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Title:
METHODS OF TREATING PRADER-WILLI SYNDROME
Document Type and Number:
WIPO Patent Application WO/2017/210540
Kind Code:
A1
Abstract:
The present invention relates to methods for regulating prohormone convertase (PC1 ) and compounds and treatments which increase PC1 levels, for treating Prader-Willi Syndrome (PWS).

Inventors:
BURNETT, Lisa, Cole (1380 Riverside Drive Apt. 8E, New York, NY, 10033, US)
EGLI, Dieter (116 Pinehurst Avenue, Apt. R43New York, NY, 10033, US)
LEIBEL, Rudolph, L. (464 Riverside Dr. #91, New York, NY, 10027, US)
COTTER, Sara (1634 Walnut Avenue, Wilmette, IL, 60091, US)
Application Number:
US2017/035655
Publication Date:
December 07, 2017
Filing Date:
June 02, 2017
Export Citation:
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Assignee:
THE TRUSTEES OF COLUMBIA UNIVERSITY IN THE CITY OF NEW YORK (412 Low Memorial Library, 535 West 116th StreetNew York, NY, 10027, US)
LEVO THERAPEUTICS, INC. (1701 E. Lake Avenue, Suite 260Glenview, IL, 60025, US)
International Classes:
A61K31/221; A61K31/198
Attorney, Agent or Firm:
DAVITZ, Michael, A. et al. (Leason Ellis LLP, One Barker AvenueFifth Floo, White Plains NY, 10601, US)
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Claims:
WHAT IS CLAIMED IS:

1. A method for regulating prohormone convertase comprising, administering a therapeutically effecti ve amount of a phosphodiesterase 4 inhibitor (PDE4 inhibitor or PDE4i),

2. A method for upregolating expression of prohormone convertase comprising, administering a 'therapeutically effective amount of a P.DB4 inhibitor.

3. The method of claim 2, wherein the PDE4 inhibitor is administered m vitro to a cell.

4. The method of claim 1 , wherein the PDE4 inhibitor is administered to a patient with Prader- Wi l it sy n drome.

5. The method of claim 4, wherein the PDE4 inhibitor is administered orally.

6 The method of claim 4, wherein the PDE4 inhibitor is administered intravenously or subcuianeo'usiy.

7. The method of claim 4, wherein the PDE4 inhibitor is administered intratheeaJly.

8. The method of claim 4, wherein the PDE4 inhibitor is administered topically. 10. The method of claim 4, wherein the PDE4 inhibi tor is administered intranasal ly.

1 1. The method of claim 4, wherein the PD.E4 inhibitor is administered in the lungs.

1 2. The method of claim 1 wherein the PDE4 inhibitor is selected from the group consisting of theophylline, rofiimilasL apremiiasf ibdulasL GSK356278, MK0952, IBMX. and combinations thereof.

1 3. A method for regulating prohormone converiase comprising administering a therapeutically effective amount of an adenylate cyclase activator.

14. The method of claim 13, wherein the adenylate cyclase activator is administered in viiro to a cell.

15. The method of claim 13, wherein the adeny late cyclase activator rs administered to a patient with Prader-Willi syndrome. 1 6. The method of claim S 3, wherein the adenylate cyclase activator is administered orally, intravenously, susbcutaneously, mtratheeaily, or intrariasaily ,

17. The method of claim 13, wherein the adenylate cyclase activator is administered topically.

1 8. The method of claim 1.3, wherein the adenylate cyclase activator is administered m the kings.

19. The method of claim 13, wherein the adenylate cyclase activator is selected from the group consisting of Forsko!in, FD i , FD2, FD3, F.D4, FD5 (NKH47?), FD6, and

combinations thereof

20. A method for regulating prohormone converiase comprising, administering a therapeutically effective amount of a PDE4 inhibitor and an adenylate cyclase activator.

21. The method of chum 20, wherein the PDE4 inhibitor and the adenylate cyclase activator are administered to a patient with Prader-Willi syndrome.

22. The method of claim 1, wherein the PDE4 inhibitor is administered to an obese subject.

23. The method of claim 13, wherein the adenylate cyclase activator is administered to an obese subject.

24. The method of claim 20, wherein the PDE4 inhibitor and the adenylate cyclase activator are administered to an obese subject,

25. A method for upregulating expression of prohormone convenase comprising administering a therapeutically effective amount of an MC4R agonise.

26. The method of clai m 25, wherein the MC4R agonist is admi nistered in vitro to a ceil.

27. The method of claim 25, wherein the MC4R agonist is administered to a patient with Prader-Willi syndrome.

28. The method of claim 25, wherein the MC4R agonist is administered to an obese subject. 29. The method of clai m 25, wherein the MC4R agonist is administered orally.

30 The method of claim 25, wherein the MC4R agonist is administered intravenously or subcuianeously. 31. The method of claim 25, wherein the MC4R agonist JS administered intrathecaily.

32. The method of claim 25, wherein the MC4R agonist is administered topically.

33. The method of claim 25, wherein the MC4R agonist is administered intranasal iy.

34. The method of claim 25, wherein the MC4R agonist is administered, in the lungs.

35. The method of claim 25, wherein the MC4R agonist is selected from the group

consisting of RM-493 (Setmelanotide). TT.P2515, 2-am.inoth.iazole derivatives, MK~ 0493, and combinations thereof.

36. The method of any one of claims 1 , 2, 13, or 20, further comprising administering a therapeutically effective amount of an MC4R agonist.

37. The method of claim 36, wherein the MC4.R agonist is administered in vitro to a cell.

38. T he method of clai m 36, wherein the MC4R agonist is administered to a patient with Prader- W i Ϊ I i sy ndro me .

39. The method of claim 36, wherein the MC4R agonist is administered to an. obese subject.

40. The method of claim 36, wherein the MC4R agonist is selec ted from the group consisting of RM-493 (Setmelanotide), TTP25 I 5, 2-aminothiazole derivatives, MK-0493, and combinations thereof.

41. The method of any one of claims 4, 15 , 21, 27, or 28, wherein the administration results in one or more of the following improvements in the patient: decreases or ameliorates Iryperphagia; increases Pc.skJ levels; increases PC I level and/or activity; decreases circulating proinsuli.n to insulin ratio; decreases circulating proghreli.n to ghreitn ratio; decreases circulating POMC to ACTH ratio; amelioration of hypothyroidism, decreases circulating ratio of pro-oxytocin to oxytocin; decreases circulating ratio of pro-bdnf to bdnf; and increases the ratio of prohormone: hormone; wherein the symptom, levels, or ratios are in reference to the patient's disease symptom, levels, or ratios.

42. A method for treating Prader-Willi Syndrome (PWS) comprising administering a phosphodiesterase 4 inhibitor (PDE4i) to a subject in need thereof thereby alleviating, el iminating or preventing one or more symptoms of PWS, 43. The method of claim 42, wherein administering the PDE4i upregulates cyclic adenosine monophosphate tcAMP) concentrations or activity in the subject.

44. The method of claim 43, wherein P WS is characterized by decreased expression of Nhlh2.

45. The method of claim 44, wherein decreased expression of Nhi.h2 results in decreased expression of Pcsk 1 .

46. The method of claim 43 , wherein increasing concentrations or activity of cAMP upreguiates expression of Fcski.

47. The method of claim 43, wherein the PDE4i is a selective PDE4t .

48. The method of claim 43, wherein the PDE4i is a non-selective PDE4i. 49. The method of claim 47. wherein the selective PDE4i is selected from AN2728, aprenrilast, cilomilast, diazepam, ibudilast, luteo!in, mesembrenone, piclaniilast, roflumilast, rolipram, E6005, GSK35627S and MK0952.

50. The method of claim 48, wherein the non-selective PDE4i selected from methylated xanthines and derivatives thereof, caffeine, ammophyllme, 3-isobutyI- 1 Hmeihylxanthirie, paraxanthine, pemoxiivl!ine, theobromine, and theophylline,

51 . The method of claim 42, wherein the one or more symptoms include hyperphagia, reduced metabolic rate, obesity, hypogonadism, decreased growth hormone production, poor muscle tone, sleep disorders, gastrointestinal disorders, reduced stamina, reduced ability to focus, impaired cognition, behavioral disorders, anx iety, growth failure, reduced conversion of immature hormones to mature and active forms, and diabetes.

52. The method of claim 42, wherein the method further comprises administering one or more additional therapeutic, agents effecti ve for treating or alleviating one or more symptoms PWS.

53. The method of claim 5 1 , wherein the immature hormones comprise one or more of insulin, ghre!m, GHRH, alpha-MSIl oxytocin, orexin, BDNF, vasopressin, NPY, AGRP, and gonadotropin.

54. The method of claim 52, wherein the one or more additional therapeutic agents effective at treating or alleviating PWS include insulin, an insulin receptor agonist, ghreltn, a ghreiin receptor agonist, GHRH, a GHRH receptor agonist, alpha-MSH, an aipha-MSH receptor agonist, oxytocin, an oxytocin receptor agonist, orexin. an orexin receptor agonist, BDNF, a BDNF receptor agonist, vasopressin, a vasopressin receptor agonist, NPY, an NPY receptor agonist, AGRP, an AGRP receptor agonist, gonadotropin, a gonadotropin receptor against, or combinations thereof.

Description:
METHODS OF TREATING PRADER-WILLI SYNDROME

CROSS-REFERENCE TO RELATED APPLICATIONS The present application claims priority to U.S. Provisional Patent Application No.

62/345, 1.33 filed June 3, 2016; U.S. Provisional Application No. 62/375,662 filed August 16, 2016, each of which is incorporated herein by reference in its entirety.

GOVERNMENT SUPPORT

This work was supported in part by a grant, from the National institute of Health R01 DKO52431 ; consequently, the U.S. Government may have certain fights in the present invention.

