OA12076A - Method and compositions for treating pulmonary diseases. - Google Patents

Abstract

This invention relates to treating pulmonary diseases such as chronic obstructive pulmonary disease or asthma by administering a phosphodiesterase 4 inhibitor in combination with anti-inflammatory corticosteroid.

Description

1 2076

Method and Compositions for Treating Pulmonary DiseasesArea of the Invention

This invention relates compositions and methods for preventing or reducing theonset of symptôme of pulmonary diseases, or treating or reducing the severity of pulmonarydiseases. In particular it relates to compositions and methods for treating pulmonarydiseases mediated by phosphodiesterase 4 (PDE4) by administering a PDE4 inhibitor withan anti-inflammatory corticosteroid.

Background of the Invention

Identification of novel therapeutic agents for treating pulmonary diseases is madedifficult by the fact that multiple mediators are responsible for the development of thedisease. Thus, it seems unlikely that eliminating the effects of a single mediator could hâvea substantial effect on ail three components of chronic asthma. An alternative to the"mediator approach" is to regulate the activity of the cells responsible for thepathophysiology of the disease.

One such way is by elevating levels of cAMP (adenosine cyclic 3',5-monophosphate). Cyclic AMP has been shown to be a second messenger mediating thebiologie responses to a wide range of hormones, neurotransmitters and drugs; [KrebsEndocrinology Proceedings of the 4th International Congress Excerpta Medica, 17-29, 1973], When the appropriate agonist binds to spécifie cell surface receptors, adenylatecyclase is activated, which converts Mg+^-ATP to cAMP at an accelerated rate.

Cyclic AMP modulâtes the activity of most, if not ail, of the cells that contribute to thepathophysiology of extrinsic (allergie) asthma. As such, an élévation of cAMP wouldproduce bénéficiai effects including: 1 ) airway smooth muscle relaxation, 2) inhibition ofmast cell mediator release, 3) suppression of neutrophil degranulation, 4) inhibition ofbasophil degranulation, and 5) inhibition of monocyte and macrophage activation. Hence,compounds that activate adenylate cyclase or inhibit phosphodiesterase should be effectivein suppressing tire inappropriate activation of airway smooth muscle and a wide variety ofinflammatory cells. The principal cellular mechanism for the inactivation of cAMP ishydrolysis of the 3'-phosphodiester bond by one or more of a family of isozymes referred toas cyclic nucléotide phosphodiesterases (PDEs).

It has been shown that a distinct cyclic nucléotide phosphodiesterase (PDE)isozyme, PDE4, is responsible for cAMP breakdown in airway smooth muscle andinflammatory cells. [Torphy, "Phosphodiesterase Isozymes: Potential Targets for NovelAnti-asthmatic Agents" in New Drugs for Asthma, Bames, ed. IBC Technical Services Ltd.,1989]. Research indicates that inhibition of this enzyme not only produces airway smoothmuscle relaxation, but also suppresses degranulation of mast cells, basophils andneutrophile along with inhibiting the activation of monocytes and neutrophils. Moreover, - 1 - 1 2076 the bénéficiai effects of PDE 4 inhibitors are markedly potentiated when adenylate cyclaseactivity of target celle is elevated by appropriate hormones or autocoids, as would be thecase in vivo. Thus PDE 4 inhibitors would be er *;ve in the lung, where levels ofprostaglandin E2 and prostacyclin (activators of adenylate cyclase) are elevated. Suchcompounds would offer a unique approach toward the pharmacotherapy of bronchialasthma and possess significant therapeutic advantages over agents currently on the market.

In addition, it could be useful to combine thérapies in light of the fact that theetioîogy of many pulmonary diseases involves multiple mediators. In this invention there ispresented the combination of a PDE 4 inhibitor and an anti-inflammatory corticosteroid,particularly one deiivered by inhalation, for treating pulmonary diseases. This combinationis particularly useiul for treating chronic obstructive pulmonary disease (COPD) or asthma.Suromarv of the Invention

In a first aspect this invention relates to a method for treating a pulmonary diseasein a mammal by administering to a patient in need thereof an effective amount of a PDE 4-specific inhibitor and an effective amount of a steroidal anti-inflammatory agent whereinthe drugs are administered concomitantly together or separately and sequentially where thesequential administration is close in time or remote in time.

