Combination therapy for treating amyotrophic lateral sclerosis using pridopidine and other active agents

Abstract

Provided herein are methods for treating a human subject afflicted with ALS by administering to the subject a therapeutically effective amount of pridopidine, or a pharmaceutically acceptable salt thereof, in combination with sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a sodium phenylbutyrate (PB) / tauroursodeoxycholic acid combination (i.e., AMX0035), zilcoplan, bergypelstat, CNM-Au8 nanocrystalline gold, SLS-005 (trehalose), IC14, or a combination thereof as combination or add-on therapy.

Description

Technical Field

[0001] In this specification, a method for treating a human subject suffering from ALS is provided by administering a therapeutically effective amount of pridopidine or a pharmaceutically acceptable salt thereof in combination therapy or adjunctive therapy in combination with sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), Zilucoplan, verdiperstat, CNM-Au8 nanocrystalline gold, SLS-005 or ICI4.

Background Art

[0002] Amyotrophic Lateral Sclerosis

[0003] Amyotrophic lateral sclerosis (ALS) is a devastating neurodegenerative disease characterized by the progressive loss of motor neurons in the motor cortex, brainstem, and spinal cord (Peters 2015). This rapidly progressive and fatal disease leads to weakness in the limbs, respiratory system, and bulbar muscles. Patients gradually lose control of their voluntary muscles, leading to loss of limb function, as well as loss of the ability to chew, swallow, speak, and ultimately breathe.

[0004] ALS is a rare condition with an average incidence rate of 2.8 per 100,000 in Europe and 1.8 per 100,000 in North America, and an average prevalence rate of 5.40 per 100,000 in Europe and 3.40 per 100,000 in North America (Bozzoni 2016).

[0005] In approximately 90% of cases, there is no obvious genetic mutation underlying the disease (sporadic ALS). Approximately 5% - 10% of ALS cases are familial (fALS) and are caused by genetic mutations. There are over 25 genes associated with ALS that are recognized as causative. The most common pathogenic mutations are C9ORF72 (33.7% of fALS) and SOD1 (14.8% of fALS) (Zou et al. 2017).

[0006] ALS patients experience progressive muscle atrophy and weakness, increased fatigue, and signs and symptoms of dysphagia, which usually lead to aspiration pneumonia, respiratory failure, and death. The progressive functional deficits lead to a loss of overall independence and death.

[0007] ALS begins in the limbs in about two-thirds of patients and most often starts in the arms. The first symptoms are usually unilateral and localized. Initial findings include foot drop, difficulty walking, loss of manual dexterity, or difficulty lifting the arms above the head. Eventually, limb function is lost, which can lead to dependence on caregivers. Patients may fall or lose the ability to walk altogether. Bulbar-onset disease, which occurs more frequently in older women, appears to have a worse prognosis (Chio et al. 2009).

[0008] Non-motor symptoms of ALS include behavioral disorders, executive dysfunction, and frontotemporal dementia. Frontotemporal dementia develops in about 15% of patients, but up to 50% of patients are found to have impairment by neuropsychological testing (Lomen-Hoerth et al. 2003; Gordon et al. 2011). Changes include language, judgment, personality, affect, and executive function. ALS and dementia patients likely have a shorter survival due to a probable decline in decision-making ability (Olney et al. 2005). The median survival is 2 - 4 years from onset, and only 5 - 10% of patients survive beyond 10 years (Chio et al. 2013).

[0009] Disease-modifying therapies for the treatment of ALS are not currently known. The two approved drugs are riluzole and edaravone. Riluzole slows the rate of disease progression and extends survival by two to three months, and edaravone delays physical decline (Jaiswal 2018).

[0010] The pathophysiological mechanisms of ALS appear to be multifactorial, with several mechanisms contributing to neurodegeneration. These include defects in autophagy, mitochondrial dysfunction, glutamate excitotoxicity, oxidative stress, and neuroinflammation. Initial pathological events in ALS include disturbances in axonal transport, formation of toxic protein aggregates, and NMJ disruption. All of these lead to axonal degeneration and motor neuron death (Ionescu et al. 2019).

[0011] The neuropathological features of ALS include muscle atrophy, loss of anterior horn cells, and sclerosis of the lateral columns of the spinal cord (Martel 2016). Gliosis, defined as activation of astrocytes and microglia, is also a feature of ALS.

[0012] Pridopidine

[0013] Pridopidine (previously ACR16, Huntexil®) is a unique compound in clinical development for the treatment of Huntington's disease (HD) and ALS. The chemical name of pridopidine is 4-(3-(methylsulfonyl)phenyl)-1-propylpiperidine, and its chemical registration number is CAS 346688-38-8 (CSID:7971505, 2016). The chemical registration number of pridopidine hydrochloride is 882737-42-0 (CSID:25948790 2016). The process for the synthesis of pridopidine and its pharmaceutically acceptable salts is disclosed in U.S. Patent No. 7,923,459 and PCT Application Publication No. WO2017 / 015609. U.S. Patent No. RE46,117 discloses pridopidine for the treatment of various diseases and disorders.

[0014] Pridopidine is a very potent and selective sigma-1 receptor (S1R) agonist developed by Prilenia for the treatment of neurodegenerative and neurodevelopmental disorders.

[0015] S1R is an intracellular ligand-operated protein mainly located in the mitochondria-associated membrane (MAM) and is involved in cell differentiation, neuroplasticity, neuroprotection, and cognitive function in the brain.

[0016] S1R is highly expressed in motor neurons of the brainstem and spinal cord (Mavlyutov et al., 2010; 2012; Waterhouse et al., 1997) and is widely expressed in the nervous system (Gundlach et al., 1986).

[0017] S1R regulates important cellular processes related to neurodegenerative diseases such as calcium signaling, cytoskeletal dynamics, neurotrophic factor release, mitochondrial function, and ER stress (Ryskamp, Korban, et al., 2019; Hayashi, 2019; Kourrich et al., 2012; Su et al., 2010). These pathways are impaired in ALS.

[0018] Pridopidine exerts neuroprotective properties through the activation of S1R in a number of non-clinical models including HD, ALS, Parkinson's disease (PD), and Alzheimer's disease (AD). Pridopidine enhances the S1R-dependent secretion of neuroprotective brain-derived neurotrophic factor (BDNF) in neuroblastoma cell lines (Geva, 2016) and rescues spinal cord injury and abnormal calcium signaling by activation of S1R (Ryskamp, 2017).

[0019] PCT International Patent Application Publication No. WO 2016 / 138135 discloses the use of S1R agonists, in particular, for the treatment of familial adult amyotrophic lateral sclerosis (ALS) and juvenile amyotrophic lateral sclerosis (ALS).

[0020] The need for an effective treatment for ALS, particularly sporadic ALS, remains unaddressed. SUMMARY OF THE INVENTION MEANS FOR SOLVING THE PROBLEM

[0021] In embodiments, the present invention provides a method of treating a subject suffering from amyotrophic lateral sclerosis (ALS), the method comprising administering to the subject a first composition comprising pridopidine or a pharmaceutically acceptable salt thereof, which is effective for treating the subject, and a second composition comprising sodium phenylbutyrate (PB), tauroursodeoxycholic acid (TUDCA), a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilucoplan, beraprostat, CNM-Au8 nanocrystalline gold, ICI4, SLS-005, or a combination thereof.

[0022] In some embodiments, the ALS is sporadic ALS.

[0023] In some embodiments, the ALS is familial ALS.

[0024] In embodiments, the present invention provides a method of delaying the onset of symptoms of ALS in a subject, reducing the progression of symptoms, or improving the symptoms, the method comprising administering to the subject a first composition comprising pridopidine or a pharmaceutically acceptable salt thereof, which is effective for delaying the onset of symptoms of ALS in the subject, reducing the progression of symptoms, or improving the symptoms, and a second composition comprising any one of sodium phenylbutyrate (PB), tauroursodeoxycholic acid (TUDCA), a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilucoplan, beraprostat, CNM-Au8 nanocrystalline gold, SLS-005, or ICI4, or a combination thereof.

[0025] In another embodiment, the symptoms are muscle rigidity, muscle weakness, muscle wasting, muscle spasms, dysarthria, dysphagia, shortness of breath, dysphagia, difficulty walking, fasciculation, worsening of posture, worsening of respiratory function, muscle weakness, worsening of bulbar function, worsening of speech, worsening of salivation, dysphagia, difficulty writing, difficulty cutting food and handling utensils, difficulty dressing, dyspnea, orthopnea, or combinations thereof.

[0026] In an embodiment, the present invention provides a method of treating a subject suffering from amyotrophic lateral sclerosis (ALS), the method comprising administering to the subject a first composition comprising pridopidine or a pharmaceutically acceptable salt thereof and a second composition comprising sodium phenylbutyrate (PB), tauroursodeoxycholic acid (TUDCA), a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilucoplan, beraprostat, CNM-Au8 nanocrystalline gold, SLS-005 ICI4, or combinations thereof, the method being further effective to enhance BDNF axonal transport and mitochondrial axonal transport in motor neurons, enhance ERK activation, improve the formation and preservation of (neuromuscular junction) NMJ, preserve NMJ structure, preserve NMJ function, improve the innervation rate of muscle tissue, enhance motor neuron axonal growth, reduce axonal degeneration, reduce motor neuron axonal degeneration, enhance muscle cell survival, enhance the diameter and function of muscle fibers, and reduce SOD1 and / or TDP43 aggregation.

[0027] In an embodiment, the present invention provides a method for treating a subject suffering from amyotrophic lateral sclerosis (ALS), the method comprising administering to the subject a first composition comprising pridopidine or a pharmaceutically acceptable salt thereof, and a second composition comprising sodium phenylbutyrate (PB), tauroursodeoxycholic acid (TUDCA), a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilucoplan, berupipstat, CNM-Au8 nanocrystalline gold, SLS-005 ICI4, or a combination thereof, the method further reducing the progression of pseudobulbar disease, reducing the progression of muscle fiber atrophy, and / or improving muscle contraction, reducing muscle stiffness, reducing muscle weakness, muscle atrophy, muscle spasm, improving dysarthria, improving salivation, improving dysphagia, improving difficulty in writing, improving difficulty in cutting food and handling utensils, improving difficulty in changing clothes and hygiene, improving difficulty in turning over and adjusting bedding, improving difficulty in ascending and descending stairs, improving shortness of breath, improving orthopnea, improving breathlessness, improving chewing difficulty, improving walking difficulty, improving muscle fiber fasciculation, and / or improving postural deterioration, maintaining or reducing plasma and CSF NFL levels, pNPH and urinary P75 levels in a subject suffering from ALS.

[0028] In an embodiment, the present invention provides a method for treating a subject suffering from amyotrophic lateral sclerosis (ALS), the method comprising administering to the subject a first composition comprising pridopidine or a pharmaceutically acceptable salt thereof, and a second composition comprising sodium phenylbutyrate (PB), tauroursodeoxycholic acid (TUDCA), a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilucoplan, beraprostat, CNM-Au8 nanocrystalline gold, SLS-005 ICI4, or a combination thereof, wherein the first composition and the second composition comprising pridopidine or a pharmaceutically acceptable salt thereof are administered to the subject more frequently than once a day, twice a day, twice a week, or three times a week. In another embodiment, the first composition comprising pridopidine or a pharmaceutically acceptable salt thereof is administered orally or by gastrostomy tube. In another embodiment, the amount of pridopidine or a pharmaceutically acceptable salt thereof administered is from 10 mg / day to 135 mg / day. In another embodiment, pridopidine is pridopidine hydrochloride.

[0029] In some embodiments, the second composition comprises sodium phenylbutyrate (PB). In other embodiments, the amount of sodium phenylbutyrate administered is from 1 to 10 grams per day (orally).

[0030] In some embodiments, the second composition comprises tauroursodeoxycholic acid (TUDCA). In other embodiments, the amount of tauroursodeoxycholic acid (TUDCA) administered is from 0.1 to 6 grams per day. In other embodiments, the amount of tauroursodeoxycholic acid (TUDCA) administered is from 0.5 to 3 grams per day (orally).

[0031] In some embodiments, the second composition comprises a combination of tauroursodeoxycholic acid (TUDCA) and sodium phenylbutyrate (PB), which refers to either two separate compositions of tauroursodeoxycholic acid (TUDCA) and sodium phenylbutyrate (PB) respectively, or a composition comprising both tauroursodeoxycholic acid (TUDCA) and sodium phenylbutyrate (PB) such as AMX0035. In other embodiments, the amount of the composition comprising both tauroursodeoxycholic acid (TUDCA) and sodium phenylbutyrate (PB) administered is 0.1 - 5 grams per day of tauroursodeoxycholic acid (TUDCA), and 1 - 10 grams per day of sodium phenylbutyrate. In other embodiments, the amount of the composition comprising both tauroursodeoxycholic acid (TUDCA) and sodium phenylbutyrate (PB) administered is 0.5 - 3 grams per day of tauroursodeoxycholic acid (TUDCA), and 1 - 10 grams per day of sodium phenylbutyrate (oral).

[0032] In some embodiments, the second composition comprises zilcoplan. In other embodiments, the amount of zilcoplan administered is 0.05 - 0.5 mg / kg / day (subcutaneous injection).

[0033] In some embodiments, the second composition comprises belperstat. In other embodiments, the amount of belperstat administered is 200 - 2000 mg / day (oral).

[0034] In some embodiments, the second composition comprises CNM - Au8 nanocrystalline gold. In other embodiments, the amount of CNM - Au8 nanocrystalline gold administered is 5 - 50 mg / day (oral).

