US 2010.0029591A1 (19) United States (12) Patent Application Publication (10) Pub. No.: US 2010/0029591 A1 STOFFELS (43) Pub. Date: Feb. 4, 2010

(54) COMBINATIONS OF A PYRIMIDINE (30) Foreign Application Priority Data CONTAINING NNRT WITH RT INHIBITORS

Sep. 3, 2003 (EP) ...... 03103.275.8 (76) Inventor: Paul STOFFELS, Hoogstraten Sep. 8, 2003 (EP) ...... O3103319.4 (BE) Sep. 10, 2003 (EP) ...... O3103335.O Oct. 2, 2003 (EP) ...... O3103668.4 Correspondence Address: PHILIP S. JOHNSON O O JOHNSON & JOHNSON Publication Classification ONE JOHNSON & JOHNSON PLAZA (51) Int. Cl. NEW BRUNSWICK, NJ 08933-7003 (US) A63/675 (2006.01) A 6LX 3L/505 (2006.01) (21) Appl. No.: 12/574,881 (22) Filed: Oct. 7, 2009 (52) U.S. Cl...... 514/80; 514/256 Related U.S. Application Data (63) Continuation of application No. 10/570.228, filed on (57) ABSTRACT Feb. 28, 2006, filed as application No. PCT/EP2004/ - O52O28 on Sep. 3, 2004 The present invention concerns combinations of a pyrimidine On Sep. 3, containing NNRTI with nucleoside (60) Provisional application No. 60/499,771, filed on Sep. inhibitors and/or nucleotide reverse transcriptase inhibitors 3, 2003, provisional application No. 60/508,486, filed useful for the treatment of HIV infected patients or for the on Oct. 3, 2003. prevention of HIV transmission or . US 2010/0029591 A1 Feb. 4, 2010

COMBINATIONS OF A PYRIMIDNE 0007 An overview of new antiretroviral drugs is given in CONTAINING NNRT WITH RT INHIBITORS Clinical Microbiology and Infection 2003, Vol. 9:3, pp. 186 193. FIELD OF THE INVENTION 0008 WO 03/016306 specifically discloses more than 250 0001. The present invention concerns combinations of a pyrimidine derivative having MV replication inhibiting prop pyrimidine containing NNRTI with nucleoside reverse tran erties that act as non-nucleoside RT inhibitors (NNRTIs) Scriptase inhibitors and/or nucleotide reverse transcriptase having the ability to inhibit the replication both wild-type and inhibitors useful for the treatment of HIV infected patients or of mutant strains. One of said NNRTIs is 4-4-4-(2-cyano for the prevention of HIV transmission or infection. ethenyl)-2,6-dimethylphenyl-amino-2-pyrimidinyl amino]-benzonitrile (herein referred to as TMC278). WO BACKGROUND OF THE INVENTION 03/016306 also discloses the methods to synthesize these 0002. Despite the fact that significant progress has been compounds. It further discloses combinations of said made by the introduction of HAART therapy (Highly Active NNRTTs with other antiretrovirals, i.e. suramine, pentami Anti-Retroviral Therapy), resistance of the HIV virus against dine, thymopentin, castanospermine, dextran (dextran Sul nucleoside reverse transcriptase inhibitors (NRTIs), non fate), -Sodium (trisodium phosphono formate), nucleoside reverse transcriptase inhibitors (NNRTIs), nucle (3'-azido-3'-deoxythymidine, AZT), otide reverse transcriptase inhibitors (NtRTIs), protease (2',3'-di-deoxyinosine; ddI), (dideoxycytidine, inhibitors and even the more recent fusion inhibitors is still a ddC), (2'-3'-dideoxy-3'-thiacytidine, 3TC), stavu major cause of therapy failure. For instance, half of the dine (2',3'-didehydro-3'-deoxythymidine, d4T), , patients receiving anti-HIV combination therapy do not (11-cyclopropyl-5,11-dihydro-4-methyl-6H respond fully to the treatment, mainly because of resistance of dipyrido-32-b: 2',3'-e 1,4diazepin-6-one), , the virus to one or more drugs used. Moreover, it has been , TMC120, TMC125, tenofovir, (S)-8-chloro-4,5, shown that resistant virus is carried over to newly infected 6,7-tetrahydro-5-methyl-6-(3-methyl-2-butenyl)imidazo-4, individuals, resulting in severely limited therapy options for 5,1-jk 1.4benzodiazepine-2(1H)-thione, C.-(2-nitrophe these drug-naive patients. On the International AIDS Confer nyl)amino-2,6-dichloro-benzene-acetamide, RO-5-3335. ence in Paris in July 2003, researchers released that the big , , , (ABT-378), nelfi gest study so far of resistance to AIDS drugs finds that about navir, , TMC126, BMS-232632, VX-175, T-20, 10 percent of all newly infected people in Europe have drug T-1249, AMD-3100 and hydroxyurea. resistant strains. Smaller tests to determine the spread of 0009. Notwithstanding existing combination therapy, resistance have been done in the high-risk city center of San there is still a need for improved antiretroviral therapy, more Francisco. This test showed the highest level of resistance at particularly AIDS therapy. This need is particularly acute for 27 percent. therapy that is effective not only on wild type HIV virus, but 0003. The pharmacokinetic profile of many commercially also on the increasingly more common resistant HIV viruses. available antiretrovirals does not allow relatively low thera It is thus highly desirable especially for first line therapy to peutic doses. Poor pharmacokinetic profiles often in combi design a combination regimen with a low pill burden that nation with poor solubility properties of the antiretrovirals limits or even Suppresses the recurrence of drug resistant cause the AIDS patient to face a high pill burden which is virus and which can be used and remains effective for a long particularly undesirable for drug-naive patients or first line term. therapy. Moreover, as a consequence of the AIDS virus even 0010. It is an object of the invention to provide combina resisting antiretroviral combination therapy, a physician will tions of more than one therapeutically effective antiretroviral boost the plasma levels of the active drugs in order for said drug, which combinations can be used as first line therapy in antiretrovirals to regain effectivity against the mutated HIV drug-naive patients for a long period of time. viruses, the consequence of which is an even higher increase in pill burden. Boosting plasma levels may also lead to an 0011. It is also an object of the invention to provide com increased risk of non-compliance with the prescribed therapy binations of more than one therapeutically effective antiret and to increased side-effects. roviral drug in which the antiretroviral drugs have a comple 0004 Several attempts have been made to date to design mentary resistance profile thus creating a high resistance combination regimens. For instance, the combination of barrier and thus allowing a drug-naive patient to take the lamivudine (a nucleoside RT inhibitor also named 3TC) at a combinations for a long period of time. 150 mg dose and zidovudine (a nucleotide RT inhibitor also 0012 Another object of the invention is to provide com named AZT) at a 300 mg dose, formulated in an oral tablet binations of more than one therapeutically active antiretrovi and dosed twice daily, or the combination of abacavir sulfate ral drug wherein each of the active antiretroviral drugs of the at a dose equivalent to 300 mg abacavir (a nucleoside RT combinations can be administered once daily thus reducing inhibitor), lamivudine at a 150 mg dose and zidovudine at a the pill burden for the patient. 300 mg dose, formulated in an oral tablet and dosed twice 0013. A further object of the invention is to provide com daily. binations of more than one therapeutically active antiretrovi 0005 WO 93/23021 describes therapeutic combinations ral drug wherein each of the active antiretroviral drugs of the for the treatment of HIV- comprising zidovudine combinations can be co-formulated. and an agent serving to enhance the antiviral activity against 0014. Yet a further object of the invention is to provide HIV populations otherwise resistant to zidovudine. combinations of more that one therapeutically active antiret 0006 WO 96/01110 describes a triple combination of roviral drug wherein a therapeutically effective amount of Zidovudine, lamivudine and loviride, the latter being a non each of the active antiretroviral drugs of the combinations can nucleoside RT inhibitor of the O.-APA class. be co-formulated in one single pharmaceutical formulation. US 2010/0029591 A1 Feb. 4, 2010

