US20130303583A1 - Methods of treating headaches using 5-ht agonists in combination with long-acting nsaids - Google Patents

Methods of treating headaches using 5-ht agonists in combination with long-acting nsaids Download PDF

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US20130303583A1
US20130303583A1 US13872832 US201313872832A US2013303583A1 US 20130303583 A1 US20130303583 A1 US 20130303583A1 US 13872832 US13872832 US 13872832 US 201313872832 A US201313872832 A US 201313872832A US 2013303583 A1 US2013303583 A1 US 2013303583A1
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hours
naproxen
sumatriptan
migraine
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John R. Plachetka
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Pozen Inc
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    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61KPREPARATIONS FOR MEDICAL, DENTAL, OR TOILET PURPOSES
    • A61K31/00Medicinal preparations containing organic active ingredients
    • A61K31/33Heterocyclic compounds
    • A61K31/395Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine, rifamycins
    • A61K31/40Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine, rifamycins having five-membered rings with one nitrogen as the only ring hetero atom, e.g. sulpiride, succinimide, tolmetin, buflomedil
    • A61K31/403Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine, rifamycins having five-membered rings with one nitrogen as the only ring hetero atom, e.g. sulpiride, succinimide, tolmetin, buflomedil condensed with carbocyclic rings, e.g. carbazole
    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61KPREPARATIONS FOR MEDICAL, DENTAL, OR TOILET PURPOSES
    • A61K31/00Medicinal preparations containing organic active ingredients
    • A61K31/185Acids; Anhydrides, halides or salts thereof, e.g. sulfur acids, imidic, hydrazonic, hydroximic acids
    • A61K31/19Carboxylic acids, e.g. valproic acid
    • A61K31/192Carboxylic acids, e.g. valproic acid having aromatic groups, e.g. sulindac, 2-arylpropionic acids, ethacrynic acid
    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61KPREPARATIONS FOR MEDICAL, DENTAL, OR TOILET PURPOSES
    • A61K31/00Medicinal preparations containing organic active ingredients
    • A61K31/33Heterocyclic compounds
    • A61K31/395Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine, rifamycins
    • A61K31/40Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine, rifamycins having five-membered rings with one nitrogen as the only ring hetero atom, e.g. sulpiride, succinimide, tolmetin, buflomedil
    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61KPREPARATIONS FOR MEDICAL, DENTAL, OR TOILET PURPOSES
    • A61K31/00Medicinal preparations containing organic active ingredients
    • A61K31/33Heterocyclic compounds
    • A61K31/395Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine, rifamycins
    • A61K31/40Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine, rifamycins having five-membered rings with one nitrogen as the only ring hetero atom, e.g. sulpiride, succinimide, tolmetin, buflomedil
    • A61K31/403Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine, rifamycins having five-membered rings with one nitrogen as the only ring hetero atom, e.g. sulpiride, succinimide, tolmetin, buflomedil condensed with carbocyclic rings, e.g. carbazole
    • A61K31/404Indoles, e.g. pindolol
    • A61K31/405Indole-alkanecarboxylic acids; Derivatives thereof, e.g. tryptophan, indomethacin
    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61KPREPARATIONS FOR MEDICAL, DENTAL, OR TOILET PURPOSES
    • A61K31/00Medicinal preparations containing organic active ingredients
    • A61K31/33Heterocyclic compounds
    • A61K31/395Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine, rifamycins
    • A61K31/41Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine, rifamycins having five-membered rings with two or more ring hetero atoms, at least one of which being nitrogen, e.g. tetrazole
    • A61K31/4151,2-Diazoles
    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61KPREPARATIONS FOR MEDICAL, DENTAL, OR TOILET PURPOSES
    • A61K31/00Medicinal preparations containing organic active ingredients
    • A61K31/33Heterocyclic compounds
    • A61K31/395Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine, rifamycins
    • A61K31/435Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine, rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
    • A61K31/47Quinolines; Isoquinolines
    • A61K31/48Ergoline derivatives, e.g. lysergic acid, ergotamine
    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61KPREPARATIONS FOR MEDICAL, DENTAL, OR TOILET PURPOSES
    • A61K31/00Medicinal preparations containing organic active ingredients
    • A61K31/33Heterocyclic compounds
    • A61K31/395Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine, rifamycins
    • A61K31/495Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine, rifamycins having six-membered rings with two or more nitrogen atoms as the only ring heteroatoms, e.g. piperazine or tetrazines
    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61KPREPARATIONS FOR MEDICAL, DENTAL, OR TOILET PURPOSES
    • A61K45/00Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
    • A61K45/06Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca

Abstract

The invention is directed to methods and compositions that can be used in the treatment of headaches. In particular, methods and compositions are described involving the combination of a long-acting NSAID and a 5-HT1B/1D agonist.

Description

    PRIORITY CLAIM
  • [0001]
    The present application is a divisional application of U.S. patent application Ser. No. 13/183,983, which is a continuation of U.S. patent application Ser. No. 10/414,493, filed Apr. 16, 2003, which is a continuation-in-part of U.S. patent application Ser. No. 09/559,753, filed Apr. 27, 2000 (now U.S. Pat. No. 6,586,458, issued Jul. 1, 2003), which is a continuation-in-part of U.S. patent application Ser. No. 09/151,912, filed Sep. 11, 1998 (now U.S. Pat. No. 6,060,499, issued May 9, 2000), which is a division of U.S. patent application Ser. No. 08/907,826, filed Aug. 14, 1997 (now U.S. Pat. No. 5,872,145, issued Feb. 16, 1999) which claims priority to U.S. provisional patent application 60/024,129, filed on Aug. 16, 1996 (now abandoned), all of which are incorporated herein by reference.
  • BACKGROUND OF THE INVENTION
  • [0002]
    1. Field of the Invention
  • [0003]
    The invention is directed to methods of treating patients for headache by administering compositions containing a 5-HT1B/1D agonist, preferably sumatriptan, and a long-acting NSAID, preferably naproxen. Other preferred long-acting NSAIDs include cyclooxygenase-2 inhibitors (COX-2 inhibitors).
  • [0004]
    2. Description of the Relevant Art
  • [0005]
    5-hydroxytryptamine (5-HT), also known as serotonin or enteramine, is a vasoactive agent and an endogenous neurotransmitter. It acts on receptors found in the central and peripheral nervous system as well as on blood vessels. Other drugs acting at these receptor sites are known as 5-HT agonists or antagonists. The 5-HT receptors have been divided into several sub-classes, some of which themselves contain subtypes. Examples of subtypes of serotonin receptors are 5-HT1, 5-HT1-like, 5-HT1B, 5-HT1D, 5-HT2, 5-HT3, etc.
  • [0006]
    Agonists that act preferentially at 5-HT1B and 5-HT1D receptors, the triptans, make up a group of therapeutics that may be used for the treatment of migraine headache. A representative member of this group is sumatriptan succinate (distributed under the name Imitrex™ by Glaxo Wellcome, and described in U.S. Pat. No. 4,816,470). Unfortunately, it has been reported that many patients who experience migraine symptom relief within two hours after receiving a 5-HT agonist, experience migraine symptoms again within the next 24 hours. These subsequent headaches are typically termed “rebound,” “relapse,” “recurrent” or “secondary” headaches.
  • [0007]
    A variety of analgesics have also been administered to migraine patients. For example, K. M. A. Welch (New Eng. J. Med. 329:1476-1483 (1993)) sets forth the following dosages of analgesics as being useful: aspirin, 500-650 mg; acetaminophen, 500 mg; naproxen sodium, 750-825 mg; tolfenamic acid, 200-400 mg; and ibuprofen, 200 mg. However, these agents, when taken alone, are rarely effective in providing complete relief symptoms and, after initial remission, migraine symptoms often return.
