JP2010501476A - Parathyroid hormone analogs and methods of use thereof - Google Patents

Abstract

The present invention relates to a novel method for treating patients with bone deficiency disorders. In general, the method involves a pharmaceutically acceptable comprising a parathyroid hormone (PTH) peptide analog at a daily dose sufficient to produce an effective pharmacokinetic profile and maintenance of adenylate cyclase activity. Including administering the formulation to a patient in need thereof and simultaneously reducing undesirable side effects. The present invention also relates to specific formulations of Ostabolin-C, including inhaled powders and stabilized formulations with improved bioavailability.

Description

(Field of Invention)
The present application relates to methods and compositions for treating a subject having a bone deficiency disorder. In general, the method involves a subject in need of a pharmaceutically acceptable formulation comprising a parathyroid hormone (PTH) peptide or analog at a dose sufficient to produce an effective pharmacokinetic profile. And reducing undesirable side effects at the same time. In addition, the dose can be optimized based on the weight, body surface area, body mass index (BMI), lean body mass or other body characteristics of the patient to be treated. This dose optimization approach applies to PTH peptides and analogs and other therapeutic agents as described herein.

(Background of the Invention)
Bone remodeling or turnover consists of two antagonisms: old bone degradation (resorption) by osteoclasts and new bone formation by osteoblasts. Bone loss occurs as part of the natural aging process. Calcium is constantly added to and removed from the bone. If calcium is removed faster than it is added, the bone becomes lighter, less dense, and more porous. This makes the bone more fragile and increases the risk of fracture.

  As existing bone breaks down faster than new bone is created, bone becomes thinner with age (called osteopenia). When this occurs, the bone loses minerals, weight (amount) and structure, making it weaker and more fragile. With further bone loss, osteopenia progresses to osteoporosis. Therefore, the thicker the bone, the longer it takes to develop osteoporosis. Osteoporosis can occur in men but is most common in women over 65 years of age.

  Osteoporosis often results in the physical and mental deterioration characteristics of idiopathic fractures of load bone and immobilization damage. In particular, postmenopausal osteoporosis is caused by the disappearance of estrogens that cause the promotion of bone turnover and is accompanied by an increased imbalance between old bone resorption and new bone formation. Osteoclasts, the cells that destroy old bones (resorption of bone), outweigh the osteoblasts, the cells that build new bones (form bones), so bone loss is reduced rather than stable bone mass Occurs. This promotion of bone loss through resorption without proper compensation by bone formation results in progressive thinning, increased porosity and loss of load bone.

  End stage renal disease is necessarily associated with a bone disease known as renal osteodystrophy (ROD). ROD can be present in a high rotation form characterized by high circulating concentrations of parathyroid hormone (PTH) and overactive bone tissue, often accompanied by cystic fibrotic osteoarthritis. Low-rotation type disease, also known as aplastic osteopathy, is characterized by normal or low circulating concentrations of PTH. Histologically, the bone surface is dormant with little or no cellular activity and osteomalacia may be present. The incidence of the disease is increased by aging, the presence of corticosteroid therapy, the presence of calcimimetic therapy, calcium-containing phosphorus adsorbents and high doses of vitamin D sterols. However, aplastic osteopathy is currently difficult to treat without leading to unacceptable serum calcium. There is therefore a need for effective therapies that are not always met.

  In the treatment of osteoporosis (which historically included increased dietary calcium, estrogen therapy and increased dose of vitamin D), human parathyroid hormone (hPTH) treatment builds bone and bone mass due to osteoporosis Used to compensate for the decrease. Parathyroid hormone is produced by the parathyroid gland and is involved in the regulation of blood calcium levels. It is a hypercalcemic hormone and increases blood calcium levels. PTH is a polypeptide, and the synthetic polypeptide can be synthesized by the method disclosed in Non-Patent Document 1, preferably by the method of Non-Patent Document 2 or the method modified by Non-Patent Document 3. Can be prepared. When serum calcium falls below the “normal” concentration, the parathyroid gland releases PTH, resulting in bone calcium resorption and increased intestinal calcium absorption and renal calcium resorption. The antagonist of PTH is calcitonin, which acts to reduce the concentration of circulating calcium. High concentrations of PTH can remove calcium from bone, but intermittent low doses can actually promote bone growth. For example, native hPTH- (1-84) and its fragments hPTH- (1-34) (as sold under the trade name FORTEO® by Eli Lilly and Co.) are useful for the treatment of osteoporosis. It is shown that. However, natural hPTH- (1-84) and hPTH- (1-34) fragments suffer from the disadvantage of activating bone resorption while at the same time promoting bone formation. As a result, hPTH- (1-34) is effective in reducing the frequency of fractures in trabecular bone (which constitutes the bone of the body axis skeleton and includes the rib cage, spine / skull and vertebra). The fracture reducing effect on (which helps protect against torsional loads, including for example hips and wrists) is significantly lower.

Erickson and Merrifield, The Proteins, Neuroth et al. (Ed.), Academic Press, New York, 1976, 257. Hodges et al., Peptide Research, 1, 19 (1988) Atherton, E .; And Sheppard, R .; C. , Solid Phase Peptide Synthesis, IRL Press, Oxford, 1989

  There remains a need for therapeutic approaches using suitable PTH analogs to restore bone in trabecular and cortical bone and increase bone mineral density in patients with osteoporosis and other bone degeneration / deficiency disorders. Furthermore, suitable PTH to restore bone and increase bone mineral density and formation without stimulating bone resorption in patients with osteoporosis and other bone degenerative disorders and without significantly increasing serum calcium levels There remains a need for therapeutic approaches using analogs.

(Summary of the Invention)
The present invention provides pharmaceutical compositions and formulations comprising a suitable PTH peptide or analog thereof for use in a method intended to treat a subject suffering from various bone degeneration or bone deficiency disorders. The PTH peptides or analogs described herein induce bone formation in trabecular and cortical bone, thereby increasing bone mineral density and restoring bone. Unexpectedly, the PTH peptides or analogs described herein induce bone formation while producing less bone resorption than known PTH analogs, and have a lower incidence and severity of hypercalcemia. Show.

  The PTH peptides or analogs disclosed herein are effective in reversing the effects of osteoporosis on cortical bone in animals when administered within a specific dose range. Correcting the imbalance between old cortical bone resorption and new cortical bone formation, these PTH peptides or analogs have been shown to reverse the effects of osteoporosis on bone. Thus, the methods described herein promote cortical bone growth in animals without significantly increasing cortical bone porosity.

  These PTH peptides or analogs also promote recovery from bone damage. Thus, administration of specific doses of the PTH peptides or analogs of the present invention restores osteoporotic cortical bone and promotes bone healing in a variety of situations such as fracture treatment.

  In one aspect, the invention provides a method of treating osteoporosis, treating fractures, inducing bone formation in trabecular and cortical bone, treating or preventing renal osteodystrophy (ROD) and related disorders, The method comprises administering to a subject in need a pharmaceutically acceptable formulation comprising a parathyroid hormone (PTH) peptide or analog, wherein the PTH peptide analog has a decrease in phospholipase C activity. Together with maintaining adenylate cyclase activity, the dose produces an effective pharmacokinetic profile and effective biological activity.

  Another embodiment treats osteoporosis, treats or prevents fractures, induces bone formation in trabecular and cortical bone, treats or prevents renal osteodystrophy (ROD) and related disorders, or PTH Provided is the use of a PTH peptide or analog of the invention for any other therapeutic use, in which case calcium monitoring is not required.

  Another embodiment treats osteoporosis, treats or prevents fractures, induces bone formation in trabecular and cortical bone, treats or prevents renal osteodystrophy (ROD) and related disorders, or PTH The use of the PTH peptide of the present invention for any other therapeutic use is provided, in which no warning is required regarding the formation of osteosarcoma, administration of the PTH peptide of the present invention compared to administration of Forteo Low osteosarcoma incidence.

  In another embodiment, the present invention provides an aqueous formulation of a therapeutically effective amount of a parathyroid hormone (PTH) peptide or analog in a unit dosage form in a daily dose range of 2-100 μg and a pharmaceutically acceptable dosage. A pharmaceutical formulation for subcutaneous administration comprising a dosage form, diluent or carrier or a combination thereof, wherein said PTH peptide or analog has reduced phospholipase-C activity, maintains adenylate cyclase activity, and Has an effective pharmacokinetic profile and effective biological activity. Other therapeutically effective amounts within the pharmaceutical formulation include a daily dose range of 0.5-50 μg for subcutaneous delivery of a formulation stabilized with propylene glycol and / or ethanol or 100-3, Includes a daily dose range of 000 μg as well as a weekly dose 3-7 times the daily dose. Other embodiments include any dose by any route of administration that produces an effective pharmacokinetic profile and effective biological activity.

  Another embodiment of the invention treats a bone deficiency disorder comprising a label or package insert containing a therapeutically effective amount of the above-described pharmaceutical composition and instructions for use housed in the device in one or more containers. It is a kit to do.

  A PTH analog optionally includes fewer than the first 34 amino acids at the N-terminus. The PTH peptide analogs of the invention have less than full activation of phospholipase-C as compared to full length PTH peptide or other PTH peptide analogs of 34 amino acid residues or longer, Maintains increased bone mineral density (BMD) at various sites in the body, causing less bone resorption and lower incidence or lower severity of hypercalcemia.

Specific embodiments of the PTH peptide analogs of the invention include the following: PTH- (1-31) NH ₂ , Ostabolin; PTH- (1-3O) NH ₂ ; PTH- (1-29) NH ₂ PTH- (1-28) NH ₂ ; Leu ²⁷ PTH- (1-31) NH ₂ ; Leu ²⁷ PTH- (1-30) NH ₂ ; Leu ²⁷ PTH- (1-29) NH ₂ ; Leu ²⁷ cyclo (22-26) PTH- (1-31) NH ₂ Ostabolin-C ™; Leu ²⁷ cyclo (22-26) PTH- (1-34) NH ₂ ; Leu ²⁷ cyclo (Lys ²⁶ -Asp ³⁰ ) PTH - (1-34) NH _2; cyclo ^{(Lys 27 -Asp 30) PTH- (} 1-34) NH 2; Leu 27 cyclo (22-26) PTH- (1-31) NH ; ^{Ala 27} or ^{Nle 27,} or ^{Tyr 27} or ^{Ile 27} cyclo _{(22-26) PTH- (1-31) NH} 2; Leu 27 cyclo _{(22-26) PTH- (1-32) NH} 2; Leu 27 cyclo ( 22-26) PTH- (1-31) OH; Leu ²⁷ cyclo (26-30) PTH- (1-31) NH ₂ ; Cys ²² Cys ²⁶ Leu ²⁷ cyclo (22-26) PTH- (1-31) ^{_{NH 2; Cys 22 Cys 26 Leu}} 27 cyclo (26-30) PTH- (1-31) NH 2; cyclo _{(27-30) PTH- (1-31) NH} 2; Leu 27 cyclo (22-26) PTH - (1-30) NH _2; cyclo (22-26) PTH- (1-31) NH 2; cyclo _{(22-26) PTH- (1-30) NH} 2; Leu 2 Cyclo _{(22-26) PTH- (1-29) NH} 2; Leu 27 cyclo ^{_{(22-26) PTH- (1-28) NH}} 2; Glu 17, Leu 27 cyclo (13-17) (22-26) PTH- (1-28) NH ₂ ; and Glu ¹⁷ , Leu ²⁷ cyclo (13-17) (22-26) PTH- (1-31) NH ₂ .

  Other embodiments of the invention include compositions and methods for treating bone deficiency disorders and reducing side effects associated with administration of parathyroid hormone, the methods comprising an effective pharmacokinetic profile and adenylate cyclase. Simultaneously administering a pharmaceutically acceptable formulation comprising a parathyroid hormone (PTH) peptide analog to a subject with bone deficiency disorder at a daily dose sufficient to cause maintenance of activity Including reducing side effects. Optionally, the PTH peptide analog can cause a decrease in phospholipase-C activity.

In another embodiment, the effective pharmacokinetic profile can be achieved by a variety of routes of administration using a variety of formulations, a) half-life of the PTH peptide analog from 2 minutes to 60 minutes; b) and from d) _{C max} of 10~400pg / ml the PTH peptide analogue of; exposure time of the PTH peptide analogue of 30 minutes to 4 hours; c) of the PTH peptide analogue of 2 minutes to 30 minutes _{T max} A pharmacokinetic parameter selected from the group consisting of: In a further embodiment, the half-life is 5-30 minutes, the exposure time is 1-2 hours, the T _max is 15-30 minutes, and the C _max is 50-200 pg / ml. is there.

  This pharmacokinetic profile can be oral, topical, transdermal, nasal, intrapulmonary, transcutaneous (if the skin is damaged by mechanical or energy means), rectal, buccal, trans It can be accomplished by any route of administration well known to those skilled in the art including vaginal, trans-transplant reservoir or parenteral. Parenteral includes subcutaneous, intravenous, intramuscular, intraperitoneal, intraarticular, intrasynovial, intrasternal, intrathecal, intrahepatic, intralesional and intracranial injection or infusion. More preferably, the route of administration is subcutaneous, transcutaneous, intranasal, transdermal, oral or inhalation.

  In further embodiments, undesirable side effects that are reduced include bone resorption, cold sensation, fatigue, malaise, loose stool, heat, hypogastric pain, injection site reaction, joint pain, injection site bleeding, throat pain, muscle spasm And abdominal pain. More specifically, the undesirable side effect to be reduced is selected from the group consisting of hypercalcemia, elevated mean serum calcium concentration, headache, nausea, back pain, dizziness and limb pain.

  The PTH peptides of the present invention can also be administered at various doses. Effective doses may vary depending on the type of PTH peptide or analog being administered and the route of administration. One skilled in the art can modify the dosage route or formulation by modifying the route of administration or formulation so that the dosage can produce a pharmacokinetic or biological profile similar to that which can result from the preferred dosage ranges described herein. Can be adjusted. Exemplary dosages are 2-100 μg daily dose for subcutaneous delivery of aqueous formulations, 0.5-50 μg daily dose for subcutaneous delivery of formulations stabilized with propylene glycol and / or ethanol. Including a daily dose of 100-3,000 μg for inhalation delivery and a weekly dose of 3-7 times the daily dose. Other suitable dosages include any dosage by any route of administration that produces a bioavailability or pharmacokinetic profile similar to that produced by the dosage ranges described above.

Preferred doses for subcutaneous delivery of aqueous formulations are 5-9 μg, 10-19 μg, 20-30 μg, 31-40 μg, 42-45 μg, 46-50 μg, more specifically 5 μg, 7.5 μg, 10 μg, Includes doses at 15 μg, 20 μg, 25 μg, 30 μg, 35 μg, 40 μg, 45 μg or 50 μg. Most preferred doses for subcutaneous delivery of aqueous formulations include 7.5, 15, 30 or 45 μg. The dose can also be calculated based on the size of the subject. Dose in μg is normalized to patient characteristics such as height, weight, body surface area, BMI, lean body mass, etc. by converting μg to μg / kg or μg / m ² or μg / ml Can be done.

  The PTH peptide of the present invention is used at a daily dose of 0.20 to 0.90 μg / kg, more preferably 0.30 to 0.70 μg / kg, and still more preferably 0.46 to 0.69 μg / kg. It can also be administered.

  Further embodiments of the invention include sequential therapy. One embodiment of such a treatment regimen begins treatment with a high dose of a suitable PTH peptide or analog, which may then be 1-12 months, but preferably 3-9 months, most preferably After a period of 4-8 months, switch to a lower dose that maintains bone formation at low levels but does not allow stimulation of bone resorption. Sequential therapy may begin treatment at a lower dose and then switch to a higher dose. Such sequential therapy can be administered at all doses disclosed herein.

  One suitable dosing regimen comprises administering an aqueous formulation of PTH peptide or analog by subcutaneous administration at a first daily dose of 35 μg to 100 μg, and then 2 μg to 35 μg after completion of the first phase. Administering a second dose of the PTH peptide analog of the second period. Another suitable dosing regimen comprises administering an aqueous formulation of a PTH peptide or analog by subcutaneous administration at a first daily dose of 2 μg to 35 μg, and then 35 μg to 100 μg after the end of the first phase. Administering a second dose of the PTH peptide analog of the second period. In addition, the PTH peptides of the present invention are administered by inhalation at the first and second daily doses of 100 μg to 2,000 μg or the first and second weekly doses 3-7 times greater than the daily dose Can be done. Similarly, doses for sequential therapy can be calculated for inhaled administration or formulations stabilized with propylene glycol or ethanol, or any other formulation administered by any route known in the art.

  Another embodiment of the invention is the administration of a dose to a patient based on the patient's weight, height, body surface area, BMI or other patient characteristics and / or manifestation of symptoms. This weight cut-off method provides a method of determining a therapeutically effective dose and maintaining a low incidence of side effects on the patient based on the patient's weight, body surface area or BMI. By giving the subject different doses based on the body weight or weight of the subject, the amount of drug exposure to the various subjects becomes more uniform. Dose selection based on patient weight, body surface area or BMI improves the overall efficacy and proportion of patients responding to that dose, and reduces the side effects of doses that result in high exposure to the patient. Improve the risk versus benefit profile of the peptides of the invention.

All of the osteoporosis therapeutic agents that have an outstanding effect of stimulating bone formation can be administered in a manner whose dosage is based on the patient's weight, height, body surface area, BMI or other body type characteristics of the patient. Examples of such therapeutic agents within the scope of the present invention include anti-sclerostin Mabs, inhibitors of negative regulators of the Wnt signaling pathway and activin receptor agonists. In addition, doses based on a subject's body weight, body surface area or BMI are effective for all therapeutic agents whose osteogenic effect is mediated by the effects of PTH on its receptors, including PTH, The full length (1-84) and fragments thereof, PTH analogs, PTHrP and PTHrP analogs are included. Specific PTH peptides that are more effective with doses based on patient weight, body surface area or BMI include, but are not limited to, full length PTH 1-84, PTH 1-34, PTH- (1-31) NH ₂ , Ostabolin; PTH- (1-3O) NH ₂ ; PTH- (1-29) NH ₂ ; PTH- (1-28) NH ₂ ; Leu ²⁷ PTH- (1-31) NH ₂ ; Leu ²⁷ PTH- (1-30 ) NH ₂ ; Leu ²⁷ PTH- (1-29) NH ₂ ; Leu ²⁷ cyclo (22-26) PTH- (1-31) NH ₂ Ostabolin-C ™; Leu ²⁷ cyclo (22-26) PTH- _(1-34) NH 2; ^{Leu 27} cyclo ^{(Lys 26 -Asp 30) PTH- (} 1-34) NH 2; cyclo ^{(Lys 27} -Asp 30) PTH- _1-34) NH 2; ^{Leu 27} cyclo _{(22-26) PTH- (1-31) NH} 2; Ala 27 or ^{Nle 27,} or ^{Tyr 27} or ^{Ile 27} cyclo (22-26) PTH- (1-31) NH ₂ ; Leu ²⁷ cyclo (22-26) PTH- (1-32) NH ₂ ; Leu ²⁷ cyclo (22-26) PTH- (1-31) OH; Leu ²⁷ cyclo (26-30) PTH- (1- ^{_{31) NH 2; Cys 22 Cys}} 26 Leu 27 cyclo ^{_{(22-26) PTH- (1-31) NH}} 2; Cys 22 Cys 26 Leu 27 cyclo (26-30) PTH- (1-31) NH 2; cyclo _{(27-30) PTH- (1-31) NH} 2; Leu 27 cyclo (22-26) PTH- (1-30) NH 2; cyclo (22-26) PTH- ( -31) NH _2; cyclo _{(22-26) PTH- (1-30) NH} 2; Leu 27 cyclo _{(22-26) PTH- (1-29) NH} 2; Leu 27 cyclo (22-26) PTH- (1-28) NH ₂ ; Glu ¹⁷ , Leu ²⁷ cyclo (13-17) (22-26) PTH- (1-28) NH ₂ ; and Glu ¹⁷ , Leu ²⁷ cyclo (13-17) (22-26) ) containing PTH- (1-31) NH _2.

  In addition, suitable examples of therapeutic agents that can be administered based on the patient's weight, body surface area or BMI include any agent with a narrow therapeutic window, more specifically hormonal therapy. Specific therapeutic agents also include calcium receptor antagonists that stimulate endogenous PTH production, such as those that act as agonists of the PTH receptor, including PTH, full length and fragments thereof, PTH analogs, PTHrP and its analogs are included. Administration of doses based on patient weight, body surface area or BMI can be used in a variety of indications including osteoporosis, fracture repair, renal bone disease, corticosteroid-induced osteoporosis, transplants and trabeculae and Induction of bone formation in cortical bone is included.

  The present invention also relates to specific formulations of Ostabolin-C, including inhaled powders and stabilized formulations with improved bioavailability. One such stabilized formulation includes Ostabolin-C, 40% ethanol and 60% water (pH 6.0-8.0), which is stable for at least 2 years at 5 ° C. Another formulation includes Ostabolin-C, 40% propylene glycol and 60% water (pH 6.0-8.0), which is stable for at least 2 years at 5 ° C. These formulations, alone or in combination, may also contain methionine, lipoic acid, sucrose and NaCl.

  In FIGS. 1 to 17, unless otherwise indicated, measurements after Ostabolin-C administration were performed after daily subcutaneous administration of the indicated dose of the 15 week course, and changes were measured compared to baseline. As used herein, baseline is an individual measurement of a patient prior to receiving treatment.

