Methylthioninium for use in the treatment of synaptopathy - Patent Application 20070233633

Abstract

The present invention relates generally to methods and materials for treating synaptopathy based on the use of the leucomethylthioninium acid salts disclosed herein to increase synaptophysin levels in various brain regions at therapeutically relevant doses in both animal models of neurodegenerative disease and normal animals.

Description

[Technical field]

[0001] Technical Field The present invention relates generally to methods and materials for treating synaptopathy. [Background technology]

[0002] Background technology Synapses are essential components of neurons and allow the systematic flow of information in the brain. The development, diversification, and differentiation of synapses played a central role in the evolution of higher brain functions and cognition in vertebrates. On the one hand, modulation of synaptic activity constitutes a major strategy to control brain homeostasis. On the other hand, subtle but persistent disturbances in synaptic physiology can lead to major defects that can manifest as brain disorders.

[0003] Synaptic vesicle (SV)-mediated transmitter release is a major mechanism of neuronal signaling. SVs are characterized by highly specific polypeptide compositions that facilitate this tightly regulated process.

[0004] Synaptophysin is an abundant and integral membrane glycoprotein of SVs with four transmembrane domains and a unique cytoplasmic tail rich in proline, glycine, and tyrosine.

[0005] Synaptophysin has been implicated in the regulation of neurotransmitter release and synaptic plasticity, as well as in SV biogenesis and recycling. Increased synaptophysin expression has been found to correlate with long-term potentiation, suggesting that modulation of synaptophysin expression may affect mechanisms underlying learning and memory.

[0006] Abnormal synaptophysin expression has been associated with neurodegenerative diseases and psychiatric disorders. It has been reported that the removal of synaptophysin in mice causes behavioral changes, such as increased exploratory behavior, impaired object novelty recognition, and reduced spatial learning (Schmitt, U., et al. "Detection of behavioral alterations and learning deficits in mice lacking synaptophysin." Neuroscience 162.2 (2009): 234-243).

[0007] The term "synaptic degeneration" has been used to refer to brain disorders resulting from synaptic dysfunction. There is now evidence for the importance of synaptic dysfunction as a major determinant of several neurodevelopmental disorders (e.g., schizophrenia, major depression, autism spectrum disorder (ASD), Down's syndrome, startle syndrome, and epilepsy), nervous system disorders (e.g., dystonia, levodopa-induced dyskinesia, and ischemia), and neurodegenerative diseases (e.g., Alzheimer's and Parkinson's diseases) (Lepeta et al., 2016).

[0008] US Patent Application Publication No. 20020040032 relates to a method of increasing the synthesis and / or secretion of synaptophysin comprising administering to a patient having or at risk of developing a nervous system disease an effective amount of a purine derivative or analogue, a tetrahydroindolone derivative or analogue, or a pyrimidine derivative or analogue. Examples of nervous system diseases mentioned include neurodegenerative diseases such as Alzheimer's disease or neurodevelopmental disorders such as Down's syndrome.

[0009] However, characterising further compounds capable of modulating, and in particular increasing, synaptophysin levels in the brain could be seen as realising a contribution to the art. Summary of the Invention [Problem to be solved by the invention]

[0010] Disclosure of the Invention The inventors have unexpectedly discovered that leucomethylthioninium acid salts (herein referred to as "LMTX" salts) are capable of increasing synaptophysin levels in various brain regions at therapeutically relevant doses in both animal models of neurodegenerative disease and in normal (wild-type) animals. [Means for solving the problem]

[0011] The present findings demonstrate novel utility for LMTX salts at therapeutically relevant doses for use in the treatment of synaptic degeneration.

[0012] Bis(hydromethanesulfonate) (LMTM; USAN name, hydromethylthionine mesylate) is being developed as a treatment to target pathological aggregation of tau protein in AD (Wischik et al., 2018). The methylthioninium (MT) moiety is a cytochrome P450 (CYP450)-dependent agonist (CYP450) that converts tau protein into its oxidized form (MT + ) and reduced (LMT) forms. LMTM is the oxidized form MT + It is a stabilized salt of LMT that has much better pharmaceutical properties than the MT form (Baddeley et al., 2015; Harrington et al., 2015). +Instead, we recently reported that LMT is the active species that blocks tau aggregation in vitro (Al-Hilaly et al., 2018). LMT blocks tau aggregation in vitro in cell-free and cell-based assays (Harrington et al., 2015;Al-Hilaly et al., 2018) and reduces tau aggregation pathology and associated behavioral impairments at clinically relevant doses in vivo in tau transgenic mouse models (Melis et al., 2015a). LMT also disaggregates tau protein in paired helical filaments (PHFs) isolated from AD brain tissue, converting tau to a form susceptible to proteases (Wischik et al., 1996;Harrington et al., 2015).

[0013] Orally given LMTM produces brain levels sufficient for in vitro and in vivo activity (Baddeley et al., 2015), but it had minimal apparent efficacy when taken as an add-on treatment to symptomatic treatment in two large Phase 3 AD clinical trials (Gauthier et al., 2016;Wilcock et al., 2018). However, in subjects receiving LMTM as monotherapy, treatment produced a significant slowing of cognitive and functional decline, a reduction in the rate of progression of brain atrophy measured by MRI, and a reduction in the decrease in glucose uptake measured by FDG-PET (Gauthier et al., 2016;Wilcock et al., 2018). When these results were analyzed in combination with population pharmacokinetic data available from subjects participating in the trial, it was found that LMTM produced concentration-dependent effects whether taken alone or in combination with symptomatic treatment, such as an acetylcholinesterase inhibitor. However, the treatment effect in monotherapy subjects was substantially greater than in those taking LMTM in combination with an approved symptomatic treatment for AD.

[0014] LMTM and other leucomethylthioninium bis-protonic acid salts have been suggested for the treatment of various diseases, disorders and pathologies in several published documents, e.g., WO 2007 / 110627, WO 2008 / 155533, WO 2009 / 044127, WO 2012 / 107706, WO 2018019823 and WO 2018041739.

[0015] The present studies were conducted with the objective of understanding the mechanisms involved in the reduced efficacy of LMTM as an add-on to the symptomatic treatments discussed above. In these studies, a well-characterized tau transgenic mouse model (Line 1, "L1"; (Melis et al., 2015b)) was compared to wild-type mice.

[0016] One conclusion from these studies is that homeostatic mechanisms downregulate multiple neural systems at different levels of brain function, compensating for the chronic pharmacological activation induced by previous symptomatic treatments. The effect of this downregulation is to reduce neurotransmitter release, levels of synaptic proteins, mitochondrial function and behavioral benefits when LMTM is given against a background of previous chronic exposure to an acetylcholinesterase inhibitor, compared to LMTM given alone.

[0017] Unexpectedly, however, these studies also revealed that LMTX salts increased synaptophysin levels in various brain regions at therapeutically relevant doses in both L1 and wild-type mice, a finding that provides novel utility for LMTX in diseases of synaptic dysfunction.