0015. Another object of the present invention is to provide given drug, whether the mutated virus will have any chance of combinations of more than one active antiretroviral drug Survival under the pressure of the drug, how much drug is which combinations can be used to prevent HIV transmission needed to limit or to suppress the recurrence of such mutated or infection in humans. Virus, and at what frequency such drug has to be given to 10016 All references cited herein are incorporated by ref maintain suppression of the development of a resistant virus CeCe. that can break through the genetic barrier of the drug. SUMMARY OF THE INVENTION DETAILED DESCRIPTION OF THE INVENTION 0017 Thus in a first aspect, the present invention provides I0025. As used herein the term “therapeutically effective a combination comprising (i) TMC278 or a stereoisomeric HIV inhibitors at a dose that can be administered once daily form thereof; or a pharmaceutically acceptable salt thereof; or means that the HIV inhibitors are suitable for dosing every 24 a prodrug thereof, and (ii) a nucleoside reverse transcriptase hours. The term suitable for dosing every 24 hours’ means inhibitor and/or a nucleotide reverse transcriptase inhibitor; that the HIV inhibitors are such that they can be administered wherein TMC278 and the nucleotide reverse transcriptase every 24 hours and give effective blood plasma concentra inhibitor and/or the nucleoside reverse transcriptase inhibitor tions of the active ingredients such that they are effective to are therapeutically effective HIV inhibitors at a dose that can suppress HIV infection over a period of 24 hours. The HIV be administered once daily. inhibitors for use in the invention can be dosed every 24 0018 Thus in a second aspect, the present invention pro hours. vides a combination comprising (i) TMC278 or a stereoiso 0026 TMC278 or 4-4-4-(2-cyanoethenyl)-2,6-dim meric form thereof; or a pharmaceutically acceptable salt ethylphenyl-amino-2-pyrimidinyl-amino-benzonitrile is thereof; or a prodrug thereof; and (ii) a nucleoside reverse a known NNRTI, which can be prepared as described in transcriptase inhibitor; wherein TMC278 and the nucleoside WO03/016306. TMC278 can be used in base form or, which reverse transcriptase inhibitor are therapeutically effective is preferred, as a suitable pharmaceutically acceptable salt HIV inhibitors at a dose that can be administered once daily. form, in particular as an acid addition salt form. The pharma 0019. In a third aspect there is provided a combination ceutically acceptable addition salts are meant to comprise the comprising (i) TMC278 or a stereoisomeric form thereof; or therapeutically active non-toxic salt forms. The acid addition a pharmaceutically acceptable salt thereof, or a prodrug salt forms can be obtained by treating the base form with thereof; and (ii) a nucleotide reverse transcriptase inhibitor; appropriate acids as inorganic acids, for example, hydrohalic wherein TMC278 and the nucleotide reverse transcriptase acids, e.g. hydrochloric, hydrobromic and the like: sulfuric inhibitor are therapeutically effective HIV inhibitors at a dose acid; nitric acid; phosphoric acid and the like; or organic that can be administered once daily. acids, for example, acetic, propanoic, hydroxyacetic, 2-hy 0020. In a fourth aspect there is provided a triple combi droxy-propanoic, 2-oxopropanoic, oxalic, malonic, succinic, nation comprising (i) TMC278 or a stereoisomeric form maleic, fumaric, malic, tartaric, 2-hydroxy-1,2,3-propanetri thereof; or a pharmaceutically acceptable salt thereof; or a carboxylic, methanesulfonic, ethanesulfonic, benzene-sul prodrug thereof; and (ii) a nucleoside reverse transcriptase fonic, 4-methylbenzenesulfonic, cyclohexanesulfamic, 2-hy inhibitor; and (iii) a nucleotide reverse transcriptase inhibitor; droxybenzoic, 4-amino-2-hydroxybenzoic and the like acids. wherein TMC278 and the nucleotide reverse transcriptase Preferred for use in the present invention are the hydrohalic inhibitor and the nucleoside reverse transcriptase inhibitor are acid salts, in particular the hydrochloride salt. therapeutically effective HIV inhibitors at a dose that can be 0027 TMC278 occurs in stereoisomeric forms, more in administered once daily. particular as E- and Z-isomeric forms. Both isomers may be 0021. In a fifth aspect there is provided a triple combina used in the combinations of the present invention. Whenever tion comprising (i) TMC278 or a stereoisomeric form reference is made hereinto TMC278, the E- and the Z-form as thereof; or a pharmaceutically acceptable salt thereof; or a well as any mixture of both forms are meant to be included. prodrug thereof; and (ii) a nucleoside reverse transcriptase 0028. A preferred form of TMC278 for use in the inven inhibitor, and (iii) a second nucleoside reverse transcriptase tion is the E-isomer, i.e. (E)-4-4-4-(2-cyanoethenyl)-2,6- inhibitor different from the nucleoside reverse transcriptase dimethylphenyl-amino-2-pyrimidinyl-amino-benzoni inhibitor of (ii); wherein TMC278 and the first and second trile (hereinafter called E-TMC278). The Z-isomer of nucleosidereverse transcriptase inhibitors are therapeutically TMC278, i.e. (Z)-4-4-4-(2-cyanoethenyl)-2,6-dimeth effective HIV inhibitors at a dose that can be administered ylphenyl-amino-2-pyrimidinyl-amino-benzonitrile (here once daily. inafter called compound Z-TMC278) can also be used. It has 0022. In another aspect there is provided a pharmaceutical relatively high potency against wild-type HIV-1 but is less formulation comprising a pharmaceutically acceptable car active against single and double mutants in comparison to the rier and a combination as specified herein. E-isomer. Table 1 shows the ICs value in mM of the E and 0023 The invention also concerns the use of the combi Z-isomer of TMC278. nations specified herein as HIV inhibitors and the use thereof in the treatment of HIV infected patients or in the prevention TABLE 1. of HIV transmission or infection. 0024. The invention is based on the finding that TMC278 HIVRT mutation E-isomer Z-isomer is a potent reverse transcriptase inhibitor that has an Wild-type 0.4 0.6 extremely high genetic barrier in combination with a favour 10OI 0.4 6.3 103N O.3 1.6 able pharmacokinetic profile allowing once daily dosing. It 181C 1.3 5.0 was surprising to discover that TMC278 has all these prop 188L 2.0 32 erties together. This is unusual because one cannot predict 227C 2.0 4.0 what mutations will be selected in the HIV-1 genome by a US 2010/0029591 A1 Feb. 4, 2010