FIELD OF THE INVENTION

The present invention relates to methods for regulating prohormone convertase (PC ! ) and compounds and treatments which increase PCI levels,

BACKGROUND OF THE INVENTION

Prader-Willi, syndrome (PWS) is caused by a loss of paternally expressed genes in an imprinted region of chromosome 1 5q. Among the canonical phenotypes are hyperphagic obesity, central hypogonadism and low growth hormone. Rare microdeletion PWS patients define a 91 kb minimum critical deletion region encompassing 3 genes, including the non- coding SNOR.D116. We have found that NH.LH2 and PC I are downregulated in PWS iPSC- derived neurons as compared to unaffected controls. NMh2 and Pcsk! transcript levels are reduced in hypothalami of fasted Snord mice.

Deficiency of Nhih2 in mice causes obesity, hypogonadism,, and growth failure. Nhlh2 promotes expression of the prohormone convertase, ( PCM). Humans and mice deficient in PCI display hyperphagic obesity, hypogonadism, decreased growth hormone, and diabetes due to impaired prohormone processing. For example, mice display in vivo .functional defects in. prohormone processing of proinsulin, proGH.RH, and proghxelin associated with reductions in PC I .

Currently there are no treatments for PWS patients and effective treatments and model systems are urgently needed. SUMMARY OF THE INVENTION

The methods of the present invention provide for regulating prohormone convertase by administering an effective amount of a phosphodiesterase 4 inhibitor (PDE4 inhibitor or PDE4i). Expression of the prohormone convertase may be upreguSated by admi nistration of a therapeutically effective amount of a PDE4 inhibitor. The PDE4 inhibitor may be administered to a ceil or to a patient with Prader-Willi syndrome. The P.DE4 inhibitor may be administered to an obese subject, it is also expected that these methods will be useful for treating patients with Schaaf-Yang Syndrome and Autism Spectrum Disorder.

The PDE4 inhibitor may be administered orally, intravenously, subcutaneously, intrat.heca.Hy, topically, intranasal I y. or to the lungs.

The PDE4 inhibitor can include, theophylline, roflumilast, apremi!ast, ibdulast, GSK356278, MK09S2, IBMX as well as combinations of these drugs.

in certain embodiments, the PDE4 inhibitor can include any of the inhibitors from Tables 1 A or Table I B.

l n additional embodiments, combinations of PDE4 inhibitors may be used in the present methods.

The methods of the present invention also include administering a therapeutically effective amount of an adenylate cyclase activator. The adenylate cyclase activator can be administered to a ceil or to a patient with Prader-Willi syndrome. The adenylate cyclase activator may he administered to an obese subject.

The adenylate cyclase activator can be administered orally, intravenously, intrathecally , intransally, topically, or to the lungs. The adenylate cyclase activator can include, Forskolm, FD 1 , FD2, FD3, FD4, FD5 (NKH477X FD6 as well as combinations of these drugs.

The PDE4 inhibitor may also be administered together with the adenylate cyclase activator .

The methods of the present invention also include administering a therapeutically effective amount of an MC4R agonist, The MC4R agonist can be administered to a cell or to a patient with Prader-Willi syndrome. The MC4R agonist may be administered to an obese subject. The MC4R agonist can be administered orally, intravenously, intrathecaSly, intranasally, topically, or to the lungs. The MC4R agonist can include RM-493 (Setmelanotide), TTP2515, 2-arninot.hiazoie derivatives, MK-0493, and combinations thereof. T he MC4R agonist can be administered in combination with the PDE4 inhibitors and/or adenylate cyclase activators described herein.

The methods of the present invention aiso include methods wherein the administration results in one or more of the following improvements in the patient: decreases or ameliorates hyperphagia; increases PCSK1 levels: increases PCI level and/or activity; decreases circulating proinsuiin to insulin ratio, thus increasing insulin secretion; decreases circulating proghreli.il to ghreii.n ratio; decreases circulating PO.MC to ACTI l. ratio; amelioration, of hypothyroidism, decreases circulating ratio of pro-oxytocin to oxytocin, thus increasing oxytocin production in the brain and increases aipha-MSl i. production in the brain; decreases circulating ratio of pro-BDNF to B ' DNF ( increase brain levels of BDNF); and increases the ratio of prohormone; hormone (decreases pro-mature hormone); wherein the symptom, levels, or ratios are in reference to the patient's disease symptom, levels, or ratios.

in certain embodiments, the methods provide for treating Prader-Willi Syndrome (PWS) comprising administering a phosphodiesterase 4 inhibitor (P.DE4j) to a subject in need thereof, thereby alleviating, eliminating or preventing one or more symptoms of PWS. in certain embodiments, administering the PDE4i upregulates cyclic adenosine monophosphate ( cAMP) concentrations or activity in the subject. in certain embodiments, PWS is characterized by decreased expression of NHLH2.

In additional embodiments, decreased expression of NHLH2 results in decreased expression of FCSKl . in certain embodiments, increasing concentrations or activity of cAMP upregulates expression of PcskL

In additional embodiments, the PDE4i is a selective PDE4i. In additional

embodiments, the PDE4i is a non-se!ective PDE4i, in certain embodiments, the selective PDE4i is selected from AN2728, apremilast, eiiomilast, diazepam, ibndilast, luteolin, mesemhrenone. pielamilast, roilumilast, rolipram, £6005, GSK356278 and MK09S2. In certain embodiments, the non-selective PDE4i selected from methylated xanthines ami derivatives thereof, caffeine, amirtophylline, 3-isobutyl-1-methylxamhine, paraxanihine, pentoxifylline, theobromine, and theophylline.

In yet additional embodiments, the one or more symptoms include hyperphagia, reduced metabolic rate, obesity, hypogonadism, fiypoadrenalisrn, decreased growth hormone production, poor muscle tone, sleep disorders, gastrointestinal disorders, reduced stamina, reduced ability to focus, impaired cognition, behavioral disorders, anxiety, growth failure, reduced conversion of immature hormones to mature and active forms, and diabetes mellitus and diabetes insipidus. In certain embodiments, the method further comprises administering one or more additional therapeutic agents effective for treating or alleviating one or more symptoms of PWS.

In certain embodiments, the immature hormones comprise one or more of insulin, ghrelin, GH.RH, alpha-MSH, oxytocin, orexin, BDNF, vasopressin, NPY, AGRP, and gonadotropins, ACTM.

In certain embodiments, the one or more additional therapeutic agents effective at treating or alleviating PWS include insulin, an insulin receptor agonist, ghrelin, a ghrelin receptor agonist, GH.R.H. a GHRfi receptor agonist, alpha-MSH. an alpha-MSH receptor agonist, oxytocin., an oxytocin receptor agonist, orexin, an orexin receptor agonist, BDNF, a BDNF receptor agonist, vasopressin, a vasopressin receptor agonist, NPY. an NPY receptor agonist, AGRP, an AGRP receptor agonist, gonadotropin, a gonadotropin receptor against, or combi nat ions thereof.

BRIEF DESCRIPTION OF THE DRAWINGS

Figure 1 is a model showing how deficiencies in Nhlh2 and PC I may drive the major neuroendocrine phenotypes of PWS. A deficiency in prohormone processing owing to deficits in PC I and Nhlh2 production may explain many of the major neuroendocrine phenotypes of PWS. Ii is hypothesized (hat paternal ioss of SNORDl 16 may be sufficient to cause deficiencies in Nhlh2 and PCI , in turn causing functional defects in prohormone processing. Arrows/fines that are dashed indicate theoretical connections. Arrows/lines that are soiid indicate pathways that have been investigated.

Figure 2 is a schematic showing the rationale for treatment of PWS utilizma agents that increase cellular cAMP levels in order to increase level and/or activity of cellular PCl and increase prohormone processing.

Figures 3A-P are graphs showing downregulation of PC I in PWS models is associated with impaired prohormone processing; PCSK l transcript levels can be increased in unaffected control by treatment, with Forskolin.

Figure 4 is a schematic showing the therapeutic rationale for co-administration of MC4R agonists and/or AgRP inhibitors in combination with Forskolin and/or Theophylline in individuals with PWS and possibly other types of obesity, including common obesity.

Figures 5A-H are graphs showing that (he application of Forskolin, an AC agonist, elevates PCSKl /Peskl transcript levels in primary mouse neurons. iPSC-derived neurons, and primary mouse pancreatic islets,

Figures 6A-F are graphs showing thai application of phosphodiesterase inhibitors to i.PSC-derived neurons increases PCSKl transcript levels and prohormone processing. Fig. 6A: Theophylline increases PCSKl transcript levels in D34 iPSC-derived hypothalamic ARC neurons ( 1023 A line) at 10 mM concentration. Figs. 6B-C: Roflumilast increases PCSKl transcript levels in iPSC-derived neurons at Day 40 of differentiation ( 1043D3 line) at 1 mM concentration. Figs. 6Ό-Ε: Combination treatment with Roflumilast ( 100 nM) and Forskolin (1 μM) increase PCSKl transcript levels and increase POMC processing to ACTH at lower concentrations than either agent alone, suggesting an additive or possibly synergistic effect. Fig. 6.F: MK0952 applied at 10 μΜ in combination with 1 μΜ Forskolin increases PCSKl transcript levels -2-fold in iPSC -derived neurons ( 1043D3 line). Figures 7A~B are graphs showing (hat a single treatment with NIK0952 increases hypothalamic PcskJ in wild type mice. Fig. 7Λ is a graph showing that body weights of all mice used were comparable. Fig. 7B is a graph showing that MK0952 administered by oral gavage in 10% methyl cellulose at a dose of 10 mg/kg body weight increased hypothalamic Pcskl levels by about 25%. Treatment with Forskolm at 25 mg/kg did not result m increased hypothalamic I'cskl levels. Combination treatment with MK0952 ( 10 mg/kg ) and Forskolm (25 mg/kg) also resulted in a 25% increase in hypothalamic Pcskl transcript levels, likely due largely to the effects of MK0952.

