5 10 15 20 CA 2890081 2020-03-06 -1- Uses of Bremelanotide in Therapy for Female Sexual Dysfunction BACKGROUND OF THE INVENTION Field of the Invention (Technical Field): The present invention relates to formulations and methods for treatment of sexual dysfunction, including female sexual dysfunction, by administration of selected dosesofa melanocortin agonist. In particular, the present invention relates to methods for the treatment of female sexual dysfunction while reducing or minimizing side-effects, or adverse effects, associated with the administration of melanocortin agonists. More specifically, the invention relates to the pharmaceutical compositions in which the melanocortin agonist is bremelanotide and methods in which these pharmaceutical compositions are administered to patients for the treatment of female sexual dysfunction, including specifically female sexual dysfunction in premenopausal women, while reducing or minimizing side effects. Description of Related Art: Note that the following discussion refers to a number of publications by author(s) and year of publication, and that due to recent publication dates certain publications are not to be considered as prior art vis-a-vis the present invention. Discussion of such publications herein is given for more complete background and is not to be construed as an admission that such publications are prior art for patentability determination purposes. 5 10 15 20 25 CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -2- ftis known that agonists of the melanocortin receptor, and particular melanocortin 4 receptor (MC4-R) agonists, may be employed for treatment of sexual dysfunction. See, for example,lH T Van der Ploeg W.J. Martin, A.D. Howard, R.P Nargund st a) . A role for the melanocortin 4 receptor in sexual function. Proc. Natl. Acad. Set. USA 99:11381-86 (2002). The cyclic, heptapeptide melanocortin receptor agonist Ac-Nle-cydo(-Asp-His-D-Phe-Arg-Trp-Lys)-OH, with the USAN adopted name bremelanotide and formerly known as PT-141, as further disclosed in U.S. Patent Nos. 6,579,968 and 6,794,489, has been employed in clinical trials for sexual dysfunction, including both male erectile dysfunction (ED) and female sexual dysfunction or disorder (PSD). There has been substantial progress in the definition and classification of the range of disorders that comprise FSD, The Diagnostic and Statistical Manual of Mental Disorders,4* edition (DSM-iV) recognizes four major disorders that define ISO decreased sexual desire, decreased sexual arousal, dyspareunie, and difficulty in achieving orgasm. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4* ed, text revision ed. Washington, DC: American Psychiatric Publishing, Inc . 2000. In the United States approximately 43% of adult women experience some form of female sexual arousal disorder (FSAD) and/or hypoactive sexual desire disorder (HSDD), with approximately 22% of these women reporting being distressed by their sexual dysfunction. E.O. Laumann, A. Paik and R.C. Rosen, Sexual dysfunction in the United States: prevalence and predictors. JAMA 281:537-544 (1999); and, J.L Shifted, B.U. Monz,PA. Russo, A, Se^efi and C.B. Johannes, Sexual problems and distress in United States women: prevalence and correlates. Obstet Gynecol 112:970-978 (2008). The current Diagnostic and Statistical Manna! of Mental Disorders, Fifth Edition (DSM-5), released in May 2013 by the American Psychiatric Association, revised the classification of female sexual dysfunction, replacing FSAD and HSDD with a new diagnosis of female sexual interest and arousal disorder (FSI/AD). and expanding the current concept of FSD to include receptivity to and initiation of sexual activity as part of the diagnostic heuristic. However, definitions of FSAD and HSDD remain In use, and are consistent with the description of female sexual dysfunction in the current version of the International Classification of Diseases (ICD-10). CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -3- Sexual therapy and education presently form the basis of treatment for FSAD and/or HSDD. Pharmaceutical treatments are limited; no drug is currently approved in the United States and one drug was approved in the European Union but subsequently withdrawn {INTRINSA* a testosterone transdermai patch previously marketed by Warner Chiicott). 5 The female sexual response cycle is complex and dependent on physioiogical, psychological and social factors. For many women, spontaneous desire is not the motivating factor to engage in sexual activity. Frequently, desire is a consequence of subjective arousal caused by avariety of sexual stvnub An understanding of the female sexual response cycle provides a basis for the design and development of pharmacological interventions for treating FSAD and/or HSDD. 10 The mechanisms and corresponding pharmaceutical therapies underlying female sexual response are different from those underlying male sexual response. For instance, male sexual responseinvolves both central nervous system function as well as nitric oxide production leading to an increasein blood How to the penis. Conversely, female sexual response is dominated by central nervous system function, while the nitric oxide production pathway is of minor importance compared 15 to results in men. Therefore, while therapies for treatment of mate sexual dysfunction can be targeted to either or both mechanisms of action, therapies for treatment of female sexual dysfunction typically must be targeted to and must rely on the central nervous system function, AM Shadiack, S.D. Sharma, D.C. Earle, C. Spana and TJ. Hallam, Meianocortins in the Treatment of Male and Female Sexual Dysfunction. Current Topics tn Medicinal Chemistry 7;1137-1144 (2007), Thus 20 phosphodiesterase 5 (PDE-5) inhibitors such as sildenafil, tadatefil or vardenafil areeffective in men with erectile dysfunction through a mechanism involving selective inhibition of PDE-5, thereby pieventingthe hydrolysis of cyclic guanosine monophosphate, lesuilmg in increased blood flow to toe penis. However, in women with female sexual dysfunction white POE-5 inhibitors have some effect on genital vasocongeston, the drugs have little or no effect on treatment of female sexual 25 dysfunction, including treatment of sexual arousal problems ML. Chivers and R.C. Rosen, Phosphodiesterase type 5 inhibitors and female sexual response: faulty protocols or paradigms? 2. Sex. Med. 7:858-72 (2010). 5 10 15 20 CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 25 43:370-375 (2004); U. Nordheim, JR Nicholson, K. Dokiadny, P Dunant and K.G. Hofbauer, Cardiovascular responses to melanocortin 4-receptor stimulation in conscious unrestrained normotensive rats. Peptides 27:438-443 (2006). -4- 8oth animal and human studies have suggested that bremelanotide has central nervous system effects unrelated to local genital vasocongestion. In animal studies utilizing female rats, a selective pharmacological effect on appetitive sexual behavior was observed, with subcutaneous injections of bremelanotide inducing the immediate-early gene product Fos in a variety of limbic and hypothaiamic structures, and increasing dopamine release in the medial preoptic area. J G Pfaus, A. Shadiack, T. Van Soest, M. Tse and P. Molinoff, Selective facilitation of sexual solicitaëon in the female rat by a melanocortin receptor agonist. Proc Natl. Acad. Sci. USA 101:10201-4 (2004); J. Pfaus, F, Giuliano and H. Gelez. Bremelanotide; an overview of preclinical CNS effects on female sekuai dysfunction. J. Sex. Med. 4.269-279 (2007), In humans, statistically relevant reported feelings of sexuai arousal in women diagnosed with sexual arousal disorder were observed foilowing a single intranasai dose of 20 mg of bremelanotide, but without statistically relevant differences, compared to placebo, in vaginal pulse amplitude measures. L.E. Diamond, O.C. Earle, J.R. Heiman. R.C. Rosen. M.A. Perelman and R. Haming, An effect on the subjective sexual response in premenopausal women with sexual arousal disorder by bremelanotide (PT-141), a melanocortin receptor agonist. J. Sex. Med. 3:628-638 (2006) This is in contrast to the effect in men diagnosed with erectile dysfunction, where statistically significant erectile response compared to placebo, as determined by a plethysographto device measuring penile responses, with concomitant increased blood flow in the genital region, were seen with subcutaneous injection of either a 4 or 6mg dose of bremelanotide Shadiack, 2007, supra it has been reported in ths literature that MC4R agonists induce an adrenergic response, resulting in an increase in blood pressure and heart rate. See, for example, JJ. Kuo, AA Silva and J.E Hall, Hypothalamic