Abstract:
The invention relates to a method of treating multiple sclerosis by the use of (Z)-2-cyano-3-hydroxy-but-2-enoic acid-(4′-trifluoromethylphenyl)-amide in combination with another compound, which is effective in the treatment of multiple sclerosis.

Description:
[0001]    This application is a continuation of U.S. application Ser. No. 10/113,078 filed Apr. 1, 2002, now allowed, which claims the benefit of U.S. provisional application Ser. No. 60/281,685 filed Apr. 5, 2001 and Great Britain application No. 0123571.2 filed Oct. 2, 2001. 
     
    
     
       FIELD OF THE INVENTION  
         [0002]    The present invention relates to methods of treating multiple sclerosis. In particular, the present invention relates to the treatment of multiple sclerosis with (Z)-2-cyano-3-hydroxy-but-2-enoic acid-(4′-trifluoromethylphenyl)-amide, commonly known as teriflunomide.  
         BACKROUND OF THE INVENTION  
         [0003]    (Z)-2-cyano-3-hydroxy-but-2-enoic acid-(4′-trifluoromethylphenyl)-amide (teriflunomide) has the structure illustrated in Formula I:  
                         
 
         Formula I  
         [0004]    It is an active metabolite of the disease-modifying, antirheumatic drug 5-methylisoxazole-4-carboxylic-(4-trifluoromethyl)-anilide commonly known as lefunomide, the structure of which is shown in Formula II. Lefunomide was first disclosed generically in U.S. Pat. No. 4,087,535, issued on May 2, 1978 and specifically in U.S. Pat. No. 4,284,786, issued on Aug. 18, 1981, wherein it was disclosed that the compound could be used for the treatment of multiple sclerosis. The aforementioned patents are both incorporated herein by reference.  
                         
