Ampleloxetine for use in the treatment of multiple system atrophy

Abstract

Methods for treating a subject with multiple system atrophy (MSA) using ampleloxetine or a pharma- ceutically acceptable salt thereof are disclosed. The disclosed methods include using ampleloxetine or a pharma- ceutically acceptable salt thereof to (i) treat symptoms of neurogenic orthostatic hypotension in a subject with MSA, (ii) reduce the magnitude of the decline in quality of life in a subject with MSA, and / or (iii) increase the level of norepinephrine in a subject with MSA.

Description

[Technical field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This application claims the benefit under 35 U.S.C. §119(e) of U.S. Provisional Application No. 63 / 324,313, filed March 28, 2022, which is incorporated by reference in its entirety. [Background technology]

[0002] The present application discloses methods for treating a subject with multiple system atrophy (MSA) using ampleloxetine or a pharma- ceutically acceptable salt thereof. The disclosed methods include using ampleloxetine or a pharma- ceutically acceptable salt thereof to (i) treat symptoms of neurogenic orthostatic hypotension in a subject with MSA, (ii) reduce the magnitude of the decline in quality of life in a subject with MSA, and / or (iii) increase the level of norepinephrine in a subject with MSA.

[0003] Background technology Neurogenic orthostatic hypotension (nOH) is a form of orthostatic hypotension (OH) and is a highly associated symptom of multiple system atrophy (MSA) or Parkinson's disease (PD). nOH is caused by central or peripheral neuropathy, such as MSA or PD, respectively. Such disorders can cause insufficiency or dysregulation of norepinephrine, the main neurotransmitter that regulates blood pressure in response to postural changes (Loavenbruck et al, Curr. Med. Res. Opin., 2015;31:2095-2104). As a result, the autonomic nervous system is unable to properly regulate blood pressure during postural changes, and patients experience a significant drop in blood pressure that can result in, for example, dizziness, weakness, fatigue, blurred vision, impaired concentration, head and neck discomfort, or fainting.

[0004] Therefore, one goal of nOH treatment is to increase the level of norepinephrine in patients. One way to increase norepinephrine levels is to administer an agent that generates norepinephrine. For example, droxidopa (L-threo-3-4-dihydroxyphenylserine) is an amino acid that is converted to norepinephrine by decarboxylation in both the central and peripheral nervous systems, thereby increasing the level of norepinephrine (Kaufmann et al., Circulation, 2003; 108: 724-728; Kaufmann, Clin. Auton. Res. (2008) 18 [Suppl 1]: 19-24); and Isaacson et al., Vascular Health and Risk Management, 2014, 10: 169-176). Droxidopa is approved in the United States for the treatment of orthostatic dizziness, lightheadedness, or "feelings of blacking out" in adult patients with symptomatic nOH caused by primary autonomic failure (Parkinson's disease, multiple system atrophy, and pure autonomic failure), dopamine beta-hydroxylase deficiency, and nondiabetic autonomic neuropathy. The main side effect of droxidopa is supine hypertension, and its prescribing information includes a black box warning for this serious side effect. Additionally, the prescribing information for droxidopa states that efficacy of treatment beyond 2 weeks has not been established.

[0005] Alternatively, norepinephrine levels can be increased in patients by inhibiting the norepinephrine transporter responsible for norepinephrine reuptake.For example, atomoxetine is a selective norepinephrine reuptake inhibitor approved in the United States for the treatment of attention deficit hyperactivity disorder (ADHD).Atomoxetine has been shown to increase blood pressure in patients with central autonomic failure (Ramirez et al., Hypertension, 2014; 64: 1235-40, and Shibao et al., Hypertension, 2007; 50: 47-53). However, atomoxetine is primarily metabolized through the CYP2D6 enzyme pathway, and therefore its pharmacokinetic properties vary depending on whether the subject has low CYP2D6 activity (poor metabolizers) or normal CYP2D6 activity (extensive metabolizers) (Ring et al., Drug Metabolism and Distribution, 2002, 30:319-323). Additionally, when used to treat ADHD, atomoxetine is associated with several gastrointestinal adverse effects, including dry mouth and nausea. Atomoxetine is not approved for the treatment of nOH. Furthermore, recent studies have shown that atomoxetine is ineffective against nOH in MSA patients, while showing improvement in non-MSA patients. (Urechie et al., Hypertension, 2022;79[Suppl.1]:AP063-AP063)

[0006] The α1-adrenoceptor agonist, midodrine, is the only other FDA-approved drug for the treatment of symptomatic nOH; other medications used to treat nOH include synthetic mineralocortioids; fludrocortisone; and the cholinesterase inhibitor, pyridostigmine. Side effects of these medications can include supine hypertension, paresthesia (including scalp tingling), piloerection (goosebumps), and urinary urgency or retention for midodrine; hypokalemia, headache, peripheral edema, cardiac failure, and supine hypertension for fludrocortisone; and abdominal discomfort and urgency for pyridostigmine.

[0007] It would therefore be desirable to have other options available for treating nOH, particularly for MSA patients. In particular, it would be desirable to provide safe and well-tolerated agents with predictable pharmacokinetic properties for use in the treatment of nOH, which are effective for long periods of time, and which are effective for various patient subgroups. [Prior art documents] [Non-patent literature]

[0008] [Non-Patent Document 1] Loavenbruck et al,Curr.Med.Res.Opin.,2015;31:2095-2104 [Non-Patent Document 2] Kaufmann et al.,Circulation,2003;108:724-728 [Non-Patent Document 3] Kaufmann, Clin. Auton. Res. (2008) 18[Suppl 1]: 19-24 [Non-Patent Document 4] Isaacson et al.,Vascular Health and Risk Management,2014,10:169-176 [Non-Patent Document 5] Ramirez et al.,Hypertension,2014;64:1235-40 [Non-Patent Document 6] Shibao et al.,Hypertension,2007;50:47-53 [Non-Patent Document 7] Ring et al.,Drug Metabolism and Distribution,2002,30:319-323 [Non-Patent Document 8] Urechie et al.,Hypertension,2022;79[Suppl.1]:AP063-AP063 Summary of the Invention [Means for solving the problem]

[0009] It has now been discovered that when a subject with multiple system atrophy is treated with ampleroxetine, certain symptoms associated with nOH are surprisingly reduced for a long period of time.For example, in a subject with multiple system atrophy and symptomatic neurogenic orthostatic hypotension, ampleroxetine treatment for at least about 22 weeks surprisingly results in a measurable reduction in both (i) the subject's symptoms of dizziness, lightheadedness, fainting, or feeling like they may black out, and (ii) the subject's overall impression of the severity of symptoms.In addition, the magnitude of the reduction in the quality of life of a subject with multiple system atrophy can be reduced when the subject is treated with ampleroxetine for at least about 22 weeks.Surprisingly, it has also been discovered that the norepinephrine level of a subject with multiple system atrophy continues to increase for at least about 8 weeks when the subject is treated daily with ampleroxetine.

[0010] Thus, the present disclosure provides a method for treating a subject with multiple system atrophy using ampleloxetine or a pharma- ceutically acceptable salt thereof, or a pharmaceutical composition comprising ampleloxetine or a pharma- ceutically acceptable salt thereof and a pharma- ceutically acceptable carrier. The methods disclosed herein include, but are not limited to, the use of ampleloxetine or a pharma- ceutically acceptable salt thereof to (i) treat symptoms of neurogenic orthostatic hypotension in a subject with multiple system atrophy, (ii) reduce the magnitude of the decline in quality of life in a subject with multiple system atrophy, and / or (iii) increase norepinephrine levels in a subject with MSA.

[0011] In one aspect, the disclosure relates to a method for treating symptomatic neurogenic orthostatic hypotension (nOH) in a subject with multiple system atrophy (MSA), the method comprising administering to the subject daily for at least about 8 weeks a pharmaceutical composition comprising a pharma- ceutical carrier and about 10 mg (free base equivalent) of ampleloxetine or a pharma- ceutical acceptable salt thereof, wherein the administration results in a reduction in at least one of the following: Orthostatic Hypotensive Symptom Assessment (OHSA) composite score, Orthostatic Hypotensive Daily Activities Scale (OHDAS) item 1 score (brief standing), and OHDAS item 3 score (brief walking).

[0012] In some embodiments, the pharmaceutical composition is administered to the subject orally and / or once daily. In some embodiments, in the absence of treatment with the pharmaceutical composition, the subject being treated experiences symptoms of neurogenic orthostatic hypotension as determined using the Orthostatic Hypotension Scale (OHSA). In some embodiments, the subject has MSA subtype P (MSA-P) or MSA subtype C (MSA-C). In some embodiments, the subject has a sustained reduction in BP of ≥20 mmHg (systolic) or ≥10 mmHg (diastolic) within 3 minutes of standing as part of an orthostatic standing test or tilting up from a supine position ≥60° as determined by tilt table testing prior to administration. In some embodiments, prior to treatment, the subject has a score of 4 or less on the Unified Multiple System Atrophy Rating Scale (UMSARS) Part IV prior to administration. In some embodiments, the subject has an OHSA item 1 score of at least 4 prior to administration. In some embodiments, the pharmaceutical composition is administered for at least about 12 weeks. In some embodiments, ampleloxetine is administered as the hydrochloride salt. In some embodiments, the pharma- ceutically acceptable carrier comprises one or more of microcrystalline cellulose, lactose, and magnesium stearate.

[0013] In one aspect, the disclosure relates to a method for treating symptomatic neurogenic orthostatic hypotension (nOH) in a subject with multiple system atrophy (MSA), the method comprising administering to the subject daily for at least about 22 weeks a pharmaceutical composition comprising a pharma- ceutical acceptable carrier and about 10 mg (free base equivalent) of ampleloxetine or a pharma- ceutical acceptable salt thereof; (a) in the absence of treatment with the pharmaceutical composition, the subject being treated experiences symptoms of neurogenic orthostatic hypotension as determined using the Orthostatic Hypotension Assessment Scale (OHSA); (b) administration of the pharmaceutical composition daily to a subject for at least about 22 weeks results in a measurable reduction in at least one of the subject's (i) OHSA composite score, (ii) Orthostatic Hypotension Questionnaire (OHQ) composite score, (iii) Orthostatic Hypotension Daily Activities Scale (OHDAS) composite score, or (iv) OHDAS item 1 (Short Standing).

[0014] In some embodiments, the pharmaceutical composition is administered orally to the subject. In some embodiments, the pharmaceutical composition is administered once a day to the subject. In some embodiments, the subject has a supine plasma norepinephrine level less than about 350 pg / mL prior to treatment with the pharmaceutical composition. In some embodiments, the subject has a supine plasma norepinephrine level greater than about 500 pg / mL about 8 weeks after treatment with the pharmaceutical composition. In some embodiments, the subject has MSA subtype P (MSA-P). In some embodiments, the subject has been diagnosed with MSA at least 1.3 years prior to administration. In some embodiments, the subject has had nOH 1.6 years or more prior to administration. In some embodiments, the subject has an OSHA composite score of 5 or greater prior to administration. In some embodiments, the subject has an OSHA Item 1 score of 7 or greater prior to administration. In some embodiments, the subject has a score of ≦4 on the Unified Multiple System Atrophy Rating Scale (UMSARS) Part IV prior to administration. In some embodiments, the subject has a score of 4 on the Unified Multiple System Atrophy Rating Scale (UMSARS) Part IV prior to administration. In some embodiments, ampleloxetine is administered as a hydrochloride salt. In some embodiments, the pharmaceutical composition is administered for at least about 12 months. In some embodiments, the pharmaceutical acceptable carrier comprises one or more of microcrystalline cellulose, lactose, and magnesium stearate.

[0015] In one aspect, the disclosure relates to a method for identifying a subject having multiple system atrophy (MSA) and responding to ampleloxetine, the method comprising administering to the subject a pharmaceutical composition comprising a pharma- ceutical carrier and about 10 mg (free base equivalent) of ampleloxetine or a pharma- ceutical acceptable salt thereof for at least 8 weeks.

[0016] In some embodiments, the pharmaceutical composition is administered for at least 12 weeks. In some embodiments, the method further comprises determining whether the subject exhibits at least a 2-point reduction in Orthostatic Hypotensive Symptom Assessment (OHSA) item 1 score after administration. In some embodiments, the pharmaceutical composition is administered orally to the subject. In some embodiments, the pharmaceutical composition is administered once daily to the subject. In some embodiments, the MSA has MSA subtype P (MSA-P) or MSA subtype C (MSA-C).

[0017] In one aspect, a method of treating symptomatic neurogenic orthostatic hypotension (nOH) in a subject with multiple system atrophy (MSA) comprises administering to the subject a pharmaceutical composition comprising a pharma- ceutical acceptable carrier and ampleloxetine or a pharma- ceutical acceptable salt thereof, wherein the subject: (a) an Orthostatic Hypotension Assessment Scale (OSHA) composite score of 5 or greater prior to dosing; and / or (b) have an OSHA item 1 score of 7 or greater prior to administration;

[0018] Also provided herein is the use of a pharmaceutical composition comprising a pharma- ceutically acceptable carrier and about 10 mg (free base equivalent) of ampleloxetine or a pharma- ceutically acceptable salt thereof for the treatment of symptomatic neurogenic orthostatic hypotension (nOH) in a subject with multiple system atrophy (MSA).

[0019] Other aspects and embodiments are disclosed herein.

[0020] Various aspects of the present disclosure will now be illustrated by reference to the accompanying drawings. [Brief description of the drawings]

[0021] [Figure 1][Figure 1A] OHSA item 1 scores of subjects with multiple system atrophy who received either ampleloxetine or placebo at the end of the 6-week double-blind randomized period. [Figure 1B] OHSA composite scores of subjects with multiple system atrophy who received either ampleloxetine or placebo at the end of the 6-week double-blind randomized period. [Diagram 2] [Figure 2A] The OHDAS composite score of subjects with multiple system atrophy who received either ampleloxetine or placebo at the end of the 6-week double-blind randomized period. [Figure 2B] The mean change in systolic blood pressure of subjects with multiple system atrophy who received either ampleloxetine or placebo at the end of the 6-week double-blind randomized period. [Diagram 3] FIG. 1 shows OHSA and OHDAS composite scores and individual subscores for symptoms and daily activities in subjects with multiple system atrophy receiving either ampleloxetine or placebo at the end of a 6-week double-blind randomized period. [Figure 4] EQ-VAS score mean for subjects with multiple system atrophy at various weeks of treatment. [Diagram 5] 1 shows the mean difference in OHSA composite scores between ampleloxetine and placebo in subgroups of subjects with multiple system atrophy who received either ampleloxetine or placebo at the end of the 6-week double-blind randomized period. [Figure 6] 1 shows the mean difference in OHQ composite scores between ampleloxetine and placebo in subgroups of subjects with multiple system atrophy who received either ampleloxetine or placebo at the end of the 6-week double-blind randomized period. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0022] In various aspects and embodiments, the present application discloses methods for treating a subject with multiple system atrophy using ampleloxetine or a pharma- ceutically acceptable salt thereof.

[0023] definition When describing the aspects and embodiments disclosed herein, the following terms have the following meanings unless otherwise indicated.

[0024] The singular terms "a," "an," and "the" include the corresponding plural terms unless the context of usage clearly dictates otherwise.

[0025] The term "about" means plus or minus 5 percent of the specified value.

[0026] The term "melting point" means the temperature at which maximum endothermic heat flow is observed by differential scanning calorimetry for the thermal transition corresponding to a phase change from solid to liquid.

[0027] The term "pharmaceutical acceptable" means acceptable for administration to a subject (eg, having an acceptable degree of safety for a particular use).

[0028] The term "pharmaceutically acceptable salts" refers to salts (including zwitterions) prepared from acids and bases that are acceptable for administration to a subject (e.g., salts that have acceptable safety for a given administration regimen).

[0029] The term "subject" means a human subject or patient.

[0030] The term "therapeutically effective amount" means an amount sufficient to effect treatment, e.g., the amount needed to obtain a desired therapeutic effect, when administered to a subject in need of treatment.

[0031] The term "treating" or "treatment" means ameliorating or inhibiting the medical condition or disorder being treated; or alleviating the symptoms of the medical condition or disorder.

[0032] The term "unit dosage form" or "unit dose" means a physically discrete unit suitable for administration to a subject, i.e., each unit containing a predetermined amount of a therapeutic agent calculated to produce a therapeutic effect, either alone, or in combination with one or more additional units. Examples include capsules, tablets, and the like.

[0033] The term "sitting systolic blood pressure" refers to the systolic blood pressure recorded after 5 and 10 minutes of sitting.

[0034] The term "orthostatic systolic blood pressure" refers to the systolic blood pressure recorded after standing for 1, 3, 5, and 10 minutes.

[0035] All other terms used herein are intended to have their ordinary meanings as understood by those of ordinary skill in the art to which they belong.

[0036] Compounds of Formula I Ampleroxetine, or 4-[2-(2,4,6-trifluorophenoxymethyl)phenyl]piperidine, is a norepinephrine reuptake inhibitor having formula I. [ka] See, e.g., Smith et al., Int J Neuropsychopharmacol. 2015;18(2)pyu027. Ampleloxetine is also known as TD-9855.

[0037] U.S. Patent Nos. 8,304,432, 8,604,058, 9,162,982, 9,675,599, 10,034,870, 10,306,913, 10,441,579, 10,722,504, and 10,946,007 disclose 4-[2-(2-fluorophenoxymethyl)phenyl]piperidine compounds, including ampleloxetine and pharma- ceutically acceptable salts thereof. Additionally, U.S. Patent Nos. 8,304,433, 8,592,596, 9,073,859, 10,226,454, 10,576,073, and 10,946,006 disclose crystalline hydrochloride salts of ampleloxetine. These patents disclose various uses for ampleloxetine and its salts, including the treatment of pain disorders, depressive disorders, cognitive disorders, stress urinary incontinence, chronic fatigue syndrome, obesity, vasomotor symptoms associated with menopause, chronic back pain, osteoarthritis, and other disorders.

[0038] U.S. Patent No. 10,238,642 discloses a method for treating neurogenic orthostatic hypotension (nOH) and its symptoms in human patients with multiple system atrophy (MSA), Parkinson's disease (PD), or pure autonomic failure (PAF) using ampleloxetine and its pharmacologic acceptable salts.

[0039] Ampleroxetine has been evaluated in several clinical trials. For example, the safety and tolerability of ampleroxetine have been evaluated in single ascending dose studies in healthy subjects at doses ranging from 2 to 50 mg, and in multiple ascending dose studies in healthy subjects at daily doses of 4, 10, 20, and 40 mg for up to 14 days. In healthy subjects, single doses of up to 50 mg and multiple ascending doses of up to 20 mg ampleroxetine once daily were generally well tolerated.

[0040] The safety, tolerability, and efficacy of ampleloxetine were also evaluated in two Phase 2 studies in subjects with attention-deficit hyperactivity disorder and fibromyalgia. Ampleloxetine doses of 5 mg or 20 mg were administered once daily for 6 weeks in both studies, and ampleloxetine was generally well tolerated with no clinically significant safety signals.

[0041] In these studies, the pharmacokinetic (PK) properties of amploxetine were characterized by the maximum concentration (C max Ampleroxetine had a linear, near dose-proportional exposure with respect to dose and area under the curve (AUC). Ampleroxetine had an elimination half-life (t ) of approximately 30-40 hours, achieving steady state by 6 days. 1 / 2 ). Consistent with the elimination half-life, a 3-4-fold accumulation of ampleloxetine was observed at steady state. Based on clinical PK studies in healthy subjects, ampleloxetine is >90% eliminated by metabolism using cytochrome P450 1A2 (CYP1A2), the primary enzyme involved in ampleloxetine metabolism. See, for example, Kanodia et al., “Pharmacokinetics of Ampreloxetine, a Norepinephrine Reuptake Inhibitor, in Healthy Subjects and Adults with Attention-Deficit / Hyperactive Disorder or Fibromyalgia Pain,” Clin Pharmacokinetics, (2021) 60:121-131.

[0042] Ampleroxetine was also evaluated in a multicenter, randomized, three-part, single-blind (Part A), double-blind, placebo-controlled (Part B), and open-label repeated dose extension (Part C) Phase 2 study in subjects with symptomatic nOH. Part A evaluated the dose response of single, ascending doses of ampleroxetine up to 20 mg. No dose response was observed, but a numerical trend for increased sitting and standing systolic blood pressure (SBP) was observed at higher doses. An improvement in standing time of approximately 100 seconds was observed 4 hours after dosing with 10 mg. In Part B, subjects were treated with ampleroxetine (up to 15 mg) in a double-blind, placebo-controlled, 1-day, inpatient study. Subjects receiving ampleroxetine showed sustained increases in SBP over baseline after 3 minutes of standing at 4 and 7 hours after dosing. No increase in SBP was observed in placebo-treated subjects at these time points. See, e.g., Kaufmann et al., Clin Auton Res (2021) 31:699-711, and Kaufmann et al., “A Phase 2, Dose-Escalation Study of Ampreloxetine (TD-9855), a Norepinephrine Reuptake Inhibitor, Given Once-Daily to Treat Neurogenic Orthostatic Hypotension (nOH) in Subjects with Synucleinopathies.” Poster 126 presented at the International Parkinson and Movement Disorder Society; September 22-26, 2019; Nice, France.