  • [0008]
    The problems that occur with migraine headaches may also be present in other types of headache as well. In all cases, an ideal therapy would reduce or eliminate the symptoms associated with the initial attack and minimize the frequency of later recurrences.
  • [0009]
    The following studies provide background information that should aid in understanding the present invention.
    • 1. Plosker, et al., Drugs 47:622-655 (1994).
    • 2. Sheftel, et al., Headache 34:67-72 (1994).
    • 3. Wilkinson, et al., Cephalalgia 15:337-357 (1995).
    • 4. Silberstein, S D, Curr. Opin. Neurol. 7:258-263 (1994).
    • 5. Welch, K. M. A., New Eng. J. Med. 329:1476-1483 (1993).
    • 6. Kumar, K. L., J. Gen. Int. Med. 9:339-348 (1994).
    SUMMARY OF THE INVENTION
  • [0016]
    The present invention is based upon the discovery that co-administration of an agonist that acts preferentially at 5-HT1B and 5-HT1D receptor subtypes (abbreviated as “5-HT1B/1D agonists,” i.e., the triptans) together with a long-acting, non-steroidal anti-inflammatory drug (LA-NSAID) represents an improved treatment for a wide variety of headaches. Compared to the administration of either drug alone, the combination produces longer lasting efficacy and a substantial reduction in the frequency relapse of headaches. As used herein, the term “longer lasting efficacy” means that drugs produce relief from symptoms associated with a headache for a longer period of time.
  • [0017]
    In its first aspect, the invention is directed to a method of treating a patient for headache by administering a 5-HT1B/1D agonist together with a long-acting, non-steroidal anti-inflammatory drug (i.e., a drug with a pharmacokinetic half life of at least 4 hours and a duration of action of at least 6 hours). Preferably these two agents are administered simultaneously (e.g. within a minute or two of one another), and, most preferably, together in a single oral dosage form. Oral dosage forms include tablets, capsules, dragees, trochees and other forms that are equivalent to these. The amount of 5-HT1B/1D agonist and LA-NSAID administered should be sufficient to reduce the frequency of headache relapse in patients or produce longer lasting efficacy compared to the administration of either one of these agents in the absence of the other. This procedure may be used to treat headaches falling into any of a wide variety of classes including: migraine headache; tension-type headache; cluster headache and chronic paroxysmal hemicrania; miscellaneous headache unassociated with a structural lesion; headache associated with a non-vascular intracranial disorder; headache associated with the administration of a substance or its withdrawal; headache associated with noncephalic infection; headache associated with a metabolic disorder; headache associated with a disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structure; cranial neuralgias; and nerve trunk pain and deafferentiation pain. (For a description of classes, see Olesen, et al., The Headaches, pp. 9-14, Raven Press; see also, “Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain,” Headache Classification Committee of the International Headache Society, Cephalalgia 8(supp. 7):1-96 (1988)).
  • [0018]
    The invention is also directed to a pharmaceutical composition useful in treating headache patients and which contains, in a single oral dosage form, a 5-HT1B/1D agonist and a long-acting, non-steroidal, anti-inflammatory drug (LA-NSAID), i.e., an NSAID with a pharmacokinetic half life of at least 4 hours and a duration of action of at least 6 hours. The two therapeutic agents, i.e., the 5-HT1B/1D agonist and LA-NSAID, should be present in amounts such that they are effective, upon co-timely or simultaneously administration of one or more of the single oral dosage forms to produce longer lasting efficacy compared to the administration of the 5-HT1B/1D agonist in the absence of said LA-NSAID or the administration of said LA-NSAID in the absence of said 5-HT1B/1D agonist. The oral dosage forms include tablets, capsules, dragees, trochees and other forms that are equivalent to these. The pharmaceutical composition may be included as part of a therapeutic package in which one or more single oral dosage forms are placed in a finished pharmaceutical container. Labeling may be included to provide directions for using the pharmaceutical composition in the treatment of headache, particularly migraine headache.
  • [0019]
    The methods and compositions discussed above are also compatible with non-oral dosage forms and non-oral routes of administration. Thus, agents may be administered intranasally, rectally, parenterally, or transdermally. Dosage forms may include tablets (including quick dissolve tablets), trochees, capsules, caplets, dragees, lozenges, parenterals, liquids, powders, and formulations designed for implantation or administration to the surface of the skin. Optionally, these dosage forms may be coordinated or designed for the slow release of therapeutic agents. They can be prepared using methods that are standard in the art and may include additional therapeutic agents, e.g., one or more additional analgesics.
  • [0020]
    Preferred 5-HT1B/1D agonists for use in methods and compositions include sumatriptan, eletriptan, rizatriptan, frovatriptan, almotriptan, zolmitriptan, and naratriptan. The most preferred 5-HT1B/1D agonist is sumatriptan. Among the preferred long-acting NSAIDs for use in compositions and methods are: naproxen, flurbiprofen, oxaprozin, indomethacin, ketorolac, mefenamic acid, piroxicam, etodolac, nabumetone and lornoxicam. Of these, the most preferred is naproxen or a pharmaceutically acceptable salt of naproxen. This should be administered to patients and present in a unit dose in an amount of greater than 200 mg and preferably between 200 mg and 600 mg. The most preferred oral composition contains sumatriptan in an amount of 5 mg to 100 mg and naproxen in an amount of 200 mg to 600 mg naproxen. Although not essential, it is expected that the sodium salt of naproxen will generally be used. Two specific preferred compositions are: a) a composition containing 85 mg of sumatriptan and 500 mg of naproxen sodium; and b) a composition containing 40 mg of sumatriptan and 400 mg of naproxen sodium.
  • [0021]
    A second group of preferred long-acting NSAIDs for use with the above compositions and methods are the cyclooxygenase-2 (COX-2) inhibitors. These are defined herein as NSAIDs that inhibit COX-2 to a greater extent than cyclooxygenase-1 (COX-1) and include some of the compounds recited above, especially etodolac and mefenamic acid, both of which have been reported to be highly specific for COX-2 (Feldman, et al., Ann. Intern Med. 132:134-143 (2000); Sengupta, Ind. J. Pharmacol. 31:322-332 (1999)). Other members include: celecoxib; rofecoxib; meloxicam; JTE-522; L-745,337; NS398; and pharmaceutically acceptable salts thereof. The most preferred of this group is celecoxib in an amount of between 50 and 500 mg. Any of the 5-HT1B/1D agonists discussed above may be used in combination with the COX-2 inhibitors with sumatriptan being preferred. For example, a method or composition may utilize a dosage of 5 to 100 mg of sumatriptan and 100 to 400 mg celecoxib.
  • [0022]
    The COX-2 inhibitors, like the other NSAIDs, are especially useful in the treatment of migraine headaches. Thus, the invention includes a method of treating a migraine patient by administering a 5-HT1B/1D agonist in combination with a COX-2 inhibitor. These agents should be given concomitantly and should be delivered in an amount sufficient to reduce migraine relapse or produce longer lasting efficacy relative to the effect of either agent alone. The invention also includes pharmaceutical compositions in unit dose form which are designed for treating migraine patients and which contain these agents, i.e., a 5-HT1B/1D agonist and a COX-2 inhibitor. If desired, one or more additional therapeutic agents, e.g., an additional analgesic, may be included. The compositions may be included as part of a therapeutic package in which one or more unit doses are placed in a finished pharmaceutical container. The package may include labeling directing the use of the composition in the treatment of migraine.
