NZ538020A - Novel combination of glucocorticoids and PDE-4-inhibitors for treating respiratory diseases, allergic diseases, asthma and COPD - Google Patents

Abstract

Disclosed is a composition comprising a first active ingredient loteprednol, or a pharmaceutically acceptable ester thereof, and a second active ingredient N-(3,5-dichloropyridin-4-yl)-2-[1-(4-fluorobenzyl)-5-hydroxyindol-3-yl]-2-oxoacetamide (DFHO), or a pharmaceutically acceptable salt thereof, in fixed or free combination. The combination disclosed is useful in the treatment of respiratory disease, allergic diseases, asthma and chronic obstructive pulmonary diseases.

Description

New Zealand Paient Spedficaiion for Paient Number 538020 538020 Novel combination of glucocorticoids and PDE-4 inhibitors for treating respiratory diseases, allergic diseases, asthma and COPD The present invention relates to a combination of the soft steroid loteprednol (the glucocorticoid), and N-(3,5-dichloropyridin-4-yl)-2-[1-(4-fluorobenzyl)-5-hydroxyindol-3-yl]-2-oxoacetamide (the PDE-4 inhibitor), for a simultaneous, sequential or separate 10 administration in the treatment of respiratory diseases, allergic diseases, asthma and chronic obstructive pulmonary diseases (COPD).

Allergic diseases and chronic obstructive pulmonary 15 diseases (COPD) are based on inflammatory processes characterized by an increased number of inflammatory cells and increased release or secretion of inflammation mediators. Studies over the last 20 years have revealed that inflammation of the respiratory 20 tract is of central importance for the respiratory dysfunction in asthma and COPD. Comparable changes have been observed in allergic inflammations of the nose and of the eyes. Normally, the mucosa is infiltrated by a large number of cells, including mast cells, 25 eosinophils and lymphocytes. These cells release a number of mediators, including in particular interleukin-4 (IL-4), GM-CSF (granulocyte/macrophage colony-stimulating factor) and the tumor necrosis factor a (TNF-a), which eventually bring about the 30 inflammations and the symptoms of allergic diseases and of COPD.

At the present time, a similar anti-inflammatory therapeutic approach is followed for all allergic 35 diseases. The pathology of these diseases has revealed that the inflammatory process in the mucosa of patients primarily determines the symptom activity. Of the antiinflammatory compounds currently available for the 'NTEnfp£eAkirR0PERTV OFFICE OF f\J,Z -7 AUG 2009 R E C EIV P n 538020 treatment of asthma, rhinitis or conjunctivitis, glucocorticoids are the most effective. Active ingredients which can be administered topically by inhalational, intranasal or intraocular administration 5 are preferably employed. On the basis of the successful use of inhalable glucocorticoids in the treatment and prevention of respiratory inflammations and permanent lung damage in asthma patients, this therapeutic approach has also been applied to COPD patients 10 although there are no data which might unambiguously prove a long-term efficacy of these active ingredients in COPD patients (Whittaker AJ, Spiro SG; Curr Opin Pulm Med 2000; 6:104-9).

One of the most important anti-inflammatory properties of glucocorticoids arises from inhibition of cytokine release. It is known that several cytokines such as IL-4, IL-5, GM-CSF and TNF-a are involved in respiratory inflammation. The efficacy of glucocorticoids can in 20 part be explained by the inhibitory effect on cytokine synthesis and cytokine release (Marx et al.; Pulm Pharmacol Ther 2002; 15:7-15).

One disadvantage of glucocorticoids arises from their possible systemic side effects such as, for example, growth retardation or else osteoporosis. Sensible measures for reducing the risk of side effects on topical administration of glucocorticoids include the use of the minimum effective dose or restriction of the systemic availability of the active ingredient. A novel route is opened up by the use of so-called soft steroids. In contrast to other glucocorticoids, most of which undergo degradation to pharmacodynamically inactive metabolites only in the liver, the soft steroids undergo partial metabolic inactivation even at the site of their administration {intranasal, ocular or intrapulmonary). Following this partial local metabolism, only very little, or no, intellectual property office of n.z. - 7 AUG 2009 DC/^cn/r r> 538020 " 3 - pharmacodynamically active substance reaches the systemic blood circulation, so that the steroid-specific side effects are not to be expected in practice. The most prominent example of this novel 5 class of active ingredients is loteprednol, which is already approved for the therapy of allergic conjunctivitis and uveitis.