[0018] Thus, in one aspect, there is provided a method of increasing levels of synaptophysin in the brain of a mammalian subject, the method comprising orally administering MT to the subject per day; The MT compound is the LMTX compound of the following formula: [ka] (Wherein, each of HnA and HnB (when present) is a protonic acid which may be the same or different; p=1 or 2; q=0 or 1; n=1 or 2; (p+q)×n=2).

[0019] A subject may be selected as being in need of increased levels of synaptophysin.

[0020] The subject may be a human subject or patient having synaptopathy or at risk of developing synaptopathy.

[0021] The subject can be a human subject or patient having a neurodevelopmental, neurological, or neurodegenerative disease or at risk of developing a neurodevelopmental, neurological, or neurodegenerative disease.

[0022] Increased levels can be in multiple brain regions. For example, the temporal lobe, which is important for memory, is usually affected in epilepsy. Schizophrenia is often considered a neurodevelopmental disorder; by imaging, it is characterized by generalized cortical loss and ventricular enlargement, with smaller thalamus and temporal lobes and larger caudate nucleus. However, depending on brain connectivity, the effects of synaptic dysfunction can be exerted in multiple brain regions.

[0023] The inventors' findings have implications for novel uses of LMTX compounds in neurodevelopmental, neurological and neurodegenerative diseases where no need for LMTX compounds has been previously demonstrated. The inventors' findings further have implications for use in patient subgroups in diseases where LMTX has previously been suggested for use, where synaptic dysfunction has been more specifically implicated.

[0024] Thus, another aspect of the invention provides a method for the therapeutic treatment of a disorder in a subject. Suitable disorders are listed below. In particular, "synaptic disorders" in which LTMX may have utility include: Schizophrenia Depression Epilepsy Startle syndrome (Tourette's syndrome and anxiety disorders) Autism spectrum disorders (ASD) (Autism, Asperger syndrome, Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS), and Childhood Disintegrative Disorder) Focal hand dystonia Cerebral ischemia Experimental allergic encephalitis (EAE) ·Multiple sclerosis (MS) Glaucoma Includes.

[0025] There is much evidence for a role for synaptophysin in AD. Synapses are thought to be the earliest site of pathology, and synapse loss is the best pathological correlate of cognitive decline in subjects with AD (Terry et al., 1991). Synaptic abnormalities in the hippocampus correlate with the severity of neuropathology and memory deficits in individuals with AD, and this deficit may precede neuropsychological evidence of cognitive decline in the early stages of AD (Sze et al., 1997).

[0026] Furthermore, genome-wide association studies (GWAS) have identified more than 20 genetic loci associated with late-onset AD, which are grouped into three main biological pathways: lipid metabolism, immune system, and synaptic dysfunction / cell membrane processes (Van Giau et al., 2019; Verheijen and Sleegers, 2018, Understanding Alzheimer Disease at the Interface between Genetics and Transcriptomics. Trends Genet. 34: 434-447).

[0027] Synaptic density can be detected in vivo in AD using positron emission tomography imaging (Chen et al. 2018, Assessing synaptic density in Alzheimer disease with synaptic vesicle glycoprotein 2a positron emission tomographic imaging. JAMA Neurol. 75:1215-1224). This can be used both for patient selection criteria and as an outcome measure for disease-modifying therapeutic trials, especially those targeting synaptic preservation and restoration. For example, patients may be assessed by 11C-UCB-J-PET BPND to select those showing at least a 30% reduction in hippocampal SV2A-specific binding compared to cognitively normal participants (see Chen, 2018).

[0028] Thus, subjects in the subgroup with late-onset AD, particularly those characterized as having synaptic dysfunction, form a further target patient population for the present invention.

[0029] Lysosomal storage diseases (LSDs) are a group of about 70 rare inherited metabolic disorders that result from defects in lysosomal function (e.g., Parenti, Andria and Ballabio, 2015, Lysosomal Storage Diseases: From Pathophysiology to Therapy. Ann. Rev. Med. 66:471-486; Lloyd-Evans and Haslett, 2016, The lysosomal storage disease continuum with ageing-related neurodegenerative disease. Ageing Research Reviews 32:104-121). Lysosomes digest large molecules within the cell and send the fragments to other parts of the cell for recycling. If the enzymes in this process are defective, the large molecules accumulate within the cell, leading to cell death. There is no known cure for lysosomal storage diseases, and treatments are mostly symptomatic.

[0030] LSDs are generally classified by the nature of the primary stored material involved and can be broadly divided into the following disorders: lipid storage disorders; sphingolipidoses, including Gaucher disease and Niemann-Pick disease; gangliosidoses (including Tay-Sachs disease); cerebral leukodystrophies; mucopolysaccharidoses (including Hunter syndrome and Hurler disease); glycoprotein storage disorders; mucolipidoses; glycogen storage disease type II (Pompe disease); and cystinosis.

[0031] Alternatively, LSDs may be classified by protein targets, e.g., defects in various lysosomal enzymes (including Tay-Sachs disease, I-cell diseases, and sphingolipidoses, e.g., Krabbe disease, gangliosidosis, Gaucher disease, Niemann-Pick disease, metachromatic leukodystrophy); post-translational modifications of sulfatases (multiple sulfatase deficiencies); enzyme protective proteins (e.g., defective cathepsin A in galactosialidosis); transmembrane proteins (e.g., sphingolipid activator protein and sialin in Salla disease) (see, e.g., http: / / www.lysosomaldiseasenetwork.org / official-list-lysosomal-diseases).

[0032] Lysosomal storage disorders (LSDs) often represent a neurodegenerative process, and no therapies exist to treat the central nervous system in LSDs. Furthermore, the mechanisms driving neuronal degeneration in these pathological conditions remain largely unknown. In mouse models of LSD, impaired lysosomal activity leads to perikaryocytic accumulation of insoluble α-synuclein and increased proteasomal degradation of cysteine ​​string protein α (CSPα) (Sambri et al., 2017, Lysosomal dysfunction disrupts presynaptic maintenance and restoration of presynaptic function prevents neurodegeneration in lysosomal storage diseases. EMBO Molecular Medicine 9:112-132). As a result, the availability of both α-synuclein and CSPα in nerve terminals is strongly reduced, thus inhibiting SNARE complex assembly and synaptic vesicle recycling.

[0033] Neurodegeneration in LSD may be slowed by re-establishing presynaptic function. Thus, improving synaptic maintenance as disclosed herein provides one means for treating or mitigating the effects of LSD.

[0034] Both WO 2012 / 107706 and WO 2018 / 0198823 discuss the usefulness of LMTX compounds in their capacity as tau aggregation inhibitors in treating lysosomal storage disorders associated with tau pathology. Both Niemann-Pick disease type C (NPC) and Sanfilippo syndrome type B are mentioned (Suzuki et al. 1995, Neurofibrillary tangles in Niemann-Pick type C, Acta Neuropathol., 89(3) 227-238; Ohmi et al. 2009 Sanfilippo syndrome type B, a lysosomal storage disease, is also a tauopathy. Proceedings of the National Academy of Sciences 106:8332-8337).