  • DETAILED DESCRIPTION OF THE INVENTION
  • [0023]
    It has been discovered that a combination therapy of a 5-HT1B/1D agonist together with a long acting nonsteroidal anti-inflammatory drug (LA-NSAID) substantially reduces or eliminates relapse in a significant portion of headache patients that experience this phenomenon. The combination results in an enhanced therapeutic effect allowing for greater efficacy and/or lower doses than can be obtained with the conventional doses of either individual agent. Naproxen sodium is the most preferred long acting NSAID and sumatriptan is the most preferred 5-HT1B/1D agonist. The invention will best be understood with reference to the following definitions:
  • [0024]
    A. “Long acting” in relation to NSAIDs means a pharmacokinetic half-life of at least 4 hours, preferably at least 6 hours and more preferably at least 8-14 hours and a duration of action equal to or exceeding about 6-8 hours. Examples of appropriate NSAIDs are: flurbiprofen with a half-life of about 6 hours; naproxen and naproxen sodium with a half-life of about 12 to 15 hours and about 12 to 13 hours respectively; oxaprozin with a half-life of about 42 to 50 hours; etodolac with a half-life of about 7 hours; indomethacin with a half-life of about 4 to 6 hours; ketorolac with a half-life of up to about 8-9 hours; nabumetone with a half-life of about 22 to 30 hours; mefenamic acid with a half-life of up to about 4 hours; piroxicam with a half-life of about 4 to 6 hours; and lornoxicam with a half-life of about 4 hours. If an analgesic does not naturally have a half life sufficient to be long acting, it can be made long acting by the way in which it is formulated. Unless otherwise indicated, the term “long-acting NSAID” shall include NSAIDs (e.g., acetaminophen, ibuprofen, aspirin) specially formulated to be long-acting. Methods for making appropriate long-acting formulations are well known in the art (see e.g., Remington's Pharmaceutical Sciences, 16th ed., A. Oslo editor, Easton, Pa. (1980); Controlled Drug Delivery, Edith Mathiowitz, John Wiley & Sons (1999), ISBN: 0471148288).
  • [0025]
    B. “Therapeutically effective amount” as to drug dosage shall mean a dosage that provides the specific pharmacological response for which the drug is administered in a significant number of subjects in need of such treatment. It is emphasized that headaches are not well understood and the etiologies of particular headaches will vary, as does the response to particular drugs. Thus, reference to “specific pharmacological response for which the drug is administered in a significant number of subjects in need of such treatment” is a recognition that a “therapeutically effective amount,” administered to a particular subject in a particular instance may not abort the onset of a headache or relieve headache pain, even though such dosage is deemed a “therapeutically effective amount” by those skilled in the art. It is to be further understood that drug dosages are, in particular instances, measured as oral, or parenteral or inhaled dosages or with reference to drug levels as measured in blood.
  • [0026]
    For 5-HT1B/1D agonists, NSAIDs and non-NSAID analgesics (particularly with respect to those already on the market) a therapeutically effective amount shall include (but not be limited to) the dosage that has been determined as safe and effective for any indication. Nevertheless, in particular applications, this does not exclude substantially lesser (or greater) dosages than established minimum (or maximum) dosages for which a particular 5-HT1B/1D agonist or NSAID could be used to effectively treat an episode of headache.
  • [0027]
    Sumatriptan is presently provided as oral tablets of 25 mg, 50 mg and 100 mg and as a parenteral dosage form containing about 6 mg/ml and about 6 mg/0.5 ml for subcutaneous administration. Oral doses of about 1-300 mg are useful for the present methods and compositions with doses of about 5-100 mg being preferred. Peak serum concentrations of approximately 1-300 ng/ml are produced with doses in these ranges. Subcutaneous injections of about 1 to 8 mg of sumatriptan are useful, with particular reference to about 3 to 6 mg doses. Injections produce peak serum concentrations of approximately 1 to 150 ng/ml. Other dosage forms of sumatriptan include, but are not limited to, suppositories, aerosols for inhalation or intranasal administration, and nose drops, all of which may be used in the practice of this invention.
  • [0028]
    With respect to NSAIDs, it is expected that the skilled practitioner will adjust dosages on a case by case basis using methods well established in clinical medicine. Nevertheless, the following general guidelines may be of help. Indomethacin is particularly useful when contained in tablets of from about 25 to 75 mg, in suppositories of about 50 mg, and in oral suspensions of about 25 mg/5 ml. A typical daily oral dosage of indomethacin is three 25 mg doses taken at intervals during one day, amounting to 75 mg total. However, daily doses of up to about 150 mg are useful in some subjects. Sustained release dosage forms of indomethacin are also available and provide longer lasting blood levels than conventional tablets. In particular, a 75 mg sustained release dosage form can be used as an alternative to 25 mg three times daily or 75 mg twice daily can be substituted for 50 mg three times daily.
  • [0029]
    Flurbiprofen is particularly useful when contained in tablets of from about 50 to 100 mg. Daily doses of about 100 to 500 mg, and particularly about 200 to 300 mg total are useful.
  • [0030]
    Naproxen is particularly useful when contained in tablets of from about 200 to about 600 mg and in oral suspensions of about 125 mg/5 ml.
  • [0031]
    Oxaprozin has a pharmacokinetic half-life of 42-50 hours and a bioavailability of 95%. It is usefully provided as caplets of 600 mg. Daily doses of 1200 mg have been found to be particularly useful and should not exceed 180 mg or 26 mg/kg. The lowest effective dose should always be used.
  • [0032]
    Etodolac is usefully provided in capsules of 200 mg and 300 mg or in tablets of 400 mg. Useful doses for acute pain are 200-400 mg every 6-8 hours, not to exceed 1200 mg/day. Patients<60 kg are advised not to exceed doses of 20 mg/kg. Amounts for other uses are also limited to 1200 mg per day, preferably in divided doses, e.g., 2, 3, or 4 times daily.
  • [0033]
    Ketorolac is usefully provided in tablets of 10 mg and as a sterile parenteral preparation for injection in 15 mg/ml and 30 mg/ml dosage forms. Oral doses of up to 40 mg with particular reference to 10-30 mg per day and parenteral doses up to 120-150 mg per day have been useful in the amelioration of pain.
  • [0034]
    Nabumetone is usefully provided in tablets of 500 mg and 750 mg. Daily doses of up to 1500-2000 mg/day after an initial dose of 1000 mg are of particular use.
  • [0035]
    Mefenamic acid is particularly useful when contained in capsules of from about 250 mg. For acute pain such as migraine, an initial dosage of about 100 to 1000 mg and particularly about 500 mg is useful, though other dosages may be required for specific subjects.
  • [0036]
    Meclofenamate sodium is usefully provided as capsules of 50 mg and 100 mg. Daily doses up to 400 mg are useful, particularly in individual doses of 50-100 mg every 4-6 hours.
  • [0037]
    Piroxicam is particularly useful when in tablets of from about 10 to 20 mg. It is noted that, as steady state plasma concentrations are not reached until about 7 to 12 days of dosing, prophylactic use of piroxicam is a specific avenue of therapy to establish a plasma concentration of greater than about 5 to 6 μg/ml. In such a situation, coordination and co-timely administration of a 5-HT1B/1D agonist is achieved by the administration of the 5-HT1B/1D agonist approximately at the onset of a migraine attack.
  • [0038]
    Celecoxib (Celebrex®) is particularly useful when contained in tablets of from about 100 to 200 mg. Recommended dosages are typically 100 mg twice per day or 200 mg once per day. A sub-med amount of celecoxib is less than about 150 mg per day and particularly less than about 100 mg per day, e.g., about 75 mg per day or 50 mg per day (see, Bolten, J., Rheumatolog. Suppl., 51:2-7 (May, 1998)). Celecoxib peak plasma concentrations occur approximately 3 hours after oral dosing. The effective half-life is approximately 11 hours. In one embodiment, coordination and co-timely administration of a 5-HT1B/1D agonist is achieved by the administration of the 5-HT1B/1D agonist approximately at the onset of a migraine.