^{[Leu 27]} cyclo ^{[Glu 22 -Lys 26] -PTH- (} 1-31) receiving a pharmaceutical formulation containing -NH _2, shows the percent change in lumbar spine bone mineral density (BMD) in patients with moderate osteoporosis It is a bar graph figure. FIG. 4 is a graph showing the percent change in lumbar bone mineral density (BMD) in patients with moderate osteoporosis receiving a pharmaceutical formulation comprising hPTH- (1-34) teriparatide, Forteo®. ^{[Leu 27]} cyclo ^{[Glu 22 -Lys 26] -PTH- (} 1-31) receiving a pharmaceutical formulation containing -NH _2, shows the percent change in total hip mineral density (BMD) in patients with moderate osteoporosis It is a bar graph figure. ^{[Leu 27]} cyclo ^{[Glu 22 -Lys 26] -PTH- (} 1-31) receiving a pharmaceutical formulation containing -NH _2, percent change in femoral neck bone mineral density in patients with moderate osteoporosis (BMD) FIG. ^{[Leu 27]} cyclo ^{[Glu 22 -Lys 26] -PTH- (} 1-31) receiving a pharmaceutical formulation containing -NH _2, the percent change in trochanteric bone mineral density (BMD) in patients with moderate osteoporosis FIG. ^{[Leu 27]} cyclo ^{[Glu 22 -Lys 26] -PTH- (} 1-31) receiving a pharmaceutical formulation containing -NH _2,% of the distal radius bone mineral density in patients with moderate osteoporosis (BMD) It is a bar graph figure which shows a change. ^{[Leu 27]} cyclo ^{[Glu 22 -Lys 26] -PTH- (} 1-31) receiving a pharmaceutical formulation containing -NH _2, percent change of the radius midshaft bone mineral density in patients with moderate osteoporosis (BMD) FIG. ^{[Leu 27]} cyclo ^{[Glu 22 -Lys 26] -PTH- (} 1-31) receiving a pharmaceutical formulation containing -NH _2, in patients with moderate osteoporosis, I procollagen amino terminal is a bone formation marker It is a bar graph which shows the percent change of propeptide (P1NP). ^{[Leu 27]} cyclo ^{[Glu 22 -Lys 26] -PTH- (} 1-31) receiving a pharmaceutical formulation containing -NH _2, in patients with moderate osteoporosis shows the percent change in osteocalcin is a bone formation marker It is a bar graph figure. ^{[Leu 27]} cyclo ^{[Glu 22 -Lys 26] -PTH- (} 1-31) receiving a pharmaceutical formulation containing -NH _2, in patients with moderate osteoporosis, bone-specific alkaline phosphatase bone formation markers ( It is a bar graph which shows the percent change of (BSAP). ^{[Leu 27]} cyclo ^{[Glu 22 -Lys 26] -PTH- (} 1-31) -NH receiving a pharmaceutical formulation containing _2, in patients with moderate osteoporosis is the bone resorption marker N- telopeptide (NTx ) Is a bar graph showing the percent change. ^{[Leu 27]} cyclo ^{[Glu 22 -Lys 26] -PTH- (} 1-31) receiving a pharmaceutical formulation comprising a -NH _2, in patients with moderate osteoporosis, C-terminal, telopeptide which is a bone resorption marker It is a bar graph which shows the percent change of (CTx). FIG. 6 is a graph showing the percent change in bone formation and bone resorption markers in patients with moderate osteoporosis receiving a pharmaceutical formulation comprising rhPTH- (1-34), teriparatide, Forteo®. ^{[Leu 27]} cyclo ^{[Glu 22 -Lys 26] -PTH- (} 1-31) receiving a pharmaceutical formulation containing -NH _2, a bar graph showing the percentage of abnormal serum calcium concentrations in patients with moderate osteoporosis is there. Deal et al. (2005) J. MoI. Bone Min. Res. FIG. 20 is a slide diagram showing Forteo data derived from pages 20, 1905-1991. It is a slide figure which shows the effectiveness of Ostabolin-C and Forteo. It is a slide figure which shows the effectiveness of Ostabolin-C and Forteo. FIG. 2 is a graph showing the phase I pharmacokinetics of Ostabolin-C at different doses. FIG. 6 is a graph showing the pharmacokinetics of Ostabolin in female rats at different doses. It is a graph which shows the pharmacokinetics of Ostabolin in the monkey in a 6-week subcutaneous test. FIG. 6 is a graph showing the administration data of Ostabolin-C at 30 ug, including effects on lumbar spine, mid-radial shaft, hypercalcemia and anabolic window. FIG. 6 is a graph showing Ostabolin-C administration data at 45 ug, including effects on lumbar spine, mid-radial shaft, hypercalcemia and anabolic window. It is a graph which shows the data of the change (%) from the baseline of the lumbar vertebra BMD in 4 months by the Ostabolin-C exposure increase. Linear regression analysis assessing the full range of Ostabolin-C exposure, and% change from baseline in lumbar BMD at 4 and 12 months after exposure to increased Ostabolin-C exposure compared to placebo FIG. FIG. 6 is a graph showing the effect of 45 ug dose Ostabolin-C on lumbar spine BMD, change from baseline (sa) (%) at 4 and 12 months. Linear regression analysis assessing the full range of Ostabolin-C exposure and changes from baseline in P1NP and CTx at 4 and 12 months after exposure to increased Ostabolin-C exposure compared to placebo (% FIG. Linear regression analysis assessing the full range of Ostabolin-C exposure, and change from baseline in total hip BMD at 4 and 12 months after exposure to increased Ostabolin-C exposure compared to placebo (% FIG. Linear regression analysis to assess the full range of exposure of Ostabolin-C and change from baseline in serum calcium concentrations at 4 and 12 months after exposure to increased Ostabolin-C exposure compared to placebo (% FIG. Linear regression analysis to assess the full range of Ostabolin-C exposure, and% change from baseline in femoral neck BMD at 4 months after exposure to increased Ostabolin-C exposure compared to placebo. FIG. Linear regression analysis to assess the full range of Ostabolin-C exposure, as well as the percent change from baseline in mid-radial BMD at 12 months after exposure to increased Ostabolin-C exposure compared to placebo. FIG. FIG. 5 is a graph showing the development of hypercalcemia (at least one episode) after administration of Ostabolin-C at various doses. FIG. 5 is a graph showing the development of hypercalcemia (only one episode compared to two or more episodes) after administration of Ostabolin-C at various doses. FIG. 6 is a graph showing the exposure range of Ostabolin-C administered at 7.5, 20, 30, and 45 ug doses. FIG. 5 is a graph showing the exposure range of Ostabolin-C administered at 7.5, 20, 30 and 45 ug doses, overlaying the effects of dose optimization on exposure. It is a graph which shows the exposure range of Ostabolin-C administered to a woman and a man at 30 ug. Women are represented by solid lines and men are represented by dashed lines. The average weight of men was 82 kg, and the average weight of women was 64 kg. FIG. 6 is a graph showing the exposure range of Ostabolin-C administered to men and women using a weight cut-off of 68 kg. Women are represented by solid lines and men are represented by dashed lines. This graph shows that this weight cut-off gives men and women almost the same exposure. It is a graph which shows the incidence rate of the hypercalcemia in 4 months using a weight cut-off. The graph shows that the observed hypercalcemia (%) is less than 15% with a weight cut-off of about 68 kg. It is a graph which shows the incidence rate of the hypercalcemia at the time of 12 months using a body weight cut-off. It is a graph which shows the incidence rate of hypercalcemia of more than 1% at the time of 4 months using a weight cut-off. It is a graph which shows the incidence of hypercalcemia of more than 1% at the time of 12 months using a weight cut-off. It is a graph which shows the result of the weight cutoff change with respect to bone formation. It is a graph which shows the result of the weight cutoff change with respect to bone resorption. It is a graph which shows the result of the weight cutoff change with respect to a bone formation / resorption ratio. It is a graph which shows the incidence rate of the lumbar spine BMD at the time of 4 months to which a weight cut-off is applied. It is a graph which shows the incidence rate of the lumbar spine BMD at the time of 12 months to which a weight cut-off is applied. It is a graph which shows the incidence rate of the responder who applied the weight cut-off and whose lumbar vertebrae BMD is more than 3% in 4 months. It is a graph which shows the dissociation result of a weight cut-off by comparing a hypercalcemia and a lumbar BMD responder ratio. FIG. 4 is a graph showing the dissociation of BMD responders by comparing site-specific effects of weight cut-off changes. It is a graph which shows the comparison result of the weight cut-off by comparing the effect | action of the weight cut-off with respect to CTx and hypercalcemia. It is a graph which shows the comparison result of the body weight cutoff by comparing the effect | action of the body weight cutoff with respect to CTx and serum calcium. It is a graph which shows the comparison result of the weight cut-off by comparing the effect | action of the weight cut-off with respect to serum calcium and lumbar spine BMD. It is a graph which shows the incidence rate of the headache and nausea at the time of 4 months to which a weight cut-off was applied. It is a graph which shows the expression rate of all the hip joint BMD at the time of 4 months to which a weight cut-off was applied. It is a graph which shows the incidence rate of the total hip joint BMD at the time of 12 months to which a weight cut-off is applied. FIG. 4 is a graph showing the biological AUC (0-4) levels achieved by OCIP on the first day after Ostabolin-C inhalation administration. FIG. 2 is a graph showing the biological Cmax levels achieved by OCIP on the first day after Ostabolin-C inhalation administration. FIG. 3 is a graph showing the biological Tmax levels achieved by OCIP on the first day after Ostabolin-C inhalation administration. FIG. 6 is a graph showing the biological Cmax levels achieved by OCIP on days 1 and 7 after Ostabolin-C inhalation administration. FIG. 4 is a graph showing the biological AUC (0-4) levels achieved by OCIP on days 1 and 7 after Ostabolin-C inhalation administration. It is a graph which shows the average blood concentration of the 1st day of Ostabolin-C in pg / ml. It is a graph which shows the cAMP density | concentration in urine after Ostabolin-C inhalation administration. It is a graph which shows the cAMP density | concentration in urine after Ostabolin-C inhalation administration. It is a graph which shows the relationship between the raise of the cyclic | annular cAMP density | concentration after Ostabolin-C inhalation administration, and the increase in AUC (0-2) level. It is a graph which shows the relationship between the raise of the cyclic AMP density | concentration after inhalation administration of Ostabolin-C, and the increase in a Cmax level. It is a graph which shows the average change (%) of P1NP after Ostabolin-C inhalation administration. It is a graph which shows the average change (%) of osteocalcin after Ostabolin-C inhalation administration. It is a graph which shows the relationship between the increase in the P1NP level after Ostabolin-C inhalation administration, and the increase in an AUC (0-2) level. It is a graph which shows the average change (%) of CTx after Ostabolin-C inhalation administration. It is a graph which shows the average heart rate after Ostabolin-C inhalation administration. It is a graph which shows the average heart rate after Ostabolin-C inhalation administration. FIG. 5 is a graph showing the biological AUC (0-tz) levels achieved with various Ostabolin-C formulations after subcutaneous administration. FIG. 3 is a graph showing the biological Cmax levels achieved with various Ostabolin-C formulations after subcutaneous administration. FIG. 3 is a graph showing the biological AUC (0-tz) levels achieved with various Ostabolin-C formulations after intramuscular and intravenous administration. FIG. 3 is a graph showing the biological Cmax levels achieved with various Ostabolin-C formulations after intramuscular and intravenous administration. FIG. 2 is a graph showing plasma concentrations of various Ostabolin-C formulations in female rats after intravenous administration. It is a graph which shows the plasma concentration of various Ostabolin-C formulation in a female rat after subcutaneous administration. FIG. 2 is a graph showing the plasma concentrations of various Ostabolin-C formulations in female rats after intramuscular administration. FIG. 6 is a graph showing the effect of dose cutoff for Ostabolin-C compared to Forteo.

(Detailed description of the invention)
The present invention provides pharmaceutical compositions and formulations comprising suitable PTH peptide analogs for use in methods intended to treat patients suffering from various bone degeneration or bone deficiency disorders. The PTH peptide analog compounds described herein induce bone formation in trabecular and cortical bone, thereby increasing bone mineral density and restoring bone. Unexpectedly, the PTH peptide analogs described herein induce bone formation and result in less bone resorption than known PTH analogs, and exhibit a lower incidence and severity of hypercalcemia . In addition, the PTH peptides of the present invention provide a shorter PK profile, which maintains efficacy and reduces side effects.

  The present invention also provides dose optimization as a method of reducing the side effects associated with prior art PTHs. The peptides of the present invention can be administered to patients at various doses based on the particular patient's weight, height, size, body surface area or BMI and / or manifestation of symptoms. This weight, body surface area, or BMI cut-off method provides a method of determining a therapeutically effective dose and maintaining a low incidence of side effects on the patient based on the patient's weight, body surface area, or BMI. Doses that give high exposure to certain patients increase the likelihood of side effects, including hypercalcemia. In addition, the dose for a particular patient was too low in the situation for a patient with a particular body weight, body surface area or BMI that would have been able to tolerate higher doses of therapeutic agent. Lack of efficacy can be observed in some patients.

  Transient exposure to PTH receptor agonists produces an osteogenic response, while continuous exposure to some PTH receptor agonists produces a strong bone resorption effect. Even transient exposure to PTH receptor agonists, characterized by conventional subcutaneous injection, results in some degree of bone resorption stimulation, which is a detrimental clinical trial involving hypercalcemia and increased cortical porosity. Related to action. Altering drug delivery that shortens the duration of exposure to a PTH receptor agonist reduces the stimulation level of bone resorption for a given dose and maintains or increases bone formation levels, regardless of dose interval and route of administration Thus, the therapeutic range of the PTH receptor agonist is improved.

  The present invention relates to PTH analogs, including Ostabolin-C and related analogs disclosed herein, that have a shorter PK profile than conventional PTHs. Such PTHs reduce the stimulation level of bone resorption for a given dose equivalent and cause an expansion of the treatment area by maintaining or increasing bone formation levels.

  The present invention also relates to the reduction of undesirable side effects associated with the administration of PTH analogs because of the shorter PK profile. Undesirable side effects that can be reduced include bone resorption, cold sensation, fatigue, loose stool, hot sensation, lower abdominal pain, injection site reaction, joint pain, injection site bleeding, sore throat, muscle cramps and abdominal pain. More specifically, undesirable side effects that can be reduced include hypercalcemia, elevated mean serum calcium levels, headache, nausea, back pain, dizziness and limb pain.

  The present invention relates to a method for increasing bone toughness and / or stiffness in a patient and / or reducing fracture incidence by administering parathyroid hormone. The method may be used to increase toughness and / or stiffness at a latent or actual trauma site. In general, trauma includes fractures, surgical trauma, joint replacement, orthopedic procedures, and the like. In general, improving bone toughness and / or stiffness includes increasing cortical bone mineral density, increasing bone strength, increasing resistance to loading, and the like. In general, the reduction in fracture incidence includes the possibility of a patient fracture or a reduction in the actual fracture incidence compared to an untreated control population.

  The present invention increases the toughness and / or stiffness of bone, including trabecular and cortical bone, and / or reduces the incidence and / or severity of fractures by administering the parathyroid hormone described herein. Regarding the method. More particularly, the present invention relates to a method for increasing bone toughness or stiffness at a potential or actual trauma site. Improvements in bone toughness and / or stiffness can be manifested in a number of ways well known to those skilled in the art, such as increased bone mineral density, increased bone mineral content, increased work to failure. And so on. In one embodiment, the methods of the invention reduce the incidence or severity of spinal and / or non-vertebral fractures. The methods of the present invention can be used to reduce the risk of such fractures or to treat such fractures. In particular, the method of the present invention may reduce the incidence of spinal and / or non-vertebral fractures, reduce the severity of vertebral fractures, reduce the incidence of multiple vertebral fractures, and improve bone quality. it can.

The inventors have found that PTH peptide analogs that have reduced phospholipase C activity and maintain adenylate cyclase activity have bone bone doses of about 2 to about 100 μg / day without significantly increasing serum calcium levels. It has been found to be surprisingly useful in inducing bone formation in beams and cortical bone and producing less bone resorption than conventional PTH analogs. In general, the method provided by the present invention induces bone formation and results in less bone resorption and lower hypercalcemia compared to administration of PTH analogs 34 amino acid residues in length or longer. Is administered by administering a dose of PTH compound in an amount of about 2 to about 100 μg / day or a weekly dose 3-7 times greater than the daily dose to an animal in need thereof. The In addition, the PTH peptides of the present invention can be administered by inhalation at a daily dose of 100 μg to 2,000 μg.
The PTH peptide analogs of the present invention, alone or in combination with other bone strengthening agents, to treat any mammal, including humans and animals suffering from diseases, symptoms or conditions associated with bone deficiency Can be used. In one embodiment of the invention, the patient in need of increased bone formation is a human patient such as a man or woman. In a preferred embodiment, the patient is a postmenopausal woman.

(Definition)
The following definitions are provided to help the viewer. Unless defined otherwise, all technical terms, notations, and other scientific or medical terms or terminology used herein have the meaning commonly understood by one of ordinary skill in the chemical and medical arts. In some instances, terms with commonly understood meanings are defined herein for clarity and / or immediate reference, and the inclusion of such definitions herein is generally recognized in the art. Should not be construed as representing substantial differences in the definitions of terms as such may be understood.

  As used herein, “PTH peptide analogs” of the present invention are preferably, but not limited to, non-natural and can be obtained recombinantly or by peptide synthesis. The PTH analogs of the present invention have full-length PTH (1-84), 1-31 of human, rat, porcine or bovine PTH with human PTH activity as found in an ovariectomized osteoporotic rat model. And other fragments or fragment variants (Kimmel et al., Endocrinology, 1993, 32 (4): 1577). Human PTH activity includes the ability of PTH to increase trabecular and / or cortical bone growth. The PTH analogs of the present invention enhance AC activity when administered to cultured cells that contain or express a PTH receptor, such as osteoblasts or osteoclasts. The PTH analogs of the present invention have several additional functional activities as defined below.

  As used herein, a PTH peptide analog having “reduced phospholipase-C activity” is less than or equal to the full length PTH peptide or other PTH peptide analogs that are at least 34 amino acid residues long. The PTH peptide analog is cleaved or modified in some way to induce the activity of phospholipase-C.

  As used herein, a PTH peptide analog that results in “reduced bone resorption” is less bone compared to a full-length PTH peptide or other PTH peptide analogs that are at least 34 amino acid residues long. A PTH peptide analog that has been cleaved or modified in some manner to induce absorption.

  As used herein, PTH peptide analogs that produce “reduced levels of hypercalcemia” are compared to full-length PTH peptides or other PTH peptide analogs that are at least 34 amino acid residues long, A PTH peptide analog that has been cleaved or modified in some manner to cause a lower incidence of hypercalcemia or lower severity of hypercalcemia.

  As used herein, “treating” a medical condition or patient or “treating” a medical condition or patient refers to taking action to obtain a beneficial or desired result, including clinical results. For the purposes of the present invention, beneficial or desired clinical results include, but are not limited to, alleviation or amelioration of one or more diseases, symptoms or conditions associated with bone deficiency. Generally, such bone deficiency diseases, symptoms or conditions are treated by inducing bone formation as measured by an increase in bone mineral density ("BMD"). For example, symptoms of osteoporosis include back pain, reduced height and forward bending posture, spinal curvature (senile dorsum), or fractures that can occur with minor injuries (especially hip, spine or wrist). Paget's disease symptoms most commonly include bone pain. Other symptoms may include headache and hearing loss, neck pain, nerve compression, head circumference or spinal flexion, hip pain, articular cartilage damage (which can cause arthritis), and a barrel-shaped rib cage. Symptoms of osteoarthritis can include joint pain, range of motion limitation and instability, radiographic evidence of articular cartilage erosion, joint space narrowing, subchondral bone sclerosis, and osteophytes (bone processes) . Symptoms of rheumatoid arthritis include painful, swollen, tender and stiff joints on both sides of the body (symmetry), especially on the hands, wrists, elbows, feet, knees or neck. In approximately one third of patients with rheumatoid arthritis, rheumatoid nodules (bumps) that range from bean grains to moss balls develop. These nodules usually occur on the body pressure point, for example, the elbow, knuckles, spine and lower limb bones.

  As used herein, “reduction” of symptom (s) (and grammatical equivalents of this phrase) is a reduction in severity or frequency of symptom (s) or symptom (s). ) Means removal.

  As used herein, “administering” an agent or pharmaceutical composition or formulation described herein or “administering” an agent or pharmaceutical composition or formulation described herein includes direct administration, including self-administration. Includes indirect administration, including administration and the act of prescribing drugs. For example, as used herein, a physician instructing a patient to self-administer a drug and / or giving the patient a prescription for the drug is administering the drug to the patient.

  Various routes of administration can be used in accordance with the present invention. An effective amount of the peptides described herein can be administered parenterally, orally, by inhalation, topically, rectally, nasally, buccally, vaginally or via a transplant reservoir.

  In one preferred embodiment of the invention, an effective amount of the peptides described herein can be administered parenterally. The term “parenteral” as used herein refers to transdermal, transcutaneous, subcutaneous, intravenous, intramuscular, intraarticular, intrasynovial, intrasternal, needleless injection, Includes intrathecal, intrahepatic, intralesional and intracranial injection or infusion. More preferably, the route of administration is subcutaneous administration.

  As used herein, a “therapeutically effective amount” of a drug or pharmaceutical composition or formulation or agent described herein, when administered to a patient having a disease or condition, has a desired therapeutic effect, For example, an amount of a drug or agent that has alleviation, amelioration, alleviation or elimination of one or more symptoms of a disease or condition in a patient. A complete therapeutic effect does not necessarily result from a single dose administration, but can only occur after a series of doses. Thus, a therapeutically effective amount can be administered in one or more administrations.

  As used herein, a “prophylactically effective amount” of a drug or pharmaceutical composition or formulation or agent described herein, when administered to a patient, is intended for a prophylactic effect, such as a disease or condition. The amount of a drug or an agent having prevention or delay of the onset (or recurrence) of the disease, or reduction of the possibility of onset (or recurrence) of the disease or symptoms. A complete prophylactic effect does not necessarily result from administration of a single dose, but can only occur after administration of a series of doses. Accordingly, a prophylactically effective amount can be administered in one or more administrations.

  Administration of a bone strengthening agent “in combination with” a drug or pharmaceutical composition or formulation described herein may be performed in parallel (ie, administration of a drug and bone strengthening agent to a patient over a period of time, simultaneous administration (drug and bone strengthening). Agents are administered at about the same time, eg within about a few minutes to hours of each other) and co-administration (drug and bone strengthening agent combined or combined into a single dosage form suitable for oral or parenteral administration) Included).

  A “patient” is a mammal, preferably a human but an animal in need of veterinary treatment, such as companion animals (eg, dogs, cats, etc.), livestock (eg, cows, sheep, pigs, horses). Etc.) and experimental animals (eg, rats, mice, guinea pigs, etc.).

  It should be noted that references to numerical ranges throughout this specification are intended to encompass all numbers within the disclosure. Thus, for example, a presentation in the range of about 1% to about 50% is 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8% or 9%, 10%, 12%, 14%, 16%, 20%, 25%, 30%, 35%, 40%, 45% and 50% and, for example, 21.3%, 7.9% and 44.5%.

  The composition of the present invention may contain additional active ingredients. The selection is not limited, but can be selected for the desired combined effect. For example, active ingredients that can be added for complementary therapeutic effects include, but are not limited to, vitamin D and analogs, estrogens, calcitonin, bisphosphonates and mixtures thereof. A particularly desirable choice is calcitonin.

(Bone disorders and diseases)
(Bone deficiency)
In one aspect, the patient in need has bone deficiency, which means that the patient has less bone than desired, or the bone is less dense or less tough than desired. Bone deficiency can be local, such as caused by a fracture, or systemic, such as caused by osteoporosis. Bone deficiency can result from a bone remodeling disorder that results in a shift in the balance between bone formation and bone resorption, resulting in bone deficiency. Examples of such bone remodeling disorders include, for example, osteoporosis, Paget's disease, renal osteodystrophy, renal rickets, osteoarthritis, rheumatoid arthritis, achondroplasia, osteochodritis, accessory Hyperthyroidism, osteogenesis imperfecta, congenital hypophosphataseemia, fibromatous lesions, fibrous dysplasia, multiple myeloma, abnormal bone turnover, osteolytic bone Diseases and periodontal disease are included. Bone remodeling disorders include metabolic bone diseases characterized by disorders of organic matrix, bone mineralization, bone remodeling, endocrine, nutritional and other factors that regulate skeletal / mineral homeostasis. Such disorders can be hereditary or acquired and are generally systemic and affect the entire skeletal system.

  Thus, in one aspect, the human patient can have a bone remodeling disorder. Bone remodeling, as used herein, refers to the continuous rotation of bone matrix and minerals, with bone resorption by osteoclasts and bone formation by osteoblasts, to remove old bone and form new bone. The process of being done.

  Osteoporosis is a common bone remodeling disorder that is usually characterized by a decrease in bone density in mineralized bone, resulting in thinning of the trabecular bone and increased porosity of the bone cortex. Skeletal weakness caused by osteoporosis makes patients more susceptible to increased rates of bone pain and fractures. Progressive bone loss in this pathology can cause a maximum 50% reduction in the initial skeletal mass. Primary osteoporosis includes idiopathic osteoporosis that occurs in children or young adults with normal gonad function, and type I osteoporosis, also expressed as postmenopausal osteoporosis. Type II osteoporosis, which is senile osteoporosis, is primarily Occurs in the elderly. The causes of secondary osteoporosis are endocrine (eg, glucocorticoid hyperactivity, hyperparathyroidism, hypogonadism), drug-induced (eg, corticosteroids, heparin, tobacco) and many other ( For example, chronic renal failure, liver disease, and malabsorption syndrome osteoporosis).

  As used herein, the phrase “at risk of developing bone deficiency” is intended to encompass patients who have a tendency to develop above average bone loss. As an example, those prone to osteoporosis include postmenopausal women, elderly men (eg, those over 65 years old), and those who have been treated with drugs known to cause osteoporosis as a side effect (eg, steroid-induced Osteoporosis). Certain factors that can be used to identify those at risk of developing bone deficiency due to bone remodeling disorders such as osteoporosis are well known in the art. Risk factors for osteoporosis are known in the art and are associated with hypogonadal conditions, conditions that induce hypogonadism, diseases or drugs, and nutritional factors associated with osteoporosis (low), regardless of age. Calcium or Vitamin D is most common), smoking, alcohol, drugs associated with bone loss (eg glucocorticoids, thyroxine, heparin, lithium, anticonvulsants, etc.), loss of vision to facilitate falls, space travel , Immobilization, chronic hospitalization or bedrock, and other systemic diseases associated with an increased risk of osteoporosis.

  Signs of the presence of osteoporosis are known in the art and include x-ray evidence of at least one spinal compression fracture, low bone mass (typically at least one standard deviation below the mean youth normal), and And / or atraumatic fractures. Other important factors include family history, lifestyle, estrogen or androgen deficiency and negative calcium balance. Postmenopausal women are particularly at risk of developing osteoporosis. Hereinafter, references to the treatment of bone diseases shall include management and / or prevention, unless otherwise contextual.

(Bone trauma)
The methods of the present invention are beneficial to patients who may be suffering from or suffering from trauma to one or more bones. The method is beneficial to mammalian patients such as humans, horses, dogs and cats, especially humans. Bone trauma can be a problem for racehorses and dogs, as well as domestic pets. Humans can suffer from any of a variety of bone traumas resulting from, for example, an accident, medical intervention, disease or disorder. In the younger age, bone trauma may result from fractures, medical interventions to repair fractures, or repair of joints or connective tissue damaged by, for example, athletics. Associated with treatment for other types of bone trauma such as osteoporosis, degenerative bone disease (eg, arthritis or osteoarthritis), hip replacement or other systemic conditions (eg, glucocorticoid osteoporosis, burns or organ transplantation) Trauma resulting from secondary disease is most often found in the elderly.

  Osteoporosis can cause, for example, spinal and / or non-vertebral fractures. A vertebral fracture is a fracture that includes the vertebral column, and a non-vertebral fracture refers to any fracture that does not include the vertebral column. Non-vertebral fractures are more common than vertebral fractures, with an estimated 850,000 non-vertebral fractures occurring in the United States, compared to 700,000 vertebral fractures annually. Non-vertebral fractures include over 300,000 hip and 250,000 carpal fractures, plus 300,000 fractures at other non-vertebral sites. Other examples of non-vertebral fractures include lumbar fractures, distal forearm fractures, proximal humeral fractures, wrist fractures, radial fractures, ankle fractures, humeral fractures, radial fractures, foot fractures, pelvic fractures or these Is included.

  The methods of the present invention can be used to reduce the risk of such fractures or to treat such fractures. For example, increasing bone strength and / or stiffness in the lumbar region, spine, or both reduces the risk of fracture and promotes fracture healing. Typical women at risk for osteoporosis are postmenopausal women or premenopausal women with hypogonadism. Preferred patients are postmenopausal women and are independent of concurrent hormone replacement therapy (HRT), estrogen or equivalent therapy or anti-absorption therapy. The method of the present invention can benefit the patient at any stage of osteoporosis, but in particular at the early and advanced stages.

  The present invention provides a method that is particularly effective in preventing or reducing the occurrence of fractures in patients at risk for or at risk of developing osteoporosis. For example, the present invention can reduce the occurrence of vertebral and / or non-vertebral fractures, reduce the severity of vertebral fractures, reduce the occurrence of multiple vertebral fractures, and improve bone quality. In another embodiment, the methods of the present invention may be used in patients with low bone mass or past fractures at risk for future multiple skeletal fractures, for example, patients with skeletal osteoporosis may be rapidly progressing. Can be profitable.

