US20070065492A1 - Cladribine formulations for improved oral and transmucosal delivery - Google Patents

Cladribine formulations for improved oral and transmucosal delivery Download PDF

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US20070065492A1
US20070065492A1 US10/551,094 US55109404A US2007065492A1 US 20070065492 A1 US20070065492 A1 US 20070065492A1 US 55109404 A US55109404 A US 55109404A US 2007065492 A1 US2007065492 A1 US 2007065492A1
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cyclodextrin
cladribine
complex
dosage form
saturated
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Nicholas Bodor
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Ares Trading SA
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Ivax LLC
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    • C08B—POLYSACCHARIDES; DERIVATIVES THEREOF
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    • C08B37/0006—Homoglycans, i.e. polysaccharides having a main chain consisting of one single sugar, e.g. colominic acid
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Definitions

  • the invention relates to a composition comprising a cladribine-cyclodextrin complex formulated into a solid oral dosage form or a transmucosal dosage form and to a method for enhancing the oral and transmucosal bioavailability of cladribine.
  • Cladribine which is an acid-labile drug, has the chemical structure as set forth below:
  • Cladribine is an antimetabolite which has use in the treatment of lymphoproliferative disorders. It has been used to treat experimental leukemias such as L1210 and clinically for hairy cell leukemia and chronic lymphocytic leukemia as well as Waldenstrom's macroglobulinaemia. It has also been used as an immunosuppressive agent and as a modality for the treatment of a variety of autoimmune conditions including rheumatoid arthritis, inflammatory bowel disease (e.g., Crohn's disease, ulcerative colitis) and multiple sclerosis (see e.g., J. Liliemark, Clin. Pharmacokinet, 32(2): 120-131, 1997).
  • rheumatoid arthritis e.g., Crohn's disease, ulcerative colitis
  • multiple sclerosis see e.g., J. Liliemark, Clin. Pharmacokinet, 32(2): 120-131, 1997.
  • lymphomas Langerhan's cell histiocytosis, lupus erythematosus, chronic plaque psoriasis, Sezary syndrome, Bing-Neel syndrome, recurrent glioma, and solid tumors.
  • Oral delivery of drugs is often preferred to parenteral delivery for a variety of reasons, foremost patient compliance, or for cost or therapeutic considerations.
  • Patient compliance is enhanced insofar as oral dosage forms alleviate repeated health care provider visits, or the discomfort of injections or prolonged infusion times associated with some active drugs.
  • the reduced costs associated with oral or transmucosal administration versus parenteral administration costs gain importance.
  • the cost of parenteral administration is much higher due to the requirement that a health care professional administer the cladribine in the health care provider setting, which also includes all attendant costs associated with such administration.
  • therapeutic considerations such as the need for a slow release of cladribine over a prolonged period of time may be practically met only by oral or transmucosal delivery.
  • Cyclodextrins are cyclic oligosaccharides composed of cyclic ⁇ -(1 ⁇ 4) linked D-glucopyranose units. Cyclodextrins with six to eight units have been named ⁇ -, ⁇ - and ⁇ -cyclodextrin, respectively. The number of units determines the size of the cone-shaped cavity which characterizes cyclodextrins and into which drugs may include to form stable complexes. A number of derivatives of ⁇ -, ⁇ - and ⁇ -cyclodextrin are known in which one or more hydroxyl groups is/are replaced with ether groups or other radicals. These compounds are thus known complexing agents and have been previously used in the pharmaceutical field to form inclusion complexes with water-insoluble drugs and to thus solubilize them in aqueous media.
  • these dosage ranges include many combinations which may be suitable as mixtures but not for complex formation.
  • a ratio of 1 mg of cladribine to 500 mg of cyclodextrin contains too much cyclodextrin, so that the drug would not readily leave the complex and achieve its therapeutic function.
  • 15 mg of cladribine and only 100 mg of cyclodextrin would not be enough to complex that amount of cladribine.
  • the Schultz et al. patent does suggest improving the stability of cladribine in oral dosage forms by combining/complexing it with cyclodextrin, but does not suggest improving the drug's oral bioavailability by such means; in fact, the patent does not describe or suggest a method for enhancing or maximizing the bioavailability of cladribine from a solid oral dosage form of cladribine and cyclodextrin, or a composition specially designed to do so. Further, Schultz et al.
  • cladribine/cyclodextrin combinations for transmucosal administration, that is, in a form intended for administration through the mucosa lining the nasal, oral, vaginal or rectal cavities rather than via the orogastric route, much less enhancing the bioavailability of the drug when administered via such a dosage form.
  • the present invention provides a pharmaceutical composition
  • a pharmaceutical composition comprising a saturated cladribine-cyclodextrin complex formulated into a solid oral dosage form or a transmucosal dosage form which is substantially free of cyclodextrin in excess of the minimum amount needed to maximize the amount of cladribine in the complex.
  • the pharmaceutical composition comprises a saturated cladribine-cyclodextrin complex formulated into a solid oral dosage form or a transmucosal dosage form which is substantially free of cyclodextrin in excess of the minimum amount needed to maintain substantially all of the cladribine in the complex.
  • This composition provides cladribine in its highest thermodynamic activity state at the time it contacts the gastric mucosa (in the case of an oral dosage form) or the rectal, vaginal, buccal or nasal mucosa (in the case of transmucosal dosage forms).
  • the invention also provides a method for increasing the oral or transmucosal bioavailability of cladribine comprising administering to a subject in need thereof, a pharmaceutical composition comprising a saturated cladribine-cyclodextrin complex formulated into a solid oral dosage form or a transmucosal dosage form which is substantially free of cyclodextrin in excess of the minimum amount needed to maximize the amount of the cladribine in the complex.
  • the composition administered comprises a saturated cladribine-cyclodextrin complex formulated into a solid oral dosage form or a transmucosal dosage form which is substantially free of cyclodextrin in excess of the minimum amount needed to maintain substantially all of the cladribine in the complex.
