Combination of 5-amino-2,3-dihydro-1,4-phthalazinedione and 6'-methoxycinchonan-9-ol for the treatment of coronavirus infections

Abstract

The present application relates to a combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof, which are used for the prophylaxis or treatment of coronavirus infections. In particular, the present invention relates to a combination of 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt and quinine or quinidine. Also disclosed are pharmaceutical compositions and advantageous formulation techniques.

Description

[Technical field]

[0001] The present application relates to a combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts with 6'-methoxycinchonan-9-ol or its pharmaceutically acceptable salt for use in the prevention or treatment of coronavirus infections. The invention particularly relates to a combination of 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt with quinine or quinidine or its pharmaceutically acceptable salt for said purpose. Pharmaceutical compositions and advantageous formulation techniques are disclosed. [Background technology]

[0002] As a result of ecological, climatic, and demographic changes, so-called "emerging" viruses are increasingly transferring from natural animal hosts to humans. Accelerating globalization puts emerging viruses at risk of causing pandemics. Emerging viruses can cause acute and often life-threatening illnesses. Viruses from the Coronaviridae family have become notorious for such infections. Examples include the Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV), Middle East Respiratory Syndrome-related Coronavirus (MERS-CoV), and more recently, the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2, COVID-19) outbreak. A total of more than 244 million SARS-CoV-2 cases worldwide, with approximately 4.9 million deaths, were reported by the Johns Hopkins University Coronavirus Resource Center as of October 27, 2021. The incubation period for SARS-CoV-2 ranges from 2 days to 2 weeks, but can extend up to a month in some cases. The disease resulting from SARS-CoV-2 infection is called COVID-19.

[0003] The typical symptoms of COVID-19 are fever, cough, and shortness of breath. However, the infection can also cause severe lung damage, leading to rapid and progressive pulmonary insufficiency, especially with regard to the ability to take in oxygen. This is usually accompanied by the failure of other organs. This state of acute lung injury (ALI) is accompanied by widespread pulmonary inflammation and accumulation of fluid in the alveoli. It is characterized by diffuse pulmonary microvascular injury, leading to increased permeability and consequent noncardiogenic pulmonary edema. This results in pathologically reduced oxygen levels in the lungs. Other common conditions associated with COVID-19 patients in ICU care are pulmonary embolism, thrombosis, venous thromboembolism, and cerebral ischemia.

[0004] Coronaviruses spread mainly through close contact, especially respiratory droplets from coughing and sneezing. Unlike SARS-CoV and MERS-CoV, SARS-CoV-2 can be transmitted from person to person during the incubation period, when infected people do not yet show symptoms of the disease. Moreover, SARS-CoV-2 can already replicate in the throat. In contrast, the receptors of SARS-CoV and MERS-CoV are located deep in the lungs. Therefore, SARS-CoV-2 is much more easily transmitted from person to person compared to SARS-CoV and MERS-CoV, significantly increasing the infection rate.

[0005] In general, coronaviruses (family Coronaviridae, group of coronaviruses) form a relatively diverse group of large enveloped positive-stranded RNA viruses that can cause various types of diarrheal and respiratory diseases in humans and animals. They have a very narrow host range and are very difficult to replicate in cell culture. However, cell culture systems for SARS-CoV-2 could be established.

[0006] Sequencing of SARS-CoV-2 revealed a genome of approximately 29.8 kbp consisting of 14 open reading frames. Furthermore, the virus is phylogenetically closely related to SARS-CoV (nucleotide similarity 89.1%) (Wu et al., 2020, Nature579:265-269). Like other coronaviruses, SARS-CoV-2 enters cells by endocytosis and membrane fusion. The virus is released from cells by the secretory pathway. The natural host of this virus is unknown.

[0007] To date, no specific treatment has been established for the treatment of SARS-CoV-2 infection, or COVID-19. The antiviral drugs remdesivir, favipiravir, molnupiravir, and paxlovid (nilmatrervir / ritonavir) may provide some benefit. A nasal spray containing nanoantibodies against the SARS-CoV-2 spike protein is a promising development (AeroNabs). Administration of the glucocorticoid dexamethasone has been shown to be effective in severe COVID-19 patients.

[0008] Therefore, there is a strong medical need for effective drug treatments for patients infected with SARS-CoV-2 or similar coronaviruses and to limit the spread of the current epidemic of this virus. Ideally, such treatments should also provide at least one treatment option for future coronavirus outbreaks.

[0009] 5-Amino-2,3-dihydro-1,4-phthalazinedione sodium salt was able to inhibit the replication of SARS-CoV-2 in vitro in a dose-dependent manner (WO2021 / 249667).Such an effect has also been reported for quinine and quinidine, 6'-methoxycinchonan-9-ol (WO2021 / 219244).

[0010] Surprisingly, this effect could be significantly enhanced by administration of a pharmaceutical combination of 5-amino-2,3-dihydro-,4-phthalazinedione or a pharma- ceutically acceptable salt or solvate, hydrate, and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt. The combination of 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt and quinine sulfate or quinidine sulfate was able to inhibit the replication of SARS-CoV-2 in vitro at much lower concentrations than either substance alone.

[0011] Thus, the present application discloses a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione, or any of its pharma- ceutically acceptable salts, hydrates or solvates, and 6'-methoxycinchonan-9-ol, or a pharma- ceutically acceptable salt thereof.

[0012] In particular, a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof for use in medicine is disclosed.

[0013] In particular, a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof is disclosed for use in the prophylaxis or treatment of a coronavirus infection, in particular SARS-CoV-2 infection, COVID-19.

[0014] 5-Amino-2,3-dihydro-1,4-phthalazinedione (luminol) belongs to the pharmaceutical class of phthalazinedione. This class of compounds is known for its beneficial anti-inflammatory properties. 5-Amino-2,3-dihydro-1,4-phthalazinedione is also known by the name luminol. Luminol has excellent chemiluminescent properties. It is widely used in diagnostic assays as a means of detection and in forensic science, such as tracing bloodstains. In medicine, 5-Amino-2,3-dihydro-1,4-phthalazinedione has been developed in the form of its sodium salt. It has been approved in some countries for a wide range of acute and chronic inflammatory diseases, including acute infections, especially of the intestinal tract, caused by bacteria and viruses, inflammations such as hepatitis B and C, gastroenteritis, prostatitis, endometriosis, pharyngitis, bronchial asthma, pneumonia, periodontitis, pyelonephritis, Crohn's disease, ulcerative colitis, systemic lupus erythematosus, autoimmune diseases such as scleroderma. 5-Amino-2,3-dihydro-1,4-phthalazinedione can effectively prevent cytokine storm caused by excessive immune response. In addition, there is a long list of scientific and patent literature for indications in which 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt has been tested for therapeutic use or has been suggested to have beneficial uses (see, for example, WO2004 / 041169, WO2007 / 018546, WO2012 / 127441, WO2016 / 096143, WO2017 / 202496, WO2018 / 082814).

[0015] While many conventional immunomodulatory drugs have serious side effects or are at least problematic for long-term use, 5-amino-2,3-dihydro-1,4-phthalazinediones and their pharmacologic acceptable salts are well tolerated and have a high margin of safety with respect to dosage.

[0016] To enhance solubility and bioavailability, pharma- ceutically acceptable salts of 5-amino-2,3-dihydro-1,4-phthalazinedione are used. Sodium, potassium and lithium salts have been described for therapeutic use (see WO2010 / 082858). The crystal structures of lithium, sodium, potassium, rubidium and cesium salts are described in Guzei et al., Journal of Coordination Chemistry (2013, 66:3722-3739). Thus, this patent application also refers to the use of any pharma- ceutically acceptable salt of 5-amino-2,3-dihydro-1,4-phthalazinedione.

[0017] 6'-Methoxycinchonan-9-ol exists in two diastereomers: quinine ((-)-(8α,9R)-6'-methoxycinchonan-9-ol, synonyms: 1-(6-methoxyquinolin-4-yl)-1-(5-vinyl-1-azabicyclo[2.2.2]oct-2-yl)methanol, 1-(6-methoxyquinolin-4-yl)-1-(5-vinyl-1,4-ethanopiperidin-2-yl)methanol) and quinidine ((+)-(9S)-6'-methoxycinchonan-9-ol, synonyms: (2-ethenyl-4-azabicyclo[2.2.2]oct-5-yl)-(6-methoxyquinolin-4-yl)-methanol).

[0018] Thus, within the scope of this disclosure, the term "6'-methoxycinchonan-9-ol" shall refer to quinine and / or quinidine, or a pharma- ceutically acceptable salt thereof, unless expressly stated otherwise.

[0019] Quinine and quinidine are quinoline alkaloids. Traditionally, quinine was extracted from the bark of the cinchona tree (Cinchona pubescens, a plant of the Rubiaceae family that grows in the highland forests of South America).

[0020] Quinine is a bitter-tasting, white, poorly water-soluble crystalline powder. It has been used for many years in folk medicine to treat febrile illnesses. Quinine was the first drug found to be effective in treating malaria, especially the complicated form of falciparum malaria. Quinine complexes with the toxic ferriprotoporphyrin IX and inhibits the formation of non-toxic beta-hematin in the vacuoles of blood schizonts of Plasmodium falciparum. It is still used today to treat chloroquine-resistant malarial pathogens and when artemisinin is not indicated. In the United States, it is often used to treat falciparum malaria. It is also used to treat babesiosis (Babesia infection).

[0021] Quinine also has analgesic, local anesthetic and antipyretic properties, so small amounts of quinine are used in China to treat colds.

[0022] When given in low doses as quinine sulfate, it is also used to relieve cramps, including nocturnal leg cramps.

[0023] It was also used to treat restless legs syndrome, but was discontinued due to side effects.

[0024] Other indications include systemic lupus erythematosus, osteoarthritis, and rheumatoid arthritis.

[0025] Side effects include thrombocytopenia, thrombotic microangiopathy, and methemoglobinemia. Long-term administration of quinine sulfate at high doses can cause nausea, headache, sweating, tinnitus, visual disturbances, fever, hypotension, hemolytic anemia, acute kidney injury, hepatotoxicity, blindness, gastrointestinal, dermis, cardiovascular (thrombocytopenia, hemolytic uremic syndrome / thrombotic thrombocytopenic purpura (HUS / TTP), long QT syndrome, torsades de pointes, blackwater fever, disseminated intravascular coagulation, leukopenia, and other severe arrhythmias such as neutropenia), nervous system disorders, and rarely asthma and hemoglobinemia (Liles et al., (2016) Am J Hematol 91:461-466).

[0026] In the food industry, quinine is used as a bittering agent: it is added to premium beverages such as bitter lemon and tonic water (up to 100 mg / kg in the European Union, 85 mg / kg in Germany) and to alcoholic drinks such as gin and tonic and bitters (up to 300 mg / kg in the European Union, 250 mg / kg in Germany).

[0027] Quinidine was the first antiarrhythmic drug found to be effective. It can be administered intravenously or orally. Quinidine is classified as a class 1A antiarrhythmic drug because it binds to sodium channels (especially Nav1.5). The quinidine / ion channel complex dissociates only slowly, so its action is frequency-dependent (use-dependent block). Quinidine also decreases potassium conductance (especially Kv1.4, Kv4.2, and Kv11.1), resulting in increased cardiac action potential duration and prolongation of the QT interval. In addition, quinidine blocks cardiac calcium channels in an atropine-like manner and is an alpha-1 blocker (Shibata et al., (1998) Circulation 97:1227-1230). Quinidine is used to treat atrial fibrillation, premature beats, and ventricular tachycardia.

[0028] Rarely, intravenous quinidine is used to treat Plasmodium falciparum malaria.

[0029] Quinidine is now rarely used due to its serious side effects. These side effects include long QT syndrome, atrioventricular block, torsades de pointes arrhythmias, ventricular tachycardia, and gastrointestinal disorders. When administered intravenously, quinidine significantly reduces vascular resistance. Other side effects include thrombocytopenia (eventually leading to thrombotic thrombocytopenic purpura), granulomatous hepatitis, and myasthenia gravis.

[0030] In addition, quinidine inhibits the cytochrome P450 enzyme 2D6, thereby increasing the blood levels of many drugs.

[0031] Quinine and quinidine can be provided as pharma- ceutically acceptable salts of organic and inorganic acids. Suitable examples include hydrochloric acid, hydrobromic acid, sulfuric acid, phosphoric acid, acetic acid, citric acid, oxalic acid, malonic acid, salicylic acid, p-aminosalicylic acid, malic acid, fumaric acid, succinic acid, ascorbic acid, maleic acid, sulfonic acid, phosphonic acid, perchloric acid, nitric acid, formic acid, propionic acid, gluconic acid, digluconic acid, lactic acid, tartaric acid, hydroxymaleic acid, pyruvic acid, phenylacetic acid, benzoic acid, p-aminobenzoic acid, p-hydroxybenzoic acid, dinitrobenzoic acid, chlorobenzoic acid, methanesulfonic acid, ethanesulfonic acid, nitric acid, hydroxyethanesulfonic acid, Examples of suitable salts include salts from ethylenesulfonic acid, p-toluylsulfonic acid, naphthylsulfonic acid, sulfanilic acid, camphorsulfonic acid, alginic acid, capric acid, hippuric acid, pectinic acid, phthalic acid, quinic acid, mandelic acid, o-methylmandelic acid, hydrogen benzenesulfonic acid, picric acid, adipic acid, cyclopentanepropionic acid, do-toluyltartaric acid, tartronic acid, benzenesulfonic acid, α-methylbenzoic acid, (o, m, p-)methylbenzoic acid, naphthylaminesulfonic acid, and other mineral or carbonic acids well known to those skilled in the art. These salts are produced by contacting the free base with a sufficient amount of the respective acid to form the salt in a conventional manner.

[0032] Commonly used salts of quinine include quinine sulfate, quinine dihydrochloride, quinine gluconate, quinine hydrochloride, quinine sulfate dihydrate, etc. Preferred are quinine sulfate and quinine dihydrochloride. Commonly used salts of quinidine include quinidine sulfate, quinidine dihydrochloride, quinidine gluconate, quinidine hydrochloride monohydrate, quinidine citrate, quinidine acetate, quinidine sulfate dihydrate, etc. Preferred are quinidine sulfate and quinidine gluconate. Further salts of quinine and quinidine are disclosed in US2009 / 239900A1.

[0033] In this application, pharmaceutically acceptable salt should be regarded as an active agent that contains the compound according to the present invention in the form of salt, especially when this salt provides specific or improved pharmacokinetic properties compared with the free form of the active agent or another salt of the active agent.Pharmaceutically acceptable salt can also provide the active agent with pharmacokinetic properties that it does not have in the free form.Therefore, it can even have a positive effect on the pharmacodynamics of the active agent with regard to its therapeutic effect in organisms.

[0034] Therefore, finding an agent capable of enhancing the effect of quinidine or its pharmaceutical salts is desirable to improve the efficacy of the treatment of coronavirus infections. A further desirable measure would be to reduce the dosage of the respective antiviral drug, so as to avoid or at least reduce the adverse side effects associated with them.

[0035] To avoid ambiguity in the art, the terms drug-drug interaction are defined as follows. They are used in this sense throughout the disclosure. When at least two substances (e.g., pharmaceuticals) are administered and at least one of these substances affects the activity of at least one other substance, a so-called drug-drug interaction occurs. When said interaction leads to an exaggerated or increased effect of the drug substances, the effect is synergistic. The respective formulas can be expressed as (A+B)>A or (A+B)>B, where A and B are the percentage or fractional effect (i.e., values ​​between 0 and 1) seen when each substance is administered alone, and (A+B) is the percentage or fractional effect seen after co-administration, respectively. A net effect equal to the sum of the effects seen with the administration of the drugs alone is an additive synergistic effect. If the net effect is greater than the predicted effect, the term superadditivity is used. If the effect is smaller, it is subadditive. On the other hand, if an interaction between drugs reduces the effect of the drug components, the effect is not synergistic at all, but antagonistic.

[0036] Thus, within the scope of this disclosure, the terms "antagonism" and "antagonistic" are used for a decrease in drug effect induced by a drug-drug interaction, and the terms "synergy" and "synergistic" are used for an increase in drug effect induced by a drug-drug interaction. To describe and determine the degree of this synergy, the terms "subadditive," "additive," and "superadditive" and their respective nouns are used. Thus, the term superadditive is used to describe the effect of two or more combined drugs that is greater than the expected additive effect of the drugs alone.

[0037] The use of synergistic drug combinations can enhance both therapeutic efficacy and potency, the latter primarily serving to reduce off-target toxicity.

[0038] The identification of drug-drug interactions relies on the null hypothesis of "no interaction", which is based on the observed drug response and not on a model of the mechanism. Thus, for two different drugs, their degree of additivity is based on a reference point of reading that depends on the mathematical model chosen. There are various methods for identifying such interactions, calculating the expected additive effect of two substances, and determining whether the actual synergistic effect observed is subadditive, additive, or superadditive. Various methods are advocated in the field. The most common methods are outlined below.

[0039] Basic methods such as constructing simple arithmetic sums or fractional products provide an easy way to gain initial insight into whether a particular combination has superadditivity.

[0040] The simple arithmetic sum method of additivity is based on the equation A+B=(A+B), where A and B are the percent or fractional effect seen when each substance is administered alone, and (A+B) is the percent or fractional effect seen after administering these substances in combination using the same doses as when administered alone. If A+B>(A+B), superadditivity is indicated. An obvious and significant drawback of this method is that results with A+B ≥ 100% cannot be analyzed for superadditivity. Therefore, this method is primarily used to interpret suboptimal dose combinations.

[0041] The fractional product method is based on the formula 1-(1-A)*(1-B)=(A+B), where A and B are the fractal effects seen when each substance is administered alone, and (A+B) is the fractal effect seen after co-administration of each substance at the same dose as when each substance was administered alone. Superadditivity is demonstrated when 1-(1-A)*(1-B)>(A+B).

