Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/20—Pills, tablets, discs, rods
  • A61K9/2072—Pills, tablets, discs, rods characterised by shape, structure or size; Tablets with holes, special break lines or identification marks; Partially coated tablets; Disintegrating flat shaped forms
  • A61K9/2086—Layered tablets, e.g. bilayer tablets; Tablets of the type inert core-active coat
  • A61K9/209—Layered tablets, e.g. bilayer tablets; Tablets of the type inert core-active coat containing drug in at least two layers or in the core and in at least one outer layer
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
  • A61K31/44—Non condensed pyridines; Hydrogenated derivatives thereof
  • A61K31/445—Non condensed piperidines, e.g. piperocaine
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/21—Esters, e.g. nitroglycerine, selenocyanates
  • A61K31/215—Esters, e.g. nitroglycerine, selenocyanates of carboxylic acids
  • A61K31/22—Esters, e.g. nitroglycerine, selenocyanates of carboxylic acids of acyclic acids, e.g. pravastatin
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/60—Salicylic acid; Derivatives thereof
  • A61K31/612—Salicylic acid; Derivatives thereof having the hydroxy group in position 2 esterified, e.g. salicylsulfuric acid
  • A61K31/616—Salicylic acid; Derivatives thereof having the hydroxy group in position 2 esterified, e.g. salicylsulfuric acid by carboxylic acids, e.g. acetylsalicylic acid
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/0002—Galenical forms characterised by the drug release technique; Application systems commanded by energy
  • A61K9/0007—Effervescent
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/0012—Galenical forms characterised by the site of application
  • A61K9/0053—Mouth and digestive tract, i.e. intraoral and peroral administration
  • A61K9/006—Oral mucosa, e.g. mucoadhesive forms, sublingual droplets; Buccal patches or films; Buccal sprays
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
  • A61P25/04—Centrally acting analgesics, e.g. opioids
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P29/00—Non-central analgesic, antipyretic or antiinflammatory agents, e.g. antirheumatic agents; Non-steroidal antiinflammatory drugs [NSAID]
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P29/00—Non-central analgesic, antipyretic or antiinflammatory agents, e.g. antirheumatic agents; Non-steroidal antiinflammatory drugs [NSAID]
  • A61P29/02—Non-central analgesic, antipyretic or antiinflammatory agents, e.g. antirheumatic agents; Non-steroidal antiinflammatory drugs [NSAID] without antiinflammatory effect
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/20—Pills, tablets, discs, rods
  • A61K9/2004—Excipients; Inactive ingredients
  • A61K9/2022—Organic macromolecular compounds
  • A61K9/205—Polysaccharides, e.g. alginate, gums; Cyclodextrin

Definitions

• Fentanyl (CAS Registry No. 437-38-7) N-phenyl-N-[1-(2-phenyl-ethyl)-4-piperidinyl] propanamide and its salts, in particular its citrate salt (CAS Registry No. 990-73-8) are opiates, controlled substances, and extremely potent narcotic analgesics.
• Fentanyl and its citrate salt are currently marketed by a number of companies in a number of delivery formats.
• Fentanyl citrate for example, is available as an injectable and an oral lozenge on a stick, the latter sold under the trade name ACTIQ.
• breakthrough cancer pain was defined as a transient flare of moderate-to-severe pain occurring in cancer patients experiencing persistent cancer pain otherwise controlled with maintenance doses of opiate medications, including at least 60 mg of morphine/day, 50 micrograms transdermal fentanyl/hour or equianalgesic dose of another opiate for a week or longer.
• opiate medications including at least 60 mg of morphine/day, 50 micrograms transdermal fentanyl/hour or equianalgesic dose of another opiate for a week or longer.
• Fentanyl is an expensive drug, costing manufacturers as much as $100/gram or more. While cost is by no means an overriding issue, the cost of medication is an issue to be considered.
• a formulation that allows for a reduction in the amount of fentanyl could reduce the overall cost of a patient's care.
• fentanyl as a mu-opiate agonist can produce drug dependence and tolerance. Drug dependence in and of itself is not necessarily a problem with these types of cancer patients. But, fentanyl can be used in the treatment of other types of pain as well. In such treatment protocols, dependence and tolerance may be significant issues. Moreover, cancer patients are generally undergoing heavy medication. The longer that a lower dose of medication can be provided, the better.
• U.S. Pat. No. 6,200,604 which issued Mar. 13, 2001 to CIMA LABS INC., 10000 Valley View Road, Eden Prairie, Minn. 55344, exemplifies two fentanyl formulations each containing 36% effervescence and 1.57 milligrams of fentanyl salt. See example I thereof, col. 5, ln. 60 through col. 6, ln. 30.
• the '604 patent describes the use of, amongst other things, effervescence as a penetration enhancer for influencing oral drug absorption. See also U.S. Pat. Nos. 6,759,059 and 6,680,071.
• the present invention relates to an orally disintegrable/dissolvable dosage form, methods of making such dosage forms methods of using such dosage forms to treat pain and uses for the manufacture of a medicament, wherein fentanyl, or one or more of its pharmaceutically acceptable salts (where “fentanyl” is recited herein, it should be assumed to include all pharmaceutically acceptable salts unless the context suggests otherwise) are administered orally at doses containing at least about 45% less fentanyl when compared to noneffervescent lollipop formulations (both lozenge and pressed tablets) currently available. Despite the lower dose, these orally disintegrable dosage forms of the invention should have a C max which is comparable to other dosage forms containing much more, e.g., about twice as much drug.
• “Comparable” in this context means that the C max of a dosage form of the present invention is at least about 75% that of ACTIQ having about twice as much fentanyl.
• the tablet in accordance with the present invention would have a C max which is at least about 75% to about 125% of the C max of the 800 microgram ACTIQ formulation.
• the 400 microgram ACTIQ formulation will have a much lower C max . This is true for doses of up to about 800 micrograms based on the weight of fentanyl in free form.
• “about” in this context means ⁇ 10%.
• about 100 to about 800 ⁇ g is 90 to 880 ⁇ g.
• “comparable” in the context of the invention may also mean that the C max of a dosage form of the present invention is between about 80 and about 120% that of ACTIQ having about twice as much fentanyl by weight. This can also be referred to as being “highly comparable.”
• “comparable” in the context of the invention may also mean that the C max of a dosage form of the present invention is between about 85 and about 115% that of ACTIQ having about twice as much fentanyl by weight. This can also be referred to as being “very highly comparable”.
• Oral dosage form in the context of the invention preferably excludes lollipop-like lozenges like ACTIQ® and instead includes orally disintegrable dissolvable tablets, capsules, caplets, gels, creams, films and the like.
• these dosage forms are effervescent tablets.
• they may include a pH adjusting substance and a disintegrant.
• these dosage forms are applied to or placed in a specific place in the oral cavity and they remain there while they disintegrate and/or dissolve, generally in a period of about 10 to 30 minutes.
• an orally disintegrable effervescent dosage form designed for the administration of fentanyl and/or pharmaceutically acceptable salts thereof through the oral cavity such as through buccal, gingival or sublingual administration routes, rather than being swallowed.
• This formulation preferably will not include a stick or other such device permitting it to be easily held in the hand of a patient or removed from the mouth once the dosage form has been wetted in the mouth.
