阅读说明：本技术 皮特-霍普金斯综合征的治疗 (Treatment of pitt-hopkins syndrome ) 是由 D·布朗 于 2020-02-26 设计创作，主要内容包括：本发明涉及阿米替林或其药学上可接受的盐,其用于治疗皮特-霍普金斯综合征。(The present invention relates to amitriptyline or a pharmaceutically acceptable salt thereof for use in the treatment of pitter-hopkins syndrome.)

1. Amitriptyline (amitriptyline) or a pharmaceutically acceptable salt thereof, for use in the treatment of Pitt-Hopkins syndrome (Pitt-Hopkins syndrome).

2. Amitriptyline for use according to claim 1, wherein the subject of treatment is a human.

3. Amitriptyline for use according to any one of claims 1 or 2, wherein the dose of amitriptyline is 1mg to 400mg, preferably 50mg to 300mg, most preferably 150mg to 300 mg.

4. Amitriptyline for use according to any one of the preceding claims, wherein administration is by a single daily dose.

5. Amitriptyline for use according to claim 4, wherein the single daily dose is 1mg to 400mg, preferably 300mg to 400 mg.

6. Amitriptyline for use according to any one of claims 1-3, wherein administration is by a dose twice daily.

7. Amitriptyline for use according to claim 6, wherein the dose is 1mg to 5mg or 150mg to 200 mg.

8. Amitriptyline for use according to any one of the preceding claims, which is administered orally.

9. Amitriptyline for use according to any one of claims 1-7, administered by parenteral, transdermal, sublingual, rectal, or inhalation administration.

10. Amitriptyline for use according to any one of the preceding claims, wherein the patient exhibits signs of impaired intelligence, hyperactivity, stereotypy, social anxiety and/or hypotonia.

11. A method of treating pitt-hopkins syndrome comprising administering amitriptyline or a pharmaceutically acceptable salt thereof to a patient.

12. A method according to claim 11 having any of the further features of claims 2 to 9.

Technical Field

The present invention relates to the treatment of Pitt-Hopkins syndrome (PTHS).

Background

The pitter-hopkins syndrome is a rare inherited neurological disorder caused by molecular variants of TCF4 that are involved in embryonic neuronal differentiation.

PTHS are characterized by unique facial features (complex face), developmental delay (bradykinesia), intellectual disability, early myopia, seizures, constipation and dyspnea (hyperventilation-apnea attacks, i.e. recurrent attacks of their tachypnea, usually followed by attacks of their difficult or temporary cessation of breathing) and low muscle tone (hypotonia). Additional symptoms include repetitive non-functional hand movements and behavioral abnormalities, such as hyperactivity and anxiety. Many affected individuals meet the criteria for autism spectrum disorders.

PTHS is caused by a pathogenic variant of the TCF4 gene found on chromosome 18q 21.2. This syndrome was first described in 1978 in two unrelated individuals who shared similar properties of facial features of deformity, developmental delay, clubbing, and abnormal breathing patterns. The syndrome was assumed to be an autosomal recessive disorder before the TCF4 gene (MIM number: 602272) was identified in 2007, confirming the autosomal dominant mode of inheritance secondary to a single dose deficiency of TCF 4. Transcription factor 4 (the protein product of TCF 4) is a basic helix-loop-helix E-protein thought to be involved in early brain development and neuronal differentiation.

There is currently no effective therapy for treating PTHS. There is a need for therapies for treating PTHS.

Amitriptyline (Amitriptyline) is a tricyclic antidepressant (TCA). Amitriptyline is a derivative of dibenzosuberene and inhibits the reuptake of norepinephrine and serotonin by presynaptic neuronal membranes in the Central Nervous System (CNS), thereby increasing synaptic concentrations of norepinephrine and serotonin. Due to constant stimulation of these receptors, amitriptyline may produce down-regulation of adrenergic and serotonin receptors, which may contribute to antidepressant activity.

Amitriptyline is commonly administered in the form of amitriptyline HCL and is known under the systematic name 3- (10, 11-dihydro-5H-dibenzo [ a, d ] cyclohepten-5-ylidene) -N, N-dimethyl-1-propylamine hydrochloride. It is a white odorless crystalline compound that is freely soluble in water.

