Combination

Abstract

The present invention provides a combination comprising (a) a sulfonylurea; and (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist, for example in combinations comprising (a) glibenclamide or a structural or functional analog thereof; and (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) potassium canlylate or a structural or functional analogue thereof. The combination is suitable for use in the treatment of stroke and other neurodegenerative conditions, as well as in the treatment and / or prevention of ischemia and / or reperfusion injury of various important organs, including the brain and heart. Other aspects of the invention relate to pharmaceutical products and pharmaceutical compositions comprising the combination according to the invention, as well as methods of treatment using the same.

Description

[0001] This patent application is a divisional application of the patent application with the application number 2020800577686, the application date of July 9, 2020, and the invention title of "Combination". Technical Field

[0002] The present invention provides a combination suitable for use in treating stroke and neurodegenerative disorders and for treating and / or preventing ischemia and / or reperfusion injury of various vital organs including the brain and the heart.

[0003] Other aspects of the present invention relate to pharmaceutical products and pharmaceutical compositions comprising the combination, and methods of treatment using them. Background Art

[0004] Stroke is caused by a lack of blood flow in the brain (ischemic stroke) or by bleeding in the brain (hemorrhagic stroke), both of which result in the death of brain cells. According to the World Health Organization, stroke caused approximately 6 million deaths in 2016 and is the second leading cause of death globally. According to the Global Burden of Disease study (Johnson CO et al., Lancet Neurol. 2019; 18: 439-58), there were 13.7 million new stroke cases and 80.1 million prevalent stroke cases globally in 2016. The high global stroke burden indicates that primary prevention strategies have neither been widely implemented nor are sufficiently effective. There are already guidelines for controlling acute ischemic stroke (Powers WJ et al., Stroke. 2018; 49: e46-e99). Intriguingly, the guidelines conclude that there is currently no pharmacological or non-pharmacological treatment with a recognized neuroprotective measure that can demonstrate efficacy in improving the prognosis after ischemic stroke, and therefore, other neuroprotective agents are not recommended. There are also guidelines for controlling hemorrhagic stroke; however, these guidelines do not recommend treatments for controlling the neurodegenerative outcomes of hemorrhagic stroke other than rehabilitation (Hemphill JC 3rd et al., Stroke. 2015; 46: 2032-2060).

[0005] The above data clearly demonstrate that there is currently a lack of effective pharmacological treatments for ischemic or hemorrhagic stroke and that there is a need for neuroprotective treatments in stroke patients. Effective treatment of reperfusion injury associated with stroke has the potential to provide neuroprotection. However, to date, attempts to develop effective neuroprotective treatments for stroke patients based on reducing reperfusion injury have not been successful (Savitz SI et al., Stroke. 2017;48:3413 - 3419; Patel RAG et al., Prog Cardiovasc Dis. 2017;59:542 - 548). Previous research in the fields of cardioprotection and reperfusion injury has revealed the surprising finding that combination therapies not applicable for treating cardiovascular conditions can produce significant synergistic effects to prevent myocardial reperfusion injury if used at dose levels lower than those applicable for these other conditions (WO2017 / 077378; US10,172,914; Genesis Pharma SA).

[0006] Therapies that are expected to show neuroprotective effects can be used to treat neurodegenerative disorders. Neurodegenerative disorders are due to the progressive loss of the structure or function of neurons, which ultimately leads to neuronal death. Neurodegenerative disorders include currently incurable diseases such as Parkinson's disease, Alzheimer's disease, Huntington's disease, amyotrophic lateral sclerosis, and vascular dementia. During the period 2007 to 2017, Alzheimer's disease showed the highest growth (46.7%) among global neurological disorders, reaching 2.51 million deaths in 2017 (Roth GA et al., Lancet 2018; 392: 1736 - 88). In the same study, Parkinson's disease also showed a 38.3% increase, resulting in 340,600 deaths globally in 2017. The prevalence of amyotrophic lateral sclerosis per 100,000 population is 5.40 in Europe, 3.40 in the United States, and 2.34 in Asia (Marin B et al., Int J Epidemiol 2017; 46: 57 - 74). Huntington's disease is an inherited neurological disorder and is considered a rare disease, with a prevalence per 100,000 population ranging from 0.4 in Asia to 7.3 in North America (Rawlins MD. NeuroPaditiomicology. 2016; 46: 144 - 53). Vascular dementia is dementia caused by problems with blood supply to the brain, usually a series of mild strokes, leading to a progressive decline in cognition. The term refers to a syndrome composed of the complex interaction of cerebrovascular diseases and risk factors that cause changes in brain structure due to stroke and lesions, and lead to changes in cognition. In the elderly, vascular dementia is the second most common form of dementia after Alzheimer's disease (AD) (Battistin L, (December 2010), Neurochemical Research 35, (12):

[0007] 1933 - 8; "Vascular Dementia: A Resource List"). The prevalence of the disease is 1.5% in Western countries and approximately 2.2% in Japan. Vascular dementia accounts for 50% of all dementia in Japan, 20% - 40% of all dementia in Europe, and 15% of all dementia in Latin America. 25% of stroke patients develop new - onset dementia within one year of their stroke. One study found that in the United States, the prevalence of vascular dementia among all people over 71 years old is 2.43%, and another study found that the prevalence of dementia doubles every 5.1 years (Plassman BL, (2007), Neuroepithaliology.29(1 - 2); Jorm AF (November 1987), Acta Psychiatca Scandinavica.76(5):465 - 79). Currently, there are no drugs specifically approved for the prevention or treatment of vascular dementia. The currently approved treatments for Alzheimer's disease provide only modest benefits (Atri A. Med Clin North Am. 2019; 103:263 - 293). Many pharmacological treatments are available for controlling the motor and non - motor symptoms of Parkinson's disease, but they are essentially symptomatic treatments and will ultimately induce dyskinesia, and none of them provide neuroprotection (Chaudhuri KR et al., Parkinsonism Relat Disord. 2016; 33(Suppl 1):S2 - S8). Currently, there are only two approved drugs (riluzole and edaravone) that slow (although minimally) the progression of amyotrophic lateral sclerosis, and there are no approved drugs for the treatment of Huntington's disease.

[0008] Accordingly, there is a clear need for additional and better treatments that provide neuroprotection, particularly in the context of treating stroke, cerebral reperfusion injury, and certain neurodegenerative diseases. SUMMARY OF THE INVENTION

[0009] The present invention provides a combination that is neuroprotective and suitable for preventing or treating cerebral reperfusion injury, stroke, and other conditions / diseases that require neuroprotection. Advantageously, compared to treatment methods using single - active - ingredient drug formulations, the presently claimed combination and other aspects of the present invention provide a more effective treatment method and superior clinical outcomes.

[0010] A first aspect relates to a combination comprising:

[0011] (a) a sulfonylurea; and

[0012] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0013] The second aspect relates to a combination, comprising:

[0014] (a) Glibenclamide or a structural or functional analogue thereof; and

[0015] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenone potassium or a structural or functional analogue thereof.

[0016] The third aspect relates to a pharmaceutical composition, comprising:

[0017] (a) a sulfonylurea; and

[0018] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist; and

[0019] a pharmaceutically acceptable carrier, diluent or excipient.

[0020] The fourth aspect relates to a pharmaceutical composition, comprising:

[0021] (a) Glibenclamide or a structural or functional analogue thereof; and

[0022] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenone potassium or a structural or functional analogue thereof; and

[0023] a pharmaceutically acceptable carrier, diluent or excipient.

[0024] The fifth aspect relates to a pharmaceutical product, comprising:

[0025] (a) a sulfonylurea; and

[0026] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0027] The sixth aspect relates to a pharmaceutical product, comprising:

[0028] (a) Glibenclamide or a structural or functional analogue thereof; and

[0029] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenone potassium or a structural or functional analogue thereof.

[0030] The seventh aspect relates to the following uses of the combination or pharmaceutical composition or pharmaceutical product as defined above: for treating and / or preventing one or more of ischemia and / or reperfusion injury, stroke, neurodegenerative diseases, neonatal asphyxia, cardiac arrest, cardiogenic shock, and acute myocardial infarction, or for providing cardioprotection against cardiotoxic drugs, or for providing neuroprotection against, for example, neurotoxic drugs.

[0031] The eighth aspect relates to the following uses of the pharmaceutical product as defined above: for treating and / or preventing one or more of ischemia and / or reperfusion injury, stroke, neurodegenerative diseases, neonatal asphyxia, cardiac arrest, cardiogenic shock, and acute myocardial infarction, or for providing cardioprotection against cardiotoxic drugs, or for providing neuroprotection against, for example, neurotoxic drugs, wherein the components are for simultaneous, sequential, or separate administration.

[0032] The ninth aspect relates to a method for treating and / or preventing one or more of ischemia and / or reperfusion injury, stroke, neurodegenerative diseases, neonatal asphyxia, cardiac arrest, cardiogenic shock, and acute myocardial infarction, or for providing cardioprotection against cardiotoxic drugs, or for providing neuroprotection against, for example, neurotoxic drugs, the method comprising simultaneously, sequentially, or separately administering to a subject in need thereof:

[0033] (a) a sulfonylurea; and

[0034] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0035] The tenth aspect relates to a method for treating and / or preventing one or more of ischemia and / or reperfusion injury, stroke, neurodegenerative diseases, neonatal asphyxia, cardiac arrest, cardiogenic shock, and acute myocardial infarction, or for providing cardioprotection against cardiotoxic drugs, or for providing neuroprotection against, for example, neurotoxic drugs, the method comprising simultaneously, sequentially, or separately administering to a subject in need thereof:

[0036] (a) glibenclamide or a structural or functional analogue thereof; and

[0037] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) potassium canrenoate or a structural or functional analogue thereof.

[0038] The eleventh aspect relates to the use of the following substances in the manufacture of a medicament for treating and / or preventing one or more of ischemia and / or reperfusion injury, stroke, neurodegenerative diseases, neonatal asphyxia, cardiac arrest, cardiogenic shock and acute myocardial infarction, or for providing cardioprotection against cardiotoxic drugs, or for providing neuroprotection against, for example, neurotoxic drugs:

[0039] (a) Sulfonylurea; and

[0040] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0041] The twelfth aspect relates to the use of the following substances in the manufacture of a medicament for treating and / or preventing one or more of ischemia and / or reperfusion injury, stroke, neurodegenerative diseases, neonatal asphyxia, cardiac arrest, cardiogenic shock and acute myocardial infarction, or for providing cardioprotection against cardiotoxic drugs, or for providing neuroprotection against, for example, neurotoxic drugs:

[0042] (a) Glibenclamide or a structural or functional analogue thereof; and

[0043] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenoate potassium or a structural or functional analogue thereof.

[0044] The thirteenth aspect relates to the use of a combination for treating and / or preventing ischemia and / or reperfusion injury of an ex vivo organ before or during transplantation, the combination comprising:

[0045] (a) Sulfonylurea; and

[0046] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0047] The fourteenth aspect relates to the use of a combination for treating and / or preventing ischemia and / or reperfusion injury of an ex vivo organ before or during transplantation, the combination comprising:

[0048] (a) Glibenclamide or a structural or functional analogue thereof; and

[0049] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenoate potassium or a structural or functional analogue thereof. Detailed Description

[0050] The preferred embodiments listed below apply to any one of the above aspects of the present invention, as appropriate.

[0051] As used herein, a structural analogue, also known as a chemical analogue, is a compound that has a structure similar to another compound but differs from that other compound in certain components. It can differ in one or more atoms, functional groups or substructures, where the difference is the replacement of one or more atoms, groups or substructures by other atoms, groups or substructures. At least theoretically, it is conceivable to form structural analogues from other compounds. Structural analogues are usually isoelectronic.

[0052] As used herein, a functional analogue is a compound that has physical, chemical, biochemical or pharmacological properties similar to those of another compound. A functional analogue is not necessarily a structural analogue with a similar chemical structure.

[0053] Sulfonylurea

[0054] The combination of the present invention contains sulfonylurea as an essential component.

[0055] Sulfonylureas are a class of oral hypoglycemic agents that are mainly used to control type 2 diabetes and certain forms of monogenic diabetes. Sulfonylureas lower blood glucose levels by stimulating insulin secretion from pancreatic β-cells. The main target of sulfonylureas is the sulfonylurea receptor (SUR1) subunit of the ATP-sensitive potassium (K ATP ) channel in the β-cell plasma membrane (Proks P et al., Diabetes. 2002; 51 (Suppl 3): S368-76; Gribble FM and Reimann F. Diabetologia. 2003; 46: 875-891).

[0056] Sulfonylureas are customarily divided into two generations, in line with their time of introduction into clinical practice, with the main difference being their disposition, which allows for a lower frequency of administration of drugs belonging to the second generation (Sola D et al., Arch Med Sci. 2015; 11: 840-8):

[0057] · The first generation includes chlorpropamide, tolbutamide, acetohexamide, carbutamide, glibornuride, tolhexamide, metahexamide and tolazamide;

[0058] However, these are no longer used in clinical practice;

[0059] · The second generation includes glibenclamide, gliboruride, gliclazide, glipizide, glimepiride, gliquidone, glisoxepide and glipril. For some second-generation sulfonylureas (gliclazide, glipizide), there are modified / sustained-release formulations.

[0060] When metformin alone cannot achieve adequate control, current guidelines recommend the use of second-generation sulfonylureas as second-line therapy in combination with metformin, and second-generation sulfonylureas can also be used in triple combination therapy if glycemic control cannot be achieved with the combination of two drugs (Garber AJ et al., Endocr Pract. 2019;25:69-100; Inzucchi SE et al., Diabetes Care. 2015;38:140-9). The decision to use a sulfonylurea should take into account patient characteristics and potential adverse events associated with sulfonylureas (Cordiner RLM, Pearson ER. Diabetes Obes Metab. 2019;21:761–771).

[0061] In a particularly preferred embodiment, the sulfonylurea is a Sur-1 receptor antagonist. Suitable Sur-1 receptor antagonists can be confirmed using known assays.

[0062] In a particularly preferred embodiment, the sulfonylurea is a SUR1-TRPM4 channel antagonist. Suitable SUR1-TRPM4 channel antagonists can be confirmed using known assays.

[0063] The present invention also encompasses structural or functional analogs of sulfonylureas, particularly those modified to extend the half-life of the formulation, such as conjugates of sulfonylureas.

[0064] In a preferred embodiment, the sulfonylurea is selected from glibenclamide (glyburide), glibornuride, gliclazide, glipizide, glimepiride, gliquidone, glisoxepide, and glipril.

[0065] In a highly preferred embodiment, the sulfonylurea is selected from glibenclamide and its structural and functional analogs.

[0066] Preferably, the sulfonylurea is selected from acylhydrazone, sulfonamide, and sulfonylthiourea derivatives of glibenclamide, glimepiride, glipizide, and gliclazide.

[0067] In a preferred embodiment, the sulfonylurea is glimepiride, which has the structure shown below:

[0068]

[0069] In a preferred embodiment, the sulfonylurea is gliclazide, which has the structure shown below:

[0070]

[0071] In a preferred embodiment, the sulfonylurea is glipizide, which has the structure shown below:

[0072]

[0073] In a particularly preferred embodiment, the sulfonylurea is glibenclamide.

[0074] The systematic (IUPAC) name of glibenclamide is 5-chloro-N-[2-[4-(cyclohexylcarbamoylsulfamoyl)phenyl]ethyl]-2-methoxybenzamide (chemical formula C 23 H 28 ClN3O5S), and its molecular weight is 494; it has the following chemical structure:

[0075]

[0076] The present invention also encompasses structural and functional analogs of glibenclamide, particularly those that are modified to extend the half-life of the formulation, such as conjugates of glibenclamide.

[0077] Glibenclamide (also known as glyburide) is a sulfonylurea receptor-1 (Sur-1) receptor antagonist that is used as an antidiabetic agent to treat diabetes. Glibenclamide is being developed as a treatment for reducing edema after brain injury, such as ischemic stroke, traumatic brain injury, and subarachnoid hemorrhage, but the results to date have been inconsistent (Wilkinson CM et al., PLoS One. 2019;14:e0215952; Xu F et al., Brain Behav. 2019;9(4):e01254; King ZA et al.; Drug Des Devel Ther. 2018;12:2539-2552). The inventors investigated the role of glibenclamide as part of a combination therapy aimed at reducing reperfusion injury and potentially providing neuroprotection.

[0078] Glibenclamide is available as a generic product and is sold under many brand names in doses of 1.25 mg, 2.5 mg, and 5 mg, including Gliben-J, Daonil, Diabeta, Euglucon, Gilemal, Glidanil, Glybovin, Glynase, Maninil, Micronase, and Semi-Daonil. Glibenclamide is taken orally as a tablet formulation (for adults) or as an oral suspension (for children) for the treatment of type 2 diabetes. The defined daily dose (DDD) of glibenclamide for the treatment of type 2 diabetes is 7 mg for micronized formulations and 10 mg for conventional formulations, with the micronized formulations having a higher bioavailability. The defined daily dose (DDD) is the assumed average daily maintenance dose of a drug for its main indication in adults as defined by the WHO Collaborating Centre for Drug Statistics Methodology. The DDD is a unit of measurement and does not necessarily reflect the recommended or prescribed daily dose. The treatment dose for individual patients and patient groups is usually different from the DDD because the treatment dose will be based on individual characteristics (such as age, weight, ethnic differences, type and severity of the disease) and pharmacokinetic considerations. The DDD value of glibenclamide was obtained from the WHO Collaborating Centre for Drug Statistics Methodology (see https: / / www.whocc.no / atc_ddd_index / ?code=A10BB01&showdescription=yes). The usual starting dose of glibenclamide (micronized formulation) in initial treatment is 2.5 mg to 5 mg per day, and the usual maintenance dose ranges from 1.25 mg to 20 mg per day, which can be given as a single dose or in divided doses, administered with breakfast or the first main meal (according to the FDA label for glyburide tablets). For a 70 kg adult, this corresponds to a maintenance dose of approximately 18 μg / kg to approximately 285 μg / kg.

