Treatment of brain copper disorders

Abstract

The present disclosure relates to the treatment and prevention of impaired cognitive function, cognitive decline and / or dementia or cerebral nervous system degenerative conditions in a subject suffering from diabetes mellitus by administering a pharmaceutical composition comprising a compound capable of reducing copper levels or amounts elsewhere in the hippocampus or brain of the subject.

Description

[0001] Statement on related applications

[0002] This application claims priority to U.S. Provisional Patent Application No. 63 / 332,551, filed on April 19, 2022, the entire contents of which are incorporated herein by reference for all purposes. Technical Field

[0003] The present invention relates to diabetes, dementia, impaired cognitive function, copper binders and compounds capable of normalizing copper metabolism.

[0004] Incorporated by Reference

[0005] All U.S. patents, U.S. patent application publications, U.S. patent applications (including provisional patent applications), foreign patents, foreign and PCT published applications, treatises and other documents, references and publications identified herein, as well as all documents listed as references cited in any one or more of the patents issued thereby, are incorporated herein by reference in their entirety. The information incorporated is made part of this application to the same extent as if all text and other content were repeated in this application and will be considered part of the text and content of this application as filed. Background Art

[0006] The following includes information that may be useful in understanding the present invention. No admission is made that any of the information is prior art or relevant to the presently described or claimed invention, or that any publication or document specifically or implicitly referenced is prior art or reference that may be used to evaluate the patentability of the described or claimed invention.

[0007] Essential metals are essential for the normal physiological function of biological systems. They are usually present in metalloprotein / metalloenzyme complexes and mediate a variety of processes, including mitochondrial function, transcriptional regulation, and cellular metabolism. However, at concentrations outside the physiological range of essential metals, the presence of essential metals can lead to severe cellular dysfunction.

[0008] Copper is an essential trace element involved in a large number of biological processes in living cells. Analysis of the human proteome has identified 54 copper-binding proteins, of which 12 are copper transporters, about half are enzymes, and one (antioxidant factor 1 copper chaperone, ATOX1) is a transcription factor. Most of the copper in the body is located in organs with high metabolic activity, such as the liver, kidney, heart, and brain, with approximately 5% of the total copper in serum, of which up to 95% is bound to ceruloplasmin.

[0009] Copper is also implicated in oxidative stress, and unbound copper behaves as a potent oxidant, catalyzing the formation of highly reactive hydroxyl radicals, leading to DNA, protein, and lipid damage. Therefore, cellular copper concentrations need to be finely regulated through a complex homeostatic mechanism of absorption, excretion, and bioavailability.

[0010] Wilson's disease and Menkes' disease are genetically transmitted disorders of copper metabolism caused by defects in the genes encoding the ATP-linked cellular copper transporters ATP7B and ATP7A, respectively (de Bie P et al., Molecular pathogenesis of Wilson and Menkes disease: correlation of mutations with molecular defects and disease phenotypes, J Med Genet, 2007;44:673-88). Excess brain copper, such as occurs in Wilson's disease (Cumings JN. The copper and iron content of brain and liver in the normal and in hepato-lenticular degeneration. Brain, 1948;71(part 4):410-5), and brain copper deficiency, such as occurs in Menkes's disease (Walker-Smith JA et al. Therapeutic implications of copper deficiency in Menkes's steely-hair syndrome. Arch Dis Child, 1973;48:958-62), are known to cause severe neurological degeneration if not treated by pharmacological restoration of brain copper levels. Wilson disease and Menkes disease can be used as models for the effects of defective copper homeostasis patterns on the brain because in each disease, the disease mechanism is known to be defective copper homeostasis leading to tissue damage, caused by copper overload and copper deficiency, respectively.

[0011] Regarding copper and diabetes, there are some reports of increased copper in the urine or serum of people with type 2 diabetes. G. J. Cooper, G. J. et al., (2005) Diabetes 54, 1468-147. On the other hand, clinical studies comparing plasma or serum copper levels in patients with diabetes and healthy individuals have reported contradictory findings (Qiu, Q. et al., Copper in Diabetes Mellitus: a Meta-Analysis and Systematic Review of Plasma and Serum Studies, Biol Trace Elem Res, 177, 53-63 (2017)). See also Lowe, J. et al., Dissecting Copper Homeostasis in Diabetes Mellitus, IUBMB Life, 69(4): 255-262 (2017).

[0012] Likewise, although defective brain metal metabolism is present in various age-related neurodegenerative diseases, there is no consensus on the role of impaired metal homeostasis in their pathogenesis. Alzheimer's disease is a neurodegenerative disorder characterized by amyloid plaques in the brain tissue of patients. Plaques are mainly composed of β-amyloid peptide and proteins including Zn 2+ , Cu 2+ and Fe 2+of trace elements. Some have suggested that Alzheimer's disease can be considered a type of metal homeostasis disorder, and many studies have focused on copper ions, which appear to be one of the main cationic elements in plaque formation. However, the role of copper in Alzheimer's disease has not been determined, with some studies showing copper deficiency and other data suggesting copper overload. S. Bogheri S. et al., Role of Copper in the Onset of Alzheimer's Disease Compared to Other Metals, Front Aging Neurosci., 2017; 9:446. See S. C. Drew, SC (2017), The Case for Abandoning Therapeutic Chelation of Copper Ions in Alzheimer's Disease, Front. Neurosci., 11:317.

[0013] Similarly, although many studies have linked increased levels of free copper to an increased risk of Parkinson's disease, another neurodegenerative disorder, this association remains unproven. Various studies support the hypothesis that both increased copper (causing increased intracellular oxidative conditions) and copper deficiency (allowing for the formation of superoxide dismutase 1 aggregates) are associated with an increased risk of developing the disease. Marco Bisaglia and Luigi Bubacco, Copper Ions and Parkinson's Disease: Why Is Homeostatsis So Relevant?, Biomolecules, 2020 Feb;10(2):195. See Ajsuvakova OP et al., Assessment of copper, iron, zinc and manganese status and speciation in patients with Parkinson's disease: A pilot study, J. Trace Elem. Med. Biol., 2019: 126423.

[0014] According to a 2016 study, people with type 2 diabetes are about 60% more likely to develop Alzheimer's disease or another type of dementia, such as vascular dementia, than people without diabetes. Chatterjee S et al., Type 2 Diabetes as a Risk Factor for Dementia in Women Compared With Men: A Pooled Analysis of 2.3 Million People Comprising More Than 100,000 Cases of Dementia. Diabetes Care. 2016 Feb;39(2):300-307. Some have even suggested that Alzheimer's disease should be classified as a type of diabetes. The term "type 3 diabetes" has been proposed to describe the hypothesis that Alzheimer's disease, a major cause of dementia, is triggered by a type of insulin resistance and insulin-like growth factor dysfunction that occurs specifically in the brain. This condition is also used by some to describe people who have type 2 diabetes and are also diagnosed with Alzheimer's dementia.

[0015] According to Mayo Clinic scientists, a link has been established between Alzheimer's disease and type 2 diabetes. "Researchers link Alzheimer's gene to Type 3 diabetes" (October 25, 2017) www.newsnetwork.mayoclinic.org / discussion / researchers-link-alzheimers-gene-to-type-iii-diabetes, and some believe that Alzheimer's disease may be triggered by insulin resistance in the brain, with some saying that Alzheimer's disease is just "diabetes in the brain." See de la Monte SM and Wands JR, Alzheimer's Disease Is Type 3 Diabetes - Evidence Reviewed, J Diabetes Sci Technol. 2008 Nov;2(6):1101-1113 (concluding that the term "type 3 diabetes" accurately reflects the fact that Alzheimer's disease represents a form of diabetes that selectively involves the brain and has molecular and biochemical features that overlap with type 1 and type 2 diabetes).

[0016] There is strong evidence that the rate of lacunar infarcts and brain atrophy is increased in type 2 diabetes (de Bresser J et al. Progression of cerebral atrophy and white matter hyperintensities in patients with type 2 diabetes. Diabetes Care 2010;33(6):1309-14; van Harten B et al. Brain imaging in patients with diabetes: a systematic review. Diabetes Care 2006;29(11):2539-48), with the hippocampus often being severely affected (Gold SM et al. Hippocampal damage and memory impairments as possible early brain complications of type 2 diabetes). type2diabetes), Diabetologia, 2007;50(4):711-9; Li M et al., Atrophy patterns of hippocampal subfields in T2DM patients with cognitive impairment, Endocrine, 2020;68:536-48), even in the early stages (Dong S et al., Individuals in the prediabetes stage exhibit reduced hippocampal tail volume and executive dysfunction, Brain Behav 2019;9(8):e01351). Gao De et al. found deficits in hippocampal-based memory performance and preservation of other cognitive domains. They reported that brain volume reduction in individuals with diabetes was limited to the hippocampus relative to controls, and that glycemic control was inversely related to hippocampal volume.

[0017] In addition to hippocampal atrophy in type 2 diabetes, hippocampal atrophy is also a prominent early aspect of neurological degeneration in sporadic Alzheimer's disease (Dubois B, Feldman HH, Jacova C, et al., Advancing research diagnostic criteria for Alzheimer's disease: the IWG-2 criteria. Lancet Neurol. 2014;13:614-29), the most common form of dementia in which hippocampal Cu levels are severely reduced to values ​​similar to brain Cu levels reported in Menkes disease (JA Walker-Smith et al., Therapeutic implications of copper deficiency in Menkes-Stein syndrome. Archives of Disease in Childhood 1973;48:958-62). However, copper levels in the cerebrospinal fluid of AD patients are 2.2 times higher than controls, and increased levels of ceruloplasmin in the brain and cerebrospinal fluid have been observed. Basun H et al., Metals and trace elements in plasma and cerebrospinal fluid in normalaging and Alzheimer's disease, J. Neural. Transm. Park Dis. Dement. Sect., 1991;3:231-258.

[0018] Longitudinal epidemiological studies have implicated chronic hyperglycemia and microvascular disease in the pathogenesis of diabetes-related cognitive dysfunction, but the causal pathways underlying the statistical association between type 2 diabetes and dementia are unknown (McCrimmon RJ et al. Diabetes and cognitive dysfunction. Lancet 2012;379:2291-9).

[0019] We unexpectedly found that brain hippocampal copper was significantly elevated in type 2 diabetes, approaching literature values ​​for Wilson's disease, a copper-excess neurodegenerative disease, whereas in contrast, we found hippocampal copper values ​​to be severely deficient in the brains of patients with sporadic Alzheimer's disease, as in Menkes disease, a copper-deficient neurodegenerative disease. We also found that elevated hippocampal copper levels were the only substantial disturbance in essential metal homeostasis in the brains of patients with type 2 diabetes, with no changes in the organization of the frontal or temporal cortex or meninges.

[0020] The present invention discloses and claims a method of reducing hippocampal copper levels for treating a patient suffering from diabetes or vascular dementia who exhibits or is at risk of impaired cognitive function, cognitive decline, or who exhibits signs of cerebral neurodegeneration and / or dementia. Summary of the invention

[0021] The invention described and claimed herein has many attributes and embodiments, including but not limited to those set forth or described or mentioned in the Summary of the Invention. It is not intended to be fully inclusive, and the invention described and claimed herein is not limited to or by the features or embodiments identified in this Introduction, which are included for illustrative purposes only and not limiting.

[0022] The present invention relates to a method for treating or preventing impaired cognitive function, cognitive decline, or symptoms of degeneration of the brain nervous system or dementia in a subject with diabetes, comprising administering to the subject a pharmaceutical composition comprising a compound capable of reducing, lowering or normalizing copper levels and / or copper metabolism. In some embodiments of the method, the compound is a copper antagonist, such as a copper deprivation agent, a copper masking agent, or a copper remover. In some embodiments, the compound is a copper chelator. In some embodiments, the method of the present invention causes the copper value in the subject to be within the normal range. In some embodiments, the method of the present invention causes the copper value in the subject to be within 75% to 110% of the normal range. In some embodiments, the method of the present invention causes the hippocampal copper to be within the normal expected range, or at least causes the copper to be reduced or causes the copper to be reduced to a range that reduces impaired cognitive function, cognitive decline, or symptoms of degeneration of the brain nervous system or dementia. In some embodiments, the method of the present invention is used to cause the copper level in the blood of the subject to be within about 70 to 140 micrograms / deciliter (mcg / dL). Copper levels can be assessed and monitored, for example, using urinalysis. Serum and fecal copper measurements are also available, but urine copper measurements are preferred.

[0023] In some embodiments, the method for treating or preventing impaired cognitive function, cognitive decline or brain neurological degeneration symptoms or dementia in a subject with diabetes comprises administering to the subject a composition comprising or consisting essentially of a copper chelator or other copper binding compound or copper remover. In some embodiments, the composition reduces the total copper in the subject. In some embodiments, the composition reduces the copper value in the subject. In some embodiments, the composition reduces the amount of copper (II) and / or copper (I) in the subject. In some embodiments, the composition reduces excessive copper (II) and / or copper (I) in the subject. In some embodiments, the composition reduces excessive hippocampal copper in the subject. In some embodiments, the excessive hippocampal copper in the subject is copper (II). In some embodiments, the excessive hippocampal copper in the subject is copper (I). In some embodiments, the composition chelates copper (II) and copper (I) in the subject. In some embodiments of the method, the active ingredient in the composition is trientine. In some embodiments, trientine is triethylenetetramine disuccinate. In some embodiments, trientine is triethylenetetramine dihydrochloride or triethylenetetramine tetrahydrochloride.

[0024] In some embodiments of the method, the subject treated in the aforementioned method suffers from vascular dementia with or without diabetes, such as with or without type 1 diabetes, with or without type 2 diabetes, with or without type 3 diabetes and / or with or without type 4 diabetes.

[0025] In some embodiments of the method, one or more symptoms of the treated condition (e.g., impaired cognitive function, cognitive decline, or degenerative symptoms of the brain nervous system and / or dementia) are reduced or alleviated. In some method embodiments, one or more symptoms of the treated condition (e.g., impaired cognitive function and / or dementia, etc.) are substantially eliminated.

[0026] In some embodiments, the methods of the present invention are used to treat frontotemporal dementia (FTD). In some embodiments of the methods, one or more symptoms of frontotemporal dementia are reduced or alleviated. In some method embodiments, one or more symptoms of frontotemporal dementia are substantially eliminated.

[0027] In some embodiments, the methods of the present invention are used to treat frontotemporal dementia (FTLD). In some embodiments of the methods, one or more symptoms of frontotemporal dementia are reduced or alleviated. In some method embodiments, one or more symptoms of frontotemporal dementia are substantially eliminated.

[0028] In some embodiments, the methods of the invention are used to treat amyotrophic lateral sclerosis (ALS) and / or associated motor neuron disease (MND) dementia. In some embodiments of the methods, one or more symptoms of ALS and / or MND are reduced or alleviated. In some method embodiments, one or more symptoms of ALS and / or MND are substantially eliminated.

[0029] In some embodiments, the methods of the present invention are used to treat dementia with Lewy bodies (DLB). In some embodiments of the methods, one or more symptoms of DLB ​​are reduced or alleviated. In some method embodiments, one or more symptoms of DLB ​​are substantially eliminated.

[0030] In some embodiments, the methods of the present invention are used to treat multiple sclerosis (MS). In some embodiments of the methods, one or more symptoms of MS are reduced or alleviated. In some method embodiments, one or more symptoms of MS are substantially eliminated.

[0031] In some embodiments, methods of treating FTD, FTLD, ALS, MND, DLB, and MS comprise administering to a subject a pharmaceutical composition comprising a compound capable of normalizing copper metabolism. In some embodiments, the compound capable of reducing or lowering copper values, copper levels, or total copper, or capable of normalizing copper values, copper levels, total copper, or copper metabolism is a copper chelator or other copper binding agent or a copper remover. Other embodiments of these methods and agents, compounds, compositions, and procedures useful for these methods are described herein.

[0032] In some embodiments of the method, the subject suffers from diabetes and dementia and / or cognitive decline and / or cognitive and / or memory impairment. In certain embodiments, the subject suffers from type 2 diabetes. In other embodiments, the subject suffers from type 1 diabetes. In certain embodiments, the subject suffers from type 3 diabetes. In certain embodiments, the subject suffers from type 4 diabetes.

[0033] In some embodiments, the subject being treated has type 1 diabetes, and one or more of the cognitive domains negatively affected by the subject's cognitive impairment is a decrease in global cognition, fluid and crystallized intelligence, information processing speed, psychomotor efficiency, visual and sustained attention, mental flexibility, and / or visual perception.

[0034] In some embodiments, the subject being treated has type 2 diabetes, and one or more of the cognitive domains negatively affected by the subject's cognitive impairment is memory (verbal memory, visual retention, working memory, immediate recall, delayed recall), psychomotor speed and frontal / executive function, processing speed, complex motor function, verbal fluency, and / or attention.

[0035] In some embodiments, cognitive impairment prevents an individual with diabetes (eg, type 2 diabetes) from concentrating, recalling memories, and / or causes mental fatigue.