or pharmaceutically acceptable salt or its prodrug, and (ii) a TABLE 1-continued nucleoside reverse transcriptase inhibitor, and (iii) a nucle otide reverse transcriptase inhibitor, wherein (1) TMC278 HIVRT mutation E-isomer Z-isomer and the nucleotide reverse transcriptase inhibitor and the 1OOI- 103N 7.9 790 nucleoside reverse transcriptase inhibitor are therapeutically 103N - 181C 1.O 40 effective HIV inhibitors at a dose that can be administered 227L - 106A 1.O 4.0 once daily and (2) the nucleotide reverse transcriptase inhibi tor and the nucleoside reverse transcriptase inhibitor select 0029 Whenever reference is made hereinto the E-form of mutations in the reverse transcriptase that do not cause resis TMC278 (i.e. E-TMC278), the pure E-isomeror any isomeric tance to TMC278. mixture of the E- and the Z-forms wherein the E-form is predominantly present is meant to be comprised, i.e. an iso 0035. In another preferred embodiment, a triple combina meric mixture containing more than 50% or in particular tion is provided comprising (i) TMC278 or its stereoisomeric more than 80% of the E-form, or even more than 90% of the form or pharmaceutically acceptable salt or its prodrug, and E-form. Of particular interest is the E-form substantially free (ii) a nucleoside reverse transcriptase inhibitor, and (iii) a of the Z-form. Substantially free in this context refers to second nucleoside reverse transcriptase inhibitor different E-Z-mixtures with no or almost no Z-form, e.g. isomeric from the nucleoside reverse transcriptase inhibitor of (ii); mixtures containing as much as 90%, in particular 95% or wherein (1)TMC278 and the nucleoside reverse transcriptase even 98% or 99% of the E-form. Equally, whenever reference inhibitors are therapeutically effective HIV inhibitors at a is made herein to the Z-form of TMC278 (i.e. Z-TMC278), dose that can be administered once daily and (2) the nucleo the pure Z-isomer or any isomeric mixture of the Z- and the side reverse transcriptase inhibitors select mutations in the E-forms wherein the Z-form is predominantly present is reverse transcriptase that do not cause resistance to TMC278. meant to be comprised, i.e. an isomeric mixture containing 0036 Preferred nucleotide reverse transcriptase inhibitors more than 50% or in particular more than 80% of the Z-form, that can be used in the combinations subject of this invention or even more than 90% of the Z-form. Of particular interest is include tenofovir and its prodrug fuma the Z-form substantially free of the E-form. Substantially free rate. in this context refers to E-Z-mixtures with no or almost no 0037 Tenofovir is an adenosine nucleotide analogue cur E-form, e.g. isomeric mixtures containing as much as 90%, in rently commercially available with activity against retrovi particular 95% or even 98% or 99% of the Z-form. ruses. Tenofovir disoproxil fumarate (tenofovir DF) is a once 0030. Also meant to be included for use in this invention daily, orally administered prodrug oftenofovir. For antiviral are salts of the isomeric forms of TMC278, in particular the activity, tenofovir DF needs to be hydrolysed to the ANP salts mentioned above. Of particular interest are Z-TMC278 analogue and then phosphorylated to the active diphosphate hydrochloride and specifically E-TMC278 hydrochloride. moiety Arimillietal Antiviral Chemistry and Chemotherapy 0031 Advantageously, the nucleotide reverse tran 1997, 8:6 (557-564); Fridland et at. Antiviral Research 1997, Scriptase inhibitor and the nucleoside reverse transcriptase 34. After entry in to lymphocytes or macrophages, the pro inhibitor select mutations in the reverse transcriptase that do drug is quantitatively converted to the parent analogue, teno not cause resistance to TMC278. Of particular interest there fovir, and phosphorylated to mono- and diphosphate metabo fore is any combination specified herein wherein (1) TMC278 lites. The cellular enzymes that are responsible for and the nucleoside/nucleotide reverse transcriptase inhibitor phosphorylation of this drug are adenylate kinase and nucleo or inhibitors are therapeutically effective HIV inhibitors at a side diphosphate kinase Robbins et al. Antimicrobial Agents dose that can be administered once daily and (2) the nucleo and Chemotherapy 1995, 39:10 (2304-2308); Robbins et al. side/nucleotide reverse transcriptase inhibitor or inhibitors Antimicrobial Agents and Chemotherapy 1998, 42:3 (612 select mutations in the reverse transcriptase that do not cause 617). Unlike other nucleoside analogues, such as zidovudine resistance to TMC278. or , both of whose phosphorylation is cell cycle 0032 Specifically, in one embodiment, a combination is dependent, tenofovir is efficiently phosphorylated in resting provided comprising (i) TMC278 or its stereoisomeric form as well as cycling peripheral blood lymphocytes Robbins et or pharmaceutically acceptable salt or its prodrug, and (ii) a al. 1998. Tenofovir can inhibit HIV-1 replication in different nucleoside reverse transcriptase inhibitor, wherein (1) cell types that may target HIV, including primary human TMC278 and the nucleoside reverse transcriptase inhibitor blood lymphocytes and macrophages Perno et al. Antiviral are therapeutically effective HIV inhibitors at a dose that can Research 1992 (289-304); Perno et al. Molecular Pharma be administered once daily and (2) the nucleoside reverse cology 1996, 50:2 (359-366). The primary target oftenofovir transcriptase inhibitor selects mutations in the reverse tran diphosphate is reverse transcriptase (RT). Tenofovir diphos scriptase that do not cause resistance to TMC278. phate is a competitive inhibitor for the incorporation of 0033. In another embodiment, a combination is provided deoxyadenosine triphosphate into nascent proviral DNA comprising (i) TMC278 or its stereoisomeric form or phar chains. Inhibition of HIV-1 RT by tenofovir diphosphate has maceutically acceptable salt or its prodrug, and (ii) a nucle an inhibition constant of approximately 0.9 uM, and if the otide reverse transcriptase inhibitor, wherein (1) TMC278 analogue is incorporated into the growing viral DNA chain it and the nucleotide reverse transcriptase inhibitor are thera may terminate further chain elongation. Tenofovir inhibits peutically effective HIV inhibitors at a dose that can be viral RT much more effectively than it inhibits cellular DNA administered once daily and (2) the nucleotide reverse tran polymerases Suo etal Journal of Biological Chemistry 1998, Scriptase inhibitor selects mutations in the reverse tran 273:42 (2750-2758). The concentration required to inhibit scriptase that do not cause resistance to TMC278. the replication of various HIV-1 strains by 50% (EC50) in 0034. In a preferred embodiment, a triple combination is lymphocyte and macrophage cell types (MT-2, CEM, ACH8) provided comprising (i) TMC278 or its stereoisomeric form ranges from 0.2 to 10 uM. The antiviral effect is achieved at US 2010/0029591 A1 Feb. 4, 2010

