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US00874 8419 B2

(12) United States Patent (10) Patent No.: US 8,748,419 B2 Seed et al. (45) Date of Patent: Jun. 10, 2014

(54) TREATING WITH MUSCARINIC 5,585,347 A 12/1996 Meier et al. 5,597,797 A * 1/1997 Clark ...... 514/12 RECEPTOR MANTAGONISTS 5,668,155 A * 9/1997 Cincotta et al...... 514,340 5,700,795 A 12/1997 Cincotta (75) Inventors: Brian Seed, Boston, MA (US); Jordan 5,712,265 A 1/1998 Cincotta et al. Mechanic, Sunnyvale, CA (US) 5,795,895 A * 8/1998 Anchors ...... 514,253.04 6,403,657 B1 * 6/2002 Hinz ...... 424,682 (73) Assignee: Theracos, Inc., Marlborough, MA (US) 6,703,383 B2 3/2004 Wu et al. (Continued) (*) Notice: Subject to any disclaimer, the term of this patent is extended or adjusted under 35 FOREIGN PATENT DOCUMENTS U.S.C. 154(b) by 0 days. CA 2193530 A1 12/1995 (21) Appl. No.: 11/763,313 CN 101472571 B 11, 2012 (Continued) (22) Filed: Jun. 14, 2007 OTHER PUBLICATIONS (65) Prior Publication Data Bernard Testa, Research: Futile or Fertile?, 68 Biochem. US 2007/O293481 A1 Dec. 20, 2007 Pharmacol. 2097 (2004.* Related U.S. Application Data (Continued) (60) Provisional application No. 60/805,066, filed on Jun. 16, 2006, provisional application No. 60/829,225, Primary Examiner — Ernst Arnold filed on Oct. 12, 2006. Assistant Examiner — Kyung Sook Chang (74) Attorney, Agent, or Firm — Kilpatrick Townsend & (51) Int. C. Stockton LLP CO7D 487/04 (2006.01) A6 IK3I/55 (2006.01) (57) ABSTRACT C07D 333/20 (2006.01) Provided are methods of treating obesity and effecting C07D 307/80 (2006.01) desired weight loss or preventing undesired weight gain by A6 IK3I/35 (2006.01) administration of a preferential muscarinic (52) U.S. C. receptor Mantagonist, optionally with at least one antide USPC ...... 514/220; 514/221; 514/438: 514/469; pressant other than a selective muscarinic acetylcholine 514/649; 514/657 receptor Mantagonist. The preferential muscarinic acetyl (58) Field of Classification Search receptor Mantagonist, optionally can be adminis None tered with an anti-obesity agent, for example, an anorexiant. See application file for complete search history. The invention also provides for pharmaceutical compositions and kits for administration of at least one selective muscarinic (56) References Cited Mantagonist in combination with at least one other than a selective muscarinic U.S. PATENT DOCUMENTS acetylcholine receptor Mantagonist. 5,344,832 A 9, 1994 Cincotta et al. 5,436,272 A 7, 1995 Scheinbaum 10 Claims, 15 Drawing Sheets

Effect of Chronic Telenzepine (TZP), (PHN), Telenzepine or Co-Infusion on Body Weights of SD Rat on a High Fat Diet

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(56) References Cited http://www.ncbi.nlm.nih.gov.pubmed/2168703, Institut de Recher che Jouveinal, Arzneimittelforschung, 1990, No. 40(6), p. 633-40. U.S. PATENT DOCUMENTS Table 17-1, Goodman & Gilman's The Pharmacological Basis of Therapeutics, 11" Edition, Brunton, Lazo and Parker, Eds. 6,803,357 B1 10/2004 Bachovchin et al. McGraw-Hill (2006), p. 434. 6,872,716 B2 3, 2005 Wu et al. Appolinario, et al., “Psychotropic Drugs in Treatment of Obesity.” 7,109,198 B2 9, 2006 Gaddle et al. CNS Drugs (2004) 18(10):629-51. 2004/0204472 A1* 10/2004 Briggs et al...... 514,406 Campfield et al., “Strategies and Potential Molecular Targets for 2005/0143350 A1* 6/2005 Seed ...... 514,114 Obesity Treatment.” Science280, 1383-1387 (1998). 2005/0227998 A1 10, 2005 Voelker Cascade, et al., “Real-World Data on SSRI Antidepressant Side 2006/0073217 A1* 4/2006 Barak ...... 424,722 Effects.” Psychiatry (Edgemont), 2009;6(2):16-18. Fava, et al., “ Versus and Paroxetime in Major FOREIGN PATENT DOCUMENTS Depressive Disorder: Changes in Weight With Long-Term Treat ment.”J Clin Psychiatry 61:11, Nov. 2000, 863-867. JP 2009-530697 8, 2009 WO WO95/35110 12/1995 Greenway, et al., “Rational Design of a Combination for WO WO99/13877 A1 3, 1999 the Treatment of Obesity.” Obesity, (Silver Spring), Jan. WO WO99/43647 A1 9, 1999 2009; 17(1):30-9. WO WOOOf 10551 A2 3, 2000 Halford, et al., “ Drugs—Effects on Appetite Expression WO WO 2005/051297 A2 6, 2005 and Use for the Treatment of Obesity.” Drugs (2007) 67(1):27-55. WO 2006/017614 2, 2006 Herremans, et al., “Effects of Infusion of Drugs into the WO WO 2006/127418 A1 11, 2006 Prefrontal Cortex Area on Delayed Matching to Position Perfor WO 2007 1471.23 12/2007 mance in the Rat.” Brain Research 711 (1996) 102-111. Jia, et al., “Mechanism of Drug Combinations: Interaction and Net OTHER PUBLICATIONS work Perspectives.” Nature Reviews—Drug Discovery (2009) 8:111 128. W. Londong, et al. Telenzepine is at Least 25 Times More Potent Korner et al., “Pharmacological Approaches to Weight Reduction: Than —A Dose Response and Comparative Secretory Therapeutic Targets.” J. Clin. Endocrinol. Metab., 2004 89: 2616 Study in Man, 28 GUT 888 (1987).* 2621. Thomas A. Wadden, et al. Effects of Plus in Li, et al., “N-, a Major Metabolite of , Obese Women Following 1 Year of Treatment by Sibutramine Alone: Increases Cortical Acetylcholine and Release InVivo via A Placebo-Controlled Trial, 8 Obesity Res. 431 (Sep. 2000).* Stimulation of M Muscarinic Receptors.” Neuropsychopharmacol Thomas Wadden, et al. Effects of Sibutramine Plus Orlistatin Obese ogy (2005) 30:1986-1995. Women Following 1 Year Treatment by Sibutramine Alone: A Pla Li et al., “Meta-Analysis: Pharmacologic Treatment of Obesity.” cebo-Controlled Trial, 8 Obesity Res. 431 (Sep. 2000).* Ann. Intern, Med. 2005: 142:532-546. Bevan, J., et al., "Cholinergic blockade with pirenzepine induces Maina, et al., “Weight Gain During Long-Term Treatment of Obses dose-related reduction in glucose and responses to a mixed sive-Compulsive Disorder: A Prospective Comparison Between meal in normal Subjects and non-insulin dependent diabetics.” Clini Reuptake Inhibitors.”J Clin Psychiatry 65:10 Oct. 2004, cal Endocrinology, vol. 35, pp. 85-91 (1991). 