[0035] However, in view of the present disclosure, it can be seen that other types of LSDs, even those not associated with tau pathology, can be improved by the use of LMTX type compounds.Thus, the treatment of LSDs, which are optionally not tauopathies, such as NPC or Sanfilippo syndrome type B, forms an aspect of the present invention.Examples include Gaucher disease; Tay-Sachs disease; leukodystrophy; mucopolysaccharidoses (including Hunter syndrome and Hurler disease); glycoprotein storage disorders; mucolipidosis; glycogen storage disease type II (Pompe disease); cystinosis; I-cell disease; Krabbe disease; gangliosidosis; metachromatic leukodystrophy; multiple sulfatase deficiency; galactosialidosis; Salla disease.

[0036] Other examples include activator deficiency, GM2-gangliosidosis;GM2-gangliosidosis, AB variant;alpha-mannosidosis;beta-mannosidosis;aspartylglucosaminuria;lysosomal acid lipase deficiency;Chanarin-Dorfman syndrome;Danon disease;Fabry disease;Farber disease;Farber lipogranulomatosis;Fucosidosis;Galactosialidosis (mixed neuraminidase and beta-galactosidase deficiency);GM1-gangliosidosis;Mucopolysaccharidosis disorders;MPS I, Hurler syndrome;MPS I, Hurler-Scheie syndrome;MPS I, Scheie syndrome;MPS II, Hunter syndrome;MPS II, Hunter syndrome;Morquio syndrome, type A / MPS IVA;Morquio syndrome, type B / MPS IVB;MPS IX hyaluronidase deficiency;MPS VI Marotele-Lamy syndrome;MPS VII Sly syndrome;mucolipidosis I, sialidosis;pseudo-Hurler polydystrophy / mucolipidosis type III;mucolipidosis IIIC / ML III GAMMA;mucolipidosis type IV;neuronal ceroid lipofuscinosis;CLN6 disease-atypical late-onset pediatric, late-onset variant, early juvenile;Batten-Spielmeier-Voigt / juvenile NCL / CLN3 disease;Finnish variant late-onset pediatric CLN5;Jansky-Beerschowski disease / late-onset pediatric CLN2 / TPP1 disease;Kuchs / adult-onset NCL / CLN4 disease;Northern epilepsy / atypical late-onset pediatric CLN8;Santavoli-Hartia / pediatric CLN1 / PPT disease;pycnodysostosis;Sandho Includes: Sandhoff disease / GM2 gangliosidosis; Sandhoff disease / GM2 gangliosidosis; Sandhoff disease / GM2 gangliosidosis; Schindler disease; Kanzaki disease; Infantile free sialic acid storage disease (ISSD); Spinal muscular atrophy with progressive myoclonic epilepsy (SMAPME); Christianson syndrome; Rowe oculocerebrorenal syndrome; Charcot-Marie-Tooth type 4J, CMT4J; Eunice-Baron syndrome; Bilateral temporo-occipital polymicrogyria (BTOP); X-linked hypercalciuric nephrolithiasis, Dent-1; Dent disease 2.

[0037] Another aspect of the invention relates to a methylthioninium (MT)-containing LTMX compound as described herein for use in such methods, e.g., a method of increasing the level of synaptophysin in the brain of a mammalian subject, or a method of treating certain diseases as described herein.

[0038] Another aspect of the invention relates to the use of a methylthioninium (MT)-containing LTMX compound as described herein in the manufacture of a medicament for use in the methods described above, e.g., a method of increasing the level of synaptophysin in the brain of a mammalian subject, or a method of treating certain diseases described herein.

[0039] Particularly (but not exclusively) related to cognitive impairment, the subject may be naive and not previously treated with acetylcholinesterase inhibitors (AChEI) or memantine, an N-methyl-D-aspartate receptor antagonist. Examples of acetylcholinesterase inhibitors include donepezil (Aricept™), rivastigmine (Exelon™) or galantamine (Reminyl™). One example of an NMDA receptor antagonist is memantine (Ebixa™, Namenda™).

[0040] For example, the subject group may be completely naive to these other treatments, having not previously received one or both of these.

[0041] However, the subject group may have previously received one or both of these treatments, but have discontinued medication for at least 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, or 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 12 weeks, or 16 weeks, or more preferably at least 1 month, 2 months, 3 months, 4 months, 5 months, or 6 months, etc., prior to treatment with the MT compounds according to the present invention.

[0042] Any aspect of the invention may include an active step of selecting a subject group according to these criteria.

[0043] The term "treatment" includes "combination" therapeutic treatments, where two or more treatments treating related diseases are combined, for example sequentially or simultaneously.

[0044] In combination treatments, the agents (i.e., an MT compound as described herein plus one or more other agents) may be administered simultaneously or sequentially, with individually varying dose schedules and by different routes. For example, when administered sequentially, the agents can be administered closely spaced apart (e.g., over a period of 5-10 minutes) or at longer intervals (e.g., 1 hour, 2 hours, 3 hours, 4 hours or more apart, or even longer periods apart, in some circumstances), with the exact dosage regime commensurate with the properties of the therapeutic agents.

[0045] One example of a combination treatment of the present invention is the use of an MT compound with a treatment for the same disease previously known in the art. Schizophrenia: Therapeutic agents for the treatment of schizophrenia are typically antipsychotics that generally affect dopamine or serotonin neurotransmission. First generation antipsychotics include chlorpromazine, fluphenazine, haloperidol, and perphenazine. Second generation antipsychotics have fewer side effects and include clozapine, olanzapine, quetiapine, and risperidone. Depression may involve treatment with second generation antipsychotics. Epilepsy can be treated with a variety of antiepileptic drugs, whose action aims to reduce excessive electrical activity in the brain. These include sodium valproate (Epilin), levetiracetam, phenobarbital, topiramate and zonisamide. Startle syndromes (Tourette's syndrome and anxiety disorders). The class of medications with the most proven effectiveness in treating tic symptoms are the typical and atypical neuroleptics, including risperidone (Risperdal), ziprasidone (Geodon), haloperidol (Haldol), pimozide (Orap) and fluphenazine (Prolixin). Autism spectrum disorder (ASD). Over half of U.S. children diagnosed with ASD are prescribed psychoactive or anticonvulsant medications, with the most common drug classes being antidepressants, stimulants, and antipsychotics. Only antipsychotics have clearly demonstrated efficacy. Selective serotonin reuptake inhibitors (SSRIs) and dopamine blockers can reduce some of the maladaptive behaviors associated with ASD. Focal hand dystonia: This condition is often treated with injections of botulinum neurotoxin A, which reduces the symptoms of the disorder but is not a cure. Anticholinergics, such as Artane, may be prescribed for off-label use. Cerebral ischemia. Alteplase is a thrombolytic drug. It is a tissue plasminogen activator approved by the U.S. Food and Drug Administration for the treatment of acute ischemic stroke. Experimental allergic encephalitis (EAE) is an autoimmune demyelinating condition that can be treated with therapies used to treat multiple sclerosis. Multiple sclerosis (MS) is a chronic inflammatory demyelinating condition that can be treated with dimethyl fumarate, fingolimod (a sphingosine-1-phosphate receptor modulator), natalizumab (Tysabri), alemtuzumab, ocrelizumab, interferons, and glatiramer acetate. Glaucoma: Several classes of medications can be used to treat glaucoma. Prostaglandin analogs, such as latanoprost, bimatoprost, and travoprost, increase the uveoscleral pathway of aqueous humor. Topical beta-adrenergic receptor antagonists, such as timolol, levobunolol, and betaxolol, decrease aqueous humor production by the epithelium of the ciliary body. Alpha 2-adrenergic agonists, such as brimonidine and apraclonidine, act by a dual mechanism of decreasing aqueous humor production and increasing the uveoscleral pathway. Less selective alpha agonists, such as epinephrine, decrease aqueous humor production by vasoconstriction of the ciliary body blood vessels. Miotics (parasympathomimetics), such as pilocarpine, act by contraction of the ciliary muscle, opening the trabecular meshwork and allowing increased outflow of aqueous humor. Echothiophate, an acetylcholinesterase inhibitor, is used in chronic glaucoma. Carbonic anhydrase inhibitors, such as dorzolamide, brinzolamide, and acetazolamide, reduce the secretion of aqueous humor by inhibiting carbonic anhydrase in the ciliary body. · LSD: Treatments include enzyme replacement therapy, small molecule pharmacological chaperones, or gene therapy strategies to correct genetic mutations (Bruni S, Loschi L, Incerti C, Gabrielli O, Coppa GV. Update on treatment of lysosomal storage diseases. Acta Myol. 2007;26(1):87-92.); Parenti, Giancarlo, et al. “New strategies for the treatment of lysosomal storage diseases.” International journal of molecular medicine 31.1 (2013):11-20.

