Pharmaceutical formulations and uses thereof in the treatment of female sexual dysfunction.

(54) Title: PHARMACEUTICAL FORMULATIONS AND USES OF THE SAME IN THE TREATMENT OF FEMALE SEXUAL DYSFUNCTION.

(54) Title: PHARMACEUTICAL FORMULATIONS AND USES THEREOF IN THE TREATMENT OF FEMALE SEXUAL DYSFUNCTION.

(57) Summary

The present invention relates to the use of a combination of a PDE5 inhibitor and testosterone for the preparation of a medicament for the treatment of Female Sexual Dysfunction.

(57) Abstract

The present invention relates to the use of a combination of a PDE5-inhibitor and testosterone for the preparation of a medication for the treatment of Female Sexual Dysfunction.

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Industrial L_j

Mexican Property Institute

PATENT TITLE NO. 347237

Owner (s): EB IR LYBRIDO BV

Address: Louís Armstrongweg 78, 1311, RL Almere, THE NETHERLANDS

Name: PHARMACEUTICAL FORMULATIONS AND USES OF THE SAME IN THE TREATMENT OF FEMALE SEXUAL DYSFUNCTION.

Classification: lnt.CI.8: A61K31 / 519; A61K31 / 53; A61K45 / 06; A61P15 / 00

Inventor (s): JAN JOHAN ADRIAAN TUITEN

Number:

MX / a / 2013/000851

REQUEST

VWW: International filing date! May 11, 2005

I Divisional Patent Number: 309819; PRIORITY

Country:

EP EP EP EP EP

<td> 1 4</td><td>Date:</td><td>Number: Ϊ</td>

<td></td><td>May 11, 2004</td><td> 04076402.9=</td>

<td></td><td>November 4, 2004</td><td> 04078033.0</td>

<td>i</td><td>December 13, 2004</td><td> 04078380.5</td>

<td>i</td><td>December 13, 2004</td><td> 04078381.3</td>

<td>i</td><td>December 21, 2004</td><td> 04078455.5-</td>

Validity: Twenty year ^

Expiration Date: May 11, 2025

The reference patent was granted based on articles 1, 2^or fraction V, 6^or HI fraction. and 59 of the Industrial Property Law.

In accordance with article 23 of the Industrial Property Law, this patent is valid for twenty years, non-extendable, counted from the filing date of the international application and will be subject to the payment of the fee to keep the rights in force. .

Whoever signs this title does so based on the provisions of articles 6^or Sections III and 7 “bis 2 of the Industrial Property Law (Official Gazette of the Federation (DOF) 06/27/1991, amended on 08/02/1994, 10/25/1996, 12/26/1997, 17 / 05/1999, 26/01/2004, 16/06/2005, 25/01/2008, 06/05 / 2009,06 / 01/2010, 18/06/2010, 28/06/2010, 27/01 / 2012 and 04/09/2012); Articles 1, 3^or fraction V part a), 4^or and 12th sections I and III of the Regulations of the Mexican Institute of Industrial Property (DOF 12/14/1999, amended on 07/01/2002, 07/15/2004, 07/28/2004 and 09/07/2007) ; Articles 1, 3^or, 4°, 5^or Section V subsection a), 16 sections I and III and 30 of the Organic Statute of the Mexican Institute of Industrial Property (DOF 12/27/1999, amended on 10/10/2002, 07/29/2004, 08/04/2004 and 09/13/2007); 1st, 3^orand 5th subsection a) of the Agreement that delegates powers to the Deputy General Directors, Coordinator, Divisional Directors, Heads of Regional Offices, Divisional Deputy Directors, Departmental Coordinators and other subordinates of the Mexican Institute of Industrial Property. (DOF 12/15/1999, amended on 02/04/2000, 07/29/2004, 08/04/2004 and 09/13/2007).

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MEXICAN INCTHVTO DE LA MOEIEDAP industrial

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PHARMACEUTICAL FORMULATIONS AND USES OF THE SAME IN THE _____ TREATMENT OF FEMALE SEXUAL DYSFUNCTION

DESCRIPTION OF THE INVENTION

The invention relates to the field of female sexual dysfunction. This is especially related to the influence of the combination of testosterone or an analog of it and a PDE5 inhibitor (such as sildenafil, vardenafil or tadalafil) on sexual health in female subjects with female sexual dysfunction (such as Arousal Disorder Female Sexual Desire (FSAD) or Female Sexual Desire Disorder (FSDD)

Female Sexual Dysfunction (FSD) refers to various disturbances or impairments of sexual function, including a lack of interest in sexual activity, repeated failure to achieve or maintain sexual arousal, inability to achieve orgasm after sufficient arousal. A recent study estimates that 43% of women suffer from sexual dysfunction in the United States¹ Low sexual desire (22% prevalence) and sexual arousal problems (14% prevalence) belong to the most common categories of sexual dysfunction in women.These categories are convenient for providing job definitions and a vocabulary acceptable to women. researchers and therapists However, it may be incorrect to assume that these

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INSTITUTO MUaolMO MUHOHEDAD INDUSTRIAL disorders are completely independent ..... maintaining case studies such as epidemiological studies show that these disorders can overlap and can be interdependent In some cases, it may be possible to identify the primary disorder that led to the others, but in many cases this may be impossible

Numerous different treatments have been suggested and applied for the treatment of female sexual disorder, with varying degrees of success. These treatments have not been completely successful or the side effects are hardly acceptable. The present invention provides a new combination of therapeutic substances, given a particular dose scheme, which combination is effective and does not have serious side effects.

