Combination therapy for treating hearing and balance disorders

Abstract

The present application relates to combinations of inhibitors directed at down-regulation of genes associated with hearing loss including HES1, HES5, HEY2, CDKN1B and NOTCH1, exhibiting a beneficial effect and useful in treating or attenuating hearing loss, treating balance impairment, promoting the replacement, regeneration, or protection of otic (sensory) hair cells of the inner ear, and or effecting hearing restoration/regeneration.

1 . A combination of a HES1 inhibitor, a HES5 inhibitor and a HEY2 inhibitor, for simultaneous, separate or sequential use in a subject for preventing, treating, or delaying of progression of a hearing disorder, a hearing loss, and/or a balance impairment, or for preventing the loss of otic (sensory) hair cells of the inner ear in the subject. 
     
     
         2 . A method of preventing, treating, or delaying of progression of a hearing disorder, a hearing loss, and/or a balance impairment, or of preventing the loss of otic (sensory) hair cells of the inner ear in a subject, comprising use of a HES1 inhibitor, a HES5 inhibitor and a HEY2 inhibitor. 
     
     
         3 . The combination or method of  claim 1  or  2 , wherein the HES1 inhibitor, the HES5 inhibitor and the HEY2 inhibitor are to be administered substantially simultaneously or sequentially. 
     
     
         4 . A composition comprising a combination of a HES1 inhibitor or a pharmaceutically acceptable salt or prodrug thereof, a HES5 inhibitor or a pharmaceutically acceptable salt or prodrug thereof and a HEY2 inhibitor or a pharmaceutically acceptable salt or prodrug thereof; and a pharmaceutically acceptable carrier. 
     
     
         5 . The combination, method, or composition of any one of  claims 1  to  4 , wherein each inhibitor is independently selected from the group consisting of a small organic molecule; a protein, an antibody or fragments thereof, a peptide, a peptidomimetic and a nucleic acid molecule. 
     
     
         6 . The combination, method, or composition of  claim 5 , wherein each inhibitor comprises a nucleic acid molecule, or a pharmaceutically acceptable salt thereof. 
     
     
         7 . The combination, method or composition of  claim 6 , wherein a first nucleic acid molecule is a double-stranded oligonucleotide that binds a nucleotide sequence encoding a HES1 gene, a second nucleic acid molecule is a double-stranded oligonucleotide that binds a nucleotide sequence encoding a HES5 gene, and a third nucleic acid molecule is a double-stranded oligonucleotide that binds a nucleotide sequence encoding a HEY2 gene. 
     
     
         8 . The combination, method or composition of  claim 7 , wherein each of the double-stranded oligonucleotides comprises a dsRNA molecule having a sense strand and an antisense strand. 
     
     
         9 . The combination, method or composition of  claim 7  or  8 , wherein the nucleic acid molecules are linked or wherein the nucleic acid molecules are annealed in RNAistar formation. 
     
     
         10 . The combination, method or composition of any one of  claims 7  to  9 , wherein:
 a first double-stranded oligonucleotide comprises a sense strand and an antisense strand, wherein: 
 (a) each strand is independently 18 to 49 nucleotides in length; 
 (b) a 18 to 49 nucleotide sequence of the antisense strand is complementary to a sequence of an mRNA encoding HES1; and 
 (c) a 18 to 49 nucleotide sequence of the sense strand is complementary to the antisense strand; 
 a second double-stranded oligonucleotide comprises a sense strand and an antisense strand, wherein: 
 (a) each strand is independently 18 to 49 nucleotides in length; 
 (b) a 18 to 49 nucleotide sequence of the antisense strand is complementary to a sequence of an mRNA encoding HES5; and 
 (c) a 18 to 49 nucleotide sequence of the sense strand is complementary to the antisense strand; and 
 a third double-stranded oligonucleotide comprises a sense strand and an antisense strand, wherein: 
 (a) each strand is independently 18 to 49 nucleotides in length; 
 (b) a 18 to 49 nucleotide sequence of the antisense strand is complementary to a sequence of an mRNA encoding HEY2; and 
 (c) a 18 to 49 nucleotide sequence of the sense strand is complementary to the antisense strand. 
 
