ES2399914T3 - Use of a liquid allergy vaccine formulation for oromucosal administration - Google Patents

Abstract

An allergen for use in prevention or treatment of allergy in a human subject by means of oral administration of a liquid vaccine formulation in a dosage regimen that does not include an increase in dose.

Description

Use of a liquid allergy vaccine formulation for oromucosal administration

Field of the Invention

The present invention relates to an allergy vaccine formulation for oromucosal administration.

Background of the invention

Allergy is a major health problem in countries where the western lifestyle is adapted. Additionally, the prevalence of allergic disease is increasing in these countries. Although allergy in general cannot be considered a life-threatening disease, asthma produces a significant number of deaths annually. An exceptional prevalence of approximately 30% in adolescents leads to a substantial loss of quality of life, work days and money, and requires a classification among the main health problems in the western world.

Allergy is a complex disease. Many factors contribute to the sensitization event. Among these is the susceptibility of the individual defined as an interaction not yet sufficiently understood between several genes. Another important factor is allergen exposure above certain thresholds. Several environmental factors can be important in the sensitization process, including contamination, infections in children, parasitic infections, intestinal microorganisms etc. Once an individual has been sensitized and the allergic immune response has been established, the presence of only very small amounts of allergen efficiently translates into symptoms.

The natural evolution of allergic disease is usually accompanied by an aggravation at two levels. First, a progression of the symptoms and the severity of the disease, in addition to the progression of the disease, for example from hay fever to asthma. Secondly, dissemination of the causative allergens occurs most frequently and results in allergic multireactivity. Chronic inflammation leads to a general weakening of the mucosal defense mechanisms, which results in nonspecific irritation and, ultimately, destruction of the mucous tissue. Infants are primarily sensitized to food, that is, milk, which results in eczema or gastrointestinal disorders; however, they more often overcome these symptoms spontaneously. These infants are at risk of developing inhalation allergy later in their lives.

The most important sources of allergens are among the most prevalent particles of a certain size in the air we breathe. These sources are considerably universal and include plant pollens, fecal particles from house dust mites that, together, are responsible for approximately 50% of all allergies. Of great importance are also animal dander, that is, cat and dog dander, other pollens, such as artemis and pollen pollens, such as Alternaria. Depending on the region, other pollens can dominate, such as birch pollen in northern and central Europe, Ambrosia in the eastern and central United States, and Japanese cedar pollen in Japan. Insects, that is, bee and wasp poisons, and foods each represent approximately 2% of all allergies.

Allergy, that is, type I hypersensitivity, is caused by an inadequate immune reaction to foreign non-pathogenic substances. Important clinical manifestations of allergy include asthma, hay fever, eczema and gastrointestinal disorders. The allergic reaction is rapid and reaches a maximum in 20 minutes after contact with the causative allergen. In addition, the allergic reaction is specific in the sense that a particular individual is sensitized to specific allergens (s), while the individual does not necessarily show an allergic reaction to other substances known to cause allergic disease. The allergic phenotype is characterized by a pronounced inflammation of the mucosa of the target organ and by the presence of specific antibodies of the IgE class allergen in the circulation and on the surface of mast cells and basophils.

An allergic attack is initiated by the reaction of the foreign allergen with allergen-specific IgE antibodies, when the antibodies are bound to specific high affinity IgE receptors on the surface of mast cells and basophils. Mast cells and basophils contain previously formed mediators, that is, histamine, tryptase and other substances that are released after overcrossing of two or more IgE antibodies bound to the receptor. IgE antibodies are overcrossed by the simultaneous binding of an allergen molecule. Therefore, it follows that a foreign substance that only has an antibody binding epitope does not initiate an allergic reaction. Overcrossing the receptor-bound IgE on the mast cell surface also leads to the release of signaling molecules responsible for the attraction and eosinophils, allergen-specific T lymphocytes and other cell types to the site of the allergic response. These cells in interaction with the allergen, IgE and effector cells, lead to a burst of symptoms that occur 12-24 hours after the encounter with the allergen (late phase reaction).

The treatment of allergic disease includes diagnosis and treatment, including prophylactic treatments. The diagnosis of allergy depends on the demonstration of allergen-specific IgE and the identification of the source of the allergen. In many cases, a careful history for the

Allergy diagnosis and for the identification of the source material of the causal allergen. However, most often the diagnosis is supported by objective measures, such as skin prick test, blood test or provocation test.

The therapeutic options fall into three main categories. The first opportunity is the avoidance of the allergen or the reduction of exposure. While allergen avoidance is obvious, for example in the case of food allergens, it can be difficult or expensive, as for house dust mite allergens, or it may be impossible, as for pollen allergens. The second therapeutic option and the most used is the prescription of classic symptomatic drugs such as antihistamines and steroids- Symptomatic drugs are safe and efficient; however, they do not alter the natural cause of the disease or control the spread of the disease. The third therapeutic alternative is the specific allergy vaccination that, in most cases, reduces or relieves allergic symptoms caused by the allergen in question.

Specific vaccination for conventional allergy is a causal treatment of allergic disease. It interferes with the basic immunological mechanisms that result in a persistent improvement in the immune status of patients. Therefore, the protective effect of allergy-specific vaccination extends beyond the treatment period in contrast to symptomatic drug treatment. Some patients who receive treatment are cured and, in addition, most patients experience relief in the severity of the disease and the symptoms experienced, or at least a break in the worsening of the disease. Therefore, allergy-specific vaccination has preventive effects in reducing the risk of hay fever that develop in asthma and in reducing the risk of developing new sensitivities.

