Note: Descriptions are shown in the official language in which they were submitted.
CA 02561293 1994-11-18
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TREATMENT OF INCONTINENCE
This invention belongs to the fields of pharmaceutical
chemistry and pharmacological treatment, and provides a new
method of treating incontinence in humans, making use of a
series of 3-aryloxypropanamines, particularly duloxetine.
Urinary incontinence is a common condition, and often
is so severe as to constitute an embarrassing and even disabling
difficulty. It is a frequent cause of elderly people's
confinement to nursing homes and other protected environments.
While it is more common among women than among men, at all ages,
it afflicts significant numbers of both sexes. It is well known
that many children past the usual age of toilet-training suffer
from nocturnal enuresis, and less frequently from daytime
urinary incontinence, and it is also well known that the elderly
are quite likely to develop urinary incontinence~as they grow
older. However, some studies have reported daily incontinence
among as many as 17o of young, apparently healthy, women.
Thus, it is clear that reliable and safe methods of
treating urinary incontinence are seriously needed. The need is
not, at present, adequately met.
Urinary incontinence is a manifestation of the failure
of control of the muscles of the urinary sphincter and of the
bladder. Those muscles are in balance, when the system is
operating properly. The urinary sphincter should be
sufficiently strong to hold back the pressure exerted by the
muscles of the bladder, except when the subject consciously
relaxes the sphincter in order to urinate.
Incontinence results when the pressure within the
bladder is too great, as a result of excessive force exerted by
the muscles of the bladder, or when the urinary sphincter is too
weak to hold back the normal intra-bladder pressure.
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Incontinence is broadly classified as urge incontinence (caused
by excessive intra-bladder pressure), and stress incontinence
(caused by a weak urethral sphincter). Patients often are seen
with both urge and stress incontinence, a condition which is
called mixed incontinence.
Urinary incontinence, appearing in different types of
patients, has a number of different causes or apparent causes,
including Parkinsonism, multiple sclerosis, cerebral vascular
system damage, cerebral arteriosclerosis, lesions of the central
nervous system, and infections of the bladder. Instability of
the muscles of the bladder or urethra can have many causes, and
interstitial cystitis can result in instability of the bladder
detrusor muscles and result in a particularly painful and
unpleasant variety of urge incontinence.
Neurological disorders, including Parkinsonism,
Alzheimer's disease, and multiple sclerosis, often result in
urge incontinence, occurring through hyperactivity of the
bladder muscles. Urinary incontinence is an early symptom of
Parkinsonism, and in fact, is often made worse by anti-
Parkinson's drugs.
It is well known that children frequently have
nocturnal incontinence. It has been reported that nocturnal
incontinence occurs in 300 of 4-year-old children, and in 100 of
6-year-old children. This condition is a variety of urge
incontinence and is a well-known source of emotional unrest in
both children and their parents.
Many elderly people suffer from incontinence, which
may result from many causes and include both stress and urge
incontinence, as well as mixed incontinence resulting from a
complex of causes. Urge incontinence is most common in the
elderly, usually caused by abnormal nervous or muscular
responses of the bladder. Stress incontinence, relatively rare
in elderly men, but more common in elderly women, can result
from surgery, decreased muscle tone and anatomical changes in
the pelvic organs, deterioration of the urethra, and
deterioration in the neuromuscular response of the urethra. The
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diseases of the elderly, especially Alzheimer's disease, also
frequently result in incontinence.
Thus, it is clear that urinary incontinence is one of
the major diseases of today. It is believed to afflict
approximately 12 million people in the United States alone, and
to occur in from 15 to 30~ of the population over the age of 60.
Its treatment at present is quite unsatisfactory.
Probably most patients are not treated at all, but use
diapers, and other aids, mostly remaining close to home in a
state of embarrassment and isolation. Some types of
incontinence can be improved by surgery, at great cost and some
risk. The improvement is usually temporary with the average
patient receiving 2.3 surgeries in her lifetime. A few drugs
are in use, including particularly imipramine and other anti-
cholinergic and anti-spasmotic agents. Benzodiazepine anti-
depressants, ephedrine and phenylpropanolamine are used to some
extent .
All of the drugs now used for urinary incontinence
have the disadvantage of possessing numerous pharmacological
activities, and therefore causing unwanted responses in the
patients. The anti-cholinergic effects of the benzodiazepines
and of imipramine are particularly significant and are likely to
produce side effects which require withdrawal of the medication,
or result in noncompliance by the patient.
Thus, it is clear that pharmaceuticals effective for
the treatment of urinary incontinence, and free from undesired
side effects, are badly needed. The present invention provides
such pharmaceuticals.
