AU2016205002B2 - Methods and compositions for administration of iron - Google Patents

Abstract

The present invention generally relates to treatment of iron-related conditions with iron carbohydrate complexes. One aspect of the invention is a method of treatment of iron related conditions with a single unit dosage of at least about 0,6 grams of elemental iron via an iron carbohydrate complex. The method generally employs iron carbohydrate complexes with nearly neutral pH, physiological osmolarity, and stable and non immunogenic carbohydrate components so as to rapidly administer high single unit doses of iron intravenously to patients in need thereof

Description

The present invention generally relates to treatment of iron-related conditions with iron carbohydrate complexes. One aspect of the invention is a method of treatment of ironrelated conditions with a single unit dosage of at least about 0.6 grams of elemental iron via an iron carbohydrate complex. The method generally employs iron carbohydrate complexes with nearly neutral pH. physiological osmolarity, and stable and nonimmunogenic carbohydrate components so as to rapidly administer high single unit doses of iron intravenously to patients in need thereof.

2016205002 18 Jul 2016

AUSTRALIA

PAT ENTS ACT 1990

REGULATION 3.2

Name of Applicant: LUITPOLD PHARMACEUTICALS, INC.

Actual Inventor/s: Mary Jane Helenek;

Marc L. Tokars; and Richard P. Lawrence.

Address for Service: E. F. WELLINGTON & CO.,

Patent and Trade Mark Attorneys,

312 St. Kilda Road,

Melbourne, Southbank,

Victoria, 3006.

Invention Title:

“METHODS AND COMPOSITIONS FOR ADMINISTRATION OF IRON”

Details .of Associated Provisional Applications Nos:

the following statement is a full description of this invention including the best method of performing It known to us.

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CROSS •REFERENCE TO RELATED APPLICATIONS (0001 ] This application is a ‘divisional' application derived imro Australian Patent Application No. 2013206429, which is turn is a ‘divisional* application derived from Australian : Patent Application No. 20072051.67 (PCWS2007.'000176:· WO 2DQ7;OSt 744), claiming priority of CS Appheauon Nos 60.C57 Ii 9 and 11 620786, the entire text of which are hereby incorporated herein by reference, (0002] The present invention generally relates to treatment of irorwelated conditions with iron carbohydrate complexes;.

BACKGROUND (00031 Parenteral iron therapy is known to be effective in a variety of diseases and conditions iriclncfing, bat not limited to, severe iron deficiency; iron deficiency anemia, problems of intestinal iron absorption, intestinal bon intolerance, cases whore regular intake of an oral iron preparation is not guaranteed, ton deficiency where there is no response to oral therapy (e.g., dialysis patients), and situations where iron stores are scarcely or not at all formed but would bo toportant for further therapy (e.g.. in combination with erythropoietin), Geisser et at, Aronotoitfalfomchung (1992) 42(12), 1439-1452. There exist various commercially available parenteral ton formulations. But many currently available parenteral iron drugs, while purportedly effective at reptetiog Iron stores, have health risks and dosage limitations associated with their use.

(0004] Currently available parenteral ton formulations approved for .use in the U,S, include iron dextran (e.g„ InFed, Dexferrum), sodium ferric gluconate complex in sucrose (Fenfeeil), and iron sucrose (Venofer). Although seriousand life-threatehtng reactions occur most frequently with iron dextran, they are also known to occur with other parenteral iron : products. In addition, non-life threatening reactions such as arthralgia, back pain, hypotension, fever, myalgia, pruritus, vertigo, and vomiting also Occur. These reactions, white not life·· threatening, often preclude further dosing and therefore iron repletion.

£0 ο o s 1 Iron dextran, ihe first parenteral iron product available. In the United States (US), has been associated with an Incidence of anaphylactoid-type reactions (tie., dyspnea, * wheezing, chest pain, hypotension, urticaria, angtoedema). See generafiy Fishbone, Am J KidneyDfe (2003) 41(5Suppl), 18-26; Landry et at (2005) Am J Nephrol 25,400-410,407. This high incidence of anaphylactoid reactions is believed to be caused by the formation of antibodies to the dextran moiety, Oliver parenteral iron products (e.g., iron sucrose and iron gluconate) do not contain the dextran moiety, and tire incidence of anaphylaxis with these products is markedly lower, Rshbane, Am J Kidney Dis(2003)41{5Suppl>, 13-25; Gelsser at at,

Arzneimitteiforoehung (1992) 42(12), 1439-52. However, the physical characteristics of, for next page is page 2

2016205002 18 Jul 2016 example, Iron gluconate and iron sucrose lead to dosage and administration rate limitations, Negative characteristics include high pH, high osmolarity, low dosage limits (e.g., maximum 500 mg iron once per week, not exceeding 7 mg tron/kg foody weight), and the long duration of adm inlsfration (e,g,, 100 mg iron over at least 5 minutes as an injection; 500 mg iron over at least 3,5 hours as a drip infusion). Furthermore, injectable high molecular mass substances produce more allergic reactions than the corresponding low molecular mass substances. Geisser et at (1992) Arzne/m/ffe/forschung 42; 1439-1452, iococi Ferumoxytol is a newer parenteral iron formulation: but limited Information Is available as to its efficacy and administration, Sea e.g., Landry et al. (2005) Am J Nephrol 25, 400-410, 403; and Spinowiizet al. (2005) Kidney inti 53, 1801-1507: U.S. Patent No. 6,599,498.

(090 7 3 Various pharmacokinetic studies suggest that doses of Iron complexes higher than 200 mg of Iron are generally unsuitable and foal the conventional therapy model prescribes repeated applications of lower doses over several days, See Geisser et al„ (1992) AnenermiWforsoOungf 42; 1439-1452, For example, to achieve iron repletion under current therapy models, a total dose of 1 g typically requires 5 to 10 sessions over an extended period of time. These delivery modes incur significant expense for supplies such as tubing and infusate, costty nursing time, multiple administrations, end patient Inconvenience,

SUMMARY GF THE INVENTION (ο ο o 81 Among the various aspects of the present invention is the provision of a method of treatment of Iron-associated diseases, disorders, or conditions with iron formulations. Briefly, therefore, the present invention is directed to use of iron carbohydrate complexes that can be administered parenterally at relatively high single unit dosages, thereby providing a safe end efficient means for delivery of a total dose of iron in fewer sessions over the course of therapeutic treatment (0009] The present teachings Include methods of treating a disease, disorder, or condition characterized by iron def iciency or dysfunctional iron metabolism through the administration of at least 0.6 grams of elemental iron via a single unit dosage of an iron carbohydrate complex to a subject that is in need of such therapy.

{0010) In various embodiments, the method treats anemia. In some embodiments, the anemia is an iron deficiency anemia, such as that associated with chronic blood loss; acute blood loss; pregnancy; childbirth; childhood development; psychomotor and cognitive development in children; breath holding spells; heavy uterine bleeding; menstruation; chronic recurrent hemoptysis; idiopathic pulmonary sidereste; chronic internal bleeding; gastrointestinal bleeding; parasitic infections; chronic kidney disease; dialysis; surgery or scute trauma; and chronic ingestion of alcohol, chronic ingestion of salicylates, chronic ingestion of steroids; chronic ingestion of non-steroidlai anti-infiammatory agents, or chronic ingestion of erythropoiesis »2 35

2016205002 18 Jul 2016 to stimulating agents, in some aspects, the anemia Is anemia of chronic disease, such as' rheumatoid arthritis: cancer; Hodgkins ieukemia; non-Hodgkins leukemia; cancer chemotherapy; inflammatory bowel disease; ulcerative colitis thyroiditis; hepatitis; systemic lupus erythematosus; polymyalgia rheumatiea; scleroderma; mixed connective tissue disease; Sgsgren’s syndrome; congestive heart failure / cardiomyopathy; or idiopathic geriatric anemia. In some embodiments, the anemia is due to impaired iron absorption or poor nutrition, such as anemia associated with ‘ Crohn’s Disease; gastric surgery; Ingestion of drug products that inhibit iron absorption; and chronic use of calcium. in various embodiments, the method treats restless leg syndrome; biood donation; Parkinson's disease; hair loss; or attention deficit disorder.

[ ο ο 111 in various embodiments, the single dosage unit of elemental iron is between at least about 0.6 grams and 2.5 grams. in some embodiments, the singie dosage unit of elemental iron is at least about Q.7 grams;at feast about 0.6 grams; at feast about 0.9 grams; at least about 1.0 grams; at least about 1.1 grama; at least about 1,2 grams;at least about 1.3 grams; at least about 1,4 grams; at feast about 1,5 grams; at least about 1,6 grams; at least about 1,7 grams; at least about 1,8 grams; at least about 1.9 grams; at least about 2.0 grams; at least about 2.1 grams; at least about 2,2 grams; at least about 2.3 grams; at least about 2.4 grams; or at least about 2,5 grams.

f o o l 21 in various embodiments, the single dosage unit of elemental iron is administered in about 15 minutes or less, in some embodiments, the single dosage unitof elemental Iron is administered in about 10 minutes or less, about 5 minutes or less , or about 2 minutes or less.

(0013] In various embodiments, the subject does not experience a significant adverse reaction to the single dosage unit adminfetratiori, (0 0143 in various embodiments, the iron carbohydrate complex has a pH between about 5.0 to about 7,0; physlologlcai osmolarity; an Iron core size ng greater than about 9 nm; a mean diameter particle size no greater than about 35 nm; a blood half-life of between about 10 hours to about 20 hours; a substantially non-immunogenic carbohydrate component; and substantially no cross reactivity with anti-dextran antibodies.

(00153 In various embodiments, the iron carbohydrate complex contains about 24% to about 32% elemental iron; contains about 25% to about 50% carbohydrate; has a molecular weight of about 90,000 daifons to about 800,000 daStons, or some combination thereof.

in various embodiments, the Iron carbohydrate complex is an Iron monosaccharide complex, an iron disaccharide complex, or an iron polysaccharide complex. In som e embodiments, the Iron carbohydrate complex is iron carboxymaitose complex, iron mannitoi complex, iron pofyisomaitose complex, iron polymaltose complex, iron gluconate complex, iron sorbitol complex, or an iron hydrogenated dextran complex. in some embodiments, the iron

2016205002 18 Jul 2016 carbohydrate complex is an iron polyglucose sorbitol carboxymethyl ether complex, In some preferred embodiments, the iron carboxymaitese complex contains about 24% to about 32% elemental Iron, about 25% to about 50% carbohydrate, and is about 100,000 daitons to about 350,000 daltons, In some preferred embodiments, the Iron carboxymaitese complex is obtained from an aqueous solution of iron (III) salt and an aqueous solution of the oxidation product of one or more maltodextrins using an aqueous hypochlorite solution at a pH value within the alkaline range, wherein, when one maltodextrln Is applied, Its dextrose equivalent lies between 5 and 20, and when a mixture of several maltodextrins Is applied, the dextrose equivalent lies between 5 and 20 and the dextrose equivalent of each Individual maitodextrin contained in the mixture lies between 2 and 20. In some preferred embodiments, the Iron carboxymaitese complex has a chemical formula of KiC_sH_wO_s)_3t (C_eM,₂O₇)}, % where n is about 103, m Is about 8,1 is about 11» and K Is about 4; contains about 28% elemental ironrand has a molecular weight of about 150,000 Da. In some preferred embodiments, the Iron carboxymaltose complex tetrahydroxy-hexanoate, f OCXS) In various embodiments, the iron carbohydrate complex comprises an iron core with a mean iron core size of no greater than about 9 nm, In some embodiments, the mean Iron core size is at least about 1 nm but no greater than about 9 nm; at least about 3 nm but no greater than about 7 rsm; or at least about 4 nm but not greater than about 5 nm.