non-toxic doses oftenofovir (selectivity index ranging from identified mutations at codon 184 from Met (ATG) to Val 100 to 2000). Tenofovir DF is currently available as 300 mg (GTG or GTA) Schinazi et al Antimicrobial Agents and tablets to be taken once daily. Chemotherapy 1993, 37:4 (875-881); Tisdale et al Antiviral 0038 Viral resistance to tenofovir in vitro emerges slowly. Research 1993, 20: Suppl 1; Smith et al Journal of Virology A recombinant virus expressing the K65R mutation showed a 1997, 71:3 (2357-2362): Harrer et al Journal of Infectious 3-fold decreased susceptibility to tenofovir in vitro Chem Diseases 1996, 173:2 (476-479); Tisdale etal Proceedings of ington et al. Interscience Conference on Antimicrobial Agents the National Academy of Sciences of the United States of and Chemotherapy 1997, 37th. Notably, clinical HIV strains America 1993, 90:12 (5653-5656). Due to this observed expressing the M184V lamivudine-associated resistance single mutation in the YMDD of reverse transcriptase in the mutation on RT show wild-type or increased susceptibility to tenofovir invitro, independent of changes in Ki for the mutant HIV-infected patients, (-)-FTC is not suitable for mono enzyme Miller et al. Interscience Conference on Antimicro therapy and needs to be administered in combination with bial Agents and Chemotherapy 1998. Long-term treatment other antiretroviral agents to effectively treat patients infected (5 to 15 weeks) of newborn rhesus macaques with tenofovir with HIV. is available as 200 mg capsules to be (doses of 30 mg/kg) starting 3 weeks after inoculation with taken once a day. simian immunodeficiency virus, resulted in emergence of 0043 Lamivudine has the chemical name (-)-2',3'- SIV with approximately 5-fold decreased susceptibility to dideoxy-3'-thiacytidine and is described for instance in tenofovir Van Rompay et al. Antimicrobial Agents and Che EP-382 526 as an antiviral . It is also a motherapy 1996, 40:11 (2586-2591)). This low level of resis well established and useful antiretroviral which is commer tance was associated with the appearance of the K65R muta cially available for instance as 150 mg oral tablets. Lamivu tion. dine is also commercially available in combination with 0039. In a preferred embodiment, a combination is pro zidovudine (300 mg zidovudine/150 mg lamivudine), and in vided comprising (i) TMC278 or its stereoisomeric form or combination with lamivudine and abacavir sulfate (300 mg pharmaceutically acceptable salt or its prodrug, and (ii) teno zidovudine/150 mg lamivudine/equivalent of 300 mg aba fovir or its prodrug tenofovir disoproxil fumarate, wherein cavir). TMC278 and tenofovir or its prodrug tenofovir disoproxil 0044 Abacavir is a well established and useful antiretro fumarate are therapeutically effective HIV inhibitors at a dose viral which is commercially available for instance as an oral that can be administered once daily. Solution of abacavir Sulfate in a strength equivalent to 20 mg 0040. In another preferred embodiment, a triple combina abacavir base/ml, or as an oral tablet of abacavir sulfate in a tion is provided comprising (i) TMC278 or its stereoisomeric strength equivalent to 300 mg abacavir base. Abacavir sulfate form or pharmaceutically acceptable salt or its prodrug, and is also commercially available in combination with lamivu (ii) a nucleoside reverse transcriptase inhibitor, and (iii) teno dine and zidovudine (300 mg zidovudine/150 mglamivudine/ fovir disoproxil fumarate; wherein TMC278 and the nucleo equivalent of 300 mg abacavir). side reverse transcriptase inhibitor and tenofovir disoproxil 0045 Abacavir is a carbocyclic nucleoside with potent fumarate are therapeutically effective HIV inhibitors at a dose and selective anti-HIV activity. Abacavir in its optically that can be administered once daily. active form is disclosed in EP-434 450. The cis-isomer of 0041 Preferred nucleoside reverse transcriptase inhibitors abacavir with unspecified absolute stereochemical configu that can be used in the combinations of this invention include ration is described in EP-349242. Abacavir is one of the most abacavir or a pharmaceutically acceptable salt thereof, potent NRTI developed to date. An average reduction in viral emtricitabine, racemic FTC and lamivudine (also named load of more than 1.4 log 10 RNA copies/ml is observed after 3TC). a short course of abacavir monotherapy. In vitro, resistant 0042 Emtricitabine or (-)-FTC is the left (-) rotatory virus is not rapidly selected by abacavir. A significant enantiomeric form of racemic FTC or (+)-cis-4-amino-5- decrease in susceptibility to abacavir in wild-type or zidovu fluoro-1-2-(hydroxymethyl)-1,3-oxathiolan-5-yl)-2(1H)- dine-resistant HIV-1 strains was not observed until after eight pyrimidinone (FTC). It is a commercially available nucleo to ten passages in MT-4 cells. A set of resistance mutations at side analogue and exhibits activity against HIV-1 Hoong et HIV reverse transcriptase (RT) codons, 65R, 74V, 115F and/ al. Journal of Organic Chemistry 1992 (5563-5565); Jeong et or 184V, are selected during in vitro passage with abacavir, alJournal of Medicinal Chemistry 1993, 36:2 (181-195); Van and a combination of these mutations was required to confer Roey et al. Antiviral Chemistry and Chemotherapy 1993, 4:6 a 10-fold reduction in abacavir susceptibility in a laboratory (369-3751. The in vitro anti-HIV-1 activity of (-)-beta-enan strain of HIV. The first mutation detected upon passage of tiomer of FTC was reported to be 20-fold more than the HIV-1 in an increasing concentration of abacavir is M184V, (+)-beta-enantiomer, and the (+)-enantiomer was signifi which confers only a 3-fold decrease in HIV-1 susceptibility. cantly more toxic than the (-)-enantiomer to myeloid pro Phenotype resistance to 3TC and/or the presence of the 184V genitor cells Schinazi et al Antimicrobial Agents and Che mutation does not prevent viral load response to abacavir motherapy 1992, 36:11 (2423-2431). The potential for therapy. Resistance to multiple nucleosides is associated with HIV-1 resistance to FTC was evaluated by serial passage of a decreased or absent response to abacavir Kumaretal Anti the virus in human PBMCs and MT-2 cells in the presence of microbial Agents and Chemotherapy 1999, 43:3 (603-608); increasing drug concentrations. Highly drug-resistant HIV-1 Lanier et al International Conference on Retroviruses and variants dominated the replicating virus population after two Opportunistic Infections 1998, 5th: Chicago: posted on 16 or more cycles of infection. RT derived from drug-resistant Apr. 1999). viral particles was 15- to 50-fold less susceptible to the 0046. In a preferred embodiment, a combination is pro 5'-triphosphate of FTC compared with the enzyme from vided comprising (i) TMC278 or a stereoisomeric form parental drug Susceptible virus. DNA sequence analysis of thereof, or a pharmaceutically acceptable salt thereof, or a the RT gene amplified from resistant viruses consistently prodrug thereof; and (ii) emitricitabine, wherein TMC278 and US 2010/0029591 A1 Feb. 4, 2010

emtricitabine are therapeutically effective HIV inhibitors at a fumarate are therapeutically effective HIV inhibitors at a dose dose that can be administered once daily. that can be administered once daily. 0047. In a preferred embodiment, a combination is pro 0055. In another preferred embodiment, a triple combina vided comprising (i) TMC278 or a stereoisomeric form tion is provided comprising (i) TMC278 or a stereoisomeric thereof, or a pharmaceutically acceptable salt thereof, or a form thereof; or a pharmaceutically acceptable salt thereof; or prodrug thereof; and (ii) lamivudine, wherein TMC278 and a prodrug thereof, and (ii) abacavir or a pharmaceutically lamivudine are therapeutically effective HIV inhibitors at a acceptable salt form thereof, preferably abacavir sulfate; and dose that can be administered once daily. (iii) tenofovir or its prodrug tenofovir disoproxil fumarate, 0048. In another preferred embodiment, a combination is wherein TMC278 and abacavir or a pharmaceutically accept provided comprising (i) TMC278 or a stereoisomeric form able salt form thereof, preferably abacavir sulfate and teno thereof, or a pharmaceutically acceptable salt thereof, or a fovir or its prodrug tenofovir disoproxil fumarate are thera prodrug thereof, and (ii) abacavir or a pharmaceutically peutically effective HIV inhibitors at a dose that can be acceptable salt thereof, characterized in that, TMC278 and administered once daily. abacavir are therapeutically effective HIV inhibitors at a dose 0056. The following preferred triple combinations are also that can be administered once daily. included 0049. In another preferred embodiment, a combination is 0057 (a) TMC278 or a stereoisomeric form thereof; or a provided comprising (i) TMC278 or a stereoisomeric form pharmaceutically acceptable Salt thereof, or a prodrug thereof, or a pharmaceutically acceptable salt thereof, or a thereof; with emitricitabine and tenofovir disoproxil fuma prodrug thereof, and (ii) abacavir Sulfate, characterized in rate; that, TMC278 and abacavir sulfate are therapeutically effec 0058 (b) TMC278 or a stereoisomeric form thereof; or a tive HIV inhibitors at a dose that can be administered once pharmaceutically acceptable Salt thereof, or a prodrug daily. thereof; with lamivudine and tenofovir disoproxil fuma 0050. In another preferred embodiment, a triple combina rate. tion is provided comprising (i) TMC278 or a stereoisomeric form thereof; or a pharmaceutically acceptable salt thereof; or 0059 (c) TMC278 or a stereoisomeric form thereof; or a a prodrug thereof, and (ii) emitricitabine, and (iii) a nucleotide pharmaceutically acceptable Salt thereof, or a prodrug reverse transcriptase inhibitor, wherein TMC278 and the thereof; with abacavir sulfate and tenofovir disoproxil nucleotide reverse transcriptase inhibitor and emitricitabine fumarate. are therapeutically effective HIV inhibitors at a dose that can 0060 (d) TMC278 or a stereoisomeric form thereof; or a be administered once daily. pharmaceutically acceptable Salt thereof, or a prodrug 0051. In another preferred embodiment, a triple combina thereof, with emtricitabine and lamivudine; tion is provided comprising (i) TMC278 or or a stereoiso 0061 (e) TMC278 or a stereoisomeric form thereof; or a meric form thereof, or a pharmaceutically acceptable salt pharmaceutically acceptable Salt thereof, or a prodrug thereof, or a prodrug thereof, and (ii) lamivudine, and (iii) a thereof emitricitabine and abacavir or a pharmaceutically nucleotide reverse transcriptase inhibitor, wherein TMC278 acceptable salt thereof, preferably abacavir sulfate. and the nucleotide reverse transcriptase inhibitor and lamivu 0062 (f) TMC278 or a stereoisomeric form thereof; or a dine are therapeutically effective HIV inhibitors at a dose that pharmaceutically acceptable Salt thereof, or a prodrug can be administered once daily. thereof abacavir or a pharmaceutically acceptable salt 0052. In another preferred embodiment, a triple combina thereof, preferably abacavir sulfate and lamivudine. tion is provided comprising (i) TMC278 or or a stereoiso 0063. In particular, in each of the combinations (a)-(f) the meric form thereof, or a pharmaceutically acceptable salt active ingredients, in particular TMC278, emitricitabine, thereof, or a prodrug thereof, and (ii) abacavir or a pharma lamivudine, abacavir or a pharmaceutically acceptable salt ceutically acceptable salt thereof, or preferably abacavir sul form thereof, preferably abacavir sulfate, and tenofovir or its fate, and (iii) a nucleotide reverse transcriptase inhibitor, prodrug tenofovir disoproxil fumarate, are therapeutically wherein TMC278 and the nucleotide reverse transcriptase effective HIV inhibitors at a dose that can be administered inhibitor and abacavir or a pharmaceutically acceptable salt once daily. thereof, or preferably abacavir sulphate, are therapeutically 0064. The double combinations of the present invention effective HIV inhibitors at a dose that can be administered may contain one or more additional active ingredients, which once daily. can be agents useful for treating HIV infected patients or 0053. In another preferred embodiment, a triple combina other active agents. The triple combinations of the present tion is provided comprising (i) TMC278 or or a stereoiso invention may equally contain one or more additional active meric form thereof, or a pharmaceutically acceptable salt ingredients, which can be agents useful for treating HIV thereof, or a prodrug thereof, and (ii) emitricitabine, and (iii) infected patients or other active agents. Preferably any of tenofovir or its prodrug tenofovir disoproxil fumarate, these additional agents are therapeutically effective at a dose wherein TMC278 and emitricitabine and tenofovir or its pro that can be administered once daily. drug tenofovir disoproxil fumarate are therapeutically effec 0065. The active ingredients of the combinations of the tive HIV inhibitors at a dose that can be administered once present invention may be administered simultaneously, con daily. currently or sequentially. Simultaneous administration may 0054. In another preferred embodiment, a triple combina be done by employing a unitary pharmaceutical formulation tion is provided comprising (i) TMC278 or a stereoisomeric or separate pharmaceutical formulations. In general, the com form thereof; or a pharmaceutically acceptable salt thereof; or binations may be administered by topical, oral, rectal, intra a prodrug thereof; and (ii) lamivudine and (iii) tenofovir or its venous, Subcutaneous or intramuscular routes. For first line prodrug tenofovir disoproxil fumarate, wherein TMC278 and therapy of HIV infection, simultaneous administration lamivudine and tenofovir or its prodrug tenofovir disoproxil employing a unitary pharmaceutical formulation is preferred. US 2010/0029591 A1 Feb. 4, 2010

