\
`
`Express Mail Label No.
`EV 749839845 US
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`t Q/!) 'Jl 'J t!,
`IAP9 Rec~d PCTIPTO 0 5 S EP 200~
`
`Attorney Docket: AGP-002
`
`METHODS FOR TREATING DISORDERS OR DISEASES ASSOCIATED
`
`WITH HYPERLIPIDEMIA AND HYPERCHOLESTEROLEMIA WHILE
`
`MINIMIZING SIDE-EFFECTS
`
`CROSS-REFERENCE TO RELATED APPLICATIONS
`[0001] This application
`is a national phase application under 35 U.S.C. § 371 of
`
`PCTIUS05/007435 filed March 7, 2005 which in tum claims priority benefit of U.S. Serial
`
`No. 60/550,915, filed March 5, 2004, all of which are hereby incorporated by reference in
`
`their entireties.
`
`FIELD OF THE INVENTION
`[0002] The present invention generally relates to therapy for hypercholesterolemia and
`
`hyperlipidemia.
`
`BACKGROUND OF THE INVENTION
`
`[0003] Hypercholesterolemia is a well-known risk factor for ASCVD, the major cause of
`
`mortality in the Western world. Numerous epidemiological studies have clearly demonstrated
`
`that pharmacological lowering of total cholesterol (TC) and Low-density Lipoprotein (LDL)
`
`Cholesterol (LOL-C) is associated with a significant reduction in clinical cardiovascular
`
`events. Hypercholesterolemia is often caused by a polygenic disorder in the majority of cases
`
`and modifications in lifestyle and conventional drug treatment are usually successful in
`
`reducing cholesterol levels. However, in few cases, as in familial hypercholesterolemia (FH),
`
`the cause is a monogenic defect and the available treatment in homozygous patients can be
`
`much more challenging and far from optimal because LDL-C levels remain extremely
`
`elevated despite aggressive use of combination therapy. Therefore, for this group of high-risk
`
`patients, effective medical therapy is urgently needed.
`
`[0004] Triglycerides are common types of fats (lipids) that are essential for good health when
`
`present in normal amounts. They account for about 95 percent of the body's fatty tissue.
`
`Abnormally high triglyceride levels may be an indication of such conditions as cirrhosis of
`
`the liver, underactive thyroid (hypothyroidism), poorly controlled diabetes, or pancreatitis
`
`(inflammation of the pancreas). Researchers have identified triglycerides as an independent
`
`risk factor for heart disease.
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`[0005] Higher-than-normal triglyceride levels are often associated with known risk factors
`
`for heart disease, such as low levels ofHDL ("good") cholesterol, high levels of LDL ("bad")
`cholesterol and obesity. Triglycerides may also contribute to thickening of artery walls- a
`
`physical change believed to be a predictor of atherosclerosis.
`[0006] Therefore, high triglyceride levels are at least a warning sign that a patient's heart
`
`health may be at risk. In response, physicians may be more likely to stress the importance of
`losing weight, getting enough exercise, quitting smoking, controlling diabetes and other
`strategies that patients can use to protect their own cardiovascular health.
`[0007) A large number of genetic and acquired diseases can result in hyperlipidemia. They
`can be classified into primary and secondary hyperlipidemic states. The most common causes
`
`ofthe secondary hyperlipidemias are diabetes mellitus, alcohol abuse, drugs, hypothyroidism,
`chronic renal failure, nephrotic syndrome, cholestasis and bulimia. Primary hyperlipidemias
`
`familial combined
`into common hypercholesterolemia,
`have also been classified
`hyperlipidemia, familial hypercholesterolemia, remnant hyperlipidemia, chylomicronemia
`
`syndrome and familial hypertriglyceridemia.
`[0008] A number of treatments are currently available for lowering serum cholesterol and
`triglycerides. However, each has its own drawbacks and limitations in terms of efficacy, side(cid:173)
`effects and qualifying patient population.
