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WO1996008239A1 - Use of 5-alpha-reductase inhibitors to increase hdl cholesterol levels - Google Patents

Use of 5-alpha-reductase inhibitors to increase hdl cholesterol levels Download PDF

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Publication number
WO1996008239A1
WO1996008239A1 PCT/US1995/007215 US9507215W WO9608239A1 WO 1996008239 A1 WO1996008239 A1 WO 1996008239A1 US 9507215 W US9507215 W US 9507215W WO 9608239 A1 WO9608239 A1 WO 9608239A1
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Prior art keywords
inhibitor
reductase inhibitor
reductase
administration
hmg
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PCT/US1995/007215
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French (fr)
Inventor
Jonathan A. Tobert
Keith D. Kaufman
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Merck & Co., Inc.
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Application filed by Merck & Co., Inc. filed Critical Merck & Co., Inc.
Priority to AU27684/95A priority Critical patent/AU2768495A/en
Publication of WO1996008239A1 publication Critical patent/WO1996008239A1/en

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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/56—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/56—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids
    • A61K31/58—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids containing heterocyclic rings, e.g. danazol, stanozolol, pancuronium or digitogenin

Definitions

  • Cholesterol is a major building block of all plasma membranes and a key compound for the synthesis of steroid hormones and bile salts. Cholesterol and triglycerides are lipophilic and cannot dissolve in water and thus cannot travel through the bloodstream in their unaltered forms. They are made water-soluble by combining with proteins produced by the liver and intestine called apolipoproteins and the complexes thus formed are called lipoproteins, which vary in size, weight and density. Two of the major classes are called low-density lipoproteins (LDLs) and high density lipoproteins (HDLs). LDL contains 60 to 70 percent of serum cholesterol and is believed to pick up cholesterol and deposit it in body cells, including smooth muscle cells in arteries.
  • LDLs low-density lipoproteins
  • HDLs high density lipoproteins
  • HDL which contains 20 to 30 percent of total serum cholesterol
  • VLDL very low density lipoprotein
  • MEVACOR® lovastatin
  • ZOCOR® simvastatin
  • PRAVACHOL® pravastatin
  • LESCOL® fluvastatin
  • lipid-lowering drugs including niacin (nicotinic acid), fibrates such as gemfibrozil, and inhibitors of HMG-CoA reductase, such as lovastatin and simvastatin.
  • niacin nicotinic acid
  • fibrates such as gemfibrozil
  • HMG-CoA reductase such as lovastatin and simvastatin.
  • HMG-CoA reductase such as lovastatin and simvastatin.
  • the fibrates have the side effects of gastrointestinal disturbances and an increased risk of gallstones.
  • HMG-CoA reductase inhibitors are relatively safe and well- tolerated, their effect on HDL-cholesterol is small, usually about less than 10%, even at maximum dose.
  • the compounds employed in the present invention are 5cc- reductase inhibitors.
  • Finasteride PROSCAR®
  • PROSCAR® is a commercially available 5 -reductase inhibitor
  • BPH benign prostatic hype ⁇ lasia
  • Inhibition of 5 -reductase is extremely well-tolerated, probably because the only known function of the enzyme in adults is to support certain male secondary sexual characteristics, including prostate growth.
  • Males who are homozygous for 5 ⁇ -reductase deficiency have small prostates and do not develop BPH.
  • Women who are homozygous for 5 -reductase deficiency are phenotypically normal, indicating that the enzyme serves no general biological pu ⁇ ose.
  • Finasteride the first member of this class to be available for prescription, is a very well- tolerated drug. It is well known that the concentration of HDL cholesterol is lower in men than in women.
  • 5 -reductase inhibitors increases serum HDL cholesterol levels.
  • lipid lowering agents such as HMG-CoA reductase inhibitors, squalene synthase inhibitors, HMG-CoA synthase inhibitors, bile acid sequestrants, niacin, probucol, and the fibric acids to reduce the risk of coronary artery disease mortality and morbidity.
  • two or more 5 -reductase inhibitors may be used in combination to increase serum HDL cholesterol levels.
  • This invention relates to the use of 5 ⁇ -reductase inhibitors to increase serum (or plasma) HDL cholesterol levels either alone or in combination with other lipid-altering agents.
  • 5 -reductase inhibitor as used herein is intended to include compounds which are active as inhibitors of either or both of the isozymes of 5 ⁇ -reductase, such as, e.g., inhibitors of 5 ⁇ - reductase type 1, such as, e.g., 4,7 ⁇ -dimethyl-4-aza-5 -cholestan-3-one (also known as MK-386; as disclosed in WO 93/23420 to Merck & Co., Inc.), inhibitors of 5 ⁇ -reductase type 2, such as, e.g., finasteride, epristeride (also known as SKF-105657, SmithKline Beecham), ONO- 3805 (Ono Pharmaceutical Co., Ltd.), FK-143 (Fujisawa), KF- 18678 to Kyowa Hakko-Koygo and TZP-4238 (Teikokuzoki), and those which are active as dual inhibitors of both isozymes type 1 and
  • reductase type 1 with an inhibitor of 5 ⁇ -reductase type 2, such as, e.g., the use of a combination of finasteride with MK-386.
  • an inhibitor of 5 ⁇ -reductase type 2 such as, e.g., the use of a combination of finasteride with MK-386.
  • Many compounds which are 5 ⁇ -reductase inhibitors have been described in the art; compounds which are 5 ⁇ -reductase inhibitors can also be determined by the 5cc-reductase assay, further described below.
  • Examples of compounds which are 5 -reductase inhibitors include, but are not limited to, those described in the following patents and publications: U.S. Patent No's: 5,017,568; 5,061 ,803; 5,061 ,801 ; 5,061 ,802; 5,026,882; 4,377,584; 4,760,071 ; 4,845,104; 4,859,681 ; 5,049,562; 5,120,742; 5,138,063; 5,302,528; 5,302,528; and
  • Especially preferred 5 ⁇ -reductase inhibitors are the following:
  • the 5 ⁇ -reductase inhibitors of the present invention may also be beneficially administered as a combination of 5 ⁇ -reductase inhibitors.
  • administration refers to both concurrent and sequential administration of the active agents.
  • a combination of a Type 1 and a Type 2 5 ⁇ -reductase inhibitor is especially preferred.
  • Salts encompassed within the term “pharmaceutically acceptable salts” refer to non-toxic salts of the compounds of this invention which are generally prepared by reacting the free base with a suitable organic or inorganic acid. Representative salts include the following salts:
  • pharmacologically effective amount shall mean that amount of a drug or pharmaceutical agent that will elicit the biological or medical response of a tissue, system, animal or human that is being sought by a researcher or clinician.
  • alkyl shall mean straight or branched chain alkanes of one to ten total carbon atoms, or any particularly specified number of carbon atoms.
  • alkyl or its prefix root appears in a name of a substituent (e.g., aralkoxyaryloxy) it shall be inte ⁇ reted as including those limitations given above for "alkyl", unless otherwise indicated.