  • [0039]
    Rofecoxib (Vioxx®) for oral administration is available in tablets of 12.5, 25 or 50 mg and in an oral suspension containing either 12.5 mg or 25 mg rofecoxib per 5 ml. The recommended initial daily dosage for the management of acute pain is 50 mg. Peak plasma concentrations of rofecoxib typically occur about 2-3 hours after oral administration and the drug has a half life of about 17 hours.
  • [0040]
    Valdecoxib (Bextra®) for oral administration is available in tablets of 10 or 20 mg. The recommended daily dosage for dysmenorhea is 20 mg or 40 mg. Peak plasma concentrations of valdecoxib typically occur about 2-3 hours after oral administration and the drug has a half life of 8-11 hours.
  • [0041]
    Lornoxicam for oral administration is available as tablets of 4 mg or 8 mg or as a powder to be reconstituted for injection at 4 mg/ml. Typical dosage schedules include a dose of 4 mg administered 4 times a day or 8 mg administered twice a day. Lornoxicam has a plasma half-life of approximately 4 hours and reaches a peak concentration approximately two hours after administration.
  • [0042]
    Many scientific articles have suggested that COX-2 specific inhibitors may sometimes offer advantages over nonselective inhibitors. While not being bound by any theory, it is believed that the GI and renal toxicity associated with use of NSAIDs is the result of COX-1 inhibition, stemming from a reduction in the protective prostaglandins that preserve the integrity of the stomach lining and maintain normal renal function. Likewise, anti-inflammatory effects are believed to be largely due to inhibition of COX-2 and the resultant decreases in pro-inflammatory prostaglandins, like thromboxane. Drugs which selectively inhibit the COX-2 isozyme, like mefenamic acid, etodolac, celecoxib, rofecoxib, meloxicam, JTE-522, etorocoxib, valdecoxib and L-745,337, produce analgesia and reduce inflammation without removing the protective prostaglandins in the stomach and kidney.
  • [0043]
    In certain embodiments, selective inhibition of the COX-2 isozyme may provide a beneficial therapeutic profile in the treatment of headaches, particularly migraine headaches. While the precise etiology of migraine remains unknown, the intense head pain is thought to result from sensitization and neurogenic inflammation at the trigeminal sensory nerve terminals which enervate cerebral blood vessels. NSAIDs have been shown to alleviate migraine headache pain, probably through a combination of their analgesic and anti-inflammatory properties. In the practice of the present invention, selective inhibitors of COX-2 (which have little effect on COX-1) produce similar effects, based on the preservation of prostacyclin levels, while being better tolerated in terms of potential GI and renal toxicity, and this effect is not negated in combination with 5-HT1B/1D agonists. Additional information on COX-2 inhibitors may be found in the following references:
    • 1. Sharma-S, et al., Indian J. Exp. Biol. 35:1025-31 (1997).
    • 2. Lane, J. Rheumatol 24 (Suppl 49):20-4 (1997).
    • 3. Lipsky, et al., J. Rheumatol. 24 (Suppl 49):9-14 (1997).
    • 4. Furst, Semin. Arthritis. Rheum 26 (6 Suppl 1):21-7 (1997). Note particularly the dosage range of meloxicam at about 7.5 mg per day or more, and including 15 mg per day in arthritis pain indications.
    • 5. Donnelly et al., Aliment-Pharmacol-Ther. 11(2):227-36 (1997).
    • 6. Griswold, et al., Med. Res. Rev. 16(2): 181-206 (1996).
  • [0050]
    C. “Co-timely” with respect to drug administration means administration of a second drug for headache symptom relief while a first drug is still present in a therapeutically effective amount.
  • [0051]
    D. “Coordinated” in the practice of the present invention means administration of an NSAID in such a manner that effective plasma levels of the NSAID are present in a subject from about one hour to about 12-24 hours after the onset of migraine or onset of precursor symptoms of a migraine. In some embodiments, this will be about 1 to 12 hours after a 5-HT1B/1D agonist has been administered. The coordination time is clearly related to the route of NSAID administration. For example, intramuscular routes will generally have shorter lead times to peak plasma levels for particular NSAIDs as follows: flurbiprofen peaks in about 1 to 2 hours; naproxen and naproxen sodium peak at about 2 to 4 hours and 1 to 2 hours respectively; oxaprozin peaks at about 3 to 5 hours; etodolac peaks at about 1 to 2 hours; indomethacin peaks at about 1 to 4 hours; ketorolac peaks about one-half to 1 hour; nabumetone peaks at about 2.5 to 4 hours; mefenamic peaks at about 2 to 4 hours; meclofenamate peaks in 0.5-1 hours; and piroxicam peaks at about 3 to 5 hours.
  • [0052]
    E. “5-HT1B/1D agonist” is to be understood to encompass drugs that act preferentially at 5-HT1B and 5-HT1D receptors. As used herein the term is synonymous with “triptan.” In this regard, particular reference is made to sumatriptan succinate and related heterocyclic compounds described in U.S. Pat. No. 4,816,470; eletriptan as described in European Patent Application 379314; Allelix ALX 1323; rizatriptan; frovatriptan; and almotriptan; and naratriptan.
  • [0053]
    F. “Relapse headaches” variously and interchangeably termed “rebound,” “relapse,” “recurrent” or “secondary” headaches occur when people experiencing initial symptom relief (or avoidance of migraine in the case of treated precursor symptoms) upon administration of a therapeutic agent, experience a return of headache or other related symptoms within the next 24 hours.
  • [0054]
    G. “Initial migraine relief” shall be understood to be the reduction or abolition of symptoms from first onset of either a migraine attack or the precursor indicia of a migraine headache such as the aura and visual “scotoma” in about a 24 hour period.
  • [0055]
    H. “Unit dosage from” shall mean a single drug administration entity. By way of example, a single tablet, capsule, dragee, or trochee, suppository, or syringe combining both a 5-HT1B/1D agonist and an NSAID would be a unit dosage form. Administration of one or more unit dosage forms will result in blood levels of the NSAID required to produce a therapeutic effect within about the first hour after dosing and will still be present at least about 8-12 hours after initial dosing, and in particular instances, for as long as about 24 hours after dosing. Blood levels of the 5-HT1B/1D agonist normally associated with a therapeutic effect will be present within the first hour and should persist in measurable quantities for at least about 4-6 hours.
  • [0056]
    I. “Quick dissolve” in reference to a tablet or other oral dosage form shall mean that the oral dosage form is at least 95% dissolved within 20 minutes after administration. In determining “quick dissolve,” reference is made to standard USP test methodology.
  • [0057]
    J. “Enhanced therapeutic effect” in the context of the present invention means that the initial relief of migraine symptoms occurs more quickly with a claimed combination of two agents compared to the same doses of each component given alone; or that doses of one or both component(s) are below what would otherwise be a minimum effective dose (a “sub-MED”).
  • [0058]
    While the experienced clinician is able to monitor and adjust dosages for each patient relative to the severity of the headache attack and the presence of side-effects, generally available information on maximum common daily dosages of NSAIDs is useful as a cautionary guideline. Maximum daily dosages in milligrams are as follows: flurbiprofen 300; naproxen 1500, naproxen sodium 1375; oxaprozin 1800; etodolac 1200; indomethacin 150 to 200; ketorolac 120 mg i.m. and 40 oral; nabumetone 2000; mefenamic acid 1000; and piroxicam 20. In particular instances, however, exceeding these “maximum” doses is the therapeutic choice of the medical professional.