• the dosage form will include at least about 45% less fentanyl (based on its weight calculated as a free base material) and more preferably between about 45% and about 55% less fentanyl when compared to the corresponding ACTIQ® product. Yet they will be comparable, preferably highly comparable and even more preferably very highly comparable in terms of C max , as well as generally equally efficacious.
• the corresponding dosage form in accordance with the present invention would include approximately 880 micrograms of fentanyl or less. More preferably, it would include about 800 micrograms of fentanyl. Yet despite such a dramatic reduction in the amount of drug, at least one or more of the traditional pharmacokinetic properties measured for various drugs, such as C max , would be similar, if not superior.
• formulations may have a shorter T max , the time at which the maximum concentration is reached and/or a comparable, if not superior, C max , the highest observed concentration in the blood of a patient after administration, when compared to the corresponding ACTIQ® product containing at least 80% more fentanyl by weight.
• AUC or areas under the curve will generally be linear for dosage forms of increasing fentanyl content over the dosage ranges contemplated.
• the formulations can be produced having a roughly linear relationship between dose of fentanyl (measured by weight as a free base) and C max , specifically, over dose ranges of about 100-800 micrograms per dose.
• “Linear” should be understood to mean that there will be no significant difference in the dose-normalized C max in the dose of 90 to 880 micrograms (more preferably 100-810 ⁇ g) using ANOVA within a p of 0.15 (p less than or equal to 0.15) when formulated as part of a series of at least three dosage forms with varying doses between 90 and 880 micrograms of fentyl. This is the preferred way of determining linearity in accordance with the invention.
• the slope of ln (C max ) versus ln(dose) should be 1 ⁇ 15% (0.85-1.15).
• doses of 200, 500 and 810 ⁇ g were “linear” in accordance with the present invention.
• the ratio of C max to dose in this dosage range is between about 2.0 and about 4.0 picograms/mL/microgram. That is picograms of fentanyl base per mL of serum or a proportionate amount if determined in blood or other fluid, normalized per microgram of the dose.
• “Between” in accordance with the present invention includes the endpoints. More preferably, the ratio is about 2.5 to about 3.5 and even more preferably between about 2.7 and about 3.5 picograms/mL/microgram. These ranges are based on mean data calculated for at least 10 patents in an appropriate clinical trial. In contrast, testing has established that ACTIQ provides a ratio of about 1.4 picograms/mL/microgram.
• the present invention can provide about twice the C max , if not more, up to doses of 880 micrograms, e.g., about 800 micrograms using the invention.
• these dosage forms would also provide a linear relationship between dose and C max when formulated over a range of about 100 to about 800 micrograms of fentanyl (free base) or a proportionate amount of salt.
• this means that the ratio of dose and C max for that dose will have a linear relationship to a series produced by merely varying the same formulation to include more or less fentanyl over the described range.
• effervescent dosage forms of fentanyl designed to be administered buccally, gingivally or sublingually containing 880 micrograms or less of fentanyl, by weight, based on the weight of the free base material and having a T max of less than about 1.5 hours and most preferably less than about 1 hour. Yet these dosage forms will have a desirable C max as discussed above of between about 2.0 and about 4.0 picograms/mL/microgram. Methods of administering these dosage forms to treat pain are also contemplated.
• these formulations include effervescence to act as a penetration enhancer with or without, but preferably with an additional pH adjusting substance.
• the pH adjusting substance is something other than one of the components, compounds or molecules used to generate effervescence.
• Particularly preferred dosage forms also include a disintegrant which permits the dose reduction, linearity and/or ratio of C max and dose described herein.
• a disintegrant is a starch glycolate.
• dosage forms including a filler which faciliates the same performance as the disintegrants just described. Most preferably the filler is mannitol.
• an oral dosage form suitable for buccal, sublingual or gingival administration containing up to one milligram, and more preferably 100, 200, 300, 400, 600 or 800 micrograms of fentanyl by weight measured as the free base and further including at least one effervescent couple, at least one pH adjusting substance and suitable excipients.
• a formulation will be capable of providing a T max of 1.5 hours or less and/or a C max between about 2.0 and about 4.0 picograms/mL/microgram.
• the C max of the dosage forms of the present invention are comparable to the C max of an ACTIQ® formulation containing at least about 80 percent more fentanyl by weight.
• these dosage forms will have a C max that is within about 25% of that of ACTIQ® having at least about 80% more fentanyl free base by weight, preferably within about 20% and even more preferably within about 15% thereof.
• an orally disintegrable tablet suitable for buccal, sublingual or gingival administration containing about 100, 200, 300, 400, 600 or 800 micrograms of fentanyl, measured as a free base, at least one effervescent couple, and at least one pH adjusting substance, as well as suitable excipients, said dosage form being capable of providing a T max of about 1.5 hours or less and/or a C max of between about 2.7 and about 3.5 picograms/mL/microgram.
• any of the formulations previously mentioned herein may consist essentially of fentanyl, preferably in an amount of about 800 micrograms or less (i.e., up to 880 ⁇ g), an effervescent couple, at least one pH adjusting substance and suitable excipients which are capable of providing a C max of between about 2.0 and about 4.0 picograms/mL/microgram, more preferably between about 2.5 and about 3.5 picograms/mL/microgram, and most preferably between about 2.7 and about 3.5 picograms/mL/microgram and containing at least about 45% less fentanyl than an ACTIQ® dosage form providing comparable C max .
• “consisting essentially of” is meant to exclude any excipient or combination of excipients or, as appropriate, any amount of any excipient or combination of excipients, as well as any pH adjusting substance or any amount of pH adjusting substance that would alter the basic and novel characteristics of the invention.
• a particular excipient or mixture of excipients that would increase the T max to 2.5 hours or greater would be excluded.
• a combination of excipients provided in a specific amount which would alter C max to a level not contemplated would be excluded.
• dosage forms consisting essentially of: between 90 and 880 micrograms of fentanyl, calculated as fentanyl free base, or a salt thereof, sodium starch glycolate, mannitol, at least one pH adjusting substance and at least one effervescent couple.
• these dosage forms provide a T max of about 1.5 hours or less, a ratio of C max to dose of between about 2.0 and about 4.0 picograms/mL/microgram, a linear C max with dose, and/or a C max that is comparable as defined herein, the dosage form being suitable for buccal, sublingual or gingival administration. More preferably, the amount of fentanyl measured as a free base is 100-800 micrograms.
• Also contemplated as another aspect of the invention are methods of administering fentanyl to patients experiencing pain in general including but not limited to: back pain, lower back pain, joint pain, any form of arthritic pain, pain from trauma or accidents, neuropathic pain, surgical or postoperative pain, pain from a disease or condition other than cancer, cancer pain and in particular, breakthrough pain as a result of cancer.
• a preferred method includes the steps of administering to a patient in need thereof any orally disintegrable effervescent tablet disclosed herein for buccal, gingival or sublingual administration, which includes a dose of fentanyl of between about 100-800 micrograms (measured as a free base), and holding the dosage form in the mouth of the patient for a time sufficient to allow transport of said dose (or a therapeutically significant and/or effective portion thereof) from the oral cavity to the blood stream.
• the patient is instructed, trained or watched to ensure that the dose is not swallowed and instead to the extent practicable, the fentanyl enters the body through one or more of the surfaces within the mouth and oral cavity.
• the method also preferably includes the step of holding the dosage form in the mouth, substantially without moving it within the oral cavity.
• the dose dissolves/disintegrates or has a mean dwell time of between 5 and 30 minutes.