[0046] The use of MT compounds in the methods or uses described herein in combination with any of these other therapeutic agents forms an aspect of the invention.

[0047] In other embodiments, the treatment is a "monotherapy," that is, the MT-containing compound is not used in combination (within the meaning discussed above) with another active agent.

[0048] As noted above, it is specifically anticipated that administration of the MT compounds may be initiated in subjects who have not previously received (and are not currently receiving) an AChEI or memantine.

[0049] However, such AChEI or memantine treatment may optionally be initiated or resumed after the initiation of treatment with the MT compound, for example after approximately three months of treatment with the MT compound, which may be desirable, for example, for subjects being treated for late-onset AD (synaptic dysfunction). DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0050] LMTX compound Preferably, the MT compound is a "LMTX" compound of the type described in WO 2007 / 110627 or WO 2012 / 107706.

[0051] Thus, the compound may be selected from compounds of the formula: or a hydrate or solvate thereof:

[0052] [Table 1]

[0053] H n A and H n Each occurrence of B (when present) is a protic acid which may be the same or different.

[0054] "Protonic acid" refers to the amount of protons (H + ) donor. In the protonic acid, A - Or B -is therefore the conjugate base. Thus, protic acids have a pH of less than 7 in water (i.e., the concentration of hydronium ions is less than 10 per liter). -7 (Molar excess).

[0055] In one embodiment, the salt has the formula:

[0056] [Table 2]

[0057] where HA and HB are different monoprotic acids.

[0058] However, preferably the salt is not a mixed salt but has the formula

[0059] [Table 3]

[0060] wherein H n Each X is a protic acid, for example a diprotic acid or a monoprotic acid.

[0061] In one embodiment, the salt has the formula:

[0062] [Table 4]

[0063] where H2A is a diprotic acid.

[0064] Preferably, the salt is a bismonoprotic acid salt of the formula

[0065] [Table 5]

[0066] has.

[0067] Examples of protonic acids that may be present in the LMTX compounds used herein are: Inorganic acids: hydrohalic acids (e.g., HCl, HBr), nitric acid (HNO3), sulfuric acid (H2SO4), Organic acids: Carbonic acid (H2CO3), acetic acid (CH3COOH), methanesulfonic acid, 1,2-ethanedisulfonic acid, ethanesulfonic acid, naphthalenedisulfonic acid, p-toluenesulfonic acid Includes. Preferred acids are monoprotic acids and the salts are bis(monoprotic acid) salts.

[0068] A preferred MT compound is LMTM.

[0069] [Table 6]

[0070] The anhydrous salt has a molecular weight of approximately 477.6. Based on a molecular weight of 285.1 for the LMT core, the weight factor for using this MT compound in the present invention is 1.67. "Weight factor" refers to the relative weight of the pure MT-containing compound to the weight of MT it contains.

[0071] Other weight coefficients can be calculated for the example MT compounds herein, and corresponding dosage ranges can be calculated therefrom.

[0072] Thus, the present invention encompasses total daily doses of LMTM of approximately 2-100 mg / day.

[0073] More preferably, a total dose of approximately 6-12 mg / day of LMTM is utilized, which corresponds to approximately 3.5-7 mg of MT.

[0074] Other example LMTX compounds are as follows, their molecular weights (anhydrous) and weight coefficients are also given:

[0075] [Table 7]

[0076] In the various aspects of the invention described herein (as they relate to MT-containing compounds), this can optionally be any of those compounds described above.

[0077] In one embodiment, it is compound 1.

[0078] In one embodiment, it is compound 2.

[0079] In one embodiment, it is compound 3.

[0080] In one embodiment, it is compound 4.

[0081] In one embodiment, it is compound 5.

[0082] In one embodiment, it is compound 6.

[0083] In one embodiment, it is compound 7.

[0084] In one embodiment, it is compound 8.

[0085] Alternatively, the compound may be a hydrate, solvate, or a mixed salt of any of these.

[0086] Based on the results herein, as well as previous and concurrent results using LMTM in the treatment of diseases, it can be concluded that MT dosages in the range of 2-80 or 100 mg / day may be beneficial for the synaptic degenerative diseases described herein.

[0087] More specifically, further analysis of the concentration response for LMTM with respect to the treatment of disease supports the assertion that a preferred dose is at least 2 mg / day, with doses in the range of 20-40 mg / day, or 20-60 mg / day, being expected to maximize cognitive benefits, while nevertheless maintaining a desirable profile with respect to being well tolerated with minimal side effects.

[0088] Thus, in one embodiment, the total MT dose can be from about any of 2, 2.5, 3, 3.5, 4 mg to about any of 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59 or 60 mg.

[0089] Example dosages are from 2 to 60 mg, for example, 20, 30, 40, 50, or 60 mg.

[0090] An example dosage is 20-40 mg.

[0091] Further example dosages are 8 or 16 or 24 mg / day.

[0092] The subject of the present invention may be an adult human, and the dosages described herein are based on that basis (typical body weight 50-70 kg). If necessary, corresponding dosages may be utilized for subjects outside this range by using a subject weight factor, whereby the subject's body weight is divided by 60 kg to provide a multiplicative factor for that individual subject.

[0093] As one of skill in the art will recognize, for a given daily dose, more frequent dosing results in greater accumulation of drug.

[0094] We derived a putative accumulation factor for MT as follows.

[0095] [Table 8]

[0096] For example, considering a total daily dose of 3.5-7 mg of MT: When given as a single daily dose, this may equate to an accumulation of MT in plasma of 4.5 to 8 When divided by bi-day, this may equate to an accumulation of MT in plasma of 5.1 to 10.3. When divided by tid, this may equate to an accumulation of MT in plasma of 5.8 to 11.6.