Thus the invention provides the use of a combination of PDE5 inhibitor and testosterone or an analog thereof, in the preparation of a medicament for the treatment of female sexual dysfunction according to the invention, although it is not considered limited by the theory, an effect on the central nervous system and the peripheral system is required, Therefore, the signal to the central system is provided by testosterone or an analog of it (which has a little activity) and the peripheral signal is provided by a PDE5 inhibitor According to the invention the level of free testosterone should

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IΜ ΡΙ

ΙΜΠΤΤυΤΟ M1UCANO Dt LA PHOPItCMB INDUSTRIAL be a peak plasma level of free testosterone of at least about 0 010 nmol / 1, which typically occurs about 20 after the administration of testosterone. According to the invention, the effect of the peak plasma level of at least 0 010 nmol / 1 of free testosterone should be reached approximately at the same time as the effect of the PDE-5 inhibitor. For an optical effect it is desirable that the peak effect of both compounds match. However, even if the peak effects only partially overlap, this will result in the desired effect (FSD treatment) There is a time span for the effect of testosterone (or analog) of about 3-6 (so more specific about 3-4 5) hours, in particular about 4 hours PDE-5 inhibitors such as vardenafil and sildenafil typically reach their peak plasma concentration (which should be at least 35 ng / ml for sildenafil, 2 μυ / ύ for vardenafil and 40 pg / ml L for tadalafil) after approximately 1 hour after administration and thus the two drugs are presented as a set of parts with instructions on administration, or they are packaged in a page or formula with differential release properties for the two compounds

Testosterone in the circulation is typically bound by SHBG (hormone binding globulin

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a'nrruTOMaacM'o steroid) and by albumin, It is important that the plasma peak of testosterone as defined in the present invention is present and is calculated as free testosterone, as well as a fraction not bound by albumin and SHBG. Thus the testosterone dose should be high enough to saturate albumin and SHBG (i.e. the testosterone concentration should be high enough to overcome the complete binding of testosterone by SHBG or albumin), or another way should be designed to avoiding binding to albumin or SHBG, such as using a competitor for the binding site on testosterone on SHBG,

Testosterone is preferably given in a formulation where there is a short height peak in the blood circulation of the subject to which it was administered The invention therefore provides a use, where testosterone or an analog thereof is provided in the form of a sublingual formulation, preferably a sublingual formulation comprising cyclodextrins as a carrier. A. The typical effect of that formulation is hydroxypropyl-beta cyclodextrin, but other beta cyclodextrins and other usual excipients, diluents and the like are within the skill of the art to prepare a formulation comprising testosterone or a craving for it, which essentially releases all

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IMPI tstttotomoKno 'DthA rwofttDA »INDUSTRIAL testosterone within a ror ^ a burst, That burst will typically be within a short time interval (eg within 60-120 seconds, more preferably within 60 seconds) after administration , leading to peak blood levels of testosterone approximately 15-20 minutes later In a preferred embodiment, the drug is designed for sublingual administration and even more preferably the composition comprises cyclodextrin such as hydroxypropylbeta cyclodextrin, A typical example of a prepared testosterone sample (for 0 5 mg of testosterone) contains 0 5 mg of testosterone, 5 mg of hydroxypropylbetacyclodextrins (support), 5 mg of ethanol and 5 ml of water, but each of the amounts of this substance can be greater or less

Of course the pharmaceutical preparation comprising PDE5 inhibitor will also be designed to give a peak level in plasma at approximately the time when the effect of testosterone is maximum, Those compositions are within the knowledge of the art, a typical example for an oral administration occurs in vardenafil HC1 which is designated solely as piperazine, 1 - [[3- (1,4-dihydro-5-methyl-4-oxo-7-propyllimidazo [5,1-f] [1,2,4] triacin-2-yl) -4-ethoxyphenyl] sulfonyl] -4-ethyl-, monohydrochloride In addition to the active ingredient, vardenafil HC1, each tablet contains

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microcrystalline cellulose, crospovidone, colloidal silicon dioxide, magnesium stearate, hypromellose, polyethylene glycol, titanium dioxide, yellow ferric oxide, and red ferric oxide Another example is sildenafil citrate which is chemically designated as citrate. - [[3- (6,7-dihydro-1-methyl-7-oxo-3-propyl-1H-pyrazolo [4,3-d] pyrimidin-5-yl) -4-ethoxyphenyl] sulfonyl] -4-methylpiperazine. In addition to the active ingredient, sildenafil citrate, each tablet contains the following ingredients microcrystalline cellulose, anhydrous dibasic calcium phosphate, croscarmellose sodium, magnesium stearate, hydroxypropylmethylcellulose, titanium dioxide, lactose, triacetin, and Aluminum Lake Blue # 2 FD &amp; C Another example is given by tadalafil which is chemically designated as pyrazino [1 ', 2' 1,6] pyrido [3,4-b] indole-1,4-dione, 6- (1,3benzodioxol-5-yl) -2,3,6,7,12,12a-hexahydro-2-methyl-, (6R, 12aR) - In addition to the active ingredient, tadalafil, each tablet contains the following ingredients croscarmellose sodium, hydroxypropyl cellulose, hypromellose, iron oxide, lactose monohydrate, magnesium stearate, microcrystalline cellulose, sodium lauryl sulfate, talc, titanium dioxide, and triacetin.

It is clear that preferably the effect (peak) of the PDE5 inhibitor as well as the effect (peak) of testosterone coincide (completely).

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Note that if the peak effect of the - and ...... ^ ~ PDE5 inhibitor only partially overlaps this will result in the desired effect When testosterone is delivered so that it releases essentially all of the testosterone within one burst cuts to a female subject, the PDE5 inhibitor is preferably provided so that a peak plasma concentration results at least 3 hours after administration of the testosterone. More preferably, the effect of PDE5-I is present 3-5 hours after consumption of the testosterone. It is clear that the exact time of administration of the PDE5 inhibitor depends on the type of formulation used. If the PDE5 inhibitor formulation is released shortly after administration, it is not useful to provide it at the same time as the testosterone is provided, since the effects will hardly overlap If it takes some time before the PDE5 inhibitor is available of the formulation used, for example 3 to 4 hours, this can be / is administered at the same time as testosterone is administered.