The immune mechanism underlying successful vaccination is not known in detail. A specific immune response, such as the production of antibodies against a specific pathogen, is known as an adaptive immune response. This response can be distinguished from the innate immune response, which is a nonspecific reaction to pathogens. An allergy vaccine is directed at the adaptive immune response, which includes cells or molecules with antigenic specificity, such as T lymphocytes and antibody-producing B lymphocytes. B lymphocytes cannot mature to antibody producing cells without the help of T lymphocytes of the corresponding specificity. T lymphocytes participate in the stimulation of allergic immune responses are mainly of the Th2 type. It has been proposed that the establishment of a new balance between Th1 and Th2 cells is beneficial and crucial for the immunological mechanism of allergy-specific vaccination. There is controversy over whether this is caused by a reduction of Th2 cells, a change of Th2 cells to Th1 or a regulation by increase of Th1 cells. Recently it has been proposed that regulatory T lymphocytes are important for the allergy vaccination mechanism. According to this model, regulatory T lymphocytes, that is Th3 or Tr1 cells, regulate by decreasing Th1 and Th2 cells of the corresponding antigen specificity. Despite these ambiguities, it is generally believed that an active vaccine should have the ability to stimulate allergen-specific T lymphocytes, preferably Th1 cells.

Despite its virtues, allergy-specific vaccination is not widely used, mainly for two reasons. One reason is the discomfort associated with the traditional vaccination program, which includes repeated vaccinations, that is, injections for several months. The other reason is, most importantly, the risk of allergic side reactions. The usual vaccinations against infectious agents are performed efficiently using a single or several high dose immunizations. However, this strategy cannot be used for allergy vaccinations, since the pathological immune response has already been launched.

Therefore, vaccination for conventional specific allergy is carried out using multiple subcutaneous immunizations applied over an extended period of time. The cycle is divided into two phases, the dose increase and the maintenance phase. Increasing doses are applied in the dose increase phase, usually over a period of 16 weeks, starting with minimal doses. When the recommended maintenance dose is reached, this dose is applied for the maintenance phase, usually with injections every six weeks. After each injection, the patient should remain under medical supervision for 30 minutes due to the risk of anaphylactic side reactions, which, in principle, although extremely rare, could be life-threatening. In addition, the clinic must be equipped with emergency support treatment. There is no doubt that a vaccine based on a different route of administration would eliminate or reduce the risk of allergic side reactions inherent in the current subcutaneous vaccine, in addition to facilitating more widespread use, possibly even allowing self-vaccination at home.

Attempts to improve vaccines for vaccination for specific allergy have been made for more than 30 years and include multifactorial approaches. Several strategies have addressed the allergen itself by modifying the reactivity of IgE. Others have addressed the route of administration.

The immune system is accessible through the oral cavity and sublingual administration of allergens is a known route of administration. Administration can be carried out by placing the vaccine formulation under the tongue and leaving it there for a short period of time, for example approximately 2 minutes.

Conventionally, the allergy vaccine that uses the oromucosal route consists in the daily dosage of an allergen solution. In comparison, the therapeutic maintenance doses (cumulative) administered exceed the maintenance doses of a subcutaneous treatment by a high factor. It is known that oromucose administration does not produce side effects or these are minor, mainly in the form of itching in the mouth and, sometimes, itching in the eyes and ears.

WO 04/047794 discloses a solid fast dispersion dosage form for sublingual administration of an allergy vaccine.

WO-A-00/45847 discloses an allergy vaccination for administration through a mucous membrane of a subject, the oral route is clearly distinguished from the sublingual / oral route. The only explicit disclosure of a dosage regimen without dose increase is by peroral administration (direct release in the stomach).

A commercial allergy vaccine for sublingual administration in the form of drops comprises an allergen dissolved in a liquid mixture of 50% glycerol and 50% water.

Commercial liquid allergy vaccines for sublingual administration are conventionally administered using a dosage schedule comprising a period of dose increase, usually 10 to 20 days of daily dosing, in which the dose is gradually raised to the dose level of maintenance, followed by a maintenance period in which the patient receives a maintenance dose. Recently, in a series of studies and has investigated the possibility of performing the dose increase by means of the so-called rapid dose increase treatment performed in a few days, a day or even a few hours, in which the increasing doses are administered with only a short period of time, for example one hour or two hours, between each administration. However, this rapid dose increase treatment has the disadvantage that the occurrence of side effects cannot be ruled out and, therefore, as subcutaneous administration requires the supervision of an allergy specialist.

The object of the present invention is to provide an improved use of the prevention or treatment of allergy in a subject by oromucosal administration.

Summary of the invention

This object is obtained by the present invention, which refers to the use of an allergen for the manufacture of a liquid vaccine formulation to prevent or treat allergy in a subject by oromucosal administration in a dosage regimen that does not include dose increase, it is This can be started by administering a maintenance dose, for example using the standard dose schedule of the maintenance phase.

The present invention is based on a clinical trial in which, surprisingly, it has been shown that allergy vaccination by oromucosal administration using a liquid formulation can be carried out without increasing the dose while maintaining an acceptable level of effects. secondary. This finding is very surprising in the sense that until now it has been believed that a phase of dose increase of some kind is essential to avoid serious side effects.

The possibility of avoiding a phase of dose increase as a whole provides the oromucosal treatment with a liquid vaccine formulation the advantage that it greatly simplifies the dosage schedule. Additionally, the simple dosage schedule increases patient compliance with treatment.

Detailed description of the invention

Allergen

The allergen of the formulation according to the present invention may be a natural protein that has been indicated to induce IgE-mediated allergic reactions upon repeated exposure to an individual. Examples of natural allergens include pollen allergens (tree pollen allergens, herbs, weeds and lawns), insect allergens (inhaled, saliva and poison allergens, for example mite allergens, cockroach and mosquito allergens, poison allergen of hymenoptera), animal hair and dander allergens (from, for example, dogs, cats, horses, rats, mice, etc.) and food allergens. Important allergens of tree, grass and grass pollen are those that come from the taxonomic orders of Fagales, Oleales, Pinales and platanaceae, including, among others, birch (Betula), alder (Alnus), hazelnut (Corylus), carpe (Carpinus ) and olive (Olea), cedar (Cryptomeria and Juniperus), banana (Platanus), the order of Poales, including, among other grasses of the genera Lolium, Phleum, Poa, Cynodon, Dactylis, Holcus, Phalaris, Secale and Sorghum, Asteral and Urtical orders, including, among others, herbs of the genus Ambrosia, Artemisia and Parietaria. Other important inhalation allergens are those of house dust mites of the genus Dermatophagoides and Euroglyphus, cellar mite, e.g., Lepidoglyphys, Glycyphagus and Tyrophagus, cockroaches, mosquitoes and fleas, for example Blatella, Periplaneta, Chironomus and Ctenocepphalides , and those of mammals such as dogs, cats and horses, allergens of poisons including those that come from bites or insect bites, such

such as those of the taxonomic order of hymenoptera, including bees (Apidae superfamily), wasps (Vespidea superfamily) and ants (Formicoidae superfamily). Important fungal inhalation allergens are, among others, those that come from the Alternaria and Cladosporium genera.