Amitriptyline HCl in the form of a 10mg, 25mg, 50mg, 75mg, 100mg or 150mg tablet as And (5) selling. Each tablet contains inactive ingredients: colloidal silicon dioxide, hydroxypropyl methylCellulose, lactose monohydrate, magnesium stearate, microcrystalline cellulose, polyethylene glycol, polysorbate, sodium starch glycolate, and titanium dioxide.Can be used for treating depression.

Disclosure of Invention

The present invention is amitriptyline, or a pharmaceutically acceptable salt thereof, for use in the treatment of PTHS. As will be apparent from the in vivo data presented below, amitriptyline is effective in treating PTHS. Long-term treatment with amitriptyline significantly improved the Tcf4 +/-mouse phenotype, rescue fear of condition, open field, nesting, self-grooming, social and strength testing. This is evidence that amitriptyline is useful in PTHS therapy.

A first aspect of the invention is amitriptyline, or a pharmaceutically acceptable salt thereof, for use in the treatment of pitt-hopkins syndrome.

Drawings

Figure 1 shows the results of the amitriptyline in vivo conditioned fear test (learning and memory).

Figure 2 shows the results of the open field test (hyperactivity) in amitriptyline.

Figure 3 shows the results of the amitriptyline in vivo nesting test (daily life test).

Figure 4 shows the results of the self-hairing (stereotypy), i.e. repetitive movement, test in amitriptyline.

Figure 5 shows the results of the amitriptyline in vivo social test.

Figure 6 shows the results of the amitriptyline in vivo strength test (strength).

Figure 7 shows the results of dose response experiments in 5 behavioral tests.

In the figures, "ns" means no significant difference from the wild type control group. This indicates that the drug-treated knockouts behaved similarly to the untreated or treated wild-type group in the behavioral assay, suggesting that the compounds are significantly effective in improving the phenotype of the syndrome.

Detailed Description

Patients with pitter-hopkins syndrome have many different manifestations and symptoms. These manifestations and symptoms include: hyperactivity and repetitive behavior, including repetitive non-functional hand movements; mental impairments such as learning and memory difficulties, e.g., cognitive, executive and linguistic performance, short-term memory, executive function, visual memory, visual-spatial relationship and spatial working memory difficulties; engraving; social anxiety (i.e., difficulty in social interaction); low muscle tone (hypotony); constipation, sleep disorders, seizures; irregular or abnormal breathing patterns and severe myopia (myopia).

In the present invention, and as demonstrated by the following in vivo data, amitriptyline is used to treat one or more of the above symptoms, and is therefore an effective treatment for PTHS. Preferably, amitriptyline is used for the treatment of PTHS, wherein the patient exhibits symptoms typical of a syndrome comprising: hyperactivity; social anxiety; impaired intelligence, particularly learning and memory difficulties; engraving; and hypotonia.

The term "intellectual impairment" has its normal meaning in the art. Which encompasses impaired learning and impaired memory. Impaired learning may also be referred to as intellectual impairment. It encompasses cognitive impairment, delay or limitation of mental function, such as reasoning. Impaired memory refers to the inability to retain information for short or long periods of time. Which may include cognitive, executive and linguistic manifestations, executive function and visual memory difficulties. It may also contain working memory, also known as short-term memory (i.e., temporarily storing information while processing the same or other information) difficulties and speech memory (or oral working memory) difficulties. This symptom was tested in mice under "conditioned fear" (see in vivo data below).

The term "overactive" has its normal meaning in the art. Hyperactivity can include very short duration of attention, hypersensitivity to visual, auditory, tactile and olfactory stimuli, distraction, impulse, agitation and/or hyperactivity. This symptom was tested in mice under "open field" (see in vivo data below).

The term "test of daily living" has its normal meaning in the art. It may also mean the ability to perform things normal to the species, including any daily activities performed, such as bedding, feeding, etc. This symptom was tested in mice under "nesting" (see in vivo data below).