• One such method is a method of treating episodes of breakthrough cancer pain comprising the steps of providing an initial dose of about 100 micrograms of fentanyl calculated as a fentanyl free base or an equivalent amount of a salt thereof, in a dosage form comprising an effervescent couple in amount of about 5 to about 85% by weight of the dosage form, a pH adjusting substance in an amount of about 0.5 to about 25% by weight of the dosage form, and a starch glycolate in the amount of 0.25 to about 20% by weight of the dosage form.
• the dosage form is suitable for delivery of said fentanyl across the oral mucosa of a patient.
• the method includes placing the dosage form in the mouth of the patient between the cheek and the upper or lower gum, for a time sufficient to deliver a therapeutically effective amount of said fentanyl across said oral mucosa.
• the same method may be employed for the treatment of other types of pain including any type of back pain, surgical or postoperative pain and neuropathic pain.
• a theraputically effective amount an amount which can provide some measure of pain relief
• a theraputically effective amount generally more than 75%, more preferably more than 80% and most preferably 90% or more of the fentanyl dose is absorbed into the blood stream from the oral cavity across the oral mucosa.
• C max of dosage forms having so much less active drug compared to currently marketed products could be linear in terms of C max to dose, for example, ⁇ 15% confidence interval over a range of about 100 to about 800 ⁇ g (90-880 ⁇ g).
• a buccal, gingival or sublingual, effervescent fentanyl dosage form capable of providing one or more of: a linear relationship between dose and Cmax over a range of about 100 to about 800 micrograms; a comparable Cmax at a dose of at least about 45% less fentanyl when compared to a non-effervescent formulation such as ACTIQ at the same dose; and a ratio of Cmax to dose of 2.0 to 4.0 picograms/mL/micrograms.
• localized pH adjusting substance capable of producing a change in the localized pH in the microenvironment at the surface contact area of the oral mucosa and the dosage form once placed in the mouth of a patient
• localized pH as measured as described herein, of at least 0.5 pH units when compared to an identical formulation without the pH adjusting substance
• a disintegrant which permits the dose reduction, linearity
• the method is used to make a dosage form, preferably a tablet, that produces a linear relationship between dose and Cmax over a range of about 100 to about 800 micrograms, a highly comparable Cmax at a dose of at least about 50% less fentanyl when compared to ACTIQ at the same dose and/or a ratio of Cmax to dose of between about 2.7 and about 3.5 picorgrams/mL/micrograms.
• fentanyl or a salt thereof appropriate to provide a predetermined number of dosage forms each having between about 100 and about 800 micrograms of fentanyl, an effervescent couple in an amount of about 5 to about 85% by weight of the finished dosage forms (w/w), a pH adjustig substance in an amount of between about 0.5 to about 25% w/w, a starch glycolate in an amount of between about 0.25 and about 20% w/w with or without mannitol, and compressing same into a tablet in a dry state.
• the pH adjusting substance will provide a change in localized pH of at least about 1 pH unit when compared to an identical formulation without same.
• the word “comprise” and variations of the word such as “comprising” and “comprises,” as well as “have,” “having,” “includes,” “include” and “including,” and variations thereof, means that the named steps, elements or materials to which it refers are essential, but other steps, elements or materials may be added and still form a construct with the scope of the claim or disclosure.
• the word “comprise” and variations of the word such as “comprising” and “comprises,” as well as “have,” “having,” “includes,” “include” and “including,” and variations thereof, means that the named steps, elements or materials to which it refers are essential, but other steps, elements or materials may be added and still form a construct with the scope of the claim or disclosure.
• the term “substantially” as applied to any criteria, such as a property, characteristic or variable means to meet the stated criteria in such measure such that one skilled in the art would understand that the benefit to be achieved, or the condition or property value desired is met.
• the present invention includes, in one aspect, a dosage form comprising between about 100 and about 800 ⁇ g (micrograms) of fentanyl, calculated as fentanyl free base, or a salt thereof, suitable for buccal, sublingual or gingival administration.
• the dosage form when properly administered by contacting it to the oral mucosa for a sufficient time, is capable of providing a T max of 1.5 hours or less.
• the ratio of C max to dose of between about 2.0 and about 4.0, more preferably between about 2.3 and about 3.5 and most preferably between about 2.7 and about 3.5 picograms/mL/microgram will be realized.
• the relationship between dose and C max is linear for dose of between about 100 and about 800 micrograms compared to other doses otherwise formulated in the same way.
• the dosage form preferably further comprises at least one pH adjusting substance and at least one effervescent couple. These are each provided in an amount that is sufficient to provide the desired T max and/or C max .
• the dosage form also preferably comprises at least one excipient that is selected and provided in an amount which, in combination with the at least one pH adjusting substance and the at least one effervescent couple, provide the desired T max and/or C max .
• a method of administering fentanyl to a patient experiencing pain is another aspect of the invention.
• This method can comprise the steps of contacting the oral mucosa of a patient in need thereof with an orally disintegrable, dosage form.
• the dosage form includes a dose of fentanyl of between about 100-800 (90-880) micrograms (measured as a free base), per dosage form, or a salt thereof.
• the dosage form is capable of providing a T max of 1.5 hours or less, and/or a ratio of C max to dose of between about 2.0 and about 4.0, more preferably between about 2.3 and about 3.5 and most preferably between about 2.7 and about 3.5 picograms/mL/microgram and/or a linear relationship between C max and dose, preferably for a dosage form that includes at least 45% less fentanyl than would otherwise be prescribed using commercially known delivery formats.
• the dosage form is held in contact with the oral mucosa of the patient for a time sufficient to allow transport of a therapeutically significant or effective portion of the fentanyl, preferably more than 75%, more preferably more than 80% and most preferably 90% or more of the dose, from the oral cavity to the blood stream across the oral mucosa.
• Another aspect of the invention provides a dosage form comprising: between about 100 and about 800 micrograms of fentanyl per dosage form, calculated as fentanyl free base.
• a fentanyl salt when used, is used in an amount providing an equivalent amount of fentanyl free base by weight.
• the dosage form is suitable for buccal, sublingual or gingival administration.
• the dosage form when properly administered by contacting it to the oral mucosa for a sufficient time, is capable of providing a C max which is at least about 75 to about 125%, more preferably between about 80 and about 120%, and most preferably between about 85% to about 115% that of an ACTIQ® formulation wherein the latter includes at least 80% more fentanyl by weight.
• this dosage form also includes at least one pH adjusting substance and at least one effervescent couple in an amount which is sufficient to provide the stated C max .
• the dosage form further comprises at least one excipient in an amount which, in combination with the at least one pH adjusting substance and/or at least one effervescent couple is sufficient to provide the desired C max .
• a method of administering fentanyl to a patient experiencing pain comprising the steps of contacting the oral mucosa of a patient in need thereof with an orally disintegrable, dosage form which includes a dose of fentanyl of between about 100-800 micrograms (measured as a free base) per dosage form, or an equivalent amount of a salt thereof.
• the dosage form exhibits a C max which is at least about 75% to about 125%, more preferably between about 80 and about 120%, and most preferably between about 85% to about 115% that of an ACTIQ® formulation including at least 80% more fentanyl by weight.
• the dosage form is held in contact with the oral mucosa of the patient for a time sufficient to allow transport a therapeutically significant or effective portion of the fentanyl, preferably more than 75%, more preferably more than 80% and most preferably 90% or more of the dose, from the oral cavity to the blood stream across the oral mucosa.