[0043] Part C of this study evaluated the durability of response, safety, and tolerability of ampleloxetine in an open-label, phase 2, multicenter study of subjects with nOH. Subjects were treated with oral ampleloxetine (3-20 mg) once daily for up to 20 weeks, with a 4-week follow-up after ampleloxetine treatment was discontinued. The primary efficacy endpoint of Part C was an improvement from baseline of at least 2 points in the Orthostatic Hypotension Symptom Assessment (OHSA) Question 1 (OHSA#1) score. OHSA#1 is a measure of feeling dizzy, lightheaded, faint, or about to black out. The majority of subjects met this endpoint.See, for example, Kaufmann et al., Clin Auton Res (2021) 31:699-711, and Kaufmann et al., “Efficacy, Durability, and Safety of Ampreloxetine, a Norepinephrine Reuptake Inhibitor, Given Once-Daily to Treat Neurogenic Orthostatic Hypotension (nOH) in Subjects with Primary Autonomic Failure.” Poster 087 presented at the World Congress on Parkinson’s Disease and Related Disorders; June 16-19, 2019; Montreal, Canada, and Kaufmann et al., “A Phase 2 study of the Efficacy, Durability, and Safety of Ampreloxetine (TD-9855), a Norepinephrine Reuptake Inhibitor, Given Once-Daily to Treat Neurogenic Orthostatic Hypotension (nOH) in Subjects with Synucleinopathies.” Poster 125 presented at the International Parkinson and Movement Disorder Society; September 22-26, 2019; Nice, France.

[0044] More recently, ampleloxetine has been evaluated in two Phase 3 studies. The first Phase 3 study was a randomized, double-blind, placebo-controlled, parallel-group, multicenter study designed to evaluate its efficacy, safety, and tolerability in subjects with primary autonomic failure (MSA, PD, or PAF) and symptomatic nOH after 4 weeks of treatment. The primary objective of this study was to evaluate the efficacy of ampleloxetine in subjects with MSA, PD, or PAF experiencing symptomatic nOH compared to placebo at 4 weeks, as measured by change from baseline in OHSA#1 score. After 4 weeks of treatment, the study did not meet its primary endpoint.

[0045] The second Phase 3 study was a multicenter, randomized withdrawal study to evaluate the sustained benefits in efficacy and safety of ampleloxetine in subjects with primary autonomic failure (MSA, PD, or PAF) and symptomatic nOH after 22 weeks of treatment. The study consisted of a 16-week open-label (OL) treatment period with ampleloxetine, followed by a 6-week double-blind randomized withdrawal period in which subjects received either ampleloxetine or placebo.

[0046] Aspects and embodiments disclosed herein include amploxetine (TD-9855 or 4-[2-(2,4,6-trifluorophenoxy-methyl)phenyl]piperidine), having formula I: [ka] Or a pharma- ceutically acceptable salt thereof is used.

[0047] Ampleroxetine and intermediates thereof can be prepared as described in the Examples herein or by the methods and procedures disclosed in U.S. Pat. Nos. 8,304,432, 8,304,433, 8,247,433, and 10,640,467, and related patents, which are incorporated herein by reference.

[0048] In some embodiments, ampleloxetine is used in the form of a pharma- ceutically acceptable salt. Exemplary pharma-ceutically acceptable salts include salts of the following acids (with the corresponding anion shown in parentheses): acetic acid (acetate), ascorbic acid (ascorbate), benzenesulfonic acid (benzenesulfonate or besylate), benzoic acid (benzoate), camphorsulfonic acid (camphorsulfonate), chlortheophylline (chlortheophyllinate), citric acid (citrate), ethanesulfonic acid (ethanesulfonate), ethanesulfonate, ... Disulfonic acid or edisylic acid (ethanedisulfonate or edisylate), fumaric acid (fumarate), gentisic acid (gentisate), gluconic acid (gluconate), glucuronic acid (glucronate), gluceptic acid (gluceptate), glutamic acid (glutamate), hippuric acid (hippurate), hydrobromic acid (bromide), hydrochloric acid (chloride), hydroiodic acid (iodide), isethionic acid (isethionate), lactic acid (lactate), lactobionic acid (lactate), lauryl sulfonic acid (laurylsulfonic acid) sulfonate), maleic acid (maleate), malic acid (malate), mandelic acid (mandelate), methanesulfonic acid (methanesulfonate or mesylate), methylsulfonic acid (methylsulfonate), mucic acid (mucate), naphthalenesulfonic acid (naphthalenesulfonate or napsylate), naphthalene-1,5-disulfonic acid (naphthalene-1,5-disulfonate), naphthalene-2,6-disulfonic acid (naphthalene-2,6-disulfonate), naphthoic acid (naphthoate), nicotinic acid (nicotinic acid Acid addition salts include, for example, nitric acid (nitrate), octadecanoic acid (octadecanoate), oleic acid (oleate), orotic acid (orotate), oxalic acid (oxalate), pamoic acid (pamoate), pantothenic acid (pantothenate), phosphoric acid (phosphate), polygalacturonic acid (polygalacturonate), succinic acid (succinate), sulfosalicylic acid (sulfosalicylate), sulfuric acid (sulfate), tartaric acid (tartrate), p-toluenesulfonic acid (p-toluenesulfonate or tosylate), and xinafoic acid (xinafoate). Such salts are sometimes called acid addition salts.

[0049] The salts can be prepared by contacting 1 molar equivalent of ampleroxetine with about 0.95 to about 1.05 molar equivalents of an acidic proton in a pharma- ceutically acceptable acid. For example, 1 molar equivalent of ampleroxetine can be contacted with about 1 molar equivalent of hydrochloric acid to form ampleroxetine hydrochloride, or 1 molar equivalent of ampleroxetine can be contacted with about 0.5 molar equivalent of sulfuric acid to form ampleroxetine sulfate.

[0050] Such reactions are typically conducted in a diluent such as dichloromethane, ethanol, ethyl acetate, isopropyl acetate, water, and the like, at a temperature ranging from about -20°C to about 65°C for about 0.5 to about 12 hours or until the reaction is substantially complete. Upon completion of the reaction, the product is typically isolated using conventional techniques such as filtration, chromatography, recrystallization, and the like. The product of such reactions may or may not be crystalline.

[0051] In some embodiments, a protected derivative of ampleroxetine, such as 4-[2-(2,4,6-trifluorophenoxymethyl)phenyl]piperidine-1-carboxylic acid tert-butyl ester, is contacted with a pharma- ceutically acceptable acid, such as hydrochloric acid, to deprotect and form a pharma- ceutically acceptable salt of ampleroxetine.

[0052] In some embodiments, the compound used is ampleloxetine hydrochloride. In another embodiment, the compound is a crystalline hydrochloride of ampleloxetine characterized by a powder X-ray diffraction pattern comprising diffraction peaks at 2θ values ​​of 4.44±0.2, 10.22±0.2, and 21.78±0.2. In another embodiment, the crystalline hydrochloride is further characterized by having one or more additional diffraction peaks at 2θ values ​​selected from 8.11±0.2, 13.18±0.2, 16.06±0.2, 17.16±0.2, 18.38±0.2, 23.76±0.2, 26.32±0.2, 27.24±0.2, 29.60±0.2, and 31.94±0.2. In another embodiment, the compound is a crystalline hydrochloride of ampleloxetine characterized by a differential scanning calorimetry trace having a melting point of about 197±2° C.

[0053] In some embodiments, the crystalline hydrochloride salt of amploxetine has about 0 to about 2 percent water by weight, eg, the crystalline hydrochloride salt adsorbs or desorbs water based on the relative humidity.

[0054] The crystalline hydrochloride salt of ampleloxetine used can be prepared as described in the Examples herein or by the methods and procedures disclosed in U.S. Pat. Nos. 8,304,432, 8,304,433, and 8,247,433, and related patents.

[0055] Pharmaceutical Compositions, Formulations, and Dosage Forms As used herein, ampleloxetine or a pharma- ceutically acceptable salt thereof is typically administered to a subject or patient in the form of a pharmaceutical composition or formulation. When describing a composition or formulation herein, ampleloxetine or a pharma- ceutically acceptable salt thereof may be referred to as an "active agent" to distinguish it from other components of the formulation, such as carriers or excipients. Thus, the term "active agent" includes ampleloxetine and its pharma- ceutically acceptable salts. Additionally, the terms "carrier" and "excipient" are used interchangeably herein and have the same meaning unless otherwise indicated.

[0056] A pharmaceutical composition typically contains a therapeutically effective amount of an active agent. However, one of skill in the art will recognize that a pharmaceutical composition may contain amounts that are greater than a therapeutically effective amount, e.g., a bulk composition, or amounts that are less than a therapeutically effective amount, e.g., individual unit doses designed for multiple administration to achieve a therapeutically effective amount.

[0057] Typically, a pharmaceutical composition contains from about 0.01 to about 30% by weight, for example, from about 0.01 to about 95% by weight, including from about 0.01 to about 10% by weight, of the active agent, the actual amount depending on the formulation, route of administration, frequency of administration, etc. For example, a pharmaceutical composition suitable as an oral dosage form may contain from about 0.1 to about 10% by weight, including from about 0.5 to about 5% by weight, of the active agent.

[0058] In a representative embodiment, the pharmaceutical composition contains about 0.5 to about 20 mg of active agent per unit dose, including about 1 to about 10 mg of active agent per unit dose. For example, the active agent can be formulated in 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 mg unit doses, such as 1 mg, 3 mg, 5 mg, 10 mg, and 15 mg unit doses (each dose referring to the free base equivalent of amploxetine). In a particular embodiment, the pharmaceutical composition contains about 10 mg of active agent (free base equivalent) per unit dose.

[0059] Any conventional or suitable pharma- ceutically acceptable carrier can be used in the pharmaceutical composition. The selection of a particular carrier or combination of carriers depends on various factors, such as the mode of administration, the dosage, the frequency of administration, the timing of the release of the active agent, etc. In this regard, the preparation of a suitable pharmaceutical composition for a particular mode of administration is well within the skill of a person skilled in the pharmaceutical art, and the carriers used in such compositions are commercially available. As further examples, conventional formulations and formulation techniques can be found, for example, in Remington: The Science and Practice of Pharmacy, 23 rdEdition, Academic Press, Cambridge, MA (2020), and Loyd V. Allen, Jr. et al., Ansel's Pharmaceutical Dosage Forms and Drug Delivery Systems, 11 th Edition, Lippincott Williams & Wilkins, Philadelphia, PA (2017).

[0060] Representative examples of pharma- ceutically acceptable carriers include, but are not limited to, sugars such as lactose, glucose, and sucrose, starches such as corn starch and potato starch, celluloses such as crystalline cellulose and its derivatives, such as sodium carboxymethylcellulose, ethylcellulose, and cellulose acetate, powdered tragacanth, malt, gelatin, talc, excipients such as cocoa butter and suppository waxes, oils such as peanut oil, cottonseed oil, safflower oil, sesame oil, olive oil, corn oil, and soybean oil, glycols such as propylene glycol, polyols such as glycerin, sorbitol, mannitol, and polyethylene glycol, esters such as ethyl oleate and ethyl laurate, agar, buffers such as magnesium hydroxide and aluminum hydroxide, alginic acid, pyrogen-free water, isotonic saline, Ringer's solution, ethyl alcohol, phosphate buffer solutions, compressed propellants such as chlorofluorocarbons and hydrofluorocarbons, and other non-toxic compatible substances used in pharmaceutical compositions.

[0061] Pharmaceutical compositions are typically prepared by thoroughly and intimately mixing or blending the active agent with a pharma- ceutically acceptable carrier and any optional ingredients, and the resulting homogeneously blended mixture may then be formed or filled into tablets, capsules, pills, canisters, cartridges, vials, bottles, dispensers, and the like using conventional techniques and equipment.

[0062] In some embodiments, the pharmaceutical compositions are suitable for oral administration. Pharmaceutical compositions for oral administration can be in the form of, for example, capsules, tablets, pills, lozenges, cachets, dragees, powders, granules, solutions, suspensions, emulsions, elixirs, syrups, and the like, each containing a predetermined amount of active agent.

[0063] If intended for oral administration in a solid dosage form (e.g., capsules, tablets, etc.), the pharmaceutical composition typically includes the active agent and one or more pharma- ceutically acceptable solid carriers, such as sodium citrate or dicalcium phosphate. Solid dosage forms may also contain fillers or extenders, such as starch, microcrystalline cellulose, lactose, sucrose, glucose, mannitol and / or silicic acid; binders, such as carboxymethylcellulose, alginates, gelatin, polyvinylpyrrolidone, sucrose and / or acacia; humectants, such as glycerol; disintegrating agents, such as croscarmellose sodium, agar, calcium carbonate, potato or tapioca starch, alginic acid, certain silicates and / or sodium carbonate; solution retarding agents, such as paraffin; absorption accelerators, such as quaternary ammonium compounds; wetting agents, such as cetyl alcohol and / or glycerol monostearate; absorbents, such as kaolin and / or bentonite clay; lubricants, such as talc, calcium stearate, magnesium stearate, solid polyethylene glycols, sodium lauryl sulfate and / or mixtures thereof; colorants; buffering agents; release agents. coating agents; sweetening, flavoring, and / or fragrance agents; and preservatives and antioxidants.

[0064] Representative coating agents for tablets, capsules, pills, etc. include those used for enteric coating, such as cellulose acetate phthalate, polyvinyl acetate phthalate, hydroxypropyl methylcellulose phthalate, methacrylic acid-methacrylic acid ester copolymer, cellulose acetate trimellitate, carboxymethylethylcellulose, hydroxypropyl methylcellulose acetate succinate, and polyvinyl alcohol.

[0065] Representative antioxidants include water-soluble antioxidants such as ascorbic acid, cysteine ​​hydrochloride, sodium bisulfate, sodium metabisulfate, sodium sulfite, and the like; oil-soluble antioxidants such as ascorbyl palmitate, butylated hydroxyanisole, butylated hydroxytoluene, lecithin, propyl gallate, alpha-tocopherol, and the like; and metal chelating agents such as citric acid, ethylenediaminetetraacetic acid, sorbitol, tartaric acid, phosphoric acid, and the like.

[0066] Pharmaceutical compositions can also be formulated to provide delayed or controlled release of active agent, for example, by using various proportions of hydroxypropylmethylcellulose or other polymer matrices, liposomes and / or microspheres.In addition, pharmaceutical compositions can contain opacifying agents, and they can be formulated to release active agent only or preferentially in a certain part of the digestive tract, optionally in a delayed manner.Examples of embedding compositions that can be used include polymeric substances and waxes.Active agent can also be in microencapsulated form, optionally with one or more of the above-mentioned excipients.

[0067] Suitable liquid dosage forms for oral administration include, by way of example, pharma- ceutically acceptable emulsions, microemulsions, solutions, suspensions, syrups, and elixirs. Liquid dosage forms typically contain an active agent and an inert diluent, such as water, juice, or other solvent, solubilizers and emulsifiers, such as ethyl alcohol, isopropyl alcohol, ethyl carbonate, ethyl acetate, benzyl alcohol, benzyl benzoate, propylene glycol, 1,3-butylene glycol, oils (e.g., cottonseed, groundnut, corn, germ, olive, castor, and sesame oils), glycerol, tetrahydrofuryl alcohol, polyethylene glycol, and fatty acid esters of sorbitan, and mixtures thereof. Suspensions may contain suspending agents, such as ethoxylated isostearyl alcohol, polyoxyethylene sorbitol and sorbitan esters, microcrystalline cellulose, aluminum metahydroxide, bentonite, agar, and tragacanth, and mixtures thereof.

[0068] In another embodiment, the pharmaceutical composition is suitable for topical administration, for example, transdermal administration.For such administration, known transdermal delivery systems and excipients can be used.For example, the active agent can be mixed with a penetration enhancer, for example, propylene glycol, polyethylene glycol monolaurate, azacycloalkan-2-one, and the like, and incorporated into a patch or similar delivery system.Additional excipients, including gelling agents, emulsifiers, and buffers, can be used in such transdermal compositions if desired.

[0069] In another embodiment, the pharmaceutical composition is suitable for parenteral administration (e.g., by subcutaneous, intravenous, intramuscular or intraperitoneal injection). For such administration, the active agent is provided in a sterile solution, suspension or emulsion. Examples of carriers for preparing such formulations include water, saline, low molecular weight alcohols such as propylene glycol, polyethylene glycol, oils, gelatin, fatty acid esters such as ethyl oleate, and the like. Parenteral formulations may also contain one or more solubilizing agents, stabilizing agents, preservatives, wetting agents, emulsifying agents, and dispersing agents. These formulations can be made sterile by the use of a sterile injectable medium, a sterilizing agent, filtration, irradiation, or heat.

[0070] A typical intravenous formulation is a sterile pH 4-7 aqueous solution containing the active agent and a physiologically acceptable aqueous carrier. Representative physiologically acceptable aqueous carriers include, by way of example, Sterile Water for Injection, USP; Dextrose Injection, USP (e.g., including 2.5, 5.0, 10, 20% dextrose, 5% dextrose injection (D5 / W)); Dextrose and Sodium Chloride Injection, USP (e.g., dextrose ranging from 2.5-10% and sodium chloride ranging from 0.12 (19 mEq sodium) to 0.9% (154 mEq sodium)); Mannitol Injection, USP ( For example, 5, 10, 15, 20 and 25% mannitol; Ringer's Injection, USP (e.g., 147 mEq sodium, 4 mEq potassium, 4.5 mEq calcium and 156 mEq chloride per liter); Lactated Ringer's Injection, USP (e.g., 2.7 mEq calcium, 4 mEq potassium, 130 mEq sodium and 28 mEq lactate per liter); Sodium Chloride Injection, USP (e.g., 0.9% sodium chloride) and the like. When administered to a subject, the active agent is typically diluted in about 0.1 mL to about 10 mL of aqueous carrier per mg of active agent, e.g., about 0.5 to about 5 mL per mg. The dosing solution is then typically administered to the subject by intravenous infusion.

[0071] By way of example, representative pharmaceutical compositions can be prepared as illustrated in the Examples below.

[0072] A. Hard gelatin capsules The active agent (5 g), spray-dried lactose (485 g) and magnesium stearate (10 g) are thoroughly blended. The resulting composition is then loaded into hard gelatin capsules (500 mg of composition per capsule). Each capsule provides 5 mg of active agent per unit dose suitable for oral administration.

[0073] B. Hard gelatin capsules The active agent (2 g) is thoroughly blended with starch (98 g), microcrystalline cellulose (98 g), and magnesium stearate (2 g). The mixture is then passed through a No. 45 mesh US sieve and loaded into a hard gelatin capsule (200 mg of composition per capsule). Each capsule provides 2 mg of active agent per unit dose suitable for oral administration.

[0074] C. Soft gelatin capsules The active agent (5 g) is thoroughly blended with polyoxyethylene sorbitan monooleate (65 g) and starch powder (330 g). The mixture is then loaded into soft gelatin capsules (400 mg of composition per capsule). Each capsule provides 5 mg of active agent per unit dose suitable for oral administration.

[0075] D. Soft gelatin capsules The active agent (1 g) is thoroughly blended with microcrystalline cellulose (290 g) and magnesium stearate (9 g). The mixture is then loaded into soft gelatin capsules (300 mg of composition per capsule). Each capsule provides 1 mg of active agent per unit dose suitable for oral administration.

[0076] E. Tablets The active agent (10 g), starch (45 g), and microcrystalline cellulose (35 g) are passed through a No. 20 mesh US sieve and thoroughly mixed. The resulting granules are dried at 50-60° C. and passed through a No. 16 mesh US sieve. Separately, a solution of polyvinylpyrrolidone (4 g as a 10% solution in sterile water) is mixed with sodium carboxymethyl starch (4.5 g), magnesium stearate (0.5 g), and talc (1 g), and this mixture is passed through a No. 16 mesh US sieve. The resulting mixture is then added to the granules. After thoroughly mixing, the mixture is compressed in a tablet press to form tablets each weighing 100 mg. Each tablet provides 10 mg of active agent per unit dose suitable for oral administration.

[0077] F. Tablets The active agent (40 g) is thoroughly blended with microcrystalline cellulose (445 g), fumed silicon dioxide (10 g), and stearic acid (5 g). The mixture is then compressed in a tablet press to form tablets weighing 100 mg each. Each tablet provides 8 mg of active agent per unit dose suitable for oral administration.

[0078] G. Tablets The active agent (10 g) is thoroughly blended with corn starch (50 g), croscarmellose sodium (25 g), lactose (110 mg), and magnesium stearate (5 mg). The mixture is then compressed in a tablet press to form tablets weighing 200 mg each. Each tablet provides 10 mg of active agent per unit dose suitable for oral administration.

[0079] H. Tablets The active agent (10 g) is thoroughly blended with corn starch (230 g) and an aqueous gelatin solution (50 g). The mixture is dried and ground to a fine powder. Microcrystalline cellulose (100 g) and magnesium stearate (10 g) are then mixed with the gelatin formulation, granulated, and the resulting mixture is compressed in a tablet press to form tablets each weighing 200 mg. Each tablet provides 5 mg of active agent per unit dose suitable for oral administration.

[0080] I. Syrup The following ingredients are thoroughly mixed until all solid ingredients are dissolved. [Table 1]

[0081] The resulting syrup contains 5 mg of active agent per 10 mL of syrup suitable for oral administration.

[0082] J. Sterile intravenous solutions The active agent (5 mg) is blended with 0.4 M sodium acetate buffer (2.0 mL). The pH of the resulting solution is adjusted to pH 4 using 0.5 N aqueous hydrochloric acid or 0.5 N aqueous sodium hydroxide as necessary, and then sufficient water for injection is added to provide a total volume of 20 mL. The mixture is then filtered through a sterile filter (0.22 micron) to provide a sterile solution suitable for administration by intravenous infusion.

[0083] Co-administration and Combinations If desired, ampleloxetine or a pharma- ceutically acceptable salt thereof may be administered in combination with one or more other therapeutic agents (a "second agent").