melanocortin receptors and chronic regulation of arterial pressure and renal function. Hypertension 41 768-774 (2003); JJ, Kuo, A.A. da Silva, LS. Tailam and J.E. Halt Role of adrenergic activity in pressor responses to chronic melanocortin receptor activation. Hypertension CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -5- Adverse events have been observed with metanocortin agonists, inducting bremeianotide, primarily relating to an increase in blood pressure, and nausea and vomiting. both immediate and delayed. There is a need for a therapeutic method for treatment of sexual dysfunction, including but not 5 limited to FSD, by means of administrator! of a melanocortin agonist which provides the desired therapeutic benefit, but which does not induce, or does not significant!y induce, or which reduces or minimizes adverse cardiovascular and other effects, such adverse effects including but not limited to increases in systolic blood pressure, diastolic blood pressure, heart rate or incidence of nausea or vomiting, it is against this background that the invention was made. 10 BRIEF SUMMARY OF THE INVENTION Provided herein are methods for treating FSD in a female patient diagnosed with FSD and anticipating sexual activity by administration of a low dose of bremeianotide or a pharmaceutically acceptable salt thereof. The tow dose may be administered via subcutaneous injection. The low doses of bremeianotide or a pharmaceutically acceptable salt thereof as provided herein were found 15 to be efficacious, despite previous indications that a higher dose may be required to treat FSD. The low doses of bremeianotide or a pharmaceutically acceptable salt thereof as provided herein were also found to be associated with fewer side effects compared to administration of higher doses of the compound. Administration by subcutaneous injection resulted in a significantly tower %CV at peak plasma concentration In a patient population, compared to %CV at peak plasma concentration in a 20 patient population administered bremeianotide or pharmaceutscary acceptable salt thereof by intranasal administration. The compositions and methods provided herein, including, without limitation, when administered by subcutaneous injection, may additionally be associated with lower side effectscompared to intranasal administration of a comparable dose, such as a comparable dose based on peak plasma concentration within 60 minutes after administration of bremeianotide. 25 In one aspect, the invention provides a method for treating FSD in a female patient diagnosed with FSD and anticipating sexual activity, while reducing side effects associated with the administration of bremeianotide, comprising administering the female patient by subcutaneous injection a composition comprising no more than about 1.75 mg of bremeianotide or a CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -6- pharmaceuticaHy acceptable salt of bremelanotide, thereby treating FSD while reducing undesirable side effects In one aspect of this method, no more than 1,25 mg of bremeianohae or a pharmaceutically acceptable salt of bremelanotide is administered by subcutaneous injection. In another aspect, between about 1,00 and 1.75 mg of bremelanotide or a pharmaceutically acceptable 5 salt of bremeianotide is administered. In yet another aspect, between about 1 25 and 1.75 mg of bremeianotide or a pharmaceutically acceptable salt of bremelanotide is administered. The composition for subcutaneous injection may be an aqueous solution camprising acetate salt of bremeianotide and glycerin. In one aspect, the composition is an aqueous solution consisting essentially of acetate salt of bremelanotide and 2.5% glycerin (w/v). The acetate salt of 10 bremeianotide may be between about 6% and 12% (w/w) acetic acid in an aqueous solution of bremelanotide In one aspect, the composition is at a pH of about 5.0, and further comprises agents to adjust pH, which agents to adjust pH may comprise, without limitation, hydrochloric acid and sodium hydroxide. In another aspect, the undesirable side effects that are reduced are selected from the group 15 consisting of nausea, emesis, flushing and an increase in blood pressure. In one aspect, the female patient is premenopausal, and In another aspect, the female patient is postmenopausal The invention further provides for use of a formulation dose comprising no more than about 1.75 mg of bremelanotide or a phermaceuticaiiy acceptable salt ofbremelanotide in the manufacture of a subcutaneous injectable medicament for the treatment of FSD in a female patient diagnosed with 20 FSD and anticipating sexual activity. In a related aspect, the formulation dose comprises between about 1,00 and 1.75 mg of bremelanotide or a pharmaceutically acceptable salt of bremelanotide. or between about 1.25 and 1.75 mg of bremelanotide or a pharmaceutically acceptable salt of bremelanotide. in another aspect the invention provides a prefilled dose unit comprising an aqueous solution 25 of acetate salt of no more than about 1 75 mg of bremelanoiide. The prefilled dose unit may include a prefiiled syringe, or may include a cartridge adapted for use in a subcutaneous administration drug delivery device. CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -7- ln yet another aspect, the invention provides a method for treating FSD in a female patient diagnosed with FSD and anticipating sexual activity, white reducing side effects associated with the administration of bremeianotide, comprising administering the female patient by subcutaneous injection a composition comprising bremeianotide or a pharmaceutical!y acceptable salt of 5 bremeianotide in an amount sufficient to result in a peak plasma concentration within 60 minutes after administration of bremeianotide in the female patient of no more than about 120 ng/ml, thereby treating FSD while reducing undesirable side effects, in a related aspect, the invention provides a methodfor treating FSD in a female patient diagnosed with FSD and anticipating sexual activity, while reducing side effects associated with the administration of bremeianotide, comprising administering 10 the female patient by subcutaneous injection a composition comprising bremeianotide or a pharmaceutically acceptable salt of bremeianotide in an amount sufficient to result in a peak plasma concentration with 60 minutes resulting from subcutaneous administration of a dose of between about 1,0 mg and 1,75mg of bremeianotide or a pharmaceutically acceptable salt of bremeianotide, thereby treating FSD while reducing undesirable side effects 15 In yet another aspect, the invention provides a method for treating FSD in a female patient diagnosed with FSD and anticipating sexual activity, while reducing side effects associated with the administration of bremeianotide, comprising administering the female patient by subcutaneous injection a composition comprising no more than about 1.75 mg of bremeianotide or a pharmaceutically acceptable salt of bremeianotide, thereby treating FSD while reducing one or more 20 side effects compared to intranasal administration of an equivalent dosage of bremeianotide or a pharmaceutically acceptable salt of bremeianotide. In some embodiments, the side effects comprise one or more of nausea, flushing, headache, changes in systolic blood pressure, changes in diastolic blood pressure, changes in heart rate, vomiting, and hypertension. The equivalent dosage of bremeianotide or a phannaceuticaiiy acceptable sait of bremeianotide comprises a dose resulting in a 25 substantially similar peak plasma concentration within 60 minutes after administration of bremeianotide compared to subcutaneous injection of the composition comprising no more than about 1.75 mg of bremeianotide or a pharmaceutically acceptable salt of bremeianotide The substantially similar peak plasma concentration can be a mean peak plasma concentration in a patient population CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -8- of between about 60 and 120 ng/ml of bremeianotide. in one aspect of the method, no more than 1.25 mg of bremeianotide or a pharmaceutically acceptable sait of bremeianotide is administered by subcutaneous injection. In another aspect, between about 1.00 and 1.75 mg of bremeianotide or a pharmaceutically acceptable salt of bremeianotide is administered, or alternatively between about 5 1.25 and 1.75 mg of bremeianotide or a pharmaceutically acceptable salt of bremeianotide is administered. The composition of the method can be an aqueous solution comprising acetate salt of bremeianotide and glycerin, and can consist essentially of acetate salt of bremeianotide and 2,5% glycerin (w/v). In such solution, the acetate