  • the invention further provides a method for enhancing the bioavailability of cladribine from a solid oral dosage form or a transmucosal dosage form in a mammal in need of treatment with cladribine, the method comprising: (a) determining the minimum amount of cyclodextrin required to complex with a selected amount of cladribine and to maintain said selected amount of cladribine in the complex; (b) combining an amount of cladribine in excess of said selected amount with said minimum amount of cyclodextrin in an aqueous medium; (c) removing uncomplexed cladribine from the complexation medium; (d) removing water from the resultant solution to afford the dry saturated cladribine-cyclodextrin complex; (e) formulating said dry saturated cladribine-cyclodextrin complex into a solid oral dosage form or a transmucosal dosage form substantially free of cyclodextrin in excess of the minimum amount required to
  • step (e) comprises formulating said dry saturated cladribine-cyclodextrin complex into a solid oral dosage form or a transmucosal dosage form substantially free of cyclodextrin in excess of the minimum amount required to maintain substantially all of the cladribine in the complex.
  • the invention further provides for treatment of conditions responsive to administration of cladribine in mammals by administering thereto the composition of the invention.
  • Use of cladribine in the preparation of the pharmaceutical compositions of the invention for administration to treat symptoms of cladribine-responsive conditions and for enhancing the oral or transmucosal bioavailability of cladribine is also provided.
  • the invention provides a novel 1:2 complex of cladribine: ⁇ -cyclodextrin which is particularly advantageous.
  • FIG. 1 is a graphical representation of the results of phase solubility studies, where various cyclodextrin (CD) molar concentrations are plotted against various cladribine molar concentrations, with ( ⁇ ) representing hydroxypropyl- ⁇ -cyclodextrin, ( ⁇ ) representing hydroxypropyl- ⁇ -cyclodextrin with added hydroxypropyl methylcellulose, and ( ⁇ ) representing ⁇ -cyclodextrin.
  • CD cyclodextrin
  • FIG. 2 shows plasma profiles for cladribine in dogs after administration of 5 mg single doses of cladribine with data showing the average concentration of cladribine in the plasma, in pg/ml, ⁇ SD for 5-6 animals per group, plotted against time in hours, following administration of the following cladribine formulations: ( ⁇ ) intravenous (i.v.) bolus; saturated buccal cladribine ⁇ -cyclodextrin complex; (x) saturated buccal cladribine-hydroxypropyl- ⁇ -cyclodextrin complex; ( ⁇ ) saturated oral cladribine- ⁇ -cyclodextrin complex; ( ⁇ ) oral capsule of physical mixture of cladribine with ten times excess ⁇ -cyclodextrin; ( ⁇ ) oral capsule of cladribine complex with ten times excess ⁇ -cyclodextrin; ( ⁇ ) saturated oral cladribine-hydroxypropyl- ⁇ -cyclodextrin complex; and ( ⁇ ) oral capsule of
  • FIG. 3 represents a comparison of plasma profiles for cladribine in dogs after administration of 5 mg single doses of cladribine, with data showing the average concentration, in pg/mL, ⁇ SD for 5-6 animals per group, plotted against time in hours, following administration of the following cladribine formulations: ( ⁇ ) intravenous (i.v.) bolus, ( ⁇ ) saturated oral cladribine- ⁇ -cyclodextrin complex, and ( ⁇ ) saturated oral cladribine-hydroxypropyl- ⁇ -cyclodextrin complex.
  • FIG. 4 represents a comparison of plasma profiles for cladribine in dogs after oral administration of 5 mg single doses of cladribine, with data showing the average concentration, in pg/mL, ⁇ SD for 5-6 animals per group, plotted against time in hours, following administration of the following cladribine formulations: ( ⁇ ) saturated oral cladribine- ⁇ -cyclodextrin complex; ( ⁇ ) oral capsule of physical mixture of cladribine with ten times excess ⁇ -cyclodextrin; and ( ⁇ ) oral capsule of cladribine complex with ten times excess ⁇ -cyclodextrin.
  • FIG. 5 represents a comparison of plasma profiles for cladribine in dogs after oral administration of 5 mg single doses of cladribine, with data showing the average concentration, in pg/mL, ⁇ SD for 5-6 animals per group, plotted against time in hours, following administration of the following cladribine formulations: ( ⁇ ) saturated oral cladribine-hydroxypropyl- ⁇ -cyclodextrin complex; and ( ⁇ ) oral capsule of physical mixture of cladribine with ten times excess hydroxypropyl- ⁇ -cyclodextrin.
  • FIG. 6 illustrates the average cumulative area under the curve (AUC), in pg ⁇ h/mL, for cladribine in groups of 5-6 dogs, plotted against time in hours, after administration of each of the formulations described with reference to FIG. 2 , where the symbols are as indicated in that paragraph.
  • AUC average cumulative area under the curve
  • complex means an inclusion complex, in which the hydrophobic portion of the cladribine molecule (the nitrogen-containing ring system) is inserted into the hydrophobic cavity of the cyclodextrin molecule.
  • the terms “comprise(s)” and “comprising” are to be interpreted as having an open-ended meaning. That is, the terms are to be interpreted synonymously with the phrases “having at least” or “including at least”.
  • the term “comprising” means that the process includes at least the recited steps, but may include additional steps.
  • the term “comprising” means that the composition includes at least the recited features or components, but may also include additional features or components.
  • the basic and novel features herein are the provision of a saturated cladribine-cyclodextrin complex in a solid oral dosage form or a transmucosal dosage form which is substantially free of cyclodextrin in excess of the minimum amount required to maximize the amount of cladribine in the complex, so as to provide improved bioavailability and/or lower interpatient variation following administration.
  • the basic and novel features herein are the provision of a saturated cladribine-cyclodextrin complex in a solid oral dosage form or a transmucosal dosage form which is substantially free of cyclodextrin in excess of the minimum amount required to maintain substantially all of the cladribine in the complex, providing particularly enhanced bioavailability and/or low interpatient and/or low intrapatient variability following administration.
  • saturated when used in conjunction with a complex of cladribine in cyclodexctrin means that the complex is saturated with cladribine, that is, the complex contains the maximum amount of cladribine which can be complexed with a given amount of cyclodextrin under the conditions of complexation used.
  • a phase solubility study can be used to provide this information, as described in more detail hereinafter.
  • a saturated complex may be arrived at empirically by simply adding cladribine to an aqueous solution of the selected cyclodextrin until a precipitate (of uncomplexed cladribine) forms; ultimately, the precipitate is removed and the solution lyophilized to provide the dry saturated complex.
  • the expression “substantially”, as in “substantially free” or “substantially all”, means within 20% of the exact calculated amount.
  • the minimum amount of cyclodextrin needed to maintain the cladribine in the complex can be obtained from phase solubility studies as explained in more detail below.