0066. Thus, in another aspect there is provided a product ents mentioned herein such as emitricitabine, racemic FTC, containing a combination as specified herein as a combined lamivudin, tenofovir and its prodrug tenofovir disoproxil preparation for simultaneous, separate or sequential use fumarate. against HIV infection. 0074 The products as mentioned above may contain sepa 0067. The invention also provides a product containing (i) rate formulations of the active ingredients, or two or where applicable more of the active ingredients may be co-formu TMC278 or a stereoisomeric form thereof; or a pharmaceu lated. tically acceptable salt thereof, or a prodrug thereof, and (ii) a 0075. In still a further aspect the invention provides phar nucleoside reverse transcriptase inhibitor and/or a nucleotide maceutical formulations containing a combination as speci reverse transcriptase inhibitor; wherein TMC278 and the fied herein and a suitable carrier. nucleotide reverse transcriptase inhibitor and/or the nucleo 0076. In another aspect there is provided a pharmaceutical side reverse transcriptase inhibitor are therapeutically effec formulation comprising a pharmaceutically acceptable car tive HIV inhibitors at a dose that can be administered once rier and as active ingredients (i) TMC278 or a stereoisomeric daily; as a combined preparation for simultaneous, separate form thereof; or a pharmaceutically acceptable salt thereof; or or sequential use against HIV infection. a prodrug thereof, and (ii) a nucleoside reverse transcriptase 0068. In a further aspect there is provided a product con inhibitor and/or a nucleotide reverse transcriptase inhibitor; taining (i) TMC278 or a stereoisomeric form thereof; or a wherein TMC278 and the nucleoside reverse transcriptase pharmaceutically acceptable salt thereof, or a prodrug inhibitor and/or the nucleotide reverse transcriptase inhibitor thereof; and (ii) a nucleoside reverse transcriptase inhibitor; are therapeutically effective HIV inhibitors at a dose that can wherein TMC278 and the nucleoside reverse transcriptase be administered once daily. inhibitor are therapeutically effective HIV inhibitors at a dose 0077. The invention further provides a pharmaceutical that can be administered once daily; as a combined prepara formulation comprising a pharmaceutically acceptable car tion for simultaneous, separate or sequential use against HIV rier and as active ingredients (i) TMC278 or a stereoisomeric infection. form thereof; or a pharmaceutically acceptable salt thereof; or a prodrug thereof, and (ii) a nucleoside reverse transcriptase 0069. In another aspect there is provided a product con inhibitor; wherein TMC278 and the nucleoside reverse tran taining (i) TMC278 or a stereoisomeric form thereof; or a scriptase inhibitor are therapeutically effective HIV inhibi pharmaceutically acceptable salt thereof, or a prodrug tors at a dose that can be administered once daily. thereof; and (ii) a nucleotide reverse transcriptase inhibitor, 0078. In still another aspect there is provided a pharma wherein TMC278 and the nucleotide reverse transcriptase ceutical formulation comprising a pharmaceutically accept inhibitor are therapeutically effective HIV inhibitors at a dose able carrier and as active ingredients (i) TMC278 or a stere that can be administered once daily; as a combined prepara oisomeric form thereof, or a pharmaceutically acceptable salt tion for simultaneous, separate or sequential use against HIV thereof; or a prodrug thereof; and (ii) a nucleotide reverse infection. transcriptase inhibitor, wherein TMC278 and the nucleoside 0070. In another aspect there is provided a product con reverse transcriptase inhibitor and the nucleotide reverse tran taining (i) TMC278 or a stereo-isomeric form thereof; or a scriptase inhibitor are therapeutically effective HIV inhibi pharmaceutically acceptable salt thereof, or a prodrug tors at a dose that can be administered once daily. thereof; and (ii) a nucleoside reverse transcriptase inhibitor; 0079. In still another aspect there is provided a pharma and (iii) a nucleotide reverse transcriptase inhibitor; wherein ceutical formulation comprising a pharmaceutically accept TMC278 and the nucleotide reverse transcriptase inhibitor able carrier and as active ingredients (i) TMC278 or a stere and the nucleoside reverse transcriptase inhibitor are thera oisomeric form thereof, or a pharmaceutically acceptable salt peutically effective HIV inhibitors at a dose that can be thereof, or a prodrug thereof, and (ii) a nucleoside reverse administered once daily; as a combined preparation for transcriptase inhibitor; and (iii) a nucleotide reverse tran simultaneous, separate or sequential use against HIV infec scriptase inhibitor; wherein TMC278 and the nucleoside tion. reverse transcriptase inhibitor and the nucleotide reverse tran 0071. In another aspect there is provided a product con scriptase inhibitors are therapeutically effective HIV inhibi taining (i) TMC278 or a stereoisomeric form thereof; or a tors at a dose that can be administered once daily. pharmaceutically acceptable salt thereof, or a prodrug 0080. In still another aspect there is provided a pharma thereof; and (ii) a nucleoside reverse transcriptase inhibitor; ceutical formulation comprising a pharmaceutically accept and (iii) a second nucleoside reverse transcriptase inhibitor able carrier and as active ingredients (i) TMC278 or a stere other than the nucleoside reverse transcriptase inhibitor of oisomeric form thereof, or a pharmaceutically acceptable salt (ii); wherein TMC278 and the nucleoside reverse tran thereof, or a prodrug thereof, and (ii) a nucleoside reverse scriptase inhibitors are therapeutically effective HIV inhibi transcriptase inhibitor, and (iii) a second nucleoside reverse tors at a dose that can be administered once daily; as a com transcriptase inhibitor different from the nucleoside reverse bined preparation for simultaneous, separate or sequential transcriptase inhibitor of (ii); wherein TMC278 and the use against HIV infection. nucleoside reverse transcriptase inhibitors are therapeutically 0072 The active ingredients in the products of the inven effective HIV inhibitors at a dose that can be administered tion are present in therapeutically effective amounts, the latter once daily. meaning an amount that is sufficient to exert a sufficient HIV I0081. The active ingredients in the pharmaceutical formu inhibitory effect during a certain time period, i.e. the time lations of the invention are present in therapeutically effective period between each intake of the formulations, preferably amounts, the latter meaning an amount that is sufficient to for about 24 hours. exert a sufficient HIV inhibitory effect during a certain time 0073 Particular embodiments are products as specified period, i.e. the time period between each intake of the formu above containing one or more of the specific active ingredi lations, preferably for about 24 hours. US 2010/0029591 A1 Feb. 4, 2010

