Classifications

• • 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
  • A61K31/40—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having five-membered rings with one nitrogen as the only ring hetero atom, e.g. sulpiride, succinimide, tolmetin, buflomedil
  • A61K31/401—Proline; Derivatives thereof, e.g. captopril
• • 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
  • A61K31/40—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having five-membered rings with one nitrogen as the only ring hetero atom, e.g. sulpiride, succinimide, tolmetin, buflomedil
  • A61K31/4015—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having five-membered rings with one nitrogen as the only ring hetero atom, e.g. sulpiride, succinimide, tolmetin, buflomedil having oxo groups directly attached to the heterocyclic ring, e.g. piracetam, ethosuximide
• • 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
  • A61K31/56—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids
• • 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
  • A61K31/56—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids
  • A61K31/57—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids substituted in position 17 beta by a chain of two carbon atoms, e.g. pregnane or progesterone
  • A61K31/573—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids substituted in position 17 beta by a chain of two carbon atoms, e.g. pregnane or progesterone substituted in position 21, e.g. cortisone, dexamethasone, prednisone or aldosterone
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
  • A61K45/06—Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P11/00—Drugs for disorders of the respiratory system
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P11/00—Drugs for disorders of the respiratory system
  • A61P11/06—Antiasthmatics
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P11/00—Drugs for disorders of the respiratory system
  • A61P11/08—Bronchodilators
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P37/00—Drugs for immunological or allergic disorders
  • A61P37/08—Antiallergic agents

Definitions

• the present invention describes the combination of topically inhaled medicinal formulations comprising an anticholinergic component and a glucocorticosteroid component and its use in the symptomatic and prophylactic treatment of diseases of the respiratory tract, especially with an obstructive component or underlying inflammation like asthma and chronic obstructive pulmonary disease (COPD). It further comprises the presentation of this combination in a locally applied (inhaled) formulation and application in an inhalation device for instance in the Novolizer®.
• COPD chronic obstructive pulmonary disease
• COPD chronic airflow obstruction
• episodic acute exacerbations which result in increased morbidity and mortality.
• Patients hospitalized with exacerbations have an overall mortality rate of 3% to 4%, and up to 24% of patients requiring care in the intensive care unit die (Blanchard, Clin Cornerstone. 2003; 5(1): 28-36).
• Bronchial asthma remains a significant cause of mortality at all ages as well (Sidebotham und Roche, Histopathology. 2003 August; 43(2): 105-17).
• Bronchial asthma causes characteristic histological changes in the mucosa of the airways which includes fibrous thickening of the lamina reticularis of the epithelial basement membrane, smooth muscle hypertrophy and hyperplasia, increased mucosal vascularity and an eosinophil-rich inflammatory cell infiltrate (Sidebotham and Roche, Histopathology. 2003 August; 43(2): 105-17).
• COPD chronic inflammation leads to (partially) fixed narrowing of small airways and alveolar wall destruction (emphysema) (Barnes, Annu Rev Med. 2003; 54: 113-29. Epub 2001 Dec. 3).
• both diseases comprise a kind of narrowing of the small airways due to smooth muscle hypertrophy and a kind of inflammatory process as well.
• the management of the diseases consists therefor on the one hand of a symptomatic reliever medication which dilates the small airways and on the other hand of a causal treatment which controls the underlying inflammation process.
• Inhaled anticholinergic agents and ⁇ 2-adrenoreceptor agonists
• COPD GOLD Guideline, 2002
• asthma GINA Guideline, 2002
• a causal treatment with anticholinergic agents is not possible, nor a rapid symptomatic relief is expected with glucocorticosteroids.
• Anticholinergic agents are exemplified by the belladonna alkaloids atropine and scopolamine, which inhibit the muscarinic action of acetylcholine on structure innervated by postganglionic cholinergic nerves. These agents typically inhibit bronchoconstriction by relaxing of smooth muscles and cause considerable bronchodilation. Anticholinergic agents also are known to exert central effects which include pupil dilatation and stimulation and/or depression of the central nervous system. Novel anticholinergic pharmaceuticals have been developed which have a limited capacity to pass across the blood-brain barrier, and therefore have a limited capacity to produce central effects. Examples of these agents are the quaternary ammonium compounds methscopolamine, ipratropium, tiotropium and the enantiomers of glycopyrrolate.
• Antimuscarinic treatment of asthma and COPD has a relatively long history leading to its present day use as an effective bronchodilating drug for obstructive pulmonary diseases.
• Present formulations are, however, limited to oxitropium, ipratropium, and the recently approved tiotropium bromide.
• Anticholinergics are agents of first choice for the symptomatic treatment of patients with COPD.
