Methods of treating or preventing cardiovascular conditions while preventing or minimizing muscular degeneration side effects

FIELD OF THE INVENTION

[0002] The present invention relates to methods of treating or preventing cardiovascular conditions while preventing or minimizing muscular degeneration side effects associated with certain HMG-CoA reductase inhibitors by coadministration of at least one sterol or 5α-stanol absorption inhibitor, pharmaceutically acceptable salts or solvates thereof, and at least one HMG-CoA reductase inhibitor, the latter being used sparingly in amounts insufficient to cause muscle degeneration.

BACKGROUND OF THE INVENTION

[0003] Atherosclerotic coronary heart disease (CHD) represents the major cause for death and vascular morbidity in the western world. Risk factors for atherosclerotic coronary heart disease include hypertension, diabetes mellitus, family history, male gender, cigarette smoke and elevated serum cholesterol. As per the NCEP ATP III recommendations, a total cholesterol level in excess of 200 mg/dl is associated with significant elevation of risk of CHD.

[0004] Cholesteryl esters are a major component of atherosclerotic lesions and the major storage form of cholesterol in arterial wall cells. Formation of cholesteryl esters is also a step in the intestinal absorption of dietary cholesterol. Thus, inhibition of cholesteryl ester formation and reduction of serum cholesterol can inhibit the progression of atherosclerotic lesion formation, decrease the accumulation of cholesteryl esters in the arterial wall, and block the intestinal absorption of dietary cholesterol.

[0005] The regulation of whole-body cholesterol homeostasis in mammals and animals involves the regulation of dietary cholesterol and modulation of cholesterol biosynthesis, bile acid biosynthesis and the catabolism of the cholesterol-containing plasma lipoproteins. The liver is the major organ responsible for cholesterol biosynthesis and catabolism and, for this reason, it is a prime determinant of plasma cholesterol levels. The liver is the site of synthesis and secretion of very low density lipoproteins (VLDL) which are subsequently metabolized to low density lipoproteins (LDL) in the circulation. LDL are the predominant cholesterol-carrying lipoproteins in the plasma and an increase in their concentration is correlated with increased atherosclerosis. When intestinal cholesterol absorption is reduced, by whatever means, less cholesterol is delivered to the liver. The consequence of this action is decreased hepatic lipoprotein (VLDL) production and an increase in the hepatic clearance of plasma cholesterol, mostly as LDL. Thus, the net effect of inhibiting intestinal cholesterol absorption is a decrease in plasma cholesterol levels.

[0006] U.S. Pat. Nos. 5,767,115, 5,624,920, 5,668,990, 5,656,624 and 5,688,787, respectively, disclose hydroxy-substituted azetidinone compounds and substituted β-lactam compounds useful for lowering cholesterol and/or in inhibiting the formation of cholesterol-containing lesions in mammalian arterial walls. U.S. Pat. Nos. 5,846,966 and 5,661,145, respectively, disclose hydroxy-substituted azetidinone compounds or substituted β-lactam compounds in combination with HMG CoA reductase inhibitors for preventing or treating atherosclerosis and reducing plasma cholesterol levels.

[0007] Recently, certain HMG CoA reductase inhibitors, commonly known as statins, allegedly have caused severe muscle degeneration in patients. For example, cerivastatin allegedly has been associated with deaths due to rhabdomyolysis. Although certain statins have been associated with very rare reports of rhabdomyolysis, cases of fatal rhabdomyolysis have been reported more with cerivastatin than other commercially available statins. Fatalities have been reported more frequently when cerivastatin is used in combination with gemfibrozil.

[0008] Rhabdomyolysis is a disorder caused by the toxic effects of the contents of muscle cells upon the kidney. When muscle cells break down, myoglobin, an iron-containing pigment, is released into the bloodstream. Myoglobin is filtered out of the bloodstream by the kidneys, but may occlude the structures of the kidney (tubular necrosis) and may break down into other toxic compounds that can cause kidney failure. Degeneration of a necrosis of skeletal muscle may cause fluid to shift from the bloodstream and into the muscle, resulting in a reduction in relative fluid volume of the body and reduced blood flow to the kidneys.

[0009] Moreover, a potential side effect could be “myopathy,” including muscle aches or muscle weakness in conjunction with increases in creatine phosphokinase (CPK) values over ten times the upper limit of normal. Risk of myopathy may be increased during use of high dose statins and/or when statins are administered with other drugs such as fibrates, niacin, azole, antifungals, erythromycin, and cyclosporin. For purposes of this description, all side effects relating to muscle degradation, aches, and/or weakness that may be associated with the administration of certain statins, including myopathy and/or rhabdomyolysis, will be herein referenced as “muscle degeneration.”

[0010] Notwithstanding the rare, but undesirable, occurrences of muscle degeneration such as rhabdomyolysis (with or without acute renal failure secondary to myoglobinuria) associated with certain statins, these compounds provide an important means for lowering cholesterol and other sterols and treating and/or preventing vascular diseases associated with hypercholesterolemia, hyperlipidaemia, such as arteriosclerosis, atherosclerosis, hypertension and the like. There is a need for a therapy that employs statins in a sparing manner along with other coadministered compositions which do not suffer from the disadvantages of statins, but which together provide a safer and more effective treatment of these diseases.

[0011] Despite recent improvements in the treatment of cardiovascular disease, there remains a need in the art for improved compositions and treatments for hyperlipidaemia, atherosclerosis and other vascular conditions, and in particular there is a need to do so while preventing or minimizing the muscle degeneration side effects of statins.

SUMMARY OF THE INVENTION

[0012] In one embodiment, the present invention provides a method of treating or preventing at least one vascular condition while preventing or minimizing muscular degenerative side effects associated with HMG-CoA reductase inhibitors, said method comprising administering to a subject in need thereof at least one sterol or 5α-stanol absorption inhibitor in combination with at least one HMG-CoA reductase inhibitor.

[0013] In another embodiment, the present invention provides a method of treating at least one vascular condition while preventing or minimizing muscular degenerative side effects associated with HMG-CoA reductase inhibitors, said method comprising administering to a subject in need thereof at least one sterol absorption inhibitor in combination with at least one HMG-CoA reductase inhibitor to provide a reduction in plasma cholesterol levels of at least about 10%.

[0014] In another embodiment, the present invention provides a therapeutic combination comprising at least one HMG-CoA reductase inhibitor and at least one sterol absorption inhibitor, wherein the at least one HMG-CoA reductase inhibitor and the at least one sterol absorption inhibitor are present in a combined amount sufficient to lower plasma sterol levels in a subject, and the at least one HMG-CoA reductase inhibitor is present in amounts insufficient to cause muscle degeneration.

[0015] In another embodiment, the present invention provides a method of preventing or reducing risk of atherosclerosis, arteriosclerosis and/or cardiovascular event while preventing or minimizing muscular degenerative side effects associated with HMG-CoA reductase inhibitors, comprising administering to a subject in need thereof at least one sterol or 5α-stanol absorption inhibitor in combination with at least one HMG-CoA reductase inhibitor.

[0016] Other than in the operating examples, or where otherwise indicated, all numbers expressing quantities of ingredients, reaction conditions, and so forth used in the specification and claims are to be understood as being modified in all instances by the term “about.”

DETAILED DESCRIPTION

[0017] In one embodiment, the present invention is directed to compositions, pharmaceutical compositions, therapeutic combinations, kits and methods of treatment using the same comprising the coadministration of at least one (one or more) sterol or 5α-stanol absorption inhibitor(s) and a minimal amount of at least one (one or more) HMG-CoA reductase inhibitor to prevent or minimize muscular degenerative side effects associated with HMG-CoA reductase inhibitors.

[0018] The inventive methods and therapeutic combinations are administered in a therapeutically effective amount to treat the specified condition, and in particular, vascular conditions such as are discussed in detail below, without the side effects of muscle degeneration. In this regard, smaller doses of HMG-CoA reductase inhibitors are used to prevent or lessen the potential for side effects, and in particular, muscle degeneration side effects. By coadministering these cholesterol biosynthesis inhibitors with sterol or 5α-stanol absorption inhibitors, the reduction of cholesterol, other sterols and/or 5α-stanol can be achieved effectively without such side effects. The relative amounts of these coadministered compounds will vary depending upon the HMG-CoA reductase inhibitor and sterol or 5α-stanol absorption inhibitor combination chosen.

[0019] Non-limiting examples of suitable HMG CoA reductase inhibitors include statins such as lovastatin (for example MEVACOR® which is available from Merck & Co.), pravastatin (for example PRAVACHOL® which is available from Bristol Meyers Squibb), fluvastatin, simvastatin (for example ZOCOR® which is available from Merck & Co.), atorvastatin, [cerivastatin] withdrawn from the market, CI-981, rivastatin (sodium 7-(4-fluorophenyl)-2,6-diisopropyl-5-methoxymethylpyridin-3-yl)-3,5-dihydroxy-6-heptanoate) and pitavastatin (such as NK-104 of Negma Kowa of Japan). Preferred HMG CoA reductase inhibitors include lovastatin, pravastatin , atorvastatin and simvastatin. The most preferred HMG CoA reductase inhibitors are simvastatin and atorvastatin.

[0020] Typically, cholesterol biosynthesis inhibitors, i.e., HMG-CoA reductase inhibitors, have been administered in a dosage range of from 5 to 80 or more mg per day. See Physicians' Desk Reference, Medical Economics Co., Inc. at page 2054 (2001), incorporated by reference herein. By replacing a portion of the HMG-CoA reductase inhibitor dosage with the sterol or 5α-stanol absorption inhibitor(s), the amount of HMG-CoA reductase inhibitor needed may be reduced to lower the possibility of side effects such as muscular degeneration or rhabdomylosis while still achieving desirable effects in lowering sterol or 5α-stanol levels. In the compositions of the present invention, therefore, the amount of HMG-CoA reductase inhibitor can range from about 0.1 to about 60 mg per day, preferably about 0.1 to about 40 mg per day, and more preferably about 0.1 to about 10 mg per day. In general, the recommended dosage is substantially lower than those amounts administered when the HMG-CoA reductase inhibitor is given alone.

[0021] For example, the approved dose of the HMG-CoA reductase inhibitor may be combined with the at least one sterol or 5α-stanol absorption inhibitor, e.g.;

1HMG CoA Reductase InhibitorApproved Dose (mg)simvastatin5, 10, 20, 40, 80pravastatin10, 20, 40atorvastatin10, 20, 40, 80lovastatin10, 20, 40

[0022] The at least one sterol absorption inhibitor may be combined with any dose of the HMG CoA reductase inhibitor, preferably a lower dose of the statin to achieve a reduction in sterol (such as cholesterol) and/or 5α-stanol levels comparable to a level achieved with higher statin doses but without side effects such as muscle degeneration.

[0023] The term “therapeutically effective amount” means that amount of a therapeutic agent of the composition, such as the HMG-CoA reductase inhibitor(s), the sterol or 5α-stanol absorption inhibitor(s) and other pharmacological or therapeutic agents described below, that will elicit a biological or medical response of a tissue, system, subject (animal or mammal) that is being sought by the administrator (such as a researcher, doctor or veterinarian) which includes alleviation of the symptoms of the condition or disease being treated and the prevention, slowing or halting of progression of the condition, i.e., which provides treatment of the vascular condition yet which minimizes or eliminates adverse muscular degenerative effects and/or prevents or reduces the risk of the occurrence of a biological or medical event (such as a coronary event).

[0024] As used herein, “combination therapy” or “therapeutic combination” means the administration of two or more therapeutic agents, such as HMG-CoA reductase inhibitor(s) and sterol or 5α-stanol absorption inhibitor(s), to prevent or treat vascular conditions while minimizing or eliminating potential muscular degenerative side effects associated with HMG-CoA reductase inhibitors. As used herein, “vascular” means relating to blood vessels, including but not limited to arteries and/or veins, and includes cardiovascular, cerebrovascular, peripheral vascular and combinations thereof. Such administration includes coadministration of these therapeutic agents in a substantially simultaneous manner, such as in a single tablet or capsule having a fixed ratio of active ingredients or in multiple, separate capsules for each therapeutic agent. Also, such administration includes use of each type of therapeutic agent in a sequential manner. In either case, the treatment using the combination therapy will provide beneficial effects in treating lipid and/or lipoprotein disorders. By using a combination of therapeutic agents, the side effects of the individual compounds can be reduced as compared to a monotherapy, which can improve patient compliance. Also, therapeutic agents can be selected to provide a broader range of complimentary effects or complimentary modes of action.

[0025] As discussed above, the compositions, pharmaceutical compositions and therapeutic combinations of the present invention comprise one or more sterol absorption inhibitors and/or one or more 5α-stanol absorption inhibitors, such as substituted azetidinone or substituted β-lactam sterol absorption inhibitors discussed in detail below. As used herein, “sterol absorption inhibitor” means a compound capable of inhibiting the absorption of one or more sterols, including but not limited to cholesterol, phytosterols (such as sitosterol, campesterol, stigmasterol and avenosterol) when administered in a therapeutically effective (sterol absorption inhibiting) amount to a subject. “5α-stanol absorption inhibitor” means a compound capable of inhibiting the absorption of one or more 5α-stanols (such as cholestanol, 5α-campestanol, 5α-sitostanol) when administered in a therapeutically effective (5α-stanol absorption inhibiting) amount to a mammal or human. Mixtures of sterol and 5α-stanol absorption inhibitors are contemplated herein.

[0026] In a preferred embodiment, sterol or 5α-stanol absorption inhibitors useful in the compositions, therapeutic combinations and methods of the present invention are represented by Formula (I) below:

[0027] or a pharmaceutically acceptable salt thereof or a solvate thereof, wherein, in Formula (I) above:

[0028] Ar1 and Ar2 are independently selected from the group consisting of aryl and R4-substituted aryl;

[0029] Ar3 is aryl or R5-substituted aryl;

[0030] X, Y and Z are independently selected from the group consisting of —CH2—, —CH(lower alkyl)- and —C(dilower alkyl)-;

[0031] R and R2 are independently selected from the group consisting of —OR6, —O(CO)R6, —O(CO)OR9 and —O(CO)NR6R7;

[0032] R1 and R3 are independently selected from the group consisting of hydrogen, lower alkyl and aryl;

[0033] q is 0 or 1; r is 0 or 1; m, n and p are independently selected from 0, 1, 2, 3 or 4; provided that at least one of q and r is 1, and the sum of m, n, p, q and r is 1, 2, 3, 4, 5 or 6; and provided that when p is 0 and r is 1, the sum of m, q and n is 1, 2, 3, 4 or 5;

[0034] R4 is 1-5 substituents independently selected from the group consisting of lower alkyl, —OR6, —O(CO)R6, —O(CO)OR9, —O(CH2)1-5OR6, —O(CO)NR6R7, —NR6R7, —NR6(CO)R7, —NR6(CO)OR9, —NR6(CO)NR7R8, —NR6SO2R9, —COOR6, —CONR6R7, —COR6, —SO2NR6R7, S(O)0-2R9, —O(CH2)1-10—COOR6, —O(CH2)1-10CONR6R7, -(lower alkylene)COOR6, —CH═CH—COOR6, —CF3, —CN, —NO2 and halogen;

[0035] R5 is 1-5 substituents independently selected from the group consisting of —OR6, —O(CO)R6, —O(CO)OR9, —O(CH2)1-5OR6, —O(CO)NR6R7, —NR6R7, —NR6(CO)R7, —NR6(CO)OR9, —NR6(CO)NR7R8, —NR6SO2R9, —COOR6, —CONR6R7, —COR6, —SO2NR6R7, S(O)0-2R9, —O(CH2)1-10—COOR6, —O(CH2)1-10CONR6R7, -(lower alkylene)COOR6 and —CH═CH—COOR6;

[0036] R6, R7 and R8 are independently selected from the group consisting of hydrogen, lower alkyl, aryl and aryl-substituted lower alkyl; and

[0037] R9 is lower alkyl, aryl or aryl-substituted lower alkyl.

[0038] Preferably, R4 is 1-3 independently selected substituents, and R5 is preferably 1-3 independently selected substituents.

[0039] As used herein, the term “alkyl” or “lower alkyl” means straight or branched alkyl chains having from 1 to 6 carbon atoms and “alkoxy” means alkoxy groups having 1 to 6 carbon atoms. Non-limiting examples of lower alkyl groups include, for example methyl, ethyl, propyl, and butyl groups.

[0040] “Alkenyl” means straight or branched carbon chains having one or more double is bonds in the chain, conjugated or unconjugated. Similarly, “alkynyl” means straight or branched carbon chains having one or more triple bonds in the chain. Where an alkyl, alkenyl or alkynyl chain joins two other variables and is therefore bivalent, the terms alkylene, alkenylene and alkynylene are used.

[0041] “Cycloalkyl” means a saturated carbon ring of 3 to 6 carbon atoms, while “cycloalkylene” refers to a corresponding bivalent ring, wherein the points of attachment to other groups include all positional isomers.

[0042] “Halogeno” refers to fluorine, chlorine, bromine or iodine radicals.

[0043] “Aryl” means phenyl, naphthyl, indenyl, tetrahydronaphthyl or indanyl.

[0044] “Phenylene” means a bivalent phenyl group, including ortho, meta and para-substitution.

