HRP20000859A2 - Therapeutic combinations of (selective) estrogen receptor modulators (serm) and growth hormone secretagogues (ghs) for treating musculoskeletal frailty - Google Patents

Description

Background of the invention

This invention relates to a pharmaceutical combination of a selective estrogen receptor modulator (SERM) and a growth hormone secretagogue (GHS) that stimulates bone formation, increases bone mass, decreases serum lipid levels and increases muscle mass. The invention also relates to kits containing such combinations and to the use of such combinations for the treatment of musculoskeletal weakness, including osteoporosis, osteoporotic fracture, low bone mass, weakness, low muscle mass and the like, in mammals, including humans. In particular, this invention relates to a combination of (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydro-naphthalene -2-ol or its pharmaceutically acceptable salts and 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydro-pyrazolo -[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide or its pharmaceutically acceptable salts, kits containing such a combination, and use of such a combination for treating muscle- skeletal weaknesses, including osteoporosis, osteoporotic fracture, low bone mass, low muscle mass and the like, in mammals, including humans.

Osteoporosis is a disease of the skeletal system, characterized by low bone mass and deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. In the US, this condition affects more than 25 million people and causes more than 1.3 million fractures each year, including 500,000 spine, 250,000 hip and 240,000 joint fractures annually. Hip fractures are the most serious, with 5-20% of patients dying within 1 year, and over 50% of survivors being disabled.

Older people are at the highest risk of osteoporosis, so the problem is predicted to increase as the population ages. Worldwide, fracture incidence is predicted to triple over the next 60 years, and one study predicts that there will be 4.5 million hip fractures worldwide in 2050.

Although both men and women are susceptible to musculoskeletal weakness, including osteoporosis, women are at greater risk of osteoporosis than men. Women experience a marked acceleration of bone loss immediately after menopause. Other factors that increase bone loss leading to osteoporosis include smoking, alcohol dependence, a sedentary lifestyle, and insufficient calcium intake.

Estrogen is the agent of choice in preventing osteoporosis or post-menopausal bone loss in women. Further, Black et al in EP 0605193A1 describe that estrogen, particularly when taken orally, lowers plasma levels of LDL and raises those of beneficial high density lipoproteins (HDL). However, long-term estrogen therapy can lead to a host of conditions, including an increased risk of uterine cancer, endometrial cancer, and possible breast cancer, causing many women to either avoid this treatment or only take the drug for a short period of time. Although the risk of endometrial cancer is thought to be reduced with the comparative use of progesterone, there is still interest in the possible increased risk of breast cancer with the use of estrogen. Recently proposed therapeutic regimens, which seek to reduce the risk of cancer, such as administration of combinations of progesterone and estrogen, cause unacceptable bleeding in the patient. Further, combining progesterone with estrogen appears to blunt the serum cholesterol-lowering effects of estrogen. Significant adverse side effects associated with estrogen therapy support the need to develop alternative therapies for osteoporosis that have the desired beneficial effect on serum LDL but do not cause unwanted side effects.

Recently, several selective estrogen receptor modulators have been proposed for the treatment of osteoporosis. Thus it was reported ("Osteoporosis Conference Script", No. 1812/16/20 p. 29, April 13, 1993) that raloxifene, 6-hydroxy-2-(4-hydroxyphenyl)-3-[4-(2- piperidinoethoxy) benzoyl] benzo[b] thiophene, mimics the beneficial effect of estrogen on bone and lipids but, unlike estrogen, has a minimal stimulatory effect on the uterus. (L.J. Black et al.: "Raloxifene (LZ139481 Hcl) Prevents Bone Loss and Reduces Serum Cholesterol Without Causing Uterine Hypertrophy in Ovariectomized Rats, J. Clin. Invest.", 93:63-69, (1994); and P.D. Delmas et al. colleagues: "Effects of Raloxifene on Bone Mineral Density, Serum Cholesterol Concentration, and Uterine Endometrium in Postmenopausal Women, New England Journal of Medicine", 337:1641-1647, (1997)).

Agents such as droloxifene, US patent no. 5,254,595, prevent bone loss and thereby reduce the risk of fracture without the side effects of estrogen. However, estrogen and estrogen agonists are expected to only reduce fracture risk by about 50%, leaving approximately 50% of women with osteoporosis at risk for osteoporotic fracture.

Oft-cited US Patent No. 5,552,412, which is incorporated herein by reference, describes SERM compounds of the formula

[image]

where the variables are defined as given there.