In a specific embodiment of the invention, the allergen is Bet v 1, Aln g 1, Cor a 1 and Car b 1, Que a 1, Cry j 1, Cry j 2, Cup a 1, Cup s 1, Jun a 1 , Jun to 2, Jun to 3, Ole e 1, Lig v 1, Pla l 1, Pla a 2, Amb a 1, Amb a 2, Amb t 5, Art v 1, Art v 2, Par j 1, Par j 2, Par j 3, Salt k 1, Ave e 1, Cyn d 1, Cyn d 7, Dac g 1, Fes p 1, Hol l 1, Lol p 1 and 5, Pha a 1, Pas n 1, Phl p 1, Phl p 5, Phl p 6, Poa p 1, Poa p 5, Sec c 1, Sec c 5, Sor h 1, Der f 1, Der f 2, Der p 1, Der p 2, Der p 7 , Der m 1, Eur m 2, Gly d 1, Lep d 2, Blo t 1, Tyr p 2, Bla g 1, Bla g 2, Per a 1, Fel d 1, Can f 1, Can f 2, Bos d 2, Equ c 1, Equ c 2, Equ c 3, Mus m 1, Rat n 1, Apis m 1, Api m 2, Ves v 1, Ves v 2, Ves v 5, Dol m 1, Dil m 2 , Dol m 5, Pol a 1, Pol a 2, Pol a 5, Sol i 1, Sol i 2, Sol i 3 and Sol i 4, Alt a 1, Cla h 1, Asp f 1, Bos d 4, Mal d 1, Gly m 1, Gly m 2, Gly m 3, Ara h 1, Ara h 2, Ara h 3, Ara h 4, Ara h 5 and restructured hybrids of molecular generation of any of these.

In a preferred embodiment of the invention, the allergen is selected from the group consisting of a tree pollen allergen, a grass pollen allergen or a house dust mite allergen, a storage mite allergen, a bad allergen herbs, a mold allergen, a cat allergen or a dog allergen.

In yet another embodiment of the invention, the formulation comprises at least two different types of allergens that originate from the same allergic source or that originate from different allergenic sources, for example allergens of lawns group 1 and lawns group 65 allergens of group 1 and group 2 of mites of different species of mites and lawns, respectively, weed antigens such as allergens of short and giant ragweed, different fungal allergens such as Alternaria and Cladosporium, three allergens such as birch allergens, hazelnut , carpe, oak and alder, food allergens such as peanut, soy and milk allergens.

The allergen incorporated in the formulation may be in the form of an extract, a purified allergen, a modified allergen, a recombinant allergen or a mutant of a recombinant allergen. An allergenic extract can naturally contain one or more isoforms of the same allergen, while a recombinant allergen usually only represents an isoform of an allergen. In a preferred embodiment, the allergen is in the form of an extract. In another preferred embodiment, the allergen is a recombinant allergen. In a further preferred embodiment, the allergen is a natural mutant of low IgE binding or a recombinant mutant of low IgE binding. Additionally, the allergen can be a mixture of a series of allergens, for example from 2 to 10 allergens, in particular from 3 to 9 allergens, more specifically from 4 to 8 and most specifically from 5 to 7 allergens.

Allergens may be present in equimolar amounts or the proportion of allergens present may preferably vary up to 1:20.

In a further embodiment of the invention, the low IgE binding allergen is an allergen according to WO 99/47680, WO 02/40676 or WO 03/096869 A2.

The preferred potency of a single dose formulation intended for daily administration is 1 to 2,000 UTE, more preferably 50 to 1,000 UTE, more preferably 100 to 500 UTE, more preferable 130 to 350 UTE, and most preferably 150 to 150 250 UTE

The preferred potency of a single dose formulation intended for daily administration is 100 to 500,000 SQu, more preferable 200 to 300,000 SQ-u, more preferable 500 to 200,000 SQ-u, more preferable 1,000 to 100,000 SQ-u, more preferable , from 1,500 to 80,000 SQ-u, and most preferably from 2,000 to 50,000 SQ-u.

The amount of allergen that corresponds to a given power level varies considerably depending on the species of allergen. In a further embodiment of the invention, the concentration of the main allergen in a single dose intended for daily administration is 0.05 to 50 μg, more preferably 0.05 to 30 μg, more preferably 0.06 to 25 μg, more preferably from 0.07 to 20 μg, more preferably from 0.08 μg to 15 μg, more preferably from 0.09 μg to 10 μg and, most preferably, from 0.1 μg to 7 μg.

Oromucosa Administration

The immune system is accessible through the oral cavity and sublingual administration of allergens is a known route of administration. Administration can be carried out by placing the vaccine formulation under the tongue and leaving it there for a short period of time, for example 30 to 300 seconds, preferably 45 to 240 seconds, more preferably 60 to 180 seconds, more preferably from 90 to 150 seconds and, most preferably, from 90 to 120 seconds.

Oromucosal administration comprises any administration procedure in which the formulation, all or part, comes into contact with the mucosa of the oral cavity and / or the patient's pharynx. Oromucosal administration procedures include sublingual administration and oral administration.

In one embodiment of the invention, the subject is subjected to a vaccination protocol comprising daily administration of the vaccine. In another embodiment of the invention, the vaccination protocol comprises the administration of

the vaccine on alternate days, every three days or every four days. For example, the vaccination protocol comprises administering the vaccine for a period of more than 4 weeks, preferably more than 8 weeks, more preferably more than 12 weeks, more preferably more than 16 weeks, more preferably more than 20 weeks, more preferably more than 24 weeks, more preferably more than 30 weeks and more preferably more than 36 weeks.

