Patent Description:
This invention relates to treatment of age-related macular degeneration.

Age-related macular degeneration (AMD) is a disease that causes blurred or reduced vision due to the thinning of the macula, a part of retina responsible for clear vision in direct line of sight. AMD affects about <NUM> million individuals worldwide. In the United States, an estimated <NUM> million individuals currently suffer from AMD.

There are two basic types of AMD - dry and wet. About <NUM> to <NUM> percent of the AMD cases are the "dry" (atrophic) type while about <NUM> to <NUM> percent are the "wet" (exudative) type.

The cause of the dry form is multifactorial with genetic, epigenetic, and immunological components. At present, the vitamin and supplement formulations described in Age Related Eye Disease Studies (AREDS and AREDS2) have some benefit in reducing progression rates; however, the results are mixed [Chew, <NUM>]. The late or advanced form of AMD has two types: the dry form with geographic atrophy and the wet form with choroidal neovascularization, which hemorrhage and can cause significant visual loss. The wet form currently is treated with intraocular injections of anti-vascular endothelial growth factor (VEGF) antibodies.

Drusen are small, yellow deposits of fatty proteins that accumulate under the retina and are associated with the onset of AMD. Drusen are disruptive to the retinal pigment epithelium (RPE) and create a pro-inflammatory and toxic environment to the macula. The innate immune system, and Toll-like receptor <NUM> (TLR4) specifically, plays a key role in combating toxic or damage-associated proteins (DAMPs), such as β-amyloid, in the macula and contributes significantly to the pro-inflammatory environment created by drusen as illustrated in <FIG>. The five-year risk of progression is <NUM>% in early AMD, <NUM>% in intermediate AMD, and <NUM>% in intermediate-large AMD as determined by the AREDS study [Davis, <NUM>]. <FIG> shows the relationship between aging and prevalence of early (drusen only) and late [advanced geographic atrophy (GA) or choroidal neovascularization] AMD.

Currently there are no effective preventive measures or treatment available for patients suffering from dry AMD. Accordingly, there is a need for new approaches to treat dry AMD.

<CIT>; <CIT>; <NPL>); <CIT>; <NPL>) and <NPL>) disclose or suggest a usefulness of resveratrol in the treatment of AMD.

Dry AMD is treated by oral administration to a patient afflicted with AMD a therapeutically effective amount of a synergistic combination of a stilbene, a flavonol, and a curcumin compound as active ingredients, as further defined in the claims. The stilbene according to the present invention is resveratrol (R), the flavonol is quercetin (Q), and the curcumin compound is curcumin (C).

Resveratrol, quercetin and curcumin are administered daily in the following amounts: <NUM> to <NUM>,<NUM> milligrams of resveratrol, <NUM> to <NUM>,<NUM> milligrams of quercetin, and <NUM> to <NUM>,<NUM> milligrams (such as <NUM> to <NUM>,<NUM> milligrams) of curcumin, preferably <NUM> to <NUM>,<NUM> milligrams of resveratrol, <NUM> to <NUM>,<NUM> milligrams of quercetin, and <NUM>,<NUM> to <NUM>,<NUM> milligrams of curcumin.

Selected embodiments of the invention are shown and described herein. These embodiments are presented by way of example only. Variations, changes and substitutions will readily occur to those skilled in the art without departing from the invention, which is defined in the claims.

Any subject-matter beyond the scope of the claims is not part of the present invention and provided for reference or comparison purposes only.

Any reference to a method of treatment of the human or animal body by therapy using a certain compound or composition is to be understood as a reference to said compound or composition for use in said treatment.

Unless defined otherwise, all technical and scientific terms used herein have the same meaning as is commonly understood by one skilled in the art to which this invention belongs.

As used herein and in the claims, the singular form "a," "an," and "the" includes plural references unless the context clearly dictates otherwise.

The terms "treatment," or "treating" or "ameliorating" as used in the specification and claims refer to an approach for achieving beneficial or desired results, including but not limited to a therapeutic benefit and/or a prophylactic benefit.