`
`[0009] Bile-acid-binding resins are a class of drugs that interrupt the recycling of bile acids
`from the intestine to the liver; e.g., cholestyramine (Questran Light®, Bristol-Myers Squibb),
`and colestipol hydrochloride (Colestid®, The Upjohn Company). When taken orally, these
`positively-charged resins bind to the negatively charged bile acids in the intestine. Because
`the resins cannot be absorbed from the intestine, they are excreted carrying the bile acids with
`them. The use of such resins, however, at best only lowers serum cholesterol levels by about
`20%, and is associated with gastrointestinal side-effects, including constipation and certain
`vitamin deficiencies. Moreover, since the resins bind other drugs, other oral medications must
`
`be taken at least one hour before or four to six hours subsequent to ingestion of the resin;
`thus, complicating heart patient's drug regimens.
`[0010] The statins are cholesterol-lowering agents that block cholesterol synthesis by
`inhibiting HMGCoA reductase--the key enzyme involved in the cholesterol biosynthetic
`pathway. The statins, e.g., lovastatin (Mevacor®, Merck & Co., Inc.), simvastatin (Zocor®,
`Merck & Co., Inc.), atorvastatin (Lipitor®, Pfizer), rosuva (Crestor®, Astra Zeneca) and
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`pravastatin (Pravachol®, Bristol-Myers Squibb Co.), and combinations thereof, are
`sometimes used in combination with bile-acid-binding resins. Statins significantly reduce
`serum cholesterol and LDL-serum levels, and slow progression of coronary atherosclerosis.
`However, serum HDL cholesterol levels are only moderately increased. The mechanism of
`
`the LDL lowering effect may involve both reduction of VLDL concentration and induction of
`
`cellular expression of LDL-receptor, leading to reduced production and/or increased
`catabolism of LDLs. Side effects, including liver and kidney dysfunction are associated with
`the use of these drugs (Physicians Desk Reference, Medical Economics Co., Inc., Montvale,
`N.J., 2004; hereinafter "PDR"). The FDA has approved atorvastatin to treat rare but urgent
`cases of familial hypercholesterolemia.
`[0011) Ezetimibe
`is a cholesterol absorption inhibitor which reduces the amount of
`cholesterol absorbed by the body. Ezetimibe is used to reduce the amount of total
`cholesterol, LDL cholesterol (by about 18%), and apolipoprotein B. Ezetimibe is often used
`with a low cholesterol diet and, in some cases, other cholesterol lowering medications.
`[0012] Niacin, or nicotinic acid, is a water soluble vitamin B-complex used as a dietary
`supplement and antihyperlipidemic agent. Niacin diminishes production of VLDL and is
`effective at lowering LDL.
`In some cases, it is used in combination with bile-acid binding
`resins. NIASPAN® has been approved to prevent recurrent heart attacks in patients with
`high cholesterol. Niacin can increase HDL when used at adequate doses, however, its
`usefulness is limited by serious side effects when used at such high doses.
`[0013] Fibric acid derivatives ("fibrates") are a class of lipid-lowering drugs used to treat
`various forms of hyperlipidemia (i.e., elevated serum triglycerides) which may also be
`associated with hypercholesterolemia. Fibrates appear to reduce the VLDL fraction and
`modestly increase HDL. However, the effects of these drugs on serum cholesterol is
`
`variable. Fibrates are mainly used to lower high triglyceride levels. Although fibrates
`typically do not appear as effective as statins in lowering total cholesterol and LDL
`cholesterol levels, they are sometimes used in combination with statins or other medications
`to lower very high cholesterol levels. For example, fibrates are also sometimes added to
`statins to raise HDL cholesterol levels. In the United States, fibrates have been approved for
`use as antilipidemic drugs, but have not received approval as hypercholesterolemia agents.
