CN1301160A - Therapeutic combination of a (selective) estrogen receptor modulator (SERM) and a growth hormone secretagogue (GHS) for the treatment of musculoskeletal fragility - Google Patents

Abstract

The present invention relates to pharmaceutical combination compositions and methods comprising (-) -cis-6-phenyl-5- (4- (2-pyrrolidin-1-yl-ethoxy) -phenyl) -5, 6,7, 8-tetrahydronaphthalene-2-ol or a pharmaceutically acceptable salt thereof and 2-amino-N- (2- (3a (R) -benzyl-2-methyl-3-oxo-2, 3,3a,4,6, 7-hexahydropyrazolo [4, 3-c ] pyridin-5-yl) -1 (R) -benzyloxymethyl-2-oxo-ethyl) -isobutyramide or a pharmaceutically acceptable salt thereof, methods of using said compositions and kits containing said compositions. The composition can be used for treating musculoskeletal frailty, including osteoporosis, osteoporotic fractures, low bone mass, frailty, and low muscle mass.

Description

Therapeutic combination of a (selective) estrogen receptor modulator (SERM) and a growth hormone secretagogue (GHS) for the treatment of musculoskeletal fragility

Background of the invention

The present invention relates to a drug combination of a selective estrogen receptor modulator (SERM) and a growth hormone secretagogue (GHS) that stimulates bone formation, increases bone mass, decreases serum lipid levels and increases muscle mass. The invention also relates to kits containing said combination and said combination for the treatment of musculoskeletal frailty, including osteoporosis, osteoporotic fractures, low bone mass, frailty, low muscle mass, in mammals, including humans. quality, etc. In particular, the present invention relates to (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8- Tetralin-2-ol or its pharmaceutically acceptable salts and 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4, 6,7-Hexahydropyrazolo[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide or its pharmaceutical Combinations with salts, kits containing said combinations and said combinations in mammals, including humans, for the treatment of musculoskeletal frailty, including osteoporosis, osteoporotic fractures, low bone mass, frailty, Uses for low muscle mass etc.

Osteoporosis is a systemic skeletal disease characterized by low bone mass and degeneration of bone tissue, with consequent increased fragility of bones and susceptibility to fractures. In the United States, the condition affects more than 25 million people and causes more than 1.3 million fractures each year, including 500,000 spine fractures, 250,000 hip fractures, and 240,000 lumbar fractures each year. Hip fractures are the most serious, with 5-20% of patients dying within a year and more than 50% of survivors incapacitated.

Older adults are at greatest risk for osteoporosis and, therefore, the problem is expected to increase significantly as the population ages. The incidence of fractures worldwide is expected to triple within the next 60 years, with one study estimating that in 2050, 4.5 million hip fractures will occur worldwide.

Although both men and women are prone to developing muscular and skeletal frailties, including osteoporosis, women are at greater risk of developing osteoporosis than men. Immediately after menopause, women experience dramatic bone loss. Other factors that increase bone loss leading to osteoporosis include smoking, alcohol abuse, a sedentary lifestyle, and insufficient calcium intake.

Estrogens are drugs that can be used to prevent osteoporosis or bone loss in women after menopause. Furthermore, Black et al. reported in EP 0605193A1 that estrogen, especially when administered orally, can lower plasma LDL levels and raise beneficial high-density lipoprotein (HDL) levels. However, long-term estrogen therapy is associated with an increased risk of various diseases, including cancer of the uterus, endometrium, and possibly breast cancer, causing many women to either refuse the therapy or use it only for short periods of time. Although the literature teaches that the risk of endometrial cancer can be reduced by concomitant use of progesterone, there are concerns that the use of estrogen may increase the risk of breast cancer. Recently proposed treatments aimed at reducing the risk of cancer, such as the combination of progesterone and estrogen, have been associated with unacceptable bleeding in patients. In addition, combining progesterone with estrogen appears to attenuate the serum cholesterol-lowering effect of estrogen. In view of the significant adverse side effects associated with estrogen therapy, there is a need to develop other approaches to the treatment of osteoporosis that have the desired beneficial effect on serum LDL without causing adverse side effects.

A number of selective estrogen receptor modulators have recently been proposed for the treatment of osteoporosis. As reported (Osteoporosis Conference entry 1812/13, April 16-20, 1993, p. 29), raloxifene, 6-hydroxy-2-(4-hydroxyphenyl)-3-[4-( 2-Pyridylethoxy)benzoyl]benzo[b]thiophene, which mimics the beneficial effects of estrogen on bone and lipids but, unlike estrogen, is very less uterine stimulating [Black , L.J. et al., Raloxifene (LY139481 HCl) prevents bone loss and lowers serum cholesterol in ovariectomized rats without causing uterine hypertrophy, "Journal of Clinical Research" (J.Clin.Invest.), 1994,93: 63-69 and Delmas, P.D., et al., Effects of Raloxifene on Bone Mineral Density, Serum Cholesterol Concentration, and Endometrium in Postmenopausal Women, New England Journal of Medicine, 1997, 337:1641 -1647].

