WO2008009071A2

WO2008009071A2 - Combination therapy using betaine and endothelin antagonists

Info

Publication number: WO2008009071A2
Application number: PCT/BE2006/000082
Authority: WO
Inventors: Jallal Messadek
Original assignee: Jallal Messadek
Priority date: 2006-07-20
Filing date: 2006-07-20
Publication date: 2008-01-24

Abstract

Methods and compositions are provided for preventing or inhibiting cardiovascular events in a subject, in which a subject in need is administered a betaine and one or more endothelin receptor antagonist. Methods and compositions for improving the efficacy of one or more endothelin antagonist are also provided, comprising administering to a subject in need thereof a betaine together with one or more endothelin receptor antagonist.

Description

uombination therapy using betaine and endothelin antagonists

ABSTRACT

FIELD OF THE INVENTION

This invention relates to novel methods and compositions for treating hypertension, cardiovascular diseases, inflammation diseases, cancer diseases, metabolic diseases, pulmonary hypertension and endothelial abnormalities and/or for lessening adverse effects induced by administration of one or more endothelin receptors antagonists.

BACKGROUND OF THE INVENTION

The three endogenous isoforms of endothelin (ET) in humans, ET-1 , ET- 2 and ET-3, mediate their actions via two receptor subtypes, ETA and ETB, that have been isolated and cloned from mammalian tissues. Both subtypes belong to the seven-transmembrane-domain spanning, G- protein-coupled receptor superfamily.

The only other endogenous peptides displaying a high degree of sequence similarity to the ETs are the sarafotoxins (S6a, S6b, S6c and S6d), a family of 21 -amino-acid peptides isolated from the venom of the snake Atractaspis engadensis.

ET receptors are widely expressed in all tissues, consistent with the physiological role of ET-1 ,the most abundant isoform, as a ubiquitous endothelium derived vasoactive peptide contributing to the maintenance of normal vascular tone. Receptors are also localized to non-vascular structures (such as epithelial cells) and expressed in the central nervous system (glia and neurons).

In human blood vessels, ETA receptors are present mainly on vascular smooth muscle cells, and are chiefly responsible for contraction. ETB receptors are also thought to be localized to the single layer of endothelial cells lining the vessel wall. Activation of endothelial ETB receptors may lead to the release of endothelium-derived relaxing factors (nitric oxide and prostanoids). Nonvascular ETB receptors in organs including the kidney may beneficially clear ET-1 from the circulation.

ET stimulates proliferation in a number of different cell types, including smooth muscle cells (mainly via the ETA subtype) and astrocytes (via

ETB). In most of these cells, ET is thought to be co-mitogenic, potentiating the actions of other growth factors, such as platelet-derived growth factor.

Endothelins are polypeptides of 21 amino acid residues with two disulfide bridges connecting cystein residues. Three endothelins, I, Il and HI, different only by some amino acids, are described. Endotheline I (ET-1) is considered as the most active. They act on at least two types of receptors called ETA and ETB.

Endothelins are found primarily in vascular endothelium (which explains their denomination), but also in brain, kidney, intestine, adrenal gland.

Their formation is carried out from prepropeptides, preproendotheline, which is hydrolyzed by endopeptidases into pro-endothelins (39 amino acids) which, under the influence of endothelin converting enzyme, ECE, a zinc enzyme, give endothelins

An increase in plasma endothelins can be observed during arterial hypertension, myocardial infarction, congestive heart failure, Raynaud disease.

Endothelin activates ETA and ETB receptors:

• ETA, located in vascular smooth muscles, their stimulation gives vasoconstriction and a mitogenic effect. . ETB, o present in vascular smooth muscles: their activation gives vasoconstriction o present in endothelial cells: their activation leads to the release of nitric oxide, NO, and of prostacyclin and leads to vasodilation.

The vasoconstrictive effect is widely predominant.

Cardiovascular effects

Endothelins, by activating ETA and ETB receptors, elicit a general vasoconstriction of long duration, including coronary and pulmonary arteries. This long duration of action contrasts with their very short half- life, of about one minute. The vasoconstriction can be preceded by an hypotension of very short duration whose mechanism is not well known.

They increase heart rate (positive chronotropic effect) and contraction forces (positive inotropic effect).

As angiotensin, they could, by a mitogenic effect, induce development of cardiac hypertrophy and atherosclerosis.

Other effects

Endothelins, have a bronchoconstrictive effect but they do not seem to play a determining part in asthma. They constrict intestinal fibers. Endothelins elicit release of other transmitters such as nitric oxide, NOES, certain prostaglandins (prostacyclin), atrial natriuretic factor.

Endothelins act via the G proteins and phospholipase C and release of intracellular calcium; they also inhibit adenylcyclase activity.

Taking into account the generally harmful effects of endothelins, one currently seeks inhibitors of their synthesis, in particular endothelin converting enzyme inhibitors, and antagonists of their receptors.

ANTAGONISTS Antagonists are currently classified as ETA-selective, ETB-selective, or mixed antagonists that display similar affinities for both receptor subtypes. However, only ETA-selective or ETAJETB antagonists are currently being evaluated in clinical trials. The most highly selective peptide antagonists (4±5 orders of selectivity) for the ETA receptors are the cyclic pentapeptide BQ123 and the modified linear peptide FR139317.

A peptide structurally similar to FR139317 has been radiolabeled, PD151242, which displays subnanomolar affinity for the ETA subtype. BQ123 is also available as a tritiated analogue, and a non-peptide antagonist, PD164333, displays high affinity and selectivity for this subtype.

Unlike peptide antagonists, many non-peptide ETA receptor-selective antagonists have oral bioavalibility, and some may cross the blood±brain barrier. The majority are more potent than peptide antagonists, with pA₂ values of up to 10, compared with 7±8 for BQ123 or FR139317 (where PA2 is defined as - log-io of the molar concentration of an antagonist that makes it necessary to double the concentration of agonist required to elicit the original submaximal response). However, they are less selective, and plasma binding may be significant in vivo. A limited number of peptide and non-peptide ETB receptor antagonists have been developed, reflecting the lack of clinical need for this type of compound. They are less potent than ETA antagonists and display lower selectivity (usually only 1±2 orders of magnitude) for the ETB subtype. The distinction between antagonists that are ETAs elective and those that block both ETA and ETB receptors is not precise, but generally the former display greater than 100-fold selectivity for the ETA subtype and the latter less than 100-fold. These compounds are seldom reported as having equal affinity for both subtypes, and this should be taken into consideration in experimental designs.

From a pharmacological point of view, to reduce the effects of endothelins, it is possible

- to decrease its formation, by inhibition of endothelin conversion enzyme for example, but there is no drug now available.

- to directly reduce its effects by inhibition of its receptors. The first drug of this group is bosentan.

For example Bosentan is an antagonist of type A and B receptors, ETA and ETB (ET for endothelins) but it has an affinity approximately 50 times more important for type A receptors than for type B. The international common name of antagonists of endothelins receptors ends by "-sentan".

However, despite their potency, when targeting endothelin the most potent vasoconstrictor in human, endothelin antagonists display some undesired side effects such as liver enzymes elevations or drug interactions leading to limitations in their uses.

Several attempts have been made to combine their clinical uses with other pharmacological active molecules but with conflicting results, notably on safety, lack of convenience of administration (injectable vs. oral) or lack of synergistic effects. It is the goal of the present invention to provide novel combinations having higher pharmacological activities while presenting a good safety profile and/or lessening the limitations described above.

The present invention describes, provides and claims methods and compositions for treating and/or preventing one or more trouble/disease selected selected from cardiovascular diseases, pulmonary hypertension, pulmonary arterial hypertension, metabolic diseases, diabetes, chronic kidney disease, pulmonary vascular resistance, hypertension, chronic heart failure, congestive heart failure, stroke, restenosis of arteries after balloon angioplasty, stent implantation, cancer, prostate cancer, benign prostate hyperplasia, digital ulcers, pulmonary fibrosis, Raynaud's Disease, Raynaud's phenomenon, human immunodeficiency virus infection (HIV), metastatic melanoma, scleroderma, connective tissue diseases, collagen diseases, blood flow disturbances, thrombosis, asthma, asthmatic complications, bronchoconstriction, Arthritis, rheumatic and musculoskeletal diseases, diabetic complications, diabetic hyperglycaemia, diabetes-induced vascular complications, insulin resistance, defects in functional cardiac performances, obstructive sleep apnoea, sleep apnoea, dyspnoea, exercise-induced dyspnea, migraine, migraine attacks, renal diseases, renin induced diseases, renal dysplasia, nephropathies, impaired cerebral hemodynamics, fluid percussion brain injury, digital ulcers, pulmonary embolism, pulmonary thromboembolism, pulmonary complications, pulmonary fibrosis, lung transplants rejection, Vasospasm, Posttraumatic Vasospasm, Sickle Cell Disease, Alzheimer disease, Vascular dementia, Parkinson disease, autoimmune connective tissue diseases, vasculopathy, intermittent claudication, Peripheral Vascular Disease, small vessel obliterative vasculopathy complicated by secondary infections and gangrene, gangrene, hypoxia, glaucoma, open angle glaucoma, retinal damages, blood coagulation disorders, organ damages, ischemia reperfusion, ischemia reperfusion damages, organ damages following transplantation, tissue damages following transplantation, haemodialysis induced troubles, systemic lupus erythematosous, lupus anticoagulant, sepsis, chronic thromboembolic pulmonary hypertension, acute thromboembolic pulmonary hypertension, inflammation, lung alveolitis, fibrosis, idiopathic pulmonary fibrosis, proliferative diseases, progressive lung diseases, induced pulmonary fibrosis, drugs induced pulmonary fibrosis and systemic sclerosis, in which a subject in need thereof is administered a betaine and one or more endothelin antagonist.

