Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/66—Phosphorus compounds
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P19/00—Drugs for skeletal disorders
  • A61P19/08—Drugs for skeletal disorders for bone diseases, e.g. rachitism, Paget's disease
  • A61P19/10—Drugs for skeletal disorders for bone diseases, e.g. rachitism, Paget's disease for osteoporosis
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P43/00—Drugs for specific purposes, not provided for in groups A61P1/00-A61P41/00

Definitions

• One of the most common bone disorders is post- menopausal osteoporosis which affects an estimated 20 to 25 million women in the United States alone. Women after menopause experience an increase in the rate of bone turnover with resulting net loss of bone, as circulating estrogen levels decrease.
• the rate of bone turnover differs between bones and is highest in sites enriched with trabecular bone, such as the vertebrae and the proximal femur.
• the potential for bone loss at these sites immediately following menopause is up to 4-5% per year or more.
• the resulting decrease in bone mass and enlargement of bone spaces leads to increased fracture risk, as the mechanical integrity of bone deteriorates .
• Osteoclasts are unique in their ability to resorb both the hydroxyapatite mineral and organic matrix of bone. They are somewhat similar to the cartilage resorbing cells, termed chondroclasts . It is for this reason that potent inhibitors of osteoclastic bone resorption may also inhibit the cell- mediated degradation of cartilage observed in rheumatoid arthritis and osteoarthritis.
• Estrogens have been shown clearly to arrest the bone loss observed after menopause and limit the progression of osteoporosis; but patient compliance has been poor because of estrogen side-effects. These side effects include resumption of menses, mastodynia, increase in the risk of uterine cancer, and possibly an increase in the risk of breast cancer.
• raloxifene HCl a selective estrogen receptor modulator (SERM)
• SERM selective estrogen receptor modulator
• compositions containing a bisphosphonate and an anti-resorptive agent for inhibiting bone loss are disclosed in European Patent Application Publ . No. 0 693 285 A2 , inventors Black, L.J. and Cullinan, G.J., with a publication date of Jan. 24, 1996.
• Third generation bisphosphonates such as alendronate are potent inhibitors of bone resorption, resulting in marked reductions in bone metabolic activity.
• alendronate especially when co-administered with estrogen, may result in suppression of bone turnover to levels that are below the mean for normal premenopausal women; Lindsay et al . , J. Clin . Endocrinol . Metab. 84, 3076-3081 (1999).
• the current invention invokes the sequential use of a bisphosphonate followed by switching to raloxifene or pharmaceutically acceptable salt or solvate thereof, for the purpose of further increasing BMD in humans previously treated with a bisphosphonate.
• This benefit on BMD is associated with a shift of bone turnover markers back toward normal levels, reducing the risks of "frozen bone” that may be associated with excessive suppression of bone turnover by administration of highly potent antiresorptives either alone or in combination.
• This invention relates to a method for enhancing bone mineral density gain acquired through previous bisphosphonate therapy comprising administering to a human in need thereof a bone-enhancing amount of raloxifene or a pharmaceutically acceptable salt or solvate thereof. Further, this invention relates to a method of inhibiting bone loss in a human in need thereof comprising administering a bone-enhancing amount of raloxifene or a pharmaceutically acceptable salt or solvate thereof subsequent to a course of bisphosphonate therapy.
• This invention further relates to the use of raloxifene or a pharmaceutically acceptable salt or solvate thereof, in the preparation of a medicament for enhancing bone mineral density gain in a human, wherein said bone mineral density gain is acquired through previous bisphosphonate therapy.
• this invention relates to the use of raloxifene or a pharmaceutically acceptable salt or solvate thereof, in the preparation of a medicament for inhibiting bone loss in a human subsequent to a course of bisphosphonate therapy.
• the term "inhibit” is defined to include its generally accepted meaning which includes preventing, prohibiting, restraining, and slowing, stopping or reversing progression, or severity, and holding in check and/or treating existing characteristics.
• the present method includes both medical therapeutic and/or prophylactic treatment, as appropriate.
• the phrase "enhance" is defined to include its generally accepted meaning which includes increasing, magnifying, amplifying, heightening, escalating, improving, boosting, intensifying and augmenting.
• Rises or gains in lumbar BMD with biphosphonate therapy for osteoporosis are generally in the range of four to eight percent compared to baseline with a majority of this rise occurring during the first twelve months of treatment.