For the present invention the route of administration of choice is those which are invasive merfos. Motivation for sexual behavior should not be negatively influenced by invasive routes of administration. Because there is a time lapse in

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Mexican nvmrvTo DCl ^ HlOUSDAD

IMPI effect of testosterone, the two drugs necessary for a central effect and a peripheral effect cannot be administered at the same time (unless the administration of the PDE5 inhibitor is designed so that the drug is released after 3-5 hours after administration) The invention therefore provides a kit of parts comprising at least one pharmaceutical composition comprising testosterone or an analog thereof and at least one pharmaceutical composition comprising a PDE5 inhibitor, thus the composition comprising testosterone designed to release all testosterone essentially immediately (for example within 60 seconds) at the target site The kit preferably contains instructions for using a pharmaceutical composition comprising testosterone 3 5-5 5 hours before of sexual activity and a pharmaceutical composition comprising a PDE5 inhibitor 1-2 hours prior to sexual activity The kit of parts may comprise a Sublingual formulation of testosterone or an analog thereof or a tablet or other formulation comprising a PDE5 inhibitor Preferred PDE-5 inhibitors are sildenafil, vardenafil or tadalafil The amount of pharmaceutical testosterone comprising testosterone is at least 0 3 mg of testosterone and at least 2 5 mg of testosterone Higher or lower doses may be necessary depending on the

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albumin and SVG levels and the weight of the subject to be treated.The pharmaceutical composition comprising a PDE5 inhibitor comprises at least 25 mg of sildenafil (or 5 mg of vardenafil, or 5 mg of tadalafil) and in addition 100 mg of sildenafil (or 20 mg of vardenafil, or 20 mg of tadalafil), or comparable doses of other PDE5 inhibitors Again these doses may vary with the weight of the patient For the reasons already explained above, a kit according to the invention may further comprise a compound capable of competing with testosterone or an analog thereof for binding to SHBG)

In a preferred embodiment, the testosterone analog is a metabolic precursor to testosterone. In the case that a testosterone precursor is used, the kit also includes instructions to (if necessary) increase the period of time from 3 5-5 5 hours adding the time that is necessary to convert the precursor into testosterone. If a testosterone metabolite is used, the time period of 3-5 hours is shortened.

To further enhance the effects of the kit of part of the invention the kit may further comprise means for interventions and cognitive stimulation. This information can be present on any data carrier (paper, CD, DVD), passive or active, or it can be a link to a website designed at least partially.

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IMRTUW RUklÍANO et m nowfDAD INDUSTRIAL For the purpose of cognitive stimulation, it is preferred to present the subconscious cognitive stimulating information, for example subliminally.

To further enhance the effects of the kit of the present invention, a substance can be added to the kit that stimulates the mesolimbic dopaminergic pathway in the subject. This pathway is related to a relatively different type of reward system that helps provide increased reward seeking involved in sexual behavior. Examples of these compounds are Apomorphine, a dopamine D2 agonist; Aripiprazole, a partial dopamine D2 agonist; Pergolide, a non-selective dopamine (DA) agonist; Pramipexole, a novel dopamine receptor agonist with preference for D3 receptors compared to D2 and D4; Bromocriptine, a non-selective dopamine (DA) agonist; Ropinirole hydrochloride, a dopamine agonist other than ergoline with relatively high in vitro specificity and total intrinsic activity at dopamine D receptor subtypes₂and D₃; binds with higher affinity D receptor subtypes₃ what D₂ or D₄; Roxindole, a potent selective dopamine D3 agonist (autoreceptor), · Cabergoline, a dopamine D2 agonist; Lisuride, a non-selective dopamine (DA) agonist and autoreceptor antagonists; (+) - AJ 76, D3, dopamine autoreceptor (DA) agonist is preferred; (+) -

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MUICANO INSTITUTE

M THE INDUSTRIAL CURRENCY

UH232, a stimulant of dopamine transmission, which can preferably antagonize autoreceptors of dopamine nerve terminals, as well as reuptake blockers; Bupropione, an inhibitor of neuronal uptake of norepinephrine, serotonin, and dopamine; Aminaptin, a (relatively) selective dopamine reuptake inhibitor; GBR 12909 (vanoxerin), a dopamine reuptake inhibitor; and Amantadine; an NMDA receptor antagonist and dopamine reuptake inhibitor,

To further improve the effect of the equipment of the present invention, a substance is added (optionally) which inhibits the central and peripheral adrenergic tone, that is, it inhibits or reduces the peripheral central extracellular concentrations of norepinephrine. The activation of the receptors alpha 2 localized to the central nervous system results in inhibition of sympathetic tone. Examples of these compounds are clonidine, an alpha 2 agonist; imidazoline, a partial alpha 2 agonist; dexmedetomidine, and an alpha 2 agonist

The parts kit is used by any individual who suffers from any form of FSD, whether through psychological or physiological causes or combinations thereof.This is thus useful also for subjects who have FSD due to other medications and / or drugs. as

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IMPI your Mexican rrmrro «la romeo *» «• usnuAL

SSRI; subjects suffering from hypogonadism, - '&lt;j) fee .....¹

Low sexual desire, sexual arousal problems and hampered orgasms are candidates for psychopharmacological treatment These categories of sexual problems are also linked to three phases (transitional and overlapping) of the human sexual response (sexual desire, sexual arousal and orgasms ), which are regulated by relatively independent neurotransmitter functions Traditionally, Motivated behaviors have been divided into appetitive and consummatory components. Activities aimed at obtaining reward and satisfaction belong to the appetitive component. The fundamental appetitive motivational process is an intrinsic brain function, and is especially related to the predictive value of stimuli to obtain rewards.Processing motivationally relevant information (that is, stimuli that predict reward) produces an increase in the activity of the dopaminergic system (DA) (i.e. the DA neurons of the vertebral pigmental area (VTA) that enervate the nucleus accumbens) (NAS) a component of the mesolimbic system of dopamine. The activity of this system is increased during flexible approach behavior when a reward related to copulation is anticipated. Increased activity in these dopaminergic pathways facilitates sexual motivation, in particular

