crosses the blood brain barrier to penetrate the brain,

The pres=ence of the alkanesulfonic acid in the CSF wwas determined in patients who Fad received treatment for three months. In these patients, CSF w as collected five hours followin gdosing, and levels of alkanesulfonic acid were determined by» LC-MS/MS. The test alkanestaifonic acid was fourmd to be present in CSF of patients in a dose- «dependent manner, e.g, patients receiving 200 or 3000 mg daily dosing had a greater concentrati-on than that seen in patients wit h 100 mg daily dossing.

Cognitive function with combination therapy — alkanesulfonic acid plus an acetyl cholenesterase inhibitor. Mild to moderate Alzheime=r’s disease patients who had be=en on cognitior= enhancers (Aricept™ or Exelon™) were c-medicated with daily doses of ~ test drug ’ (300 mg alkanesulfonic acid) for six months. At the time the experiments were unde=rtaken the

] peer-revieveved medical literature indicated that patients who had been on AChE inhibitors for . more than twelve months would be expected to show a decline in cognitive functions of at leamst two to thre«e points on the ADAS-Cog scale over a six rmonth period. In order to determine whether thes drug could potentiate or even stabilize the ®benefits of AChE inhibitors, patients weere ’ 5 treated with both AChE and the test drug for a period o six months. Although the expectatiomn was that thes cognitive functions of patients receiving orily AChE inhibitors would inevitably decline, thes study shows that patients receiving co-med ication had stable or improved ADAS—

Cog, as illustrated in Graph A of the Figures, attached Inereto. These results show that the test= drug given concomitantly with AChE inhibitors is able to maintain and even improve the cognitive function of patients.

Claims (1)

1. We’ 0 2004/058258 PCT/CA2003/002011 CLAIMS

   1. Use of at least one first agermt, which is selected from a conrpound which structure is shown in any of Figures M-13 and 15-30 and pharmaceutically acceptable salts thereof; and at least one second agent sel ected from the group consistin_g of therapeutic drugs and nutritive supplements; for the manufacture of a mecdicament or kit of medicamentss for the concomitant therapeutic treatment or progohylaxis of an amyloid-f related disease, neurodegeneration, or cellul ar toxicity in a subject.

   2. The use according to claim 1, wherein said amyloid—3 related disease is selected from the group consisting off Mild Cognitive Impairment, vascular dementia, Alzheimer’s disease, sporad ic (non-heriditary) Alzheimer’s disease, familial (hereditary) Alzheimer’s dis-ease, a condition associated with Alzheimer’s disease, cerebral amyloid am giopathy, hereditary cerebral lm emorrhage, senile dementia, Down’s syndromes, inclusion body myositis, or amge-related macular degeneration. 3_ The use according to claim 2, wherein said condition assoc=iated with Alzheimer’s disease is selected from the group consisting of a symptom. characteristic of Alzheimer’s disease, a neurological condition, or a psychoMBogical condition. 4_ The use according to claim 3, wherein said symptom chara cteristic of Alzheimer’s disease is selected from the group consisting of hypothyroi dism, cerebrovascular disease, cardiovascular disease, memory loss, anxiety, a be=havioral dysfunction, apathy, aggression or incont inence. 5- The use according to claim =3, wherein said neurological co-ndition is selected from the group consisting of Hun®ington's disease, amyotrophic lateral sclerosis, acquired immunodeficiency Parkinson’s disease, aphasia, apraxia, agnosia, Pick disease, dementia with Lew =y bodies, altered muscle tone, seizures, sensory loss, visual field deficits, incoord ination, gait disturbance, transi_ent ischemic attack or stroke, transient alertness, atctention deficit, frequent falls, syncope, neuroleptic sensitivity, normal pressure hydrocephalus, subdural hema-toma, brain tumor, posttraumatic brain injury, cer posthypoxic damage. 106 Amended s heet: 17 September 2007

   6. “The use according to claim 3, wherein said psychological condition i s selected from the group consisting of depressiom, delusions, illusions, hallucimations, sexual disorders, weight loss, psychosis, a sleep disturbance includin g insomnia, “behavioral disinhibition, poor insight, ssuicidal ideation, depressed mood or Arritability, anhedonia, social withdrawal, or excessive guilt.