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The present invention provides a method of treating
urinary incontinence in a human in need of such treatment,
comprising administering to such human an effective
incontinence-reducing dose of venlafaxine or a compound of the
formula
R~ -CHCH2CH2NR2R3
I
O
Ar I
wherein: R1 is CS-C~ cycloalkyl, thienyl, halothienyl,
(C1-C4 alkyl)thienyl, furanyl, pyridyl or thiazolyl;
m
R4
1
Ar i s ~ ~ or
R5
n
each of R2 and R3 independently is hydrogen or methyl;
each R4 independently is halo, C1-Cq alkyl, C1-C3
alkoxy or trifluoromethyl;
each RS independently is halo, C1-Cq alkyl or
trifluoromethyl;
m is 0, 1 or 2;
n is 0 or 1; or
a pharmaceutically acceptable acid addition salt
thereof.
The invention also provides a pharmaceutical product
for the treatment of urinary incontinence in a human, which
product comprises venlafaxine or a compound of formula I, in the
form of a pharmaceutical formulation additionally comprising a
pharmaceutically acceptable excipient, in combination with
packaging material suitable for the pharmaceutical formulation,
said packaging material including instructions for the use of
the pharmaceutical formulation to treat urinary incontinence.
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The invention also provides the use of venlafaxine or
a compound of formula I for treating urinary incontinence in a
human in need of such treatment.
Further, the invention provides the use of venlafaxin
or a compound of formula I for the manufacture of a medicament
for the treatment of urinary incontinence.
Figure 1 - The effect of administration of duloxetine
on bladder capacity.
Figure 2 - The effect of duloxetine on the activity of
external urethral sphincter muscles, measured by EMG activity.
Figure 3 - The effects of duloxetine on hypogastric
nerve activity, external urethral EMG and bladder pressure.
Figure 4 - The effects of LY53857, for comparison with
Figure 3; LY53857 was administered at the time indicated by the
arrow.
Figure 5 - The effects of duloxetine on hypogastric
nerve activity, external urethral EMG and bladder pressure,
compared with LY53857 and prazocin.
In this document, all temperatures will be indicated
in degrees Celsius, and all indications of percentage, ratio,
concentration and like will be expressed in weight measurements
unless otherwise indicated.
The compounds useful in the present invention are
selective inhibitors of the reuptake of both serotonin and
norepinephrine, and have substantially no other pharmacological
effects. That is to say, any other pharmacological effects
which the compounds may have occur only at concentrations or
dosages at least 10, and usually 100 times larger than the
effective concentrations or dosages at which the compounds
inhibit the uptake of serotonin and norepinephrine. Thus, the
compounds are substantially unable to cause undesired side
effects in the patients to whom the compounds are administered.
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Venlafaxine is a known compound in the literature, and
its method of synthesis and its activity as an inhibitor of
serotonin and norepinephrine uptake are taught by U.S. Patent
No. 4,761,501. Venlafaxine is identified as compound A in that
document. At column 9
of that patent, it is stated that compound A has no muscarinic
anti-cholinergic actions.
The compounds of formula I have been taught by U.S.
Patent No. 4,956,388. The most preferred compound
of formula I is duloxetine,
(+)-N-methyl-3-(1-naphthalenyloxy)-3-(2-thienyl)propanamine,
usually administered as the hydrochloride salt. Duloxetine is
prepared in the form of the oxalate in Example 2 of that patent,
which shows its high potency in the inhibition of serotonin and
norepinephrine uptake at column 16.
Since the compounds of formula I are completely taught
in U.S. Patent No. 4,956,388, the reader may learn the methods
of synthesis and the complete description of the compounds from
that document. Certain of the compounds are preferred for use
in the presently disclosed invention, however, and groups of
those preferred compounds will be mentioned here. It will be
understood that preferred groups described below may be combined
at will to describe other, more limited subgroups, which are
also particularly preferred in the practice of the present
invention.
a) R1 is thienyl;
b) R1 is thienyl, halothienyl, or (C1-C4
alkyl)thienyl;
c) R1 is C5-C~ cycloalkyl;
d) R1 is furanyl, pyridyl or thiazolyl;
e) Ar is phenyl or substituted phenyl;
f) Ar is napthyl or substituted napthyl;
g) Ar is unsubstituted phenyl or unsubstituted
napthyl;
h) R2 is methyl and R3 is hydrogen;
i) R2 and R3 are both methyl.
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The reader will understand that the compounds of
formula I, as well as venlafaxine, possess an asymmetric carbon
atom, and that they accordingly exist in the form of individual
stereoisomers, as well as the racemic mixture. When the
stereoisomeric form of a compound is not indicated in this
document, it will be understood that both of the possible
isomeric forms, as well as the racemate, are intended. When an
individual stereoisomer is indicated, as in the case of
duloxetine, the isomeric form will be stated as part of the
name.
For example, the following specific compounds
illustrate the compounds of formula I which are contemplated in
the scope of the present invention.
