CA2536906A1

CA2536906A1 - Compositions for treating pathologies that necessitate suppression of gastric acid secretion

Info

Publication number: CA2536906A1
Application number: CA002536906A
Authority: CA
Inventors: Ayelet David; Sabina Glozman; Lada Paul
Original assignee: Individual
Current assignee: VECTA Ltd
Priority date: 2003-08-27
Filing date: 2004-08-25
Publication date: 2005-03-10
Also published as: RU2006109357A; EP1658089A4; JP2007503427A; KR20060083198A; WO2005020879A3; IL173944A0; AU2004268446A1; EP1658089A2; WO2005020879A2

Abstract

The present invention is related to novel oral compositions comprising an irreversible gastric H+/K+-ATPase proton pump inhibitor (PPI) as a gastric acid secretion inhibitor, pentagastrin (PG) or a PG analogue as an activator of parietal cells in the gastric lumen. In a preferred embodiment, the composition further comprises at least one agent that preserves the availability of PG in the gastric fluids, thus enabling PG to act locally in the stomach. Unexpectedly, the compositions of the present invention exhibit anti-acid activity locally in the stomach that is meal-independent, exhibit fast onset and prolonged inhibition of acid secretion.

Description

DEMANDES OU BREVETS VOLUMINEUX
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JUMBO APPLICATIONS / PATENTS
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COMPOSITIONS FOR TREATING PATHOLOGIES THAT NECESSITATE
SUPPRESSION OF GASTRIC ACID SECRETION
FIELD OF THE INVENTION
The present invention relates to novel oral compositions for inhibition of gastric acid secretion that possess fast onset, prolonged inhibition effect on gastric acid secretion and are meal-independent.
BACKGROUND OF THE INVENTION
A wide number of pathological conditions are characterized by the need to suppress gastric acid secretion. Such conditions include, but are not limited to Zollinger/Ellison syndrome (ZES), gastroesophageal reflux disease (GERD), peptic ulcer disease, duodenal ulcers, esophagitis, and the like. Conditions such as peptic ulcers can have serious complications and represent some of the most prevalent diseases in industrialized nations.
Presently, the main therapies employed in the treatment of GERD and peptic ulcer diseases include agents for reducing the stomach acidity, for example by using the histamine HZ-receptor antagonists or proton pump inhibitors (PPI's). PPI's act by inhibiting the parietal cell H+/K+ ATPase proton pump responsible for acid secretion from these cells.
PPI's, such as, omeprazole, and its pharmaceutically acceptable salts are disclosed for example in EP
05129, EP 124495 and US Patent No. 4,255,431.
PPI agents are acid-labile pro-drugs that are usually administered in enteric-coated granules. Following their absorption in the small intestine PPIs, which are weak bases, preferentially accumulate within the acid milieu of parietal cells. The acid environment within the acid milieu of parietal cells causes the conversion of the pro-drugs into the active sulfenamids, which are the active agents that bind and inhibit the parietal cell H+/K+ ATPase pumps.
Despite their well-documented efficacy, PPIs have notable limitations. The time of dosing and ingestion of meals may influence the pharmacokinetics of these agents as well as their ability to suppress gastric acid secretion (Hatlebakk et al., Aliment Pharmacol Ther.
2000;14(10):1267-72). Specifically, the PPI must be taken prior to ingestion of food in order to achieve optimal suppression of gastric acid secretion. Furthermore, PPIs have a relatively °slow onset of pharmacological action and may require several days to achieve maximum acid suppression and symptom relief, limiting their usefulness in on-demand GERD
therapy (Sachs G, Eur J Gastroenterol Hepatol. 2001;13 Suppl 1:535-41). Moreover, PPIs fail to provide 24-h suppression of gastric acid and nocturnal acid breakthrough that leads to heartburn pain in GERD patients and occurs even with twice-daily dosing of PPIs (Tytgat GN, Eur J Gastroenterol Hepatol. 2001;13 Suppl 1:529-33). Finally, these drugs exhibit substantial inter-patient variability in pharmacokinetics and may have significant interactions with other drugs (Hatlebakk et al., Clin Pharmacokinet. 1996; 31(5):386-406).
Thus, an improvement of PPI-mediated activity is a well-recognized challenge in gastroenterology.
Pentagastrin (PG) ((3-alanyl-L-tryptophyl-L-methionyl-L- aspartyl-L-phenyl-alanyl amide; SEQ ID N0:2) is a pentapeptide containing the carboxyl terminal tetrapeptide of gastrin. This carboxyl terminal tetrapeptide is the active portion found in essentially all natural gastrins. In animals, PG acts to induce gastric acid secretion mainly via induction of histamine release from enterochromafin-like (ECL) cells residing in the stomach. The release of histamine and the consequent activation of histamine receptors residing on the parietal cells, leads to the activation of the parietal cells to actively secrete proton ions to the gastric lumen. It is also possible that PG acts directly on the parietal cells to induce its activation.
PG is typically used in the art as a diagnostic agent for the evaluation of gastric acid secretory function.
The low solubility of PG in acidic environment and the fact that PG is prone to pepsin degradation in the stomach, rendered its use as an inducer of gastric acid secretion following oral administration clearly unexpected until Applicants discovery. Prior to Applicants discovery, PG was considered by anyone skilled in the art to only be effectively active at inducing acid secretion if administered via parenteral routes. Indeed, no effect on acid secretion was noted in four normal subjects subjected to oral administration of PG, whereas some effect was noted in three additional patients with gastrointestinal abnormalities (Morrell & Keynes Lancet. 1975; 2(7937):712). In fact, this study was cited in a pharmacology textbook as a proof of lack of PG activity when administered orally (Martifzdale Thirty-secorZd editiota, p1616, the Chapter: "Supplerneratary Drugs and Other Substayzces").
W001/22985 to Pisegna et al. (the '985 publication) discloses the use of PG
administered systemically in conjunction with a proton pump inhibitor (PPI).
According to the '985 publication, administration of PG in combination with a PPI increases the efficacy of the PPI in reducing/mitigating excess gastric acid secretion. The '985 publication discloses and teaches that PG should preferably be administered by injection (e.g., subcutaneous injection). The '985 publication does, however, disclose generically that PG
and PPI can be administered by intravenous, parenteral, or oral means. The '985 publication also generically discloses that PPI and PG could be prepared in a tablet. The '985 publication, however, does not disclose any particular dosage or formulation that should be used and does not provide any working examples. Furthermore, the '985 publication does not provide any teachings or suggestion how one might avoid the prior art teachings that PG is not effective if delivered orally and provides no examples of suggested oral dosage amounts of PG that would be effective. In addition, the '985 publication also does not disclose that PG is active locally in the stomach, which the present inventors surprisingly discovered. The '985 publication also does not teach the use of PG preservation agents to preserve the biological activity of PG
activity in the stomach in order to achieve local effect in the gastric lumen.
In view of the state of the art at the time of the present invention, the '985 publication's generic disclosure fails to motive one skilled in the art to prepare an oral composition comprising PG for local delivery.
De Graef et al., Gastroenterology, 91, 333-337 (1986) (De Graef publication) discloses that omeprazole is more effective in inhibiting gastric acid secretion when administered to dogs pretreated intravenously with PG. There is no mention in the De Graef publication that oral administration of PG would be effective by acting locally in the gastric lumen to potentiate the effect of omeprazole.
US Patent Nos. 6,489,346; 6,645,988; and 6,699,885; to Phillips (jointly the "Phillips patents") disclose pharmaceutical compositions and methods of treating acid-caused gastrointestinal disorders using oral compositions consisting of a PPI, at least one buffering agent and specific parietal cell activators. The parietal cell activators disclosed in the Phillips patents include, for example, chocolate, sodium bicarbonate, calcium, peppermint oil, spearmint oil, coffee, tea and colas, caffeine, theophylline, theobromine and amino acids residues. As indicated in the Phillips patents, all these proposed parietal cell activators induce the release of endogenous gastrin that exerts both inhibitory and stimulatory effects on acid secretion. The Phillips patents, however, do not disclose or suggest the use of PG, which possesses a solely stimulatory activity, binding only to CCK-B
receptors, unlike the parietal cell activators mentioned in the Phillips patents, which would activate both CCK-A
and CCK-B receptors - including both inhibitory and stimulatory effects.
The development of an effective treatment for pathologies in which inhibition of gastric acid secretion is required would fulfill a long felt need. Despite the wide-spread use of PPI's, a need still exist for increasing the PPI efficacy, e.g., faster effective onset, prolonged effect including night time acid breakthrough, greater effect at reduced dosage and meal-independent administration.
SUMMARY OF THE INVENTION
It is the object of the present invention to provide oral compositions for inhibition of gastric acid secretion that are meal-independent and exhibit fast onset with prolonged inhibition effect on gastric acid secretion.
It is another object of the present invention to provide oral compositions for inhibition of gastric acid secretion comprising an irreversible gastric H-'-/K+-ATPase proton pump inhibitor (PPI) and a parietal cell activator, wherein the PPI anti-acid activity is meal-independent and exhibit fast onset and prolonged inhibitory effect on acid secretion.
In one embodiment of the present invention the oral compositions comprises an irreversible gastric H+/K+-ATPase proton pump inhibitor (PPI) as a gastric acid secretion inhibitor, pentagastrin (PG) andlor a PG analogue as an activator of parietal cells and one or more agents that preserve the availability of PG in the gastric fluids, so that the biological activity of PG is maintained thus enabling PG to act locally in the stomach.
Unexpectedly, the compositions of the present invention possess anti-acid activity in the stomach that is meal-independent and exhibit fast onset and prolonged inhibition of acid secretion. The present compositions may be used for treating a subject suffering from chronic or acute disorders in which suppression of acid secretion in the stomach is required.
The proton pump inhibitors (PPIs) according to the present invention are compounds that inhibit the activity of the H+lK+-adenosine triphosphatase (ATPase) proton pump in the gastric parietal cells. In its pro-drug form, PPI is non-ionized and therefore is capable of passing through the cellular membrane of the parietal cells. Once reaching the parietal cells, the non-ionized PPI moves into the acid-secreting portion of activated parietal cells, the secretory canaliculus. The PPI trapped in the canaliculus becomes protonated, thus converted to the active sulfenamide form that can form disulfide covalent bonds with cysteine residues in the alpha subunit of the proton pump, thereby irreversibly inhibiting the proton pump.
As mentioned above, the present invention is based on the inventors surprising discovery that PG is active locally when administered orally, preferably by acting locally in the gastric lumen to activate the parietal cells. Active parietal cells possess acidic pH, which is required for the conversion of the PPI to the active protonated sulfenamide form.