[0097] Thus, in certain embodiments of the invention, when dosed more frequently (eg, twice a day [bid] or three times a day [tid]), the total daily dosage of the MT compound may be lower.

[0098] In one embodiment, LMTM is administered at approximately 9 mg once daily; 4 mg bid; 2.3 mg tid (based on the weight of LMTM).

[0099] In one embodiment, LMTM is administered at approximately 34 mg once daily; 15 mg bid; 8.7 mg tid (based on the weight of the LMTM).

[0100] The MT compound of the present invention, or a composition containing it, is administered orally to a subject.

[0101] In some embodiments, the MT compound is administered as a composition comprising a LMTX compound as described herein and a pharma- ceutically acceptable carrier, excipient, or additive.

[0102] The term "pharmacologically acceptable," as used herein, refers to compounds, ingredients, materials, compositions, dosage forms, etc., that are suitable for use in contact with the tissues of a subject of interest without excessive toxicity, irritation, allergic response, or other problem or complication, commensurate with a reasonable benefit / risk ratio. Each carrier, excipient, additive, etc. must also be "acceptable" in the sense of being compatible with the other ingredients of the formulation.

[0103] Compositions comprising LMTX salts have been described in several published documents, for example, WO 2007 / 110627, WO 2009 / 044127, WO 2012 / 107706, WO 2018019823, and WO 2018041739.

[0104] In some embodiments, the compositions are compositions comprising at least one LMTX compound as described herein, together with one or more other pharma- ceutically acceptable ingredients known to those of skill in the art, including, but not limited to, pharma- ceutically acceptable carriers, excipients, additives, adjuvants, fillers, buffers, preservatives, antioxidants, lubricants, stabilizers, solubilizers, surfactants (e.g., wetting agents), masking agents, colorants, flavoring agents, and sweetening agents.

[0105] In some embodiments, the composition further comprises other active agents.

[0106] Suitable carriers, excipients, additives, etc. can be found in standard pharmaceutical textbooks, see, for example, Handbook of Pharmaceutical Additives, 2nd Edition (eds. M. Ash and I. Ash), 2001 (Synapse Information Resources, Inc., Endicott, New York, USA), Remington's Pharmaceutical Sciences, 20th edition, pub. Lippincott, Williams & Wilkins, 2000; and Handbook of Pharmaceutical Excipients, 2nd edition, 1994.

[0107] In some embodiments, the composition is a tablet.

[0108] In some embodiments, the composition is a capsule.

[0109] In some embodiments, the capsule is a gelatin capsule.

[0110] In some embodiments, the capsule is an HPMC (hydroxypropyl methylcellulose) capsule.

[0111] In some embodiments, the amount of MT in the unit is between 2 and 60 mg.

[0112] In some embodiments, the amount of MT in the unit is 10-40, or 10-60 mg.

[0113] In some embodiments, the amount of MT in the unit is 20-40, or 20-60 mg.

[0114] An example dosage unit may contain from 2 to 10 mg of MT.

[0115] Further example dosage units may contain 2-9 mg of MT.

[0116] Further example dosage units may contain 3-8 mg of MT.

[0117] Further preferred dosage units may contain 3.5 to 7 mg of MT.

[0118] Further preferred dosage units may contain 4-6 mg of MT.

[0119] In some embodiments, the amount is about 2, 2.5, 3, 3.5, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, or 20 mg of MT.

[0120] Using the weight factors described or illustrated herein, one of ordinary skill in the art can select the appropriate amount of MT-containing compound for use in an oral formulation.

[0121] As explained above, the MT weight factor for LMTM is 1.67. Because it is convenient to use uniform or simple fractions of the active ingredient, non-limiting example LMTM dosage units may contain about 3, 3.5, 4, 5, 6, 7, 8, 9, 10, 15, 16, 17, 34, 50, 63 mg, etc.

[0122] The compositions described herein (e.g., a prescribed dose of an MT-containing compound, plus optionally other ingredients) can be provided in a labeled packet with instructions for their therapeutic or prophylactic use.

[0123] In one embodiment, the pack is a bottle as is well known in the pharmaceutical art. A typical bottle may be made from pharmacopoeia grade HDPE (high density polyethylene) with a child-resistant HDPE push lock closure and may contain a silica gel desiccant present in a sachet or canister. The bottle itself may include a label and be packaged in a cardboard container along with instructions for use and, optionally, a further copy of the label.

[0124] In one embodiment, the pack or packet is thus a substantially moisture-impervious blister pack (preferably one with an aluminum cavity and aluminum foil), in which case the pack may be packaged in a cardboard container with instructions for use and a label on the container.

[0125] The label or instructions may provide information regarding the maximum allowable daily dosage of a composition as described herein, for example, on a once daily, bid, or tid basis.

[0126] The label or instructions may provide information regarding the recommended duration of treatment.

[0127] Salts and solvates Although the LMTX-containing compounds described herein are salts, they may also be provided in the form of mixed salts (i.e., a compound of the invention in combination with another salt). Such mixed salts are intended to be encompassed by the term "and pharma-ceutically acceptable salts thereof." Unless otherwise specified, a reference to a particular compound also includes its salts.

[0128] The compound of the present invention may also be provided in the form of a solvate or hydrate. The term "solvate" is used herein in its normal sense to refer to a complex of a solute (e.g., a compound, a salt of a compound) and a solvent. When the solvent is water, the solvate may conveniently be referred to as a hydrate, for example, a monohydrate, a dihydrate, a trihydrate, a pentahydrate, etc. Unless otherwise specified, a reference to a compound also includes a solvate and any hydrate form thereof.

[0129] Of course, solvates or hydrates of the salts of the compounds are also encompassed by the present invention.

[0130] Several patents and publications are cited herein in order to more fully describe and disclose the invention and the state of the art to which the invention pertains. Each of these references is incorporated by reference in its entirety into this disclosure to the same extent as if each individual reference was specifically and individually indicated to be incorporated by reference.

[0131] Throughout this specification, including the claims which follow, unless the context requires otherwise, the word "comprise" and variations such as "comprises" and "comprising" are understood to imply the inclusion of a stated integer or step, or group of integers or steps, but not the exclusion of any other integer or step, or group of integers or steps.

[0132] It must be noted that as used in this specification and the appended claims, the singular forms "a," "an," and "the" include plural referents unless the context clearly dictates otherwise. Thus, for example, reference to a "pharmaceutical carrier" includes mixtures of two or more such carriers, and the like.

[0133] Ranges are often expressed herein as from "about" one particular value, and / or to "about" another particular value. When such a range is expressed, another embodiment includes from the one particular value and / or to the other particular value. Similarly, when values ​​are expressed as approximations, by use of the antecedent "about," it will be understood that the particular value forms another embodiment.

[0134] Any subheadings herein are included for convenience only and are not to be construed as limiting the disclosure in any way.

[0135] The invention will now be further described with reference to the following non-limiting figures and examples, in view of which other embodiments of the invention will occur to those skilled in the art.