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IMPI INSTITUTO MEXICANO DE LA PROPERTY anticipated sexual behavior The ArigJT ^ P ^ -z among others, an example of a painkiller that — has — TTrf ± ereiK! Wf on dopaminergic pathways, and that can be used in combination with testosterone or an analog of it and the PDE5 inhibitor to affect the motivation of sexual behavior Aripripazole is a high affinity partial agonist of the dopamione D2 receptor and the serotonin 5-HTla receptor, and an antagonist of the 5-HT2a receptor, Aripiprazole is described as a stabilizer of a dopamine system which is due to its partial diagnostic actions at the D2 receptor, especially the presynaptic D2 receptors, for which they have an affinity. Stimulation of autoreceptors located on dopamine motor terminals results in the inhibition of dopamine synthesis and release.Thus, in a low dopamine state of the mesoaccumbens DA system, aripiprazole would antagonize presynaptic D2 receptors, releasing the nuclei of DA that project ÑAS on the VTA of self-inhibition, The middle prefrontal cortex (mPFC) mediates inhibition of behavior. Dopamine in mPFC plays an important role in behavior. Illustrative of the DA inhibitory role of mPFC is inhibition of the DA meso-accumbens system; at high extracellular concentrations of DA activity mesoaccumbens inhibit DA, and extracellular concentrations at

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INSTtTUT · MfoOCANC d »la nontDAo INtUSTMAl low meso-accumbal DA activity activates mPFC-DA through disinhibition. Therefore it is conceivable that a dopaminergic role in FSD is not restricted to mesoaccumbal DA, but extends to mPFC-DA, where FSD symptoms improve with high mPFC-DA activity, still via DA inhibition. accumbal or via the inhibition of three cognitive or emotional factors involved in FSAD. The partial agonist action of aripiprazole will then have a positive effect on the relief of FSD (symptomatology) through the agonism of the presynaptic D2 receptor in the mPFC thus converting the release of DA in this area. Anticipation of the sexual response will produce arousal of the genitalia, in which at least three key neurotransmitters are involved: acetylcholine, norepinephrine and nitric oxide Acetylcholine and nitric oxide promote both erections in men and lubrication and swelling in women Norepinephrine inhibits erections in men and lubrication and swelling in women Orgasm, the consuming phase of the response Human sexual intercourse is facilitated by descending spinal non-adrenalgic fibers and the innervation of the genitalia, and inhibited by descending spinal serotonergic fibers

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INSTITUTO MEX1CAN · • BLA PtOMíBAD TOUSTMML

Testosterone in women

In many species of mammals, female sexual spheroids are necessary for the expression of female sexual behavior.As a result, the copulation capacity in these animals is limited to periods of ovulation.^4,5 Higher primates -like humans show sexual intercourse outside the periovulatory period.For these animals it is suggested that testosterone is involved in female sexual behavior⁶ The disappearance of testosterone after oophorectomy and adrenalectomy is accompanied by a complete loss of libido⁷'⁸, while the replacement of this spheroid maintains sexual desire and fantasies after surgical menopause⁹

Testosterone, exposure to sexual views of vaginal arousal in normal women.

An important aspect of sexual motivation is the physiological sexual response Measured with an increase in vaginal vasocongestion produced by sexual stimuli, this response is considered preparatory for copulatory behavior¹⁰ In hypogonadotropic hypogonadal women, substitution with 40 mg of testosterone undecanoate orally over a period of 8 weeks was found to improve vaginal response.¹⁰ This effect was not found

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in another group of hypogonadotropic hypogonadic patients (unpublished data) In both studies the subjects received testosterone every morning, but the patients in the first experiment were tested during the afternoon and the patients in the second experiment in the morning. The different results on the physiological response between these experiments may be caused by a time-dependent effect of testosterone on vaginal arousal A third experiment, examining whether the administration of a single dose of testosterone sublingually, compared to a placebo, increases vasocongestion during the presentation of visual erotic stimuli¹¹ One day of treatment we exposed 8 sexually functional women at half hour intervals to six erotic movies featuring sexual intercourse. The consumption of testosterone produced a sharp increase in plasma levels of testosterone for a short time. Approximately three to four and a half hours after this testosterone spike, we found that the strange increase in vaginal response when subjects were exposed to visual sexual stimuli (see also Figure 1) Those discoveries later demonstrate a time lag in the effect of sublingually administered testosterone on genital arousal in sexually functional women

The results of the studies mentioned

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ΙΝϊητυτβΜΜκ ^ ο

D »LA WORÍBah INDUSTRIAL previously demonstrate that testosterone_ is involved in female sexual motivation in a time-dependent manner The influence of sexual spheroids on sexual behavior can be explained by a neural network that responds to spheroids, a highly interconnected neurons containing sex hormone receptors in the brain¹² This network is not a closed circuit, but serves for reproductive purposes functioning as a center of integration and activation between external sensory views, hormonal processes and reproductive behavior, This is partially achieved by the selective filtering of sensory input and amplification of signals that can facilitate sexual behavior. We assume that an increase in vaginal vasocongestion induced by sexual stimuli is preparatory for copulatory behavior. Visual exposure to sexual intercourse between the member of the spectator species is a powerful liberating stimulus for that preparatory emotional response, Both men and women have an enormous capacity to respond to erotic movies with a genital response¹³ The increased emotional sensitivity from testosterone-induced sexual views is presumably the result of an altered brain state, in which the dopaminergic, serotonergic, and noradrenergic pathways are involved. East

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IMPI í

ΤΝΓΠΤυΤΟ MtXICANr

MMMOHEBad INDUSTRIAL altered state can also be sensitive to internal views such as those evoked by sexual fantasies

In another experiment we demonstrated that attention directed to alterations in genital arousal produced concordance between physiological and subjective indices of sexual arousal¹⁴ There are reciprocal relationships between sexual desire, sexual arousal and the capacity and power of orgasm A reduced sexual desire will affect sexual arousal and vice versa; both indices of sexual function can influence orgasm potency and vice versa.