[0036] In some embodiments of the methods of the present invention, the structural relevance of diabetes-related cognitive impairment is assessed with brain magnetic resonance imaging (MRI). MRI can be used to assess subjects before and / or during treatment. In some embodiments, when assessing cognitive impairment in patients with diabetes (e.g., patients with type 2 diabetes) treated as described herein, MRI is used to examine or confirm the presence of normal or abnormal brain structures before and / or during treatment.

[0037] In some embodiments, in patients with type 2 diabetes, for example, white matter hyperintensities are associated with decreased performance on tests of attention, executive function, information processing speed, and memory, and provide a structural basis for treatment with the compounds of the invention. In some embodiments, MRI is used to examine or confirm the presence of white matter hyperintensities before and / or during treatment.

[0038] In some embodiments, MRI is used to demonstrate or confirm that, before treatment with the compounds of this invention, a subject with diabetes (e.g., type 2 diabetes) suffers from lacunar infarctions, hippocampal atrophy and / or amygdala atrophy or other hippocampal defects, including hippocampal atrophy patterns. In some embodiments, MRI is used to assess, during treatment with the compounds of this invention, a subject with diabetes (e.g., type 2 diabetes) suffers from hippocampal and / or amygdala atrophy or other hippocampal defects, including hippocampal atrophy patterns.

[0039] In some embodiments, MRI is used to assess hippocampal and / or amygdala atrophy in a subject with type 2 diabetes before, during, and / or after treatment according to the methods of the invention.

[0040] In some embodiments, the present invention relates to a method for treating or preventing impaired cognitive function in an object suffering from vascular dementia (sometimes also referred to as vascular cognitive impairment or VCI), comprising administering to the object a pharmaceutical composition comprising a compound capable of normalizing copper metabolism. In some embodiments, the object may or may not suffer from diabetes, such as type 1 diabetes, type 2 diabetes, type 3 diabetes, and type 4 diabetes. In some embodiments, the compound capable of reducing or lowering copper values, copper levels, or total copper or capable of normalizing copper values, copper levels, total copper, or copper metabolism is a copper chelator or other copper binder or copper remover. In some embodiments, the object suffering from vascular dementia or VCI has problems in reasoning, planning, judgment, memory, and other thought processes. In some embodiments, the composition reduces the total copper in the object. In some embodiments, the composition reduces the copper value in the object. In some embodiments, the composition reduces the amount of copper (II) and / or copper (I) in the object. In some embodiments, the composition reduces excessive copper (II) and / or copper (I) in the object. In some embodiments, the composition reduces excessive hippocampal copper in the object. In some embodiments, the excess hippocampal copper in the subject is copper (II). In some embodiments, the excess hippocampal copper in the subject is copper (I). In some embodiments, the composition chelates copper (II) and / or copper (I) in the subject. In some embodiments, the active ingredient in the composition is trientine. In some embodiments, trientine is triethylenetetramine disuccinate, triethylenetetramine dihydrochloride, and / or triethylenetetramine tetrahydrochloride.

[0041] In some embodiments of the methods of the present invention, the compound capable of normalizing copper metabolism is capable of reducing or lowering elevated copper in a subject.

[0042] In some embodiments of the methods of the present invention, the copper antagonist (e.g., copper reducing / removing or copper normalizing compound) in the composition binds copper 2+ In some embodiments, the copper antagonist compound in the composition chelates copper 2+ In some embodiments of the methods of the present invention, the copper removal agent in the composition administered to the subject is combined with copper 2+ . Thereby reducing total copper, copper values ​​and / or hippocampal copper in the subject.

[0043] In some embodiments of the methods of the present invention, the compound administered that is effective in reducing the total copper or copper value content in the subject is a copper chelating compound. In some embodiments, the compound administered that is effective in reducing the total copper or copper value content in the subject comprises, consists essentially of, or consists of an agent that binds or chelates copper (I). In other embodiments, the compound administered that is effective in reducing the total copper or copper value content in the subject comprises, consists essentially of, or consists of an agent that binds or chelates copper (II). In other embodiments, the agent administered that is effective in reducing the total copper or copper value content in the subject comprises, consists essentially of, or consists of an agent that binds or chelates both copper (I) and copper (II).

[0044] In one embodiment, the compound effective for reducing copper, total copper or copper value (and thus hippocampal copper) in a subject comprises or consists essentially of or consists of a compound selected from the group consisting of: D-penicillamine; N-acetylpenicillamine; triethylenetetramine (also known as TETA, TECZA, trien, triene and trientine) and pharmaceutically acceptable salts thereof; trithiomolybdate, tetrathiomolybdate, ammonium tetrathiomolybdate, choline tetrathiomolybdate; bis-choline tetrathiomolybdate (thiomolybdate USAN, trade name Decuprate), 2,2,2-tetraaminetetrahydrochloride; 2,3,2-tetraaminetetrahydrochloride; ethylenediaminetetraacetate (EDTA, a non-preferred non-specific metal binder, used with caution to avoid toxicity); diethylenetriaminetetraacetic acid (DPTA, a non-preferred non-specific metal binder, used with caution to avoid toxicity due to essential metals such as Zn and Mn chelation-induced toxicity); 5,7,7'12,14,14'-hexamethyl-1,4,8,11-tetraazacyclotetradecane; 1,4,8,11-tetraazacyclotetradecane, including cyclam S, cylams and copper-chelated cyclam derivatives such as Bn-cyclam-EtOH, oxo-cyclam-EtOH and oxo-Bn-cyclam-EtOH, (HOCH2CH2CH2)2(PhCH2)2 Blue and (HOCH2CH2CH2)2(4-CF3PhCH2)2 Cyclamen; 1,4,8,11-tetraazacyclotetradecane-1,4,8,11-tetraacetic acid; 1,4,8,11-tetraazabicyclo[6.6.2]hexadecane; 4,11-bis(N,N-diethyl-amidomethyl)-1,4,8,11-tetraazabicyclo[6.6.2]hexadecane; 4,11-bis(amidoethyl)-1,4,8,11-tetraazabicyclo[6.6.2] Hexadecane; melatonin; cyclic 3-hydroxymelatonin (3OHM); N(1)-acetyl-N(2)-formyl-5-methoxykynurenine (AFMK); N(1)-acetyl-5-methoxykynurenine (AMK); N,N'-diethyldithiocarbamate; bathocuproine disulfonicacid; bathocuproine disulfonate; trimetazidine; triethylenetetramine tetrahydrochloride; 2,3,2-tetramine; 1,10-phenanthroline; 3,4-dihydroxybenzoic acid; 2,2'-bicinchinonic acid acid); diamsar; 3,4',5, trihydroxystilbene (resveratrol); mercaptodextran; disulfiram (Antabuse); sarcophagine; DiAmSar; diethylenetriaminepentaacetic acid; and trisodium calcium diethylenetriaminepentaacetate; neocuproine; bathocuproine; and carnosine. In some embodiments, the compound or agent that reduces the amount and / or level of copper, reduces total copper, or reduces the copper value content preferentially binds to Cu. 1+ In another embodiment, the compound or agent that reduces the amount and / or level of copper, reduces total copper or reduces the copper value content preferentially binds to Cu 2+ In some embodiments, Cu is preferentially bound 2+ The compound or agent for reducing the amount and / or level of copper, reducing total copper or reducing the copper value content is triethylenetetramine disuccinate. In another embodiment, the compound or agent combines Cu 1+ and Cu 2+ In some embodiments, Cu is preferentially bound 1+ and Cu 2+ The compound or agent that reduces the amount and / or level of copper, reduces total copper or reduces the copper value content is a penicillamine copper chelator. In some embodiments, the penicillamine copper chelator is D-penicillamine.

[0045] In some embodiments, the agent is administered to reduce total copper and / or hippocampal copper in the subject. In some embodiments, the pharmaceutical composition used in the methods of the present invention comprises a therapeutically effective amount of triethylenetetramine and a pharmaceutically acceptable carrier, glidant, diluent or excipient. In some embodiments, triethylenetetramine is in the form of a pharmaceutically acceptable salt.

[0046] In another embodiment, the compound or agent is administered to reduce total copper and / or hippocampal copper to maintain total copper in the subject within the normal human serum or plasma range of about 0.8 to 1.2 mg / L or about 10 to 25 micromoles / L. In another embodiment, the agent used to reduce copper maintains total copper in the subject within at least about 70%, such as at least about 75%, of the normal range of about 0.8 to 1.2 mg / L or about 10 to 25 micromoles / L. In another embodiment, the compound or agent used to reduce copper maintains total copper in the subject within about 75% to about 85%, or about 85% to about 95% of the normal range of copper in human plasma or serum. In one aspect of the methods of the invention, the copper status of the subject to whom the copper reducing compound or agent is provided is determined by assessing copper in the subject's urine. In some embodiments, the copper status of the subject to whom the copper reducing compound or agent is provided is determined by assessing copper in the subject's plasma. In some embodiments, the copper status of the subject to whom the copper reducing compound or agent is provided is determined by assessing copper in the subject's liver.

[0047] In one embodiment, the triethylenetetramine is the hydrochloride salt of triethylenetetramine. In some embodiments, the triethylenetetramine is the succinate salt of triethylenetetramine.

[0048] In one aspect of the invention, the method employs a pharmaceutical composition comprising substantially pure triethylenetetramine disuccinate and a pharmaceutically acceptable excipient. In another aspect, the method employs a pharmaceutical composition comprising substantially pure triethylenetetramine dihydrochloride and / or tetrahydrochloride and a pharmaceutically acceptable excipient.

[0049] In one aspect of the invention, the method employs a pharmaceutical composition comprising triethylenetetramine disuccinate in crystalline form or triethylenetetramine hydrochloride in crystalline form. In another aspect of the invention, the method employs a pharmaceutical composition comprising anhydrous triethylenetetramine disuccinate or anhydrous triethylenetetramine hydrochloride.

[0050] In certain embodiments, the triethylenetetraamine succinate salt is a triethylenetetraamine disuccinate polymorph. In certain embodiments, the triethylenetetraamine hydrochloride salt is a triethylenetetraamine hydrochloride salt polymorph.

[0051] In some embodiments of the methods of the invention, the methods comprise administering to the subject a therapeutically effective amount of a compound selected from the group consisting of trientine, a succinate addition salt of triethylenetetramine, a hydrochloric acid addition salt of triethylenetetramine and a pharmaceutically acceptable salt of D-penicillamine, N-acetylpenicillamine, tetrathiomolybdate, ammonium tetrathiomolybdate and choline tetrathiomolybdate. The compound reduces total copper, copper values ​​and / or hippocampal copper in the treated subject, and one or more symptoms of impaired cognitive function, cognitive decline and / or dementia described herein, including vascular dementia. The reduction in total copper or copper values ​​in the subject results in a reduction in hippocampal copper and is a surrogate for a reduction in hippocampal copper.

[0052] In some embodiments of the methods of the present invention, the subject shows signs of brain degeneration or impaired cognitive function before treatment. In other embodiments, the subject suffers from brain degeneration or impaired cognitive function or suffers from cognitive decline and / or dementia or is at risk thereof. The risk of these conditions can be determined by measuring the copper level in the subject. In some embodiments, copper is measured in the urine of the subject before treatment, during treatment, or both. Other risk factors for diagnosing diabetes, such as atrophy of the hippocampus and / or amygdala as shown by MRI, or reduced glucose absorption in the hippocampus and / or amygdala as shown by positron emission tomography (PET) screening.

[0053] In some embodiments, subjects with diabetes or vascular dementia have elevated urinary copper output. In some embodiments, subjects with diabetes or vascular dementia have diminished spatial memory or the ability to remember direction, position, and orientation. In some embodiments, subjects with diabetes or vascular dementia have elevated urinary copper output and diminished spatial memory or the ability to remember direction, position, and orientation.

[0054] In some embodiments of the methods of the present invention, the methods further comprise administering one or more additional therapeutic agents selected from anti-inflammatory agents, agents for treating cardiovascular disease, agents for treating hypertension, agents for treating kidney disease, agents for treating depression, and agents for treating type 2 diabetes and / or dementia.

[0055] In some embodiments, the one or more additional therapeutic agents for treating type 2 diabetes are selected from the group consisting of: alpha-glucosidase inhibitors, biguanides, dopamine agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 receptor agonists, meglitinides, sodium-glucose transporter (SGLT) 2 inhibitors, sulfonylureas, and thiazolidinediones.

[0056] In some embodiments, the one or more additional therapeutic agents for treating dementia are selected from the group consisting of: cholinesterase inhibitors, antibodies targeting amyloid beta protein (a biomarker for Alzheimer's disease and other dementias), and N-methyl-D-aspartate (NMDA) receptor antagonists. In some embodiments, the cholinesterase inhibitor is donepezil (Aricept), galantamine (Razadyne, Razadyne ER, Reminyl), or Rivastigmine (Exelon). In some embodiments, the antibody targeting amyloid beta protein is Aducanumab-avwa (Aduhelm). In some embodiments, the NMDA receptor antagonist is memantine (Axura, Ebixa, Namenda, etc.).

[0057] In some embodiments, the subject is a human.

[0058] In some embodiments, the pharmaceutical composition is administered orally in the form of a capsule or tablet.

[0059] In some embodiments, the compound is triethylenetetramine dihydrochloride and is administered in an amount of about 1200 mg per day. In some embodiments, 1200 mg triethylenetetramine dihydrochloride is administered in 600 mg divided doses BID, in 400 mg divided doses TID, or in 300 mg divided doses QID.

[0060] In certain embodiments, the compound is triethylenetetramine disuccinate, and is used in a dosage of about 2400mg to about 3000mg or larger every day. In certain embodiments, the compound is triethylenetetramine disuccinate, and is used in an amount of about 2800mg every day. Other useful dosages of triethylenetetramine disuccinate are provided to be equal to about 1050mg / days to about 2300mg / days, about 1400mg / days to about 3500mg / days, about 2400mg / days to about 3200mg / days and about 2800mg / days to about 5600mg / days. In certain embodiments, these daily triethylenetetramine disuccinate amounts are used in divided doses.

[0061] The present invention also provides a therapeutic treatment kit for treating or preventing impaired cognitive function in a subject with diabetes, comprising: a) a pharmaceutical composition comprising a copper antagonist compound capable of reducing or lowering copper in the subject, such as reducing or lowering copper values, reducing or lowering total copper, reducing or lowering copper levels and / or amounts (e.g., urinary copper levels and / or amounts), and / or normalizing copper metabolism, including one or more of the compounds described herein, including copper (I) and / or copper (II) chelators; and b) instructions for use for therapeutic treatment or prevention of impaired cognitive function, cognitive decline, and / or dementia, etc., described herein in a subject with diabetes. In some embodiments, the subject suffers from type 1, type 2, type 3, or type 4 diabetes. In some embodiments, the subject of the instructions suffers from vascular dementia with or without diabetes.

[0062] In some embodiments, the compound in the kit is selected from the group consisting of triethylenetetramine dihydrochloride, triethylenetetramine tetrahydrochloride, and triethylenetetramine disuccinate. In some embodiments, the triethylenetetramine disuccinate in the kit is anhydrous triethylenetetramine disuccinate.

[0063] In one aspect, the invention comprises an article of manufacture comprising a package insert instructing a user to administer a copper antagonist compound capable of reducing or lowering copper in the subject, e.g., reducing or lowering copper values, reducing or lowering total copper, and / or normalizing copper metabolism, to a patient with diabetes and a condition or disorder characterized by dementia (or risk of dementia), including one or more of the compounds described herein, including copper (I) and / or copper (II) chelators. The condition or disorder characterized by dementia in a patient with diabetes may be Alzheimer's disease. The condition or disorder characterized by dementia in a patient with diabetes may be vascular dementia.

[0064] In another aspect, the comorbidity in patients with dementia (or patients at risk of dementia) that can be treated with a compound capable of normalizing copper metabolism (e.g., one or more of the copper chelators described herein) is characterized by excess copper, such as type 2 diabetes. In another aspect, the comorbidity in patients with dementia that can be treated with a compound capable of normalizing copper metabolism (e.g., one or more of the copper chelators described herein) is characterized by copper deficiency, such as Alzheimer's disease. In another aspect, the disease, condition or disorder is selected from the group consisting of diabetes, Alzheimer's disease and Parkinson's disease.

[0065] A preferred pharmaceutical composition for use in the methods of the invention comprises, consists essentially of, or consists of substantially pure triethylenetetramine disuccinate. Another preferred composition comprises, consists essentially of, or consists of substantially pure anhydrous triethylenetetramine disuccinate. Another preferred composition is a composition comprising, consists essentially of, or consists of substantially pure triethylenetetramine disuccinate crystals having alternating layers of triethylenetetramine molecules and succinate molecules.

[0066] In another aspect of the invention, the methods of the invention maintain copper levels in a subject at about 70% to about 110% of normal, thereby inducing an effect by lowering copper values ​​and / or reducing or decreasing hippocampal copper levels in the mammalian patient.