[0045] The statements wherein, for example, R, R1, R2 and R3 are said to be independently selected from a group of substituents, mean that R, R1, R2 and R3 are independently selected, but also that where an R, R1, R2 and R3 variable occurs more than once in a molecule, each occurrence is independently selected (e.g., if R is —OR6, wherein R6 is hydrogen, R2 can be —OR6 wherein R6 is lower alkyl). Those skilled in the art will recognize that the size and nature of the substituent(s) will affect the number of substituents that can be present.

[0046] Compounds of the invention have at least one asymmetrical carbon atom and therefore all isomers, including enantiomers, stereoisomers, rotamers, tautomers and racemates of the compounds of Formulae I-XII are contemplated as being part of this invention. The invention includes d and I isomers in both pure form and in admixture, including racemic mixtures. Isomers can be prepared using conventional techniques, either by reacting optically pure or optically enriched starting materials or by separating isomers of a compound of the Formulas I-XII. Isomers may also include geometric isomers, e.g., when a double bond is present.

[0047] Those skilled in the art will appreciate that for some of the compounds of the Formulas I-XII, one isomer will show greater pharmacological activity than other isomers.

[0048] Compounds of the invention with an amino group can form pharmaceutically acceptable salts with organic and inorganic acids. Examples of suitable acids for salt formation are hydrochloric, sulfuric, phosphoric, acetic, citric, oxalic, malonic, salicylic, malic, fumaric, succinic, ascorbic, maleic, methanesulfonic and other mineral and carboxylic acids well known to those in the art. The salt is prepared by contacting the free base form with a sufficient amount of the desired acid to produce a salt. The free base form may be regenerated by treating the salt with a suitable dilute aqueous base solution such as dilute aqueous sodium bicarbonate. The free base form differs from its respective salt form somewhat in certain physical properties, such as solubility in polar solvents, but the salt is otherwise equivalent to its respective free base forms for purposes of the invention.

[0049] Certain compounds of the invention are acidic (e.g., those compounds which possess a carboxyl group). These compounds form pharmaceutically acceptable salts with inorganic and organic bases. Examples of such salts are the sodium, potassium, calcium, aluminum, gold and silver salts. Also included are salts formed with pharmaceutically acceptable amines such as ammonia, alkyl amines, hydroxyalkylamines, N-methylglucamine and the like.

[0050] As used herein, “solvate” means a molecular or ionic complex of molecules or ions of solvent with those of solute (for example, one or more compounds of Formulae I-XII, isomers of the compounds of Formulae I-XII, or prodrugs of the compounds of Formulae I-XII). Non-limiting examples of useful solvents include polar, protic solvents such as water and/or alcohols (for example methanol).

[0051] Prodrugs of the compounds of Formulae I-XII are contemplated as being part of this invention. As used herein, “prodrug” means compounds that are drug precursors which, following administration to a patient, release the drug in vivo via some chemical or physiological process (e.g., a prodrug on being brought to the physiological pH or through enzyme action is converted to the desired drug form).

[0052] Preferred compounds of Formula (I) are those in which Ar1 is phenyl or R4-substituted phenyl, more preferably (4-R4)-substituted phenyl. Ar2 is preferably phenyl or R4-substituted phenyl, more preferably (4-R4)-substituted phenyl. Ar3 is preferably R5-substituted phenyl, more preferably (4-R5)-substituted phenyl. When Ar1 is (4-R4)-substituted phenyl, R4 is preferably a halogen. When Ar2 and Ar3 are R4-and R5-substituted phenyl, respectively, R4 is preferably halogen or —OR6 and R5 is preferably —OR6, wherein R6 is lower alkyl or hydrogen. Especially preferred are compounds wherein each of Ar1 and Ar2 is 4-fluorophenyl and Ar3 is 4-hydroxyphenyl or 4-methoxyphenyl.

[0053] X, Y and Z are each preferably —CH2—. R1 and R3 are each preferably hydrogen. R and R2 are preferably —OR6 wherein R6 is hydrogen, or a group readily metabolizable to a hydroxyl (such as —O(CO)R6, —O(CO)OR9 and —O(CO)NR6 R7. defined above).

[0054] The sum of m, n, p, q and r is preferably 2, 3 or 4, more preferably 3. Preferred are compounds wherein m, n and r are each zero, q is 1 and p is 2.

[0055] Also preferred are compounds of Formula (I) in which p, q and n are each zero, r is 1 and m is 2 or 3. More preferred are compounds wherein m, n and r are each zero, q is 1, p is 2, Z is —CH2— and R is —OR6, especially when R6 is hydrogen.

[0056] Also more preferred are compounds of Formula (I) wherein p, q and n are each zero, r is 1, m is 2, X is —CH2— and R2 is —OR6, especially when R6 is hydrogen.

[0057] Another group of preferred compounds of Formula (I) is that in which Ar1 is phenyl or R4-substituted phenyl, Ar2 is phenyl or R4-substituted phenyl and Ar3 is R5-substituted phenyl. Also preferred are compounds in which Ar1 is phenyl or R4-substituted phenyl, Ar2 is phenyl or R4-substituted phenyl, Ar3 is R5-substituted phenyl, and the sum of m, n, p, q and r is 2, 3 or 4, more preferably 3. More preferred are compounds wherein Ar1 is phenyl or R4-substituted phenyl, Ar2 is phenyl or R4-substituted phenyl, Ar3 is R5-substituted phenyl, and wherein m, n and r are each zero, q is 1 and p is 2, or wherein p, q and n are each zero, r is 1 and m is 2 or 3.

[0058] In a preferred embodiment, a sterol or 5α-stanol absorption inhibitor of Formula (I) useful in the compositions, therapeutic combinations and methods of the present invention is represented by Formula (II) (ezetimibe) below:

[0059] or a pharmaceutically acceptable salt or solvate thereof. The compound of Formula (II) can be in anhydrous or hydrated form.

[0060] Compounds of Formula I can be prepared by a variety of methods well known to those skilled in the art, for example such as are disclosed in U.S. Pat. Nos. 5,631,365, 5,767,115, 5,846,966, 6,207,822, U.S. patent application Ser. No. 10/105,710 filed Mar. 25, 2002, and PCT Patent Application WO 93/02048, each of which is incorporated herein by reference, and in the Example below. For example, suitable compounds of Formula I can be prepared by a method comprising the steps of:

[0061] (a) treating with a strong base a lactone of the Formula A or B:

[0062] wherein R′ and R2′ are R and R2, respectively, or are suitably protected hydroxy groups; Ar10 is Ar1, a suitably protected hydroxy-substituted aryl or a suitably protected amino-substituted aryl; and the remaining variables are as defined above for Formula I, provided that in lactone of formula B, when n and r are each zero, p is 1-4;

[0063] (b) reacting the product of step (a) with an imine of the formula

[0064] wherein Ar20 is Ar2, a suitably protected hydroxy-substituted aryl or a suitably protected amino-substituted aryl; and Ar30 is Ar3, a suitably protected hydroxy-substituted aryl or a suitably protected amino-substituted aryl;

[0065] c) quenching the reaction with an acid;

[0066] d) optionally removing the protecting groups from R′, R2′, Ar10, Ar20 and Ar30, when present; and

[0067] e) optionally functionalizing hydroxy or amino substituents at R, R2, Ar1, Ar2 and Ar3.

[0068] Using the lactones shown above, compounds of Formula IA and IB are obtained as follows:

[0069] wherein the variables are as defined above; and

[0070] wherein the variables are as defined above.

[0071] Alternative sterol or 5α-stanol absorption inhibitors useful in the compositions, therapeutic combinations and methods of the present invention are represented by Formula (III) below:

[0072] or a pharmaceutically acceptable salt thereof or a solvate thereof, wherein, in Formula (III) above:

[0073] Ar1 is R3-substituted aryl;

[0074] Ar2 is R4-substituted aryl;

[0075] Ar3 is R5-substituted aryl;

[0076] Y and Z are independently selected from the group consisting of —CH2—, —CH(lower alkyl)- and —C(dilower alkyl)-;

[0077] A is selected from —O—, —S—, —S(O)— or —S(O)2—;

[0078] R1 is selected from the group consisting of —OR6, —O(CO)R6, —O(CO)OR9 and —O(CO)NR6R7; R2 is selected from the group consisting of hydrogen, lower alkyl and aryl; or R1 and R2 together are ═O;

[0079] q is 1, 2 or3;

[0080] p is 0, 1, 2, 3 or 4;

[0081] R5 is 1-3 substituents independently selected from the group consisting of —OR6, —O(CO)R6, —O(CO)OR9, —O(CH2)1-5OR9, —O(CO)NR6R7, —NR6R7, —NR6(CO)R7, —NR6(CO)OR9, —NR6(CO)NR7R8, —NR6SO2-lower alkyl, —NR6 SO2-aryl, —CONR6R7, —COR6, —SO2NR6R7, S(O)0-2-alkyl, S(O)0-2-aryl, —O(CH2)1-10—COOR6, —O(CH2)1-10CONR6R7, o-halogeno, m-halogeno, o-lower alkyl, m-lower alkyl, -(lower alkylene)- COOR6, and —CH═CH—COOR6;

[0082] R3 and R4 are independently 1-3 substituents independently selected from the group consisting of R5, hydrogen, p-lower alkyl, aryl, —NO2, —CF3 and p-halogeno;

[0083] R6, R7 and R8 are independently selected from the group consisting of hydrogen, lower alkyl, aryl and aryl-substituted lower alkyl; and R9 is lower alkyl, aryl or aryl-substituted lower alkyl.

[0084] Preferred compounds of Formula I include those in which Ar1 is R3-substituted phenyl, especially (4-R3)-substituted phenyl. Ar2 is preferably R4-substituted phenyl, especially (4-R4)-substituted phenyl. Ar3 is preferably R5-substituted phenyl, especially (4-R5)-substituted phenyl. Mono-substitution of each of Ar1, Ar2 and Ar3 is preferred.

[0085] Y and Z are each preferably —CH2—. R2 is preferably hydrogen. R1 is preferably —OR6 wherein R6 is hydrogen, or a group readily metabolizable to a hydroxyl (such as O(CO)R6, —O(CO)OR9 and —O(CO)NR6R7, defined above). Also preferred are compounds wherein R1 and R2 together are ═O.

[0086] The sum of q and p is preferably 1 or 2, more preferably 1. Preferred are compounds wherein p is zero and q is 1. More preferred are compounds wherein p is zero, q is 1, Y is —CH2— and R1 is —OR6, especially when R6 is hydrogen.

[0087] Another group of preferred compounds is that in which Ar1 is R3-substituted phenyl, Ar2 is R4-substituted phenyl and Ar3 is R5-substituted phenyl.

[0088] Also preferred are compounds wherein Ar1 is R3-substituted phenyl, Ar2 is R4-substituted phenyl, Ar3 is R5-substituted phenyl, and the sum of p and q is 1 or 2, especially 1. More preferred are compounds wherein Ar1 is R3-substituted phenyl, Ar2 is R4-substituted phenyl, Ar3 is R5-substituted phenyl, p is zero and q is 1.

[0089] A is preferably —O—.

[0090] R3 is preferably —COOR6, —CONR6R7, —COR6, —SO2NR6R7, S(O)0-2-alkyl, S(O)0-2-aryl, NO2 or halogeno. A more preferred definition for R3 is halogeno, especially fluoro or chloro.

[0091] R4 is preferably hydrogen, lower alkyl, —OR6, —O(CO)R6, —O(CO)OR9, —O(CO)NR6R7, —NR6R7, COR6 or halogeno, wherein R6 and R7 are preferably independently hydrogen or lower alkyl, and R9 is preferably lower alkyl. A more preferred definition for R4 is hydrogen or halogeno, especially fluoro or chloro.

[0092] R5 is preferably —OR6, —O(CO)R6, —O(CO)OR9, —O(CO)NR6R7, —NR6R7, -(lower alkylene)-COOR6or —CH═CH—COOR6, wherein R6 and R7 are preferably independently hydrogen or lower alkyl, and R9 is preferably lower alkyl. A more preferred definition for R5 is —OR6, -(lower alkylene)-COOR6 or —CH═CH—COOR6, wherein R6 is preferably hydrogen or lower alkyl.

[0093] Methods for making compounds of Formula III are well known to those skilled in the art. Non-limiting examples of suitable methods are disclosed in U.S. Pat. No. 5,688,990, which is incorporated herein by reference.

[0094] In another embodiment, sterol or 50α-stanol absorption inhibitors useful in the compositions, therapeutic combinations and methods of the present invention are represented by Formula (IV):

[0095] or a pharmaceutically acceptable salt thereof or a solvate thereof, wherein, in Formula (IV) above:

[0096] A is selected from the group consisting of R2-substituted heterocycloalkyl, R2-substituted heteroaryl, R2-substituted benzofused heterocycloalkyl, and R2-substituted benzofused heteroaryl;

[0097] Ar1 is aryl or R3-substituted aryl;

[0098] Ar2 is aryl or R4-substituted aryl;

[0099] Q is a bond or, with the 3-position ring carbon of the azetidinone, forms the spiro group

[0100] and

[0101] R1 is selected from the group consisting of:

[0102] —(CH2)q—, wherein q is 2-6, provided that when Q forms a spiro ring, q can also be zero or 1;

[0103] —(CH2)e—G—(CH2)r—, wherein G is —O—, —C(O)—, phenylene, —NR8— or —S(O)0-2—, e is 0-5 and r is 0-5, provided that the sum of e and r is 1-6;

[0104] —(C2-C6 alkenylene)-; and

[0105] —(CH2)f—V—(CH2)g—, wherein V is C3-C6 cycloalkylene, f is 1-5 and g is 0-5, provided that the sum of f and g is 1-6;

[0106] R5 is selected from:

[0107] R6 and R7 are independently selected from the group consisting of —CH2—, —CH(C1-C6 alkyl)—, —C(di-(C1-C6) alkyl), —CH═CH— and —C(C1-C6 alkyl)═CH—; or R5 together with an adjacent R6, or R5 together with an adjacent R7, form a —CH═CH— or a —CH═C(C1-C6 alkyl)- group;

[0108] a and b are independently 0, 1, 2 or 3, provided both are not zero; provided that when R6 is —CH═CH— or —C(C1-C6 alkyl)═CH—, a is 1; provided that when R7 is —CH═CH— or —C(C1-C6 alkyl)═CH—, b is 1; provided that when a is 2 or 3, the R6's can be the same or different; and provided that when b is 2 or 3, the R7's can be the same or different;

[0109] and when Q is a bond, R1 also can be selected from:

[0110] where M is —O—, —S—, —S(O)— or —S(O)2—;

[0111] X, Y and Z are independently selected from the group consisting of —CH2—, —CH(C1-C6 alkyl)- and —C(di-(C1-C6) alkyl);

[0112] R10 and R12 are independently selected from-the group consisting of —OR14, —O(CO)R14, —O(CO)OR16 and —O(CO)NR14R15;

[0113] R11 and R13 are independently selected from the group consisting of hydrogen, (C1-C6)alkyl and aryl; or R10 and R11 together are ═O, or R12 and R13 together are ═O;

[0114] d is 1, 2 or 3;

[0115] h is 0, 1, 2, 3 or 4;

[0116] s is 0 or 1; t is 0 or 1; m, n and p are independently 0-4; provided that at least one of s and t is 1, and the sum of m, n, p, s and t is 1-6; provided that when p is 0 and t is 1, the sum of m, s and n is 1-5; and provided that when p is 0 and s is 1, the sum of m, t and n is 1-5;

[0117] v is 0 or 1;

[0118] j and k are independently 1-5, provided that the sum of j, k and v is 1-5;

[0119] R2 is 1-3 substituents on the ring carbon atoms selected from the group consisting of hydrogen, (C1-C10)alkyl, (C2-C10)alkenyl, (C2-C10)alkynyl, (C3-C6)cycloalkyl, (C3-C6)cycloalkenyl, R17-substituted aryl, R17-substituted benzyl, R17-substituted benzyloxy, R17-substituted aryloxy, halogeno, —NR14R15, NR14R15(C1-C6 alkylene)-, NR14R15C(O)(C1-C6 alkylene)-, —NHC(O)R16, OH, C1-C6 alkoxy, —OC(O)R16, —COR14, hydroxy(C1-C6)alkyl, (C1-C6)alkoxy(C1-C6)alkyl, NO2, —S(O)0-2R16, —SO2NR14R15 and —(C1-C6 alkylene)COOR14; when R2 is a substituent on a heterocycloalkyl ring, R2 is as defined, or is ═O or

[0120] and, where R2 is a substituent on a substitutable ring nitrogen, it is hydrogen, (C1-C6)alkyl, aryl, (C1-C6)alkoxy, aryloxy, (C1-C6)alkylcarbonyl, arylcarbonyl, hydroxy, —(CH2)1-6CONR18R18,

[0121] wherein J is —O—, —NH—, —NR18— or —CH2—;

[0122] R3 and R4 are independently selected from the group consisting of 1-3 substituents independently selected from the group consisting of (C1-C6)alkyl, —OR14, —O(CO)R14, —O(CO)OR16, —O(CH2)1-5OR14, —O(CO)NR14R15, —NR14R15, —NR14(CO)R15, —NR14(CO)OR16, —NR14(CO)NR15R19, —NR14 SO2R16, —COOR14, —CONR14R15, —COR14, SO2NR14R15, S(O)0-2R16, —O(CH2)1-10—COOR14, —O(CH2)1-10CONR14R15, —(C1-C6 alkylene)-COOR14, —CH═CH—COOR14, —CF3, —CN, —NO2 and halogen;

[0123] R8 is hydrogen, (C1-C6)alkyl, aryl (C1-C6)alkyl, —C(O)R14 or —COOR14;

[0124] R9 and R17 are independently 1-3 groups independently selected from the group consisting of hydrogen, (C1-C6)alkyl, (C1-C6)alkoxy, —COOH, NO2, —NR14R15, OH and halogeno;

[0125] R14 and R15 are independently selected from the group consisting of hydrogen, (C1-C6)alkyl, aryl and aryl-substituted (C1-C6)alkyl;

[0126] R16 is (C1-C6)alkyl, aryl or R17-substituted aryl;

[0127] R18 is hydrogen or (C1-C6)alkyl; and

[0128] R19 is hydrogen, hydroxy or (C1-C6)alkoxy.