     
     
         11 . The combination, method or composition of any one of  claims 1 - 10 , wherein the inhibitors are co-administered to the subject in the same formulation. 
     
     
         12 . The combination or method of any one of  claims 1 - 3  and  5 - 10 , wherein the inhibitors are co-administered to the subject in different formulations. 
     
     
         13 . The combination, method or composition of any one of  claims 1 - 10 , wherein the inhibitors are co-administered to the subject by the same route. 
     
     
         14 . The combination or method of any one of  claim 1 - 3  or  5 - 10 , wherein the inhibitors are co-administered to the subject by different routes. 
     
     
         15 . The combination, method or composition of  claim 13 , wherein the inhibitors are co-administered to the subject by transtympanic injection. 
     
     
         16 . The combination, method or composition of  claim 13 , wherein the inhibitors are co-administered topically. 
     
     
         17 . The combination, method or composition of  claim 16 , wherein the topical administration comprises application of ear drops to the eardrum. 
     
     
         18 . The combination or method of any one of  claims 1 - 3 , wherein the administering is substantially simultaneous. 
     
     
         19 . The combination or method of any one of  claims 1 - 3 , wherein the administering is sequential. 
     
     
         20 . The combination, method or composition of any one of  claims 7  to  19 , wherein at least one double-stranded oligonucleotide independently comprises a structure (A1): 
       
         
           
                 
                 
               
                     
                   (A1) 
                 
                     
                   (antisense strand) 
                 
                     
                   5′ (N)x − Z 3′ 
                 
                     
                     
                 
                     
                   (sense strand) 
                 
                     
                   3′ Z′-(N′)y − z″ 5′ 
                 
             
                
                
                
                
                
                
               
            
           
         
         wherein each of N and N′ is a ribonucleotide which may be unmodified or modified, or an unconventional moiety; 
         wherein each of (N)x and (N′)y is an oligonucleotide in which each consecutive N or N′ is joined to the next N or N′ by a covalent bond; 
         wherein each of Z and Z′ is independently present or absent, but if present is independently 1-5 consecutive nucleotides, 1-5 consecutive non-nucleotide moieties or a combination thereof covalently attached at the 3′ terminus of the strand in which it is present. 
         wherein z″ may be present or absent, but if present is a capping moiety covalently attached at the 5′ terminus of (N′)y; 
         wherein each of x and y is independently an integer between 18 and 40; 
         wherein the sequence of (N′)y is complementary to the sequence of (N)x; and 
         wherein (N)x comprises an antisense sequence complementary to an mRNA selected from an mRNA encoding HES1, an mRNA encoding HES5, and an mRNA encoding HEY2. 
       
     
     
         21 . The combination, method or composition of  claim 20 , wherein in the double-stranded oligonucleotide x=y=19. 
     
     
         22 . The combination, method or composition of any one of  claims 7  to  19 , wherein at least one double-stranded oligonucleotide independently comprises a structure (A2): 
       
         
           
                 
                 
               
                     
                   (A2) 
                 
                     
                   (antisense strand) 
                 
                     
                   5′ N 1 -(N)x − Z 3′ 
                 
                     
                     
                 
                     
                   (sense strand) 
                 
                     
                   3′ Z′-N 2 -(N′)y − z″ 5′ 
                 
             
                
                
                
                
                
                
               