• ICF Informed Consent Forms
• the study utilized a single-dose, randomized, open-label, 2-way crossover design of the designated test and reference products, and subjects were randomized to receive one of three additional test formulations during Period 3. All subjects were randomized and were in a fasted state following a 10-hour overnight fast. There was a 7-day washout interval between the three dose administrations. The subjects were confined to the clinic through 36 hours post-fentanyl administration.
• the subjects were screened within 21 days prior to study enrollment.
• the screening procedure included medical history, physical examination (height, weight, frame size, vital signs, and ECG), and clinical laboratory tests (hematology, serum chemistry, urinalysis, HIV antibody screen, hepatitis B surface antigen screen, hepatitis C antibody screen, serum pregnancy [females only]), and a screen for cannabinoids and opioids.
• the subjects were not to consume any alcohol-, broccoli-, citrus-, caffeine-, or xanthine-containing foods or beverages for 48 hours prior to and during each period of confinement. Subjects were to be nicotine- and tobacco-free for at least 6 months prior to enrolling in the study. In addition, over-the-counter medications were prohibited 7 days prior to dosing and during the study. Prescription medications were not allowed 14 days prior to dosing and during the study (excluding hormonal contraceptives for females).
• Subjects assigned to Treatments A, B, C, and D received an oral dose of one 50 mg naltrexone tablet taken with 240 mL of water at 15 hours and 3 hours prior to and 12 hours following the fentanyl dose.
• Subjects assigned to Treatment E received an oral dose of one 50 mg naltrexone tablet taken with 240 mL of water at 15 hours and 3 hours prior to the fentanyl dose.
• Actiq® oral transmucosal fentanyl citrate
• Sitting vital signs blood pressure, pulse, and respiration were assessed each morning prior to dosing (Hour 0) and at 0.25, 0.5, 0.75, 1, 1.25, 1.5, 1.75, 2, 2.25, 2.5, 2.75, 3, 3.25, 3.5, 3.75, 4, 5, 6, 8, 10, 24, and 36 hours postdose.
• Continuous pulse oximetry was conducted for the first 8 hours postdose.
• a 12-lead electrocardiogram, a clinical laboratory evaluation (hematology, serum chemistry, and urinalysis), and a physical examination with complete vital signs were performed at the completion of the study.
• Oral irritation assessments were conducted 4 hours postdose. Subjects were instructed to inform the study physician and/or nurses of any adverse events that occurred during the study.
• Blood samples (7 mL) were collected at the following times for subjects assigned to Treatments A-D: predose (Hour 0), and 10, 20, 30, and 45 minutes; and 1, 2, 4, 6, 8, 10, 12, 16, 20, 24, 28, 32, and 36 hours postdose. Blood samples (7 mL) were collected at the following times for subjects assigned to Treatment E: predose (Hour 0), and 10, 20, 30, and 45 minutes; and 1, 2, 4, 6, 8, 9, 10, 11, 12, 14, 16, 20, and 24 hours postdose.
• a total of 54 blood samples (378 mL) were drawn during the study for drug analysis. Samples were collected and processed at room temperature under fluorescent lighting. Serum samples were allowed to clot, separated by centrifugation, frozen at ⁇ 20° C., and kept frozen until assayed.
• AUC(0-t) Area under the fentanyl concentration- time curve calculated using linear trapezoidal summation from time zero to time t, where t is the time of the last measurable concentration (Ct).
• This study was a single-dose, randomized, open-label, 2-way crossover of the designated test and reference products. (Treatment A and Treatment B, Periods 1 and 2) with subjects randomized to receive one of three additional test formulations (Treatment C, Treatment D, or Treatment E) during Period 3. Due to the larger number of subjects, the study was run in two groups. The primary comparison in this study was Treatment A versus Treatment B. For the analysis of variance comparing these two treatments, only two sequences (AB, BA), two periods (1, 2), and two treatments (A, B) were considered.
• a parametric (normal-theory) general linear model was applied to the log-transformed AUC(0-inf), AUC(0-t), and Cmax values from Treatments A and B.
• the full analysis of variance (ANOVA) model considered group in the model and included the following factors: group, period within group, treatment, sequence, sequence by group, subject within sequence by group, and treatment by group. Since the treatment by group interaction was not significant, the model was reduced to sequence, subject within sequence, period, and treatment. The sequence effect was tested using the subject within sequence mean square and all other main effects were tested using the residual error (error mean square). The two one-sided hypotheses were tested at the 5% level for AUC(0-t), AUC(0-inf), and C max by constructing 90% confidence intervals for the ratio of the test and reference means (Treatment A versus Treatment B).
• Serum fentanyl concentrations and pharmacokinetic parameters were also determined following Treatment C, Treatment D, and Treatment E (1300 ⁇ g, 810 ⁇ g, and 270 ⁇ g OraVescent® Fentanyl Citrate tablet, respectively).
• Treatment C, Treatment D, and Treatment E (1300 ⁇ g, 810 ⁇ g, and 270 ⁇ g OraVescent® Fentanyl Citrate tablet, respectively).
• a mixed linear model was applied to the dose-normalized Cmax and AUC parameters from Treatments A, C, D, and E. 5-7
• the full model considered group and included the following terms: group, period within group, treatment, sequence, sequence by group, subject within sequence by group, and treatment by group.
• the dwell time values (length of time the formulation was present in the oral cavity) were calculated by subtracting the treatment administration time from the time of perceived and documented disappearance of the formulation. These values were tabulated and summary statistics were presented.
• the mean age of the subjects was 27 years (range 19-55 years), the mean height of the subjects was 68 inches (range 62-74 inches), and the mean weight of the subjects was 152.1 pounds (range 109.0-197.0 pounds).
• subjects were to have respirations taken at the 3.5-hour vital signs time point. Respirations were not taken at the 3.5-hour time point for one subject during Period 2. Vital sign recheck was not performed at the 3-hour time point of Period 2 for two subjects. Vital sign recheck was not performed at the 2.25-hour time point of Period 3 for one subject. The blood samples for these two subjects were not labeled properly at the 0.33-hour time point of Period 1 (Treatment A). These samples were not analyzed. According to the protocol, subjects were to have pulse taken at the 3.5-hour vital signs time point. Pulse was not taken at the 3.5-hour time point for one subject during Period 1. No one subject was exposed to more than one of the foregoing deviations. No serious adverse events were reported.
• the dose proportionality assessment including p-values for Treatments A, C, D, and E are summarized in the following table. Summary of the Dose-Normalized Parameters of Serum Fentanyl for Treatments A, C, D and E Serum Fentanyl Treatment A Treatment C Treatment D Treatment E Pharmacokinetic Arithmetic Arithmetic Arithmetic Arithmetic Parameters P-Value Mean SD Mean SD Mean SD Mean SD Cmax/dose — 2.5 0.8 2.1 0.7 3.3 1.0 3.0 1.2 (pg/mL/mcg) AUC(0-t)/dose — 15.4743 5.01901 14.555 4.9771 18.937 5.2597 16.050 5.9180 (pg ⁇ hr/mL/mcg) AUC(0-inf)/dose — 16.5851 5.00318 16.179 5.6510 20.779 5.4935 15.637 6.4732 (pg ⁇ hr/mL/mcg ln(Cmax/dose) 0.0127 0.