[0067] The foregoing summary and the following detailed description are exemplary and explanatory. They are intended to provide further details of the present invention, but should not be interpreted as limiting. Other objectives, advantages and novel features will be apparent to those skilled in the art from the following detailed description of the present invention. BRIEF DESCRIPTION OF THE DRAWINGS

[0068] Figure 1 Concentrations of nine essential elements (A to I) in four human brain regions compared between control (red) and T2D (green) postmortem tissue are shown. Data are mean ± 95% CI. In the MN data, a single outlier for both Mg and Cu analyses was removed from the graph for clarity: this did not change the results or conclusions. Nonstandard abbreviations: FC, frontal cortex; TC, temporal cortex; HP, hippocampus; MN, meninges.

[0069] Figure 2 Display corresponds to Figure 1 Data from the second technical replicate of the analysis showing repeated measurements of dry weight concentrations of nine essential elements (A to I) in four brain regions compared between control (red) and T2D (green) human postmortem tissue. Data are mean ± 95% CI. Within the MN, single outliers for Mg and Cu were removed from the graph for clarity of presentation: this did not change the results or conclusions. Non-standard abbreviations: FC: frontal cortex; TC: temporal cortex; HP: hippocampus; MN: meninges.

[0070] Figure 3 shows two-dimensional PCA and PLS-DA plots of VIP scores for human dry weight hippocampal postmortem tissue. Data represent A) PCA and B) PLS-DA plots of AD (red; n = 9), control (green; n = 14) and T2D (blue; n = 6) hippocampal tissue. The colored ellipse plots of the PCA and PLS-DA plots represent 95% confidence regions. In the PCA plot, the first principal component (PC1) represents 48.3% of the total variance, while the second (PC2) represents 19.3%. In both the PCA and PLS-DA plots, the two cases (AD relative to T2D) exhibit almost complete separation, while there is a significant overlap between T2D and the control. The VIP score plot (bottom) shows the relative contribution of each metal to the variance between AD, T2D and the control in C) component 1 and D) component 2. Larger VIP scores indicate a greater contribution to group separation. The colored box on the right indicates whether the metal concentration in the affected group is increased (red) or decreased (green). Cu, Na and Mn obtained the top three VIP scores for both components, with Na obtaining the highest VIP score for both components. Nonstandard abbreviations: AD: Alzheimer's disease; Con: control; PCA: principal component analysis; PC: principal components; PLS-DA: partial least squares-discriminant analysis; T2D: type 2 diabetes; VIP: variable projection importance.

[0071] Figure 4 Scree plot showing dry weight hippocampal postmortem tissue. Data represent scree plot showing individual variance explained in the first five dimensions after PCA of the hippocampus.

[0072] Figure 5 shows two-dimensional PCA and PLS-DA plots of human dry weight T2D temporal cortex and AD temporal gyrus postmortem tissue. Data represent Figure 5 (A) PCA and Figure 5 (B) PLS-DA plots of AD (red; n = 9; mineral temporal gyrus), control (green; n = 13; temporal cortex / middle temporal gyrus) and T2D (blue; n = 6: temporal cortex). The colored ellipse plots of the PCA and PLS-DA plots represent 95% confidence regions. And in the PCA plot, the first principal component (PC1) represents 41.2% of the total variance, while the second (PC2) represents 24.5%. The two cases (AD vs. T2D) do not show separation in the PCA plot, while in the PLS-DA plot, separation is visible due to the inclusion of supervised modeling.

[0073] Figure 6 shows two-dimensional PCA and PLS-DA plots of human dry weight frontal cortex and meningeal postmortem tissue. Data represent control (red; n=6) and T2D (green; n=6) frontal cortex ( Fig. 6A and Figure 6B ) and meninges ( Figure 6C and Fig.6D ) organization PCA( Fig. 6A and Figure 6C) and PLS-DA( Figure 6B and Figure 6C ) Plot. Colored ellipses for PCA and PLS-DA plots represent 95% confidence regions. For both frontal cortex and meningeal postmortem tissue, no separation was visible in either of the multivariate plots. DETAILED DESCRIPTION

[0074] There is a prevalence of both diabetes and dementia in the elderly. The risk of dementia is increased in patients with diabetes, and patients with dementia and diabetes appear to be at greater risk of severe hypoglycemia. The exact factors that lead to the increased risk of dementia in elderly people with diabetes are unclear. Neurobiological changes observed in the aging hippocampus, including increased oxidative stress and neuroinflammation, altered intracellular signaling and gene expression, and reduced neurogenesis and synaptic plasticity, are thought to be associated with age-related cognitive decline. For example, diabetes, including type 2 diabetes, has been shown to increase the risk of cognitive decline and dementia, such as in Alzheimer's disease and vascular dementia.

[0075] The deleterious effects of diabetes on the retina, kidney, cardiovascular and peripheral nervous systems are widely recognized. There is less concern about the effects of diabetes on cognitive function. Both type 1 and type 2 diabetes have been found to be associated with decreased performance in many areas of cognitive function. The exact pathophysiology of cognitive dysfunction in diabetes is not yet fully understood, but it is believed that hyperglycemia, vascular disease, hypoglycemia and insulin resistance may play an important role. Over the years, the methods of studying the effects of diabetes on the brain have evolved, including neurocognitive testing, evoked response potentials and magnetic resonance imaging, and can be used for use in combination with the method of the present invention before and during treatment.

[0076] A recent meta-analysis included 33 studies investigating cognitive function in adult subjects with diabetes. Kodl and Seaquist, Cognitive Dysfunction and Diabetes, Endocr Rev. 2008 Jun;29(4):494-511. Subjects with type 1 diabetes were found to have significantly reduced global cognition, fluid and crystallized intelligence, information processing speed, psychomotor efficiency, visual and sustained attention, mental flexibility, and / or visual perception compared with controls. There were no differences in memory, motor speed, selective attention, and language. (See Table 1 in Kodl and Seaquist.)

[0077] Cordell and Seaquist in their article reported that patients with type 2 diabetes were also found to have cognitive impairment (ibid., see Table 2 in Cordell and Seaquist). The authors provide a citation stating that type 2 diabetes has been found to be associated with decreased psychomotor speed, frontal / executive function, verbal memory, processing speed, complex motor function, working memory, immediate recall, delayed recall, verbal fluency, visual retention, and attention. The authors reference a study by Sinclair et al. (2000, Cognitive dysfunction in older subjects with diabetes mellitus: impact on diabetes self-management and use of care services, All Wales Research into Elderly (AWARE) Study, Diabetes Res Clin Pract, 50:203-212), which found that subjects with a Mini-Mental State Examination score of less than 23 performed worse on measures of self-care and ability to perform activities of daily living compared with controls, and also showed increased need for personal care and increased hospitalization. Type 2 patients also have an increased incidence of Alzheimer's disease and an increased incidence of vascular dementia. Recently, Bruce et al. found that 17.5% of elderly patients with type 2 diabetes had moderate to severe impairments in activities of daily living, 11.3% had cognitive impairment, and 14.2% had depression (2003, Cognitive impairment, physical disability and depressive symptoms in older diabetic patients: the Fremantle Cognition in Diabetes Study, Diabetes Research Clinical Practice 61:59-67). See also Zillox L. et al., Diabetes and Cognitive Impairment, Curr Diab Rep., 2016 Sep;16(9):87.

[0078] Type 2 diabetes is characterized by chronic hyperglycemia and a tendency to glucose-mediated damage in many organs; impaired copper (Cu) homeostasis; elevated rates of cognitive impairment and dementia; and epidemiological association with sporadic Alzheimer's disease (sAD). In contrast, sAD presents widespread progressive age-related cerebral neurodegeneration and dementia; widespread elevations in brain glucose in the absence of significant hyperglycemia; and widespread brain Cu deficiency.

[0079] The study in the following example describes a method to determine whether sAD-like brain metal disorders occur in T2D, in which the levels of nine essential metals were measured from four brain regions in short postmortem delay cases (n=6) and matched controls (n=6) and compared with case-control data from a sAD study (n=9 / group) conducted using equivalent methods. Intergroup differences in hippocampal data using supervised and unsupervised multivariate statistical methods were compared. To determine whether sAD-like brain metal disorders occur in type 2 diabetes, the levels of nine essential metals were measured from four brain regions in short postmortem delay cases (n=6) and matched controls (n=6) and compared with case-control data from a sAD study (n=9 / group) conducted using equivalent methods. Intergroup differences in hippocampal data using supervised and unsupervised multivariate statistical methods were compared.

[0080] Unexpectedly, hippocampal Cu levels were found to be significantly elevated in T2D (P=0.005 and 0.007 in consecutive technical replicates), approaching literature values ​​in Wilson disease (WD) brains, whereas hippocampal Cu values ​​in sAD were severely deficient in contrast. Multivariate analysis identified significant differences in the corresponding metal-related patterns between hippocampal case-control datasets from type 2 diabetes and sAD.

[0081] In other words, hippocampal copper is significantly elevated in type 2 diabetes, whereas hippocampal copper values ​​are severely deficient in sporadic Alzheimer's disease brains. It should be understood that failure to remove excess copper in WD brains can lead to irreversible brain damage.

[0082] Hippocampus is usually affected in the early stage of the development of neurodegeneration caused by type 2 diabetes and sAD. As shown in the following examples, hippocampus Cu levels significantly increase in type 2 diabetes cases, while by contrast, hippocampus Cu is lacking in sAD, which is consistent with the extensive severe brain Cu deficiency reported therein. Therefore, the mechanism of hippocampus Cu changes is different between type 2 diabetes and sAD. Hippocampus Cu increases will contribute to the pathogenesis of brain neurodegeneration and cognitive impairment in type 2 diabetes, which is consistent with the known adverse effects of similar brain Cu increases in WD. Drawing on the therapeutic brain copper reduction method currently used in WD will be useful for type 2 diabetes patients showing impaired cognitive function as described herein or signs of brain neurodegeneration, etc.

[0083] Given the known adverse effects of elevated brain copper in WD, elevated hippocampal Cu levels are consistent with their contribution to the pathogenesis of cerebral neurodegeneration and cognitive impairment in type 2 diabetes. Therapeutic hippocampal and brain copper lowering methods would be useful in patients with type 2 diabetes who exhibit, are at risk for, or test positive for increased hippocampal and / or brain copper.

[0084] The following example demonstrates that elevated hippocampal Cu levels are the only substantial disturbance of essential metal homeostasis detected in the brains of patients with type 2 diabetes. In contrast, there were no substantial case-control differences in tissues from the frontal or temporal cortex or meninges.

[0085] To further determine the significance of these findings, additional analysis was performed to compare the observations in this case-control study of type 2 diabetes with individual patient measurements from a case-control study of directly comparable sAD, in which brain metal levels were determined by the same method as used herein for type 2 diabetes and control subjects. Unexpectedly and in direct contrast to the findings in type 2 diabetes, the hippocampal Cu levels in sAD were significantly lower than those in matched controls. Therefore, the Cu imbalance pattern (i.e., hippocampal Cu deficiency) in the measured sAD forms a strong contrast with the pattern (hippocampal Cu increase) in type 2 diabetes. Therefore, hippocampal Cu levels increase compared to control values ​​in type 2 diabetes, while decreases compared to controls in sAD. In addition, Cu disorders in sAD are extensive, while Cu disorders in type 2 diabetes may be more limited. It can be concluded that the process that causes or causes a more limited defective Cu homeostasis in type 2 diabetes is fundamentally different from the process that causes extensive brain Cu deficiency in sAD.

[0086] Cu is the third most abundant transition metal in the brain (after Zn and Fe), where it plays an important role in many processes, including cellular respiration, regulation of Fe metabolism, and antioxidant pathways. Defective Cu regulation is known to play an important role in the pathogenesis of two genetic disorders: WD, which is characterized by toxic Cu overload in the liver, eyes, and brain; and Menkes disease, in which, conversely, brain damage is caused by brain Cu deficiency. Both diseases can cause severe neurodegeneration unless normal brain Cu levels are restored by rapid pharmacological intervention after diagnosis. Here, it was determined that the increase in Cu levels measured in the T2D hippocampus was close to the multiple changes reported for WD in areas adjacent to the hippocampus (Table 3).

[0087] Our root cause (RCA) analysis revealed an almost complete separation between the signals of sAD and type 2 diabetes, while type 2 diabetes and control hippocampal tissues showed a large amount of overlap. This is in contrast to the parallel findings in other type 2 diabetes brain regions studied, in which case values ​​and control values ​​overlapped a lot. In order to further examine the distinction between cases and controls, partial least squares-discriminant analysis (PLS-DA) modeling was adopted, which showed a cluster separation similar to the RCA analysis. These findings further illustrate the contrasting patterns of brain metal homeostasis disorders between type 2 diabetes and sAD. Based on PLS-DA modeling, VIP scores show that Na, Mn, Cu and Fe each have a score of >1, showing that these metals provide reliable distinguishing factors for cluster separation. Although Na obtains the highest VIP score in both components, the VIP scores of Cu in components 1 and 2 rank third and second highest, respectively. This shows that Cu is one of the key variables that separate AD and type 2 diabetes clusters, and supports the conclusion that Cu disorder plays a key role in the neuropathogenesis of type 2 diabetes. Consistent with our initial ICP-MS findings, metal dysregulation identified using the same multivariate analysis was not significant between type 2 diabetes and controls in the remaining brain regions. Although common pathophysiological traits were previously observed between AD and type 2 diabetes (S Chatterjee S, A Mudher A, Alzheimer's disease and type 2 diabetes: A critical assessment of the shared pathological traits, Front Neurosci, 2018, June 8; 12:383), these findings support that Cu-related neurodegenerative processes may be opposite in these two diseases.

[0088] In order to detect the possible influence of sample size in this study (T2D is relative to control, n=6 / 6), the post-hoc statistical power test of hippocampal tissue was carried out to confirm that there was no type II error. In two technical repeated experiments, Cu had the highest efficacy level (>0.90; see Table 7 in the following examples), and all other metals had an efficacy level of <0.80. In addition, a priori analysis identified that only Cu had a required sample size limit (n=10) lower than that used in this study. When explaining the measurement differences of other hippocampal metal levels, these efficacy levels were considered. A recent paper reported that brain metal levels were not affected by the PMD length of up to 72 hours. Therefore, it is also concluded that the PMD in this study does not significantly affect brain metal levels. See M. Schofield et al., Evidence that levels of nine essential metals in postmortem human-Alzheimer's-brain and exvivo rat-brain tissues are unaffected by differences in postmortem delay, age, disease staging, and brain bank location. Metallomics 2020;12:952-62.

[0089] In summary, the study in the example provides strong evidence that the hippocampus Cu level increases in type 2 diabetes cases, and the hippocampus Cu correspondingly decreases in sAD. This is the first study to report the multi-regional metal concentration in the type 2 diabetes brain using a metallomics approach, which allows simultaneous quantitative measurement of all essential metals in a manner that other methodologies (such as MRI) cannot achieve. The Cu change multiples in type 2 diabetes are close to those reported in WD, and in WD, nervous system degeneration is due to Cu toxicity. PCA and PLS-DA are used to determine the significant contrast pattern of brain metal levels in type 2 diabetes, sAD and control. Cu has one of the highest VIP scores, indicating that it is responsible for the key distinguishing factor for separation between sAD and type 2 diabetes clusters here. In summary, these findings demonstrate that there is a contrasting nervous system degeneration process in type 2 diabetes and sAD.

[0090] The present invention discloses and claims therapeutic methods for copper reduction and copper normalization for treating diabetic patients who exhibit or are at risk of impaired cognitive function, cognitive decline and / or dementia or exhibit signs of degeneration of the cerebral nervous system. The methods of the present invention may also be used to prophylactically treat or prevent impaired cognitive function, cognitive decline and / or dementia, etc. in diabetic patients. Patients include patients with diabetes (e.g., type 2 diabetes) and / or vascular dementia with or without diabetes. The methods of the present invention may also be used to reduce chelatable copper in these subjects to treat or prevent these conditions.

[0091] In some embodiments, copper lowering and copper normalizing therapeutic methods are disclosed and claimed for treating (actively or prophylactically) a patient having, suspected of having, or at risk for frontotemporal dementia (FTD). In some embodiments of the methods, one or more symptoms of frontotemporal dementia are reduced or alleviated. In some method embodiments, one or more symptoms of frontotemporal dementia are substantially eliminated.

[0092] In some embodiments, copper lowering and copper normalizing therapeutic methods are disclosed and claimed for treating (actively or prophylactically) a patient having, suspected of having, or at risk for frontotemporal dementia (FTLD). In some embodiments of the methods, one or more symptoms of frontotemporal dementia are reduced or alleviated. In some method embodiments, one or more symptoms of frontotemporal dementia are substantially eliminated.

[0093] In some embodiments, copper lowering and copper normalizing therapeutic methods are disclosed and claimed for treating (actively or prophylactically) a patient having, suspected of having, or at risk of amyotrophic lateral sclerosis (ALS) and / or concomitant motor neuron disease (MND) dementia. In some embodiments of the methods, one or more symptoms of ALS and / or MND are reduced or alleviated. In some method embodiments, one or more symptoms of ALS and / or MND are substantially eliminated.