  In addition, other patients may be at risk of bone trauma or may be suffering from bone trauma and can benefit from the methods of the present invention. For example, a wide variety of patients at risk for one or more of the above-mentioned fractures can expect surgery to produce bone trauma, or in abnormally low bone mass or poor bone structure or mineral-deficient skeletal sites Can undergo orthopedic procedures to manipulate bones. For example, functional recovery after surgery, eg, joint replacement (eg, knee or hip joint) or spinal fusion or other procedures that fix bone or skeleton may be improved by the methods of the invention. The methods of the present invention can also facilitate recovery from orthopedic procedures that manipulate bone at sites of abnormally low bone mass or poor bone structure, which can include surgical procedures including, for example, osteotomy. Bone separation, loss of bone structure, includes joint replacement procedures that require reconstruction by hip acetabulation and prevention of prosthetic slippage. Other patients suitable for the practice of the present invention include those suffering from hypoparathyroidism or kyphosis, which are associated with the progression of hypoparathyroidism or kyphosis, Or it can suffer trauma caused by it.

(Bone toughness and stiffness)
The method of the present invention reduces the risk of trauma or promotes recovery from trauma by increasing bone toughness, stiffness, or both. In general, bone toughness or stiffness is derived from the amount and strength of cortical bone and trabecular bone (cancellous bone). The methods of the present invention can provide a level of bone toughness, stiffness, amount and / or strength within or above the normal population. Preferably, the present invention provides an improved level relative to the level resulting from or creating a risk of trauma. An increase in toughness, stiffness, or both reduces the risk or likelihood of fractures compared to an untreated control population.

  Some properties of bone when improved confer increased bone toughness and / or stiffness. Such properties include bone mineral density (BMD), bone mineral content (BMC), activation frequency or bone formation rate, trabecular number, trabecular thickness, trabecular and other connectivity, periosteum and cortex Internal bone formation, cortical porosity, bone cross-sectional area and bone mass, resistance to loading and / or work to failure. An increase in one or more of these properties is a favorable outcome of the method of the present invention.

  Some properties of bone, such as reduced bone marrow space and elastic modulus, impart increased bone toughness and / or stiffness. Newer (higher toughness and stiffness) bones have crystallites that are generally smaller than those of older bones. Thus, generally, reducing the crystallite size of bone increases bone toughness and stiffness and reduces the onset of fractures. In addition, maturation of bone microcrystals can impart additional desired properties to the bone, including increased bone toughness and / or stiffness, and / or reduce the onset of fractures. . Reduction of one or more of these properties can be a favorable outcome of the method of the present invention.

  The method of the present invention is effective in increasing the toughness and / or stiffness of any bone of the plurality of bones. For example, the present invention provides bone toughness including hipbone such as the iliac bones, lower limb bones such as the femur, spinal bones such as the vertebrae, or arm derived bones such as the distal forearm bone or the proximal humerus. And / or rigidity can be increased. This increase in toughness and / or stiffness can be found throughout the bone, or can be localized in several parts of the bone. For example, the toughness and / or stiffness of the femur can be increased by increasing the toughness and / or stiffness of the femoral neck or femoral trochanter. Hip toughness and / or stiffness can be increased by increasing the toughness and / or stiffness of the iliac crest or iliac spine. Vertebral toughness and / or stiffness can be increased by increasing the toughness and / or stiffness of the pedicle, lamina or vertebral body. Advantageously, the action is on vertebrae in multiple parts of the spine, eg cervical, thoracic, lumbar, sacral and / or caudal vertebrae. The action is preferably on one or more middle thoracic vertebrae and / or upper lumbar vertebrae.

  An increase in toughness and / or stiffness can be found in each type of bone or primarily one type of bone. Bone types include cancellous (reticular, cord-like or lamellar) bone and dense (cortical or high density) bone and fracture callus. The method of the present invention preferably increases toughness and / or stiffness through its action on cancellous and cortical bone or cortical bone alone. The trabecular bone to which the connective tissue is attached can also be increased in toughness and / or rigidity by the method of the present invention. For example, it may be advantageous to provide additional toughness at the site of ligament, tendon and / or muscle attachment.

  In another aspect of the invention, increased toughness or stiffness can reduce the onset of fractures. In this aspect, an increase in toughness or stiffness is a decrease in the onset of vertebral fractures, a decrease in the onset of severe fractures, a decrease in the onset of moderate fractures, a decrease in the onset of non-vertebral fractures, a decrease in the onset of multiple fractures or those May be included.

  The methods of the invention can also be used to enhance bone formation in pathologies where bone deficiency is caused by factors other than bone remodeling disorders. Such bone deficiency is associated with fractures, bone trauma, trauma bone surgery (eg, bone grafting or bone fusion), post-arthroplasty, post osteoplasty, post dental surgery, bone chemotherapy and bone radiation therapy. Includes medical condition. Fractures include all types of microscopic and macroscopic fractures. Examples of fractures and / or injuries include exfoliation fractures, crush fractures, non-adhesive fractures, transverse fractures, oblique fractures, spiral fractures, segmental fractures, segmental gaps, dislocation fractures, inset fractures, young tree fractures in any bone of the patient, These include bulging fractures, fatigue fractures, intra-articular fractures (epiphyseal fractures), closed fractures (simple fractures), open fractures (complex fractures), bone voids and occult fractures.

  As noted above, a wide variety of bone diseases, such as any bone disease associated with a bone remodeling cycle, can be treated according to the present invention. Examples of such diseases include all forms of osteoporosis, osteomalacia and rickets. Of particular note is osteoporosis, particularly postmenopausal, male, post-transplantation, and steroid-induced osteoporosis. In addition, PTH peptide analogs find use as bone promoters and bone anabolic agents. Such use forms another aspect of the present invention.

(Parathyroid hormone analog)
As an active ingredient, the pharmaceutically acceptable composition or solution described herein is an ovariectomized osteoporotic rat model reported by human PTH or Kimmel et al., Endocrinology, 1993, 32 (4): 1577. Rat, porcine or bovine PTH full-length PTH (1-84), 1-31 and 1-34 fragments and other fragments or fragments containing substitutions, deletions or insertions having human PTH activity as found in May be incorporated. Human PTH activity includes the ability of PTH to increase trabecular and / or cortical bone growth. The PTH analogs of the present invention enhance AC activity when administered to cultured cells that contain or express a PTH receptor, such as osteoblasts or osteoclasts. The PTH analogs used in the present invention are natural or non-natural and desirably incorporate fewer residues than the first 34 N-terminal residues of PTH.

PTH acts through activation of two second messenger systems, G _s protein activated adenylate cyclase (AC) and G _q protein activated phospholipase C. The latter causes stimulation of membrane bound protein kinase Cs (PKC) activity. PKC activity has been shown to require PTH residues 29-32 (Joishomme et al. (1994) J. Bone Mineral Res. 9, (1179-1189). In increasing bone growth, ie in the treatment of osteoporosis. It has been determined that this useful effect is linked to the ability of the peptide sequence to increase AC activity.

The native PTH sequence and its 1-34 truncated form have been shown to have all of these activities. The hPTH- (1-34) sequence is
Ser Val Ser Glu Ile Gln Leu Met His Asn Leu Gly Lys His Leu Asn Ser Met Glu Arg Val Glu Trp Leu Arg Lys Lys H
It is.

AC activity has been shown to require the first few N-terminal residues of the molecule. Thus, in accordance with this embodiment of the invention, it is possible to remove those biological activities associated with PKC activity by deleting the selected terminal portion of the hPTH- (1-34) molecule. In one embodiment, it is desirable that these truncated analogs are in the form of carboxyl-terminated amides. Accordingly, one feature of the present invention is that the human parathyroid analog PTH (1-25) -NH ₂ , PTH (1-26) -NH ₂ , PTH (1-27) -NH ₂ , PTH (1-28 _{) -NH 2, PTH (1-29)} -NH 2, PTH (1-30) -NH 2, and include variants of PTH (1-31) -NH _2.

In accordance with another feature of the PTH analogs used in the present invention, it was surprisingly found that replacing Lys ₂₇ with Leu in the native hPTH sequence resulted in higher activity against AC stimulation. This analog also exhibits its maximum activity when in the form of a carboxyl-terminated amide. Therefore, another aspect of the present _invention, PTH analogs containing [Leu 27] -PTH- (1-25) from _{-NH 2 [Leu 27] -PTH- (} 1-31) all sequences up -NH ₂ Including use of the body.

In accordance with another feature of the invention, including, for example, the side chain of Glu22 and Lys26 or the coupling of side chains Lys26 and Asp30, Lys ₂₇ can be substituted with Leu or various other hydrophobic residues, and the C-terminal free amide Cyclization with a terminal or C-terminal free carboxyl terminus forms a lactam of the PTH analog. Such substitutions include ornithine, citrulline, alpha-aminobutyric acid or any linear or branched alpha-amino fatty acid having 2-10 carbons in the side chain, any of such analogs It has a polar group or a charged group at the end of the aliphatic chain. Examples of polar groups or charged groups include amino, carboxyl, acetamide, guanide and ureido. Ile, norleucine, Met and ornithine are assumed to be most active.

Thus, the PTH analogs of the invention can be characterized, for example, by lactam formation between residues Glu22 and Lys26, Ly26 and Asp30, or Glu22 and Lys27. The substitution of Lys ₂₇ to Leu results in a more hydrophobic residue on the hydrophobic face of the amphipathic helix. This resulted in increased adenylyl cyclase stimulating activity in a rat osteosarcoma (ROS) cell line containing the PTH receptor. One skilled in the art will appreciate that other such substitutions can result in analogs having the same or increased activity. These hydrophobic substitutions include residues such as Met or norleucine. The combined effect of substitution and any lactam formation is assumed to stabilize the alpha-helix, increase biological activity, and protect this molecular region from proteolysis. Furthermore, the presence of an amide at the C-terminus is assumed to protect the peptide from exo-type proteolysis (Leslie, FM and Goldstein, A. (1982) Neuropeptides 2, 185-196).

In a preferred embodiment of the invention, the peptide used in the disclosed method is PTH (1-31) -NH2 having the following sequence:
Ser-Val-Ser-Glu-Ile-Gln-Leu-Met-His-Asn-Leu-Gly-Lys-His-Leu-Asn-Ser-Met-Glu-Arg-Val-Glu-Trp-Leu-Arg- Lys-Xaa-Leu-Gln- Asp-Val-NH 2 ( SEQ ID NO: 2).

  Xaa is selected from the group consisting of Lys, Leu, Ile, Nle, and Met. In a preferred embodiment, Xaa is Lys (SEQ ID NO: 3). This embodiment is also referred to as OSTABOLIN.

In another preferred embodiment of the invention, the peptide used in the disclosed method is cyclo (22-26) PTH- (1-31)-cyclized in the form of a lactam between Glu ²² and Lys ^26. NH2 and has the following sequence:
Ser-Val-Ser-Glu-Ile-Gln-Leu-Met-His-Asn-Leu-Gly-Lys-His-Leu-Asn-Ser-Met-Glu-Arg-Val-Glu-Trp-Leu-Arg- Lys-Xaa-Leu-Gln-Asp-Val-Y (SEQ ID NO: 4).

Xaa is selected from the group consisting of Leu, Ile, Nle and Met, and Y is NH ₂ or OH. When Xaa is Leu and Y is NH ₂ (SEQ ID NO: 5), the PTH is also referred to as OSTABOLIN-C ™.

  Thus, the PTH analogs used in the present invention can be cyclized or linear and can optionally be amidated at the C-terminus. Alternatives in the form of PTH variants improve the stability of PTH against oxidation of 1-5 amino acid substitutions that improve the stability and half-life of PTH, for example methionine residues at positions 8 and / or 18. Incorporates substitutions with leucine or other hydrophobic amino acids, as well as substitutions of amino acids in the 25-27 region with trypsin-insensitive amino acids such as histidine or other amino acids that improve the stability of PTH against proteases. Other suitable forms of PTH include PTHrP, PTHrP (1-34), PTHrP (1-36) and analogs of PTH or PTHrP that activate the PTH1 receptor. These forms of PTH are encompassed by the term “parathyroid hormone analog” as used generically herein. The hormones are known recombinant or synthetic methods, such as US Pat. Nos. 4,086,196; 5,556,940; 5,955,425; 6,541,450; 6,316,410; and 6,110,892 (incorporated herein by reference).

Specific embodiments of the PTH peptide analogs of the invention include the following: PTH- (1-31) NH ₂ , Ostabolin; PTH- (1-30) NH ₂ ; PTH- (1-29) NH ^{_{2; PTH- (1-28) NH 2}} ; Leu 27 PTH- (1-31) NH 2; Leu 27 PTH- (1-30) NH 2; Leu 27 PTH- (1-29) NH 2; Leu 27 Cyclo (22-26) PTH- (1-31) NH ₂ Ostabolin-C ™; Leu ²⁷ cyclo (22-26) PTH- (1-34) NH ₂ ; Leu ²⁷ cyclo (Lys26-Asp30) PTH- (1-34) NH _2; cyclo (Lys27-Asp30) PTH- (1-34 ) NH 2; Leu 27 cyclo (22-26) PTH- (1-31) NH 2 Ala ²⁷ or Nle ²⁷ or Tyr ²⁷ or Ile ²⁷ cyclo (22-26) PTH- (1-31) NH ₂ ; Leu ²⁷ cyclo (22-26) PTH- (1-32) NH ₂ ; Leu ²⁷ cyclo ( 22-26) PTH- (1-31) OH; Leu ²⁷ cyclo (26-30) PTH- (1-31) NH ₂ ; Cys ²² Cys ²⁶ Leu ²⁷ cyclo (22-26) PTH- (1-31) ^{_{NH 2; Cys 22 Cys 26 Leu}} 27 cyclo (26-30) PTH- (1-31) NH 2; cyclo _{(27-30) PTH- (1-31) NH} 2; Leu 27 cyclo (22-26) PTH - (1-30) NH _2; cyclo (22-26) PTH- (1-31) NH 2; cyclo _{(22-26) PTH- (1-30) NH} 2; Leu 27 Cyclo _{(22-26) PTH- (1-29) NH} 2; Leu 27 cyclo ^{_{(22-26) PTH- (1-28) NH}} 2; Glu 17, Leu 27 cyclo (13-17) (22-26) PTH- (1-28) NH ₂ ; and Glu ¹⁷ , Leu ²⁷ cyclo (13-17) (22-26) PTH- (1-31) NH ₂ .

  In general, preferred embodiments of PTH peptide analogs are those that, when administered, result in decreased phospholipase-C activity, decreased bone resorption, and decreased levels of hypercalcemia. As defined in the Definitions section herein, “reduced phospholipase-C activity” refers to a sub-total phospholipase compared to a full-length PTH peptide or other PTH peptide analogs that are at least 34 amino acid residues long. A PTH peptide analog that has been cleaved or modified in some way to elicit the activity of -C. “Reduced bone resorption” refers to PTH that has been cleaved or modified in any way to cause less bone resorption compared to full-length PTH peptides or other PTH peptide analogs that are at least 34 amino acid residues long. Refers to peptide analogs. And “reduced levels of hypercalcemia” refers to a lower incidence of hypercalcemia or lower high calcium compared to full-length PTH peptides or other PTH peptide analogs that are at least 34 amino acid residues long. Refers to a PTH peptide analog that has been cleaved or modified in some manner to cause the severity of septicemia.

Preferred PTH analogs administered by the methods described herein are those sold under the trade name OSTABOLIN-C ™ by Zelos Therapeutics, Inc. As it improved by ^{[Leu 27]} cyclo ^{[Glu 22 -Lys 26] -PTH- (} 1-31) -NH 2 and a ^{[Leu 27] PTH- (1-31)} -NH 2. In another embodiment of the present invention, ^{[Leu 27]} cyclo ^{[Glu 22 -Lys 26] -PTH- (} 1-30) -NH 2 is used in the methods described herein. In another embodiment, the hormone may be a linear analog PTH (1-31) that has a free carboxyl terminus or may be amidated at the C-terminus. In yet another embodiment, the hormone may be PTH (1-30) or [Leu ²⁷ ] PTH- (1-30) -NH ₂ which has a free carboxyl terminus or may be amidated at the C-terminus. . Suitable stabilizing solutions of these and other PTH analogs that can be used in the methods of the present invention are US Pat. Nos. 5,556,940; 5,955,425; 6,541,450; 6,316,410; and 6,110,892 (incorporated herein by reference).

(Method of the present invention and drug useful in the method)
In general, the methods provided by the present invention require a daily or weekly dose of a PTH compound in an amount effective to induce bone formation and inhibit or reduce bone loss or bone resorption. By administering to the animal.

  One aspect of the present invention is to administer a pharmaceutically acceptable formulation comprising a PTH peptide analog to a patient in need at a daily subcutaneous dose of 2 μg to 100 μg or a weekly dose of 14 μg to 700 μg. To provide a method of treating osteoporosis, wherein the PTH peptide analog has reduced phospholipase-C activity but maintains adenylate cyclase activity. Exemplary doses include 0.5-50 μg daily dose for subcutaneous delivery of formulations stabilized with propylene glycol and / or ethanol, 100-3,000 μg daily dose for inhalation delivery and 1 Includes a weekly dose of 3-7 times the daily dose. Other suitable doses include any dose by any route of administration that produces a bioavailability or pharmacokinetic profile similar to that produced by the above dose ranges. In one embodiment, the patient is a human male or female. In a preferred embodiment, the woman is postmenopausal.

  In another embodiment, the osteoporosis is selected from the group consisting of advanced stage osteoporosis, hypogonadal osteoporosis, vertebral osteoporosis, transplant-induced osteoporosis and steroid-induced osteoporosis.

  Bone strengthening agents known in the art for increasing bone formation, bone density or bone mineralization or inhibiting bone resorption can be used in the methods and pharmaceutical compositions of the present invention. Also suitable bone strengthening agents are, for example, natural or synthetic hormones such as selective estrogen receptor modulators (SERMs), estrogens, androgens, calcitonin, prostaglandins and paratolumon; growth factors such as platelet derived growth factors, Insulin-like growth factor, transforming growth factor, epidermal growth factor, connective tissue growth factor and fibroblast growth factor; vitamins, in particular vitamin D; minerals such as calcium, aluminum, strontium, lanthanides (eg US Pat. No. 7 , 078,059 (incorporated herein by reference) and lanthanum (III) compounds) and fluorides; isoflavones such as ipriflavone; pravastatin, fluvastatin, simvastatin, donkey Statin drugs including tachin and atorvastatin; agonists or antagonists of receptors on the surface of osteoblasts and osteoclasts, including paratormon receptors, estrogen receptors and prostaglandin receptors; bisphosphonates and bone anabolic agents Those skilled in the art of osteogenesis recognize that In one embodiment, vitamin D, calcium or both are co-administered with the pharmaceutical formulation of the present invention.

  In general, preferred embodiments of PTH peptide analogs include those that when administered result in decreased phospholipase-C activity, decreased ability to stimulate bone resorption, and decreased levels of hypercalcemia. As defined in the Definitions section herein, “reduced phospholipase-C activity” refers to causing less than full phospholipase-C activity compared to full-length PTH peptide or other PTH peptide analogs. , Refers to PTH peptide analogs that are cleaved or modified in some manner. “Reduced bone resorption” refers to a PTH peptide analog that has been cleaved or modified in some manner to cause less bone resorption than full-length PTH peptide or other PTH peptide analogs. And “reduced levels of hypercalcemia” cause a lower incidence of hypercalcemia or lower severity of hypercalcemia compared to full-length PTH peptides or other PTH peptide analogs. Thus, it refers to a PTH peptide analog that has been cleaved or modified in some manner.

Preferred PTH analogs administered by the methods described herein are those sold under the trade name OSTABOLIN-C ™ by Zelos Therapeutics, Inc. As it improved by ^{[Leu 27]} cyclo ^{[Glu 22 -Lys 26] -PTH- (} 1-31) -NH 2 and Zelos Therapeutics under the trade name OSTABOLIN (TM), Inc. PTH- (1-31) -NH ₂ as modified by In another embodiment of the present invention, ^{[Leu 27]} cyclo ^{[Glu 22 -Lys 26] -PTH- (} 1-30) -NH 2 is used in the methods described herein. In another embodiment, the hormone may be a linear analog PTH (1-31) that has a free carboxyl terminus or may be amidated at the C-terminus. In yet another embodiment, the hormone has a free carboxyl terminus, or PTH that can be amidated at the C-terminus (1-30) or ^[Leu 27]-PTH (1-30) or an -NH ₂ . Suitable stabilizing solutions of these and other PTH analogs that can be used in the methods of the present invention are US Pat. Nos. 5,556,940; 5,955,425; 6,541,450; 6,316,410; and 6,110,892 (incorporated herein by reference).

  In addition, the pharmaceutical compositions and formulations described herein induce osteogenesis by stimulating osteoblast differentiation in trabecular and cortical bone at the doses and routes of administration described in detail below, while at the same time providing high calcium. It acts to reduce the onset of septicemia (ie blood calcium above normal levels).

  In another aspect of the invention, a method for treating a fracture in a patient is provided. A preferred method may comprise administering a pharmaceutically acceptable formulation of a PTH peptide analog to a patient in need at a daily dose of 30 μg for 3 months, wherein the PTH peptide analog is phospholipase C activity While maintaining adenylate cyclase activity, the PTH peptide analog induces bone formation. In another embodiment, the method comprises administering a pharmaceutically acceptable formulation of a PTH peptide analog to a patient in need at a daily subcutaneous dose of 30 μg to 45 μg for 1, 2 or 3 months. And the PTH peptide analog has reduced phospholipase C activity and maintains adenylate cyclase activity, the PTH peptide analog induces bone formation.

  The pharmaceutical formulations described herein can be used to promote fracture healing in any bone of the patient's skeleton. In a preferred embodiment, the pharmaceutical formulation of the present invention is used to heal fractures of the waist, forearm, upper arm, wrist, ribs, ankle joint, ribs, femur, tibia and foot. The fracture can be multiple types of fractures as described above, and healing can occur simultaneously in multiple bones that may be fractured.

  In another aspect, the present invention relates to trabecular and cortical as measured by elevated BMD by administering a daily dose of a pharmaceutically acceptable formulation of a PTH peptide analog to a patient in need thereof. Provided is a method for inducing bone formation in bone, wherein the peptide analog has reduced phospholipase C activity and maintains adenylate cyclase activity.

  In a preferred embodiment, the pharmaceutical formulation can be used to induce bone formation in the spine, skull, ribs, hips, ankles and wrists, but any bone of the patient's skeleton can form bone Can be induced. In another embodiment, after administration of the PTH pharmaceutical formulation of the present invention, the incidence in patient populations with serum calcium concentrations above normal is lower than that observed for conventional PTH peptide administration.

  In yet another aspect, the present invention treats renal osteodystrophy (ROD) and related disorders by administering to a patient in need thereof a daily dose of a pharmaceutically acceptable formulation of a PTH peptide analog. Alternatively, a method of prevention is provided, wherein the peptide analog has reduced phospholipase C activity and maintains adenylate cyclase activity.

  In one embodiment, the ROD-related disorder is cystic fibrotic osteomyelitis and aplastic osteopathy.

(Unexpected results)
The pharmaceutical compositions and formulations described herein induce osteogenesis by stimulating osteoblast differentiation in trabecular and cortical bone at the doses and routes of administration described in detail below, while at the same time osteoclast differentiation. And thus act to reduce or inhibit bone resorption. PTH analogs of less than 34 amino acids in length are preferred because these truncated forms maintain the positive effect of increased bone formation and minimize the negative effect of increased bone resorption. Minimizing bone resorption also causes a decrease in cortical porosity.

  Administration of the PTH analogs of the present invention at various doses has resulted in unexpectedly superior results compared to administration of conventional PTH analogs. The PTH analogs of the present invention, when administered over a 4 month course, are compared to prior art PTH analogs of at least 34 amino acid residues long administered over a course of at least 1 year and lumbar, hip, femoral neck and It has been shown to have a similar or better effect on trochanteric BMD elevation. For results of prior art PTH analogs, see Neer, N .; Eng. J. et al. Med Vol 344, no. 19, May 2001, pages 1434-1441. These unexpected results are described in detail in the examples and figures.

  Administration of the peptides of the present invention also has a positive effect on cortical bone, especially the carpal (distal radius and mid-diaphysis, FIGS. 6 and 7). Historically, PTH has been known to increase bone resorption, which increases cortical porosity, thus making it difficult for PTH to increase cortical bone BMD. The dosages and formulations of the present invention have a positive effect on cortical bone growth compared to placebo and teriparatide, Forteo®. This is an unprecedented finding and shows a statistically significant difference from placebo for 3 working doses.

  Administration of the PTHs of the present invention also has unexpected results for bone formation and bone resorption markers. Osteogenic markers include P1NP, osteocalcin and BSAP, and bone resorption markers include NTx and CTx. Compared to placebo, Ostabolin-C ™ has higher changes (%) in osteogenesis markers when administered at 15, 30 and 45 μg (FIGS. 8-10). When Ostabolin-C ™ is administered at 30 and 45 μg, there is a strong effect of increasing osteogenic markers. The bone resorption markers in FIGS. 11-13 have some increase in bone resorption after Ostabolin-C ™ administration, but this increase is less than the increase after administration of the prior art teriparatide, Forteo® PTH (Neer Et al. 2001).

  It has also been shown that administration of the PTH peptides of the present invention unexpectedly results in a much lower incidence and severity of hypercalcemia compared to PTHs known in the art. Hypercalcemia in patients receiving a PTH peptide is the expression of at least one serum calcium level in the patient above the upper limit of normal (2.64 mmol / L; 10.6 mg / dL) (Neer et al., 2001).

