The present invention relates to a combination of active ingredients and to compositions containing this combination in medical use and in the preparation of medicaments useful for the treatment of type 2 dia¬ betes and cardiovascular diseases.

Diabetes is a widespread disease throughout the world and is associ¬ ated with major clinical complications involving the microvascular dis¬ trict, such as diabetic retinopathy, diabetic neuropathy and nephropa¬ thy, and the macrovascular district, such as atherosclerosis, peripheral vasculopathies, myocardial infarct and stroke.

Insulin resistance, which characterises type 2 diabetes and its micro- and macrovascular complications is also involved in syndrome X, poly¬ cystic ovary syndrome, obesity, hypertension, hyperlipidaemias and hypercholesterolaemias (J. Am. Osteopath. Assoc, 2000 Oct.; 100(10):621-34; Jama, 2002 Nov., 27;288(20):2579-88).

It is known that hyperlipidaemias, hypercholesterolaemias and hyper¬ tension play a decisive role in the onset of coronary heart disease (CHD).

It is also known that an increase in glycosylation of proteins is in¬ volved in the above-mentioned complications of diabetes (Diabetologia 2001 Feb; 44(2): 129-46).

Said complications constitute a serious threat to the life and well-being of the individual.

Various clinical forms of diabetic disease are known, the most common being type 2 and type 1 diabetes. Type 2 diabetes is characterised by reduced sensitivity to the action of insulin (insulin resistance) and gives rise to an increase in insulin levels in the body in an attempt to compensate for this deficiency and to a consequent increase in glucose levels. Numerous reports have confirmed the involvement of insulin resistance in many disease conditions in addition to type 2 diabetes itself, such as dyslipidaemia, obesity, arterial hypertension and certain macrovascular and microvascular manifestations characteristic of dia¬ betic disease itself. The combination of insulin resistance and obesity, hypertension and dyslipidaemia is known as Syndrome X.

Drugs used for many years such as the biguanides and sulphonylurea drugs are available on the market for the treatment of type 2 diabetes. Many of these, such as, for example, methformin, present gastrointes¬ tinal disorders, danger of acidosis in conditions of renal, cardiac, he¬ patic, pulmonary insufficiency, etc., as side effects. The sulphonylureas have episodes of hypoglycaemia as their possible side effects. Drugs recently introduced onto the market are the thiazolidinediones, whose side effects such as liver toxicity, increased LDL cholesterol, weight gain and oedema have given cause for concern.

Hyperlipidaemia is a serious aspect of diabetic disease, constituting, together with the hypertension which is often present, a risk factor for atherosclerosis and for cardiovascular disease which is the primary cause of death in diabetes.

Cardiovascular disease is recognised as the primary cause of death in the industrialised countries with a high standard of living.

The social cost is enormous, both in terms of disability and invalidity of subjects suffering from it, and in terms of the actual cost of health facilities and insurance.

Dyslipidaemia is often associated, also as a consequence, with diabe¬ tes.

In WO 02/43659 a combination of statin, docosahexanoic acid, vitamins E, C B6 and B 12, folic acid and calcium is described to reduce the risk factors for cardiovascular disease, such as hypercholesterolaemia and hypertension. In this document there is never any mention of insulin resistance.

Ever increasing attention is being devoted to the so-called risk factors recognised as underlying these diseases, and there is still a perceived need for a medicament capable of acting on the various sources of this pathological picture, without, at the same time, being associated with severe side effects, which, as in the case of certain antidiabetic drugs, may even make it necessary to discontinue the therapy.

Summary of the invention

It has now surprisingly been found that a certain combination of sub¬ stances, known for their specific pharmacological actions, is particu¬ larly indicated for the treatment of insulin resistance, and of the pathological aspects related to it, as well as of cardiovascular diseases.

The combination according to the invention comprises essentially at least one omega-3 fatty acid, optionally esterified or salified, at least one statin, Coenzyme QlO, resveratrol, at least one policosanol, pantethine, selenium and zinc.

The unique combination according to the present invention exerts a surprising effect on insulin resistance, which is not predictable on the basis of our knowledge of the individual components thereof, and, in any event, their combination leads to an unexpected synergistic effect.