  • the compounds of the present invention can be admin ⁇ istered in such oral dosage forms as tablets, capsules (each including timed release and sustained release formulations), pills, powders, granules, elixers, tinctures, suspensions, syrups and emulsions. Like ⁇ wise, they may also be administered in intravenous (both bolus and infusion), intraperitoneal, subcutaneous or intramuscular form, all using forms well known to those of ordinary skill in the pharmaceutical arts. An effective but non-toxic amount of the compound desired can be employed as an agent to increase HDL cholesterol levels.
  • the dosage regimen utilizing the compounds 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; the route of administration; the renal and hepatic function of the patient; and the particular compound or salt thereof employed.
  • An ordinarily skilled physician or veter ⁇ inarian can readily determine and prescribe the effective amount of the drug required to prevent, counter or arrest the progress of the condition.
  • Oral dosages of the present invention when used for the indicated effects, will range between about 0.05 to 1000 mg/day orally.
  • the compositions are preferably provided in the form of tablets containing 0.2, 0.5, 1.0, 2.5, 5.0, 10.0, 15.0, 25.0 and 50.0 mg of active ingredient.
  • compounds of the present invention may be administered in a single daily dose, or the total daily dosage may be administered in divided doses of two, three or four times daily.
  • preferred compounds for the present invention can be administered in intranasal form via topical use of suitable intranasal vehicles, or via transdermal routes, using those forms of transdermal skin patches well known to those of ordinary skill in that art.
  • the dosage administration will, of course, be continuous rather than intermittant throughout the dosage regimen.
  • Other preferred topical preparations include creams, ointments, lotions, aerosol sprays and gels, wherein the concentration of active ingredient would range from 0.1 % to 15%, w/w or w/v.
  • the compounds herein described in detail can form the active ingredient, and are typically administered in admixture with suitable pharmaceutical diluents, excipients or carriers (collectively referred to herein as "carrier” materials) suitably selected with respect to the intended form of administration, that is, oral tablets, capsules, elixirs, syrups and the like, and consistent with conventional pharmaceutical practices.
  • carrier suitable pharmaceutical diluents, excipients or carriers
  • suitable pharmaceutical diluents, excipients or carriers suitably selected with respect to the intended form of administration, that is, oral tablets, capsules, elixirs, syrups and the like, and consistent with conventional pharmaceutical practices.
  • the active drug component can be combined with an oral, non-toxic pharmaceutically acceptable inert carrier such as ethanol, glycerol, water and the like.
  • suitable binders, lubricants, disintegrating agents and coloring agents can also be inco ⁇ orated into the mixture.
  • Suitable binders include starch, gelatin, natural sugars such as glucose or beta-lactose, com sweeteners, natural and synthetic gums such as acacia, tragacanth or sodium alginate, carboxymethylcellulose, polyethylene glycol, waxes and the like.
  • Lubricants used in these dosage forms include sodium oleate, sodium stearate, magnesium stearate, sodium benzoate, sodium acetate, sodium chloride and the like.
  • Disintegrators include, without limitation, starch, methyl cellulose, agar, bentonite, xanthan gum and the like.
  • the compounds of the present invention can also be administered in the form of liposome delivery systems, such as small unilamellar vesicles, large unilamellar vesicles and multilamellar vesicles.
  • Liposomes can be formed from a variety of phospholipids, containing cholesterol, stearylamine or phosphatidylcholines.
  • Compounds of the present invention may also be delivered by the use of monoclonal antibodies as individual carriers to which the compound molecules are coupled.
  • the compounds of the present invention may also be coupled with soluble polymers as targetable drug carriers.
  • Such polymers can include polyvinylpyrrolidone, pyran copolymer, polyhydroxypropylmethacrylamidephenol, polyhydroxy- ethylaspartamidephenol, or polyethyleneoxidepolylysine substituted with palmitoyl residues.
  • the compounds of the present invention may be coupled to a class of biodegradable polymers useful in achieving controlled release of a drug, for example, polylactic acid, polyepsilon caprolactone, polyhydroxy butyric acid, polyorthoesters, polyacetals, polydihydropyrans, polycyanoacrylates and cross-linked or amphipathic block copolymers of hydrogels.
  • the compounds of this invention may also be administered in combination with other cholesterol lowering agents such as those which inhibit an enzymatic pathway in the biosynthesis of cholesterol. Such administration includes concurrent as well as sequential administration. Examples of such agents would include but are not limited to HMG-CoA reductase inhibitors, HMG-CoA synthase inhibitors, squalene epoxidase inhibitors and squalene synthase inhibition.
  • HMG-CoA reductase inhibitors are lovastatin and related compounds as disclosed in U.S. Patent No. 4,231 ,938 simvastatin and related compounds such as disclosed in U.S. Patent No.
  • HMG-CoA synthase inhibitors are: the beta- lactone derivatives disclosed in U.S. Patent No. 4,806,564, 4,816,477, 4,847,271 , and 4,751 ,237; the beta lactam derivatives disclosed in U.S. 4,983,597 and the substituted oxacyclopropane analogues disclosed in European Patent Publication EP O 41 1 703.
  • the squalene synthetase inhibitors suitable for use herein include, but are not limited to, those disclosed by Biller et al., J. Med. Chem., 1988 Vol. 31 , No. 10, pp. 1869-1871 , including isoprenoid (phosphinylmethyl)-phosphonates such as those of the formula
  • squalene synthetase inhibitors including the triacids thereof, triesters thereof and tripotassium and trisodium salts thereof as well as other squalene synthetase inhibitors disclosed in pending U.S. Patent No. 4,871 ,721 and 4,924,024 and in Biller et al, J. Med.Chem., 1988, Vol. 31, No. 10, pp. 1869 to 1871.
  • other squalene synthetase inhibitors suitable for use herein include the te ⁇ enoid pyrophosphates disclosed by P. Ortiz de Montellano et al., J. Med.
  • the benzodiazepine squalene synthase inhibitors described in EP O 567 026 to Takeda Chemical Industries the quinuclidinyl squalene synthase inhibitors described in PCT publications WO 94/03451 , WO 93/09115, WO 93/21 183, WO 93/21 184, WO 93/24486, and U.S. 5,135,935, may be employed in combination with the 5 ⁇ -reductase inhibitors of the present invention.
  • squalene epoxidase inhibitors are disclosed in European Patent Publication EP O 318 860 and in Japanese Patent Publication J02 169-571 A.
  • LDL-receptor gene inducer molecules are disclosed in U.S. Patent Application Serial No. 07/670,640 filed March 18, 1991.
  • Other cholesterol lowering agents include niacin, probucol, and the fibric acids, clofibrate and gemfibrozil.
  • the dose of HMG-CoA reductase inhibitor contemplated for use in the co-administration of the present invention are from about 1 to 200 mg per day, preferably given in single or divided doses. Most preferred are dosages from 5 to 80 mg per day.
  • the doses of HMG-CoA synthase inhibitor contemplated for use in the co-administration of the present invention are from about 20 to 200 mg, preferably given in single or divided doses.
  • the doses of squalene synthase inhibitor contemplated for use in the co-administration of the present invention are from about 2 to 2000 mg per day, preferably given in single or divided doses.