`For example, clofibrate (Atromid-S®, Wyeth-Ayerst Laboratories) is an antilipidemic agent
`which acts to lower serum triglycerides by reducing the VLDL fraction. Although serum
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`cholesterol may be reduced in certain patient subpopulations, the biochemical response to the
`
`drug is variable, and is not always possible to predict which patients will obtain favorable
`
`results. Atromid-S® has not been shown to be effective for prevention of coronary heart
`
`disease. The chemically and pharmacologically related drug, gemfibrozil (Lopid®, Parke(cid:173)
`
`Davis) is a lipid regulating agent which moderately decreases serum triglycerides and VLDL
`
`cholesterol, and moderately increases HDL cholesterol--the HDL2 and HDL3 subfractions as
`
`well as both ApoA-1 and A-II (i.e., the AIIAII-HDL fraction). However, the lipid response is
`
`heterogeneous, especially among different patient populations. Moreover, while prevention of
`
`coronary heart disease was observed in male patients between 40-55 without history or
`
`symptoms of existing coronary heart disease, it is not clear to what extent these findings can
`
`be extrapolated to other patient populations (e.g., women, older and younger males). Indeed,
`
`no efficacy was observed in patients with established coronary heart disease. Fenofibrate
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`(Tricor, Secalip) is also used to reduce levels of cholesterol and triglycerides. Serious side(cid:173)
`
`effects have been associated with the use of several fibrates including toxicity such as
`
`malignancy, (especially gastrointestinal cancer), gallbladder disease and an
`
`increased
`
`incidence in non-coronary mortality. Fibrates are often not indicated for the treatment of
`
`patients with high LDL or low HDL as their only lipid abnormality (Physician's Desk
`
`Reference, 2004, Medical Economics Co., Inc. Montvale, N.J.).
`
`[0014] Oral
`
`estrogen
`
`replacement
`
`therapy may
`
`be
`
`considered
`
`for moderate
`
`hypercholesterolemia in post-menopausal women. However, increases in HDL may be
`
`accompanied with an increase in triglycerides. Estrogen treatment is, of course, limited to a
`
`specific pati~nt population (postmenopausal women) and is associated with serious side
`
`effects including induction of malignant neoplasms, gall bladder disease, thromboembolic
`
`disease, hepatic adenoma, elevated blood pressure, glucose intolerance, and hypercalcemia.
`
`[0015] Homozygous familial hypercholesterolemia (hoFH) is a serious life-threatening
`
`genetic disease caused by homozygosity or compound heterozygosity for mutations in the
`
`low density lipoprotein (LDL) receptor. Total plasma cholesterol levels are generally over
`
`500 mg/dl and markedly premature atherosclerotic vascular disease is the major consequence.
`
`Untreated, most patients develop atherosclerosis before age 20 and generally do not survive
`
`past age 30. The primary goal of therapy consists of controlling the hypercholesterolemia to
`
`delay the development of atherosclerotic cardiovascular disease (ASCVD). However,
`
`patients diagnosed with hoFH are largely unresponsive to conventional drug therapy and have
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`limited treatment options. A mean LDL-C reduction of only about 5.5% has been recently
`
`reported in patients with genotype-confirmed hoFH treated with the maximal dose of statins
`
`(atorvastatin or simvastatin 80 mg/day). The addition of ezetimibe 10 mg/day to this regimen
`
`resulted in a total reduction of LDL-C levels of 27%, which is still far from optimal. Several
`
`non-pharmacological options have also been tested. Surgical interventions, such as portacaval
`
`shunt and ileal bypass have resulted only in partial and transient LDL-C lowering. Orthotopic
`
`liver transplantation has been demonstrated to substantially reduce LDL-C levels in hoFH
`
`patients, but obvious disadvantages and risks are associated with this approach. Although
`
`hoFH could be an excellent model for gene therapy, this modality of treatment is not
`
`foreseeable in the near future due to the limitations on the availability of safe vectors that
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`provide long-term expression of LDL receptor gene. Thus, the current standard of care in
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`hoFH is LDL apheresis, a physical method of filtering the plasma of LDL-C which as
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`monotherapy can transiently reduce LDL-C by about SO%. Apheresis uses affinity columns
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`to selectively remove apoB-containing lipoproteins. However, because of rapid re(cid:173)
`
`accumulation of LDL-C in plasma, apheresis has to be repeated frequently (every 1-2 weeks)
`
`and requires 2 separate sites for IV access. Although anecdotally this procedure may delay
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`the onset of atherosclerosis,
`
`it
`
`is
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`laborious, expensive, and not readily available.