[0084] Representative classes of therapeutic agents that may be administered in combination with ampleloxetine or a pharma- ceutically acceptable salt thereof include, by way of example, alpha 1-adrenergic receptor (alpha 1-adrenergic receptor) agonists, alpha 2-adrenergic receptor (alpha 2-adrenergic receptor) antagonists, corticosteroids, norepinephrine precursors, cholinesterase inhibitors, or combinations thereof. Those skilled in the art will appreciate that the terms "alpha 1-adrenergic receptor agonist", "alpha 2-adrenergic receptor antagonist", "corticosteroid", "norepinephrine precursor" and "cholinesterase inhibitor" include all forms of the compound, e.g., pharma- ceutically acceptable salts, solvates, crystalline forms, polymorphs, prodrugs, etc., that have the specified activity after administration to a subject. Similarly, the term "second agent" includes all forms of the second agent, e.g., pharma-ceutically acceptable salts, solvates, crystalline forms, polymorphs, prodrugs, etc.

[0085] Representative examples of α1-adrenergic receptor agonists include desglymidodrine, etilefrine, metaraminol, midodrine, etc., or in each case, their pharmaceutically acceptable salts.Midodrine is a prodrug of desglymidodrine, which is an α1-adrenergic receptor agonist.In some embodiments, the second drug is midodrine or its pharmaceutically acceptable salt, for example, midodrine hydrochloride.

[0086] Representative examples of α2-adrenergic receptor antagonists include yohimbine or a pharma- ceutically acceptable salt thereof.

[0087] Representative examples of corticosteroids include fludrocortisone, fludrocortisone acetate, etc., or in each case, their pharma- ceutically acceptable salts. Fludrocortisone acetate is a prodrug of fludrocortisone. In some embodiments, the second agent is fludrocortisone acetate.

[0088] Representative examples of norepinephrine precursors include droxidopa or a pharma- ceutically acceptable salt thereof. In some embodiments, the second agent is droxidopa.

[0089] Representative examples of cholinesterase inhibitors include pyridostigmine or a pharma- ceutically acceptable salt thereof. In some embodiments, the second agent is pyridostigmine or a pharma- ceutically acceptable salt thereof, such as pyridostigmine bromide.

[0090] Ampleloxetine or its pharmaceutically acceptable salt and the second drug may be physically mixed to form a composition containing both drugs; or each drug may be administered separately to a subject, either simultaneously or sequentially. For example, ampleloxetine or its pharmaceutically acceptable salt may be mixed with the second drug using conventional techniques and equipment to form a drug combination comprising ampleloxetine or its pharmaceutically acceptable salt and the second drug. Additionally, the drug may be combined with a pharmaceutically acceptable carrier to form a pharmaceutical composition comprising ampleloxetine or its pharmaceutically acceptable salt, the second drug, and a pharmaceutically acceptable carrier. In this embodiment, the components of the composition are typically mixed or blended to create a physical mixture. The physical mixture is then administered to a subject by any suitable route of administration, for example, oral, topical, or parenteral administration mode.

[0091] Alternatively, these agents may remain separate and distinct before administration to a subject. In this embodiment, these agents are not physically mixed together before administration, but are administered simultaneously or at different times as separate compositions. Such compositions may be packaged separately or packaged together in a kit. When administered at different times, the second agent is typically administered less than 24 hours after administration of ampleloxetine or a pharma- ceutically acceptable salt thereof, for example, anywhere from simultaneous administration to about 24 hours after administration. This is also referred to as sequential administration. Thus, for example, ampleloxetine or a pharma- ceutically acceptable salt thereof may be orally administered simultaneously or sequentially with the second agent using two tablets (e.g., one tablet for each active agent), where sequential includes administration immediately before or after administration of ampleloxetine or a pharma- ceutically acceptable salt thereof, or at some other time (e.g., 1 hour before or after, or 3 hours before or after, etc.). Alternatively, the combination may be administered by different routes of administration, for example one orally and the other topically or parenterally.

[0092] When used, the second agent is used in a therapeutically effective amount, i.e., an amount that produces a therapeutically beneficial effect when co-administered with ampleloxetine or a pharma- ceutically acceptable salt thereof. For example, such agents are typically used at their approved dosages. For example, midodrine hydrochloride is typically orally administered in an amount ranging from about 2.5 mg to about 10 mg up to three times a day, and droxidopa is typically orally administered in an amount ranging from about 100 mg to about 600 mg up to three times a day.

[0093] usefulness Ampleloxetine or a pharma- ceutically acceptable salt thereof (such as the hydrochloride salt) has been evaluated for the treatment of subjects with multiple system atrophy. Multiple system atrophy (MSA), also known as Shy-Drager syndrome, is a progressive neurodegenerative disorder characterized by a combination of symptoms affecting both the autonomic nervous system and movement. Early symptoms of MSA are often difficult to distinguish from those of Parkinson's disease and include slowness, tremor, or rigidity of movement; clumsiness or loss of coordination; speech impairment, croaky, quivering voice; fainting or lightheadedness due to orthostatic hypotension; and bladder control problems, such as a sudden urge to urinate or difficulty emptying the bladder. MSA is divided into two different types depending on the most noticeable symptom at the time the individual is evaluated: parkinsonian type (MSA-P) (having core features similar to Parkinson's disease (e.g., slow movements, stiffness and tremors) along with problems with balance, coordination and autonomic nervous system dysfunction); and cerebellar type (MSA-C) (having primary symptoms characterized by ataxia (balance and coordination problems), difficulty swallowing, speech abnormalities or trembling voice and abnormal eye movements). The cause of MSA is unknown. A distinguishing feature of MSA is the accumulation of the protein alpha-synuclein in glia, the cells that support nerve cells in the brain. These alpha-synuclein deposits occur specifically in oligodendrocytes, a type of cell that produces myelin, a coating on nerve cells that allows them to conduct electrical signals quickly. Recent studies have shown that a prion form of the alpha-synuclein protein may be the cause of the disease (Prusiner et al, PNAS, (2015) 112:E5308-17).

[0094] MSA is characterized by degeneration of central autonomic pathways; however, peripheral postganglionic noradrenergic fibers and catecholamine reuptake mechanisms appear to be intact in MSA subjects, thus maintaining sympathetic tone (Biaggioni, Pharmacolgical Reviews (2017) 69(1):53-62). Normally, the peripheral increase in norepinephrine concentration upon standing is counterbalanced by CNS sympatholytic activity mediated by central α2-adrenoceptors activated by norepinephrine, thus buffering the peripheral pressor effect and maintaining postural normotension. However, in MSA, the intact peripheral sympathetic postganglionic adrenergic fibers are essentially "disconnected" from CNS regulation, thus allowing full exposure of the norepinephrine pressor effect. The remaining sympathetic tone in these subjects cannot be regulated by baroreflex pathways or CNS inputs due to this "disconnection," but it can be targeted pharmacologically. Increasing peripheral sympathetic synaptic norepinephrine using ampleloxetine or a pharma- ceutically acceptable salt thereof should induce a hypertensive effect in MSA subjects with nOH.

[0095] Ampleroxetine or a pharma- ceutically acceptable salt thereof is typically administered to a subject in need of treatment in an amount ranging from about 0.5 mg to about 20 mg per day, or as needed. In some embodiments, the amount administered to the subject is in the range of about 1 mg to about 10 mg per day. In some embodiments, the amount administered to the subject is in the range of about 3 mg to about 10 mg per day. In some embodiments, the amount administered to the subject is 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 mg per day, including 1 mg, 3 mg, 5 mg, or 10 mg per day. In some embodiments, ampleroxetine or a pharma- ceutically acceptable salt thereof is administered to the subject in an amount of about 10 mg per day. In some embodiments, ampleroxetine or a pharma- ceutically acceptable salt thereof is administered to the subject in an amount of about 10 mg once per day. In some embodiments, ampleloxetine or a pharma- ceutically acceptable salt thereof is administered to a subject in an amount of about 10 mg per day, where 10 mg is the free base equivalent of ampleloxetine. The amount administered to a subject, the route of administration, and the frequency of administration are typically determined by the physician treating the subject.

[0096] Ampleroxetine or a pharma- ceutically acceptable salt thereof may be administered to a subject by any acceptable route of administration, including, for example, oral, topical (including transdermal), and parenteral (including intravenous) modes of administration.

[0097] In some embodiments, ampleloxetine or a pharma- ceutically acceptable salt thereof is orally administered to a subject in a solid or liquid dosage form. In certain embodiments, the form administered to a subject is a solid dosage form, including a tablet or capsule. In another particular embodiment, the form administered to a subject is a liquid dosage form, including a solution, syrup, suspension, or emulsion.

[0098] In another embodiment, the route of administration is topical. In a particular embodiment, the route of administration is transdermal, using a transdermal patch.

[0099] In another embodiment, the route of administration is parenteral, hi a particular embodiment, the route of administration is intravenous.

[0100] Ampleroxetine or a pharmaceutically acceptable salt thereof may be administered to a subject in a single daily dose (e.g., once a day); in multiple doses per day (e.g., twice, three times, or four times a day); or in multiple doses per week (e.g., twice, three times, four times, five times, or six times a week). Alternatively, the pharmaceutical composition may be administered continuously, for example, using a transdermal patch. In certain embodiments, ampleroxetine or a pharmaceutically acceptable salt thereof is administered to a subject once a day.

[0101] Unlike other currently available therapies, ampleloxetine can be administered for a long period of time and shows efficacy for a long period of time (e.g., more than 2 weeks). In some cases, depending on the dosage schedule, ampleloxetine needs to be administered for a certain period of time to show efficacy. For example, ampleloxetine or a pharma- ceutically acceptable salt thereof is administered to a subject for at least about 4 weeks, at least about 5 weeks, at least about 6 weeks, at least about 7 weeks, at least about 8 weeks, at least about 9 weeks, at least about 10 weeks, at least about 11 weeks, at least about 12 weeks, at least about 13 weeks, at least about 14 weeks, at least about 15 weeks, at least about 16 weeks, at least about 17 weeks, at least about 18 weeks, at least about 19 weeks, at least about 20 weeks, at least about 21 weeks, at least about 22 weeks, at least about 23 weeks, at least about 24 weeks, at least about 1 year, or at least 2 years. In some embodiments, a pharmaceutical composition comprising a pharma- ceutically acceptable carrier and about 10 mg (free base equivalent) of ampleloxetine or a pharma- ceutically acceptable salt thereof may be administered over the aforementioned time periods. The examples provided herein illustrate some embodiments of such administration over extended periods.

[0102] In some embodiments, a pharmaceutical composition comprising a pharma- ceutically acceptable carrier and about 10 mg (free base equivalent) of ampleloxetine or a pharma- ceutically acceptable salt thereof may be administered to an MSA patient or subject for at least about 8 weeks to treat nOH. Administration may be for at least about 9 weeks, about 10 weeks, about 11 weeks, about 12 weeks, about 13 weeks, about 14 weeks, about 15 weeks, about 16 weeks, about 17 weeks, about 18 weeks, about 19 weeks, about 20 weeks, about 21 weeks, about 22 weeks, about 23 weeks, or about 24 weeks. In some embodiments, administration may be for longer periods, such as 6, 12, 18, and 24 months or more.

[0103] Such administration of ampleloxetine may result in an improvement in nOH symptoms, which may be evidenced by a reduction from baseline in one or more of the following: Orthostatic Hypotension Symptom Assessment (OHSA) items 1, 2, 3, 4, 5, 6, and composite score, Orthostatic Hypotension Daily Activities Scale (OHDAS) items 1, 2, 3, 4, and composite score, Orthostatic Hypotension Questionnaire (OHQ) composite score, and EQ-5D-5L Health Questionnaire scale score. In some embodiments, the reduction in OHSA (composite or any individual item), OHDAS (composite or any individual item), or OHQ composite score may be at least 1, 2, 3, or 4 points. Administration of ampleloxetine may result in an increase in sitting or standing systolic blood pressure (e.g., greater than about 20 mmHg), which may exceed the threshold for inducing fainting. In some embodiments, administration may result in improvement in one or more of Patient Global Impression of Change (PGI-C), Patient Global Impression of Severity (PGI-S), Hospital Anxiety and Depression Scale (HADS) (including anxiety total score), Columbia-Suicide Severity Scale (C-SSRS), UMSARS scale, COMPASS-31, Non-Motor Symptom Scale (NMSS), Family Caregiver Burden Scale-Short Version (BSFC-s), incidence of falls, and time spent in standing position (e.g., 3 minutes or more).

[0104] Patients or subjects for administration of ampleloxetine may be selected from different groups of patients / subjects and may show efficacy (as evidenced by the parameters described above) in a wide variety of patients / subjects. For example, the patient or subject may have one or more of the following characteristics: male or female; at least 30 years old; less than 65 years old, at least 65 years old. Prior to treatment, the subject or patient may have a Unified Multiple System Atrophy Rating Scale (UMSARS) part IV of less than 4; a UMSARS part IV of 4; a UMSARS part IV of greater than 4; a sustained reduction in BP of ≥20 mmHg (systolic) or ≥10 mmHg (diastolic) within 3 minutes of tilting ≥60° up from supine as determined by tilt-table testing; an OHSA item 1 of at least 3, 4, 5, 6, or 7; a diagnosis of possible or probable MSA, Parkinson's disease subtype (MSA-P) or cerebellar subtype (MSA-C); and / or a plasma NE level of >100 pg / mL after 30 minutes in a sitting position. In some embodiments, the subject or patient may have had nOH less than about 0.5, 1, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 2, or 3 years prior to treatment. In some embodiments, the subject or patient may have developed nOH at least about 0.5, 1, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 2, or 3 years prior to treatment. In some embodiments, the subject or patient may have received an MSA diagnosis at least about 0.5, 1, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 2, or 3 years prior to treatment. In some embodiments, the subject or patient may have received an MSA diagnosis at least about 0.5, 1, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 2, or 3 years prior to treatment. In some embodiments, the subject or patient may have an OHSA composite score of less than 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.3, 4.5, 4,7, 5, 5.3, 5.5, 5.7, 6, 6.3, 6.5, 6.7, 7, 7.5, 8, 8.5, 9, 9.5, or 10 prior to treatment.In some embodiments, the subject or patient may have a pre-treatment OHSA composite score of at least 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.3, 4.5, 4,7, 5, 5.3, 5.5, 5.7, 6, 6.3, 6.5, 6.7, 7, 7.5, 8, 8.5, 9, 9.5, or 10. In some embodiments, the subject or patient may have an OHSA item 1, 2, 3, 4, 5, or 6 score of at least but less than 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.3, 4.5, 4,7, 5, 5.3, 5.5, 5.7, 6, 6.3, 6.5, 6.7, 7, 7.5, 8, 8.5, 9, 9.5, or 10 prior to treatment. In some embodiments, the subject or patient may have an OHSA item 1, 2, 3, 4, 5, or 6 score prior to treatment of at least 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.3, 4.5, 4,7, 5, 5.3, 5.5, 5.7, 6, 6.3, 6.5, 6.7, 7, 7.5, 8, 8.5, 9, 9.5, or 10. In some embodiments, the subject or patient may have an OHDAS composite score prior to treatment of less than 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.3, 4.5, 4,7, 5, 5.3, 5.5, 5.7, 6, 6.3, 6.5, 6.7, 7, 7.5, 8, 8.5, 9, 9.5, or 10. In some embodiments, the subject or patient may have, prior to treatment, an OHDAS composite score of at least 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.3, 4.5, 4,7, 5, 5.3, 5.5, 5.7, 6, 6.3, 6.5, 6.7, 7, 7.5, 8, 8.5, 9, 9.5, or 10. In some embodiments, the subject or patient may have, prior to treatment, an OHDAS item 1, 2, 3, or 4 score of at least but less than 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.3, 4.5, 4,7, 5, 5.3, 5.5, 5.7, 6, 6.3, 6.5, 6.7, 7, 7.5, 8, 8.5, 9, 9.5, or 10. In some embodiments, a subject or patient may have an OHDAS item 1, 2, 3, or 4 score of at least 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.3, 4.5, 4,7, 5, 5.3, 5.5, 5.7, 6, 6.3, 6.5, 6.7, 7, 7.5, 8, 8.5, 9, 9.5, or 10 prior to treatment.In some embodiments, the subject or patient may have an OHQ composite score prior to treatment of less than 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.3, 4.5, 4,7, 5, 5.3, 5.5, 5.7, 6, 6.3, 6.5, 6.7, 7, 7.5, 8, 8.5, 9, 9.5, or 10. In some embodiments, the subject or patient may have an OHQ composite score prior to treatment of at least 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.3, 4.5, 4,7, 5, 5.3, 5.5, 5.7, 6, 6.3, 6.5, 6.7, 7, 7.5, 8, 8.5, 9, 9.5, or 10. In some embodiments, the subject or patient may have an Orthostatic Hypotension Scale (OSHA) composite score of 5 or greater prior to administration, and / or an OSHA Item 1 score of 7 or greater prior to administration.

[0105] In some embodiments, the subject or patient may not have a systemic disease that causes autonomic neuropathy, including but not limited to amyloidosis and autoimmune neuropathies, and / or diabetes mellitus (DM). In some embodiments, the subject may not have a known intolerance to other NRIs or SNRIs. The subject or patient should not use concomitant antihypertensive drugs for the treatment of essential hypertension. In some embodiments, the subject or patient should not use strong CYP1A2 inhibitors or inducers, midodrine, or droxidopa concomitantly. In some embodiments, the subject or patient may have no known or suspected alcohol or drug abuse, clinically unstable coronary artery disease, or may have a history of a major cardiovascular event (e.g., myocardial infarction), significant uncontrolled cardiac arrhythmia, complete heart block in the past 6 months, significant QTc prolongation (>450 ms in men and >470 ms in women), untreated angle-closure glaucoma or treated angle-closure glaucoma (Montreal Cognitive Assessment (MoCA) <21 in the opinion of an ophthalmologist), congestive heart failure ( New York Heart Association [NYHA] class 3 or 4), any malignancy other than intraepithelial neoplasia or basal cell carcinoma of the cervix within the past 2 years prior to treatment, known gastrointestinal (GI) condition, psychiatric, neurological, or behavioral disorder that may interfere with cognitive performance, clinically significant abnormal laboratory test(s) (e.g., alanine aminotransferase [ALT] or aspartate aminotransferase [AST] ≥ 3.0 × upper limit of normal [ULN]; blood bilirubin [total] ≥ 3.0 × ULN; estimated glomerular filtration rate (eGFR) < 30 mL / min / 1.73 m 2 The subjects may not have had any abnormal laboratory values ​​(e.g., pulmonary function, pulmonary circulation, or any abnormal laboratory values ​​that may interfere with the safety of the subject).

[0106] In some embodiments, subjects or patients who respond to or can be treated with ampleroxetine may be first identified before long-term administration (e.g., 8 weeks or more) of ampleroxetine for more efficient and effective treatment. For example, the subject or patient may be administered a pharmaceutical composition comprising a pharma- ceutically acceptable carrier and about 10 mg of ampleroxetine for at least 8 weeks. If the subject or patient responds to ampleroxetine, the patient or subject may show improvement in nOH symptoms, which may be evidenced by a reduction from baseline in one or more of the following: Orthostatic Hypotensive Symptom Assessment (OHSA) items 1, 2, 3, 4, 5, 6, and composite score, Orthostatic Hypotensive Daily Activities Scale (OHDAS) items 1, 2, 3, 4, and composite score, Orthostatic Hypotensive Questionnaire (OHQ) composite score. In some embodiments, the reduction in OHSA (composite or any individual item), OHDAS (composite or any individual item), or OHQ composite score may be at least 1, 2, 3, or 4 points. For example, administration for at least 8 weeks may result in a reduction of at least 1 or 2 points in the Orthostatic Hypotension Symptom Assessment (OHSA) Question 1 score ("Feeling dizzy, lightheaded, faint, or about to black out"). If it is determined that the subject or patient responds to ampleloxetine, treatment may be continued and a pharmaceutical composition comprising ampleloxetine may be administered to the subject or patient for an extended period of time (at least 8 weeks, 9 weeks, 10 weeks, 11 weeks, 12 weeks, 13 weeks, 14 weeks, 15 weeks, 16 weeks, 17 weeks, 18 weeks, 19 weeks, 20 weeks, 21 weeks, 22 weeks, 23 weeks, 24 weeks, 1 year, 2 years, or 3 years). If it is determined that the patient subject does not respond to ampleloxetine, treatment may not be continued and the pharmaceutical composition is no longer administered.

[0107] Embodiment Embodiment 1. A method for treating symptomatic neurogenic orthostatic hypotension in a subject with multiple system atrophy, the method comprising administering to the subject daily for at least about 22 weeks a pharmaceutical composition comprising a pharma- ceutical carrier and about 10 mg (free base equivalent) of ampleloxetine or a pharma- ceutical acceptable salt thereof; (a) in the absence of treatment with the pharmaceutical composition, the subject being treated experiences symptoms of neurogenic orthostatic hypotension as determined using the Orthostatic Hypotension Assessment Scale (OHSA); (b) the method, wherein daily administration of the pharmaceutical composition to a subject for at least about 22 weeks results in a measurable reduction in both (i) the subject's symptoms of dizziness, lightheadedness, feeling faint, or feeling like they may black out, as determined using the subject's OHSA Question 1 score, and (ii) the subject's overall impression of the severity of their symptoms, as determined using the subject's OHSA Composite score.

[0108] Embodiment 2. The method of embodiment 1, wherein administration of the pharmaceutical composition daily for at least about 22 weeks further results in a measurable reduction in the subject's Orthostatic Hypotension Daily Activities Scale (OHDAS) composite score.

[0109] Embodiment 3. The method of embodiment 1 or 2, wherein administration of the pharmaceutical composition daily for at least about 22 weeks further results in a measurable increase in the subject's systolic blood pressure upon standing for 3 minutes.