Therefore, the synchronized activation of the parietal cells by PG acting directly in the gastric lumen maximizes the inhibition of the pumps by the PPI.
The oral compositions of the present invention exhibit the following advantages over the known PPI-based compositions aimed to reduce gastric acid secretion. The present compositions permit activation of the parietal cells by PG without any side effects associated with systemic administration of PG due to the local effect of PG in the gastric lumen. Pre-activation of parietal cells by PG facilitates the conversion of the PPI to the active sulfenamide form leading to fast onset of the effect of PPI. Furthermore, the present compositions exhibit fast onset of anti-acid activity in the stomach in a meal-independent manner. Thus, the combined active agents in the oral compositions provide an efficient solution for acute conditions in which fast reduction of acid secretion is required. Finally, the present oral compositions provide prolonged suppression of gastric acid secretion for at least 24 h using a single medication.
The oral compositions according to the present invention comprise PG or a PG
analogue as an local activator of parietal cells in the gastric lumen. In addition to PG that comprises the amino acid sequence (3Ala-Trp-Met-Asp-PheNH2 (SEQ ID N0:2), this invention contemplates the use of gastrin or PG analogues or derivatives thereof as parietal cell activators. Such variants include, but are not limited to the 34-, 17-, and 14-amino acid species of gastrin, and other truncation variants comprising the active C-terminal tetrapeptide of gastrin Trp-Met-Asp-PheNH2 (SEQ ID N0:1), which is reported in the literature to have full pharmacological activity (see Tracey and Gregory (1964) Nature (London), 204: 935).
Also included are variants of gastrin and/or truncated gastrins where native amino acids are replaced with conservative substitutions. Various analogues of these molecules are also included, for example, but not limited to the N-protected derivative of PG Boc-(3Ala-Trp-Met-Asp-PheNH2 in which Boc is tent-butyloxycarbonyl group or F-Moc-(3Ala-Trp-Met-Asp-PheNHz in which Moc is methoxycarbonyl.
In a non-limiting embodiment, the oral compositions according to the present invention further comprise one or more agents that preserve the availability of PG in the acidic gastric fluids. These agents preferably are in an amount sufficient to preserve the availability of PG in the gastric fluids by retaining the solubility of PG in the gastric fluids and preventing its degradation, so that the local biological activity of PG in the stomach is preserved. This enables PG to act locally in the stomach to activate the parietal cells. Such agents are preferably antacids or alkaline agents that when dissolved in the gastric juice are capable of temporally elevating the pH of the gastric fluids to a value in which pepsin is inhibited, thereby inhibiting the degradation of PG in the gastric fluids by pepsin. Since PG
is soluble only in alkaline conditions, the temporal elevation of the pH in the gastric fluids ensures that at least significant proportion of PG remains soluble in the gastric fluids.
It is noted that any weak or strong base (and mixtures thereof) can be utilized as the alkaline agent in the present oral compositions. The alkaline agent or the antacid is present in the composition in an amount sufficient to substantially preserve the stability and the solubility of PG in the acidic gastric fluids. Therefore, the alkaline agent of the present invention, when dissolved in the gastric juice, is capable of elevating the pH
of the stomach to a value sufficient to achieve adequate availability of PG to effect therapeutic action.
According to a preferred embodiment, the alkaline agent in the composition is present in an amount sufficient to elevate the pH of the gastric fluids to a value above 4, and more preferably above 5, for a time period sufficient for PG to reach and activate the parietal cells in the stomach. In more preferred embodiment, the alkaline agent is capable of elevating the pH of the gastric fluids to a value above 5 for a time period ranging from 5 to 60 minutes, preferably for a time period ranging from 5 to 30 minutes. Thus, the alkaline agent according to the present invention preserves the solubility of PG in the gastric fluids for a time period sufficient for PG to activate the parietal cells. Furthermore, the temporal alkali condition in the gastric fluid prevents the degradation of PG by pepsin that is active only in acidic pH.
According to various embodiments, the present compositions further comprise other agents that preserve the availability of PG in the acidic gastric fluids. Such agents are for example pepsin inhibitors (i.e., pepstain and its derivative bacitracin -cyclic dodecapeptide) that reduce the degradation of the peptide in the stomach or mucolytic agents that reduce the viscosity of the gastric mucosa, thereby accelerating the ability of PG to reach the cells responsible for acid secretion. Such mucolytic agents are for example reducing agents such as N-acetyl cysteine, dithiothreitol, citric acid or mannitol. The present compositions may further comprise an antibiotic effective against bacteria residing in the stomach.
The active ingredients of the present invention may be formulated in a single oral dosage form, preferably a solid dosage form. Liquid dosage forms such as suspensions may be used as well. Thus, in one embodiment the PPI, PG and the agent that preserves the availability of PG in the gastric fluids may be formulated as multi-layered tablets, suspension tablets, effervescent tablets, powder, pellets, granules, hard gelatin capsules comprising multiple beads, or soft gelatin capsules containing a lipid-based vehicle.

According to one embodiment, the solid dosage form of the present invention is a capsule or a mufti-layered tablet containing PPI particles coated with either enteric pH-dependent release polymers or non-enteric time-dependent release polymers, particles of PG
and particles of one or more alkaline agents. In order to ensure that the activation of parietal cells in the gastric lumen by PG is synchronized with the absorption of the PPI in the proximal part of the small intestine, the single oral dosage form may comprise PG beads coated with time-dependent release polymer that extends the PG releasing time in the stomach. Thus, the extension of PG release in the stomach permits the synchronization between the activity of PG and the activity of the PPI on the parietal cells.
The active ingredients of the present invention may also be formulated in separate dosage forms. For example, PG and the agent that preserves the availability of PG in the gastric fluids may be formulated in an oral suspension or a solid dosage form such as capsules, tablets, suspension tablets, or effervescent tablets and the PPI may be formulated in a separate solid dosage form, preferably capsules or tablets comprising beads with enteric pH-dependent release polymers or non-enteric time-dependent release polymers. The separate dosage forms may be provided as a kit containing PG and the agent that preserves the availability of PG in the gastric fluids in one dosage form and the PPI in a separate dosage form. In this case, the PG is administered in conjunction with the PPI so that there is at least some chronological overlap in their physiological activity. The PPI and PG can be administered simultaneously and/or sequentially.
The PPI particles used in the present invention may be coated with either enteric pH-dependent release polymer, non-enteric time-dependent release polymer or may be without coating layer. The stability of the non-coated PPI while passing the stomach is preserved by the one or more alkaline agents present in the composition. It was previously demonstrated that the absorption of buffered suspension of non-enteric-coated PPI in the proximal part of the small intestine is faster than the absorption of the enteric-coated PPI
granules (Pilbrant and Cederberg, Scand. J. Gastroenterol 1985:20 (supp. 108): 113-120).
Therefore, it is not necessary to delay the release of PG in the stomach if non-coated PPI
particles are used in the composition. However, when coated PPI particles are used, it is required to synchronize the release of the PPI with the release of PG by delaying the release of PG in the stomach for example by using polymeric coated PG particles.
In another embodiment, the present invention is directed to a method of treating a subject suffering from a disorder in which suppression of gastric acid secretion is required or a disorder normally treated by suppression of gastric acid secretion. The method comprising administering to the subject a pharmaceutical composition comprising a PPI as a gastric acid secretion inhibitor, PG or a PG analogue as an activator of parietal cells in the gastric lumen, and at least one preservation agent in an mount sufficient to preserve the availability of PG in the gastric lumen.
The compositions of the present invention may be used for preventing or treating pathologies in a mammal in which inhibition of gastric acid secretion is required. Preferably the mammal is human. The compositions of the present invention are effective both in treating the pathologies and in minimizing the risk of development of such pathologies before onset of symptoms.
The pharmaceutical compositions of the present invention may be used in a wide number of pathological conditions that are treated by suppression of gastric acid secretion.
Such conditions include, but are not limited to Zollinger/Ellison syndrome (ZES), gastroesophageal reflux disease (GERD), esophagitis, peptic ulcer diseases, duodenal ulcers, gastritis and gastric erosions, dyspepsia, and the like.
The present invention also includes an oral pharmaceutical kit. The kit typically comprises as active ingredients a pharmaceutically effective amount of: (i) a peptide comprising the amino acid sequence of SEQ )D NO:1; (ii) an irreversible gastric I~/I~+-ATPase proton pump inhibitor (PPI); and (iii) at least one agent that preserves the availability of the peptide in the gastric fluids. In one embodiment, the active ingredients are formulated in separate dosage unit forms. The kit may be used to treat or prevent a disorder in a subject in which suppression of gastric acid secretion is required by administering to a subject the active ingredients. The peptide is typically administered simultaneously, prior to or following the administration of the PPI.
These and further embodiments will be apparent from the detailed description and examples that follow.

