Patent Description:
Myalgic encephalomyelitis (ME), also known as Chronic fatigue syndrome (CFS), refers to a group of debilitating medical conditions characterized by persistent fatigue and other specific symptoms that last for a minimum of six months in adults (and <NUM> months in children or adolescents). This disease is also referred to as systemic exertion intolerance disease (SEID), post-viral fatigue syndrome (PVFS) and chronic fatigue immune dysfunction syndrome (CFIDS).

ME/CFS is characterized by persistent and debilitating fatigue, diffuse musculoskeletal pain, sleep disturbances, neuropsychiatric symptoms and cognitive impairment which cannot be explained by an underlying medical condition. The symptoms of ME/CFS are not caused by ongoing exertion and are not relieved by rest.

ME/CFS is a symptom-based diagnosis or clinical diagnosis without distinguishing physical examination or routine laboratory findings. Infectious, immunological, neuroendocrine, sleep and psychiatric mechanisms have been investigated; however, a unifying etiology for ME/CFS has not yet emerged. The majority of ME/CFS cases start suddenly and they are usually accompanied by a "flu-like illness", while a significant proportion of cases begin within several months of severe adverse stress (<NPL>). Often, there are courses of remission and relapse of symptoms which make the illness difficult to manage. Persons who feel better for a period may overextend their activities, and the result can be a worsening of their symptoms with a relapse of the illness.

ME/CFS often occurs together with other diseases such as fibromyalgia (FM), multiple chemical sensitivities, irritable bowel syndrome and temporomandibular joint disorder. In particular, co-morbidity with fibromyalgia has been studied (Afari N et al, supra). Fibromyalgia is a nonarticular rheumatic syndrome characterized by myalgia and multiple points of focal muscle tenderness to palpation (trigger points). Patients with FM often experience muscle pain aggravated by inactivity or exposure to cold. This condition is often associated with general symptoms, such as sleep disturbances, fatigue, stiffness, headaches and occasionally depression.

Despite the contrasting definitions of the two disorders, <NUM> - <NUM> % of patients with fibromyalgia also meet the criteria for chronic fatigue syndrome, and conversely, <NUM> - <NUM> % of those with chronic fatigue syndrome-like illnesses have concurrent fibromyalgia (Afari N et al, supra).

ME/CFS is a common disorder. Estimates of the prevalence of ME/CFS range from <NUM> % to <NUM> % in the general adult population and is lower in children and adolescents (Afari N et al, supra). The prevalence of the related fibromyalgia (FM) is <NUM> - <NUM> %. This means that in Sweden at least <NUM><NUM> patients suffer from ME/CFS and <NUM><NUM> from FM (for review see <NPL>).

Many patients suffering from ME/CFS experience significant functional impairment. Nearly all patients with ME/CFS notice a decrease in social relationships in addition to other unwanted consequences of illness; about one-third are unable to work or study, and another one-third can only work part-time (Afari N et al, supra). Many patients suffering from ME/CFS also experience depression symptoms and are diagnosed with clinical depression, and likewise, patients who suffer from depression often experience symptoms of debilitating fatigue.

Currently, patients suffering from ME/CFS are treated by cognitive behavioral therapy (CBT) or graded exercise therapy (GET), which have shown moderate effectiveness in multiple randomized controlled trials, however many patients do not make recovery (<NPL>;<NPL>). At present, medication plays a minor role in disease management (<NPL>).

<CIT> discloses a method of treatment for persons meeting diagnoses for major depressive disorder, or other unipolar (non-bipolar, nonpsychotic and non-treatment resistant) depression. The method comprises administering a combination of two categories of drugs, antipsychotics or dopamine system stabilizers, in combination with a newer antidepressant such as a selective serotonin reuptake inhibitor, as initial treatment or as soon as possible.

<CIT> discloses a pharmaceutical composition that comprises a carbostyril derivative and a serotonin reuptake inhibitor in a pharmaceutically acceptable carrier. The carbostyril derivative may be aripiprazole or a metabolite thereof, which is a dopamine-serotonin system stabilizer. The serotonin reuptake inhibitor may be fluoxetine, duloxetine, venlafaxine, milnacipran, citalopram, fluvoxamine, paroxetine, sertraline or escitalopram. The pharmaceutical composition of the present invention is for treating patients with mood disorders, particularly depression or major depressive disorder.

<CIT> discloses the use of a heterocyclic amine-type compound, a substituted phenylazacycloalkane-type compound, or a cabergoline-type compound to prepare a medicament for the treatment of symptoms of fibromyalgia syndrome, or chronic fatigue syndrome.

<CIT> discloses the use of a dopamine stabilizing substance in an oral, subcutaneous or intramuscular daily dose of <NUM> -<NUM> or in an intravenous daily dose of <NUM> -<NUM> in treatment of a neurological or psychiatric disorder characterized by a hypofunction of the dopamine system. The use of a dopamine stabilizing substance in an oral, subcutaneous or intramuscular daily dose of <NUM>-<NUM> in treatment of a disorder caused by instability of neural circuits is also disclosed.

Chi-Un Pae et aldiscuss fatigue syndrome (CFS), the poor understanding of the pathophysiological mechanisms underlying CFS. and how current evidence indicates similarities in symptomatology, and possibly etiology and pathogenesis, between CFS and depression. The review provides a summary of available data related to antidepressants and other psychotropic agents in CFS.

Abdallah Hadj Tahar et al. discuss the compound (S)-(-)-<NUM>-(<NUM>-(methylsulfonyl)phenyl)-<NUM>-propylpiperidine ((-)-OSU6162) and the effect of (-)-OSU6162, on L-<NUM>,<NUM>-dihydroxyphenylalanine (L-DOPA)-induced dyskinesias in a primate model of Parkinson's disease. The generated data suggests that (-)-OSU6162 could be of clinical value to reduce L-DOPA-induced dyskinesias in fluctuating advanced Parkinson's disease patients.

Moncrieff et al. present a historical study of the emergence of the concept of the antidepressant and the social forces that influenced its adoption.

Nilsson, M. reported on a study that investigated the safety and effectiveness of (-)-OSU6162 in patients with myalgic encephalomyelitis/chronic fatigue syndrome. (-)-OSU6162 was found to be safe and well tolerated; (-)-OSU6162 was not found to differ significantly from placebo in alleviating fatigue in ME patients but was superior to placebo in counteracting fatigue in a subgroup of ME patients who received concomitant pharmacological treatment for depression.