Growth hormone (GH), which is secreted by the pituitary gland, stimulates the growth of all body tissues that are capable of growth. Furthermore, GH is known to have the following basic effects on the body's metabolic process:

1. Increased speed of protein synthesis in practically all cells of the body;

2. Decreased rate of use of carbohydrates in body cells;

3. Increased mobility of free fatty acids and utilization of fatty acids for energy.

Deficiency in GH results in a multitude of medical conditions. In children, dwarfism is caused. In adults, the consequences of acquired GH deficiency include a strong reduction in body meat mass, which causes an increase in total body fat, especially in the trunk. Reduced skeletal and cardiac muscle mass and muscle strength lead to a significant reduction in exercise capacity. Bone density is also reduced. Administration of exogenous GH has been shown to trigger many metabolic changes. Additional benefits of the therapy included reduction of LDL cholesterol and improvement in physiological status.

In cases where increased GH levels are desired, the problem is generally solved with the administration of exogenous GH or with administration of an agent that stimulates GH production and/or release. In any case, the peptidyl nature of the compound required that it be administered by injection. Initially, the source of GH was extracted from the pituitary gland of cadavers. This resulted in an expensive product, and was done with the risk that a disease associated with the source of the pituitary gland could be transmitted to the GH recipient (eg, Jacob-Creutzfeldt disease). Recently, recombinant GH has become available, which no longer carries any risk of disease transmission, but which is still a very expensive product that must be given by injection or nasal spray.

Most GH deficiencies are caused by defects in GH release, which are not primary defects in pituitary GH synthesis. Therefore, an alternative strategy to normalize serum GH levels is to stimulate its release from somatotrophs. An increase in GH secretion can be achieved by stimulating or inhibiting various neurotransmitter systems in the brain and hypothalamus. As a result, the development of synthetic GH-releasing agents to stimulate pituitary GH secretion has been driven, which may have several advantages over expensive and inappropriate GH replacement therapy. By acting along physiological regulatory pathways, most of the desired agents could stimulate pulsatile GH secretion, and the excessive GH levels associated with the unwanted side effects of exogenous GH administration could be avoided by intact negative feedback loops.

Physiological and pharmacological stimulators of GH secretion include arginine, L-3,4-dihydroxyphenylalanine (L-DOPA), glucagon, vasopressin, and hypoglycemia-induced insulin. Likewise, activities such as sleep and exercise indirectly induce GH release from the pituitary by acting on the hypothalamus, which in some way can decrease somatostatin secretion or increase secretion of a known secretagogue of GH-releasing factor (GHRF) or an unknown endogenous GH-releasing hormone, or all of these. .

The oft-cited PCT patent application published as WO 97/24369, assigned inter alia to the US, describes GH secretagogue formulas

[image]

where the variables are defined as given there. This PCT patent application published as WO 97/24369 is incorporated herein by reference.

Tang et al.: "Restoring and Maintaining Bone in Osteogenic Female Rat Skeleton: I. Changes in Bone Mass and Structure," J. Bone Mineral Research, 7(9), p. 1093-1104, (1992) describes data for the loss, recovery and maintenance (LRM) concept, and a practical procedure for reversing existing osteoporosis. The LRM concept uses anabolic agents to restore bone mass and architecture (+ phase) and then switches to an agent with established ability to maintain bone mass so that new bone is preserved (+/- phase). Studies in rats have used PGE2 and risedronate, a bisphosphonate, to show that most of the PGE2-induced new cancellous and cortical bone can be maintained for at least 60 days after withdrawal of PGE2 with risedronate.

Shen et al.: "Effects of Reciprocal Treatment with Estrogen and Estrogen plus Parathyroid Hormone on Bone Structure and Strength in Ovariectomized Rats, J. Clinical Investigation", 96:2331-2338, (1995) describes data for combination and/or sequential administration anti-resorptive agents and anabolic agents for the treatment of osteoporosis.

The frequently cited PCT patent application published as WO 97/31640, assigned inter alia to the US, describes the use of some GH secretagogues in combination with some SERMS for the treatment of osteoporosis. Said PCT patent application published as WO 97/31640 is incorporated herein by reference.

The essence of invention

This invention is directed to a pharmaceutical preparation containing:

a. first compound, where said first compound is (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydro- naphthalen-2-ol or a pharmaceutically acceptable salt thereof; and

b. second compound, where said second compound is 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexa hydropyrazolo- [4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide or a pharmaceutically acceptable salt thereof.

The invention is also directed to a pharmaceutical preparation as described in one of the first two paragraphs of this Part of the invention, wherein said first compound is (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy) )-phenyl)-5,6,7,8-tetrahydro-naphthalen-2-ol D-tartrate, and the second compound mentioned is 2-amino-N-(2-(3a(R)-benzyl-2-methyl- 3-oxo-2,3,3a,4,6,7-hexahydro-pyrazolo-[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide- L-tartrate.