The term "therapeutic benefit" as used in the specification and the claims means eradication or amelioration of the underlying disorder being treated. A therapeutic benefit is achieved with the eradication or amelioration of one or more of the physiological symptoms associated with the underlying disorder such that an improvement is observed in the subject, notwithstanding that the subject may still be afflicted with the underlying disorder. For prophylactic benefit, the present compositions may be administered to a subject at risk of developing a particular affliction or disease, or to a subject reporting one or more of the physiological symptoms of a disease even though a diagnosis of the disease may not have been made.

The term "antagonist" as used in the specification and claims refers to a compound having the ability to inhibit a biological function of a target protein or receptor. Accordingly, the term "antagonist" is defined in the context of the biological role of the target protein or receptor.

The term "effective amount" or "therapeutically effective amount" refers to that amount of active ingredients described herein that is sufficient to achieve the intended effect. The effective amount may vary depending upon the intended application or the subject and disease condition being treated, e.g., the weight and age of the subject, the severity of the disease condition, the manner of administration and the like, which can be determined readily by one skilled in the art. The specific dose may vary depending on the particular compounds that constitute the composition, the dosing regimen to be followed, timing of administration, and the physical delivery system in which the composition is carried.

The "effective amount" or "therapeutically effective amount" is determined using methods known in the art such as the evaluation of drug synergy based on a flow cytometry assay to measure platelet activation and superactivation. This method can be used to determine optimal dose ranges for a group of patients by identifying the most effective dose combination on average. This method can also be used to determine optimal doses and/or optimal dose ranges for individual patients.

The term "pharmaceutically acceptable excipient" as used in the specification and claims includes any and all solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic and absorption retarding agents, and the like. The use of such agents and media for pharmaceutically-active substances is well known in the art. Supplementary active ingredients can also be incorporated into the compositions described herein.

Dosage forms comprise the above-described compounds and a pharmaceutically acceptable carrier therefor. Suitable pharmaceutically acceptable carriers include solids, gels, solutions, emulsions, dispersions, micelles, liposomes, and the like. Pharmaceutically acceptable carriers are those which render the active ingredients amenable to oral delivery and the like.

Compositions embodying the present invention can be prepared in the form of a solid, a gel, a solution, an emulsion, a dispersion, a micelle, a liposome, and the like. The active ingredients are compounded, for example, with a non-toxic, pharmaceutically acceptable carrier for tablets, pellets, capsules, and the like. The carriers include glucose, lactose, gum acacia, gelatin, mannitol, starch paste, magnesium trisilicate, talc, corn starch, keratin, colloidal silica, potato starch, urea, medium chain length triglycerides, dextrans, and other carriers suitable for use in manufacturing preparations, in solid, semisolid, or liquid form.

Compositions containing the active ingredients in a form suitable for oral use are, for example, tablets, troches, lozenges, aqueous or oily suspensions, dispersible powders or granules, emulsions, hard or soft capsules, or syrups or elixirs. Compositions for oral use can be prepared according to any method known to the art for the manufacture of pharmaceutical compositions. Such formulations may contain one or more agents selected from the group consisting of a sweetening agent such as sucrose, lactose, or saccharin, flavoring agents such as peppermint, oil of wintergreen or cherry, coloring agents and preserving agents in order to provide pharmaceutically elegant and palatable preparations. Non-toxic, pharmaceutically acceptable excipients can be, for example (<NUM>) inert diluents such as calcium carbonate, lactose, calcium phosphate or sodium phosphate; (<NUM>) granulating and disintegrating agents such as corn starch, potato starch or alginic acid; (<NUM>) binding agents such as gum tragacanth, corn starch, gelatin or acacia, and (<NUM>) lubricating agents such as magnesium stearate, steric acid or talc. The tablets may be uncoated or they may be coated by known techniques to delay disintegration and absorption in the gastrointestinal tract and thereby provide a sustained action over a longer period. A time delay material such as glyceryl monostearate or glyceryl distearate can be utilized as well.

In some embodiments, compositions for oral use are in the form of hard gelatin capsules wherein the active ingredient is mixed with inert solid diluent(s), for example, calcium carbonate, calcium phosphate or kaolin. In the form of soft gelatin capsules the active ingredients are mixed with water or an oil medium, for example, peanut oil, liquid paraffin, olive oil, and the like.