• the primary objective of this study was to assess the bioequivalence of a 1080 ⁇ g dose of CIMA LABS INC OraVescent® Fentanyl Citrate tablet (Treatment A, test) compared to a marketed 1600 ⁇ g oral transmucosal fentanyl citrate, Actiq® (Treatment B, reference) under fasted conditions.
• the study was a single-dose randomized, open-label, 2-way crossover design for Periods 1 and 2. All subjects also returned in Period 3 for administration of one of three OraVescent® Fentanyl Citrate test formulations: 1300 ⁇ g (Treatment C), 810 ⁇ g (Treatment D), or 270 ⁇ g (Treatment E).
• Dose-proportionality of the OraVescent® Fentanyl Citrate tablet formulation was evaluated.
• a total of 42 healthy subjects were initially enrolled in the study. 39 subjects completed all three periods of the study, and 40 subjects completed both Treatments A and B (Periods 1 and 2). Data from the 40 subjects completing Treatments A and B were included in the pharmacokinetic and statistical analysis.
• the ratios of geometric least square means (test/reference) for fentanyl Cmax, AUC(0-t), and AUC(0-inf) were 123.4%, 101.4%, and 101.1%, respectively, for Treatment A versus Treatment B. These data indicate that the average fentanyl exposure was similar but the peak exposure was higher for Treatment A compared to Treatment B.
• the Tmax for Treatment A (0.998 hour) occurred an hour earlier than Treatment B (2.00 hour) and Cmax was 23% higher, indicating that the rate of fentanyl absorption was significantly faster for Treatment A compared to Treatment B.
• the Cmax of Treatment A indicates that a dose of about 30-35% less fentanyl by weight given using the OraVescent® formulation exemplified in Example 1 provided a statistically significantly higher Cmax when compared to a 1600 microgram Actiq® formulation.
• an OraVescent® fentanyl formulation including at least about 45%, more preferably about 47.5% and even more preferably about 50% less fentanyl (calculated as free fentanyl by weight) than found in the comparator Actiq® tablet. In this instance, approximately 800-880 micrograms was compared to a 1600 microgram ACTIQ.
• Fentanyl AUC increased proportionally (linearly as defined herein) to the dose in the range of 270 to 1300 ⁇ g following administration of the OraVescent® Fentanyl Citrate tablet formulation. There were no significant differences in dose-normalized AUC(0-t) or AUC(0-inf) among the 4 OraVescent® doses. A significant overall treatment effect was found for the comparison of dose-normalized Cmax. Pairwise comparisons were performed using Treatment A as the reference because all subjects received Treatment A. No pattern was observed with the pairwise comparisons. A significant difference between Treatment D (810 ⁇ g) and Treatment A (1080 ⁇ g) was found.
• Fentanyl AUC increased proportionally to the dose, but not completely linearly over the whole dose range in the range of 270 to 1300 ⁇ g for the OraVescent® Fentanyl Citrate formulation.
• dwell time in accordance with the invention is the amount of time between beginning of use of dosage form (insertion into the mouth) and disappearance of all visually identifiable dosage form.
• the subjects were screened within 21 days prior to study enrollment.
• the screening procedure included medical history, physical examination (height, weight, frame size, vital signs, and electrocardiogram [ECG]), and clinical laboratory tests (hematology, serum chemistry, urinalysis, HIV antibody screen, hepatitis A antibody screen, hepatitis B surface antigen screen, hepatitis C antibody screen, and serum pregnancy [females only]), and a screen for cannabinoids and opiates.
• the subjects were not to consume any alcohol, broccoli, caffeine-, or xanthine-containing foods or beverages for 48 hours prior to and during each period of confinement. Grapefruit was restricted 10 days prior to dosing and throughout the study. Subjects were to be nicotine- and tobacco-free for at least 6 months prior to and throughout the completion of the study. In addition, over-the-counter medications (including herbal supplements) were prohibited 7 days prior to dosing and during the study. Prescription medications (including MAO inhibitors) were not allowed 14 days prior to dosing and during the study.
• Subjects randomized to Treatment A received a single oral dose of one Oravescent® Fentanyl Citrate 200 ⁇ g tablet placed between the upper gum and cheek, above a molar tooth, and allowed to disintegrate for 10 minutes.
• Sitting vital signs blood pressure, heart rate, and respiratory rate were assessed each morning prior to dosing and at 0.25, 0.5, 0.75, 1, 1.25, 1.5, 1.75, 2, 2.25, 2.5, 2.75, 3, 3.25, 3.5, 3.75, 4, 5, 6, 8, 10, 24, and 36 hours postdose.
• Continuous pulse oximetry was obtained for the first 8 hours postdose and whenever the subject attempted to sleep during the first 12 hours postdose.
• a 12-lead ECG, a clinical laboratory evaluation (hematology, serum chemistry, and urinalysis) and a brief physical examination with complete vital signs were performed at the completion of the study.
• Oral irritation assessments were conducted 4 hours postdose. At each check-in, the oral cavity was examined to ensure that the subjects did not have canker sores in the area of drug application. Subjects were instructed to inform the study physician or nurses of any adverse events that occurred during the study.
• Blood samples (7 mL) were collected at the following times for subjects assigned to Treatment A: Predose (Hour 0), 10, 20, 30, and 45 minutes; and 1, 2, 4, 6, 8, 9, 10, 11, 12, 14, 16, 20, and 24 hours postdose. Blood samples (7 mL) were collected at the following times for subjects assigned to Treatments B, C and D: Predose (Hour 0), 10, 20, 30, and 45 minutes; and 1, 2, 4, 6, 8, 10, 12, 16, 20, 24, 28, 32, and 36 hours postdose.
• AUC(0-t) Area under the fentanyl concentration-time curve calculated using linear trapezoidal summation from time zero to time t, where t is the time of the last measurable concentration (Ct).
• Plasma concentration values for fentanyl were listed and summarized by treatment and time point with descriptive statistics (mean, standard deviation [SD], coefficient of variation [CV], standard error of the mean [SEM], sample size, minimum, maximum, and median). 9-11 Values below the lower limit of quantification (LOQ) were set to zero. Mean and individual concentration-time plots were presented. Fentanyl pharmacokinetic parameters and dose-normalized pharmacokinetic parameters were tabulated by treatment and summary statistics were calculated.
• Dose proportionality from 200 ⁇ g to 1080 ⁇ g was assessed using the methodology described by Smith et al. 8 First, log-transformed parameters were analyzed using a mixed effects model including the log-transformation of dose as well as fixed and random effects for intercept. This model was fit using SAS Proc Mixed. 9-11
• a secondary analysis to examine the difference in dose-normalized Cmax between the 3 lowest dose levels (200 ⁇ g, 500 ⁇ g, and 810 ⁇ g) was performed.
• a parametric (normal-theory) GLM was applied to the dose-normalized Cmax values from Treatments A, B, and C following log-transformation.
• the analysis of variance (ANOVA) model included the following factors: treatment, sequence, subject within sequence and period. A p-value less than 0.05 was considered statistically significant.
• the dwell time values (length of time the formulation was present in the oral cavity) were calculated by subtracting the medication administration time from the time of perceived and documented disappearance of the formulation. These values were tabulated and summary statistics were presented.
• the mean age of the subjects was 33 years (range 19-55 years), the mean height of the subjects was 68.6 inches (range 60-76 inches), and the mean weight of the subjects was 160.9 pounds (range 110-215 pounds).