salt of bremeianotide is between about 6% and 12% (w/w) acetic add in an aqueous solution of bremeianotide. The composition can be at a pH of about 10 5.0, and further comprise one or more agents to adjust pH, including where the one or more agents to adjust pH comprise hydrochloric acid and sodium hydroxide. In the method, the female patient may be premenopausal or alternatively postmenopausal. The variability in peak plasma concentration within 60 minutes after subcutaneous injection administration is a %CV less than 30. Reduction in side effects comprises the variability in peak plasma concentration within 60 minutes after 15 subcutaneous injection administration of the composition comprising no more than about 1.75 mg of bremeianotide or a pharmaceutically acceptable salt of bremeianotide being is less than the variability in peak plasma concentration within 60 minutes after intranasal administration of bremeianotide or a pharmaceutically acceptable sait of bremeianotide. The variability in peak plasma concentration within 60 minutes after intranasal administration can be a %CV greater than 30. Variability in peak plasma 20 concentration can be determined in a patient population. In yet another aspect, the invention provides a method for treating FSD in a femate patient diagnosed with FSD and anticipating sexual activity comprising administering the female patient by subcutaneous injection a composition comprising no more than about 175 mg of bremeianotide or a pharmaceutically acceptable salt of bremeianotide, thereby treating FSD. wherein the treatment has 25 increased efficacy compared to tntranasal administration of an equivalent dosage of bremeianotide or a pharmaceutically acceptable salt of bremeianotide. la some embodiments, the increased efficacy is indicated by an increase in frequency of satisfying sexual events upon administration of the bremeianotide or pharmaceutically acceptable salt thereof. Increased efficacy may be indicated by an CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -9- increase in frequency of satisfying sexual events upon administration of the bremelanotide or pharmaceutically acceptable salt thereof, or by improved overall sexual function, including where improved overall sexual function is measured by the Female Sexual Function index, such as a Female Sexual Function Index total score improvement of 3 or greater. Increased efficacy may also 5 be indicated by reduced associated distress related to sexual dysfunction, including where reduced associated distress related to sexuai dysfunction is measured by the Female Sexuai Distress ScaieDAO. in this method, an equivalent dosage of bremelanotide or a pharmaceutically acceptable salt of bremeianotide comprises a dose resulting in a substantially similar peak plasma concentration within 60 minutes after administration of bremelanotide compared to subcutaneous injection of the 10 composition comprising no more than about 1.75 mg of bremelanotide or a pharmaceutically acceptable salt of bremelanotide. The substantially similar peak plasma concentration may be a mean peak plasma concentration of between about 60 and 120 ng/mL of bremelanotide in a patient popufation. In one aspect of the method, no more than 1,25 mg of bremelanotide or a pharmaceutically acceptable salt of bremelanotide is administered by subcutaneous injection, or 15 alternatively between about 1,00 and 175 mg of bremelanotide or a pharmaceutically acceptable salt of bremeianotide, or alternatively between about 1.25 and 1.75 mg of bremelanotide or a pharmaceutically acceptable salt of bremelanotide is administered. The composition of the method can be an aqueous solution comprising acetate salt of bremelanotide and glycerin, and can consist essentially of acetate salt of bremelanotide and 2.5% glycerin (wAr). in such solution, the acetate sail 20 of bremeianotide is between about 6% and 12% (w/w) acetic acid in an aqueous soiution of bremelanotide. The composition can be at a pH of about 5.0. and further comprise one or more agents to adjust pH, including where the one or more agents to adjust pH comprise hydrochtoriG acid and sodium hydroxide. In the method, the female patient may be premenopausal or alternatively postmenopausal. 25 In yet another aspect, the invention provides for use of a formulation dose comprising no more than about 175 mg of bremelanotide or a pharmaceutically acceptable salt of bremeianotide in the manufacture of a subcutaneous injectable medicament for the treatment of FSD in a female patient diagnosed with FSD and anticipating sexuai activity. Such formulation may comprise no more than CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -10- 1.25 mg of bremelanotide or a pharmaceutically acceptable salt of bremelanotide, and may further compose between about 1.00 and 175 mg of bremelanotide or a pharmaceutically acceptable salt of bremelanotide or alternatively between about 1 2b and 175 mg of bremelanotide or a pharmaceutically acceptable salt of bremelanotide. The formulation of this use can be an aqueous 5 solution comprising acetate sait of bremelanotide and glycerin, and can consist essentially of acefate salt of bremelanotide and 2 5% glycerin (w/v). In such solution, the acetate salt of bremelanotide is between about 6% and 12% (w/w) acetic acid in an aqueous solution of bremelanotide. The formulation can be at a pH of about 5.0, and further comprise one or more agents to adjust pH, including where the one or more agents to adjust pH comprise hydrochloric acid and sodium 10 hydroxide. A primary object of the present invention is to provide methods for the treatment of FSD which employ bremelanotide white limiting adverse events, including but not limited to increases in systolic blood pressure, diastolic blood pressure, heart rate or incidence of nausea or vomiting. Another object of the present invention is to provide methods for the treatment of FSD which 15 employ bremelanotide while reducing the incidence of adverse events, including but not limited to increases In systolic blood pressure, diastolic blood pressure, heart rate or incidence of nausea or vomiting, compared with alternative prior art doses and methods of administering bremelanotide. Another object of the present invention is to provide methods for the treatment of FSD which employ bremelanotide while minimizing adverse events, including but not limited to increases in 20 systolic blood pressure, diastolic blood pressuré, heart rate or incidence of nausea or vomiting, compared with alternative prior art doses and methods of administering bremelanotide. Another object of the present invention is to provide a dose of bremelanotide, such as a dose delivered by subcutaneous injection, which is efficacious in treating FSD but which does not induce, or which does not significantly induce, drug-associated adverse events, including but not limited to 25 increases in systolic blood pressure, diastolic blood pressure, heart rate or incidence of nausea or vomiting. Other aspects and novel features, and further scope of applicability of the present invention will be set forth in part in the detailed description to follow, taken in conjunction with the CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -11- accompanying drawings, and in part will become apparent to those skilled in the art upon examination of the following, or may be learned by practice of the invention. The aspects of the invention may be realized and attained by means of the instrumentalities and combinations particularly pointed out in the appended claims, 5 BRIEF DESCRIPTION OF THE SEVERAL. VIEWS OF THE DRAWINGS The accompanying drawings, which are incorporated into and form a part of the specification, illustrate one or more embodiments of the present invention and, together with the description, serve to explainthe principles of the invention. The drawings are only for the purpose of illustrating one or more preferred embodiments of the invention and are not to be construed as limiting the Invention. In 10 the drawings; FIG1 is a plot showing resulting peak plasma concentrations of bremeianotide, measured in ng/mL,Mowing intranasai administration of 5, 7.5, 10, 12.5, and 15 mg of bremeianotide in an aqueous solution, and subcutaneous administration 2 5 mg of bremeianotide in an aqueous solution. FIG 2 is plot showing mean plasma concentrations (in ng/mL) of bremeianotide (¥ axis) over 15 time (X axis, in hours) foilowing subcutaneous administration of 0 3 ( o ), 1.0 ( a ), 3.0( 0 j, 5.0 (triangle, apex up), 7.5 (inverted triangle, apex down) and 10 (•) mg of bremeianotideIn an aqueous solution in healthy adult males. FIG 3 is a plot showingmean plasma concentrations (in ng/mL)of bremeianotide over time following subcutaneous administration of 0.75, 1.25 and 1.75 mg of bremeianotide in an aqueous 20 solution in premenopausal women diagnosed with FSO, FIG 4A is a graph of mean change in satisfying sexual events (SSEsi from doubte-bhnd baseline to end-of-study among at-home users of double-blind study drug in the Study of Example 1. The mean absolute number of SSEs for the screening month (no-treatment month) and the baseline month (placebo month) ranged from 0. 