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• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/56—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids
  • A61K31/57—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids substituted in position 17 beta by a chain of two carbon atoms, e.g. pregnane or progesterone
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/20—Pills, tablets, discs, rods
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P15/00—Drugs for genital or sexual disorders; Contraceptives
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P15/00—Drugs for genital or sexual disorders; Contraceptives
  • A61P15/18—Feminine contraceptives
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P35/00—Antineoplastic agents
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P35/00—Antineoplastic agents
  • A61P35/04—Antineoplastic agents specific for metastasis
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P5/00—Drugs for disorders of the endocrine system
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P5/00—Drugs for disorders of the endocrine system
  • A61P5/24—Drugs for disorders of the endocrine system of the sex hormones
  • A61P5/36—Antigestagens
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P7/00—Drugs for disorders of the blood or the extracellular fluid
  • A61P7/04—Antihaemorrhagics; Procoagulants; Haemostatic agents; Antifibrinolytic agents
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P7/00—Drugs for disorders of the blood or the extracellular fluid
  • A61P7/06—Antianaemics

Definitions

• This invention relates to a method for treating uterine fibroids, also called leiomyomata, or tumors deriving therefrom.
• Leiomyomata are common pelvic fibroid tumors occurring in up to 20% of women over 30 years of age. Leiomyomata represent one of the most frequent indications of surgical procedures in woman of reproductive age. Studies show that up to 77% of women have microscopic or macroscopic uterine fibroids at the time of menopause (Cramer et al, 1990). Leiomyomata may be lmm to 20cm in diameter.
• Leiomyomata are monoclonal sex-hormone responsive tumors of myometrial cells with abundant extra cellular collagen matrix. The histological appearance is similar to that of normal myometrium surrounded by a pseudocapsule of compressed myometrium, although areas of fibrosis and calcification (thought to represent degeneration) may be present. Leiomyomata are almost always benign in pre-menopausal women but may be indistinguishable from leiomyosarcomas, a tumor most common in post-menopausal women.
• the treatment of leiomyomata depends on the symptoms, location, and size of the tumor, and the age of the woman. Expectant treatment is recommended for asymptomatic women and medical treatment of menorrhagia for those with excessive bleeding. Because high levels of estradiol cause tumour growth, other approaches include temporizing until menopause, when gonadal steroid levels fall.
• Endometrial ablation to destroy the endometrium targets the source of endometrial bleeding and may be effective when that is the primary symptom.
• a number of small studies with limited follow-up suggest that uterine artery embolization can decrease bloodflow to the uterus, and reduce leiomyoma and uterine size.
• the procedure may be painful and cause infection and bleeding that leads to surgery. Because of damage to the uterine and ovarian blood supply, it is not recommended for pre-menopausal women interested in preserving fertility. Pregnancy outcomes following this procedure are not well studied.
• the invention provides a method for treating uterine fibroids or tumors deriving therefrom, which method comprises administering to a patient in need thereof, an effective amount of ulipristal or of a metabolite thereof.
• the patient is administered with a tablet comprising ulipristal or a metabolite thereof.
• a low dosage e.g. a daily dosage of 5 to 15mg, preferably lOmg, ulipristal was the most effective.
• the patient may be administered with an oral dosage of ulipristal or of a metabolite thereof during a period of about 2 to about 4 months, which period can be repeated once a year.
• Ulipristal or a metabolite thereof is particularly efficient to reduce or stop bleeding in a patient afflicted with uterine fibroids, or to reduce the size of uterine fibroids.
• Ulipristal or a metabolite thereof may be useful as a contraceptive while treating the uterine fibroids or tumors derived thereof.
• the patient is affected with metastatic leiomyoma, also called metastatic or metastasizing leiomyomatosis.
• a subject of the invention is a method for treating metastasizing leiomyomatosis, which method comprising administering to a patient in need thereof, an effective amount of 17 ⁇ - acetoxy-l l ⁇ -[4-JV, ⁇ /-dimethylamino-phenyl)-19-norpregna- 4, 9-diene-3, 20-dione (ulipristal) or of a metabolite thereof.
• Figure 1 is a graph that shows the treatment-related change in fibroid volume after 3 months administration with ulipristal (CDB-2914).
• Figure 2 is a graph that shows the average number of bleeding days by cycle and treatment group, i.e. placebo, lOmg, or 20mg ulipristal (CDB-2914) orally.
• Ulipristal formerly known as CDB-2914, is 17 ⁇ -acetoxy-l l ⁇ -[4-JV, JV-dimethylamino- phenyl)-19-norpregna- 4, 9-diene-3, 20-dione, represented by formula I:
• Metabolites of CDB-2914 include those described in Attardi et al, 2004 , e.g. monodemethylated CDB-2914 (CDB-3877) ;didemethylated CDB-2914 (CDB-3963) ;
• CDB-3236 17alpha-hydroxy CDB-2914
• CDB-4183 aromatic A-ring derivative of CDB-2914
• ulipristal or a metabolite thereof for treating uterine fibroids, more particularly for reducing or stopping bleeding in a patient afflicted with uterine fibroids, reducing the size of uterine fibroids and/or reducing uterine volume More particularly the inventors have shown in a randomized, placebo-controlled, double blinded, parallel trial, that ulipristal significantly reduces fibroid volume after 3 months, and stops bleeding.