A further class of potential therapeutics for allergic 10 diseases and COPD comprises the phosphodiesterase-4 inhibitors. Phosphodiesterase enzymes are responsible for the inactivation of cyclic adenosine monophosphate (cAMP) and cyclic guanosine monophosphate (cGMP). Inhibition of phosphodiesterase-4 leads to an increase 15 in cAMP in the cells, in turn leading to downregulation of the function of virtually all proinf larranatory cells or immune cells. It is of interest that inflammatory cells involved in the pathogenesis of diseases such as asthma, conjunctivitis, rhinitis or chronic obstructive 20 pulmonary disease preferentially express the phosphodiesterase-4 enzymes.

In recent years there have been advances in the development of phosphodiesterase-4 inhibitors which can 25 be employed for the therapy of allergic diseases, asthma or COPD. It has been possible to show the in vitro inhibitory activity on cytokine release and the therapeutic efficacy in asthma models for example for the active ingredients roflumilast, cilomilast or else 30 piclamilast (Torphy et al.; Pulm Pharmacol Ther 1999; 12:131-5; Poppe et al.; Allergy 2000; 55(Suppl 63):270; Giembycz MA; Expert Opin Investig Drugs 2001; 10:1361-79; Ezeamuzie CI; Eur J Pharmacol 2001; 417:11-8). There is particular interest in a novel class of 35 substituted hydroxyindoles which are described in DE 19 818 964, DE 19 917 504 and US 6,251,923, and also novel 7-azaindoles which are disclosed in DE 10 053 275 and PCT/EP 01/12376. intellectual property office of n.z. -7 AUG 2009 RECEIVED 538020 It has now surprisingly been found that the novel combination of the glucocorticoid with the phosphodiesterase-4 inhibitor is advantageous in the 5 treatment of respiratory diseases, allergic diseases, asthma and/or chronic obstructive pulmonary diseases. Add-on therapy of the phosphodiesterase-4 inhibitor, which can be administered orally, intranasally or by inhalation, with the glucocorticoid is distinguished by 10 improved therapeutic efficacy as well as by the occurrence of few side effects.

The invention serves to improve the therapy of respiratory diseases, allergic diseases, asthma and 15 chronic obstructive pulmonary diseases, as well as the prophylaxis thereof. It is possible with the phosphodiesterase-4 inhibitor present in the combination and with the glucocorticoid successfully to control the inflammations which underlie the 20 pathological states. Moreover, add-on therapy with the phosphodiesterase-4 inhibitor leads to a smaller use of the glucocorticoid, thus reducing the risk of side effects.

The present invention therefore relates to a composition comprising a first active ingredient loteprednol, or a pharmaceutically acceptable ester thereof, and a second active ingredient N-(3,5-dichloropyridin-4-yl)-2-[1-(4-fluorobenzyl)-5-30 hydroxyindol-3-yl]-2-oxoacetamide (DFHO), or a pharmaceutically acceptable salt thereof, in fixed or free combination, and to the use thereof for producing a medicament. The invention also relates to a medicament for the treatment of respiratory diseases, 35 allergic diseases, asthma and/or chronic obstructive pulmonary diseases, which comprises the composition as above, and to a process for the production thereof. intellectual property office of n.z -7 AUG 2009 RECEIVED 538020 - 5 " The preparation of loteprednol and loteprednol etabonate is described in the German patent DE 3 126 732, the corresponding US patent 4,996,335 and the corresponding Japanese patent JP-89011037.

The substituted hydroxyindole derivative N-(3,5-dichloropyridin-4-yl)-2-[1-(4-fluorobenzyl)-5-hydroxyindol-3-yl]-2-oxoacetamide ("DFHO" hereinafter) is described in DE 19 818 964. This phosphodiesterase-4 10 inhibitor can also be employed as a pharmaceutically acceptable salt as is known to the skilled worker.

The combination as described above can be administered both prophylactically and after the appearance of 15 symptoms. The combination can also be used to retard or prevent progression of the diseases.

The following description of experiments serves to explain the inventive teaching in detail without 20 restricting it.

