EA042749B1 - METFORMIN COMPOSITIONS AND METHODS FOR THE TREATMENT OF GLUCOSE METABOLISM DISORDERS - Google Patents

Description

cross reference

The present application is a partial continuation of US application No. 13/345135 and application

PCT No. PCT/US2012/020548 filed on January 6, 2012. This application also claims priority to U.S. Provisional Application No. 61/649171, filed May 18, 2012. The entire content of each of the above applications is incorporated herein by reference.

Technical field

The present invention relates to compositions for the targeted administration of metformin to a subject, for example, in methods of treating metabolic disorders.

State of the art

Despite ongoing, massive efforts to develop effective treatments for diabetes, metabolic syndrome, obesity, overweight, and related metabolic conditions, the number of people worldwide suffering from them is growing rapidly. These conditions lead to multiple medical complications, reduced quality of life, reduced life expectancy, decreased work capacity, overburdened medical systems, and burdened health insurance providers, resulting in overall higher prices. In addition, maintaining health is essential, including a healthy body weight and healthy blood glucose levels.

Treatments for type II diabetes currently in use or under development are aimed at lowering blood glucose concentrations. They include GLP-1 (glucagon-like peptide-1) mimetics, a hormone that plays a key role in the regulation of insulin, glucose, and hunger. Examples of mimetics are the GLP-1 receptor agonists, exenatide (Byetta®) and the GLP-1 analog liraglutide. Other drugs inhibit DPP-IV, an enzyme that rapidly degrades endogenous GLP-1. Exenatide is a GLP-1 receptor agonist that is more slowly degraded by DPP-IV. Liraglutide, a GLP-1 analog, is attached to a fatty acid molecule that binds to albumin and slows down the rate of GLP-1 release and degradation. (See, for example, Nicolucci, et al., 2008, Incretin-based therapies: a new potential treatment approach to overcome clinical inertia in type 2 diabetes, Acta Biomedica 79(3): 184-91 and US Pat. No. 5,424,286 Exendin- 3 and exendin-4 polypeptides, and pharmaceutical compositions comprising the same.)

Metformin, a biguanide, is an antihyperglycemic agent that improves glucose tolerance in patients with type II diabetes by lowering both basal and postprandial plasma glucose. Its pharmacological mechanisms of action differ from other classes of oral antihyperglycemic agents. Metformin reduces hepatic glucose production, decreases intestinal glucose uptake, and improves insulin sensitivity by increasing peripheral glucose uptake and utilization. However, metformin has been described to be largely excreted by the kidneys, and the risk of metformin accumulation and lactic acidosis increases with the degree of deterioration in renal function. For example, in patients with known or suspected impaired renal function, such as elderly patients, administration of metformin requires careful monitoring and dose titration to prevent lactic acidosis, a potentially lethal metabolic complication. Patients with underlying cardiovascular or hepatic disease, sepsis, and hypoxia also have an increased risk of lactic acidosis. Consequently, metformin remains an unsatisfactory and/or dangerous treatment for some patient groups due to its side effects.

Until recently, obesity treatments included two FDA-approved drugs. Orlistat (Xenical®) reduces intestinal fat absorption by inhibiting pancreatic lipase. Sibutramine (Meridia®), withdrawn from the European and US market, reduces appetite by inhibiting the deactivation of the neurotransmitters norepinephrine, serotonin and dopamine. Unwanted side effects have been described for these drugs, including effects on blood pressure. (See, for example, Prescription Medications for the Treatment of Obesity, NIH Publication No. 07-4191, December 2007). Surgical treatments may be used, including gastric bypass surgery and gastric banding, but only in exceptional cases. These procedures can be dangerous and may also be inappropriate for patients in need of more moderate weight loss.

Brief description of the invention

This document provides compositions containing metformin or its saltmetformin, as well as methods of treatment using these compositions.

In some embodiments, the compositions provided herein are configured to minimize the systemic bioavailability of a compound as compared to a composition containing an equivalent amount of the compound formulated for immediate release. In some embodiments, the compositions described herein can be made to be released in the upper or small intestine, in the lower or large intestine, or both. The introduction of the compositions into the intestine is carried out by any known method, including oral. In some embodiments, the compositions described herein comprise metformin, or a salt thereof, configured to release a therapeutically effective amount of metformin, or a salt thereof, outside the stomach.

In the compositions and methods described herein, metformin or a salt thereof may contain an asymmetric center or centers and form compositions of a racemic mixture, a diastereomeric mixture, a single enantiomer, an enantiomeric diastereomer, a meso compound, a pure epimer or a mixture of epimers, etc. In other embodiments, metformin or a salt thereof contains one or more double bonds, wherein said compound is a mixture of cis/trans, E/Z, or its E or Z geometric isomer. The compound may be a salt selected from hydrochloride, hydrobromide, acetate, propionate, butyrate, sulfate, hydrosulfate, sulfite, carbonate, hydrogen carbonate, phosphate, phosphinate, oxalate, hemi-oxalate, malonate, hemi-malonate, fumarate, hemi-fumarate, maleate , hemi-maleate, citrate, hemi-citrate, tartrate, hemi-tartrate, aspartate and glutamate.

In the methods described herein, metformin or a salt thereof can be formulated into a composition containing components A, B and C, while

A is the protonated form of a natural or non-natural amino acid;

B is an acid dianion; And

C is the protonated form of Metformin or its solimetformin or its salt. In some implementations.

A is the protonated form of a natural amino acid selected from alanine, aspartic acid, asparagine, arginine, glycine, glutamine, glutamic acid, lysine, phenylalanine, tyrosine, serine, threonine, tryptophan, leucine, isoleucine, histidine, methionine, proline, cysteine and cystine; And

B is a dianion of an acid selected from oxalic, malonic, citric, maleic, fumaric, tartaric, aspartic and glutamic acids.

C is the protonated form of metformin or a salt thereof. In other embodiments, a therapeutically effective amount of metformin, or a solimetformin thereof, or a salt thereof, is from about 1 mg to about 2000 mg. In other embodiments, a therapeutically effective amount of metformin or a salt thereof is from about 10 mg to about 1500 mg. In other embodiments, a therapeutically effective amount of metformin, or a solimetformin thereof, or a salt thereof, is from about 50 mg to about 1000 mg. In other embodiments, a therapeutically effective amount of metformin, or a solimetformin thereof, or a salt thereof, is from about 100 mg to about 500 mg.

In preferred embodiments, the compositions described herein are capable of reducing or minimizing the systemic bioavailability of a compound, e.g., minimizing the circulating plasma concentration of metformin or its salts in the patient's body, and/or reducing the mean systemic bioavailability of the compound, e.g., compared to an immediate formulation. release containing an equivalent amount of the specified connection. In some embodiments, the minimized circulating plasma concentrations are less than about 5, 4, 3, 2, 1, 0.5, or 0.24 μg/mL in subjects with normal or impaired renal function. In other embodiments, the adapted compound composition has a relative bioavailability of 70%, 60%, 50%, 40%, 30%, 20%, or 10% relative to an immediate release composition containing the same amount of said compound.

In some embodiments, the compositions provided herein are configured to release a therapeutically effective amount of metformin or a salt thereof in one or more parts of the intestine.

In some embodiments, the compositions are configured to be released into the duodenum, small intestine, ileum, caecum, colon, and/or rectum. In other embodiments, the compositions are configured to be released into the small intestine, ileum, caecum, colon, and/or rectum. In some embodiments, the composition is formulated for release in the lower intestine. In further embodiments, the composition is formulated to be released in the upper intestine. In further embodiments, the composition is formulated to be released in the upper intestine and in the lower intestine.

In one embodiment, the composition releases metformin or a salt thereof with onset of action at about 75 minutes, about 105 to about 135 minutes, about 165 to about 195 minutes, or about 225 to about 255 minutes, or a range of combinations thereof, after oral administration to a subject.

In other embodiments, the composition releases metformin or a salt thereof with onset of action at about pH 5.0, about pH 5.5, about pH 6.0, about pH 6.5, about pH 7.0, or a combination thereof, after oral administration. introduction to the subject.

Also provided herein are compositions containing metformin or a salt thereof which further comprise one or more chemosensory receptor ligands selected from a sweet taste receptor ligand, a umami taste receptor ligand, a fat receptor ligand, a bile acid receptor ligand, a ligand for bitter taste receptor, or any combination thereof. In some embodiments, the composition further comprises a ligand for the sweet taste receptor. In other embodiments, the composition further comprises a taste receptor ligand

- 2 042749 umami. In other embodiments, the composition further comprises a sweet taste receptor ligand and a umami taste receptor ligand.

Ligands for the sweet taste receptor include glucose, sucrose, aspartame, stevioside, rebaudioside, neotame, acesulfame-K, and saccharin. Ligands for the umami taste receptor include glutamate salts, glutamines, acetylglycines, or aspartame. Fat receptor ligands include linoleic acids, oleic acids, palmitates, oleoylethanolamides, mixed fatty acid emulsions, omega-3 fatty acids, and N-acylphosphatidylethanolamine (NAPE). Ligands for the sour taste receptor include citric acid and hydroxycitric acid. Bile acids include deoxycholic acids, taurocholic acids and chenodeoxycholic acids. In some embodiments, the chemosensory receptor ligand is non-metabolizable. In some embodiments, the chemosensory receptor ligand is an agonist. In some embodiments, the chemosensory receptor ligand is an enhancer.

Accordingly, compositions containing metformin or a salt thereof are also provided herein, which further comprise a chemosensory receptor enhancer selected from the group consisting of a sweet taste receptor enhancer, a bitter taste receptor enhancer, a umami taste receptor enhancer, a fat receptor enhancer, a sour taste receptor enhancer. and a bile acid receptor enhancer. In some embodiments, the chemosensory receptor enhancer is a umami taste receptor enhancer that enhances the action of food on umami taste receptors in the gut.

The compositions described herein may be formulated with an enteric coating. In another aspect, the compositions described herein may be formulated with a modified release system. In another aspect, the compositions described herein may be formulated with a timed release system. In an additional aspect, the compositions described herein can be formulated with a modified release system and an enteric coating. In an additional aspect, the compositions described herein can be formulated with a timed release system and an enteric coating.

Provided herein is a method of treating certain conditions in a subject, comprising administering to the subject a composition containing metformin, or a salt thereof, as described herein.

In one aspect, said method comprises administering metformin or a salt thereof to a subject, said composition being configured to minimize systemic bioavailability of the compound and/or release a therapeutically effective amount of metformin or salt thereof in one or more parts of the intestine.

In preferred embodiments, said composition results in a reduction or minimization of the systemic bioavailability of the compound, e.g., minimization of the circulating plasma concentration of metformin or its salts in the patient's body, and/or a decrease in the mean systemic bioavailability of the compound, e.g., compared to an immediate release composition containing an equivalent amount of the specified connection. In some embodiments, the minimized circulating plasma concentration is less than about 5, 4, 3, 2, 1, 0.5, or 0.25 μg/mL in subjects with normal or impaired renal function. In other embodiments, the composition has a relative bioavailability of 60%, 50%, 40%, 30%, or 20% lower than an immediate release composition containing the same amount of said compound.

Provided herein is a method of treating certain conditions by administering a composition containing metformin or a salt or metformin thereof, or a salt thereof, to the lower intestine of a subject. In another embodiment, said composition containing at least one metformin or salt thereof is administered to the subject's upper intestine. In another embodiment, said composition, metformin or a salt thereof, is administered to the upper intestine and lower intestine of the subject.

Provided herein is a method of treating certain conditions by administering a composition containing metformin or a salt thereof to the duodenum, small intestine, ileum, caecum, colon and/or rectum. In other embodiments, said composition containing metformin or a salt thereof is administered to the subject's duodenum. In another embodiment, said composition containing metformin or a salt thereof is administered to the subject's small intestine. In another embodiment, said composition containing metformin or a salt thereof is administered to the subject's ileum. In another embodiment, said composition containing metformin or a salt thereof is administered to the subject's caecum. In another embodiment, said composition containing metformin or a salt thereof is administered to the subject's colon. In another embodiment, said composition containing metformin or a salt thereof is administered to the subject's rectum. In another embodiment, said composition containing metformin or a salt thereof is administered to the duodenum, small intestine, ileum, caecum, colon, and/or rectum of a subject.

This document provides a method of treating certain conditions by administering one

- 3,042,749 or more formulations of metformin or a salt thereof that is released with onset of action after about 75 minutes, about 105 to about 135 minutes, about 165 to about 195 minutes, about 225 to about 255 minutes, or a range of combinations thereof after oral administration to a subject.

Provided herein is a method of treating certain conditions by administering one or more compositions of metformin, or a salt thereof, that has an onset of action in about 120 minutes, about 180 minutes, about 240 minutes, or combinations thereof, following oral administration to a subject. In one embodiment, the composition is released with onset of action about 120 minutes after administration to a subject. In one embodiment, the composition is released with onset of action about 180 minutes after administration to a subject. In one embodiment, the composition is released with onset of action about 240 minutes after administration to a subject. In one embodiment, the composition is released with onset of action at about 120 minutes, about 180 minutes, and about 240 minutes after oral administration to a subject.

In some embodiments, the metformin or salt composition(s) has an onset of release at about pH 5.5, about pH 6.0, about pH 6.5, and/or about pH 7.0.

In some embodiments, the metformin or salt compositions are released with onset of action at two different pH ranges, said two pH ranges being selected from the ranges of about pH 5.0 to about pH 6.0, about pH 6.0 to about 7 0 and from about pH 7.0 to about pH 8.0.

Provided herein are methods for modulating the circulating concentration of one or more hormones including, but not limited to, GLP-1, GLP-2, GIP, oxyntomodulin, PYY, CCK, glycentin, insulin, glucagon, ghrelin, amylin, insulin, C- peptide and uroguaniline, by administering to the subject a composition containing metformin or a salt thereof as described herein. Provided herein are methods for modulating the hormonal profile of the lower intestine by administering a composition containing metformin or a salt thereof to the lower intestine of a subject. In one embodiment, the implementation of the hormonal profile is a profile of GLP-1, oxyntomodulin and PYY.

Provided herein are methods for modulating the hormonal profile of the upper intestine by administering a composition containing metformin or a salt thereof to the upper intestine of a subject. In one embodiment, the hormonal profile is GLP-1, GLP-2, oxyntomodulin, PYY, GIP, C-peptide, glucagon, insulin, CCK, or any combination thereof.

The present document further provides methods for sensitizing lower intestinal chemosensory receptors by stimulating bitter taste receptors in the upper intestine with metformin or a salt thereof.

Provided herein are methods for treating certain conditions with the biguanide or related heterocyclic compound compositions described herein. These conditions include metabolic syndrome, type I diabetes, type II diabetes, obesity, binge eating, unwanted hunger, food addiction, desire to reduce food intake or to lose weight or maintain weight loss, desire to maintain a healthy weight, desire to maintain normal glucose metabolism in anorexia, prediabetes, glucose intolerance, gestational diabetes mellitus (GDM), impaired fasting glycemia (IFG), postprandial hyperglycemia, accelerated gastric emptying, dumping syndrome, delayed gastric emptying, dyslipidemia, postprandial dyslipidemia, hyperlipidemia, hypertriglyceridemia, posthypertriglyceridemia, insulin resistance , bone loss disorders, osteopenia, osteoporosis, muscle atrophy disease, muscle degenerative disorders, polycystic ovary syndrome (PCOS), non-alcoholic fatty liver disease (NAFL), non-alcoholic steatohepatitis (NASH), immune bowel disorders (e.g. celiac disease), bowel dysfunction, irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), including, for example, ulcerative colitis, Crohn's disease, short bowel syndrome, and peripheral neuropathy, such as diabetic neuropathy. In some embodiments, said condition is obesity. In some embodiments, said condition is diabetes. In additional embodiments, the subject has undergone bariatric surgery. In other embodiments, the methods provided herein further comprise administering a drug for the treatment of diabetes or obesity.

In some embodiments, these conditions include depression, stress, sadness, anxiety, an anxiety disorder (eg, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, or social anxiety disorder), or a mood disorder (eg, depression, bipolar disorder). , dysthymic disorder and cyclothymic disorder). In some embodiments, the compositions described herein can be used to initiate feelings of happiness, well-being, or contentment.

In addition, the compositions described herein can be used for dietary treatment of the conditions listed above.

Also provided herein are methods of treating a disease, disorder, or error in energy homeostasis in a subject, comprising administering a composition as described herein. In one aspect, the composition is configured to release a therapeutically effective amount of metformin or a salt thereof in one or more parts of the intestine.

Also provided herein are methods for treating overweight in a subject, comprising administering a composition as described herein. In one aspect, the composition is configured to release a therapeutically effective amount of metformin or a salt thereof in one or more parts of the intestine.

Also provided herein are methods for treating obesity in a subject, comprising administering a composition as described herein. In one aspect, the composition is configured to release a therapeutically effective amount of metformin or a salt thereof in one or more parts of the intestine.

Also provided herein are methods for reducing food intake in a subject, comprising administering a composition as described herein. In one aspect, the composition is configured to release a therapeutically effective amount of metformin or a salt thereof in one or more parts of the intestine.

Also provided herein are methods for treating type II diabetes in a subject, comprising administering a composition as described herein. In one aspect, the composition is configured to release a therapeutically effective amount of metformin or a salt thereof in one or more parts of the intestine.

Also provided herein are methods for maintaining a healthy body weight in a subject, comprising administering a composition as described herein. In one aspect, the composition is configured to release a therapeutically effective amount of metformin or a salt thereof in one or more parts of the intestine.

Also provided herein are methods for treating prediabetes in a subject, comprising administering a composition as described herein. In one aspect, the composition is configured to release a therapeutically effective amount of metformin or a salt thereof in one or more parts of the intestine.

Also provided herein are methods for increasing the concentration of GLP-1 in a subject, comprising administering a composition as described herein. In one aspect, the composition is configured to release a therapeutically effective amount of metformin or a salt thereof in one or more parts of the intestine.

Also provided herein are methods for increasing the concentration of PYY in a subject, comprising administering a composition as described herein. In one aspect, the composition is configured to release a therapeutically effective amount of metformin or a salt thereof in one or more parts of the intestine.

In some embodiments of the methods provided herein, prior to administration of said composition, the subject is prescreened for endogenous chemosensory receptor content and types for use in adjusting the amount of composition to be administered.

The methods described herein may also further include administering a DPP-IV inhibitor, a chemosensory receptor ligand (e.g., sweet taste receptor ligand, bitter taste receptor ligand, umami taste receptor ligand, sour taste receptor ligand, a fat or bile acid receptor ligand, or a combination thereof, a chemosensory receptor agonist (eg, lactisol), a chemosensory receptor enhancer), an anti-obesity agent, or an anti-diabetic agent.

Also provided herein are pharmaceutical dosage forms comprising (a) an immediate release enteric coated component at pH 6.5 containing metformin hydrochloride and a pharmaceutically acceptable excipient; and (b) an enteric-coated sustained release component at pH 6.5 containing metformin hydrochloride and a pharmaceutically acceptable excipient; and while the total amount of metformin from both components is less than 400 mg, and metformin has a subtherapeutic area under the pharmacokinetic curve in plasma and subtherapeutic C _max in plasma.

In some embodiments, the ratio of metformin hydrochloride in the immediate release component to metformin hydrochloride in the sustained release component is about 20/80, 30/70, 35/65, 40/60, 45/55, or 50/50. In other embodiments, the dosage form exhibits a dissolution release profile of 80-100% of the amount of metformin hydrochloride 75 minutes after oral administration.

In some embodiments, the plasma pharmacokinetic area under the curve and the plasma C _max due to administration of the dose are 50% or less than the plasma pharmacokinetic area under the curve and the plasma C _max due to administration of a single dose of GLUMETZA 500 mg.

In some embodiments, the dosage form further comprises a DPPIV inhibitor in (a), (b), or both. In other embodiments, the dosage form further comprises an anti-diabetic or anti-obesity agent.

In some embodiments, the dosage form further comprises (c) an immediate release component containing metformin hydrochloride. In some cases, the immediate release component (c) is enteric coated at pH 5.0. In some cases, the total amount of metformin from components (a)-(c) is less than 600 mg.

In some embodiments, the excipient in the sustained release component is selected from the group consisting of ethylcellulose, hydroxypropylmethylcellulose, hydroxypropylcellulose, polyvinylpyrrolidone, xanthan gum, sodium alginate, polysorbate-80, and mixtures thereof.

In some embodiments, the total amount of metformin hydrochloride is about 250 mg.

In some embodiments, the dosage form is a bilayer tablet. In other embodiments, the dosage form is a capsule with two components in the form of encapsulated mini-tablets.

Also provided herein are pharmaceutical dosage forms comprising (a) an immediate release enteric coated component at pH 6.5 containing metformin hydrochloride and a pharmaceutically acceptable excipient; and (b) an enteric-coated sustained release component at pH 6.5 containing metformin hydrochloride and a pharmaceutically acceptable excipient; while metformin hydrochloride has a reduced mean systemic bioavailability.

In some embodiments, the mean systemic bioavailability is less than the mean systemic bioavailability of an immediate release metformin formulation containing an equivalent amount of metformin. In other embodiments, the average systemic bioavailability is less than 15%.

In some embodiments, the total amount of metformin hydrochloride is less than 400 mg.

Inclusion by reference

All publications, patents, and patent applications referred to in this specification are incorporated herein by reference to the same extent as if each individual publication, patent, or patent application were specifically and separately indicated for inclusion by reference.

Brief description of graphic materials

Fig. 1 illustrates the design of the test described in example 5.

Fig. 2 illustrates events during the treatment period in the trial described in Example 5.

Fig. 3 illustrates plasma concentrations of metformin (•) and re-metformin () (x-axis, ng/mL) versus time (y-axis, min) after swallowing at t=-240 and after eating at t=0 min. .

Fig. 4A illustrates PYY plasma concentration (x-axis; pg/mL) versus time (y-axis; min) in subjects at baseline (□, o) or after ingestion of metformin ( ) or remetformin () and after a meal. at t=0 min. Fig. 4B illustrates plasma concentration of active GLP-1 (x-axis; GLP-1A pmol/l) versus time (y-axis; min) in subjects at baseline (□, o) or after ingestion of metformin ( ) or re -metformin () and after eating at t=0 min. Fig. 4C illustrates plasma concentration of total GLP-1 (x-axis; GLP-1T pmol/l) versus time (y-axis; min) in subjects at baseline (□, o) or after ingestion of metformin ( ) or re -metformin () and after eating at t=0 min. For FIG. 4A-C, the percentage increase in absolute area under the pharmacokinetic curve is compared to baseline.

Fig. 5A illustrates plasma glucose concentration (x-axis; mg/dL) versus time (y-axis; min) in subjects at baseline (□, o) or after ingestion of metformin ( ) or remetformin () and after a meal. at t=0 min. Fig. 5B illustrates plasma insulin concentration (x-axis; pmol/L) versus time (y-axis; min) in subjects at baseline (□, o) or after ingestion of metformin ( ) or re-metformin () and after food intake at t=0 min. For FIG. 5A,B, percentage reduction in absolute area under the pharmacokinetic curve compared to baseline.

Fig. 6 is a graph illustrating the area under the PYY curve (x-axis; log conversion) versus the area under the curve of metformin (ng/mL*min) after ingestion of metformin (·) and re-metformin ().

Fig. 7A illustrates plasma concentration of metformin (·) and re-metformin () (x-axis; ng/mL) versus time (axis; min) after swallowing at t=-240 and after ingestion at t=0 min. Fig. 7B illustrates PYY plasma concentration (x-axis; pg/ml) versus time (y-axis; min) in subjects at baseline (□, o) or after ingestion of metformin ( ) or re-metformin () and after food intake at t=0 min.

Fig. 8 is a design of a 12-week, randomized, double-blind, placebo-controlled, parallel-group, multicenter study to determine the safety and efficacy of twice daily administration of remetformin in subjects with type 2 diabetes mellitus.

- 6 042749

Detailed description of the invention

The present invention relates to methods and compositions for the treatment of certain conditions, such as metabolic conditions, including obesity and diabetes, using metformin or its salt. Metformin or its salt modulates the synthesis, secretion and/or storage of hormones such as GLP-1, GLP-2, oxyntomodulin, PYY, GIP, insulin, C-peptide, glycentin, glucagon, amylin, ghrelin, uroguanilin and/or CCK, which are major regulators of energy and metabolic processes such as glucose metabolism.

The embodiments described herein further contemplate the targeted administration of metformin or its solimetformin or salt thereof to specific parts of the intestine. Enteroendocrine cells, such as L-cells, K-cells and I-cells, each of which are secreted by different groups of metabolic hormones in response to chemosensory stimulation, are found along the entire length of the intestine. The concentrations and proportions of these enteroendocrine cell types are different in different intestinal segments and, as noted above, each cell type has a different metabolic hormone expression profile. Targeting the compositions of the present invention to specific segments of the intestine, for example, through the use of drugs designed to be released in one or more specified segments of the intestine, provides an additional level of control over the action of such compositions, for example, in modulating hormones involved in metabolism.

Thus, the present options described herein include a new approach to the treatment of certain conditions, for example, by modulating the secretion of metabolic hormones by activating the enteroendocrine chemosensory receptor with metformin or a salt thereof. These implementation options further include the ability to select complex therapies specifically designed for the specific needs of individuals with different hormonal profiles.

Metformin or a salt thereof may be used in combination with one or more chemosensory receptor ligands to modulate hormonal profiles in an individual. Exemplary chemosensory receptor ligands and their use in modulating hormonal profiles are described, for example, in US Publication Nos. 20100267643, 20110065660 and 20120094942; and also in PCT Application Publication Nos. WO 2010123930, WO 2011133180, WO 2012054523, WO 2012054526, WO 2012054527, WO 2012054528 and WO 2012054530, the entire contents of each of which are incorporated herein by reference.

Embodiments described herein include compositions and methods for modulating circulating enteroendocrine cellular hormone concentrations, including but not limited to GLP-1, GLP-2, GIP, oxyntomodulin, PYY, CCK, glycentin, insulin, glucagon, Cpeptide, ghrelin, amylin, uroguanilin, and so on, such compositions and methods include administering at least one bigunide or related heterocyclic compound to a subject for the treatment of certain conditions. Hormonal modulation can be achieved by administering a composition containing a biguanide or related heterocyclic compound that acts on the bitter taste receptor.

In specific embodiments, the combination of metformin or a salt thereof with one or more sweet, umami, bitter, free fatty acid, and bile acid receptor agonists stimulates the simultaneous release of important hormones and neutral signals from enteroendocrine cells and thereby facilitates absorption and distribution of nutrients from food. In further embodiments, the combination of metformin or a salt thereof with one or more sweet, umami, bitter, free fatty acid, and bile acid receptor agonists inhibits the synthesis, activity, or action of grilin, or its post-translational modification (ghrelin-octonoyl- acyltransferase or GOAT) and/or secretion or release of ghrelin.

Biguanides and related heterocyclic compounds

The compositions and methods described herein relate to biguanides and related heterocyclic compounds. As a premise, metformin is one of the simplest structural variants of the class of compounds known as biguanides. Structurally, metformin is similar to a pharmacophore, or fragment of a larger biologically active chemical structure. The original biguanide structure, as well as the structure of metformin, phenformin, buformin, proguanil, imeglimine, and its enantiomers are presented below.

- 7 042749

Biguanide (original structure}

Metorformin

Phenformin (discontinued)

Buformin (discontinued)

Proguanil (an antimalarial)

Imeglimin (6R} [right] and enantiomer (65} [left]

Without wishing to be bound by theory, although the geometry of metformin and related open chain biguanides in the context of their interactions with biological targets is not fully understood, this geometry is presumably limited to the cis and trans forms depicted below.

Again, without wishing to be bound by theory, these two forms are low energy forms of the structure with an inherent energy barrier to core bond rotation that prevents the cis-to-transform from interconverting. X-ray testing of a crystal of metformin dinitrate demonstrates that the cis structure is the preferred conformer in the solid phase. Fridrichova M, Cisarova I, Nemec I. 1,1-Dimethyl-biguanidium(2+) dinitrate. Acta Crystallogr Sect E Struct Rep Online. January 1, 2012; 68(Pt 1):o18-9. e-publ. December 3, 2011. A related set of structures, the dihydrotriazines, exemplified by the compound known as imeglimin (which is currently in late-stage clinical trials at Poxel Pharmaceuticals), have the cis conformation fixed in their structures as shown below:

Synthesis of compounds

The compounds described herein can be synthesized using standard synthetic techniques known to those skilled in the art, or using methods known in the art in combination with the methods described herein. In addition, the solvents, temperatures, and other reaction conditions presented herein may vary according to the practice and knowledge of those skilled in the art.