• Treatment A Treatment B
• Treatment C Treatment D
• Subject Time Time Time Time Number (Minutes) (Minutes) (Minutes) (Minutes)
• Treatment A 200 ⁇ g
• Treatment B 500 ⁇ g
• Treatment C 810 ⁇ g
• Treatment D 1080 ⁇ g
• Treatment A Two subjects reported slight oral irritation (2 and 3 on a scale of 1 to 10) that occurred following Treatment A. The irritation was on the left side of the mouth following test product administration during Period 2 for both subjects; one of these subjects also exhibited redness upon visual inspection of the area by study personnel. One additional subject reported pain in the upper left buccal area at the gum line 11 minutes following Treatment C. No serious or unexpected adverse events were reported.
• Treatment A Of the 28 subjects enrolled, 25 subjects completed Treatment A, 26 subjects completed Treatment B, and 27 subjects completed Treatments C and D. Statistical analysis was performed on the pharmacokinetic data for all subjects. The elimination rate constant could not be calculated in one subject in Treatment A because there were limited data points in the terminal phase. Thus, AUC(0-inf), AUCR, and T1/2 could not be calculated for this subject.
• the maximal dose ratio such that the 90% CI for ⁇ 1 lay entirely within the critical range was 3.33.
• the maximal dose ratio such that the 90% CI for ⁇ 1 fell entirely outside the critical range was 30.48.
• the primary objective of this study was to evaluate the extent to which dose proportionality exists for fentanyl AUC and Cmax following fentanyl doses of 200 ⁇ g (Treatment A), 500 ⁇ g (Treatment B), 810 ⁇ g (Treatment C), and 1080 ⁇ g (Treatment D) as OraVescent® Fentanyl Citrate tablets.
• this study was conducted to confirm previous observations relating to Cmax following the administration of 810 ⁇ g and 1080 ⁇ g doses of OraVescent® Fentanyl Citrate tablets. This study was a single-dose, randomized, open-label, 4-period crossover design.
• a secondary analysis using ANOVA to compare dose-normalized Cmax from the 200 ⁇ g, 500 ⁇ g, and 810 ⁇ g doses indicated no statistically significant difference (p 0.13) between these dose levels.
• the LS means for ln(Cmax/dose) were 1.06 (200 ⁇ g), 1.06 (500 ⁇ g), and 0.94 (810 ⁇ g), showing no difference between the 200 and 500 ⁇ g doses and a minimal (less than 15%) difference in the 810 ⁇ g dose compared to the lower doses.
• the mean dwell time for the 200 ⁇ g, 500 ⁇ g, 810 ⁇ g, and 1080 ⁇ g OraVescent® Fentanyl Citrate tablets were similar, at 14 minutes, 14 minutes, 17 minutes, and 15 minutes, respectively.
• Fentanyl AUC increased proportionally with increasing dose in the range of 200 ⁇ g to 1080 ⁇ g.
• Fentanyl Cmax increased less than proportionally to dose at the two highest dose levels. The increase was, however, linear as defined herein in all but the dose greater than 1 milligram.
• Mean ln(Cmax/dose) for the 810 ⁇ g dose was 10 to 11% lower than the 200 ⁇ g and 500 ⁇ g doses.
• Mean ln(Cmax/dose) for the 1080 ⁇ g dose was 20 to 21% lower than the 200 ⁇ g and 500 ⁇ g. There was not a clinically important deviation in dose proportionality in Cmax from 200 ⁇ g to 810 ⁇ g.
• the mean dwell time for the 200 ⁇ g, 500 ⁇ g, 810 ⁇ g, and 1080 ⁇ g OraVescent® Fentanyl Citrate tablets were similar, at 14 minutes, 14 minutes, 17 minutes, and 15 minutes, respectively.
• Any formulation which contains sufficient effervescent material and pH adjusting substance, preferably with a suitable disintegrant, which is capable of providing a dosage form useful in buccal, gingival, or sublingual administration of fentanyl at dose levels which are contemplated herein and providing for the dose reductions and/or dose to Cmax relationships disclosed herein may be used.
• any effervescent couple and/or pH adjusting substance which can be provided in an amount that produces a dosage form having a T max of 1.5 hours or less and/or provides a C max to dose of between about 2.0 and about 4.0 picograms/mL/micrograms, more preferably between about 2.5 and about 3.5, and even more preferably between about 2.7 and about 3.5 picograms/mL/micrograms may be used.
• the dosage forms will also exhibit a linear relationship between C max and dose as described herein. This means that the Cmax to dose ratio will fall along the line (p ⁇ 0.15) generated by a series of at least three different doses between 100 and 800 micrograms of fentanyl of the invention having the same composition but for the amount of fentanyl.
• any amount of effervescent couple and pH adjusting substance which provides a dosage form having comparable C max when compared to an ACTIQ formulation having at least about 80% more fentanyl is contemplated. That is it has a C max of at least 75% to 125% of the C max of such an ACTIQ formulation, more preferably between about 80% and about 125% (p less than or equal to 0.15) and most preferably between about 85% and about 115% of an ACTIQ formulation, despite having at least 45% less fentanyl (calculated as a freebase).
• these formulations will not include a significant amount of any disintegrant or excipient or combination of excipients which will interfere with such performance characteristics.
• Spray dried mannitol is a preferred filler.
• Another preferred excipient is a distintegrant which is starch glycolate and in particular sodium starch glycolate.
• the former is typically characterized as a filler and the latter a disintegrant. However, such characterizations are not controlling.
• Formulations in the '604 patent which included lactose monohydrate in an amount of greater than 20% and/or microcrystalline cellulose in an amount of at least about 20% and cross-linked PVP in an amount of 5% or more are believed to be unable to provide formulations having the desirable linear behavior of dose and C max of the levels discussed herein, despite the presence of a pH adjusting substance and an effervescent couple.
• the formulations in the '604 patent also have more than 880 ⁇ g of fentanyl.
• a preferred effervescent, orally disintegrable dosage form in accordance with the present invention is one that includes, based on the weight of the free base material, between about 100 and 800 micrograms of fentanyl (90 to 880), or a proportionate weight of one of its pharmaceutically acceptable salts.
• these numbers are meant to include normal processing variabilities such as content uniformity, etc.
• Particularly preferred doses are about 100 micrograms, about 200 micrograms, about 300 micrograms, about 400 micrograms, about 600 micrograms and about 800 micrograms, respectively.
• the mean particle size as determined by a laser diffraction technique of fentanyl used in the present formulation range from between about 0.2 to about 150 microns, more preferably from between about 0.5 to about 100 and most preferably from between about 1 to about 20 microns.
• Effervescent couples generally are water- or saliva-activated materials usually kept in an anhydrous state with little or no absorbed moisture or in a stable hydrated form. Typically these involve at least one acid source and at least one source of a reactive base, usually a carbonate or bicarbonate. Each of the components of the effervescent couple may be any which are safe for human consumption.
• the acids generally include food acids, acid anhydrides and acid salts.
• Food acids include citric acid, tartaric acid, malic acid, fumeric acid, adipic acid, ascorbic acid and succinic acid. Acid anhydrides or salts of these acids may be used. Salts in this context may include any known salt but in particular, sodium, dihydrogen phosphate, disodium dihydrogen phosphate, acid citrate salts and sodium acid sulfate.
• Bases useful in accordance with the invention typically include sodium bicarbonate, potassium bicarbonate and the like. Sodium carbonate, potassium carbonate, magnesium carbonate and the like may also be used to the extent they are used as part of an effervescent couple. However, they are more preferably used as a pH adjusting substance.
