CA2329762A1 - Pharmaceutical imidazole combination for locally treating vulvovaginitis and vaginosis - Google Patents

Abstract

The invention concerns a pharmaceutical composition comprising a combination of at least two imidazole derivatives having reinforcing synergy against germs which cause infectious vulvovaginitis and vaginosis and selected from the group comprising metronidazole, econazole, miconazole, clotrimazole, terconazole, bifonazole, cloconazole, isoconazole, oxiconazole, sulconazole, tioconazole and their salts, preferably metronidazole combined with econazole. The composition is advantageously in galenic form of a hard or soft capsule having an solid hard or soft outer envelope containing gelatine, enclosing an internal non-aqueous lipophilic liquid or semi-liquid phase wherein the imidazole derivatives are suspended in a lipophilic agent, a water-dispersible agent and a bioadhesive agent.

Description

WO 99/55333 1 PCT / FR99 / Oi1973 Pharmaceutical association of imidazoles for treatment local infectious vulvovaginitis and vaginosis The present invention relates to a pharmaceutical composition for the empirical treatment of infectious vulvovaginitis and vaginosis.
These infections result in the presence of protozoa such as Trichomonas uaginalis, yeasts such as Candida albicc ~ ns and non aclbicans (notably Candida tropicales and Cccndida glabrata), as well as anaerobic bacteria such as fragile Bacteroides and Gardnerella vacginalis (in the case of vaginosis, which are vagini-your anaerobic germs).
The empirical treatment of these conditions is to prescribe im-mediately a pharmaceutical composition on the sole basis of clinical examination, without waiting for the results of a bacteriological analysis laboratory gic which would allow to determine with precision the or the germs involved in the condition studied.
The prescribed pharmaceutical compositions include a active ingredient alone or a combination of several active ingredients taking into account the diversity of the germs responsible for these affections.
Most often, this combination combines a broad antifungal spectrum such as nystatin to one or more antibiotics such as the polymyxin or neomycin.
This association is not without its drawbacks, especially because of the antibiotics used. So neomycin is for example contraindicated in pregnant women. On the other hand, badly-Thanks to the wide spectrum of (association, we often observe cases of recurrence dive.
We know specialties whose active ingredient is a derivative imi-dazole such as econazole nitrate, known for its antifun-Gram + antibacterial and gic with a spectrum comparable to that nystatin, or metronidazole, known for its properties ante-trichomonasides.
It has also been proposed (WO-A-97/44032) to combine two definitions imidazole rives such as metronidazole and miconazole in order to add WO 99/55333 PC'T / FR99 / 00973

2 titer their respective spectra and thus improve the general efficiency.
of treatment. This particular association, however, presents the agrees to cause significant irritation to the patient which is added to that resulting from the affection itself. So that this com-position can be tolerated, it is necessary to include anesthesia only local such as lidocaine or benzocaine, substances which are not not without drawbacks. In addition, it is necessary to provide a particular galenic which allows a continuous release but slow anesthetic in order to adapt its duration of action to that of the two other active ingredients.
One of the aims of the invention is to propose a pharmaceutical composition.
maceutical adapted to the local empirical treatment of vulvovaginitis infectious and vaginosis, which are more effective than associations already proposed and devoid of the drawbacks of these ners (this is a treatment for simple, uncomplicated conditions, local, requiring only purely local treatment).
Essentially, the composition of the invention comprises a com-pairing of at least two imidazole derivatives exhibiting synergy reinforcing (potentiation) against germs responsible for infectious vulvovaginitis and vaginosis and selected from the group com taking metronidazole, econazole, miconazole, c1ofrimazo1e, terconazole, bifonazole, cloconazole, isoconazole, oxiconazole, sulconazole, tioconazole and their salts, preferably the group including metronidazole, econazole, miconazole, clotrimazo-le, terconazole and their salts, and with the exception of metronidazole combi-born with miconazole, tioconazole or c1ofrimazo1e.
In a preferred combination, one of the imidazole derivatives is metronidazole and the other is selected from the group consisting of eco-friendly nazole, c1ofrimazo1e, terconazole, bifonazole, cloconazole, iso-conazole, oxiconazole, sulconazole and their salts, preferably the group comprising econazole, c1ofrimazo1e, terconazole and their salts, very preferably econazole and its salts.
Very advantageously, the composition comprises metronidazole and econazole nitrate at a total daily dose of 250 to 1050 mg, the metronidazole / econazole nitrate dose ratio possibly WO 99/5533