Starting materials used to synthesize the compounds described herein can be obtained from commercial sources such as Aldrich Chemical Co. (Milwaukee, Wisconsin), Sigma Chemical Co. (St. Louis, Missouri), or the starting materials can be synthesized. The compounds described herein and other related compounds having other substituents may be synthesized using procedures and materials known to those skilled in the art, such as those described, for example, in March, ADVANCED ORGANIC CHEMISTRY 4th Ed., (Wiley 1992); Carey and Sundberg, ADVANCED ORGANIC CHEMISTRY 4th ed., vols. A and B (Plenum 2000, 2001) and Green and Wuts, PROTECTIVE GROUPS IN ORGANIC SYNTHESIS 3rd ed., (Wiley 1999) (all of which are incorporated by reference in full). General methods for preparing the compounds described herein can be derived from reactions known in the art, and these reactions can be modified by using appropriate reagents and conditions understood by those skilled in the art to incorporate the various moieties contained in the formulas presented in this document.

Additional biguanide and related heterocyclic compounds, as well as methods and schemes for the synthesis of compounds described herein, are presented in US application serial No. 12/593479 (published as U.S. 2010/0130498); US application serial number 12/593398 (published as U.S. 2010/0184796); US patent No. 7829299; US application serial number 11/578013 (published as U.S. 2010/0056621); US patent No. 7416867; US application serial number 11/455693 (published as U.S. 2007/0037212); US application serial number 13/059730 (published as U.S. 2011/0143376), US application serial number 12/996670 (published as U.S. 2011/0311991), US patent No. 7811788; US application serial number 11/182942 (published as U.S. 2006/0019346); US application serial number 12/993542 (published as U.S. 2011/0086138), US application serial number 12/373235 (published as U.S. 2010/0055209); International application serial number PCT/IL2007/000454 (published as WO 2007/116404); US application serial number 10/472056 (published as U.S.

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2004/0138189); US Pat. No. 5,891,919; US patent No. 6376657; US application serial number 11/554982 (published as U.S. 2007/0104805); US application serial number 11/926745 (published as U.S. 2008/0108604); International application serial number PCT/CA2OO9/OO1688 (published as WO 2010/060198); US application serial number 12/735557 (published as U.S. 2010/0330205); International application serial number PCT/CA2OO7/OO1O66 (published as WO 2008/000063); US application serial number 11/438204 (published as U.S. 2006/0269617); US application serial number 10/563713 (published as 2006/0172020); US application serial number 10/902352 (published as U.S. 2006/0024335); US application serial number 10/538038 (published as U.S. 2006/0275765), US application serial number 11/555617 (published as U.S. 2008/0187936); US application serial number 12/739264 (published as U.S. 2010/0316736); US application serial number 12/215609 (published as U.S. 2009/0042813); US application serial number 11/893088 (published as U.S. 2008/0050499); US patent No. 7807204; US application serial number 11/811166 (published as U.S. 2008/0003268); US patent No. 6376657; International application serial number PCT/US 2011/041183 (published as WO 2011/163183); International application serial number PCT/EP 2011/059814 (published as WO 2011/157692); US application serial number 12/790292 (published as U.S. 2011/0293753); International application serial number PCT/JP 2009/071700 (published as WO 2010/076879); US application serial number 13/032530 (published as U.S. 2011/0217394); International application serial number PCT/EP 2011/000110 (published as WO 2011/085979); International application serial number PCT/US 2010/058467 (published as WO 2011/068814); US application serial number 13/060996 (published as U.S. 2011/0152361); US application serial number 12/09253 (published as U.S. 2011/0124609); US application serial number 12/687962 (published as U.S. 2011/0119499); and in International Application Serial No. PCT/EP 2010/004623 (published as WO 2011/012298); each of which is incorporated by reference in its entirety.

Other notable biguanide and related compounds include chlorhexidine, a compound with antiseptic properties:

cycloguanil, a compound with antimalarial properties:

/=\ %a _n

Cl 4 ) N ^h > NH _?

MM y= _N

H _? N polyhexamethylene biguanide, a compound with antiseptic properties:

{mon mo n n n — —’n a compound designated JPC-2067-B, known as a toxoplasma gondii inhibitor:

These and other biguanide and related heterocyclic compounds are intended to be within the scope of the present disclosure. In further embodiments, the biguanide and related heterocyclic compound is metformin or a salt thereof.

Metformin

Metformin has low bioavailability in terms of circulating blood concentrations compared to many other orally administered drugs. For example, metformin is described as having an average systemic bioavailability of 30-60%, while many relatively small molecules have bioavailability greater than 60%. See, for example, Tucker et al., Metformin kinetics in healthy subjects and in patients with diabetes mellitus Br. J, Clinic. Pharmacol. 1981, 12(2) 235-246. Administration of metformin has been described to increase the release of GLP-1 from L-cells located in the intestine. However, release of GLP-1 from L cells (and activation of enteroendocrine cells) is triggered by luminal signals on the epithelial portion of the intestinal surface. There are no known examples of bloodborne or circulating signals that can activate enteroendocrine cells to release their hormonal contents. Therefore, it is assumed that metformin does not act due to its presence in the circulating plasma per se. Metformin can induce enteroendocrine cell activation (eg, by binding to a bitter taste receptor on an L cell or other enteroendocrine cell), including the release of GLP-1 from L cells by interacting with the luminal or epithelial surface of L cells.

Minimizing Systemic Exposure

Provided herein, in some embodiments, are compositions of metformin, or a salt thereof, configured to minimize the systemic bioavailability of the compound, for example, through intestinal delivery. In some embodiments, the compositions of metformin or a salt thereof adapted to be delivered to enteroendocrine cells described herein minimize the absorption of metformin into the subject's plasma. In other embodiments of the composition of metformin or its salts, minimize C _max in plasma and/or area under the pharmacokinetic curve. In other embodiments, the compositions of metformin, or a salt thereof, have negligible plasma metformin absorption, _Cmax , and/or area under the pharmacokinetic curve. In other embodiments, the C _max and/or area under the pharmacokinetic curve for metformin, or a salt thereof, are those previously considered sub-therapeutic for the compositions described, compared to the described C _max and/or area under the pharmacokinetic curve for known formulations of these compounds. .

In preferred embodiments, the compositions described herein are capable of reducing or minimizing the systemic bioavailability of a compound, e.g., minimizing the circulating plasma concentration of metformin or its salts in the patient's body, and/or reducing the mean systemic bioavailability of the compound, e.g., compared to an immediate formulation. release containing an equivalent amount of the specified connection. In some embodiments, the minimized circulating plasma concentration is less than about 5, 4, 3, 2, 1, 0.5, or 0.25 μg/mL in subjects with normal or impaired renal function. In other embodiments, the adapted compound formulation provides 70%, 60%, 50%, 40%, 30%, or 20% less relative bioavailability of the compound as compared to an immediate release formulation containing the same amount of said compound.

Minor or sub-therapeutic values of Metformin plasma _Cmax and/or AUC include 50%, 40%, 30%, 20% and 10% of the reported _Cmax values and/or AUC of known metformin preparations (e.g. GLUMETZA, GLUCOPHAGE, GLUCOPHAGE XR, RIOMET, FORTAMET, OBIMET, GLUFORMIN, DIANBEN, DIABEX, DIAFORMIN, Metformin IR, Metformin SR and the like). For example, the known sustained release drug of metformin, GLUMETZA, has mean Cmax values of 473 ± 145, 868 ± 223, 1171 ± 297, and 1630 ± 399 ng/mL for single doses of 500, 1000, 500 and 2500 mg, respectively. For area under the pharmacokinetic curve, mean values for GLUMETZA are 3501±796, 6705±1918, 9299±2833 and 14161±4432 ng-h/mL for single doses of 500, 1000, 1500 and 2500 mg, respectively (GLUMETZA package leaflet) .

In additional embodiments, metformin compositions or salts thereof have a reduced mean systemic bioavailability. The reduced mean systemic bioavailability, in some embodiments, is a lower mean systemic bioavailability compared to an immediate release metformin formulation (relative bioavailability) containing an equivalent amount of metformin. In other embodiments, reduced mean systemic bioavailability occurs when mean systemic bioavailability, eg, relative bioavailability, is less than 40%, 30%, less than 25%, less than 15%, less than 10%, and less than 5%. In some cases, the average systemic bioavailability is less than 15%.

To achieve these effects, a modified release metformin delivery vehicle is being developed that, for example, persists in the gastrointestinal tract and/or releases doses of metformin in amounts that minimize plasma absorption. Delivery of metformin to one or more areas of the intestine is carried out by any known method, including, for example, oral, rectal, nasogastric tube, parenteral injection, such as intraluminal intestinal injection. In some cases, delivery is oral. Oral delivery of metformin formulations is described in the modified release formulations section and includes timed release systems, enteric coatings and pH dependent systems, gastroretentive systems, floating systems, bioadhesive systems, swellable systems, and the like. In some embodiments, the metformin compositions described herein use a multicomponent system in which metformin is delivered to various sites in the gastrointestinal tract after administration, such as the duodenum, small intestine, ileum, lower intestine, or combinations thereof. For example, the metformin composition can be delivered to the small intestine through the use of immediate release and timed or sustained (enteral) release components. Multicomponent systems of metformin compositions can be in single dosage forms,

- 10 042749 such as bi- or tri- or multilayer tablets, or in the form of multiple particles, such as encapsulated microtablets, or as separate dosage forms, for example, individual tablets taken together or at periodic intervals.

In some embodiments, a composition of metformin or a salt thereof capable of being delivered to one or more areas of the intestine contains two metformin delivery components, with the first component being released immediately and the second component being released immediately or over time and coated with an enteric coating. The second component is released after reaching the desired pH due to the enteric coating. Suggested pH values include about pH 5.0, about pH 5.5, about pH 6.0, about pH 6.5, and about pH 7.0. After the set pH has been reached, the release of the second component begins. The second components, which contain metformin, release metformin immediately within about 15 minutes, about 20 minutes, about 25 minutes, or 30 minutes after the pH is reached, while the second components with timed, sustained, or slow release release it over a longer period. time, such as about 1 hour, about 2 hours, about 3 hours, about 4 hours, about 5 hours, about 6 hours, about 7 hours, or about 8 hours. tablet. Three, four, and additional components are contemplated within the embodiments. For example, the third or fourth component may contain a gastroretentive component or a component that delivers and releases metformin only in the lower intestine.

For compositions containing metformin or a salt thereof, dosages of metformin may range from about 1 mg to about 2000 mg, about 10 mg to about 1500 mg, about 50 mg to about 1000, or about 100 mg, or about 500 mg per day. In some cases, the dose of metformin or its salt is about 2000 mg, about 1500, about 1000 mg, about 800 mg, about 600 mg, about 500 mg, about 400 mg, about 300 mg, about 250 mg, about 200 mg, about 150 mg, about 100 mg, about 75 mg, about 50 mg, about 25 mg, about 10 mg, or about 1 mg per day. In some embodiments, the dose of metformin or a salt thereof is less than 400 mg. In some embodiments, the dose of metformin or a salt thereof is 250 mg.

Metformin salts include, but are not limited to, hydrochloride, phosphate, sulfate, hydrobromide, salicylate, maleate, benzoate, succinate, ethanesulfonate, fumarate, glycolate, pamoate, oratate, acetate, isobutyrate, acetylsalicylate, nicotinic acid salt, adamantoate, zinc chlorophyllin , salt of carboxylic acid, salt of benzoic acid, salt of dichloroacetic acid, theophylline-7-acetate, clofibrate, tartrate, oxalate, tannate and hydroxyl acid salts. In some cases, the metformin salt is metformin hydrochloride.

Metformin or salt compositions capable of being delivered to one or more areas of the intestine are, in some embodiments, administered or combined with additional agents such as the anti-obesity and/or anti-diabetes agents described herein. Known agents for combination with the metformin compositions described herein include DPP-IV inhibitors (eg, sitagliptin, saxacliptin, berberine, vildagliptin, linagliptin, alogliptin, and the like), thiazolidinediones (eg, pioglitazone, rivoglitazone, rosiglitazone, troglitazone, and the like). the like), sulfonylureas (eg, glipzid, glibenclamide (glyburide), gliquidone, glycopyramide, glimepiride, gliclazide, acetohexamide, carbutamide, chlorpropamide, tolbutamide, tolazamide, and the like), and dual PPAR agonists (aleglitazar, muraglitazar, tezaglitazar, and the like).

In further embodiments, a chemosensory receptor modifier is administered with a biguanide or a related heterocyclic compound to alter or alter receptor activity for said compound. In additional embodiments, a chemosensory receptor enhancer is administered with a biguanide or a related heterocyclic compound to enhance, potentiate, or enhance the effect of said compound. In some cases, modifiers and/or enhancers are administered prior to the administration of a compound to enhance, potentiate, or increase the activity of said compound. In other instances, modifiers and/or enhancers are administered with a compound to enhance, potentiate, or increase the activity of said compound.

Modulators and enhancers may be specific to a certain chemosensory type and/or several chemosensory types. Specific chemosensory modulators and enhancers may include, but are not limited to, umami taste receptor modulators and enhancers, sweet taste receptor modulators and enhancers, bitter taste receptor modulators and enhancers, fat receptor modulators and enhancers, bile acid receptor modulators and enhancers, modulators and enhancers sour taste receptors and the like.

In some embodiments, the bitter taste receptor enhancer is selected from enhancer compounds described herein or known in the art. Bitter taste receptor enhancers include, but are not limited to, ligands for the sweet taste receptor in sub-bitter amounts, that is, in amounts that do not elicit a bitter taste response. In some embodiments, the bitter taste receptor enhancer is a silver salt. Silver salts include silver acetate and silver lactate.

Combinations

The biguanide or related heterocyclic compounds may be administered alone or in combination with each other. Doses for each metformin or salt thereof may be determined by methods known in the art. Maximum response doses and maximum tolerated doses can be determined from animal and human protocols as described herein. Additional relative doses, expressed as a percentage of the maximum response dose or maximum tolerated dose, can be readily obtained from this protocol.

In an exemplary dose-dependent experiment, biguanide or related heterocyclic compounds are administered separately in animal models (eg, diabetic or obese rat models) to determine optimal doses for each metformin or salt thereof. The biguanide or related heterocyclic compounds are administered individually in increasing amounts (mg/kg/min) with each subject receiving a fixed mg/kg/min. dose, and this dose is maintained at this predetermined level for a certain period. Blood samples are collected at short intervals (eg, every 1, 2, or 5 minutes) during the specified period and analyzed for hormone concentrations. Hormones analyzed include CCK, GIP, GLP-1, oxyntomodulin, PYY, insulin, C-peptide and GLP-2. For each metformin or its salt, 50% of the maximum response dose and 50% of the maximum tolerated dose are determined.

In some embodiments, metformin or a salt thereof is administered at a concentration that is 50% of the maximum response dose. In other embodiments, metformin or a salt thereof is administered at a concentration that is 50% of the maximum tolerated dose. Biguanide or related heterocyclic compounds may be administered at 5%, 10%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100% of the dose. maximum response or maximum tolerated dose, including all input integer values.

Combinations of biguanide or related heterocyclic compounds may be administered as a single composition or in multiple compositions. Several compositions may be administered simultaneously or at different times. The compositions may be administered in a variety of delivery forms (i.e. tablets, powders, capsules, gels, liquids, nutritional supplements, edible food preparations (e.g., health foods, tabs, gels, granule-filled capsules, chewing gums, lozenges, lozenges, liquids). and so on)), as well as in any combination of such forms.

In one non-limiting example, a tablet containing metformin or a salt thereof is administered simultaneously with another tablet containing metformin or a salt thereof to provide the desired dose. In an additional example, these two tablets are administered at different times. In another non-limiting example, a tablet containing a given combination of metformin or a salt thereof is administered to provide a full dose. Any combination of delivery forms, compositions, and delivery times is contemplated herein.

The constituents of the compositions of the present invention may vary both in terms of individual constituents and in relation to the proportions of these constituents. In one embodiment, the implementation of the relative proportion of the components is optimized to provide a given synergistic activity of the drug combination. For example, in a composition containing, or in a method involving the introduction of two components, for example, two metformin or its salt, or as another non-limiting example, metformin or its salt and a chemosensory receptor ligand, these components can be contained in ratios equal to or around, e.g. 1:1, 1:2, 1:3, 1:4, 1:5, 1:6, 1:7, 1:8, 1:9, 1:10, 1:15, 1 :20, 1:25, 1:30, 1:35, 1:40, 1:45, 1:50, 1:60, 1:70, 1:80, 1:90, 1:100, 1:200 , 1:300, 1:400, 1:500, 1:1000 and so on. In a composition containing, or in a method involving the administration of three components, for example, two metformin or its salt and a metabolized ligand to the chemosensory receptor, these components can be contained in ratios equal to or about, for example, 1:1:1, 2:1 :1, 2:2:1, 3:1:1, 3:3:1, 3:2:2, 3:3:2, 3:2:1, 4:1:1, 4:4:1 , 4:2:2, 4:4:2, 4:2:3, 4:3:3, 4:4:3, 4:2:1, 5:1:1, 5:5:1, 5 :2:1, 5:3:1, 5:3:2, 5:3:4, 5:5:2, 5:5:3, 5:5:4, 10:1:1, 10:10 :1 and so on.

When more than one metformin or salt thereof is used in combination with at least one other chemosensory receptor ligand or compound, it is to be understood that a combination treatment regimen includes treatment regimens in which administration of one of the compounds is started before, during, or after treatment with the second or an additional agent in the specified combination, and continue until any time during treatment with another agent in the specified combination, or after cessation of treatment with any other agent. Treatment regimens also include regimens in which the agents to be used in combination are administered simultaneously or at different times and/or at decreasing or increasing intervals during the treatment period. Comprehensive treatment includes intermittent treatment that starts and ends at different times to facilitate the clinical management of the patient.

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Indications

Among the conditions contemplated for treatment with the compositions and methods of the embodiments provided herein are metabolic syndrome, type I diabetes, type II diabetes, obesity, compulsive overeating, unwanted hunger, food addiction, desire to reduce food intake or reduce weight. or support weight loss, desire to maintain a healthy weight, desire to maintain normal blood glucose metabolism, anorexia, prediabetes, glucose intolerance, gestational diabetes mellitus (GDM), impaired fasting glucose (IFG), postprandial hyperglycemia, accelerated gastric emptying (dumping syndrome) ), delayed gastric emptying, dyslipidemia, postprandial dyslipidemia, hyperlipidemia, hypertriglyceridemia, post-hypertriglyceridemia, insulin resistance, bone loss disorders, osteopenia, osteoporosis, muscular atrophy disease, muscular degenerative disorders, polycystic ovary syndrome (PCOS), non-alcoholic fatty liver disease (NAFL), non-alcoholic steatohepatitis (NASH), immune bowel disorders (eg, celiac disease), bowel dysfunction, irritable bowel syndrome (IBS), or inflammatory bowel disease (IBD), including, for example, ulcerative colitis, Crohn's disease, and short intestine, peripheral neuropathy, such as diabetic neuropathy. In some embodiments, the methods include treating a subject suffering from depression, stress, sadness, anxiety, an anxiety disorder (e.g., generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, or social anxiety disorder), or a mood disorder. (eg, depression, bipolar disorder, dysthymic disorder, and cyclothymic disorder) by administering a composition containing biguanides or related heterocyclic compounds provided herein. In some embodiments, these methods include methods for initiating a sense of happiness, well-being, or contentment in subjects by administering a composition containing metformin or a salt thereof provided herein.

In addition, the compositions and methods described herein can be used for dietary treatment of the conditions listed above. In some embodiments, the compositions and methods provided herein are indicated for the treatment, prevention, or maintenance of a metabolic disorder, disease, or defect. Metabolic disorders, diseases or defects may include disorders, diseases or defects in energy homeostasis and disorders, diseases or defects in fuel homeostasis.

In some embodiments, the compositions and methods provided herein are indicated for the treatment, prevention, or maintenance of disorders, diseases, and defects associated with energy homeostasis. Energy homeostasis generally refers to the signaling pathways, molecules, and hormones associated with food intake and energy expenditure. Disorders, diseases, and defects associated with energy homeostasis include, but are not limited to, type I diabetes, type II diabetes, prediabetes, impaired fasting glycemia (IFG), impaired postprandial glucose, and gestational diabetes. In some instances, the compositions and methods provided herein are indicated for the treatment, prevention, or maintenance of type I or type II diabetes.

In some embodiments, the compositions and methods provided herein are indicated for the treatment, prevention, or maintenance of disorders, diseases, and defects associated with fuel homeostasis. Disorders, diseases, and defects associated with fuel homeostasis include, but are not limited to, non-alcoholic fatty liver disease (NAFL), non-alcoholic steatohepatitis (NASH), hyperlipidemia, post-hypertriglyceridemia, hypertriglyceridemia, insulin resistance, and polycystic ovary syndrome (PCOS).

Embodiments also provide compositions and methods useful for treating conditions that benefit from increased insulin secretion or control of glucose concentrations by modifying enteroendocrine cellular hormones (eg, GLP-1 or GIP). These conditions include, but are not limited to, metabolic syndrome, type 1 diabetes, type II diabetes, gestational diabetes, glucose intolerance, and related conditions, including conditions in which patients suffer from glucose intolerance.

Embodiments also provide compositions and methods for modulating the growth (proliferation) and/or formation (neogenesis) and/or prevention of cell death (apoptosis) of insulin producing and secreting cells (beta cells) by releasing neural and hormonal signals, from the intestine in response to luminal chemosensory stimulation. Gut hormones such as GLP-1, PYY, GLP-2, and gastrin are involved in beta cell maintenance or beta cell mass increase. In one aspect, chemosensory stimulation provides a hormonal signal associated with a nerve signal. The hormonal signal may occur before, after, or at the same time as the nerve signal.

Embodiments also provide compositions and methods for treating conditions that benefit from appetite suppression by modulating, for example, PYY, oxintomodulin, and/or CCK. These conditions include, but are not limited to, obesity, compulsive eating, unwanted hunger, desire to reduce food intake or lose weight or maintain weight loss, and related conditions.

Further provided are compositions and methods for treating conditions that benefit from intestinal cell proliferation by modulating, for example, GLP-2, such as short bowel syndrome, Crohn's disease, inflammatory bowel disease, ulcerative colitis, and other conditions resulting from intestinal injury. including osteoporosis.

Methods of treatment

Disorders of glucose metabolism

In the embodiments described herein, compositions and methods for the treatment and prevention of glucose metabolism disorders and related conditions are provided.

For example, provided herein are methods of treating mammalian subjects with diabetes, including primary essential diabetes, such as type I diabetes or type II diabetes (NIDDM), as well as secondary non-essential diabetes, comprising administering to said subject at least one metformin or a salt thereof. described in this document. According to the method of the present invention, a symptom of diabetes or the likelihood of developing a symptom of diabetes such as atherosclerosis, obesity, hypertension, hyperlipidemia, fatty liver, nephropathy, neuropathy, retinopathy, foot ulceration and cataract can be reduced, each symptom being associated with diabetes.

The methods and compositions of the present invention are useful in preventing or improving diseases and symptoms associated with hyperglycemia and insulin resistance or low insulin levels. Although a single patient may present with several associated signs and symptoms at the same time, in many cases only one symptom may dominate due to individual differences in the susceptibility of many physiological systems affected by insulin resistance. However, since hyperglycemia and insulin resistance are major contributors to many disease states, agents targeting these cellular and molecular defects are useful in preventing or improving virtually any symptom in any organ system that may be due to or exacerbated by hyperglycemia and insulin resistance.

Metabolic syndrome is a cluster of metabolic abnormalities including abnormal obesity, insulin resistance, glucose intolerance, diabetes, hypertension, and dyslipidemia. These pathologies are known to be associated with an increased risk of vascular disease.

In addition to the metabolic disorders associated with insulin resistance mentioned above, patients with NIDDM also experience painful symptoms secondary to hyperglycemia. These include nephropathy, peripheral neuropathy, retinopathy, microvascular disease, extremity ulceration, and lead to non-enzymatic glycosylation of proteins, such as damage to collagen and other connective tissues. Relief of hyperglycemia reduces the rate and severity of these effects of diabetes. Because the compositions and methods of the present invention help to reduce hyperglycemia in diabetes, they are useful in preventing and ameliorating the complications of chronic hyperglycemia.

Elevated blood levels of triglycerides and free fatty acids affect a significant proportion of the population and represent an important risk factor for atherosclerosis and myocardial infarction. This document provides compositions and methods useful for reducing circulating triglycerides and free fatty acids in hyperlipidemic patients. Hyperlipidemic patients often have elevated blood cholesterol concentrations, which also increase the risk of cardiovascular disease. Cholesterol-lowering drugs such as HMG-CoA reductase inhibitors (statins) can be administered to a hyperlipidemic patient in addition to the metformin or salt compositions of the present invention, optionally being administered in the same pharmaceutical composition.

A significant proportion of the population suffers from fatty liver disease, also known as non-alcoholic steatohepatitis (NASH); NASH often accompanies obesity and diabetes. Hepatic steatosis, the presence of triglyceride droplets with hepatocytes, predisposes the liver to chronic inflammation (detected in biopsy specimens as an infiltration of inflammatory leukocytes), which can lead to fibrosis and cirrhosis. Fatty liver disease is usually detected by the observation of elevated serum concentrations of liver-specific enzymes such as ALT and AST transaminases, which serve as indicators of hepatocyte involvement, and by the presence of symptoms that include weakness and pain in the liver region, although evidence-based diagnosis is often a biopsy is required. The expected benefit is to reduce liver inflammation and fat content, resulting in attenuation, arrest, or reversal of NASH progression to fibrosis and cirrhosis.

Hypoinsulinemia is a condition in which there are reduced compared to normal amounts of insulin circulating in the body, which generally does not involve obesity. This condition includes type I diabetes.

Type 2 diabetes or abnormal glucose metabolism may be due to various factors and may present with various symptoms. Previously, type 2 diabetes was viewed as a relatively distinct disease, but current understanding has revealed that type 2 diabetes (and associated hyperglycemia or dysglycemia) is often a manifestation of a larger underlying disorder that includes the metabolic syndrome, as noted above. This syndrome is sometimes referred to as Syndrome X and is a cluster of risk factors for cardiovascular disease that, in addition to glucose intolerance, includes hyperinsulinemia, dyslipidemia, hypertension, visceral obesity, hypercoagulability, and microalbuminuria.

Also provided herein are compositions and methods for the treatment of obesity comprising administering to a subject at least one metformin or salt thereof as described herein in an amount effective to treat said condition. This agent may be administered orally and, alternatively, other routes of administration that may be used in accordance with the present invention include rectal and parenteral, by injection (eg, intraluminal intestinal injection).

Human subjects and non-human mammals can be treated according to the methods of the present invention. Embodiments of the present invention provide compositions and methods for the prevention or treatment of diabetes in a wide range of mammalian subjects, in particular human patients who suffer, have suffered, may be suffering from, or predisposed to developing diabetes. The diabetes mellitus is selected from the group consisting of insulin dependent diabetes mellitus (IDDM or type I diabetes) and non-insulin dependent diabetes mellitus (NIDDM or type II diabetes). Examples of disorders associated with diabetes mellitus have been described and include, but are not limited to, impaired glucose tolerance (IGT); adult type diabetes mellitus in young (MODY); leprechaunism (insulin receptor mutation), tropical diabetes, diabetes due to pancreatic disease or surgery; diabetes associated with a genetic syndrome (eg, Prader-Willi syndrome); pancreatitis; diabetes on the background of endocrinopathy; obesity; and metabolic syndrome (syndrome X).

Diabetic subjects suitable for treatment with the compositions and methods of the present invention can be readily identified by a physician and are characterized by, for example, fasting hyperglycemia, impaired glucose tolerance, glycosylated hemoglobin, and, in some cases, ketoacidosis associated with trauma or disease. . Hyperglycemia or high blood sugar is a condition in which an excessive amount of glucose circulates in the blood plasma. Typically, blood glucose is 10+ mmol/L, but symptoms and effects may not be noticeable up to higher values such as 15-20+ mmol/L. Patients with NIDDM have an abnormally high fasting blood glucose concentration and delayed cellular uptake of glucose after a meal or after a diagnostic test known as a glucose tolerance test. NIDDM is diagnosed based on known criteria (American Diabetes Association, Physician's Guide to Insulin-Dependent (Type I) Diabetes, 1988; American Diabetes Association, Physician's Guide to Non-Insulin-Dependent (Type II) Diabetes, 1988). The optimal dose of a particular composition of metformin or a salt thereof for a particular subject can be determined in a clinical setting by an experienced clinician.

Chronic kidney disease, diabetic nephromatia, macular degeneration and diabetes-related conditions

The compositions and methods provided herein can be used to prevent or treat kidney disease. Diabetes is the most common cause of chronic kidney disease and kidney failure, accounting for about 44 percent of new cases. Even with controlled diabetes, this disease can lead to chronic kidney disease and kidney failure. Most people with diabetes do not develop chronic kidney disease, which is severe enough to progress to kidney failure. About 24 million people in the United States of America suffer from diabetes, and about 180,000 people live with kidney failure as a result of diabetes. High blood pressure or hypertension is a major factor in the development of kidney disease in people with diabetes.