            
           
         
         wherein each of N 2 , N and N′ is independently an unmodified or modified ribonucleotide, or an unconventional moiety; 
         wherein each of (N)x and (N′)y is an oligonucleotide in which each consecutive N or N′ is joined to the adjacent N or N′ by a covalent bond; 
         wherein each of x and y is independently an integer between 17 and 39; 
         wherein N 2  is covalently bound to (N′)y; 
         wherein N 1  is covalently bound to (N)x and is mismatched to the target mRNA selected from HES1 mRNA, HES5 mRNA and HEY2 mRNA or is a complementary deoxyribonucleotide moiety to the mRNA selected from HES1 mRNA, HES5 mRNA and HEY2 mRNA; 
         wherein N 1  is a moiety selected from the group consisting of natural or modified: uridine, deoxyribouridine, ribothymidine, deoxyribothymidine, adenosine or deoxyadenosine, an abasic ribose moiety and an abasic deoxyribose moiety; 
         wherein z″ may be present or absent, but if present is a capping moiety covalently attached at the 5′ terminus of N 2 — (N′)y; and 
         wherein each of Z and Z′ is independently present or absent, but if present is independently 1-5 consecutive nucleotides, 1-5 consecutive non-nucleotide moieties or a combination thereof covalently attached at the 3′ terminus of the strand in which it is present; 
         wherein the sequence of (N′)y has complementarity to the sequence of (N)x; and wherein the sequence of (N)x has complementarity to a consecutive sequence selected from a sequence in HES1 mRNA (SEQ ID NO:1); HES5 mRNA (SEQ ID NO:2), and HEY2 mRNA (SEQ ID NO:10). 
       
     
     
         23 . The combination, method or composition of  claim 22 , wherein in the double-stranded oligonucleotide x=y=18. 
     
     
         24 . A commercial package comprising the combination or composition of any one of  claims 1  or  3  to  23 . 
     
     
         25 . The commercial package of  claim 24 , wherein the package includes a label or package insert that provides certain information about methods of using the combination or composition of any one of  claims 1  or  3  to  23 . 
     
     
         26 . The commercial package of  claim 25 , wherein the label or package insert includes dosing information. 
     
     
         27 . The commercial package of  claim 26 , wherein the label or package insert includes indications for use. 
     
     
         28 . The commercial package of any one of  claims 25  to  27 , wherein the label or package insert indicates that the combination of any one of  claims 1  or  3  to  15  is suitable for use in therapy. 
     
     
         29 . The commercial package of any one of  claims 25  to  27 , wherein the label or package insert indicates that the combination or composition of any one of  claims 1  or  3  to  15  is suitable for use in preventing, treating, or delaying of progression of a hearing disorder, a hearing loss, and/or a balance impairment, or for preventing the loss of otic (sensory) hair cells of the inner ear in a subject. 
     
     
         30 . A combination of a CDKN1B inhibitor, a NOTCH1 inhibitor and a HEY2 inhibitor, for simultaneous, separate or sequential use in preventing, treating, or delaying of progression of a hearing disorder, a hearing loss, and/or a balance impairment, or for preventing the loss of otic (sensory) hair cells of the inner ear in a subject. 
     
     
         31 . A method of preventing, treating, or delaying of progression of a hearing disorder, a hearing loss, and/or a balance impairment, or of preventing the loss of otic (sensory) hair cells of the inner ear in a subject, comprising use of a CDKN1B inhibitor, a NOTCH1 inhibitor and a HEY2 inhibitor. 
     
     
         32 . The combination or method of  claim 30  or  31 , wherein the CDKN1B inhibitor, the NOTCH1 inhibitor and the HEY2 inhibitor are to be administered substantially simultaneously or sequentially. 
     
     
         33 . A composition comprising at least one CDKN1B inhibitor or a pharmaceutically acceptable salt or prodrug thereof, at least one NOTCH1 inhibitor or a pharmaceutically acceptable salt or prodrug thereof; and at least one HEY2 inhibitor or a pharmaceutically acceptable salt or prodrug thereof; and a pharmaceutically acceptable carrier. 
     
     
         34 . The combination, method, or composition of any one of  claims 30  to  33 , wherein each inhibitor is independently selected from the group consisting of a small organic molecule; a protein, an antibody or fragments thereof, a peptide, a peptidomimetic and a nucleic acid molecule. 
     