`
`Furthermore, although it is a procedure that is generally well tolerated, the fact that it needs
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`frequent repetition and IV access can be challenging for many of these young patients.
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`Therefore, there is a tremendous unmet medical need for new medical therapies for hoFH.
`
`[0016] Patients with heterozygous FH can usually be successfully treated with combination
`
`drug therapy to lower the LDL-C to acceptable levels. In contrast, hoFH is unresponsive to
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`conventional drug therapy and thus there are limited treatment options. Specifically,
`
`treatment with statins, which reduce LDL-C by inhibiting cholesterol synthesis and
`
`upregulating the hepatic LDL receptor, have negligible effect in patients whose LDL
`
`receptors are non-existent or defective.
`
`[0017] In July 2004, the NCEP published a paper entitled "Implications of Recent Clinical
`
`Trials for
`
`the National Cholesterol Education Program Adult . Treatment Panel III
`
`Guidelines", updating certain elements of the "Adult Treatment Panel III (A TP III)"
`
`cholesterol guidelines released in 2001. For high-risk patients, individuals who have coronary
`
`heart disease (CHD) or disease of the blood vessels to the brain or extremities, or diabetes, or
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`multiple (2 or more) risk factors that give them a greater than 20 percent chance of having a
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`heart attack within 10 years, the A TP III update recommends that the overall goal for high(cid:173)
`risk patients is still an LDL less than 100 mgldL with a therapeutic option to set the goal at an
`
`LDL less than 70 mgldL for very high-risk patients, those who have had a recent heart attack,
`or those who have cardiovascular disease combined with either diabetes, or severe or poorly
`
`controlled risk factors (such as continued smoking), or metabolic syndrome (a cluster of risk
`factors associated with obesity that includes high triglycerides and low HDL cholesterol).
`
`The ATP III update also recommends consideration of drug treatment in addition to lifestyle
`therapy for LDL levels 100 mgldL or higher in high-risk patients, and characterizes drug
`treatment as optional for LDL less than 100 mg/dL. For moderately high-risk patients,
`individuals who have multiple (2 or more) CHD risk factors together with a 10-20 percent
`
`risk for a heart attack within 10 years, the ATP III update recommends the overall goal for
`moderately high-risk patients to be an LDL less than 130 mgldL. There is a therapeutic
`option to set the treatment goal at an LDL less than 100 mg/dL, and to use drug treatment if
`LDL is 100-129 mg/dL. For high-risk and moderately high-risk patients, the A TP III update
`advises that the intensity of LDL-lowering drug treatment in high-risk and moderately high(cid:173)
`risk patients be sufficient to achieve at least a 30 percent reduction in LDL levels.
`[0018] Patients suffering from severe hypercholesterolemia may also be unable to reach the
`new goals for LDL and HDL described above. For example, a large number of patients may
`be unable to attain LDL levels less than 70 using maximally tolerated current methodologies.
`[0019] Abetalipoproteinemia is a rare genetic disease characterized by extremely low
`cholesterol and TG levels, absent apolipoprotein (apo) B-containing lipoproteins in plasma,
`fat malabsorption, severe vitamin E deficiency, and progressive spinocerebellar and retinal
`degeneration. It has been determined that mutations in the MTP were the genetic cause of
`abetalipoproteinemia. MTP is responsible for transferring lipids, particularly TG, onto the
`assembling chylomicron and VLDL particles in the intestine and the liver, respectively.
`Although the mechanisms by which lipoproteins are formed are not completely understood, it
`is currently believed that the assembly of apoB containing lipoproteins requires two steps.