The term "unit dosage form" as used in the specification and claims refers to physically discrete units suitable as unitary dosages for human subjects, each unit containing a predetermined quantity of active material calculated to produce the desired therapeutic effect in association with the required pharmaceutical diluent, carrier, or vehicle. The specifications for the novel unit dosage forms of this invention are dictated by and directly dependent on (a) the unique characteristics of the active material and the particular therapeutic effect to be achieved, and (b) the limitations inherent in the art of compounding such active material for therapeutic use in humans and animals, as disclosed in detail in the specification, these being features of the present invention. Examples of suitable unit dosage forms in accord with this invention are tablets, capsules, pills, powder packets, granules, wafers, sachets, segregated multiples of any of the foregoing, and other forms as herein described.

The designation "µM," as used herein, denotes the micromolar concentration (<NUM>-<NUM> mol/L) of the indicated compound, e.g., the stilbene, the flavonol, curcumin, and biologically active analogs of curcumin.

The resveratrol, the quercetin and the curcumin preferably are present in the composition as a synergistic combination. The description and composition of each preferred component is shown below.

Resveratrol (trans-resveratrol; <NUM>-[(1E)<NUM>-(<NUM>-hydroxyphenyl)ethenyl]-<NUM>,<NUM>-benzenediol) is a naturally occurring stilbenoid polyphenol found in foods such as grapes (wine), certain berries, and peanuts. In plants, resveratrol is produced as a primary response to oxidative stress, injury, and infection. Resveratrol is found in both the trans- and cis- configurations, however the trans- form is more stable and is the predominant form consumed in the average diet. Resveratrol and trans-resveratrol are used synonymously in this document.

Resveratrol has a range of targets including inflammation, oxidative stress, and angiogenesis. The molecule also has other biological effects including vasodilation and β-amyloid plaque clearance.

Resveratrol is a known dietary supplement in a variety of formulations and has been determined to be GRAS by the FDA (GRAS Notice <NUM>). The average daily consumption of resveratrol is estimated to be between <NUM>-<NUM>/day. It has undergone safety and efficacy testing in numerous clinical trials and has been found to be well-tolerated with low toxicity at doses as high as <NUM> per day.

Quercetin (<NUM>,<NUM>,<NUM>',<NUM>'-flavon-<NUM>-ol) is a polyphenol flavonoid found in onions, blueberries, kale, and a variety of other fruits and vegetables. Quercetin, one of the most common plant flavonoids, is the aglycone form of a number of other flavonoid glycosides such as rutin. Quercetin is safe for consumption in humans and has been declared as GRAS by the FDA (GRAS Notices <NUM>, <NUM>, and <NUM>). The average daily consumption of quercetin in the U. is estimated to be <NUM>-<NUM>. The primary therapeutic effects of quercetin reported in the literature include anti-inflammatory activity, neuroprotective activity, and anti-oxidant activity.

Quercetin is sold as a dietary supplement in a variety of formulations and has undergone safety and efficacy testing in numerous clinical trials. It has been found to be well tolerated and without toxicity in doses as high as <NUM> per day.

Curcumin ((1E,6E)-<NUM>,<NUM>-bis(<NUM>-Hydroxy-<NUM>-methoxyphenyl)-<NUM>,<NUM>-heptadiene-<NUM>,<NUM>-dione) is a naturally occurring diarylheptanoid polyphenol. It is the major curcuminoid found in the roots of turmeric (Curcuma longa L. ), which is a member of the ginger family Zingaberaceae. Curcumin is a polyphenol with anti-inflammatory, anti-oxidant, anti-apoptotic, and neuroprotective effects.

Curcumin, in a variety of formulations, has been determined to be GRAS by the FDA (GRAS Notices <NUM>, <NUM>, and <NUM>). The average daily consumption of curcumin is estimated to be <NUM>-<NUM>. Curcumin has undergone multiple clinical trials, which have all concluded that curcumin is safe for use in humans at high doses. A review of clinical trials with curcumin indicates that it is safe and well tolerated at doses up to <NUM>-<NUM>/day with only minimal side effects which are most often gastrointestinal in nature and resolved naturally or by ingestion with or after meals. No maximum tolerable dose has been reported using curcumin.

