Optimizing dosing of diaminophenothiazines in populations.

Abstract

To provide an optimised dosage of diaminophenothiazines in populations.SOLUTION: The invention provides novel dosing regimens for Leuco-Methylthioninium (LMT) compounds which maximize a proportion of subjects in which MT concentration will exceed concentration in which therapeutic efficacy in relation to treatment of neurodegenerative disorders such as Alzheimer's disease and frontotemporal dementias can be achieved, while maintaining a desirable clinical profile. Also there are provided LMT- containing dosage units and other compositions.SELECTED DRAWING: None

Description

[Technical Field]

[0001] The present invention relates generally to optimized dosing regimens of diaminophenothiazines in the treatment or prevention of neurodegenerative disorders, and particularly to such dosing regimens in populations of individuals with different pharmacokinetic responses. [Background technology]

[0002] Abnormal protein aggregation is believed to be a proximate cause of numerous disease states that can manifest as neurodegeneration, clinical dementia and other pathological symptoms.

[0003] In general, aberrant protein aggregation is protein aggregation that results from induced conformational polymerization interactions, i.e., conformational changes in the protein or its fragments, leading to the templated binding and aggregation of additional (precursor) protein molecules in a self-propagating manner.

[0004] Once nucleation is initiated, an aggregation cascade can ensue involving directed conformational polymerization of additional protein molecules, leading to the formation of toxic product fragments in the aggregates that are substantially resistant to further proteolysis.

[0005] For example, certain conditions of dementia can be characterized by the progressive accumulation of intracellular and / or extracellular deposits of proteinaceous structures, such as β-amyloid plaques and neurofibrillary tangles (NFTs), in the brains of affected patients. The appearance of these lesions primarily correlates with pathological neurofibrillary degeneration and brain atrophy, as well as cognitive impairment (see, e.g., Mukaetova-Ladinska, EB et al., 2000).

[0006] Currently approved treatments for Alzheimer's disease include acetylcholinesterase inhibitors (AChEIs) and the N-methyl-D-aspartate receptor antagonist memantine. These are symptomatic treatments and do not address the underlying disease pathology. Treatments targeting amyloid pathology have proven unsuccessful in late-stage clinical trials (Geerts et al., 2013; Mullane and Williams, 2013). According to a recent Lancet Neurology Commission report, "effective treatments for AD are perhaps the greatest unmet medical need facing modern medicine" (Winblad et al., 2016). Notably, the global economic cost of dementia is estimated at $818 billion, or 0.65% of global gross domestic product (Alzheimer's Disease International, 2015).

[0007] NFTs, a pathology discovered by Alois Alzheimer (Alzheimer, 1907), are composed of paired helical filaments (PHFs) that are primarily composed of 12 kDa repeat domain fragments of the microtubule-associated protein tau (Wischik et al., 1985; Wischik et al., 1988a,b). Numerous studies have demonstrated that functional molecular interactions in Alzheimer's disease correlate with the severity of clinical dementia. Quantitative correlations between the extent of neurofibrillary tangle pathology and the amount of aggregated tau, along with imaging deficits, have been identified (Arriagada et al., 1992; Brier et al., 2016; Giannakopoulos et al., 2003; Josephs et al., 2003; Maruyama et al., 2013). Because pathological aggregation of tau protein begins at least 20 years before any clinical symptoms (Braak and del Tredici, 2013), targeting this pathology may provide a promising pathological approach to mitigating AD and the associated tau aggregation. It provides a rational approach to both the treatment and prevention of disorders ( Huang and Mucke, 2012 ; Wischik et al., 2014 ; Wischik et al., 2010 ).

[0008] Originally identified as a unique structural component of the PHF core, the tau fragment exhibits prion-like properties in that it captures normal tau protein with very high affinity (Lai et al., 2016) and converts it into proteolytically stable copies of itself in a self-propagating and autocatalytic process (Wischik et al., 1996; Harrington et al., 2015). Phosphorylation is inhibitory to aggregation (Lai et al., 2016) and is unlikely to drive the cascade (Mukaetova-Ladinska et al., 2000; Schneider et al., 1999; Wischik et al., 1995). Direct inhibition of tau aggregation is a promising therapeutic intervention. This is a promising point for entry.

[0009] Methylthioninium (MT) acts as a tau aggregation inhibitor (TAI) in vitro (Wischik et al., 1996; Harrington et al., 2015) and inhibits tau aggregation in Alzheimer's disease brain tissue. It dissolves PHFs from tissue (Wischik et al., 1996) and reduces tau pathology and associated behavioral deficits in transgenic mouse tau models at brain concentrations consistent with human oral dosing (Melis et al., 2015; Baddeley et al., 2015).

[0010] MT has also been shown to inhibit other disease-associated protein aggregation (see, eg, WO 2007 / 110629 and references therein).

[0011] MT is a redox molecule that can form a reduced form [leucomethylthioninium (LMT)] and an oxidized form [MT + ) exists in equilibrium with

[0012] WO 96 / 30766 describes such MT-containing compounds for use in the treatment and prevention of various diseases, including AD and Lewy body disease. One example compound is the oxidized form of methylthioninium (MT), i.e., MT + The chloride salt of methylthioninium chloride ("MTC"), commonly known as methylene blue. [ka]

[0013] WO 96 / 30766 describes a daily dose of about 50 mg to about 700 mg, preferably about 150 mg to about 300 mg, for oral administration, preferably divided into 1 to 3 unit doses.

[0014] WO 2007 / 110630 discloses certain diaminophenothiazine compounds related to MTC, including (so-called) ETC, DEMTC, DMETC, DEETC, MTZ, ETZ, MTI, MTILHI, ETI, ETLHI, MTN, and ETN, which are useful as drugs in the treatment of, for example, Alzheimer's disease and other diseases, such as frontotemporal dementia (FTD).

[0015] WO 2007 / 110630 describes dosage units containing 20 to 300 mg, e.g., 30 to 200 mg, e.g., 30 mg, 60 mg, 100 mg, 150 mg, 200 mg, of the 3,7-diaminophenothiazine (DAPTZ) compounds described therein. A suitable dose of the DAPTZ compound is about 1 mg per kilogram of subject body weight per day. Doses in the range of 00 ng to about 25 mg (more typically about 1 μg to about 10 mg), e.g., 100 mg three times a day, 150 mg twice a day, and 200 mg twice a day, have been proposed. Doses of 50 mg three or four times a day have also been discussed.

[0016] A preliminary pharmacokinetic model for methylene blue based on studies of urinary excretion data sets in humans, dogs, and rats was proposed by DiSanto and Wagner, J Pharm Sci 1972, 61:1086-1090 and 1972, 61:1090-1094, and Moody et al., Biol Psych 1989, 26: 847-858.

[0017] Peter et al. (2000) Eur J Clin Pharmacol 56: 247-250 provided a model for integrating blood concentration data, which was consistent with earlier data by DiSanto and Wagner and with terminal elimination. There was a contradiction about the half-life.

[0018] May et al. (Am J Physiol Cell Physiol, 2004, Vol. 286, pp. C1390-C1398) showed that human erythrocytes continuously reduce and internalize MTC, i.e., MTC itself is not internalized by these cells, but only reduced MTs cross the plasma membrane. They also showed that the rate of internalization is enzyme-dependent and that both oxidized and reduced MTs are enriched in cells (reduced MTs re-equilibrate to form oxidized MTs once inside the cell).

[0019] Based on these and other disclosures, it is believed that orally administered MTC and similar drugs dissolve in the intestine and enter the bloodstream, with unabsorbed drug traveling down the gastrointestinal tract to the distal gut. One important unwanted side effect is the effects of unabsorbed drug in the distal gut, such as distal gut sensitization and / or antibacterial effects of unabsorbed drug on the distal gut bacterial flora, both of which result in diarrhea.

[0020] MTC was clinically tested in a phase 2 trial (Wischik et al., 2015). A safe and effective minimum dose was identified as 138 mg / day, although a higher dose of 218 mg / day was also recommended due to absorption limitations, possibly due to the need to increase the dose of MTC to allow efficient absorption by passive diffusion. + However, it had limited effectiveness due to the need for reduction to the leuco-MT (LMT) form.

[0021] WO 2009 / 044127 discloses the results of a phase 2 clinical trial showing that MTC had two pharmacological systemic effects, cognitive and hematological, that were separable. Specifically, its cognitive effects did not show a monotonic dose-response relationship, whereas its hematological effects did. Two different species were proposed to be responsible for the two types of pharmacological activity. MTC absorbed as the uncharged LMT form is responsible for beneficial cognitive activity, while MTC absorbed as the oxidized dimeric species is responsible for the oxidation of hemoglobin. WO 2009 / 044127 describes how dosage forms can be used to maximize the bioavailability of the therapeutically active (cognitively beneficial) species, regardless of whether it is administered with an oxidized DAPTZ compound or a leuco-DAPTZ compound.

[0022] Because reduced MTs are the ones that are taken up by cells, it has been proposed to administer the reduced form to patients, which would also reduce reliance on the rate-limiting step of enzymatic reduction.

[0023] The phenothiazin-5-ium salt MTC can be considered to be the "oxidized form" relative to the corresponding 10H-phenothiazine compound N,N,N',N'-tetramethyl-10H-phenothiazine-3,7-diamine, which can be considered to be the "reduced form." [ka]

[0024] The "reduced" form (or "leuco" form) is known to be unstable and can be readily oxidized to give the corresponding "oxidized" form.

[0025] WO 02 / 055720 discloses the use of reduced forms of certain diaminophenothiazines to treat protein aggregation disorders, primarily tauopathies. Based on the in vitro activity of the reduced diaminophenothiazines in this publication, the suggested daily dosage is 3.2-3.5 mg / kg, and also describes dosages of 20 mg three times a day, 50 mg three times a day, or 100 mg three times a day, combined with a 2x mg ratio of ascorbic acid in a manner to achieve greater than 90% reduction before oral ingestion.

[0026] WO 2007 / 110627 discloses certain 3,7-diamino-10H-phenothiazinium salts that are effective as drugs or prodrugs for treating diseases, including Alzheimer's disease and other disorders, such as frontotemporal dementia (FTD). These compounds also exist in a "reduced" or "leuco" form when considered in relation to MTC. These leucomethylthioninium compounds are referred to as "LMTX" salts, and these included the following salts: [ka]

[0027] WO 2012 / 107706 describes other LMTX salts that have superior properties to the above-listed LMTX salts, including leuco-methylthioninium bis(hydromethanesulfonate) (LMTM). [ka]

[0028] In particular, LMTM retains TAI activity in vitro and in vivo (Harrington et al., 2015; Melis et al., 2015) and has excellent pharmaceutical properties in terms of solubility and pKa. MT + and are less susceptible to the limitations of type absorption ( Baddeley et al., 2015 ).

[0029] WO 2007 / 110627 and WO 2012 / 107706 describe dosage units containing 20 to 300 mg, e.g., 30 to 200 mg, e.g., 30 mg, 60 mg, 100 mg, 150 mg, or 200 mg, of the DAPTZ compounds described in these documents. Suitable doses of the DAPTZ compound are suggested to be in the range of about 100 ng to about 25 mg (more typically about 1 μg to about 10 mg) per kilogram of subject body weight per day, e.g., 100 mg three times a day, 150 mg twice a day, or 200 mg twice a day.

[0030] WO 2018 / 019823 discloses a method for treating psoriasis using methylthioninium (MT)-containing compounds. They describe novel regimens for the treatment of neurodegenerative disorders using MT compounds. Briefly, these regimens were determined to be influenced by two major factors: the first factor was related to the dosage of MT compounds, and the second factor was their interaction with symptomatic treatments based on regulating acetylcholinesterase levels.

[0031] In the analysis described in WO 2018 / 019823, low doses of MT compounds (e.g., 4 mg twice daily) demonstrated therapeutic efficacy when comparing monotherapy versus add-on. The efficacy profile was similar for most of the outcomes measured in subjects with mild and moderate disease.

[0032] Furthermore, the treatment benefit (by study criteria) in AD was limited to patients receiving LMTM as monotherapy. In contrast, in the majority of patients receiving LMTM in combination with AD-labeled treatments (acetylcholinesterase inhibitors [AChEIs] and / or memantine), the declines seen at the corresponding doses were indistinguishable from those seen in the control group for all parameters.

[0033] The ability of LMT compounds to be active at low doses and the lack of an apparent dose-response was discussed in WO 2018 / 019823, and it was hypothesized that a critical threshold for activity at tau aggregation inhibitor targets may exist, and that the effects of higher doses may plateau or even become negative at brain concentrations above 1 μM (Melis, 2015). Based on these analyses, and given that the lower dose (4 mg twice daily) had a better overall clinical profile than the higher dose (100 mg twice daily), WO 2018 / 019823 teaches a method for treating neurodegenerative disorders of protein aggregation comprising oral administration of an MT-containing compound to a subject, the administration providing a total of 0.5 to 20 mg of MT per day, optionally as a single dose or divided into two or more doses.

[0034] Other references using "low dose" or "low dosage" in reference to MT-containing compounds are found in WO 2018 / 019823, for example: Telch, Michael J., et al. "Effects of post-session administration of methylene "Low-dose methylene blue on fear extinction and contextual memory in adults with claustrophobia." American Journal of Psychiatry 171.10 (2014): 1091-1098: This publication discusses the use of "low-dose methylene blue" for the maintenance of fear extinction and contextual memory following fear extinction training. The paper reports that methylene blue is a diaminophenothiazine drug with neurometabolic stimulatory properties at low doses (0.5-4 mg / kg). The dosage used in this publication was 260 mg / day for adult participants, corresponding to a dose of 4 mg / kg.

[0035] Gonzalez-Lima F and Auchter A (2015) “Protection against neurodegeneration with low-dose methylene blue and near-infrared light.” Front. Cell. Neurosci. 9:179. doi: 10.3389 / fncel.2015.00179: This publication describes the use of low-dose methylene blue and near-infrared light. The paper discusses the cellular mechanisms mediating the neuroprotective effects of high doses of near-infrared light. The publication cites previous studies that have found methylene blue at doses of 0.5-4 mg / kg to be safe and effective.

[0036] Alda, Martin, et al. "Methylene blue treatment for residual symptoms of bipolar disorder: randomized crossover study." The British Journal of Psychiatry (2016): doi: 10.1192 / bjp.bp.115.173930: This publication describes the use of a "low dose" of 15 mg of methylene blue as a placebo in a 6-month trial. The "effective dose" was 195 mg. In each case, the dose was divided into three doses per day.