[0129] As used in Formula (IV) above, “A” is preferably an R2-substituted, 6-membered heterocycloalkyl ring containing 1 or 2 nitrogen atoms. Preferred heterocycloalkyl rings are piperidinyl, piperazinyl and morpholinyl groups. The ring “A” is preferably joined to the phenyl ring through a ring nitrogen. Preferred R2 substituents are hydrogen and lower alkyl. R19 is preferably hydrogen.

[0130] Ar2 is preferably phenyl or R4-phenyl, especially (4-R4)-substituted phenyl. Preferred definitions of R4 are lower alkoxy, especially methoxy, and halogeno, especially fluoro.

[0131] Ar1 is preferably phenyl or R3-substituted phenyl, especially (4-R3)-substituted phenyl.

[0132] There are several preferred definitions for the —R1—Q— combination of variables:

[0133] Q is a bond and R1 is lower alkylene, preferably propylene;

[0134] Q is a spiro group as defined above, wherein preferably R6 and R7 are each ethylene and R5 is

[0135] Q is a bond and R1 is

[0136] wherein the variables are chosen such that R1 is —O—CH2—CH(OH)—;

[0137] Q is a bond and R1 is

[0138] wherein the variables are chosen such that R1 is —CH(OH)—(CH2)2—; and

[0139] Q is a bond and R1 is

[0140] wherein the variables are chosen such that R1 is —CH(OH)—CH2—S(O)0-2—.

[0141] Methods for making compounds of Formula IV are well known to those skilled in the art. Non-limiting examples of suitable methods are disclosed in U.S. Pat. No. 5,656,624, which is incorporated herein by reference.

[0142] In another embodiment, sterol or 5α-stanol absorption inhibitors useful in the compositions, therapeutic combinations and methods of the present invention are represented by Formula (V):

[0143] or a pharmaceutically acceptable salt thereof or a solvate thereof, wherein, in Formula (V) above:

[0144] Ar1 is aryl, R10-substituted aryl or heteroaryl;

[0145] Ar2 is aryl or R4-substituted aryl;

[0146] Ar3 is aryl or R5-substituted aryl;

[0147] X and Y are independently selected from the group consisting of —CH2—, —CH(lower alkyl)- and —C(dilower alkyl)-;

[0148] R is —OR6, —O(CO)R6, —O(CO)OR9 or —O(CO)NR6R7; R1 is hydrogen, lower alkyl or aryl; or R and R1 together are ═O;

[0149] q is 0 or 1;

[0150] r is 0, 1 or 2;

[0151] m and n are independently 0, 1, 2, 3, 4 or 5; provided that the sum of m, n and q is 1, 2, 3, 4 or 5;

[0152] R4 is 1-5 substituents independently selected from the group consisting of lower alkyl, —OR6, —O(CO)R6, —O(CO)OR9, —O(CH2)1-5OR6, —O(CO)NR6R7, —NR6R7, —NR6(CO)R7, —NR6(CO)OR9, —NR6(CO)NR7R8, —NR6SO2R9, —COOR6, —CONR6R7, —COR6, —SO2NR6R7, S(O)0-2R9, —O(CH2)1-10—COOR6, —O(CH2)1-10CONR6R7, -(lower alkylene)COOR6 and —CH═CH—COOR6;

[0153] R5 is 1-5 substituents independently selected from the group consisting of —OR6, —O(CO)R6, —O(CO)OR9, —O(CH2)1-5OR6, —O(CO)NR6R7, —NR6R7, —NR6(CO)R7, —NR6(CO)OR9, —NR6(CO)NR7R8, —NR6SO2R9, —COOR6, —CONR6R7, —COR6, —SO2NR6R7, S(O)0-2R9, —O(CH2)1-10—COOR6, —O(CH2)1-10CONR6R7, —CF3, —CN, —NO2, halogen, -(lower alkylene)COOR6 and —CH═CH—COOR6;

[0154] R6, R7 and R8 are independently selected from the group consisting of hydrogen, lower alkyl, aryl and aryl-substituted lower alkyl;

[0155] R9 is lower alkyl, aryl or aryl-substituted lower alkyl; and

[0156] R10 is 1-5 substituents independently selected from the group consisting of lower alkyl, —O(CO)R6, —O(CO)OR6, —O(CH2)1-5OR6, —O(CO)NR6R7, —NR6R7, —NR6(CO)R7, —NR6(CO)OR9, —NR6(CO)NR7R8, —NR6SO2R9, —COOR6, —CONR6R7, —COR6, —SO2NR6R7, —S(O)0-2R9, —O(CH2)1-10—COOR6, —O(CH2)1-10CONR6R7, —CF3, —CN, —NO2 and halogen.

[0157] Within the scope of Formula V, there are included two preferred structures. In Formula VA, q is zero and the remaining variables are as defined above, and in Formula VB, q is 1 and the remaining variables are as defined above:

[0158] R4, R5 and R10 are each preferably 1-3 independently selected substituents as set forth above. Preferred are compounds of Formula (V) wherein Ar1 is phenyl, R10-substituted phenyl or thienyl, especially (4-R10)-substituted phenyl or thienyl. Ar2 is preferably R4-substituted phenyl, especially (4-R )-substituted phenyl. Ar3 is preferably phenyl or R5-substituted phenyl, especially (4-R5)-substituted phenyl. When Ar1 is R10-substituted phenyl, R10 is preferably halogeno, especially fluoro. When Ar2 is R4-substituted phenyl, R4 is preferably —OR6, especially wherein R6 is hydrogen or lower alkyl. When Ar3 is R5-substituted phenyl, R5 is preferably halogeno, especially fluoro. Especially preferred are compounds of Formula (V) wherein Ar1 is phenyl, 4-fluorophenyl or thienyl, Ar2 is 4-(alkoxy or hydroxy)phenyl, and Ar3 is phenyl or 4-fluorophenyl.

[0159] X and Y are each preferably —CH2—. The sum of m, n and q is preferably 2, 3 or 4, more preferably 2. When q is 1, n is preferably 1 to 5.

[0160] Preferences for X, Y, Ar1, Ar2 and Ar3 are the same in each of Formulae (VA) and (VB).

[0161] In compounds of Formula (VA), the sum of m and n is preferably 2, 3 or 4, more preferably 2. Also preferred are compounds wherein the sum of m and n is 2, and r is 0 or 1.

[0162] In compounds of Formula (VB), the sum of m and n is preferably 1, 2 or 3, more preferably 1. Especially preferred are compounds wherein m is zero and n is 1. R1 is preferably hydrogen and R is preferably —OR6 wherein R6 is hydrogen, or a group readily metabolizable to a hydroxyl (such as —O(CO)R6, —O(CO)OR9 and —O(CO)NR6R7, defined above), or R and R1 together form a ═O group.

[0163] Methods for making compounds of Formula V are well known to those skilled in the art. Non-limiting examples of suitable methods are disclosed in U.S. Pat. No. 5,624,920, which is incorporated herein by reference.

[0164] In another embodiment, sterol or 5α-stanol absorption inhibitors useful in the compositions, therapeutic combinations and methods of the present invention are represented by Formula (VI):

[0165] or a pharmaceutically acceptable salt thereof or a solvate thereof, wherein:

[0166] R1 is

[0167] R2 and R3 are independently selected from the group consisting of: —CH2—, —CH(lower alkyl)-, —C(di-lower alkyl)-, —CH═CH— and —C(lower alkyl)═CH—; or R1 together with an adjacent R2, or R1 together with an adjacent R3, form a —CH═CH— or a —CH═C(lower alkyl)- group;

[0168] u and v are independently 0, 1, 2 or 3, provided both are not zero; provided that when R2 is —CH═CH— or —C(lower alkyl)═CH—, v is 1; provided that when R3 is —CH═CH— or —C(lower alkyl)═CH—, u is 1; provided that when v is 2 or 3, the R2's can be the same or different; and provided that when u is 2 or 3, the R3's can be the same or different;

[0169] R4 is selected from B—(CH2)mC(O)—, wherein m is 0, 1, 2, 3, 4 or 5; B—(CH2)q—, wherein q is 0, 1, 2, 3, 4, 5 or 6; B—(CH2)e—Z—(CH2)r—, wherein Z is —O—, —C(O)—, phenylene, —N(R8)— or —S(O)0-2—, e is 0, 1, 2, 3, 4 or 5 and r is 0, 1, 2, 3, 4 or 5, provided that the sum of e and r is 0, 1, 2, 3, 4, 5 or 6; B—(C2-C6 alkenylene)-; B—(C4-C6 alkadienylene)-; B—(CH2)t—Z-(C2-C6 alkenylene)-, wherein Z is as defined above, and wherein t is 0, 1, 2 or 3, provided that the sum of t and the number of carbon atoms in the alkenylene chain is 2, 3, 4, 5 or 6; B—(CH2)f—V—(CH2)g—, wherein V is C3-C6 cycloalkylene, f is 1, 2, 3, 4 or 5 and g is 0, 1, 2, 3, 4 or 5, provided that the sum of f and g is 1, 2, 3, 4, 5 or 6; B—(CH2)t—V—(C2-C6 alkenylene)- or B—(C2-C6 alkenylene)-V—(CH2)t—, wherein V and t are as defined above, provided that the sum of t and the number of carbon atoms in the alkenylene chain is 2, 3, 4, 5 or 6; B—(CH2)a—Z—(CH2)b—V—(CH2)d—, wherein Z and V are as defined above and a, b and d are independently 0, 1, 2, 3, 4, 5 or 6, provided that the sum of a, b and d is 0, 1, 2, 3, 4, 5 or 6; or T—(CH2)s—, wherein T is cycloalkyl of 3-6 carbon atoms and s is 0, 1, 2, 3, 4, 5 or 6; or

[0170] R1 and R4 together form the group

[0171] B is selected from indanyl, indenyl, naphthyl, tetrahydronaphthyl, heteroaryl or W-substituted heteroaryl, wherein heteroaryl is selected from the group consisting of pyrrolyl, pyridinyl, pyrimidinyl, pyrazinyl, triazinyl, imidazolyl, thiazolyl, pyrazolyl, thienyl, oxazolyl and furanyl, and for nitrogen-containing heteroaryls, the N-oxides thereof, or

[0172] W is 1 to 3 substituents independently selected from the group consisting of lower alkyl, hydroxy lower alkyl, lower alkoxy, alkoxyalkyl, alkoxyalkoxy, alkoxycarbonylalkoxy, (lower alkoxyimino)-lower alkyl, lower alkanedioyl, lower alkyl lower alkanedioyl, allyloxy, —CF3, —OCF3, benzyl, R7-benzyl, benzyloxy, R7-benzyloxy, phenoxy, R7-phenoxy, dioxolanyl, NO2, —N(R8)(R9), N(R8)(R9)-lower alkylene-, N(R8)(R9)-lower alkylenyloxy-, OH, halogeno, —CN, —N3, —NHC(O)OR10, —NHC(O)R10, R11O2SNH—, (R11O2S)2N—, —S(O)2NH2, —S(O)0-2R8, tert-butyldimethyl-silyloxymethyl, —C(O)R12, —COOR19, —CON(R8)(R9), —CH═CHC(O)R12, -lower alkylene-C(O)R12, R10C(O)(lower alkylenyloxy)-, N(R8)(R9)C(O)(lower alkylenyloxy)- and

[0173] for substitution on ring carbon atoms, and the substituents on the substituted heteroaryl ring nitrogen atoms, when present, are selected from the group consisting of lower alkyl, lower alkoxy, —C(O)OR10, —C(O)R10, OH, N(R8)(R9)-lower alkylene-, N(R8)(R9)-lower alkylenyloxy-, —S(O)2NH2 and 2-(trimethylsilyl )-ethoxymethyl;

[0174] R7 is 1-3 groups independently selected from the group consisting of lower alkyl, lower alkoxy, —COOH, NO2, —N(R8)(R9), OH, and halogeno;

[0175] R8 and R9 are independently selected from H or lower alkyl;

[0176] R10 is selected from lower alkyl, phenyl, R7-phenyl, benzyl or R7-benzyl;

[0177] R11 is selected from OH, lower alkyl, phenyl, benzyl, R7-phenyl or R7-benzyl;

[0178] R12 is selected from H, OH, alkoxy, phenoxy, benzyloxy,

[0179] —N(R8)(R9), lower alkyl, phenyl or R7-phenyl;

[0180] R13 is selected from —O—, —CH2—, —NH—, —N(lower alkyl)- or —NC(O)R19;

[0181] R15, R16 and R17 are independently selected from the group consisting of H and the groups defined for W; or R15 is hydrogen and R16 and R17, together with adjacent carbon atoms to which they are attached, form a dioxolanyl ring;

[0182] R19 is H, lower alkyl, phenyl or phenyl lower alkyl; and

[0183] R20 and R21 are independently selected from the group consisting of phenyl, W-substituted phenyl, naphthyl, W-substituted naphthyl, indanyl, indenyl, tetrahydronaphthyl, benzodioxolyl, heteroaryl, W-substituted heteroaryl, benzofused heteroaryl, W-substituted benzofused heteroaryl and cyclopropyl, wherein heteroaryl is as defined above.

[0184] One group of preferred compounds of Formula VI is that in which R21 is selected from phenyl, W-substituted phenyl, indanyl, benzofuranyl, benzodioxolyl, tetrahydronaphthyl, pyridyl, pyrazinyl, pyrimidinyl, quinolyl or cyclopropyl, wherein W is lower alkyl, lower alkoxy, OH, halogeno, —N(R8)(R9), —NHC(O)OR10, —NHC(O)R10, NO2, —CN, —N3, —SH, —S(O)0-2-(lower alkyl), —COOR19, —CON(R8)(R9), —COR12, phenoxy, benzyloxy, —OCF3, —CH═C(O)R12 or tert-butyidimethylsilyloxy, wherein R8, R9, R10, R12 and R19 are as defined for Formula IV. When W is 2 or 3 substituents, the substituents can be the same or different.

[0185] Another group of preferred compounds of Formula VI is that in which R20 is phenyl or W-substituted phenyl, wherein preferred meanings of W are as defined above for preferred definitions of R21.

[0186] More preferred are compounds of Formula VI wherein R20 is phenyl or W-substituted phenyl and R21 is phenyl, W-substituted phenyl, indanyl, benzofuranyl, benzodioxolyl, tetrahydronaphthyl, pyridyl, pyrazinyl, pyrimidinyl, quinolyl or cyclopropyl; W is lower alkyl, lower alkoxy, OH, halogeno, —N(R8)(R9), —NHC(O)OR10, —NHC(O)R10, NO2, —CN, —N3, —SH, —S(O)0-2-(lower alkyl), —COOR19, —CON(R8)(R9), —COR12, phenoxy, benzyloxy, —CH═CHC(O)R12, —OCF3 or tert-butyl-dimethyl-silyloxy, wherein when W is 2 or 3 substituents, the substituents can be the same or different, and wherein R8, R9, R10, R12 and R19 are as defined in Formula VI.

[0187] Also preferred are compounds of Formula VI wherein R1 is

[0188] Another group of preferred compounds of Formula VI is in which R2 and R3 are each —CH2— and the sum of u and v is 2, 3 or 4, with u=v=2 being more preferred.

[0189] R4 is preferably B—(CH2)q— or B—(CH2)e—Z—(CH2)r, wherein B, Z, q, e and r are as defined above. B is preferably

[0190] wherein R16 and R17 are each hydrogen and wherein R15 is preferably H, OH, lower alkoxy, especially methoxy, or halogeno, especially chloro.

[0191] Preferably Z is —O—, e is 0, and r is 0.

[0192] Preferably q is 0-2.

[0193] R20 is preferably phenyl or W-substituted phenyl.

[0194] Preferred W substituents for R20 are lower alkoxy, especially methoxy and ethoxy, OH, and —C(O)R12, wherein R12 is preferably lower alkoxy.

[0195] Preferably R21 is selected from phenyl, lower alkoxy-substituted phenyl and F-phenyl.

[0196] Especially preferred are compounds of Formula VI wherein R1 is

[0197] or

[0198] R2 and R3 are each —CH2—, u=v=2, R4 is B—(CH2)q—, wherein B is phenyl or phenyl substituted by lower alkoxy or chloro, q is 0-2, R20 is phenyl, OH-phenyl, lower alkoxy-substituted phenyl or lower alkoxycarbonyl-substituted phenyl, and R21 is phenyl, lower alkoxy-substituted phenyl or F-phenyl.

[0199] Methods for making compounds of Formula VI are well known to those skilled in the art. Non-limiting examples of suitable methods are disclosed in U.S. Pat. No. 5,698,548, which is incorporated herein by reference.