Phosphodiesterase 5 inhibitors and sexual arousal

Selective phosphodiesterase type 5 (PDE5) inhibitors have been shown in several studies to improve erectile function in men with erectile dysfunction, on average close to normal function¹⁵ In the penis, nitric oxide (NO) released from nerves and endothelium, induces the production of cyclic guanosine monophosphate (cGMP) .cGMP is a key mechanism in smooth muscle relaxation, necessary for the induction of an erection. This nucleotide is hydrolyzed by phosphodiesterases, of which the main activity in the corpus cavernosum is due to PDE5 Therefore, during sexual stimulation, the action of NO / cGMP on function

IMPI ινπτγτγο mtticAN ·, _z COIN OR erectile will be increased by inhibitors of^wW® 5 genitalia of both sexes have origins ¹ COMMON EITIBPHYELOGIOUS Recently, the clitoris has been shown to consist of a complex erectile tissue, which includes the anterior vaginal wall. Erection of the clitoris and the anterior wall of the vagina are widely involved in female sexual arousal and response. Sildenafil - PDE5 inhibitor - has recently been shown to improve sexual performance in sexually functional women¹⁷

Although similar specialized vascular mechanisms are involved in genital response in both men and women, an increase in Vaginal Pulse Width (VPA) cannot be considered equivalent to an erection. A necessary but not sufficient condition for an erection is the dilation of the arteries and the resulting increased inflow of blood.In the penis there are bodies (corpora cavernosa (two) and corpus spongiosum (one)) that contain small irregular compartments (vascular spaces). smooth muscles in the cavernous sinusoidal walls are normally tonic restricted under the control of an active sympathetic (adrenergic) tone Relaxation of the cavernous smooth muscle of the body results in the filling and enlargement of the compartments with blood which will be accompanied by an erection. Although the precise mechanisms are unknown, it is believed that²⁰ IMPI ^ wnfruroMftncAMG

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INDUSTRIAL ^X'^ 3E2S sympathetic innervations and Nitric Oxide are both main mediators in the relaxation of the osseous corporeal muscles. In the penis, the sympathetic innervations of the blood vessels are scarce, whereas the smooth muscles are richly innervated by this system. In contrast, The blood vessels of the penis are richly innervated by the parasympathetic system, while the innervations of the smooth muscles by this system are scarce. there are relatively independent effects of these two parts of the peripheral nervous system on the processes involved in the occurrence of an erection.The onset of dilation of the penile arteries and the subsequent increase in blood flow to the cavernous tissue is regulated by the nervous system parasympathetic (the onset of an increase in this cholinergic activity depends on signals from the brain) However, without relaxation of the smooth muscles there will be no erection. Reduction of sympathetic tone and consequent relaxation of smooth muscles appears to be a relative independent prerequisite for the initiation of an erection.Thus, erection of the penis occurs in response to increased activity of sacral parasympathetic innervations and decreased of the activity of the sympathetic pathways In the penis, nitric oxide (NO) released from the nerves and the endothelium induces the production of cyclic guanosine monophosphate (cGMP)

The cGMP is a

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INSTITUTO mhucaní DE LA MtoHEDAC INDUSTEIA The key mechanism in the relaxation of smooth muscle, necessary for the induction of an erection, The production and release of NO can be influenced by a decrease in the activity of the sympathetic branch

Brain activity mediates the influence of physiological circumstances on sexual behavior and sexual feelings via the inhibitory and regulatory mechanism of arousal&gt;

The prefrontal cortices of the human brain are crucial for the cognitive functions involved in the planning, execution and control of the compartment. An important aspect of these cognitive functions is the inhibition of emotional responses induced by the limbic system, such as sexual behavior. involved in three distinct phases (transitional and overlapping) of human sexual response, as well as disturbances in those phases that lead to low sexual desire, problems with sexual arousal and obstructed orgasm.In this way, an increase in the activity of the prefrontal cortex associated with inhibition can reduce sexual desire, sexual arousal and desire for orgasm. Activity in the prefrontal cortices is also involved in the regulation of the sympathetic and parasympathetic branches of the peripheral nervous system

MEXICAN INSTITUTE

M THE CURRENCY .Α1 · * Μ «ίΤί | industrial Sglgrwy

An increase in prefrontal activity is accompanied by a decrease in parasympathetic activity and an increase in sympathetic activity. The alterations in these branches occur asymmetrically. Furthermore, the sympathetic branching of the peripheral nervous system appears to be more sensitive to induced psychogenic alterations. This psychological process controlled by the prefrontal cortices appears to be directly involved in the physiological mechanism that regulates the induction of an erection. It can be assumed that the same physiological mechanisms regulate the different components of the female sexual response (that is, parasympathetic innervations are regulatory for VPA, and sympathetic innervations are, together with Nitric oxide, responsible for swelling and lubrication).

In a recently conducted (unpublished) experiment in healthy sexually functional women we used a delayed measurement design in which subjects ingested a dose of testosterone (05 mg sublingual) or placebo and after 4 hours experienced fMRl while watching neutral and erotic videos Subsequently, the subjects were taken to a laboratory where their VPA was measured in response to neutral and erotic videos. As expected, In the placebo condition, we found activation of the cortical and subcortical structures and deactivation of the dorsal prefrontal areas, comparable with other studies

IMPI

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MiAnorasA »INDUSWaL imaging on brain activation in response to erotic stimuli Due to the delayed effect of testosterone on increasing VPA, we expected an enhancement of those erotic structures from fMRI However, the opposite is true Women with testosterone , showed a decrease in the activity of all brain structures during erotic exposure involved in normal sexual response. 2 Structures showed a very significant increase in the septum, which functions as a container of emotional momentum, and the left dorsolateral PFC, which functions as an inhibitor of automated / reflexive responses As established, deactivation of the dorsal prefrontal areas is usually observed

Depending on circumstances and individual differences, testosterone may produce effects that deviate from expectations, given the functional role of testosterone in regulating sexual behavior. This inhibition of the centrally regulated autonomous sexual response was also evident in the relative change in VPA. Contrary to expectations that VPA was lower in testosterone conditions compared to placebo, and probably the result of a continuous inhibition mechanism induced during the fMRI procedure

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Synergistic effect of a combination of tRSBLuBLeroHa and PDE-5 inhibitor on vaginal arousal in women suffering from Female Sexual Disorder

In a recently conducted experiment (see the experimental part) in women suffering from Female Sexual Dysfunction, we found no effect at different time intervals of a dose of testosterone, nor of a PDE5 inhibitor compared to a placebo on the arousal capacity vaginal, not on sexual desire and genital sensations In this experiment we found, however, that a dose of testosterone (0 5 mg sublingual) combined with the administration of a PDE5 inhibitor (dosed in such a way that the T max rises to approximately 3 5 5 5 hours after the peak of free testosterone) occurs four hours after the plasma testosterone peak a significantly higher Vaginal Pulse Amplitude during exposure to erotic stimuli This effect was more pronounced in a subgroup of women who were sexually abused during their childhood We did not find effects on sexual desire and on subjective sexual arousal. Treatment with testosterone as well as the combination of testosterone and a PDE5 inhibitor produced an increase in an attention link (or withdrawal) of sexual tension, compared to placebo and / or PDE5 inhibitor.