Inhibition of GM-CSF release from LPS-stimulated monocytes EDTAized human whole blood was mixed with Hanks' buffer in the ratio 1:1. Histopaque 1077 solution (15 ml) was cautiously overlaid with max. 40 ml of the blood: Hanks' mixture and centrifuged (2000 rpm) at room temperature for 30 min. The band enriched with 30 leukocytes was aspirated off, washed twice with Hanks' buffer and transferred into RPMI 1640 medium with Glutamax I (Gibco BRL, Eggenstein). The monocytes were removed through their adherence to the cell culture bottle over a period of two hours. The cells were then 35 thoroughly washed with medium in order to remove nonadherent cells. The resulting monocytes were cultured in RPMI 1640 medium with 10% heat-inactivated fetal calf's serum (FCS) and 100 U/ml penicillin and i intellectual property office of N.z - 7 AUG 2009 538020 100 jig/ml streptomycin in a C02 incubator (5% C02, 96% relative humidity, 37°C).

Primary monocytes were seeded in 24-well plates at 5x10s 5 cells/well. The cells were preincubated with the stated test substances for 30 minutes. LPS was then added, and incubation was continued for a period of 24 h. The supernatants were aspirated off and investigated by ELISA.

The amount of secreted human GM-CSF in the cell culture supernatants was determined by using an OptEIA™ human GM-CSF ELISA test (Pharmingen, San Diego). It was carried out in microtiter plates. Anti-human monoclonal 15 antibodies were coupled as antibodies to the plate at 4°C overnight. This coating and three washes were followed by saturation of nonspecific bindings by means of assay diluent solution™ (PBS with 10% FCS, pH 7.0) (Pharmingen, San Diego) at RT for 1 h. This was 20 followed by incubation with the samples and the standard (recombinant human GM-CSF) at 4°C overnight. The samples were prepared undiluted or in a dilution of 1:50, of the standard dilutions according to the protocol starting from a stock solution with 500 pg/ml 25 human GM-CSF. Bound human GM-CSF was detected with the aid of biotinylated monoclonal anti-human GM-CSF antibodies and an avidin-horseradish peroxidase reagent at RT for 1 h. All the steps were followed by washing 5 or 7 times with PBS/0.05% Tween 20. The enzyme activity 30 was determined using substrate solution™ (tetramethylbenzidine (TMB) and hydrogen peroxide, Pharmingen, San Diego) as substrate at RT for 30 min. The enzyme-substrate reaction was stopped with 1M phosphoric acid, and the extinction at 450 nm was 35 measured.

Results intellectual property officf of n.z, - 7 AUG 2009 RECEIVED 538020 Firstly, dose-activity plots were established separately for N-(3,5-dichloropyridin-4-yl)-2-[1-(4-fluorobenzyl)-5-hydroxyindol-3-yl]-2-oxoacetamide (DFHO) and loteprednol. From these, the IC50 for GM-CSF 5 release from human monocytes was calculated respectively as 3.2 jjM for DFHO and 53.7 nM for loteprednol. In further experiments, IC50 values for DFHO and loteprednol were established in the presence of sub-ICso concentrations of the respective other 10 substance. In these cases, addition of 5 nM DFHO lowered the IC50 for loteprednol from 53.7 nM to 13.4 nM. Conversely, addition of 10 nM loteprednol lowered the IC50 for DFHO from 3.2 pM to 0.06 pM.

The IC50 values found for loteprednol for release of TNF 15 and of GM-CSF from LPS-stimulated monocytes correspond to the IC50 values indicated in the literature for other cell systems. This means that the cell system used is valid and suitable, and the investigations which are necessary for the aim of the project with this system 20 come to a reliable conclusion. The IC50 values for DFHO correspond to those values indicated in the literature.

When 5 nM DFHO was given, the reduction in the IC50 for loteprednol for TNF release was 65% and for GM-CSF 25 release was 75%. The concentration of 5 nM DFHO is far below the IC50 for this substance, which is respectively 5.7 and 3.2 pM, so that no effect is to be observed when 5 nM DFHO is given on its own.

Conversely, the reduction in the IC50 for DFHO for TNF 30 release was 99% and for GM-CSF release was 98% when 10 nM loteprednol was given simultaneously. The concentration of 10 nM loteprednol is far below the IC50 of this substance, which is 85.5 nM and 53.7 nM respectively, so that no effect is to be observed when 35 10 nM loteprednol is given on its own.