N-Methyl-3-(1-naphthalenyloxy)-3-(3-thienyl)-
propanamine phosphate
(+)-N-Methyl-3-(2-naphthalenyloxy)-3-(cyclohexyl)-
propanamine citrate
(+)-N,N-Dimethyl-3-(4-chloro-1-naphthalenyloxy)-3-(3-
furanyl)propanamine hydrochloride
N-Methyl-3-(5-methyl-2-naphthalenyloxy)-3-(2-
thiazolyl)propanamine hydrobromide
N-Methyl-3-[3-(trifluoromethyl)-1-naphthalenyloxy)-3-
(3-methyl-2-thienyl)propanamine oxalate
(-)-N-Methyl-3-(6-iodo-1-naphthalenyloxy)-3-(4-
pyridyl)propanamine maleate
N,N-Dimethyl-3-(1-naphthalenyloxy)-3-(cycloheptyl)-
propanamine.formate
(-)-N,N-Dimethyl-3-(2-naphthalenyloxy)-3-(2-pyridyl)-
propanamine
(+)-N-Methyl-3-(1-naphthalenyloxy)-3-(2-furanyl)-
propanamine sulfate
(+)-N-Methyl-3-(4-methyl-1-naphthalenyloxy)-3-(4-
thiazolyl)propanamine oxalate
N-Methyl-3-(2-naphthalenyloxy)-3-(2-thienyl)-
propanamine hydrochloride
(-)-N,N-Dimethyl-3-(6-iodo-2-naphthalenyloxy)-3-(4-
bromo-3-thienyl)propanamine malonate
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(-)-N,N-Dimethyl-3-(1-naphthalenyloxy)-3-(3-
pyridyl)propanamine hydroiodide
N,N-Dimethyl-3-(4-methyl-2-naphthalenyloxy)-3-(3-
furanyl)propanamine maleate
(+)-N-Methyl-3-(2-naphthalenyloxy)-3-(cyclohexyl)-
propanamine caprate
(-)-N-Methyl-3-(6-n-propyl-1-naphthalenyloxy)-3-(3-
isopropyl-2-thienyl)propanamine citrate
(+)-N,N-Dimethyl-3-(2-methyl-1-naphthalenyloxy)-3-(4-
thiazolyl)propanamine monohydrogen phosphate
3-(1-Naphthalenyloxy)-3-(5-ethyl-3-thienyl)propanamine
succinate
3-[3-(Trifluoromethyl)-1-naphthalenyloxy]-3-
(pyridyl)propanamine acetate
(-)-N-Methyl-3-(6-methyl-1-naphthalenyloxy)-3-(4-
chloro-2-thienyl)propanamine tartrate
3-(2-Naphthalenyloxy)-3-(cyclopentyl)propanamine
(-)-N-Methyl-3-(4-n-butyl-1-naphthalenyloxy)-3-(3-
furanyl)propanamine methanesulfonate
(+)-3-(2-Chloro-1-naphthalenyloxy)-3-(5-thiazolyl)-
propanamine oxalate
(+)-N-Methyl-3-(1-naphthalenyloxy)-3-(3-furanyl)-
propanamine tartrate
N,N-Dimethyl-3-(phenoxy)-3-(2-furanyl)propanamine
oxalate
N,N-Dimethyl-3-[4-(trifluoromethyl)phenoxy]-3-
(cyclohexyl)propanamine hydrochloride
N-Methyl-3-(4-methylphenoxy)-3-(4-chloro-2-
thienyl)propanamine propionate
(-)-N-Methyl-3-(phenoxy)-3-(3-pyridyl)propanamine
oxalate
3-[2-Chloro-4-(trifluoromethyl)phenoxy]-3-(2-
thienyl)propanamine
(+)-N,N-Dimethyl-3-(3-methoxyphenoxy)-3-(3-bromo-2-
thienyl)propanamine citrate
N-Methyl-3-(4-bromophenoxy)-3-(4-thiazolyl)propanamine
maleate
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(-)-N,N-Dimethyl-3-(2-ethylphenoxy)-3-(5-methyl-3-
thienyl)propanamine
N-Methyl-3-(2-bromophenoxy)-3-(3-thienyl)propanamine
succinate
(-)-N-Methyl-3-(2,6-dimethylphenoxy)-3-(3-methyl-2-
thienyl)propanamine acetate
3- (3- (Trifluoromethyl) phenoxy] -3- (3-furanyl) -
propanamine oxalate
(-)-N-Methyl-3-(2,5-dichlorophenoxy)-3-(cyclopentyl)-
propanamine
3- [4 - (TrifluUrUCUeLhy1) ylL:IIUXy]-3- (2-Lhi~z~lyl) -
propanamine
(+)-N-Methyl-3-(phenoxy)-3-(5-methyl-2-thienyl)-
propanamine citrate
(+)-3-(4-(Methoxyphenoxy)-3-(4-pyridyl)propanamine
hydrochloride
N,N-Dimethyl-3-(3-methyl-5-bromophenoxy)-3-(3-
thienyl)propanamine
N-Methyl-3-(3-n-propylphenoxy)-3-(2-thienyl)-
propanamine hydrochloride
(+)-N-Methyl-3-(phenoxy)-3-(3-thienyl)propanamine
phosphate
(-)-N-Methyl-3-(4-methoxyphenoxy)-3-(cycloheptyl)-
propanamine citrate
3-(2-(Chlorophenoxy)-3-(5-thiazolyl)propanamine
propionate
3-[2-Chloro-4-(trifluoromethyl)phenoxy]-3-(3-thienyl)-
propanamine oxalate
3-(Phenoxy)-3-(4-methyl-2-thienyl)propanamine
(+)-N,N-Dimethyl-3-(4-ethylphenoxy)-3-(3-pyridyl)-
propanamine maleate
(-) -N, N-Dimethyl-3- [4- (trifluoromethyl) phenoxy] -3- (2-
pyridyl)propanamine
A particularly preferred synthesis of the most
preferred compound, duloxetine, will be set out below to assure
that the reader is fully informed.