[0200] In another embodiment, sterol or 5α-stanol inhibitors useful in the compositions, therapeutic combinations and methods of the present invention are represented by Formulas (VIIA) and (VIIB):

[0201] or a pharmaceutically acceptable salt or solvate thereof, wherein:

[0202] A is —CH═CH—, —C≡C— or —(CH2)p— wherein p is 0, 1 or 2;

[0203] B is

[0204] B′ is

[0205] D is —(CH2)mC(O)— or —(CH2)q— wherein m is 1, 2, 3 or 4 and q is 2, 3 or 4;

[0206] E is C10 to C20 alkyl or —C(O)—(C9 to C19)-alkyl, wherein the alkyl is straight or branched, saturated or containing one or more double bonds;

[0207] R is hydrogen, C1-C15 alkyl, straight or branched, saturated or containing one or more double bonds, or B—(CH2)r—, wherein r is 0, 1, 2, or 3;

[0208] R1, R2, R3, R1′, R2′, and R3′ are independently selected from the group consisting of hydrogen, lower alkyl, lower alkoxy, carboxy, NO2, NH2, OH, halogeno, lower alkylamino, dilower alkylamino, —NHC(O)OR5, R6O2SNH— and —S(O)2NH2;

[0209] R4 is

[0210] wherein n is 0, 1, 2 or 3;

[0211] R5 is lower alkyl; and

[0212] R6 is OH, lower alkyl, phenyl, benzyl or substituted phenyl wherein the substituents are 1-3 groups independently selected from the group consisting of lower alkyl, lower alkoxy, carboxy, NO2, NH2, OH, halogeno, lower alkylamino and dilower alkylamino; or a pharmaceutically acceptable salt thereof or a prodrug thereof.

[0213] Preferred are compounds of Formula (VIIA) wherein R is hydrogen, saturated or mono-unsaturated C1-C10 alkyl or phenyl. Another group of preferred compounds of Formula (VIIA) is that in which D is propyl (i.e., —(CH2)q— and q is 3). A third group of preferred compounds of Formula (VIIA) is that wherein R4 is p-methoxyphenyl or 2,4,6-trimethoxyphenyl. Still another group of preferred compounds of Formula (VIIA) is that wherein A is ethylene or a bond (i.e., —(CH2)p— wherein p is zero). R1′, R2′, and R3′ are preferably each hydrogen, and preferably R1 is hydrogen, hydroxy, nitro, lower alkoxy, amino or t-butoxycarbonyl-amino and R2 and R3 are each hydrogen.

[0214] More preferred are compounds of Formula (VIIA) wherein R1′, R2′, and R3′ are each hydrogen; R1 is hydrogen, hydroxy, nitro, lower alkoxy, amino or t-butoxycarbonyl-amino and R2 and R3 are each hydrogen; R is hydrogen, ethyl or phenyl; D is propyl; R4 is p-methoxyphenyl or 2,4,6-trimethoxyphenyl; and A is ethylene or a bond.

[0215] Preferred compounds of Formula (VIIA), wherein B′ is phenyl, are shown in the following table:

2DRABR4—(CH2)3—H—p-MeO—p-MeO-phenylphenyl—CH2C(O)—phenyl—phenylp-MeO-phenyl—(CH2)3—H—phenylp-MeO-phenyl—(CH2)3—H—p-OH—p-MeO-phenylphenyl—(CH2)3—Hethylenep-MeO—p-MeO-phenylphenyl—(CH2)3—H—3-MeO—p-MeO-phenylphenyl—(CH2)3—ethyl—phenylp-MeO-phenyl—(CH2)3—phenyl—phenylp-MeO-phenyl—(CH2)3—ethyl—phenyl2,4,6-tri-MeO-phenyl—(CH2)3—methyl—phenylp-MeO-phenyl—(CH2)3—H—p-NH2—p-MeO-phenylphenyl

[0216] The first-listed compound in the above table having the (3R,4S) absolute stereochemistry is more preferred.

[0217] Preferred compounds of Formula (VIIB) are those wherein R is hydrogen, methyl, ethyl, phenyl or phenylpropyl. Another group of preferred compounds of Formula (VIIB) is that wherein R4 is p-methoxyphenyl or 2,4,6-trimethoxyphenyl. Still another group of preferred compounds of Formula (VIB) is that wherein A is ethylene or a bond. Yet another group of preferred compounds of Formula (VIIB) is that wherein E is decyl, oleoyl or 7-Z-hexadecenyl. Preferably R1, R2 and R3 are each hydrogen.

[0218] More preferred compounds of Formula (VIIB) are those wherein R is hydrogen, methyl, ethyl, phenyl or phenylpropyl; R4 is p-methoxyphenyl or 2,4,6-trimethoxyphenyl; A is ethylene or a bond; E is decyl, oleoyl or 7-Z-hexadecenyl; and R1, R2 and R3 are each hydrogen.

[0219] A preferred compound of Formula (VIIB) is that wherein E is decyl, R is hydrogen, B-A is phenyl and R4 is p-methoxyphenyl.

[0220] In another embodiment, sterol or 5α-stanol absorption inhibitors useful in the compositions and methods of the present invention are represented by Formula (VIII):

[0221] or a pharmaceutically acceptable salt thereof or a solvate thereof, wherein, in Formula (VIII) above,

[0222] R26 is H or OG1;

[0223] G and G1 are independently selected from the group consisting of

[0224] provided that when R26 is H or OH, G is not H;

[0225] R, Ra and Rb are independently selected from the group consisting of H, —OH, halogeno, —NH2, azido, (C1-C6)alkoxy(C1-C6)-alkoxy or —W—R30;

[0226] W is independently selected from the group consisting of —NH—C(O)—, —O—C(O)—, —O—C(O)—N(R31)—, —NH—C(O)—N(R31)— and —O—C(S)—N(R31)—;

[0227] R2 and R6 are independently selected from the group consisting of H, (C1-C6)alkyl, aryl and aryl(C1-C6)alkyl;

[0228] R3, R4, R5, R7, R3a and R4a are independently selected from the group consisting of H, (C1-C6)alkyl, aryl(C1-C6)alkyl, —C(O)(C1-C6)alkyl and —C(O)aryl;

[0229] R30 is selected from the group consisting of R32-substituted T, R32-substituted-T-(C1-C6)alkyl, R32-substituted-(C2-C4)alkenyl, R32-substituted-(C1-C6)alkyl, R32-substituted-(C3-C7)cycloalkyl and R32-substituted-(C3-C7)cycloalkyl(C1-C6)alkyl;

[0230] R31 is selected from the group consisting of H and (C1-C4)alkyl;

[0231] T is selected from the group consisting of phenyl, furyl, thienyl, pyrrolyl, oxazolyl, isoxazolyl, thiazolyl, iosthiazolyl, benzothiazolyl, thiadiazolyl, pyrazolyl, imidazolyl and pyridyl;

[0232] R32 is independently selected from 1-3 substituents independently selected from the group consisting of halogeno, (C1-C4)alkyl, —OH, phenoxy, —CF3, —NO2, (C1-C4)alkoxy, methylenedioxy, oxo, (C1-C4)alkylsulfanyl, (C1-C4)alkylsulfinyl, (C1-C4)alkylsulfonyl, —N(CH3)2, —C(O)—NH(C1-C4)alkyl, —C(O)—N((C1-C4)alkyl)2, —C(O)—(C1-C4)alkyl, —C(O)—(C1-C4)alkoxy and pyrrolidinylcarbonyl; or R32 is a covalent bond and R31, the nitrogen to which it is attached and R32 form a pyrrolidinyl, piperidinyl, N-methyl-piperazinyl, indolinyl or morpholinyl group, or a (C1-C4)alkoxycarbonyl-substituted pyrrolidinyl, piperidinyl, N-methylpiperazinyl, indolinyl or morpholinyl group;

[0233] Ar1 is aryl or R10-substituted aryl;

[0234] Ar2 is aryl or R11-substituted aryl;

[0235] Q is a bond or, with the 3-position ring carbon of the azetidinone, forms the spiro group

[0236] and

[0237] R1 is selected from the group consisting of

[0238] —(CH2)q—, wherein q is 2-6, provided that when Q forms a spiro ring, q can also be zero or 1;

[0239] —(CH2)e—E—(CH2)r—, wherein E is —O—, —C(O)—, phenylene, —NR22— or —S(O)0-2—, e is 0-5 and r is 0-5, provided that the sum of e and r is 1-6;

[0240] —(C2-C6)alkenylene-; and

[0241] —(CH2)f—V—(CH2)g—, wherein V is C3-C6 cycloalkylene, f is 1-5 and g is 0-5, provided that the sum of f and g is 1-6;

[0242] R12 is

[0243] R13 and R14 are independently selected from the group consisting of —CH2—, —CH(C1-C6 alkyl)-, —C(di-(C1-C6) alkyl), —CH═CH— and —C(C1-C6 alkyl)═CH—; or R12 together with an adjacent R13, or R12 together with an adjacent R14, form a —CH═CH— or a —CH═C(C1-C6 alkyl)- group;

[0244] a and b are independently 0, 1, 2 or 3, provided both are not zero;

[0245] provided that when R13 is —CH═CH— or —C(C1-C6 alkyl)═CH—, a is 1;

[0246] provided that when R14 is —CH═CH— or —C(C1-C6 alkyl)═CH—, b is 1;

[0247] provided that when a is 2 or 3, the R13's can be the same or different; and

[0248] provided that when b is 2 or 3, the R14's can be the same or different;

[0249] and when Q is a bond, R1 also can be:

[0250] M is —O—, —S—, —S(O)— or —S(O)2—;

[0251] X, Y and Z are independently selected from the group consisting of —CH2—, —CH(C1-C6)alkyl- and —C(di-(C1-C6)alkyl);

[0252] R10 and R11 are independently selected from the group consisting of 1-3 substituents independently selected from the group consisting of (C1-C6)alkyl, —OR19, —O(CO)R19, —O(CO)OR21, —O(CH2)1-5OR19, —O(CO)NR19R20, —NR19R20, —NR19(CO)R20, —NR19(CO)OR21, —NR19(CO)NR20R25, —NR19SO2R21, —COOR19, —CONR19R20, —COR19, —SO2NR19R20, S(O)0-2R21, —O(CH2)1-10—COOR19, —O(CH2)1-10CONR19R20, —(C1-C6 alkylene)-COOR19, —CH═CH—COOR19, —CF3, —CN, —NO2 and halogen;

[0253] R15 and R17 are independently selected from the group consisting of —OR19, —O(CO)R19, —O(CO)OR21 and —O(CO)NR19R20;

[0254] R16 and R18 are independently selected from the group consisting of H, (C1-C6)alkyl and aryl; or R15 and R16 together are ═O, or R17 and R18 together are ═O;

[0255] d is 1, 2 or 3;

[0256] h is 0, 1, 2, 3 or 4;

[0257] s is 0 or 1; t is 0 or 1; m, n and p are independently 0-4;

[0258] provided that at least one of s and t is 1, and the sum of m, n, p, s and t is 1-6;

[0259] provided that when p is 0 and t is 1, the sum of m, s and n is 1-5; and provided that when p is 0 and s is 1, the sum of m, t and n is 1-5;

[0260] v is O or 1;

[0261] j and k are independently 1-5, provided that the sum of j, k and v is 1-5; and when Q is a bond and R1 is

[0262] Ar1 can also be pyridyl, isoxazolyl, furanyl, pyrrolyl, thienyl, imidazolyl, pyrazolyl, thiazolyl, pyrazinyl, pyrimidinyl or pyridazinyl;

[0263] R19 and R20 are independently selected from the group consisting of H, (C1-C6)alkyl, aryl and aryl-substituted (C1-C6)alkyl;

[0264] R21 is (C1-C6)alkyl, aryl or R24-substituted aryl;

[0265] R22 is H, (C1-C6)alkyl, aryl (C1-C6)alkyl, —C(O)R19 or —COOR19;

[0266] R23 and R24 are independently 1-3 groups independently selected from the group consisting of H, (C1-C6)alkyl, (C1-C6)alkoxy, —COOH, NO2, —NR19R20, —OH and halogeno; and

[0267] R25 is H, —OH or (C1-C6)alkoxy.

[0268] Ar2 is preferably phenyl or R11-phenyl, especially (4-R11)-substituted phenyl. Preferred definitions of R11 are lower alkoxy, especially methoxy, and halogeno, especially fluoro.

[0269] Ar1 is preferably phenyl or R10-substituted phenyl, especially (4-R10)-substituted phenyl. Preferably R10 is halogeno, and more preferably fluoro.

[0270] There are several preferred definitions for the —R1-Q- combination of variables:

[0271] Q is a bond and R1 is lower alkylene, preferably propylene;

[0272] Q is a spiro group as defined above, wherein preferably R13 and R14 are each ethylene and R12 is

[0273] and R1 is —(CH2)q wherein q is 0-6;

[0274] Q is a bond and R1 is

[0275] wherein the variables are chosen such that R1 is —O—CH2—CH(OH)—;

[0276] Q is a bond and R1

[0277] wherein the is variables are chosen such that R1 is —CH(OH)—(CH2)2—; and

[0278] Q is a bond and R1 is

[0279] wherein the variables are chosen such that R1 is —CH(OH)—CH2—S(O)0-2—.

[0280] A preferred compound of Formula (VIII) therefore, is one wherein G and G1 are as defined above and in which the remaining variables have the following definitions:

[0281] Ar1 is phenyl or R10-substituted phenyl, wherein R10 is halogeno;

[0282] Ar2 is phenyl or R11-phenyl, wherein R11 is 1 to 3 substituents independently selected from the group consisting of C1-C6 alkoxy and halogeno;

[0283] Q is a bond and R1 is lower alkylene; Q, with the 3-position ring carbon of the azetidinone, forms the group

[0284] wherein preferably R13 and R14 are each ethylene and a and b are each 1, and wherein R12 is

[0285] Q is a bond and R1 is —O—CH2—CH(OH)—; Q is a bond and R1 is —CH(OH)—(CH2)2—; or Q is a bond and R1 is —CH(OH)—CH2—S(O)0-2—.

[0286] Preferred variables for G and G1 groups of the formulae

[0287] are as follows:

[0288] R2, R3, R4, R5, R6 and R7 are independently selected from the group consisting of H, (C1-C6)alkyl, benzyl and acetyl.

[0289] Preferred variables for group G or G1 of the formula:

[0290] are as follows:

[0291] R3, R3a, R4 and R4a are selected from the group consisting of H, (C1-C6)alkyl, benzyl and acetyl;

[0292] R, Ra and Rb are independently selected from the group consisting of H, —OH, halogeno, —NH2, azido, (C1-C6)alkoxy(C1-C6)alkoxy and —W—R30,

[0293] wherein W is —O—C(O)— or —O—C(O)—NR31—, R31 is H and R30 is (C1-C6)alkyl, —C(O)—(C1-C4)alkoxy-(C1-C6)alkyl, T, T-(C1-C6)alkyl, or T or T-(C1-C6)alkyl wherein T is substituted by one or two halogeno or (C1-C6)alkyl groups.

[0294] Preferred R30 substituents are selected from the group consisting of: 2-fluorophenyl, 2,4-difluoro-phenyl, 2,6-dichlorophenyl, 2-methylphenyl, 2-thienylmethyl, 2-methoxy-carbonylethyl, thiazol-2-yl-methyl, 2-furyl, 2-methoxycarbonylbutyl and phenyl.

[0295] Preferred combinations of R, Ra and Rb are as follows:

[0296] 1) R, Ra and Rb are independently —OH or —O—C(O)—NH—R30, especially wherein Ra is —OH and R and Rb are —O—C(O)—NH—R30 and R30 is selected from the preferred substituents identified above, or wherein R and Ra are each —OH and Rb is —O—C(O)—NH—R30 wherein R30 is 2-fluorophenyl, 2,4-difluoro-phenyl, 2,6-dichlorophenyl;

[0297] 2) Ra is —OH, halogeno, azido or (C1-C6)-alkoxy(C1-C6)alkoxy, Rb is H, halogeno, azido or (C1-C6)alkoxy(C1-C6)-alkoxy, and R is —O—C(O)—NH—R30, especially compounds wherein Ra is —OH, Rb is H and R30 is 2-fluorophenyl;

[0298] 3) R, Ra and Rb are independently —OH or —O—C(O)—R30 and R30 is (C1-C6)alkyl, T, or T substituted by one or two halogeno or (C1-C6)alkyl groups, especially compounds wherein R is —OH and Ra and Rb are —O—C(O)—R30 wherein R30 is 2-furyl; and

[0299] 4) R, Ra and Rb are independently —OH or halogeno. Three additional classes of preferred compounds are those wherein the C1′ anomeric oxy is beta, wherein the C2′ anomeric oxy is beta, and wherein the R group is alpha.

[0300] G and G1 are preferably selected from:

[0301] wherein Ac is acetyl and Ph is phenyl.

[0302] Preferably, R26 is H or OH, more preferably H. The —O-G substituent is preferably in the 4-position of the phenyl ring to which it is attached.