[0079] Several studies in animal models have shown the protective effects of glibenclamide in inflammation-related injuries, including reducing adverse neuroinflammation and improving behavioral outcomes after central nervous system injury (Zhang G et al., Mediators Inflamm. 2017; 2017: 3578702) or ischemic and hemorrhagic stroke (Caffes N et al., Int J Mol Sci. 2015; 16: 4973-84). In a traumatic brain injury model in rats, glibenclamide was administered intraperitoneally at a loading dose of 10 μg / kg, followed by an infusion of 200 ng / hr for 7 days (Patel AD et al., J Neuropathol Exp Neurol. 2010; 69: 1177-90), while in a mouse model of traumatic brain injury, the dose of glibenclamide administered for three days after controlled cortical impact injury was 10 μg (Xu ZM et al., J Neurotrauma. 2017; 34: 925-933). In a rodent model of cerebral ischemia and reperfusion injury, it was shown that administration of a dose of 1 mg / kg of glibenclamide 10 minutes before reperfusion was effective (Abdallah DM et al., Brain Res. 2011; 1385: 257-62). In a rodent model of subarachnoid hemorrhage, glibenclamide was shown to be effective when administered intraperitoneally at a loading dose of 10 μg / kg, followed by an infusion of 200 ng / hr for 24 hours (Simard, J.M et al., Journal of Cerebral Blood Flow and Metabolism. 2009; 29; 317-330) or for one week (Tosun C et al., Stroke. 2013; 44: 3522-8). In a thromboembolic model of stroke in rats, glibenclamide administered as a continuous infusion (75 ng / h) 7 days after middle cerebral artery occlusion reduced brain edema, infarct volume, and mortality by 50%, with the reduction in infarct volume being associated with cortical preservation (Simard JM et al., Nat Med. 2006; 12: 433-40).Administration of glibenclamide at a dose of 10 μg either before or 2 hours after experimental intracerebral hemorrhage in mice was shown to reduce cerebral edema, disrupted blood-brain barrier (BBB), and neurological deficits (Xu F et al., Brain Behav. 2019;9:e01254), and similar findings were obtained in another study (Jiang B et al., Transl Stroke Res. 2017;8:183 - 193). However, when intracerebral hemorrhage was produced by stereotactic injection of collagenase, the widely used and effective dose of glibenclamide in other studies (10 μg / kg loading dose, then up to 200 ng / h for up to 7 days) was shown to be ineffective (Wilkinson CM et al., PLoS One. 2019;14(5):e0215952).

[0080] In some clinical trials, glibenclamide has also been shown to have beneficial effects on stroke patients. For patients with large hemispheric infarcts, in the Glibenclamide in Acute Malignant Edema and Stroke (GAMES) clinical trial, intravenous administration of glibenclamide (RP - 1127) was performed by an intravenous bolus injection of 0.13 mg within the first 2 minutes, then at an infusion rate of 0.16 mg / h for the first 6 hours, and then at an infusion rate of 0.11 mg / h for the remaining 66 hours, and promising findings regarding brain swelling (midline shift), MMP - 9, functional outcome, and mortality were revealed (King ZA et al., Drug Des Devel Ther. 2018;12:2539 - 2552). In an exploratory study of oral administration of glibenclamide to patients with acute hemispheric infarcts, the treatment was shown to be safe, but the treatment did not substantially improve the 6 - month functional outcome, although it was associated with less severe cerebral edema and a slight trend towards less severe disability, and death was observed (Huang K et al., Acta Neurol Scand. May 29, 2019). A retrospective analysis of data from diabetic patients with acute ischemic stroke who did not use sulfonylureas during the following days compared with those who did use sulfonylureas found a strong association between sulfonylurea treatment and improved survival, better functional independence, lower NIH Stroke Scale scores, and less hemorrhagic transformation (Kunte H et al., Ann Neurol. 2012;72:799 - 806).

[0081] The above preclinical and clinical findings may be related to upregulation of the UR1 - TRPM4 channel after brain injury such as ischemia (Woo SK et al., J Biol Chem. 2013;288:3655 - 67; Mehta RI et al., J Neuropathol Exp Neurol. 2015;74:835 - 49).

[0082] Neuroprotective effects of other sulfonylureas, such as the neuroprotective effect of gliclazide in animal models of ischemia and reperfusion injury (Tan F et al., Brain Res. 2014; 1560: 83-90), and protective effects in animal models of ischemia and reperfusion injury in other tissues, such as the protective effect of glimepiride on the myocardium (Nishida H et al., J Pharmacol Sci. 2009; 109: 251-6) have also been reported.

[0083] Some other drugs have insulin secretagogue effects similar to sulfonylureas; examples include meglitinides (e.g., repaglinide, nateglinide, and mitiglinide). In addition, other compounds, such as resveratrol, have been shown to bind to sulfonylurea receptors (Hambrock A et al., J Biol Chem. 2007; 282: 3347-56) and have neuroprotective effects in stroke and traumatic CNS injury (Lopez MS et al., Neurochem Int. 2015; 89: 75-82).

[0084] Studies by the applicant and described in more detail in the appended examples have shown that the administration of a sulfonylurea (e.g. glibenclamide) in combination with a second active substance, which is an aldosterone antagonist (e.g. potassium canrenoate) or an insulin regulator (e.g. exenatide), produces a neuroprotective effect even when the sulfonylurea is administered only in very low doses.

[0085] Insulin regulators

[0086] In one embodiment, the combination of the invention comprises, in addition to the sulfonylurea component described above, an insulin modulator.

[0087] As used herein, the term "insulin modulator" refers to an agent that can directly or indirectly increase or decrease insulin activity, which in turn can increase or decrease insulin-mediated physiological responses.

[0088] In one embodiment, the insulin modulator is selected from the group consisting of a GLP-1 agonist, a DPP-4 inhibitor, a PPAR agonist, insulin, and analogs thereof.

[0089] Examples of GLP-1 agonists include exenatide, lixisenatide, albiglutide, liraglutide, tasiroglutide and dulaglutide (LY2189265), and pharmaceutically acceptable salts thereof.

[0090] Examples of DPP-4 inhibitors include sitagliptin, vildagliptin, saxagliptin, linagliptin, alagliliptin, teneligliptin, alogliptin, trelagliptin, gemagliptin, dutogliptin and omagliliptin (MK-3102) and pharmaceutically acceptable salts thereof.

[0091] Examples of PPAR agonists include clofibrate, gemfibrozil, ciprofibrate, bezafibrate, fenofibrate, saroglitazar, aleglitazar, moglitazone, and tesaglitazar, as well as their pharmaceutically acceptable salts.

[0092] Examples of insulin analogs include insulin lispro, insulin aspart, insulin glulisine, insulin detemir, insulin degludec, insulin glargine, and their pharmaceutically acceptable salts.

[0093] Thus, in one embodiment, the insulin modulator is selected from exenatide, lixisenatide, albiglutide, liraglutide, taspoglutide, dulaglutide (LY2189265), sitagliptin, vildagliptin, saxagliptin, linagliptin, alogliptin, teneligliptin, anagliptin, treagliptin, gilteritinib, dutogliptin, oreglitin (MK-3102), clofibrate, gemfibrozil, ciprofibrate, bezafibrate, fenofibrate, saroglitazar, aleglitazar, moglitazone, tesaglitazar, insulin lispro, insulin aspart, insulin glulisine, insulin detemir, insulin degludec, insulin glargine, and their pharmaceutically acceptable salts.

[0094] In one embodiment, the insulin modulator is a GLP-1 agonist selected from exenatide, lixisenatide, albiglutide, liraglutide, taspoglutide, dulaglutide (LY2189265), and their pharmaceutically acceptable salts. The GLP-1 agonist is preferably exenatide.

[0095] Exenatide

[0096] In a preferred embodiment, the insulin modulator is selected from exenatide and its structural and functional analogs and their pharmaceutically acceptable salts.

[0097] In a preferred embodiment, exenatide is in the form of a pharmaceutically acceptable salt, more preferably in the form of exenatide acetate. In another preferred embodiment, exenatide is in free base form.

[0098] As used herein, the term "exenatide" refers to a 39-amino acid peptide having the following sequence:

[0099] H-His-Gly-Glu-Gly-Thr-Phe-Thr-Ser-Asp-Leu-Ser-Lys-Gln-Met-Glu-Glu-Glu-Ala-Val-Arg-Leu-Phe-Ile-Glu-Trp-Leu-Lys-Asn-Gly-Gly-Pro-Ser-Ser-Gly-Ala-Pro-Pro-Pro-Ser-NH2

[0100] Exenatide (synonym: exendin-4) was initially isolated from the saliva of the Gila monster (Heloderma suspectum) by Eng in 1992. It is an insulin secretagogue with glucose-regulating effects similar to those of human glucagon-like peptide-1 (GLP-1).

[0101] Exenatide mimics human glucagon-like peptide 1 (GLP-1), an intestinal incretin hormone that is released in response to nutrient ingestion (Goke et al., J. Biol. Chem., 1993, 268: 19650-19655). It exerts insulinotropic and insulin-mimetic properties through the GLP-1 receptor. The GLP-1 receptor is widely expressed in many organs, including the heart and vascular endothelium (Bullock et al., Endocrinology, 1996, 137: 2968-2978; Nystrom et al., Am J Physiol Endocrinol Metab, 2004, 287: E1209-E1215). Currently, exenatide has been approved as an anti-diabetic drug for the treatment of patients with type 2 diabetes. The recommended dose for this indication is an initial dose of 5 μg (micrograms) twice daily, which is increased to 10 μg twice daily after 1 month based on the clinical response.

[0102] GLP-1 is ineffective as a therapeutic agent because it has a very short circulating half-life (less than 2 minutes) due to rapid degradation by dipeptidyl peptidase-4. Exenatide has 50% homology with GLP-1 but has a half-life of 2.4 hours in humans because it lacks a dipeptidyl peptidase-4 cleavage site.

[0103] Exenatide enhances glucose-dependent insulin secretion by pancreatic β-cells, thereby inhibiting inappropriately elevated glucagon secretion and slowing gastric emptying. Exenatide is very effective, with a minimum effective concentration in humans of 50 pg / mL (12 pM). Current treatment methods using exenatide involve twice-daily injections In addition, extended-release formulations have been approved for once-weekly injections.

[0104] As used herein, a functional analogue of exenatide refers to a compound that has a similar structure but differs from it in certain aspects (e.g., the functional analogue may differ in one or more atoms, functional groups, amino acid residues, or substructures, which are replaced by other moieties). Functional analogues exhibit similar pharmacological properties and may be structurally related.

[0105] In one embodiment, a structural or functional analogue of exenatide is a structural or functional analogue of exenatide modified to extend its half-life, such as a conjugate of exenatide.

[0106] In a preferred embodiment, the structural or functional analogue of exenatide is PEGylated exenatide. For example, in a preferred embodiment, the structural or functional analogue is monomethoxypolyethylene glycol (mPEG)-exenatide with a 40 kDa PEG. PEGylated exenatide can be prepared by methods known in the art. For example, the PEGylated forms of exenatide are described in WO2013 / 059323 (Prolynx LLC), the content of which is incorporated herein by reference. Exenatide can also be conjugated to other molecules, such as proteins.

[0107] In a particularly preferred embodiment, the structural or functional analogue of exenatide is a sustained-release form, such as the sustained-release form sold under the trade name In another preferred embodiment, the structural or functional analogue of exenatide is in the form of multilayer nanoparticles for sustained delivery, such as the form described in Kim JY et al., Biomaterials, 2013; 34:8444-9, the content of which is incorporated herein by reference.

[0108] In another particularly preferred embodiment, exenatide is in an injectable form, such as the injectable form sold under the trade name Functional analogues of exenatide include GLP receptor agonists. Suitable functional analogues of exenatide include lixisenatide, albiglutide, liraglutide, taspoglutide, and dulaglutide (LY2189265).

[0109] In one embodiment, functional analogues of exenatide include modified exenatide in which one or more amino acid residues are replaced with another amino acid residue and / or in which one or more amino acid residues are deleted and / or in which one or more amino acid residues are added and / or inserted.

[0110] In one embodiment, relative to exenatide, a functional exenatide analogue comprises fewer than 10 amino acid modifications (substitutions, deletions, additions (including insertions), and any combination thereof), or relative to exenatide, comprises fewer than 9, 8, 7, 6, 5, 4, 3, or 2 modifications.

[0111]

[0112] ​In one embodiment, the functional exenatide analogs include 10 amino acid modifications (substitutions, deletions, additions (including insertions), and any combination thereof) relative to exenatide, or relative to exenatide, contain 9, 8, 7, 6, 5, 4, 3, or 2 modifications.

[0113] As used herein, structural or functional analogs of exenatide also include its salts, isomers, enantiomers, solvates, polymorphs, prodrugs, and metabolites.

[0114] Aldosterone antagonist

[0115] In one embodiment, in addition to the sulfonylurea component described above, the combination of the present invention further comprises an aldosterone antagonist.

[0116] Acute myocardial infarction and its subsequent hemodynamic changes result in complex neurohormonal activation. The renin-angiotensin-aldosterone pathway is the basis for this neurohormonal activation. It has been reported that aldosterone, which presents at the highest levels after acute myocardial infarction, promotes a broad spectrum of harmful cardiovascular effects, including acute endothelial dysfunction, inhibition of NO activity, increased endothelial oxidative stress, increased vascular tone, inhibition of tissue norepinephrine reuptake, rapid occurrence of vascular smooth muscle cell and cardiomyocyte necrosis, collagen deposition in blood vessels, myocardial hypertrophy, and fibrosis (Struthers, Am Heart J, 2002, 144: S2-S7; Zannad and Radauceanu, Heart Fail Rev, 2005, 10: 71-78). In addition, it has been found to predict its adverse consequences (Beygui et al., Circulation, 2006, 114: 2604-2610).

[0117] Aldosterone antagonists or mineralocorticoid antagonists are diuretics that antagonize the action of aldosterone on the mineralocorticoid receptor. This group of drugs is often used to treat chronic heart failure. Such members are also used to treat hyperaldosteronism (including Conn syndrome) and hirsutism in women (due to additional antiandrogenic effects). Most mineralocorticoid antagonists are the steroidal spironolactone.

[0118] Antagonism of the mineralocorticoid receptor inhibits sodium reabsorption in the collecting ducts of the nephrons in the kidney. This interferes with sodium / potassium exchange, thereby reducing urinary potassium excretion and slightly increasing water excretion (diuresis). In congestive heart failure, aldosterone antagonists are used, among other drugs, for additional diuretic effects, thereby reducing edema and cardiac load.

[0119] Based on the results of the EPHESUS trial, current guidelines recommend the use of mineralocorticoid receptor antagonists in patients who develop heart failure after myocardial infarction.

[0120] Several studies in animal models and clinical settings of acute myocardial infarction have demonstrated the benefits of aldosterone blockade in preventing reperfusion injury and improving cardiac function in STEMI patients. There are indications in the literature that mineralocorticoid receptor antagonists may have beneficial effects in the cerebrovascular system and during stroke (Dinh QN et al., Neural Regen Res. 2016;11:1230-1).

[0121] Examples of aldosterone antagonists include spironolactone (the first and most widely used member of this class), eplerenone (more selective for the target than spironolactone, but less potent and effective), canrenone and potassium canrenoate, finerenone (non-steroidal and with better efficacy and selectivity than eplerenone or spironolactone), and prorenone. Some drugs have secondary anti-mineralocorticoid effects in addition to their main mechanism of action. Examples include progesterone, drospirenone, gestodene, and benidipine.

[0122] In a particularly preferred embodiment, the aldosterone antagonist is potassium canrenoate.

[0123] The present invention also includes structural and functional analogs of aldosterone antagonists, particularly those modified to extend the half-life of the agent, such as conjugates of aldosterone antagonists.

[0124] Potassium canrenoate

[0125] Potassium canrenoate or potassium etiocholanolone-17-carboxylate, also known as the potassium salt of canrenic acid, is an aldosterone antagonist of the spironolactone group. Like spironolactone, it is a prodrug and is metabolized in the body to canrenone. Potassium canrenoate is usually administered intravenously at a dose of 200 mg / day to 600 mg / day for the treatment of hyperaldosteronism or hypokalemia.

[0126] The systematic (IUPAC) name of potassium canrenoate is potassium 3-[(8R,9S,10R,13S,14S,17R)-17-hydroxy-10,13-dimethyl-3-oxo-2,8,9,11,12,14,15,16-octahydro-1H-cyclopenta[a]phenanthren-17-yl]propionate, with the molecular formula C 22 H 29 KO4 and the chemical structure is as follows:

[0127]

[0128] Combination

[0129] In one aspect, the present invention relates to a combination comprising:

[0130] (a) A sulfonylurea; and

[0131] (b) At least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0132] The preferred embodiments described below apply, mutatis mutandis, to other aspects of the present invention, including methods, uses, products and compositions.

[0133] In a preferred embodiment, the combination comprises a sulfonylurea and an insulin modulator.

[0134] In a preferred embodiment, the combination consists of a sulfonylurea and an insulin modulator.

[0135] In another preferred embodiment, the combination comprises a sulfonylurea and an aldosterone antagonist.

[0136] In another preferred embodiment, the combination consists of a sulfonylurea and an aldosterone antagonist.

[0137] In another preferred embodiment, the combination comprises a sulfonylurea, an insulin modulator and an aldosterone antagonist.

[0138] In another preferred embodiment, the combination consists of a sulfonylurea, an insulin modulator and an aldosterone antagonist.

[0139] In one embodiment, the insulin modulator is defined according to any of the above embodiments of the insulin modulator.

[0140] In one embodiment, the aldosterone antagonist is defined according to any of the above embodiments of the aldosterone antagonist.