7 to 0.8 and 1 5 to 1.9, respectively. P < 0.05 for the 1.75 mg 25 dose, as determined by Van Elteren test. FIG 4B is a graph of mean change in Female Sexual Function Index (FSFi)totalscore from double-blind baseline to end-of-study among at-home users of double-blind study drugin the Study of Exampie1. The mean absolute FSFI Score for the screening month (no-treatment month) and the 5 10 15 20 25 CA 02890081 2015-05-01 -12- baseline month (placebo month) ranged from 17.09 to 18.22 and 21.52 to 22.75, respectively. The total possible score is from 2 to 36. Higher scores indicate a greater level of sexual function. Pfor the 1.25 mg dose was < 0.05 and for the 1.75 mg dose was < 0.01, as determined by Van Elteren test. FIG 4C is a graph of mean decrease in Female Sexual Distress Scale-Desire/Arousal/Orgasm (FSDS-DAO) total score from double-blind baseline to end-of-study among at-home users of double¬ blind study drug in the study of Example 1. The mean absolute FSDS-DAO Score for the screening month (no-treatment month) and the baseline month (placebo month) ranged from 38.9 to 41.7 and 30.5 to 33.2, respectively. Total score can range from 0 to 60. The higher the score the greater the distress associated with sexual dysfunction. P < 0.001 for the 1.75 mg dose, as determined by Van Elteren test. FIG 5A is a graph of mean change in the desire sub-domain of the FSFI from double-blind baseline to end-of-study among at-home users of double-blind study drug in the study of Example 1. **p < 0.01 as determined by ANCOVA, ANOVA, or Van Elteren test. FIG 5B is a graph of mean change in the arousal sub-domain of the FSFI from double-blind baseline to end-of-study among at-home users of double-blind study drug in the study of Example 1. **p < 0.01 as determined by ANCOVA, ANOVA, or Van Elteren test. FIG 5C is a graph of mean change in the desire sub-domain of the FSDS-DAO (Item 13) from double-blind baseline to end-of-study among at-home users of double-blind study drug in the study of Example 1. **p < 0.01 as determined by ANCOVA, ANOVA, or Van Elteren test. FIG 5D is a graph of mean change in the arousal sub-domain of the FSDS-DAO (Item 14) from double-blind baseline to end-of-study among at-home users of double-blind study drug in the study of Example 1. *p < 0.05 as determined by ANCOVA, ANOVA, or Van Elteren test. FIG 6A is a graph of mean change in FSFI total score from double-blind baseline to end-ofstudy among at-home users of double-blind study drug diagnosed with mixed HSDD/FSAD in the study of Example 1. *p < 0.05 as determined by Wilcoxon rank-sum test. 5 10 15 20 25 CA 2890081 2020-03-06 -13- FIG 6B is a graph of mean change in FSFI total score from double-blind baseline to end-of-study among at-home users of double-blind study drug diagnosed with HSDD only in the study of Example 1. **p < 0.01 as determined by Wilcoxon rank-sum test. FIG 7A is a plot of mean change of FSFI total score from baseline over time for a three month period with subcutaneous administration of placebo ( ) or 0.75 ( ), 1.25 ( A ) or 1.75 ( • ) mg of bremelanotide in the study of Example 1. FIG 7B is a plot of mean change of FSDS-DAO total score change from baseline over time for a three month period with subcutaneous administration of placebo ( ) or 0.75 ( ), 1.25 ( A ) or 1.75 ( •) mg of bremelanotide in the study of Example 1. FIG 8 is a plot of Cmax (ng/mL) against AUC for zero to two hours (hours times ng/mL), utilizing combined data from visits 5 and 7 of the trial study of Example 1, illustrating that a linear relationship exists between these parameters. DETAILED DESCRIPTION OF THE INVENTION Definitions. Before proceeding with the description of the invention, certain terms are defined as set forth herein. The “amino acid” and “amino acids” used in this invention, and the terms as used in the specification and claims, include the known naturally occurring protein amino acids, which are referred to by both their common three letter abbreviation and single letter abbreviation. See generally Synthetic Peptides: A User's Guide. G. A. Grant, editor, W.H. Freeman & Co., New York, 1992, including the text and table set forth at pages 11 through 24. As set forth above, the term "amino acid" also includes stereoisomers and modifications of naturally occurring protein amino acids, non-protein amino acids, post-translationally modified amino acids, enzymatically synthesized amino acids, derivatized amino acids, constructs or structures designed to mimic amino acids, and the like. Modified and unusual amino acids are described generally in Synthetic Peptides: A User’s Guide, cited above; V. J. Hruby, F. Al-Obeidi and W. Kazmierski: Biochem. J. 268:249-262, 1990; and C. Toniolo: Int. J. Peptide Protein Res. 35:287-300, 1990. CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -14- in the listing of compounds according to the present invention, the amino acid residues have their conventional meaning as given in Chapter 2400 of the Manual of Patent £xamining Procedure, 8* Ed. Thus, “Nie" is norieucine; "Asp” is aspartic acid; "His” is histidine; "D-Phe" is D-phenylalanine; "Arg” is arginine; "Tip" is tryptophan; and ’Lys" is lysine; "Ac" refers to a peptide or amino acid 5 sequence that is acetylated [(CHS)-CO-). The term “composition”, as in pharmaceutical composition, is intended to encompass a product comprising the active ingredient(s), and the inert ingredients) that make up the carrier, as wellas any product which results, directly or indirectly, from combination, complexation or aggregation of any two or more of the ingredients, or from dissociation of one or more of the ingredients, or from 10 other types of reactions or interactions of one or more of She ingredients. Accordingly, the pharmaceutical compositions utilized in the present invention encompass any composition made by admixing an active ingredient and one or more pharmaceutically acceptable carriers. “Sexual dysfunction" means any condition that inhibits or impairs normal sexual function, including coitus. The term is not limited to physiological conditions, and includes psychogenic 15 conditions or perceived impairment without a tomia! diagnosis of pathology or disorder. Sexual dysfunction includes ED in a male mammal and PSD in a female mamma!. “Erectile dysfunction" (ED) is a disorder involving the failure of a male mammal to achieve functional erection, ejaculation, or both. Erectile dysfunction is accordingly synonymous with impotence, and includes the inability to attain or sustain an erection of sufficient rigidity for coitus. 20 “Female sexual dysfunction” (FSD) is recognized in DSM-IV as four major disorders that define FSD: decreased sexual desire, decreased sexual arousal, dyspareunia, anddifficulty in achieving orgasm. For purposes of diagnosis and therapy, FSD may be further defined to include female sexual arousal disorder (FSAD) and hypoactive sexual desire disorder (HSOD) The Draft Guidance Tor Industry, Female Sexual Dysfunction: Clinical Development of Drug Products for 25 Treatment. U.S. Food and Drug Administration. May 2000. lists four recognized components of FSD: decreased sexual desire; decreased sexual arousal; dyspareunia; and persistent difficulty in achieving or inability to achieve orgasm, with the components associated with personal distress, as determined by the affected woman. Sexual dysfunction in females can also include inhibited orgasm and CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -15- dysparainia, which is painful or difficult coitus. Female sexual dysfunction includes,bulls not limited to, a number of categories of diseases, conditions and disorders including HSDD, sexual anhedonia, sexual arousal disorder, dyspareunia and vaginismus. Hypoactive sexual desire disorder includes a disorder in which sexual fantasies and desire for sexual activity are persistently or recurrently 5 diminished or absent, causing marked distress or interpersonal difficulties. Hypoactive sexual desire disorder can be related to boredom or unhappiness in a long-standing relationship, depression, dependence on alcohol or psychoactive drugs, side effects from prescription drugs, or hormonal deficiencies. Sexual anhedonla includes decreased or absent pleasure in sexual activity. Sexual anhedonia can be caused by depression, drugs or interpersonal factors. Sexual arousal disorder can 10 be caused by reduced estrogen, illness, or treatment with diuretics, antihistamines, antidepressants, or antihypertensive agents. Dyspareunia and vaginismus are sexual pain disorders characterized by pain resulting from penetration and may be caused, for exampie, by medications which reduce lubrication, endometriosis, peivic inflammatory disease, inflammatory bowel disease or urinary tract problems. 