In a second aspect this invention relates to a composition for treating a pulmonarydisease in a mammal comprising an effective amount of a PDE4-specific inhibitor, aneffective amount of a steroidal anti-inflammatory agent and a pharmaceutically acceptableexcipient.

Detailed Description of the Invention

The combination therapy contemplated by this invention comprises administering aPDE4 inhibitor with a steroidal anti-inflammatory agent to prevent onset of a pulmonarydisease event or to treat an existing condition. The compounds may be administeredtogether in a single dosage form. Or they may be administered as two differentformulations which inay be the same or different. To illustrate, both drugs may be providedseparately as oral formulations, or one may be an oral préparation and the other as aninhalant, or both may be provided in an inhaled dose form. They may be administered at thesame time. Or they may be administered either close in time or remotely, such as where onedrug is administered in the moming and the second drug is administered in the evening.

The combination may be used prophylactically or after the onset of symptoms. Insorne instances the combination(s) may be used to prevent the progression of a pulmonarydisease or to arrest the décliné of a function, such as lung function.

The PDE4-specific inhibitor useful in this invention may be any compound that isknown to inhibit the PDE4 enzyme or which is discovered to act in as PDE4 inhibitor, andwhich are only PDE4 inhibitors, not compounds which inhibit other members of the PDE -2- 1 2076 family as well as PDE4. Generally it is preferred to use a PDE4 antagonists which has anIC5Q ratio of about 0.1 or greater as regards the IC5Q for the PDE4 catalytic foim whichbinds rolipram with a high affinity divided by the IC5Q for the form which binds rolipramwith a low affinity. PDE inhibitors used in treating inflammation and as bronchodilators, drugs liketheophylline and pentoxyfyllin, inhibit PDE isozymes indiscriminately in ail tissues. Thesecompounds exhibit side effects, apparently because they non-selectively inhibit ail 5 PDEisozyme classes in ail tissues. The targeted disease State may be effectively treated by suchcompounds, but unwanted secondary effects may be exhibited which, if they could beavoided or minimized, would increase the overall therapeutic effect of this approach totreating certain disease States. For example, clinical studies with the sélective PDE 4inhibitor rolipram, which was being developed as an antidepressant, indicate it haspsychotropic activity and produces gastrointestinal effects, e.g., pyrosis, nausea and emesis.

For purposes of this disclosure, the cAMP catalytic site which binds R and Srolipram with a low affinity is denominated the "low affinity" binding site (LPDE 4) andthe other form of this catalytic site which binds rolipram with a high affinity is denominatedthe "high affinity" binding site (HPDE 4). This term "HPDE4" should not be confused withthe term "hPDE4" which is used to dénoté human PDE4.

Initial experiments were conducted to establish and validate a [3H]-roliprambinding assay. Details of this work are given in Example 1 below.

To détermine whether both the high affinity binding activity and the low affinitybinding activity resided in the same gene product, yeast were transformed by knownmethods and the expression of recombinant PDE 4 was followed over a 6 hour fermentationperiod. Western blot analysis using an antibody directed against PDE 4 indicated that theamount of PDE 4 expressed increased with time, reaching a maximum after 3 hour ofgrowth. In addition, greater than 90% of the immunoreactive product was in the high speed(100,000 x g) supematant of yeast lysâtes. [^H]R-(-)-Rolipram binding and PDE activitywere monitored along with protein expression. PDE 4 activity was co-expressed withrolipram binding activity, indicating that both functions exist on the same gene product.Similar to results with tire Western plot analysis, greater than 85% of the rolipram-inhibitable PDE activity and pH]-rolipram binding activity was found to be présent in theyeast supematant fraction.