[0035] In some embodiments, the second composition comprises SLS - 005. In other embodiments, the amount of SLS - 005 administered is 20 - 200 g / day (oral or intravenous).

[0036] In some embodiments, the second composition comprises IC14. In other embodiments, the amount of IC14 administered is 0.2 - 8 mg / kg / day (intravenous).

[0037] In some embodiments, administration of the second composition precedes administration of pridopidine or a pharmaceutically acceptable salt thereof. In other embodiments, administration of the first composition comprising pridopidine or a pharmaceutically acceptable salt thereof precedes administration of the second composition. In other embodiments, the first composition comprising pridopidine or a pharmaceutically acceptable salt thereof is administered in combination with the second composition. In other embodiments, the second composition is administered in combination with the first composition comprising pridopidine or a pharmaceutically acceptable salt thereof.

[0038] In some embodiments, the present invention provides a pharmaceutical composition comprising a quantity of pridopidine or a pharmaceutically acceptable salt thereof and a quantity of sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilucoplan, belfiperstat, CNM - Au8 nanocrystalline gold, SLS - 005, ICI4, or a combination thereof.

[0039] The present invention provides a method for treating a subject afflicted with amyotrophic lateral sclerosis (ALS), comprising administering to the subject a quantity of sodium phenylbutyrate (PB), tauroursodeoxycholic acid (TUDCA), a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilucoplan, belfiperstat, CNM - Au8 nanocrystalline gold, SLS - 005, ICI4, or any combination thereof, effective to treat the human subject, and a quantity of pridopidine or a pharmaceutically acceptable salt.

[0040] The present invention also provides a combination therapy for use in the treatment of a human subject suffering from ALS, comprising pridopidine or a pharmaceutically acceptable salt thereof and sodium phenylbutyrate (PB), tauroursodeoxycholic acid (TUDCA), a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplan, or berupipstat, or CNM-Au8 nanocrystalline gold, or ICI4, or SLS-005, or a combination thereof.

[0041] In some embodiments, the subject is suffering from sporadic ALS.

[0042] In some embodiments, the subject is suffering from familial ALS.

[0043] The present invention also provides a pharmaceutical composition for treating a human subject suffering from ALS, comprising an effective amount of pridopidine or a pharmaceutically acceptable salt thereof and zilcoplan, or berupipstat, or CNM-Au8 nanocrystalline gold, or ICI4, or SLS-005, or sodium phenylbutyrate (PB), tauroursodeoxycholic acid (TUDCA), or a combination thereof.

[0044] The present invention also provides the use of pridopidine or a pharmaceutically acceptable salt thereof in the manufacture of a medicament combined with zilcoplan, or berupipstat, or CNM-Au8 nanocrystalline gold, or ICI4, or SLS-005, or sodium phenylbutyrate (PB), tauroursodeoxycholic acid (TUDCA), or a combination thereof for the treatment of ALS.

[0045] A method of treating a subject afflicted with ALS is further provided, comprising administering to the subject a quantity of zilcoplan, or belperstat, or CNM-Au8 nanocrystalline gold, or SLS-005, or ICI4, or sodium phenylbutyrate (PB), or tauroursodeoxycholic acid (TUDCA), a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), or a combination thereof, and a quantity of pridopidine or a pharmaceutically acceptable salt thereof.

[0046] A method of treating a subject afflicted with ALS is further provided, comprising administering to the subject a quantity of a combination of sodium phenylbutyrate (PB) and tauroursodeoxycholic acid (i.e., AMX0035) and a quantity of pridopidine or a pharmaceutically acceptable salt thereof.

[0047] A method of treating a subject afflicted with ALS is further provided, comprising administering to the subject a quantity of zilcoplan, or belperstat, or CNM-Au8 nanocrystalline gold, or SLS-005, or ICI4, or a combination thereof, and a quantity of pridopidine or a pharmaceutically acceptable salt thereof.

[0048] In some embodiments, the combination therapy of the present invention for the treatment of ALS comprises a first pharmaceutical composition comprising zilcoplan, or belperstatin, or CNM-Au8 nanocrystalline gold, or SLS-005, or ICI4, or sodium phenylbutyrate (PB), tauroursodeoxycholic acid, or a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), or a combination thereof, and a second pharmaceutical composition comprising pridopidine or a pharmaceutically acceptable salt thereof. When treating a subject suffering from ALS, pridopidine is further provided for use as an additional therapy or combination therapy with sodium phenylbutyrate (PB). When treating a subject suffering from ALS, pridopidine is further provided for use as an additional therapy or combination therapy with tauroursodeoxycholic acid. When treating a subject suffering from ALS, pridopidine is further provided for use as an additional therapy or combination therapy with a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035). Pridopidine is further provided for use as an additional therapy or combination therapy with zilcoplan. Pridopidine is further provided for use as an additional therapy or combination therapy with belperstatin. Pridopidine is further provided for use as an additional therapy or combination therapy with CNM-Au8 nanocrystalline gold. Pridopidine is further provided for use as an additional therapy or combination therapy with SLS-005. Pridopidine is further provided for use as an additional therapy or combination therapy with IC14.

[0049] The invention also provides a pharmaceutical composition comprising a quantity of sodium phenylbutyrate (PB), tauroursodeoxycholic acid or a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilcoplan, belperstatin, CNM-Au8 nanocrystalline gold, SLS-005, IC14 or a combination thereof, a quantity of pridopidine or a pharmaceutically acceptable salt thereof, and at least one pharmaceutically acceptable carrier.

[0050] The present invention also relates to the preparation of a combination for treating a subject suffering from ALS, (a) an amount of sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilucoplan, berdipstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, and (b) an amount of pridopidine or a pharmaceutically acceptable salt thereof, and provides for the use, wherein an amount of sodium phenylbutyrate (PB), tauroursodeoxycholic acid or a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilucoplan, berdipstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14 or a combination thereof and an amount of pridopidine are administered simultaneously or contemporaneously.

[0051] The present invention also provides a pharmaceutical composition containing an amount of sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilucoplan, berdipstat, CNM-Au8 nanocrystalline gold, SLS-005 or IC14 in combination with an amount of pridopidine or a pharmaceutically acceptable salt thereof for use in treating a subject suffering from a movement disorder by administering the pharmaceutical composition and the amount of pridopidine or a pharmaceutically acceptable salt thereof to the subject.

[0052] The invention also provides a pharmaceutical composition comprising pridopidine or a pharmaceutically acceptable salt thereof in an amount combined with an amount of sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilcoplan, belperstat, CNM-Au8 nanocrystalline gold, SLS-005 or IC14, for use in treating a subject suffering from a movement disorder by periodically administering the pharmaceutical composition to the subject.

[0053] In another aspect, the invention provides a combination of pridopidine or a pharmaceutically acceptable salt thereof for use as an agent for the treatment, prevention or alleviation of ALS, with sodium phenylbutyrate (PB), tauroxicolic acid, a combination of sodium phenylbutyrate (PB) / tauroxicolic acid (i.e., AMX0035), zilcoplan, verdiperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14 or a combination thereof.

[0054] In another aspect, the invention provides a combination of pridopidine or a pharmaceutically acceptable salt thereof for use as an agent, with sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilcoplan, belperstat, CNM-Au8 nanocrystalline gold, SLS-005 or IC14.

[0055] In another aspect, the present invention provides a pharmaceutical composition comprising a therapeutically effective amount of pridopidine or a pharmaceutically acceptable salt thereof, and sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilcoplan, berdipstat, CNM-Au8 nanocrystalline gold, SLS-005 or IC14, together with one or more adjuvants, excipients, carriers and / or diluents.

[0056] In another aspect, the present invention provides a method of treating ALS in a living animal body including a human, the method comprising administering to a living animal body in need of such treatment a therapeutically effective amount of pridopidine or a pharmaceutically acceptable salt thereof in combination therapy with sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilcoplan, berdipstat, CNM-Au8 nanocrystalline gold, SLS-005 or IC14.

[0057] In another aspect, the present invention provides a parts kit comprising at least two separate unit dosage forms (A) and (B), wherein (A) comprises pridopidine or a pharmaceutically acceptable salt thereof, and (B) comprises sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilcoplan, berdipstat, CNM-Au8 nanocrystalline gold, SLS-005 or IC14, and optionally (C) instructions for co-administration or concurrent administration to a patient in need thereof of the pridopidine or a pharmaceutically acceptable salt thereof in (A) and the sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilcoplan, berdipstat, CNM-Au8 nanocrystals, gold, or SLS-005 or IC14 in (B).

[0058] In another aspect, the present invention provides a method of treating a subject afflicted with ALS, comprising administering to the subject a therapeutically effective amount of pridopidine or a pharmaceutically acceptable salt thereof, in combination with a therapeutically effective amount of sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilucoplan, beraprostat, CNM-Au8 nanocrystalline gold, SLS-005 or IC14, wherein the amounts when combined are effective for the treatment of a human patient. BRIEF DESCRIPTION OF THE DRAWINGS

[0059]

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Mode for Carrying Out the Invention

[0060] The present invention provides a method for treating a subject suffering from amyotrophic lateral sclerosis (ALS), which comprises periodically administering to the subject a therapeutically effective amount of pridopidine or a pharmaceutically acceptable salt thereof.

[0061] In an embodiment, the present invention provides a method for treating a subject suffering from amyotrophic lateral sclerosis (ALS), the method comprising administering to the subject a first composition comprising pridopidine or a pharmaceutically acceptable salt thereof, which is effective for treating the subject, and a second composition comprising sodium phenylbutyrate (PB), tauroursodeoxycholic acid (TUDCA), a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilucoplan, beraprostat, CNM-Au8 nanocrystalline gold, SLS-005 (trehalose), IC14, or a combination thereof.

[0062] The present invention further provides a method for delaying the onset, improving the decline, or reducing the decline of ALS functionality, respiratory function, muscle strength, bulbar function, speech, or any combination thereof in a subject suffering from amyotrophic lateral sclerosis (ALS), which comprises administering to the subject a therapeutically acceptable amount of pridopidine.

[0063] In an embodiment of the present invention, ALS is sporadic ALS.

[0064] In an embodiment of the present invention, the ALS is familial ALS (FALS). In some embodiments, the ALS is juvenile ALS (JALS).

[0065] In some embodiments, the ALS is not FALS. In some embodiments, the ALS is not juvenile ALS (JALS).

[0066] In one embodiment of the present invention, the type of ALS is classical, bulbar, flail arm, flail leg, corticospinal and respiratory ALS, progressive muscular atrophy, primary lateral sclerosis, or progressive bulbar palsy.

[0067] In one embodiment of the present invention, the subject has a variant of a gene that causes or is involved in the cause of ALS. In some embodiments, the variant of this gene is selected from the group of genes consisting of superoxide dismutase 1 (SOD1), TAR DNA-binding protein (TARDBP) encoding TDP-43, fused in sarcoma (FUS), p62 (SQSTM1), ubiquitin-2 (UBQLN2), TANK-binding kinase 1 (TBK1), profilin 1 (PFN1), VCP or p97 (VCP), angiogenin (ANG), optineurin (OPTN), C9 or f72, sigma-1 receptor (S1R), tubulin alpha-4A (TUBA4A), dynactin (DCTN1), hnRNPA1 (HNRNPA1), matrin 3 (MATR3), coiled-coil-helix-coiled-coil-helix domain-containing 10 (CHCHD10) gene, and any combination thereof.

[0068] In some embodiments of the present invention, maintaining, improving, or reducing the decline in ALS functionality includes maintaining, improving, or reducing the decline in speech, salivary secretion, swallowing, writing, food cutting, and handling of utensils, dressing and hygiene, turning over and bedding adjustment, walking, ascending and descending stairs, dyspnea, orthopnea, respiratory failure, or any combination thereof in ALS patients.

[0069] In an embodiment of the present invention, changes in respiratory function are evaluated by slow vital capacity (SVC).

[0070] In an embodiment of the present invention, maintaining, improving, or reducing muscle strength decline is measured isometrically using a handheld dynamometer (HHD), bilateral handgrip, or a combination thereof.

[0071] In an embodiment of the present invention, maintaining, improving, or reducing bulbar function decline is measured by the ALSFRS-R bulbar subdomain (Q1-Q3) score.

[0072] In an embodiment of the present invention, maintaining, improving, or reducing bulbar function decline is measured by CNS-BFS.

[0073] In an embodiment of the present invention, the subject has bulbar dysfunction.

[0074] In an embodiment of the present invention, the subject has rapid baseline progression.

[0075] In an embodiment of the present invention, the amount of pridopidine is effective to change the time to the first evidence of bulbar dysfunction.

[0076] In an embodiment of the present invention, maintaining, improving, or reducing speech decline is measured by the ALSFRS-R speech domain score (Q1).

[0077] In an embodiment of the present invention, maintaining, improving, or reducing speech decline is measured by automated algorithm evaluation of speech digitally collected to detect early changes and track progression. In an embodiment of the present invention, maintaining, improving, or reducing decline is measured by the ALS Functional Rating Scale-Revised (ALSFRS-R).

[0078] In embodiments of the present invention, the amount of pridopidine or a pharmaceutically acceptable salt thereof used in combination with sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilcoplan, belperstat, CNM-Au8 nanocrystalline gold, SLS-005 (trehalose), IC14, or a combination thereof is effective to inhibit or reduce the progression of ALS symptoms in a subject.

[0079] In embodiments of the present invention, the ALS symptoms are the clinical symptoms of ALS.