15 By a meianocortin receptor “agonist” is meant an endogenous or drug substance or compound, including a compound such as bremelanotide. which can Interact with a meianocortin receptor and initiate a pharmacological response, including but not limited to adenyl cyclase expression, characteristic of the meianocortin receptor. By the abbreviation "%CV” is meant the coefficient of variation, which is the ratio of the 20 standard déviation (SD) to the meanexpressed as a percentage. in the specification and claims, where there is a reference to a weight of bremelanotide ora pharmaceutically acceptable salt of bremelanotide per dose (such as, e.g., administering a dose of 1.75 mg bremelanotide or a pharmaceutically acceptable salt of bremelanotide), it is to be understood that that such weight is net peptide weight, that is, net of the salt in the instance of a pharmaceutically 25 acceptable salt. Clinical Applications. The methods and pharmaceutical compositions disclosed herein can be used for both medical applications and animalhusbandry or veterinary applications. Typically, the methods are used in CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -16- humans,inciuding specifically female humans, but may also be used in other mammals'. The term "patient* isintended to denote a mammalian individual, and is so used throughout the specification and in the claims. The primary applications of this invention involve human ternate patients, but this invention may be applied to laboratory, farm, zoo, wildlife, pet, sport or other animals. Compounds of the Invention. In a preferred embodiment of the present invention, toe metanocortin receptor agonist is; Ac-Nle-cycfo(-Asp-His-D-Phe-Arg-Trp-Lys)-OH (bremelanotide) The peptide of bremelanotide has a formula of CsoHegNwOw, and a net molecular weight of 1025.18. This peptide may be synthesized by conventional means, including either solid-phase or 10 liquid-phase techniques, and purified to greater than 89% purity by HPIC, yielding a whitepowder that is a clear, colorless solution in water. The structure of bremelanotide is: Inone embodiment of the invention, bremelanotide is synthesized by solid-phase synthesis 15 and purified according to methods known in the art. Any of a number of well-known procedures utilizing a variety of resins and reagents may be used to prepare bremeianotide. Bremeianotide may be in the form of any pharmaceutically acceptable salt. Acid addition salts of the compounds of this invention are prepared in a suitable solvent from the peptide and an excess -17- of an acid, such as hydrochloric, hydrobromic, sulfuric, phosphoric, acetic, trifluoroacetic, maleic, citric, tartaric, oxalic, succinic or methanesulfonic acid. The acetate salt form is especially useful. In a preferred embodiment, bremelanotide is an acetate salt form, and is formulated in a buffered aqueous solution including glycerin, and prepackaged in a syringe and auto-injector 5 device. In alternative embodiments, bremelanotide is any pharmaceutically acceptable salt form, and is formulated in any pharmaceutically acceptable aqueous solution, the aqueous solution optionally including one or more salts, such as sodium chloride, one or more acids, such as citric acid, and one or more additional ingredients, including cellulose or derivatives thereof, saccharides or polysaccharides such as dextrose, and any of a wide variety of surfactants, chelating agents 10 and preservatives. This application is related to U.S. Patents No. 6,579,968 (Application No. 09/606,501), 6,794,489 (Application No. 10/040,547), 7,176,279 (Application No. 10/638,071), 7,235,625 (Application No. 11/139,730), 7,417,027 (Application No. 10/756,212), 7,473,760 (Application No. 11/267,271) and 7,897,721 (Application No. 12/348,489), and the teachings, including the 15 specification, claims and prosecution history. Uses of Bremelanotide. Over 2500 subjects have received bremelanotide in a total of 30 clinical trials, with bremelanotide administered via intravenous, intranasal and subcutaneous routes. The majority of studies conducted were of men diagnosed with erectile dysfunction. Bremelanotide administered intranasally demonstrated promising clinical activity in pre- and 20 postmenopausal women with FSAD. However, with intranasal administration significant variability was seen in bremelanotide Cmax and the area under the concentration-time curve (AUC) compared to subcutaneous administration, as is shown generally in FIG 1 (data derived from men administered intranasal or subcutaneous bremelanotide). In pharmacokinetic studies of subcutaneous administration of bremelanotide in a healthy 25 adult male population, quantifiable concentrations of bremelanotide were observed in plasma within 15 minutes after subcutaneous administration, with median Tmax occurring at 0.50 to 1.0 hours after administration. See FIG 2. Results of Tmax values were compared between subcutaneous CA 2890081 2020-03-06 CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -18- administration (SG) and intranasai (IN) administration of various doses of bremelanotide, as shown in FIG T. There was material and significant variability in peak plasma bremelanotide with intranasai administration, white subcutaneous injection of a dose of 2.5 mg resulted in substantially tighter peak plasma bremelanotide concentrations, with little or no excursion outside of predefined parameters. 5 intranasal bremelanotide was shown to increase sexual desire and arousal compared to placeboin both premenopausal and postmenopausal women with FSAD in two Phase 2 trials. However, use of intranasai bremelanotide was associated with increased adverse events compared to placebo in both premenopausal and postmenopausal women, with 92.5% of premenopausal subjectsreceiving bremelanotide reporting at least one adverse event, compared to 61 1%for 10 placebo,and 100% of postmenopausal subjects receiving bremelanotide reported at least one adverse event, compared to 47.7% for placebo. In the bremelanotide premenopausal arm, 42.5% of the subjects were discontinued due to hypertension, nausea, vomiting or myalgia. Subjects received a 10 mg intranasal dose of bremelanotide, with premenopausal subjects determined to have a mean plasma concentration of 88.5 ± 51.9 ng/mL and a %CV of 58 6. and postmenopausal subjects 15 determined to have a mean plasma concentration of 93,2 ± 68,5 ng/mL and a %CV of 73.5. The minimum and maximum plasma concentration levels for all women at thirty minutes post dose range from 0.0 ng/mL to 207.0 ng/mL. Subjects who experienced vomiting and/or nausea following in-clinic dosing had a substantially higher pharmacokinetic concentration of bremelanotide thansubjects who did net experience these symptoms. Furthermore, stratification of subject arousal rate and level of 20 desire success rate by pharmacokinetic concentration group showed a larger change in subject arousal rate and level of desire success rate from baseline to selected visits in subjects with a bremeianotide concentration between 50 to <100 ng/mL than subjects with a tower or higher bremelanotide concentration. Ina double-blind, placebo-controlled, single dose, dose escalation Phase 1 study to determine 25 the maximum tolerated dose tn healthy adult female subjects, doses of from 0.3 to 5.0 mg (0.3, 1.0, 3.0 and 5.0 mg) of bremelanotide were administered by subcutaneous injection. However, this study specifically excluded women with a diagnosis of FSD, and thus could not determine aneffective dose for treatment of FSD. The study did employ a measure of pharmacodynamic effect defined as an CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -19- increaseoï sexual arousal response in the presence of visual sexual stimulation as measured by vaginal blood flow with vaginal photoplethysmography (using a Geer gauge device);which measures vaginal pulse amplitude. However, by this measure a statistically significant pharmacodynamic effect was seen only in subjects receiving 3 and 5 mg of bremelanotide, with no apparent pharmacodynamic 5 effect compared to placebo or baseline seen at 0.3 or 1.0 mg doses of bremelanotide. Prior to the study disclosed hereafter as Exampie 1, no studies examining efficacy for PSD using subcutaneous administration had been conducted, in Phase 1 studies using normal female volunteers as discussed above, a pharmacodynamics effect was seen only at subcutaneous doses of 3 mg or greater of bremelanotide, 10 While not intending to be bound by any particular theory, it is believed that bremelanotide may treat F SO primarily via a central nervous system mechanism of action, with minimal innervation or action in the genital area. This mechanism of action differs from the mechanism of action in treatment of male sexual dysfunction, in which efficacy is strongly correlated to innervation or action in the genital area, and specifically inducing an erection. 