  • [0059]
    The 5-HT1B/1D agonist and NSAID combined compositions of the present invention possess valuable pharmacological properties. They effect long term migraine attack relief with a substantially reduced incidence of relapse headaches. In some instances, they provide initial migraine relief with a reduced incidence of side effects, and/or greater efficacy. This effect can be demonstrated, for example, using the methods employed in the clinical studies reviewed by Plosker and McTavish (Drugs 47:622-651 (1999); Wilkinson, et al., Cephalalgia 15:337-357 (1995)) and Visser, et al., (Cephalalgia 16:264-269 (1996)).
  • [0060]
    The pharmacologically active compositions of the invention can be produced in accordance with conventional methods of Galenic pharmacy for making medicinal agents for administration to patients, e.g., mammals including humans. The compositions, individually or in combination, are employed in admixture with conventional excipients, i.e., pharmaceutically acceptable organic or inorganic carrier substances suitable for parenteral, enteral (e.g., oral or intranasal) or topical application which do not deleteriously react with the active compositions. Suitable pharmaceutically acceptable carriers include but are not limited to water, salt solutions, alcohols, gum arabic, vegetable oils, benzyl alcohols, polyethylene glycols, gelatin, carbohydrates such as lactose, amylose or starch, magnesium stearate, talc, titanium dioxide, silicic acid, viscous paraffin, perfume oil, fatty acid esters, hydroxymethycellulose, polyvinylpyrrolidone, etc. The pharmaceutical preparations can be sterilized and, if desired, mixed with auxiliary agents, e.g., lubricants, preservatives, stabilizers, wetting agents, emulsifiers, salts for influencing osmotic pressure, buffers, coloring, flavoring and/or aromatic substances and the like which do not deleteriously react with the active agents. They can also be combined with other active agents, e.g., vitamins. In some embodiments of the present invention, dosage forms include instructions for the use of such compositions. For parenteral application, particularly suitable are injectable, sterile solutions, preferably oily or aqueous solutions, as well as suspensions, emulsions, or implants, including suppositories. Ampules, vials, and injector cartridges are convenient unit dosages.
  • [0061]
    Generally, the compositions of this invention are dispensed in unit dosage forms comprising 5-100 mg of sumatriptan or equivalent doses of other 5-HT1B/1D agonists and 200-600 mg of naproxen sodium or equivalent doses of other NSAIDs in a pharmaceutically acceptable carrier per unit dosage. The actual preferred amounts of active compositions in a specific case will vary according to the specific compositions being utilized, the particular compositions formulated, the mode of application, and the particular route of administration. Dosages for a given subject can be determined using conventional considerations, e.g., by customary comparison of the differential activities of the subject compositions and of a known agent, or by means of an appropriate, conventional pharmacological protocol.
  • [0062]
    Although many different formulations are compatible with the present invention, the most preferred dosage form is a tablet for oral administration comprising 35-40 mg (most preferably 40 mg) of sodium succinate, and 375-400 mg (most preferably 400 mg) naproxen sodium. When using a triptan and naproxen, substantially all of the triptan should be found in one layer of the tablet and substantially all of the naproxen in a second, separate layer. These two layers should be in a side-by-side arrangement such that the dissolution of the naproxen occurs independently of the dissolution of triptan. This may be achieved by juxtaposing the layers symmetrically along a single planar surface so that essentially all of the triptan-containing layer is on one side of the plane and essentially all of the NSAID-containing layer is on the other side. These layers may come into direct contact with one another or, alternatively, they may be separated by one or more additional layers, e.g., a barrier layer or coating which prevents the therapeutic agents from interacting with one another. In preferred embodiments, the tablets are in a bilayer arrangement and may be surrounded with a film coating. Preferred formulations for each layer of the tablet are provided in Example 4 and appropriate manufacturing methods are provided in Examples 5 and 6.
  • EXAMPLES Example 1 Evidence of Synergy with Respect to Relapse and Efficacy
  • [0063]
    A study was conducted to evaluate the combination of sumatriptan and the long acting NSAID naproxen in migraine patients known to have a high relapse rate, greater than 50% recurrence, when given sumatriptan alone. This was an open-label, randomized out-patient study in which 16 patients treated two successive migraine attacks with either sumatriptan alone (50 mg) or with sumatriptan (50 mg) plus naproxen as the sodium salt (500 mg). Headache pain was assessed by the patients on a 4-point scale (no pain, mild pain, moderate pain, or severe pain). Each patient was treated for two migraine attacks of moderate or severe intensity at baseline and pain scores were recorded every 30 minutes for the first two hours following dosing and at 3, 4, 6, 12 and 24 hours post-dose. “Relapse” was defined to occur in those patients who responded with an adequate reduction in headache pain (moderate or severe at baseline, reduced to no pain or mild pain) at 2 hours after administration and, in whom, over the next 22 hours either: (a) headache pain returned to moderate or severe intensity; or (b) “rescue medication” was required to treat the recurrent headache pain.
  • [0064]
    In each treatment arm, 13 of the 16 patients achieved adequate pain relief at 2 hours. Two patients in each arm took rescue medication prior to the 2 hour assessment point, and one patient in each arm failed to reach the mild or no pain level. This high rate of response was expected since the selected patients were all known responders to sumatriptan. After treatment with sumatriptan alone, 46% of the responding patients experienced a relapse of headache pain during the study period. When sumatriptan was given in combination with naproxen the relapse rate was substantially reduced, to 23%. Thus, based on these relapse rates, seven of 16 patients (44%) achieved a 24 hour sustained response after taking oral sumatriptan alone, whereas 10 of 16 patients (63%) had a 24 hour sustained response when taking the combination of sumatriptan and naproxen. Thus, the coordinated use of the two agents increased the sustained response rate by over 40%.
  • [0065]
    This open-label study did not include a treatment arm with naproxen sodium alone, so no direct conclusions could be made regarding the comparative relapse and 24 hour sustained response rates. However, in a second, larger, Phase II study (which compared another experimental compound with a control formulation of naproxen sodium alone) a group of 57 patients were treated for a single migraine attack of moderate or severe intensity with the control formulation containing 500 mg of naproxen. Headache relief at two hours was determined in a manner identical to that described above, but the relapse and sustained response rates were calculated based solely on a return of moderate or severe headache pain (i.e., no “rescue medication” protocol was used as a separate indicator of relapse).
  • [0066]
    In order to compare the results from the first, 16 patient, study with the second study's treatment arm receiving 500 mg of naproxen (as the sodium salt) as a single agent, the sumatriptan+naproxen data in the first study were analyzed using the same criteria as the second study (i.e., the relapse and 24 hour sustained response rates were calculated based solely on a return of moderate or severe headache pain). It was found that 40% of the patients receiving sumatriptan alone experienced relapse and 26% of patients had relapse when treated with 500 mg naproxen alone. When sumatriptan and naproxen were given together, none of the 13 responding patients experienced a return of moderate or severe pain.
  • [0067]
    The results on relapse discussed above were only concerned with patients that initially responded to therapy. Another measure of effectiveness is the “sustained response rate.” A sustained responder is a patient that: (a) initially responds to therapy; and (b) does not experience a relapse in twenty-four hours. For example, if results indicated that three people administered a treatment at the onset of a migraine headache did not respond at all, two people responded but had a relapse within twenty-four hours, and five people responded with no relapse, then the sustained response rate would be 50%. (In contrast, the relapse rate, which only considers responders, would be 2 of 7 or 29%.) Using this measure, it was found that sumatriptan alone gave a 56% sustained response rate, and naproxen alone gave a 46% sustained response rate. However, when the two drugs were given together, the sustained response rate was found to increase to 94%.
  • [0068]
    Based upon these results it was concluded that the treatment of migraine headache using the combination of a long acting NSAID and a 5-HT1B/1D agonist exhibits a synergistic effect.