[0042] A more sophisticated method is the use of so-called isobolograms. These are graphs constructed on a coordinate system defined by the individual drug doses, showing a "line of additivity" that allows to distinguish between subadditive, additive (effects along the line) and superadditive effects. The "line of additivity" connects single drug doses that show the same effect (e.g. 50% inhibition of a certain marker). All possible dose combinations along this line are expected to show the same efficacy. Dose combinations that lie within the triangle constructed by the coordinates and the line of additivity, i.e. close to any point, show the same effect and are considered superadditive. Dose combinations that lie outside the triangle are considered subadditive. Each diagram can be mapped using specific software such as CompuSyn (Chou and Martin, ComboSyn, Inc. Paramus, NJ 2007 [www.combosyn.com]).

[0043] Also, further specific index values, such as, for example, the combination index (CI, formula from Chou and Talalay (1984) Adv Enzyme Reg 22:27-55) and the dose reduction index (DRI, formula from Chou, 1984), can be easily calculated using the specific software mentioned above. Both of these values ​​allow to determine whether drug substances act superadditively or synergistically when administered simultaneously. The CI is based on the principle of the law of mass action and can be applied to any kind of drug combination, regardless of the mechanism of action, the kinetic order, or the units of the amount used for each drug in the combination. The CI value defines the synergistic effect as superadditive if CI<1 and additive if CI=1. If CI>1, the effect is either subadditive or antagonistic. Therefore, CI=1 also refers to the "line of additivity". In the classical isobologram mentioned above. In a simplified approach, it can be calculated as follows: CI=A(t) / A(x)+B(t) / B(x), where A(t) and B(t) are the doses of drugs A and B alone that inhibit x%, respectively, and A(x) and B(x) represent the proportion of each drug in the combination that also inhibits x%. The DRI is a measure of how many times the dose of each drug in a synergistic combination can be reduced at a given level of efficacy, compared to the dose of each drug alone. Thus, DRI=1 indicates additivity, while DRI>1 and <1 indicate superadditivity and subadditivity (or antagonism), respectively. For presentation purposes, isobolograms, i.e. isoeffectiveness curves at various concentrations or doses of the two aforementioned drugs, are a dose-oriented graphical approach based on a special case of the CI formula. However, a more convenient graphical approach is the effect-oriented so-called FaCI plot, which displays the combination index (CI) against the fractal effect (Fa), preferably for a specific dose combination.

[0044] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof for use in reducing or inhibiting the replication of coronavirus in humans.

[0045] In another aspect, the present application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof for use in reducing coronavirus viral load in humans.

[0046] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione, or any of its pharma- ceutically acceptable salts, hydrates, or solvates, and 6'-methoxycinchonan-9-ol, or a pharma- ceutically acceptable salt thereof, for use in the prophylaxis or treatment of COVID-19 in humans.

[0047] The severity of COVID-19 is usually classified according to the WHO clinical progression scale (Published in: Lancet Infect Dis (2020) 20: e192-e197). Within the scope of this disclosure, the following classification follows this scale.

[0048] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof for use in the prophylaxis or treatment of coronavirus infection in asymptomatic humans.

[0049] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof for use in the prophylaxis or treatment of coronavirus infection in humans exhibiting mild coronavirus infection-associated symptoms and not requiring hospitalization.

[0050] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof, for use in the treatment of coronavirus infection in a human exhibiting severe coronavirus infection-associated symptoms and requiring hospitalization.

[0051] In another aspect, the present application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof for use in the treatment of coronavirus infection in a human exhibiting severe coronavirus infection-associated symptoms and suffering from acute lung injury.

[0052] In particular, the present application discloses a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma-ceutically acceptable salt thereof for use in the prophylaxis or treatment of coronavirus infection, wherein the pharma-ceutically acceptable salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is the sodium salt of 5-amino-2,3-dihydro-1,4-phthalazinedione.

[0053] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma-ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma-ceutically acceptable salt thereof, for use in reducing or inhibiting the replication of coronavirus in humans, wherein the pharma-ceutically acceptable salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is the sodium salt of 5-amino-2,3-dihydro-1,4-phthalazinedione.

[0054] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma-ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma-ceutically acceptable salt thereof for use in reducing coronavirus viral load in humans, wherein the pharma-ceutically acceptable salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is the sodium salt of 5-amino-2,3-dihydro-1,4-phthalazinedione.

[0055] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma-ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma-ceutically acceptable salt thereof, for use in the prophylaxis or treatment of COVID-19 in a human, wherein the pharma-ceutically acceptable salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is the sodium salt of 5-amino-2,3-dihydro-1,4-phthalazinedione.

[0056] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma-ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma-ceutically acceptable salt thereof, for use in the prophylaxis or treatment of a coronavirus infection in an asymptomatic human, wherein the pharma-ceutically acceptable salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is the sodium salt of 5-amino-2,3-dihydro-1,4-phthalazinedione.

[0057] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma-ceutically acceptable salt thereof, for use in the prophylaxis or treatment of coronavirus infection in humans exhibiting mild coronavirus infection-associated symptoms and not requiring hospitalization, wherein the pharma-ceutically acceptable salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is the sodium salt of 5-amino-2,3-dihydro-1,4-phthalazinedione.

[0058] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma-ceutically acceptable salt thereof, for use in the treatment of a coronavirus infection in a human exhibiting severe coronavirus infection-associated symptoms and requiring hospitalization, wherein the pharma-ceutically acceptable salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is the sodium salt of 5-amino-2,3-dihydro-1,4-phthalazinedione.

[0059] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma-ceutically acceptable salt thereof, for use in the treatment of a coronavirus infection in a human exhibiting severe coronavirus infection-associated symptoms and suffering from acute lung injury, wherein the pharma-ceutically acceptable salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is the sodium salt of 5-amino-2,3-dihydro-1,4-phthalazinedione.

[0060] 5-amino-2,3-dihydro-1,4-phthalazinedione is often used as a hydrate, for example as the sodium salt dihydrate. Therefore, the present application also refers to the use of all hydrates and other solvates of 5-amino-2,3-dihydro-1,4-phthalazinedione and its pharma-ceutically acceptable salts. 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharma-ceutically acceptable salts may form a complex with a suitable ligand. Therefore, the present application also refers to such complexes.

[0061] To ensure reproducible and standardized API manufacturing and to improve the stability properties of the active agent, anhydrous formulations are often preferred. The anhydrous forms of 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt have been described as crystalline polymorphs in WO2011 / 107295 (form I, form II) and WO2016 / 096143 (form III). These crystalline polymorphs are substantially free of phase impurities and are characterized by X-ray powder diffraction. This method provides a set of characteristic d values ​​indicating the interplanar spacing [Å] and the corresponding two-theta (2θ) angles [°] at which the Bragg reflections occur. This provides a unique and unambiguous fingerprint of each polymorph.

[0062] For Form I the following values ​​were determined: d-values: 13.5, 6.9, 5.2, 4.6, 3.9, 3.5, 3.4, 3.3, 3.1, 3.0 and / or 2-theta values: 6.5, 12.7, 16.9, 19.3, 22.8, 25.8, 26.6, 27.2, 28.7, 30.3.

[0063] Form II is characterized by the following values: d-values: 12.9, 7.9, 7.1, 6.5, 5.3, 4.0, 3.7, 3.6, 3.3, 3.2 and / or 2-theta values: 6.8, 11.2, 12.5, 13.7, 16.7, 22.4, 24.3, 24.9, 27.2, 27.8.

[0064] For Form III the following values ​​were obtained: d-value: 13.131;7.987;7.186;6.566;6.512;5.372;3.994;3.662;3.406;3.288;3.283;3.222;3.215;3.127;2.889 and / or 2Theta values: 6.73; 11.07; 12.31; 13.48; 13.59; 16.49; 22.24; 24.29; 26.14; 27.10; 27.14; 27.67; 27.72; 28.52; 30.93.

[0065] The use of the anhydrous form I of the sodium salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is preferred.

[0066] In a mouse COPD model, ex vivo lungs were exposed to cigarette smoke. Application of 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt form I resulted in a near complete reduction of 3-nitrotyrosine. Therefore, it is conceivable that 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt may protect lungs from oxidative and nitrosative stress, which play a major role in the pathophysiology of COPD and other inflammatory lung diseases (https: / / copdnewstoday.com / 2020 / 04 / 16 / mp1032-may-protect-lungs-from-oxidative-stress-inhibit-biomarker-3-nitrotyrosine-preclinical-study / , as of March 3, 2021).

[0067] 5-Amino-2,3-dihydro-1,4-phthalazinedione itself also exhibits polymorphism: Form I (Paradies (1992) Ber. Bunsen-Ges. Phys. Chem 96:1027-1031) and Form II (WO2017 / 140430) have been disclosed.

[0068] WO2017 / 140430 also discloses that 5-amino-2,3-dihydro-1,4-phthalazinedione has great potential for the immunomodulatory treatment of inflammatory and autoimmune diseases. Crystalline Form II is particularly useful for the treatment of inflammatory and autoimmune respiratory diseases, such as upper and lower respiratory tract infections.

[0069] The present patent application therefore also refers to the use according to the invention of all crystalline forms of 5-amino-2,3-dihydro-1,4-phthalazinedione and its pharma- ceutically acceptable salts, hydrates and solvates, and of its polymorphs. The use of form II of 5-amino-2,3-dihydro-1,4-phthalazinedione is preferred.

[0070] Similar therapeutic effects are known for various phthalazinediones, which are derivatives of 5-amino-2,3-dihydro-1,4-phthalazinedione and its pharma-ceutically acceptable salts. One example is 6-amino-2,3-dihydrophthalazine-1,4-dione (isoluminol). A summary of suitable phthalazinediones is given in WO2007 / 018546. It is reasonable to assume that these compounds will show similar effects when used in the therapeutic applications of the present invention.

[0071] EP0531370A1 discloses the use of PARP (poly(ADP-ribose) polymerase) inhibitors, such as luminol, for the treatment of viral infections in which the viral DNA integrates into the host chromosome during the replication cycle. The virus is preferably a retrovirus, such as HIV. However, coronaviruses are positive-stranded RNA viruses and therefore cannot integrate into human DNA. Thus, EP0531370A1 does not suggest the use of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharma-ceutically acceptable salts for the treatment of coronavirus infections.

[0072] Tautomerism is related to the rapid internal transformation of organic compounds in which a hydrogen atom or proton formally moves within the compound. This involves the switching of a single bond and an adjacent double bond. A single form is called a tautomer. For example, keto-enol tautomerism occurs in 5-amino-2,3-dihydro-1,4-phthalazinedione (Proescher and Moody (1939) J Lab Clin Med, 1183-1189). Thus, this application also refers to the use of all tautomers of 5-amino-2,3-dihydro-1,4-phthalazinedione, and its pharma-ceutically acceptable salts, hydrates, and solvates.

[0073] Isomers are a general term for molecules that have the same chemical formula but different chemical structures. They can be distinguished into constitutional (structural) isomers (where an exchange of atoms or functional groups occurs) and stereoisomers. Stereoisomers can be subdivided into enantiomers (non-superimposable mirror images of the same molecule) and diastereomers (the same molecule with different configurations at one or more stereocenters). Diastereomers can be subdivided into cis / trans isomers (referring to the relative orientation of functional groups in a molecule) and, on the other hand, into conformational isomers (formally rotation around a single bond) and rotamers (different rotation positions around a single bond). An example of a constitutional isomer of 5-amino-2,3-dihydro-1,4-phthalazinedione is 6-amino-2,3-dihydrophthalazine-1,4-dione (isoluminol). Stereoisomers can occur in phthalazinedione derivatives. This application therefore also refers to the use of all isomeric forms of 5-amino-2,3-dihydro-1,4-phthalazinedione, its derivatives, and its pharma- ceutically acceptable salts, hydrates and solvates.

[0074] In some applications, for example for diagnostic purposes, it may be desirable to use isotopically enriched forms of the compounds of the invention, and therefore the present application also refers to such isotopically enriched forms of the compounds of the invention.

[0075] From a pharmacokinetic point of view or for manufacturing reasons, it may be preferable to use prodrugs as dosage forms. Prodrugs are administered in a pharmacologically inactive form and are converted in the body by metabolism into active forms. This conversion may occur systemically or locally. Therefore, this patent application also refers to prodrugs of the compounds of the present invention.

[0076] The term "5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharma- ceutically acceptable salts" as used throughout this application is intended to encompass all the aforementioned molecular variants of 5-amino-2,3-dihydro-1,4-phthalazinedione, i.e., 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharma- ceutically acceptable salts or solvates, hydrates, crystalline polymorphs, tautomers, or isotopically enriched forms.

[0077] Unless otherwise defined, technical or scientific terms used herein have the meanings ascribed to them by one of ordinary skill in the relevant art.

[0078] Coronavirus infections that can be treated with the pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma-ceutically acceptable salt thereof are, inter alia, infections caused by the highly pathogenic SARS-CoV, MERS-CoV and SARS-CoV-2. However, infections caused by the less pathogenic Coronaviridae family can also be treated in this way: The term "coronavirus" or "coronavirus-based" refers primarily to the subfamily Orthocoronavirus, which are subdivided into the genera Alphacoronavirus, Betacoronavirus, Gammacoronavirus and Deltacoronavirus. Alphacoronaviruses include Coracovirus (species: bat coronavirus CDPHE15), Decavirus (bat coronavirus HKU10, Rhinolophus ferrumequinum alphacoronavirus HuB-2013), Dubinacovirus (human coronavirus 229E), Luchacovirus (Lucheng Rn rat coronavirus), Minakovirus (ferret coronavirus, mink coronavirus 1), Minunacovirus (miniopterus bat coronavirus 1, miniopterus bat coronavirus HKU8), Myotachovirus (Myotis ricketti alphacoronavirus Sax-2011), Nyctalusvirus (Nyctalus velutinus alphacoronavirus SC-2013), Pedakovirus (porcine epidemic diarrhea virus, Scotophilus bat coronavirus 512), and Rhinolophus bat coronavirus (Rhinolophus bat coronavirus). HKU2), Setrachovirus (human coronavirus NL63 and the NL63-related bat coronavirus strain BtKYNM63-9b) and Tegacovirus (an alphacoronavirus type 1 species) subgenera. Betacoronaviruses consist of the subgenus Embecovirus (Betacoronavirus 1 (subspecies: human coronavirus OC43), Chinese rat coronavirus HKU24, human coronavirus HKU1, mouse coronavirus type species), Hibecovirus (Bat Hp-Betacoronavirus Zhejiang 2013), Merbecovirus (Hedgehog coronavirus 1, MERS-CoV), Pisciutto bat coronavirus HKU5, Cyronycteris bat coronavirus HKU4), Novecovirus (Rouset bat coronavirus GCCDC1, Rouset bat coronavirus HKU9), and Sarbecovirus (Severe acute respiratory syndrome-related coronavirus (subspecies: SARS-CoV, SARS-CoV-2)). Gammacoronaviruses consist of the subgenus Segakovirus (beluga coronavirus SW1) and Igakovirus (avian coronavirus type species). Deltacoronavirus consists of the subgenera Andechovirus (Wigeon coronavirus HKU20), Burdechovirus (Bulbul coronavirus HKU11 species, Porcine coronavirus HKU15, Munia coronavirus HKU13, White-eye coronavirus HKU16), Herdechovirus (Night-Heron coronavirus HKU19), and Murdechovirus (River coronavirus HKU21).

[0079] To date, the coronaviruses pathogenic to humans are SARS-CoV, SARS-CoV-2, MERS-CoV, HCoV-HKU1, HCoV-NL-63, HCoV-OC43, and HCoV-229E, the last four of which cause relatively mild symptoms (Andersen et al.: The Proximal Origin of SARS-CoV-2, virologica.org, as of February 17, 2020).

[0080] The present application therefore particularly relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharma- ceutically acceptable salts, hydrates or solvates with 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof for use in the prophylaxis or treatment of a coronavirus infection selected from the group consisting of SARS-CoV, SARS-CoV-2, MERS-CoV, HCoV-HKU1, HCoV-NL-63, HCoV-OC43, and HCoV-229E infections.

[0081] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharma-ceutically acceptable salts, hydrates or solvates with 6'-methoxycinchonan-9-ol or a pharma-ceutically acceptable salt thereof for use in reducing or inhibiting the replication of a coronavirus in a human, wherein the coronavirus infection is selected from the group consisting of SARS-CoV, SARS-CoV-2, MERS-CoV, HCoV-HKU1, HCoV-NL-63, HCoV-OC43, and HCoV-229E infection.

[0082] In another aspect, the present application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharma-ceutically acceptable salts, hydrates or solvates with 6'-methoxycinchonan-9-ol or a pharma-ceutically acceptable salt thereof for use in reducing the viral load of a coronavirus infection in a human, wherein the coronavirus infection is selected from the group consisting of SARS-CoV, SARS-CoV-2, MERS-CoV, HCoV-HKU1, HCoV-NL-63, HCoV-OC43, and HCoV-229E infection.

[0083] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates or solvates and 6'-methoxycinchonan-9-ol or a pharmaceutically acceptable salt thereof for use in the prophylaxis or treatment of a coronavirus infection in a human, wherein the human is asymptomatic and the coronavirus infection is selected from the group consisting of SARS-CoV, SARS-CoV-2, MERS-CoV, HCoV-HKU1, HCoV-NL-63, HCoV-OC43, and HCoV-229E infection.

[0084] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharma- ceutically acceptable salts, hydrates or solvates and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof for use in the prophylaxis or treatment of a coronavirus infection in a human, wherein the human exhibits mild coronavirus infection-associated symptoms and does not require hospitalization, and the coronavirus infection is selected from the group consisting of SARS-CoV, SARS-CoV-2, MERS-CoV, HCoV-HKU1, HCoV-NL-63, HCoV-OC43, and HCoV-229E infection.