   7. “The use according to claim 1, wherein said first agent is a substituted or -unsubstituted alkanesulfonic acid, subsstituted or unsubstituted alkanesulfuric acid, substituted or unsubstituted alkylthiosialfonic acid, substituted or uns ubstituted -alkylthiosulfuric acid, or an ester or amide thereof, including pharma_ceutically -acceptable salts thereof.

   8. “The use according to claim 7, whereim said alkanesulfonic acid is su bstituted with .substituent selected from the group corsisting of halogeno, trifluorormethyl, nitro, ~cyano, C,-Ce alkyl, C,-C;, alkenyl, C,-&C; alkynyl, C,-C; alkylcarbon=yloxy, -arylcarbonyloxy, C,-Cs alkoxycarbony~=loxy, aryloxycarbonyloxy, “C,-C; alkylcarbonyl, C,-C¢ alkoxycarbonyl, C;-Cs alkoxy, C;-Cs alk ylthio, -arylthio, heterocyclyl, aralkyl, and aryl groups.

   9. “The use according to claim 1, wherein said first agent is a compound or mixture «of compounds having the following structure

   Y. 7 sox —where Y is -NR°R® or -SO;X"', wherein n is an integer from 1 to 5, amd X" is “hydrogen or a cationic group.

   10. “The use according to claim 1, wherein said first agent is 3-amino-1-peropane =sulfonic acid or its sodium salt.

   11. “The use according to claim 1, wherein said second agent is selected £rom the _group consisting of adrenergics, anti-acdrenergics, anti-androgens, an®i-anginal «drugs, anti-anxiety drugs, anticonvulsant drugs, antidepressant drugs, anti-epileptic drugs, antihyperlipidemiccs, antihyperlipoproteinemics, antihypertensives, anti-inflammatory d_rugs, antiobessionals, antiparkzinsonian «drugs, antipsychotics, adrenocortical steroids, adrenocortical suppres sants, aldosterone antagonists, amino acids, amnabolic steroids, analeptic age=nts, 107 Amended sheet: 17 September 2007 androgens, blood glucose regulatoxs, cardioprotectants, cardiovascular a_gents, cholinergic agonists, cholinergic antagonists, cholinesterase deactivatorss, cholinesterase inhibitors, cognition adjuvants, cognition enhancers, dopaminergic agents, enzyme inhibitors, estrogem and related steroid hormoncs, frec oxygen radical scavengers, GABA agonists, glutamate antagonists, hormones, antihypocholesterolemic agents, hypolipidemic agents, hypotensive agemts, immunizing agents, immunostimulants, monoamine oxidase inhibitors, neuroprotective agents, NMDA an tagonists, AMPA antagonists, competitive NMDA antagonists, non-competitive NMDA antagonists, opioid antagomnists, potassium channel openers, non-hormonal sterol derivatives, post-stroke treatments, post-head trauma treatxments, prostaglandins, psychotropics, relaxants, sedatives, sedative-hypnotics, selective adenosine antagonists, serotonin antagonists, serotonin inhibitors, selective serotonin uptake inhibitors, sesrotonin receptor antagonists, mixed norepi nephrine/dopamine reuptake inhibitors, mixed serotonin/norepinephrine reuptake inhibitors, tetracyclic antidepressants-, antidepressants, sodium and calcium channel blockers, steroids, stimulamts, and thyroid hormones and inhibitors.

   12. The use according to claim 1, whexein said second agent is selected frorm the group consisting of neuro-transmission enhancers, psychotherapeutic drugs, acetylcholineesterase inhibitors, calcium channel blockers, biogenic amines, benzodiazepine tranquilizers, acetylcholine synthesis enhancers, acetylcholine storage enhancers, acetylcholine release enhancers, acetylcholine postsynaptic receptor agonists, monoamine oxidase-A or —B inhibitors, N-methyl-D-aspartate glutamate receptor antagonists, nomsteroidal anti-inflammatory drugs, antioxidants, serotonergic receptor antagonists, postsynaptic receptor ag onists, vasodilators, nootropic direct braira metabolic enhancer drugs, selective “D2 antagonists, sulfonyl fluorides, anti-rage drugs, tranquilizers, and angiot ensin- converting enzyme inhibitors,