  • the actual amount of cyclodextrin should be within 20% of that minimum, plus or minus, preferably within 10% of that minimum, plus or minus, even more preferably within 5% of that minimum, plus or minus, and should maintain at least 90% or more, preferably at least 95% or more, of the drug in the complex.
  • interpatient variability refers to variation among patients to which a drug is administered.
  • intrapatient variability refers to variation experienced by a single patient when dosed at different times.
  • variable can be equal to any integer value of the numerical range, including the end-points of the range.
  • variable can be equal to any real value of the numerical range, including the end-points of the range.
  • a variable which is described as having values between 0 and 2 can be 0, 1 or 2 for variables which are inherently discrete, and can be 0.0, 0.1, 0.01, 0.001, or any other real value for variables which are inherently continuous.
  • compositions useful to achieve desirable pharmacokinetic properties.
  • Such compositions stem from the discovery that solutions of cyclodextrin and cladribine in which cladribine is in its highest thermodynamic state, when presented to the mucosa through which they are absorbed (gastric, nasal, rectal, buccal, sublingual or vaginal) are associated with improved cladribine absorption, as reflected by higher bioavailability and/or lower interpatient variation.
  • the free cladribine formed from dissociation of the complex in a saturated aqueous solution seeks a more stable activity level, and if excess cyclodextrin were present, the cladribine would seek greater stability by re-complexing with the cyclodextrin.
  • this cladribine will seek a state of lower thermodynamic activity/greater stability by being absorbed through the gastric musoca (in the case of a solid oral dosage form) or through the nasal, buccal, vaginal or rectal mucosa (in the case of a transmucosal dosage form).
  • This approach is shown hereinafter inter alia to increase bioavailability, likely by avoiding or minimizing the inhibition of cladribine absorption which would result from the presence of excess cyclodextrin.
  • the cladribine in solution would be expected to recombine with cyclodextrin. This will not achieve optimum bioavailability, because it is essential that the cladribine move out of the complex in which it is encapsulated if the drug is to accomplish its therapeutic function.
  • these dosage forms should be formulated to release a localized saturated cladribine solution, upon contact of the solid dosage forms with body fluid at the mucosa, in which cladribine is in its HTA state.
  • a localized saturated solution in vivo, it is important to first identify the optimal ratio of cladribine to cyclodextrin, which ratio is referred to herein as the HTA ratio, to be used in the solid dosage form.
  • the HTA ratio the optimal ratio of cladribine to cyclodextrin
  • a highly concentrated solution made by dissolving the saturated complex in a minimal amount of water and placing this solution in the buccal cavity can accomplish the same effect.
  • the HTA ratio is empirically determined and is identified as the ratio of cladribine to a specific cyclodextrin which corresponds to the maximum amount of cladribine that can be complexed with a given amount of cyclodextrin.
  • the HTA ratio may be determined using an empirical method such as a phase solubility study to determine the saturation concentration of cladribine that can be solubilized with different concentrations of cyclodextrin solutions. Hence, the method identifies the concentrations at which a saturated cladribine-cyclodextrin complex is formed.
  • the molar ratio represented by a point on the phase solubility graph shows how many moles of cyclodextrin are the minimum needed to maintain the drug in the complex, under given conditions; this may then be converted to a weight ratio. For example, if a phase solubility diagram shows that 9 moles of a given cyclodextrin are needed to maintain substantially all of the cladribine in a saturated complex, then multiplying the number of moles of cladribine by its molecular weight and multiplying the number of moles the cyclodextrin by its molecular weight, one can arrive at the ratio of the products as an appropriate optimized weight ratio.
  • a phase solubility study also provides information about the nature of the cladribine-cyclodextrin complex formed, for example whether the complex is a 1:1 complex (1 molecule of drug complexed with 1 molecule of cyclodextrin) or a 1:2 complex (1 molecule of drug complexed with 2 molecules of cyclodextrin).
  • cyclodextrin or cladribine as the fixed variable to which an excess of the other is added to identify various HTA data points (indicating saturated cladribine-cyclodextrin complexes) and draw the resultant HTA line.
  • cladribine is added to an aqueous solution having a known concentration of cyclodextrin under conditions empirically found to promote complex formation.
  • a concentrated solution for example, of approximately 27% for ⁇ -cyclodextrin and approximately 40% for hydroxypropyl- ⁇ -cyclodextrin, is in one embodiment particularly advantageous.
  • the complexation is conducted at room temperature or with slight heating (up to about 50° C.
  • the graph is a phase solubility diagram which can be used to determine the saturation amount of cladribine for any specific concentration of cyclodextrin used to form a saturated cladribine-cyclodextrin complex under a given set of complexation conditions.
  • concentrations at which saturated cladribine-cyclodextrin complexes are formed may be identified by a variety of alternative methodologies. Accordingly, any method known in the field suitable to identify these concentrations is within the scope of the invention.
  • cyclodextrins within the scope of this invention include the natural cyclodextrins ⁇ , ⁇ , and ⁇ -cyclodextrin, and derivatives thereof, in particular, derivatives wherein one or more of the hydroxy groups are substituted, for example, by alkyl, hydroxyalkyl, carboxyalkyl, alkylcarbonyl, carboxyalkoxyalkyl, alkylcarbonyloxyalkyl, alkoxycarbonylalkyl or hydroxy-(mono or polyalkoxy)alkyl groups; and wherein each alkyl or alkylene moiety preferably contains up to six carbons.
  • Substituted cyclodextrins can generally be obtained in varying degrees of substitution, for example, from 1 to 14, preferably from 4 to 7; the degree of substitution is the approximate average number of substituent groups on the cyclodextrin molecule, for example, the approximate number of hydroxypropyl groups in the case of the hydroxypropyl- ⁇ -cyclodextrin molecule, and all such variations are within the ambit of this invention.
  • Substituted cyclodextrins which can be used in the invention include polyethers, for example, as described in U.S. Pat. No. 3,459,731.
  • substituted cyclodextrins include ethers wherein the hydrogen of one or more cyclodextrin hydroxy groups is replaced by C 1-6 alkyl, hydroxy-C 1-6 alkyl, carboxy-C 1-6 alkyl or C 1-6 alkyloxycarbonyl-C 1-6 alkyl groups or mixed ethers thereof.
  • such substituted cyclodextrins are ethers wherein the hydrogen of one or more cyclodextrin hydroxy groups is replaced by C 1-3 alkyl, hydroxy-C 2-4 alkyl or carboxy-C 1-2 alkyl or more particularly by methyl, ethyl, hydroxyethyl, hydroxypropyl, hydroxybutyl, carboxymethyl or carboxyethyl.