The term "cliche action" has its normal meaning in the art. It may also be referred to as repetitive movement or repetitive behavior. This symptom was tested in mice under "self-grooming" (see in vivo data below).

The term "social anxiety" has its normal meaning in the art. It may also be referred to as social interaction difficulty or social low. Social anxiety may include poor eye contact, aversive gaze, extended time to begin social interaction, social avoidance or withdrawal, and challenges in forming peer relationships. This symptom was tested in mice under "social" conditions (see in vivo data below).

The term "hypotonia" has its normal meaning in the art. This symptom was tested in mice under the "strength test". The term "force" has its normal meaning in the art. It may also mean the force or energy put into action.

As used herein, a pharmaceutically acceptable salt is a salt with a pharmaceutically acceptable acid or base. Pharmaceutically acceptable acids include inorganic acids such as hydrochloric acid, sulfuric acid, phosphoric acid, diphosphoric acid, hydrobromic acid or nitric acid; and organic acids such as citric acid, fumaric acid, maleic acid, malic acid, ascorbic acid, succinic acid, tartaric acid, benzoic acid, acetic acid, methanesulfonic acid, ethanesulfonic acid, salicylic acid, stearic acid, benzenesulfonic acid, or p-toluenesulfonic acid. Pharmaceutically acceptable bases include alkali metal (e.g., sodium or potassium) and alkaline earth metal (e.g., calcium or magnesium) hydroxides and organic bases such as alkyl amines, aryl amines or heterocyclic amines.

In the present invention, amitriptyline can be administered in a variety of dosage forms. In one embodiment, amitriptyline may be formulated in a form suitable for oral, rectal, parenteral, intranasal, or transdermal administration or administration by inhalation or by suppository.

Amitriptyline can be administered orally, e.g., in the form of tablets, troches, lozenges, aqueous or oily suspensions, dispersible powders or granules. Preferably, amitriptyline is formulated such that it is suitable for oral administration, such as tablets and capsules.

Amitriptyline can also be administered parenterally, whether subcutaneously, intravenously, intramuscularly, intrasternally, transdermally, or by infusion techniques. Amitriptyline may also be administered in the form of suppositories.

Amitriptyline can also be administered by inhalation. An advantage of inhaled drugs, compared to many drugs taken by the oral route, is that they are delivered directly to areas where the blood supply is abundant. Absorption is very rapid because the alveoli have a large surface area and a rich blood supply, and bypass first pass metabolism.

The invention also provides an inhalation device containing amitriptyline. Typically, the device is a Metered Dose Inhaler (MDI) which contains a pharmaceutically acceptable chemical propellant to push the medicament out of the inhaler.

Amitriptyline can also be administered by intranasal administration. The highly permeable tissue of the nasal cavity is very receptive to the drug and absorbs the drug quickly and efficiently. Nasal drug delivery is less painful and invasive than injection, thereby reducing anxiety in the patient. In this way, absorption is very rapid and first pass metabolism is often bypassed, thereby reducing inter-patient variability. Further, the present invention also provides an intranasal device containing amitriptyline.

Amitriptyline can also be administered by transdermal administration. For topical delivery, transdermal and transmucosal patches, creams, ointments, gels, solutions or suspensions may be used. Accordingly, the present invention also provides a transdermal patch containing amitriptyline.

Amitriptyline can also be administered by sublingual administration. Accordingly, the present invention also provides a sublingual tablet comprising amitriptyline.

Amitriptyline may also be formulated with agents that reduce degradation of substances by processes other than the normal metabolism of the patient, such as antibacterial agents or protease inhibitors that may be present in the patient or in commensal or parasitic organisms living on or in the patient, and which proteases are capable of degrading the compounds.

Liquid dispersions for oral administration may be syrups, emulsions and suspensions.

Suspensions and emulsions may contain as carrier, for example, natural gums, agar, sodium alginate, pectin, methyl cellulose, carboxymethyl cellulose or polyvinyl alcohol. Suspensions or solutions for intramuscular injections may contain, together with the active compound, a pharmaceutically acceptable carrier, e.g., sterile water, olive oil, ethyl oleate, glycols (e.g., propylene glycol), and, if desired, a suitable amount of lidocaine hydrochloride.