Suitable stilbenes for the present compositions are resveratrol (<NUM>,<NUM>,<NUM>'-trihydroxy-trans-stilbene), α,β-dihydroresveratrol (<NUM>,<NUM>',<NUM>-trihydroxybibenzyl), pterostilbene (<NUM>',<NUM>'-dimethoxy resveratrol), pinosylvin (<NUM>',<NUM>-dihydroxy-trans-stilbene), piceatannol (<NUM>,<NUM>,<NUM>',<NUM>'-tetrahydroxy-trans-stilbene), and the like. The preferred stilbene, which is also the one used in the present invention, is resveratrol.

Illustrative covalently binding biologically active derivatives of stilbenes are <NUM>,<NUM>-dihydroxy-<NUM>-fluorosulfonyl-trans-stilbene, <NUM>,<NUM>-dihydroxy-<NUM>-fluorosulfonyloxy-trans-stilbene, <NUM>,<NUM>'-dihydroxy-<NUM>-fluorosulfonyl-trans-stilbene, <NUM>,<NUM>'-dihydroxy-<NUM>-fluorosulfonyloxy-trans-stilbene, and the like.

Suitable flavonols are quercetin (<NUM>,<NUM>',<NUM>',<NUM>,<NUM>-pentahydroxy-<NUM>-phenylchromen-<NUM>-one), <NUM>-hydroxyflavone, azaleatin, fisetin, galangin, gossypetin, kaempferide, kaempferol, isorhamnetin, morin, myricetin, natsudaidain, pachypodol, zhamnazin, zhamnetin, and the like. The preferred flavonol, which is also the one used in the present invention, is quercetin.

Illustrative covalently binding biologically active derivatives of flavonols are <NUM>,<NUM>',<NUM>,<NUM>-tetrahydroxy-<NUM>'-fluorosulfonyl-<NUM>-phenylchromen-<NUM>-one, <NUM>,<NUM>',<NUM>,<NUM>-tetrahydroxy-<NUM>'-fluorosulfonyloxy-<NUM>-phenylchromen-<NUM>-one, and the like.

The term "curcumin compound" means curcumin and its biologically active analogs. The curcumin compound according to the present invention is the compound curcumin.

Suitable biologically active curcumin analogs outside the scope of the present invention are compounds represented by Formula I below,.

wherein Ar<NUM> is a phenyl group or a substituted phenyl group represented by Formula II:
<CHM>
Ar<NUM> is a phenyl group represented by Formula III:
<CHM>
and L is a divalent linking group.

In Formulas II and III each of R<NUM> through R<NUM> is independently hydrogen, hydroxyl, methyl, methoxyl, dimethylamine, trifluoromethyl, chloro, fluoro, acetoxyl, cyano, or carboxymethyl.

The divalent linking group L is an alkylene or an alkenylene having <NUM> to <NUM> backbone carbon atoms wherein one or more of the backbone carbon atoms is part of a carbonyl or a secondary alcohol. The linking group can be saturated or unsaturated. Preferably, linking group L contains at least one unsaturated carbon-carbon bond.

L is preferably an alkylene or an alkenylene selected from the group consisting of: -CH=CH-CHO-, -CH=CH-(CO)-CH=CH-, -CH<NUM>-CH<NUM>-(CO)-CH<NUM>-CH<NUM>-, -CH<NUM>-CH<NUM>-CH(OH)-CH<NUM>-CH<NUM>-,
<CHM>
-CH=CH-(CO)-CR-C(OH)-CH=CH-, -CH=CH-(CO)-CR<NUM>-(CO)-CH=CH-, and -CH=CH-(CO)-CH-C(OH)-CH=CH-; R is an alkyl or aryl group including <NUM> carbon atoms or less.

Illustrative covalently binding biologically active derivatives of TLR4/MD2 receptor antagonists are <NUM>-(cyclopropylmethyl)-<NUM>,5α-epoxy-<NUM>-hydroxy-<NUM>-fluorosulfonyl-morphinan-<NUM>-one, <NUM>-(cyclopropylmethyl)-<NUM>,5α-epoxy-<NUM>-hydroxy-<NUM>-fluorosulfonyloxy-morphinan-<NUM>-one, fluorosulfate derivatives of curcumin, and the like.

Fluorosulfate derivatives of curcumin can be produced by treating available phenolic OH groups of curcumin with sulfuryl fluoride (SO<NUM>F<NUM>) as described in <CIT>.

The foresaid active ingredients can be administered as oral dosage forms such as tablets, capsules (each of which can include sustained release or timed release formulations), pills, and the like.