[0080] In embodiments of the present invention, the ALS symptoms are muscle weakness and atrophy, fasciculation and spasm, spastic muscle hypertonia, hyperreflexia, dysarthria, dysphagia and respiratory failure, behavioral disorders, executive function disorders, functional disorders, respiratory function disorders, muscle strength decline, bulbar function disorders, speech disorders, or any combination thereof, or frontotemporal dementia.

[0081] In embodiments of the present invention, the ALS symptoms are neuropathological symptoms.

[0082] In some embodiments, the symptoms are bulbar palsy or pathological laughing and crying (PBA).

[0083] In embodiments of the present invention, the ALS symptoms are muscle atrophy, loss of motor neurons, loss of anterior horn cells, sclerosis of the lateral columns of the spinal cord, or gliosis.

[0084] In one embodiment, the ALS symptoms are (a) the rate of decline in lung function, (b) the rate of decline in functional impairment, or (c) the rate of decline in the lower limb ability score. In embodiments of the present invention, the amount of pridopidine is effective to enhance the survival period of the subject or to cause neuroprotection in the subject.

[0085] In some embodiments of the present invention, the treatment of a subject with sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilucoplan, belperstat, CNM-Au8 nanocrystalline gold, SLS-005 (trehalose), IC14, or a combination thereof, in combination with pridopidine, or a pharmaceutically acceptable salt thereof, results in a delay in the onset of ALS symptoms, a reduction in the decline of ALS symptoms, or an improvement in ALS symptoms in one or more of the following domains in the subject. (1) Speech, (2) Salivation, (3) Swallowing, (4) Writing, (5) Cutting food and handling utensils (regardless of the presence or absence of gastrostomy), (6) Dressing and hygiene, (7) Turning in bed and adjusting bedding, (8) Walking, (9) Ascending and descending stairs, (10) Breathing, (11) Dyspnea, (12) Orthopnea, and (13) Dysfunction.

[0086] In some embodiments, the patient is monitored for changes in the above domains using an assessment scale, such as the Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS) or the Revised ALSFRS (ALSFRS-R), and the functional changes in the patient are monitored over time.

[0087] In some embodiments, pathological laughing and crying (PBA) (measured by CNS-LS) is monitored in the patient. In some embodiments, the severity and / or frequency of emotional outbursts in subjects experiencing PBA is reduced by pridopidine treatment.

[0088] In some embodiments of the present invention, the use of pridopidine, or a pharmaceutically acceptable salt thereof, in combination with sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplan, belperstat, CNM-Au8 nanocrystalline gold, SLS-005 (trehalose), IC14, or a combination thereof, maintains, improves, or reduces the severity of the disease as measured by the revised ALS Functional Rating Scale (ALSFRS-R) and / or ALSAQ-5 in ALS patients.

[0089] In some embodiments of the present invention, the use of pridopidine, or a pharmaceutically acceptable salt thereof, in combination with sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplan, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof, maintains, improves, or reduces the decline in respiratory function as evaluated by slow vital capacity (SVC) in ALS patients.

[0090] In some embodiments of the present invention, the use of pridopidine, or a pharmaceutically acceptable salt thereof, in combination with sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplan, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof, maintains, improves, or reduces the decline in muscle strength as measured by handheld dynamometer measurement (HHD) in ALS patients.

[0091] In some embodiments of the present invention, the use of pridopidine or a pharmaceutically acceptable salt thereof, tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zirconopran, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof, in combination with sodium phenylbutyrate (PB), results in the maintenance, reduction, or less increase of phosphorylated neurofilament heavy chain (pNfH) and neurofilament light chain (NfL) in the plasma and CSF of ALS patients.

[0092] In some embodiments of the present invention, the use of pridopidine or a pharmaceutically acceptable salt thereof, tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zirconopran, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof, in combination with sodium phenylbutyrate (PB), results in the maintenance, reduction, or less increase of urinary neurotrophin receptor p75 extracellular domain (p75 ECD ) in ALS patients.

[0093] In some studies, it has been found that jitter, shimmer, speech rate, speaking rate, and pause rate are affected in ALS. In some embodiments of the present invention, the use of pridopidine maintains, improves, or reduces the decline in speech characteristics measured by an automated algorithm evaluation of digitally collected speech, as described in Stegmann, G. et al., 2020, which is incorporated herein by reference.

[0094] In some embodiments of the present invention, the use of pridopidine or a pharmaceutically acceptable salt thereof, tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplan, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof, in combination with sodium phenylbutyrate (PB) maintains, improves, reduces the decline of, and delays the onset of speech characteristics as measured by the slope of the change in the CNS-BFS speech subdomain in ALS patients.

[0095] In some embodiments of the present invention, the use of sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplan, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof, in combination with pridopidine or a pharmaceutically acceptable salt thereof, in ALS patients maintains, improves, delays the onset of, or reduces the decline of voice characteristics as determined by the Aural Analytics set of analyses in ALS patients.

[0096] In some embodiments of the present invention, the use of sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplan, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof, in combination with pridopidine or a pharmaceutically acceptable salt thereof, in ALS patients maintains, improves, delays the onset of, or reduces the decline of cognitive function as measured by the Edinburgh Cognitive and Behavioral ALS Screen (ECAS).

[0097] In some embodiments of the present invention, the use of sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplan, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof in combination with pridopidine, or a pharmaceutically acceptable salt thereof, maintains, improves, delays the onset of, or reduces the decline in home clinical evaluations (weekly ALSFRS-R, SVC, pinch strength) in ALS patients.

[0098] In some embodiments, the use of sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplan, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof in combination with pridopidine, or a pharmaceutically acceptable salt thereof, maintains, improves, delays the onset of, or reduces the decline in bulbar function as measured by the CNS-BFS (Center for Neural Circuitry Research Bulbar Function Scale) and the bulbar subdomain (Q1-Q3) scores of the ALSFRS-R total score in ALS patients.

[0099] In some embodiments of the present invention, the use of sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplan, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof in combination with pridopidine, or a pharmaceutically acceptable salt thereof, maintains, improves, delays the onset of, or reduces the decline in muscle strength measured isometrically by handheld dynamometer measurement (HHD) and grip strength in ALS patients.

[0100] In some embodiments, the use of pridopidine or a pharmaceutically acceptable salt thereof, in combination with sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcpuran, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof, maintains, improves, delays the onset of, or reduces the decline in bulbar function as measured by the slope of the change in the total CNS-BFS score in ALS patients.

[0101] In some embodiments, the use of sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcpuran, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof, in combination with pridopidine or a pharmaceutically acceptable salt thereof, maintains, improves, delays the onset of, or reduces the decline in bulbar function as measured by the slope of the change in the total CNS-BFS score in ALS patients with a calculated ALSFRS-R slope at baseline (48-ALSFRS-R total score at baseline / onset time point) of 0.75 pt / month or greater.

[0102] In some embodiments, the use of sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcpuran, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof, in combination with pridopidine or a pharmaceutically acceptable salt thereof, reduces the percentage of ALS patients who develop bulbar symptoms within 6 months among trial participants who have no active bulbar symptoms at baseline (defined as CNS-BFS score < 30 at baseline), compared to the placebo group.

[0103] In embodiments of the present invention, pridopidine or a pharmaceutically acceptable salt thereof, which is used in combination with sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplam, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof, is administered daily.

[0104] In embodiments of the present invention, pridopidine or a pharmaceutically acceptable salt thereof, which is used in combination with sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplam, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof, is administered at a frequency greater than once a day.

[0105] In embodiments of the present invention, pridopidine or a pharmaceutically acceptable salt thereof, which is used in combination with sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplam, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof, is administered twice a day. In embodiments of the present invention, pridopidine or a pharmaceutically acceptable salt thereof, which is used in combination with sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplam, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof, is administered three times a day.

[0106] In embodiments of the present invention, pridopidine or a pharmaceutically acceptable salt thereof, when used in combination with sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplam, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof, is administered at a frequency less than once a day, for example, every other day, three times a week, twice a week, or once a week.

[0107] In embodiments of the present invention, pridopidine or a pharmaceutically acceptable salt thereof, when used in combination with sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplam, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof, is administered daily, twice a week, three times a week, or at a frequency greater than once a day.

[0108] In embodiments of the present invention, pridopidine or a pharmaceutically acceptable salt thereof, when used in combination with sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplam, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof, is administered orally.

[0109] In some embodiments, the unit dose of the pharmaceutical composition contains 10 - 250 mg of pridopidine or a pharmaceutically acceptable salt thereof. In some embodiments, the composition contains 10 mg, 22.5 mg, 45 mg, 67.5 mg, 90 mg, or 112.5 mg of pridopidine.

[0110] In an embodiment, 10 to 250 mg of pridopidine or a pharmaceutically acceptable salt thereof is administered to a patient per day. In another embodiment, 45 to 180 mg of pridopidine or a pharmaceutically acceptable salt thereof is administered to a patient per day. In another embodiment, 10 mg, 22.5 mg, 45 mg, 67.5 mg, 90 mg, 100 mg, 112.5 mg, 125 mg, 135 mg, 150 mg, or 180 mg of pridopidine or a pharmaceutically acceptable salt thereof is administered to a patient per day.

[0111] In an embodiment, the pharmaceutical composition is administered twice a day. In another embodiment, an equal amount of the pharmaceutical composition is administered at each administration. In an embodiment, the two doses are administered at an interval of at least 6 hours, at least 7 hours, at least 8 hours, at least 9 hours, at least 10 hours, or at least 11 hours. In some embodiments, the pharmaceutical composition is administered for at least 12 weeks, at least 20 weeks, at least 24 weeks, at least 26 weeks, at least 52 weeks, or at least 78 weeks.

[0112] In one embodiment of the present invention, the pridopidine salt is selected from the group consisting of hydrochloride, hydrobromide, nitrate, perchlorate, phosphate, sulfate, formate, acetate, aconate, ascorbate, benzenesulfonate, benzoate, cinnamate, citrate, embonate, enanthate, fumarate, glutamate, glycolate, lactate, maleate, malonate, mandelate, methanesulfonate, naphthalene-2-sulfonate, phthalate, salicylate, sorbate, stearate, succinate, tartrate, and toluene-sulfonate. In an embodiment, pridopidine is pridopidine hydrochloride.

[0113] In one embodiment, the subject is a human subject.

[0114] The present invention also provides pridopidine for use in the treatment of a human subject suffering from ALS.

[0115] The present invention also provides a pharmaceutical composition for use in the treatment of a human subject suffering from ALS comprising an effective amount of pridopidine.

[0116] The present invention further provides a method for the treatment of ALS, the method comprising regularly administering to a subject in need thereof a quantity of pridopidine or a pharmaceutically acceptable salt thereof in combination with phenylbutyrate sodium (PB), tauroursodeoxycholic acid, a combination of phenylbutyrate sodium (PB) / tauroursodeoxycholic acid, zilucoplan, beraprostat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof, which is effective for treating ALS.

[0117] In some embodiments, the present invention provides a pharmaceutical composition comprising a quantity of pridopidine or a pharmaceutically acceptable salt thereof and a quantity of phenylbutyrate sodium (PB), tauroursodeoxycholic acid, a combination of phenylbutyrate sodium (PB) / tauroursodeoxycholic acid, zilucoplan, beraprostat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof.

[0118] In some embodiments, the present invention provides a pharmaceutical composition for use in the treatment of ALS comprising a quantity of pridopidine or a pharmaceutically acceptable salt thereof and a quantity of phenylbutyrate sodium (PB), tauroursodeoxycholic acid, a combination of phenylbutyrate sodium (PB) / tauroursodeoxycholic acid, zilucoplan, beraprostat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof.

[0119] In one embodiment, a pharmaceutical composition for use in the treatment of a subject suffering from ALS comprises pridopidine or a pharmaceutically acceptable salt thereof and a second composition comprising sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplan, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof, which are prepared to be administered simultaneously or contemporaneously.

[0120] In an embodiment, the pharmaceutical composition is in a unit dosage form useful for the treatment of a subject suffering from ALS, which (a) an amount of pridopidine or a pharmaceutically acceptable salt thereof, and (b) an amount of sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplan, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof, wherein the respective amounts of the sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplan, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof, and the pridopidine or a pharmaceutically acceptable salt thereof in the composition are effective upon co-administration of one or more of the unit dosage forms of the composition to the subject for treating the subject.

[0121] In an embodiment, the pharmaceutical composition comprises a certain amount of pridopidine for use in the treatment of a subject suffering from ALS as an add-on therapy to a second compound. In another embodiment, the pharmaceutical composition comprises a certain amount of pridopidine or a pharmaceutically acceptable salt thereof for use in the treatment of a subject suffering from ALS as an add-on therapy to phenylbutyrate sodium (PB) of a second compound. In another embodiment, the pharmaceutical composition comprises a certain amount of pridopidine or a pharmaceutically acceptable salt thereof for use in the treatment of a subject suffering from ALS as an add-on therapy to tauroursodeoxycholic acid of a second compound. In another embodiment, the pharmaceutical composition comprises a certain amount of pridopidine for use in the treatment of a subject suffering from ALS as an add-on therapy to a combination of phenylbutyrate sodium (PB) and tauroursodeoxycholic acid (i.e., AMX0035). In another embodiment, the pharmaceutical composition comprises a certain amount of pridopidine for use in the treatment of a subject suffering from ALS as an add-on therapy to zilcoplan of a second compound. In another embodiment, the pharmaceutical composition comprises a certain amount of pridopidine for use in the treatment of a subject suffering from ALS as an add-on therapy to belperstat of a second compound. In another embodiment, the pharmaceutical composition comprises a certain amount of pridopidine for use in the treatment of a subject suffering from ALS as an add-on therapy to CNM-Au8 nanocrystalline gold of a second compound. In another embodiment, the pharmaceutical composition comprises a certain amount of pridopidine for use in the treatment of a subject suffering from ALS as an add-on therapy to SLS-005 of a second compound. In another embodiment, the pharmaceutical composition comprises a certain amount of pridopidine for use in the treatment of a subject suffering from ALS as an add-on therapy to IC14 of a second compound.