[0110] Embodiment 4. The method of any one of embodiments 1-3, wherein the pharmaceutical composition is orally administered to the subject.

[0111] Embodiment 5. The method of any one of embodiments 1-4, wherein the pharmaceutical composition is administered to the subject once daily.

[0112] Embodiment 6. The method of any one of embodiments 1-5, wherein the subject has a supine plasma norepinephrine level of the pharmaceutical composition of less than about 200 pg / mL prior to administration.

[0113] Embodiment 7. The method of any one of embodiments 1 to 6, wherein the subject has a supine plasma norepinephrine level of less than about 350 pg / mL prior to treatment with the pharmaceutical composition.

[0114] Embodiment 8. The method of any one of embodiments 1-7, wherein the supine plasma norepinephrine level in the subject is greater than about 500 pg / mL after about 8 weeks of treatment with the pharmaceutical composition.

[0115] Embodiment 9. The method of any one of embodiments 1-8, wherein ampleloxetine is administered as the hydrochloride salt.

[0116] Embodiment 10. The method of any one of embodiments 1-9, wherein amploxetine is administered as a crystalline hydrochloride salt characterized by an X-ray powder diffraction pattern comprising diffraction peaks at 2θ values ​​of 4.44±0.2, 10.22±0.2, and 21.78±0.2.

[0117] Embodiment 11. The method of embodiment 10, wherein the crystalline amplexetine hydrochloride is further characterized by having one or more additional diffraction peaks at 2θ values ​​selected from 8.11±0.2, 13.18±0.2, 16.06±0.2, 17.16±0.2, 18.38±0.2, 23.76±0.2, 26.32±0.2, 27.24±0.2, 29.60±0.2, and 31.94±0.2.

[0118] Embodiment 12. The method of any one of embodiments 1-11, wherein amploxetine is administered as a crystalline hydrochloride salt characterized by a differential scanning calorimetry trace having a melting point of about 197±2°C.

[0119] Embodiment 13. The method of any one of embodiments 1-12, wherein the pharma- ceutically acceptable carrier comprises microcrystalline cellulose.

[0120] Embodiment 14. The method of any one of embodiments 1 to 12, wherein the pharma- ceutically acceptable carrier comprises lactose.

[0121] Embodiment 15. The method of any one of embodiments 1 to 12, wherein the pharma- ceutically acceptable carrier comprises magnesium stearate.

[0122] Embodiment 16 The method of any one of embodiments 1-12, wherein the pharma- ceutically acceptable carrier comprises microcrystalline cellulose, lactose, and magnesium stearate.

[0123] Embodiment 17. A method for reducing the magnitude of decline in quality of life in a subject with multiple system atrophy, the method comprising administering to the subject daily for at least about 22 weeks a pharmaceutical composition comprising a pharma- ceutical carrier and about 10 mg (free base equivalent) of ampleloxetine or a pharma- ceutical acceptable salt thereof, wherein the magnitude of decline in the subject's quality of life is measured using the subject's self-rated health rating on a vertical analog scale.

[0124] Embodiment 18. The method of embodiment 17, wherein the vertical analog scale includes endpoints labeled "Best Imaginable Health" and "Worst Imaginable Health."

[0125] Embodiment 19. The method of embodiment 17 or 18, wherein the vertical analog scale is part of the EQ-5D-5L questionnaire.

[0126] Embodiment 20. The method of any one of embodiments 17-19, wherein the pharmaceutical composition is orally administered to the subject.

[0127] Embodiment 21. The method of any one of embodiments 17-20, wherein the pharmaceutical composition is administered to the subject once a day.

[0128] Embodiment 22. The method of any one of embodiments 17-21, wherein the magnitude of the decrease in the subject's quality of life increases when the pharmaceutical composition is not administered to the subject.

[0129] Embodiment 23. The method of any one of embodiments 17-22, wherein the subject being treated experiences symptoms of neurogenic orthostatic hypotension in the absence of treatment with the pharmaceutical composition, as determined using the Orthostatic Hypotension Scale (OHSA), and wherein daily administration of the pharmaceutical composition to the subject for at least about 22 weeks results in a measurable reduction in the subject's symptoms of dizziness, lightheadedness, feeling faint, or feeling like they may black out, as determined using the subject's OHSA Question 1 score.

[0130] Embodiment 24. The method of any one of embodiments 17-23, wherein the subject being treated experiences symptoms of neurogenic orthostatic hypotension in the absence of treatment with the pharmaceutical composition, as determined using the Orthostatic Hypotension Scale (OHSA), and wherein daily administration of the pharmaceutical composition to the subject for at least about 22 weeks results in a measurable reduction in the subject's global impression of the severity of the symptoms, as determined using the subject's OHSA composite score.

[0131] Embodiment 25. The method of any one of embodiments 17-24, wherein the subject being treated experiences symptoms of neurogenic orthostatic hypotension in the absence of treatment with the pharmaceutical composition as determined using the Orthostatic Hypotension Assessment Scale (OHSA), and wherein daily administration of the pharmaceutical composition for at least about 22 weeks further results in a measurable reduction in the subject's Orthostatic Hypotension Daily Activities Scale (OHDAS) composite score.

[0132] Embodiment 26 The method of any one of embodiments 17-26, wherein administration of the pharmaceutical composition daily for at least about 22 weeks further results in a measurable increase in the subject's systolic blood pressure upon standing for 3 minutes.

[0133] Embodiment 27. The method of any one of embodiments 17-26, wherein the subject has a supine plasma norepinephrine level of the pharmaceutical composition of less than about 200 pg / mL prior to administration.

[0134] Embodiment 28 The method of any one of embodiments 17-30, wherein the subject has a supine plasma norepinephrine level of less than about 350 pg / mL prior to treatment with the pharmaceutical composition.

[0135] Embodiment 29. The method of any one of embodiments 17-28, wherein the supine plasma norepinephrine level in the subject is greater than about 500 pg / mL after about 8 weeks of treatment with the pharmaceutical composition.

[0136] Embodiment 30. The method of any one of embodiments 17-29, wherein ampleloxetine is administered as the hydrochloride salt.

[0137] Embodiment 31. The method of any one of embodiments 17 to 30, wherein amploxetine is administered as a crystalline hydrochloride salt characterized by an X-ray powder diffraction pattern comprising diffraction peaks at 2θ values ​​of 4.44±0.2, 10.22±0.2, and 21.78±0.2.

[0138] Embodiment 32. The method of embodiment 31, wherein the crystalline amplexetine hydrochloride is further characterized by having one or more additional diffraction peaks at 2θ values ​​selected from 8.11±0.2, 13.18±0.2, 16.06±0.2, 17.16±0.2, 18.38±0.2, 23.76±0.2, 26.32±0.2, 27.24±0.2, 29.60±0.2, and 31.94±0.2.

[0139] Embodiment 33. The method of any one of embodiments 17-32, wherein ampleloxetine is administered as a crystalline hydrochloride salt characterized by a differential scanning calorimetry trace having a melting point of about 197±2°C.

[0140] Embodiment 34. The method of any one of embodiments 17-33, wherein the pharma- ceutically acceptable carrier comprises microcrystalline cellulose.

[0141] Embodiment 35. The method of any one of embodiments 17-33, wherein the pharma- ceutically acceptable carrier comprises lactose.

[0142] Embodiment 36. The method of any one of embodiments 17-33, wherein the pharma- ceutically acceptable carrier comprises magnesium stearate.

[0143] Embodiment 37. The method of any one of embodiments 17-33, wherein the pharma- ceutically acceptable carrier comprises microcrystalline cellulose, lactose, and magnesium stearate.

[0144] Embodiment 38. A method for increasing supine plasma norepinephrine levels in a subject having multiple system atrophy, the method comprising administering to the subject daily for at least about 8 weeks a pharmaceutical composition comprising a pharma- ceutical acceptable carrier and about 10 mg (free base equivalent) of amproxetine or a pharma- ceutical acceptable salt thereof, wherein the supine plasma norepinephrine level in the subject is greater than about 500 pg / mL after about 8 weeks of treatment with the pharmaceutical composition.

[0145] Embodiment 39 The method of embodiment 38, wherein the pharmaceutical composition is administered orally to the subject.

[0146] Embodiment 40 The method of embodiment 37 or 39, wherein the pharmaceutical composition is administered to the subject once a day.

[0147] Embodiment 41 The method of any one of embodiments 37-40, wherein the subject has a supine plasma norepinephrine level of the pharmaceutical composition of less than about 200 pg / mL prior to administration.

[0148] Embodiment 42. The method of any one of embodiments 37-41, wherein the subject has a supine plasma norepinephrine level of the pharmaceutical composition of less than about 350 pg / mL prior to administration.

[0149] Embodiment 43 The method of any one of embodiments 37 or 42, wherein ampleloxetine is administered as the hydrochloride salt.

[0150] Embodiment 44. The method of any one of embodiments 37 to 43, wherein amploxetine is administered as a crystalline hydrochloride salt characterized by an X-ray powder diffraction pattern comprising diffraction peaks at 2θ values ​​of 4.44±0.2, 10.22±0.2, and 21.78±0.2.

[0151] Embodiment 45. The method of embodiment 44, wherein the crystalline amplexetine hydrochloride is further characterized by having one or more additional diffraction peaks at 2θ values ​​selected from 8.11±0.2, 13.18±0.2, 16.06±0.2, 17.16±0.2, 18.38±0.2, 23.76±0.2, 26.32±0.2, 27.24±0.2, 29.60±0.2, and 31.94±0.2.

[0152] Embodiment 46. The method of any one of embodiments 37-45, wherein ampleloxetine is administered as a crystalline hydrochloride salt characterized by a differential scanning calorimetry trace having a melting point of about 197±2°C.

[0153] Embodiment 47. The method of any one of embodiments 37-46, wherein the pharma- ceutically acceptable carrier comprises microcrystalline cellulose.

[0154] Embodiment 48. The method of any one of embodiments 37-46, wherein the pharma- ceutically acceptable carrier comprises lactose.

[0155] Embodiment 49. The method of any one of embodiments 37-46, wherein the pharma- ceutically acceptable carrier comprises magnesium stearate.

[0156] Embodiment 50. The method of any one of embodiments 37-46, wherein the pharma- ceutically acceptable carrier comprises microcrystalline cellulose, lactose, and magnesium stearate. EXAMPLES

[0157] The following examples are provided to illustrate various aspects and embodiments of the present disclosure and are not intended to limit the scope of the disclosure, unless specifically indicated.

[0158] All reagents, starting materials and solvents used in the examples described below were purchased from commercial suppliers (e.g., Sigma-Aldrich (St. Louis, MO) and its affiliates) and used without further purification unless otherwise indicated.

[0159] The following abbreviations have the following meanings unless otherwise indicated: [Table 2-1] [Table 2-2]

[0160] Other abbreviations used but not defined herein have their ordinary meaning as understood by one of ordinary skill in the art to which they pertain.

[0161] Example 1 Radioligand binding and neurotransmitter uptake assays The in vitro pharmacology of ampleloxetine at human recombinant and rat native monoamine transporters was characterized as described in Smith et al., Inter. J. Neuropsychopharmcol. (2015) 1-11, and Tsuruda et al., J. Pharmacol. Toxicol. Meth. (2010) 61:192-204. See also, for example, U.S. Patent Nos. 8,304,432 B2 and 8,304,433 B2. Radioligands were used commercially (Perkin Elmer LifeSciences or GE Healthcare Life Sciences).

[0162] Briefly, membranes prepared from HEK293 (human embryonic kidney 293) or CHO-K1 (Chinese hamster ovary-K1) cells stably transfected with human recombinant SERT (HEK293-hSERT), NET (HEK293-hNET), or DAT (CHO-K1-hDAT) were incubated with 4-[2-(2,4,6-trifluorophenoxymethyl)phenyl]piperidine and, for SERT, [ 3 H]-citalopram (1.0 nM) for NETs, ​​and [ 3 H]-nisoxetine (2.0 nM) and for DAT, [ 3 The rat cortical membrane preparations were incubated for 1 h at 22° C. in the absence or presence of [H]-WIN35428 (3.0 nM). 3 H]-citalopram (2.0 nM) or [ 3 H]-nisoxetine (4.0 nM) for 1 h at 22° C. In the neurotransmitter uptake assay, HEK293-hSERT, hNET or hDAT cells were pre-incubated in 7.5 mM HEPES, 12.5 mM Tris-HCl, 2.2 mM sodium phosphate, 120 mM NaCl, 5 mM KCl, 0.4 mM MgCl2, 7.5 mM glucose, 1.7 mM CaCl2, 250 μM ascorbic acid, 150 μM pargyline, 0.025% BSA, pH 7.4, in the absence or presence of ampleloxetine for 30 min at 37° C., and then incubated with [ 3 H]-5-HT (20 nM), 3 H]-NE (40 nM), or [ 3 Rat cortical synaptosomes were incubated with [H]-DA (100 nM) for 10 min. 3 H]-5-HT or [ 3 H]-NE for 6 min, and striatal synaptosomes were incubated with [ 3The cells were incubated with [H]-DA for 6 min. The binding and uptake assays were terminated by rapid filtration and radioactivity was determined by liquid scintillation spectroscopy. 3 H]-neurotransmitter concentrations were determined by their respective K m Significantly lower than pIC 50 is approximately the functional pK i The selectivity for NET (rounded to one significant figure) was determined as follows: Selectivity=10 (NETのpKi又はpIC50-SERT又はDATのpKi又はpIC50)。

[0163] The in vitro pharmacological profile of ampleloxetine was similar at human and rodent monoamine transporters, as shown in Table 1. [Table 3]

[0164] The data in Table 2 show that amploxetine is a potent inhibitor of NET and SERT, but not of DAT, and the inhibition of NET was 4-fold more potent than that of SERT. Similarly, amploxetine inhibited the [ 3 H]-NE and [ 3 Ampleroxetine is a potent inhibitor of both [H]-5-HT uptake and NET over SERT, with apparent functional selectivity (10-fold) for NET over SERT, similar to that observed with the human transporter. Consistent with the functional inhibition studies, ampleroxetine showed high affinity for binding to human NET and SERT, but not DAT (Table 2). Apparent binding affinity values ​​for rat native NET and SERT in membranes prepared from rat cortex were similar (overlapping confidence intervals) to the corresponding values ​​for the human transporter, consistent with a lack of species dependency (Table 2).

[0165] Example 2 Ex vivo transporter occupancy studies Adult male Sprague Dawley rats (Charles River) were housed under controlled laboratory conditions (temperature of 21 ± 1 °C) with a 12:12 h light:dark cycle. Upon arrival at the facility, animals were allowed free access to food and water and were allowed to habituate to the holding room for at least 48 h. Animals were fasted for 15-18 h prior to dosing but had free access to water.

[0166] Rats (n=6 / time point / dose level) were given a single oral dose of 4-[2-(2,4,6-trifluorophenoxymethyl)phenyl]piperidine (0.3, 1, 5, 10, 30 and 60 mg / kg) and euthanized by decapitation at the specified time points post-dose (0.5, 2, 4, 6 and 8 hours for the 5 mg / kg dose level; 2 hours for the 0.3, 1, 10, 30 and 60 mg / kg dose levels). Spinal cords were dissected from the same animals for ex vivo transporter occupancy and PK assessment. Spinal cords were harvested by hydraulic extrusion using phosphate buffered saline and lumbar sections were dissected and frozen on dry ice. The remaining spinal cord sections were collected and homogenized in water (25% w / w) for PK analysis. All samples were stored at -80°C until analysis.

[0167] To determine NET and SERT occupancy in rat spinal cord, a kinetic radioligand binding assay was used as previously described in Bourdet et al., J. Pharm. Exp. Ther. (2012) 341:137-145. PK / PD parameters were estimated by a compartmental modeling approach (WinNonlin version 5.0.1, Pharsight Corporation). One- and two-compartment PK models with first-order absorption and elimination were evaluated. A one-compartment model was selected. The pharmacodynamic model included an effect compartment E directly connected to a central PK compartment. max The models used were WinNonlin PK model 3, PD model 101. Model selection was based on visual inspection of fit, Akaike information criterion, and weighted sum of squared error using the Gauss-Newton minimum method. The following parameters were estimated: k01(time-1 ): First order absorption rate constant. V / F (L / kg): Volume of the central compartment divided by oral bioavailability k10(hours -1 ): Efflux rate constant from the central compartment E max (Occupancy%): Maximum SERT or NET occupation in the spinal cord EC 50 (ng / mL): Plasma 4-[2-(2,4,6-trifluorophenoxymethyl)phenyl]piperidine concentration with 50% SERT or NET occupancy k eo (time -1 ): First-order equilibrium rate constant between the central pharmacokinetic compartment and the pharmacodynamic effect compartment PK and PD parameter estimates were derived from effect compartment PK / PD analyses for NET and SERT occupancy shown in Table 2. [Table 4]

[0168] As shown in Table 2, the EC estimated for occupancy 50 were 11.7 ng / mL for NET and 50.8 ng / mL for SERT in rat spinal cord. Accounting for species differences in plasma protein binding (90.2% and 79.1% in rats and humans, respectively), the estimated human plasma EC 50 Values ​​were 5.5 ng / mL for NET and 23.9 ng / mL for SERT.

[0169] Example 3 Cardiovascular model in anesthetized rats These studies were performed to evaluate the effects of a single dose of ampleloxetine on heart rate (HR) and mean arterial pressure (MAP) in anesthetized rats. This cardiovascular model was used to evaluate the intrinsic effects of ampleloxetine on HR and inhibition of the tyramine pressor response as surrogate measures reflecting its ability to inhibit the norepinephrine transporter in the periphery.

[0170] A. Experimental Design Normotensive male Sprague-Dawley rats weighing 250-350 g were anesthetized by intraperitoneal injection (IP) of thiobutabarbital (Inactin). All animals were maintained under full anesthesia (i.e., no response to the toe pinch test) throughout surgery and the study period. The right common carotid artery and jugular vein were isolated and catheterized. The trachea was intubated to keep the airway open throughout the study. After completion of surgery, the arterial catheter was connected to a pressure transducer and baseline blood pressure [systolic (SBP), mean arterial (MAP) and diastolic (DBP)] and heart rate (HR) were recorded using a Notocord-HEM data acquisition system. After at least 60 minutes of baseline (i.e., the last 10 minutes were stable), vehicle (10% Tween® 20, 2 mL / kg, IP) was administered and monitored for any possible effects for at least 10 minutes. After this period, rats were injected with either vehicle or ampleloxetine (0.01-30 mg / mL, 2 mL / kg, IP) and changes in MAP and HR were monitored for 25 min. Rats were then challenged intravenously via the jugular catheter with non-cumulative bolus doses of tyramine (0.03, 0.1, 0.3, and 1 mg / kg, 1 mL / kg, IV) given at 5 min intervals. Data acquisition continued for an additional 10 min after the last dose of tyramine, after which the experiment was terminated. In separate groups of animals, blood was collected to assess the concentration of ampleloxetine in plasma 15 and 60 min after dosing. Free plasma concentrations obtained from 15 min were used to construct concentration-response curves (CRC) for MAP and HR, and concentrations from 60 min were used for the tyramine CRC. Animals were euthanized by carbon dioxide asphyxiation followed by thoracotomy.

[0171] B. Data Analysis Intrinsic hemodynamic effects were reported as the maximum change in MAP or HR induced by ampleloxetine before tyramine challenge. Inhibition of tyramine effects was normalized to the response to a 1 mg / kg dose of tyramine in the vehicle control group. Concentration response curves (CRCs) of changes in MAP, HR and inhibition of tyramine response were analyzed through iterative curve fitting to a logistic equation using Prism 5.00™ (GraphPad, Inc.). The equation used was as follows: Y=(Bottom+Top-Bottom) / (1+10^((LogEC50-X)*HillSlope)) where X is the log of the dose and Y is the response, which starts at Bottom (constrained to 0 for all) and rises sigmoidally to Top. If the change in MAP or HR decreased at the higher dose(s), a more accurate estimate of Top (i.e., maximum efficacy) was obtained by carrying over the maximum effect that occurred at the lower dose to all subsequent higher doses. For tyramine CRC, TOP was constrained to 100. The potency of the pressor effect was calculated as MAP PC 10 The potency of the HR effect was reported as the HR PC, the free plasma concentration that produced a change in HR of 25 bpm. 25 Finally, the potency of inhibiting the effect of tyramine was reported as the Tyr EC 50 reported as.

[0172] Inhibitory potency (pIC) obtained by measuring the inhibition of labeled 5-HT uptake by the rat serotonin transporter (rSERT) in rat cortical synaptosomes 50 value) into this expression: Using Y=(10^(-x))×(10^9), we get IC 50 converted to a value.

[0173] C. Results Ampleroxetine (0.01-30 mg / kg, IP) dose-dependently increased MAP and HR in anesthetized rats. When plotted against the corresponding free plasma concentration for each dose, the estimated MAP and HR potencies were 101.4 nM (MAP EC 10 ) and 8.6 nM (HR EC 25 ). Maximum changes in MAP and HR were 13.2 (4.4-22.1) mmHg and 28.1 (22.4-33.7) bpm, respectively. Ampleroxetine also inhibited the tyramine-induced increase in SBP. The estimated potency of ampleroxetine, expressed as % inhibition of the response to 1 mg / kg intravenously administered tyramine, was 0.86 nM.

[0174] D. Conclusion In a cardiovascular model in anesthetized rats, ampleloxetine produced a strong inhibition of the tyramine pressor response and tachycardia consistent with inhibition of peripheral NETs.

[0175] Example 4 Preparation of oral administration solutions Oral dosing solutions of ampleroxetine hydrochloride were prepared in two steps: first, a 3 mg / mL aqueous stock solution was prepared, and then oral solutions in filtered apple juice with various dose strengths were prepared prior to dosing.