In one embodiment the endothelin antagonist can targets and/or antagonises one or more endothelin receptor.

SUMMARY OF THE INVENTION

The invention provides pharmacological combinations of one or more betaine in therapeutically effective amount with one or more endothelin antagonist in therapeutically effective amount which favourably ameliorated patients in need. The combinations effects were more efficient than the effects of one or more endothelin antagonist when administrated alone. The combinations showed fewer side effects than the effects of one or more endothelin antagonist when administrated alone.

The invention provides compositions and methods for preventing and/or alleviating and/or inhibiting a trouble and/or a disease in a subject in need, comprising administering to said subject a betaine and one or more endothelin antagonist such as, but non limited to, bosentan (RO470203), ambrisentan, sitaxsentan (TBC 11251), tezosentan (RO 610612), darusentan (LU 135 252), enrasentan (SB 217 242), astrasentan (ABT627), TAK-044, A-127722 , A-182086, CM 020, BQ123, BQ788

FR139317, J-104132, ABT-627, BQ-153, L-749,329, SB 209670, LU

208075, J-104132, BQ3020, IRL1620, A192621 , novel peptide-based endothelin antagonists, non-peptidic endothelin antagonists and compounds structurally similar and/or with similar effects on endothelin of one or more of the preceding compounds. Others compounds, suitable for the compositions and methods of treatment of the invention, are described by Anthony P. DAVENPORT and Bruno BATTISTINI in "Classification of endothelin receptors and antagonists in clinical development" Clinical Science (2002) 103 (Suppl. 5. 48), 1 S-3S, the content of which is incorporated by reference in its entirety in the present application.

In one embodiment the troubles and/or diseases are endothelin mediated.

The general aims of the invention are to provide compositions ando methods for treating endothelin related disorders and diseases in a subject, comprising administering to a subject in need thereof a betaine and one or more endothelin receptor antagonist compound/agent.

The betaine and the endothelin antagonist and/or peptide-based endothelin antagonists may be administered sequentially, or may be co-5 administered. The betaine and the endothelin antagonist and/or peptide- based endothelin antagonists may be administered as a single dosage unit or according to different paths.

According to the invention the betaine can be partially and/or completely in slow release dosage forms and/or controlled release dosages forms0 and the endothelin antagonist and/or peptide-based endothelin antagonists may be in immediate release dosage forms. The betaine and the endothelin antagonist and/or peptide-based endothelin antagonists may be administered as a single dosage unit or according to different paths. 5 According to the invention the betaine can be partially and/or completely in slow release dosage forms and/or controlled release dosages forms and the endothelin antagonist and/or peptide-based endothelin antagonists may partially and/or completely in slow release dosage forms and/or controlled release dosages forms. The betaine and the endothelin antagonist and/or peptide-based endothelin antagonists may be administered as a single dosage unit or according to different paths

According to an other aspect, the invention provides pharmaceutical compositions and methods of treatments for improving the efficacy of one or more endothelin antagonist, consisting in administering to a subject in need thereof one or more betaine together with one or more endothelin antagonist.

According to an other aspect, the invention provides pharmaceutical compositions and methods of treatments for improving the pharmacological efficiency of one or more endothelin antagonist, consisting in administering to a subject in need thereof one or more betaine together with one or more endothelin antagonist.

According to an other aspect, the invention provides pharmaceutical compositions and methods of treatments for improving the pharmacological efficiency of one or more endothelin antagonist, consisting in administering to a subject in need thereof one or more betaine together with one or more endothelin antagonist

According to an other aspect, the invention provides pharmaceutical compositions and methods of treatments for lowering the amount needed for pharmacological effective effect of one or more endothelin antagonist, consisting in administering to a subject in need thereof one or more betaine together with one or more endothelin antagonist.

According to an other aspect, the invention provides pharmaceutical compositions and methods of treatments for lowering the side effects of one or more endothelin antagonist, consisting in administering to a subject in need thereof one or more betaine together with one or more endothelin antagonist.

According to an aspect of the invention, the invention provides combinations and/or methods for treating cancer, tumour angiogenesis, metastasis, prostate cancer or benign prostate hyperplasia (BPH) in a subject, comprising administering to a subject in need thereof a betaine and one or more endothelin antagonist.

According to another aspect of the invention the combinations and/or methods for treating cancer, tumour angiogenesis, metastasis, prostate cancer or benign prostate hyperplasia (BPH)) in a subject can further comprise an anti-cancerous agent. The compositions of the invention may be administered sequentially, or may be co-administered with the anti-cancerous agent. The compositions of the invention may be administered as a single dosage unit with the anti-cancerous agent or according to different paths.

In one embodiment, betaine alone can be combined with one or more prostaglandin such as epoprostenol (prostacyclin), iloprost, teprostinil, beraprost and their mixtures for achieving the therapeutical goals of the invention. Such combinations can be made according to the methods, dosages forms

In another embodiment, betaine alone can be combined with one or more phosphodiesterase inhibitor such as sildenafil, tadalafil or with other compounds such as losartan,, aviptadil, iloprost, teprostinil, beraprost, UK-369003, ABT-306552, PRX-08066, PulmoLAR, Gleevec (imatinib) and their mixtures for achieving the therapeutical goals of the invention.

DETAILED DESCRIPTION OF THE INVENTION

In accordance with the invention, the one or more endothelin receptor antagonist and their pharmaceutically acceptable salts can be administered substantially simultaneously with the betaine and its pharmaceutically acceptable salts (i.e., co-administered), or the two or more agents, as their pharmaceutically acceptable salts, can be administered sequentially according to a suitable schedule readily determined by one of ordinary skill in the art.

According to the invention pharmaceutical compositions and/or methods of treatments are provided in which pharmaceutical effective amounts of one or more endothelin antagonist and pharmaceutical effective amounts of one or more betaine are acting synergistically for obtaining a better pharmacological effect than each compound alone.

According to another aspect of the invention there is provided a pharmaceutical composition comprising, in synergistic effective amounts, an endothelin antagonist, and its pharmaceutically acceptable salts, and a betaine, and its pharmaceutically acceptable salts, said pharmaceutical composition as a single dosage unit. The single dosage unit can further comprise any pharmaceutically acceptable vehicle. The single dosage unit provides for simultaneous or substantially simultaneously administration of the endothelin antagonist and a betaine.

As used herein, the term "treating" is intended to mean inhibiting, reducing, preventing (e.g., prophylaxis), reversing (e.g., alleviating), ameliorating, controlling, or managing.

As used herein, the term "betaine" is intended to mean compounds of formula CH₃)₃N⁺(CH₂)_nCOO^' with n an integer from 1 to 5 pharmaceutically acceptable salts thereof, esters thereof, precursors thereof, and mixtures thereof.

The term "Betaine" as employed herein refers advantageously to compounds of formula (CH₃)₃N⁺(CH2)nCOO^" preferably glycine betaine (n = 1 - CAS Number: 107-43-7), pharmaceutically acceptable salts thereof, esters thereof, precursors thereof, and mixtures thereof. The term "Betaine" as employed refers also to lipidic betaines and betaine lipids which are structural components of membranes commonly found in ferns, mosses, fungi, amoeba, eukaryotes such as nonseed plants and algae. Betaine lipids are ether-linked, nonphosphorous glycerolipids that resemble the more commonly known phosphatidylcholine in overall structure. Most common glycerolipids are containing a diacyl-glycerol moiety to which a polar head group is attached. This head group can be a carbohydrate moiety as in the very abundant plant galactolipids or a phosphorylester as in the glycerophospholipids, the most common lipid class in animals. Betaine lipids represent a third class of glycerolipids in which a quaternary amine alcohol is bound in an ether linkage to the diacylglycerol moiety. They can be obtained by extraction, by biosynthesis or by synthesis. The betaine lipid diacylglyceryl- 0-4' - (N, N, N- trimethyl) homoserine and a closely related isoform diacylglyceryl - O-2' - (hydroxymethyl) (N, N, N- trimethyl)-β-alanine are the most common. In the scope of the present invention "lipidic betaines" and "betaine lipids" are suitable for the methods and combinations of the invention.

The term "pharmaceutically acceptable salts" is meant to include salts of the active compounds which are prepared with relatively nontoxic acids or bases, depending on the particular substituents found on the compounds described herein. When compounds of the present invention contain relatively acidic functionalities, base addition salts can be obtained by contacting the neutral form of such compounds with a sufficient amount of the desired base, either neat or in a suitable inert solvent. Examples of pharmaceutically acceptable base addition salts include sodium, potassium, calcium, ammonium, organic amino, or magnesium salt, or a similar salt. When compounds of the present invention contain relatively basic functionalities, acid addition salts can be obtained by contacting the neutral form of such compounds with a sufficient amount of the desired acid, either neat or in a suitable inert solvent. Examples of pharmaceutically acceptable acid addition salts include, but are not limited to, those derived from inorganic acids like hydrochloric, hydrobromic, nitric, carbonic, monohydrogencarbonic, phosphoric, monohydrogenphosphoric, dihydrogenphosphoric, hydriodic, sulfuric, monohydrogensulfuric, or phosphorous acids and the like, as well as the salts derived from relatively nontoxic organic acids like acetic, propionic, isobutyric, oxalic, maleic, malonic, benzoic, succinic, suberic, fumaric, mandelic, phthalic, benzenesulfonic, p-tolylsulfonic, citric, tartaric, methanesulfonic, and the like. Also included are salts of amino acids such as arginate and the like, and salts of organic acids like glucuronic or galactunoric acids and the like (see, for example, Berge, S. M., et al.,

"Pharmaceutical Salts", Journal of Pharmaceutical Science, 1977, 66, 1- 19). Certain specific compounds of the present invention contain both basic and acidic functionalities that allow the compounds to be converted into either base or acid addition salts.