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PREPARATION 1
(S)-(-)-N,N-dimethyl-3-hydroxy-3-(2-thienyl)-
propanamine
A mixture of 8.18 g of 2-acetylthiophene, 6.66 g of
dimethylamine hydrochloride, 2.9 g of paraformaldahyde and 0.31
g of concentrated hydrochloric acid in 20 ml of isopropanol was
heated to reflux and stirred for 6 hours. The mixture was then
cooled to 0° and stirred for one hour more. The slurry was then
filtered, and the solid was washed with cold ethanol. The
washed solid was dried for 16 hours at 50° to obtain 12.5 g of
2-~hieuyl 2--dimcthylaminoethyl ketone hydrochloride, a3 a white
solid. A 12.0 g portion of that intermediate product was
stirred in 90 ml of ethanol at ambient temperature, and the pH
of the solution was raised to 11-12 by slow addition of sodium
hydroxide. A 1. U3 g portion of sodium rorohydride was added,
and the mixture was stirred at ambient temperature for 4 hours.
Then 7.5 ml of acetone was added, and the mixture was stirred
for 20 minutes more. The mixture was then concentrated by
evaporation to a white slurry, and 120 ml of methyl ~,-butyl
ether was added. The mixture was acidified to pH 1-1.5 by
addition of concentrated hydrochloric acid, and the solution was
stirred for ten minutes. The pH was then made basic to pH 12 by
slow addition of sodium hydroxide.
The layers were then separated, the aqueous phase was
extracted with 30 ml of methyl ~-butyl ether, and the organic
phases 'were combined and washed once with 50 ml of water. The
organic phase was concentrated by evaporation to 118 ml, and was
heated to 50°.
In a separate vessel, (S)-(+)-mandelic acid, 4.18 g,
was dissolved in 12 ml of ethanol at 50°, and the mandelic acid
solution was added slowly to the previous solution. The
resulting slurry was then heated to reflux and stirred for 45
minutes. It was then cooled to ambient temperature, stirred for
one hour, and filtered, and the solid was washed with methyl
butyl ether. The solid was then dried under vacuum at 50° to
obtain 7.29 g of the mandelic acid salt of the desired product,
which is isolated as the free amine by dissolution in water,
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basification with sodium hydroxide solution, extraction into an
organic solvent, and evaporation to remove the solvent.
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Preparation 2
(S)-(+)-N,N-dimethyl-3-(1-naphthalenyloxy)-3-(2-
thienyl)propanamine, phosphoric acid salt
A 13.5 g portion of (S)-(-)-N,N-dimethyl-3-hydroxy-3-
(2-thienyl)propanamine was dissolved in 80 ml of
dimethylsulfoxide at 25°. To the solution was slowly added 3 g
of sodium hydride as a 60~ dispersion in mineral oil, with
vigorous stirring. After 15 minutes of stirring, 1.17 g of
potassium benzoate was added and stirring was continued at
approximately constant temperature for another 15 minutes.
Then, 12.8 g of 1-fluoronaphthalene was slowly added to the
reaction mixture, and after the addition was complete, the
mixture was heated and was stirred for 2.5 hours at 60-65°. The
mixture was then poured slowly iiWo 190 ml of ~:ol~l watci ana the
pH was adjusted to 4.8 by addition of acetic acid. The
temperature of the mixture was brought to 25°, and 75 ml of
hexane was added and stirring was continued for 10 minutes. The
layers were then separated and the aqueous phase was stirred
again with 75 ml of hexane and the phases separated. The pH of
the aqueous phase was adjusted to 10.2 by addition of aqueous
sodium hydroxide, and 75 ml of ethyl acetate was added. That
mixture was stirred for 15 minutes at 25°, and the 2-phase
mixture was vacuum filtered through a pad of filter aid. The
phases of the filtrate were allowed to separate, and the aqueous
phase was extracted with 75 ml of ethyl acetate. The extract
was combined with the previous ethyl acetate layer, and that
mixture was washed with 100 mI of water. The organic layer was
stirred at 25°, and to it was added, dropwise, 7 g of 850
phosphoric acid. After the addition was complete, the mixture
was stirred for 20 minutes more and was then cooled to 0° and
stirred for 1 hour at that temperature. The slurry was then
filtered and the solids washed three times with 20 ml portions
of cold ethyl acetate. The solid was dried at 60° to afford
24.19 g of the title compound as a white solid, 98.10 potency,
adjusted yield 79.6, 91o EE.