• Ulipristal or a metabolite thereof alleviates symptoms of uterine fibroids, including bleeding, pelvic pain, pressure.
• Ulipristal or a metabolite thereof is useful for preventing or treating anemia in patients afflicted with uterine fibroids.
• the inventors further have shown that ulipristal or a metabolite thereof is efficient against pelvic and lung lesions in metastasizing leiomyomatosis after three months.
• the invention relates to a method for treating tumors that derive from leiomyomata, including begnin or cancerous tumors, e.g. leiomyosarcomas, leiomyomatosis or metastasizing leiomyomatosis.
• leiomyosarcomas e.g., leiomyosarcomas, leiomyomatosis or metastasizing leiomyomatosis.
• Metastasizing leiomyomatosis originates from an antecedent leiomyoma of the uterus in virtually all cases. It appears that tumor metastasizes to lungs or other extrauterine tissues via hematogenous spread. However, the origin of the tumor remains controversial.
• Ulipristal or a metabolite thereof may be administered by any convenient route, including oral, buccal, parenteral, transdermal, vaginal, uterine, rectal, etc.
• nontoxic solid carriers include, for example, pharmaceutical grades of mannitol, lactose, starch, magnesium stearate, sodium saccharine, talcum, cellulose, glucose, sucrose, magnesium, carbonate, and the like.
• a pharmaceutically acceptable nontoxic composition is formed by incorporating any of the normally employed excipients, such as those carriers previously listed.
• Oral solid dosage forms preferentially are compressed tablets or capsules.
• Compressed tablets may contain any of the excipients described above which are diluents to increase the bulk of the ulipristal so that production of a compressed tablet of practical size is possible.
• Binders which are agents which impart cohesive qualities to powdered materials are also necessary.
• Starch, gelatin, sugars such as lactose or dextrose, and natural and synthetic gums are used.
• Disintegrants are necessary in the tablets to facilitate break-up of the tablet. Disintegrants include starches, clays, celluloses, algins, gums and crosslinked polymers.
• lubricants and glidants are included in the tablets to prevent adhesion to the tablet material to surfaces in the manufacturing process and to improve the flow characteristics of the powder material during manufacture.
• Colloidal silicon dioxide is most commonly used as a glidant and compounds such as talc or stearic acids are most commonly used as lubricants. Procedures for the production and manufacture of compressed tablets are well known by those skilled in the art (See
• Capsules are solid dosage forms using preferentially either a hard or soft gelatin shell as a container for the mixture of ulipristal or a metabolite thereof and inert ingredients. Procedures for production and manufacture of hard gelatin and soft elastic capsules are well known in the art (See Remington).
• U.S. patent application 20050208129 describes a prolonged release bioadhesive mucosal therapeutic system containing at least one active principle, with an active principle dissolution test of more than 70% over 8 hours and to a method for its preparation.
• Said bioadhesive therapeutic system comprises quantities of natural proteins representing at least 50% by weight of active principle and at least 20% by weight of said tablet, between 10% and 20% of a hydrophilic polymer, and compression excipients, and comprising between 4% and 10% of an alkali metal alkylsulphate to reinforce the local availability of active principle and between 0.1% and 1% of a monohydrate sugar.
• fluid unit dosage forms are prepared utilizing the compounds and a sterile vehicle, water being preferred. Ulipristal or a metabolite thereof, depending on the vehicle and concentration used, can be either suspended or dissolved in the vehicle.
• the compound can be dissolved in water for injection and filtered sterilized before filling into a suitable vial or ampoule and sealing.
• adjuvants such as a local anesthetic, preservative and buffering agents can be dissolved in the vehicle.
• the composition can be frozen after filling into the vial and the water removed under vacuum. The dry lyophilized powder is then sealed in the vial and an accompanying vial of water for injection is supplied to reconstitute the liquid prior to use.
• Parenteral suspensions can be prepared in substantially the same manner except that the compounds are suspended in the vehicle instead of being dissolved and sterilization cannot be accomplished by filtration.
• the compound can be sterilized by exposure to ethylene oxide before suspending in the sterile vehicle.
• a surfactant or wetting agent is included in the composition to facilitate uniform distribution ofulipristal.
• a suppository can be employed to deliver ulipristal.
• the active compound can be incorporated into any of the known suppository bases by methods known in the art. Examples of such bases include cocoa butter, polyethylene glycols (carbowaxes), polyethylene sorbitan monostearate, and mixtures of these with other compatible materials to modify the melting point or dissolution rate. These suppositories can weigh from about 1 to 2.5 gm.
• Transdermal delivery systems comprising a penetration enhancer and an occlusive backing are of use to deliver ulipristal or a metabolite thereof.