The advantage of having such a combination is therefore evident to experts in the field. It is possible, in fact, to treat insulin resistance, and the pathological forms related to it, particularly as regards the implications of abnormal lipid status, and, at the same time, the com¬ plications or risks affecting the cardiocirculatory system. The combination according to the present invention can also be used for the treatment of cardiovascular diseases, without there necessarily being any need to treat insulin resistance.

Therefore, one object of the present invention is a combination com¬ prising at least one omega-3 fatty acid, optionally esterified or salified, at least one statin, Coenzyme QlO, resveratrol, at least one polico- sanol, pantethine, selenium, and zinc.

The combination according to the invention can also comprise other useful elements, without this substantially impairing the activity.

Another object of the present invention is a pharmaceutical composi¬ tion containing the above-mentioned combination, optionally in a mix¬ ture with one or more pharmaceutically acceptable vehicles or excipi- ents.

The combination according to the present invention can also be formu¬ lated as a food supplement, which constitutes a further object of the invention.

Other objects of the present invention are various uses of the above- mentioned combination as a medicament, in particular for the prepa¬ ration of a medicament for the treatment of insulin resistance and type 2 diabetes, with antilipaemic action and a protective action on the car¬ diovascular system.

In particular, the present invention provides for the use of the above- mentioned combination for the preparation of a medicament useful for the treatment of diseases involving insulin resistance, such as type 2 diabetes, Syndrome X, polycystic ovary syndrome, obesity, hyperten¬ sion, hperlipidaemias and hypercholesterolaemias.

The medicament according to the invention can be used to treat the individual disease states or to exert a preventive or protective action against them, or to treat a complex pathological picture that includes one or more of the therapeutic aspects seen above. For example, a me¬ dicament with a combined action for the treatment of type 2 diabetes and insulin resistance and an antilipaemic and protective action on the cardiovascular system, particularly in certain severe forms of type 2 diabetes associated with obesity.

Detailed description of the invention

The combination according to the present invention consists essen¬ tially of active ingredients which are known in the medical field and already used in clinical practice. Therefore, they are very easy to pro¬ cure, inasmuch as they are products which have been on the market for some time and are of a grade suitable for human or animal admini¬ stration.

The statins are a known class of drugs used for lowering cholesterol levels. Statins are available on the market or can be prepared accord¬ ing to known methods described in the literature.

Any statin is suitable for the purposes of the present invention. Exam¬ ples of statins are simvastatin, lovastatin, fluvastatin, pravastatin, atorvastatin, cerivastatin and rosuvastatin. Among these, the one pre¬ ferred is simvastatin.

According to the present invention, it is also possible to combine a number of statins, depending on their pharmacological characteristics and on the basis of the common knowledge of experts in the field.

The omega- 3 fatty acids are known for their triglyceride -lowering ef¬ fects and for their effects in raising the levels of high-density lipopro¬ teins (HDL). These fatty acids can be obtained by synthesis or, pref¬ erably, from fish oil. In that case, it is possible to use various mixtures of omega- 3 fatty acids depending on their characteristics. Preferably, the omega-3 fatty acids are the long-chain ones (from 20 to 22 carbon atoms). The ones most preferred are 5,8,11,14,17-eicosapentanoic acid (EPA) and cis 0,13,16,19-docosahexanoic acid (DHA). In a preferred embodiment of the invention, the omega-5 fatty acid is cis 4,7,10,13, 16,19-docosahexanoic acid (DHA), most preferably in a ratio of 1:1. These omega-3 fatty acids can optionally be esterified or salified to pharmaceutically acceptable derivatives, with alcohols or bases, re¬ spectively. The omega-3 fatty acids, or their esters or salts, alone or in mixtures thereof, can be procured on the market, or can be prepared by known methods. The mixtures can be specifically formulated for the combination according to the invention.

Coenzyme QlO is now so well known in its human use that it requires no particular explanation and the substance is available on the mar¬ ket. Experts in the field can refer to the patent documents filed by the present applicant, where this substance is amply described.

Similar considerations also apply to resveratrol.

The policosanols are long-chain aliphatic alcohols. Examples of polico- sanols are triacontanol, hexacosanol, hexacontanol, ecocontanol, tetra- cosanol, dotriacontanol, and tetracontanol. The policosonal can be pre¬ sent as such or in the form of an extract from natural products that contain it, e.g. wheat or rice germs, the waxy cuticle of sugar cane, or Ginkgo biloba leaves. See, for example, WO 99/06039.