3 PCT / FR99 / 00973 be between 2: 1 and 5: 1, preferably between 3: 1 and 4: 1, very preferably between 3: 1 and 3.5: 1.
From the galenic point of view, imidazole derivatives are pre ference suspended in a lipophilic phase comprising as ex containers a lipophilic agent, a water-dispersible agent and a bio-agent adhesive, for example a lipophilic phase formulated, for a dose tidienne, to: micronized econazole nitrate, 150 mg; metronidazole mid-cronized, 500 mg; hydroxypropylcellulose, 20 mg; PEG-7 glyceryl co-coate, 20 mg; silicone oil, 1560 mg.
A particularly advantageous dosage form is that of a hard or soft capsule including a hard solid outer shell or soft containing gelatin, enclosing an internal liquid phase or will be non-aqueous liquid comprising the lipophilic phase.

We will give various examples of pharmaceutical compositions carried out according to the teachings of the invention.
These various examples concern, in different galenic forms ques, a combination of metronidazole and econazole nitrate, which constitute the two combined active ingredients of the composition.
Microbiological efficacy The two irnidazole derivatives given as examples are already known separately, each with its own spectrum of activity - metronidazole is active on Gardnerella vagi-anaerobic bacteria such as fragile Bacteroides, - econazole has a dual activity, antifungal against Candidcc albicans and non albicans, and antibacterial in par particularly on the main Gram + bacteria responsible for episo superinfection of vulvovaginal yeast infections (the imbalance of the vaginal ecosystem caused by a yeast infection may indeed be a favorite ser the pathogenic development of certain Gram + sapro germs phytes from the vaginal environment such as Staphylococcus aureus, Strepto-

4 coccus, Bacillus).
The combination of these two imidazole derivatives, however, presents characteristic of the invention, an additive synergy (potentialisa-tion), proven by a measurement of MIC (minimum concentration inhibi-active ingredients taken separately and then mixed vis-à-vis different germs.
To this end, the following solutions have been prepared - stock solution of metronidazole at 77 mg / ml in dimethylfor-mamide, - stock solution of econazole nitrate at 23 mg / ml in dimethyl-formamide, - stock solution of a mixture of 77% metronidazole and 23%
econazole nitrate (corresponding to a respective proportion 500: 150 of these two active ingredients) at 100 mg / ml in dimé
i5 thylformamide, i.e. 77 mg / ml metronidazole and 23 mg / ml ni trate of econazole.
The MIC was determined according to an experienced protocol classic rimental featuring - successive dilutions in microplates, 2 in 2, for each of the mother solutions, - bringing each dilution into contact with an equivalent volume of culture medium containing 106 microorganisms / ml, - repeating the test at least four times, - incubation of microplates 4 $ hours at 37 ° C, aerobically or anaerobic according to the microorganism tested, - after incubation, each test cup is subcultured on a medium agar adapted to confirm the visual reading of the development of microorganisms.
In some cases, the moderate presence of micro-organisms in wells where no microbial development is visible: the microorganisms brought in at the start of the test are not developed but remained alive; this is indeed an inhibition.
Transplanting the cups therefore confirms the visual reading results and also to distinguish bactericidal concentrations inhibitory concentrations.