BRIEF DESCRIPTION OF THE FIGURES
Figure 1 demonstrates that NaHC03 preserves PG stability in artificial gastric fluid;
Figure 2 demonstrates the percentage of non-degraded PG in various pH values;
Figure 3 is a schematic illustration of a double-layered tablet comprising PG, non-enteric-coated omeprazole and buffering agents;
Figure 4 is a schematic illustration of PG granules used in the multi particulate capsule formulation;
Figure 5 is a schematic illustration of a capsule comprising time release-coated beads;
Figure 6 demonstrates that PG stimulates gastric acid secretion in rats in a dose-dependent manner ;
Figure 7 demonstrates that PG enhances PPI-mediated effect on gastric acid secretion in rats;
Figure 8 demonstrates that Lansoprazole inhibits gastric acid secretion in conscious animals in a dose-dependent manner;
Figure 9 demonstrates that PG increases the efficacy of Lansoprazole in the blockade of gastric acid secretion when Lansoprazole is administered prior to PG (A) and not when Lansoprazole is administered following PG (B);
Figure 10 demonstrates that administration of Lansoprazole in combination with PG
during 3 consecutive days resulted in significantly higher intragastric pH (A) and lower gastric acid secretion (B) as compared to Lansoprazole alone.
DETAILED DESCRIPTION OF THE INVENTION
The term "alkaline agent" refers to any pharmaceutically appropriate weak base or strong base (and mixtures thereof) that, when formulated or delivered with (e.g., before, during and/or after) PG, functions to temporally elevate the pH in the gastric lumen to a value that substantially preserves the availability of PG in the stomach.
The term "an agent that preserves the availability of PG in the stomach"
refers to any agent that is capable of maintaining the solubility and stability of PG in the stomach.
Specifically, such an agent is capable of maintaining at least a substantial amount of PG in a soluble form and non-degraded in the gastric juice, so that the biological activity of PG in the stomach is maintained.
The term "biological activity of PG in the stomach" refers to its activation of parietal cells located in the gastric lumen.