The present invention is further directed to a method, denoted as method A, for treating a mammal suffering from musculoskeletal weakness, which comprises administering to said mammal a pharmaceutical preparation as set forth in any of the first 3 paragraphs of this Invention.

A preferred procedure within procedure A, denoted as procedure B, is where the mammal suffers from osteoporosis.

Another preferred procedure within procedure A, denoted as procedure C, is where the mammal suffers from osteotomy, childhood idiopathic bone loss, or bone loss associated with periodontitis.

The present invention is further directed to a method, denoted as method A1, for treating a mammal suffering from musculoskeletal weakness, which comprises administering to said mammal:

a. of the first compound, where said first compound is (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydro- naphthalen-2-ol or a pharmaceutically acceptable salt thereof; and

b. a second compound, where said second compound is 2-amino-N-(1(R)-(2,4-difluoro-benzyloxymethyl)-2-oxo-(3-oxo-3a(R)-pyridine-2- ylmethyl)-2-(2,2,2-trifluoro-ethyl)-2,3,3a,4,6,7-hexahydro-pyrazolo[4,3-c]pyridin-5-yl)-ethyl)-2 -methyl-propionamide or its pharmaceutically acceptable salt.

This invention is particularly directed to the process of process A1, where the first compound and the second compound are introduced essentially simultaneously.

This invention is also directed to the process of process A1, designated as process D, where the second compound is introduced over a period of about 3 months to about 3 years.

This procedure is more precisely directed to the procedure from procedure D, followed by the introduction of the first compound for a period of about 3 months to about 3 years without the introduction of the second compound for a period of about 3 months to about 3 years.

This invention is also more specifically directed to the process of process D, followed by the introduction of the first compound for a period of more than about 3 years without the introduction of the second compound for a period of more than about 3 years.

The present invention is also directed to a method, denoted as method E, for treating musculoskeletal weakness in a mammal suffering from it, which comprises administering to said mammal a therapeutically effective amount of a composition as set forth in any of the first 3 paragraphs of this Summary of the Invention.

A preferred procedure within procedure E is one where bone healing accompanied by facial reconstruction, maxillary reconstruction, or mandibular reconstruction is improved, spinal synostosis is induced, long bone lengthening is improved, healing rate of bone growth or long bone fracture is improved, or prosthetic growth is improved. Additionally, a method is preferred which comprises introducing into said mammal:

a. of the first compound, where said first compound is (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydro- naphthalen-2-ol or a pharmaceutically acceptable salt thereof; and

b. a second compound, where said second compound is 2-amino-N-(1(R)-(2,4-difluoro-benzyloxymethyl)-2-oxo-(3-oxo-3a(R)-pyridine-2- ylmethyl)-2-(2,2,2-trifluoro-ethyl)-2,3,3a,4,6,7-hexahydro-pyrazolo[4,3-c]pyridin-5-yl)-ethyl)-2 -methyl-propionamide or its pharmaceutically acceptable salt.

This invention is also directed to a method for increasing muscle mass in a mammal, which comprises administering to said mammal for increasing muscle mass an effective amount of a preparation as set forth in any of the first 3 paragraphs of this Bite of the invention. Additionally, a method comprising administration to said mammal is preferred

a. of the first compound, where said first compound is (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydro- naphthalen-2-ol or a pharmaceutically acceptable salt thereof; and

b. a second compound, where said second compound is 2-amino-N-(1(R)-(2,4-difluoro-benzyloxymethyl)-2-oxo-(3-oxo-3a(R)-pyridine-2- ylmethyl)-2-(2,2,2-trifluoro-ethyl)-2,3,3a,4,6,7-hexahydro-pyrazolo[4,3-c]pyridin-5-yl)-ethyl)-2 -methyl-propionamide or its pharmaceutically acceptable salt.

In all methods of the present invention, it is particularly suitable that the mammal is a human.

The present invention is also directed to kits comprising treatment for a mammal suffering from musculoskeletal weakness, comprising:

a. a therapeutically effective amount of (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydro-naphthalen-2-ol or a pharmaceutically acceptable salt thereof and a pharmaceutically acceptable carrier, in the form of a first dosage unit;

b. a therapeutically effective amount of 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydro-pyrazolo-[4,3 -c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide or its pharmaceutically acceptable salts and a pharmaceutically acceptable carrier, in the form of a second dosage unit; and

c. tank.

This invention is particularly directed to kits as described in the immediately preceding paragraph, wherein said first dosage unit form contains (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl )-5,6,7,8-tetrahydro-naphthalen-2-ol D-tartrate, and the mentioned second dosage unit form contains 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3 -oxo-2,3,3a,4,6,7-hexahydro-pyrazolo-[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide L -tartrate.