Figures 8A-C are schematics, tables and graphs showing aspects of the clinical trial

DETAILED DESCRIPTION

The present disclosure provides for methods to regulate PC I (prohormone convertase 1 ) levels in vitro or in vivo. The methods can be used to upregulate ( increase expression) or increase PC 1 levels and/or activity. Also encompassed by the present disclosure are methods to treat Prader-Willi syndrome (PWS) and other forms of obesity. The methods may comprise the step of administering a therapeutically effective amount of a PDE4 inhibitor and/or an adenylate cyclase activator. It is also expected that these methods will he useful for treating patients with Sehaaf-Yang Syndrome and Autism Spectrum Disorder (Fahienne Schaller Franeoise Watrin Rachel Stu.rny Arrnick Massaerier Pierre Szepetows.ki Franeoise Muscateili; Hum Mol Genet (2010) 19 (24): 4895-4905. DOT.

Green L, Fein D, Modahl C, Feinstem C, Waterhouse L,

Morris M. Oxytocin and autistic disorder; alterations in peptide forms. Biol Psychiatry. 2001 Oct 15;50(8):609-1 3.

Theoretical mechanisms to increase cellular prohormone convertase 1 levels/activity include but are not limited to: ( 1 ) upreguSatioo at the transcript level by engaging endogenous promoters, (2) directly increasing enzymatic activity of PCI , (3) increasing rates of translation of PCSKl to PC I , (4) decreasing degradation of PC I enzyme/protein, one possible approach is by decreasing levels (via aatisense ol igo "genetic knockdown " traditional small molecule inhibition, or other) of the endogenous inhibitor of PC I , ProSAAS, (5) decreasing degradation imiRNA targeted, non-sense mediated decay, putative mRNA methylation levels) of PCSKl transcript, thereby increasing translation, ((>) PC I itself is processed from a 92 kDa zymogen to a 66 kPa mature enzyme, thus increasing levels of preproPOi processing could also have therapeutic utility, and (7) delivery of additional PCSK! cDN .A to the ceil by gene therapy methods, (8) delivery of SNORDU6 RNAs by gene therapy methods, and (9) direct delivery of the PCI enzyme into the circulation and-'or tissues with enzyme replacement therapies.

The present findings suggest that the major neuroendocrine features of PWS are likely due to functional PC I deficiency. See Figure i . As the gene encoding PCI , PCSK l , is intact in PWS, increasing the levels of PC I expression and/or activity in PWS patients will correct this functional PC I deficiency, Pharmacologically, this increase m PCM levels can be achieved by administration of agents that increase cyclic adenosine monophosphate (cAMP) levels or block cAMP degradation.

Cyclic nucleotide phosphodiesterases (PDEs) catalyze the hydrolysis of cyclic AMP and cyclic GMP, thereby regulating the intracellular concentrations of these cyclic nucleotides, their signaling pathways and, consequently, a myriad of biological responses in health and disease. Maurice et al. Advances in targeting cyclic nucleotide phosphodiesterases Nat. Rev. Drug. Discoy. 13(4):290-314 (2014). PDE4 isoibrms are highly expressed in ceils that regulate imniunonillammatory responses and tissue remodeling. Id. Inhibition of PDE4 results in an increase in cAMP levels in the cell. A large number of PDE4 inhibitors are available. Non- limiting examples of PDE4 Inhibitors include: Theophylline, Rollu.milast, Aprernilast, Ibudilast, GSK33627S, MK0952, ί ' ΒΜΧ (3-isobutyl- 1 -meihylxanthine), Mesembrenone, Rolipram, Pieiamilast, Luteolin, Drotaverine, AN2728, Cilomilast, Diazepam, Luieol.in, and E6005, Other phosphodiesterase inhibitors include, methylated xanthines and derivatives (such as caffeine, aminophylline, paraxanthine, pentoxifylline, theobromine, and theophylline).

The levels of cAMP may also be increased using agents which activate adenylate cyclase. Non-limiting examples of adenylate cyclase activators include: Forsko!m, FD i, FD2, FD3, FD4, FD5 (NKH477), and FD6.

PDE4 inhibitors and adenylate cyclase activators can be referred to alone or in combination as therapeutic agents,

Table I A: Selected PDE4 Inhibitors

Abbreviations

AC ' T ' H : adrenocorticotropic hormone. AgRP: Agouti-related protein; a protein also produced in the arcuate nucleus and is an inverse agonist at MC4R. Pro AgRP is processed to AgRP fay PC I . cAMP: cyclic adenosine monophosphate

G1 I . Ghrelin (the "hunger hormone", also known as knomorelin (INN), is a peptide hormone produced by enteroendoerme ceils in the fundus of the stomach which functions as a neuropeptide in the central nervous system. proGHRH : progrowth hormone-releasing hormone. GHRH: Growth hormone-releasing hormone (GHRH), also known as somatoliberin or by several other names in its endogenous forms and as somatorelin (INN ) in its pharmaceutical form, is a releasing hormone of growth hormone (GH). It is a 44-a.tnino acid peptide hormone produced in the arcuate nucleus of the hypothalamus. PC 1 : Proprotein convertase I , also known as prohormone convertase I , prohormone convertase 3, proprotein convertase 3, neuroendocrine convertase 1 , or neuroendocrine convertase 3, and often abbreviated as PC 13 is an enzyme that in humans is encoded by the PCSK1 gene. PC 1 and PC2, the protein products of the PCSK 1 and PCSK2 genes, differentially c!eave many neuroendocrine or endocrine hormones, including, proopiomelanocortin . proinsuiin, and proglucagon.

PC2 : Proprotein convertase 2 (PC2) also known as prohormone convertase 2 or neuroendocrine convertase 2 (NEC2 ) is a serine protease and proprotein convetlase PC2, like proprotein convertase i (PC I ), is an en/.yme responsible for the first step in the maturation of many neuroendocrine peptides from their precursors, such as the conversion of proinsuiin to insulin intermediates. To generate the bioactive form of insulin (and many other peptides), a second step involving the removal of C -terminal basic residues is required; this step is mediated by carboxypeptidases E and/or D. PC2 plays only a minor role in the first step of insulin biosynthesis, but a greater role in the first step of glucagon biosynthesis compared to PCI . PC2 binds to the neuroendocrine protein named ?B2, and if this protein is not present, proPC2 cannot become enzymatically active. 7B2 accomplishes this by preventing the aggregation of proPC2 to inactivatable forms. The C-terminal domain of 7B2 also inhibits PC2 activity until it is cleaved into smaller inactive forms. Thus, 7B2 is both an activator and an inhibitor of PC2. in humans, proprotein convertase 2 is encoded by the PCSK2 gene, it is related to the bacterial enzyme subtilisin, and altogether there are 9 different snbulisin-Uke genes in mammals: furin, PACE4, PC4, PC 5/6, PC7/8 , PCSK9. and SKI I/S I P.

PCSK1 the gene encoding PC I .

PCSK2: the gene encoding PC2.

POMC: Pro-piomelanocortin (POMC) is a precursor polypeptide with 241 amino acid residues. POMC is synthesized in the pituitary from the 285-ammo-aeid-long polypeptide precursor pre-pro-opiomelanocortin (pre-POMC), by the removal of a 44-amino-acid-iong signal peptide sequence during translation. PDE4: phosphodiesterase 4.

PWS: Prader Willi Syndrome.

SNORD 1 16: SNORD 1 16 (also known as HBH-85) is a non-coding RNA (ncRNA) molecule whtch functions in the modification of other small nuclear RNAs (snRNAs). This type of modifying RNA is usually located in the nucleolus of the eukaryoiic cell which is a major site of snRNA biogenesis. It is known as a small nucleolar RNA (snoRNA) and also often referred to as a guide RNA. SNORD 1 16 belongs to the C/D box class of snoRNAs which contain the conserved sequence motifs known as the C box (UGAUGA) and the D box (CUGA). Most of the members of the box C/D family function in directing site-specific 2 -0- methylation of substrate RNAs. in the human genome, there are 29 tandem ly repeated copies of SNORD 1 16, in the PWS region of chromosome 15. in addition, other non-coding RNA species are endoeing from the SNORD l .16 locus, including the long noncoding RNA, 1 1 6110 , five sno-lncRNAs, and two spa-IncRNAs. S N ORD Li 6 is an orphan non-coding RNA locus thai lacks clearly defined targets. Mouse models lacking paternal Snord i 16 show similar symptoms to human PWS including hyperphagia and growth deficiency,

DPI devices/inhalers: dry powder inhalers; typically hand-held.

MDI devices: metered-dose inhalers; typically hand-held.

aMSH:: is an endogenous ligand of the melanocortin 4 receptor.

MG2R: melanocortin 2 receptor,

MC4R: melanocortin 4 receptor.

WT: wildtype.

Definitions

The term "pharmaceutically acceptable carrier", as used herein means a pharmaceuiicaliy-accepiable material, composition or vehicle, such as a liquid or solid filler, diluent, excipienl, solvent or encapsulating material, involved in carrying or transporting a chemical agent. The diluent or carrier ingredients should not be such as to diminish the therapeutic effects of the active compound(s).

The term "composition" as used herein means a product which results from the mixing or combining of more than one element or ingredient. "Treating" or "treatment " of a state, disorder or condition includes: (1 ) preventing or delaying the appearance of clinical symptoms of the state, disorder, or condition developing in a person who may be afflicted with or predisposed to the state, disorder or condition but does not. yet experience or display clinical symptoms of the state, disorder or condition: or (2) inhibiting the state, disorder or condition, i .e., arresting, reducing or delaying the development of the disease or a relapse thereof t in case of maintenance treatment) or at least one clinical symptom, sign, or test, thereof; or

(3) relieving the disease, i.e., causing regression of the state, disorder or condition or at least one of its clinical or sub-clinical symptoms or signs. The benefit to a subject to he treated is either statistically significant or at least perceptible to the patient or to the physician.