On an Escherichia coli CIP 54127 reference strain, the their MICs, expressed in mg of product per ml of solvent, are the following - 3.125 mg / ml for metronidazole alone,

5 - 0.94 mg / ml for econazole nitrate alone, - 2.03 mg / ml for the mixture (1.56 mg / ml for metronidazole and 0.47 mg / ml for econazole nitrate).
Or a content divided by 2 compared to the content found for each active ingredient tried alone.
The MIC was also determined on a strain of Bacteroides fragilis CIP 77 16 T incubated anaerobically (this germ, which is a ger-anaerobic met in vaginosis and not treated with antibiotics ticks, is a good tracer of anaerobic infections).
The results are as follows:
- 4.075 mg / ml for metronidazole alone, - 0.0014 mg / ml for econazole nitrate alone, 0.0015 mg / ml for the mixture (0.00115 mg / ml for metronida-zole and 0.000345 mg / ml for econazole nitrate).
The combination of the two active ingredients thus reduces the MIC of the tronidazole by 65 times and that of econazole nitrate by 4 times, revealing strong potentiation.
The MIC was also determined on a strain of Propioni-bacterium acnes CIP 53 117 T incubated anaerobically.
The results are as follows:
- 2.41 mg / ml for metronidazole alone, - 0.0056 mg / ml for econazole nitrate alone, - 0.0122 mg / ml for the mixture (0.00939 mg / ml for metronida-zole and 0.0028 mg / ml for econazole nitrate).
The combination of the two active ingredients thus reduces the MIC of the tronidazole 257 times and that of econazole nitrate 2 times, revealing here again a strong potentiation.
It is thus possible, for the same therapeutic effect, to use doses of active ingredients significantly lower than those which would have been necessary if they had been used alone.
Measurements were also carried out on strains of Sta-

6 phylococcus aureus (131actamase +), Streptococcus agalactie, Candida albicans, tropical Candida, vaginal Peptostreptococcus. In this case, the activity of the mixture is only due to the presence of nitrate econazole, but the presence of metronidazole in the mixture does not create no antagonism likely to affect antifungal activity or antimicrobial econazole nitrate.
A CMI study was also carried out on Lactobacillus acidophiles and Lactobacillus crispatus, which are germs not pa thogens existing physiologically in the vaginal flora, and that should be preserved.
This study was carried out using the agar dilution method Columbia (Oxoid Ltd.), supplemented with 5% horse blood, followed the procedures described by the NCCLS. The strains studied were reference strains of the Institut Pasteur de Paris Lactobacillus acidophiles CIP 76 13 T and Lactobacillus crispatus CIP 102990 T, transplanted beforehand on Columbia Agar with 5% blood added sheep (Beckton-Dickinson) and incubated at 37 ° C under 10% C02 for 24 and 48 hours.
MICs obtained for metronidazole alone, for nitrate econazole alone and for the metronidazole / econazole nitrate mixture were always equal to or greater than 16 mg / 1, for both strains studied. These results reveal an absence of synergistic effect of the mixture on the two strains considered, which all exhibited high MICs (? 16 mg / 1). These can therefore be considered as resistant to this combination of active ingredients.
Tolerance A safety study was also carried out versus placebo on rabbits to assess the presence of erythema or edema drivers of possible irritation, as well as body weight and alimentary consommation.
No significant difference was noted concerning these differences.
many factors between the group receiving the active substance and that who received the placebo.