In all of these preparations, methods and kits of this invention, it is particularly preferred to use the D-tartrate salt of (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)- phenyl)-5,6,7,8-tetrahydro-naphthalen-2-ol and to use the L-tartrate salt of 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3- oxo-2,3,3a,4,6,7-hexahydro-pyrazolo-[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide.

The phrase "a condition presenting with low bone mass" refers to a condition where the level of bone mass is below the age-specific normal, which is defined in the standards of the World Health Organization "Assessment of Fracture Risk and Its Application to Screening for Postmenopausal Osteoporosis, (1994) , Report of a World Health Organization Study Group, World Health Organization Technical Series 843". Childhood idiopathic and primary osteoporosis are also included. The treatment of osteoporosis includes the prevention or weakening of long-term complications such as bending of the spine, weight loss, prosthetic surgery, and prevention of prostate dysfunction. Also included is an increase in the rate of bone fracture healing and an increase in the rate of successful bone grafting. Periodontal disease and alveolar bone loss are also involved.

The phrase "a condition presenting with low bone mass" also refers to mammals known to have a significantly higher than average chance of developing such conditions, such as those described above including osteoporosis (eg, post-menopausal women, men over 60 years, and people treated with drugs known to cause osteoporosis as a side effect (such as glucocorticoids)).

Experts will know that the term "bone mass" actually refers to bone mass per unit area, which is sometimes (though not entirely correctly) described as natural bone density.

The phrase "musculoskeletal weakness" refers to a condition where a subject has low bone mass and/or low muscle mass, and includes diseases, conditions and conditions such as (but not limited to) conditions presenting with low bone mass, osteoporosis , conditions presenting with low muscle mass, osteotomy, pediatric idiopathic bone loss, bone loss associated with periodontitis, bone treatment followed by facial reconstruction, maxillary reconstruction, mandibular reconstruction and bone fracture. Furthermore, weakness also includes such conditions as adaptations between newly fixed prostheses and bones that require transplantation.

The term "treatment" or "treatment" as used herein includes curative, preventive (eg, prophylactic) and palliative treatment.

The parenthetical negative or positive sign used herein in the nomenclature indicates that the direction of the polarized light is rotated with the particular stereoisomer.

The compositions of this invention may include hydrates of the compounds used herein.

The pharmaceutical preparations and methods of this invention result in faster and greater gains in bone mass size than can be achieved with the same doses of (-)-cis-6-phenyl-5-[4-(2-pyrrolidin-1-yl-ethoxy) alone. )-phenyl]-5,6,7,8-tetrahydro-naphthalen-2-ol as described above, or 2-amino-N-[2-(3a(R)-benzyl-2-methyl-3- oxo-2,3,3a,4,6,7-hexahydro-pyrazolo-[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl]-isobutyramide as above described. Furthermore, these combinations increase bone density and muscle mass, while at the same time reducing fat mass and total serum cholesterol. Thus, these combinations increase bone mass and reduce fracture sizes to a greater extent than can be achieved through the use of a single agent. This invention makes a significant contribution to the technique by providing preparations and procedures that increase and maintain bone mass, resulting in the prevention, retardation, and/or reversal of osteoporosis and related bone diseases.

Other characteristics and advantages will be apparent from the specification and claims describing the invention.

Detailed description of the invention

The first compound of this invention is (-)-cis-6-phenyl-5-[4-(2-pyrrolidin-1-yl-ethoxy]-phenyl)-5,6,7,8-tetrahydro-naphthalene-2- ol or a pharmaceutically acceptable salt thereof, having the structural formula I:

[image] .

(-)-cis-6-phenyl-5-[4-(2-pyrrolidin-1-yl-ethoxy)-phenyl]-5,6,7,8-tetrahydro-naphthalen-2-ol and its pharmaceutically acceptable salt are obtained as described in the frequently cited US Pat. No. 5,552,412, which is referenced herein.

(-)-cis-6-phenyl-5-[4-(2-pyrrolidin-1-yl-ethoxy)-phenyl]-5,6,7,8-tetrahydro-naphthalen-2-ol D-tartrate is obtained as set forth in the immediately preceding paragraph or, alternatively, as set forth in PCT patent application published as WO 97/164434, also assigned to the US, which is incorporated herein by reference.

Another compound of this invention is 2-amino-N-[2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydro-pyrazolo-[4, 3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl]-isobutyramide or a pharmaceutically acceptable salt thereof, having the structural formula II:

[image] .

2-amino-N-[2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydro-pyrazolo-[4,3-c]pyridine- 5-yl)-1(R)-benzyloxy methyl-2-oxo-ethyl]-isobutyramide and its pharmaceutically acceptable salts are prepared as described in the commonly cited PCT patent application published as WO 97/24369, which is referenced herein.