[0094] In some embodiments, copper lowering and copper normalization therapeutic methods are disclosed and claimed for treating (actively or prophylactically) a patient suffering from, suspected of suffering from, or at risk of dementia with Lewy bodies (DLB). In some embodiments of the methods, one or more symptoms of DLB ​​are reduced or alleviated. In some method embodiments, one or more symptoms of DLB ​​are substantially eliminated.

[0095] In some embodiments, copper lowering and copper normalizing therapeutic methods are disclosed and claimed for treating (actively or prophylactically) a patient having, suspected of having, or at risk for multiple sclerosis (MS). In some embodiments of the methods, one or more symptoms of MS are reduced or alleviated. In some method embodiments, one or more symptoms of MS are substantially eliminated.

[0096] In some embodiments, methods of treating FTD, FTLD, ALS, MND, DLB and / or MS comprise administering to a subject a pharmaceutical composition comprising or consisting essentially of a compound capable of normalizing copper metabolism. In some embodiments, the compound capable of reducing or lowering copper values, copper levels, or total copper or capable of normalizing copper values, copper levels, total copper, or copper metabolism is a copper chelator or other copper binding agent or copper remover. Other embodiments of these methods for treating FTD, FTLD, ALS, MND, DLB and / or MS and agents, compounds, compositions, and procedures useful in these methods are described herein, including, for example, copper antagonists, copper chelators, and compounds capable of normalizing copper values ​​useful therein and in the treatment thereof.

[0097] definition

[0098] Copper(II) is also referred to as Cu(II) or Cu +2 or copper +2 , or "copper valence" (copper +2 The copper (I) mentioned herein is also referred to as Cu(I) or Cu +1 or copper + , or "monovalent copper" (copper +1 cation).

[0099] As used herein, the term "chelatable copper" includes any chelatable form of copper, including different oxidation states, such as copper (I) and copper (II). Thus, the term "copper value" (e.g., elemental copper, copper salts, etc.) means any suitable form of copper that can be used in vivo for such chelation (e.g., in the hippocampus) and / or can be reduced or removed by other means. Certain methods and compositions of the present invention can be used to combine chelatable copper, such as chelatable copper (II), to reduce hippocampal copper while maintaining normal or near-normal copper values ​​(e.g., about 70-110% of normal values, such as 75-105% of normal values, within 80-100% of normal values, or other copper value amounts that are not harmful to the subject).

[0100] The term "pharmaceutical formulation" refers to a preparation in a form that permits the biological activity of the active ingredient contained therein to be effective and that does not contain additional components that are unacceptably toxic to the subject to which the formulation is to be administered. The pharmaceutical formulations of the present invention that can be used to reduce hippocampal copper in diabetes comprise, or consist essentially of, one or more copper antagonists, such as one or more copper deprivation agents, such as one or more copper chelators or binders (alone or with other therapeutic agents), one or more copper sequestering agents, and / or one or more copper removers. A pharmaceutical composition as used herein is a "pharmaceutical formulation". In some embodiments, the pharmaceutical formulations or compositions of the present invention comprise trientine, such as triethylenetetramine disuccinate, and a pharmaceutically acceptable carrier. In some embodiments, the pharmaceutical formulations or compositions are specifically designed for administration to humans with diabetes.

[0101] Copper antagonists, including copper chelators, copper sequestering agents, copper deprivation agents, copper reducing agents, copper removers, alone or with other therapeutic agents (including anti-dementia drugs, therapeutic agents selected from anti-inflammatory agents, agents for treating cardiovascular disease, agents for treating hypertension, agents for treating kidney disease, agents for treating depression, and agents for treating type 2 diabetes and / or dementia, or agents for any other condition disclosed herein), can be administered alone or in combination with one or more additional ingredients, and can be formulated into pharmaceutical compositions including one or more pharmaceutically acceptable excipients, diluents and / or carriers.

[0102] "Pharmaceutically acceptable" means, for example, a carrier, diluent or excipient that is compatible with the other ingredients of the formulation and is generally safe for administration to its recipient or does not cause undesirable adverse physical reactions when administered. As used herein, "pharmaceutically acceptable carrier" refers to an ingredient other than the active ingredient in a pharmaceutical formulation that can be safely administered to a subject. Pharmaceutically acceptable carriers include, but are not limited to, buffers, excipients, stabilizers or preservatives. Pharmaceutically acceptable diluents, carriers and / or excipients include those that can be used to prepare pharmaceutical compositions, can be co-administered with the compounds described herein, while allowing them to perform their intended functions, and are generally safe, non-toxic and neither biologically nor otherwise undesirable. Pharmaceutically acceptable diluents, carriers and / or excipients include those diluents, carriers and / or excipients suitable for veterinary and human pharmaceutical uses. Taking into account the properties of the compounds of the present invention, a person of ordinary skill in the art will readily identify suitable carriers and / or excipients. However, by way of example, diluents, carriers and / or excipients include solutions, solvents, dispersion media, delay agents, polymers and lipid agents, microspheres, emulsions, etc. By way of further example, suitable liquid carriers, particularly for injectable solutions, include water, aqueous saline, aqueous dextrose, etc., with isotonic solutions being preferred for intravenous, intraspinal and intracisternal administration, for example, vehicles such as liposomes, also being suitable for administration of the agents of the invention.

[0103] "Copper chelators" bind or modulate copper, including copper chelators that selectively bind or modulate copper (I) or copper (II) values ​​and are used to reduce or normalize blood and / or tissue copper levels and prevent unwanted copper accumulation. Copper chelators include prodrugs thereof. Included within this definition are other agents that normalize copper values ​​and other agents that selectively bind or modulate copper (II), whether now known or later developed.

[0104] "Copper antagonists" include "copper sequestering agents" and "copper deprivation agents" and "copper reducers," and are agents that can reduce, bind and / or inhibit the ability of copper in any or all of its various forms (e.g., as copper atoms or copper ions (including copper (II) and / or copper (I)) to interact (including in the hippocampus) with any chemical or physical reaction that could otherwise be performed. Copper deprivation agents include chelators, agents that reduce the amount of total copper, agents that reduce copper values, agents that reduce the amount of intracellular copper, including the agents described herein. Copper deprivation agents also include copper modulators, i.e., agents used to reduce hippocampal copper by regulating copper levels in the body (including intracellular levels) or by regulating copper availability. It should be understood that copper is an essential intracellular nutrient, and therefore the present invention includes methods of reducing intracellular copper levels while maintaining safe patient copper levels. Copper deprivation agents include copper removers, i.e., agents that remove copper from the body and / or from inside cells. "Copper removers" are compounds that can selectively bind copper in the form of a complex and remove copper from its binding sites in the body, whereby the complexed Cu ions are preferentially removed from the tissues via the plasma into the urine or feces, thereby being removed from the body. "Copper remover" compounds can be selective for Cu(I), Cu(II), or similarly or equivalently for Cu(I) and Cu(II).

[0105] A "compound capable of normalizing copper values" is a compound that selectively binds copper (Cu) in the tissues of mammals, such as humans, and removes copper from its binding site, wherein the removed Cu is generally in the form of a complex, and by said binding process the body's Cu content is restored to a level that is not significantly different from the level in a comparable physiologically normal individual.

[0106] The term "comprising," which is synonymous with "comprising," "containing," or "characterized by," is inclusive or open-ended and does not exclude additional, unlisted elements or ingredients from a medicament (or, in the case of a method, a step). The phrase "consisting of excludes any element, step, or ingredient not specified in a medicament (or, in the case of a method, a step). The phrase "consisting essentially of refers to the specified materials and those materials that do not materially affect the basic and novel characteristics of the medicament (or, in the case of a method, a step). The basic and novel characteristics of the present invention are described throughout the specification and include the ability of the compounds, compositions, and methods of the present invention to reduce copper levels, reduce total copper, reduce copper values, reduce copper (preferably copper (II)), and / or chelate copper (preferably copper (II)). The basic and novel characteristics of the present invention also include the ability of the compounds, compositions, and methods of the present invention to provide clinically relevant changes in impaired cognitive function by reducing or normalizing copper, copper values, and / or total copper, and thus hippocampal copper, in subjects with diabetes or vascular dementia. In another aspect of one of the methods of the invention, the basic and novel features of other compositions and methods of the invention include the ability to at least partially prevent or reduce the presentation of symptoms of impaired cognitive function, cognitive decline, and / or dementia or cerebral nervous system degeneration in subjects with diabetes (e.g., type 2 diabetes). These concepts are combined with the ability to, for example, reduce or eliminate the harmful effects of excess hippocampal copper. Some symptoms of impaired cognitive function, cognitive decline, dementia, and cerebral nervous system degeneration in subjects with diabetes are described herein, but are not limited to those specific symptoms, but include symptoms known or later identified in the art.

[0107] As used herein, the term "subject" and the like (including "individual" and "patient", all of which are used interchangeably herein) refers to any mammal, including humans. Preferred mammals herein are, for example, humans, including adults, children, including humans with diabetes or vascular dementia. In certain embodiments, the subject, individual or patient is human. In some embodiments, the subject suffers from atrophy of the hippocampus and / or amygdala or another hippocampal structural defect. In some embodiments, MRI or other imaging devices are used to visualize atrophy of the hippocampus and / or amygdala or other hippocampal structural defects in subjects with diabetes. In some embodiments, before and / or during treatment, brain magnetic resonance imaging (MRI) is used to assess the structural relevance of diabetes-related cognitive impairment in the subject. In some embodiments, when assessing cognitive impairment in patients with diabetes (e.g., patients with type 2 diabetes) treated as described herein, MRI is used to examine or confirm the presence of normal or abnormal brain structures before and / or during treatment. In some embodiments, in patients with type 2 diabetes, for example, high white matter signals are associated with decreased performance in attention, executive function, information processing speed and memory tests, and provide a structural basis for treatment with the compounds of the present invention. In certain embodiments, MRI is used to check or confirm the presence of white matter hyperintensities before and / or during treatment. In certain embodiments, MRI is used to show or confirm that before treatment with the compounds of this invention, the object suffering from diabetes (such as type 2 diabetes) suffers from lacunar infarction, hippocampal atrophy and / or amygdala atrophy or other hippocampal defects, including hippocampal atrophy patterns. In certain embodiments, MRI is used to assess during treatment with the compounds of this invention, the hippocampus and / or amygdala atrophy or other hippocampal defects of the object suffering from diabetes (such as type 2 diabetes), including hippocampal atrophy patterns. In certain embodiments, MRI is used to assess before, during and / or after treatment according to the method of the invention, the hippocampus and / or amygdala atrophy of the object suffering from type 2 diabetes.

[0108] As used herein, "mammal" has its ordinary meaning and includes primates (e.g., humans and non-human primates), laboratory animals (e.g., rodents such as mice and rats), farm animals (e.g., cattle, pigs, minks, sheep, and horses), and domestic animals (e.g., dogs and cats).

[0109] As used herein, the term "subjecting a patient to" or "administering" includes any active or passive mode of ensuring the presence in the body of a compound (e.g., triethylenetetraamine disuccinate) for reducing or normalizing copper, copper values, total copper, etc., including hippocampal copper levels. Preferably, the mode of administration is oral. However, all other modes of administration (particularly parenteral, e.g., intravenous, intramuscular, CNS, etc.) are contemplated. Also contemplated are nasal administration to bypass the blood-brain barrier, administration of the compounds of the invention with blood-brain barrier penetration enhancers, and cerebrospinal fluid delivery.

[0110] The term "treatment of impaired cognitive function" etc. refers to preventing, slowing down, reducing, lowering, reducing, stopping and / or reversing the impaired cognitive function of the object or one or more symptoms thereof, including, for example, one or more of the reduction in overall cognition, fluid and crystallized intelligence, information processing speed, psychomotor efficiency, visual and sustained attention, mental flexibility and / or visual perception. The term "treatment of impaired cognitive function" etc. can also refer to preventing, slowing down, reducing, reducing, reducing, stopping and / or reversing the impaired cognitive function of the object or one or more symptoms thereof, including, for example, one or more of memory (verbal memory, visual retention, working memory, immediate recall and / or delayed recall, etc.), psychomotor speed and frontal lobe / executive function, processing speed, complex motor function, verbal fluency and / or impaired attention. In some embodiments, cognitive disorders prevent individuals from focusing, recalling memories and / or causing mental fatigue. The compounds and treatment methods described herein can be used to treat impaired cognitive function in diseases, disorders or conditions characterized by excessive or undesirable copper levels in the hippocampus. Compounds and methods of treatment can be used to treat impaired cognitive function, cognitive decline and / or dementia or cerebral nervous system degeneration symptoms in subjects suffering from diabetes (including, for example, type 2 diabetes). In some embodiments, the treated subject suffers from type 1 diabetes, and one or more of the cognitive fields negatively affected by the cognitive impairment of the subject are overall cognition, fluid and crystallized intelligence, information processing speed, psychomotor efficiency, vision and sustained attention, psychological flexibility and / or visual perception. In some embodiments, the treated subject suffers from type 2 diabetes, and one or more of the cognitive fields negatively affected by the cognitive impairment of the subject are memory (verbal memory, visual retention, working memory, immediate recall, delayed recall), psychomotor speed and frontal lobe / executive function, processing speed, complex motor function, verbal fluency and / or attention. In some embodiments, the cognitive impairment treated or prevented is a cognitive impairment that prevents individuals suffering from diabetes (such as type 2 diabetes) from focusing, recalling memory and / or causing mental fatigue.

[0111] "Treating copper excess" refers to preventing, slowing, reducing, lowering, decreasing, stopping and / or reversing, in whole or in part, pathological, excessive or undesirable copper in the hippocampus of a subject, and / or treating one or more symptoms of excessive or undesirable copper. The compounds and treatment methods described herein can be used to treat copper excess. The compounds and treatment methods described herein can be used to remove or reduce undesirable levels or amounts of chelatable copper. The subject will be assessed before and / or during treatment, and copper in urine (or another source) will be measured, and / or a reduction or reversal of hippocampal atrophy will be demonstrated by one or more imaging methods (e.g., by MRI). In some embodiments, excess copper in a subject can be measured by methods such as mass spectrometry analysis of tissue samples, cerebrospinal fluid (CSF) aspirates, and / or urinary copper output. In some embodiments, copper excess treatment can be measured by observing a reduction or reversal of hippocampal atrophy in a subject undergoing treatment using known imaging methods (e.g., MRI, magnetic resonance imaging).

[0112] The term "prevention" means to prevent, improve or control completely or partially. Thus, preventing impaired cognitive function, cognitive decline and / or dementia or signs of degeneration of the cerebral nervous system means to prevent, improve or control one or more symptoms of one or more of these conditions completely or partially. The compounds and treatment methods described herein can be used to prevent copper excess that leads to impaired cognitive function, cognitive decline and / or dementia or signs of degeneration of the cerebral nervous system in diabetes (including, for example, type 2 diabetes).

[0113] As used herein, the term "effective amount" or "therapeutically effective amount" refers to an amount of a compound that can be used to treat hippocampal copper excess. The term "effective amount" or "therapeutically effective amount" is also used to refer to the amount of a copper antagonist compound used to treat and / or prevent impaired cognitive function, cognitive decline and / or dementia or signs of cerebral nervous system degeneration in diabetes (including, for example, type 2 diabetes). Triethylenetetramine disuccinate is one such compound. Exemplary effective amounts of this compound are described herein and include doses ranging from about 2400 mg per day to about 3000 mg per day, which contain a fixed dose of triethylenetetramine disuccinate or are essentially composed of it. In one aspect, the effective amount of triethylenetetramine disuccinate is at least about 95% pure, at least about 99% pure, or 100% pure. In another aspect, the effective amount of triethylenetetramine disuccinate is a crystalline form of triethylenetetramine disuccinate. In yet another aspect of this method, the effective amount of triethylenetetramine disuccinate is anhydrous triethylenetetramine disuccinate. In yet another aspect of the method, an effective amount of triethylenetetraamine disuccinate is in the form of a fixed dose tablet or capsule. In a preferred embodiment, the effective fixed dose of triethylenetetraamine disuccinate is about 350 mg, 400 mg, about 500 mg, about 600 mg or about 700 mg.

[0114] Therefore, in one aspect, an "effective amount" refers to an amount that is effective to achieve the desired therapeutic or preventive result at the necessary dosage and time period. For example, and without limitation, an "effective amount" may refer to an amount of a copper antagonist, such as a copper masking agent or a copper deprivation agent (including those disclosed herein, including, for example, copper chelators, such as triethylenetetraamine disuccinate), which is able to treat impaired cognitive function, cognitive decline and / or signs and / or symptoms of dementia or signs of cerebral neurodegeneration in people with diabetes by reducing or lowering hippocampal copper or hippocampal copper le. Advantageously, these compounds and methods will also reduce excess copper in other areas of the brain. In one embodiment, the effectiveness of the amount is assessed by measuring the subject's response and / or the amount of copper in the subject's urine or plasma after administration of a copper antagonist as disclosed herein. Preferably, the effective amount maintains normal copper levels, or maintains the subject's copper levels within at least about 70% of normal values, preferably within at least about 80% of normal values, within at least about 90% of normal values, within the levels described herein or within other levels. In one embodiment, these are urine copper levels. In other embodiments, serum copper is not reduced by more than about 5-10%, ie, serum copper is maintained within about 90-95% of normal and used as a safety variable.