  Administration of Forteo® resulted in an increased level of onset of hypercalcemia compared to placebo. FDA approval of Forteo (R) is based on the outcome of 1637 postmenopausal women (with a history of vertebral fractures) using Forteo (R) at 20 or 40 [mu] g / day for an average of 19 months Met. Forteo® package insert (incorporated herein in its entirety) and Neer. In general, although the tolerability of the drug was high, hypercalcemia was observed at least once in 11% of patients in the 20 μg group and 28% of patients in the 40 μg group compared to 2% in the placebo group. In contrast, low dose administration (7.5, 15 and 30 μg) of the PTH peptides of the present invention resulted in a very slight increase in the development of hypercalcemia compared to placebo. As an example, hypercalcemia was observed at least once in 5% of the placebo group and 5% of the 15 μg dose group, and the hypercalcemia was not a net increase.

  Thus, administration of PTH analogs of the present invention at various doses yields the following unexpected results: 1) over a course of only 4 months compared to prior art PTH analogs administered over at least a year course Similar or greater effect on lumbar, hip, femoral neck and trochanteric BMD elevation when administered; 2) Cortical bone, whereas prior art PTH peptides resulted in decreased cortical BMD In particular, increased BMD in the carpals (distal radius and midshaft); and (3) Onset and severity of lower amounts of hypercalcemia compared to prior art PTH peptides.

  Since the PTH peptides of the present invention are anabolic agents that result in a much lower incidence and severity of hypercalcemia, they provide a substantial improvement over currently available therapies. Based on preclinical and clinical experiments to date, the PTH peptides of the present invention are safe and highly effective anabolic agents for treating osteoporosis without inducing hypercalcemia. Due to its reduced effect on bone resorption, the PTH peptides of the present invention also have an improved clinical profile with respect to their effect on bone quality.

  A decrease in bone resorption can be measured by a decrease in the level of bone resorption markers. Biochemical markers of bone turnover cannot indicate how much bone is present at any given time and therefore can diagnose osteoporosis or how severe the disease can be Biochemical markers, in conjunction with the pharmaceutical compositions and formulations of the present invention, (1) predict bone loss in menopausal and postmenopausal women, and (2) Can be used to monitor skeletal responses. Unlike bone mineral density (BMD) measurements, biochemical markers can detect rapid changes in bone turnover. Usually, BMD tests detect changes in bone density in years, but markers can detect changes in bone metabolism in weeks or months. Bone turnover can be assessed by measuring various biochemical markers. There are two basic types of markers: bone formation markers and bone resorption markers. In addition, these markers are group 2: markers that measure substances released by osteoblasts and osteoclasts, and substances that are produced during the formation or degradation of collagen, the main protein found in bone And can be classified as a marker. When bone remodeling occurs, these substances are released into the blood and eventually excreted in the urine. Many biochemical markers can be detected and measured in blood (serum) and urine.

  The most commonly used assay for bone formation is a serum test for bone-specific alkaline phosphatase (BSAP), osteocalcin and procollagen peptides, proteins produced by osteoblasts and released into the bloodstream during bone formation . Typically, bone resorption markers measure the degradation of the product of collagen, the main protein of bone. These include type I collagen cross-linked pyridinoline, deoxypyridinoline, urinary deoxypyridinoline (urinary DPD), N-telopeptide (NTX) and C-telopeptide (CTX).

  Early assays such as total alkaline phosphatase and hydroxyproline are still used to monitor metabolic bone diseases such as Paget's disease. However, these tests are sensitive enough to be used to monitor more subtle bone remodeling changes, which tend to occur in osteoporosis, as their levels tend to be in the normal range in patients with the disease is not.

  A further unexpected result is the lack of onset of osteosarcoma formation with long-term administration of the PTH peptides of the present invention. Prior art Forteo® includes a warning label in its packaging that Forteo® caused an increased incidence of osteosarcoma in rats. The label warns that patients with increased baseline risk for osteosarcoma should not be prescribed Forteo®. In contrast, the risk of developing osteosarcoma with long-term use of the PTH peptides of the present invention is minimal. The PTH peptides of the present invention may have no or less onset of osteosarcoma based on different sequences and different signal transduction compared to PTH (1-34). Phospholipase-C and downstream protein kinase C activity minimized by administration of the PTH peptides of the present invention may be involved in osteoblast growth.

  Another unexpected result with the PTH peptides of the present invention is that there is no need to monitor the serum calcium concentration of patients taking these peptides for the likelihood of developing hypercalcemia. The serum calcium concentration of patients taking prior art Forteo® is monitored through blood and / or urine samples during the course of treatment. The Forteo® package insert warns that administration of Forteo® may “aggravate hypercalcemia”. The use of Forteo® is not recommended for patients with high blood calcium (hypercalcemia), bone cancer or other bone diseases. In contrast, administration of the PTH peptide of the present invention results in a lower incidence of hypercalcemia compared to administration of Forteo®. Therefore, it can be said that calcium monitoring is not necessary for the administration of the PTH peptide of the present invention.

  Another unexpected result for the peptides of the present invention is the ability to adjust the dose administered to a patient based on the patient's weight, body surface area or BMI, and manifestation of symptoms. The patient weight, body surface area or BMI cut-off method provides a method of determining a therapeutically effective dose and maintaining a low incidence of side effects on the patient based on the patient weight, body surface area or BMI. Doses that give high exposure to certain patients increase the likelihood of side effects, including hypercalcemia. In addition, there may be a lack of efficacy in certain patients, particularly men, for patients with certain weights, body surface areas or BMIs that could be tolerated for higher doses of therapeutic agents. This is because the dose for that particular patient was too low in the situation.

All therapeutic agents for osteoporosis that have an outstanding effect of stimulating bone formation can be administered in a manner whose dosage is based on the patient's body weight, body surface area or BMI. Examples of such therapeutic agents within the scope of the present invention include anti-sclerostin Mabs, inhibitors of negative regulators of the Wnt signaling pathway and activin receptor agonists. In addition, doses based on patient body weight, body surface area or BMI are effective for all therapeutic agents whose osteogenic effect is mediated by the effects of PTH on its receptors, including PTH, complete Long and fragments thereof, PTH analogs, PTHrP and PTHrP analogs are included. Specific PTH peptides that are more effective with doses based on patient weight, body surface area or BMI include, but are not limited to, full length PTH 1-84, PTH 1-34, PTH- (1-31) NH ₂ , Ostabolin; PTH- (1-3O) NH ₂ ; PTH- (1-29) NH ₂ ; PTH- (1-28) NH ₂ ; Leu ²⁷ PTH- (1-31) NH ₂ ; Leu ²⁷ PTH- (1-30 ) NH ₂ ; Leu ²⁷ PTH- (1-29) NH ₂ ; Leu ²⁷ cyclo (22-26) PTH- (1-31) NH ₂ Ostabolin-C ™; Leu ²⁷ cyclo (22-26) PTH- _(1-34) NH 2; ^{Leu 27} cyclo ^{(Lys 26 -Asp 30) PTH- (} 1-34) NH 2; cyclo ^{(Lys 27} -Asp 30) PTH- _1-34) NH 2; ^{Leu 27} cyclo _{(22-26) PTH- (1-31) NH} 2; Ala 27 or ^{Nle 27,} or ^{Tyr 27} or ^{Ile 27} cyclo (22-26) PTH- (1-31) NH ₂ ; Leu ²⁷ cyclo (22-26) PTH- (1-32) NH ₂ ; Leu ²⁷ cyclo (22-26) PTH- (1-31) OH; Leu ²⁷ cyclo (26-30) PTH- (1- ^{_{31) NH 2; Cys 22 Cys}} 26 Leu 27 cyclo ^{_{(22-26) PTH- (1-31) NH}} 2; Cys 22 Cys 26 Leu 27 cyclo (26-30) PTH- (1-31) NH 2; cyclo _{(27-30) PTH- (1-31) NH} 2; Leu 27 cyclo (22-26) PTH- (1-30) NH 2; cyclo (22-26) PTH- ( -31) NH _2; cyclo _{(22-26) PTH- (1-30) NH} 2; Leu 27 cyclo _{(22-26) PTH- (1-29) NH} 2; Leu 27 cyclo (22-26) PTH- (1-28) NH ₂ ; Glu ¹⁷ , Leu ²⁷ cyclo (13-17) (22-26) PTH- (1-28) NH ₂ ; and Glu ¹⁷ , Leu ²⁷ cyclo (13-17) (22-26) ) containing PTH- (1-31) NH _2.

  In addition, preferred therapeutic agents that can be administered based on patient weight, body surface area or BMI include those that act as calcium receptor antagonists that stimulate endogenous PTH production, such as agonists of the PTH receptor. Included, including PTH, full length and fragments thereof, PTH analogs, PTHrP and analogs thereof. Administration of doses based on patient weight, body surface area or BMI can be used in a variety of indications including osteoporosis, fracture repair, renal bone disease, corticosteroid-induced osteoporosis, transplants and trabeculae and Induction of bone formation in cortical bone is included.

  By assessing the effectiveness of the dose range of the peptides of the present invention, low doses can be ruled out to reduce the number of non-responders, and high doses that usually raise safety concerns can also be ruled out. The selection of multiple effective doses improves the overall efficacy and the proportion of patients responding to that dose, and reduces the risk versus benefit of the peptides of the invention by reducing the side effects of doses that result in high exposure to patients. Improve sex profile.

(Improved PK profile)
Administration of the PTH analogs of the present invention resulted in shorter (sharp peaks) PK profiles compared to known PK profiles. This shorter PK profile will maintain the positive effects of PTH treatment while reducing side effects. Preferred PK parameters within the scope of the present invention are: PTH peptide analog half-life of 2 minutes to 60 minutes; PTH peptide analog exposure time of 30 minutes to 4 hours; PTH peptide analog of 2 minutes to 30 minutes Body Tmax; and 10 to 400 pg / ml PTH peptide analog Cmax. More preferred PK ranges include a half-life of 15-30 minutes, an exposure time of 1-2 hours, a Tmax of 15-30 minutes and a Cmax of 50-200 pg / ml.

  Details of the pharmacokinetics within the scope of the present invention are shown in the figures for human and animal administration. For PTH administered to humans, Ostabolin-C was administered in a liquid formulation (pH 3-5) containing a buffer, polyol and stabilizer. Another embodiment of PTHs that produce a similar pharmacokinetic profile may also be administered. For PTH administered to animals, Ostabolin-C was formulated in acidified saline and adjusted with phosphoric acid to pH 7.2 +/− 0.4. Pharmacokinetics using the Ostabolin-C PTH formulation described above are shown in FIGS.

(Pharmaceutical composition / formulation, dosing and administration)
A variety of PTH peptide analog compounds may be used in the methods and compositions of the invention. In general, preferred embodiments of PTH peptide analogs include those that, when administered, result in decreased phospholipase-C activity, decreased bone resorption, and decreased levels of hypercalcemia. As defined in the Definitions section herein, “reduced phospholipase-C activity” refers to a sub-total phospholipase compared to a full-length PTH peptide or other PTH peptide analogs that are at least 34 amino acid residues long. A PTH peptide analog that has been cleaved or modified in some way to elicit the activity of -C. “Reduced bone resorption” refers to PTH that has been cleaved or modified in any way to cause less bone resorption compared to full-length PTH peptide or other PTH peptide analogs that are at least 34 amino acid residues long. Refers to peptide analogs. And “reduced levels of hypercalcemia” means a lower incidence of hypocalcemia or lower high calcium compared to full-length PTH peptides or other PTH peptide analogs that are at least 34 amino acid residues long. Refers to a PTH peptide analog that has been cleaved or modified in some manner to cause the severity of septicemia.

Preferred PTH analogs administered by the methods described herein are those sold under the trade name OSTABOLIN-C ™ by Zelos Therapeutics, Inc. As it improved by ^{[Leu 27]} cyclo ^{[Glu 22 -Lys 26] -PTH- (} 1-31) -NH 2 and Zelos Therapeutics under the trade name OSTABOLIN (TM), Inc. PTH- (1-31) -NH ₂ as modified by In another embodiment of the present invention, ^{[Leu 27]} cyclo ^{[Glu 22 -Lys 26] -PTH- (} 1-30) -NH 2 is used in the methods described herein. In another embodiment, the hormone may be a linear analog PTH (1-31) that has a free carboxyl terminus or may be amidated at the C-terminus. In yet another embodiment, the hormone may be PTH (1-30) or [Leu ²⁷ ] PTH- (1-30) -NH ₂ which has a free carboxyl terminus or may be amidated at the C-terminus. . Suitable stabilization solutions of PTH peptide analogs that can be used in the methods of the present invention are US Pat. Nos. 5,556,940; 5,955,425; 6,541,450; 6,316. 410; and 6,110,892 (incorporated herein by reference).

(Dose)
An effective amount of a PTH peptide analog for use in the present invention is an amount that provides a desired benefit or therapeutic effect after administration according to a predetermined regimen. Effective doses may vary according to the formulation type of PTH peptide or analog administered and the route of administration. Those skilled in the art will adjust the dosage by altering the route of administration or formulation so that the dosage can produce a pharmacokinetic or biological profile similar to that resulting from the preferred dosage ranges described herein. can do. Exemplary doses are 2-100 μg daily dose for subcutaneous delivery of aqueous formulations, 0.5-50 μg daily dose for subcutaneous delivery of formulations stabilized with propylene glycol and / or ethanol, Includes a daily dose of 100-3,000 μg for inhalation delivery and a weekly dose of 3-7 times the daily dose. Other suitable doses include any dose by any route of administration that produces a bioavailability or pharmacokinetic profile similar to that produced by the above dose ranges.

  A non-limiting example of an effective amount of a PTH analog administered subcutaneously in an aqueous formulation is about 2 μg / day to about 100 μg / day, preferably about 5 μg / day to about 45 μg / day, more preferably about 7. 5 μg / day to about 20 μg / day, more preferably about 20 μg / day to about 30 μg / day, more preferably about 30 μg / day to about 45 μg / day, more preferably about 5,7.5,10, It can range from 15, 20, 25, 30, 35, 40, 45 or 50 μg / day. Further preferred doses are 5, 6, 7, 7.5, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44 or 45 μg / day. Further examples of effective amounts of PTH analog administered subcutaneously in an aqueous formulation are about 14 μg / week to about 420 μg / week, preferably about 35 μg / week to about 280 μg / week, more preferably about 70 μg / week. Weeks to about 140 μg / week, more preferably about 140 μg / week to about 210 μg / week, more preferably 35, 70, 105, 140, 175, 205 or 245 μg / week. The dose can be administered daily, every 2 days, every 3 days, every 4 days, every 5 days, every 6 days, or every 7 days (once / week). These doses can also be adjusted to correct for bioavailability. Also, the dose can be measured in mmol taking into account the molecular weight of the PTH peptide used.

  Also, the dosage can be calculated based on the size of the patient. The dose in μg is determined by converting the μg to μg / kg or μg / m 2 or μg / ml, or by other suitable conversions known in the art, such as patient characteristics such as height, weight, body Normalized to surface area, BMI, lean body mass, etc. In a preferred embodiment, the dose can also be administered subcutaneously on a μg / kg basis. This calculation is performed as follows using 30 μg and 45 μg as exemplary doses. Based on the assumption that the average weight of a human patient is about 65 kg, the 30 μg and 45 μg doses are converted to 0.46 μg / kg and 0.69 μg / kg. To convert μg to μg / kg, the μg dose is divided by 65 kg to obtain a μg / kg dose (dose / body weight = μg / kg). At a dose of 30 μg, 30 μg per 65 kg of human average body weight results in a μg / kg dose of approximately 0.46 μg / kg. At 45 μg, 45 μg per 65 kg average human body weight results in a μg / kg dose of about 0.69 μg / kg. Doses within the scope of the present invention for subcutaneous delivery of aqueous formulations are 0.20-0.90 μg / kg, more preferably 0.30-0.70 μg / kg, even more preferably 0.46-0. Contains 69 μg / kg. A dose within the preferred range maximizes the effectiveness of PTH therapy while reducing side effects.

  For inhalation therapy, the PTH peptide or analog can be administered at a dose of 100 μg to 3,000 μg / day. More specifically, the PTH peptide or analog is 100 μg, 200 μg, 300 μg, 400 μg, 500 μg, 600 μg, 700 μg, 800 μg, 900 μg, 1000 μg, 1100 μg, 1200 μg, 1300 μg, 1400 μg, 1500 μg, 1600 μg, 1700 μg, 1800 μg, 1900 μg , 2000 μg, 2100 μg, 2200 μg, 2300 μg, 2400 μg, 2500 μg, 2600 μg, 2700 μg, 2800 μg, 2900 μg or 3000 μg / day. Inhalation therapy can also be administered weekly at 3-7 times the daily dose.

  To determine MTD in postmenopausal women, compare its PK profile with Phase II subcutaneous doses, and assess bioactivity with respect to biomarkers of cAMP and bone turnover, Ostabolin-C ™ inhalation powder (OCIP ) Was used to conduct phase I clinical trials. The preferred doses of 300 μg and 800 μg resulted in a PK profile similar to subcutaneous administration. This PK profile shows the half-life of the PTH peptide analog from 2 minutes to 60 minutes; the exposure time of the PTH peptide analog from 30 minutes to 4 hours; the Tmax of the PTH peptide analog from 2 minutes to 30 minutes; and 10 to 400 pg. / Ml of PTH peptide analog Cmax. More preferred PK ranges include a half-life of 15-30 minutes, an exposure time of 1-2 hours, a Tmax of 15-30 minutes and a Cmax of 50-200 pg / ml. Details of the inhalation dose are given in Example 14.

  The dose can also be administered in various amounts based on the onset of the patient's symptoms and body weight, body surface area or BMI. Such dose optimization is discussed in detail below.

(Dose optimization)
Dose optimization is important for any drug, especially drugs that have a narrow therapeutic window. Common hormones including PTH and its analogs are drugs that have such a narrow therapeutic window. Because of this narrow therapeutic window, a standardized single dose for all patients with various symptoms may not always be effective. Our separate dose optimization approaches of 30 μg and 45 μg for patients with different symptoms and different body weight, body surface area or BMI address this challenge.

  Dose optimization of administration of PTH analogs to human patients with the appropriate risk / benefits ratio has proven difficult with prior art PTHs. The administration and marketability of PTH analogs has been analyzed by many companies, and it is difficult to obtain the most effective and least toxic dose. Two such companies that are studying PTH dosing are Lilly (with Forteo 1-34 hPTH) and NPS (Preos-recombinant full-length human parathyroid hormone, rhPTH 1-84). .

  Dose optimization of the PTH peptides of the present invention provides benefits beyond the single dose currently available at Forteo. Lilly's Forteo is only approved for a 20 μg dose. Lilly considered the possibility of administering doses of 20 μg and 40 μg, but only the 20 μg dose was approved. The risk / benefit ratio for the 40 μg dose was too great because hypercalcemia was observed at least once in 28% of patients receiving Forteo 40 μg. Thus, the 20 μg dose of Forteo (hPTH 1-34) is the only dose available for all symptoms in all patients. There are some patients whose 20 μg dose does not confer sufficient benefit. In addition, in Forteo's approval review summary, the FDA indicated that the proper dose for men should be 30 μg. Our two dose optimization approaches of 30 μg and 45 μg overcome the risk of Forteo's 40 μg dose and the lack of effectiveness in some patients with Forteo's 20 μg dose.

  In addition, NPS is examining various doses of its recombinant full-length human parathyroid hormone rhPTH 1-84, Preos. In Phase II clinical trials, NPS analyzed doses of 50, 75 and 100 μg / day. In Phase III clinical trials, the dose administered was limited to a single dose of 100 μg. This dose has not yet been approved due to the high incidence of hypercalcemia.

  The dose / body weight cut-off described in connection with the present invention helps to avoid the prior art problems where the risk of administering a single dose of PTH exceeds the benefits gained. Thus, doses can be administered based on patient weight, body surface area or BMI. As shown in the data below, the maximum benefit with minimal side effects is that Ostabolin-C is at a dose of about 30 μg for patients with a body weight cut-off value and for those with a body weight cut-off value above. Obtained when administered at a dose of about 45 μg. These same benefits of dose / weight cutoff occur in addition to Ostabolin-C, as well as PTH analogs and other therapeutic agents described herein, which are negative regulation of anti-sclerostin Mab, Wnt signaling pathway Inhibitors of factors, activin receptor agonists, PTH, full-length and fragments thereof, PTH analogs, therapeutic agents whose osteogenic effect is mediated by the action of PTH on its receptors and PTHrP analogs and Include calcium receptor antagonists that stimulate endogenous PTH production to act as agonists of PTH receptors including PTH, full length and fragments thereof, PTH analogs, PTHrP and analogs thereof.

  The 4-month and 12-month phase II data from the Ostabolin-C subcutaneous program, detailed in the examples herein, shows that a 30-45 μg daily dose is appropriate for the treatment of osteoporosis versus risk Indicates having a profile. The 30 μg dose shows a clinically beneficial increase in lumbar spine BMD with a low incidence of hypercalcemia and reduced incidence of side effects. The 45 μg dose causes a higher rise in lumbar spine BMD and also causes an increase in hip BMD. It is therefore interesting to explore whether dose optimization can incorporate some or all of the positive beneficial effects of high doses without suffering the increased side effects observed at high doses. This analysis is described below.

  At the 30 μg dose, lumbar BMD is elevated, mid-radius BMD is elevated, the percent incidence of hypercalcemia is relatively low, and there is a large increase in bone formation relative to bone resorption, as indicated by the anabolic window. . The benefits of this 30 μg dose include an early and significant increase in bone formation with evidence of reduced bone resorption compared to Forteo. Although PTHs within the scope of the present invention with shorter PK profiles provide similar benefits to those seen for Forteo in positive BMD changes in the lumbar and hip joints, the present invention Reduces side effects with reduced potential for reduction. The present invention also shows a reduced tendency to cause hypercalcemia. The administration data for 30 and 45 μg doses of Ostabolin-C are shown in FIGS.

  Administration of a PTH analog at a 45 μg dose also provides additional benefits. These same benefits arise for the PTH analogs described herein in addition to Ostabolin-C. This 45 μg dose has excellent efficacy but is accompanied by side effects. Administration of a 45 μg dose of Ostabolin-C results in a strong early BMD change in the hip and lumbar spines associated with a strong osteogenic effect. This positive effect is also combined with some evidence of bone resorption stimulation and hypercalcemia. These results are shown in FIG.

  Based on the effects shown above for the 30 and 45 μg doses, it is clear that dose optimization is important to gain benefit while minimizing adverse effects. One way to optimize the dose is to administer a dose that produces a shorter PK profile. Preferred PK parameters within the scope of the present invention are: PTH peptide analog half-life of 2 minutes to 60 minutes; PTH peptide analog exposure time of 30 minutes to 4 hours; PTH peptide analog of 2 minutes to 30 minutes Body Tmax; and 10 to 400 pg / ml PTH peptide analog Cmax. More preferred PK ranges include a half-life of 15-30 minutes, an exposure time of 1-2 hours, a Tmax of 15-30 minutes and a Cmax of 50-200 pg / ml.

  Another way to optimize the dose is to administer different doses depending on the patient's weight, height, body surface area or BMI. As shown in the data herein, the high dose of 45 μg has a potency that has been previously observed for Forteo, especially in the hip joint. However, this high dose also represents a risk factor for hypercalcemia for some patients. A low dose of 30 μg is at least as effective as that observed for Forteo and does not indicate a risk factor for hypercalcemia. Neither the 30 μg dose nor the 45 μg dose is optimal for all patients. The dose optimization presented herein provides a dosing regimen that combines the positive properties of 30 and 45 μg doses, ie, excellent efficacy with a low risk of adverse effects. This dosing regimen provides different doses based on the patient's physical characteristics including weight, height, BMI, lean body mass or body surface area.

  In this way, the possibility of non-response in patients is reduced by avoiding low doses in large patients, and the potential for adverse effects in patients is reduced by avoiding high doses in small patients. Doses within the scope of the present invention include administration of 45 μg to a patient having a body weight of 50 kg or more, more strictly 65 kg or more, more strictly 68 kg or more, more strictly 70 kg, and less than 90 kg, More precisely, administration of 30 μg to a patient having a body weight of less than 75 kg, more strictly less than 68 kg, more strictly less than 65 kg, more strictly less than 59 kg, more strictly less than 50 kg. Including.

This dose / weight cut-off optimization provides the ability to adjust the dose administered to a patient based on the patient's weight, body surface area or BMI and manifestation of symptoms. The weight cut-off method provides a method of determining a therapeutically effective dose and maintaining a low incidence of side effects on the patient based on the patient's weight, body surface area or BMI. Higher doses for certain patients increase the likelihood of side effects, including hypercalcemia. In addition, the dose for a particular patient was too low in the situation for a patient with a particular body weight, body surface area or BMI that would have been able to tolerate higher doses of therapeutic agent. Lack of efficacy can be observed in some patients.
By assessing the effectiveness of the dose range, low doses can be ruled out to reduce the number of non-responders, and high doses that usually raise safety concerns can also be ruled out. Body weight, body surface area or BMI cutoff limits the dose administered to a patient to a high or low dose. The selection of multiple effective doses improves the overall efficacy and proportion of patients responding to that dose, and reduces the risk versus benefit of the peptides of the invention by reducing the side effects of doses that result in high exposure to patients. Improve sex profile.