 
           [0005]    (Z)-2-cyano-3-hydroxy-but-2-enoic acid-(4′-trifluoromethylphenyl)-amide (teriflunomide, Formula 1) use in treating chronic graft-versus-host disease has been disclosed in U.S. Pat. No. 4,965,276 issued on Oct. 23, 1990, incorporated herein by reference. U.S. Pat. No. 5,459,163 issued on Oct. 21, 1997 and U.S. Pat. No. 5,679,709 issued on Oct. 21, 1997 disclose compositions useful for treating autoimmune diseases in particular lupus erythematosus. Both of the aforementioned patents are incorporated herein by reference. Teriflunomide has been shown to produce antiproliferative effects on a wide variety of immune cells and cell lines (Cherwinski H. M., et al., J Pharmacol. Exp. Ther. 1995;272:460-8; Prakash A., et al., Drugs 1999;58(6):1137-66; Bartlett R. R. et al., Agent Action 1991;32(1-2):10-21). Additionally, it inhibits the enzyme dihydrooate dehydrogenase, an enzyme essential for the synthesis of pyrimidines (Bruneau J-M, et al., Biochem. J. 1998; 336:299-303).  
           [0006]    Multiple sclerosis (MS) is a debilitating, inflammatory, neurological illness characterized by demyelination of the central nervous system. The disease primarily affects young adults with a higher incidence in females. Symptoms of the disease include fatigue, numbness, tremor, tingling, dysesthesias, visual disturbances, dizziness, cognitive impairment, urologic dysfunction, decreased mobility, and depression. Four types classify the clinical patterns of the disease: relapsing-remitting, secondary progressive, primary-progressive and progressive-relapsing (S. L. Hauser and D. E. Goodkin, Multiple Sclerosis and Other Demyelinating Diseases in Harrison&#39;s Principles of Internal Medicine 14 th  Edition, vol. 2, Mc Graw-Hill, 1998, pp.2409-2419).  
           [0007]    The exact etiology of MS is unknown; however, it is strongly suspected that the demyelination characteristic of the disease is the result of an autoimmune response perhaps triggered by an environmental insult, e.g. a viral infection. Specifically, it is hypothesized that MS is caused by a T-cell-mediated, autoimmune inflammatory reaction. The autoimmune basis is strongly supported by the fact that antibodies specific to myelin basic protein (MBP) have been found in the serum and cerebrospinal fluid of MS patients and these antibodies along with T-cells that are reactive to MBP and other myelin proteolipids increase with disease activity. Furthermore, at the cellular level it is speculated that T-cell proliferation and other cellular events, such as activation of B cells and macrophages and secretion of cytokines accompanied by a breakdown of the blood-brain barrier can cause destruction of myelin and oligodendrocytes (R. A. Adams, M. V. Victor and A. H. Ropper eds, Principles of Neurology, Mc Graw-Hill, New York, 1997, pp.903-921).  
           [0008]    At the present time there is no cure for MS. Current therapies are aimed at alleviating the symptoms of the disease and arresting its progress, as much as possible. Depending upon the type, drug treatment usually entails the use of disease-modifying agents such as the interferons (interferon beta 1-a, beta 1-b and alpha 2), glatiramer acetate or coritcosteroids such as methylprednisolone and prednisone. Also, chemotherapeutic agents such as methotrexate, azathioprine, cladribine, cyclophosphamide and cyclosporine have been used. All the above treatments have side-effect liabilities, little or no effect on fatigue and depression, limited effects on relapse rates and on ability to prevent exacerbation of the disease. Therefore, there still exists a strong need for new drugs, which can be used alone or in combination with other drugs to combat the progression and symptoms of MS.  
         SUMMARY OF THE PRESENT INVENTION  
         [0009]    The present invention is a method of treating multiple sclerosis in patients by administering a compound of Formula I or a pharmaceutically acceptable salt thereof, in a therapeutically effective amount to treat the disease. The present invention also comprises a method of treating multiple sclerosis in patients by administering a combination of a compound of Formula I or a pharmaceutically acceptable salt thereof, with another compound known to be effective for the treatment of multiple sclerosis in therapeutically effective amounts to treat the disease.  
         DETAILED DESCRIPTION OF THE INVENTION  
         [0010]    Terms used herein have the meanings defined in this specification.  
           [0011]    a) “Pharmaceutically acceptable salts” means either an acid addition salt or a basic addition salt, whichever is possible to make with the compounds of the present invention.  
           [0012]    “Pharmaceutically acceptable acid addition salt” is any non-toxic organic or inorganic acid addition salt of the base compounds represented by Formula I. Illustrative inorganic acids which form suitable salts include hydrochloric, hydrobromic, sulfuric and phosphoric acid and acid metal salts such as sodium monohydrogen orthophosphate and potassium hydrogen sulfate. Illustrative organic acids, which form suitable salts include the mono-, di- and tri-carboxylic acids. Illustrative of such acids are, for example, acetic, glycolic, lactic, pyruvic, malonic, succinic, glutaric, fumaric, malic, tartaric, citric, ascorbic, maleic, hydroxymaleic, benzoic, hydroxybenzoic, phenylacetic, cinnamic, salicyclic, 2-phenoxybenzoic, p-toluenesulfonic acid and sulfonic acids such as methanesulfonic acid and 2-hydroxyethanesulfonic acid. Either the mono- or di-acid salts can be formed, and such salts can exist in either a hydrated or substantially anhydrous form. In general, the acid addition salts of these compounds are more soluble in water and various hydrophilic organic solvents and which in comparison to their free base forms, generally demonstrate higher melting points.  
           [0013]    “Pharmaceutically acceptable basic addition salts” means non-toxic organic or inorganic basic addition salts of the compounds of Formula I. Examples are alkali metal or alkaline-earth metal hydroxides such as sodium, potassium, calcium, magnesium or barium hydroxides; ammonia, and aliphatic, alicyclic, or aromatic organic amines such as methylamine, trimethylamine and picoline. The selection of the appropriate salt may be important so that the ester is not hydrolyzed. The selection criteria for the appropriate salt will be known to one skilled in the art.  
           [0014]    b) “Patient” means a warm blooded animal, such as for example rat, mice, dogs, cats, guinea pigs, and primates such as humans.  
           [0015]    c) “Treat” or “treating” means to alleviate symptoms, eliminate the causation of the symptoms either on a temporary or permanent basis, or to prevent or slow the appearance of symptoms of the named disorder or condition.  
           [0016]    d) “Therapeutically effective amount” means an amount of the compound, which is effective in treating the named disorder or condition.  
           [0017]    e) “Pharmaceutically acceptable carrier” is a non-toxic solvent, dispersant, excipient, adjuvant or other material which is mixed with the compound of the present invention in order to permit the formation of a pharmaceutical composition, i.e., a dosage form capable of administration to the patient. One example of such a carrier is pharmaceutically acceptable oil typically used for parenteral administration.  
           [0018]    f) “Stereoisomers” is a general term for all isomers of the individual molecules that differ only in the orientation of their atoms in space. It includes mirror image isomers (enantiomers), geometric (cis/trans) isomers, and isomers of compounds with more than one chiral center that are not mirror images of one another (diastereoisomers).  
           [0019]    g) “Lefunomide” is the generic name for 5-methylisoxazole-4-carboxylic-(4-trifluoromethyl)-anilide.  
           [0020]    h) “Teriflunomide” is the generic name for (Z)-2-cyano-3-hydroxy-but-2-enoic acid-(4′-trifluoromethylphenyl)-amide.  
           [0021]    The synthesis of the compound of Formula 1 has been disclosed, and is accomplished by methods that are well known to those skilled in the art. For example, U.S. Pat. No. 5,504,084, issued on Apr. 2, 1996, and U.S. Pat. No. 5,990,141, issued on Nov. 23, 1999 disclose methods of synthesis. The aforementioned patents are incorporated herein by reference. One synthesis as disclosed in U.S. Pat. No. 5,990,141 is illustrated in Scheme 1.  
                         