[0115] As used herein, a "prophylactically effective amount" refers to an amount effective to achieve the desired prophylactic result at the necessary dosage and time period. Typically, but not necessarily, since a prophylactic dose of a copper antagonist is used in a subject before or in an early stage of cognitive impairment, cognitive decline, and / or dementia or degenerative symptoms of the cerebral nervous system, the prophylactic effective amount may be less than the therapeutically effective amount. Once cognitive impairment, cognitive decline, and / or dementia or degenerative symptoms of the cerebral nervous system have been controlled by, for example, one or more initial, bolus or starting doses (all of which are, for example, as described herein), the prophylactic dose may also be used as a maintenance dose.

[0116] As used herein, the terms "treatment" or "treating" of signs and / or symptoms of impaired cognitive function, cognitive decline and / or dementia or degeneration of the cerebral nervous system in a mammal means (i) preventing the condition or disease, i.e., avoiding one or more clinical symptoms of impaired cognitive function, cognitive decline and / or dementia or degeneration of the cerebral nervous system; (ii) inhibiting the development or progression of one or more clinical symptoms of impaired cognitive function, cognitive decline and / or dementia or degeneration of the cerebral nervous system; and / or (iii) alleviating the symptoms of impaired cognitive function, cognitive decline and / or dementia or degeneration of the cerebral nervous system, i.e., causing the regression of one or more clinical symptoms (including one or more of the symptoms described herein). Thus, "treatment" (and grammatical variants thereof, such as "treat" or "treating") generally refers to clinical intervention in an attempt to alter the natural course of the individual, tissue or cell being treated, and may be used for prevention or performed during clinical pathology. The term does not necessarily mean that the subject is treated until full recovery. Thus, "treatment" includes reducing, lowering, alleviating or ameliorating the symptoms or severity of impaired cognitive function, cognitive decline and / or dementia or signs of degeneration of the cerebral nervous system, or preventing or otherwise reducing the risk of developing impaired cognitive function, cognitive decline and / or dementia or signs of degeneration of the cerebral nervous system. It may also include maintaining or promoting a state of complete or partial remission of impaired cognitive function, cognitive decline and / or dementia or signs of degeneration of the cerebral nervous system. The copper antagonist compounds described herein, including, for example, triethylenetetramine disuccinate, are used for treatment.

[0117] As used herein, "associated with" simply means that both conditions exist, and should not be interpreted as meaning that one condition is necessarily causally related to the other condition.

[0118] The structural correlates of diabetes-related cognitive impairment can be assessed using brain magnetic resonance imaging (MRI) before and / or during treatment as described and claimed herein. See Jongen C, Biessels GJ: Structural brain imaging in diabetes: a methodological perspective, Eur J Pharmacol, 2008;585:208-218.

[0119] In some embodiments, as mentioned, when assessing cognitive impairment in patients with diabetes (e.g., type 2 diabetes) treated as described herein (or during thereof), magnetic resonance imaging (MRI) is used to examine or confirm the presence of normal or abnormal brain structures before and / or during treatment. In some embodiments, in patients with type 2 diabetes, for example, white matter hyperintensities are associated with decreased performance in attention, executive function, information processing speed, and memory tests, and provide a structural basis for treatment with the compounds of this invention. In some embodiments, as mentioned, MRI is used to show or confirm that before and / or during treatment with the compounds of this invention, the subject with type 2 diabetes suffers from atrophy of the hippocampus and / or amygdala. In some embodiments, MRI is used to assess the normality and / or atrophy or shrinkage of the hippocampus and / or amygdala of the subject with diabetes before and / or during treatment with the compounds of this invention. Abnormalities in the middle temporal gyrus and / or entorhinal cortex can also be assessed before treatment and / or during recovery during treatment. In some embodiments, the subject suffers from type 2 diabetes. The hippocampus and amygdala are responsible for functions such as memory and behavior, and interestingly, atrophy is also found in Alzheimer's patients.

[0120] The present invention provides a method for treating or preventing impaired cognitive function, cognitive decline and / or dementia or signs of cerebral nervous system degeneration in a subject with diabetes, the method comprising administering to the subject a pharmaceutical composition comprising a compound capable of reducing, lowering or normalizing the level or amount of copper in the hippocampus. In some embodiments, the compound is capable of treating copper overdose. In some embodiments, the compound is a copper antagonist. In some embodiments, the copper antagonist is a copper chelator or other copper binder or remover or sequester. In some embodiments, the copper chelator or other copper binder is trientine. In some embodiments, trientine is triethylenetetramine disuccinate. In other embodiments, trientine is triethylenetetramine dihydrochloride or tetrahydrochloride. In other embodiments, the compound is another compound that is effective in reducing copper in the subject, reducing total copper, or reducing copper value content (and therefore hippocampal copper) as described herein. In other embodiments, the compound is another compound that is now known in the art or later identified as effective in reducing copper in the subject, reducing total copper, or reducing copper value content (and therefore hippocampal copper).

[0121] The present invention also provides methods for treating or preventing cognitive and / or memory disorders in subjects suffering from diabetes. In some embodiments, the subject suffers from type 2 diabetes. In other embodiments, the subject suffers from type 1 diabetes. In some embodiments, the subject suffers from type 3 diabetes. In some embodiments, the subject suffers from type 4 diabetes.

[0122] In some embodiments, the present invention provides a method of treating a subject having diabetes (e.g., type 1 diabetes), and a decrease in one or more of global cognition, fluid and crystallized intelligence, information processing speed, psychomotor efficiency, visual and sustained attention, mental flexibility, and / or visual perception with a copper antagonist, by administering one or more compounds or compositions of the present invention to improve one or more of the subject's global cognition, fluid and crystallized intelligence, information processing speed, psychomotor efficiency, visual and sustained attention, mental flexibility, and / or visual perception.

[0123] In some embodiments, the present invention provides methods of treating a subject with diabetes (e.g., type 2 diabetes) and having one or more negatively affected cognitive domains (including memory (verbal memory, visual retention, working memory and / or immediate recall and / or delayed recall), psychomotor speed and frontal / executive function, processing speed, complex motor function, verbal fluency and / or attention) by administering one or more compounds or compositions of the present invention to improve one or more or another of these negatively affected cognitive domains in the subject. In some embodiments, the cognitive impairment to be treated to prevent is a cognitive impairment that prevents individuals with diabetes (e.g., type 2 diabetes) from concentrating, recalling memory, and / or causing mental fatigue.

[0124] In other embodiments, the present invention relates to a method for treating or preventing impaired cognitive function or cognitive decline in a subject with vascular dementia (sometimes also referred to as vascular cognitive impairment or VCI), comprising administering to the subject a pharmaceutical composition comprising a copper antagonist, the copper antagonist comprising a compound capable of reducing, lowering and / or normalizing copper metabolism. In some embodiments, the subject may or may not have diabetes. In some embodiments, the copper antagonist compound is a copper chelator or other copper binding agent. In some embodiments, subjects with vascular dementia or VCI have problems with reasoning, planning, judgment, memory, and other thought processes, and the compounds, compositions, and methods of the present invention completely or partially reduce and alleviate these problems.

[0125] In some embodiments of the methods of the present invention, the compound capable of normalizing copper metabolism is capable of reducing or ameliorating elevated copper levels in a subject and increasing decreased copper levels in a subject. In some embodiments, the compound capable of reducing elevated copper levels in a subject and increasing decreased copper levels in a subject is trientine. In some embodiments, trientine is triethylenetetramine disuccinate.

[0126] In some embodiments of the methods of the present invention, the copper antagonist is a copper-binding 2+ In some embodiments, the copper-binding compound is a copper chelator. In some embodiments, the copper chelator chelates copper 2+In some embodiments of the methods of the present invention, the copper antagonist is a copper-binding 1+ In some embodiments, the copper-binding compound is a copper chelator. In some embodiments, the copper chelator chelates copper 1+ In some embodiments, the copper chelator chelates copper 1+ and copper 2+ In some embodiments, the agent preferentially binds to Cu 1+ In some embodiments, the agent preferentially binds to Cu 2+ In some embodiments, Cu is preferentially bound 2+ The agent is triethylenetetramine disuccinate. In some embodiments, the agent is combined with Cu 1+ and Cu 2+ In one embodiment, Cu is preferentially bonded 1+ and Cu 2+ Both agents are penicillamine copper chelators, preferably D-penicillamine.

[0127] In some embodiments, the pharmaceutical composition used in the methods of the present invention comprises a therapeutically effective amount of triethylenetetramine and a pharmaceutically acceptable carrier, glidant, diluent or excipient. In some embodiments, triethylenetetramine is in the form of a pharmaceutically acceptable salt.

[0128] In one embodiment, a copper deprivation agent or copper antagonist is an agent that is effective in reducing the copper value or total copper and hippocampal copper in a subject. In another embodiment, the agent administered to a subject with diabetes and / or vascular dementia comprises, consists essentially of, or consists of an agent that binds or chelates copper (II). In another embodiment, the agent comprises, consists essentially of, or consists of an agent that binds or chelates copper (I). In another embodiment, the agent comprises, consists essentially of, or consists of an agent that binds or chelates both copper (I) and copper (II).

[0129] In one embodiment, the copper antagonist or agent effective for reducing copper levels in a subject or otherwise removing excess hippocampal copper comprises or consists essentially of or consists of an agent selected from the group consisting of: D-penicillamine; N-acetylpenicillamine; triethylenetetramine (also known as TETA, TECZA, trien, triene, and trientine) and pharmaceutically acceptable salts thereof; trithiomolybdate, tetrathiomolybdate, ammonium tetrathiomolybdate, choline tetrathiomolybdate; bis-choline tetrathiomolybdate (thiomolybdate USAN, trade name Dekupar), 2,2,2-tetraamine tetrahydrochloride; 2,3,2-tetraamine tetrahydrochloride ; ethylenediaminetetraacetate (EDTA, a non-preferred non-specific metal binder, used with caution to avoid toxicity); diethylenetriaminetetraacetic acid (DPTA, a non-preferred non-specific metal binder, used with caution to avoid toxicity due to chelation of essential metals such as Zn and Mn); 5,7,7'12,14,14'-hexamethyl-1,4,8,11-tetraazacyclotetradecane; 1,4,8,11-tetraazacyclotetradecane, including Cyclamen S, Cyclamens, and copper-chelated Cyclamen derivatives such as Bn-Cyclamen-EtOH, Oxo-Cyclamen-EtOH and Oxo-Bn-Cyclamen-EtOH, (HOCH2CH2C H2)2(PhCH2)2 Cyclamen and (HOCH2CH2CH2)2(4-CF3PhCH2)2 Cyclamen; 1,4,8,11-tetraazacyclotetradecane-1,4,8,11-tetraacetic acid; 1,4,8,11-tetraazabicyclo[6.6.2]hexadecane; 4,11-bis(N,N-diethyl-amidomethyl)-1,4,8,11-tetraazabicyclo[6.6.2]hexadecane; 4,11-bis(amidoethyl)-1,4,8,11-tetraazabicyclo[6.6.2]hexadecane; melatonin; cyclic 3-hydroxymelatonin (3OHM); N(1)-acetyl-N(2)-formyl-5-methyl AFMK; N(1)-acetyl-5-methoxykynurenine (AMK); N,N'-diethyldithiocarbamate; bathocuproin disulfonic acid; bathocuproin disulfonate; trimetazidine; triethylenetetramine tetrahydrochloride; 2,3,2-tetramine; 1,10-phenanthroline; 3,4-dihydroxybenzoic acid; 2,2'-bicinchoninic acid; diamsar; 3,4',5, trihydroxystilbene (resveratrol); mercaptodextran; disulfiram (anthamide); Sarcosafir gold; DiAmSar; diethylenetriamine pentaacetic acid; and diethylenetriamine pentaacetic acid calcium trisodium; neocuprous reagent; bathocuproin; and carnosine.

[0130] In one embodiment, the agent reduces hippocampal copper in the subject. In some embodiments, the agent reduces total copper in the subject. In some embodiments, the copper antagonist or copper reducer maintains total copper in the subject within a normal human serum or plasma range of about 0.8 to 1.2 mg / L or about 10 to 25 micromoles / L. In some embodiments, the copper reducer maintains total copper in the subject within at least about 70%, such as at least about 75%, of the normal range of about 0.8 to 1.2 mg / L or about 10 to 25 micromoles / L. In some embodiments, the copper reducer maintains total copper in the subject within about 75% to about 85%, or about 85% to about 95% of the normal range of copper in human plasma or serum. In some embodiments, one aspect of the copper status of a subject providing a copper antagonist or other copper reducer or an agent for addressing elevated hippocampal or brain copper according to the methods of the present invention is determined by assessing the level or amount of copper in the subject's urine.

[0131] In some embodiments, the compound administered to a subject performing any of the methods of the invention is triethylenetetramine. In some embodiments, the triethylenetetramine is the hydrochloride salt of triethylenetetramine. In one embodiment, the triethylenetetramine hydrochloride salt is triethylenetetramine dihydrochloride. In another embodiment, the triethylenetetramine hydrochloride salt is triethylenetetramine tetrahydrochloride. In another embodiment, the triethylenetetramine is the succinate salt of triethylenetetramine. In one embodiment, the triethylenetetramine succinate salt is triethylenetetramine disuccinate. In one aspect of the invention, the method employs triethylenetetramine disuccinate or triethylenetetramine hydrochloride salt in crystalline form. In another aspect of the invention, the method employs anhydrous triethylenetetramine disuccinate or anhydrous triethylenetetramine hydrochloride salt.

[0132] In one aspect of the invention, the method employs a pharmaceutical composition comprising substantially pure triethylenetetraamine disuccinate. In another aspect, the method employs a pharmaceutical composition comprising substantially pure triethylenetetraamine disuccinate and a pharmaceutically acceptable excipient. In another aspect, the method employs a pharmaceutical composition comprising substantially pure triethylenetetraamine dihydrochloride or tetrahydrochloride and a pharmaceutically acceptable excipient. Preferred pharmaceutical compositions for use in the methods of the invention comprise substantially pure triethylenetetraamine disuccinate or consist essentially of or consist of. Another preferred composition comprises substantially pure anhydrous triethylenetetraamine disuccinate or consists essentially of or consists of. Another preferred composition is a composition comprising substantially pure triethylenetetraamine disuccinate crystals having alternating layers of triethylenetetramine molecules and succinate molecules or consisting essentially of or consists of.

[0133] In certain embodiments, the triethylenetetraamine succinate is a triethylenetetraamine disuccinate polymorph. Triethylenetetraamine disuccinate polymorphs are described in the art. In certain embodiments, the triethylenetetraamine hydrochloride is a triethylenetetraamine hydrochloride polymorph.

[0134] In some embodiments, the present invention comprises a method for treating cognitive impairment in a subject with diabetes and excess hippocampal copper, the method comprising administering to the subject a therapeutically effective amount of a compound selected from the group consisting of trientine, a succinate addition salt of triethylenetetramine, a hydrochloride addition salt of triethylenetetramine and a pharmaceutically acceptable salt of D-penicillamine, N-acetylpenicillamine, tetrathiomolybdate, ammonium tetrathiomolybdate and choline tetrathiomolybdate. In some embodiments, these compounds are used to treat and / or prevent impaired cognitive function, cognitive decline and / or dementia or signs of degeneration of the cerebral nervous system in these subjects, including subjects with type 1 diabetes, type 2 diabetes, type 3 diabetes, type 4 diabetes and / or vascular dementia.

[0135] In some embodiments of the methods of the invention, the subject exhibits signs of brain degeneration prior to treatment. In other embodiments, the subject suffers from or is at risk of impaired cognitive function, cognitive decline and / or dementia or signs of brain neurodegeneration.

[0136] In some embodiments, subjects with diabetes and / or vascular dementia have diminished spatial memory or the ability to remember direction, location, and orientation.

[0137] In some embodiments of the methods of the present invention, the methods further comprise administering one or more additional therapeutic agents selected from anti-inflammatory agents, agents for treating cardiovascular disease, agents for treating hypertension, agents for treating kidney disease, agents for treating depression, and agents for treating type 2 diabetes and / or dementia.

[0138] In some embodiments, the one or more additional therapeutic agents for treating type 2 diabetes are selected from the group consisting of: alpha-glucosidase inhibitors, biguanides, dopamine agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 receptor agonists, meglitinides, sodium-glucose transporter (SGLT) 2 inhibitors, sulfonylureas, and thiazolidinediones.

[0139] In some embodiments, one or more additional therapeutic agents for treating dementia are selected from the group consisting of: cholinesterase inhibitors, antibodies targeting amyloid beta protein (a biomarker for Alzheimer's disease and other dementias), and N-methyl-D-aspartate (NMDA) receptor antagonists. In some embodiments, the cholinesterase inhibitor is donepezil (Aricept), galantamine (Lazadin, Lazadin ER, Liyilin) ​​or levosteramine (Exelon). In some embodiments, the antibody targeting amyloid beta protein is Avadulumab (Aiduron). In some embodiments, the NMDA receptor antagonist is memantine (Aisura, Ibis, Nameda, etc.).