The term "in conjunction with" means that when the PPI and the PG are administered in separate dosage forms, there is at least some chronological overlap in their physiological activity. Thus the PPI and PG can be administered simultaneously and/or sequentially.
The present invention is based on the surprising discovery that PG is capable of remaining active following oral administration to activate the parietal cells, preferably by acting locally in the stomach. Importantly, parietal cell activation is required for the conversion of the PPI pro-drug to the active form that acts as an irreversible inhibitor of the gastric H+lI~+-ATPase proton pump. The oral compositions of the present invention provide a unique combination of active agents that increase the efficacy of the PPI in inhibiting gastric acid secretion.
The compositions of the present invention may be used for preventing or treating pathologies in a mammal in which inhibition of gastric acid secretion is required. The compositions of the present invention are effective both in treating the pathologies and in minimizing the risk of development of such pathologies before onset. Such pathologies include for example: reflux esophagitis, gastritis, duodenitis, gastric ulcer and duodenal ulcer.
Furthermore, the compositions of the present invention may be used for treatment or prevention of other gastrointestinal disorders where gastric acid inhibitory effect is desirable, e.g. in patients on nonsteroidal anti-inflammatory drugs (NSAID) therapy (including low dose aspirin), in patients with Non Ulcer Dyspepsia, in patients with symptomatic gastro-esophageal reflux disease (GERD), and in patients with gastrinomas. They may also be used in patients in intensive care situations, in patients with acute upper gastrointestinal bleeding, in conditions of pre-and postoperatively to prevent aspiration of gastric acid and to prevent and treat stress ulceration. Further, they may be useful in the treatment of Helicobacter infections and diseases related to these. Other conditions well suited for treatment include, but are not limited to Zollinger-Ellison syndrome (ZES), Werner's syndrome, and systemic mastocytosis.
The parietal cell activator according to the present invention is preferably PG having the amino acid sequence denoted as SEQ ID N0:2. However, any PG analog that comprises the C-terminal tetrapeptide of gastrin Trp-Met-Asp-PheNH2 (denoted as SEQ ID
NO:1) may be used as a parietal cell activator. Such analogues include, but are not limited to the 34-, 17-, and 14-amino acid species of gastrin, and other truncation variants. Also included are variants of gastrin and/or truncated gastrins where native amino acids are replaced with conservative substitutions. Also included are various analogues of these molecules, including for example, but not limited to the N-protected derivatives of PG. Suitable protecting groups for PG include standard hydroxyl protecting groups known in the art, e.g., methoxymethyl (MOM), (3-methoxyethoxymethyl (MEM), trialkylsilyl, triphenylmethyl (trityl), tert-butoxycarbonyl (t-BOC), ethoxyethyl (EE), f-MOC (methoxycarbonyl), TROC, etc.
The protecting groups) may be removed by using standard procedures generally known to those skilled in the art to give the desired PG derivatives (T. W. Green, Protective Groups in Organic Synthesis, Chapter 2, pages 10-69 (1981)).
Gastrins, pentagastrins, or analogues thereof are commercially available. In addition, synthetic protocols are well known. Thus, for example, PG can be chemically synthesized using well-known peptide synthesis methodologies (see, e. g. Barany and Merrifield Solid-Phase Peptide Synthesis; pp. 3-284 in The Peptides: Analysis, Synthesis, Biology. Vol. 2 Special methods in peptide synthesis, part a.; Merrifield et al. (1963) J. Am.
Chem. Soc., 85: 2149-2156; and Stewart et al. (1984) Solid Phase Peptide Synthesis, 2nd ed. Pierce Chem. Co., Rockford, ILL.). Additionally, PG can be chemically synthesized, for example, by conjugation of a Boc-Ala residue to the tetrapeptide Trp-Met-Asp-PheNH2.
The compositions of the present invention comprise PG or an analog thereof in an effective amount to achieve a pharmacological effect on the parietal cells without undue adverse side effects. The standard approximate amount of PG present in the compositions is preferably in an amount of 1-100 mg, more preferably 2-60 mg, and most preferably 4-40 mg of PG (or an equivalent amount of a PG analogue).
The compositions of the present invention further comprise a PPI that acts as an irreversible inhibitor of the gastric Ii+/K+-ATPase proton pump. The PPI used in the present invention can be any substituted benzimidazole compound having Ii+, K+ -ATPase inhibiting activity. For the purposes of this invention, the term "PPI" shall mean any substituted benzimidazole possessing pharmacological activity as an inhibitor of H+,K+ -ATPase, including, but not limited to, omeprazole, lansoprazole, pantoprazole, rabeprazole, dontoprazole, perprazole (s-omeprazole magnesium), habeprazole, ransoprazole, pariprazole, and leminoprazole in neutral form or a salt form, a single enantiomer or isomer or other derivative or an alkaline salt of an enantiomer of the same.
Examples of gastric Ii+/K+-ATPase proton pump inhibitors that may be used in the present invention are disclosed for example in LTS Patent 6,093,738 that describes novel thiadiazole compounds that are effective as proton pumps inhibitors. European Patent Nos.
322133 and 404322 disclose quinazoline derivatives, European Patent No. 259174 describes quinoline derivatives, and WO 91/13337 and US Patent 5,750,531 disclose pyrimidine derivatives, as proton pump inhibitors. Suitable proton pump inhibitors are also disclosed for example in EP-A1-174726, EP-A1-166287, GB 2163 747 and W090/06925, W091/19711, W091/19712, W094/27988 and W095/01977.
The PPI particles in the compositions according to the present invention may be either coated or non-coated. The preparation of enteric-coated particles comprising a PPI such as Omeprazole is disclosed for example in US Patents Nos. 4,786,505 and 4,853,230.
The compositions of the present invention comprise a PPI in an effective amount to achieve a pharmacological effect or therapeutic improvement without undue adverse side effects. A therapeutic improvement includes but is not limited to: raising of gastric pH, reduced gastrointestinal bleeding, or improvement or elimination of symptoms.
According to a preferred embodiment, the typical daily dose of the PPI varies and will depend on various factory such as the individual requirements of the patients and the disease to be treated. In general, the daily dose of PPI will be in the range of 1-400 mg. A preferred standard approximate amount of a PPI present in the composition is typically about 20-40 mg of omeprazole, about 30 mg lansoprazole, about 40 mg pantoprazole, about 20 mg rabeprazole, and the pharmacologically equivalent doses of the following PPIs: habeprazole, pariprazole, dontoprazole, ransoprazole, perprazole (s-omeprazole magnesium), and leminoprazole.
In a preferred embodiment, the compositions of the present invention further comprise one or more agents that preserve the availability of PG in the acidic gastric fluids. More specifically, the preservation agent maintains the stability or the solubility of PG in the gastric fluids. This enables PG to act locally in the stomach to activate the parietal cells. Such agents are preferably alkaline agents or antacids that when dissolved in the gastric juice are capable of elevating the pH of the gastric fluids to a pH in which the gastric-residing peptidases are inhibited and at least significant proportion of PG remains soluble in the gastric fluids.
Alkaline agents to be used in the present invention include for example:
sodium or potassium bicarbonate, magnesium oxide, hydroxide or carbonate, magnesium lactate, magnesium glucomate, aluminum hydroxide, aluminium, calcium, sodium or potassium carbonate, phosphate or citrate, di-sodium carbonate, disodium hydrogen phosphate, a mixture of aluminum glycinate and a buffer, calcium hydroxide, calcium lactate, calcium carbonate, calcium bicarbonate, and other calcium salts. It is noted that while sodium bicarbonate dissolves easily in water, calcium carbonate is water-insoluble and is slowly soluble only in acidic environment. Therefore, calcium carbonate may be useful when sustained dissolution of the alkaline agent in the stomach is desired.
Examples of Antacids to be used in the present invention include one or more of the following: alumina, calcium carbonate, and sodium bicarbonate; alumina and magnesia;
alumina, magnesia, calcium carbonate, and simethicone; alumina, magnesia, and magnesium carbonate; alumina, magnesia, magnesium carbonate, and simethicone; alumina, magnesia, and simethicone; alumina, magnesium alginate, and magnesium carbonate; alumina and magnesium carbonate; alumina, magnesium carbonate, and simethicone; alumina, magnesium carbonate, and sodium bicarbonate; alumina and magnesium trisilicate; alumina, magnesium trisilicate, and sodium bicarbonate; alumina and simethicone; alumina and sodium bicarbonate; aluminum carbonate, basic ; aluminum carbonate, basic, and simethicone ;
aluminum hydroxide; calcium carbonate; calcium carbonate and magnesia; calcium carbonate, magnesia, and simethicone; calcium carbonate and simethicone;
calcium and magnesium carbonates; magaldrate; magaldrate and simethicone; magnesium carbonate and sodium bicarbonate; magnesium hydroxide; magnesium oxide.
Preferably, the compositions of the present invention comprise one or more alkaline agents or antacids in an effective amount to achieve a pharmacological effect.
Specifically, the alkaline agents or antacids in the composition are present in an amount sufficient to elevate the pH of the gastric fluids to a pH above the pH optima for proteases found in the stomach for a time period sufficient for PG to activate the parietal cells in the stomach. In a preferred embodiment, the alkaline agents or antacids are present in an amount sufficient to elevate the pH of the gastric fluids to a pH above 5 for a time period ranging from 5 to 60 minutes, preferably for a time period ranging from 5 to 30 minutes. The quantity of alkaline agents required in the compositions of the present invention will necessarily vary with several factors including the type of alkaline agent used and the equivalents of base provided by a given alkaline agent. In practice, the amount required to provide good availability of PG in the stomach is an amount which, when added to a solution of 200 milliliters of artificial gastric fluid (prepared according to the United States Pharmacopea (USP) guideline), raises the pH of that HCl solution to at least pH 5Ø Preferably, at least 100 milligrams, and more preferably at least 300, and most preferably at least 500 milligrams of the alkaline agents are used in the pharmaceutical compositions of the invention.
In another embodiment, the compositions of the present invention further comprise other agents that preserve the availability of PG in the acidic gastric fluids. For example, the compositions may comprise pepsin inhibitors such as the activated pentapeptide pepstatin and its derivatives, either of natural or synthetic origin. These inhibitors might decrease the degradation of PG by pepsin. Furthermore, the compositions may comprise mucolytic agents that reduce the viscosity of the gastric mucosa, thereby accelerating the ability of PG to reach the parietal cells. Such mucolytic agents are for example reducing agents such as N-acetyl cysteine, dithiothreitol, citric acid or mannitol. The compositions alternatively may also comprise a polymeric coating for PG, such as, an enteric-coating of polymers to protect the PG from the acidic environment of the stomach.
The active ingredients of the present invention are preferably formulated in a single oral dosage form containing all active ingredients. The compositions of the present invention may be formulated in either solid or liquid form. It is noted that solid formulations are preferred in view of the improved stability of solid formulations as compared to liquid formulations.
In one embodiment, the PPI particles, PG and the one or more agents that preserve the availability of PG in the gastric fluids are formulated in a single solid dosage form such as mufti-layered tablets, suspension tablets, effervescent tablets, powder, pellets, granules or capsules comprising multiple beads. In another embodiment, the active agents may be formulated in a single liquid dosage form such as suspension containing all active ingredients or dry suspension to be reconstituted prior to use.
In the single dosage form, the PPI particles and the PG particles may be coated with either enteric pH-dependent release polymer or non-enteric, time-dependent release polymer in order to synchronize between the local biological activity of PG in the stomach and the systemic effect of the PPI on parietal cells. For example, if coated PPI
particles are used resulting in delayed absorption in blood, it is desirable that the PG
particles be coated as well to delay its release. In one specific embodiment, the PPI particles are coated with a thick non-enteric layer so as the release of the PPI is preferably delayed by between, 20-80 min, more preferably 25-75 min, most preferably 30-60 min, and the PG particles are coated with a thin non-enteric polymer layer so as the release of PG is preferably delayed by 5-60 min, more preferably between 8-45 min, and most preferably 10-30 min. These conditions permit pre-activation of the parietal cells by PG prior to the achievement of a pharmacological PPI
plasma concentration.
Non-limiting examples of suitable pH-dependent enteric polymers to be used in the present invention are: cellulose acetate phthalate, hydroxypropylnethylcellulose phthalate, polyvinylacetate phthalate, methacrylic acid copolymer, shellac, hydroxypropylmethylcellulose succinate, cellulose acetate trimellitate, and mixtures of any of the foregoing. A suitable commercially available enteric material, for example, is sold under the trademark Eudragit L 100-55. This coating can be spray coated onto the substrate.
Non-enteric time-dependent release polymers include, for example, one or more polymers that swell in the stomach via the absorption of water from the gastric fluid, thereby increasing the size of the particles to create thick coating layer. The time-dependent release coating generally possesses erosion and/or diffusion properties that are independent of the pH
of the external aqueous medium. Thus, the active ingredient is slowly released from the particles by diffusion or following slow erosion of the particles in the stomach.
The erosion properties of the polymer in the stomach resulting from the interaction of fluid with the surface of the dosage form are determined mainly by the polymer molecular weight and the drug/polymer ratio. In order to ensure a delay of between about 10 min to about 60 min in the release of PG and PPI, it is recommended that the molecular weight of the polymer be in the range from about 105 to about 10' gram/mol. Furthermore, it is recommended that the PG or PPI/polymer ratio be in the range of about 2:3 to about 9:1, preferably about 3:2 to 9:1, and most preferably about 4:1 to 9:1.
Suitable non-enteric time-dependent release coatings are for example: film-forming compounds such as cellulosic derivatives, such as methylcellulose, hydroxypropyl methylcellulose (HPMC), hydroxyethylcellulose, and/or acrylic polymers including the non-enteric forms of the Eudragit brand polymers. Other film-forming materials may be used alone or in combination with each other or with the ones listed above. These other film forming materials generally include poly(vinylpyrrolidone), Zein, polyethylene glycol), polyethylene oxide), polyvinyl alcohol), polyvinyl acetate), and ethyl cellulose, as well as other pharmaceutically acceptable hydrophilic and hydrophobic film-forming materials.
These film-forming materials may be applied to the substrate cores using water as the vehicle or, alternatively, a solvent system. Hydro-alcoholic systems may also be employed to serve as a vehicle for film formation.
Other materials which are suitable for making the time-dependent release coating of the invention include, by way of example and without limitation, water soluble polysaccharide gums such as carrageenan, fucoidan, gum ghatti, tragacanth, arabinogalactan, pectin, and xanthan; water-soluble salts of polysaccharide gums such as sodium alginate, sodium tragacanthin, and sodium gum ghattate; water-soluble hydroxyalkylcellulose wherein the alkyl member is straight or branched of 1 to 7 carbons such as hydroxymethylcellulose, hydroxyethylcellulose, and hydroxypropylcellulose; synthetic water-soluble cellulose-based lamina forrriers such as methyl cellulose and its hydroxyalkyl methylcellulose cellulose derivatives such as a member selected from the group consisting of hydroxyethyl methylcellulose, hydroxypropyl methylcellulose, and hydroxybutyl methylcellulose; other cellulose polymers such as sodium carboxymethylcellulose; and other materials known to those of ordinary skill in the art. Other lamina forming materials that can be used for this purpose include poly(vinylpyrrolidone), polyvinylalcohol, polyethylene oxide, a blend of gelatin and polyvinyl-pyrrolidone, gelatin, glucose, saccharides, povidone, copovidone, poly(vinylpyrrolidone)-polyvinyl acetate) copolymer.
Another approach for delaying the release of PG in the stomach is the use of floating particles having density lower than the gastric fluid, thereby delaying the release of PG from the particles. In one preferred embodiment, floating particles are obtained by the release of carbon dioxide within ethylcellulose-coated sodium bicarbonate beads upon contacting with the gastric juice. The release of carbon dioxide from the ethylcellulose-coated sodium bicarbonate core permits the buoyancy of the particles, thereby delaying the release of PG
from the particles.
Other delayed gastric emptying approaches may be used in order to delay the release of PG in the stomach. These include the use of indigestible polymers or fatty acid salts that change the motility pattern of the stomach to a fed state, thereby decreasing the gastric emptying rate and permitting considerable prolongation of drug release (disclosed for example in Singh and Kim, J. of Controlled Release 63 (2000) 235-259).
In certain conditions, it is desirable to prolong the retention time of PG in the stomach by using dosage forms that unfold rapidly within the stomach to a size that resists gastric emptying. Such systems retain their integrity for an extended period and will not empty from the stomach at all until breakdown into small pieces occurs. Caldwell (Caldwell, L. J., Gardener, C. R., Cargill, R. C. (1988), U.S. Pat. No. 4,767,627) describes a cross shaped device made of erodible polymer and loaded with drug which is folded and inserted into a hard gelatin capsule. Following oral administration the gelatin shell disintegrates and the folded device opens out. With a minimum size of 1.6 cm and a maximum size of 5 cm it will not pass from the stomach through the pylorus until the polymer erodes to the point where the system is sufficiently small that it can be passed from the stomach.