• the BMD is either generally stable or tending to decrease whereas markers of bone turnover return toward baseline.
• bisphosphonate therapy refers to administration of an effective amount of a bisphosphonate for a period of time sufficient to approach a plateau for bone density effect.
• a preferred length of time for a course of bisphosphonate therapy is at least six months, including treatment for six months to three years, preferably for at least about one year, with discontinuation of the therapy when appropriate to avoid excessive bone turnover .
• BMD refers to bone mineral density.
• salt or “pharmaceutically acceptable salt” refers to salts of the compounds of the above classes that are substantially non-toxic to living organisms. Typical pharmaceutically acceptable salts include those salts prepared by reaction of a compound of the above class with a pharmaceutically acceptable mineral or organic acid, or a pharmaceutically acceptable alkali metal or organic base, depending on the types of ' substituents present on the compound.
• Examples of pharmaceutically acceptable mineral acids which may be used to prepare pharmaceutically acceptable salts include hydrochloric acid, phosphoric acid, sulfuric acid, hydrobromic acid, hydroiodic acid, phosphorous acid and the like.
• Examples of pharmaceutically acceptable organic acids which may be used to prepare pharmaceutically acceptable salts include aliphatic mono and dicarboxylic acids, oxalic acid, carbonic acid, citric acid, succinic acid, phenyl-substituted alkanoic acids, aliphatic and aromatic sulfonic acids and the like.
• Such pharmaceutically acceptable salts prepared from mineral or organic acids thus include hydrochloride, hydrobromide, nitrate, sulfate, pyrosulfate, bisulfate, sulfite, bisulfite, phosphate, monohydrogenphosphate, dihydrogenphosphate, metaphosphate, pyrophosphate, hydroiodide, hydrofluoride, acetate, propionate, formate, oxalate, citrate, lactate, p- toluenesulfonate, methanesulfonate, maleate, and the like.
• Many compounds of the above classes which contain a carboxy, carbonyl, or hydroxy or sulfoxide group may be converted to a pharmaceutically acceptable salt by reaction with a pharmaceutically acceptable alkali metal or organic base.
• pharmaceutically acceptable organic bases which may be used to prepare pharmaceutically acceptable salts include ammonia, amines such as triethanolamine, triethylamine, ethylamine, and the like.
• pharmaceutically acceptable alkali metal bases included compounds of the general formula MOZ, where M represents an alkali metal atom, e.g.
• Z represents hydrogen or C1-C4 alkyl, wherein C1-C4 alkyl represents a straight or branched chain alkyl radical of one to four carbon atoms such as methyl, ethyl, propyl, isopropyl and the like.
• any salt of this invention is not critical, so long as the salt, as a whole, is pharmacologically acceptable and as long as the anion or cationic moiety does not contribute undesired qualities .
• solvates may form solvates with water or common organic solvents. Such solvates are included within the scope of the present invention and solvates thereof.
• the class of compounds known as bisphosphonates includes those compounds which contains a di-phosphonic acid moiety separated by a carbon link and include a variety of side-chains, usually containing a basic function.
• the compounds have the following general structure:
• Y, Ri and R 2 may be those substitutents as defined in US Patent 5,139,786, and EPO Publication 0416689A2, published March 13, 1991, incorporated herein by reference, although not limited to such.
• a variety of bisphosphonic acids have been disclosed as being useful in the treatment and prevention of diseases involving bone resorption. Representative examples may be found in the following: U.S. Pat. Nos. 3,962,432, 4,054,598, 4,267,108, 4,327,039, 4,621,077, 4,624,947, 4,746,654, and 4, 922 , 077 , each of which is incorporated by reference herein as if fully set forth.
• the second generation of bisphosphonates refers to the compounds clodronate and pamidronate .
• Clodronate and pamidronate are both is marketed for Paget ' s disease and hypercalcemia maligancy.
• Pamidronate will probably be approved for osteoporosis in some European countries in the near future.
• the third generation of bis-phosphonates refer to alendronate, residronate, and tiludronate and a host of lesser known compounds. Pharmacologically, these compounds are much more potent and are claimed to have fewer side- effects.
• bisphosphonates While some bisphosphonates are indicated for treating osteoporosis; they also appear to have potential detrimental side-effects. For example, bisphosphonates have the potential of inhibiting bone formation as well as resorption; they are poorly adsorbed via oral administration and are known to cause gastrointestinal irritation; they have extremely long half-lives in bone; they may all have the potential for causing osteomalacia; and there is concern as to the bio-mechanical strength of the bones treated with bisphosphonates.