Accumulation of glomerular mesangial extracellular matrix (ECM) leading to glomerulosclerosis is a common finding in diabetic nephropathy and other chronic kidney diseases. Several series of data show that accumulation of ECM in these chronic kidney diseases leads to increased synthesis and reduced destruction of ECM components, and it is generally accepted that the destruction of ECM in glomeruli and glomerular cells is mediated by the plasminogen activator-plasmin-matrix metalloproteinase-2 (MMP)-2 cascade. . In addition, various studies have described a decrease in plasminogen activator (PA) activity, a decrease in plasmin activity, or an increase in PA 1 inhibitor (PAI-1; a major PA inhibitor) concentrations in glomeruli obtained from animals with experimentally induced glomerular lesions, which are known to lead to mesangial matrix accumulation (Baricos, et al, Extracellular Matrix Degradation by Cultured Mesangial Cells: Mediators and Modulators (2003) Exp. Biol. Med. 228:1018-1022).

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Macular degeneration (AMD) is a loss of photoreceptors in an area of the central retina called the macula, which is responsible for sharp vision. Macular degeneration is associated with abnormal deposition of extracellular matrix components and other residues in the membrane between the retinal pigment epithelium and the vascular choroid. This debris-like material is called druze. Drusen are observed during fundoscopic examination of the eyes. Normal eyes may not contain drusen in the macula, but drusen may be widespread in the periphery of the retina. The presence of soft drusen in the macula, with no or any reduction in macular vision, is considered an early stage of AMD.

Choroidal neovascularization (CNV) usually occurs in macular degeneration in addition to other ophthalmic disorders and is associated with proliferation of choroidal endothelial cells, extracellular matrix oversynthesis, and formation of a vascular fibrous subretinal membrane. The proliferation of retinal pigment epithelium cells and the production of angiogenic factors affect choroidal neovascularization.

Diabetic retinopathy (DR) is an ophthalmic disorder that develops in diabetes due to thickening of capillary basement membranes and loss of contact between pericytes and capillary endothelial cells. The decrease in pericytes increases the permeability of capillaries and leads to the destruction of the barrier between the blood and the retina.

Proliferative vitreoretinopathy is associated with cellular proliferation of cell and fibrotic membranes in the stalk membranes and on the surface of the retina. In this ophthalmic disorder, proliferation and migration of retinal pigment epithelial cells are common. The membranes associated with proliferative vitreoretinopathy contain extracellular matrix components such as collagen types I, II, and IV, as well as fibronectin, and become progressively fibrotic.

The compositions of the embodiments described herein may, if necessary, be administered in combination with one or more standard therapeutic treatments known in the art. For example, for the treatment of diabetic nephropathy, the compounds of the present invention may be administered in combination with, for example, ACE inhibitors, angiotensin II receptor blockers (ARBS), or any other standard therapies such as, for example, glucose regulation.

Obesity and eating disorders

This document further provides compositions and methods that can be used to reduce weight or to prevent or treat obesity. General obesity, characterized by a high waist-to-hip ratio, is a serious risk for metabolic syndrome. Metabolic syndrome, as described above, is a combination of medical disorders that often includes type 2 diabetes mellitus, high blood pressure, high blood cholesterol and triglyceride concentrations (Grundy SM (2004), J. Clin. Endocrinol. Metab. 89(6 ): 2595-600). Obesity and other eating disorders are described, for example, in US Patent Application Publication No. 2009/0062193, Compositions and Methods for the Control, Prevention and Treatment of Obesity and Eating Disorders.

Overweight and obesity are designations for weight ranges that are in excess of what is generally considered healthy for a given height. These terms also indicate weight ranges that have been shown to increase the likelihood of certain diseases and other health problems. An adult with a BMI value in the range of 25 to 25.9 is generally considered to be overweight. An adult with a BMI value of 30 or higher is generally considered obese. However, anyone who needs or desires to reduce body weight or prevent weight gain can be considered overweight or obese. Morbid obesity usually refers to a condition in which the BMI is 40 or more. In embodiments of the methods described herein, subjects have a BMI of less than about 40. In embodiments of the methods described herein, subjects have a BMI of less than about 35. In embodiments of the methods described herein, subjects have a BMI of less than about 35. than about 35, but greater than about 30. In other embodiments, subjects have a BMI of less than about 30, but greater than about 27. In other embodiments, subjects have a BMI of less than about 27, but greater than about 25. In embodiments, the subject may suffer from or be predisposed to a nutritional condition, such as compulsive overeating or hunger.

Mental health conditions, disorders, or illnesses such as depression, stress, sadness, anxiety, anxiety disorder (eg, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, or social anxiety disorder), or anxiety disorder mood disorders (eg, depression, bipolar disorder, dysthymic disorder, and cyclothymic disorder) can be diagnosed by mental health professionals. Similarly, mental health professionals may assess feelings of happiness, well-being, or contentment.

The subject may include any mammal, including humans. The subject may also

- 16 042749 include other mammals kept as pets or farm animals (eg dogs, cats, horses, cows, sheep, pigs, goats). Subjects who may benefit from the methods presented herein may be overweight or obese; however, they can also be thin. Subjects who may benefit from the methods provided herein may desire to lose weight or may be suffering from an eating disorder such as compulsive overeating or an eating condition such as hunger. Subjects who may benefit from the methods presented herein may wish to change food preferences. They may be suffering from a metabolic disorder or condition in addition to these conditions. Illustrative metabolic disorders include diabetes, metabolic syndrome, insulin resistance, and dyslipidemia. Subjects can be of any age. Accordingly, these disorders can be found in young and old people (eg, aged 65 years or less), as well as in infants, children, adolescents, and the elderly (eg, aged 65 years).

Metabolic rate refers to the amount of energy released/expended per unit of time. Metabolism per unit time can be measured by food intake, energy released as heat, or oxygen used in metabolic processes. As a rule, those who want to lose weight, it is desirable to have a higher metabolic rate. For example, an individual with a high metabolic rate may expend more energy (and burn more calories) to perform activities than an individual with a low metabolic rate for the same activities.

As used herein, lean mass or lean body mass refers to muscles and bones. Lean body mass does not necessarily indicate free fat mass. Lean body mass contains a small percentage of fat (about 3%) in the central nervous system (brain and spinal cord), bone marrow and internal organs. Lean body mass is measured by density. Methods for measuring fat mass and lean mass include, but are not limited to, underwater weighing, plethysmograph air displacement, x-rays, dual energy x-ray absorptiometry (DEXA) scans, MRI, and CT scans. In one embodiment, fat mass and lean mass are measured by underwater weighing.

Fat distribution refers to the location of body fat in the body. Such locations of fat deposits include subcutaneous, visceral, and ectopic fat accumulations.

Subcutaneous fat refers to the deposition of lipids just below the surface of the skin. The amount of subcutaneous fat in a subject can be measured using any method available for measuring subcutaneous fat. Methods for measuring subcutaneous fat are known in the art, such as those described in US Pat. No. 6,530,886.

Visceral fat means the deposition of fat in the form of intraperitoneal adipose tissue. Visceral fat surrounds vital organs and can be metabolized by the liver to form cholesterol in the blood. Visceral fat is associated with an increased risk of conditions such as polycystic ovary syndrome, metabolic syndrome, and cardiovascular disease.

Ectopic fat storage refers to lipid deposits in or around tissues and organs that make up lean body mass (eg, skeletal muscle, heart, liver, pancreas, kidneys, blood vessels). Typically, ectopic fat storage is an accumulation of lipids outside of the classical body fat deposits.

Fat mass can be expressed as a percentage of total body weight. In some aspects, fat mass is reduced by at least 1%, at least 5%, at least 10%, at least 15%, at least 20%, or at least 25% during the course treatment. In one aspect, the subject's lean mass does not decrease over the course of treatment.

In another aspect, the subject's lean mass is maintained or increased over the course of treatment. In another aspect, the subject is on a low calorie or restricted diet. A low calorie diet means that a subject consumes fewer calories per day than the same subject's normal diet. In one instance, the subject consumes at least 50 fewer calories per day. In other cases, the subject consumes at least 100, 150, 200, 250, 300, 400, 500, 600, 700, 800, 900, 1000 fewer calories per day. In some embodiments, said method includes metabolizing visceral fat or ectopic fat, or both, at a rate that is at least about 5%, 10%, 15%, 20%, 25%, 30%, 40%, or 50% faster than subcutaneous fat. In one aspect, these methods result in favorable fat distribution. In one embodiment, the favorable fat distribution is an increase in the ratio of subcutaneous fat to visceral fat, ectopic fat, or both. In one aspect, said method comprises an increase in lean body mass, for example, as a result of an increase in muscle cell mass. In one embodiment, the amount of subcutaneous fat in the subject's body is reduced by at least about 5%. In some embodiments, the amount of subcutaneous fat is reduced by at least about 10%, 15%, 20%, 25%, 30%, 40%, or 50% compared to the subject prior to administration of the metformin composition or salt thereof.

The methods described herein can be used to reduce the amount of visceral fat in a subject. In one instance, the subject's visceral fat is reduced by at least about 5%. In other instances, the subject's visceral body fat is reduced by at least about 10%, 15%, 20%, 25%, 30%, 40%, or 50% compared to the subject prior to administration of the metformin composition or salt thereof. Visceral fat can be measured by any means available to determine the amount of visceral fat in a subject.

Such methods include, for example, abdominal tomography using CT scanning and MRI. Other methods for determining visceral fat are described in, for example, US Pat. Nos. 6,864,415, 6,850,797 and 6,487,445.

In one embodiment, a method for preventing or reducing ectopic fat accumulation in a subject's body is provided, which comprises administering to a subject in need thereof a composition of metformin or a salt thereof effective to prevent ectopic fat accumulation or reduce ectopic fat in the subject's body. It should be understood that treatment may be a series of discrete doses or a treatment regimen administered to a subject over a period of time. In one instance, the amount of ectopic fat in a subject's body is reduced by at least about 5% compared to an untreated subject. In other cases, the amount of ectopic fat is reduced by at least about 10%, 15%, 20%, 25%, 30%, 40%, or 50%. Alternatively, the amount of ectopic fat is proportionately reduced by 5%, 10%, 15%, 20%, 25%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or 100% of the subcutaneous fat in the subject. Ectopic fat can be measured in the subject's body by any method available for measuring ectopic fat.

In another embodiment, methods for changing anthropometric parameters such as waist circumference, hip circumference, and waist circumference to hip ratio are provided. Waist circumference is a measure of abdominal fat. In one embodiment, methods are provided for reducing a subject's waist circumference, which comprises administering to a subject in need thereof a composition of metformin or a salt thereof in an amount effective to reduce the subject's waist circumference. In one embodiment, the subject's waist circumference is reduced by at least about 1%. In some embodiments, the subject's waist circumference is reduced by at least about 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, or 10% compared to the subject prior to administration of the metformin or salt composition provided herein. In one embodiment, the subject's waist circumference is reduced by at least about 1 cm. In other embodiments, the subject's waist circumference is reduced by at least about 2 cm, 3 cm, 4 cm, 5 cm, or 6 cm, compared to the subject to administering the metformin composition or salt thereof.

In another embodiment, methods are provided for reducing the circumference of a subject's thighs, which comprises administering to a subject in need thereof a metformin composition or salt thereof provided herein in an amount effective to reduce the circumference of the subject's thighs. In one embodiment, the subject's hip circumference is reduced by at least about 1%. In some embodiments, the subject's waist circumference is reduced by at least about 2%, 3%, 4%, 5%, or 6% compared to the subject prior to administration of the metformin composition or salt thereof. In one embodiment, the subject's waist circumference is reduced by at least about 1 cm. In some embodiments, the subject's waist circumference is reduced by at least about 2, 3, 4, 5, or 6 cm compared to the subject prior to administration of the metformin composition or its salt.

Also provided are methods of reducing the weight of a morbidly obese subject by first reducing the subject's weight to below the morbidly obese score, followed by administering an effective amount of a metformin composition or salt thereof to further reduce the subject's weight. Methods for reducing a subject's weight to below those of morbid obesity include reducing caloric intake, increasing physical activity, drug therapy, bariatric surgery such as gastric bypass surgery, or combinations of the previous methods. In one aspect, administration of said treatment method results in a reduction in caloric intake, which further reduces the weight of the subject. In another embodiment, methods are provided for reducing a body mass index (BMI) in a subject having a BMI of 40 or less by administering a composition of metformin or a salt thereof in an amount and regimen effective to further reduce the subject's weight. In another embodiment, methods are provided for reducing a body mass index (BMI) in a subject having a BMI of 35 or less by administering a composition of metformin or a salt thereof in an amount and regimen effective to further reduce the subject's weight.

In embodiments, methods are provided for reducing the risk of developing metabolic disorders, which include administering to said subject a composition of metformin or a salt thereof in an amount effective to reduce weight or control the subject's blood glucose. Also provided herein are methods for maintaining a healthy or normal weight and/or glucose concentrations which comprise administering to said subject a composition of metformin or a salt thereof in an amount effective to maintain a healthy or normal weight and/or glucose concentrations.

In another embodiment, methods for controlling or modifying eating behavior are provided which comprise administering to a subject in need thereof a metformin composition or

- 18 042749 its salt, effective for controlling or changing the eating behavior of the subject. In one embodiment, methods for controlling binge eating are provided which comprise administering to a subject in need thereof a composition of metformin or a salt thereof in an amount effective to control or limit the subject's binge eating. In one embodiment, the metformin composition or salt thereof is administered at the time of day when the subject is most likely to binge. In one aspect, binge eating is characterized by 1) eating in a particular time period (e.g., during any 2-hour period) food that is clearly more than what most people consume in that same time period and under the same conditions, and 2) feeling loss of control over eating during a particular episode (eg, feeling someone cannot stop eating or control what and how much they eat). Reducing binge eating includes reducing the frequency of binge eating episodes, the duration of binge eating episodes, the total amount of food consumed during a binge eating episode, the difficulty in resisting the onset of a binge eating episode, and any combination of these compared to such frequency, duration, amount, and opposition in the absence of compositions of metformin or a salt thereof. For example, in one embodiment, the method may include reducing the frequency of binge eating episodes. In another embodiment, the method may include reducing the duration of binge eating episodes. In another embodiment, the method may include reducing the total amount of food consumed during a binge eating episode. In another embodiment, the method may include reducing the difficulty in resisting the onset of a binge eating episode.

Some of the signs of binge eating include eating large amounts of food in the absence of physical hunger, eating quickly, withholding food because the individual senses concern from others that he or she is eating large amounts of food, eating to uncomfortable satiety, or any combination of these. Many binge eaters suffer from emotional eating, meaning their binge eating is triggered by their emotional state (for example, some binge eaters eat when they are sad, some eat when they are happy, and some eat when they are stressed). A large number of binge eaters suffer from anxiety disorders such as obsessive-compulsive disorder; from impulse control problems; or from personality disorders such as borderline personality disorder or depression. In one embodiment, binge eating is a response to stressful conditions. Other people suffering from compulsive overeating are people who abuse psychoactive substances, such as people who abuse drugs or alcohol. Not all people with binge eating disorder are overweight, as is the case for people with binge eating disorder diagnosed with bulimia.

Compulsive binge eating subjects often do so at certain times of the day, and therefore, treatment should be tailored according to when said subject is most likely to binge eat. For example, if a subject compulsively binges primarily after 7 pm, then the subject should be administered the composition of metformin or a salt thereof at or shortly before 7 pm. In one embodiment, a composition of metformin or a salt thereof is administered to the subject at a time when the subject is experiencing compulsive overeating. In some embodiments, the subject is administered the composition of metformin or a salt thereof at least about 5 minutes, at least about 15 minutes, at least about 30 minutes, at least about 45 minutes, at least about 1 hour. , at least about 1 hour and 30 minutes, or at least about 2 hours before the time when he is subject to compulsive overeating. An effective amount of a composition of metformin or a salt thereof in this embodiment is an amount effective to stop or control a subject's urge to binge. Therefore, the effective amount of the composition of Metformin or its salt varies depending on the subject and the degree of his desire to compulsive overeating. In addition, if the subject's desire to binge is lower at one time of day than at another, then the dose may be adjusted accordingly to provide a lower dose at the time of day when the subject has a lower desire to binge and to provide more a high dose at a time of day when the subject has a higher desire for compulsive overeating. In one embodiment, the subject is administered a peak dose of the metformin composition or salt thereof at a time when the subject has a high craving for binge eating. In some embodiments, the subject is administered a peak dose of the metformin composition or salt thereof at least about 5 minutes, at least about 15 minutes, at least about 30 minutes, at least about 45 minutes, at least about 1 hour, at least about 1 hour and 30 minutes, or at least about 2 hours before the time when he has a high desire to binge.

In another embodiment, methods for altering a subject's food preferences are provided which include administering to a subject in need thereof a composition of metformin or a salt thereof in

- 19 042749 amount effective to change the food preferences of the subject. The chemosensory receptor that the composition acts on can influence the subject's desire to consume the appropriate food.

Changes in food preferences may include a decrease in preference for such food, a decrease in the amount of consumption of such food, an increase in preference for one type of food over another type of food, a change in the frequency of craving for such food, the duration of craving for such food, the intensity of craving for such food, the difficulty in resisting craving for such food , the frequency of eating in response to a craving for such food, and any combination thereof, compared to that frequency, duration, intensity, or resistance in the absence of treatment. In another embodiment, the method may include reducing the subject's preference for sweet foods, spicy foods, high fat foods, salty foods, sour foods, and any combination thereof.

In one embodiment, the method may include reducing the frequency of a subject's craving for sweet foods, spicy foods, high fat foods, salty foods, sour foods, and any combination thereof. In another embodiment, the method may include reducing the subject's duration of craving for sweet foods, spicy foods, high fat foods, salty foods, sour foods, and any combination thereof, and so on. In another embodiment, the method may include reducing the subject's craving for sweet foods, spicy foods, high fat foods, salty foods, sour foods, and any combination thereof. In one embodiment, the method may include reducing the frequency of a subject's craving for sweet foods, spicy foods, high fat foods, salty foods, sour foods, and any combination thereof. In another embodiment, the method may include reducing the subject's eating frequency in response to a craving for sweet foods, spicy foods, high fat foods, salty foods, sour foods, and any combination thereof. In another embodiment, the method may include reducing the subject's intake of sugary foods, spicy foods, high fat foods, salty foods, sour foods, and any combination thereof.

Treatment of bowel disorder

The compositions and methods provided herein may be used to treat short bowel syndrome and impaired intestinal function (eg, small bowel resection, colitis, enteritis, irritable bowel syndrome, ischemic bowel, and chemotherapeutic bowel injury). Short bowel syndrome refers to a set of symptoms caused by bowel resection. Its symptoms include intractable diarrhea, dehydration, macronutrient malabsorption, weight loss, vitamin and trace element malabsorption, and malnutrition. GLP-2 is known to slow gastric emptying, increase intestinal transit time, and inhibit gastric acid secretion induced by sham feeding. Ejunostomy patients often have an impaired food-stimulated GLP-2 response and hence impaired absorption. Administration of GLP-2 to eunostomic patients has been shown to improve intestinal energy absorption and intestinal absorption of wet weight, as well as increase the duration of gastric emptying of solids and liquids. See Jeppesen, P.B., 2003, Clinical significance of GLP-2 in short-bowel syndrome, Journal of Nutrition 133 (11): 3721-4. It is also described that GLP-2 stimulates intestinal growth, in addition to inhibiting gastric secretion and gastric motility. Burrin et al., 2001, Glucagon-like peptide 2: a nutrient-responsive gut growth factor, Journal of Nutrition 131 (3): 709. Modulating GLP-2 secretion by administering the compositions described herein may provide treatment for the syndrome short bowel and impaired intestinal function, including, but not limited to, small bowel resection, colitis, enteritis, irritable bowel syndrome, ischemic bowel, and chemotherapeutic bowel injury.

Delivery to specific areas of the intestine

The density of L-cells increases along the length of the intestine, with the lowest density occurring at the level of the duodenum and the highest in the rectum. As measured by the content of YY peptide, the increase in L-cell density from the duodenum to the rectum is approximately 80 times. See Adrian et al., Gastroenterology 1985; 89:1070-77. Given that nutrients or bile salts do not seem to reach the colon much less than the rectum, the mechanism of these L cells in regulating metabolism is not well understood. It is hypothetically possible that products formed under the action of the colon flora can inform the intestine about the microbial mass and composition through L-cell sensors, and, in turn, this information can be transmitted to the CNS through hormonal and neuronal signals originating from the colon area. and the rectum, which is innervated quite differently than the small intestine. Regardless of the role of neuroendocrine cells in the colon and rectum, the basis of the present invention is to stimulate these cells in any location (for example, different individuals and diabetic patients are expected to have a different distribution and number of these cells) by providing one or more stimuli taste and/or food receptors, as well as other stimuli for the treatment of metabolic disorders.

The upper intestine has different EECs than the lower intestine. For example, CCK and GIP are released from the upper and sometimes from the lower intestine, corresponding to I and K cells predominantly located in the upper intestine. Conversely, L-cells are located mainly in the lower intestine. The hormonal release pathways are not only specific for the chemosensory receptor ligand and a specific combination, they are also specific for a specific area of the intestine.

In embodiments, it is contemplated that uptake and/or metabolism of nutrients in the upper intestine amplifies certain responses from the lower intestine. Moreover, L cells located in the upper intestine may behave differently than L cells located in the lower intestine, providing the next level of control for targeting metformin or its salt. For example, in embodiments, certain combinations of metformin or a salt thereof, or combinations of biguanide and a chemosensory receptor ligand, delivered to the upper intestine may be more favorable for the hormonal release pathway in the treatment of one disorder, such as diabetes, while the same combination delivered into the lower intestine, may be more appropriate for another disorder, such as obesity. It is also envisioned that the same composition can provide a more favorable hormonal profile when presented simultaneously in the upper and lower intestines.

Therefore, the embodiments described herein provide a method of treatment comprising a combination of metformin or a salt thereof that is designed to deliver certain metformin or a salt thereof to one or more intestinal sites, for example, to achieve an optimized hormonal pathway.

In some of the embodiments provided herein, the biguanide or related heterocyclic compounds are delivered to one or more regions of the intestine. In some of the embodiments provided herein, the biguanide or related heterocyclic compounds are delivered to one or more sites located after or away from the stomach. In some embodiments, the biguanide or related heterocyclic compounds are delivered to one or more regions of the upper intestine. In some embodiments, the biguanide or related heterocyclic compounds are delivered to the duodenum, jejunum, ileum, or a combination thereof. In some embodiments, the biguanide or related heterocyclic compounds are delivered to one or more regions of the lower intestine. In some embodiments, the biguanide or related heterocyclic compounds are delivered to the caecum, colon, rectum, or a combination thereof. In other embodiments, the biguanide or related heterocyclic compounds are delivered to areas downstream or away from the duodenum. In additional embodiments, the biguanide or related heterocyclic compounds are delivered to areas downstream or away from the jejunum.

In other embodiments, the biguanide or related heterocyclic compounds are delivered to one or more regions of the upper intestine and one or more regions of the lower intestine. For example, biguanide or related heterocyclic compounds can be delivered to the duodenum and colon. In another non-limiting example, biguanide or related heterocyclic compounds can be delivered to the duodenum, jejunum, ileum, and colon. Additional implementation options are described in the Preparations section.

Administration of metformin, or a salt thereof, to specific areas or locations of the intestine is achieved by any known method. In some embodiments, enteral administration of metformin or a salt thereof is performed, for example, in rodents or humans. Intubation/catheterization is performed in lightly anesthetized patients using silicone tubes. The tubes are placed in the postpyloric region and rectum and set to the maximum depth. These locations are used singly and in combination because food taken in the upper intestine can signal to the lower intestine and vice versa. In some embodiments, the biguanide or related heterocyclic compounds are formulated in a modified release formulation for oral delivery that delivers metformin or a salt thereof to desired areas or locations in the intestine. In other embodiments, the biguanide or related heterocyclic compounds are formulated for rectal delivery in the form of a suppository, douche, enema, or the like for delivery to desired areas or locations in the intestinal tract, such as the rectum or colon.

If the delivery of metformin or its salt is carried out in two or more areas of the gastrointestinal tract, then the compounds can be delivered in any ratio and by any means. In some embodiments, certain biguanide or related heterocyclic compounds are targeted and delivered to specific areas, such as one compound for the jejunum and another compound for the colon, or in another example, a compound for the stomach and another compound for the duodenum. intestines, and another compound for the large intestine. In some embodiments, the biguanide or related heterocyclic compounds are delivered in specific proportions to each region of the intestine.

- 21 042749

Introduction

Complex therapies

The compositions of the embodiments described herein may be administered in conjunction with known therapies to treat any of the conditions described herein. Co-administration may also provide an additive or synergistic effect, resulting in reduced doses of known therapy, the compositions described herein, or both. Additional benefits of co-administration include a reduction in toxicity associated with any known therapy.

Co-administration includes simultaneous administration in separate compositions, administration at different times in separate compositions, or administration in compositions in which both agents are present. Thus, in some embodiments, the compositions described herein and a known treatment are administered as part of a single treatment. In some embodiments, the compositions described herein and a known treatment are mixed in the resulting composition. In some embodiments, the compositions described herein and the known treatment are administered in separate compositions or administrations.

Administration of the compositions described herein and the known treatments described herein may be by any suitable method. Administration of the composition described herein and the second compound (eg, an anti-diabetic drug or an anti-obesity drug) may be by any suitable method. If the compositions described herein and the second compound are administered as separate compositions, they may be administered by the same route or by different routes. If the compositions described herein and the second compound are administered as a single composition, they may be administered by any suitable route, such as, for example, oral administration. In some embodiments, the compositions of metformin or a salt thereof and the second compound may be administered to the same area or to different areas of the gastrointestinal tract. For example, biguanide or related heterocyclic compounds can be administered in combination with an antidiabetic drug for delivery to the duodenum, jejunum, ileum, or colon.

Therapies, drugs, and compounds useful in the treatment of diabetes, metabolic syndrome (including glucose intolerance, insulin resistance, and dyslipidemia), and/or diseases or conditions associated therewith, may be administered together with biguanide or related heterocyclic compounds. Medications and compounds for the treatment of diabetes include, but are not limited to, those that lower triglyceride concentrations, lower glucose concentrations, and/or modulate insulin (e.g., stimulate insulin production, mimic insulin, increase glucose-dependent insulin production, suppress glucagon secretion or action, improve action of insulin or insulin sensitizers, or are exogenous forms of insulin).

Medications that lower triglycerides include, but are not limited to, ascorbic acid, asparaginase, clofibrate, colestipol, mevastatin fenofibrate, pravastatin, simvastatin, fluvastatin, or omega-3 fatty acid. Medicines that lower LDL cholesterol include, but are not limited to, clofibrate, gemfibrozil and fenofibrate, nicotinic acid, mevinolin, mevastatin, pravastatin, simvastatin, fluvastatin, lovastatin, cholesterol, colestipol, or probucol.

In another aspect, the compositions of the embodiments described herein may be administered in combination with glucose lowering compounds.

The thiazolidinedione (also called glitazones), sulfonylurea, meglitinide, biguanides, alphaglucosidase inhibitors, DPP-IV inhibitors, and incretin mimetics classes of drugs are used as adjuvant therapy for the treatment of hyperglycemia and diabetes mellitus (type 2) and related diseases.

Medications that lower glucose include, but are not limited to, glipizides, glyburides, exenatide (Byetta®), incretins, sitagliptin (Januvia®), pioglithizone, glimepiride, rosiglitazone, metformin, vildagliptin, saxagliptin (OnglyzaTM), sulfonylurea, meglitinide (eg Prandin®) gluosidase inhibitor, biguanides (eg Glucophage®), repaglinide, acarbose, troglitazone, nateglinide, natural, synthetic or recombinant insulin and its derivatives, as well as amylin and amylin derivatives.

When administered sequentially, the combination may be administered over two or more administrations. In an alternative implementation, you can enter one or more bigunadine or related heterocyclic compounds and one or more additional active ingredients in various ways. Those skilled in the art will also appreciate that the various active ingredients may be administered in combination with one or more biguanide or related heterocyclic compounds, which may act to increase or synergistically enhance the control, prevention, amelioration, amelioration, or treatment of obesity or nutritional disorders or conditions.