Further, when the compounds or their pharmaceutically acceptable salts of this invention form hydrates or solvates they are also within the scope of the invention.

The pharmaceutical combinations and methods of this invention are all adapted for therapeutic use as agents that activate bone turnover or prevent bone resorption or increase bone formation in mammals, particularly humans. As these functions are closely related to the development of osteoporosis and bone-related diseases, these combinations, through their action on bone, prevent, stop, slow or reverse osteoporosis.

The utility of the compositions and methods of this invention as medicinal agents in the treatment of musculoskeletal weakness (e.g., conditions presented with low bone mass or low muscle mass including osteoporosis) in mammals (e.g., humans) has been demonstrated with the activity of the compounds of this invention. in suitable experiments as given in US Pat. No. 5,552,412 and PCT patent application published as WO 97/24369. Further evidence of the usefulness of this combination is given in Example 1 below. Such experiments also provide a means by which the activities of the compounds of this invention can be compared with each other and with the activities of other known compounds. The results of these comparisons are useful for determining dosage levels in mammals, including humans, for the treatment of such diseases.

Administration of the compounds of the present invention may be via any method that delivers the compound of the combination of the present invention systemically and/or locally. These methods include oral routes, parenteral, intraduodenal routes, etc. In general, the compounds of this invention are administered orally, but parenteral administration (eg, intravenous, intramuscular, transdermal, subcutaneous, or intramedullary) may be used, for example, where oral administration is not suitable for this purpose or where the patient is unable to swallow the medicine. Two different compounds of the present invention may be co-administered simultaneously or sequentially in any order, or a single pharmaceutical preparation comprising a first compound as described above and a second compound as described above in a pharmaceutically acceptable carrier may be administered.

In any case, the amount and time of the introduced compounds will, of course, depend on the subject being treated, on the severity of the disease, the method of introduction and the opinion of the competent physician. Thus, due to differences between patients, the dosages given below are indicative, and the physician may titrate drug doses to achieve the activity (eg, increase in bone mass) that the physician deems appropriate for the individual patient. When considering the level of desired activity, the doctor must balance many factors, such as the initial level of bone mass, the age of the patient, the presence of an existing disease, as well as the presence of other diseases (eg cardiovascular). For example, the introduction of (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydro-naphthalen-2-ol can provide cardiovascular benefits especially for post-menopausal women. The following paragraphs describe preferred dosage ranges for the various components of the invention.

Effective dosing for (-)-cis-6-phenyl-5-[4-(2-pyrrolidin-1-yl-ethoxy)-phenyl]-5,6,7,8-tetrahydro-naphthalen-2-ol is in range from 0.0001 to 100 mg/kg/day, preferably 0.001 to 10 mg/kg/day.

Effective dosing for 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydro-pyrazolo-[4,3-c ]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide is in the range of 0.0001 to 100 mg/kg/day, preferably 0.01 to 5 mg/kg/day.

Where a tartrate salt or other pharmaceutically acceptable salt of one of the above compounds is used in the present invention, one skilled in the art will be able to calculate effective dosage amounts by calculating the molecular weight of the salt form and by calculating simple stoichiometric ratios.

The compounds of the present invention are generally administered in the form of a pharmaceutical preparation containing at least one of the compounds or pharmaceutically acceptable salts thereof of the present invention together with a pharmaceutically acceptable carrier or diluent. Thus, the compounds and their pharmaceutically acceptable salts of the present invention may be administered separately or together in any suitable oral, parenteral or transdermal dosage form. When administered separately, administration of the second compound or a pharmaceutically acceptable salt thereof of the invention follows.

For oral administration, the pharmaceutical preparation can be in the form of solutions, suspensions, tablets, pills, capsules, powders and the like. Tablets containing various excipients such as sodium citrate, calcium carbonate and calcium phosphate are used together with various disintegrants such as starch, especially potato or tapioca starch and some complex silicates, together with binding agents such as polyvinylpyrrolidone, sucrose, gelatin and acacia. Additionally, lubricants such as magnesium stearate, sodium lauryl sulfate, and talc are often useful for tableting purposes. Solid preparations of a similar type are often used as fillers in soft and firmly filled gelatin capsules; preferred materials in this regard also include lactose or milk sugar, and high molecular weight polyethylene glycols. When aqueous suspensions and/or elixirs are desired for oral administration, the compounds or pharmaceutically acceptable salts thereof of this invention may be combined with various sweetening agents, flavoring agents, coloring agents, emulsifying agents and/or suspending agents, as well as such diluents as which are water, ethanol, propylene glycol, glycerin and various combinations thereof.