[0141] In one embodiment, the sulfonylurea is defined according to any of the above embodiments of the sulfonylurea.

[0142] In a preferred embodiment, the present invention relates to a combination comprising:

[0143] (a) Glibenclamide or a structural or functional analogue thereof; and

[0144] (b) At least one of the following components: (i) Exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) Canrenoate potassium or a structural or functional analogue thereof. Preferably, the combination comprises (b)(i) and (b)(ii).

[0145] In a preferred embodiment, the present invention relates to a combination comprising:

[0146] (a) at least one of glibenclamide, glibornuride, gliclazide, glipizide, glimepiride, gliquidone, glibutide, glyclopyramide, chlorpropamide, tolbutamide, acetohexamide, carbutamide, glisolamide, tolcyclamide, methexamide, and tolazamide; and

[0147] (b) at least one of the following components:

[0148] (i) at least one of exenatide, lixisenatide, albiglutide, liraglutide, taspoglutide, and dulaglutide (LY2189265) or a pharmaceutically acceptable salt thereof, and

[0149] (ii) at least one of potassium canrenoate, canrenone, spironolactone, eplerenone, finerenone, and prorenone or a pharmaceutically acceptable salt thereof (e.g., a pharmaceutically acceptable salt of canrenone, spironolactone, eplerenone, finerenone, and prorenone), as appropriate.

[0150] In one embodiment, the present invention relates to a combination comprising:

[0151] at least one of glibenclamide, glibornuride, gliclazide, glipizide, glimepiride, gliquidone, glibutide, glyclopyramide, chlorpropamide, tolbutamide, acetohexamide, carbutamide, glisolamide, tolcyclamide, methexamide, and tolazamide; and

[0152] at least one of exenatide, lixisenatide, albiglutide, liraglutide, taspoglutide, and dulaglutide (LY2189265) or a pharmaceutically acceptable salt thereof, and

[0153] at least one of potassium canrenoate, canrenone, spironolactone, eplerenone, finerenone, and prorenone or a pharmaceutically acceptable salt thereof, as appropriate.

[0154] In one embodiment, the present invention relates to a combination comprising:

[0155] at least one of glibenclamide, glibornuride, gliclazide, glipizide, glimepiride, gliquidone, glibutide, glyclopyramide, chlorpropamide, tolbutamide, acetohexamide, carbutamide, glisolamide, tolcyclamide, methexamide, and tolazamide; and

[0156] at least one of exenatide, lixisenatide, albiglutide, liraglutide, taspoglutide, and dulaglutide (LY2189265) or a pharmaceutically acceptable salt thereof.

[0157] In another embodiment, the present invention relates to a combination comprising:

[0158] at least one of glibenclamide, glibornuride, gliclazide, glipizide, glimepiride, gliquidone, glisoxepide, glyclopyramide, chlorpropamide, tolbutamide, acetohexamide, carbutamide, glicyclamide, tolcyclamide, methexamide, and tolazamide; and

[0159] at least one of potassium canrenoate, canrenone, spironolactone, eplerenone, finerenone, and prorenone, or a pharmaceutically acceptable salt thereof, as appropriate.

[0160] In one embodiment, the present invention relates to a combination as follows or a combination comprising:

[0161] exenatide or a pharmaceutically acceptable salt thereof, and

[0162] at least one of glibenclamide, glibornuride, gliclazide, glipizide, glimepiride, gliquidone, glisoxepide, glyclopyramide, chlorpropamide, tolbutamide, acetohexamide, carbutamide, glicyclamide, tolcyclamide, methexamide, and tolazamide.

[0163] In one embodiment, the present invention relates to a combination as follows or a combination comprising:

[0164] exenatide or a pharmaceutically acceptable salt thereof, and

[0165] at least one of glibenclamide, glibornuride, gliclazide, glipizide, glimepiride, gliquidone, glisoxepide, glyclopyramide, and glyclopyramide.

[0166] In one embodiment, the present invention relates to a combination as follows or a combination comprising:

[0167] exenatide or a pharmaceutically acceptable salt thereof, and

[0168] glibenclamide.

[0169] In one embodiment, the present invention relates to a combination as follows or a combination comprising:

[0170] at least one of exenatide, lixisenatide, albiglutide, liraglutide, taspoglutide, and dulaglutide (LY2189265), or a pharmaceutically acceptable salt thereof, and

[0171] glibenclamide.

[0172] In one embodiment, the present invention relates to a combination as follows or a combination comprising:

[0173] potassium canrenoate, and

[0174] At least one of glibenclamide, glibornuride, gliclazide, glipizide, glimepiride, gliquidone, glibexamide, glisoxepide, chlorpropamide, tolbutamide, acetohexamide, carbutamide, glisolamide, tolcyclamide, methexamide, and tolazamide.

[0175] In one embodiment, the present invention relates to a combination or a combination comprising:

[0176] Potassium canrenoate, and

[0177] At least one of glibenclamide, glibornuride, gliclazide, glipizide, glimepiride, gliquidone, glibexamide, and glisoxepide.

[0178] In one embodiment, the present invention relates to a combination or a combination comprising:

[0179] At least one of potassium canrenoate, canrenone, spironolactone, eplerenone, finerenone, and prorenone, or a pharmaceutically acceptable salt thereof, as appropriate, and

[0180] Glibenclamide.

[0181] In one embodiment, the present invention relates to a combination or a combination comprising:

[0182] Potassium canrenoate; and

[0183] Glibenclamide.

[0184] In one embodiment, the present invention relates to a combination comprising:

[0185] Glibenclamide; and

[0186] At least one of exenatide, lixisenatide, albiglutide, liraglutide, taspoglutide, and dulaglutide (LY2189265), or a pharmaceutically acceptable salt thereof, and

[0187] At least one of potassium canrenoate, canrenone, spironolactone, eplerenone, finerenone, and prorenone, or a pharmaceutically acceptable salt thereof, as appropriate.

[0188] In one embodiment, the present invention relates to a combination comprising:

[0189] At least one of glibenclamide, glibornuride, gliclazide, glipizide, glimepiride, gliquidone, glibexamide, glisoxepide, chlorpropamide, tolbutamide, acetohexamide, carbutamide, glisolamide, tolcyclamide, methexamide, and tolazamide; and

[0190] Exenatide or a pharmaceutically acceptable salt thereof, and

[0191] Potassium canrenoate, canrenone, spironolactone, eplerenone, finerenone, and prorenone, or at least one of their pharmaceutically acceptable salts, as the case may be.

[0192] In one embodiment, the present invention relates to a combination comprising:

[0193] At least one of glibenclamide, glibornuride, gliclazide, glipizide, glimepiride, gliquidone, glyclopyramide, glisoxepide, chlorpropamide, tolbutamide, acetohexamide, carbutamide, cycloguanil pamoate, tolcyclamide, metahexamide, and tolazamide; and

[0194] At least one of exenatide, lixisenatide, albiglutide, liraglutide, taspoglutide, and dulaglutide (LY2189265), or their pharmaceutically acceptable salts, and

[0195] Potassium canrenoate or canrenone.

[0196] In one embodiment, the present invention relates to a combination as follows or a combination comprising the following substances:

[0197] Exenatide or its pharmaceutically acceptable salt

[0198] Potassium canrenoate; and

[0199] Glibenclamide.

[0200] In one aspect of the present invention, for each of the above embodiments, the combination consists of a sulfonylurea and an aldosterone antagonist and / or an insulin modulator, i.e., they are the only active agents. In another (alternative) aspect, the combination further comprises one or more additional active agents as described below.

[0201] The effects of drug combinations are inherently unpredictable, and there is often a tendency for one drug to partially or completely inhibit the effect of another drug. The present invention demonstrates that when a combination comprising the following substances is administered simultaneously, separately, or sequentially, no significant or substantial adverse interaction between the two agents will occur: a sulfonylurea such as glibenclamide or its structural or functional analog, and at least one of (i) an insulin modulator such as exenatide or its structural or functional analog or its pharmaceutically acceptable salt and (ii) an aldosterone antagonist such as potassium canrenoate or a structural or functional analog. The unexpected absence of any such antagonistic interaction is crucial for the clinical application of the combination.

[0202] Furthermore, the preferred combinations according to the present invention surprisingly exhibit an enhancement of the effects of the respective components, such that the optimal dose of the agents is lower than the recommended dose of these agents in the approved indications, and / or also lower than the doses reported in the literature for reperfusion injury.

[0203] In one embodiment, the combination of the active agents of the present invention produces an enhanced effect as compared to the individual drugs administered alone.

[0204] By way of illustration, the Applicant's studies have shown that, in the case of the combination claimed in the present invention, the preferred dose of glibenclamide that produces a synergistic effect is significantly lower than the doses previously reported in the literature for reducing blood glucose (e.g., diabetes). In fact, the preferred dose of glibenclamide used in the combination claimed in the present invention is approximately 20 to 285 times lower than the recommended maintenance dose of glibenclamide (micronized formulation) for treating diabetes. For the glibenclamide micronized formulation, the recommended maintenance daily dose is 1.25 mg to 20 mg, which, for a 70 kg adult, corresponds to 18 μg / kg to 285 μg / kg, which is very different from the preferred dose of glibenclamide required in the combination therapy claimed in the present invention, where the preferred dose of glibenclamide required in the combination therapy claimed in the present invention can be as low as 1 μg / kg body weight. Advantageously, using glibenclamide at these preferred lower doses avoids any effect on blood glucose levels that could otherwise lead to adverse side effects. The Applicant's studies have also shown that the clinically effective dose of glibenclamide used as a dual or triple combination according to the present invention, together with low doses of exenatide and / or canrenoate potassium, is also significantly lower than the dose of glibenclamide that has shown neuroprotective properties in clinical studies published in the literature (continuous infusion at 0.16 mg / h or 0.11 mg / h, i.e., 3.84 mg or 2.64 mg per day) (see King ZA et al.).

[0205] Furthermore, in another embodiment, the combination of the active agents of the present invention (e.g.) produces a surprising synergistic effect in the treatment and / or prevention of reperfusion injury, particularly cerebral or myocardial reperfusion injury.

[0206] Combinations of two or more drugs can result in different types of drug interactions. A drug interaction is considered additive when the combined effect of two drugs is equal to the sum of the effects of the individual agents administered alone. If the combined effect of two drugs exceeds the total effect of the individual agents administered alone, the drug interaction is considered synergistic (Goodman and Gilmans' “The Pharmacological Basis of Therapeutics”, 12th Edition).

[0207] Combination therapy is an important treatment modality for many disease conditions, including cardiovascular diseases, cancers, and infectious diseases. Recent scientific advancements have deepened the understanding of the pathophysiological processes underlying these and other complex diseases. This enhanced understanding provides further impetus for the development of new treatment methods that use combinations of drugs targeting multiple therapeutic targets to improve treatment response, minimize the development of resistance, or minimize adverse events. There is increasing interest in the development of new combinations of two or more drugs where combination therapy offers significant therapeutic advantages.

[0208] Advantageously, a synergistic combination can allow the components to be present at lower doses, thereby reducing the toxicity of the treatment while producing and / or maintaining the same therapeutic effect or an enhanced therapeutic effect. Thus, in particularly preferred embodiments, the components of the combination are present in subtherapeutic amounts. The term "subtherapeutically effective amount" refers to an amount that is lower than the amount typically required to produce a therapeutic effect when each agent is used alone.

[0209] In one embodiment, the present invention relates to a synergistic combination comprising a sulfonylurea and an insulin modulator.

[0210] In another embodiment, the present invention relates to a synergistic combination comprising a sulfonylurea and an aldosterone antagonist.

[0211] In another embodiment, the present invention relates to a synergistic combination comprising a sulfonylurea, an insulin modulator, and an aldosterone antagonist.

[0212] In one embodiment, the insulin modulator is defined according to any of the above embodiments of the insulin modulator.

[0213] In one embodiment, the aldosterone antagonist is defined according to any of the above embodiments of the aldosterone antagonist.

[0214] In one embodiment, the sulfonylurea is defined according to any of the above embodiments of the sulfonylurea.

[0215] In one embodiment, the present invention relates to a synergistic combination comprising a sulfonylurea, and at least one of exenatide, lixisenatide, albiglutide, liraglutide, taspoglutide, and dulaglutide (LY2189265) or a pharmaceutically acceptable salt thereof.

[0216] In one embodiment, the present invention relates to a synergistic combination comprising a sulfonylurea, and at least one of potassium canrenoate, canrenone, spironolactone, eplerenone, finerenone, and prorenone or a pharmaceutically acceptable salt thereof, as appropriate.

[0217] In one embodiment, the present invention relates to a synergistic combination comprising:

[0218] At least one of glibenclamide, glibornuride, gliclazide, glipizide, glimepiride, gliquidone, glyclopyramide, and glipizamide; and

[0219] At least one of exenatide or a pharmaceutically acceptable salt thereof, and

[0220] Potassium canrenoate.

[0221] In one embodiment, the present invention relates to a synergistic combination comprising:

[0222] At least one of glibenclamide, glibornuride, gliclazide, glipizide, glimepiride, gliquidone, glyclopyramide, and glipizamide;

[0223] At least one of exenatide, lixisenatide, albiglutide, liraglutide, taspoglutide, and dulaglutide (LY2189265) or a pharmaceutically acceptable salt thereof; and

[0224] Potassium canrenoate.

[0225] In one embodiment, the present invention relates to a synergistic combination comprising:

[0226] At least one of exenatide, lixisenatide, albiglutide, liraglutide, taspoglutide, and dulaglutide (LY2189265) or a pharmaceutically acceptable salt thereof; and

[0227] Glibenclamide.

[0228] In one embodiment, the present invention relates to a synergistic combination comprising:

[0229] Exenatide or a pharmaceutically acceptable salt thereof; and

[0230] Glibenclamide.

[0231] In one embodiment, the present invention relates to a synergistic combination comprising:

[0232] Exenatide or a pharmaceutically acceptable salt thereof; and

[0233] At least one of glibenclamide, glibornuride, gliclazide, glipizide, glimepiride, gliquidone, glyclopyramide, and glipizamide.

[0234] In one embodiment, the present invention relates to a synergistic combination comprising:

[0235] At least one of potassium canrenoate, canrenone, spironolactone, eplerenone, finerenone, and prorenone or a pharmaceutically acceptable salt thereof; and

[0236] Glibenclamide.

[0237] In one embodiment, the present invention relates to a synergistic combination comprising:

[0238] Potassium canrenoate; and

[0239] At least one of glibenclamide, glibornuride, gliclazide, glipizide, glimepiride, gliquidone, glyclopyramide and glipril.

[0240] In one embodiment, the present invention relates to a synergistic combination comprising potassium canrenoate and glibenclamide.

[0241] In one embodiment, the present invention relates to a synergistic combination comprising exenatide or a pharmaceutically acceptable salt thereof, potassium canrenoate and glibenclamide.

[0242] Other active pharmaceutical ingredients

[0243] In one embodiment, the above combination comprises at least one other active pharmaceutical ingredient (API).

[0244] In one embodiment, the above combination may further comprise at least one other API selected from the following: β-blockers, renin-angiotensin inhibitors, statins (HMG-CoA reductase inhibitors), platelet activation or aggregation inhibitors, phosphodiesterase-3 inhibitors, calcium sensitizers, antioxidants and anti-inflammatory agents.

[0245] Examples of β-blockers include propranolol, metoprolol, bucindolol, carteolol, carvedilol, labetalol, nadolol, oxprenolol, penbutolol, pindolol, sotalol and timolol.

[0246] Renin-angiotensin inhibitors include angiotensin-converting enzyme inhibitors, angiotensin AT1 receptor inhibitors and renin inhibitors.

[0247] Examples of angiotensin-converting enzyme inhibitors include captopril, zofenopril, enalapril, ramipril, quinapril, perindopril, lisinopril, benazepril, imidapril, trandolapril, cilazapril and fosinopril.

[0248] Examples of angiotensin AT1 receptor antagonists include losartan, irbesartan, olmesartan, candesartan, valsartan, eprosartan and telmisartan.

[0249] Examples of renin inhibitors include remikiren and aliskiren.

[0250] Examples of calcium sensitizers include levosimendan and its analogs.

[0251] Examples of statins include atorvastatin, lovastatin, pravastatin, rosuvastatin and simvastatin.

[0252] Examples of platelet activation or aggregation inhibitors include prostacyclin (epoprostenol) and its structural and functional analogs (e.g., treprostinil, iloprost), irreversible cyclooxygenase inhibitors (e.g., aspirin, triflusal), adenosine diphosphate (ADP) receptor inhibitors (e.g., clopidogrel, prasugrel, ticagrelor, ticlopidine), phosphodiesterase inhibitors (e.g., cilostazol), protease-activated receptor-1 (PAR-1) antagonists (e.g., vorapaxar), glycoprotein IIb / IIIa inhibitors (e.g., abciximab, eptifibatide, tirofiban), adenosine reuptake inhibitors (e.g., dipyridamole), and thromboxane inhibitors, including thromboxane synthase inhibitors and thromboxane receptor antagonists (e.g., terutroban).

[0253] Examples of phosphodiesterase-3 (PDE-3) inhibitors include amrinone, milrinone, and their analogs.

[0254] Examples of antioxidants include ascorbic acid, lipoic acid, glutathione, melatonin, and resveratrol.

[0255] Examples of anti-inflammatory agents include COX-2 inhibitors (e.g., celecoxib), glucocorticoids (e.g., hydrocortisone), and non-steroidal anti-inflammatory drugs (e.g., ibuprofen).

[0256] In one embodiment, the above combination comprises at least one other API selected from the group consisting of propranolol, metoprolol, bucindolol, carteolol, carvedilol, labetalol, nadolol, oxprenolol, penbutolol, pindolol, sotalol, timolol, captopril, zofenopril, enalapril, ramipril, quinapril, perindopril, lisinopril, benazepril, imidapril, trandolapril, cilazapril, fosinopril, losartan, irbesartan, olmesartan, candesartan, valsartan, eprosartan, telmisartan, remikiren, aliskiren, melatonin, and resveratrol.