Additionally, many disorders, in addition to ME/CFS and FM, are characterized by symptoms of debilitating fatigue. Such disorders include mental fatigue, post stroke fatigue, Huntington's disease, Parkinson's disease, multiple sclerosis, narcolepsy, post cancer fatigue, fatigue associated with cancer with or without cytostatic treatment, depression and combinations thereof.

Thus there is a large need for novel therapies and treatments to alleviate fatigue symptoms, such as ME/CFS associated fatigue symptoms and fatigue symptoms associated with other clinical indications, and thus the provision thereof remains a matter of substantial interest within the field.

It is an object of the present disclosure to provide to a new and efficient treatment for patients who are suffering from disorders characterized by persistent and debilitating fatigue.

It is an object of the present disclosure to provide a medicament for use in the treatment of said patients.

It is another object of the present disclosure to provide a method of treatment of a disorder characterized by debilitating fatigue for patients in need thereof.

These and other objects which are evident to the skilled person from the present disclosure are met by different aspects of the invention as claimed in the appended claims and as generally disclosed herein.

The present inventors have unexpectedly found that the clinical outcome of treatment of disorders characterized by debilitating fatigue is significantly improved by the combination of a dopamine stabilizing agent and an anti-depressive agent.

Thus, in the first aspect of the disclosure, there is provided a dopamine stabilizing agent and an anti-depressive agent for use in the treatment of one or more symptoms of a disorder characterized by debilitating fatigue;.

Thus, said dopamine stabilizing agent can be (<NUM>)-<NUM>-[<NUM>-(methylsulfonyl)phenyl]-<NUM>-propylpiperidine or a pharmaceutically acceptable salt thereof. In one embodiment of the present disclosure, said dopamine stabilizing agent may be (<NUM>)-<NUM>-[<NUM>-(methylsulfonyl)phenyl]-<NUM>-propylpiperidine hydrochloride.

Dopamine stabilizing substances of formula I and pharmaceutically acceptable salts thereof have been described in <CIT>. <CIT> discloses the compounds belonging to this group and also gives the definitions for the different terms used - see in particular column <NUM>, line <NUM> - column <NUM>, line <NUM>. <CIT> also discloses how these compounds may be obtained - see in particular column <NUM>, lines <NUM>-<NUM> and the Examples.

According to one embodiment, said dopamine stabilizing agent for use in the treatment as described herein is in the form of a pure enantiomer or a pharmaceutically acceptable salt thereof, such as a pure S-enantiomer or a pharmaceutically acceptable salt thereof.

As stated above, the dopamine stabilizing agent may be a pharmaceutically acceptable salt of a compound of (<NUM>)-<NUM>-[<NUM>-(methylsulfonyl)phenyl]-<NUM>-propylpiperidine or a pharmaceutically acceptable salt thereof. The term "pharmaceutically acceptable salt(s)", as used herein, means those salts of compounds of the disclosure that are safe and effective for oral, subcutaneously, intramuscularly or intravenously administration in mammals and that possess the desired biological activity. Pharmaceutically acceptable salts include salts of acidic or basic groups present in compounds of the invention. Pharmaceutically acceptable acid addition salts include, but are not limited to, hydrochloride, hydrobromide and hydroiodide.

Thus, in one embodiment, there is provided a dopamine stabilizing agent of (<NUM>)-<NUM>-[<NUM>-(methylsulfonyl)phenyl]-<NUM>-propylpiperidine or a pharmaceutically acceptable salt thereof for use in the treatment as described herein, wherein said pharmaceutically acceptable salt is hydrochloride, hydrobromide or hydroiodide, such as hydrochloride. In one embodiment, said pharmaceutically acceptable salt is a hydrochloride of said compound. In one embodiment, said pharmaceutically acceptable salt is (<NUM>)-<NUM>-[<NUM>-(methylsulfonyl)phenyl]-<NUM>-propylpiperidine hydrochloride.

As used herein, the terms "antidepressants" and "anti-depressive agents" refer to medicaments used for the treatment of a major depressive disorder, which is a mental disorder characterized by a pervasive and persistent low mood that is accompanied by low self-esteem and by a loss of interest or pleasure in normally enjoyable activities; and other similar medical conditions. A non-limiting list of major types on anti-depressive agents includes selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs).

One major class of anti-depressive agents are selective serotonin reuptake inhibitors (SSRIs) which increase the extracellular level of the neurotransmitter serotonin by inhibiting its reuptake into the presynaptic cell and thus increase the level of serotonin in the synaptic cleft available to bind to the postsynaptic receptor. Non-limiting examples of SSRI include citalopram, fluvoxamine, escitalopram, paroxetine, sertaline and fluoxetine. Another large class of anti-depressive agents are serotonin-norepinephrine reuptake inhibitors (SNRIs) which are potent inhibitors of the reuptake of serotonin and norepinephrine. Non-limiting examples of SNRIs include venlafaxine, milnacipran, duloxetine, levomilnacipran, desvenlafaxine and sibutramine. Thus, in one embodiment, there is provided a dopamine stabilizing agent and an anti-depressive agent for use in the treatment of a disorder characterized by debilitating fatigue as described herein, wherein said anti-depressive agent is selected from the group consisting of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). In one embodiment, said anti-depressive agent is selected from the group consisting of selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRI) or combinations thereof. In one embodiment, said selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) is selected from the group consisting of escitalopram, citalopram, sertraline, fluoxetine, paroxetine, duloxetine, fluvoxamine, dapoxetine, indalpine, zemelidinem, venlafaxine, desvenlafaxine, milnacipran, levomilnacipran and sibutramine or combinations thereof, such as the group consisting of escitalopram, citalopram, sertraline, fluoxetine, paroxetine, fluvoxamine, dapoxetine, indalpine, zemelidinem venlafaxine, desvenlafaxine, milnacipran, levomilnacipran and sibutramine or combinations thereof. In another embodiment, said selective serotonin reuptake inhibitors (SSRI), serotonin-norepinephrine reuptake inhibitors (SNRI) is selected from the group consisting of escitalopram, citalopram, sertraline, fluoxetine, paroxetine, duloxetine and venlafaxine or combinations thereof, such as the group consisting of escitalopram, citalopram, sertraline, fluoxetine, paroxetine and venlafaxine or combinations thereof.

As mentioned above, the present disclosure is based on the unexpected finding that the clinical outcome of treatment of disorders characterized by debilitating fatigue is significantly improved by the combination of a dopamine stabilizing agent and an anti-depressive agent in the patient. The skilled person will appreciate that a patient may have a therapeutically effective concentration in blood of a dopamine stabilizing agent as defined above and of an anti-depressive agent, irrespective of in which order said agents are administered relative to each other. In other words, the skilled person will appreciate that the co-administration of said agents may be simultaneous or concomitant. As used herein, the term "co-administration" refers to the administration of two or more drugs together, such as administration of the dopamine stabilizing agent as defined herein and an anti-depressive agent.