[0037] Rodriguez, Pavel, et al. "Multimodal Randomized Functional MR Imaging of the Effects of Methylene Blue in the Human Brain." Radiology (2016): 152893: This publication also discusses the "known" pharmacokinetic and side effects of "low doses" (0.5-4.0 mg / kg) of methylene blue, contrasting with the effects of doses above 10 mg / kg. The dose used in this publication was 280 mg / day, which approximates a dose of 4 mg / kg for adult participants.

[0038] Naylor et al. (1986) "A two-year double-blind crossover trial of the prophylactic effect of methylene blue in manic-depressive psychosis." Biol. Psychiatry 21:915-920 and Naylor et al. (1987) "A controlled trial of methylene blue in severe depressive psychosis." Biol. Psychiatry 22:657-659: These studies used 300 mg 15 mg / day of methylene blue was used as a placebo treatment. However, in the latter paper, the authors proposed that the placebo dose could act as an antidepressant.

[0039] As discussed above, MT-based compounds have been proposed for the treatment of FTD due to their activity on tau and TDP-43 aggregation (see WO 2007 / 110630; WO 2007 / 110627; WO 2009 / 044127; WO 2012 / 107706, all supra).

[0040] WO 2018 / 041739 describes the results of a phase 3 clinical trial investigating the treatment of frontotemporal dementia (FTD) disease using LMTM.

[0041] The results showed that even relatively low doses of MT compounds (used in the study as controls) can be beneficial in FTD compared with the cognitive decline seen in historical controls.

[0042] Furthermore, unexpectedly, results showed a strong interaction when MT was co-administered with AD treatments that modulate synaptic neurotransmission in the brain. FTD patients who received MT in combination with such AD treatments (e.g., acetylcholinesterase inhibitors and / or memantine) showed significant cognitive benefits compared to MT alone. WO 2018 / 041739 further describes how MT compounds can be used in combination with acetylcholinesterase inhibitors and / or memantine without any apparent incompatibility.

[0043] The insights in WO 2018 / 019823 and WO 2018 / 041739 provide an important contribution to the art regarding minimal dosing of MT compounds to achieve cognitive benefits in subjects suffering from or at risk for neurodegenerative disorders such as AD and FTD.

[0044] However, it is well known that there is inter-individual variability among subjects as to how a given dose of a drug translates into a concentration of the drug in the subject's body fluids. It would be advantageous for any dosing regimen applied to such a population of subjects to take such variability into account, to the extent possible, in order to ensure maximum therapeutic effect in all subjects without the need for an individualized regimen, yet maintaining a desirable clinical profile. Summary of the Invention

[0045] Disclosure of the Invention The inventors have devised a novel pharmacokinetic (PK) model for dosing MT compounds in patient populations. This versatile model was derived from a Phase 1 study in elderly volunteers and is described in the following examples.

[0046] The novel population PK model was then used to estimate the Cmax of parent MT in patients administered LMTM in two Phase 3 AD studies described in WO 2018 / 019823 (Studies "005" and "015," respectively, for the treatment of patients with mild or mild-to-moderate AD). Once the Cmax was estimated in each of the subjects, a distribution of Cmax estimates for each of the treated populations could be derived.

[0047] As expected, there was significant variation in MT Cmax values ​​across the population at a given low dose. Analysis of this distribution confirmed the findings in WO 2018 / 019823 that the low dose (4 mg MT twice daily) was effective (e.g., as measured by reduced decline in the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-cog)). It further confirmed that monotherapy provided a significant benefit by this measure compared with add-on therapy with an AChEI and / or memantine (the mean benefit between monotherapy and add-on was approximately 4 ADAS-cog units over 65 weeks) (see Figure 3a).

[0048] However, unexpectedly, given previous literature describing a lack of a discernible dose response, the new analysis revealed the presence of a concentration response within the low-dose treated population. This was seen in ADAS-cognitive scores over 65 weeks in pooled patients from Studies 015 and 005. 11 Decreasing Sigmoid E max Using the analysis, it can be shown for patients receiving 8 mg / day (Figure 12).

[0049] Based on the population median Cmax threshold split, individuals with a "high" estimated Cmax showed an improvement of approximately 2-3 ADAS-cog units compared to individuals with a "low" estimated Cmax (see Figure 3a).

[0050] However, based on dividing patients by a threshold of 0.373 ng / ml, which includes the 35% of patients with the lowest values, the treatment difference in patients receiving the 8 mg / day dose is -3.4 ADAS-cog units (see Figure 14).

[0051] These findings suggest that MT concentrations, whether taken alone or in combination with (or at least preceded by) symptomatic treatment, max or C ave It suggests that it would be advantageous to employ a dosing regimen that maintains a relatively low dose so as to maximize the proportion of subjects exceeding the threshold and also maximize the expected therapeutic efficacy of LMTM, while nevertheless maintaining a desirable clinical profile with minimal side effects and good tolerability.

[0052] The overall biphasic concentration-response of LMTM shown in Figure 17 supports the notion that although good efficacy may be seen at doses of 100 mg or more, particularly in AD patients not previously treated with symptomatic therapy, the minimum dose that achieves all of these objectives is at least 20 mg / day, and that doses in the range of 20-40 mg / day, or 20-60 mg / day, would be expected to maximize therapeutic efficacy.

[0053] The novel population PK model was further used to estimate the Cmax of parent MT in patients receiving different doses of LMTM twice daily in a phase 3 clinical trial investigating the treatment of bvFTD described in WO 2018 / 041739.

[0054] These results confirm a concentration-response relationship of low-dose monotherapy for clinical benefit as measured by changes in cognitive (ACE-R) and functional (FAQ) measures over 52 weeks similar to that seen in AD. There is a similar concentration-response relationship for MRI measures of brain atrophy progression (frontotemporal volume, lateral ventricle volume, whole brain volume), which is shown in Figure 18. .

[0055] As can be seen by comparing the corresponding expanded Hill equation plots for AD and bvFTD (FIGS. 17 and 20), the biphasic nature of the concentration-response relationship is more evident in bvFTD, meaning that the optimal dosing range to achieve maximum therapeutic benefit in bvFTD is somewhat narrower in bvFTD, i.e., 20-40 mg / day, or less preferably, 20-60 mg / day.

[0056] As previously seen in WO 2018 / 041739, there is additional benefit to be gained from combining with symptomatic treatment, particularly C max,ss This may be seen in patients with plasma levels below the population average.

[0057] In light of the results described herein, there are at least two distinct benefits to using the lowest dose of MT compound that maximizes beneficial therapeutic effects. First, certain rare adverse events or side effects associated with MT occur in a dose-related manner. Therefore, avoiding higher doses than would be necessary is clearly desirable to maintain an optimal clinical profile. Second, there is evidence of an inverse dose-response relationship for certain therapeutic criteria at higher doses: therefore, benefits may actually be attenuated at higher doses.

[0058] Overall, these novel findings demonstrate the benefit of using slightly higher "low-dose" LMT treatment than previously assumed, and further indicate that in some circumstances, LMT treatment can be advantageously used as an add-on to symptomatic treatment, increasing the versatility of MT-based treatment regimes.

[0059] Further analysis by the inventors showed that doses above 20 mg MT (e.g., administered as LMTM) would achieve a Cmax above the median-derived threshold in 90-100% of subjects, the exact percentage depending on the number of fractional doses utilized (see Figure 5).

[0060] For AD treatment, such treatment would preferably be monotherapy, or at least introduced either before or after cessation of the currently available AD treatments, AChEI and memantine. Importantly, however, and as explained above, the analyses described herein indicate that even when MT treatment is used as add-on therapy, there may be benefit in dosing to achieve suprathreshold Cmax (approximately 2 ADAS-cog units or more) compared with lower Cmax values.

[0061] Thus, in one embodiment, there is provided a method of therapeutic treatment of a neurodegenerative disorder, e.g., a neurodegenerative disorder (e.g., of protein aggregation), in a subject, comprising orally administering to said subject a methylthioninium (MT)-containing compound, said administration providing the subject with a total daily dose of MT of 20.5 to 40, 20.5 to 50, 20.5 to 60, 20.5 to 70, 20.5 to 80, or 20.5 to 99, or 100 mg per day, optionally divided into two or more doses; MT-containing compounds [ka] or a hydrate or solvate thereof.

[0062] The total daily dose of MT can be 20.5 or 21 to 60 mg.

[0063] The total daily dose can be from about 20.5, 21, 21.5, 22, 22.5, 23, 23.5, 24 mg up to approximately any of 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60 mg.

[0064] The total daily dose can be about 20.5, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40 mg.

[0065] Example doses are 20.5 or 21 to 40 mg.

[0066] A further example dosage is 22 to 35 mg.

[0067] A further example dosage is 23-30 mg.

[0068] The present invention relates to the administration of MT in reduced (LMT) form.

[0069] The total daily dosage of the compounds may be administered as divided doses two or three times daily.

[0070] As explained below, when administering divided MT doses in a greater number of doses per day, it may be desirable to use a lower total amount within the recited ranges compared to a single daily dosing or a smaller number of doses per day.

[0071] As described herein, in some embodiments, particularly for the treatment of AD, the treatment will be monotherapy or will at least exclude co-administration of an AChEI and memantine. In some embodiments, subjects are selected who have not received recent prior treatment with an AChEI or memantine or other symptomatic therapy, although such treatment is optionally initiated or resumed after initiation of treatment with LMT.

[0072] Thus, as set forth herein, in other embodiments, treatment will be co-administration with add-on therapy, e.g., AChEI and / or memantine, such that patients already receiving AChEI and / or memantine may benefit from receiving these doses of MT compounds, while patients receiving these doses of MT compounds may benefit from AChEI and / or memantine.

[0073] In some embodiments, the treatment is part of a treatment regimen that includes: (i) orally administering to said subject an MT-containing compound for a first period of time, said administration , orally administering to the subject a total daily dose of MT of 1 to 10 mg per day, optionally 8 mg per day, optionally divided into two or more doses; (ii) orally administering to said subject an MT-containing compound for an immediate period thereafter, said administration providing said subject with a total daily dose of MT of 20.5-40 mg, 20.5-60, 20.5-80, or 20.5-100 mg per day, optionally divided into two or more doses, optionally about 21-40, 50, or 60 mg per day; (iii) Optionally, treatment (ii) is combined with the administration of a neurotransmitter-modulating compound that is a modulator of acetylcholine or glutamate neurotransmitter activity, such as an AChEI and / or memantine.

[0074] These different phases of the regimen typically follow immediately after each other.

[0075] Also provided herein are methods for the prophylactic treatment of neurodegenerative disorders of protein aggregation. [Brief explanation of the drawings]

[0076] [Figure 1] Figure 1 is a schematic diagram of the simplified population PK model for MT. [Figure 2a] 10 is a histogram of Bayesian post-hoc estimates of steady-state parental MT Cmax for AD patients in Studies 005 and 015 who received LMTM 4 mg twice daily. [Figure 2b] 1 is a histogram of Bayesian post-hoc estimates of steady-state parental MT Cmax for AD patients from Studies 005 and 015 who received approximately (c.) 200 mg / day of LMTM. [Figure 3a]ADAS-cog change over 65 weeks for the pooled 8 mg / day dose as monotherapy or add-on therapy in AD subjects in Study 005 by estimated steady-state Cmax. Note the lower p-value for "strata.Acmem" is due to the larger number of subjects receiving LMTM as add-on treatment. [Figure 3b] ADAS-cog change over 65 weeks for the pooled 8 mg / day dose as monotherapy or add-on therapy in AD subjects in Study 015 by estimated steady-state Cmax. Note the lower p-value for "strata.Acmem" is due to the larger number of subjects receiving LMTM as add-on treatment. [Figure 4] Analysis of AD subjects showing reduced brain atrophy and ventricular dilation in the high Cmax group both as monotherapy and as add-on. [Figure 5] Estimated proportion of AD subjects in the high Cmax group by dose. The y-axis indicates the % above threshold. 4 mg twice daily is 50%, reflecting the original median split between the high and low Cmax groups at this dose. [Figure 6] Distribution of estimated Cmax values ​​for bvFTD study subjects at 8 and 200 mg / day. [Figure 7] Difference in reduction in ACE-R scale by Cmax group in patients with bvFTD receiving LMTM 8 mg / day as monotherapy for the treatment of bvFTD. [Figure 8] Difference in reduction in ACE-R scale by Cmax group in patients with bvFTD receiving LMTM 200 mg / day as monotherapy for the treatment of bvFTD. [Figure 9] Difference in reduction in FAQ scale by Cmax group in patients with bvFTD receiving LMTM 8 mg / day as monotherapy. [Figure 10] Difference in reduction in FAQ scale by Cmax group in patients with bvFTD receiving LMTM 8 mg / day or 200 mg / day as monotherapy. [Figure 11a]Difference in WBV by Cmax group in patients with bvFTD receiving LMTM 8 mg / day as monotherapy. [Figure 11b] Difference in FTV by Cmax group in patients with bvFTD receiving LMTM 8 mg / day as monotherapy. [Figure 11c] Differences in LVV by Cmax group in patients with bvFTD receiving LMTM 8 mg / day as monotherapy. [Figure 12] Sigmoidal Emax analysis of ADAS-cog11 decline at week 65, with model covariates at population means and 90% bootstrap confidence intervals, using Day 1 Cmax,ss for low-dose AD patients in Studies TRx-237-005 and TRx-237-015. [Figure 13] Concentration-response relationships of clinical and MRI volumetric endpoints for Cmax, ss classification in patients with AD receiving LMTM at a dose of 8 mg / day [Figure 14] Comparison of primary clinical and MRI volumetric endpoints for all AD patients: categorized by Cmax,ss above ("high exposure") or below ("low exposure") the parent MT threshold of 0.373 ng / mL. [Figure 15] Predicted percentage of AD patients above the critical therapeutic thresholds of Cmax,ss (0.393 ng / ml) and Cave,ss (0.223 ng / ml) with once-daily (qd) and twice-daily (bid) dosing regimes. [Figure 16] Comparison of primary clinical and MRI endpoints in patients with AD receiving LMTM, 8 mg / day: stratified by Cmax,ss above ("high exposure") or below ("low exposure") the parent MT threshold of 0.373 ng / mL and AChEI and / or memantine use status. [Figure 17] Pharmacokinetic-pharmacodynamic response on the ADAS-cog scale over 65 weeks in patients with AD receiving LMTM at a dose of 8 mg / day and classified by concurrent medication status with AD-labeled treatments. [Figure 18] Concentration-response relationships of ACE-R, FAQ, FTV, LVV, and WBV in patients with bvFTD. [Figure 19] Estimated change from baseline over time in clinical and MRI neuroimaging endpoints in bvFTD patients receiving 8 mg / day and categorized by plasma levels above or below the Cmax,ss threshold of 0.346 ng / ml. [Figure 20] Fit of the extended Hill equation to the change in whole brain volume over 52 weeks in patients with bvFTD. DETAILED DESCRIPTION OF THE INVENTION

[0077] These aspects and embodiments are now described in more detail:

[0078] [Table 1]

[0079] The MT-containing compounds used in the present invention contain the MT moiety in reduced form (referred to as "LMT") as an active ingredient. The LMT moiety is not stable by itself. Therefore, they will be administered as LMT compounds, for example, as LMT salts.