[0085] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof for use in the treatment of a coronavirus infection in a human, wherein the human is exhibiting severe coronavirus infection-associated symptoms and requiring hospitalization, and the coronavirus infection is selected from the group consisting of SARS-CoV, SARS-CoV-2, MERS-CoV, HCoV-HKU1, HCoV-NL-63, HCoV-OC43, and HCoV-229E infection.

[0086] In another aspect, the present application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof for use in the treatment of a coronavirus infection in a human, wherein the human is exhibiting severe coronavirus infection-associated symptoms and suffering from acute lung injury, and the coronavirus infection is selected from the group consisting of SARS-CoV, SARS-CoV-2, MERS-CoV, HCoV-HKU1, HCoV-NL-63, HCoV-OC43, and HCoV-229E infection.

[0087] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates or solvates with 6'-methoxycinchonan-9-ol or a pharmaceutically acceptable salt thereof for use in reducing or inhibiting the replication of coronavirus in humans, wherein the pharmaceutically acceptable salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt, and said coronavirus infection is selected from the group consisting of SARS-CoV, SARS-CoV-2, MERS-CoV, HCoV-HKU1, HCoV-NL-63, HCoV-OC43, and HCoV-229E infection.

[0088] In another aspect, the present application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates or solvates with 6'-methoxycinchonan-9-ol or a pharmaceutically acceptable salt thereof for use in reducing the viral load of a coronavirus in a human, wherein the pharmaceutically acceptable salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt, and said coronavirus infection is selected from the group consisting of SARS-CoV, SARS-CoV-2, MERS-CoV, HCoV-HKU1, HCoV-NL-63, HCoV-OC43, and HCoV-229E infection.

[0089] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates or solvates with 6'-methoxycinchonan-9-ol or a pharmaceutically acceptable salt thereof for use in the prophylaxis or treatment of a coronavirus infection in a human, wherein the pharmaceutically acceptable salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt, and wherein the human is asymptomatic, and the coronavirus infection is selected from the group consisting of SARS-CoV, SARS-CoV-2, MERS-CoV, HCoV-HKU1, HCoV-NL-63, HCoV-OC43, and HCoV-229E infection.

[0090] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates or solvates with 6'-methoxycinchonan-9-ol or a pharmaceutically acceptable salt thereof for use in the prophylaxis or treatment of a coronavirus infection in a human, wherein the pharmaceutically acceptable salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt, and wherein the human exhibits mild coronavirus infection-associated symptoms and does not require hospitalization, and wherein the coronavirus infection is selected from the group consisting of SARS-CoV, SARS-CoV-2, MERS-CoV, HCoV-HKU1, HCoV-NL-63, HCoV-OC43, and HCoV-229E infection.

[0091] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates or solvates and 6'-methoxycinchonan-9-ol or a pharmaceutically acceptable salt thereof for use in the treatment of a coronavirus infection in a human, wherein the pharmaceutically acceptable salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt, and wherein the human exhibits severe coronavirus infection-associated symptoms and requires hospitalization, and wherein the coronavirus infection is selected from the group consisting of SARS-CoV, SARS-CoV-2, MERS-CoV, HCoV-HKU1, HCoV-NL-63, HCoV-OC43, and HCoV-229E infection.

[0092] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates, or solvates and 6'-methoxycinchonan-9-ol or a pharmaceutically acceptable salt thereof, for use in the treatment of a coronavirus infection in a human, wherein the pharmaceutically acceptable salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt, and the human is exhibiting severe coronavirus infection-associated symptoms and suffering from acute lung injury, and the coronavirus infection is selected from the group consisting of SARS-CoV, SARS-CoV-2, MERS-CoV, HCoV-HKU1, HCoV-NL-63, HCoV-OC43, and HCoV-229E infection.

[0093] Thus, the present application particularly relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof for use in the prophylaxis or treatment of a coronavirus infection, said coronavirus infection being a SARS-CoV-2 infection.

[0094] In another aspect, the present application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof for use in reducing or inhibiting the replication of a coronavirus in a human, wherein said coronavirus infection is a SARS-CoV-2 infection.

[0095] In another aspect, the present application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof for use in reducing the viral load of a coronavirus infection in a human, wherein said coronavirus infection is a SARS-CoV-2 infection.

[0096] In another aspect, the present application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof for use in the prophylaxis or treatment of a coronavirus infection in a human, wherein the human is asymptomatic and the coronavirus infection is a SARS-CoV-2 infection.

[0097] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof for use in the prophylaxis or treatment of a coronavirus infection in a human, wherein the human exhibits mild coronavirus infection-associated symptoms and does not require hospitalization, and wherein the coronavirus infection is a SARS-CoV-2 infection.

[0098] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof for use in the treatment of a coronavirus infection in a human, wherein the human is exhibiting severe coronavirus infection-associated symptoms and requiring hospitalization, and wherein the coronavirus infection is a SARS-CoV-2 infection.

[0099] In another aspect, the present application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof for use in the treatment of a coronavirus infection in a human, wherein the human is exhibiting severe coronavirus infection-associated symptoms and suffering from acute lung injury, and wherein the coronavirus infection is a SARS-CoV-2 infection.

[0100] In another aspect, the present application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof for use in reducing or inhibiting the replication of coronavirus in humans, wherein the pharma- ceutically acceptable salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt, and said coronavirus infection is a SARS-CoV-2 infection.

[0101] In another aspect, the present application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharmaceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharmaceutically acceptable salt thereof for use in reducing coronavirus viral load in humans, wherein the pharmaceutically acceptable salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt, and said coronavirus infection is a SARS-CoV-2 infection.

[0102] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof for use in the prophylaxis or treatment of a coronavirus infection in a human, wherein the pharma- ceutically acceptable salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt, and the human is asymptomatic, and the coronavirus infection is a SARS-CoV-2 infection.

[0103] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates or solvates and 6'-methoxycinchonan-9-ol or a pharmaceutically acceptable salt thereof for use in the prophylaxis or treatment of a coronavirus infection in a human, wherein the pharmaceutically acceptable salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt, and wherein the human exhibits mild coronavirus infection-associated symptoms and does not require hospitalization, and wherein the coronavirus infection is a SARS-CoV-2 infection.

[0104] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates or solvates and 6'-methoxycinchonan-9-ol or a pharmaceutically acceptable salt thereof for use in the treatment of a coronavirus infection in a human, wherein the pharmaceutically acceptable salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt, wherein the human exhibits severe coronavirus infection-associated symptoms and requires hospitalization, and wherein the coronavirus infection is a SARS-CoV-2 infection.

[0105] In another aspect, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates or solvates and 6'-methoxycinchonan-9-ol or a pharmaceutically acceptable salt thereof for use in the treatment of a coronavirus infection in a human, wherein the pharmaceutically acceptable salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt, wherein the human is exhibiting severe coronavirus infection-associated symptoms and suffering from acute lung injury, and wherein the coronavirus infection is a SARS-CoV-2 infection.

[0106] More preferred is a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof for use in the prophylaxis or treatment of a coronavirus infection, wherein the coronavirus infection is SARS-CoV-2.

[0107] More preferred is a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and quinine or a pharma- ceutically acceptable salt thereof for use in the prophylaxis or treatment of a coronavirus infection, wherein the coronavirus infection is SARS-CoV-2.

[0108] More preferred is a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and quinidine or a pharmaceutical salt thereof for use in the prophylaxis or treatment of a coronavirus infection, wherein the coronavirus infection is SARS-CoV-2.

[0109] Most preferred is a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof for use in the prophylaxis or treatment of a coronavirus infection, wherein said coronavirus infection is SARS-CoV-2.

[0110] Most preferred is a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt and quinine or a pharma- ceutically acceptable salt thereof for use in the prophylaxis or treatment of a coronavirus infection, wherein said coronavirus infection is SARS-CoV-2.

[0111] Most preferred is a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt and quinidine or a pharmaceutical salt thereof for use in the prevention or treatment of a coronavirus infection, wherein said coronavirus infection is SARS-CoV-2.

[0112] It is understood that within the scope of this application, all the aforementioned aspects of the invention are disclosed as combinations of 6'-methoxycinchonan-9-ol, or quinine, or quinidine, or a pharma-ceutically acceptable salt thereof, 5-amino-2,3-dihydro-1,4-phthalazinedione, or a pharma-ceutically acceptable salt, hydrate, or solvate thereof, particularly 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt.

[0113] The aforementioned other animal coronaviruses have not yet infected humans (zoonotic diseases) but may in the future infect with unpredictable pathology. The scope of the present application therefore also relates to the pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharma- ceutically acceptable salts, hydrates or solvates with 6'-methoxycinchonan-9-ol or its pharma-ceutically acceptable salts for use in the prophylaxis or treatment of these animal coronavirus infections in animals and humans.

[0114] The concept of treatment of coronavirus infections in all species is based on the structural similarities of coronaviruses. Therefore, it is conceivable that treatment and / or prevention options could be transferred from one coronavirus to another. Coronavirus particles contain four major structural proteins: spike (S), membrane (M), envelope (E), and nucleocapsid (N), all of which are encoded within the 3' end of the viral genome.

[0115] Coronaviruses contain a non-segmented, positive-stranded RNA genome of approximately 30 kb. The genome contains a 5' cap structure and a 3' poly(A) tail, which serve as the mRNA for translation of the replicase polyprotein. The replicase genes, which code for the nonstructural proteins (nsps), occupy two-thirds of the genome, approximately 20 kb, whereas the structural and accessory proteins occupy only approximately 10 kb of the viral genome. The coronavirus genome has the following structure: 5'-leader-UTR-replicase-S (spike)-E (envelope)-M (membrane)-N (nucleocapsid)-3'UTR-poly(A) tail, with the accessory genes interspersed within the structural genes at the 3' end of the genome. Most accessory proteins are not essential for replication in tissue culture. However, some have been shown to play important roles in viral pathogenesis (Zhao et al., (2012) Cell Host Microbe 11:607-616).

[0116] The coronavirus life cycle begins with the initial attachment of the virus particle to the host cell by the interaction of the S protein with its receptor. The location of the receptor binding domain (RBD) within the S1 region of the coronavirus S protein varies among different viruses. The interaction of the S protein with the receptor is the main determinant for coronaviruses to infect host species and also governs the tissue tropism of the virus. Many coronaviruses utilize peptidases as cellular receptors. The reason for the use of peptidases is unclear, as entry can occur in the absence of the enzymatic domain of these proteins. Many alphacoronaviruses utilize aminopeptidase N (APN) as a receptor, many betacoronaviruses, such as SARS-CoV, SARS-CoV-2, and HCoV-NL63, use the angiotensin-converting enzyme II (ACE2) receptor, MHV enters through CEACAM1, and MERS-CoV binds to dipeptidyl peptidase 4 (DPP4) to enter human cells. After receptor binding, the virus next needs to access the cytoplasm of the host cell. This is usually accomplished by acid-dependent proteolytic cleavage of the S protein by a cathepsin, TMPRRS2, or another protease, followed by fusion of the viral and cell membranes and ultimately release of the viral genome into the cytoplasm.

[0117] Coronaviruses encode two or three proteases that cleave the replicase polyprotein. These are the papain-like protease (PLpro), encoded within nsp3, and the serine-type protease, or major protease, or Mpro, encoded by nsp5. Most coronaviruses encode two PLpro within nsp3, except for gammacoronaviruses, SARS-CoV and MERS-CoV, which express only one PLpro (Mielech et al., (2014) Virus Res doi:10.1016).

[0118] This papain-like protease (PLpro) was found to act in SARS-CoV in the same way as a deubiquitinating enzyme in the human cellular ubiquitin proteasome system (UPS) (see Raaben et al. (2010) J Virol 84:7869-7879). The PLpro of SARS-CoV-2 has a very high homology with SARS-CoV (96.1%, Nguyen et al. (2020) https: / / doi:org / 10:1101 / 2020.02.05.936013).

[0119] The term "composition" or "pharmaceutical composition" includes at least one active ingredient in at least one pharmacologically acceptable defined dosage and administration form, and at least one pharma- ceutically acceptable excipient, as well as any pharmaceutical agents produced directly or indirectly in combination, as a deposit, complex or crystal, or as a result of other reactions or interactions, from the ingredients outlined below, and optionally at least one additional pharmaceutical agent listed below.

[0120] In this application, the term "excipient" is used to refer to an ingredient of a pharmaceutical composition other than the pharma- ceutical active ingredient. Selection of an appropriate excipient depends on a variety of factors, such as the dosage form, the dosage amount, the desired solubility, and the stability of the composition.

[0121] The terms "effect," "therapeutic effect," "action," "therapeutic action," "efficacy," and "effectiveness" with respect to the disclosed pharmaceutical formulations or other active substances described herein refer to a beneficial result that occurs causally in an organism to which the substance has previously been administered.

[0122] According to the present invention, the terms "effective amount" and "therapeutically effective amount" refer to an amount of a pharmaceutical combination of the present disclosure sufficient to produce a desired beneficial effect in a subject in need of such treatment.

[0123] The terms "treatment" and "therapy" include administration of at least an agent of the invention alone or in combination with at least one other pharmaceutical agent, regardless of the chronological order of administration. Such administration is intended to significantly ameliorate the disease course of coronavirus infection by either curing the disease altogether or by halting or slowing the progression of disorders during the course of the disease.

[0124] The terms "prophylaxis" or "prophylactic treatment" include administration of at least a substance of the invention alone or in combination with at least one other medicinal agent, regardless of the chronological order of administration, to prevent or inhibit the manifestation of symptoms resulting from coronavirus infection, particularly in patients whose condition is expected with reasonable probability that such a manifestation will occur in the distant or near future.

[0125] The terms "subject" and "patient" include any individual suffering from, and having confirmed or suspected diagnosis of, a disease or disorder associated with a coronavirus infection. The individual may be a mammal, particularly a human.

[0126] The pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof may be used as a monotherapy or may be further combined with at least one further active ingredient selected from the group comprising active ingredients used in the disease modifying therapy of coronavirus infections, the symptomatic treatment of coronavirus infections, and the treatment of complications.

[0127] The pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate, solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof can be used simultaneously, separately, or sequentially to treat or prevent disease conditions. At least two active agents are provided in a single dosage form or as separate formulations, each formulation containing at least one of the two active agents. One or either active agent can be formulated as a bolus.

[0128] In particular, the present application discloses a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione, or one of its pharma- ceutical acceptable salts, and 6'-methoxycinchonan-9-ol, or a pharma- ceutical acceptable salt, for use in the treatment of coronavirus infections that have been refractory to previous treatment with at least one other pharma- ceutical active agent.

[0129] The term "medicine" or "healthcare" includes veterinary medicine as well as human medicine.

[0130] The term "organism" refers to an organism having an autoregulatory immune system, particularly a human or animal.

[0131] The term "host organism" is used to refer to an organism that is infected with a virus, particularly a retrovirus, and is subsequently utilized for viral replication.

[0132] The term "active agent" in this application, unless otherwise specified, refers to 5-amino-2,3-dihydro-1,4-phthalazinedione or any of its pharma- ceutically acceptable salts, hydrates, solvates, or quinine, quinidine, or its pharma- ceutically acceptable salts. Furthermore, this term may include further agents known from the state of the art.

[0133] The terms "composition" and "pharmaceutical composition" include a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate, or solvate thereof, and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof, in any pharmacologically appropriate defined dose and dosage form, together with at least one suitable excipient or carrier substance, and all substances which result directly or indirectly as a combination, accumulation, complexation or crystallization of the aforementioned components, or as a result of other reactions or interactions.

[0134] The term "excipient" is used in this application to describe each component of an excipient. A pharmaceutical composition contains excipients in addition to the active agent. The selection of an appropriate excipient depends on factors such as the dosage form and dosage, and the effect of the excipient itself on the solubility and stability of the composition.

[0135] The term "action" describes the unique and specific mode of action of each drug within the scope of this application.

[0136] The terms "effect," "therapeutic effect," "action," and "therapeutic effect" with respect to at least one active agent according to the present invention refer to a beneficial outcome that causally occurs to an organism to which the at least one active agent is administered.

[0137] In this application, "therapeutically effective amount" means that a sufficient amount of the pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof is administered to an organism or patient in need of such treatment.

[0138] The terms "co-administration", "combined administration" or "simultaneous administration" of at least one pharmaceutical agent according to the present invention and / or at least one pharmaceutical agent according to the state of the art include administration of the mentioned agents at the same time or virtually close to each other, as well as administration of said agents at different times within a consistent experiment. The chronological order of administration of said agents is not limited by these terms. Those skilled in the art will be able to easily deduce from their own knowledge and experience the chronological or local order of the described administration.

[0139] The term "organism" refers to any animal, particularly a vertebrate animal, including humans. A "patient" in this application refers to an organism suffering from a definable and diagnosable disease and to which an appropriate active agent can be administered.

[0140] The terms "prevention," "treatment," and "therapy" include the administration to an organism of a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate, or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof to prevent the onset of a particular disease, suppress and / or alleviate the symptoms, or initiate the healing process of the respective disease.

[0141] The pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate, or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof can be applied for the prophylaxis or treatment of coronavirus infection by any medically acceptable route of administration to a patient in need thereof. Such medically acceptable routes of administration can be, for example, inhalation, intubation, oral, parenteral, intraperitoneal, intravenous, intraarterial, intramuscular, topical, transdermal, subcutaneous, intradermal, sublingual, conjunctival, intravaginal, rectal, or intranasal.

[0142] A preferred oral formulation for use in the prevention or treatment of a coronavirus infection comprises a capsule or tablet containing 5-amino-2,3-dihydro-1,4-phthalazinedione or any of its pharmaceutically acceptable salts, hydrates and solvates in an amount of 50 mg, 100 mg, 150 mg, 200 mg, 300 mg, 400 mg, 500 mg or 600 mg, preferably 100 mg, 150 mg, 200 mg, 300 mg or 400 mg, most preferably 300 mg, and 6'-methoxycinchonan-9-ol or a pharmaceutically acceptable salt thereof.