Solutions for injection or infusion may contain, for example, sterile water as the carrier, or preferably the solution may be in the form of a sterile, aqueous, isotonic saline solution.

In embodiments of the invention, amitriptyline is administered in an effective amount to treat the symptoms of the pitat-hopkins syndrome. Effective dosages will be apparent to those skilled in the art and will depend on many factors that the medical practitioner will be able to determine, including age, sex, body weight.

In a preferred embodiment, amitriptyline is administered at a dose of 0.5 to 400mg, more preferably 1 to 400mg, more preferably 2.5 to 400mg, more preferably 5mg to 400mg, more preferably 50mg to 300mg, most preferably 150mg to 300 mg. The lower limit of the dosage is preferably 0.5mg, 1mg, 1.5mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 10mg, 15mg, 20mg, 25mg, 30mg, 35mg, 40mg, 45mg, 50mg, 55mg, 60mg, 65mg, 70mg, 75mg, 80mg, 85mg, 90mg, 95mg, 100mg, 110mg, 120mg, 130mg, 140mg, 150mg, 160mg, 170mg, 180mg, 190mg or 200 mg. The upper dosage limit is preferably 400mg, 390mg, 380mg, 370mg, 360mg, 350mg, 340mg, 330mg, 320mg, 310mg, 300mg, 290mg, 280mg, 270mg, 260mg, 250mg, 240mg, 230mg, 220mg or 210 mg. The lower or upper limits of any of the above ranges may be combined with each other and are disclosed herein. In some embodiments, the dose is 150mg to 300 mg. In some embodiments, the dose is 2 to 100mg or about 2.5 mg.

Any of the above doses may be administered once daily, twice daily, three times daily, or four times daily.

In embodiments of the invention, amitriptyline is administered at least once daily. Preferably, it is administered in the form of a single daily dose. Preferably, the single daily dose is from 200mg to 400mg or from 2 to 100 mg. Preferably, the single daily dose is 2.5mg, 200mg, 300mg or 400 mg.

It will be appreciated that lower doses may be required in pediatric patients. For example, a dose of about 2.5mg may be suitable for pediatric patients.

In an embodiment of the invention, amitriptyline is administered twice daily. Preferably, each dose is from 1 to 20mg or from 150mg to 200mg, with a total daily dose of from 2 to 40mg or from 300mg to 400 mg.

Alternatively, it may be administered three times per day. Preferably, each dose is 1 to 20mg or 100mg to 130 mg.

Alternatively, it may be administered four times per day. Preferably, each dose is from 1 to 20mg or from 75mg to 100 mg.

Preferably, the dosage regimen is such that the total daily dose of amitriptyline does not exceed 400mg, more preferably 300 mg.

To treat the pita-hopkins syndrome, amitriptyline is used in a chronic dosage regimen, i.e., chronic, long-term treatment.

The invention also relates to the use of amitriptyline or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for the treatment of pita-hopkins syndrome. This embodiment of the invention may have any of the preferred features described above.

The present invention also relates to a method of treating pitt-hopkins syndrome comprising administering amitriptyline or a pharmaceutically acceptable salt thereof to a patient. This embodiment of the invention may have any of the preferred features described above. The method of administration may be according to any of the routes described above.

For the avoidance of doubt, the present invention also encompasses prodrugs which react in vivo to give the compounds of the invention.

The following study demonstrates the present invention.

Study 1

Pitt-hopkins syndrome (PTHS) is characterized by cognitive dysfunction, wide mouth and unique facial features, and intermittent high hyperventilation, followed by apnea (Zweier et al, 2007). Cognitive dysfunction associated with the loss of one copy of the TCF4 gene in humans (known as single dose insufficiency) leads to the pita-hopkins syndrome, a condition associated with autism associated with significant learning deficits.

The pitter-hopkins syndrome (PTHS) is an inherited neurodevelopmental disorder associated with a mutation/deletion of the transcription factor TCF 4. TCF4 may also be associated with schizophrenia, suggesting that precise pathogenic mutations are associated with cellular, synaptic and behavioral consequences.