0082 Particular embodiments are pharmaceutical formu I0087 Furthermore there is provided a method of treating lations as specified above containing one or more of the HIV infected patients, said method comprising administering specific active ingredients mentioned herein Such as emitric TMC278 or its stereoisomeric form or pharmaceutically itabine, racemic FTC, lamivudin, tenofovir and its prodrug acceptable salt or its prodrug, in combination with a nucleo tenofovir disoproxil fumarate. side reverse transcriptase inhibitor and/or a nucleotide reverse transcriptase inhibitor, in which method a therapeu 0083. The pharmaceutical formulations of the present tically effective amount of TMC278 and the nucleoside invention may be formulated into various forms for different reverse transcriptase inhibitor and/or nucleotide reverse tran types of administration. To prepare the pharmaceutical for Scriptase inhibitor can be administered once daily. mulations of this invention, effective amounts of the active I0088. Furthermore there is provided a method of treating ingredients, optionally in addition salt form, is combined in HIV infected patients, said method comprising administering intimate admixture with a pharmaceutically acceptable car TMC278 or its stereoisomeric form or pharmaceutically rier, which carrier may take a wide variety of forms depending acceptable salt or its prodrug, in combination with a nucleo on the form of preparation desired for administration. The side reverse transcriptase inhibitor, in which method a thera pharmaceutical formulations of the invention are preferably peutically effective amount of TMC278 and the nucleoside formulated in unitary dosage form Suitable, particularly, for reverse transcriptase inhibitor can be administered once daily. administration orally, rectally, percutaneously, or by I0089. In a further aspect of this invention concerns a parenteral injection. For example, in preparing the formula method of treating HIV infected patients said method com tions in oral dosage form, any of the usual pharmaceutical prising administering TMC278 or its stereoisomeric form or media may be employed Such as, for example, water, glycols, pharmaceutically acceptable salt or its prodrug, and a nucle oils, alcohols and the like in the case of oral liquid prepara otide reverse transcriptase inhibitor, in which method athera tions such as Suspensions, syrups, elixirs, emulsions and solu peutically effective amount of TMC278 and the nucleotide tions; or Solid carriers such as starches, Sugars, kaolin, dilu reverse transcriptase inhibitor can be administered once daily. ents, lubricants, binders, disintegrating agents and the like in 0090 Still a further aspect of this invention comprises a the case of powders, pills, capsules, and tablets. Because of method of treating HIV infected patients said method com their ease in administration, tablets and capsules represent the prising administering TMC278 or its stereoisomeric form or most advantageous oral dosage unit forms, in which case pharmaceutically acceptable salt or its prodrug, in combina Solid pharmaceutical carriers are obviously employed. For tion with a nucleoside reverse transcriptase inhibitor, and a parenteral compositions, the carrier will usually comprise nucleotide reverse transcriptase inhibitor, in which method a sterile water, at least in large part, though other ingredients, therapeutically effective amount of TMC278, the nucleotide for example, to aid solubility, may be included. Injectable reverse transcriptase inhibitor and the nucleoside reverse Solutions, for example, may be prepared in which the carrier transcriptase inhibitor can be administered once daily. comprises saline Solution, glucose solution or a mixture of 0091 Still a further aspect of this invention comprises a saline and glucose solution. Injectable Suspensions may also method of treating HIV infected patients said method com be prepared in which case appropriate liquid carriers, Sus prising administering TMC278 or its stereoisomeric form or pending agents and the like may be employed. pharmaceutically acceptable salt or its prodrug, in combina 0084. In one aspect of the invention, the present combina tion with a nucleoside reverse transcriptase inhibitor, and a tions can be formulated in an oral tablet form further com second nucleoside reverse transcriptase inhibitor different prising pharmaceutically acceptable excipients having a from the former nucleoside reverse transcriptase inhibitor, in weight ranging between 150 mg and 600 mg, Suitable ranging which method a therapeutically effective amount of between 200 and 400 mg. Convenient oral tablet forms con TMC278, the nucleoside reverse transcriptase inhibitors can taining the active ingredients according to the present inven be administered once daily. tion have a total nominal weight ranging between 200mg and 0092. The active ingredients in the methods of the inven 1500 mg, suitably between 500 mg and 1250 mg, more suit tion are administered in therapeutically effective amounts, able between 600 and 1100 mg. the latter meaning an amount that is sufficient to exert a 0085. An advantage of the pharmaceutical formulations of sufficient HIV inhibitory effect during a certain time period, the invention resides in the fact that each of the ingredients of i.e. the time period between each intake of the formulations, the present combinations can be co-formulated in one phar preferably for about 24 hours. maceutical formulation and do not have to be administered 0093 Particular embodiments are methods as specified separately. The daily therapeutic antiretroviral amount of the above wherein one or more of the specific active ingredients ingredients of the present combinations of Such co-formu mentioned herein such as emitricitabine, racemic FTC, lami lated single pharmaceutical form preferably is administered Vudin, tenofovir and its prodrug tenofovir disoproxil fuma in a single unit dosage form but, if desired, also multiple unit rate, are administered. dosage forms, such as two, three, four, five or even more unit 0094. One embodiment of the present invention relates to dosage forms may be administered. A physician will be able the present combinations for use as a medicine. Another to determine the exact dosage to be given taking into account embodiment relates to the combinations of the present inven the severity of the patient's condition as well as the patient’s tion for use in the manufacture of a medicament to treat HIV weight, gender and possibly other parameters such as indi infected patients. vidual differences in absorption, biodistribution, metabolism 0095. Of particular interest are any of the combinations as and excretion rates for each drug as well as other factors specified herein, or any of the products, pharmaceutical for known to those skilled in the art. mulations, unit dosage forms, methods and uses being based I0086. This invention also provides a method of treating on said combinations, wherein TMC278 is E-TMC287, or HIV infected patients said method comprising administering preferably TMC278 hydrochloride salt or more preferably a combination as specified herein. E-TMC278 hydrochloride salt. US 2010/0029591 A1 Feb. 4, 2010