[0143] The dosage of quinine sulfate is 200 mg, 260 mg, 324 mg, or 648 mg (equivalent to 524 mg of quinine base) for hard gelatin capsules, preferably 200 mg and 324 mg, most preferably 324 mg, and for film-coated tablets, 200 mg and 300 mg, even more preferably 200 mg of quinine sulfate.

[0144] The injection solution contains 600 mg of quinine dihydrochloride in a 2 ml ampoule, which corresponds to a concentration of 300 mg / ml.

[0145] The dosage of quinidine sulfate is 200 mg and 300 mg for tablets and 300 mg for extended-release tablets. 200 mg is preferred. Quinidine gluconate extended-release tablets are available in strengths of 324 mg.

[0146] Quinidine gluconate 80 mg / ml injection was available but has been discontinued in the United States.

[0147] It is understood that within the scope of this application, any combination of the above dosage amounts of 5-amino-2,3-dihydro-1,4-phthalazinedione or any of its pharmaceutically acceptable salts, hydrates and solvates with quinine or quinidine or any of their pharmaceutically acceptable salts is disclosed.

[0148] In another aspect of the present invention, a pharmaceutical composition is disclosed for use in the prevention or treatment of coronavirus infection, the pharmaceutical composition comprising 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates or solvates, 6'-methoxycinchonan-9-ol or its pharmaceutically acceptable salts, a carrier, and at least one pharmaceutically acceptable excipient.

[0149] The term "pharmaceutical acceptable excipient" refers to natural or synthetic compounds added to pharmaceutical formulations together with the active pharmaceutical ingredient. They may help bulk the formulation, improve the desired pharmacokinetic properties or stability of the formulation, and are also beneficial to the manufacturing process. Advantageous classes of excipients according to the present invention include carriers, binders, colorants, buffers, preservatives, antioxidants, coating agents, sweeteners, thickeners, pH adjusters, acidity adjusters, acidifiers, solvents, isotonicity agents, disintegrants, glidants, lubricants, emulsifiers, solubilizers, stabilizers, diluents, anti-caking agents (anti-adherents), adsorbents, foaming agents, antifoaming agents, opacifiers, fatliquoring agents, viscosity enhancers, hydrotropes, fragrances and flavorings.

[0150] Generally, one or more pharma- ceutically acceptable carriers are added to the pharma- ceutically active agent.All carriers known in the art and their combinations are suitable.For solid dosage forms, for example, vegetable and animal fats, wax, paraffin, starch, tragacanth, cellulose derivatives, polyethylene glycol, silicone, bentonite, silica, talc, zinc oxide, etc.For liquid dosage forms and emulsions, suitable carriers are, for example, solvents, solubilizers, emulsifiers, such as water, ethanol, isopropanol, ethyl carbonate, ethyl acetate, benzyl alcohol, benzyl benzoate, propylene glycol, 1,3-butyl glycol, cottonseed oil, peanut oil, olive oil, castor oil, sesame oil, glycerol fatty acid ester, polyethyl glycol, sorbitan fatty acid ester, etc. Suspensions according to the present invention may use carriers known in the art, such as diluents (e.g., water, ethanol or propylene glycol), ethoxylated isostearyl alcohol, polyoxyethylene and polyoxyethylene sorbitan esters, microcrystalline cellulose, bentonite, agar, tragacanth, and the like.

[0151] The term binder refers to a substance that binds or adheres powders together and provides cohesion through granule formation. Binders act as the "glue" of the formulation. Binders enhance the cohesive strength of any diluent or filler that is provided.

[0152] Suitable binders include, for example, starches derived from wheat, corn, rice or potato, gelatin, natural sugars such as glucose, sucrose or beta-lactose, sweeteners derived from corn, natural and synthetic gums such as acacia, tragacanth or calcium ammonium alginate, sodium alginate, carboxymethylcellulose, sodium carboxymethylcellulose, hydroxypropyl carboxymethylcellulose, polyethylene glycol, polyvinylpyrrolidone, magnesium aluminum silicate, waxes, etc. The proportion of binder in the composition is in the range of 1-30% by weight, preferably 2-20% by weight, more preferably 3-10% by weight, most preferably 3-6% by weight.

[0153] Colorants are excipients that impart color to pharmaceutical formulations. These excipients may be food colorants. They may be adsorbed onto suitable adsorption means such as clay or aluminum oxide. A further advantage of colorants is that they can make aqueous solutions spilled on the nebulizer and / or mouthpiece visible to facilitate cleaning. The amount of colorant can vary in the range of 0.01-10% by weight of the pharmaceutical composition, preferably in the range of 0.05-6%, more preferably in the range of 0.1-4%, and most preferably in the range of 0.1-1%.

[0154] Suitable pharmaceutical colours include, for example, curcumin, riboflavin, riboflavin-5'-phosphate, tartrazine, alkannin, quinolion yellow WS, fast yellow AB, sodium riboflavin-5'-phosphate, yellow 2G, sunset yellow FCF, orange GGN, cochineal, carminic acid, citrus red 2, carmoisine, amaranth, ponceau 4R, ponceau SX, ponceau 6R, erythrosine, red 2G, allura red AC, indanthrene blue RS, patent blue V, indigo carmine, brilliant blue FCF, chlorophyll and chlorophyllin, copper complexes of chlorophyll and chlorophyllin, green S, fast green FCF, plain caramel, caustic sulphite caramel, ammoniacal caramel, ammoniacal sulphite caramel, black PN, carbon black, vegetable colours and the like. Carbon, Brown FK, Brown HT, α-carotene, β-carotene, γ-carotene, annatto, bixin, norbixin, paprika oleoresin, capsanthin, capsorubin, lycopene, β-apo-8'-carotenal, β-apo-8'-carotenoic acid ethyl ester, flavaxanthin, lutein, cryptoxanthin, rubixanthin, violaxanthin, rhodoxanthin, canthaxanthin, zeaxanthin, citranaxanthin, astaxanthin, betanin, anthocyanin, saffron, calcium carbonate, titanium dioxide, iron oxide, iron hydroxide, aluminum, silver, gold, rubin pigment, tannin, orcein, ferrous gluconate, and ferrous lactate.

[0155] Furthermore, buffers are preferred for liquid formulations, especially pharmaceutical liquid formulations. The terms buffer, buffer system, and buffer, especially for aqueous solutions, refer to the ability of the system to resist pH changes due to the addition of acid or base, or dilution with a solvent. Preferred buffer systems include formic acid, lactic acid, benzoic acid, oxalic acid, fumaric acid, aniline, acetate buffer, citrate buffer, glutamate buffer, phosphate buffer, succinic acid, pyridine, phthalic acid, histidine, MES (2-(N-morpholino)ethanesulfonic acid), maleic acid, cacodylic acid (dimethylarsenic acid), carbonic acid, ADA (N-(2-acetamido)iminodiacetic acid, PIPES (4-piperazine-bis-ethanesulfonic acid), BIS-TRIS propane (1,3-bis[tris(hydroxymethyl) The buffer may be selected from the group including N-(2-[(methylamino)propane), ethylenediamine, ACES (2-[(amino-2-oxoethyl)amino]ethanesulfonic acid), imidazole, MOPS (3-(N-morpholino)propanesulfonic acid), diethylmalonate, TES (2-[tris(hydroxymethyl)methyl]aminoethanesulfonic acid), HEPES (N-2-hydroxyethylpiperazine-N'-2-ethanesulfonic acid), and other buffers with a pKa between 3.8 and 7.7.

[0156] Preferred are carbonate buffers such as acetate buffers, dicarboxylic acid buffers such as fumaric acid, tartaric acid, phthalic acid, and tricarboxylic acid buffers such as citric acid.

[0157] A further group of preferred buffers are inorganic buffers such as sulfate hydroxide, borate hydroxide, carbonate hydroxide, oxalate hydroxide, calcium hydroxide, phosphate buffers, etc. Another group of preferred buffers are nitrogen-containing buffers such as imidazole, diethylenediamine, piperazine, etc. Further preferred are sulfonic acid buffers such as TES, HEPES, ACES, PIPES, [(2-hydroxy-1,1-bis-(hydroxymethyl)ethyl)amino]-1-propanesulfonic acid (TAPS), 4-(2-hydroxyethyl)piperazine-1-propanesulfonic acid (EEPS), MOPS, and N,N-bis-(2-hydroxyethyl)-2-aminoethanesulfonic acid (BES). Another group of preferred buffers are glycine, glycyl-glycine, glycyl-glycyl-glycine, N,N-bis-(2-hydroxyethyl)glycine, and N-[2-hydroxy-1,1-bis(hydroxymethyl)ethyl]glycine (tricine). Also preferred are amino acid buffers such as glycine, alanine, valine, leucine, isoleucine, serine, threonine, phenylalanine, tyrosine, tryptophan, lysine, arginine, histidine, aspartic acid, glutamic acid, asparagine, glutamine, cysteine, methionine, proline, 4-hydroxyproline, N,N,N-trimethyllysine, 3-methylhistidine, 5-hydroxylysine, o-phosphoserine, γ-carboxyglutamic acid, [ε]-N-acetyllysine, [ω]-N-methylarginine, citrulline, ornithine, and derivatives thereof. Particularly preferred is KH2PO4 buffer.

[0158] Preservatives for liquid and / or solid dosage forms may be used as needed. These include sorbic acid, potassium sorbate, sodium sorbate, calcium sorbate, methylparaben, ethylparaben, methylethylparaben, propylparaben, benzoic acid, sodium benzoate, potassium benzoate, calcium benzoate, heptyl parahydroxybenzoate, sodium methyl parahydroxybenzoate, sodium ethyl parahydroxybenzoate, sodium propyl parahydroxybenzoate, benzyl alcohol, benzalkonium chloride, phenylethyl alcohol, cresol, cetylpyridinium chloride, chlorobutanol, thiomersal (sodium 2-(ethylmercurythio)benzoate), sulfur dioxide, sodium sulfite, sodium bisulfite, sodium metabisulfite, potassium metabisulfite, potassium sulfite, calcium sulfite. ammonium, calcium bisulfite, potassium bisulfite, biphenyl, orthophenylphenol, sodium orthophenylphenol, thiabendazole, nisin, natamycin, formic acid, sodium formate, calcium formate, hexamine, formaldehyde, dimethyl dicarbonate, potassium nitrite, sodium nitrite, sodium nitrate, potassium nitrate, acetic acid, potassium acetate, sodium acetate, sodium diacetate, calcium acetate, ammonium acetate, dehydroacetic acid, sodium dehydroacetate, lactic acid, propionic acid, sodium propionate, calcium propionate, potassium propionate, boric acid, sodium tetraborate, carbon dioxide, malic acid, fumaric acid, lysozyme, copper (II) sulfate, chlorine, chlorine dioxide, and other suitable substances or compositions known to those of skill in the art.

[0159] Adding sufficient amount of antioxidant is especially preferred for liquid and topical dosage forms.Suitable examples of antioxidant include sodium metabisulfite, α-tocopherol, ascorbic acid, maleic acid, sodium ascorbate, ascorbyl palmitate, butylated hydroxyanisole, butylated hydroxytoluene, fumaric acid or propyl gallic acid.The use of sodium metabisulfite, α-tocopherol and ascorbyl palmitate is preferred.

[0160] Tablets or pills are usually coated, i.e. the coating constitutes the outer layer. This can be a film coating, a sugar coating including sugars, and a compression coating. Pharmaceutically acceptable varnishes or waxes, HPMC (hydroxypropyl methylcellulose), MC (methylcellulose), or HPC (hydroxypropyl cellulose) can be used. Such coatings may serve to mask taste and facilitate swallowing or identification. Coatings often include plasticizers and pigments. Capsules usually have a gelatinous shell that encases the pharmaceutical composition according to the disclosure. The particular composition and thickness of this gelatin layer determines how quickly absorption occurs after ingestion of the capsule. Of particular interest are sustained release formulations known in the art.

[0161] Suitable sweeteners may be selected from the group consisting of mannitol, glycerol, acesulfame potassium, aspartame, cyclamate, isomalt, isomaltitol, saccharin and its sodium, potassium and calcium salts, sucralose, alitame, thaumatin, glycyrrhizin, neohesperidin dihydrochalcone, steviol glycosides, neotame, aspartame-acesulfame salt, maltitol, maltitol syrup, lactitol, xylitol, erythritol.

[0162] Suitable thickening agents may be selected from the group including, but not limited to, polyvinylpyrrolidone, methylcellulose, hydroxypropyl methylcellulose, hydroxypropyl cellulose, dextrin, polydextrose, modified starch, alkaline modified starch, bleached starch, oxidized starch, enzyme treated starch, monostarch phosphate, di-starch phosphate esterified with sodium trimetaphosphate or phosphorus oxychloride, di-starch phosphate, acetylated di-starch phosphate, starch acetate esterified with acetic anhydride, starch acetate esterified with vinyl acetate, acetylated di-starch adipate, acetylated di-starch glycerol, di-starch glycerin, hydroxypropyl starch, hydroxypropyl di-starch glycerin, hydroxypropyl di-starch phosphate, hydroxypropyl di-starch glycerol, sodium starch octenyl succinate, acetylated oxidized starch, hydroxyethyl cellulose.

[0163] Suitable pH adjusting agents for liquid dosage forms include, for example, buffer substances such as sodium hydroxide, hydrochloric acid, sodium dihydrogen phosphate or disodium hydrogen phosphate.

[0164] Suitable acidity regulators include acetic acid, potassium acetate, sodium acetate, sodium diacetate, calcium acetate, carbon dioxide, malic acid, fumaric acid, sodium lactate, potassium lactate, calcium lactate, ammonium lactate, magnesium lactate, citric acid, mono-, di-, trisodium citrate, mono-, di-, tripotassium citrate, mono-, di-, tricalcium citrate, tartaric acid, mono-, disodium tartrate, mono-, dipotassium tartrate, sodium potassium tartrate, orthophosphoric acid, lecithin citrate, magnesium citrate, ammonium malate, sodium malate, sodium hydrogen malate, calcium malate, calcium hydrogen malate, adipic acid, adipic acid, citric ... Sodium adipate, potassium adipate, ammonium adipate, succinic acid, sodium fumarate, potassium fumarate, calcium fumarate, ammonium fumarate, 1,4-heptonolactone, triammonium citrate, ferric ammonium citrate, calcium glycerophosphate, isopropyl citrate, potassium carbonate, potassium bicarbonate, ammonium carbonate, ammonium bicarbonate, magnesium carbonate, magnesium bicarbonate, ferrous carbonate, ammonium sulfate, potassium aluminum sulfate, ammonium aluminum sulfate, sodium hydroxide, potassium hydroxide, ammonium hydroxide, magnesium hydroxide, gluconic acid.

[0165] Oxidizing agents are inorganic chemicals that produce or become acids. Suitable examples include ammonium chloride and calcium chloride. Suitable solvents may be selected from the group including, but not limited to, water, carbonated water, water for injection, water containing an isotonic agent, saline, isotonic saline, alcohol, particularly ethyl alcohol and n-butyl alcohol, and mixtures thereof.

[0166] Suitable isotonicity agents include, for example, pharma- ceutically acceptable salts, particularly sodium chloride and potassium chloride, sugars such as glucose or lactose, sugar alcohols such as mannitol and sorbitol, citrates, phosphates, borates, and mixtures thereof.

[0167] Suitable disintegrants may be selected from the group consisting of starch, cold water soluble starches such as carboxymethyl starch, cellulose derivatives such as methylcellulose and sodium carboxymethylcellulose, crosslinked microcrystalline cellulose such as microcrystalline cellulose and croscarmellose sodium, natural and synthetic gums such as guar, agar, Karaya (Indian tragacanth), locust bean gum, tragacanth, clays such as bentonite, xanthan gum, alginates such as alginic acid and sodium alginate, among others, effervescent compositions. Moisture expansion is promoted by, for example, starch, cellulose derivatives, alginates, polysaccharides, dextran, crosslinked polyvinylpyrrolidone. The amount of disintegrant in the composition may vary from 1 to 40% by weight, preferably from 3 to 20% by weight, most preferably from 5 to 10% by weight.

[0168] Glidants are substances that prevent seizing of the respective supplement and improve the flow properties of the granules so that the flow is smooth and consistent. Suitable glidants include silicon dioxide, magnesium stearate, sodium stearate, starch, and talc. The amount of glidant in the composition varies from 0.01 to 10% by weight, preferably from 0.1 to 7% by weight, more preferably from 0.2 to 5% by weight, and most preferably from 0.5 to 2% by weight.

[0169] The term "lubricant" refers to a substance added to a dosage form to facilitate the release of tablets, granules, etc. from a press die or exit nozzle. Lubricants reduce friction or wear. Lubricants are usually added just before pressing, since they need to be present on the surfaces of the granules and between the granules and the parts of the press die. The amount of lubricant in the composition can vary between 0.05-15% by weight, with 0.2-5% by weight being preferred, 0.3-3% by weight being more preferred, and 0.3-1.5% by weight being most preferred. Suitable lubricants are, among others, metal stearates such as sodium oleate, sodium stearate, calcium stearate, potassium stearate, magnesium stearate, stearic acid, sodium benzoate, sodium acetate, sodium chloride, boric acid, high melting point waxes, polyethylene glycol.