1365-1371. Chau, D.T. et al., "Nucleus accumbens muscarinic receptors in the Maslanski, et al., “Assesment of the Muscarinic Receptor Subtypes control of behavioral depression: antidepressant-like effects of local Involved in -Induced Seizures in Mice.” Neuroscience Mantagonist in the Porsolt Swim test.” Neuroscience, vol. 104(3), Letters, 168 (1994) 225-228. pp. 791-798 (Jun. 2001). Mayorga, et al., "Characterization of the Muscarinic Receptor Sub Hammer, R., et al., “The pharmacokinetic profile of pirenzepine.” type Mediating Pilocarpine-Induced Tremulous Jaw Movements in Scand. J. Gastroenterol. Suppl., vol. 57, pp. 1-6 (1979). Rats.” European Journal of Pharmacology, 364 (1999) 7-11. Miyakawa, T., et al., “Hyperactivity and intact hippocampus-depen Power, et al., “Cholinergic Modulation of Memory in the Basolateral dent learning in mice lacking the M1 muscarinic acetylcholine recep Amygdala Involves Activation of both M1 and M2 Receptors.” tor.” The Journal of Neuroscience, vol. 21 (14), pp. 5239-5250 (Jul. Behavioural Pharmacology 2003 14:207-213. 2001). Quinn, “Comparing Rat's to Human's Age: How Old is my Rat in Rogóz, Z. et al., “Central Action of Pirenzepine.” Pol. J. Pharmacol. People Years.” Nutrition (2005), 21:775-777. Pharm., vol. 33, pp. 615-626 (1981). Sansone, et al., “Naturalistic Study of the Weight Effects of Trummlitz, G., et al., “Conformational analysis of the antiulcer drug , Fluoxetine, and Sertraline in an Outpaient Medical pirenzepine. X-ray investigations, molecular mechanics and quan Setting.” J Clinical Psychopharmacol (2000) 20(2): 272-4. tum mechanical calculations and comparisons with structurally or Valentino et al., “Central and Peripheral Molecular Targets for Anti pharmacologically related compounds ' Arzneimittelforschung, vol. obesity Pharmacotherapy.” Nature Publishing, vol. 87, No. 6, Jun. 34(8), pp. 849-859 (1984). 2010, 652-662. Longdong, et al., “Telenzepine is at Least 25 Times More Potent Than Wadden, et al., "Sertraline and Relapse Prevention Training Follow Pirenzepine—A Dose Response and Comparative Secretory Study in ing Treatment by Very-Low-Calorie Diet: A Controlled Clinical Man.” 28 GUT 888 (1987). Trial.” Obesity Res (1995)3(6):549-557. Muratori. F., et al., "Accute Cholinergic Blockade with Pirenzepine Jackson et al., “Comparison of the effects of sibutramine and other Reduces the Insulin and Glucose Responses to Oral Glucose Test in monoamine reuptake inhibitors on food intake in the rat.” J. Obese Women.” International Journal of Obesity, Newman Pub. Pharmacol, 1997, vol. 121, No. 8, pp. 1758-1762. London, GB, vol. 28, No. Suppl. 1, Apr. 1, 2004, p, S221. Mancini et al., “Pharmacological treatment of obesity.” Arq Bras Gouret, et al., “Biochemical and pharmacological evaluation of the Endocrinol Metabol., 2006, vol. 50, No. 2, pp. 377-389. novel antidepressant and serotonin uptake inhibitor 2-(3. 4-Dicholoobenzyl)-2-dimethylamino-1-propanol hydrochloride.” * cited by examiner U.S. Patent Jun. 10, 2014 Sheet 1 of 15 US 8,748,419 B2

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OII GOI OOI (eueSeg Jo O/o) ufew Apog US 8,748,419 B2 1. 2 TREATING OBESITY WITH MUSCARINC observation that pirenzepine does not exhibit significant pen RECEPTOR MANTAGONISTS etration of the blood-brain barrier in various species, includ ingrodents and humans (see, Hammer, R., Koss, F.W., Scand. CROSS-REFERENCE TO RELATED J. GastroenteroL, Suppl., 1979, Vol. 14, no. 57, pp. 1-6: APPLICATIONS Bymaster, F. P. et al., J. Pharmacol. Exp. Ther:, 1993, Vol. 267, no. 1, pp. 16-24). It is for that reason that the above This application claims the benefit of U.S. Provisional mentioned study of the effect of pirenzepine in the Porsolt Application No. 60/805,066, filed Jun. 16, 2006 and U.S. swim test utilized direct injection of the drug into the brain of Provisional Application No. 60/829,225, filed Oct. 12, 2006, test animals. the entire disclosures of both of which are hereby incorpo 10 Others have also disclosed using selective MRantagonists rated herein by reference. for altering lipid metabolism and for reducing body fat stores. See, e.g. U.S. Pat. No. 5,668,155. However, it was required to STATEMENT AS TO RIGHTS TO INVENTIONS administer the MR antagonists at a predetermined time in a MADE UNDER FEDERALLY SPONSORED 24-hour period to achieve desired results. Further, Bevan, et RESEARCH AND DEVELOPMENT 15 al., Clinical Endocrinology (1991) 36:85-91 disclose admin istering pirenzepine to non-obese and obese human patients Not Applicable diagnosed with non-insulin dependent diabetes (NIDDM). Bevan related the timing of administration of pirenzepine FIELD OF THE INVENTION with the timing of a meal, but does not disclose or Suggest the ability of pirenzepine to interfere with lipogenic sensitivity or The present invention relates to the treatment of obesity its use in facilitating weight loss. and the facilitation of weight loss by administration of a There exists a need for new and effective for selective M muscarinic receptor (MR) antagonist, alone or the treatment of obesity and for facilitating weight loss. The in combination with an antidepressant. present invention addresses this and other needs. 