• stoichiometric equivalent amounts of acid, acid anhydride or acid salt and base are used. It is possible, however, that some excess of acid or base be used. However, care should be exercised when so formulating a formulation, particularly in view of the overall pH adjusting effect of such components, if any. An excess could affect absorption.
• the amount of effervescent material useful in accordance with the present invention is an effective amount and is determined based on properties other than those which would be necessary to achieve disintegration of the tablet in the mouth. Instead, effervescence is used as a basis for enhancing transmission of the fentanyl across mucosal membranes via buccal, gingival or sublingual administration in the oral cavity. Accordingly, the amount of effervescent couple should range from between about 5 to about 85 percent, more preferably between about 15 to 60 percent, even more preferably between about 30 and 45 percent and most preferably between about 35 to about 40 percent, based on the weight of the total formulation.
• the relative proportion of acid base will depend upon the specific ingredients (for example, whether the acid monoprotic, diprotic or triprotic) relative molecular weights, etc. However, preferably, a stoichiometric amount of each is provided although, of course, excesses are acceptable.
• formulations in accordance with the present invention include at least one pH adjusting substance.
• this permits a drug which is susceptible to changes in ionization state can be administered by ensuring the proper conditions for its dissolution as well as transmission across one or more of the membranes or tissues within the oral cavity such as across the oral mucosa. If the ideal conditions for transmission of a particular drug are basic, the addition of a sufficient excess of suitably strong acid as part of the manufacture of an effervescent couple or as a pH adjusting substance may not be indicated.
• another pH adjusting substance such as, for example, anhydrous sodium carbonate which operates separate and apart from the effervescent agents would be preferred.
• pH adjusting substances in accordance with the present invention can be used to provide further permeation enhancement.
• the selection of the appropriate pH adjusting substance will depend on the drug to be administered and, in particular, to the pH at which it is ionized or unionized, and whether the ionized or unionized form facilitates transmission across the oral mucosa.
• a basic substance is preferred for the delivery of fentanyl.
• pH adjusting substances in accordance with the present invention can include, without limitation, any substance capable of adjusting the localized pH to promote transport across the membranes in the oral cavity in amounts which will result in a pH's generally ranging from between about 3 to 10 and more preferably between about 4 to about 9.
• the pH is the “localized pH” at the microenvironment in the mouth of a patient at the surface contact area of the oral mucosa and the dosage form or any portion thereof (such as when it disintegrates).
• the localized pH can be determined as follows: to characterize the dynamic pH changes displayed by the tablets in question, an in vitro pH measurement was used. The method consists of using 0.5-10 mL of phosphate buffered saline in an appropriately sized test tube or similar vessel. The amount of media is dependent on the tablet size and dosage. For example, when measuring the pH profile for fentanyl tablets, a volume of 1 mL was used for tablets which weighed 100 mg.
• the pH profile of the solution is monitored as a function of time, using a micro-combination pH electrode.
• the materials which can be used as pH adjusting substances in accordance with the present invention include carbonates such as sodium, potassium or calcium carbonate or a phosphate such as calcium or sodium phosphate. Most preferred is sodium carbonate.
• the amount of pH adjusting substance useful in accordance with the present invention can vary with the type of pH adjusting substance used, the amount of any excess acid or base from the effervescent couple, the nature of the remaining ingredients and, of course, the drug which, in this case, is fentanyl.
• the amount of pH adjusting substance will range from between about 0.5 to about 25 percent, more preferably between about 2 to about 20 percent, even more preferably between about 5 to about 15 percent and most preferably between about 7 to about 12 percent by weight based on the weight of the total formulation.
• the most preferred pH adjusting substance is a carbonate, bicarbonate, or phosphate.
• those pH adjusting substances which, when provided in a suitable amount, can provide a change in the localized pH of at least about 0.5 pH units, more preferably about 1.0 pH units and even more preferably about 2.0 pH units when compared to an otherwise identical formulation without the pH adjusting substance.
• any filler or any amount of a filler may be used as long as the resulting dosage forms achieve the results described herein.
• Most preferred amongst the fillers are sugar and sugar alcohols and these may include non-direct compression and direct compression fillers.
• Non-direct compression fillers generally, at least when formulated, have flow and/or compression characteristics which make them impractical for use in high speed tableting process without augmentation or adjustment. For example, a formulation may not flow sufficiently well and therefore, a glidant such as, for example, silicon dioxide may need to be added.
• Direct compression fillers do not require similar allowances. They generally have compressibility and flowability characteristics which allow them to be used directly. It is noted that, depending upon the method by which formulations are made, non-direct compression fillers may be imparted with the properties of direct compression fillers. The reverse is also true. As a general matter, non-direct compression fillers tend to have a relatively smaller particle size when compared to direct compression fillers. However, certain fillers such as spray dried mannitol have relatively smaller particle sizes and yet are often directly compressible, depending upon how they are further processed. There are also relatively large nondirect compression fillers as well.
• Fillers that are preferred in accordance with the present invention include mannitol, lactose, sorbitol, dextrose, sucrose, xylitol and glucose, to the extent their use can provide the results described herein. More preferably in accordance with the present invention, the filler is not lactose monohydrate used in an amount of 20% or more based on the weight of the formulation and even more preferably no lactose monohydrate is used. Most preferred in accordance with the present invention, spray dried mannitol is used. The amount of filler can range from 10 to about 80% and more preferably about 25 to about 80%, most preferably 35 to about 60% by weight of the formulation.
• Disintegrants may also be used in accordance with the present invention so long as they permit or even facilitate the dose reductions, linearity and/or ratio of Cmax and dose as described herein. These may also include binders that have disintegrating properties. Disintegrants in accordance with the present invention can include microcrystalline cellulose, cross-linked polyvinyl pyrrolidone (PVP-XL), sodium starch glycolate, croscarmellose sodium, cross-linked hydroxypropyl cellulose and the like. Of course, the selection of the disintegrant depends upon whether or not, in a given system, the results described herein may be obtained.
• the formulation will be free of more than about 20% microcrystalline cellulose and cross-linked polyvinyl pyrrolidone in an amount of about 5% or more, especially in a formulation that includes in additional 20% lactose monohydrate.
• Most preferred for use as a disintegrant is a starch glycolate and in particular sodium starch glycolate. Indeed, it has been found that the use of sodium starch glycolate in the formulations of the present invention can provide significant improvement in the degree of dose reduction, while still providing a comparable Cmax, when compared to effervescent formulations which include pH adjusting substances and other disintegrants.
• a particularly useful sodium starch glycolate is GLYCOLYS® (standard grade) available from Roquette of Lestrem France. Indeed, it is even more preferred that the formulation include neither microcrystalline cellulose nor cross-linked PVP.
• the amount of disintegrant will vary with known factors such as, the size of the dosage form, the nature and amounts of the other ingredients used, etc. However, in general the amount should range from between about 0.25 to about 20% by weight of the final formulation, more preferably between about 0.5 to about 15% w/w, even more preferably 0.5 to about 10% w/w and even more preferably between about one and about eight percent by weight. This is again based on the weight of the finished formulation.
• a tableting or ejection lubricant is also generally useful in accordance with the present invention.
• the most common known lubricant is magnesium stearate and the use of magnesium stearate is preferred.
• the conventional wisdom behind tableting lubricants is that less is more. It is preferred in most circumstances that less than about one percent of a tableting lubricant be used. Typically, the amount should be half a percent or less.