[0170] The emulsifiers can be chosen, for example, from the following anionic and nonionic emulsifiers: anionic emulsifier waxes, cetyl alcohol, cetylstearyl alcohol, stearic acid, oleic acid, polyoxyethylene polyoxypropylene block polymers, addition products of 2 to 60 moles of ethylene oxide onto castor oil and / or onto hydrogenated castor oil, wool wax oil (lanolin), sorbitan esters, polyoxyethylene alkyl esters, polyoxyethylene sorbitan fatty acid esters, polyoxyethene sorbitan monolaurate, polyoxyethylene ... Ethene sorbitan monooleate, polyoxyethene sorbitan monopalmitate, polyoxyethene sorbitan monostearate, polyoxyethene sorbitan tristearate, polyoxyethene stearate, polyvinyl alcohol, metatartaric acid, calcium tartrate, alginic acid, sodium alginate, potassium alginate, ammonium alginate, calcium alginate, propane-1,2-diol alginate, carrageenan, modified eukemium seaweed, locust bean gum, tragacanth, acacia gum, karaya gum, gellan gum, ghatti Gums, glucomannan, pectin, amidated pectin, ammonium phospholipids, brominated vegetable oils, sucrose acetate isobutyrate, glycerol esters of wood rosin, disodium phosphate, trisodium phosphate, tetrasodium phosphate, dicalcium phosphate, dihydrogen calcium phosphate, trisodium phosphate, pentapotassium phosphate, sodium polyphosphate, sodium calcium polyphosphate, calcium polyphosphate, ammonium polyphosphate, beta-cyclodextrin, powdered cellulose, methylcellulose, ethylcellulose, hydroxypropylcellulose, hydroxypropylmethylcellulose, ethylmethylcellulose, carboxymethylcellulose, sodium carboxymethylcellulose, ethylhydroxyethylcellulose, croscarmellose, enzymatically hydrolyzed carboxymethylcellulose, mono- and diglycerides of fatty acids, glyceryl monostearate, glyceryl distearate, acetate esters of mono- and diglycerides of fatty acids, lactate esters of mono- and diglycerides of fatty acids, citric acid esters of mono- and diglycerides of fatty acids, tartaric acid esters of mono- and diglycerides of fatty acids,Mono- and diacetyl tartaric acid esters of mono- and diglycerides of fatty acids, mixed acetic and tartaric acid esters of mono- and diglycerides of fatty acids, succinic acid monoglycerides, sucrose esters of fatty acids, sucroglycerides, polyglycerol esters of fatty acids, polyglycerol polyricinoleate, propane-1,2-diol esters of fatty acids, propylene glycol fatty acid esters, lactic acid fatty acid esters of glycerol and propane-1, thermooxidized soybean oil interacted with mono- and diglycerides of fatty acids, sodium dioctyl sulfosuccinate, sodium stearoyl-2-lactylate, calcium stearoyl-2-lactylate, stearyl tartaric acid, stearyl citrate, stearic acid Sodium stearoyl fumarate, calcium stearoyl fumarate, stearyl tartaric acid, stearyl citrate, sodium stearoyl fumarate, calcium stearoyl fumarate, sodium lauryl sulfate, ethoxylated mono- and diglycerides, methyl glucoside-coconut oil esters, sorbitan monostearate, sorbitan tristearate, sorbitan monolaurate, sorbitan monooleate, sorbitan monopalmitate, sorbitan trioleate, calcium sodium polyphosphate, calcium polyphosphate, ammonium polyphosphate, cholic acid, choline salts, distarch glycerol, sodium starch octenylsuccinate, acetylated oxidized starch. Preferred are phospholipids such as glycerol monooleate, stearic acid, and lecithin.

[0171] Suitable surface-active solubilizers include, for example, diethylene glycol monoethyl ester, polyethylene propylene glycol copolymer, cyclodextrins such as α-cyclodextrin and β-cyclodextrin, glyceryl monostearates such as Solutol HS15 (BASF macrogol-15-hydroxystearate, PEG660-15 hydroxystearate), sorbitan esters, polyoxyethylene glycol, polyoxyethylene sorbitan acid esters, polyoxyethylene sorbitan monooleate, polyoxyethylene oxystearic acid triglyceride, polyvinyl alcohol, sodium dodecyl sulfate, and (anionic) glyceryl monooleate.

[0172] Stabilizers are substances that can be added to prevent undesirable changes. Stabilizers are not true emulsifiers, but they also contribute to the stability of an emulsion. Suitable examples of stabilizers include oxystearin, xanthan gum, agar, oat gum, guar gum, tara gum, polyoxyethylene stearate, aspartame acesulfame salt, amylase, protease, papain, bromelain, ficin, invertase, polydextrose, polyvinylpyrrolidone, polyvinylpolypyrrolidone, triethyl citrate, maltitol, maltitol syrup, etc.

[0173] Diluents or fillers are inert substances added to drugs to handle the minimum amount of active agent.Examples of suitable diluents include water, mannitol, pregelatinized starch, starch, microcrystalline cellulose, powdered cellulose, silicified microcrystalline cellulose, dibasic calcium phosphate dihydrate, calcium phosphate, calcium carbonate, hydroxypropyl cellulose, hydroxyethyl cellulose, hydroxypropyl methyl cellulose, polyethylene glycol, xanthan gum, gum arabic, or combinations thereof.

[0174] Anti-caking agents (anti-adherents) can be added to the supplement or the composition of the supplement to prevent the formation of lumps and facilitate packaging, transportation, release from at least one chamber of the dispensing cap, and consumption.Suitable examples include tricalcium phosphate, powdered cellulose, magnesium stearate, sodium bicarbonate, sodium ferrocyanide, potassium ferrocyanide, calcium ferrocyanide, bone phosphate, sodium silicate, silicon dioxide, calcium silicate, magnesium trisilicate, talc powder, sodium aluminosilicate, potassium aluminosilicate, calcium aluminosilicate, bentonite, aluminosilicate, stearic acid, polydimethylsiloxane, etc.

[0175] Sorbents are substances that absorb oil from water. Suitable examples include natural sorbents such as peat moss, sawdust, feathers, and other natural substances containing carbon, and synthetic sorbents such as polyethylene and nylon. Sorbents are used to protect tablets / capsules from moisture by limited liquid adsorption (the absorption of liquids or gases by adsorption or sorption) in dry conditions.

[0176] In some herbal formulations, it may be desirable to generate a foam when the liquid oral dosage form dissolves. Such an effect can be supported by the addition of effervescent agents that lower the surface tension of the liquid, promoting foam formation; or inhibiting bubble coalescence, thereby enhancing colloidal stability; or stabilizing the foam. Suitable examples include mineral oil, Quillaja extract, triethyl citrate, sodium lauryl ether sulfate, sodium lauryl sulfate, and ammonium lauryl sulfate.

[0177] Alternatively, some liquid oral dosage forms may foam slightly when prepared. While this does not prevent the intended use, it may affect patient compliance in the case of pharmaceuticals and commercial success in the case of dietary supplements. Therefore, it may be desirable to add a pharma- ceutically acceptable antifoaming agent (defoamer). Examples include polydimethylsiloxane or silicone oil in dietary supplements and simethicone in pharmaceuticals.

[0178] An opacifier is a substance that renders a liquid dose opaque when necessary. The opacifier must have a refractive index substantially different from that of the solvent (most often water). At the same time, it must be inert to the other components of the composition. Suitable examples include titanium dioxide, talc, calcium carbonate, behenic acid, cetyl alcohol, or mixtures thereof.

[0179] Suitable fatliquors include, for example, decyl oleate, hydrated castor oil, light mineral oil, mineral oil, polyethylene glycol, sodium lauryl sulfate, and the like.

[0180] Examples of viscosity enhancers include cetyl alcohol, cetyl ester wax, hydrated castor oil, microcrystalline wax, non-ionic emulsifying wax, beeswax, paraffin, or stearyl alcohol.

[0181] Suitable hydrotropes are alcohols, such as ethanol, isopropyl alcohol, or polyols, such as glycerin.

[0182] Suitable aroma and flavoring substances include essential oils that can be used for this purpose. In general, the term refers to volatile extracts from plants or plant parts that have their characteristic odor. These can be extracted from plants or plant parts by steam distillation.

[0183] Suitable examples include essential oils and aromatic substances such as achillea, sage, cedar, clove, chamomile, anise, anise seed, star anise, thyme, tea tree, peppermint, mint oil, menthol, cineole, borneol, gingerol, eucalyptus, mango, fig, lavender oil, chamomile flower, pine needles, cypress, orange, rose, rosewood, plum, currant, cherry, birch leaf, cinnamon, lime, grapefruit, tangerine, juniper, valerian, lemon, lemon balm, lemongrass, palmarosa, cranberry, pomegranate, rosemary, ginger, pineapple, guava, echinacea, ivy leaf extract, blueberry, persimmon, melon, α- or β-pinene, α-pinene oxide, α-camphorenic aldehyde, α-citronellol. α-Isoamyl cinnamic acid, α-Cinnamic terpinene, α-Terpineol, α-Terpinene, Aldehyde C16, α-Phellandrene, Amyl cinnamic aldehyde, Amyl salicylic acid, Anisaldehyde, Basil, Anethole, Bay leaf, Benzyl acetate, Benzyl alcohol, Bergamot, Bitter orange peel, Black pepper, Calamus, Camphor, Cananga oil, Cardamom, Carnation, Carvacrol, Carveol, Cassia, Castor, Cedarwood, Cinnamic aldehyde, Cinnamic alcohol, Cis-Pinane, Citral, Citronella, Citronellal, Citronellol dextro, Citronellol, Citronellyl acetate. Citronellyl nitrile, Unshu mandarin orange, clary sage, clove bud, coriander, corn, cottonseed, d-dihydrocarvone, decyl aldehyde, diethyl phthalate, dihydroanethole, dihydrocarveol, dihydrolinalool, dihydromyrcene, dihydromyrcenol, dihydromyrcenyl acetate, dihydroterpineol, dimethylsalicylic acid, dimethyloctanal, dimethyloctanol, dimethyloctanyl acetate, diphenyl oxide, dipropylene glycol, d-limonene, d-pulegone, estragole, ethyl vanillin, eucalyptol. Eucalyptus citriodora, Eucalyptus globulus, Eugenol, Evening primrose, Fencol, Fennel, Ferniol, Fish, Florazone, Galaxolide, Geraniol, Geranium, Geranyl acetate,Geranyl nitrile, guaiacol, guaiacwood, gurjun balsam, heliotropin, herbanate, hiba, hydroxycitronellal, i-carvone, i-methyl acetate, ionone, isobutylquinolein, isobornyl acetate, isobornyl methyl ether, isoeugenol, isolongifolene, jasmine, lavender, limonene, linalool oxide, linalool, linalool, linalyl acetate, flaxseed, litseacube, i-methyl acetate, longifolene, mandarin, mint, menthane Roperoxide, Menthol Crystals, Menthol Laevo, Menthone Laevo, Methyl Anthranilic Acid, Methyl Cedryl Ketone, Methyl Chavicol, Methyl Hexyl Ether, Methyl Ionone, Methyl Salicylic Acid, Minerals, Mint, Musk Ambrette, Musk Ketone, Musk Xylol, Myrcene, Nerol, Neryl Acetate, Nonyl Aldehyde, Nutmeg, Orris Root, Para-Cymene, Para-Hydroxyphenylbutanone Crystals, Patchouli, p-Cymene, Pennyroyal Oil, Pepper, Perillaldehyde, Petitgrain, Phenylethyl Alcohol , phenylethyl propionate, phenylethyl-2-methylbutyrate, pimento berry, pimento leaf, pinane hydroperoxide, pinanol, pine esters, pine, pinene, piperonal, piperonyl acetate, piperonyl alcohol, purinol, purinyl acetate, pseudoionone, rhodinol, rhodinyl acetate, rosalin, rue, sandalwood, sandenol, sassafras, sesame, soybean, spearmint, spices, spike lavender, spilanthol, starflower, tea seed, terpenoids, terpineol ole, terpinolene, terpinyl acetate, tert-butylcyclohexyl acetate, tetrahydrolinalool, tetrahydrolinalyl acetate, tetrahydromyrcenol, tulasi, thymol, tomato, trans-2-hexenol, trans-anethole, turmeric, turpentine, vanillin, vetiver, vitalizer, white cedar, white grapefruit, wintergreen, etc., or mixtures thereof, as well as menthol, peppermint and star anise oils or mixtures of menthol and cherry flavors.

[0184] These aromatic or flavouring substances may be present in amounts ranging from 0.0001 to 10% by weight (particularly in the composition) of the total composition, preferably from 0.001 to 6% by weight, more preferably from 0.001 to 4% by weight and most preferably from 0.01 to 1% by weight. It may be advantageous to use different amounts in relation to the application or individual case.

[0185] According to the present invention, all the aforementioned excipients and excipient classes can be used without restriction, either alone or in any conceivable combination, as long as it does not interfere with the use of the invention, does not cause toxic effects, or does not violate the laws of the respective countries.

[0186] In another aspect of the present invention, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof, or a pharmaceutical composition according to the present invention, for use in a formulation for oral administration in the prophylaxis or treatment of coronavirus infection.

[0187] Pharmaceutical formulations suitable for oral administration of the pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof may be administered in discrete units in the form of tablets, soft gelatin capsules, hard gelatin capsules, dragees or pills, powders or granules, juices, syrups, drops, teas, solutions or suspensions in aqueous or non-aqueous liquids, edible foams or mousses, or oil-in-water or water-in-oil emulsions.

[0188] In oral dosage forms such as tablets and capsules, the active agent can be combined with a non-toxic, pharma- ceutically acceptable inert carrier, such as ethanol, glycerol, water, etc. Powders are produced by grinding the compound to a suitable small particle size and mixing in a similar manner with a pharmaceutical carrier, such as an edible carbohydrate, such as starch or mannitol. Flavoring, preservative, dispersing agent, or coloring agent may also be present.

[0189] Tablets are formulated by preparing, granulating or dry pressing a powder mixture, adding a lubricant and disintegrant, and compressing the mixture into tablets. The powder mixture is produced by mixing the compound, suitably comminuted, with the aforementioned diluents or bases, and, if applicable, with binders such as carboxymethylcellulose, alginates, gelatin or polyvinylpyrrolidone, dissolution retarders such as paraffin, absorption enhancers such as quaternary salts, and / or absorbents such as bentonite, kaolin or dicalcium phosphate. The powder mixture can be granulated by wetting it with a binder such as syrup, starch paste, acacia mucilage or solutions of cellulose or polymeric materials and pressing it through a sieve. As an alternative to granulation, the powder mixture can be passed through a tablet machine to produce lumps of non-uniform shape which are broken into granules. The granules can be lubricated with the addition of stearic acid, a stearate salt, talc, or mineral oil to prevent the granules from sticking to the tablet mold. The lubricated mixture is then compressed to give tablets. The compounds of the present invention can also be mixed with a free-flowing inert excipient and compressed directly to give tablets without going through the granulation or dry pressing steps.

[0190] In another aspect of the present invention, pharmaceutical combinations of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof are provided in hard gelatin capsules. These are produced by preparing a powder mixture as described above and filling it into formed gelatin covers. Glidants and lubricants such as highly dispersed silica, talc, magnesium stearate, calcium stearate or polyethylene glycol can be added as solids to the powder mixture. Disintegrants or solubilizers such as agar-agar, calcium carbonate or sodium carbonate can be added as well to improve the availability of the drug after ingestion of the capsule. Furthermore, suitable binders and / or coloring agents can be added to the mixture if desired or necessary.

[0191] In another aspect of the invention, the pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof is contained in a soft gelatin capsule (SGC). SGCs dissolve as they pass through the digestive tract. They consist primarily of gelatin fortified with various amounts of plasticizers such as glycerol or sorbitan. The release rate depends on the specific formulation of the SGC carrier material. They are also suitable for sustained release of active agents. SGCs are particularly useful for the administration of active agents that are poorly soluble in water.

[0192] In another aspect of the invention, a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof is formulated into a chewable tablet or hard caramel, wherein the substances are incorporated into the matrix of the tablet or caramel.

[0193] In another aspect of the invention, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof, or a pharmaceutical composition according to the invention in a formulation for administration by inhalation for use in the prophylaxis or treatment of coronavirus infection.

[0194] For an effective prophylactic or therapeutic treatment of coronavirus infections that may cause pneumonia, pulmonary edema and / or acute lung damage, it is advantageous for the pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharma- ceutically acceptable salts, hydrates or solvates with 6'-methoxycinchonan-9-ol or its pharma- ceutically acceptable salts, i.e. the pharmaceutical composition of the present invention, to reach the alveoli of the patient. Therefore, the particle size must be small enough to reach the lowest part of the airways of the lung tissue. The most suitable class of inhalation devices for the inhalation application of pharma- ceutical active agents are the so-called mesh nebulizers. Within the scope of the present application, virtually all mesh nebulizers known in the art can be used, from relatively simple disposable mesh nebulizers for cough and cold or decorative purposes to sophisticated high-end mesh nebulizers for clinical or home treatment of severe diseases or symptoms of the lower respiratory tract.