Thus, in one embodiment, there is provided a dopamine stabilizing agent and an anti-depressive agent for use in treatment as described herein, wherein said use involves concomitant or simultaneous co-administration of said agents. Concomitant administration may be co-administration, wherein said dopamine stabilizing agent and said anti-depressive agent are administered within a predefined time period (irrespective of which agent is administered first). For example, the predefined time period may be <NUM> hours, <NUM> hours, <NUM> hours, <NUM> hours, <NUM> hours or <NUM> hour. Thus, in one embodiment there is provided a dopamine stabilizing agent and an anti-depressive agent for use as defined herein, wherein said co-administration is concomitant administration within less than <NUM> hours, such as within less than <NUM> hours, such as within less than <NUM> hours, such as within less than <NUM> hours, such as within less than <NUM> hours, such as within less than <NUM> hour. In another embodiment, said administration is simultaneous. It will be appreciated that the patient may be on ongoing treatment with an anti-depressive agent at the time point of starting said co-administration, such as treatment that has been ongoing for at least <NUM> months, such as at least <NUM> months, such as at least <NUM> month, such as at least <NUM> weeks.

In one embodiment, there is provided a dopamine stabilizing agent and an anti-depressive agent for use in the treatment as described herein, wherein at least one or both agents is/are administered orally, subcutaneously, intramuscularly or intravenously, such as orally. The skilled person will appreciate that one or both of said agents may be administered by any one of said administration routes. For example, said dopamine stabilizing agent may be administered subcutaneously while said anti-depressive agent may be administered orally. Alternatively, both agents may be administered by the same administration route. It will be appreciated that non-invasive administration may generally be preferable. Thus, in one embodiment, said dopamine stabilizing agent and said at least one anti-depressive agent are administered orally. In one embodiment, said administration is in a dose of approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM> or such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as <NUM> or <NUM>.

In one embodiment, said administration is at a dose of approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as <NUM> and in another embodiment, said dose is approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as <NUM>.

In one embodiment, wherein said dopamine stabilizing agent is administered orally said dose is approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as <NUM> or <NUM>. When the administration is subcutaneous or intramuscular, it may be suitable that the administered dose corresponds to approximately half of the oral dose. Thus, in one embodiment, wherein said dopamine stabilizing agent is administered subcutaneously or intramuscularly, the dose is approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as approximately <NUM> ,<NUM> or <NUM>.

In another embodiment, wherein the dopamine stabilizing agent is administered intravenously, the dose of said agent is approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>.

In order to obtain high patient compliance, that is the degree to which a patient correctly follows medical advice, it is generally considered that the treatment regimes may not be complex in order to for a patient to be able to easily follow them. For example, it may be preferable that the administration of a drug is once, twice or three times a day, such as twice or once a day. Thus, in one embodiment, there is provided a dopamine stabilizing agent and an anti-depressive agent for use as described herein, wherein said dopamine stabilizing agent is administered once, twice or three times a day, such as once or twice a day. To clarify, thus the dopamine stabilizing agent may for example be administered orally twice a day in a dose of <NUM>, resulting in a daily dose of <NUM>. For example, it may be preferred that said dopamine stabilizing agent and an anti-depressive agent are concomitantly administered once, twice or three times a day, such as once or twice a day. It will be appreciated, that said dopamine stabilizing agent and said anti-depressive agent may be administered a different number of times a day. For example, said dopamine stabilizing agent may be administered twice a day and said anti-depressive agent may be administered once a day.

As disclosed in the Example section, superior patient outcomes were observed in patients whose blood plasma concentration of dopamine stabilizing agent was approximately <NUM>-<NUM>. In particular, superior outcomes were observed in patients whose blood plasma concentration of dopamine stabilizing agent was approximately <NUM>-<NUM>. Thus, in one embodiment there is provided a dopamine stabilizing agent and at least one anti-depressive agent for use as described herein, wherein, upon administration, the therapeutically effective blood plasma concentration of said dopamine stabilizing agent is approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>.

As disclosed in the Example section of the present disclosure, a dopamine stabilizing agent as defined herein and an anti-depressive agent may be useful in the treatment of a disorder characterized by debilitating fatigue, which disorder often includes symptoms such as persistent and/or recurrent debilitating fatigue, diffuse musculoskeletal pain, sleep disturbances and subjective cognitive impairment. Non-limiting examples of such disorders include myalgic encephalomyelitis (ME), also known as chronic fatigue syndrome (CFS), which refers to a group of debilitating medical conditions characterized by persistent and debilitating fatigue, diffuse musculoskeletal pain, sleep disturbances, neuropsychiatric symptoms and cognitive impairment that last for a minimum of at least six months in adults. ME/CFS often occurs together with other diseases such as fibromyalgia (FM), multiple chemical sensitivities, irritable bowel syndrome and temporomandibular joint disorder. Additionally, a number of other disorders are also characterized by disabling fatigue. A non-limiting list of such diseases includes FM, mental fatigue, post stroke fatigue, Huntington's disease, Parkinson's disease, multiple sclerosis, narcolepsy, post cancer fatigue, ADHD, depression and combinations thereof. Additionally, fatigue may be associated with cancer with or without cytostatic treatment. The skilled person will appreciate that the disorder characterized by disabling fatigue may be a fatigue disorder or a pain disorder.

Thus, in one embodiment, there is provided a dopamine stabilizing agent and an anti-depressive agent as described herein for use in the treatment of a disorder characterized by persistent and debilitating fatigue, wherein said disorder is selected from the group consisting of myalgic encephalomyelitis/chronic fatigue syndrome, fibromyalgia, mental fatigue, post stroke fatigue, Huntington's disease, Parkinson's disease, multiple sclerosis, narcolepsy, post cancer fatigue, fatigue associated with cancer with or without cytostatic treatment, depression and combinations thereof.