The dosage regimen utilizing the active ingredients of the present invention is selected in accordance with a variety of factors including type, species, age, weight, sex and medical condition of the patient; the severity of the condition to be treated and the route of administration; the renal and hepatic function of the patient; and the particular composition employed. An ordinarily skilled physician or clinician can readily determine and prescribe the effective amount of the drug required to prevent, counter or arrest the progress of the condition.

To determine the "effective amount," the minimum dose and the maximum possible dose was first calculated for each component in order to form a range of effective doses. The minimum effective dose concentration for each component of RQC is <NUM> R, <NUM> Q, and <NUM> (preferably <NUM>) C, corresponding to daily doses of <NUM>/day R, <NUM>/day, and <NUM> (preferably <NUM>) C based on the bioavailability calculations shown in TABLE <NUM>, below. The maximum dose is defined as the highest dose of each component evaluated in a repeated-dose clinical trial and found to be safe and tolerable. The maximum dose for each component of RQC is <NUM>/day R, <NUM>/day Q, and <NUM>/day C, corresponding to estimated plasma concentrations of <NUM> R, <NUM> Q, and <NUM> C based on the bioavailability calculations in TABLE <NUM>, below. The minimum dose and the maximum dose for each component therefore form the following range of effective doses:.

The dose ranges given above constitute a range of "effective amounts" for each component of RQC. Optimal dosing for the treatment and/or prevention of age-related macular degeneration is determined by an evaluation of synergistic drug interactions and considerations for tolerability and/or experimental findings regarding tolerability.

Synergistic drug interactions are determined using the in-vitro flow cytometry platelet assay described below.

Briefly, platelet-rich plasma (PRP) from patients with age-related macular degeneration (n = <NUM>) are isolated from whole blood and challenged using dual agonists thrombin and convulxin (collagen substitute) to stimulate superactivated platelets (SAPs). SAPs are defined as positive for surface fibrinogen and negative for activated integrin αIIbβ3, whereas activated platelets are defined as negative for surface fibrinogen and positive for activated integrin αIIbβ3. Surface fibrinogen is detected by pre-treating platelets with biotinylated-fibrinogen (<NUM>µg/mL) followed by staining with any common fluorophore conjugated to streptavidin. The streptavidin-fluorophore complex binds to the biotin-fibrinogen complex present on SAPs but not activated platelets due to the differing composition of charged surface proteins. Activated integrin αIIbβ3 - characteristic of activated platelets - is detected using the PAC-<NUM> antibody conjugated to any compatible fluorophore. PAC-<NUM> does not bind to the de-activated form of integrin αIIbβ3 present on the surface of SAPs and is therefore used to distinguish SAPs from the larger population of activated platelets. The effect of RQC on SAPs is determined by pre-treating diluted PRP samples with combinations of R, Q, and/or C for <NUM> minutes at <NUM> followed by challenge with thrombin and convulxin for <NUM> minutes at <NUM>. The samples are then stained with the fluorophore-conjugates and fixed in <NUM>% formalin before analysis using a flow cytometer. SAP percentage is calculated as a percentage of all platelets. The effect size of RQC is determined by the change ion SAP percentage before and after treatment with RQC and is used as input to calculate drug synergy using the CompuSyn software developed by Chou, et al. Drug synergy, additivism, and antagonism are defined as a combination index (CI) score less than, equal to, or greater than <NUM>, respectively. The level of drug synergy can be further stratified by quantile, tertile, or quartile in cases where numerous synergistic doses are compared.

As stated hereinabove, dry AMD is a common disease characterized by retinal pathology. A typical finding of dry AMD is the presence of drusen and/or geographic atrophy. TABLE <NUM> below depicts drusen volume at baseline and after <NUM> months according to drusen size in all participants (C or RQC). TABLE <NUM> below depicts drusen volume at baseline and after <NUM> months according to drusen size in participants taking oral curcumin (<NUM>/day). TABLE <NUM>, below depicts drusen volume at baseline and after <NUM> months according to drusen size in participants taking oral RQC (resveratrol: <NUM>/day, quercetin: <NUM>/day, curcumin: <NUM>/day).