15 In one aspect of invention, the variability in peak plasma concentration within 60 minutes after subcutaneous injection administration is a %CV less than about 30, or alternatively less than about 25. or alternatively less than about 20. The variability in peak plasma concentration within 60 minutes after intranasal administration is a %CV greater than about 25, or alternatively greater than about 30, or alternatively greater than about 40, or alternatively greater than about 50, or alternatively greater 20 than about 60, or alternatively greater than about 70. Adverse Events with Subcutaneous Administration. Subcutaneous dosing was tested in 5 Phased trials (3 in females, 2 in males) and one Phase 2 triai (males). The most common adverse events associated with singte-dose SC bremelanotide administration (Trials -14, -Û6. and -10) were somnolence (30%), flushing (15%), nausea (19%), and vomiting (10%). 25 In a trial in males, 1 of 6 subjects at the 5-mg dose level, 1 of 6 subjects at the 7.5 mg dose level, and 3 of 6 subjects at the 10-mg dose level experienced vomiting that was mild or moderate in intensity and delayed 6 to 15 hours. Vomiting could be resolved with administration of intramuscular CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -20- ondansetron (a S-hydroxytryptamineS antagonist). Singie subcutaneous bremeianotide dosas of 4 and 6 mgshowed improved tolerability by maie subjects with ED and preexisting hypertension. In a study with obese women, the dosing regimen included subcutaneous injections of either bremeianotide or placebo 3 times daily for 15 days for a total of 45 planned doses. On Day 1, the first 5 dose was 1.25 mg with subsequent doses of 1.0 mg. On Days 2 through 15, the first daily dose was 2,5 mg with second and third daily doses of 2.0 mg. No measure of sexual response was made in this study. Three subjects were withdrawn from the triai prematurely due to adverse events of vomiting(piacebo group), hypertension (noted prior to daily dosing, bremeianotide group), and nausea (bremeianotide group} respectively, ail of which were assessed as mild in intensity and 10 probably (vomiting and hypertension) or possibly (nausea) related to trial drug. Ail 3 events resolved by trial conclusion. Alt subjects who participated in the triât experienced at least 1 treatment-emergent adverse event and ail subjects experienced at least 1 treatment-related adverse event. Determining Efficacy. In clinical trials to determine the efficacy of drugs and therapies for treatment of FSD, any of a number of validated patient-reported outcome questionnaires are utilized. 15 These include: FSEP-R FSDS-DAO FSFI Femate Sexual Encounter Profile- RevisedFemale Sexual Distress Scale ~ Desire/Arousai/OrgasmFemale Sexual Function Index GAQ SÎDI-F WITS-9 General Assessment QuestionsSexual Interest and Desire Inventory -- FemaleWomen’s inventory of Treatment Satisfaction Electronic diary devices can be employed for use by subjects to complete questionnaires,"including but not limited to the FSEP-R questionnaire, which can be completed outside of the clinic (at home) 20 following a sexual encounter. Use of Prefilled Syringes and Auto-Injector Devices. In one aspect, a prefixed syringe may be utilized, optionally with an anta-injector device, permitting a patient to rapidly and simply seif¬ administer a subcutaneous dose of bremeianotide. Bremeianotide injection, a parenteral drug product for subcutaneous injection, is formulated in an aqueous system containing 2.5% w/v glycerin CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -21- at pH 5. It is packaged in single-use Type I glass 1ml prefixed syringes with staked one-half inch 29 gauge needles fitted with a needle shield and closed with gray Flurotec plunger stoppers. The primary container is secondarily fitted with a plunger rod for actuation and a safety device to prevent accidental access to the needle after use. Each unit is filled to deliver a minimum volume of 0.3 mL 5 The following is a list of ail components used tn the manufacture of the drug product: • Bremeianotide API • Glycerin, USP vegetable grade » Hydrochloric Acid, NF (if needed) for pH adjustment • Sodium Hydroxide, NF (if needed) for pH adjustment 10 • Water for Injection, USP or Sterile Water for Injection, USP Quantitative Composition of Bremeianotide Injection Drug Product Bremeianotide Injection (Quantity in each syringe) Component and Function 0.75 mg 1 0.3 mL1.25 mg /0.3mL 1.75 mg f 0.3 mL(5.83mg/mL)1.75 mg (2.50 mg/mL)0.75 mg (4.17 mg/mL)1.25 mg Bremeianotide API* Glycerin, USP. vegetable grade [tonicity agent] Hydrochloric Acid, NF [to adjust pH] Sodium Hydroxide, NF (to adjust pH] Water For Injection, USP [diluent and solubilizing agent] 7.5 mg 7.5 mg 7.5 mg To adjust pH To adjust pH To adjustpH To adjust pH To adjust pH To adjust pH QS to 0.3 mL QS to 0.3ml QS to 0.3 mL * Net bremeianotide (anhydrous, free base equivalent) The bremeianotide drug product for subcutaneous injection is packaged in single-use pre- 15 filled syringes with Flurotec plunger stoppers, a plunger rod for actuation, and a plastic safety device. The package components are further described below: Syringe: BD Hypak SCF 1mL Long Syringe Barrel with 29G x %" 5 Bevel needle, Formulation BD260 (Primary container closure, Sterile, Clean and Ready-to-fiil) (BD, Franklin Lakes. NJ, US) CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -22- Stopper BD Hypak NSCF 1ml Long Plunger Stopper, Formulation W4023 Fiurotec Daikyo Coated (Primary container closure, Sterile, Clean and Ready-to-fill) (BD, Franklin Lakes, NJ, US)BD Hypak 1 mL Long Plunger Rod Polypropylene (Lies outside primary container Plunger rod; 5 closure, non-steriie). (BD, Franklin Lakes, NJ, US) Auto-Injector; YpsoMate, automatic injection device for pre-filled syringe manufactured by Ypsomed (Burgdorf, Switzerland) Example 1 A multi-centered, placebo-controlled, randomized, parallel group trial with fixed dose levels 10 and designed to identify appropriate doses of bremelanotide administered by subcutaneous injection in premenopausal females with FSAD and/or HSOD, under the conditions of homa use, was conducted. Subjects received a single dose of placebo (subject-blinded) in-clinic followed by 4 weeks of subject-Winded placebo treatment at home (subjects self-administered treatment as needed). Subjects who continued to qualify for the trial then received 2 single in-clinic doses of randomized 15 treatment (double-blind: approximately one week apart), followed by 12 of double-blind treatment at home (subjects self-administered treatment as needed). Baseline characteristic of the subjects is shown in Table 1 below. Table 1. Subject Baseline Characteristics j Characteristic Placebo group (N 97} Bremelanotide groups 075 mg (N = 10Û) 1.25 mg (N = 99) 1,75 mg (N = 98) Age (years), mean(SD) 37.0 (77) 37.6 (7.8) 35.7 (7,2) 37.0 (7.6) Race,n (%) White Black I Other 75 (77%) 19 (20%) 3 (3%) 71 (71%) 25 (25%) 4(4%) 65 (66%) 32 (32%) 2 (2%) 70 (71%) 23 (23%) 5 (5%) ’ Weight at screening (lbs), mean (SD) 164.4 (42,1) 168.2 (37.9) 174.0(43.2) 179,2 (45,9)s Diagnosis, n (%) FSAD HSDD Mixed 4 (4%) 24 (25%) 69(71%) 3 (3%) 20 (20%) 77 (77%) 3 (3%) 24 (24%) 72 (73%) 2 (2%) 24 (24%) 72 (72%) Menses frequency | regular,« (%) 72 (74%) 75 (75%) 86 (87%) 79 (81%) Used oral contraception within the 30 days I before Visit 1, n (%) 12 (12%) 15 (15%) 11 (11%) 15 (15%) CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -23- = 97. FSAD, female sexual arousal disorder HSDD, hypoactive sexual desire disorder, SD, standard déviation. 5 Subjects were randomized (1 1 f 1) to one of four study treatment groups (placebo or doses with 0,75,1.25, or 175 mg net weight bremelanotide), Randomization occurred immediately prior to the first in-clinic dose of double-blind treatment, Study drug and placebo was provided as pre-filled syringes tn 0.3 mlvolume, with subjects instructed on seif-administration into the anterior thigh er abdomen. 