The Tcf4 +/-mouse model has been developed to mimic PTHS and thus evaluate potential treatments. Mice have deficiencies in hippocampus-dependent learning and memory, spatial working memory, social interaction, stereotypical movements, hyperactivity, and daily life paradigms. Tcf4 +/-mice also exhibited hind limb grip deficiency.

Animal(s) production

Mice were purchased from Jackson laboratories (The Jackson Laboratory) and maintained on a C57BL/6 background. Mice grew in a 12:12 bright: dark cycle with food and water ad libitum. The control consisted of TCF4 +/+. All mice used were heterozygous for the Tcf4 mutation, as homozygous mutations resulted in embryonic/postpartum lethality.

Assay design

During all tests and data analysis, experiments were randomized and blinded to genotype and treatment. Individual investigators prepared and encoded dosing solutions, mice were assigned to study treatment groups, animals were dosed, and behavioral data were collected.

Treatment group

Four treatment groups were used for each compound in the study, with 10 male mice used per treatment group (all mice were treated for 14 weeks of age): group 1: wild type littermates treated with vehicle (WT + veh); group 2: tcf4+/-KO mice treated with vehicle (Tcf4+/- + veh); group 3: WT + drug; and group 4: tcf4+/- + drug.

Behavioral and strength testing

This includes:

1. conditioned fear (testing for learning and memory);

2. open field (a measure of hyperactivity);

3. nesting (daily life test);

4. self-grooming (evaluation of engraving action);

5. social/zoning test (assessment of social anxiety);

6. strength test (test of hindlimb strength).

The term "learning and memory" has its normal meaning in the art. It may also be referred to as memory impairment. It means that information cannot be retained for short or long periods. Which may include cognitive, executive and linguistic manifestations, executive function and visual memory difficulties. It may also contain working memory, also known as short-term memory (i.e., temporarily storing information while processing the same or other information) difficulties and speech memory (or oral working memory) difficulties.

The term "overactive" has its normal meaning in the art. Hyperactivity can include very short duration of attention, hypersensitivity to visual, auditory, tactile and olfactory stimuli, distraction, impulse, agitation and/or hyperactivity.

The term "test of daily living" has its normal meaning in the art. It may also mean the ability to perform things normal to the species, including any daily activities performed, such as bedding, feeding, etc.

The term "self-grooming" has its normal meaning in the art. It may also mean self-cleaning and maintaining the normal appearance of skin, hair, fur, etc. Excessive performance through continuous repetitive behavior may be referred to as "stereotype actions.

The term "social anxiety" has its normal meaning in the art. It may also be referred to as social interaction difficulty or social low. Social anxiety may include poor eye contact, aversive gaze, extended time to begin social interaction, social avoidance or withdrawal, and challenges in forming peer relationships.

The term "force" has its normal meaning in the art. It may also mean the force or energy put into action.

1. Fear of condition

Tcf4+/_ mice showed a reduction in rigidity in the context of the implied conditioned fear test indicating hippocampal-dependent memory and learning deficits. The dependency measure used in contextual fear is the catalepsy response after pairing of the unregulated stimulus (foot shock) with the regulated stimulus (specific context). Rigidity is a species-specific response to fear, defined as "absence of movement except for respiration". This may last from seconds to minutes depending on the strength of the aversive stimulus, the number of times and the degree of learning achieved by the subject. The test involved placing the animal in a new environment (dark room), providing an aversive stimulus (1 second shock to the paw, 0.2mA), and then removing it.

2. Open field

Open field devices are used to test for hyperactivity. During the 30 minute trial open field, Tcf4+/_ mice showed hyperactivity in terms of distance traveled per minute compared to WT littermates. The device is a 50 x 9 x 30cm arena (arena) enclosed by grey PVC divided into a 10 x 10cm grid. Mice were brought to the laboratory 5-20 minutes prior to testing. Mice were placed in corner-facing dish angle squares (corner squares) and observed for 3 minutes. The number of squares (voluntary activity) entered through the body was counted. The movement of the mouse around the field was recorded with a video tracking device for 3 minutes (NT4.0 version, Viewpoint).