`The first step occurs within the endoplasmic reticulum that involves the synthesis of particles
`that contain only a small fraction of the lipid core found in the secreted lipoprotein. A larger
`core of lipid is added to the nascent particle in a second step. MTP is thought to be essential
`for the transfer of lipid to the apoB during the first step of the process. In the absence of
`functional MTP, chylomicrons and VLDL are not effectively assembled or secreted in the
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`circulation and apoB is likely targeted for degradation. VLDL serves as the metabolic
`precursor to LDL and the inability to secrete VLDL from the liver results in the absence of
`LDL in the blood. The concept that MTP may regulate apoB lipoprotein assembly is
`supported by observations in mice models. In heterozygous knockout mice MTP mRNA,
`protein and activity have been reported approximately half of normal and the apoB plasma
`concentration was reduced about 30%. Dramatic reduction of apoB-1 00 concentration in
`plasma was also seen in liver-specific MTP knockout mice. The finding that MTP is the
`genetic cause of abetaliproteinemia and that is involved in apoB-containing particles
`
`assembly and secretion led to the concept that pharmacologic inhibition of MTP might be a
`successful strategy for reducing atherogenic lipoproteins levels in humans.
`
`impact on the treatment of atherosclerosis and
`tremendous
`[0020] Because of the
`cardiovascular disease that can be derived from the pharmacologic inhibition of hepatic
`
`secretion of apoB containing lipoproteins, several MTP inhibitors have been developed. Both
`in vitro and in vivo animal studies with these compounds support the concept that inhibition
`of MTP results in inhibition of apoB containing lipoproteins secretion and consequent
`reduction of plasma cholesterol levels. Interestingly, the animal studies cited above had been
`conducted in Watanabe-heritable hyperlipidemic (WHHL) rabbits and LDLR-/- mice, two
`models for hoFH.
`[0021] Bristol-Myers Squibb (BMS) developed a series of compounds, including BMS-
`201 038, as potent inhibitors of MTP-mediated neutral
`lipid transfer activity. These
`compounds are described, for example, in U.S. Patents 5, 789,197, 5,883, I 09, 6,066,653, and
`6,492,365, each of which is incorporated herein by reference in its entirety. MTP inhibitors
`are described throughout U.S. Patent 6,066,653, in particular in columns 3-28. In in vitro
`
`studies, BMS-201038 appears to inhibit lipid transfer by directly binding to MTP. In cell
`culture studies, the IC50 for inhibition of apoB secretion by BMS-201 038 was much lower
`than that for apoAI secretion (0.8 nM vs 6.5 ~), indicating that the compound is a highly
`selective inhibitor of apoB secretion. The efficacy to inhibit accumulation of triglyceride-rich
`particles in plasma of rats after injection of Triton is similar in both fed and fasted states,
`suggesting that both intestinal and hepatic lipoprotein secretions are inhibited by this
`compound. Six-month toxicity studies were conducted by BMS in rats and dogs and their
`results are detailed in IND# 50,820. Doses tested were 0, 0.02, 0.2, 2.0, and 20 mglkg in rats
`and 0, 0.01, 0.1, 1.0, and 10 mglkg in dogs. Dose-related lipid accumulation in the liver and
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`small intestine correlated with decrease in serum TG and cholesterol levels. These changes
`
`are a consequence of the pharmacologic effects of BMS-20 1038. In rats, but not in dogs,
`doses of 0.2 mg/kg and higher were associated with subacute inflammation and single-cell
`necrosis of hepatocytes and histiocytosis (phospholipidosis) in the lungs. The hepatic
`accumulation of lipids was reversed in rats at the end of a 1-month washout period. Studies in
`animals indicated that BMS-201038 effectively reduced plasma cholesterol levels in a dose
`dependent manner. BMS-201038 was found to be effective in reducing cholesterol levels in
`rabbits that lack a functional LOL receptor: The E050 value for lowering cholesterol was 1.9
`mg/kg and a dose of 10 mglkg essentially normalized cholesterol levels with no alteration in
`plasma AST or ALT. This study, conducted in the best accepted animal model for the
`homozygous FH, indicated that MTP inhibition by BMS-20 1038 might be effective in
`
`substantially reducing cholesterol levels in patients with hoFH.
`[0022] Clinical development ofBMS-201038 as a drug for large scale use in the treatment of
`hypercholesterolemia has been discontinued, because of significant and
`serious
`
`hepatotoxicities. For example, gastrointestinal side effects, elevation of serum transaminases
`and hepatic fat accumulation were observed, primarily at 25mg/day or higher doses. Thus,
`
`there is a need to develop methods for treating hyperlipidemia and/or hypercholesterolemia
`that are efficacious in lowering serum cholesterol and LDL, increasing HDL serum levels,
`
`preventing coronary heart disease, and/or treating diseases associated with hyperlipidemia
`and/or hypercholesterolemia, without the side-effects associated with known treatments.