In one embodiment, said fatigue disorder is characterized by at least one of the conditions selected from fibromyalgia, mental fatigue, myalgic encephalomyelitis/chronic fatigue syndrome and depression. In one embodiment, said disorder is selected from the group consisting of fibromyalgia, mental fatigue, myalgic encephalomyelitis/chronic fatigue syndrome, Huntington's disease and depression. In another embodiment, said disorder is a pain disorder characterized by at least one of the conditions selected from of fibromyalgia, mental fatigue myalgic encephalomyelitis/chronic fatigue syndrome- and depression. In one embodiment, said disorder is ME/CFS. In one embodiment, said disorder is mental fatigue. In one embodiment, said disorder is depression and in another embodiment, said disorder is fibromyalgia. In one embodiment, said disorder is a combination of two or more above mentioned disorders, such as a combination selected from the group of: a combination of myalgic encephalomyelitis/chronic fatigue syndrome and fibromyalgia; a combination of myalgic encephalomyelitis/chronic fatigue syndrome and mental fatigue; a combination of myalgic encephalomyelitis/chronic fatigue syndrome and depression; a combination of mental fatigue and depression; a combination of fibromyalgia and depression; and a combination of mental fatigue and fibromyalgia. In one embodiment, said combination is selected from: a combination of myalgic encephalomyelitis/chronic fatigue syndrome, mental fatigue and fibromyalgia; a combination of myalgic encephalomyelitis/chronic fatigue syndrome, mental fatigue and depression; a combination of myalgic encephalomyelitis/chronic fatigue syndrome, depression and fibromyalgia; a combination of depression, mental fatigue and fibromyalgia.

The skilled person will appreciate that the embodiments discussed above in relation to the first aspect of the present disclosure, are equally relevant and applicable to the second, third, fourth, fifth, sixth, seventh and eighth aspect disclosed herein. This particularly applies to embodiments relating to the identity of the dopamine stabilizing agent, the identity of the anti-depressive agent, as well as, where applicable, the mode and route of administration as well as amounts of agents administered. For the sake of brevity these will not be repeated here or will only be briefly mentioned.

In a second aspect of the present disclosure, there is provided a pharmaceutical composition comprising a dopamine stabilizing agent that is (<NUM>)-<NUM>-[<NUM>-(methylsulfonyl)phenyl]-<NUM>-propylpiperidine or a pharmaceutically acceptable salt thereof; and an anti-depressive agent selected from the group consisting of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs).

In one embodiment, said pharmaceutical composition further comprises at least one pharmaceutically acceptable excipient or carrier. Non-limiting examples of excipients includes diluents, disinteragrants, binders, lubricants, glidants and agents that modify release of the active agent, such as polymers. The skilled person is aware of suitable excipients and carriers.

In another embodiment, said pharmaceutical composition further comprises at least one additional active agent. In one embodiment, said additional agent is an anti-fatigue agent, such as a stimulant, for example a caffeine-based stimulant or a central nervous system stimulating agent, such as methylphenidate and various amphetamines.

In one embodiment, there is provided a pharmaceutical composition as described herein comprising an amount of dopamine stabilizing agent of approximately <NUM>-<NUM>, such as <NUM>-<NUM>, such as approximately <NUM>-<NUM> or such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as <NUM> or <NUM>. In one embodiment, said amount is approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as <NUM> and in another embodiment, said amount is approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as <NUM>.

In one embodiment, said pharmaceutical composition is formulated for oral, subcutaneous, intramuscular or intravenous administration. As discussed above, it will be appreciated that non-invasive administration may be generally preferable. In one particular embodiment, said pharmaceutical composition is formulated for oral administration.

In one embodiment, wherein said pharmaceutical is formulated for oral administration, the pharmaceutical composition comprises approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as <NUM> or <NUM> of dopamine stabilizing agent. When said pharmaceutical is formulated for subcutaneous or intramuscular administration, it may be suitable that the administered dose corresponds to approximately half of the oral dose. Thus, in one embodiment wherein said pharmaceutical is formulated for subcutaneously or intramuscularly administration, the pharmaceutical composition comprises approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as approximately <NUM>,<NUM> or <NUM>.

In another embodiment, wherein said pharmaceutical composition is formulated for intravenous administration, the pharmaceutical composition comprises approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM> dopamine stabilizing agent.

In one embodiment, there is provided a pharmaceutical composition formulated as a pill, tablet, capsule, dragee, liquid, gel capsule, syrup, slurry or suspension, such as a pill.

In one embodiment, there is provided a pharmaceutical composition formulated for administration once, twice or three times a day, such as once or twice a day.

In one embodiment, there is provided a pharmaceutical composition for use as described herein, said composition being formulated to provide, upon administration, a therapeutically effective blood plasma concentration of said dopamine stabilizing agent of approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>.

It is furthermore contemplated that the dopamine stabilizing agent as defined herein and an anti-depressive agent are combined into a combination kit.

For example, a combination kit could comprise a dosage form of said dopamine stabilizing agent as described herein and a dosage form of an anti-depressive agent. Additionally, said kit may comprise printed matter with information and/or a suitable box container for storage of said agents.

The kit is envisioned to provide all components necessary for the administration of the dopamine stabilizing agent and the anti-depressive agent in a safe and convenient manner. For example, if the dopamine stabilizing agent and the anti-depressive agent are to be administered separately in tablet or pill form, it may be suitable for the kit to comprise an indicator for indicating that a corresponding number of tablets or pill of each types has been administered. In the instance when at least one of said agents is to be administered by injection, said kit may comprise an injection device. Thus, kits for administration by injection, such as subcutaneous, intramuscular or intravenous injection are also contemplated. Such kits may comprise said dopamine stabilizing agent and said anti-depressive agent in the same container, in form of a solution or powder or the like. Also contemplated are kits wherein said dopamine stabilizing agent and said at least one anti-depressive agent are present in separate containers. Said kits may furthermore comprise for example an injection device and/or written information.

Thus, in third aspect of the present disclosure, there is provided a combination kit comprising a dopamine agent as defined herein and an anti-depressive agent as defined herein.

In one embodiment of the present aspect, there is provided a combination kit wherein said dopamine stabilizing agent and said anti-depressive agent are formulated for concomitant or simultaneous administration. Kits comprising oral dosage forms are contemplated, for example kits wherein said dopamine stabilizing agent and said anti-depressive agent are present in one pill, tablet, capsule, dragee, liquid, gel capsule, syrup, slurry or suspension (or other suitable form); and kits wherein said dopamine stabilizing agent and said anti-depressive agent are present as separate pills, tablets, capsules, dragees, liquids, gel capsules, syrups, slurrys or suspensions (or other suitable forms).

In one embodiment, said combination kit is formulated to comprise an amount of dopamine stabilizing agent of approximately <NUM>-<NUM> such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM> or such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as <NUM> or <NUM>.

In one embodiment, said amount is approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as <NUM> and in another embodiment, said amount is approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as <NUM>.