An alternative approach to prolong the retention time of PG in the stomach is to use a hydrophilic erodible polymer system such as Polyethylene oxide) (Polyox) and Hydroxypropyl-methylcellulose (HI'MC) that is of a convenient size for administration to humans. On imbibing fluid the system swells over a short period of time to a size that will encourage prolonged gastric retention, allowing sustained delivery of contained drug to absorption sites in the upper gastrointestinal tract. Because these systems are made of an erodible and hydrophilic polymer or polymer mixture, they readily erode over a reasonable time period to pass from the stomach. The time period of expansion is such that this will not occur in the esophagus and if the system passes into the intestine in a partially swollen state, the erodibility and elastic nature of the hydrated polymer will eliminate the chance of intestinal obstruction by the device.
In one specific example, the composition of the present invention is formulated as a single dosage form comprising multiple beads contained in hard or soft gelatin capsules. The capsules contain mixed population of beads selected from: beads comprising enteric-coated PPI or beads comprising PPI coated with time-dependent release polymer, beads comprising calcium carbonate and beads comprising ethylcellulose sodium bicarbonate beads coated with PG, calcium carbonate and hydroxypropyl methylcellulose. The cellulose-based polymer in the composition permits the floating of the PG beads, thus delaying the release of PG from the beads. The rate of PG release is determined by the thickness and the erosion rate of the hydroxypropyl methylcellulose.
In another specific example, the gelatin capsules contain mixed population of beads selected from: beads comprising enteric-coated PPI or beads comprising PPI
coated with time-dependent release coating, beads comprising calcium carbonate and beads comprising alginate coated with PG, calcium carbonate and hydroxypropyl methylcellulose.
In yet another specific example, the gelatin capsules contain mixed population of beads selected from: beads comprising enteric-coated PPI, beads comprising PPI
coated with time-dependent release polymer, beads comprising calcium carbonate and particles in the form of mini-tabs comprising PG, calcium carbonate and hydroxypropyl methylcellulose.
In yet another example, the compositions of the present invention are formulated as press-coat or double-layered tablets comprising enteric-coated PPI in one layer and PG, calcium carbonate and hydroxypropyl methylcellulose in a second layer.
In yet another example, the compositions of the present invention may be formulated as two layer non-aqueous semi-solid fill into hard gelatin capsules in which the PPI is solubilized in a lipid base (non-aqueous, quick release) which is liquid above room temperature but forms a semi-solid on cooling and can therefore be filled into hard gelatin capsules. A lipid soluble alkaline agent such as an amine or a fine suspension of sodium bicarbonate may be included as well.
The single dosage form compositions of the present invention preferably comprise non-coated PPI instead of the enteric-coated PPI particles or the time-dependent release particles. The absorption of non-coated PPI in the upper portion of the small intestine is faster than the absorption of the coated PPI. Therefore, the use of non-coated PPI in the compositions permits more precise synchronization between the biological activity of PG in the stomach and the time period in which the PPI is active without the need for delaying the release of PG. Thus, according to various preferred embodiments, the compositions according to the present invention are formulated as double-layered tablets, press-coat tablets, effervescent tablets or suspension tablets comprising PG, non-coated PPI and one or more alkaline agents.
The active ingredients of the present invention may be formulated in a multiple oral dosage forms in which PG and the one or more agents that preserve the availability of PG in the gastric fluids are administered in a separate dosage form but in conjugation with the PPI.
For example, PG and the one or more agents that preserve the availability of PG in the gastric fluids may be formulated in oral suspension or a solid dosage form such as capsules, tablets, suspension tablets, or effervescent tablets and the PPI may be formulated in a separate solid dosage form, preferably enteric-coated beads or time-dependent release beads contained in capsules or tablets.
When using multiple oral dosage forms, the PG and the one or more agents that preserve the availability of PG in the gastric fluids can be administered before, simultaneously with, or after the PPI. In sequential administration, there may be some substantial delay (e. g., minutes or even few hours) between the administration of PG and the PPI as long as the PG has exerted some physiological effect when the PPI is administered or becomes active. In a preferred embodiment, the PPI administered is in the enteric-coated or the time-dependent release form. According to this embodiment, it is preferable that the PPI
administration precedes the PG administration in order to ensure that the PPI
absorbed in the proximal part of the small intestine will be available for inhibiting the Ii+/K+-ATPase pumps while PG is still active in the stomach.

The active ingredients of the present invention may be incorporated within inert pharmaceutically acceptable beads. In this case, the drugs) may be mixed with further ingredients prior to being coated onto the beads. Ingredients include, but are not limited to, binders, surfactants, fillers, disintegrating agents, alkaline additives or other pharmaceutically acceptable ingredients, alone or in mixtures. Binders include, for example, celluloses such as hydroxypropyl methylcellulose, hydroxypropyl cellulose and carboxymethyl-cellulose sodium, polyvinyl pyrrolidone, sugars, starches and other pharmaceutically acceptable substances with cohesive properties. Suitable surfactants include pharmaceutically acceptable non-ionic or ionic surfactants. An example of a suitable surfactant is sodium lauryl sulfate.
The particles may be formed into a packed mass for ingestion by conventional techniques. For instance, the particles may be encapsulated as a "hard-filled capsule" using known.encapsulating procedures and materials. The encapsulating material should be highly soluble in gastric fluid so that the particles are rapidly dispersed in the stomach after the capsule is ingested.
In another embodiment, the active ingredients of the present invention are packaged in compressed tablets. The term "compressed tablet" generally refers to a plain, uncoated tablet for oral ingestion, prepared by a single compression or by pre-compaction tapping followed by a final compression. Such solid forms can be manufactured as is well known in the art.
Tablet forms can include, for example, one or more of lactose, mannitol, corn starch, potato starch, microcrystalline cellulose, acacia, gelatin, colloidal silicon dioxide, croscarmellose sodium, talc, magnesium stearate, stearic acid, and other excipients, colorants, diluents, buffering agents, moistening agents, preservatives, flavoring agents, and pharmaceutically compatible carriers. The manufacturing processes may employ one, or a combination of, four established methods: (1) dry mixing; (2) direct compression; (3) milling; and (4) non-aqueous granulation. Lachman et al., The Theory and Practice of Industrial Pharmacy (1986). Such tablets may also comprise film coatings, which preferably dissolve upon oral ingestion or upon contact with diluent.
Non-limiting examples of alkaline agents which could be utilized in such tablets include sodium bicarbonate, alkali earth metal salts such as calcium carbonate, calcium hydroxide, calcium lactate, calcium glycerophosphate, calcium acetate, magnesium carbonate, magnesium hydroxide, magnesium silicate, magnesium aluminate, aluminum hydroxide or aluminum magnesium hydroxide. A particular alkali earth metal salt useful for making an antacid tablet is calcium carbonate.

In another alternative, the compositions of the present invention are formulated in compressed forms, such as suspension tablets and effervescent tablets, such that upon reaction with water or other diluents, the aqueous form of the composition is produced for oral administration. These forms are particularly useful for medicating children and the elderly and others in a way that is much more acceptable than swallowing or chewing a tablet.
The present pharmaceutical tablets or other solid dosage forms disintegrate alkaline agent with minimal shaking or agitation.
The term "suspension tablets" as used herein refers to compressed tablets which rapidly disintegrate after they are placed in water, and are readily dispersible to form a suspension containing a precise dosage of the PPI, the PG and the alkaline agent. In one non-limiting example, the suspension tablets may comprise 20-40 mg omeprazole, 4 mg PG and about 1-4 grams of sodium or calcium bicarbonate as an alkaline agent. To achieve rapid disintegration of the tablet, a disintegrant such as Croscarmellose sodium may be added to the formulation. The disintegrant may be blended in compressed tablet formulations either alone or in combination with microcrystalline cellulose, which is well known for its ability to improve compressibility of difficult to compress tablet materials.
Microcrystalline cellulose, alone or co-processed with other ingredients, is also a common additive for compressed tablets and is well known for its ability to improve compressibility of difficult to compress tablet materials. It is commercially available under the Avicel trademark.
The suspension tablet composition may, in addition to the ingredients described above, contain other ingredients often used in pharmaceutical tablets, including flavoring agents, sweetening agents, flow aids, lubricants or other common tablet adjuvants, as will be apparent to those skilled in the art. Other disintegrants, such as crospividone and sodium starch glycolate may be employed, although croscarmellose sodium is preferred.
In addition to the above ingredients, the oral dosage forms described above may also contain suitable quantities of other materials, e.g. diluents, lubricants, binders, granulating aids, colorants, flavorants and glidants that are conventional in the pharmaceutical art. The quantities of these additional materials will be sufficient to provide the desired effect to the desired formulation. Specific examples of pharmaceutically acceptable carriers and excipients that may be used to formulate oral dosage forms are described in the Handbook of Pharmaceutical Excipients, American Pharmaceutical Association (196), incorporated by reference herein.