The neutral forms of the compounds can be regenerated by contacting the salt with a base or acid and isolating the parent compound in the conventional manner. The parent form of the compound differs from the various salt forms in certain physical properties, such as solubility in polar solvents, but otherwise the salts are equivalent to the parent form of the compound for the purposes of the present invention.

In addition to salt forms, the present invention provides compounds, either betaine or endothelin antagonist, that are in a prodrug form. Prodrugs of the compounds described herein are those compounds that readily undergo chemical changes under physiological conditions to provide the compounds of the present invention. Additionally, prodrugs can be converted to the compounds of the present invention by in vivo, chemical or biochemical methods in an ex vivo environment. For example, prodrugs can be slowly converted to the compounds of the present invention when placed in a reservoir such as transdermal patch and/or enteral reservoir and/or an implantable reservoir with a suitable enzyme or chemical reagent.

In one embodiment one or more endothelin antagonist can be synthesised, linked, extracted and/or combined to one or more betaine moieties to form new chemical entities, such new chemical entities being advantageously used in combination with one or more betaine for achieving the goals of the present invention. Certain compounds of the present invention can exist in unsolvated forms as well as solvated forms, including hydrated forms. In general, the solvated forms are equivalent to unsolvated forms and are intended to be encompassed within the scope of the present invention. Certain compounds of the present invention can exist in multiple crystalline or amorphous forms. In general, all physical forms are equivalent for the uses contemplated by the present invention and are intended to be within the scope of the present invention.

Certain compounds of the present invention possess asymmetric carbon atoms (optical centers) or double bonds; the racemates, diastereomers, geometric isomers and individual isomers are all intended to be encompassed within the scope of the present invention.

The compounds of the present invention can also contain unnatural proportions of atomic isotopes, stable isotopes etc., at one or more of the atoms that constitute such compounds. For example, the compounds may be radiolabeled with radioactive isotopes, such as for example tritium (.sup.3 H), iodine-125 (.sup.125 I) or carbon-14 (.sup.14 C). All isotopic variations of the compounds of the present invention, whether radioactive or not, are intended to be encompassed within the scope of the present invention.

The term "prodrug" refers to compounds that are drug precursors, which, following administration, release the drug in vivo via a chemical or physiological process (e.g., a prodrug on being brought to the physiological pH is converted to the desired drug form).

"A combination amount sufficient," "an effective combination amount"

"therapeutically effective combination amount" or "an effective amount of the combination of" all refer to a combined amount of both a compound of Formula _. I and the endothelin antagonist agent that is effective to ameliorate symptoms associated with diabetic diseases. As used herein, the term "combination" of compound of Formula I with an endothelin antagonist agent means the two compounds can be delivered in a simultaneous manner, in combination therapy wherein the compound of Formula I is administered first, followed by the endothelin antagonist agent, as well as wherein the endothelin antagonist agent is delivered first, followed by a compound of Formula I. The desired result can be either a subjective relief of a symptom(s) or an objectively identifiable , improvement in the recipient of the dosage.

The terms "synergistic effective amount" refers to a combined amount of both a compound of Formula I and an endothelin antagonist agent that is effective to cause a synergistic effect. Synergy is a biological phenomenon, in which the effectiveness of two or more active components in a mixture is more than additive, i.e., the effectiveness is greater than the equivalent concentration of either component alone. In certain aspects, the effectiveness of the combination therapy of a compound of Formula I and an endothelin antagonist agent is synergistic. Thus, synergism is a result, or function, that is more than the sum of the results, or functions of individual elements.

The term "simultaneous manner" and "combination treatment" refer to an administration protocol wherein the compounds of the present invention, i.e. a betaine and at least one endothelin antagonist agent are administered within a single 24-hour period.

In one embodiment the period can be longer such as a week, a month, 3 months, 6 months, etc. Such longer periods are necessary when the compounds of the invention are administrated with implanted mini-pumps and/or devices and/or dosages forms suitable for long period deliveries in the body.

The pharmaceutical combinations of betaine and endothelin antagonists can be but non limited to, oral, parenteral, subcutaneous, inhaled, transdermal, slow release, controlled release, delayed release dosages forms suitable for oral, parenteral, subcutaneous, transdermal, rectal and vaginal administrations according to different paths. The forms, dosages forms, routes of administrations, techniques, methods of treatment as described in Inventor's applications US 20060128657, US 20060034918, US 20020065320, WO02062322, US 20040033223, WO2004049095, PCT/BE 2004/000053, BE 2004/ 0364, PCT/BE 2004/00110 are incorporated herein by reference in their entirety and claimed to be suitable for the methods of treatment of the present invention as for the realisation/manufacture of the pharmaceutical combinations of betaine and the other compounds described in the present application.

In one embodiment, the pharmaceutical combinations and dosages forms of US 20060128657, US 20060034918, US 20020065320, WO02062322,

US 20040033223, WO2004049095, PCT/BE 2004/000053, BE 2004/ 0364, PCT/BE 2004/00110 can be combined with the other compounds described in the present application.

As used herein, the term "cardiovascular diseases" is intended to encompass for example, hypertension, congestive heart failure, stroke, coronary revascularization, peripheral artery disease, fatal and non-fatal myocardial infarction, vasospasm, thrombotic events, syncope, endothelial dysfunction, atherosclerosis, angina, systemic pathogenic vascular remodeling, sexual dysfunction, or an increase in the subject's probability of acquiring any such disease.

Sepsis refers to the systemic response to an infection or to circulating bacterial products.

As used herein, the terms "endothelin antagonist" or "endothelin receptors antagonist" are intended to mean any pharmaceutically acceptable compound which effectively inhibits, prevents or blocks the actions of endothelin, either directly or indirectly, including any pharmaceutically acceptable salt, ester, or prodrug thereof. For example, an endothelin antagonist according to the invention may act at the level of inhibiting endothelin-receptor binding, inhibiting endothelin converting enzyme, inhibiting release of endothelin from endothelial cells or inhibiting post-receptor intracellular signal transduction pathways. Both peptidic and non-peptidic compounds are encompassed by this term. Numerous endothelin antagonists, such as endothelin receptor A (ET.sub.A) and endothelin receptor B (ET.sub.B) antagonists, and pharmaceutically acceptable salts thereof, have been identified and can be obtained commercially (e.g., Sigma, American Peptide Company Inc.). Attention is also directed to U.S. Pat. 5,284,828 (Hemmi et al.), U.S. Pat. 5,378,715

(Stein et al.), and U.S. Pat. 5,382,569 (Cody et al.), which describe in detail the chemical structures of various endothelin receptor antagonists, and to U.S. Pat. 5,338,726 (Shinosaki et al.), which describes the chemical structure of endothelin converting enzyme inhibitors.

For example, ET.sub.A and ET.sub.B antagonists are available commercially from various sources such as American Peptide Company Inc. Such Endothelin Antagonists suitable to be utilised in the methods and/or combinations of the present invention are:

ET.sub.A Endothelin Antagonist c(DTrp-DAsp-Pro-DVal-Leu) 88-2-10 Endothelin Receptor c(DGIU-Ala-Allo-Dlle-Leu-DTrp) 88-2-20 Antagonist

(BE18257B)

Endothelin Antagonist (JKC-301) c(Dlle-Leu-DTrp-DAsp-Pro) 88-2-30 Endothelin Antagonist (JKC-302) c(DVal-Leu-DTrp-DSer-Pro) 88-2-31

Endothelin Antagonist (BQ-610) (N,N-hexamethylene)carbamoyl-Leu- 88- 2-32 DTrp(CHO)-DTrp

Endothelin Antagonist (DGIu-Ala-DVal-Leu-DTrp) 88-2-40 (W-7338A) ET.sub.B [Cys11 , Cys 15]

Endothelin-1 (DGIu-Ala-DVal-Leu-DTrp) 88-2-41 (8-21), (1 RL-1038) [AIaH ₁ 15]

Endothelin-1 (6-21 ), Ac-Leu-Met-Asp-Lys-Glu-Ala-Tyr-Phe- 88-2-42 N-

Acetyl Ala-His-Leu-Asp-lle-lle-Trp N-Suc-[Glu9, Ala11 ,15]

Endothelin- Suc-Asp-Glu-Glu-Ala-Val-Tyr-Phe- 88-2-50 1 , (8-21), (LRL- 1620) Ala-His-Leu-Asp-lle-lle-Trp, and compounds structurally similar and/or with similar effects on endothelin to one or more of the preceding compounds.

According to the invention a preferred endothelin antagonist is Bosentan, particularly suitable for the compositions and methods described in the present invention. Bosentan is a non-peptide, orally active antagonist of both ETA and ETB receptors.

Other preferred endothelin antagonist according to the invention are endothelin receptor A antagonists (ETRA).

Other preferred endothelin antagonists according to the invention are endothelin receptors A and B antagonists (ETRA ET_A/ET_B antagonists).

The invention provides a treatment for hypertension in which such risk is reduced. In accordance with this aspect of the invention there is provided a method for treating hypertension in a subject comprising administering to the subject a betaine and an endothelin antagonist.

In accordance with yet another aspect of this invention there is provided a method for improving the efficacy of one or more endothelin antagonist, comprising administering together one or more endothelin antagonist with a betaine.