Pantethine is used on compositions for hair cosmetics and also in com¬ positions for the treatment of dyslipidaemias, as described, for exam¬ ple, in WO 2004/041257. It is therefore a well-known compound avail¬ able to the expert in the field.

Selenium and zinc are commonly used in food supplements, as de¬ scribed in several patents, e.g. EP 0 797 993 and US 6.602.512. As already mentioned, the individual components have long been used in human subjects, and therefore their pharmaco-toxicological profiles are known.

This implies that, apart from the consideration of the synergistic effect demonstrated here below, the dosages and ratios of the individual components can be determined by the expert in the field with normal preclinical and clinical trials, or with the usual considerations regard¬ ing the formulation of a dietetic product.

The amounts of the individual compounds advised for the preparation of a pharmaceutical composition for human use are the following.

Omega-3 fatty acid: from 500 mg to 2 g/day, preferably 1 g/day;

Simvastatin; from 10 mg to 40 mg/day, preferably 10 mg/day;

Coenzyme QlO: from 5 mg to 50 mg/day, preferably 10 mg/day;

Resveratrol: from 1 mg to 5 mg/day, preferably 2.5 mg/day;

Policosanols: hexacosanol: from 5 mg to 15 mg/day, preferably 10 mg/day;

Pantethine: from 10 mg to 30 mg/day, preferably 20 mg/day;

Selenium: from 25 μg to 75 μg/day, preferably 50 μg/day;

Zinc: from 5 mg to 15 mg/day, preferablylO mg/day.

The pharmaceutical composition can have a unitary form, in which the active ingredients are present in a single pharmaceutical form (tablet, sachet, capsule, vial) or the active ingredients can be administered in a coordinated sequential manner. In the latter case, the pharmaceutical composition can be formulated, supplying the components in separate containers, accompanied by instructions for their sequential admini¬ stration.

The compositions covered by the present invention are entirely conven¬ tional and are obtained with methods that are common practice in the pharmaceutical industry. According to the administration route opted for, the compositions will be in solid or liquid form, suitable for oral, parenteral or intravenous administration. The compositions according to the present invention contain, along with the active ingredient, at least one pharmaceutically acceptable vehicle or excipient. Particularly useful may be formulation adjuvants such as, for example, solubilising agents, dispersing agents, suspension agents and emulsifying agents. A general reference work is Remington's Pharmaceutical Sciences Handbook, latest edition.

The following examples further illustrate the invention.

Example 1

Antidiabetic and serum lipid-lowering activity in db/db mice

Mutations in laboratory animals have made it possible to develop models that present non-insulin-dependent diabetes associated with obesity, hyperlipidaemia and insulin resistance and that enable us to test the efficacy of new antidiabetic compounds (Reed and Scribner, Diabetes, obesity and metabolism 1: 75 - 86, 1999).

A much used genetically diabetic mouse model is the C57BL/KsJ db/db mouse.

The genetic basis of this model is a defect in the leptin receptor gene which gives rise to leptin resistance and leads to hyperphagia, obesity, hyperinsulinaemia and insulin resistance, with subsequent symptoms of insufficient insulin secretion and hyperglycaemia (Kodama et al., Diabetologia 37: 739 - 744, 1994; Chen et al, Cell 84: 491 - 495, 1996). Since hyperglycaemia is accompanied by obesity and insulin resis¬ tance, the db/db mouse has characteristics that are close to those of type 2 diabetes in man and is useful for assaying insulin-sensitising compounds.

The C57BL/KsJ db/db mice used in the experiments were supplied by Jackson Lab (via Ch. River). After 10 days of acclimatisation in stan¬ dard conditions (22 ± 2°C; 55 ± 15% humidity; 15-20 air changes/hour; 12 hour light-darkness cycle with light from 7 a.m. to 7 p.m.) on a standard 4 RF21 diet (Mucedola), blood samples were taken in post- absorption conditions (fasting from 8.30 a.m. to 4.30 p.m.) from the caudal vein with the aid of a Jelco 22G catheter (Johnson and John¬ son). Glucose, insulin, triglyceride, cholesterol, free fatty acid and urea levels were checked in the plasma to ensure well-matched distribution of the mice in the treatment groups.