• penetration enhancers include dimethyl sulfoxide, dimethyl acetamide and dimethylformamide.
• Suitable delivery systems include subcutaneous devices or implants such as those routinely used to deliver norgestrienone or progestin R2323 and other medicaments.
• the daily unit dosage of ulipristal is preferably between 5 to 15 mg per day. Surprisingly enough, the reduction of fibroid volume is more important with an oral dose of lOmg, compared to 20mg. An oral dose of lOmg per day is thus most preferred. A lower dosage is also contemplated, e.g. between 1 mg and 10 mg daily, preferably between 5 and lOmg daily. The oral route is preferred. Other routes of administration can be suitable in comparison with oral routes using blood levels to provide clinical success.
• the amount of ulipristal or a metabolite thereof is effective to alleviate the symptoms of uterine leiomyomata without clinically significant antiglucocorticoid activity.
• the patient may be administered with an oral dosage of ulipristal during a period of about 2 to about 4 months.
• the invention provides a method for treating leiomyomata or tumors deriving therefrom in women comprising the administration of a daily dosage of between 5 and 15mg ulipristal or a metabolite thereof administered orally, in a micronized form.
• a maintenance dosage of around 5 mg can be administered over a long period, e.g., in excess of 12 months.
• the method according to the invention then further comprises a period of treatment during which a daily dosage of ulipristal or a metabolite thereof is administered, wherein said dosage is administered at less than one half the initial treatment daily dosage.
• the treatment period may be repeated once a year, or every two years.
• the patient can be any human female, but may also be a non-human mammalian female.
• the patient may be administered with ulipristal or a metabolite thereof at any time when needed.
• the treatment with ulipristal or a metabolite thereof stops all bleeding and renders the patient amenorrheic, which improves hemostasis and general condition of the patient before surgery. Furthermore it favors non- or minimally invasive removal or destruction of the fibroids, against invasive surgery like myomectomy, hysterectomy. Surgical interventions and uterine artery embolisation can then be performed by means of a laparoscope or transvaginally preferably. Ultrasound or thermal treatment may also be sufficient to destroy the remaining fibroids.
• ExAblate® device may be useful in that respect. This device provides a uterine-sparing alternative for women that is a non-invasive treatment.
• MRI magnetic resonance imaging
• EXAMPLE 1 Randomized, Placebo-Controlled, Double Blinded, Parallel Trial of the Selective Progesterone Receptor Modulator, Ulipristal (CDB-2914) Materials and Methods:
• Excessive uterine bleeding evidenced by either of the following: profuse bleeding with flooding or clots or repetitive periods lasting for more than 8 days; or anemia due to acute or chronic blood loss; or pelvic discomfort caused by leiomyomata, either acute or severe or chronic lower abdominal or low back pressure or bladder pressure with urinary frequency not due to urinary tract infection.
• Exclusion criteria included pregnancy, hemoglobin ⁇ 10 g/dL, current hormone therapy, rapidly enlarging uterus and FSH >20 IU/mL.
• MR images were obtained to record fibroid number, location and volume, before starting study drug and within 2 weeks of surgery. Women took ulipristal at an oral dose of 10 or 20 mg, or placebo (PLC: microcrystalline cellulose) for 3 cycles, or 90 days if they became anovulatory. The percent change in total fibroid volume was compared. Wilcoxon rank sum test and t-test were used as needed.
• ulipristal at 10 or 20 mg daily significantly reduced the size of fibroids by 36% and 21%, respectively, after 90 days, and induced amenorrhea.
• TUNEL assay and IHC for Ki67 and phosphorylated histone 3 (phospho H3) were applied to paraffin embedded tissue sections, and the percentage of positive stained cells was noted to assess apoptosis and proliferation.
• RT-PCR results and proliferation assays were analyzed using two-tailed student t-test; Kruskal-Wallis test was used to assess TUNEL assay results; P ⁇ 0.05 was considered significant.
• RT-PCR validated the differential expression of Clusterin (CIu), Fas apoptotic inhibitory molecule 2 (FAIM2), Norrie disease protein (NDP), wingless-type MMTV integration site family, member 5 A (Wnt5 A), B-cell leukemia/lymphoma 2 (Bcl2), sterile-alpha motif and leucine zipper containing kinase AZK (ZAK), proteo lipid protein 1 (PLPl) (see the table below).
• CIu Clusterin
• FIM2 Fas apoptotic inhibitory molecule 2
• NDP Norrie disease protein
• Wnt5 A wingless-type MMTV integration site family
• member 5 A Wnt5 A
• Bcl2 B-cell leukemia/lymphoma 2
• ZAK sterile-alpha motif and leucine zipper containing kinase AZK
• PLAK proteo lipid protein 1
• a woman with known benign metastatic leiomyoma status post abdominal surgery that confirmed multiple nodules was treated with ulipristal (daily oral dose of 10-20mg), in a compassionate protocol.

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• 2008
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