"Patient" or "subject' ' refers to mammals and includes human and veterinary subjects.

"Inhibitor" and "antagonists," or "activators" and "agonists," refer to inhibitory or activating molecules, respectively, e.g., for the activation of, e.g., a ligand, receptor, cofactor, a gene, cell, tissue, or organ. A modulator of, e.g., a gene, a receptor, a ligand, or a cell, is a molecule that alters an activity of the gene, receptor, ligand, or cell, where activity can be activated, inhibited, or altered in its regulators'' properties. The modulator may act alone, or it may use a cefaclor, e.g., a protein, metal ion, or small molecule. Inhibitors are compounds that decrease, block, prevent, delay activation, inactivate, desensitize, or down regulate, e.g., a gene, protein, ligand, receptor, or cell. Activators are compounds that increase, activate, facilitate, enhance activation, sensitize, or up regulate, e.g., a gene, protein, ligand, receptor, or cell. An inhibitor may also be defined as a compound that reduces, blocks, or inactivates a constitutive activity. An "agonist" is a compound thai interacts with a target to cause or promote an increase in the activation of the target. An "antagonist" is a compound that opposes the actions of an agonist. An antagonist prevents, reduces, inhibits, or neutralizes the activity of an agonist. An antagonist can also prevent, inhibit, or reduce constitutive activity of a target, e.g., a target receptor, even where there is no identified agonist.

To examine the extent of inhibition, for example, samples or assays comprising a given, e.g.. protein, gene, cell, or organism, are treated with a potential activator or inhibitor and are compared to control samples w ithout the inhibitor. Control samples, i.e., samples not treated with antagonist, are assigned a relative activity value of 100%. Inhibition is achieved when the activity value relative to the control is about 90% or less, typically 85% or less, more typically 80% or less, most typically 75% or less, generally 70% or less, more generally 65% or less, most generally 60% or less, typically 55% or less, usually 50% or less, more usually 45% or less, most usually 40% or less, preferably 35% or less, more preferably 30% or less, still more preferably 25% or less, attd most preferably less than 25%. Activation is achieved when the activity value relative to the control is about 1 10%, generally at least 120%, more generally at least 140%, more generally at least 160%, often at least 180%, more often at least 2-fold, most often at least 2.5-fold, usually at least 5 -fold, more usually at least 10-fold, preferably at least 20-fold, more preferably at least 40-fold, and most preferably over 40-fold higher,

The dosage of the therapeutic formulation will vary widely, depending upon the nature of the disease, the patient's medical history, the frequency of administration, the manner of administration, the clearance of the agent from the host, and the like. The initial dose may be larger, followed by smaller maintenance doses. The dose may be administered as infrequently as weekly or biweekly, or fractionated into smaller doses and administered daily, semi -weekly, etc., to maintain an effective dosage level. In some cases, oral administration will require a higher dose than if administered intravenously. In some cases, topical administration will include application several times a day, as needed, for a number of days or weeks in order to provide an effective topical dose.

The term "carrier" refers to a diluent, adjuvant, excipient, or vehicle with which the compound is administered. Such pharmaceutical carriers can be sterile liquids, such as water and oils, including those of petroleum, animal, vegetable or synthetic origin, such as peanut oil, soybean oil, mineral oik olive oil, sesame oil and the like. Water or aqueous solution saline solutions and aqueous dextrose and glycerol solutions are preferably employed as carriers, particularly .for injectable solutions. Alternatively, the carrier can be a solid dosage form carrier, incl uding but not limited to one or more of a binder (for compressed pills), a g!idant, an encapsulating agent, a flavorant, and a colorant. Suitable pharmaceutical carriers are described in "Remington's Pharmaceutical Sciences " by E. W. Martin.

Therapeutic compositions described herein may be administered by any method known in the art, including, without limitation, intranasal, oral, transdermal, ocular, intraperitoneal, inhalation, intravenous, 1CV, inrracisternal injection or infusion, subcutaneous, implant, vaginal, sublingual, urethral (e.g., urethral suppository), subcutaneous, intramuscular, intravenous, rectal, sub-lingual, mucosal, ophthalmic, spinal, intrathecal, mtra-artieular, intra-arterial, sub-arachinoid, bronchial or lymphatic administration. Topical formulation may be in the form of gel, ointment, cream, aerosol, etc.; intranasal formulation can be delivered as a spray or in a drop, transdermal formulation may be administered via a transdermal patch or iontorphoresis; or. inhalation formulations can he delivered using a nebulizer or similar device. Compositions can also take the form of tablets, pills, capsules, semisolids, powders, sustained release formulations, solutions, suspensions, elixirs, aerosols, or any other appropriate compositions.

To prepare such pharmaceutical compositions, one or more PDE4 inhibitors and/or one or more adenylate cyclase activators, and/or one or more MC4R agonists may be mixed together with a pharmaceutical acceptable carrier, adjuvant and/or excipient, according to conventional pharmaceutical compounding techniques, Pharmaceutically acceptable carriers that can be used in the present compositions encompass any of the standard pharmaceutical carriers, such as a phosphate buffered saline solution, water, and emulsions, such as an oil/water or water/oil emulsion, and various types of wetting agents. The compositions can additionally contain solid pharmaceutical excipients such as starch, cellulose, talc, glucose, lactose, sucrose, gelatin, malt, nee, flour, chalk, silica gel, magnesium stearaie, sodium siearate, glycerol monosiearate, sodium chloride, dried skim milk and the like. Liquid and semisolid excipients may be selected from glycerol, propylene glycol, water, ethanol and various oils, including those of petroleum, animal, vegetable or synthetic origin, e.g., peanut oil, soybean oil, mineral oil, sesame oil, etc. Liquid carriers, particularly for injectable solutions, include water, saline, aqueous dextrose, and glycols. For examples of carriers, stabilizers and adjuvants, see Remington's Pharmaceutical Sciences, edited by E. W. Martin ( Mack Publishing Company, 1 8th ed. 1990). The compositions also can include stabilizers and preservatives.

As used herein, the term a "therapeutically effective amount" is an amount sufficient to treat a specified disorder or disease or alternatively to obtain a pharmacological response treating a disorder or disease in vitro or in vivo in a mammal such as a human or non-human patient. Methods of determining the most effective means and dosage of administration can vary with the composition used for therapy, the purpose of the therapy, the target cell being treated, and the subject being treated. Treatment dosages generally may be titrated to optimize safely and efficacy. Single or multiple administrations can be carried out with the dose level and pattern being selected by the treating physician. Suitable dosage formulations and methods of administering the agents can be readily determined by those of skill in the art. for example, the composition is administered at about 0.01 mg/kg to about 200 mg/kg, about 0.1 mg/kg to about 100 mg/kg, or about 0.5 nig/kg to about 50 mg/kg. When the compounds described herein are co-administered with another agent or therapy, the effective amount may be less than equal to or greater than when either agent is used alone.

T ransdermal formulations may be prepared by incorporating the active agent in a thixotropie or gelatinous carrier such as a celluiosic medium, e.g., methyl cellulose or hydroxyethyl cellulose, with the resulting formulation then being packed in a transdermal device adapted to be secured in dermal contact with the skin of a wearer. If the composition is in the form of a gel the composition may be rubbed onto a membrane of the patient, for example, the skin, preferably intact, clean, and dry skirt, of the shoulder or upper arm and or the tipper torso, and maintained thereon .for a period of time sufficient for delivery of the P.DE4 inhibitor and/or the adenylate cyclase activator to the blood serum of the patient. The composition of the present invention tn gel form may be contained in a tube, a sachet, or a metered pump. Such a tube or sachet may contain one unit dose, or more than one unit dose, of the composition. A metered pump may be capable of dispensing one metered dose of the composition.

Th is invention also provides the compositions as described above for intranasal administration. As such, the compositions can further comprise a permeation enhancer. SouthalS et al, Developments in Nasal Drug Delivery, 2000. The PDE4 inhibitor and/or the adenylate cyclase activator may be administered intranasally in a liquid form such as a solution, an emulsion, a suspension, drops, or in a solid form such as a powder, gel, or ointment. Devices to deliver intranasal medications are well known in the art. Nasal drug delivery can be carried out using devices including, but not limited to, intranasal inhalers, intranasal spray devices, atomizers, nasal spray bottles, unit dose containers, pumps, droppers, squeeze bottles, nebulizers, metered dose inhalers (MDI), pressurized dose inhalers, insufflators, and bi-directional devices. The nasal delivery device can be metered to administer an accurate effective dosage amount to the nasal cavity, The nasal delivery device can be for single unit delivery or multiple unit delivery. In a specific example, the ViaNase Electronic Atomizer from Kurve Technology (Bethell, Washington) can be used in this invention (http: //wvvw.kurvetech.com). The compounds of the present invention may also be delivered through a tube, a catheter, a syringe, a packtail, a pledget, a nasal tampon or by submucosal infusion. U.S. Patent Publication Nos. 20090326275, 20090291 894, 20090281522 and 20090317377.

T he PDE4 inhibitor and or the adenylate cyclase activator can be formulated as aerosols using standard procedures. The PDE4 inhibitor and/or the adenylate cyclase activator may be formulated with or without solvents, and formulated with or without carriers. The formulation may be a solution, or may be an aqueous emulsion wills one or more surfactants, for example, an aerosol spray may he generated from pressurized container with a suitable propellant such as, dichlorodifluoromethane, trichlorofluororaethane, dich!orotetrailtKrroethane, hydrocarbons, compressed air, nitrogen, carbon dioxide, or other suitable gas. The dosage unit can. be determined by providing a valve to deliver a metered amount. Pump spray dispensers can. dispense a metered dose or a dose having a specific particle or droplet si/.e. As used herein, the term "aerosol" refers to a suspension of fine solid particles or liquid solution droplets in a gas. Specifically, aerosol includes a gas-borne suspension of droplets of a PDE4 inhibitor and/or the adenylate cyclase activator as may be produced in any suitable device, such as an MDi, a nebulizer, or a mist sprayer. Aerosol also includes a dry powder composition of the composition of the instant invention suspended in air or other carrier gas. Gonda ( 1990) Critical Reviews in Therapeutic Drug Carrier Systems 6:273-313. Raeburn et al.. ( 1992) Pharmacol. Toxicol. Methods 27: 143- 159.

