FI105389B - Procedure for monitoring the tolerance of levosimendan administration - Google Patents

Description

1 105389

METHOD FOR MONITORING THE PERMISSIBILITY OF LEVOSIMENDANAN DOSAGE

Engineering

The invention relates to a method for monitoring and / or evaluating the tolerability of levosimendan administration, especially oral administration, in patients. Levosimendan, (-) - [[4- (1,4) 5,6-tetrahydro-4-methyl-6-oxo-3-pyridazinyl) phenyl] hydrazono] -propanidinitrile, is useful in the treatment of congestive heart failure.

BACKGROUND OF THE INVENTION Levosimendan, which is the (-) enantiomer of [[4- (1,4,5,6-tetrahydro-4-methyl-6-oxo-3-pyridazinyl) phenyl] hydrazono] propanedonitrile, and a process for is described in EP 565546 B1. Levosimendan is effective in the treatment of heart failure and has a significant calcium dependent binding to troponin. Levosimendan can be represented by the formula: n.

\ 'H

NsC = N-N - // \ = o

c / ^ W / N - hiH

15 ^

The hemodynamic effects of levosimendan in man are described in Sundberg, S. et al., Am. J. Cardiol., 1995; 75: 1061-1066. The pharmacokinetics of levosimendan in man following intravenous and oral administration are described in Sandell, E.-P. et al., J. Cardiovasc. Pharmacol., 26 (Suppl.l), S57-S62, 1995. The use of levosi-20 mendane in the treatment of myocardial ischemia is described in WO 93/21921. The beneficial effects of levosimendan in heart failure patients have been confirmed in clinical trials.

Oral administration of levosimendan has proved difficult. In humans, the elimination half-life of levosimendan is short, about 1 hour. Thus, conventional conventional immediate release oral formulations should be administered repeatedly throughout the day. In addition, levosimendan is rapidly absorbed from the gastrointestinal tract. Therefore, with immediate release oral formulations, 2,105,389 high peak plasma levels of levosimendan are achieved rapidly and abruptly, typically within 1 hour. High plasma concentrations of levosimendan tend to increase the heart rate, which is an undesirable effect in patients with heart failure.

Compositions which release the drug over a prolonged period of time or exhibit many advantages over conventional immediate release compositions. Such advantages include: less variation in drug levels in plasma resulting in a steady therapeutic response, fewer administrations and fewer side effects.

However, attempts to administer levosimendan orally in sustained release formulations have been disappointing due to unexpected tolerability issues. Undesirable effects such as severe headaches, increased heart rate and palpitations are repeatedly observed in some patients. Tolerability varies greatly between individuals, making it difficult to find the right dose.

Thus, there is a need for methods of monitoring and / or assessing the tolerability of levosimendan administration, particularly oral administration, in patients.

Summary of the Invention

Levosimendan has been found to be prone to metabolism in the lower gastrointestinal tract, especially in the colon, by the action of intestinal bacteria. This metabolic pathway eventually results in the formation of an active metabolite of the upstream metabolism, (R) -N- [4- (1,4,5,6-tetrahydro-4-methyl-6-oxo-3-pyridazinyl) phenyl] acetamide (II). the elimination half-life is substantially longer than that of levosimendan. Accumulation of the active metabolite has been found to be the cause of tolerability problems associated with the oral administration of sustained release formulations of levosimendan. The discovery of the active metabolite and its formation pathway now makes it possible to use this metabolite as a tool for monitoring and / or evaluating the tolerability of levosimendan administration in patients.

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Brief Description of the Drawings Γ “.

Figure 1 shows a calibration sample of the active metabolite (II) from a volunteer as measured by liquid chromatography-tandem mass spectroscopy.

3, 105389

Figure 2 shows a post-dose plasma sample of active metabolite (II) from a volunteer as measured by liquid chromatography-tandem mass spectroscopy.

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Figure 3 shows the correlation of heart rate with plasma concentration (ng / ml) of metabolite (II) in patients with heart failure.

Detailed Description of the Invention

The invention provides a method for monitoring and / or evaluating the tolerability of levosimendan administration, particularly oral administration, in a patient comprising determining the concentration of metabolite (II) in a patient's plasma following administration of levosimendan.

There is a clear correlation between the plasma concentration of metabolite (II) and the occurrence of undesirable effects such as severe headache, increased heart rate and palpitations. For optimal treatment of levosimendan in patients with heart failure, the plasma concentration of the metabolite (II) should be less than 20 ng / ml, preferably less than 10 ng / ml.

Because of the slow accumulation of the active metabolite, the plasma concentration of the metabolite (II) is preferably determined at least 48 hours after levosimendan administration. Preferably, the plasma concentration of metabolite (II) is determined at steady state.

The method for monitoring and / or assessing the tolerability of levosimendan administration is particularly important when administering controlled / sustained release formulations of levosimendan.

Levosimendan may be administered monthly, weekly or daily or 25 times daily depending on the needs of the patient. The daily dose of levosimendan in man for oral administration is from about 0.1 to about 20 mg, typically from about 0.5 to about 10 mg, more typically from about 1 to about 4 mg, once daily or divided into multiple% administrations per day. The dose depends, for example, on the age of the patient, the weight of the patient and the state of health.

Preferably, levosimendan is administered daily 1 to 3 times daily.