  • Example 2 Evidence for Synergy in Rapid Pain Relief and for Other Migraine Symptoms—Additional Evidence with Respect to Sustained Pain Relief
  • [0069]
    In addition to the data presented above, data was obtained suggesting that triptans and long acting NSAIDs produce a surprising reduction in total, pain relief. In these experiments, a comparison was made between: patients administered triptan alone; patients administered NSAID alone; patients administered a combination of triptan and NSAID (“MT400”); and, in some cases, patients administered a placebo. The results demonstrate, inter alia, that when the combination is used, there is a dramatic increase in the percentage of patients that experience rapid, within two hours, pain relief. The results suggest that, in addition to the synergistic effects relating to relapse, there is also synergy with respect to both the short term and sustained pain response, parameters that are obviously of great importance to patients.
  • [0070]
    It was found that, at two hours, 65% of patients receiving the combination experienced an improvement from moderate or severe pain at baseline to mild or no pain, compared to 49% receiving the triptan alone, 46% receiving naproxen alone and 27% receiving placebo. Sustained response was evaluated based upon the number of patients that experience an initial pain response without a return of pain for the 24 hours after dosing. The sustained response data are shown in Table 1 below. Analysis of the sustained response data demonstrated that a significantly (p<0.001) higher percentage of subjects treated with MT 400 (46%) had a sustained response than subjects treated with either of the individual components (Imitrex, 28.8%; naproxen, 24.7%) or placebo (17%).
  • [0000]
    TABLE 1
    Sustained Pain Response
    Treatment Groups
    MT 400 Imitrex Naproxen Placebo
    Parameter (N = 250) (N = 229) (N = 247) (N = 241)
    Sustained Response 115 66 61 41
    (46.0%) (28.8%) (24.7%) (17.0%)
    P-value vs. placebo <0.001
    p-value vs. Imitrex <0.001
    p-value vs. naproxen <0.001
  • [0071]
    The results are even more surprising when the effect of placebo is taken into accounted. Therapeutic gain is calculated by subtracting the placebo response from the response rates for active treatment. For pain response, patients receiving the combination experienced a therapeutic gain of 38% over placebo, whereas patients receiving the triptan alone experienced 22% gain and naproxen alone a 19% gain. For sustained response, the results were also dramatic. Patients receiving the combination experienced a therapeutic gain of 29% over placebo, while patients receiving triptan alone experienced a 12% gain and those receiving naproxen alone experienced 8% gain, thus demonstrating a truly synergistic effect of the combination. Again, the combination is statistically significantly superior (p<0.05) to individual components in this measure.
  • [0072]
    The most desirable outcome for the treatment of migraine is that the pain be eliminated quickly and not return. This outcome measure is termed Sustained Pain Free. Responders are defined as patients having a pain score of 0 at 2 hours and nothing more than 0 from 2 to 24 hours post dose without the need for rescue. Therapeutic gain for this measure was 20.2% for MT 400 versus gains of 5.9% and 6.7% for Imitrex and naproxen, respectively. As shown in Table 2 below, 25% of subjects treated with MT 400 were responders compared to less than 12% for naproxen and Imitrex and 5% for placebo. The response differences between MT 400 and all other treatment groups was significant at p<0.001.
  • [0000]
    TABLE 2
    Sustained Pain Free
    Treatment Groups
    MT 400 Imitrex Naproxen Placebo
    Parameter (N = 250) (N = 229) (N = 247) (N = 241)
    Sustained Response 63 25 29 12
    (25.2%) (10.9%) (11.7%) (5.0%)
    P-value vs. placebo <0.001
    p-value vs. Imitrex <0.001
    p-value vs. naproxen <0.001
  • Example 3 Effect of Combination Therapy on Secondary Symptoms of Migraine
  • [0073]
    As migraine is a pathological complex characterized by unilateral headache, often accompanied by associated symptoms of nausea, photophobia and phonophobia, efficacy against these other parameters is important in evaluating the efficacy of a drug candidate. The surprising benefits of MT 400 are further demonstrated in its impact on these associated symptoms. Analysis of secondary migraine symptom response is presented in Table 3. The percentage of MT 400 treated subjects with nausea at 2 hours was significantly lower than for placebo. The percentage of subjects with photophobia or phonophobia at 2 hours was significantly lower in the group treated with MT 400 than in either of the component groups or placebo. Only the combination provided relief against any or all secondary symptoms versus placebo to a statistically significant extent, and the combination was statistically significantly superior to individual components with respect to photophobia and phonophobia.
  • [0000]
    TABLE 3
    Associated Symptoms of Migraine
    Treatment Groups
    MT 400 Imitrex Naproxen Placebo
    (N = 250) (N = 229) (N247) (N = 241)
    Number (%) with 70  73  77  88
    nausea   (28%)** (31.9%) (31.2%) (36.5%)
    Number (%) with 97 115 142 160
    photophobia (38.8%)* (50.2%) (57.5%) (66.4%)
    Number (%) with 79 102 118 138
    phonophobia (31.6%)* (44.5%) (47.8%) (57.3%)
    *Statistically different from placebo and components (p < 0.001)
    **Statistically different from placebo (p = 0.002)
  • Example 4 Formulations
  • [0074]
    As discussed previously, the most preferred dosage form is a tablet in which sumatriptan in the form of its succinate salt and naproxen in the form of its sodium salt are separated into separate layers of a tablet. The sumatriptan should be present in one layer at 35-40 mg and naproxen should be present in the second layer at 375-500 mg. One preferred formulation for the sumatriptan layer is provided in Table 4 and a preferred formulation for naproxen is provided in Table 5.
  • [0000]
    TABLE 4
    Formulation composition for Sumatriptan 40 mg granulation1
    Ingredient mg/Tablet
    Intra-Granular Ingredients:
    Sumatriptan Succinate 56.00
    Lactose Monohydrate, NF 56.00
    Microcrystalline Cellulose, NF 13.76
    Purified Water, USP2 QS
    Extra-Granular Ingredients:
    Microcrystalline Cellulose, NF 13.76
    Croscarmellose Sodium, NF 1.42
    Magnesium Stearate, NF 1.07
    Total 142.01
    1Free base equivalent. Representative formulation shown above; quantities of excipients may be varied by ±10% to improve pharmaceutical processing efficiencies. A suitable binder may be included depending upon manufacturing process and scale.
    2Purified Water, USP is removed during the drying process.
  • [0000]
    TABLE 5
    Formulation composition for Naproxen Sodium 400 mg granulation1
    Ingredient mg/Tablet
    Intra-Granular Ingredients:
    Naproxen Sodium, USP 400.00
    Microcrystalline Cellulose, NF 42.36
    Povidone, USP 18.88
    Purified Water, USP2 QS
    Extra-Granular Ingredients:
    Microcrystalline Cellulose, NF 42.36
    Croscarmellose Sodium, NF 10.80
    Talc, USP 21.60
    Magnesium Stearate, NF 4.00
    Total 540.00
    1Representative formulation shown above; quantities of excipients may be varied by ±10% to improve pharmaceutical processing efficiencies. Tablet weight may be adjusted for granulation moisture content.
    2Purified Water, USP is removed during the drying process.
  • Example 5 Manufacturing of Dosage Form
  • [0075]
    The manufacture of bilayer tablets is described below and involves the application of standard methods well known in the art of pharmaceutical sciences (Rubinstein, M. H. In Pharmaceutics: The Science of Dosage Form Design; Bandelin, In Pharmaceutical Dosage Forms: Tablets, Lieberman, et al. eds., Marcel Dekker, Inc., New York, 1989, p. 131-193; and Carstensen, J. T. In Pharmaceutics of Solids and Solid Dosage Forms, John Wiley & Sons: New York, 1977). The separate processes for each granulation incorporate high shear granulation, fluid-bed drying, milling, blending, and lubrication. The formulation composition for each separate granulation is provided in Tables 6 and 7. The dose ratios of the components may be varied within the therapeutic ranges.