• inhaled bronchodilators such as ipratropium bromide have proven useful (Hall et al.).
• Tiotropium is a long-acting inhaled anticholinergic designed for once-daily bronchodilator treatment of COPD.
• Tiotropium is a selective antagonist of pulmonary Ml and M3 muscarinic receptor subtypes, that produces a long-lasting (24 hours), dose-dependent bronchodilation and bronchoprotection against constrictive stimuli, e.g. methacholine, following inhalation of single doses.
• Anticholinergic drugs have long since been used in the treatment of chronic obstructive pulmonary disease (COPD) and asthma (Joos, Monaldi Arch Chest Dis. 2000 October; 55(5): 411-4).
• COPD chronic obstructive pulmonary disease
• Clinical studies with inhaled tiotropium bromide confirm that it is a potent and long-lasting bronchodilator in COPD and asthma (Barnes et al., Life Sci. 1995; 56(11-12): 853-9).
• Current therapeutic options for acute severe asthma consist of ipratropium and glucocorticosteroids in combination with beta2 selective drugs (McFadden, Am J Respir Crit Care Med. 2003 October 1; 168(7): 740-59).
• the goals of treatment of adult asthma may be summarized as relief of airflow obstruction by administration of inhaled beta-agonists and anticholinergics, and reduction of airway inflammation and prevention of future relapses by using early administration of s corticosteroids (Rodrigo, Curr Opin Allergy Clin Immunol. 2003 June; 3(3): 169-75).
• Inhaled glucocorticosteroids are the most effective therapy in controlling chronic asthma symptoms (Barnes, J Aerosol Med. 1996 Spring; 9(1): 131-41). Randomized, controlled clinical studies confirm the efficacy of early intervention with inhaled glucocorticosteroids in patients with mild persistent asthma. Regular use of an inhaled glucocorticosteroids can reduce the number of exacerbations and hospitalizations in patients of all ages and with all disease severities (Chapman, Clin Ther. 2003; 25 Suppl C:C 2 -C 14 ).
• fluticasone Within inhaled glucocorticosteroids, fluticasone is endowed of a potent antiinflammatory activity, due to its high affinity for the the glucocorticoid receptor (allowing the use of 50% of the dose of other ICS) and of a negligible oral bioavailability ( ⁇ 1%), indicating a low potential for systemic exposure. Due to its high therapeutical index, fluticasone can be used in the management of severe asthma or other airway diseases at doses devoid of relevant unwanted systemic effects. Scientific literature has broadly demonstrated its efficacy and safety, even at high doses and in the long term use (Solidoro et al., Minerva Pediatr. 2003 August; 55(4): 345-55).
• budesonide When combined with delivery devices suitable for a spectrum of patient groups, the physical and pharmacokinetic properties of budesonide lend it many of the characteristics of an ideal inhaled glucocorticosteroid, including favorable efficacy and tolerability profiles (O'Connell, Clin Ther. 2003; 25 Suppl C:C42-60). Whereas budesonide has clinical efficacy similar to that of other currently available ICSs, it has a good safety profile—and hence a favorable therapeutic margin—that is supported by long-term clinical data (Skoner, Clin Ther. 2003; 25 Suppl C:C61-74).
• Glucocorticosteroids should mainly be used to reduce exacerbations and improve the health status of these patients (Man et al., JAMA. 2003 Nov. 5; 290(17): 2313-6). But it has to be admitted that current pharmacological treatment of COPD is unsatisfactory, as it does not significantly influence the severity of the disease or its natural course.
• a solution is given by the combination of inhaled glycopyrrolate with an inhaled glucocorticoid like budesonide, fluticasone, ciclesonide, or beclometason.
• Glycopyrrolate belongs to the so-called quaternary ammonium anticholinergic drugs and antagonizes the neurotransmitter acetylcholine at its muscarinic receptors. This effect leads to a considerable smooth muscle relaxation resulting in a prolonged bronchodilating effect. Due to the fast onset and the long duration of action anticholinergic agents are the first choice for the symptomatic treatment of COPD.
• Topically inhaled glucocorticosteroids such as budesonide and fluticasone suppress inflammation in asthmatic airways by affecting the transcription of several steroid-responsive genes and have become first-line therapy for the long-term asthma control.
• the combination of a symptomatic and a causal treatment is superior to that of the mono-compounds resulting in over-additive effects and/or diminished side-effects, respectively. Therefore, the combination can be useful in the treatment of obstructive airway diseases of different origins like COPD or asthma.