At the start of treatment, the body weight of the animals was checked and monitoring of the animals' consumption of water and feed was scheduled.

The mice were divided into groups and treated orally twice daily with:

Omega-3 fatty acid (EPA +DHA 1:1) 200 mg/kg;

Simvastatin 100 mg/kg;

Omega-3 fatty acid (200 mg/kg) + simvastatin (100 mg/kg);

Omega-3 fatty acid (200 mg/kg) + simvastatin (100 mg/kg); Coenzyme QlO (50 mg/kg) + resveratrol (5 mg/kg) + policosanols (hexacosanol 25 mg/kg) + pantethine (100 mg/kg + selenium (0.5 μg/kg) + zinc (2.5 mg/kg). In the course of the experiment, serum glucose levels, glucose toler¬ ance (OGTT), a number of lipid status variables and weight gain were monitored.

The combination according to the invention was capable of lowering serum glucose levels in the feeding condition (Table 1); in the post- absorption condition (Table 2); and in the fasting condition (Table 3); and capable of improving glucose tolerance (Table 4), and of reducing the levels of fructosamine, an indicator of protein glycosylation (Table 5) which, as mentioned above, plays an important role in the develop¬ ment of the micro- and macrovascular complications of diabetes.

The combination according to the invention also shows good ability to reduce serum triglyceride levels (Table 6) and to increase HDL- cholesterol levels (Table 7).

An increase in HDL-cholesterol values constitutes an indicator of a reduced risk of atherosclerosis and of cardiovascular complications such as atherosclerosis and infarct. Table 1

Blood glucose levels of db/db mice, treated orally twice daily for 12 days with the compounds and at the doses indicated in the table. Sample in feeding condition, approximately 15 hours after the last treatment.

Mean values + S. E. and variation (%) vs control.

Compound Glucose % P mg/dl Variation (Student's t- test) Control 487 ± 25

Simvastatin 450 ± 21 -7.6 NS

Omega-3 466 ± 28 -4.3 NS

Omega-3 + simvastatin 403 ± 34 -17.2 NS

Omega-3 (200 mg/kg) + simvastatin (100 303 + 16 -37.8 PO.001 mg/kg)+ Coenzyme QlO (50 mg/kg)+ resvera- vs control trol (5 mg/kg) + hexacosanol 25 mg/kg) + pantethine (100 mg/kg + selenium (0.5 μg/kg) + zinc (2.5 mg/kg) Number of animals per group: 6. Table 2

Blood glucose levels of db/db mice, treated orally twice daily for 12 days with the compounds and at the doses indicated in the table. Sample in post-absorption condition (fasting from 9 a.m. to 5 p.m.) and 8 hours after the last treatment.

Mean values ± S. E. and variation (%) vs control.

Compound Glucose % P mg/dl Variation (Student's t test) Control 414 ± 11

Simvastatin 419 ± 33 1.2 NS

Omega-3 421 ± 30 1.6 NS

Omega-3 + simvastatin 409 ± 11 -1.2 NS

Omega-3 (200 mg/kg) + simvastatin (100 216 + 16 -47.8 PO.001 mg/kg); + Coenzyme QlO (50 mg/kg) + res- vs control veratrol (5 mg/kg) + hexacosanol 25 mg/kg) + pantethine (100 mg/kg + selenium (0.5 Dg/kg) + zinc (2.5 mg/kg) Number of animals per group: 6. Table 3

Blood glucose levels of db/db mice, treated orally twice daily for 18 days with the compounds and at the doses indicated in the table. Sample in mice fasted for 18 hours and 5 hours after the last treat¬ ment.

Mean values ± S.E. and variation (%) vs control.

Compound Glucose % P mg/dl Variation (Student's t-test)

Control 344 ± 35

Simvastatin 325 ± 27 -5.5 NS

Omega-3 314 ± 21 -8.7 NS

Omega- 3 + simvastatin 384 ± 20 11.6 NS

Omega-3 (200 mg/kg) + simvastatin (100 144 + 3 -58.0 PO.001 mg/kg); + Coenzyme QlO (50 mg/kg) + res- vs control veratrol (5 mg/kg) + hexacosanol 25 mg/kg) + pantethine (100 mg/kg + selenium (0.5 μg/kg) + zinc (2.5 mg/kg) Number of animals per group: 6. Table 4

Area under the curve (AUC) of the OGTT in the blood of db/db mice, treated orally twice daily for 18 days with the compounds and at the doses indicated in the table. OGTT test (glucose 3 g/kg) in mice fasted for 18 hours and 5 hours af¬ ter the last treatment.