[0257] In another embodiment, the above combination comprises at least one other API selected from the group consisting of carvedilol, metoprolol, losartan, irbesartan, olmesartan, candesartan, valsartan, eprosartan, telmisartan, captopril, zofenopril, enalapril, ramipril, quinapril, perindopril, lisinopril, benazepril, imidapril, trandolapril, cilazapril, fosinopril, remikiren, aliskiren, melatonin, and resveratrol.

[0258] In another embodiment, the above combination comprises at least one other API selected from carvedilol, metoprolol, melatonin, and resveratrol.

[0259] Pharmaceutically acceptable salts

[0260] The active pharmaceutical formulations of the present invention may exist in the form of pharmaceutically acceptable salts.

[0261] Pharmaceutically acceptable salts of the agents of the present invention include their suitable acid addition salts or base salts. A review of suitable pharmaceutical salts can be found in Berge et al., J Pharm Sci, 66, 1-19 (1977). The salts are formed with (for example) the following acids: strong inorganic acids, such as mineral acids, for example sulfuric acid, phosphoric acid or hydrohalic acids (for example HCl, HBr); strong organic carboxylic acids, such as unsubstituted or substituted (for example, halogen-substituted) alkanoic acids having 1 to 4 carbon atoms, such as acetic acid; saturated or unsaturated dicarboxylic acids, for example oxalic acid, malonic acid, succinic acid, maleic acid, fumaric acid, phthalic acid or pyromellitic acid; hydroxycarboxylic acids, for example ascorbic acid, glycolic acid, lactic acid, malic acid, tartaric acid or citric acid; amino acids, for example aspartic acid or glutamic acid; benzoic acid; or organic sulfonic acids, such as unsubstituted or substituted (for example, halogen-substituted) (C1-C4)-alkylsulfonic acids or arylsulfonic acids, such as methanesulfonic acid or p-toluenesulfonic acid.

[0262] Enantiomers / Tautomers

[0263] The present invention also suitably includes all enantiomers and tautomers of the active pharmaceutical formulations. Those skilled in the art will recognize compounds having optical properties (one or more chiral carbon atoms) or tautomeric properties. The corresponding enantiomers and / or tautomers can be separated / prepared by methods known in the art.

[0264] Stereoisomers and geometric isomers

[0265] Some of the active agent pharmaceutical formulations of the present invention may exist in the form of stereoisomers and / or geometric isomers, which may have one or more asymmetric centers and / or geometric centers and thus can exist in two or more stereoisomeric and / or geometric isomeric forms. The present invention encompasses the use of all individual stereoisomers and geometric isomers of those inhibitors, as well as mixtures thereof. The terms used in the claims include these forms, provided that the forms retain suitable functional activity (although not necessarily to the same extent).

[0266] The present invention also includes all suitable isotopic variants of the active pharmaceutical formulation or its pharmaceutically acceptable salt. Isotopic variants of the formulations of the present invention or their pharmaceutically acceptable salts are defined as cases where at least one atom is replaced by an atom having the same atomic number but an atomic weight different from that usually found in nature. Examples of isotopes that can be introduced into the agent and its pharmaceutically acceptable salts include isotopes of hydrogen, carbon, nitrogen, oxygen, phosphorus, sulfur, fluorine and chlorine, for example they are respectively 2 H, 3 H, 13 C, 14 C,15 N, 17 O, 18 O, 31 P, 32 P, 35 S, 18 F and 36 Cl. Certain isotopic variants of the agent and its pharmaceutically acceptable salts are useful in drug and / or substrate tissue distribution studies, such as those incorporating radioactive isotopes (e.g., 3 H or 14 C) isotopic variants. For ease of preparation and detection, tritium (i.e., 3 H) and carbon-14 (i.e., 14 C) isotopes are particularly preferred. In addition, substitution with isotopes (e.g., deuterium, i.e., 2 H) can provide a degree of therapeutic advantage due to greater metabolic stability, such as an extended in vivo half-life or a reduced dosage requirement, and thus may be preferred in certain instances. Generally, isotopic variants of the agents of the present invention and their pharmaceutically acceptable salts can be prepared by conventional methods using appropriate isotopic variants of suitable agents.

[0267] Solvates

[0268] The present invention also includes solvate forms of the active pharmaceutical formulations of the present invention. The terms used in the claims include these forms.

[0269] Polymorphs

[0270] The present invention also relates to the active pharmaceutical formulations of the present invention in their various crystalline, polymorphic, and anhydrous / hydrated forms. Methods are well established in the pharmaceutical art for separating compounds in any of these forms by slightly varying the purification methods and / or the form of solvent used in the synthesis for preparing the compounds.

[0271] Pharmaceutical Compositions

[0272] In another aspect, the present invention relates to a pharmaceutical composition comprising a combination according to the present invention as described above and a pharmaceutically acceptable carrier, diluent, or excipient.

[0273] In one aspect, the present invention relates to a pharmaceutical composition comprising:

[0274] (a) a sulfonylurea; and

[0275] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist;

[0276] and a pharmaceutically acceptable carrier, diluent, or excipient.

[0277] In a preferred embodiment, the present invention relates to a pharmaceutical composition comprising:

[0278] (a) glyburide or a structural or functional analogue thereof; and a pharmaceutically acceptable carrier, diluent or excipient; and

[0279] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenone potassium or a structural or functional analogue;

[0280] and a pharmaceutically acceptable carrier, diluent or excipient.

[0281] In one aspect, the present invention relates to a pharmaceutical composition consisting of:

[0282] (a) a sulfonylurea; and

[0283] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist;

[0284] and a pharmaceutically acceptable carrier, diluent or excipient.

[0285] In a preferred embodiment, the present invention relates to a pharmaceutical composition consisting of:

[0286] (a) glyburide or a structural or functional analogue thereof; and a pharmaceutically acceptable carrier, diluent or excipient; and

[0287] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenone potassium or a structural or functional analogue;

[0288] and a pharmaceutically acceptable carrier, diluent or excipient.

[0289] Although the compounds of the present invention (including their pharmaceutically acceptable salts) may be administered alone, they are usually administered in admixture with a pharmaceutical carrier, excipient or diluent, particularly for human therapy. The pharmaceutical compositions may be used separately for human or non-human animal applications in human medicine or veterinary medicine.

[0290] Examples of such suitable excipients for the various different forms of pharmaceutical compositions described herein can be found in "Handbook of Pharmaceutical Excipients", 2nd Edition, (1994), edited by A Wade and PJ Weller.

[0291] Acceptable carriers or diluents that can be used for therapeutic purposes are well known in the pharmaceutical field and are described, for example, in Remington's Pharmaceutical Sciences, Mack Publishing Co. (edited by A.R. Gennaro, 1985).

[0292] The choice of a pharmaceutical carrier, excipient, or diluent can be selected according to the intended route of administration and standard pharmaceutical practice. Examples of routes of administration include parenteral (e.g., intravenous, intramuscular, intradermal, intraperitoneal, or subcutaneous), oral, inhalation, transdermal (topical), intraocular, iontophoresis, and transmucosal administration.

[0293] In one embodiment, the pharmaceutical composition is for parenteral administration (e.g., intravenous, intraarterial, intrathecal, intramuscular, intradermal, intraperitoneal, or subcutaneous). Preferably, the composition is prepared from a sterile or sterilizable solution.

[0294] In another embodiment, the pharmaceutical composition is for intravenous, intramuscular, or subcutaneous administration.

[0295] In another embodiment, the pharmaceutical composition is for intravenous administration.

[0296] Solutions or suspensions for parenteral, intradermal, or subcutaneous administration may contain the following components: a sterile diluent such as water for injection, saline solution, fixed oils, polyethylene glycol, glycerol, propylene glycol, or other synthetic solvents; an antibacterial agent such as benzyl alcohol or methylparaben; an antioxidant such as ascorbic acid or sodium bisulfite; a chelating agent such as ethylenediaminetetraacetic acid; a buffer such as acetate, citrate, or phosphate, and an osmotic pressure regulator such as sodium chloride or glucose. The pH can be adjusted with an acid or a base (such as hydrochloric acid or sodium hydroxide).

[0297] A pharmaceutical composition suitable for injection may include a sterile aqueous solution (in the case of water solubility) or a dispersion and a sterile powder for the extemporaneous preparation of a sterile injectable solution or dispersion. For intravenous administration, suitable carriers include normal saline, bacteriostatic water, Cremophor TM or phosphate buffered saline (PBS). In all cases, the composition for parenteral administration must be sterile and should be fluid to the extent that easy injection is possible. It should be stable under the conditions of manufacture and storage and must be preserved against the contaminating action of microorganisms such as bacteria and fungi.

[0298] Aseptic injectable solutions can be prepared by incorporating the required amount of the active compound, as needed, into a suitable solvent with one or a combination of the ingredients listed above, followed by filtration sterilization. Generally, dispersions are prepared by incorporating the active compound into a sterile vehicle that contains a basic dispersion medium and the required other ingredients from those listed above. In the case of sterile powders for the preparation of aseptic injectable solutions, typical methods of preparation include vacuum drying and freeze drying, which yield a powder of the active ingredient plus any other required ingredients from its previously sterile-filtered solution. The present invention also encompasses liposome and nanoparticle formulations containing the active agent. These formulations and their methods of preparation are familiar to those of ordinary skill in the art.

[0299] Drug product

[0300] In another aspect, the present invention relates to a drug product comprising:

[0301] (a) A sulfonylurea; and

[0302] (b) At least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0303] In a preferred embodiment, the present invention relates to a drug product comprising:

[0304] (a) Glibenclamide or a structural or functional analogue thereof; and

[0305] (b) At least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenone potassium or a structural or functional analogue.

[0306] In another aspect, the present invention relates to a drug product consisting of:

[0307] (a) A sulfonylurea; and

[0308] (b) At least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0309] In a preferred embodiment, the present invention relates to a drug product consisting of:

[0310] (a) Glibenclamide or a structural or functional analogue thereof; and

[0311] (b) At least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenone potassium or a structural or functional analogue.

[0312] In a preferred embodiment, each component of the drug product is for separate administration.

[0313] In one embodiment, the pharmaceutical product is a kit of components comprising all the necessary equipment for the treatment process (e.g., drug vials, diluent vials, syringes, and needles).

[0314] The components of the kit and the pharmaceutical product are defined as above. In a preferred embodiment, each component of the kit or the pharmaceutical product is mixed with one or more pharmaceutically acceptable diluents, excipients, and / or carriers.

[0315] In one embodiment, the kit includes separate containers for the respective active agents. The containers can be ampoules, disposable syringes, or multi-dose vials.

[0316] In another embodiment, the kit includes a container containing a combined preparation of the respective active agents.

[0317] The kit may further include instructions for the treatment and / or prevention of reperfusion injury.

[0318] Medical Use

[0319] The present invention also relates to the use of the above combination, pharmaceutical product, or pharmaceutical composition in the treatment of various therapeutic conditions detailed below, and the related treatment methods.

[0320] In a preferred embodiment, each pharmaceutically active component of the combination, pharmaceutical product, or pharmaceutical composition is administered separately.

[0321] In one aspect, the present invention relates to the following use of a combination: for the treatment and / or prevention of one or more of ischemia and / or reperfusion injury, stroke, neurodegenerative diseases, neonatal asphyxia, cardiac arrest, cardiogenic shock, and acute myocardial infarction, or for providing cardioprotection against cardiotoxic drugs, or for providing neuroprotection, for example, against neurotoxic drugs; the combination comprises:

[0322] (a) a sulfonylurea; and

[0323] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0324] In a preferred embodiment, the combination is used to provide neuroprotection. Preferably, the combination is used to provide neuroprotection against neurotoxic drugs.

[0325] In a preferred embodiment, the present invention relates to the following combined use: for treating and / or preventing one or more of ischemia and / or reperfusion injury, stroke, neurodegenerative diseases, neonatal asphyxia, cardiac arrest, cardiogenic shock, and acute myocardial infarction, or for providing cardioprotection against cardiotoxic drugs, or for providing neuroprotection against neurotoxic drugs; the combination comprises:

[0326] (a) Glyburide or a structural or functional analogue thereof; and

[0327] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenoate potassium or a structural or functional analogue thereof.

[0328] In another aspect, the present invention relates to the following use of a pharmaceutical composition comprising the combination: for treating and / or preventing one or more of ischemia and / or reperfusion injury, stroke, neurodegenerative diseases, neonatal asphyxia, cardiac arrest, cardiogenic shock, and acute myocardial infarction, or for providing cardioprotection against cardiotoxic drugs, or for providing neuroprotection against neurotoxic drugs; the combination comprises:

[0329] (a) Sulfonylurea; and

[0330] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0331] In a preferred embodiment, the present invention relates to the following use of a pharmaceutical composition comprising the combination: for treating and / or preventing one or more of ischemia and / or reperfusion injury, stroke, neurodegenerative diseases, neonatal asphyxia, cardiac arrest, cardiogenic shock, and acute myocardial infarction, or for providing cardioprotection against cardiotoxic drugs, or for providing neuroprotection against neurotoxic drugs; the combination comprises:

[0332] (a) Glyburide or a structural or functional analogue thereof; and

[0333] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; (ii) canrenoate potassium or a structural or functional analogue thereof.

[0334] In another aspect, the present invention relates to the following use of a pharmaceutical product: for treating and / or preventing one or more of ischemia and / or reperfusion injury, stroke, neurodegenerative diseases, neonatal asphyxia, cardiac arrest, cardiogenic shock, and acute myocardial infarction, or for providing cardioprotection against cardiotoxic drugs, or for providing neuroprotection against neurotoxic drugs; the pharmaceutical product comprises:

[0335] (a) A sulfonylurea; and

[0336] (b) At least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist;

[0337] wherein the components are for simultaneous, sequential or separate administration.

[0338] In a preferred embodiment, the present invention relates to the use of the following for the treatment and / or prevention of one or more of ischemia and / or reperfusion injury, stroke, neurodegenerative diseases, neonatal asphyxia, cardiac arrest, cardiogenic shock and acute myocardial infarction, or for providing cardioprotection against cardiotoxic drugs, or for providing neuroprotection against neurotoxic drugs; the pharmaceutical product comprises:

[0339] (a) Glibenclamide or a structural or functional analogue thereof; and

[0340] (b) At least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenone potassium or a structural or functional analogue thereof;

[0341] wherein the components are for simultaneous, sequential or separate administration.

[0342] In another aspect, the present invention relates to the use of the following in the manufacture of a medicament for the treatment and / or prevention of one or more of ischemia and / or reperfusion injury, stroke, neurodegenerative diseases, neonatal asphyxia, cardiac arrest, cardiogenic shock and acute myocardial infarction, or for providing cardioprotection against cardiotoxic drugs, or for providing neuroprotection against neurotoxic drugs:

[0343] (a) A sulfonylurea; and

[0344] (b) At least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0345] In another preferred embodiment, the present invention relates to the use of the following in the manufacture of a medicament for the treatment and / or prevention of one or more of ischemia and / or reperfusion injury, stroke, neurodegenerative diseases, neonatal asphyxia, cardiac arrest, cardiogenic shock and acute myocardial infarction, or for providing cardioprotection against cardiotoxic drugs, or for providing neuroprotection against neurotoxic drugs:

[0346] (a) Glibenclamide or a structural or functional analogue thereof; and

[0347] (b) At least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenone potassium or a structural or functional analogue thereof.

[0348] In one embodiment, the present invention relates to the use of a combination in the treatment and / or prevention of reperfusion injury, said combination comprising:

[0349] (a) a sulfonylurea; and

[0350] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0351] In a preferred embodiment, the present invention relates to the use of a combination in the treatment and / or prevention of reperfusion injury, said combination comprising:

[0352] (a) glibenclamide or a structural or functional analogue thereof; and

[0353] (b) at least two of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; (ii) canrenone potassium or a structural or functional analogue thereof.

[0354] In another embodiment, the present invention relates to the use of a pharmaceutical composition in the treatment and / or prevention of reperfusion injury, said pharmaceutical composition comprising:

[0355] (a) a sulfonylurea; and

[0356] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0357] In another preferred embodiment, the present invention relates to the use of a pharmaceutical composition comprising a combination in the treatment and / or prevention of reperfusion injury, said combination comprising:

[0358] (a) glibenclamide or a structural or functional analogue thereof; and

[0359] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; (ii) canrenone potassium or a structural or functional analogue thereof.

[0360] In another embodiment, the present invention relates to the use of a pharmaceutical product in the treatment and / or prevention of reperfusion injury, said pharmaceutical product comprising:

[0361] (a) a sulfonylurea; and

[0362] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist;

[0363] wherein the components are for simultaneous, sequential or separate administration.

[0364] In another preferred embodiment, the present invention relates to the use of a pharmaceutical product in the treatment and / or prevention of reperfusion injury, said pharmaceutical product comprising:

[0365] (a) Glibenclamide or a structural or functional analogue thereof; and

[0366] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; (ii) canrenone potassium or a structural or functional analogue thereof;

[0367] wherein the components are for simultaneous, sequential or separate administration.

[0368] In another embodiment, the present invention relates to the use of the following substances in the manufacture of a medicament for the treatment and / or prevention of reperfusion injury:

[0369] (a) Sulfonylurea; and

[0370] (b) at least one of the following components: (i) insulin modulator and (ii) aldosterone antagonist.

[0371] In another preferred embodiment, the present invention relates to the use of the following substances in the manufacture of a medicament for the treatment and / or prevention of reperfusion injury:

[0372] (a) Glibenclamide or a structural or functional analogue thereof,

[0373] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenone potassium or a structural or functional analogue thereof.

[0374] In a preferred embodiment, the present invention relates to the use of a combination in the treatment and / or prevention of ischemia, said combination comprising:

[0375] (a) Sulfonylurea; and

[0376] (b) at least one of the following components: (i) insulin modulator and (ii) aldosterone antagonist.