To compare the changes in drusen volume found in this study in subjects taking oral curcumin against what would be expected over the natural course of the disease, optical coherence tomography (OCT) scans were evaluated. OCT is a new retinal imaging technology which is useful to analyze drusen volume and geographic atrophy. Each subject was scanned <NUM> months before treatment. This allowed for the examination of the natural history of a subject's drusen progression compared to progression with treatment.

In total, <NUM> of the <NUM> subjects who completed the study had prior OCT scans available. Over the <NUM> months prior to enrollment, mean drusen volume increased from <NUM> to <NUM><NUM> (<NUM>%).

All drusen, drusen ≥ <NUM>, and drusen <NUM>-<NUM> were significantly decreased by C/RQC treatment. Large drusen are amenable to treatment with C/RQC. Volume is expressed in mm<NUM>.

Standard deviation (SD) is expressed in mm<NUM>. Statistical significance was determined by Wilcoxon Rank Sum test. Drusen volume was measured by manual segmentation using ImageJ software. Drusen size was determined by the widest width of the drusen and expressed in µm. Drusen formation was decreased by C or RQC in all drusen, extra-large drusen ≥ <NUM>, large drusen <NUM>-<NUM>, but not medium drusen <NUM>-<NUM>. Therefore extra-large drusen ≥ <NUM> are highly decreased by <NUM>% and large drusen <NUM>-<NUM> are highly decreased by <NUM>%.

As show in Table <NUM>, all drusen and drusen ≥ <NUM> were significantly decreased by C treatment.

Drusen volume is expressed in mm<NUM>. Standard deviation (SD) is expressed in mm3. Statistical significance was determined by Wilcoxon Rank Sum test. Drusen volume was measured by manual segmentation using ImageJ software. Drusen size was determined by the widest width of the drusen and expressed in µm. In the curcumin group, total macular drusen volume decreased from <NUM> (± <NUM>) to <NUM> (± <NUM>) mm3 (-<NUM>%, p = <NUM>) while drusen <NUM> or larger decreased from <NUM> (± <NUM>) to <NUM> (± <NUM>) mm3 (-<NUM>%, p = <NUM>). AMD subjects taking RQC exhibited greater reductions in total drusen volume (-<NUM>% vs. -<NUM>%, p = <NUM>) and drusen <NUM> or greater (-<NUM>% vs. -<NUM>%, p = <NUM>) than subjects taking curcumin alone.

RQC was more effective than C at reducing drusen volume. All drusen and drusen ≥ <NUM> were significantly decreased by RQC treatment.

Drusen volume is expressed in mm<NUM> Standard deviation (SD) is expressed in mm<NUM>. Statistical significance was determined by Wilcoxon Rank Sum test. Drusen volume was measured by manual segmentation using ImageJ software. Drusen size was determined by the widest width of the drusen and expressed in µm. In the RQC group, total macular drusen volume decreased from <NUM> (± <NUM>) to <NUM> (± <NUM>) mm3 (-<NUM>%, p = <NUM>) while drusen <NUM> or larger decreased from <NUM> (± <NUM>) to <NUM> (± <NUM>) mm3 (-<NUM>%, p = <NUM>). AMD subjects taking RQC exhibited greater reductions in total drusen volume (-<NUM>% vs. -<NUM>%, p = <NUM>) and drusen <NUM> or greater (-<NUM>% vs. -<NUM>%, p = <NUM>) than subjects taking curcumin alone.

As shown in Table <NUM>, above, oral administration of RQC significantly decreased volume in all drusen (p = <NUM>) and drusen ≥ <NUM> (p = <NUM>) compared with curcumin alone. Statistical significance was determined by Wilcoxon Rank Sum test.

Geographic atrophy is an advanced form of dry AMD. The clinical manifestations are variable with characteristic circular, cookie cutter-like areas of atrophy. The retinal atrophy is through the full thickness of the retina including the retinal pigment epithelium (RPE) and involves the choriocapillaris. The choriocapillaris commonly affects the wet form of AMD. At present, there is no treatment modality for geographic atrophy and it cannot be reversed. The goal of treatment is to slow the growth of geographic atrophy.

The effect of RQC and curcumin on geographic atrophy growth was evaluated in a Phase <NUM> study (TABLE <NUM>, below).