Overall, most of the recombinant PDE 4 expressed in this System exists as LPDE 4and only a srnall fraction as HPDE 4. Consequently, inhibition of recombinant PDE 4catalytic activity priinarily reflects the actions of compounds at LPDE 4. Inhibition of PDE4 catalytic activity can thus be used as an index of the potency of compounds at LPDE 4.The potency of compounds at HPDE 4 can be assessed by examining their ability to -3- 1 2076 compete for [3H]R-rolipram. To develop SARs for both the iow affinity and high affinityrolipram binding sites, the potencies of selected compounds were determined in two assaySystems. Results from experiments using standard compounds were tabulated. Asexpected, certain compounds were clearly more potent in competing with pHj-roiipram atthe site for which rolipram demonstrated high affinity binding as compared with the othersite, the one at which rolipram is a low affinity binder. SAR corrélation between highaffinity binding and low affinity binding was poor and it was concluded that the SAR forinhibition of high affinity pH]-rolipram binding was distinct from the SAR for binding tothe low affinity rolipram binding site.

It is now known that there are at least two binding forms on human monocyterecombinant PDE 4 (hPDE 4) with which inhibitors interact. One explanation for theseobservations is that hPDE 4 exists in two distinct forms. One binds the likes of rolipramand denbufylline with a high affinity while the other binds these compounds with a lowaffinity. The preferred PDE4 inhibitors of use in this invention will be those compoundswhich hâve a salutary therapeutic ratio, i.e., compounds which preferentially inhibit cAMPcatalytic activity where the enzyme is in the form that binds rolipram with a low affinity,thereby reducing the side effects which apparently are linked to inhibiting the form whichbinds rolipram with a high affinity. Another way to State this is that the preferredcompounds will hâve an IC5Q ratio of about 0.1 or greater as regards the IC50 for the PDE4 catalytic form which binds rolipram with a high affinity divided by the IC5Q for the formwhich binds rolipram with a low affinity. A further refinement of this standard is that of one wherein the PDE4 inhibitor hasan IC5Q ratio of about 0.1 or greater; said ratio is the ratio of the IC5Q value for competingwith the binding of lnM of pH]R-rolipram to a form of PDE4 which binds rolipram with ahigh affinity over the IC5Q value for inhibiting the PDE4 catalytic activity of a form whichbinds rolipram with a low affinity using 1 microM(^H]-cAMP as the substrate. A furtherreview explanation with of this test can be found in co-pending U.S. application 08/456274filed 31 May 1995, the text of which is incorporated herein by reference to the extent thattext is necessary to the practice of this invention.

Examples of useful PDE4 inhibitors are: (R)-(+)-l-(4-bromobenzyl)-4-[(3-cyclopentyloxy)-4-methoxyphenyl]-2-pyrroîidone; (R)-(+)-l-(4-bromobenzyl)-4-[(3-cyclopentyloxy)-4-methoxypheny]]-2-pyrrolidone, 3-(cyclopentyloxy~4-methoxyphenyl)-1 -(4-N'-[N2-cyano-S-methy 1-isothioureido]benzyl)-2-pyrrolidone, cis 4-cyano-4-(3-cyclopentyloxy-4-methoxyphenyl)cyclohexan-1 -carboxylic acid];cis-[4-cyano-4-(3-cyclopropylmethoxy-4-difluoromethoxyphenyl)cyclohexan-l-ol];(R)-(+)~ethyl [4-(3-cyclopentyioxy-4-methoxyphenyl)pyrrolidine-2-ylidene]acetate; -4- 1 2076 (S)-(-)-ethyl [4-(3-cyclopentyloxy-4-methoxyphenyl)pyrrolidine-2-ylidene]acetate,Most preferred are those PDE 4 inhibitors which hâve an IC50 ratio of greater than 0.5, and particularly those compounds having a ratio of greater than 1.0. Preferredcompounds are cis 4-cyano-4-(3-cyclopentyloxy-4-methoxyphenyl)cyclohexan-l-carboxylicacid, 2-carbomethoxy-4-cyano-4-(3~cyclopropylmethoxy-4- difluoromethoxyphenyl)cyclohexan-l-one, and is-[4-cyano-4-(3-cyclopropylmethoxy-4-difluoromethoxyphenyl)cyclohexan-l-ol]; these are examples of compounds which bindpreferentially to the low afïinity binding site and which hâve an IC5Q ratio of 0.1 or greater.