  To study the dosing range of 30-45 μg / day, the dose was converted to μg / kg (daily dose / kg body weight × 100 (to avoid decimal)) and based on exposure to individual drugs, Ostabolin − The response to C was analyzed. All patients undergoing active treatment were changed to individual dose exposure and then reorganized into an incremental exposure dose cohort of μg / kg (0-15, 16-25, 26-35, 36-45, 46-55,> 56 μg / kg). Average rates of change in primary and secondary endpoints after 4 months of treatment in these new dose exposure cohorts were calculated. Linear regression analysis allowed the effects of exposure to Ostabolin-C to be assessed over the full range of dose exposure. The population mean is presented as a linear regression analysis with 95% CI of the continuous variable. Lumbar spine BMD (FIGS. 23 to 24), femoral neck BMD (FIG. 29), forearm midshaft (FIG. 30), total hip joint (FIGS. 27 and 53 to 54), serum calcium (FIG. 28), hypercalcemia ( Data of the action on the bone formation and bone resorption markers (FIG. 26) are shown in the figure. The results show that all biomarkers and BMD endpoints and serum calcium (all continuous variables) change in a linear pattern over the entire dose range tested in this study.

  Based on the assumption that the average human patient has a body weight of about 65 kg, the 30 μg and 45 μg doses were converted to 0.46 μg / kg and 0.69 μg / kg. To convert μg to μg / kg, the μg dose is divided by 65 kg to obtain a μg / kg dose (dose / body weight = μg / kg). At a dose of 30 μg, 30 μg per 65 kg of human average body weight results in a μg / kg dose of approximately 0.46 μg / kg. At 45 μg, 45 μg per 65 kg average human body weight results in a μg / kg dose of about 0.69 μg / kg. These doses are shown in the figure. Doses within the scope of the present invention include 0.20-0.90 μg / kg, more preferably 0.30-0.70 μg / kg, even more preferably 0.46-0.69 μg / kg. A dose within the more preferred range maximizes the effectiveness of PTH therapy while reducing side effects.

  One way to reduce the dose exposure range in the study population is to use two dose strengths with a single body weight cutoff (ie, all patients with a body weight below the cutoff receive a low dose (30 μg)). On the other hand, all patients who exceed the weight cutoff receive a high dose (45 μg)). The effect of this dose optimization method on Ostabolin-C exposure is shown in FIGS.

  The effect of the weight cut-off at 68 kg reduces the spread of exposure in the 30 and 45 μg dose groups. This is shown in detail in the examples. Comparison of modeling data for three different BMD parameters shows that progressively higher dose exposure is required to affect total hip and femoral neck BMD compared to lumbar spine BMD. This allows treatment to be tailored to individual patient needs. For lumbar BMD, the presented weight cutoff is 68 kg, so patients with lumbar BMD weighing less than 68 kg will receive a 30 μg dose, and patients with lumbar BMD weighing 68 kg or more will receive a 45 μg dose. Can be administered. In the hip and femoral neck, the suggested cut-off weight is lower than 68 kg because higher doses need to have a similar positive effect.

(Plasma concentration-AUC)
The dose can also be selected to provide an effective plasma concentration of the PTH analog or other osteoporosis therapeutic agent. Examples of effective maximum plasma concentrations of peptide concentration are from about 10 pg / mL to about 400 pg / mL, preferably from about 20 pg / mL to about 300 pg / mL; from about 50 pg / mL to about 280 pg / mL; from about 80 pg / mL to about 250 pg / mL; can range from about 100 pg / mL to about 150 pg / mL. Other suitable dose ranges for maximum plasma concentrations of PTH peptide analogs are 20-40 pg / mL, 40-60 pg / mL, 60-80 pg / mL, 80-100 pg / mL, 100-120 pg / mL, 120 ~ 140 pg / mL, 140-160 pg / mL, 160-180 pg / mL, 180-200 pg / mL, 200-230 pg / mL, 230-260 pg / mL, 260-300 pg / mL, 300-350 pg / mL and 350-400 pg / ML.

  In another specific embodiment of the invention, the peptide has an area under the curve (herein “AUC”) in the plasma peptide concentration versus time curve in the range of 5 pg · h / mL to 400 pg · h / mL. The dose is administered in an effective amount. More preferably, the AUC range is 10 pg · h / mL to 350 pg · h / mL. More preferably, the AUC is in the range of 20 pg · h / mL to 300 pg · h / mL. More preferably, the AUC is in the range of 50 pg · h / mL to 250 pg · h / mL. More preferably, the AUC is in the range of 70 pg · h / mL to 200 pg · h / mL. More preferably, the AUC is in the range of 90 pg · h / mL to 150 pg · h / mL. More preferably, the AUC is in the range of 95 pg · h / mL to 125 pg · h / mL. Other suitable AUC ranges are 5 pg · h / mL to 20 pg · h / mL, 20 pg · h / mL to 50 pg · h / mL, 50 pg · h / mL to 70 pg · h / mL, 70 pg · h / mL ~ 90 pg · h / mL, 90 pg · h / mL to 100 pg · h / mL, 100 pg · h / mL to 110 pg · h / mL, 110 pg · h / mL to 120 pg · h / mL, 120 pg · h / mL to 130 pg H / mL, 130 pg · h / mL to 150 pg · h / mL, 150 pg · h / mL to 175 pg · h / mL, 175 pg · h / mL to 200 pg · h / mL, 200 pg · h / mL to 225 pg · h / ML, 225 pg · h / mL to 250 pg · h / mL, 250 pg · h / mL to 275 pg · h / mL, 275 pg · h / mL to 300 pg · h / mL, A 00~350pg · h / mL or 350pg · h / mL~400pg · h / mL.

  Accordingly, in one aspect, the invention provides a pharmaceutical formulation comprising a therapeutically effective amount of a PTH peptide analog as an active ingredient in a daily dose range of 2 μg to 60 μg or a weekly dose range of 14 μg to 420 μg, PTH peptide analogs have reduced phospholipase C activity and maintain adenylate cyclase activity in a mixture with pharmaceutically acceptable excipients, diluents or carriers, or combinations thereof. Effective doses may vary depending on the type of PTH peptide or analog being administered and the route of administration. One skilled in the art can modify the dosage route or formulation by modifying the route of administration or formulation so that the dosage can produce a pharmacokinetic or biological profile similar to that which can result from the preferred dosage ranges described herein. Can be adjusted. Exemplary dosages are 2-100 μg daily dose for subcutaneous delivery of aqueous formulations, 0.5-50 μg daily dose for subcutaneous delivery of formulations stabilized with propylene glycol and / or ethanol. Including a daily dose of 100-3,000 μg for inhalation delivery and a weekly dose of 3-7 times the daily dose. Other suitable dosages include any dosage by any route of administration that produces a bioavailability or pharmacokinetic profile similar to that produced by the dosage ranges described above.

(Administration route)
Administration of the PTH peptide analogs of the present invention includes direct administration including self-administration and indirect administration including the act of prescribing the drug. For example, as used herein, a physician instructing a patient to self-administer a drug and / or giving the patient a prescription for the drug is administering the drug to the patient.

  Various routes of administration may be used according to the present invention, including oral, topical, transdermal, nasal, intrapulmonary, transcutaneous (if the skin is damaged by mechanical or energy means), Includes transrectal, buccal, vaginal, trans-transplant reservoir or parenteral. Parenteral includes subcutaneous, intravenous, intramuscular, intraperitoneal, intraarticular, intrasynovial, intrasternal, intrathecal, intrahepatic, intralesional and intracranial injection or infusion. More preferably, the route of administration is subcutaneous, transcutaneous, intranasal, transdermal, oral or inhalation.

(Formulation)
The stabilizing solution of parathyroid hormone can contain stabilizers, buffers, preservatives, antibacterial agents and the like. Stabilizers incorporated into the solution or composition include saccharides, preferably monosaccharides or disaccharides such as glucose, trehalose, raffinose or sucrose; sugar alcohols such as mannitol, sorbitol or inositol and polyhydric alcohols such as Includes alcohols, ethanol or polyols containing glycerin or propylene glycol or combinations thereof. Preferred polyols are mannitol or propylene glycol. The concentration of the polyol may range from about 1 to about 20 wt% of the total solution, preferably from about 3 to about 10 wt%.

  The buffer used in the solution or composition of the present invention may be any pharmaceutically acceptable acid or salt combination. Useful buffer systems are, for example, acetate, tartrate or citrate sources. A preferred buffer system is an acetate or tartrate source, most preferred is an acetate source. The concentration of the buffering agent is about 2 mM to about 500 mM, preferably about 2 mM to about 100 mM.

  The stabilizing solution or composition of the present invention may also include a parenterally acceptable preservative. Such preservatives include, for example, cresol, benzyl alcohol, phenol, benzalkonium chloride, benzethonium chloride, chlorobutanol, phenylethyl alcohol, methyl paraben, propyl paraben, thimerosal, and phenylmercuric nitrate. Preferred preservatives are m-cresol or benzyl alcohol, most preferred is m-cresol. The amount of preservative used may range from about 0.1 to about 2 wt% of the total solution, preferably from about 0.3 to about 1.0 wt%.

  Parathyroid hormone compositions, if desired, can contain up to 2% by weight of water resulting from lyophilization of a sterile hormonal aqueous solution prepared by mixing selected parathyroid hormone, buffers and stabilizers as described above. Can be provided in powder form. Particularly useful as a buffer in preparing lyophilized powder is a source of tartrate. Particularly useful stabilizers include glycine, sucrose, trehalose and raffinose.

  A ready-to-use formulation containing hPTH or, more specifically, Ostabolin-C, is not stable at room temperature and needs to be stored under refrigerated conditions (2-8 ° C). Since hPTH undergoes hydrolysis, oxidation, and deamidation in an aqueous medium, it is difficult to develop a solution formulation for storage at room temperature. The formulation is stable at 5 ° C., but the formulation is preferably stable at a pH of about 7.5, which is relatively close to physiological pH. Studies have shown that the Ostabolin-C solution is less stable at pH 7.5 than the ready-to-use formulation. Both oxidation and deamidation occur above pH 7.0. As such, a 100% aqueous formulation with a pH greater than 7.0 under refrigerated conditions cannot be feasible. Therefore, in order to evaluate the stability of the formulation of the present invention, an ethanol / water or propylene / water mixture was used together with the antioxidants methionine or lipoic acid.

  Another additive that helps maintain the stability of the hPTH formulation is methionine. Methionine is a potential antioxidant and has been shown to improve the stability of hPTH. Furthermore, polyols have the potential to stabilize peptide and protein formulations, and it has been found that sucrose at concentrations up to 1M at pH 5.5 reduces the rate of deamidation and oxidation of hPTH.

  In addition, parathyroid hormone is formulated with typical buffers and excipients used in the art to stabilize and solubilize proteins for parenteral administration. Buffers also have an effect on stability. Previous models have shown that for pH> 7, Tris buffer has a much lower deamidation rate constant than the corresponding phosphate buffer. Due to its physiological ionic strength, the addition of NaCl also has a positive effect on the formulation. Pharmaceutical carriers and formulations thereof recognized in the art are described in Martin, “Remington's Pharmaceutical Sciences,” 15th edition; Mack Publishing Co. , Easton (1975). Further details of stabilizing additives for hPTH formulations are given in Examples 15 and 16.

  PTH peptide analogs may also be formulated through the skin by any route of administration, eg, oral (including sublingual), topical, transdermal (patches, ointments, creams, gels, salves, etc. Percutaneous absorption), intranasal, rectal or pulmonary delivery, can be formulated into a composition suitable for administration by inhalation as a dry powder, aerosol or mist.

  Such forms of the compounds of the invention produce aerosols or administer dry powder medicaments using devices such as metered dose inhalers, nasal sprayers, dry powder inhalers, jet nebulizers or ultrasonic nebulizers, for example. Can be administered by conventional means. Such a device may optionally include a mouthpiece mounted around the opening. However, it should be understood that the present invention encompasses any form of administration that allows PTH peptide analogs to be obtained systemically or locally.

  In addition to the usual meaning of administering the formulations described herein to any part, tissue or organ whose primary function is gas exchange with the external environment, for purposes of the present invention, “intrapulmonary” is associated with the respiratory tract. To include tissue or cavity, particularly the sinus. For pulmonary administration, aerosol formulations comprising an active agent, manual pump spray, nebulizer or pressurized metered dose inhaler and a dry powder drug are contemplated. Suitable formulations of this type may also contain other agents, such as antistatic agents, to maintain the disclosed compound as an effective aerosol.

  A drug delivery device for delivering an aerosol comprises a suitable aerosol canister with a metering valve comprising an aerosol pharmaceutical formulation as described above, and an actuator adapted to hold the canister and allow drug delivery Including a housing. The canister in the drug delivery device has a headspace that represents about 15% or more of the total volume of the canister. High molecular compounds intended for pulmonary administration are often dissolved, suspended or emulsified in a mixture of solvent, surfactant and propellant. The mixture is maintained under pressure in a canister sealed with a metering valve.

  Orally administrable compositions can include one or more physiologically compatible carriers and / or excipients, if desired, and can be solid or liquid. Intranasal administration to a patient includes administering a therapeutically effective amount of a PTH peptide analog to the patient's nasal passage or nasal mucosa. Pharmaceutical compositions for nasal administration can include, for example, spray nasal drops, nasal drops, suspensions, gels, ointments, creams or powders.

  Pharmaceutically acceptable compositions of the peptides described herein can be used according to the methods of the invention. The pharmaceutical compositions described herein may optionally include one or more pharmaceutically acceptable excipients. Such pharmaceutically acceptable excipients are well known in the art and include, for example, salts such as protamine sulfate, disodium hydrogen phosphate, potassium hydrogen phosphate, sodium chloride, zinc salts, colloidal silica. And magnesium trisilicate), surfactants, water-soluble polymers (eg, polyvinylpyrrolidone, cellulose-based materials, polyethylene glycol, polyethylene glycol 400, polyacrylate, sodium carboxymethylcellulose, wax and polyethylene-polyoxypropylene block) Polymers), antiseptics, antibacterial agents, antioxidants, antifreezing agents, wetting agents, viscosity agents, tonicity modifiers, emollients, absorption enhancers, penetration enhancers, pH modifiers, mucoadhesives , Colorants, flavoring agents, diluents, emulsifiers, suspending agents, solvents, co-solvents, buffering agents (eg, phosphoric acid, A mixture of partial glycerides of lysine, sorbic acid, potassium sorbate and saturated plant fatty acids), serum proteins (eg, human serum albumin), ion exchangers, tocopherol, polyethylene glycol 1000 succinate (TPGS) myoly oil, labrosol, sugars including labrofac, ethanol, fillers such as lactose sucrose, mannitol or sorbitol; cellulose preparations such as corn starch, wheat starch, rice starch, potato starch, gelatin, tragacanth gum, methylcellulose, hydroxypropylmethyl-cellulose, carboxy Contains sodium methylcellulose and / or polyvinylpyrrolidone (PVP) and combinations of these excipients. If desired, disintegrating agents such as cross-linked polyvinyl pyrrolidone, agar or alginic acid or a salt thereof such as sodium alginate may be added. Further examples of such carriers or excipients include, but are not limited to, polymeric compounds such as calcium carbonate, calcium phosphate, various sugars, starch, cellulose derivatives, gelatin and polyethylene glycol.

  Examples of suitable surfactants for use in the formulations of the present invention include, but are not limited to, cholic acid and cholate, deoxycholic acid and deoxycholate, taurocholic acid and taurocholate, polyvinylpyrrolidone, PEG compound, For example, cocamine, glyceryl stearate, glyceryl stearate, hydrogenated lanolin, lanolin, laurate and oleate, sorbitan laurate, sorbitan palmitate, sorbitan stearate, quaternium surfactant, sodium sulfate, glyceryl compound, palmitic acid and its Derivatives and oleic acid and its derivatives.

  Excipients included within the pharmaceutical compositions of the invention are selected based on the expected route of administration of the composition in therapeutic applications. Thus, compositions designed for oral, translingual, sublingual, buccal and buccal administration can be prepared without undue experimentation by means well known in the art, for example inert diluents or edible carriers. Can be used. The composition can be enclosed in gelatin capsules or compressed into tablets. For the purpose of oral therapeutic administration, the pharmaceutical compositions of the present invention can be combined with excipients and used in the form of tablets, troches, capsules, elixirs, suspensions, syrups, wafers, chewing gums and the like.

  Solid dosage forms such as tablets, pills and capsules contain one or more binders, fillers, suspensions, disintegrants, lubricants, sweeteners, flavoring agents, preservatives, buffering agents, wetting agents, degrading substances , Foaming agents and other excipients may also be included. Such excipients are known in the art. Examples of fillers are lactose monohydrate, anhydrous lactose and various starches. Examples of binders are various celluloses and cross-linked polyvinyl pyrrolidone, microcrystalline cellulose and silicified microcrystalline cellulose (SMCC). Suitable lubricants containing substances that affect the fluidity of the powder to be compressed are colloidal silicon dioxide, talc, stearic acid, magnesium stearate, calcium stearate and silica gel. Examples of sweeteners are any natural or artificial sweeteners such as sucrose, xylitol, sodium saccharin, cyclamate, aspartame and accsulfame K. Examples of flavoring agents are bubble gum flavor, fruit flavor and the like. Examples of preservatives are potassium sorbate, methylparaben, propylparaben, benzoic acid and its salts, other esters of parahydroxybenzoic acid such as butylparaben, alcohols such as ethyl or benzyl alcohol, phenolic compounds such as phenol or Quaternary compounds such as benzalkonium chloride. Suitable diluents include pharmaceutically acceptable inert fillers such as microcrystalline cellulose, lactose, dicalcium phosphate, sugars and / or mixtures of any of the foregoing. Examples of diluents include microcrystalline cellulose, lactose such as lactose monohydrate, anhydrous lactose, dicalcium phosphate, mannitol, starch, sorbitol, sucrose and glucose. Suitable disintegrants include corn starch, potato starch and modified starch, crospovidone, sodium glycolate starch and mixtures thereof. Examples of blowing agents are effervescent pairs such as, for example, organic acids and carbonates or bicarbonates. Suitable organic acids include, for example, citric acid, tartaric acid, malic acid, fumaric acid, adipic acid, succinic acid and alginic acid, and anhydrides and acid salts. Suitable carbonates and bicarbonates include, for example, sodium carbonate, sodium bicarbonate, potassium carbonate, potassium bicarbonate, magnesium carbonate, sodium glycine carbonate, L-lysine carbonate and arginine carbonate. Alternatively, only the foamable pair acid component may be present.

  Various other materials may be present as coatings or to modify the physical form of the dosage unit. For instance, tablets may be coated with shellac, sugar or both. A syrup or elixir may contain, in addition to the active ingredient, sucrose as a sweetening agent, methyl propylparaben as a preservative, a dye and flavoring such as cherry or orange flavor.

  The composition may take any convenient form, such as tablets, coated tablets, capsules, lozenges, aqueous or oily suspensions, solutions, emulsions, syrups, elixirs, and water before use or otherwise. A dry product suitable for reconstitution with a suitable liquid vehicle. The composition can be advantageously prepared in dosage unit form. Tablets and capsules according to the invention may be combined with a binder such as syrup, gum arabic, gelatin, sorbitol, tragacanth gum or polyvinyl-pyrrolidone; if desired, fillers such as lactose, sugar, corn starch, calcium phosphate, sorbitol or glycine. Lubricants such as magnesium stearate, talc, polyethylene glycol or silica; disintegrants such as potato starch; or acceptable wetting agents such as conventional ingredients such as sodium lauryl sulfate. The tablets can be coated according to methods well known in the art.

  The liquid composition can be a suspension such as sorbitol syrup, methylcellulose, glucose / sugar syrup, gelatin, hydroxymethylcellulose, carboxymethylcellulose, aluminum stearate gel or hydrogenated edible fat; emulsifier such as lecithin, sorbitan monooleate or Gum arabic; edible oils such as vegetable oils such as peanut oil, almond oil, coconut oil, fish liver oil, oily esters such as polysorbate 80, propylene glycol or ethyl alcohol; non-aqueous vehicles; and preservatives such as p -Conventional additives such as methyl or propyl hydroxybenzoate or sorbic acid may be included. The liquid composition is conveniently encapsulated, for example, in gelatin to give the product in dosage unit form.

  Formulations for oral delivery can be formulated in delayed release formulations so that the PTH peptide analog is delivered to the large intestine. Delayed release formulations are well known in the art and include, for example, delayed release capsules or time pills, osmotic delivery capsules and the like.

  Compositions for parenteral administration are formulated using injectable liquid carriers such as pyrogen-free sterile water, peroxide-free sterile ethyl oleate, absolute alcohol or propylene glycol or an anhydrous alcohol / propylene glycol mixture. And can be injected intravenously, intraperitoneally, subcutaneously or intramuscularly. Sterile solutions for injection are prepared by incorporating the required amount of active compound into a suitable solvent and then filter sterilizing, along with the various other ingredients listed above as required. Generally, dispersions are prepared by incorporating various sterilized active ingredients into a sterile vehicle that contains a basic dispersion medium and the required other ingredients from those enumerated above. In the case of sterile powders for the preparation of sterile solutions for injection, the preferred method of preparation is by vacuum drying and lyophilization methods to yield a powder of the active ingredient and any desired additional ingredients from the solution that have been previously filter sterilized. is there.

  A composition for rectal administration may be formulated using a conventional suppository base such as cocoa butter or another glyceride.

  Compositions for topical administration include ointments, creams, gels, lotions, shampoos, applications, powders (including spray powders), pessaries, tampons, sprays, dipping, aerosols, pour-ons and drops. The active ingredient can be formulated, for example, with a hydrophilic or hydrophobic base as appropriate.

  In order to enhance the shelf life, it may be advantageous to incorporate antioxidants such as ascorbic acid, butylated hydroxyanisole or hydroquinone in the compositions of the invention. The pharmacokinetic profiles of various formulations containing Ostabolin-C are detailed in Example 17.

(Medication regimen)
Administration in the present invention can consist of one or more cycles. During these cycles there are one or more periods in which osteoclast and osteoblast activity occurs and one or more periods in which there is neither osteoclast activity nor osteoblast activity. Alternatively, administration can be performed in an uninterrupted regimen, such a regimen can be a long-term regimen, such as a continuous regimen.

  It will be appreciated that the dosage and duration of administration of the composition according to the invention will vary depending on the requirements of the particular patient. The exact dosing regimen will be determined by the attending physician or veterinarian considering factors such as weight, age and symptoms (if any). The composition may incorporate one or more additional active ingredients if desired.

  During the dosing regimen, the hormone can be periodic (eg, daily or more than once a week), intermittent (eg, daily or weekly, irregular) or periodic (eg, days or weeks). Thereafter, it can be administered periodically) followed by periods of no administration. Regular administration is once a day, once every two days, once every three days, once every four days, once every five days, once every six days or once every seven days (once / week) ). Preferably, PTH is administered once daily in osteoporotic patients for a period ranging from 3 months up to 3 years for 1-7 days. In a further embodiment, PTH is administered for 8 days. The invention also encompasses embodiments in which PTH is administered on a weekly basis.

  Preferably, the periodic administration comprises administration of parathyroid hormone during at least two bone remodeling cycles and withdrawal of parathyroid hormone during at least one bone remodeling cycle. Another preferred regimen of periodic administration includes administration of parathyroid hormone for at least about 12 to about 24 months and withdrawal of parathyroid hormone for at least 6 months. Usually, the benefits of administration of parathyroid hormone persist after a period of time. The benefits of several months of administration can last for one year, two years or more without further administration.

  If desired, the PTH peptide analog compound can be administered simultaneously or sequentially with other active ingredients, such as bone strengthening agents. These active ingredients may include, for example, other agents or compositions that can interact with the bone remodeling cycle and / or are useful for fracture repair. Such an agent or composition may be useful, for example, for the treatment of osteoarthritis or osteoporosis as described above.

  In a further aspect, the present invention provides a method for the treatment or prevention of bone-related diseases, particularly osteoporosis, which includes (a) about 6-24 months in mammals, including humans in need of such treatment. Administering an effective amount of a bone resorption inhibitor for a period of about 12 to 36 months after the administration of PTH is completed. The bone resorption inhibitor may be a bisphosphonate, such as alendronate; or a substance having an estrogenic effect, such as estrogen; or a selective estrogen receptor modulator, such as raloxifene, tamoxifen, droloxifene, toremifene, idoxifene Or levormeroxifene; or a calcitonin-like substance such as calcitonin; or a vitamin D analog; or a calcium salt.

  As mentioned above, the high dose Ostabolin-C and other PTH analogs of the present invention confer significant early bone formation and BMD response but reduce bone mineralization levels and cortical porosity Is associated with stimulated bone resorption with the potential to reduce the rate of improvement in bone strength by increasing. Lower doses of Ostabolin-C and other PTH analogs also cause increased bone formation at low levels, but lack bone resorption stimulating activity. A preferred treatment regimen within the scope of the present invention is sequential therapy in order to obtain the early benefits of higher dose therapy while minimizing side effects. One embodiment of such a treatment regimen begins treatment with a high dose of Ostabolin-C or other suitable PTH analog, which may then be 1-12 months, but preferably 3-9 months, Most preferably, after a period of 4-8 months, switch to a lower dose that maintains bone formation at a lower level but does not allow stimulation of bone resorption. Sequential therapy may begin treatment at a lower dose and then switch to a higher dose. Such dosing regimens are superior to high-dose and low-dose therapies because they allow full maturation of sustained and early bone formation caused by high-dose treatment without reduction due to stimulated bone resorption. It is also superior to high-dose therapy in that it reduces the incidence of adverse events related to safety and tolerability. Thus, such sequential therapy is an effective treatment while minimizing side effects.

  Such sequential therapy can be administered at all doses disclosed herein. One suitable dosing regimen is subcutaneous administration to the human of a first daily dosage aqueous formulation at a dose range of 35 μg to 100 μg of a PTH peptide analog, and then after completion of the first phase, Administration of a second dose of 2 [mu] g to 35 [mu] g PTH peptide analog to said human for two periods.