The administration period may be a continuous period. Alternatively, the administration period is a discontinuous period interrupted by one or more periods without administration. Preferably, the (total) period without administration is shorter than the (total) period of administration.

In a further embodiment of the invention, the vaccine is administered to the patient once a day. Alternatively, the vaccine is administered to the patient twice a day. The vaccine can be a single dose vaccine.

Liquid Vaccine Formulation

The liquid vaccine formulation of the invention may further comprise any adjuvant and other excipients suitable for this type of formulation. Such excipients are well known to those skilled in the art and include, but are not limited to, solvents, emulsifiers, wetting agents, plasticizers, coloring substances, fillers, preservatives, viscosity adjusting agents, buffering agents, pH adjusting agents, agents of adjustment of isotonicity, mucoadhesive substances and the like. Examples of formulation strategies are well known to the person skilled in the art.

The adjuvant can be any conventional adjuvant, including oxygen-containing metal salts, for example aluminum hydroxide, thermolabile enterotoxin (TL), cholera toxin (CT), cholera toxin subunit B (CTB), polymerized liposomes, mutant toxins , for example LTK63 and LTR72, microcapsules, interleukins

(e.g., IL-1�, IL-2, IL-7, IL-12, INFy), GM-CSF, MDF derivatives, CpG oligonucleotides, LPS, MPL, phosphoacenes, Adju-Phos®, glucan, antigen formulation, liposomes, DDE, DHEA, DMPC, DMPG, DOC / alumina complex, incomplete Freund's adjuvant, ISCOMs®, oral adjuvant LT, muramyl dipeptide, monophosphoryl lipid A, muramyl tripeptide and phosphatidylethanolamine.

Aqueous solutions of metal salts containing oxygen usually have the form of gels. The concentration of aluminum hydroxide in the formulation is preferably 0.035-1,000 mg / ml, more preferably 0.10-100 mg / ml, more preferably 0.25-10 mg / ml and, most preferably, 0.5 -5 mg / ml However, the formulation of the invention may also be in the form of a highly concentrated gel or gel formulation.

In a specific embodiment of the invention, the formulation according to the invention further comprises an enhancer. An enhancer is a substance that increases the bioavailability of a pharmaceutically active substance i) by increasing the penetration of the active substance through the biomembrane by opening the paracellular pathways (tight junctions), that is by increasing the absorption of the active substance and / or ii ) through the bioadhesive effect of the enhancer, which increases the absorption period.

Examples of enhancers are an alcohol, for example ethanol, chitosan, chitin, propylene glycol, glycerol, dimethylsulfoxide, dimethylformamide, dimethylacetamide, preferably glycerol. The enhancer is preferably present in an amount of 20% to 80% (v / v), more preferably 30% (v / v) to 70% (v / v /) and, most preferably, 40% (v / v) at 60% (v / v).

The formulation of the present invention can be prepared by dissolving the adjuvants and other excipients, where appropriate, in a solvent, preferably water, adding the allergen and allowing the allergen and the adjuvants and other excipients to react for a period of time. The reaction period may be 0.1 to 48 hours, preferably 12 to 24 hours. The reaction is preferably carried out at a temperature of 4 to 45 ° C, more preferably 4 to 20 ° C.

Metal salts that contain oxygen

In a preferred embodiment of the invention, the liquid vaccine formulation of the invention comprises an oxygen salt metal salt adjuvant. Preferably, the metal cation of the metal salt containing oxygen is selected from the group consisting of Al, K, Ca, Mg, Zn, Ba, Na, Li, B, Be, Fe, Si, Co, Cu, Ni, Ag , Au and Cr.

The anion of the oxygen-containing compound can be any anion that contains oxygen, including an organic or inorganic anion or a combination of organic and inorganic anions. Examples of suitable metal salts containing oxygen are, for example, those in which the anion is selected from the group consisting of sulfates, hydroxides, phosphates, nitrates, iodates, bromates, carbonates, hydrates, acetates, citrates, oxalates and tartrates, as well as mixed forms thereof. Metal salts containing oxygen further comprise coordination complexes. A definition of coordination complexes is provided in, for example, The Handbook of Chemistry and Physics 56 Ed., Section B, Chapter 7 (197576).

Within the present context, the term "mixed forms" is intended to include combinations of the various anions as well as combinations with, for example, chlorides and sulfides.

Examples of metal salts containing oxygen according to the invention are aluminum hydroxide, aluminum phosphate, aluminum sulfate, aluminum acetate, potassium aluminum sulfate, calcium phosphate, calcium tartrate, Maalox (mixture of aluminum hydroxide and hydroxide magnesium), beryllium hydroxide, zinc hydroxide, zinc carbonate, zinc sulfate and barium sulfate.

Most preferred are aluminum hydroxide, aluminum phosphate, aluminum acetate, calcium phosphate, calcium tartrate and zinc sulfate.

The pI of the metal salt containing oxygen is usually in the range of 2-11. The pI for allergenic proteins is usually in the range of 4-9. Preferably, the allergen and the metal salt containing oxygen are selected so that the allergen pI is lower than the pI of the metal salt containing oxygen.

When, for example, aluminum hydroxide is used as an oxygen-containing metal salt, the concentration of aluminum hydroxide in the formulation is preferably 0.035-1,000 mg / ml, more preferably 0.10-100 mg / ml, more preferably 0.25-10 mg / ml and, most preferably, 0.5-5 mg / ml. For metal salts containing oxygen, the concentration of the metal salt is preferably 0.035-1,000 mg / ml, more preferably 0.35-100 mg / ml, more preferably 0.7-50 mg / ml and, most preferably 1.0-20 mg / ml. The concentration of allergen in the formulation is preferably 0.01-100 mg / ml, more preferably 0.1-10 mg / ml. The proportion between the oxygen-containing metal salt and the allergen is preferably 0.1 to 100, more preferably 1 to 20. The degree of allergen adsorbed in the oxygen-containing metal salt is normally 5 to 99. %, more preferably from 10 to 99% of the amount added. The adsorption of the allergen in the metal containing oxygen depends on the buffer system and the reaction conditions, including the temperature and reaction time, at which the adsorption takes place.