7 The association studied thus presents a tolerance equal to that of placebo, without irritant effect or effect of treatment on the weight of animals, which would tend to establish the absence of systemic toxicity of association.
Dosage forms advantageously, the two active ingredients are associated with a excipient comprising a lipophilic phase (fatty phase).
This lipophilic phase, in addition to its compatibility with the two principles active, must be able to promote homogenization with vagi secretions nales by bringing a certain hydrophilic character and, on the other hand, provide bioadhesion to avoid phenomena as much as possible of flow. In contact with vaginal secretions, the hydrophilic agent bioadhesive gels, and the dosage form emulsifies thanks to the pre smell of the water-dispersible agent, which in particular allows a diffusion direct passive ion of the active ingredient between the emulsified excipient and the vaginal mucosa with which it is in contact. The character bioadhesive (more specifically, mucoadhesive) of the hydrophilic gelling agent makes the emulsion sticky on the mucosa, with a weak also, providing long-term maintenance.
This long-term maintenance makes it possible in particular to space the administrations, which may only be daily.
The lipophilic phase thus comprises a lipophilic agent, an agent water dispersible and a bioadhesion agent.
The lipophilic agent can be a silicone oil such as a dimer dimethicone 100 ~ thylpolysiloxane, in accordance with the pharmacopoeia French tenth edition and European pharmacopoeia third editing ; its viscosity is between 50.10-s and 150.10'6 m2 / s (50 and 150 centistokes). It can also be chosen from: cocoa butter, Carnauba wax, solid hemisynthetic triglycerides (type Sup-pocire ~ AIML or Witepsol ~ H15), oil fatty acid triglycerides copra (Softisan type ~ 378), liquid triglycerides (Miglyol type ~
812).
The water-dispersible agent can be chosen from: 7-glyceryl-cocoate polyoxyethylene glycol (Cetiol ~ HE type), fatty acid esters or

8 polyols, lauric alcohol and polyethylene glycol ether, castor oil polyoxyethylenated, polyoxyethylenated glycerides (Labrafil type ~ or Labrasol ~), polyoxyethylene glycols, palm oil sucroglycerides, rectified ethyldiethylene glycol.
The bioadhesion agent can be chosen from: hydroxypropylcellu-lose (HIucel ~ HXF type), carboxyvinyl acids, carboxymethylcellu-lose, sodium carboxymethylcellulose, methylcellulose, hydroxypropyl-methylcellulose, locust bean gum, xanthan gum, Guar gum, si-aluminum licate, carrageenans.
A typical example of the formulation of an oily phase is Formula Formula centesimal unit Conazole micronis nitrate 150 mg 6.67 g Mtronidazole micronis 500 mg 22.22 g Hydroxypropylcellulose (HIucel ~ HXF) 20 mg 0, $ 9 g PEG-7 glycryl cocoate (Ctiol ~ HE) 20 mg 0.89 g Silicone oil (Dimticone ~ 100) 1560 mg 69.33 g 2.25 g 100 g This fatty phase has a dynamic viscosity of the order of 10,000 mPa.st 20%.
It can be incorporated into a wide variety of dosage forms for local administration such as soft capsule, capsule, egg, application single-dose cator, sachet, or tube.
Several examples of such galleys will be given below.
roques.
Example 1 (ovum) Micronized econazole nitrate 150 mg Micronized metronidazole 500 mg Polyoxyethylene glycol 7-glyceryl-cocoate (Cetiol ~ HE) 20 mg WO 99/55333 PCT / F'R99 / 00973

9 Hydroxypropylcellulose (HIucel ~ HXF) 20 mg Silicone oil (Dimethicone ~ 100): 0 to 25%, i.e. 0 to 327.5 mg Solid triglycerides (Suppose ~ AIML) qs 2000 mg Example 2 (2.5 ml capsule) Micronized econazole nitrate 150 mg Micronized metronidazole 500 mg Polyoxyethylene glycol 7-giyceryl-cocoate (Cetiol ~ HE) 20 mg Hydroxypropylcellulose (HIucel ~ HXF) 20 mg Silicone oil (Dimethicone ~ 100) qs 2400 mg Example 3 (soft capsule, sachet or single dose) Micronized econazole nitrate 150 mg Micronized metronidazole 500 mg Polyoxyethylene glycol 7-glyceryl-cocoate (Cetiol ~ HE) 20 mg Hydroxypropylcellulose (HIucel ~ HXF) 20 mg Silicone oil (Dimethicone ~ 100) q. s, 2250 mg The dosage form called "soft capsule" is, as far as it is concerned, well known, with an initially solid external phase - therefore easy to handle and put in place - including gelatin, in particular -made up of gelatin and glycerin, enclosing an inter-not liquid or semi-liquid containing a therapeutic agent. Through example, EP-A-0 121 321 describes a soft capsule comprising a active ingredient dissolved or in suspension and a composition preventing embrittlement of the soft capsule.
The internal phase whose formulation has been given above is in-once prepared in an external envelope containing gelatin, including an outer shell of gelatin / glycerin cor-corresponding to a structure known under the name of "capsule soft ". Note that the above formulation provides a certain hydrophilic internal fatty phase (to promote homogenous generatization with vaginal secretions), but that this hydro-phile remains compatible with the external phase comprising gelatin so as not to distort it (otherwise the capsule would melt by itself even before being used).
5 Example 4 (1240 mg tablet) Conazole micronis nitrate 150 mg Mtronidazole micronis 500 mg Microcrystalline cellulose 200 mg