3. Nesting device

The tests were performed in individual cages. Ordinary bedding covers the floor to a depth of 0.5 cm. Each cage was supplied with "Nestlet", a 5cm thick stock²Pressed batting (Ancare). Mice were placed individually in nest cages 1 hour prior to the dark phase and the results were evaluated the next morning. Nesting was scored on a 5-point scale.

Score 1: the Nestlet is largely unaffected (> 90% intact).

And (3) scoring 2: the Nestlet is partially torn (50-90% remains intact).

And 3, scoring: most of the Nestlet is shredded, but there are usually no identifiable nest sites: < 50% Nestlet.

Score 4: identifiable but flat nests, < 90% of the nestlets are torn, gathering the material into a flat nest (the walls of which are higher than the height of a mouse rolled up on one side of it by less than 50% of its circumference).

Score 5: (near) perfect nest: > 90% of the nestlets are torn, the nest is a crater, the walls of which are higher than the height of the mouse over more than 50% of its circumference.

4. Self-hair-tidying device

Tcf4+/_ mice groomed themselves significantly more than WT mice that exhibited a higher level of stereotypical behavior than control mice.

Typically, in a sitting position, the mouse will lick its fur, groom with the forepaws, or scratch with any limb. Typically, a mouse will mix all of these grooming behaviors. Hair management generally follows a sequence consisting of four behaviors:

-elliptical drawing: the front paw is asymmetrically moved in an ellipse above the nose and the mouth, and large-amplitude paddling and small-amplitude paddling are alternated.

-one-sided scribing: the front paw touches the palpus and the eyes alternately.

-double-sided scribing: the front paw starts from behind the ear and is stroked across the face with a large amplitude, symmetrically on both sides.

-licking by the body: licking the entire body, usually from the beginning to the tail.

5. Is divided intoZone testing

In the three-room social task, the exploration of the novel social stimuli (novel mice) by the test mice (subject mouse) was evaluated. When the test mouse was proposed to choose to stay with a new mouse or an empty cup, the three-compartment social proximity task monitored direct social proximity behavior. Socialization was defined as the test mice spending more time in the mouse-containing chamber than in the empty chamber. Social novelty preference was defined as the more time to stay with the new mouse in the room. The device is a rectangular three-compartment box in which each compartment measures 20cm (length) x 40.5cm (width) x 22cm (height). The partition walls are made of a transparent complex material (perplex) with small openings (10cm width x 5cm height) allowing access to each chamber. The three-compartment task is illuminated from below (10 lux). The mice were allowed to freely explore the three-compartment device in three 10-minute experiments. During the experiment, one wire cup was placed upside down in one of the side chambers and a new mouse was placed under the other wire cup in the other side chamber (new mouse stimulation), leaving the middle chamber empty. The position of the new mouse throughout the experiment was offset to minimize any potential confounding due to the preference for the chamber position. The time spent exploring the new mice was recorded as the exploration ratio.

6. Force testing

When compared to WT mice, the hind limb strength (not forelimb) of the Tcf4 +/-mice showed significant deficiency. The neuromuscular function of the hindlimb was tested with a grip dynamometer (San Diego Instruments). The mouse's nape of the neck was covered, the tail was grasped, and lifted to an upright position. The mouse was then lowered towards the device, allowed to grip a smooth metal mesh (hind limb only), and pulled back in the horizontal plane. The force exerted on the grid when the grip was released was recorded.

Statistical analysis of behavioral data

Data were analyzed by two-way analysis of variance (ANOVA), followed by post-Test comparisons using the graph-based Multiple Comparison Test (Tukey's Multiple Comparison Test) where appropriate. Data are expressed as mean and Standard Error of Mean (SEM).

Conclusion

As is evident from the above data, long-term treatment of Tcf4 +/-mice with amitriptyline significantly improved learning and memory; hyperactivity; testing daily life; engraving; social anxiety and strength tests. Since the mouse model mimics PTHS, this is evidence that amitriptyline has therapeutic effects on PTHS.

Study 2

Dose response experiments were performed according to the protocol described above. The results are shown in fig. 7. Amitriptyline rescued all behavioral tests at 5 and 10 mg/kg.