Drugs such as droloxifene (US Patent 5,254,595) reduce the risk of fractures by preventing bone loss without the side effects of estrogen. However, estrogen and estrogen agonists alone are expected to reduce the risk of fracture by only about 50%, leaving the remaining about 50% of osteopenic women at risk for osteoporotic fracture.

其中的变量如该专利中所定义。Commonly assigned U.S. Patent 5,552,412 (which patent is incorporated herein by reference) discloses SERM compounds of the formula:

The variables therein are as defined in the patent.

Growth hormone (GH) is secreted by the pituitary gland and stimulates the growth of all tissues in the body that can grow. In addition, GH is known to have the following fundamental effects on the body's metabolic processes:

1. Increases the rate of protein synthesis in almost all cells of the body;

2. Decreases the rate of utilization of carbohydrates in the cells of the body;

3. Increases the metabolism of free fatty acids and the utilization of fatty acids for energy.

A deficiency of GH can lead to various medical disorders. In children, dwarfism can result. In adults, the consequences of acquired GH deficiency include a dramatic decrease in lean body mass and a concomitant increase in total body fat, especially in the trunk region. Loss of skeletal and cardiac muscle mass and loss of muscle strength lead to a marked decline in exercise capacity. Bone density also decreases. Administration of exogenous GH has been shown to reverse many metabolic changes. Other beneficial effects of treatment include lowering of LDL cholesterol and improvement of psychological status.

In cases where elevated GH levels are desired, the problem can usually be resolved by providing exogenous GH or administering drugs that stimulate GH production and/or release. In each case, the peptide nature of the compound necessitates administration by injection. Originally, GH was obtained by extracting the pituitary gland from a cadaver. Therefore, the product is expensive and there is a risk that diseases related to pituitary origin may be transmitted to GH users (eg Jacob-Creutzfeld disease). More recently recombinant GH has emerged and although it no longer poses any risk of infectious disease, it is still a very expensive product and must be given by injection or nasal spray.

Most GH deficiency is due to a defect in GH release, not primarily a defect in pituitary GH synthesis. Therefore, another strategy to normalize serum GH levels is to stimulate its release from somatotroph cells. GH secretion can be increased by stimulating or inhibiting various neurotransmitter systems in the brain and hypothalamus. Therefore, the development of synthetic GH releasing agents that stimulate pituitary GH secretion has been initiated, which has many advantages over expensive and inconvenient GH replacement therapies. By acting along physiological regulatory pathways, optimal drugs can stimulate pulsatile GH secretion and, through an integral negative feedback loop, avoid excess GH levels associated with adverse side effects of exogenous GH administration.

Physiological and pharmacological stimulators of GH secretion, including arginine, L-3,4-dihydroxyphenylalanine (L-DOPA), glucagon, vasopressin, insulin-induced hypoglycemia, and activity , such as sleep and exercise, can indirectly cause GH release from the pituitary gland by acting on the hypothalamus in a manner that may decrease the secretion of somatostatin or increase the known secretagogue GH-releasing factor ( GHRF) or unknown secretion of endogenous GH releasing hormone or all of these.

Commonly assigned International Patent Application Publication No. WO 97/24369 (in which the United States is designated) discloses GH secretagogues of the formula: The variables therein are as defined in the patent. International Patent Application No. WO97/24369 is incorporated herein by reference.

Tang et al., Restoration and maintenance of bone in osteogenic female rat skeleton: Ⅰ. Changes in bone mass and structure, "J.Bone Mineral Research" (J.Bone Mineral Research) 7 (9), pp. 1093-1104, 1992 discloses the concept of loss, restoration and maintenance (LRM) (a kind of reversal of pre-existing A practical approach to osteoporosis). The LRM concept uses anabolic agents to restore bone mass and structure (Phase +), followed by switching to drugs with proven ability to preserve bone mass to maintain new bone (Phase +/-). Rat studies using PGE ₂ and risedronate (a bisphosphonate) to demonstrate that administration of risedronate can still abolish most of the PGE _{2 -} induced The new cancellous and cortical bone is maintained.

Shen et al., Effects of estrogen and estrogen plus parathyroid hormone interactive treatment on bone structure and strength in ovariectomized rats, "Journal of Clinical Investigation" (J.ClinicalInvestigation), 1995,96:2331-2338 discloses the and/or data on the sequential use of antiresorptive and anabolic agents in the treatment of osteoporosis.

Commonly assigned International Patent Application Publication No. WO97/31640, in which the United States is designated, discloses the use of certain GH secretagogues in combination with certain SERMS for the treatment of osteoporosis. International Patent Application Publication No. WO97/31640 is incorporated herein by reference.

Summary of the invention

The present invention relates to a pharmaceutical composition, which contains:

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

b. The second compound, the second compound is 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6 , 7-hexahydropyrazolo[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide or its pharmaceutically acceptable Salt.

The present invention also relates to the pharmaceutical composition described in the preceding paragraph further comprising a pharmaceutical carrier.