[00171 in various embodiments, the mean size of a particle of the iron carbohydrate complex is no greater than about 35 nm. In some embodiments, the particle mean size is no greater than about 30 nm. In some embodiments, the particle mean size Is no greater than about 25 nm. In some embodiments, the particle mean size is no greater than about 20 nm; no greater than about 15 nm; no greater than about 10 nm; or at least about 6 nm but no greater than about 7 nm.

£0018] in various embodiments, the iron carbohydrate complex is administered parenterally, for example intravenousiy or inlramuscufariy, in some embodimente, the iron carbohydrate complex Is intravenously infused. In certain embodiments, the single unit dose of iron carbohydrate complex is Intravenously infused at a concentration of about 1000 mg elemental iron in about 200 m l to about 300 ml of diluent, for example, about 250 mi of diluent or about 215 m l of diluent In some embodiments, the Iron carbohydrate complex is Intravenously injected as a bolus. in certain embodiments, the iron carbohydrate complex is intravenously injected a® a bolus at a concentration of about 1000 mg elemental iron lh about 200 ml to about 300 mi of diluent, for example, about 250 ml of diluent or about 215 m! of diluent, in some embodiments, the iron carbohydrate complex is intramuscularly infused at a concentration of about 1900 mg elemental iron in about 200 ml to about 309 ml of diluent, for example, about 250 mi of diluent or about 215 mt of diiuent, In some embodiments, the iron carbohydrate complex is

2016205002 18 Jul 2016

IS intramuscuishy infused at a concentration of about 500 mg elementai front in iess than about 10 ml diluent.

(001&] in various embodiments, the method aiso includes a second administration of the iron carbohydrate complex upon recurrence of atleast one symptom of the treated disease, disorder, or condition.

(002 0) in various embodiments, the method aiso Includes a second administration of the iron carbohydrate complex after 1 day to 12 months after the first administration.

{0021J Ina preferred embodiment, the method of treating a disease, disorder, or condition characterized by Iron deficiency or dysfuncdonai iron metabolism comprises intravenously administering to a subject in need thereof an iron carboxymaitose complex In a single dosage unit of at least about 1000 mg of elemental iron in about 200 ml to about 300 ml of diluent In about 6 minutes or less* wherein the iron earboxymaffose complex comprises an iron core with a mean iron core size of at least about 1 nm but no greater than about 9 nm; 'mean size of a particle of the iron carboxymaltose complex Is no greater than about 35 nm; and the Iron carboxymaitose complex is administered intravenously infused or intravenously injected at a concentration of about 1000 mg elemental iron in about 200 ml to about 300 mi of diluent in some these embodiments, the iron Carboxymaitose eompiex is polynuclear iron (iii)-hydroxide 4{RXpoly~{l“~*4}-Qrod$ucopyranosyt}-oxy~2{R),3(S},S{R)_[6-tetrahydroxy~haxanoate. in some these embodiments, the iron carboxymaitose complex Is obtained from an aqueous solution of iron {III) salt and an aqueous solution of the oxidation product of one or more maftodextrins using an aqueous hypoohlonte solution at a pH value within the alkaline range, wherein, when one maitodextrin is applied, its dextrose equivalent lies between about 5 and about 20, and when a mixture of several maftodextrins is applied, the dextrose equivalent lies between about 5 and about20 and the dextrose equivalent of each individual maitodextrin contained In the mixture iies between about 2 and about 20,

10022} Other objects and features wil! be in part apparent and in part pointed out hereinafter.

BRIEF DESCRIPTION OF THE DRAWINGS [00233 Those of sklii in the art wil! understand that the drawings, described below, are for illustrative purposes only. The drawings are not intended to limit the scope of the present teachings in any way.

[0024} FIG 1 is a series of electron micrographs that depict the particle size of three iron carbohydrate complexes. FIG 1A is an electron micrograph depicting the particle size of Dexferrum (an iron dextran), FIG 18 is an electron micrograph depicting the particle size of Venofer (an iron sucrose). FiG 10 is an electron micrograph depicting the particle size of

-5polynuclear iron (tii)mydroxide4{R)-(poly~(1-->4pO-a-glucQpyrafrosyi)-oxy-2{R),3(S),5(R),6~ tetrahydroxy-hexanoate CVir-45”, an iron carboxymaitpse complex).

[0025 ] FiG 2 te a schematic representation of an exemplary Iron carboxymsitose complex.

DETAILED DESCRIPTION OF THE INVENTION

2016205002 18Jul2016

IS [0026] The present Invention makes use of Iron carbohydrate complexes that can be administered parenteral^ at relatively high single unit dosages for the therapeutic treatment of a variety of iron-associated diseases, disorders, or conditions. Generally, states indicative of a need for therapy with high single unit dosages of iron carbohydrate complexes indude, but are not limited to iron deficiency anemia, anemia of chronic disease, and states characterized by dysfunctional iron metabolism. Efficacious treatment of these, and other, diseases and conditions with parenteral iron formulations (supplied at lower single unit dosages than those described herein) Is generally known In the art, Gee e,g., Van Wyck et al. (2004) J Am Soc Nephrol IS, S91-S92, The present invention is directed to use of iron carbohydrate complexes that can be administered parenteroily at roiativeiy high single unit dosages, thereby providing a safe and efficient means for delivery of a total dose of iron In fewer sessions over the course of therapeutic treatment (0027] Iron deficiency anemia is associated with, for example, chronic blood loss; acute blood ioss; pregnancy; childbirth; childhood development; psychomotor and cognitive development in children; breath holding spoils; heavy uterine bleeding; menstruation; chronic recurrent hemoptysis; idiopathic pulmonary siderosis; chronic Internal bleeding; gastrointestinal Weeding; parasitic infections; chronic kidney disease; dialysis; surgery or acute trauma; and chronic ingestion of alcohol, chronic ingestion of salicylates, chronic ingestion of steroids; chronic ingestion of nors-sterotdial anti-inflammatory agents, or chronic ingestion of erythropoiesis stimulating agents.

(002 8] Anemia of chronic disease Is associated with, for example, rheumatoid arthritis; cancer; Hodgkins leukemia; non-Hodgkins leukemia; cancer chemotherapy; inflammatory bowel disease; ulcerative colitis thyroiditis; hepatitis; systemic lupus erythematosus; polymyalgia rheumatics; scleroderma; mixed connective tissue disease; Sojgren’s syndrome; congestive heart failure f cardiomyopathy; and idiopathic geriatric anemia.

(0023) Anemia is also associated with, for example, Crohn's Disease; gastric surgery; ingestion of drug products that inhibit Iron absorption; and chronic use of calcium, (003 0 J States characterized by dysfunctional iron metabolism and treatable with the single unit dosages of Iron carbohydrate complexes described herein include, but are not limited to, restless leg syndrome; blood donation; Parkinson’s disease; hair loss- and attention deficit disorder.

-s [0032 ] Again, each of the abovelisted states, diseases, disorders, and conditions, as well as others, can benefit from the treatment methodotogtes described herein. Generally, treating a state, disease, disorder, or condition includes preventing or delaying the appearance of clinical symptoms in a mamma! that may be afflicted with or predisposed to the state, disease, disorder, or condition but does not yet experience or display clinics! or subciinicai symptoms thereof. Treating can also include Inhibiting the stats, disease, disorder, or condition, e.g., arresting or reducing the development of toe disease or at least one clinical or subciinicai symptom thereof. Furthermore, treating can include relieving the disease, e.g., causing regression of toe state, disease, disorder, or condition oral least one of its clinical or subdinteai symptoms.

[0032] The benefit to a subject to be heated is either statistically significant or at least perceptible to toe patient or to toe physician. Measures of efficacy of iron replacement therapy : are generally based on measurement of iron-related parameters in blood. The aim of treatment is usually to return both Hb and iron stores to normal levels. Thus, efficacy of I ron replacement therapy can be interpreted in terms of toe ability to normalise Hb levels and iron stores. The effectiveness of treatment with one or more single unit doses of iron carbohydrate complex, as described hereto, can be demonstrated, for example, by improvements in ferritin and transferrin saturation, and in raising hemoglobin levels In anemic patients. Iron stores can be assessed by interpreting serum ferrifin levels, TfS Is frequently used, in addition, to diagnose absolute or functional iron deficiencies. In patients with Iron deficiency, serum transferrin is elevated and will decrease following successful iron treatment, [0033] Administration ( 0034} Methods of treatment of various diseases, disorders, or conditions with iron complex compositions comprise toe administration of the complex to single unit dosages of at least 0.6 grams of elemental iron to about at feast 2,5 grams of elemental iron. Administration of single unit dosages can be, for example, over predetermined time Intervals or to response to the appearance and/or reappearance of symptoms. For example, the iron carbohydrate complex can be re-edministered upon recurrence of at least one symptom of the disease or disorder. As another example» the iron carbohydrate complex cars be re-administered at some time period after the initei administration (e.g,, after 4 days to 12 months).

(00353 Any route of delivery of the single unit dose of iron carbohydrate complex is acceptable so tong as iron from the iron complex is released such that symptoms are treated.

The single unit dose of iron carbohydrate complex can be administered parenteraiiy, for example intravenously or totramusculariy, intravenous administration can be delivered as a bolus or preferably as an Infusion. For example, the stogie unit dose of iron carbohydrate compiex can be intravenously infused at a concentration of about WOO mg elemental iron in about 200 ml to about 300 mi of diluent, preferably about 215 ml of diluent or about 250 mi of difuent. The iron

- ?»

2016205002 18Jul2016 carbohydrate complex can be intravenously injected as a bolus. For example, the iron catoohydrate complex can be intravenously injected as a bolus ata concentration of about WOO mg elemental iron In about 200 mi to about 300 mi of diluent, preferably about 215 mi of diluent or about 250 ml of diluent,' The iron carbohydrate complex can be intramuscularly infused at a concentration of, for example, about 1000 mg elemental iron in about 200 ml to about 300 mt of diluent, preferably, about 250 ml of diluent or about 215 ml of diluent. If applied as an infusion, the iron carbohydrate complex can be diluted with sterile saline (e.g., polynuclear iron (111)hydroxide 4(P)-(poiy-(1™f4)-Oto-glucopyranos^>oxy“2(R)_j3(S3,5(R)_!6-tatrahydroxy-hexanoafe {^βνΐΤ·45^Β} 0,9% rn/V NaCl or 500 mg iron ih up to 250 mt NaCl). The iron carbohydrate complex can be intravenously injected as a bolus without dilution. As an example, the Iron carbohydrate complex can be Intramuscularly injected at a concentration of about 500 mg elemental iron io less than about 10 mi diluent preferably about 5 mt [003 63 Generally, total iron dosage will depend on the Iron deficit of thepattent One skilled In the art can tailor the total iron dose required for a subject while avoiding Iron overload, as overdosing with respect to the totai required amount of iron has to be avoided, as is the case for all iron preparations, [0037] The total iron dosage can be delivered as a single unit dosage or a series of single unit dosages. An appropriate single unit dosage level will gsneraiiy be at least 0,6 grams of elemental iron, particularly at least 0,7 grams; at least 0.8 grams; at least 0,9 grams; at least 1.0 grams; at least 1.1 grams; at least 1.2 grams; at feast 1,3 grams; at least 1,4 grams; at least 1.5 grams; at ieast 1.6 grams; at least 1,7 grams; at least 1.8 grams; at least 1.9 grams; at least 2.0 grams; at least 2.1 grams; at least 2.2 grams; at least 2.3 grams; at least 2.4 grams; or at least 2.5 grams. For example, a single unit dosage is at least 1.0 grams of elemental iron. As another example, a single unit dosage is at ieast 1.6 grams of elemental Iron, As a further example, a slngie unit dosage is at ieast 2.0 grams of elemental iron. In yet another example, a single unit dosage is at least 2.6 grams of elemental iron.