  For human administration, the preparation must meet sterility, pyrogenicity, general safety and purity standards as defined by the FDA.

(kit)
The present invention also includes kits comprising the pharmaceutical composition of the present invention and used in the method of the present invention. The kit can include, for example, a vial containing the formulation of the invention and a suitable carrier in a dry or liquid form. The kit further includes instructions for use and administration of the compound in the form of a label on the vial and / or a package insert contained within the box in which the vial is packaged. The instructions can also be printed on the box in which the vial is packaged. The instructions include information such as sufficient dose and administration information to allow a person skilled in the art to administer the drug. Persons in the field are expected to include any doctor, nurse or technician who can administer the drug, or a patient who can self-administer the pharmaceutical composition.

  In one embodiment, the kit comprises a drug delivery pen containing a cartridge assembly comprising a vial or cartridge capable of holding a supply of about 60 days of a daily dose of the pharmaceutical composition described herein. Including. In a further embodiment, the pen has the ability to hold a daily dose of 1, 2, 3, 4, 5, 6, 7 or 8 weeks of the pharmaceutical composition described herein. In a preferred embodiment, the pen has the ability to hold a 2 or 4 week supply of the daily dose of the pharmaceutical composition described herein. Such a device provides ease of use for self-administration of the pharmaceutical compositions described herein.

  In further embodiments, the cartridge may contain a liquid or frozen dose of a pharmaceutical composition that is reconstituted by the user prior to injection. Drug delivery pens, cartridge assemblies for pens for holding liquid or frozen pharmaceutical dosage formulations and methods for freezing and sealing injectable compositions are described in US Pat. Nos. 5,334,162; 6,053. , 893; and 6,648,859 (the teachings of which are incorporated herein by reference), one of ordinary skill in the pharmaceutical arts knows to be known in the art. Acknowledge.

  The following examples illustrate, but do not limit the invention.

(Example 1 ^{[Leu 27]} cyclo ^{[Glu 22 -Lys 26] -hPTH- (} 1-31) Synthesis and purification of -NH ₂₎
This peptide in which Lys-Alloc, Glu-OA11 is substituted at positions 26 and 22, respectively, as described in US Pat. No. 5,955,425, the teachings of which are incorporated herein by reference. Was synthesized and purified. After addition of Fmoc-Ser ¹⁷ , the peptide resin was transferred from the column to a reaction vial (Minivial, Applied Science) and tetrakis (triphenylphosphine) palladium (0) (0.24 mmol) in dichloromethane (DCM) under argon. Suspend in a 1.7 ml solution of 5% acetic acid and 2.5% N-methylmorpholine (NMM) and then shake for 6 hours at 20 ° C. to remove allyl and alloc protecting groups (Sole, (1993) Peptides: Chemistry, Structure, and Biology, Smith, J. and Hodges, R. (eds), ESCOM pages 93-94, incorporated herein by reference). The peptide resin was then washed with 0.5% diethyldithiocarbamate (DEDT), 0.5% NMM in DMF (50 ml) and then with DMF (50 ml) and DCM (50 ml). The peptide (0.06 mmol) was cyclized by shaking with 0.06 mmol 1-hydroxy-7-azabenzotriazole (HOAt) /0.12 mmol NMM in 2 ml DMF for 14 hours at 20 ° C. (Carpino, LA (1993) J. Am. Chem. Soc. 115, 4397-4398). The peptide resin was filtered and then washed once with DMF, repacked into the column and washed with DMF until air bubbles were removed from the suspension. The rest of the synthesis was performed as the linear counterpart. However, the N-terminal Fmoc group was not removed. Fmoc-peptide was cleaved from the resin using K reagent as described above. HPLC was performed as the linear counterpart above, and the Fmoc group was removed before final HPLC.

  Other suitable stabilizing solutions for PTH peptide analogs that can be used in the methods of the present invention are US Pat. Nos. 5,556,940; 5,955,425; 6,541,450; 316,410; and 6,110,892 (the teachings of which are incorporated herein by reference) may be synthesized and purified.

(Example 2 ^{[Leu 27]} cyclo ^{[Glu 22 -Lys 26] -hPTH- (} 1-31) -NH 2 promotes growth in trabecular and cortical bone in monkeys model)
Peptide ^{[Leu 27]} cyclo ^{[Glu 22} -Lys 26] ^-hPTH- the _{(1-31) -NH 2 Ostabolin-C} ( TM), 52 weeks, subcutaneous at 0,2,10 and 25 [mu] g / kg dose levels The gonadal intact cynomolgus monkeys (4 / sex / group) were administered daily by injection. The monkeys were 30-40 months old (2.3-3.5 kg) at the start of treatment. After labeling with calcein green 15 and 5 days before euthanasia, the tibia was retained for histomorphometry. Bone mass as measured by DXA (dual energy x-ray absorption measurement) and QCT (quantitative computed tomography) increased in the lumbar spine, femur and tibia. Changes in spinal BMD (bone mineral density) resulted in a significant increase in bone strength. Peptide ^{[Leu 27]} cyclo ^{[Glu 22 -Lys 26] -hPTH- (} 1-31) -NH 2 is at full dose, substantially the accretion of bone in the cancellous bone and cortical bone compartment of proximal tibia Increased to Tibial trabecular bone volume compared to the control peptide ^{[Leu 27]} cyclo ^{[Glu 22 -Lys 26] -hPTH- (} 1-31) -NH 50% ultra increased in ₂ treatment groups, the tibial midshaft, the medullary portion There was an increase in cortical width and associated cortical areas with simultaneous decrease. Only a slight increase in cortical porosity was observed at the two maximum dose levels. The increase in bone mass appeared to be related to a decrease in bone resorption as measured by increased bone formation and a significant decrease in osteoclast surface. An increase in bone formation index was associated with a decrease in bone resorption index (decreased bone resorption markers, reduced osteoclast surface area, minimal cortical porosity) and was consistent with uncoupling of these events. This combination of anabolic and anti-catabolic effects can have significant therapeutic value in the treatment of osteoporosis.

(Example 3 Preclinical cortical porosity data)
Comparative data on increased cortical bone porosity in monkey patients using Ostabolin C and prior art PTHs 1-34 at various doses is shown below.

（実施例４ 前臨床毒性データ）
以下の表は、従来技術のＰＴＨ，１−３４、テリパラチド、Ｆｏｒｔｅｏ（登録商標）が、Ｏｓｔａｂｏｌｉｎ−Ｃ（商標）より腎毒性が高いことを示し、その相違はおそらく異なる高カルシウム血症状態に関連している。以下に示すように、ＰＴＨ−（１−３４）はサル及び、おそらく、ラットにおいて石灰化腎毒性を誘発する。サルに対する無毒性量（ＮｏＡＥＬ）は確定しなかった。Ｏｓｔａｂｏｌｉｎ−Ｃ（商標）はサルにおいてのみ腎毒性を示し、無毒性量（ＮｏＡＥＬ）が確定した。Ｏｓｔａｂｏｌｉｎ−Ｃ（商標）はＰＴＨ−（１−３４）より少なくとも４倍安全である。

Example 4 Preclinical Toxicity Data
The table below shows that the prior art PTH, 1-34, teriparatide, Forteo (R) is more nephrotoxic than Ostabolin-C (TM), and the difference is probably related to different hypercalcemia conditions is doing. As shown below, PTH- (1-34) induces calcified nephrotoxicity in monkeys and possibly rats. No non-toxic dose (NoAEL) for monkeys was established. Ostabolin-C ™ showed nephrotoxicity only in monkeys and a non-toxic dose (NoAEL) was established. Ostabolin-C ™ is at least 4 times safer than PTH- (1-34).

（実施例５ ＯＳＴＡＢＯＬＩＮ−Ｃ（商標）の臨床試験）
低骨ミネラル密度（ＢＭＤ）を有する閉経後女性におけるＯｓｔａｂｏｌｉｎ−Ｃ（商標）の安全性、忍容性及び有効性を検討するため、４カ月間の第ＩＩ相臨床試験を行った。本試験由来の比較データは、Ｏｓｔａｂｏｌｉｎ−Ｃ（商標）の使用が、現行の治療法、１−３４ ＰＴＨ、テリパラチド、Ｆｏｒｔｅｏ（登録商標）の使用に優る多くの利点を有することを示す。臨床プロトコルは、低骨ミネラル密度（ＢＭＤ）を有する閉経後女性におけるＯｓｔａｂｏｌｉｎ−Ｃ（商標）の安全性、忍容性及び有効性を検討するための１６週間第ＩＩ相無作為化二重盲検プラセボ対照並行群間用量設定試験である。本試験では、患者２６１名がプラセボ群及び４つの実薬投与群の４カ月間連日投与を受けた。実薬投与群は、７．５，１５，３０及び４５μｇの用量でのＯｓｔａｂｏｌｉｎ−Ｃ（商標）の連日投与を含んだ。Ｏｓｔａｂｏｌｉｎ−Ｃ（商標）は、予め充填されたシリンジ内に供される無色透明液体として調合され、皮下（ＳＣ）注入される。患者は、割り振られた用量のＯｓｔａｂｏｌｉｎ−Ｃ（商標）７．５，１５，３０及び４５μｇ或いはプラセボの０．１ｍｌ注射剤を、腹部の四分円（ｒｏｔａｔｉｎｇ ｑｕａｄｒａｎｔｓ ｏｆ ｔｈｅ ａｂｄｏｍｅｎ）に１６週間連日、皮下自己投与する。患者は中等度の骨粗鬆症を有する閉経後女性（少なくとも５年間）であった。

Example 5 Clinical Study of OSTABOLIN-C ™
To investigate the safety, tolerability and efficacy of Ostabolin-C ™ in postmenopausal women with low bone mineral density (BMD), a 4-month phase II clinical trial was conducted. Comparative data from this study shows that the use of Ostabolin-C ™ has many advantages over the use of current therapies, 1-34 PTH, teriparatide, Forteo ™. The clinical protocol is a 16-week phase II randomized double-blind study to investigate the safety, tolerability and efficacy of Ostabolin-C ™ in postmenopausal women with low bone mineral density (BMD) This is a placebo-controlled parallel group dose-setting study. In this study, 261 patients received daily treatment for 4 months in a placebo group and 4 active treatment groups. The active treatment group included daily administration of Ostabolin-C ™ at doses of 7.5, 15, 30, and 45 μg. Ostabolin-C ™ is formulated as a clear colorless liquid that is provided in a pre-filled syringe and injected subcutaneously (SC). Patients received an allocated dose of Ostabolin-C ™ 7.5, 15, 30, and 45 μg or placebo 0.1 ml injection in the abdominal quadrants of the abdomen for 16 weeks, Subcutaneous self-administration. The patient was a postmenopausal woman (at least 5 years) with moderate osteoporosis.

The primary endpoint of this study includes changes in mean BMD in the lumbar spine as measured by dual energy X-ray absorption measurement (DEXA) and measured by changes from baseline visits (Baseline visit). Baseline visit is the patient's first visit before receiving treatment. Secondary efficacy endpoints include the following items as measured by changes from the baseline visit.
DEXA:
・ Average femoral neck BMD
・ Average trochanter BMD
・ Average total hip joint BMD
Average rib BMD (distal end and midshaft)
・ Bone mineral content (BMC)
・ Bone area Bone formation and resorption markers:
Serum osteocalcin Serum type I procollagen amino terminal propeptide (P1NP)
・ Bone specific alkaline phosphatase (BSAP)
Serum C-telopeptide (CTx)
Serum N-telopeptide (NTx)
Other measurements:
Thoracic vertebrae, lumbar vertebra side and left front and back lumbar radiographs Height (Example 6 Clinical Results-Effects of Low Dose (7.5, 15 and 30 μg) Ostabolin-C ™)
Administration of 7.5, 15, and 30 μg daily doses of Ostabolin-C ™ as described above in Example 5, without the negatively associated effects previously observed with respect to the use of prior art PTHs, It exhibits strong bone anabolism at multiple parts of the body including the hip joint and wrist. The unprecedented increase in BMD in the mid ribs and the lower incidence and severity of hypercalcemia make them highly attractive doses.

  As shown in FIG. 1, administration of 7.5, 15, and 30 μg daily doses of Ostabolin-C ™ over a 15 week course results in an increase in lumbar BMD. Figures 3, 4 and 5 show mild increases in lumbar, femoral neck and trochanter BMD after 15 weeks of Ostabolin-C ™ administration.

  FIGS. 6 and 7 show that daily administration of 7.5, 15, and 30 μg of Ostabolin-C ™ has an unexpected positive effect on cortical bone, especially on the carpal (distal radius and midshaft). Indicates. There were statistically significant effects in the mid-radius with no negative effects of bone resorption at daily doses of 7.5, 25 and 30 μg. Historically, PTH has been known to increase bone resorption, which increases cortical porosity and reduces BMD in radial cortical bone (Neer et al., 2001). As described in Neer, administration of the prior art Forteo® PTH 1-34 resulted in a decrease in BMD (increased cortical porosity) at the distal radius and midshaft compared to placebo. In contrast, administration of the dosages and formulations of the present invention, ie, 7.5, 15 and 30 μg Ostabolin-C ™, compared to placebo and teriparatide, Forteo®, compared to distal radius and shaft. It actually increases cortical BMD in the middle. This is an unprecedented finding and shows a statistically significant difference from placebo for 3 working doses (7.5, 15 and 30 μg). 8-13 show the action of the PTHs of the present invention on bone formation and bone resorption markers. Osteogenic markers include P1NP, osteocalcin and BSAP, and bone resorption markers include NTx and CTx. Compared to placebo, Ostabolin-C ™ has higher changes (%) when administered at 15 and 30 μg.

  The bone resorption markers in FIGS. 11-13 have some increase in bone resorption after Ostabolin-C ™ administration, but this increase is less than the increase after administration of the prior art teriparatide, Forteo® PTH.

  It has also been shown that daily administration of 7.5, 15, and 30 μg Ostabolin-C ™ has a much lower incidence of hypercalcemia compared to PTHs known in the art. FIG. 14 shows that there was no significant difference from placebo with respect to abnormal serum calcium percent for doses of Ostabolin-C ™ containing up to 30 μg. In comparison, teriparatide, Forteo® has been shown to have a much higher effect at equivalent doses. In patients taking Forteo®, hypercalcemia was observed at least once in 11% of 20 μg group patients and 28% of 40 μg group patients compared to 2% in the placebo group (Neer et al., 2001). ). Low dose administration (7.5, 15 and 30 μg) of the PTH peptides of the present invention did not result in a significant increase in the incidence of hypercalcemia compared to placebo. Hypercalcemia was observed at least once in the 5% placebo group and the 30 μg dose group, and there was no net increase. This is in contrast to the 11% observed for Forteo® administered at 20 μg.

  Thus, the above results indicate that administration of Ostabolin-C ™ at daily doses of 7.5, 15 and 30 μg offers many advantages over administration of Forteo® at 20 μg. Show. Unexpected results include increased cortical BMD at the distal radius and midshaft compared to placebo, less bone resorption than prior art PTH, and lower incidence and severity of hypercalcemia, and Maintaining anabolic bone growth as measured by increased BMD at various sites including the hip joint.

Example 7 Preclinical Results-Effect of High Dose (45 μg) Ostabolin-C ™
Administration of a 45 μg daily dose of Ostabolin-C ™ has demonstrated an unprecedented ability to build bone at various sites including the spine and hip joints, with early onset with slightly mild hypercalcemia signal It had an effect. This is an improvement over the prior art teriparatide, Forteo® 1-34 PTH.

  FIGS. 1 and 2 show that administration of 45 μg Ostabolin-C ™ results in an increase in BMD in the lumbar spine. FIG. 2 shows an increase in lumbar BMD with administration of Forteo® 20 and 40 μg.

  Figures 3, 4 and 5 and the table below show that a daily dose of 45 μg Ostabolin-C ™ has a positive effect on bone formation in the hip, femoral neck and trochanter. This is an unprecedented finding, showing a statistically significant and clinically significant benefit at 45 μg at 15 weeks. The table below shows the hip joint, femoral neck and femoral neck, which compared the administration of teriparatide, Forteo® (20 μg) over the course of at least 12 months with Ostabolin-C ™ (45 μg) at 15 weeks. The change of trochanter BMD is shown. As shown below, in hip joints and trochanters, 45 μg of Ostabolin-C ™ achieved results similar to those obtained with Forteo administration over a course of at least 12 months at 15 weeks. Regarding the femoral neck, Ostabolin-C ™ shows a much larger increase in BMD in a shorter period of time.

図８〜１３は、本発明のＰＴＨｓが骨形成及び骨吸収マーカーに対して有する作用を示す。骨形成マーカーは、Ｐ１ＮＰ、オステオカルシン及びＢＳＡＰを含み、骨吸収マーカーは、ＮＴｘ及びＣＴｘを含む。プラセボと比べ、Ｏｓｔａｂｏｌｉｎ−Ｃ（商標）が４５μｇにて投与されると、骨形成マーカーはより高い変化（％）を有する。Ｏｓｔａｂｏｌｉｎ−Ｃ（商標）が４５μｇにて投与されると、骨形成マーカー増大の強固な作用がある。図１１〜１３における骨吸収マーカーは、Ｏｓｔａｂｏｌｉｎ−Ｃ（商標）投与後に骨吸収のある程度の増大があるが、この増大は従来技術のテリパラチド、Ｆｏｒｔｅｏ（登録商標）ＰＴＨ投与後の増大より少ない。

8-13 show the action of the PTHs of the present invention on bone formation and bone resorption markers. Osteogenic markers include P1NP, osteocalcin and BSAP, and bone resorption markers include NTx and CTx. Compared to placebo, osteogenic markers have a higher percentage change when Ostabolin-C ™ is administered at 45 μg. When Ostabolin-C ™ is administered at 45 μg, there is a strong effect of increasing osteogenic markers. The bone resorption markers in FIGS. 11-13 have some increase in bone resorption after Ostabolin-C ™ administration, but this increase is less than the increase after administration of the prior art teriparatide, Forteo ™ PTH.

  Thus, the above results provide many advantages of administration of Ostabolin-C ™ at a daily dose of 45 μg over administration of rhPTH 1-34 teriparatide, Forteo® at 20 and 40 μg. It shows that. Unexpected results include increased BMD in the spine and hip joints with less bone resorption and lower incidence of hypercalcemia than prior art PTH.

(Example 8: Pharmacokinetic (PK) evaluation of Ostabolin-C)
The purpose of this part of the study was to assess the pharmacokinetics of Ostabolin-C under steady-state conditions when administered subcutaneously (sc) once daily to postmenopausal female patients with low bone mineral density. there were.

  This study was a phase II multicenter randomized, double-blind, placebo-controlled, parallel group dose-setting study in postmenopausal female patients. Following the screening procedure and 2 weeks of placebo run-in phase, patients were dosed with placebo or Ostabolin-C (7.5, 15, 30, or 45 μg) once a day for 16 weeks. Blood was collected for Ostabolin-C measurements on a subset of patients from all treatment groups to determine PK parameters and compare them with previous studies.

  The total study period for this study was 22 weeks, which included a 6 week screening period with a 2 week placebo run-in followed by 16 weeks of treatment. A subset of patients for this component of the study was treated like all other patients except for additional blood collection at baseline and week 12.

(Data processing and PK analysis)
With the exception of one (baseline 2 hour time point), all values from placebo patients were below the detection assay level (ie, 10 pg / ml). With very limited exceptions, all values from placebo patients in previous trials were below detection levels. Therefore, this single value was considered an experimental error and the PK parameters for this placebo patient were not calculated.

  No pre-dose sample was obtained at baseline or week 12. In all prior studies, the pretreatment value was below the detection level, and the 24 hour time point at doses of 40 μg and below was below the detection level. Therefore, in order to calculate PK without expecting an observable value, the pretreatment value of the base visit was set to zero.

  Prior to dosing at Week 12, based on prior studies, it was also expected that the value would be below the detection level and that the 24 hour post-dosing value would demonstrate this. Only the binary values at the 24 hour time point were above the detection level, ie 24 hours after administration at the baseline of patient 030-003 and 24 hours after administration at the 12th week of patient 030-0004. Both of these 24 hour timepoint values were slightly above the detection assay level. Both of these patients had values below the detection level on the previous day, at 4 hours and 6 hours after administration. Therefore, these values are likely artifacts and not actual values. No valid 24 hour time point sample was obtained for patient 032-0001 at week 12. However, the AUC (0-24) value was estimated on the assumption that the 6-hour time point after administration at the 12th week was below the detection level, and therefore the value at the 24-hour time point was also below the detection level. Therefore, the pre-dose value at week 12 was also set to zero in order to calculate PK parameters.

The estimated pharmacokinetic parameters at baseline and at week 12 are as follows.
-Area under the drug concentration-time curve from zero to four hours (AUC _(0-4) )
_-Area under the drug concentration-time curve from zero to 24 hours (AUC _(0-24) )
-Maximum observed drug concentration ( _Cmax )
-Maximum drug concentration time ( _Tmax )
Because there were very few patients in this subset of patients and the time points used for collection were limited, no additional PK parameters were calculated.

  AUC values were estimated by simple summation of trapezoidal regions from each time. Data from each dose group was summarized using simple statistics in the Excel® spreadsheet, ie mean (AVG) and standard deviation (STD). In particular, it should be noted that with respect to low doses and associated low blood levels, and at late time points, the values directly above and below the assay limit of detection can have a disproportionate effect on the AUC calculation. This increases the variation in the number of calculations.

(PK value)
The following table outlines the estimated PK parameters.

本試験のこのパートに実際に参加した患者が極く少数であり、また、Ｃｍａｘ，Ｔｍａｘ及びＡＵＣの値がベースラインと第１２週とで酷似しているように思われたため、すべての時期の値を平均化し、これらのパラメータの別の推定値を得た。下記表を参照されたい。安定状態の動態があるべき平衡に達した際、ベースラインと第７日との同様のＰＫ値が、この用量範囲を含む以前の２つの第１相試験において認められていた。

Because there were very few patients who actually participated in this part of the study and the Cmax, Tmax and AUC values seemed to be very similar between baseline and week 12, The values were averaged to obtain another estimate of these parameters. See the table below. Similar equilibrium PK values at baseline and day 7 were observed in two previous Phase 1 trials that included this dose range when steady state kinetics had reached an equilibrium.

^＊注意−患者０３２−０００１の有効な２４時間時点サンプルは得られなかったが、６時間時点が検出レベル以下であったため、２４時間時点の値も検出レベル以下であると想定し、ＡＵＣ（０−２４）値を推定した。

^* Caution-No valid 24-hour sample of patient 032-0001 was obtained, but since the 6-hour time point was below the detection level, the value at the 24-hour time point was also assumed to be below the detection level, and AUC (0 −24) The value was estimated.

^＊注意：Ｎ＝患者数；ベースラインと第１２週との組合せ由来のデータ、各患者は各パラメータに対して２値を有していた。

^* Note: N = number of patients; data from the combination of baseline and week 12, each patient had two values for each parameter.

Since T _max appears to be dose-dependent in this and previous studies, the T _max from all doses in this study, determined at baseline and week 12, was averaged to obtain an overall estimate An STD of 0.34 hours and 0.21 hours was obtained.

(Discussion)
A very limited number of patients involved in the study limit the statistical confidence in the results derived from the study data. However, this data is basically consistent with the previous test.

  There was no evidence of an accumulative effect as observed in previous studies. The PK parameters after 12 weeks of administration were very similar to the PK parameters on day 1 at baseline.

  Tmax was independent of dose and the overall average from all doses and times was 0.34 hours (srd = 0.21 hours).

  Cmax and AUC values increased with dose. There is a rough dose relationship between Cmax and AUVC values in the averaged data.

Example 9 Treatment of Renal Osteodystrophy
End stage renal disease is necessarily associated with a bone disease known as renal bone dystrophy (ROD) (see Chapter 74 of Primer on Metabolic Bone Diseases and Disorders of Mineral Metabolism for details of etiology). ROD may be present in a high rotation form characterized by high circulating concentrations of PTH (secondary hyperparathyroidism) and overactive bone tissue. This condition is often associated with bone pain, muscle weakness, extraosseous calcification and deformation, and growth retardation in children. It is believed that a reduction in PTH concentration is necessary to treat these disorders. Low-rotation disease, also known as aplastic osteopathy, is characterized by normal or low circulating concentrations of PTH and is used to effectively control secondary hyperparathyroidism, such as vitamin D The incidence is increasing due to increased use of sterols, calcium-based phosphate binders and calcimimetics. Histologically, the bone surface is dormant with little or no osteoblast activity. The clinical consequences of this histological condition include fractures and an increased risk of developmental delay in prepubertal children.

  Currently, aplastic osteopathy is difficult to treat. The use of parathyroid hormone is contraindicated because lowering parathyroid hormone levels is one of the important goals of treatment leading to aplasia. Hypercalcemia is a frequent complication of current therapies that can be exacerbated by the use of exogenous PTH. Thus, in this context, restoration of normal levels of osteogenic activity is difficult to achieve and there is a need for an effective treatment that is not met. PTH receptor agonists, including cyclized or linear PTH (1-31) analogs, but also other cyclic and linear smaller size analogs and analogs of PTHrP, are osteogenic. Has been shown to increase, but does not tend to stimulate the bone resorption seen with other PTH fragments and natural hormones. This type of PTH receptor agonist stimulates osteoblast function and bone formation, and thus can effectively treat aplastic ossification without exacerbation of the risk of hypercalcemia. The use of low doses of these agents can provide a restoration of normal osteoblast activity with minimal bone resorption stimulating activity and can be particularly effective in the prevention and treatment of aplastic osteopathy. This type of PTH receptor agonist is used in combination with calcimimetics, vitamin D sterols or other drugs known to increase the onset and / or severity of aplastic osteopathy to prevent this onset or exacerbation Specific treatment scenarios can be created.