25 BACKGROUND OF THE INVENTION BRIEF SUMMARY OF THE INVENTION The neurotransmitter acetylcholine (ACh) interacts with The present invention provides methods for treating obe two types of receptors in effector cell membranes: nicotinic sity, Suppressing appetite, facilitating or promoting weight receptors (nAChR), which are ligand-gated ion channels, and 30 loss, facilitating or promoting maintenance of a desired muscarinic receptors (mAChR), which are G protein-coupled weight, and preventing or decreasing undesired weight gain, receptors. In mammals five subtypes of mAChR, designated by administering atherapeutically effective amount of one or M to Ms., have been identified. The M muscarinic receptor more MR-selective antagonists. In practicing the present (MR) is found in both the central and peripheral nervous methods, the one or more MR-selective antagonists can be systems, particularly the cerebral cortex and sympathetic 35 administered without other pharmacological agents or in ganglia. The muscarinic effects mediated by MR have been combination with other pharmacological agents, for example, studied largely by use of MR-selective antagonists and, more one or more other than a MR-selective recently, by the development of MR-null mice. antagonist. In some embodiments, one or more MR-selec Although no currently known mAChRantagonists display tive antagonists can be co-administered with one or more absolute selectivity for a single muscarinic receptor Subtype, 40 anti-obesity agents. In some embodiments, one or more MR the drugs pirenzepine and telenzepine exhibit high relative selective antagonists combined with one or more antidepres affinity for MR and are therefore often considered MR sants other than a MR-selective antagonist can be co-admin selective. Pirenzepine is used to treat peptic ulcer disease in istered with one or more anti-obesity agents. Europe, Japan and Canada. TelenZepine has been tested in The one or more MR-selective antagonists need not be clinical trials for the same indication. At therapeutic doses, 45 administered at a predetermined time in a 24-hour period. they moderately reduce gastric acid and pepsin secretion Efficacious results can be achieved without correlating the without inhibiting Smooth muscle activity as do non-selective administration of the one or more MR-selective antagonists mAChRantagonists. with a peak or nadir in a circadian oscillation of a hormone. There are several lines of evidence suggesting that the MR The administration of the one or more MR-selective antago Subtype may be involved in certain aspects of depressive 50 nists need not be correlated with a particular time of day or disorders and anxiety. Direct injection of pirenzepine into the with a meal. In some embodiments, the administration of the nucleus accumbens in the forebrain of rats resulted in one or more MR-selective antagonists is timed to correlate increased Swimming time in the Porsolt Swim test (see, Chau, with a meal, for example, before, during or after a meal. D. T., et al., Neuroscience, 2001, vol. 104, no. 3, pp. 791-8), a Accordingly, in a first aspect, the invention provides meth common measure of antidepressant activity. MR-null mice 55 ods for promoting weight loss or facilitating maintenance of also displayed increased Swimming time in the Porsolt Swim a stable weight, the method comprising administering to an test, as well as increased social contacts in a social interaction obese or overweight individual in need thereof a therapeuti test (see, Miyakawa, T., et al., J. Neurosci., 2001, Vol. 21, no. cally effective amount of one or more MR-selective antago 14, pp. 5239-50). nists to effectuate weight loss, whereby weight loss is pro While pirenzepine and telenzepine are structurally similar 60 moted or maintenance of a stable weight is facilitated. to antidepressants such as , they are not In another aspect, the invention provides pharmaceutical known to have psychotropic effects when taken orally for the compositions comprising a mixture of therapeutically effec treatment of peptic ulcer disease. In addition, in earlier stud tive amounts of one or more MR-selective antagonists and ies of mice and rats, pirenzepine administered systemically one or more antidepressants other than a MR-selective failed to elicit any behavioral effects (see, Rogoz, Z. Skuza, 65 antagonist. In some embodiments, the pharmaceutical com G., Sowinska, H., Pol. J. Pharmacol. Pharm., 1981, Vol. 31, positions comprise a mixture of therapeutically effective pp. 615-26). The lack of such effects can be explained by the amounts of one or more MR-selective antagonists and one or US 8,748,419 B2 3 4 more anti-obesity agents. In some embodiments, the pharma the one or more antidepressants other than a MR-selective ceutical compositions comprise a mixture of therapeutically antagonist is sertraline or its S-enantiomer, Zoloft(R). effective amounts of one or more MR-selective antagonists, In one embodiment, the one or more MR-selective one or more antidepressants other than a MR-selective antagonists is telenzepine (racemic or an optical isomer) and antagonist, and one or more anti-obesity agents. the one or more antidepressants other than a MR-selective In another aspect, the invention provides kits comprising a antagonist is (or ). mixture of therapeutically effective amounts of one or more In one embodiment, the one or more MR-selective MR-selective antagonists and one or more antidepressants antagonists is telenzepine (racemic or an optical isomer) and other thana M R-selective antagonist. In some embodiments, the one or more antidepressants other than a MR-selective the kits comprise a mixture of therapeutically effective 10 antagonist is . amounts of one or more MR-selective antagonists and one or In one embodiment, the one or more MR-selective more anti-obesity agents. In some embodiments, the kits antagonists is telenzepine (racemic or an optical isomer) and comprise a mixture of therapeutically effective amounts of the one or more antidepressants