A surprising observation which could not have been predicted by the skilled worker is that there is here a intellectual property office of n.z. -■7 AUG 2009 538020 superadditive effect brought about by the simultaneous administration of loteprednol and DFHO on the inhibition of TNF and GM-CSF release.

The dosage forms mentioned below are particularly suitable for administration of the inventive combination of active ingredients.

Thus, the active ingredients present in the combination 10 can for example be administered separately as two oral formulations, or one active ingredient is in the form of an oral formulation and the other is in topical form (intranasal, inhalational).

In one embodiment of the invention, the phosphodiesterase-4 inhibitor can be administered orally. Customary pharmaceutical formulations are used in this case, such as tablets, syrup, capsules, preparations with slowed release (sustained release 20 formulation), pastilles or effervescent granules.

Solid pharmaceutical forms such as tablets may comprise inert ingredients and carriers such as, for example, calcium carbonate, calcium phosphate, sodium phosphate, 25 lactose, starch, mannitol, alginates, gelatin, guar gum, magnesium stearate or aluminum stearate, methyl-cellulose, talc, colloidal silicas, silicone oil, high molecular weight fatty acids (such as stearic acid), agar-agar or vegetable or animal fats and oils, solid 30 high molecular weight polymers (such as polyethylene glycol); preparations suitable for oral administrations may, where appropriate, comprise additional flavorings or sweeteners. The compositions in capsule form can be produced by generally customary processes, for example 35 by using the aforementioned carriers in a hard gelatin capsule shell. For compositions in the form of soft gelatin capsules it is possible to employ pharmaceutical carriers normally used for producing intellectual property office of n.z -7 AUG 2009 n ■»» r— i % i r— r> 538020 dispersions or suspensions, such as, for example, aqueous gums, celluloses, silicates or oils, which are incorporated into a soft gelatin capsule shell. Syrup formulations normally consist of a suspension or 5 solution of the compound or of a salt thereof in a liquid carrier such as, for example, ethanol, peanut oil, olive oil, glycerol or water, it being possible for flavorings and colorants to be present.

It is possible through topical administration of the inventive combination of active ingredients to achieve therapeutically effective concentrations even with lower dosages. For this reason, topical formulations, which include in particular intranasal and inhalational formulations, are preferred for the purposes of the present invention.

Intranasal preparations may be administered as aqueous or oily solutions, suspensions or emulsions. For the administration of an active ingredient by inhalation, it can be administered in the form of a suspension, solution or emulsion which is present as dry powder or as aerosol, it being possible to use all customary propellants.

In a preferred embodiment of the invention, the phosphodiesterase-4 inhibitor composition is in the form of a nasal spray or of a metered aerosol or of a metered dry powder for inhalation. The glucocorticoid composition is preferably a formulation in the form of nasal spray, metered aerosol or metered dry powder for inhalation.

Loteprednol etabonate is preferably formulated as a 35 suspension in water, with further ingredients such as preservatives, stabilizers, tonicity agents, thickeners, suspension stabilizers, excipients to adjust the pH, buffer systems and wetting agents. For intellectual property office of n.z -7 AUG 2009 Dcr»cn/cr\ 538020 further details of suitable excipients, reference is made for example to DE 19 947 234.

The pharmaceutical preparations of the invention may, 5 besides the glucocorticoid and the phosphodiesterase-4 inhibitor active ingredients, comprise further ingredients such as customary preservatives, stabilizers, thickeners, flavorings, etc.

Exemplary embodiment Nasal spray suspension with loteprednol etabonate (1%) Loteprednol etabonate 1.000 g Avicel RC 5 91 1.100 g Polysorbate 80 0.100 g Sorbitol solution 70% 6.000 g Sodium edetate 0.050 g Benzalkonium chloride 0.020 g Purified water ad 100 ml Production Introduce 45 kg of purified water into a suitable agitating container with homogenizing device, and homogenize Avicel RC 591 therein at high speed. Then dissolve the substances polysorbate 80, sorbitol solution, sodium edetate and benzalkonium chloride 20 together while agitating.

Subsequently homogenize the active ingredient loteprednol etabonate at high speed until a uniform suspension is produced. Then make up the final volume 25 with purified water and homogenize further. Subsequently evacuate the suspension in order to remove the air bubbles which have been produced. The resulting suspension is subsequently dispensed into bottles which are then provided with a suitable nasal spray pump. [ inltllfcctual property office of n.z -7 AUG 2009 Received!