[0122] In an embodiment, the pharmaceutical composition comprises a certain amount of pridopidine or a pharmaceutically acceptable salt thereof for use in the treatment of a subject suffering from ALS simultaneously with, or contemporaneously with, a second compound. In another embodiment, the pharmaceutical composition comprises a certain amount of pridopidine or a pharmaceutically acceptable salt thereof for use in the treatment of a subject suffering from ALS simultaneously with, or contemporaneously with, a second compound which is sodium phenylbutyrate (PB). In another embodiment, the pharmaceutical composition comprises a certain amount of pridopidine or a pharmaceutically acceptable salt thereof for use in the treatment of a subject suffering from ALS simultaneously with, or contemporaneously with, a second compound which is tauroursodeoxycholic acid. In another embodiment, the pharmaceutical composition comprises a certain amount of pridopidine or a pharmaceutically acceptable salt thereof for use in the treatment of a subject suffering from ALS simultaneously with, or contemporaneously with, a combination of sodium phenylbutyrate (PB) and tauroursodeoxycholic acid (i.e., AMX0035). In another embodiment, the pharmaceutical composition comprises a certain amount of pridopidine or a pharmaceutically acceptable salt thereof for use in the treatment of a subject suffering from ALS simultaneously with, or contemporaneously with, a second compound which is zilucoplan. In another embodiment, the pharmaceutical composition comprises a certain amount of pridopidine or a pharmaceutically acceptable salt thereof for use in the treatment of a subject suffering from ALS simultaneously with, or contemporaneously with, a second compound which is belfiperstat. In another embodiment, the pharmaceutical composition comprises a certain amount of pridopidine or a pharmaceutically acceptable salt thereof for use in the treatment of a subject suffering from ALS simultaneously with, or contemporaneously with, a second compound which is CNM-Au8 nanocrystalline gold. In another embodiment, the pharmaceutical composition comprises a certain amount of pridopidine or a pharmaceutically acceptable salt thereof for use in the treatment of a subject suffering from ALS simultaneously with, or contemporaneously with, a second compound which is SLS-005. In another embodiment, the pharmaceutical composition comprises a certain amount of pridopidine or a pharmaceutically acceptable salt thereof for use in the treatment of a subject suffering from ALS simultaneously with, or contemporaneously with, a second compound which is IC14.

[0123] In another embodiment, the pharmaceutical composition comprises a compound of a certain amount of sodium phenylbutyrate (PB) for use in the treatment of a subject suffering from ALS as an add-on therapy to pridopidine or a pharmaceutically acceptable salt thereof. In another embodiment, the pharmaceutical composition comprises a compound of a certain amount of tauroursodeoxycholic acid for use in the treatment of a subject suffering from ALS as an add-on therapy to pridopidine or a pharmaceutically acceptable salt thereof. In another embodiment, the pharmaceutical composition comprises a combination of a certain amount of sodium phenylbutyrate (PB) and tauroursodeoxycholic acid for use in the treatment of a subject suffering from ALS as an add-on therapy to pridopidine or a pharmaceutically acceptable salt thereof. In another embodiment, the pharmaceutical composition comprises a compound of a certain amount of zilcoplan for use in the treatment of a subject suffering from ALS as an add-on therapy to pridopidine or a pharmaceutically acceptable salt thereof. In another embodiment, the pharmaceutical composition comprises a compound of a certain amount of belperstat for use in the treatment of a subject suffering from ALS as an add-on therapy to pridopidine or a pharmaceutically acceptable salt thereof. In another embodiment, the pharmaceutical composition comprises a certain amount of CNM-Au8 nanocrystalline gold for use in the treatment of a subject suffering from ALS as an add-on therapy to pridopidine or a pharmaceutically acceptable salt thereof. In another embodiment, the pharmaceutical composition comprises a certain amount of SLS-005 for use in the treatment of a subject suffering from ALS as an add-on therapy to pridopidine or a pharmaceutically acceptable salt thereof. In another embodiment, the pharmaceutical composition comprises a certain amount of IC14 for use in the treatment of a subject suffering from ALS as an add-on therapy to pridopidine or a pharmaceutically acceptable salt thereof.

[0124] In an embodiment, the pharmaceutical composition comprises a compound which is a certain amount of sodium phenylbutyrate (PB) for use in the treatment of a subject suffering from ALS, simultaneously with, or contemporaneously with, pridopidine or a pharmaceutically acceptable salt thereof. In another embodiment, the pharmaceutical composition comprises a compound which is a certain amount of tauroursodeoxycholic acid for use in the treatment of a subject suffering from ALS, simultaneously with, or contemporaneously with, pridopidine or a pharmaceutically acceptable salt thereof. In another embodiment, the pharmaceutical composition comprises a combination of a certain amount of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035) for use in the treatment of a subject suffering from ALS, simultaneously with, or contemporaneously with, pridopidine or a pharmaceutically acceptable salt thereof. In an embodiment, the pharmaceutical composition comprises a compound which is a certain amount of zilcoplan for use in the treatment of a subject suffering from ALS, simultaneously with, or contemporaneously with, pridopidine or a pharmaceutically acceptable salt thereof. In another embodiment, the pharmaceutical composition comprises a compound which is a certain amount of belfiperstat for use in the treatment of a subject suffering from ALS, simultaneously with, or contemporaneously with, pridopidine or a pharmaceutically acceptable salt thereof. In another embodiment, the pharmaceutical composition comprises a certain amount of CNM-Au8 nanocrystalline gold for use in the treatment of a subject suffering from ALS. In another embodiment, the pharmaceutical composition comprises a combination of a certain amount of SLS-005 for use in the treatment of a subject suffering from ALS. In another embodiment, the pharmaceutical composition comprises a combination of a certain amount of IC14 for use in the treatment of a subject suffering from ALS, simultaneously with, or contemporaneously with, pridopidine or a pharmaceutically acceptable salt thereof.

[0125] The present invention also provides a compound which is sodium phenylbutyrate (PB) for use as an adjunctive therapy to pridopidine or a pharmaceutically acceptable salt thereof in treating a subject suffering from ALS.

[0126] The present invention also provides a compound, tauroursodeoxycholic acid, for use as an adjunctive therapy to pridopidine or a pharmaceutically acceptable salt thereof in treating a subject suffering from ALS.

[0127] The present invention also provides a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035) for use as an adjunctive therapy to pridopidine or a pharmaceutically acceptable salt thereof in treating a subject suffering from ALS.

[0128] The present invention also provides a compound, zilcoplan, for use as an adjunctive therapy to pridopidine or a pharmaceutically acceptable salt thereof in treating a subject suffering from ALS.

[0129] The present invention also provides a compound, belperstat, for use as an adjunctive therapy to pridopidine or a pharmaceutically acceptable salt thereof in treating a subject suffering from ALS.

[0130] The present invention also provides CNM-Au8 nanocrystalline gold for use as an adjunctive therapy to pridopidine or a pharmaceutically acceptable salt thereof in treating a subject suffering from ALS.

[0131] The present invention also provides SLS-005 (trehalose) for use as an adjunctive therapy to pridopidine or a pharmaceutically acceptable salt thereof in treating a subject suffering from ALS.

[0132] The present invention also provides IC14 for use as an adjunctive therapy to pridopidine in treating a subject suffering from ALS.

[0133] The present invention also provides pridopidine or a pharmaceutically acceptable salt thereof for use as an adjunctive therapy to a compound, sodium phenylbutyrate (PB), in treating a subject suffering from ALS.

[0134] The present invention also provides pridopidine or a pharmaceutically acceptable salt thereof for use as an adjunctive therapy to a compound which is tauroursodeoxycholic acid when treating a subject suffering from ALS.

[0135] The present invention also provides pridopidine or a pharmaceutically acceptable salt thereof for use as an adjunctive therapy to a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035) when treating a subject suffering from ALS.

[0136] In an embodiment, the adjunctive therapy is for the treatment, prevention, or alleviation of symptoms of ALS.

[0137] The present invention also provides pridopidine or a pharmaceutically acceptable salt thereof for use as an adjunctive therapy to zilcopram when treating a subject suffering from ALS.

[0138] The present invention also provides pridopidine or a pharmaceutically acceptable salt thereof for use as an adjunctive therapy to belperstat when treating a subject suffering from ALS.

[0139] The present invention also provides pridopidine or a pharmaceutically acceptable salt thereof for use as an adjunctive therapy to CNM-Au8 nanocrystalline gold when treating a subject suffering from ALS.

[0140] The present invention also provides pridopidine or a pharmaceutically acceptable salt thereof for use as an adjunctive therapy to SLS-005 when treating a subject suffering from ALS.

[0141] The present invention also provides pridopidine or a pharmaceutically acceptable salt thereof for use as an adjunctive therapy to IC14 when treating a subject suffering from ALS.

[0142] The present invention also provides a combination of a compound, sodium phenylbutyrate (PB), and pridopidine or a pharmaceutically acceptable salt thereof for use in delaying the onset of symptoms of ALS, improving the decline thereof, or reducing the decline thereof.

[0143] The present invention also provides a combination of a compound, tauroursodeoxycholic acid, and pridopidine or a pharmaceutically acceptable salt thereof for use in delaying the onset of symptoms of ALS, improving the decline thereof, or reducing the decline thereof.

[0144] The present invention also provides a combination of a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035) and pridopidine or a pharmaceutically acceptable salt thereof for use in delaying the onset of symptoms of ALS, improving the decline thereof, or reducing the decline thereof.

[0145] The present invention also provides a combination of zilcoplan and pridopidine or a pharmaceutically acceptable salt thereof for use in delaying the onset of symptoms of ALS, improving the decline thereof, or reducing the decline thereof.

[0146] The present invention also provides a combination of belperstat and pridopidine or a pharmaceutically acceptable salt thereof for use in delaying the onset of symptoms of ALS, improving the decline thereof, or reducing the decline thereof.

[0147] The present invention also provides a combination of CNM-Au8 nanocrystalline gold and pridopidine or a pharmaceutically acceptable salt thereof for use in delaying the onset of symptoms of ALS, improving the decline thereof, or reducing the decline thereof.

[0148] The present invention also provides a combination of SLS-005 with pridopidine or a pharmaceutically acceptable salt thereof for use in delaying the onset of symptoms of ALS, improving the decline thereof, or reducing the decline thereof.

[0149] The present invention also provides a combination of IC14 with pridopidine or a pharmaceutically acceptable salt thereof for use in delaying the onset of symptoms of ALS, improving the decline thereof, or reducing the decline thereof.

[0150] The present invention also provides the use of pridopidine or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for the treatment of ALS.

[0151] The methods, uses, and compositions further include reducing neurological regression in a subject.

[0152] In an embodiment, the method of the present invention further comprises administering to a subject a therapeutically effective amount of a second compound that is sodium phenylbutyrate (PB) or tauroursodeoxycholic acid. In an embodiment, the method of the present invention further comprises administering to a subject a therapeutically effective amount of a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035). In another embodiment, the second compound is sodium phenylbutyrate (PB) or tauroursodeoxycholic acid. In an embodiment, the method of the present invention further comprises administering to a subject a therapeutically effective amount of a second compound that is zilcpuran. In an embodiment, the method of the present invention further comprises administering to a subject a therapeutically effective amount of a second compound that is belfiperstat. In an embodiment, the method of the present invention further comprises administering to a subject a therapeutically effective amount of Au8 nanocrystalline gold. In an embodiment, the method of the present invention further comprises administering to a subject a therapeutically effective amount of SLS-005. In an embodiment, the method of the present invention further comprises administering to a subject a therapeutically effective amount of IC14. In an embodiment of the present invention, pridopidine or a pharmaceutically acceptable salt thereof and a second compound (e.g., sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcpuran, belfiperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof) are administered in one unit. In another embodiment, pridopidine and a second compound (e.g., sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcpuran, belfiperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof) are administered in two or more units.

[0153] In an embodiment, the amount of pridopidine or a pharmaceutically acceptable salt thereof and the amount of a second compound (sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplan, berdipstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof) are administered simultaneously. In an embodiment, the amount of pridopidine or a pharmaceutically acceptable salt thereof and the amount of a second compound (sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplan, berdipstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof) are administered contemporaneously.

[0154] In another embodiment, administration of the second compound (sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplan, berdipstat, CNM-Au8 nanocrystalline gold, IC14, or a combination thereof) precedes administration of pridopidine or a pharmaceutically acceptable salt thereof. In another embodiment, administration of pridopidine or a pharmaceutically acceptable salt thereof precedes administration of the second compound (sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplan, berdipstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof).

[0155] In an embodiment, the subject has received sodium phenylbutyrate (PB) prior to initiating pridopidine therapy. In another embodiment, the subject has received tauroursodeoxycholic acid prior to initiating pridopidine therapy. In another embodiment, the subject has received a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035) prior to initiating pridopidine therapy.

[0156] In an embodiment, the subject has received zilcoplan therapy before initiating pridopidine therapy. In an embodiment, the subject has received belperstat therapy before initiating pridopidine therapy. In an embodiment, the subject has received CNM-Au8 nanocrystalline gold therapy before initiating pridopidine therapy. In an embodiment, the subject has received SLS-005 (trehalose) therapy before initiating pridopidine therapy. In an embodiment, the subject has received IC14 therapy before initiating pridopidine therapy.