• topically inhaled anticholinergic agents such as glycopyrrolate, including one of its enantiomers, especially R,R-glycopyrrolate or their physiologically acceptable salts or a mixture thereof administered in combination with topically inhaled glucocorticosteroids is effective and safe in the treatment of asthma and chronic obstructive pulmonary disease (COPD) which allows for lower doses or which decreases side-effects.
• COPD chronic obstructive pulmonary disease
• PBMCs peripheral blood mononuclear cells
• PBMCs were isolated from heparinized blood samples of healthy donors by density gradient centrifugation. An equal volume of Hanks buffer (Life Technologies, Heidelberg, Germany) is added to heparinized whole blood samples. 15 ml Histopaque-1077. (Sigma, Deisenhofen, Germany) are overlayed with a maximum of 40 ml of blood/Hanks mixture were centrifuged for 30 min at room temperature (2000 rpm). A visible band containing PBMCs is transferred to a fresh tube and washed twice with Hanks-buffer.
• Hanks buffer Life Technologies, Heidelberg, Germany
• PBMCs were cultured in RPMI 1640 medium supplemented with 10% fetal calf serum (FCS) at 37° C. 5% CO 2 overnight.
• FCS fetal calf serum
• Cytokine measurements in culture supernatants are done by sandwich ELISA using matched antibody pairs (Pharmingen, Heidelberg, Germany).
• ELISA plates (Maxisorb, Nunc) are coated overnight with anti-cytokine monoclonal antibody (mAb) in 0.1 M carbonate buffer, pH 9.5. After being washed, plates are blocked with Assay Diluent (Pharmingen, Heidelberg, Germany) for 1 h and washed again. Appropriately diluted supernatant samples and standards are distributed in duplicates and the plates are incubated for 2 h at room temperature.
• Plates are washed, incubated for 1 h with working detector (biotinylated anti-cytokine antibody and Avidin-horseradish peroxidase conjugate). After washing, substrate (TMB and hydrogen peroxide) is added. The reaction is stopped by adding of 1M H 3 PO 4 . Plates are read at 450 nm (reference 570 nm) in a microplate reader (Dynatech). The results are expressed as a percentage of the control level of cytokines production by cells stimulated in the absence of the compound.
• the combination therapy disclosed by this invention comprises administering a glucocorticosteroid together with a long-acting anticholinergic bronchodilator to prevent onset of a pulmonary disease event or to treat an existing condition and to reduce obstruction and airway inflammation.
• the compounds may be administered together in a single dosage form. Or they may be administered in different dosage forms. These drugs are usually administered as an aerosol (with or without propellant), or as an inhaled powder for instance with the Novolizer®. This invention contemplates either co-administering both drugs in one delivery form such as an inhaler, that is putting both drugs in the same inhaler. Formulations are within the skill of the art and may contain all usual excipients, adjuncts, and additives.
• the active ingredients may be given from 1 to 8 times a day, sufficient to exhibit the desired activity.
• the active components are given about once or four times a day, more preferably once or twice a day.
• the compounds of the combination may be administered at the same time. Or they may be administered either close in time or remotely, such as where one drug is administered in the morning and the second drug is administered in the evening. Or in another scenario, one drug could be taken twice daily and the other once daily, either at the same time as one of the twice-a-day dosing occurred, or separately.
• both drugs should be taken together at the same time.
• the inhaled anticholinergic drug, racemic glycopyrrolate, one of its enantiomers, especially R,R-glycopyrrolate or a mixture thereof and its salts, solvates and hydrates can be administered in an amount of between 5 and 500 ⁇ g/day adult human with the preference of 15 to 300 ⁇ g/day in dependence of the magnitude of symptoms.
• a dosage range between 5 and 100 ⁇ g/day is especially preferred.
• Glucocorticosteroids can be administered inhaled in conformity with approved labeling in an amount of 100 to 1.600 ⁇ g/day preferably between 200 and 400 ⁇ g/day.
• the combination may be used prophylactically or after the onset of symptoms has occurred. In some instances the combination(s) may be used to prevent the progression of a pulmonary disease or to arrest the decline of a function such as lung function.
• a quantity of 250 g micronized fluticasone is mixed with 1000 g alpha lactose monohydrate, the mixture is given on a sieve of 0.5 mm mesh size and finally mixed again.
• 20 g micronized glycopyrrolate is mixed with 100 g alpha lactose monohydrate, the mixture is given on a sieve of 0.8 mm mesh size and finally mixed again.
• the two mixtures received are blended and filled up with alpha lactose monohydrate to 15000 g. Subsequently, it is mixed again and the powder mixture received is filled in powder inhalers releasing 15 mg of powder per single dose.
• Per single dose 250 ⁇ g fluticasone and 20 ⁇ g glycopyrrolate are released from a powder inhaler and supplied to the patient's airways.

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