   13. The use according to claim 1, whexein said second agent is selected fromm the group consisting of phosphatidylcholine, 4-aminopyridine, bifemelane, 3,4-diaminopyridine, choline, vesamicol, secoverine, bifemelane, tetraphhenylurea, nicotinamide, arecoline, oxotremoxine, bethanechol, ethyl nipecotate, levacecamine, milacemide meman tine, moclobemide, selegiline, thiamimne, sulbutiamine, D-cycloserine, anfacine, linopirdine, deferoxamine, ketansserin, 108 Amended sheet: 17 Septe=mber 2007 mianserin, idesbenone, propentophylline, pentoxifylline, citicoline, piracetarm, oxiracetam, a miracetam, pramiracetam, pyroglu tamic acid, tenilsetam, rolziracetam, etiracetam, dupracetam, vinpocetine (Cavinton™), ebiratide, [-carbolines, naloxone, ergoloid mesylates, cyc=landclatc, isoxsuprene, nafronyl, papaverine, smiloctidil, vinburnine, vincamine, v~indeburnol, flunarizine, nimodipine, micergoline, razobazam, exifone, rolipram, sabeluzole, phosphatidylserine, ifenprodil, amantadine, calcium hopantenate, lisuride, bifemelane, iradeloxazine, tiapride, haloperidol, bromperidol, thioridazine, thiothixene, fTluphenazine, perphenazine, molinadone, tocopherols, ascorbic acid, deferoxamine=, physostigmine, heptylphysostigrmine, tetrahydroaminoacridirme (tacrine), 9-armino-1,2,3,4-tetrahydroacridin- 1-ol, metrifonate, velnacrine m_aleate, methanesulfonyl fluoride, phenylmethanesulforyl fluoride, huperzines A armd B, edrophonium_, miotine, diltiazem, verapamil, ni fedipine, nicardipine, isradipine, amlodipine, feelodipine, clonidine, guanfacine, aalaproclate, fipexide, zimeldi ne, citalopram, pmropranolol, carbamazepine, fluoxe=tine, benzodiazepine agents, and captopril.

   14. The use according to claim 1, wherein said second agent is selected from th e group consist-ing of citalopram (Celexa), escital opram (Lexapro), fluoxetine= (Prozac™), fl uvoxamine (Luvox™), paroxetine (Paxil™), sertraline (Zolof&™), bupropion (W/ellbutrin™), nefazodone (Serzone=™), trazodone (Desyrel™), venlafaxine (EEffexor™), phenelzine (Nardil™) _ tranylcypromine (Parnate™=1), maprotiline, rmirtazapine (Remeron™), amitriptyline (Elavil™), amoxapine , clomipramine= (Anafranil™), desipramine (Norgoramin™), doxepin (Sinequan™), imipramine (_Tofranil™), nortriptyline (AventylM™, Pamelor™), protriptylin_e (Vivactil™), —trimipramine (Surmontil™), mocl obemide (Manerix™), and miratazepine.

   15. The use according to claim 1, wherein said second agent is selected from th e group consisting of aripiprazole (Abilify™), clozapine (Clozaril™), olanzapine (Zyprexa™), quetiapine (Seroquel™), risperidone (Risperdal™), ziprasidore (Geodon™), eolanzapine (Zyprexa™), quetiapirae (Seroquel™), haloperidol (Haldol™), ri_speridone (Risperidal™), zuclope=nhixol (Clopixol™), ziprazi«done, thioridazine (_Mellaril™), clozapine (Clozaril™), olanzapine, and lithium. 109 Amended sheet: 17 Septemb -er 2007

   16. The use according to claim 1, wherein saicl second agent is selected from the group consisting of anti-agitation/mood-staabilizing agents, anti-epileptics for convulsi_ons, gabapentin, phenytoin, clona—zepam, valproic acid, neuroleptics, colchicire, dapsone, meloxicam, nimesulicie, flurbiprofen, cyclophosphamide, methotrexate, B-interferon, gamma-interfe ron, etanercept, infliximab, chelato Ts, penicillaamine, hormonal therapies, leuprol ide, homocysteine reducing vitamims, metafolin, antioxidants, lipoic acid, selege line,anti-thrombotics, aspirin, levodopa, folic acid, anxiolytics hypnotics, sedatives , diazepam, chlordiazepoxide, lorazepam, oxazepam, buspirone (Buspar™T M), zolpidem (Ambien™), bromazepam (Lectopam™), alprazolam (Xanax™), flur-azepam (Dalmane™), temazepam (Restorill™), triazolam (Halcion™), nitraz <pam (Mogadon™), anti-Parkinsora drugs, benztopine (Cogentin™), procyclid ine (Kernadrin™), ACE inhibitors, analgesiccs, anesthetics, antienemics, miner—als, vitamin dietary supplements, antibiotics, antidiarrheals, antiepileptics, amtigout drugs, antihistamines, antihype rtensives, anti-inflammatory drugss, antirheumatoid drugs, antipruritics, antithrormbotics, beta-blockers, calcium ch annel blockers, cardioactive glycosides, corticost-eroids, antitussives, diuretics, anti diabetes drugs, antiseptics, antiinfec=tives, laxatives, psychoanaleptics, psycholeptics, serum lipid-reducimg drugs, se=x hormones, thyroid hormones, arid urological drugs.