[0080] LMT-containing compounds are generally stabilized, for example, by the presence of one or more protic acids, for example, two protic acids.

[0081] The MT content of such salts can be readily calculated by one of ordinary skill in the art based on the molecular weight of the compound and the molecular weight of the MT moiety. Examples of such calculations are provided herein.

[0082] LMT compounds Preferably, the LMT compound is a "LMTX" compound of the type described in WO 2007 / 110627 or WO 2012 / 107706.

[0083] Thus, the compound may be selected from compounds of the following formula: or a hydrate or solvate thereof: [ka]

[0084] H n A and H n Each B, if present, is a protic acid, which may be the same or different.

[0085] "Protonic acid" refers to the acid that reacts with protons (H + ) donor. Therefore, in protonic acids, A - or B - is the conjugate base. Therefore, protic acids have a pH of less than 7 in aqueous solution (i.e., the concentration of hydronium ions is less than 10 per liter). -7 (more than a mole).

[0086] In one embodiment, the salt is a mixed salt having the following formula, where HA and HB are different monoprotic acids: [ka]

[0087] However, preferably the salt is not a mixed salt but has the following formula: n X has a protic acid (eg, a diprotic acid or a monoprotic acid). [ka]

[0088] In one embodiment, the salt has the following formula, where H2A is a diprotic acid: [ka]

[0089] Preferably, the salt has the formula: ##STR1## which is a bismonoprotic acid. [ka]

[0090] Examples of protic acids that may be present in the LMTX compounds used herein include: Inorganic acids: hydrohalide acids (e.g., HCl, HBr), nitric acid (HNO3), sulfuric acid (H2SO4) Organic acids: carbonic acid (H2CO3), acetic acid (CH3COOH), methanesulfonic acid, 1,2-ethanedisulfonic acid, ethanesulfonic acid, naphthalenedisulfonic acid, p-toluenesulfonic acid Examples include:

[0091] Preferred acids are monoprotic acids and the salts are bis(monoprotic acid) salts.

[0092] A preferred MT compound is LMTM. [ka]

[0093] weight factor The anhydrous salt has a molecular weight of approximately 477.6. Based on a molecular weight of 285.1 for the LMT core, the weight factor for this MT compound for use in the present invention is 1.67. "Weight factor" refers to the relative weight of the pure MT-containing compound to the weight of the MT it contains.

[0094] Other weight factors can be calculated, for example, for the MT compounds herein, from which corresponding dosage ranges can be calculated.

[0095] Thus, the present invention encompasses total daily doses of LMTM of approximately 34 to 67, 34 to 100, 34 to 134, or 34 to 167 mg / day.

[0096] Other examples of LMTX compounds are as follows, along with their molecular weights (anhydrous) and weight factors: [ka]

[0097] Thus, dosages described herein for MT apply mutatis mutandis to these MT-containing compounds, as adjusted for molecular weight.

[0098] accumulation factor As one of skill in the art will recognize, for a given daily dose, more frequent dosing may result in greater drug accumulation.

[0099] Thus, in certain embodiments of the present invention, the total daily dosage of an MT compound may be relatively lower when administered more frequently (e.g., twice daily [bid] or three times daily [tid]), or may be higher when administered once daily [qd].

[0100] Treatment and Prevention The term "treatment", when used herein in the context of treating a condition, whether in a human or animal (e.g., veterinary application), relates broadly to treatments and therapies in which a desired therapeutic effect is achieved, such as inhibiting the progression of the condition, including slowing the rate of progression, halting the rate of progression, reversing the condition, ameliorating the condition, and curing the condition.

[0101] The term "therapeutically effective amount," as used herein, refers to an amount of a compound of the present invention, or a material, composition, or dosage form containing said compound, that is effective to produce a desired therapeutic effect when administered in accordance with a desired treatment regimen, and that is commensurate with a reasonable benefit / risk ratio. The present inventors have demonstrated that the therapeutically effective amount of the MT compound for the diseases of the present invention may be significantly lower than that previously understood in the art.

[0102] The present invention also encompasses treatment as a preventative measure. Accordingly, the present invention also provides a method of preventing a neurodegenerative disorder (e.g., protein aggregation) in a subject, the method comprising orally administering to the patient an MT-containing compound, wherein the administration provides to the subject a total of 20, 21 to 40 mg, 20.5 to 60, 20.5 to 99, or 100 mg of MT per day, optionally divided into two or more doses as described above.

[0103] The term "prophylactically effective amount," as used herein, relates to an amount of a compound of the invention, or a material, composition, or dosage form containing said compound, that is effective, when administered in accordance with a desired treatment regimen, to produce some desired prophylactic effect, commensurate with a reasonable benefit / risk ratio.

[0104] "Prophylaxis" in the context of this specification should not be understood to define complete success, i.e., complete protection or complete prevention. Rather, prophylaxis in this context refers to measures administered before a symptomatic condition is detected with the intent of preserving health by helping to delay, alleviate, or avoid a particular condition.

[0105] Combination Treatments and Monotherapy The term "treatment" includes "combination" treatments and "combination" therapies, in which two or more treatments or therapies for the same neurodegenerative disorder are combined, e.g., sequentially or simultaneously. These may be symptomatic or disease-modifying therapies.

[0106] The particular combination can be determined at the discretion of the physician.

[0107] In combination treatments, the agents (i.e., an MT compound as described herein and one or more other agents) may be administered simultaneously, sequentially, or individually on different dosing schedules and via different routes. For example, when administered sequentially, the agents may be administered closely spaced (e.g., 5-10 minutes) or widely spaced (e.g., 1, 2, 3, 4, or more hours apart, or even longer if necessary), with the exact dosing regimen being commensurate with the properties of the therapeutic agents.

[0108] An example of a combination treatment (for AD) of the present invention would be an agent that is an MT-containing compound at a particular dose combined with an agent that is an inhibitor of amyloid precursor protein processing to beta-amyloid (e.g., an inhibitor of amyloid precursor protein processing that increases the production of beta-amyloid).

[0109] The present invention allows for the co-administration of either an acetylcholinesterase inhibitor or an N-methyl-D-aspartate receptor antagonist, or both.

[0110] As described herein, in connection with combination therapy, the present invention provides a method of increasing the therapeutic effect of a first compound, which is an MT compound, at the doses described herein, for the treatment of a neurodegenerative disorder in a subject, comprising administering to the subject a second compound that directly modulates synaptic neurotransmission in the subject's brain (e.g., an acetylcholinesterase inhibitor or an N-methyl-D-aspartate receptor antagonist).

[0111] The present invention further provides a first compound that is an MT compound at the doses described herein in a method of treating a neurodegenerative disorder in a subject in a treatment regimen that additionally includes treatment with a second compound that directly modulates synaptic neurotransmission in the brain of the subject.

[0112] The present invention further provides the use of a compound that directly modulates synaptic neurotransmission in the brain of a subject to enhance the therapeutic effect of an MT compound at the doses described herein in treating a neurodegenerative disorder in the subject.

[0113] The present invention further provides MT compounds and compounds that directly modulate synaptic neurotransmission in the brain at the doses described herein for use in the combination methods of the present invention.

[0114] The present invention further provides compounds that directly modulate synaptic neurotransmission in the brain of a subject for use in a method of increasing the therapeutic effect of an MT compound at the doses described herein in treating a neurodegenerative disorder in a subject.

[0115] The present invention further provides for the combination of a first compound that is an MT compound, at the doses described herein, with a second compound that directly modulates synaptic neurotransmission in the brain of a subject, in the manufacture of a medicament for the treatment of a neurodegenerative disorder.

[0116] The present invention further provides the use of an MT compound, at the doses described herein, in the manufacture of a medicament for use in treating a neurodegenerative disorder syndrome in a subject, further comprising the use of a second compound that directly modulates synaptic neurotransmission in the brain of the subject.

[0117] The present invention further provides the use of a compound that directly modulates synaptic neurotransmission in the brain in the manufacture of a medicament for use in treating a neurodegenerative disorder in a subject, further comprising the use of an MT compound and a compound that directly modulates synaptic neurotransmission in the brain of a subject at doses described herein.

[0118] In other embodiments, the treatment is a "monotherapy," i.e., the MT-containing compound is not used in combination (within the sense discussed above) with another active agent for treating the same neurodegenerative disorder of protein aggregation in the subject.

[0119] Duration of the procedure For the treatment of neurodegenerative disorders described herein, a treatment regimen based on low doses of MT compounds may preferably be long-term, with the particular duration being determined by the physician's judgment.

[0120] For example, the duration of the treatment At least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 months or more. At least 2, 3, 4, 5 years or more. 6 to 12 months. 1-5 years. It could be.

[0121] In the case of prevention, treatment may be continued.

[0122] In all cases, the duration of treatment will usually be subject to medical advice and review.

[0123] Desired evaluation items The methods (dosing regimens) described herein can be used to achieve specific therapeutic or preventative outcomes. The specific outcomes can be quantified according to measures relevant to the neurodegenerative disorder. Such measures may, for example, measure changes in cognitive, functional, or physical criteria associated with the disorder. The examples herein describe suitable measures by which the effects of a dosing regimen can be ascertained compared to a placebo or other reference point (e.g., a different dosing regimen). These include the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog), used in connection with AD, and the Addenbrooke's Cognitive Assessment-Revised (ACE-R), used in connection with bvFTD.

[0124] Thus, as a non-limiting example, in one embodiment where the treatment is an AD treatment, optionally, the treatment achieves (or is intended to achieve) a reduction in cognitive decline in the subject of at least a 1, 2, 2.5, 3, 4, 5, or 6 point reduction in decline on the 11-item Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-cog) over 65 weeks compared to a matched control or control population not treated according to the present invention.

[0125] In one embodiment, the treatment is a bfFTD treatment that achieves (or is intended to achieve) the following: In each case compared to a corresponding control or control population not treated according to the present invention (i) optionally, a reduction in the subject's cognitive decline by at least a 1, 2, 3, 4, 5, 6, 7, or 8 point reduction in decline on the Addenbrooke's Cognitive Assessment-Revised (ACE-R) scale over 52 weeks; or (ii) optionally, a reduction in the subject's functional decline by at least a 1, 2, 3, 4, 5, or 6 point reduction in decline on the Functional Activities Questionnaire (FAQ) over 52 weeks.

[0126] Pharmaceutical dosage forms The MT compound of the present invention or a pharmaceutical composition comprising the same is orally administered to a subject / patient.

[0127] Typically, in the practice of the present invention, the compound will be administered as a composition comprising the compound and a pharmaceutically acceptable carrier or diluent.

[0128] In some embodiments, the composition is a pharmaceutical composition (e.g., formulation, preparation, medicament) comprising a compound as described herein and a pharmaceutically acceptable carrier, diluent, or excipient.

[0129] The term "pharmaceutically acceptable," as used herein, refers to compounds, ingredients, materials, compositions, dosage forms, and the like, that are suitable for use in contact with the tissues of a subject (e.g., a human) of interest without excessive toxicity, irritation, allergic response, or other problem or complication, commensurate with a reasonable benefit / risk ratio, within the scope of sound medical judgment. Each carrier, diluent, excipient, etc. must also be "acceptable" in the sense of being compatible with the other ingredients of the formulation.

[0130] In some embodiments, the composition is a pharmaceutical composition comprising at least one compound as described herein together with one or more other pharmaceutically acceptable ingredients known to those of skill in the art, including, but not limited to, a pharmaceutically acceptable carrier. , diluents, excipients, adjuvants, fillers, buffers, preservatives, antioxidants, lubricants, stabilizers, solubilizers, surfactants (e.g., wetting agents), masking agents, colorants, flavors, and sweeteners.

[0131] In some embodiments, the composition further comprises other active agents, for example, other therapeutic or prophylactic agents.

[0132] Suitable carriers, diluents, excipients, etc. can be found in standard pharmaceutical textbooks, e.g., Handbook of Pharmaceutical Additives, 2nd Edition (eds. M. Ash and I. Ash), 2001 (Synapse Information Resources, Inc., Endicott, New York, USA). , Remington's Pharmaceutical Sciences, 20th edition, pub. Lippincott, Williams & See Wilkins, 2000, and Handbook of Pharmaceutical Excipients, 2nd edition, 1994.

[0133] One aspect of the present invention relates to a dosage unit (e.g., a pharmaceutical tablet or capsule) comprising an MT compound as described herein (e.g., obtained or obtainable by a method as described herein and having a purity as described herein) and a pharmaceutically acceptable carrier, diluent, or excipient.

[0134] Although the "MT Compound" is present in relatively small amounts, it is the active agent of the dosage unit, i.e., it is intended to have a therapeutic or prophylactic effect with respect to a neurodegenerative disorder of protein aggregation. Conversely, other components in the dosage unit, such as carriers, diluents, or excipients, are therapeutically inactive. Thus, preferably, no other active ingredients are present in the dosage unit, and no other agents are intended to have a therapeutic or prophylactic effect with respect to the disorder for which the dosage unit is intended to be used.

[0135] In some embodiments, the dosage unit is a tablet. In some embodiments, the dosage unit is a capsule.

[0136] In some embodiments, the capsule is a gelatin capsule.

[0137] In some embodiments, the capsule is an HPMC (hydroxypropyl methylcellulose) capsule.

[0138] The appropriate amount of MT in the composition will vary depending on how often per day the subject takes the composition.

[0139] An example dosage unit may contain 8 to 32 mg of MT.

[0140] Further examples of dosage units may contain 8 to 16 mg of MT.

[0141] In some embodiments, the amount is about 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60 mg of MT.

[0142] Using the weight factors described or illustrated herein, one skilled in the art can select the appropriate amount of MT-containing compound for use in an oral formulation.

[0143] As explained above, the MT weight factor for LMTM is 1.67. Because it is convenient to use unit amounts or simple fractions of the active ingredient, non-limiting examples of LMTM dosage units can include 13.4, 15, 16.7 mg, etc.

[0144] In one embodiment, a dosage unit of the pharmaceutical composition is provided that contains 34, 67, or 100 mg of LMTM.