[ 0 o 3 S] An appropriate slngie unit dosage level can also be determined on the basis of patient weight. For example, an appropriate single unit dosage level will generally be at least 9 mg of elemental iron per kg body weight, particularly at least 10.5 mg/kg, at least 12 mg/kg, at least 13.5 mg/kg, et least 15 mg/kg, at least 16.5 mg/kg, at least 18 mg/kg, at least 19,5 mg/kg, at least 21 mg/kg, at least 22.5 mg/kg, at least 24 mg/kg, at least 25.5 mg/kg, at least 27 mg/kg, at least 28,5 mg/kg, at least 30 mg/kg, at least 31.5 mg/kg, at least 33 mg/kg, at least 34.5 mg/kg, at least 36 mg/kg, or at least 37,5 mg/kg, [0039) Preferably, s single unit dosage can be administered to 15 minutes or less.

For example, the single unit dosage can be administered In 14 minutes or less, 13 minutes or less, 12 minutes or less, 11 minutes or teas, W minutes or fess, 9 minutes or less, 8 minutes or

2016205002 18 Jul 2016 less, 7 minutes or less* 6 minutes or less, S minutes or less, 4 minutes or less, 3 minutes or less, or 2 minutes or less.

JO

I ο o 4 o 1 Administration of iron can occur as a one-lime deli very of a single unit dose or over a course of treatment involving delivery of multiple single unit doses. Multiple single unit doses can be administered, for example, over predetermined time Intervals 'or in response to the appearance and reappearance of symptoms. The frequency of dosing depends on the disease or disorder being treated, the response of each individual patient, and the administered amount of elemental iron. An appropriate regime of dosing adequate to allow the body to absorb the iron from the bloodstream can be, for example, a course of therapy once every day to once every eighteen months.

[0 041] Such consecutive single unit dosing can be designed to deliver a relatively high total dosage of iron over a relatively low period of time. For example, a single unit dose (e.g., 1000 mg) can be administered every 24 hours. As illusfration, a total dose of 2000,2500, 3000, 3500, 4000,4500. or 5000 mg of elemental iron can be delivered via consecutive daily single unit doses of about 600 mg to about 1000 mg of elemental iron. Given that a single unit dose of 1000 mg can be intravenously introduced into a patient In a concentrated form over, for example, two minutes, such: administrative protocol provides a practitioner and patient with an effective, efficient, and safe means to deliver elemental iron, [0 042] As another example, a single unit dose can be administered every 3-4 days. As a further example, a single unit dose can be administered once per week. Alternatively, the single unit doses of iron complex may be administered ad hoc, that Is, as symptoms reappear, as long as safety precautions are regarded as practiced by medical professionals;

[004 3 ] it will be understood, however, that the specific dose and frequency of administration for any particular patient may be varied and depends upon a variety of factors, including the activity of the employed iron complex, the metabolic stability and length of action of that complex, the age, body weight, general health, sex, diet, mode and time of administration, rate of excretion, drug combination, the severity and nature of the particular condition, and the host undergoing therapy.

[0044] The foilowing provides but a few examples of treatment protocols for various diseases or disorders.

[0045] Iron carbohydrate complex can be given as a single unit dose for the treatment of Restless Leg Syndrome. For example, 1000 mg of elemental iron from an Iron cartaymaftose (e.g., polynuclear iron (iil)-hydroxide 4(RHPOly-{1-*4)-0~a-glucopyranosyi)~oxyaiRi.SiSf.SCRXe-tetrahydroxy-hexanoate} can be Intravenously injected as a single dose (e.g.,

1.5-5 mg Sron/mi in norma! saline) to a subject suffering from Restless Leg Syndrome. A single intravenous treatment can provide relief of symptoms for an extended period of time,

-s5

2016205002 18Jul2016

IS approximately two to twelve months, although relief may be granted for «hotter or longer periods. See U.S. Patent Pub, No, 2004/0180846, incorporated herein by reference, If desired, postinfusion changes in central nervous system iron status can ba monitored using measurements of cerebral spinal fluid (CSF) ferritin (and other iron-related proteins) and of brain Iran stores using MRS. Post-infusion changes in Restless Leg Syndrome are assessed using standard subjective (e.g,, patient diary, rating scale) and objective (e.g., P50, SiT, Leg Activity Meters) measures of clinical status. If desired, to better evaluate RLS symptom amelioration, GSF and serum iron values, MRI measures of brain iron and full clinical evaluations with steep and immobilization tests are obtained prior to treatment, approximately two weeks after treatment, and again twelve months later or when symptoms return. Citnicai ratings, Leg Activity Meter recordings and serum ferritin are obtained monthly after treatment. CSF ferritin changes can atso be used to assess symptom dissipation, id 04 s3 iron carbohydrate complex can be given as a single unit dose for the treatment of iron deficiency anemia secondary io heavy uterine bleeding. For example, a single unit dose of 1,000 mg of elemental iron from an Iron carboxymaitose in about 250 co normal saline can be intravenously injected into a Subject suffering from iron deficiency anemia secondary to heavy uterine bleeding over IS minutes every week until a calculated iron deficit dose has been administered. The Iron deficit dose can be calculated as foiSows;

if basdins TSAT < 20% or Baseline Farnfin <50 ng/ml:

Dose ~ Baseline weight (kg) x (IS-BaseiineHgb jg/dtj) x2.4 + 500 mg

OR if baseline TSAT >20% and Baseline Ferritin > 50 ng/mt;

Dose = Baseline weight (kg) x (IS-Baseiine Hgb (g/dL]} x 2 4 (NOTE; Baseline Hgb equals the average of the last two centra! iab Hgb’s) (004 7} Iron carbohydrate complex can be given as a single unit dose for the treatment of iron deficiency anemia, A subject diagnosed as suffering from iron deficiency anemia can be, for example, intravenously injected with a dose of 1,000 mg of iron as V1T- 45 (or 15 mg/kg for weight < 65 kg) in 250 co of normal saline over 15 minutes. Subjects with iron deficiency anemia secondary to dialysis or non-dialysis dependenFChronic Kidney Disease (CKO) as per K/DOQI guidelines wlii generally have Hgb < 12 g/dL; TSAT <25%; and Ferritin < 360 ng/mt, Subjects with iron deficiency anemia secondary to inflammatory Bowel Disease will generally have Hgb < 12 g/dL; TSAT < 25%; and Ferritin < 300 ng/mt. Subjects with iron deficiency anemia secondary to other conditions will generally have Hgb < 12 g/dL; TSAT < 25%; and Ferritin < 100 ng/mt.

t o 04 8 3 Subject in need thereof (0049] Single unit dosages of intravenous iron described herein can be administered to a subject where there is a clinical need to deliver iron rapidly or in higher doses and/or in

IQ35

2016205002 18Jul2016

IS subjects with functional iron deficiency such as those on aryforopafeffn therapy, A determination r

of the need for treatment with parenteral iron is within the abilities of one skilled in foe art. For example, need can be assessed by monitoring a patient’s iron status, The diagnosis of iron deficiency can be based on appropriate laboratory tests, for example, haemoglobin (Hb), serum ferritin, serum iron, transferrin saturation (TfS), end hypochromic red ceils, [0050] A determination of the need for treatment with high dosages of parenterai iron can be also be determined through diagnosis of a patient as suffering from a disease, disorder, or condition that »s associated with iron deficiency dr dysfunctional iron metabolism. For example, many chronic renal failure patients receiving erythropoietin will require intravenous iron to maintain target iron tovels. As another example, most hemodialysis patients will require repeated intravenous iron administration, due to diaiysis-assceSated blood fess and resulting negative iron balance, [0051 ] Monitoring frequency can depend upon the disease, disorder, or condition the patient is afflicted with or at risk for. For example, in a patient initiating erythropoietin therapy, iron indices ere monitored monthly. As another example, in patients who have achieved target range Hb or are receiving intravenous iron therapy, TSAT and ferritin levels can be monitored every 3 months.

(0 052} A patient's iron status can be indicative of an absolute or a functional iron deficiency, both of which can be treated with the compositions and methods described herein. An absolute iron deficiency occurs when an insufficient amount of iron is available to meet the body’s requirements. The insufficiency may be due io inadequate iron intake, reduced btoavailabiiity of dietary iron, increased utilization of iron, or chronic blood toss, Prolonged iron deficiency can lead to iron deficiency anemia—a microcytic, hypochromic anemia in which there are Inadequate iron stores, Absolute iron deficiency is generally indicated where TSAT <20% and Ferritin <100 ng/mt.

[ 0 0 5 3} Functional iron deficiency can occur where there is a failure to release iron rapidly enough to keep pace with the demands of the bone marrow for erythropoiesis, despite adequate totai body iron stores, in these cases, ferritin levels may be normal or high, but the supply of iron to the erythron is limited, as shown by a tow transferrin saturation and an increased number of microcytic, hypochromic erythrocytes. Functional iron deficiency can be characterised by the following characteristics: inadequate hemoglobin response to erythropoietin', Serum ferritin may be normal or high; Transferrin saturation (TSAT) usually <20%; and/or reduced mean corpuscular volume (MCV) or mean corpuscular hemoglobin concentration (MCHC) in severe cases. Functional iron deficiency (i.e,, iron stores are thought to be adequate but unavailable for iron delivery) is generally indicated where TSAT <20% and Ferritin >100 ng/mt, [0054] Assessing the need for intravenous iron therapy as described herein can be according to the National Kidney Foundation's Kidney Disease Outcomes Quality initiative. See n

2016205002 18 Jul 2016

NKF-K/DOOS, Clinical Practice Guidelines for Anemia of Chronic Kidney Disease (2000); Am J Kidney Dis (2001) 37(supp 1), 8182-8238. The DOQI provides optima! clinical practices for the treatment of anemia In chronic renai failure. The DOQI guidelines specify intravenous iron treatment of kidney disease based on hemoglobin, transferrin saturation (TSAT), and ferritin levels.

IS [ 0 OS Si Assessment of need for intravenous iron therapy can also be according to a patient's target iron level. For example, the target hemoglobin ievei of a patient can be selected as 11,0 g/til to 12,0 g/dl (hematocrit approximately 33% to 33%). To achieve forget hemoglobin with optimum erythropoietin doses, sufficient iron, supplied via an iron carbohydrate complex, ts provided to maintain TSAT £20% and ferritin £100 ng/ml, in erythropoietin-treated patients, if TSAT levels are below 20%, the Oketlbood that hemoglobin wifi rise or erythropoietin doses fall after Iron administration Is high. Achievement of target hemoglobin levels with optimum erythropoietin doses Is ass ociated with providing sufficient iron to maintain TSAT above 20%.

loose) iron therapy can be given to maintain target hemoglobin while preventing iron deficiency and also preventing iron overload. Adjusting dosage of Iron to maintain target levels of hemoglobin, hematocrit, and laboratory parameters of Iron storage is Within the normal skill In the art. For example, where a patient is anemic or Iren deficient. Intravenous iron can be administered when a patient has a ferritin <800, a TSAT<50, and/or a Hemoglobin <12. Iron overload can be avoided by withholding iron for TSAT >SQ% and/or ferritin >300 ng/ml, (005?) Where a patient Is not anemic or Iran deficient but is In need of Iran administration, for example a patient suffering from Restless Leg Syndrome, hemoglobin and TSAT levels are not necessarily relevant, while ferritin >S00 can still provides a general cut off point for administration.