   17. The use =according to claim 1, wherein said second agent is an acetylcholinest erase inhibitor.

   18. The use zaccording to claim 1, wherein said second agent is a butyrylcholinest erase inhibitor .

   19. The use aaccording to claim 1, wherein saidl second agent is phenserine.

   20. The use aaccording to claim 1, wherein saidl second agent is selected from the group co sisting of tacrine, donepezil, riva_stigmine, and galanthamine.

   21. The use aaccording to claim 1, wherein said second agent is memantine.

   22. The use maccording to claim 1, wherein said. first agent inhibits, reduces, or prevents amyloid-p fibril formation. 110 Amended sheet: 17 September 2007

   23. The use accordingz to claim 1, wherein said first agemt enhances the clearance of amyloid-f from tlhe brain.

   24. The use according to claim 1, wherein said first agemt penetrates into the brain.

   25. The use according to claim 1, wherein said first agerm t maintains soluble amyloid- B in a non-fibrillaT form.

   26. The use according to claim 23, wherein said amyloidl-f is a peptide having 39-43 amino-acids.

   27. The use according to claim 1, wherein said second agent is selected from the group consisting of vitamin E (a-tocopherol), vitamim C (ascorbic acid), vitamin B12, vitammin A (retinoic acid), selegiline, co--enzyme Q, curcumin, precursors of acetylcholine, lecithin, choline, Ginkgo biloba, acetyl-L-carnitine, idebenone, properitofylline derivatives, and xanthine derivatives.

   28. The use according to claim 1, wherein the use comprises using a neuroprotective agent that protects against NMDA agonist damages as a further second agent.

   29. The use according to claim 1, wherein said medicameent or kit of medicaments is/are adapted for oral administration to a subject.

   30. The use according to claim 1, wherein said medicaments are to be simultaneously administered to a subject.

   31. The use according to claim 1, wherein the therapeutic treatment has the effect that the concentration of amyloid-f or tau in the CSF of s aid subject changes versus an untreated subject.

   32. The use according to claim 1, wherein the therapeutic treatment has the effect that cognitive function is stabilized or further deterioratio-n in cognitive function is prevented, slowedl, or stopped in said subject.

   33. The use of claim B, wherein the medicament or kit o£ medicaments is for the therapeutic treatment or prophylaxis of a human. 111 Amernded sheet: 17 September 2007 wNO 2004/058258 PC T/CA2003/002011 24, The use of claim 1, wherein the medicament or kit of medicaments is for the therapeutic treatment or prophylaxis of a subject having Alzheimem’s disease or a genetic predisposition for developing Alzheimer’s disease.

   325. The use of claim 1, wherein the medicament or kit of medicamentss is for the therapeutic treatment or prophyRaxis of a subject having Mild Cognitive Impairment.

   Re. Use of at least one first agent, w~hich is selected from a compound —which structure 1s shown in any of Figures 1-13 and Figures 15-30 and pharmaceutically acceptable salts thereof; and at least one second agent selected from the group consisting of therapeutic drugs and nutritive supplements; for the manufacture of a medica ment or kit of medicaments for the= concomitant therapeutic treatment or prophylaxis of Mild Cognitive Impairmen t, Mild-to- Moderate Cognitive Impairment, Alzheimer’s disease or a condition associated with Alzheimer’s disease in a hvaman subject.