10 Ambulatory blood pressure monitoring was conducted following both placebo and randomized treatment group in-clinic administrations. Three periods of ambulatory blood pressure monitoring were included, the first period was from before to 24 hours after a single, in-clinic doss of placebo (to establish a baseline); the second and third periods occurred from before to 24 hours after each of 2 single, in-clinic doses of double-blind treatment, administered within 14 days of each other. Blood 15 samples for pharmacokinetic analysis were collected before and at 0.5, 1.0. and 2.0 hours after each in-clinic bremelanotide single-dose treatment (double-blind only). to permit analysis of concentration¬ response relationships. Enrolled subjects were premenopausal women who met the diagnostic criteria for F8AD, HSDD. or mixed FSAD/HSDD, utilizing a diagnostic screening guide including categorization of the 20 sexual dysfunction as both acquired (vs. lifelong) and generalized (vs. situational). Subjects enrolled had previously been sexually “functional^ that Is, experienced sexual arousal during sexual activity and/or a normal level of desire at some point in the past for a period of at least 2 years. Table 2 below shews the FSD measures at double-blind baseline, which defines a modified intent to treat (modified ITT) population. 25 CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -24- Tabte 2. Subjects' FSD Measures at Double-Blind Baseline. 1 FSD parameter Placebo group(N = 91) Bremelanotide groups1.25 mg(N = 75) Û.75 mg (N « 87s) 1.75 mg (H=74F) SSEs during the 28 days before randomization Mean (SD) | Median (range) 17(1.9) 1 OfO-9] 1.9 (2.1) 1 0 (0-1Û) 1.5 (1.6) 1.ÔÎ0-8) 1.8 (2.6) 1.0(0-16] FSFI total score Mean (SO) 21.94(5.94) 22 75 (5.43) 21.52 (5.42) 21.65(4.98) FSDS-DAO total score Mean (SD) 32.1 (12.8) 30.5(12.4) 32.7 (13.8) 33 3 (12.7) ’For SSEs, N = 85 bFor SSEs, N = 73. Enrolled subjects were provided with an electronic diary system (eDiary) with instructions to complete an FSEP-R. questionnaire with each sexual encounter. At selected in-clinic visits, subjects completed other assessment questionnaires, including SIDI-F. FSDS-DAO, FSFI, GAQ and WITS-9. in addition, various vital sign measures were conducted and blood and urine samples ejected at 10 selected in-clinic visits. The primary endpoint data analysis of 327 pre-menopausal women with FSD showed a clinically meaningful and statistically significant improvement (p = 0 018) in the frequency of Satisfying Sexual Events (SSEs) in women taking bremelanotide doses (mean change from 16 at baseline increasing to 2.4; pooled 1.25 mg and 175 mg doses) versus placebo (mean change from 1.7 at 15 baseline increasing to 1.9) over the study period, resulting in a 50% increase in SSEs with bremelanotide versus 12% with placebo. The study met its primary endpoint by demonstrating a clinically meaningful and statistically significant improvement in the change from baseline fa end of studyin the number of SSEs, The measurement period was defined as the number of events during the last four weeks of treatment minus the number of events during the baseline period, with 20 outcomes reported for pooled results of women taking the two highest bremelanotide dose levels versus placebo. The following shows p values for changes in SSEs for three bremelanotide doses and pooled 1.25 and 1.75 mg bremelanotide over the measurement period: Bremelanotide (!.25 and 1.75 mg pooled vs. placebo) p = 0.0180 5 10 15 20 25 CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -25- Bremeîanotide (1.75 mg vs placebo) Bremelanotide (1.25 mg vs. placebo) Bremelanofide (0.75 mg vs placebo) p= 0.0215p - 0 0807p= 0.4430 Preliminary analysis of key secondary endpoints showed clinically meaningful and statistically significant improvement in patients who received bremelanotide vs. placebo (mean change from baseline to end of study; pooled 1.25 mg and 1.75 mg bremelanotide doses); • Improved overall sexual functioning, as measured by the Female Sexual Function Index (F St4) The F SH is a t Them questionnaire which provides for an additional measurement of changes over a longer recall period, a FSFI total score improvement (mean change of 3.55 vs. 1,88, p=Q.Q0l7) « Reduced associated distress related to sexual dysfunction, as measured by the Female Sexual Distress Scale-DAO (FSDS-DAO). The FSDS-DAO 154tem questionnaire is designed to assess and quantify the change in personal distress associated with FSD. o FSDS-DAO total score improvement (mean change of -11.1 vs.-6.8, p=0.036). The FSDS Total Score and FSFI Total Score were each significantly correlated to dose (p=0.00277 and 0.00767, respectively); the correlation between the number of SSEs and actual dose wasnot significant The relationship between key efficacy endpoints and weight-normalized dose (mg/kg) shows that the FSDS-DAO Totai Score was statistically significantly correlated fey weightnormafeed dose The FSFI Total Score trended toward a statistically significant correlation. Only the FSDS-DAO Total Score was significantly correlated with Cmax. Both FSDS-DAO TotalScore and FSFI Total Score were significantly correlated with AUC(0-2hj ^0.0485). Thus the correlation of FSDS-DAO Total Score with Cmax was statistically significant, as were the correlations for FSDSDAO Total Score and FSFI Total Score with AUC(0-2h). Accordingly, the 1.75 mg dose was the most optimal dose for efficacy. Mean pharmacokinetic parameters were determined by bremelanotide dose and visit, including Cmax determinations (the highest ng/ml concentration at either 0.5 or 1 hour post CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -26- adminfetrafion) and AUC determinations at two hours and, for a subset of subjects in eachgroup, at four hours. The resuits are shown in Table 3 below: Table 3, Mean Pharmacokinetic Parameters by Bremetanohde Dose and Visit Bremeianotide Oose (mg) Statistic Visit 5 Visit? Cmax (ng/mL) AUC(0-2h) (h-ng/mL) AUC(0-4h) (h-ng /mL) Cmax (ng/mL) AUC(0-2h) (h-ng /mL) AUC(0-4h) (hng/mLj 0.75 N 95 95 31 86 86 27 Mean 37 53 84 38 53 80 Median 36 52 80 37 52 79 %CV 27 24 23 27 24 20 Min 17 25 50 20 26 51 Max 60 85 126 78 92 120 1.25 N 96 96 31 81 81 26 Mean 60 86 138 60 84 142 Median 56 81 136 60 84 144 %CV 31 25 20 33 25 25 Min 29 42 86 18 24 39 Max 126 148 187 150 144 199 175 N 92 92 31 86 86 27 Mean 77 112 178 78 112 184 Median 78 112 179 77 111 180 %CV 25 23 29 25 25 25 Min 15 17 25 27 28 72 Max 115 171 289 127 176 276 5 %CV, coefficient of variation; AUG, area under the curve; Cmax. maximum observed concentration; AUC((Mh) was computed for fewer subjects than AUC(0-2h) becauseof elimination of the 4-hour blood sample by protocol amendment during the study The Cmax for the mean curve was calculated by averaging the concentrations at each time 10 point (0.5. 1, 2 and 4 hours), and this is shown in FIG 3 There was a high correlation between the Cmax and AUC, and a linear relationship exists between these parameters, as shown on FIG 8. Therefore, either parameter can be used when assessing PK correlations to dose, efficacy, or safety, Mean changes in blood pressure were characterized in all subjects based on sequential 15 supervised dosing of single-blind subcutaneous placebo and two doses of randomized study drug. The primary analysis for mean changes was the difference between treatment groups in the change CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -27- from single-blind placebo to randomized drug (Visit 2 vs. Visits 5/7). These changes are summarized in Table 4. There were between 86 to 100 subjects in each dose group Table 4. Treatment Group Difference (from Placebo) in Mean Change in Blood Pressure from Corresponding Period during Single-blind Placebo Abbreviations: BMT, bremeianotide; DBP, diastolic blood pressure; HR-BP, heart rate-blood pressure; J BMT Dose pSSL. IntervalV5V7 V5 V7 V5 V7 V5 V7 0-4 1.8 1.Ï 1.5 I 0.6 -5.2* 4.8* -492.8* -491.9* SE ,P DBP *ulse HR-BP Product 0.75 4-8 0.9 1.6 1.3 Î 1.7 -6.2* -5.5* -676.5* -503.3* 8-24 0.9 1.6 1.0 Î 1.3* -0.4 0.1 5.2 114.9 0-24 1.1 1.5 1.1* Î 1.3* -2.2* -1.6 -187.7 -32 3 0-4 2.4” 2.1* 3.0* -8 2' -6.1* -436.4* -583.3* 1.25 4-8 1.4 1.3* 2.2* 0.9 -6.1* -6.5* -621.0* -669.7* 8-24 0.7 1.5* 1.4* Î 1.7* -1.5 -0.7 -127.4 4.2 0-24 1.1 1.6* 1.9* I 1.7* -2.9* -2.6* -265.9 -206.5 0-4 3.1* 2 5* 3 2* Î 2.6* -4.6* 4.7* -305.9 -375.4* 1.75 4-8 2.1 2.2 2.3* 2.2* -6.6* -6.6* -608.1* -624.5* CO 04 0.9 0.6 1.4* Î 1.4 -0.6 -0.5 -23.7 -31.3 0-24 1.6 1.3 1.9* I 18* -2.2* -Ï39.1 -184,1 SBP, systolic blood pressure; V. visit. Asterisks denote P 0.05. 