- 22 042749

According to the methods provided herein, when at least one other anti-obesity (or anti-obesity) or weight-reducing drug is co-administered, the biguanide or related heterocyclic compound can be: (1) formulated into one composition and administered or delivered simultaneously as part of a combination product; (2) delivered alternately or in parallel as separate preparations; or (3) any other combination therapy regimen known in the art. When delivered in alternating therapy, the present methods may include administering or delivering the active ingredients sequentially, for example, in a separate solution, emulsion, suspension, tablet, pill or capsule, or as separate injections in separate syringes. In general, during interleaved therapy, an effective dose of each active ingredient is administered sequentially, that is, serially, whereas in complex therapy, effective doses of two or more active ingredients are administered together. Different sequences of alternating complex therapy can also be used.

In some embodiments, the compositions provided herein may be used with other commercially available dietary supplements or other anti-obesity agents such as, for example, PYY and PYY agonists, GLP-1 and GLP-1 agonists, a DPP- IV, CCK and CCK agonists, exendin and exendin agonists, GIP and GIP agonists, amylin and amylin agonists, ghrelin modulators AEterna Zentaris Inc., [D-Arg(1),D-Phe(5),DTrp(7,9),Leu(11)]-substance P, D-Lys3-GHRP-6, YIL-781 and YIL870, developed by Bayer (see, for example, Esler et al. (2007) Endocrinology 148:5175-85), and EX-1350 developed by Elixer Pharmaceuticals), as well as leptin and leptin agonists. In some instances, the metformin or salt compositions provided herein are used in combination with amylin, amylin agonists or mimetics. Exemplary amylin agonists or mimetics include pramlintide and related compounds. In some instances, the metformin or salt compositions provided herein are used in combination with leptin, leptin agonists or mimetics. Additional leptin agonists or mimetics can be determined using the methods described in US patent No. 7247427, which is incorporated herein by reference. In additional instances, the metformin or salt compositions provided herein increase leptin sensitivity and enhance the efficacy of leptin, leptin agonists or mimetics.

Additional anti-obesity agents for use in the methods provided herein, which are currently under development, are also of interest for use in the methods of the present invention. Other anti-obesity agents include phentermine, fenfluramine, sibutramine, rimonabant, topiramate, bupropion zonisamide, naltrexone, lorcaserin and orlistat alone or any combination. Therapies, drugs, and compounds useful in the treatment of weight loss, binge eating, food addictions, and food cravings may be administered with the compositions described herein. For example, the subject may additionally be administered at least one other drug known to suppress hunger or control appetite. Such therapies, drugs, and compounds include, but are not limited to, phentheramines such as Meridia® and Xenical®. Additional therapies, drugs, and compounds are known in the art and are contemplated herein.

Therefore, in one aspect, biguanide or related heterocyclic compounds can be used as part of a complex therapy for the control, prevention or treatment of obesity or nutritional disorders or conditions. Compounds used as part of complex therapy for the treatment of obesity or weight loss include, but are not limited to, central nervous system agents that act on neurotransmitters or neuronal ion channels, including antidepressants (bupropion), norepinephrine reuptake inhibitors (GW320659), selective serotonin 2c receptor agonists, selective 5HT 2c receptor agonists, anticonvulsants (topiramate, zonisamide), some dopamine antagonists and cannabinoid-1 receptor antagonists (CB-1 receptor antagonists) (rimonabant); leptin/insulin/central nervous system pathway agents, including leptin analogs, leptin transport promoters and/or leptin receptor promoters, ciliary neurotrophic factor (axokine), neuropeptide Y and agoutis-related peptide antagonists, transcription promoters regulated by pro-opiomelanocortin and cocaine, and amphetamine , α-melanocyte-stimulating hormone analogues, melanocortin-4 receptor agonists, and agents that act on insulin metabolism/activity, which include protein tyrosine phosphatase-III inhibitors, proliferator-activated γ-receptor antagonists peroxisomes, short-acting bromocriptine (ergoset), somatostatin agonists (octreotide), and adiponectin/Acrp30 (famoxin or initiator of metabolic fatty acid oxidation); gastrointestinal-nervous system pathway agents, including agents that increase cholecystokinin (CCK) activity, PYY activity, NPY activity, and PP activity, increase glucagon-like peptide-1 activity (exendin 4, liraglutide, dipeptidyl peptidase IV inhibitors) , as well as those that reduce the activity of ghrelin, as well as analogs of amylin (pramlintide); agents,

- 23 042749 which can increase resting metabolic rate (selective P-3 stimulants/agonists, unbound protein homologues and thyroid receptor agonists); other more versatile agents, including melanin-concentrating hormone antagonists, phytostanol analogs, functional oils, P57, amylase inhibitors, growth hormone fragments, synthetic dehydroepiandrosterone sulfate analogs, adipocyte-11B-hydroxysteroid dehydrogenase type 1 activity antagonists, corticotropin-releasing hormone agonists, inhibitors of fatty acid synthesis (cerulenin and C75), carboxypeptidase inhibitors, indanone/indanols, aminosterols (trodusquemin/trodulamine) and other gastrointestinal lipase inhibitors (ATL962); amphetamines such as dextroamphetamine; other sympathomimetic adrenergic agents including phentermine, benzphetamine, phendimetrazine, mazindol and diethylpropion.

Other compounds include ecopipam; oxyntomodulin (OM); inhibitors of glucose-dependent insulinotropic polypeptide (GIP); gastrin-releasing peptide; neuromedin B; enterostatin, amphebutamon, SR-58611; CP-045598; AOD-0604; QC-BT16; rGLP-1; 1426 (HMR-1426); N-5984; ISIS113715; solabegron; SR-147778; Org-34517; melanotan-P; cetilistat; c-2735; c-5093; c-2624; APD-356; radafaxine; fluasterone; GP-389255; 856464; S-2367; AVE-1625; T-71; oleoyl-estrone; peptide YY [3-36], intranasal; androgen receptor agonists; PYY 3-36; DOV-102677; tagatose; SLV-319; 1954 (Aventis Pharma AG); oxyntomodulin, Thiakis; bromocriptine, PLIVA; treatment of diabetes/hyperlipidaemia, Yissum; CKD-502; thyroid beta receptor agonists; beta-3 adrenoceptor agonists; CDK-A agonists; galanin antagonist; dopamine D1/D2 agonists; melanocortin modulators; verongamine; neuropeptide Y antagonists; melanin-concentrating hormone receptor antagonists; dual alpha/gamma PPAR agonists; CGEN-P-4; kinase inhibitors; human MCH receptor antagonists; GHS-R antagonists; ghrelin receptor agonists; DG70 inhibitors; cotinine; CRFBP inhibitors; urocortin agonists; UCL-2000; impentamine; .beta.-3 adrenergic receptor; MC4 pentapeptide agonists; trodusquemin; GT-2016; C-75; CPOP; MCH-1 receptor antagonists; RED-103004; aminosterols; orexin-1 antagonists; neuropeptide Y5 receptor antagonists; DRF-4158; PT-15; FTPase inhibitors; A37215; SA-0204; glycolipid metabolites; MC-4 agonist; produlestane; PTP-1B inhibitors; GT-2394; neuropeptide Y5 antagonists; melanocortin receptor modulators; MLN-4760; dual PPAR gamma/delta agonists; NPY5RA-972; 5-HT2C receptor agonist; neuropeptide Y5 receptor antagonists (phenylurea analogues); AGRP/MC4 antagonists; neuropeptide Y5 antagonists (benzimidazole); glucocorticoid antagonists; MCHR1 antagonists; acetyl-CoA carboxylase inhibitors; R-1496; HOB1 modulators; NOX-B11; peptide YY 3-36 (eligen); modulators 5-HT 1; pancreatic lipase inhibitors; GRC-1087; CB-1 antagonists; MCH-1 antagonists; LY448100; bombesin BRS3 agonists; ghrelin antagonists; MC4 antagonists; stearoyl-CoA desaturase modulators; histamine H3 antagonists; pan PPAR agonists; EP-01492; hormone-sensitive lipase inhibitors; fatty acid binding protein 4 inhibitors; thiolactone derivatives; protein tyrosine phosphatase 1B inhibitors; MCH-1 antagonists; P-64; PPAR gamma ligands; melanin-concentrating hormone antagonists; thiazole gastroprokinetics; PA-452; T-226296; A-331440; immunopreparation vaccines; drugs for diabetes/obesity (Bioagency, Biofrontera Discovery GmbH); P-7 (Genfit); DT-011M; a PTP1B inhibitor; antidiabetic peptide conjugates; KATP agonists; anti-obesity drugs (Lexicon); 5-HT2 agonists; MCH-1 receptor antagonists; GMAD-1/GMAD-2; STG-a-MD; neuropeptide Y antagonist; angiogenesis inhibitors; G protein-coupled receptor agonists; nicotine preparations (ChemGenex); anti-obesity agents (Abbott); neuropeptide Y modulators; melanin-concentrating hormone; GW-594884A; MC-4R agonist; histamine H3 antagonists; orphan GPCR modulators; MITO-3108; NLC-002; HE-2300; IGF/IBP-2-13; 5-HT2C agonists; ML-22952; neuropeptide Y receptor antagonists; AZ-40140; anti-obesity agents (Nisshin Flour); GNTI; melanocortin receptor modulators; alpha-amylase inhibitors; neuropeptide Y1 antagonist; beta-3 adrenoceptor agonists; ob gene products (Eli Lilly &Co.);SWR-0342-SA; beta-3 adrenoceptor agonist; SWR-0335; SP-18904; oral insulin mimetics; beta-3 adrenoceptor agonists; NPY-1 antagonists; .beta.-3 agonists; anti-obesity agents (7TM Pharma); 11betahydroxysteroid dehydrogenase (HSD)1 inhibitors; QRX-431; E-6776; RI-450; melanocortin-4 antagonists; melanocortin 4 receptor agonists; anti-obesity drugs (CuraGen); leptin mimetics; A-74498; second generation leptin; NBI-103; CL-314698; CP-114271; beta-3 adrenoceptor agonists; NMI-8739; UCL-1283; BMS-192548; CP-94253; PD-160170; nicotinic agonists; LG-100754; SB-226552; LY355124; CKD-711; L-751250; PPAR inhibitors; G-protein preparations; anti-obesity agents (Amylin Pharmaceuticals Inc.); BW-1229; monoclonal antibody (ObeSys/CAT); L-742791; (S)-sibutramine; MBU-23; YM-268; BTS-78050; barrel protein genes; genomic drugs (eating disorders; Allelix/Lilly); MS-706; GI-264879A; GW-409890; analogues of FR-79620; anti-obesity agents (Hybrigenics SA); ICI-198157; ESP-A; 5-HT2C agonists; PD-170292; AIT-202; LG-100641; GI-181771; anti-obesity agents (Genzyme); leptin modulator; GHRH mimetics; anti-obesity agents (Yamanouchi Pharmaceutical Co. Ltd.); SB-251023; CP-331684; BIBO-3304; cholesten-3-ones; LY-362884; BRL-48962; NPY-1 antagonists; A-71378; RTM.-didesmethylsibutramine; amide derivatives; anti-obesity agents (Bristol-Myers Squibb Co.); anti-obesity agents (Ligand Pharmaceuticals Inc.); LY-226936;

- 24 042749 NPY antagonists; CCK-A agonists; FPL-14294; PD-145942; ZA-7114; CL-316243; SR-58878; R-1065; BIBP-3226; HP-228; talibegron; FR-165914; AZM-008; AZM-016; AZM-120; AZM-090; vomeropherin; BMS-187257; D-3800; AZM-131; gene discoveries (Axys/Glaxo); BRL-26830A; SX-013; ERR modulators; adipsin; AC-253; A-71623; A-68552; BMS-210285; TAK-677; MPV-1743; anti-obesity agents (Modex); GI-248573; AZM-134; AZM-127; AZM-083; AZM-132; AZM-115; exopipam; SSR-125180; anti-obesity agents (Melacure Therapeutics AB); BRL-35135; SR-146131; P-57; AZM-140; CGP-71583A; RF1051; BMS-196085; manifaxin, beta-3 agonists; DMNJ (Korea Research Institute of Biological Sciences and Biotechnology); BVT-5182; LY-255582; SNX-024; galanin antagonists; neurokinin-3 antagonists; dexfenfluramine; mazindol; diethylpropion; phendimetrazine; benzphetamine; amphebutmon; sertraline; metformin; AOD-9604; ATL-062; BVT-933; GT389-255; SLV319; HE-2500; PEGaxokine; L-796568; and ABT-239.

In some embodiments, compounds for use in combination with a metformin or salt composition provided herein include rimonabant, sibutramine, orlistat, PYY or an analog thereof, a CB-1 antagonist, leptin, phentermine, and exendin analogs. Illustrative dosage ranges include phentermine gum (30 mg in the morning), fenfluramine hydrochloride (20 mg three times a day) and a combination of phentermine gum (15 mg in the morning) and fenfluramine hydrochloride (30 mg before the evening meal) and sibutramine (10-20 mg) . Weintraub et al. (1984) Arch. Intern. Med. 144:1143-1148.

In additional embodiments, compounds for use in combination with a metformin or salt composition provided herein include GPR119 agonists (e.g., anandamide; AR-231, 453; MBX-2982; oleoylethanolamide; PSN-365,963; PSN-632,408; palmitoylethanolamide ), GPR120 agonists (e.g., omega-3 fatty acids, including, but not limited to, α-linolenic acid, docosapentaenoic acid, docosahexaenoic acid, eicosatrienoic acid, eicosatetraenoic acid, eicosapentaenoic acid, geneicosapentaenoic acid, hexadecatrienoic acid, stearidonic acid, tetracosahexaenoic acid acid and tetracosapetnaenoic acid), as well as GPR 40 agonists (eg, free fatty acids, including short, medium and long saturated and unsaturated fatty acids).

In some embodiments, the metformin or salt composition provided herein is used as adjuvant therapy for bariatric surgery. Bariatric surgery is a weight loss surgery and refers to changes in the gastrointestinal tract, and includes such operations as gastric banding, sleeve gastrectomy, gastrointestinal bypass surgery (for example, gastric bypass with Py gastrojejunostomy, biliary-duodenal bypass , loop gastric bypass), intragastric balloon, vertical band gastroplasty, endoluminal sleeve, biliopancreatic bypass, and the like. In some cases, the composition of Metformin or its salt is an aid in gastric banding. In some cases, the composition of Metformin or a salt thereof is an adjuvant in gastro-intestinal bypass operations. In other cases, the composition of Metformin or its salt is auxiliary in sleeve gastrectomy. In some embodiments, a composition of metformin or a salt thereof as adjuvant therapy for bariatric surgery is administered prior to bariatric surgery. In some embodiments, a composition of metformin or a salt thereof as adjuvant therapy for bariatric surgery is administered after bariatric surgery. In some cases, when using adjuvant therapy, the dose and amount of the composition of Metformin or its salt can be adjusted in accordance with the needs of the indicated bariatric surgery. For example, amounts of a metformin composition or salt thereof administered as adjuvant therapy in bariatric surgery may be reduced to half normal doses, or as directed by a healthcare professional.

Combination therapy can be used, for example, in the modulation of the metabolic syndrome (or the treatment of the metabolic syndrome and its associated symptoms, complications and disorders), while the metformin or salt compositions provided herein can be effectively used in combination, for example, with the active agents discussed above for the modulation, prevention or treatment of diabetes, obesity, hyperlipidemia, atherosclerosis and/or their associated symptoms, complications and disorders.

Preparations

Formulations of the compositions provided herein include those suitable for oral or rectal administration, and the most appropriate route of administration may depend, for example, on the condition and disorder of the recipient. The formulations may conveniently be presented in unit dosage forms, and may be prepared by any of the methods well known in the art of pharmacy. All methods include the step of bringing into association the active ingredient with the carrier which constitutes one or more accessory ingredients.

Formulations suitable for oral administration may be presented as discrete units such as capsules, sachets or tablets, each containing a predetermined amount of the active ingredient; in the form of powders or granules; as a solution or suspension in an aqueous liquid or in a non-aqueous liquid; or as an oil-in-water liquid emulsion or a water-in-oil liquid emulsion.

Complex preparations that can be used orally include tightly packed gelatin capsules, as well as soft, sealed capsules made from gelatin and a plasticizer such as glycerol or sorbitol. Tablets may be made by compression or moulding, optionally with one or more auxiliary components. Compressed tablets can be prepared by compressing in a suitable machine the active ingredient in a free-flowing form such as powder or granules, optionally mixed with binders (e.g. povidone, gelatin, hydroxypropyl methylcellulose), inert diluents, preservatives, tablet disintegrating agents (e.g. sodium starch glycolate, cross-linked povidone, cross-linked sodium carboxymethyl cellulose) or lubricants, surfactants or dispersants. Molded tablets can be obtained by molding in a suitable machine a mixture of powder components moistened with an inert liquid diluent. Tablets may optionally be coated or rough and may be formulated to provide slow or controlled release of the active ingredient. Tablets may optionally be provided with an enteric coating to provide release in parts of the intestine other than the stomach. All preparations for oral administration must be formulated in doses suitable for such administration. Tightly packed capsules may contain the active ingredients in admixture with an excipient such as lactose, binders such as starches and/or lubricants such as talc or magnesium stearate and optionally stabilizers. In soft capsules, the active compounds may be dissolved or suspended in suitable liquids such as fixed oils, liquid paraffin or liquid polyethylene glycols. In addition, stabilizers may be added. Dragee cores are coated with appropriate coatings. For this purpose, concentrated sugar solutions can be used, which additionally contain gum arabic, talc, polyvinylpyrrolidone, carbopol gel, polyethylene glycol and/or titanium dioxide, glaze solutions and appropriate organic solvents or solvent mixtures. Dyes or pigments may be added to tablet or dragee coatings to identify or characterize various combinations of active compound doses.

For buccal or sublingual administration, the compositions may take the form of tablets, lozenges, lozenges or gels formulated in the usual manner. Such compositions may contain the active ingredient in a flavor base such as sucrose and gum arabic or gum tragacanth. Such compositions can be formulated to deliver the biguanide or related heterocyclic compounds to a target area of the gastrointestinal system.

It should be understood that, in addition to the components specifically mentioned above, the compounds and compositions described herein may include other agents conventional in the art relevant to the type of preparation in question, for example, those suitable for oral administration may include flavorings.

The compositions described herein may also contain biguanide or related heterocyclic compounds in a form suitable for oral administration, for example, in the form of tablets, lozenges, lozenges, aqueous or oily suspensions, dispersible powders or granules, emulsions, hard or soft capsules, or syrups, or elixirs. Compositions intended for oral use may be prepared in accordance with any method known in the art for the manufacture of pharmaceutical compositions, and such compositions may contain one or more agents selected, as a non-limiting example, from sweeteners, flavors, colors and preservatives to obtain pharmaceutically simple and palatable compositions.

Tablets may contain the active ingredient in admixture with non-toxic pharmaceutically acceptable excipients suitable for the manufacture of tablets. These excipients can be, for example, inert diluents such as calcium carbonate, sodium carbonate, lactose, calcium phosphate or sodium phosphate; granulating and disintegrating agents such as microcrystalline cellulose, croscarmellose sodium, corn starch or alginic acid; binding agents, for example starch, gelatin, polyvinylpyrrolidone or gum arabic; and lubricating agents, for example magnesium stearate, stearic acid or talc. Tablets may be uncoated or coated by known methods to mask the taste of the drug or to delay degradation and absorption in the gastrointestinal tract and thus ensure stable action over an extended period. For example, a water-soluble taste masking material such as hydroxypropyl methylcellulose or hydroxypropyl cellulose, or a time delay material such as ethyl cellulose or cellulose acetate butyrate can be used, if necessary. Formulations for oral administration may also be presented as hard gelatin capsules wherein the active ingredient is mixed with an inert solid diluent such as calcium carbonate, calcium phosphate or kaolin, or as soft gelatin capsules where the active ingredient is mixed with a water soluble carrier,

- 26 042749 such as polyethylene glycol, or with an oil medium such as peanut oil, liquid paraffin or olive oil.

In various embodiments, the metformin compositions or salts thereof provided herein are in liquid form. Liquid forms include, by way of non-limiting example, neat liquids, solutions, suspensions, dispersions, colloids, foams, and the like. In some cases, liquid forms also contain a nutritional component or base (eg, derived from milk, yogurt, neck or juice). In some aspects, the biguanide or related heterocyclic compounds are micronized or in liquid form in the form of nanoparticles. In some instances, the biguanide or related heterocyclic compounds are coated to mask palatability. In other instances, the biguanide or related heterocyclic compounds are coated to modify intestinal and colonic delivery.

Aqueous solutions or suspensions contain the active ingredient(s) in admixture with excipients suitable for the manufacture of aqueous suspensions. Such excipients are suspending agents, for example sodium carboxymethylcellulose, methylcellulose, hydropropylmethylcellulose, sodium alginate, polyvinylpyrrolidone, gum tragacanth and gum arabic; dispersing or wetting agents can be natural phosphatides, for example lecithin, or condensates of alkylene oxide with fatty acids, for example polyoxyethylene stearate, or condensates of ethylene oxide with long chain aliphatic alcohols, for example heptadecaethylene oxycetanol, or condensates of ethylene oxide with partial esters , derived from fatty acids and hexitol, such as polyoxyethylene sorbitol monooleate, or condensation products of ethylene oxide with partial esters derived from fatty acids and hexitol anhydrides, such as polyethylene sorbitol monooleate. Aqueous solutions or suspensions may also contain one or more preservatives, such as ethyl or n-propyl phydroxybenzoate, one or more colorants, one or more flavors, and one or more sweeteners, such as sucrose, saccharin, or aspartame. In some cases, the flavors are biguanide or related heterocyclic compounds.

Oil suspensions can be prepared by suspending the active ingredient(s) in a vegetable oil such as peanut oil, olive oil, sesame oil or coconut oil, or in a mineral oil such as liquid paraffin. Oily suspensions may contain a thickening agent such as beeswax, hard paraffin or cetyl alcohol. Sweeteners such as those mentioned above and flavoring agents may be added to provide a pleasant taste to the oral composition. These compositions may be preserved by the addition of an antioxidant such as butylated hydroxyanisole or alpha-tocopherol.

Dispersible powders and granules suitable for the preparation of aqueous solutions or suspensions by the addition of water present the active ingredient in admixture with a dispersing or wetting agent, a suspending agent and one or more preservatives. Suitable dispersing or wetting agents and suspending agents are presented in the examples mentioned above. Additional adjuvants may also be present, such as sweeteners, flavoring agents, and colorants. These compositions may be preserved by the addition of an antioxidant such as ascorbic acid.

The compositions may also be in the form of an oil-in-water emulsion. The oil phase may be a vegetable oil, such as olive oil or peanut oil, or a mineral oil, such as liquid paraffin, or a mixture thereof. Suitable emulsifying agents can be natural phosphatides, such as soybean lecithin, and esters or partial esters derived from fatty acids and hexitol anhydrides, such as sorbitol monooleate, and the condensation products of said partial esters with ethylene oxide, such as polyoxyethylene sorbitol monooleate. Emulsions may also contain sweeteners, flavors, preservatives and antioxidants.

Syrups and elixirs may be prepared with sweeteners such as glycerin, propylene glycol, sorbitol, or sucrose. Such formulations may also contain a sedative, a preservative, flavors and colors, and an antioxidant.

The compositions may also be formulated into rectal compositions such as suppositories or retention enemas, for example containing a conventional suppository base such as cocoa butter, polyethylene glycol or other glycerides. These compositions can be prepared by mixing the inhibitors with a suitable non-irritating excipient which is solid at ordinary temperatures but liquid at the rectal temperature and therefore melts in the rectum to release the drug. Such materials include cocoa butter, gelatin with glycerol, hydrogenated vegetable oils, mixtures of polyethylene glycols of various molecular weights and fatty acid esters of polyethylene glycol.

The composition may, for example, be in a form suitable for oral administration as a tablet, capsule, sachet, pill, lozenge, powder or granule, sustained release formulation, solution, liquid or suspension. The pharmaceutical composition may be in single dosage forms.

- 27 042749 forms suitable for single administration of precise doses. Pharmaceutical compositions contain a conventional pharmaceutical carrier or excipient and a compound of the present invention as the active ingredient. In addition, they may contain other medical or pharmaceutical agents, carriers, adjuvants, and so on.

Suitable carriers include inert diluents or excipients, water, and various organic solvents. These compositions may optionally contain additional ingredients such as flavors, binders, excipients, and the like. Thus, for oral administration, tablets containing various excipients such as citric acid may be used together with various disintegrants such as starch or other cellulosic materials, alginic acid and certain complex silicates, as well as binding agents such as sucrose, gelatin and gum arabic. In addition, lubricating agents such as magnesium stearate, sodium lauryl sulfate and talc are often used for tabletting purposes. Other reagents may also be added, such as an inhibitor, surfactant or solubilizer, plasticizer, stabilizer, viscosity increasing agent or film forming agent. Solid compositions of the same type can also be used in soft and hard filled gelatin capsules. Materials include lactose or milk sugar as well as high molecular weight polyethylene glycols. If aqueous suspensions and/or elixirs are designed for oral administration, the active compound may be mixed with various sweetening or flavoring agents, coloring or coloring agents, and, if necessary, with emulsifying or suspending agents, together with diluents such as water, ethanol, propylene glycol, glycerin, or combinations thereof.

The present invention also provides nutritional compositions, including therapeutic nutrition compositions and preparations containing the compositions of the present invention described herein, as well as nutritional or dietary supplements included in the compositions of the present invention. Food products, such as health foods containing compositions of metformin or a salt thereof, include edible forms such as sticks, lozenges, powders, gels, snacks, soups, and liquids. Chewing gums are also provided within the food compositions. Metformin or its salt for clinical nutrition can be formulated to control the amounts and types of metformin or salt(s) thereof, as well as the content of other edible additives and ingredients (eg, carbohydrates, proteins, fats, fillers, excipients). Exemplary nutritional compositions include, but are not limited to, wafers with defined and/or limited amounts of metformin or a salt thereof. Nutritional compositions may be packaged in a ready-to-eat form, with a predetermined amount of metformin or a salt thereof contained in a predetermined dose. Examples include frozen foods, yogurts, snacks, and the like. In another aspect, food compositions may be semi-finished products, wherein the individual assembles various components such as flavors, sauces, extracts, and so on, into a ready-to-eat product, eg, soup base, packaged pasta, dessert jelly. Metformin or its salt may be contained in one or more components of a semi-finished food composition made with the possibility of mixing metformin or its salt during cooking or sprinkling them on prepared, cooked food.

Modified release preparations

In various embodiments, methods and compositions relating to the biguanide or related heterocyclic compound are in the form of controlled, sustained or sustained release formulations, collectively known as modified release formulations. The compositions may be administered by modified release means or delivery devices, which are well known to those skilled in the art. Examples include, but are not limited to, those described in US Pat. Nos. 3,845,770; 3916899; 3536809; 3598123; 4008719; 5674533; 5059595; 5591767; 5120548; 5073543; 5639476; 5354556; and 5,733,566. Such dosage forms can be used to provide modified release of one or more active ingredients using, for example, hydroxypropyl methylcellulose, other polymer matrices, gels, permeable membranes, osmotic systems, multilayer coatings, microparticles, liposomes, microspheres, or combinations thereof to providing a given release profile in various proportions. Suitable modified release formulations known to those skilled in the art, including those described herein, can be readily selected for use with the active ingredients of the present invention. Thus, the present invention encompasses oral dosage forms for single use, such as, but not limited to, tablets, capsules, gelatin capsules and capsule-shaped tablets, which are made with the possibility of controlled or sustained release.

Many strategies can be used to achieve a modified release in which the release rate exceeds the rate of metabolism of the compound when present and/or the site of release is controlled. For example, modified release can be achieved with proper selection of formulation parameters and ingredients (eg, correct controlled release formulations and coatings). Examples include disposable or reusable tablet or capsule formulations, oily solutions, suspensions, emulsions, microcapsules, microspheres, nanoparticles, patches, and liposomes. The release mechanism can be controlled so that compounds are released at periodic intervals, release can be immediate, delayed release of one of the combination agents can be achieved if an earlier release of one particular agent is preferred over the other, or the site of release is controlled. The various delivery systems described herein can also be combined to release with onset of action at multiple time intervals (e.g., about 30 minutes, about 120 minutes, about 180 minutes, and about 240 minutes after oral administration) or at multiple sites (e.g., , release in the lower intestinal tract, upper intestinal tract, duodenum, jejunum, ileum, caecum, colon and/or rectum), or combinations thereof. For example, a pH dependent system can be combined with a timed release system, or with any of the other systems described herein, to achieve a given release profile.

In some embodiments, the modified release systems are formulated to release the compound with a duration of about 75 minutes, about 80 minutes, about 90 minutes, about 100 minutes, about 110 minutes, about 120 minutes, about 130 minutes, about 140 minutes, about 150 minutes. min, about 160 min, about 170 min, about 180 min, about 190 min, about 200 min, about 210 min, about 220 min, about 230 min, about 240 min, about 250 min, about 260 min, about 270 min, about 280 min, about 290 min, about 300 min, about 310 min, about 320 min, about 330 min, about 340 min, about 350 min, about 360 min, about 370 min, about 380 min, about 390 min, about 400 , about 400, about 410 or about 420 minutes after the start of the release. In multiple release embodiments, modified release systems are formulated to be released over more than one time period at different time points.