  • the doses of squalene epoxidase inhibitor contemplated for use in the co-administration of the present invention are from 2 to 200 mg per day, preferably given in single or divided doses.
  • Additional combinations are those containing 0.01 to 1000 mg of a 5oc-reducta.se inhibitor in combination with up to 1000 mg probucol, up to 2 g clofibrate, 0.5 to 8 g of niacin, 800 to 1500 mg gemfibrozil or fenofibrate, or 20 to 300 mg of an LDL receptor gene inducer.
  • the 5cc-reductase inhibitors of the present invention may also be co-administered with pharmaceutically acceptable nontoxic cationic polymers capable of binding beta acids in a non- resorbable form in the gastrointestinal tract.
  • pharmaceutically acceptable nontoxic cationic polymers capable of binding beta acids in a non- resorbable form in the gastrointestinal tract.
  • examples of such polymers include cholestyramine, colestipol, and poly[methyl-(3- trimethylaminopropyl)imino-trimethylene dihalide].
  • Lipids Study Design A 60-week, double-blind, radomized, placebo-controlled, multicenter study was conducted in which 137 healthy male subjects were assigned to begin the 2 week placebo run-in period at the Week -2 visit. The subjects were allocated to receive either finasteride 5 mg (PROSCAR®) or placebo for 24 weeks at the Week 1 visit. At the end of the active treatment period (Week 24) subjects discontinued the assigned medication. Thirty-six weeks after stopping the medication (Week 60), subjects were seen in the clinic for the final visit.
  • finasteride 5 mg PROSCAR®
  • Week 1 visit At the end of the active treatment period (Week 24) subjects discontinued the assigned medication. Thirty-six weeks after stopping the medication (Week 60), subjects were seen in the clinic for the final visit.
  • Fasting lipid profile (total cholesterol, triglycerides, HDL cholesterol, LDL cholesterol, VLDL cholesterol, Lp(a), apoAI, All, B) was obtained at Weeks 1, 12, 24 and 60. The subject must have fasted for a minimum of 12 hours. The serum was frozen at -20°C for shipment to a central reference laboratory for analysis.
  • Tables 1 and 2 contain the results of the percent change at Week 12 or Week 24, respectively, from Week 1 (baseline) for total cholesterol (tot. chol), HDL cholesterol (hdl), LDL cholesterol (ldl), and triglycerides (trig).
  • variable group N mean std med p-value p-value within between
  • PROSCAR ® 56 4.5 14.7 2.1 0.019 0.081 ldl
  • PROSCAR® 56 0.6 19.2 1.6 0.878 0.681
  • variable group N mean std med p-value p-value within between
  • PLACEBO 48 0.4 12.1 0.2 0.755
  • PROSCAR ® 53 9.1 14.5 6.8 0.000 0.022 ldl
  • Tables 3 and 4 contain the results at Week 12 and Week 24, respectively, of change from Week 1 in mg/dl for each variable, i.e., the change in each measurement unit for each of the above variables.
  • variable group N mean std med p-value p-value within between
  • PLACEBO 51 2.0 18.9 5.0 0.377
  • PROSCAR® 56 1.4 23.8 1.0 0.580 0.882 hdl
  • PROSCAR® 56 1.5 7.3 1.0 0.043 0.134 ldl
  • PLACEBO 51 0.5 15.6 2.0 0.686
  • variable group N mean std med p-value p-value within between
  • PROSCAR ® 53 1.6 18.4 1.0 0.590 0.090
  • Samples of human tissue were pulverized using a freezer mill and homogenized in 40 mM potassium phosphate, pH 6.5, 5 mM magnesium sulfate, 25 mM potassium chloride, 1 mM phenylmethyl- sulfonyl fluoride, 1 mM dithiothreitol (DTT) containing 0.25 M sucrose using a Potter-Elvehjem homogenizer.
  • a crude nuclear pellet was prepared by centrifugation of the homogenate at 1 ,500 x g for 15 min. The crude nuclear pellet was washed two times and resuspended in two volumes of buffer. Glycerol was added to the resuspended pellet to a final concentration of 20%.
  • the enzyme suspension was frozen in aliquots at -80°C. The prostatic and scalp reductases were stable for at least 4 months when stored under these conditions. 5 -reductase assay
  • the reaction mixture for the type 1 5 ⁇ -reductase contained 40 mM potassium phosphate, pH 6.5, 5 mM [7-3H] -testosterone, 1 mM dithiothreitol and 500 ⁇ M NADPH in a final volume of 100 ⁇ l.
  • the reaction mixture for the type 2 5 ⁇ -reductase contained 40 mM sodium citrate, pH 5.5, 0.3 mM [7-3H]-testosterone, 1 mM dithiothreitol and 500 ⁇ M NADPH in a final volume of 100 ⁇ l.
  • the assay was initiated by the addition of 50-100 ⁇ g prostatic homogenate or 75-200 ⁇ g scalp homogenate and incubated at 37°C. After 10-50 min. the reaction was quenched by extraction with 250 ⁇ l of a mixture of 70% cyclohexane: 30% ethyl acetate containing 10 ⁇ g each DHT and T. The aqueous and organic layers were separated by centrifugation at 14,000 ⁇ m in an Eppendorf microfuge.
  • the organic layer was subjected to normal phase HPLC (10 cm Whatman partisil 5 silica column equilibrated in 1 ml/min 70% cyclohexane: 30% ethyl acetate; retention times: DHT, 6.8-7.2 min.; androstanediol, 7.6-8.0 min.; T, 9.1-9.7 min.).
  • HPLC system consisted of a Waters Model 680 Gradient System equipped with a Hitachi Model 655 ⁇ autosampler, Applied Biosystems Model 757 variable UV detector, and a Radiomatic Model A 120 radioactivity analyzer.
  • the conversion of T to DHT was monitored using the radioactivity flow detector by mixing the HPLC effluent with one volume of Flo Scint 1 (Radiomatic). Under the conditions described, the production of DHT was linear for at least 25 min.
  • the only steroids observed with the human prostate and scalp preparations were T, DHT and androstanediol.
  • IC50 values represent the concentration of inhibitor required to decrease enzyme conversion of testosterone to dihydrotestosterone by 50% of the control. IC50 values were determined using a 6 point titration where the concentration of the inhibitor was varied from 0.1 to 1000 nM.
  • a compound referred to herein as a 5 ⁇ -reductase 2 inhibitor is a compound that shows inhibition of the 5 ⁇ -reductase 2 isozyme in the above-described assay, having an IC50 value of about or under 100 nM.
  • a compound referred to herein as a 5 ⁇ -reductase type 1 inhibitor is a compound that shows inhibition of the 5 ⁇ -reductase type 1 isozyme in the above-described assay, having an IC50 value of about or under 100 nM.
  • a compound referred to herein as a dual 5 -reductase type 1 and 2 inhibitor is a compound that shows inhibition of both the type 1 and type 2 isozymes, having an IC50 value of about or under 100 nM for each isozyme.
  • an oral composition of a compound of this invention 5 mg finasteride and 40 mg simvastatin are formulated with sufficient finely divided lactose to provide a total amount of 580 to 590 mg to fill a size 0 hard gelatin capsule.