Mean values ± S. E. and variation (%) vs control.

Compound AUC Glucose % P u.a. Variation Student's t-test

Control 51182 + 2392

Simvastatin 48174 + 3555 -5.9 NS

Omega-3 46476 + 1827 -9.2 NS

Omega-3 + simvastatin 45192 ± 1546 -11.7 NS

Omega-3 (200 mg/kg) + simvastatin (100 24527 + 889 -52.1 PO.001 mg/kg); + Coenzyme QlO (50 mg/kg) + res- vs control veratrol (5 mg/kg) + hexacosanol 25 mg/kg) + pantethine (100 mg/kg + selenium (0.5 μg/kg) + zinc (2.5 mg/kg) Number of animals: 6. Table 5

Plasma fructosamine levels of db/db mice, treated orally twice daily for 25 days with the compounds and at the doses indicated in the table. Sample in post-absorption condition (fasting from 9 a.m. to 4.30 p.m.) and 7.30 hours after the last treatment.

Mean values ± S. E. and variation (%) vs control.

Compound Fructosamine % P mM Variation Student's t-test

Control 0.80 ± 0.03

Simvastatin 0.78 + 0.12 -2.5 NS

Omega-3 0.81 + 0.04 1.3 NS

Omega-3 + simvastatin 0.82 ± 0.02 2.5 NS

Omega-3 (200 mg/kg) + sim¬ 0.41 ± 0.04 -48.8 PO.001 vastatin (100 mg/kg) + vs control Coenzyme QlO (50 mg/kg) + resveratrol (5 mg/kg) + hex- acosanol 25 mg/kg) + pantethine (100 mg/kg + selenium (0.5 μg/kg) + zinc (2.5 mg/kg) Number of animals per group: 6. Table 6

Plasma triglyceride levels of db/db mice, treated orally twice daily for 25 days with the compounds and at the doses indicated in the table. Sample in post-absorption condition (fasting from 9 a.m. to 4.30 p.m.) and 7.30 hours after the last treatment.

Mean values + S. E. and variation (%) vs control.

Compound Triglycer¬ % P ides Variation Student's t-test mg/dl

Control 95.4 + 6.2

Simvastatin 79.7 ± 5.1 -16.5 NS

Omega-3 88.3 ± 10.7 -7.4 NS

Omega-3 + simvastatin 73.5 + 4.5 -22.9 0.05 vs control

Omega-3 (200 mg/kg) + simvastatin 45.3 + 2.3 -52.5 0.001 (100 mg/kg) + Coenzyme QlO (50 vs control mg/kg)+ resveratrol (5 mg/kg) + hex- acosanol 25 mg/kg) + pantethine (100 mg/kg + selenium (0.5 μg/kg) + zinc (2.5 mg/kg) Number of animals per group: 6. Table 7

Plasma HDL-cholesterol levels of db/db mice, treated orally twice daily for 25 days with the compounds and at the doses indicated in the table. Sample in post-absorption conditions (fasting from 9 a.m. to 4.30 p.m.) and 7.30 hours after the last treatment.

Mean values + S.E. and variation (%) vs control.

Compound HDL-cholesterol % mg/dl Variation Student's t-test

Control 82.0 ± 5.1 Simvastatin 72.4 ± 4.6 -11.7 NS Omega-3 74.8 ± 3.8 -8.8 NS Omega-3 + simva-statin 78.4 ± 4.1 -4.4 NS Omega-3 (200 mg/kg) + simvastatin (100 98.0 + 3,5 19.5 0.05 mg/kg);+ Coenzyme QlO (50 mg/kg) + resvera- vs control trol (5 mg/kg) + hexacosanol 25 mg/kg) + pantethine (100 mg/kg + selenium (0.5 μg/kg) + zinc (2.5 mg/kg)

The results reported above clearly demonstrate the unexpected syner¬ gism of the combination according to the present invention, contrary to what was expected on the basis of the individual components, or even of the combination of simvastatin and omega-3 fatty acids.