In addition to the agents listed above, examples of endothelin antagonists suitable for use in accordance with the present invention include ABT-627 (Abbott, III.), Bosentan (Ro 47-0203; Roche, N.J.) and SB209670 (SmithKline Beecham, Pa.), and GTN. Pharmaceutical Formulations

The ratios betaine/endothelin antagonists can vary from 4:1 to 100:1 based on dry weight, preferably between 60:1 and 40:1.

Such compositions comprise advantageously more than 98% by weight betaine (especially glycine betaine), preferably more than 95% by weight betaine (especially glycine betaine), most preferably between 90% and 85% by weight betaine (glycine betaine), such as 80 %by weight, 75% by weight, 70 % by weight, 65 % by weight, 60 % by weight, 55% by weight, 50% by weight. Higher betaine content is possible in specific case, such as 98,5 %% by weight, 99 % by weight, etc

Pharmaceutical formulations for the administration of one or more endothelin antagonist in combination with a betaine in accordance with the methods of the present invention may take the form of ointments, transdermal patches, transbuccal patches, injectables, nasal inhalant forms, spray forms for deep lung delivery through the mouth, orally administered ingestible tablets and capsules, sachets, pouches, tablets or lozenges, slow release formulations, controlled release formulations, "lollipop" formulations for administration through the oral mucosal tissue. The latter formulations included tablets, lozenges and the like which are dissolved while being held on or under the tongue, or in the buccal pouch.

The pharmaceutical compositions of the present invention comprise a therapeutically effective amount of an endothelin antagonist in combination with a therapeutically effective amount of betaine formulated together with one or more pharmaceutically acceptable carriers. As used wherein, the term "pharmaceutically acceptable carrier" means a nontoxic, inert solid, semi-solid or liquid filler, diluent, encapsulating material or formulation auxiliary of any type. Some examples of materials which can serve as pharmaceutically acceptable carriers are sugars such as lactose, glucose and sucrose; starches such as corn starch and potato starch; cellulose and its derivatives such as sodium carboxymethyl cellulose, ethyl cellulose and cellulose acetate; powdered tragacanth; malt; gelatin; talc; excipients such as cocoa butter and suppository waxes; oils such as peanut oil, cottonseed oil; safflower oil; sesame oil; olive oil; corn oil and soybean oil; glycols; such as propylene glycol; esters such as ethyl oleate and ethyl laurate; agar; buffering agents such as magnesium hydroxide and aluminum hydroxide; alginic acid; pyrogen- free water; isotonic saline; Ringer's solution; ethyl alcohol, and phosphate buffer solutions, as well as other non-toxic compatible lubricants such as sodium lauryl sulfate and magnesium stearate, as well as coloring agents, releasing agents, coating agents, sweetening, flavoring and perfuming agents, preservatives and antioxidants can also be present in the composition, according to the judgment of the formulator. The pharmaceutical compositions of this invention can be administered to humans and other animals orally, rectally, parenterally, intracisternally, intravaginally, intraperitoneally, topically (as by powders, ointments, or drops), supralingually (on the tongue) sublingually (under the tongue), buccally (held in the buccal pouch), or as an oral or nasal spray. The oral spray may be in the form of a powder or mist which is delivered to the deep lungs by oral inhalation.

Liquid dosage forms for oral administration include pharmaceutically acceptable emulsions, microemulsions, solutions, suspensions, syrups and elixirs. In addition to the active compounds, the liquid dosage forms may contain inert diluents commonly used in the art such as, for example, water or other solvents, solubilizing agents and emulsifiers such as ethyl alcohol, isopropyl alcohol, ethyl carbonate, ethyl acetate, benzyl alcohol, benzyl benzoate, propylene glycol, 1 ,3-butylene glycol, dimethylformamide, oils (in particular, cottonseed, groundnut, corn, germ, olive, castor, and sesame oils), glycerol, tetrahydrofurfuryl alcohol, polyethylene glycols and fatty acid esters of sorbitan, and mixtures thereof. Besides inert diluents, the oral compositions can also include adjuvants such as wetting agents, emulsifying and suspending agents, sweetening, flavoring, and perfuming agents. Injectable preparations, for example, sterile injectable aqueous or oleaginous suspensions may be formulated according to the known art using suitable dispersing or wetting agents and suspending agents. The sterile injectable preparation may also be a sterile injectable solution, suspension or emulsion in a nontoxic parenterally acceptable diluent or solvent, for example, as a solution in 1 ,3-butanediol. Among the acceptable vehicles and solvents that may be employed are water, Ringer's solution, U.S. P. and isotonic sodium chloride solution. In addition, sterile, fixed oils are conventionally employed as a solvent or suspending medium. For this purpose any bland fixed oil can be employed including synthetic mono- or diglycerides. In addition, fatty acids such as oleic acid are used in the preparation of injectables.

The injectable formulations can be sterilized, for example, by filtration through a bacterial-retaining filter, or by incorporating sterilizing agents in the form of sterile solid compositions which can be dissolved or dispersed in sterile water or other sterile injectable medium prior to use.

In cases where it is desirable to prolong the effect of the drug, the absorption of the drug from subcutaneous or intramuscular injection can be slowed. This may be accomplished by the use of a liquid suspension of crystalline or amorphous material with poor water solubility. The rate of absorption of the drug then depends upon its rate of dissolution which, in turn, may depend upon crystal size and crystalline form. Alternatively, delayed absorption of a parenterally administered drug form is accomplished by dissolving or suspending the drug in an oil vehicle.

Injectable depot forms are made by forming micro-encapsulated matrices of the drug in biodegradable polymers such as polylactide-polyglycolide. Depending upon the ratio of drug to polymer and the nature of the particular polymer employed, the rate of drug release can be controlled. Examples of other biodegradable polymers include poly(orthoesters) and poly(anhydrides). Depot injectable formulations are also prepared by entrapping the drug in liposomes or micro-emulsions which are compatible with body tissues.

Compositions for rectal or vaginal administration are preferably suppositories which can be prepared by mixing the compounds of this invention with suitable non-irritating excipients or carriers such as cocoa butter, polyethylene glycol or a suppository wax which are solid at ambient temperature but liquid at body temperature and therefore melt in the rectum or vaginal cavity and release the active compound.

Solid dosage forms for oral administration include capsules, tablets, pills, powders, and granules. In such solid dosage forms, the active compound is mixed with at least one inert, pharmaceutically acceptable excipient or carrier such as sodium citrate or dicalcium phosphate and/or a) fillers or extenders such as starches, lactose, sucrose, glucose, mannitol, and silicic acid, b) binders such as, for example, carboxymethylcellulose, alginates, gelatin, polyvinylpyrrolidone, sucrose, and acacia, c) humectants such as glycerol, d) disintegrating agents such as agar-agar, calcium carbonate, potato or tapioca starch, alginic acid, certain silicates, and sodium carbonate, e) solution retarding agents such as paraffin, f) absorption accelerators such as quaternary ammonium compounds, g) wetting agents such as, for example, cetyl alcohol and glycerol monostearate, h) absorbents such as kaolin and bentonite clay, and i) lubricants such as talc, calcium stearate, magnesium stearate, solid polyethylene glycols, sodium lauryl sulfate, and mixtures thereof. In the case of capsules, tablets and pills, the dosage form may also comprise buffering agents.

Solid compositions of a similar type may also be employed as fillers in soft and hard-filled gelatin capsules using such excipients as lactose or milk sugar as well as high molecular weight polyethylene glycols and the like. The solid dosage forms of tablets, dragees, capsules, pills, and granules can be prepared with coatings and shells such as enteric coatings and other coatings well known in the pharmaceutical formulating art. They may optionally contain opacifying agents and can also be of a composition that they release the active ingredient(s) only, or preferentially, in a certain part of the intestinal tract, optionally, in a delayed manner. Examples of embedding compositions which can be used include polymeric substances and waxes.

Solid compositions of a similar type may also be employed as fillers in soft and hard-filled gelatin capsules using such excipients as lactose or milk sugar as well as high molecular weight polyethylene glycols and the like. The active compounds can also be in micro-encapsulated form with one or more excipients as noted above. The solid dosage forms of tablets, dragees, capsules, pills, and granules can be prepared with coatings and shells such as enteric coatings, release controlling coatings and other coatings well known in the pharmaceutical formulating art. In such solid dosage forms the active compound may be admixed with at least one inert diluent such as sucrose, lactose or starch. Such dosage forms may also comprise, as is normal practice, additional substances other than inert diluents, e.g., tableting lubricants and other tableting aids such a magnesium stearate and microcrystalline cellulose. In the case of capsules, tablets and pills, the dosage forms may also comprise buffering agents. They may optionally contain opacifying agents and can also be of a composition that they release the active ingredient(s) only, or preferentially, in a certain part of the intestinal tract, optionally, in a delayed manner. Examples of embedding compositions which can be used include polymeric substances and waxes.

Powders and sprays can contain, in addition to the compounds of this invention, excipients such as lactose, talc, silicic acid, aluminum hydroxide, calcium silicates and polyamide powder, or mixtures of these substances. Sprays can additionally contain customary propellants such as chlorofluorohydrocarbons.

Dosage forms for topical or transdermal administration of a compound of this invention include ointments, pastes, creams, lotions, gels, powders, solutions, sprays, inhalants or patches. The active component is admixed under sterile conditions with a pharmaceutically acceptable carrier and any needed preservatives or buffers as may be required. Ophthalmic formulation, ear drops, eye ointments, powders and solutions are also contemplated as being within the scope of this invention. Transdermal patches have the added advantage of providing controlled delivery of a compound to the body. Such dosage forms can be made by dissolving or dispensing the compound in the proper medium. Absorption enhancers can also be used to increase the flux of the compound across the skin. The rate can be controlled by either providing a rate controlling membrane or by dispersing the compound in a polymer matrix or gel.