The present invention also relates to the pharmaceutical composition described in any one of the first two paragraphs of the Summary of the Invention, wherein the first compound is (-)-cis-6-phenyl-5-(4-(2 -pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetralin-2-ol D-tartrate, the second compound is 2-amino-N -(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydropyrazolo[4,3-c]pyridine-5 -yl)-l(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide L-tartrate.

The present invention also relates to a method (designated Method A) of treating a mammal suffering from musculoskeletal frailty, the method comprising administering to said mammal a medicament as described in any of the preceding three paragraphs of this Summary of the Invention combination.

In method A, a preferred method (designated as method B) is wherein the mammal suffers from osteoporosis.

In Method A, another preferred method (designated as Method C) is wherein the mammal suffers from osteotomy, childhood idiopathic bone loss, or bone loss associated with periodontitis.

The present invention also relates to a method of treatment of a mammal suffering from musculoskeletal frailty (designated method A ¹ ), which method comprises, administering to said mammal:

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

b. The second compound, the second compound is 2-amino-N-(1(R)-(2,4-difluoro-benzyloxymethyl)-2-oxo-2-(3- Oxo-3a(R)-pyridin-2-ylmethyl)-2-(2,2,2-trifluoroethyl)-2,3,3a,4,6,7-hexahydropyrazolo[ 4,3-c]pyridin-5-yl)-ethyl)-2-methylpropanamide or a pharmaceutically acceptable salt thereof.

In particular, the invention relates to method ^A1 , wherein the first compound and the second compound are administered substantially simultaneously.

The present invention also particularly relates to the method of method ^A1 (hereinafter referred to as method D), wherein the second compound is administered for a period of about 3 months to about 3 years.

In particular, the present invention relates to the method of Method D, followed by administration of the first compound for a period of about 3 months to about 3 years, with no administration of the second compound for a period of about 3 months to about 3 years.

In particular, the present invention relates to the method of Method D, followed by administration of the first compound for a period greater than about 3 years and no administration of the second compound for a period greater than about 3 years.

The present invention also relates to a method of treating said disease in a mammal suffering from musculoskeletal frailty (hereinafter referred to as Method E), which method comprises, administering to said mammal a therapeutically effective amount of the first three paragraphs of this Summary of the Invention The pharmaceutical composition described in any paragraph.

In method E, the preferred method is to enhance bone healing after facial reconstruction, maxillary reconstruction or mandibular reconstruction; induce vertebral osseointegration; enhance elongation of long bones; increase the healing rate of bone grafts or long bone fractures or enhance Inward growth of the prosthesis. A more preferred method comprises, administering to said mammal:

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

b. The second compound, the second compound is 2-amino-N-(1(R)-(2,4-difluoro-benzyloxymethyl)-2-oxo-2-(3- Oxo-3a(R)-pyridin-2-ylmethyl)-2-(2,2,2-trifluoroethyl)-2,3,3a,4,6,7-hexahydropyrazolo[ 4,3-c]pyridin-5-yl)-ethyl)-2-methylpropanamide or a pharmaceutically acceptable salt thereof.

The present invention also relates to a method for increasing muscle mass in a mammal, the method comprising administering to the mammal an effective amount of increasing muscle mass of the pharmaceutical composition described in any of the first three paragraphs of this Summary of the Invention. A more preferred method comprises, administering to said mammal:

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

b. The second compound, the second compound is 2-amino-N-(1(R)-(2,4-difluoro-benzyloxymethyl)-2-oxo-2-(3- Oxo-3a(R)-pyridin-2-ylmethyl)-2-(2,2,2-trifluoroethyl)-2,3,3a,4,6,7-hexahydropyrazolo[ 4,3-c]pyridin-5-yl)-ethyl)-2-methylpropanamide or a pharmaceutically acceptable salt thereof.

In all methods of the invention it is particularly preferred that the mammal is a human.

The invention also relates to a kit for the treatment of mammals with musculoskeletal frailty, said kit comprising:

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

b. A therapeutically effective amount of 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6, 7-Hexahydropyrazolo[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide or its pharmaceutically acceptable salt and a pharmaceutically acceptable carrier; and

c. container.

The present invention relates in particular to the kit described in the preceding paragraph, wherein said first unit dosage form contains (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl -ethoxy)-phenyl)-5,6,7,8-tetralin-2-ol D-tartrate, said second unit dosage form containing 2-amino-N-(2-(3a( R)-Benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydropyrazolo[4,3-c]pyridin-5-yl)-1(R )-benzyloxymethyl-2-oxo-ethyl)-isobutyramide L-tartrate.

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

The phrase "there is a condition of low bone mass" refers to a level of bone mass below World Health Organization standards "Assessment of fracture risk and its application to screening for postmenopausal osteoporosis (1994), report of the World Health Organization research group. World Conditions of age-specific normal values as defined in WHO Technical Series 843". Pediatric idiopathic and primary osteoporosis are also included. Treatment of osteoporosis includes prevention or relief of long-term complications such as curvature of the spine, loss of stature, revision surgery, and prevention of prostate dysfunction. Also included is an increased rate of fracture healing and an improved success rate of bone grafting. Also included are periodontal disease and alveolar bone loss.