[0176] A. Preparation of Stock Solutions Ampleroxetine hydrochloride (500 mg, 89.9% purity) was added to a 250 mL clear glass bottle. Sterile water for injection (150 mL) was added and the bottle was capped. The bottle was gently swirled in a circular motion until no solid material was observed (approximately 20 minutes). The bottle may also be sonicated if necessary. The bottle was labeled and the stock solution (3 mg / mL) was used within 2 hours or stored in a refrigerator at 2-8°C until use. Any stock solution not used within 6 days of initial preparation was discarded.

[0177] B. Preparation of Oral Dosing Solutions Oral dosing solutions having seven different dose strengths were prepared for use in either Part A or Part B of the clinical trial. The dose strengths prepared and the amounts used to prepare each dose strength were as shown in Tables 3 and 4. [Table 5] [Table 6]

[0178] To prepare the oral dosing solution, the stock solution (3 mg / mL) was removed from the refrigerator and visually checked for any precipitation. If precipitation was present, the stock solution was reprepared.

[0179] Apple juice (at least 40 mL, Mott's 100% Original Apple Juice) was drawn into a 50 mL syringe and a syringe filter (25 mm PVDF Syringe Filter, 0.2 μm, Pall Life Sciences) was attached to the syringe. The apple juice was filtered through the syringe filter, discarding the first 3 mL and collecting the remaining apple juice in a 125 mL amber bottle.

[0180] An amount of stock solution (3 mg / mL) (stock volume) shown in Table 3 or 4 was then added to a new 125 mL amber bottle, and a corresponding amount of filtered apple juice (apple juice volume) shown in Table 3 or 4 was added to the bottle. The bottle was capped and the contents mixed by swirling in a circular motion for more than 2 minutes. The resulting solution was stored at ambient room temperature for up to 18 hours before administration to subjects. A 10 mL aliquot of the oral solution was transferred to a new 125 mL amber bottle prior to administration to subjects.

[0181] Example 5 Preparation of oral tablets for Phase 3 trials Microcrystalline cellulose (35.32 kg; AVICEL Microcrystalline Cellulose, NF, Ph.Eur Type PH-112) and anhydrous lactose (21.00 kg; anhydrous 60M, NF, EP) were charged to a blending vessel and blended for 5 minutes at 20 rpm. The resulting mixture was transferred to a double polyethylene (PE) lined vessel ("Premix 1") and divided into two portions, one portion weighing approximately 10 kg ("Premix 1A") and the other portion containing the remainder ("Premix 1B"). Approximately one-half of Premix 1A was added to the jar, followed by ampleloxetinil monohydrochloride (3.382 kg; milled), then the second half of Premix 1A was added. The resulting mixture was blended for 10 minutes at 20 rpm and then transferred to a double PE lined vessel ("Active Premix 2"). Approximately one-half of Premix 1B was passed through a mill equipped with a 1.0 mm screen at 1000 rpm (800-1200 rpm) and extruded forward, followed by Active Premix 2, and then the second half of Premix 1B. The milled material was collected in a double PE lined container ("Milled Premix 3"). Milled Premix 3 was passed through a 40 mesh sieve and the sieved material was transferred to a blending bin and blended at 20 rpm for 25 minutes ("Premix 4"). Two tablespoons of Premix 4 were removed and hand mixed with magnesium stearate (300.0 g, NF) in a polyethylene bag. This mixture was then passed through a 40 mesh hand screen. The screened mixture was then returned to the blending bin and the entire mixture was blended at 20 rpm for 5 minutes ("Final Blend"). The final blend was compressed into 200 mg tablets using a tablet press and the tablets were passed through a deduster and metal detector. Acceptable tablets were collected in double PE lined containers.

[0182] Purified water (12.48 kg, USP) was added to a clean stainless steel solution preparation vessel and the mixer speed was adjusted to form a vortex. Polyvinyl alcohol-based film coating (3.12 kg; OPADRY II White 85G18490, Colorcon, Inc., West Point, PA) was added to the vortex in the mixing tank, the mixing speed was reduced to eliminate the vortex, and mixing was continued for at least 45 minutes or until the color was uniformly dispersed by visual observation. Gentle mixing was maintained before and during the coating process. The tablets prepared above were loaded into a coating pan and the pan speed was set at 6 rpm. The coating solution was pumped into the coating pan. The weight change of the coating solution was monitored while pumping the coating solution into the coating pan, and the addition of the coating solution was stopped when a 4% tablet dry weight gain based on the coating suspension utilization was achieved. The resulting white tablets contained approximately 10 mg of ampleloxetine (free base equivalent).

[0183] Example 6 A Phase 3, 4-Week Clinical Trial in Subjects with Symptomatic nOH This was a phase 3, randomized, double-blind, placebo-controlled, parallel-group, multicenter study to evaluate the efficacy, safety, and tolerability of ampleloxetine (administered as ampleloxetine hydrochloride) in subjects with primary autonomic failure (MSA, PD, or PAF) and symptomatic nOH after 4 weeks of treatment. Subjects participated in the study for approximately 10 weeks.

[0184] A total of 185 subjects completed the study. Subjects were randomized in a 1:1 ratio to either the ampleloxetine or placebo group, stratified by the subject's disease type (MSA, PD, or PAF). 98 subjects were randomized to the ampleloxetine group (8 subjects discontinued during the study) and 97 subjects were randomized to the placebo group (2 subjects discontinued during the study). 37% of subjects enrolled in the study had MSA.

[0185] A. Study Population The study enrolled adult subjects with confirmed symptomatic nOH due to MSA, PD, or PAF who met all inclusion criteria and no exclusion criteria defined in the study protocol.

[0186] 1. Selection Criteria Subjects who met the following criteria were eligible for study enrollment: (a) Subjects were male or female and at least 30 years of age. (b) For female subjects only: subjects were not pregnant or lactating. Women of childbearing potential were required to have a negative pregnancy test at screening. Women were considered of childbearing potential unless they were documented to be postmenopausal (amenorrhea for at least 2 years) or surgically sterile (bilateral tubal ligation or total hysterectomy). Female subjects were admitted to the study based on a negative urine pregnancy test. If the urine bHCG (beta human chorionic gonadotropin) test was positive, a serum bHCG test was performed. A negative pregnancy test was required for subjects to be eligible for the study. (c) During the study and for 30 days after receiving the last dose of investigational drug, females of childbearing potential or males of fatherhood potential agreed to use highly effective contraception (failure rate <1% when used consistently and correctly) or agreed to abstain from sexual intercourse. (d) Subject met diagnostic criteria for nOH as indicated by a sustained reduction in BP of ≥20 mmHg (systolic) or ≥10 mmHg (diastolic) within 3 minutes of tilting ≥60° up from supine position as determined by tilt-table testing. (e) Subject scored at least 4 on the Orthostatic Hypotension Symptom Assessment Question #1 at the randomization visit. (f) For subjects with PD only: Subjects received a diagnosis of PD according to the UK Parkinson's Disease Society (UKPDS) Brain Bank Criteria (1992). (g) For subjects with MSA only: Subjects received a diagnosis of possible or probable MSA, Parkinson's disease subtype (MSA-P) or cerebellar subtype (MSA-C) according to the Gilman criteria (2008). (h) For subjects with PAF only: Subject had documented autonomic dysreflexia, including a Valsalva maneuver performed within 24 months from the date of randomization. (i) Subjects had plasma NE levels >100 pg / mL after being in a sitting position for 30 minutes. (j) Subjects were willing and able to provide signed, dated, written informed consent prior to the initiation of any study-related procedures. (k) Subject was able to communicate well with the investigator and clinic staff, understand study expectations, and comply with study procedures, requirements, and restrictions.

[0187] 2. Exclusion criteria Subjects who met any of the following criteria were not eligible for study enrollment: (a) Subjects had a known systemic disease known to cause autonomic neuropathy, including, but not limited to, amyloidosis and autoimmune neuropathies. Subjects had diabetes mellitus and a diagnosis of PAF. Subjects with diabetes and either MSA or PD were evaluated on a case-by-case basis by a medical monitor and were considered ineligible unless they met all of the following criteria: i. Well-controlled type 2 DM on treatment with oral medications and diet alone; ii. HgbA1C ≤ 7.5% during screening or within 12 weeks prior to screening; iii. No clinically evident peripheral neuropathy (e.g., normal sensory testing of the peripheral extremities); iv. No known retinopathy (e.g., annual eye exam was sufficient); v. Absence of nephropathy (e.g., absence of albuminuria and GFR>60). (b) Subjects had known intolerance to other NRIs or serotonin norepinephrine reuptake inhibitors (SNRIs). (c) the subject was using concomitant antihypertensive medication for the treatment of essential hypertension. (d) Subject had used a strong CYP1A2 inhibitor or inducer within 7 days or 5 half-lives, whichever was longer, prior to randomization or required concomitant use until the follow-up visit. (e) Subject had changed the dose, frequency, or type of prescription medication for orthostatic hypotension within 7 days prior to the randomization visit (midodrine and droxidopa, if applicable, must have been tapered at least 7 days prior to randomization). (f) Subjects had known or suspected alcohol or drug abuse within the past 12 months (DSM-IV-TR® definitions for alcohol or drug abuse). (g) Subject had clinically unstable coronary artery disease or a major cardiovascular or neurological event within the past 6 months. (h) Subjects had used any monoamine oxidase inhibitor (MAO-I) within 14 days prior to randomization. (i) The subject had a history of untreated angle-closure glaucoma or treated angle-closure glaucoma which, in the opinion of an ophthalmologist, may place the subject at increased risk. (j) The subject had any significant uncontrolled cardiac arrhythmia. (k) Subjects had a Montreal Cognitive Assessment (MoCA) ≦23. (l) The subject was unable or unwilling to complete all protocol-specified procedures, including questionnaires. (m) The subject has had a myocardial infarction in the past 6 months or currently has unstable angina. (n) Subjects had known congestive heart failure (New York Heart Association [NYHA] class 3 or 4). (o) Subject had any malignancy other than intraepithelial or basal cell carcinoma of the cervix within the past 2 years prior to screening. (p) Subject has a known gastrointestinal (GI) condition that, in the investigator's judgment, may affect absorption of the investigational drug (e.g., ulcerative colitis, gastric bypass). (q) The subject has a psychiatric, neurological, or behavioral disorder that may interfere with the subject's ability to give informed consent or that may interfere with the conduct of the study. (r) Subjects were currently receiving or had received within 30 days of any investigational drug. Investigational drugs were defined as drugs approved by a non-regulatory agency (e.g., Food and Drug Administration). (s) Subjects have clinically significant abnormal laboratory test(s) (e.g., alanine aminotransferase [ALT] or aspartate aminotransferase [AST] > 3.0 × upper limit of normal [ULN]; blood bilirubin [total] > 1.5 × ULN; estimated glomerular filtration rate (eGFR) < 30 mL / min / 1.73 m 2 or any abnormal laboratory value that may interfere with the safety of the subject. (t) Subjects have demonstrated a lifetime history of suicidal ideation and / or behavior as outlined by the C-SSRS (Baseline / Screening Version) and should be assessed by an evaluator for suicide risk and suitability of the subject for inclusion in the study. (u) The subject had a comorbidity or condition that, in the opinion of the investigator, would confound or interfere with study participation or with the evaluation of the safety, tolerability, or pharmacokinetics of the investigational product. (v) The subject had known hypersensitivity to ampleloxetine (ampleroxetine hydrochloride) or any of the excipients in the formulation. (w) Subjects either (i) had confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection documented with a positive coronavirus disease 2019 [COVID-19] test result or (ii) were suspected of SARS-CoV-2 infection (having clinical features without documented laboratory results 2 weeks after resolution of symptoms and remaining asymptomatic through Day 1), or (iii) had close contact with a person with known (or suspected) SARS-CoV-2 infection and remaining asymptomatic through Day 1.

[0188] 3. Prohibitions and Restrictions The following were prohibited or restricted during study participation, as specified: (a) Subjects were required to discontinue concomitant strong CYP1A2 inhibitors and inducers for 7 days or 5 half-lives, whichever was longer, prior to randomization. This restriction applied to concomitant medications, herbal supplements (e.g., St. John's Wort), and usual dietary intake. (b) Prescription medications for OH other than fludrocortisone were banned. (c) alpha-blockers (e.g., prazosin, terazosin, doxazosin, silodosin, alfuzosin, tamsulosin) were prohibited. (d) Norepinephrine reuptake inhibitors (NRIs) (e.g., atomoxetine and reboxetine) and serotonin and norepinephrine reuptake inhibitors (SNRIs) (e.g., duloxetine, milnacipran, levomilnacipran, venlafaxine, desvenlafaxine) are prohibited. (e) Psychostimulants (e.g., amphetamine, dextroamphetamine, methylphenidate, pemoline) were prohibited. (f) Subjects were requested not to make any significant dietary changes during the study. Subjects were reminded to maintain adequate fluid intake during scheduled visits.

[0189] B. Test Product, Dose, and Route of Administration; Regimen; Duration of Treatment Subjects were randomized in a 1:1 ratio to receive either ampleloxetine (test product) or placebo (reference product) once daily until the end of the treatment period.

[0190] The test product was ampleloxetine supplied as 10 mg tablets in 35-count high-density polyethylene bottles that were labeled in a blinded manner (e.g., the bottle label of the test product was indistinguishable from the reference product except for the coded unique bottle number).

[0191] Ampleroxetine was administered orally with approximately 8 ounces of water each morning at approximately the same time, without regard to food.

[0192] Subjects randomized to receive ampleloxetine began taking the study drug on the morning of day 2 at a dose of 10 mg and continued to take this dose once daily until the end of the treatment period.

[0193] D. Reference products, doses, and routes of administration; regimens; duration of treatment The reference product was a placebo tablet supplied to match the test product in excipient content (excluding ampleloxetine), appearance, tablet number, and packaging (e.g., the bottle label of the reference product was indistinguishable from the test product except for a coded unique bottle number).

[0194] The placebo was administered orally with approximately 8 ounces of water at approximately the same time each morning, without regard to food.

[0195] Subjects randomized to receive placebo began taking the study drug on the morning of day 2 and continued to take the placebo once daily until the end of the treatment period.

[0196] E. Testing For the purposes of this study, symptomatic neurogenic orthostatic hypotension was defined as: (a) A sustained reduction in BP of ≥ 20 mmHg (systolic) or ≥ 10 mmHg (diastolic) within 3 minutes of standing or tilting upwards at a height of ≥ 60° from the supine position; and (b) a score of at least 4 on the Orthostatic Hypotension Symptom Assessment Question #1.

[0197] The study consisted of three periods: (i) a 4-week screening period, (ii) a 4-week randomized treatment period, and (iii) a 2-week follow-up period.

[0198] After signing the informed consent, subjects entered a screening period of up to 4 weeks to confirm eligibility. At the screening visit, which was conducted in the clinic for all subjects, subjects provided a comprehensive medical history of their diseases and treatments. The subjects' diseases were characterized and documented by the investigator. Subjects underwent evaluation of their physical status, including safety and laboratory evaluations. The presence of symptomatic nOH symptoms and reported sensations of dizziness, lightheadedness, fainting, or blacking out (OHSA#1) were confirmed by application of a tilt-table test. This tilt-table test served two purposes: (i) determination of systolic / diastolic BP (DBP) changes, and (ii) training subjects to recognize sensations associated with OHSA#1.

[0199] Eligible subjects were trained to accurately score the sensations of dizziness, lightheadedness, fainting, or blacking out as outlined by OHSA#1.

[0200] After the screening period, subjects proceeded to Visit 2 to further verify additional eligibility criteria prior to randomization. This visit included completion of the Orthostatic Hypotension Questionnaire (OHQ), where a minimum score of 4 was required on OHSA#1. Subjects who met all applicable inclusion criteria, including confirmation of relevant criteria by an independent Enrollment Steering Committee (ESC), and did not meet any of the applicable exclusion criteria, were randomized to receive either ampleloxetine or a matching placebo for the next 4 weeks.

[0201] After randomization and completion of study evaluations, subjects received a 10 mg dose of ampleloxetine (or matching placebo) once daily (QD) for the remainder of the double-blind treatment period.

[0202] Subjects were assessed weekly. Investigators were provided with a description of all assessments and detailed instructions for conducting subject assessments in clinic and remotely. These instructions were provided to ensure that the method and administration of each assessment was consistent across sites and subjects for both clinical and remote visits.

[0203] Subject discontinuation could occur at any time. Dose discontinuation criteria included meeting at least one of the following conditions: (a) A determination from the investigator that further administration of the investigational product may pose a safety concern to the subject. (b) sustained (for at least 4 hours) SBP ≥ 180 mmHg or diastolic BP (DBP) ≥ 110 mmHg after 3 minutes of standing or 5 minutes of sitting, or sustained (for at least 4 hours) SBP ≥ 180 mmHg or DBP ≥ 110 mmHg measured in the supine position (head / trunk approximately 30° above horizontal). (c) Intolerable AEs as determined by the investigator. (d) The subject becomes pregnant.

[0204] Dose reductions were not permitted at any time.

[0205] Safety assessments included physical examination, neurological examination, vital signs (temperature, HR, and BP), weight, ECG, safety laboratory tests (hematology, chemistry, and urinalysis), C-SSRS, and AEs. Safety was reviewed periodically by an independent data monitoring committee.

[0206] Subjects were asked not to make any significant dietary changes during the study. Subjects were reminded to maintain adequate fluid intake during scheduled visits.

[0207] Subjects who completed the 4-week double-blind treatment period were eligible to enroll in a separate follow-on study and continue to receive study drug. The final study visit for subjects who did not complete the 4-week double-blind treatment period or chose not to continue in the follow-on study was a follow-up visit (V7). This visit was completed 2 weeks from the date of last dose.

[0208] F. Test Objectives The primary objective of this study was to evaluate the efficacy of ampleloxetine compared to placebo at week 4 in subjects with multiple system atrophy (MSA), Parkinson's disease (PD), or pure autonomic failure (PAF) experiencing symptomatic neurogenic orthostatic hypotension (symptomatic nOH) as measured by change from baseline in Orthostatic Hypotension Symptom Assessment (OHSA) Question 1 (OHSA#1) score.

[0209] The secondary objectives of this study were to: (a) To assess the efficacy of ampleloxetine by symptom and activity assessment using the OHSA and Orthostatic Hypotension Daily Activities Scale (OHDAS). (b) To assess the efficacy of ampleloxetine using the Patient Global Impression of Change (PGI-C). (c) To assess the effectiveness of ampleloxetine in preventing the occurrence of falls. (d) To evaluate the safety and tolerability of ampleloxetine, including adverse events (AEs) and changes in blood pressure (BP), heart rate (HR), electrocardiogram (ECG), Columbia-Suicide Severity Rating Scale (C-SSRS), and clinical laboratory tests.

[0210] The exploratory objectives of this study were to: (a) To evaluate the efficacy of ampleloxetine using disease-specific instruments, the Unified Parkinson's Disease Rating Scale (UPDRS), the Parkinson's Disease Questionnaire-8 (PDQ-8), the Unified Multiple System Atrophy Rating Scale (UMSARS), and the Composite Autonomic Symptom Score-31 (COMPASS-31). (b) To evaluate the efficacy of ampleloxetine using orthostatic blood pressure during orthostatic standing testing. (c) To evaluate the efficacy of ampleloxetine using the general quality of life assessment EuroQol-5D-5L (EQ-5D-5L). (d) To explore the potential benefits of ampleloxetine on non-dopaminergic symptoms in subjects with primary autonomic failure. (e) To explore pharmacodynamic markers in subjects with primary autonomic failure. (f) Collection of sparse PK samples in subjects with primary autonomic failure to inform population PK modeling. (g) To assess caregiver burden in caring for a subject with primary autonomic failure using the Family Caregiver Burden Scale-Short Version (BSFC-s).

[0211] G. Test Evaluation Efficacy assessments in this study included: OHQ, PGI-C, and incidence of falls. Exploratory assessments included: orthostatic standing test; PK and pharmacodynamics; Non-Motor Symptom Scale (NMSS); EQ-5D-5L; Hospital Anxiety and Depression Scale (HADS); and Family Caregiver Burden Scale-Short Version (BSFC-s). For subjects with PD, study assessments included UPDRS, and PDQ-8, and for subjects with MSA, COMPASS-31 and UMSARS.

[0212] Safety and tolerability assessments included physical examination, neurological examination, vital signs including ambulatory BP; resting ECG; safety laboratory tests including chemistry, hematology, and urinalysis; concomitant medications; AEs; subject compliance with study treatment; and C-SSRS.

[0213] A sparse PK sampling strategy was employed in this study with samples collected at selected study visits for pharmacokinetic assessment. The time of study drug intake was precisely documented the day before and the day of each study visit when PK samples were collected.

[0214] For pharmacodynamic assessment, blood samples for pharmacodynamic markers (including [dihydroxyphenylglycol]DHPG and NE) were collected after subjects had been in a sitting position for approximately 30 minutes.

[0215] H. Statistical methods 1. Sample size The study was designed with a total sample size of approximately 188 subjects randomized in a 1:1 ratio to ampleloxetine or placebo groups stratified by disease type (MSA, PD, or PAF). The study was designed to enroll at least 40% subjects with MSA (i.e., at least 76 subjects with MSA overall).

[0216] The full analysis set (FAS) was defined as all randomized subjects who received at least one dose of study drug and had a baseline and at least one post-baseline OHSA#1 measurement. The primary analysis was performed when all subjects in the FAS had completed the primary endpoint assessment (OHSA#1 at Week 4) and the database was cleaned and locked. A total sample size of 170 subjects would have an overall power of 90% to detect a treatment difference of 1.5 in the primary endpoint of change from baseline in OHSA#1, assuming a standard deviation of 3.0 for both treatment groups at a two-sided alpha level of 0.05.