 
           [0022]    In Scheme 1, step A commercially available cyanoacetic acid ethyl ester is reacted with commercially available 4-trifluoromethylaniline neat at elevated temperature to give cyanoacet-(4-trifluoromethyl)anilide. In step B, the product from step A is dissolved in tetrahydrofuran and reacted with NaH in acetonitrile followed by reaction with acetyl chloride to produce the compound of Formula I.  
           [0023]    One method of showing the utility of the present compound as a pharmaceutical that may be useful for the treatment of various conditions associated with the MS is its antiproliferative effects on a wide variety of immune cells, which is supported by its ability to inhibit the inflammatory effects of experimental allergic encephalomyelitis in laboratory animals.  
           [0024]    Experimental allergic encephalomyelitis (EAE) is an animal model for MS, which entails inducing a T-cell-mediated autoimmune disease against myelin basic protein in certain susceptible mammalian species. The EAE model is an appropriate method for studying the inflammation of the brain and spinal cord associated with MS (see Bolton, C. Mult. Scler. 1995;1(3);143-9).  
           [0025]    In treating a patient afflicted with a condition described above, a compound of Formula (I) can be administered in any form or mode which makes the compound bioavailable in therapeutically effective amounts, including orally, sublingually, buccally, subcutaneously, intramuscularly, intravenously, transdermally, intranasally, rectally, topically, and the like. One skilled in the art of preparing formulations can determine the proper form and mode of administration depending upon the particular characteristics of the compound selected for the condition or disease to be treated, the stage of the disease, the condition of the patient and other relevant circumstances. For example, see Remington&#39;s Pharmaceutical Sciences, 18th Edition, Mack Publishing Co. (1990), incorporated herein by reference.  
           [0026]    The compound of the present invention may be administered orally, for example, in the form of tablets, troches, capsules, elixirs, suspensions, solutions, syrups, wafers, chewing gums and the like and may contain one or more of the following adjuvants: binders such as microcrystalline cellulose, gum tragacanth or gelatin; excipients such as starch or lactose, disintegrating agents such as alginic acid, Primogel, corn starch and the like; lubricants such as magnesium stearate or Sterotex; glidants such as colloidal silicon dioxide; and sweetening agents such as sucrose or saccharin may be added or a flavoring agent such as peppermint, methyl salicylate or orange flavoring. When the dosage unit form is a capsule, it may contain, in addition to materials of the above type, a liquid carrier such as polyethylene glycol or a fatty oil. Other dosage unit forms may contain other various materials, which modify the physical form of the dosage unit, for example, as coatings. Thus, tablets or pills may be coated with sugar, shellac, or other enteric coating agents. A syrup may contain, in addition to the present compounds, sucrose as a sweetening agent and certain preservatives, dyes and colorings and flavors.  
           [0027]    The compound of Formula I of this invention may also be administered topically, and when done so the carrier may suitably comprise a solution, ointment or gel base. The base, for example, may comprise one or more of petrolatum, lanolin, polyethylene glycols, bee wax, mineral oil, diluents such as water and alcohol, and emulsifiers and stabilizers.  
           [0028]    The solutions or suspensions may also include one or more of the following adjuvants: sterile diluents such as water for injection, saline solution, fixed oils, polyethylene glycols, glycerine, propylene glycol or other synthetic solvents; antibacterial agents such as benzyl alcohol or methyl paraben; antioxidants such as ascorbic acid or sodium bisulfite; chelating agents such as ethylene diaminetetraacetic acid; buffers such as acetates, citrates or phosphates and agents for the adjustment of tonicity such as sodium chloride or dextrose. The parenteral preparation can be enclosed in ampules, disposable syringes or multiple dose vials.  
           [0029]    The dosage range at which the compound of Formula I exhibits its ability to act therapeutically can vary depending upon its severity, the patient, the formulation, other underlying disease states that the patient is suffering from, and other medications that may be concurrently administered to the patient. Generally, the compound of Formula I will exhibit their therapeutic activities at dosages of between about 0.001 mg/kg of patient body weight/day to about 100 mg/kg of patient body weight/day.  
           [0030]    All cites to publications and patents herein are hereby incorporated by reference.  
           [0031]    The following example is being presented to further illustrate the invention. However, it should not be construed as limiting the invention in any manner. 
       