other than a MR-selective one or more MR-selective antagonists, one or more antide antagonist is (racemic or an optical isomer). pressants other than a MR-selective antagonist, and one or 15 In one embodiment, the one or more MR-selective more anti-obesity agents. antagonists is telenzepine (racemic or an optical isomer) and With regard to the embodiments for carrying out the meth the one or more antidepressants other than a MR-selective ods, and for the pharmaceutical compositions and kits, in one antagonist is . embodiment, the one or more MR-selective antagonists is In one embodiment, the one or more MR-selective selected from the group consisting of pirenzepine, telen antagonists is telenzepine (racemic or an optical isomer) and Zepine, and combinations thereof. In one embodiment, the the one or more antidepressants other than a MR-selective MR-selective antagonist is telenzepine (racemic or an opti antagonist is . cal isomer). In one embodiment, the MR-selective antago In one embodiment, the one or more MR-selective nist is pirenzepine. antagonists is telenzepine (racemic or an optical isomer) and In one embodiment, the one or more MR-selective 25 the one or more antidepressants other than a MR-selective antagonists are administered without a second pharmacologi antagonist is sibutramine. cal agent. In one embodiment, the one or more MR-selective In one embodiment, the one or more MR-selective antagonists is telenzepine (racemic or an optical isomer) and antagonists is administered in combination with or combined the one or more antidepressants other than a MR-selective with one or more antidepressants other than a MR-selective 30 antagonist is . antagonist. In one embodiment, the antidepressant is selected In one embodiment, the one or more MR-selective from the group consisting of a selective serotonin reuptake antagonists is telenzepine (racemic or an optical isomer) and inhibitor (SSRI) and a selective serotonin-norepinephrine the one or more antidepressants other than a MR-selective (SNRI). antagonist is . In one embodiment, the antidepressant is a SSRI. In one 35 In one embodiment, the one or more MR-selective embodiment, the SSRI is selected from the group consisting antagonists is telenzepine (racemic or an optical isomer) and of citalopram, escitalopram, fluoxetine, , paroX the one or more antidepressants other than a MR-selective etine and sertraline. In one embodiment, the SSRI is selected antagonist is . from the group consisting of citalopram, Sertraline, paroxet In one embodiment, the one or more MR-selective ine, and fluoxetine. 40 antagonists is telenzepine (racemic or an optical isomer) and In one embodiment, the antidepressant is a SNRI. In one the one or more anti-obesity agents is phentermine. embodiment, the SNRI is selected from the group consisting In a related aspect, the invention provides methods for of milnacipran, mirtazapine, Venlafaxine, dulloxetine, des preparing or use of a medicament for treating obesity, Sup venlafaxine and sibutramine. In one embodiment, the SNRI is pressing appetite, facilitating or promoting weight loss, Venlafaxine. 45 facilitating or promoting maintenance of a desired weight, The methods achieve efficacious results without requiring and preventing or decreasing undesired weight gain, the the administration of an anti-obesity agent, for example, medicament containing a therapeutically effective amount of without requiring administration of an anorexiant. However, one or more MR-selective antagonists. The medicament can in some embodiments, the one or more MR-selective optionally also contain one or more antidepressants other antagonists is administered in combination with or combined 50 than a MR-selective antagonist. The medicament can with one or more anti-obesity agents, for example, one or optionally also contain one or more anti-obesity agents. The more anorexiants. embodiments for the medicament are as described herein. Furthermore, efficacious results can be achieved without In some embodiments, the methods and compositions of timed administration of the one or more MR-selective the invention comprise the combinations of pharmacological antagonists. Co-administered active agents, including antide 55 agents set forth herein. In some embodiments, the methods pressants, anti-obesity agents and anorexiants also provide and compositions of the invention consist essentially of the efficacious results without timed administration. combinations of pharmacological agents set forth herein. In one embodiment, the one or more MR-selective antagonists is telenzepine (racemic or an optical isomer) and DEFINITIONS the one or more antidepressants other than a MR-selective 60 antagonist is fluoxetine (racemic or an optical isomer). The term “obese' or “obesity refers to an individual who In one embodiment, the one or more MR-selective has a body mass index (BMI) of 30 kg/m or more due to antagonists is telenzepine (racemic or an optical isomer) and excess adipose tissue. Obesity also can be defined on the basis the one or more antidepressants other than a MR-selective of body fat content: greater than 25% body fat content for a antagonist is fluvoxamine. 