   =7. A pharmaccutical composition for the therapeutic treatment or progpohylaxis of an amyloid-f} related disease, neur©degeneration or cellular toxicity, said composition comprising at least one first agent which is selected from a compound which structure is shown in any of Figures 1-13, and Figures 15-30 and pharmaceutically acceptable salts thereof; and at least one seccond agent selected from the group consisti ng of therapeutic drugs and nutritixe supplements. 38 The pharmaceutical compositiora of claim 37, wherein amyloid-[3 related disease is selected from the group consi sting of Mild Cognitive Impairmemat, vascular dementia, Alzheimer’s disease, sporadic (non-heriditary) Alzheimer’s disease, familial (hereditary) Alzheimer” s disease, a condition associated v=vith Alzheimer’s disease, cerebral armyloid angiopathy, hereditary cereloral hemorrhage, senile dementia, Down’s syndrome, inclusion body myositis, or age- related macular degeneration. x9, The pharmaceutical compositior of claim 38, wherein said condition associated with Alzheimer’s disease is selected from the group consisting of aa symptom characteristic of Alzheimer’s disease, a neurological condition, or & psychological condition. 112 Amended sheet: 17 September 2007

   40. The pharmaceutical cormposition of claim 39, wherein said mneurological condition is selected from the gro up consisting of Huntington's diseas- €, amyotrophic lateral sclerosis, acquired immunodeficiency, Parkinson’s disease, aphasia, apraxia, agnosia, Pick disease, dementia with Lewy bodies, altered muscle tone, seizures, sensory loss, visual fiel d deficits, incoordination, gait distur~bance, transient ischemic attack or stroke, transient alertness, attention defic it, frequent falls, syncope, neuroleptic sensitivity, normal pressure hydroceplmalus, subdural hematoma, brain tumor, posttraumatic brain injury, or posthaypoxic damage.

   41. The pharmaceutical cormposition of claim 39, wherein said gosychological condition is selected from the group consisting of depressiomn, delusions, illusions, hallucinations, sexual dlisorders, weight loss, psychosis, a sl eep disturbance including insomnia, behavioral disinhibition, poor insight, s uicidal ideation, depressed mood or irrit ability, anhedonia, social withdrawal, or excessive guilt.

   42. The pharmaceutical cormposition according to claim 39, wherein said symptom characteristic of Alzheimer’s disease is selected from the greoup consisting of hypothyroidism, cerebrovascular disease, cardiovascular disease, memory loss, anxiety, a behavioral dysfunction, apathy, aggression or inceontinence.

   43. The pharmaceutical cormposition according to claim 37, whesrein said first agent is (substituted- or unsubstituted-amino)-substituted alkanesulfeonic acid or pharmaceutically accep table salts thereof. 44, The pharmaceutical cormposition of claim 37, wherein said compound is 3-amino- 1-propanesulfonic acid or its sodium salt.

   45. The pharmaceutical cormposition of claim 37, wherein said second agent is an acetylcholinesterase inhibitor.

   46. The pharmaceutical cormposition of claim 37, wherein said ssecond agent is a butyrylcholinesterase irahibitor.

   47. The pharmaceutical cormposition of claim 37, wherein said second agent is phenserine.

   48. The pharmaceutical cormposition of claim 37, wherein said ssecond agent is tacrine, donepezil, rivasstigmine, or galanthamine. 113 Amended sh eet: 17 September 2007

   49, The goharmaceutical composition of claim 337, wherein said second agent is mem antine.

   50. The pharmaceutical composition of claim 37, wherein said first agent and s=aid secord agent are dissolved in a liquid pharmmaceutically acceptable carrier.

   51. The poharmaceutical composition of claim 37, wherein said first agent and said secord agent are present as a homogenous mixture in a capsule or pill. 52 The pharmaceutical composition of claim 37, wherein said pharmaceutical composition further comprises a pharmacewutically acceptable acid, base, bu ffering agent, inorganic salt, solvent, or preservatiwe.,

   53. The pharmaceutical composition of claim 37, further comprising a compourd that incre ases the cerebral bioavailability of eitlner said first agent or said second agent.

   54. A ph armaceutical composition for preventi ng or treating Alzheimer’s disease in a human subject, said composition comprisirag an effective amount of at least one first agent which is selected from a compound which structure is shown in any of Figur-es 1-13, and Figures 15-30 and pharmaceutically acceptable salts thereof; and at least one second agent which is selected from the group consisting of therapeutic drugs curative of Alzheimer’s disease or palliative of the symptoms there of.