The phrase "a condition in which low bone mass is present" also includes mammals known to have a significantly higher than average chance of developing the aforementioned disorders, including osteoporosis (e.g., postmenopausal women, men over the age of 60, men with known People who are being treated with drugs that can cause side effects of osteoporosis (such as glucocorticoids).

Those skilled in the art will understand that the term "bone mass" actually refers to the bone mass per unit area and sometimes (though not quite correctly) also refers to the mineral density of bone.

The phrase "muscle and skeletal fragility" refers to a patient with a condition of low bone mass and/or low muscle mass, including, but not limited to, diseases and conditions such as, for example, conditions with low bone mass, osteoporosis, low muscle mass Conditions of mass, osteotomy, idiopathic bone loss in children, bone loss associated with periodontitis, facial reconstruction, maxillary reconstruction, mandibular reconstruction and bone healing after fracture. Additionally, musculoskeletal fragility includes conditions such as the interface between a newly attached prosthesis and bone requiring bony ingrowth.

As used herein, the term "treatment" includes curative, preventive (eg, prophylactic) and palliative treatment.

Parenthetical negative or positive symbols used in the nomenclature herein refer to the direction in which a particular stereoisomer rotates plane polarized light.

The compositions of the present invention may contain hydrates of the compounds used herein.

The pharmaceutical composition and method of the present invention can produce the above-mentioned (-)-cis-6-phenyl-5-[4-(2-pyrrolidin-1-yl-ethoxy)-phenyl ]-5,6,7,8-tetralin-2-ol or the above 2-amino-N-[2-(3a-(R)-benzyl-2-methyl-3-oxo-2, 3,3a,4,6,7-Hexahydropyrazolo[4,3-c]pyridin-5-yl)-1-(R)-benzyloxymethyl-2-oxo-ethyl]- More rapid and higher bone mass gain with isobutyramide. Furthermore, these combined forms can reduce fat mass and total serum cholesterol while increasing bone density and muscle mass. Thus, these combinations increase bone mass and reduce fracture rates to a greater extent than either drug alone. The present invention makes a significant contribution to the prior art by providing compositions and methods that can increase and maintain bone mass to prevent, delay and/or regress osteoporosis and related bone diseases.

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

Detailed description of the invention

(-)-顺-6-苯基-5-[4-(2-吡咯烷-1-基-乙氧基)-苯基]-5,6,7,8-四氢萘-2-醇及其可药用盐按照以上引用的共同转让的美国专利5,552,412中的描述制备。The first compound of the present invention is (-)-cis-6-phenyl-5-[4-(2-pyrrolidin-1-yl-ethoxy)-phenyl]-5,6,7,8 - Tetralin-2-ol or its pharmaceutically acceptable salt, which has the structure of the following formula I:

(-)-cis-6-phenyl-5-[4-(2-pyrrolidin-1-yl-ethoxy)-phenyl]-5,6,7,8-tetrahydronaphthalene-2-ol and pharmaceutically acceptable salts thereof were prepared as described in commonly assigned US Patent No. 5,552,412 cited above.

(-)-cis-6-phenyl-5-[4-(2-pyrrolidin-1-yl-ethoxy)-phenyl]-5,6,7,8-tetrahydronaphthalene-2-ol D-Tartrate was prepared as described in the preceding paragraph or as described in International Patent Application Publication No. WO 97/16434 (designating the US), which is incorporated herein by reference.

The second compound of the present invention is 2-amino-N-[2-(3a-(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexa Hydropyrazolo[4,3-c]pyridin-5-yl)-1-(R)-benzyloxymethyl-2-oxo-ethyl]-isobutyramide or a pharmaceutically acceptable salt thereof, which Has the following structure of formula II: 2-Amino-N-[2-(3a-(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydropyrazolo[4,3 -c]pyridin-5-yl)-1-(R)-benzyloxymethyl-2-oxo-ethyl]-isobutyramide and its pharmaceutically acceptable salts can be obtained according to the commonly assigned International Patent Application Publication No. Preparation as described in WO 97/24369, which patent application is incorporated herein by reference.

Furthermore, when the compounds of the present invention or pharmaceutically acceptable salts thereof form hydrates or solvates, they are also within the scope of the present invention.

Both the pharmaceutical combinations and methods of the invention are suitable for therapeutic use as medicaments to activate bone turnover or to prevent bone resorption or to increase bone formation in mammals, especially humans. Since these functions are closely related to the occurrence of osteoporosis and bone-related diseases, these combined forms can prevent, arrest, regress or reverse osteoporosis due to their effects on bone.

The use of the compositions and methods of the present invention as medicaments for the treatment of musculoskeletal frailty (e.g., conditions in which low bone mass or low muscle mass is present, including osteoporosis) in mammals (e.g., humans) Confirmation of activity in routine assays described in US Patent 5,552,412 and International Patent Application Publication No. WO97/24369. Additional evidence of the usefulness of this combination is presented in Example 1 below. The assay also provides a means of comparing the activity of the compounds of the invention to each other and to the activity of other known compounds. The results of these comparisons can be used to determine dosage levels for the treatment of the disease in mammals, including humans.