Compounds set outinU.S. patent 5,552,438 issued 03 September, 1996. Thispatent and the compounds it discloses are incorporated herein in full by reference. Thecompound of particular interest, which is disclosed in U.S. patent 5,552,438, is cw-4-cyano- 4-[3- (cyclopentyloxy)-4-methoxyphenyl]cyclohexane-l-carboxylic acid and its salts, esters,pro-drugs or physical forms. AWD-12-281 from Astra (Hofgen, N. et al. 15th EFMC Int Symp Med Chem (Sept 6-10, Edinburgh) 1998, Abst P.98); a 9-benzyladenine dérivative nominated NCS-613(INSERM); D-44Î8 from Chiroscience and Schering-Plough; a benzodiazépine PDE4inhibitor identified as CI-1018 (PD-168787; Parke-Davis/Wamer-Lambert); a benzodioxoledérivative Kyowa Hakko disclosed in WO 9916766; V-l 1294A from Napp (Landells, LJ.et al. Eur Resp J [Annu Cong Eut Resp Soc (Sept 19-23, Geneva) 1998] 1998, 12(Suppl. 28): Abst P2393); roflumilast (CAS reference No 162401-32-3) and a pthalazinone (WO9947505) from Byk-Gulden; or a compound identified as T-440 (Tanabe Seiyaku; Fuji, K.et al. J Pharmacol Exp Ther,l998, 284(1): 162). Any one or ali of these compounds may orcould benefit from the process described herein.

The several spécifie compounds set out above which do not hâve a generic or tradename can be made by the processed described in co-pending U.S. patent applications USSN862,083 filed 30 October 1992; USSN 862, 111 filed 30 October 1992; USSN 862,030 filed30 October 1992; and USSN 862,114 filed 30 October 1992 or their progeny or U.S.patent(s) claiming priority from one or more of these applications. Each of theseapplications or related patents is incorporated herein by reference in full as if set out in thisdocument.

The steroid agents useful in this invention are oral and inhaled corticosteroids andtheir pro-drugs which hâve anti-inflammatory activity. Examples of these steroids aremethyl prednisolone, prednisone, dexamethasone, fluticasone, beclomethasone, budesonide,fiunisolide, mometasone furoate, and triamcinolone acetonide. Methyl prednisolone andprednisone are oral and injectable forms of anti-inflammatory corticosteroids; they areavailable from numerous branded and generic pharmaceutical companies. Beclomethasonedipropionate is sold as an aérosol for inhalation under the names Beconase® and Beconase -5- 1 2076 AQ® by Glaxo Wellcome. Fluticasone propionate is sold under the name Flonase® byGlaxo Wellcome as well. Triamcinolone acetonide is sold by Rhone-Poulenc Roher underthe name Nasacort ® as a nasal spray and aérosol. Flunisolide is sold as a nasal solutionunder the name Nasalide® and Nasarel TM by Roche Laboratories. Dexamethasone is soldas the sodium phosphate sait by Medeva Pharmaceuticals, Inc. under the name Dexacort™Phosphate. Mometasone furoate is sold as the monohydrate as a nasal préparation bySchering Corp under the name Nasonex®. Budesonide is yet another inhaled corticosteriodused in treating pulmonary diseases. It is market by Astra Pharmaceuticals, L.P. as apowder in a turbohaler device under the name Pulmicort Turbohaler®. Ail of these drugsand nasal préparations or oral or injectable formulations can be found in the 1999 édition ofthe Physicians' Desk Reference® (PDR), published by Medical Economies Corporation,

Inc, of New Jersey, USA and is available on the Internet at http://www.tomescps.com/ffaMain.asp?Mnu=0 and linked pages. Additional corticosteroidsnow under development and which could be used in this invention are set out in Table I.

Table I

Inhaled Corticosteroids

Drug Company Indication mometasone furoate Schering-Plough asthma SAR rofleponide AstraZeneca asthma ciclesonide Byk-Gulden/ Recordati asthma butixocort propionate Wamer-Lambert/3M asthma/rhinitis RPR-106541 Rhone-Poulenc Rorer asthma ST-126 SSP/Torii asthma A preferred combination therapy is that of one or more of dexamethasone,fluticasone, beclomethasone, budesonide, flunisolide, mometasone furoate, andtriamcinolone acetonide administered with cis 4-cyano-4-(3-cyclopentyloxy-4-methoxyphenyl)cyclohexan-l-carboxylic acid, cilomalast (Ariflo®). A preferred therapy isconcomitant administr ation of the steroid as an inhalant and the acid in an oral dose form,wherein each drug is administered once or twice a day. In regards to the acid, a controlled-release oral tablet is most preferred.