(o d se) Iron Carbohydrate Complex (0059) Iron carbohydrate complexes are commercially available, or have well known syntheses. Examples of Iron carbohydrate complexes Include iron monosaccharide complexes, iron disacchartde complexes, iron oligosaccharide complexes, and iron polysaccharide complexes, such as: iron carboxymaltose, iron sucrose, iron poSyisomaitese (iron dextran), iron polymaltose (iron dextrin), iron gluconate, Iron sorbitol, iron hydrogenated dextran, which may be further complexed with other compounds, such as sorbitol, citric acid and gluconic acid (for example Iron dextrin-sorbiioi-citric acid complex and Iron sucrose-gluconic acid complex), and mixtures thereof.

(o 0 S 0 3 Applicants have discovered that certain characteristics of Iran carbohydrate complexes make them amenable to adminisfratfon at dosages far higher than contemplated by current administration protocols, Preferably, Iron carbohydrate complexes for use in the methods described herein are those which have one or more of the following characteristics; a nearly

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2016205002 18 Jul 2016 neutral pH (e.g., aboutS to about 7); physiological osmolarity; stable carbohydrate component; an iron core size no greater than about 9 nm; mean diameter particle size no greater than about 35 nm, preferably about 25 nm to about 30 nm; slow and competitive delivery of the compiexed iron to endogenous iron binding sites; serum half-life of over about 7 hours; low toxicity; nonImmunogenfc carbohydrate component; no cross reactivity with anti-dextran antibodies; and/or tow risk of anaphylactoid / hypersensitivity reactions.

[OOSX j ft is within tee skill of the art to test various characteristics of iron carbohydrate complexes as so determine amenability to use in the methods described herein. For example, pH and osmolarity are straightforward determinations performed on a sample formulation. Likewise, techniques such as electron micrograph imaging, transmission electron microscopy, and atomic force microscopy provide direct methods to analyze both iron core and particle size. See e.g.. Figure 1; Table 1, The stability of the carbohydrate complex can be assessed through physicochemical properties such as kinetic characteristics, thermodynamic characteristics, and degradation kinetics. See Geisser et at, Arzneimitteiforschung (1SS2) 42(12), 1439-1452,

Useful techniques to assess physical and electronic properties include absorption spectroscopy, X-ray diffraction analysis, transmission electron microscopy, atomic force microscopy, and elements! analysis. See Kudasheva et al (2004) J Inorg Slochem 98,1757-1769. Pharmacokinetics can foe assessed, for example, by iron tracer experiments. Hypersensitivity reactions can be monitored and assessed as described in, for example, Bailie at al, (2085) Nephrol Dial Transplant, 20(7), 1443-1449. Safety, efficacy, and toxicity in human subjects can be assessed, for example, as described In Spinowitz et at (2005) Kidney Inti 68,1801-1807.

(0062) A particularly preferred Iron carbohydrate complex will have a pH between 5.07.0; physiological osmolarity; an iron core size no greater than 9 nm; mean diameter particle size no greater than 30 nm; serum half-life of over 10 hours; a non-lmmunogenlc carbohydrate component; and no cross reactivity with anti-dextran antibodies. One example of a preferred iron carbohydrate complex for use in the methods described herein Is an iron carboxy-maltose complex (e,g„ polynuclear iron (Sll)-hydroxide 4(RHpoty-(1-»4>0-a-gtocopyranosyl)-oxy2(R},3(S),5(R),6-tetrahydroxy-hexanoate, VST-dS), Another exampieof a preferred iron carbohydrate complex for use in the methods described herein is a carboxyaikytated reduced polysaccharide iron oxide complex (agt,, femmoxytoi, described in U.S. Patent No. 6,599,498), {0043) Preferably, an iron carbohydrate complex, tor use in methods disclosed herein, contains about 24% to about 32% elemental iron, more preferably about 28% elemental iron. Preferably, an Iron carbohydrate complex, for use In methods disclosed herein, contains about 25% to about 50% carbohydrate (&.g,, total glucose). Preferably, an Iron carbohydrate complex, for use in methods disclosed herein, is about 90,000 daitons to about 800,000 daitons, more preferably 100,000 daitons to about 350,000 daitons.

{0 0 6 4 ] iron carboxym altos© complex

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2016205002 18Jul2016 [00 SS 3 One preferred iron carbohydrate complex fer use in the methods described herein is an iron cafooxymaitose complex. An example of an iron carboxymaifose complex is polynuclear iron (lll>hydrexide 4(R)-(poiy-(1-~»4)-0-o-giucopyranosyi)-oxy-2(R),3(S)_:5(R)₎6tetrahydraxy-hexanoafe (*V1T*4S). ViT-45 is a Type i polynuclear iron (iii) hydroxide carbohydrate complex that can bo administered as parenteral iron replacement therapy for the treatment of various anemia-related conditions as wei 1 as other iron-metabolism related conditions. ViT-45 can bo represented by the chemical formula: |FeOx(OH)ytH2G)2jn U(C8Ht0O5)m (CSH12O7))! X where n is about 103, m is about 8,! is about 11, and k is about 4), The moiecuiar weight of VIT-45 Is about 150,000 Da, An exemplary depiction of VIT-45 is provided in Figure 2.

[boss] The degradation rate and physicochemical characteristics of the i ron carbohydrate complex (e.g., VIT-45) make it an efficient means of parenteral iron delivery to the body stores, it Is more efficient and less toxic than the lower molecular weight complexes such as Iron sorbifol/citrat© complex, and does not have the same limitations of high pH and osmolarity that leads to dosage and administration rate limitations in the case of, for example, Iron sucrose and iron gluconate, £ o os? 3 The iron carboxymahose complex (e.g., VIT-45) generally does not contain dextran and does not react with dextran antibodies; theroforo, the ris k of anaphylactoid /hypersensitivity reactions is very low compared to iron dextran. The iron carboxymaitose complex (e.g., VIT-45) has a nearly neutral pH (5.0 to 7.0) and physiological osmolarity, which makes it possible to administer higher single unit doses over shorter time periods than other Ironcarbohydrate complexes. The iron carboxymaitose complex (eg., VIT-45) can mimic physiologically occurring ferritin. The carbohydrate moiety of iron carboxymaitose complex (e.g,, Vfr-45) is metabolized by the glycolytic pathway, Like iron dextran, the iron carboxymaitose complex (e.g., ViT-45) Is more stable than iron gluconate and sucrose. The Iron carboxymaitose complex (ag„ VIT-45) produces a slow and competitive delivery of the complexed iron to endogenous Iron binding sites resulting in an acute toxicity one-fifth that of iron sucrose, These characteristics of the iron carboxymaitose complex (e.g., ViT-45) allow administration of higher single unit doses over shorter periods of time than, for example, iron gluconate or iron sucrose. Higher single unit doses can result in the need for fewer injections to replete iron stores, and consequently is often better suited for outpatient use.

[0068 ] After intravenous administration, the Iren carboxymaitose complex (e.g,, VIT45) is mainly found in the liver, spleen, and bone marrow. Pharmacokinetic studies using positron emission tomography have demonstrated a fast initial elimination of radioactiveiy iabeied iron (Fe) ^Fe/^Fe VIT-45 from the blood, with rapid transfer to the bone marrow and rapid deposition in toe liver and spleen. See e.g., Beshara et al. (2003) Br 3 Haematol 2003; 120(5): 853-859. Eight hours after administration, 5 to 20% of the injected amount was observed to be

Ή5

2016205002 18 Jul 2016 ίθ

IS still in ths blood, compared with 2 to 13% for Iron sucrose. The projected calculated terminal half-life (fo) was approximately 16 hours, compared to 3 to 4 days for Iron dextran and 6 hours for iron sucrose.

(0069] The iron in the Iron carboxymaitose complex (e.g., ViT-45) slowly dissociates from the complex and can be efficiently used in the bone marrow for Hgb synthesis. Under ViT45 administration, red cell utilization, followed for4 weeks, ranged from 61% to 99%. Despite the relatively higher uptake by foe bona marrow, there was no saturation of marrow transport systems. Thus, high red cell utilization of Iron carboxymaltose complex occurs in anemic patients. In addition, foe reticuloendothelial uptake of this complex reflects the safety of polysaccharide complexes. Non-saturation of transport systems fo the bone marrow indicated the presence of a large interstitial transport pool (e.g,, transferrin).

(0070) Other studies fo patients with iron deficiency anemia revealed increases in exposure roughly proportional with ViT-45 dose (maxima? total serum iron concentration was approximately 150 pg/mL and 320 pg/mL following 500 mg and 1000 mg doses, mspecSveiy). In these studies, VIT-45 demonstrated a monoexponential elimination pattern with a fra in the range 7 to 18 hours* with negligible renal elimination.

(007X) Single-dose toxicity studies have demonstrated safety and tolerance in rodents and dogs of intravenous doses of an iron carboxymaitose complex (VIT-45) up to SO times more than the equivalent of an intravenous Infusion of 1,000 mg Iron once weekly fo humans. Pre-elinicat studies In dogs and rats administered VIT-45 in cumulative doses up to 117 mg iron/kg body weight over 13 weeks showed no observed adverse effect level in dose-related clinical signs of iron accumulation In the liver, spleen, and kidneys. No treatment-related local tissue irritation was observed in intra-arterial, perivenous, or Intravenous totersnoe studies in the rabbit In vitro and in vivo mutagenicity tests provided no evidence that VIT-45 Is clastogenic, mutagenic, or causes chromosomal damage or bone marrow celi toxicity. There were no specific responses to VIT-45 in a dextran antigenicity test.

[0072} Approximately 1700 subjects have been treated with an iron carboxymaltose complex (VIT-45) In open label clinical trials (sea e.g,, Example 5). Many of these subjects have received at least one dose of 1Smg/kg (up to a maximum dose of 1,000 mg) of ViT-45 over 15 minutes Intravenously. Few adverse events and no serious adverse events or withdrawals due to adverse events related to ViT-45 administration have been reported. No clinically relevant adverse changes to safety laboratories have been seen, [ 0 073,J The phys icochemica! characteristics of the Iron carboxymaltose complex (e.g., VIT-45), the pattern of iron deposition, and foe res cits of the above described studies demonstrate that iron carboxymaltose complex can be safely adminlsfered at high single unit therapeutic doses as described herein.

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2016205002 18 Jul 2016 [0074] Polyglucosesorbitol carboxymethyl ether-coated non-stoschiometric magnetite (OO7S3 Another preferred iron carbohydrate complex for use in foe methods described herein is a polygiucos© sorbitd carboxymefoyi efoer-coated nomsioichiomefric magnetite {e.g., Wumoxyfor). Ferumoxytoi is known in the art to be effecti ve for treating anemia (at single unit doses Sower than described herein), See e.g., Spinowitz et al, (200S) Kidney inti 63,1801-1807^ Ferumoxytoi Is a super-paramagnetic iron oxide that is coated with a Sow molecutar weight semisynthetic carbohydrate, polygteose sorbitoi carhoxymethyiether. Ferumoxytoi and its synthesis are described in U.S, Patent No. 6,599,438, incorporated herein by reference. Safety, efficacy, and pharmacokinetics of ferumoxytoi era as described, for example, in Landry et al. (2005) Am J Nephrol 25,400-410, 408; and Spinowitz et ai. ¢2005) Kidney inti 68, 1801-1807, [cove) The iron oxide of ferumoxytoi is a superparamagneiic form of nonstoichiometnc magnetite with a crystal size of 8.2 to 7.3 nm. Average colloidal particle size can he about 30 nm, as determined by light scattering. Molecular weight Is approximately 750 RB. The osmolarity of ferumoxytoi is isotonic at 297 mOsm/kg and the pH is neutral. The blood halflife of ferumoxytoi is approximately 10-14 hours, it has been previously reported that ferumoxytoi can be given by direct intravenous push over 1-3 minutes in doses up to 1,800 mg elemental iron per minute, with maxima! total dose up to 420 mg per injection. Landry et al, (2005) Am d Nephrol 25, 400-410, 408.