The compounds of the invention may be administered by any method capable of systemically and/or locally delivering the compounds of the combination of the invention. These methods include oral routes, parenteral, intraduodenal routes, and the like. The compounds of the invention are usually administered orally, but parenteral (e.g., intravenous, intramuscular, transdermal, subcutaneous, or intramedullary) administration may be used, for example, when oral administration is not suitable for urgent purposes or when the patient When the medicine cannot be swallowed. Two different compounds of the present invention may be co-administered simultaneously or sequentially in any order, or a single pharmaceutical composition comprising the above-mentioned first compound and the above-mentioned second compound and a pharmaceutically acceptable carrier may be administered.

In any event, the amount and timing of administration of the compound will depend upon the subject being treated, the severity of the condition, the mode of administration and the judgment of the prescribing physician. Therefore, because of patient-to-patient variability, the dosages given below are indicative only, and the physician may vary the dosage of the drug to achieve the activity (eg, increase in bone mass) that the physician deems appropriate for a particular patient. In considering the desired degree of activity, the physician must balance various factors, such as the starting level of bone mass, the age of the patient, the presence of pre-existing diseases, and the presence of other diseases such as cardiovascular disease. For example, administration of (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydronaphthalene- 2-ols may have beneficial cardiovascular effects, especially in postmenopausal women. The following paragraphs provide preferred dosage ranges for the various ingredients of the invention.

(-)-cis-6-phenyl-5-[4-(2-pyrrolidin-1-yl-ethoxy)-phenyl]-5,6,7,8-tetrahydronaphthalene-2-ol The effective dose is in the range of 0.0001 to 100 mg/kg/day, preferably 0.001 to 10 mg/kg/day.

2-Amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydropyrazolo[4,3- c] The effective dose of pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide is in the range of 0.0001 to 100 mg/kg/day, preferably 0.001 to 5mg/kg/day.

When the tartrate or other pharmaceutically acceptable salts of any of the above compounds are used in the present invention, those skilled in the art can calculate the effective dose by calculating the molecular weight of the salt form and performing a simple stoichiometric ratio.

The compounds of the present invention are generally administered in the form of pharmaceutical compositions comprising at least one compound of the present invention or a pharmaceutically acceptable salt thereof and a pharmaceutically acceptable carrier or diluent. Accordingly, the compounds of the present invention and their pharmaceutically acceptable salts may be administered separately or simultaneously in any conventional oral, parenteral or transdermal dosage forms. When administered separately, another compound of the present invention or a pharmaceutically acceptable salt thereof is subsequently administered.

The pharmaceutical composition for oral administration can be in the form of solutions, suspensions, tablets, pills, capsules, powders and the like. Tablets contain various excipients such as sodium citrate, calcium carbonate and calcium phosphate and various disintegrants such as starch (preferably potato starch or tapioca starch) and certain complex silicates, as well as binders such as poly Vinylpyrrolidone, sucrose, gelatin and acacia. In addition, lubricating agents such as magnesium stearate, sodium lauryl sulfate and talc are often used in the manufacture of tablets. Solid compositions of a similar type may also be employed as fillers in soft and hard gelatine capsules; preferred materials in this regard also include lactose and high molecular weight polyethylene glycols. When oral administration with aqueous suspension and/or elixir is required, the compound of the present invention or a pharmaceutically acceptable salt thereof may be mixed with various sweeteners, flavoring agents, coloring agents, emulsifiers and/or auxiliary Suspending agents and diluents such as water, ethanol, propylene glycol, glycerin and various combinations thereof.

Parenteral administration may employ solutions in castor or peanut oil or aqueous propylene glycol, as well as sterile aqueous solutions of the corresponding water-soluble salts. Such aqueous solutions can be suitably buffered if necessary and the liquid diluent first rendered isotonic with sufficient saline or glucose. These aqueous solutions are particularly suitable for intravenous, intramuscular, subcutaneous and intraperitoneal injection. In this regard, the sterile aqueous vehicles employed are readily obtainable by conventional methods well known to those skilled in the art.

For purposes of transdermal (eg, topical) administration, dilute sterile aqueous or partially aqueous solutions (usually at a concentration of about 0.1% to 5%) are prepared, or similar to those described above for parenteral solutions.

Methods of preparing various pharmaceutical compositions containing certain amounts of active ingredients are known to, or will be apparent to, those skilled in the art in light of this disclosure. See, eg, Remington's Pharmaceutical Sciences, Mack Publishing Company, Easton, Pa., 19th ed. (1990).

The pharmaceutical composition of the present invention may contain 0.1%-95%, preferably 1%-70%, of the combined form of the compounds of the present invention or their pharmaceutically acceptable salts. In any event, the composition or formulation for administration will contain an amount of the compound of the present invention or a pharmaceutically acceptable salt thereof effective to treat the disease/condition in the patient to be treated.