[0157] In another embodiment, the subject has received sodium phenylbutyrate (PB) therapy for at least 1 week, 2 weeks, 4 weeks, or 6 weeks before initiating pridopidine therapy. In another embodiment, the subject has received tauroursodeoxycholic acid therapy for at least 1 week, 2 weeks, 4 weeks, or 6 weeks before initiating pridopidine therapy. In another embodiment, the subject has received a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035) therapy for at least 1 week, 2 weeks, 4 weeks, or 6 weeks before initiating pridopidine therapy.

[0158] In another embodiment, the subject has received zilcoplan therapy for at least 24 weeks, 28 weeks, 48 weeks, or 52 weeks before initiating pridopidine therapy. In another embodiment, the subject has received belperstat therapy for at least 24 weeks, 28 weeks, 48 weeks, or 52 weeks before initiating pridopidine therapy. In another embodiment, the subject has received CNM-Au8 nanocrystalline gold therapy for at least 24 weeks, 28 weeks, 48 weeks, or 52 weeks before initiating pridopidine therapy. In another embodiment, the subject has received SLS-005 therapy for at least 24 weeks, 28 weeks, 48 weeks, or 52 weeks before initiating pridopidine therapy. In another embodiment, the subject has received IC14 therapy for at least 24 weeks, 28 weeks, 48 weeks, or 52 weeks before initiating pridopidine therapy.

[0159] In an embodiment, the subject has received pridopidine therapy before starting therapy with sodium phenylbutyrate (PB), tauroursodeoxycholic acid, or a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035). In another embodiment, the subject has received pridopidine therapy for at least 24 weeks, 28 weeks, 48 weeks, or 52 weeks before starting therapy with sodium phenylbutyrate (PB), tauroursodeoxycholic acid, or a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035).

[0160] In an embodiment, the subject has received pridopidine therapy before starting zilcoplan therapy. In another embodiment, the subject has received pridopidine therapy for at least 24 weeks, 28 weeks, 48 weeks, or 52 weeks before zilcoplan therapy.

[0161] In an embodiment, the subject has received pridopidine therapy before starting belperstat. In another embodiment, the subject has received pridopidine therapy for at least 24 weeks, 28 weeks, 48 weeks, or 52 weeks before starting belperstat therapy.

[0162] In an embodiment, the subject has received pridopidine therapy before starting CNM-Au8 nanocrystalline gold therapy. In another embodiment, the subject has received pridopidine therapy for at least 24 weeks, 28 weeks, 48 weeks, or 52 weeks before starting CNM-Au8 nanocrystalline gold therapy.

[0163] In an embodiment, the subject has received pridopidine therapy before starting SLS-005 therapy. In another embodiment, the subject has received pridopidine therapy for at least 24 weeks, 28 weeks, 48 weeks, or 52 weeks before starting SLS-005 therapy.

[0164] In an embodiment, the subject has received pridopidine therapy before initiating IC14 therapy. In another embodiment, the subject has received pridopidine therapy for at least 24 weeks, 28 weeks, 48 weeks, or 52 weeks before initiating IC14 therapy.

[0165] In some embodiments, the second composition comprises sodium phenylbutyrate (PB). In other embodiments, the amount of sodium phenylbutyrate administered is 1 to 10 grams per day.

[0166] In an embodiment, sodium phenylbutyrate (PB) is administered orally. In another embodiment, 1 to 10 grams per day of sodium phenylbutyrate (PB) is administered to the patient per day. In another embodiment, it is 1 to 5 grams per day, 1 to 3 grams per day, or 4 to 10 grams per day. In another embodiment, sodium phenylbutyrate (PB) is administered once a day, twice a day, or more than twice a day.

[0167] In some embodiments, the second composition comprises tauroursodeoxycholic acid (TUDCA). In other embodiments, the amount of tauroursodeoxycholic acid (TUDCA) administered is 0.1 to 5 grams per day. In an embodiment, tauroursodeoxycholic acid is administered orally. In another embodiment, 0.1 to 5 grams per day of tauroursodeoxycholic acid is administered to the patient per day. In another embodiment, 0.5 to 3 grams per day of tauroursodeoxycholic acid is administered to the patient per day. In another embodiment, it is 0.1 to 1 gram per day, 0.1 to 2 grams per day, 0.5 to 2 grams per day, or 1 to 3 grams per day. In another embodiment, tauroursodeoxycholic acid is administered once a day, twice a day, or more than twice a day.

[0168] In some embodiments, the second composition comprises a combination of tauroursodeoxycholic acid (TUDCA) and sodium phenylbutyrate (PB), which refers to two separate compositions of tauroursodeoxycholic acid (TUDCA) and sodium phenylbutyrate (PB) respectively, or a composition comprising both tauroursodeoxycholic acid (TUDCA) and sodium phenylbutyrate (PB) such as AMX0035. In other embodiments, the amount of the composition comprising both tauroursodeoxycholic acid (TUDCA) and sodium phenylbutyrate (PB) administered is 1 to 10 grams per day of sodium phenylbutyrate, and 0.1 to 5 grams per day of tauroursodeoxycholic acid. In other embodiments, the amount of the composition comprising both tauroursodeoxycholic acid (TUDCA) and sodium phenylbutyrate (PB) administered is 1 to 10 grams per day of sodium phenylbutyrate, and 0.5 to 3 grams per day of tauroursodeoxycholic acid. In an embodiment, AMX0035 is administered orally to a patient in a therapeutic combination comprising 0.5 to 5 g of sodium phenylbutyrate, and 0.2 to 5 grams per day of tauroursodeoxycholic acid (TUDCA). In another embodiment, it is 3 grams per day of sodium phenylbutyrate, and 1 gram per day of tauroursodeoxycholic acid (TUDCA), or 6 grams per day of sodium phenylbutyrate, and 2 grams per day of tauroursodeoxycholic acid (TUDCA). In another embodiment, it is a combination comprising 1 to 10 grams per day of sodium phenylbutyrate, and 0.5 to 3 grams per day of tauroursodeoxycholic acid. In another embodiment, AMX0035 is administered once a day, twice a day, or more than twice a day.

[0169] In an embodiment, zilcoplan is administered by subcutaneous injection. In another embodiment, zilcoplan is administered at a daily dose of 0.05 to 0.5 mg / kg / day. In another embodiment, zilcoplan is administered at a daily dose of 0.22 to 0.42 mg / kg / day, 0.1 to 0.3 mg / kg / day, or 0.05 to 0.2 mg / kg / day.

[0170] In an embodiment, belperstat is administered orally. In another embodiment, belperstat is administered at a daily dose of 200 to 2000 mg / day. In another embodiment, belperstat is administered at a daily dose of 1200 mg / day, 200 to 1000 mg / day, 500 to 1100 mg / day, 1300 to 2000 mg / day. In another embodiment, belperstat is administered twice a day at a dosage of 100 to 1000 mg / bid (twice a day). In another embodiment, belperstat is administered twice a day at a dosage of 600 mg / bid, 100 to 500 mg / bid, 250 to 550 mg / bid, or 650 to 1000 mg / bid. In another embodiment, belperstat is administered once a day, twice a day, or more than twice a day.

[0171] In an embodiment, CNM-Au8 nanocrystalline gold is administered orally. In another embodiment, CNM-Au8 nanocrystalline gold is administered at a daily dose of 5 to 50 mg / day. In another embodiment, CNM-Au8 nanocrystalline gold is administered at a daily dose of 5 to 10 mg / day, 15 to 20 mg / day, 15 to 30 mg / day, 20 to 30 mg / day. In another embodiment, CNM-Au8 nanocrystalline gold is administered once a day, twice a day, or more than twice a day.

[0172] In an embodiment, SLS-005 is administered orally or intravenously. In another embodiment, SLS-005 is administered at a daily dose of 20 to 200 mg / day. In another embodiment, SLS-005 is administered at a daily dose of 20 to 50 mg / day. In another embodiment, SLS-005 is administered at a daily dose of 25 to 75 mg / day, 50 to 150 mg / day, 75 to 200 mg / day, 100 to 200 mg / day. In another embodiment, SLS-005 is administered once a day, twice a day, or more than twice a day.

[0173] In an embodiment, IC14 is administered intravenously. In another embodiment, IC14 is administered at a daily dose of 0.2 to 8 mg / kg / day. In another embodiment, IC14 is administered at a daily dose of 1 to 4 mg / kg / day, 0.2 to 4 mg / kg / day, 0.2 to 0.9 mg / kg / day, or 5 to 8 mg / kg / day. In another embodiment, IC14 is administered once a day, twice a day, or more than twice a day.

[0174] In an embodiment, the amount when each of the second compounds (sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplatin, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof) is taken alone, and the amount when pridopidine or a pharmaceutically acceptable salt thereof is taken alone is each effective for treating a subject. In another embodiment, either the amount when the second compound is taken alone, pridopidine, or the amount when a pharmaceutically acceptable salt thereof is taken alone is not very effective for treating a subject.

[0175] In an embodiment, pridopidine or a pharmaceutically acceptable salt thereof is administered in combination with a second compound (sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid, zilcoplatin, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof). In another embodiment, the second compound is administered in combination with pridopidine or a pharmaceutically acceptable salt thereof.

[0176] In an embodiment, a loading dose of an amount different from the intended dose is administered over a period at the start of regular administration.

[0177] In one embodiment, a method for enhancing axonal transport of BDNF in motor neurons of a subject suffering from ALS is provided, which includes administering to the subject a fixed amount of pridopidine or a pharmaceutically acceptable salt thereof, which is effective for enhancing axonal transport of BDNF in motor neurons of the subject, and a second compound provided herein. In another embodiment, the second compound includes sodium phenylbutyrate (PB), tauroursodeoxycholic acid, or a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035). In another embodiment, the second compound includes zilucoplan, beraprostat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof.

[0178] In one embodiment, a method for enhancing ERK activation in motor neurons of a subject suffering from ALS is provided, which includes administering to the subject a fixed amount of pridopidine or a pharmaceutically acceptable salt thereof, which is effective for enhancing ERK activation in motor neurons of the subject, and a second compound provided herein. In another embodiment, the second compound includes sodium phenylbutyrate (PB), tauroursodeoxycholic acid, or a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035). In another embodiment, the second compound includes zilucoplan, beraprostat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof.

[0179] In an embodiment, a method of preserving the neuromuscular junction (NMJ) structure in muscle cells of a subject afflicted with ALS is provided, which includes administering to the subject a fixed amount of pridopidine or a pharmaceutically acceptable salt thereof, which is effective to preserve the NMJ structure in the target muscle, and a second compound provided herein. In another embodiment, the second compound includes sodium phenylbutyrate (PB), tauroursodeoxycholic acid, or a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035). In another embodiment, the second compound includes zilcoplan, berdipstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof.

[0180] A method of improving muscle contraction function in a subject afflicted with ALS is provided, which includes administering to the subject a fixed amount of pridopidine or a pharmaceutically acceptable salt thereof, which is effective to improve muscle contraction function in the subject, and a second compound provided herein. In another embodiment, the second compound includes sodium phenylbutyrate (PB), tauroursodeoxycholic acid, or a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035). In another embodiment, the second compound includes zilcoplan, berdipstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof.

[0181] A method of improving the nerve innervation rate of muscle tissue in a subject afflicted with ALS is further provided, which includes administering to the subject a fixed amount of pridopidine or a pharmaceutically acceptable salt thereof, which is effective to improve the nerve innervation rate in the subject, and a second compound provided herein. In another embodiment, the second compound includes sodium phenylbutyrate (PB), tauroursodeoxycholic acid, or a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035). In another embodiment, the second compound includes zilcoplan, berdipstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof.

[0182] In an embodiment, a method of enhancing motor neuron axon growth in a subject afflicted with ALS is provided, comprising administering to the subject a fixed amount of pridopidine or a pharmaceutically acceptable salt thereof, which is effective to enhance motor neuron axon growth in the subject, and a second compound provided herein. In another embodiment, the second compound comprises sodium phenylbutyrate (PB), tauroursodeoxycholic acid, or a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035). In another embodiment, the second compound comprises zilcoplan, beraprostat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof.

[0183] In an embodiment, a method of enhancing muscle cell survival in a subject afflicted with ALS is provided, comprising administering to the subject a fixed amount of pridopidine or a pharmaceutically acceptable salt thereof, which is effective to enhance muscle cell survival in the subject, and a second compound provided herein. In another embodiment, the second compound comprises sodium phenylbutyrate (PB), tauroursodeoxycholic acid, or a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035). In another embodiment, the second compound comprises zilcoplan, beraprostat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof.

[0184] In an embodiment, a method for reducing the progression of muscle fiber atrophy in a subject suffering from ALS is provided, which includes administering to the subject a certain amount of pridopidine or a pharmaceutically acceptable salt thereof and a second compound provided herein, which is effective for reducing the progression of muscle fiber atrophy in the subject. In another embodiment, the second compound includes sodium phenylbutyrate (PB), tauroursodeoxycholic acid, or a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035). In another embodiment, the second compound includes zilcoplan, berdipstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof.

[0185] In an embodiment, a method for reducing axonal degeneration in a subject suffering from ALS is provided, which includes administering to the subject a certain amount of pridopidine or a pharmaceutically acceptable salt thereof and a second compound provided herein, which is effective for reducing axonal degeneration in the subject. In another embodiment, the second compound includes sodium phenylbutyrate (PB), tauroursodeoxycholic acid, or a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035). In another embodiment, the second compound includes zilcoplan, berdipstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof.