The ointments, pastes, creams and gels may contain, in addition to an active compound of this invention, excipients such as animal and vegetable fats, oils, waxes, paraffins, starch, tragacanth, cellulose derivatives, polyethylene glycols, silicones, bentonites, silicic acid, talc and zinc oxide, or mixtures thereof.

A preferred mode of delivery is one which provides a reasonably steady- state delivery of therapeutic agents, so as to maintain steady-state plasma concentrations. Such delivery avoids any substantial initial spike in plasma concentration of the agent, as it would be desirable to avoid any spike supra-threshold for negative side effects. Solid dosage forms, including sustained-release solid dosage foms, for oral administration include capsules, tablets, pills, powders, and granules, and are a preferred mode of delivery.

EXAMPLES

Examples of realisation of the invention

In said examples, bosentan has been used. However, it is obvious that said examples can be repeated with ambrisentan, sitaxsentan, tezosentan, darusentan, enrasentan, astrasentan and mixtures therof. The examples can also be repeated with other endothelin antagonists.

As betaine, anhydrous glycine betaine has been used, as being the preferred betaine. (CAS Number: 107-43-7) - (CHg)₃N⁺CH₂COO^"

Example 1

A 62.5 mg Bosentan film coated tablet (Tracleer) was placed in a capsule.

The capsule was filled then with glycine betaine powder.

The capsule was then sealed.

The capsule content was 62.5 mg Bosentan and 500 mg glycine betaine.

In other examples, the glycine betaine content was 250 mg, 500 mg, 750 mg and 1000 mg.

Example 2

The kit comprises a sealed bag containing 3g glycine betaine (powder - anhydrous form) and a film coated tablet of 62.5 mg or 125 mg Bosentan

(Tracleer®). The tablet is intended to be administered with a glass water in which glycine betaine has been dissolved. Example 3

Example 2 has been repeated except that the sealed bag comprised glycine betaine. The bag had a MVTR value inferior to 0.001 g/m² at a temperature of 38 C° and at 90% relative humidity during 24 hours.

Example 4

Examples 2 and 3 have been repeated, except that the Bosentan tablet contains 50 mg Bosentan

Example 5

Partitioned capsules have been used, so as to separate Bosentan from Glycine Betaine.

The Bosentan compartment contained 50 mg or 100 mg Bosentan, while the glycine betaine compartment contained respectively 300 mg, 500 mg,

750 mg and 1000 mg glycine betaine.

Example 6

1.6 kg betaine, 1.6 kg of a mixture comprising polyvinyl acetate and polyvinylpyrrolidone in the proportion 8:2 (Kollidon SR) and 0.02 kg of magnesium stearate have been passed through a sieve of 0.8 mm, mixed in a Turbula mixer for 10 minutes, then compacted in an eccentric press Korsch EKO so to manufacture biplanar tablets with a weight of 650 mg.

The compression strength was 3.04 kN.

The tablets were floating immediately after adding a simulated gastric fluid. The floating continued for 24 hours.

Said floating betaine tablet was attached to a Bosentan tablet of 62.5 mg (Tracleer)

Example 7

Hvdroxypropylmethylcellulose floating tablet of betaine

1.6 kg betaine, 1.6 kg of hydroxypropylmethylcellulose (Methocel K100) and 0.02 kg of magnesium stearate have been passed through a 0.8 mm sieve, mixed in a Turbula mixer for 10 minutes and then compacted in an eccentric press Korsch EKO so to manufacture biplanar tablets with a weight of 650 mg. The compression strength was 2.05 kN.

The so obtained glycine betaine tablet was attached to a Tracleer tablet of 62.5 mg Bosentan.

Example 8

Preparation of a controlled release glycine betaine granule

A mixture comprising 38% of compactable Eudragit RPL RTM₁ 60% anhydrous betaine, 1% talc stearate and 1% magnesium is prepared. After treatment in a Turbula T2C mixer, the mixture was compacted by means of an EKO apparatus of Korsch at 40,000 N/cm² and then converted into granules by means of a granulator Erweka TG Il S. The granules have then been dressed by means of a vibrator keeping only the fractions having a diameter between 100 and 150/vm.

Preparation of film coated granules of Bosentan

Bosentan granules formed by wet granulation were overcoated with an Eudragit RPL layer The so obtained granules of Bosentan and glycine betaine were used for filling capsules and for preparing tablets.

Example 9

Betaine powder (particle size of less than 250μm, in particular of less than 100μm) has been mixed with oil or wax or an alcohol solid at room temperature, for example coconut oil or stearylic alcohol. For preparing this mixture, the oil, alcohol or wax was melted so as obtain a liquid form, Betaine in powder was added to the molten oil, wax or alcohol. The weight ratio betaine / oil or wax or alcohol was varied between 0.05 and 2 (ratios lower than 1 being preferred such as 0.2, 0.3, 0.4 and 0.5).

The liquid mixture is converted in micro-spheres, for example by spraying or by extrusion - spheronization, etc. The so prepared micro-spheres have a size of 500μm, 750μm and 1 mm.

These micro-spheres have been coated in one or more steps, with a layer of a hydrophilic polymer swellable in water, but insoluble in gastric medium (for example acrylic polymer or copolymer such as Eudragit®).

The dry weight ratio hydrophilic polymer / betaine micro-sphere was varied between 1 and 10.

The so obtained balls have then been provided with a thin layer of a polymer insoluble in water, but soluble or degradable in gastric medium, for example a Eudragit polyacrylate coating.

A capsule was filled with a film coated tablet of Bosentan, with glycine powder (immediate release) and with glycine betaine microspheres (extended release).

The Bosentan content was 62.5 mg, while the glycine betaine content was from 200 and 500 mg for the immediate release powder and from 400 to 800 mg for the microspheres. The weight ratio immediate release glycine betaine / extended release glycine betaine was respectively 2:1 ; 1.25:1 ; 1 :1 ; 1 :2 and 1 :4.

Example 10

Bosentan powder (particle size of less than 250μm, in particular of less than 100μm) has been mixed with oil or wax or an alcohol solid at room temperature, for example coconut oil or stearylic alcohol. For preparing this mixture, the oil, alcohol or wax was melted so as obtain a liquid form, Bosentan in powder was added to the molten oil, wax or alcohol. The weight ratio betaine / oil or wax or alcohol was varied between 0.05 and 2 (ratios lower than 1 being preferred such as 0.2, 0.3, 0.4 and 0.5).

The liquid mixture is converted in micro-spheres, for example by spraying or by extrusion - spheronization, etc. The so prepared micro-spheres have a size of 500//m, 750/ym and 1 mm.

The dry weight ratio hydrophilic polymer / bosentan micro-sphere was varied between 1 and 10.

A capsule was filled with Bosentan microspheres with glycine powder (IE immediate release) and/or with glycine betaine microspheres (ER extended release - see example 9).

The capsule comprised for example: 50 mg Bosentan / 500 mg betaine IE

50 mg Bosentan / 200 mg betaine IE / 300 mg betaine ER Example.11

Sachets containing 3 g of anhydrous glycine betaine and 62.5 mg of Bosentan were realised. Optionally pharmaceutical acceptable excipients can be added.

Sachets material: Clay coated Paper 50g/PR 12g/ Alufoil 7 my / Co +PE 5g + 18g

Technical specifications of the coating or primary packaging material:

Example 12

Nine patients suffering from Pulmonary Arterial Hypertension and taking 125 mg Bosentan bid were randomly assigned to placebo (lactose monohydrate) 6 g bid (4 patients) or to anhydrous betaine 6 g bid (5 patients) during two weeks. They were assessed for haemodynamic variables and for 6 minutes walking test at inclusion and after the two weeks of medication with placebo or betaine. Pulmonary Artery Pressure (PAP) and Heart rate were non-invasively estimated by Doppler echocardiography method. 6MWT was performed on a treadmill. The results of the study are given in the table below:

Patients on

Betaine Week O Week 2

ECO O ECO 2 Heart rate Heart rate patients PAP PAP 0 2 6MWT 0 6MWT 2

M.S. 70 60 70 67 514 504

CB. 86 80 117 74 340 360

CM. 107 65 78 69 426 411

B.G. 65 58 66 72 406 410

FT. 84 71 85 84 360 380 mean 82,4 66,8 83,2 73,2 409,2 413

Patients on Week O Week 2 Placebo

ECO O ECO 2 Heart rate Heart rate patients PAP PAP 0 2 6MWT 0 6MWT 2

V.B. 75 75 65 70 (468) ( - ) T.S. 55 57 60 78 438 402 M.F. 36 30 106 78 524 566 PT. 70 77 92 80 195 192 mean 59 59,75 80,75 76,5 385,67 386,67 Comments: Patients on Bosentan + placebo did not show any amelioration on the tested variables after the 2 weeks of treatments, comparatively to basal values. One patient (V. B.) was not able to perform the 6 minutes walking test at the second visit, its basal value for 6MWT was not taken in account in the mean values.

On the contrary, the patients on Bosentan + Betaine showed a very significant drop in Pulmonary Arterial Pressure (PAP) from a mean of 82,4 mmHg to a mean of 66,8 mmHg. This 15,6 mmHg drop is quite significant and shows Betaine effectiveness in combination with the dual endothelin antagonist Bosentan on an essential marker of Pulmonary

Arterial Hypertension disease. Similarly, the effect of the combination therapy of Bosentan + Betaine showed a very significant drop in Heart rate of 10 beat/minute. Two weeks are a too short period of time to see changes in 6MWT, which slightly but no significantly was ameliorated (+4m). But, based on the important changes in PAP and Heart rate it is expected that significant changes may happen on longer period of time of active treatment. These results show the synergistic effects of Betaine with Bosentan a dual endothelin receptor antagonist. Hence, the invention combinations are suitable and may be efficient in all the diseases induced by pathological expressions of endothelin.