[0140] In some embodiments, the subject is a human.

[0141] In some embodiments, the pharmaceutical composition is administered orally in the form of a capsule or tablet.

[0142] In some embodiments, the compound is triethylenetetramine dihydrochloride and is administered in an amount of about 1200 mg per day. In some embodiments, 1200 mg triethylenetetramine dihydrochloride is administered in 600 mg divided doses BID, in 400 mg divided doses TID, or in 300 mg divided doses QID.

[0143] In certain embodiments, the compound is triethylenetetramine disuccinate, and is used in a dosage of about 2400mg to about 3000mg or larger every day. In certain embodiments, the compound is triethylenetetramine disuccinate, and is used in an amount of about 2800mg every day. Other useful dosages of triethylenetetramine disuccinate are provided to be equal to about 1050mg / days to about 2300mg / days, about 1400mg / days to about 3500mg / days, about 2400mg / days to about 3200mg / days and about 2800mg / days to about 5600mg / days. In certain embodiments, these daily triethylenetetramine disuccinate amounts are used in divided doses.

[0144] In another aspect of the invention, the methods of the invention maintain copper levels in a subject at about 70% to about 100% of normal values, thereby inducing an effect by lowering copper values ​​and / or reducing or lowering copper levels in a mammalian patient. In some embodiments, the methods of the invention maintain copper levels in a subject at about 70% to about 110% of normal values. Soon after initiation of treatment, urinary copper output values ​​may be up to about 300-35% of normal values, and these values ​​typically drop to about 200-250% of normal values ​​after 4-12 months.

[0145] In certain embodiments, triethylenetetraamine disuccinate is administered with an initial dose (or starting dose) followed by a maintenance dose, wherein the starting dose is about or at least 1.5 times, about or at least 2 times, about or at least 2.5 times, or about or at least 3 times greater than the maintenance dose. The maintenance dose may be, for example, about 350 mg, 400 mg, about 500 mg, about 584 mg, about 600 mg, and / or about 700 or 701 mg 1 to 4 times per day. In one embodiment, the starting dose is administered once, twice, three times, four times, or five times before the first maintenance dose, and may be administered once, twice, three times, or four times per day.

[0146] Thus, for example, in one embodiment, for a 2337 mg daily triethylenetetraamine disuccinate starting dosage regimen, triethylenetetraamine disuccinate is administered at a daily starting dosage of at least about 3505 mg (1.5×), at least about 4674 mg (2×), at least about 5842 mg (2.5×), or at least about 7001 mg (3×) (which may be provided in one or several doses in a day). In one embodiment, the triethylenetetraamine disuccinate starting dosage is administered in two doses per day, and is optionally administered over 1, 2, 3, 4, or 5 days or more. Based on a maintenance dosage of triethylenetetraamine disuccinate administered daily or at other frequencies, for example, 2804 or other maintenance dosages administered daily, other starting dosages of triethylenetetraamine disuccinate are calculated accordingly.

[0147] In one embodiment, triethylenetetramine disuccinate or other copper antagonists described herein are administered twice a day (BID) to provide the desired daily dose. In another embodiment, triethylenetetramine disuccinate or other copper antagonists described herein are administered three times a day (TID) to provide the desired daily dose. In yet another embodiment, the dose is administered four times a day (QID) to provide the desired daily dose.

[0148] The described and claimed triethylenetetraamine disuccinate dosages selectively bind or modulate copper (II) values ​​and are useful for preventing or reducing or normalizing blood and / or tissue copper levels and preventing and / or reducing undesirable copper accumulation in the hippocampus and are administered to subjects having elevated hippocampal copper (or at risk for elevated hippocampal copper) and signs of impaired cognitive function, cognitive decline and / or dementia or degenerative disorders of the cerebral nervous system.

[0149] Triethylenetetraamine disuccinate includes prodrugs thereof, wherein the dosage is adjusted to take into account the molecular weight of the "pro" portion of the triethylenetetraamine disuccinate prodrug.

[0150] The dose of triethylenetetraamine disuccinate or another copper antagonist can be administered alone or in combination with one or more additional ingredients, and can be formulated into a pharmaceutical composition comprising one or more pharmaceutically acceptable excipients, diluents and / or carriers. In some embodiments, the present invention provides a combination product comprising (a) a dose of triethylenetetraamine disuccinate or another copper antagonist, and (b) a therapeutic agent comprising one or more anti-dementia agents and / or diabetic agents, wherein components (a) and (b) are suitable for simultaneous or sequential administration. In some embodiments, component (b) is an anti-inflammatory agent, an agent for treating cardiovascular disease, an agent for treating hypertension, an agent for treating kidney disease, an agent for treating depression, and / or an agent for treating type 2 diabetes. In a specific embodiment of the present invention, the combination product according to the present invention is used in such a way that at least one of the components is administered while the other component still has an effect on the object being treated. Doses of triethylenetetramine disuccinate or other copper antagonists and component (b) therapeutic agent may be contained in the same or one or more different containers and administered separately, or mixed together in any combination and administered simultaneously. Preferably, two or all three of triethylenetetramine disuccinate (or other copper antagonist) and antidiabetic agent and / or other therapeutic agent are combined in a capsule for oral administration.

[0151] In another embodiment, the copper level can be reduced or increased, preferably by 2+Compounds that chelate or normalize copper at the level or amount of, such as triethylenetetramine disuccinate, are used in combination with agents for treating diabetes. Agents for treating diabetes according to the invention described and claimed herein include alpha-glucosidase inhibitors, biguanides, dopamine agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 receptor agonists, meglitinides, sodium-glucose transporter (SGLT) 2 inhibitors, sulfonylureas, and thiazolidinediones. Alpha-glucosidase inhibitors for the invention described and claimed herein include, for example, acarbose (Precose) and miglitol (miglitol) (Glyset). The most common biguanide is metformin (Glucophage, metformin hydrochloride ER, Glumetza, Riomet, Fortamet). Metformin for use in the invention described and claimed herein may also be combined with other type 2 diabetes medications and is an ingredient in the following medicines: metformin-alogliptin (Kazano); metformin-canagliflozin (Invokamet); metformin-dapagliflozin (Xigduo XR); XR)); metformin-empagliflozin (Synjardy); metformin-glipizide; metformin-glyburide (Glucovance); metformin-linagliptin (Jentadueto); metformin-pioglitazone (Actoplus); metformin-repaglinide (PrandiMet); metformin-rosiglitazone (Avandamet); metformin-saxagliptin (Kombiglyze XR); and metformin-sitagliptin (Janumet). Bromocriptine (Cycloset) is a dopamine agonist that may be used in the invention described and claimed herein.Dipeptidyl peptidase-4 (DPP-4) inhibitors useful in the invention described and claimed herein include: alogliptin (Nesina); alogliptin-metformin (Cazano); alogliptin-pioglitazone (Oseni); linagliptin (Tradjenta); linagliptin-empagliflozin (Glyxambi); linagliptin-metformin (Gentadoto); saxagliptin (Onglyza); saxagliptin-metformin (Combilan XR); sitagliptin (Januvia); sitagliptin-metformin (Zanumet and Zanumet XR); and sitagliptin and simvastatin (Juvisync). Glucagon-like peptide-1 receptor agonists (GLP-1 receptor agonists) for use in the invention described and claimed herein include: albiglutide (Tanzeum); dulaglutide (Trulicity); exenatide (Byetta); extended-release exenatide (Bydureon); liraglutide (Victoza); and semaglutide (Ozempic). Meglitinides for use in the invention described and claimed herein include: nateglinide (Starlix); repaglinide (Prandin); and repaglinide-metformin (Prandimet). Sodium-glucose transporter (SGLT) 2 inhibitors useful in the invention described and claimed herein include: dapagliflozin (Farxiga); dapagliflozin-metformin (Sigurdur XR); canagliflozin (Invokana); canagliflozin-metformin (Invomet); empagliflozin (Jardiance); empagliflozin-linagliptin (Glicanbi); empagliflozin-metformin (Cinapthal); and ertugliflozin (Steglatro).Sulfonylureas useful in the invention described and claimed herein include: glimepiride (Amaryl); glimepiride-pioglitazone (Duetact); glimepiride-rosiglitazone (Avandaryl); gliclazide; glipizide (Glucotrol); glipizide-metformin (Metaglip); glyburide (DiaBeta, Glynase, Micronase); glyburide-metformin (Gluvanse); chlorpropamide (Diabinese); tolbutamide (Tolinase); and tolbutamide (Orinase, Tol-Tab). Thiazolidinediones useful in the invention described and claimed herein include: rosiglitazone (Avandia); rosiglitazone-glimepirate (Avandali); rosiglitazone-metformin (Marvisma M); pioglitazone (Actos); pioglitazone-alogliptin (Oceani); pioglitazone-glimepirate (Dustat); and pioglitazone-metformin (Eplastix Met, Eplastix Met XR).

[0152] The combination products can be made according to the methods and principles provided herein and those methods and principles known in the art. Combination products used in the methods described herein are also provided.

[0153] For separate or co-administration, copper antagonist, copper chelator or other copper lowering agent formulations, such as triethylenetetramine disuccinate formulations, can be prepared to provide fast or slow release; immediate, delayed, timed or sustained release; or a combination thereof. The formulations can be in the form of liquids, solutions, suspensions, emulsions, elixirs, syrups, electuaries, drops (including but not limited to eye drops), tablets, granules, powders, lozenges, pastilles, capsules, gels, ointments, creams, emulsions, oils, foams, sprays, mists or aerosols. For example, gastric retentive or mucoadhesive formulations of triethylenetetramine disuccinate can enhance or prolong the absorption of this therapeutic preparation in the gastrointestinal tract. Delayed release forms of triethylenetetramine disuccinate will be used to avoid metabolism, prolong and increase absorption, and increase bioavailability by releasing the drug after it passes through the stomach. A variety of different methods can be used to achieve these modified release formulations. Such techniques are well known to those skilled in the art, with particular techniques and excipients being selected to address the problem or challenge posed by the ADME profile of the preparation in question.

[0154] Mucoadhesive formulations contain specific polymers that adhere to the epithelial lining at the site where they are hydrated. Therefore, the drug released, for example, in the duodenum, after passing through the stomach will adhere to the wall of the gastrointestinal tract, causing prolonged and preferential drug release and absorption at this site. Cheek, cornea, respiratory tract and vaginal tissues are also lined with mucosal tissues and are therefore targets of the formulations. The mucoadhesive properties of most polymers increase with molecular weight, so it is found that, for example, MW in the range of 200,000-700,000 is associated with the enhanced mucoadhesion of polyoxyethylene polymers and copolymers. Viscosity, pore size and degree of crosslinking are other factors to consider when selecting mucoadhesive polymers. Hydrogen bonding, flexibility, degree of hydration and swelling are also important factors in delivering drugs from mucoadhesive polymers. In addition to polyoxyethylene / polyvinyl alcohol, materials consisting of polymerized acrylates and methacrylates and hydroxylated methacrylic acid polymers can also be used for this purpose. Chitosan, cyanoacrylate, hyaluronic acid, hydroxypropyl cellulose, gellan gum, polycarbopol and sodium carboxymethylcellulose are other related polymers that have been used for mucoadhesive formulations. Taking into account the specific characteristics of nasal tissue, nasal mucoadhesive formulations are developed. Nasal delivery systems include copolymers of methyl vinyl ether, (hydroxypropyl) methylcellulose (HPMC), sodium carboxymethylcellulose, carbopol-934P and Eudragit RL-10. Mucin, gelatin, polycarbophil and poloxamer are examples of polymers for vaginal or rectal mucoadhesive formulations. Oral delivery systems for gastrointestinal mucoadhesive systems are represented by chitosan, polyacrylic acid, alginate, polymethacrylic acid and sodium carboxymethylcellulose. Mucoadhesive fixed dose triethylenetetraamine disuccinate formulations can be prepared using the compound.

[0155] Gastric retentive formulations are generally designed for drugs that have an optimal absorption window in the stomach and proximal intestine. Hydrodynamic equilibrium systems, floating microspheres, gas-generating tablets, formulations that swell to prevent passage from the stomach, and formulations that adhere to the stomach wall are examples of such formulations. A "plug" system that swells to a size that cannot easily pass through the pyloric sphincter is an example of a gastric retentive formulation. Low-density (floating) or gas-generating (carbon dioxide) formulations are retained for extended periods of time; the techniques can be used in combination to optimize the properties. Mucoadhesive polymers are also often used to design the effects into the formulation. The combination of sodium alginate with sodium carbonate or sodium bicarbonate can produce a "drifting" effect, causing the formulation to be retained in the stomach based on buoyancy in gastric fluid. Gastric retentive fixed-dose triethylenetetramine disuccinate formulations can be prepared using these methods and compounds.

[0156] In some embodiments, the copper antagonist or copper reducer is substantially pure, including at least about 90% pure, at least about 95% pure, and 100% pure. In some embodiments, the copper antagonist or copper reducer is triethylenetetramine. In some embodiments, triethylenetetramine is triethylenetetramine disuccinate. In some embodiments, triethylenetetramine disuccinate is anhydrous triethylenetetramine disuccinate. In some embodiments, triethylenetetramine disuccinate is a crystalline form of triethylenetetramine disuccinate or anhydrous triethylenetetramine disuccinate. In some embodiments of the present invention, the copper antagonist or copper reducer is a polymorph of triethylenetetramine disuccinate. Triethylenetetramine disuccinate polymorphs are described, for example, in U.S. Pat. No. 8,067,641. In one aspect, the copper antagonist or copper reducing agent comprises a polymorph of triethylenetetraamine disuccinate, wherein the polymorph is a crystal having a structure defined by the coordinates of Table 3B found in U.S. Pat. No. 8,067,641. In another aspect of the invention, the copper antagonist or copper reducing agent comprises a polymorph of triethylenetetraamine disuccinate, wherein the polymorph is a crystal having a structure defined by the coordinates of Table 3C found in U.S. Pat. No. 8,067,641. In other aspects of the invention, triethylenetetraamine disuccinate consists essentially of a crystalline triethylenetetraamine disuccinate polymorph having a structure defined by the coordinates of Table 3B in U.S. Pat. No. 8,067,641, or consists essentially of a crystalline triethylenetetraamine disuccinate polymorph having a structure defined by the coordinates of Table 3C in U.S. Pat. No. 8,067,641.

[0157] Fixed dose and daily or other regular doses

[0158] The effective fixed dose of triethylenetetraamine disuccinate is about 400 mg, about 500 mg, about 600 mg or about 700 mg. A fixed dose of 350 mg is also provided. Use a fixed dose, for example, to apply a dose of triethylenetetraamine disuccinate in the range of about 2400 mg to about 3000 mg per day or other time period. In one aspect, the effective amount of triethylenetetraamine disuccinate is at least about 95% pure, at least about 99% pure or 100% pure. On the other hand, the effective amount of triethylenetetraamine disuccinate is a crystalline form of triethylenetetraamine disuccinate. In another aspect of this method, the effective amount of triethylenetetraamine disuccinate is anhydrous triethylenetetraamine disuccinate. In another aspect of the method, the effective amount of triethylenetetraamine disuccinate is in the form of a fixed dose tablet or capsule. The total dose can be administered in a single or divided dosage unit (e.g., BID, TID), and preferably maintains normal urine and / or plasma copper levels in the subject, or a level not less than about 70% to 75% of normal. In a preferred embodiment, a fixed dose is administered BID.

[0159] manufacture

[0160] Triethylenetetraamine disuccinates suitable for use in the present invention may be obtained from known manufacturing sources or synthesized using methods known in the art. Manufacturing methods are described, for example, in U.S. Pat. No. 9,556,123, which describes the synthesis of triethylenetetramine and intermediates useful in its production. U.S. Pat. No. 8,067,641 describes methods for synthesizing substantially pure triethylenetetraamine disuccinate, substantially pure anhydrous triethylenetetraamine disuccinate, and triethylenetetraamine disuccinate polymorphs.

[0161] Pharmaceutical preparations

[0162] Also provided are pharmaceutical formulations comprising a fixed dose of a copper antagonist (e.g., triethylenetetramine, including triethylenetetramine disuccinate) in a pharmaceutically acceptable vehicle. The term "pharmaceutically acceptable" has the above meaning and includes those vehicles approved by regulatory agencies of the federal or state governments or listed in the U.S. Pharmacopeia or other generally recognized pharmacopeia for use in mammals, such as humans. The term "vehicle" refers to a diluent, adjuvant, excipient, or carrier with which the compounds of the invention are formulated for administration to a mammal.

[0163] In one aspect, the present disclosure provides pharmaceutical formulations in which a copper antagonist (e.g., triethylenetetraamine disuccinate) alone or together with another active ingredient is prepared by combining it (or them) with one or more pharmaceutically acceptable diluents, carriers, adjuvants, etc. in a manner known to those skilled in the art of pharmaceutical formulation. The dosage form can be prepared by combining it with one or more pharmaceutically acceptable diluents, carriers, adjuvants, etc. in a manner known to those skilled in the art of pharmaceutical formulation.