  • C 1-6 alkyl is meant to include straight and branched saturated hydrocarbon radicals, having from 1 to 6 carbon atoms such as methyl, ethyl, 1-methylethyl, 1,1-dimethylethyl, propyl, 2-methylpropyl, butyl, pentyl, hexyl and the like.
  • Other cyclodextrins contemplated for use herein include glucosyl- ⁇ -cyclodextrin and maltosyl- ⁇ -cyclodextrin.
  • ⁇ -cyclodextrin ethers such as dimethyl- ⁇ -cyclodextrin as described in Cyclodextrins of the Future , Vol. 9, No.
  • ⁇ -cyclodextrin and polyethers such as hydroxypropyl- ⁇ -cyclodextrin, hydroxyethyl- ⁇ -cyclodextrin, hydroxypropyl- ⁇ -cyclodextrin, and hydroxyethyl- ⁇ -cyclodextrin, as well as sulfobutyl ethers, especially ⁇ -cyclodextrin sulfobutyl ether.
  • branched cyclodextrins and cyclodextrin polymers may also be used.
  • Patents describing hydroxyalkylated derivative of ⁇ - and ⁇ -cyclodextrin include Pitha U.S. Pat. Nos. 4,596,795 and 4,727,064, Müller U.S. Pat. Nos. 4,764,604 4,870,060 and Müller et al. U.S. Pat. No. 6,407,079.
  • Cyclodextrins of particular interest for complexation with cladribine include: ⁇ -cyclodextrin; hydroxyalkyl, e.g. hydroxyethyl or hydroxypropyl, derivatives of ⁇ - and ⁇ -cyclodextrin; carboxyalkyl, e.g. carboxymethyl or carboxyethyl, derivatives of ⁇ - or ⁇ -cyclodextrin; ⁇ -cyclodextrin sulfobutyl ether; dimethyl- ⁇ -cyclodextrin; and randomly methylated ⁇ -cyclodextrin.
  • 2-Hydroxypropyl- ⁇ -cyclodextrin HP ⁇ CD
  • 2-hydroxypropyl- ⁇ -cyclodextrin HP ⁇ CD
  • compositions of a saturated cladribine-cyclodextrin complex for use in the present invention can be prepared under conditions favoring complex formation in a liquid environment as described and as exemplified herein.
  • the resultant liquid preparations can be subsequently converted to a dry form suitable for administration as a solid oral or transmucosal dosage form.
  • One of skill will appreciate that a variety of approaches are available in the field to prepare compositions as described herein.
  • One available method exemplified herein includes the steps of mixing the cladribine in an aqueous cyclodextrin solution, maintaining the complexation medium at room temperature, with stirring, for from about 6 to about 24 hours, that is, for a sufficient time to achieve equilibrium, separating un-complexed cladribine, if any (e.g., by filtering or centrifugation), and lyophilizing or freeze-drying the saturated solution to form a solid saturated cladribine-cyclodextrin complex mixture.
  • Freeze-drying also known as lyophilization, consists of three basic stages: first a freezing stage, then a primary drying stage and finally a secondary drying stage.
  • EXAMPLE 2 below provides details of lyophilization as conducted on the batches described therein. This procedure can be further optimized by following the principles described by Xiaolin (Charlie) Tang and Michael J. Pikal in Pharmaceutical Research , Vol. 21, No. 2, February 2004, 191-200, incorporated by reference herein in its entirety and relied upon.
  • compositions according to the invention may optionally include one or more excipients or other pharmaceutically inert components.
  • excipients may be chosen from those that do not interfere with cladribine, with cyclodextrin or with complex formation.
  • Dosage forms are optionally formulated in a pharmaceutically acceptable vehicle with any of the well-known pharmaceutically acceptable carriers, diluents, binders, lubricants, disintegrants, scavengers, flavoring agents, coloring agents, and excipients (see Handbook of Pharmaceutical Excipients , Marcel Dekker Inc., New York and Basel (1998); Lachman et al. Eds., The Theory and Practice of Industrial Pharmacy, 3 rd Ed., (1986); Lieberman et al., Eds.
  • a simple solid oral or transmucosal dosage form consists of the saturated cladribine-cyclodextrin complex compressed with a small amount (e.g. about 1% by weight) of a suitable binder or lubricant such as magnesium stearate.
  • the saturated cladribine-cyclodextrin complex is used for the transmucosal or the oral administration of cladribine.
  • mucosa means the epithelial membranes lining the nasal, oral, vaginal and rectal cavities, as well as those lining the stomach (the gastric mucosa).
  • mucosal and transmucosal are used interchangeably.
  • Transmucosal delivery methods and forms are well-known in the art. These include buccal and sublingual tablets, lozenges, adhesive patches, gels, solutions or sprays (powder, liquid or aerosol), and suppositories or foams (for rectal or vaginal administration).
  • Transmucosal delivery methods and forms do not include the methods and forms for oral use, which are intended to be swallowed and are simply called oral dosage forms herein, despite the fact that they ultimately deliver the drug through the gastric mucosa.
  • the transmucosal form is a liquid, it can be obtained by dissolving the saturated complex in a minimum amount of water, for example 500 mg of the saturated complex with HP ⁇ CD in 0.5 ml water (50% w/w solution), or 500 mg of the saturated ⁇ CD complex in 1.0 ml of water. A few drops of such a solution can be inserted into the buccal cavity and retained there for about 2 minutes to allow for absorption through the buccal mucosa. Nevertheless, solid transmucosal dosage forms are generally preferred over liquid forms.
  • oral or mucosal absorption may be further facilitated by the addition of various excipients and additives to increase solubility or to enhance penetration, such as by the modification of the microenvironment, or by the addition of mucoadhesive excipients to improve contact between the delivery system and the mucosal tissue.
  • Buccal drug delivery can be effected by placing the buccal dosage unit between the lower gum and the oral mucosa opposite thereto of the individual undergoing drug therapy.
  • Excipients or vehicles suitable for buccal drug administration can be used, and include any such materials known in the art, e.g., any liquid, gel, solvent, liquid diluent, solubilizer, or the like, which is nontoxic and does not interact with other components of the composition in a deleterious manner.
  • a solid dosage unit is fabricated so as to dissolve gradually over a predetermined time period, to produce a substantially saturated drug solution in the saliva of the buccal cavity, allowing absorption of cladribine through the mucosa, wherein drug delivery is provided essentially throughout the time period.