Oxygen-containing metal salts can be characterized by various physical-chemical parameters such as adsorption properties, solubility and dissolution, the ionic charge measured as the isoelectric point pI (pH at which the net charge of the substance is zero for the dissociable compound ), dissociation constants, complex coordination, electronic configurations, binding orbitals and anti-binding orbitals, deposit properties, adhesion properties, surface characteristics, particle characteristics and capacity to help.

It is believed that the biologically active substance is adsorbed (or coupled) to the metal salt that contains oxygen and this adsorption contributes to the efficacy of the vaccine. Several factors may be important or influence the adsorption between the active substance and the metal salt containing oxygen (see, for example, PM Callahan et al., Pharmaceutical Research Vol. 8, No. 7,851-858 (1991), and Vaccine Design The Subunit and Adjuvant Approach). These Factors include the pH, the duration of the adsorption reaction, the mixing conditions, the concentrations of the various components in the vaccines, the containers, the temperature, the storage, the buffer and the excipients. Furthermore, it has been found that the adsorption of the active substance can be influenced by the net / global charge of the metal salt and the load of the active substance, both pH dependent. An additional feature that is believed to be important is the solubility of metal salts that contain oxygen.

Another characteristic of the metal salts that contain oxygen is the protection of the active substance by maintaining the ideal pH for the active substance in the microenvironment, so that acid degradation is prevented, or by protecting the active substance from enzymatic degradation so that It allows the release of the substance.

Additionally, some metal salts containing oxygen have a buffer capacity. This may result in an in vivo microenvironment within the vaccine formulation, which protects the active substance from the degradable environment.

An additional feature of the metal salt (s) that contains oxygen is its ability to adhere to the mucous membrane. This is believed to increase the absorption of the allergen through the mucous membrane.

For several metal salts containing oxygen (e.g., Al (OH) 3, AlPO4, Ca3PO4), the particle size range is between 0.5 and 15 μm.

Definitions

The term "oromucosal administration" refers to a route of administration in which the dosage form is placed under the tongue or anywhere else in the oral cavity to allow the active ingredient to come into contact with the mucosa of the oral cavity. or the patient's pharynx in order to obtain a local or systemic effect of the active ingredient. An example of an oromucosal administration is sublingual administration.

The term "sublingual administration" refers to a route of administration in which a dosage form is placed under the tongue in order to obtain a local or systemic effect of the active ingredient.

The term "no dose increase" means that full doses are used from the first administration onwards, in which the expression "full dose" means the dose used in the continued treatment.

The term "liquid vaccine formulation" means any liquid or fluid formulation, including solutions, suspensions and gels with high and low viscosity.

The expression "SQ-u" means Standard Quality Unit. The SQ-u is determined according to the standardization procedure of ALK-Abelló A / S "biopower of SQ", in which 100,000 SQ units are equivalent to the standard subcutaneous maintenance dose. Normally, 1 mg of extract contains between 100,000 and 1,000,000 SQ units, depending on the source of the allergen from which they originate and the manufacturing procedure used. The precise amount of allergen can be determined by an immunoassay, that is, the total content of the main allergen and the total activity of the allergen.

The term "treat" means to cure partially or completely, relieve symptoms or inhibit the causes of symptoms.

The term "prevent" means any type of prophylactic treatment.

In the field of allergy extracts there is no accepted international standardization procedure. There are numerous different units of strength of the extract, that is, biopower. The procedures used and the units used normally measure the allergen content and biological activity. Examples thereof are SQ Units (Standardized Quality Units), BAU (Allergen Biological Units), UB (biological units), UM (mass units), UI (international units) and IR (reactivity index). Therefore, if extracts from sources other than those disclosed herein are used, they must be standardized against the extract disclosed in this document in order to determine their potency in SQ units or any of the units mentioned above. The subject matter is discussed in "Allergenic extracts", H. Ipsen et al., Chapter 20 in Allergy, principle and practice (Ed. S. Manning) 1993, Mosby-Year Book, St. Louis and Løwenstein H. (1980) Arb Paul Ehrlich Inst 75: 122.

The biopower, that is the allergenic activity in vivo, of a given extract depends on a number of factors, the most important being the content of the main allergens in the extract, which varies with the composition of the material from the biological source.

The amount of allergen extract in grams to be used to obtain a desired biopower varies with the type of extract in question and for a given type of extract the amount of the allergen extract varies from one batch to another with the actual biopower of the abstract.

For a given batch of extract, the amount of the allergen extract in grams to be used to obtain a desired biopower can be determined using the following procedure:

a) The biopower of various amounts of a reference extract is determined using one or more immunological tests in vivo to establish a relationship between the biopower and the amount of reference extract. Examples of the aforementioned immunological tests in vivo are the skin prick test (PPC), conjunctive provocation test (PPC), bronchial allergen exposure (EBA) and several clinical trials in which one or more allergy symptoms are monitored, see, for example, Haugaard et al., J Allergy Clin Immunol, Vol. 91, No. 3, p. 709-722, March 1993.

b) Based on the relationship established between biopower and the reference extract, the biopower of one or more relevant doses for use in the dosage forms of the invention is selected with due consideration of a balance of the factors of i) the effect of treating or relieving allergy symptoms, ii) the side effects recorded in in vivo immunological tests and iii) the variability of i) and ii) from one individual to another. Balancing is performed to obtain an adequate maximum therapeutic effect without experiencing an unacceptable level of side effects. The way to balance the factors is well known to those skilled in the art. The biopower of the one or more relevant doses found can be expressed in any available biopower unit, such as SQ units, BU units, IR units, IU, see above.

c) One or more standard biopower reference extracts are prepared from the reference extract and, if used, the biopotency unit values of the standard reference extracts are calculated based on the value of the biopower unit assigned to the one or more relevant doses, for example, a standard value for FDA BAUC can be taken as illustrated below.

d) For the standard reference extracts of each type of extract, a series of parameters is selected to evaluate the biopower of the extracts. Examples of such evaluation parameters are the total allergenic activity, the amount of major allergens defined and the overall molecular composition of the extract. Total allergenic activity can be measured using a competitive in vitro immunoassay, such as ELISA and MagicLite® luminescence immunoassay (LIA), using a mixture of standardized antibodies produced.