The PDE4 inhibitor and/or the adenylate cyclase activator may be delivered to the nasal cavity as a powder in a form such as microspheres delivered by a nasal insufflator. The PDE4 inhibitor and/or the adenylate cyclase activator may be absorbed to a solid surface, for example, a carrier. The powder or microspheres may be administered in a dry, air- dispensable form. The powder or microspheres may be stored in a container of the insufflator. Alternatively, the powder or microspheres may be filled into a capsule, such as a gelatin capsule, or other single dose unit adapted for nasal administration.

The pharmaceutical composition can be delivered to the nasal cavity by direct placement of the composition in the nasal cavity, for example, in the form of a gel , an ointment, a nasal emulsion, a lotion, a cream, a nasal tampon, a dropper, or a bioadhesive strip. 3n certain embodiments, it can be desirable to prolong the residence time of the pharmaceutical composition in the nasal cavity, for example, to enhance absorption. Thus, the pharmaceutical composition can optionally be formulated with a bioadhesive polymer, a gum (e.g., xanthan gum), chitosan (e.g., highly purified cat ionic polysaccharide), pectin (or any carbohydrate that thickens like a gel or emulsifies when applied to nasal mucosa), a microsphere (e.g. , starch, albumin, dextran, cyclodeytrin), gelatin, a liposome, carbamer, polyvinyl alcohol, alginate, acacia, chitosaus and/or cellulose (e.g., methyl or propyl; hydroxyl or carboxy; carboxymethyl or hydroxyipropyi).

The composition containing the PDE4 inhibitor and/or the adenylate cyclase activator can be administered by oral inhalation into the respiratory tract, i.e., the lungs. Typical delivery systems for inhakble agents include nebulizer inhalers,, dry powder inhalers (DPI), and mefered-dose inhalers (MDl).

Nebuir/er devices produce a. stream of high velocity air that causes a therapeutic agent in the form of liquid to spray as a mist. The therapeutic agent is formulated in a liquid form such as a solution or a suspension of particles of suitable size. In one embodiment, the particles are raicronized. The term "mkronimP is defined as having about 90% or more of the part icles with a diameter of less than about 10 ttm. Suitable nebulizer devices are provided commercially, for example, by PARI GmbH (Starnberg, Germany). Other nebulizer devices include Respimat (Boehringer ingeiheim ) and those disclosed in, for example, U.S. Patent Nos. 7,568,480 and 6, 123,068, and WO 97/12687, The PDE4 inhibitor and/or the adenylate cyclase activator can be formulated for use in a nebulizer device as an aqueous solution or as a liquid suspension,

DPI devices typically administer a therapeutic agent tn the form of a free flowing powder that can be dispersed in a patient's air-stream during inspiration. DPI devices which tise an external energy source may also be used in the present invention, fn order to achieve a free Slowing powder, the therapeutic agent can be formulated with a suitable excipiem (e.g., lactose). A dry powder formulation can be made, for example, by combining dry lactose having a particle size between about 1 pra and 100 pm with micronized particles of the present compounds and dry blending. Alternatively, the present compounds can be formulated without exeipients. The formulation is loaded into a dry powder dispenser, or into inhalation, cartridges or capsules for use with a dry powder delivery device. Examples of DPI devices provided commercially include Diskhaler (Gla.xoSmithKlme, Research Triangle Park, N.C.) (see, e.g., U.S. Patent No. 5,035,237); Diskus (GiaxoSmithKliue) (see, e.g., U.S. Patent No. 6,378,519; Turbuhaler (AstraZeeeca, Wilmington, Del.) (see, e.g., U.S. Patent No. 4,524,769); and Rotahaler (GlaxoSmitbKline) (see, e.g., U.S. Patent No. 4,353,365). Further examples of suitable DPI devices are described in U.S. Patent Nos. 5,415, 162, 5,239,993, and 5,715,810 and references therein.

MDI devices typically discharge a measured amount of therapeutic agent using compressed propel!ant gas. Formulations for Μ ΟΪ administration include a solution or suspension of active ingredient in a liquefied propellant . Examples of prope!lanis include hydroiluoroalklanes (HFA). such as l . ? , i,2-tett'a.nuoroetha.oe (HFA 134a) and 1 , 1 , 1 ,2,3,3,3- heptafluoro-n-propane, (HFA 227), and chiorofluorocarbons, such as CCI;;F. Additional components of HFA formulations for MDl administration include co-solvents, such as eihanot peatarie, water; and surfactants, such as sorbitan trioleate, oleic acid, lecithin, and glycerin. (See, for example, U.S. Patent No. 5.225,183, EP 0717987, and WO 92/22286). The formulation is loaded into an aerosol canister, which forms a portion of an M.D1 device. Examples of MD1 devices developed specifically for use with HFA propellants are provided in U.S. Patent Nos. 6,006,745 and 6, 143.22?. For examples of processes of preparing suitable formulations and devices suitable for inhalation dosing see U.S. Patent Nos. 6,268,533. 5,983,956, 5,874,063, and 6,221 ,398, and WO 99/53901 , WO 00/61 108, WO 99/55319 and WO 00/30614.

The PDE4 inhibitor may be encapsulated in liposomes or microcapsules for delivery via inhalation. A liposome is a vesicle composed of a lipid biiayer membrane and an aqueous interior. The lipid membrane may be made of phospholipids, examples of which include phosphatidylcholine such as lecithin and ly so lecithin; acidic phospholipids such as phosphatidylserine and phosphatidyiglycerol; and sphingophospholipids such as phosphatidylethanolamine and sphingomyelin. Alternatively, cholesterol may be added. A microcapsule is a particle coated with a coating material. For example, the coating material may consist of a mixture of a fil.rn-form.ing polymer, a hydrophobic plastkizer, a surface activating agent or/and a lubricant nitrogen-containing polymer. U.S. Patent Nos. 6,313, 176 and 7,563,768.

The PDE4 inhibitor and/or the adenylate cyclase activator can be given alone or in combination with other drugs for the treatment of t.be above diseases .for a short or prolonged period of time, e.g., 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 20, 30, 40, 50 or 60 days or 1 , 2, 4, 5, 6, 7, 8, 9, 10, I I or 12 months or continuously over the lifetime of the patient. The present compositions can be administered to a mammal, preferably a hitman patient. Mammals include, but are not limited to, mice, rats, rabbit, simians, bovines, ovine, porcine, canines, feline, farm animals, sport animals, pets, equine, and primates.

The following are non-limiting examples.

EXAMPLE I

Manipulation of PCl expression and activity hi iPSC-derived hypothalamic neurons and β-ceils

Cyclase activation by Forskoiin and/or inhibition of c-AM ' P catabolism by inhibition of phosphodiesterase (Theophylline, 1BMX) will increase PC l levels in in vitro models of PWS with consequential increases in prohormone processing. The identification of an apparent multi-tissue deficiency in PCSKI in in vivo and in vitro models of PWS enables rational therapeutic targeting that may alleviate the major neuroendocrine symptoms of PWS (Fig. 1 ).

The promoter region of the PCSKI gene contains two cyclic adenosine monophosphate (cAMP)-response elements (Conkrighl et al. 2003; tidupi et al. 1998). Agents that increase cellular levels of cAMP increase PCSKi mRNA and increase the secretion of prohormones processed by PC I (Fig. 2)(Udupi 1998). Forskolin and Theophyll ine are two FDA-approved drugs with generally safe treatment profiles in pediatric populations. Forskolin binds to adenylate cyclase close to its catalytic domain through hydrophobic interactions and hydrogen bonding {Tang and Hurley 1998. Tesmer et al. 1 999). Forskolin binding causes adenylate cyclase conformation to change to its active form, thus increasing AC activity and increasing cellular cAMP levels (Onda et al 2001). Theophylline and other phosphodiesterase 4 (PDE4) inhibitors, such as MK0952, increase cellular cAMP levels by blocking its degradation.

Non-i.imiii.ng examples of PDE4 inhibitors include Theophylline, MK0952, as well as the other PDF: inhibitors in Tables 1.A-.B. Non-limiting examples of adenylate cyclase (AC) activators include Forskolin and the activators in Table 2.

Agents that can be used in the present method also include agents that can modify G protein activity, such as G protein activators or inhibitors, as well as G protein coupled receptor agonists.