  • the buccal dosage unit may further comprise a lubricant to facilitate manufacture, e.g., magnesium stearate or the like. Additional components that may be included in the buccal dosage unit include but are not limited to flavorings, permeation enhancers, diluents, binders, and the like.
  • the remainder of the buccal dosage unit may comprise a bioerodible polymeric carrier, and any excipients that may be desired, e.g., binders, disintegrants, lubricants, diluents, flavorings, colorings, and the like, and/or additional active agents.
  • the buccal carrier can comprise a polymer having sufficient tack to ensure that the dosage unit adheres to the buccal mucosa for the necessary time period, i.e., the time period during which the cladribine is to be delivered to the buccal mucosa. Additionally, the polymeric carrier is gradually “bioerodible”, i.e., the polymer hydrolyzes at a predetermined rate upon contact with moisture. Any polymeric carriers can be used that are pharmaceutically acceptable, provide both a suitable degree of adhesion and the desired drug release profile, and are compatible with the cladribine to be administered and any other components that may be present in the buccal dosage unit.
  • the polymeric carriers comprise hydrophilic (water-soluble and water-swellable) polymers that adhere to the wet surface of the buccal mucosa.
  • hydrophilic water-soluble and water-swellable
  • polymeric carriers useful herein include acrylic acid polymers and copolymers, e.g., those known as “carbomers” for example, Carbopol®.
  • suitable polymers include, but are not limited to, hydrolyzed polyvinyl alcohol, polyethylene oxides (e.g., Sentry Polyox®), polyacrylates (e.g., Gantrez®), vinyl polymers and copolymers, polyvinylpyrrolidone, dextran, guar gum, pectins, starches, and cellulosic polymers such as hydroxypropyl methylcellulose (e.g., Methocel®), hydroxypropyl cellulose (e.g., Klucel®), hydroxypropyl cellulose ethers, hydroxyethyl cellulose, sodium carboxymethyl cellulose, methyl cellulose, ethyl cellulose, cellulose acetate phthalate, cellulose acetate butyrate, and the like.
  • hydrolyzed polyvinyl alcohol polyethylene oxides (e.g., Sentry Polyox®), polyacrylates (e.g., Gantrez®), vinyl polymers and copolymers, polyvinylpyr
  • the dosage unit need contain only the saturated cladribine-cyclodextrin complex. However, it may be desirable in some cases to include one or more of the aforenoted carriers and/or one or more additional components.
  • a lubricant may be included to facilitate the process of manufacturing the dosage units; lubricants may also optimize erosion rate and drug flux. If a lubricant is present, it will represent on the order of 0.01 wt. % to about 2 wt. %, preferably about 0.01 wt. % to 1.0 wt. %, of the dosage unit. Suitable lubricants include, but are not limited to, magnesium stearate, calcium stearate, stearic acid, sodium stearylfumarate, talc, hydrogenated vegetable oils and polyethylene glycol.
  • the saturated cladribine-cyclodextrin complex may also be administered in accord with this invention in the form of suppositories or foams for vaginal or rectal administration.
  • These compositions can be prepared by well-known methods, for example, in the case of suppositories, by mixing the saturated complex with a suitable non-irritating excipient or binder which is solid at ordinary temperatures but liquid at the vaginal or rectal temperature and will, therefore, melt in the vagina or rectum to release the drug.
  • a suitable non-irritating excipient or binder which is solid at ordinary temperatures but liquid at the vaginal or rectal temperature and will, therefore, melt in the vagina or rectum to release the drug.
  • Such materials include cocoa butter and polyethylene glycols.
  • Traditional binders and carriers include, for example, polyalkylene glycols or triglycerides [e.g., PEG 1000 (96%) and PEG 4000 (4%)].
  • Such suppositories may be formed from mixtures containing active ingredients in the range of from about 0.5 wt/wt % to about 10 wt/wt %; preferably from about 1 wt/wt % to about 2 wt/wt %.
  • a powder spray, gel or ointment may be utilized, preferably a powder form of the saturated complex.
  • a buccal dosage form especially a buccal tablet or wafer or disk, advantageously having a disintegration time of about 15-30 minutes, or a buccal patch (in which the drug is released only from the side which adheres to the buccal mucosa while the other side is nonpermeable), is of interest.
  • Buccal administration may make use of the inventions of Nagai et al. described in U.S. Pat. Nos. 4,226,848 and 4,250,163, both of which are incorporated by reference herein in their entireties and relied upon.
  • a buccal mucosa-adhesive tablet may be formulated for use herein comprising: (a) a water-swellable and mucosa-adhesive polymeric matrix comprising about 50% to about 95% by weight of a cellulose ether and about 50% to about 95% by weight of a homo- or copolymer of acrylic acid or a pharmaceutically acceptable salt thereof, and (b) dispersed therein, an appropriate quantity of cladribine, as a saturated complex with 2-hydroxypropyl- ⁇ -cyclodextrin or ⁇ -cyclodextrin.
  • the tablet is anhydrous.
  • compositions described herein offer novel therapeutic modalities for the treatment of patients in need of treatment with cladribine.
  • the invention addresses the problems of poor bioavailability traditionally associated with oral cladribine.
  • the orogastric route may be avoided entirely by administering a transmucosal delivery form.
  • compositions of the invention are particularly suitable as modalities for the treatment of any cladribine-responsive disease.
  • cladribine-responsive disease Several disease states responsive to cladribine are well-documented in the literature (see infra).
  • an effective amount of the optimized cladribine-cyclodextrin complex is used (e.g., an amount effective for the treatment of multiple sclerosis, rheumatoid arthritis, or leukemia).
  • therapeutically effective amount or “effective amount” is used to denote treatments at dosages effective to achieve the therapeutic result sought.
  • Therapeutically effective dosages described in the literature include those for hairy cell leukemia (0.09 mg/kg/day for 7 days), for multiple sclerosis (from about 0.04 to about 1.0 mg/kg/day (see U.S. Pat. No. 5,506,214)); for other diseases, see also U.S. Pat. No. 5,106,837 (autohemolytic anemia); U.S. Pat. No. 5,310,732 (inflammatory bowel disease); U.S. Pat. No. 5,401,724 (rheumatoid arthritis); U.S. Pat. No. 5,424,296 (malignant astrocytoma); U.S. Pat. No. 5,510,336 (histiocytosis); U.S. Pat. No. 5,401,724 (chronic myelogenous leukemia); and U.S. Pat. No. 6,239,118 (atherosclerosis).