  • [0076]
    Manufacturing Steps
    • 1. Separately charge the respective intra-granular ingredients from Tables 6 (sumatriptan succinate) and 7 (naproxen sodium) into suitable high shear mixer/granulators (Niro/Fielder, GP-1 or PMA-65).
    • 2. Dry mix for 5 minutes using a high impeller speed and a high chopper speed setting. Using a spray gun/nozzle, spray purified water, USP, granulating solution, at a controlled rate, while mixing continuously at the same mixing conditions. Continue to mix under the same conditions for one to three minutes or until proper granulation endpoint is reached. Record the final granulating time (solution addition and post-solution addition), amount of solution added, and mixer power consumption readings.
    • 3. Remove the wet granules from the high shear mixer/granulator and place in a drying bowl and dry in a suitable fluid bed dryer (Niro, MP2/3), using the following conditions to achieve a loss on drying of 1-5%:
      • a) inlet air temperature: 25-60° C.
      • b) outlet air temperature: 35-55° C.
    • 4. Sample the granulation to determine the moisture content.
    • 5. Mill the dried granulation into a hopper or drum using a suitable mill (Quadro Comil, Model 197S) fitted with a suitable screen (0.094R) and operating at 2,500 rpm.
    • 6. Charge the milled granulation and the respective extra-granular ingredients in Tables 6 and 7 into suitable V-blenders (Patterson-Kelly) or tote blenders (Gallay).
    • 7. Blend for 10 minutes or until uniform.
    • 8. Add lubricants, magnesium stearate and/or talc, through a #40 mesh screen and blend for five minutes.
    • 9. Transfer the separate final blends into double-line polyethylene bags.
    • 10. Weigh the respective quantities of each blend using an analytical balance.
    • 11. Manually compress the respective granulations as bilayer tablets using 7/16″ standard concave, round shaped tooling and dies using a laboratory tablet press (Carver, Model C). Load the first layer, naproxen sodium blend, into the die first and tamp to remove entrapped air. Load the second layer, sumatriptan succinate blend, on top of the naproxen sodium layer and compress using 2,000 lbs force. Target a bilayer tablet hardness range of 8 to 14 kp.
    • 12. In-process controls to ensure acceptable bilayer dosage form include respective weights of each layer, hardness (8-14 kp), thickness, friability (<1%), and disintegration (<15 minutes).
    • 13. A barrier layer, consisting of 80:20 mixture of anhydrous lactose, NF and microcrystalline cellulose, NF, may be included between the naproxen sodium and sumatriptan succinate layers.
  • [0000]
    TABLE 6
    Formulation Composition for Sumatriptan 35 mg Granulation1
    Ingredient mg/Tablet
    Intra-Granular Ingredients:
    Sumatriptan Succinate 49.00
    Lactose Monohydrate, NF 49.00
    Purified Water, USP2 QS
    Extra-Granular Ingredients:
    Anhydrous Lactose, NF 98.00
    Microcrystalline Cellulose, NF 10.85
    Croscarmellose Sodium, NF 2.10
    Magnesium Stearate, NF 1.05
    Total 210.00
    1Free base equivalent. Representative formulation shown above; quantities of excipients may be varied by ±10% to improve pharmaceutical processing efficiencies.
    2Purified Water, USP is removed during the drying process.
  • [0000]
    TABLE 7
    Formulation composition for Naproxen Sodium 375 mg granulation1.
    Ingredient mg/Tablet
    Intra-Granular Ingredients:
    Naproxen Sodium, USP 375.00
    Microcrystalline Cellulose, NF 39.71
    Povidone, USP 17.70
    Purified Water, USP2 QS
    Extra-Granular Ingredients:
    Microcrystalline Cellulose, NF 39.71
    Croscarmellose Sodium, NF 10.12
    Talc, USP 20.25
    Magnesium Stearate, NF 3.75
    Total 506.24
    1Representative formulation shown above; quantities of excipients may be varied by ±10% to improve pharmaceutical processing efficiencies. Tablet weight may be adjusted for granulation moisture content.
    2Purified Water, USP is removed during the drying process.
  • Example 6 Large Scale Manufacturing of Bilayer Tablets A. Preparation of Granulations
  • [0092]
    The separate granulations for bilayer tablet dosage forms may be manufactured by various processes depending upon scale and available equipment. The formulations may be easily adapted for a fluid bed granulation process. One suitable method of manufacture is described below.
  • [0093]
    The intra-granular ingredients described above are separately charged into a fluid bed granulator (Niro, Model MP 2/3) and the materials are fluidized to achieve a uniform distribution of active ingredient. Using a top-spray nozzle, granulating solution, consisting of purified water, USP and povidone, USP, (or other suitable binders) is dispersed at a controlled rate over the fluidized powder bed. Fluid bed granulation is continued until the proper granulation endpoint is reached. After recording the final granulating parameters and amount of solution added, drying is initiated to achieve a loss of 1-5%. The following drying parameters may be used, including an inlet air temperature of 25 to 60° C. and an outlet air temperature of 35 to 55° C. The dried granulation is milled using a Quadro Comil (Model 196) fitted with a suitable screen. The process may be repeated to yield sub-batches that are later combined to provide the desired quantities of each component granulation. Subsequent processing of fluid bed-granulated naproxen sodium and sumatriptan succinate granulations may be carried out as described in subsections B and C below.
  • B. Pilot-Scale Bilayer Tablet Manufacturing
  • [0094]
    The formulation and process for making bilayer tablets may be scaled-up for pilot-scale manufacturing (Batch size˜125,000 tablets) as described below.
  • [0095]
    The respective intra-granular ingredients are separately charged into high shear mixer/granulators (Fielder, PMA-65 or PMA-300) and mixed for 5 minutes using a high impeller speed and a high chopper speed setting. Using a spray nozzle, spray purified water, USP, granulating solution, at a suitable rate while mixing continuously at the same mixing conditions. Continue to mix under the same conditions for 1 to 3 minutes or until proper granulation endpoint is reached. Record the final granulating time (solution addition and post-solution addition), amount of solution added, and mixer power consumption readings. Remove the wet granules from the high shear mixer/granulator and place in a drying bowl and dry in a suitable fluid bed dryer (Glatt, Model GPCG 30), to achieve a loss on drying of 1-5%. The following drying parameters may be used, including an inlet air temperature of 25 to 60° C. and an outlet air temperature of 35 to 55° C. The dried granulation is milled using a Quadro Comil (Model 196) fitted with a suitable screen. The process may be repeated to yield sub-batches that are later combined to provide the desired quantities of each component granulation.
  • [0096]
    The milled granulations are transferred to suitable V-blenders (Patterson-Kelly, 2 or 5 cu. ft.) and mixed for approximately ten minutes with the respective extra-granular ingredients. Pre-sifted lubricants are added and blended for five minutes. Transfer the separate final blends into the hopper(s) for a 35-station, rotary bilayer tablet press (Manesty, Model BB-4). Compress the respective granulations as bilayer tablets using oval-shaped, concave tooling. The naproxen sodium layer is loaded into the die cavity first, and minimal compression force (˜500 lbs) is applied to remove entrapped air and form a loose compact. Once acceptable tablet weights are obtained for the naproxen sodium layer, the second layer, consisting of sumatriptan succinate granulation, is loaded into the die cavity. Sufficient compression force (˜3,800 lbs) is then applied to yield acceptable bilayer tablets with desired mechanical properties. A tablet hardness of 14 to 18 kp and friability of less than 1% are targeted. In-process controls to ensure acceptable bilayer dosage form include respective weights of each layer, hardness, thickness, friability, and disintegration.