0096. The combinations of this invention are especially 0102 Thus, an interesting combination according to the useful for the treatment of AIDS and related clinical condi present invention comprises compound E-(A) in a daily dose tions such as AIDS related complex (ARC), progressive gen ranging between 10 mg and 500 mg, a daily dose of 150 mg eralised lymphadenopathy (PGL) or AIDS related neurologi lamivudine and a daily dose of an equivalent of 300 mg cal conditions such as multiple Sclerosis. The present triple abacavir base. Suitably, such combination is formulated in a combination may be particularly useful for the treatment of single pharmaceutical form. drug-naive HIV infected patients. 0097. The combinations of the invention are also useful 0103) Another interesting combination according to the for the prevention of HIV transmission or infection in present invention comprises compound E-(A) in a daily dose humans, in particular sexual transmission. Thus, the present ranging between 50 mg and 250 mg, a daily dose of 150 mg invention relates to the use of combinations according to the lamivudine and a daily dose of an equivalent of 300 mg present invention for the manufacture of a medicament for the abacavir base. Suitably, such combination is formulated in a prevention of HIV infection or transmission via sexual inter single pharmaceutical form. course or related intimate contact between partners. The 0104. The present invention also relates to a pharmaceu invention also relates to a method of preventing HIV infection tical composition in a form adapted to be applied to a site or transmission via sexual intercourse or related intimate where sexual intercourse or related intimate contact can take contact between partners comprising administering to a Sub place, such as the genitals, rectum, mouth, hands, lower abdo ject in need thereof an effective amount of any of the combi men, upper thighs, especially the vagina and mouth, compris nations according to the present invention. ing a pharmaceutically acceptable carrier and as active ingre 0098. The respective daily dose for each of the active dients an effective amount of a combination according to the ingredients of a combination according to the present inven present invention. As appropriate special adapted composi tion may range between 10 mg and 800 mg, preferably tions there may be cited all compositions usually employed between 50 and 400 mg, more preferably between 50 and 300 for being applied to the vagina, rectum, mouth and skin Such mg, or between 100 and 300 mg. In particular, the daily dose as for example gels, jellies, creams, ointments, films, for TMC278 may range between 10 mg and 500 mg, prefer Sponges, foams, intravaginal rings, cervical caps, Supposito ably between 10 and 300, more preferably between 50 and ries for rectal or vaginal application, vaginal or rectal or 250 mg, still more preferably between 50 and 200 mg, e.g. buccal tablets, mouthwashes. To prepare such pharmaceutical about 100 mg. compositions, an effective amount of each of the particular 0099. The weight ratio of each couple of components of compounds of the triple combination as the active ingredients the triple combination taken on a daily basis may vary in a is combined in intimate admixture with a pharmaceutically range from 1/10 to 10/1. Suitably, the weight ratio of each acceptable carrier, which carrier may take a wide variety of couple varies between 1/6 and 6/1, more suitably 1/4 and 4/1, forms depending on the form of administration. In order to preferably between 1/3 and 3/1, and more preferably between increase the residence time of such pharmaceutical composi 1/2 and 2/1. tion at the site of administration, it may be advantageous to 0100 Table 2 lists some examples of the daily dose for include in the composition a bioadhesive, in particular a bio each of the active ingredients in combinations of compound adhesive polymer. A bioadhesive may be defined as a material that adheres to a live biological Surface Such as for example a E-TMC278, emtricitabine and tenofovir. mucus membrane or skin tissue. 0105 Thus, the present invention also relates to a pharma ceutical composition comprising a pharmaceutically accept Combination no. E-TMC278 Emtricitabine Tenofovir able carrier and as active ingredients an effective amount of 1 50 mg 200 mg each of the compounds of the present triple combination 2 50 mg 300 mg characterized in that the pharmaceutical composition is bio 3 100 mg 200 mg adhesive to the site of application. Preferably, the site of 4 100 mg 300 mg 5 200 mg 200 mg application is the vagina, rectum, mouth or skin, most pre 6 200 mg 300 mg ferred is the vagina. 7 50 mg 200 mg 300 mg 0106 Otten R A et al in Journal of Virology (2000), 8 100 mg 200 mg 300 mg 74(20), 9771-9775 and Witvrouw M et al in Antiviral 9 200 mg 200 mg 300 mg Research (2000), 46(3), 215-221 disclose the ability ofteno fovir to delay HIV viral breakthrough after high-risk sexual 0101 Table 3 lists some examples of the daily dose for exposure. each of the active ingredients in combinations of TMC278, 0107 Pani Aetal in Antiviral Chemistry & Chemotherapy abacavir and lamivudine wherein the dose mentioned in the (2001), 12(Suppl. 1), 51-59 describe the ability of lamivudine table for abacavir sulfate is the equivalent dose of abacavir to delay viral breakthrough. base. 0108. The ability of TMC278 to prevent HIV infection via sexual intercourse or related intimate contact between part ners can be demonstrated in the following test. Immature Abacavir monocyte derived dendritic cells (immMO-DC) represent a Combination no. E-TMC278 Lamivudine sulfate good model for interstitial dendritic cells, which are early targets during sexual HIV transmission and important initia 1 50 mg 150 mg 300 mg 100 mg 150 mg 300 mg tors of the immune response. These immMO-DC were used 3 200 mg 150 mg 300 mg in “in vitro” models to test the prevention of HIV infection via sexual intercourse or related intimate contact between part ners. One such model is described in the experimental part US 2010/0029591 A1 Feb. 4, 2010

and indicates that the TMC278 potently inhibits HIV repli of the specificity of the antiviral effect. Tested HIV strains cation in MO-DC/CD4(+) T cell co-cultures. included: Wild type (wt) HIV-1; a panel of single and double mutants, obtained by site-directed mutagenesis (SDM), and a EXAMPLES panel of clinical isolates, selected for resistance against NNR Example 1 TIS. Pharmacokinetics of E-TMC278 Activity Towards Wild Type and SDM Mutants 0109. A double-blind, randomized, placebo-controlled 0114. A limited panel of HIV-1 mutants was constructed Phase I trial was designed to evaluate safety, tolerability, and using site-directed mutagenesis (SDM) and homologous ex-Vivo pharmacokinetics of single doses of compound recombination techniques. Compound E-TMC278 was tested E-TMC278 in healthy male volunteers. Oral doses of 12.5, against an extended panel of single and double mutants 25, and 50 mg were formulated in PEG 400 and taken with a known to be resistant against commercially available NNR standard meal. The pharmacokinetic results are shown in TIs. Nevirapine (NVP) and efavirenz (EFV) were included as Table 4. controls. 0110. The pharmacokinetic results of another double blind, randomized, placebo-controlled Phase I study with 4 0115 The results are shown in Table 5 (values presented dosing sessions to evaluate the safety, tolerability, pharmaco are IC50 values in nM). For wildtype virus, the obtained IC50 kinetics and ex-Vivo pharmacodynamics of single 100 mg and was 0.4 nM (0.15 ng/ml) and the IC901.3 nM (0.48 ng/ml). 200 mg oral doses of compound E-TMC278 in healthy male The HIV strain with the lowest sensitivity against compound Subjects are also reported in Table 4. Randomization was such E-TMC278 within this selection was the double mutant that for each session 6 subjects received the same dose of 100I+103N, with an IC50 of about 8nM and an IC90 of about compound E-TMC278 and 3 subjects received placebo. 16 nM. There was a time interval of about 14 days between each dosing session TABLE 5 0111 Table 4 shows that high and dose-proportional expo Compound sures were obtained. The correlation coefficient for the 5C, NVP EFV E-TMC278 datapoints is 0.9897 and for the area under the curve values wild type 81 1.4 0.4 between 0 and 48 hours (AUC as hr) 0.9952. Half-life of 1 OOI 597 35 0.4 plasma concentrations ranged between 37 and 39 hours. The 101E 547 5 1.6 compound was well tolerated by the volunteers. No relevant 103N 2,879 28 O.3 adverse effects of the drug were noted.

TABLE 4 Parameter 12.5 mg 25 mg 50 mg 100 mg 200 mg Cmax 73 - 14 14932 267 - 27 482 121 8072O7 (ng/ml) Tax (hr) 4.0 - O 4.O. 1.3 4.O. 1.3 43 O.8 43 O.8 AUCos 1337 - 310 28.05 - 496 SO94 SO9 8162 2251 15592 2746 (nghriml) AUCo. 2210 - 473 4637 - 1164 8872 - 1342 15844. 4592 (nghriml) T12 (hr) 37.1 38.7 459 SS 18

Example 2 TABLE 5-continued Virological Profile of Compound E-TMC278 Compound 0112 Compound E-TMC278 was tested in a cell-based NVP EFV E-TMC278 assay, using natural host cells of HIV. MT-4 cells (a cell line 106A 2,983 23 O.2 of human T cells) were infected with HIV-1 (wild type or 108 2 O.3 mutants) and exposed to different concentrations of antiviral 138K 64 1.3 0.4 compound in the presence of 10% fetal calf serum. Cytotox 179D 161 6 O6 icity was determined in parallel with the antiviral activity so 179E 158 5 0.4 181C 10,000 2 1.3 that the selectivity of the antiviral effect could be assessed. 188C 3,764 5 O.1 Active compounds have to penetrate the cell membrane in 188H 241 9 O.2 order to interfere with replication steps inside the cell. 188L 10,000 78 2.0 0113. After four days of incubation at 37°C., the viability 190A 4,101 8 O.3 190S 10,000 275 O.1 of the HIV and mock-infected cells was assessed by an auto 22SH 171 2 O.3 mated tetrazolium-based calorimetric assay. This method 227C 1,816 36 2.0 enabled the calculation of both the 50% inhibitory concen 227L 78 O.3 O.3 tration for inhibition of viral cytopathicity (IC50), the IC90, 234 45 NT O.3 and the 50% cytotoxic concentration (CC50). The ratio 236L 41 1 O.3 CC50/IC50, also called the selectivity index, is an indication US 2010/0029591 A1 Feb. 4, 2010 10