[0136] The disclosures of all references cited in this specification, in so far as they may be used by those skilled in the art to carry out the present invention, are hereby expressly incorporated herein by cross-reference. [Brief description of the drawings]

[0137] [Figure 1] Effect of treatment with LMTM alone or following chronic pretreatment with rivastigmine on hippocampal levels of acetylcholine (A) or synaptophysin levels measured immunohistochemically as the mean of the hippocampus, visual cortex, diagonal band and septal area (B) in wild-type mice. (**, p<0.01; ***, p<0.001). [Diagram 2] Effect of treatment with LMTM alone or following chronic pretreatment with rivastigmine on (A) SNARE complex proteins (SNAP25, syntaxin and VAMP2) and (B) α-synuclein levels measured by immunohistochemistry as mean in the hippocampus, visual cortex, diagonal band and septal area in tau transgenic L1 mice. (*, p<0.05; ***, p<0.001; ****, p<0.0001). EXAMPLES

[0138] Working Example Example 1 - Provision of MT-containing compounds Methods for the chemical synthesis of the MT-containing compounds described herein are known in the art. For example: Compounds 1 to 7 can be synthesized by the methods described in WO 2012 / 107706 or methods similar thereto. The synthesis of compound 8 can be carried out by methods described in WO 2007 / 110627 or methods analogous thereto.

[0139] Example 2 - Characteristics of the tau transgenic mouse model used for interference studies In the L1 mouse model used in some of the present studies, there is overexpression of a three-repeat tau fragment encompassing residues 296-390 of the 2N4R tau isoform under the control of the Thy1 promoter in the NMRI mouse strain (WO 2002 / 059150). This fragment corresponds to a segment of tau originally identified within the proteolytically stable core of PHFs (Wischik et al., 1988a;Wischik et al., 1988b) and recently confirmed by cryo-electron microscopy of PHFs in AD and tau filaments in Pick's disease (Fitzpatrick et al., 2017;Falcon et al., 2018).

[0140] Further characteristics of the L1 mouse model include a marked loss of neuronal immunoreactivity for choline acetyltransferase in the basal forebrain, and a corresponding reduction in acetylcholinesterase in the neocortex and hippocampus, indicating a reduction in acetylcholine.There is also a roughly 50% reduction in glutamate release for brain synaptosome preparations from L1 mice compared to those from wild-type mice.In this regard, therefore, L1 mice also mimic the neurochemical impairments in cholinergic (Mesulam, 2013; Pepeu and Grazia Giovannini, 2017) and glutamatergic (Revett et al., 2013) functions that characterize AD and other synucleinopathies.

[0141] Underlying these impairments in neurotransmitter function, the L1 mouse model shows impairments in the integration of synaptic proteins. Quantitative immunohistochemistry for multiple synaptic proteins in the basal forebrain (vertical diagonal band) shows that there is usually a high degree of correlation in the levels of proteins comprising the SNARE complex (e.g., SNAP-25, syntaxin, VAMP2; reviewed in Li and Kavalali, 2017) as well as the vesicle glycoproteins synaptophysin and α-synuclein in wild-type mice. These correlations are largely lost in L1 mice (Table 1). The only correlations remaining are between synaptophysin, syntaxin, and VAMP2. Thus, synaptic vesicle protein levels are no longer quantitatively linked to proteins of the SNARE complex or α-synuclein. This suggests that tau oligomer pathology in L1 mice interferes with the functional integration between vesicles and membrane docking proteins at the synapse.

[0142] [Table 9]

[0143] Example 3 - Experimental paradigm, results and discussion Experimental Paradigm The treatment schedule used to study the negative interaction between symptomatic treatment and LMTM was designed to mimic the clinical condition, where subjects were first treated chronically with a cholinesterase inhibitor or memantine, and then given LMTM. Below, we summarize some of the key results obtained with the AChEI, rivastigmine.

[0144] Wild-type and L1 mice (n=7-16 for each group) were pretreated with rivastigmine (0.1 or 0.5 mg / kg / day) or memantine (2 or 20 mg / kg / day) or vehicle by gavage for 5 weeks. For the following 6 weeks, LMTM (5 and 15 mg / kg) or vehicle was added to this daily treatment regimen, also by gavage. Animals were behaviorally tested using a problem-solving task in an open-field water maze during weeks 10 and 11 and then sacrificed for immunohistochemistry and other tissue analyses.

[0145] Converting the dose from mice to humans requires consideration of several factors. A dose of 5 mg / kg / day in mice reduces the C of parent MT in plasma by 100 mg / kg / day. max Although this corresponds to roughly 8 mg / day in humans in terms of levels, this dose is at the threshold for effects on pathology and behavior. Higher doses of 15 mg / kg / day are generally required for LMTM to be fully effective in the L1 mouse model (Melis et al., 2015a). This may be related to the much shorter half-life of MT in mice (4 h) compared to humans (37 h in aged humans). Tissues dissected for immunohistochemistry were labeled with antibodies and processed using Image J, and protein expression was determined by densitometry. Data are presented as unitless Z-score transformation.

[0146] For measurement of acetylcholine (ACh) levels in the hippocampus, animals (wild type or L1) were treated with LMTM (5 mg / kg / day, 2 weeks) after 2 weeks of prior treatment with or without rivastigmine (0.5 mg / kg / day). Rivastigmine was administered subcutaneously with an Alzet minipump, while LMTM was administered by oral gavage. ACh levels were measured in the hippocampus using an implanted microdialysis probe and HPLC analysis of the extracellular fluid.

[0147] Data are presented as group means and standard errors of the means and were analyzed using parametric statistics with alpha set at 0.05.

[0148] Experiments on animals were performed in accordance with the European Communities Council Directive (63 / 2010 / EU) with local ethical approval, a project license according to the UK Scientific Procedures Act (1986), and in accordance with the German Law for Animal Protection (Tierschutzgesetz) and the Polish Law on the Protection of Animals.

[0149] result Effect of LMTM and rivastigmine treatment in wild-type mice The effects of treatment with LMTM alone or on a background of chronic rivastigmine are summarized in Table 2.

[0150] In wild-type mice, there was a significant 2-fold increase in basal ACh levels in the hippocampus following LMTM treatment, and a 30% reduction when mice received LMTM after prior treatment with rivastigmine (FIG. 1A).

[0151] There was a three-fold increase in mean synaptophysin levels measured in the hippocampus, visual cortex, diagonal band, and septal area following LMTM treatment alone, and also a statistically significant reduction of the same magnitude when LMTM was given against the background of prior treatment with rivastigmine (Figure 1B).

[0152] [Table 10]

[0153] Effect of LMTM and rivastigmine treatment in tau transgenic L1 mice The activating effect of LMTM alone and the inhibitory effect of combination with rivastigmine are greater and more generalized in tau transgenic L1 mice than in wild-type mice (see Table 3). LMTM alone produces a significant increase in ACh release in the hippocampus, glutamate release from brain synaptosome preparations, synaptophysin levels, mitochondrial complex IV activity, and behavioral changes. None of these effects were seen when LMTM was preceded by chronic rivastigmine. Indeed, in the case of SNARE complex proteins (Figure 2A) and synuclein (Figure 2B), the reductions produced by the combination were at levels below those seen in the absence of LMTM treatment.

[0154] [Table 11]

[0155] Consideration of Example 3 The results presented here show that the reduction in efficacy of LMTM can be reproduced in both wild-type and tau transgenic mouse models when given as an add-on to symptomatic treatment in humans.