  • 10 mg of cladribine in the instant solid dosage form as the saturated cladribine-cyclodextrin complex would be administered once per day for a period of five to seven days in the first month, repeated for another period of five to seven days in the second month, followed by ten months of no treatment.
  • the patient would be administered the 10 mg dose once per day for a period of five to seven days per month for six months, followed by eighteen months of no treatment.
  • U.S. Provisional Patent Application No. ______ [IVAX0021-P-USA/Attorney Docket No. 033935-011]
  • the therapeutically effective amount of cladribine administered herein may be lowered or increased by fine tuning and/or by administering cladribine according to the invention with another active ingredient.
  • the invention therefore provides a method to tailor-the administration/treatment to the particular exigencies specific to a given mammal.
  • Therapeutically effective amounts may be easily determined, for example, empirically by starting at relatively low amounts and by step-wise increments with concurrent evaluation of beneficial effect.
  • administration of cladribine in accord with this invention may be accompanied by administration of one or more additional active ingredients for treating the cladribine-responsive condition.
  • the additional active ingredient will be administered by a route of administration and in dosing amounts and frequencies appropriate for each additional active ingredient and the condition being treated.
  • interferon beta (Rebif®, Betaseron®/Betaferon®, Avonex®, identical to the naturally occurring protein found in the human body; glatiramer acetate (Copaxone®), a random chain (polymer) of the amino acids glutamic acid, lysine, alanine and tyrosine; natalizumab (Antegren®), a monoclonal antibody; alemtuzumab (Campath-1H®), a humanized anti-CD52 monoclonal antibody; 4-aminopyridine (also known as 4-AP and Fampridine), a drug that blocks the potassium channels in neurons; and amantadine, an anti-viral agent which improves muscle control and reduces muscle stiffness and is used to alleviate the symptoms of fatigue in multiple sclerosis, a purpose for which pemoline (Cylert®) and L-Carnitine (a herbal product) may also be
  • additional active ingredients may include interferon alpha, pentostatin, fludarabine, rituximab (an anti-CD 20 monoclonal antibody) and the anti-CD22 recombinant immunotoxin BL 22; other additional active ingredients may be appropriate in other types of leukemias.
  • additional active ingredients may include interferon alpha, pentostatin, fludarabine, rituximab (an anti-CD 20 monoclonal antibody) and the anti-CD22 recombinant immunotoxin BL 22; other additional active ingredients may be appropriate in other types of leukemias.
  • rheumatoid arthritis there are many other active ingredients which may be selected.
  • NSAIDS non-steroidal anti-inflammatory drugs
  • salicylates such as aspirin
  • traditional NSAIDS such as ibuprofen and indomethacin
  • COX-2 inhibitors such as celecoxib (Celebrex®), rofecoxib (Vioxx®), meloxicam (Mobic®), valdecoxib (Bextra®), lumiracoxib (Prexige®) and etoricoxib (Arcoxia®).
  • Other drugs useful in treating rheumatoid arthritis which may be used in conjunction with the present invention include DMARDS, glucocorticoids, biological response modifiers and non-NSAID analgesics.
  • DMARDS are disease-modifying anti-rheumatic drugs which include methotrexate, plaquenil, leflunomide (Arava®), sulfasalazine, gold, penicillamide, cyclosporine, methyl cyclophosamide and azathioprine.
  • Glucocorticoids include dexamethasone, prednisolone, triamcinolone and many others.
  • Biological response modifiers which restore the disease-fighting ability of the immune system
  • the non-NSAID analgesics include acetaminophen as well as narcotic analgesics such as hydrocodone, oxycodone and propoxyphene.
  • those drugs which work by a mechanism different from that of cladribine are particularly useful for concomitant therapy with the cladribine composition described herein.
  • those drugs which are effective by the oral or transmucosal route of administration and which are compatible with the instant cladribine complexes in a single dosage form may be incorporated into the instant dosage forms; otherwise, they should of course be separately administered in amounts, frequencies and via administration routes suitable to them.
  • treating means reducing, preventing, hindering the development of, controlling, alleviating and/or reversing the symptoms in the individual to which a compound of the invention has been administered, as compared to the symptoms of an individual not being treated according to the invention.
  • a practitioner will appreciate that the complexes, compositions, dosage forms and methods described herein are to be used in concomitance with continuous clinical evaluations by a skilled practitioner (physician or veterinarian) to determine subsequent therapy. Such evaluation will aid and inform in evaluating whether to increase, reduce or continue a particular treatment dose, and/or to alter the mode of administration.
  • the methods of the present invention are intended for use with any subject/patient that may experience the benefits of the methods of the invention.
  • the terms “subjects” as well as “patients” include humans as well as non-human subjects, particularly domesticated animals.
  • a phase solubility study was carried out as follows. Excess cladribine was added to cyclodextrin solutions of various concentrations of ⁇ -cyclodextrin ( ⁇ CD) or hydroxypropyl- ⁇ -cyclodextrin (HP ⁇ CD) and allowed to complex as described in Example 2 below. In addition, in one set of experiments, the effect of hydroxypropylmethyl cellulose (HPMC) on complexation was investigated. The excess, undissolved cladribine was removed by filtration. The amount of cladribine in the complexation solution was measured to obtain a data point. This process was repeated with different known concentrations of cyclodextrin until several data points were obtained.
  • ⁇ CD ⁇ -cyclodextrin
  • HP ⁇ CD hydroxypropyl- ⁇ -cyclodextrin
  • each data point representing the maximum amount of cladribine that can be complexed with a specific concentration of cyclodextrin, i.e. each point represents a saturated cladribine-cyclodextrin complex.
  • Points on the line generated by the data points represent HTA ratios. Any point on the line represents a specific, unique saturated cladribine-cyclodextrin complex.
  • cyclodextrin solutions of varying concentrations were prepared and saturated with cladribine by providing cladribine in excess.
  • Saturated cyclodextrin solutions for a given cyclodextrin at a given cyclodextrin concentration are exemplified in Table I below.
  • TABLE I Cladribine-HP ⁇ CD Cladribine-HP ⁇ CD and Cladribine- ⁇ CD Cyclodextrin (Trial A) HPMC (0.1%) (Trial B) (Trial C) Molar Conc. Absorbance mg/ml Molar conc. Absorbance mg/ml Molar conc. Absorbance mg/ml Molar conc. Absorbance mg/ml Molar conc.