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Assay Methodoloav
The product was analyzed by high performance liquid
chromatography, using a Spectra Physics SP 8800 instrument
equipped with a SP 4400 integrator and a Spectroflow 757
detector, set at 230 nm, at a sensitivity of 0.5 absorption
units, 1 second filter rise time. The column was a Dupont
Zorbax kx C8, 4 . 6 mm x l5 cart. 'fhe elud~iL was 70 o acetuiiitrile,
30~ 0.01 M phosphate buffer at pH 6, flow rate of 1.0 ml/minute,
injection volume 20 microliters. The samples were prepared by
diluting 0.1 to 0.3 g ~f reaction mixture or extract to SO ml
with 1:1 acetonitrile:water. The product peak elutes at 13-17
minutes; starting material at 6-8 minutes; fluoronaphthalene at
5-6 minutes; ~limPt-hyl~mlf~xidP at 2-3 minutes; and potassium
benzoate at 2-2.5 minutes.
When a chiral assay was to be done, the same equipment
was set at 280 nm and a sensitivity of 0.1 absorption unit, and
a Chiralcel OD column was used. The eluant for chiral assays
was 2~ isopropanol, 0.2~ diethylamine, and 97.80 hexane. The
same injection and flow settings were used. The samples were
prepared by diluting 0.1-0.3 g of reaction mixture or extract to
5 ml with dichloromethane, washing the mixture with about 5 ml
of water, and drying the organic phase over sodium sulfate. The
resulting solution was filtered and diluted to 25 ml with
eluant. The desired enantiomer elutes at 5-5.5 minutes, the
undesired enantiomer at 6-6.5 minutes and fluoronaphthalene at
3-4 minutes.
Preparation 3
(+)-N-methyl-3-(1-naphthalenyloxy)-3-(2-thienyl)-
propanamine hydrochloride
Five g of the product of Preparation 2 was stirred in
a mixture of 40 ml of toluene and 40 ml of water at 40°, and 2.5
ml of 30o ammonium hydroxide solution was added. The mixture
was stirred for 10 minutes at constant temperature and the
layers were separated. The organic phase was washed with water,
dried with magnesium sulfate and filtered. The filtrate was
concentrated to half volume under vacuum and was heated to 55°.
Then 0.16 g of diisopropylethylamine was added, followed by the
* Trade-mark
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dropwise addition of 2.39 g of phenyl chloroformate. The
mixture was stirred at 55° for 1.25 hours, and 50 ml of to
sodium bicarbonate solution was added. The mixture was stirred
for ten minutes at 40-50°, and the phases were separated. The
organic phase was washed twice with 0.5 N hydrochloric acid, and
then washed with 1~ sodium bicarbonate solution. The washed
organic phase was divided in halt, and one aliquot was
evaporated under vacuum and 26 ml of dimethylsulfoxide was added
to the residue. The mixture was heated to 45°, and 1 g of
sodium hydroxide and 6 ml of water was added dropwise. The
basic mixture was stirred for 1~3 hours at 50°, diluted with 17
roil of water, and acidified to pI3 5.0-5.5 by addition of acetic
acid. Then 20 ml of hexane was added, the mixture was stirred
for ten minutes, and the phases 5eparaLed. Tl~c aqueous phase
was made basic to pH 10.5 by addition of 50o aqueous sodium
hydroxide, and 17 ml of ethyl acetate was added. After stirring
for 10 minutes, the phases were separated, and the aqueous layer
was extracted with another 17 ml of ethyl acetate. The combined
organic extracts were washed with water and concentrated to 10
ml under vacuum. 0.46 g of concentrated hydrochloric acid was
added to the residue, and then a seed crystal and an additional
10 ml of ethyl acetate was added. The mixture was stirred for
minutes more, and the solution was concentrated to 10 ml
under vacuum. The residue was stirred for 1 hour at ambient
25 temperature and 1 hour at 0° to produce a slurry, which was
filtered. The solid was washed with chilled ethyl acetate to
obtain 1.32 g of the desired product, which was duloxetine as a
white solid of potency 99.80.
30 The Disuse and Its Treatment
The method of the present invention is used to treat
and control urinary incontinence of either or both the stress
and urge types, in patients of any age in need of such
treatment. The cause of the stress, urge or mixed urinary
incontinence is not critical to the benefit of the present
invention. Incontinence caused by deterioration of the central
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nervous system, the peripheral nervous system, the muscles of
the bladder or urethra, and infections of bladder or urethra are
all effectively treated by the present method.