In various embodiments, composition(s) of the compound are provided in the form of modified release formulations linked to an immediate release component in a unit dosage form. The immediate release component may be formulated by any known method such as coating the modified release component or the like. Exemplary ratios of immediate release (HB) active to modified release (MB) active are about 10% HB to about 90% MB, about 15% HB to about 85% MB, about 20% HB to about 80% MB, about 25% HB to about 75% MB, about 30% HB to about 70% MB, about 35% HB to about 65% MB, about 40% HB to about 60% MB, about 45% HB to about 55% MB or so 50% HB to about 50% MB. In some embodiments, the ratio of immediate release active to modified release active is about 25% HB to about 75% MB. In some embodiments, the ratio of immediate release active to modified release active is about 20% HB to about 80% MB. Unit dosage forms with HB and MB components include any formulation, including bilayer tablets, coated pellets, and the like.

Timed release systems

In one embodiment, the release mechanism is a timed or timed release (BB) system that releases the active agent, eg, metformin or a salt thereof, at specific time points following administration. Timed release systems are well known in the art, and suitable timed release systems may contain any known excipients and/or coatings. For example, excipients in a matrix, layer, or coating may cause a delay in the release of the active agent by slowing the diffusion of the active agent into the environment. Suitable timed release excipients include, but are not limited to, gum arabic (gum arabic), agar, aluminum magnesium silicate, alginates (sodium alginate), sodium stearate, kelp, bentonite, carbomer, carrageenan, carbopol, cellulose, microcrystalline cellulose , locust bean gum, carrageenan, dextrose, furcellaran, gelatin, ghatti gum, guar gum, galactomannan, hectorite, lactose, sucrose, maltodextrin, mannitol, sorbitol, honey, maize starch, wheat starch, rice starch, potato starch, gelatin, gum sterculia, xanthan gum, glyceryl behenate (eg Compritol 888 ato), glyceryl distearate (eg Precirol ato 5), polyethylene glycol (eg PEG 200-4500), polyethylene oxide, adipic acid, gum tragacanth, ethyl cellulose (eg ethyl cellulose 100), ethyl hydroxyethyl cellulose , ethyl methyl cellulose, methyl cellulose, hydroxyethyl cellulose, hydroxyethyl methyl cellulose (e.g. K100LV, K4M, K15M), hydroxypropyl cellulose, poly(hydroxyethyl methacrylate), cellulose acetate (e.g. cellulose acetate CA-398-10 NF), cellulose acetate phthalate, cellulose acetate propionate, cellulose acetate butyrate, hydroxypropyl methylcellulose acetate succinate, hydroxypropyl

- 29 042749 methylcellulose phthalate, cellulose butyrate, cellulose nitrate, hydroxypolygelatin, pectin, polygeline, povidone, propylene carbonate, polyanhydrides, methyl vinyl ether/maleic anhydride copolymer (PVM/MA), poly(methoxyethyl methacrylate), poly(methoxyethoxyethyl methacrylate), hydroxypropyl cellulose , hydroxypropyl cellulose, sodium carboxymethyl cellulose (CMC), silicon dioxide, vinyl polymers, e.g. acids), Splenda® (dextrose, maltodextrin and sucrose), and combinations thereof. The timed release excipient may be in a matrix with the active agent, in another section of the formulation layer, in a coating formulation, or any combination thereof. Varying amounts of one or more timed release excipients may be used to achieve the desired release time.

In some embodiments, timed release systems are formulated to release metformin or a salt thereof with onset of action in about 75 minutes, about 80 minutes, about 90 minutes, about 100 minutes, about 110 minutes, about 120 minutes, about 130 minutes, about 140 min, approx 150 min, approx 160 min, approx 170 min, approx 180 min, approx 190 min, approx 200 min, approx 210 min, approx 220 min, approx 230 min, approx 240 min, approx 250 min, approx 260 min , about 270 min, about 280 min, about 290 min, about 300 min, about 310 min, about 320 min, about 330 min, about 340 min, about 350 min, about 360 min, about 370 min, about 380 min, about 390 minutes, about 400, about 400, about 410 or about 420 minutes after administration. In multiple release embodiments, timed release systems are composed to release at more than one time point. In some embodiments, timed release systems are formulated for release with onset of action at about 120 minutes, about 180 minutes, and about 240 minutes after administration. In some embodiments, timed release systems are formulated to release with onset of action at about 5 to about 45 minutes, about 105 to about 135 minutes, about 165 to about 195 minutes, about 225 to about 255 minutes, or in time combinations of these intervals after administration to a subject.

In various embodiments, methods and compositions are provided relating to the biguanide or related heterocyclic compound(s) in the form of timed release formulations associated with an immediate release component in a unit dosage form. The immediate release component may be formulated by any known method such as coating the timed release component or the like. The timed release component may be formulated to be released at the exemplary time points described previously. Exemplary ratios of immediate release (HB) active agent to timed release (TB) active agent are about 10% HB to about 90% TB, about 15% HB to about 85% TB, about 20% HB to about 80% TB, about 25% HB to about 75% TB, about 30% HB to about 70% TB, about 35% HB to about 65% TB, about 40% HB to about 60% TB, about 45% HB to about 55% TB, or about 50% HB to about 50% TB. In some embodiments, the ratio of immediate release active to timed release active is about 25% HB to about 75% TB. In some embodiments, the ratio of immediate release active to timed release active is about 20% HB to about 80% TB.

Enteric coatings and pH dependent systems

The formulations may also be enteric coated which protects the active agent, eg metformin or salt thereof, from degradation in an acidic environment such as in the stomach and provides a sustained release in a targeted area, eg the duodenum, where absorption occurs.

The enteric coating may be, by way of non-limiting example, a wax or wax-like substance such as carnauba wax, fatty alcohols, hydrogenated vegetable oils, zein, shellac, sucrose, gum arabic, gelatin, dextrin, psyllium husk powder, polymethacrylates, anionic polymethacrylates , mixtures of poly(methacrylic acid, methyl methacrylate), polymers or copolymers derived from esters of acrylic and/or methacrylic acid, cellulose acetate phthalate, cellulose acetate trimellitate, hydroxypropyl methylcellulose phthalate (HPMCP), cellulose propionate phthalate, cellulose acetate maleate , polyvinyl alcohol phthalate, hydroxypropyl methylcellulose acetate succinate (HPMCAS), hydroxypropyl methylcellulose hexahydrophthalate, polyvinyl acetate phthalate, poly(methacrylic acid, ethyl acrylate) blends, ethylcellulose, methylcellulose, propylcellulose, chitosan succinate, chitosan succinate, polyvinyl acetate phthalate (PVAP), polyvinyl acetate polymers , carboxymethylcellulose and compatible mixtures thereof. Additionally, an inactive intermediate film may be placed between the active agent, eg, biguanide or related heterocyclic compound(s), and the enteric coating to prevent the active agent from interacting with the enteric coating.

Enteric coatings can be formulated to release the active agent, onto

- 30 042749 example, Metformin or its salt at a given pH, using combinations of enteric polymers. It is well known that different parts of the gastrointestinal system have specific pH values. For example, the duodenum may correspond to a pH 5.5 environment, and the jejunum may correspond to a pH 6.0 environment. In some embodiments, the enteric coatings are formulated to release metformin or a salt thereof with an onset of action at pH, including about pH 5, about pH 5.5, about pH 6, about pH 6.5, or about pH 7. In multiple release embodiments The enteric coatings are formulated to release with an onset of action at two or more pH values. In some embodiments, the enteric coatings are formulated to release with onset of action at pH 5.5, 6.0, 6.5, and 7.0. In some embodiments, the enteric coatings are formulated to release with onset of action at pH 5.5, 6.0, and 6.5. In some embodiments, the enteric coatings are formulated for release in the duodenum, jejunum, ileum, and lower intestine. In other embodiments, enteric coatings are used in combination with other release systems, such as timed release systems.

In other embodiments, enteric coatings are used in combination with immediate release/modified release unit dosage forms. For example, a unit dosage form such as a 20% HB/80% MB bilayer tablet of the metformin component or salt can be coated with an enteric coating that releases at pH 6.5 such that this release is delayed until the dosage form reaches pH 6. 5, whereby the HB component is released immediately and the MB component is released according to its MB release properties. In some cases, enteric coatings are used in combination with immediate release/timed release unit dosage forms.

Microcapsule gastroretentive systems

The microcapsule gastroretentive systems described in US Pat. Microparticles of the active agent or drug are coated by spraying a material consisting of a mixture of a film-forming polymer derivative, a hydrophobic plasticizer, a functional agent and a nitrogen-containing polymer. The obtained microcapsules have a size less than or equal to 1000 microns (g), and in some cases, such microcapsules have a size of from 100 to 500 microns. These microcapsules remain in the small intestine for at least 5 hours.

Film-forming polymeric derivatives used in such microcapsules include, but are not limited to, ethyl cellulose, cellulose acetate, and water-insoluble cellulose derivatives. Nitrogen containing polymers include, but are not limited to, polyacrylamide, poly-N-vinylamide, poly-N-vinyl lactam, and polyvinylpyrrolidone. The plasticizer used in such microcapsules includes, but is not limited to, glycerol esters, phthalates, citrates, sebacates, cetyl alcohol esters, castor oil, and cutin. The surfactant and/or lubricant used in such microcapsules includes, but is not limited to, anionic surfactants such as, for example, alkali metal or alkaline earth metal fatty acid salts, stearic acid and/or oleic acid, nonionic surfactants such as, for example, polyoxyethylene esters of sorbitol and/or polyoxyethylene ethers of sorbitol and/or polyoxyethylene derivatives of castor oil; and/or lubricants such as stearates such as, for example, calcium, magnesium, aluminum stearate, zinc stearate, stearyl fumarate, sodium stearyl fumarate and glyceryl behenate.

Other Modified Release/Gastroretentive Systems

The following exemplary modified release and gastroretentive systems are suitable for metformin or salt formulations. In one non-limiting example, chitosan and mixtures of chitosan with sodium carboxymethylcellulose (CMC-Na) as described by Inouye et al., Drug Design and Delivery 1: 297-305, 1987, were used as carriers for sustained release of active ingredients. The compounds and combination agents of the present invention, when compressed under a pressure of 200 kg/cm2, form tablets from which the active agent is slowly released upon administration to a patient. The release profile can be changed by varying the ratios of chitosan, CMC-Na and active agent(s). The tablets may also contain other additives including lactose, CaHPO ₄ dihydrate, sucrose, crystalline cellulose or croscarmellose sodium.

In another non-limiting example, Baichwal, US Pat. No. 6,245,356, describes sustained release oral solid dosage forms that contain agglomerated particles of a therapeutically active drug in amorphous form, a gelling agent, an ionizable gel strength agent, and an inert diluent. The gelling agent may be a mixture of xanthan gum and locust bean gum, capable of being cross-linked with the xanthan gum when the gums are exposed to the surrounding liquid. Preferably, the ionizing gel enhancing agent acts to enhance strength

- 31 042749 cross-linking between xanthan gum and locust bean gum, by increasing the duration of release of the drug component in the preparation. In addition to xanthan gum and locust bean gum, suitable gelling agents that may also be used include gelling agents known in the art. Examples include natural or modified natural gums such as alginates, carrageenan, pectin, guar gum, modified starch, hydroxypropyl methyl cellulose, methyl cellulose, and other cellulosic materials or polymers such as, for example, sodium carboxymethyl cellulose and hydroxypropyl cellulose, as well as mixtures of the foregoing.

In another non-limiting formulation suitable for the combinations of the present invention, Baichwal and Staniforth in US Patent No. 5,135,757 describe a free flowing, slow release granular composition for use as a pharmaceutical excipient that contains from about 20% to about 70% or more by weight of a hydrophilic material. , which includes a heteropolysaccharide (such as, for example, xanthan gum or a derivative thereof) and a polysaccharide material capable of cross-linking said heteropolysaccharide (such as, for example, galactomannans, and most preferably locust bean gum) in the presence of aqueous solutions, as well as from about 30 to about 80% by weight of an inert pharmaceutical excipient (such as, for example, lactose, dextrose, sucrose, sorbitol, xylitol, fructose, or mixtures thereof). After mixing the excipient with the tricyclic compound/corticosteroid combination or combination agent of the present invention, the mixture is directly compressed into solid dosage forms such as tablets. Tablets thus formed slowly release the drug when swallowed and exposed to gastric fluids. By varying the amount of excipient relative to the drug, a slow release profile can be achieved.

In another non-limiting example, Shell, US Pat. No. 5,007,790, describes sustained release oral dosage forms that release the active ingredient into solution at a rate controlled by the solubility of the active ingredient. The dosage form includes a tablet or capsule that contains a multiparticulate dispersion of a sparingly soluble active agent in a hydrophilic, water-swellable, cross-linked polymer that retains its physical integrity during the expiration date of the dosage form, but rapidly dissolves thereafter. Upon ingestion, the particles swell, accelerating gastric congestion and allowing gastric fluid to permeate the particles, dissolve the active ingredient and flush it out of the particles, allowing the active agent to reach the stomach in a dissolved state that is less traumatic to the stomach than a solid active ingredient. Possible programmed dissolution of the polymer depends on the nature of the polymer and the degree of cross-linking. The polymer is non-fibrous and substantially water soluble in the uncrosslinked state, and the degree of crosslinking is sufficient to allow the polymer to remain in the undissolved state for a predetermined period of time, typically at least about 4 hours to 8 hours, up to 12 hours, the choice being depends on the introduced active ingredient and medical treatment. Examples of suitable cross-linked polymers that can be used in the present invention are gelatin, albumin, sodium alginate, carboxymethyl cellulose, polyvinyl alcohol and chitin. Depending on the polymer, crosslinking can be achieved by heat or radiation treatment, or by crosslinking agents such as aldehydes, polyamino acids, metal ions, and the like.

In a further non-limiting example, silicone microspheres for pH-controlled gastrointestinal delivery have been described by Carelli et al., Int. J. Pharmaceutics 179: 73-83, 1999. These microspheres are pH sensitive semi-interpermeable polymeric hydrogels prepared from various ratios of poly(methacrylic acid-co-methyl methacrylate) (Eudragit L100 or Eudragit S100) and cross-linked polyethylene glycol 8000, which are encapsulated in silicone microspheres. Slow release formulations may contain a coating that is difficult to dissolve in water, but which is slowly exposed to and removed by water, or through which water can slowly penetrate. Thus, for example, combinations of the present invention can be spray coated with a binder solution under continuous fluidization conditions as described by Kitamori et al., US Pat. No. 4,036,948. ), pregelatinized modified starch, water soluble cellulose (e.g. hydroxypropyl cellulose, hydroxymethyl cellulose, hydroxypropyl methyl cellulose, carboxymethyl cellulose), polyvinylpyrrolidone, polyvinyl alcohol, dextrin, gum arabic and gelatin, solvent soluble binders such as cellulose derivatives (e.g. cellulose acetate phthalate, hydroxypropyl methylcellulose phthalate, ethyl cellulose).

Combinations of the present invention, or components thereof with sustained release properties, can also be formulated to apply spray drying techniques. Another form

- 32 042749 combinations with sustained release can be obtained by microencapsulation of particles of the combined agent in membranes that act as microdialysis cells. In such a formulation, gastric fluid permeates the walls of the microcapsule and causes the microcapsule to swell, allowing the active agent(s) to be dialyzed from it (see, for example, Tsuei et al., US Pat. No. 5,589,194). One commercial sustained release system of this type consists of microcapsules having gum arabic/gelatin/ethyl alcohol membranes. This product is produced by Eurand Limited (France) under the trademark DiffucapsTM. The microcapsules thus formulated may be contained in a conventional gelatin capsule or in a tablet. For the combination of the present invention, a bilayer tablet can be prepared in which two specific granulations are made for each combination agent and the two agents are compressed in a two layer press to produce one tablet.

If desired, formulations can be prepared with enteric coatings capable of being administered with a sustained or controlled release of the active ingredient. The standard type of controlled release formulation that can be used for the purposes of the present invention comprises an inert core such as a sugar ball coated with an inner layer containing the active ingredient and an outer membrane layer controlling the release of the active ingredient from the inner layer. Other formulations for targeted release of compounds in the gastrointestinal tract are also known in the art and are contemplated for use in the invention described herein. Exemplary systems for targeted delivery of a substance to the upper and/or lower gastrointestinal tract include formulations of the TIMERx® system. This controlled drug delivery system is designed for timed release (SyncroDoseTM) as well as biphasic release (Geminex®). (See, for example, Staniforth & Baichwal, TIMERx®: novel polysaccharide composites for controlled/programmed release of active ingredients in the gastrointestinal tract, Expert Opin. Drug Deliv., 2(3): 587-89 (2005)). Using such formulations as described herein, compositions can be made to target the upper GI tract, the lower GI tract, or both, in addition to the controlled time release of such compounds at any of these positions.

One non-limiting example of a lower GI delivery formulation includes a lower GI delivery tablet. The internal composition of the tablet contains from about 0.01% by weight to about 10.0% by weight of a suitable active ingredient; from about 50% by weight to about 98% by weight of hydrocolloid gum obtained from higher plants; and from about 2% by weight to about 50% by weight of a pharmaceutically acceptable excipient, such as a binder. Other optional materials may be present that contribute to the desired characteristics of the pharmaceutical composition. These include materials that can enhance absorption of the active ingredient in the lower FA, can protect the active ingredient from degradation, can prevent dissolution, and the like. There is optionally a coating around the inner composition of the tablet, which is preferably made of an enteric polymeric material.

Such a preparation is intended to take advantage of (1) the protective characteristics of the hydrocolloid, which can be obtained from higher plants, in the upper FA and (2) the degradation characteristics of said hydrocolloid in the lower FA. Thus, the internal formulation of a tablet may be of one of several designs: (a) it may be a matrix of a therapeutically effective amount of the active ingredient uniformly dispersed in combination with a high percentage of hydrocolloid and generally less other excipients; (b) it may have a core in which the active ingredient is concentrated, surrounded by a layer of material that does not contain the active ingredient, and which has a high percentage of hydrocolloid and, as a rule, a smaller amount of other excipients; (c) it may have an active ingredient concentration gradient such that a larger amount is contained in the tablet core, smaller amounts are contained in multiple layers surrounding the core, and the outer layer contains very little or no active ingredient. Regardless of the design of the tablet (a), (b) or (c) above, specificity for the site of delivery to the lower GI is enhanced by enteric coating of the tablet with an appropriate enteric coating material.

Hydrocolloids can be obtained from higher plants. By a higher plant is meant an organism from the plant kingdom that is immobile, has a cellulose cell wall, grows by inorganic synthesis, and includes the vascular plants (or tracheophytes) of the Spermatophyta division, in particular the plants of the Angiospermae class. Resins can be isolated from rhizomes, beans, peels, berries, barks, and so on. Illustrative hydrocolloid gums that can be obtained from higher plants include guar gum, gum tragacanth, karaya gum (also referred to as kadaya gum), and locust bean gum (also referred to as hornwort). Other resins are obvious to those skilled in the art. See, for example

- 33 042749 measures, The Chemistry of Plant Gums and Mucilages by Smith and Montgomery from the ACS Monograph Series, No. 141, 1959, Reinhold Publishing Company, and the 18th edition of the Merck Index. A particularly convenient and useful hydrocolloid is guar gum, which is a neutral polysaccharide and consists of long galactomannan molecules with few side chains attached. The hydrocolloids used in the present invention typically have a high hydration viscosity, are typically linear (containing at least about 50% by weight of the compound in the backbone), and typically have a high molecular weight, typically about 3x10 5 daltons, more typically more than about 1x10 6 daltons. Typically, the hydrocolloid is a powdered hydrocolloid gum and exhibits a viscosity at 1% concentration in a neutral aqueous solution of at least about 75 centipoise per second (cps) at 25°C after 24 hours on a Brookfield viscometer (model LDF) with number 3 spindle at 90 rpm, preferably at least 1x10 3 cps and most preferably at least 2x10 3 cps. Generally, viscosity increases with increasing molecular weight. See Meer Corporation, An Introduction to Polyhydrocolloids. The most suitable hydrocolloid gums are those wherein said hydrocolloid is a polysaccharide hydrocolloid which is chemically defined as galactomannan. Galactomannans are polysaccharides consisting of long chains (1-04) of I3-D-mannopyrazinosyl units, to which side chains from one unit of a-D-galactopyranosyl are attached via linkages (1-06). Galactomannans occur in a variety of plants but differ in molecular size and the number of D-galactosyl side chains. The galactomannans useful in the present invention are commonly found in the endosperm of legumes.

Galactomannan can be obtained, for example, from cyamopsis tetragonolobus, commonly referred to as guar. It exhibits a percentage of mannose residues of about 64% with a percentage of galactose residues of about 36%. Commercial guar gum is a 6682% galactomannan polysaccharide with impurities making up the rest of the composition. According to National Formulary (NF) standards, guar gum may contain up to 15% by weight. water, up to 10% wt. protein, up to 7% wt. acid-insoluble material and up to about 1.5% ash. Manufacturers of industrial guar gum - Aqualon Company, Wilmington, Delaware; Meer Corporation, Cincinnati, Ohio; Stein Hall & Company and TIC Gums, Inc., Belcamp, Maryland.

Other hydrocolloids are known in the art. See, for example, The Chemistry of Plant Gums and Mucilages by Smith and Montgomery in A.C.S. Monograph series, No. 141, 1959, Reinhold Publishing Co., and the eighteenth edition of the Merck Index. In general, the amount of hydrocolloid used is the amount that allows the composition to pass through the upper GI tract without significant degradation and without releasing significant amounts of the active ingredient in the upper GI tract, i.e. provides a sustained release profile. Typically, this amount of hydrocolloid is greater than about 50% but less than about 98%. Depending on individual variability, whether the patient has been eating or not, and other factors, the tablet passes through the stomach and upper intestinal tract in about 3 to 6 hours. During this time, a small amount of active ingredient (less than 20%, preferably less than 10%) is released from the tablet of the present invention. As soon as the tablet reaches the lower FA, the release of the active ingredient begins under the action of the enzymatic degradation of galactomannan gum.

One non-limiting example of a preparation for delivery to the upper gastrointestinal tract includes a free flowing, slow release granular composition for use as a pharmaceutical excipient that contains from about 20% to about 70% or more by weight of a hydrophilic material that includes a heteropolysaccharide ( such as, for example, xanthan gum or a derivative thereof) and a polysaccharide material capable of cross-linking said heteropolysaccharide (such as, for example, galactomannans, and most preferably locust bean gum) in the presence of aqueous solutions, as well as from about 30 to about 80 % by weight of an inert pharmaceutical excipient (such as, for example, lactose, dextrose, sucrose, sorbitol, xylitol, fructose, or mixtures thereof). After mixing the excipient with the compounds of the present invention, this mixture is directly compressed into solid dosage forms such as tablets. Tablets thus formed slowly release the drug when swallowed and exposed to gastric fluids. By varying the amount of excipient relative to the drug, a slow release profile can be achieved.

One non-limiting example of a formulation with sustained delivery to the gastrointestinal tract includes a plurality of dispersion particles of a sparingly soluble active agent in a hydrophilic, water-swellable, cross-linked polymer that retains its physical integrity during the expiration date of the dosage form, but rapidly thereafter. dissolves. Upon ingestion, the particles swell, accelerating gastric congestion and allowing gastric fluid to pass through the particles, dissolve the active ingredient and flush it out of the particles, allowing

- 34 042749 reaching the active agent of the stomach in a dissolved state, which is less traumatic for the stomach than the solid active ingredient. Possible programmed dissolution of the polymer depends on the nature of the polymer and the degree of cross-linking. The polymer is non-fibrous and substantially water soluble in the uncrosslinked state, and the degree of crosslinking is sufficient to allow the polymer to remain undissolved for a given period of time. Examples of suitable cross-linked polymers that can be used in the present invention are gelatin, albumin, sodium alginate, carboxymethyl cellulose, polyvinyl alcohol and chitin. Depending on the polymer, cross-linking can be achieved by heat or radiation treatment, or by cross-linking agents such as aldehydes, polyamino acids, metal ions, and the like.

In another non-limiting example, Villa et al., US Pat. No. 6,773,720, describes a modified release system comprising an inner lipophilic matrix in which the active ingredient beads are embedded and an outer hydrophilic matrix in which the lipophilic matrix is dispersed. The active ingredient, such as metformin or a salt thereof, is first bolstered into a low melting lipophilic excipient or mixture of excipients with heating to soften and/or melt the excipient itself, which thereby encapsulates the active ingredient by simple dispersion. Upon cooling to room temperature, an inert matrix is formed which can be ground to form matrix granules containing particles of the active ingredient. The inert matrix granules are then mixed together with one or more hydrophilic, water-swellable excipients. In this regard, upon contact of the composition with biological fluids, a highly viscous swollen layer is formed, which coordinates the solvent molecules and acts as a barrier to the penetration of the aqueous fluid itself into the new structure. Said barrier counteracts the explosive effect caused by the dissolution of the active ingredient embedded in the form of beads inside an inert matrix, which in turn is in a hydrophilic matrix. One of the industrial systems of this type is a system manufactured by Cosmo Technologies Limited (Italy) under the trademark of MMX® technology. The lipophilic/hydrophilic matrices can optionally be coated with an enteric coating for pH-specific delivery.

Compositions are known in the art for delivery to the upper intestine, the lower intestine, or both intestines. Targeting active ingredients to different areas of the intestine is described, for example, in The Encyclopedia of Pharmaceutical Technology by James Swarbrick and James Boylan, Informa Health Care, 1999, at cc. 287-308. Any suitable gastrointestinal delivery formulations for site-specific delivery and/or specific temporal delivery (i.e. delayed, controlled, sustained or sustained release) may be used in the present invention and are provided herein. In one non-limiting example, one composition comprises a first formulation for delivering at least one compound to the upper gastrointestinal tract and a second formulation for delivering at least one compound to the lower gastrointestinal tract. Thus, one composition can deliver one or more metformin or a salt thereof to the upper and lower gastrointestinal tract. Additional non-limiting examples include compositions containing preparations for delivering at least one compound to the upper gastrointestinal tract and compositions containing preparations for delivering at least one compound to the lower gastrointestinal tract. As described herein, various combinations of compounds can be formulated for the treatment of specific conditions and for delivery to specific areas of the intestinal tract.

Any of the delivery systems described herein may be used in combination with other systems to achieve multiple release and/or specific release profiles. In some embodiments, the active agent(s) is contained in a formulation that provides multiple release in areas of the gastrointestinal tract after administration. In some embodiments, the active agent(s) are contained in a multiple release formulation that, upon administration, provides a release with an onset of action of about 120 minutes, about 180 minutes, about 240 minutes, or combinations of these. In some embodiments, the active agent(s) are contained in a multiple release formulation that, upon administration, provides release with an onset of action of about 75 minutes, about 105 to about 135 minutes, about 165 to about 195 minutes, about 225 to about 255 minutes. or combinations of these values. In some embodiments, the active agent(s) are contained in a multiple release formulation that, upon administration, provides release in the duodenum, small intestine, ileum, lower intestine, or combinations thereof. In other embodiments, the active agent(s) are contained in a multiple release formulation that, upon administration, provides a release with onset of action at about pH 5.5, about pH 6.0, about pH 6.5, about pH 7.0, or combinations of these. values. In other embodiments, the active agent(s) are contained in a multiple release formulation which, upon administration, provides release in the ranges of about pH 5.0 to about pH 6.0, about pH 6.0 to about pH 7.0, about pH 7.0 to about pH 8.0 or more

- 35 042749 combinations of these values. In other embodiments, the active agent(s) are contained in a multiple release formulation that releases a fraction or portion of the active agent(s) in an immediate release and releases the remainder of the active agent(s) in a modified manner as described herein.

Excipients

Any compositions or preparations described herein contain any excipients conventional in the pharmaceutical field, which are selected based on their compatibility with the active agent(s) and properties of the release profile of the desired dosage form. Excipients include, but are not limited to, binders, fillers, flow agents/glidants, tablet disintegrators, lubricants, stabilizers, surfactants, and the like. A brief description of the excipients described herein is provided, for example, in Remington: The Science and Practice of Pharmacy, nineteenth ed. (Easton, PA: Mack Publishing Company, 1995); Hoover, John E., Remington's Pharmaceutical Sciences, (Easton, PA: Mack Publishing Co 1975); Liberman, H.A. and Lachman, L., eds., Pharmaceutical Dosage Forms (New York, NY: Marcel Decker 1980); and Pharmaceutical Dosage Forms and Drug Delivery Systems, 7th ed. (Lippincott Williams & Wilkins 1999), the entire contents of which are incorporated herein by reference.