CD4(+) T cells were purified out of the lymphocyte fraction TABLE 5-continued of the same elutration as the MO-DC and used at a concen tration of 2x10 cells/ml (ratio MO-DC/CD4(+) T. 1/5). Compound I0122) A serial dilution of a compound of formula (I) (test NVP EFV E-TMC278 compound) was added to the MO-DC/CD4(+) T cell co 1OOI- 103N 10,000 10,000 7.9 cultures. Each experiment was done in 96-well plates, in 101E - 103N 7,033 84 O.S which each cup contained 50 ul of MO-DC, 50 ul of CD4 (+) 103N - 181I 10,000 37 1.O T cells and 100 ul of test compound. Half of the culture 227L - 106A 10,000 8 1.O medium, with test compound, was refreshed twice weekly. Supernatants were analysed in ELISA after 14 days of cul ture. To determine antiviral activity, the test compound con Development of Resistance In Vitro centration able to suppress 50% of the viral replication at the 0116 NNRTIs are highly selective inhibitors of HIV-1 but end of the primary cultures (EC50) was measured. For com their current clinical use is limited by the rapid emergence of pound E-TMC278, the EC50 value was 0.55 nM. NNRTI (cross-) resistance. The rate of resistance emergence against compound E-TMC278 and the first generation NNR Example 4 TIs nevirapine and efavirenz was compared in vitro. Formulations 0117 MT4 cells were infected with wild type HIV-1 at high multiplicity of infection (>1 infectious virus per cell, to I0123 Tablet formulation of the following composition: maximize the genetic diversity of the virus population) in the presence of various concentrations of compound E-TMC278 (40, 200, 1000 and 5000xIC50), and were monitored twice a Emtricitabine 300 mg week for virus replication. Emerging virus was collected for Tenofovir diisoproxyl fumarate 300 mg pheno- and genotyping. Cultures without evidence of virus E-TMC278 hydrochloride salt 110 mg replication were further sub-cultivated in the presence of the HPMC 291O 15 Pa. S 24 mg Polysorbate 20 6 mg same concentration of inhibitor for a total duration of 30 days Crosspolyvidone 18 mg (10 passages). Lactose monohydrate 43 mg 0118 Resistance to nevirapine emerged within 3-6 days, Magnesium stearate 3 mg at all tested concentrations. Breakthrough virus harboured the Talcum 6 mg typical Y181C mutation. The same experiments with efavirenz resulted in the selection of G190E at all concentra 0.124. The active ingredients and lactose are fluidised and tions (up to 5uM) within 3 to 7 days. Compound E-TMC278 sprayed with a solution of HPMC and polysorbate in water (at did not select for resistant virus within 30 days using wild an equivalent of 120 ml/tablet). Subsequently crosspolyvi type virus. If a double resistant mutant K103N+Y181C (IC50 done is added, while still being fluidised, followed by mag 0.8 nM) was used instead of wild type virus, resistance did nesium Stearate and talcum. The thus obtained granulate is emerge at all tested concentrations. Starting from the single compressed into 13 mm cylindrical tablets using standard mutants Y181C (IC50 1.3 nM) or 103N (IC500.3 nM), virus compressing equipment. breakthrough did not occur at 40 and 200 nM, but did occurat 10 nM. 1. A combination comprising 0119. In this experimental setting of high genetic diver (i) 4-4-4-(2-cyanoethenyl)-2,6-dimethylphenyl sity, HIV-1, resistant to first generation NNRTIs, was selected amino-2-pyrimidinyl-amino-benzonitrile, also very rapidly. Resistant viruses harboured only one mutation. named TMC278, or a stereoisomeric form thereof, or a In contrast, emergence of HIV-1, resistant to compound pharmaceutically acceptable salt thereof, or a prodrug E-TMC278 was delayed or did not occur. thereof, and (ii) a nucleoside reverse transcriptase inhibitor and/or a Cardiovascular and Pulmonary Safety of Compound nucleotide reverse transcriptase inhibitor; wherein E-TMC278 TMC278 and the nucleotide reverse transcriptase inhibi 0120 Compound E-TMC278 had little or no effect on tor and the nucleoside reverse transcriptase inhibitor are cardiovascular and pulmonary parameters in Vivo at plasma therapeutically effective HIV inhibitors at a dose that levels covering and exceeding the targeted plasma levels in can be administered once daily. man and at concentrations in vitro covering or exceeding the 2. The combination according to claim 1 comprising anti-viral concentration in vitro. (i) TMC278, or a stereoisomeric form thereof; or a phar maceutically acceptable salt thereof, or a prodrug Example 3 thereof, and (ii) a nucleoside reverse transcriptase inhibitor; wherein In Vitro Models to Test the Ability of Compound TMC278 and the nucleoside reverse transcriptase E-TMC278 to Prevent HIV Infection Via Sexual inhibitor are therapeutically effective HIV inhibitors at a Intercourse or Related Intimate Contact Between dose that can be administered once daily. Partners 3. The combination according to claim 1 comprising 0121 For instance, in one model, monocyte-derived den (i) TMC278, or a stereoisomeric form thereof; or a phar dritic cells (MO-DC) were infected for 2-hours with the maceutically acceptable salt thereof, or a prodrug monotropic HIV strain Ba-L at a multiplicity of infection thereof, and (MOI) of 10. After infection, cells were washed 6 times and (ii) a nucleotide reverse transcriptase inhibitor; wherein resuspended in 10% BCS at 400.000 cells/ml. Autologous TMC278 and the nucleotide reverse transcriptase inhibi US 2010/0029591 A1 Feb. 4, 2010 11

tor are therapeutically effective HIV inhibitors at a dose 21. A pharmaceutical formulation comprising a pharma that can be administered once daily. ceutically acceptable carrier and a combination as claimed in 4. The combination according to claim 1 comprising claim 1. (i) TMC278, or a stereoisomeric form thereof; or a phar 22. The formulation of claim 21 comprising as active ingre maceutically acceptable salt thereof, or a prodrug dients (i) TMC278 or its stereoisomeric form or pharmaceu thereof, and tically acceptable salt or its prodrug, and (ii) a nucleoside (ii) a nucleoside reverse transcriptase inhibitor, and reverse transcriptase inhibitor, and (iii) a nucleotide reverse (iii) a nucleotide reverse transcriptase inhibitor; wherein transcriptase inhibitor. TMC278 and the nucleotide reverse transcriptase inhibi 23. A method of preventing HIV infection comprising tor and the nucleoside reverse transcriptase inhibitor are administering a combination as claimed in claim 1. therapeutically effective HIV inhibitors at a dose that can be administered once daily. 24. (canceled) 5. The combination according to claim 1 comprising 25. A kit, comprising the combination of claim 1 packaged (i) TMC278, or a stereoisomeric form thereof; or a phar with instructions for use. maceutically acceptable salt thereof, or a prodrug 26. The combination of claim 1, wherein said TMC278, thereof, and said tenofovir or its prodrug tenofovir disoproxil fumarate (ii) a nucleoside reverse transcriptase inhibitor, and and said emitricitabine are each in separate pharmaceutically (iii) a second nucleoside reverse transcriptase inhibitor acceptable carriers. other than the nucleoside reverse transcriptase inhibitor 27. The combination of claim 26, wherein said pharmaceu of (ii); wherein TMC278 and the nucleoside reverse tically acceptable carrier is selected from the group consisting transcriptase inhibitors are therapeutically effective of tablets, capsules, parenteral compositions, injectable solu HIV inhibitors at a dose that can be administered once tions, and injectable Suspensions. daily. 28. The combination of claim 1, wherein said TMC278, 6. The combination according to claim 1, wherein said tenofovir or its prodrug tenofovir disoproxil fumarate TMC278 occurs in its E-isomeric form. and said emitricitabine are together in a single pharmaceuti 7.-18. (canceled) cally acceptable carrier. 19. The combination according to claim 1 wherein weight 29. The combination of claim 28, wherein said pharmaceu ratio of each couple of components of the triple combination tically acceptable carrier is selected from the group consisting taken on a daily basis may vary in a range from 1/4 to 4/1. of tablets, capsules, parenteral compositions, injectable solu 20. A product containing a combination as claimed in claim tions, and injectable Suspensions. 1 as a combined preparation for simultaneous, separate or sequential use against HIV infection. c c c c c