  • the molar concentrations of cladribine to cyclodextrin in Table I are plotted and presented graphically as FIG. 1 .
  • the plotted lines for cladribine-HP ⁇ CD, cladribine-HP ⁇ CD and 0.1% HPMC, and cladribine- ⁇ CD represent maximal cladribine solubilization for the conditions tested, that is, the HTA ratio of the concentration of cladribine to the concentration of cyclodextrin.
  • the area above each of the plotted lines represents conditions where excess insoluble cladribine is present.
  • the area below each of the plotted lines represents the conditions where cyclodextrin is in excess of the amount needed to maintain the complex in solution.
  • the data in Table I and in FIG. 1 shows that HPMC, a known complexation facilitator, has no effect at lower concentrations and has a negative effect at higher concentrations.
  • the HTA plot for cladribine-HP ⁇ CD shown in FIG. 1 is approximately linear; this is indicative of a 1:1 complex, in which one molecule of the drug is complexed with one molecule of cyclodextrin.
  • FIG. 1 also shows that additional cyclodextrin is needed to maintain the cladribine in the complex.
  • ⁇ -cyclodextrin about 0.10 mole of ⁇ CD is needed to maintain about 0.01 mole of cladribine in its saturated complex
  • HP ⁇ CD about 0.10 mole of cyclodextrin is needed to maintain about 0.017 mole of caldribine in its saturated complex.
  • the two molecules of ⁇ -CD are believed to hydrogen-bond to each other at high cyclodextrin concentration and incorporate in the cavity between them the cladribine molecule.
  • This is thought to be a stepwise process, in which the 1:1 complex first forms, then a second ⁇ -CD molecule H-bonds with the ⁇ -CD in the 1:1 complex, forming the 1:2 complex.
  • a molar concentration of about 0.20 of the cyclodextrin maintains about 0.017 mole of cladribine in its saturated complex.
  • the complex with ⁇ CD is also advantageous because ⁇ CD is a natural cyclodextrin, thus presents fewer issues vis-à-vis toxicity. Further, in the case of solid oral dosage forms, it is believed that the 1:2 complex with ⁇ -CD will better protect the cladribine from attack by stomach acid because it is able to essentially surround the drug molecule with cyclodextrin and thus is uniquely well-suited for the purposes of this invention.
  • Cladribine is complexed with either HP ⁇ CD or ⁇ CD by the following general method.
  • aqueous suspension of cladribine, in excess, and a concentrated solution (approximately 27% for ⁇ -cyclodextrin and approximately 40% for HP ⁇ CD) of cyclodextrin are mixed with stirring at room temperature for about nine hours. This achieves equilibration. Excess, non-complexed cladribine, if any, is removed by filtration. To form the solid saturated cladribine-cyclodextrin complex, the aqueous cladribine-cyclodextrin solutions are dried by lyophilization prior to incorporation into solid buccal or oral tablets.
  • the lyophilization procedure comprises a freezing stage of rapidly bringing the complexation solution to a temperature of from about ⁇ 40° C.
  • ⁇ 80° C. for a period of from about 2 to 4 hours, preferably from about 3 to 4 hours, for example a temperature of about ⁇ 45° C. for approximately 200 minutes, followed by a primary drying stage at about ⁇ 25° C. for approximately 80-90 hours, typically under low pressure, and then a secondary drying stage at about 30° C. for about 15-20 hours.
  • Product made by the foregoing general procedure can be analyzed by HPLC (utilizing a Hypersil ODS 3 micron column and an acetonitrile based mobile phase, with UV detection at 264 nm) to find the weight ratio of cladribine to cyclodextrin in the final product.
  • Final product preparations can be further characterized by methods known in the art, including, for example by inspecting appearance, ascertaining the overall impurity content by HPLC, ascertaining the water content using a Karl Fischer titrator, determining the dissolution profile by a standard method, for example using USP ⁇ 711>Apparatus II equipment and UV detection at 264 nm, inspecting the content uniformity and performing quantitative assay by HPLC analysis of the active ingredient.
  • Purified water (585 ml for FD02 and 575 ml for FD03) was dispensed into a 1 liter glass vessel for each batch.
  • the ⁇ -cyclodextrin (116 g) and 2-hydroxypropyl- ⁇ -cyclodextrin (115 g) were weighed and slowly added to the stirred water over a period of 30 minutes.
  • Cladribine (2.53 g for FD02 and 2.76 g for FD03) was weighed and added to the respective stirred cyclodextrin solutions. The solutions were sonicated for 20 minutes. The resulting clear solution was stirred at room temperature for 9 hours.
  • the solutions were then filled into 100 ml lyophilization vials (20 ml solution per vial) and the filled vials were partially stoppered.
  • the lyophilization included freezing at ⁇ 45° C. for about 3.3 hours, a primary drying phase at ⁇ 25° C. under a pressure of 100 mTorr for about 85.8 hours, and a secondary drying phase at 30° C. for about 17.5 hours as set forth below: LYOPHILIZATION CYCLE Step Process Temperature Pressure (mTorr) Time (hrs) 1 Load 4° C. 2 Load Hold 4° C. n/a 2.0 3 Ramp ⁇ 45° C. n/a 2.0 4 Freezing ⁇ 45° C. n/a 3.3 5 Ramp ⁇ 25° C. 100 2.2 6 Primary ⁇ 25° C. 100 85.8 drying 7 Ramp 30° C. 50 4.0 8 Secondary 30° C. 50 17.5 drying 9 Finish 30° C. Vials closed under vacuum
  • these cladribine:cyclodextrin complexes have cladribine:cyclodextrin weight ratios of about 1:46 for cladribine: ⁇ -cyclodextrin and about 1:42 for cladribine:hydroxypropyl- ⁇ -cyclodextrin.
  • the complex materials were passed through a #18 mesh (0.9 mm) screen with magnesium stearate, blended for five minutes and compressed using 10 mm punches.
  • the 10 mm tablets had upper shallow convex tooling and lower flat beveled edge tooling.
  • the formulations for the manufacture were as follows: TABLE II PART A Batch No.
  • cladribine (0.25 mg/ml in isotonic saline) was administered intravenously to test subjects. Blood samples were collected at various time intervals over 48 hours. In the second test period, half of the subjects received buccally a tablet as described above containing a saturated cladribine- ⁇ CD or -HP ⁇ CD complex. Serial blood samples were collected over 48 hours.