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Abstract

The present invention relates to the use of 5α-reductase inhibitors to increase serum HDL cholesterol levels. These compounds may be used together with other lipid lowering agents, such as HMG-CoA reductase inhibitors, squalene synthase inhibitors, HMG-CoA synthase inhibitors, bile acid sequestrants, niacin, probucol, and the fibric acids to reduce the risk of coronary artery disease mortality. Further, two or more 5α-reductase inhibitors may be used in combination to increase serum HDL cholesterol levels.

Description

TITLE OF THE INVENTION
USE OF 5-ALPHA-REDUCTASE INHIBITORS TO INCREASE HDL
CHOLESTEROL LEVELS
BACKGROUND OF THE INVENTION
Cholesterol is a major building block of all plasma membranes and a key compound for the synthesis of steroid hormones and bile salts. Cholesterol and triglycerides are lipophilic and cannot dissolve in water and thus cannot travel through the bloodstream in their unaltered forms. They are made water-soluble by combining with proteins produced by the liver and intestine called apolipoproteins and the complexes thus formed are called lipoproteins, which vary in size, weight and density. Two of the major classes are called low-density lipoproteins (LDLs) and high density lipoproteins (HDLs). LDL contains 60 to 70 percent of serum cholesterol and is believed to pick up cholesterol and deposit it in body cells, including smooth muscle cells in arteries. As blood levels of LDL increase, the risk of coronary artery disease increases. HDL, which contains 20 to 30 percent of total serum cholesterol, is believed to gather cholesterol from body cells and transport it to the liver for elimination. As blood levels of HDL increase, the risk of coronary artery disease decreases. A third type of lipoprotein, known as very low density lipoprotein (VLDL) contains about 10 to 15 percent of total serum cholesterol and a large amount of fat. Thus, to reduce the risk of coronary artery disease, the overall goal has been to increase HDL cholesterol levels and to lower LDL and VLDL cholesterol levels.
MEVACOR® (lovastatin), ZOCOR® (simvastatin), PRAVACHOL® (pravastatin) and LESCOL® (fluvastatin), now commercially available, are members of a group of very active antihypercholesterolemic agents that function by lowering cholesterol biosynthesis by inhibiting the enzyme HMG-CoA reductase. These compounds are effective in lowering LDL and VLDL cholesterol levels, but do not exhibit a large effect in increasing HDL levels.
Figure imgf000004_0001
LOVASTATIN SIMVASTATIN
Figure imgf000004_0002
PRAVASTATIN FLUVASTATIN
Current methods for increasing HDL cholesterol include exercise, moderate alcohol consumption and several lipid-lowering drugs, including niacin (nicotinic acid), fibrates such as gemfibrozil, and inhibitors of HMG-CoA reductase, such as lovastatin and simvastatin. However, exercise and alcohol are not acceptable to many patients. Patient compliance is difficult with exercise, and many physicians do not feel comfortable encouraging alcohol consumption, which in excess can lead to problems such as cirrhosis of the liver. Each of the lipid-lowering drugs have particular side effects. Niacin, which produces the largest increases in HDL cholesterol, also has the most annoying and clinically significant side effects, including flushing in almost all patients, dyspepsia and hepatotoxicity, which greatly reduce patient compliance. The fibrates have the side effects of gastrointestinal disturbances and an increased risk of gallstones. Although HMG-CoA reductase inhibitors are relatively safe and well- tolerated, their effect on HDL-cholesterol is small, usually about less than 10%, even at maximum dose.
The compounds employed in the present invention are 5cc- reductase inhibitors. Finasteride (PROSCAR®) is a commercially available 5 -reductase inhibitor,
Figure imgf000005_0001
Finasteride
currently approved for the treatment of benign prostatic hypeφlasia (BPH). Inhibition of 5 -reductase is extremely well-tolerated, probably because the only known function of the enzyme in adults is to support certain male secondary sexual characteristics, including prostate growth. Males who are homozygous for 5α-reductase deficiency have small prostates and do not develop BPH. Women who are homozygous for 5 -reductase deficiency are phenotypically normal, indicating that the enzyme serves no general biological puφose. Finasteride, the first member of this class to be available for prescription, is a very well- tolerated drug. It is well known that the concentration of HDL cholesterol is lower in men than in women. This is true for post-menopausal as well as pre-menopausal women, suggesting that it is the high level of androgens, and not the low levels of estrogens, that depresses HDL cholesterol in men. When boys enter puberty , HDL cholesterol falls, adding further support to this concept. The two principal androgens are testosterone and dihydrotestosterone; the latter of which is formed from testosterone by the action of the enzyme 5cx-reductase. It is not known which of these androgens is the more important in the control of HDL cholesterol levels. Until the present invention, it was not known whether dihydrotestosterone contributes to the process of depressing HDL cholesterol levels and whether inhibitors of 5α-reductase might increase the levels of HDL cholesterol.
SUMMARY OF THE INVENTION
Administration of 5 -reductase inhibitors increases serum HDL cholesterol levels. These compounds may be used alone or together with lipid lowering agents, such as HMG-CoA reductase inhibitors, squalene synthase inhibitors, HMG-CoA synthase inhibitors, bile acid sequestrants, niacin, probucol, and the fibric acids to reduce the risk of coronary artery disease mortality and morbidity. Further, two or more 5 -reductase inhibitors may be used in combination to increase serum HDL cholesterol levels.
DESCRIPTION OF THE INVENTION
This invention relates to the use of 5α-reductase inhibitors to increase serum (or plasma) HDL cholesterol levels either alone or in combination with other lipid-altering agents.
The term "5 -reductase inhibitor" as used herein is intended to include compounds which are active as inhibitors of either or both of the isozymes of 5α-reductase, such as, e.g., inhibitors of 5α- reductase type 1, such as, e.g., 4,7β-dimethyl-4-aza-5 -cholestan-3-one (also known as MK-386; as disclosed in WO 93/23420 to Merck & Co., Inc.), inhibitors of 5α-reductase type 2, such as, e.g., finasteride, epristeride (also known as SKF-105657, SmithKline Beecham), ONO- 3805 (Ono Pharmaceutical Co., Ltd.), FK-143 (Fujisawa), KF- 18678 to Kyowa Hakko-Koygo and TZP-4238 (Teikokuzoki), and those which are active as dual inhibitors of both isozymes type 1 and 2, such as, e.g., those disclosed in WO 94/00121 and WO94/00125 to SmithKline Beecham and WO 93/13124 and WO 94/14833, including epimasticadienolic acid to Glaxo. Also encompassed by the instant method invention is the use of a combination of an inhibitor of 5α- - 5
reductase type 1 with an inhibitor of 5α-reductase type 2, such as, e.g., the use of a combination of finasteride with MK-386. Many compounds which are 5α-reductase inhibitors have been described in the art; compounds which are 5α-reductase inhibitors can also be determined by the 5cc-reductase assay, further described below.