Nascent GA, defined as baseline lesion size < <NUM> mm2, was present in <NUM> eyes from <NUM> subjects (<NUM> subject taking curcumin, <NUM> subjects taking RQC). The growth rate of nascent GA is unknown, although nascent GA is known to progress to GA within <NUM>-<NUM> years. Nascent GA was found to have a slower growth rate than GA. The nascent GA growth rate was <NUM><NUM>/year (<NUM>/year adjusted) in subjects taking RQC and <NUM><NUM>/year (<NUM>/year adjusted) in subjects taking curcumin. There was no statistical difference between growth rate of nascent GA in subjects taking RQC and curcumin.

The expected untreated GA growth rate reported in the literature is <NUM><NUM>/year (or <NUM>/year adjusted for baseline lesion area). After <NUM> months of treatment with RQC, the GA growth rate was found to be <NUM><NUM>/year (or <NUM>/year adjusted for baseline lesion area), representing a change of -<NUM>% in adjusted growth rate (mm/year). See TABLE <NUM>, below and <FIG>. The decrease in GA growth rate was highly significant (p = <NUM>) compared with untreated samples [Yehoshua, et al. , <NUM>] and remained highly significant when adjusted for differences in baseline lesion area (p = <NUM>). The GA growth rate of subjects taking RQC was also significantly lower than that of subjects taking curcumin (p = <NUM>). After <NUM> months of treatment with curcumin, the GA growth rate was found to be <NUM><NUM>/year (or <NUM>/year adjusted). The growth rate of subjects treated with curcumin was not significantly different from the untreated population (p = <NUM>).

RQC in triple combinations has been found to be synergistic at all dose levels evaluated including all possible combinations of each component at low, medium, and high doses (<NUM> possible combinations). The dose that exhibits the highest degree of synergy on average in AMD subjects (n=<NUM>) is <NUM> R, <NUM> Q, and <NUM> C, corresponding to a highly synergistic CI score of <NUM>. The optimal in vivo dose therefore corresponds to an available dose (i.e. plasma concentration) of <NUM> R, <NUM> Q, and <NUM> C. After accounting for the bioavailability properties of each component, an in vivo dose of <NUM> R corresponds to about <NUM> consumed, <NUM> Q corresponds to about <NUM> consumed, and <NUM> C corresponds to about <NUM> consumed.

For curcumin, which has a low bioavailability relative to resveratrol and quercetin, two capsules (<NUM> each) achieve a maximum plasma concentration of about <NUM>-<NUM>. This dose taken twice daily accounts for the relatively low half live of curcumin.

The in-vitro dose with the highest average level of synergy was found to be <NUM> R, <NUM> Q, and <NUM> C. After accounting for bioavailability, the given doses of <NUM> R, <NUM> Q, and <NUM> C per day correspond to approximately <NUM> R, <NUM> Q, and <NUM> C, respectively.

The average combination index values of low, medium, and high doses of RQC for the inhibition of SAPs in AMD subjects was determined. The Combination Index (CI) theorem derived by Chou-Talalay [Chou, <NUM>] was calculated for each combination drug treatment of R, Q, and C. The CI is useful in quantifying levels of synergism and antagonism. The theorem is based on the median-effect equation to provide a common link between a single entity and multiple entities. A CI value < <NUM> indicates synergism, a CI equal to <NUM> indicates additivity, and a CI > <NUM> indicates antagonism. RQC was very effective in low, medium, and high doses.

The in vitro analysis of RQC in triple combinations in AMD subjects (n=<NUM>) is displayed in TABLE <NUM> above. Low dose corresponds to <NUM> R, <NUM> Q, and <NUM> C; Medium dose corresponds <NUM> R, <NUM> Q, and <NUM> C; and High dose corresponds to <NUM> R, <NUM> Q, and <NUM> C. RQC in triple combinations at the low, medium, and high dose exhibits a greater degree of synergy compared with any possible double combination of RQ (CI=<NUM>), RC (CI=<NUM>), or QC (CI=<NUM>). RQC exhibits strong synergy in triple combinations at all tested dose levels. The synergy of RQC ranged from <NUM> to <NUM>.