Since the present invention relates to therapy with a combination of two active ingredients which can be administered separately, the present invention also relates to the combination of two different pharmaceutical compositions in the form of a kit. The kit contains two different pharmaceutical compositions: (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6 ,7,8-Tetralin-2-ol or its pharmaceutically acceptable salts and 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3 ,3a,4,6,7-Hexahydropyrazolo[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyl Amides or pharmaceutically acceptable salts thereof. The kit also includes containers for containing the two different compositions, such as separate vials or separate foil pouches, however, it is also possible to contain the two different compositions in a single, undivided container. A typical kit will contain instructions for administering the various ingredients. When the different components are preferably administered in different dosage forms (e.g., oral and parenteral), at different dosing intervals, or when a component of the combination requires gradual escalation by the prescribing physician, the Form is particularly advantageous.

Examples of such kits are so-called blister packs. Blister packs are well known in the packaging industry and are widely used for the packaging of pharmaceutical unit dosage forms (tablets, capsules, etc.). Blister packs generally consist of a sheet of relatively stiff material covered with a foil, preferably of transparent plastic material. During the packaging process, recesses are formed in the plastic foil. The pocket has the size and shape of the tablet or capsule to be packed. The tablet or capsule is then placed in the cavity and the plastic foil is sealed with a sheet of relatively stiff material on the opposite side of the foil forming the cavity. As a result, the tablet or capsule is sealed in the cavity between the plastic foil and the sheet. The strength of the sheet is preferably such that the tablet or capsule can be removed from the blister pack by applying pressure by hand on the recess, thereby forming an opening where the sheet is located in the recess. The tablet or capsule can then be removed through said opening.

A memory aid is preferably provided on an enclosed card, for example in the form of numbers next to the tablets or capsules, so that the numbers correspond to the days on which the given tablet or capsule regimen should be taken. Another example of such a memory aid is a calendar printed on a card such as "Week 1, Monday, Tuesday, . . . etc. . . Week 2, Monday, Tuesday, . . . " etc. Other variations of memory aids are apparent. A "daily dose" may be a single tablet or capsule, or a plurality of pills or capsules, to be taken on a given day. It is also possible that the daily dose of the SERM consists of one tablet or capsule and the daily dose of the GH secretagogue consists of several tablets or capsules. Memory aids should reflect these.

In another particular embodiment of the invention there is provided a dispenser capable of dispensing one daily dose at a time in its intended sequence of use. Preferably, the dispenser is provided with a memory aid to further facilitate compliance with the treatment regimen. An example of such a memory aid is a mechanical counter which indicates the number of daily doses which have been dispensed. Another example of such a memory aid is a battery-operated microchip memory that is linked to a liquid crystal readout or an audible reminder that reads, for example, the date of the last daily dose taken. Date and/or reminder when to take your next dose.

The following experiments are used to show that the combination and method of the present invention can increase lean body mass and reduce Japanese body mass, whereas GH secretagogues alone are expected to reduce fat body mass without altering lean body mass, and SERMs alone are expected to simultaneously increase lean body mass and fat body mass. Additionally, the combined form can increase bone density and lower total serum cholesterol.

Example 1

Female S-D rats (Harlan) were sham-operated or ovariectomized (OVX) at 3.5 months of age. Dosing was started when the rats were 9 months old (5.5 months after surgery). Sham-operated rats received daily gavage of vehicle (10% ethanol in water), while OVX rats received daily gavage of vehicle, or 2-amino-N-(2-(3a(R)-benzyl -2-Methyl-3-oxo-2,3,3a,4,6,7-hexahydropyrazolo[4,3-c]pyridin-5-yl)-1(R)-benzyloxy Methyl-2-oxo-ethyl)-isobutyramide (5 mg/kg/day, used alone), or (-)-cis-6-phenyl-5-(4-(2-pyrrolidine-1 -yl-ethoxy)-phenyl)-5,6,7,8-tetralin-2-ol (0.1 mg/kg/day, used alone), or with 2-amino-N-(2- (3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydropyrazolo[4,3-c]pyridin-5-yl)- 1(R)-Benzyloxymethyl-2-oxo-ethyl)-isobutyramide and (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl- Ethoxy)-phenyl)-5,6,7,8-tetralin-2-ol combination therapy for 4 weeks. In the combination therapy group, 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydropyrazolo [4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide to (-)-cis-6-phenyl-5 -(4-(2-Pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetralin-2-ol was administered two hours earlier. Each subgroup has 8-10 rats. All rats were injected subcutaneously with 10 mg/kg of calcein (Sigma Chemical Co., St. Louis, MO) 13 and 3 days before necropsy. Those skilled in the art will understand that the compounds used in this test can be administered in the form of pharmaceutically acceptable salts, and the dosage can be conveniently determined by calculating the molecular weight of the salts and performing simple ratio conversion.