It is contemplated that both active agents would be administered at the same time,or very close in time. Altematively, one drug could be taken in the moming and one later inthe day. Or in another scénario, one drug could be taken twice daily and the other oncedaily, either at the same time as one of the twice-a-day dosing occurred, or separateîy.Preferably both drugs would be taken together at the same time. -6- 1 2076

The présent compounds and pharmaceutically acceptable salts which are activewhen given orally can be formulated as syrups, tablets, capsules, controlled-releasepréparation or lozenges. A syrup formulation will generally consist of a suspension orsolution of the compound or sait in a liquid carrier for example, éthanol, peanut oil. oliveoil, glycerin or water with a flavoring or coloring agent. Where the composition is in thefonn of a tablet, any pharmaceutical carrier routinely used for preparing solid formulationsmay be used. Examples of such carriers include magnésium stéarate, terra alba, talc,gelatin, acacia, stearic acid, starch, lactose and sucrose. Where the composition is in theform of a capsule, any routine encapsulation is suitable, for example using theaforementioned carriers in a hard gelatin capsule shell. Where the composition is in theform of a soft gelatin shell capsule any pharmaceutical carrier routinely used for preparingdispersions or suspensions may be considered, for example aqueous gums, celluloses,silicates or oils, and are incorporated in a soft gelatin capsule shell.

Typical parentéral compositions consist of a solution or suspension of a compoundor sait in a stérile aqueous or non-aqueous carrier optionally containing a parenterallyacceptable oil, for example polyethylene glycol, polyvinylpyrrolidone, îecithin, arachis oilor sesame oil.

Typical compositions for inhalation are in the form of a solution, suspension orémulsion that may be administered as a dry powder or in the form of an aérosol using aconventional propellant such as fluroinated hydrocarbons such as trichlorofluoromethane.

Preferably the composition for the PDE4 inhibitors is a unit dosage form such as atablet or capsule. For the steroids a metered aérosol dose, rnetered dry powder inhaler ornasal spray is preferred

The active ingrédient may be administered ffom 1 to 6 times a day, sufficient toexhibit the desired activity. Preferably, the active ingrédient is administered about once ortwice a day, more preferably twice a day.

The présent compounds are useful for the treatment of exercise-induced asthma(EIA), pollution-induced asthma (PIA) and cold-induced asthma (CIA), both as chronicconditions as welî as intermittently, in anticipation of the stimulus in question. Preferably,the présent compounds are used for long-term therapy.

As for the amount of drug administered, it is believed that for the PDE4 inhibitorswill be administered in an amount of between 1 and 200 micrograms per day per adulthuman. Steroids can be administered in conformity with approved labeling. -7- 12076 1

Example 1 — Phosphodiesterase and Rolipram Binding Assavs

Example IA

Isolated human monocyte PDE 4 and hrPDE (human recombinant PDE4) wasdetermined to exist primarily in the low affinity form. Hence, the activity of testcompounds against the low affinity form of PDE 4 can be assessed using standard assaysfor PDE 4 catalytic activity employing 1 microM pH]cAMP as a substrate (Torphy et al., J.ofBiol. Chem., Vol. 267, No. 3 ppl798-18O4,1992).

Rat brain high speed supematants were used as a source of protein and bothenantionmers of pH]-rolipram were preparedto a spécifie activity of25.6 Ci/mmol.Standard assay conditions were modified from the published procedure to be identical tothe PDE assay conditions, except for the last of the cAMP: 50mM Tris HCl (pH 7.5), 5mM MgCl2, 50 microM 5-AMP and 1 nM of pH]-rolipram (Torphy et al., J. ofBiol.Chem., Vol. 267, No. 3 ppl798-18O4,1992). The assay was run for 1 hour at 30° C. Thereaction was terminated and bound ligand was separated front free ligand using a Brandelcell harvester. Compétition for the high affinity binding site was assessed under conditionsthat were identical to those used for measuring low affinity PDE activity, expect that pH]-cAMP was not présent.