Binders impart cohesive properties and include, for example, alginic acid and its salts; cellulose derivatives such as carboxymethylcellulose, methylcellulose (eg Methocel®), hydroxypropylmethylcellulose, hydroxyethylcellulose, hydroxypropylcellulose (eg Klucel®), ethylcellulose (eg Ethocel®) and microcrystalline cellulose (eg Avicel®); microcrystalline dextrose; amylose; magnesium aluminum silicate; polysaccharide acids; bentonites; gelatin; polyvinylpyrrolidone/vinyl acetate polymer; crospovidone; povidone; starch; pregelatinized starch; tragacanth, dextrin, sugar such as sucrose (eg Dipac®), glucose, dextrose, molasses, mannitol, sorbitol, xylitol (eg Xylitab®) and lactose; natural or synthetic gum such as gum arabic, tragacanth, ghatti gum, husk gluten slime extract, polyvinylpyrrolidone (e.g. Polyvidone® CL, Kollidon® CL, Polyplasdone® XL-10), larch arabinogalactan, Veegum®, polyethylene glycol, waxes, sodium alginate and the like.

Disintegrating agents facilitate the disintegration or disintegration of oral solid dosage forms after administration. Examples of disintegrating agents include starch, for example natural starch such as corn starch or potato starch, pregelatinized starch such as National 1551 or Amijel®, or sodium starch glycolate such as Promogel® or Explotab®; cellulose, such as a wood product, microcrystalline cellulose, e.g. or a cross-linked cellulose such as sodium cross-linked carboxymethyl cellulose (Ac-DiSol®), cross-linked carboxymethyl cellulose or cross-linked croscarmellose; cross-linked starch such as sodium starch glycolate; a cross-linked polymer such as crospovidone; cross-linked polyvinylpyrrolidone; an alginate such as alginic acid or a salt of alginic acid such as sodium alginate; a clay such as Veegum® HV (magnesium aluminum silicate); a gum such as agar, guar gum, locust bean gum, karaya, pectin or tragacanth; sodium starch glycolate; bentonite; natural sponge; a resin such as a cation exchange resin; citrus pulp; sodium lauryl sulfate; sodium lauryl sulfate in combination with starch; and the like.

Lubricants are compounds that prevent, reduce or retard the adhesion or friction of materials. Illustrative lubricants include, for example, stearic acid; calcium hydroxide; talc; sodium stearyl fumarate; a hydrocarbon such as mineral oil, hydrogenated castor oil or hydrogenated vegetable oil such as hydrogenated soybean oil (Sterotex®); higher fatty acids and their salts with alkali metals and alkaline earth metals such as aluminium, calcium, magnesium, zinc; stearic acid, sodium stearates, magnesium stearates, glycerin, talc, waxes, Stearowet® boric acid, sodium benzoate, sodium acetate, sodium chloride, leucine, polyethylene glycol or methoxy polyethylene glycol such as Carbowax™, ethylene oxide polymers, sodium oleate, glyceryl behenate (e.g., Compritol 888 Ato), glyceryl distearate (Precirol Ato 5), polyethylene glycol, magnesium or sodium lauryl sulfate, colloidal silicon dioxide such as Syloid™, Carb-O-Sil®, DL-leucine, starch such as cornstarch, silicone oil, superficial -active substance and the like.

Flow additives or glidants improve the flow characteristics of powder mixtures. Such compounds include, for example, colloidal silicon dioxide such as Cab-osil®; tribasic calcium phosphate, talc, corn starch, DL-leucine, sodium lauryl sulfate, magnesium stearate, calcium stearate, sodium stearate, kaolin, and micronized amorphous silica

- 36 042749 (Syloid®), and the like.

Plasticizers aid in the coating of oral solid dosage forms. Exemplary plasticizers include, but are not limited to, triethyl citrate, triacetin (glyceryl triacetate), acetyl triethyl citrate, polyethylene glycols (PEG 4000, PEG 6000, PEG 8000), Carbowax 400 (polyethylene glycol 400), diethyl phthalate, diethyl sebacate, acetyl triethyl citrate, oleic acid, glyceryl monostearate, tributyl citrate, acetylated monoglycerides, glycerol, fatty acid esters, propylene glycol and dibutyl phthalate, and the like.

The aforementioned excipients are provided as examples only and are not intended to cover all possible choices. Other classes of useful excipients include colorants, granulating agents, preservatives, defoamers, solubilizers, and the like. In addition, many excipients may have more than one role or function, or may be classified into more than one group; this classification is descriptive only and is not intended to limit any use of a particular excipient.

Methods for evaluating treatment

Hormonal profiles

Administration of a metformin composition or salt thereof provided herein modulates hormonal and/or hormone concentrations including, but not limited to, GLP-1, GLP-2, GIP, oxyntomodulin, PYY, CCK, glycentine, insulin, glucagon, ghrelin, amylin, Cpeptide and uroguanilin. Hormone sampling can be performed multiple times during compound administration. Test animals and subjects can be tested with or without systemic inhibition of dipeptidyl peptidase IV (DPP-IV) to increase the circulating half-life of relevant hormones that can be destroyed by the action of DPP-IV.

For example, in some embodiments of the methods described herein, glucose reduction is provided, wherein the hormonal profiles appropriate for the treatment of elevated blood glucose consist of, but are not limited to: 1) GLP-1 with circulating concentrations greater than baseline concentrations more than 1.5 times; 2) GIP with circulating concentrations greater than 1.5 times baseline, and 3) PYY 3-36 with circulating concentrations greater than 1.5 times baseline.

In another example, in some embodiments of the methods described herein, weight loss is provided, wherein the hormonal profiles associated with weight loss consist of, but are not limited to: 1) PYY with circulating concentrations greater than 3 times baseline. times; 2) oxynthomycin with circulating concentrations exceeding the initial concentrations by more than 2 times; 3) GPL-1 with circulating concentrations greater than 3 times baseline; and 4) CCK with circulating concentrations greater than 2-fold higher than baseline concentrations.

In another example, in some embodiments of the described methods, hormonal profiles include: 1) PYY (total) with circulating concentrations greater than 3 times baseline; and 2) GLP-1 (active) with circulating concentrations greater than 3 times baseline.

In some embodiments described herein, methods for modulating hormonal concentrations in a subject's body are provided, comprising administering a composition containing metformin or a salt thereof, said composition being adapted to deliver said compound to one or more parts of the gut of said subject. In some embodiments, administration of a metformin composition or salt thereof provided herein modulates circulating hormonal concentrations of at least one, at least two, at least three, at least four, at least five, at least six, at least seven, at least eight, at least nine, at least ten, at least eleven, at least twelve, or at least thirteen hormones. In some embodiments, administration of a metformin composition or salt thereof provided herein increases circulating hormonal concentrations of at least one, at least two, at least three, at least four, at least five, at least six, at least seven, at least eight, at least nine, at least ten, at least eleven, at least twelve, or at least thirteen hormones. In some embodiments, administration of a metformin composition or salt thereof provided herein reduces circulating hormonal concentrations of at least one, at least two, at least three, at least four, at least five, at least six, at least seven hormones. In some embodiments, administration of metformin compositions or a salt thereof modulates GLP-1. In some embodiments, administration of metformin compositions or a salt thereof modulates GLP-2. In some embodiments, administration of compositions of metformin or a salt thereof modulates GIP. In some embodiments, administration of metformin compositions or a salt thereof modulates oxyntomodulin. In some

- 37 042749 embodiments, administration of metformin compositions or a salt thereof modulates PYY. In some embodiments, administration of metformin compositions or a salt thereof modulates CCK. In some embodiments, administration of metformin compositions or a salt thereof modulates glycentin. In some embodiments, administration of metformin compositions or a salt thereof modulates insulin. In some embodiments, administration of metformin compositions or a salt thereof modulates glucagon. In some embodiments, administration of metformin compositions or a salt thereof modulates ghrelin. In some embodiments, administration of metformin compositions or a salt thereof modulates amylin. In some embodiments, administration of metformin compositions or a salt thereof modulates insulin. In some embodiments, administration of compositions of metformin or a salt thereof modulates the C-peptide. In some embodiments, administration of metformin compositions or a salt thereof modulates uroguaniline.

Hormone analysis

In embodiments, hormone levels assayed in relation to the methods of the present invention including, but not limited to, GLP-1, GLP-2, GIP, oxyntomodulin, PYY, CCK, glycentin, insulin, glucagon, ghrelin, amylin, uroguanilin, C-peptide and/or combinations thereof are detected according to standard methods described in the literature. For example, proteins can be measured by immunoassays and transcription products by nucleic acid amplification techniques. As appropriate, functional assays described in the art may also be used. In embodiments, the analyzed samples comprise cultured cells, patient cell or tissue samples, patient body fluids such as blood or plasma, and so on. Similarly, the content of analytes (eg, glucose, triglycerides, HDL, LDL, apoB, and the like) analyzed in relation to the methods of the present invention is detected in accordance with any known method.

For example, immunofluorescence can be used to assay for GLP-1. Cells can be grown on matrigel-coated coverslips to confluent monolayers in 12-well plates at 37°C, fixed in 4% paraformaldehyde in phosphate-buffered saline (PBS), and incubated with a primary antiserum (e.g., rabbit anti-alpha Gusducin, 1:150; Santa Cruz Biotechnology, and rabbit anti-GLP-1, Phoenix) overnight at 4°C followed by permeabilization with 0.4% Triton-X in PBS for 10 minutes and blocking for 1 hour at room temperature. temperature. After three washing steps with blocking buffer, the appropriate secondary antibody (AlexaFluor 488 anti-rabbit immunoglobulin, 1:1000; Molecular Probes) is applied for 1 hour at room temperature. After three washing steps, cells can be fixed in Vectashield medium and visualized by immunofluorescence.

GLP-1 RNA isolated from cells can be analyzed by real-time PCR. Isolation of RNA from cells for real-time PCR can be performed according to standard methods. The real-time PCR reaction can be performed in a volume of 50 µl in a Peltier thermal cycler (PTC-225 DNA Engine Tetrad Cycler; MJ Research), using published primer sequences (Integrated DNA Technologies). Reverse transcription can be performed at 50°C for 30 minutes; after the initial activation step at 95°C for 15 minutes. PCR can be performed by denaturing at 94°C for 1 minute, annealing at 55°C for 1 minute and elongation at 72°C for 1 minute for 40 cycles, followed by a final extension step at 72°C for 10 minutes. If necessary, negative controls may be included, for example by replacing the missing reverse transcriptase or tracing paper with water. The control may be RNA isolated, for example, from the lingual epithelium of rats. PCR products can be isolated on a 2% ethidium bromide agarose gel and visualized under UV light.

Radioimmunoassay (RIA) for total GLP-1 in patient blood samples can be performed as described in the art, e.g., Laferrere, et al., 2007, Incretin Levels and Effect are Markedly Enhanced 1 Month after Roux-en- Y Gastric Bypass Surgery in Obese Patients with Type 2 Diabetes, Diabetes Care 30(7): 1709-1716 (using commercial materials available from Phoenix Pharmaceutical, Belmont, CA). The authors describe measuring the effect of GIP and GLP-1 on insulin secretion by measuring the difference in insulin secretion (area under the curve or AUC) in response to an oral glucose tolerance test and an isoglycemic intravenous glucose test.

Measurement of plasma concentrations of GLP-1, GIP, glucagon, insulin, C-peptide, pancreatic peptide, non-esterified fatty acids, antibodies to glutamic acid decarboxylase and antibodies to islet antigens are described, for example, by Toft-Nielsen, et al., 2001 , Determinants of the Impaired Secretion of Glucagon-Like Peptide-1 in Type 2 Diabetic Patients, J. Clin. end. Met. 86(8):37173723. The authors describe the use of a radioimmunoassay for GLP-1 to measure plasma concentrations of amidated GLP-1-(7-36), using antibody code no. 89390. This assay measures the sum of GLP-1-(7-36) and its metabolite GLP -1-(9-36). The authors describe the measurement of GIP with a C-terminally targeted antibody code R65 (RIA) that interacts 100% with human GIP but not with 8 kDa GIP.

GLP-1 and PYY can be directly measured in the supernatant from venous exudates,

- 38 042749 as described, for example, in Claustre, et al. (1999, Stimulatory effect of β-adrenergic agonists on ileal L cell secretion and modulation by α-adrenergic activation, J. Endocrin. 162:271-8). (See also Plaisancie' et al., 1994, Regulation of glucagon-like peptide-1-(7-36) amide secretion by intestinal neurotransmitters and hormones in the isolated vascularly perfused rat colon, Endocrinology 135:2398-2403 and Plaisancie' et al., 1995, Release of peptide YY by neurotransmitters and gut hormones in the isolated, vascularly perfused rat colon, Scandinavian Journal of Gastroenterology 30:568-574.) In this method, 199D anti-GLP-1 antibody is used at dilution 1: 250,000. This antibody interacts 100% with GLP-1-(7-36) amide, 84% with GLP-1-(1-36) amide, and less than 01% with GLP-1-(1-37), GLP-1-(7-37), GLP-2 and glucagon. PYY is assayed with A4D anti-pig antiserum PYY at a dilution of 1:800,000.

Methods for measuring GLP-1 and GIP are also described in other sources in the art, for example, by the authors, Jang, et al., PNAS, 2007.

PYY can also be measured in the blood using a radioimmunoassay described, for example, by Weickert, et al., 2006, Soy isoflavones increase preprandial peptide YY (PYY), but have no effect on ghrelin and body weight in healthy postmenopausal women Journal of Negative Results in BioMedicine, 5:11. Blood is collected in ice-cold EDTA tubes for glucose, ghrelin and PYY analysis. After centrifugation at 1600 g for 10 minutes at 4°C, aliquots are immediately frozen at -20°C until analysis. All samples obtained from individual subjects are measured in one assay. The authors who described the measurement of immunoreactive total ghrelin performed the measurement using an industrial radioimmunoassay (Phoenix Pharmaceuticals, Mountain View, CA, USA). (See also Weickert, et al., 2006, Cereal fiber improves whole-body insulin sensitivity in overweight and obese women, Diabetes Care 29:775-780). Immunoreactive total human PYY is measured by industrial radioimmunoassay (LINCO Research, Missouri, USA, using 125I-labeled bioactive PYY as a label and PYY antiserum to determine the content of active PYY by the double antibody/PEG method. The PYY antibody is induced in guinea pigs and recognizes both forms PYY 1-36 and PYY 3-36 (active) of human PYY.

SGLT-1, intestinal sodium-dependent glucose transporter 1, is a protein involved in the delivery of glucose to the body. It has been described to be expressed in response to sugar in the intestinal lumen, via a pathway involving T1R3 (Margolskee, et al., 2007 T1R3 and gustducin in gut sense sugars to regulate expression of Na+-glucose cotransporter 1, Proc Natl Acad Sci USA 104 , 15075-15080). Expression of SGLT-1 can be detected, for example, in accordance with the publication of Margolskee, et al., for example, using quantitative PCR, as well as Western blot methods known in this field. The measurement of glucose transport has been described in the literature, for example by Dyer, et al., 1997, Gut 41:56-9 and Dyer, et al., 2003, Eur. J, Biochem., 270:3377-88. Measurement of glucose transport in brush border vesicle membranes can be performed, for example, by initiating D-glucose uptake by adding 100 µl of incubation medium containing 100 mM NaSCN (or KSCN), 100 mM mannitol, 20 mM Hepes/Tris (pH 7.4), 0, 1 mM MgSO ₄ , 0.02% (w/v) NaN ₃ and 0.1 mM D-[U14C]glucose, in BBMV (100 μg protein). The reaction is stopped after 3 seconds by adding 1 ml of ice-cold stop buffer containing 150 mM KSCN, 20 mM Hepes/Tris (pH 7.4), 0.1 mM MgSO ₄ , 0.02% (w/v) NaN ₃ and 0, 1 mM phlorizin. Take a 0.9 ml portion of the reaction mixture and filter under vacuum through a 0.22 μm cellulose acetate/nitrate porous filter (GSTF02500; Millipore, Bedford, Massachusetts). The filter is washed five times with 1 ml stop buffer and the radioactivity remaining on the filter is measured by liquid scintillation count.

Diabetes treatment evaluation

The impact of treatment with a biguanide or related heterocyclic compound of the present invention on aspects of diabetic disease can be assessed in accordance with methods known in the art and conventional physicians treating diabetic subjects.

The effectiveness of the treatment of diabetes/metabolic syndrome and diabetes-related conditions using the compositions and methods described herein can be measured using assays and techniques known in the art. For example, it is well known in the art to quantify renal function and parameters of renal dysfunction. Examples of tests to determine renal function/dysfunction include serum creatinine; the rate of excretion of creatinine; rate of excretion of cystatin C, 24-hour urinary creatinine excretion, 24-hour urinary protein secretion; glomerular filtration rate (GFR); urinary albumin to creatinine ratio (ACR); albumin excretion rate (AER); and kidney biopsy.

Quantification of pancreatic function and parameters of pancreatic dysfunction or insufficiency is also well known in the art. Examples of assays for determining pancreatic function/dysfunction include the assessment of pancreatic functions using biological and/or physiological parameters such as determining the size, growth and/or secretion activity of the islets of Langerhans, the size, growth and/or secretion activity of beta cells, secretion and concentration in insulin blood flow, blood glucose, pancreatic imaging and pancreatic biopsy, glucose uptake studies with oral sugar loading, cytokine profiles, blood gases, degree of blood perfusion in tissues, and angiogenesis in tissues.

Additional assays for the treatment of diabetes and diabetes-related conditions are well known in the art and provided herein.

Evaluation of the treatment of obesity and eating disorders

In the treatment of obesity, it is desirable that the subject's body weight and/or fat content be reduced. By weight loss is meant that the subject loses a portion of his/her total body weight during the course of treatment (regardless of whether that course of treatment lasts for days, weeks, months or years). Alternatively, weight loss can be defined as a decrease in the ratio of fat mass to lean mass (in other words, the subject loses fat mass but maintains or gains lean mass, not necessarily with a corresponding decrease in total body weight). An effective amount of treatment with metformin or a salt thereof administered in this embodiment is an amount effective to reduce the subject's body weight over the course of treatment, or alternatively, an amount effective to reduce the percentage of body fat in the subject's body over the course of the course. treatment. In some embodiments, the subject's body weight decreases during the course of treatment by at least about 1%, at least about 5%, at least about 10%, at least about 15%, or at least about 20%. %. Alternatively, during the course of treatment, the subject's body fat percentage decreases by at least 1%, at least 5%, at least 10%, at least 15%, at least 20%, or at least measure by 25%.

Total body weight and fat content can be measured at the end of the dietary period. In rats, a commonly used method for determining total body fat is the surgical removal and weighing of the retroperitoneal fat layer, the fat body located in the retroperitoneal space, in the region between the posterior abdominal wall and the posterior parietal peritoneum. The weight of this layer is considered directly related to the percentage of body fat in the animal. Since the relationship between body weight and body fat content in rats is linear, obese animals have a correspondingly higher body fat percentage and retroperitoneal fat weight.

In embodiments that provide methods for treating, reducing, or preventing hunger, said hunger may be measured using a questionnaire known in the art or developed by a hunger researcher. Such questionnaires preferably classify the degree of hunger on a numerical scale, where the subject scores 0 if they are not hungry and 10 (on a scale of 1-10) if the subject is severely hungry. The questionnaire preferably also includes questions regarding the type of food taken by the subject when hungry.

Binge eating can be defined or measured using the Binge Eating Questionnaire and Scale (BES). The degree of binge eating can be subdivided into three categories (mild, moderate and severe) based on the overall BES score (calculated by summing the scores for each individual item). Accordingly, methods are provided for reducing a subject's BES score, comprising administering to a subject in need thereof treatment with a biguanide or related heterocyclic compound in an amount effective to reduce the subject's BES score. In some embodiments, the administration of treatment with a biguanide or related heterocyclic compound changes the subject's BES category, eg, from severe to moderate, severe to mild, or moderate to mild.

Pre-treatment assessment of the patient's hormonal profile

In some embodiments, pre-treatment evaluation of patients for metabolic hormone expression is performed using the methods described herein. Therefore, the therapy provided to an individual may be directed to his or her specific needs. In embodiments, the patient's hormonal profile is pre-measured and, depending on the changes the clinician wishes to achieve, a specific combination of metformin or a salt/metabolite thereof is administered. The evaluation process may be repeated and treatment may be adjusted accordingly at any time during or after treatment.

Definitions

A chemosensory receptor as used herein includes, for example, G protein coupled receptors (GPCRs) that are expressed in the gastrointestinal tract of a subject. Chemosensory receptors comprise the family of taste receptors and are further classified by their taste characteristic. These include sweet taste receptors, umami receptors (also known as hot taste receptors), bitter taste receptors, fat receptors, bile acid receptors, salty taste receptors, and sour taste receptors. The chemosensory receptor can be any receptor associated with chemosensory perception or transmission of a signal triggered by a chemosensory ligand, such as through taste or taste-associated receptors found in taste buds, the gastrointestinal tract, and so on.

- 40 042749

Activity or functional effect in the context of the described ligands and assays for testing compounds that modulate a chemosensory receptor, e.g., enhance signal transduction mediated by a member of the chemosensory receptor family, such as receptor function or activity for sweet taste, umami taste, bitter taste, fat, bile acidity, sour taste or salty taste, includes the definition of any parameter that is indirectly or directly affected by a particular chemosensory receptor. This includes, but is not limited to, ligand binding, ion flux alteration, membrane potential, electrical current, transcription, G protein binding, GPCR phosphorylation or dephosphorylation, signal transduction, receptor-ligand interactions, second messenger concentrations (e.g., cAMP, cGMP, IP3, or intracellular Ca2+), in vitro, in vivo and ex vivo, and also includes other physiological effects such as increasing or decreasing the release of a neurotransmitter or hormone and measuring the downstream physiological effects of such release.

The term determination of the functional effect or activity of the receptor means the analysis of a compound that increases or decreases the parameter, which is indirectly or directly affected by the specified chemosensory receptor, for example, functional, physical and chemical effects. Such parameters also include the secretion of hormones such as GIP, GLP-1, GLP-2, oxyntomodulin, insulin, glucagon, insulin, peptide C, peptide YY and CCK. Such functional effects can be measured by any means known to those skilled in the art, such as changes in spectroscopic characteristics (e.g., fluorescence, absorption, refractive index), hydrodynamic (e.g., shape), chromatographic or solubility properties, clamping potential, voltage sensitive dyes, whole cell currents, radioisotope leakage, inducible markers, oocyte chemosensory receptor, eg T1R gene expression; on the chemosensory receptor of tissue culture cells, for example, T1R expression; by transcriptional activation of the chemosensory receptor, for example, the T1R genes; for ligand binding assays; by changes in voltage, membrane potential and conductivity; according to ion flow analyses; on changes in intracellular second messengers such as cAMP, cGMP and ionositol triphosphate (IP3); by changes in intracellular calcium concentrations; on the release of neurotransmitters and the like. Also included are assays to determine an increase or decrease in the secretion and/or activity of a hormone or neurotransmitter. Changes in the secretion and/or activity of a hormone or neurotransmitter can also be determined indirectly from the physiological effects due to a change in the secretion of a hormone or neurotransmitter. Functional and physical parameters that can be used to determine the functional effect or activity of the receptor include, but are not limited to, appetite suppression and weight loss.

Ligands to chemosensory receptors include metabolized ligands to chemosensory receptors that can be metabolized as a source of energy, such as food or metabolites, as well as non-metabolized ligands to chemosensory receptors that are not metabolized as a source of energy, such as flavors. The term non-metabolized chemosensory receptor ligands, as used herein, includes chemosensory receptor ligands that are metabolized to a small extent, but not substantially metabolized. That is, a non-metabolized chemosensory receptor ligand includes ligands that have negligible caloric value. Ligands for chemosensory receptors include agonists, antagonists, modifiers and enhancers, as well as other compounds that modulate chemosensory receptors. Many ligands for chemosensory receptors are known in the art and are described in the literature.

Flavoring agents, as used herein, refers to a ligand that produces a taste or taste in a subject, including sweet, sour, salty, bitter, umami, and others. The flavoring substances are generally also not metabolized in the sense that they do not have a significant caloric value.

Metabolites, as used herein, are metabolized ligands for chemosensory receptors such as, for example, glucose, glutamate salts, fatty acids, and bile acids. In some aspects, the metabolites may be obtained from food sources. The metabolites can be administered as part of a chemosensory receptor ligand composition or separately.

Antagonists/inhibitors are compounds which, for example, bind to, partially or completely block stimulation, reduce, prevent, delay activation, inactivate, desensitize or down-regulate a chemosensory receptor and/or taste transmission. Agonists/activators are compounds that, for example, bind to, stimulate, increase, open, activate, facilitate, increase activation, sensitize or upregulate chemosensory receptor signaling.

Modifiers include compounds that, for example, alter, directly or indirectly, the activity of the receptor or the interaction of the receptor with its ligands, for example, receptor ligands, biguanide or related heterocyclic compounds, and optionally bind or

- 41 042749 interact with activators or inhibitors; G-proteins; kinases (eg, homologues of rhodopsin kinase and beta-adrenergic receptor kinases that are involved in receptor deactivation and desensitization); and cause blockage, which also deactivates and desensitizes the receptors. Modifiers include genetically modified versions of chemosensory receptors, eg members of the T1R family, eg with altered activity, as well as natural and synthetic ligands, antagonists, agonists, small chemical molecules, and the like. In the present invention, they include, without limitation, sweet taste receptor ligands, umami taste receptor ligands, bitter taste receptor ligands, fatty acid ligands, bile acid receptor ligands (agonists or antagonists). Modifiers also include compounds that allosterically bind to a receptor and alter the activity of the receptor. Multipliers also include enhancers. Depending on the structure, functional properties and activity, modifiers can enhance, potentiate, induce and/or block the physiological activity of other ligands to chemosensory receptors.

Enhancers, as used herein, are a type of modifier and refer to chemosensory receptor ligands that enhance, potentiate, or multiply the action of another chemosensory receptor ligand. For example, a sweet taste receptor enhancer can increase or increase the sweetness of a chemosensory receptor ligand composition when used in combination with a sweet taste receptor ligand (eg, a sweetener such as sucrose, fructose, glucose, saccharin, aspartame, sucralose, etc.). Although a sweet taste receptor enhancer may or may not have sweet properties in some combinations when used in the absence of a sweet taste receptor ligand, enhancement of the sweet taste receptor occurs when a sweet taste receptor enhancer is used in combination with another sweet taste receptor ligand resulting in the perception of sweet taste. subject to a greater extent than the additive effect attributed to the inherent sweet properties of the sweet taste receptor enhancer (if such properties are present), plus the sweetness attributed to the presence of the sweet taste receptor ligand.

The terms gastrointestinal tract and intestines, as used herein, refer to the stomach and intestines. The small or upper intestine includes the duodenum, small intestine, and ileum, and the large or lower intestine includes the caecum, large intestine, and rectum. Outside the stomach refers to the small and lower intestines.

Treating or treating any condition, disease, or disorder refers, in some embodiments, to improving the disease, disorder, or condition (i.e., stopping or reducing the progress of the disease, disorder, or condition, or at least one of its clinical symptoms). In other embodiments, treating or treating refers to improving at least one physical parameter that may or may not be perceptible to the subject, including physical parameters that are undesirable but clinically insignificant. In other embodiments, treating or treating refers to slowing down a disease, disorder, or condition, physically (eg, stabilizing a visible symptom), physiologically (eg, stabilizing a physical parameter), or both. In other embodiments, treating or treating refers to preventing or delaying the onset of a disease, disorder, or condition.

A therapeutically effective amount or effective amount means an amount of a composition, compound, therapy, or course of treatment that, when administered to a subject for the treatment of a disease, disorder, or condition, is sufficient to achieve such treatment of the disease, disorder, or condition. A therapeutically effective amount varies depending on the composition, compound, therapy, course of treatment, disease, disorder or condition, as well as its severity and the age, weight, etc. of the subject being treated.

Where the compounds (e.g., compounds of formulas I-IV, as well as other compounds having the described chemical structure) described herein contain one or more chiral centers, the stereochemistry of such chiral centers may be independently in the R or S configuration, or be mixture of these two options. Chiral centers may be further designated as R or S, or R,S, or d,D, 1,L, or d,1, D,L. Accordingly, the amide, guanidine, biguanide and related heterocyclic compounds of the present invention, if they can exist in an optically active form, may actually be present in the form of a racemic mixture of enantiomers, or in the form of any of the individual enantiomers in substantially isolated and purified form, or as a mixture, containing any relative ratios of said enantiomers.