All rats anesthetized with ketamine/xylazine were subjected to dual-energy X-ray absorptiometry (DXA, QDR- 1000/W, Hologic Inc., Waltham, MA) to measure lean body mass and fat body mass. Rats were then autopsied and bled by cardiac puncture. Total serum cholesterol was determined with a high performance cholesterol colorimetric assay (Boehringer Mannheim Biochemicals, Indianapolis, IN). Body weight gain was calculated by subtracting day 0 body weight from body weight at necropsy. Uterine wet weights were determined immediately at necropsy.

The right femur of each rat was removed at necropsy and analyzed using a dual-energy X-ray absorptiometry (DXA, QDR-1000/W, Hologic Inc., Waltham, MA) for scanning. The size of the scanning area is 5.08×1.902cm, the resolution is 0.0254×0.0127cm, and the scanning speed is 7.25mm/sec. Femur scans were analyzed and followed H.Z.Ke et al., Droloxifene, a new estrogen antagonist/agonist, prevents bone loss in ovariectomized rats, Endocrinology 136; The method described in 2435-2441, 1995 measures total femoral area, bone mineral content and bone mineral density. Findings and Discussion

Compared with the control, 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydropyridine Azolo[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide increases both lean body mass and fat body mass, whereas alone Using (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydronaphthalene-2- Alcohol reduced fat body mass, while lean body mass did not change. 2-Amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydropyrazolo[4,3- c] pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide and (-)-cis-6-phenyl-5-(4-( 2-Pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetralin-2-ol combination increases lean body mass and decreases fat body mass. Therefore, the combined form of the two compounds is more effective than 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7 -Hexahydropyrazolo[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide or alone (-)- cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetralin-2-ol has better Body composition distribution.

A 5-6% increase in total femoral area was observed in rats receiving the combined form relative to rats receiving placebo. This result is consistent with that of (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetra Hydronaphthalene-2-ol or 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydropyridine Azolo[4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide and (-)-cis-6-phenyl - Total femur area observed in rats with 5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetralin-2-ol increases are similar. When 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydropyrazolo[4 ,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide group, the content of total femoral inorganic matter increased by 8.5%, When (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydronaphthalene- In the 2-ol group, the increase was 7.7%. However, in the combined treatment group, the content of total femoral inorganic matter increased by 12.5%, which was a significantly higher increase than either drug alone. Similar results were observed for total femoral mineral density.

When (-)-cis-6-phenyl-5-(4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetrahydronaphthalene- Total serum cholesterol decreased in the 2-ol group and in the combination treatment group.

These data indicate that 2-amino-N-(2-(3a(R)-benzyl-2-methyl-3-oxo-2,3,3a,4,6,7-hexahydropyrazolo[ 4,3-c]pyridin-5-yl)-1(R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide and (-)-cis-6-phenyl-5- The combination of (4-(2-pyrrolidin-1-yl-ethoxy)-phenyl)-5,6,7,8-tetralin-2-ol has several advantages. These advantages include increases in lean body mass and decreases in fat body mass and serum lipids. In addition, an increase in bone mass was also observed.

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

Claims (29)

1. pharmaceutical composition, described compositions contains:

A. first kind of chemical compound, described first kind of chemical compound is (-)-suitable-6-phenyl-5-(4-(2-pyrrolidine-1-base-ethyoxyl)-phenyl)-5,6,7,8-naphthane-2-alcohol or its officinal salt; With

B. second kind of chemical compound, described second kind of chemical compound is 2-amino-N-(2-(3a (R)-benzyl-2-methyl-3-oxo-2,3,3a, 4,6,7-six hydrogen pyrazolos [4,3-c] pyridine-5-yl)-1 (R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide or its officinal salt.

2. the pharmaceutical composition of claim 1 also contains pharmaceutical carrier.

3. the pharmaceutical composition of claim 1, wherein, described first kind of chemical compound is (-)-suitable-6-phenyl-5-(4-(2-pyrrolidine-1-base-ethyoxyl)-phenyl)-5,6,7,8-naphthane-2-alcohol D-tartrate, described second kind of chemical compound is 2-amino-N-(2-(3a (R)-benzyl-2-methyl-3-oxo-2,3,3a, 4,6,7-six hydrogen pyrazolos [4,3-c] pyridine-5-yl)-1 (R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide L-tartrate.

4. the pharmaceutical composition of claim 1 is used for the purposes of medicine that the mammal that suffers from flesh and skeleton fragility is treated in preparation.

5. the purposes of claim 4, wherein, described first kind of chemical compound is (-)-suitable-6-phenyl-5-(4-(2-pyrrolidine-1-base-ethyoxyl)-phenyl)-5,6,7,8-naphthane-2-alcohol D-tartrate, described second kind of chemical compound is 2-amino-N-(2-(3a (R)-benzyl-2-methyl-3-oxo-2,3,3a, 4,6,7-six hydrogen pyrazolos [4,3-c] pyridine-5-yl)-1 (R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide L-tartrate.

6. the purposes of claim 4, wherein, described mammal suffers from osteoporosis.