[0186] In an embodiment, a method for preserving neuromuscular junction (NMJ) formation in a subject suffering from ALS is provided, which includes administering to the subject a certain amount of pridopidine or a pharmaceutically acceptable salt thereof and a second compound provided herein, which is effective for preserving NMJ formation in the subject. In another embodiment, the second compound includes sodium phenylbutyrate (PB), tauroursodeoxycholic acid, or a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035). In another embodiment, the second compound includes zilcoplan, berdipstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof.

[0187] In an embodiment, a method of preserving NMJ structure and function in a subject afflicted with ALS is provided, comprising administering to the subject a fixed amount of pridopidine or a pharmaceutically acceptable salt thereof, which is effective to preserve NMJ structure and function in the subject, and a second compound provided herein. In another embodiment, the second compound comprises sodium phenylbutyrate (PB), tauroursodeoxycholic acid, or a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035). In another embodiment, the second compound comprises zilcoplan, bendepstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof.

[0188] In an embodiment, a method of reducing protein aggregation in a subject afflicted with ALS is provided, comprising administering to the subject a fixed amount of pridopidine or a pharmaceutically acceptable salt thereof, which is effective to reduce protein aggregation in the subject, and a second compound provided herein. In another embodiment, the second compound comprises sodium phenylbutyrate (PB), tauroursodeoxycholic acid, or a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035). In another embodiment, the second compound comprises zilcoplan, bendepstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof.

[0189] In an embodiment, a method is provided for slowing the progression of pseudobulbar impairment or improving pseudobulbar function in a subject suffering from ALS, which includes administering to the subject a fixed amount of pridopidine or a pharmaceutically acceptable salt thereof, which is effective in attenuating the progression of pseudobulbar disease in the subject, and a second compound provided herein. In another embodiment, the second compound includes sodium phenylbutyrate (PB), tauroursodeoxycholic acid, or a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035). In another embodiment, the second compound includes zilcoplan, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof.

[0190] The present invention further provides a method of combination therapy for the treatment of ALS, which includes administering to a subject in need of treatment a therapeutically effective amount of pridopidine or a pharmaceutically acceptable salt thereof, and a therapeutically effective amount of sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilcoplan, belperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof.

[0191] Regarding the foregoing embodiments, each of the embodiments disclosed herein is considered applicable to each of the other disclosed embodiments. For example, the elements recited in the method embodiments may be used in the pharmaceutical compositions described herein and in the use embodiments, and vice versa.

[0192] All combinations, sub-combinations, and permutations of the various elements of the methods and uses described herein are contemplated and are within the scope of the present invention.

[0193] Pharmaceutically acceptable salt

[0194] As used herein, "pregabalin" means pregabalin base or a pharmaceutically acceptable salt thereof, as well as derivatives, such as deuterium-enriched versions of pregabalin and salts. Examples of deuterium-enriched pregabalin and salts, and methods for their preparation, are described in U.S. Patent Application Publication Nos. 2013-0197031, 2016-0166559, and 2016-0095847, the entire contents of each of which are incorporated herein by reference. In certain embodiments, pregabalin is a pharmaceutically acceptable salt such as the HCl salt or the tartrate salt. Preferably, in any embodiment of the invention described herein, pregabalin is in the form of its hydrochloride salt.

[0195] Examples of pharmaceutically acceptable addition salts include, for example, non-toxic inorganic and organic acid addition salts such as hydrochloride, hydrobromide, nitrate, perchlorate, phosphate, sulfate, formate, acetate, aconitate, ascorbate, benzenesulfonate, benzoate, cinnamate, citrate, pamoate, enanthate, fumarate, glutamate, glycolate, lactate, maleate, malonate, mandelate, methanesulfonate, naphthalene-2-sulfonate, phthalate, salicylate, sorbate, stearate, succinate, tartrate, and toluene-sulfonate, but are not limited thereto. Such salts can be formed by procedures well known and described in the art.

[0196] "Deuterium-enriched" means that the abundance of deuterium at any relevant site of a compound is greater than the abundance of deuterium that naturally occurs at that site in an amount of the compound. The naturally occurring deuterium distribution is about 0.0156%. Thus, in a "deuterium-enriched" compound, the abundance of deuterium at any of its relevant sites is greater than 0.0156% and can range from greater than 0.0156% to 100%. Deuterium-enriched compounds can be obtained by exchanging hydrogen for deuterium or by synthesizing the compound from deuterium-enriched starting materials.

[0197] Pregabalin analogs

[0198] In some embodiments, the methods and uses of the present invention utilize pharmaceutical compositions comprising pridopidine or a pharmaceutically acceptable salt thereof. In one embodiment, the composition comprises pridopidine or a pharmaceutically acceptable salt thereof and at least one pridopidine analog or a pharmaceutically acceptable salt thereof. In another embodiment, the pridopidine analog is represented by the following structures of Compounds 1-7.

[0199]

Chemical formula

[0200] In other embodiments, a pharmaceutical composition is provided that comprises pridopidine of the present invention or a pharmaceutically acceptable salt thereof and compound 1 or a pharmaceutically acceptable salt thereof. In other embodiments, a pharmaceutical composition is provided that comprises pridopidine of the present invention or a pharmaceutically acceptable salt thereof and compound 2 or a pharmaceutically acceptable salt thereof. In other embodiments, a pharmaceutical composition is provided that comprises pridopidine of the present invention or a pharmaceutically acceptable salt thereof and compound 3 or a pharmaceutically acceptable salt thereof. In other embodiments, a pharmaceutical composition is provided that comprises pridopidine of the present invention or a pharmaceutically acceptable salt thereof and compound 4 or a pharmaceutically acceptable salt thereof. In other embodiments, a pharmaceutical composition is provided that comprises pridopidine of the present invention or a pharmaceutically acceptable salt thereof and compound 5 or a pharmaceutically acceptable salt thereof. In other embodiments, a pharmaceutical composition is provided that comprises pridopidine of the present invention or a pharmaceutically acceptable salt thereof and compound 6 or a pharmaceutically acceptable salt thereof. In other embodiments, a pharmaceutical composition is provided that comprises pridopidine of the present invention or a pharmaceutically acceptable salt thereof and compound 7 or a pharmaceutically acceptable salt thereof. In other embodiments, the present invention provides a pharmaceutical composition comprising pridopidine or a pharmaceutically acceptable salt thereof and compound 1 and compound 4 or a pharmaceutically acceptable salt thereof. In other embodiments, the concentration of compound 1, 2, 3, 4, 5, 6 or 7, or a pharmaceutically acceptable salt thereof in the composition is 0.001 w / w% to 10 w / w%. In other embodiments, the concentration of compound 1, 2, 3, 4, 5, 6 or 7, or a pharmaceutically acceptable salt thereof in the composition is 0.001 w / w% to 0.05 w / w%. In other embodiments, the concentration of compound 1, 2, 3, 4, 5, 6 or 7, or a pharmaceutically acceptable salt thereof in the composition is 0.001 w / w% to 0.5 w / w%. In other embodiments, the concentration of compound 1, 2, 3, 4, 5, 6 or 7, or a pharmaceutically acceptable salt thereof in the composition is 0.001 w / w% to 0.15 w / w%. In other embodiments, the concentration of compound 1, 2, 3, 4, 5, 6 or 7, or a pharmaceutically acceptable salt thereof in the composition is 0.01 w / w% to 0.15 w / w%.In other embodiments, the concentration of compound 1, 2, 3, 4, 5, 6, or 7 in the composition, or a pharmaceutically acceptable salt thereof, is from 0.01 w / w% to 0.5 w / w%. In other embodiments, the concentration of compound 1, 2, 3, 4, 5, 6, or 7 in the composition, or a pharmaceutically acceptable salt thereof, is from 0.01 w / w% to 1 w / w%.

[0201] In an embodiment, the pridopidine analog salt is selected from the group consisting of hydrochloride, hydrobromide, nitrate, perchlorate, phosphate, sulfate, formate, acetate, aconitate, ascorbate, benzenesulfonate, benzoate, cinnamate, citrate, pamoate, enanthate, fumarate, glutamate, glycolate, lactate, maleate, malonate, mandelate, methanesulfonate, naphthalene-2-sulfonate, phthalate, salicylate, sorbate, stearate, succinate, tartrate, and toluene-sulfonate.

[0202] Pharmaceutical composition

[0203] Pridopidine for use according to the present invention can be administered in the form of the crude compound, but preferably, the administration of pridopidine in the form of a physiologically acceptable salt is a pharmaceutical composition that also includes one or more adjuvants, excipients, carriers, buffers, diluents, and / or other conventional pharmaceutical aids.

[0204] In one embodiment, the present invention provides a pharmaceutical composition comprising pridopidine or a pharmaceutically acceptable salt or derivative thereof together with one or more pharmaceutically acceptable carriers, and thus optionally, sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilcoplan, berdipstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof, but not limited thereto, and other therapeutic and / or prophylactic components known and used in the art.

[0205] The carrier must be "acceptable" in the sense that it is compatible with the other ingredients of the formulation and suitable for administration to a human subject.

[0206] As used herein, unless otherwise specified, each of the following terms has the following definitions.

[0207] As used herein, "AMX0035" means an oral combination of two drugs already in use, sodium phenylbutyrate (PB) and tauroursodeoxycholic acid (TUDCA).

[0208] Sodium phenylbutyrate (PB) - Sodium phenylbutyrate is the sodium salt of phenylbutyric acid, a derivative of the short-chain fatty acid butyrate that has potential antitumor activity. Phenylbutyrate reversibly inhibits class I and II histone deacetylases (HDACs), which can lead to an overall increase in gene expression, a decrease in cell proliferation, an increase in cell differentiation, and the induction of apoptosis in sensitive tumor cell populations.

[0209] Tauroursodeoxycholic acid (TUDCA) - Tauroursodeoxycholic acid is a bile acid taurine conjugate derived from ursodeoxycholic acid. It serves as a human metabolite, anti-inflammatory agent, neuroprotective agent, apoptosis inhibitor, cardioprotective agent, and bone density maintenance agent. It is derived from ursodeoxycholic acid. It is the conjugate acid of tauroursodeoxycholate.

[0210] Zilucoplan is a synthetic macrocyclic peptide inhibitor of the terminal complement protein C5, which has potential anti-inflammatory and cytoprotective activities. When administered subcutaneously, zilucoplan binds to a unique site within the terminal complement protein C5, blocks C5 cleavage into C5b and C5b, and prevents the C5b-dependent assembly of the complement membrane-attack complex (MAC). Zilucoplan also inhibits the interaction between C5b and C6, thereby further blocking MAC assembly. Zilucoplan inhibits tissue damage caused by pathologic complement activation and has shown beneficial effects in myasthenia gravis, another previous neuromuscular disorder.

[0211] Belfiperstat, 1-(2-propan-2-yloxyethyl)-2-sulfanylidene-5H-pyrrolo[3,2-d]pyrimidin-4-one, is known for the treatment of multiple system atrophy. Belfiperstat is an oral drug that inhibits myeloperoxidase (MPO), a potent oxidation-promoting enzyme present in activated immune cells such as microglia. Belfiperstat treatment may reduce the activation of microglia.

[0212] CNM-Au8 nanocrystalline gold is a small nanocrystal that provides energy support by assisting in bioenergy reactions and eliminating harmful bioproducts of cell metabolism. CNM-Au8 shows neuroprotective effects in preclinical models. CNM-Au8 consists only of gold nanoparticles composed of geometric crystals with a cleaned and faceted surface, suspended and maintained in sodium bicarbonate buffered, pharmaceutical-grade water.

[0213] SLS-005 (trehalose) is a low-molecular-weight disaccharide ((2R,3S,4S,5R,6R)-2-(hydroxymethyl)-6-[(2R,3R,4S,5S,6R)-3,4,5-trihydroxy-6-(hydroxymethyl)oxan-2-yl]oxyoxane-3,4,5-triol) that stabilizes proteins and activates autophagy, a process that clears waste from cells. SLS-005 activates transcription factor EB, which is important for the expression of autophagy-related genes.

[0214] IC14 is a monoclonal antibody drug that inhibits CD14 on immune cells. CD14 is a master regulator of the immune system. Overactivation of CD14 leads to harmful inflammation that damages brain tissue.

[0215] As used herein, the "amount" or "dose" of pridopidine measured in milligrams refers to the milligrams of the non-derivatized pridopidine base present in the preparation regardless of the form of the preparation. A "dose of 45 mg of pridopidine" means the amount of pridopidine in the preparation sufficient to provide 45 mg of the non-derivatized pridopidine base having the naturally occurring isotope distribution, regardless of the form of the preparation. Thus, in the form of a salt, such as pridopidine hydrochloride, the mass of the salt form required to provide a dose of 45 mg of the non-derivatized pridopidine base will be greater than 45 mg due to the presence of the additional salt ions. Similarly, in the form of a deuterium-rich derivative, the mass of the derivatized form required to provide a dose of 45 mg of the derivatized pridopidine base having the naturally occurring isotope distribution will be greater than 45 mg due to the presence of the additional deuterium.

[0216] Any range disclosed herein means that all one-hundredths, tenths, and integer unit amounts within the range are specifically disclosed as part of the present invention. Thus, for example, 0.01 mg to 50 mg includes unit amounts of 0.02, 0.03 ··· 0.09; 0.1; 0.2 ··· 0.9; and 1, 2 ··· 49 mg as embodiments of the present invention. Any range of time disclosed herein (i.e., weeks, months, or years) means that all lengths of days and / or weeks within the range are specifically disclosed as part of the present invention. Thus, for example, 3 to 6 months means that 3 months and 1 day, 3 months and 1 week, and 4 months are included as embodiments of the present invention.

[0217] As used herein, "about" in the context of a numerical value or range means ± 10% of the recited or claimed numerical value or range.