   58S. A kit comprising: at least one first agent, which is selected from a compound which structure 3s shown in any of Figures 1-13, and Figures 15-30 and pharmaceutically acce=ptable salts thereof; and instructions for the concomitant administra tion of the first agent with a secosnd agent, wherein said second agent is selected from the group consisting of therapeutic drugs and nutritive supplementss.

   56. The kit of claim 55, wherein said first agen tis 3-amino-1-propanesulfonic =cid or its so dium salt.

   57. Use Of at least one of a compound which st Tucture is shown in any of Figures 1- 13, amd Figures 15-30, in combination witha at least one second agent selectesd from the group consisting of therapeutic drags and nutritive supplements, for the 114 Amended sheet: 17 Septembeer 2007 therapeutic treat-ment or prophylaxis of an amyloicdf3 related disease, neurodegeneratieon, or cellular toxicity in a subject.

   58. Use of at least one of a compound which structure= is shown in any of Figures 1- 13, and Figures 15-30, for treating, mitigating or sslowing the progression of Alzheimer’s dise=ase in a patient in need thereof.

   59. The use of at leamst one first agent, which is selecte=d from substituted or unsubstituted allxanesulfonic acids and pharmacew tically acceptable salts thereeof; and at least one =second agent wherein said second agent is curative of Alzheimer’s dise=ase or palliative of the symptomss thereof selected from the g=roup consisting of cholinesterase inhibitors and NMDA. receptor antagonists, for tlhe manufacture of &a medicament or kit of medicamerts for the concomitant therapeutic treat ment or prophylaxis of an amyloicd-f3 related disease, neurodegenerati=on, or cellular toxicity.

   60. The use of claim 59, wherein said first agent is (stabstituted- or unsubstituted— amino)-substitut-ed alkanesulfonic acid or pharmaceutically acceptable salts thereof.

   61. The use accordirmg to claim 60, wherein said first &agent is (substituted- or unsubstituted-armino)-substituted C,.¢ —alkanesulfconic acid or pharmaceutical ly acceptable salts thereof.

   62. The use of clainm 61, wherein said first agent is 3-e&amino-1-propanesulfonic ac=id or its sodium salt.

   63. The use of clainm 59, wherein said second agent is an acetylcholinesterase inhibitor.

   64. The use of claim 59, wherein said second agent is a butyrylcholinesterase inhibitor.

   65. The use of clainm 59, wherein said second agent is phenserine.

   66. The use of clainm 59, wherein said second agent is selected from the group consisting of tac=rine, donepezil, rivastigmine, and galanthamine. 115 Amnended sheet: 17 September— 2007

   67. The use of claim 59, wherein said second agemt is memantine.

   68. The use of claim 59, wherein said first agent i nhibits, reduces, or prevents amy~loid-p fibril formation.

   69. The use of claim 59, wherein said first agent enhances the clearance of amyloid-f3 frormn the brain.

   70. The use of claim 59, wherein said first agent penetrates into the brain.

   71. The use of claim 59, wherein said first agent rmaintains soluble amyloid-f in aa non—fibrillar form.

   72. The use of claim 69, wherein said amyloid-f3 As a peptide having 39-43 amino— acids.

   73. The use of claim 59, wherein said amyloid—{3 related disease is at least one disease sele cted from the group consisting of: Mild C«ognitive Impairment, Mild-to- Moderate Cognitive Impairment, vascular dermentia, Alzheimer’s disease, sporadic (non-hereditary) Alzheimer’s disease, familial (hereditary) Alzheime=r’s dise=ase, cerebral amyloid angiopathy, hereditary cerebral hemorrhage, senile dementia, Down’s syndrome, inclusion body mmyositis, and age-related macular degeneration.

   74. The use of claim 59, wherein the use comprises using a neuroprotective agent that protects against NMDA agonist damage as a further second agent.

   75. The use of claim 59, wherein said medicament or kit of medicaments is/are adapted for oral administration to a subject.

   76. The use of claim 59, wherein said medicaments are to be simultaneously administered to a subject.

   77. The use of claim 59 or 73, wherein said amyloid—p related disease is Alzheim_er’s dise=ase or a condition associated with Alzheirmer’s disease.