[0145] Nutritional Supplement Composition The MT-containing compositions of the present invention can be present in an edible form (e.g., oral dosage form) in combination with one or more nutrients in a "nutraceutical composition" containing an appropriate dose of the MT compounds described herein.

[0146] The novel nutraceutical compositions of the present invention may find use as food and beverage supplements and pharmaceutical compositions. As such, these nutraceutical compositions having the MT compound dosages described herein form another aspect of the present invention.

[0147] "Nutrient," as used herein, refers to a component of a nutritional supplement composition that plays a biochemical and / or physiological role in the human or animal body. "Nutrient" includes substances such as vitamins, minerals, trace elements, micronutrients, antioxidants, and other bioactive materials, such as enzymes or compounds biosynthetically produced by human or animal enzymes, as well as herbs and herbal extracts, fatty acids, amino acids, and their derivatives.

[0148] "Edible form" refers to a composition that can be ingested directly orally or that can be converted into an orally ingestible form, such as by dissolving in water.

[0149] Alternatively, the nutritional supplement composition can be in the form of a food or drink (e.g., a defined portion of a foodstuff (which term includes both food and drink) supplemented with a defined dose of an MT compound). These foodstuffs typically contain one or more of fat, protein, or carbohydrates.

[0150] The term "nutraceutical" as used herein denotes usefulness in both nutritional and pharmaceutical applications, and the disclosures herein relating to pharmaceutical dosage forms apply mutatis mutandis to nutraceutical compositions.

[0151] Oral dosage forms particularly suitable for nutritional supplement compositions are well known in the art and are described in detail elsewhere herein.They include powders, capsules, pills, tablets, caplets, gel capsules, and specified portions of edible foods.Liquid forms include solutions or suspensions.General examples of dosage forms and nutritional supplement forms are shown, for example, in WO 2010 / 078659.

[0152] Some examples of nutrients useful in the compositions of the present invention are: Any combination of these nutrients is contemplated by the present invention.

[0153] vitamin B-vitamin supplementation (folic acid [folate, vitamin B9], vitamin B12 Vitamin B6 (vitamin B6), a key component of the AD process, has been reported to slow the atrophy of certain brain regions associated with cognitive decline, especially in elderly subjects with elevated homocysteine ​​levels (Douaud, Gwenaelle, et al. "Preventing Alzheimer's disease-related gray matter atrophy by B-vitamin treatment." Proceedings of the National Academy of Sciences my of Sciences 110.23 (2013): 9523-9528; Quadri, Pierluigi, et al. "Homocysteine, folate, and vitamin B 12 in mild cognitive impairment, Alzheimer disease, and vascular dementia." The American journal of clinical nutrition 80.1 (2004): 114-122; Rosenberg IH, Miller JW. Nutritional factors in physical and cognitive functions of elderly people. The American journal of clinical nutrition. 1992 Jun 1;55(6):1237S-1243S.)

[0154] It has been suggested that vitamin C, together with other antioxidants (see below), may have utility in protecting neural tissue and potentially reducing β-amyloid production and acetylcholinesterase activity, and prevents endothelial dysfunction by regulating nitric oxide (e.g., Heo JH, Hyon-Lee, Lee KM. The possible role of antioxidant vitamin C in Alzheimer's disease treatment and prevention. American Journal of Alzheimer's Disease & Other Dementias. 2013 Mar;28(2):120-5).

[0155] It has also been suggested that vitamin E supplementation may play a role in treating AD (see, e.g., Mangialasche, Francesca, et al. "Serum levels of vitamin E forms and risk of cognitive impairment in a Finnish cohort of older adults." Experimental gerontology 48.12 (2013): 1428-1435).

[0156] Micronutrients and antioxidants Micronutrients or antioxidants, such as polyphenols, have been reported to have benefits in terms of protecting against or treating neurodegenerative diseases, particularly cognitive impairment and age-related diseases, including AD.

[0157] Micronutrients and / or antioxidants that may be used in the nutritional supplement compositions described herein include the flavonoids shown in the table below (reproduced from Mecocci, Patrizia, et al. "Nutraceuticals in cognitive impairment and Alzheimer's disease." Frontiers in pharmacology 5:147 (2014)):

[0158] [Table 2]

[0159] It has potential utility in the prevention or treatment of age-related diseases and is described by Mecocci et al. Other micronutrients include: Non-flavonoid polyphenols, namely resveratrol and curcumin, Carotenoids, namely lycopene, lutein, zeaxanthin, β-cryptoxanthin, α-carotene, and the most prominent carotenoid, β-carotene; Crocin (the main chemical compound identified in saffron), Diterpenes (e.g., carnosic acid and rosmarinic acid are two of the most important antioxidant compounds in rosemary) Examples include:

[0160] Herbal and plant extracts In addition to the plants listed or cross-referenced above for their micronutrients and antioxidant properties, other plant extracts and herbs have also been reported to have benefits in CNS disorders. See Kumar, Vikas. "Potential medicinal plants for CNS disorders: an overview." Phytotherapy Research 20.12 (2006): 1023-1035. These include Ginkgo biloba, Hypericum perforatum (St. John's wort), Piper methysticum Forst. (Piperaceae), also known as kava kava, Valeriana officinalis L. (Valeriana officinalis), Bacopa monniera (known locally in India as Brahmi or Jalanimba), and Convolvulus pluricaulis (also known as Shankhpushpi or shankapushpi).

[0161] Oils and Fats For example, it has been reported that omega-3 polyunsaturated fatty acids (PUFAs) may be a promising tool for preventing age-related brain degeneration. Sources of PUFAs, such as docosahexaenoic acid (DHA, 22:6) and eicosapentaenoic acid (EPA, 20:5), include fish oil (Denis, I., et al., "Omega-3 fatty acids and brain resistance to a aging and stress: body of evidence and possible mechanisms." Aging research reviews 12.2 (2013): 579-594).

[0162] Subjects, patients and patient groups The teachings of the present invention may be applied to a subject / patient that is, for example, an animal, mammal, placental, rodent (e.g., guinea pig, hamster, rat, mouse), murine (e.g., mouse), lagomorph (e.g., rabbit), avian (e.g., bird), canine (e.g., dog), feline (e.g., cat), equine (e.g., horse), porcine (e.g., pig), ovine (e.g., sheep), bovine (e.g., cow), primate, ape (e.g., monkey or ape), monkey (e.g., marmoset, baboon), monotreme (e.g., platypus), ape (e.g., gorilla, chimpanzee, orangutan, gibbon), or human.

[0163] In a preferred embodiment, the subject / patient is a human who has been diagnosed with one of the cognitive or CNS disorders described herein, or (in the case of preventative treatment) is a human who has been assessed, e.g., based on familial or genetic or other data, as being susceptible to one of the neurodegenerative disorders of protein aggregation (e.g., cognitive or CNS disorders) described herein.

[0164] The patient may be an adult, and the dosages described herein are based on that standard (typical body weight of 50-70 kg). If desired, for subjects outside this range, a corresponding dosage can be used by using a subject weight factor, i.e., dividing the subject's body weight by 60 kg to obtain a multiplicative factor for that individual subject.

[0165] Thus, for example, initial patient selection for the diagnosis and severity assessment of AD may require one or more of: rigorous evaluation by an experienced clinician; exclusion of possible non-AD diagnoses through complementary laboratory and other studies; and objective assessment of the level of cognitive function using a neuropathologically validated battery.

[0166] Diagnosis of AD and the other disorders described herein can be made by a physician by methods well known to those skilled in the art.

[0167] As described herein, MT compounds at appropriate doses can show benefit (e.g., slower rate of decline as measured by ADAS-Cog) even in subjects or patient groups being treated with acetylcholinesterase inhibitors or N-methyl-D-aspartate receptor antagonists for AD.

[0168] Examples of acetylcholinesterase inhibitors include donepezil (Aricept™), rivastigmine (Exelon™), or galantamine (Reminyl™). An example of an NMDA receptor antagonist is memantine (Ebixa™, Namenda™). Examples of total daily doses of these neurotransmission-modulating compounds are as follows: donepezil: 5-23 mg; rivastigmine: 3-12 mg; galantamine: 4-24 mg; memantine: 5-20 mg.

[0169] Accordingly, in one embodiment, the present invention provides a method of treating (or preventing) AD in a subject, comprising: The method includes orally administering to a subject a methylthioninium (MT)-containing compound at a dose described herein; The treatment may further include administration of either an acetylcholinesterase inhibitor or an N-methyl-D-aspartate receptor antagonist, or both.

[0170] In other embodiments, the AD subject or patient group may be completely naive to these other treatments and have no history of receiving either or both of an acetylcholinesterase inhibitor or an N-methyl-D-aspartate receptor antagonist.

[0171] Alternatively, the AD subject or patient population may have a history of receiving one or both of these, but have discontinued the medication, such as at least 1, 2, 3, 4, 5, 6, 7 days or 2, 3, 4, 5, 6, 7, 8, 12, or 16 weeks prior to treatment with the MT compounds of the present invention, or more preferably at least 1, 2, 3, 4, 5, or 6 months prior.

[0172] Any embodiment of the present invention may include the active steps of selecting a subject or patient group for AD according to these criteria, or selecting a subject or patient group for AD who is receiving treatment with either an acetylcholinesterase inhibitor or an N-methyl-D-aspartate receptor antagonist, or both, and discontinuing that treatment (instructing the subject or patient group to discontinue that treatment) prior to treatment with an MT compound of the present invention.

[0173] Such treatment may optionally be initiated or resumed after the initiation of treatment with the MT compound.

[0174] Labels, Instructions and Kits of Parts The unit dosage compositions described herein (e.g., low-dose MT-containing compounds and optionally other ingredients or more general MT compositions for the treatment of AD) can be provided in labeled packaging along with instructions for their use.

[0175] In one embodiment, the pack is a bottle as is well known in the pharmaceutical arts. Typical bottles are made from pharmacopoeia-grade HDPE (high density polyethylene) with child-resistant HDPE push-lock closures and may contain silica gel desiccant present in sachets or canisters. The bottle itself may be provided with a label or may be packaged in a cardboard box along with instructions and, optionally, an additional copy of the label.

[0176] In one embodiment, the pack or packet is a blister pack (preferably one having an aluminum cavity and aluminum foil) and is therefore substantially moisture impermeable. In this case, the pack may be packaged inside a cardboard box together with the instructions and label on the container.

[0177] The label or instructions may provide information regarding the protein aggregation neurodegenerative disorder (eg, cognitive or CNS disorder) that the drug targets.

[0178] If the drug is indicated for AD, the label or instructions may provide information instructing the user that the composition should not be used in combination with either an acetylcholinesterase inhibitor or an N-methyl-D-aspartate receptor antagonist.

[0179] The label or instructions may provide information regarding the maximum allowable daily dosage of a composition as described herein, for example, on a once-daily, twice-daily, or three-times-daily basis.

[0180] The label or instructions may provide information regarding the proposed duration of treatment as described herein.

[0181] Reversing and / or preventing protein aggregation One aspect of the present invention is the use of an MT compound or composition as described herein to control (e.g., reverse and / or inhibit) protein aggregation, e.g., protein aggregation associated with neurodegenerative disease and / or clinical dementia, which aggregation may be associated with disease states such as those discussed below.

[0182] Similarly, one aspect of the present invention relates to a method of controlling (e.g., reversing and / or inhibiting) protein aggregation in the brain of a mammal, wherein the aggregation is associated with a disease state as described herein, the treatment comprising administering to the mammal in need thereof a prophylactically or therapeutically effective amount of an MT compound or composition as described herein that is an inhibitor of aggregation.

[0183] Disease conditions treatable via the present invention are discussed in detail below.

[0184] Treatment method Another aspect of the present invention relates to a method of treatment, as explained above, which method comprises the step of administering to a patient in need of treatment a prophylactically or therapeutically effective amount of a compound as described herein, preferably in the form of a pharmaceutical composition.

[0185] Use in therapeutic methods Another aspect of the present invention pertains to compounds or compositions as described herein for use in a method of treatment of the human or animal body by therapy (e.g., a method of treating a disease state).

[0186] Use in pharmaceutical manufacturing Another aspect of the present invention relates to the use of an MT compound or composition as described herein in the manufacture of a medicament for use in treatment (eg, treatment of a disease state).

[0187] In some embodiments, the pharmaceutical agent is a composition, eg, a low-dose unit dose composition as described herein.

[0188] Protein Aggregation Neurodegenerative Disorders The findings described herein have implications for the administration of MT compounds in different diseases. In particular, the use of a dosing regimen that maximizes the proportion of subjects whose MT concentrations exceed the Cmax threshold while maintaining a relatively low dose to maintain a desirable clinical profile can be applied to the treatment of various diseases of protein aggregation for which MT is known to be effective.

[0189] Thus, in some embodiments, the disease state is a disease of protein aggregation, e.g., treatment is treatment with a compound or composition as described herein in an amount sufficient to inhibit aggregation of proteins associated with the disease state.

[0190] The following table lists various disease-associated aggregating proteins and the corresponding neurodegenerative diseases of protein aggregation. Use of the compounds and compositions of the invention against these proteins or diseases is encompassed by the present invention. [Table 3]

[0191] As described in WO 02 / 055720, WO 2007 / 110630 and WO 2007 / 110627, diaminophenothiazines have utility in inhibiting such protein aggregation disorders.

[0192] Thus, unless the context requires otherwise, it will be recognized that descriptions of embodiments relating to tau or tau-like proteins (e.g., MAP2, see below) should be taken as applying equally to other proteins discussed herein (e.g., TDP-43, β-amyloid, synuclein, prions, etc.) or other proteins that may initiate or undergo similar pathological aggregation due to conformational changes in domains critical for the propagation of aggregation or that confer proteolytic stability to the aggregates so formed (see, e.g., the article by Wischik et al. in "Neurobiology of Alzheimer's Disease", 2nd Edition, 2000, Eds. Dawbarn, D. and Allen, SJ, The Molecular and Cellular Neurobiology Series, Bios Scientific Publishers, Oxford). All such proteins are referred to herein as " The aggregated disease protein may be referred to as an "aggregating disease protein."

[0193] Similarly, when reference is made to "tau-tau aggregation," this refers to other "aggregating proteins" The term "protein aggregation" can also be taken to apply to "protein aggregation," e.g., β-amyloid aggregation, prion aggregation, synuclein aggregation, etc. The same applies to "tau proteolytic degradation," etc.