In one embodiment, said combination kit is formulated for oral, subcutaneous, intramuscular or intravenous administration and in another embodiment, said combination kit is formulated for oral administration.

In one embodiment, said kit is formulated for oral administration and comprises approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as <NUM> or <NUM> dopamine stabilizing agent. When said kit is formulated for subcutaneous or intramuscular administration, it may be suitable that the administered dose corresponds to approximately half of the oral dose. Thus, in one embodiment wherein said kit is formulated for subcutaneously or intramuscularly administration, the pharmaceutical composition comprises approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>, such as approximately <NUM> ,<NUM> or <NUM>. In another embodiment, said kit is formulated intravenous administration and comprises approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM> dopamine stabilizing agent.

In one embodiment, said combination kit is formulated for administration once, twice or three times a day, such as once or twice a day.

In one embodiment, said combination kit is formulated such that, upon administration, the therapeutically effective blood plasma concentration of said dopamine stabilizing agent is approximately <NUM>-<NUM>, such as approximately <NUM>-<NUM>.

As disclosed in the Example section of the present disclosure, the dopamine stabilizing agent or pharmaceutical composition comprising the same may be useful for the treatment of a disorder characterized by debilitating fatigue in a subject on treatment with at least one anti-depressive agent (AD). It will be appreciated that the subject may have been on ongoing treatment with an anti-depressive agent for at least <NUM> months, such as at least <NUM> months, such as at least <NUM> month, such as at least <NUM> weeks.

Thus, in a fourth aspect of the present disclosure there is provided a dopamine stabilizing agent as described herein for use in the treatment of a disorder characterized by debilitating fatigue in a subject on treatment with at least one anti-depressive agent. It will be appreciated that said subject may be suffering from a disorder characterized by debilitating fatigue as described above and that the mode and route of administration of said dopamine stabilizing agent and the amount administered may be as described above. In one embodiment of this aspect, said subject is on treatment with an anti-depressive agent as described above.

In the fifth aspect of the present disclosure, there is provided a method for the treatment of a disorder characterized by persistent and debilitating fatigue, wherein the method comprises administering to a subject in need thereof a therapeutically effective dose of a dopamine stabilizing agent, wherein said subject is on treatment with an anti-depressive agent and wherein said dopamine stabilizing agent is as defined above. In one embodiment, said subject in on treatment with an anti-depressive agent selected from the anti-depressive agents defined above.

In a related, sixth aspect of the present disclosure, there is provided a method of treatment of a disorder characterized by persistent and debilitating fatigue, the method comprising co-administration, to a subject in need thereof, of a therapeutically effective dose of a dopamine stabilizing agent as defined above and a therapeutically effective dose of an anti-depressive agent. In one embodiment, said anti-depressive agent may be selected from the anti-depressive agents defined above. It will be appreciated, that in the context of the sixth aspect of the present disclosure, said co-administration may be concomitant or simultaneous, such as concomitant administration within less than <NUM> hours, such as within less than <NUM> hours, such as within less than <NUM> hours, such as within less than <NUM> hour or such as simultaneous co-administration.

In embodiments of the fifth and sixth aspects of the present disclosure, the disorder characterized by debilitating fatigue may be as described above and the mode and route of administration as well as amount administrated may be as described above.

The references to any method of therapeutic treatment described above are to be interpreted as references to compounds, pharmaceutical compositions, and medicaments of the present invention for use in these methods.

As described in the Example section to follow, the clinical outcome of administration of a dopamine stabilizing agent and an anti-depressive agent to a subject suffering from a disorder as described herein or of administration of a dopamine stabilizing agent as described herein to a subject on treatment with an anti-depressive agent, may be evaluated by the following tests and questionnaires. The skilled person is aware of the applicability of these test for the evaluation of fatigue and depression related symptoms.

As used herein, the term "Clinical Global Impression" (CGI) refers to a rating scale commonly used to measure symptom severity, treatment response and the efficacy of treatments in treatment studies of patients with mental disorders (<NPL>).

As used herein "Clinical Global Impression of Change" (CGI-C) (also known as Clinical Global Impression - Improvement (CGI-I)) scale is a <NUM> point scale that requires the clinician to assess how much the patient's illness has improved or worsened relative to a baseline state at the beginning of the intervention. The ratings are as follows: <NUM>, very much improved; <NUM>, much improved; <NUM>, minimally improved; <NUM>, no change; <NUM>, minimally worse; <NUM>, much worse; or <NUM>, very much worse.

As used herein, the term "MFS" refers to a the mental fatigue self-assessment questionnaire (<NPL>).

Additionally, the clinical outcome of the treatment may be evaluated using the FF-scale, The Beck/BDI scale, VAS pain scale and by neuropsychological tests.

As used herein, the term "FF-scale" or "FF" refers to the FibroFatigue scale also known as the fibromyalgia and chronic fatigue syndrome rating scale described in by Zachrisson and coworkers (<NPL>). The FibroFatigue scale is an observer's rating scale with <NUM> items measuring pain, muscular tension, fatigue, concentration difficulties, failing memory, irritability, sadness, sleep disturbances, and autonomic disturbances and irritable bowel, headache and subjective experience of infection.

As used herein, the terms "Beck/BDI scale" and "BD" refers to the Beck Depression Inventory created by Aaron T. Beck (<NPL>). It is a <NUM>-question multiple-choice self-report inventory and one of the most widely used instruments for measuring the severity of depression. The BDI questionnaire is designed for individuals aged <NUM> and over, and is composed of items relating to symptoms of depression such as hopelessness and irritability, cognitions such as guilt or feelings of being punished, as well as physical symptoms such as fatigue, weight loss, and lack of interest in sex.

As used herein, the term "VAS pain scale" refers to the visual analog scale for measuring a patient's pain intensity or other features. The VAS scale is a psychometric response scale and is often used in questionnaires. It is a measurement instrument for subjective characteristics or attitudes that cannot be directly measured. When responding to a VAS item, respondents specify their level of agreement to a statement by indicating a position along a continuous line between two end-points.

As used herein, the term "neuropsychological tests" refers to tests designed to measure unobserved constructs, also known as latent variables. Psychological tests are typically, but not necessarily, a series of tasks or problems that the respondent has to solve and measure a respondent's maximum performance. The neuropsychological tests employed in this study are described in Example <NUM>.