65 male or more than 30% body fat content for a female. A In one embodiment, the one or more MR-selective “morbidly obese' individual has a body mass index greater antagonists is telenzepine (racemic or an optical isomer) and than 35 kg/m. US 8,748,419 B2 5 6 The term “overweight” refers to an individual who has a rinic ligand (e.g., quinuclidinyl benzilate (QNB), N-meth body mass index of 25 kg/m or more, but less than 30 kg/m. ylscopolamine (NMS)) from an M receptor subtype in com The term “body mass index” or “BMI refers to a weight to parison to displacing the non-selective muscarinic ligand height ratio measurement that estimates whether an individu from binding to the M and M receptor subtypes. The relative als weight is appropriate for their height. As used herein, an potencies for displacement of radiolabeled competitors can individual’s body mass index is calculated as follows: be expressed in terms of the concentration at which 50% of the competitor is displaced (ICs), or in terms of an equilib BMI=(poundsx700)/(height in inches)? rium dissociation constant (K). The ICso value and/or the equilibrium dissociation constant can be calculated using O 10 available software by entering the values of detected labeled ligand in the presence of titrated amounts of unlabeled test BMI=(kilograms)/(height in meters)? compound (e.g., LIGAND (Munson, P. J., and Rodbard, D., The term “baseline body weight” refers to the body weight Anal. Biochem. (1980) 107:220-39 or DATAPLOT, National presented by the individual at the initiation of treatment. Technical Information Services). AMR-selective antagonist As used herein, “administering means oral ("po') admin 15 will have an ICso value or a K value for binding to an M. istration, administration as a Suppository, topical contact, receptor subtype that is at least about 3-fold less, preferably at intravenous (“iv'), intraperitoneal (“ip'), intramuscular least about 10-fold less, and more preferably at least about (“im'), intralesional, intranasal or subcutaneous (“sc' 30-fold less than its ICso value or K value for binding to M. administration, or the implantation of a slow-release device and M receptor Subtypes. Applicable radioligand binding e.g., a mini-osmotic pump, to a Subject. Administration is by assays, using radiolabeled NMS or QNB, are disclosed in any route including parenteral and transmucosal (e.g., oral, Buckley, et al., Molecular Pharmacology (1989) 35:469-76 nasal, vaginal, rectal, or transdermal). Parenteral administra and Bolden, etal, J Pharmacol Exp. Ther. (1992) 260:576-80. tion includes, e.g., intravenous, intramuscular, intra-arteriole, As used herein, the term “anti-obesity agent” refers to a intradermal, Subcutaneous, intraperitoneal, intraventricular, pharmaceutical agent whose primary purpose is to effect and intracranial. Other modes of delivery include, but are not 25 weight loss. Exemplary anti-obesity agents include, without limited to, the use of liposomal formulations, intravenous limitation, anorexiants, dopamine , H-histamine infusion, transdermal patches, etc. antagonists, 5-HT2c receptor agonists, beta-3 adrenergic The terms “systemic administration' and “systemically receptor agonists, agonists, anti-epileptic administered refer to a method of administering a compound agents, , leptin analogs and agonists, or composition to a mammal so that the compound or com 30 (NPY) receptor antagonists and modulators, position is delivered to sites in the body, including the tar peptide-YY (PYY) receptor agonists, ciliary neurotrophic geted site of pharmaceutical action, via the circulatory sys factor, thyroid hormone receptor-beta agonists, cannabinoid tem. Systemic administration includes, but is not limited to, CB1 receptor antagonists, melanin-concentrating hormone oral, intranasal, rectal and parenteral (i.e., other than through receptor antagonists, pancreatic and gastric lipase inhibitors, the alimentary tract, Such as intramuscular, intravenous, intra 35 -4 receptor agonists, and combinations thereof. arterial, transdermal and Subcutaneous) administration, with As used herein, the term “anti-obesity agent” specifically the proviso that, as used herein, Systemic administration does excludes MR selective muscarinic antagonists and antide not include direct administration to the brain region by means pressants. other than via the circulatory system, Such as intrathecal As used herein, the term 'anorexiant' or '' inter injection and intracranial administration. 40 changeably refer to a pharmaceutical agent whose primary The term “co-administer” refers to the simultaneous pres intended effect is the Suppression of appetite. Anorexiants ence of two active agents in the blood of an individual. Active include, but are not limited to, the sympathomimetic amines. agents that are co-administered can be concurrently or The sympathomimetic amines are well known and discussed sequentially delivered. in detail in, for example, Goodman and Gilman's The Phar As used herein, the terms “treating and “treatment” refer 45 macological Basis of Therapeutics, 11" Ed., Brunton, Lazo to delaying the onset of retarding or reversing the progress of and Parker, Eds. McGraw-Hill (2006), Chapter 10, pp. 237 or alleviating or preventing either the disease or condition to 263, hereby incorporated herein by reference. As used herein, which the term applies, or one or more symptoms of Such the terms “anorexiant' or “anorectic' specifically exclude disease or condition. MR selective muscarinic antagonists and antidepressants. As used herein, the terms 'selective muscarinic receptor 50 As used herein, the phrase “consisting essentially of refers Mantagonist' and “MR-selective antagonist” refer to a to the genera or species of active pharmaceutical agents muscarinic acetylcholine that exhibits included in a method or composition, as well as any excipi preferential interaction with the muscarinic receptor M sub ents inactive for the intended purpose of the methods or type in comparison to the muscarinic receptor subtypes M. compositions. In some embodiments, the phrase “consisting and M. Exemplified MR-selective antagonists include, but 55 essentially of expressly excludes the inclusion of one or are not limited to, pirenzepine and