7. the purposes of claim 4, wherein, what treated is sacrotomy, the loss of child Te Fa bone or the bone loss relevant with periodontitis.

8. the purposes of claim 4 wherein, is used for the treatment of the knitting after face's reconstruction, upper jaw bone reconstruction or mandibular bone are rebuild; Induce the synosteosis of vertebra; Strengthen the elongation of long bone; Improve the healing speed of bone graft or the inside growth of enhancing prosthese.

9. the purposes of claim 8, wherein, what treated is people's fracture.

10. the purposes of claim 6, wherein, what treated is people's osteoporosis.

11. medicine box, described medicine box contains:

A. (-) in first unit dosage form-suitable-6-phenyl-5-(4-(2-pyrrolidine-1-base-ethyoxyl)-phenyl)-5,6,7,8-naphthane-2-alcohol or its officinal salt and pharmaceutically useful carrier or diluent;

B. (2-(the 3a (R)-benzyl-2-methyl-3-oxo-2 of the 2-amino-N-in second unit dosage form, 3,3a, 4,6,7-six hydrogen pyrazolos [4,3-c] pyridine-5-yl)-1 (R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide or its officinal salt and pharmaceutically useful carrier or diluent; With

C. container.

12. the medicine box of claim 11, wherein, described first unit dosage form contains (-)-suitable-6-phenyl-5-(4-(2-pyrrolidine-1-base-ethyoxyl)-phenyl)-5,6,7,8-naphthane-2-alcohol D-tartrate, described second unit dosage form contains 2-amino-N-(2-(3a (R)-benzyl-2-methyl-3-oxo-2,3,3a, 4,6,7-six hydrogen pyrazolos [4,3-c] pyridine-5-yl)-1 (R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide L-tartrate.

13. to the method that the mammal that suffers from flesh and skeleton fragility is treated, this method comprises, to the pharmaceutical composition of described administration claim 1.

14. the method for claim 13, wherein, described first kind of chemical compound is (-)-suitable-6-phenyl-5-(4-(2-pyrrolidine-1-base-ethyoxyl)-phenyl)-5,6,7,8-naphthane-2-alcohol D-tartrate, described second kind of chemical compound is 2-amino-N-(2-(3a (R)-benzyl-2-methyl-3-oxo-2,3,3a, 4,6,7-six hydrogen pyrazolos [4,3-c] pyridine-5-yl)-1 (R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide L-tartrate.

15. the method for claim 13, wherein, described mammal suffers from osteoporosis.

16. the method for claim 13, wherein, what treated is sacrotomy, the loss of child Te Fa bone or the bone loss relevant with periodontitis.

17. the method for claim 13 wherein, is used for the treatment of the knitting after face's reconstruction, upper jaw bone reconstruction or mandibular bone are rebuild; Induce the synosteosis of vertebra; Strengthen the elongation of long bone; Improve the healing speed of bone graft or the inside growth of enhancing prosthese.

18. the method for claim 17, wherein, what treated is people's fracture.

19. the method for claim 15, wherein, what treated is people's osteoporosis.

20. to the method that the mammal that suffers from flesh and skeleton fragility is treated, this method comprises, to described administration:

A. first kind of chemical compound, described first kind of chemical compound is (-)-suitable-6-phenyl-5-(4-(2-pyrrolidine-1-base-ethyoxyl)-phenyl)-5,6,7,8-naphthane-2-alcohol or its officinal salt; With

B. second kind of chemical compound, described second kind of chemical compound is 2-amino-N-(2-(3a (R)-benzyl-2-methyl-3-oxo-2,3,3a, 4,6,7-six hydrogen pyrazolos [4,3-c] pyridine-5-yl)-1 (R)-benzyloxymethyl-2-oxo-ethyl)-isobutyramide or its officinal salt.

21. the method for claim 20, wherein, first kind of chemical compound and second kind of chemical compound are gone up administration simultaneously substantially.

22. the method for claim 20, wherein, about 3 months of second kind of compound administration is to about 3 years time.

23. the method for claim 22 is used about 3 months of first kind of chemical compound subsequently to about 3 years time, does not use second kind of chemical compound at about 3 months in during about 3 years.

24. the method for claim 22 is used first kind of chemical compound subsequently and is surpassed about 3 years time, is not using second kind of chemical compound in during about 3 years.

25. the method for claim 20, wherein, described mammal suffers from osteoporosis.

26. the method for claim 20, wherein, described mammal suffers from sacrotomy, the loss of child Te Fa bone or the bone loss relevant with periodontitis.

27. the method for claim 20 wherein, is used for the treatment of the knitting after face's reconstruction, upper jaw bone reconstruction or mandibular bone are rebuild; Induce the synosteosis of vertebra; Strengthen the elongation of long bone; Improve the healing speed of bone graft or the inside growth of enhancing prosthese.

28. the method for claim 27, wherein, what treated is people's fracture.

29. increase the method for muscle quality in having the mammal that needs, this method comprises, increases the compositions of the claim 1 of effective dose to described administration muscle quality.