Examples of compounds which are 5 -reductase inhibitors include, but are not limited to, those described in the following patents and publications: U.S. Patent No's: 5,017,568; 5,061 ,803; 5,061 ,801 ; 5,061 ,802; 5,026,882; 4,377,584; 4,760,071 ; 4,845,104; 4,859,681 ; 5,049,562; 5,120,742; 5,138,063; 5,302,528; 5,302,528; and
5, 151 ,429; and WO 93/13124; WO 93/23038; WO 93/23039; WO 93/23040; WO 93/23041 ; WO 93/23048; WO 93/23050; WO 93/23051 ; WO 93/23419; WO 93/23420; WO 93/16996; WO 93/23042; WO 93/24442; WO 94/00121 ; WO 93/25568; WO 91/13060; WO 94/00125; WO 94/03474; WO 94/03475; WO 94/03476; WO 94/07909; WO 94/1 1385; WO 93/13124; WO 94/13691 ; WO 94/14833; EP 532,190; EP 0 51 1 477; EP O 484 094; EP O 453 321 ; EP O 294 937; EP O 291 245; JP O 5 331 059; FR 2,698,791 ; and FR 2,693,461. Compounds within these publications are included as compounds which may be used in the method of the present invention. The above list is not intended to be exhaustive, and there are many other publications which describe inhibitors of 5α- reductase.
Especially preferred 5α-reductase inhibitors are the following:
( 1 ) finasteride (PROSCAR® )
Figure imgf000007_0001
(2) 4,7β-dimethyl-4-aza-5α cholestan-3-one
Figure imgf000008_0001
(3) 3-oxo-4-aza-4,7-β-dimethyl- 16β-(4-chlorophenoxy)-5 - androstane
Figure imgf000008_0002
(4) epristeride
Figure imgf000008_0003
and pharmaceutically acceptable salts thereof. The 5α-reductase inhibitors of the present invention may also be beneficially administered as a combination of 5α-reductase inhibitors. The term "administration" refers to both concurrent and sequential administration of the active agents. Especially preferred is a combination of a Type 1 and a Type 2 5α-reductase inhibitor. Salts encompassed within the term "pharmaceutically acceptable salts" refer to non-toxic salts of the compounds of this invention which are generally prepared by reacting the free base with a suitable organic or inorganic acid. Representative salts include the following salts:
Acetate Lactobionate
Benzenesulfonate Laurate
Benzoate Malate
Bicarbonate Maleate
Bisulfate Mandelate
Bitartrate Mesylate
B orate Methylbromide
Bromide Methylnitrate
Calcium Edetate Methylsulfate
Camsylate Mucate
Carbonate Napsylate
Chloride Nitrate
Clavulanate N-methylglucamine
Citrate ammonium salt
Dihydrochloride Oleate
Edetate Oxalate
Edisylate Pamoate (Embonate)
Estolate Palmitate
Esylate Pantothenate
Fumarate Phosphate/diphosphate
Gluceptate Polygalacturonate
Gluconate Salicylate
Glutamate Stearate
Glycollylarsanilate Sulfate
Hexylresorcinate Subacetate
Hydrabamine Succinate
Hydrobromide Tannate
Hydrochloride Tartrate Hydroxynaphthoate Teoclate
Iodide Tosylate
Isothionate Triethiodide
Lactate Valerate
The term "pharmacologically effective amount" shall mean that amount of a drug or pharmaceutical agent that will elicit the biological or medical response of a tissue, system, animal or human that is being sought by a researcher or clinician. The term "alkyl" shall mean straight or branched chain alkanes of one to ten total carbon atoms, or any particularly specified number of carbon atoms.
Whenever the term "alkyl" or its prefix root appears in a name of a substituent (e.g., aralkoxyaryloxy) it shall be inteφreted as including those limitations given above for "alkyl", unless otherwise indicated.
The compounds of the present invention can be admin¬ istered in such oral dosage forms as tablets, capsules (each including timed release and sustained release formulations), pills, powders, granules, elixers, tinctures, suspensions, syrups and emulsions. Like¬ wise, they may also be administered in intravenous (both bolus and infusion), intraperitoneal, subcutaneous or intramuscular form, all using forms well known to those of ordinary skill in the pharmaceutical arts. An effective but non-toxic amount of the compound desired can be employed as an agent to increase HDL cholesterol levels.
The dosage regimen utilizing the compounds 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; the route of administration; the renal and hepatic function of the patient; and the particular compound or salt thereof employed. An ordinarily skilled physician or veter¬ inarian can readily determine and prescribe the effective amount of the drug required to prevent, counter or arrest the progress of the condition. - 9 -
Oral dosages of the present invention, when used for the indicated effects, will range between about 0.05 to 1000 mg/day orally. The compositions are preferably provided in the form of tablets containing 0.2, 0.5, 1.0, 2.5, 5.0, 10.0, 15.0, 25.0 and 50.0 mg of active ingredient. Advantageously, compounds of the present invention may be administered in a single daily dose, or the total daily dosage may be administered in divided doses of two, three or four times daily. Furthermore, preferred compounds for the present invention can be administered in intranasal form via topical use of suitable intranasal vehicles, or via transdermal routes, using those forms of transdermal skin patches well known to those of ordinary skill in that art. To be administered in the form of a transdermal delivery system, the dosage administration will, of course, be continuous rather than intermittant throughout the dosage regimen. Other preferred topical preparations include creams, ointments, lotions, aerosol sprays and gels, wherein the concentration of active ingredient would range from 0.1 % to 15%, w/w or w/v.
In the methods of the present invention, the compounds herein described in detail can form the active ingredient, and are typically administered in admixture with suitable pharmaceutical diluents, excipients or carriers (collectively referred to herein as "carrier" materials) suitably selected with respect to the intended form of administration, that is, oral tablets, capsules, elixirs, syrups and the like, and consistent with conventional pharmaceutical practices. For instance, for oral administration in the form of a tablet or capsule, the active drug component can be combined with an oral, non-toxic pharmaceutically acceptable inert carrier such as ethanol, glycerol, water and the like. Moreover, when desired or necessary, suitable binders, lubricants, disintegrating agents and coloring agents can also be incoφorated into the mixture. Suitable binders include starch, gelatin, natural sugars such as glucose or beta-lactose, com sweeteners, natural and synthetic gums such as acacia, tragacanth or sodium alginate, carboxymethylcellulose, polyethylene glycol, waxes and the like. Lubricants used in these dosage forms include sodium oleate, sodium stearate, magnesium stearate, sodium benzoate, sodium acetate, sodium chloride and the like. Disintegrators include, without limitation, starch, methyl cellulose, agar, bentonite, xanthan gum and the like. The compounds of the present invention can also be administered in the form of liposome delivery systems, such as small unilamellar vesicles, large unilamellar vesicles and multilamellar vesicles. Liposomes can be formed from a variety of phospholipids, containing cholesterol, stearylamine or phosphatidylcholines. Compounds of the present invention may also be delivered by the use of monoclonal antibodies as individual carriers to which the compound molecules are coupled. The compounds of the present invention may also be coupled with soluble polymers as targetable drug carriers. Such polymers can include polyvinylpyrrolidone, pyran copolymer, polyhydroxypropylmethacrylamidephenol, polyhydroxy- ethylaspartamidephenol, or polyethyleneoxidepolylysine substituted with palmitoyl residues. Furthermore, the compounds of the present invention may be coupled to a class of biodegradable polymers useful in achieving controlled release of a drug, for example, polylactic acid, polyepsilon caprolactone, polyhydroxy butyric acid, polyorthoesters, polyacetals, polydihydropyrans, polycyanoacrylates and cross-linked or amphipathic block copolymers of hydrogels.