• the amount of bisphosphonate administered to adult humans ranges from about 1 g/day to about 400 g/day.
• a course of bisphosphonate therapy generally lasts until a BMD plateau is achieved although such therapy may be used for repeated courses or continuously for an indefinite time.
• a preferred length of time for a course of bisphosphonate therapy is for at least about six months, including treatment for six months to three years, preferably for at least about one year, with discontinuation of the therapy when appropriate to avoid excessive suppression of bone turnover.
• Preferred bisphosphonates are alendronate and risedronate, and salts thereof.
• Alendronate sodium is sold commercially as FOSAMAX ® .
• Alendronate and salts thereof may be prepared according to known procedures such as those detailed in U.S. Pat. Nos. 4,621,077, 5,358,941, 5,681,590, 5,804,570, 5,849,726, and 6,008,207, each of which is incorporated by reference herein as if fully set forth.
• Risedronate sodium is sold commercially as ACTONEL ® .
• Risedronate and salts thereof may be prepared according to known procedures such as those detailed in U.S. Pat. No. 5,583,122, herein incorporated by reference as if fully set forth.
• an effective minimum daily dose for alendronate sodium is about 1, 2.5, 5, 10 or 20 mg.
• an effective maximum daily dose is about 200, 100, 80, 60 or 40 mg.
• a preferred daily dosage range is from about 5 mg to about 10 mg per day.
• the most preferred dosage is 10 mg once a day.
• the most preferred dosage is 5 mg once a day.
• the most preferred dosage is 5 mg once a day, except for postmenopausal women not receiving estrogen, for whom the most preferred dosage is 10 mg once per day.
• the most preferred treatment regimen is 40 mg once a day for six months.
• the preferred daily dose is about 1, 2.5, 5, 10, 15, or 30 mg.
• an effective maximum daily dose is about 300, 150, 120, 90, or 60 mg.
• the most preferred dosage ranges from about 2.5 to 20 mg per day, with 5 mg once per day being preferred.
• the most preferred treatment regimen is 30 mg once a day.
• Raloxifene hydrochloride which is 6-hydroxy-2- (4- hydroxyphenyl ) -3- [4- (2-piperidinoethoxy)benzoyl] - benzo [b] thiophene, is sold commercially as EVISTA ® and is represented by the formula:
• Raloxifene and salts and solvates thereof may be prepared according to known procedures, such as those detailed in U.S. Pat. Nos. 4,133,814, 4,418,068, 5,631,369, 5,731,327, 5,731,342, 5,750,688 and 5,977,383, each of which is incorporated by reference herein as if fully set forth.
• Preferred crystalline forms, particle sizes and pharmaceutical formulations are disclosed in U.S. Pat. Nos. 5,641,790, 5,731,327, 5,747,510, and 5 , 811, 120, each of which is incorporated by reference herein as if fully set forth.
• compositions can be prepared by procedures known in the art, such as, for example, in European Published Application 670162A1, published September 6, 1995, and in WO 97/35571 published October 2, 1997, both of which are herein incorporated by reference.
• a compound of formula I can be formulated with common excipients, diluents, or carriers, and formed into tablets, capsules, and the like.
• excipients, diluents, and carriers that are suitable for formulation include the following: fillers and extenders such as starch, sugars, mannitol, and silicic derivatives; binding agents such as carboxymethyl cellulose and other cellulose derivatives, alginates, gelatin, and polyvinyl pyrrolidone; moisturizing agents such as glycerol; disintegrating agents such as agar, calcium carbonate, and sodium bicarbonate; agents for retarding dissolution such as paraffin; resorption accelerators such as quaternary ammonium compounds; surface active agents such as cetyl alcohol, glycerol monostearate; adsorptive carriers such as kaolin and bentonire; and lubricants such as talc, calcium and magnesium stearate and solid polyethyl glycols.
• fillers and extenders such as starch, sugars, mannitol, and silicic derivatives
• binding agents such as carboxymethyl cellulose and other cellulose derivatives, alginates
• Final pharmaceutical forms may be: pills, tablets, powders, lozenges, syrups, aerosols, saches, cachets, elixirs, suspensions, emulsions, ointments, suppositories, sterile injectable solutions, or sterile packaged powders, depending on the type of excipient used.