  PTH receptor agonists can be used in dialysis patients who are at high risk of developing aplastic osteopathy because they prevent the development of aplastic osteopathy. PTH receptor agonists of the type described above can also be used to treat osteoporosis and kidney disease patients who have a particularly high risk of fractures due to aplastic ossification.

(Example 10 Rat carcinogenicity test)
Prior art PTHs cause osteosarcoma in animals when administered over a two year course. The PTH peptides of the present invention, including Ostabolin-C ™ and PTH 1-30, are administered subcutaneously to rats for 104 weeks at doses of 0.5, 5, 30, and 50 μg / kg / day. The test article is administered subcutaneously. Analysis of tumor incidence and morphology after administration has shown that administration of the PTH peptide of the present invention over a two-year course results in a lower incidence of osteosarcoma compared to administration of the prior art PTH peptide over a similar period. Can show that This difference can be attributed to different amino acid sequences and / or different signaling pathways activated by PTH molecules.

(Example 11 Comparison between OSTABOLIN-C and FORTEO)
The table below shows Deal et al. (2005) J. MoI. Bone Min. Res. Comparison of data between Ostabolin-C and Forteo from pages 20, 1905-1991 is shown. As shown below, bone resorption stimulation by Ostabolin-C 30 μg is about 50% of the expected effect of Forteo 20 μg, despite a similar effect on LS (lumbar spine) -BMD. Both the effects of Ostabolin-C 30 μg on the incidence of serum calcium and hypercalcemia are diminished. The effect of Ostabolin-C 45 μg on bone formation and BMD is greater than that of Forteo 20 μg, despite similar effects on bone resorption and calcium. Both Ostabolin-C 30 μg and 45 μg doses have an improved therapeutic window compared to Forteo. These results are also shown in FIGS.

１ ＬＳ−ＢＭＤ Ｔスコア＜−２．５のサブセット由来データ
２ Ｄｅａｌら（２００５）Ｊ．Ｂｏｎｅ Ｍｉｎ．Ｒｅｓ．２０，１９０５−１９９１頁のグラフ化データから推定。

1 LS-BMD T-score <-2.5 subset derived data 2 Deal et al. (2005) J. MoI. Bone Min. Res. Estimated from graphed data on pages 20, 1905-1991.

(Example 12) Analysis of side effects by dose administered based on patient body weight
To confirm that μg / kg exposure is an effective way to analyze the effects of Ostabolin-C, cumulative responses and side effect profiles were evaluated. Cumulative responses were analyzed by looking at the percentage of patients who increased Ostabolin-C exposure and achieved a 3% or greater change in lumbar spine BMD. This analysis shows that the assessment of the effects of Ostabolin-C exposure on an individual patient basis follows a pattern similar to linear regression analysis from dose groups formed on the basis of increased μg / kg exposure (for lumbar spine) See FIGS. 23-25). A similar trend was shown for the side effect profile as shown in the cumulative incidence analysis shown in FIGS. 31 and 32 for headache, nausea and hypercalcemia. Overall, increased exposure was associated with side effects and a higher incidence of hypercalcemia.

  A linear regression analysis of efficacy endpoints combined with a higher side effect rate and increased exposure maintains that exposure to Ostabolin-C is narrower than the range that can occur with once-daily administration to the entire cohort. If so, the observed clinical profile has the potential to be excellent. Such a method may reduce low efficacy responses by eliminating low exposure, and may reduce unwanted or excessive responses by eliminating high exposure.

Example 13 Dose Optimization-Two Dose Intensities with Weight Cutoff
As described in Example 5, analysis of the 4-month data from the Phase II study of Ostabolin-C subcutaneous formulation shows that high dose Ostabolin-C has higher efficacy than Forteo, especially in the hip joint. Demonstrating that it also exhibits some degree of hypercalcemia. The data from Example 5 also shows that low doses of Ostabolin-C are as effective as Forteo and do not cause hypercalcemia. Based on these results, we will identify the doses that combine the favorable clinical findings of both high and low doses of Phase II, and that have excellent efficacy and well tolerated doses. ,Analysis was carried out.

  One way to narrow the scope of dose exposure in the study population is to use two dose strengths with a single body weight cutoff (ie, all patients with a body weight below the cutoff receive a low dose (30 μg)). On the other hand, all patients who exceed the weight cutoff receive a high dose (45 μg). The effect of this dose optimization method on Ostabolin-C exposure is shown in FIGS.

  In contrast to the actual single dose exposure distribution found in the table shown below, the effect of the body weight cut-off at 68 kg reduces the spread of exposure in the 30 and 45 μg dose groups.

本試験の３０及び４５μｇコホート由来の実際のデータを用いてサブグループ分析を行うことにより、用量最適化方法の効果を評価した（即ち、３０μｇ用量群由来の体重カットオフ未満の患者全員と、４５μｇ用量群由来の体重カットオフ超の患者全員とを組み合わせることによる新たなサブグループの編成。下記の表に示す）。

Subgroup analysis was performed using actual data from the 30 and 45 μg cohorts of this study to assess the effect of the dose optimization method (ie, all patients below the body weight cutoff from the 30 μg dose group and 45 μg New subgroup organization by combining all patients with body weight cut-offs from dose groups, as shown in the table below).

  Various new subgroups were organized from patients who participated in phase II clinical trials. Groups from Phase II are shown above and each group received a single dose of either 7.5 μg, 15 μg, 30 μg, 45 μg or placebo. The 30 μg and 45 μg dose groups were reorganized based on patient weight and over 100 new subgroups were organized. This approach of organizing new subgroups from doses that are relatively close to each other is a novel way of conducting phase II trials.

  Initially, a new group was organized by using multiple body weight cut-offs of 0.5 kg for 105 patients who received 30 or 45 μg. For example, one new group has a weight cut-off at 59 kg, that is, all patients weighing less than 59 kg from the original low dose (30 μg) group and 59 kg weight from the original high dose (45 μg) group. All of the super patients have formed a new cohort. This new cohort represents a dose / 59 kg body weight cut-off, with patients weighing less than 59 kg receiving a low dose (30 μg) and patients weighing more than 59 kg representing a group receiving a high dose (45 μg). Another example can be shown using a weight cutoff of 68 kg. Such a group may include all patients weighing less than 68 kg and initially receiving a low dose (30 μg) and all patients weighing 68 kg and initially receiving a high dose (45 μg). By using this method, more than 100 separate cohorts were organized by varying the dose / 0.5 kg body weight cutoff. The table below summarizes the data generated from these new dose / weight cutoff cohorts using 68 kg and 59 kg as the dose / weight cutoff.

上記の表は、２つの用量／体重カットオフ（より多くの患者がより高用量を受けるため、より高い暴露プロファイルを生じさせる５９ｋｇと、より多くの患者がより低用量を受ける６８ｋｇ）で得られた実際の臨床プロファイルを示す。該表に示すプロファイルは、これら２つのカットオフが３０μｇと４５μｇとの中間臨床プロファイルを生じさせることを示す。単純なサブグループ分析に関する１つの問題点は、少数の事象を有するエンドポイントが、これらの事象の１つが一方の体重カットオフから他方の体重カットオフに移ると、発現率の大幅な変化のため、観察プロファイルを歪めうることである。従って、本試験における最低体重患者（全員が高用量を受けるため、４５μｇプロファイルに対応する）から開始し、０．５ｋｇ単位で１００ｋｇ（全員が低用量を受けるため、３０μｇプロファイルに対応する）を経てカットオフを増大させていった３０及び４５μｇ用量群由来のデータに、用量／体重カットオフ方法を体系的に適用した。このようにして得られた複数のカットオフプロファイルは、グラフ化されると、高カルシウム血症に対する作用に示されるように、個々の事象の作用を取り除くことができる。次に、図３７〜４０に示すように、臨床プロファイルに対する体重カットオフの作用をモデル化し、個々のデータポイントの歪曲作用を排除することができる。この手法を本試験の一次及び二次エンドポイントに適用した。

The above table is obtained with two dose / weight cut-offs (59 kg resulting in a higher exposure profile because more patients receive higher doses and 68 kg where more patients receive lower doses). The actual clinical profile is shown. The profile shown in the table shows that these two cut-offs produce an intermediate clinical profile of 30 and 45 μg. One problem with a simple subgroup analysis is that an endpoint with a small number of events may change due to a significant change in the incidence when one of these events moves from one weight cutoff to the other. The observation profile can be distorted. Thus, starting with the lowest body weight patient in this study (all responding to a 45 μg profile because they receive a high dose) and going through 100 kg in 0.5 kg increments (corresponding to a 30 μg profile because all receive a low dose) The dose / body weight cut-off method was systematically applied to data from the 30 and 45 μg dose groups that had increased cut-off. When the multiple cut-off profiles obtained in this way are graphed, the effects of individual events can be removed, as shown in the effect on hypercalcemia. Next, as shown in FIGS. 37-40, the effect of weight cut-off on the clinical profile can be modeled to eliminate the distorting effect of individual data points. This approach was applied to the primary and secondary endpoints of the study.

  Several interesting and unexpected results can be derived from this analysis. First, as shown in FIGS. 41-43, 49-50, changes in biomarkers (both formation and absorption) are highly sensitive to changes in body weight cutoff between 60 kg and 70 kg.

  Although these changes appear to be concurrent, the P1NP / CTx ratio also shows a significant shift in this cut-off range (see FIGS. 41-43, 49-50), with the low dose already established Shows the bone formation (P1NP) action. The incidence of hypercalcemia and changes in serum calcium also show a significant increase in this cut-off range, further strengthening the relationship between stimulation of bone resorption and the development of hypercalcemia in the clinical profile.

  By comparing modeling curves of different clinical variables, it is possible to determine if Ostabolin-C has a differential effect on clinical parameters when a specific weight cut-off is applied to the dosing regimen . As shown in FIGS. 44-47, 51, with respect to changes in the incidence of hypercalcemia and lumbar BMD responder ratio and as referred to between changes in serum calcium and lumbar BMD, 2 If the sigmoidal plots of two different clinical variables do not overlap, a differential effect can be inferred. These comparisons show that a cut-off at about 68 kg gives the greatest BMD benefit with minimal effect on serum calcium metabolism.

  Because the magnitude of change at each site is also different, the choice of BMD responder definition is different at different BMD sites. Different definitions of BMD “response” were evaluated based on a separate analysis that showed that actively treated patients had a BMD change greater than placebo at all levels of BMD change (FIGS. 46-48).

  Therefore, the response definitions for lumbar spine, femoral neck and total hip BMD were selected that produced approximately the same number of responders for each BMD ratio (greater than 3% for lumbar BMD and 0 for total hip and femoral neck BMD). %more than). Comparison of modeling data for three different BMD parameters shows that progressively higher dose exposure is required to affect total hip and femoral neck BMD compared to lumbar BMD. This allows the treatment to be tailored to the individual needs of the patient (see FIG. 48).

  An important benefit of this modeling is that the effects of individual events are eliminated so that a clinical profile for a particular weight cutoff / dose exposure area can be presented with high accuracy. The expected hypercalcemia and lumbar BMD profiles for the 68 kg cutoff are shown in the table below, which shows the changes in modeled hypercalcemia and lumbar BMD and the actual phase II for the 68 kg body weight cutoff. The data is compared. By using multiple dose cutoffs and different doses, it is also possible to model the effects of a narrower exposure range.

Ｏｓｔａｂｏｌｉｎ−Ｃへのμｇ／ｋｇ暴露の作用の分析は、優れた有効性反応を付与するとともに有害作用の発現を最小にする用量最適化に対する簡易であるが強力な手法をもたらした。この投薬手法が、男性及び女性における骨粗鬆症の処置に対し、ＰＴＨ類似体の使用への更なる柔軟性及び優れた臨床プロファイルを付与することが期待される。

Analysis of the effects of μg / kg exposure to Ostabolin-C provided a simple but powerful approach to dose optimization that confer excellent efficacy responses and minimize the onset of adverse effects. This dosing approach is expected to provide additional flexibility and superior clinical profile for the use of PTH analogs for the treatment of osteoporosis in men and women.

  These dose optimization benefits shown above for Ostabolin-C also apply to other therapeutic agents, including anti-sclerostin Mabs, inhibitors of negative regulators of the Wnt signaling pathway, activin receptors Agonists, PTH, full length and fragments thereof, PTH analogs, PTHrP and PTHrP analogs, therapeutic agents whose osteogenic action is mediated by the action of PTH on its receptors, and calcium that stimulates endogenous PTH production Receptor antagonists such as those acting as agonists of PTH receptors, including PTH, full length and fragments thereof, PTH analogs, PTHrP and analogs thereof are included.

Example 14 OSTABOLIN-C ™ Inhalation Powder Phase I Clinical Trial
To determine MTD in postmenopausal women, compare its PK profile with Phase II subcutaneous doses, and assess bioactivity with respect to biomarkers of cAMP and bone turnover, Ostabolin-C ™ inhalation powder (OCIP ) Was used to conduct phase I clinical trials. In the focus group, OCIP was administered using a Nektar T-326 dry powder inhaler (DPI), which is widely accepted by osteoporosis patients. Increasing resistance doses were used. Each cohort was randomized and included 6 active patients and 2 placebo patients. The patient was a healthy postmenopausal woman over 40 years of age and had no known history of osteoporosis or other bone diseases.

  Primary measurements were taken in clinical laboratories, patient surveys were conducted, and patients were able to describe any adverse effects. In addition, patient vital signs were measured using Holter electrocardiogram (EKG) and spirometry. Pharmacokinetics, such as blood Ostabolin-C concentration, single dose, and PK parameters after 7 days of daily administration were also measured. Pharmacokinetics were also monitored for changes in bone markers including P1NP, osteocalcin, NTx, CTx and urinary cyclic AMP.

  The overall design of this study is as follows.

下記の表は投薬概要を示す。

The table below shows a dosing summary.

下記の表は、ＯＣＩＰの投与が、Ｏｓｔａｂｏｌｉｎ−Ｃを皮下投与した際に得られるＰＫパラメータと同様のＰＫパラメータを生じさせることを示す。

The table below shows that administration of OCIP produces PK parameters similar to those obtained when Ostabolin-C is administered subcutaneously.

^＊表示用量のＯＣＩＰに正規化されたＡＵＣ及びＣｍａｘ値では、０．３ｍｇ〜１．０ｍｇ（４％）値を用いた；ＳＣは３０及び４５ｕｇ値を用いた。
^＊＊Ｔｍａｘ及びＴ１／２は用量非依存的−患者全員を平均化
下記の表は、ＯＣＩＰの投与第１日目と第７日目とにおけるＰＫパラメータが酷似していることを示す。

^* Values from 0.3 mg to 1.0 mg (4%) were used for AUC and Cmax values normalized to the indicated dose of OCIP; SC used 30 and 45 ug values.
^** Tmax and T1 / 2 are dose independent-average all patients The table below shows that the PK parameters on the first and seventh days of OCIP administration are very similar.

^＊０．６ｍｇ用量のＯＣＩＰに正規化されたＡＵＣ及びＣｍａｘ値では、０．３ｍｇ〜０．６ｍｇ（４％）値を用いた。
^＊＊Ｔｍａｘ及びＴ１／２は用量非依存的−患者全員を平均化
図５５〜６０は、ＯＣＩＰ投与で得られる薬物動態パラメータが、皮下投与で得られる薬物動態パラメータと同様であることを示す。該図は、ＯＣＩＰのＰＫプロファイルが用量比例的であることも示す。これらの図は次の測定を含む：治療ＡＵＣレベル、治療Ｃｍａｘレベル、全体的なＣｍａｘ及びｔ_ｍａｘ，ｃ_ｍａｘ，４％ＯＣＩＰ製剤に対するＡＵＣ（０−４）並びに４％ｏｃｉｐ製剤のｐｋプロファイル。

^{* For} AUC and Cmax values normalized to 0.6 mg OCIP, 0.3 mg to 0.6 mg (4%) values were used.
^** Tmax and T1 / 2 are dose independent-average all patients FIGS. 55-60 show that the pharmacokinetic parameters obtained with OCIP administration are similar to those obtained with subcutaneous administration. The figure also shows that the PIP profile of OCIP is dose proportional. These figures include the following measurements: treatment AUC level, treatment Cmax level, overall Cmax and t _max , c _max, AUC (0-4) for 4% OCIP formulation and pk profile of 4% ocip formulation.

  In general, the PK study utilized a 4% formulation in the Phase II study, confirming that the therapeutic window was dose proportional and could be single and repeated doses without accumulating effects.

The data in FIGS. 55-60 show that cAMP stimulation can be maintained with repeated doses and that osteogenic biomarkers increase with pulmonary delivery, so that pulmonary delivery of Ostabolin-C is bioactive. Show. In addition, the first day PK parameter predicts a change in cAMP. The figure also shows an increase in urinary cAMP within the therapeutic area on day 1, with consistent cAMP response with repeated administration on day 1, day 7, and day 28, respectively. It shows that cAMP production correlates with AUC and _{Cmax in the} eye.

  The figure shows that P1NP levels increased from 25 to 100% compared to baseline by day 28, and osteocalcin levels increased from 25 to maximum 100% compared to baseline by day 28. It also shows that. The figure also shows that an increase in P1NP correlates with AUC. The figure also shows that OCIP administration had no effect on bone resorption markers by showing the percent change in CTx. Therefore, the data show that there is a strong urinary cAMP and bone biomarker response with the administration of OCIP. Thus, in particular, since the OCIP cAMP dose response exceeds the subcutaneous response, the biomarker response correlates with the cAMP response, and the biomarker response is consistent and clinically relevant, it is comparable to subcutaneous administration. It is likely to be effective in phase.

(Adverse event profile)
Preliminary results for patients treated with OCIP as described above were mild in over 95%, and AE profiles were consistent with PTH class effects in that there were no adverse lung or cardiovascular events (AEs) Showed that to do. Furthermore, there were no severe adverse effects and no effect on spirometry parameters or vital signs. The table below shows the distribution of adverse events.

下記の表における有害事象の概要は、大部分（９５％超）の有害事象が軽度であったことを示す。重症とみなされる有害事象はなかった。

The summary of adverse events in the table below shows that most (> 95%) adverse events were mild. There were no adverse events considered serious.

下記の表は、頭痛、悪心及び嘔吐を含む、体験した有害事象の概要を示す。

The table below outlines the adverse events experienced, including headache, nausea and vomiting.

全般的に、ＯＣＩＰは第ＩＩ相の準備ができており、許容可能なばらつきを含む適切な過渡的ＰＫプロファイルと、治療域を確定した治療有益性を予測する生物活性を有する。更に、皮下（ＳＣ）用製剤との同等性があり、後期相での奏効確率が高い。

Overall, OCIP is ready for Phase II and has an appropriate transient PK profile, including acceptable variability, and biological activity that predicts therapeutic benefit that has defined a therapeutic window. Furthermore, it is equivalent to the preparation for subcutaneous (SC) and has a high response probability in the late phase.

Example 15 Formulation
The formulation screening test for Ostabolin-C solution to develop a stable formulation is detailed. Previous formulations undergo oxidation and deamidation above pH 7.0. Ethanol / water or propylene / water mixtures containing the antioxidants methionine or lipoic acid were evaluated and their stability was evaluated.

  Two ethanol / water formulations containing methionine were studied. In the first set of tests, the stability of Ostabolin-C solution (hPTH # 1) in a mixture of 40% ethanol / 60% water above pH 7.0 was examined. 1 mg / ml methionine was included in the formulation to control oxidation. The drug and methionine were dissolved in water and the pH was adjusted to 7 with 0.1 N NaOH, then ethanol was added to obtain the target ratio of ethanol and water. Ostabolin-C showed excellent stability in a 40% ethanol / 60% water system. The stability data for hPTH # 1 is presented in the table below.

  (Solution stability of Ostabolin-C in 40% ethanol / water with 1 mg / mL methionine at pH 7 (batch hPTH # 1))

Ｏｓｔａｂｏｌｉｎ−Ｃは４０％エタノール／６０％水系において優れた安定性を示した。０．５６〜０．５９及び０．６２〜０．６５のＲＲＴにて溶出する分解ピークは、２つの酸化的分解ピークである。それらは初期サンプルに存在し、４０℃で保存した１０６日間のサンプルを除き、すべての条件下で安定性試験時に有意には変化しなかった。これらのデータはエタノールが該製剤を安定化していることを示唆する。他に唯一認められた分解物（ＲＲＴ ０．９０）は、４０℃で１５，４５及び１０６日間の保存にて増加している加水分解産物である。加水分解産物は４５日間／２５℃で認められず、該製剤が強固であって、冷蔵条件下で２年間の保存寿命を予想しうることが示唆される。

Ostabolin-C showed excellent stability in a 40% ethanol / 60% water system. The degradation peaks eluting at 0.56-0.59 and 0.62-0.65 RRT are two oxidative degradation peaks. They were present in the initial sample and did not change significantly during the stability test under all conditions except the 106 day sample stored at 40 ° C. These data suggest that ethanol stabilizes the formulation. The only other observed degradation product (RRT 0.90) is a hydrolyzate increasing with storage at 40 ° C. for 15, 45 and 106 days. Hydrolyzate is not observed at 45 days / 25 ° C., suggesting that the formulation is robust and can be expected to have a 2 year shelf life under refrigerated conditions.

  Another approach was to consider the use of a diol (propylene glycol) to further stabilize the structure of the peptide and thus increase stability. In addition, lipoic acid, an antioxidant, was included. A sample solution was prepared by dispersing lipoic acid in water, adjusting the pH to 8.0, and then adding the drug. The pH of the solution was adjusted to pH 7.5 and propylene glycol was added to obtain a final solution of 60% propylene glycol / 40% water. Stability data is presented in the table below.

  (Stability of Ostabolin-C in 60% propylene glycol / 40% water containing 5 mg / ml lipoic acid at pH 7.5 (hPTH # 2))

上記溶剤系におけるＯｓｔａｂｏｌｉｎ−Ｃの安定性は極めて優れている。１０６日後の２５℃及び５℃保存試料において有意な分解物ピークは見出されなかった。本発明者らが認めた唯一の分解は４０℃での加水分解産物であった。１０６日後の２５℃保存試料及び５℃試料においてある程度の効力低下を認めた。しかし、分解は認められず、この効力低下はバイアルへの薬物の付着に起因しうる。ｈＰＴＨ＃１もｈＰＴＨ＃２も優れた安定性を示し、両製剤とも冷蔵保存下で２年間安定するであろう。

The stability of Ostabolin-C in the above solvent system is extremely excellent. No significant degradation peak was found in samples stored at 25 ° C. and 5 ° C. after 106 days. The only degradation we observed was a hydrolyzate at 40 ° C. Some decrease in efficacy was observed in the 25 ° C. sample and the 5 ° C. sample after 106 days. However, no degradation was observed and this reduced potency can be attributed to drug adhesion to the vial. Both hPTH # 1 and hPTH # 2 show excellent stability and both formulations will be stable for 2 years under refrigerated storage.

Example 16 Stability Enhancement
Stability tests conducted so far show that Ostabolin-C in-fridge stable formulations can be obtained with either propylene glycol / water or ethanol / water mixtures. The addition of other potential stability modifiers is determined. It is well known that hPTHs are susceptible to oxidation during storage. Methionine is a potential antioxidant and has been shown to improve the stability of hPTH. Furthermore, it is well known that polyols have the potential to stabilize peptide and protein formulations. Previously, the effect of sucrose on the stability of hPTH (1-34) was examined. A sucrose concentration of up to 1M at pH 5.5 was found to reduce the rate of deamidation and oxidation of hPTH (1-34).

The buffer type can also have an effect on stability. The aim was to study these solutions at a more physiologically relevant pH (pH 7.5). Previously, model compounds have been shown to have a much lower deamidation rate constant for Tris buffer than the corresponding phosphate buffer for pH> 7. Finally, the effect of adding 9 mg / ml NaCl was examined to better indicate the physiological ionic strength. Consider stability data for Ostabolin-C solution formulation in the presence of methionine, Tris buffer, sucrose and NaCl in a solvent system consisting of 60% propylene glycol and 40% water at pH 7.5.
Formulation description:
Form # 1: 250 μg / ml Ostabolin-C in 0.05M Tris buffer in 60% propylene glycol and 40% water with pH adjusted to 7.5 with HCl
Form # 2: 250 μg / ml Ostabolin-C in 0.05 M Tris buffer in 60% propylene glycol and 40% water and 5 mg / ml methionine, pH adjusted to 7.5 with HCl
Form # 3: 250 μg / ml Ostabolin in 0.05 M Tris buffer in 60% propylene glycol and 40% water, 5 mg / ml methionine and 200 mg / ml sucrose, pH adjusted to 7.5 with HCl -C
Form # 4: in 0.05M Tris buffer in 60% propylene glycol and 40% water, 5 mg / ml methionine, 200 mg / ml sucrose and 9 mg / ml NaCl, pH adjusted to 7.5 with HCl Of 250 μg / ml Ostabolin-C
600 ml of propylene glycol was added to a 1 liter flask. MilliQ water was added to bring the flask contents to 1 liter. The resulting solution is 60% propylene glycol and 40% water. Using this as a stock solution, an inert ingredient was added and dissolved, and the pH of the resulting solution was adjusted to about 8.0 before adding the drug to prepare each batch of formulation. Drug was added and the pH was readjusted to 7.5 with 0.1 N HCl.