R, Q, and C at three different dose levels each were tested in all possible combinations, resulting in <NUM> possible double and <NUM> possible triple combinations within each subject. The doses tested were R (<NUM>, <NUM>, and <NUM>), Q (<NUM>, <NUM>, and <NUM>), and C (<NUM>, <NUM>, and <NUM>) and the effect was based on the inhibition of SAPs. To obtain the mean number of synergistic doses in each cohort, the average CI score for each dose combination was calculated within each cohort, producing a set of <NUM> double combination CI scores and <NUM> triple combination CI scores per cohort. Out of each set of <NUM> dose combinations, the number of CI scores under <NUM> (highly synergistic) was counted and reported here. For example, in control subjects <NUM> out of <NUM> possible double combinations were synergistic while <NUM> out of <NUM> possible triple combinations were synergistic based on the mean CI for each dose in the cohort. These results are shown in Table <NUM> above, and indicate a significant difference in the synergy between double and triple combinations of RQC in each cohort.

The TLR4 receptor has three pathways leading to downstream activation: (<NUM>) ligand-induced receptor dimerization, (<NUM>) the myeloid differentiation primary response gene <NUM>-(MyD88-) dependent pathway, and (<NUM>) the TIR-domain-containing adapter-inducing interferon-β- (TRIF-) dependent pathway. RQC targets each of these pathways through various mechanisms. First, resveratrol binds to TRIF complex adaptor proteins TANK-binding kinase <NUM> (TBK1) and receptor-interacting serine/threonine-protein kinase <NUM> (RIPK1). Second, quercetin binds TOLL-interacting protein (TOLLIP). Lastly, curcumin binds directly to the TLR4/MD2 complex as well as downstream IKK activity in the MyD88-dependant pathway.

RQC act synergistically in an assay measuring TLR4 inhibition and its effect on the formation of superactivated platelets (SAPs). SAPs are a pro-coagulant subtype of activated platelets increased in subjects with AMD. TLR4 inhibitors reduce SAPs more effectively in subjects with AMD than in healthy controls as shown in Tables <NUM> and <NUM>, below.

In addition, TLR4 inhibitors have inhibitory effects on the complement system through cross-talk mechanisms with TLR4. Evidence suggests that RQC also inhibits complement activity directly. A "dual-blockade" of TLR4 and complement activity is a highly efficient therapeutic strategy for disease with an inflammatory component such as AMD.

RQC acts on TLR4 to reduce formation of SAPs. Individually, the IC50s of R, Q, and C for the reduction of SAPs are <NUM>, <NUM>, and <NUM>, respectively.

A key pathogenic mechanism in AMD is the breakdown of the choroid and RPE. As stated above, the dry form of AMD is characterized by drusen and geographic atrophy. The initial pathology involves the formation of drusen and/or choroidal abnormalities. The typical choroid changes in the dry form include (<NUM>) decrease in the number of choroidal vessels and (<NUM>) abnormal vessel formation. PLVAP is significantly altered in the disease process.

PLVAP is a type II integral membrane glycoprotein with a molecular weight of ~<NUM> kDa. It consists of three sections: a short intracellular tail with a caveolin-<NUM> binding domain, a transmembrane domain, and a long <NUM> amino acid extracellular C-terminal domain with four N-glycosylation sites and two large coiled-coil domains. The coiled-coil domain forms an alpha helix and is hydrophobic to facilitate the formation of an intermolecular superhelix. The helix forms fenestral diaphragms and consist of radial fibrils on their luminal side. PLVAP expression is known to be induced by VEGF through VEGFR-<NUM> and is regulated by the canonical Wnt pathway through β-catenin.

The first evidence of PLVAP occurs embryologically as described by Herrnberger, et al. (<NUM>), who found that PLVAP deficiency is in fact lethal (<FIG>). Electon microscopy has shown that PLAVP deficiency results in protein-losing enteropathy in human infants. Recently, Hernnberger, et al. has shown that PLVAP deficiency remarkably decreases the number of choroidal capillaries and number of fenestrations in the trabecular meshwork [Herrnberger, 2012a/b].

Claim 1:
A compound selected from the group consisting of resveratrol, quercetin, curcumin, and a combination thereof for use in a method of treating age-related macular degeneration (AMD), the method comprising administering to a human subject afflicted with AMD per day <NUM> to <NUM>,<NUM> milligrams of resveratrol, <NUM> to <NUM>,<NUM> milligrams quercetin, and <NUM> to <NUM>,<NUM> milligrams curcumin.