`
`SUMMARY OF THE INVENTION
`
`[0023] The present invention relates to methods of treating disorders associated with
`hypercholesterolemia and/or hyperlipidemia.
`
`[0024] In some embodiments the invention relates to methods of treating a subject suffering
`
`from a disorder associated with hyperlipidemia and/or hypercholesterolemia. The methods
`comprise administering to the subject an amount of an MTP inhibitor effective to ameliorate
`the disorder, wherein said administration comprises at least three step-wise, increasing
`dosages of the MTP inhibitor. In some embodiments the MTP inhibitor has the structure:
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`or a pharmaceutically acceptable salt thereof or the piperidine N-oxide thereof.
`
`[0025] The present invention further provides methods for inhibiting MTP in a subject in
`
`need thereof. The methods comprise administering to the subject an amount of an MTP
`
`inhibitor effective to inhibit MTP, wherein said administration comprises at least three step(cid:173)
`
`wise, increasing dosages of the MTP inhibitor.
`
`[0026] The present
`
`invention provides kits for
`
`treating a disorder associated with
`
`hyperlipidemia and/or hypercholesterolemia in a subject, comprising at least three sets of
`
`pharmaceutical dosage units; and instructions for use.
`
`DETAILED DESCRIPTION OF THE INVENTION
`
`[0027] The present invention is based on the surprising discovery that one may treat an
`
`individual who has hyperlipidemia and/or hyperlcholesterolemia with an MTP inhibitor in a
`
`manner that results in the individual not experiencing side-effects normally associated with
`
`the inhibitor, or experiencing side-effects to a lesser degree. Accordingly, the present
`
`invention provides methods of treating a subject suffering from a disorder associated with
`
`hyperlipidemia while reducing side-effects, the method comprising the step of administering
`
`to the subject an effective amount of the MTP inhibitor to ameliorate hyperlipidemia and/or
`
`hypercholesterolemia in the subject according to a treatment regimen that reduces and/or
`
`eliminates side-effects associated with the use ofthe inhibitors.
`
`[0028] By "treatment" is meant at least an amelioration of the symptoms associated with the
`
`pathological condition afflicting the host as well as an amelioration of the side-effects
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`associated with the MTP inhibitor seen in patients treated in accordance with traditional
`
`treatment regimens making use ofMTP inhibitors. "Amelioration" is used in a broad sense to
`
`refer to at least a reduction in the magnitude of a parameter, e.g. symptom, associated with
`
`the pathological condition being treated, such as elevated plasma VLDL or triglyceride
`
`levels, or with a side effect of treatment using the inhibitor, such as GI side-effects or
`
`hepatobiliary side-effects. As such, treatment also includes situations where the pathological
`
`condition, or at least symptoms associated therewith, are completely inhibited, e.g. prevented
`
`from happening, or stopped, e.g. terminated, such that the host no longer suffers from the
`
`pathological condition, or at least the symptoms that characterize the pathological condition,
`
`e.g. plasma VLDL and/or triglyceride levels are returned to normal.
`
`[0029] The present invention also provides methods of treating diseases/disorders associated
`
`with hypercholesterolemia and/or hyperlipidemia comprising administering to a subject an
`
`MTP inhibitor and a further lipid modifying compound. The methods reduce and/or
`eliminate side-effects associated with the use ofMTP inhibitors.
`
`[0030] As used herein, the phrase "disorders associated with hyperlipidemia and/or
`
`hypercholesterolemia" refers to diseases and disorders related to or caused by elevated lipid
`
`or cholesterol
`
`levels.
`
`Such diseases and disorders
`
`include, without
`
`limitation,
`
`hypercholesterolemia, severe hypercholesterolemia, familial combined hyperlipidemia,
`familial hypercholesterolemia, remnant hyperlipidemia, chylomicronemia syndrome and
`
`familial hypertriglyceridemia.