[0195] Suitable commercially available mesh nebulizers, jet nebulizers, ultrasonic nebulizers, dry powder inhalers, and (pressurized) metered dose inhalers include PARI eFlow® rapid, PARI LC STAR®, PARI Velox, PARI Velox Junior (PARI GmbH, Starnberg, Germany), Philips Respironics I-neb, Philips InnoSpire Go (Koninklijke Philips NV, Eindhoven, The Netherlands), VENTA-NEB®-ir, OPTI-NEB®, M-neb® dose+ mesh nebulizer inhalation MN-300 / 8, M-Neb Flow+, M-neb® mesh nebulizer MN-300 / X (NEBU-TEC, Eisenfeld, Germany), Hcmed Deepro HCM-86C and HCM860 (HCmed Innovations Co., Ltd, Taipei, Taiwan), OMRON MicroAir U22 and U100 (Omron, Kyoto, Japan), Aerogen® Solo, Aerogen® Ultra and Aerogen® PRO (Aerogen, Galway, Ireland), KTMED NePlus NE-SM1 (KTMED Inc., Seoul, Korea), Vectura Bayer Breelib™ (Bayer AG, Leverkusen, Germany), Vectura Fox, MPV Truma and MicroDrop® Smarty (MPV MEDICAL GmbH, Kirchheim, Germany), MOBI MESH (APEX Medical, New Taipei City, Taiwan), B.Well WN-114, TH-134 and TH-135 (B.Well Swiss AG, Widnau, Switzerland), Babybelle Asia BBU01 (Babybelle Asia Ltd., Hong Kong), CA-MI Kiwi and others (CA-MI sri, Langhirano, Italy), Diagnosis PRO MESH (Diagnosis SA, Białystok, Poland), DIGIO2 (DigiO2 International Co., Ltd., New Taipei City, Taiwan), feellife AIR PLUS, AEROCENTRE+, AIR 360+, AIR GARDEN, AIRICU, AIR MASK, AIRGEL BOY, AIR ANGEL, AIRGEL GIRL, AIR PRO 4 (Feellife Health Inc., Shenzhen, China), Hannox MA-02 (Hannox International Corp., Taipei, Taiwan), Health and Life HL100 and HL100A (HEALTH&LIFE Co., Ltd., New Taipei City, Taiwan), Honsun NB-810B (Honsun Co., Ltd., Nantong, China), K-jump(R) KN-9100 (K-jump Health Co., Ltd., New Taipei City, Taiwan), microlife NEB-800 (Microlife AG, Widnau, Switzerland), OK Biotech Docspray(OK Biotech Co., Ltd., Hsinchu City, Taiwan), Prodigy Mini-Mist(R) (Prodigy Diabetes Care, LLC, Charlotte, USA), Quatek NM211, NE203, NE320, NE403 (Big Eagle Holding Ltd., Taipei, Taiwan), Simzo NBM-1 and NBM-2 (Simzo Electronic Technology Ltd., Dongguan, China), Mexus® BBU01 and BBU02 (Tai Yu International Manufactory Ltd., Dongguan, China), TaiDoc TD-7001 (TaiDoc Technology Co., New Taipei City, Taiwan), Vibralung® and HIFLO Miniheart CirculaireII (Westmed Medical Group, Purchase, USA), KEJIAN (Xuzhou Kejian Hi-Tech Co., Ltd., Xuzhou, China), YM-252, P&S-T45 and P&S-360 (TEKCELEO, Valbonne, France), Maxwell YS-31 (Maxwell India, Jaipur, India), Kernmed® JLN-MB001 (Kernmed, Durmersheim, Germany).

[0196] Preferred are mesh nebulizers with piezoelectric activation of the nebulization process, or vibrating mesh nebulizers.

[0197] Therefore, in another aspect of the present invention, the present application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof, or a pharmaceutical composition according to the present invention, for use in the prophylaxis or treatment of coronavirus infection, wherein the inhalation administration is by means of a vibrating mesh nebulizer.

[0198] Mesh nebulizers can be divided into two groups according to their interaction with the patient: continuous mode devices and trigger-activated devices. In continuous mode mesh nebulizers, the nebulized aerosol is continuously released into the mouthpiece, and the patient inhales the provided aerosol. In trigger-activated devices, a defined amount of aerosol is released only during active, deep inspiration. In this way, a much larger amount of active agent-containing aerosol is inhaled and reaches the lowermost airways than in continuous mode devices. In the latter, a large amount of active agent-containing aerosol is lost to the surroundings or during passage through the upper airways, since the release of the aerosol is not linked to the respiratory cycle.

[0199] Therefore, trigger-activated mesh nebulizers, and particularly vibrating mesh nebulizers, are preferred.

[0200] Particularly preferred are trigger-activated mesh sprayers with piezoelectric actuation of the spray process.

[0201] Recommended are mesh nebulizer models PARI eFlow® rapid, Philips Respironics I-neb, Philips InnoSpire Go, M-neb® dose+ mesh nebulizer inhalation MN-300 / 8, Hcmed Deepro HCM-86C and HCM860, OMRON MicroAir U100, Aerogen® Solo, KTMED NePlus NE-SM1, Vectura Fox, Vectura Bayer Breelib®. and high-end models such as Philips Respironics I-neb, PARI Velox, Philips Respironics I-neb, M-neb® dose+mesh nebulizer inhalation MN-300 / 8, Aerogen® Solo, Vectura Fox, and Vectura Bayer Breelib®.

[0202] The average droplet size is usually characterized as MMAD (mass mean aerodynamic diameter). The individual droplet size is called MAD (mass mean aerodynamic diameter). This value indicates the diameter of 50% of the aerosolized particles (droplets) smaller or larger, respectively. Particles with MMAD >10 μm usually do not reach the lower respiratory tract and often get stuck in the throat. Particles with MMAD >5 μm and <10 μm usually reach the bronchi but not the alveoli. Particles with MMAD between 100 nm and 1 μm do not deposit in the alveoli and are quickly exhaled. Therefore, the optimal range is MMAD between 1 μm and 5 μm. Recent publications recommend a narrower range of 3.0 μm to 4.0 μm (cf. Amirav et al. (2010) J Allergy Clin Immunol 25:1206-1211; Haidl et al. (2012) Pulmonology 66:356-360).

[0203] Another commonly accepted quality parameter is the percentage of particles with a diameter between 1 μm and 5 μm in the generated aerosol (FPM, fine particle mass). FPM is a measure of particle distribution. It is calculated by subtracting the percentage of particles with a diameter less than 1 μm in the generated aerosol from the total percentage of particles with a diameter less than 5 μm in the generated aerosol (FPF, fine particle fraction).

[0204] In another aspect of the invention, the application also refers to a method for producing an aerosol according to the invention for the prevention or treatment of coronavirus infection, said method comprising the following steps: a) filling 0.1 ml to 5 ml of an aqueous solution containing a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutical acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutical acceptable salt thereof, each of the pharmaceutical compositions of the present invention and optionally at least one pharma- ceutical acceptable excipient, into the spray chamber of a mesh nebulizer; b) The mesh of the mesh nebulizer is vibrated at a frequency of 80 kHz to 200 kHz. c) The generated aerosol is discharged from the side of the mesh nebulizer opposite the spray chamber.

[0205] The vibration frequency of a vibrating mesh nebulizer is typically in the range of 80 kHz to 200 kHz, with 90 kHz to 180 kHz being preferred, 100 kHz to 160 kHz being more preferred, and 105 kHz to 130 kHz being most preferred (see Chen, The Aerosol Society: DDL 2019; Gardenshire et al. (2017) A Guide to Aerosol Delivery Devices for Respiratory Therapists, 4th ed.).

[0206] Therefore, the above method is also disclosed in said vibration frequency range.

[0207] The method of the present invention is therefore characterized in that at least 80% by weight, preferably at least 85% by weight, most preferably at least 90% by weight of the pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof, or the pharmaceutical composition of the present invention, contained in said aqueous solution, is sprayed into the aerosol generated.

[0208] The method of the present invention is particularly effective in nebulizing high concentrations of pharma- ceutical active agents from a provided aqueous solution in a short time, an important feature for patient compliance. A significant proportion of patients find the inhalation process unpleasant, tiring, and physically taxing. On the other hand, active patient cooperation is essential for effective and targeted inhalation application. It is therefore desirable to apply a therapeutically sufficient amount in as short a time as possible. Surprisingly, it has been shown that 95% of the substance provided in an aqueous solution can be nebulized in a time frame of 3 minutes, an ideal time frame for increasing patient compliance.

[0209] Thus, the methods of the present invention are characterized in that at least 80%, preferably at least 85%, and most preferably at least 90% of the aerosol generated is generated within 3 minutes of initiating nebulization with the mesh nebulizer.

[0210] Pharmaceutically active substances are usually provided in a single dosage container for each nebulization procedure, whereas the nebulizer and / or mouthpiece can be used for a certain period of time and must be replaced at specific intervals. It is recommended that the nebulizer and mouthpiece be cleaned by default after each nebulization. However, in this case, patient compliance cannot be taken for granted. However, even after careful cleaning, aerosol deposits are always present in the nebulization chamber, outlet, and / or mouthpiece. As aerosols are generated from aqueous solutions, these deposits carry the risk of generating a bacterial bioburden that can contaminate the inhaled aerosol. Deposits can also block holes in the mesh membrane of mesh nebulizers. In general, the nebulizer and / or mouthpiece must be replaced every week or two. It is therefore convenient to provide the drug and nebulizer as a combined product.

[0211] Therefore, in another aspect of the present invention, the application also refers to a kit comprising a mesh nebulizer and a pharma- ceutically acceptable container containing an effective amount of a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharma- ceutically acceptable salts, hydrates or solvates and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof, or a pharmaceutical composition according to the present invention for the prevention or treatment of coronavirus infection, and optionally an aqueous solution comprising at least one pharma- ceutically acceptable excipient.

[0212] In an alternative kit, the pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate, or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof, or a pharmaceutical composition according to the invention, is not provided in the form of an aqueous solution, but in two separate containers, one for the solid form of the active agent and one for the aqueous solution. The final aqueous solution is freshly prepared by dissolving the active agent in the final solution. The final aqueous solution is then filled into the nebulizing chamber of the mesh nebulizer. These two containers may be completely separate containers, for example two vials, or for example a dual chamber vial. To dissolve the active agent, for example a hole is made in the membrane between the two chambers, allowing the contents of both chambers to mix.

[0213] Accordingly, the present application also discloses a kit comprising a mesh nebulizer, a first pharma- ceutically acceptable container containing water for injection or saline, and a second pharma-ceutically acceptable container containing an effective dose of a solid form of a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharma-ceutically acceptable salts, hydrates or solvates and 6'-methoxycinchonan-9-ol or a pharma-ceutically acceptable salt thereof for the prophylaxis or treatment of a coronavirus infection, and optionally, at least one pharma-ceutically acceptable excipient is included within the first pharma-ceutically acceptable container and / or the second pharma-ceutically acceptable container.

[0214] The aerosols produced by the methods of the invention are administered or self-administered via a mouthpiece, which, if desired, can be additionally included in the kits described above.

[0215] A typical method is to transfer the provided or final aqueous solution to the nebulizer chamber by a syringe equipped with a needle. The aqueous solution is first drawn into the syringe and then injected into the nebulizer chamber. Optionally, such a syringe and / or needle can be additionally included in the aforementioned kit. A typical syringe made of, but not limited to, polyethylene, polypropylene, or cyclic olefin copolymer can be used, and a typical gauge for stainless steel needles ranges from 14 to 27.

[0216] In yet another aspect of the present invention, a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharma- ceutically acceptable salts, hydrates or solvates with 6'-methoxycinchonan-9-ol or its pharma- ceutically acceptable salts or pharmaceutical composition according to the present invention is disclosed for use in the prophylaxis or treatment of coronavirus infection, said pharmaceutical combination or pharmaceutical composition being provided as an additive to the ventilation air of a cardiopulmonary bypass machine, a form of assisted ventilation. As the condition of patients in intensive care deteriorates, they often need to be ventilated indefinitely with such machines until their own breathing allows for an adequate oxygen supply. Good results have been obtained using a metered dose inhaler aerosol in combination with a Y-piece inhalation chamber. This may increase the dose of bronchodilator by 1.5 to 4 times (Fuller et al., (1994) Chest 105:214-218). 38% of the pharmacologically active substance could be delivered (Marik et al., (1999) Chest 115:1653-1657), whereas constant output mesh nebulizers yielded a rate of 10-15%, as assessed in scintigraphic studies (Dugernier et al., (2016) Ann Intensive Care 6:73). Vibrating mesh nebulizers showed superior results to ultrasonic and jet nebulizers in the administration of antibiotics. With a constant output vibrating mesh nebulizer placed in the inspiratory limb 10 cm from the Y-piece and specific ventilation parameters (tidal volume 8 ml / kg, respiratory rate 12 c / min, duty cycle 50%, constant and low inspiratory flow rate < 30 l / min, end-inspiratory pause 20%), 63% of the administered medication (ceftazidime, amikacin) reached the entrance of the endotracheal tube, with extrapulmonary deposition of 37% (Lu et al., (2011) Am J Respir Crit Care Med 184:106-115). Administered medication is distributed equally in most cases to both lungs. In pigs, the use of helium (He / O2) instead of nitrogen (N2 / O2) as the inhaled gas was found to increase ceftazidime concentrations in subpleural lung specimens (Tonnelier et al., (2005) Anesthesiology 102:995-1000).

[0217] In these cases, a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof can be added to the intubation ventilation air in solid form (dry powder) or liquid form (as an aqueous solution or nebulized aerosol, as described above).

[0218] Therefore, the present application also discloses a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof with 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof, or a pharmaceutical composition according to the invention for use in the prophylaxis or treatment of coronavirus infection, wherein said substance, composition or combination is added to the ventilation air of a cardiopulmonary bypass machine.

[0219] In yet another aspect of the present invention there is provided a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof, or a pharmaceutical composition according to the present invention for use in the prophylaxis or treatment of coronavirus infection, said pharmaceutical combination or pharmaceutical composition being applied in the form of liposomes, micelles, multilamellar vesicles or cyclodextrin complexes.

[0220] In yet another aspect of the present invention, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof, or a pharmaceutical composition according to the present invention in the formulation of a sublingual tablet for use in the prophylaxis or treatment of coronavirus infection.

[0221] In yet another aspect of the present invention, the present application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof, or a pharmaceutical composition according to the present invention in liquid dosage form for use in the prophylaxis or treatment of coronavirus infection.

[0222] The present application also discloses the parenteral administration of a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof, or a pharmaceutical composition according to the present invention in the form of intravenous, intraarterial or intraperitoneal injection for the prevention or treatment of coronavirus infection.

[0223] These liquid dosage forms include solutions, suspensions, and emulsions, such as water and water / propylene glycol solutions for parenteral injection or oral solutions, suspensions, and emulsions containing sweeteners or opacifiers.

[0224] These liquid dosage forms can be stored in vials, IV bags, ampoules, cartridges, prefilled syringes, etc. Suitable excipients include solubilizers, stabilizers, buffers, tonicity adjusters, bulking agents, viscosity enhancers / reducers, surfactants, chelating agents, adjuvants, etc.

[0225] In yet another aspect of the invention, a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof or a pharmaceutical composition according to the invention is for use in the prophylaxis or treatment of coronavirus infection, said pharmaceutical combination or pharmaceutical composition being formulated as a lyophilisate, which can be reconstituted with water for injection or saline or a water / ethanol solution and administered by injection.

[0226] Common applications of intravenous injection include infusion pumps, hypodermic needles, drip chambers, peripheral cannulas (peripheral venous catheters), and pressure bags.

[0227] Generally, aqueous or saline solutions are preferred, although in the case of poorly soluble drugs of the invention, ethanol or ethanol / water mixtures may also be used.

[0228] Further suitable liquid dosage forms include eye drops, eye drops, ear drops, and the like.

[0229] While SARS-CoV and MERS-CoV primarily infect the lower respiratory tract, SARS-CoV-2 first infects the pharynx / throat area. A small percentage of these patients later develop lung infections and pneumonia. Although these pharyngeal infections usually cause only mild symptoms like a cold or no symptoms at all, these patients are highly infectious to their surroundings. In most cases, they are unaware that they have become spreaders of the infection. Therefore, there is a medical need to treat coronavirus infections while they are still in the pharyngeal stage, not only to treat such patients but also for epidemiological reasons to prevent the spread of the epidemic. For patients with pharyngeal infections, it is not ideal to administer a highly effective drug or combination of drugs only systemically, such as intravenously or orally, which may cause side effects. It is therefore desirable to provide a route of administration that treats the infected pharyngeal tissue locally.

[0230] Thus, in yet another aspect of the invention, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof, or a pharmaceutical composition according to the invention in a formulation for pharyngeal administration for use in the prophylaxis or treatment of coronavirus infection.

[0231] Administration of the drug to the pharynx can be by topical administration such as brushing the pharyngeal area with a suitable liquid dosage form such as eye drops, lotion, or tincture, by brushing the pharyngeal area with a viscous dosage form such as a gel or hydrogel, by gargling with a mouthwash, sublingual tablet, lozenge, or throat spray, or by injection into the posterior pharyngeal wall.

[0232] It is a low-viscosity topical preparation intended for application to the skin or mucous membranes. Lotions are applied to the skin or mucous membranes with bare hands, a brush, a clean cloth, or cotton wool.

[0233] The advantage of lotions is that they can be applied in a thin layer to cover large areas of the skin and mucous membranes. Common medications that can be administered in lotion form include antibiotics, antiseptics, antifungals, corticosteroids, antiacne medications, sedatives, soothing agents, moisturizers, protective agents, and antiallergic agents.

[0234] Most lotions are oil-in-water emulsions that use substances such as cetearyl alcohol to hold the emulsion together, but water-in-oil lotions have also been formulated. The main components are a water phase, an oil phase, an emulsifier to prevent the two phases from separating, and a drug component. A variety of excipients are commonly added to lotions, including fragrances, glycerol, petrolatum, dyes, preservatives, proteins, and stabilizers.

[0235] The thickness, consistency and viscosity of the lotion can be adjusted during production. The production of lotions can be carried out in two cycles: a) Emollients and lubricants are dispersed in the oil together with blending agents and thickeners, and b) Fragrances, colours and preservatives are dispersed in the aqueous phase. In both cycles, pharmacologically active ingredients are dissolved depending on the raw materials and the properties desired for the lotion.

[0236] Tinctures are usually alcoholic extracts or preparations. Solvent concentrations of 25-60% (or even 90%) are common. Other solvents used in making tinctures include vinegar, glycerin, diethyl ether, and propylene glycol. Ethanol has the advantage of being a good solvent for both acidic and alkaline ingredients. Tinctures using glycerin are called glycerates. Glycerin is generally a poorer solvent than ethanol. Vinegar is acidic, making it a good solvent for extracting alkaloids, but a poor solvent for acidic ingredients.

[0237] A gel is a colloid in which a solid dispersed phase combines with a fluid continuous phase to form a network, resulting in a viscous semi-rigid sol. Gels can vary in properties from soft and weak to hard and tough. A gel is defined as a substantially dilute cross-linked system that does not exhibit flow at steady state. By weight, a gel is mostly liquid, but behaves like a solid due to a three-dimensional cross-linked network within the liquid. It is the cross-links within the fluid that give the gel its viscosity and contribute to its stickiness. A gel is a dispersion of liquid molecules within a solid medium.