Claims (1)

1. 538020 - 11 - In an advantageous embodiment, the active components of this combination are in the form of a fixed combination, thus simplifying use for the patient. 5 Administration of the active ingredients can in this case take place simultaneously, sequentially or separately in free or fixed combination. They can be administered both in a single-dose form and as two separate formulations, which may be identical or 10 different. Delivery can take place at the same time, simultaneously, or at separate times, by which is meant both short and long intervals such as, for example, administration of loteprednol in the evening and administration of the phosphodiesterase-4 inhibitor in 15 the morning, or vice versa. The active ingredients can be administered from once to six times a day. The active ingredients are preferably administered once to twice a day, particularly 20 preferably twice a day. The dose of one or more phosphodiesterase-4 inhibitors is approximately from 0.1 to 20 mg per day per adult, preferably between 0.2 and 5 mg. The dose of the glucocorticoid can be in the region of the approved dosage, i.e. in the range from 25 0.1 to 1.6 mg per day, preferably between 0.2 and 0.8 mg per day. The actual dose depends on the general condition of the patients (age, weight, etc.) and the severity of the disease. INTELLECTUAL PROPERTY OFFICE OF N.Z. - 7 AUG 2009 RECEIVED 538020 - 12 - CLAIMS 1. A composition comprising a first active ingredient loteprednol, or a pharmaceutically acceptable ester 5 thereof, and a second active ingredient N-(3,5-dichloropyridin-4-yl)-2-[1-(4-fluorobenzyl)-5-hydroxyindol-3-yl]-2-oxoacetamide (DFHO), or a pharmaceutically acceptable salt thereof, in fixed or free combination. 10 2. The composition as claimed in claim 1, wherein the loteprednol or a pharmaceutically acceptable ester thereof is loteprednol etabonate. 15 3. The composition as claimed in claim 1 or 2, which is adapted for oral administration. 6. The composition as claimed in claim 1 or 2, which is adapted for topical administration. 20 7. The composition as claimed in claim 1 or 2, which is adapted for simultaneous, sequential or separate administration from one another, and which is adapted for intranasal or inhalable administration. 25 8. The composition as claimed in claim 5 or 7, which is an inhalable liquid or a solid preparation. 9. The composition as claimed in claim 1 or 2, 30 wherein the first or second active ingredient is adapted for oral administration and the other active ingredient is adapted for topical administration. 10. The composition as claimed in claim 1 or 2, 35 wherein the DFHO or a pharmaceutically acceptable salt thereof is adapted for oral administration. 11. A medicament comprising the composition according intellectual property office of n.z. -7 AUG 2009 538020 - 13 - to any one of claims 1 to 10, in fixed or free combination, where appropriate, together with customary excipients or carriers. 5 12. A process for producing a medicament according to claim 11, wherein loteprednol, or a pharmaceutically acceptable ester thereof, or DFHO, or pharmaceutically acceptable salt thereof, are mixed singly or together, where appropriate, together with customary excipients 10 and carriers, and the mixture obtained in this way is converted into a suitable dosage form. 13. Use of a composition according to any one of claims 1 to 10 for the manufacture of a medicament for 15 the treatment and prophylaxis of respiratory diseases, allergic diseases, asthma and/or chronic obstructive pulmonary diseases. 14. Use of a medicament according to claim 11 for the 2 0 manufacture of a medicament for the treatment and prophylaxis of respiratory diseases, allergic diseases, asthma and/or chronic obstructive pulmonary diseases. 15. A medicament produced by the process of claim 12. 25 16. The composition according to claim 1, substantially as herein described with reference to the exemplary embodiment. 30 17. The composition according to any one of claims 1 to 10, substantially as herein described. 18. The medicament according to claim 11 in which the composition is substantially as herein described with 35 reference to the exemplary embodiment. substantially as herein described. INTELLECTUAL PROPERTY OFFICE OF N.Z -7 AUG 2009 r\ p— r* i i t r* i-\ 538020 - 14 - 20. The process according to claim 12 in which the composition is substantially as herein described with reference to the exemplary embodiment. 5 21. The process according to claim 12, substantially as herein described. 22. The use according to claim 13 or 14 in which the 10 composition is substantially as herein described with reference to the exemplary embodiment. 23. The use according to claim 13 or 14, substantially as herein described. 15