The compounds of this invention may also be administered in combination with other cholesterol lowering agents such as those which inhibit an enzymatic pathway in the biosynthesis of cholesterol. Such administration includes concurrent as well as sequential administration. Examples of such agents would include but are not limited to HMG-CoA reductase inhibitors, HMG-CoA synthase inhibitors, squalene epoxidase inhibitors and squalene synthase inhibition. Illustrative of such HMG-CoA reductase inhibitors are lovastatin and related compounds as disclosed in U.S. Patent No. 4,231 ,938 simvastatin and related compounds such as disclosed in U.S. Patent No. 4,450,171 and 4,346,227 pravastatin and related compounds such as disclosed in U.S. Patent No. 4,346,227 and fluvastatin and related compounds such as disclosed in WO 84/02131. Examples of HMG-CoA synthase inhibitors are: the beta- lactone derivatives disclosed in U.S. Patent No. 4,806,564, 4,816,477, 4,847,271 , and 4,751 ,237; the beta lactam derivatives disclosed in U.S. 4,983,597 and the substituted oxacyclopropane analogues disclosed in European Patent Publication EP O 41 1 703. The squalene synthetase inhibitors suitable for use herein include, but are not limited to, those disclosed by Biller et al., J. Med. Chem., 1988 Vol. 31 , No. 10, pp. 1869-1871 , including isoprenoid (phosphinylmethyl)-phosphonates such as those of the formula
0 o 0 o R1-P-CH2-P-0 R1-P-CF2-P-0
1 I 1 I o~ o- o" o-
II
R1
Figure imgf000013_0001
including the triacids thereof, triesters thereof and tripotassium and trisodium salts thereof as well as other squalene synthetase inhibitors disclosed in pending U.S. Patent No. 4,871 ,721 and 4,924,024 and in Biller et al, J. Med.Chem., 1988, Vol. 31, No. 10, pp. 1869 to 1871. In addition, other squalene synthetase inhibitors suitable for use herein include the teφenoid pyrophosphates disclosed by P. Ortiz de Montellano et al., J. Med. Chem., 1977, 20, 243-249, the farnesyl diphosphate analog A and presqualene pyrophosphate (PSQ- PP) analogs as disclosed by Corey and Volante, J. Am. Chem. Soc. 1976, 98, 1291-1293, phosphinylphosphonate reported by McClard, R. W. et al, J.A.C.S., 1987, 109, 5544 and cyclopropanes reported by Capson, T.L., PhD dissertation, June, 1987, Dept. Med. Chem. U. of Utah, Abstract, Table of Contents, pp. 16, 17, 40-43, 48-51 , Summary. Further, the benzodiazepine squalene synthase inhibitors described in EP O 567 026 to Takeda Chemical Industries, the quinuclidinyl squalene synthase inhibitors described in PCT publications WO 94/03451 , WO 93/09115, WO 93/21 183, WO 93/21 184, WO 93/24486, and U.S. 5,135,935, may be employed in combination with the 5α-reductase inhibitors of the present invention. In addition, the zaragozic acid type squalene synthase inhibitors as described in U.S. Patents 5,284,758; 5,283,256; 5,262,435; 5,260,332; 5,264,593; 5,260,215; 5,258,401; 5,254,727; 5,256,689; 5,132,320; 5,278,067, and PCT Publications WO 92/12156; WO 92/12157; WO 92/12158; WO 92/12159; WO 92/12160; WO 93/18040; WO 93/18039; WO 93/07151 ; and European Patent Publications EP O 512 865, EP O 568 946; EP O 524,677 and EP O 450 812, as well as the acyclic tricarboxylic acid compounds 5,254,727, may be employed. Illustrative examples of squalene epoxidase inhibitors are disclosed in European Patent Publication EP O 318 860 and in Japanese Patent Publication J02 169-571 A. LDL-receptor gene inducer molecules are disclosed in U.S. Patent Application Serial No. 07/670,640 filed March 18, 1991. Other cholesterol lowering agents that may be administered include niacin, probucol, and the fibric acids, clofibrate and gemfibrozil.
The dose of HMG-CoA reductase inhibitor contemplated for use in the co-administration of the present invention are from about 1 to 200 mg per day, preferably given in single or divided doses. Most preferred are dosages from 5 to 80 mg per day.
The doses of HMG-CoA synthase inhibitor contemplated for use in the co-administration of the present invention are from about 20 to 200 mg, preferably given in single or divided doses. The doses of squalene synthase inhibitor contemplated for use in the co-administration of the present invention are from about 2 to 2000 mg per day, preferably given in single or divided doses.
The doses of squalene epoxidase inhibitor contemplated for use in the co-administration of the present invention are from 2 to 200 mg per day, preferably given in single or divided doses.
Representative of additional combinations are those containing 0.01 to 1000 mg of a 5oc-reducta.se inhibitor in combination with up to 1000 mg probucol, up to 2 g clofibrate, 0.5 to 8 g of niacin, 800 to 1500 mg gemfibrozil or fenofibrate, or 20 to 300 mg of an LDL receptor gene inducer.
The 5cc-reductase inhibitors of the present invention may also be co-administered with pharmaceutically acceptable nontoxic cationic polymers capable of binding beta acids in a non- resorbable form in the gastrointestinal tract. Examples of such polymers include cholestyramine, colestipol, and poly[methyl-(3- trimethylaminopropyl)imino-trimethylene dihalide].
The relative amounts of the compounds of this invention and these polymers is between 1 :100 and 1 : 15,000. Those skilled in the art will readily understand that known variations of the conditions and processes of the following preparative procedures can be used to prepare these compounds. - 14 -
EXAMPLE 1 Analysis of the Effect of Finasteride. a 5α-reductase Inhibitor, on
Lipids Study Design A 60-week, double-blind, radomized, placebo-controlled, multicenter study was conducted in which 137 healthy male subjects were assigned to begin the 2 week placebo run-in period at the Week -2 visit. The subjects were allocated to receive either finasteride 5 mg (PROSCAR®) or placebo for 24 weeks at the Week 1 visit. At the end of the active treatment period (Week 24) subjects discontinued the assigned medication. Thirty-six weeks after stopping the medication (Week 60), subjects were seen in the clinic for the final visit.
All medication was taken once a day in the morning before breakfast. All subjects were instructed to take their medication one hour before their scheduled clinic visit.
Fasting lipid profile (total cholesterol, triglycerides, HDL cholesterol, LDL cholesterol, VLDL cholesterol, Lp(a), apoAI, All, B) was obtained at Weeks 1, 12, 24 and 60. The subject must have fasted for a minimum of 12 hours. The serum was frozen at -20°C for shipment to a central reference laboratory for analysis.