NHLH2 and PCSKi are downregulated in PWS microdeletion and large deletion iPSC-derived neurons, as shown by RNA sequencing (Figs. 3 A, 3C). Fig, 3A: NHLH2 is downregulated in PWS microdeletion and large deletion IPSC-derived neurons compared to unaffected controls. Fig. 3B: NHLH2 protein is downregulated >90% in PWS microdeletion and large deletion iPSC-denved neurons compared to unaffected controls. Figs. 3C-D: PCSKI transcript and its protein product, PC I , are downregulated >55% and >80%, respectively in PWS microdeletion and large deletion iPSC-derived neurons compared to unaffected controls. Figs, 3 E-F: Mice in which only the paternal copy of Smrd! !6 has been deleted (rest of PWS region is intact) display >40% dowuregulation of PC l and PC2 protein in isolated islets. Fig. 3G: Proinsulin is dependent on PC I for its proper processing. There is a functional impairment in proinsulin processing in mice compared to WT

I {Herniates at 30 minutes following glucose injection. Fig. 3H: There is 60% increase in the ratio of proinsulin to insul in in the plasma of individuals with PWS compared to age and BMi-matehed controls at fasting, indicating a defect in proinsulin to insulin processing. The effect is less than that seen in a patient with a PCl mutation, coi.mste.at with the -50% reduction of PC 1 in PWS models. Fig. M: Proghreiin is also processed by PC l ; proghreiin processing is impaired in stomach iysates from mice compared to WT I (Herniates. Stomach iysates from PC I null mice are included as a positive control for impaired proghreiin processing. Fig, 3J; ProGHRH processing may also be impaired in hypothalamic Iysates from mice compared to WT fittermates. Impaired proGHRH processing is associated with low circulating Gil and dwarfism HI PCl null mice.

also display low CM and severe muting . Fig. 3K; Preliminary data suggests

thai treatment of unaffected control hypothalamic iPSC-derived neurons with Forskolin (FSK) may increase transcript levels of PCSKJ in a dose-dependent manner. POMC transcript levels may not be affected. Fig. 3L; Treatment of unaffected control iPSC-derived β-cells with Forskolin increases PCSKi transcript levels. SNORDU6 and INS transcript levels may be minimally affected. Fig. 3M: Transcript levels oiPcskl are decreased 41% in hypothalamic at fasting; there is no difference in PcskJ levels at refeedmg. Fig. 3N : Transcript levels of Nh!h2 are decreased at both fasting and after refeeding in hypothalamic compared to WT littermates. Figs. 30- P: Agrp and Npy transcript levels are increased in hypothalamic at refeeding compared to WT. Follow-up. independent experiments confirmed these changes by QPCR (gene expression) and Western blotting (protein level ) (Figs. 3B, 3D). Individuals with PWS exhibit decreased lasting insulin levels as compared to age and BMl matched controls, it was hypothesized that this may be due to impaired proinsulin processing. The present data illustrates that in a mouse model of PWS. in which only the paternal copy of is deleted.. PCI and PC2 protein levels are decreased in isolated islets and are associated with a functional impairment in the processing of proinsulin to insulin (Figs, 3E-3G). Proinsulin processing is also impaired (p :::: t ) .089) in plasma from human PWS patients compared to age, BMI-matched controls at fasting (Fig, 3H). Plasma from a fasted patient harboring, a PC l mutation was included as a positive control for impaired proinsulin processing.

The hyperghreiinemia of PWS patients is a unique phenotype that may be associated with impaired processing of proghreiin to mature ghrelin. indeed, the present results illustrate that proghreiin to mature ghrelin processing was impaired in stomach Iysates of

' m mice compared to WT littermates (Fig. 31). Stomach Iysates from PCI null .mice were included as a positive control for impaired proghreiin. processing. Like individuals with PWS, patients with PCI mutation have decreased circulating OH levels. Mice mill for PC I have severe runting and decreased circulating GH associated with impaired proGHRH to GHRFi processing. We found that. Snord! Iff mice, which are also runted and have Sow circulating GH, trend towards impaired processing of proGHRH to GHRH in hypothalamic lysates (Fig. 3 1 ).

As outlined in Fig, 2, the identification of a decrease ra PC I and impaired prohormone processing in PWS suggests a uni fied molecular theory which may account for many of the neuroendocrine features of the disease. Thus, agents that increase PCM activity and thereby increase prohormone processing, represent a rational , targeted therapy for the major neuroendocrine features of PWS.

Forskohn is known to increase cellular Pcskl levels and can increase prohormone processing. Forsko!in was applied to non-PWS iPSC-derived neurons and β-cells and the results illustrate that PCSK1 transcript levels increased compared to untreated cells (Figs. 3K-L). Studies m PWS-derived neurons and β-eells w ill be conducted.

The response of PCSKl transcript levels, PC I protein levels, and relevant prohormone processing levels will be tested in in vitro and in vivo model systems, We will treat unaffected control and hypothalamic iPSC-derived neurons with graded levels of Forskohn, Theophylline, and Forskohn + T heophylline and measure PC I transcript and protein, POMC transcript and protein, as well as protein levels of processed products of POMC including: «MSH, β-endorphin, and ACTH. These peptides will be quantitated in whole cell iysates as well as the levels secreted into the cellular medium. The cells will be treated with different concentrations of Forskohn and Theophylline in order to determine whether PC I levels can be increased in a dose-dependent manner and in order to identify an optimal dosage range to increase PC I levels and POMC processing. Other PDE4 and adenylate cyclase inhibitors will be tested in these assays as well (see. Tables 1 A-B and 2).

Batch RNA sequencing and/or single cell RNA sequencing will be performed to identify other transcripts that are most affected by the pharmacological treatments. This approach is expected to predict off-target effects upon in vivo treatment. Single cell RNA sequencing w ill be especially informative regarding PCSKl transcript increases following treatment in POMC-expressing neurons. Other adenylate cyclase activators and P.DE4 inhibitors ( Tables IA-B, 2) will be tested in iPSC-derived hypothalamic neurons following the same study protocol as described above. We will differentiate iPSC from unaffected control and PWS (large and minimum deletion) to iPSC-derived β-cells. We will treat the tPSC-derived β-cells with Forskoiin, Theophylline, and Forskoim ÷ Theophylline and measure levels of PC I at the transcript and protein level. We will also measure INS transcript levels as well as protein levels of proinsulin, insulin, and c-pepfkle from whole cell lysates as well as the concentrations of the proteins secreted by the β-cells into the media, These cells may be transplanted into nude mice to enable their maturation; these cells can be tested in vivo for insulin processing; excised cells will be tested as described. We will also use hitman isolated islets from non- diabetic, non-obese individuals (available to us through the National Pancreatic Donors Registry) to test the effects of Forskoiin, Theophylline, and Forskoiin -f Theophylline on PC I levels in ful ly mature human pancreatic islets.

EXAMPLE 2

Confirmatory molecular physiology of PCI metabolism in and

Increasing cAMP levels by adenylate cyclase (AC) activation and concurrent PDF inhibition will increase PC l levels in ex vivo and in vivo models of PWS, and may consequently increase prohormone processing in the mouse model of PWS. Because mice with a paternal deletion of (a mouse model of PWS) have impaired

processing of pro insulin to insulin associated with reductions in PC I transcript and protein, islets will be isolated from wild type ( WT) and mice and the responses of these cells to Forskolin, Theophylline, and Forskoiin -t- Theophylline will be analyzed. The same manipulations and measurements will be performed as for iPSC-derived β-cells. if protnsulin processing can be rescued in isolated islets from mice as compared to WT liuermates. then investigations of proinsulin processing rescue in mice treated

with Forskoiin, Theophylline, and Forskoiin -f Theophylline, in vivo will be conducted.

The present results illustrate that mice have reductions in proinsulin processing to insulin that are associated with reduced PC I and PC2 content in the islets (Figs. 3E-G). Furthermore, proghrelin processing is also impaired in the stomachs of

mice as well as the processing of proGHRH to GH.R.H in the hypothalami of

since compared to WT li Herniates (Figs. 3I-J). Furthermore, the ratio of proinsulin to insulin is elevated in fasted individuals with PWS compared to age and BM1 matched controls, suggesting an impairment in the processing of proinsulin to insulin (Fig. 3H). Isolated bless from Pel. null and heterozygous (.nice will be included as a control for impaired proinsul.in processing as well as a predicted negative response to pharmacological treatment. Peripheral levels of glucose, promsulin. insulin., and c-peptide will be measured at tasting, and 15, 30, 60, and 120 minutes following intraperitoneal glucose injection. Optimal duration of pharmacological treatment in and WT mice prior to peripheral measures of promsulin processing will be established empirically. Pel null and heterozygous mice will be included as a control for impaired promsuiin processing in /)? vivo experiments as well. The initial time periods for testing will be 3 days, 1 week, and 1 month. Several methods of drug delivery will also be tested.

Assays that can distinguish between proghrelin and mature ghrelin. and can thus be used to measure proghrelin processing in the circulation will be developed for both human and mouse. Proghrelin processing following the in vivo pharmacological treatments described above in PC l null, PCI heterozygous, and WT animals will be measured.

The hypothalami of WT, and Pel null and Pel heterozygous mice treated with Forskoiin, Theophylline, and Forskobn + Theophylline, and measure protein levels of PC I , POMC, aMS.fl β-endorphin, and ACTll will be analyzed m order to assess whether />? vivo treatment can affect levels of PCI and POMC processing.

Because animals are runted and do not develop obesity, the main model

by wh ich POMC processing will, be assessed is the iPSC-derived human neurons, in which more extreme downregu!ations o( NHLH2 and PC J are observed. However, PC I and POMC responses to these pharmacologic agents may also be analyzed in primary neurons from young WT POMC-GFP mice. POMC-expressing neurons can be specifically isolated using mice in which POMC neurons express GFP. We will knock down Pcskl as a control for impaired POMC processing. We may also try to knock down specific isoforms of Snordl 16 in vitro using si RNA- or 2-O-meihyl-modi.fied anti-sense ohgo-based approaches; siRNA are small, double-stranded interfering RNAs that are commonly used to knock down cytoplasmic RNAs, while 2-O-methyl-modified anti-sense oligos are used to knock down snoRNAs which typically are found in the nucleolus (Liang et al. 201 1 ). We will then measure PC I levels and POMC processing levels and investigate whether pharmacological treatment can increase levels of PC I and increase POMC processing in the primary mouse neurons in which has been knocked down relative to WT.

Additionally, mice with conditional hypomorphic alleles of SNORD 1 16 will be obtained or created. Adult animals with such alleles will have Snordl 16 acutely reduced in specific hypothalamic nuclei (e.g. the arcuate nucleus) by introduction of suitable ere- expressing constructs, including those driven by specific promoters, eg. For POMC. This approach will circumvent the somatic developmental effects (stunting) of Snordl l.6 hypomorphism in mice,

Effect of cyclase activator and/or phosphodiesterase inhibitor or greater increase in relevant prohormone processing in at least one model tested: PWS iPSC-derived neurons, PWS i PSC-derived β-cells, isolated islets, circulating

prohormones, or -knockd own primary neurons. These phenotypes would be accompanied by increases in relevant transcripts and/or proteins in the affected ceils.