telenzepine. Preferential more additional active agents other than a MR-selective binding need not be complete. For example, despite compa antagonist and an antidepressant. In some embodiments, rable affinities for M and M receptor subtypes, pirenzepine additional active agents that can be excluded include one or is classified as an MR-selective antagonist. more of a inhibitor, a prolactin stimulator, a 5-HT Preferential binding of a MR-selective antagonist can be 60 receptor antagonist, a 5-HT receptoragonist, a NK-1 receptor measured in a competitive displacement assay. A M R-selec antagonist and/or a dipeptidylpeptidase IV inhibitor. tive antagonist will preferentially displace a known MR The terms “controlled release.” “sustained release.” selective ligand (e.g. pirenzepine and/or telenZepine) in com “extended release, and “timed release' are intended to refer parison to known M. (e.g. tripitramine, , interchangeably to any drug-containing formulation in which ) and M. (e.g. , hexahydrosilad 65 release of the drug is not immediate, i.e., with a “controlled iphenidol) selective ligands. Alternatively, a MR-selective release' formulation, oral administration does not result in antagonist will preferentially displace a nonselective musca immediate release of the drug into an absorption pool. The US 8,748,419 B2 7 8 terms are used interchangeably with “nonimmediate release' administered telenZepine (3 mg/kg) and Sertraline (10 mg/kg as defined in Remington. The Science and Practice of phar or 30 mg/kg), as described in the Examples below. All active macy, 21 Ed., Lippencott Williams & Wilkins (2006). As agents were delivered in free base form. Control rats (VEH) discussed therein, immediate and nonimmediate release can were administered 37% DMSO. * indicates p<0.05 vs. be defined kinetically by reference to the following equation: VEH. ** indicates p<0.001 vs. VEH. “a” indicates p<0.001 vs. SRT. “b” indicates p<0.05 vs. TZP. FIG. 4 illustrates the effect of telenzepine (TZP) alone, Dosage Absorption ka Target ke sibutramine (SBR) alone and combined telenzepine and Form drug Pool absorption Area elimination Sibutramine on total high fat food consumption in fasted rats release 10 over 4 hours. Four-month old male Sprague-Dawley rats (n=10 per group) were administered orally telenzepine alone (30 mg/kg), Sibutramine alone (1.0 mg/kg), or co-adminis The “absorption pool' represents a solution of the drug tered telenzepine (30 mg/kg) and Sibutramine (1.0 mg/kg), as administered at a particular absorption site, and k, k, and k. described in the Examples below. All active agents were are first-order rate constants for (1) release of the drug from 15 delivered in free base form. Control rats (VEH) were admin the formulation, (2) absorption, and (3) elimination, respec istered 10% DMSO. ** indicates p<0.01 vs. VEH. "aa’ indi tively. For immediate release dosage forms, the rate constant cates p<0.01 vs. SBR. for drug release k, is far greater than the absorption rate FIG. 5 illustrates the effect of telenzepine (TZP) alone, constant k. For controlled release formulations, the opposite venlafaxine (VEN) alone and combined telenzepine and ven is true, i.e., k,

Vehicle Treatment % Reduction Dose Consumption Consumption in Compound (mg/kg) (g4 Hrs) (g 4 Hrs) Consumption p Values Citalopram 25 (ip) 7.6 0.44 5.3 O.72 31% : Sertraline O (ip) 7.6 0.44 6.0 - 0.88 21% lS 30 (ip) 7.6 0.44 S. 60.73 27% : Venlafaxine 30 (ip) 7.00.51 6.1 0.84 13% l.S. Telenzepine (ip) 7.00.51 4.0 OSO 43% ::::::::: (ip) 9.2 109 5.7 O.63 38% :::::: 3 (ip) 7.00.51 4.5 + 0.40 35% ::::::::: 3 (ip) 7.6 0.44 4.2 0.36 45% ::::::::: 3 (ip) 9.2 109 5.5 O.6O 40% :::::: O (ip) 9.2 109 4.1 - 0.55 S6% :::::: O (po) 10.3 1.05 7.4 O.64 28% l.S. 30 (po) 10.3 1.05 6.6 1.01 36% l.S. Sibutramine (po) 10.3 1.OS 10.1 - 124 O% lS (po) 6.8 1.09 4.90.68 28% l.S. 3 (po) 10.3 1.05 8.0 - 129 23% l.S. 3 (po) 6.8 1.09 3.20.33 54% :::::: O (po) 6.8 1.09 4.3 0.61 38% : US 8,748,419 B2 27 28 TABLE 1-continued a Hr Consumption

Vehicle Treatment % Reduction Dose Consumption Consumption in Compound (mg/kg) (g4 Hrs) (g 4 Hrs) Consumption p Values Venlafaxine + Telenzepine 30 + 1 (ip) 7.O-O 51 2.7 0.48 62% ***, a,b 30 + 3 (ip) 7.O-O 51 3.0 - 0.34 56% ***, aa, bb Citalopram + Telenzepine 25 + 3 (ip) 7.6 0.44 2.0 - 0.15 7396 ***, aaa, b Sertraline + Telenzepine 10 + 3 (ip) 7.6 0.44 2.4 - 0.29 69% ***, aaa. 30 + 3 (ip) 7.6 0.44 2.0 0.42 7396 ***, aaa, b Sibutramine + Telenzepine 1 +30 (po) 10.3 + 1.05 48 0.93 539 **, aa

TABLE 2 24 Hr Consumption

Vehicle Treatment % Reduction Dose Consumption Consumption in Compound (mg/kg) (g 24 Hrs) (g 24 Hrs) Consumption p Values Citalopram 25 (ip) 23.90.91 23.O.O.71 4% l.S. Sertraline O (ip) 23.90.91 23.5 O.71 29/o l.S. 30 (ip) 23.90.91 71 - 160 28% ::::::::: Venlafaxine 30 (ip) 25.0 - 1.03 24.9 152 O% l.S. Telenzepine (ip) 25.0 - 1.03 20.9 O.78 16% ::::::::: (ip) 28.9 116 23.6 1.01 18% : 3 (ip) 25.0 - 1.03 94 - 0.94 22% ::::::::: 3(ip) 23.90.91 7.5 - 1.38 279 :::::: 3 (ip) 28.9 - 1.16 9.7 O.95 32% :::::: O (ip) 28.9 - 1.16 4.5 - 1.29 SO% :::::: O (po) 3O3 + 1.54 8.5 - 233 39% :::::: 30 (po) 3O3 + 1.54 3.32.69 56% ::::::::: Sibutramine (po) 3O3 + 1.54 27.4 1.78 10% l.S. (po) 24.70.89 20.7 - 1.05 16% : 3 (po) 3O3 + 1.54 21.9 1.98 28% : 3 (po) 24.70.89 54 - 1.22 38% :::::: O (po) 24.70.89 1.9 - 1.15 52% :::::: Venlafaxine + Telenzepine 30 + 1 (ip) 25.0 - 1.03 71 - 1.68 31% ***, a,b 30 + 3 (ip) 25.0 - 1.03 5.5 - 1.18 38% ***, aa, bb Citalopram + Telenzepine 25 + 3 (ip) 23.90.91 9.5 1.23 60% ***, aaa, bbb Sertraline + Telenzepine 10 + 3 (ip) 23.90.91 26 - 127 47% ***, aaa, b 30 + 3 (ip) 23.90.91 8.8 - 1.33 63% ***, aaa, bbb Sibutramine + Telenzepine 1 +30 (po) 3O3 + 1.54 1.21.51 63% ***, aaa.