For the purposes of parenteral introduction, solutions in sesame or peanut oil or in aqueous propylene glycol can be used, as well as sterile aqueous solutions of the corresponding water-soluble salts. If necessary, such aqueous solutions can be suitably buffered, and the liquid diluent is first returned isotonic with sufficient saline or glucose. These aqueous solutions are particularly suitable for intravenous, intramuscular, subcutaneous and intraperitoneal injection. In this connection, sterile aqueous media are used which are easily obtained by standard techniques well known to those skilled in the art.

For purposes of transdermal administration (eg, topically), dilute sterile aqueous or partially aqueous solutions (usually about 0.1% to 5% concentration) are obtained, which are similar to the above parenteral solutions.

Processes for obtaining various pharmaceutical preparations with some amount of each active ingredient are known, or will be apparent to those skilled in the art in light of this disclosure. For example, see "Ramington's Pharmaceutical Sciences", Mack Publishing Company, Easton, PA, 19th ed., (1990).

Pharmaceutical preparations according to the invention may contain 0.1% to 95% of a combination of compounds or their pharmaceutically acceptable salts from this invention, preferably 1% to 70%. In any case, the preparation or formulation for introduction will contain an amount of compounds or their pharmaceutically acceptable salts from the invention in an amount effective for treating the disease/condition of the subject being treated.

As this invention relates to treatment with a combination of two active ingredients that can be administered separately, the invention also relates to the combination of special pharmaceutical preparations in the form of a kit. The kit contains two special pharmaceutical preparations: (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydro-naphthalene-2 -ol or 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydro-pyrazolo-[4,3-c ]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide or a pharmaceutically acceptable salt thereof. The kit contains a container containing special preparations, such as a divided bottle or a divided foil package; however, special preparations may also be contained within a single container. Typically, the kit contains directions for introducing specific components. The kit form is particularly suitable when special components are desired to be administered in various dosage forms (eg oral and parenteral), and are administered at various dosing intervals, or when the competent physician wants titration of individual components from the combination.

An example of such a set is the so-called medicine packaging. Drug packaging is well known in the industry, and is widely used for packaging pharmaceutical dosage unit forms (tablets, capsules, and the like). Medicine packages generally contain a sheet of relatively rigid material that is covered with a film of preferably transparent plastic material. During the packaging process, voids are formed in the plastic film. The cavities have the size and shape of tablets or capsules that are packaged. Next, the tablets or capsules are placed in the cavities, and a sheet of relatively rigid material is hermetically placed over the plastic film on the face of the film that is opposite to the direction in which the cavities were formed. As a result, the tablets or capsules are hermetically sealed in the cavities between the plastic film and the sheet. Preferably, the strength of the sheet is such that the tablets or capsules can be removed from the drug package by manually applying pressure to the cavities, forming an opening in the sheet at the site of the cavity. The tablet or capsule can then be removed through the aforementioned opening.

It is desirable to provide a memory aid on the inserted chart, for example in the form of numbers next to the tablets or capsules where the numbers correspond to the days of the regimen in which the tablets and capsules so specified are to be swallowed. Another example of such a memory aid is a calendar printed on a card, eg as follows "First week, Monday, Tuesday, ... etc.; ... Second week, Monday, Tuesday, ... etc.". Other variants of memory aids are also possible. "Daily dose" can be one pill or capsule, or several pills or capsules to be taken on the scheduled day. Also, a daily dose of a SERM may contain several tablets or capsules. A memory aid should be in line with this.

In another specific embodiment of the invention, a divider is provided, designed to divide the daily doses in time according to the order of their intended application. Preferably, the dispenser has a memory aid to further facilitate compliance with the administration regimen. An example of such a memory aid is a mechanical counter that shows the number of daily doses that have been dispensed. Another example of such a memory aid is a battery-powered memory microchip linked to a liquid crystal display, or to a reminder sound signal that, for example, reads the date of the last daily dose taken and reminds the user when the next dose should be taken. dose.

The following experiment was used to demonstrate that the combination and procedures of the invention increase lean body mass and decrease body fat mass, whereas a GH secretagogue alone can be expected to decrease body fat mass without a change in body lean mass, and a SERM alone can be expected to increase both, i.e. lean and fat body mass. Furthermore, the combination increases bone density and reduces total serum cholesterol.