[0303] In another embodiment, sterol or 5α-stanol absorption inhibitors useful in the compositions and methods of the present invention are represented by Formula (IX) below:

[0304] or a pharmaceutically acceptable salt or solvate thereof, wherein in Formula (IX):

[0305] R1 is selected from the group consisting of H, G, G1, G2, —SO3H and —PO3H;

[0306] G is selected from the group consisting of: H,

[0307] (sugar derivatives)

[0308] wherein R, Ra and Rb are each independently selected from the group consisting of H, —OH, halo, —NH2, azido, (C1-C6)alkoxy(C1-C6)alkoxy or —W—R30;

[0309] W is independently selected from the group consisting of —NH—C(O)—, —O—C(O)—, —O—C(O)—N(R31 )—, —NH—C(O)—N(R31 )— and —O—C(S)—N(R31)—;

[0310] R2 and R6 are each independently selected from the group consisting of H, (C1-C6)alkyl, acetyl, aryl and aryl(C1-C6)alkyl;

[0311] R3, R4, R5, R7, R3a and R4a are each independently selected from the group consisting of H, (C1-C6)alkyl, acetyl, aryl(C1-C6)alkyl, —C(O)(C1-C6)alkyl and —C(O)aryl;

[0312] R30 is independently selected from the group consisting of R32-substituted T, R32-substituted-T-(C1-C6)alkyl, R32-substituted-(C2-C4)alkenyl, R32-substituted-(C1-C6)alkyl, R32-substituted-(C3-C7)cycloalkyl and R32-substituted-(C3-C7)cycloalkyl(C1-C6)alkyl;

[0313] R31 is independently selected from the group consisting of H and (C1-C4)alkyl;

[0314] T is independently selected from the group consisting of phenyl, furyl, thienyl, pyrrolyl, oxazolyl, isoxazolyl, thiazolyl, isothiazolyl, benzothiazolyl, thiadiazolyl, pyrazolyl, imidazolyl and pyridyl;

[0315] R32 is independently selected from 1-3 substituents which are each independently selected from the group consisting of H, halo, (C1-C4)alkyl, —OH, phenoxy, —CF3, —NO2, (C1-C4)alkoxy, methylenedioxy, oxo, (C1-C4)alkylsulfanyl, (C1-C4)alkylsulfinyl, (C1-C4)alkylsulfonyl, —N(CH3)2, —C(O)—NH(C1-C4)alkyl, —C(O)—N((C1-C4)alkyl)2, —C(O)—(C1-C4)alkyl, —C(O)—(C1-C4)alkoxy and pyrrolidinylcarbonyl; or R32 is a covalent bond and R31, the nitrogen to which it is attached and R32 form a pyrrolidinyl, piperidinyl, N-methyl-piperazinyl, indolinyl or morpholinyl group, or a (C1-C4)alkoxycarbonyl-substituted pyrrolidinyl, piperidinyl, N-methylpiperazinyl, indolinyl or morpholinyl group;

[0316] G1 is represented by the structure:

[0317] wherein R33 is independently selected from the group consisting of unsubstituted alkyl, R34-substituted alkyl, (R35)(R36)alkyl-,

[0318] R34 is one to three substituents, each R34 being independently selected from the group consisting of HOOC—, HS—, (CH3)S—, H2N—, (NH2)(NH)C(NH)—, (NH2)C(O)— and HOOCCH(NH3+)CH2SS—;

[0319] R35 is independently selected from the group consisting of H and NH2—;

[0320] R36 is independently selected from the group consisting of H, unsubstituted alkyl, R34-substituted alkyl, unsubstituted cycloalkyl and R34-substituted cycloalkyl;

[0321] G2 is represented by the structure:

[0322] wherein R37 and R38 are each independently selected from the group consisting of (C1-C6)alkyl and aryl;

[0323] R26 is one to five substituents, each R26 being independently selected from the group consisting of:

[0324] a) H;

[0325] b) —OH;

[0326] c) —OCH3;

[0327] d) fluorine;

[0328] e) chlorine;

[0329] f) —O-G;

[0330] g) —O-G1;

[0331] h) —O-G2;

[0332] i) —SO3H; and

[0333] j) —PO3H;

[0334] provided that when R1 is H, R26 is not H, —OH, —OCH3 or —O-G;

[0335] Ar1 is aryl, R10-substituted aryl, heteroaryl or R10-substituted heteroaryl;

[0336] Ar2 is aryl, R11-substituted aryl, heteroaryl or R11-substituted heteroaryl;

[0337] L is selected from the group consisting of:

[0338] a) a covalent bond;

[0339] b) —(CH2)q—, wherein q is 1-6;

[0340] c) —(CH2)e-E-(CH2)r—, wherein E is —O—, —C(O)—, phenylene, —NR22— or —S(O)0-2—, e is 0-5 and r is 0-5, provided that the sum of e and r is 1-6;

[0341] d) —(C2-C6)alkenylene-;

[0342] e) —(CH2)f—V—(CH2)g—, wherein V is C3-C6cycloalkylene, f is 1-5 and g is 0-5, provided that the sum of f and g is 1-6; and

[0343] f)

[0344] wherein M is —O—, —S—, —S(O)— or —S(O)2—;

[0345] X, Y and Z are each independently selected from the group consisting of —CH2—, —CH(C1-C6)alkyl- and —C(di-(C1-C6)alkyl)-;

[0346] R8 is selected from the group consisting of H and alkyl;

[0347] R10 and R11 are each independently selected from the group consisting of 1-3 substituents which are each independently selected from the group consisting of (C1-C6)alkyl, —OR19, —O(CO)R19, —O(CO)OR21, —O(CH2)1-5OR19, —O(CO)NR19R20, —NR19R20, —NR19(CO)R20, —NR19(CO)OR21, —NR19(CO)NR20R25, —NR19SO2R21, —COOR19, —CONR19R20, —COR19, —SO2NR19R20, S(O)O0-2R21, —O(CH2)1-10—COOR19, —O(CH2)1-10CONR19R20, —(C1-C6 alkylene)-COOR19, —CH═CH—COOR19, —CF3, —CN, —NO2 and halo;

[0348] R15 and R17 are each independently selected from the group consisting of —OR19, —OC(O)R19, —OC(O)OR21, —OC(O)NR19R20;

[0349] R16 and R18are each independently selected from the group consisting of H, (C1-C6)alkyl and aryl;

[0350] or R15 and R16 together are ═O, or R17 and R18 together are ═O;

[0351] d is 1, 2 or 3;

[0352] h is 0, 1, 2, 3 or 4;

[0353] s is 0 or 1;

[0354] t is 0 or 1;

[0355] m, n and p are each independently selected from 0-4;

[0356] provided that at least one of s and t is 1, and the sum of m, n, p, s and t is 1-6; provided that when p is 0 and t is 1, the sum of m, n and p is 1-5; and provided that when p is 0 and s is 1, the sum of m, t and n is 1-5;

[0357] v is 0 or 1;

[0358] j and k are each independently 1-5, provided that the sum of j, k and v is 1-5;

[0359] Q is a bond, —(CH2)q—, wherein q is 1-6, or, with the 3-position ring carbon of the azetidinone, forms the spiro group

[0360] wherein R12 is

[0361] R13 and R14 are each independently selected from the group consisting of —CH2—, —CH(C1-C6 alkyl)-, —C(di-(C1-C6) alkyl), —CH═CH— and —C(C1-C6 alkyl)═CH—; or R12 together with an adjacent R13, or R12 together with an adjacent R14, form a —CH═CH— or a —CH═C(C1-C6 alkyl)- group;

[0362] a and b are each independently 0, 1, 2 or 3, provided both are not zero; provided that when R13 is —CH═CH— or —C(C1-C6 alkyl)═CH—, a is 1; provided that when R14 is —CH═CH— or —C(C1-C6 alkyl)═CH—, b is 1; provided that when a is 2 or 3, the R13's can be the same or different; and provided that when b is 2 or 3, the R14's can be the same or different;

[0363] and when Q is a bond and L is

[0364] then Ar1 can also be pyridyl, isoxazolyl, furanyl, pyrrolyl, thienyl, imidazolyl, pyrazolyl, thiazolyl, pyrazinyl, pyrimidinyl or pyridazinyl;

[0365] R19 and R20 are each independently selected from the group consisting of H, (C1-C6)alkyl, aryl and aryl-substituted (C1-C6)alkyl;

[0366] R21 is (C1-C6)alkyl, aryl or R24-substituted aryl;

[0367] R22 is H, (C1-C6)alkyl, aryl (C1-C6)alkyl, —C(O)R19 or —COOR19;

[0368] R23 and R24 are each independently selected from the group consisting of 1-3 substituents which are each independently selected from the group consisting of H, (C1-C6)alkyl, (C1-C6)alkoxy, —COOH, NO2, —NR19R20, —OH and halo; and

[0369] R25 is H, —OH or (C1-C6)alkoxy.

[0370] Examples of compounds of Formula (IX) which are useful in the methods and combinations of the present invention and methods for making such compounds are disclosed in U.S. patent application Ser. No. 10/166,942, filed Jun. 11, 2002, incorporated herein by reference.

[0371] An example of a useful compound of this invention is one represented by the formula X:

[0372] wherein R1 is defined as above.

[0373] A more preferred compound is one represented by formula XI:

[0374] Another useful compound is represented by Formula XII:

[0375] Other useful substituted azetidinone compounds include N-sulfonyl-2-azetidinones such as are disclosed in U.S. Pat. No. 4,983,597 and ethyl 4-(2-oxoazetidin-4-yl)phenoxy-alkanoates such as are disclosed in Ram et al., Indian J. Chem. Sect. B. 29B, 12 (1990), p. 1134-7, which are incorporated by reference herein.

[0376] The compounds of Formulae I-XII can be prepared by known methods, including the methods discussed above and, for example, WO 93/02048 describes the preparation of compounds wherein —R1-Q- is alkylene, alkenylene or alkylene interrupted by a hetero atom, phenylene or cycloalkylene; WO 94/17038 describes the preparation of compounds wherein Q is a spirocyclic group; WO 95/08532 describes the preparation of compounds wherein —R1-Q- is a hydroxy-substituted alkylene group; PCT/US95/03196 describes compounds wherein —R1-Q- is a hydroxy-substituted alkylene attached to the Ar1 moiety through an —O— or S(O)0-2— group; and U.S. Ser. No. 08/463,619, filed Jun. 5, 1995, describes the preparation of compounds wherein —R1-Q- is a hydroxy-substituted alkylene group attached the azetidinone ring by a —S(O)0-2— group.

[0377] The daily dose of the sterol or 5α-stanol absorption inhibitor(s) can range from about 0.1 to about 1000 mg per day, preferably about 0.25 to about 50 mg/day, and more preferably about 10 mg per day, given in a single dose or 2-4 divided doses. The exact dose, however, is determined by the attending clinician and is dependent on the potency of the compound administered, the age, weight, condition and response of the patient.

[0378] For administration of pharmaceutically acceptable salts of the above compounds, the weights indicated above refer to the weight of the acid equivalent or the base equivalent of the therapeutic compound derived from the salt.

[0379] The compositions or therapeutic combinations of the present invention can further comprise at least one (one or more) activators for peroxisome proliferator-activated receptors (PPAR). The activators act as agonists for the peroxisome proliferator-activated receptors. Three subtypes of PPAR have been identified, and these are designated as peroxisome proliferator-activated receptor alpha (PPARα), peroxisome proliferator-activated receptor gamma (PPARγ) and peroxisome proliferator-activated receptor delta (PPARδ). It should be noted that PPARδ is also referred to in the literature as PPARβ and as NUC1, and each of these names refers to the same receptor.

[0380] PPARα regulates the metabolism of lipids. PPARα is activated by fibrates and a number of medium and long-chain fatty acids, and it is involved in stimulating β-oxidation of fatty acids. The PPARγ receptor subtypes are involved in activating the program of adipocyte differentiation and are not involved in stimulating peroxisome proliferation in the liver. PPARδ has been identified as being useful in increasing high density lipoprotein (HDL) levels in humans. See, e.g., WO 97/28149.

[0381] Useful examples of PPARα activators include fibrates. Non-limiting examples of suitable fibric acid derivatives (“fibrates”) include clofibrate (such as ethyl 2-(p-chlorophenoxy)-2-methyl-propionate, for example ATROMID-S® Capsules which are commercially available from Wyeth-Ayerst); gemfibrozil (such as 5-(2,5-dimethylphenoxy)-2,2-dimethylpentanoic acid, for example LOPID® tablets which are commercially available from Parke Davis); ciprofibrate (C.A.S. Registry No. 52214-84-3, see U.S. Pat. No. 3,948,973 which is incorporated herein by reference); bezafibrate (C.A.S. Registry No.41859-67-0, see U.S. Pat. No. 3,781,328 which is incorporated herein by reference); clinofibrate (C.A.S. Registry No. 30299-08-2, see U.S. Pat. No. 3,716,583 which is incorporated herein by reference); binifibrate (C.A.S. Registry No. 69047-39-8, see BE 884722 which is incorporated herein by reference); lifibrol (C.A.S. Registry No. 96609-16-4); fenofibrate (such as TRICOR® micronized fenofibrate (2-[4-(4-chlorobenzoyl) phenoxy]-2-methyl-propanoic acid, 1-methylethyl ester) which is commercially available from Abbott Laboratories or LIPANTHYL® micronized fenofibrate which is commercially available from Labortoire Founier, France) and mixtures thereof. These compounds can be used in a variety of forms, including but not limited to acid form, salt form, racemates, enantiomers, zwitterions and tautomers.

[0382] Other examples of PPARα activators useful with the practice of the present invention include suitable fluorophenyl compounds as disclosed in U.S. Pat. No. 6,028,109 which is incorporated herein by reference; certain substituted phenylpropionic compounds as disclosed in WO 00/75103 which is incorporated herein by reference; and PPARα activator compounds as disclosed in WO 98/43081 which is incorporated herein by reference.

[0383] Non-limiting examples of PPARγ activator include suitable derivatives of glitazones or thiazolidinediones, such as, troglitazone (such as REZULIN® troglitazone (-5-[[4-[3,4-dihydro-6-hydroxy-2,5,7,8-tetramethyl-2H-1-benzopyran-2-yl)methoxy]phenyl]methyl]-2,4-thiazolidinedione) commercially available from Parke-Davis); rosiglitazone (such as AVANDIA® rosiglitazone maleate (-5-[[4-[2-(methyl-2-pyridinylamino)ethoxy]phenyl]methyl]-2,4-thiazolidinedione, -2-butenedioate) commercially available from SmithKline Beecham) and pioglitazone (such as ACTOS™ pioglitazone hydrochloride (5-[[4-[2-(5-ethyl-2-pyridinyl)ethoxy]phenyl]methyl]-2,4-]thiazolidinedione monohydrochloride) commercially available from Takeda Pharmaceuticals). Other useful thiazolidinediones include ciglitazone, englitazone, darglitazone and BRL 49653 as disclosed in WO 98/05331 which is incorporated herein by reference; PPARγ activator compounds disclosed in WO 00/76488 which is incorporated herein by reference; and PPARγ activator compounds disclosed in U.S. Pat. No. 5,994,554 which is incorporated herein by reference.

[0384] Other useful classes of PPARγ activator compounds include certain acetylphenols as disclosed in U.S. Pat. No. 5,859,051 which is incorporated herein by reference; certain quinoline phenyl compounds as disclosed in WO 99/20275 which is incorporated herein by reference; aryl compounds as disclosed by WO 99/38845 which is incorporated herein by reference; certain 1,4-disubstituted phenyl compounds as disclosed in WO 00/63161; certain aryl compounds as disclosed in WO 01/00579 which is incorporated herein by reference; benzoic acid compounds as disclosed in WO 01/12612 & WO 01/12187 which are incorporated herein by reference; and substituted 4-hydroxy-phenylalconic acid compounds as disclosed in WO 97/31907 which is incorporated herein by reference.

[0385] PPARδ compounds are useful for, among other things, lowering triglyceride levels or raising HDL levels. Non-limiting examples of PPARδ activators include suitable thiazole and oxazole derivatives, such as C.A.S. Registry No. 317318-32-4, as disclosed in WO 01/00603 which is incorporated herein by reference); certain fluoro, chloro or thio phenoxy phenylacetic acids as disclosed in WO 97/28149 which is incorporated, herein by reference; suitable non-β-oxidizable fatty acid analogues as disclosed in U.S. Pat. No. 5,093,365 which is incorporated herein by reference; and PPARδ compounds as disclosed in WO 99/04815 which is incorporated herein by reference.

[0386] Moreover, compounds that have multiple functionality for activating various combinations of PPARα, PPARγ and PPARδ are also useful with the practice of the present invention. Non-limiting examples include certain substituted aryl compounds as disclosed in U.S. Pat. No. 6,248,781; WO 00/23416; WO 00/23415; WO 00/23425; WO 00/23445; WO 00/23451; and WO 00/63153, all of which are incorporated herein by reference, are described as being useful PPARα and/or PPARγ activator compounds. Other non-limiting examples of useful PPARα and/or PPARγ activator compounds include activator compounds as disclosed in WO 97/25042 which is incorporated herein by reference; activator compounds as disclosed in WO 00/63190 which is incorporated herein by reference; activator compounds as disclosed in WO 01/21181 which is incorporated herein by reference; biaryl-oxa(thia)zole compounds as disclosed in WO 01/16120 which is incorporated herein by reference; compounds as disclosed in WO 00/63196 and WO 00/63209 which are incorporated herein by reference; substituted 5-aryl-2,4-thiazolidinediones compounds as disclosed in U.S. Pat. No. 6,008,237 which is incorporated herein by reference; arylthiazolidinedione and aryloxazolidinedione compounds as disclosed in WO 00/78312 and WO 00/78313G which are incorporated herein by reference; GW2331 or (2-(4-[difluorophenyl]-1 heptylureido)ethyl]phenoxy)-2-methylbutyric compounds as disclosed in WO 98/05331 which is incorporated herein by reference; aryl compounds as disclosed in U.S. Pat. No. 6,166,049 which is incorporated herein by reference; oxazole compounds as disclosed in WO 01/17994 which is incorporated herein by reference; and dithiolane compounds as disclosed in WO 01/25225 and WO 01/25226 which are incorporated herein by reference.