[0194] Preferred Aggregation Disease Target Proteins A preferred embodiment of the present invention is based on tau protein. The term "tau protein," as used herein, broadly refers to any protein in the tau protein family. Tau protein has been characterized as one of a large family of proteins that co-purify with microtubules during repeated cycles of assembly and disassembly (see, e.g., Shelanski et al., 1973, Proc. Natl. Acad. Sci. USA, Vol. 70, pp. 765-768) and are known as microtubule-associated proteins (MAPs). Members of the tau family share the common features of a distinctive N-terminal segment, a sequence of approximately 50 amino acids inserted into the N-terminal segment that is developmentally regulated in the brain, a distinctive tandem repeat region consisting of three or four tandem repeats of 31-32 amino acids, and a C-terminal tail.

[0195] MAP2 is the predominant microtubule-associated protein in the somatodendritic compartment (see, e.g., Matus, A., "Microtubules" [Hyams and Lloyd, Eds.] pp. 155-166, John Wiley and Sons, New York, USA). MAP2 isoforms are nearly identical to tau protein in the tandem repeat region, but differ substantially in both the sequence and extent of the N-terminal domain (see, e.g., Kindler and Garner, 1994, Mol. Brain Res., Vol. 26, pp. 218-224). Nevertheless, aggregation in the tandem repeat region is not associated with tau. It is not selective for the repeat domain, and therefore it will be appreciated that any discussion herein regarding tau protein or tau-tau aggregation should also be taken in reference to tau-MAP2 aggregation, MAP2-MAP2 aggregation, etc.

[0196] In some embodiments, the protein is a tau protein.

[0197] In some embodiments, the protein is synuclein, eg, α- or β-synuclein.

[0198] In some embodiments, the protein is TDP-43.

[0199] TAR DNA-binding protein 43 (TDP-43) is a 414-amino acid protein encoded by TARDBP on chromosome 1p36.2. This protein is highly conserved, widely expressed, and primarily localized in the nucleus, but can shuttle between the nucleus and cytoplasm (Mackenzie et al., 2010). This protein is involved in the regulation of transcription and splicing and may also be involved in other processes, such as microRNA processing, apoptosis, cell division, messenger RNA stabilization, control of neuronal plasticity, and maintenance of dendritic integrity. Furthermore, since 2006, a considerable body of evidence has accumulated supporting the gain-of-function hypothesis of TDP-43 toxicity in amyotrophic lateral sclerosis (ALS). TDP-43 is an intrinsically aggregation-prone protein, and aggregates formed in vitro are ultrastructurally similar to TDP-43 deposits found in degenerating neurons of ALS patients (Johnson et al., 2009). Johnson et al. (2008) showed that when TDP-43 was overexpressed in a yeast model, only the aggregated form was toxic. Several in vitro studies have also shown that C-terminal fragments of TDP-43 are more likely than full-length TDP-43 to form insoluble cytoplasmic aggregates that become ubiquitinated and are toxic to cells (Arai et al., 2010; Igaz et al., 2009; Nonaka et al., 2009; Zhang et al., 2009). Nonaka et al. (2009) reported that these cytoplasmic aggregates bind to endogenous full-length proteins. suggested that ATP depletes it from the nucleus, whereas Zhang et al. (2009) found maintenance of normal nuclear expression, suggesting a purely toxic effect on these aggregates. (2010) reported that the C-terminus and C-terminal domains of TDP-43 in NSC34 motor neurons in culture. We report the trapping of full-length TDP-43 within aggregates of N-terminal fragments. Neurite outgrowth, which is impaired as a result of the presence of such truncated fragments, can be rescued by overexpression of the full-length protein. Although the role of neurite outgrowth in vivo remains to be proven, this model may support the suggestion made by Nonaka and colleagues for a role for TDP-43 aggregation in ALS pathogenesis.

[0200] Expression of mutant TDP-43 in cell culture has been reported to increase the generation of C-terminal fragments, along with higher cytoplasmic aggregation and toxic effects than the wild-type protein (Kabashi et al., 2008; Sreedharan et al., 2008; Johnson et al., 2009; Nonaka et al., 2009; Arai et al., 2010; Barmarda et al., 2010; Kabashi et al., 2010).

[0201] When the protein is tau protein, in some embodiments of the present invention, a method of inhibiting the formation of protein aggregates (e.g., the formation of protein aggregates in the form of paired helical filaments (PHFs), optionally in neurofibrillary tangles (NFTs) in the mammalian brain) is provided, wherein the treatment is as described above.

[0202] Preferred indications: Diseases of protein aggregation In one embodiment, the present invention is used for the treatment of Alzheimer's disease (AD), eg, mild, moderate, or severe AD.

[0203] Notably, AD is not the only form of Alzheimer's disease (AD) in which tau protein (and its abnormal function or processing) may play a role: the pathogenesis of neurodegenerative disorders such as Pick's disease and progressive supranuclear palsy (PSP) appears to be associated with the accumulation of pathological truncated tau aggregates in stellate pyramidal cells of the dentate gyrus and neocortex, respectively. Other dementias include frontotemporal dementia (FTD), FTD with parkinsonism linked to chromosome 17 (FTDP-17), disinhibition-dementia-parkinsonism-amystrophy complex (DDPAC), pallidopontonigral degeneration (PPND), Guam-ALS syndrome, pallido-nigro-luysian degeneration (PNLD), and corticobasal degeneration (CBD) (see, e.g., the article by Wischik et al., "Neurobiology of Alzheimer's Disease," 2nd Edition, 2000, Eds. Dawbarn, D. and Allen, SJ, The Molecular and Cellular Neurobiology Series, Bios Scientific Publishers, Oxford, especially Table 5.1). All of these diseases, which are characterized primarily or in part by abnormal tau aggregation, are referred to herein as "tauopathies."

[0204] Thus, in some embodiments, the disease state is a tauopathy. In some embodiments, the disease state is a neurodegenerative tauopathy.

[0205] In some embodiments, the disease state is Alzheimer's disease (AD), Pick's disease, progressive supranuclear palsy (PSP), frontotemporal dementia (FTD), FTD linked to chromosome 17 with parkinsonism (FTDP17), frontotemporal lobar degeneration (FTLD) syndrome, disinhibition-dementia-parkinsonism-amystrophy complex (DDPAC), pallidopontonigral degeneration (PPND), Guam-ALS syndrome, pallido-nigro-luysian degeneration (PNLD), corticobasal degeneration (CBD), argyrophilic grain dementia (AgD), dementia pugilistica (DPU). pugilistica (DP) or chronic traumatic encephalopathy (CTE), Down's syndrome (DS), dementia with Lewy bodies (DLB), subacute sclerosing panencephalitis (SSPE), MCI, Niemann-Pick disease type C (NPC), Sanfilippo syndrome type B (mucopolysaccharidosis type IIIB) or myotonic dystrophy (DM) DM1 or DM2 or chronic traumatic encephalopathy (CTE).

[0206] In some embodiments, the disease state is a lysosomal storage disorder with tau pathology. NPC is caused by mutations in the gene NPC1, which affects cholesterol metabolism (Love et al 1995), and Sanfilippo syndrome type B is caused by mutations in the gene NAGLU. In Sanfilippo syndrome type B, there is lysosomal accumulation of heparin sulfate (Ohmi et al. 2009). Tau pathology is observed in these lysosomal storage disorders, and treatment can reduce the progression of the disease. Other lysosomal storage disorders may also be characterized by tau accumulation.

[0207] The use of phenothiazine diaminium salts in the treatment of Parkinson's disease and MCI is described in detail in PCT / GB2007 / 001105 and PCT / GB2008 / 002066.

[0208] In some embodiments, the disease state is Parkinson's disease, MCI, or Alzheimer's disease.

[0209] In some embodiments, the disease state is Huntington's disease or other polyglutamine disorders, such as spinal and bulbar muscular atrophy (or Kennedy's disease) and dentatorubral-pallidoluysian atrophy and various spinocerebellar ataxias.

[0210] In some embodiments, the disease state is an FTLD syndrome (which may be, for example, a tauopathy or a TDP-43 proteinopathy; see below).

[0211] In some embodiments, the disease condition is PSP or ALS.

[0212] TDP-43 proteinopathies include amyotrophic lateral sclerosis (ALS, ALS-TDP) and frontotemporal lobar degeneration (FTLD-TDP).

[0213] The role of TDP-43 in neurodegeneration in ALS and other neurodegenerative disorders has been highlighted in several recent publications (Chen-Plotkin et al., 2010; Gendron et al., 2010; Geser et al., 2010; Mackenzie et al 2010).

[0214] ALS is a neurodegenerative disease characterized by progressive paralysis and muscle wasting resulting from the degeneration of both upper and lower motor neurons in the primary motor cortex, brainstem, and spinal cord. Although ALS is sometimes referred to as motor neuron disease (MND), there are other diseases that affect only upper or lower motor neurons. A definitive diagnosis requires clear evidence of both upper and lower motor neuron manifestations in the medulla oblongata, arm, and leg musculature, and clinical progression that cannot be explained by any other disease process (Wijesekera and Leigh 2009).

[0215] Although the majority of cases are ALS-TDP, there are other cases in which the pathological protein is different from TDP-43. Misfolded SOD1 is the pathological protein in ubiquitin-positive inclusions in ALS with SOD1 mutations (Seetharaman et al., 2009), and in a very small subset (approximately 3–4%) of familial ALS cases caused by mutations in FUS (fused to the sarcoplasmic protein), the ubiquitinated pathological protein is FUS (Vance et al., 2009; Blair et al., 2010). FUS, like TDP-43, appears to be important in nucleocytoplasmic shuttling, but how an impaired nucleus imports FUS is unknown. The new molecular classification of ALS (adapted from Mackenzie et al., 2010) reflects the different underlying pathological mechanisms in different subtypes (see table below).

[0216] A new molecular classification of ALS (adapted from Mackenzie et al., 2010). In the majority of cases, TDP-43 is the ubiquitinated pathological protein found in ALS. [Table 4]

[0217] Amyotrophic lateral sclerosis has been recognized as a nosological entity for almost a century and a half, and is recognized in ICD-10 as a subtype of MND, code G12.2, with little reliance on Charcot's original report. A clinical diagnosis is available for ALS, and neuropathological criteria reflecting the underlying molecular pathology are also endorsed.

[0218] ALS is pathologically classified into three subgroups: ALS-TDP, ALS-SOD1, and ALS-FUS, although the latter two conditions are rare. The largest study to date has shown that all sporadic ALS cases have TDP-43 pathology (Mackenzie et al. Only approximately 5% of ALS cases are familial (Byrne et al., 2010), and mutations in SOD1, the most common mutation in FALS, account for 12–23% of cases (Andersen et al., 2006). SOD1 may also be involved in 2–7% of SALS cases. Mutations in S appear to be extremely rare, accounting for approximately 3-4% of FALS cases (Blair et al., 2010). Therefore, clinical cases of SALS can be reliably predicted to have TDP-43-based pathology. Similarly, this can be reliably predicted for FALS caused by TDP-43 mutations, which account for only approximately 4% of cases (Mackenzie et al., 2010). VCP (Johnson et al., 2010), ANG (Seilhean et al., 2009), which account for 1-2% of FALS, are also likely to be present. ALS with mutations in NF-kappaB (NFK) and CHMP2B (Cox et al., 2010) have also been reported to be associated with TDP-43-positive pathology. SOD1, FUS, and ATXN2 mutations have not been found to be associated with TDP-43-positive aggregates; however, TDP-43 has been reported to be involved in the pathological processes presumed to result from these mutations (Higashi et al., 2010; Ling et al., 2010; Elden et al., 2010).

[0219] Thus, TDP-43 demonstrates an important and potentially central role in the pathogenesis of the majority of SALS cases and may also be involved in the pathogenesis of a significant proportion of FALS. ALS is now widely considered to be a TDP-43 proteinopathy (Neumann et al., 2009), and numerous in vitro and in vivo studies provide support for the hypothesis that toxic gain-of-function due to TDP-43 aggregation contributes to at least some of the neurotoxicity in this disease.

[0220] FTLD syndrome is an insidious-onset, relentlessly progressive neurodegenerative condition with peak incidence in middle age, often associated with a positive family history of similar disorders in first-degree relatives.

[0221] Behavioral FTD is characterized by early and significant changes in social and interpersonal functioning, often accompanied by repetitive behaviors and changes in eating patterns. Despite this, cognitive assessments show declines in object knowledge, impaired single-word comprehension, and marked word-finding problems. Fluent aphasia presents with a combination of motor speech impairment and grammatical deficits. The core diagnostic clinical features for these three FTLD syndromes are shown in the table below and in the full criteria in Neary et al (1998). [Table 5]

[0222] Shortly after the discovery that TDP-43-positive inclusions characterize ALS and FTLD-TDP (Neumann et al., 2006), missense mutations in the TARDBP gene were identified in both familial and sporadic cases of ALS (Gitcho et al., 2008; Sreedharan et al., 2008). To date, 38 different TARDBP mutations have been reported in 79 genealogically unrelated families worldwide (Mackenzie et al., 2010). TARDBP mutations account for approximately 4% of all familial cases and approximately 1.5% of sporadic ALS cases.

[0223] As of December 2010, mutations in 13 genes associated with familial and sporadic ALS have been identified. Linkage between ALS and five other chromosomal loci has been demonstrated, but to date, no specific mutations have been identified.

[0224] TDP-43 proteinopathy MT has a mode of action that can target and reduce intracellular TDP-43 protein aggregation, which is the major pathological feature of both familial and sporadic ALS and is a hallmark of FTLD-P.

[0225] Furthermore, laboratory data indicate that methylthioninium inhibits the formation of TDP-43 aggregates in SH-SY5Y cells. After treatment with 0.05 μM MT, the number of TDP-43 aggregates was reduced by 50%. These findings were confirmed by immunoblot analysis (Yamashita et al., 2009).

[0226] Thus, the compounds and compositions of the present invention may be useful in the treatment of amyotrophic lateral sclerosis (ALS) and frontotemporal lobar degeneration (FTLD).

[0227] Huntington's disease and polyglutamine disorders MT may reduce intracellular polyglutamine protein aggregation, a pathological hallmark of Huntington's disease. Huntington's disease is caused by the expansion of translated CAG repeats located at the N-terminus of huntingtin. Wild-type chromosomes contain 6 to 34 repeats, whereas in Huntington's disease, chromosomes contain 36 to 121 repeats. Age at onset is inversely correlated with the length of the CAG tract encoding the polyglutamine repeats within the protein.

[0228] Laboratory data show that methylthioninium inhibits the formation of aggregates of a huntingtin derivative containing a 102-residue polyglutamine stretch in zebrafish (van Bebber et al. 2010). MT prevented the formation of such aggregates in a dose-dependent manner in zebrafish when tested at 0, 10, and 100 μM.