• raloxifene and its pharmaceutically acceptable salts are suited to formulation as sustained release dosage forms.
• the formulations can also be so constituted that they release the active ingredient only or preferably in a particular part of the intestinal tract, possibly over a period of time.
• Such formulations would involve coatings, envelopes, or protective matrices which may be made from polymeric substances or waxes.
• the particular dosage of raloxifene or a pharmaceutically acceptable salt thereof required to constitute a "bone-enhancing amount" according to this invention will depend upon the particular circumstances of the conditions to be treated. Considerations such as dosage, route of administration, and frequency of dosing are best decided by the attending physician.
• an effective minimum dose for oral or parenteral administration of raloxifene or a pharmaceutically acceptable salt thereof is about 1, 5, 10, 15, or 20 mg.
• an effective maximum dose is about 800, 120, 60, 50, or 40 mg.
• a particularly effective amount is 60 mg of raloxifene hydrochloride (56 mg of free base) per day via an oral route of administration.
• Such dosages will be administered to a patient in need of treatment from one to three times each day or as often as needed to effectively enhance bone mineral density gain acquired through previous bisphoshonate therapy.
• Raloxifene hydrochloride may be administered for extended periods of time including six months to two years, specifically including about one year. Raloxifene hydrochloride may be used for repeated courses or continuously for an indefinite time.
• active ingredient means a compound of formula I, or a pharmaceutical salt or solvate thereof, (preferably raloxifene hydrochloride) .
• An even more preferred formulation of a compound of formula I would be raloxifene hydrochloride in the particular crystalline form, particle size, and composition illustrated in U.S. Pat. No. 5,731,327 and PCT application WO 97/35571 (2 October 1997) the teachings of each are incorporated by reference.
• the active ingredient, starch, and cellulose are passed through a No. 45 mesh U.S. sieve and mixed thoroughly.
• the solution of polyvinylpyrrolidone is mixed with the resultant powders which are then passed through a No. 14 mesh U.S. sieve.
• the granules thus produced are dried at 50-60° C and passed through a No. 18 mesh U.S. sieve.
• the sodium carboxymethyl cellulose, magnesium stearate, and talc, previously passed through a No . 60 mesh U.S. sieve, are added to the above granules and thoroughly mixed.
• the resultant material is compressed in a tablet forming machine to yield the tablets.
• the active ingredient is mixed with ethanol and the mixture added to a portion of the propellant 22, cooled to -30°C and transferred to a filling device. The required amount is then fed to a stainless steel container and diluted with the remainder of the propellant. The valve units are then fitted to the container.
• Suspensions each containing 100 mg of a compound of formula I per 5 mL dose are prepared as follows: the active ingredient is passed through a No. 45 mesh U.S. sieve and mixed with the sodium carboxymethyl cellulose and syrup to form a smooth paste. The benzoic acid solution, flavor, and color diluted in water are added and mixture stirred thoroughly. Additional water is added to bring the entire mixture to the required volume.
• Objectives of the trial included comparing the effects of 12 months treatment with raloxifene HC1 (60 mg/day) , alendronate (10 mg/day) , or the combination of the two agents together versus placebo on BMD at the lumbar spine and at the hip and also metabolic markers of bone turnover. Additional objectives included comparing the effects of raloxifene 60 mg/day versus placebo during a second year of study on the offset of action of raloxifene or alendronate, as assessed by these same efficacy parameters .
• Subjects were eligible for the trial if they were ambulatory postmenopausal women up to 75 years of age, inclusive, and had femoral neck BMD more than 2.0 standard deviations below the mean peak bone mass for healthy premenopausal women (i.e. T-score ⁇ -2.0) .
• Subjects were ineligible if they had less than five years life expectancy, had current bone disorders (other than primary osteoporosis) , had known or suspected history of carcinoma of the breast or other estrogen-dependent neoplasm, had history of cancer within five years of study, had abnormal uterine bleeding or endometrial thickness > 5mm by ultrasonography, had history of deep venous thrombosis or pulmonary embolism, had significant liver, kidney, gastroesophageal or intestinal malaborptive disease or any endocrine condition (other than type 2 diabetes or hypothyroidism) requiring pharmacologic therapy, were currently consuming excess of alcohol or drugs of abuse or were, using or had recently received hormones or other therapies for osteoporosis.
• Table 12 Bone specific alkaline phosphatase (Median percentage change from end of 12 month alendronate treatment period)

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