[0218] As used herein, "monotherapy" means treatment with a single active agent, e.g., treatment with pridopidine alone.

[0219] As used herein, "in combination" means treatment or administration of an additional compound with a primary compound, e.g., to increase the efficacy or safety of the primary compound or to enhance its activity.

[0220] As used herein, "regular administration" means repeated / periodic administration separated by a period of time. The period between administrations is preferably consistent from time to time. Regular administration can include, for example, once a day, twice a day, three times a day, four times a day, once a week, twice a week, three times a week, four times a week, etc.

[0221] As used herein, "combination" means a collection of reagents for use in treatment by either simultaneous or contemporaneous administration. Simultaneous administration refers to the administration of a mixture of pridopidine and a second compound (e.g., AMX0035) (regardless of whether it is a true mixture, suspension, emulsion, or other physical combination). In this case, the combination may be a mixture of pridopidine and the second compound (sodium phenylbutyrate (PB), tauroursodeoxycholic acid, sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilcoplan, belfiperstat, CNM-Au8 nanocrystalline gold, SLS-005, IC14, or a combination thereof) combined immediately prior to administration or in separate containers. Contemporaneous administration, or concomitant administration, refers to the separate administration of pridopidine and a second compound (e.g., AMX0035) at the same time or at sufficiently close times such that additional or preferably synergistic activity is observed against the activity of either pridopidine or the second compound alone, or the individual therapeutic effects of each agent overlap sufficiently closely.

[0222] As used herein, "addition" or "adjunctive therapy" means a collection of reagents for use in therapy, where the subject receiving the therapy has initiated a first regimen of one or more reagents and, in addition to the first treatment regimen, initiates a second treatment regimen of one or more different reagents before starting the second treatment regimen of one or more different reagents, and thus not all of the reagents used in the therapy are initiated simultaneously. For example, adding pridopidine therapy to a patient already receiving AMX0035 therapy.

[0223] As used herein, when referring to the amount of pridopidine, "effective" means an amount of pridopidine sufficient to produce the desired therapeutic response. In a preferred embodiment, the amount of pridopidine administered does not result in adverse side effects (such as toxicity, irritation, or allergic reactions).

[0224] "Administration to a subject" or "administration to a (human) patient" means giving, dispensing, or applying a drug, medicine, or therapeutic agent to a subject / patient in order to alleviate, cure, or reduce symptoms associated with a disease, disorder, or condition, such as a pathological condition.

[0225] As used herein, "treating" includes inducing inhibition, regression, or stasis of a disease or disorder, or reducing, suppressing, inhibiting, or decreasing the severity of a disease or disorder, eliminating or substantially eliminating or ameliorating the symptoms of a disease or disorder.

[0226] "Inhibiting" a disease progression and / or disease complication in a subject means preventing or reducing the disease progression and / or disease complication in the subject.

[0227] "Symptoms" associated with a disease or disorder include any clinical or laboratory symptoms associated with the disease or disorder and are not limited to those that a subject can feel or observe.

[0228] As used herein, a "subject afflicted with" a disease, disorder, or condition means a subject clinically diagnosed as having the disease, disorder, or condition.

[0229] Glial cell line-derived neurotrophic factor (GDNF) is a protein encoded by the GDNF gene and is thought to promote the survival of many types of neurons.

[0230] Brain-derived neurotrophic factor (BDNF) is a protein produced by neurons and plays a role in maintaining function and promoting neuron growth and neurogenesis.

[0231] Throughout this application, certain publications and patent application publications are referenced. The complete citations of the publications can be found immediately preceding the claims. The disclosures of these publications and patent application publications are hereby incorporated by reference into this application in their entirety to more fully describe the state of the art relevant to this invention.

[0232] The present invention will be better understood by reference to the following experimental details, but those skilled in the art will readily understand that the specific experimental details are merely illustrative of the invention as more fully described by the claims that follow.

[0233] Details of the experiments

[0234] Experiment 1: Effect of pridopidine in an axonal transport assay.

[0235] Healthy motor neurons (MNs) extend axons over long distances and form synapses with muscles through various extracellular microenvironments. The ability of neurons to maintain this special morphology depends on the continuous transport of proteins and organelles to and from the cell body and the cytoskeletal elements. Changes in the cytoskeleton are a major pathway involved in the etiology of ALS that affects axonal transport, growth, and neuromuscular junction (NMJ) function (Eykens and Robberecht, 2015). Changes in axonal transport are one of the first cellular processes that occur in neurodegenerative diseases, including ALS.

[0236] Axonal transport was evaluated using an in vitro compartmentalization system of microfluidic chambers (MFCs) that separate neuronal cell bodies from their axons and synapses, enabling the study of retrograde / anterograde transport of fluorescently labeled molecules (e.g., Qdot-BDNF) by specific monitoring and manipulation of the cellular microenvironment (Figure 1A; Zahavi 2015; Ionescu 2016).

[0237] Quantum dot-labeled BDNF (Qdot BDNF) is retrogradely transported within the axons of motor neurons grown from spinal cord explants within a microfluidic chamber (MFC). The MFC was used to analyze Qdot BDNF axonal transport (Figure 1A). Axonal transport of BDNF is impaired in the SOD1 model (SOD1G93A) for ALS (Bilsland 2010; Perlson 2009; De Vos 2007). The effect of pridopidine on the transport of Qdot BDNF along the axons of motor neurons was evaluated in spinal cord explants from embryonic day E12.5 SOD1G93A and wild-type (WT) littermate mice (WT). Experimental workflow for the axonal transport assay (left to right, Figure 1B): SOD1G93A or wild-type (WT) spinal cord explants were implanted into the MFC. At approximately 5 days post-implantation, axons begin to invade the distal compartment. On day 6 post-implantation, a fixed amount of pridopidine is added to both compartments. On day 7, Qdot-BDNF is added to the distal compartment and axonal transport is imaged using high-resolution spinning disk confocal microscopy. Schematic of the microfluidic chamber system (Figure 1A): Explants implanted in the proximal compartment extend axons to the distal compartment, where only Qdot-BDNF is applied prior to visualization.

[0238] Qdot BDNF was tracked along the axons of motor neuron explant cultures using spinning disk confocal microscopy. Time-lapse images of Qdot-BDNF axonal transport collected at 60x magnification (Figure 1C). Arrows point to single Qdot-BDNF particles being retrogradely transported towards the cell body (left). Scale bar: 10 μm. The lower panel shows a kymograph of the full Qdot-BDNF time-lapse movie plotting movement along the axon (x-axis) as a function of time (y-axis). Scale bar: horizontal 10 μm, vertical 100 s (Figure 1C).

[0239] The vehicle and pridopidine were added to both compartments at two concentrations (0.1 μM and 1 μM) on day 6 of the experiment, and after incubating overnight with pridopidine, Qdot BDNF was added to the distal compartment (Figures 1A and 1B). Six independent biological replicates from six different cultures were tested, and approximately 250 BDNF particles per neuron / glia from each culture were tracked along axons in the groove. Velocity refers to the movement of a single BDNF particle. The experiment was repeated in MNs from mice in which the sigma-1 receptor (S1R) was genetically deleted (S1R KO or S1R− / −) (Langa, 2003). As described above, ventral spinal cord slices from S1R− / − mouse embryos were cultured and implanted in the MFC, and axonal transport of Qdot-BDNF was analyzed.

[0240] SOD1G93 and S1R− / − explants with or without pridopidine were compared to wild-type littermate controls (WT).

[0241] Qdot-BDNF particle tracking was performed in Bitplane Imaris using the semi-automated spot-tracking function. Inclusion criteria for particle analysis: tracking duration > 10 frames, average velocity ≥ 0.2 μm / sec, stop duration: 3 frames at a velocity < 0.1 μm / sec. The data were then exported to MATLAB® for further analysis of particle transport, including instantaneous velocity (Figure 2A) and stop count (Figure 2B) from six independent cultures.

[0242] Results

[0243] Figure 2A shows that pridopidine enhances the instantaneous velocity of BDNF axonal transport in SOD1G93A motor neurons. The instantaneous velocity of BDNF retrograde transport is decreased within SOD1G93A motor neurons. SOD1G93A MNs exhibit a slower velocity compared to WT MNs. Treatment with pridopidine accelerates the instantaneous velocity in SOD1G93A MNs (0.1 μM and 1 μM). Application of 25 μM or 100 μM riluzole, a standard treatment for ALS patients, to SOD1G93A MNs has no effect on the instantaneous velocity. S1R− / − MNs show a reduction in the velocity of BDNF axonal transport. Pridopidine at either 0.1 μM or 1 μM cannot rescue these defects in S1R KO MNs, indicating that the effect of pridopidine is mediated by S1R (Figure 2A).

[0244] In SOD1G93A MNs, the particle stop count (number of counted stops of Qdot-BDNF per second) is increased compared to WT MNs. Pridopidine reduces the number of pauses during axonal transport in SOD1G93A MNs (both 0.1 μM and 1 μM). Pridopidine cannot rescue the particle stop count p of Qdot-BDNF in S1R− / − MNs, indicating that the effect of pridopidine is mediated by S1R (Figure 2B). Data are shown as mean ± SEM. *p value < 0.01, **p value < 0.001, ***p value < 0.0001. (Student's t-test).

[0245] These results demonstrate that pridopidine enhances BDNF axonal transport in SOD1G93A motor neurons and corrects ALS-related deficits.

[0246] Experiment 2: Effect of pridopidine on the axon-muscle growth / degeneration assay.

[0247] The initial event in the etiology of ALS is axonal degeneration. Using a compartment co - culture microfluidic chamber system, we determined whether pridopidine alters axonal degeneration (Figure 3). Primary muscle cells from pre - symptomatic (P60) WT or SOD1G93A mice were cultured. On day 6, primary skeletal myoblasts were cultured in the distal compartment of the MFC. Approximately 6 days later (day 12), ventral spinal cord explants from WT or SOD1G93A E12.5 mouse embryos expressing HB9 - GFP (a specific motor neuron marker) were implanted into the proximal compartment, followed by application of pridopidine or vehicle to both compartments. Pridopidine was refreshed every other day. Two days after explant implantation (day 14), live imaging using a spinning disk confocal system was used to evaluate motor axon growth and degeneration. Axon growth was tracked by imaging every 10 minutes over an 8 - hour period. The experiment was repeated 3 times.

[0248] Results

[0249] Data demonstrate that pridopidine increases axon growth (Figure 4). Muscle cells carrying the SOD1G93A mutation have a reduced number of healthy axons that can invade the distal compartment of the microfluidic compartment chamber compared to WT muscle cells. Treatment with 1 μM pridopidine (the right - most bar) significantly increases the number of SOD1G93A axons invading the distal compartment (the compartment with muscle cells). (The Y - axis is the average number of grooves with axons invading the muscle compartment). Data are shown as mean ± SEM. *p - value < 0.05; (Student's t - test).

[0250] These results demonstrate that pridopidine enhances axon growth in ALS neurons.

[0251] Experiment 3: Evaluation of the effect of pridopidine on neuromuscular junction (NMJ) formation and function.

[0252] Synapses are the cellular compartments that are most rapidly destroyed in ALS. To test the ability of pridopidine to affect synapse function in an ALS model, the cultures from Experiment 2 described above were grown for an additional ~4 days (day 18) until the axons extended into the distal compartment to form NMJs. In this co-culture, MN axons formed NMJs on fully differentiated primary muscle cells. These could be observed by co-localization of the postsynaptic marker (AchR, acetylcholine receptor) located within the muscle with the Hb9:GFP neuron marker. Figure 5A: Upper panel: Phase contrast microscopy image of muscle cells in the distal compartment connected by axons (arrows). Scale bar: 20 μm. Lower panel: High magnification image of muscle cells: MN contact points reveal NMJ formation as seen by co-localization of postsynaptic AChR with HB9:GFP axons, and three-dimensional co-localization (coloc) of pre- and postsynaptic markers.

[0253] To evaluate NMJ function, videos of muscle contractions were collected at a frame rate of 30 frames per second for 1000 frames (Figure 5B). Traces of muscle contractions extracted from the measurement of muscle contraction intensity over time show flat traces of non-contractile stationary muscle cells (upper), and traces of contractile muscle cells showing multiple rupture events (lower).

[0254] To study the effect of pridopidine on the formation and function of MN and NMJ, either 0.1 μM or 1 μM pridopidine or vehicle was added. As previously reported, live cell imaging was used to evaluate the measurement of innervation and the percentage of innervation-induced contractions in myotubes (Ionescu 2015; Zahavi 2015). Briefly, the contractile activity of the muscle in the distal compartment of the MFC where at least one axon overlapped was examined. Muscles were classified into the following two groups: "contracting" or "non-contracting" according to their motility activities in the video. The motility of the muscle was verified by generating a plot of intensity over time for each muscle (Figure 5b). The number of contracting muscle fibers per chamber was divided by the total number of muscle fibers analyzed within the same chamber to obtain the percentage of contracting myotubes as an output of NMJ activity.

[0255] Results

[0256] Pridopidine enhances muscle innervation and increases NMJ function, as measured by an increase in the percentage of contracting muscle cells. The innervation rate of muscles with SOD1 mutations is lower compared to WT (wild-type) muscles (20% innervation compared to approximately 40% in WT). Pridopidine 1 μM significantly increases the innervation rate of muscles with SOD1 mutations to near WT levels (Figure 6).