[0217] Assuming a 10% dropout rate by week 4, the study was expected to randomize approximately 188 subjects to achieve 170 subjects in the FAS.

[0218] 2. Study Endpoints The primary study endpoint was change from baseline in OHSA#1 (feeling dizzy, lightheaded, faint, or blacking out) at week 4. Secondary endpoints were: Change from baseline in OHSA composite score at weeks 1 to 4; Change from baseline in OHDAS composite score at weeks 1 to 4; ● PGI-C in the fourth week, and ●The occurrence of falls. Exploratory endpoints for all subjects were: - Orthostatic systolic blood pressure during orthostatic testing; Change from baseline in OHSA#1 at weeks 1-3, Change from baseline in OHSA questions 2–6 at weeks 1–4; Change from baseline in OHDAS questions 1-4 at weeks 1-4; Change from baseline in OHQ global composite score at weeks 1 to 4; Change from baseline in OHDAS questions 1 and 2 at weeks 1 to 4; Change from baseline in EQ-5D-5L at Week 4; PK and pharmacodynamics, ●Non-motor symptom scale (NMSS), ●Hospital Anxiety and Depression Scale (HADS), and ● Family Caregiver Burden Scale-Short Version (BSFC-s). Exploratory endpoints for subjects with PD were: Change from baseline in UPDRS at week 4, and ●Change from baseline in PDQ-8 at week 4. Exploratory endpoints for subjects with MSA were: Change from baseline in COMPASS-31 at week 4, and ●Change from baseline in UMSARS at week 4. Safety and tolerability endpoints included the following: Physical examination, Neurological examination, - Vital signs including ambulatory BP, ●Resting electrocardiogram, - Laboratory tests including biochemistry, hematology, and urinalysis; Concomitant medications, Adverse events, ● Subject compliance with study procedures; and ●C-SSRS.

[0219] 3.Endpoint Analysis Analyses performed on the FAS were based on the randomized treatment assigned. The safety analysis population was defined as all randomized subjects who received at least one dose of study drug, and subjects were analyzed according to the actual study treatment they received. All data were summarized by treatment group unless otherwise stated. Continuous variables were presented using descriptive statistics. Categorical variables were summarized using the number of subjects and the percentage of subjects in the corresponding category.

[0220] The primary efficacy assessment was the change from baseline in OHSA#1 at week 4. Baseline was defined as the measurement on day 1 before dosing. To compare treatments, a mixed model for repeated measures (MMRM) was fitted. The model included fixed effects of treatment condition as class, continuous covariates of baseline disease type (MSA, PD, PAF), week, and baseline OHSA#1 score, a random subject effect, with an unstructured covariance structure using FAS.

[0221] Least squares means and 95% confidence intervals for the difference between ampleloxetine and placebo were calculated. Missing data in the MMRM analysis were assumed as missing at random (MAR) and were not imputed for the analysis of the primary endpoint. Sensitivity analyses of the primary endpoint were performed using multiple imputation. The primary analysis was repeated in a prespecified set of subgroups and presented in graphical form.

[0222] The following secondary efficacy endpoints were tested via statistical testing procedures that protected the family-wise type I error rate at a two-sided significance level of 5% until the null hypothesis could not be rejected. • Change from baseline in OHSA composite score at week 4; • Change from baseline in OHDAS composite score at week 4; ● PGI-C in the fourth week, and ●Fall occurred in the fourth week.

[0223] No statistical significance was claimed after failure to reject the null hypothesis.

[0224] Secondary efficacy endpoints, including assessment of change from baseline such as OHSA composite score and OHDAS composite score, were analyzed in a similar manner as the primary efficacy endpoint of change from baseline in OHSA#1.

[0225] PGI-C was summarized as the number and percentage of subjects with "good" and "no change or worsening" at week 4. Incidence of falls was summarized as the number and percentage of subjects with at least one fall at week 4. These end points were tested using the Cochran-Mantel-Haenszel chi-square test stratified by disease type at baseline.

[0226] Nominal p-values ​​and 95% confidence intervals without multiplicity adjustment will be provided for all supportive analyses, including sensitivity analyses of the primary efficacy endpoints and exploratory endpoints.

[0227] Safety data were listed by subject and summarized using frequency of events or descriptive statistical summaries as appropriate. Summary tables were prepared for physical examination, neurological examination, vital signs (temperature, HR, and BP), weight, ECG, safety laboratory tests (hematology, chemistry, and urinalysis), C-SSRS, AEs, and concomitant medications.

[0228] I. Test Results The study did not meet its primary endpoint. Subjects receiving ampleloxetine did not have a statistically significant change from baseline in Orthostatic Hypotension Symptom Assessment (OHSA) Question 1 (OHSA#1) scores at week 4 compared with subjects receiving placebo. The majority of treatment-related adverse events were mild or moderate in severity. Serious adverse events occurred in two subjects on placebo and four subjects on ampleloxetine, none of which were considered related to the study drug, and no deaths were reported. There was no signal for supine hypertension.

[0229] However, at week 4, subjects with MSA who received ampleloxetine also showed a reduction in total anxiety score from baseline, indicating the efficacy of ampleloxetine against anxiety due to nOH. Table 5 shows the change in total anxiety score for MSA subjects at week 4 from baseline. Total anxiety score was determined using standard procedures (see, e.g., Rishi et al. Hospital anxiety and depression scale assessment of 100 patients before and after using low vision care: A prospective study in a tertiary eye-care setting. Indian J Ophthalmol. 2017 Nov; 65(11): 1203-1208). [Table 7]

[0230] Example 7 A Phase 3, 22-Week Clinical Trial in Subjects with Symptomatic nOH This was a Phase 3, multicenter, randomized withdrawal study to evaluate the sustained benefits in efficacy and safety of ampleloxetine (administered as ampleloxetine hydrochloride) in subjects with primary autonomic failure (MSA, PD, or PAF) and symptomatic nOH after 22 weeks of treatment. Eligible subjects were either (i) completers of the study in Example 6 ("Completer group"), or (ii) symptomatic nOH subjects who met all applicable study inclusion criteria and did not meet any of the applicable exclusion criteria ("De Novo group").

[0231] The study consisted of three periods: (i) 16 weeks of open-label (OL) treatment with ampleloxetine, (ii) 6 weeks of randomized placebo-controlled treatment, and (iii) 2 weeks of follow-up (only for subjects not enrolled in the continuing Study 0171). A 4-week screening period was only applicable to the De Novo group, and a screening visit was conducted in the clinic for all subjects in the De Novo group.

[0232] A total of 203 subjects participated in this study (170 subjects in Example 6 (85 in the ampleloxetine group and 85 in the placebo group) and 33 de novo subjects). During the OL period, 55 subjects discontinued treatment. At week 16, 64 subjects were randomized to the ampleloxetine group (6 subjects discontinued the study) and 64 subjects were randomized to the placebo group (3 subjects discontinued the study). A total of 119 subjects completed the study. Of the 128 subjects entering the randomization period, 40 subjects had MSA (31%), 68 subjects had PD (53%), and 20 subjects had PAF (16%) (in each category, subjects were divided equally between ampleloxetine and placebo).

[0233] A. Study Population The study enrolled adult subjects with confirmed symptomatic nOH due to MSA, PD, or PAF who met all inclusion criteria and no exclusion criteria defined in the study protocol.

[0234] 1.Target of the completed group After signing the informed consent, subjects entered Visit 1 (V1), which took place on the same day as Visit 6 (V6 / D29) of Example 6. For a given subject, each subject's visit modality for this Example, either in-clinic or remote, matched the modality selected by the subject for Example 6. The procedures of Example 6 performed at V6 served as the baseline assessment for V1 of this Example.

[0235] Beginning on day 2, subjects received a single dose of 10 mg ampleloxetine once daily (QD) followed by a 16-week OL treatment period, after which subjects were randomized to continue on either active treatment or placebo ("PBO") for a 6-week period.

[0236] 2. De Novo group subjects Eligible subjects were trained in accurately scoring sensations of dizziness, lightheadedness, fainting, or blacking out as outlined by the Orthostatic Hypotension Symptom Assessment Question 1 (OHSA#1).

[0237] After the screening period, subjects progressed to V1 to further verify additional eligibility criteria before progression, including completion of the Orthostatic Hypotension Questionnaire (OHQ), where a minimum score of 4 on OHSA#1 was required.

[0238] Subjects who met all inclusion criteria, none of the exclusion criteria, and whose disease characterization was confirmed by an independent Enrollment Steering Committee (ESC) received ampleloxetine during the OL period.

[0239] Beginning on day 2, subjects received a single dose of 10 mg ampleloxetine once daily (QD) followed by a 16-week OL treatment period, after which subjects were randomized to continue either active treatment or PBO for a 6-week period.

[0240] 3. Inclusion Criteria Subjects in the completer group who met the following criteria were eligible for study enrollment: (a) Completed 4 weeks of double-blind treatment in Example 6 (V6) and, in the opinion of the investigator, would benefit from continued treatment with ampleloxetine. No minimum score on OHSA#1 was required for entry into V1. (b) Subjects had at least 80% study drug compliance in Example 6. (c) the subject understood the nature of the study and was able to provide written informed consent prior to any study procedures being undertaken (including an understanding that participation in the study may result in changes occurring in the subject's current treatment regimen). (d) Subjects were willing to continue treatment despite possible randomization to either ampleloxetine or PBO during the randomized weaning phase and continued to meet the inclusion criteria of the previous study (Example 6), except that tilt-table testing, ESC review, and approval of eligibility were required for participation.

[0241] Subjects in the De Novo group who met the inclusion criteria of Example 6 were eligible for study enrollment in this study.

[0242] 4. Exclusion criteria Subjects in the completer group who met any of the following criteria were not eligible for study enrollment: (a) Subjects must not be enrolled in another clinical trial (except for Example 6). (b) The subject has a psychiatric, neurological, or behavioral disorder that may interfere with the subject's ability to give informed consent or that may interfere with the conduct of the study. (c) Any medical, laboratory, or surgical problem that the investigator considers to be clinically significant. (d) There is a reasonable possibility of non-cooperation or non-compliance with the Protocol. (e) The subject has a comorbidity or condition that, in the opinion of the investigator, would confound or interfere with study participation or with the evaluation of the safety, tolerability, or pharmacokinetics of the investigational product.

[0243] Subjects in the De Novo group who met the exclusion criteria in Example 6 were not eligible for study enrollment in this study.

[0244] 5. Prohibitions and Restrictions The same prohibitions and restrictions were used as for study participation in Study Example 6.

[0245] B. Test Product, Dose, and Route of Administration; Regimen; Duration of Treatment 1. During OL treatment period All subjects received ampleloxetine and continued to take the study drug once daily until the end of the treatment period starting on day 2. The study product, ampleloxetine, was supplied as 10 mg tablets in 35 count high density polyethylene bottles.

[0246] 2. In the case of the randomized treatment period Subjects randomized to ampleloxetine received ampleloxetine tablets and continued to take the study drug once daily beginning the morning after randomization (Day 2) through the end of the treatment period. The test product, ampleloxetine, was supplied as 10 mg tablets in 35-count or 5-count high-density polyethylene bottles labeled in a blinded manner (i.e., the bottle label of the test product was indistinguishable from the reference product except for the coded unique bottle number).

[0247] 3. For both treatment periods Ampleroxetine was administered orally with approximately 8 ounces of water each morning at approximately the same time, without regard to food.

[0248] C. Reference products, doses, and routes of administration; regimens; duration of treatment 1. During OL treatment period No subjects received the reference product during the OL treatment period.

[0249] 2. In the case of the randomized treatment period Subjects randomized to PBO received PBO tablets that matched ampleloxetine tablets in excipient content (except for ampleloxetine), appearance, tablet number, and packaging (e.g., the bottle label of the reference product was indistinguishable from the test product except for the coded unique bottle number).

[0250] PBO tablets were administered orally with approximately 8 ounces of water each morning at approximately the same time, without regard to food.

[0251] D. Testing 1. Open-label period (weeks 1-16) Subjects enrolled in the OL phase of the study were scheduled to visit for evaluation on days 15, 29, and every 4 weeks thereafter, as outlined in the schedule of study procedures. To continue in the study, at V3 (week 4), after the first 4 weeks of OL treatment, subjects had to demonstrate at least a 2-point reduction in OHSA#1 compared to baseline values, as determined in Example 6 for subjects entering from Example 6, and for de novo subjects, subjects from V1. Subjects who did not meet this continuation criterion were discontinued and underwent a completion of study visit. Completion of study visits were completed within 2 weeks of the last dose date.

[0252] All subjects who completed the initial 4-week OL treatment period and met the continuation criteria continued to receive open-label ampleloxetine for an additional 12 weeks (16 weeks total).

[0253] 2. Double-blind period (weeks 17-22) After completing a total of 16 weeks of OL treatment with ampleloxetine (V6), subjects were evaluated for randomization in a 1:1 fashion. Eligible subjects received double-blind treatment with ampleloxetine or PBO once daily for 6 weeks. Only subjects with an OHSA#1 score ≦7 were eligible for randomization into the double-blind treatment period.

[0254] 3. Treatment period (weeks 1-22) No dose reductions were permitted during this treatment period. Subjects unable to tolerate 10 mg of ampleloxetine discontinued the study. If at any time during the study, the subject met at least one of the following discontinuation rules, the subject discontinued and underwent completion of study visits: (a) A determination from the PI that further administration of the investigational drug may pose a safety concern to the subject; (b) sustained (at least 4 hours) SBP ≥ 180 mmHg or diastolic BP (DBP) ≥ 110 mmHg after 3 minutes of standing or 5 minutes of sitting, or sustained (at least 4 hours) SBP ≥ 180 mmHg or DBP ≥ 110 mmHg measured in the supine position (head / trunk approximately 30° above horizontal); (c) an intolerable AE as determined by the PI; or (d) the subject is pregnant.

[0255] Safety assessments included physical examination, neurological examination, vital signs (temperature, HR, respiratory rate, and blood pressure), weight, 12-lead electrocardiogram, laboratory tests (hematology, chemistry, and urinalysis), Columbia-Suicide Severity Rating Scale (C-SSRS), and adverse event monitoring. Safety was reviewed periodically by an Independent Data Monitoring Committee (IDMC).

[0256] Subjects were asked not to make any significant dietary changes during the study. During scheduled visits, subjects were reminded to maintain adequate fluid intake.

[0257] Subjects completing the 6-week double-blind treatment period were eligible to continue into the OL, long-term safety study (Study 0171). Subjects who did not complete the 6-week double-blind treatment period or who elected not to continue into Study 0171 completed an Early Termination Visit (V9) or Follow-Up Visit (V10), respectively. The Follow-Up Visit was completed 2 weeks from the date of the last dose.

[0258] 4. Continuation Criteria To continue in the study, at V3 (week 4), after the first 4 weeks of OL treatment, subjects must demonstrate at least a 2-point reduction in OHSA#1 compared to baseline values, as determined in Example 6 for subjects entering from Example 6, and for de novo subjects, from V1.

[0259] 5. Randomization criteria for the double-blind period The following randomization criteria were used for the double-blind period: (a) Subjects had an OHSA#1 score of ≦7. (b) The subject's unused OL study medication (10 mg ampleloxetine tablets) was returned to the site. (c) Subjects had at least 80% study drug compliance during the OL treatment period. (d) Subjects were excluded if their disease or symptoms worsened excessively during the OL phase and, in the opinion of the investigator, would not benefit from continued participation in the study.

[0260] E. Test Evaluation Efficacy assessments in this study included: OHQ and PGI-S; and improvement of subject symptoms measured by the wearable device. Exploratory assessments included: orthostatic standing test, NMSS, EQ-5D-5L, HADS, and BSFC-s. For subjects with PD, exploratory assessments included: Unified Parkinson's Disease Rating Scale (UPDRS), and Parkinson's Disease Questionnaire-8 (PDQ-8). For subjects with MSA, exploratory assessments included: Unified Multiple System Atrophy Rating Scale (UMSARS), and Composite Autonomic Symptom Score-31 (COMPASS-31).

[0261] Safety and tolerability assessments in this study included physical examination, including weight; neurological examination; vital signs, including ambulatory BP; resting ECG; clinical laboratory assessments, including serum chemistry, hematology, and urinalysis; concomitant medications; AEs; and C-SSRS.

[0262] This study employed a sparse PK sampling strategy with samples collected at selected study visits, as defined in the study procedure schedule. The time of study drug intake was precisely documented the day before and the day of each study visit when PK samples were collected.

[0263] Blood samples for pharmacodynamic markers ([dihydroxyphenylglycol]DHPG and NE) were collected at selected study visits as defined in the schedule of study procedures after subjects had been in a sitting position for 30 minutes, which was applicable to all consenting subjects.

[0264] F. Statistical methods 1. Sample size A planned sample size of 154 total at randomization was designed to provide 90% power to detect a difference of 0.25 (0.25 ampleloxetine vs. 0.50 placebo) in the proportion of subjects meeting criteria for treatment failure at week 6 (V9, D155) during the double-blind randomized withdrawal phase at a significance level of 0.05, using a two-sided test. The actual total sample size at randomization was 128.

[0265] 2. Study Endpoints The primary study endpoint was the rate of treatment failure at week 6 during the double-blind randomized withdrawal phase. Treatment failure was defined as subjects meeting the following criteria at week 6 after randomization (V9, D155): a change from baseline (worsening) in OHSA#1 score of 1.0 points and a worsening in disease severity as assessed by a 1 point change on the PGI-S.

[0266] Assessments made at the week 16 (V6, D113) visit during the OL phase prior to randomization were considered the baseline for the double-blind, randomized withdrawal phase of the study. Subjects who discontinued for any reason prior to V9 (D155) or failed to provide an assessment at V9 (D155) were considered treatment failures. Secondary endpoints included: (a) Change from baseline in OHSA#1 at week 6 after randomization (V9, D155), (b) change from baseline in OHSA composite score at week 6 after randomization (V9, D155); (c) change from baseline in OHDAS composite score at week 6 after randomization (V9, D155); (d) Change from baseline in PGI-S at week 6 after randomization (V9, D155), (e) Change from baseline in percentage of time spent in an upright position as measured by a wearable device at week 6 post-randomization (V9, D155); and (f) Change from baseline in mean number of steps measured by a wearable device at week 6 post-randomization (V9, D155). Exploratory endpoints included: (a) Orthostatic SBP during orthostatic testing at week 6 after randomization (V9, D155); (b) Change from baseline in OHQ global composite score at week 6 after randomization (V9, D155); (c) change from baseline in EQ-5D-5L at week 6 after randomization (V9, D155); (d) NMSS at week 6 after randomization (V9, D155); (e) HADS at 6 weeks after randomization (V9, D155), and (f) BSFC-s at 6 weeks after randomization (V9, D155). For subjects with PD, exploratory endpoints included the following: (a) Change from baseline in UPDRS at week 6 after randomization (V9, D155), and (b) Change from baseline in PDQ-8 (V9, D155) at 6 weeks after randomization. For subjects with MSA, exploratory endpoints included the following: (a) Change from baseline in UMSARS at week 6 after randomization (V9, D155), and (b) Change from baseline in COMPASS-31 (V9, D155) at 6 weeks after randomization. Safety and tolerability endpoints included the following: (a) Physical examination; (b) neurological examination; (c) vital signs, including ambulatory BP; (d) resting ECG; (e) clinical laboratory evaluation, including biochemistry, hematology, and urinalysis; (f) Concomitant medications, (g) adverse events (AEs), and (h) Columbia-Suicide Severity Rating Scale (C-SSRS). Exploratory safety and tolerability endpoints included: (a) PK and pharmacodynamic parameters.

[0267] 3.Endpoint Analysis All efficacy analyses in the double-blind randomized withdrawal phase were performed based on the full analysis set (FAS) using the assigned randomization treatment. The FAS for the double-blind randomized withdrawal phase was defined as all randomized subjects who received at least one dose of study drug after randomization.

[0268] The safety analysis population for the double-blind, randomized withdrawal phase was identical.

[0269] The FAS and safety analysis population for the OL phase were the same and were defined as all enrolled subjects who received at least one dose of ampleloxetine.

[0270] In the double-blind randomized withdrawal phase, all data were summarized by treatment group. In the OL phase, all data were summarized overall and by enrollment group (placebo Example 6 completers, ampleloxetine Example 6 completers, and De Novo group). Continuous variables were summarized using descriptive statistics. Categorical variables were summarized using the number of subjects and the percentage of subjects in the corresponding category.

[0271] The primary study endpoint was the rate of treatment failure at week 6 during the double-blind randomized withdrawal phase. Treatment failure was defined as subjects who met the following criteria at week 6 after randomization (V9, D155): a change from baseline (worsening) in OHSA#1 score of 1.0 point, and a worsening of disease severity as assessed by a 1 point change on the PGI-S.

[0272] Assessments made at the week 16 (V6, D113) visit during the OL phase prior to randomization were considered the baseline for the double-blind randomized withdrawal phase of the study. Subjects who discontinued for any reason prior to V9 (D155) or were unable to provide an assessment at V9 (D155) were counted as treatment failures.

[0273] Logistic regression models were fitted to estimate the effect of treatment on the primary endpoint. The models included terms for treatment and baseline disease type (MSA, PAF, PD), and also included baseline OHSA#1 score and baseline PGI-S as continuous covariates. Point estimates and 95% CIs for odds ratios were presented. We also presented the "least squares" treatment failure rates (point estimates and standard errors) for each treatment and disease type. In addition, we summarized the proportion of subjects who had at least a 1-point worsening on the OHSA#1 and the proportion of subjects who had at least a 1-point worsening on the PGI-S.