If the amide, guanidine, biguanide and related heterocyclic compounds of the present invention can exist in geometric isomeric forms around, for example, a guanide bond, then they can actually be presented in the form of a mixture of geometric isomers containing any relative ratios of these isomers, or in some cases - in the form of any of the individual geometric isomers in substantially isolated and purified form.

If the compounds (for example, compounds of formulas I-IV, as well as other compounds having the described chemical structure) described herein contain one or more isolated or linearly conjugated double bonds, then the geometry around such double bonds can be independently cis/trans, E/Z mixture or E or Z geometric isomer.

Alkyl means a straight or branched, saturated monovalent hydrocarbon radical. For example, a hydrocarbon chain may have one to twenty carbon atoms, one to sixteen carbon atoms, one to fourteen carbon atoms, one to twelve carbon atoms, one to ten carbon atoms, one to eight carbon atoms, one up to six carbon atoms, one to four carbon atoms, and so on. Lower alkyl may refer to alkyls having, for example, one to six carbon atoms, one to four carbon atoms, and so on. In some examples, straight alkyl may have one to six carbon atoms and branched alkyl may have three to six carbon atoms, e.g., methyl, ethyl, propyl, 2-propyl, butyl (including all isomeric forms), pentyl (including all isomeric forms) and the like. Me means methyl, Et means ethyl, and iPr means isopropyl.

Aryl means a monovalent monocyclic or bicyclic aromatic hydrocarbon radical, eg having 6 to 20 or 6 to 10 ring atoms, eg phenyl or naphthyl.

Alkylaryl means the radical -(aluclene)-R, where R is aryl, as described above.

Cycloalkyl means a cyclic saturated or partially saturated monovalent hydrocarbon radical (or alicyclic radical. For example, cycloalkyl may have three to twenty carbon atoms, three to sixteen carbon atoms, three to fourteen carbon atoms, three to twelve carbon atoms, three up to ten carbon atoms, three to eight carbon atoms, three to six carbon atoms, etc., where one or two carbon atoms may be replaced by an oxo group, e.g. adamantanyl, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, cyclohexenyl, indanyl and the like.

Alkylcycloalkyl means the radical -(αlkulene)-R, where R is cycloalkyl as described above; for example, cyclopropylmethyl, cyclobutylmethyl, cyclopentylethyl or cyclohexylmethyl and the like.

Heterocyclyl or heterocycloalkyl means a saturated or unsaturated monovalent monocyclic group in which one or two ring atoms is a heteroatom selected from N, O or S, the remaining ring atoms are C. The heterocyclyl ring is optionally fused to (one) aryl or heteroaryl ring, as described in this document. A heterocyclyl ring fused to a monocyclic aryl or heteroaryl ring is also referred to in the present invention as a bicyclic heterocyclyl ring. In addition, one or two ring carbon atoms in the heterocyclyl ring may optionally be replaced by a -CO- group. More specifically, the term heterocyclyl includes, but is not limited to, pyrrolidino, piperidine, homopiperidino, 2-oxopyrrolidinyl, 2oxopiperidinyl, morpholino, piperazino, tetrahydropyranyl, thiomorpholino, and the like. If the heterocyclyl ring is unsaturated, it may contain one or two ring double bonds. If a heterocyclyl group contains at least one nitrogen atom, it may also be referred to herein as heterocycloamino and is a subset of heterocyclyl groups. When a heterocyclyl group is a saturated ring and is not fused to an aryl or heteroaryl ring as above, it is also referred to herein as a saturated monocyclic heterocyclyl.

Alkylheterocycloalkyl means the radical -(alkylene)-R, where R represents a heterocyclyl ring as described above, for example, tetrahydrofuranylmethyl, piperazinylmethyl, morpholinylethyl and the like.

Heteroaryl means a monovalent monocyclic or bicyclic aromatic radical in which one or more, preferably one, two or three ring atoms is a heteroatom selected from N, O or S, the remaining ring atoms are carbon. Illustrative examples include, but are not limited to, pyrrolyl, thienyl, thiazolyl, imidazolyl, furanyl, indolyl, isoindolyl, oxazolyl, isoxazolyl, diazolyl, pyrazolyl, triazolyl, benzothiazolyl, benzoxazolyl, quinolinyl, isoquinolinyl, pyridinyl, pyrimidinyl, pyrazinyl, pyridazinyl, tetrazolyl and the like.

Oxo or carbonyl means a =(O) group or a C=O group, respectively.

The term "substituted" means that the group referred to is substituted with one or more additional groups, individually and independently selected from the groups described herein. In some embodiments, the optional substituent is selected from oxo, halo, -CN, -NH2, -OH, -NH(CH ₃ ), -N(CH ₃ ) ₂ , alkyl (including straight, branched, and/or unsaturated alkyl), substituted or unsubstituted cycloalkyl, substituted or unsubstituted heterocycloalkyl, fluoroalkyl, substituted or unsubstituted heteroalkyl, substituted or unsubstituted alkoxy, fluoroalkoxy, -S-alkyl, -S(O) ₂ -alkyl, -CONH((substituted or unsubstituted alkyl) or (substituted or

- 43 042749 unsubstituted phenyl)), -CON(H or alkyl) ₂ , -OCON(substituted or unsubstituted alkyl) ₂ , -NHCONH((substituted or unsubstituted alkyl) or (substituted or unsubstituted phenyl)), -NHCO-alkyl, -N(substituted or unsubstituted alkyl)CO(substituted or unsubstituted alkyl), -NHCOO(substituted or unsubstituted alkyl), -C(OH)(substituted or unsubstituted alkyl) ₂ and -C(NH ₂ )(substituted or unsubstituted alkyl) ₂ . In some embodiments, for example, the optional substituent is selected from oxo, fluorine, chlorine, bromine, iodine, -CN, -NH2, -OH, -NH(CH ₃ ), -N(CH ₃ ) ₂ , -CH3, -CH ₂ CH3, -CH(CH3)2, -CF3, -CH2CF3, -OCH3, -OCH2CH3, -OCH(CH2)2, -OCF3, -OCH2CF3, -S(O) _{2 -CH3} , -CONH2, -CONHCH3 , -NHCONHCH3, -COCH ₃ , -COOH and the like. In some embodiments, the substituted groups are substituted with one, two, or three of the previous groups. In some embodiments, the substituted groups are substituted with one or two of the previous groups. In some embodiments, the substituted groups are substituted with one of the previous groups. Additionally, unless otherwise indicated, a formula with chemical bonds shown only as straight lines and not as wedges or dotted lines also includes each possible isomer, for example, each enantiomer and diastereomer, as well as mixtures of isomers, such as racemic or scalemic mixtures.

In some embodiments, a compound of the present disclosure (eg, compounds of formulas I-IV, as well as other compounds having the described chemical structure) is present in the composition as a salt. In some embodiments, salts are prepared by reacting a compound of this disclosure with acids. In some other embodiments, pharmaceutically acceptable salts are prepared by reacting a compound of this disclosure with a base. In other embodiments, the compounds are used in free acid or free base form in the manufacture of the compositions described herein. Types of salts include, but are not limited to: (1) acid addition salts formed by reacting the free base form of the compound with a pharmaceutically acceptable inorganic acid such as, for example, hydrochloric acid, hydrobromic acid, sulfuric acid, phosphoric acid, metaphosphoric acid, and the like. similar; or with an organic acid such as, for example, acetic acid, propionic acid, hexanoic acid, cyclopentanepropionic acid, glycolic acid, pyruvic acid, lactic acid, malonic acid, succinic acid, malic acid, maleic acid, fumaric acid, trifluoroacetic acid, tartaric acid, citric acid, benzoic acid, 3(4-hydroxybenzoyl)benzoic acid, cinnamic acid, mandelic acid, methanesulfonic acid, ethanesulfonic acid, 1,2-ethanedisulfonic acid, 2-hydroxyethanesulfonic acid, benzenesulfonic acid, toluenesulfonic acid, 2-naphthalenesulfonic acid acid, 4methylbicyclo-[2.2.2]oct-2-en-1-carboxylic acid, glucoheptonic acid, 4,4'-methylenebis-(3hydroxy-2-en-1-carboxylic acid), 3-phenylpropionic acid, trimethylacetic acid , tert-butylacetic acid, laurylsulfuric acid, gluconic acid, glutamic acid, hydroxynaphthoic acid, salicylic acid, stearic acid, muconic acid, butyric acid, phenylacetic acid, phenylbutyric acid, valproic acid and the like; (2) salts formed by replacing an acidic proton present in the parent compound with a metal ion such as an alkali metal ion (eg lithium, sodium, potassium), an alkaline earth metal ion (eg magnesium or calcium), or an aluminum ion. In some instances, the biguanide or related heterocyclic compound described herein is reacted with an organic base such as, but not limited to, ethanolamine, diethanolamine, triethanolamine, tromethamine, N-methylglucamine, dicyclohexylamine, tris(hydroxymethyl)methylamine. In other instances, the compounds described herein form salts with amino acids such as, but not limited to, arginine, lysine, and the like. Acceptable inorganic bases used to form salts with compounds that contain an acidic proton include, but are not limited to, aluminum hydroxide, calcium hydroxide, potassium hydroxide, sodium carbonate, sodium hydroxide, and the like.

The term amino acid includes any of the twenty naturally occurring amino acids or the D-form of any of the naturally occurring amino acids. In addition, the term amino acid also includes other non-natural amino acids, in addition to D-amino acids, which are functional equivalents of natural amino acids. Such non-natural amino acids include, for example, norleucine (Nle), norvaline (Nva), L- or D-naphthalanine, ornithine (Orn), homoarginine (homoArg), and others well known in the peptide art such as those described in M. Bodanzsky. , Principles of Peptide Synthesis, 1st and 2nd revised ed., Springer-Verlag, New York, NY, 1984 and 1993, and Stewart and Young, Solid Phase Peptide Synthesis, 2nd ed., Pierce Chemical Co., Rockford , Illinois, 1984, each of which is incorporated herein by reference.

Amino acids and amino acid analogs can be purchased from commercial suppliers (Sigma Chemical Co.; Advanced Chemtech) or can be synthesized by methods known in the art.

Within the scope of embodiments, the compounds described herein (for example, compounds of formula I-V and the like) include additional forms of the compounds, such as pharmaceuticals

- 44 042749 Tically acceptable salts, solvates (including hydrates), amorphous phases, partially crystalline and crystalline forms (including all polymorphs), prodrugs, metabolites, N-oxides, isotopically labeled, epimers, pure epimers, epimer mixtures, enantiomers, including but not limited to, mono-enantiomers and enantiomeric diastereomers, meso compounds, stereoisomers, racemic mixtures, and diastereomeric mixtures. Compounds described herein having one or more double bonds include cis/trans isomers, E/Z isomers, and geometric isomers. The compounds described herein may be prepared as pharmaceutically acceptable salts formed by replacing the acidic proton contained in the parent compound with a metal ion, such as an alkali metal ion, an alkaline earth metal ion, or an aluminum ion; or when it is coordinated with an organic base. In addition, salt forms of the described compounds can be obtained using salts of starting materials or intermediates.

In some embodiments, the compounds described herein include solvent addition forms or crystalline forms, in particular solvates or polymorphs. Solvates contain stoichiometric or non-stoichiometric amounts of solvent and may be formed during crystallization with pharmaceutically acceptable solvents such as water, ethanol, and the like. Hydrates are formed when the solvent is water, or alcoholates are formed when the solvent is alcohol.

In some embodiments, the compounds described herein have one or more stereocenters, and each center independently exists in the R or S configuration. The compounds provided herein include all diastereomeric, enantiomeric and epimeric forms, as well as their respective mixtures.

In some embodiments, the sites in the compounds described herein are subject to various metabolic reactions. Therefore, the introduction of appropriate substituents in the sites of metabolic reactions reduces, minimizes or eliminates these metabolic pathways. In particular embodiments, an appropriate substituent to reduce or eliminate the aromatic ring's susceptibility to metabolic reactions is, for example, a halogen, deuterium, or alkyl group.

In some embodiments, the compounds described herein have an isotopic label that is identical to the compounds listed in the various formulas and structures presented herein, except for the fact that one or more atoms are replaced by an atom having an atomic mass or mass number , which is different from the atomic mass or mass number normally found in nature. In some embodiments, one or more hydrogen atoms are replaced by deuterium. In some embodiments, the metabolic sites in the compounds described herein are deuterated. In some embodiments, deuterium substitution provides some therapeutic benefits that result from greater metabolic resistance, such as, for example, increased in vivo half-life or reduced dosage requirements. In the present description, those skilled in the art may choose the groups and their substituents to obtain stable moieties and compounds.

Examples

Example 1

Illustrative composition of meformin and its administration.

Composition A Chemosensory receptor ligand For one oral solid dosage form (mg) Dose (mg) B.i.d. Total per day Metformin HC1 50 200 400

A single oral solid dosage form (eg, tablet, pill, capsule, and the like) contains the listed component(s). A single dose for administration is a set of 4 units of oral solid dosage form (for example, 4 tablets or 4 capsules). Each of the 4 units contains the identical active ingredient(s); however, each individual unit is formulated to release at a different pH: pH 5.5, pH 6.0, or pH 6.5. One unit releases about 20% of its components within about 15 to about 60 minutes after entering an intestinal pH of about 5.5 and releases the remaining 80% of its components within about 2 hours. Another unit releases about 20% of its components within about 15 to about 60 minutes after entering an intestinal pH of about 6.0 and releases the remaining 80% of its components within about 4 hours. The third unit releases about 20% of its components within about 15 to about 60 minutes after entering the intestinal pH of about 6.5 and releases the remaining 80% of its components within about 4 hours. The fourth unit releases about 20% of its components within about 15 to about 60 minutes after entering the intestinal pH of about 6.0, and releases the remaining 80% of its components within about 7 hours. Dosing

- 45 042749

b.i.d. occurs at meals, usually breakfast or the first meal of the day and dinner or the third meal of the day.

Double layer tablet.

Compositions a.

The biguanide or related heterocyclic compound of composition A (metformin) is incorporated into bilayer tablet cores with excipients as shown in the following table (expressed in proportional units).

The HB column in the table above refers to a 20% by weight bilayer tablet that releases its contents in about 15 to about 60 minutes. BK2, BK4 and BK7 refer to the remaining 80% of the components, which are released within approximately 2, 4 or 7 hours. The bilayer tablet core contains the HB compound and one of the components BK, BK4 or BK7. The purity of all ingredients is >99.8% and the concentrations of all impurities for all ingredients are well below the limits set in accordance with the guidelines of the International Conference on Harmonization (ICH).

The cores of bilayer tablets are coated with the following coating compositions for release at the specified pH, presented in the following table (expressed in proportional units).

Composition nv/vk 2 hours pH 5.5 NR/EC 4 hours pH 6.0 NV/VK 4 hours pH 6.5 HB/VK 7 hours pH 6.0 Eudragit L30 D55 833.4 750.06 625.05 750.06 Eudragit FS 30D 0 83.34 208.35 83.34 Talc 125.0 T riethyl citrate 25.0 Water 1016

Example 2

An exemplary composition of metformin combined with additional chemosensory receptor ligands and its administration.

Composition D Chemosensory receptor ligand For one oral solid dosage form (mg) Dose (mg) B.i.d. Total per day Rebaudioside A 200 800 1600 Stevioside 100 400 800 Sucralose 100 400 800 Metformin HC1 25 100 200 L-Glutamine 50 200 400

A single oral solid dosage form (eg, tablet, pill, capsule, and the like) contains the listed components. A single dose for administration is a set of 4 units of oral solid dosage form (for example, 4 tablets or 4 capsules). Each of the 4 units contains identical active ingredients; however, each individual unit is formulated to release at a different pH: pH 5.5, pH 6.0, or pH 6.5. One unit releases about 20% of its components within about 15 to about 60 minutes after entering an intestinal pH of about 5.5 and releases the remaining 80% of its components within about 2 hours. Another unit releases about 20% of its components within about 15 to about 60 minutes after entering an intestinal pH of about 6.0 and releases the remaining 80% of its components within about 4 hours. The third unit releases about 20% of its components within

- 46 042749 about 15 to about 60 minutes after entering the intestinal pH of about 6.5 and releases the remaining 80% of its components within about 4 hours. The fourth unit releases about 20% of its components within about 15 to about 60 minutes after entering an intestinal pH of about 6.0 and releases the remaining 80% of its components within about 7 hours. Dosing b.i.d. occurs at meals, usually breakfast or the first meal of the day and dinner or the third meal of the day.

Double layer tablet.

Compositions V.

Composition B chemosensory receptor ligands (rebaudioside A, stevioside, sucralose, metformin HCl and L-glutamine) are injected into bilayer tablet cores with excipients as shown in the following table (expressed in proportional units).

HB VK7 VC4 VK2 Stevioside 12.65 13.72 13.72 13.72 Sucralose 12.65 13.72 13.72 13.72 Metformin HC1 3.17 3.43 3.43 3.43 L-Glutamine 6.35 6.86 6.86 6.86 Reb A 25.38 27.45 27.45 27.45 Prosol HD90 28.71 9.6 12.0 15.6 Pruv h, o h, o h, o h, o Croscarmellose sodium 4.0 Methocel K4M 11.0 8.6 5.0 Klucel EXF 4.0 4.0 4.0 4.0

The IR column in the table above refers to a 20% by weight bilayer tablet that releases its contents in about 15 to about 60 minutes. HB, BK4 and BK7 refers to the remaining 80% of the components, which are released within approximately 2, 4 or 7 hours. The bilayer tablet core contains an IR compound and one of the components BK, BK4 or BK7. With the exception of stevioside (>90% purity), all ingredients are >99.8% pure, and the concentrations of all impurities for all ingredients are well below the limits set in accordance with International Conference on Harmonization (ICH) guidelines.

The cores of bilayer tablets are coated with the following coating compositions for release at the specified pH, presented in the following table (expressed in proportional units). ___________________________________________________________

Composition nv/vk 2 hours pH 5.5 n/v 4 hours pH 6.0 NV/VK 4 hours pH 6.5 HB/VK 7 hours pH 6.0 Eudragit L30 D55 833.4 750.06 625.05 750.06 Eudragit FS 30D 0 83.34 208.35 83.34 Talc 125.0 T riethyl citrate 25.0 Water 1016

Example 3

Illustrative composition of meformin in a bilayer tablet and its administration.

Composition C Chemosensory receptor ligand For one layer HB layer/enteric layer (mg) Total dose (mg) B.i.d. Total per day Metformin HC1 50/200 250 500

The biguanide or related heterocyclic compound of composition C (metformin) is incorporated into bilayer tablet cores with excipients as shown in the following table (expressed in proportional units).

-47042749

HB VC4 Metformin HC1 60.29 65.2 Prosol HD90 28.71 12.0 Pruv h, o h, o Croscarmellose sodium 4.0 Methocel K4M HB VC4 - 8.6 Klucel EXF 4.0 4.0

The IR column in the table above refers to the immediate release component of the bilayer tablet, which releases its contents (20% metformin) in about 15 to about 60 minutes. VC4 refers to the remaining 80% of metformin, which is released within approximately 4 hours. All ingredients are >99.8% pure, and concentrations of all impurities for all ingredients are well below the International Conference on Harmonization (ICH) guidelines.

The immediate release and extended release tablet cores in the bilayer tablet are coated with one of the following coating compositions for release at the specified pH as shown in the following table (expressed in proportional units).

Composition pH 5.5 pH 6.0 pH 6.5 pH 6.0 Eudragit L30 D55 833.4 750.06 625.05 750.06 Eudragit FS 30D 0 83.34 208.35 83.34 Talc 125.0 T riethyl citrate 25.0 Water 1016

Example 4

Absorption of metformin into plasma, not required for enteroendocrine production of PYY, GLP-1A and GLP-1T, as well as for lowering glucose and insulin.

Example 4.1. Materials and methods.

Group: Approximately 18 eligible male and female subjects, aged 18 to 65 years, with a BMI of 25.0 to 35.0 kg/m ² were randomized for this study. For eligibility, each subject also meets the following criteria: (a) not breastfeeding; (b) has a negative pregnancy test result (human chorionic gonadotropin, beta subunit); (c) is surgically sterile, postmenopausal, or, if childbearing, has been using appropriate contraceptive measures throughout the study period; (d) has passed a medical examination without clinically significant pathologies, including, but not limited to, the following conditions: (i) liver disease; (i) kidney disease; (iii) gastrointestinal disease; (iv) endocrine disorder including diabetes; (v) cardiovascular disease; (vi) epilepsy; (vii) organ transplantation; and (viii) chronic infection; and (e) is able to understand and is willing to comply with the requirements of the protocol.

Preparations.

Metformin formulation that results in plasma absorption, EFB0026, (500 mg Metformin, uncoated; referred to as Metformin in the figures), and Metformin formulation that minimizes plasma absorption, EFB0027, (500 mg Metformin pH 6.5 enteric-coated , indicated as re-metformin in the figures) were purchased as bulk tablets in screw-cap containers labeled with container number and lot number. Experimental preparations were stored in cool and dry conditions as indicated on the label and used only as directed by the research staff.

Introduction.

The experimental drug was distributed by the unmasked pharmacist or study staff according to a randomization scheme at visits 2 and 4. At the end of visits 2 and 4, subjects were released from the clinic with the experimental drugs prescribed and instructions for self-administration until the next study visit to the facility (visit 3 or 5).

The experimental drug was administered orally as whole tablets (swallowed whole, not chewed or broken) and with water. The first dose and the last two doses of the experimental drug for each treatment period were administered to the subjects by qualified staff of the study facility (the first dose at Visits 2 and 4 and the last two doses at Visits 3 and 5). Subjects self-administered the assigned experimental drugs as instructed until they were returned for the next study visit (Visit 3 or 5).

Study site staff contacted subjects by phone on the second day of dosing of each treatment period to check for compliance and adverse events using a non-targeted survey. If the subject experienced significant gastrointestinal symptoms, in the opinion of the investigator, then the subjects were instructed not to increase the dose.

Instructions for self-administration of experimental drugs were as follows.

Take one tablet with a small amount of water in the evening before going to bed, take one tablet the next morning and one tablet tomorrow night before bed.

Research Center staff will contact you tomorrow (Day 2) to remind you to increase your dose the next day (Day 3) to two tablets in the morning and two tablets at bedtime, the next day (Day 4) two tablets in the morning before you return this same day for next visit

After putting the tablets in the mouth, they should be swallowed whole with water, and the tablets should not be crushed or chewed.

The procedures performed during the study are listed below in the following three tables.

Table 1

Study plan (LCPOC6 protocol)

Grade Screenshots ING Period Initial value of period 1, visit 2 treatment 2 day treatment period phone call [1] 1 End of period a 1 Visit 3 Period Initial value of period 2, visit 4 treatment 2 day treatment period phone call [1] 2 End of period 2 / Study Termination Visit 5 premature termination Fasting (>8 hours X X X X X Informed X Full history X objective X body weight and X X X X X X Chemistry, hematology, X X X Test for Randomization X X — X X Planned TTG\G\G\T T TLG\G\T>TT G”21 Introduction X X X X experimental drug[4] X X X X Distribution of experimental drug Evaluation of adherence to the regimen reception experiment phone call X X X X X Grade X X X X X X RELATED

- 49 042749

[1] Phone calls to confirm adherence to the regimen and adverse events through a non-targeted interview, as well as to remind subjects to increase the dose.

[2] A pregnancy test is required for all female subjects unless the subject has had a hysterectomy or is postmenopausal.

[3] GLP-1, PYY, plasma glucose, insulin, and triglycerides at visits 2 and 4; GLP-1, PYY, plasma glucose, insulin, triglycerides, and metformin at visits 3 and 5.

After meals at visit 2 and visit 4. Evening dose on day 4 and morning dose on day 5 at visits 3 and 5.

[1] Total blood volume 6 ml per sampling time point for PYY, GLP-1, plasma glucose, insulin, and triglycerides.

[2] Subjects should be instructed to take a standardized breakfast within 20 minutes.

- 50 042749

Table 3

Day, dosing schedule, standardized breakfast and

[1] Total blood volume 6 ml per sampling time point for PYY, GLP-1, plasma glucose, insulin, and triglycerides.

[2] Subjects should be instructed to take a standardized breakfast within 20 minutes.

[3] Total blood volume 2 ml per time sampling point for Metformin evaluation.

research procedures.

Selection procedures at 1 visit.

At visit 1, subjects arrive at the clinic in the morning on an empty stomach, without food for at least 8 hours, and the following procedures are performed.

Obtaining a signed informed consent form.

Conducting a subject suitability assessment based on inclusion and exclusion criteria.

Obtaining a complete medical history, including menopausal status (for women).

Review of concomitant medications.

Performing an objective examination.

Measurement of body weight and height.

Measurement of vital signs (systolic and diastolic blood pressure while sitting, heart rate and body temperature).

Blood sampling (fasting samples) for clinical chemistry and hematology Urine sampling for urinalysis.

For female subjects of childbearing potential, a serum or urine pregnancy test is performed.

Individuals were deemed ineligible if the results of any laboratory test were abnormal and clinically significant, at the discretion of the investigator or medical observers. Individuals with an abnormal test result may be re-evaluated for enrollment in the study within 2 weeks of eligibility by repeating that test again with acceptable results,

- 51 042749 decision of the investigator or medical observer (or authorized representatives).

When all qualifying results have been received, individuals are notified by telephone or otherwise of their eligibility status. Those found eligible return to the clinical research site within 14 days of enrollment to be enrolled and randomized at visit 2.

Visit 2 (baseline 1 treatment period): enrollment and randomization.

Subjects arrive at the clinic the evening before the standardized meal test. Perform the following procedures.

Confirm suitability for research.

Randomize the treatment sequence for eligible subjects.

Review concomitant medications and adverse events.

They measure vital signs (systolic and diastolic blood pressure while sitting, heart rate and body temperature), as well as body weight.

At t=0 min. subjects start on ~1000 kcal of a standardized breakfast that is completed within 20 minutes.

Fourteen 6 ml blood samples are taken at the following time points relative to standardized breakfast intake for PYY, GLP-1, glucose, insulin, and triglyceride assays (see Table 2): t= -15, -5, 30, 45, 60, 90 , 120, 150, 180, 210, 240, 270, 300 and 330 min.

The first dose of the randomized experimental drug (1 tablet) is administered by the center staff after the last blood draw 330 minutes later.

Subjects are given their assigned experimental drugs and instructions for self-administration of their assigned experimental drug prior to their next clinic visit.

Subjects return to the study site with the remaining amount of study drugs on the fourth day of the Treatment Period for Visit 3.

On day 2 of the treatment period, study site personnel make a scheduled phone call to ask any questions, verify administration of the experimental drug, and remind the subject to increase dose on day 3 of treatment.

Visit 3 (end of treatment period 1).

Subjects arrive at the clinic in the evening before their standardized meal on the fourth day of the first treatment period, prior to the evening dose.

At the 3rd visit, the following procedures are performed.

Review concomitant medications and adverse events.

They measure vital signs (systolic and diastolic blood pressure while sitting, heart rate and body temperature), as well as body weight.

At the research facility, subjects are given dinner on the fourth day of the first treatment period.

The evening dose on the fourth day of the treatment period is administered after dinner at the study center.

All unused experimental drugs are collected from subjects after their evening dose.

At t=-240 min the next morning, subjects are given the last dose of the assigned experimental drug for the first treatment period.

At t=0 min, subjects begin ˜1000 kcal of a standardized breakfast, which is completed within 20 min.

Blood samples are taken at t= -245, -120, -15, -5, 30, 45, 60, 90, 120, 150, 180, 210, 240, 270, 300, 330, 360, 420 and 480 minutes relative to administration standardized breakfast, for the analysis of metformin and PYY, GLP-1, glucose, insulin and triglycerides (see Table 3 for details).

360 minutes after blood sampling, subjects may be given a snack.

Subjects are released from the center at the end of visit 3 procedures and are returned to the center for visit 4 after a washout period of at least 7 but not more than 14 days to evaluate baseline for 2 treatment periods.

Visit 4 (baseline 2 treatment periods).

Subjects arrive at the clinic the evening before the standardized meal test. Perform the following procedures.

Review concomitant medications and adverse events.

They measure vital signs (systolic and diastolic blood pressure while sitting, heart rate and body temperature), as well as body weight.

At t=0 min, subjects begin ˜1000 kcal of a standardized breakfast, which is completed within 20 min.

Fourteen 6 ml blood samples are taken at the following time points relative to standardized breakfast intake for PYY, GLP-1, glucose, insulin, and triglyceride assays (see Table 2): t= -15, -5, 30, 45, 60, 90 , 120, 150, 180, 210, 240, 270, 300 and 330 min.

The first dose of the randomized experimental drug for the second treatment period (1 tablet) is administered by the center staff after the last blood draw at 330 minutes.

- 52 042749

Subjects are provided with the assigned experimental drugs for the second treatment period and instructions for self-administration of the experimental drug prior to their next clinic visit.