[0257] The percentage of contractile myotubes is decreased in SOD1 myocytes innervated by WT MNs compared to WT myocytes innervated by WT MNs. Treatment of SOD1G93A myocytes co-cultured with pridopidine (0.1 μM and 1 μM) significantly increases the proportion of contractile myocytes and restores neuromuscular activity to WT levels. Both WT and SOD1 myocytes show a decrease in contractility when innervated by S1R− / − MNs. The combination of S1R− / − MNs and WT myocytes decreases the number of contractile myotubes compared to WT MNs. Application of 0.1 μM pridopidine to S1R− / − co-cultures does not restore neuromuscular activity as seen in co-cultures with the same concentration of pridopidine in WT neurons, indicating that the effect of pridopidine is mediated through S1R. Data are shown as mean ± SEM. *p value < 0.05, **p value < 0.01, ***p value < 0.001, ****p value < 0.0001. (Student's t test).

[0258] Experiment 4: Effect of pridopidine on ERK activation in WT and SOD1G93A MNs

[0259] The ERK pathway promotes a number of cellular functions including proliferation and differentiation. ERK phosphorylation (activation) in neurons is associated with neurotrophic signaling such as BDNF that promotes neuroprotection and neuronal survival (Bonni 1999). Pridopidine has previously been established to enhance BDNF signaling in the rat striatum via S1R, thereby enhancing ERK activation. Primary MN cultures at 2 DIV were starved overnight in neurotrophin- and serum-free medium (PNB). The next day, the cultures were treated with pridopidine or BDNF for 30 min as positive controls, and the levels of ERK and phosphorylated ERK proteins were measured.

[0260] Results

[0261] Pridopidine induces a significant increase in phosphorylated ERK (pERK) (0.1 μM and 1 μM) as early as 30 minutes after application in WT (left panel) and SOD1G93A (central panel) MN cultures. Pridopidine has no effect in S1R− / − MN cultures (right panel), indicating that the activation of ERK by pridopidine is mediated via S1R (Figure 8A). Quantification of pERK reveals an approximately 3.5- and approximately 4-fold increase in WT MNs following 0.1 μM and 1 μM pridopidine, respectively. SOD1G93A shows an approximately 2.9- and approximately 8.5-fold increase in pERK following 0.1 μM and 1 μM pridopidine, respectively. Data are shown as mean pERK / ERK ratio ± SEM. *p value < 0.05, ~p value < 0.1 (Student's t-test) (Figure 8B).

[0262] Experiment 5: Effect of pridopidine on mutant SOD1 aggregates in the spinal cord of SOD1G93A mice.

[0263] Pridopidine induces neuroprotective properties upon activation of S1R, as demonstrated for its effects on axonal transport, axonal degeneration, NMJ function, and ERK activation. S1R is constitutively present on the ER membrane in close proximity to the outer mitochondrial membrane, where mutant SOD1 protein tends to aggregate in the spinal cord of SOD1G93A mice (Millecamps and Julien 2013).

[0264] Pre-symptomatic SOD1G93A mice (5 weeks old) and WT controls were treated with either saline or 30 mg / kg pridopidine daily by s.c. (subcutaneous) administration for 11 weeks (until 16 weeks old). At the end of the experiment, lumbar spinal cords (L1–L6) were extracted, fixed, and embedded for cryosectioning. Next, 10-μm sections were prepared and stained with NSC500 dye to visualize SOD1 aggregates (Hammarstrom 2010). The in vivo effect of pridopidine treatment on the number of mutant SOD1 aggregates in the gray matter (GM) and white matter (WM) of the spinal cord was evaluated.

[0265] Results

[0266] Figure 9A - Left panel: Representative low - magnification images of fluorescently labeled spinal cords for three mouse groups. Right panel: High - magnification images for the regions marked with squares in the left panel. Scale bar: Left panel::500 μm: Right panel 50 μm Top to bottom: WT vehicle, SOD1G93A vehicle, SOD1G93A 30 mg / kg, all stained with NSC500 dye to label mutant SOD1 protein aggregates.

[0267] A significant increase in the number of mSOD1 aggregates is observed in both the gray and white matter of the spinal cord of SOD1G93A mice compared to WT mice. 30 mg / kg of pridopidine significantly reduces the number of aggregates in both the gray matter (Figure 9B) and white matter (Figure 9C) of the SOD1G93A spinal cord by approximately 50% (Figure 9A - 9C). Data are shown as mean ± SEM. *p - value < 0.05, **p - value < 0.01 (one - way ANOVA, followed by Fisher's LSD post - hoc test). (The y - axis in Figures 9B - 9C is the number of NSC500 - positive SOD1 aggregates per square mm).

[0268] Experiment 6: Pridopidine effect on muscle fiber atrophy and NMJ preservation in vivo.

[0269] The destruction of the NMJ and subsequent skeletal muscle wasting are two major pathologies in ALS. The effects of pridopidine on muscle fiber atrophy and NMJ preservation were evaluated in vivo. Pre-symptomatic SOD1G93A mice and WT controls (5 weeks old) were treated by daily s.c. administration with either saline or pridopidine 30 mg / kg for 11 weeks. Gastrocnemius muscles from vehicle or pridopidine-treated (30 mg / kg s.c.) mice were harvested at 16 weeks of age from SOD1G93A and WT mice. Muscle cross-sections were stained with hematoxylin & eosin (H&E), and the mean muscle fiber diameter was quantified for each group (Figure 10a). NMJ preservation was evaluated by confocal imaging co-localizing pre-synaptic (neuronal, NFH+ synapsin-I) and post-synaptic (muscle, AchR(BTX)) markers and counting the number of fully innervated NMJs within the gastrocnemius muscle (Figure 11A).

[0270] Results

[0271] Figure 10A: Representative images of H&E-stained cross-sections of mouse gastrocnemius muscle from three groups: WT-vehicle-treated, SOD1G93A-vehicle-treated, and SOD1G93A-30 mg / kg pridopidine-treated mice: The muscle tissue structure of SOD1G93A-vehicle mice is poor, and it is clear that the diameter of muscle fibers is smaller compared to WT-vehicle (Figure 10A - 10B). Pridopidine (30 mg / kg, daily s.c. administration) results in a significant increase in muscle fiber diameter of approximately 4 μm in SOD1G93A (Figure 10B).

[0272] The muscles of SOD1G93A vehicle-treated mice show a substantial loss of approximately 60% of the expected NMJs and morphological changes in the post-synaptic organ compared to WT mice (Figure 11A - 11B). Notably, pridopidine treatment limits the loss of NMJs in SOD1G93A mice to approximately 20%. Data are shown as mean ± SEM. *p value < 0.05, **p value < 0.01, ***p value < 0.001 (two-tailed Student's t-test).

[0273] Overall, these results demonstrate that pridopidine exerts a neuroprotective effect in cellular and animal models of ALS.

[0274] In vitro, in SOD1G93A MNs, pridopidine enhances BDNF axonal transport, upregulates ERK activation, enhances axonal growth, restores muscle innervation, and improves NMJ formation and function. These neuroprotective effects are mediated by S1R as a genetic deletion of the S1R gene abolishes the effects of pridopidine. In vivo pridopidine treatment of SOD1G93A ALS mice reduces mutant SOD1 aggregation in the spinal cord (one of the characteristic disease phenotypes), increases ALS-reduced muscle fiber diameter, and preserves the degenerated NMJs observed in diseased tissue. These data support the use of pridopidine as a neuroprotective agent and S1R as a therapeutic target for the treatment of ALS patients.

[0275] In the figure, the abbreviations are as follows. Geno. = genotype (i.e., wild type (WT), mutant SOD1), Prido. = pridopidine, mpk = milligrams per kilogram.

[0276] Experiment 7: Effect of pridopidine on neurite length and neuronal survival in C9orf72 iPSC-derived motor neurons.

[0277] The effect of pridopidine alone on neurite length and neuronal survival is evaluated in a unique human transcription factor-induced pluripotent stem cell (iPSC) differentiation line. iPSCs with the ALS mutation C9orf72 and isogenic controls differentiate into motor neurons by doxycycline-induced activation of an integrated transcription factor cassette (Ngn2, Isl1, and Lhx3). Neuronal survival duration and neurite length are evaluated by high-content image analysis using the Incucyte system. C9orf72 cells show a reduction in survival duration and a decrease in axonal growth compared to healthy isogenic control cells.

[0278] Evaluate the effect of pridopidine in C9orf72 iPSC-derived MNs and isogenic controls using the Incucyte system.

[0279] Experiment 8: Effect of pridopidine in combination with other drugs on the survival and neurite length of C9ORF72 human iPSC-derived motor neurons.

[0280] Evaluate the effect of pridopidine in combination with additional drugs on the neuronal cell survival and neurite length of C9orf72 iPSC-derived MNs using high-content analysis in the Incucyte system. The drugs evaluated are selected from the following: (1) combination of sodium phenylbutyrate (PB) and tauroursodeoxycholic acid (AMX0035), (2) zilucoplan, (3) beraprostat, (4) CNM-Au8 nanocrystalline gold, (5) SLS-005 (trehalose) or (6) _ICI4.

[0281] The combination of pridopidine and the additional drug shows either an additive or synergistic effect on neurite outgrowth and cell survival.

[0282] Experiment 9. Treatment of ALS in human subjects with the combination of pridopidine and another drug in the present invention.

[0283] In the present invention, the oral administration of pridopidine regularly together with an additional drug provides a clinically significant advantage in reducing the symptoms of ALS in human subjects suffering from ALS. Pridopidine combination therapy provides the efficacy to treat patients without excessive harmful side effects and is effective in at least one of the following 1 to 7 1. This therapy is effective in improving the symptoms of ALS. 2. This therapy is effective in enhancing cell survival and neurite growth. 3. This therapy is effective in enhancing BDNF axonal transport in motor neurons and / or enhancing ERK activation. 4. This therapy is effective in improving the formation and preservation of the NMJ, preserving the NMJ structure, preserving the NMJ function, and / or improving the innervation rate of muscle tissue. 5. This therapy is effective in enhancing motor neuron axonal growth and / or reducing axonal degeneration, including motor neuron axonal degeneration. 6. This therapy is effective in enhancing muscle cell survival duration, enhancing muscle fiber diameter and function, reducing the progression of muscle fiber depletion, and / or improving muscle contraction. 7. This therapy is effective in reducing SOD1 aggregation and / or reducing the progression of pseudobulbar palsy.

[0284] In some patients, the attending physician administers pridopidine and a second compound, which is sodium phenylbutyrate (PB), tauroursodeoxycholic acid, a combination of sodium phenylbutyrate (PB) / tauroursodeoxycholic acid (i.e., AMX0035), zilcoplan, berdyperstat, CNM-Au8 nanocrystalline gold, SLS-005 (trehalose), IC14, or a combination thereof.

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Claims

1. A pharmaceutical composition for use in the treatment of a subject suffering from amyotrophic lateral sclerosis (ALS), comprising: a first composition comprising pridopidine or a pharmaceutically acceptable salt thereof, which is effective for treating said subject; and a second composition comprising CNM-Au8 nanocrystalline gold.

2. The pharmaceutical composition according to claim 1, wherein said ALS is sporadic or familial ALS.

3. The pharmaceutical composition according to claim 1, wherein said first composition and said second composition are effective for delaying the onset, reducing the progression, or improving the symptoms of ALS in said subject.

4. The pharmaceutical composition according to claim 3, wherein said symptoms are muscle stiffness, muscle weakness, muscle atrophy, muscle spasm, dysphonia, dysphagia, shortness of breath, dysarthria, chewing difficulty, walking difficulty, fasciculation, postural deterioration, respiratory function deterioration, muscle strength deterioration, bulbar function deterioration, speech deterioration, salivary secretion deterioration, writing difficulty, voice characteristic decline, food cutting and utensil handling difficulty, dressing difficulty, dyspnea, orthopnea.

5. The pharmaceutical composition according to claim 1, wherein said first composition and said second composition are effective for enhancing BDNF axonal transport in motor neurons, enhancing ERK activation in motor neurons, improving the formation and preservation of NMJs, preserving NMJ structure, enhancing NMJ function, improving the innervation rate of muscle tissue, enhancing motor neuron axonal growth, reducing axonal degeneration, reducing motor neuron axonal degeneration, enhancing the survival period of muscle cells, enhancing muscle fiber diameter and function, or reducing SOD1 aggregation.

6. The pharmaceutical composition according to claim 1, wherein said first composition and said second composition further reduce the progression of pseudobulbar disorder, reduce the progression of muscle fiber atrophy, and / or improve muscle contraction in said subject suffering from ALS.

7. The pharmaceutical composition according to any one of claims 1 to 6, wherein said first composition and said second composition are administered daily, twice a day, twice a week, three times a week, or more frequently than once a day.

8. The pharmaceutical composition according to any one of claims 1 to 7, wherein said first composition is administered orally or via a gastrostomy tube.

9. The pharmaceutical composition according to any one of claims 1 to 8, wherein the amount of pridopidine or a pharmaceutically acceptable salt thereof in the first composition is from 10 mg per day to 135 mg per day.

10. The pharmaceutical composition according to any one of claims 1 to 9, wherein the pridopidine in the first composition is pridopidine hydrochloride.

11. The pharmaceutical composition according to any one of claims 1 to 10, wherein the amount of CNM-Au8 nanocrystalline gold is 5 to 50 mg / day and is administered orally.

12. The pharmaceutical composition according to any one of claims 1 to 11, wherein the second composition is administered prior to the first composition.

13. The pharmaceutical composition according to any one of claims 1 to 11, wherein the first composition is administered prior to the second composition.

14. The pharmaceutical composition according to any one of claims 1 to 11, wherein the first composition is administered in combination with the second composition.

15. The pharmaceutical composition according to any one of claims 1 to 11, wherein the second composition is administered in combination with the first composition.

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