[0156] The results we now report show that there are two classes of effects produced by LMTM treatment in wild-type and tau transgenic mice: those that are subject to dynamic modulation by prior exposure to a cholinesterase inhibitor, and those that are not. In tau transgenic mice, treatment effects that can be modulated include increased ACh release in the hippocampus, changes in synaptic proteins, increases in mitochondrial complex IV activity, and reversal of behavioral decline. The only treatment effects that are not subject to pharmacological modulation are the primary effects on tau aggregation pathology, as measured, for example, by restoration of choline acetyltransferase expression in the basal forebrain, and its immediate effects on neuronal function.

[0157] The effects subject to pharmacological modulation are themselves of two types: those that are augmented by the effects on tau aggregation pathology, and those that are also seen in wild-type mice. Among the outcomes we measured, the positive treatment effects of LMTM given alone in wild-type mice included increased ACh levels in the hippocampus and increased synaptophysin levels in multiple brain regions. Thus, LMTM treatment can activate neuronal function at therapeutically relevant doses in wild-type mice that lack tau aggregation pathology.

[0158] An increase in synaptophysin indicates an increase in the number or size of synaptic vesicles required for release of neurotransmitters from presynapses following activation via action potentials. Thus, increased levels of synaptophysin appear to be associated with an increase in several neurotransmitters required to support cognitive and other mental functions.

[0159] Although the MT moiety has been reported to be a weak cholinesterase inhibitor ( Pfaffendorf et al., 1997 ; Deiana et al., 2009 ), it is unlikely that this is the mechanism responsible for increasing ACh levels.

[0160] Specifically, further experiments using scopolamine, which increases ACh levels (by blocking M2 / M4 negative feedback receptors), showed that the increase produced by LMTM was less than that seen with rivastigmine alone, and the combination was again inhibitory in wild-type mice. Under the conditions of cholinesterase inhibition used in these experiments (very small amounts of the cholinesterase inhibitor, 100 nanomolar rivastigmine, added to the perfusate), ACh levels in the hippocampus increased, and when they increased strongly enough, they limited further ACh release by activating presynaptic muscarinic receptors of the M2 / M4 subtype (so-called negative feedback receptors).

[0161] In this situation, the addition of scopolamine (1 μM) to the perfusate blocks these presynaptic receptors, resulting in a 3- to 5-fold increase in ACh levels. The fact that LMTM is not additive with rivastigmine in these experiments supports the conclusion that LMTM has a different mechanism of action than rivastigmine. In other words, although LMTM has been described as a weak inhibitor of cholinesterase at high concentrations, this effect appears to be independent of cholinesterase inhibition, since there is no additive effect with small amounts of rivastigmine.

[0162] The increase in ACh and synaptophysin levels could be theoretically explained by an increase in presynaptic mitochondrial activity, since the MT portion is known to enhance mitochondrial complex IV activity (Atamna et al., 2012), and mitochondria have an important role in homeostatic regulation of presynaptic function (Devine and Kittler, 2018). In particular, the MT portion is thought to enhance oxidative phosphorylation by acting as an electron shuttle between complex I and complex IV (Atamna et al., 2012). The MT portion has a redox potential of approximately 0 mV, which is intermediate between the redox potentials of complex I (-0.4 mV) and complex IV (+0.4 mV).

[0163] However, direct measurements of complex IV activity in wild-type mice showed no increase following LMTM treatment. The activating effects of LMTM also did not correlate with improvements in spatial recognition memory in wild-type mice.

[0164] Although qualitatively similar, the effects of LMTM given alone are much more pronounced and broader in tau transgenic L1 mice. The most likely explanation for this is that LMTM combines together an inhibitory effect on tau oligomers with an intrinsic activating effect that is not tau-dependent. The reduction in tau oligomer levels following LMTM treatment promotes more pronounced activation of synaptic function and release of neurotransmitters such as ACh and glutamate. Similarly, LMTM reverses spatial memory deficits seen in tau transgenic L1 mice (Melis et al., 2015a). Alternatively, LMTM may act via a different mechanism that is not dependent on tau, as seen, for example, in wild-type mice lacking tau pathology. The negative effects seen when LMTM is introduced against a chronic rivastigmine background appear to simply reflect the reversal of activation seen with LMTM alone.

[0165] The deleterious effect of tau oligomers on synaptic protein function can be easily understood as a result of direct interference with synaptic vesicle docking, membrane fusion and neurotransmitter release. In tau transgenic L1 mice, for example, synaptic vesicle protein levels are no longer quantitatively linked to proteins of the SNARE complex or α-synuclein, implying a loss of functional integration between vesicles and membrane docking proteins in synapses. The consequences of this can be seen directly as an impairment in glutamate release from synaptosomal preparations from tau transgenic mice, and the restoration of normal glutamate release following treatment with LMTM.

[0166] A further consideration is whether the homeostatic downregulation we have shown works similarly when LMTM treatment is first and symptomatic treatment is added later.The experiments we have performed to date were originally designed to mimic clinical symptoms, but here LMTM is added to patients who are already receiving symptomatic treatment.If homeostatic downregulation is determined by the treatment that comes first, it is inevitable that the treatment effect of LMTM will be dominant, even though the response to add-on symptomatic treatment may be reduced to some extent.

[0167] Example 4 - Synaptopathy As disclosed herein, LMTX compounds can increase the average level of synaptic proteins in various brain regions at therapeutically relevant doses in both injured and wild-type mice.This increase in synaptic proteins can be used to compensate for the loss of synaptic protein integrity in diseases, such as synaptic degeneration, i.e., brain disorders resulting from synaptic dysfunction, or where such synaptic dysfunction contributes to the pathogenesis or symptoms of the disorder.A non-limiting list of such diseases includes:

[0168] Schizophrenia is a devastating psychiatric disorder with a complex etiology that arises as an interaction between genetic and environmental factors. Schizophrenia is a neurodevelopmental disorder, and synaptic dysfunction plays a crucial role in disease development. In 1982, Feinberg proposed that schizophrenia may arise as a result of abnormal synaptic pruning. Synaptic dysfunction cannot be studied and understood as an independent disease hallmark, but only as part of a complex network of homeostatic events. Development, glial-neuronal interactions, alterations in energy homeostasis, diverse genetic predispositions, neuroimmune processes, and environmental influences may all alter the delicate homeostatic balance of synaptic morphology and connectivity in unique and distinct ways, thus resulting in the emergence of various symptoms of this devastating disorder. Faludi and Mirnics (2011) have loosely stratified schizophrenia into “synaptic”, “oligodendroglial”, “metabolic” and “inflammatory” subclasses.

[0169] The levels of SNAP-25 are significantly depleted in the cerebellum of schizophrenia (Mukaetova-Ladinska et al., 2002). Tau and MAP2, as well as synaptic proteins other than SNAP25, such as synaptophysin and syntaxin, are not affected. This provides evidence that alterations in the cerebellar synaptic network occur in schizophrenia. These alterations may affect cerebellar-forebrain connections, especially connections with the frontal lobe, resulting in cognitive dysmetrization that is characteristic of the clinical phenotype in schizophrenia.