None of the patients dropped out of the study and no undesired effects were noted in the patients on Bosentan + Betaine, which is quite unusual in other therapies combining endothelin antagonists (such as Bosentan) with other medicines (e.g. Sildenafil, etc.). Hence, the combinations of the invention may represent a true benefit for Pulmonary Hypertension patients, when providing more effective treatment while preserving and/or ameliorating patients' safety, quality of life and survival.

The contents of all publications cited in this disclosure are incorporated herein by reference in their entireties. While there have been shown and described various embodiments of the present invention, it will be obvious to one of ordinary skill in the art that modifications may be made therein without departing from the scope of the invention as it is defined by the appended claims.

Claims

What I claim is:

1. Pharmaceutical composition for treating human in need, said composition comprising: - one or more endothelin antagonist compound, which is not a betaine, and

- a betaine, whereby the weight ratio betaine/ one or more endothelin antagonist compound is comprised between 4:1 and 100:1.

2. Pharmaceutical composition of claim 1 , which comprises less than 125 mg of endothelin antagonist compound.

3. Pharmaceutical composition of claim 1 , which comprises less than 100 mg of endothelin antagonist compound.

4. Pharmaceutical composition of claim 1 , which comprises less than 75 mg of endothelin antagonist compound.

5. Pharmaceutical composition of claim 1 , which comprises less than 50 mg of endothelin antagonist compound.

6. Pharmaceutical composition of claim 1 , which comprises a controlled release form of endothelin antagonist compound, said controlled release form being selected from the group consisting of slow release forms, controlled release forms, buoyant forms, extended release forms, retard release forms and combination thereof.

7. Pharmaceutical composition of claim 1 , which comprises betaine in a form adapted for being released before the release of the endothelin antagonist compound.

8. Pharmaceutical composition of claim 1 , which comprises betaine in a form adapted for being released at least 15 minutes before the release of the endothelin antagonist compound.

9. Pharmaceutical composition of claim 1 , which comprises betaine in a form adapted for being released at least 30 minutes before the release of the endothelin antagonist compound.

10. Pharmaceutical composition of claim 1 , which comprises betaine in a form adapted for being released at least 1 hour before the release of the endothelin antagonist compound.

11. Pharmaceutical composition of claim 1 , which comprises betaine in a form adapted for being released at least 2 hours before the release of the endothelin antagonist compound.

12. Pharmaceutical composition of claim 1 , which comprises an endothelin antagonist compound in a form selected from the group consisting of normal release form, immediate release forms and combinations thereof, and an endothelin antagonist compound in a form selected from the group consisting of slow release forms, extended release form, retard release forms and combinations thereof.

13. Pharmaceutical composition of claim 1 which comprises a first endothelin antagonist compound containing form selected from the group consisting of normal release form, immediate release forms and combinations thereof, and a second endothelin antagonist compound containing form selected from the group consisting of slow release forms, extended release form, retard release forms and combinations thereof, the endothelin antagonist compound of the first form being the same or different of the endothelin antagonist compound of the second containing form.

14. The composition of claim 13 wherein the weight ratio between endothelin antagonist compound of the first form/ endothelin antagonist compound of the second form being comprised between 10:1 and 1 :10.

15. The composition of claim 13 wherein the weight ratio between endothelin antagonist compound of the first form/ endothelin antagonist compound of the second form being comprised between 1 :1 and 1 :10.

16. The composition of claim 13 wherein the weight ratio between endothelin antagonist compound of the first form/ endothelin antagonist compound of the second form being comprised between 1 :2 and 1 :10.

17. Pharmaceutical composition of claim 1 , in which the endothelin antagonist is selected from the group consisting of bosentan, ambrisentan, sitaxsentan, tezosentan, darusentan, enrasentan, astrasentan and combinations thereof.

18. Pharmaceutical composition of claim 1 , in which the betaine is glycine betaine.

19. Pharmaceutical composition of claim 1 , in which the betaine has a first portion in a form selected from the group consisting of immediate release form, normal release form, and a second portion in a form selected from the group consisting of slow release forms, controlled release forms, buoyant controlled release forms, extended release forms, retard release forms and combinations thereof.

20. Pharmaceutical composition of claim 1 , in which the betaine has a first portion in a form selected from the group consisting of immediate release form, normal release form, and a second portion in a form selected from the group consisting of slow release forms, extended release forms, controlled release forms, buoyant controlled release forms, retard release forms and combinations thereof, the betaine weight ratio first portion/second portion being comprised between 10:1 and 1 :100.

21. Pharmaceutical composition of claim 1 , in which the betaine has a first portion in a form selected from the group consisting of immediate release form, normal release form, and a second portion in a form selected from the group consisting of slow release forms, extended release forms, controlled release forms, buoyant controlled release forms, retard release forms and combinations thereof, the betaine weight ratio first portion/second portion being comprised between 2:1 and 1 :20.

22. Pharmaceutical composition of claim 1 which is an oral dosage form suitable for an effective treatment for at least 12 hours.

23. Pharmaceutical composition of claim 1 , which is an oral once-a-day form.

24. Pharmaceutical composition of any of claims 1-23 for treating and/or preventing one or more trouble/disease selected from cardiovascular diseases, pulmonary hypertension, pulmonary arterial hypertension, metabolic diseases, diabetes, chronic kidney disease, pulmonary vascular resistance, hypertension, chronic heart failure, congestive heart failure, stroke, restenosis of arteries after balloon angioplasty, stent implantation, cancer, prostate cancer, benign prostate hyperplasia, digital ulcers, pulmonary fibrosis, Raynaud's Disease, Raynaud's phenomenon, human immunodeficiency virus infection (HIV), metastatic melanoma, scleroderma, connective tissue diseases, collagen diseases, blood flow disturbances, thrombosis, asthma, asthmatic complications, bronchoconstriction, Arthritis, rheumatic and musculoskeletal diseases, diabetic complications, diabetic hyperglycaemia, diabetes-induced vascular complications, insulin resistance, defects in functional cardiac performances, obstructive sleep apnoea, sleep apnoea, dyspnoea, exercise-induced dyspnea, migraine, migraine attacks, renal diseases, renin induced diseases, renal dysplasia, nephropathies, impaired cerebral hemodynamics, fluid percussion brain injury, digital ulcers, pulmonary embolism, pulmonary thromboembolism, pulmonary complications, pulmonary fibrosis, lung transplants rejection, Vasospasm, Posttraumatic Vasospasm, Sickle Cell Disease, Alzheimer disease, Vascular dementia, Parkinson disease, autoimmune connective tissue diseases, vasculopathy, intermittent claudication, Peripheral Vascular Disease, small vessel obliterative vasculopathy complicated by secondary infections and gangrene, gangrene, hypoxia, glaucoma, open angle glaucoma, retinal damages, blood coagulation disorders, organ damages, ischemia reperfusion, ischemia reperfusion damages, organ damages following transplantation, tissue damages following transplantation, haemodialysis induced troubles, systemic lupus erythematosous, lupus anticoagulant, sepsis, chronic thromboembolic pulmonary hypertension, acute thromboembolic pulmonary hypertension, inflammation, lung alveolitis, fibrosis, idiopathic pulmonary fibrosis, proliferative diseases, progressive lung diseases, induced pulmonary fibrosis, drugs induced pulmonary fibrosis and systemic sclerosis.

25. Method for treating and/or preventing one or more trouble/disease selected from cardiovascular diseases, pulmonary hypertension, pulmonary arterial hypertension, metabolic diseases, diabetes, chronic kidney disease, pulmonary vascular resistance, hypertension, chronic heart failure, congestive heart failure, stroke, restenosis of arteries after balloon angioplasty, stent implantation, cancer, prostate cancer, benign prostate hyperplasia, digital ulcers, pulmonary fibrosis, Raynaud's Disease, Raynaud's phenomenon, human immunodeficiency virus infection (HIV), metastatic melanoma, scleroderma, connective tissue diseases, collagen diseases, blood flow disturbances, thrombosis, asthma, asthmatic complications, bronchoconstriction, Arthritis, rheumatic and musculoskeletal diseases, diabetic complications, diabetic hyperglycaemia, diabetes-induced vascular complications, insulin resistance, defects in functional cardiac performances, obstructive sleep apnoea, sleep apnoea, dyspnoea, exercise-induced dyspnea, migraine, migraine attacks, renal diseases, renin induced diseases, renal dysplasia, nephropathies, impaired cerebral hemodynamics, fluid percussion brain injury, digital ulcers, pulmonary embolism, pulmonary thromboembolism, pulmonary complications, pulmonary fibrosis, lung transplants rejection, Vasospasm, Posttraumatic Vasospasm, Sickle Cell Disease, Alzheimer disease, Vascular dementia, Parkinson disease, autoimmune connective tissue diseases, vasculopathy, intermittent claudication, Peripheral Vascular Disease, small vessel obliterative vasculopathy complicated by secondary infections and gangrene, gangrene, hypoxia, glaucoma, open angle glaucoma, retinal damages, blood coagulation disorders, organ damages, ischemia reperfusion, ischemia reperfusion damages, organ damages following transplantation, tissue damages following transplantation, haemodialysis induced troubles, systemic lupus erythematosous, lupus anticoagulant, sepsis, chronic thromboembolic pulmonary hypertension, acute thromboembolic pulmonary hypertension, inflammation, lung alveolitis, fibrosis, idiopathic pulmonary fibrosis, proliferative diseases, progressive lung diseases, induced pulmonary fibrosis, drugs induced pulmonary fibrosis and systemic sclerosis, in which a subject in need thereof is administered a betaine and one or more endothelin antagonist in the form of a composition according to any one of the claims 1 to 24.