This study employs statistical evaluations of obtained data. The skilled person is aware of and knows how to employ the tests used herein. Any deviations from standard calculations procedures are explained in the Example section of the disclosure. Briefly, the statistics test employed herein are as follows:
The Mann-Whitney U test (also called the Mann-Whitney-Wilcoxon (MWW), Wilcoxon rank-sum test (WRS), or Wilcoxon-Mann-Whitney test) is a nonparametric test of the null hypothesis that two populations are the same against an alternative hypothesis, especially that a particular population tends to have larger values than the other.

The <NUM>-way interaction analysis (<NUM>-way analysis of variance (ANOVA)) is a test that examines the influence of two different categorical independent variables on one continuous dependent variable. The two-way ANOVA not only aims at assessing the main effect of each independent variable but also at assessing if there is any interaction between them.

The <NUM>-way interaction analysis (<NUM>-way analysis of variance (ANOVA)) is a test that examines if there is a <NUM>-way interaction that varies across levels of a third variable.

Spearman's rank correlation coefficient is a nonparametric measure of statistical dependence between two variables. It assesses how well the relationship between two variables can be described using a monotonic function. If there are no repeated data values, a perfect Spearman correlation of +<NUM> or -<NUM> occurs when each of the variables is a perfect monotone function of the other.

While the invention has been described with reference to various exemplary aspects and embodiments, it will be understood by those skilled in the art that various changes may be made and equivalents may be substituted for elements thereof without departing from the scope of the invention. Therefore, it is intended that the invention not be limited to any particular embodiment contemplated, but that the invention will include all embodiments falling within the scope of the appended claims.

The following Examples disclose the outcome of a phase II clinical study aiming at investigating the therapeutic effects of the S enantiomer of (<NUM>)-<NUM>-[<NUM>-(methylsulfonyl)-phenyl]-<NUM>-propylpiperidine hydrochloride (herein interchangeably referred to as OSU6162 and (-)-OSU6162) for the treatment of ME/CFS as measured by mental fatigue self-assessment (MFS) questionnaire and Clinical Global Impression of Change (CGI-C) as well as some other additional parameters. The study was performed as a double-blind placebo-controlled study, wherein half of the patients were administered the active drug and the other half were administered placebo. Importantly, the study demonstrated significantly improved outcomes in a subgroup of patient who were treated with an anti-depressive agent compared to the corresponding sub-group being treated by OSU6162 without any anti-depressive treatment.

The study was performed in accordance with the current version of the declaration of Helsinki (52nd WMA General Assembly, Edinburgh, Scotland, October <NUM>) and in compliance with the requirements of the Medical Products Agency of Sweden. The trial was conducted in agreement with the International Conference on Harmonisation (ICH) guidelines on Good Clinical Practise (GCP). All patients provided written informed consent to participate in the study prior to being screened.

<FIG> shows an overview of the study performed. The overview shows when, where and what data was collected from the patients at each instance.

The Fukuda criteria and the International Consensus Criteria (ICC) for diagnosis of ME/CFS were applied as inclusion criteria in this study.

The ICC for the diagnosis ME was presented in the <NPL>) and are an update of the previously used Fukuda (<NPL>) and Canadian Criteria (<NPL>).

Patients were recruited from the ambulatory service at the Gottfries Clinic AB. <NUM> patient were screened and <NUM> did not meet the inclusion criteria for various reasons (significant pathological lab finding and not permitted concomitant medication: <NUM> patient; significant pathological lab findings: <NUM> patients; depression: <NUM> patients; high blood pressure: <NUM> patients; diagnostic criteria ME not fulfilled: <NUM> patient; concomitant medications: <NUM> patients; post commotio cerebri: <NUM> patient; pregnancy: <NUM> patient; cancelation by patient due to night work: <NUM> patient; drop-out: <NUM> patient; technical mistake with study drug by research nurse: <NUM> patients) resulting in a group of <NUM> patients which were randomized.

Medication that is known/judged not to interfere with OSU6162 was permitted. Medications which were not permitted were anti-epileptics or antipsychotics.

Patients with active substance abuse, pregnant women, women of childbearing age not on contraceptives and patients with abnormal laboratory parameters (e.g. Hb, white blood cells count, electrolytes, tests of liver and kidney functions, TSH, T4, B12, folic acid) judged to be of clinical significance were not accepted.

Unstable therapies were not allowed but stable therapies were allowed. A stable therapy is defined as having started at least <NUM> months before the study and continued to be unchanged during the study period. Examples of such therapies are treatments with anti-depressants. Other stable therapies with hypnotics and anxiolytics were also allowed if they were given at doses recommended by the manufacturers.

Furthermore, analgesics such as NSAIDs, e.g. acetyl salicylic acid, paracetamol and duloxetine were permitted as well as stable anti-hypertensive therapy. Acute or chronic medications for other medical conditions were allowed based on clinical judgment.

Occasional use of over-the-counter (OTC) medications was allowed at the investigator's discretion.

All concomitant medications, whether OTC or prescription, were noted.

Patients were free to withdraw from the study at any time without giving a reason. Patients were advised that a request to withdraw from the study, at any time during the trial, would have no negative consequences. The investigators could also withdraw patients from the trial if they deemed it appropriate for safety or ethical reasons or if they considered further participation in the study detrimental to the well-being of the patient. Patients who withdrew or were withdrawn underwent a final evaluation as soon as possible.

Any adverse event (AE) or serious adverse event (SAE) were reported and to the Ethics committee according to regulations.

To summarize, <NUM> patient were included in the study population and <NUM> patient withdrew from the study (Table <NUM>). One patient in the OSU6162 treatment group, who lacked detectable levels of plasma OSU6162 was not included in the analysis.

The study was performed as a double-blinded placebo-controlled study, where half of the patients received the active drug and the other half received placebo. Circular coated tablets for oral use of <NUM> and matching placebos was used. The tablets were administered by research nurses at the study site.

The investigated substance is the S enantiomer with the chemical name (S)-<NUM>-[<NUM>-(methylsulfonyl) phenyl]-<NUM>-propylpiperidine hydrochloride, referred herein to as OSU6162. The substance is a white powder with a melting point of <NUM>-<NUM> and water solubility of > <NUM>/ml.

OSU6162 belongs to a group of compounds called dopaminergic stabilizers which modulate dopaminergic transmission.

Randomization of patients participating in the study was done by an external agent. The randomization procedure was performed in agreement with CONSORT (Consolidated Standards of Reporting Trials) guidelines.

Tablets were delivered in sets of <NUM> packages of tablets containing <NUM> with active substance and <NUM> with placebo. Procedures were taken to guarantee blinding and the code was kept in a locked drawer at the study site. All persons dealing with the patients were blinded towards active drug or placebo.