Example IB

Measurcmcnt <>f Phosphodicstcrase Activity PDE activity was assayed using a pH]cAMP SPA or [-'H]cGMP SPA enzymeassay as described by the supplier (Amersham Life Sciences]. The réactions wereconducied in 96-well plates a! room température, in 0.1 ml of reaction bufïer containing(final concentrations): 50 mM Tris-llCl. pH 7.5. 8.5 mM MgCl2. 1.7 mM EGTA.PHjcAMP or [-'HJ cGMP (approximately 2000 dpni pmol). enzyme and varionsconcentrations of the inhibitors. The assay was alioweri to proceed for 1 hr and w<k terminated by adding 50 ul of SPA yttrium silicate bonds tn the présence of zinc sullate.

The plates were shaken and allowed to stand at room température for 20 min. Radioiabeleuproduct formation was assessed by scintillation spectrometry. pH|R-roiipram binding nssm

The pH]R-rolipram binding assay was performed by modification of the method ofSchneider and co-workers. .->ee Nicholsou. et al.. Trends Phannacoi. Set.. Vol. 12. pp.19-2" ( 19oi ) and McHale et ah. Moi. Piiarmaco!.. Vol. 59, Ι09-Γ.3 ( >9o] ). R-Rolipram binds tothe catalytic site of PDE4 see Torphy et al., Mol. Pharmacol., Vol. 39, pp. 376-384 (1991).Consequently, compétition for pHJR-rolipram binding provides an independentconfirmation of the PDE4 inhibitor potencies of unlabeled competitors. The assay wasperformed at 30°C for 1 hr in 0.5 ul buffer containing (final concentrations); 50 mM Tris-HC1, pH 7.5, 5 mM MgC12, 0.05% bovine sérum albumin, 2 nM pH]R-rolipram (5.7 x 104 -8- 12076 1 dpm/pmol) and various concentrations of non-radiolabeled inhibitors. The reaction wasstopped by the addition of 2.5 ml of ice-cold reaction buffer (without pH]-R-rolipram) andrapid vacuum filtration (Brandel Cell Harvester) through Whatman GF/B filters that hadbeen soaked in 03% poiyethylenimine. The filters were washed with an additionaî 7.5-mlof cold buffer, dried, and counted via liquid scintillation spectrometry.

Example 2

Cilomalast/Low dose Inhaled Corticosteroid (ICS), Dose-ranging StudyStudy Design: • This was a phase HB, randomised, placebo-controlled, dose-ranging studywith a one-week single-blind placebo run-in, a 6-week double-blindtreatment phase and a one-week follow-up phase in patients withmild/moderate asthma. • Study population: Male or female patients aged between 18 and 70 years,with mild to moderate asthma, who were not adequately controlled on lowdoses of inhaled corticosteroids (no greater than 500 mcg beclomethasonedipropionate/day or équivalent) were eligible. Patients were required to hâvea screening FEV } of > 50% and < 80% predicted for height, âge, sex andrace and a 12% or greater reversibility after beta-2 agonist administration.Patients had to hâve a summary symptom score of 6 or more on 4 out of 7 days preceding the baseline visit to be randomised. The sample size was300 évaluable patients. • cilomalast was dosed at 5 mg, 10 mg 15 mg twice daily for 6 weeks. » Subjects were on a médian of 500 mcg of beclomethasone équivalent although themean dose of ICS was 652 mcg. • Primary endpoint: change from baseline to endpoint in trough clinic expiratoryvolume in 1 second (FEV}), changes in clinic FEVj every week and over a 4hour period following first dose of double-blind médication. ® Secondary endpoints: use of rescue medicines and ovemight symptoms. • Tertiarty endpoints: clinic forced vital capacity (FVC), clinic peak expiratoryflow rate (PEFR), forced expiratory flow at 25-75% (FEF25-75) and 75%(FEF75), domiciliary PEFR variability, domiciliary PEFR, summary symptom scores.