IMPI

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n * mvTOKuucM «o O» LAr »OHÍDAD MPUSTMAL important function for normal human sexuality. Testosterone combined with a PDE5 inhibitor produced a statistically significant increase in genital arousal

In one of its embodiments, the invention provides the use of a combination of a PDE5 inhibitor and testosterone or an analog thereof, and the preparation of a medicament for the treatment of female sexual dysfunction.

Testosterone is also known under the chemical name of 17-p-hydroxyandrost-4-en-3-one, which can be obtained in various ways, can be isolated and purified from nature or produced synthetically in any way.

The term or an analog thereof includes any useful metabolite or precursor of testosterone, for example the dihydrotestosterone metabolite. It is clear to one skilled in the art that if a testosterone metabolite or precursor is used, the time point for administration of the PDE-5 inhibitor probably needs to have been adapted.

If, for example, dihydrotestosterone is used, the administration time of the PDE5 inhibitor is approximately half an hour earlier (since this is the approximate time it takes for excess testosterone to be converted to dihydrotestosterone) The amount of inhibitors of PDE5 is expanding and non-limiting examples are the following GF-196960 / IC351 (tadalafil),

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Bay-38-9456 (vardenafil), UK-103320 (Sildenafi), E-4021, E

8010, E-4010, AWD-12-217 (zaprinast), AWD 12-210, UK-343,664,

UK-369003, UK-357903, BMS-341400, BMS-223131, FR226807, FR229934, EMR-6203, Sch-51866, IC485, TA-1790, DA-8159, NCX-911 or KS-505a. Other examples can be found in W 96/26940,

Preferably, the PDE-5 inhibitor is provided at least 3 hours after administration of the testosterone, more preferably so that the C_max it is reached approximately 3-5 to 5 hours after the plasma free testosterone peak. As already described above and depending on the formulation, the PDE5 inhibitor can also be given at the same time as testosterone is administered.

Conditioning of positive associations between different modalities of sexual response

Treatments with a dose of testosterone combined with a PDE5 inhibitor produce alterations in brain and body functions that will lead to the learning of positive associations between sexual stimuli, genital arousal and possible subjective experiences In addition, the treatment of FSD, in combination of testosterone and a PDE5 inhibitor is preferably enhanced by an approach induction treatment to create a more psychological change

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uwwtvro MMOWO OF PROPERTY •• ximuAi permanent, central processes and nnTpnrfÍ, lftci., frt.ivadns ñor testosterone and a PDE5 inhibitor under sexually relevant stimuli need to be perceived and need to be associated with a positive hedonic tone or activation of the approach behavior system, The perception of bodily reactions to focus attention on genital arousal are made possible by testosterone (whereby genital arousal is synergistically increased by the PDE-5 inhibitor) and can be emphasized by verbal instructions A positive hedonic tone cannot be guaranteed in the FSD patient population, To achieve a positive tone, patients can be exposed to positive stimuli during the effective phase of the drugs (i.e., at least 3 hours after testosterone consumption). These positively motivated stimuli consist of photographs of happy faces of people of the sexually preferred gender of the patient, including possibly the face of the couple, The photographs of the faces are presented subliminally, so that in a non-objective way the approach behavior system is activated,

Treatment of FSD may consist of creating a situation in which the patient learns to associate genital arousal with a positive hedonic tone or activation of the approach behavior system.

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This requires induction of genital arousal (by sexual stimuli and a PDE5 inhibitor), sustained attention to sexual stimuli and genital arousal (made possible by testosterone), and activation of the approach behavior system (by subliminal presentation of pictures of happy faces)

The invention further provides a method of treating women suffering from female sexual dysfunction by providing women with a combination of PDE5 inhibitor and testosterone or an analog thereof,

The invention will be explained in greater detail in the following non-limiting example

Examples

Participants

Fourteen women with a heterosexual orientation (Average age: 40 6 years; of: 10 4; premenopausal n = 8, postmenopausal n = 6) who had been experiencing FSD (i.e., low sexual desire, low sexual arousal, or decreased power of orgasm) for at least six months prior to entering the study participated in this study. of childbearing age used contraceptives (IUD, sterilization, oral contraceptives, except contraceptives containing antiandrogens) A pregnancy test was part of the procedure Subjects were ₂₉ IMPI

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INDUSTRIAL * —- ~ ^ interviewed and examined by a gynecologist to exclude pregnancy or lactation, vaginal infections, operations greater than the vagina and / or vulva, or unexplained gynecological complications. The patients had no history of endocrinological, neurological, or psychiatric treatment. Cardiovascular condition was tested and an ECG was verified for significant abnormalities. Standard chemical and hematological blood tests were performed. Participants were not drug abusing and required not to use alcohol or psychoactive drugs overnight prior to the day of experimentation. The patients were unable to make appointments during their menstruation period.