The following examples are presented in order to more fully illustrate certain embodiments of the invention. They should in no way, however, be construed as limiting the broad scope of the invention. One skilled in the art can readily devise many variations and modifications of the principles disclosed herein without departing from the scope of the invention.
EXAMPLES
Example l: NaHC03 preserves PG stability in artz'ficial gastric fluid The stability of PG in acidic pH in the presence of NaHC03 was tested in vitro using artificial gastric fluid. Artificial gastric fluid was prepared in accordance with U.S.
Pharmacopoeia (USP) 2000 Ed., P. 235. For preparing 200 ml of gastric fluid, 0.4 g of NaCI
and 0.64 g of Pepsin were dissolved in 16 ml 1M HCl and 184 ml of water. The pH of the gastric fluid was 1.2. Ten or twenty ml of 8.4% (1M) NaHC03 (final concentration 3.72 mg/ml or 7.12 mg/ml, respectively) and 16 ml of 250 ppm PG solution (0.25 mg/ml) were added to the solution. The concentration of PG in the final solution was 16 ppm. When indicated, Omeprazole granules were added as well (solutions B and C). In order to determine the stability of PG in the final solution over time, HPLC analysis was performed on samples taken at the following time points post preparation: 0' (immediately following preparation), 5', 10', 20', 40', 60'. To stop the reaction, the pH was adjusted to 7.5 - 8.5 using NH40H.
As demonstrated in Figure 1, fast degradation of PG was observed in solutions A and B that comprise PG in the presence of 3.72 mg/ml of NaHC03 (pH 1.2). However, PG
remained stable for 1h in solution C that comprises 7.12 mg/ml of NaHC03 (pH
5.7). These results indicate that the addition of an alkaline agent such as NaHC03 in a concentration sufficient to elevate the pH above 5.0 prevents the degradation of PG by pepsin. Figure 2 further demonstrates that at least 80% of PG remains non-degraded for at least 15 min in pH
4.8.
A. For»zulatiou descri~ntiorz- Tablets corztainitz~ port-enteric-coated Omenrazole:
Example 2: Press-coated or double-layered tablets cofnprisittg PG, rzon-enteric-coated omeprazole, sodium bicarbonate and calcium carbonate Press-coated or double-layered tablets are formulated as a single dosage form in which each tablet containing the following ingredients:

Omeprazole (powder) 40 mg PG 4 mg NaHC03 500 mg CaC03 500 mg Croscarmellose sodium hydroxypropyl methylcellulose (HPMC) Microcrystalline cellulose (Avicel) Magnesium stearate Starch Press-coated or double-layered tablets are prepared in a two-step process. For a single tablet, 4 mg PG, 250 mg calcium carbonate and microcrystalline cellulose are mixed and pre-compressed into the first layer of the tablet. The layer containing the PG is further coated with a thin layer of HPMC that permits a delay of 10-15 min in the release of PG from the tablet. For the second layer, 40 mg of non-enteric-coated omeprazole powder together with 500 mg NaHC03, 250 mg CaC03 and the appropriate binders are compressed onto the PG layer to form the second layer of the tablet. The second layer of the tablet disintegrates immediately after digestion to permit prompt release of omeprazole. A schematic illustration of a double-layered tablet comprising PG, non-enteric-coated omeprazole, sodium bicarbonate and calcium carbonate is presented in Figure 3.
Example 3: Fast disintegrating tablets comprising PG, non-enteric-coated onzeprazole, sodium bicarbonate and calcium carbonate Fast disintegrating tablets are formulated as a single dosage containing the following ingredients:
Omeprazole (powder) 40 mg PG 4 mg NaHC03 500 mg CaC03 500 mg Croscarmellose sodium Microcrystalline cellulose Magnesium stearate Starch Non-enteric-coated omeprazole (40 mg), PG (4 mg), NaHC03, CaC03, Croscarmellose sodium, Microcrystalline cellulose and Magnesium stearate are mixed and the resulting mixture is compressed into tablets using standard tablet pressing to yield a fast disintegrating tablet (intravescent).
Example 4: Effervescent sacs comprising PG, enteric-coated omeprazole, and sodium bicarbonate Effervescent tablets are formulated as a single dosage containing the following ingredients:
Omeprazole 40 mg PG 4 mg NaHC03 958 mg Citric acid 832 mg Potassium carbonate 312 mg Magnesium stearate Starch Enteric-coated omeprazole (40 mg) and PG (4mg) are placed into a mortar and triturated with a pestle to a fine powder. Sodium bicarbonate, citric acid, potassium carbonate and all other excipients are added to the mixture to form a homogeneous mixture of effervescent powder. The resulting powder is mixed with 40mg enteric-coated omeprazole and packed in packets of unit dose.
B. Formulation description- Multi particulate capsules coutaiuin~ coated Omenrazole:
Example 5: Capsules comprising ethylcellulose-PG beads, enteric-coated omeprazole beads, and calcium carbonate.
This example illustrates the steps involved in manufacturing mufti particulate hard gelatin capsules. Hard gelatin capsules are formulated as a single dosage form comprising mixed population of particles. Each capsule contains the following ingredients:

40 mg omeprazole as enteric-coated beads 4 mg PG loaded on ethylcelluiose-coated sodium bicarbonate beads 600 mg calcium carbonate (CaC03) hydroxypropyl methylcellulose (HPMC) PG solution is prepared by dissolving PG in ammonium carbonate buffer pH 8.
The PG solution is sprayed on the ethylcellulose-coated sodium bicarbonate beads in a fluidized bed apparatus. After drying, the PG-sodium bicarbonate beads are further coated with CaC03 and with hydroxypropyl methylcellulose (HPMC) to form the final PG particles.
The final PG particles are packed together with enteric-coated omeprazole beads and calcium carbonate powder into size 0 hard gelatin capsules in an amount corresponding to 40 mg omeprazole, 4 mg PG and 600 mg calcium carbonate per capsule.
Upon dissociation of the gelatin capsules in the gastric juice of the stomach, the HPMC layer of the PG-containing beads expands and the gastric acid reacts with sodium bicarbonate to form COZ inside the bead core. The release of carbon dioxide from the ethylcellulose-coated sodium bicarbonate core permits the buoyancy of the particles, thereby delaying the release of PG and calcium carbonate from the particles. The rate of PG release is determined by the thickness and the erosion rate of the HPMC layer of the PG
beads. CaC03 increases the gastric pH for a prolonged period of time, to protect PG upon release. The enteric-coated omeprazoie beads pass the stomach and omeprazole is absorbed in the upper part of the small intestine without any delay.
Exanzple 6: Capsrcles cofnprising alginate-PG beads, entez-ic-coated ofneprazole beads, arid calcium carbonate Hard gelatin capsules are formulated as a single dosage form comprising mixed population of particles. Each capsule contains the following ingredients:
40 mg omeprazole as enteric-coated beads 4 mg PG loaded on alginate particles 600 mg calcium carbonate (CaC03) hydroxypropyl methylcellulose (HPMC) Alginate particles are made by dropping an alginate solution into calcium chloride solution following by freeze-drying to yield alginate particles. The PG
solution prepared as in Example 5 is sprayed on the alginate particles in a fluidized bed apparatus.
After drying, the PG-alginate beads are further coated with CaC03 and with hydroxypropyl methylcellulose (HPMC) to form the final PG particles. The final PG particles together with the enteric-coated omeprazole beads and calcium carbonate powder are packed into size 0 hard gelatin capsules in an amount corresponding to 40 mg omeprazole, 4 mg PG and 600 mg calcium carbonate per capsule.
Upon dissociation of the gelatin capsules in the stomach, the PG beads are expanded IO due to the contact of the HPMC layer with the gastric juice. The freeze-dried alginate particles permit the buoyancy of the particles due to their low density thereby delaying the release of PG from the particles. The rate of PG release is determined by the thickness and the erosion rate of the HPMC layer of the PG beads. The enteric-coated omeprazole beads pass the stomach and omeprazole is absorbed in the upper part of the small intestine without any delay.
Example 7: Capsules co»tprisiug sucrose-PG beads, enteric-coated o»teprazole beads, and calciu»z carbo»ate Hard gelatin capsules are formulated as a single dosage form comprising mixed population of particles. Each capsule contain the following ingredients:
40 mg omeprazole as enteric-coated beads 4 mg PG loaded on inert sugar beads 600 mg calcium carbonate (CaC03) hydroxypropyl methylcellulose (HPMC) The PG solution is sprayed on inert sugar pellets (Nu-Pareils, 25/30) in a fluidized bed apparatus. After drying, the PG-sugar beads are further coated with CaC03 and with hydroxypropyl methylcellulose (HPMC) to form the final PG particles. A
schematic illustration of the PG granules is presented in Figure 4. The final PG
particles together with the enteric-coated omeprazole beads and calcium carbonate powder are packed into size 0 hard gelatin capsules in an amount corresponding to 40 mg omeprazole, 4 mg PG
and 600 mg calcium carbonate per capsule.