against the extract obtained using standard procedures, for example antibodies produced in mice or rabbits, or a set of sera from allergic patients. The content of the main allergens can be quantified by, for example, rocket immunoelectrophoresis (RIE). The overall molecular composition can be investigated using, for example, cross immunoelectrophoresis (CIE) and sodium polyacrylamidate decyl sulfate gel electrophoresis (SDS-PAGE).

e) For a given batch of unknown biopower extract (test extract), the amount of extract to be used to obtain a desired biopower level (effective dose for use in the solid dosage form in accordance with the present invention ) can be determined as follows. For each evaluation parameter selected, the test extract is compared with the standard reference extracts using the relevant measurement procedures as described above and based on the measurement results the amount of extract having the desired biopower is calculated.

SQ unit: The SQ unit is determined in accordance with the standardization procedure of ALK-Abelló A / S “biopower of SQ”, in which 100,000 SQ units are equivalent to the standard subcutaneous maintenance dose. Normally, 1 mg of extract contains between 100,000 and 1,000,000 SQ units, depending on the source of the allergen from which they originate and the manufacturing procedure used. The precise amount of allergen can be determined by an immunoassay, that is, the total content of the main allergen and the total activity of the allergen.

UTE stands for Specific Treatment Unit and UTE is an empirical unit based on the biological activity of the respective allergen extract used for allergy specific allergy vaccination. 1,000 UTE corresponds to the potency of the highest maintenance dose used in a liquid formulation for SLIT, in which the maintenance dose is the recommended dose in the specific allergy vaccination to obtain the lowest safety / efficacy ratio in the average population of allergic patients.

The BAU (biological allergen units) is the unit of biological potency determined in accordance with the FDA requirements for the allergen product described in "Quantitative determination of relative potency of allergenic extracts".

("Methods of the allergen products testing Laboratory" "ELISA competition assay". Page 15, # 49N-0012, FDA, October 1993). A dose of 100,000 SQ units containing grass extract is equivalent to a content of 2600-4700 BAU according to the previous procedure. Other extracts can also be evaluated according to the previous procedure.

Examples

Example 1: Sublingual immunotherapy (SLIT) (SLITone®) without dose increase - Introduction of a new treatment program

Several studies with sublingual immunotherapy (SLIT) have been carried out in recent years that have provided evidence of efficacy combined with a favorable safety profile (1).

In order for patients to obtain a high level of effect from a self-administered treatment such as SLITone®, compliance must be high (2). Since one of the cornerstones of compliance is comfort, it is relevant to improve this product feature. The excellent tolerance of SLIT has led to consider the possibility of eliminating the dose increase phase. This would improve patient comfort and, thus, compliance can be increased and potentially increase the treatment effect. This study was designed to assess the tolerability of SLITone® without increasing the dose in patients with mite allergy

or lawns.

Materials and procedures

Medicine

SLITone® (ALK-Abelló) is a single dose liquid formulation that contains a 0.2 ml solution containing an allergen dose of 200 UTE, in which the solution is 50% (v / v) glycerol and 50% ( v / v) of water.

Patients

A total of 135 patients were included - 66 patients allergic to grass and 69 to mites) aged between 7 and 55 years all with a diagnosis of moderate-severe rhinitis or rhinoconjunctivitis with / without asthma symptoms due to sensitivity to mites or lawns. The diagnosis was made by a skin puncture test (puncture test, ALK-Abelló, S.A., 100 BU / ml) positive and / or positive IgE (CAP ≥ pharmaceutical class 2). According to WHO recommendations (3), the trial excluded patients in whom immunotherapy treatment was contraindicated, allergen-sensitive patients other than those evaluated in the trial and those who had received previous immunotherapy.

Study design

The study was a randomized, multi-center, double-blind, placebo-controlled and parallel group study. The total duration was 90 days.

The patients were assigned to two groups. Group 1 (N = 69) received active treatment during the study. This included 10 days of dose increase (T1), 20 days of maintenance treatment (T2) and two consecutive 30-day periods (T3 and T4) in the maintenance treatment. Group 2 (N = 66) received a placebo dose increase during T1, maintenance with placebo during T2 and active treatment initiated at the beginning of T3 and active treatment continued until the end of the study (T4). Data were collected at baseline and at T1-T4. Each patient received a card in which all the clinical incidents related to each dose of treatment were recorded. The investigator noted the adverse events in the data collection notebooks.

The study was double blind and the blind did not open at any time until the end of the study. All patients signed an informed consent form before beginning their participation in the trial. The study was approved by all the Ethics Committees of the participating centers, as well as the Health Authorities.

Treatment

SLITone® (ALK-Abelló) was administered sublingually and is composed of an extract of mites (Dermatophagoides pteronyssinus or Dermatophagoides pteronyssinus + Dermatophagoides farinae) or an extract of a mixture of lawns (Dactylis glomerata, Festuca pratensne, Phycan pratensne, Phycan pratensne , Poa pratensis, Secale cereale). The treatment consisted of 10 days of dose increase with a multidose vial (starting with 1 drop and increasing to 10 drops) and a maintenance phase with single dose containers. Administration was performed once a day. The dose of the main allergens administered in each single dose container was 2 μg of the main allergen 5 (for lawns) and 0.8 / 0.4 μg of Der 1 / Der 2 (for mites).

The appearance, smell and taste of the placebo treatment were similar to those of the active treatment.

Statistics

Descriptive statistics was used. The description included a series of patients reporting adverse events (AA) (N), the percentage of patients experiencing SS (%) and the number of AA (E).

Results

Of the 135 patients included, 123 completed the study. The characteristics of the patients are shown in Table 1. The age of patients varied from 7 to 55 years with a mean age of 22 in both treatment groups.