[0164] The choice of excipient will be determined in part by the active ingredient, as well as the particular method used to administer the composition.Thus, there is a wide variety of suitable formulations of the pharmaceutical compositions of the invention.

[0165] Dosage forms useful herein include any suitable dosage forms known in the art to be suitable for pharmaceutical formulation of the compound, which are suitable for administration to mammals, especially humans, and are particularly (although not exclusively) suitable for stabilization in solutions, tablets or capsules containing the therapeutic compound for administration to humans.

[0166] The composition may take the form of any standard known dosage form, including those described above, and includes tablets, pills, capsules, semisolids, powders, sustained release formulations, solutions, suspensions, elixirs, aerosols, liquids for injection, transdermal delivery devices (e.g., transdermal patches), or any other suitable composition. A person of ordinary skill in the art to which the present invention relates will understand, without any undue experimentation, the most appropriate dosage form taking into account the condition to be treated and the nature of the active agent to be used. Various doses and dose ranges are described herein, including doses and dose ranges of triethylenetetramine disuccinate. It should be understood that one or more other active agents (e.g., anti-inflammatory agents, etc., as well as the other active agents described) can be formulated into a single composition with the copper antagonist dose. In certain embodiments, preferred dosage forms include injectable solutions, topical formulations in transdermal patches, and oral formulations. The dosage forms of the present invention include any suitable dosage forms now known or later discovered in the art, which are suitable for pharmaceutical formulations of compounds suitable for administration to humans.

[0167] One example is an oral delivery form of tablets, capsules, lozenges, etc., or any liquid form that can protect the compound from degradation before causing the effect, for example, if it is an oral dosage form, in the digestive tract. Particular formulations for use in the present invention are in solid form, especially tablet or capsule form for oral administration.

[0168] Slow or modified release copper antagonist formulations (eg, formulations of triethylenetetraamine disuccinate) in tablet or capsule form are preferred. Nasal administration, bypassing the blood-brain barrier, is one method of administration, as well as oral, parenteral, and the like.

[0169] In addition to standard diluents, carriers and / or excipients, compositions according to the present invention can be formulated together with one or more additional components, or formulated in such a way that, for example, activity or bioavailability is enhanced, integrity is helped to be protected or its half-life or shelf life is increased, release can be slowed down when applied to an object, or other desired benefits are provided. For example, slow release vehicles include macromonomers, poly (ethylene glycol), hyaluronic acid, poly (vinyl pyrrolidone) or hydrogels, so as to allow the product to be continuously released from the matrix over time. As a further example, compositions can also include preservatives, solubilizers, stabilizers, wetting agents, emulsifiers, sweeteners, coloring agents, flavoring agents, coating agents, buffers, etc. Those skilled in the art involved in the present invention can easily identify other additives that may be suitable for a specific purpose.

[0170] The copper antagonist dose of the present invention can be administered by a sustained release system. Suitable examples of sustained release compositions include semipermeable polymer matrices in the form of shaped articles, such as films or microcapsules. Sustained release matrices include polylactide (U.S. Pat. No. 3,773,919; EP 58,481), copolymers of L-glutamic acid and γ-ethyl-L-glutamate, poly (2-hydroxyethyl methacrylate), ethylene vinyl acetate or poly-D-(-)-3-hydroxybutyric acid (EP 133,988). Sustained release compositions also include liposome-coated (e.g., encapsulated) compounds. Liposomes containing copper chelators (alone or with antiviral and / or anti-inflammatory agents) can be prepared by known methods, including, for example, those described in DE 3,218,121; EP 52,322; EP 36,676; EP 88,046; EP 143,949; EP 142,641; Japanese Patent Application 83-118008; U.S. Pat. Nos. 4,485,045 and 4,544,545; and EP 102,324. Typically, liposomes can be used to encapsulate triethylenetetramine disuccinate and are of the smaller (from or about 200 to 800 angstroms) monolayer type, with a lipid content greater than about 30 mol% cholesterol, the selected ratio being adjusted to obtain the most effective therapy. For example, slow release delivery using PGLA nano- or micro-particles or in situ ion-activated gelling systems can also be used.

[0171] In one such example, the desired salt form can be formulated using a gastric retention dosage form (GRDF). The purpose of formulating the delivery form is to prolong gastric retention time, thereby enhancing absorption. The strategy can use, for example: 1) via a delaying agent; 2) a large single unit dosage form; 3) a bioadhesive drug delivery system; 4) a heavy granule; and 5) a buoyant form. As some examples thereof, polymers such as Carbopol, polyglucosamine, sodium alginate, HPMC, polyacrylic acid, polyethylene glycol, and modified forms of these polymers are variously used to achieve gastric retention.

[0172] In a second example of a modified dosage form for non-immediate release, the product is formulated to delay the release of the drug until after the dosage form leaves the stomach. In a delayed release form, the release profile is similar to or equal to that of the immediate release form, but the actual release of the drug is delayed, for example, by an enteric coating, so that the active ingredient is not released from the dosage form particles until transgastric transit is complete. As an example of this strategy, an enteric coating is achieved by using, for example, a (meth)acrylic acid polymer that does not dissolve in an aqueous medium until the pH is above 5.5, thereby obtaining a dosage form that does not release the copper antagonist active ingredient when passing through the stomach.

[0173] The difference between extended release dosage form and delayed release is that the release curve of the drug is extended beyond the release curve of the immediate release product. The mechanism of extended release includes delayed dissolution, diffusion, delivery from complete dosage form by osmotic pressure, maintenance of hydrological or fluid dynamic equilibrium and ion exchange. The traditional method of obtaining extended release delivery is to prepare in the matrix of non-ionic cellulose ether (such as HPMC; See US8865778B2) in the presence of the non-crosslinked swelling agent of selected amount, such as carboxymethyl starch or sodium starch glycolate. Other methods for achieving the same result are known. For example, the drug delivery formula core containing permeabilizing agent and water-swellable polymer is easily used as the driving force for delivering the drug in a controlled, extended manner.

[0174] The therapeutic formulations useful in the methods and compositions of the present invention may be prepared by any of the methods well known in the art of pharmacy. See, e.g., Gilman et al. (eds.), GOODMAN AND GILMAN'S: THE PHARMACOLOGICAL BASES OF THERAPEUTICS (8th ed.), Pergamon Press (1990); and Remington, THE SCIENCE OF PRACTICE AND PHARMACY, 20th ed., (2001), Mack Publishing Co., Easton, Pa.; Avis et al. (eds.) (1993), PHARMACEUTICAL DOSAGE FORMS: PARENTERAL MEDICATIONS, Dekker, New York; Lieberman et al. (eds.) (1990), PHARMACEUTICAL DOSAGE FORMS: TABLETS, 20th ed., (2001), Mack Publishing Co., Easton, Pa. (eds.) (1990), PHARMACEUTICAL DOSAGE FORMS: DISPERSE SYSTEMS, Decker, New York. The compositions may also be formulated according to standard techniques, such as those found in standard reference texts, e.g., Gennaro AR: Remington: The Science and Practice of Pharmacy, 20th Supplemental Edition, Lippincott, Williams & Wilkins, 2000.

[0175] Certain formulations of the invention are in a form for nasal administration, such as a nanoemulsion. Other formulations of the invention are in the form of a transdermal patch.

[0176] Products / Kits

[0177] The present invention also provides a product or "kit" containing materials that can be used to treat or prevent impaired cognitive function, cognitive decline and / or dementia or brain nervous system degeneration symptoms in subjects with diabetes (e.g., type 2 diabetes) and / or vascular dementia (e.g., VCI), comprising: (a) a pharmaceutical composition comprising a copper antagonist compound that can reduce, lower and / or normalize the level or amount of hippocampal copper; and (b) instructions for use for therapeutic treatment or prevention of impaired cognitive function, cognitive decline and / or dementia or brain nervous system degeneration symptoms in subjects with diabetes and / or vascular dementia (e.g., VCI). In some embodiments, the subject suffers from type 1, type 2, type 3 or type 4 diabetes. In some embodiments, the subject of the instructions suffers from vascular dementia with or without diabetes.

[0178] The kit comprises a container with a composition, the composition comprising a certain dose of a copper reducer or consisting essentially of it, the copper reducer such as triethylenetetramine disuccinate, preferably substantially pure anhydrous triethylenetetramine disuccinate. The kit may further include a label or drug instructions (or a labeling that can be obtained online or in the cloud or in a flash drive or another storage mechanism) on or associated with the container. The term "drug instructions" is used to refer to instructions that are usually included in the commercial packaging of the therapeutic product (or can be obtained online), which contains information related to the indications, uses, dosages, administration, contraindications and / or warnings for the use of the therapeutic product. Suitable containers include, for example, bottles, blister packaging, etc. The container can be formed by various suitable materials, including, for example, plastics. The container can also be a packaging containing a composition in the form of tablets or capsules, the latter being a preferred form, wherein the copper antagonist or copper reducer (e.g., triethylenetetramine disuccinate) is provided, for example, in a blister packaging. The label or package insert indicates that the composition is used to treat a subject with diabetes and / or vascular dementia who has (or is suspected of having) impaired cognitive function, cognitive decline, and / or dementia or signs of degenerative diseases of the cerebral nervous system associated with excessive or undesirable levels of hippocampal copper. In one embodiment, the instructions state that a copper antagonist or copper lowering agent (e.g., triethylenetetramine disuccinate) should be administered to a patient with diabetes and impaired cognitive function, cognitive decline, and / or dementia or signs of degenerative diseases of the cerebral nervous system who is also receiving another therapeutic agent for cardiovascular disease, hypertension, diabetes, kidney disease, inflammation, depression, and / or dementia, etc. The instructions may reference one or more dosages or dosing regimens described herein.

[0179] In some embodiments, the compound in the kit is selected from the group consisting of triethylenetetramine dihydrochloride, triethylenetetramine tetrahydrochloride, and triethylenetetramine disuccinate. In some embodiments, the triethylenetetramine disuccinate in the kit is anhydrous triethylenetetramine disuccinate, preferably substantially pure anhydrous triethylenetetramine disuccinate.

[0180] In one aspect, the invention comprises an article of manufacture comprising a package insert instructing a user to administer a copper antagonist compound capable of reducing or lowering the level or amount of copper in the subject, e.g., reducing copper values, reducing total copper, and / or normalizing copper levels or amounts and / or copper metabolism, to a patient with diabetes and a condition or disorder characterized by dementia (or risk of dementia), including one or more of the compounds described herein, including copper (I) and / or copper (II) chelators. The compound will address excess copper in the hippocampus or elsewhere in the subject's brain. The condition or disorder characterized by dementia in a patient with diabetes may be Alzheimer's disease. The condition or disorder characterized by dementia in a patient with diabetes may be vascular dementia.

[0181] In another aspect, the comorbidity in the dementia patients that can be treated with a compound capable of reducing copper and / or normalizing copper metabolism (e.g., one or more of the copper chelators or copper reducing agents described herein) is characterized by excess or reduced copper, such as type 2 diabetes or Alzheimer's disease, respectively. Thus, in another aspect, the comorbidity in the dementia patients that can be treated with a compound capable of reducing and / or normalizing copper levels or amounts and / or copper metabolism (e.g., one or more of the copper chelators described herein) is characterized by copper deficiency, such as Alzheimer's disease. In another aspect, the disease, condition or disorder is selected from the group consisting of diabetes, Alzheimer's disease, Parkinson's disease and Huntington's disease.

[0182] In another embodiment of the present invention, the article comprises a container, a label and a drug instruction sheet. Suitable containers include, for example, bottles, blister packs, etc. The container can be formed of various materials such as glass or plastic. The container holds one or more doses of a copper antagonist or other copper deprivation agent or remover composition (e.g., triethylenetetramine disuccinate) that is effective for treating impaired cognitive function, cognitive decline and / or dementia or signs of degeneration of the cerebral nervous system and one or more symptoms described herein. The label on or associated with the container indicates that the copper antagonist or other copper deprivation agent or remover dosage composition (e.g., triethylenetetramine disuccinate) is used for treatment as described herein. In certain embodiments, the patient suffers from type 2 diabetes. In certain embodiments, the patient suffers from another form of diabetes. In certain embodiments, the patient suffers from type 1 or type 3 diabetes. In certain embodiments, the patient suffers from heart failure. In certain embodiments, the patient suffers from diabetic cardiomyopathy. In certain embodiments, the patient suffers from left ventricular hypertrophy. The drug instruction sheet may optionally contain some or all clinical trial results, such as those found on clinicaltrials.gov or published later.

[0183] Evaluation of treatment with a copper antagonist or other copper reducing or removing agent (e.g., triethylenetetraamine disuccinate) can be accomplished by reference to available copper values ​​in mammals, including humans. Reference herein to "elevated" in relation to the presence of copper values ​​will include humans having at least about 10 mcg of free copper / dL of serum when measured. Measurement of free copper, which is equal to total plasma copper minus ceruloplasmin bound copper, can be performed using a variety of procedures. A preferred procedure is disclosed in the Merck & Co data sheet (www.Merck.com) for SYPRINE (Trientine hydrochloride) capsules, a compound used to treat Wilson's disease, in which a 24-hour urine copper analysis is performed to determine free copper in serum by calculating the difference between the quantitatively determined total copper and ceruloplasmin copper.

[0184] Examples

[0185] The aim of this study was to evaluate hippocampal copper in type 2 diabetes (T2D) and sporadic Alzheimer's disease (sAD). The results of these experiments unexpectedly showed that brain hippocampal copper was significantly elevated in type 2 diabetes, approaching literature values ​​in Wilson's disease, while in contrast, hippocampal copper values ​​were severely deficient in sporadic Alzheimer's disease patients, supporting the use of therapeutic copper normalization approaches in diabetic patients who show or are at risk for cognitive impairment or decline, or who show signs of neurodegenerative brain disease or vascular dementia.

[0186] method

[0187] Ethics. All experiments were performed in accordance with the relevant guidelines and regulations as described below. The study of human postmortem brain tissue was approved by the University of Manchester Research Ethics Committee. Informed consent for tissue collection for T2D / control studies was provided by the National Disease Research Interchange (NDRI, Philadelphia, PA), which hosts the Human Tissues and Organs for Research Resource Program (www.ndriresource.org), funded by the National Institutes of Health.

[0188] Acquisition and sampling of human brain. Regional tissues (frontal cortex, temporal cortex, hippocampus and associated meninges) from T2D cases and matched controls were obtained from NDRI and transferred to the University of Auckland, where they were dissected by a neuroanatomist and stored at -80°C until processing. Wet weight aliquots of 50 ± 5 mg were: dissected using a ceramic scalpel to avoid metal contamination; TM; Thermo-Fisher, Waltham, MA) and the dry weight was determined by weighing with an analytical balance (DV215CD; Ohaus, Northamptonshire, UK). The dry weight measurements used here are preferred for determination of tissue metal levels in clinical laboratories (e.g., measurement of liver Cu for diagnosis of WD), and are also commonly used for brain metal measurements (Xu J, Si Church Si, S Patassini S, et al., Evidence for widespread, severe brain copper deficiency in Alzheimer's dementia. Metallomics 2017;9:1106-19), and the postmortem metal levels thus determined were found to be stable, robust, and reproducible (Scholefield M, Si Church Si, Xu et al., Evidence that levels of nine essential metals in postmortem human Alzheimer's disease brain tissue and isolated rat brain tissue are not affected by postmortem delay, age, disease stage, and differences in brain bank location. Metallomics 2020;12:952-62).

[0189] Diagnosis and severity. T2D cases were diagnosed by clinical history, whereas matched controls had no antemortem signs of diabetes. Neither cases nor controls had a history or postmortem signs of dementia or other brain disease. The presence of cognitive impairment was not recorded in the NDRI metadata and was not excluded by formal mental status examination. For the AD / control study, the diagnosis and severity of sAD were determined by a consultant neuropathologist as described in Xu et al., Evidence of widespread and severe brain copper deficiency in Alzheimer's disease dementia, Metallomics 2017;9:1106-19. Group characteristics for the T2D / control and AD / control cohorts are shown in Table 1 , and individual NDRI patient characteristics including age and postmortem delay are shown in Table 2 .

[0190] Table 1. NDRI sample set characteristics

[0191]

[0192] The values ​​are age and postmortem delay.

[0193] p<0.05 compared to control; all other differences were not significant.

[0194] Table 2. Individual patient characteristics of T2D cases and matched controls

[0195]

[0196] Abbreviations: AAA: abdominal aortic aneurysm; CVA: cerebrovascular accident; ESRD: end-stage renal disease; PMD: delayed postmortem; T2D: type 2 diabetes. Cause of death was the primary cause listed on the death certificate.