Upon dissociation of the gelatin capsules in the stomach, the PG beads are expanded due to the contact of the HPMC layer of the PG-containing beads with the gastric juice, thereby delaying the release of PG from the particles. The rate of PG release is determined by the thickness and the erosion rate of the HPMC layer of the PG beads. The enteric-coated omeprazole beads pass the stomach and omeprazole is absorbed in the upper part of the small intestine without any delay.
Exa»anle 8: Hard gelatin capsules comprising HPMC-PG »ainitabs, enteric-coated omeprazole beads, and calcium carbonate Hard gelatin capsules are formulated as a single dosage form comprising mixed population of particles. Each capsule contains the following ingredients:
40 mg omeprazole as enteric-coated omeprazole beads 4 mg PG loaded on inert sugar beads 600 mg calcium carbonate (CaC03) hydroxypropyl methylcellulose (HPMC) PG is granulated in combination with HPMC and CaC03 and compressed into mini-tabs. The mini-tabs possess the ability of fast swelling upon contact with the gastric juice of the stomach, thereby enabling gastric retention. The release of PG into the stomach is controlled by the erosion rate of the polymeric matrix of the swelled mini-tabs. The PG mini-tabs together with the enteric-coated omeprazole beads are packed into size 0 hard gelatin capsules in an amount corresponding to 40 mg omeprazole, 4 mg PG and 600 mg calcium carbonate per capsule.
Example 9: Multi particulate capsules containing Omeprazole and PG beads coated with non-enteric tifne-dependent release coating:
This example illustrates the steps involved in manufacturing multi particulate hard gelatin capsules. Capsules are formulated as a single dosage form comprising mixed population of particles: PG beads coated with time-dependent release coating, omeprazole beads coated with time-dependent release coating, and calcium carbonate. A
schematic illustration of the capsule is present in Figure 5. Each capsule contains the following ingredients:
~ 40 mg omeprazole beads coated with thick HPMC layer ~ 4 mg PG loaded on sugar spheres and coated with thin HPMC layer ~ 600 mg calcium carbonate (CaC03) The composition of the coating is designed such that the core is rapidly disintegrated into an aqueous environment when the media come into contact with the core.
For this purpose Sugar sphere will be coated with an antacid (NaHC03 or CaC03) layer.
PG solution is prepared by dissolving PG in ammonium carbonate buffer pH ~. The PG
solution is sprayed on to the above antacid-coated beads in a fluidized bed apparatus.
After drying, the beads are further coated with a thin layer of HPMC to create PG particles with approx. 10 min delayed release. Omeprazole is layered over the antacid-coated Sugar spheres and is covered with a thick time-release HPMC coating. A disintegrant also may be added to the core of the particle to facilitate the prompt release of omeprazole after the HPMC is dissolved. The coated Omeprazole beads are aimed to pass the stomach and are absorbed at the upper parts of the small intestine after the HPMC is dissolved and the Omeprazole is released at once. The final PG particles are packed together with the omeprazole beads and calcium carbonate powder into size 0 hard gelatin capsules in an amount corresponding to 40 mg omeprazole, 4 mg PG and 600 mg calcium carbonate per capsule. The rate of PG and OMP release is determined by the thickness and the erosion rate of the HPMC
layer of the beads. CaCO3 increases the gastric pH for a prolonged period of time, to preserve PG upon release.
C For»tulatio~t descrintiou- Tablets cofttainin~ enteric-coated Omenra ole:
Exa»tnle 10: Press-coated tablets comprising PG, enteric-coated o»teprazole beads, and calciu»a carbonate Press-coated tablets are formulated as a single dosage form containing the following ingredients:
40 mg omeprazole as enteric-coated omeprazole beads 4 mg PG granules Calcium carbonate hydroxypropyl methylcellulose (HPMC) Press-coated tablets are prepared in a two-step process. For a single tablet, 4 mg PG, 900 mg calcium carbonate and HPMC are mixed and pre-compressed into the central core of the tablet. 40 ing of enteric-coated omeprazole beads are press-coated onto the PG core to form the external layer of the tablet. The final tablet is composed of controlled-release PG
core layer and immediate release outer layer of omeprazole enteric-coated beads. In another example, the active ingredients are compressed into double-layered tablet wherein the first layer comprises 4 mg PG, 900 mg calcium carbonate and HPMC and the second layer comprises 40 mg of enteric-coated omeprazole beads.
The compressed tablet may include one or more of the following excipients:
lactose, mannitol, corn starch, potato starch, microcrystalline cellulose, acacia, gelatin, colloidal silicon dioxide; croscarmellose sodium, talc, magnesium stearate, stearic acid, and other excipients, colorants, diluents, buffering agents, moistening agents, preservatives, flavoring agents, and pharmaceutically compatible carriers.
Exaznnle 1l: Fast disintegrating tablets comprising PG, enteric-coated onzeprazole beads atzd calciunz carbonate Fast disintegrating suspension tablets are formulated as a single dosage containing the following ingredients:
40 mg omeprazole as enteric-coated omeprazole beads 4 mg PG granules 900 mg calcium carbonate Croscarmellose sodium Microcrystalline cellulose Magnesium stearate hydroxypropyl methylcellulose (HPMC).
PG granules are coated with CaC03 and with hydroxypropyl methylcellulose (HPMC) to form the final PG particles. The final PG particles are mixed with enteric-coated omeprazole beads and the excipients listed above and the resulting mixture is compressed into tablets using standard tablet pressing. The resulting tablets possess rapid disintegration time and may be swallowed with water for fast disintegration in the stomach.
Upon disintegration of the suspension tablet, the PG particles are expanded due to the contact of the HPMC layer of the PG-containing beads with aqueous environment, thereby delaying the release of PG from the particles. The rate of PG release is determined by the thickness and the erosion rate of the HPMC layer of the PG beads. The enteric-coated 2~

omeprazole beads pass the stomach and omeprazole is absorbed in the upper part of the small intestine without any delay.
D In vivo experiments Example 12: Stimulation of Gastric Acid Secretion Following Oral Ad»zifzistration of PG i» Rats Inhibition of gastric acid secretion by a combination of PG and PPI is based on the ability of orally administered PG to trigger acid secretion locally within the stomach. To address this issue anesthetized rats were administered (per os) with increasing amounts of PG
and gastric acid secretion was monitored in a pylorus-ligated stomachs.
Increasing amounts (10, 30, and 90p.g/kg) of PG were administered by oral gavage to pylorus-ligated rats.
Following 30 min treatment, gastric juice was collected from the gastric lumen, and acid concentration was determined by titration with NaOH and total acid output expressed in ~.Eq HCl was calculated by multiplying the sample volume by the acid concentration.
Results are expressed as means ~ SEM of 7-~ animals from each experimental group. As demonstrated in Figure 6, orally administered PG significantly enhanced gastric acid secretion in a dose-dependent manner, suggesting that orally administered PG successfully induces gastric acid secretion in a local manner.
Example 13: The effect of PG administered with o»zeprazole o» intragastric pH
To test the effect of the PG-PPI combination on suppression of gastric acid secretion, anesthetized rats were subjected to intragastric injection of either omeprazole (10 mg/kg) alone or in combination with PG (350 ~,g/kg). Rats treated with the combination received PG
15 minutes before omeprazole. The gastric juice was collected by suction at 30, 45, and 60 minutes after the treatment and an effect of drugs on gastric acid secretion was detected by monitoring pH. The data demonstrated that the intragastric pH value at all time points was markedly higher in rats treated with combination of PG and omeprazole than with omeprazole alone (Figure 7). These results indicate that PG enhances the anti-secretory activity of PPI in rats.
Example 14: Larzsoprazole inhibits gastric acid secretion in conscious ani»zals in a dose-dependent manner.

In this experiment, a different model of pylorus-ligated rats that permits the analysis of the effect of drugs on gastric acid secretion in conscious animals was used. This model eliminates the effect of anesthesia on gastric acid secretion. The study drugs alone or in combination were administered per os. One or two hours later the animals were anesthetized using anesthetic gas machine for a short period (5 minutes) that is sufficient to perform the pylorus ligation procedure and to close the abdomen. The animals were then placed back into its cage for recovery. Several hours later the animals were sacrificed, the ligature was placed around the esophagus, the stomach removed and gastric content was collected.
Following centrifugation the gastric juice samples were automatically titrated with 0.01 N NaOH to endpoint pH 7 and titratable acid output was calculated.
Lansoprazole was administered by oral gavage as a simplified suspension (SLS).
SLS
was prepared as follows: the content of one 30 mg capsule (Zoton) was suspended in 8.4%
sodium bicarbonate. Rats were treated with three doses of Lansoprazole (20, 5 and 1.25 mg/kg) 2 hours before pylorus ligation. 8.4% NaHC03 was administered into the control group as a placebo. Figure 8 demonstrates that Lansoprazole inhibited the gastric acid secretion in a dose-dependent manner.
Example I5: The effect of Lansoprazole administered in combination with PG on gastric acid secretion in conscious pylorus-ligated rats.
In this experiment, rats were treated with SLS at a dose 5 mg/kg either 15 minutes before (A) or after (B) PG (300 ~g/kg). The control rats were injected with combination of 8.4% NaHC03 and PG-vehicle as a placebo. All drugs were administered by oral gavage 2 hours before pylorus ligation. The gastric juice was collected during 3 hours.
Data is presented as mean~SEM. Number of animals is 8-9 in each experimental group.
As can be seen in Figure 9A the administration of SLS 15 minutes before PG led to a greater extent of acid inhibition as compared to Lansoprazole alone, whereas acid output in rats pretreated with PG and then treated with SLS did not differ from that of Lansoprazole alone-treated rats (Figure 9B). These results indicate that PG increases the efficacy of Lansoprazole in the blockade of gastric acid secretion. Moreover, the timing between the two compounds is important in order to get increased effectiveness of PG/Lansoprazole combined treatment.
In another experiment, rats were treated once daily during 3 consecutive days with either SLS at a dose 2.5 mg/kg and vehicle or SLS and PG (300 ~,g/kg). SLS was administered 15 minutes before PG or vehicle. The control rats were injected with combination of 8.4% NaHC03 and PG-vehicle as a placebo. All drugs were administered by oral gavage. The pylorus ligation was performed on third day 2 hours following treatment.
The gastric juice was collected during 3 hours. Data is presented as mean~SEM.
Number of animals is 8 in each experimental group. As demonstrated in Figures 10A and 10B, administration of SLS in combination with PG during 3 consecutive days resulted in significantly higher intragastric pH as compared to SLS alone. Similarly, the gastric acid secretion in rats treated with SLS/PG combination for three consecutive days was lower than that following administration of SLS alone.
Example 16: The effect of a CCK B Ahtagohist oh PG-Mediated gastric acid secretioya ih pats As PG is a gastrin hormone homologue, its local effect is thought to be mediated via gastrin pathway, i.e. an activation of gastrin receptor (CCKB). To test this hypothesis the effect of the specific CCKB antagonist (Itriglumide) on PG-mediated acid secretion in rats was examined.
In this study, rats were anesthetized with I~etamine and Domitor mixture and provided with 20 mg/kg of Itriglumide that was administered intraduodenally (i.d.).
Following 15 min, gastric pylorus was ligated and 300 ~ug/kg PG was administered into the stomach (i.g.). After 30 min, gastric juice was obtained, centrifuged and the volume and pH
of the supernatants were measured. The acid concentration (titratable acidity) was analyzed by titration the gastric juice samples with NaOH and total acid output expressed in E,~Eq HCl was calculated by multiplying the sample volume by the acid concentration. As revealed from the results presented in Table 1 below, intraduodenal injection of CCKB
antagonist (ant.) inhibits the local effect of PG on gastric acid secretion in rats.
Table 1:

Group Acid Output MEAN SEM

PG (i.g.), 300 uglkg60.056 10.43 CCI~B ant. (i.d.) 15.24 2.82 20 mglkg Placebo of PG (i.g.)-19.25 3.03 Placebo of CCKB ant.12.93 1.55 -saline (i.d.) PG (i.g.), 300 ug/kg22.884 2.70 and CCKB ant.(i.d.) 20 mg/ml PG (i.g.), 300 ug/kg51.74 9.35 and Placebo of CCKB ant.
-saline (i.d.) Student t-test PG vs.ant.+PG P=0.0023 P=0.0042 P=0.0016 Example 17: The effect of intraduodehal iujectio~a of PG oh acid secretion iu anesthetized pylorus-ligated rats The effect of intraduodenal injection of PG on acid secretion in anesthetized pylorus-ligated rats was examined. In this study, 300 pg/kg PG was administered intraduodenaly in anesthetized pylorus-ligated rats and the level of gastric acid secretion was determined 30 minutes later. Gastric juice was obtained, centrifuged and the volume and pH
of the supernatants were measured. The acid concentration (titratable acidity) was analyzed by titration gastric juice samples with NaOH and total acid output expressed in ~.Eq HCl was calculated by multiplying the sample volume by the acid concentration. As a control the equal amount of PG was injected intragastrically and the effect of PG on gastric secretion was determined. As demonstrated in Table 2, both intragastric and intraduodenal injection of PG
induce gastric acid secretion in anesthetized pylorus-ligated rats.

Tahle 2:
Grou Acid Out ut MEAN
SEM

PG (i. .), 300 a 45.89 6.37 /k Placebo (i. .) 12.46 2.65 PG (i.d.), 300 a 42.26 6.95 /k Placebo (i.d.) 11.65 1.44 Student t-test (i.g.) vs. Placebo P= 0.000125 P= 0.000243 P= 1.981x105 It will be appreciated by a person skilled in the art that the present invention is not limited by what has been particularly shown and described hereinabove. Rather, the scope of the invention is defined by the claims that follow.

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Claims

1. An oral pharmaceutical composition comprising as active ingredients a pharmaceutically effective amount of: (i) a peptide comprising the amino acid sequence of SEQ ID NO:1, which activates parietal cells; (ii) an irreversible gastric H+/K+-ATPase proton pump inhibitor (PPI); and (iii) at least one agent that preserves the availability of the peptide in gastric fluids.

2. The oral composition of claim 1, wherein the peptide is pentagastrin (PG) having the amino acid sequence of SEQ ID NO:2 or a synthetic analog thereof.

3. The oral composition of claim 2, wherein the preservation agent is one or more alkaline agents, wherein the amount of the alkaline agents is sufficient to preserve the availability of PG in the stomach so that the biological activity of PG is maintained.

4. The oral composition of claim 3, wherein the alkaline agent is selected from the group consisting of: calcium carbonate, sodium or potassium bicarbonate, magnesium oxide, hydroxide or carbonate, magnesium lactate, magnesium glucomate, aluminum hydroxide, aluminium, calcium, sodium or potassium carbonate, phosphate or citrate, di-sodium carbonate, disodium hydrogen phosphate, a mixture of aluminum glycinate and a buffer, calcium hydroxide, calcium lactate, calcium carbonate and calcium bicarbonate.

5. The oral composition of claim 3, wherein the oral composition is formulated in a single unit dosage form and the alkaline agent is in an amount of at least 300 mg.

6. The oral composition of claim 2, wherein the peptide is in an amount sufficient to locally activate parietal cells located in the gastric lumen.

7. The oral composition of claim 2, wherein the active ingredients are formulated in a single unit dosage form.

8. The oral composition of claim 7, wherein the amount of PG is between 2 to mg.

9. The oral composition of claim 7, wherein the single unit dosage form is a double-layered tablet, a press-coat tablet, a multi-particulate capsule, an effervescent tablet, a suspension tablet, solution, or suspension comprising PPI beads, PG beads and at least one alkaline agent.

10. The oral composition of claim 9, wherein the amount of the alkaline agent is sufficient to preserve the availability of PG in the stomach so that the biological activity of PG is maintained.

11. The oral composition of claim 10, wherein the PPI beads and the PG beads are coated with enteric-coating or with time-dependent release polymers, wherein the release of the PPI from the PPI beads is delayed relative to the release of PG from the PG beads.

12. The oral composition of claim 11, wherein the time-dependent release polymers comprise at least one polymer capable of swelling in aqueous environment.

13. The oral composition of claim 12, wherein at least one polymer is selected from the group consisting of: a synthetic polymer and cellulose-based polymer, or substituted derivative thereof.

14. The oral composition of claim 11, wherein the PG beads further comprise at least one carbonate salt capable of reacting with gastric acid to form carbon dioxide which is entrapped within the PG beads, thereby inducing the buoyancy of said PG beads over the gastric juice.

15. The oral composition of claim 14, wherein the carbonate salts are sodium bicarbonate or calcium carbonate.

16. The oral composition of claim 10, comprising non-coated PPI beads, PG
beads and at least one alkaline agent, wherein the release of PG from the PG beads is delayed relative to the release of the PPI from the PPI beads.

17. The oral composition of claim 16, wherein the one or more alkaline agents are selected from the group consisting of: calcium carbonate, sodium or potassium bicarbonate, magnesium oxide, hydroxide or carbonate, magnesium lactate, magnesium gluconate, aluminum hydroxide, aluminium, calcium, sodium or potassium carbonate, phosphate or citrate, di-sodium carbonate, disodium hydrogen phosphate, a mixture of aluminum glycinate and a buffer, calcium hydroxide, calcium lactate, calcium carbonate and calcium bicarbonate.

18. The oral composition of claim 16, wherein the composition comprises non-coated PPI beads, PG beads and one or more alkaline agents formulated in the form of a press-coat tablet, a double-layered tablet, a multi-particulate capsule, an effervescent tablet, a suspension tablet, solution, or suspension.

19. The oral composition of claim 1, wherein the PPI is selected from the group consisting of: rabeprazole, omeprazole, isomeprazole, lansoprazole, pantoprazole, leminoprazole, single enantiomers thereof, alkaline salts thereof and mixtures thereof.

20. The oral composition of claim 1, wherein the composition further comprising a pepsin inhibitor, a mucolytic agent or an antibiotic effective against bacteria residing in the stomach.

21. The oral composition of claim 2, wherein the peptide is the N-protected derivative of PG selected from the group consisting of: methoxymethyl (MOM), .beta.-methoxyethoxymethyl (MEM), trialkylsilyl, triphenylmethyl (trityl), TIPSO, tert-butoxycarbonyl (t-BOC), ethoxyethyl (EE), F-MOC, and TROC.

22. An oral pharmaceutical kit comprising as active ingredients a pharmaceutically effective amount of: (i) a peptide comprising the amino acid sequence of SEQ
ID NO:1; (ii) an irreversible gastric H+/K+-ATPase proton pump inhibitor (PPI); and (iii) at least one agent that preserves the availability of the peptide in the gastric fluids.

23. The kit of claim 22, wherein the active ingredients are formulated in separate unit dosage forms.

24. A method of treating or preventing a disorder in a subject in which suppression of gastric acid secretion is required, comprising administering to a subject in need of such treatment a therapeutically effective amount of a composition according to claim 1.

25. The method of claim 24, wherein the disorder is selected from the group consisting of: reflux esophagitis, gastritis, duodenitis, gastric ulcer, duodenal ulcer, pathologies associated with nonsteroidal anti-inflammatory drugs (NSAID), non-ulcer Dyspepsia, gastro-esophageal reflux disease, gastrinomas, acute upper gastrointestinal bleeding, stress ulceration, Helicobacter pylori infections, Zollinger-Ellison syndrome (ZES), Werner's syndrome, and systemic mastocytosis.

26. The method of claim 24, wherein the subject is a human subject.

27. A method of treating or preventing a disorder in a subject in which suppression of gastric acid secretion is required, comprising administering to a subject in need of such treatment a therapeutically effective amount of a composition according to claim 22.

28. The method of claim 27, wherein the peptide is administered simultaneously, prior to or following the administration of the PPI.