The types of urinary incontinence which have been
cal7.ed or caused by detrusor instability, interstitial cystitis,
and nocturnal enuresis of either the primary or secondary type,
are included within either stress or urge incontinence and are
effectively treated by the present method. Still further,
urinary incontinence brought about by pelvis surgery, anatomical
changes in the gPOmetry of the bladder and »retnra, l~rPthral
deterioration as a result of cessation of estrogen production,
and bladder hyperactivity are all effectively treated.
It will be demonstrated by the biological testing
examples which follow that the method of the present invention
has the astonishing ability to increase the effective volume of
the bladder, and simultaneously to increase the contractility
and nervous system control of the muscles which manage the
urethra. Accordingly, it is clear that the present invention
controls both urge incontinence, by increasing the effective
volume of the bladder and decreasing involuntary muscular
activity around the bladder, and stress incontinence, by
increasing voluntary control of the urethral sphincter and
improving tone of the urethral musculature.
Accordingly, the method of the present invention is
carried out simply by administering an incontinence-decreasing
dose of a compound of formula I, or venlafaxine, to a patient in
need of that treatment. The effective dose is variable, and
will always be determined by the physician in charge of'the
patient. Further, it should be noted that it may be necessary
to adjust the dose of a compound when it is administered in the
form of a salt such as, e.g., a laurate, the salt-forming moiety
of which has an appreciable molecular weight. In general,
however, the range of effective doses is from about 1 to about
50 mg/day per patient. A preferred rate range is from about 5
to about 20 mg/kg day. Of course, it is often practical to
administer the daily dose of a pharmaceutical compound in
portions, at various hours of the day.
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The route of administration of the compounds of this
invention is not critical. The compounds are absorbed from the
alimentary tract, and so it is usually preferred to administer
them orally, for convenience. They may be administered,
however, by any pharrnaceuLi~dlly d~~eptaLle rc~utr if desired in
a given instance.
The compounds of this invention are usually
administered as pharmaceutical compositions which, in
combination with appropriate instructions for administering the
composition in order to provide treatment for incontinence, are
important and novel embodiments of the invention. The patents
which teach the compounds also discuss the pharmaceutical
compositions. All of the usual types of pharmaceutical
compositions may be used, including tablets, chewable tablets,
capsules, solutions, parenteral solutions, suspensions,
suppositories, and troches. Compositions are preferably
formulated to contain a daily dose, or a convenient fraction of
a daily dose, in a dosage unit which may be a single solid
entity such as a tablet, or may be~convenient volume of a liquid
or semi-solid. The activity of the compounds does not depend on
the compositions in which they are administered or on the
concentration of the compositions, and thus, the compositions
are chosen and formulated solely for reasons of convenience and
economy in use. Any of the compounds may be readily formulated
as tablets, capsules and the like; it is obviously preferable to
prepare solutions, such as those for injection, from water-
soluble salts of the compounds.
In general all of the compositions are prepared
according to methods usual in pharmaceutical chemistry. A group
of typical formulae of compositions will be mentioned below, but
the principles of such formulations are so well known that no
detailed discussion will be provided.
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Hard gelatin capsules are prepared using the following
ingredients
Quantity
t mg~l~~~ s L ~ a 1
Duloxetine hydrochloride 5
Starch, dried 445
Magnesium stearate
Total 460 mg
A tablet is prepared using the ingredients below:
Quantity
(+) -N-methyl-3- ( 1-
naphthalenyloxy)-3-(2-
thiazolyl)propanamine
oxalate 10
Cellulose, microcrystalline 640
Silicon dioxide, fumed 10
Stearic acid
Total 665 mg
The components are blended and compressed to form
tablets each weighing 665 mg.
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An aerosol solution is prepared containing the
following components:
Weight
N-methyl-3-[~-
(tritluoromethyl)phenoxy]-3-
(2-furanyl)propanamine
maleate 0.25
Ethanol 29.75
Propellant 22
(Chlorodifluoromethane) 7000
Total 100.00
The active aomp~mnd is mixed with ethanol and the
mixture added to a portion of the propellant 22, cooled to -30°C
and transferred to a filling device. The required amount is
then fed to a stainless steel container and diluted with the
remainder of the propellant. The valve units are then fitted to
the container.
Tablets, each containing 20 mg of active ingredient,
are made as follows:
N,N-dimethyl-3-(4-methyl-1-
naphthalenyloxy)-3-(2-
thienyl)propanamine
phosphate 20 mg
Starch 85 mg
Microcrystalline cellulose 35 mg
Polyvinylpyrrolidone
(as 10~ solution in water)
~ mg
Sodium carboxymethyl starch 4.5 mg
Magnesium stearate 0.5 mg
Talc 1 ma
Total 150 mg
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The active ingredient, starch and cellulose are passed
through a No. 45 mesh U.S. sieve and mixed thoroughly. The
aqueous solution containing polyvinylpyrrolidone is mixed with
the resultant powder, and the mixture then is passed through a
No. 14 mesh U.S. sieve. The granules so produced are dried at
50° and passed through a No. 18 mesh U.S, sieve. The sodium
carboxymethyl starch, magnesium stearate and talc, previously
passed through a No. 60 mesh U.S. sieve, are then added to the
granules which, after mixing, are compressed on a tablet machine
to yield tablets each weighing 150 mg.