Subjects return to the study site with the remaining study drug on the fourth day of the second treatment period for Visit 5.

On day 2 of the treatment period, study site personnel make a scheduled phone call to ask any questions, verify administration of the experimental drug, and remind the subject to increase dose on day 3 of treatment.

Visit 5 (end of treatment period 2).

Termination of the study.

Subjects arrive at the clinic prior to the evening dose on the fourth day of the second treatment period. At the 5th visit, the following procedures are performed.

Review concomitant medications and adverse events.

They measure vital signs (systolic and diastolic blood pressure while sitting, heart rate and body temperature), as well as body weight.

At the research facility, subjects are given dinner on the fourth day of the second treatment period.

The evening dose on day 4 of the second treatment period is administered after dinner at the study center.

All unused experimental drugs are collected from subjects after their evening dose.

Receive blood samples for clinical chemistry, hematology and serum pregnancy test (women of childbearing potential).

Taking a urine sample for urinalysis.

At t=-240 min the next morning, subjects are given the last dose of the assigned experimental drug for the second treatment period.

At t=0 min, subjects begin ˜1000 kcal of a standardized breakfast, which is completed within 20 min.

Blood samples are taken at t= -245, -120, -15, -5, 30, 45, 60, 90, 120, 150, 180, 210, 240, 270, 300, 330, 360, 420 and 480 minutes relative to administration standardized breakfast, for the analysis of metformin and PYY, GLP-1, glucose, insulin and triglycerides (see Appendix 3 for details)

After 360 min after blood sampling, an afternoon snack can be provided.

Subjects who have completed all study procedures at visit 5 are considered to have completed the study.

Premature termination.

Subjects who withdrew from the study prior to completion of visit 5 procedures completed abort procedures in a timely manner as follows.

Review of adverse events (AE) and concomitant medications.

Measurement of body weight.

Measurement of vital signs (systolic and diastolic blood pressure while sitting, heart rate and body temperature).

Collection of used and unused experimental drugs.

Collection of blood samples for clinical chemistry, hematology and serum pregnancy test (women of childbearing potential).

Collection of urine samples for urinalysis.

Pharmacodynamic tests.

Blood samples were collected in accordance with the schemes presented in table. 1, 2 and 3 and as described above. Fasting and postprandial plasma concentrations of the intestinal hormones GLP-1 and PYY, as well as plasma glucose, insulin and triglyceride concentrations were measured by analytical methods. Blood samples at each visit were processed and stored at -70°C for further exploratory analyzes for additional hormones.

Pharmacokinetic tests.

Blood samples were collected in accordance with the schemes presented in table. 1, 2 and 3 and as described above. Plasma metformin concentrations were measured by analytical methods. Blood samples at each visit were processed and stored at -70°C for further exploratory analyzes for additional hormones.

Clinical laboratory tests.

Samples were collected in accordance with the schemes presented in table. 1, 2 and 3, and as in the previous section.

Chemistry.

Chemical analyzes included the following: urinary nitrogen, creatinine, total protein, albumin, uric acid, total bilirubin, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, gamma-glutamyltranspeptidase, creatine phosphokinase, glucose, sodium, potassium, chlorides, bicarbonates, phosphorus , lactate, and calcium (or other standard chemistry approved by the sponsor).

- 53 042749

Hematology.

Hematologic analyzes included the following: RBC count, hemoglobin, hematocrit, WBC count, platelets, WBC count, mean cell volume, mean RBC hemoglobin, and mean RBC hemoglobin concentration (or other standard hematology tests approved by the sponsor).

Analysis of urine.

Urinalysis included the following: pH, specific gravity, glucose, blood, ketones, and protein (or other standard urinalysis as approved by the sponsor).

Pregnancy test.

All female subjects, regardless of childbearing status (unless the subject is menopausal or undergoing hysterectomy), provided blood and urine for pregnancy tests. The experimental drug was not administered until a negative result was obtained.

Vital signs and other observations related to safety.

Clinically significant abnormalities in vital signs and other safety-related observations were performed by the investigator and, if necessary, evaluated by additional tests before diagnosing the underlying cause or normalizing the condition.

Vital signs.

Vital sign measurements included sitting systolic and diastolic blood pressure, heart rate, and body temperature. Vital signs were measured after the subject rested for about 5 minutes and with the subject in a seated position. The blood pressure measurement was repeated after at least 30 seconds and the average of the two values was recorded.

Example 4.2. Results.

The design of the study and the timing of the events are depicted in FIG. 1-2. Below in table. Figures 4 and 5 show the final distribution of study participants and groups (Table 4) and the demographic and baseline characteristics of the 18 subjects (Table 5).

Table 4

the subject was excluded from the group suitable for clinical evaluation; 1 was deemed ineligible and 1 failed the experimental meal at the end of study period 2.

Table 5 ________Demographic and Baseline Characteristics (n=18)________

Parameter Result Gender (M/F) 9/9 Mean age (years) ± standard deviation 44 ± 10 Race 9 whites, 7 Hispanics, 2 blacks Average BMI (kg/m2) ± standard deviation 29.3±2.8

Fig. 3 illustrates that ingestion of re-metformin minimizes metformin plasma adsorption compared to metformin. Area under the curve (AUC) and Cmax values for re-metformin and metformin are shown in Table 1 below. 6.

- 54 042749

Pharmacokinetics of metformin in plasma

The ratio of average values according to the least method p-value squares re-metformin/metformin Abs. AUC 0.83 0.02 Abs. Stakh 0.73 0.003 Incremental Stach 0.45 <0.001

Fig. 4A-C illustrate an increase in food-induced elevated dietary hormones in 16 subjects after treatment with remetformin, comparable to that for metformin, although treatment with remetformin minimizes systemic metformin levels compared with metformin treatment (Fig. 3). Additionally, Fig. 5A-B illustrate a reduction in food-induced increases in glucose and insulin after treatment with remetformin in 16 subjects, comparable to that of metformin. Fig. 6 illustrates that treatment with remetformin results in the same PYY response as metformin, but with lower systemic exposure. Fig. 7A-B illustrate that the PK/PD relationship of metformin was inconsistent in at least one patient.

Example 5

Evaluation of the effectiveness of compounds formulated for release in the lower intestine, including those that may be accompanied by poor absorption.

Key measurements required include plasma concentrations of test compounds, effects on GLP-1 levels, effects on PYY levels, glucose differences as measured by the acute glucose tolerance test, and insulin levels and differences in gut microbiota composition as measured by 16S RNA sequencing. or microarray analysis.

Materials and Methods (adapted from: Dao T-M A, Waget A, Klopp P, Serino M, Vachoux C, Pechere L, Drucker D J, Champion S, Barthqlemy S, Barra Y, Burcelin R, Sqrqe E. Resveratrol Increases Glucose Induced GLP-1 Secretion in Mice: A Mechanism which Contributes to the Glycemic Control PLoS One 2011; 6(6): e20700).

Exemplary formulation of test compound and dose.

Two exemplary test compounds can be prepared, a standard 200 µm solid material version and a coated version designed to release material in the lower intestine at pH 6.5, with a 200 µm particle size. Each of these is formulated with an appropriate carrier (including, but not limited to, polysorbate 20 and polyglyceryl-3-dioleate). For some experiments, an exemplary test compound is mixed into an animal diet at a dose ranging from 1 to 60 mg/kg/day. For other experiments, a dose of 1 to 60 mg/kg was formulated into an oral gavage formulation as a solution or as a uniform suspension of fine particles.

In addition, 500 mg GLUCOPHAGE® XR (metformin hydrochloride), extended release tablets targeted at 6% enteric coating at pH 6.5 for release in the lower intestine was evaluated; compared to standard uncoated GLUCOPHAGE® XR (metformin hydrochloride) extended release tablets.

Animals and treatment.

General ways.

Eight-week-old male C57B1/6J wild-type mice (Charles River, after acclimatization under special pathogen-free conditions in individual ventilated cages with a light (10 a.m.)/dark (10 p.m.) cycle of 12/12 h and with free access to water and food). Mice were maintained on a standard diet (energy content: 12% fat, 28% protein, and 60% carbohydrates), or a high fat diet (energy content: about 72% fat containing corn oil and lard, 28% protein and, 1 % carbs) for five weeks. This diet induces diabetes before the onset of obesity (see Cani PD, Amar J, Iglesias MA, Poggi M, Knauf C, et al. (2007) Metabolic endotoxemia initiates obesity and insulin resistance. Diabetes 56: 1761-1772; Cani PD, Bibiloni R, Knauf C, Waget A, Neyrinck AM, et al (2008) Changes in gut microbiota control metabolic endotoxemia-induced inflammation in high-fat diet-induced obesity and diabetes in mice. Cani PD, Ait-Belgnaoui A, Benani A, Dray C, et al (2008) Brain glucagon-like peptide 1 signaling controls the onset of high-fat diet-induced insulin resistance and reduces energy expenditure Endocrinology 149: 4768-4777 Cani PD, Neyrinck AM, Fava F, Knauf C, Burcelin RG, et al (2007) Selective increases of bifidobacteria in gut microflora improve high-fat-diet-induced diabetes in mice through a mechanism associated with endotoxaemia. 2374-2383.) Food intake, body weight, and glucose tolerance are measured by standard methods previously described (Riant E, Waget A, Cogo H, Arnal J, Burcelin R, et al. (2009) Estrogens

- 55 042749 protect against high-fat diet-induced insulin resistance and glucose intolerance in mice. Endocrinology 150: 2109-2117). All experimental procedures on animals are performed at a facility certified by the International Association for the Certification and Accreditation of Laboratory Animal Care and then further approved by the local Animal Ethics Committee. Statistical significance is usually obtained by having n=6 or more in each group of each trial, including controls.

Sharp experiments.

For instantaneous experiments, exemplary test compounds are formulated into a mouthpiece as described above and administered twice daily over a period of 24 to 48 hours.

chronic experiments.

For chronic experiments, exemplary test compounds are formulated into a food composition as described above and administered with food twice daily for a period of 28 days. If gut microbiota analysis is part of the protocol, collect faeces from each mouse in all study groups at the end of day 1, at the end of day 28 and save for later analysis/transport by ultra-fast freezing at -80°C. In addition, at the end of the experiment, the caecum is excised from each mouse, harvested and preserved for later analysis/shipped by ultra-fast freezing at -80°C.

Oral glucose tolerance test and insulin analysis.

An oral glucose tolerance test (OGTT, 2 g/kg glucose) is performed in mice, fasted, 6 hours after acute or chronic treatment. Blood glucose concentrations are monitored from tail vein tip samples using a standard portable glucometer (Onetouch manufactured by Life Scan or equivalent) at −30, 0, 30, 60, 90, and 120 minutes after oral glucose administration as previously described. For each group of mice calculate the area under the curve (AUC) (30-90). Plasma insulin concentration is determined by an enzyme-linked immunosorbent assay (eg, Mercodia, Uppsala, Sweden) using 10 μl of plasma from normal-fed and high-fat mice treated with the exemplary test compound.

Plasma GLP-1 measurement from portal vein blood samples.

To quantify GLP-1 in portal vein plasma, mice (fed) are rapidly anesthetized with an intraperitoneal injection (0.1 ml/10 mg body weight) of ketamine (Vibrac) and xylazine hydrochloride, 2%, RompunH (Bayer), in sodium chloride ( 0.9%; 2:1:7 v/v/v), make an incision and collect blood samples from the portal vein in EDTA tubes (Sarstedt, Neumbrecht, Germany) containing a cocktail of enzyme inhibitors, including a DPP-4 inhibitor (Linco Research, St. Charles, Missouri, USA). GLP-1 (7-36) amide concentrations are determined by ELISA (active glucagon-pobod peptide-1 ELISA kit, Millipore).

PK measurements by LC-MS or LC-MS/MS.

For each of the illustrative test compounds, an appropriate sensitivity assay was developed in plasma or whole blood using a PE Sciex 4000, PE Sciex 5000 (triple quadrupole tandem mass spectrometers) or a Thermo LCQ mass ion trap. Blood samples are collected from the tail vein of each mouse at regular intervals on day 1 of studies (chronic and acute) and on day 28 of studies (chronic only), mixed with an enzyme inhibitor cocktail plus EDTA, then directly analyzed (LC/MS/MS).

RNA extraction and real-time PCR.

Total RNA is isolated from tissues using the Trizol reagent (Life Technologies) and quantified using NanoDrop (NanoDrop technologies Inc.). Total RNA (1 μg) was reverse transcribed with Moloney mouse leukemia virus reverse transcriptase (Life Technologies) and random primers at 42° C. for 1 hour. Expression of target genes is determined using Stratagene Mx 3005p. The mRNA concentration of the target genes is normalized to the p2 actin mRNA content and the results are expressed as relative expression levels (REL). These data are quantified by the 2-DDCt method.

Characteristics of the intestinal microflora.

Total DNA was isolated from the caecum using the Trizol reagent (Life Technologies) and amplified by PNR targeting the V3 region of the 16S rRNA gene using the HDA1-GC and HDA2 universal bacterial primers (Table 1).

Each reaction mixture (25 µl) contains 4 µl of DNA diluted to 50 ng/µl, deoxynucleotide triphosphate (Sigma-Aldrich) at 200 mM, 0.3 µM of each primer, and 0.07 µl of Taq polymerase (Sigma-Aldrich) . The following amplification program is used: 94°C for 5 min, 30 cycles consisting of 94°C for 30 s, 55°C for 45 s and 72°C for 60 s, and 30 min at 72°C. Denaturing gradient gel electrophoresis (DGGE) is then performed using DGGE 2401 systems (CBS & Scientific Co.) and 8% polyacrylamide gels with a urea gradient of 35-55% (99.0-100.5% - Sigma-Aldrich) and formamide (99+% - Sigma-Aldrich), which rises in the direction

- 56 042749 electrophoresis. Electrophoretic analyzes were performed in Tris-acetate-EDTA buffer (40 mmol/L Tris, 20 mmol/L acetic acid, and 1 mmol/L EDTA) at 60 V and 60°C for 18 h. Gels were stained with SYBR Safe 16 (Life Technologies) for 30 minutes, washed with deionized water, then scanned and analyzed with a Typhoon 9400 variable-mode imaging device (Amersham Biosciences). Hierarchical grouping was performed using Permutmatrix 1.9.3.0 (Caraux G, Pinloche S (2005) PermutMatrix: a graphical environment to arrange gene expression profiles in optimal linear order. Bioinformatics 21: 1280-1281).

Weight loss.

Treated and untreated animals are weighed periodically to measure the weight gain or loss of the treated animals compared to the control group.

Statistical analyses.

Results are expressed as means ± standard error of the mean. Statistical analyzes were performed using GraphPad Prism version 5.0 for Windows (GraphPad Software, San Diego, CA; www.graphpad.com). The significance level is set to p<0.05.

Exemplary test compounds representing Formulas I, IA, II, III and IV were tested in the assays described above as follows. For example:

Biguanides: Formula (I)

He

Triazoles: Formula (IA)

He

Trazynes: Formula (II)

Dihydrohyrazines: Formula (III)

7-ring cyclic biguanides: Formula (IV)

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Example 5

A 12-week, randomized, double-blind, placebo-controlled, parallel group, multicenter study to determine the safety and efficacy of twice daily administration of EFB0027 in subjects with type 2 diabetes mellitus.

The experiments described in Example 5 (1) compare the effect on glycemic control, as measured by HbA1c, of EFB0027 administered twice a day (BID) before morning and evening meals with placebo for 12 weeks in subjects with type 2 diabetes mellitus , (2) evaluate the safety and tolerability of the dose range of EFB0027 administered by BID for 12 weeks in subjects with type 2 diabetes mellitus, (3) evaluate the dose-response effect on HbA1c for EFB0027 administered by BID for 12 weeks in subjects with type 2 diabetes , and (4) compare EFB0027, EFB0026, a combination of EFB0026 and EFB0027, and placebo, administered by BID for 12 weeks to subjects with type 2 diabetes mellitus, by the following parameters.

Pharmacokinetics of metformin (FC).

Change in HbA1 from baseline over time.

Proportion of subjects achieving HbA1c <7% at 12 weeks.

Body weight.

Change from baseline for fasting plasma glucose, insulin, triglycerides, peptide YY (PYY), and glucagon-like peptide 1 (GLP-1) over time.

Example 5.1: materials and methods.

Example 5.1.1: study design.

During the study, 8 visits are envisaged; one screening visit (visit 1), followed by 2 introductory visits during the stabilization period (visits 2 and 3) and 5 visits during the randomized treatment period (visits 4-8).

Subjects will receive EFB0026, 500 mg BID (1000 mg/day) for 2 weeks, followed by 1000 mg BID (2000 mg/day) for 4 weeks during a single-blind, 6-week run-in stabilization period.

At visit 4, each of approximately 250 subjects will be randomized to one of 5 treatment groups in a 1:1:1:1:1 ratio. Randomization will be done for HbA1c at visit 3 (-1 week).

Treatment groups. Treatment group N Treatment* A 50 Placebo BID IN 50 EFB0026, 500 mg BID WITH 50 EFB0027, 500 mg BID D 50 EFB0026, 1000 mgVU E 50 EFB0027, 1000 mgVU F 50 EFB0026 500 mg plus EFB0027 1000 mg BID

*EFB0026 = metformin HCl tablets (not enteric-coated);

EFB0027 = pH 6.5 Enteric Coated Metformin HCl Tablets (Enteric Coated) Treatment Groups B and C will include 2 placebo tablets per dose and Treatment Groups D and E will include 1 placebo tablet per dose to maintain blinding.

At visits during the Lead-in Stabilization Period and Randomized Treatment Period (Visits 2, 3, 4, 5, 6, 7 and 8):

subjects arrive at the study clinic in the morning on an empty stomach, without eating for at least 10 hours;

subjects are instructed not to take the morning dose of experimental product (EP) on experimental visit days until fasting blood sampling is performed.

The morning dose is administered at the study site on experimental visit days (visits 2-7 only).

Lipidogram is obtained at selection, on day 1, and at week 12 (visits 1, 3 and 7).

Fasting blood samples (one 6 ml sample and one 2 ml sample) are taken for plasma measurements of metformin, glucose, insulin, GLP-1 and PYY during all experimental visits. Triglycerides are also assessed during visits that do not include a complete lipid profile (visits 2, 3,

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5, 6 and 7).

HbAlc is measured at screening, week -6, week -1, day 1, and weeks 4, 8 and 12 (visits 1, 2, 3, 4, 6, 7 and 8).

If the subject's underlying diabetes is poorly controlled on randomized treatment and if the subject experiences hyperglycemia that is significantly worse from baseline (as indicated by an HbA1c value >10% or an increase greater than 1.0% from the value at Visit 3), then the subject is withdrawn from studies and accepts appropriate alternative treatment.

Example 5.1.2: visit structure.

During the study, 8 visits are envisaged; one screening visit (visit 1), followed by 2 introductory visits during the stabilization period (visits 2 and 3) and 5 visits during the randomized treatment period (visits 4, 5, 6, 7 and 8). Treatments for 1 visit can be completed within >1 day. The interval separating the start of visit 1 and visit 2 procedures should be <28 days. Visits 2 and 3 (-6 weeks and -1 weeks) should be scheduled for -6 weeks ±3 days and -1 weeks ±3 days, relative to visit 4 (1 day). Visits 5, 6, 7 and 8 are scheduled for 2, 4, 8 and 12 weeks ±3 days, relative to visit 4 (1 day). Subjects may be released from the clinic after the completion of each visit's procedures. Subjects complete the study after the completion of visit 8 procedures.

Example 5.1.3: study duration.

The total duration of the study ranged from 132 to 163 days, depending on the number of days between experimental visits.

Example 5.1.3: experimental group.

Each research subject must meet the following criteria.

1. At selection, has an age of 18 to 65 years (1 visit).

2. Diagnosed with type 2 diabetes and being treated with diet and exercise only, metformin alone, DPP-4 inhibitor alone, or metformin plus DPP-4 inhibitor regimen (stable regimen for at least 2 months at 1 visit).

3. Has HbA1c between 6.5 and 9.0% (inclusive) at visit 1 and visit 3.

4. Has a serum creatinine concentration below the upper limit of normal at 1 visit and an estimated creatinine elimination period of more than 80, according to the Cockcroft-Gault equation:

(CrCl=[(140 - age)-body weight in kg]/(serum creatinine-72)-(0.85 for women).

5. Has BMI from 25.0 kg/m ² to 45.0 kg/m ² inclusive, at 1 visit.

6. Has a stable body weight, i.e., varying by no more than >10% during the last 6 months prior to the 1st visit, as documented by the investigator.

7. Is male or female and meets all of the following criteria:

a) is not breastfeeding;

b) has a negative pregnancy test result (human chorionic gonadotropin, beta subunit) at 1 visit (selection);

c) is surgically sterile, postmenopausal, or, if childbearing is possible, is using and willing to continue using appropriate contraceptives throughout the study.

8. Passed a medical examination without clinically significant pathologies, at the discretion of the investigator.

9. Has a fasting blood glucose concentration of <240 mg/dL at 1 visit.

10. Untreated or on stable treatment with any of the following drugs for at least 3 months prior to Visit 1 (selection):

a) hormone replacement therapy (female subjects);

b) oral contraceptives (female subjects);

c) antihypertensive agents;

d) lipid-lowering agents;

e) thyroid hormone replacement therapy;

f) antidepressant agents.

11. Willing and able to follow experimental procedures.

12. Is able to read, understand, and sign the Informed Consent Form (ICF) and Authorization Form for the use and disclosure of protected health information (compliant with the Health Insurance Accountability and Security Act [HIPAA] legislation of 1996, answer research questions, communicate with the investigator, and understand and follow protocol requirements.

Subjects that meet any of the following criteria are subject to exclusion.

1. Has a clinically significant medical condition that could potentially affect study participation and/or patient health, at the discretion of the investigator, including, but not limited to, the following conditions:

a) liver disease;

b) kidney disease;

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c) gastrointestinal diseases;

d) endocrine disorder other than diabetes;

e) cardiovascular disease;

f) epilepsy;

g) organ transplants;

h) chronic infection (eg tuberculosis, human immunodeficiency virus, hepatitis B virus or hepatitis C virus).

2. Has any chronic medical condition requiring treatment that has been corrected within the past 90 days (subjects may occasionally take over-the-counter medications such as Tylenol as needed).

3. Takes any drug treatment that can affect gastric pH (prescription or over-the-counter), including any antacids or medications such as Rolaids or Pepcid, within 2 days prior to 1 visit (selection).

4. Has kidney disease or renal dysfunction (eg, suggested by serum creatinine levels >1.5 mg/dL (men), >1.4 mg/dL (women) or abnormal creatinine excretion).

5. Has a known hypersensitivity or allergy to metformin hydrochloride or any component of the experimental treatment.

6. Has clinical laboratory test abnormalities (clinical chemistry, hematology, or urinalysis) other than those expected for patients with diabetes and considered clinically significant by the investigator at visit 1 (selection).

7. Has a physical, psychological, or retrospective handicap that, in the opinion of the investigator, renders the subject unsuitable for the study.

8. Current or past drug or alcohol abuse that, in the opinion of the investigator, makes the individual unsuitable for study procedures.

9. Was a blood donor within 2 months prior to the 1st visit (selection) or plans to become a blood donor during the study.

10. Used insulin for 3 months prior to 1 visit (selection).

11. Took GLP-1 receptor agonists and/or thiazolidinedione treatment for 6 months prior to visit 1 (selection).

12. Took furosemide, nifedipine, thiazides or other diuretics, corticosteroids, cationic drugs, or thyroid products for 6 months prior to visit 1 (selection).

13. Underwent major surgery or blood transfusion within 6 months prior to visit 1 (selection).

14. Took any experimental drug for one month (or five half-lives of the experimental drug, whichever is greater) prior to 1 visit (draw-off).

15. Is the next of kin (spouse, parent, child, sibling; biologically or legally verified) of a person directly involved in a study at a clinical experimental center or directly involved in a study at a clinical experimental center.

16. Is an employee of Elcelyx Therapeutics, Inc. (Elcelyx) (i.e., is a staff member, temporary contract worker, or designee responsible for conducting the study).

Once selected and deemed eligible to participate, the subject receives the following instructions.

Do not eat for at least 10 hours (food or drink other than water) before each visit.

Do not take any new prescription or over-the-counter drugs without prior approval from the investigator (who may seek the advice of the sponsor).

Do not take any diabetes medication other than the experimental product during the study. Discontinue any DPP-4 inhibitors or prescribed metformin prior to enrollment (Visit 2).

Do not take caffeine before (at least 10 hours before) or during experimental visits.

On experimental visit days, do not take the dose of the experimental product at home prior to the visit.

Bring any previously distributed empty, partially used, or unused experimental product containers at each visit.

Do not start a diet or weight loss program during the study.

Avoid active exercise and alcohol intake 24 hours before each scheduled visit.

Refrain from smoking during the experimental visits (i.e., do not smoke until the completion of all procedures during the visit).

Example 5.1.4: experimental products.

-

Claims (12)

placebo. EFB0026: Metformin HCl 500 mg tablet (not enteric coated). EFB0027: 500 mg metformin HCl enteric-coated tablets at pH 6.5 (enteric-coated). Example 5.1.5: experimental methods. EFB0026, 500 mg BID (1000 mg/day) is administered for 2 weeks, followed by 1000 mg BID (2000 mg/day) for 4 weeks during the run-in stabilization period. Randomized treatment administered BID for 12 weeks. Data on HbA1c, metformin FC, fasting glucose, insulin, GLP-1, PYY, lipids and body weight are obtained at scheduled time points. Efficacy is assessed by HbA1c and body weight, pharmacokinetic analysis is performed by plasma metformin, and pharmacodynamic analysis is performed by fasting glucose, insulin, GLP-1, PYY, and lipids. Safety is assessed by monitoring for adverse events, electrocardiogram and clinical chemistry. Example 5.1.6: statistical tests. Analysis groups are selected and described in terms of statistical analysis. Study endpoints include HbA _lc , metformin FA, fasting glucose, insulin, GLP1, PYY, lipids, and body weight. Deographic and initial characteristics are summarized descriptively. While some embodiments of the present invention are shown and described herein, those skilled in the art will appreciate that such embodiments are provided by way of example only. Numerous variations, modifications and substitutions will be understood by those skilled in the art without deviating from the spirit of the present invention. It should be understood that various alternatives to the embodiments of the present invention described herein may be used in the practice of the present invention. The following claims are intended to define the scope of the present invention, and as such, the methods and structures in the claims, as well as their equivalents, are contemplated. CLAIM 1. A method for lowering blood glucose levels in a patient in need thereof, comprising administering to the patient a pharmaceutical dosage form containing metformin or a salt thereof, in which said pharmaceutical dosage form has an enteric coating that has an onset of release for said metformin or its salt in the area after the duodenum and wherein said pharmaceutical dosage form results in a circulating plasma concentration of metformin in said patient of less than about 1.0 μg/mL. 2. A method for treating a glucose metabolism disorder in a patient in need thereof, comprising administering to the patient a pharmaceutical dosage form containing metformin or a salt thereof, wherein said pharmaceutical dosage form has an enteric coating that has a release onset for said metformin or its salt in an area after the duodenum, and wherein said pharmaceutical dosage form results in a circulating plasma concentration of metformin in said patient of less than about 1.0 μg/mL. 3. The method of claim 1 or 2, wherein the sustained release composition results in a circulating plasma concentration of metformin in said patient of less than about 0.5 μg/mL. 4. The method of claim 1 or 2, wherein the sustained release composition results in a circulating plasma concentration of metformin in said patient of less than about 0.25 μg/mL. 5. The method according to any one of claims 1 to 4, wherein said pharmaceutical dosage form provides at least 20% less relative systemic bioavailability of metformin compared to an immediate release formulation containing the same amount of metformin or a salt thereof, where the average systemic bioavailability of metformin in plasma is as measured by AUC (area under the curve). 6. The method according to claim 5, where the average systemic bioavailability is as measured by the level of metformin in plasma C _max . 7. The method of claim 5 wherein the mean systemic plasma bioavailability of metformin, as measured by AUC, is 70%, 60%, 50%, 40%, or 30% lower as a result of administration of said pharmaceutical dosage form compared to the mean systemic plasma bioavailability of metformin, measured by AUC upon administration of an immediate release formulation containing an equivalent amount of metformin or a salt thereof. 8. The method according to any one of claims 1 to 7, wherein said start of release is at a pH of about 6.0. 9. The method according to any one of claims 1 to 7, wherein said start of release is at a pH of about 6.5. 10. The method according to any one of claims 1 to 7, wherein said start of release is at a pH of about 7.0. 11. The method according to any one of claims 1 to 7, wherein said start of release is at a pH equal to or greater than 6.0. 12. The method according to any one of claims 1 to 7, where the specified release start is at a pH equal to -