[0377] In a preferred embodiment, the present invention relates to the use of a combination in the treatment and / or prevention of ischemia, said combination comprising:

[0378] (a) Glibenclamide or a structural or functional analogue thereof; and

[0379] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; (ii) canrenone potassium or a structural or functional analogue thereof.

[0380] In another embodiment, the present invention relates to the use of a pharmaceutical composition comprising a combination in the treatment and / or prevention of ischemia, said combination comprising:

[0381] (a) a sulfonylurea; and

[0382] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0383] In another preferred embodiment, the present invention relates to the use of a pharmaceutical composition comprising a combination in the treatment and / or prevention of ischemia, said combination comprising:

[0384] (a) glibenclamide or a structural or functional analogue thereof; and

[0385] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenone potassium or a structural or functional analogue thereof.

[0386] In another embodiment, the present invention relates to the use of a pharmaceutical product in the treatment and / or prevention of ischemia, said pharmaceutical product comprising:

[0387] (a) a sulfonylurea; and

[0388] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist;

[0389] wherein the components are for simultaneous, sequential or separate administration.

[0390] In another preferred embodiment, the present invention relates to the use of a pharmaceutical product in the treatment and / or prevention of ischemia, said pharmaceutical product comprising:

[0391] (a) glibenclamide or a structural or functional analogue thereof; and

[0392] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenone potassium or a structural or functional analogue thereof;

[0393] wherein the components are for simultaneous, sequential or separate administration.

[0394] In another embodiment, the present invention relates to the use of the following substances in the manufacture of a medicament for the treatment and / or prevention of ischemia:

[0395] (a) a sulfonylurea; and

[0396] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0397] In another preferred embodiment, the present invention relates to the use of the following substances in the manufacture of a medicament for the treatment and / or prevention of ischemia:

[0398] (a) Glibenclamide or a structural or functional analogue thereof; and

[0399] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; (ii) canrenone potassium or its structure or function.

[0400] In a preferred embodiment, the present invention relates to the use of a combination in the treatment and / or prevention of stroke, said combination comprising:

[0401] (a) Sulfonylurea; and

[0402] (b) at least one of the following components: (i) insulin regulator and (ii) aldosterone antagonist.

[0403] In a preferred embodiment, the present invention relates to the use of a combination in the treatment and / or prevention of stroke, said combination comprising:

[0404] (a) Glibenclamide or a structural or functional analogue thereof; and

[0405] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; (ii) canrenone potassium or a structural or functional analogue thereof.

[0406] In another embodiment, the present invention relates to the use of a pharmaceutical composition comprising a combination in the treatment and / or prevention of stroke, said combination comprising:

[0407] (a) Sulfonylurea; and

[0408] (b) at least one of the following components: (i) insulin regulator and (ii) aldosterone antagonist.

[0409] In another preferred embodiment, the present invention relates to the use of a pharmaceutical composition comprising a combination in the treatment and / or prevention of stroke, said combination comprising:

[0410] (a) Glibenclamide or a structural or functional analogue thereof; and

[0411] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenone potassium or a structural or functional analogue thereof.

[0412] In another embodiment, the present invention relates to the use of a pharmaceutical product in the treatment and / or prevention of stroke, said pharmaceutical product comprising:

[0413] (a) Sulfonylurea; and

[0414] (b) At least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist;

[0415] wherein each component is for simultaneous, sequential or separate administration.

[0416] In another preferred embodiment, the present invention relates to the use of a pharmaceutical product in the treatment and / or prevention of stroke, said pharmaceutical product comprising:

[0417] (a) Glibenclamide or a structural or functional analogue thereof; and

[0418] (b) At least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenone potassium or a structural or functional analogue thereof;

[0419] wherein each component is for simultaneous, sequential or separate administration.

[0420] In another embodiment, the present invention relates to the use of the following substances in the manufacture of a medicament for the treatment and / or prevention of stroke:

[0421] (a) Sulfonylurea; and

[0422] (b) At least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0423] In another preferred embodiment, the present invention relates to the use of the following substances in the manufacture of a medicament for the treatment and / or prevention of stroke:

[0424] (a) Glibenclamide or a structural or functional analogue thereof; and

[0425] (b) At least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; (ii) canrenone potassium or a structural or functional analogue thereof.

[0426] In a preferred embodiment, the stroke is a hemorrhagic stroke.

[0427] In another preferred embodiment, the stroke is an ischemic stroke.

[0428] As used herein, the term "reperfusion injury" refers to tissue damage that occurs when blood supply returns to tissue after a period of ischemia. The lack of oxygen and nutrients in the blood creates a situation where, by inducing oxidative stress, the restoration of circulation leads to inflammation, mitochondrial dysfunction, and oxidative damage, rather than the restoration of normal function. Reperfusion injury can occur after a spontaneous event (such as arterial occlusion) or a planned event (such as any of a number of surgical procedures). Myocardial reperfusion injury can occur, for example, after a myocardial infarction or as a result of a heart transplant. Cerebral reperfusion injury can occur, for example, after an ischemic stroke or as a result of neonatal asphyxia.

[0429] In one embodiment, the ischemia and / or reperfusion injury is ischemia and / or reperfusion injury of the brain, heart, lung, kidney, or other organ / tissue susceptible to ischemia and / or reperfusion injury.

[0430] In one embodiment, the ischemia and / or reperfusion injury is ischemia and / or reperfusion injury of the brain, preferably cerebral ischemia and / or cerebral reperfusion injury.

[0431] In one embodiment, the ischemia and / or reperfusion injury is ischemia and / or reperfusion injury of the heart, preferably myocardial ischemia and / or myocardial reperfusion injury.

[0432] In one embodiment, the present invention relates to the use of a combination in the treatment and / or prevention of a neurodegenerative disorder, the combination comprising:

[0433] (a) a sulfonylurea; and

[0434] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0435] In a preferred embodiment, the present invention relates to the use of a combination in the treatment and / or prevention of a neurodegenerative disorder, the combination comprising:

[0436] (a) glibenclamide or a structural or functional analogue thereof; and

[0437] (b) at least two of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; (ii) canrenone potassium or a structural or functional analogue thereof.

[0438] In another embodiment, the present invention relates to the use of a pharmaceutical composition in the treatment and / or prevention of a neurodegenerative disorder, the pharmaceutical composition comprising:

[0439] (a) a sulfonylurea; and

[0440] (b) At least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0441] In another preferred embodiment, the present invention relates to the use of a pharmaceutical composition comprising a combination in the treatment and / or prevention of neurodegenerative disorders, said combination comprising:

[0442] (a) Glibenclamide or a structural or functional analogue thereof; and

[0443] (b) At least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; (ii) canrenone potassium or a structural or functional analogue thereof.

[0444] In another embodiment, the present invention relates to the use of a pharmaceutical product in the treatment and / or prevention of neurodegenerative disorders, said pharmaceutical product comprising:

[0445] (a) A sulfonylurea; and

[0446] (b) At least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist;

[0447] wherein the components are for simultaneous, sequential or separate administration.

[0448] In another preferred embodiment, the present invention relates to the use of a pharmaceutical product in the treatment and / or prevention of neurodegenerative disorders, said pharmaceutical product comprising:

[0449] (a) Glibenclamide or a structural or functional analogue thereof; and

[0450] (b) At least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; (ii) canrenone potassium or a structural or functional analogue thereof;

[0451] wherein the components are for simultaneous, sequential or separate administration.

[0452] In another embodiment, the present invention relates to the use of the following substances in the manufacture of a medicament for the treatment and / or prevention of neurodegenerative disorders:

[0453] (a) A sulfonylurea; and

[0454] (b) At least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0455] In another preferred embodiment, the present invention relates to the use of the following substances in the manufacture of a medicament for the treatment and / or prevention of neurodegenerative disorders:

[0456] (a) Glibenclamide or a structural or functional analogue thereof; and

[0457] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; (ii) canrenone potassium or a structural or functional analogue thereof.

[0458] In a preferred embodiment, the neurodegenerative disorder is selected from Parkinson's disease, amyotrophic lateral sclerosis (ALS), Huntington's disease, and Alzheimer's disease.

[0459] In a preferred embodiment, the neurodegenerative disorder is Parkinson's disease.

[0460] In a preferred embodiment, the neurodegenerative disorder is amyotrophic lateral sclerosis (ALS).

[0461] In a preferred embodiment, the neurodegenerative disorder is vascular dementia.

[0462] In a preferred embodiment, the neurodegenerative disorder is Alzheimer's disease.

[0463] The insulin modulator, the aldosterone antagonist, and the sulfonylurea can be administered simultaneously, sequentially, or individually (as part of a dosing regimen).

[0464] Exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof, canrenone potassium or a structural or functional analogue thereof, and glibenclamide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof, can be administered simultaneously, sequentially, or individually (as part of a dosing regimen).

[0465] As used herein, "simultaneously" is used to indicate that two agents are administered at the same time.

[0466] As used herein, "sequentially" is used to indicate that the active agents are not administered at the same time, but one after another. Thus, "sequentially" administration may permit the administration of another agent 5 minutes, 10 minutes, or approximately several hours after one agent, provided that the circulating half-life of the first administered agent enables both to be present in therapeutically effective amounts at the same time. The time delay between the administrations of the respective components varies depending on the exact nature of the respective components, their interaction with each other, and their respective half-lives. In contrast to "sequentially", "individually" as used herein indicates that the interval between the administration of one agent and another is significant, i.e., when the second agent is administered, a therapeutically effective amount of the first administered agent may no longer be present in the bloodstream.

[0467] In one embodiment, the respective components of the combination are for simultaneous administration.

[0468] Method of treatment

[0469] In another aspect, the present invention relates to a method for treating and / or preventing ischemia and / or reperfusion injury, the method comprising administering to a subject simultaneously, sequentially or separately:

[0470] (a) a sulfonylurea; and

[0471] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0472] In another preferred embodiment, the present invention relates to a method for treating and / or preventing ischemia and / or reperfusion injury, the method comprising administering to a subject in need thereof simultaneously, sequentially or separately:

[0473] (a) glibenclamide or a structural or functional analogue thereof; and

[0474] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenone potassium or a structural or functional analogue thereof.

[0475] In one embodiment, the present invention relates to a method for treating and / or preventing reperfusion injury, the method comprising administering to a subject in need thereof simultaneously, sequentially or separately:

[0476] (a) a sulfonylurea; and

[0477] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0478] In a preferred embodiment, the present invention relates to a method for treating and / or preventing reperfusion injury, the method comprising administering to a subject in need thereof simultaneously, sequentially or separately:

[0479] (a) glibenclamide or a structural or functional analogue thereof; and

[0480] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenone potassium or a structural or functional analogue thereof.

[0481] In another embodiment, the present invention relates to a method for treating and / or preventing ischemia, the method comprising administering to a subject in need thereof simultaneously, sequentially or separately:

[0482] (a) a sulfonylurea; and

[0483] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0484] In another embodiment, the present invention relates to a method for treating and / or preventing ischemia, the method comprising administering to a subject in need thereof, simultaneously, sequentially or separately:

[0485] (a) Glyburide or a structural or functional analogue thereof; and

[0486] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenoate potassium or a structural or functional analogue thereof.

[0487] In one embodiment, the method relates to treating and / or preventing ischemia and / or reperfusion injury in the brain, heart, lung, kidney or other organ / tissue susceptible to ischemia and / or reperfusion injury.

[0488] In one embodiment, the method relates to treating and / or preventing reperfusion injury in the brain, heart, lung, kidney or other organ / tissue susceptible to reperfusion injury.

[0489] In one embodiment, the method relates to treating and / or preventing ischemia in the brain, heart, lung, kidney or other organ / tissue susceptible to ischemia.

[0490] In another embodiment, the method relates to treating and / or preventing ischemia and / or reperfusion injury in the brain, preferably cerebral ischemia and / or cerebral reperfusion injury.

[0491] In another embodiment, the method relates to treating and / or preventing reperfusion injury in the brain, preferably cerebral reperfusion injury.

[0492] In another embodiment, the method relates to treating and / or preventing ischemia and / or reperfusion injury in the heart, preferably myocardial ischemia and / or myocardial reperfusion injury.

[0493] In another embodiment, the method relates to treating and / or preventing reperfusion injury in the heart, preferably myocardial reperfusion injury.

[0494] In a particularly preferred embodiment, the method relates to treating and / or preventing acute myocardial infarction. Acute myocardial infarction is one of the most common clinical indications of reperfusion injury.

[0495] In a particularly preferred embodiment, the method relates to treating and / or preventing stroke.

[0496] In a preferred embodiment, the stroke is a hemorrhagic stroke.

[0497] In a particularly preferred embodiment, the method relates to treating and / or preventing ischemic stroke. Ischemic stroke is one of the most common clinical indications of reperfusion injury.

[0498] In another embodiment, the method involves treating and / or preventing neonatal asphyxia.

[0499] Neonatal asphyxia (or perinatal asphyxia) is a medical condition caused by the lack of oxygen in a newborn infant that persists for a sufficient period during the birth process to cause physical harm, usually to the brain. The most common causes of neonatal asphyxia are (for example) inadequate circulation or perfusion, difficulty breathing or inadequate ventilation, leading to a decrease in maternal blood pressure during childbirth or other interference with blood flow to the infant's brain.

[0500] Neonatal asphyxia can cause hypoxic injury to most of the infant's organs (heart, lungs, liver, intestine, kidneys), but brain injury is the most concerning and is perhaps the least likely to be quickly or completely cured. In more obvious cases, the infant will survive, but its brain will be damaged, manifested as mental disability (such as developmental delay) or intellectual disability, or physical disability (such as spasticity). Infants with severe perinatal asphyxia usually have poor color (cyanosis), perfusion, reactivity, muscle tone, and respiratory behavior. Severe asphyxia can lead to cardiac arrest and death. Neonatal asphyxia occurs in 2 to 10 out of every 1000 full-term newborns, and there are more cases in premature newborns. It is estimated by the WHO that 4 million newborns die each year due to birth asphyxia, accounting for 38% of the deaths of children under 5 years of age.

[0501] In another embodiment, the method involves treating and / or preventing cardiac ischemia, preferably myocardial ischemia.

[0502] In another embodiment, the present invention relates to a method for treating and / or preventing stroke, the method comprising administering to a subject in need thereof simultaneously, sequentially, or separately:

[0503] (a) a sulfonylurea; and

[0504] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0505] In another embodiment, the present invention relates to a method for treating and / or preventing stroke, the method comprising administering to a subject in need thereof simultaneously, sequentially, or separately:

[0506] (a) glibenclamide or a structural or functional analogue thereof; and

[0507] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenone potassium or a structural or functional analogue thereof.

[0508] In another embodiment, the present invention relates to a method for treating and / or preventing neurodegenerative diseases, the method comprising administering to a subject in need thereof simultaneously, sequentially or separately:

[0509] (a) a sulfonylurea; and

[0510] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0511] In another embodiment, the present invention relates to a method for treating and / or preventing neurodegenerative diseases, the method comprising administering to a subject in need thereof simultaneously, sequentially or separately:

[0512] (a) glibenclamide or a structural or functional analogue thereof; and

[0513] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenone potassium or a structural or functional analogue thereof.

[0514] In another embodiment, the present invention relates to a method for providing neuroprotection, the method comprising administering to a subject in need thereof simultaneously, sequentially or separately:

[0515] (a) a sulfonylurea; and

[0516] (b) at least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0517] In another embodiment, the present invention relates to a method for providing neuroprotection, the method comprising administering to a subject in need thereof simultaneously, sequentially or separately:

[0518] (a) glibenclamide or a structural or functional analogue thereof; and

[0519] (b) at least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenone potassium or a structural or functional analogue thereof.

[0520] In one embodiment, the subject is a mammal, more preferably a human.

[0521] In one embodiment, the method comprises parenterally (e.g., intravenously, intramuscularly, intradermally, intraperitoneally or subcutaneously) administering the components to the subject. The combined pharmaceutically active components may be administered separately or as a combined preparation. Preferably, the pharmaceutically active components are administered separately.

[0522] In another embodiment, the method comprises intravenously, intramuscularly or subcutaneously administering the components to the subject.

[0523] In another embodiment, the method comprises intravenously administering the components to a subject.

[0524] The components can be administered by the same or different routes as the other components. Preferably, the components are administered by the same route.

[0525] In one embodiment, the combination is administered to a donor subject and / or a recipient subject before and / or during and / or after a heart transplant. For example, in some embodiments, the combination can be administered to a first subject, and the heart organ removed from the first subject is used for transplantation into a second subject. Additionally or alternatively, in some embodiments, the combination is administered to the removed heart organ before introducing the heart organ into the second subject. Additionally or alternatively, in some embodiments, the combination therapy is administered to the second subject before, during, and / or after a heart transplant.

[0526] In one embodiment, the combination is for administration to a subject suffering from a stroke. A stroke refers to the death of cells caused when poor blood flow enters the brain. There are two main types of stroke: ischemic stroke (due to lack of blood flow) and hemorrhagic stroke (due to bleeding). They cause parts of the brain to not function properly. The signs and symptoms of a stroke may include the inability to move or feel on one side of the body, problems with understanding or speaking, feeling that the world is spinning, or loss of vision in one of the sides. Ischemic stroke is usually caused by a blocked blood vessel. Treatments for ischemic stroke include surgically opening (reperfusion) the artery to the brain with a stenosis problem. If an ischemic stroke is detected within three to four and a half hours, it can be treated with a drug that can break up the clot. In 2013, stroke was the second most common cause of death after coronary artery disease, resulting in 6.4 million deaths (12% of the total).