[0274] The primary analysis was repeated for the per-protocol analysis set defined in the statistical analysis plan (SAP).

[0275] To assess the consistency of the ampleloxetine:placebo odds ratios for treatment failure across subgroups, the analysis of the primary endpoint was repeated for each of the subgroups specified in the SAP: MSA, PD, and PAF subjects; men and women; and subjects with baseline NE < 200 pg / mL and ≥ 200 pg / mL. Forest plots showing the ampleloxetine:placebo odds ratio point estimates and 95% CIs for each subgroup are provided.

[0276] Secondary endpoints were analyzed by fitting mixed models for repeated measures with conditions on treatment, disease type (MSA, PD, PAF), visit, and treatment by visit interaction, and baseline values ​​of endpoints as continuous covariates. Within-subject correlations were modeled using an unstructured variance-covariance matrix. The Kenward-Roger method was used to approximate the denominator degrees of freedom. Missing endpoint values ​​were assumed missing at random (MAR). Least squares means and 95% confidence intervals for the difference between ampleloxetine and placebo were calculated and presented.

[0277] Exploratory endpoints, including assessment of change from baseline at multiple time points, such as orthostatic SBP during orthostatic testing, were analyzed similarly.

[0278] Exploratory endpoints, including assessment of change from baseline only at week 6 post-randomization (V9, D155), such as PDQ-8, UPDRS, UMSARS, and COMPASS-31, were analyzed by fitting an analysis of covariance model with conditions for treatment, baseline disease type (MSA, PD, PAF), and baseline score of the endpoint as continuous covariates.

[0279] A multiple test design was used to control the family-wise type 1 error rate of the primary and secondary endpoints to 0.05. If the primary endpoint was met, i.e., the odds of treatment failure for ampleloxetine vs. placebo at week 6 after randomization (V9, D155) were <1 with a p-value of 0.05, the secondary efficacy endpoints were tested in the order shown below until the first failure to reject the null hypothesis occurred: 1. Change from baseline in OHSA#1 at week 6 after randomization (V9, D155), 2. Change from baseline in OHSA composite score at week 6 after randomization (V9, D155), 3. Change from baseline in OHDAS composite score at week 6 after randomization (V9, D155), 4. Change from baseline in PGI-S at week 6 after randomization (V9, D155) 5. Change from baseline in percentage of time spent in an upright position (including walking) as measured by a wearable device at week 6 after randomization (V9, D155), 6. Change from baseline in mean number of steps measured by a wearable device at week 6 post-randomization (V9, D155).

[0280] For all other analyses, there was no adjustment for multiplicity.

[0281] Safety data were listed by subject and summarized narratively. Summaries and listings were presented separately for the OL phase and the double-blind randomized withdrawal phase. Summary tables were provided for vital signs, weight, ECG, safety laboratory tests, C-SSRS, AEs, and concomitant medications.

[0282] G. Test Results It has been surprisingly discovered that in subjects with multiple system atrophy and symptomatic neurogenic orthostatic hypotension, treatment with ampleloxetine for 22 weeks results in a measurable reduction in both (i) the subject's symptoms of dizziness, lightheadedness, feeling like they may black out, as determined using the subject's OHSA Item 1 score, and (ii) the subject's overall impression of the severity of their symptoms, as determined using the subject's OHSA Composite score. For example, Figure 1A shows that the OHSA item 1 scores of MSA subjects receiving placebo worsened (+1.8) at the end of the 6-week double-blind randomized withdrawal period compared to subjects receiving ampleloxetine (+0.3; p=0.0861), and Figure 1B shows that the OHSA composite scores of MSA subjects receiving placebo significantly worsened (+1.54) during the 6-week double-blind randomized withdrawal period compared to subjects receiving ampleloxetine (-0.03; p=0.0056).

[0283] It has also now been discovered that in subjects with multiple system atrophy and symptomatic neurogenic orthostatic hypotension, 22 weeks of ampleloxetine treatment surprisingly results in a measurable reduction in the subjects' orthostatic hypotension everyday activities scale (OHDAS) composite score and a measurable increase in the subjects' systolic blood pressure when standing for 3 minutes.For example, Figure 2A shows that the OHDAS composite score of MSA subjects receiving placebo is significantly worse (+0.97) compared to subjects receiving ampleloxetine (+0.16; p=0.196) during the 6-week double-blind randomized period of Example 7.Figure 2B shows that the systolic blood pressure when standing for 3 minutes is significantly worse (-12.4 mmHg) compared to subjects receiving ampleloxetine (+6.1) during the 6-week double-blind randomized period of Example 7.

[0284] FIG. 3 shows that the OHSA and OHDAS composite scores and individual subscores of symptoms and daily activities in MSA subjects all favored ampleloxetine at the end of the 6-week double-blind randomized period, except for OHDAS extended walking, which favored placebo.

[0285] OHSA item 1 scores are OHQ item scores and OHSA and OHDAS composite scores are OHQ subscale scores (see Appendix 1 and, e.g., Kaufmann et al., Clin. Auton. Res. (2012), 22:79-90).

[0286] Additionally, it has now been discovered that in subjects with multiple system atrophy, the magnitude of the decline in quality of life can be reduced when the subject is treated with ampleloxetine.For example, Figure 4 shows that the quality of life declines in MSA subjects who receive placebo, but declines less or improves in subjects who receive ampleloxetine.Quality of life is measured using the EQ-5D-5L visual analog scale (see Appendix 2, and for example, McCaffrey et al. Health and Quality of Life Outcomes (2016) 14:133).

[0287] It has further been discovered that supine norepinephrine levels in subjects with multiple system atrophy continue to increase for at least about 8 weeks when the subjects are treated daily with ampleloxetine, as shown in Table 8. [Table 8]

[0288] Table 8 shows that supine norepinephrine (NE) levels in subjects with MSA continue to increase beyond 4 weeks of treatment with ampleloxetine. Prior to treatment with ampleloxetine, supine norepinephrine (NE) levels in subjects with MSA are less than about 350 pg / mL. After about 8 weeks of treatment, supine norepinephrine levels are greater than about 500 pg / mL. Supine norepinephrine levels were determined using standard procedures (see, e.g., Goldstein et al., Annals of Neurology, 1989:26(4)558-563, and Palma et al., Neurology, 2018:91(16)e1539-e1544).

[0289] For the subgroup of MSA subjects, OHSA and OHDAS scores were analyzed at week 22 (end of the 6-week double-blind randomized period) and shown to favor ampleloxetine across virtually all subgroups of MSA subjects. For example, Figure 5 and Table 9 show that the OHSA composite scores for the subgroup of MSA subjects were all in favor of ampleloxetine at week 22. Subgroups included: MSA-Parkinsonism (MSA-P), MSA-Cerebellar Ataxia (MSA-C), onset of nOH <1.6 years before study start (onset of nOH <1.6 years), onset of nOH 1.6 years or more before study start (onset of nOH ≥1.6 years), MSA diagnosis <1.3 years before study start (MSA diagnosis <1.3 years), MSA diagnosis ≥1.3 years before study start (MSA diagnosis ≥1.3 years), Unified Multiple System Atrophy Rating Scale (UMSARS) part IV <4 (UMSARS part IV <4), UMSARS part IV ≥4 (UMSARS part IV ≥4), male, female, age <65 years (<65 years), and age ≥65 years (≥65 years). [Table 9-1] [Table 9-2]

[0290] It was surprising that amproxetine was able to treat or alleviate symptomatic nOH in patients with severe, advanced, or late stage MSA, including subjects with onset of nOH 1.6 years or more prior to study entry, MSA diagnosis 1.3 years or more prior to study entry, MSA diagnosis less than 1.3 years prior to study entry, or a UMSARS part IV score of 4 or greater.

[0291] Table 10 shows that OHDAS item 1 (activities requiring brief standing) scores for subgroups of MSA subjects were predominantly in favor of ampleloxetine at week 22. Subgroups included MSA-Parkinsonian (MSA-P), MSA-Cerebellar Ataxia (MSA-C), nOH onset <1.6 years prior to study start (nOH onset <1.6 years), nOH onset 1.6 years or more prior to study start (nOH onset ≥1.6 years), MSA diagnosis <1.3 years prior to study start (MSA diagnosis <1.3 years), MSA diagnosis ≥1.3 years prior to study start (MSA diagnosis ≥1.3 years), Unified Multiple System Atrophy Rating Scale (UMSARS) part IV, <4 (UMSARS part IV <4), male, female, age <65 years (<65 years), and age ≥65 years (≥65 years). [Table 10-1] [Table 10-2]

[0292] Again, it was surprising that amproxetine was able to treat or alleviate symptomatic nOH in patients with more severe, advanced, or late stage MSA, such as subjects with onset of nOH 1.6 years or more prior to study entry, MSA diagnosis 1.3 years or more prior to study entry, MSA diagnosis less than 1.3 years prior to study entry, or a UMSARS part IV score of 4 or greater.

[0293] Figure 6 shows that the OHQ composite scores for subgroups of MSA subjects were all in favor of ampleloxetine at week 22 (end of the 6-week double-blind randomization period). Subgroups included MSA-Parkinsonian (MSA-P), MSA-Cerebellar Ataxia (MSA-C), nOH onset <1.6 years prior to study initiation (nOH onset <1.6 years), nOH onset 1.6 years or more prior to study initiation (nOH onset ≥1.6 years), MSA diagnosis <1.3 years prior to study initiation (MSA diagnosis <1.3 years), MSA diagnosis ≥1.3 years prior to study initiation (MSA diagnosis ≥1.3 years), Unified Multiple System Atrophy Rating Scale (UMSARS) Part IV, <4 (UMSARS Part IV <4), male, female, age <65 years (<65 years), and age ≥65 years (≥65 years).

[0294] Subgroup analysis also shows that, despite MSA being a progressive condition, ampleloxetine was surprisingly beneficial for subjects with different baseline severity levels of nOH. Table 11 shows the change in OHSA composite score for subgroups of MSA subjects at week 22 (end of the 6-week double-blind randomized period), each of which had a different degree of nOH, as indicated by OHSA composite score or OHSA item 1 score, before the double-blind randomized period (RW baseline) or before treatment (pre-treatment baseline). [Table 11]

[0295] It was also shown that at week 22 (the end of the 6-week double-blind randomized period), MSA subjects receiving ampleloxetine showed a reduction in total anxiety score, indicating the efficacy of ampleloxetine for anxiety associated with MSA and / or nOH. Table 12 shows the change in total anxiety score for MSA subjects at week 22 from baseline. Total anxiety score was determined using standard procedures (see, e.g., Rishi et al. Hospital anxiety and depression scale assessment of 100 patients before and after using low vision care: A prospective study in a tertiary eye-care setting. Indian J Ophthalmol. 2017 Nov; 65(11): 1203-1208). [Table 12]

[0296] Compared to the MSA subjects at week 4 shown in Table 5 (Example 6), ampleloxetine showed greater improvement in anxiety associated with MSA and / or nOH, suggesting that long-term treatment (i.e., 4 weeks or more) provides surprisingly greater efficacy. Similarly, long-term administration of ampleloxetine showed clear improvement in nOH symptoms as shown in Tables 9-11 and Figures 5 and 6, but ampleloxetine did not meet the endpoint at week 4 in Example 6. Thus, surprisingly, when administered for a long period of time (i.e., 4 weeks or more), ampleloxetine is suggested to show efficacy that may not be shown when administered for a short period of time (i.e., less than 4 weeks).

[0297] Example 8 Phase 3 efficacy and durability of ampleloxetine for the treatment of symptomatic nOH in subjects with multiple system atrophy This is a Phase 3, multicenter, randomized withdrawal and long-term extension study to evaluate the sustained benefits in efficacy and durability of ampleloxetine (administered as ampleloxetine hydrochloride) in subjects with MSA and symptomatic nOH after 20 weeks of treatment. Eligible subjects are those with MSA and symptomatic nOH who meet all applicable study entry criteria and do not meet any of the applicable exclusion criteria.

[0298] The study will consist of four periods: (i) screening of up to 14 days, (ii) 12 weeks of open-label (OL) treatment with ampleloxetine, (ii) 8 weeks of double-blind, randomized, placebo-controlled treatment, and (iii) a 2-year long-term extension period.

[0299] A. Study Population This study will enroll adult subjects with confirmed symptomatic nOH who have MSA and who meet all applicable inclusion criteria and do not meet the applicable exclusion criteria defined below.

[0300] 1. Selection Criteria Subjects who meet the following applicable criteria are eligible for study enrollment: (a) The subject is male or female and is at least 30 years of age. (b) Subjects have a diagnosis of possible or probable MSA, Parkinson's disease subtype (MSA-P) or cerebellar subtype (MSA-C), according to the Gilman criteria (2008). (c) Subjects have a diagnosis of possible or probable MSA, Parkinson's disease subtype (MSA-P) or cerebellar subtype (MSA-C), confirmed by the Enrollment Steering Committee (ESC). (d) The subject meets diagnostic criteria for nOH as indicated by a sustained reduction in BP of ≥ 20 mmHg (systolic) or ≥ 10 mmHg (diastolic) within 3 minutes of standing as part of orthostatic standing test or tilting ≥ 60° upward from supine position as determined by tilt table testing. (e) Subjects must have a score ≦4 on the UMSARS Part IV at Visit 1 (Screening). (f) Subjects must score at least 4 on OHSA Item 1 at Visit 2 (Day 1). (g) Subjects must be willing not to take any prohibited medications during the study. (h) If the subject is female, the subject must not be pregnant, nursing, or planning to become pregnant during the course of the study. Women of childbearing potential must have a negative pregnancy test at screening. Women are considered of childbearing potential unless they are documented to be postmenopausal (amenorrhea for at least 2 years) or surgically sterile (bilateral tubal ligation or total hysterectomy). Female subjects may be admitted to the study on the basis of a negative urine pregnancy test. If the urine beta-human chorionic gonadotropin (bHCG) test is positive, a serum bHCG test must be performed. A negative pregnancy test must be confirmed to qualify the subject for the study. (i) During the study and for 30 days after receiving the last dose of investigational product, women of childbearing potential or men of fatherhood potential must agree to use highly effective contraception (with a failure rate of <1% when used consistently and correctly) or agree to abstain from sexual intercourse (see Section 4.3). (j) Subjects are willing and able to provide signed, dated, written informed consent prior to the initiation of any study-related procedures. (k) Subject is able to communicate well with the investigator and clinic staff, understand study expectations, and comply with study procedures, requirements, and restrictions.

[0301] 4. Exclusion criteria Subjects who meet any of the following criteria are not eligible for study enrollment: (a) Subjects have a systemic disease known to cause autonomic neuropathy, including, but not limited to, amyloidosis and autoimmune neuropathies. Subjects with diabetes mellitus (DM) will be evaluated on a case-by-case basis by a medical monitor and will be considered ineligible unless they meet all of the following criteria: 1. Well-controlled type 2 DM treated with oral medications and diet alone 2. HbA1C ≤ 7.5% during screening or within 12 weeks prior to screening 3. No clinically evident peripheral neuropathy (e.g., normal sensory testing of the peripheral extremities) 4. No known retinopathy (e.g., annual eye exam is sufficient) 5. Absence of nephropathy (e.g., absence of albuminuria and GFR>60). (b) The subject has a known intolerance to other NRIs or SNRIs. (c) Subject is currently using concomitant antihypertensive medications for the treatment of essential hypertension. (d) Subject has used a strong CYP1A2 inhibitor or inducer within 7 days or 5 half-lives, whichever is longer, prior to Visit 2 (Day 1) or requires concomitant use until the safety follow-up visit. (e) Subject had changed the dose, frequency, or type of prescription medication for orthostatic hypotension within 7 days prior to Visit 2 (Day 1). Midodrine and droxidopa (if applicable) must be tapered and discontinued at least 7 days prior to Visit 2 (Day 1). (f) Subject has known or suspected alcohol or drug abuse within the past 12 months (Diagnostic and Statistical Manual of Mental Disorders, Fourth Revised Edition [DSM-IV-TR®] definition of alcohol or drug abuse). (e) Subject has clinically unstable coronary artery disease or has had a major cardiovascular event (e.g., myocardial infarction) within the past 6 months. (f) Subject has a history of significant uncontrolled cardiac arrhythmia, complete heart block, or significant QTc prolongation (≧450 ms for men and ≧470 ms for women). (g) Subject has a new onset of a neurological event (i.e., seizure, confusion, altered level of consciousness, etc.) in the past 6 months. (h) Subjects had used any monoamine oxidase inhibitors (MAOIs) within 14 days prior to Visit 2 (Day 1). (i) the subject has untreated angle-closure glaucoma or a history of treated angle-closure glaucoma which, in the opinion of an ophthalmologist, may place the subject at increased risk. (j) Subject has a Montreal Cognitive Assessment (MoCA) <21. (k) Subjects are able or willing to complete all protocol-specified procedures, including questionnaires. (l) Subject has known congestive heart failure (New York Heart Association [NYHA] class 3 or 4). (m) Subject had any malignancy other than intraepithelial or basal cell carcinoma of the cervix within the past 2 years prior to screening. (n) Subject has a known gastrointestinal (GI) condition that, in the investigator's judgment, may affect absorption of the investigational drug (e.g., ulcerative colitis, gastric bypass). (o) The subject has a mental, neurological, or behavioral disorder that may interfere with the cognitive ability to give informed consent and to understand and comply with study procedures, or that may interfere with the performance of the study. (p) Subjects were currently receiving or had received an investigational drug within 30 days of receiving any investigational drug. An investigational drug is defined as a drug that has not been approved by a regulatory agency (e.g., the Food and Drug Administration (FDA)). (q) The subject has clinically significant abnormal laboratory finding(s) (e.g., alanine aminotransferase [ALT] or aspartate aminotransferase [AST] ≥ 3.0 x upper limit of normal [ULN]; blood bilirubin [total] ≥ 3.0 x ULN; estimated glomerular filtration rate (eGFR) < 30 mL / min / 1.73 m2, or any abnormal laboratory value that may interfere with the subject's safety). (r) Subjects have demonstrated lifetime suicidal ideation and / or suicidal behavior as outlined in the C-SSRS (Baseline / Screening Version). Subjects should be assessed by an evaluator for suicide risk and suitability for inclusion in the study. (s) The subject has a comorbidity or condition (e.g., COVID-19) that, in the opinion of the investigator, would confound or interfere with study participation or the evaluation of the safety, tolerability, or absorption of the investigational product. (t) The subject has a known hypersensitivity to ampleloxetine (ampleroxetine hydrochloride) or any of the excipients in the formulation. (u) Major surgery occurring less than 4 weeks prior to enrollment (i.e., procedures involving higher risk of infection and long recovery periods, such as joint replacement, gastric bypass, open-heart surgery, or organ transplant).

[0302] B. Test Product, Dose, and Route of Administration; Regimen; Duration of Treatment 1. During OL treatment period All subjects will receive ampleloxetine and will continue to take the study drug once daily through the end of the OL period starting on day 2. The study product is ampleloxetine supplied as 10 mg tablets in 30 count high density polyethylene bottles.

[0303] 2. During the RW period Subjects randomized to ampleloxetine will receive ampleloxetine tablets and will continue to take the study drug once daily starting the morning after Visit 5 (Day 2 of the RW Period, Day 86) through the end of the RW Period. The study product was ampleloxetine supplied as 10 mg tablets in 30-count high-density polyethylene bottles labeled in a blinded manner (i.e., the bottle label of the study product was indistinguishable from the reference product except for the coded unique bottle number).

[0304] 3. During the LTE treatment period Subjects will receive ampleloxetine and continue to take the study drug once daily through the end of the LTE period starting on Day 142. The study product is ampleloxetine supplied as 10 mg tablets in 30 count high density polyethylene bottles.

[0305] 4. For all treatment periods Ampleroxetine is administered orally with approximately 8 ounces (240 mL) of water at approximately the same time each morning, without regard to food.

[0306] C. Reference products, doses, and routes of administration; regimens; duration of treatment 1. During OL treatment period No subjects received the reference product during the OL treatment period.

[0307] 2. During the RW period Subjects randomized to PBO will receive a placebo tablet once daily starting the morning after Visit 5 (Day 2 of the RW Period, Day 86) until the end of the RW Period. PBO tablets will be matched to ampleloxetine tablets in excipient content (except for the absence of ampleloxetine), appearance, tablet number, and packaging (i.e., the bottle label of the reference product will be indistinguishable from the test product except for the coded unique bottle number).

[0308] 3. During the LTE period No subjects received the reference product during the LTE treatment period.

[0309] 4. For all treatment periods PBO tablets were administered orally with approximately 8 ounces of water each morning at approximately the same time, without regard to food.

[0310] D. Testing 1. Screening Subjects enter a screening period of up to 14 days to confirm eligibility. At Visit 1 (Screening), subjects provide a comprehensive medical history of disease and treatment. The subject's disease is characterized and documented by the Principal Investigator (PI) or sub-investigator. Subjects undergo a physical status assessment, including safety, laboratory evaluations, and relevant aspects of the disease state. Eligible subjects receive training on how to accurately score the items on the OHQ. After the screening period (up to 14 days), subjects proceed to Visit 2 (Day 1) to further confirm additional eligibility criteria before progressing. This includes completion of the OHQ, which requires a minimum score of 4 on OHSA item 1. Subjects who meet all inclusion criteria, none of the exclusion criteria, and whose disease characterization is confirmed by an independent Enrollment Steering Committee (ESC) will receive ampleloxetine during the OL period.

[0311] 2. Open-label period (weeks 1-12) Beginning on Day 2 (the morning after Visit 2), subjects will receive a single dose of ampleloxetine OL 10 mg once daily, followed by a 12-week OL period.