Other than fasting before the office visit, subjects consumed a normal diet throughout the study.
Results
Subjects who had not been fasting were excluded from the analysis. Tables 1 and 2 contain the results of the percent change at Week 12 or Week 24, respectively, from Week 1 (baseline) for total cholesterol (tot. chol), HDL cholesterol (hdl), LDL cholesterol (ldl), and triglycerides (trig).
In the Tables below, "N" represents the number of subjects in the group, "mean" is the mean, "std" is the standard deviation, and "med" is the median value. TABLE 1 Week 12: Percent change from Week 1
variable group N mean std med p-value p-value within between
tot. chol
PLACEBO 51 1.6 9.8 2.8 0.21 1
PROSCAR® 56 1.5 13.5 0.7 0.449 0.994 hdl
PLACEBO 51 -0.2 12.1 0.0 0.784
PROSCAR® 56 4.5 14.7 2.1 0.019 0.081 ldl
PLACEBO 51 2.0 14.0 2.5 0.454
PROSCAR® 56 0.6 19.2 1.6 0.878 0.681
TABLE 2 Week 24: Percent change from Week 1
variable group N mean std med p-value p-value within between
tot. chol
PLACEBO 48 0.4 12.1 0.2 0.755
PROSCAR® 53 4.7 1 1.8 3.2 0.003 0.072 hdl
PLACEBO 48 2.8 12.4 2.1 0.213
PROSCAR® 53 9.1 14.5 6.8 0.000 0.022 ldl
PLACEBO 48 -3.3 16.7 -4.3 0.172
PROSCAR® 53 2.6 18.5 0.9 0.565 0.100 Tables 3 and 4 contain the results at Week 12 and Week 24, respectively, of change from Week 1 in mg/dl for each variable, i.e., the change in each measurement unit for each of the above variables.
TABLE 3 Week 12: Change from Week 1 in mg/dl
variable group N mean std med p-value p-value within between
tot. chol
PLACEBO 51 2.0 18.9 5.0 0.377
PROSCAR® 56 1.4 23.8 1.0 0.580 0.882 hdl
PLACEBO 51 -0.5 5.6 0.0 0.609
PROSCAR® 56 1.5 7.3 1.0 0.043 0.134 ldl
PLACEBO 51 0.5 15.6 2.0 0.686
PROSCAR® 56 -1.0 19.4 2.0 0.939 0.649
TABLE 4 Week 24: Change from Week 1 in mg/dl
variable group N mean std med p-value p-value within between
tot. chol
PLACEBO 48 -0.9 24.6 0.5 0.988
PROSCAR® 53 7.0 20.5 7.0 0.005 0.084 hdl
PLACEBO 48 1.0 5.8 1.0 0.432
PROSCAR® 53 3.8 6.4 3.0 0.000 0.023 ldl
PLACEBO 48 -5.1 21.2 -4.0 0.099
PROSCAR® 53 1.6 18.4 1.0 0.590 0.090
HDL There was a significant HDL percent increase (mean =
4.5%) from Week 1 to Week 12 for the finasteride 5 mg (PROSCAR®) treatment group. From Week 1 to Week 24, the increase doubled (mean = 9.1 %) for the finasteride group.
For the placebo group, there was minimal HDL percent change (mean = -0.2% from Week 1 to Week 12). The mean of the HDL percent change was 2.8% from Week 1 to Week 24 for the placebo group. This 2.8% increase was not statistically significant.
Between the two treatment groups, the difference of 4.7% in the mean of the HDL percent change from Week 1 to Week 12 was not significant (p = 0.081). The difference of 6.3% in the mean of the HDL percent increase from Week 1 to Week 24 was significant (p = 0.022).
The absolute change in HDL increased 3.8 mg/dl from Week 1 to Week 24 for the finasteride 5 mg group and 1.0 mg/dl for the placebo group. The 2.8 mg/dl absolute difference between the two treatment groups was statistically significant. LDL
There was no significant change in LDL for either group. The group treated with finasteride had an increase in LDL of 2.6% (1.6 mg/dl) from Week 1 to Week 24. The placebo group had a decrease in LDL of 3.3% (5.1 gm/dl) from Week 1 to Week 24.
Total Cholesterol
There was a significant total increase (4.7% or 7.0 mg/dl) from Week 1 to Week 24 for the finasteride group. There was no significant change for the placebo group. The increase in total cholesterol for the finasteride group was not statistically significant relative to the placebo group.
EXAMPLE 2 BIOLOGICAL ASSAYS
Preparation of Human prostatic and scalp 5 - reductase s
Samples of human tissue were pulverized using a freezer mill and homogenized in 40 mM potassium phosphate, pH 6.5, 5 mM magnesium sulfate, 25 mM potassium chloride, 1 mM phenylmethyl- sulfonyl fluoride, 1 mM dithiothreitol (DTT) containing 0.25 M sucrose using a Potter-Elvehjem homogenizer. A crude nuclear pellet was prepared by centrifugation of the homogenate at 1 ,500 x g for 15 min. The crude nuclear pellet was washed two times and resuspended in two volumes of buffer. Glycerol was added to the resuspended pellet to a final concentration of 20%. The enzyme suspension was frozen in aliquots at -80°C. The prostatic and scalp reductases were stable for at least 4 months when stored under these conditions. 5 -reductase assay
The reaction mixture for the type 1 5α-reductase contained 40 mM potassium phosphate, pH 6.5, 5 mM [7-3H] -testosterone, 1 mM dithiothreitol and 500 μM NADPH in a final volume of 100 μl. The reaction mixture for the type 2 5α-reductase contained 40 mM sodium citrate, pH 5.5, 0.3 mM [7-3H]-testosterone, 1 mM dithiothreitol and 500 μM NADPH in a final volume of 100 μl. Typically, the assay was initiated by the addition of 50-100 μg prostatic homogenate or 75-200 μg scalp homogenate and incubated at 37°C. After 10-50 min. the reaction was quenched by extraction with 250 μl of a mixture of 70% cyclohexane: 30% ethyl acetate containing 10 μg each DHT and T. The aqueous and organic layers were separated by centrifugation at 14,000 φm in an Eppendorf microfuge. The organic layer was subjected to normal phase HPLC (10 cm Whatman partisil 5 silica column equilibrated in 1 ml/min 70% cyclohexane: 30% ethyl acetate; retention times: DHT, 6.8-7.2 min.; androstanediol, 7.6-8.0 min.; T, 9.1-9.7 min.). The HPLC system consisted of a Waters Model 680 Gradient System equipped with a Hitachi Model 655α autosampler, Applied Biosystems Model 757 variable UV detector, and a Radiomatic Model A 120 radioactivity analyzer. The conversion of T to DHT was monitored using the radioactivity flow detector by mixing the HPLC effluent with one volume of Flo Scint 1 (Radiomatic). Under the conditions described, the production of DHT was linear for at least 25 min. The only steroids observed with the human prostate and scalp preparations were T, DHT and androstanediol.