Procedures

This study was approved by the Dutch Medical Ethics Committee (STEGMETC) Experimental trials were preceded by means of selected visits At this selected visit, subjects were interviewed by a psychologist / gynecologist for the diagnosis of FSD and to determine eligibility for the participation in the study Weight, height, blood pressure (supine and standing), heart rate, breathing rate and body temperature A 12 supine or lying ECG was recorded and examined by a physician (and when necessary, by a cardiologist) A gynecological examination and

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Selected subjects were subjected to a familiarization test after selection. A trained female experimenter familiarized the subjects with the study requirements and procedures This included the use of vaginal photoplethysmography (a tampon-shaped device) Subjects viewed a neutral film clip for 5 minutes followed by a 5 minute erotic film clip. minutes later they practiced on a short version of Stroop's emotional homework. For experimental trials we used a randomized, double-blind, placebo-controlled driven design with four drug conditions

1) Placebo

2) PDE-5 inhibitor

3) Testosterone (0 5 mg sublingual)

4) testosterone + PDE-5 inhibitor (the two compounds were given at the same time, but the PDE5 inhibitor was dosed / formulated so that the effect of testosterone and the effect of the PDE5 inhibitor overlapped at least partially) Each subject underwent all four different drug treatments (i.e. PDE5i, testosterone, PDE5i + testosterone, and placebo) on four separate experimental days All four

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During each day of drug manipulation, the subjects were subjected to the following measurements

-1 00 hrs Emotional Stroop Task

-0 15 hrs Test 1

00 hrs Drug consumption

05 hrs Essay2

Four. Five hrs Rehearsal3

fifteen hrs Rehearsal4

Each day began with a physical examination (measurement of vital signs, blood pressure, heart rate, temperature, and rate of respiration) Blood samples (8 ml) were taken for hormone analysis The subjects were then seated in the dimly lit experimental room , sound attenuated To make this room less sterile, geographical posters were hung on the walls and an air scent was placed behind the subjects. The subjects then performed the Emotional Stroop task (15 minutes). The experimenter brought the vaginal probe and the subject was left alone in a room to insert the probe. The subject was instructed to sit as still as possible while viewing film clips A 10 minute neutral clip was followed by a 5 minute erotic film clip After these measurements

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or placebo) sublingually, with cyclodextrins as support and

Vardenafil (10 mg, or placebo) hidden in a capsule, The medication was followed by another set of fragments of neutral (5 minutes) and erotic (5 minutes) film The subjects removed the vaginal probe and were taken to a waiting room to a two-hour break During this break they were able to consume their lunch; coffee and tea were available without limitation, This break was followed by a third set of clips of neutral (5 minutes) and erotic (5 minutes) films Again the subjects had to wait two hours, so that the last measurement of VPA was taken four hours after medication This last film test (fragments of neutral film, erotic) was followed by a second presentation of Emotional Stroop.The experimentation day ended with a short physical examination including obtaining a blood sample (8 ml for hormone analysis) and collecting AE and SAE, Figure 2 shows the effect of the pharmaceutical preparation according to the invention (P &lt;0 035) compared to a placebo / PDE5 inhibitor on VPA in women suffering from FSB, Figure 3 shows the effect of the pharmaceutical preparation according to the invention (P &lt;0 04) in comparison with a placebo, a PDE5 inhibitor and testosterone in women suffering from FSD, I instituted »MÍXICAN ·

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Emotional Stroop Task

An Emotional Stroop Task that compares color latencies on neutral and erotic words were used in an unmasked and masked version.In both unmasked and masked conditions, eight erotic and neutral words were presented in different colors (i.e. red, green, blue and yellow) An extra set of stimuli consisting of letter strings was used for practical trials The subjects were instructed to ignore the content of the words and name the color of the words as quickly as possible (in the masked condition, the mask color would have to be named) Each trial consisted of a fixation point which is displayed for 750 ms, followed by the white or objective stimulus (the non-neutral or erotic colored word) The masked condition the word image was presented for approximately 24 ms and then was masked by randomly cutting it, the letters were mounted again with the same color A microphone connected to a voice level detector was placed on the front of the subject The beginning of the vocal response was recorded by a computer clock and the presentation of the target target ended (with a maximum no response of 3000 ms) Thirty-two neutral words and thirty-two blocked erotic words were presented The same words were used for each test, however,

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Results

VPA measurements

During the testosterone condition, the subject experienced nausea when watching the erotic movie and decided not to participate further on that day. For the physiological evaluation the VPA (Vaginal Pulse Amplitude) was used. The VPA reflects the basic changes in the corresponding blood volume for each heart beat; higher levels indicate higher levels of blood flow The dependent variable used is pulse wave amplitude Before the mean VPA was calculated, the raw signal (the sample rate © was 20 Hz) was filtered per step waveform digitally with a butterworth filter (-3 dB cutoff frequency range 0 7-1 5 Hz; descending / octave of 40 dB) The artifacts with movement were detected by visual inspection of the signal and removed manually Subsequently, the amplitude was measured as the distance between the upper part and the lower part of the pulse wave The mean VPA was calculated with a average of these amplitudes over 30 s periods

The magnitude of the VPA response also depends on the exact placement of the probe. To compare

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The differences of the resulting scores were subjected to repeated measurements ANOVA, 2 with Spheroids (testosterone yes / no) x 2 PDE5i (vardenafil yes / no) x 2 before-after (trial 1 versus trial 4) An interaction effect was found for the condition of the spheroids during the tests (F (1.12) = 5.75; p &lt;0 04) implying that the increase before to after the measurement was significantly greater for the conditions with drugs containing the spheroids (testosterone + placebo and testosterone + Vardenafil) than for the conditions with drugs without the spheroid (placebo + placebo and placebo + Vardenafil) Further analyzes of the responses from before medication (Trial 1) versus after medication (Trial 4) showed that the increase in VPA between the neutral films and erotic is not significant in the placebo condition and in the placebo condition and in the Vardenfil or testosterone condition (see also Figure 4) Only the combined treatment condition (Vardenfil +

testosterone) led to

An increment

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We assume that the effects of sexual stimulation and medication on genital responses are associated with changes in central mechanisms To test the associations with changes in attention processes we use the StroopRT as a measurement point, The StroopRT is the difference in times media reaction on assigning color or neutral and sexual words

During visual inspection of the data, we found two subgroups within our sample; a group of women who had been subjected to sexual abuse during childhood and a group of women who did not report such abuse. We decided to include women who were sexually abused during childhood among variable subjects in the analysis.