`
`In
`
`some embodiments,
`
`the disease
`
`is
`
`severe
`
`hypercholesterolemia.
`
`In some embodiments, the disease is homozygous/heterozygous
`
`familial hypercholesterolemia. In some embodiments the disease is hypertriglyceridemia.
`
`[0031] Microsomal triglyceride transfer protein {MTP) is known to catalyze the transport of
`triglyceride and cholesteryl ester by preference to phospholipids such as phosphatidylcholine.
`
`It was demonstrated by D. Sharp et al., Nature (1993) 365:65 that the defect causing
`abetalipoproteinemia is in the MTP gene. This indicates that MTP is required for the
`
`synthesis of Apo B-containing lipoproteins such as VLDL, the precursor to LDL. It therefore
`
`follows that an MTP inhibitor would inhibit the synthesis of VLDL and LDL, thereby
`lowering levels ofVLDL, LDL, cholesterol and triglyceride in humans.
`
`[0032] MTP inhibitors belong to the class of polyarylcarboxamides. MTP inhibitors,
`
`methods of use and preparation thereof are known to the art skilled and are described, inter
`alia, in WO 96/26205; U.S. Pat. No. 5,760,246; WO 96/40640; W0-98/27979. Canadian
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`Patent Application Ser. No. 2,09I,I02, U.S. application Ser. No. II7,362, WO 92/26205
`
`published Aug. 29, I996, U.S. application Ser. No. 472,067, filed Jun. 6, I995, U.S.
`application Ser. No. 548,8II, filed Jan. II, I996, U.S. provisional application Ser. No.
`60/0I7,224, filed May 9, I996, U.S. provisional application Ser. No. 60/0I7,253, filed May
`I 0, I996, U.S. provisional application Ser. No. 60/0 I7,254, filed May I 0, I996, U.S.
`provisional application Ser. No. 60/028,2I6, filed Oct. I, I996, U.S. Patent 5,595,872, U.S.
`Patent 5,789,I97, U.S. Patent 5,883,I09, and U.S. Patent 6,066,653. All of the above,
`including structures, are incorporated herein by reference.
`[0033] Pharmacologic inhibition ofMTP with Bristol-Myers Squibb's BMS-20I038, a potent
`inhibitor of MTP, has been shown to reduce low density lipoprotein cholesterol (LDL-C) by
`
`up to 65% in healthy volunteers with hypercholesterolemia. Despite these impressive LDL-C
`reductions, steatorrhea, elevation of serum transaminases and hepatic fat accumulation were
`
`observed, primarily at 25mg/day or higher doses. Thus, Bristol-Myers Squibb decided that
`these side effects made it unlikely that BMS-20I038 could be developed as a drug for large
`scale use in the treatment of hypercholesterolemia. Combinations using MTP inhibitors and
`
`other cholesterol or triglyceride drugs have been previously disclosed (U.S. Patents 6,066,653
`and 5,883, I 09) but suffer the same drawbacks as described above for MTP inhibitors used
`alone.
`[0034] In some embodiments the MTP inhibitors are piperidine, pyrrolidine or azetidine
`compounds. In some embodiments, the MTP inhibitor has a structure as set forth in U.S.
`Patent 6,066653.
`In some embodiments
`the MTP
`inhibitor
`is 9-[4-[4-[[2-(2,2,2-
`trifluoromethyl)-benzoyl]am ino ]-I-piperidinyl]butyi]-N-( 2,2,2-trifluoroethyi)-9H-fluorene-
`9-carboxamide. In some embodiments, the MTP inhibitor is BMS-20I038. As used herein,
`the phrase "BMS-20 I 03 8" refers to a compound known as N-(2,2,2-Tri fluorethyl)-9-[ 4-[ 4-
`[[[ 4'-(trifluoromethyl)[ I, I'biphenyl]-2-Yl]carbonyl]amino ]-I-piperidinyl]butyi]9H-fluorene-
`9-carboxamide, methanesulfonate, having the formula:
`
`-11-
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`CFAD Ex. 1008 (11 of 41)
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`

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`Attorney Docket: AGP-002
`
`or a pharmaceutically acceptable salt thereof or the piperidine N-oxide thereof.