Evaluation Criteria

The primary efficacy measure was defmed as the change from baseline toendpoint in trough clinic forced expiratory volume in 1 second (FEV}). Changes in -9- 1 2076 clinic FEV j were also analysed at each week of the double-blind treatment phaseand over a 4-hour period immediately following the fïrst dose of double-blindmédication. Secondary efficacy variables were use of inhaled/nebulised beta-2agonist and ovemight asthma symptoms. Tertiaiy efficacy variables were forced vitalcapacity (FVC), clinic peak expiratory flow rate (PEFR), forced expiratory flow at25-75% (FEF25-75) and 75% (FEF75), domiciliary PEFR variability, domiciliaryPEFR (moming and evening), summary symptom score (a composite score ofovemight, moming and overall daytime asthma), moming asthma, overall daytimeasthma, inhaled corticosteroid use, cough, wheeze, breathlessness/chest tightness,asthma exacerbation rates and global assessments by the physician and the patient.

Study Results: • No statistical improvement in trough FEV j at endpoint ITT analysis 15 mgcilomalast BID vs placebo ( 0.16 L; p=0.062) • Response was dose-ordered for trough FEV j at endpoint ITT analysis

» Significant improvement in trough FEVj (0.21 L; p=0.033) if excluded patients onICS doses > 500 mcg of beclamethasone while on cilomalast 15 mg BID • Corroborating support for cilomalast 15 mg BID included 4 hour FEV1, domiciliaryPEFR, FEF25-75 and physician and patient global assessment scores

Example 3

Cilomalast/High dose Inhaled Corticosteriod (ICS) Study

Study Design: • R, DB, PC, DR in patients with mild/moderate asthma on > 800 mcg ofbeclomethasone ® cilomalast® doses were 5, 10 and 15 mg twice daily for 4 weeks. • 2 week run-in. • Primary endpoint: trough clinic FEV j. • Secondary endpoints: moming PEFR, symptoms, PEFR variability, evening PEFR,clinic PEFR, FEF25-75, FEF75, rescue médication used.

Study Results: • No statistically significant change in clinic trough FEV ] in any dose group wasnoted in the ΓΓΤ analysis • No dose ordering was observed for the primary endpoint • Trough FEV j statistically improved at 10 mg of cilomalast BID using repeatedmeasures analysis is patients excluded on < 800 mcg of ICS (0.16 L; p=0.009) - 10- 1 2076 ’ ICS (beciamethasone) dose ranged from 100 to 4000 me g and averaged 1136 meg* Corroborative support for the 10 mg of cilomalast B1D as the effective dose aiso

came from numerically superior results in the 4 hour clinic FEV1, cîinic FVC,PEFR 5 * No dose-response lelationship could be determined, trough concentrations were dose proportionai and similar to previous studies.

Table 1

Comparison between compounds in selected studiesAllergen challenge studies

Legend·. Data on cilomalast was taken from the protocol analysis in asthma patients on <652 meg of ICS. Data on montelukast (MT), budesonide (BDP) and both was taken from asingle study in the Singulair SBA that examined the effect of Singulair relative to inhaled 15 corticosteroids.

There aie significant différences between the behavior of the placebo (Pbo) groupsin both studies. Conclusion is that cilomalast outperformed Singulair when added to lowdose ICS, despite the fact that the Pbo group also improved in the cilomalast study.

The foregoing statements and examples are intended to illustrate the invention, not20 to limit it. Reference is made to the daims for what is reserved to the inventors hereunder. - 11 -

Claims (2)

1. Use of a PDE 4 inhibitor and an anti-inflammatory corticosteroid in a combined form, orseparately, in the manufacture of a médicament for use in a method of treating a pulmonarydisease.

1 2076 What is claimed is:

2. Use according to claim 1 wherein the PDE4 inhibitor is cis 4-cyano-4-(3-cyclopentyloxy-4-methoxyphenyl)cyclohexan-l-carboxylic acid and the steroid is selected from the groupconsisting of dexamethasone, fluticasone, beclomethasone, budesonide, flunisolide, mometasonefuroate and triamcinolone acetonide. -ta-