5 Efficacy outcomes are graphed by dosage and PSD diagnosis in FIG 6. On all key endpoints, exploratory analyses demonstrated statistically significant efficacy or a clinically significant trend versus placebo in the HSDD-only and mixed HSDD/FSAD subgroups at 1.25 mg, 1.75 mg, and/or 1.25/1.75 mg pooled. The data also showed that the mean change from baseline scores with the FSFI and FSDSW DAO were still increasing in the third treatment month, as shown in FIG 7. In addition, an exploratory analysts showed a higher percentage of women who were administered bremelanotlde (versus placebo) had end-of-study scores for the FSFI and FSDS-DAO total score levels above 26.5 and 18. CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -28- The most common adverse events during study-drug treatment (occurring in >5% in any group) were nausea, flushing, and headache. Drug treated subjects had -2 mm Hg change in blood pressure, predominantly within 4 hours of dosing; patients meeting the predefined blood pressure withdrawal criteria were evenly distributed among placebo and active arms of the study. Of 7 serious 5 adverse events, none were considered related to bremelanotide treatment Bremelanotide administration resulted in a small increase in both systolic and diastoi c pressures, with a maximal change in systolic pressure of 3.15 mm Hg (average of Visits 5 and 7) in the 1.75 mg dosing group. The 0 to 4 hour changes were statistically different than placebo (95% Ci not intersecting 0) for the 2 high dose groups only. Importantly, the increase in systolic blood pressure 10 was confined to the first 4 hours foliowing bremelanotide administration, in ail cases, the 4-to- 8 -hour interval and later intervals were not statistically different from placebo. The small changes in systolic and diastolic pressures were accompanied by decrease in heart rate of between 3 to 6 beats per minute. These changes were statistically separable and occurred between 0 and 8 hours after bremelanotide administration. While it is not known whether these 15 changes represent a baroreceptor reflex to the increase in blood pressure, a central process, or some combination of processes, available data suggests that the reduction in pulse and puise-biood pressure product may be physiologically adaptive and reduce any potential cardiac risk of the small concurrent increase in systolic blood pressure. Although there were an increased number of outliers for maximal changes from baseline In 20 systolic blood pressure in drug-treated patients, the duration of these events was quite limited. The interrogation interval during ambulatory blood pressure monitoring assessments of 15 minutes allowed definition of the maximal duration of such excursions. As can be seen from Table 5 below, few changes of greater than 10 mm Hg systolic lasted greater than 30 minutes, while no increases of 15 mm Hg systolic or greater lasted longer than 30 minutes. These data included are not selected 25 with regard to concomitant activity, concomitant medications or other potential clinical contributory factors. The clinical significance of such changes, if any, is small. CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -29- Table 5. Systolic Blood Pressure Shifts by Duration Abbreviations: A, change; BMT, bremelanotide; SBP. systolic biood pressure. Treatment Arm ASBP >10 mm Hg< Duration > 30 minutes ASBP > 15mm Hg, Duration > 30 minutes Placebo 1 1 BMT 0,75 mg 1 0 BMT 1,25 mg 2 0 BMT 1.75 mg 0 0 Bremelanotide was well-tolerated during the trial. The most common types of treatmentemergent adverse events reported more frequently in the bremelanotide arms were facial flushing, 5 nausea, emesis and headache, The study dosed 395 patients, A total of 26 patients discontinued from the study based on preset blood pressure changecriterion spread across all arms(N~26, Placebo: 6, bremelanotide arms - 0,75 mg 4, 1.25 mg: 9, 1.75 mg: 7). A total of 19 patients discontinued from the study based on adverse events spread across ail arms (N=19, Placebo: 5, bremelanotide arms - 0.75 mg. 2, 1.25 mg: 4, 1.75 mg: 8). The adverse events that most commonly 10 lead to discontinuation (other than meeting the blood pressure criterion) were flushing, nausea and emesis. Based on a safety review by an independent Data Safety Monitoring Board, no significant safety issues or concerns were identified during the study. There were no serious adverse events reported attributable to bremelanotide. Adverse events during the double-blind treatment period are shown on Table 6 below. Table 6, Adverse Events During Double-Blind Treatment, I Adverse event Placebo group(N = 97) Bremelanotide groups1.25 mg(N = 99)61 (62%) 22 (22%) 14(14%) 9 (9%) 6 (6%) 5 (5%) 0.75 mg(N = 100)64 (64%) 18(18%) 17(17%) 9 (9%) 6 (6%) 8 (8%) 1.75 mg(N = 98)67 (68%)24 (24%)17 (17%)14 (14%)7 (7%)4 (4%) Anya ) Nausea Flushing I Headache Injection-site pain Upper respiratory tract infection 49(51%) 3 (3%) 0 3 (3%) 3 (3%) 4 (4%) Injection-site | pruritus 0 4 (4%) 4 (4%) 6 (6%) Any leading to I withdrawal® 5 (5%) 2 (2%) 4 (4%) 8 (8%) CA 02890081 2015-05-01 WO 2014/071339 PCT/US2013/068386 -30- 3The types listed are those with incidence s5% among bremeianotide users at any dose, ^he types fisted are those that occurred in >1 bremeianotide user across dosing groups. I Adverse event Placebo group (N «97) Bremeianotide groups 0.75 mg (N = 100) 1.25 mg (N = 99) 1.75 mg (N = 98) Vomiting 0 0 1 (1%) 3 (3%) I Hypertension 2 (2%) 2 (2%) 0 1 (1%) I Nausea 0 0 0 3 (3%) i Flushing 0 0 1 (1%) 1 (1%) 5 Thus in premenopausal women with FSDs, bremeianotide seif-administered at home at 1.25 and 1.75 mg SC was effective in decreasing distress, increasing areusai and desire, and increasing the number of sSEs, with robust dose response and consistency of effect across all key endpoints. Efficacy was seen in both HSDD and mixed HSDD/FSAD populations. These improvements 10 continued throughout the treatment period, indicating that patients may be able to continue improving after three months of treatment. Women receiving bremeianotide were more likely tan placebotreated women to reach key score thresholds for both FSFI and FSDS-DAO. Bremeianotide was generally well tolerated. Example 2 15 Comparison of results of the study of Example 1 with prior intranasal studies of bremeianotide in premenopausal and postmenopausal women with f SAD showed significantly different parameters for both efficacy and adverse events. Results with premenopausal women in a placebo-controlled, randomized, double-blind, parallel group, at-home exploratory study to evaluate the efficacy and safety of intranasally administered bremeianotide in subjects with female sexual arousal disorder 20 (I SAD} were compared against results in the study of Example 1. In the intranasal study, a total of 76 premenopausal subjects were randomized, with 4Q subjects to receive bremeianotide and 36 to receive placebo. Twenty-two subjects treated with bremeianotide and 29 treated with placebo completed the study, with 16 subjects who received bremeianotide (40%) discontinuing from the study due to an adverse event. This compares to the study of Example 1 in which as shown by Table 6 25 only 8% of subjects on the 1.75 mg subcutaneous dose discontinuing due to an adverse event. In the intranasal study, premenopausal women self-administered a IQ mg intranasal dose. At 30 minutes post dosing, this resulted in a Cmax mean of 88.5 ± 51.9 ng/mL, a median Cmax of 81.1 -31- ng/mL, the median was 78 ng/mL, %CV was 25, the minimum was 15 ng/mL and the maximum was 115 ng/mL. Subjects who experienced vomiting, nausea or both following in-clinic dosing in the intranasal study had a substantial higher pK concentration of bremelanotide than subjects who did 5 not experience these symptoms. Thus pK variability with intranasal administration had a direct impact on adverse events, and contributed to adverse events. Similarly, stratification of subject arousal rate and level of desire success rate by pK concentration group showed a larger change in subject arousal rate and level of desire success rate from baseline to visits 3 and 4 in the intranasal study in subjects with a bremelanotide concentration between 50 to <100 ng/mL than 10 subjects with a lower or higher bremelanotide concentration. Thus variability in the effective dose with intranasal administration contributed to both increased adverse events and decreased efficacy, compared to administration of a 1.25 mg or 1.75 mg subcutaneous dose. Although the invention has been described in detail with particular reference to these preferred embodiments, other embodiments can achieve the same results. Variations and 15 modifications of the present invention will be obvious to those skilled in the art and it is intended to cover all such modifications and equivalents. CA 2890081 2020-03-06