[0077) Core and Particle Size [0078) Intravenous iron agents are generally spheroidal iron-carbohydrate nanopartictes, At foe core of each particle is an iron-oxyhydroxide gel. The core is surrounded by a she» of carbohydrate that stabilizes the iron-oxyhydroxide, slows tire release of bioacfive iron, and maintains the resulting particles in colloidal suspension, iron agents generally share the same core chemistry but differfrom each other by the size of the core and the identity and the density of the surrounding carbohydrate. See Tabla 1; Figure 1.

-. ϊδ~

2016205002 18 Jul 2016

Table 1: Core and Particle Size of iron Carbohydrate Complexes

Iron (III)

Control

Release Test Size of the Particle (nm) +/- SEM T-zs (min) iron core Total Particle

Dexferrum (an iron dextran)	122.5	11,8 ±4	27 ±6
VIT -45 (an iron carboxymaitose)	117.8	4.45:1,4	6.7 ±2.5
Vender (an Iron sucrose)	10,2	2.8 ±1	5.5 ±4

(0070} Differences In com size and carbohydrate chemistry can determine pharmacological and biological differences, including clearance rate after injection, iron release rate in vitro, early evidence of iron bioactlvity in vivo, and maximum tolerated dose and rate of infusion, , f0080} One of the primary determinants of iron bioactlvity is the size of the cere and the surface area to volume ratio. Generally, the rate of labile iron release In each agent is inversely related to the size of its iron core. Van Wyck (2004) J. Am, See, Nephrology 15, S107$11'1, S109, Furthermore, in vitro iron donation to transferrin Is inversely related to core size. Core s ize can depend upon the number of iron atoms contained within. For example, the number of iron atoms contained within a 1 nm core is calculated to be 13. whiles 10 nm coreis calculated to contain 12770 iron atoms. Where agents share the same core chemistry, the rate of iron release per unit surface area Is likely similar, differing perhaps by the strength of th© carbohydrate ligand«core iron bound. But for the same total amount of core iron, surface area available for iron release Increases dramatically as core radius decreases, That is to say, for equal amounts of Iron, the smaller the core, the greater fee surface area available for iron * release. Of course, the explanation for this nonrtinear trend Is the fact that volume is radius cubed, in short, a collection of many small spheres exposes a greater total surface area than does a collection of an equal mass of fewer, largerspheres.

f o 0 Si 1 A smaller Iran core size of an iron complex administered for the treatment of various diseases, disorders, or conditions allows wider distribution through tissues, a greater rate of labile iron release, and Increased in vitro iron donation to transferrin. Furthermore, the iron complex is more evenly distributed and metabolizes faster due to the smaller core size. But if the core size Is too small, fee iron complex can move Into ceils unable to metabolize Iron, in one embodiment, an iron complex with a mean Iron core size pf no greater than about S hm is

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2016205002 18 Jul 2016 administered, in various embodiments, mean iron core size is less than about 9 nm but greater than about T orn , about 2 nm, about 3 nm, about4 nm, aboutS nm, about § nm, about 7 nm, or about 8 nm. Mean iron core size can be, for example, between about 1 nm and about 9 nm; between about 3 nm and about 7 nm; or between about 4 nm and about 5 nm, [ ο o s 2 3 The moiecuiar weight (/. e., the whole molecular weight of the agent) is considered a primary determinant in the pharmacokinetics, or in other words, how quickly if is cleared from the blood stmam, The amount of labile {/.e,, biologicaly available) iron is inversely correlated with the moiecuiar weight of the iron-carbohydrate complex. Van Wyck (2004) J. Am. Soc. Nephroiogy 15, S107-S111, S109, That is to say, the magnitude of iabiie iron effect is greatest in iron-carbohydrate compounds of lowest molecular weight and least In those of the highest molecular weight Generally, there is a direct relationship between the molecular weight of the agent and the mean diameter of the entire particle (to., the iron core along with the carbohydrate sheSi), in various embodiments, the mean diameter size of a particle of the iron carbohydrate complex is no greater than about 35 nm. For example, the particle mean size can be no greater than about 30 nm. As another example, the particle mean size can be no greater than about 25 ran, As another example, me particle mean size can be no greater than about 20 nm. As another example, the particle mean size can be no greater than about 15 nm. As a further example, the particle mean size can be no g reater than about 10 nm, As another example, the particle mean size can be no greater than about 7 nm.

[0083 3 Absence of Significant Adverse Reaction to Ute Single Dosage Unit Administration (00841 Generally, a safe and effective amount of an iron carbohydrate complex is, for example, that amount that would cause the desired therapeutic effect i n a patient while minimizing undesired side effects. The dosage regimen will be determined by skilled clinicians, based on factors such as the exact nature of the condition being treated, the seventy of the condition, the age and genera! physical condition of the patient, and so on. Generally, treatmentemergent adverse events wifi occur in less than about 5% of treated patients. For example, treatment-emergent adverse events will occur in less than 4% or 3% of treated patients. Preferably, treatment-emergent adverse events wili occur in less than about 2% of treated patients.

[008 5j For example, minimized undesirable side effects can include those related to hypersensitivity reactions, Sometimes classified as sudden onset closely related to the time of dosing, including hypotension, broncliospasm, layngospasm, angioedema or uticaria or several of these together, Rypersensitwfty reactions are reported with, all current intravenous Iron products Independent of dose. See generally Bailie at ai. (2005) Nephrol Dial Transplant, 20(7), 1443-1449, As another example, minimized undesirable side effects can include those minted to labile iron reactions, sometimes classified as nausea, vomiting, crampSj back pain, chest pain.

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2016205002 18 Jul 2016 and/or hypotension. Labile iron reactions are more common with iron sucrose, iron gluconate, and iron dextran when doses are large and given fast £ 0 OS 6 3 Pharmaceutical Formulations £00873 in many oases, a singie unit dose of iron carbohydrate complex may be delivered as a simple composition comprising the Iron complex and the buffer in which It is dissolved. However, other products may be added, if desired, for example, to maximize iron delivery, preservation, or to optimize a particular method of delivery, £008 s3 A “pharmaceuticaiiy acceptable carrier includes any and ail solvents, dispersion media, coatings, antibacterial and antHungat agents, isotonic and absorption delaying agents, and the like, compatible with pharmaceutical administration {see e.g.. Banker, Modern Pharmaceutics, Drugs and the Pharmaceutical Sciences, 4th ed. (2002) iSSN 0824706749: Remington The Science and Practice of Pharmacy, 21st ed. (2005) ISBN 0781746736), Preferred examples of such caoiers or diluents include, but are not limited to, water, saline, Finger’s solutions and dextrose solution. Supplementary active compounds can also be incorporated into the compositions. For intravenous administration, the iron carbohydrate complex is preferably diluted in normal saline to approximately 2-5 mg/ml. The volume of the pharmaceutical solution is based on the safe volume for the individual patient, as determined by a medical professional.

£ 0 0 8 9 3 An iron complex composition of the invention for administration is formulated to be compatible with the intended route of administration, such as intravenous Injection, Solutions and suspensions used for parenteral, intradermal or subcutaneous application can indude a sterile diluent, such as water for Injection, saline solution, polyethylene giycols, glycerine, propylene glycoi or other synthetic solvents: antibacterial agents such as benzyl alcohol or methyl parabens; antioxidants such as ascorbic acid or sodium bisulfite* buffers such as acetates, citrates or phosphates, and agents for the adjustment of tonicity such as sodium chloride rx* dextrose. The pH can be adjusted with acids or bases, such as hydrochloric acid or sodium hydroxide. Preparations can be enclosed in ampules, disposable syringes or multiple dose vials made of glass or plastic.

[00903 solutions or dispersions for the extemporaneous preparation of sterile Injectable solutions or dispersion. For intravenous administration, suitable earners include physiological saline, bacteriostatic water, Cramophor EL* (BASF; Pafsippany, NJ.) or phosphate buffered saline (PBS), The composition must ba sterile and should be fluid so as to be administered using a syringe. Such compositions should be stable during manufacture and storage and must be preserved against contamination from microorganisms, such as bacteria and fungi. The carrier can be a dispersion medium containing, for example, water, polyol (such as glycerol, propylene glycol, and liquid polyethylene glycol), and other compatible, suitable mixtures. Various

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2016205002 18 Jul 2016 antibacterial and anti-fungal agents, for example, parahens, chiorobotanoi, phenol, ascorbic acid, and thimerosal, can contain microorganism contamination, isotonic agents such as sugars, polyaicohois, such as manitoi, sorbitob and sodium chloride can be included in the composition. Compositions that can delay absorption include agents such as aluminum monostearate and gelatin.

fospi] Sterile injectable solutions can be prepared by incorporating an iron complex in the required amount in an appropriate solvent with a single or combination of Ingredients as required, followed by sterilization. Methods of preparation of sterile solids for the preparation of sterile injectabie solutions include vacuum drying and. freeze-drying to yteld a solid containing the iron complex and any other desired ingredient [00921 Active compounds may be prepared with carriers that protect the compound against rapid elimination from tee body, such as a controSied release formulation, including implants and microencapsulated delivery systems. Biodegradable or blocompatible polymers can be used, such as ethylene vinyl acetate, poiyanhydrides, poiygiycolic acid, collagen, poiyorthoesters, and poiyiactic acid. Such materials can be obtained commercially from ALZA Corporation {Mountain View, CA) and NOVA Pharmaeeuticate, inc. (Lake Elsinore, CA), or prepared by one of skill in the art.

[0093) A single unit dose of iron carbohydrate complex may be intravenously administered In a volume of pharmaceuticaiiy acceptable carrier of, for example, about WOO mg of elemental iron in about 200 mi to about 300 ml of diluent For example, a single unit dose of iron carbohydrate complex may be intravenously administered in a volume of phannaceuiicaiiy acceptebie carrier of about 1000 mg of elemental iron in about 280 mi of diluent As anothe r example, a single unit dose of iron carbohydrate complex may be intravenously administered in a volume of pharmaceuticaiiy acceptable carrier of about 1000 mg of elemental iron in about 215 mi of diluent (0094) A preferred pharmaceutical composition for use in tee methods described herein contains VlT-45 as tee active pharmaceutical ingredient (API) with about 28% weight to weight (m/m) of iron, equivalent to about 53% m/m iron {li!)-hydroxide, about 37% m/m of ligand, £6% m/m of NaCl, and £10% m/m of water.

(o ops) Kite for pharmaceutical compositions

I OOPS) Iron complex compositions can be included in a kit, container, pack or dispenser, together with instructions for administration according to tee meteods described herein. When the invention is supplied as a kit, the different components of the composition may be packaged in separate containers, such as ampules or vials, and admixed immediately before use. Such packaging of tee components separately may permit long-term storage without losing

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2016205002 18 Jul 2016 the activity of the components. Kits may also include reagents in separate containers that facilitate the execution of a specific test, such as diagnostic teste.