In group 1, 36 patients received grass extract and 33 received mite extract compared to 33 who received grass extract and 33 who received mite extract in group 2. A total of 229 AA was reported; The investigator evaluated 157 AA (68 and 89 in groups 1 and 2, respectively) as related to the treatment and were included in the analysis. The AA reported with the most frequency (> 5% of patients in any group) related to the treatment were oral itching, ocular itching, rhinitis and sublingual edema (Table 2); In total, these accounted for 57.3% of all related AAs. The oral itching was the AA most frequently reported related to the treatment; 16 patients (23.2%) reported 28 events of oral itching in group 1 compared with 21 patients (31.8%) who reported 39 events of oral itching in group 2. Oral itching was the only AA reported by > 10% of patients in any group and as a total accounted for 42.7% of all events.

The total number of doses of SLIT administered was 6,258 and 6,081 in groups 1 and 2, respectively. The oral itch rate per dose administered per time (T1 - T4) is shown in Table 3.

The most frequent AAs related to treatment for patients � 14 years of age (children) and for patients> 14 years of age (adolescents and adults) are shown in Table 4.

A total of 5 patients withdrew due to adverse events. In group 1, three subjects withdrew due to headache in T1, asthma, rhinitis and pruritus in T1 and sublingual edema in T4, respectively. In group 2, two subjects withdrew due to dyspnea and cough in T2, and lingual and oral edema in T4, respectively.

Discussion

The purpose of this randomized, double-blind, placebo-controlled and parallel-group study was to investigate the tolerability of SLIT administered daily without an initial phase of dose increase. The results presented in this document indicate that SLITone® (lawns and mites) is well tolerated and that tolerance is not influenced by the omission of the dose increase phase. In general, the number of patients who report AA was slightly higher in group 2 (receiving a dose increase with placebo) compared to group 1 (receiving a dose increase of the active substance) and also the number of events. However, it fits

note that in group 2 a considerable number of events were reported during placebo treatment (T1 and T2). The most frequent AA reported was oral itching. Oral itching is an expected and well-known side effect of sublingual immunotherapy and has been reported to the same extent or more frequently by other authors (4-7).

The use of the dose increase in SLIT is empirical and based on tradition and probably adapted from the necessary stepwise increase in the dose used in subcutaneous immunotherapy. Data from previous clinical trials (4,6) and pharmacovigilance studies (7) indicate an excellent tolerance of SLIT, but it has not been until recently that the discussion of the impact of the dose increase phase on the tolerability The possible impact of the dose increase on SLIT is speculative. Assuming that the effect of the dose increase in SLIT is so that the patient can administer the maintenance dose in a safe way after the dose increase, the data presented in this document prove that this hypothesis is wrong. The number of patients in group 2 who reported oral itching in T3 (when active treatment was started as maintenance dose) was higher than in group 1 in T1, but this was similar to the number of patients in group 1 who reported oral itching in T2, at which time the hypothetized effect of the dose increase phase on the patient's tolerability gave a smaller number. The oral itch rate per administered dose also indicates that these events were reported with equal frequency in group 1 in T2 and in group 2 in T3- Additionally, when the first 30 days of active treatment in both groups are compared (T1 + T2 for group 1 and T3 for group 2), the cumulative rate of oral itching per administered dose was 0.83% and 0.74% for group 1 and group 2, respectively. The short duration of this study does not allow us to reach any firm conclusion about whether the notification of oral itching will decrease over time or not. However, the relatively few withdrawals observed indicate that patients did not consider the intensity or duration of oral itching annoying.

Sublingual edema was reported more frequently in group 2 than in group 1.

This type of event was reported in group 2 when the active treatment (T3 and T4) was administered and resolved within 1 hour to 3 days. One patient withdrew from the study due to this AA in T4 after a minimum of 30 days with active treatment. Sublingual edema was also reported in group 1 in T4. When oral itching was compared in children and adolescents and adults, it seems that oral itching is reported more frequently in children than in adolescents and adults. The reasons for this are not obvious, but it seems a subject for further research. However, the number withdrawn among children was not different from that of adolescents and adults. Additionally, withdrawals among children (N = 2) were not related to oral itching.

In conclusion, these study results indicate that SLITone® (lawns and mites) is well tolerated and that treatment can be started safely without increasing the dose.

References

(one)

Wilson DR, Torres LM, Durham SR. Sublingual immunotherapy for allergic rhinitis: systematic review and metaanalysis. Allergy 2005; 60 (1): 4-12.

(2)

 Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005; 353 (5): 487-497.

(3)

 Bousquet J, Lockey RF, Malling HJ. WHO Position Paper. Allergen immunotherapy: Therapeutic vaccines for allergic diseases. Allergy 1998; 53 (44): 1-42.

(4)

 Pajno GB, Morabito L, Barberio G, Parmiani S. Clinical and immunologic effects of long-term sublingual immunotherapy in asthmatic children sensitized to mites: a double-blind, placebo-controlled study. Allergy 2000; 55 (9): 842-849.

(5)

 Canonica GW, Passalacqua G. Noninjection routes for immunotherapy. J Allergy Clin Immunol 2003; 111 (3): 437

448

(6)

 Quirino T, lemoli E, Siciliani E, Parmiani S, Milazzo F. Sublingual versus injective immunotherapy in grass pollen allergic patients: a double blind (double dummy) study. Clin Exp Allergy 1996; 26 (11): 1253-1261.

(7)

 Di Rienzo V, Pagani A, Parmiani S, Passalacqua G, Canonica GW. Post-marketing surveillance study on the safety of sublingual immunotherapy in pediatric patients. Allergy 1999; 54 (10): 1110-1113.