The tablets were circular coated tablets for oral use containing <NUM> OSU6162. Matching placebos were used. The start dose was <NUM> OSU6162 twice daily (before breakfast and lunch) during <NUM> week with dose increase up to <NUM> twice daily during the following week.

The dosage was individually flexible which means that if a patient experienced adverse events, the dose was reduced with <NUM> OSU6162 (one tablet), thus continuing with <NUM> once daily taken in the morning.

Total period for active drug treatment for each participant was two weeks.

All study treatment was administered by the study investigator or designated member of staff. To ensure drug accountability the investigator or designated deputy maintained accurate records of the dates and amounts of drug received, to whom it was dispensed and accounts of any supplies which were accidentally or deliberately destroyed; these details were recorded on a drug accountability form. All unused clinical supplies and the drug accountability forms were returned to the sponsor at the end of the study.

Efficacy was measured according to ratings using the self-assessment questionnaire for mental fatigue and related symptoms (MFS) after neurological disorders and injuries (Johansson et al, supra). Another primary endpoint was the result of the rating by the Clinical Global Impression of Change (Guy, supra), which rating was made by the doctor in charge of the patient. CGI-C scores range from <NUM> (very much improved) through to <NUM> (very much worse).

Additionaly, the clinical effect was evaluated using the FF-scale, The Beck/BDI scale, VAS pain scale and with neuropsychological tests.

Patient safety was measured by ECG and was subject to clinical investigation of vital signs and laboratory tests.

<FIG> provides a summary of the assessment and analysis done at each of the visits to the clinic.

In this Example, outcome variables of the treatment with OSU6162 alone or concomitant with anti-depressant treatment were evaluated.

Data from <NUM> patients was analyzed, whereof <NUM> received the placebo control and <NUM> received treatment with OSU6162. In each group, <NUM> patients were on treatment with a stable dose of an anti-depressive agent (AD). Table <NUM> summarizes the antidepressant agents taken by patients included in the study. <FIG> shows an overview of the demographic distribution of the patient population, as well as the base line characteristics of the patients at the start of the study (week <NUM>). No significant difference was observed between the placebo and the OSU6162 group and no significant difference was observed between the patients on anti-depressant treatment and the patients not on antidepressant treatment. Thus, it was concluded that the randomization was satisfactory.

Clinical Global Impression of Change (CGI-C) was evaluated by the clinician for each patient.

After one week of treatment, <NUM> of <NUM> (<NUM>%) OSU6162-treated patients exhibited improved CGI-C values and <NUM> of <NUM> (<NUM>%) placebo-treated patients exhibited improved CGI-C values. After two weeks, <NUM> of <NUM> (<NUM>%) OSU6162-treated patients exhibited improved CGI-C values and <NUM> of <NUM> (<NUM>%) placebo-treated patients exhibited improved CGI-C values. Thus, no significant difference in CGI-C was observed the between treatment groups for the entire patient population (<FIG>).

Importantly, in the subgroup receiving concomitant antidepressant treatment (for the treatment of depression), there was a clear tendency after one week for a greater improvement among patients treated with OSU6162 than among those treated with placebo (Mann-Whitney U-test: p=<NUM>) (<FIG>).

In order to investigate if the was any interaction between two different, categorical independent variables on the treatment outcome, <NUM>-way ANOVA analysis was performed.

<NUM>-way ANOVA analysis did not show any interactions between treatment and time, i.e. the effect of OSU6162 vs. placebo did not differ over time.

For MFS there was a borderline significant trend to an overall group difference between OSU6162 and placebo treatment (F<NUM>,<NUM> = <NUM>, p=<NUM> (<FIG>). None of the other outcome targets (FF (<FIG>), BDI (<FIG>) and neuropsychological tests) showed any main effect of treatment.

Consistently, all outcome targets (FF, MFS, BDI, pain VAS and neuropsychological tests) showed main effects of time, i.e. regardless of treatment there were improvements in these scale scores over time (p<<NUM>). Compared to week <NUM>, FF and MFS scores were improved after both week <NUM> (week <NUM>-<NUM>) and week <NUM> (week <NUM>-<NUM>) but not at follow-up after <NUM> weeks. BDI score was significantly improved after week <NUM> compared to week <NUM>. Statistical analysis was performed using IBM SPSS Statistics. Version <NUM> software and is presented below:.

To examine the effect of treatment and concomitant use of an antidepressant, antidepressant was included as a fixed factor in the analyses. This resulted in improved models and reduced level of unexplained variance. The antidepressant factor included two levels: <NUM>) patients on stable antidepressant therapy to treat depression (i. since at least <NUM> months before start of the trial) and <NUM>) patients who did not receive medication to treat depression. Outcome targets FF, MFS and BDI were measured.

Similarly to the <NUM>-way interaction analysis there were no significant interactions between treatment and time, nor main effect of treatments. However, the tendency to an overall difference between OSU6162 and placebo treatment on MFS remained (F<NUM>,<NUM> = <NUM>, p=<NUM>) and FF, MFS and BDI showed main effects of time (p<<NUM>; <FIG>, B and E).

Importantly, it was unexpectedly observed that there were statistically significant <NUM>-way interactions between the effects of treatment with OSU6162 and antidepressant over time (week*treatm*antidepr) for FF (F<NUM>,<NUM> = <NUM>, p=<NUM>) (dashed line, empty triangle, <FIG>) and MFS (F<NUM>,<NUM> = <NUM> p=<NUM>) (dashed line, empty triangle, <FIG>). The significant interactions were found between week <NUM> and inclusion for FF and MFS. Statistical analysis was performed using IBM SPSS Statistics. Version <NUM> software and is presented below:.

These significant <NUM>-way interactions were followed by post hoc t-test comparisons. Changes from week <NUM> were used to evaluate the effect of OSU6162 treatment in patients on stable antidepressant therapy and in patients who were not on treatment for depression, respectively. Significant improvements after one week of treatment were observed on the FF- and MFS-scales in the OSU6162 treated patient group on antidepressant therapy compared to placebo treated patient group on antidepressant therapy [FF (F<NUM>,<NUM> = <NUM>; p=<NUM>); <NUM>% confidence interval for the difference: -<NUM> (-<NUM> to -<NUM>) and MFS (F<NUM>,<NUM> = <NUM>; p=<NUM>); <NUM>% CI for the difference: -<NUM> (-<NUM> to -<NUM>); Bonferroni correction for multiple comparisons was applied]. No difference between OSU6162 treated and placebo treated patients on any scale was observed in the groups of patients who were not on antidepressant therapy.