[ Q 09 7 3 The reagents included in kits can be supplied in containers of any sort such that the life of the different components are preserved and are not adsorbed or altered by the materials of the container, For example, sealed glass ampules or vials may contain lyophilized iron complex or buffer that have been packaged under a neutral non-reacting gas, such as nitrogen. Ampules may consist of any suitable material, such as giass, organic polymers, such as polycarbonate, polystyrene, ete., ceramic, metal or any other material typically employed to hold reagents. Other examples of suitable containers include bottles that are fabricated from

Ϊ0 similar substances as ampules, and envelopes that consist of foil-lifted interiors, such as aluminum or an alloy. Other containers include test tubes, vials, flasks, bottles, syringes, etc.. Containers may have a sterile access port, such as a hottie having a stopper that can be pierced by a hypodermic Injection needle. Other containers may have two compartments that ate separated by a readily removable membrane that, upon removal, permits the components to mix. Removable membranes may be glass, plastic, rubber, etc.

[ 00983 Kits may also be supplied with instructional materials. Instructions mey be printed on paper or other substrate, and/or may be supplied on an efectronio-readabie medium, such as a floppy disc, CD-ROM, DVD-ROM, mini-disc, SACD, Zip disc, videotape, audiotape, etc. Detailed instructions may not be physically associated with the kit; instead, a user may be directed to an internet web site specified by the manufacturer or distributor of the kit, or supplied as electronic mail.

(0099] Having described the invention in detail, it WHS be apparent that modifications, variations, and equivalent embodiments are possible without departing the scope of the invention defined in the appended claims, it should be understood that all references cited are incorporated herein by reference.

Furthermore, it should be appreciated that a!i exempfes in the present disclosure are provided as non-limiting examples.

EXAMPLES [o 100] Thd following nen-ikniting examples are provided to further illustrate the present invention, it should be appreciated by those of skill in the art that tee techniques disclosed in the examples that follow represent approaches the inventors have found function wail in tee practice of the invention, and thus can bo considered to constitute examples of modes for its practice, However, those of skill in tee art should, in tight of the present disclosure, appreciate that many changes can be made in the specific embodiments teat are disclosed and still obtain a like or similar result without departing from tee spirit and scope of the Invention,

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2016205002 18 Jul 2016

Example t; Non-Toxicity Studies (0101 } Nonciinicai toxicity of VIT-45 is very tow, as is norma! for Type ί polynuclear

Iron {lli>bydroxide carbohydrate complexes, The single dose toxicity is so tow that the LD·» could not be estimated and is higher than 2000 mg iron/kg tow. Mice tested with a stogie dose of 250 mg iron/kg tow., injected within 2 seconds, showed no signs of illness. The highest noniethal dose level of 1000 mg iron/kg b.w. in mice and rats is aiso very high in comparison to a single unit dose of, for example, 15 mg iron/kg tow, once per week in humans. These results provide factors of about 70-fold a human dose, demonstrating a large safety margin for acute toxicity of the product ^f

Example 2: Pharmoklnetic Studies £0102 ] Pharmacokinetic and red blood ceil measurements of ®^sFe/^s®Fe iabelted VIT45 following iv, administration using PET in 6 patients showed a red blood cell utilization from 61 to 99%. The 3 patients with iron deficiency anemia showed a utitizatton of radteiabeilad iron of 91 to 09% after 24 days, compared to 61 to 84% for 3 patients with renal anaemia. The terminal ti« forVIT-45 was calculated to be approximately 16 hours, compared to about 6 hours for Iron sucrose. In two further studies in patients with iron deficiency anemia, pharmacokinetic analyses revealed increases in exposure roughly proportional with VIT-45 dose (Cmax approximately 150 pg/mt and 320 pg/mL following 500 mg and 1000 mg doses, respectively). VIT-45 demonstrated a monoexponential elimination pattern with a in the range 7 to 18hours, There was negiigibie renai elimination.

Example 3: Efficacy Studies £0103} The main pharmacodynamic effects of VIT-45 we re transient elevations of serum iron levels, TfS and serum ferritin. These effects were seen to all studies (where measured), following both stogie doses end repeated doses. The increase in serum ferritin levels Illustrated the replenishment of the depleted iron stores, which is a well-identified and desired effect of toon therapy. In addition, transiently elevated TfS indicated that iron binding capacity was aimost fully utilized following VIT-45 infusion.

£0104} Efficacy of iron replacement therapy is interpreted malniy to teens of the abi lity to normalise Hb levels and iron stores. In toe multiple dose studies, patients demonstrated a siowiy-developtng, sustained increase in Hb levels during stody participation. In one study, 37% and 48% of patients to Cohorts 1 and 2, respectively, had achieved normal Hb ievels et the 4week follow-up visit, and 75% and 73%, respectively, had achieved a £20 g/L increase in Hb on ai least 1 occasion.

£ 0105 J In another study (patients receiving regular haemodialysis), the majority of patients (61,7%) achieved an increase of Hb of £10 g/L at any point during toe study. Serum ferritin and TfS levels showed a more prolonged elevation following repeated VIT-45 infusions,

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IS indicating a sustained replenishment of iron s tores. Hbwever, elevated levels of ferritin and TfS indicating iron overload were avoided, to both of these studies, there was a gradual decrease in transferrin over time, also Indicating successful Iron replacement,

Example 4: Safety Assessments [010 6) Safety assessments were made in 73 patients with iron deficiency anemia (27 singie-dose, 46 repeated-dose), and 166 patients with renal anaemia (3 single-dose, 163 repeated-dose) who received VIT-45 at Individual iron doses of 100 mg up to 1060 mg (cumulative doses of 100 to 2200 mg). These studies showed a safety profile equal to, or exceeding, currently available parenteral iron formulations.

(0107 ] In the single-dose studies, there were few adverse events and no seripus adverse events or withdrawals due to adverse events. There were also no related clinically relevant adverse changes in vital signs, 12~!ead EGGs or laboratory safety tests, [0X083 In the repeated-dose studies, there were no deaths attributed to VIT-45, while 10 patients experienced serious adverse events. All of these cases occurred In patients with renal anaemia receiving haemodialysis and were considered not related to the ViT-45 treatment. Very few patients were withdrawn from toe studies due to treatment-emergent adverse events, · and only 2 withdrawals (due to allergic skin reactions) were considered possibly related to treatment, in each of the repeated-dose studies, no patients experienced cilnieaiiy significant changes in 12-ieed ECGs that were related to treatment There were no consistent changes in laboratory safety parameters , although there was a low incidence (total 6 patients) of laboratory values reported as treatment-related treatment-emergent adverse events (elevated CRP, AST, ALT and GGT, abnormal liver function tests and elevated WBC), (oxo s i Although many patients In these 2 studies had serum ferritin above SCO pg-'L on at least1 occasion during the study, very few patients also had TfS values >50%. Generaiiy, the elevations of ferritin and TfS were of short duration, iron overload was avoided using the dosing schedules defined in the studies.

Example 5: integrated Safe ty Studies [o xx o) The following example demonstrates the safety and effectiveness of parenteral ViT-45 in the treatment of anemia In a variety of patient populations, as determined from several integrated safety studies.

(0 ll 1 ] A total of 2429 subjects were treated With V IT-45 or confrai agents oyer 10 studies teat provide safely data for VIT-45. Of these, 1709 subjects received ViT-45 (1995 in completed muitieenterstudies, 584 in piaeeho-controited, single-dose, crossover studies and 30 In pharmacokinetic studies). The mean total dose of VIT-45 administered among the 1095 subjects in the completed muiticenter studies was apprextmately 1300 mg; however, some

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2016205002 18 Jul 2016 subjects received ViT-45 doses as high as 3400 mg. The majority of the subjects treated were able to receive their calculated iron requirement in only 1 or 2 doses.

[03. x 23 Table 2 provides a summary of VIT-45 studies described In this example.

[c ix3j Study A was a single-center, single-dose escalation, randomized, doubleblind, placebo-controlled pharmacokinetic study. Subjects were male and female, between 18 and 45 years of age, Inclusive, with mild iren-deflcienoy anemia, Treatment was a slngie IV boius Injection of VIT-45 at 100 mg, 500 mg, 800 mg, or 1000 mg. Examined pharmacokinetic parameters included fetal serum iron and pharmacodynamic (serum ferritin and transferrin, iron binding capacity, %TSATpost, hemogiobin, reticulocyte, and serum transferrin receptor ccncehtrafions) endpoints. Examined safety parameters included adverse events, clinical laboratory evaluations, Vital signs, EGG, and physical examinations.

[0114] Study S was a single-center, single-dose, open label, uncontrolled pharmacokinetic study. Subjects were between IS and 75 years of age wife iron-deficiency or renal anemia wife no other cause of anaemia, inclusion criteria included hemoglobin concentration between 3 and 13 g/dt, no blood transfusions in the previous 3 months, and no history of treatment with intravenous iron In the last 2 weeks. Treatment was a single IV bolus injection of VIT-45 at 100 mg labelled With ^saFe and ^s®Fe. Examined primary pharmacokinetic parameters included fee distribution of ^S2Fe and incorporation of ^saFe into red biood cells, Examined safety parameters Included adverse events, clinicaS laboratory evaluations, vital signs, andphysieal examinations.

[ 0 2153 Study G was an open-label, muiticenter, randomized, multiple-dose, activecontrolled postpartum anemia study. Subjects were female, postpartum within 10 days after delivery, with hemoglobin <10 g/dL at Baseline based on the average of 2 hemogiobin values drawn Sd S hours postpartum. Treatment was once weekly doses of ViT-45 for six weeks. VIT45 dosage was based on the calculated iron deficit {^2500 mg total). Where screening serum transferrin saturation (T5AT) was s20% or screening ferritin was <50 ng/mL, dosage ~ prepregnancy weight (kg) x (15-baseSine hemoglobin (g/dLl) x 2.4 * 500 mg. Where screening TSAT was >28% and screening ferritin was >50 ng/mL, dosage « pre-pregnancy weight (kg) x (15-baseline hemoglobin (g/dLj) x 2.4. infusion of ViT-45 was as follows: <200 mg, administered as an undiluted intravenous push (IVP) over 1-2 minutes; 300-400 mg, administered in 100 co normal saline solution (HSS) over 6 minutes; 500-1,000 mg administered in 250 co NSS over 1S minutes, For primary efficacy, “success” was defined as an increase in hemoglobin of >2 g/dL anytime between baseline and end of study or time of intervention, white “failure® was defined as <2 g/dL increase in hemoglobin at all limes between baseline and end of study or time of intervention. Examined safety parameters included adverse events, clinical laboratory evaluations, vital signs, and physical examinations.

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ΙΟ [02163 Study D was a multicenter, open-label, randomized, active-controlled, muifipledose postpartum anemia study. Subjects were adult women a18 years old with postpartum anaemia within 6 days after delivery. Treatment was administered once-weekly for a maximum of: 3 infusions. Patients received iV infusions of 16,7 ml/min to deliver a maximum dose of 1000 mg Iron per infusion, Patients received VIT-45 infusions once weekly for up to 3 occasions unfit the calculated cumulative dose was reached. Patients <63 kg received a minimum dose of 2.00 mg and a maximum dose of 15 rog sron/kg during each infusion. Patients >86 kg received a dose of 1000 mg on the first dosing occasion, and a minimum dose of 200 mg and a maximum dose of 1000 mg sf each subsequent dosing, Poses of 200-400 mg were diluted in 100 cc MSS and 500-1000 mg were diluted in 250 cc NSS. Primary efficacy was examined as change from baseline levels of hemoglobin to Week 12. Examined safety parameters included adverse events in the mother and breast-fed infant, adverse events leading to discontinuation of treatment, vital signs, 12-tead electrocardiogram (EC©\ physical examinations, and clinical laboratory panels.