[0527] Ischemic stroke and acute myocardial infarction require urgent reperfusion to improve functional outcomes (Patel and Saver, 2013, Stroke, 44:94 - 98). For a long time, intravenous tissue plasminogen activator has been the only reperfusion therapy proven to be clinically beneficial for patients with acute ischemic stroke. As occurs in acute myocardial infarction, intravascular methods of restoring reperfusion in acute ischemic stroke may subject patients to more severe ischemia / reperfusion injury, thereby hindering the benefits of recanalization by promoting both hemorrhagic transformation and severe vasogenic edema as markers of reperfusion injury (Bai and Lyden, 2015, Int J Stroke, 10:143 - 152). Experimental evidence suggests that cerebral ischemia-reperfusion injury (similar to that occurring in myocardial reperfusion injury) may be reduced by ischemic preconditioning and postconditioning. In rats, glibenclamide has shown enhanced therapeutic benefits for early hypothermia after severe stroke (Zhu S et al., Aging Dis. 2018;9:685 - 695). Additionally, in a clinically relevant rat model of stroke (middle cerebral artery occlusion), reperfusion was initiated 4.5 h later, accompanied by the administration of recombinant tissue plasminogen activator, followed by the administration of glibenclamide (10 μg / kg IP loading dose plus 200 ng / h by constant subcutaneous infusion) starting 4.5 h or 10 h after the onset of ischemia; glibenclamide significantly reduced hemisphere swelling at 24 h and mortality at 48 h, and improved the Garcia score at 48 h, thus indicating that the therapeutic window of glibenclamide is extended to 10 h after the onset of ischemia. This finding is consistent with the observations in retrospective clinical studies, which have shown that the use of sulfonylureas is beneficial in the context of rt-PA-assisted recanalization / reperfusion after acute ischemic stroke (Simard, JM et al., Ann. N.Y. Acad. Sci. 2012;1268:95 - 107).

[0528] In one embodiment, the combination is for administration to a subject suffering from cardiogenic shock. Cardiogenic shock is a life-threatening medical condition caused by inadequate blood circulation resulting from primary failure of the ventricles of the heart to function effectively. This condition occurs in 2% to 10% of patients hospitalized due to myocardial infarction and is the leading cause of death in these patients (Holmes et al., 1995, J Am Coll Cardiol, 26:668-674). More specifically, cardiogenic shock is the result of a complex process of oxygen delivery failure, systemic ATP depletion, and multi-organ dysfunction triggered by cardiac pump failure (Okuda, 2006, Shock, 25:557-570). Since this is a form of circulatory shock, tissue perfusion is insufficient to meet the demand for oxygen and nutrients. Symptoms involve increasingly widespread cell death caused by oxygen deficiency (hypoxia) and nutrient deficiency (e.g., hypoglycemia). As such, it can lead to cardiac arrest (or circulatory arrest), which is the sudden cessation of cardiac pump function (along with cessation of breathing and loss of consciousness). Cardiogenic shock is defined as persistent hypotension with inadequate tissue perfusion despite adequate left ventricular filling pressure. Signs of inadequate tissue perfusion include low urine output (<30 mL / hour), cool extremities, and altered level of consciousness. Several large trials have demonstrated that coronary revascularization is the most important strategy for improving patient survival (Hochman et al., 1999, N Engl J Med, 341:625-634). However, acute revascularization in patients who develop cardiogenic shock has a poor prognosis, which may be due to reperfusion injury and is thought to be related to infarct size. In fact, it has been demonstrated that hypothermia can provide tissue protection in myocardial ischemia, and preclinical studies have shown beneficial results in reducing infarct size in experimentally induced myocardial infarction (Dae et al., 2002, Am J Physiol Heart Circ Physiol, 282:H1584-H1591). Thus, in a porcine model, mild therapeutic hypothermia reduced the acute mortality of cardiogenic shock and improved hemodynamic parameters (Gotberg et al., 2010, Resuscitation, 81:1190-96).

[0529] In one embodiment, the combination is for administration to a subject suffering from cardiac arrest. Cardiac arrest is the sudden cessation of effective blood flow due to the heart's inability to contract effectively. The most common cause of cardiac arrest is coronary artery disease. Treatment of cardiac arrest is immediate cardiopulmonary resuscitation (CPR), and defibrillation if a shockable heart rate is present. In the United States, approximately 13 out of every 10,000 people (326,000 cases) experience an out-of-hospital cardiac arrest each year. Another 209,000 cases of cardiac arrest occur in the hospital (Kronic et al., Circulation, 2015, 132: S397 - S413). In addition to providing high-quality cardiopulmonary resuscitation, optimizing the treatment of post-cardiac arrest syndrome is crucial for improving the long-term outcomes of patients who have had a cardiac arrest. In this syndrome ("post-cardiac arrest syndrome"), there are three main areas of focus: (1) brain injury after cardiac arrest; (2) myocardial dysfunction and reperfusion injury after cardiac arrest; and (3) the systemic ischemia-reperfusion response. It is now clear that post-resuscitation care can affect long-term survival as well as myocardial and neurological recovery and function in survivors (Kern, 2015, Circ J, 79: 1156 - 1163).

[0530] In one embodiment, the subject is at risk of (or susceptible to) vascular occlusive injury or cardiac ischemia-reperfusion injury.

[0531] In one embodiment, the combination is for providing neuroprotection to a subject or a method for providing neuroprotection to a subject.

[0532] As used herein, the term "neuroprotection" refers to protecting neural entities, including the brain, e.g., by preventing, reducing, or delaying brain injury that can lead to neuronal death and neurodegenerative disorders such as Alzheimer's disease, Parkinson's disease, or vascular dementia.

[0533] In one embodiment, the combination is for providing neuroprotection to a subject against the neurotoxic effects of a chemical, or a method for providing neuroprotection to a subject against the neurotoxic effects of a chemical. Examples of neurotoxic chemicals are described by Gouzoulis-Mayfrank and Daumann (Dialogues Clin Neurosci. 2009, 11(3): 305 - 17). Neurotoxic chemicals include abused chemicals (e.g., 3,4-methylenedioxymethamphetamine, methamphetamine, and amphetamine), pesticides (e.g., organophosphate-based pesticides), certain chemotherapies (e.g., platinum), and dopamine.

[0534] In one embodiment, the claimed combination is for providing cardioprotection to a subject against the cardiotoxic effects of a drug (such as amrinone), or a method for providing cardioprotection to a subject against the cardiotoxic effects of a drug (such as amrinone). Bovelli et al. (Annals of Oncology 21(Suppl 5): v277 - v282, 2010) describe examples of cardiotoxic drugs.

[0535] As used herein, the term "cardioprotection" means protecting the heart, for example, by preventing, reducing, or delaying myocardial injury. Cardiotoxic drugs include drugs associated with heart failure, drugs associated with ischemia or thromboembolism, drugs associated with hypertension, drugs associated with other toxic effects such as tamponade and endomyocardial fibrosis, hemorrhagic myocarditis, bradyarrhythmias, Raynaud's phenomenon, autonomic neuropathy, QT prolongation or torsades de pointes, or pulmonary fibrosis. Examples of cardiotoxic drugs include anthracyclines / anthraquinones, cyclophosphamide, trastuzumab and other monoclonal - antibody - based tyrosine kinase inhibitors, antimetabolites (fluorouracil, capecitabine), antimicrotubule agents (paclitaxel, docetaxel), cisplatin, thalidomide, bevacizumab, sunitinib, sorafenib, busulfan, paclitaxel, vinblastine, bleomycin, vincristine, arsenic trioxide, bleomycin, and methotrexate.

[0536] In one embodiment, the components are administered simultaneously.

[0537] In one embodiment, the components are administered sequentially or separately.

[0538] For a combination of three components, all three components can be administered simultaneously, or any two components can be administered simultaneously, with the third component being administered separately or sequentially. Alternatively, all three components can be administered separately or sequentially in any order.

[0539] In one embodiment, a sulfonylurea is administered before an insulin regulator is administered sequentially or separately.

[0540] In another embodiment, an insulin regulator is administered before a sulfonylurea is administered sequentially or separately.

[0541] In one embodiment, a sulfonylurea is administered before an aldosterone antagonist is administered sequentially or separately.

[0542] In one embodiment, an aldosterone antagonist is administered before a sulfonylurea is administered sequentially or separately.

[0543] In one embodiment, exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; canrenone potassium or a structural or functional analogue thereof; and glibenclamide or a structural or functional analogue thereof are administered sequentially or separately.

[0544] In one embodiment, each component is administered in a therapeutically effective amount relative to the individual components.

[0545] As used herein, the term "therapeutically effective amount" means an amount sufficient to achieve the desired therapeutic and / or prophylactic effect, e.g., an amount that results in the prevention or reduction of ischemia and / or reperfusion injury or one or more symptoms associated with ischemia and / or reperfusion injury.

[0546] In the case of therapeutic or prophylactic applications, the amount of the composition administered to a subject will depend on the type and severity of the disease and the characteristics of the individual, such as general health, age, sex, body size, weight, and resistance to the drug. It will also depend on the severity and type of the disease. Those skilled in the art will be able to determine the appropriate dosage based on these and other factors. The composition can also be administered in combination with one or more other therapeutic agents.

[0547] In one embodiment, each component is administered in a sub-therapeutically effective amount relative to the individual components.

[0548] In one embodiment, the components are administered to the subject prior to reperfusion.

[0549] In one embodiment, the components are administered to the subject during reperfusion.

[0550] In one embodiment, the components are administered to the subject after reperfusion.

[0551] In one embodiment, the components are administered to the subject before and / or during and / or after reperfusion.

[0552] In some embodiments of the method, a sulfonylurea is continuously administered to the subject before, during, and after reperfusion of the subject, and an insulin modulator is administered to the subject in a bolus dose before reperfusion.

[0553] In some embodiments of the method, an insulin modulator is continuously administered to the subject before, during, and after reperfusion of the subject, and a sulfonylurea is administered to the subject in a bolus dose before reperfusion.

[0554] In some embodiments of the method, a sulfonylurea is continuously administered to the subject before, during, and after reperfusion of the subject, and an aldosterone antagonist is administered to the subject in a bolus dose before reperfusion.

[0555] In some embodiments of the method, an aldosterone antagonist is administered continuously to a subject before, during, and after reperfusion of the subject, and a sulfonylurea is administered to the subject as a bolus dose before reperfusion.

[0556] In some embodiments of the method, each component is administered continuously to a subject before, during, and after reperfusion of the subject.

[0557] In some embodiments of the method, there may be an additional administration of one or more components after reperfusion. Preferably, the repeated administration is carried out at least twice, more preferably from 2 to 100 times, or it may be carried out in the form of a continuous infusion.

[0558] In some embodiments of the method, each component is administered to the subject as a bolus dose before reperfusion.

[0559] In some embodiments of the method, each component is administered to the subject as a bolus dose during reperfusion.

[0560] In some embodiments of the method, each component is administered to the subject as a bolus dose after reperfusion.

[0561] As used herein, "reperfusion" is the restoration of blood flow to any organ or tissue in which blood flow has been reduced or blocked. For example, blood flow can be restored to any organ or tissue affected by ischemia or hypoxia. Restoration of blood flow (reperfusion) can be achieved by any method known to those skilled in the art. For example, reperfusion of ischemic cardiac tissue can be achieved by revascularization.

[0562] In one embodiment, reperfusion is achieved by a revascularization procedure. In one embodiment, the revascularization procedure is selected from the group consisting of: percutaneous coronary intervention; balloon angioplasty; bypass graft implantation; stent implantation; directional coronary atherectomy; treatment with one or more thrombolytic agents; and removal of occlusions.

[0563] In one embodiment, the one or more thrombolytic agents are selected from the group consisting of: tissue plasminogen activator; urokinase; prourokinase; streptokinase; acylated form of plasminogen; acylated form of plasmin; and acylated streptokinase-plasminogen complex.

[0564] Dose

[0565] One of ordinary skill in the art can readily determine the appropriate dosage for administering one of the compositions of the present invention to a subject without undue experimentation. Generally, a physician will determine the actual dosage most suitable for an individual patient, which will depend on various factors, including the activity of the specific compound employed, the metabolic stability and duration of action of that compound, age, body weight, general health, sex, diet, mode and time of administration, rate of excretion, drug combination, the severity of the particular disorder, and the individual undergoing treatment. The dosages disclosed herein are exemplary of average cases. Of course, there can be individual cases with higher or lower dosage ranges, all of which are within the scope of the present invention.

[0566] In a highly preferred embodiment of the present invention, the dosage of the insulin modulator (e.g., exenatide) in the combination is generally lower than the dosage typically used in its currently approved therapy in monotherapy, and / or lower than the general dosage reported in the reperfusion injury literature.

[0567] In a highly preferred embodiment of the present invention, the dosage of the aldosterone antagonist (e.g., potassium canrenoate) in the combination is generally lower than the dosage typically used in its currently approved therapy in monotherapy, and / or lower than the general dosage reported in the reperfusion injury literature.

[0568] In a highly preferred embodiment of the present invention, the dosage of the sulfonylurea (e.g., glibenclamide) in the combination is generally lower than the dosage typically used in its currently approved therapy in monotherapy, and / or lower than the general dosage reported in the reperfusion injury literature.

[0569] Each component of the claimed combination can be formulated in unit dosage form, i.e., in the form of discrete portions containing a unit dosage or multiple unit dosages or sub-units of a unit dosage. The dosages described herein can be used for each of the medical uses described above.

[0570] When used in the claimed combination of the present invention, the insulin modulator (e.g., exenatide) is preferably administered at a dosage of about 0.001 μg / kg to about 1.5 μg / kg, more preferably about 0.005 μg / kg to about 0.15 μg / kg. In a preferred embodiment, the insulin modulator (e.g., exenatide) is preferably administered at a dosage of about 0.01 μg / kg to about 1.5 μg / kg, more preferably about 0.05 μg / kg to about 1.5 μg / kg. As used herein, the insulin modulator dosage is in μg / kg body weight (μg = microgram).

[0571] In a preferred embodiment, the insulin modulator (e.g., exenatide) is preferably administered at a dose of about 0.01 μg / kg to about 0.5 μg / kg, more preferably about 0.02 μg / kg to about 0.5 μg / kg, or about 0.03 μg / kg to about 0.5 μg / kg, or about 0.04 μg / kg to about 0.5 μg / kg, or about 0.05 μg / kg to about 0.5 μg / kg, or about 0.05 μg / kg to about 0.2 μg / kg, or about 0.05 μg / kg to about 0.15 μg / kg.

[0572] In a preferred embodiment, the insulin modulator (e.g., exenatide) is preferably administered at a dose of about 0.01 μg / kg to about 0.1 μg / kg, more preferably about 0.02 μg / kg to about 0.08 μg / kg, or about 0.03 μg / kg to about 0.07 μg / kg, or about 0.04 μg / kg to about 0.06 μg / kg, or at a dose of about 0.05 μg / kg.

[0573] When used in the combination claimed in the present invention, the aldosterone antagonist (e.g., potassium canrenoate) is preferably administered at a dose of about 0.03 mg / kg to about 10 mg / kg, or about 0.1 mg / kg to about 10 mg / kg, or about 0.3 mg / kg to about 5 mg / kg, or about 1 mg / kg to about 10 mg / kg, or about 1 mg / kg to about 5 mg / kg, or about 1 mg / kg to about 3 mg / kg. As used herein, the aldosterone antagonist dose is in mg / kg body weight.

[0574] In a preferred embodiment, the aldosterone antagonist (e.g., potassium canrenoate) is preferably administered at a dose of about 0.1 mg / kg to about 3 mg / kg, or about 0.2 mg / kg to about 2 mg / kg, or about 0.3 mg / kg to about 1.5 mg / kg, or about 0.3 mg / kg to about 1 mg / kg.

[0575] In a preferred embodiment, the aldosterone antagonist (e.g., potassium canrenoate) is preferably administered at a dose of about 0.1 mg / kg to about 0.5 mg / kg, or about 0.2 mg / kg to about 0.5 mg / kg, more preferably about 0.2 mg / kg to about 0.4 mg / kg, even more preferably about 0.3 mg / kg to 0.4 mg / kg.

[0576] When used in the combination claimed in the present invention, the sulfonylurea (e.g., glibenclamide) is preferably administered at a dose of about 0.001 μg / kg to about 30 μg / kg, more preferably about 0.01 μg / kg to about 5 μg / kg, even more preferably about 0.01 μg / kg to about 2 μg / kg. The sulfonylurea dose used herein is in μg / kg body weight.

[0577] In a preferred embodiment, the sulfonylurea (e.g., glibenclamide) is preferably administered at a dose of about 0.5 μg / kg to about 20 μg / kg, or about 0.5 μg / kg to about 15 μg / kg, or about 0.5 μg / kg to about 10 μg / kg, or about 1 μg / kg to about 10 μg / kg.

[0578] In a preferred embodiment, the sulfonylurea (e.g., glibenclamide) is preferably administered at a dose of about 0.5 μg / kg to about 8 μg / kg, or about 0.5 μg / kg to about 7 μg / kg, or about 0.5 μg / kg to about 6 μg / kg, or about 0.5 μg / kg to about 5 μg / kg. In a preferred embodiment, the sulfonylurea (e.g., glibenclamide) is preferably administered at a dose of about 0.5 μg / kg to about 3 μg / kg, or about 0.5 μg / kg to about 2 μg / kg, or about 0.5 μg / kg to about 1.5 μg / kg, or about 0.8 μg / kg to about 1.2 μg / kg, or about 1 μg / kg.

[0579] In a highly preferred embodiment, the combination is a fixed-dose combination comprising a predetermined dose of the respective pharmaceutically active components, such as to allow administration of the above doses to a subject, e.g., about 0.005 μg / kg to about 0.15 μg / kg exenatide and about 0.001 μg / kg to about 30 μg / kg glibenclamide.

[0580] Preferably, the fixed-dose combination comprises a predetermined dose of the respective pharmaceutically active components to allow administration of the following doses to a subject.

[0581] In a highly preferred embodiment, the combination is a fixed-dose combination comprising about 0.01 μg / kg to about 0.5 μg / kg exenatide and about 0.5 μg / kg to about 20 μg / kg glibenclamide.