Formulation 5
(-) -N, N-dimethyl-3- ( 1-
naphthalenyloxy)-3-
(cyclohexyl)propanamine
oxalate 5 mg
Starch 134 mg
Microcrystalline cellulose 59 mg
Magnesium stearate 2 ma
Total 200 mg
The active ingredient, cellulose, starch, and
magnesium stearate are blended, passed through a No. 45 mesh
U.S. sieve, and filled into hard gelatine capsules in 200 mg
quantities.
Formulation 6
Suppositories, each containing 10 mg of active
ingredient, are made as follows:
(+) -N-methyl-3- ( 1-
naphthalenyloxy)-3-(3-
pyridyl)propanamine
hydrochloride 10 mg
Saturated fatty acid
glycerides x.000 ma
Total 2,010 mg
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The active ingredient is passed through a No. 60 mesh
U.S. sieve and suspended in the saturated fatty acid glycerides
previously melted using the minimum heat necessary. The mixture
is then poured into a suppository mold of nominal 2 g capacity
and allowed to cool.
Formulation 7
Suspensions, each containing 10 mg of active
ingredient per 5 ml dose, are made as follows:
N,N-dimethyl-3-(4-methoxyphenoxy)-
3-(2-thienyl)propanamine citrate 10 mg
S~dimi~ carboxymethyl cellulose 50 mg
Syrup 1.25 ml
Benzoic acid solution 0.10 ml
Flavor q.v.
Color q.v.
Purified water to total 5 ml
The active ingredient is passed through a No. 45 mesh
U.S, sieve and mixed with the soidum carboxymethyl cellulose and
syrup to form a smooth paste. The benzoic acid solution, flavor
and color are diluted with a portion of the water and added,
with stirring. Sufficient water is then added to produce the
required volume.
Formulation 8
An intravenous formulation may be prepared as follows:
(-) -N, N-dimethyl-3- ( 4-
chlorophenoxy)-3-(4-chloro-2-
thienyl)-propanamine succinate 100 mg
Isotonic saline 1,000 ml
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The solution of the above ingredients generally is
administered intravenously to a subject at a rate of 1 ml per
minute.
The amount of active ingredient incorporated into the
formulation of this invention is not critical; the concentration
should only be in a range sufficient to permit ready
administration of the formulation in an amount which will
deliver the desired amount of active ingredient. .
Example of Therapeutic Effect
Tests showing the powerful effect of the preferred
ccmi~r~uti~i i n rh~. t.reatmc~nt of both stress and urge incontincncc
are presentec.~here. It will be understood that the results
shown here are representative of the virtues of the invention in
its full scope.
Seven female cats (2.5-3.5 kg) were anesthetized with
alpha-chloralose (50-75 mg/kg i.v.) following induction with
isoflurane. A cannula was inserted into the trachea. One
catheter was inserted into the carotid artery for measuring
systemic blood pressure, and another was placed in the radial
vein for injecting drugs.
Cystometrograms (CMGs) were conducted via a catheter
(PE90) inserted through the dome of the bladder, which was used
for both saline infusion and for recording of intravesical
pressure. EMG electrodes were placed in the peri-urethral
striated muscle. CMG infusion rates ranged from 0.3 ml/min to 1
ml/min to achieve a micturition contraction within 10 minutes of
starting infusion. Micturition contractions were accompanied by
release of bladder contents, which was measured by collecting
the fluid in a cylinder attached to a force transducer. After
reaching micturition threshold, saline infusion was continued
and resulted in rhythmic bladder contractions and releases being
maintained. During this time of rhythmic bladder activity,
duloxetine was administered and its effects on rhythmic
contractions noted. Five minutes after duloxetine
administration, the bladder was emptied and another CMG
performed.
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In 3 of the 7 cats, efferent input to the bladder was
activated by electrically stimulating the pelvic nerve with
square-wave pulses of 0.05 msec, 10 Hz, sub-maximal intensity
(0.5-8V) and the resultant pressure increase was recorded.
Duloxetine was dissolved in 14o ethanol (10 mg/ml) and
diluted with saline to allow appropriate dose injection in a
volume of 0.1 - 0.3 ml/kg administered intravenously. Prazosin,
an al adrenergic receptor antagonist, (Sigma, St. Louis, MO) was
dissolved in dilute HCL to a concentration of 1 mg/ml and
diluted with saline to a concentration of 0.1 mg/ml. LY53857,
6-methyl-1-(1-methylethyl)ergoline-8-carboxylic acid, 2-hydroxy-
1-methylpropyl ester (Z)-2-butenedioate, a 5HT2 receptor
antagonist, was dissolved in saline with gentle warmin7.