[01273 Study £ was a mulficenter, open-label, randomised, active-controlled, multipledose hemodialysis-associated anemia study. Subjects were adult ma te or female subjects between the ages of 18 and 80 years (Inciusivey requiring haemodialysis with iron deficiency secondary to chronic renal failure. Dosing started on Day 1, Week 0 for both treatment arms and continued 2 or 3 times weekly unfit the individual calculated cumulative dose was reached. Patients received 200 mg VIT-45 during their scheduled haemodialysis sessions (2-3 sessions/week) until the calculated cumulative dose was reached. Cumulative total iron requirement was calculated for each patient using the Ganaoni formula, Primary Efficacy was examined as the percentage of patients reach ing an increase in hemoglobin z10 g/L at 4 weeks after baseline. Examined safety parameters included adverse events, vital signs, 12-!ead EGG, physical examinations, and clinical laboratory evaluations.

[ OHS 3 Study F was a muitfcenter, open-label, mufti pie dose, unconiroited hemodialysis-associated anemia study . Subjects were male and female patients 16-65 years of age, inclusive, with haemodialysis-associated anaemia undergoing maintenance haemodialysis. Treatment duration was a maximum of six weeks. Patients received 200 mg VIT-45 during their scheduled haemodialysis sessions (2-3 sessions/week) until the calculated cumulative doss was reached . Cumulative total iron requirement was calculated for each patient using the Ganzonl formula. Efftclcacy was examined as correction of iron deficiency and hemoglobin concentration of the patient Examined safety parameters included adverse events, vital Signs, 12-iead ECG, physical examinations, haematology and blood chemistry profiles, and urea reduction ratio, [ 02ip) Study G was a multteenter, multiple-dose open-label, uncontrolled gastrointestinal disorder-associated anemia study, Subjects were mafes and females between 18 and 60 years of age, inclusive, wife moderate stable iron-deficiency anemia secondary to a

-255 <N

Ή gastrointestinal disorder and a cateuiated total iron requirement &1000 mg; >50% of patients in each cohort were to require >1 500 mg totai Iron. Duration of treatment was single doses at weekly intervals for up to 4 weeks (Cohort 1) or 2 weeks (Cohort 2), Administration of VIT-45 was by IV bolus injection of 500 mg (Cohortd) or 1000 mg (Cohort 2), where total iron requirement for each patient, which determined how many weekly infusions were received, was cafcoiated using the formate of Ganzoni. Examined pharmacokinetic parameters included total serum iron and pharmacodynamic (hemogiobin, ferritin, TSAT) endpoints. Examined safety parameter included adverse events, citelcai laboratory evaluations, vital signs, EC’S, physical examinations, and elevated serum ferritin {>500 pg/L) AND elevated TSAT (>45%).

(0120] Study H was a mufticenter, muitipie-dossrandomized, open-iabei, active-controlled gastrointestinal disorder-associated anemia study. Subjects were males and femaies aged 18 to 80 years, inclusive, with iron-deficiency anaemia secondary to chronic inflammatory bowei disease (ulcerative coiiiis or Crohn’s disease) and a calculated total Iron requirement of at least 1000 mg total iron. Treatment was weekly ViT-45 infusions, with a maximum of 3 infusions permitted in a single treatment cycle, Administration consisted of an infusion on Day 1, with subsequent infusions at weekly intervals up to a maximum of 1000 mg iron per dose. The doses were continued until the patient received the cumulative dose based on their Individual requirement for iron. Primary efficacy was examined as change from baseline to Week 12 in hemogiobin. Examined safety parameters included adverse events, vital signs, 12-iead EGG, physical examinations, and clinical laboratory evaluations.

[o i 2 χ) Study 1 was an open label, multiple-dose, multicenter, randomized, activecontrol anemia due to heavy uterine bleeding study, Subjects were femaies at ieast 18 years of age with iron-deficiency anemia secondary to heavy uterine bleeding. Duration of treatment was six weeks. VST-45 dosage was based on the calculated iron deficit as follows: Where baseline TSAT ^20% or baseline ferritin <50 ng/mt, VITAS total dose in rog - baseline weight (kg) x (15baseline hemogiobin [g/dLft x 2,4 * 500; where baseline TSAT >20% and baseline ferritin >50 ng/mt, ViT~45 total dose in mg ~ baseline weight (kg) x (15~baseSto© hemoglobin (g/dLj) x 2.4, For administration, ^200 mg was administered as an undiluted IVP over 1-2 minutes;

300-400 mg was administered in 100 cc NSS over 6 minutes; and 500-1,000 mg was administered in 250 cc NSS over 15 minutes, Primary efficacy was examined as the proportion of subjects achieving success, defined as an increase in hemogiobin of >2.0 g/dt anytime between baseline and end of study or time of intervention. Examined safety parameters included adverse ©vents, ciinicai laboratory evaluations, vital signs, and physical examinations.

[01223 Study 3 was a multicenter, stogie-dose bitoded, randomized, placebocontrolled crossover iron deficiency anemia study. Subjects were male or femaSe, at least 18 years of age, with a hemogiobin <s12 g/dt, TSAT £25%, and ferritin <30Q ng/mt (irondeficiency anemia due to dialysis or non-diaiysls dependent chronic kidney disease or • 2«5

2016205002 18 Jul 2016

Inflammatory bowel disease), or ferritin <400 ng/mt (iron-deficiency anemia due to other conditions), Trsatment was two single doses seven days apart Administration of VST-4S occurred over 15 minutes and was <1000 mg (15 mg/kg for weight <88 kg). For pharmacokinetic variables, total serum iron was assessed using Atomic Absorption methodology. Examined safety parameters included adverse events, ciinicsi laboratory evaluations* vital signs, and physical examinations,

TABLE 2: Summary of Safety Studies of VIT-45

Study Nuraber	Subject*	Intravenous Ewiejs}efViT-4S	CW8(W»W
Pliatmacohirieitc Stud fcs
A	To»!;» νΠΜ3;ϊ4	Single doses o f; SCO mg via {jcdiis injection SCO mg, 800 ret®, iii® jpg diluted in 350 mt. ef USS administered by fVftfitffaattteisthmuses	Placebo
8	Tew!; d ViT-45:6	SingSc dose of S 00 mg labelled with to'c and toe administered as an iV ipjectinh ever 10 minutes	hfooe

Studies in Subjects with Postpartum Anemia

C		Tot#fc3S2 VlT-4St Ϊ74	CsisiiitiaStveSWat iron requiremersi was ealcuhsted for each patient, Patients received JV mfttsfens w deliver a maximum dose nf !OU0 mg iron per m&afait, PattenM received ViT-45 i«h«do«s enee weekly w>;i 1 the caicttiared eunmfetkre dose was reached sre a tttaximutn «03500 mg had been udadnisterod. Duses $300 mg were abaniststeted (Vpusit ever )-2 minutes; ttescs of 300-400 mg ware diluted in J 00 ee NSSajidadtninisietdd «Vet 6 minutes; doses of StXS -fOOO mg were diluted in 230 co NS3 and administered ovc; IS miswtes.	Oral iwh {ferrous suShtte} »5 mg TiD for ft wacks
D		T«iak344 vrr-45;22?	Curmifative totai iroft roqtaeement was cniatjared for etreh patient «stag the Oartxuht formuls.	Oral iron (ferrous stdfete) )00»!s 8£O for! 2 Weeks

Ssudtss in Subjects Uiidefgatng Hemai&tySis

£	Taetfesdr vrMst ns	Patients received 208mg IV teftts ittjeitttitt of stu^t drag during their seheduted herobdralyiis sessions (2-5 sesnonaAueeh) «mil theeaituiared cumulative dose was reached, CtitmtiBisye total iron rerjitiretf'erit was calctOaied (breach pafier» usirtg thc’Canroni lormois.	VtinoiKt'·'; jifttieiits received 300 mg SV Injection ever 18 rrtiniiics df study drug during their seheduied hentadisiysia sessions: {2,3 sessions/wdefe) trad! ite caieulausS eutnuisttivT dose was reached. Cunwistivc lota! trett requirement was cak'.itated &r each patient using the Omreoni fownuiaA
F	Total; JdJ ViT-45; 102	Patients received 20i> mg !V push ofstutly drug during then- scheduled hettssdialyttis sessions:(23 5CSsiat!S.'-Afet!} until the cs.l0ifis.ed cumulative dose was reached. Cumulative iotai tosh retjoitetnestt was esietthsted fcr each patient using theGahaow ibwiuia.	None

-27 2016205002 18 Jul 2016

Studies tb Subjseis with Gastfottiresiittai pbooft»»
G	VIT-45; 46	SS© mg or S COO rog Iren by. IV fcfwsio» »i weekly fewvafe f«r »p io 4 weeks ¢588 trtg) or 3 weeks (i088 η'.% waxwvum total dose of 2803 atg. The fast doss could have bees less, ddpeiwSmg sm the sa!eul3t«3 tetsi irott reejirfremebt, Poses wettt dibited m 258 se NS$ end administered by JV infusion over !5 minutes.	Nolte
H	Total: 20» VfMS; 137	CtwMjSttbve fetal irott requirementwas csisuiated Cor each pattens using tbs Gattzotti fe,t;ttt;ia.	Cm! trod {fetracs sulfate} 180 tag S© for 12 weeks
Study in Subjects with ffeavy Uterine Slcedtitg
ί	to»!: 456 ViT-45:238	SS S300 aigrweek (15 mg/kg for Weight 566 kgX patients received VST-4S fnfusjcme once weekly until the ealcuiatcd ctsmufai ive dose was renebed Or a liiaxiinum of 2580 mg hod been administered. Doses S28t>mg tvere administered IV push over l2 tntrttites; doses of300-480 tug were dilated io !00 cc NSS 3nd pdfriiotslsred over 6 minutes; doses of 580- i800 mg were diluted in 7.50 ec NSS and administered over ! 5 minutes.	Orel iron {ferrous sulfate) 325 mg TiO ft»· 6 .weeks
Study tnSa^ecls with iron Oeifciency Attends
ί	Teal: 594 Vrr-45: 584	Single dose of 61000 ngOy iV infusion over 15 minute; (15' tttg/ks for weight 566 kg). Doses 6500 rag were diluted in 100 e»t NSS and doses of >500-1008 mg were diluted in ?.5i)ee >VSS.	f’Saeeho
		Pbarrmeoktnottc StrbiCeis: single 1 >000 trig dose by IV irtftiStort