[0229] Thus, the compounds and compositions of the present invention may be useful in the treatment of Huntington's disease and other polyglutamine disorders, such as spinal and bulbar muscular atrophy (or Kennedy's disease) and dentatorubral-pallidoluysian atrophy and various spinocerebellar ataxias (Orr & Zoghbi, 2007).

[0230] Mitochondrial disease and Lafora disease In addition to skeletal muscle, the central nervous system (CNS) is the most frequently affected organ in mitochondrial disorders, particularly respiratory chain diseases (RCDs). CNS manifestations of RCDs include stroke-like episodes, epilepsy, migraines, ataxia, spasticity, movement disorders, psychiatric disorders, cognitive decline, or even dementia (mitochondrial dementia). Mitochondrial dementia has been reported in MELAS, MERRF, LHON, CPEO, KSS, MNGIE, NARP, Leigh syndrome, and Alpers-Huttenlocher disease (Finsterer, 2009). The mitochondrial respiratory chain contains four complexes involved in the sequential electron transport. Abnormal function of any of these complexes can lead to mitochondrial disease secondary to abnormal electron transport chain and subsequent abnormal mitochondrial respiration. Complex III of the mitochondrial respiratory chain functions to transfer electrons to cytochrome c.

[0231] The compounds and compositions of the present invention can also be used to treat mitochondrial diseases associated with incomplete and / or impaired function of Complex III of the respiratory chain. The compounds have the ability to act as effective electron carriers and / or electron transporters because the thioninium moiety has a low redox potential to convert between oxidized and reduced forms. When Complex III function is impaired and / or defective, leading to mitochondrial diseases, the compounds of the present invention can be used to treat mitochondrial diseases. The substance can also transport and transfer electrons from complex III because the thioninium moiety can shuttle between oxidized and reduced forms, acting as an electron carrier to transfer electrons to cytochrome c in place of the suboptimally functioning complex III.

[0232] The compounds and compositions of the present invention also have the ability to generate active thioninium moieties that have the ability to divert misfolded proteins / amino acid monomers / oligomers from the ADP-associated protein accumulation and / or refolding pathway of Hsp70 and instead redirect these aberrantly folded protein monomers / oligomers to a pathway that directly leads to the ATP-dependent ubiquitin-proteasome system (UPS) of Hsp70, a pathway that removes these misfolded proteins / amino acid monomers / oligomers via a direct pathway (Jinwal et al. 2009).

[0233] Lafora disease (LD) is an autosomal recessive, teenage-onset, fatal epilepsy associated with the gradual accumulation of hypobranched, insoluble glycogen (called polyglucosan) in many tissues. In the brain, polyglucosan bodies, or Lafora bodies, form in neurons. Inhibition of Hsp70 ATPase by MT (Jinwal et al. 2009) can upregulate the clearance of misfolded proteins. Lafora disease is primarily caused by defects in the lysosomal ubiquitin-proteasome system (UPS) due to mutations in either the Laforin or Malin genes (both located on chromosome 6), which result in inclusions that can accelerate the aggregation of misfolded tau protein. Secondary mitochondrial damage due to impaired UPS can lead to further suppression of mitochondrial activity and abnormalities in the electron transport chain, resulting in additional lipofuscin and causing the epilepsy characteristic of Lafora's disease.

[0234] By inhibiting the ATPase activity of Hsp70, MTs can disaggregate existing tau aggregates, reduce the accumulation of larger amounts of tau, and increase lysosomal efficiency. MTs can reduce tau tangles by enhancing the ubiquitin-proteasome system's removal of tau monomers / oligomers through their inhibitory effect on the ATPase activity of Hsp70.

[0235] Thus, the compounds and compositions of the present invention may have utility in the treatment of Lafora's disease.

[0236] A mixture of oxidized and reduced MT compounds The LMT-containing compounds used in the present invention contain oxidized forms (MT) as an "impurity" during synthesis. + ) compounds, which may be oxidized (e.g., autoxidized) after synthesis to yield the corresponding oxidized form. Thus, it is possible, if not inevitable, that compositions containing compounds of the invention will contain at least some of the corresponding oxidized compounds as impurities. For example, "LMT" salts may contain up to 15%, e.g., 10-15%, of MT. + May contain salt.

[0237] When mixed MT compounds are used, the dose of MT can be easily calculated using the molecular weight factors of the compounds present.

[0238] Salts and solvates The MT-containing compounds described herein are salts themselves, but may also be provided in the form of mixed salts (i.e., a compound of the present invention with another salt). Such mixed salts are intended to be encompassed by the term "and pharmaceutically acceptable salts thereof." Unless otherwise specified, a reference to a particular compound also encompasses its salts.

[0239] The compounds of the present invention may also be provided in the form of a solvate or hydrate. The term "solvate" means The term "solvate" is used herein in its conventional sense to refer to a complex of solute (e.g., compound, salt of compound) and solvent. When the solvent is water, the solvate may conveniently be referred to as a hydrate, e.g., a monohydrate, a dihydrate, a trihydrate, a pentahydrate, etc. Unless otherwise specified, any reference to a compound includes its solvates and any hydrate forms.

[0240] Of course, solvates or hydrates of the salts of the compounds are also encompassed by the present invention.

[0241] In order to more fully describe and disclose the invention and the state of the art to which it pertains, several patents and publications are cited herein. Each of these references is incorporated by reference in its entirety into this disclosure to the same extent as if each individual reference was specifically and individually indicated to be incorporated by reference.

[0242] Throughout this specification, including the claims set forth below, the word "comprise" and variations such as "comprises" and "comprising" are used unless the context otherwise requires. It is understood that "inclusive" means the inclusion of a stated integer or step or group of integers or steps, but not the exclusion of any other integer or step or group of integers or steps.

[0243] It should be noted that as used in the specification and the appended claims, the singular forms "a," "an," and "the" include plural referents unless the context clearly dictates otherwise. Thus, for example, reference to "a pharmaceutical carrier" includes mixtures of two or more such carriers, and the like.

[0244] Ranges are often expressed herein as from "about" one particular value and / or to "about" another particular value. When such a range is expressed, another embodiment includes from the one particular value and / or to the other particular value. Similarly, when values ​​are expressed as approximations, by use of the antecedent "about," it will be understood that the particular value forms another embodiment.

[0245] Any subheadings herein are included for convenience only and should not be construed as limiting the disclosure in any way.

[0246] The present invention is hereinafter further described with reference to the following non-limiting figures and examples, in light of which other embodiments of the invention will occur to those skilled in the art.

[0247] The disclosures of all references cited herein are expressly incorporated herein by cross-reference in order that one skilled in the art may use the disclosures to practice the present invention. [Example]

[0248] Example Example 1 - Provision of MT-containing compounds Methods for chemically synthesizing the MT-containing compounds described herein are known in the art, for example: Compounds 1 to 7 can be synthesized according to the method described in WO 2012 / 107706 or methods analogous thereto.

[0249] The synthesis of compound 8 can be carried out according to the method described in WO 2007 / 110627 or methods analogous thereto.

[0250] Example 2 - Providing symptomatic treatment for AD Symptomatic treatments for AD include those that directly regulate synaptic neurotransmission in the brain, such as acetylcholinesterase inhibitors. It is marketed as a cholinesterase inhibitor (AChEI) or NMDA receptor antagonist.

[0251] Examples of AChEIs include tacrine (Cognex™, First Horizon), donepezil (Aricept™, Eisai / Pfizer), rivastigmine (Exelon™, Novartis), and galantamine (Razadyne™, formerly Reminyl™, Ortho-McNeil). The product is available as Ebixa™ or Namenda™ from, for example, Forest.

[0252] Example 3 - De novo population PK model of MT In an initial model (not shown), the kinetics of all MT moieties (parent MT, desmethyl MT, and LMT-conjugate) were simultaneously characterized using a multicompartment model. The kinetics of parent MT after oral administration were adequately described by a two-compartment model, in which binding occurred in the plasma and tissue compartments and delayed absorption occurred via two transit compartments. This model had a fixed Vc. With increasing dose, there was a trend toward a slower absorption rate, which was incorporated into the model using a dose-dependent absorption rate constant (Ka). The apparent oral clearance (CL / F) of parent MT was related to renal function, as only a small portion of the variability in parent CL was described by the normalized creatinine clearance (CLCRN). A smaller portion of parent MT was metabolized to desmethyl MT, and the kinetics of desmethyl MT were described by a two-compartment model with linear elimination. Parent MT was also converted to LMT-glucuronide, the kinetics of which were described by a one-compartment model with linear elimination. Importantly, a portion of the LMT-conjugates underwent enterohepatic recirculation (EHR), which was physiologically mimicked by the latent gallbladder compartment with a pulsatile pattern of bile secretion.

[0253] The above model was applied to data from a single- and multiple-dose Phase 1 study in elderly subjects (Study 036) to assess the model's ability to predict steady-state PK of parent MT. The model was successfully fitted to data from subjects receiving either 4 mg twice daily or 10 mg once daily of LMTM in Study 036.

[0254] This PK model was then further developed and simplified to a two-compartment model that fits only the parent MT concentration. A schematic of this simplified population PK model for MT is given in Figure 1. This model has a fixed Vc, but the dose-dependent Ka is omitted.

[0255] This model was derived from Study 036, discussed above. The kinetics of parent MT after oral administration of LMTM were adequately described by a two-compartment model, with delayed absorption occurring through two transit compartments. The apparent oral clearance (CL / F) of parent MT was related to renal function, such that only a small portion of the variability in parent CL was described by normalized creatinine clearance (CLCRN).

[0256] The model was successfully fitted to data obtained from subjects in Study 036 who received either 4 mg twice daily or 10 mg once daily of LMTM.

[0257] The simplified model gives a similar fit to the previous more sophisticated model, but allows for simultaneous modeling of all of the data from Study 036.

[0258] Overall, an excellent fit to the individual subject data was obtained, suggesting that the model gave an adequate description of the PK of parent MT following administration of LMTM.

[0259] Example 4 - 4 mg twice daily dose in Phase 3 AD studies (Studies "005" and "015") Estimation of Cmax of parent MT in given patient The study designs for the Phase 3 AD studies "005" and "015" are described in Examples 4 and 3, respectively, of WO 2018 / 019823, which also discuss their results. The disclosures of those Examples are specifically incorporated herein by reference. Briefly, those Phase 3 studies compared high doses of LMTM (150-250 mg / day) with a lower dose (8 mg / day) intended as a mask for possible urinary discoloration (Gauthier 2016; Wilcock 2018). These included the evaluation of disease progression on clinical and brain imaging endpoints. These results demonstrate the potential utility of LMTM, particularly as monotherapy, in delaying bowel movements and that higher doses offered no potential benefit beyond the 8 mg / day dose.

[0260] A population PK model was then used to estimate the Cmax of parent MT for patients receiving 4 mg or higher doses (approximately (c.) 200 mg / day) in these Phase 3 AD studies. This Bayesian process involved fixing the population mean and interindividual variability parameters to estimates obtained from fitting the population PK model to the steady-state data from Study 036 and allowing a program to select a set of parameters, given these Bayesian priors, that would best predict each individual's parent MT concentration from Day 1. Ta.

[0261] The distribution of Cmax estimates obtained is given in Figures 2a and 2b. The approximately 200 mg / day group represents the pooled high-dose subjects from Study 015 (150 and 250 mg / day) and Study 005 (200 mg / day).

[0262] In these figures, the vertical black lines indicate the median of each distribution, which can be used to separate patients into low and high Cmax groups.

[0263] Example 5 - Evaluation of the Differential Effects of Pooled 8 mg / day Dose as Monotherapy or Add-on Therapy in Studies 005 and 015 in High and Low Cmax Groups at Steady State Mixed effect Model Repeat Measurement (MMRM) procedure Using the method, the ADAS-cog change over 65 weeks for the pooled 8 mg / day dose as monotherapy or add-on therapy in Studies 005 and 015 was then calculated for the "high Cmax" and "low Cmax" groups, in each case separated into those who received LMTM as monotherapy and those who received it in combination with ("add-on") symptomatic treatment (AChEI and / or memantine). The results are shown in Figures 3a and 3b, which show the same data. Patients who used symptomatic treatment are designated "Achmem."

[0264] Figure 3a highlights the finding in WO 2018 / 019823 that symptomatic treatment interferes with LMTM treatment efficacy. The mean difference between monotherapy and add-on can be seen to be approximately 4 ADAS-cog units.

[0265] As highlighted in Figure 3b, unexpectedly, analysis of this low (8 mg / day) dose also revealed a difference of approximately 2.4 ADAS-cog units between the high and low Cmax monotherapy groups and a difference of approximately 2.7 ADAS-cog units between the high and low Cmax add-on groups, the same concentration-dependent differences seen with monotherapy and add-on treatment.

[0266] In further analysis, Figure 4 shows that the high Cmax group had less whole brain and temporal lobe atrophy and less ventricular enlargement, both as monotherapy and as add-on therapy. As expected, there was less brain atrophy in the monotherapy group than in the add-on group. It should be noted that the difference only reached statistical significance in the add-on group, which had a significantly larger number of subjects.

[0267] A corresponding analysis of the pooled high-dose group (mean 200 mg / day) showed that both monotherapy and adjuvant On the other hand, there was no corresponding differential treatment effect between the high and low Cmax groups (data not shown).

[0268] Example 6 - Safety and Adverse Events: Benefits of Using the Lowest Effective Dose of LMT Compounds Three phase 3 double-blind, controlled trials of LMTM have been completed (one each in subjects with mild and mild-to-moderate AD and one in subjects with bvFTD), and the results of the AD trials have been published (Gauthier et al., 2016; Wilcock et al., 2018).

[0269] Across these three studies, 1897 subjects received at least one dose of LMTM (safety population [five additional subjects with AD at one site in Study TRx-237-005 received study drug doses but were excluded from the full analysis due to GCP violations], 1679 subjects had AD and 218 subjects had bvFTD). Of these, 860 subjects received control (LMTM 8 mg / day; 750 had AD and 110 had bvFTD), and 1037 subjects received at least one dose of LMTM at a higher dose of 150–250 mg / day (929 had AD and 108 had bvFTD).

[0270] The mean age of study participants was 71 years (maximum 89 years) for AD subjects and 63 years (maximum 79 years) for bvFTD subjects. Overall, there was equal gender representation (55% female), with a female predominance among AD subjects (58%) and a male predominance among bvFTD subjects (63%). Most subjects were Caucasian (88% AD and 91% bvFTD). Approximately 17% of AD subjects received LMTM as monotherapy (as recorded in the concomitant medication case report form, not by stratification [overall, 87% of subjects received AChEI and / or memantine based on stratified randomization]), with the remaining subjects receiving concomitant AChEI and / or memantine. On the other hand, most bvFTD subjects received LMTM as monotherapy (79%). Psychiatric disorders / symptoms were common, with depression reported in 23% of subjects overall and anxiety in 12%. Concomitant use of antidepressants and antipsychotics was more common in subjects with bvFTD (50% and 22%, respectively) compared with subjects with AD (36% and 10%, respectively).