     
         35 . The combination, method, or composition of  claim 34 , wherein each inhibitor comprises a nucleic acid molecule or a pharmaceutically acceptable salt thereof. 
     
     
         36 . The combination, method, or composition of  claim 35 , wherein a first nucleic acid molecule is a double-stranded oligonucleotide that binds a nucleotide sequence encoding a CDKN1B gene, a second nucleic acid molecule is a double-stranded oligonucleotide that binds a nucleotide sequence encoding a NOTCH1 gene, and a third nucleic acid molecule is a double-stranded oligonucleotide that binds a nucleotide sequence encoding a HEY2 gene. 
     
     
         37 . The combination, method, or composition of  claim 36 , wherein each of the double-stranded oligonucleotides comprises a dsRNA molecule having a sense strand and an antisense strand. 
     
     
         38 . The combination, method, or composition of  claim 36  or  37 , wherein the nucleic acid molecules are linked; or wherein the nucleic acid molecules are annealed in RNAistar formation. 
     
     
         39 . The combination, method, or composition of any one of  claims 35 - 38 , wherein:
 a first double-stranded oligonucleotide comprises a sense strand and an antisense strand, wherein;   (a) each strand is independently 18 to 49 nucleotides in length;   (b) a 18 to 49 nucleotide sequence of the antisense strand is complementary to a sequence of an mRNA encoding CDKN1B; and   (c) a 18 to 49 nucleotide sequence of the sense strand is complementary to the antisense strand;   a second double-stranded oligonucleotide comprises a sense strand and an antisense strand, wherein;   (a) each strand is independently 18 to 49 nucleotides in length;   (b) a 18 to 49 nucleotide sequence of the antisense strand is complementary to a sequence of an mRNA encoding NOTCH1; and   (c) a 18 to 49 nucleotide sequence of the sense strand is complementary to the antisense strand; and   a third double-stranded oligonucleotide comprises a sense strand and an antisense strand, wherein;   (a) each strand is independently 18 to 49 nucleotides in length;   (b) a 18 to 49 nucleotide sequence of the antisense strand is complementary to a sequence of an mRNA encoding HEY2; and   (c) a 18 to 49 nucleotide sequence of the sense strand is complementary to the antisense strand.   
     
     
         40 . The combination, method or composition of any one of  claims 30 - 39 , wherein the inhibitors are co-administered to the subject in the same formulation. 
     
     
         41 . The combination or method of any one of  claims 30 - 32  and  34 - 39 , wherein the inhibitors are co-administered to the subject in different formulations. 
     
     
         42 . The combination, method or composition of any one of  claims 30 - 39 , wherein the inhibitors are co-administered to the subject by the same route. 
     
     
         43 . The combination or method of any one of  claims 30 - 32  and  34 - 39 , wherein the inhibitors are co-administered to the subject by different routes. 
     
     
         44 . The combination or method of  claim 42 , wherein the inhibitors are co-administered to the subject by transtympanic injection. 
     
     
         45 . The combination or method of  claim 42 , wherein the inhibitors are co-administered topically. 
     
     
         46 . The combination or method of  claim 45 , wherein the topical administration comprises application of ear drops to the eardrum. 
     
     
         47 . The combination or method of any one of  claims 30 - 32 , wherein the administering is substantially simultaneous. 
     
     
         48 . The combination or method of any one of  claims 30 - 32 , wherein the administering is sequential. 
     
     
         49 . The combination, method, or composition of any one of  claims 36  to  48 , wherein at least one double-stranded oligonucleotide independently comprises a structure (A1): 
       
         
           
                 
                 
               
                     
                   (A1) 
                 
                     
                   (antisense strand) 
                 
                     
                   5′ (N)x − Z 3′ 
                 
                     
                     
                 
                     
                   (scnsc strand) 
                 
                     
                   3′ Z′-(N′)y − z″ 5′ 
                 
             
                
                
                
                
                
                
               