Note on Effects: 45 and was essentially without effect over 24 hours (0%, n.s.). 3 24-hour consumption effects better reflect the sustained mg/kg of telenZepine produced a larger reduction in con duration of action and are better exemplars of anorectic sumption over 4 hours (35%, p<0.001), which was still sig effects than are the 4-hour consumption effects. All doses of nificant over 24 hours (22%, p<0.001). Co-administration of telenzepine tested (ip) significantly reduced consumption these compounds produced a significant reduction in con 50 sumption over 4 hours (56%, p<0.001) and 24 hours (38%, when given alone (FIGS. 1 and 6). Also, after 24 hours nearly p<0.001) (see FIGS. 5 and 10 for 4-hr and 24-hr effects, all combinations resulted in reductions in consumption that respectively). The magnitude of both the 4 hour and the 24 were greater than predicted from mere additivity. hour effects are indicative of synergy as they are greater than For example, 25 mg/kg of citalopram produced a modest what would be expected from additive effects. Similarly, co reduction in consumption over 4 hours (31%, p<0.05), but 55 administration of a lower dose of telenzepine (1 mg/kg) with was essentially without effect over 24 hours (4%, n.s.). 3 30 mg/kg of venlafaxine also resulted in Synergistic effects on mg/kg of telenZepine produced a larger reduction in con consumption over both intervals. sumption over 4 hours (45%, p<0.001), which was still sig In a further example, 30 mg/kg of Sertraline produced a nificant over 24 hours (27%, p<0.01). Co-administration of modest reduction in consumption over 4 hours (27%, these compounds produced a significant reduction in con- 60 p-0.05), that was maintained over 24 hours (28%, p<0.001), sumption over 4 hours (73%, p<0.001) and 24 hours (60%, while the lower dose (10 mg/kg) displayed lessened efficacy p-0.001) (see FIGS. 2 and 7 for 4-hr and 24-hr effects, respec and duration (non-significant reductions of 21% and 2% over tively). The magnitude of the 24 hour effect is indicative of 4 hours and 24 hours, respectively). 3 mg/kg of telenzepine synergy as it is greater than what would be expected from produced a larger reduction in consumption over 4 hours additive effects. 65 (45%, p<0.001), which was still significant over 24 hours In another example, 30 mg/kg of Venlafaxine produced a (27%, p<0.01). Co-administration of telenzepine and the non-significant reduction in consumption over 4 hours (13%), “high dose” of Sertaline produced a significant reduction in US 8,748,419 B2 29 30 consumption over 4 hours (73%, p<0.001) and 24 hours gavage daily over 14 days at a Volume of 3 mL/kg. Data (63%, p<0.001). Likewise, co-administration of telenzepine collection was continued under drug treatment for approxi and the “low dose” of sertaline produced a significant reduc mately two more weeks. Change in body weight (expressed in tion in consumption over 4 hours (69%, p<0.001) and 24 grams) was calculated for the treatment interval. In this assay, hours (47%, p<0.001) (see FIGS. 3 and 8 for 4-hr and 24-hr 5 vehicle-treated rats typically gain approximately 35-40 effects, respectively). The magnitude of both the 4 hour and grams (+9%) over the two-week interval. Treatment effects the 24 hour effects are indicative of synergy as they are greater are presented in Table 3 as % Weight Gain (Body Weight at than what would be expected from additive effects. End of Drug Infusion-Baseline Body Weight)/Baseline Body In nearly all combinations of the present example, reduc Weight)x100%, for both Vehicle and Treatment groups; as tions produced by the combinations are significantly different 10 well as % Reduction=(% Weight Gain for Treatment from not only vehicle treated rats, but also from the effect of group-% Weight Gain for Vehicle group). Body weights either compound given alone. In nearly all combinational throughout the treatment period are presented in FIGS. 11-15 experiments, consumption was reduced by greater than 50% as the percentage of baseline body weight. Similar Super over both intervals. The clinical reference, sibutramine, was scripts in the Dose column of Table 3 denote values derived also effective when given alone, although oral administration 15 from the same experiment (to facilitate comparisons between was required to produce a significant reduction (ip data not individual treatments and co-administrations). Statistical given). Additionally, when 30 mg/kg of telenzepine was co analyses were performed using a 1-way ANOVA (analysis of administered, the effective dose of sibutramine could be low variance) followed by a Bonferroni multiple comparison test ered to 1 mg/kg, representing a 3-fold (4 hour consumption) with the overall alpha set at 0.05. In Table 3, asterisks (*) to 10-fold (24 hour consumption) reduction in dose. denote significant effects compared to vehicle-treated rats, while letters (a or b) denote significant effects compared to Example 2 rats treated with a single compound (“a” for significance from antidepressant and “b' for significance from telenzepine). In Reduction in Weight Gain: Three- to four-month-old (475 Table 3, one symbol denotes p-0.05, two symbols denote 550 grams) male, Sprague-Dawley rats (individually housed) 25 p-0.01 and three symbols denote p-0.001). The symbols were used to assess compounds for their ability to prevent used for denoting statistical significance may be different in weight gain. At the onset of chronic experiments, rats had the corresponding figures. TABLE 3