Duloxetine produced dose-dependent increases in
bladder capacity in all 7 cats, to about five times the capacity
seen under control conditions (Figs. 1, 2, 4, and 5). Doses of
10 mg/kg (n=3) completely abolished micturition contractions
(infusions were stopped after reaching the tonus limb of the CMG
profile, which indicates that the elastic limits of the bladder
are being reached). The increase in bladder capacity was not
accompanied by changes in the amplitude or duration of the
contractions upon reaching micturition threshold volumes (Figs.
2, 3, 4, and 5). Similarly, there was no increase in the
residual volume of the bladder (calculated by subtracting the
amount released from the amount infused). Duloxetine also
reduced the frequency of micturition contractions (200 of
control frequency at 3 mg/kg) and proportionately increased the
amount of urine released with each contraction (5 fold at 3
mg/kg). The effects of duloxetine on bladder activity were seen
within 4 minutes of administration. No effects of duloxetine
were seen on bladder contractions evoked by maximal electrical
stimulation of efferent fibers in the pelvic nerve. LY53857 (3
mg/kg, i.v.), alone or in combination with prazosin (300 ~g/kg,
i.v.), did not reverse duloxetine's effects on bladder activity.
Under control conditions (Figs. 3 and 5), there was
very little peri-urethral muscle EMG activity during the filling
phase of the CMG.
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Within 4 minutes of duloxetine administration there
was a dose-dependent increase in peri-urethral muscle EMG
activity recorded during rhythmic bladder contractions produced
by continuous infusion. During the filling phase of the CMG,
activity increased (Figs. 2, 3, 4, and 5) to 8 times control
levels at a dose of 0.3 mg/kg with larger doses producing no
greater effect on average. Activity was also increased about 8
fold during the period immediately following the micturition
contraction. In the 4 cats that originally showed peri-urethral
activity during micturition contractions, the intermittent
periods of quiescence (i.e. bursting patterns) were maintained.
In t.hvse 3 c:al.5 l.liat displayed no urethral EMG activity during
bladder contractions under cnntrnl r_r~nciiti«ns, marker_i inhi?_~iti«n
of peri-uretliral sphincter activity was observed during bladder
contractions. In other words, despite the increase in peri-
urethral EMG activity during the filling phase of the CMG,
synergy between the bladder contraction and sphincter relaxation
was maintained in these latter 3 cats (Fig. 5).
In 4 of 6 cats, the increase in peri-urethral
sphincter EMG activity was completely abolished by LY53857 (100
- 300 ~g/kg, i.v.), a 5HT2 receptor antagonist (Fig. 4). In the
other 2 of 6 cats, LY53857 (100 ~.g/kg, i.v.) decreased peri-
urethral sphincter EMG activity to 50o and 330 of the
duloxetine-induced levels of activity, respectively, and larger
doses (to 3 mg/kg, i.v.) produced no further decrease (Fig. 5).
Subsequent administration of prazosin (100 ~.ig/kg, i.v.) did
abolish peri-urethral sphincter EMG activity (Fig. 5).
The results show that duloxetine increases bladder
capacity and peri-urethral (i.e. sphincteric) striated muscle
activity.
Concurrent with increases in peri-urethral EMG
activity, duloxetine also inhibited bladder activity, increasing
the bladder volume necessary to evoke micturition. Although
capacity was increased, there was no effect on the amplitude or
duration of the contractions once they were initiated. This
indicates that duloxetine increases the sensory threshold
necessary to elicit a micturition contraction, but it was not
effecting motor response of the contraction once the elevated
CA 02561293 1994-11-18
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micturition threshold was passed. This finding, and more
importantly the finding that there was no effect of duloxetine
on bladder contractions evoked by stimulation of peripheral
efferent axons in the pelvic nerve, indicates that the
inhibitory effects of duloxetine on bladder activity were
mediated centrally. It is also important to note that although
duloxetine increased urethral sphincter activity, the
synergistic interaction between bladder contraction and
sphincter activity was maintained.
The increase in bladder capacity by duloxetine
indicates utility for the treatment of urge incontinence, while
the increase in tonic peri-urethral sphincter EMG activity
indicates utility for stress incontinence. Since there is
c~.~rrcnfi 1 y nn .~, i ngl c~ nffert i vc~ t rc~atmcnt for hot.h t.ypc~~; ~f
urinary incontinence, such a compound provides a substantial
medical advancement for these patients. Since duloxetine had no
effect on the magnitude of the bladder contraction once it had
reached micturition threshold, micturition occurred as
efficiently as it had before drug treatment. This is important
in light of the fact that current incontinence medicines
(primarily anticholinergics) cause decreased efficiency of
micturition and increases in residual urine due to compromise of
bladder contractile force.