  • the third test period repeated the second test period with the exception that the subjects previously receiving the ⁇ -cyclodextrin buccal tablet were now given hydroxypropyl- ⁇ -cyclodextrin buccal tablets, with hydroxypropyl- ⁇ -cyclodextrin tablet recipients from the second period receiving ⁇ -cyclodextrin buccal tablets.
  • the fourth and fifth test periods repeated test periods two and three with the exception that the tablets were given orally.
  • Cladribine levels in the blood were measured by HPLC and an LC/MS/MS method.
  • the TopFit 2.0 Pharmacokinetic and Pharmacodynamic Data Analysis System was used for the pharmacokinetic analysis of the data.
  • the results of the bioavailability study for control (intravenous) and cladribine-cyclodextrin complexes are presented in Tables III to VII and summarized in Table VIII.
  • C initial is the extrapolated value at the end of the bolus
  • C first is the first measured concentration at 5 minutes after the dose is administered
  • t1 ⁇ 2 terminal is the terminal elimination half-life
  • AUD is the area under the measured data, integrated with the linear trapezoidal rule
  • AUD ext is the extrapolated area from the last measured time-point to infinity
  • AUC is AUD extrapolated to infinity
  • MRT tot is the mean residence time.
  • C max is the peak concentration measured
  • T max is the time to C max ;
  • t1 ⁇ 2 terminal is the terminal elimination half-life
  • AUD is the area under the measured data, integrated with the linear trapezoidal rule
  • AUD ext is the extrapolated area from the last measured time-point to infinity
  • AUC is AUD extrapolated to infinity
  • MRT tot is the mean residence time
  • F is the bioavailability expressed in %.
  • the peak areas, calibration curves, accuracy, precision values and the concentrations were determined using Analyst Software 1.1 (PE SCIEX, Foster City, US). For calculation of mean and standard deviation, Excel 5.0 software was used. The calibration curve was fitted using the ratio of concentrations of analyte and internal standard versus the ratio of the peak areas of them. A straight line was fitted on the experimental points by weighted least squares linear regression analysis. The weighting scheme used was 1/concentration squared as pg/ml plasma.
  • the points determining the regression line i.e. the terminal phase, were selected by visual determination of the linear segment of the semilogarithmic curve.
  • the AUC values were normalized by the actual dose given in the particular period.
  • the buccal/oral AUC/dose value was divided by the intravenous AUC/dose value.
  • the individual plasma level-time curves were obtained. Small inter-individual variability was found after intravenous administration. After a very rapid initial decrease, the terminal elimination half-life of cladribine was about 10 hours. The mean total clearance proved to be 17 ml/min/kg.
  • the dissolution period was longer for the cladribine: ⁇ -cyclodextrin complex compared to the cladribine:HP- ⁇ -cyclodextrin complex.
  • the peak concentrations and the absorption profiles showed high inter-individual variability after both buccal and oral administrations, the total exposures (AUC) showed much lower variability.
  • the oral bioavailability proved to be good: 50 ⁇ 3% and 45 ⁇ 5% for ⁇ -cyclodextrin and hydroxypropyl- ⁇ -cyclodextrin complexes, respectively.
  • the buccal bioavailability values were lower: 37 ⁇ 10% for the ⁇ -cyclodextrin complex and 30 ⁇ 4.5% for the hydroxypropyl- ⁇ -cyclodextrin complex.
  • FIG. 2 shows the plasma profile for cladribine in dogs after administration of 5 mg single doses in the various formulations described above, where the data are the average ⁇ SD for 5-6 animals per group.
  • the average drug concentration in pg/ml of plasma is plotted against time in hours. Although each test was conducted for a 48-hour period, only the first 6 hours were presented in the graphs; after 6 hours, most concentrations had returned to or near baseline and therefore are not shown in the graphs.
  • Intravenous values ( ⁇ ) are considered to give 100% bioavailability, and plasma levels for oral and buccal forms were compared thereto. The meanings of the symbols are given in the BRIEF DESCRIPTION OF THE DRAWINGS hereinabove.
  • FIG. 3 provides a comparison of the plasma profiles for the intravenous formulation ( ⁇ ), the oral saturated cladribine- ⁇ -cyclodextrin complex formulation ( ⁇ ) and the oral saturated cladribine-hydroxypropyl- ⁇ -cyclodextrin complex formulation ( ⁇ ) shown in FIG. 2 . Both of these oral formulations afforded desirable profiles.
  • FIG. 4 provides a comparison of the plasma profiles for the oral saturated cladribine- ⁇ -cyclodextrin complex formulation ( ⁇ ), the oral capsule of a physical mixture of cladribine with ten-times excess ⁇ -cyclodextrin ( ⁇ ) and the oral capsule of the cladribine- ⁇ CD complex with ten times excess ⁇ -cyclodextrin ( ⁇ ) shown in FIG. 2 .
  • excess cyclodextrin decreases the amount of cladribine in the plasma, particularly in the first hour after administration.
  • FIG. 5 provides a comparison of the plasma profiles, for the oral saturated hydroxypropyl- ⁇ -cyclodextrin complex formulation ( ⁇ ) and the oral capsule of a physical mixture of cladribine with ten-times excess hydroxypropyl- ⁇ -cyclodextrin ( ⁇ ) shown in FIG. 2 .
  • excess cyclodextrin decreases the amount of cladribine in the complex. In this case, the decrease is seen in the first two hours after administration.
  • FIG. 6 depicts the cumulative areas under the curves (AUCs) in pg xh/ml for the eight formulations shown in FIG. 2 . Again, data are the average for 5-6 animals per group.

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PL2026832T3 (pl) 2006-05-24 2012-08-31 Merck Serono Sa Skojarzony reżim interferonu beta i kladrybiny do leczenia stwardnienia rozsianego
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RU2758436C1 (ru) * 2021-04-05 2021-10-28 Общество с ограниченной ответственностью «ФармЭко» Способ получения аморфных ко-эвапоратов кладрибина с циклодекстринами
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US20100129353A1 (en) * 2004-12-22 2010-05-27 Laboratoires Serono S.A. Combination and treatment for multiple sclerosis
WO2015140790A1 (en) * 2014-03-17 2015-09-24 Mapi Pharma Ltd. Sublingual delivery of glatiramer acetate
US10493122B2 (en) 2014-03-17 2019-12-03 Mapi Pharma Ltd. Sublingual delivery of glatiramer acetate

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