• the amount of magnesium stearate used can be greater than 1.0%. Indeed, it is preferably greater than about 1.5% and most preferably between about 1.5% and about 3%. Most preferred is the use of about 2% magnesium stearate.
• Other conventional tableting lubricants such as, for example, stearic acid, calcium stearate and the like may also be used in place of some or all of the magnesium stearate.
• Effervescent tablets in accordance with the present invention can be relatively soft or robust. They can, for example, be manufactured in accordance with the methods described in U.S. Pat. No. 5,178,878 and will have a hardness of generally less than about 15 Newtons. Unlike the formulations described in the '878 patent, the active ingredient here will not necessarily be coated with a protective material. Indeed, preferentially, the fentanyl active will not be coated. When tablets as soft and pliable/friable as these are produced, they may be advantageously packaged in a blister package such as found in U.S. Pat. No. 6,155,423. They may also be robust with a hardness of greater than about 15 newtons, manufactured in accordance with the procedures set forth in U.S. Pat.
• the fentanyl dosage forms of the invention are provided in a blister package which is child resistant. See for example U.S. Pat. No. 6,155,423 to Katzner et al., issued Dec. 5, 2000 and assigned to CIMA LABS INC., the text of which is hereby incorporated by reference. Most preferably, the package meets the standards set forth in 16 U.S.C. ⁇ 1700.15 and 0.20 (2003). Packages also preferred include those commonly referred to in the industry as so-called “F1” and “F2” packages. “F1” packages are most preferred.
• Tablets in accordance with the present invention may be designed slightly differently for buccal, gingival, or sublingual administration.
• the in mouth disintegration time/dissolution (dwell time) achieved by the formulations is preferably less than about 30 minutes and most preferably, about 20 minutes or less. It is usually more than five minutes, most often 10 minutes or more. This is a subjective determination based on the response of the patient.
• an effervescent orally disintegrable tablet designed for buccal, sublingual or gingival administration of fentanyl, or pharmaceutically acceptable salt thereof, comprising between about 100 and about 800 micrograms of fentanyl (by weight based on the weight of the free base), an effective amount of an effervescent couple and an effective amount of a pH adjusting substance and a starch glycolate.
• the formulation may further include mannitol.
• the formulations described above do not include an amount of lactose monohydrate and/or cross-linked PVP which render it incapable of obtaining a dose reduction relative to ACTIQ® of at least about 45% fentanyl by weight.
• the formulation is free from all but incidental amounts of these excipients.
• Most preferred in accordance with the present invention are the use of sodium starch glycolate as a disintegrant and mannitol as a filler.
• Most preferred filler includes spray dried mannitol.
• the formulations in accordance with the present invention can include other conventional excipients in generally known amounts to the extent they do not detract from the advantages described herein. These can include without limitation binders, sweeteners, coloring components, flavors, glidants, lubricants, preservatives, disintegrants, and the like.
• Tablets can be made by any known tableting technique.
• the materials used are dry blended and directly compressed. While the tablets may result from granulation, this is not preferred.
• particular excipients and materials used in formulations in accordance with the present invention may be wet or dry granulated.
• granulated mannitol could be used as a filler. It may also be desirable to granulate or pre-mix some portion of the formulation prior to final blending and compression.
• the materials in question are preselected to provide the right dose and content uniformity and the dose reduction, Cmax/dose ratio and/or dose linearity described herein.
• an appropriate amount of an effervescent couple, a suitable and appropriate pH adjusting substance and an appropriate disintegrant are selected, provided in predetermined amounts and formulated to dosage forms, preferably tablets.
• the preferred pH adjusting substances are carbonates, bicarbonates, or phosphates
• the preferred disintegrant is a starch glycolate.
• the amounts used of each are described elsewhere herein.
• the disintegrant is selected and provided in an amount which can provide a further dose reduction in the amount of fentanyl used when compared to an otherwise identical formulation containing an effervescent couple and a pH adjusting substance without the disintegrant.
• the pH adjusting substance preferably is selected and provided in an amount sufficient which is capable of providing a change in localized pH of at least 0.5 pH units, more preferably 1.0 pH unit and most preferably about 2.0 pH units or more.
• While tablets may be compressed to any hardness and/or friability, same must be accomplished without adversely affecting dwell times and drug release and transmission across the oral mucosa.
• the dosage forms in accordance with the present invention may be used to treat any type of pain and in particular pain for which opiates are commonly prescribed. As with all opiates, fentanyl products and particularly those of the present invention should always be taken in consultation with a doctor and under a physician's strict care and supervision.
• the general directions for the use of the ACTIQ product as found in the previously mentioned label found in the Physician's Desk Reference and the warnings and contraindications therein are broadly applicable to the use of dosage forms in accordance with the present invention. This includes generally titrating patients with lower doses before dose escalation.
• the dosage forms in accordance with the present invention are administered by being placed in the mouth of a patient, preferably under the tongue or in between the cheek and gum, where they remain until their dissolution/disintegration is substantially complete and they cease to be recognizable as a dosage form.
• swallowing is minimized to assist in facilitating the maximum transfer of the fentanyl across the adjacent oral mucosa.
• a single dose such as, for example, 800 micrograms of fentanyl
• Preferably such multiple dosage form dosing will involve all of the dosage forms being administered within an hour, more preferably roughly contemporaneously if not simultaneously.
• one method of making a tablet in accordance with the present invention useful for buccal, gingeval, or sublingual administration comprises providing fentanyl or a salt thereof in an amount of between about 100 and about 800 micrograms per dose (measured as fentanyl base), or an equivalent amount of salt thereof.
• an effervescent couple in an amount of 5 to about 85% by weight of the dosage form, at least one pH adjusting substance in an amount of between about 0.5 and about 25% by weight of the dosage form and at least one disintegrant, preferably a starch glycolate, provided in an amount between about 0.25 to about 20% by weight of the dosage form.
• the filler is used as well.
• a portion of the filler may be preblended with the fentanyl or another excipient such as, for example, a coloring agent.
• one of the excipients often used in accordance with the present invention is a lubricant such as magnesium sterate. Generally this is added toward the end of the blending period. Blending is often interrupted and then magnesium sterate is added before blending resumes for few additional minutes.
• a blister package containing a dosage from and in accordance with the present invention should be opened immediately prior to the product's use.
• the patient should place the dosage form in his or her mouth, preferably between the cheek and the upper or lower gum.
• the dosage form should not be sucked or chewed.
• Fentanyl as with many opiates, is preferably titrated with the initial dose being a relatively low dose.
• the initial dose for dosage forms for fentanyl formulations in accordance with the present invention, especially those used to treat episodes of breakthrough cancer pain, should be 100 micrograms.
• the patient should be provided with a limited initial titration supply of 100 microgram dosage forms, thus limiting the number of units in the home during titration. Thereafter, doses may be escalated under a doctor's care.
• materials were screened prior to use, charged into a V-blender, or can be blended in any other appropriate low shear blender, and blended for an appropriate time. After discharge from the blender, the materials were compressed on a standard rotary tablet press to a target hardness of 13 Newtons and a target weight of 100 or 200 mg as described in each example.
• the materials may be screened prior to use, charged into a V-blender or other appropirate low shear blender, and blended for an appropriate time. After discharge from the blender, the materials may be compressed on a standard rotary tablet press to a target hardness of 13 Newtons and a target weight of 200 mg/tablet.

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