[0170] Regulated formation of SNARE complexes and abnormal expression of SNARE proteins and accessory molecules in specific regions of the human brain (the orbitofrontal cortex) are associated with schizophrenia (Katrancha et al., 2015).

[0171] Depression. Stress-induced neuronal atrophy and loss of glutamatergic synaptic connections are important contributors to the symptoms of depression. In addition to the HPA axis, synapse number and function are altered by other factors, notably neurotrophic factors, that have been implicated in depression (Duman et al., 2016).

[0172] Autism spectrum disorder is a complex group of disorders associated with abnormal synaptic transmission and synaptic plasticity (Giovedi et al., 2014). Levels of both postsynaptic Homer 1 and presynaptic synaptophysin were significantly reduced in the adult brain of a shank3b-deficient zebrafish model of ASD (Liu et al., 2018).

[0173] Epilepsy: Several synaptic proteins have been implicated in epilepsy (Giovedi et al., 2014). Electrical kindling increases synaptophysin immunoreactivity in both the hippocampal formation and piriform cortex in rats (Li et al., 2002).

[0174] Startle disease (hypergastric startle disorder) is a rare non-epileptic disorder characterized by an exaggerated and sustained startle response to unexpected auditory, somatosensory and visual stimuli, generalized muscle rigidity, and nocturnal myoclonus. The predominant form has a genetic basis: mutations in GLRA1, the alpha 1 subunit of the glycine receptor gene, or related genes (Bakker et al., 2006). Related syndromes include Tourette's syndrome and anxiety disorders.

[0175] Focal hand dystonia is a syndrome characterized by muscle spasms resulting in involuntary movements and abnormal postures. Substantial alterations in synaptic plasticity have been described in dystonia animal models and patients (Quartarone and Pisani, 2011).

[0176] Cerebral ischemia results in synaptic changes consistent with ischemic long-term potentiation (LTP) and represents a novel model to characterize abnormal forms of synaptic plasticity (Orfila et al., 2018). Immunoreactivity for synaptophysin is transiently increased in the ischemic lesion 3-7 days after cerebral ischemia, but synaptophysin immunostaining in the damaged area gradually decreased in rats and eventually almost disappeared 1 month after transient cerebral ischemia (Korematsu et al., 1993).

[0177] The inflammatory cytokines tumor necrosis factor (TNF) and interleukin-1β (IL-1β) play important physiological roles in LTP and synaptic scaling. However, the effects of these cytokines on synaptic plasticity may be altered under conditions of neuroinflammation. Altered synaptic plasticity occurs under physiological or inflammatory conditions, particularly for experimental allergic encephalitis (EAE) and multiple sclerosis (MS) (Rizzo et al. 2018). Synaptophysin, synapsin I, and PSD-95 immunoreactivity were reduced in both gray and white matter in both chronic and acute models of EAE (Zhu et al., 2013).

[0178] Glaucoma and AD share several features. They both affect the elderly and are neurodegenerative, chronic and progressive, leading to irreversible cell death. AD and glaucoma also share some common features, e.g., Aβ accumulation / aggregation, tau aggregation and hyperphosphorylation. Both diseases are characterized by early alterations of neuronal circuits and the propagation of neurodegenerative processes leading to phosphorylation of mitogen-activated protein kinases (MAPKs), followed by inflammatory processes, glial reactions, reactive oxygen species production, oxidative stress and mitochondrial abnormalities, cell death. Both diseases are characterized by common features, e.g., synaptic dysfunction and neuronal cell death at the level of the inner retina. Glaucoma is recognized as a disease frequently associated with AD and aging (Criscuolo et al., 2017).

[0179] References for Example 4 Bakker, MJ, van Dijk, JG, van den Maagdenberg, AMJM, Tijssen, MAJ (2006) Startle syndromes. 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Claims

1. A therapeutic composition comprising a methylthioninium (MT)-containing compound for a method of therapeutic treatment of a synaptic degenerative disorder in a subject, the disorder being selected from the list consisting of schizophrenia; cerebral ischemia; multiple sclerosis (MS); depression; startle syndrome; Tourette's syndrome; autism spectrum disorder (ASD); focal hand dystonia; experimental allergic encephalitis (EAE); glaucoma; lysosomal storage disease not associated with tau pathology; the method comprising orally administering to the subject an MT-containing compound; The MT-containing compound is a LMTX compound of the formula: 【Chemistry 1】 (In the formula, H ｎ A and H ｎ each B, if present, is a protic acid, which may be the same or different; p=1 or 2; q=0 or 1; n=1 or 2; (p+q)×n=2). or a hydrate or solvate thereof.

2. 2. The therapeutic composition of claim 1, which increases the level of synaptophysin in the brain of a mammalian subject.

3. The therapeutic composition of claim 1 , wherein the treatment is in combination with an additional therapeutic agent for the disorder.

4. 3. The therapeutic composition of claim 1 or claim 2, wherein the total daily dose is from 2 to 100 mg MT or from 10 to 60 mg MT per day to said subject.

5. The therapeutic composition of claim 4, wherein the total daily dose is divided into two or more doses.

6. A total daily dose of approximately 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, or 20 mg to approximately 25, 26, 27, 28, 29, 30, 31, 32, or 35 mg.

6. The therapeutic composition according to any one of claims 1 to 5, wherein the dosage is 3, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, or 60 mg.

7. The therapeutic composition of claim 6, wherein the total daily dose is from 20 to 40 mg.

8. 8. The therapeutic composition of any one of claims 1 to 7, wherein the subject is a human who has been diagnosed as having said synaptic degenerative disorder or the method comprises making said diagnosis.

9. The LMTX compound has the formula: 【Chemistry 3】 9. The therapeutic composition of any one of claims 1 to 8, having the formula:

10. The LMTX compound has the formula: 【Chemistry 4】 wherein H ｎ 10. The therapeutic composition of claim 9, wherein each X is a protic acid.

11. The LMTX compound has the formula: 【Chemistry 5】 and H ２ 10. The therapeutic composition of claim 9, wherein A is a diprotic acid.

12. The LMTX compound has the formula: 【Chemistry 6】 11. The therapeutic composition of claim 10, which is a bis-monoprotonic acid salt.

13. A therapeutic composition according to any one of claims 9 to 12, wherein the or each protic acid is an inorganic acid.

14. A therapeutic composition according to claim 13, wherein the or each protic acid is selected from a hydrohalic acid or HCl; HBr; HNO3; H2SO4.

15. A therapeutic composition according to any one of claims 9 to 12, wherein the or each protic acid is an organic acid.

16. A therapeutic composition as claimed in claim 15, wherein the or each protonic acid is selected from: H 2 CO 3 ; CH 3 COOH; methanesulfonic acid, 1,2-ethanedisulfonic acid, ethanesulfonic acid, naphthalenedisulfonic acid, p-toluenesulfonic acid.

17. The LMTX compound is LMTM: 【Chemistry 7】 The therapeutic composition according to any one of claims 1 to 8,

18. The LMTX compound is 【Chemistry 8】 【Chemistry 9】 The therapeutic composition according to any one of claims 1 to 8, selected from the list consisting of:

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