    
    
     EXAMPLE  
     Rat Experimental Allergic Encephalomyelitis (Rat EAE)  
       [0032]    Experimental allergic encephalomyelitis (EAE) is a T-cell-mediated autoimmune disease of the nervous system that develops in susceptible animals following sensitization with either whole spinal cord homogenate or a component (myelin basic protein). The EAE rodent model is an appropriate tool for studying the inflammation of the brain and spinal cord observed in MS patients. In rodents, injection of whole spinal cord or spinal cord components such as myelin basic protein induces an autoimmune response based on the activation of T-lymphocytes. Clinical disease typically becomes manifest around day 10 after inoculation, observed as a broad spectrum of behavioral anomalies ranging from mild gait disturbances and tail atony to complete paralysis and death. Weight loss typically occurs. In animals that survive, spontaneous recovery occurs, accompanied by the recovery of most motor function. Depending on the species, allergen, and methodology used, animals tested by the EAE model may experience a single (acute EAE) or several (chronic relapsing EAE) attacks. Several treatment paradigms may be used: the drug or treatment of choice may be administered before immunization, during the nonsymptomatic period or during the clinical disease.  
         [0033]    Animals:  
         [0034]    Female Lewis rats, 160-220 g (Charles River)  
         [0035]    Antigen:  
         [0036]    Whole Guinea Pig spinal cord (Harlan Biosciences).  
         [0037]    Complete Freund&#39;s adjuvant H37 Ra [1 mg/ml  Mycobacterium Tuberculosis  H37 Ra] (Difco).  
         [0038]    Additional Antigen:  
         [0039]    [0039] Mycobacterium Tuberculosis  (Difco).  
         [0040]    [0040] Bordetella Pertussis  [Heat Killed] (Difco).  
         [0041]    Antigen preparation: (for approximately 720 animals)  
         [0042]    1. Weigh 5 grams of frozen guinea pig spinal cord.  
         [0043]    2. Add 5 g spinal cord to 5 ml 0.9% saline (1 g/ml) in a round bottom centrifuge tube  
         [0044]    3. Homogenize on ice with the Tissue-tech until the tissue is completely disrupted (approximately 5 minutes).  
         [0045]    4. Add 10 ml Complete Freund&#39;s adjuvant H37 Ra supplemented with 200 mg  Mycobacterium Tuberculosis  (20 mg/ml Complete Freund&#39;s adjuvant H37 Ra).  
         [0046]    5. Extract homogenate/adjuvant from tube by sucking it into a 10 ml syringe fitted with an 18 gauge emulsifying needle.  
         [0047]    6. Emulsify between two 30 ml glass syringes until it becomes difficult to continue passing the material through the needle. (Approximately 5 minutes {there must be no separation between the oil phase and the aqueous phase}).  
         [0048]    7. Use immediately or keep on ice until needed (not more than 30 min) (do not freeze).  
       Protocol  
       [0049]    1. Female Lewis rats (Charles River) are given free access to food and water and should be acclimated a minimum of 3 days before use in experiments.  
         [0050]    2. Rats weighing 160 and 220 grams are initially induced with 5% isoflurane (Aerrane, Fort Dodge), 30% O 2 , 70% N 2 O for 2-5 minutes.  
         [0051]    3. The rat is then placed onto a circulating water heating blanket (Gaymar) (dorsal surface up) and into the nose cone for spontaneous respiration of anesthetic gases. The isoflurane is reduced to 2%.  
         [0052]    4. Two subcutaneous injections (0.1 ml each) of either antigen or normal saline are made into ventral surface of the hind paws.  
         [0053]    5. The animals are removed from the nose cone, weighed and numbered.  
         [0054]    6. The rats are allowed to awake from anesthesia and are placed into individual cages.  
         [0055]    7. The animals are observed daily for signs of EAE induction (see criteria below)  
                                       STAGE: 0   NORMAL       STAGE 1   Abnormal gate and tail atony       STAGE 2   Mild but definite weakness of one or both hind legs       STAGE: 3   Severe weakness of one or both hind legs or mild ataxia       STAGE: 4   Severe papraparesis and minimal hind leg movement       STAGE: 5   No hind leg movement and paraplegia       STAGE: 6   Moribund state with no spontaneous movement and impaired           respiration.           Increasing degree of front leg involvement and urinary and           fecal incontinence may also occur       STAGE: 7   DEATH                  
 
         [0056]    Treatment was begun on day 10 after immunization. Since the disease symptoms in this model typically appear 10-11 days after inoculation, this time point may be considered to represent the initial phase of an acute episode of MS. It is judged that this delay of the start of treatment mimicks the clinical situation more closely than the traditionally used protocols where drugs are administered at the time of, or even before, inoculation (Teitelbaum D. et al., Proc Natl Acad Sci USA 1999; 96: 3842-3847 and Brod S. A., et al., Ann Neurol 2000; 47:127-131)  
         [0057]    The effect of teriflunomide on symptoms of EAE in rat at various doses is illustrated in FIG. 1. Dexamethasone is included in the figure for comparison.