[0238] A hydrogel is a network of hydrophilic polymer chains, which may exist as a colloidal gel in which water is the dispersion medium. The hydrophilic polymer chains are linked by crosslinks to form a three-dimensional solid. The inherent crosslinks ensure that the structural integrity of the hydrogel network is not dissolved by high concentrations of water. Hydrogels are highly absorbent (contains more than 90% water) natural or synthetic polymer networks. Their high water content also gives them flexibility very similar to natural tissues. In medicine, hydrogels can encapsulate chemical systems, releasing certain pharmacologically active substances into the environment, most often by transitioning from a gel-sol to a liquid state, upon stimulation by an external factor such as a change in pH.

[0239] Suitable gel-forming agents may be selected from the group including, but not limited to, agar, algin, alginic acid, bentonite, carbomer, carrageenan, hectorite, hydroxyethyl cellulose, hydroxypropyl cellulose, polyvinyl alcohol, polyvinylpyrrolidone, sodium carbomer.

[0240] A mouthwash is a liquid that is passively held in the mouth or swirled around the mouth by contraction of the perioral muscles and / or head movements, and can be gargled by tilting the head back and lathering the liquid in the back of the mouth. An aqueous or alcoholic solution of a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharma- ceutically acceptable salts, hydrates or solvates and 6'-methoxycinchonan-9-ol or a pharma-ceutically acceptable salt thereof, or a pharmaceutical composition according to the invention, thus prepared, can be administered to the pharynx.

[0241] Sublingual administration is an alternative to oral administration because it bypasses hepatic metabolism. For some drugs, especially those used to treat acute diseases, a rapid onset of pharmacological effect is often desired. Sublingual tablets disintegrate rapidly, and the presence of small amounts of saliva is usually sufficient to achieve disintegration of the drug with better dissolution and increased bioavailability.

[0242] Drugs must be lipophilic enough to pass through the lipid bilayer, but not so lipophilic that once inside, they cannot exit again. According to the diffusion model of absorption, the flow across the lipid bilayer is directly proportional to the concentration gradient. Thus, low solubility in saliva results in low absorption, and vice versa. In general, drugs formulated for sublingual use should ideally have a molecular weight below 500 to facilitate diffusion. The pH range of the oral cavity is narrow, between 5.0 and 7.0. Including an appropriate buffer in the formulation of an ionizable drug can control the pH of aqueous saliva.

[0243] Taste masking is necessary to avoid unpleasant tastes and odors of medications. Sweeteners, flavors, and other taste masking agents are essential ingredients. Sugar-based excipients dissolve quickly in saliva and generate an endothermic heat of solution. They create a pleasant sensation in the mouth and, together with other flavors, are ideal for sublingual tablets.

[0244] Common techniques for manufacturing sublingual tablets include direct compression, compression molding, freeze-drying, and hot melt extrusion (Khan et al., (2017) J Pharmaceut Res 16:257-267).

[0245] If swallowing is avoided, administration of the active ingredient via a sublingual tablet can also reach the pharynx / throat locally. The majority of the active ingredient is absorbed via the pharyngeal mucosa.

[0246] A troche (lozenge) is a small disk- or diamond-shaped object made of a setting paste containing an astringent, antiseptic, or demulcent, used for the local treatment of the mouth and throat, held in the mouth until it dissolves. The medium or base of a troche is usually sugar, mixed with acacia or tragacanth, a fruit paste made from black or red currants, rose sweetbread, or balsam of torus to make it sticky.

[0247] In particular, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof, or a pharmaceutical composition according to the invention for use in the prophylaxis or treatment of coronavirus infection in a formulation for pharyngeal administration, the pharyngeal administration being by throat spray.

[0248] A throat spray is a medicated liquid administered as a spray into the throat to treat sore throats and coughs.

[0249] Throat sprays usually contain a local anesthetic (such as lidocaine or benzocaine), an antiseptic (such as chlorhexidine or cetylpyridinium chloride), an herbal extract, or a combination of these. Whatever the formulation, it should not contain excessive amounts of sugar or ethanol, which can further irritate the mucous membrane. And finally, it should not leave users with an unpleasant aftertaste.

[0250] The standard for throat sprays is currently a bottle containing 10-30ml of liquid formulation fitted with a metering pump. The formulation is filled into a glass or plastic bottle and the pump is fixed by a screw fastening, crimped onto the neck of the bottle or simply snapped on. Regardless of the fastening method chosen, the system must be tightly sealed and show no visible leaks when carried or handled by the user. The container is usually made of glass or plastic.

[0251] Typically, throat spray pumps administer doses ranging from 50 to 200 μl per actuation. For targeted administration, pumps are equipped with actuators with long nozzles. The nozzles are 30 to 70 mm long. Using such long fixed nozzles makes it easier to target the affected area, but they may be too large for the user to carry. Therefore, actuators with folding or rotating nozzles are preferred.

[0252] Alternatively, devices use continuous valves, which allow targeted treatment but not precise dosing, as the formulation is aerosolized while the actuator is depressed. One technical solution is a tin or aluminum can with a pressurized headspace. When the valve is actuated, the increase in internal pressure forces the formulation out of the can as long as the valve stem is depressed.

[0253] A related but more sophisticated system is the bag-on-valve (BOV) system. The product is placed into a bag and propellant (most often compressed air) fills the space between the bag and an outer canister. When a continuous valve is activated, the product is forced out of the bag by the compressed air. BOV systems can function in any orientation around 360°.

[0254] Caution is advised with throat spray formulations as they contain very potent ingredients that can reduce surface tension. A simple test of spray performance can be performed to ensure that the formulation can be aerosolized by the system and that the spray pattern and particle size are appropriate for the intended application.

[0255] The spray pattern and droplet size distribution are the most important parameters for throat spray. Spray pattern is a term that describes the spray angle and jet shape of the fully developed spray. Droplet size is characterized once the spray is fully developed using laser diffraction techniques. Fine particles (droplets with a mean dynamic diameter less than 10 μm) should be as few as possible to avoid droplet deposition in the lower respiratory tract.

[0256] Recently, several carragellose-based throat sprays have appeared, claiming to be effective in preventing viral upper respiratory tract infections. The first polymer in this platform is Carragellose®, an antiviral compound that is broadly effective in treating respiratory diseases. In addition to its moisturizing effect, this compound prevents the binding of viruses to mucosal cells.

[0257] Alternatively, a handheld nebulizer can be used that is high-powered and calibrated to a droplet size suitable for deposition in the upper airway. Breathing through a face mask can result in droplet deposition on mucous membranes throughout the upper airway (see Marx and Nadler (2018) Drug Development & Delivery).

[0258] In particular, the present application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof, or a pharmaceutical composition of the present invention, for use in the prophylaxis or treatment of coronavirus infections, as a preparation for pharyngeal administration, the pharyngeal administration being by posterior pharyngeal wall injection.

[0259] This technique is used in pharyngoplasty by injection of calcium hydroxyapatite and other procedures in orthopedic surgery. However, local injections can also be made into the pharyngeal tissue to administer pharmacologically active agents. The injection fluid is similar to that for intravenous or intramuscular injections. An aqueous solution, saline, or, in the case of fairly lipophilic pharmacologically active agents, an ethanol / water mixture is preferred.

[0260] In a further aspect of the invention, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof with 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof, or a pharmaceutical composition according to the invention in a nasal formulation for use in the prophylaxis or treatment of SARS-CoV-2 infection.

[0261] In particular, nasal administration is by means of a nasal spray or drops.

[0262] Common formulation types used for nasal sprays are solutions, suspensions, and emulsions. Nasal spray formulations can be aqueous, alcoholic, or non-aqueous based. Depending on the type of system, the formulations include various functional excipients such as solvents and co-solvents, mucoadhesives, pH buffers, antioxidants, preservatives, osmotic and tonicity agents, penetration enhancers, suspending agents, and surfactants. The formulation type and excipients selected are determined by the solubility and stability of the pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate, or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof, as well as the concentration required to deliver an effective dose in a typical 100 μl spray (see Kulkarni and Shaw (2016) in: Essential Chemistry for Formulators of Semisolid and Liquid Dosages, Elsevier). The Carragelose® technology described above is also used for nasal sprays.

[0263] Nasal sprays are administered using a similar formula, but are administered by dripping rather than by pressing a dispenser.

[0264] In particular, the application relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof with 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof, or a pharmaceutical composition according to the invention for use in a formulation for nasal administration in the prevention or treatment of SARS-CoV-2 infection, wherein nasal administration is by nasal spray or nasal drops.

[0265] The mucous membrane of the eye is known to be another point of entry of SARS-CoV-2 into the organism: for example, people can transfer the virus to their hands while rubbing their eyes.

[0266] The present application therefore also relates to a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof, or a pharmaceutical composition according to the invention, wherein the administration of said pharmaceutical combination or pharmaceutical composition according to the invention is carried out by means of eye drops.

[0267] Eye drops are mostly aqueous solutions containing pharmacologically active substances. The pH is usually adjusted to 7.1-7.5. Common buffer solutions for eye drops are boric acid and monosodium phosphate. Osmolarity is adjusted with 0.9% saline (or other isotonicity agents such as potassium nitrate, boric acid, sodium acetate, sodium acetate phosphate buffer, mannitol, etc.) to an osmolarity isosmotic to the corneal epithelium (225-430 mosm / kg). Suitable preservatives include thiomersal, organic mercury compounds such as phenylmercury, benzalkonium chloride, chlorhexidine, benzyl alcohol, etc. To extend the contact time, viscosity-increasing substances (thickeners) such as cellulose derivatives (hypromellose, methylcellulose, hydroxypropylmethylcellulose), hyaluronic acid, cellulose acetate phthalate, polyethylene glycol, polyvinyl alcohol, and poloxamer can be added. Wetting agents or surfactants such as benzalkonium chloride, polysorbate 20, polysorbate 80, dioctyl sodium sulfosuccinate, etc. may be included. Optionally, certain amino acids may be useful alone or in combination with sodium hyaluronate to promote tissue reconstitution. Suitable amino acids are glycine, leucine, lysine, proline (see EP1940381B1).

[0268] Surprisingly, co-administration of pharmaceutical combinations according to the present invention is shown to not only exhibit a general additive effect, but to exhibit this effect across the broad range of fixed ratios tested.

[0269] The term "ratio" or "fixed ratio" herein refers to any kind of ratio between two components, regardless of the units used. Such ratios are valid for weight, weight %, concentration specifications, and other units feasible in the pharmaceutical field. Thus, for example, a ratio of 6'-methoxycinchonan-9-ol or a pharmacologically acceptable salt thereof to 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmacologically acceptable salts is 1:10, which can be implemented in, for example, 1mg:10mg, 1mg / kg:10mg / kg, 1mM / 10mM, 1%:10%, etc., or other units, as long as the ratio itself is 1:10.

[0270] The present patent application also relates to a pharmaceutical combination comprising 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutically acceptable salt, hydrate or solvate thereof and 6'-methoxycinchonan-9-ol or a pharma- ceutically acceptable salt thereof, or a pharmaceutical composition according to the present invention for use in the prophylaxis or treatment of coronavirus infection, wherein the efficacy of the prophylaxis or treatment is significantly improved as compared to the respective treatment with quinine or quinidine alone.

[0271] Furthermore, the pharmaceutical combination according to the present disclosure may be used for the prevention or treatment of coronavirus infection, wherein the components may be used in any ratio.

[0272] However, in order to obtain the best possible effect on the medical indication being treated, the feasibility of the potency, application form and ratio of the pharmaceutical combination according to the disclosure must be considered from a practical point of view, the latter in particular in order to maintain patient compliance.

[0273] Below, some possible combinations and their respective ratios are provided, but the pharmaceutical combinations according to the present invention are not limited to these examples. Depending on the form of application, the indication for treatment, and the patient's personal risk profile, in the treatment of malaria or nocturnal leg cramps, quinine is administered, for example, as 2x324 mg tablets every 8 hours (every 8 hours). When used as an injectable solution, an initial dose of 20 mg / kg quinine, followed by 10 mg / kg every 8 hours, is recommended.

[0274] For antiarrhythmic treatment, a test dose of quinidine sulfate is 200 mg po or 2 mg / kg body weight. A total dose of 30 mg / kg BW per day or 900 mg / m2 per day is recommended, or 15-60 mg / kg BW per day in 5 divided doses every 6 hours. For the treatment of atrial fibrillation, 300-400 mg po every 6 hours is recommended. For the treatment of PSVT, 400-600 mg po every 2-3 hours is recommended. For the treatment of atrial / ventricular premature contractions, 200-300 mg po every 6-8 hours is recommended. Maintenance doses are 200-400 mg po every 6-8 hours. Daily doses should not exceed 3-4 g / day. The recommended dose of quinidine gluconate is correspondingly higher.

[0275] 5-Amino-2,3-dihydro-1,4-phthalazinedione sodium salt has been shown to be very safe, however, for compliance reasons, the dosage should not exceed 10 g / day for tablets or capsules.

[0276] Thus, the pharmaceutical combination according to the present disclosure can be used for the prevention or treatment of coronavirus infection, wherein the weight ratio of quinine or a pharma- ceutical acceptable salt thereof to 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutical acceptable salt, hydrate, and solvate thereof is preferably in the range of 4:1 to 1:50, more preferably 3:1 to 1:25, even more preferably 2:1 to 1:10, and most preferably 1:1 to 1:3.

[0277] Thus, the pharmaceutical combination according to the present disclosure can be used for the prevention or treatment of coronavirus infection, wherein the molar ratio of quinine or a pharma- ceutical acceptable salt thereof and 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutical acceptable salt, hydrate, or solvate thereof is preferably in the range of 1:1 to 1:10,000, more preferably 1:10 to 1:5,000, even more preferably 1:15 to 1:500, and most preferably 1:20 to 1:70.

[0278] Thus, the pharmaceutical combinations according to the present disclosure can be used for the prevention or treatment of coronavirus infections, wherein the weight ratio of quinidine or a pharmaceutical salt thereof to 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutical acceptable salt, hydrate, and solvate thereof is preferably in the range of 8:1 to 1:15, more preferably 6:1 to 1:10, even more preferably 4:1 to 1:5, and most preferably 2:1 to 1:2.

[0279] Thus, the pharmaceutical combination according to the present disclosure can be used for the prevention or treatment of coronavirus infection, wherein the molar ratio of quinidine or a pharma- ceutical acceptable salt thereof to 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharma- ceutical acceptable salt, hydrate, or solvate thereof is preferably in the range of 1:1 to 1:10,000, more preferably 1:10 to 1:5,000, even more preferably 1:15 to 1:500, and most preferably 1:20 to 1:70.

[0280] Accordingly, the present application relates to pharmaceutical combinations for use in accordance with the disclosure, wherein the weight ratio of the dosage amounts of quinine or one of its pharma- ceutical acceptable salts to 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharma- ceutical acceptable salts, hydrates or solvates is in the range of 4:1 to 1:50, and the weight ratio of the dosage amounts of quinidine or one of its pharma- ceutical acceptable salts to 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharma- ceutical acceptable salts, hydrates or solvates is in the range of 8:1 to 1:15.

[0281] Accordingly, the present application relates to a pharmaceutical combination for use in accordance with the disclosure, wherein the molar ratio of quinine or one of its pharma- ceutical acceptable salts to 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharma- ceutical acceptable salts, hydrates or solvates, or the weight ratio of quinidine or one of its pharma- ceutical acceptable salts to 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharma- ceutical acceptable salts, hydrates or solvates, is in the range of 1:1 to 1:10,000, respectively.

[0282] However, higher doses and / or volumes may be administered in liquid form without adversely affecting patient compliance.

[0283] Due to the superadditive nature of the pharmaceutical combinations of the present invention, the dosage of quinine or quinidine or pharmaceutical salts thereof can be reduced depending on the individual patient, the indication, and the ratio of the ingredients used. In some cases, dosages and ratios may need to be adjusted over time to obtain optimal results.

[0284] Therefore, the dosage of quinine or a pharma- ceutical acceptable salt thereof in the pharmaceutical combination of the present invention can be reduced by 80%, preferably by 50%, and most preferably by 20%, compared to the dosage when quinine or a pharma- ceutical acceptable salt thereof is administered alone.

[0285] Therefore, the dosage of quinidine or a pharmaceutical salt thereof in the pharmaceutical combination of the present invention can be reduced by 80%, preferably by 50%, and most preferably by 20% compared to the dosage when quinidine or a pharmaceutical salt thereof is administered alone.

[0286] In a further aspect of the present invention, a method for treating coronavirus infection is disclosed comprising administering an effective amount of a pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates or solvates and 6'-methoxycinchonan-9-ol or its pharmaceutically acceptable salt or the pharmaceutical composition according to the present invention to a patient in need thereof or to a healthy person at risk of infection with coronavirus.

[0287] The present invention also relates to 5-amino-2,3-dihydro-1,4-phthalazinedione or any one of its pharmaceutically acceptable salts, hydrates or solvates for use in a method of treating and / or preventing a coronavirus infection in a subject, the method comprising administering to the subject an effective amount of 5-amino-2,3-dihydro-1,4-phthalazinedione or any one of its pharmaceutically acceptable salts, hydrates or solvates, simultaneously with or subsequently to an effective amount of 6'-methoxycinchonan-9-ol or a pharmaceutically acceptable salt thereof.

[0288] The present invention also relates to 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates or solvates for use in a method for treating and / or preventing a coronavirus infection in a subject, the method comprising administering to the subject an effective amount of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates or solvates, concomitantly or subsequently, an effective amount of 6'-methoxycinchonan-9-ol or a pharmaceutically acceptable salt thereof, wherein 5-amino-2,3-dihydro-1,4-phthalazinedione is a sodium salt.