Vehicle: Treatment: Dose % Weight % Weight % Compound (mg/kg) Gain Gain Reduction p Values Citalopram 15 (sc) 8.6 1.4% 6.21.0% -2.4% n.s. Sertraline 5 (sc) 9.30.3% 7.21.2% -2.1% n.s. 10 (sc) 9.1 - 0.7% 6.O-O.8% -3.19% * * 15 (sc) 9.6 0.7%. 28 O.8% -6.8% *** 20 (sc) 6.3 O.4% 28 0.7% -3.5% * Venlafaxine 30 (sc) 8.1 O.8% 7.4 0.5% -0.7% n.s. Phentermine 4 (sc) 5.3 0.8% 420.6% -1.1% n.s. Telenzepine 0.3 (sc) 5.3 0.8% 4.4 O.6% -0.9% n.s. 1 (po) 6.40.5%. 33 - 0.6% -3.19% * * 3 (sc) 8.10.8% 4.3 - 0.8% -3.8% * 3 (sc) 8.6 1.4% 1.5 - 1.0% -7.10, * * * Sibutramine 0.3 (po) 6.40.5% 4.70.5% -1.7% n.s. 3 (po) O3 + O.9% -5.7 1.2% -6.0% *** Citalopram + Telenzepine 15 + 3 (sc) 8.6 14% -0.2 - 1.1% -8.8% ***, aa. Sertraline + Telenzepine 15 + 3 (sc) 9.6 + 0.7% -1.7 + 1.6% -11.3% ***, aaa, b Venlafaxine + Telenzepine 30 + 3 (sc) 8.1 + 0.8% -1.0 + 1.1% -9.1% ***, aaa, bbb Phentermine + Telenzepine 4 + 0.3 (sc) 5.3 0.8% 23 O.7% -3.09% * * Sibutramine + Telenzepine 0.3 + 1 (po) 6.4 + 0.5% 3.3 + 0.8% -3.19% * * Citalopram 15 (sc) 8.6 1.4% 6.21.0% -2.4% n.s. Sertraline 5 (sc) 9.30.3% 7.21.2% -2.1% n.s. 10 (sc) 9.1 - 0.7% 6.O-O.8% -3.19% * * 15 (sc) 9.6 0.7%. 28 O.8% -6.8% *** 20 (sc) 6.3 O.4% 28 0.7% -3.5% * been maintained (ad libitum access) on a “high fat’ diet 55 Note on Effects: (BioServ Diet #F3282 or Research Diets #12451) for TelenZepine given alone (po or Sc) significantly reduced approximately one month. Individual body weights and water the weight gain of rats on a high fat diet when compared consumptions were recorded three times per week throughout against vehicle treated controls (3% to 7% reduction from the duration of the experiment. After approximately two baseline) (see FIGS. 11-15). The clinical reference com weeks of data collection, rats were counter-balanced to pro 60 pound, Sibutramine, also significantly reduced weight gain duce treatment groups with equivalent mean body weights. when compared against vehicle treated controls (6% reduc Under isofluorane-induced anesthesia, rats were Surgically tion from baseline) (see FIG. 13). Additionally, sertraline at implanted (subscapular, Subcutaneous Sc placement) with higher doses (10 and 15 mg/kg, but not 5 mg/kg) also signifi osmotic mini-pumps (Alzet 2mL2) containing the appropri cantly reduced weight gain when compared against vehicle ate drug concentration (based on mean body weights and 65 treated controls (3% to 7% reductions from baseline) (see calculated durations of delivery). Alternatively, for studies FIG. 12). All other compounds/doses used in the combination using the oral route of administration, rats were dosed by studies produced no effect on body weights when given alone. US 8,748,419 B2 31 32 Combinations of sertraline--telenzepine and venlafaxine-- applications cited herein are hereby incorporated by refer telenzepine produced reductions in body weight that were ence in their entirety for all purposes. Synergistic and significantly greater than observed with not What is claimed is: only vehicle treatment, but also than observed with either 1. A method for promoting weight loss or facilitating main compound alone. tenance of a stable weight, the method comprising co-admin In the case of sertraline--telenzepine (FIG. 12), 15 mg/kg of istering to an obese or overweight human individual in need sertraline alone produced a significant reduction (6.8%, thereof telenzepine and sertraline for at least 80 days to effec p<0.001) in body weight compared to vehicle treated rats, and tuate weight loss, wherein the telenzepine is administered at 3 mg/kg of telenzepine alone also produced a significant a dose of about 0.5 mg per day to about 10 mg per day and the reduction (3.8%, p<0.05) in body weight compared to vehicle 10 sertraline is administered at a dose of about 50 mg per day to treated rats. However, co-administration of sertraline and about 200 mg per day, whereby weight loss is promoted or telenzepine at these same doses resulted in an 11.3% reduc maintenance of a stable weight is facilitated. tion from baseline that was significant compared to not only 2. The method of claim 1, wherein the telenzepine and the vehicle treatment (p<0.001) but also treatment with sertraline sertraline are administered concurrently. alone (p<0.001) or telenzepine alone (p<0.05). 15 3. The method of claim 2, wherein the telenzepine and the In the case of venlafaxine--telenzepine (FIG. 14), 30 mg/kg sertraline are administered as an admixture. of venlafaxine alone failed to produced a significant reduction 4. The method of claim 1, wherein the telenzepine and the (0.7%) in body weight compared to vehicle treated rats, while sertraline are administered sequentially. 3 mg/kg of telenzepine alone produced a significant reduction 5. The method of claim 1, wherein the telenzepine is (3.8%, p<0.05) in body weight compared to vehicle treated administered at a dose of about 1 mg per day to about 5 mg per rats. However, co-administration of Venlafaxine and telen day. Zepine at these same doses resulted in a 9.1% reduction from 6. The method of claim 1, wherein the sertraline is admin baseline that was significant compared to not only vehicle istered at a dose of about 100 mg per day to about 150 mg per treatment (p<0.001) but also treatment with venlafaxine day. alone (p<0.001) or telenzepine alone (p<0.001). In both 25 7. The method of claim 1, wherein the telenzepine is above examples, synergistic effects are evidenced by the administered with a meal. increased magnitude of total reduction in body weights under 8. The method of claim 1, wherein one or both of the co-administration. telenzepine and the sertraline are administered in a sustained It is understood that the examples and embodiments release formulation. described herein are for illustrative purposes only and that 30 9. The method of claim 1, wherein the telenzepine and the Various modifications or changes in light thereof will be sug sertraline are co-administered for at least 150 days. gested to persons skilled in the art and are to be included 10. The method of claim 1, wherein the telenzepine and the within the spirit and purview of this application and scope of sertraline are co-administered for at least 200 days. the appended claims. All publications, patents, and patent