`
`[0035] In some embodiments, MTP activity is inhibited by 10%, 20%, 25%, 30%, 40%, 50%,
`
`60%, 70%, 75%, 80, 90%, 95%, or 100% compared to a MTP activity in an untreated or
`
`control subject. Methods for testing for inhibition ofMTP activity are known to those of skill
`
`in the art and are set forth, for example, in U.S. Patent 5,789,197.
`
`[0036] As used herein, the phrase "untreated or control subject" refers to a subject who has
`
`not been administered an MTP inhibitor in at least three step-wise, increasing dosages.
`
`[0037] In some embodiments, the methods further comprise the administration of other lipid
`
`modifying compounds. As used herein, the phrase "lipid modifying compounds" and the
`
`like, refers to medicaments for treating disorders associated with hypercholesterolemia and/or
`
`hyperlipidemia using standard dosing, e.g. a treatment not including at least three step-wise,
`
`increasing dosages of an MTP inhibitor. Lipid modifying compounds which may be used in
`
`the method of the invention include, without limitation, HMG CoA reductase inhibitors,
`
`cholesterol absorption inhibitors, ezetimide, squalene synthetase inhibitors, fibrates, bile acid
`
`sequestrants, statins, probucol and derivatives, niacin, niacin derivatives, PPAR alpha
`
`agonists, fibrates, PPAR gamma agonists, thiazolidinediones, and cholesterol ester transfer
`
`protein (CETP) inhibitors.
`
`[0038] HMG CoA reductase inhibitors suitable for use herein include, but are not limited to,
`
`mevastatin and related compounds as disclosed in U.S. Pat. No. 3,983,140, lovastatin
`
`(mevinolin) and related compounds as disclosed in U.S. Pat. No. 4,231,938, pravastatin and
`
`related compounds such as disclosed in U.S. Pat. No. 4,346,227, simvastatin and related
`
`-12-
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`CFAD Ex. 1008 (12 of 41)
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`Atto'mey Docket: AGP-002
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`compounds as disclosed in U.S. Pat. Nos. 4,448, 784 and 4,450, 171, with pravastatin,
`
`lovastatin or simvastatin being preferred. Other HMG CoA reductase inhibitors which may
`
`be employed herein
`
`include, but are not limited to, fluvastatin, rosuva, cerivastatin,
`
`atorvastatin, pyrazole analogs of mevalonolactone derivatives as disclosed in U.S. Pat. No.
`
`4,613,61 0, indene analogs of mevalonolactone derivatives as disclosed in PCT application
`
`WO 86/03488, 6-[2-(substituted-pyrrol-1-yl)alkyl]pyran-2-ones and derivatives thereof as
`
`disclosed in U.S. Pat. No. 4,647,576, Searle's SC-45355 (a 3-substituted pentanedioic acid
`
`derivative) dichloroacetate, imidazole analogs of mevalonolactone as disclosed in PCT
`
`application WO 86/07054, 3-carboxy-2-hydroxy-propane-phosphonic acid derivatives as
`
`disclosed in French Patent No. 2,596,393, 2,3-di-substituted pyrrole, furan and thiophene
`
`derivatives as disclosed in European Patent Application No. 0221025, naphthyl analogs of
`
`mevalonolactone as disclosed in U.S. Pat. No. 4,686,237, octahydronaphthalenes such as
`
`disclosed in U.S. Pat. No. 4,499,289, keto analogs of mevinolin (lovastatin) as disclosed in
`
`European Patent Application No. 0, 142, 146 A2, as well as other known HMG CoA reductase
`
`inhibitors. In addition, phosphinic acid compounds useful in inhibiting HMG CoA reductase
`
`suitable for use herein are disclosed in GB 2205837.
`
`[0039] Squalene synthetase inhibitors suitable for use herein include, but are not limited to,
`
`a-phosphonosulfonates disclosed in U.S. application Ser. No. 08/266,888, filed Jul. 5, 1994
`
`(HX59b), those disclosed by Biller etal, J. Med. Chern. 1988, Vol.