[0582] In a highly preferred embodiment, the combination is a fixed-dose combination comprising about 0.01 μg / kg to about 0.1 μg / kg exenatide and about 0.5 μg / kg to about 8 μg / kg glibenclamide.

[0583] In a highly preferred embodiment, the combination is a fixed-dose combination comprising about 0.01 μg / kg to about 0.1 μg / kg exenatide and about 0.5 μg / kg to about 1.5 μg / kg glibenclamide.

[0584] In a highly preferred embodiment, the combination is a fixed-dose combination comprising a predetermined dose of the respective components, such as about 0.03 mg / kg to about 10 mg / kg potassium canrenoate and about 0.001 μg / kg to about 30 μg / kg glibenclamide.

[0585] In a highly preferred embodiment, the combination is a fixed-dose combination comprising about 0.1 mg / kg to about 3 mg / kg canrenoate potassium and about 0.5 μg / kg to about 20 μg / kg glibenclamide.

[0586] In a highly preferred embodiment, the combination is a fixed-dose combination comprising about 0.1 mg / kg to about 0.5 mg / kg canrenoate potassium and about 0.5 μg / kg to about 8 μg / kg glibenclamide.

[0587] In a highly preferred embodiment, the combination is a fixed-dose combination comprising about 0.1 mg / kg to about 0.5 mg / kg canrenoate potassium and about 0.5 μg / kg to about 1.5 μg / kg glibenclamide.

[0588] In a highly preferred embodiment, the combination is a fixed-dose combination comprising a predetermined dose of the respective components, such as about 0.03 mg / kg to about 10 mg / kg canrenoate potassium, about 0.001 μg / kg to about 30 μg / kg glibenclamide, and about 0.005 μg / kg to about 0.15 μg / kg exenatide.

[0589] In a highly preferred embodiment, the combination is a fixed-dose combination comprising about 0.1 mg / kg to about 3 mg / kg canrenoate potassium, about 0.5 μg / kg to about 20 μg / kg glibenclamide, and about 0.01 μg / kg to about 0.5 μg / kg exenatide.

[0590] In a highly preferred embodiment, the combination is a fixed-dose combination comprising about 0.1 mg / kg to about 0.5 mg / kg canrenoate potassium, about 0.5 μg / kg to about 8 μg / kg glibenclamide, and about 0.01 μg / kg to about 0.1 μg / kg exenatide.

[0591] In a highly preferred embodiment, the combination is a fixed-dose combination comprising about 0.1 mg / kg to about 0.5 mg / kg canrenoate potassium, about 0.5 μg / kg to about 1.5 μg / kg glibenclamide, and about 0.01 μg / kg to about 0.1 μg / kg exenatide.

[0592] In a highly preferred embodiment, the combination is a fixed-dose combination comprising about 0.05 μg / kg exenatide and 1 μg / kg glibenclamide.

[0593] In a highly preferred embodiment, the combination is a fixed-dose combination comprising about 0.33 mg / kg canrenoate potassium and about 1 μg / kg glibenclamide.

[0594] In a highly preferred embodiment, the combination is a fixed-dose combination comprising about 0.05 μg / kg exenatide, about 0.33 mg / kg canrenone potassium, and about 1 μg / kg glibenclamide.

[0595] Non-therapeutic use

[0596] On the other hand, the present invention relates to the use of a combination for treating and / or preventing ischemia and / or reperfusion injury of an ex vivo organ before or during transplantation, the combination comprising:

[0597] (a) A sulfonylurea; and

[0598] (b) At least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0599] In another preferred embodiment, the present invention relates to the use of a combination for treating and / or preventing ischemia and / or reperfusion injury of an ex vivo organ before or during transplantation, the combination comprising:

[0600] (a) Glibenclamide or a structural or functional analogue thereof; and

[0601] (b) At least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenone potassium or a structural or functional analogue thereof.

[0602] In one embodiment, the present invention relates to the use of a combination for treating and / or preventing reperfusion injury of an ex vivo organ before or during transplantation, the combination comprising:

[0603] (a) A sulfonylurea; and

[0604] (b) At least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0605] In a preferred embodiment, the present invention relates to the use of a combination for treating and / or preventing reperfusion injury of an ex vivo organ before or during transplantation, the combination comprising:

[0606] (a) Glibenclamide or a structural or functional analogue thereof; and

[0607] (b) At least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; (ii) canrenone potassium, or a structural or functional analogue thereof.

[0608] In one embodiment, the present invention relates to the use of a combination for treating and / or preventing ischemia of an ex vivo organ before or during transplantation, the combination comprising:

[0609] (a) A sulfonylurea; and

[0610] (b) At least one of the following components: (i) an insulin modulator and (ii) an aldosterone antagonist.

[0611] In a preferred embodiment, the present invention relates to the use of a combination for treating and / or preventing ischemia of an ex vivo organ before or during transplantation, the combination comprising:

[0612] (a) Glibenclamide or a structural or functional analogue thereof; and

[0613] (b) At least one of the following components: (i) exenatide or a structural or functional analogue thereof or a pharmaceutically acceptable salt thereof; and (ii) canrenone potassium or a structural or functional analogue thereof.

[0614] Ex vivo (removed from the body) organs are susceptible to reperfusion injury due to lack of blood flow. Thus, the combination of the present invention can be used to prevent reperfusion injury of the removed organ. Preferably, the organ is the heart, liver or kidney, more preferably the heart.

[0615] In some embodiments, the removed organ is placed in a standard buffer solution containing the combination of the present invention, such as a buffer solution commonly used in the art containing the combination of the present invention. For example, the removed heart can be placed in a cardioplegic solution containing exenatide, canrenone potassium and glibenclamide. Those skilled in the art can readily determine the concentrations of exenatide, canrenone potassium and glibenclamide to be used in the standard buffer solution. Such concentrations can be (for example) between about 0.1 nM and about 10 μM, preferably about 1 nM to about 10 μM.

[0616] The present invention is further described with reference to the following non-limiting examples and the following drawings, wherein:

[0617] Figure 1Shows the relative cerebral infarction volume (%) of the low-dose triple combination (Treatment S) compared to the control animals in Part I and Part II and the animals receiving the corresponding monotherapies (Treatments A, E, and I) and the corresponding dual combinations (Treatments M, N, and O) on the 7th day after repeated administration (for 7 days) in a transient middle cerebral artery occlusion rat model. Treatment A: Exenatide 0.05 μg / kg (n = 4); Treatment E: Canrenoate potassium 0.33 mg / kg (n = 3); Treatment I: Glibenclamide 1 μg / kg (n = 4); Treatment M: Exenatide 0.05 μg / kg and Canrenoate potassium 0.33 mg / kg (n = 13); Treatment N: Exenatide 0.05 μg / kg and Glibenclamide 1 μg / kg (n = 12); Treatment O: Canrenoate potassium 0.33 mg / kg and Glibenclamide 1 μg / kg (n = 11); Treatment S: Exenatide 0.05 μg / kg and Canrenoate potassium 0.33 mg / kg and Glibenclamide 1 μg / kg (n = 7). Control Part I (n = 6); Control animals Part II (n = 5).

[0618] Figure 2 Shows the changed neurological severity score of the low-dose triple combination (Treatment S) compared to the control animals in Part I and Part II and the animals receiving the corresponding monotherapies (Treatments A, E, and I) and the corresponding dual combinations (Treatments M, N, and O) on the 2nd day after repeated administration (for 7 days) in a transient middle cerebral artery occlusion rat model. Treatment A: Exenatide 0.05 μg / kg (n = 4); Treatment E: Canrenoate potassium 0.33 mg / kg (n = 3); Treatment I: Glibenclamide 1 μg / kg (n = 4); Treatment M: Exenatide 0.05 μg / kg and Canrenoate potassium 0.33 mg / kg (n = 13); Treatment N: Exenatide 0.05 μg / kg and Glibenclamide 1 μg / kg (n = 12); Treatment O: Canrenoate potassium 0.33 mg / kg and Glibenclamide 1 μg / kg (n = 11); Treatment S: Exenatide 0.05 μg / kg and Canrenoate potassium 0.33 mg / kg and Glibenclamide 1 μg / kg (n = 7). Control Part I (n = 6); Control animals Part II (n = 5).

[0619] Figure 3Shows the altered neurological severity scores of the low-dose triple combination (Treatment S) compared to those in the control animals in Parts I and II and in the animals receiving the corresponding monotherapies (Treatments A, E, and I) and the corresponding dual combinations (Treatments M, N, and O) on Day 7 after repeated administration (for 7 days) in a transient middle cerebral artery occlusion rat model. Treatment A: Exenatide 0.05 μg / kg (n = 4); Treatment E: Canrenoate potassium 0.33 mg / kg (n = 3); Treatment I: Glibenclamide 1 μg / kg (n = 4); Treatment M: Exenatide 0.05 μg / kg and Canrenoate potassium 0.33 mg / kg (n = 13); Treatment N: Exenatide 0.05 μg / kg and Glibenclamide 1 μg / kg (n = 12); Treatment O: Canrenoate potassium 0.33 mg / kg and Glibenclamide 1 μg / kg (n = 11); Treatment S: Exenatide 0.05 μg / kg and Canrenoate potassium 0.33 mg / kg and Glibenclamide 1 μg / kg (n = 7). Control Part I (n = 6); Control animals Part II (n = 5).

[0620] Figure 4 Shows the relative cerebral infarction volume (%) of the higher-dose triple combination (Treatment T) compared to those in the control animals in Parts I and II and in the animals receiving the corresponding monotherapies (Treatments B, F, and K) and the corresponding dual combinations (Treatments Q and R) on Day 7 after repeated administration (for 7 days) in a transient middle cerebral artery occlusion rat model. Treatment B: Exenatide 0.15 μg / kg (n = 8); Treatment F: Canrenoate potassium 1 mg / kg (n = 8); Treatment K: Glibenclamide 10 μg / kg (n = 8); Treatment Q: Exenatide 0.15 μg / kg and Glibenclamide 10 μg / kg (n = 4); Treatment R: Canrenoate potassium 1 mg / kg and Glibenclamide 10 μg / kg (n = 5); Treatment T: Exenatide 0.15 μg / kg and Canrenoate potassium 1 mg / kg and Glibenclamide 10 μg / kg (n = 7). Control Part I (n = 6); Control animals Part II (n = 5).

[0621] Figure 5Shows the altered neurological severity scores of the higher-dose triple combination (Treatment T) compared to the control animals in Part I and Part II and in animals receiving the corresponding monotherapies (Treatments B, F, and K) and corresponding dual combinations (Treatments Q and R) on Day 2 after repeated administration (7 days) in a transient middle cerebral artery occlusion rat model. Treatment B: Exenatide 0.15 μg / kg (n = 8); Treatment F: Canrenoate potassium 1 mg / kg (n = 8); Treatment K: Glibenclamide 10 μg / kg (n = 8); Treatment Q: Exenatide 0.15 μg / kg and Glibenclamide 10 μg / kg (n = 4); Treatment R: Canrenoate potassium 1 mg / kg and Glibenclamide 10 μg / kg (n = 5); Treatment T: Exenatide 0.15 μg / kg and Canrenoate potassium 1 mg / kg and Glibenclamide 10 μg / kg (n = 7). Control Part I (n = 6); Control Animals Part II (n = 5).

[0622] Figure 6 Shows the altered neurological severity scores of the higher-dose triple combination (Treatment T) compared to the control animals in Part I and Part II and in animals receiving the corresponding monotherapies (Treatments B, F, and K) and corresponding dual combinations (Treatments Q and R) on Day 7 after repeated administration (7 days) in a transient middle cerebral artery occlusion rat model. Treatment B: Exenatide 0.15 μg / kg (n = 8); Treatment F: Canrenoate potassium 1 mg / kg (n = 8); Treatment K: Glibenclamide 10 μg / kg (n = 8); Treatment Q: Exenatide 0.15 μg / kg and Glibenclamide 10 μg / kg (n = 4); Treatment R: Canrenoate potassium 1 mg / kg and Glibenclamide 10 μg / kg (n = 5); Treatment T: Exenatide 0.15 μg / kg and Canrenoate potassium 1 mg / kg and Glibenclamide 10 μg / kg (n = 7). Control Part I (n = 6); Control Animals Part II (n = 5).

[0623] Figure 7 Shows the histological TUNEL staining results of apoptosis in the hippocampal region of rats treated with the exenatide / canrenoate potassium / glibenclamide triple combination in a vascular dementia rat model. More specifically, Figure 7 Shows the percentage of apoptotic cells (mean ± SEM) in rats treated with 0.05 μg / kg exenatide + 0.33 mg / kg canrenoate potassium + 1 μg / kg glibenclamide (Group 2M; 13 animals; intravenous administration) compared to the vehicle-treated control group (Group 1M; 9 animals).

[0624] Examples

[0625] The present invention is further illustrated by the following examples, which should not be construed as limiting in any way.

[0626] Example 1. Dose - effect study of the efficacy of exenatide, canrenoate potassium, and glibenclamide and their combinations in a rat model of cerebral ischemia and reperfusion injury

[0627] The aim of this study was to evaluate (a) the dose - effect of the neuroprotective effects of glibenclamide, exenatide, and canrenoate potassium in a rat model of cerebral ischemia and reperfusion injury after repeated intravenous administration as monotherapy (Study Part I) and (b) the effect of combinations of the compounds compared to the corresponding monotherapies (Study Part II).

[0628] Transient middle cerebral artery occlusion (t - MCAO) was performed according to the method described by R. Schmid - Elsaesser et al. (Stroke. 1998; 29(10): 2162 - 70). The test compounds were administered intravenously 20 minutes before reperfusion and then twice daily intravenously for six consecutive days thereafter. On Study Day 2 (one day after surgery) and Study Day 7 (7 days after surgery and before study termination), the modified neurological severity score (NSS) was graded from 0 to 18 (where a normal score is 0 and the maximum deficit score is represented by 18); it consists of a set of clinical neurological tests (a combination of motor, sensory, reflex, and balance tests). At the end of the study, the brains were collected, cut into five 2 - mm thick coronal sections, and stained with triphenyltetrazolium chloride (TTC) to measure the infarct size using the ImageJ program. Incidence, mortality, body weight, and clinical observations were also recorded. Numerical results are shown as mean ± standard deviation of the mean. Using two - way ANOVA, followed by Bonferroni post hoc test, with the GraphPad Prism5 program, the statistical significance (P) of the treatment groups compared to the untreated control group was determined.

[0629] In Study Part I, a total of 112 male Sprague - Dawley rats (270 gr to 320 gr at arrival) were divided into 13 groups (5 or 10 rats per treatment group and 8 rats in the control group). Due to mortality in some groups, the number within each group was adjusted to have sufficient animals in all groups. The groups were as follows:

[0630] Control (saline)

[0631] Exenatide was administered at 0.05 μg / kg, 0.15 μg / kg, 0.5 μg / kg, and 1.5 μg / kg;

[0632] Canrenoate potassium was administered at 0.33 mg / kg, 1 mg / kg, 3 mg / kg, and 10 mg / kg;

[0633] Glibenclamide was administered at 1 μg / kg, 3 μg / kg, 10 μg / kg and 30 μg / kg.

[0634] The results of the efficacy endpoints obtained in Part I are summarized in Table 1 and are also presented as percentage changes compared to the respective controls, including the results of the statistical comparison of each treatment to the respective control group. During the study period in all groups, twenty-seven animals died (1 died during surgery, 5 died after occlusion, 1 was euthanized on day 2, 7 died shortly after reperfusion, and 13 were found dead in their cages one to five days after surgery). There were no statistically significant differences in body weight between all animal groups.

[0635] All monotherapies, except for the lowest doses of exenatide, canrenoate potassium and glibenclamide (Treatments A, E and I), showed a statistically significant reduction in the size of the cerebral infarct compared to the control group. There was no clear indication of a dose effect.

[0636] Regarding the modified neurological severity score (NSS), on day 2, compared to the control group, only the lowest doses of exenatide, canrenoate potassium and glibenclamide (Treatments A, E and I) and the 3 μg / kg dose of glibenclamide (Treatment J) did not show a statistically significant reduction, while on day 7, compared to the control group, only the lowest doses of exenatide, canrenoate potassium and glibenclamide (Treatments A, E and I) and the 0.5 μg / kg dose of exenatide (Treatment C) did not show a statistically significant reduction. As in the case of the size of the cerebral infarct, for the modified NSS, there was no clear indication of a dose effect on both day 2 and day 7.

[0637] In Study Part II, a total of 86 male Sprague-Dawley rats (270 gr to 320 gr at arrival) were divided into 9 groups (7 or 15 rats per treatment group and 6 rats in the control group). Due to the mortality in some groups, the numbers within each group were adjusted to have sufficient animals in all groups. The groups were as follows:

[0638] Control (saline)

[0639] Exenatide was administered at 0.05 μg / kg and canrenoate potassium at 0.33 mg / kg;

[0640] Exenatide was administered at 0.05 μg / kg and glibenclamide at 1 μg / kg;

[0641] Canrenoate potassium was administered at 0.33 mg / kg and glibenclamide at 1 μg / kg;

[0642] Exenatide was administered at 0.15 μg / kg and canrenoate potassium at 0.33 mg / kg;

[0643] Exenatide was administered at 0.15 μg / kg, and glibenclamide was administered at 10 μg / kg;

[0644] Canrenoate potassium was administered at 1 mg / kg, and glibenclamide was administered at 10 μg / kg;

[0645] Exenatide was administered at 0.05 μg / kg, and canrenoate potassium was administered at 0.33 mg / kg, and glibenclamide was administered at 1 μg / kg;

[0646] Exenatide was administered at 0.15 μg / kg, and canrenoate potassium was administered at 1 mg / kg, and glibenclamide was administered at 10 μg / kg.