[0312] Subjects enrolled in the OL portion of the study are scheduled for visits on Day 29 (Visit 3, Week 4), Day 57 (Visit 4, Week 8), and Day 85 (Visit 5, Week 12) as outlined in the schedule of study procedures (Table 1). At Visit 4, after 8 weeks of OL treatment, subjects must demonstrate a reduction in OHSA item 1 of at least 2 points compared to baseline values ​​(i.e., measured at Visit 2) in order to continue in the study.

[0313] All subjects who meet the retention criteria at Visit 4 (Week 8) will continue to receive OL ampleloxetine tablets for an additional 4 weeks (total 12 weeks).

[0314] Subjects who do not meet this retention criterion at Visit 4 must discontinue and undergo an Early Termination visit within 3 days of the last dose. The Safety Follow-Up Visit (End-of-Study) must be completed 30 days (± 7 days) after the date of the last dose and may be conducted in-clinic or over the telephone.

[0315] 3. Double-blind randomized withdrawal period (weeks 13-20) After completion of a total of 12 weeks of OL treatment with ampleroxetine, subjects will be evaluated for randomization in a 1:1 manner at Visit 5. Only subjects with an OHSA Item 1 score ≦7 will be eligible for randomization into the double-blind treatment period.

[0316] Eligible subjects will receive 8 weeks of double-blind treatment with 10 mg ampleloxetine once daily or placebo.

[0317] There will be an upper limit for randomization (visit 5) for subjects with a UMSARS part IV score of 4 at screening (visit 1) once 25% have been reached (i.e., 18 randomized subjects).

[0318] Subjects not eligible for randomization must discontinue and undergo an Early Termination Visit within 3 days of the last dose. A Safety Follow-Up Visit (End-of-Study Visit) must be completed 30 days (± 7 days) after the date of the last dose and may be conducted in-clinic or by telephone.

[0319] 4. Treatment period (weeks 1-22) No dose reductions will be permitted during this treatment period. Subjects unable to tolerate 10 mg of ampleloxetine will discontinue the study. If at any time during the study, the subject meets at least one of the following discontinuation rules, the subject will be required to discontinue and undergo an Early Termination Visit and a Safety Follow-Up Visit (End of Study Visit): (a) A determination from the PI that further administration of the investigational drug may pose a safety concern to the subject. (b) Sustained (for at least 4 hours) SBP ≥ 180 mmHg or diastolic BP (DBP) ≥ 110 mmHg after 3 minutes of standing or 5 minutes of sitting, or sustained (for at least 4 hours) SBP ≥ 180 mmHg or DBP ≥ 110 mmHg measured in the supine position (head / trunk approximately 30° above horizontal). (c) Intolerable AEs as determined by the investigator (d) the female subject is pregnant

[0320] Safety assessments included physical examination, neurological examination, vital signs (temperature, HR, respiratory rate [RR], and BP), weight, 12-lead ECG, clinical laboratory tests (hematology, chemistry, and urinalysis), Columbia-Suicide Severity Rating Scale (C-SSRS), and monitoring of AEs.

[0321] Subjects are requested not to make any significant dietary changes during the study. During scheduled visits, subjects should be reminded to maintain adequate fluid intake.

[0322] For subjects who have not completed the 8-week double-blind RW period, an Early Termination visit will be completed within 3 days of the last dose date. For all subjects, a Safety Follow-Up Visit (End-of-Study Visit) must be completed 30 days (± 7 days) from the last dose date and may be conducted in-clinic or by telephone. Subjects who complete the 8-week double-blind RW period are eligible to continue into the 2-year LTE period.

[0323] 5. Long-term treatment extension During LTE, subjects will receive 10 mg of ampleloxetine once daily and will undergo study visits either consistent with standard treatment for subjects outside of clinical trials or at least one in-clinic visit per year (Table 1).

[0324] All sites are permitted, at the discretion of the investigator, to conduct either in-clinic or remote scheduled outpatient visit(s) for subject safety or unanticipated subject medical need outside of the normal visit schedule. Data collected during these visits may include any protocol-specified assessments that will be captured in the clinical database.

[0325] A safety follow-up visit (end-of-study) must be completed 30 days (± 7 days) after the last dose date and may be conducted in-clinic or over the phone.

[0326] E. Test Evaluation Efficacy assessments in this study included: OHQ, OST (orthostatic test) including a 3-minute orthostatic test, and pharmacokinetic assessments.

[0327] Exploratory assessments included: Hospital Anxiety and Depression Scale (HADS), Patient Global Impression of Severity-Symptoms (PGIS-Symptoms), Patient Global Impression of Severity-Activity (PGIS-Activity), Patient Global Impression of Change-Symptoms (PGIC-Symptoms), and Patient Global Impression of Change-Activity (PGIC-Activity).

[0328] Safety and tolerability assessments in this study included: C-SSRS; AEs; medical and medical history, physical examination; neurological examination; height and weight; vital signs, ECG; clinical laboratory tests, hematology, chemistry, urinalysis, distribution and / or collection of medication diaries; and unscheduled visits.

[0329] F. Statistical methods 1. Sample size A total sample size of 64 provides an overall power of greater than 90% to detect a difference of 1.5 points with a standard deviation of 1.8 points at a two-sided alpha level of 0.05 for the primary endpoint of change in OHSA composite score at week 8 (visit 9, day 141) during the double-blind RW period. Power calculations include a single interim analysis of efficacy for approximately 56% of subjects, where a Hwang-Shih-DeCani alpha-spending function with gamma parameter (-3.5) is constructed to implement group sequential boundaries that control for type I error rates. Considering a 10% dropout rate during the RW period, a sample size of 72 is required at randomization (visit 5).

[0330] Assuming 70% are eligible for randomization at the end of the 12-week OL period, approximately 102 subjects are expected to be enrolled and 72 subjects are expected to continue into the randomized treatment period.

[0331] 2. Study Endpoints The primary study endpoint is the change in OHSA composite score at week 8 (Visit 9, Day 141) during the double-blind RW period. The assessment performed at the week 12 (Visit 5, Day 85) visit during the OL period before randomization will be considered the baseline for the double-blind RW period of the study.

[0332] Secondary endpoints were: (a) Change from baseline in OHDAS item 1 (activities requiring brief standing) at week 8 after randomization (Visit 9, Day 141) (b) Change from baseline in OHDAS item 3 (activities requiring brief walking) at week 8 after randomization (Visit 9, Day 141) Exploratory endpoints included: (c) Change from baseline in 3-minute orthostatic SBP during OST at week 8 after randomization (Visit 9, Day 141) (d) Change from baseline in OHQ composite score at week 8 after randomization (Visit 9, Day 141) (e) Change from baseline in the short daily activities composite score (OHDAS item 1 and OHDAS item 3) at week 8 post-randomization (Visit 9, Day 141); the short daily activities composite score is defined as the average of the OHDAS item 1 and OHDAS item 3 item scores from the OHQ questionnaire. (f) Change from baseline in the HADS anxiety domain at week 8 post-randomization (Visit 9, Day 141) (g) Change from baseline in the HADS depression domain at week 8 after randomization (Visit 9, Day 141) (h) PGIS-Symptoms and PGIS-Activity at baseline and 8 weeks after randomization (Visit 9, Day 141) (i) Change from baseline in PGIS-Symptoms and PGIS-Activity at Week 8 after randomization (Visit 9, Day 141) (j) PGIC-symptoms and PGIC-activity at Week 8 after randomization (Visit 9, Day 141)

[0333] 3.Endpoint Analysis The primary estimate will address the following objective clinical question: The mean difference in change in OHSA composite score at week 8 during the double-blind RW period in subjects with MSA and symptomatic nOH treated with ampleloxetine versus placebo, regardless of discontinuation of the study intervention for any reason and regardless of initiation of rescue medication.

[0334] The primary estimates are according to treatment policy strategy and are described by the following attributes: (a) Population: Subjects with MSA and symptomatic nOH (i.e., FAS in the double-blind RW period). (b) Endpoint: change in OHSA composite score at week 8 during the double-blind RW period. (c) Treatment condition: Study intervention (treatment strategy), with or without rescue medication, regardless of discontinuation for any reason. (d) Population-level summary: differences in mean changes between treatment conditions.

[0335] Primary estimates are analyzed using a mixed model for repeated measures (MMRM) to compare treatment differences based on the FAS. The model includes fixed effects class treatment condition, continuous covariates of Visit 1 and UMSARS Part IV at Visit 1 (<4, 4), baseline score (Visit 5, Day 85), and random subject effects with an unstructured covariance structure. Visit*treatment and Visit*baseline interaction terms are also included. If the model does not converge, compound symmetry or other covariance structures are used as alternative covariance structures. Least squares means and 95% confidence intervals for the difference between ampleloxetine and placebo are calculated and presented. Missing data are assumed to be missing at random (MAR).

[0336] Sensitivity analyses of the primary analyses will be conducted using a not-missing-at-random approach to missing data via multiple imputation. Supplementary estimation strategies will be specified in the statistical analysis plan (SAP).

[0337] The primary analysis will be repeated in a pre-specified set of subgroups and presented in graphical form, details of which will be specified in the SAP.

[0338] The individual components of the OHSA composite score are presented as supportive analyses and will be analyzed using similar mixed models for repeated measures (MMRM) as outlined for the primary analyses.

[0339] Following the treatment policy strategy, there are four objective key secondary estimates with the same treatment conditions as the primary endpoint, remaining intercurrent events, and population-level summary attributes. The population and estimate attributes are as follows: Key secondary estimates1 (a) Population: Subjects with MSA and symptomatic nOH at Visit 1 and UMSARS Part IV <4 (b) Endpoint: Change from baseline in the impact of symptoms on activities requiring brief standing (OHDAS item 1) at Week 8 post-randomization (Visit 9, Day 141) Key secondary estimate 2 (a) Population: Subjects with symptomatic nOH due to MSA (b) Endpoint: Change from baseline in the impact of symptoms on activities requiring brief standing (OHDAS item 1) at Week 8 post-randomization (Visit 9, Day 141) Key secondary estimate 3 (a) Population: Subjects with symptomatic nOH due to MSA and UMSARS Part IV <4 at Visit 1 (b) Endpoint: Change from baseline in symptom impact on activities requiring brief walking (OHDAS item 3) at Week 8 post-randomization (Visit 9, Day 141) Key secondary estimates4 (a) Population: Subjects with symptomatic nOH due to MSA (b) Endpoint: Change from baseline in symptom impact on activities requiring brief walking (OHDAS item 3) at Week 8 post-randomization (Visit 9, Day 141)

[0340] Secondary efficacy endpoints are analyzed using MMRM to compare treatment differences. Models in the UMSARS Part IV <4 subpopulation analysis include fixed effect class treatment condition, visit, and continuous covariates of baseline scores for each scale, random subject effects, with an unstructured covariance structure. Visit*treatment and Visit*baseline interaction terms are included. If the model does not converge, compound symmetry or other covariance structures are used as alternative covariance structures. Least squares means and 95% confidence intervals for the difference between ampleloxetine and placebo are calculated and presented. Analytical models in the full population also include fixed effect class term of UMSARS Part IV at Visit 1 (<4, 4).

[0341] Exploratory endpoints, including assessment of change from baseline at multiple time points, such as OHQ composite score, will be analyzed similarly to the primary analysis.

[0342] For exploratory endpoints including assessment of change from baseline but only at Week 8 post-randomization (Visits 9 and 141), such as HADS domains, treatment differences will be compared based on the FAS using analysis of covariance (ANCOVA). The model will include a fixed effect of treatment and a continuous covariate of baseline score for each scale.

[0343] The analyses of the PGIS and PGIC to support the interpretation of the primary and secondary endpoints are detailed in the SAP.

[0344] In addition, a descriptive analysis of efficacy data collected during the OL period will be performed for all subjects. ***

[0345] Although the subject matter of the present disclosure has been described with reference to specific aspects or embodiments thereof, it will be understood by those skilled in the art that various modifications can be made or equivalents can be substituted without departing from the true spirit and scope of the present disclosure. Additionally, to the extent permitted by applicable patent laws and regulations, all publications, patents, and patent applications cited herein are incorporated by reference in their entirety to the same extent as if each document was individually incorporated by reference herein.

Claims

1. A pharmaceutical composition for the treatment of symptomatic neurogenic orthostatic hypotension (nOH) in subjects with multiple system atrophy (MSA), wherein the pharmaceutical composition comprises about 10 mg (free base equivalent) of ampreloxetine or a pharmaceutically acceptable salt thereof and a pharmaceutically acceptable carrier, characterized in that the pharmaceutical composition is administered to the subject daily for at least about 8 weeks, and the administration results in a reduction of at least one of the following: the Orthostatic Hypotension Symptom Assessment (OHSA) composite score, the Orthostatic Hypotension Daily Activity Scale (OHDAS) item 1 score (short periods of standing), and the OHDAS item 3 score (short periods of walking).

2. The pharmaceutical composition according to claim 1, characterized in that the pharmaceutical composition is administered orally to the subject.

3. The pharmaceutical composition according to claim 1, characterized in that the pharmaceutical composition is administered to the subject once a day.

4. The pharmaceutical composition according to claim 1, wherein, as determined using an Orthostatic Hypotension Assessment Scale (OHSA), the treated subject experiences symptoms of neurogenic orthostatic hypotension in the absence of treatment with the pharmaceutical composition.

5. The pharmaceutical composition according to claim 1, wherein the subject has MSA subtype P (MSA-P).

6. The pharmaceutical composition according to claim 1, wherein the subject has MSA subtype C (MSA-C).

7. The pharmaceutical composition according to claim 1, wherein, if the subject is determined by a tilt table test before administration, the subject exhibits a sustained reduction of BP by ≥20 mmHg (systolic) or ≥10 mmHg (diastolic) within 3 minutes of standing up or tilting upward from a supine position at ≥60° as part of an orthostatic test.

8. The pharmaceutical composition according to claim 1, wherein the subject has a score of 4 or less on the Unified Multiple System Atrophy Rating Scale (UMSARS) Part IV before administration.

9. The pharmaceutical composition according to claim 1, wherein the subject has a score of 4 on the Unified Multiple System Atrophy Rating Scale (UMSARS) Part IV prior to the administration.

10. The pharmaceutical composition according to claim 1, wherein the subject has at least 4 on the OHSA item 1 score before administration.

11. The pharmaceutical composition according to claim 1, characterized in that the pharmaceutical composition is administered for at least about 12 weeks.

12. The pharmaceutical composition according to claim 1, characterized in that ampleloxetine is administered as a hydrochloride salt.

13. The pharmaceutical composition according to claim 1, wherein the pharmaceutically acceptable carrier comprises one or more of microcrystalline cellulose, lactose, and magnesium stearate.

14. A pharmaceutical composition for the treatment of symptomatic neurogenic orthostatic hypotension (nOH) in subjects with multiple system atrophy (MSA), wherein the pharmaceutical composition comprises about 10 mg (free base equivalent) of ampreloxetine or a pharmaceutically acceptable salt thereof and a pharmaceutically acceptable carrier, and the pharmaceutical composition is administered to the subject daily for at least about 22 weeks. (a) When determined using the Orthostatic Hypotension Assessment Scale (OHSA), the subject being treated experiences symptoms of neurogenic orthostatic hypotension in the absence of treatment with the pharmaceutical composition, (b) A pharmaceutical composition in which daily administration to the subject for at least about 14 weeks results in a measurable reduction in (i) the subject's OHSA composite score, (ii) the Orthostatic Hypotension Questionnaire (OHQ) composite score, (iii) the Orthostatic Hypotension Daily Activity Scale (OHDAS) composite score, or (iv) OHDAS item 1 (short standing time).

15. The pharmaceutical composition according to claim 14, characterized in that the pharmaceutical composition is administered orally to the subject.

16. The pharmaceutical composition according to claim 14, characterized in that the pharmaceutical composition is administered to the subject once a day.

17. The pharmaceutical composition according to claim 14, wherein the supine plasma norepinephrine level in the subject is less than approximately 350 pg / mL before treatment with the pharmaceutical composition.

18. The pharmaceutical composition according to claim 14, wherein the supine plasma norepinephrine level in the subject is greater than approximately 500 pg / mL approximately 8 weeks after treatment with the pharmaceutical composition.

19. The pharmaceutical composition according to claim 14, wherein the subject has MSA subtype P (MSA-P).

20. The pharmaceutical composition according to claim 14, wherein the subject has been diagnosed with MSA at least 1.3 years prior to the administration of the drug.

21. The pharmaceutical composition according to claim 14, wherein the subject had developed nOH 1.6 years or more prior to the administration.

22. The pharmaceutical composition according to claim 14, wherein the subject had an OSHA composite score of 5 or more before administration.

23. The pharmaceutical composition according to claim 14, wherein the subject had an OSHA item 1 score of 7 or more before administration.

24. The pharmaceutical composition according to claim 14, wherein the subject has a score of ≤4 on the Unified Multiple System Atrophy Rating Scale (UMSARS) Part IV prior to the administration.

25. The pharmaceutical composition according to claim 14, wherein the subject has a score of 4 on the Unified Multiple System Atrophy Rating Scale (UMSARS) Part IV prior to the administration.

26. The pharmaceutical composition according to claim 14, characterized in that ampleloxetine is administered as a hydrochloride salt.

27. The pharmaceutical composition according to claim 14, characterized in that the pharmaceutical composition is administered for at least about 12 months.

28. The pharmaceutical composition according to claim 14, wherein the pharmaceutically acceptable carrier comprises one or more of microcrystalline cellulose, lactose, and magnesium stearate.

29. A pharmaceutical composition for treating symptomatic neurogenic orthostatic hypotension (nOH) in subjects with multiple system atrophy (MSA), wherein the pharmaceutical composition comprises ampreloxetine or a pharmaceutically acceptable salt thereof, and the subject is (a) A composite score of 5 or higher on the Orthostatic Hypotension Rating Scale (OSHA) prior to administration, and / or (b) A pharmaceutical composition diagnosed with MSA based on a score of 7 or more OSHA item 1 prior to administration.

30. A pharmaceutical composition for the treatment of symptomatic neurogenic orthostatic hypotension (nOH) in subjects with multiple system atrophy (MSA), wherein the pharmaceutical composition comprises about 10 mg (free base equivalent) of ampreloxetine or a pharmaceutically acceptable salt thereof and a pharmaceutically acceptable carrier, wherein administration results in a reduction of at least one of the following: the Orthostatic Hypotension Symptom Assessment (OHSA) composite score, the Orthostatic Hypotension Daily Activity Scale (OHDAS) composite score, the Orthostatic Hypotension Daily Activity Scale (OHDAS) Item 1 score (short periods of standing), and the OHDAS Item 3 score (short periods of walking).

31. The pharmaceutical composition according to claim 30, characterized in that the pharmaceutical composition is administered orally to the subject.

32. The pharmaceutical composition according to claim 30, wherein the pharmaceutical composition is for administration to the subject once a day.

33. The pharmaceutical composition according to claim 30, wherein, as determined using an Orthostatic Hypotension Assessment Scale (OHSA), the treated subject experiences symptoms of neurogenic orthostatic hypotension in the absence of treatment with the pharmaceutical composition.

34. The pharmaceutical composition according to claim 30, wherein the subject has MSA subtype P (MSA-P).

35. The pharmaceutical composition according to claim 30, wherein the subject has MSA subtype C (MSA-C).

36. The pharmaceutical composition according to claim 30, wherein, if the subject is determined by a tilt table test prior to treatment, the subject has a sustained reduction of BP of ≥20 mmHg (systolic) or ≥10 mmHg (diastolic) within 3 minutes of standing up or tilting upward from a supine position at ≥60° as part of an orthostatic test.

37. The pharmaceutical composition according to claim 30, wherein, prior to treatment, the subject has a score of 4 or less on the Unified Multiple System Atrophy Rating Scale (UMSARS) Part IV.

38. The pharmaceutical composition according to claim 30, wherein, prior to treatment, the subject has a score of 4 on the Unified Multiple System Atrophy Rating Scale (UMSARS) Part IV.

39. The pharmaceutical composition according to claim 30, wherein the subject has an OHSA item 1 score of at least 4 before administration.

40. The pharmaceutical composition according to claim 30, characterized in that the pharmaceutical composition is administered for at least about 12 weeks.

41. The pharmaceutical composition according to claim 30, characterized in that ampleloxetine is administered as a hydrochloride salt.

42. The pharmaceutical composition according to claim 30, wherein the pharmaceutically acceptable carrier comprises one or more of microcrystalline cellulose, lactose, and magnesium stearate.

43. A pharmaceutical composition for use in a method for identifying a subject having multiple system atrophy (MSA) and responding to ampreloxetine, wherein the pharmaceutical composition comprises a pharmaceutically acceptable carrier and about 10 mg (free base equivalent) of ampreloxetine or a pharmaceutically acceptable salt thereof, and the method comprises administering the pharmaceutical composition to the subject for at least 8 weeks.

44. The pharmaceutical composition according to claim 43, characterized in that the pharmaceutical composition is administered for at least 12 weeks.

45. The pharmaceutical composition according to claim 43, further comprising determining whether the subject shows a decrease of at least 2 points in the Orthostatic Hypotension (OHSA) Item 1 score after administration.

46. The pharmaceutical composition according to claim 43, characterized in that the pharmaceutical composition is administered orally to the subject.

47. The pharmaceutical composition according to claim 43, characterized in that the pharmaceutical composition is administered to the subject once a day.

48. The pharmaceutical composition according to claim 43, wherein the MSA is MSA subtype P (MSA-P).

49. The pharmaceutical composition according to claim 43, wherein the MSA is MSA subtype P (MSA-C).

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