Cyclase activation

Forskolin was applied to various cellular models and the results illustrate that it robustly and reliably increases transcript levels, PC I protein levels, and functionally increases prohormone processing. transcript levels increased between 2-3 fold in iPSC-derived neurons and primary mouse neurons exposed to 10 μΜ Forskolin (Figs. 5A, C, D).

Cyclic AMP concentrations increased about 8.5-fold in iPSC-derived hypothalamic ARC neurons exposed to 10 μM Forskolin, supporting the inference that application of Forskolin increases transcript levels by raising cellular cAMP levels which in turn

activate s cAMP-response element promoter. Fig, 5A is a graph showing primary fbrebrai.n. neurons were isolated from gestational day 19.5 (E l 9.5) embryos of wild type mice and cultured for 72 hours. Subsequently, cells were exposed to either 10 μΜ Forskolin or its vehicle, dimethyl sulfoxide ( DMSO) for 20 hours. Pcskl transcript increased -2.5-fold in primary neurons exposed to Forskolin. Fig. 5B is a graph showing unaffected control hypothalamic arcuate-like (ARC) neurons (Hes Nkx2- l hESC line) at day 3? (D3?) of differentiation were treated with 10 uM Forskolin or vehicle for thirty minutes. Cyclic adenosine monophosphate (cAMP) levels were increased about 8.5 -fold in cells exposed to Forskolin. Fig. 5C is a graph showing exposure of unaffected control hypothalamic iPSC- derived neurons (line 1023A) at day 30 of differentiation to graded concentrations of Forskolin elicits a dose-dependent response in transcript levels. Fig. 5D is a graph showing exposure of iPSC-derived neurons (line 1043D3) to 10 μ.Μ Forskolin for multiple time intervals finds that s not significantly upregulated after only l hour of exposure, but is significantly upregulated by 4 and 18 hours of exposure. Four hours of exposure yielded the maximal increase in upregulation, about 2.5-fold, of the time points tested. Figs. 5E-P are graphs showing treatment of unaffected control ( 1023 A) jPSC-derived hypothalamic ARC neurons at day 30 of differentiation with graded concentration of Forskolin identifies a dose-dependent increase in POMC processing to both p-endorphin (PEP) and α- melanocyte stimulating hormone (oMSH). Figs. 5G-H are graphs showing treatment of isolated islets from adult ($- 12 week old) WT mice with multiple concentrations of Forskol in shows upregu!ation of PC I , but noi PC2, protein levels at 25 and 50 μ.Μ Forskolin concentrations, respectively.

Treatment with forskolin not only elevated transcript levels but also had functional consequences in that POMC processing to both β-endorphin and αMSH were increased (Figs. 5E-F), Furthermore, application of Forskolin to isolated islets from wild type mice resulted in —3-fold increase in PC l protein levels (Fig. S G). PC 2 protein levels were unaffected (Fig. 5H ). Taken together, these results show that PC I levels increase in response to Forskolin in three separate model systems: iPSC-derived neurons, primary neurons, and isolated islets. Furthermore, ForskoStn-induced elevation of PCI is functionally consequential, resulting in increased levels of prohormone processing.

Phosphodiesterase inhibition

PDF inhibitors have also been tested in iPSC-derived neurons and found that inhibition of phosphodiesterase can also increase transcription However, the effect size of PDE inhibition on PCSK! transcript levels is less than that induced by AC agonism with forskolin, Theophylline ( 10 mM) and Roffumilast ( 1 mM) both increase PCSK1 transcription as single agents, while MK0952 has thus far only been found to increase PCSKl transcription in combination with Forskolin in vitro (Figs. 6Λ-0. F). Combination treatment with Forskolin and Roffumilast demonstrates that these agents can work together in an additive, possibly synergistic, manner inducing and increased PCSKI transcription at lower concentrations ( 1 μΜ Forskolin, 100 n.Vi Roffumilast) than when either agent is given alone (Fig. 6D). Again, increased PCSKI transcription due to combination treatment with Forskolin and Roffumilast also increases prohormone processing of POMC to ACTFI (Fig. 6E). Specifically, tests with graded concentrations of Forskolin in isolated mouse islets showed a 3-fold upregulation of PCI protein at 25 μ.Μ and 50 μΜ concentrations. No change in PC2 protein levels were observed in response to Forskolin application. We also found that 10 uM Forskolin applied to primary mouse neurons isolated from E l 9.5 nitee increased transcript levels -2~idld. MK0952

The phenotype most limiting to PWS patients is hyperphagia which is most likely mediated by processes occurring in the central nervous system, particularly the hypothalamus. Thus agents that aim to ameliorate hyperphagia must be able to penetrate the blood brain barrier. MK0952 is an intrinsically potent (iC¾ ::: 0.6 nM) brairs-peneuam PDE4 inhibitor with limited whole blood activity (IC«« - 555 nM) (M. Gallant et ai. 2010). As described herein, MK0952 is the lead PDE inhibition candidate at present

A preliminary in vivo test of MK0952 was performed in wild type mice. A single administration of N1K0952 at 10 mg/kg body weight results in a 25% increase in hypothalamic Pcskl transcript levels (Fig. 7A). Administration of Forskolin at 25 mg/kg did not result m increased hypothalamic Pcskl transcript levels. Co-administration of MK0952 at 1 0 mg/kg and Forskolin at 25 mg/kg again induced an -25% increase in hypothalamic Pcsk/ levels, suggesting thai, this increase was due primarily to the actions of M.K0952 (Fig 7B). We will also analyze circulating cAMP levels, cortical proBDNF/SDNF, cerebellar Pcskl , gastric Pcsk I , and gastric proghrelm/ghrehn, circulating promsuHn and insulin concentrations (and their ratios), and finally pulmonary Pcsk l transcript and cAMP levels from these animals as well.

The first in vivo study with MK.0952 administered by oral gavage while forskolin was administered intraperitoneally one time to -4 hour fasted wild type mice was completed. Hypothalamic transcript levels of Pcskl were unregulated -25% following administration of either 10 mg/kg MK095.2 as a single agent or both 10 mg/kg MK0952 and 25 mg/kg Forskolin. However, administration of 25 mg/kg Forskolin only did not result in an upregulation of hypothalamic Pcsk/, suggesting the Forskolin at this dose does cannot access the hypothalamus in sufficient quantities to affect Pcskl transcription. This also suggests that the increase in hypothalamic Pcski following administration of both 25 mg/kg Forskolin and 1 0 mg/kg MK0952 was mainly due to the actions of MK0952 in the hypothalamus, This difference likely reflects greater CNS penetrance of the MK0952.. not the general relevance of a cyclase activator to therapy of PWS. No change in the ratio of circulating proinsuiiir.msuliri was detected following administration MK.0952 or Forskolin. Because the processing of proinsulin to insulin is already quite efficient in WT animals, it is in hindsight unlikely that it would further increase at. fasting. However, these 'baseline' data are still valuable for assessing proinsulin to insulin processing under the setting of an intraperitoneal glucose tolerance test at 3 mg/kg glucose in both WT and mice. Additionally, samples were collected for measurement of circulating cAMF levels, cortical proBDNF/BDNF, cerebellar Pcskp gastric Pcsk!, and gastric proghrelin/ghrelin, and finally pulmonary PcskJ transcript and cAMP levels.

EX AM PLE 3

Clinical study of compounds 5» patients with Prader Willi Syndrome (PWS)

The preliminary design of the proposed clinical study for individuals with PWS is based on the hypothesis that the expression of proconvertase l (PC I ) in decreased in the neurons of individuals with PWS (Burnett et al . 201 7). Experimental in vitro and in viva exposure to adenylate cyclase agonists and PDE4 inhibitors causes up-regulation of PC I expression and activity in human stem cell-derived and rodent forebrain neurons, and human fibroblasts. It is anticipated thai administration of these drugs will increase the conversion of implicated pro-hormones to active hormones.

The clinical study will address and illustrate the efficacy of the drug in enhancing the activity of PCI as follows:

I . To illustrate the effects of the candidate therapeutic agents on the behavioral and the endocrine phenotypes of PWS.

2. To monitor the clinical safety profile of such agents.

Study design:

The clinical study will utilize a cross-over study design (Cieophas et al. 2006, We!lek and Blettner 2012, and Louis et al. I 9S4). This design provides the power to assess the effect of treatment accounting for the variability between subjects in a small cohort (Fig. 8A). The washout period between the two treatment arms will mitigate carryover effects; the short duration of the study minimizes the "time-effects " (effects on the change in disease process over time).

inclusion criteria*:

1 . Genetically proven diagnosis of PWS

2. Age > .18 years

* Recombinant growth hormone therapy is permissible.

1. Severe psychiatric disorder 2. Uncooperative to take the medication

3. Systemic illness., e.g. serious gastrointestinal illness like inflammatory bowel disease, cardiac disease, especially rhythm disturbances, diagnosis of diabetes, hepatic or renal disease or failure.

4. Anemia defined as hemoglobin < l O gm/dL

5. Patients on drugs that have potential interaction with the target drug, e.g. PDE4 inhibitors interact with anti-seizure medications, cimettdine, omeprazole, antibiotics etc. Many of these drugs alter hepatic enzyme activity and could interfere with the metabolism of a PDE4 inhibitor. A complete list of exclusion drugs will be based on the pharmacokinetic and pharmacodynamic properties of the identified therapetttic agent.