Inhibition studies
Compounds were dissolved in 100% ethanol. The compound to be tested was pre-incubated with the enzyme (either 5α- reductase type 1 or 2) prior to initiation by addition of substrate testosterone. IC50 values represent the concentration of inhibitor required to decrease enzyme conversion of testosterone to dihydrotestosterone by 50% of the control. IC50 values were determined using a 6 point titration where the concentration of the inhibitor was varied from 0.1 to 1000 nM.
A compound referred to herein as a 5α-reductase 2 inhibitor is a compound that shows inhibition of the 5α-reductase 2 isozyme in the above-described assay, having an IC50 value of about or under 100 nM.
A compound referred to herein as a 5α-reductase type 1 inhibitor is a compound that shows inhibition of the 5α-reductase type 1 isozyme in the above-described assay, having an IC50 value of about or under 100 nM.
A compound referred to herein as a dual 5 -reductase type 1 and 2 inhibitor is a compound that shows inhibition of both the type 1 and type 2 isozymes, having an IC50 value of about or under 100 nM for each isozyme.
EXAMPLE 3 ORAL COMPOSITION
As a specific embodiment of an oral composition of a compound of this invention, 5 mg finasteride and 40 mg simvastatin are formulated with sufficient finely divided lactose to provide a total amount of 580 to 590 mg to fill a size 0 hard gelatin capsule.
While the foregoing specification teaches the principles of the present invention, with examples provided for the puφose of illustration, it will be understood that the practice of the invention encompasses all of the casual variations, adaptations, modifications, deletions, or additions of procedures and protocols described herein, as come within the scope of the following claims and its equivalents.

Claims

WHAT IS CLAIMED IS:
1. A method of raising HDL cholesterol levels in a patient in need of such treatment comprising the administration of an HDL cholesterol raising dose of a 5oc-reductase inhibitor.
2. The method of raising HDL cholesterol levels of Claim 1 comprising the administration of one or more 5 -reductase inhibitors to the patient.
3. The method of Claim 2 wherein a Type 1 5oc- reductase inhibitor and a Type 2 5α-reductase inhibitor are administered to the patient.
4. The method of Claim 1 wherein the 5α-reductase inhibitor is a Type 2 5α-reductase inhibitor.
5. The method of Claim 1 wherein the 5cc-reductase inhibitor is selected from: ( 1 ) finasteride
Figure imgf000023_0001
(2) 4,7β-dimethyl-4-aza-5α cholestan-3-one
Figure imgf000024_0001
(3) 3-oxo-4-aza-4,7-β-dimethyI- 16β-(4-chlorophenoxy)-5α- androstane
Figure imgf000024_0002
(4) epristeride
Figure imgf000024_0003
6. The method of Claim 5 wherein the 5ot-reductase inhibitor is finasteride:
Figure imgf000025_0001
7. The method of Claim 1 wherein the dose of the 5cx- reductase inhibitor is from 0.2 to 1000 mg per day.
8. A method of reducing the risk of coronary artery disease mortality in a patient comprising the administration of an HDL cholesterol raising dose of a 5 -reductase inhibitor.
9. The method of reducing the risk of coronary artery disease of Claim 8 comprising the administration of one or more 5cx- reductase inhibitors to the patient.
10. The method of reducing the risk of coronary artery disease of Claim 8 additionally comprising administration of a cholesterol-lowering agent selected from:
(a) an HMG-CoA reductase inhibitor, (b) an HMG-CoA synthase inhibitor,
(c) a squalene epoxidase inhibitor,
(d) a squalene synthase inhibitor,
(e) probucol,
(f) clofibrate, (g) niacin,
(h) fenofibrate,
(i) gemfibrizol, and
(j) a bile acid sequesterant. 24 -
1 1. The method of Claim 10 wherein the cholesterol lowering agent is an HMG-CoA reductase inhibitor selected from: (a) lovastatin, (b) simvastatin,
(c) pravastatin, and
(d) fluvastatin and pharmaceutically acceptable salts and esters thereof.
12. The method of reducing the risk of coronary artery disease of Claim 8 additionally comprising the administration of a pharmaceutically acceptable nontoxic cationic polymer capable of binding bile acids in a nonresorbable form in the gastro-intestinal tract.
13. The method of Claim 12 wherein the pharmaceutically acceptable nontoxic cationic polymer capable of binding bile acids in a nonresorbable form is selected from cholestyramine, colestipol and poly[methyl-(3- trimethylaminopropyl)imino-trimethylene dihalide], and pharmaceutically acceptable salts and hydrates thereof.
14. The method of Claim 8 wherein the 5α-reductase inhibitor is selected from:
( 1 ) finasteride
Figure imgf000026_0001
(2) 4,7β-dimethyl-4-aza-5α cholestan-3-one
Figure imgf000027_0001
(3) 3-oxo-4-aza-4,7-β-dimethyl- 16β-(4-chlorophenoxy)-5α- androstane
Figure imgf000027_0002
(4) epristeride
Figure imgf000027_0003
15. The method of Claim 14 wherein the 5oc-reductase inhibitor is finasteride:
Figure imgf000028_0001
16. A method of treating atherosclerosis in a patient in need of such treatment comprising the administration of an HDL cholesterol raising dose of a 5oc-reductase inhibitor.
17. The method of treating atherosclerosis of Claim 16 comprising the administration of one or more 5cx-reductase inhibitors to the patient.
18. The method of reducing the risk of coronary artery disease of Claim 16 additionally comprising administration of a cholesterol-lowering agent selected from:
(a) an HMG-CoA reductase inhibitor,
(b) an HMG-CoA synthase inhibitor,
(c) a squalene epoxidase inhibitor,
(d) a squalene synthase inhibitor, (e) probucol,
(f) clofibrate,
(g) niacin,
(h) fenofibrate,
(i) gemfibrizol, (j) a bile acid sequesterant, and
(k) a pharmaceutically acceptable nontoxic cationic polymer capable of binding bile acids in a nonresorbable form in the gastro-intestinal tract.
19. The method of Claim 16 wherein the 5α-reductase inhibitor is selected from: (1 ) finasteride
Figure imgf000029_0001
(2) 4,7β-dimethyl-4-aza-5 cholestan-3-one
Figure imgf000029_0002
(3) 3-oxo-4-aza-4,7-β-dimethyl- 16β-(4-chlorophenoxy)-5α- androstane
Figure imgf000029_0003
and (4) epristeride
Figure imgf000030_0001
20. A pharmaceutical composition comprising a 5 - reductase inhibitor, a cholesterol lowering agent selected from:
(a) an HMG-CoA reductase inhibitor,
(b) an HMG-CoA synthase inhibitor,
(c) a squalene epoxidase inhibitor,
(d) a squalene synthase inhibitor,
(e) probucol,
(f) clofibrate,
(g) niacin,
(h) fenofibrate,
(i) gemfibrizol,
(j) a bile acid sequesterant, and
(k) a pharmaceutically acceptable nontoxic cationic polymer capable of binding bile acids in a nonresorbable form in the gastro-intestinal tract; and a pharmaceutically acceptable carrier.
PCT/US1995/007215 1994-09-13 1995-06-06 Use of 5-alpha-reductase inhibitors to increase hdl cholesterol levels WO1996008239A1 (en)

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