[0271] The most common treatment-emergent adverse events (TEAEs) considered at least possibly related to LMTM administered at the 8 mg / day dose were GI (mostly diarrhea and nausea), genitourinary (mostly urinary frequency and urinary incontinence), hematologic (anemia, decreased folate levels, and folate deficiency), and nervous system-related (mostly fatigue, dizziness, headache, agitation, and insomnia). Other common events are considered to represent expected events in this patient population over a 12- to 18-month duration.

[0272] At the higher LMTM doses tested, 150-250 mg / day, there was a dose-related increase in the incidence of anemia-related TEAEs (anemia, folate depletion, and folate deficiency, along with decreased hemoglobin), gastrointestinal events (including vomiting and diarrhea and nausea, along with possibly related observations of weight loss), and genitourinary events (including dysuria, urgency, and frequency and incontinence, along with overt urinary tract infections). The lack of a dose response for falls and neurological / psychiatric events (other than agitation) suggests that these are related to the underlying pathology of the subjects rather than the treatment.

[0273] The incidence of the most common TEAEs is summarized by dose in Table EX1 below. This includes TEAEs that occurred with an incidence of 2.0% or greater in subjects randomized to either LMTM 8 mg / day or higher doses (150-250 mg / day). A subset of TEAEs that were severe in intensity is also included. As can be seen, very few events occurred with severe intensity, regardless of dose.

[0274] [Table 6]

[0275] [Table 7]

[0276] TEAEs were further analyzed using the associated MedDRA (Medical Dictionary for Regulatory Activities) Preferred Term classification to better estimate the incidence of potentially treatment-related adverse events. The incidence of all categories for subjects classified by dose (8 mg / day vs. higher doses of 150-250 mg / day) is shown in Table EX2 below:

[0277] [Table 8]

[0278] Categories occurring in ≥10.0% of subjects treated with LMTM 8 mg / day included falls and related terms (22%), GI events (21%), renal and urinary tract disorders including infections (16%), behavioral symptoms, and terms describing anemia (13% of each category).

[0279] There is a dose-related trend in the increased incidence of all of these (except falls and behavioral symptoms). For the less common categories, there is also evidence of a dose-related trend in liver dysfunction.

[0280] The fact that some TEAEs appear to be dose-related clearly demonstrates the desirability of utilizing the lowest effective dose of MT.

[0281] Example 7 - Effect of Cmax on treatment efficacy using other measures From the available data, no Cmax effect was seen when assessing temporal lobe FDG-PET decline. On this measure, although some monotherapy benefit remained, it appears that high-dose LMTM (pooled 200 mg / day) actually attenuated the benefit otherwise seen with LMTM monotherapy (data not shown).

[0282] From the available data, no Cmax effect was seen when assessing the outcome measure: Alzheimer's Disease Cooperative Study-Activities of Daily Living (ADCS-ADL) decline.

[0283] Example 8 - Providing an optimized dosing regimen in an AD subject population In summary, a PK model was developed based on data from a carefully sampled Phase 1 study. From this per-subject steady-state, Cmax was estimated. and used it to separate patients receiving the 8 mg / day dose into high (above the median) and low (below the median) Cmax groups. Unexpectedly, the high and low Cmax groups differed in cognitive decline (as assessed using the ADAS-cog) by approximately 2.5 units, with effects observed in both the monotherapy and add-on treatment groups. Interestingly, there was evidence of an inverse dose-response relationship for FDG-PET at the higher doses.

[0284] Therefore, treatment response is determined by two factors: 1 Add-on treatment status versus monotherapy 2 Plasma concentrations vary within a population even for a given dose.

[0285] Therefore, in both groups (monotherapy and add-on), there is benefit in dosing at a level sufficient to maximize the proportion of subjects in the high Cmax group (while avoiding high doses with less favorable clinical profiles). Figure 5 estimates the proportion of subjects expected to be in the high Cmax group by dose.

[0286] For example: At 4 mg twice daily, 50% of subjects are above the Cmax threshold and the predicted treatment effect versus placebo is approximately 5 ADAS-cog units over 65 weeks.

[0287] At least 16 mg twice daily, or more preferably approximately 20 mg / day (10 mg twice daily), the estimated ratio is approximately 100%, and even greater ADAS-cog treatment effects may be observed by utilizing these.

[0288] Therefore, based on Figure 5, a dosing regimen higher than 4 mg twice daily is desirable, but there may be little benefit in going above around 20 mg twice daily (40 mg total) because at that level, the vast majority of subjects treated are expected to be in the high Cmax group, whether the dose is divided or not.

[0289] There are at least two distinct reasons for wanting to use the lowest concentration that maximizes beneficial cognitive treatment effects. First, TEAEs, most notably GI events, renal and urinary tract disorders including infections, and hemolytic anemia, occurred in a dose-related manner. Therefore, avoiding higher doses than would be necessary is clearly desirable to maintain an optimal clinical profile. Second, there is evidence of an inverse dose-response relationship with FDG-PET at higher doses, i.e., the benefit may actually be attenuated at higher doses.

[0290] Overall, these novel findings demonstrate that there is benefit in utilizing slightly higher "low-dose" LMT treatment than previously estimated, and further demonstrate that LMT treatment can be used as an add-on to symptomatic treatment (albeit less effective than monotherapy).

[0291] Example 9 - Providing an optimized dosing regimen in the bvFTD subject population The study design for a Phase 3 trial of LMTM in behavioral frontotemporal dementia (bvFTD) is described in Examples 3-10 of WO 2018 / 041739, which Examples also discuss those results, the disclosures of which Examples are specifically incorporated herein by reference.

[0292] In WO 2018 / 041739 it was concluded that 4 mg twice daily and 100 mg twice daily resulted in less cognitive decline (assessed using the ACE-R) than would have been expected from historical studies. This could be explained if both 4 mg twice daily (the "control" group) and 100 mg twice daily (the "active" group) demonstrated efficacy.

[0293] Furthermore, concurrent AD medication status and severity were found to be significant covariates. Considering these covariates, LMTM as an off-label AD treatment ( A significant benefit of ACE-R was demonstrated in patients taking it in combination with an acetylcholinesterase inhibitor (ACER) and / or memantine. There also appeared to be directionally supportive benefits for FAQ, MMSE, and temporal volume.

[0294] The population PK model described above was used to estimate the Cmax of parent MT for patients in the bvFTD study. As in the AD study described above, the median value at each dose was used as the threshold to separate patients into "high Cmax" and "low Cmax" groups.

[0295] Figure 6 shows the distribution of Cmax values ​​in bvFTD. The vertical black line indicates the median value separating the low Cmax group from the high Cmax group.

[0296] Figure 7 shows the difference in decline on the Addenbrooke's Cognitive Assessment-Revised (ACE-R) scale by Cmax group in patients with bvFTD receiving LMTM 8 mg / day as monotherapy. The decline in the low Cmax group was found to be -13.3 ± 1.8 (equivalent to Kipps et al., (2008) = -15.3 ± 1.4). However, the decline in the high Cmax group was much greater. The overall efficacy analysis was based on the MMRM approach.

[0297] The difference between the low and high Cmax groups at 32 weeks was 4.2±2.0 (p=0.0389), and at 52 weeks it was 7.3±2.6 (p=0.0059).

[0298] As shown in Figure 8, there was a highly significant difference between the high and low Cmax groups at 8 mg / day. At 200 mg / day, there actually appeared to be an inverse dose-response.

[0299] Figure 9 shows the difference in decline on the Functional Activities Questionnaire (FAQ) scale by Cmax group in patients with bvFTD receiving LMTM 8 mg / day as monotherapy. Again, decline was lower in the high Cmax group on this scale (decrease in the low Cmax group at 52 weeks: 8.3 ± 0.9; decline in the high Cmax group at 52 weeks: 2.9 ± 0.9; difference at 32 weeks: -3.6 ± 1.2 (p = 0.0022); difference at 52 weeks: -5.4 ± 1.3 (p < 0.0001).

[0300] Figure 10 shows that the FAQ benefit seen in the high Cmax at 8 mg / day is significantly reduced at 200 mg / day. Furthermore, there is an inverse dose-response such that the overall benefit is reduced at 200 mg / day.

[0301] Figures 11a, 11b, and 11c show the corresponding changes in whole brain volume (WBV), temporal atrophy, and lateral ventricle volume (LVV) in bvFTD patients.

[0302] In the WBV of Figure 11a, the decrease in Cmax in the low group at 52 weeks was -24.5±2.6 (cm 3 The decrease in Cmax in the high group at 52 weeks was -15.3 ± 2.5. The difference at 52 weeks was 9.2 ± 3.5 (p = 0.0089).

[0303] Figure 11b shows the difference in progression of frontotemporal atrophy by Cmax group in patients with bvFTD receiving LMTM 8 mg / day as monotherapy (decrease in the Cmax-low group at 52 weeks: -2.3 ± 0.2 (cm 3 ); Decrease in Cmax in the high group at 52 weeks: -1.7±0.2; difference at 52 weeks: 0.6±0.3 (p=0.0247)).

[0304] Figure 11c. Differences in ventricular expansion by Cmax group in patients receiving LMTM 8 mg / day as monotherapy (increase in the low Cmax group at 52 weeks: 8.3 ± 0.8 cm 3 ); Increase in Cmax in the high group at 52 weeks: 5.0±0.8; difference at 52 weeks: -3.3±1.1 (p=0.0027)).

[0305] Interestingly, in ACE-R, there was also an inverse dose-response at the high dose, 200 mg / day.

[0306] As concluded in WO 2018 / 041739, this further analysis Triple therapy (MT, acetylcholinesterase inhibitor, and memantine) confirmed additional benefit from the combination with potentially beneficial symptomatic treatment. Given the small group size and therefore large error bars on estimates (data not shown), the benefit of exceeding Cmax (related to ACE-R and FAQ) could not be confirmed for combination therapy. Furthermore, the same data showed that the addition of symptomatic treatment overcomes the high-dose deterioration (inverse dose-response), at least with respect to these measures (data not shown). Significant MRI volumetric benefit with respect to Cmax was best seen as add-on therapy (data not shown).

[0307] These results confirmed a concentration-response relationship for 8 mg / day monotherapy on cognitive function in bvFTD similar to that seen in AD. There was also a concentration-response relationship for 8 mg / day monotherapy on the Functional FAQ scale in bvFTD and an inverse dose-response for higher dose monotherapy (i.e., 200 mg / day was worse than 8 mg / day).

[0308] Overall, a low dose (e.g., approximately 20 mg / day (10 mg twice daily)) administered in a regimen ensuring a high Cmax appears to be the optimal monotherapy treatment for bvFTD.

[0309] However, as seen previously, and in contrast to AD, there is an additional benefit in combination with symptomatic treatment, which can be seen especially in the low Cmax group.

[0310] In light of these factors, one regimen might begin with LMTX monotherapy at 8 mg / day, then increase the dose to approximately 20 mg / day, with the potential addition of AD symptomatic treatment in bvFTD as the disease progresses.

[0311] Example 10 - Further analysis of optimized dosing regimens in AD subject populations A more informative approach that allows for statistical analysis is to classify patients receiving LMTM at a dose of 8 mg / day using a threshold that defines an upper limit of at least 35% of patients with plasma levels below the validated limit of quantification after the first dose on day 1 (0.2-10 ng / ml; N=208). max,ss The threshold is less than 0.373 ng / mL.

[0312] The remaining 65% is divided into three equal-sized C max,ss Grouping into groups (N approximately 128 per group) allowed for better visualization of the concentration-response relationships. Higher doses were grouped by dose (N = 187-329 per group). These groups and model-based estimates of plasma exposure at the higher doses are shown in Table EX3 below:

[0313] [Table 9]

[0314] ADAS-cognitive 11 , ADCS-ADL 23 Least squares means and standard error estimates of changes in LVV, WBV, and C in patients receiving LMTM at a dose of 8 mg / day max,ss A clear concentration-response as a function of class is shown (Figure 13). There is an overall trend for outcomes to be worse at higher exposure levels associated with doses in the 150-250 mg / day range, implying the presence of a biphasic dose-response.

[0315] Example 11 - Critical Therapeutic C of 0.393 ng / ml Associated with Optimized Dosing Regimen in an AD Subject Population max,ss Threshold-based analysis Based on the splitting of patients by the 0.373 ng / ml threshold, the treatment difference for patients receiving the 8 mg / day dose is -3.4 ADAS-cog units (see Table EX4 below; see Example 8 for median split showing approximately 2-3 ADAS-cog units):

[0316] [Table 10]

[0317] C above or below the threshold of 0.373 ng / mL max,ss The corresponding longitudinal trajectories for each patient over 65 weeks are shown in Figure 14.

[0318] Because only 65% ​​of patients receiving 8 mg / day have plasma concentrations above the threshold required for significant therapeutic benefit, it is desirable to determine the lowest dose at which 100% of patients are expected to have plasma levels within the therapeutic range. Given the population variability observed in the large available data sets, it is desirable to determine the C for both once-daily (QD) and twice-daily (BID) dosing regimes. max,ss (0.393ng / ml) and C ave,ss It was possible to estimate the expected percentage of patients who would be above the critical therapeutic threshold of (0.223 ng / ml). As can be seen in Figure 15, using either the baseline or dosing regime, LMTM would need to be administered at a dose of at least 16 mg / day for 100% of patients to have plasma levels within the therapeutic range.

[0319] Example 12 - Incorporation of a discriminator between monotherapy and add-on therapy An additional consideration is whether patients receive LMTM alone or in combination with approved AD treatments (AChEI and / or memantine). Patients receiving the 8 mg / day dose were further examined by their co-medication status with these medications. As seen in Table EX5 below, the difference between patients with steady-state plasma levels below the 0.373 ng / ml threshold and those with steady-state plasma levels above it reaches statistical significance for cognitive (ADAS-cog) and brain atrophy (LVV and WBV) endpoints, regardless of whether LMTM is taken as monotherapy or add-on therapy.

[0320] [Table 11]

[0321] The corresponding longitudinal trajectories over 65 weeks were analyzed using ADAS-cog 11 , ADCS-ADL 23 , LVV, and WBV are shown below in FIG.