Example one

Female S-D rats (Hartan) at the age of 3.5 months were sham-operated or ovariectomized (OVX). Drug administration started when the rats were 9 months of age or 5.5 months after surgery. Sham-operated rats received a daily dose of vehicle (10% ethanol in water), while OVX rats received a daily dose of vehicle or 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo) alone -2,3,3a,4,6,7-hexahydro-pyrazolo-[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide at 5 mg/ kg/day, or (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydro-naphthalene-2- ola at 0.1 mg/kg/day, or co-treatment of 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6, 7-hexahydro-pyrazolo-[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide and (-)-cis-6-phenyl-5-( 4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydro-naphthalen-2-ol, for 4 weeks. In the combination group, from 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydro-pyrazolo-[4,3 -c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide was administered 2 hours before (-)-cis-6-phenyl-5-(4-(2-pyrrolidine- 1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydro-naphthalen-2-ol. There were 8 to 10 rats in each subgroup. All rats were injected subcutaneously with 10 mg/kg calcein (Sigma Chemical Co., St. Louis, MO) on days 13 and 3 before necropsy. It will be clear to those skilled in the art that the compounds used in this experiment can be administered in the form of a pharmaceutically acceptable salt and that the dosage amount can easily be determined by calculating the molecular weight of the salt and determining simple relationships.

Before necropsy on the final day of the experiment, all rats were subjected to dual energy X-ray absorptiometry (DXA, QDR-1000/W, Hologic Inc., Waltham, MA) under ketamine/xylazine anesthesia to determine lean and fat body mass. The rats were then necropsied, and blood was obtained by cardiac puncture. Total serum cholesterol was determined using a high-performance cholesterol colorimetric assay (Boehringer Mannheim Biochemicals, Indianapolis, IN). Body weight gain was calculated as body weight at autopsy minus body weight on day 0. Uterine wet weight was determined directly at autopsy.

The right femur from each rat was removed at necropsy and scanned using dual energy X-ray absorptiometry (DXA, QDR-1000/W, Hologic Inc., Waltham, MA) equipped with "High Resolution Regional Scanning" software (Hologic Inc., Waltham, MA). The scanning field size was 5.08 × 1.902 cm, the resolution was 0.0254 × 0.0127 cm, and the scanning speed was 7.25 mm/second. Scan images of the femur were analyzed, and the total area of the femur, bone mineral content, and bone mineral density were determined according to the procedure described by H.Z. Ke et al.: "Droloxifene, a New Estrogen Antagonist/Agonist, Prevents Bone Loss in Ovariectomized Rats", Endocrinology", 136; 2435-2441, (1995).

Results of the study and discussion

Compared to controls, 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydro-pyrazolo-[4,3 -c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide alone increased both lean and fat body mass, while (-)-cis-6-phenyl-5-(4 -(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydro-naphthalen-2-ol alone reduced fat body mass without change in lean body mass. Combination of 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydro-pyrazolo-[4,3-c]pyridine) -5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide and (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl )-5,6,7,8-tetrahydro-naphthalen-2-ol increased lean body mass and decreased fat body mass. Therefore, the combination of both compounds has a better body composition profile than 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydro- pyrazolo-[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide alone or from (-)-cis-6-phenyl-5-(4-( 2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydro-naphthalen-2-ol itself.

A 5-6% increase in total femur area was observed in subjects receiving the combination compared to those subjects receiving placebo. This result is similar to the increase in total femur bone surface area observed in subjects receiving one of the (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl) -5,6,7,8-tetrahydro-naphthalen-2-ol or from 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4 ,6,7-hexahydro-pyrazolo-[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide and (-)-cis-6-phenyl-5 -(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydro-naphthalen-2-ol itself. The total mineral content of the femur increased by 8.5% with 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7) alone -hexahydro-pyrazolo-[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide, and 7.7% for (-)-cis-6- phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydro-naphthalen-2-ol. However, in the combination group, total femur bone mineral content increased by 12.5%, a significant increase compared to either intake alone. A similar pattern was found for total femoral bone mineral density.

Total serum cholesterol decreased in the (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydro-naphthalene- 2-ola and in the combination group.

These data indicated that the combination of 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydro-pyrazolo-[4, 3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide and (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl) -ethoxy)-phenyl)-5,6,7,8-tetrahydro-naphthalen-2-ol has multiple advantages. These benefits include an increase in lean mass and a decrease in fat mass and serum lipids. Furthermore, an increase in bone mass was observed.

It is to be understood that the invention is not limited to the particular embodiments described herein, but that certain changes and modifications may be made without departing from the spirit and scope of the present invention as defined in the following claims.