[0387] Other useful PPAR activator compounds include substituted benzylthiazolidine-2,4-dione compounds as disclosed in WO 01/14349, WO 01/14350 and WO/01/04351 which are incorporated herein by reference; mercaptocarboxylic compounds as disclosed in WO 00/50392 which is incorporated herein by reference; ascofuranone compounds as disclosed in WO 00/53563 which is incorporated herein by reference; carboxylic compounds as disclosed in WO 99/46232 which is incorporated herein by reference; compounds as disclosed in WO 99/12534 which is incorporated herein by reference; benzene compounds as disclosed in WO 99/15520 which is incorporated herein by reference; o-anisamide compounds as disclosed in WO 01/21578 which is incorporated herein by reference; and PPAR activator compounds as disclosed in WO 01/40192 which is incorporated herein by reference.

[0388] The peroxisome proliferator-activated receptor(s) activator(s) can be administered in a therapeutically effective amount to treat the specified condition, for example in a daily dose preferably ranging from about 50 to about 3000 mg per day, and more preferably about 50 to about 2000 mg per day, given in a single dose or 2-4 divided doses. The exact dose, however, is determined by the attending clinician and is dependent on such factors as the potency of the compound administered, the age, weight, condition and response of the patient.

[0389] Also useful with the present invention are compositions or therapeutic combinations that can further comprise one or more pharmacological or therapeutic agents or drugs such as other cholesterol biosynthesis inhibitors and/or lipid-lowering agents discussed below.

[0390] Non-limiting examples of cholesterol biosynthesis inhibitors suitable for use in the compositions, therapeutic combinations and methods of the present invention include squalene synthase inhibitors, squalene epoxidase inhibitors and mixtures thereof. Non-limiting examples of suitable HMG CoA synthetase inhibitors, for example L-659,699 ((E,E)-11-[3′R-(hydroxy-methyl)-4′-oxo-2′R-oxetanyl]-3,5,7R-trimethyl-2,4-undecadienoic acid); squalene synthesis inhibitors, for example squalestatin 1; and squalene epoxidase inhibitors, for example, NB-598 ((E)-N-ethyl-N-(6,6-dimethyl-2-hepten-4-ynyl)-3-[(3,3′-bithiophen-5-yl)methoxy] benzene-methanamine hydrochloride) and other sterol biosynthesis inhibitors such as DMP-565.

[0391] Generally, a total daily dosage of other cholesterol biosynthesis inhibitor(s) can range from about 0.1 to about 160 mg per day, and preferably about 0.2 to about 80 mg/day in single or 2-3 divided doses.

[0392] The compositions, therapeutic combinations or methods of the present invention can further comprise one or more bile acid sequestrants. Bile acid sequestrants bind bile acids in the intestine, interrupting the enterohepatic circulation of bile acids and causing an increase in the faecal excretion of steroids. Use of bile acid sequestrants is desirable because of their non-systemic mode of action. Bile acid sequestrants can lower intrahepatic cholesterol and promote the synthesis of apo B/E (LDL) receptors which bind LDL from plasma to further reduce cholesterol levels in the blood.

[0393] Non-limiting examples of suitable bile acid sequestrants include cholestyramine (a styrene-divinylbenzene copolymer containing quaternary ammonium cationic groups capable of binding bile acids, such as QUESTRAN® or QUESTRAN LIGHT® cholestyramine which are available from Bristol-Myers Squibb), colestipol (a copolymer of diethylenetriamine and 1-chloro-2,3-epoxypropane, such as COLESTID® tablets which are available from Pharmacia), colesevelam hydrochloride (such as WelChol® Tablets (poly(allylamine hydrochloride) cross-linked with epichlorohydrin and alkylated with 1-bromodecane and (6-bromohexyl)-trimethylammonium bromide) which are available from Sankyo), water soluble derivatives such as 3,3-ioene, N-(cycloalkyl) alkylamines and poliglusam, insoluble quaternized polystyrenes, saponins and mixtures thereof. Other useful bile acid sequestrants are disclosed in PCT Patent Applications Nos. WO 97/11345 and WO 98/57652, and U.S. Pat. Nos. 3,692,895 and 5,703,188 which are incorporated herein by reference. Suitable inorganic cholesterol sequestrants include bismuth salicylate plus montmorillonite clay, aluminum hydroxide and calcium carbonate antacids.

[0394] Generally, a total daily dosage of bile acid sequestrant(s) can range from about 1 to about 50 grams per day, and preferably about 2 to about 16 grams per day in single or 2-4 divided doses.

[0395] The compositions or treatments of the present invention can further comprise one or more ileal bile acid transport (“IBAT”) inhibitors (or apical sodium co-dependent bile acid transport (“ASBT”) inhibitors) coadministered with or in combination with the peroxisome proliferator-activated receptor activator(s) and sterol absorption inhibitor(s) discussed above. The IBAT inhibitors can inhibit bile acid transport to reduce LDL cholesterol levels. Non-limiting examples of suitable IBAT inhibitors include benzothiepines such as therapeutic compounds comprising a 2,3,4,5-tetrahydro-1-benzothiepine 1,1-dioxide structure such as are disclosed in PCT Patent Application WO 00/38727 which is incorporated herein by reference.

[0396] Generally, a total daily dosage of IBAT inhibitor(s) can range from about 0.01 to about 1000 mg/day, and preferably about 0.1 to about 50 mg/day in single or 2-4 divided doses.

[0397] The compositions or treatments of the present invention can further comprise nicotinic acid (niacin) and/or derivatives thereof. As used herein, “nicotinic acid derivative” means a compound comprising a pyridine-3-carboxylate structure or a pyrazine-2-carboxylate structure, including acid forms, salts, esters, zwitterions and tautomers, where available. Examples of nicotinic acid derivatives include niceritrol, nicofuranose and acipimox (5-methyl pyrazine-2-carboxylic acid 4-oxide). Nicotinic acid and its derivatives inhibit hepatic production of VLDL and its metabolite LDL and increases HDL and apo A-1 levels. An example of a suitable nicotinic acid product is NIASPAN® (niacin extended-release tablets) which are available from Kos.

[0398] Generally, a total daily dosage of nicotinic acid or a derivative thereof can range from about 500 to about 10,000 mg/day, preferably about 1000 to about 8000 mg/day, and more preferably about 3000 to about 6000 mg/day in single or divided doses.

[0399] The compositions or treatments of the present invention can further comprise one or more AcylCoA:Cholesterol O-acyltransferase (“ACAT”) Inhibitors, which can reduce LDL and HDL levels, coadministered with or in combination with the peroxisome proliferator-activated receptor activator(s) and sterol absorption inhibitor(s) discussed above. ACAT is an enzyme responsible for esterifying excess intracellular cholesterol and may reduce the synthesis of VLDL, which is a product of cholesterol esterification, and overproduction of apo B-100-containing lipoproteins.

[0400] Non-limiting examples of useful ACAT inhibitors include avasimibe ([[2,4,6-tris(1-methylethyl)phenyl]acetyl]sulfamic acid, 2,6-bis(1-methylethyl)phenyl ester, formerly known as Cl-1011), HL-004, lecimibide (DuP-128) and CL-277082 (N-(2,4-difluorophenyl)-N-[[4-(2,2-dimethylpropyl)phenyl]methyl]-N-heptylurea). See P. Chang et al., “Current, New and Future Treatments in Dyslipidaemia and Atherosclerosis”, Drugs July 2000;60(1); 55-93, which is incorporated by reference herein.

[0401] Generally, a total daily dosage of ACAT inhibitor(s) can range from about 0.1 to about 1000 mg/day in single or 2-4 divided doses.

[0402] The compositions or treatments of the present invention can further comprise one or more Cholesteryl Ester Transfer Protein (“CETP”) Inhibitors coadministered with or in combination with the peroxisome proliferator-activated receptor activator(s) and sterol absorption inhibitor(s) discussed above. CETP is responsible for the exchange or transfer of cholesteryl ester carrying HDL and triglycerides in VLDL.

[0403] Non-limiting examples of suitable CETP inhibitors are disclosed in PCT Patent Application No. WO 00/38721 and U.S. Pat. No. 6,147,090, which are incorporated herein by reference. Pancreatic cholesteryl ester hydrolase (pCEH) inhibitors such as WAY-121898 also can be coadministered with or in combination with the peroxisome proliferator-activated receptor(s) activator and sterol absorption inhibitor(s) discussed above.

[0404] Generally, a total daily dosage of CETP inhibitor(s) can range from about 0.01 to about 1000 mg/day, and preferably about 0.5 to about 20 mg/kg body weight/day in single or divided doses.

[0405] The compositions or treatments of the present invention can further comprise probucol or derivatives thereof (such as AGI-1067 and other derivatives disclosed in U.S. Pat. Nos. 6,121,319 and 6,147,250), which can reduce LDL and HDL levels, coadministered with or in combination with the peroxisome proliferator-activated receptor activator(s) and sterol absorption inhibitor(s) discussed above.

[0406] Generally, a total daily dosage of probucol or derivatives thereof can range from about 10 to about 2000 mg/day, and preferably about 500 to about 1500 mg/day in single or 2-4 divided doses.

[0407] The compositions or treatments of the present invention can further comprise low-density lipoprotein (LDL) receptor activators, coadministered with or in combination with the peroxisome proliferator-activated receptor activator(s) and sterol absorption inhibitor(s) discussed above. Non-limiting examples of suitable LDL-receptor activators include HOE-402, an imidazolidinyl-pyrimidine derivative that directly stimulates LDL receptor activity. See M. Huettinger et al., “Hypolipidemic activity of HOE-402 is Mediated by Stimulation of the LDL Receptor Pathway”, Arterioscler. Thromb. 1993; 13:1005-12.

[0408] Generally, a total daily dosage of LDL receptor activator(s) can range from about 1 to about 1000 mg/day in single or 2-4 divided doses.

[0409] The compositions or treatments of the present invention can further comprise fish oil, which contains Omega 3 fatty acids (3-PUFA), which can reduce VLDL and triglyceride levels, coadministered with or in combination with the peroxisome proliferator-activated receptor activator(s) and sterol absorption inhibitor(s) discussed above. Generally, a total daily dosage of fish oil or Omega 3 fatty acids' can range from about 1 to about 30 grams per day in single or 2-4 divided doses.

[0410] The compositions or treatments of the present invention can further comprise natural water soluble fibers, such as psyllium, guar, oat and pectin, which can reduce cholesterol levels. Generally, a total daily dosage of natural water soluble fibers can range from about 0.1 to about 10 grams per day in single or 2-4 divided doses.

[0411] The compositions or treatments of the present invention can further comprise plant sterols, plant stanols and/or fatty acid esters of plant stanols, such as sitostanol ester used in BENECOL® margarine, which can reduce cholesterol levels. Generally, a total daily dosage of plant sterols, plant stanols and/or fatty acid esters of plant stanols can range from about 0.5 to about 20 grams per day in single or 2-4 divided doses.

[0412] The compositions or treatments of the present invention can further comprise antioxidants, such as probucol, tocopherol, ascorbic acid, β-carotene and selenium, or vitamins such as vitamin B6 or vitamin B12. Generally, a total daily dosage of antioxidants or vitamins can range from about 0.05 to about 10 grams per day in single or 2-4 divided doses.

[0413] The compositions or treatments of the present invention can further comprise monocyte and macrophage inhibitors such as polyunsaturated fatty acids (PUFA), thyroid hormones including throxine analogues such as CGS-26214 (a thyroxine compound with a fluorinated ring), gene therapy and use of recombinant proteins such as recombinant apo E. Generally, a total daily dosage of these agents can range from about 0.01 to about 1000 mg/day in single or 2-4 divided doses.

[0414] Also useful with the present invention are compositions or therapeutic combinations that further comprise hormone replacement agents and compositions. Useful hormone agents and compositions for hormone replacement therapy of the present invention include androgens, estrogens, progestins, their pharmaceutically acceptable salts and derivatives. Combinations of these agents and compositions are also useful.

[0415] The dosage of androgen and estrogen combinations vary, desirably from about 1 mg to about 4 mg androgen and from about 1 mg to about 3 mg estrogen. Examples include, but are not limited to, androgen and estrogen combinations such as the combination of esterified estrogens (sodium estrone sulfate and sodium equilin sulfate) and methyltestosterone (17-hydroxy-17-methyl-, (17B)-androst-4-en-3-one) available from Solvay Pharmaceuticals, Inc., Marietta, Ga., under the tradename Estratest.

[0416] Estrogens and estrogen combinations may vary in dosage from about 0.01 mg up to 8 mg, desirably from about 0.3 mg to about 3.0 mg. Examples of useful estrogens and estrogen combinations include:

[0417] (a) the blend of nine (9) synthetic estrogenic substances including sodium estrone sulfate, sodium equilin sulfate, sodium 17α-dihydroequilin sulfate, sodium 17α-estradiol sulfate, sodium 17β-dihydroequilin sulfate, sodium 17α-dihydroequilenin sulfate, sodium 17β-dihydroequilenin sulfate, sodium equilenin sulfate and sodium 17β-estradiol sulfate; available from Duramed Pharmaceuticals, Inc., Cincinnati, Ohio, under the tradename Cenestin;

[0418] (b) ethinyl estradiol (19-nor-17α-pregna-1,3,5(10)-trien-20-yne-3,17-diol; available by Schering Plough Corporation, Kenilworth, N.J., under the tradename Estinyl;

[0419] (c) esterified estrogen combinations such as sodium estrone sulfate and sodium equilin sulfate; available from Solvay under the tradename Estratab and from Monarch Pharmaceuticals, Bristol, Tenn., under the tradename Menest;

[0420] (d) estropipate (piperazine estra-1,3,5(10)-trien-17-one, 3-(sulfooxy)-estrone sulfate); available from Pharmacia & Upjohn, Peapack, N.J., under the tradename Ogen and from Women First Health Care, Inc., San Diego, Calif., under the tradename Ortho-Est; and

[0421] (e) conjugated estrogens (17α-dihydroequilin, 17α-estradiol, and 17β-dihydroequilin); available from Wyeth-Ayerst Pharmaceuticals, Philadelphia, Pa., under the tradename Premarin.

[0422] Progestins and estrogens may also be administered with a variety of dosages, generally from about 0.05 to about 2.0 mg progestin and about 0.001 mg to about 2 mg estrogen, desirably from about 0.1 mg to about 1 mg progestin and about 0.01 mg to about 0.5 mg estrogen. Examples of progestin and estrogen combinations that may vary in dosage and regimen include:

[0423] (a) the combination of estradiol (estra-1,3,5(10)-triene-3, 17β-diol hemihydrate) and norethindrone (17β-acetoxy-19-nor-17α-pregn-4-en-20-yn-3-one); which is available from Pharmacia & Upjohn, Peapack, N.J., under the tradename Activella;

[0424] (b) the combination of levonorgestrel (d(−)-13β-ethyl-17α-ethinyl-17β-hydroxygon-4-en-3-one) and ethinyl estradial; available from Wyeth-Ayerst under the tradename Alesse, from Watson Laboratories, Inc., Corona, Calif., under the tradenames Levora and Trivora, Monarch Pharmaceuticals, under the tradename Nordette, and from Wyeth-Ayerst under the tradename Triphasil;

[0425] (c) the combination of ethynodiol diacetate (19-nor-17α-pregn-4-en-20-yne-3β, 17-diol diacetate) and ethinyl estradiol; available from G.D. Searle & Co., Chicago, Ill., under the tradename Demulen and from Watson under the tradename Zovia;

[0426] (d) the combination of desogestrel (13-ethyl-11- methylene-18,19-dinor-17α-pregn-4-en-20-yn-17-ol) and ethinyl estradiol; available from Organon under the tradenames Desogen and Mircette, and from Ortho-McNeil Pharmaceutical, Raritan, N.J., under the tradename Ortho-Cept;

[0427] (e) the combination of norethindrone and ethinyl estradiol; available from Parke-Davis, Morris Plains, N.J., under the tradenames Estrostep and femhrt, from Watson under the tradenames Microgestin, Necon, and Tri-Norinyl, from Ortho-McNeil under the tradenames Modicon and Ortho-Novum, and from Warner Chilcott Laboratories, Rockaway, N.J., under the tradename Ovcon;

[0428] (f) the combination of norgestrel ((±)-13-ethyl-17-hydroxy-18, 19-dinor-17α-preg-4-en-20-yn-3-one) and ethinyl estradiol; available from Wyeth-Ayerst under the tradenames Ovral and Lo/Ovral, and from Watson under the tradenames Ogestrel and Low-Ogestrel;

[0429] (g) the combination of norethindrone, ethinyl estradiol, and mestranol (3-methoxy-19-nor-17α-pregna-1,3,5(10)-trien-20-yn-17-ol); available from Watson under the tradenames Brevicon and Norinyl;

[0430] (h) the combination of 17β-estradiol (estra-1,3,5(10)-triene-3,17β-diol) and micronized norgestimate (17α-17-(Acetyloxyl)-13-ethyl-18,19-dinorpregn-4-en-20-yn-3-one3-oxime); available from Ortho-McNeil under the tradename Ortho-Prefest;

[0431] (i) the combination of norgestimate (18,19-dinor-17-pregn-4-en-20-yn-3-one, 17-(acetyloxy)-13-ethyl-,oxime, (17(α)-(+)-) and ethinyl estradiol; available from Ortho-McNeil under the tradenames Ortho Cyclen and Ortho Tri-Cyclen; and

[0432] (j) the combination of conjugated estrogens (sodium estrone sulfate and sodium equilin sulfate) and medroxyprogesterone acetate (20-dione, 17-(acetyloxy)-6-methyl-, (6(α))-pregn-4-ene-3); available from Wyeth-Ayerst under the tradenames Premphase and Prempro.