Recruitment; The recruitment of the subjects will be facilitated by partnership with the PWS Foundation (FPVVR and PWSA), patient support groups and the clinicians caring for children with PWS. Phone screening will identify potentially eligible subjects who will be invited for the screening visit,

The study will last for 4-6 weeks and consist of the following visits;

Screening visa: At this visit, a complete review of medical records, medications and physical examination will be performed along with screening lab measurements (from Fig. 8B. same as safety profile aside from the drug level). Subjects will be provided a week of placebo for the run-in period to assess compliance. This will be a short outpatient visit (-3 hours). All other study visits will be 6-8 hours long short in-patient stay, 2. Baseline visa ill and / 3 from Fig, SA): Subjects who successfully complete the run-in period will be invited to participate in ihe study. Hue eligible subjects will be randomized to either the A.P group, or the PA group (Fig.8 A). Subjects will be advised to fast for > 8 hours for the visit. Physical profiling will include height, weight, body fat measurement, vital signs, resting energy expenditure and a complete physical examination. A. complete pituitary profile that includes ΑϋΤΉ, Cortisol, FSR/LH, estrogen/ testosterone, TSH/free T4, GH, IGF- 1 , IGFBP3 will be performed. The subjects will undergo a mixed meal tolerance test (MMTT) with standardized meal and blood measurements will be obtained at 0,30,60,90,120 and 180 minutes from an indwelling IV catheter (Fig. 8B).

The primary guardians will complete questionnaires relating to hyperphagia (Dykens or modified Dykens) and behavioral assessment will be performed using the Oxytocin Study Questionnaire (25-28). In addition to this, they will complete a food frequency questionnaire on 3 separate days io include at least one weekend. The visit is expected to last 6-8 hours.

Study medication for I week wi ll be dispensed with caregiver instruction

.?. Fo!!ow-ιφ vis if (i.2 and f 4 from Fig. 1): The subject will return for a .follow-up visit in I week after the initiation of the study medication. The measurements mentioned above will be repealed at this visit., and a medication count will be obtained, along with structured questionnaire for the assessment of toxicity. Each of these visits will be 6-8 hours. A washout period of 1 -2 weeks will be allowed prior to the 2 >ui phase of the study.

Outcome measures:

I . Hormonal pro/tie m response io a .standard meal: Based on the effect of PC l on conversion of prohormones (such as proinsulin to insulin etc. ). it is anticipated that administration of the drug will cause an increase in the ratio of prohormone: hormone (e.g. proinsulin; insulin) (Burnett et al. 2017). This will be tested by hormonal response to a standard MMTT. MMTT is performed by administration of a liquid meal (6ec/kg of Boost or equivalent to a maximum of 360 cc) followed by periodic measurement of insulin, proinsulin. POMC prohormone, ACTH . AgRP, proglueagon, glucagon, GLP 1 , oxytocin (and propeptide), ghrelin, proghrelin, free fatty acids, and glucose. MMTT has been validated in clinical studies of subjects with PWS (P. Gumus Baiikcioglu et al. 2015).

Relative to values obtained prior to drug administration, it is anticipated that there will be an absolute increase in insulin release, decrease in proinsulin release and an increase in msuhn/proinsulm ratio. All in 25% range, It is also expected that glucose concentrations will be decreased by 15-20 and ffa as well. In plasma obtained prior io the M.MT, it is anticipated that POMC will be increased and AgRP reduced by -25%. Oxytocin should be increased by 15-20% as well. It is also anticipated that proghrehn/ghreiin ratio will be reduced. Spinal fluid may also be examined/studied in these subjects as well, but would not be evaluated in relationship to a meal . The following components may be assayed: pome prohormone, beta endorphin, alpha msh. AgRP and oxytocin, anticipating that the drugs would reduce pome prohormone, and increase beta endorphin, alpha msh and oxytocin, and reduce AgRP in. comparison to untreated subjects,

2. Fkarmacomelabolomic profile: Metaboiomic profiling provides an additional opportunity to understand the effects of the drug on the metabolic phenotype. Metaboiomic profile of the study subjects before and after treatment with the drug will be performed io identify hiomatkers for a) response to treatment in the pathways of interest, viz. insulin metabolism pathway and others, b,t to identify individual di fferences in treatment, by identification of pathways selectively up- or down- regulated in different individuals, and c) identify the profiles of side-efiects or toxicity using a pathway based analysis that may not be obvious by the standard study of established larger molecular profiling ( R . Kaddurah-Daouk, R. Weinshiiboum, N. 2015; R.D. Beger et al. 2016).

3. Changes in Hyperphagia related behavior: The Dykens (and modified Dykens) questionnaire assesses the behavior, severity and drive for hunger, in addition to these outcomes, the Oxytocin Behavior Questionnaire will assess social and emotional behavior related with eating. These outcomes will be supplemented with the analysis of the food frequency questionnaires, it is expected that treatment will also improve behavior and-or emotional state.

Sample size: A pilot sample size of 6 subjects will be recruited for this study. The power of this sample size to detect outcomes of interest will depend on the effect size ascertained by in vivo hormonal or pharmaeoraetaboiomie profiling in animal .models. As reflected in Fig. 8C, an effect size of - 1.47 is required to detect a significant change in a cohort of 6 subjects. The effect size is calculated as the difference in the means of the observation w ith the placebo as compared to the active drug divided by the standard deviation of the change. As each subject serves as his/her own control, the crossover study design limits the variability and allows reaching power in ¼ of the subjects for a similar parallel arm study design.

Additional Study Information:

1 . Based on the prior studies in children with PWS and tire need to achieve high effect size, the standard mixed meal has been selected for the study.

2. The study will be conducted in the outpatient facility of the Irving institute for

Clinical and Translational Research.

S. An IRB protocol for the study will be prepared directed to the appropriate PDE inhibitor and or cyclase activator.

4. The metabolomic profiling - if obtained in this preliminary study - wall be performed in the Hormone and Metabolite (.'ore of the Diabetes and Endocrinology Research

Center. EXAMPLE 4

Methods of Treating Prader-Willi syndrome - Combination therapy of endogenous and exogenous MC4R agonism.

Individuals with PWS will be treated using agents that increase endogenous levels of processed hormones by virtue of increasing PCI production through raising levels of cellular cAM ' P production and or blocking its degradation.

In the arcuate nucleus. PO.MC is processed to ctMSH by proconvetlase i (PC I) (S.L. Wardlaw 201 1.) «MSH is an. endogenous Hgand of the melanocortin 4 receptor (MC4R). Humans and mice with inactivating mutations in POMC, PCSKJ (gene product otPCSKi is PC I ), of MC4R are hyperphagic and obese (C. Vaisse et al. 1998). Mutations in MC4R are the most common single gene cause of obesity in humans ( R J. Loos et al. 2008). AgRP is also produced in the arcuate nucleus and is an inverse agonist at MC4R. ProAgRP is processed to AgRP by PC i (S.L. Wardlaw 201 3.).

H is possible that increases in PC I production may increase the production of both aMSH and AgR P, which have opposite effects at MC4R (Fig. 4). The use of smal l molecule or peptide-based MC4.R agonists could help to ensure that the extracellular pools of agents thai agonize MC4R are in excess of those that antagonize MC4R (Fig. 4, Table 3). This would be expected to push signaling at the MC4R. towards anorexigenic responses ( Fig. 4). Agents that bind to AgRP and block its effects at MC4R could also be a useful strategy in this setting (Table 3) (E.C. Lee and P. A Carpino 2016). Compounds that act similarly that are not mentioned in Table 3 may also be useful. This strategy may be efficacious not just for treating PWS, but also other forms of monogenic/syndromic obesity as well as common obesity.

Table 3: Example Compounds that could be co-administered with FSK and PDE Inhibitors

SUMMARY/CONCLUSIONS

Although the gene encoding PC I , PCSKL is downregulaied in ceil based and animal models of PWS, the gene itself is intact and thus could be subject to pharmacological manipulation. The present data provides results of ongoing preclinical studies to pharmacologically manipulate cellular levels of PCSKl /PCI . in vitro experiments demonstrate that application of Forskol.in, an adenylyi cyclase agonist robustly and reliably upregulates PCSKl expression in human stem cell-derived neurons, mouse primary neurons, and increases PC 3 protein level in mouse isolated islets. Furthermore, Forskelin treatment also increases POMC prohormone processing m stern cell-derived hypothalamic neurons. Application of PDF inhibitors Theophylline and RoOumilast to stem cell neurons increases PCSK! transcript levels both as single agents and in combination with Forskolio. Combination treatment of Roflumiiast and Forskelm also addnively increases POMC prohormone processing (to aoorexigenic peptides) in stent ceil hypothalamic neurons. Treatment of stem cell-derived neurons with both Forskolin and MK0952 (a class 4 PDF inihibitor) increases PCSKl mRNA. Finally, a single oral dose of 10 mg/kg MK0952 increases hypothalamic PcskJ transcript levels by 25% in wild type mice. Longer appl ications of MK0952 in vivo in both wild type and mice hypomorphic for paternal Si!(>rdl I6 will be tested next. In addition we will collaborate with Andrea Haqq and colleagues to measure circulating pro- and processed hormone levels (e.g. proinsulm, POMC, pro~oxytocin, proBDNF) in individuals with PWS and matched controls.

Also provided is a protocol for preliminary clinical study of MK0952 and other candidate compounds in individuals with PWS. The major aims of this clinical study will be to monitor the clinical safety profile of these agents in PWS subjects as well as 10 measure behavioral and neuroendocrine endpoints to assess preliminary efficacy.

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T he scope of the present invention is not limited by what has been specifically shown and described hereinabove. Numerous references, including patents and various publications, are cited and discussed in the description of this invention. The citation and discussion of such references is provided merely to clarify the description of the present invention and is not an admission that any reference is prior ail to the invention described herein. All references cited and discussed in this specification, are incorporated herein by reference in their entirety. Variations, modifications and other implementations of what is described herein will occur to those of ordinary skill m the art without departing from the spirit and scope of the invention. While certain embodiments of the present invention have been shown arid described, it will be obvious to those skilled in the art that changes and modifications may be made without departing from the spirit, and scope of the invention. The matter set forth in the foregoing description and accompanying drawings is offered by way of illustration, only and not as a limitation. The actual scope of the invention is intended to be defined in the following claims.