            
           
         
         wherein each of N and N′ is a ribonucleotide which may be unmodified or modified, or an unconventional moiety; 
         wherein each of (N)x and (N′)y is an oligonucleotide in which each consecutive N or N′ is joined to the next N or N′ by a covalent bond; 
         wherein each of Z and Z′ is independently present or absent, but if present is independently 1-5 consecutive nucleotides, 1-5 consecutive non-nucleotide moieties or a combination thereof covalently attached at the 3′ terminus of the strand in which it is present. 
         wherein z″ may be present or absent, but if present is a capping moiety covalently attached at the 5′ terminus of (N′)y; 
         wherein each of x and y is independently an integer between 18 and 40; 
         wherein the sequence of (N′)y is complementary to the sequence of (N)x; and wherein (N)x comprises an antisense sequence to an mRNA selected from an mRNA encoding CDKN1B, an mRNA encoding NOTCH1, and an mRNA encoding HEY2. 
       
     
     
         50 . The combination, method, or composition of  claim 49 , wherein in the double-stranded oligonucleotide x=y=19. 
     
     
         51 . The combination, method, or composition of any one of  claims 36  to  48 , wherein at least one double-stranded oligonucleotide independently comprises a structure (A2): 
       
         
           
                 
                 
               
                     
                   (A2) 
                 
                     
                   (antisense strand) 
                 
                     
                   5′ N 1 -(N)x − Z 3′  
                 
                     
                     
                 
                     
                   (sense strand) 
                 
                     
                   3′ Z′-N 2 -(N′)y − z″ 5′  
                 
             
                
                
                
                
                
                
               
            
           
         
         wherein each of N 2 , N and N′ is independently an unmodified or modified ribonucleotide, or an unconventional moiety; 
         wherein each of (N)x and (N′)y is an oligonucleotide in which each consecutive N or N′ is joined to the adjacent N or N′ by a covalent bond; 
         wherein each of x and y is independently an integer between 17 and 39; 
         wherein N 2  is covalently bound to (N′)y; 
         wherein N 1  is covalently bound to (N)x and is mismatched to the target mRNA selected from CDKN1B mRNA, NOTCH1 mRNA and HEY2 mRNA or is a complementary deoxyribonucleotide moiety to the mRNA selected from CDKN1B mRNA, NOTCH1 mRNA and HEY2 mRNA; 
         wherein N 1  is a moiety selected from the group consisting of natural or modified: uridine, deoxyribouridine, ribothymidine, deoxyribothymidine, adenosine or deoxyadenosine, an abasic ribose moiety and an abasic deoxyribose moiety; 
         wherein z″ may be present or absent, but if present is a capping moiety covalently attached at the 5′ terminus of N 2 —(N′)y; and 
         wherein each of Z and Z′ is independently present or absent, but if present is independently 1-5 consecutive nucleotides, 1-5 consecutive non-nucleotide moieties or a combination thereof covalently attached at the 3′ terminus of the strand in which it is present; 
         wherein the sequence of (N′)y has complementarity to the sequence of (N)x; and wherein the sequence of (N)x has complementarity to a consecutive sequence selected from a sequence in CDKN1B mRNA (SEQ ID NO:7); NOTCH1 mRNA (SEQ ID NO:11), and HEY2 mRNA (SEQ ID NO:10) 
       
     
     
         52 . The combination, method or composition of  claim 51 , wherein in the double-stranded oligonucleotide x=y=18. 
     
     
         53 . A commercial package comprising the composition or the combination of any one of  claims 30  to  32  or  34  to  52 . 
     
     
         54 . The commercial package of  claim 53 , wherein the label or package insert indicates that the composition or the combination of any one of  claims 30  to  32  or  34  to  52  is suitable for use in therapy. 
     
     
         55 . The commercial package of  claim 53  or  54 , wherein the label or package insert indicates that the composition or the combination of any one of  claims 30  to  32  or  34  to  52  is suitable for use in preventing, treating, or delaying of progression of a hearing disorder, a hearing loss, and/or a balance impairment, or for preventing the loss of otic (sensory) hair cells of the inner ear in a subject.