[0433] In general, a dosage of progestins may vary from about 0.05 mg to about 10 mg or up to about 200 mg if microcized progesterone is administered. Examples of progestins include norethindrone; available from ESI Lederle, Inc., Philadelphia, Pa., under the tradename Aygestin, from Ortho-McNeil under the tradename Micronor, and from Watson under the tradename Nor-QD; norgestrel; available from Wyeth-Ayerst under the tradename Ovrette; micronized progesterone (pregn-4-ene-3, 20-dione); available from Solvay under the tradename Prometrium; and medroxyprogesterone acetate; available from Pharmacia & Upjohn under the tradename Provera.

[0434] The compositions, therapeutic combinations or methods of the present invention can further comprise one or more obesity control medications. Useful obesity control medications include, but are not limited to, drugs that reduce energy intake or suppress appetite, drugs that increase energy expenditure and nutrient-partitioning agents. Suitable obesity control medications include, but are not limited to, noradrenergic agents (such as diethylpropion, mazindol, phenylpropanolamine, phentermine, phendimetrazine, phendamine tartrate, methamphetamine, phendimetrazine and tartrate); serotonergic agents (such as sibutramine, fenfluramine, dexfenfluramine, fluoxetine, fluvoxamine and paroxtine); thermogenic agents (such as ephedrine, caffeine, theophylline, and selective β3-adrenergic agonists); an alpha-blocking agent; a kainite or AMPA receptor antagonist; a leptin-lipolysis stimulated receptor; a phosphodiesterase enzyme inhibitor; a compound having nucleotide sequences of the mahogany gene; a fibroblast growth factor-10 polypeptide; a monoamine oxidase inhibitor (such as befloxatone, moclobemide, brofaromine, phenoxathine, esuprone, befol, toloxatone, pirlindol, amiflamine, sercloremine, bazinaprine, lazabemide, milacemide and caroxazone); a compound for increasing lipid metabolism (such as evodiamine compounds); and a lipase inhibitor (such as orlistat). Generally, a total dosage of the above-described obesity control medications can range from 1 to 3,000 mg/day, desirably from about 1 to 1,000 mg/day and more desirably from about 1 to 200 mg/day in single or 2-4 divided doses.

[0435] The compositions, therapeutic combinations or methods of the present invention can further comprise one or more blood modifiers. Useful blood modifiers include but are not limited to anti-coagulants (argatroban, bivalirudin, dalteparin sodium, desirudin, dicumarol, lyapolate sodium, nafamostat mesylate, phenprocoumon, tinzaparin sodium, warfarin sodium); antithrombotic (anagrelide hydrochloride, bivalirudin, cilostazol, dalteparin sodium, danaparoid sodium, dazoxiben hydrochloride, efegatran sulfate, enoxaparin sodium, fluretofen, ifetroban, ifetroban sodium, lamifiban, lotrafiban hydrochloride, napsagatran, orbofiban acetate, roxifiban acetate, sibrafiban, tinzaparin sodium, trifenagrel, abciximab, zolimomab aritox); fibrinogen receptor antagonists (roxifiban acetate, fradafiban, orbofiban, lotrafiban hydrochloride, tirofiban, xemilofiban, monoclonal antibody 7E3, sibrafiban); platelet inhibitors (cilostazol, clopidogrel bisulfate, epoprostenol, epoprostenol sodium, ticlopidine hydrochloride, aspirin, ibuprofen, naproxen, sulindae, idomethacin, mefenamate, droxicam, diclofenac, sulfinpyrazone, piroxicam, dipyridamole); platelet aggregation inhibitors (acadesine, beraprost, beraprost sodium, ciprostene calcium, itazigrel, lifarizine, lotrafiban hydrochloride, orbofiban acetate, oxagrelate, fradafiban, orbofiban, tirofiban, xemilofiban); hemorrheologic agents (pentoxifylline); lipoprotein associated coagulation inhibitor; Factor VIIa inhibitors (4H-31-benzoxazin-4-ones, 4H-3,1-benzoxazin-4-thiones, quinazolin-4-ones, quinazolin-4-thiones, benzothiazin-4-ones, imidazolyl-boronic acid-derived peptide analogues TFPI-derived peptides, naphthalene-2-sulfonic acid {1-[3-(aminoiminomethyl)-benzyl]-2-oxo-pyrrolidin-3-(S)-yl} amide trifluoroacetate, dibenzofuran-2-sulfonic acid {1-[3-(aminomethyl)-benzyl]-5-oxo-pyrrolidin-3-yl}-amide, tolulene-4-sulfonic acid {1-[3-(aminoiminomethyl)-benzyl]-2-oxo-pyrrolidin-3-(S)-yl}-amide trifluoroacetate, 3,4-dihydro-1H-isoquinoline-2-sulfonic acid {1-[3-(aminoiminomethyl)-benzyl]-2-oxo-pyrrolin-3-(S)-yl}-amide trifluoroacetate); Factor Xa inhibitors (disubstituted pyrazolines, disubstituted triazolines, substituted n-[(aminoiminomethyl)phenyl] propylamides, substituted n-[(aminomethyl)phenyl] propylamides, tissue factor pathway inhibitor (TFPI), low molecular weight heparins, heparinoids, benzimidazolines, benzoxazolinones, benzopiperazinones, indanones, dibasic (amidinoaryl) propanoic acid derivatives, amidinophenyl-pyrrolidines, amidinophenyl-pyrrolines, amidinophenyl-isoxazolidines, amidinoindoles, amidinoazoles, bis-arlysulfonylaminobenzamide derivatives, peptidic Factor Xa inhibitors).

[0436] The compositions, therapeutic combinations or methods of the present invention can further comprise one or more cardiovascular agents. Useful cardiovascular agents include but are not limited to calcium channel blockers (clentiazem maleate, amlodipine besylate, isradipine, nimodipine, felodipine, nilvadipine, nifedipine, teludipine hydrochloride, diltiazem hydrochloride, belfosdil, verapamil hydrochloride, fostedil); adrenergic blockers (fenspiride hydrochloride, labetalol hydrochloride, proroxan, alfuzosin hydrochloride, acebutolol, acebutolol hydrochloride, alprenolol hydrochloride, atenolol, bunolol hydrochloride, carteolol hydrochloride, celiprolol hydrochloride, cetamolol hydrochloride, cicloprolol hydrochloride, dexpropranolol hydrochloride, diacetolol hydrochloride, dilevalol hydrochloride, esmolol hydrochloride, exaprolol hydrochloride, flestolol sulfate, labetalol hydrochloride, levobetaxolol hydrochloride, levobunolol hydrochloride, metalol hydrochloride, metoprolol, metoprolol tartrate, nadolol, pamatolol sulfate, penbutolol sulfate, practolol, propranolol hydrochloride, sotalol hydrochloride, timolol, timolol maleate, tiprenolol hydrochloride, tolamolol, bisoprolol, bisoprolol fumarate, nebivolol); adrenergic stimulants; angiotensin converting enzyme (ACE) inhibitors (benazepril hydrochloride, benazeprilat, captopril, delapril hydrochloride, fosinopril sodium, libenzapril, moexipril hydrochloride, pentopril, perindopril, quinapril hydrochloride, quinaprilat, ramipril, spirapril hydrochloride, spiraprilat, teprotide, enalapril maleate, lisinopril, zofenopril calcium, perindopril erbumine); antihypertensive agents (althiazide, benzthiazide, captopril, carvedilol, chlorothiazide sodium, clonidine hydrochloride, cyclothiazide, delapril hydrochloride, dilevalol hydrochloride, doxazosin mesylate, fosinopril sodium, guanfacine hydrochloride, methyldopa, metoprolol succinate, moexipril hydrochloride, monatepil maleate, pelanserin hydrochloride, phenoxybenzamine hydrochloride, prazosin hydrochloride, primidolol, quinapril hydrochloride, quinaprilat, ramipril, terazosin hydrochloride, candesartan, candesartan cilexetil, telmisartan, amlodipine besylate, amlodipine maleate, bevantolol hydrochloride); angiotensin II receptor antagonists (candesartan, irbesartan, losartan potassium, candesartan cilexetil, telmisartan); anti-anginal agents (amlodipine besylate, amlodipine maleate, betaxolol hydrochloride, bevantolol hydrochloride, butoprozine hydrochloride, carvedilol, cinepazet maleate, metoprolol succinate, molsidomine, monatepil maleate, primidolol, ranolazine hydrochoride, tosifen, verapamil hydrochloride); coronary vasodilators (fostedil, azaclorzine hydrochloride, chromonar hydrochloride, clonitrate, diltiazem hydrochloride, dipyridamole, droprenilamine, erythrityl tetranitrate, isosorbide dinitrate, isosorbide mononitrate, lidoflazine, mioflazine hydrochloride, mixidine, molsidomine, nicorandil, nifedipine, nisoldipine, nitroglycerine, oxprenolol hydrochloride, pentrinitrol, perhexiline maleate, prenylamine, propatyl nitrate, terodiline hydrochloride, tolamolol, verapamil); diuretics (the combination product of hydrochlorothiazide and spironolactone and the combination product of hydrochlorothiazide and triamterene).

[0437] The compositions, therapeutic combinations or methods of the present invention can further comprise one or more antidiabetic medications for reducing blood glucose levels in a human. Useful antidiabetic medications include, but are not limited to, drugs that reduce energy intake or suppress appetite, drugs that increase energy expenditure and nutrient-partitioning agents. Suitable antidiabetic medications include, but are not limited to, sulfonylurea (such as acetohexamide, chlorpropamide, gliamilide, gliclazide, glimepiride, glipizide, glyburide, glibenclamide, tolazamide, and tolbutamide), meglitinide (such as repaglinide and nateglinide), biguanide (such as metformin and buformin), thiazolidinedione (such as troglitazone, rosiglitazone, pioglitazone, ciglitazone, englitazone, and darglitazone), alpha-glucosidase inhibitor (such as acarbose, miglitol, camiglibose, and voglibose), certain peptides (such as amlintide, pramlintide, exendin, and GLP-1 agonistic peptides), and orally administrable insulin or insulin composition for intestinal delivery thereof. Generally, a total dosage of the above-described antidiabetic medications can range from 0.1 to 1,000 mg/day in single or 2-4 divided doses.

[0438] Compositions and therapeutic combinations of the present invention having the above-described sterol or 5α-stanol absorption inhibitors are also useful for treating or preventing vascular inflammation or for reducing c-reactive protein levels in a subject in need of such treatment. Vascular inflammation refers to arterial damage and bodily responses thereto. For example, cholesteryl esters are a major component of atherosclerotic lesions which results in vascular inflammation and an increase in plasma c-reactive protein levels. The inhibition of cholesteryl ester formation and reduction of serum cholesterol can inhibit the progression of atherosclerotic lesion formation, thereby treating or preventing vascular inflammation. Moreover, these sterol absorption inhibitors are useful for lowering or controlling c-reactive protein blood levels in a subject to less than about 3.4 mg/dL, desirably to less than 1.0 mg/dL, and more desirably to less than 0.4 mg/dL.

[0439] Mixtures of any of the pharmacological or therapeutic agents described above can be used in the compositions and therapeutic combinations of these other embodiments of the present invention.

[0440] The compositions and therapeutic combinations of the present invention can be administered to a mammal in need of such treatment in a therapeutically effective amount to treat vascular conditions. The compositions and treatments can be administered by any suitable means that produce contact of these compounds with the site of action in the body, for example in the plasma, liver or small intestine of a subject or mammal.

[0441] The daily dosage for the various compositions and therapeutic combinations described above can be administered to a subject in a single dose or in multiple subdoses, as desired. Subdoses can be administered 2 to 6 times per day, for example. Sustained release dosages can be used. Where the at least one HMG-CoA reductase inhibitor and the sterol absorption inhibitor(s) are administered in separate dosages, the number of doses of each component given per day may not necessarily be the same, e.g., one component may have a greater duration of activity and will therefore need to be administered less frequently.

[0442] The compositions, therapeutic combinations or medicaments of the present invention can further comprise one or more pharmaceutically acceptable carriers, one or more excipients and/or one or more additives. The pharmaceutical compositions can comprise about 1 to about 99 weight percent of active ingredient (one or more compounds of Formula I-XII), and preferably about 5 to about 95 percent active ingredient.

[0443] Useful pharmaceutically acceptable carriers can be either solid, liquid or gas. Non-limiting examples of pharmaceutically acceptable carriers include solids and/or liquids such as magnesium carbonate, magnesium stearate, talc, sugar, lactose, ethanol, glycerol, water and the like. The amount of carrier in the treatment composition or therapeutic combination can range from about 5 to about 99 weight percent of the total weight of the treatment composition or therapeutic combination. Non-limiting examples of suitable pharmaceutically acceptable excipients and additives include non-toxic compatible fillers, binders such as starch, polyvinyl pyrrolidone or cellulose ethers, disintegrants such as sodium starch glycolate, crosslinked polyvinyl pyrrolidone or croscarmellose sodium, buffers, preservatives, anti-oxidants, lubricants, flavorings, thickeners, coloring agents, wetting agents such as sodium lauryl sulfate, emulsifiers and the like. The amount of excipient or additive can range from about 0.1 to about 95 weight percent of the total weight of the treatment composition or therapeutic combination. One skilled in the art would understand that the amount of carrier(s), excipients and additives (if present) can vary. Further examples of pharmaceutically acceptable carriers and methods of manufacture for various compositions can be found in A. Gennaro (ed.), Remington: The Science and Practice of Pharmacy, 20th Edition, (2000), Lippincott Williams & Wilkins, Baltimore, Md.

[0444] Useful solid form preparations include powders, tablets, dispersible granules, capsules, cachets and suppositories. An example of a preparation of a preferred solid form dosage formulation is provided below.

[0445] Useful liquid form preparations include solutions, suspensions and emulsions. As an example may be mentioned water or water-propylene glycol solutions for parenteral injection or addition of sweeteners and opacifiers for oral solutions, suspensions and emulsions. Liquid form preparations may also include solutions for intranasal administration.

[0446] Aerosol preparations suitable for inhalation may include solutions and solids in powder form, which may be in combination with a pharmaceutically acceptable carrier, such as an inert compressed gas, e.g. nitrogen.

[0447] Also useful are solid form preparations which are intended to be converted, shortly before use, to liquid form preparations for either oral or parenteral administration. Such liquid forms include solutions, suspensions and emulsions.

[0448] The compounds of the invention may also be deliverable transdermally. The transdermal compositions can take the form of creams, lotions, aerosols and/or emulsions and can be included in a transdermal patch of the matrix or reservoir type as are conventional in the art for this purpose.

[0449] Preferably the compound is administered orally.

[0450] In another embodiment, the present invention provides the use of at least one compound represented by Formulae (I-XII) for manufacture of a medicament (such as one of the compositions discussed above) for the treatment of vascular conditions.

[0451] The methods, combinations and treatments of the present invention can further be used to treat or prevent vascular disease or conditions (such as for example atherosclerosis, arteriosclerosis, hypercholesterolemia and/or sitosterolemia), cardiovascular events, hypertension, obesity, stroke, lowering of a concentration of a sterol in plasma of a mammal, reducing vascular inflammation or to prevent or treat blood clotting or similar disorders and to prevent bone loss and osteoporosis.

[0452] Vascular disease is a term that broadly encompasses all disorders of blood vessels including small and large arteries and veins and blood flow. The most prevalent form of vascular disease is arteriosclerosis, a condition associated with the thickening and hardening of the arterial wall. Arteriosclerosis of the large vessels is referred to as atherosclerosis. Atherosclerosis is the predominant underlying factor in vascular disorders such as coronary artery disease, aortic aneurysm, arterial disease of the lower extremities and cerebrovascular disease.

[0453] The methods of the present invention can be used to prevent or reduce the risk of an occurrence of a fatal or non-fatal cardiovascular event in patients having no history of clinically evident coronary heart disease prior to the initial administration of the compounds and treatments of the present invention, as well as patients having a history of clinically evident coronary heart disease. The phrase “cardiovascular event” includes but is not limited to fatal and non-fatal acute major coronary events, coronary revascularization procedures, peripheral vascular disease, stable angina and cerebrovascular insufficiency such as stroke.

[0454] The phrase “acute major coronary event” includes fatal myocardial infarction, witnessed and unwitnessed cardiac death and sudden death occurring from 1 hour up to 24 hours after collapse, non-fatal myocardial infarction including definite acute Q-wave myocardial infarction, non-Q-wave myocardial infarction, and silent subclinical (remote) myocardial infarction, and unstable angina pectoris. As used herein, “myocardial infarction” includes both Q-wave and non-Q-wave myocardial infarction and silent subclinical (remote) myocardial infarction.