No statistically significant results were found in the unexpected condition. The analyzes reported so far reflect the results in the masked condition of the Stroop task. The MANOVA revealed a significant interaction between the Spheroid, the Trial and the Sexual Abuse in childhood (F (2,10) = 13 6; p = 0 001) Within the subjects the contrasts confirmed significant effects for both of the VPA ( F (l, 11) = 10.97; p = 0.007) and StroopRT (F (1.11) = 5.85; p = 0 034 (Figure 5)

Subjects who had been sexually abused

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during childhood they showed an attenuated VPA to erotic .jest-iTniJ ^ (the increase of the medication before in the VPA during the erotic film in relation to the neutral film is &lt;60%, compared to the increase of&gt; 90% for subjects without abuse) and without increase during the tests with or without testosterone. However, these subjects are not sensitive to testosterone. Under the influence of testosterone they developed a deviation of attention from sexual stimuli (StroopRT increases). Subjects without abuse showed an opposite pattern; his attention to sexual stimuli increased (StroopRT decreased) and in parallel his response to VPA to erotic film increased in testosterone versus non-testosterone conditions. (Univariate analysis: VPA: ANOVA with VPA with 2 spheroids (testosterones yes / no) x 2 Trials (anterior and posterior medication) as within the subject-dependent measurement and sexual abuse as a factor among subjects F (2,10 ) = 5.9; p = &lt;0.035; StroopRT: ANOVA with StroopRT with 2 spheroids (testosterones yes / no) x 2 Trials (before-after) as a dependent measure and sexual abuse as a factor between subjects F (2,10) = 4.2, - p &lt;0 07)

In this group of women suffering from FSD, Vardenafil did not lead to a significant difference in VPA under conditions of sexual stimulation compared to placebo. Apparently, peripheral manipulations are not

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We found that we were able to distinguish subgroups of subjects For a subgroup of women who were sexually abused, testosterone has an effect on attention to sexual stimuli When these subjects had greater attention to sexual stimuli their genital response was not increased Both in healthy women how women with FSD who were not sexually abused respond with a genital reaction when their attention is directed to sexual stimuli We show in this study that for a patient with a history of abuse, the combination of testosterone and a PDE5 inhibitor is beneficial and that it increases both the resources allocated to the processing of sexual stimuli as well as her genital response to those sexual stimuli The observed effect was less pronounced in a subset of women who were sexually abused during their childhood For these women, testosterone or its analogue includes a PDE5 inhibitor that is as IMPI »*

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In a small study (N = 4) we further investigated the efficacy of subliminal presentation of happy men's faces during the erotic movie segment in 4 healthy women, after the administration of the combination of testosterone and PDE5 inhibitor Women reported a Increased subjective sexual arousal in the condition of subliminal concentration of happy men's faces, compared to the condition that only the erotic film

Figure 1

Graphs describing a delay between the administration of testosterone and VPA in healthy subjects

Figure 2

Results of VPA measurement in women suffering from FSD receiving a placebo combined with a PDE inhibitor or the pharmaceutical preparation according to the present invention comprising testosterone from a PDE5 inhibitor (this last combination is also known as Librido)

Figure 3

Results of VPA measurement in women suffering from

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Figure 4

VPA measurements of different treatments

Figure 5

Sexual abuse, diversion of attention, and VPA.

References

Laumann, E „0. , Paik. A. and Rosen, R..C Sexual dysfunction in the United States prevalence and predictors JAMA 10 281, 537, 1999

Ikemoto, 5 &amp; Panksepp J The role of nucleus accumbens dopamine in motivated behavior a unifying interpretation with special reference to reward-seeking Br Res Rev 31 6-41, 1999

Melis, MR &amp; Argiolis, A. Dopamine and sexual behavior Neuroso Biobehavioural Reviews 19 19-38, 1995

McCarthy MM, Albrecht ED. Steroid regulation of sexual behavior Trends Endocrinol Metab. 1996; 7 324-327

Pfaff DW, Schwatz-Giblin S, McCarthy MM, Kowl LM. Cellular and molecular mechanisms of female reproductive

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IMPI wJTrrtTOMeucA&gt; *&gt; dilarronkmd KDUSTWIal behaviors In; Knobil E, Neill JD, eds The Physiology of

Reproduction, 2nd ed, vol 2 New York, NY · Raven Press; 1994

107-220

Freeman LM, Rissman EF Neural aromatization and the control of sexual behavior Trends Endocrinol Metab,

1996,-7 334-337

Waxenberg SE, Drellich MG, Sutherland AM. Changes in female sexuality after adrenalectomy J Clin End Metab, 1959, -19 193-202

Drellich MG, Waxenberg SE, Erotic and affectional component of female sexuality In: Masserman J, ed. Science and psycho-analysis New York: Gruñe and Stratton, 1966

Sherwin BB, Gelfland MM &amp; Brender W- Androgens enhances sexual motivation in females a prospective, crossover study of sex steroid administration in the surgical menopause Psychosomatic Medicine, 49, 397, 1985

Tuiten A, Laan E, Panhuysen G, Everaerd W, de Haan E, Koppeshaar H &amp; Vroon P: Discrepancies between genital responses and subjective sexual function during testosteron substitution in women with hypothalamic amenorrhea, Psychosomatic Medicine, 58.234, 1996

Tuiten A, van Honk J, Koppeschaar H, Bernaards C, Thijssen J &amp; Verbaten R; Time course of effects of testosterone administration on sexual arousal in women,

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Archives of General Psychiatry, 2000, 5⁷,149-1^

Cottingham SL, Pfaff J) Interconnectedness of steroid hormone-binding neurons existence and implications Curr Topics Neuroendocrinol 1986, -7 223-249

Bancroft, J Human Sexuality and its Problems (Churchill Livingstone, Edinburg London Melbourne and New York, 1989)

Tuiten A, van Honk J, Verbaten R, Laan E, Everaerd W, Stam H. Can Subliminal Testosterone increase subjective and physiological measures of laboratory-induced sexual arousal? Archives of General Psychiatry, 2002, 59, 465-466

Potempa, AJ, Bernard I, and Ulbrich E, Under Flexible dosing, Real world condition PDE5 inhibitor improved erectile function in a broad population of men, Europ Urol Suppl 2 96, 2003. Klotz T., Sashe R,, Heidrich

A., et al PDE5 inhibitor increases penile rigidity and tumescence in erectile dysfunction patients a Rigiscan and pharmacokinetic study World J Urol 19 32-39,

It is noted that in relation to this date, the best method known to the applicant for putting the aforementioned invention into practice is the one that is clear from the present description of the invention.

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