  • [0097]
    The core bilayer tablets are film-coated in a perforated pan-coater (36″ Accela-Cota), using a pre-mixed hydroxypropyl methylcellulose (HPMC) polymer-based dispersion with colorants (Opadry®, Colorcon, Inc.). A 12% w/w aqueous coating suspension is typically prepared. The tablets are coated using two spray guns with an inlet temperature of ˜60° C. and an outlet temperature of ˜40° C. The pan speed may range from 6 to 12 rpm. The finished tablets are stored in double-lined polyethylene bags prior to packaging.
  • C. Commercial-Scale Bilayer Tablet Manufacturing
  • [0098]
    The formulation and process may also be successfully scaled-up for commercial-scale manufacturing (Batch size˜1,250,000 tablets). The respective intra-granular ingredients are separately charged into high shear mixer/granulators (Fielder, PMA 300 or PMA-1200). Dry mix for 5 minutes using a high impeller speed and a high chopper speed setting. Using a spray nozzle, spray purified water, USP, granulating solution, at a suitable rate while mixing continuously at the same mixing conditions. Continue to mix under the same conditions for 1 to 3 minutes or until proper granulation endpoint is reached. Record the final granulating time (solution addition and post-solution addition), amount of solution added, and mixer power consumption readings. Remove the wet granules from the high shear mixer/granulator and place in a drying bowl and dry in a suitable fluid bed dryer (Niro Aeromatic, Model T9), to achieve a loss on drying of 1-5%. The following drying parameters may be used, including an inlet air temperature of 25 to 60° C. and an outlet air temperature of 35 to 55° C. The dried granulation is milled using a Quadro Comil (Model 199) fitted with a suitable screen. The process may be repeated to yield sub-batches that are later combined to provide the desired quantities of each component granulation.
  • [0099]
    The milled granulations are transferred to suitable bin blenders (Bohle Bin Blender) and mixed for approximately ten minutes with the respective extra-granular ingredients, described elsewhere. Pre-sifted lubricants are added and blended for five minutes. Transfer the separate final blends into the hopper(s) for a 51-station, rotary bilayer tablet press (Elizabeth Hata, Model HT-HX51). Compress the respective granulations as bilayer tablets using appropriately shaped tooling. The naproxen sodium layer is loaded into the die cavity first, and minimal compression force (˜500 lbs) is applied to remove entrapped air and form a loose compact. Once acceptable tablet weights are obtained for the naproxen sodium layer, the second layer, consisting of sumatriptan succinate granulation, is loaded into the die cavity. Sufficient compression force (˜3,800 lbs) is then applied to yield acceptable bilayer tablets with desired mechanical properties. The rotary tablet press speed is approximately 40 rpm. A tablet hardness of 16 to 18 kp and friability of less than 1% are targeted. In-process controls to ensure acceptable bilayer dosage form include respective weights of each layer, hardness, thickness, friability, and disintegration.
  • [0100]
    The core bilayer tablets are film-coated in a perforated pan-coater (48″ Accela-Cota), using a pre-mixed hydroxypropyl methylcellulose (HPMC) polymer-based dispersion with colorants (Opadry®, Colorcon, Inc.). The batch is sub-divided to yield suitable pan loading. A 12% w/w aqueous suspension is typically prepared for coating. The tablets are coated using three spray guns with an inlet temperature of ˜60° C. and an outlet temperature of ˜40° C. The pan speed may range from 4 to 8 rpm. The finished tablets are stored in double-lined polyethylene bags prior to packaging.
  • Example 7 First Treatment Example
  • [0101]
    An adult female migraineur complains of a migraine attack consisting of typical migraine headache, nausea and sensitivity to light and sound. She is dosed with a single oral tablet containing sumatriptan 40 mg and naproxen sodium 400 mg. Her symptoms start to diminish within one hour and by three hours she is completely symptom free. No relapse over the next 48 hours is reported.
  • Example 8 Second Treatment Example
  • [0102]
    An adult female migraineur complains of a migraine attack consisting of typical migraine headache, nausea and sensitivity to light and sound. She is dosed with a single oral tablet containing 12.5 mg sumatriptan and 550 mg naproxen sodium. Her symptoms start to diminish within one hour. By three hours she is completely symptom free and has no relapse over the next 48 hours.
  • [0103]
    All references cited herein are fully incorporated by reference. Having now fully described the invention, it will be understood by those of skill in the art that the invention may be performed within a wide and equivalent range of conditions, parameters and the like, without affecting the spirit or scope of the invention or any embodiment thereof.

Claims (11)

  1. 1. A method of treating a patient for a migraine headache, comprising simultaneously administering to said patient:
    (a) a 5-HT1B/1D agonist; and
    (b) a nonsteroidal anti-inflammatory drug having a pharmacokinetic half-life of at least 4 hours and a duration of action of at least 6 hours (“LA-NSAID”);
    wherein:
    said 5-HT1B/1D agonist and said LA-NSAID are administered to said patient orally after the onset of migraine symptoms; and
    the amount of said 5-HT1B/1D agonist and said LA-NSAID administered to said patient are sufficient to produce longer lasting efficacy compared to the administration of said 5-HT1B/1D agonist in the absence LA-NSAID or the administration of said LA-NSAID in the absence of said 5-HT1B/1D agonist.
  2. 2. The method of claim 1, wherein said 5-HT1B/1D agonist and said LA-NSAID are administered together in a single dosage form.
  3. 3. The method of claim 2, wherein said single dosage form is a tablet, capsule, dragee or trochee.
  4. 4. The method of claim 1, wherein said 5-HT1B/1D agonist is selected from the group consisting of: sumatriptan; eletriptan; rizatriptan; frovatriptan; almotriptan; zolmitriptan; and naratriptan.
  5. 5. The method of claim 1, wherein said LA-NSAID is selected from the group consisting of: flurbiprofen; naproxen; oxaprozin; indomethacin; ketorolac; mefenamic acid; nabumetone, etodolac; and piroxicam.
  6. 6. The method of claim 1, wherein said LA-NSAID inhibits COX-2 to a greater extent than it inhibits COX-1.
  7. 7. The method of claim 6, wherein said LA-NSAID is either etodolac or mefenamic acid.
  8. 8. The method of claim 6, wherein said 5-HT1B/1D agonist is sumatriptan.
  9. 9. The method of claim 1, wherein said 5-HT1B/1D agonist is sumatriptan.
  10. 10. The method of claim 1, wherein said 5-HT1B/1D agonist and said LA-NSAID are administered in a single dosage form and wherein said 5-HT1B/1D agonist is sumatriptan present at between 5 mg and 100 mg and said LA-NSAID is naproxen present at between 200 mg and 600 mg.
  11. 11-20. (canceled)
US13872832 1996-08-16 2013-04-29 Methods of treating headaches using 5-ht agonists in combination with long-acting nsaids Abandoned US20130303583A1 (en)

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US2412996 true 1996-08-16 1996-08-16
US08907826 US5872145A (en) 1996-08-16 1997-08-14 Formulation of 5-HT agonist and NSAID for treatment of migraine
US09151912 US6060499A (en) 1996-08-16 1998-09-11 Anti-migraine methods and compositions using 5-HT agonists with long-acting NSAIDs
US09559753 US6586458B1 (en) 1996-08-16 2000-04-27 Methods of treating headaches using 5-HT agonists in combination with long-acting NSAIDs
US10414493 US8022095B2 (en) 1996-08-16 2003-04-16 Methods of treating headaches using 5-HT agonists in combination with long-acting NSAIDs
US13183983 US20110275691A1 (en) 1996-08-16 2011-07-15 Methods of treating headaches using 5-ht agonists in combination with long-acting nsaids
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