Claims (29)

1. Pharmaceutical preparation, characterized by the fact that it contains: a. first compound, where said first compound is (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydro- naphthalen-2-ol or a pharmaceutically acceptable salt thereof; and b. second compound, where said second compound is 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydro-pyrazolo -[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide or a pharmaceutically acceptable salt thereof. 2. Pharmaceutical preparation according to claim 1, characterized in that it additionally contains a pharmaceutical carrier. 3. Pharmaceutical preparation according to claim 1, characterized in that said first compound is (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7 ,8-tetrahydro-naphthalen-2-ol D-tartrate, and the mentioned second compound is 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a, 4,6,7-Hexahydro-pyrazolo-[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide L-tartrate. 4. The pharmaceutical preparation from claim 1, characterized in that it is used to obtain a medicine that treats a mammal suffering from musculoskeletal weakness. 5. Application from claim 4, characterized in that said first compound is (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7, 8-tetrahydro-naphthalen-2-ol D-tartrate, and the mentioned second compound is 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4 ,6,7-Hexahydro-pyrazolo-[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide L-tartrate. 6. Use according to claim 4, characterized in that said mammal suffers from osteoporosis. 7. Use according to claim 4, characterized in that osteotomy, pediatric idiopathic bone loss and bone loss associated with periodontitis are treated. 8. Use according to claim 4, indicated by the fact that bone treatment is followed by treatment of facial reconstruction, maxillary reconstruction, vertebral synostosis is induced or long bone extension is enhanced, speed of bone transplantation treatment is increased or prosthetic development is enhanced. 9. Use according to claim 8, characterized in that a bone fracture is treated in a human. 10. Application from claim 6, characterized in that osteoporosis is treated in humans. 11. The set, characterized by the fact that it contains: a. (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydro-naphthalen-2-ol or its pharmaceutical an acceptable salt and a pharmaceutically acceptable carrier or diluent in the form of a first dosage unit; b. 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydro-pyrazolo-[4,3-c] pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide or a pharmaceutically acceptable salt thereof and a pharmaceutically acceptable carrier or diluent in the form of a second dosage unit; and c. tank. 12. The kit of claim 11, characterized in that said first dosage unit contains (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7 ,8-tetrahydro-naphthalen-2-ol D-tartrate, and said second dosage unit contains 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a ,4,6,7-hexahydro-pyrazolo-[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide L-trate. 13. A method for treating a mammal suffering from musculoskeletal weakness, indicated by the fact that it includes the introduction into said mammal of the pharmaceutical preparation from claim 1. 14. The method of claim 13, characterized in that said first compound is (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7, 8-tetrahydro-naphthalen-2-ol D-tartrate, and the mentioned second compound is 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4 ,6,7-Hexahydro-pyrazolo-[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide L-tartrate. 15. The method of claim 13, characterized in that said mammal suffers from osteoporosis. 16. The method of claim 13, characterized in that osteotomy, pediatric idiopathic bone loss and bone loss associated with periodontitis are treated. 17. The method of claim 13, characterized in that the bone treatment is followed by the treatment of facial reconstruction, maxillary reconstruction, vertebral synostosis is induced or long bone extension is enhanced, the speed of bone transplantation treatment is increased or prosthetic development is enhanced. 18. The method of claim 17, characterized in that the bone fracture is treated in a human. 19. The method of claim 15, characterized in that osteoporosis is treated in humans. 20. A procedure for treating a mammal suffering from musculoskeletal weakness, characterized by the fact that it includes introducing into said mammal: a. of the first compound, where said first compound is (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydro- naphthalen-2-ol or a pharmaceutically acceptable salt thereof; and b. of another compound, where said second compound is 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydro-pyrazolo -[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide or a pharmaceutically acceptable salt thereof. 21. The method of claim 20, characterized in that the first compound and the second compound are introduced essentially simultaneously. 22. The method of claim 20, characterized in that the second compound is introduced during a period of about 3 months to about 3 years. 23. The method of claim 22, characterized in that it is followed with the introduction of the first compound during a period of about 3 months to about 3 years without the introduction of the second compound during a period of about 3 months to about 3 years. 24. The method of claim 22, characterized in that it is followed by the introduction of the first compound during a period longer than about 3 years without the introduction of the second compound during a period longer than about 3 years. 25. The method of claim 20, characterized in that said mammal suffers from osteoporosis. 26. The method of claim 20, characterized in that osteotomy, pediatric idiopathic bone loss and bone loss associated with periodontitis are treated. 27. The method of claim 20, characterized in that the bone treatment is followed by the treatment of facial reconstruction, maxillary reconstruction, vertebral synostosis is induced or long bone extension is enhanced, the speed of bone transplantation treatment is increased or prosthetic development is enhanced. 28. The method of claim 27, characterized in that the bone fracture is treated in a human. 29. A method for increasing muscle mass in a mammal in need of it, indicated by the fact that it includes the introduction into said mammal for increasing muscle mass of an effective amount of the preparation from claim 1.