   78. The use of claim 77, wherein said condition associated with Alzheimer’s dise=ase is mmemory loss, anxiety, or a behavioral dysfuanction. 116 Amended sheet: 17 September 2007

   79. The use of claim 59, wherein the therapeutic treatment has the effect that the concentration of amyBoid-B or tau in the CSF of said si-abject changes versus an untreated subject.

   80. The use of claim 59, wherein the therapeutic treatment has the effect that cognitive function is stabilized or further deterioration in cognitive function is prevented, slowed, or stopped in said subject.

   81. The use of claim 59, wwherein the medicament or kit of medicaments is for the therapeutic treatment or prophylaxis of a human.

   82. The use of claim 59 wherein the medicament or kit of mmedicaments is for the therapeutic treatment or prophylaxis of a subject havin_g Alzheimer’s disease or a genetic predisposition for developing Alzheimer’s dise=ase.

   83. The use of claim 59, wwherein the medicament or kit of medicaments is for the therapeutic treatment or prophylaxis of a subject havin_g Mild Cognitive Impairment.

   84. A pharmaceutical composition comprising: a first agent, which is selected from substituted or unsubstituted alkanesulfonic acids and pharmaceutically acceptable salts thereof; and a second agent, wherein said second agent is cumrative of Alzheimer’s disease or palliative o fthe symptoms thereof selected from the group consisting of cholinesterase inhibitors and NMDA receptor antagonists.

   85. The pharmaceutical composition according to claim 84—, wherein said first agent is (substituted- or unsub stituted-amino)-substituted alkan esulfonic acid or pharmaceutically acceptable salts thereof.

   86. The pharmaceutical composition according to claim 85s, wherein said first agent is (substituted- or unsub stituted-amino)-substituted C,-Ce alkanesulfonic acid or pharmaceutically acceptable salts thereof.

   87. The pharmaceutical composition of claim 86, wherein =said compound is 3-amino- 1-propanesulfonic acid or its sodium salt. 117 Amend ed sheet: 17 September 2007

   88. The pharmaceutical composition of claim 84, wherein said second agent is an acet ylcholinesterase inhibitor.

   89. The pharmaceutical composition of claim 84, wherein said second agent is =a buty rylcholinesterase inhibitor.

   90. The pharmaceutical composition of claim 84, wherein said second agent is pherserine.

   91. The pharmaceutical composition of claim 84, wherein said second agent is tacrine, donepezil, rivastigmine, or galanthamine.

   92. The pharmaceutical composition of claim 84, wherein said second agent is memantine.

   93. A kt comprising: a first agent, which is selected from substituted or unsubstituted alka nesulfonic acids and pharmaceutically ac ceptable salts thereof; and packaged witha instructions for concomitant administration of the first agent with a second agent, wherein said second agent is curative Of Alzheimer’s disease or palliative of tlhe symptoms thereof selected from cholinesterase inhibitors or NMDA receptor antagonists.

   94. The kit according to claim 93, wherein said fi rst agent is (substituted- or unsubstituted-amino)-substituted alkanesulfomic acid or pharmaceutically accesptable salts thereof.

   95. The kit according to claim 94, wherein said fi rst agent is (substituted- or unsuibstituted-amino)-substituted C,.s-alkanessulfonic acid or pharmaceutically acceptable salts thereof.

   96. The kit of claim 95, wherein said first agent iss 3-amino-1-propanesulfonic aacid or its monosodium salt. 118 Amended sheet: 17 Septembeer 2007

   )

   97. A Kkit comprising: an agent, wherein said agent is curative of Alzheimer’s disease or palliative of the symptoms thereof selected from the group consisting of cholinester-ase inhibitors and NMDA recepto 1 antagonists; packaged with instructions for concommitant administration of the agzent with anoth er agent, which is selected from substituted or unsubstituted alkanesulfonic acids and pharmaceutically acsceptable salts thereof.

   98. The kit according to claim 97, wherein said other agent is (substituted- or unsubstituted-amino)-substituted alkanesulfo-nic acid or pharmaceutically acceptable salts thereof.

   99. The kit according to claim 98, wherein said other agent is (substituted- or unsubstitutced-amino)-substituted C;_¢-alkane=sulfonic acid or pharmaceutically acceptable salts thereof.

   100. The kit of «claim 99, wherein said other agent is 3-amino-1-propanesulfonics acid or its soditmm salt. 119 Amended sheet: 17 Septembwer 2007