10 Lactose 350 mg Polyvidone (Kollidon ~ K30) 20 mg Magnesium starate 20 mg Example 5 (1270 mg tablet) Conazole micronis nitrate 150 mg Mtronidazole micronis 500 mg Lactose 350 mg Hydroxypropylcellulose (Klucel ~ HXF) 20 mg Carboxyvinylic acid (Carbopol ~ 974 P) 50 mg Microcrystalline cellulose 150 mg Crospovidone (Kollidon ~ CL) 30 mg Staric acid 20 mg Example 6 (emulsion) Conazole micronis nitrate 150 mg Mtronidazole micronis 500 mg Polysorbate 80 40 mg Sorbitan ester (Montane ~ 80) 40 mg Ctyl alcohol 150 mg PEG 400 monolaurate 70 mg Parabnes (preservative) 0.5 mg Citric acid qs pH = 4.5 Water purifies to 2.5 g WO 99/55333 PCT / FR99 / 0097 ~

11 Example 7 (sachet for aqueous suspension) Micronized econazole nitrate 150 mg Micronized metronidazole 500 mg Citric acid 20 mg Patent blue 2 ~
Microcrystalline cellulose (Avicel ~ RC) 40 mg Lactose qs 4 g

Claims (8)

12 1. A pharmaceutical composition for the local treatment of infectious vulvovaginitis and vaginosis, characterized in that it comprises a combination of at least two imidazole derivatives having a reinforcing synergy with the germs responsible for infectious vulvovaginitis and vaginosis and selected from the group including metronidazole, econazole, miconazole, clotrimazole, terconazole, bifonazole, cloconazole, isoconazole, oxiconazole, sulconazole, tioconazole and their salts, preferably the group including metronidazole, econazole, miconazole, clotrimazole, terconazole and their salts, and with the exception of combined metronidazole miconazole, tioconazole or clotrimazole. 2. The pharmaceutical composition of claim 1, wherein one of the imidazole derivatives is metronidazole. 3. The pharmaceutical composition of claim 2, wherein the other imidazole derivative is selected from the group comprising econazole, clotrimazole, terconazole, bifonazole, cloconazole, isoconazole, oxiconazole, sulconazole and their salts, preferably the group comprising econazole, clotrinazole, terconazole and their salts, very preferably econazole and its salts. 4. The pharmaceutical composition of claim 3, comprising metronidazole and econazole nitrate once daily total from 250 to 1050 mg. 5. The pharmaceutical composition of claim 4, wherein metronidazole/econazole nitrate dose ratio is included between 2:1 and 5:1, preferably between 3:1 and 4:1, very preferably between 3:1 and 3.5:1. 6. The pharmaceutical composition of claim 1, wherein the imidazole derivatives are suspended in a lipo-phase phile comprising as excipients a lipophilic agent, an agent water-dispersible and a bioadhesive agent. 7. The pharmaceutical composition of claim 6, of which the formulation of the lipophilic phase is, for a daily dose:
Micronized Econazole Nitrate 150mg Micronized metronidazole 500 mg Hydroxypropylcellulose 20mg PEG-7 glyceryl cocoate 20mg Silicone Oil 1560mg 8. The pharmaceutical composition of claim 6, in the form hard or soft capsule formulation comprising an outer shell hard or soft solid containing gelatin, enclosing a phase non-aqueous liquid or semi-liquid internal comprising said phase lipophilic.