During oral administration of levosimendan, the plasma concentration of metabolite (II) is determined at least 48 hours after levosimendan administration, and preferably after 4,105,389, when steady-state plasma levels of metabolite (Π) are reached. At the daily dose, steady state plasma levels of the metabolite (Π) are typically achieved within 7 to 14 days of the first dose. In heart failure patients with impaired renal function, plasma concentrations of metabolite (II) 5 can be significantly different between patients, regardless of levosimendan dose. Plasma levels of the metabolite (Π) are preferably monitored throughout the oral treatment period, e.g., by periodically sampling the patient, e.g. daily, weekly, biweekly or monthly. By monitoring plasma concentrations of metabolite (II), the correct dose can be adjusted on a patient-by-patient basis to minimize patient variability.

The plasma concentration of the active metabolite (II) can be determined by any method known in the art. Example 1 describes in detail an example of a method by which the plasma concentration of metabolite (II) can be determined.

EXAMPLE 1. Determination of Active Metabolite (II) in Human Plasma by Liquid Chromatography-Tandem Mass Spectroscopy

Preparation of calibration samples

The active metabolite (II) is added in 20 µl of phosphate buffer (pH 7.2) to 0.5 ml of analyte-free plasma. The amounts of analyte to be added are 0.100; 0.250; 0.500; 20 1.00; 2.50; 3.75; 5.00; 7.50 and 12.5 ng. After stirring the solution for 20 seconds and then standing for 10 min, 2500 µg of internal standard (R) -N- [4- (1,4,5,6-tetrahydro-4-ethyl-6-oxo-3- pyridazinyl) phenyl] acetamide in 20 µl of phosphate buffer (pH 7.2). The mixture is stirred for 1 min and left to stand for 15 min. Calibration samples are alkalized with 50 µl of 0.1 M sodium hydroxide and mixed for 20 to 25 seconds. Extract the calibration samples with 5 ml of ethyl acetate: hexane (8: 2).

stirring for 3 min. After centrifugation for 7 Miri, the organic layer is separated and concentrated at 40 ° C using a TurboVap evaporator. After the calibration samples have dried, add 200 μΐ of ethyl acetate: hexane (8: 2), stir for 1 min, and concentrate at 40 ° C using a TurboVap evaporator. Thereafter, additional T

30 μl methanol-2 mM ammonium acetate (1: 1), the calibration samples are mixed for 1 min and left to stand for 5 min. After centrifugation (7 min), the supernatant is transferred to an unused aero-conical flask for liquid chromatography-tandem mass spectroscopy.

105389 Preparation of Samples Samples are prepared as above except that the first buffer addition does not contain analyte.

Liquid Chromatography-Tandem Mass Spectrometry Analyzes were performed using a PE Sciex API 300 triple quadrupole mass spectrometer equipped with a heated nebulizer interface. The liquid chromatograph (HPLC) used was Hewlett-Packard HP 1090L. The column used was a LiChrosorb RP-18 reverse phase column (250 x 4 mm inner diameter, 10 µm particle size, E. Merck). The running solution was methanol-2mM ammonium acetate pH 5 (60:40).

10 Flow rate 1 ml / min. 100 μΐ of the extract was injected into the liquid chromatography column.

The flow from the liquid chromatography to the mass spectrometer was not split. The discharge needle current was set to 4 μ Al. The pressure of the nebulizer gas (nitrogen) was 5 bar. Interface heat was set at 500 ° C. The voltage of the Orifice plate was 25 V. Positive ions reached the mass analyzer.

Assays were performed using selected reaction monitor technology (SRM).

The first quadrupole of the mass spectrometer, Q1, was set to pass the protonated molecule m / z 246 of the active metabolite (II) and its internal standard protonated molecule m / z 260 into the collision chamber Q2. The impact of collisions results in the decomposition of the molecule in Q2. The daughter ions corresponding to the molecular ions, m / z 204 and m / z 218, were allowed to be monitored through Q3 20 quadrupole. The measurement time (dwell time) used for reaction monitoring was 200 ms and the pause time 100 ms. Measurements are made using the PE Sciex API 300 data system.

Quantification and calculation

The peak area ratios of analyte to internal standard are plotted against concentrations. Calibration curve equations and unknown sample concentrations are performed using the PE Sciex API 300 Data System and PE Sciex MacQuan 1.4. The limit of determination is 0.200 ng / ml. A calibration curve of the active metabolite (II) is prepared.

«Specificity The ionic products of the active metabolite (II) and the internal standard are monitored using selected reaction monitor technology. The method is specific for plasma 6105389 background. No interfering peaks were observed in the analyte-free plasma extracts. Figures 1 and 2 show a calibration plasma sample and a post-dose plasma sample from a volunteer.

5 EXAMPLE 2. Correlation of change in heart rate with plasma concentration of metabolite (II) in heart failure patients.

Levosimendan was administered orally (0; 0.25; 0.5; 1; 2 and 4 mg q.i.d) to patients with heart failure for 7 to 10 days. The plasma concentration of metabolite (II) and the change in heart rate were measured 4 hours after the last 10 doses. Correlation between mean heart rate change (AHR, beats / min) and metabolite (II) plasma concentration (ng / ml) after a 7-10 day treatment period is shown in Figure 3.

Claims (4)

7 105389 A method for monitoring and / or evaluating the tolerability of levosimendan administration in a patient comprising determining the metabolite (R) -N- [4- (1,4,5,6-tetrahydro-4-methyl-6-oxo-3-pyridazinyl) ) Phenyl] acetamide (II) concentration in the patient's plasma after administration of levosimendan. The method of claim 1, wherein the administration is oral. The method of claim 1 or 2, wherein the plasma concentration of metabolite (II) is determined at least 48 hours after levosimendan administration. The method according to any one of claims 1,2 or 3, wherein the determined plasma concentration of metabolite (II) is the steady state plasma level of metabolite (II). t 105389