(0X23 3 The majority of the subjects who received VST-45 completed the study. The incidence of premature discontinuations in the compioted muHicenter studies was 10% in the ViT-45 group which is comparable to that observed in the oral ton (9,6%) and Venofer (13.6%) groups. Reasons for prematura discontinuation ware generaliy comparable among the treatment groups, except that the incidence of adverse events feeding to discontinuation were higher in the Venofer group (5.9%) compared to the VIT-45 (1.8%) and oral iron (2,1%) groups, demonstrating the overali toierabiifty of VIT-45, [0X24} The overall incidences of treatment-emergent adverse events were comparabie between the VIT-45 (49,5%) end oral iron (51.2%) groups in the completed muiticenter studies; the incidence in the Venofer group was lower (39.0%); however, the number of subjects in the VIT-45 group Is almost 1Q-feld that of the Venofer group. Treatment-emergent adverse events experienced by >2% of the 1095 ViT-45 subjects included headache (8.6%), abdominal pain (2.5%), nausea (2.4%). blood phosphate decreased (2.4%), hypertension (2.2%), nasopharyngitis (2.0%), and hypotension (2.0%). As expected, the most notable difference between subjects treated with ViT-45 and those treated with oral ton was for the incidence of gastrointestinal events (31,0% vs. 12,8%), specificaiiy the incldences of constipation, diarrhea, nausea, and vomiting, which were more than double that observed in the ViT-45 group, (ο 125) in the calculated dose/first-dose 1,000 mg studies, no statistically significant difference was observed between the VST-45 (49,5%) and oral iron (51.2%) groups for the overall incidence of treatment-emergent adverse events , The incidence of gastrointestinal disorders

-2S5

2016205002 18 Jul 2016 was statistically significantly <p<0,a0Qt j higher in the oral iron group (31 .0%) compared to the VST-45 group (15,2%), whiie theincidences of adverse events associated with investigations and skin and subcutaneous tissue disorders were statisficaiiy significantly higher in the ViT-45 group (9,1% and 7,3%, respectively) compared to fee oral iron group (3.9% and 2.4%, respectively). Among the gastrointestinal disorders, greater proportions of subjects in the oral iron group than fee ViT-45 group experienced constipation, nausea, diarrhoea, and vomiting, white a greater proportion of ViT-45 subjects experienced abdominal pain than oral iron subjects. Among the adverse events associated with investigations, greater proportions of VIT-45 subjects experienced blood phosphate decreased and GOT increased than oral iron subjects. Among the adverse events associated wife skin and subcutaneous tissue disorders, greater proportions of ViT-45 subjects experienced rash and pruritus than oral iron subjects, [0126) The oniy drug-related treatment-emergent adverse events reported by at leas t 2% of VIT-45 subjects in the caiculated dose/nrst-dosa 1,000 mg studies were headache (3.9%) and blood phosphate decreased <3,3%), The Incidence of treatment-emergent adverse events reported on the first day of dosing in the caiculated dose/first-dose 1,000 mg studies was statistically significant higher in the VIT-45 group compared to the oral iron group (6.6% vs, 2,7%).- On fee first day of dosing, the VIT-45 group had sfatlsticaiiy significantly greater proportions of subjects who experienced general disorders and administration site conditions, primarily events associated with the site of study drug infusion, and skin and subcutaneous tissue disorders, primarily rash and urticaria, compared to the oral Iron group.

[0X273 The overall incidence of treatment-emergent adverse events was similar among VIT-45 subjects treated with either fee 200 mg or 1000 mg doses, The oniy notable difference was for the higher incidence of headache in fee 1000-mg group, which was almost doubie that observed for fee 200-mg group. No meaningful trends were apparent with respect to the incidence of treatment-emergent adverse events when analyzed by gender, age, race, weight, or etiology of anemia.

[ 012 S J Thera were no deaths in fee study attributed to VIT-45. The incidence of other serious adverse events among ViT-45 subjects waslow (3% In ali completed muitieenter studies and 0,3% in fee placebo-controiied, single-dose crossover study) and none were considered related to study drug. The incidence of premature discontinuation due to adverse events was comparable between the VIT-45 group (2.1%) and the other active treatment groups (3.1% oral Iron and 2,5% Venofer). The incidence of drug-related treatment-emergent adverse events of hypersensitivity was 0.2%, fee sameas that observed with oral Iron (0.2%). Drug-related mild or modera te hypotension was observed In 4 (0,2% ) VIT-45 subjects, none of which were considered serious, ted to premature discontinuation, or were symptomatic. Treatment-emergent adverse events Indicative of potential allergic reactions including rash, pruritus, and urticaria

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2016205002 18Jul2016 were reported by <2% of subjects who were treated wife ViT~4S; none of these events was considered serious and few ted to premature discontinuation.

(01291 Laboratory evaluations of mean changes from baseline and potentially clinically significant values demonstrated no cilnicaijy meaningful changes for the majority of the parameters evaluated. However, during fee conduct of the latter portion of the clinical program, transient, asymptomatic decreases in blood phosphate levels were observed among subjects treated with VIT-4S. The decreases were apparent approximately 7 days after fee initial dose of VIT-45 and fee median time to recovery was approximately 2 weeks. No subjects reported; an adverse event feat was related to serum phosphate and no subject discontinued from the study due to decreased serum phosphate. The only predictor of change In serum phosphate was feat subjects with higher baseline serum phosphate values had larger decreases in serum phosphate. The fact that fee majority of oral iron-treated subjects also had a post-baseline decrease in phosphate and the negative correlation of baseline serum phosphate with changes in serum phosphate for both the V1T-4S and oral iron treatment groups suggest that fee mechanism is intrinsic to iron therapy in this severely anemic population.

( 013 01 Overall, no clinfcaiiy meaningful changes in vitals signs evaluations were associated wife VfT-45 administration.

(o 13 χ ] Safety data from more than 1700 subjects demonstrate fee safety and tolerability of VIT-45, (01 32] A reference herein to a patent document .or other matter which is given as prior art is not taken as an admission that, that document or prior art was part of common general ; knowledge at the priority date of any of the claims.

i [0133] With reference ίο the use of fee wordfs) “comprise” or '‘comprises or comprising” in the foregoing description .and/or in the following claims, unless the -context, requires otherwise, those words are used on fee basis and clear understanding that they ate to he interpreted inclusively, rather than exclusively, and that .each of those words is to he so interpreted in construing the foregoing description and/or the following claims.

Claims (2)

1. The claims defining the invention are as follows:

   2016205002 10 Jan 2018

   1. A method of treating a disease, disorder, or condition characterized by iron deficiency or dysfunctional iron metabolism resulting in reduced bioavailability of

   5 dietary iron, comprising:

   administering to a subject in need thereof an iron carbohydrate complex in a single dosage unit of at least 0.7 grams of elemental iron;

   wherein:

   the iron carbohydrate complex is an iron polyisomaltose complex;

   10 the iron carbohydrate complex has a substantially non-immunogenic carbohydrate component; and the subject does not experience a significant adverse reaction to the single dosage unit administration.

   15 2. A method of claim 1, wherein the iron carbohydrate complex has substantially no cross reactivity with anti-dextran antibodies.

   3. The method of claim 1 or claim 2, wherein the iron carbohydrate complex has a pH from about 5.0 to about 7.0.

   4. The method of any one of claims 1 to 3, wherein the iron carbohydrate complex has physiological osmolarity.

   5. The method of any one of claims 1 to 4, wherein the disease, disorder, or condition

   25 comprises anemia.

   6. The method of claim 5, wherein the anemia comprises iron deficiency anemia.

   7. The method of claim 5, wherein:

   30 (i) the anemia comprises an iron deficiency anemia associated with chronic blood loss; anemia associated with acute blood loss; anemia associated with pregnancy; anemia associated with childbirth; anemia associated with childhood development; anemia associated with psychomotor and cognitive development in children; anemia associated with breath holding spells; anemia associated

   35 with heavy uterine bleeding; anemia associated with menstruation; anemia associated with chronic recurrent hemoptysis; anemia associated with idiopathic pulmonary siderosis; anemia associated with chronic internal bleeding; anemia associated with gastrointestinal bleeding; parasitic infections; anemia

   -31 2016205002 10 Jan 2018 associated with chronic kidney disease; anemia associated with dialysis;

   anemia associated with surgery or acute trauma; anemia associated with chronic ingestion of alcohol; anemia associated with chronic ingestion of salicylates; anemia associated with chronic ingestion of steroids; anemia

   5 associated with chronic ingestion of non-steroidal anti-inflammatory-agents, or anemia associated with chronic ingestion of erythropoiesis stimulating agents;

   (ii) the anemia associated with a chronic disease selected from the group consisting of anemia associated with rheumatoid arthritis; cancer; anemia associated with Hodgkins leukemia; anemia associated with non-Hodgkins

   10 leukemia; anemia associated with cancer chemotherapy; anemia associated with inflammatory bowel disease; anemia associated with ulcerative colitis thyroiditis; anemia associated with hepatitis; anemia associated with systemic lupus erythematosus; anemia associated with polymyalgia rheumatica; anemia associated with scleroderma; anemia associated with mixed connective tissue

   15 disease; anemia associated with Sojgren's syndrome; anemia associated with congestive heart failure/cardiomyopathy; and idiopathic geriatric anemia;

   (iii) anemia associated with impaired iron absorption or poor nutrition;

   (iv) anemia associated with Crohn's Disease; anemia associated with gastric surgery; anemia associated with ingestion of drug products that inhibit iron

   20 absorption; or anemia associated with chronic use of calcium.

   8. The method of any one of claims 1 to 6, wherein the disease, disorder, or condition is selected from the group consisting of anemia associated with restless leg syndrome; anemia associated with blood donation; Parkinson's disease; anemia

   25 associated with hair loss; and anemia associated with attention deficit disorder.

   9. The method of any one of claims 1 to 6, wherein the disease, disorder, or condition is anemia associated with congestive heart failure/cardiomyopathy.

   30 10. The method of any one of claims 1 to 8, wherein the single dosage unit of elemental iron is at least about 1.0 grams.

   11. The method of any one of claims 1 to 8, wherein the single dosage unit of elemental iron is at least about 1.5 grams.

   12. The method of any one of claims 1 to 8, wherein the single dosage unit of elemental iron is at least about 2.0 grams.

   -322016205002 10 Jan 2018

   13. The method of any one of claims 1 to 12, wherein the single dosage unit of elemental iron is administered in about 15 minutes or less.

   14. The method of any one of claims 1 to 12, wherein the single dosage unit of

   5 elemental iron is administered in about 5 minutes or less.

   15. The method of any one of claims 1 to 14, wherein:

   the mean iron core size is at least about 1 nm but no greater than about 9 nm; or the mean size of a particle of the iron carbohydrate complex is no greater than

   10 about 35 nm.

   16. The method of any one of claims 1 to 15, wherein the iron carbohydrate complex is administered parenterally.

   15 17. The method of claim 16, wherein:

   (i) parental administration comprises intravenous infusion and the single unit dose of iron carbohydrate complex is administered at a concentration of about 1000 mg elemental iron in about 200 ml to about 300 ml of diluent;

   (ii) parenteral administration comprises bolus injection and the single unit dose of

   20 iron carbohydrate complex is administered at a concentration of about 1000 mg elemental iron in about 200 ml to about 300 ml of diluent; or (iii) parenteral administration comprises intramuscular injection and the single unit dose of iron carbohydrate complex is administered at a concentration of about 500 mg elemental iron in less than about 10 ml diluent.

   18. The method of any one of claims 1 to 17, further comprising a second administration of said iron carbohydrate complex upon recurrence of at least one symptom of the disease, disorder, or condition.

   30 19. The method of any one of claims 1 to 18, wherein the single unit dosage is at least about 0.6 grams up to about 2.0 g of elemental iron.

   20. The method of any one of claims 1 to 18, wherein the single unit dosage is at least about 0.8 grams up to about 2.0 g of elemental iron.

   21. The method of any one of claims 1 to 18, wherein the single unit dosage is at least about 1.0 grams up to about 2.0 g of elemental iron.

   -33 1/2

   2016205002 18 Jul2016

   FIGURE t

   FIG. 1A

   FIG. 18

   FIG. 1C

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2. 2/2