[0322] Example 13 - ADAS-cog 11 Analysis of plasma concentrations for decline Further analysis of ADAS-cog decline over 65 weeks was performed using a modified form of the Hill equation (Wagner, 1968) to estimate minimum and maximum plasma concentrations for expected treatment response over 65 weeks. The Hill equation was applied under the assumption of noncooperativity and yielded a C of 0.29 ng / ml based on visual inspection of the data. max,ss An imposed overall zero value was used, with a null level of 11 units in concentration. The use of different limits did not meaningfully change the results. Additionally, a linear term was added to allow trends occurring at higher concentrations to be included in the model, using data from doses ranging from 150 to 250 mg / day. The extended Hill equation was applied to the data in the following form: Parameter change = E min -(E max *([C]-0.29)) / (EC 50 +([C]-0.29))+(A * ([C]-0.29) In the formula, E min is the forced zero value, and E max is the maximum treatment effect assumed in the standard Hill equation, and EC 50 is the maximum treatment effect assumed in the standard Hill equation, C max,ss and A is an additional linear term estimated by the model to account for potential biphasic responses. max,ss was also expressed as an equivalent mean dose estimate using the relationship obtained by fitting a linear model to the mean plasma concentrations at the 8, 150, 200, and 250 mg / day doses: Dose estimate (mg / day) = 0.045 * C max,ss +0.016.

[0323] As can be seen in Figure 17, there is an overall biphasic concentration-response of LMTM taken alone or in combination with symptomatic treatment. The dose range estimated to produce the best therapeutic response is 20-60 mg / day.

[0324] Compared to monotherapy, the estimated maximal treatment reduction is approximately 4 ADAS-cog units when LMTM is combined with symptomatic treatment. Further benefit is seen in the C required for half-maximal treatment response. max,ss There is a rightward shift in concentration from 0.32±0.01 ng / ml to 0.40±0.05 ng / ml.

[0325] It appears that the effects of plasma concentrations and concurrent medication conditions are additive. This suggests that an 8 mg / day dose administered as monotherapy would result in plasma levels above the 0.373 ng / ml threshold. This allows for an overall estimation of treatment utility comparing patients with a therapeutic plasma level of the drug with patients receiving the same dose in combination with symptomatic treatment who have plasma levels below this threshold. As can be seen from Figure 17, the latter group most closely approaches a minimal measurable treatment response. This analysis demonstrates that the treatment effect of an 8 mg / day dose as monotherapy in patients with therapeutic plasma levels of the drug is minimal in the ADCS-ADL. 23 , LVV, and WBV, along with the corresponding treatment effects of -7.53 (CI -9.93--5.13, p<0.0001) ADAS-cog 11 Indicate units (Table EX6 below):

[0326] [Table 12]

[0327] Example 14 - Implications of findings regarding monotherapy versus add-on therapy in relation to dosing regimens As is evident from the above, there is a reduction in the maximum effect of LMTM when it is combined with symptomatic treatment. However, it should be noted that this is relevant in situations where LMTM is administered to patients on the background of chronic pretreatment with symptomatic medication. This mechanism was elucidated in a series of experiments using a well-characterized tau transgenic mouse model. When these animals were chronically treated with a cholinesterase inhibitor (rivastigmine), almost all of the neurobiological effects seen when LMTM was administered alone were reduced or completely abolished, eliminating the beneficial effects of LMTM on spatial learning and memory. Similarly, pretreatment with memantine abolished the effect on spatial learning and memory (results not shown).

[0328] The mechanism appears to be a systemic, homeostatic downregulation affecting many synaptic and neurotransmitter systems in the brain that counteracts the activating effects of allopathic drugs. Thus, the effects evoked by LMTM are subject to dynamic downregulation when the brain has already been subjected to previous chronic stimulation by allopathic drugs.

[0329] Example 15 - Further Analysis of Providing Optimized Dosing Regimen in FTD Subject Populations The cutoff defining the upper limit of the lowest 35% group (corresponding to the percentage of patients with plasma levels below the validated limit of quantitation on Day 1) was 0.346 ng / ml in the bvFTD population.

[0330] For AD (see Example 10), the remainder with plasma levels within the validated quantification range on day 1 at the 8 mg / day dose were divided into three groups of approximately equal size (22% each; see Table EX7 below).

[0331] [Table 13]

[0332] There is a similar concentration-response relationship for measures of progression of brain atrophy by MRI (frontotemporal volume, lateral ventricle volume, whole brain volume), which is shown in Figure 18.

[0333] Alternative efficacy analyses were performed in which the group of patients with the lowest systemic exposure to the drug was used as a surrogate for placebo. These are shown in Table EX8 below and depicted in Figure 19.

[0334] Example 16 - Analysis of Chance in Plasma Concentration vs. Outcome As can be seen in Figure 18 above, for all outcomes, treatment effects were poor at the high dose of 200 mg / day, indicating a biphasic concentration-response relationship in bvFTD.

[0335] For AD, the extended Hill equation was applied under the assumption of noncooperativity, yielding a C of 0.29 ng / ml based on visual inspection of the data. max,ss The no-effect level in terms of concentration was -12 ACE-R units, 8 FAQ units, or -30 cm of total brain volume. 3An overall forced zero value of 0.05 was used. The use of different limiting values ​​did not meaningfully change the results. Additionally, a linear term was added to allow trends occurring at higher concentrations to be included in the model, using the average decline occurring at the 200 mg / day dose.

[0336] The extended Hill equation provided a robust fit to the mean concentration-response of ACE-R, FAQ, and whole brain volume changes over 52 weeks. Model fit for all outcomes is consistent with the assumption that the lower plasma concentration limit required for treatment response is 0.29 ng / ml in patients receiving the 8 mg / day dose. By dividing the whole brain volume data for patients receiving the 200 mg / day dose into three subgroups (Figure 20), it was possible to estimate the maximum critical concentration at which treatment effect was lost, namely 13.57 ng / ml (corresponding to a predicted dose of 301 mg / day).

[0337] [Table 14]

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[0340] Thanks for reading Gauthier , S , Feldman , HH , Schneider , LS , Wilcock , GK , Frisoni , GB , Hardlund , JH , Moebius , HJ , Bentham , P , Kook , KA , Wischik , DJ , Schelter , BO , Davis , CS , Staff , RT , Bracoud , L , Shamsi , K , Storey , JMD , Harrington , CR & Wischik , CM (2016) Efficacy and safety of tau-aggregation inhibitor t herapy in patients with mild or moderate Alzheimer's disease: a randomized, controlled, double-blind, parallel-arm, phase 3 trial. The Lancet 388, 2873–2884. Wilcock, G.K., Gauthier, S., Frisoni, G.B., Jia, J., Hardlund, J.H., Moebius, H.J., Bentham, P., Kook, K.A., Schelter, B.O., Wischik, D.J., Davis, C.S., Staff, R.T., Vuksanovic, V., Ahearn, T., Bracoud, L., Shamsi, K., Marek, K., Seibyl, J., Reidel, G., Storey, J.M.D., Harrington, C.R. & Wischik, C.M. (2018) Potential of low dose leuco-methylthioninium bis(hydromethanesulphonate) (LMTM) monotherapy for treatment of mild Alzheimer’s disease: cohort analysis as modified primary outcome in a phase 3 clinical trial. Journal of Alzheimer's Disease 61, 635-657. Kipps, C.M., Nestor, P.J., Dawson, C.E., Mitchell, J., Hodges, J.R. (2008) Measuring progression in frontotemporal dementia: Implications for therapeutic interventions. Neurology 70:2046-2052. Wagner JG. Kinetics of pharmacologic response I. Proposed relationships between response and drug concentration in the intact animal and man. J Theor Biol. 1968;20(2): 173-201.

Claims

1. 1. A therapeutic composition comprising a methylthioninium (MT)-containing compound for a method of therapeutic or prophylactic treatment of a neurodegenerative disorder in a human subject, comprising: orally administering the therapeutic composition to the subject; said administering providing said subject with a total daily oral dose of MT of 20.5 to 60 mg per day; The MT-containing compound The following formula: 【Chemistry 1】 (In the formula, H ｎ A and H ｎ each B (when present) is a protic acid, which may be the same or different, and is a compound where p=1 or 2; q=0 or 1; n=1 or 2; (p+q)×n=2); and the disorder is: (i) a synucleinopathy; or (ii) FTLD syndrome; or (iii) a polyglutamine disease; or (iv) hereditary cerebrovascular disease, amyotrophic lateral sclerosis, familial encephalopathy with neuronal inclusions, or Lafora disease is selected from and a therapeutic composition wherein said therapeutic treatment is not combined with an acetylcholinesterase inhibitor or an N-methyl-D-aspartate receptor antagonist.

2. 2. The therapeutic composition of claim 1, wherein the disorder is (i) a TAR DNA-binding protein 43 (TDP-43) proteinopathy, and / or (ii) FTLD with tau pathology or FTLD with TDP-43 pathology, and / or (iii) an FTLD syndrome selected from behavioral variant frontotemporal dementia (bvFTD), primary progressive aphasia, and semantic dementia.

3. 2. The therapeutic composition of claim 1, wherein the disorder is a polyglutamine disease selected from Huntington's disease, spinal-bulbar muscular atrophy, dentatorubral-pallidoluysian atrophy, or spinocerebellar ataxia.

4. 2. The therapeutic composition of claim 1, wherein the disorder is a synucleinopathy selected from Parkinson's disease, dementia with Lewy bodies, and multiple system atrophy.

5. 2. The therapeutic composition of claim 1, wherein the disorder is hereditary cerebrovascular disease, amyotrophic lateral sclerosis, familial encephalopathy with neuronal inclusions, or Lafora's disease.

6. 3. The therapeutic composition of claim 2, wherein the FTLD syndrome is behavioral frontotemporal dementia (bvFTD).

7. The therapeutic composition of claim 6, wherein the total daily dose is 20.5 to 40 mg of MT per day to the subject.

8. The MT-containing compound has the following formula: 【Chemistry 2】 8. The therapeutic composition of claim 1, wherein HA and HB are different monoprotic acids.

9. The MT-containing compound has the following formula: 【Transformation 3】 (In the formula, H ｎ Each of X is a protic acid. The therapeutic composition of any one of claims 1 to 7, comprising:

10. The MT-containing compound has the following formula: 【Chemistry 4】 and H ２ The therapeutic composition of any one of claims 1 to 7, wherein A is a di-protic acid.

11. The MT-containing compound has the following formula: 【Transformation 5】 10. The therapeutic composition of claim 9, wherein the acid is a bis-monoprotic acid.

12. A therapeutic composition according to any preceding claim, wherein the or each protic acid is an inorganic acid.

13. 13. The therapeutic composition of claim 12, wherein each protonic acid is a hydrohalide acid.

14. A therapeutic composition according to any preceding claim, wherein the or each protic acid is an organic acid.

15. 15. A therapeutic composition according to claim 12 or 14, wherein the or each protic acid is selected from H2CO3; CH3COOH; methanesulfonic acid, 1,2-ethanedisulfonic acid, ethanesulfonic acid, naphthalenedisulfonic acid, p-toluenesulfonic acid.

16. The therapeutic composition of any one of claims 1 to 6, wherein the MT-containing compound has the formula: 【Transformation 6】

17. The MT-containing compound is selected from the group consisting of: 【Transformation 7】 【Transformation 8】 The therapeutic composition of any one of claims 1 to 6, selected from the list consisting of:

18. 1. A therapeutic composition comprising a methylthioninium (MT)-containing compound for a method of therapeutic or prophylactic treatment of a neurodegenerative disorder in a human subject, comprising: orally administering the therapeutic composition to the subject; said administering providing said subject with a total daily oral dose of MT of 20.5 to 60 mg per day; The MT-containing compound has the following formula: 【Chemistry 9】 and and a therapeutic composition wherein the disorder is mild cognitive impairment.

19. 19. The therapeutic composition of claim 18, wherein the therapeutic treatment is not in combination with an acetylcholinesterase inhibitor or an N-methyl-D-aspartate receptor antagonist.

20. 19. The therapeutic composition of claim 18, wherein the therapeutic treatment is in combination with an acetylcholinesterase inhibitor or an N-methyl-D-aspartate receptor antagonist.

21. 21. The therapeutic composition of claim 20, wherein the acetylcholinesterase inhibitor is selected from the list consisting of donepezil; rivastigmine; and galantamine, and / or the N-methyl-D-aspartate receptor antagonist is memantine.

22. 22. The therapeutic composition of any one of claims 18-21, wherein the treatment is a combination therapy in which a first agent that is the MT-containing compound at a specified dosage is combined with a second agent that is an inhibitor of amyloid precursor protein processing to β-amyloid.

23. The treatment comprises: (i) treating said subject with said MT-containing compound for a first period of time, wherein said administration provides said subject with a total daily dose of MT of 1-10 mg per day; (ii) treating the subject with the MT-containing compound for an additional period of time, wherein the administration provides the subject with a total daily dose of MT of 20.5 to 40, 20.5 to 60, 20.5 to 80, or 20.5 to 100 mg per day; The therapeutic composition of any one of claims 18 to 22, which is part of a treatment regimen comprising:

24. 24. The therapeutic composition of any one of claims 1 to 23, wherein the subject is a human diagnosed with said neurodegenerative disorder or said method comprises making said diagnosis.

25. 24. The therapeutic composition of any one of claims 1 to 23, wherein the subject is a human assessed to be susceptible to or at risk of developing the disorder based on familial or genetic or other data.

26. 26. The therapeutic composition of any one of claims 1 to 25, wherein the total daily dose of MT is 21 to 40 mg; 21 to 32 mg; or 24 to 32 mg.

27. 27. The therapeutic composition of any one of claims 1 to 26, wherein the total daily dose is 20.5, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40 mg.

28. 28. The therapeutic composition of any one of claims 1-27, wherein the total daily dose of the MT-containing compound is administered once daily, or as divided doses, twice daily, or three times daily.

29. The subject: (a) have not received treatment with an acetylcholinesterase inhibitor or an N-methyl-D-aspartate receptor antagonist; or (b) a patient has a history of treatment with an acetylcholinesterase inhibitor or an N-methyl-D-aspartate receptor antagonist, and the treatment has not been discontinued with the MT-containing compound; or stopped at least 1, 2, 3, 4, 5, 6, 7 days or 2, 3, 4, 5, 6, 7, 8 weeks before treatment with (c) the subject is selected as having undergone treatment with an acetylcholinesterase inhibitor or an N-methyl-D-aspartate receptor antagonist, and said treatment is discontinued prior to treatment with the MT-containing compound; A therapeutic composition according to any one of claims 1 to 28.

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