[0455] In another embodiment, the present invention provides a method of preventing or reducing risk of a cardiovascular event while preventing or minimizing muscular degenerative side effects associated with HMG-CoA reductase inhibitors, comprising administering to a subject in need thereof at least one sterol or 5α-stanol absorption inhibitor in combination with at least one HMG-CoA reductase inhibitor.

[0456] In another embodiment, the present invention provides a method of preventing or reducing risk of a cardiovascular event while preventing or minimizing muscular degenerative side effects associated with HMG-CoA reductase inhibitors, comprising administering to a subject in need thereof at least one sterol or 5α-stanol absorption inhibitor in combination with at least one HMG-CoA reductase inhibitor to a subject having no history of clinically evident coronary heart disease prior to the initial administration.

[0457] The following formulation exemplifies one of the dosage forms of this invention. In the formulation, the term “Active Compound I” designates a sterol or 5α-stanol absorption inhibitor described herein above and the term “Active Compound II” designates a HMG CoA reductase inhibitor described herein above.

EXAMPLE

[0458]

3

Tablets

No.
Ingredient
mg/tablet

1
Active Compound I
10

2
Lactose monohydrate NF
55

3
Microcrystalline cellulose NF
20

4
Povidone USP (K29-32)
4

5
Croscarmellose sodium NF
8

6
Sodium lauryl sulfate NF
2

7
Magnesium stearate NF
1

Total
100

[0459] In the present invention, the above-described tablet can be coadministered with a tablet, capsule, etc. comprising a dosage of Active Compound II, for example simvastatin as described above.

[0460] Method of Manufacture

[0461] Mix Item No. 4 with purified water in suitable mixer to form binder solution. Spray the binder solution and then water over Items 1, 2 and 6 and a portion of item 5 in a fluidized bed processor to granulate the ingredients. Continue fluidization to dry the damp granules. Screen the dried granule and blend with Item No. 3 and the remainder of Item No. 5. Add Item No. 7 and mix. Compress the mixture to appropriate size and weight on a suitable tablet machine.

[0462] For coadministration in separate tablets or capsules, representative formulations comprising a sterol or 5α-stanol absorption inhibitor such as are discussed above are well known in the art and representative formulations comprising a HMG CoA reductase inhibitor such as are discussed above are well known in the art. It is contemplated that where the two active ingredients are administered as a single composition, the dosage forms disclosed above for sterol or 5α-stanol absorption inhibitor may readily be modified using the knowledge of one skilled in the art.

[0463] Since the present invention relates to treating vascular conditions or reducing the plasma sterol (especially cholesterol) or 5α-stanol concentrations or levels by treatment with a combination of active ingredients wherein the active ingredients may be administered separately, the invention also relates to combining separate pharmaceutical compositions in kit form. That is, a kit is contemplated wherein two separate units are combined: a pharmaceutical composition comprising at least one sterol or 50α-stanol absorption inhibitor and a separate pharmaceutical composition comprising at least one HMG CoA reductase inhibitor as described above. The kit will preferably include directions for the administration of the separate components. The kit form is particularly advantageous when the separate components must be administered in different dosage forms (e.g., oral and parenteral) or are administered at different dosage intervals.

[0464] The treatment compositions and therapeutic combinations of the present invention can inhibit the intestinal absorption of sterols such as cholesterol or 5α-stanols in subjects and can be useful in the treatment and/or prevention of vascular conditions, such as atherosclerosis, hypercholesterolemia and sitosterolemia, stroke, obesity and lowering of plasma levels of sterols such as cholesterol or 5α-stanols in subject, in particular in humans.

[0465] An advantage of the compositions and therapeutic combinations of the present invention is that they can prevent, reduce or eliminate the muscular degeneration associated with administration of large dosages of certain statins, as discussed above.

[0466] Muscular degeneration can be diagnosed by a trained clinician based upon patient comments and observations regarding symptoms such as muscle aches and/or weakness. Alternatively, muscular degeneration can be determined by increases in creatine phosphokinase (“CPK” or “CK”) values over ten times the upper limit of normal.

[0467] CPK values in serum or plasma can be measured using a Hitachi 747-200 or other similar serum chemistry analyzer following NCCLS guidelines.

[0468] Principle

[0469] The formation of NADPH (nicotinamide adenine dinucleotide phosphate) proceeds at the same rate as the formation of creatine in equimolar amounts. The rate of NADPH formation is directly proportional to the CK activity and can be measured spectrophotometrically as the change in absorbance at 340 nanometers. Results are evaluated by comparison with a standard of known concentrations of CK. Measurements of creatine kinase and its isoenzymes are used in the diagnosis and treatment of myocardial infarction, myositis, muscle necrosis and muscle disease such as progressive, Duchenne-type muscular dystrophy.

[0470] Specimen:

[0471] Use serum free of hemolysis.

[0472] EDTA or heparin are acceptable anticoagulants.

[0473] CPK is stable in serum or plasma for 7 days at 2-8° C. or 24 hours at 20-25° C. For longer periods, store at −20° C.

[0474] Reagents (available from Medical Research Laboratories Int'l, Inc. of Highland Heights, Ky.):

[0475] The components of CK/NAC R1 Cat.No. 1126005 include:

[0476] Bottle 1 buffer

[0477] Reactive ingredients:

[0478] 110 mmol/L Imidazole buffer, pH=6.7

[0479] 20.5 mmol/L D-glucose

[0480] 2.05 mmol/L EDTA

[0481] Nonreactive ingredient: Preservative

[0482] Bottle 1a Enzymes/Coenzyme

[0483] Reactive ingredients:

[0484] 1.47 mmol ADP (adenosine 5′-diphosphate)

[0485] 3.58 mmol AMP (adenosine monophosphate)

[0486] 1.47 mmol NADP (nicotinamide adenine dinucleotide phosphate)

[0487] >/=1822 U HK (hexokinase) (EC 2.7.3.2; yeast; 25° C.)

[0488] >/=1058 U G-6-PDH (glucose-6-phosphate dehydrogenase) (EC 1.1.1.49; E. Coli; 25° C.)

[0489] 14.7 mmol NAC (N-acetyl-L-cysteine)

[0490] 7.05 μmol D-A-5-P (diadenosine-5′-pentaphosphate)

[0491] The components of CK/NAC R2 include:

[0492] Bottle 2 buffer:

[0493] Reactive ingredients:

[0494] 25 mmol/L Imidazole buffer, pH=7.5

[0495] 20.5 mmol/L D-glucose

[0496] 61 mmol/L Magnesium ion

[0497] 2.05 mmol/L EDTA

[0498] Nonreactive ingredient: Preservative

[0499] Bottle 2a substrate:

[0500] Reactive Ingredient: 25.5 mmol Creatine phosphate

[0501] The Controls are supplied ready to use and are stable until the date on the label when stored at 2-8° C. Once opened, they are stable for 3 weeks when stored tightly capped at 2-12° C.

[0502] Testing Procedures

[0503] Instrument Settings:

4Test[CPK]Assay Code[Rate - A][35]-[50]Wavelength (SEC)[376] nm Wavelength (Primary) [340] nmSample Volume[7][7]Expected Value[0]-[120]Panic Value[0]-[359]ABS. Limit (INC/DEC)[13000] [Increase]Prozone Limit[0] [Lower]-R1--R2-RE Reagent Volume[250]R2 reagent volume[50]R1 Refresh interval[0]R1 Refresh interval [0]Dilution volume[0]Calib. Method[K Factor]Std.Conc.RackPos.Points[0]1 SALINE[0][1][1]SD Limit[0.1]2[0][0][0]Duplicate Limit[100]3[0][0][0]Sensitivity Limit[0]4[0][0][0]STD 1 ABS Level[0]-[4000]5[0][0][0]Instrument Factor[0.62]*6[0][0][0]*An instrument factor is used to convert CPK results to 30° C.

[0504] Calculation:

[0505] The analyzer uses changes in absorbance measurements to calculate CK (CPK) activity as follows:

C

x

=K
(ΔAx−ΔAb)+Cb

[0506] Where:

[0507] Cx=activity of sample

[0508] K=factor for determining enzyme activity, established for each kinetic assay during installation.

ΔAx=Change in absorbance per minute of Sample+R1+R2 during cycles 35 through 50.

ΔAb=Change in absorbance per minute of STD 1+R1+R2 during cycles 35 through 50.

[0509] Cb=Concentration of Std. 1.

[0510] In 4.7 Compensated Test, the following formula is used for CPK:

CPK=CPK×
0.96×0.99

[0511] Serum

[0512] Reference Range: 0-120 Units/L. SI units 120 IU/L.

[0513] Reporting Results:

[0514] CPK results are reported in whole numbers in both U/L and SI units. Linearity: Up to 1,430 U/I. Specimens above 1,430 U/I should be reassayed after dilution with physiological saline.

[0515] Limitations on Procedure

[0516] Significant positive hemoglobin interference at 200 mg/dl. No significant interference from triglycerides up to 1120 mg/dl.

[0517] In another embodiment of the present invention, the compositions and therapeutic combinations of the present invention can reduce plasma concentration of at least one sterol selected from the group consisting of cholesterol or phytosterols (such as sitosterol, campesterol, stigmasterol and avenosterol), and/or 5α-stanols (such as cholestanol, 5α-campestanol, 5α-sitostanol), and mixtures thereof. The plasma concentration can be reduced by administering to a subject in need of such treatment an effective amount of at least one treatment composition or therapeutic combination comprising at least one HMG CoA reductase inhibitor in a reduced amount and at least one sterol or 5α-stanol absorption inhibitor described above. The reduction in plasma concentration of sterols or 50α-stanols can range from about 10 to about 70 percent, and preferably about 10 to about 50 percent. Methods of measuring serum total blood cholesterol and total LDL cholesterol are well known to those skilled in the art and for example include those disclosed in PCT WO 99/38498 at page 11, incorporated by reference herein. Methods of determining levels of other sterols in serum are disclosed in H. Gylling et al., “Serum Sterols During Stanol Ester Feeding in a Mildly Hypercholesterolemic Population”, J. Lipid Res. 40: 593-600 (1999), incorporated by reference herein.

[0518] Illustrating the invention is the following example which, however, are not to be considered as limiting the invention to its details. Unless otherwise indicated, all parts and percentages in the following example, as well as throughout the specification, are by weight.

EXAMPLE

PREPARATION OF COMPOUND OF FORMULA (II)

[0519] Step 1): To a solution of (S)-4-phenyl-2-oxazolidinone (41 g, 0.25 mol) in CH2Cl2 (200 ml), was added 4-dimethylaminopyridine (2.5 g, 0.02 mol) and triethylamine (84.7 ml, 0.61 mol) and the reaction mixture was cooled to 0° C. Methyl-4-(chloroformyl)butyrate (50 g, 0.3 mol) was added as a solution in CH2Cl2 (375 ml) dropwise over 1 h, and the reaction was allowed to warm to 22° C. After 17 h, water and H2SO4 (2N, 100 ml), was added the layers were separated, and the organic layer was washed sequentially with NaOH (10%), NaCl (sat'd) and water. The organic layer was dried over MgSO4 and concentrated to obtain a semicrystalline product.

[0520] Step 2): To a solution of TiCl4 (18.2 ml, 0.165 mol) in CH2Cl2 (600 ml) at 0° C., was added titanium isopropoxide (16.5 ml, 0.055 mol). After 15 min, the product of Step 1 (49.0 g, 0.17 mol) was added as a solution in CH2Cl2 (100 ml). After 5 min., diisopropylethylamine (DIPEA) (65.2 ml, 0.37 mol) was added and the reaction mixture was stirred at 0° C. for 1 h, the reaction mixture was cooled to −20° C., and 4-benzyloxybenzylidine(4-fluoro)aniline (114.3 g, 0.37 mol) was added as a solid. The reaction mixture was stirred vigorously for 4 h at −20° C., then acetic acid was added as a solution in CH2Cl2 dropwise over 15 min, the reaction mixture was allowed to warm to 0° C., and H2SO4 (2N) was added. The reaction mixture was stirred an additional 1 h, the layers were separated, washed with water, separated and the organic layer was dried. The crude product was crystallized from ethanol/water to obtain the pure intermediate.

[0521] Step 3): To a solution of the product of Step 2 (8.9 g, 14.9 mmol) in toluene (100 ml) at 50° C., was added N,O-bis(trimethylsilyl)acetamide (BSA) (7.50 ml, 30.3 mmol). After 0.5 h, solid TBAF (0.39 g, 1.5 mmol) was added and the reaction mixture stirred at 50° C. for an additional 3 h. The reaction mixture was cooled to 22° C., CH3OH (10 ml), was added. The reaction mixture was washed with HCl (1N), NaHCO3 (1N) and NaCl (sat'd.), and the organic layer was dried over MgSO4.

[0522] Step 4): To a solution of the product of Step 3 (0.94 g, 2.2 mmol) in CH3OH (3 ml), was added water (1 ml) and LiOH.H2O (102 mg, 2.4 mmole). The reaction mixture was stirred at 22° C. for 1 h and then additional LiOH.H2O (54 mg, 1.3 mmole) was added. After a total of 2 h, HCl (1N) and EtOAc was added, the layers were separated, the organic layer was dried and concentrated in vacuo. To a solution of the resultant product (0.91 g, 2.2 mmol) in CH2Cl2 at 22° C., was added ClCOCOCl (0.29 ml, 3.3 mmol) and the mixture stirred for 16 h. The solvent was removed in vacuo.

[0523] Step 5): To an efficiently stirred suspension of 4-fluorophenylzinc chloride (4.4 mmol) prepared from 4-fluorophenylmagnesium bromide (1M in THF, 4.4 ml, 4.4 mmol) and ZnCl2 (0.6 g, 4.4 mmol) at 4° C., was added tetrakis(triphenyl-phosphine)palladium (0.25 g, 0.21 mmol) followed by the product of Step 4 (0.94 g, 2.2 mmol) as a solution in THF (2 ml). The reaction was stirred for 1 h at 0° C. and then for 0.5 h at 22° C. HCl (1N, 5 ml) was added and the mixture was extracted with EtOAc. The organic layer was concentrated to an oil and purified by silica gel chromatography to obtain 1-(4-fluorophenyl)-4(S)-(4-hydroxyphenyl)-3(R)-(3-oxo-3-phenylpropyl)-2-azetidinone:

[0524] HRMS calc'd for C24H19F2NO3=408.1429, found 408.1411.

[0525] Step 6): To the product of Step 5 (0.95 g, 1.91 mmol) in THF (3 ml), was added (R)-tetrahydro-1-methyl-3,3-diphenyl-1H,3H-pyrrolo-[1,2-c][1,3,2] oxazaborole (120 mg, 0.43 mmol) and the mixture was cooled to −20° C. After 5 min, borohydride-dimethylsulfide complex (2M in THF, 0.85 ml, 1.7 mmol) was added dropwise over 0.5 h. After a total of 1.5 h, CH3OH was added followed by HCl (1 N) and the reaction mixture was extracted with EtOAc to obtain 1-(4-fluorophenyl)-3(R)-[3(S)-(4-fluorophenyl)-3-hydroxypropyl)]-4(S)-[4-(phenylmethoxy)phenyl]-2-azetidinone (compound 6A-1) as an oil. 1 H in CDCl3 d H3=4.68. J=2.3 Hz. Cl (M+H) 500.

[0526] Use of (S)-tetra-hydro-1-methyl-3,3-diphenyl-1H,3H-pyrrolo-[1,2-c][1,3,2] oxazaborole gives the corresponding 3(R)-hydroxypropyl azetidinone (compound 6B-1). 1H in CDCl3 d H3=4.69. J=2.3 Hz. Cl (M+H) 500.

[0527] To a solution of compound 6A-1 (0.4 g, 0.8 mmol) in ethanol (2 ml), was added 10% Pd/C (0.03 g) and the reaction mixture was stirred under a pressure (60 psi) of H2 gas for 16 h. The reaction mixture was filtered and the solvent was concentrated to obtain compound 6A. Mp 164-166° C.; Cl (M+H) 410. [α]D25=−28.1° (c 3, CH3OH). Elemental analysis calc'd for C24H21F2NO3: C 70.41; H 5.17; N 3.42; found C 70.25; H 5.19; N 3.54.

[0528] Similarly treat compound 6B-1 to obtain compound 6B.

[0529] Mp 129.5-132.5° C.; Cl (M+H) 410. Elemental analysis calc'd for C24H21F2NO3: C 70.41; H 5.17; N 3.42; found C 70.30; H 5.14; N 3.52.

[0530] Step 6′ (Alternative): To a solution of the product of Step 5 (0.14 g, 0.3 mmol) in ethanol (2 ml), was added 10% Pd/C (0.03 g) and the reaction was stirred under a pressure (60 psi) of H2 gas for 16 h. The reaction mixture was filtered and the solvent was concentrated to afford a 1:1 mixture of compounds 6A and 6B.

[0531] It will be appreciated by those skilled in the art that changes could be made to the embodiments described above without departing from the broad inventive concept thereof. It is understood, therefore, that this invention is not limited to the particular embodiments disclosed, but it is intended to cover modifications that are within the spirit and scope of the invention, as defined by the appended claims.

	Number	Date	Country
	60324121	Sep 2001	US
	60351957	Jan 2002	US

Methods of treating or preventing cardiovascular conditions while preventing or minimizing muscular degeneration side effects

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