[0647] The results of the efficacy endpoints obtained in Part II are summarized in Table 2 and are also expressed as percentage changes relative to the respective controls, including the results of the statistical comparisons of each treatment compared to the respective control groups. During the study period in all groups, nineteen animals died (2 were euthanized on day 6, 4 died shortly after reperfusion, and 13 were found dead in their cages within one to five days after surgery). There were no statistically significant differences in body weight between all animal groups.

[0648] When compared to the control group, all dual combinations (Groups M, N, O, P, Q, and R) and triple combinations (Groups S and T) showed statistically significant changes in the size of the brain infarct. There were no differences between the dual doses (Groups M, N, O, P, Q, and R) or triple dose combinations (Groups S and T). After administration of the dual combination (Group M) with the lowest doses of exenatide and canrenoate potassium, the reduction in the size of the brain infarct was statistically different from that after the corresponding monotherapies (Groups A and E). After administration of the dual combination (Group N) with the lowest dose of exenatide and glibenclamide, the reduction in the size of the brain infarct was only statistically different from that of the corresponding glibenclamide monotherapy (Group I). In addition, compared to the corresponding monotherapies, the lowest dose (Group S) rather than the higher dose (Group T) of the triple combination showed statistical significance in the reduction of the size of the brain infarct.

[0649] When compared to the control group, all of the dual combinations (Groups M, N, O, P, Q, and R) and two of the triple combinations (Groups S and T) showed a statistically significant decrease in the modified neurological severity score (NSS) on Days 2 and 7. Additionally, on Day 2, the decrease in the modified NSS of the triple combination (Treatment “S”) using the lowest doses of exenatide, canrenoate potassium, and glyburide was statistically significantly different from the corresponding canrenoate potassium and glyburide monotherapies (Groups E and I), and on Day 7, was significantly different from all three corresponding monotherapies (Groups A, E, and I), but was not significantly different from any of the corresponding dual combinations (Groups M, N, and O). The triple combination (Treatment “T”) with higher doses of exenatide, canrenoate potassium, and glyburide was not statistically significantly different from any of the corresponding dual combinations (Groups Q and R).

[0650] To evaluate the effect of combination therapy, comparisons of the lowest dose triple combination (Treatment “S”) with the corresponding monotherapies and dual combinations are shown in Figures 1 to 3 for relative cerebral infarct volume and modified neurological severity score on Days 2 and 7, respectively. Similarly, the results of the comparison of the higher dose triple combination (Treatment “T”) with the corresponding monotherapies and dual combinations are shown in Figures 4 to 6 .

[0651] It is clear from the results obtained that low doses of exenatide, canrenoate potassium, and glyburide (which were ineffective when administered as monotherapies) showed a statistically significant efficacy when combined (as dual or triple combinations), indicating a synergistic effect. The results of the present invention provide strong evidence that combination therapy of glyburide with exenatide and / or canrenoate potassium

[0652] · alleviates the degree of cerebral infarction and / or

[0653] · improves the neurological severity score and / or

[0654] · improves the motor behavior score,

[0655] This is because the combined effect obtained exceeds the sum of the individual drug treatment effects. Additionally, it was surprisingly found that the dose of glibenclamide that produced this synergistic effect in the present study (i.e., 1 μg / kg twice daily, which is 0.66 μg for a 330 g rat used in the study) was significantly lower than the dose reported in previous literature for stroke, i.e., an infusion of 200 ng / h daily, which is 4.8 μg (Simard et al., Transl Stroke Res. 2012). Importantly, in the context of the present invention, this very low dose of glibenclamide is equivalent to such a dose (i.e., 70 μg / day) that is 100 times lower than the defined daily dose (oral 7 mg of the micronized preparation) or approximately 20 to 285 times lower than the recommended maintenance dose of glibenclamide (micronized preparation), and thus this dose is expected to have no effect on blood glucose levels or no side effects. The above-mentioned clinically effective dose of glibenclamide as a dual or triple combination with low-dose exenatide and / or potassium canrenoate is also significantly lower than the dose of glibenclamide that has been proven to have a neuroprotective effect in clinical studies reported in the literature (continuous infusion of 0.16 mg / h or 0.11 mg / h, i.e., 3.84 mg or 2.64 mg daily) (see King ZA et al.).

[0656] Example 2. Efficacy study of the combination of exenatide, potassium canrenoate, and glibenclamide in a rat model of vascular dementia

[0657] The chronic cerebral hypoperfusion model in Wistar rats causes brain damage in the rat brain by permanently occluding both common carotid arteries, which also results in cognitive function deficits. This model is similar to the model of vascular dementia, and this technique can reduce blood flow in the cerebral cortex and hippocampus by up to 40% to 80% for several months, which induces certain learning disabilities.

[0658] Study objective

[0659] The objective of this study was to evaluate the neuroprotective efficacy of the combination of exenatide, potassium canrenoate, and glibenclamide using a Wistar rat model of vascular dementia. The combination was administered intravenously 24 hours after permanent ligation of both common carotid arteries and then twice daily for three weeks.

[0660] Treatment groups

[0661] The treatment groups were as follows:

[0662] Group 1M: Carrier-treated control (9 animals, administered intravenously);

[0663] Group 2M: Exenatide 0.05 μg / kg + potassium canrenoate 0.33 mg / kg + glibenclamide 1 μg / kg (13 animals; administered intravenously).

[0664] Exenatide acetate was obtained from Bachem AG, Switzerland. Potassium canrenoate was obtained from Pfizer, Switzerland. Glibenclamide was obtained from Tocris Bioscience.

[0665] Study design and timeline

[0666] This study evaluated the neuroprotective effect of the combination administered intravenously at a low dose twice a day for three weeks in a vascular dementia model of Wistar rats. The test compound was administered twice a day for three weeks starting 24 hours after bilateral common carotid artery occlusion. On day 1, both common carotid arteries were permanently ligated. The Morris water maze test was performed before bilateral common carotid artery occlusion as baseline training and at weeks 4 and 8 thereafter. At the end of the study, the brains were collected. Histological analysis of the tissues was performed. The study timeline was as follows:

[0667]

[0668] CCAO = bilateral common carotid artery occlusion; D = day; W = week; BW = body weight; MWM = Morris water maze

[0669] The first dosing day was designated as "day 1" and the study was terminated on "day 56", eight weeks after bilateral common carotid artery occlusion.

[0670] Histological analysis

[0671] Tissue preparation and trimming (affected hemisphere), X3 precise cross-sections of the striatum (corpus callosum), dorsal hippocampus, and optic nerve of each brain. Preparation of paraffin blocks for H&E and TUNEL staining, IHC: doublecortin for neurogenesis in the subventricular zone. MBP (myelin in white matter), Iba-1 for microglia, and GFAP for astrocytes. Olig-2 for all oligodendrocytes and NG2 for young oligodendrocytes. Evaluation and analysis of sections; cell body counting in the CA1 and CA3 regions of the hippocampus - three sections per brain, three fields per section; neuron death counting and morphometric analysis of MBP.

[0672] Animals

[0673] Male Wistar rats weighing 290 g to 390 g at the start of the study were used.

[0674] Animal management

[0675] Housing

[0676] Animal handling was performed according to the guidelines of the National Institutes of Health (NIH) and the Association for Assessment and Accreditation of Laboratory Animal Care International (AAALAC). Animals were housed in polycarbonate cages (up to 3 rats / cage) measuring 42.5 cm × 26.5 cm × 18.5 cm, with a stainless steel top grid for pelleted food and drinking water in plastic bottles; bedding: steam-sterilized clean rice husk (Envigo, Sani-chips cat#7090C). Bedding material was changed with the cage at least twice a week.

[0677] Diet

[0678] Animals were fed ad libitum a commercially available rodent diet (Teklad Certified Global 18% Protein Diet, Envigo cat#2018SC). Animals had free access to standard potable tap water obtained from the municipal supply and treated according to Pharmaseed's SOP No. 214, "Water Systems". Animal feed came with an analysis certificate, and the water was autoclaved before use.

[0679] Environmental conditions

[0680] For a period of time after surgery, animals were housed individually in a climate-controlled environment. The air was filtered (HEPA F6 / 6), with an adequate fresh supply provided (minimum of 15 air changes per hour). The temperature was maintained between 18°C and 24°C and the relative humidity between 30% and 70%. Animals were exposed to a 12-hour light and 12-hour dark cycle (6AM / 6PM).

[0681] Randomization

[0682] Animals were randomly assigned to cages according to Pharmaseed's SOP#027, "Random Allocation of Animals".

[0683] Surgery and evaluation

[0684] Surgery: Bilateral common carotid artery ligation

[0685] On the day of surgery, an anesthetic state was induced on a heating pad with a mixture of 70% N2O and 30% O2 containing 4% isoflurane, and the anesthetic state was maintained with 1.5% to 2% isoflurane. Buprenorphine at 0.1 mg / kg was injected subcutaneously. Two common carotid artery occlusions were performed according to the method described by HyunJoon Lee et al. (Citicoline Protects Against Cognitive Impairment in a Rat Model of Chronic Cerebral Hypoperfusion, J Clin Neurol. 2009;5(1):33-38). The two common carotid arteries (CCAs) were exposed through a midline cervical incision, and were carefully dissected free from the surrounding nerves and fascia. The two arteries were doubly ligated with 4-0 silk thread 8 to 10 mm below the visible area of the external carotid artery. The surgical wound was closed, and the animals were returned to their cages to recover from the anesthetic state. At the end of the day, analgesic treatment was administered again with buprenorphine, and for the next four days, analgesic treatment was administered with buprenorphine twice a day.

[0686] Combined administration

[0687] Treatment was started by intravenous (IV) injection 24 hours after arterial ligation. The treatment was performed twice a day for three consecutive weeks.

[0688] Body weight

[0689] The body weight of the animals was monitored during the acclimation period and before common carotid artery ligation, and the body weight of the animals was monitored twice a week after common carotid artery ligation. The animals were weighed according to Pharmaseed's SOP No. 010, "Weighing Laboratory Animals". The individual body weight changes were calculated.

[0690] Clinical observation

[0691] Clinical signs were monitored once during the acclimation period, once in the first 4 hours after surgery, twice a day for the first two days after surgery, and then twice a week.

[0692] Morris water maze test

[0693] The Morris water maze (MWM) test was designed to evaluate cognitive deficits after common carotid artery ligation. The test was conducted according to Pharmaseed's SOP100 (Morris Water Maze Test V6) and relevant publications (e.g., Brandeis R, Brandys Y, and Yehuda S, "The use of the Morris Water Maze in the study of memory and learning", Int J Neurosci. 1989;48(1-2):29-69).

[0694] Pre-surgery training

[0695] According to Pharmaseed's SOP 100 and scientific publications (e.g., see Brandeis R et al.), animals were trained and conditioned in the Morris water maze for one week. Before the MWM, the rats' cages were transferred from the animal house to the behavioral test room and allowed to acclimate for approximately one hour.

[0696] The results of the last day of training were considered as the baseline data for comparison. The MWM test had the following exclusion criteria: failure to escape to the platform within 90 seconds (on the 3rd day of training).

[0697] Post-common carotid artery ligation test

[0698] Before the MWM, the rats' cages were transferred from the animal house to the behavioral test room and allowed to acclimate for approximately one hour.

[0699] The MWM test was conducted at the 4th and 8th weeks after common carotid artery ligation.

[0700] Statistical analysis

[0701] Numerical results were given as mean and standard deviation or standard error. Whenever possible, descriptive statistics and group comparisons of the data were performed using a statistical analysis program (GraphPad Prism version 5.02 for Windows, GraphPad Software, San Diego, California, USA). Appropriate parametric or non-parametric tests were conducted, followed by appropriate post hoc analyses. A probability of 5% (p ≤ 0.05) was considered statistically significant.

[0702] Results

[0703] Preliminary results of the MWM test showed that, in terms of the average time (seconds) to reach the platform and the average distance (cm) swum to the platform, animals treated with the exenatide / canrenoate potassium / glyburide triple combination (treatment group 2M; 13 animals) performed better than animals treated with the vehicle (group 1M; 9 animals). In addition, quantitative evaluation of histological TUNEL staining of apoptosis in the hippocampal region showed that treatment group 2M had a statistically significant neuroprotective effect compared to group 1M (vehicle) (at p = 0.03, according to the Mann-Whitney test). Figure 7 The percentage of apoptotic cells (mean ± SEM) in each group is shown.

[0704] Therefore, it can be concluded that in a vascular dementia model of Vistar rats, when administered intravenously at a low dose twice a day for three weeks, the exenatide / canrenoate potassium / glyburide triple combination showed a neuroprotective effect, thus showing improved cognitive behavior and reduced apoptosis in the hippocampal brain region.

[0705] Various modifications and variations of the described aspects of the present invention will be apparent to those skilled in the art without departing from the scope and spirit of the present invention. Although the present invention has been described in connection with specific preferred embodiments, it should be understood that the claimed invention should not be unduly limited by these specific embodiments. Indeed, various modifications to the described manner of implementing the present invention that are apparent to those skilled in the relevant art are intended to fall within the scope of the appended claims.

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[0772] Table 1: Effects of exenatide, canrenoate potassium, and glibenclamide on cerebral infarction on day 7 and on the modified neurological severity score (NSS) on days 2 and 7 after repeated administration (7 days) as monotherapy in a rat model of transient middle cerebral artery occlusion. The percentage change in the effect in the treatment group compared with the effect in the control group, and the results of the statistical comparison of the effect in the treatment group compared with the control group are shown in parentheses (NS: not statistically significant; *: P < 0.05; **: P < 0.01; ***: P < 0.001)

[0773]

[0774] Table 2: Effects of exenatide, canrenoate potassium, and glibenclamide on cerebral infarction on day 7 and on the modified neurological severity score (NSS) on days 2 and 7 after repeated administration (7 days) as dual or triple combinations in a rat model of transient middle cerebral artery occlusion. The percentage change in the effect in the treatment group compared with the effect in the control group, and the results of the statistical comparison of the effect in the treatment group compared with the control group are shown in parentheses (NS: not statistically significant; *: P < 0.05; **: P < 0.01; ***: P < 0.001)

[0775]

Claims

1. Use of the following components in the manufacture of a medicament for treating and / or preventing one or more of ischemia and / or reperfusion injury, stroke, neurodegenerative diseases, neonatal asphyxia, cardiac arrest, cardiogenic shock and acute myocardial infarction, or for providing cardioprotection against cardiotoxic drugs, or for providing neuroprotection: (a) A sulfonylurea, which is glibenclamide or a structural or functional analogue thereof; and (b) At least one of the following components: (i) An insulin regulator, which is exenatide or a structural or functional analogue thereof, or a pharmaceutically acceptable salt thereof; and (ii) An aldosterone antagonist, which is potassium canrenoate or a structural or functional analogue thereof.

2. The use according to claim 1, wherein the exenatide structural or functional analogue is a GLP-1 receptor agonist.

3. The use according to claim 1, wherein the exenatide structural or functional analogue is selected from lixisenatide, albiglutide, liraglutide, taspoglutide and dulaglutide (LY2189265).

4. The use according to claim 1, wherein the glibenclamide structural or functional analogue is selected from hydrazone, sulfonamide and sulfonylthiourea derivatives of glibenclamide, glimepiride, glipizide and gliclazide.

5. The use according to claim 1, which includes the use of the following components in the manufacture of a medicament for treating and / or preventing one or more of ischemia and / or reperfusion injury and stroke: (a) Glibenclamide; and (b) Potassium canrenoate.

6. The use according to claim 1, which includes the use of the following components in the manufacture of a medicament for treating and / or preventing one or more of ischemia and / or reperfusion injury and stroke: (a) Glibenclamide; (b) Potassium canrenoate; and (c) Exenatide or a pharmaceutically acceptable salt thereof.

7. The use according to claim 5 or claim 6, wherein the ischemia and / or reperfusion injury is ischemia and / or reperfusion injury of the brain, heart, lung or kidney.

8. The use according to claim 1, claim 5 or claim 6, wherein the ischemia and / or reperfusion injury is cerebral ischemia, cerebral reperfusion injury or ischemic stroke.

9. The use according to claim 1, which includes the use of the following components in the manufacture of a medicament for treating and / or preventing vascular dementia: (a) Glibenclamide; (b) Potassium canrenoate; and (c) Exenatide or a pharmaceutically acceptable salt thereof.

10. The use according to claim 1, wherein, Each component is administered parenterally.

11. The use according to claim 1, wherein each component is administered intravenously, intramuscularly or subcutaneously.

12. The use according to claim 1, wherein the component is for oral administration.

13. The use according to claim 1, wherein each component is administered during reperfusion.

14. The use according to claim 1, wherein each component is administered before reperfusion.

15. The use according to claim 1, wherein each component is administered after reperfusion.

16. The use according to claim 1, which includes administering each component to the subject simultaneously.

17. Use of a combination for treating and / or preventing ischemia and / or reperfusion injury of an ex vivo organ before or during transplantation, said combination comprising: (a) A sulfonylurea, which is glibenclamide or a structural or functional analogue thereof; and (b) At least one of the following components: (i) An insulin modulator, which is exenatide or a structural or functional analogue thereof, or a pharmaceutically acceptable salt thereof; and (ii) An aldosterone antagonist, which is potassium canrenoate or a structural or functional analogue thereof.

18. The use according to claim 17, wherein the exenatide structural or functional analogue is a GLP-1 receptor agonist.

19. The use according to claim 17, wherein the exenatide structural or functional analogue is selected from lixisenatide, albiglutide, liraglutide, taspoglutide and dulaglutide (LY2189265).

20. The use according to claim 17, wherein the glibenclamide structural or functional analogue is selected from acylhydrazone, sulfonamide and sulfonylthiourea derivatives of glibenclamide, glimepiride and gliclazide.

21. The use according to claim 17, wherein the ischemia and / or reperfusion injury is cerebral ischemia, cerebral reperfusion injury or stroke.

22. The use according to any one of claims 17 to 21, wherein each component is administered before transplantation.

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