[0197] Tissue digestion. Prior to digestion, all samples were briefly centrifuged at 2400 × g (Heraeus Pico 17 centrifuge; Thermo Fisher Scientific, MA, US) to ensure that the tissue aliquot was at the bottom of the tube. Concentrated nitric acid (A509 trace metal grade; Fisher, Loughborough, UK) and 5% Agilent internal standard mixture (5183-4681; Agilent Technologies, Cheadle, UK) were combined to prepare a tissue digestion mixture ((M. Schofield, S. Church, Hsu et al., showed that nine essential metals were present in postmortem human Alzheimer's disease brain tissue and isolated rat brain tissue) Evidence that genus levels are not affected by differences in postmortem delay, age, disease stage, and brain bank location, Metallomics 2020;12:952-62). Calibration standards were prepared at appropriate dilutions (Table SI) using an environmental calibration standard mixture (Agilent 5189-4688) and 2% (v / v) nitric acid digestion solution. For these dry weight analyses, 200 I.L1 of digestion solution was added to each sample, including two empty 2 mL microcentrifuge tubes as digestion blanks. Before transferring to Dri-Block Before DB3 heater (Techne, Staffordshire, UK), puncture the tube cap with a septum remover at room temperature to prevent pressure buildup. The temperature was set to 60°C for 30 minutes and then raised to 100°C for another 3.5 hours. Thereafter, 100 1.1.1 of each sample or blank was added to 5 mL of LC / MS grade water in a 15 ml Falcon tube (Greiner), and the samples were kept at room temperature for ICP-MS analysis.

[0198] ICP-MS. Metal concentrations were measured using an Agilent 7700xICP-MS spectrometer equipped with a MicroMist atomizer (Glass Expansion, Melbourne, Australia), a Scott double-column spray chamber, and a nickel sample and a skimmer cone. Samples were introduced into the spray chamber using an Agilent integrated autosampler (I-AS). Before each analysis, peristaltic pump sample tubes were replaced to limit abnormal sample delivery to the atomizer. Before each analysis, ICP-MS system optimization and performance reports were generated on Agilent MassHunter workstation software (G7201A, A.01.01) to ensure constant system performance.

[0199] To remove spectral interferences, two collision cell gas modes were used. All elements were analyzed in helium mode (5.0 ml min - 1 He) analysis, except Se, which was analyzed in high energy helium mode (HEHe; 10 ml min'He) as recommended by Agilent to reduce interferences from polyatomic ion formation. Germanium and indium internal standards were analyzed in both modes. Integration times for relevant trace metals were 3 s for Se; 0.01 s for Fe; 0.03 s for Mn, Cu and Zn; and 0.1 s for Na, Mg, K and Ca. A multi-element method using serial dilutions of environmental calibration standards (Table 6; Agilent 5183-4688) was implemented for each analytical batch. 50 μg / l and 5 μg / l internal standard calibration standard solutions were used as periodic mass controls 1 and 2, respectively. The limit of quantification, limit of detection and background equivalent concentration for each trace metal analyzed in this report were automatically generated by Agilent MassHunter software.

[0200] Table 6. ICP-MS Calibration Standard Solutions

[0201]

[0202] Data analysis.ICP-MS data sets were first exported to individual Microsoft Excel (2010) worksheets, corrected for sample weight and dilution, and then converted to mmol / kg or μmol / kg as needed. Mean values ​​(±95% CI) were calculated, and the significance of differences between groups was determined by unpaired Welch's test (a test that allows for unequal variances and sample sizes). Statistical calculations were performed using Prism v8.1.1 (GraphPad; La Jolla, CA). P values ​​<0.05 were considered significant. To identify cluster separation between T2D metal and AD metal datasets (Xu, SI Church, S Patassini, et al., Evidence for widespread and severe brain copper deficiency in Alzheimer's disease dementia, Metallomics, 2017;9:1106-19), multivariate principal component analysis (PCA) and partial least squares-discriminant analysis (PLS-DA) were applied using the R platform MetaboAnalyst (www.metaboanalyst.ca). Chong J, Wishart DS, Xia J, Using MetaboAnalyst 4.0 for Comprehensive and Integrative Metabolomics Data Analysis, Curr Protoc Bioinformatics, 2019;68(1):e86.

[0203] The mean of two T2D technical replicates for each regional analysis was calculated and then used for all subsequent PCA and PLS-DA analyses. In order to assess the suitability of each data set for PCA, the Kaiser-Meyer-Olkin measure and Bartlett's test of adequacy of sampling accuracy were first performed using SPSS version 23 (IBM; Armonk, NY). Prior to multivariate analysis, all metal data sets were mean-centered and divided by the standard deviation of each variable. Based on the PLS-DA model, metals with a variable projection importance (VIP) score of >1 were considered to contribute to group separation.

[0204] result

[0205] Results showed significant increases in hippocampal copper in six replicate T2D cases compared with six matched controls ( Figure 1 This interpretation is further supported by similar results for copper in two consecutive technical replicates (P = 0.005 and P = 0.007, respectively). The results provide strong evidence for the reproducibility of hippocampal Cu values ​​in this dataset ( Figure 1 ; Tables 3 and 4). See National Academies of Sciences, Engineering, and Medicine, Reproducibility and Replicability in Science: Washington, DC: The National Academies Press; 2019.

[0206] Table 3. Multi-regional dry heavy metal concentrations in T2D and control brain (run 1)

[0207]

[0208]

[0209] Data are mean values ​​(±95% CI); P values ​​for significance of differences between groups were calculated by Welch's T test based on measurements from control (n=6) and T2D (n=6) brains. *P<0.05, **P<0.01. Three samples (2 controls and 1 T2D) could not be analyzed due to insufficient tissue.

[0210] Table 4. Multi-regional dry heavy metal concentrations in T2D and control brain (Run 2)

[0211]

[0212]

[0213] Data are mean values ​​(±95% CI); P values ​​for significance of differences between groups were calculated by Welch's T test based on measurements from control (n=6) and T2D (n=6) brains. *P<0.05, **P<0.01.

[0214] Mean hippocampal copper content was elevated 2.2-fold in cases compared with controls (394.8 vs. 180.2 μmol / kg dry tissue, respectively; Table 6). In contrast, the other eight elements showed no consistent differences between cases and controls in the technical replicate analysis ( Figure 1; Table 3 and Table 4). In the first technical replication, in any of the other regions (frontal cortex, temporal cortex and meninges), only Zn was significantly different between cases and controls (Table 3). Cases and controls were matched in postmortem delay (PMD) and sex (Table 3 and Table 4), while diabetic cases (70 years, 66-75 [mean; range]) were slightly younger than controls (76 years, 69-78; p=0.011).

[0215] In a second technical replicate analysis, only mean hippocampal levels of copper (P = 0.007) and Fe (P = 0.044) were significantly increased in diabetic cases compared with controls (see Figure 2 ). As in the first analysis, the hippocampus showed the greatest concentration difference between case and control copper values. However, for Fe, the greatest changes in metal levels were in the meninges. None of the other physiological metals analyzed in this study showed any statistically significant differences between the groups.

[0216] Table 6. Comparison of brain copper concentrations and fold changes between Wilson disease, T2D, and controls

[0217]

[0218] Data is taken from Cummings (WD) 19 and the mean (range) and fold change of dry weight Cu concentrations in this study (T2D). It should be noted that Cummings 19 The Cu values ​​in the data were obtained using the sodium diethyldithiocarbamate method (not the reference method). Since different methods were used in these two studies, determining the fold change would be the preferred method for comparing Cu values ​​between T2D and WD. The method used for the T2D measurement is the current reference method. No measure of significance could be obtained for the Cumings data because it only provides mean Cu concentrations for controls, not individual brain concentrations. Cu values ​​were significantly different between cases and controls only in the T2D hippocampus (P = 0.005 and 0.007 in two consecutive technical replicates ( Figure 1 and Figure 2 )).

[0219] Hippocampal copper showed a P value close to the 3σ threshold for two technical replicates, consistent with robust data. See Colquhoun D, ​​An investigation of the false discovery rate and the misinterpretation of p-values, R Soc Open Sci, 2014; 1(3): 140216. Furthermore, subsequent statistical power analysis revealed that copper was the only metal to achieve a power > 0.9 in these studies. Thus, in the context of statistical validity, this body of evidence shows that the finding of increased hippocampal copper in T2D has a high level of importance and significance. (See Table 7).

[0220] Table 7. Power analysis of NDRI dry weight hippocampus measurements

[0221]

[0222]

[0223] Statistical power test for individual NDRI hippocampal dry weight data. Values ​​highlighted in bold meet a statistical power of 80% or a required sample size of ≤ 12. The required sample size was generated using a statistical power of 80% and an alpha error probability of 0.05. Values ​​were determined using G*Power (v. 3.1.9.4) alpha.

[0224] Since hippocampal copper is the main essential metal disturbed in T2D studies, multivariate principal component analysis (PCA) was used to further characterize patterns within hippocampal tissue from AD (n=9), T2D (n=6), and control (n=14) brains. Prior to conducting PCA, the suitability of the analysis methods was assessed. The Kaiser-Meyer-Olkin measure of sampling accuracy for the hippocampal dataset was 0.71, providing strong evidence for the adequacy of these datasets for PCA. Bartlett's test of sphericity was statistically significant (χ 2 (36) = 178.313, p < 0.001), providing strong evidence for a significant correlation between the variables, thus supporting data reduction. Visual inspection of the scree plot revealed that the first two components accounted for 67.8% of the total variance, thus confirming its utility for two-dimensional PCA ( Figure 4 ). As the PCA plots comparing controls from the AD and T2D cohorts showed a large amount of overlap, the two control cohorts were merged and then used as a single control group for comparisons between AD and T2D, a procedure specified a priori. The hippocampal PCA plot showed almost complete separation between AD and T2D, while there was a large amount of overlap between T2D and controls ( Figure 3A ), providing further strong evidence for differences in the hippocampal metalloid profile between AD and T2D.

[0225] To enhance data discrimination, partial least squares-discriminant analysis (PLS-DA) was also performed on the same hippocampus dataset. The PLS-DA model showed similar patterns to PCA ( Figure 3B ), further supporting the main findings. Based on the PLS-DA model, VIP scores were generated, which indicate the relative importance of each metal to the group separation. For main components 1 and 2; Na, Mn, Cu and Fe all had VIP scores>1, thus meeting the criteria for identifying these metals as reliable discriminators within the hippocampus dataset of the present invention. Na obtained the highest VIP score in both components, while Cu obtained the third and second highest VIP scores in components 1 and 2, respectively ( Figure 3C and Figure 3D ; Table 5).

[0226] Table 5. Variable projection importance scores for the first five principal components

[0227]

[0228]

[0229] The values ​​highlighted in bold represent the top two highest scores for each principal component.

[0230] In order to allow the multi-region comparison between PCA, the data set from frontal cortex and temporal cortex and meninges is also analyzed by applying the same statistical method as the hippocampus data set.It should be noted that cluster separation (Fig. 5 and Fig. 6) is not detected in any one of the remaining three regions.These studies confirm that the processing of the hippocampus signal in PCA source is significantly different from those sent from each of three other regions (frontal cortex and temporal cortex and meninges).The signal localization in the hippocampus is also consistent with the localization of hippocampus damage in T2D.

[0231] ***

[0232] The invention described and claimed herein has many attributes and embodiments, including but not limited to those set forth or described or referenced in this Detailed Description. It is not intended to be fully inclusive, and the invention described and claimed herein is not limited to or by the features or embodiments identified in this Detailed Description, which are included for purposes of illustration only and not limitation.

[0233] All patents, publications, scientific papers, websites and other documents and materials referenced or mentioned herein indicate the technical level of technicians in the field to which the present invention belongs, and each of the referenced documents and materials is incorporated by reference here to the same extent as if they have been individually incorporated by reference in their entirety or set forth in their entirety herein. The applicant reserves the right to actually incorporate any and all materials and information from any of the patents, publications, scientific papers, websites, electronically available information, and other reference materials or documents into this specification. Reference to any application, patent, and disclosure in this specification is not and should not be regarded as an admission or any form of suggestion that it constitutes a valid prior art or forms part of the common general knowledge in any country in the world.

[0234] The specific methods and compositions described herein are representatives of preferred embodiments, and are exemplary and not intended as limitations on the scope of the invention. Other objectives, aspects and embodiments will occur to those skilled in the art after considering this specification, and the other objectives, aspects and embodiments are encompassed within the spirit of the invention defined by the scope of the claims. Therefore, for example, in each case herein, and in embodiments or examples of the present invention, any one of the terms "comprising", "consisting essentially of ... " and "consisting of ... " in this specification can be replaced by any of the other two terms. The methods and processes appropriately described illustratively herein can be implemented in different step sequences, and they are not necessarily limited to the step sequences indicated herein or in the claims. Unless the context clearly provides otherwise, the singular forms "a", "an" and "the" include plural references as used herein and in the appended claims. This patent must not be interpreted as being limited to the specific examples or embodiments or methods specifically disclosed herein. This patent shall in no way be construed as limited by any statement made by any examiner or any other officer or employee of the Patent and Trademark Office unless such statement is expressly agreed to and expressly incorporated in the applicant's response without any qualification or reservation.

[0235] The terms and expressions that have been used are used as terms of description rather than limitation, and when used, there is no intention to exclude any equivalents of the features shown and described or portions thereof, but it is recognized that various modifications may be made within the scope of the invention claimed. Therefore, it should be understood that although the present invention has been specifically disclosed by preferred embodiments and optional features, modifications and variations of the concepts disclosed herein may be adopted by those skilled in the art, and the modifications and variations are considered to be within the scope of the invention as defined by the appended claims.

[0236] Other embodiments are within the following claims.In addition, where features or aspects of the invention are described in terms of Markush groups, those skilled in the art will recognize that the invention is also thereby described in terms of any individual member or subgroup of members of the Markush group.

Claims

1. A method for treating impaired cognitive function in a subject with type 2 diabetes, comprising administering to the subject a pharmaceutical composition comprising a compound capable of reducing copper in the subject, wherein urinary copper increases after administration of the composition and the subject's impaired cognitive function is alleviated.

2. The method of claim 1, wherein the compound is capable of reducing elevated hippocampal copper levels in the subject.

3. The method of claim 1, wherein the pharmaceutical composition comprises a therapeutically effective amount of triethylenetetramine and a pharmaceutically acceptable carrier, glidant, diluent or excipient.

4. The method of claim 3, wherein the triethylenetetramine is in the form of a pharmaceutically acceptable salt.

5. The method of claim 4, wherein the triethylenetetramine salt is selected from the group consisting of triethylenetetramine dihydrochloride, triethylenetetramine tetrahydrochloride, and triethylenetetramine disuccinate.

6. The method of claim 1, wherein the compound is triethylenetetramine disuccinate.

7. The method of claim 1, wherein the triethylenetetraamine disuccinate is a crystalline form of triethylenetetraamine disuccinate.

8. The method according to claim 1, wherein the triethylenetetramine disuccinate is anhydrous triethylenetetramine disuccinate.

9. The method of claim 1, wherein the subject exhibits signs of brain degeneration and one or more signs of brain degeneration are improved.

10. The method of claim 1, wherein the subject suffers from or is at risk of suffering from cognitive decline and / or dementia, and the cognitive decline and / or dementia in the subject is improved.

11. The method of claim 1, wherein the subject has impaired spatial memory or the ability to remember direction, position and orientation, and the subject's spatial memory and / or the ability to remember direction, position and / or orientation is improved.

12. The method of claim 1, further comprising administering one or more additional therapeutic agents selected from anti-inflammatory agents, agents for treating cardiovascular disease, agents for treating hypertension, agents for treating kidney disease, and agents for treating type 2 diabetes.

13. The method of claim 12, wherein the agent for treating type 2 diabetes is selected from the group consisting of: α-glucosidase inhibitors, biguanides, dopamine agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 receptor agonists, meglitinides, sodium-glucose transporter (SGLT) 2 inhibitors, sulfonylureas, and thiazolidinediones.

14. The method of claim 1, wherein the subject is a human.

15. The method of claim 1, wherein the pharmaceutical composition is administered orally in the form of a capsule or tablet.

16. The method of claim 1, wherein the compound is triethylenetetramine dihydrochloride and is administered in an amount of about 1200 mg per day.

17. The method of claim 1, wherein the compound is triethylenetetramine disuccinate and is administered at a daily dosage of about 2400 mg per day to about 3000 mg per day of triethylenetetramine disuccinate.

18. The method of claim 1, wherein the compound is triethylenetetramine disuccinate and is administered in an amount of about 2800 mg per day.

19. The method of claim 16, wherein the 1200 mg is administered in 600 mg divided doses BID, in 400 mg divided doses TID, or in 300 mg divided doses QID.

20. The method of claim 18, wherein the 2800 mg is administered in divided doses.

21. A therapeutic treatment kit for treating or preventing impaired cognitive function in a subject with type 2 diabetes, comprising: a) a pharmaceutical composition comprising a compound capable of reducing copper levels and / or normalizing copper metabolism in a subject; and b) instructions for use for therapeutically treating or preventing impaired cognitive function in a subject with type 2 diabetes.

22. The kit of claim 21, wherein the compound is selected from the group consisting of triethylenetetramine dihydrochloride, triethylenetetramine tetrahydrochloride, and triethylenetetramine disuccinate.

23. The kit according to claim 22, wherein the triethylenetetramine disuccinate is anhydrous triethylenetetramine disuccinate.

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