[0289] The present invention also relates to 5-amino-2,3-dihydro-1,4-phthalazinedione or any one of its pharmaceutically acceptable salts, hydrates or solvates for use in a method for the treatment and / or prevention of a coronavirus infection in a subject, the method comprising administering to the subject an effective amount of 6'-methoxycinchonan-9-ol or a pharmaceutically acceptable salt thereof, concomitantly or subsequently with an effective amount of 5-amino-2,3-dihydro-1,4-phthalazinedione or any one of its pharmaceutically acceptable salts, hydrates or solvates.

[0290] The present invention also relates to 5-amino-2,3-dihydro-1,4-phthalazinedione or any one of its pharmaceutically acceptable salts, hydrates or solvates for use in a method for treating and / or preventing a coronavirus infection in a subject, the method comprising administering to the subject an effective amount of 5-amino-2,3-dihydro-1,4-phthalazinedione or a pharmaceutically acceptable salt, hydrate or solvate thereof, concomitantly or subsequently with an effective amount of 6'-methoxycinchonan-9-ol or a pharmaceutically acceptable salt thereof, wherein the 5-amino-2,3-dihydro-1,4-phthalazinedione is a sodium salt. EXAMPLES

[0291] In all experiments, solutions containing 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt were prepared using 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt anhydrous Form I (provided by MetrioPharm) as described above. Quinine sulfate and quinidine sulfate were purchased from Sigma-Aldrich, Darmstadt, Germany.

[0292] Example 1: The pharmacological combination of 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt and quinine sulfate superadditively inhibits SARS-CoV-2 replication in infected Calu-3 cells in qRT-PCR.

[0293] qRT-PCR (quantitative real-time polymerase chain reaction) experiments were performed. This method is a highly sensitive method for quantitatively determining the number of SARS-CoV-2 RNA copies in infectious viral particles released from cells in the supernatant. The method was performed according to Corman et al. (2020) Euro Surveill. 25:2000045. Calu-3 cells (see Park et al. (2021) Biomol Ther 29:273-281) were kindly provided by Professor Jean Minnich, Institute of Molecular Virology, University of Ulm, Germany. These cells were cultured in Minimum Essential Medium (MEM) containing 20% ​​(v / v) inactivated FCS (fetal calf serum), 1 mM L-glutamine, 100 U / mL penicillin, 100 μg / mL streptomycin and 1 mM sodium pyruvate.

[0294] Treatment plan: Day 0: Seed Calu-3 cells in 24-well plates (1*105 cells / well, using 500 μl medium per well). Day 1: Infection and treatment After treatment Confluent monolayers of Calu-3 cells were infected with SARS-CoV-2 for 1 h using a 1:100 dilution of field isolate SARS-CoV-2PR-1 (isolated from a 61-year-old patient 6 days after the estimated date of infection and 2 days after the onset of mild COVID-19 symptoms) in FCS-free DMEM. Discard the media Add fresh medium containing the substance (500 μl) for 3 days. Day 3: Preparation of supernatant containing viral particles for qRT-PCR Take 200 μl of the supernatant into a 1.5 ml Eppendorf reaction tube. Centrifuge at 6000 rpm for 5 minutes. Transfer the supernatant to a new 1.5 ml Eppendorf reaction tube. Heat at 95°C for 10 minutes 5 μl of qRT-PCR analysis

[0295] For each experiment, each treatment was performed in quadruplicate, and at harvest time, the respective supernatants were pooled, corresponding to n=1.

[0296] Samples containing released viral particles were quantified by Ambion's real-time PCR, AgPath-ID One-Step RT-PCR Kit (Cat. No.: 4387424), which allows reverse transcription, cDNA synthesis, and PCR amplification in one step. The gene sequence amplified by qRT-PCR was from RdRp (viral RNA-dependent RNA polymerase), a major gene of RNA viruses.

[0297] The sequences of the qRT-PCR primers used are as follows: RdRp_fwd:5′-GTG-ARA-TGG-TCA-TGT-GTG-GCG-G-3′ RdRp_rev:5′-CAR-ATG-TTA-AAS-ACA-CTA-TTA-GCA-TA-C-3′ Probe:5′--CAG-GTG-GAA- / ZEN / CCT-CAT-CAG-GAG-ATG-C-3′ (Label: FAM / IBFQ Iowa Black FQ).

[0298] As a positive control, specific targets against the E and RdRp genes of SARS-CoV-2 were used and were produced by Integrated DNA Technologies. Control: 5´-TAA-TAC-GAC-TCA-CTA-TAG-GGT-ATT-GAG-TGA-AAT-GGT-CAT-GTG-TGG-CGG-TTC-ACT-ATA- TGT-TAA-ACC-AGG-TGG-AAC-CTC-ATC-AGG-AGA-TGC-CAC-AAC-TGC-TTA-TGC-TAA-TAG-TGT-TTT-TAA-CA T-TTG-GAA-GAG-ACA-GGT-ACG-TTA-ATA-GTT-AAT-AGC-GTA-CTT-CTT-TTT-CTT-GCT-TTC-GTG-GTA-TTC- TTG-CTA-GTT-ACA-CTA-GCC-ATC-CTT-ACT-GCG-CTT-CGA-TTG-TGT-GCG-TAC-TGC-TGC-AAT-ATT-GTT-3´

[0299] Samples were analyzed with 7500 Software v2.3 (Applied Bioscience). Plots were generated using Microsoft Excel and PrismGraphPad software.

[0300] The following concentrations and combinations were tested: 5-Amino-2,3-dihydro-1,4-phthalazinedione sodium salt alone: a) 500μM b) 250μM c) 125μM Quinine sulfate alone: a) 10μM b) 1μM c) 0.1μM All of these concentrations were combined with each other. Results for all three concentrations of quinine sulfate combined with 500 μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt are shown in Figure 1A, for all three concentrations of quinine sulfate combined with 250 μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt are shown in Figure 1B, and for all three concentrations of quinine sulfate combined with 125 μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt are shown in Figure 1C, all results set to 100% for untreated cells.

[0301] This highly sensitive method demonstrated that 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt and quinine sulfate, and all their combinations, reduced the amount of SARS-Cov-2 RNA copies in a dose-dependent manner, and furthermore, all combinations showed greater than additive effects compared to the corresponding concentrations of 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt and quinine sulfate as single substances.

[0302] These experiments demonstrated that not only the single substances 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt and quinine sulfate dose-dependently inhibited SARS-CoV-2 replication in Calu-3 cells, but also all tested combinations were able to inhibit SARS-CoV-2 replication in a dose-dependent manner and with greater than additive effects.

[0303] n=3; statistics: unbalanced t-test with Welch's correction. Data are expressed as mean + SEM.

[0304] Example 2: Checking for additive effects CompuSyn software checks for additive effects in all drug combinations of 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt and quinine sulfate.

[0305] As mentioned above, the CompuSyn software model for additive effects (www.combosyn.com) is a computer model for evaluating the additive effects of two substances in biological systems. Through mathematical transformation, the results of each drug combination in Example 1 are related to the results of both single substances.

[0306] Fa / CI plots for all drug combinations tested (non-constant ratios)

[0307] The horizontal axis shows the fractal effect (Fa), i.e., a value between 0 and 1 for the relative inhibition of each drug combination of 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt and quinine sulfate on the replication of SARS-CoV-2 in Calu-3 cells, where 1 means 100% inhibition and 0 means no inhibition. The vertical axis shows the combination index (CI) calculated by CompuSyn software, where a value of 1 indicates additivity, values ​​less than 1 indicate superadditivity, and values ​​greater than 1 indicate subadditivity, no effect, or antagonism. The closer the value is to 0, the more pronounced the superadditivity.

[0308] This software produced the plot in Figure 2, which shows significant superadditive effects for all combinations. This computational evaluation confirms the results of the evaluation in Example 1.

[0309] Example 3: The pharmaceutical combination of 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt and quinidine sulfate dose-dependently inhibits the replication of SARS-CoV-2 in infected Calu-3 cells in qRT-PCR.

[0310] The experiment was carried out similarly to Example 1, using different concentrations of quinidine sulfate alone or in combination with 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt.

[0311] The following concentrations and combinations were tested: 5-Amino-2,3-dihydro-1,4-phthalazinedione sodium salt alone: a) 500μM b) 250μM c) 125μM Quinidine sulfate alone: a) 10μM b) 1μM c) 0.1μM 5-Amino-2,3-dihydro-1,4-phthalazinedione sodium salt and quinidine sulfate, as well as all combinations thereof, demonstrated a dose-dependent reduction in SARS-CoV-2 RNA copy number, and all combinations showed greater than additive effects compared to the corresponding concentrations of the single substances 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt and quinine sulfate.

[0312] These experiments demonstrated that not only were 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt and quinidine sulfate single substances able to inhibit SARS-CoV-2 replication in Calu-3 cells in a dose-dependent manner, but also all tested combinations were able to inhibit SARS-CoV-2 replication in a dose-dependent manner and with greater than additive effects.

[0313] n=2; statistics: unbalanced t-test with Welch's correction. Data are expressed as mean + SEM.

[0314] Example 4: Checking for additive effects CompuSyn software checks for additive effects for all drug combinations of 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt and quinidine sulfate. The experiment was performed similarly to Example 2. The software produced the plot in Figure 4, which shows that all combinations exhibited significant superadditivity effects. This computational evaluation confirms the results of the evaluation in Example 3. [Brief description of the drawings]

[0315] [Figure 1]L: Luminol sodium salt (= 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt) Q: Quinine sulfate qRT-PCR amplified RdRp (viral RNA-dependent RNA polymerase) copy number percentage (compared to untreated cells) *: p<0.05; **: p<0.01 A: Bar untreated cells (set to 100%) 500μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt 10μM quinine sulfate 10μM quinine sulfate + 500μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt 1μM quinine sulfate 1μM quinine sulfate + 500μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt 0.1μM quinine sulfate 0.1μM quinine sulfate + 500μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium saltB: Bar untreated cells (set to 100%) 250μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt 10μM quinine sulfate 10μM quinine sulfate + 250μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt 1μM quinine sulfate 1μM quinine sulfate + 250μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt 0.1μM quinine sulfate 0.1μM quinine sulfate + 250μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium saltC: Bar untreated cells (set to 100%) 125μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt 10μM quinine sulfate 10μM quinine sulfate + 125μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt 1μM quinine sulfate 1μM quinine sulfate + 125μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt 0.1μM quinine sulfate 0.1μM quinine sulfate + 125μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt

[0316] [Diagram 2]Fa / CI diagram of the results of Example 1 generated by CompuSyn software. Fa: Fractal effect CI: Combination index

[0317] [Diagram 3]L: Luminol sodium salt (= 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt) QD: Quinidine sulfate qRT-PCR amplified RdRp (viral RNA-dependent RNA polymerase) copy number percentage (compared to untreated cells) *: p<0.05; **: p<0.01 A: Bar untreated cells (set to 100%) 500μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt 10μM Quinidine sulfate 10μM Quinidine sulfate + 500μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt 1μM Quinidine sulfate 1μM Quinidine sulfate + 500μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt 0.1μM Quinidine sulfate 0.1μM Quinidine sulfate + 500μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt B: Bar untreated cells (set to 100%) 250μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt 10μM Quinidine sulfate 10μM Quinidine sulfate + 250μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt 1μM Quinidine sulfate 1μM Quinidine sulfate + 250μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt 0.1μM Quinidine sulfate 0.1μM Quinidine sulfate + 250μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt C: Bar untreated cells (set to 100%) 125μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt 10μM Quinidine sulfate 10μM Quinidine sulfate + 125μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt 1μM Quinidine sulfate 1μM Quinidine sulfate + 125μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt 0.1μM Quinidine sulfate 0.1μM Quinidine sulfate + 125μM 5-amino-2,3-dihydro-1,4-phthalazinedione sodium salt

[0318] [Figure 4]Fa / CI diagram of the results of Example 3 generated by Compusyn software. Fa: Fractal effect CI: Combination index

Claims

1. A pharmaceutical for preventing or treating coronavirus infections, comprising as active ingredients 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates, or solvates, and 6'-methoxycinchonan-9-ol or its pharmaceutically acceptable salt.

2. The pharmaceutical for preventing or treating coronavirus infection according to claim 1, wherein the pharmaceutically acceptable salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is the sodium salt of 5-amino-2,3-dihydro-1,4-phthalazinedione.

3. The medicament for the prevention or treatment of coronavirus infections according to claim 2, wherein the sodium salt of 5-amino-2,3-dihydro-1,4-phthalazinedione is provided as one of crystalline anhydrous polymorphic forms I, II or III, characterized by the following crystallographic values ​​as determined by X-ray powder diagram: For Form I, d values: 13.5; 6.9; 5.2; 4.6; 3.9; 3.5; 3.4; 3.3; 3.1; 3.0 and / or 2-theta values: 6.5; 12.7; 16.9; 19.3; 22.8; 25.8; 26.6; 27.2; 28.7; 30.3, For Form II, d values: 12.9; 7.9; 7.1; 6.5; 5.3; 4.0; 3.7; 3.6; 3.3; 3.2 and / or 2-theta values: 6.8; 11.2; 12.5; 13.7; 16.7; 22.4; 24.3; 24.9; 27.2; 27.8, and For Form III, d values: 13.131; 7.987; 7.186; 6.566; 6.512; 5.372; 3.994; 3.662; 3.406; 3.288; 3.283; 3.222; 3.215; 3.127; 2.889 and / or 2-theta values: 6.73; 11.07; 12.31; 13.48; 13.59; 16.49; 22.24; 24.29; 26.14; 27.10; 27.14; 27.67; 27.72; 28.52; 30.

93.

4. The pharmaceutical composition for preventing or treating a coronavirus infection according to claim 1, wherein the coronavirus infection is selected from the group consisting of SARS-CoV, MERS-CoV, SARS-CoV-2, HCoV-HKU1, HCoV-NL-63, HCoV-OC43, and HCoV-229E infection.

5. The pharmaceutical for preventing or treating a coronavirus infection according to any one of claims 1 to 4, wherein the 6'-methoxycinchonan-9-ol is quinine or a pharmaceutically acceptable salt thereof, and the weight ratio of the dose of quinine or one of its pharmaceutically acceptable salts to the dose of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates, or solvates is in the range of 4:1 to 1:

50.

6. The pharmaceutical for preventing or treating a coronavirus infection according to any one of claims 1 to 4, wherein the 6'-methoxycinchonan-9-ol is quinidine or a pharmaceutically acceptable salt thereof, and the weight ratio of the dosage of quinidine or one of its pharmaceutically acceptable salts to the dosage of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates, or solvates is in the range of 8:1 to 1:

15.

7. The pharmaceutical for preventing or treating a coronavirus infection according to any one of claims 1 to 4, wherein the molar ratio of the dosage of quinine or one of its pharmaceutically acceptable salts to 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates, or solvates, or of quinidine or one of its pharmaceutically acceptable salts to 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates, or solvates, is in the range of 1:1 to 1:10,000.

8. Use of 5-amino-2,3-dihydro-1,4-phthalazinedione, or one of its pharmaceutically acceptable salts, hydrates, or solvates, and 6'-methoxycinchonan-9-ol, or one of its pharmaceutically acceptable salts, hydrates, or solvates, in the manufacture of a pharmaceutical composition, the pharmaceutical composition comprising 5-amino-2,3-dihydro-1,4-phthalazinedione, or one of its pharmaceutically acceptable salts, hydrates, or solvates, 6'-methoxycinchonan-9-ol, or one of its pharmaceutically acceptable salts, carriers, and at least one pharmaceutically acceptable excipient.

9. 9. Use of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates or solvates and 6'-methoxycinchonan-9-ol or its pharmaceutically acceptable salt in the manufacture of the pharmaceutical composition according to claim 8, wherein the pharmaceutical composition is orally applied in the form of a tablet, a soft gelatin capsule, a hard gelatin capsule, a dragee, a pill, a powder, a granule, a liquid, a syrup, drops, a tea, a solution or suspension in an aqueous or non-aqueous liquid, an edible foam, a mousse, an oil-in-water emulsion or a water-in-oil emulsion.

10. Use of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates, or solvates, and 6'-methoxycinchonan-9-ol or its pharmaceutically acceptable salt in the manufacture of the pharmaceutical composition according to claim 8, wherein the pharmaceutical composition is for the prevention or treatment of coronavirus infection in a formulation for inhalation administration.

11. 9. Use of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates, or solvates, and 6'-methoxycinchonan-9-ol or its pharmaceutically acceptable salt in the manufacture of the pharmaceutical composition according to claim 8, wherein the pharmaceutical composition is for the prevention or treatment of coronavirus infection, and the pharmaceutical composition is added to the ventilation air of a cardiopulmonary bypass machine.

12. Use of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates, or solvates, and 6'-methoxycinchonan-9-ol or its pharmaceutically acceptable salt in the manufacture of the pharmaceutical composition according to claim 8, wherein the pharmaceutical composition is a pharmaceutical composition for the prevention or treatment of coronavirus infection in a sublingual tablet formulation.

13. 9. Use of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates, or solvates, and 6'-methoxycinchonan-9-ol or its pharmaceutically acceptable salt in the manufacture of the pharmaceutical composition according to claim 8, wherein the pharmaceutical composition is for the prevention or treatment of a coronavirus infection, and the pharmaceutical composition is administered by nasal spray, nasal drops, or eye drops.

14. Use of 5-amino-2,3-dihydro-1,4-phthalazinedione or one of its pharmaceutically acceptable salts, hydrates, or solvates, and 6'-methoxycinchonan-9-ol or its pharmaceutically acceptable salt in the manufacture of the pharmaceutical composition according to claim 8, wherein the pharmaceutical composition is a formulation for pharyngeal administration and is a pharmaceutical composition for the prevention or treatment of coronavirus infection.

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