26. Pharmaceutical kit for treating human in need, said composition comprising : - one or more endothelin antagonist formulation, which comprises an endothelin antagonist which is not a betaine, and

- a betaine formulation, whereby the weight ratio betaine/endothelin antagonist compound is comprised between 4:1 and 100:1.

27. Pharmaceutical kit of claim 26, which comprises less than 125 mg of endothelin antagonist compound.

28. Pharmaceutical kit of claim 26, which comprises less than 100 mg of endothelin antagonist compound.

29. Pharmaceutical kit of claim 26, which comprises less than 75 mg of endothelin antagonist compound.

30. Pharmaceutical kit of claim 26, which comprises less than 50 mg of endothelin antagonist compound.

31. Pharmaceutical kit of claim 26, which comprises a controlled release formulation of one or more endothelin antagonist compound, said controlled release formulation being selected from the group consisting of slow release form, extended release form, controlled release forms, buoyant controlled release forms, retard release forms and combinations thereof.

32. Pharmaceutical kit of claim 26, which comprises a betaine formulation in a form adapted for being released before the release of the endothelin antagonist compound.

33. Pharmaceutical kit of claim 26, which comprises a betaine formulation in a form adapted for being released at least 15 minutes before the release of the endothelin antagonist compound.

34. Pharmaceutical kit of claim 26, which comprises a betaine formulation in a form adapted for being released at least 30 minutes before the release of the endothelin antagonist compound.

35. Pharmaceutical kit of claim 26, which comprises a betaine formulation in a form adapted for being released at least 1 hour before the release of the endothelin antagonist compound.

36. Pharmaceutical kit of claim 26, which comprises a betaine formulation in a form adapted for being released at least 2 hours before the release of the endothelin antagonist compound.

37. Pharmaceutical kit of claim 26, which comprises an endothelin antagonist formulation selected from the group consisting of normal release form, immediate release forms and combinations thereof, and an endothelin antagonist compound in a form selected from the group consisting of slow release forms, extended release form, controlled release forms, buoyant controlled release forms, retard release forms and combinations thereof.

38. Pharmaceutical kit of claim 26, which comprises a first endothelin antagonist formulation selected from the group consisting of normal release form, immediate release forms and combinations thereof, and a second endothelin antagonist formulation selected from the group consisting of slow release forms, extended release form, controlled release forms, buoyant controlled release forms, retard release forms and combinations thereof.

39. Pharmaceutical kit of claim 26, which comprises a first endothelin antagonist formulation selected from the group consisting of normal release form, immediate release forms and combinations thereof, and a second endothelin antagonist formulation selected from the group consisting of slow release forms, extended release form, controlled release forms, buoyant controlled release forms, retard release forms and combinations thereof, the endothelin antagonist compound of the first form being the same or different of the endothelin antagonist compound of the second containing form.

40. The composition kit of claim 38 wherein the weight ratio between endothelin antagonist compound of the first formulation/ endothelin antagonist compound of the second formulation being comprised between 1 :1 and 1 :10.

41. The composition kit of claim 38 wherein the weight ratio between endothelin antagonist compound of the first formulation/ endothelin antagonist compound of the second formulation being comprised between 1 :2 and 1 :10.

42. Pharmaceutical kit of claim 26, in which the endothelin antagonist is selected from the group consisting of bosentan, ambrisentan, sitaxsentan, tezosentan, darusentan, enrasentan, astrasentan and combinations thereof.

43. Pharmaceutical kit of claim 26, in which the betaine is glycine betaine.

44. Pharmaceutical kit of claim 26, in which the betaine formulation has a first portion in a form selected from the group consisting of immediate release forms, normal release forms, and a second portion in a form selected from the group consisting of slow release forms, controlled release forms, buoyant controlled release forms, extended release forms, retard release forms and combinations thereof.

45. Pharmaceutical kit of claim 26, in which the betaine formulation has a first portion in a form selected from the group consisting of immediate release forms, normal release forms, and a second portion in a form selected from the group consisting of slow release forms, controlled release forms, buoyant controlled release forms, extended release forms, retard release forms and combinations thereof, the betaine weight ratio first portion/second portion being comprised between 10:1 and 1 :100.

46. Pharmaceutical kit of claim 26, in which the betaine formulation has a first portion in a form selected from the group consisting of immediate release form, normal release form, and a second portion in a form selected from the group consisting of slow release forms, controlled release forms, buoyant controlled release forms, extended release forms, retard release forms and combinations thereof, the betaine weight ratio first portion/second portion being comprised between 2:1 and 1 :20.

47. Pharmaceutical kit of claim 26 which is adapted for an oral dosage suitable for an effective treatment for at least 12 hours.

48. Pharmaceutical kit of claim 26, which is adapted for an oral once-a-day dosage.

49. Pharmaceutical kit of any of claims 26-49 for treating and/or preventing one or more trouble/disease selected from cardiovascular diseases, pulmonary hypertension, pulmonary arterial hypertension, metabolic diseases, diabetes, chronic kidney disease, pulmonary vascular resistance, hypertension, chronic heart failure, congestive heart failure, stroke, restenosis of arteries after balloon angioplasty, stent implantation, cancer, prostate cancer, benign prostate hyperplasia, digital ulcers, pulmonary fibrosis, Raynaud's Disease, Raynaud's phenomenon, human immunodeficiency virus infection (HIV), metastatic melanoma, scleroderma, connective tissue diseases, collagen diseases, blood flow disturbances, thrombosis, asthma, asthmatic complications, bronchoconstriction, Arthritis, rheumatic and musculoskeletal diseases, diabetic complications, diabetic hyperglycaemia, diabetes-induced vascular complications, insulin resistance, defects in functional cardiac performances, obstructive sleep apnoea, sleep apnoea, dyspnoea, exercise-induced dyspnea, migraine, migraine attacks, renal diseases, renin induced diseases, renal dysplasia, nephropathies, impaired cerebral hemodynamics, fluid percussion brain injury, digital ulcers, pulmonary embolism, pulmonary thromboembolism, pulmonary complications, pulmonary fibrosis, Vasospasm, Posttraumatic Vasospasm, Sickle Cell Disease, Alzheimer disease, Vascular dementia, Parkinson disease, autoimmune connective tissue diseases, vasculopathy, intermittent claudication, Peripheral Vascular Disease, small vessel obliterative vasculopathy complicated by secondary infections and gangrene, gangrene, hypoxia, glaucoma, open angle glaucoma, retinal damages, blood coagulation disorders, organ damages, ischemia reperfusion, ischemia reperfusion damages, organ damages following transplantation, tissue damages following transplantation, haemodialysis induced troubles, systemic lupus erythematosous, lupus anticoagulant, sepsis, chronic thromboembolic pulmonary hypertension, acute thromboembolic pulmonary hypertension, inflammation, lung alveolitis, fibrosis, idiopathic pulmonary fibrosis, proliferative diseases, progressive lung diseases, induced pulmonary fibrosis, drugs induced pulmonary fibrosis and systemic sclerosis.

50. Method or process for treating and/or preventing one or more trouble/disease selected from cardiovascular diseases, pulmonary hypertension, pulmonary arterial hypertension, metabolic diseases, diabetes, chronic kidney disease, pulmonary vascular resistance, hypertension, chronic heart failure, congestive heart failure, stroke, restenosis of arteries after balloon angioplasty, stent implantation, cancer, prostate cancer, benign prostate hyperplasia, digital ulcers, pulmonary fibrosis, Raynaud's Disease, Raynaud's phenomenon, human immunodeficiency virus infection (HIV), metastatic melanoma, scleroderma, connective tissue diseases, collagen diseases, blood flow disturbances, thrombosis, asthma, asthmatic complications, bronchoconstriction, Arthritis, rheumatic and musculoskeletal diseases, diabetic complications, diabetic hyperglycaemia, diabetes-induced vascular complications, insulin resistance, defects in functional cardiac performances, obstructive sleep apnoea, sleep apnoea, dyspnoea, exercise-induced dyspnea, migraine, migraine attacks, renal diseases, renin induced diseases, renal dysplasia, nephropathies, impaired cerebral hemodynamics, fluid percussion brain injury, digital ulcers, pulmonary embolism, pulmonary thromboembolism, pulmonary complications, pulmonary fibrosis, Vasospasm, Posttraumatic Vasospasm, Sickle Cell Disease, Alzheimer disease, Vascular dementia, Parkinson disease, autoimmune connective tissue diseases, vasculopathy, intermittent claudication, Peripheral Vascular Disease, small vessel obliterative vasculopathy complicated by secondary infections and gangrene, gangrene, hypoxia, glaucoma, open angle glaucoma, retinal damages, blood coagulation disorders, organ damages, ischemia reperfusion, ischemia reperfusion damages, organ damages following transplantation, tissue damages following transplantation, haemodialysis induced troubles, systemic lupus erythematosous, lupus anticoagulant, sepsis, chronic thromboembolic pulmonary hypertension, acute thromboembolic pulmonary hypertension, inflammation, lung alveolitis, fibrosis, idiopathic pulmonary fibrosis, proliferative diseases, progressive lung diseases, induced pulmonary fibrosis, drugs induced pulmonary fibrosis and systemic sclerosis and combinations thereof, in a human, in which said human is administered with :

- an effective amount of an endothelin antagonist compound, which is not a betaine, and - an effective amount of a betaine administered to said patient at most 12hours after the administration of the endothelin antagonist, whereby the weight ratio betaine/endothelin antagonist compound is comprised between 4:1 and 100:1.