In summary, the above analyses show that OSU6162 was, after one week of treatment, more efficient than placebo in improving symptoms according to the FF- and MFS-scales in patients on stable antidepressant therapy.

Next, the concentration of OSU6162 in blood plasma was measured and analyzed for correlations with time and changes in FF, MFS and BDI score.

Plasma concentrations of OSU6162 were measured in <NUM> patients who received placebo and in <NUM> patients who received OSU6162. The blood sample was drawn in the morning after the tablet was taken - the time of the tablet intake was noted and reported to the clinic by the patient. The blood sample was taken at minimum <NUM> and at maximum <NUM> minutes after tablet intake. The mean time was <NUM> minutes and the standard deviation <NUM> minutes.

As expected, no concentration of OSU6162 was detected in placebo-treated patients. In one patient who received OSU6162 treatment there was no detectable level of OSU6162, hence this patient was omitted from the statistical analyses.

A correlation analysis (Spearman rank correlation) was made between plasma concentration of OSU6162 and time elapsed in minutes between intake of tablet and blood sampling. No significant correlation was found.

In order to analyze the relationship between the treatment outcome and the concentration of OSU6162 in blood plasma, OSU6162 concentrations in patients measured after week <NUM> were plotted against change in FF, MFS and BDI score (<FIG>, <FIG> and <FIG>). It was noted that there seems to be a therapeutic optimum around <NUM>-<NUM> as concentrations above <NUM> do not seem to lead to any further improvement.

Correlation analyses (Spearman rank correlation) showed a significant correlation between OSU6162 concentration and change in FF, MFS and BDI score, respectively, within the concentration interval <NUM>-<NUM>. Statistical analysis was performed using
IBM SPSS Statistics. Version <NUM> software and is presented below:.

Next, patients were evaluated using a neuropsychological test. <NUM> patients were included in a neuropsychological examination. All subjects were tested once in connection with the randomization with the BNIS neuropsychological screening test. <NUM>-<NUM> minutes was required for this test. With the purpose of measuring the cognitive effects of the OSU6162 treatment six more tests were distributed at a first occasion before the initiation of treatment and at a second occasion after the treatment was completed. These tests required <NUM> minutes each. All tests were performed by a neuropsychologist.

Below follows a description of the tests performed and the results thereof:.

Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) is a screening test constructed to quantitatively and qualitatively reflect the outcome of a range of higher cerebral functions. The three initial items are pre-screening items where arousal level, basic communication skills and level of cooperation are assessed (a maximum score of <NUM>) to decide whether the status of the patients allows further testing. At least two points in each item are required. The BNIS contains the following domains: speech and language (maximum score <NUM>), orientation (maximum score <NUM>), attention/concentration (maximum score <NUM>), visual and visual spatial problem solving (maximum score <NUM>), learning and memory (maximum score <NUM>), affect (maximum score <NUM>) and awareness vs. performance (maximum score <NUM>). The test provides a total score = <NUM> of overall cognitive functioning and subscale scores. A score less than <NUM> indicates brain dysfunction.

Results: Table <NUM> show the results from the BNIS test for the OSU6162 treated patient group and for the placebo treated patient group. No significant difference was observed between the groups.

The Coding test is a subtest from WAIS, Wechsler Adult Intelligence Scale and measures the processing speed. The performance reflects abilities such as visual-motor coordination, motor and mental speed and working memory. It requires the subject to copy, as quickly and correctly as possible, nine symbols, one by one in <NUM> boxes, placed below each number. The symbol connected with the numbers is available. The score is the number of symbols registered within <NUM> seconds. Results: Table <NUM> shows the results from the Coding test before and after treatment from patients treated with OSU6162 and patients treated with placebo. No significant differences were observed between the groups.

Trail making test A (TMT A) requires the subject to draw a line as quickly as possible connecting a series of numbers. It is a time-based measure of attention, where time and quality are noted and requires motor effectiveness, visual scanning, speed and flexibility. The test has a high sensitivity for brain dysfunction.

Results: Table <NUM> shows the results from the TMT A before and after treatment from patients treated with OSU6162 and patients treated with placebo. No significant differences were observed between the groups.

Trail making test B (TMT B) demonstrates the effectiveness of visual scanning and measures alternating attention. The subject follows a mental track and the test requires the ability to handle more than one stimulus at a time, as well as flexibility in shifting between different activities. It has a high sensitivity for brain dysfunction and is regarded to be related to prefrontal functioning.

Results: Table <NUM> shows the results from the TMT B before and after treatment from patients treated with OSU6162 and patients treated with placebo. No significant differences were observed between the groups.

The Stroop test (Victoria version) is a time-based test sensitive to frontal lobe dysfunction. It measures executive functioning and is validated and used internationally. Depression and anxiety could influence the results. Speeds of processing and conceptual abilities contribute to the performance. It also reflects the ability of concentration. The test consists of three cards each containing six rows of four items.

Stroop I is on the first card. In this subtest the subject must name as quickly as possible the color of <NUM> dots printed in blue, green, red and yellow. Each color is used six times and the four colors are arranged in pseudo-random order within the array, each color appears once in a row.

Stroop <NUM> is on the second card. In this subtest the dots are replaced by common words printed in lower-case letters. The subject is required to name the colors in which the stimuli are presented and to disregard their verbal content.

Stroop <NUM> is on the third card. In this subtest the colored stimuli are the color names "blue, green, red and yellow" printed in lower case letters so that the print color never corresponds to the color name.

Results: Table <NUM> shows the results from the Stroop tests before and after treatment from patients treated with OSU6162 and patients treated with placebo. No significant differences were observed between the groups.

Claim 1:
A dopamine stabilizing agent and an anti-depressive agent for use in the treatment of one or more symptoms of a disorder characterized by debilitating fatigue;
wherein said dopamine stabilizing agent is (<NUM>)-<NUM>-[<NUM>-(methylsulfonyl)phenyl]-<NUM>-propylpiperidine or a pharmaceutically acceptable salt thereof;
wherein said anti-depressive agent is selected from the group consisting of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRls); and
wherein said disorder is selected from the group consisting of myalgic encephalomyelitis/chronic fatigue syndrome, fibromyalgia, mental fatigue, post stroke fatigue, Huntington's disease, Parkinson's disease, multiple sclerosis, narcolepsy, post cancer fatigue, fatigue associated with cancer with or without cytostatic treatment, depression, and combinations thereof; and
wherein said one or more symptoms are selected from the group consisting of persistent and/or recurrent debilitating fatigue, diffuse musculoskeletal pain, sleep disturbances, neuropsychiatric symptoms, hopelessness, irritability and sadness.