Table 1: Patient characteristics

Total n = 135

Group 1 Group 2

N = 69

N = 66

Sex

 Male Female 38 (55%) 31 (45%) 31 (47%) 35 (53%)

Age (years)

Medium (SD) 22.6 (± 11.2) 22.1 (± 9.7)

≤ 14 years> 14 years

21 (30%) 48 (70%) 19 (29%) 47 (71%)

(continuation)

Total n = 135

Group 1 Group 2

N = 69

N = 66

Diagnosis

 Rhinitis Rhinitis + Asthma 33 (48%) 36 (52%) 32 (48%) 34 (52%)

Withdrawals

 Total 6 6

AA related

3 2

Table 2: Most frequent AA (> 5% in any group) related to treatment

n = 135

Group 1 Group 2

N = 69

N = 66

N (%) E

N (%) E

Oral itching

T1 T2 T3 T4 Total 4 (5.9%) 5 12 (18.2%) 13 5 (7.7%) 5 5 (7.8%) 5 13 (23.2%) 28 8 (12.1%) 8 5 (7.6%) 6 13 (20.6%) 15 9 (14.8%) 10 21 (31.8%) 39

Eye itching

T1 T2 T3 T4 Total 4 (5.9%) 4 1 (1.5%) 1 0 (0.0%) 0 0 (0.0%) 0 5 (7.2%) 5 1 (1.5%) 1 0 (0.0%) 0 1 (1.6%) 1 0 (0.0%) 0 1 (1.5%) 2

Rhinitis

T1 T2 1 (1.5%) 1 0 (0.0%) 0 1 (1.5%) 1 1 (1.5%) 3

T3 T4

1 (1.5%) 1 0 (0.0%) 0 0 (0.0%) 0 1 (1.6%) 1

Total

2 (2.9%) 2 4 (6.1%) 5

Sublingual edema

T1 T2 0 (0.0%) 0 0 (0.0%) 0 0 (0.0%) 0 0 (0.0%) 0

T3 T4

1 (1.5%) 1 1 (1.7%) 1 3 (4.8%) 3 4 (6.6%) 4

Total

1 (1.4%) 2 4 (6.1%) 7

The number of patients (N) who report the most frequent adverse events (by> 5% of patients in any group), the percentage of the population of the group (%), the number of events (E) and the time of the notification in both treatment groups. Group 1 received active treatment of T1-T4, group 2 received placebo during T1 and T2. The total number of patients is corrected for patients who repeatedly report the same type of adverse events.

Table 3. Rate of oral itching by administered dose (%) by notification time

Group 1

Group 2

Weather

 AND  Dose Rate (%) AND Dose Rate (%)

T1 T2 T3 T4 Total

5 13 5 5 28 875 1288 2039 2056 6258 0.57 1.01 0.25 0.24 0.45 8 6 15 10 39 811 1238 2027 2005 6081 0.99 0.48 0.74 0.50 0.64

E: Number of oral itching events

10 Rate of events per administered dose (%) in the most frequently reported adverse event (oral itching) at the time of notification.

Table 4. Number of patients with more frequently reported adverse events related to treatment by age

Group 1 Group 2

≤ 14 years N (%) N (%)

n = 21 n = 19 Oral itch 8 (38.1%) 8 (42.1%) Ocular itch 1 (4.8%) 1 (5.3%) Rhinitis 2 (9.5%) 3 (15, 8%) Sublingual edema 0 (0.0%) 2 (10.5%)

> 14 years n = 48 n = 47

Oral itching 8 (16.7%) 13 (27.7%) Eye itching 4 (8.3%) 0 (0.0%) Rhinitis 0 (0.0%) 1 (2.1%) Sublingual edema 1 (2.1%) 2 (4.3%)

Number of patients with the most frequently reported adverse event related to age treatment.

Claims (19)

one.

 An allergen for use in the prevention or treatment of allergy in a human subject by oromucose administration of a liquid vaccine formulation in a dosage regimen that does not include an increase in dose.

2.

The allergen for use according to claim 1, wherein the concentration of the main allergen in a single dose intended for daily administration is 0.05 to 50 μg, more preferably 0.05 to 30 μg, more preferably 0 , 06 to 25 μg, more preferably 0.07 to 20 μg, more preferably 0.08 μg to 15 μg, more preferably 0.09 μg to 10 μg and, most preferably, 0.1 μg to 7 μg

3.

The allergen for use according to claim 1 or 2, which is selected from the group consisting of a tree pollen allergen, a grass pollen allergen, a house dust mite allergen, a storage mite allergen, a weed allergen, a mold allergen, a cat allergen or a dog allergen.

Four.

 The allergen for use according to any of the preceding claims, wherein the oromucosal administration is sublingual administration.

5.

 The allergen for use according to any of the preceding claims, which is formulated with an enhancer.

6.

The allergen for use according to claim 5, wherein the enhancer is glycerol.

7.

 An allergen for use according to any of the preceding claims, wherein the vaccine further comprises an adjuvant selected from the group of metal salts containing oxygen.

8.

 An allergen for use according to claim 7, wherein the oxygen-containing metal salt is selected from the group consisting of aluminum hydroxide, aluminum phosphate and calcium phosphate.

9.

 An allergen for use according to claim 8, wherein the metal salt containing oxygen is aluminum hydroxide.

10.

 An allergen for use according to claim 9, wherein the concentration of the metal salt containing oxygen is 0.035-1000 mg / ml, more preferably 0.10-100 mg / ml, more preferably 0.25-10 mg / ml and, most preferably, 0.5-5 mg / ml.

eleven.

 The allergen for use according to claim 1, which is a tree pollen allergen, which is formulated together with glycerol and the oromucosal administration is sublingual administration.

12.

 The allergen for use according to claim 11, wherein the tree pollen allergen is a birch pollen allergen.

13.

 The allergen for use according to claim 1, which is a grass pollen allergen, which is formulated together with glycerol and the oromucosal administration is sublingual administration.

14.

 The allergen for use according to claim 1, which is a house dust mite allergen, which is formulated together with glycerol and oromucose administration is sublingual administration.

fifteen.

The allergen for use according to claim 1, wherein the allergen is allergen is a storage mite allergen, which is formulated together with glycerol and oromucosal administration is sublingual administration.

16.

 The allergen for use according to claim 1, which is a weed allergen, which is formulated together with glycerol and oromucosal administration is sublingual administration.

17.

 The allergen for use according to claim 1, which is a mold allergen, which is formulated together with glycerol and oromucosal administration is sublingual administration.

18.

 The allergen for use according to claim 1, which is a cat allergen, which is formulated together with glycerol and oromucosal administration is sublingual administration.

19.

 The allergen for use according to claim 1, which is a dog allergen, which is formulated together with glycerol and oromucosal administration is sublingual administration.