51. The process of claim 50, which comprises the step of administering a daily dose of less than 250 mg of endothelin antagonist compound.

52. The process of claim 50, which comprises the step of administering a daily dose of less than 200 mg of endothelin antagonist compound.

53. The process of claim 50, which comprises the step of administering a daily dose of less than 150 mg of endothelin antagonist compound.

54. The process of claim 50, which comprises the step of administering a daily dose of less than 100 mg of endothelin antagonist compound.

55. The process of claim 50, which comprises the step of administering a controlled release form of endothelin antagonist compound, said controlled release form being selected from the group consisting of slow release forms, extended release forms, controlled release forms, buoyant controlled release forms, retard release forms and combination thereof.

56. The process of claim 50, which comprises the step of administering betaine in a form adapted for being released before the release of the endothelin antagonist compound.

57. The process of claim 50, which comprises the step of administering betaine in a form adapted for being released at least 15 minutes before the release of the endothelin antagonist compound.

58. The process of claim 50, which comprises the step of administering betaine in a form adapted for being released at least 30 minutes before the release of the endothelin antagonist compound.

59. The process of claim 50, which comprises the step of administering betaine in a form adapted for being released at least 1 hour before the release of the endothelin antagonist compound.

60. The process of claim 50, which comprises the step of administering betaine in a form adapted for being released at least 2 hours before the release of the endothelin antagonist compound.

61. The process of claim 50, which comprises the step of administering a first endothelin antagonist form selected from the group consisting of normal release forms, immediate release forms and combinations thereof, and a second endothelin antagonist form selected from the group consisting of slow release forms, extended release forms, controlled release forms, buoyant controlled release forms, retard release forms and combinations thereof.

62. The process of claim 50, which comprises the step of administering a first endothelin antagonist form selected from the group consisting of normal release forms, immediate release forms and combinations thereof, and a second endothelin antagonist form selected from the group consisting of slow release forms, extended release forms, controlled release forms, buoyant controlled release forms, retard release forms and combinations thereof, the weight ratio endothelin antagonist of the first form/ endothelin antagonist of the second form being comprised between 10:1 and 1 :10.

63. The process of claim 50, which comprises the step of administering a first endothelin antagonist form selected from the group consisting of normal release form, immediate release forms and combinations thereof, and a second endothelin antagonist form selected from the group consisting of slow release forms, extended release form, controlled release forms, buoyant controlled release forms, retard release forms and combinations thereof, the weight ratio endothelin antagonist of the first form/ endothelin antagonist of the second form being comprised between 1 :1 and 1 :10.

64. The process of claim 50, which comprises the step of administering a first endothelin antagonist form selected from the group consisting of normal release forms, immediate release forms and combinations thereof, and a second endothelin antagonist form selected from the group consisting of slow release forms, extended release forms, controlled release forms, buoyant controlled release forms, retard release forms and combinations thereof, the weight ratio endothelin antagonist of the first form/ endothelin antagonist of the second form being comprised between 1 :2 and 1 :10.

65. The process of claim 50, in which the endothelin antagonist is selected from the group consisting of bosentan, ambrisentan, sitaxsentan, tezosentan, darusentan, enrasentan, astrasentan and mixtures thereof.

66. The process of claim 50, in which the betaine is glycine betaine.

67. The process of claim 50, which comprises the step of administering an effective amount of betaine for controlling the liver elimination of the endothelin antagonist compound.

68. The process of claim 50, which comprises the step of administering a daily dose of less than 250 mg of endothelin antagonist compound.

69. The process of claim 50, which comprises the step of administering a daily dose of less than 200 mg of endothelin antagonist compound.

70. The process of claim 50, which comprises the step of administering a daily dose of less than 150 mg of endothelin antagonist compound.

71. The process of claim 50, which comprises the step of administering a daily dose of less than 100 mg of endothelin antagonist compound.

72. The process of claim 50, which comprises the step of administering a controlled release form of endothelin antagonist compound, said controlled release form being selected from the group consisting of slow release forms, extended release forms, controlled release forms, buoyant controlled release forms, retard release forms and combination thereof.

73. The process of claim 50, which comprises the step of administering betaine in a form adapted for being released before the release of the endothelin antagonist compound.

74. Pharmaceutical composition of claim 1 , in which the betaine has a first portion in a form selected from the group consisting of immediate release forms, normal release forms, and a second portion in a form selected from the group consisting of slow release forms, extended release forms, controlled release forms, buoyant controlled release forms, retard release forms and combinations thereof.

75. Pharmaceutical kit of claim 26, in which the betaine formulation has a first portion in a form selected from the group consisting of immediate release forms, normal release forms, and a second portion in a form selected from the group consisting of slow release forms, extended release forms, controlled release forms, buoyant controlled release forms, retard release forms and combinations thereof, the betaine weight ratio first portion/second portion being comprised between 10:1 and 1 :100.

76. Pharmaceutical kit of claim 26, in which the betaine formulation has a first portion in a form selected from the group consisting of immediate release forms, normal release forms, and a second portion in a form selected from the group consisting of slow release forms, extended release forms, controlled release forms, buoyant controlled release forms, retard release forms and combinations thereof, the betaine weight ratio first portion/second portion being comprised between 2:1 and 1 :20.

77. Method or Process for treating human with pulmonary hypertension, in which said human is administered with :

- an effective amount of an endothelin antagonist compound, which is not a betaine, and

- an effective amount of a betaine administered to said patient whereby the weight ratio betaine/endothelin antagonist compound is comprised between 4:1 and 100:1.

78. The process of claim 77, which comprises the step of administering betaine in a form adapted for being released at least 15 minutes before the release of the endothelin antagonist compound.

79. Pharmaceutical composition of claim 1 or kit of claim 26, which comprises an effective amount of betaine for enhancing the pharmacological effects of one or more endothelin antagonist compound selected from the group consisting of bosentan, ambrisentan, sitaxsentan, tezosentan, darusentan, enrasentan and astrasentan and mixtures thereof.

80. Pharmaceutical composition of claim 1 or kit of claim 26, which comprises an effective amount of betaine for lowering the side effects of one or more endothelin antagonist compound selected from the group consisting of bosentan, ambrisentan, sitaxsentan, tezosentan, darusentan, enrasentan and astrasentan and mixtures thereof.

81. Pharmaceutical composition of claims 79 and 80 which comprises an effective amount of betaine for lowering the side effects and for enhancing the pharmacological effects of one or more endothelin antagonist compound selected from the group consisting of of bosentan, ambrisentan, sitaxsentan, tezosentan, darusentan, enrasentan and astrasentan and mixtures thereof.

82. Pharmaceutical composition of claim 1 or kit of claim 26, which comprises an effective amount of betaine for controlling the liver elimination of one or more endothelin antagonist compound.

83. Pharmaceutical composition which comprises a first endothelin antagonist compound containing form selected from the group consisting of normal release form, immediate release forms and combinations thereof, and a second endothelin antagonist compound containing form selected from the group consisting of slow release forms, extended release form, controlled release forms, buoyant controlled release forms, retard release forms and combinations thereof, the endothelin antagonist compound of the first form being the same or different of the endothelin antagonist compound of the second containing form.

84. The composition of claim 83 wherein the weight ratio between the first endothelin antagonist compound of the first form/ endothelin antagonist compound of the second form being comprised between 10:1 and 1 :10.

85.A pharmaceutical unit dosage form of the compositions of any of claims 1-23, said dosage form being selected from the group consisting of sachets, pouches, blisters and bags, wherein the pharmaceutical unit dosage form is provided with moisture barrier property defined by an increase of weight of the composition of less than 1% after storage of the unit dosage form in sealed condition in an environment with a temperature of 38°C and a relative humidity of 90% during 30 days.

86. The composition of claim 85 wherein the compositions are submitted to a drying process before being sealed in the pharmaceutical unit dosage form which is provided with a moisture barrier property defined by an increase of weight of the compositions of less than 1 % after storage of the unit dosage form in sealed condition in an environment with a temperature of 38°C and a relative humidity of 90% during 30 days.

87. Pharmaceutical unit dosage form of any of claims 1 -23, said dosage form being selected from the group consisting of sachets, pouches, blisters and bags, wherein the pharmaceutical unit dosage form is provided with moisture barrier property defined by an increase of weight of the composition of less than 1% after storage of the unit dosage form in sealed condition in an environment with a temperature of 38°C and a relative humidity of 90% for 30 days.

88. Pharmaceutical unit dosage form of any of claims 1 -23, said dosage form being selected from the group consisting of sachets, pouches, blisters and bags, wherein the pharmaceutical unit dosage form is provided with moisture barrier property defined by an MVTR value inferior to 0.2g/m², advantageously inferior to 0.1 g/m², preferably inferior to 0.01 g/m², more preferably inferior to 0.001 g/m², specifically inferior to 0.0001 g/m² at a temperature of 38 C° and at 90% relative humidity during 24 hours.

89. The pharmaceutical unit dosage form of claims 85 to 88 wherein the tensile strength, the tearing strength and the coefficients of friction of the packaging material are selected as to augment the pharmaceutical unit dosage form compliance.

90. The pharmaceutical unit dosage form of claims 85 to 89 comprising oxygen and/or a light barrier.

91.The use of pharmaceutical compositions, according to any of the claims 1 to 90, for lowering pulmonary arterial pressure in a patient in need.

92. The use of pharmaceutical compositions, according to any of the claims 1 to 90, for lowering heart rate in a patient in need.