  All test batches were placed at 40 ° C., 25 ° C. and 5 ° C. for stability testing. From early stability studies, the main degradation peaks of Ostabolin-C are three oxidation peaks OX1 (RRT about 0.59), OX2 (RRT about 0.65), OX3 (RRT about 0.7), two Hydrolysis peaks (RRT about 0.90 (HYD1) and 0.98 (HYD2)), three late elution peaks (RRT 1.01-1.25; DEG1, DEG2 and DEG3) and additional peaks (RRT> 1. 4. Elution 45 minutes after gradient washout time; identified as gradient elution peak GEP (#)). The numbers in parentheses indicate the number of peaks that elute as the slope changes. The decomposition peaks observed during the stability analysis are presented using the terms specified above.

  Again, the drug appears to adhere to the glass and therefore 100% of the drug is not recovered. There is no increase in decomposition peak area, and a decrease in efficacy is observed over time. The 4-week stabilization of the above formulation at 40 ° C. and 25 ° C. has been completed and the data is summarized in the table below.

４つの被験製剤はすべて、４０℃で４週間の保存後、５．３〜８．３面積パーセントの範囲のＨＹＤ１を示した。加水分解はスクロース及び塩化ナトリウムを含む製剤（形態＃４）において最も低く、塩化ナトリウムの存在が加水分解を遅延或いは鈍化させることが示唆される。しかし、Ｏｓｔａｂｏｌｉｎの効力は同一保存期間で６５〜７２の範囲であり、製剤により可変的な薬物の回収が示唆される。上記の表に示すように、全製剤が２５℃で４週間の保存にて分解をほとんど示さなかった。加水分解は依然としてスクロース及びＮａＣｌを含む製剤（形態＃４）において最も低い。他の製剤ははるかに高いレベルの加水分解を有し（約１面積％）、加水分解が塩化ナトリウムの存在又は反応媒体のイオン強度に影響されることが示唆される。

All four test formulations showed HYD1 ranging from 5.3 to 8.3 area percent after 4 weeks storage at 40 ° C. Hydrolysis is lowest in the formulation containing sucrose and sodium chloride (Form # 4), suggesting that the presence of sodium chloride delays or slows the hydrolysis. However, the efficacy of Ostabolin ranges from 65 to 72 over the same storage period, suggesting variable drug recovery depending on the formulation. As shown in the table above, all formulations showed little degradation upon storage for 4 weeks at 25 ° C. Hydrolysis is still lowest in the formulation containing sucrose and NaCl (Form # 4). Other formulations have much higher levels of hydrolysis (about 1 area%), suggesting that hydrolysis is affected by the presence of sodium chloride or the ionic strength of the reaction medium.

  With respect to oxidative degradation, formulations # 1-4 showed a small percentage of oxidative degradation despite the presence of a high concentration (5 mg / ml) of the antioxidant methionine. However, addition of the antioxidant methionine in the formulation slowed oxidative degradation by 50% (form # 1 vs. form # 2-4). Interestingly, no oxidative degradation was found for the first 3 weeks in the formulation containing antioxidants. However, stability analysis of the 4 week data of the 40 ° C. sample showed that all formulations showed the presence of all three oxidative degradation products.

  A stability analysis of the 25 ° C / 4 week sample showed oxidative degradation in formulations # 1-2. In addition, only two oxidative degradation peaks were observed. In addition to hydrolysis and oxidative degradation, a late elution peak presented as DEG1 in the table was also observed. The area percentage of this degradation peak ranged from 1-2% over a 4 week storage period at 40 ° C. and was not observed at 25 ° C. under the same conditions.

上記試験に加え、スクロース（２００ｍｇ／ｍｌ）及び塩化ナトリウム（９ｍｇ／ｍｌ）を加え、或いは加えない、ｐＨ調整を行わない水中Ｏｓｔａｂｏｌｉｎ、それぞれ、製剤＃Ａ，＃Ｂの安定性を調べた。これらの製剤のｐＨ測定値は約５．６である。

In addition to the above test, the stability of formulation #A and #B, respectively, Ostabolin in water with or without the addition of sucrose (200 mg / ml) and sodium chloride (9 mg / ml) and without pH adjustment was examined. The pH value of these formulations is about 5.6.

  One week stability data at 40 ° C. or 25 ° C. showed severe degradation relative to the control water sample (Form #A). The main degradation products are oxidative degradation products and other degradation products eluting before the oxidative degradation products. Unlike the stability in the pH 7.5 system, no peak was observed at RRT> 1.0. The stability of the same water formulation (form #B) in the presence of sucrose and sodium chloride was significantly improved. The level of oxidative degradation products is significantly reduced compared to Form #A. However, multiple late elution peaks were observed. The table below gives an overview of the stability data.

これらのデータは、全体としてプロピレングリコール／水混合物がＯｓｔａｂｏｌｉｎ−Ｃ（形態＃Ａ対形態＃１）の溶液安定性を有意に高めることを示す。スクロース及びＮａＣｌの付加は更なる安定性を付与する（形態＃１対形態＃４及び形態＃Ａ対形態＃Ｂ）。

These data show that overall the propylene glycol / water mixture significantly increases the solution stability of Ostabolin-C (form #A vs. form # 1). Addition of sucrose and NaCl confers additional stability (form # 1 vs. form # 4 and form #A vs. form #B).

Example 17 Pharmacokinetic Profile of the above Formulation
The following plasma pharmacokinetic profiles of various formulations of Ostabolin-C were examined and compared: subcutaneous, intramuscular and intravenous administration to rats (clinical formulation), and subcutaneous administration including subcutaneous administration (preclinical formulation) ( New formulation). The following shows the details of the preparation used.

  The formulation was prepared only once as follows: the bulk lyophilized peptide was dissolved in 0.01M acetic acid (provided by Fisher Scientific, Loughborough, UK) at a 1: 1 ratio and reconstituted in a dosing vial. It was dispensed and snap frozen (about -70 ° C). The vial was lyophilized below -20 ° C and stored frozen until needed. The lyophilized aliquot for injection was reconstituted with water for injection (Animal Ltd, provided by York, UK). The peptide was dissolved in an appropriate amount of purified water to a concentration of about 2-3 mg / mL. Phosphate buffered saline (pH 7.4) was added to obtain the final required concentration (pH about 7.2). The capped vial was mixed thoroughly so that the peptide was completely dissolved. Aseptic methods and glass vials were used throughout the dose preparation. The dose was not sterile filtered. Clinical formulation (50 mg / mL mannitol, 0.166 mg / mL sodium acetate trihydrate, 0.4 mg / mL glacial acetic acid (pH 4.5)). The calculated amount of mannitol, sodium acetate trihydrate and glacial acetic acid were weighed and then dissolved in the appropriate amount of water for injection. The test article was weighed and added to the solution and stirred to dissolve. Depending on the initial pH, the pH was adjusted to 4.5 with 0.1 N NaOH or HCl (provided by Covance, Harrogate). Water was added to obtain the required amount.

(New formulation 1 (40% propylene glycol))
The calculated amount of lipoic acid was weighed and transferred to a suitable container and then dispersed in water for injection. The pH was adjusted to 7.7 with 1N NaOH (provided by BDH Laboratory Supplies, a division of Merck Ltd, Poole, UK). The test article was weighed, added, and stirred to dissolve. The pH was adjusted to 7.5 with 1N NaOH. Propylene glycol was added to obtain the proper amount. The final pH recorded was 6.6.

(New formulation 2 (40% ethanol in water (pH 7.5)))
The calculated amount of DL-methionine was weighed and transferred to a suitable container and dispersed in water for injection. The test article was weighed and added to the solution. The pH was adjusted to 7.5 with 0.1N NaOH. Ethanol was added to make the required amount.

  The following dose levels were selected.

処置１＝標準製剤（酸性化食塩水）
処置２＝臨床製剤（５０ｍｇ／ｍＬのマンニトール、０．１６６ｍｇ／ｍＬの酢酸ナトリウム三水和物、０．４ｍｇ／ｍＬの氷酢酸（ｐＨ４．５））
処置３＝新規製剤１（４０％プロピレングリコール）
処置４＝新規製剤２（水中４０％エタノール（ｐＨ７．５））
対照＝臨床製剤（ビヒクル）
処置５＝臨床製剤
処置６＝臨床製剤

Treatment 1 = Standard formulation (acidified saline)
Treatment 2 = clinical formulation (50 mg / mL mannitol, 0.166 mg / mL sodium acetate trihydrate, 0.4 mg / mL glacial acetic acid (pH 4.5))
Treatment 3 = New formulation 1 (40% propylene glycol)
Treatment 4 = New formulation 2 (40% ethanol in water (pH 7.5))
Control = clinical formulation (vehicle)
Treatment 5 = clinical formulation Treatment 6 = clinical formulation

対照２＝臨床製剤（ビヒクル）
処置７＝臨床製剤
処置８＝臨床製剤
標準製剤と比べ、被験製剤におけるＯｓｔａｂｏｌｉｎ−Ｃの相対バイオアベイラビリティは著明に高く、臨床製剤、新規製剤２、新規製剤１において、それぞれ、１．５，２７．１，３７．７倍高かった。臨床製剤として筋肉内投与したＯｓｔａｂｏｌｉｎ−Ｃの相対バイオアベイラビリティは、全皮下（ＳＣ）投与製剤より著明に高く、標準製剤より約２００倍高く、新規製剤１より５倍高かった。Ｏｓｔａｂｏｌｉｎ−Ｃは筋肉内（ＩＭ）対照動物（第八群）由来の血漿試料において定量化できなかった。

Control 2 = clinical formulation (vehicle)
Treatment 7 = Clinical formulation Treatment 8 = Clinical formulation The relative bioavailability of Ostabolin-C in the test formulation is significantly higher than that in the standard formulation, and 1.5, 27 in the clinical formulation, the new formulation 2 and the new formulation 1, respectively. .1,37.7 times higher. The relative bioavailability of Ostabolin-C administered intramuscularly as a clinical formulation was significantly higher than the total subcutaneous (SC) administered formulation, about 200 times higher than the standard formulation, and 5 times higher than the new formulation 1. Ostabolin-C could not be quantified in plasma samples from intramuscular (IM) control animals (Group 8).

  After approximately 4 minutes of single intravenous injection (IV) of Ostabolin-C at 200 μg / kg to female rats, the maximum quantifiable plasma concentration of Ostabolin-C occurred at tmax 5 minutes after the end of injection. However, the plasma concentration at 2 minutes after the end of injection was not quantified and was over 610000 pg / mL, suggesting that true Cmax occurred at this early time point.

  After a single subcutaneous (SC) administration of Ostabolin-C as four different formulations (standard, clinical, novel formulations 1 and 2), plasma drug concentrations rapidly increased, and initial blood sampling 5 minutes after administration for all formulations Reached the maximum level in time. A single intramuscular (IM) administration of the clinical formulation resulted in a tmax of 10 minutes after slightly slower administration.

  Ostabolin-C has a total plasma clearance (CL) of 45.4 mL / min / kg, similar to liver blood flow. The distribution volumes (Vz and Vss) were similar, 0.471 L / kg and 0.479 L / kg, respectively, suggesting a wide distribution of Ostabolin-C.

  The toxicokinetic parameters of Ostabolin-C after intravenous (IV) administration are presented below.

処置６＝静脈内（ＩＶ）臨床製剤
皮下（ＳＣ）及び筋肉内（ＩＭ）投与後のＯｓｔａｂｏｌｉｎ−Ｃの薬物動態パラメータを下記に提示する。

Treatment 6 = Intravenous (IV) clinical formulation The pharmacokinetic parameters of Ostabolin-C after subcutaneous (SC) and intramuscular (IM) administration are presented below.

処置１＝皮下（ＳＣ）標準製剤（酸性化食塩水）
処置２＝皮下（ＳＣ）臨床製剤（５０ｍｇ／ｍＬのマンニトール、０．１６６ｍｇ／ｍＬの酢酸ナトリウム三水和物、０．４ｍｇ／ｍＬの氷酢酸（ｐＨ４．５））
処置３＝皮下（ＳＣ）新規製剤１（４０％プロピレングリコール）
処置４＝皮下（ＳＣ）新規製剤２（水中４０％エタノール（ｐＨ７．５））
処置５＝筋肉内（ＩＭ）臨床製剤
剖検にて新規製剤２を投与された動物（第四群）の一部の皮下注射部位において発赤又は赤色部分が記録され、概して、これは顕微鏡的に認められた所見と相関した。概して、皮下投与経路により処置された動物の顕微鏡所見は、頻度が低く、重要性が低かった。鬱血／出血の顕微鏡所見は注射時のわずかな機械的損傷と一致していた。筋肉内投与経路により処置された動物（対照及び臨床製剤、第五及び六群）において、微小レベルの筋炎／ミオパシーが記録された。これは注射に起因する軽度の機械的損傷と一致し、被験物品に関連するとは考えられない。

Treatment 1 = Subcutaneous (SC) standard formulation (acidified saline)
Treatment 2 = Subcutaneous (SC) clinical formulation (50 mg / mL mannitol, 0.166 mg / mL sodium acetate trihydrate, 0.4 mg / mL glacial acetic acid (pH 4.5))
Treatment 3 = Subcutaneous (SC) new formulation 1 (40% propylene glycol)
Treatment 4 = subcutaneous (SC) new formulation 2 (40% ethanol in water (pH 7.5))
Treatment 5 = Intramuscular (IM) clinical formulation Redness or red area is recorded at some subcutaneous injection sites in animals (Group 4) that received the new formulation 2 at necropsy, which is generally observed microscopically Correlated with the findings. In general, microscopic findings in animals treated by the subcutaneous route of administration were less frequent and less important. Microscopic findings of congestion / bleeding were consistent with slight mechanical damage at the time of injection. Minimal levels of myositis / myopathy were recorded in animals treated by the intramuscular route of administration (control and clinical products, groups 5 and 6). This is consistent with minor mechanical damage due to injection and is not considered to be related to the test article.

  After a single subcutaneous (SC) administration of Ostabolin-C as four different formulations (standard, clinical, novel formulations 1 and 2), plasma drug concentrations rapidly increased, and initial blood sampling 5 minutes after administration for all formulations Reached the maximum level in time. A single intramuscular (IM) administration of the clinical formulation resulted in a tmax of 10 minutes after slightly slower administration.

  After subcutaneous (SC) and intramuscular (IM) administration, the plasma concentration of Ostabolin-C appeared to decrease generally biphasically after reaching Cmax. The terminal elimination half-life could only be tentatively obtained for the clinical preparation after the subcutaneous (SC) administration and the new preparation 2, which were 42.4 minutes and 9.1 minutes, respectively. The measurement of t1 / 2 for the clinical formulation was measured over a duration of less than one half-life and therefore is not considered robust.

  The apparent clearance (CL / F) and volume of distribution (Vz / F) calculated for the subcutaneous formulation when possible are formulation dependent, with 3850 mL / min / kg for the new formulation 2 and clinical formulation, 36600 mL / min / kg, 50.6 L / kg, and 2240 L / kg.

  The absolute bioavailability of each subcutaneous (SC) formulation was very low (less than 2%), lowest in the standard formulation (Fabs = 0.04%), and highest in the new formulation 1 (Fabs = 1.6%). Both other subcutaneous (SC) formulations (new formulation 2 and clinical formulation) had about 1% Fabs. In contrast, the absolute bioavailability of the intramuscular (IM) formulation was much higher, 8.7%.

  Compared to the standard preparation, the relative bioavailability of Ostabolin-C in the test preparation was remarkably high, and 1.5, 27.1, and 37.7 times higher in the clinical preparation, the new preparation 2, and the new preparation 1, respectively. The relative bioavailability of Ostabolin-C administered intramuscularly as a clinical formulation was significantly higher than the total subcutaneous (SC) administered formulation, about 200 times higher than the standard formulation, and 5 times higher than the new formulation 1. The plasma concentration of Ostabolin-C after intravenous (IV) administration is shown in FIG. 75 (treatment 6), and the plasma concentration of subcutaneous and intramuscular Ostabolin-C is shown in FIGS. 76 and 77 (treatments 1-5). These figures show the increased bioavailability of the new formulation.

AUC0-tz and Cmax after subcutaneous (SC) administration of standard, clinical, novel 1 and novel 2 formulations, and Ostabolin-C AUC0-tz and Cmax after intramuscular (IM) and intravenous (IV) administration of clinical formulations Are shown in FIGS.
Overall, after a single dose of 200 μg / kg Ostabolin-C to female rats by subcutaneous (SC), intramuscular (IM) and intravenous (IV) routes of administration, the maximum plasma concentration of Ostabolin-C is It reached quickly 5 minutes after subcutaneous (SC) administration. Tmax occurred 10 minutes after intramuscular (IM) administration of the clinical formulation. The terminal excretion half-life when calculated was in the range of 7.2-42.4 minutes.

  The absolute bioavailability of Ostabolin-C after subcutaneous (SC) administration was very low (less than 2%), lowest in the standard formulation (Fabs = 0.04%), and highest in the new formulation 1 (Fabs = 1. 6%). The absolute bioavailability after intramuscular (IM) administration was significantly higher, 8.7%.

  Although the invention has been particularly shown and described with respect to preferred embodiments thereof, it will be appreciated that various changes in form and detail may be made without departing from the scope of the invention as encompassed by the appended claims. Those skilled in the art will understand.

Claims (48)

  A method of treating bone deficiency disorders in a patient and reducing side effects associated with administration of parathyroid hormone, wherein the parathyroid hormone peptide analog or other peptide has a narrow therapeutic window in an effective amount for the patient. An effective amount for the patient is determined based on the weight of the patient, there are a plurality of effective doses for patients exhibiting different weights, and the effective amount is based on a predetermined weight cutoff Calculated by The PTH peptide analogue is PTH 1-84, PTH 1-34, PTH- (1-31) NH ₂ ; PTH- (1-30) NH ₂ ; PTH- (1-29) NH ₂ ; PTH- ( ^{_{1-28) NH 2; Leu 27 PTH-}} (1-31) NH 2; Leu 27 PTH- (1-30) NH 2; Leu 27 PTH- (1-29) NH 2; Leu 27 cyclo (22-26 ) PTH- (1-31) NH ₂ Ostabolin-C ™; Leu ²⁷ cyclo (22-26) PTH- (1-34) NH ₂ ; Leu ²⁷ cyclo (Lys ²⁶ -Asp ³⁰ ) PTH- (1- 34) NH _2; cyclo ^{(Lys 27 -Asp 30) PTH- (} 1-34) NH 2; Leu 27 cyclo _{(22-26) PTH- (1-31) NH} 2; Ala 27 or N e ²⁷ or ^{Tyr 27} or ^{Ile 27} cyclo _{(22-26) PTH- (1-31) NH} 2; Leu 27 cyclo _{(22-26) PTH- (1-32) NH} 2; Leu 27 cyclo (22-26) PTH- (1-31) OH; Leu ²⁷ cyclo (26-30) PTH- (1-31) NH ₂ ; Cys ²² Cys ²⁶ Leu ²⁷ cyclo (22-26) PTH- (1-31) NH ₂ ; Cys ²² Cys ²⁶ Leu ²⁷ cyclo (26-30) PTH- (1-31) NH ₂ ; cyclo (27-30) PTH- (1-31) NH ₂ ; Leu ²⁷ cyclo (22-26) PTH- (1- 30) NH _2; cyclo (22-26) PTH- (1-31) NH 2; cyclo _{(22-26) PTH- (1-30) NH} 2; Leu 27 cyclo (22-26 ^{_{PTH- (1-29) NH 2; Leu}} 27 cyclo ^{_{(22-26) PTH- (1-28) NH}} 2; Glu 17, Leu 27 cyclo (13-17) (22-26) PTH- ( 1-28 The method of claim 1, selected from the group consisting of:) NH ₂ ; and Glu ¹⁷ , Leu ²⁷ cyclo (13-17) (22-26) PTH- (1-31) NH ₂ .   3. The method of claim 2, wherein the PTH peptide analog is selected from the group consisting of a PTH- (1-31) peptide analog and a PTH- (1-30) peptide analog.   4. The method of claim 3, wherein the PTH peptide analog is Ostabolin-C (TM).   The peptide having the narrow therapeutic window is composed of an anti-sclerostin Mab, an inhibitor of a negative regulator of the Wnt signaling pathway, an activin receptor agonist, a hormone, and a calcium receptor antagonist that stimulates endogenous PTH production. The method of claim 1, which is selected.   2. The method of claim 1, wherein the dose is a high dose or a low dose.   The method of claim 6, wherein the low dose is in the range of 5-30 μg.   The method of claim 7, wherein the low dose is 30 μg.   The method of claim 6, wherein the high dose is in the range of 45-60 μg.   The method of claim 9, wherein the high dose is 45 μg.   7. The method of claim 6, wherein a low dose is administered if the patient is below a weight cutoff.   7. The method of claim 6, wherein if the patient exceeds a weight cut-off, a high dose is administered.   The method of claim 1, wherein the single weight cutoff point is 60-70 kg.   14. The method of claim 13, wherein the single weight cut-off point is 68 kg.   The undesirable side effects that are reduced include bone resorption, hypercalcemia, increased mean serum calcium concentration, headache, nausea, back pain, dizziness, extremity pain, cold feeling, fatigue, loose stool, heat, lower abdominal pain, 2. The method of claim 1, wherein the method is selected from the group consisting of injection site reaction, joint pain, injection site bleeding, throat pain, muscle spasm and abdominal pain.   The method of claim 1, wherein the PTH peptide analog is administered at a daily dose of 0.25 to 0.75 μg / kg.   17. The method of claim 16, wherein the PTH peptide analog is administered at a daily dose of 0.30 to 0.50 [mu] g / kg.   The method according to claim 1, wherein the administration is oral administration, topical administration, intrapulmonary administration, transdermal administration, intranasal administration, transcutaneous administration, parenteral injection or subcutaneous injection.   The method of claim 18, wherein the administration is intrapulmonary administration.   20. The method of claim 19, wherein the PTH peptide analog is administered at a daily inhalation dose of 100 [mu] g to 2,000 [mu] g.   21. The method of claim 20, wherein the PTH peptide analog is administered at a daily inhalation dose of 300 [mu] g to 800 [mu] g.   21. The method of claim 20, wherein the PTH peptide analog is administered as a weekly inhalation dose at 3-7 times the daily dose. The effective pharmacokinetic profile is
a) half-life of said PTH peptide analogue from 2 minutes to 60 minutes;
b) exposure time of said PTH peptide analogue from 30 minutes to 4 hours,
c) of the PTH peptide analogue of 2 minutes to 30 minutes _{T max,}
20. The method of claim 19, comprising d) a C _{max of} 10 to 400 pg / ml of the PTH peptide analog; and a pharmacokinetic parameter selected from the group consisting of:   20. The method of claim 19, wherein the effective pharmacokinetic profile comprises a half-life of the PTH peptide analog from 2 minutes to 60 minutes.   25. The method of claim 24, wherein the half-life is 15-30 minutes.   20. The method of claim 19, wherein the effective pharmacokinetic profile comprises an exposure time of the PTH peptide analog of 30 minutes to 4 hours.   27. The method of claim 26, wherein the exposure time is 1-2 hours. 20. The method of claim 19, wherein the effective pharmacokinetic profile comprises a T _max of the PTH peptide analog from 2 minutes to 30 minutes. 29. The method of claim 28, wherein the _Tmax is 15-30 minutes. 20. The method of claim 19, wherein the effective pharmacokinetic profile comprises a C _max of the PTH peptide analog of 10-400 pg / ml. 32. The method of claim 30, wherein the _Cmax is 50-200 pg / ml.   A therapeutically effective amount of a parathyroid hormone (PTH) peptide analog in unit dosage form at a dose determined by presentation of the patient's weight and symptoms and a pharmaceutically acceptable excipient, diluent or carrier or combinations thereof A pharmaceutical composition comprising, when administered, produces an effective pharmacokinetic profile and maintenance of adenylate cyclase activity while reducing undesirable side effects associated with administration of PTH.   33. The pharmaceutical composition of claim 32, wherein if the patient has a body weight above a predetermined weight cutoff, a high dose is administered, and if the patient has a body weight below a predetermined weight cutoff, a low dose is administered. .   34. The pharmaceutical composition according to claim 33, wherein the weight cutoff is 60-80 kg.   33. The pharmaceutical composition according to claim 32, wherein the weight cut-off is 68 kg.   35. The pharmaceutical composition of claim 34, wherein the low dose is 5-30 [mu] g.   34. The pharmaceutical composition according to claim 33, wherein the low dose is 30 [mu] g.   36. The pharmaceutical composition according to claim 35, wherein the high dose is 45-60 [mu] g.   40. The pharmaceutical composition according to claim 38, wherein the high dose is 45 [mu] g.   A pharmaceutical aqueous solution containing Ostabolin-C at a concentration of about 100 to 500 μg / ml containing ethanol and water, having a pH of 6.0 to 8.0, and being sterilized for parenteral administration to human patients Pharmaceutical aqueous solution in   41. The solution of claim 40, comprising 40% ethanol and 60% water.   41. The solution of claim 40, further comprising a buffer and a stabilizer selected from the group consisting of methionine, lipoic acid, sucrose and NaCl and mixtures thereof.   A pharmaceutical aqueous solution comprising Ostabolin-C at a concentration of about 100-500 ug / ml with improved bioavailability, further comprising propylene and water, having a pH of 6.0-8.0, sterilized and human patient A pharmaceutical aqueous solution ready for parenteral administration.   44. The solution of claim 43, further comprising a buffer and a stabilizer selected from the group consisting of methionine, lipoic acid, sucrose and NaCl and mixtures thereof.   45. The solution of claim 44, wherein the buffer is Tris.   46. The solution of claim 45, wherein the concentration of the buffering agent is in the range of about 2 mM to 100 mM.   44. The solution of claim 43, wherein the buffer concentration is about 5 mM.   45. The pharmaceutical solution according to claim 40 or 44, wherein the concentration of Ostabolin-C is 250 ug / ml.

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